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10772285-DS-3
| 10,772,285 | 23,216,168 |
DS
| 3 |
2153-05-05 00:00:00
|
2153-05-05 09:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Percocet
Attending: ___.
Chief Complaint:
L arm pain
Major Surgical or Invasive Procedure:
revision ORIF L both bone forearm fracture
History of Present Illness:
___ male with past medical history significant for left both
bone forearm fracture status post ORIF (ulna and radius by Dr.
___ in ___ and subsequent hardware removal (ulnar
plate by Dr. ___ in ___ presents with the left both
bone forearm fracture s/p mechanical fall while playing
basketball today.
Past Medical History:
Past medical history is notable for depression and anxiety as
well as hyperlipidemia.
Past surgical histories include a left foot surgery arch implant
complicated by infection, status post I and D and plastics
coverage.
Social History:
___
Family History:
NC
Physical Exam:
Gen:
L upper extremity:
- dressing clean/dry/intact
- Fires EPL/FPL/DIO
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse, WWP
Pertinent Results:
Please see OMR for pertinent results.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a L both bone forearm fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for revision L both bone forearm
fracture, which the patient tolerated well. He had a wound vac
closure due to inability to close the skin. He underwent L
forearm I&D, closure on ___. For full details of the
procedure please see the separately dictated operative reports.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non weight bearing in the left upper extremity, and will be
discharged on aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
clonazepam 0.5mg ___
escitalopram 10mg qd
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Severe
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
three to six hours Disp #*40 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home
Discharge Diagnosis:
L both bone forearm fracture
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- non weight bearing left upper extremity in splint
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin 81 mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___. Call
___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
- non weight bearing left upper extremity in splint
- ROM shoulder/digits
- NO ROM wrist
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Please remain in the splint until follow-up appointment. Please
keep your splint dry. If you have concerns regarding your
splint, please call the clinic at the number provided.
Followup Instructions:
___
|
10772630-DS-17
| 10,772,630 | 22,236,428 |
DS
| 17 |
2186-12-01 00:00:00
|
2186-12-03 14:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
NSAIDS / trazodone / oxycodone / chloroquine
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with past medical history of thyroiditis HTN, obesity,
GERD who presents with midsternal chest pressure that started on
0100 on ___. About one week ago, pt developed burning
substernal chest pressure. She was seen at ___
last week for same and her pain was relieved with nitroglycerin.
She had 2 troponins and was discharged. Last night she developed
chest pressure again while at work, which prompted her to come
to the ED. She describes the pain as constant, worse with
exertion. The pain radiates to her back. Denies any arm
pain/paresthesias, jaw pain, HA, diaphoresis. She has had some
mild nausea, no emesis. She has a history of severe GERD but
states this pain is different.
Denies fevers, chills, difficulty breathing, abdominal pain,
nausea, vomiting, diarrhea, unilateral leg swelling.
Pt had exercise stress test on ___ which showed ___epression during exercise & late recovery in leads II, III,
V4-6, consistent with ischemia, by EKG criteria. Exercise
capacity was mildly reduced and the test was stopped due to leg
fatigue.
ED COURSE
-In the ED intial vitals were: 97.9 84 151/92 18 100% RA
-EKG: NSA <1mm ST depression in lead ii
-Labs/studies notable for: Trop-T: <0.01
-Patient was given: SL Nitroglycerin SL .4 mg which relieved her
pain, also received PO Aspirin 324 mg, PO Pantoprazole 40 mg,
PO/NG Calcium Carbonate 500 mg
-CXR with normal chest radiograph.
Vitals on transfer: 98.5 66 132/74 18 100% RA
On the floor, pt notes her pain is much improved.
REVIEW OF SYSTEMS: On review of systems, positive for dark
stools for past week and constipation. denies any prior history
of stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, red stools. Denies recent fevers, chills or rigors.
Denies calf pain.
Cardiac review of systems is notable for chest pain as above as
well as palpitations. Denies orthopnea, ankle edema, syncope.
She can not lay flat at night but states this is secondary to
severe GERD
Past Medical History:
PMH: HTN, GERD, Uterine fibroids
PSH: L breast lumpectomy x2, most recent in ___. Multiple
c-sections. L knee surgery.
Social History:
___
Family History:
DM, Breast Cancer
Physical Exam:
ADMISSION
VS: 97.9, 137/83, 67, 18, 97% on RA
GENERAL: Oriented x3. NAD
HEENT: Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. No xanthelasma.
NECK: Supple, no JVD
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. Chest pain
not reproducible with palpation
LUNGS: Resp were unlabored, no accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND.
EXTREMITIES: No edema, warm, well perfused
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE
Vitals: 98.3 (98.3) 126/73 (100-120/50-70) 74 (60-70) 18 100%RA
Tele: no events, HR ___ sinus
Last 8 hours I/O: not recorded
Last 24 hours I/O: 1100/BRP
Weight on admission: not obtained
Today's weight: not obtained
General: well-appearing, NAD
Neck: supple, JVP 7cm
Lungs: CTAB, no crackles
CV: RRR no murmurs;
Abdomen: no TTP or masses
Ext: no edema
Pertinent Results:
ADMISSION
___ 12:00PM BLOOD WBC-6.6 RBC-4.71 Hgb-13.2 Hct-41.0#
MCV-87# MCH-28.0 MCHC-32.2 RDW-13.8 RDWSD-44.1 Plt ___
___ 12:00PM BLOOD ___ PTT-36.5 ___
___ 06:15PM BLOOD ALT-24 AST-23 LD(LDH)-146 AlkPhos-64
TotBili-0.4
___ 12:00PM BLOOD cTropnT-<0.01
___ 06:15PM BLOOD CK-MB-1 cTropnT-<0.01
___ 01:10AM BLOOD CK-MB-1 cTropnT-<0.01
___ 11:54PM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:41AM BLOOD Albumin-4.1 Calcium-10.0 Phos-4.1 Mg-1.9
DISCHARGE
___ 07:00AM BLOOD WBC-5.3 RBC-5.00 Hgb-14.0 Hct-43.4 MCV-87
MCH-28.0 MCHC-32.3 RDW-13.9 RDWSD-43.2 Plt ___
___ 07:00AM BLOOD Glucose-99 UreaN-13 Creat-0.9 Na-137
K-4.4 Cl-100 HCO3-26 AnGap-15
___ 05:41AM BLOOD ALT-23 AST-23 LD(LDH)-150 AlkPhos-62
TotBili-0.3
___ 07:00AM BLOOD Calcium-10.0 Phos-3.5 Mg-2.1
CXR ___
Normal chest radiograph.
STRESS TEST ___
The estimated peak MET capacity was 8.7 which represents an
average functional capacity for her age. At peak exercise the
patient
reported a sub-sternal chest discomfort that resolved with rest
and 0.3
mg of sl NTG by minute 11 of recovery. Also at peak exercise,
there was
___epression in leads II and III that resolved
within
15 seconds of stopping exercise. The rhythm was sinus with no
ectopy.
Appropriate hemodynamic response to exercise and recovery.
IMPRESSION: Anginal type symptoms with ischemic EKG changes.
Nuclear
report sent separately.
CARDIAC PERFUSION ___
FINDINGS: Left ventricular cavity size is normal.
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 73%.
IMPRESSION: Normal myocardial perfusion and function.
Brief Hospital Course:
___ female with past medical history of thyroiditis, HTN,
obesity, GERD who presents with midsternal chest pressure.
#Chest pain: Pt presents with substernal chest pain, recent
exercise stress with 1mm ST depressions in II, III, V4-6. Risk
factors for CAD include obesity and HTN. Pt states pain resolved
with nitro in ED. Also on ddx of chest pain includes severe
GERD however pt states current pain feels different than her
typical GERD. PE unlikely as no risk factors (no history DVT, no
recent travel, no unilateral leg swelling) and pt saturating
well on RA. Troponins negative. LFTs normal. She ultimately
underwent a nuclear MIBI stress which revealed normal myocardial
perfusion. Of note, she was maintained on omeprazole in house
(instead of home deslansoprazole) and her pain did not recur.
Accordingly, we discharged her with a prescription for
omeprazole. Encouraged follow up with cardiologist Dr. ___.
#Dark stool, ? melena: On review of systems, pt reports one week
history of dark, hard black stool. Unclear if melena. HDS and
no melena while in house.
#GERD: switching to omeprazole from deslansoprazole as above
#HTN: d/c'ed home medication of metoprolol succinate in favor of
Verapamil 180 mg daily
#Insomnia: cont home Ativan prn insomnia
TRANSITIONAL ISSUES
[] Follow up appointment with PCP
[] Follow up appointment with cardiology
[] New medications: Omeprazole 20 mg bid (pt in favor of this
instead of deslansoprazole)
[] Patient discharged on Verapamil 180mg daily; please continue
monitoring BP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5 mg PO QHS:PRN insomnia
2. Ranitidine 300 mg PO BID:PRN GERD
3. Hyoscyamine 0.250 mg PO TID:PRN abdominal cramps
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Dexilant (dexlansoprazole) 60 mg oral BID
Discharge Medications:
1. Lorazepam 0.5 mg PO QHS:PRN insomnia
2. Ranitidine 300 mg PO BID:PRN GERD
3. Hyoscyamine 0.250 mg PO TID:PRN abdominal cramps
4. Verapamil SR 180 mg PO Q24H
RX *verapamil 180 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*28
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Chest pain
Secondary:
Hypertension
GERD
Insomnia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ was a pleasure taking care of you at the ___
___. You were hospitalized for chest pain.
Your recent stress test showed that you might have coronary
artery disease. Because of this, we performed a different kind
of stress test here at our lab. This test showed normal heart
function without evidence of coronary artery disease. You
should follow up with your PCP and cardiologist.
It was a pleasure taking care of you!
Your ___ team
Followup Instructions:
___
|
10772636-DS-16
| 10,772,636 | 23,849,703 |
DS
| 16 |
2134-12-17 00:00:00
|
2134-12-25 15:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
LBP, LLE pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ yo male with a long standing history of LBP.
According to Mr. ___, this began in ___ after lifting a
5 pound bag. He states that coughed and strained at the same
time and caused a left L3-L4 disc herniation. He has been
followed at the ___ Spine Unit since ___. He has had
multiple
injections, which have have typically reduced his symptoms. He
has also done physical therapy, which according to the pt, has
not worked. His last pain injection was ___. He states
that the pain relief was for only one day and his symptoms of
LBP and left thigh pain returned. He states that his pain
travels from the area of his hips to above his knee. He states
that he has
difficulty ambulating secondary to pain.
Past Medical History:
CAD (stents ___, GERD, Asthma, Degenerative disc
disease, HTN
Social History:
___
Family History:
non contributory
Physical Exam:
Physical Exam:
Vitals: 97.4 HR 90 BP 131/80 RR 16 O2 95% RA
General: mild distress ___ pain, A&Ox3, appears to be stated age
CV: NSR
PULM: no difficulty breathing
Abd: Soft, NT, ND
Neuro: PERRL, EOMI, no facial droop, tongue midline, ___
strength
in upper extremities with sensation to light touch intact. Left
hip flexion ___, knee flexion/extention, dorsiflexion and
planter flexion ___. Right lower extremity ___ strength
throughout. Sensation to light touch intact bilaterally. DTR +2
in bilateral patellar and ankle.
Exam is sometimes pain limited.
EXAM ON DISCHARGE:
EOMI
CN ___ grossly intact
no drift
Decreased sensation in left leg from lateral thigh to knee
___ motor strength throughout
Pertinent Results:
___ MRI L-spine: right L4-5 disc herniation, left L3-4
foraminal narrowing from prominent facet
___ AP/Lat Hip: No evidence of fracture. Mild degenerative
changes.
Brief Hospital Course:
The patient was admitted to the neurosurgical service for pain
control. On ___ he was started on decadron, toradol, and
flexeril with good effect. Blood sugars on ___ were elevated
after receiving high dose dexamethasone requiring insulin dosing
and so on ___ he was switched to a lower dose methylprednisone
taper. He ambulated with nursing and on ___ his pain was
improved. Blood sugars continued to be elevated and the patient
required increasing doses of insulin ___ consult was
obtained for glucose management and home insulin teaching while
the patient remained on steroids.
At the time of discharge he was tolerating a regular diet,
ambulating without difficulty, afebrile with stable vital signs.
Medications on Admission:
Diclofenac 50mg, Nortriptyline 10mg, Ca/VitD 500mg, Pantoprazole
40mg, Metformin 850, Valsartan 160, Terazosin 5mg, Glyburide
5mg, Simvastatin 20mg, Diltazem 120mg, Aspirin 325mg
Discharge Medications:
1. Cyclobenzaprine 10 mg PO TID
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
2. Diltiazem Extended-Release 120 mg PO BID
3. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*1
4. GlyBURIDE 5 mg PO BID
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q ___
Disp #*60 Tablet Refills:*1
6. MetFORMIN (Glucophage) 850 mg PO BID
7. Nortriptyline 10 mg PO HS
8. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
9. Simvastatin 20 mg PO QPM
10. Terazosin 5 mg PO HS
11. Valsartan 160 mg PO DAILY
12. One Touch Ultra Test (blood sugar diagnostic) 50
miscellaneous qd
one bottle of 50
RX *blood sugar diagnostic [One Touch Ultra Test] 1 daily Disp
#*50 Strip Refills:*0
13. One Touch Delica Lancets (lancets) 33 gauge miscellaneous
daily
one box of 100
RX *lancets [One Touch Delica Lancets] 33 gauge 1 1 Disp #*50
Each Refills:*0
14. HumuLIN N KwikPen (NPH insulin human recomb) 100 unit/mL (3
mL) subcutaneous 1
patient needs one pen
RX *NPH insulin human recomb [Humulin N KwikPen] 100 unit/mL (3
mL) 20 units sc q am Disp #*1 Syringe Refills:*0
15. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous 1
1 pen
RX *insulin lispro [Humalog] 100 unit/mL 1 1 sc every six (6)
hours Disp #*1 Cartridge Refills:*0
16. Pen Needle (insulin needles (disposable)) 32 x ___
miscellaneous 1
1box
RX *insulin needles (disposable) [Pen Needle] 32 gauge X ___ 1
1 Disp #*50 Needle Free Injection Refills:*0
17. NPH 20 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [One Touch Ultra Test] strips daily
Disp #*50 Strip Refills:*0
RX *insulin lispro [Humalog KwikPen] 100 unit/mL 1 Up to 18
Units QID per sliding scale Disp #*1 Syringe Refills:*0
RX *NPH insulin human recomb [Humulin N KwikPen] 100 unit/mL (3
mL) 1 20 Units before BKFT; Disp #*1 Syringe Refills:*0
18. Methylprednisolone 4 mg PO DAILY
16 mg ___
RX *methylprednisolone [Medrol] 4 mg 1 tablet(s) by mouth once a
day Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right L4-5 disc herniation
Left L3-4 foraminal narrowing
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Instructions for your insulin while you are on steroids:
NPH 20 units on ___
then decrease by 2 units each day after that while you are and
continue to decrease while you are on steroids.
Stop taking your NPH when you are no longer taking steroids and
resume your oral medications as you were taking before w/o
suplamental insulin.
Followup Instructions:
___
|
10772636-DS-18
| 10,772,636 | 26,846,307 |
DS
| 18 |
2135-02-08 00:00:00
|
2135-02-08 18:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Severe low back pain
Major Surgical or Invasive Procedure:
___ Lumbar wound washout and exploration
History of Present Illness:
___ s/p L3 laminectomy on ___ with instrumentation with
sudden onset of weakness while driving yesterday ___. Had been
recovering well from surgery without need for pain medications
with steady ___ back pain. After onset of pain, needed a
friend's assistance to walk out of his car. Was having no
numbness, weakness, or pain in his legs. Vomited with any food
intake. Reports no incontinence of bowel or urine, although
described an episode where he urinated on himself because he was
too weak to make it to the bathroom. No saddle anesthesia, did
not feel feverish at the time, and had no cough, shortness of
breath, urinary symptoms, or diarrhea. Wife came home to find
him rigoring in bed, presented to ___ ED late ___ of ___.
In the ED, initial vital signs were: T 98.6 P ___ BP 122/76 R
136 RR 18 O2 98RA
Exam notable for normal sensation in bilateral ___. DP 2+
bilaterally. Dorsiflexion/plantar flexion in tact. Became
febrile in ED to 101.5, also reported stiff neck and headache,
so started on emperic cefepime, vancomycin, and ampicillin. Also
received dilaudid and acetaminophen. Blood and urine cultures
taken. MRI showed two posterior fluid collections near surgical
site, one abutting the right psoas. CXR showed no acute
cardiopulmonary processes.
Seen by neurosurgery who examined the wound, removed staples and
found no acute neurosurgical issue. Spoke to medicine attending
over the phone, requested no LP if possible.
Past Medical History:
diabetes type 2
plantar fasciitis
severe bronchitis including coughing spells that has caused him
to dislocate his shoulder and fracture multiple ribs.
HTN
GERD
CAD s/p 2xstents ___ AND ___
Asthma
COPD
esophagitis
anemia
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: 98.1 157/93 107 18 100RA
General: Rigoring and moving uncomfortably in bed, awake and
alert
HEENT: EOMI, PERRLA sclera non-injected and anicteric
Neck: full ROM, no meningismus, full chin-to-chest
Lymph: No cervical or perimeter ___
CV: Distant heart sounds, exam limited by rigors. Peripheral
pulses intact, no JVD
Lungs: CTAB w/o adventitious sounds. Good movement in all fields
b/l
Abdomen: NBS, soft and nontender, non-distended
GU: deferred
Neuro: No meningeal signs. ___ flexion at the R. hip, ___ on L.
___ b/l planter flexion, dorsiflexion. Normal upper extremity
strength and sensation.
Skin: WWP. No c/c/e. Surgical scar healing without erythema,
purulence, edema, appropriately tender about wound.
Discharge Physical Exam:
alert and oriented
___ strength BLE
sensation is grossly intact
incision is c/d/i closed with sutures, drain site with suture
Pertinent Results:
Admission Labs:
___ 09:44PM BLOOD WBC-11.0# RBC-3.64*# Hgb-10.9*#
Hct-32.4*# MCV-89 MCH-29.9 MCHC-33.6 RDW-14.8 Plt ___
___ 09:44PM BLOOD Neuts-84.1* Lymphs-9.3* Monos-5.7 Eos-0.7
Baso-0.2
___ 09:44PM BLOOD Glucose-92 UreaN-16 Creat-1.4* Na-133
K-3.9 Cl-99 HCO3-17* AnGap-21*
___ 10:01PM BLOOD Lactate-2.8*
___ 06:10AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 06:10AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 06:10AM URINE CastHy-3*
___ 06:10AM URINE Color-Yellow Appear-Clear Sp ___
Notable Findings:
MRI L-spine w/o contrast (___)
IMPRESSION:
1. Postoperative change of L3-L4 laminectomy with posterior
stabilization hardware and posterior fluid collection at the
operative level which causes mass effect on the thecal sac and
could represent seroma or hematoma although infection is not
excluded.
2. Additional soft tissue fluid collection on the right at the
L4 level, extending around the L4 vertebral body and abutting
the posterior aspect of the right psoas muscle, which may
represent hematoma or seroma although infection is not excluded.
3. Multilevel degenerative spondylosis, greatest at the L4-L5
level, as described.
Brief Hospital Course:
___ s/p L3 laminectomy on ___ with instrumentation
presenting with sudden onset of weakness, rigors, found to have
perispinal fluid collections on MRI.
ACUTE ISSUES:
# Sepsis: Tachycardic, febrile in ED. Presumed source in
perispinal fluid collections. Lactate 2.8 in the ED, likely
volume contracted w/ Creat 1.4. Rigoring on transfer, now abated
w/ benadryl and acetaminophen. Currently covered broadly with
vanc/zosyn and 2L NS since transfer to floor. Spinal cord
involvement unlikely d/t negative MRI, and clinical exam though
fluid collections abutt R. psoas, which correlates with R. hip
flexion weakness. Source control challenging d/t ?abscess.
- VS q4h
- continue vanc/zosyn
- 125cc/hr maintenence fluid
- ___ consult for fluid collection/abscess drainage
- f/u blood cultures
- Acetaminophen prn Fever/Pain
- dilaudid prn back pain
# s/p laminectomy: Seen and evaluated by neurosurgery. Rec no
surgical intervention and prev surgery unlikely contributing to
current picture.
- Appreciate neurosurg recs, will follow
CHRONIC ISSUES:
# DM 2 - glucose of 50 on arrival to floor
- ISS
- glucose gel prn for hypoglycemia
# COPD
-BID Fluticasone-Salmeterol Diskus
-nebs prn
# GERD
-continue home PPI
# CAD s/p stent placement
- continue ASA 325
Mr. ___ was transferred to the Neurosurgery service on
___ after undergoing his wound revision with Dr. ___.
The patient was recovered in PACU and sent to the inpatient ward
for further management. Intraoperative cultures were shown to
grow Serratia marcesens and gram positive cocci. The patient
was continued on vancomycin and cefepime was initiated.
Infectious Disease was consulted. Due to urinary retention, the
patient was catheterized once. He was unable to void
successfuly thereafter.
Between ___ and ___, Mr. ___ continued to recover
well. He was started on his home blood pressure medications.
His oral diabetic medications were not initiated until he was
taking adequate oral intake. During this time, his blood sugar
was within normal limits (< 100).
On ___ his JP drain remained in and ID continued to follow and
watch sensitivities in order to guide antibiotic therapy
On ___ Patient worked with ___ who recommended ___ more visits
prior to discharge. ID recommended continuing on regimen of
vancomycin and cefepime.
On ___ Patient was evaluated by ___ who cleared patient for
home. JP drain was removed, drain site was sutured closed. Home
IV infusions were arranged. Patient was discharged home in
stable condition with home antibiotic infusion. His pain was
well controlled at the time of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nortriptyline 50 mg PO HS
2. Vitamin D 400 UNIT PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. MetFORMIN (Glucophage) 850 mg PO BID
6. Valsartan 160 mg PO DAILY
7. Terazosin 5 mg PO DAILY
8. GlyBURIDE 10 mg PO BID
9. Simvastatin 20 mg PO QPM
10. Diltiazem 120 mg PO BID
11. Cyanocobalamin 1000 mcg PO Frequency is Unknown
12. Aspirin 325 mg PO DAILY
13. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
Wheezing
14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Calcium Carbonate 500 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. GlyBURIDE 10 mg PO BID
5. MetFORMIN (Glucophage) 850 mg PO BID
6. Pantoprazole 40 mg PO Q12H
7. Simvastatin 20 mg PO QPM
8. Terazosin 5 mg PO DAILY
9. Valsartan 160 mg PO DAILY
10. Acetaminophen 650 mg PO Q6H:PRN Pain
11. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth DAILY PRN for
constipation Disp #*60 Tablet Refills:*0
12. Cyclobenzaprine 10 mg PO TID:PRN muscle spasms
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth TID PRN muscle
spasm Disp #*90 Tablet Refills:*0
13. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth BID for
constipation Disp #*60 Capsule Refills:*0
14. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth Q4H PRN pain Disp
#*90 Tablet Refills:*0
15. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 g by
mouth DAILy prn CONSTIPATION Refills:*0
16. Pregabalin 100 mg PO BID
17. Vancomycin 1000 mg IV Q 12H
RX *vancomycin 1 gram 1 g IV Q12 Disp #*84 Vial Refills:*0
18. Cyanocobalamin 1000 mcg PO DAILY
19. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
Wheezing
20. Nortriptyline 50 mg PO HS
21. Vitamin D 400 UNIT PO DAILY
22. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin 750 mg 1 tablet(s) by mouth Q12 Disp #*84
Tablet Refills:*0
23. Diltiazem Extended-Release 120 mg PO BID
24. Outpatient Physical Therapy
25. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
RX *sodium chloride 0.9 % [Normal Saline Flush] 0.9 % ___ mL
IV DAILY Q8 for PICC line flush Disp #*30 Syringe Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Lumbar wound infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ Neurosurgery service due to
concerns of a wound infection. You were taken to the Operating
Room on ___ for a wound washout and exploration. A drain was
placed during that time to facilitate drainage of fluids.
Fluids obtained during the procedure was sent for culture and
showed an infection. You were started on IV antibiotics and the
Infectious Disease service was consulted.
You are now being discharged ___ with the following
instructions:
Do not smoke.
Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery. You must keep
your sutures dry until they are removed.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Have a friend or family member check your incision daily for
signs of infection.
If you are required to wear one, wear your cervical collar or
back brace as instructed.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
Do not take any medications such as Aspirin unless directed by
your doctor.
Unless you had a fusion, you should take Advil/Ibuprofen
400mg three times daily
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
- The dressing over your drain site may be removed ___
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 101° F.
Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
___
|
10772889-DS-3
| 10,772,889 | 22,964,925 |
DS
| 3 |
2121-02-23 00:00:00
|
2121-02-27 15:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
___ EGD
___ EGD
___ Colonoscopy
History of Present Illness:
The patient is a ___ with a history of HTN, HLD, and AFib on
Coumadin presenting as a transfer from ___ for ___. The
patient reports bright red blood per rectum last night; noting
dark black stools with streaks of blood. He had numerous similar
episodes overnight leading up to the day of admission, noting
some light headedness as well. He presented to the ___
where he was found to have a rectal exam which was grossly
positive for melena. His INR was 3.8, and the patient got 10 of
Vitamin K. His H and H at that time was 10.6/31.2, and the
patient was transferred to the BI for further care. His baseline
Hgb is reportedly 16.
Of note, the patient does report a history of duodenal ulcer
disease as a teenager.
Past Medical History:
SLEEP APNEA
___, split night study with an AHI of 69,RDI 81 and oxygen
desaturation to 88%
ATRIAL FIBRILLATION AND FLUTTER
HYPERTENSION
OBESITY
HYPERCHOLESTEROLEMIA
Social History:
___
Family History:
Father -STROKE
Son - SNORING
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
VITALS: T 99 HR 131 -> 104 afib BP 92/73-102/47 RR 18 Sat 99%
GENERAL: Alert, oriented, no acute distress; well nourished
___ speaking man, pleasant
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: regularly irregular rhythm, tachycardic, normal S1 S2, no
murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no lesions noted on arms, legs, upper chest
NEURO: CN II-XII grossly intact, strength ___ in UE and ___
bilaterally
DISCHARGE PHYSICAL EXAM
========================
VITALS: 97.3, 101/68, 80, 18, 98%RA
GENERAL: Alert, oriented, no acute distress; well nourished
___ speaking man, pleasant
HEENT: Sclera anicteric, MMM, oropharynx clear, pale conjunctiva
NECK: supple
LUNGS: CTAB
CV: regularly irregular rhythm, regular rate normal S1 S2, no
murmurs, rubs, gallops
ABD: +BS, soft, non-tender, non-distended, no rebound or
guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no lesions noted on arms, legs, upper chest
NEURO: CN II-XII grossly intact, strength ___ in UE and ___
bilaterally
Pertinent Results:
ADMISSION LABS
===============
___ 01:25PM BLOOD WBC-12.0*# RBC-3.30*# Hgb-10.0*#
Hct-29.5*# MCV-89 MCH-30.3 MCHC-33.9 RDW-13.2 RDWSD-42.7 Plt
___
___ 01:25PM BLOOD Neuts-78.8* Lymphs-16.4* Monos-3.9*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-9.49* AbsLymp-1.98
AbsMono-0.47 AbsEos-0.00* AbsBaso-0.02
___ 01:25PM BLOOD ___ PTT-37.4* ___
___ 01:25PM BLOOD Glucose-195* UreaN-35* Creat-0.7 Na-141
K-4.7 Cl-107 HCO3-18* AnGap-16
DISCHARGE LABS
==============
___ 08:35AM BLOOD WBC-5.7 RBC-2.93* Hgb-8.8* Hct-26.7*
MCV-91 MCH-30.0 MCHC-33.0 RDW-16.6* RDWSD-49.2* Plt ___
___ 08:35AM BLOOD Glucose-127* UreaN-13 Creat-0.6 Na-141
K-3.6 Cl-103 HCO3-25 AnGap-13
MCIRO
=====
___ Blood culture: NEGATIVE
___ Urine culture: NEGATIVE
IMAGING
========
___ CTA Abd/pelvis
1. No CT evidence of focal pancreatic mass. Diverticulum
arising from the
first stage of the duodenum near the gastroduodenal junction may
account for the extrinsic compression identified on upper
endoscopy.
2. Marked prostatomegaly with diffuse urinary bladder wall
thickening which may be in keeping with some degree of chronic
bladder outlet obstruction.
___ EGD:
Esophagus: Lumen: A Schatzki's ring was found in the
gastroesophageal junction.
Stomach:
Mucosa: Normal mucosa was noted.
Duodenum:
Lumen: An 8mm stricture was found in the duodenal bulb looking
into the second portion of the duodenum. The scope could not
transverse the lesion.
Other An area of heaped up mucosa from the duodenal bulb into
the second portion of the duodenum was seen. No evidence of
active bleeding.
Impression:
Schatzki's ring
Normal mucosa in the stomach
An area of heaped up mucosa from the duodenal bulb into the
second portion of the duodenum was seen. No evidence of active
bleeding.
Stricture of the duodenal bulb into the second portion of the
duodenum
Otherwise normal EGD to third part of the duodenum
___ EGD
Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum:
Excavated Lesions A single non-bleeding diverticulum with large
opening was found in the duodenal bulb and second part of the
duodenum junction.
Impression: Diverticulum in the duodenal bulb and second part of
the duodenum junction Otherwise normal EGD to third part of the
duodenum
___ Colonoscopy:
Protruding Lesions Small non-bleeding internal hemorrhoids were
noted.
Other - No evidence of fresh or retained blood. No identifiable
source of bleeding - Prep inadequate for colorectal screening as
small polyps may have been missed
Impression: - No evidence of fresh or retained blood. No
identifiable source of bleeding - Prep inadequate for colorectal
screening as small polyps may have been missed
Internal hemorrhoids
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
ASSESSMENT & PLAN:
===================
___ with a history of HTN, HLD, and AFib on Coumadin presenting
as a transfer from ___ for GIB in the setting of
supratherapeutic INR, with course complicated by Afib with RVR.
#Acute upper GIB:
#Anemia
Pt presenting with likely rapid upper GIB. He reports recent
history of epigastric pain without clear trigger and reported 4
episodes of dark black/bright red stool for which he was given
4u PRBCs and 2u platelets. EGD without active bleed x2 but did
see duodenal diverticula and a duodenal stricture. He was
evaluated with a colonoscopy which showed no active bleeding nor
evidence of fresh or retained blood. There were several
non-bleeding internal hemorrhoids. He will need further
evaluation for source of bleeding as an outpatient but will
likely need dilation of stricture prior to capsule study. Though
no source was found he remained hemodynamically stable until the
time of discharge, and his H/H at discharge was 8.8/26.7. At
time of discharge H.pylori was pending. He was discharged on PPI
once a day. He will follow up with GI for further workup of GI
bleeding.
#AFib with RVR:
Patient presented to ___ and found to be tachycardic to 120s in
afib with RVR. PMHx of aflutter and afib, not on any rate
control as an outpatient as asymptomatic/failure and side
effects from sotalol, propefenone per ___ Cards note. A-fib
with RVR at this presentation was thought to be likely in
setting of stress from increased demand in setting of bleed.
CHADS2VASC = 2 (Age, HTN) (moderate-high risk). He was started
on diltiazem for rate control and tolerated it well. His
warfarin was held in setting of acute GI bleed. It was felt
unsafe to restart warfarin as an outpatient given lack of
localization of bleed, also because of his relatively low
CHADS2VASC. He should continue to hold warfarin until further
workup by GI. He will follow up with Cardiology for further
titration of his rate control.
CHRONIC ISSUES/RESOLVED ISSUES
==============================
#OSA:
- Home acetazolamide held
- Continued CPAP at night
#Leukocytosis: WBC elevated up to 14K over the course of this
admission but normalized prior to discharge. Unclear etiology,
possibly reactive in setting of GIB per above. He reports a few
day history of epigastric pain but denies infectious symptoms or
sick contacts. Patient was afebrile and otherwise without
localizing signs/symptoms of infection. UA bland. BCx/UCx
without growth. No ABX were given due to low concern for
infection.
TRANSITIONAL ISSUES
===================
MEDICATIONS STARTED: Diltiazem Extended-Release 120 mg PO DAILY
[]HR well controlled on diltiazem while in house. Would f/u HR
and evaluate need for adjustment in diltiazem dosing.
[]Repeat CBC at PCP ___ (discharge H/H 8.8/26.7)
[]Continued on PPI once a day, he should continue this until he
follows up with GI
[]H.pylori pending at time of discharge
[]No source of bleeding noted on EGD or colonoscopy. Would eval
for any additional episodes of bleeding or need for GI f/u.
Colonoscopy report also noted prep was not suitable for
colorectal cancer screening. Would schedule screening ___ as
needed.
[]Warfarin was not restarted at time of discharge given risk of
rebleeding and no known source of bleeding. Should weight risk
and benefits of restarting anticoagulation and hold until
further workup of GI bleed.
#Communication: HCP: ___
Relationship: WIFE
Phone: ___
Other Phone: ___
#Code: Full, confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. AcetaZOLamide 125 mg PO QHS
2. Warfarin 5 mg PO DAILY16
3. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Diltiazem Extended-Release 120 mg PO DAILY
RX *diltiazem HCl 120 mg 1 capsule(s) by mouth Once a day Disp
#*30 Capsule Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth Once a day Disp #*30
Tablet Refills:*0
3. AcetaZOLamide 125 mg PO QHS
4. Simvastatin 40 mg PO QPM
5. HELD- Warfarin 5 mg PO DAILY16 This medication was held. Do
not restart Warfarin until you follow up with your PCP and GI
___ Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
C/f upper GIB
Acute blood loss anemia
Atrial fibrillation with rapid ventricular response
SECONDARY DIAGNOSES
===================
Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure to take care of you at ___.
WHY WAS I HERE?
You were admitted to the hospital because you had bleeding from
your GI tract.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
- While you were in the hospital you were given blood. You had
endoscopy to look for source of bleeding. They initially found a
ring of tissue in your duodenum.
- CT of your abdomen was done to rule out a mass as a cause of
this ring but was negative.
- A second endoscopy was done and showed a diverticulum in your
small intestines that was not bleeding.
- Your warfarin was held during admission due to bleeding
- You were also evaluated with a colonoscopy which showed no
source of bleeding
WHAT SHOULD I DO WHEN I GET HOME?
1) Follow up with your Primary Care Doctor.
2) Follow up with your Cardiologist
3) Follow up with GI to further work up source of your bleeding
4) You were not restarted on your Warfrain due to risk of
bleeding again.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10773055-DS-23
| 10,773,055 | 24,378,044 |
DS
| 23 |
2184-08-30 00:00:00
|
2184-08-31 20:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vicodin / Vasotec / Morphine / Codeine
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with end-stage renal disease secondary to
polycystic kidney disease who underwent a living-related kidney
transplant from her sister on ___, history of
cholecystectomy complicated by multiple episodes of bacteremia,
who presented with from ___ with 3 days of dark
urine, and fever yesterday to 100.4. At ___ had tbili
elevation to 3.3. Her CT AP was reportedly normal. Due to her
fever, history of multiple episodes of bacteremia, history of
renal transplant followed by Dr. ___ here at ___, and
rising LFT's, she was transferred to ___.
Of note, the patient has a history of "sump syndrome" defined as
a condition after gallbladder surgeries, described by distal
common bile duct acting as a 'sump' or stagnant reservoir for
stones and other debris that can lead to abdominal pain,
cholangitis, pancreatitis, or biliary obstruction. She has had
multiple episodes of bacteremia characterized by fevers and
occasionally abdominal pain. She was last admitted to ___ for
this in ___, but the patient has had other admissions since
then to ___.
In the ED, initial vitals were 97.3 95 120/67 16 94% RA
Labs were notable for normal CBC, ALT 99, AST 89, Tb 2.1 (down
from 3.3 at OSH), creatinine 1.2 (baseline 1.0-1.1), UA
unremarkable, lactate 1.6
Imaging was notable for CXR with small b/l pleural effusions,
RUQUS with surgically absent gallbladder, no ductal dilation.
Renal transplant was consulted and recommended: blood cultures,
broad spectrum abdominal antibiotics (zosyn), continue
immunosuppression, and admit to transplant service.
Patient was given: Azathioprine 50 mg, metoprolol succinate 25
mg, prednisone 5 mg, flecainide 50 mg, Zosyn 2.25 g.
Decision was made to admit for fevers, infectious workup, and
LFT abnormalities.
Transfer vitals were 98.2 68 ___ 98% RA
Upon arrival to the floor, patient reports that she first felt
chills on the morning of ___. She realized that this was
similar to her previous episodes of cholangitis/bacteremia, so
she took her ciprofloxacin that she had had from ___ years prior.
She continued to be concerned and wasn't able to schedule an
appointment with her PCP, so she presented to the ___
___ at that time. She did report on episode of upper
abdominal pain relieved by simethicone 3 days prior to
admission. She also has had a mild cough with minimal sputum
production but no dyspnea. Currently, she is feeling much
better, denying any abdominal pain, fevers/chills, dysuria,
nausea/vomiting. She has been eating well.
ROS:
(+/- per HPI)
Past Medical History:
1. Polycystic kidney disease - daughter also has this.
2. ESRD ___ PCKD s/p living donor in ___
3. Diverticulosis with sigmoid colectomy prior to renal
transplant, then one episode of diverticulitis just after renal
transplant.
4. Paroxysmal atrial fibrillation - on rate control, states that
she converts to afib when dig stopped
5. Dyslipidemia
6. Hypertension
7. Migraines
8. h/o upper gastrointestinal bleed with gastritis
9. h/o recurrent Escherichia coli bacteremia prior to
cholecystectomy in ___.
10. Infected right index finger in ___. "stump" syndrome resulting in polymicrobial bacteremia, incl
E.coli, E. faecium, and B.frag
12. Recurrent skin cancers, which are closely followed by Dr.
___
13. Gout - affected her right great toe
14. Chronic venous stasis - complains of chronic left lower
extremity edema.
15. Renal osteodystrophy
Social History:
___
Family History:
Mother died of liver cancer.
___ daughters has PKD (not needing HD, not on transplant).
Pt's kidney donor was her sister.
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
VS: 97.9 PO 120 / 72 Lying 66 18 95 Ra
GENERAL: Pleasant, well-appearing, in no apparent distress.
Lying comfortably in bed. Patient witnessed walking around the
room, steady gait.
HEENT: normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, OP clear, MMM.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
HEART: RRR, normal S1/S2, no murmurs rubs or gallops.
LUNGS: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended.
Surgical scar in RUQ.
EXTREMITIES: Warm, well-perfused. Trace b/l edema. Legs tender
to palpation (baseline per patient)
SKIN: Multiple skin tags throughout. No obvious rashes or
concerning lesions.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
DISCHARGE PHYSICAL EXAM:
=============================
VS: 97.7F BP 109/63 HR 64 RR 18 95% on Ra
GENERAL: Pleasant. NAD. Lying comfortably in bed.
HEENT: NC/AT. No conjunctival pallor or scleral icterus. MMM.
NECK: Supple.
HEART: RRR with normal S1/S2, I/VI SEM murmur at LLSB. No rubs
or gallops.
LUNGS: Normal respiratory effort. CTAB without wheezes, rales or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended.
No suprapubic or CVA TTP.
EXTREMITIES: Warm, well-perfused. No ___ edema.
SKIN: Many skin tags throughout. No obvious rashes or concerning
lesions.
NEUROLOGIC: A&Ox3. Moves all extremities.
Pertinent Results:
ADMISSION LABS:
===============
___ 06:25AM BLOOD WBC-5.5 RBC-4.78# Hgb-15.2# Hct-47.0*#
MCV-98 MCH-31.8 MCHC-32.3 RDW-14.7 RDWSD-53.6* Plt ___
___ 06:25AM BLOOD Neuts-81.5* Lymphs-7.1* Monos-9.1 Eos-1.6
Baso-0.2 Im ___ AbsNeut-4.49 AbsLymp-0.39* AbsMono-0.50
AbsEos-0.09 AbsBaso-0.01
___ 06:25AM BLOOD Glucose-69* UreaN-21* Creat-1.2* Na-140
K-4.1 Cl-99 HCO3-23 AnGap-18*
___ 06:25AM BLOOD ALT-99* AST-89* AlkPhos-195* TotBili-2.1*
DirBili-1.2* IndBili-0.9
___ 06:25AM BLOOD Albumin-3.5
___ 06:46AM BLOOD Lactate-1.6
PERTINENT LABS/MICRO:
====================
___ 06:25AM BLOOD Lipase-45
___ 06:46AM BLOOD Lactate-1.6
___ 07:56AM URINE Color-Yellow Appear-Clear Sp ___
___ 07:56AM URINE Blood-TR* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-40* Bilirub-SM* Urobiln-4* pH-6.0 Leuks-NEG
___ 07:56AM URINE RBC-6* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
___ Urine culture: No growth
___ Blood culture: No growth
___ C.diff PCR: Negative
DISCHARGE LABS:
==============
___ 05:58AM BLOOD WBC-3.7* RBC-4.08 Hgb-13.2 Hct-40.2
MCV-99* MCH-32.4* MCHC-32.8 RDW-14.8 RDWSD-54.4* Plt ___
___ 05:58AM BLOOD Glucose-78 UreaN-22* Creat-1.0 Na-144
K-4.2 Cl-106 HCO3-25 AnGap-13
___ 05:58AM BLOOD ALT-35 AST-24 LD(LDH)-170 AlkPhos-142*
TotBili-0.6
___ 05:58AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.8
PERTINENT IMAGING:
================
___ RUQ US:
-The gallbladder is surgically absent.
-No intra or extrahepatic biliary duct dilatation.
___ CXR:
Small bilateral pleural effusions. No focal consolidation or
edema.
Brief Hospital Course:
Ms. ___ is an ___ woman with ESRD ___ polycystic
kidney disease who underwent a living-related kidney transplant
(___) and h/o cholecystectomy w/ resulting "sump syndrome" who
presented from ___ with 3 days of dark urine,
elevated serum bilirubin, and fever to 100.4 concerning for
cholangitis and bacteremia.
ACTIVE MEDICAL ISSUES ADDRESSED:
==============================
#Fever:
#Hyperbilirubinemia
Presented with fever, dark urine, and elevated LFTs/bilirubin to
3.3 on admission, concerning for infectious process, especially
given her history of sump syndrome and recurrent bacteremia. RUQ
US was overall unchanged without ductal dilation. Chest X-ray
and urinalysis were both unremarkable and there were no other
signs of infection. She was started on cefepime/flagyl overnight
and was subsequently narrowed to ciprofloxacin the next morning
after she remained afebrile, her labs improved, and she felt
much better. She was monitored one more day and then discharged
with a plan to continue ciprofloxacin for a 14 day course (end
date ___. She had ___ episodes of diarrhea the day prior to
discharge (similar to other times she had been on ciprofloxacin)
in the setting of a normal WBC. A c.diff PCR was sent but
pending at discharge. Her symptoms improved the following day
and she was discharged. C.diff PCR later returned negative.
STABLE PROBLEMS:
===============
#H/o ESRD ___ renal transplant: Patient has a history of renal
transplant in ___ due to polycystic kidney disease. She was
continued on both azathioprine 50 mg and prednisone 5 mg daily
without any changes made.
#Atrial fibrillation: Stable on flecainide and metoprolol
succinate. Previously not deemed an appropriate candidate for
anticoagulation given h/o upper GI bleeding from gastritis. She
was continued on her home regimen. Of note, ASA was held from
___ onwards given upcoming SCC removal of the face.
#dCHF: At home, she had been on Lasix 20 mg 3x/week as well as
standing potassium. Both were held while inpatient given the
concern for bacteremia. Restarted at discharge.
DISCHARGE RESULTS:
==================
QTC: 468 (___)
TRANSITIONAL ISSUES:
==================
[ ] Will need follow up with GI department here at ___ to
evaluate for any further procedures necessary to prevent
recurrence of sump syndrome. GI notified and scheduling an
appointment.
[ ] Cipro 500 mg bid x14 days. Needs an ECG as an outpatient to
monitor QTC given that she is also on flecainide. QTc 468 on
___.
# CODE: Full
# CONTACT: ___
___: Daughter
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Gabapentin 300 mg PO DAILY:PRN sciatica
3. ALPRAZolam 0.25 mg PO QHS:PRN insomnia
4. Metoprolol Succinate XL 25 mg PO BID
5. Flecainide Acetate 50 mg PO Q12H
6. Pravastatin 10 mg PO QNOON
7. AzaTHIOprine 50 mg PO DAILY
8. Furosemide 20 mg PO 3X/WEEK (___)
9. Omeprazole 20 mg PO DAILY
10. Potassium Chloride 10 mEq PO 3X/WEEK (___)
11. Aspirin 81 mg PO DAILY
12. ipratropium bromide 0.03 % nasal DAILY
13. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
14. nystatin 100,000 unit/gram topical DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 11 Days
take one dose evening of ___, then twice daily through ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice daily
Disp #*23 Tablet Refills:*0
2. ALPRAZolam 0.25 mg PO QHS:PRN insomnia
3. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
4. AzaTHIOprine 50 mg PO DAILY
5. Flecainide Acetate 50 mg PO Q12H
6. Furosemide 20 mg PO 3X/WEEK (___)
7. Gabapentin 300 mg PO DAILY:PRN sciatica
8. ipratropium bromide 0.03 % nasal DAILY
9. Metoprolol Succinate XL 25 mg PO BID
10. nystatin 100,000 unit/gram topical DAILY
11. Omeprazole 20 mg PO DAILY
12. Potassium Chloride 10 mEq PO 3X/WEEK (___)
13. Pravastatin 10 mg PO QNOON
14. PredniSONE 5 mg PO DAILY
15. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until your skin surgeon tells you to resume
it
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Sump syndrome with fever, transient bacteremia
Secondary: APKD s/p renal transplant ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You are admitted to ___ for a
fever and dark colored urine. Your lab results showed elevated
liver function tests. You were started on broad spectrum
antibiotics and subsequently, your fever resolved, your liver
function tests improved and you felt better. We then switched
you to oral antibiotics (ciprofloxacin), which you should take
for a total of two weeks (end date ___. Otherwise, your
home medications, including your immunosuppression medications
were not changed. You should follow-up at the ___ clinic as
outlined below and you should see the gastroenterologists as an
outpatient. Please contact your primary care doctor if you have
worsening diarrhea in the next couple of weeks.
It was a pleasure taking care of you. We wish you the best of
luck.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10773055-DS-24
| 10,773,055 | 25,959,222 |
DS
| 24 |
2184-11-04 00:00:00
|
2184-11-04 18:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vicodin / Vasotec / Morphine / Codeine
Attending: ___
Chief Complaint:
orange urine, fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is an ___ with cholecystectomy c/b recurrent
infections ___ "sump syndrome" and ESRD secondary to PCKD s/p
LRRT (___) on prednisone 5 mg and azathioprine who presents
with
fatigue and orange urine.
She reports that she was discharged from ___ on
___ after developing shewanella infection from eating
contaminated oysters. She had initially developed
nausea/vomiting/diarrhea but subsequently developed pneumonia
and
was discharged on 10 days of IV antibiotics (she cannot remember
the name). After finishing the antibiotics on ___ and having
her
PICC removed she began to feel increasingly fatigued and in the
past few days noticed that her urine was orange. This has
happened in the past when she had CBD infections related to her
"sump syndrome" (a condition occurring after gallbladder
surgeries in which the distal CBD acts as a "sump" or reservoir
for stones and other debris and can lead to infection or biliary
obstruction). She has had past admissions for this in which she
has developed bacteremia. Her most recent admission was ___
in
which she had a normal RUQ US but abnormal LFTs and was started
on on cefepime/flagyl narrowed to cipro for 14 day course with
plan to f/u with GI (this follow up did not occur).
She currently has had no abdominal pain, nausea, vomiting,
diarrhea, fevers, or chills.
In the ED, initial VS were: 0 97.4 94 127/80 16 98% RA
Labs showed:
WBC 7.4 Hgb 14.1 Plts 211
Na 137 K 5.0 (mod hemolyzed) Bicarb 24
BUN 30/ Cr 1.2
ALT: 55 AP: 358 Tbili: 2.6 Alb: 3.2
AST: 61
___: 12.8 PTT: 30.9 INR: 1.2
UA: 3 WBCs, small ___, neg nitrites, few bacteria, 2 epis
9 RBCs, small blood, 30 protein, moderate bili
Imaging showed:
Renal transplant US:
1. No hydronephrosis or perinephric fluid collection.
2. Elevated resistive indices approaching one noting lack of
reliable
diastolic flow in the arteries above background noise. Consider
short interval follow-up.
RUQ US: No intrahepatic or extrahepatic biliary dilation.
CXR: Subtle densities in the left lower lobe without lateral
correlate, which may reflect atelectasis or pneumonia in the
appropriate clinical context.
Patient received:
___ 22:43 IV CefTRIAXone (1 g ordered)
Transfer VS were: 0 98.0 90 112/55 16 98% RA
On arrival to the floor, patient reports feeling well. She has
no
abd pain, no pain over her graft, no confusion. No dysuria.
Otherwise symptoms as above.
Past Medical History:
1. Polycystic kidney disease - daughter also has this.
2. ESRD ___ PCKD s/p living donor in ___
3. Diverticulosis with sigmoid colectomy prior to renal
transplant, then one episode of diverticulitis just after renal
transplant.
4. Paroxysmal atrial fibrillation - on rate control, states that
she converts to afib when dig stopped
5. Dyslipidemia
6. Hypertension
7. Migraines
8. h/o upper gastrointestinal bleed with gastritis
9. h/o recurrent Escherichia coli bacteremia prior to
cholecystectomy in ___.
10. Infected right index finger in ___. "stump" syndrome resulting in polymicrobial bacteremia, incl
E.coli, E. faecium, and B.frag
12. Recurrent skin cancers, which are closely followed by Dr.
___
13. Gout - affected her right great toe
14. Chronic venous stasis - complains of chronic left lower
extremity edema.
15. Renal osteodystrophy
Social History:
___
Family History:
Mother died of liver cancer.
___ daughters has PKD (not needing HD, not on transplant).
Pt's kidney donor was her sister.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: 97.9 94/51 108 18 94 RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, conjunctivae noninjected, MMM
HEART: RRR, S1/S2, soft systolic murmur, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no tenderness over graft
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
DISCHARGE PHYSICAL EXAM:
=======================
VS: 97.5 PO 92 / 57 L Lying 93 18 94 Ra
GENERAL: Elderly woman laying in bed in NAD
HEENT: anicteric sclera, MMM
HEART: RRR, S1/S2, soft systolic murmur, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no tenderness over graft
EXTREMITIES: trace pitting edema in LEs. no cyanosis or clubbing
SKIN: Many seborrheic keratosis. Chronic venous stasis changes
on
legs.
NEURO: A&Ox3, moving all 4 extremities with purpose
Pertinent Results:
===============
Admission labs
===============
___ 08:05PM BLOOD WBC-7.4# RBC-4.54 Hgb-14.1 Hct-44.2
MCV-97 MCH-31.1 MCHC-31.9* RDW-15.9* RDWSD-57.1* Plt ___
___ 08:05PM BLOOD Neuts-79.4* Lymphs-9.8* Monos-9.4
Eos-0.7* Baso-0.3 Im ___ AbsNeut-5.85 AbsLymp-0.72*
AbsMono-0.69 AbsEos-0.05 AbsBaso-0.02
___ 08:12PM BLOOD ___ PTT-30.9 ___
___ 08:05PM BLOOD Glucose-101* UreaN-30* Creat-1.2* Na-137
K-5.0 Cl-95* HCO3-24 AnGap-18
___ 08:05PM BLOOD ALT-55* AST-61* AlkPhos-358* TotBili-2.6*
___ 08:43AM BLOOD Albumin-3.1* Calcium-8.9 Phos-3.2 Mg-1.9
===============
Discharge labs
===============
___ 05:39AM BLOOD WBC-5.1 RBC-3.98 Hgb-12.4 Hct-38.6 MCV-97
MCH-31.2 MCHC-32.1 RDW-16.0* RDWSD-56.8* Plt ___
___ 05:39AM BLOOD Plt ___
___ 05:39AM BLOOD ___ PTT-31.1 ___
___ 05:39AM BLOOD Glucose-99 UreaN-23* Creat-1.0 Na-139
K-4.4 Cl-101 HCO3-24 AnGap-14
___ 05:39AM BLOOD ALT-19 AST-24 LD(LDH)-148 AlkPhos-242*
TotBili-0.8
___ 05:39AM BLOOD Albumin-2.9* Calcium-8.6 Phos-3.0 Mg-1.9
===============
Studies
===============
CXR (___): IMPRESSION: Subtle densities in the left lower lobe
without lateral correlate, which may reflect atelectasis or
pneumonia in the appropriate clinical context
RUQUS (___): IMPRESSION: No intrahepatic or extrahepatic
biliary
dilation.
Renal US (___): IMPRESSION: 1. No hydronephrosis or perinephric
fluid collection. 2. Elevated resistive indices approaching one
noting lack of reliable diastolic flow in the arteries above
background noise. Consider short interval follow-up.
===============
Microbiology
===============
__________________________________________________________
___ 10:05 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 8:43 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 3:05 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:10 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:29 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 6:05 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
SUMMARY: Ms. ___ is an ___ with cholecystectomy complicated by
recurrent infections ___ "sump syndrome" and ESRD secondary to
polycystic kidney disease status-post living releated renal
transplant (___) on prednisone 5 mg and azathioprine who
presents with fatigue and orange urine, concerning for biliary
infection. She was admitted to the Transplant Nephrology team
and treated for the following problems:
Acute Cholangitis
-----------------
Patient with fatigue and orange urine, concerning for repeat
cholangitis secondary to "sump syndrome." LFTs were notably
elevated on admission. She also has a history of recent
shewanella bacteremia at ___ for which she was on
IV antibiotics for, which can colonize the biliary tract. She
has had past hospitalizations for similar infections, most
recently being treated with ciprofloxacin. RUQUS showed no
biliary dilation. To rule out other infections, urine culture
was done which was contaminated, but the patient had no urinary
tract symptoms. CXR showed densities that were felt to be
atelectasis, as the patient had no pulmonary symptoms. She was
treated with IV vancomycin, cefepime, and Flagyl. Blood cultures
were collected which were pending. Infectious Diseases was
consulted who recommended narrowing antibiotic coverage to
ciprofloxacin for 7 day course. They also recommended cipro
daily 500mg for suppression of further infections and she will
follow up with them as an outpatient.
Acute kidney injury
-------------------
Patient has history of renal disease secondary to polycystic
kidney disease status post living related renal transplant. Her
Cr was 1.2 on admission from baseline of 0.9, likely a pre-renal
etiology in the setting of infection. She was given IV fluids
and her creatinine improved. She was continued on her home
prednisone 5 mg and azaithroprine 50 mg daily. Cr 1.0 on
discharge.
Atrial fibrillation
-----------------
CHADS2-VASc Score 4. Patient has a history of pacemaker
placement. She was noted to be in atrial fibrillation on
admission. She was continued on her home metoprolol, flecainide,
and aspirin. She was previously determined not to be an
appropriate candidate for anticoagulation given her history of
upper GI bleeding from gastritis.
Chronic diastolic heart failure
Home diuretics held temporarily in setting of ___.
History of gastritis
-------------------
Continued home omeprazole.
Hyperlipidemia
---------------
Continued home pravastatin.
Vaginal yeast infection
Patient noted ongoing external vaginal pruritis since last round
of antibiotics. She declined exam, but was started on miconazole
vaginal cream for 7 days for suspected vaginal yeast infection.
===============
Transitional Issues
===============
[] complete BID Cipro course on ___ and start daily Cipro
suppression ___
[] Follow up with Infectious Disease for recurrent cholangitis
[] Continue to discuss possible anticoagulation for atrial
fibrillation with moderate-high risk CHADS2-VASc Score of 4
[] Confirm vaginal pruritis has resolved, and if not, would
perform pelvic exam with further workup of cause
[] please consider restarting diuretics within 1 week if
hypervolemic
[] Medication changes: furosemide held, started Cipro daily
suppression
Advanced Care Planning
#CODE: Full (presumed)
#CONTACT: ___: Daughter
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.25 mg PO QHS:PRN insomnia
2. AzaTHIOprine 50 mg PO DAILY
3. Flecainide Acetate 50 mg PO Q12H
4. Metoprolol Succinate XL 25 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Pravastatin 10 mg PO QNOON
7. PredniSONE 5 mg PO DAILY
8. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
9. Aspirin 81 mg PO DAILY
10. Furosemide 20 mg PO 3X/WEEK (___)
11. Gabapentin 300 mg PO DAILY:PRN sciatica
12. ipratropium bromide 0.03 % nasal DAILY
13. nystatin 100,000 unit/gram topical DAILY
14. Potassium Chloride 10 mEq PO 3X/WEEK (___)
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice daily
Disp #*5 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. ALPRAZolam 0.25 mg PO QHS:PRN insomnia
4. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
5. Aspirin 81 mg PO DAILY
6. AzaTHIOprine 50 mg PO DAILY
7. Flecainide Acetate 50 mg PO Q12H
8. Gabapentin 300 mg PO DAILY:PRN sciatica
9. ipratropium bromide 0.03 % nasal DAILY
10. Metoprolol Succinate XL 25 mg PO BID
11. nystatin 100,000 unit/gram topical DAILY
12. Omeprazole 20 mg PO DAILY
13. Potassium Chloride 10 mEq PO 3X/WEEK (___)
14. Pravastatin 10 mg PO QNOON
15. PredniSONE 5 mg PO DAILY
16. HELD- Furosemide 20 mg PO 3X/WEEK (___) This
medication was held. Do not restart Furosemide until your doctor
tells you to restart
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses
==================
Acute cholangitis
Secondary diagnoses
==================
History of end-stage renal disease secondary to polycystic
kidney disease status post renal transplant
Acute kidney injury
Atrial fibrillation
Chronic diastolic heart failure
History of gastritis
Hyperlipidemia
Vaginal yeast infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
Why was I a dmitted to the hospital?
============================
- You were admitted because you had had symptoms at home
(fatigue and orange urine) that were concerning for a repeat
infection in your liver, which you are prone to getting after
having your gallbladder removed.
What happened while I was in the hospital?
=================================
- You had tests done to see where your infection was coming
from. This showed you had no infection in your blood, urine, or
lungs. You did not have any blockages in your liver either.
- Your labs showed that your kidneys were somewhat dehydrated,
so you were given IV fluids and your kidney function improved.
- An ultrasound of your transplanted kidney showed no concerning
findings.
- You were treated with IV antibiotics, which were later
transitioned to oral ciprofloxacin, which you will take twice
per day until ___ and then you should take one pill
per day every day starting ___.
What should I do after leaving the hospital?
==================================
- Please weigh yourself every morning, before you eat or take
your medications. ___ your MD if your weight changes by more
than 3 pounds
- Please stick to a low salt, high protein diet and monitor your
fluid intake.
- Avoid eating raw seafood.
- Take your medications as prescribed.
- Keep your follow up appointments with your team of doctors.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10773055-DS-25
| 10,773,055 | 23,190,624 |
DS
| 25 |
2184-12-20 00:00:00
|
2184-12-22 11:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vicodin / Vasotec / Morphine / Codeine
Attending: ___.
Chief Complaint:
Pneumonia, transfer
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
___ y/o F with a history of ESRD ___ ADPKD s/p LRRT in ___ s/p
cholecystectomy c/b recurrent biliary infections in the setting
of sump syndrome, atrial fibrillation s/p PPM, chronic dCHF, who
presents as transfer for shortness of breath and elevated LFTs.
Patient reports feeling more short of breath with exertion over
last few days. Denies any fevers, chills, cough, chest pain.
Also
notes feeling sore in her RUQ as well. Patient seen by PCP ___
___, where she was found to be feeling well as well jaundiced
and found to have elevated bili to 7.1 ___s elevated ALP.
She was therefore referred to admission to ___, but initially
presented to ___ to be transferred ED to ED.
Patient has history of recurrent abdominal infections, and
recently was admitted here in ___ and discharged on
ciprofloxacin to complete 7 day course for cholangitis, and was
started on daily cipro as a suppressive abx. Patient reports
taking cipro daily although at times would miss ___ dose as it was
causing her to be nauseous.
Also of note, recently admitted to ___, for what
was thought to be pneumonia and CXR did not clear after abx. PCP
(Dr. ___ concerned for mets in the lungs from a primary
source of pancreas or liver and would like her worked up for
this.
Past Medical History:
1. Polycystic kidney disease - daughter also has this.
2. ESRD ___ PCKD s/p living donor in ___
3. Diverticulosis with sigmoid colectomy prior to renal
transplant, then one episode of diverticulitis just after renal
transplant.
4. Paroxysmal atrial fibrillation - on rate control, states that
she converts to afib when dig stopped
5. Dyslipidemia
6. Hypertension
7. Migraines
8. h/o upper gastrointestinal bleed with gastritis
9. h/o recurrent Escherichia coli bacteremia prior to
cholecystectomy in ___.
10. Infected right index finger in ___. "stump" syndrome resulting in polymicrobial bacteremia, incl
E.coli, E. faecium, and B.frag
12. Recurrent skin cancers, which are closely followed by Dr.
___
13. Gout - affected her right great toe
14. Chronic venous stasis - complains of chronic left lower
extremity edema.
15. Renal osteodystrophy
Social History:
___
Family History:
Mother died of liver cancer.
___ daughters has PKD (not needing HD, not on transplant).
Pt's kidney donor was her sister.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: 98.6 121/77 113 20 96% 2LNC
GENERAL: laying comfortably in no acute distress
HEENT: EOMI, PERRL, icteric sclera
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Crackles b/l at bases
ABDOMEN: soft, mildly tender in RUQ. +BS.
EXTREMITIES: trace pitting edema in ___. Chronic venous stasis
changes on ___ b/l
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: multiple sebhorrheic keratosis. jaundiced.
DISCHARGE PHYSICAL EXAM:
========================
VITALS: 97.4 125 / 76 130 16 95% Ra
24h I/Os: ___
GENERAL: No acute distress
HEENT: NCAT, EOMI, MMM.
NECK: supple, no LAD, prominent EJ
CV: irregularly irregular rhythm, S1S2 normal
RESP: diminished breath sounds at bases, breathing comfortably
while lying in bed
GI: soft, NDNT, graft nontender with well-healed incision.
EXTREMITIES: 2+ lower extremity edema with chronic venous
changes. Soft tissue swelling of the right forearm, distal to
medical information bracelet, improved.
SKIN: multiple crusted ___ grey lesions (skin cancers per
patient, ___ azathioprine) scattered across arms and legs
NEURO: AAOx3, strength and sensation grossly normal throughout
PSYCH: normal affect
Pertinent Results:
ADMISSION LABS
==============
___ 06:45PM BLOOD WBC-7.0 RBC-4.49 Hgb-14.1 Hct-42.9 MCV-96
MCH-31.4 MCHC-32.9 RDW-20.0* RDWSD-68.7* Plt ___
___ 06:45PM BLOOD Neuts-85.0* Lymphs-7.1* Monos-6.9
Eos-0.1* Baso-0.3 Im ___ AbsNeut-5.95 AbsLymp-0.50*
AbsMono-0.48 AbsEos-0.01* AbsBaso-0.02
___ 06:45PM BLOOD ___ PTT-29.8 ___
___ 11:30PM BLOOD Glucose-104* UreaN-19 Creat-1.0 Na-138
K-4.0 Cl-100 HCO3-27 AnGap-11
___ 11:30PM BLOOD ALT-23 AST-49* AlkPhos-342* TotBili-7.6*
DirBili-5.9* IndBili-1.7
___ 11:30PM BLOOD Lipase-26
___ 11:30PM BLOOD Albumin-2.8*
___ 11:35PM BLOOD Lactate-2.1*
INTERVAL LABS
==============
___ 09:40AM BLOOD ___
___ 04:32AM BLOOD Smooth-NEGATIVE
___ 04:32AM BLOOD ___
___ 09:40AM BLOOD CRP-165.8*
___ 02:19PM BLOOD SED RATE 39 H
___ HEPATITIS B AND C SEROLOGIES: NEGATIVE
___ 09:40AM BLOOD AMA-NEGATIVE
___ 09:40AM BLOOD IgG-1019
___ 06:04
IGG SUBCLASSES 1,2,3,4
Test Result Reference
Range/Units
IMMUNOGLOBULIN G SUBCLASS 1 364 L 382-929 mg/dL
IMMUNOGLOBULIN G SUBCLASS 2 ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 3 80 ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 4 58 ___ mg/dL
IMMUNOGLOBULIN G, SERUM ___ mg/dL
DISCHARGE LABS
=============
___ 09:15AM BLOOD WBC-7.3 RBC-4.56 Hgb-14.5 Hct-44.1 MCV-97
MCH-31.8 MCHC-32.9 RDW-20.1* RDWSD-70.2* Plt ___
___ 09:15AM BLOOD ___
___ 09:15AM BLOOD Glucose-114* UreaN-16 Creat-0.8 Na-134*
K-4.1 Cl-95* HCO3-23 AnGap-16
___ 09:15AM BLOOD ALT-22 AST-54* LD(LDH)-291* AlkPhos-361*
TotBili-9.9*
___ 09:15AM BLOOD Calcium-7.8* Phos-2.2* Mg-1.7
IMAGING:
=========
-RUQUS ___
1. No intrahepatic or extrahepatic biliary ductal dilatation to
suggest choledocholithiasis.
2. A short segment of echogenic material in the proximal left
portal vein is suspicious for thrombus. Appropriate color flow
is
demonstrated proximal and distal to this area. If clinically
warranted, further evaluation could performed with a contrast CT
study.
3. Small right pleural effusion and ascites.
-CT Abdomen with contrast ___:
1. Since ___, there is interval increase in intra and
extrahepatic biliary ductal dilatation however no obstructing
cause is identified as the CBD tapers gradually towards the
ampulla. Dilatation of the pancreatic duct is also stable in
comparison to multiple prior studies.
2. Known polycystic kidney disease with innumerable cysts seen
throughout the liver and both native kidneys.
3. Interval increase in size of a right cardiophrenic angle
lymph
node measuring 1.8 x 1.4 cm, of unclear etiology.
4. Moderate bilateral pleural effusions and small volume
perihepatic ascites
-ERCP ___:
- The scout film was normal.
- The major papilla was seen on the lateral rim of a large
___ diverticulum. Evidence of a previous
sphincterotomy was noted at the major papilla.
- Contrast injection revealed a dilated CBD and CHD up to 15 mm.
The biliary bifurcation and IHDs were difficult to visualize,
with poor contrast filling at first. No filling defects were
seen. Although a stricture could not be seen, these findings are
concerning for an obstruction secondary to a stricture. However,
this would not account for the dilated EH ducts, likely
secondary to the post-cholecystectomy status.
- The biliary tree was swept with a Extractor Pro Rx ___ mm
balloon starting at the bifurcation. A small quantity of pus and
a larger quantity of blood were removed.
- Given the difficulties in assessing the cause of biliary
obstruction, a cholangioscopy was performed using the Spyglass
system. The bifurcation was seen and appeared normal. The
cholangioscope was advanced further into the right IHD, however
visualization was poor and no stricture was seen. An abnormal
finding at that level was blood seen within the ducts.
- Brushings were performed at the level of the bifurcation and
right IHD and sent for cytology.
- A ___ x 5cm biliary double pigtail plastic stent was
successfully placed in the right IHD.
- Excellent bile and contrast drainage was seen endoscopically
and fluoroscopically.
-CT Chest ___:
1. Simple moderate to large right and small left pleural
effusions with associated atelectasis, unchanged from prior
abdominal CT. No loculated components.
2. Dilation of the main pulmonary trunk suggestive of underlying
pulmonary hypertension.
3. No focal lung lesion.
4. Multiple hepatic and renal cysts are better evaluated on
dedicated abdominal CT.
-ECHO ___ :
The left atrium is mildly dilated. The right atrium is markedly
dilated. A 1.2 x 0.4 cm mass/thrombus associated with a
catheter/pacing wire is seen in the right atrium attached to the
right atrial pacing wire. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with septal hypokinesis in the setting of
ventricular interdependence and loss of septal contribution to
contraction. The right ventricular cavity is moderately dilated
with moderate global free wall hypokinesis. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] There is abnormal
diastolic septal motion/position consistent with right
ventricular volume overload. 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. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Mild to moderate (___) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. [Due to acoustic
shadowing, the severity of tricuspid regurgitation may be
significantly UNDERestimated.] There is mild pulmonary artery
systolic hypertension. [In the setting of at least moderate to
severe tricuspid regurgitation, the estimated pulmonary artery
systolic pressure may be underestimated due to a very high right
atrial pressure.] No vegetation/mass is seen on the pulmonic
valve. There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
Brief Hospital Course:
PATIENT SUMMARY
================
___ yo woman with ESRD secondary to PCKD s/p LRRT (___),
cholecystectomy c/b recurrent infections ___ "sump syndrome",
atrial fibrillation s/p PPM, chronic HFpEF, who presents with
shortness of breath and elevated LFTs, found to have unexplained
hyperbilirubinemia and jaundice. She remained clinically stable
without evidence of infection, and underwent uncomplicated
diagnostic/therapeutic ERCP with placement of a stent. She
tolerated the procedure well, but bilirubin remained elevated.
The pathology results of brushings taken during ERCP were
negative for malignancy. Given that MRCP was not possible given
incompatible pacemaker lead, no further interventions were
taken. The patient's dyspnea was attributed to a subacute
exacerbation of her known diastolic heart failure, leading to
pulmonary effusions and lower extremity edema. The etiology was
likely diuretic holidays during multiple recent hospitalizations
for cholangitis. Her diuretics were restarted at low doses iso
soft blood pressures, and she was discharged to rehab for
physical therapy to help mobilize the fluid in her legs and
lungs.
ACTIVE ISSUES:
================
# Hyperbilirubinemia
Ms. ___ has had multiple recent hospitalizations for
cholangitis secondary to "sump syndrome," in the setting of her
abnormal GI anatomy from bowel surgeries following
cholecystectomy. She presented this admission with painless
jaundice concerning for
intrahepatic obstruction vs malignancy. Her infectious workup
was negative, including blood cultures, and initial broad
spectrum antibiotics were discontinued after 48 hours. She
underwent a CT Abd w/ contrast which showed increased intra and
extrahepatic biliary ductal dilatation. She underwent ERCP with
placement of a stent. Patient remained afebrile, but bilirubin
remained elevated. Hepatology was consulted, and a full
autoimmune workup was pursued, which was negative. Ultimately,
it was felt that her symptoms were due to secondary sclerosing
cholangitis in the setting of her polycystic kidney disease and
recurrent cholangitis. She was discharged on Ursodiol with
hepatology follow up.
# Dyspnea:
# Recent Pneumonia
# Bilateral Pleural effusions
# Lower extremity edema
# Chronic diastolic heart failure
Ms. ___ was seen the week prior to her admission by her
primary doctor for ___ slowly resolving pneumonia, which made him
concerned for possible malignancy. She had bilateral moderate
pleural effusions seen on initial CXR here, and later better
characterized on Chest CT, which did NOT show evidence of a
primary malignancy. She remained afebrile with no leukocytosis.
She was evaluated by Pulmonology, who recommended diuresis for
large simple effusions, likely ___ heart failure. ECHO results
as in discharge summary, with RV dilation and TR, with mild
interventricular impairment of left ventricle (EF 45%). Pro-BNP
was 12347. The patient's home diuretic (Lasix 20mg 3x/week) had
been held off and on over the past 2 months during
hospitalizations for cholangitis. She underwent gentle diuresis
with 40mh PO Lasix given her soft blood pressures, and was
discharged on Lasix 20mg PO daily. ___ has recommended acute
rehabilitation, which should help mobilize lower extremity edema
and pulmonary effusions. No pulmonary follow up indicated.
# H/o ESRD secondary to PCKD s/p LRRT (___)
# Acute kidney injury
Patient presented with increase in Cr to 1.2 (baseline 0.9),
possible pre-renal in setting of infection, now resolved to
baseline. Continued prednisone 5 mg and azathioprine 50 mg.
# Afib s/p PPM
# Pacemaker lead mass:
On flecainide and metoprolol, not on anticoagulation (not to be
an appropriate candidate for AC due to history of significant
upper GI bleeding following GI surgeries, as well as delicate
skin with multiple skin cancers that bleed easily). Continued
home metoprolol, home flecainide, aspirin 81 mg. Permanent
___, placed in ___ is MRI compatible, but
pacemaker LEADS are NOT MRI compatible. ECHO showed evidence of
pacemaker RA mass concerning for vegetation (unlikely given
afebrile, neg BCx) vs thrombus (not on AC except aspirin).
Patient has decided that TEE is not within her goals of care,
and has declined further evaluation of the pacemaker lead mass
after a thoughtful discussion of all options with MDs.
TRANSITIONAL ISSUES:
===================
[ ] Prophylactic Antibiotics:
Ciprofloxacin 500mg mg, to be taken if patient develops a fever
at home/rehab.
[ ] Biliary Stent:
Repeat ERCP with Dr. ___ in 3 weeks (___) for biliary
stent retrieval and re-evaluation.
[ ] Pacemaker thrombus/vegetation:
Incidental finding on ECHO. Per goals of care discussion with
patient, no intervention at this time, as she does not wish to
start anticoagulation.
[ ] Diuresis:
Lasix was increased to 20mg daily for volume overload. Will need
close monitoring, due to low baseline blood pressures.
Objective Data:
-Discharge Cr: 0.8
-Discharge Hg: 14.5
-Discharge ALP: 361
-Discharge Bili: 9.9
-Discharge Weight: 62.1 kg
New Meds:
-Ursodiol 300mg BID for hyperbilirubinemia
Changed Meds:
-Lasix 20mg MWF --> Lasix 20 mg Daily
-Ciprofloxacin 500mg daily --> Ciprofloxacin 500mg IF patient
becomes febrile > 100.4F, for empiric coverage of cholangitis.
#CODE: Full (presumed)
#CONTACT: ___
___: Daughter
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.25 mg PO QHS:PRN insomnia
2. Aspirin 81 mg PO DAILY
3. AzaTHIOprine 50 mg PO DAILY
4. Flecainide Acetate 50 mg PO Q12H
5. Omeprazole 20 mg PO DAILY
6. Pravastatin 10 mg PO QNOON
7. PredniSONE 5 mg PO DAILY
8. Potassium Chloride 10 mEq PO 3X/WEEK (___)
9. Ciprofloxacin HCl 500 mg PO Q24H
10. Furosemide 20 mg PO 3X/WEEK (___)
11. FLUoxetine 10 mg PO DAILY
12. Metoprolol Tartrate 25 mg PO BID
Discharge Medications:
1. Magnesium Oxide 400 mg PO DAILY
2. Ursodiol 300 mg PO BID
3. Furosemide 20 mg PO DAILY
4. Potassium Chloride 10 mEq PO DAILY
5. ALPRAZolam 0.25 mg PO QHS:PRN insomnia
6. Aspirin 81 mg PO DAILY
7. AzaTHIOprine 50 mg PO DAILY
8. Ciprofloxacin HCl 500 mg PO DAILY:PRN if you have a fever
9. Flecainide Acetate 50 mg PO Q12H
10. FLUoxetine 10 mg PO DAILY
11. Metoprolol Tartrate 25 mg PO BID
12. Omeprazole 20 mg PO DAILY
13. Pravastatin 10 mg PO QNOON
14. PredniSONE 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Secondary sclerosing cholangitis
Hyperbilirubinemia
SECONDARY DIAGNOSES
Subacute on chronic diastolic heart failure
Pleural effusions
Right atrial pacemaker lead mass
AD Polycystic kidney disease
ESRD s/p LDRT
Cholecystectomy s/p recurrent cholangitis in setting of "sump
syndrome"
Hypertension
Hyperlipidemia
Chronic venous stasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for a high bilirubin level and yellow skin
(jaundice).
What was done for me in the hospital?
- You were monitored for signs of infection
- You underwent an "ERCP", a procedure where they looked at the
inside of your intestinal tract for a reason for your high level
of bilirubin. They took tissue samples and placed a stent to
help drain the bilirubin.
- You had imaging of your chest with a CT scan to look at the
fluid in your lungs, which is why we believe you are having
shortness of breath. You were seen by the pulmonary doctors, who
recommended using medicines to help remove the water, instead of
a drainage procedure. You will also need to participate in
physical therapy at your rehab center to help regain your
strength and help clear the fluid from your lungs and legs.
- You had imaging of your heart, which showed a small mass on
one of your pacemaker leads. We weren't sure if it was a blood
clot or a small infection. We had a long discussion about what
to do about this, and ultimately decided to leave it alone. You
did not want to start anticoagulation, given your bleeding
history.
What should I do when I leave the hospital?
- Please take all medicines as prescribed. It is especially
important to keep taking your Ciprofloxacin antibiotic every day
to prevent infections.
- Please follow up in 3 weeks with Dr. ___ removal of
your biliary stent.
- Please make sure you are weighed every day, and if you gain
more than 3 pounds, make sure you let your primary care doctor
know.
- Please follow up with your cardiologist, who will continue to
follow up on the small "vegetation" on your pacemaker lead.
We wish you the best of luck in your health!
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
10773377-DS-15
| 10,773,377 | 29,498,066 |
DS
| 15 |
2161-01-18 00:00:00
|
2161-01-18 14:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness, aphasia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is an ___ right-handed woman with a PMHx of
basilar tip aneurysm c/b SAH now s/p coiling and VP shunt (in
___, ___ in ___, dementia, prior strokes (details
unknown but has bilateral BG strokes on CT), and recent
admission (___) to ___ for influenza and elevated
troponin (0.05, repeat normal, thought to be demand ischemia
from influenza) who presents as a transfer from ___ with an
episode of right-sided weakness (face/arm/leg), decreased verbal
output, and loud breathing through the nose for 5 minutes around
8:00am followed by a repeat episode around 8:10am with EMS for
___ minutes.
The patient is only able to say that she does not recall the
events that brought her in (she recalls she was told she was
unresponsive), and she feels like she is at baseline. She
recalls her recent admission for influenza. History is provided
by ___ ___, ___ House) who
witnessed the event and social worker ___ (___) who
knows the patient's baseline and history. As above, the patient
was recently admitted for influenza, and her last dose of
Tamiflu was yesterday. Her mental status/level of functioning
and indpendence has been declining over the last year, and she
has had waxing/waning confusion since the onset of flu symptom
wherein she seems dazed, does not understand instructions, or is
less cooperative with staff. This morning, she woke up around
7:00am and seemed more confused than usual. Then, around 8:00am,
while being assisted in the shower, her right arm and leg became
limp, and she had a right facial droop. She was leaning to the
right, and she would have fallen over if not caught by ___ and
assisted to the shower chair. She was not speaking at that time
and did not appear to respond to questioning. She had a "dead
stare" like "a trance" although eyes were open. She was
breathing loudly through her nose. There is note made in the ED
notes of left gaze preference vs deviation, but ___ denies
seeing this. No rhythmic shaking, tongue biting, incontinence,
or head version. This episode lasted 5 minutes and then
subsided; thereafter, the patient gave ___ word answers that
were sometimes inappropriate, and she was not following
commands. She did not recognize the ___, which is unusual, and
her speech was dysarthric. She then had epistaxis. When given a
tissue and told to wipe her nose, she wiped her perineum. After
EMS arrival, she had a repeat episode for ___ minutes. Per
___, she did not return to baseline mental status before she
left for ___. ___ per EMS 157.
NIHSS at ___ was 3 (2 points for not knowing age or month, 1 for
mild dysarthria). Also, the patient was only alert and oriented
x 1 (details not specified). Labs notable for K of 2.6 and WBC
12.4. CT angiogram of the head and neck demonstrated cerebral
aneurysm off of
the basilar tip which did not appear to be completely occluded
by her previous coiling, so she was transferred to ___ for
neurology and neurosurgery evaluations.
In addition to the episodes above, she has had 5 episodes of
staring blankly for one second in the last 6 months and ___
episodes of staring for ___ minutes with associated weakness of
the right, left, or both sides (although the staff is not sure
about which side it has previously presented on, could be same
side). These typically occur immediately after awakening or
within 30 minutes of doing so. Afterward, she does not recall
the episodes although she does typically know the staff and acts
appropriately. She has also had urinary incontinence at night
for the last few days, which is a change from baseline. ___
notes that, after the episodes lasting ___ minutes with
associated weakness, they always call EMS; she often returns to
baseline by EMS arrival and declines to go to the ED. ___
noted that she has also presented to ___ a few times for these
symptoms; however, I can only find a note about episodes of
decreased responsiveness lasting less than a minute in ___ with no mention of weakness--she was treated for UTI at
that time.
At baseline, she feeds herself and ambultes with a walker. She
requires assistance with dressing and bathing. She requires help
wtih all iADLs.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus, and hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, and parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation,
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
GERD
Aneurysmal SAH w/ VPS s/p coiling ___
Prior strokes (details unknown, has R>L BG lacunes on CT)
Dementia (?AD per OMR, patient's ALF not sure)
recent admission (___) to ___ for influenza and
elevated troponin (0.05, repeat normal, thought to be demand
ischemia from influenza)
Social History:
___
Family History:
Maternal cousins with diabetes. Denies history of strokes,
seizures, or aneurysms.
Physical Exam:
ON ADMISSION
=============
Vitals: T: 97.9F P: 70 R: 18 BP: 212/111-->161/60 SaO2: 97%RA
General: Awake, cooperative, NAD. Dry cough.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, no tongue bite, dried blood on nares
Neck: Supple. No nuchal rigidity.
Pulmonary: no work of breathing
Cardiac: warm and well-perfused
Abdomen: non-distended
Extremities: No C/C/E bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
Please see top of note for NIHSS.
-Mental Status: Alert, oriented to person, ___, month, and
year. Thought it was ___ instead of ___. Unable to relate
details of today's events but did recall recent ___ admission as
well as what she was told about today's events. Attentive, able
to name ___ backward without difficulty. Language is fluent with
intact repetition and comprehension. Normal prosody. There were
no paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. Pt was able to register 3 objects and recall ___ at 5
minutes ___ with categorical prompts, ___ with MC prompts).
There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: R 4-->2, L 3-->2 both brisk. Does not fully
bury sclera with abduction bilaterally and limited upgaze, no
nystagmus. VFF to confrontation. Fundoscopic exam revealed no
papilledema, exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: Mild L NLFF (subtle)
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk and tone. No pronation, no drift. No
orbiting with arm roll. No adventitious movements, such as
tremor, noted. No asterixis noted.
[___]
[C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, cold sensation, vibratory
proprioception throughout. No extinction to DSS.
-DTRs: reflexes brisk except absent absent L patella, absent
Achilles. Toes withdrawal bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Deferred given patient uses walker at baseline which was
not available.
===============
Discharge Exam:
Vitals: 24 HR Data
98.4 PO 153 / 77 74 20 93 Ra
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus
Neck: Supple. No nuchal rigidity.
Pulmonary: normal work of breathing
Cardiac: warm and well-perfused
Abdomen: non-distended
Extremities: No C/C/E bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to person, "hospital", month.
Says year is ___ something". Knows president is Trump.
Language
is fluent with intact repetition and comprehension. Normal
prosody. There were no paraphasic errors. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Pt was able to register 3 objects and recall ___ with
category clues. There was no evidence of apraxia or neglect.
-Cranial Nerves: R 4-->2, L 3-->2 both brisk. There is
persistent
upbeating nystagmus on upward gaze. Mild L NLFF. Palate elevates
symmetrically. Tongue protrudes in midline.
-Motor: Normal bulk and tone. No pronation, no drift. No
adventitious movements, such as tremor, noted. No asterixis
noted. Moves all extremities easily antigravity and able to
provide some resistance, although with giveway weakness.
-Sensory: deferred
-DTRs: deferred
-___: No intention tremor, no dysdiadochokinesia noted.
-Gait: Deferred
Pertinent Results:
#Labs
___ 04:25AM BLOOD %HbA1c-5.7 eAG-117
___ 04:25AM BLOOD Triglyc-91 HDL-42 CHOL/HD-4.1 LDLcalc-112
___ 04:25AM BLOOD TSH-1.1
___ 05:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 05:01PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 04:40AM BLOOD WBC-14.4* RBC-3.67* Hgb-9.6* Hct-29.7*
MCV-81* MCH-26.2 MCHC-32.3 RDW-17.5* RDWSD-49.7* Plt ___
___ 04:45AM BLOOD WBC-12.9* RBC-3.58* Hgb-9.3* Hct-29.3*
MCV-82 MCH-26.0 MCHC-31.7* RDW-18.1* RDWSD-51.0* Plt ___
___ 04:40AM BLOOD Plt ___
___ 04:45AM BLOOD Plt ___
___ 04:40AM BLOOD Glucose-101* UreaN-26* Creat-0.9 Na-141
K-3.4* Cl-100 HCO3-26 AnGap-15
___ 04:45AM BLOOD Glucose-101* UreaN-21* Creat-0.9 Na-141
K-3.8 Cl-101 HCO3-27 AnGap-13
___ 04:40AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.2
___ 04:45AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.2
# Chest x-ray:
Mild bibasilar opacities likely represent atelectasis.
# Non-Contrast CT of Head and CTA head/neck:
FINDINGS: Brain Parenchyma: There is no intracranial
hemorrhage. Old
bilateral thalamotomy infarcts. Patient has a aneurysm clip
involving the right middle cerebral artery region.
Ventricles and cisterns: There is a right-sided
ventriculoperitoneal
shunt tubing in the right ventricle. The ventricles are of
normal
size.
Calvarium: The bony calvarium appears intact.
Sinuses: Paranasal sinuses are clear
Scalp: No evidence of hematoma or laceration.
# CT Head w/ contrast:
1. Streak artifact from a basilar tip aneurysm coil limits
evaluation of the surrounding brain parenchyma. Otherwise no
definite evidence of mass lesion within the limitations of CT.
Please note contrast enhanced MRI of the brain is more sensitive
for the evaluation of intracranial mass.
2. 8 mm berry aneurysm of the basilar tip adjacent to patient's
aneurysm coil, as seen on recent outside CTA.
3. Right VP shunt catheter terminates in the frontal horn of the
right lateral ventricle. No evidence of hydrocephalus.
4. Hypodensity in the right frontal lobe along the right VP
shunt catheter, as well as in the left frontal lobe under a old
left burr hole, likely at the site of a prior VP shunt.
Brief Hospital Course:
Ms ___ is an ___ year old R handed woman with a history of
aneurysmal SAH (s/p coiling and VP shunt in ___, possible
dementia, prior strokes, and recent influenza, who presents
after two recent episodes of right face, arm, and leg weakness
and aphasia. She is amnestic to these episodes. She has
apparently had several (___) similar episodes over the last 6
months.
Neurologic exam on admission was generally non-focal, only
notable for hearing loss, mild disorientation and difficulty
with recall.
Differential diagnosis for her episodes primarily includes
seizure, TIA/infarct, or recrudescence of old deficits in the
setting of infection. In the hospital continuous EEG monitoring
showed only right hemispheric slowing. There were no
epileptiform discharges or seizures. No episodes of weakness or
aphasia were captured. We attempted to perform an MRI, but were
unable to obtain information from her family, other providers,
or the ___ about her VPS make/model or settings.
Therefore, a CT head with contrast was obtained. This showed no
acute lesions to account for her episodes.
Overall, given the description of the events, and particularly
her amnesia for them, it was felt that clinically they were
consistent with seizure. As she has had several events in the
past six months, an antiepileptic medication is warranted. She
was started on keppra 750mg q12h.
TRANSITIONAL ISSUES:
-CTA on admission showed that her basilar tip aneurysm was only
partially coiled. Neurosurgery was consulted and recommended
outpatient follow up. She will need to call the ___
clinic to schedule an appointment.
- Started keppra as above
- Hypertensive with systolics in the 180-190s, she was started
on amlodipine 5mg PO daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Vitamin D ___ UNIT PO 2X/WEEK (MO,WE)
3. Omeprazole 20 mg PO DAILY
4. Venlafaxine XR 150 mg PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 5 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
2. LevETIRAcetam 750 mg PO Q12H
RX *levetiracetam [___] 750 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*60 Tablet Refills:*3
3. Aspirin 81 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Venlafaxine XR 150 mg PO DAILY
6. Vitamin D ___ UNIT PO 2X/WEEK (___,WE)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Complex partial seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms ___,
It was a pleasure caring for you at ___
___. You were in the hospital because of several
episodes of weakness and difficulty speaking.
In the hospital, we monitored you on an EEG to look for
seizures. We did not see any evidence of seizure, but it is
still possible that the events you were having at home were
seizure.
We also did a CT scan of your head, which showed that the
aneurysm in your head is only partially coiled. You will need to
see the Neurosurgeons in clinic to monitor this and discuss the
next steps.
When you leave the hospital, we will start you on a medication
to prevent seizures called Keppra. It is very important to take
this every day, since missing doses of the medication can cause
seizure. We will also start you on a medicine for high blood
pressure, called Amlodipine.
Best wishes,
Your ___ team
Followup Instructions:
___
|
10773382-DS-19
| 10,773,382 | 28,332,028 |
DS
| 19 |
2160-11-14 00:00:00
|
2160-11-14 21:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Propulsid / IV Dye, Iodine Containing Contrast Media
Attending: ___.
Chief Complaint:
FEVER
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram
Endoscopic Retrograde Cholangiopancreatography (ERCP) with
common bile duct stent placement
CT-guided hepatic abscess drainage
Ultrasound-guided needle aspiration of hepatic subcapsular fluid
collection
History of Present Illness:
___ with PMH of HD-dependent ESRD & PVD, admitted for fever.
.
Pt was discharged from this hospital on ___ after she
presented with fever, confusion, and hyperglycemia. Course was
complicated by AFIB w/RVR requiring amiodarone, and sepsis of
unknown origin. The presumed source was thought to be her HD
catheter and there was intensive discussion of what it would
take to remove her dialysis catheter -- it seems this procedure
would be highly morbid & was therefore deferred. See last d/c
summary for details. She was discharged with a plan for 3 weeks
of vancomycin qHD. Antibiotic dwells were recommended but the
patient's HD center did not have this capacity.
.
Today she felt feverish and reported to an OSH, where her
temperature was measured at 101.8. Lowest BP recorded was 94/48.
CXR was checked and found to be negative. UA bland. She was
given a gram of vancomycin, a gram of tylenol and transfered to
___.
.
In the ED, initial VS 98.7 60 112/43 16 97%. BCX were drawn off
of the line. On arrival to the floor she felt fine. Pt and
husband denied ___, chills, rhinorrhea, congestion,
cough, SOB, abdominal pain, nausea, vomiting diarrea, hematuria
and dysuria. Only complaint was vague fatigue over the past few
weeks.
Past Medical History:
- CAD s/p CABG ___, PCI w/multiple stents
- CHF EF ___
- ESRD on HD since ___ ___ in ___
- dialysis catheter thrombosis x2; 3 failed fistulas
- HTN
- hyperlipidemia
- diabetes mellitus type 2
- diabetic gastroparesis
- bleeding gastric ulcers at ___ ___
- previous CVA with residual L>R lower extremity weakness,
baseline AOX2, has not walked in several months
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 98.3F, 121/53 BP , 84 HR , 18 R , O2-sat 95% 2L RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, JVD to the Jaw, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, Early Peaking systolic
murmur, midline sternotomy scar, Catheter site CDI
LUNGS - bibasilar crackles, good air movement, resp unlabored,
no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, dopplerable peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
.
DISCHARGE EXAM
VS T 98.3 BP 150/52 (120-150/40-50) HR 78 (60-70s) RR 18 O2
94-99/RA ___ 109
24h I/O 120+100/DNV+1 med soft formed BM
GEN elderly woman lying in bed in HD smiling, NAD
HEENT NCAT PERRLA, MMM, OP clear
HEART RRR, nl S1-S2, III/VI systolic murmur best@LUSB, midline
sternotomy scar, LIJ tunneled HD line site CDI, no erythema or
tenderness
LUNGS - bibasilar crackles b/l (unchanged)
ABDOMEN - obese, NABS, nontender nondistended
EXTR - WWP, no c/c/e
SKIN - L buttock stage II sacral decub ulcer dressing c/d/i
NEURO - speaks in brief sentences, AOX2; follows commands,
CN2-12 intact, L>R-sided weakness (L grip strength, ___ right
grip strength)
Pertinent Results:
ADMISSION LABS
___ 10:50PM BLOOD WBC-21.8*# RBC-3.07* Hgb-10.5* Hct-32.8*
MCV-107* MCH-34.2* MCHC-32.0 RDW-15.9* Plt ___
___ 10:50PM BLOOD Neuts-94.8* Lymphs-2.4* Monos-2.3 Eos-0.2
Baso-0.4
___ 10:50PM BLOOD ___ PTT-25.3 ___
___ 10:50PM BLOOD Glucose-81 UreaN-35* Creat-7.7*# Na-143
K-4.4 Cl-96 HCO3-36* AnGap-15
___ 07:40AM BLOOD Calcium-10.2 Phos-5.2*# Mg-2.2
___ 10:50PM BLOOD Vanco-44.7*
.
PERTINENT INTERVAL LABS
___ 09:25AM BLOOD ALT-30 AST-17 LD(LDH)-186 AlkPhos-114*
TotBili-0.5
___ 01:05PM BLOOD CK-MB-2 cTropnT-0.91*
___ 09:20PM BLOOD CK-MB-2 cTropnT-0.84*
___ 07:19AM BLOOD Calcium-11.3* Phos-6.3* Mg-2.5
.
___ TREND
___ 10:50PM BLOOD WBC-21.8*
___ 07:19AM BLOOD WBC-14.7*
___ 07:15AM BLOOD WBC-12.1*
___ 07:00AM BLOOD WBC-26.1*
___ 10:15AM BLOOD WBC-14.8*
___ 08:30AM BLOOD WBC-18.7*
___ 10:00PM BLOOD WBC-20.3*
___ 07:25AM BLOOD WBC-21.8*
___ 07:20AM BLOOD WBC-18.0*
.
MICROBIOLOGY
.
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
___ 7:15 am BLOOD CULTURE (Final ___: NO GROWTH.
(SUBSEQUENT BLOOD CULTURES DRAWN ___ NEGATIVE, ___ & ___
PENDING)
.
___ 4:30 pm LIVER ABSCESS **FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
Reported to and read back by ___. ___ @ 1845,
___.
FLUID CULTURE (Final ___:
ESCHERICHIA COLI. MODERATE GROWTH.
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
.
___ PERIHEPATIC BILE LEAK, FLUID ASPIRATE
___ 11:30 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
___ 6:55 pm URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
.
___ STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-NEGATIVE
___ STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-NEGATIVE
___ 09:11AM STOOL CLOSTRIDIUM DIFFICILE TOXIN, PCR
*POSITIVE*
.
IMAGING
.
___ CXR
IMPRESSION:
1. No focal consolidation concerning for pneumonia.
2. Mild mediastinal and pulmonary vascular engorgement.
3. Stable moderate cardiomegaly with possible calcification at
the cardiac apex suggesting aneurysm formation or prior
myocardial infarction.
4. Findings equivocal for mild pulmonary edema in the setting of
low lung
volumes. No pleural effusions.
.
___ HD LINE U/S
IMPRESSION: Limited study. No obvious fluid collection around
the line.
Clinical correlation and a different imaging test is warranted
if there is a concern. Ultrasound cannot delineate what was
requested on the study
.
___ CT ABDOMEN/PELVIS
IMPRESSION:
1. 2.5cm liver lesion increased in size from ultrasound of ___,
This is concerning for liver abscess
2. Large focus of air between the bladder and sigmoid colon is
likely
due to giant colonic divertoculum. No inflammation is noted in
this region
3. Extensive arterial calcifications including coronary artery
and mitral
valve calcifications.
4. Central venous catheter which terminates in the low right
atrium near the cavoatrial junction.
.
___ LIVER U/S
IMPRESSION: No evidence of large perihepatic fluid collection to
suggest
hematoma, though the exam is limited secondary to patient
tolerance. If
concern and pain persists, would recommend evaluation via CT.
.
___ R SHOULDER FILMS
There are calcifications along the course of the rotator cuff,
consistent with calcific tendinitis, which are unchanged
compared to ___. There is no fracture or dislocation
appreciated. The glenohumeral and acromioclavicular joints
appear preserved.
.
___ R HIP FILMS
There are mild degenerative changes of both hips. No fracture or
dislocation is appreciated. There is enthesopathy at the greater
and lesser trochanters. Vascular calcifications are noted.
Phleboliths are noted within the pelvis and there may be a
calcified diverticulum as well.
.
___ CXR
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. No evidence of free air. Moderate cardiomegaly with
signs of mild
pulmonary edema. The left internal jugular vein catheter is in
unchanged
position. No pneumothorax.
.
___ NON-CON CT ABD PELVIS
IMPRESSION:
1. Relative stable size of a right hepatic abscess. Trace fluid
adjacent to the liver related to the recent procedure.
2. Severe coronary artery disease. Severe aortic and mesenteric
vascular
atherosclerotic calcification.
3. Evidence for prior left ventricular infarction with a small
calcified
aneurysm. Stable.
.
___ C- CT HEAD
IMPRESSION: Several white matter hypodensities, of uncertain
etiology. If
there is continued concern for infection or infarction, MR head
may be
considered if no contraindications are present.
.
___ C- MRI HEAD
IMPRESSION:
1. No evidence of acute infarct, hemorrhage, or septic emboli.
2. Extensive bilateral subcortical and periventricular T2-FLAIR
hyperintensity which is nonspecific and likely representing
microangiopathic chronic ischemic changes.
.
___ RUQ U/S
IMPRESSION:
1. No drainable intrahepatic fluid collection.
2. New perihepatic fluid. Given the patients pain,
considerations include
biliary leak. Other possibilities are perihepatic hemorrhage or
serous fluid.
.
___ CXR
FINDINGS: In comparison with study of ___, there is little
change in the low lung volumes, enlargement of the cardiac
silhouette, and mild pulmonary vascular congestion. No evidence
of acute focal pneumonia. The apparent poor definition of the
right hemidiaphragm on the lateral view could be artifactual or
reflect some crowding of vessels.
.
___ C- CT ABD/PELVIS
1. Minimal increased size of a perihepatic fluid. Differential
would include a bile leak or small volume hematoma. If there is
concern for a bile leak, then a HIDA scan could be performed to
evaluate.
2. Slight decreased size of an abscess within the right lobe of
the liver.
3. Increased right pleural effusion with right basilar
atelectasis.
4. Severe atherosclerotic disease. Severe coronary artery
calcification.
Stable left ventricular calcified aneurysm.
.
___ RUQ US
FINDINGS: Visualization of the liver is somewhat limited due to
the limited sonographic window. A heterogeneous round region is
again seen in the right lobe of the liver consistent with the
abscess seen on prior imaging. This area is not significantly
increased in size measuring 4.1 x 3.9 x 3.9 cm (previously 3.3 x
4.1 cm). No additional fluid is seen within the liver. No
biliary dilatation is seen and the common duct measures .5 cm.
No free fluid is seen in the perihepatic space. There is a small
right pleural effusion.
IMPRESSION: No significant change in the region of the prior
abscess seen within the right lobe of the liver. No perihepatic
fluid is identified. 2) Small right pleural effusion.
.
___ CXR
FINDINGS: Patient's condition required examination in sitting
upright position using AP frontal and left lateral views. Direct
comparison is made with the next preceding single AP chest view
of ___. Direct comparison of the frontal views does
not demonstrate evidence of any new pulmonary parenchymal
infiltrate could be identified as pneumonia. The patient is
status post sternotomy and multiple surgical clips in the left
anterior mediastinal structures are indicative of previous
bypass surgery.
Mild-to-moderate cardiac enlargement is present. The on previous
examination identified perivascular haze and the pulmonary
circulation has normalized to some degree and there is no
evidence of new pulmonary pleural effusions as the lateral and
posterior pleural sinuses remain free. Position of previously
described double-lumen dialysis catheter is unchanged. No
pneumothorax can be identified. On the lateral view, posterior
pleural sinuses are grossly free and thus no evidence of
significant pleural effusion is present. Review of multiple
previous chest examinations as well as CT interventional
procedure and reference chest examinations from other
institutions beginning in ___ is performed. Already on
the first examination, one could identify a circular
calcification overlying the cardiac apical area on the frontal
view.
It is difficult to identify this on the portable chest
examinations,
considering the patient's bypass surgery, possibility of a
calcified left ventricular apical aneurysm comes to mind.
Unfortunately, we have no access to patient's initial diagnostic
procedure when the cardiac surgery was performed. The
interventional procedure of ___, demonstrated
extensive arterial calcifications in the mesenteric area as
well. Noteworthy is that the patient at that time was
successfully treated for a liver abscess.
IMPRESSION: Less marked pulmonary congestion since next
preceding portable chest examination. Again, no evidence of
acute pneumonic infiltrate can be suspected to be the culprit
for patient's rising white blood count. Can liver abscess
explain these findings?
.
OTHER STUDIES
.
ECHO (___)
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is mildly dilated. There is mild regional
left ventricular systolic dysfunction with severe hypo/akinesis
of the inferolateral wall. The remaining segments contract
normally (LVEF = 45 %). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve
leaflets and supporting structures are mildly thickened. A
vegetation cannot be excluded. An eccentric, jet of mild (1+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Left ventricular cavity
enlargement with regional systolic dysfunction c/w CAD. Mild
aortic valve stenosis. Mitral leaflet thickening with eccentric
jet of mild mitral regurgitation. Pulmonary artery hypertension.
If clinically indicated, a TEE is suggested to better define the
mitral valve morphology.
.
ECHO (___):
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. Right and left atrial appendage
ejection velocities are good (>20 cm/s). No atrial septal defect
is seen by 2D or color Doppler. No thrombi are seen on the right
atrial catheter. Overall left ventricular systolic function is
normal (LVEF>55%). [Intrinsic function may be depressed given
the severity of mitral regurgitation.] Right ventricular
systolic function is normal. There are complex (>4mm,
non-mobile) atheroma in the aortic arch and the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened with no aortic regurgitation. No masses or vegetations
are seen on the aortic valve. The mitral valve leaflets are
moderately thickened. Echodensities are identified on the left
atrial side of the valve and likely represent partial posterior
mitral leaflet flail/torn chordae, though a vegetation cannot be
fully excluded. An eccentric, anteriorly directed jet of severe
(4+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened with mild to moderate regurgitation. No
vegetation/mass is seen on the tricuspid valve. No
vegetation/mass is seen on the pulmonic valve.There is no
pericardial effusion.
IMPRESSION: Mitral leaflet thickening with focal echodensities
on the left atrial side most suggestive of partial leaflet
flail/torn chordae (though cannot exclude vegetation if
endocarditis is clinically suggested) and eccentric jet of
severe mitral regurgitation. Aortic valve sclerosis. Non-mobile
complex aortic atheroma.
.
PROCEDURE NOTES
.
CT-Guided Liver Abscess Drainage (___)
18-gauge ___ needle was steadily introduced under the CT
fluoroscopic
guidance into the right lobe abscess. Once confirmed within the
abscess,
total of 16 mL of purulent material was aspirated. The abscess
was septated and different types of fluid were aspirated from
different pockets of the abscess ranging from pus to brownish
cloudy fluid. The liver abscess decreased in size after
aspiration. The patient tolerated the procedure well and there
are no immediate complication. The fluid was sent for
microbiology, for culture and sensitivity, Gram-Stain as per
request.
IMPRESSION: Aspiration of 16 mL of purulent fluid from the right
liver
abscess. The abscess was septated, fluid was aspirated fom
different pockets as described above.
.
U/S Guided Bile Drainage (___):
IMPRESSION: 700 cc aspiration of bilious perihepatic fluid
suggesting biliary leak.
.
ERCP (___):
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla
Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique. Contrast
medium was injected resulting in complete opacification.
Biliary Tree Fluoroscopic interpretation: A mild diffuse
dilation was seen at the biliary tree with the CBD measuring
8-10 mm. No filling defects or extravasation of contrast was
noted.
Due to known liver abscess, a high pressure cholangiogram was
not performed.
Procedures: A 7cm by ___ Cotton ___ biliary stent was placed
successfully given high suspicion for bile leak.
Impression: Normal major papilla
A mild diffuse dilation was seen at the biliary tree with the
CBD measuring 8-10 mm. No filling defects or extravasation of
contrast was noted.
Due to known liver abscess, a high pressure cholangiogram was
not performed.
A biliary stent was placed successfully.
DISCHARGE LABS
___ 07:20AM BLOOD WBC-18.0* RBC-2.96* Hgb-10.0* Hct-33.5*
MCV-113* MCH-33.7* MCHC-29.8* RDW-14.9 Plt ___
___ 07:20AM BLOOD Glucose-117* UreaN-14 Creat-3.6*# Na-134
K-4.1 Cl-94* HCO3-31 AnGap-13
___ 07:20AM BLOOD Calcium-9.3 Phos-3.0 Mg-2.2
Studies pending on discharge:
None
Brief Hospital Course:
___ with hx coronary artery disease s/p CABG and PCI and
dialysis-dependent end stage renal disease admitted with fever
and encephalopathy and found to have sepsis from E. coli liver
abscess and concurrent E. coli septicemia. Hospital course was
notable for bile leak leading to peritonitis, drainage of liver
abscess, placement of biliary stent to relieve biliary
obstruction, and treatment of separate E. coli urinary tract
infection and C. difficile colitis. Patient was seen by
Infectious Disease, Renal, and Surgical services, and no changes
were made to her indwelling left IJ hemodialysis catheter.
#Sepsis due to E. coli liver abscess and E. coli septicemia/E.
coli urinary tract infection/C. difficile colitis:
Patient was admitted with fevers and blood cultures from outside
hospital and this hospital grew pansensitive E. coli. The
patient was initially treated empirically with
vancomycin/cefepime and then narrowed to cefazolin. HD line
locks were also initiated. All parties seriously considered HD
line pull due to possibilities of seeding or sourcing, but it
was deemed by multiple surgical services that the procedure may
be quite morbid, as the line is unable to be easily pulled and
likely attached to the lining of either a blood vessel or R
heart. Therefore, the HD line was left in place with all blood
cultures negative following initiation of antibiotics. Imaging
studies localized infectious source to a hepatic abscess which
was drained percutaneously (see below). Soon thereafter,
antibiotics were re-broadened to vancomycin/zosyn in the setting
worsening clinical status and a discovered perihepatic bile
leak. Antibiotics were changed yet again on ___ (from
vanc/zosyn -> ceftaz/flagyl) when WBC count rose despite overall
clinical improvement and the discovery of a separate E. coli
urinary tract infection and positive C. diff PCR in the setting
of leukocytosis and diarrhea. Patient did well with ceftaz and
flagyl and po vancomycin for C. diff and was discharged to
complete a 6 week course of antibiotics for E. coli septicemia
(given concurrent HD line) with po vancomycin to be continued
for 2 weeks after discontinuation of all other antibiotics. Pt
will follow-up with infectious disease in ___ clinic for this
and other ongoing infections (see below). Antibiotic end-dates
determined by infectious disease consult team (see discharge
medication list for length of treatment).
# HEPATIC ___ BILE LEAK
In search for infectious souce, hepatic abscess was identified
on CT scan. Drained by CT-guided interventional radiology
proceduralist on ___ - fluid grew out pan-sensitive E coli. A
few days thereafter she developed acute-onset R-sided pain.
After multiple imaging studies, moderate amount of ___
fluid identified. This fluid was sampled by US-guided needle
aspiration (700cc bile drained, thought likely a ___
drainage complication). The fluid was bilious; fluid
culture/gram stain showed no evidence of infection. To decrease
likelihood of ongoing biliary leak, pt underwent CBD stenting
for biliary obstruction on ___. Abdominal discomfort and
white count improved after these procedures (until development
of Cdiff colitis, see below). A repeat interval U/s s/p drainage
demonstrated only scant re-accumulation of fluid in the abscess
& ___ space. Pt treated with antibiotics as above;
discharged on ceftaz/flagyl with course determined by ID (see ___
med list). Note: the biliary stent needs to be removed
approximately one month after deployment (f/u ERCP procedure
scheduled).
#Leukocytosis:
WBC count trended down after treatment of E. coli UTI and C.
difficile. Pt was hemodynamically stable and afebrile for
several days prior to discharge.
.
# ESRD on HD
Pt is dialysis-dependent & oliguric. Access via LIJ HD line (see
above). The patient was continued on T, Th, Sa HD w/ cefazolin
line locks which were transitioned to ceftazidime locks when
systemic antibiotics were changed. Trended Ca x Phos product,
which had been elevated; this improved with increased doses
cinacalcel, sevelamer, and HD dialysate modifications. Renal
consult followed closely throughout the hospitalization and
arranged antibiotics/antibiotic line locks for post-dc HD
sessions at rehab.
.
#Chronic systolic heart failure complicated by severe mitral
regurgitation:
Antihypertensive medications (imdur, lasix & carvedilol) were
held in setting of relative hypotension in the setting of
infection were also held on discharge. Volume was managed with
HD. Patient did not have evidence of significant pulmonary edema
during hospitalization. Would consider initiation of afterload
reducing agents if BPs are consistently >140s/40s or if patient
has symptomatic mitral regurgitation/heart failure.
#Encephalopathy:
This was felt to be related to concurrent infections and
improved with treatment of infection. Patient did have waxing
and waning sensorium w/stereotypic tongue movement. Neuroimaging
showed no e/o acute stroke or bleed. Neurology consulted for
question of epilepsy (sharps seen on EEG) but felt tongue
movements not stereotypic or rhythmic, likely habitual/no need
for AEDs. Mental status returned to baseline with
discontinuation of all sedating medications and ongoing
treatment for underlying infectious processes and abdominal
pain. Therefore, AMS most likely was metabolic encephalopathy in
the setting of severe illness & pain superimposed upon
background of prior CVA. Husband felt pt at baseline for 5 days
prior to discharge.
.
# C DIFFICILE COLITIS
BMs alternated between constipation and loose stools. Cdiff
toxin assay negative twice, then Cdiff PCR positive on ___.
Started PO vancomycin which should continue past discontinuation
of all other antibiotics (see discharge med list for end-date).
.
# DECUBITUS ULCERS
Pt found to have stage II sacral decubitus ulcers and L heel
ulcer on admission. Followed by wound care consult. Nurses
followed recommendations daily, including dressing changes,
limiting sit-time and moving the patient in bed regularly. Wound
care nursing evaluation and recommendations (see OMR) were
provided to rehab facility with discharge paperwork.
.
========================
CHRONIC ISSUES
========================
#Type 2 Diabetes mellitus:
Titrated home lantus to fasting AM fingersticks (decreased to
35U qHS)BS well-controlled. No sliding scale required for most
of hospitalization.
. .
# CHRONIC MACROCYTIC ANEMIA
Hct 33.7 w/MCV 115, at baseline. B12 and folate not deficient.
.
# CAD
Hx CABG, stents and CVA. ASA 81 started during this admission.
.
# HYPERLIPIDEMIA
Continued pravastatin 40 mg qHS.
.
# DEPRESSION
Continued fluoxetine 40 mg daily.
.
# ATRIAL FIBRILLATION
HR well-controlled, 80s on telemetry, no alarms for RVR.
Continued digoxin 125 mcg QOD, diltiazem HCl 120 mg ER QD.
.
# GERD
Continued Nexium 40 mg BID.
.
========================
TRANSITIONAL ISSUES
========================
1. ___ clinic follow-up for multiple infections as above
(scheduled), will adjust end-dates for antibiotics if necessary.
3. Ensure pt receives ceftaz + antibiotic line locks at HD.
4. If blood pressure consistently >140/40, consider restarting
afterload reducer (previously on imdur) and/or lasix and
carvedilol
5. Physical therapy
6. Follow-up pending studies/cultures
7. Repeat ERCP for CBD stent removal/exchange (scheduled at end
of ___
Medications on Admission:
Lantus 50u Daily
Carbamazepine 100 mg ER q12 hr
zolpidem 10 mg qHS insomnia
pravastatin 40 mg qHS
Sevelemer 800 mg TID with meals.
quinine sulfate 324 mg 2 Capsule PO pre-dialysis.
isosorbide mononitrate 60 mg ER daily
Lasix 80 AM 40 ___ Tablet BID
Nephrocaps 1 mg Dialy
Lorazepam 1 mg Daily
Carvedilol CR 20 mg Cap, ER 24 hr PO
ketoconazole 2 % Cream Topical
Cinacalcet 30 mg qHS
Metoclopramide 5 mg TID
fluoxetine 40 mg daily
Epogen Injection
digoxin 125 mcg QOD
diltiazem HCl 120 mg Capsule, Ext Release
vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous 3X
WEEKLY WITH HD: LAST DOSE ___.
Nexium 40 mg Capsule twice a day.
COMPAZINE 10 MG po Q6h prn NAUSEA/VOMITING
Discharge Medications:
1. Lantus 100 unit/mL Solution Sig: ___ (35) units
Subcutaneous at bedtime.
2. carbamazepine 100 mg Tablet Extended Release 12 hr Sig: One
(1) Tablet Extended Release 12 hr PO every twelve (12) hours.
3. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. sevelamer carbonate 800 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*360 Tablet(s)* Refills:*2*
5. quinine sulfate 324 mg Capsule Sig: Two (2) Capsule PO QHD
(each hemodialysis).
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
Disp:*90 Tablet(s)* Refills:*2*
8. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
9. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
10. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea/vomiting.
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
14. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
15. ceftazidime 1 gram Recon Soln Sig: One (1) recon solution
bag Intravenous after HD for 37 days: 8 week total course
starting ___ to be completed ___.
Disp:*QS bags* Refills:*0*
16. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 42 days: to be completed ___.
Disp:*168 Capsule(s)* Refills:*0*
17. Outpatient Lab Work
Please obtain CBC, BMP and LFTs *weekly* and fax results to
___ Attn Dr. ___ FAX ___.
18. antibiotic line lock
CefTAZidime-Heparin Lock 1.25 mg LOCK qHD (after dialysis
complete)
[CefTAZidime 0.5mg/mL + Heparin 100 Units/mL]
Last date: ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
E coli septicemia from biliary source
Hepatic abscess
Biliary leak
C difficile colitis
SECONDARY DIAGNOSES
Ischemic chronic systolic heart failure
Insulin-dependent Type II Diabetes Mellitus
End-stage renal disease, hemodialysis-dependent
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 ___,
___ was a pleasure taking care of you.
You were admitted to the ___
for a fever. You had a prolonged hospitalization because we
discovered multiple infections. You were treated for a
bloodstream infection, a liver abscess (infected fluid
collection) and infectious diarrhea. The infected fluid
collection in your liver was drained twice. You were also found
to have a bowel infection called Clostridium difficile infection
which will also be treated with antibiotics.
We made the following changes to your medications:
DISCONTINUED lasix
DISCONTINUED imdur
DISCONTINUED reglan
DISCONTINUED lorazepam (ativan)
DISCONTINUED zolpidem (ambien)
DISCONTINUED carvedilol
DISCONTINUED ketoconazole cream
CHANGED DOSE LANTUS INSULIN (to 35 units in the morning)
CHANGED DOSE sevelamer (INCREASED to 3200 MG three times a day
with meals)
CHANGED DOSE cinacalcet (INCREASED to 90 mg at bedtime)
STARTED ANTIBIOTICS:
1. CEFTAZIDIME, 1 G INFUSION AFTER EACH DIALYSIS SESSION FOR 37
DAYS, LAST DAY ___
2. FLAGYL (METRONIDAZOLE) ONE 500 MG TABLET EVERY 8 HOURS FOR 7
MORE DAYS
3. VANCOMYCIN, ONE 125 MG TABLET EVERY 6 HOURS FOR 42 DAYS, LAST
DAY ___.
Please review your medications with the rehab MD and with your
primary care doctor at your next appointment.
Followup Instructions:
___
|
10773964-DS-22
| 10,773,964 | 23,648,416 |
DS
| 22 |
2191-01-01 00:00:00
|
2191-01-05 22:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___ IV
Attending: ___.
Chief Complaint:
s/p unwitnessed fall
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ year old ___ speaking woman with
a history of diastolic heart failure with multiple prior CHF
exacerbations, HTN, CAD, and blindness who presents after an
unwitnessed fall. Per the patient and her son, she had last
been seen by her son prior to going bed. Overnight, she awoke
to use her commode and upon returning, experienced a fall where
she did not strike her head and did not lose consciousness, and
did not feel chest pain, shortness of breath, or palpitations.
However, she did not have the strength to get up afterwards so
was found this morning on the floor of her apartment in assisted
living by her home health aid.
Of note, the patient recently presented to ___ ED last week
after another unwitnessed fall where she landed on her L
shoulder. Head CT, L shoulder films, and R knee films conducted
at the time did not show any evidence of acute fracture so she
was discharged home with some residual left shoulder and right
knee bruising. Since that time, her son has noticed the patient
has had increased unsteadiness of her gait. Specifically, she
has been favoring her left legs as if afraid to bear weight on
her right knee.
At baseline, the patient does not have exertional dypsnea or
anginal chest pain. Although she has bilateral lower extremity
edema L>R, she and her son do not think that it is increased
from baseline. Notably, the patient has had a gradual decreased
dose of her Lasix from 20mg BID to 10mg daily. She is otherwise
negative for missing medication doses, changes in her diet. She
currently has a headache, but otherwise denies fever, chills,
night sweats, recent weight loss or gain, nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
1. CHF (LVEF 60% and 3+ mitral regurg. on ___
2. CAD (40% LAD in ___ and nml MIBI in ___ chronic angina
3. Hypertension.
4. Glaucoma.
5. History of complete heart block.
6. Low back pain with severe spinal stenosis.
7. Chronic cough
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97.8 BP: 125/50 P: 64 R: 16 O2: 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Crackles in the bilateral lower lung fields. No focal
consolidation, dullness to percussion, ronchi
CV: Regular rate and rhythm, normal S1 + S2, II/VII systolic
murmur in aortic region, no rubs or gallops
Abdomen: soft, ___, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&O. CN ___ intact. No gross motor or sensory
deficits.
DISCHARGE PHYSICAL EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Trace crackles in lower lungs. No focal consolidation,
dullness to percussion, ronchi, or wheezing.
CV: Regular rate and rhythm, normal S1 + S2, II/VII systolic
murmur in aortic region, no rubs or gallops
Abdomen: soft, ___, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&O. CN ___ intact. No gross motor or sensory
deficits.
Pertinent Results:
ADMISSION LABS:
___ 12:44PM BLOOD ___
___ Plt ___
___ 12:44PM BLOOD ___
___
___ 12:44PM BLOOD ___ ___
___ 12:44PM BLOOD ___
___
___ 12:44PM BLOOD cTropnT-<0.01 ___
___ 12:44PM BLOOD ___
PERTINENT TABS:
___ 06:35AM BLOOD ___
___ Plt ___
___ 06:35AM BLOOD ___
___
___ 06:35AM BLOOD ___
___ 06:35AM BLOOD ___
___ 03:35PM BLOOD ___
___
___ 03:35PM BLOOD ___
___ 07:00AM BLOOD ___
___ Plt ___
___ 07:00AM BLOOD ___
___
___ 07:00AM BLOOD ___
DISCHARGE LABS:
MICROBIOLOGY:
None
STUDIES:
___ EKG: Sinus bradycardia. Left ___ block.
Compared to the previous tracing of ___ sinus bradycardia
is now present.
___ CXR: Mild pulmonary edema.
___ Bilateral: There is severe osseous demineralization but
no evidence of fracture or dislocation. Moderate degenerative
changes of both hips are noted. There is no evidence of a pelvic
fracture or diastasis of the symphysis pubis. Degenerative
changes of the SI joints and lumbar spine are observed in these
limited views. There are extensive vascular calcifications and
the bowel gas pattern is unremarkable.
___ CT Head w/o contrast: There is severe osseous
demineralization but no evidence of fracture or dislocation.
Moderate degenerative changes of both hips are noted. There is
no evidence of a pelvic fracture or diastasis of the symphysis
pubis. Degenerative changes of the SI joints and lumbar spine
are observed in these limited views. There are extensive
vascular calcifications and the bowel gas pattern is
unremarkable.
___ CT ___: Severe degenerative changes as described
above, placing the patient at increased risk for cord injury (MR
may be considered if clinical concern for cord injury), but no
evidence of fracture; stable grade I anterolisthesis of C2 and
C7 as described above.
___ ECHO: Mild LVH with normal global and regional
biventricular systolic function. Mild aortic stenosis. Moderate
mitral regurgitation. Mild pulmonary hypertension. Compared with
the report of the prior study (images unavailable for review) of
___, mild aortic stenosis has developed. The other
findings appear similar.
Brief Hospital Course:
___ year old ___ speaking woman with a history of diastolic
heart failure with multiple prior CHF exacerbations, HTN, CAD,
and blindness who presents after an unwitnessed fall found to
have pulmonary edema on CXR.
# s/p Fall: The patient presented after being found after an
unwitnessed fall in her apartment. Of note, she recently
presented to ___ one week prior to admission after another
unwitnessed fall where Head CT and ___ of her left shoulder
and right knee did not show any acute process or fracture. Per
her report (with translator), she did not lose consciousness an
the fall was not precipitated by chest pain, heart palpitations,
or positional change. However, she reports chronic right knee
pain and the son noted that she had unsteady gait in the few
days prior to admission. Also, she was noted to be on an
aggressive antihypertensive regimen on admission which may have
caused low blood pressure or orthostasis which precipitated her
fall. Head CT, CT ___, and bilateral hip ___ conducted on
admission did not show acute process. During this hospital
admission, the patient had two sets of cardiac enzymes that were
negative. She was also kept on telemetry which revealed
couplets and premature ventricular contractions. Physical
therapy was consulted on two days to evaluate the patient's
unsteady gait and recommended that patient would benefit from
rehab. However, on the evening prior to anticipated discharge,
the patient's son wanted to take pt home despite these
recommendations, and did not want to wait until the following
morning to discuss alternative ways to make a discharge home
more safe. It was determined that the patient did not have
capacity to make this decision. Therefore, the risks of early
discharge were discussed with the son. He acknowledged these
risks and the patient was discharged AMA.
# Acute on chronic diastolic heart failure: The patient has a
history of Diastolic CHF with most recent ECHO in ___ showing
normal EF and 3+ MR. ___ was noted to be slightly volume
overloaded with small bilateral pleural effusions noted on CXR
and trace lower extremity edema. This was likely the setting of
decreasing her lasix dose of the last several weeks. A repeat
transthoracic ECHO was conducted on ___ that showed mild
aortic stenosis with 3+ mitral regurgitation. The patient's
home dose of Lasix 10mg PO daily was increased to 20mg PO daily
with improvement in her lung exam. Her electrolytes remained
within normal limits and her kidney function was within her
baseline throughout this admission. Because of early discharge
we could not ensure a consistent stable volume status on her
higher lasix dosage.
# Hyponatremia: The patient was found to be hyponatremic with a
sodium level of 130 on admission (her sodium level was 132 on
her prior ED visit a week prior to this admission). In the
setting of her mild pulmonary edema, the hyponatremia was
thought to be in the setting of volume overload. When she was
mildly diuresed, her sodium level did not improve, so it was
thought that is was possible that her hyponatremia could be due
to intravascular volume depletion. Na was 130 at time of
discharge. This should be rechecked at follow up.
# Hypertension: The patient's blood pressures were in the
systolics of SBP ___ on the night after admission. Given
the concern that hypotension could be contributing to her fall
as well as given the patient's ___ (coronary artery
disease and diastolic heart failure), the patient's home regimen
was changed by STOPPING her amlodipine and hydralizine, and
CHANGING lisinopril to 20 mg daily. Her Imdur and Metoprolol
were maintained at the same dose. However, we could not
effectively communicate this new regimen to her son at
discharge.
# Coronary artery disease: She was continued on ASA, ___,
imdur. She was without active anginal symptoms throughout this
hospitalization.
# Arthritis/ low back pain: The patient was maintained on her
home Tylenol without symptoms increased from baseline.
TRANSITIONAL ISSUES:
- electrolytes should be checked at follow up
- blood pressure will need to be closely monitored given recent
medication adjustments during admission
PENDING STUDIES:
- None
___:
- patient should schedule an appointment with her PCP
MEDICATIONS
- CHANGED Furosemide 10mg PO daily to 20mg PO daily
- DISCONTINUED Hydralazine
- DISCONTINUED Amlodipine
CODE STATUS: DNR/DNI during this admission
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Amlodipine 5 mg PO QAM
2. Amlodipine 2.5 mg PO QPM
3. azelastine *NF* 137 mcg NU BID:PRN allergies
4. Furosemide 10 mg PO DAILY
5. HydrALAzine 25 mg PO BID
6. Isosorbide Mononitrate (Extended Release) 60 mg PO BID
7. Lisinopril 10 mg PO BID
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. Acetaminophen 325 mg PO BID headahce
11. Aspirin 81 mg PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Metamucil *NF* (psyllium;<br>psyllium husk;<br>psyllium husk
(with sugar);<br>psyllium seed (sugar)) 0.52 gram Oral TID:PRN
constipation
14. Senna 1 TAB PO BID:PRN constipation
15. Simethicone 80 mg PO BID:PRN constipation
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Nitroglycerin SL 0.4 mg SL PRN chest pain
3. Simethicone 80 mg PO BID:PRN constipation
4. Metamucil *NF* (psyllium;<br>psyllium husk;<br>psyllium husk
(with sugar);<br>psyllium seed (sugar)) 0.52 gram Oral TID:PRN
constipation
5. azelastine *NF* 137 mcg NU BID:PRN allergies
6. Aspirin 81 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Isosorbide Mononitrate (Extended Release) 60 mg PO BID
9. Senna 1 TAB PO BID:PRN constipation
10. Acetaminophen 325 mg PO BID headahce
11. Lisinopril 10 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Mechanical fall
Secondary Diagnoses: Hypertension, coronary artery disease,
arthritis
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. ___,
It was a pleasure to take care of you during this
hospitalization. You were admitted to ___
___ after you had an unwitnessed fall. Scans of your
head and hips did not show any signs of acute fracture from your
fall. A Chest ___, however, did show a little fluid in your
lungs from your congestive heart failure. For your fall, you
were kept on a continuous heart monitor that did not find any
abnormal heart rhythm, and lab tests for a injury to your heart
were also negative. For the fluid in your lungs, you were given
Lasix at a slightly increased dose that you were taking at home
(Lasix 20mg PO). We wanted to send you to rehab on ___.
On the evening of discharge, your son was ___ about taking
you home despite our recommendations to keep you in the hospital
till the morning. We spoke with your son trying to convince him
to keep you in the hospital for one more night so we could
possibly send you home with services on ___. We offered to
place you in a private room where your son would be able to stay
with you overnight, but your son refused. Since we determined
that you would not be able to make these decisions by yourself,
your son has made these decisions for you. Your son understood
the risks/benefits of taking you home and still wished to bring
you home. Your son understood that she may get sicker at home
because your sodium level is slightly low and we have been
changing your blood pressure medications.
PLEASE STOP HYDRALAZINE, LASIX, and AMLODIPINE until you can see
Dr. ___. It is important for your son to call Dr. ___
tomorrow on ___. We will also send Dr. ___.
Please CALL ___. ___ TOMORROW ___ (___) for an urgent follow up visit to see if he can assist
you in setting up home services.
Followup Instructions:
___
|
10774120-DS-12
| 10,774,120 | 20,454,614 |
DS
| 12 |
2131-03-05 00:00:00
|
2131-03-09 15:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
naproxen / ___ pig
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with poorly controlled asthma, bronchiectasis, history
of positive PPD and tobacco use presents with shortness of
breath.
The patient has had a complicated course over the last couple of
years with exacerbations requiring frequent steroid tapers,
antibiotics and hospital admissions. She has at least two ICU
stays with one intubation and one bipap. Over the last few
weeks, she reports worsening shortness of breath again. She was
prescribed a steroid taper that started around ___. She
reports improving on the 40mg dose, but by the time she tapered
to 10mg, the symptoms has started again. She increased herself
back to 30mg prednisone for 2 days on ___ and ___ but then
stopped completely because she was out of medication and did not
have any refills. So she has been without steroids since ___.
She reports increased dyspnea, especially on exertion. SHe is
unable to walk across the room to get to her bathroom. She has
chest tightness and wheezing. She has been using her home
nebulizers and inhalers with increased frequency, with nebs up
to four times a day (previously only once a day), which provide
some relief. She denies any fevers or chills.
Patient was seen in outpatient ___ clinic and was
referred to ___ for respiratory distress. At the outside
office, her FEV1 fell to 30% from 90% at baseline. Her work-up
through the outpatient clinic has included negative ANCA, but
there was still a concern that patient has ANCA-negative
___. She received 125mg IV solumedrol, 2 duonebs and
750mg levaquin. She had a flu swab taken and labs including IgE,
ESR, CRP, ANCA were all drawn in clinic, as well as a sputum
culture.
In the ED intial vitals were: 98.0 95 130/88 30 95% RA
- Labs were significant for WBC 11
- Patient was given duonebs, levoflox and methylpred
- CT scan showed some improvement from previous scans of tree in
___ pattern
Vitals prior to transfer were: 98 77 126/87 18 98% RA
Past Medical History:
MEDICAL & SURGICAL HISTORY:
- Asthma (diagnosed in ___
- Brochiectasis
- Pulmonary nodules (detected in ___, follow-up CT in ___
showed no progression)
- positive PPD
Social History:
___
Family History:
FAMILY HISTORY: Grandmother had asthma. Father had ___,
HTN, and died of Stomach cancer. Mother had HTN and uterine
cancer. Daughter has ___.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
=============================
Vitals- 98.6 1074/81 93 20 96% RA
General- NAD, but becomes dyspneic with speech
HEENT- PERRL, no scleral icterus, no OP erythema or exudates
Neck- supple, no cervical LAD
Lungs- poor air movement bilaterally and diffuse wheezes
CV- RRR, no m/r/g
Abdomen- soft, NT, ND
Ext- no peripheral edema
Neuro- nonfocal
PHYSICAL EXAM ON DISCHARGE:
============================
Vitals: 98.3 ___ 98%
General: Alert, oriented, no acute distress, no conversational
dyspnea, can speak in full sentences but coughs with deep
breathing on lung exam
HEENT: Sclera anicteric, MMM, a few white lesions in the hard
palate
Neck: supple, JVP not elevated, no LAD
Lungs: mild wheezes with good air entry
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes
Neuro: non-focal
Pertinent Results:
LABS ON ADMISSION:
==================
___ 09:35PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:35PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR
___ 09:35PM URINE RBC-7* WBC-10* BACTERIA-FEW YEAST-NONE
EPI-1
___ 06:53PM ___ PO2-62* PCO2-40 PH-7.41 TOTAL CO2-26
BASE XS-0
___ 06:53PM LACTATE-1.8
___ 06:53PM O2 SAT-90
___ 06:45PM GLUCOSE-171* UREA N-10 CREAT-0.7 SODIUM-140
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-24 ANION GAP-16
___ 06:45PM WBC-11.8* RBC-5.22 HGB-14.3 HCT-45.0 MCV-86
MCH-27.4 MCHC-31.8 RDW-14.0
___ 06:45PM NEUTS-92.4* LYMPHS-6.0* MONOS-0.8* EOS-0.4
BASOS-0.5
___ 06:45PM PLT COUNT-316
PERTINENT LABS:
==============
___ 06:50AM BLOOD ALT-27 AST-21 LD(LDH)-198 AlkPhos-81
TotBili-0.2
___ 06:50AM BLOOD Albumin-3.9 Calcium-9.3 Phos-3.7 Mg-2.0
___ 06:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 06:15AM BLOOD HCG-<5
___ 06:50AM BLOOD HCV Ab-NEGATIVE
LABS ON DISCHARGE:
===================
___ 06:15AM BLOOD WBC-15.1* RBC-4.62 Hgb-12.5 Hct-39.8
MCV-86 MCH-27.1 MCHC-31.5 RDW-14.2 Plt ___
___ 06:15AM BLOOD Glucose-211* UreaN-20 Creat-0.8 Na-139
K-4.2 Cl-102 HCO3-25 AnGap-16
___ 06:15AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.3
MICROBIOLOGY:
===============
DFA ___:
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
BLOOD CULTURE ___: NO GROWTH.
STUDIES:
=========
CT CHEST ___:
1. Overall improvement of bronchial wall thickening and mucous
plugging. Marginally more prominent ___ opacities in
right upper lobe suggestive of small airways disease in light of
other findings.
2. Pulmonary nodule in the left lower lobe laterally, similar
to prior exam. Recommend follow-up CT chest in one year if she
has risk factors.
CXR ___:
Frontal and lateral views of the chest. Heart size and
cardiomediastinal
contours are normal. Lungs are clear without focal
consolidation, pleural effusion, or pneumothorax.
IMPRESSION:
No focal consolidation.
Brief Hospital Course:
___ yo F with poorly controlled asthma, bronchiectasis, history
of positive PPD and tobacco use presents with shortness of
breath.
# Asthma exacerbation - Most likely due to discontinuing home
prednisone and non-compliance with medications. We initially
placed pt on solumedrol 125mg Q6hr x2 days and further
transitioned her to prednisone 40mg. However, patient's symptoms
and lung exam worsened upon transitioning to prednisone and
thus, taper may have been too quick for her. We resumed
solumedrol 125mg Q6hr x2 days, then tapered to 80mg Q8 x1 day
and then to prednisone 60mg daily with the following taper: 60mg
x5 days, 50mg x3 days, 40mg x3 day, 30mg x3 days, 20mg x3 days,
10mg until f/u with Dr. ___. We also treated her with
levofloxacin for total of 7 days, last dose on ___. Per
pulmonogy recommendation, we initiated azathioprine 50mg daily
upon discharge upon normal LFT's, negative hepatitis serology,
and negative serum HCG. Given concern for EGPA on behalf of
primary pulmonologist, we consulted rheumatology who believed
that current presentation is unlikely to be due to EGPA given
lack of symptoms suggestive of vasculitis and other systemic
involvement. We also initiated bactrim for PCP ___.
There was evidence of thrush due to chronic steroid use and
patient was started on nystatin mouth wash. The following were
found on outside hospital records: IgE 181 and ESR 34.
# hand and leg pain/numbness - Peripheral neuropathy is a common
presentation in EGPA but usually presents as mononeuritis
multiplex, or as peripheral neuropathy in "stocking and glove"
distribution. Her presentation is more c/w radicular vs.
vasculitic.
- outpatient f/u w/ neurology as previous work-up suggestive of
cervical stenosis, had recommended MRI.
- Rheum consult as above
# pulmonary nodules - unclear significance
- radiology recommends f/u study with CT in ___ year.
TRANSITIONAL ISSUES:
[] neuropathy of ___ - has appointment scheduled with
neurology as there is concern for radicular neuropathy
[] hypertension: pt hypertensive to 150's/100's throughout
hospital course. Currently, on no antihypertensives. Renal
function normal.
[] attention to follow-up regarding LLL pulmonary nodule noted
on
chest CT dated ___
[] please schedule close follow-up (within ___ weeks) with Dr.
___ pulmonary) and with PCP
[] drug monitoring as above
[] follow-up pending studies as above
[] follow-up blood glucose level as outpatient while on steroid
therapy
[] Has received pneumonia vaccine in ___ at ___ and flu vaccine
on ___. Will need prevnar at clinic follow-up when on lower
dose of steroids
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
3. PredniSONE 10 mg PO DAILY
4. Montelukast Sodium 10 mg PO DAILY
5. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation
BID
6. Tiotropium Bromide 1 CAP IH DAILY
7. Omeprazole 40 mg PO DAILY
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
9. Ipratropium Bromide Neb 1 NEB IH Q6H SOB
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. Montelukast Sodium 10 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
6. Tiotropium Bromide 1 CAP IH DAILY
7. Nystatin Oral Suspension 5 mL PO QID thrush
RX *nystatin 100,000 unit/mL 5 cc by mouth four times a day Disp
#*1 Bottle Refills:*0
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg One tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
9. PredniSONE 60 mg PO DAILY
RX *prednisone 10 mg One tablet(s) by mouth daily Disp #*80
Tablet Refills:*0
10. Ipratropium Bromide Neb 1 NEB IH Q6H SOB
11. Azathioprine 50 mg PO DAILY
RX *azathioprine 50 mg One tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
12. Pulmicort Flexhaler (budesonide) 180 mcg/actuation
inhalation BID
Discharge Disposition:
Home
Discharge Diagnosis:
1. asthma exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You presented to us with shortness of breath
and worsening of your asthma. We placed you on antibiotics,
scheduled nebulizer treatments, and IV steroid. You are being
discharged on prednisone, a new medication called azathioprine
as recommended by your pulmonologist, and bactrim. We consulted
pulmonology who agreed with our plan and made recommendations.
Please follow up with your pulmonology, Dr. ___, as scheduled.
We also consulted rheumatology to assess for Churg ___ and
they believed that your current presentation is unlikely to be
due to this illness since you lack many symptoms suggestive of
this disease.
Please take your medications as instructed. Please attend all
your follow up appointments.
Followup Instructions:
___
|
10774160-DS-2
| 10,774,160 | 28,309,821 |
DS
| 2 |
2137-11-12 00:00:00
|
2137-11-18 11:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with history of hyperlipidemia who presents with
sudden onset vertigo this am. He reports that he was sitting and
watching TV around 8:30am when he suddenly felt pulled to the
left and fell to the ground. When he tried to get up he felt
dizzy, which he describes as a sensation of spinning and feeling
off balance. He was able to crawl up the stairs to get his wife,
and once he got to the top he began to feel better and was
actually able to stand up and walk into the bedroom. They
decided
to call ___. When EMS arrived he turned his head toward the
right
and immediately felt a sensation of spinning again, which
resolved as soon as he stopped moving his head. He then was able
to stand up and walk to the ambulance, but when he was laid down
in the ambulance he again felt dizzy and a bit nauseous. This
again resolved once he sat back up. Upon arrival to the ED he
was
continuing to feel dizzy with position changes and was a bit
unsteady on tandem gait. A code stroke was called at 11:34.
NIHSS
was 0 on our assessment. Noncontrast CT head was negative and a
CTA showed no significant stenoses/occlusions (final read
pending).
Currently he is awake and alert and his dizziness has resolved
completely, even with positional changes. He denies any other
symptoms including hearing loss, tinnitus, headache, vision
changes, weakness, numbness/tingling. He has had no recent
illnesses.
On review of his records he was previously seen by neurology in
___ regarding brief episodes of dizziness and dysarthria. An
MRI
brain showed a small cavernous malformation of the left temporal
lobe associated with a small developmental venous anomaly. He
also had an EEG at that time which was normal. He does not
recall
any further episodes since that time, except for one instance
about ___ years ago when he had been playing golf for 6 days and
then returned home and went to play tennis. About halfway
through
the match he began to feel very lightheaded and had to sit down.
He was taken to the ED and was told that he was likely
dehydrated, and his symptoms improved with IVF.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, tinnitus or hearing
difficulty. He reports that his speech seemed slightly slurred
on
a couple of brief instances over the last week but otherwise
denies any difficulties producing or comprehending speech.
Denies
focal weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Hyperlipidemia
Social History:
___
Family History:
No known history of any neurologic diseases
Physical Exam:
ADMISSION PHYSICAL EXAM:
Physical Exam:
Vitals: 97.8 67 144/67 18 99% RA
General: Awake, pleasant and cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert and oriented. Attentive, able to relate a
detailed history without difficulty. Language is fluent without
dysarthria. Normal prosody. There were no paraphasic errors. Pt
was able to name both high and low frequency objects. Able to
follow both midline and appendicular commands. The pt had good
knowledge of current events. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI with a few beats of end-gaze nystagmus on R
lateral gaze which quickly fatigued and could not be reproduced.
Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
___ and head thrust test were negative.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 1
R 1 1 1 1 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: No truncal ataxia when sitting unsupported on edge of
bed.
Arises independently with good initiation of gait. Casual gait
is
narrow based and steady. He is slightly unsteady on tandem gait
but is able to take a few steps.
DISCHARGE PHYSICAL EXAM:
Same as admission although we were able to get nystagmus looking
to the left and a positive ___ maneuver when coming
back up to the left.
Pertinent Results:
ADMISSION LABS:
___ 10:00AM BLOOD WBC-5.8 RBC-4.74 Hgb-15.1 Hct-44.6 MCV-94
MCH-31.7 MCHC-33.8 RDW-12.3 Plt ___
___ 10:00AM BLOOD Neuts-68.7 ___ Monos-7.2 Eos-3.8
Baso-1.2
___ 10:00AM BLOOD Glucose-93 UreaN-18 Creat-0.8 Na-141
K-5.8* Cl-107 HCO3-25 AnGap-15
DISCHARGE LABS:
___ 06:10AM BLOOD WBC-6.7 RBC-4.70 Hgb-15.0 Hct-44.1 MCV-94
MCH-31.9 MCHC-34.0 RDW-12.3 Plt ___
___ 06:10AM BLOOD Glucose-81 UreaN-16 Creat-0.8 Na-139
K-4.3 Cl-104 HCO3-26 AnGap-13
___ 06:10AM BLOOD %HbA1c-5.3 eAG-105
___ 06:10AM BLOOD Triglyc-66 HDL-44 CHOL/HD-2.8 LDLcalc-65
REPORTS:
EKG ___: Sinus rhythm. Left axis deviation consistent with
left anterior fascicular block. Minor non-specific
repolarization changes. No previous tracing available for
comparison.
CTA HEAD AND NECK ___: IMPRESSION: Unremarkable noncontrast
head CT without evidence of infarct, hemorrhage or mass effect.
Unremarkable head neck CTA without evidence of significant
stenosis, aneurysm or dissection.
CXR ___: IMPRESSION: PA and lateral chest compared to
___: Normal heart, lungs, hila, mediastinum and
pleural surfaces.
MRI ___: IMPRESSION:
1. No acute intracranial abnormality; specifically, there is no
evidence of acute ischemia.
2. Mild bifrontal cortical atrophy, likely age-related.
Brief Hospital Course:
___ is a ___ man with history of
hyperlipidemia who presented with sudden onset vertigo. He was
admitted for a TIA workup which showed negative MRI, CTA head
and neck and normal HgA1C and lipids. On repeat exam we found
that when looking to the left he had nystagmus and his
___ was positive. These findings were suggestive a
peripheral process such as BPPV, so we did not change any of his
medications and do not feel he had a TIA.
TRANSITIONAL CARE ISSUES:
- we gave him Epley maneuver instructions to be used when he has
vertiginour episodes in the future.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. EpiPen 2-Pak (EPINEPHrine) 0.3 mg/0.3 mL (1:1,000) injection
as directed
2. PredniSONE 20 mg PO ONCE, MAY REPEAT ONCE
3. PredniSONE 40 mg PO DAILY
4. PredniSONE 30 mg PO DAILY
Start: After 40 mg tapered dose
5. PredniSONE 20 mg PO DAILY
Start: After 30 mg tapered dose
6. PredniSONE 10 mg PO DAILY
Start: After 20 mg tapered dose
7. Ranitidine 150 mg PO BID
8. Simvastatin 20 mg PO DAILY
9. Ascorbic Acid ___ mg PO BID
10. Aspirin 81 mg PO DAILY
11. Cetirizine 10 mg oral BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cetirizine 10 mg oral BID
3. Ranitidine 150 mg PO BID
4. Simvastatin 20 mg PO DAILY
5. Ascorbic Acid ___ mg PO BID
6. EpiPen 2-Pak (EPINEPHrine) 0.3 mg/0.3 mL (1:1,000) injection
as directed
7. PredniSONE 20 mg PO ONCE, MAY REPEAT ONCE
8. PredniSONE 40 mg PO DAILY
9. PredniSONE 30 mg PO DAILY
Start: After 40 mg tapered dose
10. PredniSONE 20 mg PO DAILY
Start: After 30 mg tapered dose
11. PredniSONE 10 mg PO DAILY
Start: After 20 mg tapered dose
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral Vestibulopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were seen in the hospital for symptoms of intermittent
dizziness. We think this is related to your inner ear. We
performed an MRI that showed no evidence of stroke and on your
neurological exam on the day of discharge we found signs
consistent with inner ear dyfunction. We instructed you on how
to do corrective exercises for this and sent you home with
instructions. You should perform these exercises 10 times a day
or until your dizziness improves, at which point you can stop.
We made no changes to your medications. Please continue to take
your medications as previously prescribed.
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
___
|
10774186-DS-17
| 10,774,186 | 21,614,558 |
DS
| 17 |
2178-01-26 00:00:00
|
2178-01-29 14:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of Afib off coumadin, HTN, HLD, cerebellar CVA,
and VRE UTI presenting from assisted living with progressive
confusion, agitation.
Per outpatient provider ___:
"Ms. ___ has not been eating. She needs to be coaxed frequently
to have juice or food some food. Caretakers at her facility feel
that this may be related to her recent lost dentures.
She has also had multiple falls recently. When she has had
these falls, she has been evaluated at ___
in which head scanning have been unrevealing.
The patient also has been making more inappropriate comments and
exhibiting escalating behavior changes. Her psychiatrist and
psychiatric nurse practitioner have been in but do not feel that
there is much more to do."
Apparently, there has also been concern for a UTI. Workup was
planned through ___ but patient became very agitated when
visiting nurse attempted to draw blood and perform urinalysis.
Therefore, given patient's mental status changes, behavior
changes, and failure to take adequate PO's, it was recommended
patient be admitted for further eval.
Per most recent PCP note, ___ has become progressively more
demented over the past months with fixed delusions and some
agitation.
In the ED intial vitals were: 97.2 82 135/67 18 98%
- Labs were significant for UA with 23WBCs. CT was negative for
acute process and CXR showed no PNA.
- Patient was given CTX 1g
Vitals prior to transfer were: 98.1 70 135/48 10 98% RA
Review of Systems:
Otherwise negative in detail
Past Medical History:
Atrial fibrillation
Hypertension
Hyperlipidemia with high triglycerides
Polycythemia ___
___ of Cerebellar CVA in ___ when PCV diagnosed
Major Depression disorder, Anxiety Disorder
Osteoporosis
Pseudogout
History of C4 fracture, ___
Varicose Veins, Right Leg
History of Nosebleeds with daily Aspirin
Recent hosp for MVR c/b afib on anticoagulation
UTI, VRE treated w/ linezolid
Hemorrhoids
s/p Hysterectomy
s/p Tonsillectomy
Social History:
___
Family History:
Sisters: CVA, ___
Son: ___
Physical ___:
ADMISSION:
98.2 68 122/82 18 98% RA
General- pleasant, conversant, NAD
HEENT- EOMI, PERRL, MMM
Neck- supple
Lungs- CTAB
CV- irregularly, irregular
Abdomen- s/nt/nd normoactive bs
GU- no foley
Ext- no edema
Neuro- nonfocal, A&Ox1 (self), moving all 4 extremities equally,
otherwise nonfocal
DISCHARGE:
Vitals: 98.1 128/64 78 18 96% on RA
General- pleasant, conversant, NAD, answers questions and
follows commands, speech clear but c/w dellusions
HEENT- EOMI, PERRL, MMM
Neck- supple
Lungs- CTAB
CV- irregularly, irregular
Abdomen- s/nt/nd normoactive bs
GU- no foley
Ext- no edema
Neuro- nonfocal, A&Ox1 (self), moving all 4 extremities equally,
otherwise nonfocal
Pertinent Results:
LABS ON ADMISSION:
========================
___ 09:10PM GLUCOSE-123* UREA N-15 CREAT-1.1 SODIUM-136
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-23 ANION GAP-18
___ 09:10PM estGFR-Using this
___ 09:10PM WBC-9.1 RBC-4.93 HGB-12.8 HCT-40.3 MCV-82
MCH-25.9* MCHC-31.7 RDW-15.4
___ 09:10PM NEUTS-70.1* ___ MONOS-9.6 EOS-1.6
BASOS-0.7
___ 09:10PM PLT COUNT-432
___ 09:00PM URINE HOURS-RANDOM
___ 09:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
___ 09:00PM URINE RBC-1 WBC-23* BACTERIA-NONE YEAST-NONE
EPI-<1
___ 09:00PM URINE MUCOUS-OCC
PERTINENT LABS:
================
___ 01:43AM BLOOD ALT-15 AST-21 LD(LDH)-271* CK(CPK)-26*
AlkPhos-134* TotBili-0.2
___ 11:15AM BLOOD ALT-14 AST-17 LD(___)-216 CK(CPK)-16*
AlkPhos-136* TotBili-0.2
___ 01:43AM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:15AM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:43AM BLOOD TSH-3.4
DISCHARGE LABS:
================
___ 11:15AM BLOOD WBC-6.0 RBC-4.93 Hgb-12.5 Hct-40.3 MCV-82
MCH-25.3* MCHC-31.0 RDW-15.4 Plt ___
___ 11:15AM BLOOD Glucose-97 UreaN-13 Creat-1.0 Na-141
K-4.4 Cl-106 HCO3-25 AnGap-14
___ 11:15AM BLOOD ALT-14 AST-17 LD(LDH)-216 CK(CPK)-16*
AlkPhos-136* TotBili-0.2
___ 11:15AM BLOOD Albumin-3.3* Calcium-8.6 Phos-3.5 Mg-2.1
MICRO:
==========
-URINE CULTURE ___: NO GROWTH.
STUDIES:
================
CT HEAD ___
IMPRESSION: No acute intracranial process.
CXR:
IMPRESSION: No acute cardiopulmonary process.
EKG:
Atrial fibrillation with moderately controlled ventricular
response. Rhythm change is new compared to the previous tracing
of ___. Otherwise, no significant change.
Brief Hospital Course:
___ with hx of Afib off coumadin, HTN, HLD, cerebellar CVA,
and VRE UTI presenting from assisted living with progressive
confusion, agitation and to r/o UTI.
#) Sterile pyuria: Urine culture on ___ with no growth, and
thus we discontinued ceftriaxone. 23 WBCs on UA with no bacteria
and moderate leuks. Pt with no dysuria though there is concern
that her acute agitation and MS changes may be related to
infection. Given her MS changes and pending urine culture, we
kept pt on ctx until urine culture returned as no growth. She
did receive 3 doses of ceftriaxone, so was treated empirically
for a UTI.
#) Dementia: Most likely d/t worsening dementia as now UTI has
been ruled out. NCHCT with no acute abnormalities. She has no
new medications changes and her infectious w/u is thus far
negative. Pt resides in a locked dementia unit and has been
hospialized multiple times in the past in the psych unit. Given
pt's needs, she may need 24-hour care in a nursing home as she
now resides in an assisted care living (locked dementia unit).
- hold sedating/deliriogenic medications such as hydroxyzine
- outpatient f/u including neuropsychiatric evaluation
#) Recurrent Falls - unclear etiology though may be related to
deconditioning vs orthostasis vs mechanical falls vs
tacchyarrhythmia. Seems to be a chronic issue. EKG shows a-fib
but is rate-controlled and is unlikely to be the cause. Patient
has history of CVA and may most likely be due to residual
ataxia.
#) HTN: normotensive here, continued on home medications.
- continue losatan
- continue dilt
#) Afib/flutter: rate controlled here. not anticoagulated as an
outpatient so was not started here.
- continue diltiazem
#) Depression: stable. Her behavioral changes may be explained
by depression.
- continue duloxetine
- continue mirtazapine
#) Hypothyroidism: stable
- continue levothyroxine
- TSH 3.4
#) Pruritis: stable
- holding hydroxyzine
- sarna lotion prn
TRANSITIONAL ISSUES:
[] given progressive decline in cognition, further imaging such
as MRI may be warranted
[] outpatient neuropsychiatric evaluation given worsening of
confusion and agitation
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Losartan Potassium 100 mg PO DAILY
3. Calcium Carbonate 1000 mg PO BID
4. Mirtazapine 7.5 mg PO HS
5. Hydroxyurea 500 mg PO EVERY OTHER DAY
6. Diltiazem Extended-Release 300 mg PO DAILY
7. Bisacodyl 10 mg PO DAILY:PRN constipation
8. Docusate Sodium 100 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. melatonin 6 mg oral qhs
12. saccharomyces boulardii 250 mg oral daily
13. Duloxetine 30 mg PO DAILY
14. Levothyroxine Sodium 50 mcg PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Calcium Carbonate 1000 mg PO BID
4. Diltiazem Extended-Release 300 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Duloxetine 30 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9. Mirtazapine 7.5 mg PO HS
10. Multivitamins 1 TAB PO DAILY
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Vitamin D 1000 UNIT PO DAILY
13. melatonin 6 mg oral qhs
14. saccharomyces boulardii 250 mg oral daily
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for evaluation of agitation and for
obtaining a urinalysis. While you were here, we felt you did
not have a urine infection, however we treated you since it was
equivocal. You grew no bacteria from urine cultures. Also
there was concern about agitation, however you were very
pleasant here at ___. This is likely a progression of dementia
rather than an acute issue. We feel you would benefit from 24
hour care.
Followup Instructions:
___
|
10774186-DS-18
| 10,774,186 | 21,348,249 |
DS
| 18 |
2178-03-04 00:00:00
|
2178-03-04 14:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Possible chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ yo woman with H/O of atrial
flutter/fibrillation (not on anticoagulation), severe mitral
regurgitation now S/P porcine MVR, pulmonary hypertension,
hyperlipidemia, hypertension, polycythemia ___, severe dementia
and hypothyroidism who presents with ST elevations on EKG.
Patient reportedly experienced 2 unwitnessed falls with
headstrike at her rehabilitation facility and was brought to
___. To most examining physicians, she did
not endorse any symptoms of chest pain or palpitations (although
she subsequently told another physician that she had experienced
severe chest pain that had since resolved). Per her HCP, patient
has been having worsening dementia for several years and has
repeatedly voiced her desire to die. She was found to have TnT
0.32 (per report, unable to locate lab report in chart) and EKG
showing inferior STEMI. Head and neck CT were negative. She was
then transferred to the ___. In the ___ initial VS T 97.6 P
72 BP 145/74 RR 16 O2 Sat 97% on RA. Labs were remarkable for
TnT 0.32, WBC 11.4, HCO3 21, AG 17, UA with RBCs. EKG showed
atrial flutter with ventricular rate 81 bpm with 1 mm STE in
III, ?II, and avF. CXR showed old hilar calcification, prominent
interstitial markings and a hilar opacity for which infection
was in the differential diagnoses. Cardiology was consulted and,
after discussion with patient's HCP, it was felt that, in light
of goals of care and the patient's likely inability to cooperate
during an invasive procedure, coronary angiography and
intervention was deferred in favor of medical management. She
received ASA 325 mg PO x 1 and was started on a heparin drip. On
the floor, patient reported diffuse abdominal pain, which she
states has been present for several weeks. She reports chronic
shortness of breath. She did not endorse chest pain at the time
of admission to Cardiology. She is A+O to self, "mental
hospital", "___" and "Obama". She is unable to describe the
reason for her hospitalization. Several hours after arrival,
patient was found on floor sitting and leaning against bed by
PCA (per nursing report, several seconds after bed alarm rang).
ROS: On review of systems, patient denies H/O DVT, pulmonary
embolus, bleeding at the time of surgery, myalgias, joint pains,
cough, hemoptysis, black stools or red stools. She denies recent
fevers, chills or rigors. She denies exertional buttock or calf
pain. All of the other review of systems were negative. (Note
the patient does have dementia.)
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
-Atrial fibrillation
-Hypertension
-Hyperlipidemia with high triglycerides
-Polycythemia ___
-History of Cerebellar CVA in ___ when PCV diagnosed
-Major Depression disorder, Anxiety Disorder
-Osteoporosis
-Pseudogout
-History of C4 fracture, ___
-Varicose Veins, Right Leg
-History of Nosebleeds with daily aspirin
-Mitral valve replacement with 27-mm ___ Epic
tissue valve ___ complicated by atrial fibrillation on
anticoagulation
-UTI with VRE treated wwith linezolid
-Hemorrhoids
-s/p Hysterectomy
-s/p Tonsillectomy
Social History:
___
Family History:
Sisters: CVA, ___
Son: ___
Physical ___:
On Admission
GENERAL: Elderly Caucasian woman in NAD. Oriented to self,
"mental hospital" for location, "___" for year and "Obama" for
president.
VS: T 97.8, BP 108/72, Pulse 76, RR 18, SaO2 92% on RA
HEENT: NCAT. Sclera anicteric. EOMI. No xanthelasma.
NECK: Supple with JVP of 12 cm.
CARDIAC: Irregularly irregular, normal S1, S2. No murmurs, rubs
or gallops. No thrills, lifts.
LUNGS: No wheezes or rhonchi. Crackles at right base.
ABDOMEN: Soft, not distended. No HSM. Mild diffuse tenderness to
palpation. Abd aorta not enlarged by palpation.
EXTREMITIES: No clubbing, cyanosis or edema. Mild tenderness to
palpation on lateral aspect of right thigh.
SKIN: No stasis dermatitis, ulcers, scars, ecchymoses or
xanthomas.
PULSES: 2+ radial pulses bilaterally
NEURO: CN II-XII intact; Strength ___ in all distal extremities.
Sensation intact to LT and symmetric.
At Discharge
GENERAL: In NAD, sitting in chair, appears sad
VS: T 98.2 BP 140/72(121-140/60-72) Pulse 79 SaO2 100% on RA
HEENT: NCAT. Sclera anicteric. EOMI.
NECK: Supple
CARDIAC: Irregularly irregular, normal S1, S2. No murmurs, rubs
or gallops.
LUNGS: CTA bilaterallly anteriorly
ABDOMEN: Soft, not distended
EXTREMITIES: No clubbing, cyanosis or edema
NEURO: Alert, Answers questions appropriately, no focal neuro
deficits
PSYCH: calm, sitting on chair, affect blunt
Pertinent Results:
___ 09:10PM WBC-11.4*# RBC-4.70 HGB-11.3* HCT-36.9
MCV-79* MCH-24.0* MCHC-30.5* RDW-15.7*
___ 09:10PM NEUTS-83.1* LYMPHS-8.6* MONOS-6.8 EOS-0.9
BASOS-0.7
___ 09:10PM PLT COUNT-508*
___ 10:02PM URINE HOURS-RANDOM
___ 10:02PM URINE GR HOLD-HOLD
___ 10:02PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:02PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 10:02PM URINE RBC-24* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 09:10PM GLUCOSE-106* UREA N-18 CREAT-1.1 SODIUM-141
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-21* ANION GAP-22*
___ 09:10PM cTropnT-0.31*
___ 09:10PM TSH-2.6
Trop trend
___ 09:10PM BLOOD cTropnT-0.31*
___ 02:44AM BLOOD CK-MB-2 cTropnT-0.32*
___ 01:17PM BLOOD CK-MB-2 cTropnT-0.25*
___ 03:45PM BLOOD CK-MB-2 cTropnT-0.26*
DISCHARGE LABS
___ 08:30AM BLOOD WBC-10.9 RBC-4.76 Hgb-11.0* Hct-37.4
MCV-79* MCH-23.2* MCHC-29.5* RDW-16.2* Plt ___
___ 06:57AM BLOOD Glucose-102* UreaN-14 Creat-1.0 Na-141
K-4.4 Cl-106 HCO3-22 AnGap-17
___ 06:57AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.3
ECG ___ 8:43:22 ___
Possible atrial flutter with variable block. See the flutter
waves in lead V1. Compared to the previous tracing of ___
atrial flutter is present.
CXR ___:
Single frontal view of the chest was obtained. The patient is
status post median sternotomy. Calcified mediastinal and hilar
nodes are again noted. There is increased prominence of the
interstitial markings concerning for pulmonary edema. No large
pleural effusion is seen. Right infrahilar opacity along the
right heart border is slightly more prominent as compared to the
prior study and could be due to consolidation from infection or
atelectasis. The cardiac silhouette is mildly enlarged. The
aorta is calcified.
CXR ___:
There are lower lung volumes. There are increasing opacities in
the lower lobes consistent with increasing atelectasis. Small
bilateral effusions are more conspicuous than before. There is
no evident pneumothorax. Mild interstitial edema has increased.
Multiple calcified lymph nodes in the mediastinum and hila are
again noted. Sternal wires are aligned.
IMPRESSION: Worsening pulmonary edema. Of note, evaluation of
rib fractures is very limited due to technique and patient body
habitus. If clinical persistent concern, dedicated rib series
are recommended.
ECG ___:
Sinus rhythm. Baseline artifact. Consider prior inferior wall
myocardial infarction. Compared to the previous tracing of
___ sinus rhythm has appeared. There is variation in
precordial lead placement and apparent more prominent lateral T
wave changes. Clinical correlation is suggested.
Hip/pelvis X-ray ___:
In comparison with the outside study of ___, there is little
overall change. No definite evidence of acute fracture or
dislocation. However, if there is serious clinical concern for
an occult fracture, cross-sectional imaging could be obtained.
There are mild degenerative changes symmetrically involving
the hip joints, essentially within normal limits for patient
age. Severe degenerative changes are seen in the lower lumbar
spine.
KUB ___:
Supine radiographs of the abdomen and pelvis demonstrate normal
bowel gas pattern. There is no evidence of intraperitoneal free
air on limited supine view. There is interval improvement in
bibasilar opacities, with residual pulmonary edema at the bases
versus possibly underlying interstitial lung disease. Lower
median sternotomy wires are noted.
IMPRESSION: Normal bowel gas pattern without evidence of ileus
or obstruction.
CXR ___:
Compared to the prior study there is improved aeration
bilaterally but there continues to be patchy areas of alveolar
infiltrate and increased interstitial markings and ___
B-lines with a small left effusion.
IMPRESSION: Improvement in CHF.
Brief Hospital Course:
Ms. ___ is an ___ yo woman with H/O of atrial
flutter/fibrillation (not on anticoagulation), severe mitral
regurgitation now S/P bovine MVR, pulmonary hypertension,
hyperlipidemia, hypertension, polycythemia ___, severe dementia
and hypothyroidism who presents with a STEMI.
# STEMI: Patient presented in transfer to the ED with evidence
of inferior STEMI with elevated troponin, ECG changes, chronic
abdominal pain and inconsistent self-reports regarding chest
pain (mostly reporting no chest pain, but told one examiner that
she had experienced severe chest pain). In addition, her
unwitnessed falls might have represented an ischemia-related
ventricular arrhythmia. Given discussion regarding goals of care
and concerns about patient's ability to cooperate with an
invasive procedure, she was treated medically with heparin for
48 hrs, aspirin, clopidogrel, high dose statin and metoprolol.
The peak TnT was 0.32 early after presentation (? more subacute
presentation) with normal CKMB. She did not report any chest
pain during her admission. Echocardiographic evaluation of
infarct size and LV systolic function was not obtained due to
patient's inability to cooperate with even this non-invasive
examination. Due to patient's H/O multiple recent falls, we
decided to discontinue clopidogrel on ___ (as the risk of
major bleeding on ASA+clopidogrel is no better than the risk on
warfarin alone, and she was already deemed not a candidate for
oral anticoagulation for her atrial fibrillation). Patient
developed some shortness of breath and hypoxemia on HD1. Chest
plain film showed some pulmonary vascular congestion consistent
with acute diastolic heart failure. She was given furosemide 10
mg IV and her respiratory status improved. She was discharged
on ASA, metoprolol succinate, atorvastatin and losartan.
# Atrial fibrillation/flutter - CHADS of 5. Discussed
anticoagulation with patient's PCP and HCP and confirmed that
she was high risk for fall and anticoagulation was contrary to
her goals of care. Patient was rate controlled with metoprolol,
and her diltiazem was stopped. She was continued on home ASA
after short inpatient courses of heparin and clopidogrel.
# Major Depression/Severe Dementia: Patient expressed some
passive suicidal ideation during her hospitalization. She was
placed on 1:1 sitter precautions and did not try to injure
herself. She did not report a plan and was evaluated by the
psychiatric nurse and determined not to be threat to her self.
She denied suicidal ideation by time of discharge. She was
continued on home mirtazapine and rivastigmine. At times, the
patient refused her pills, especially in the evening. Her
medications were changed to once daily preparations dosed in the
morning.
# Polycythemia ___ thrombocytosis - Patient's
platelet counts rose to 848 on day of discharge. Her hydroxyurea
was restarted during hospitalization (500 mg PO 3x/week) given
concern for recurrent acute coronary syndrome in the setting of
thrombocytosis.
# S/P Fall: During hospitalization, patient slid out of her
geriatric chair (witnessed, no trauma). After getting back in
the chair, patient complained of some bilateral hip pain. Plain
films were performed that did not show any trauma. As her
symptoms improved, CT scanning was not pursued.
# Hypothyroidism: Patient was continued on home levothyroxine 50
mcg daily. TSH was checked and within normal limits.
# Hematuria: Patient had one episode of hematuria in the setting
of aspirin and clopidogrel use. The clopidogrel was discontinued
and the hematuria resolved. Follow up UA showed small blood and
no evidence of UTI.
CODE STATUS: DNR/DNI
Health Care Proxy: ___ # ___
___ issues
- Patient should have CBC checked in one week to make sure that
platelets improving on hydroxyurea.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Calcium Carbonate 1000 mg PO BID
4. Diltiazem Extended-Release 300 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Duloxetine 30 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9. Mirtazapine 7.5 mg PO HS
10. Multivitamins 1 TAB PO DAILY
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Vitamin D 1000 UNIT PO DAILY
13. melatonin 6 mg oral qhs
14. saccharomyces boulardii 250 mg oral daily
15. rivastigmine 4.6 mg/24 hour transdermal daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Duloxetine 30 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Losartan Potassium 100 mg PO DAILY
7. Mirtazapine 7.5 mg PO HS
8. Multivitamins 1 TAB PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. rivastigmine 4.6 mg/24 hour transdermal daily
11. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
once a day Disp #*30 Tablet Refills:*0
12. Calcium Carbonate 1000 mg PO BID
13. melatonin 6 mg oral qhs
14. saccharomyces boulardii 250 mg oral daily
15. Vitamin D 1000 UNIT PO DAILY
16. Hydroxyurea 500 mg PO MWF
17. Metoprolol Succinate XL 50 mg PO DAILY
18. Atorvastatin 80 mg PO QAM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Inferior ST elevation myocardial infarction
Coronary artery disease
Acute left ventricular diastolic heart failure
Pulmonary edema
Hypoxemia
Dementia
Atrial fibrillation
Polycythemia ___
Hyperlipidemia
Suicidal ideation
Recurrent falls
Medication non-compliance
Hematuria
Prior vancomycin resistant Enterococcus infection
Prior bioprosthetic mitral valve replacement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to the hospital for a heart attack. We
treated ___ medically with IV heparin and started ___ on
medications to protect your heart. We now think that ___ are
ready to leave the hospital.
Please see below for medication changes and follow up
appointments
Followup Instructions:
___
|
10774229-DS-3
| 10,774,229 | 23,626,898 |
DS
| 3 |
2139-04-28 00:00:00
|
2139-04-28 19:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
MRI Abnormalities
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
The pt is a ___ old woman with history of ulcerative
proctitis and a 9- month history of left-sided headaches who is
referred for expedited inpatient workup of multifocal
intraparenchymal lesions seen on brain MRI.
Briefly, the patient begins her history ___ years ago when she
slipped and fractured her c-spine. Since then, she recovered but
for a time experienced transient right and left sided neck pain
that would radiate up into the occiput. About 9 months ago, in
___, she began to develop new headaches, described as
"head pain" located on the left temporoparietal region, which
tended to occur when she was lying flat rather than standing.
There may also be a "strange sensation" over her left ear, which
is hard for her to describe. The pain is described as
continuous, rather than throbbing, and occurred intermittently,
in episodes. However, over the past month or so, they have
become much more frequent, and over the past few weeks she has
experienced this head pain at least daily. There is no
hyperesthesia or numbness when she touches the area. There is no
blurred vision or diplopia, or transient visual loss with
episodes, or jaw claudication. However, over the past year she
has had a small number of migraines preceded by a sensation of
flashing lights in her left visual field, responsive to
excedrin, which is unusual, as her typical migraines occurred in
her ___ and stopped after that.
She has developed no other symptoms since, but due to the
frequency of these head pains, she sought evaluation and saw Dr.
___ in clinic a few days ago. He ordered brain and C-spine
MRI, which revealed diffuse T2 hyperintensities scattered
throughout the cortical/subcortical areas including basal
ganglia and medulla, as well as within the cervical cord. He
called her with results and urged her to present to the ED for
expedited workup. She otherwise feels well.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Ulcerative colitis, well controlled on mesalamine
Low back pain
Osteoporosis
Bladder prolpase, uses pessary
Social History:
___
Family History:
Mother with strokes at age ___, but no vascular risk factors.
Father with CAD s/p CABG, prostate cancer, and pancreatic
cancer.
Physical Exam:
Physical Exam:
General: Awake, Cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: supple, no nuchal rigidity
Pulmonary: breathing comfortably on room air
Cardiac: RRR, nl
Abdomen: soft, NT/ND
Extremities: warm, well perfused
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Alert, oriented x3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Fundoscopic
exam revealed no papilledema, exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2 2 3 2
R 3 2 2 3 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
DISCHARGE EXAM:
Physical Exam:
___ 1540 Temp: 97.8 PO BP: 109/63 HR: 76 RR: 18 O2 sat: 99%
O2 delivery: RA FSBG: 111
General: awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: supple, no nuchal rigidity
Pulmonary: breathing comfortably on room air
Cardiac: RRR
Abdomen: soft, NT/ND
Extremities: warm, well perfused, bilateral lower extremity non
pitting edema
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Alert, oriented x3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
comprehension. Normal prosody. There were no paraphasic errors.
Speech was not dysarthric. Able to follow both midline and
appendicular commands. There was no evidence of neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 4 to 3mm and brisk. EOM full, end gaze
extinguishing nystagmus bilaterally. 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 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, No extinction to DSS.
Vibration felt at the MTP of the great toe 4 seconds on the
right, 7 seconds on the left.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2 2 3 2
R 3 2 2 2 2
No jaw jerk
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, No dysmetria on FNF
bilaterally.
Pertinent Results:
___ 04:15PM ___ PTT-30.7 ___
___ 04:15PM PLT COUNT-249
___ 04:15PM NEUTS-78.7* LYMPHS-12.1* MONOS-7.2 EOS-0.8*
BASOS-0.6 IM ___ AbsNeut-6.80* AbsLymp-1.04* AbsMono-0.62
AbsEos-0.07 AbsBaso-0.05
___ 04:15PM WBC-8.6 RBC-4.99 HGB-14.8 HCT-44.9 MCV-90
MCH-29.7 MCHC-33.0 RDW-13.9 RDWSD-45.2
___ 04:15PM CRP-0.8
___ 04:15PM TRIGLYCER-69 HDL CHOL-82 CHOL/HDL-3.2
LDL(CALC)-167*
___ 04:15PM %HbA1c-5.7 eAG-117
___ 04:15PM VIT B12-655
___ 04:15PM ALBUMIN-4.5 CALCIUM-9.8 PHOSPHATE-4.2
MAGNESIUM-2.4 CHOLEST-263*
___ 04:15PM ALT(SGPT)-18 AST(SGOT)-26 ALK PHOS-100 TOT
BILI-0.2
___ 04:15PM GLUCOSE-120* UREA N-29* CREAT-0.9 SODIUM-139
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-25 ANION GAP-15
___ 10:30PM URINE RBC-8* WBC-11* BACTERIA-FEW* YEAST-NONE
EPI-<1
___ 10:30PM URINE BLOOD-NEG NITRITE-POS* PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG*
___ 10:30PM URINE COLOR-Straw APPEAR-Clear SP ___
MRI Head ___:
IMPRESSION:
1. Diffuse subcortical T2/FLAIR white matter hyperintensities
involving the bilateral frontotemporoparietal lobes, bilateral
basal ganglia and medulla, without evidence of associated
enhancement. Many of these lesions demonstrate DWI
hyperintensity without clear ADC hypointensity.
2. The differential consideration is broad and may represent
sequela of chronic embolic infarcts, vasculitides or potentially
inflammatory/infectious process. Sarcoidosis is a
consideration, although one would expect nodular enhancement.
This is not in a distribution typical for demyelinating process,
although this is not excluded. Metabolic disorder is
consideration, although less likely given the patient's age.
3. There is a left frontal convexity extra-axial CSF collection
measuring approximately 4.1 cm in greatest dimension compatible
with an arachnoid cyst exerting mild adjacent local sulcal
effacement.
4. Additional findings as described above.
ADDENDUM In addition, neoplastic process should be considered.
MRI C-Spine ___:
IMPRESSION:
1. Subtle hazy T2 hyperintense nonenhancing signal of the
cervical cord spanning C2-C3 through C4-C5. Possible regions of
abnormal cord signal in the visualized lower cervical and upper
thoracic cord. This is nonspecific. Please refer to concurrent
MRI head for differential considerations which ranges from
sequela of inflammatory/infectious etiology, demyelinating
process to embolic/ischemic disease. Neoplastic process while
considered less likely given lack of postcontrast enhancement is
not entirely excluded.
2. Mild degenerative changes as described above without
high-grade spinal canal or neural foraminal narrowing.
3. Additional findings described above.
___ CTA and CTA Neck
IMPRESSION:
1. No evidence of hemorrhage or infarction.
2. Mild multifocal atherosclerotic disease within the
intracranial and
cervical vasculature, without high-grade stenosis, occlusion,
dissection, or aneurysm.
3. Slight irregularity of the left humeral head is only imaged
on the scout. There is a small round, well corticated ossific
density in the region of the left shoulder. These findings may
be chronic in nature, although a left shoulder radiograph could
be considered if clinically indicated.
4. Additional findings, as above.
___ SHOULDER ___ VIEWS NON TRAUMA LEFT
IMPRESSION:
Mild AC joint degenerative changes. Previously seen rounded
radiodensity
projecting over the superolateral humeral head is likely
external to the
patient, on the patient's clothing.
___ Echo
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. No thrombus
or mass visualized.
___ 04:05AM BLOOD WBC-5.7 RBC-4.31 Hgb-13.0 Hct-39.6 MCV-92
MCH-30.2 MCHC-32.8 RDW-14.0 RDWSD-47.7* Plt ___
___ 04:05AM BLOOD ___ PTT-30.0 ___
___ 04:05AM BLOOD Lupus-PND
___ 04:05AM BLOOD Glucose-89 UreaN-19 Creat-0.7 Na-145
K-4.4 Cl-107 HCO3-25 AnGap-13
___ 04:05AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.4 Cholest-201*
___ 04:05AM BLOOD VitB12-518
___ 04:15PM BLOOD %HbA1c-5.7 eAG-117
___ 04:05AM BLOOD Triglyc-54 HDL-71 CHOL/HD-2.8 LDLcalc-119
___ 04:05AM BLOOD TSH-3.0
___ 04:05AM BLOOD ANCA-PND
___ 04:05AM BLOOD RheuFac-<10
___ 04:05AM BLOOD ___ CRP-1.1 dsDNA-PND
___ 04:05AM BLOOD C3-94 C4-40
___ 04:05AM BLOOD HIV Ab-NEG
___ 04:05AM BLOOD COPPER (SPIN NVY/NO ADD)-PND
___ 04:05AM BLOOD SED RATE-PND
___ 04:05AM BLOOD CARDIOLIPIN ANTIBODIES (IGG, IGM)-PND
___ 04:05AM BLOOD Beta-2-Glycoprotein 1 Antibodies IgG-PND
___ 04:05AM BLOOD VITAMIN E-PND
___ 04:05AM BLOOD RO & ___
___ 04:05AM BLOOD RNP ANTIBODY-PND
___ 04:05AM BLOOD ANGIOTENSIN 1 - CONVERTING ___
___ 04:05AM BLOOD NEUROMYELITIS OPTICA
(NMO)/AQUAPORIN-4-IGG CELL-BINDING ASSAY, SERUM-PND
Brief Hospital Course:
The pt is a ___ year old woman with history of ulcerative
proctitis and a 9 month history of left sided headaches who is
referred to the ___ for expedited inpatient workup of
multifocal intraparenchymal lesions seen on brain MRI.
As mentioned on MRI report, the differential diagnosis for her
findings is quite broad and includes infectious, inflammatory,
autoimmune, malignant, and demyelinating etiologies. Also taking
into account her presentation with a subacute history of
headaches in conjunction with her age, either CNS isolated
vasculitis or neurologic involvement of a systemic vasculitis
must be ruled out. History of ulcerative colitis could also
raise her risk of developing additional autoimmune entities.
Will admit for expedited workup including vessel imaging and CSF
sampling.
-------------------
Ms. ___ is a ___ year old woman with ulcerative proctitis and
a 9 month history of left sided headaches who was admitted to
the Neurology service for evaluation for multifocal
intraparenchymal lesions seen on brain MRI. She had a non focal
neurologic examination. Differential for her CNS lesions include
subacute stroke, infectious, inflammatory, autoimmune,
malignant,and demyelinating etiologies. She was started on daily
aspirin 81 mg.
Her stroke risk factors include the following:
1) DM: A1c 5.7%
2) Mild multifocal atherosclerotic disease within the
intracranial and
cervical vasculature, without high-grade stenosis, occlusion,
dissection, or
aneurysm seen on CTA.
3) Hyperlipidemia: LDL 167, Total cholesterol 263, HDL 82;
repeat with LDL 119, Total cholesterol 201, HDL 71. Low dose
atorvastatin started with plan to monitor for tolerance and
increase as an outpatient.
4) Screening for cardiac risk factors: screening echocardiogram
showed normal biventricular cavity sizes with preserved global
and regional biventricular systolic function. No thrombus or
mass visualized. Patient discharged home with cardiac rhythm
monitoring to evaluate for paroxysmal atrial fibrillation.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. No thrombus
or mass visualized.
She had a shoulder xray which showed degenerative joint changes.
Urinalysis was positive however patient was asymptomatic and
reported that her urine is always falsely positive due to
pessary. Screening CXR was normal. She underwent a lumbar
puncture which has 0 WBC, 0 RBC, and normal protein and glucose.
Flow was attempted however because sample was acellular,
cytology could not be performed. Patient had a low-pressure
headache following the lumbar puncture which was controlled with
IV fluids and fioricet. Gabapentin was started for neuropathic
pain.
Additional serum and CSF studies are pending.
AHA/ASA Core Measures for Ischemic Stroke and Transient
Ischemic Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? (x) Yes - () No not applicable
4. LDL documented? (x) Yes (LDL = 119 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL if LDL >70, reason not given: started low dose atorvastatin
and will monitor for tolerance given muscle ackes
[ ] Statin medication allergy
[x] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL]
6. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
() Yes - (x) No patient direct admission from home, no
rehabilitation needs
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Code/Contact: Full
TRANSITIONAL ISSUES
[ ] Patient started on atorvastatin 20 mg nightly; monitor
tolerance and increase to 40 mg nightly if tolerated
[ ] started on gabapentin 100 mg nightly for neuropathic pain,
if needed consider increasing
[ ] Follow up with Neurology Dr. ___ at
9:00 AM
[ ] repeat brain MRI in 2 months per Dr. ___
[ ] pending results of cardiac monitor, may consider
conventional angiogram
[ ] f/u pending CSF and serum studies
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mesalamine ___ 1600 mg PO BID
2. estradiol 0.01 % (0.1 mg/gram) vaginal 1X/WEEK
3. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
4. Ascorbic Acid ___ mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
8. Vitamin B Complex 1 CAP PO DAILY
The Preadmission Medication list is accurate and complete.
1. Mesalamine ___ 1600 mg PO BID
2. estradiol 0.01 % (0.1 mg/gram) vaginal 1X/WEEK
3. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
4. Ascorbic Acid ___ mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
8. Vitamin B Complex 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *butalbital-acetaminophen-caff [Fioricet] 50 mg-300 mg-40 mg
1 capsule(s) by mouth every 6 hours Disp #*12 Capsule Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*3
3. Atorvastatin 20 mg PO QPM
Your doctor may increase the dose if you are tolerating the
medication.
RX *atorvastatin 20 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*2
4. Gabapentin 100 mg PO QHS
RX *gabapentin 100 mg 1 capsule(s) by mouth nightly Disp #*30
Capsule Refills:*2
5. Ascorbic Acid ___ mg PO DAILY
6. Estradiol 0.01 % (0.1 mg/gram) vaginal 1X/WEEK (___)
7. Mesalamine ___ 1600 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Vitamin B Complex 1 CAP PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *butalbital-acetaminophen-caff [Fioricet] 50 mg-300 mg-40 mg
1 capsule(s) by mouth every 6 hours Disp #*12 Capsule Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*3
3. Atorvastatin 20 mg PO QPM
Your doctor may increase the dose if you are tolerating the
medication.
RX *atorvastatin 20 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*2
4. Gabapentin 100 mg PO QHS
RX *gabapentin 100 mg 1 capsule(s) by mouth nightly Disp #*30
Capsule Refills:*2
5. Ascorbic Acid ___ mg PO DAILY
6. Estradiol 0.01 % (0.1 mg/gram) vaginal 1X/WEEK (___)
7. Mesalamine ___ 1600 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Vitamin B Complex 1 CAP PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Abnormal brain imaging
Hyperlipidemia
Neuropathic Pain
Low Pressure Headache
Discharge Condition:
Alert and oriented. Non focal neurologic exam. Able to ambulate
independently.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized for evaluation of lesions on your brain
MRI of unclear etiology which may be related to infection,
inflammation, or small strokes. Although we do not know if you
had small strokes, a condition where a blood vessel providing
oxygen and nutrients to the brain is blocked by a clot, we still
assessed you for medical conditions that might raise your risk
of having stroke. In order to prevent future strokes, we plan to
modify those risk factors. Your risk factors are:
- high cholesterol
We are changing your medications as follows:
Take atorvastatin 20 mg nightly because your cholesterol is
elevated. You will discuss increasing this medication with your
doctor.
Take gabapentin 100 mg nightly for neuropathic pain (your "pain
in head").
Take aspirin 81 mg daily.
Take fioricet as needed for headache related to lumbar puncture.
Do not take with Tylenol.
Please take your other medications as prescribed.
We also evaluated for cardiac risk factors for stroke. Your
echocardiogram was unremarkable. You will be monitored at home
with a cardiac monitor to evaluate for atrial fibrillation which
can also cause strokes.
You had a imaging study called a CT angiogram that showed mild
atherosclerotic disease in the blood vessels in your brain.
You had a shoulder xray which showed degenerative joint changes.
You had a lumbar puncture which showed no concerning cells for
inflammation or infection but there are some other specific
tests pending. You had a mild "low pressure headache" after the
lumbar puncture. You can increase fluid intake, drink caffeine,
lay flat and take Fioricet as prescribed to help with this pain.
You will follow-up with Dr. ___ further management.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). Please pay attention to the sudden onset
and persistence of these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10774318-DS-13
| 10,774,318 | 25,793,182 |
DS
| 13 |
2156-12-19 00:00:00
|
2156-12-19 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:
Palpitations / tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with history of HTN, HLD, type 2 diabetes, alcoholic
cirrhosis, EtOH abuse 2 months in remission, presenting with
palpitations since last evening. Transferred to ICU on esmolol
gtt.
Patient notes that symptoms started at 6PM last evening when ___
felt his heart racing, with fast beating sensation in chest. No
chest pain, fevers/chills, shortness of breath, nausea/vomiting.
No cough, dysuria, hematuria, or hemotochezia. ___ presented to
___ where ___ was given 2 rounds of adenosine (first
6mg then 12mg) and given PO dilt (no IV dilt available) and IV
metoprolol without effect, and was then started on esmolol gtt
and transferred to ___. On esmolol gtt, patient was in sinus
rhythm. Patient notes that ___ feels a lot of anxiety during
these
episodes, and notes feeling similar episodes about ___ times
prior to last evening, this past week, while lying in bed at
night.
Patient has a history of ETOH abuse, but denies drinking
presently (patient went to detox and has been sober for 2
months.) ___ has a history of alcoholic cirrhosis, and notes an
admission to ___ in ___, for which ___ required
intubation, and noted being jaundiced.
In the ED,
- Initial vitals were: 98.2 84 130/75 16 98% RA
Esmolol gtt was stopped, and IV dilt 15mg was given, however,
patient had rates back to 150s, esmolol was restarted.
- Exam notable for:
Stool was weakly guaiac positive and brown
- Labs notable for:
Normal chem7
Mg 1.4
CBC: 10.6 > 8.7 / 26.2 < 162
Trop-T < 0.01
ALT/AST ___, AP 197, Tbili 4.8, Alb 3.6, Lip 33
UCx pending
- Studies notable for: EKGs done, not uploaded
- Patient was given: Diltiazem 15mg IV, and esmolol gtt
In the ED, while off the esmolol patient
- Transfer vitals were: 95 ___ 97% RA
On arrival to the CCU, patient notes feeling relatively
comfortable. Notes no palpitations, but does have chronic pain
in
his left hip and asking for pain medications.
Past Medical History:
Hypertension
Hyperlipemia
Kidney stones
Osteoarthritis
Type 2 diabetes mellitus with diabetic nephropathy
Microalbuminuria
Elevated LFTs
Gouty arthropathy
Alcohol abuse, in remission
Alcoholic cirrhosis of liver with ascites
H/O: upper GI bleed
Social History:
___
Family History:
Father with afib in old age
Mother did not have cardiac disease
Physical Exam:
===============================
ADMISSION PHYSICAL EXAMINATION:
===============================
VS: 98.4, 82 sinus, 127/80, 95% RA
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic, atraumatic. Sclera anicteric. EOMI.
NECK: Supple. JVP 12cm at 45 degrees.
CARDIAC: Normal rate, regular rhythm. systolic murmur heard
loudest at apex, holosystolic, III/VI, no rubs or gallops.
LUNGS: Respiration is unlabored with no accessory muscle use.
Mild crackles at the bases bilaterally
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. Scant edema bilaterally
SKIN: several excoriations on the back
NEURO: A&Ox3, moving all extremities with purpose.
===============================
DISCHARGE PHYSICAL EXAMINATION:
===============================
24 HR Data (last updated ___ @ 422)
Temp: 98.4 (Tm 98.7), BP: 141/86 (125-150/71-86), HR: 84
(81-88), RR: 17 (___), O2 sat: 97% (96-100), O2 delivery: Ra
Fluid Balance (last updated ___ @ 641)
Last 8 hours Total cumulative -475ml
IN: Total 0ml
OUT: Total 475ml, Urine Amt 475ml
Last 24 hours Total cumulative -250ml
IN: Total 1120ml, PO Amt 1120ml
OUT: Total 1370ml, Urine Amt 1370ml
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic, atraumatic. Sclera anicteric. EOMI.
NECK: Supple. JVP 12cm at 45 degrees.
CARDIAC: Normal rate, regular rhythm. systolic murmur heard
loudest at apex, holosystolic, III/VI, no rubs or gallops.
LUNGS: Respiration is unlabored with no accessory muscle use.
Mild crackles at the bases bilaterally
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. Scant edema bilaterally
SKIN: several excoriations on the back
NEURO: A&Ox3, moving all extremities with purpose
Pertinent Results:
==============
ADMISSION LABS
==============
___ 11:11PM GLUCOSE-128* UREA N-9 CREAT-0.9 SODIUM-139
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-21* ANION GAP-15
___ 11:11PM CALCIUM-9.1 PHOSPHATE-2.6* MAGNESIUM-1.4*
___ 11:11PM WBC-10.3* RBC-2.56* HGB-8.5* HCT-25.1* MCV-98
MCH-33.2* MCHC-33.9 RDW-16.9* RDWSD-61.3*
___ 11:11PM PLT COUNT-153
___ 05:30AM URINE HOURS-RANDOM
___ 05:30AM URINE UHOLD-HOLD
___ 05:30AM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 05:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-NEG
___ 05:30AM URINE RBC-0 WBC-3 BACTERIA-FEW* YEAST-NONE
EPI-<1
___ 05:30AM URINE GRANULAR-1* HYALINE-4*
___ 05:30AM URINE MUCOUS-RARE*
___ 04:00AM GLUCOSE-116* UREA N-6 CREAT-0.8 SODIUM-142
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-22 ANION GAP-14
___ 04:00AM estGFR-Using this
___ 04:00AM ALT(SGPT)-22 AST(SGOT)-48* ALK PHOS-197* TOT
BILI-4.8*
___ 04:00AM LIPASE-33
___ 04:00AM cTropnT-<0.01
___ 04:00AM ALBUMIN-3.6 CALCIUM-8.9 PHOSPHATE-3.3
MAGNESIUM-1.4*
___ 04:00AM TSH-3.3
___ 04:00AM WBC-10.6* RBC-2.64* HGB-8.7* HCT-26.2*
MCV-99* MCH-33.0* MCHC-33.2 RDW-16.8* RDWSD-61.2*
___ 04:00AM NEUTS-68.2 ___ MONOS-7.8 EOS-3.1
BASOS-0.5 IM ___ AbsNeut-7.21* AbsLymp-2.10 AbsMono-0.82*
AbsEos-0.33 AbsBaso-0.05
___ 04:00AM PLT COUNT-162
=================
PERTINENT STUDIES
=================
___ TTE
Mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global biventricular systolic function. Mild
pulmonary artery systolic hypertension. Mild mitral
regurgitation. Very small circumferential pericardial effusion.
___ RUQUS
Coarse hepatic parenchymal echotexture with minimal peripheral
intrahepatic biliary ductal dilation. No focal liver lesions
identified. The main portal vein is patent with normal
direction of flow. There is a recanalized umbilical vein. Trace
free fluid in the left lower quadrant.
Splenomegaly with the spleen measuring 15 cm in the craniocaudal
axis.
Conglomeration of these findings raise concern for chronic liver
disease with portal hypertension.
============
MICROBIOLOGY
============
Microbiology Results(last 7 days) ___
__________________________________________________________
___ 5:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
==============
DISCHARGE LABS
==============
___ 07:54AM BLOOD WBC-8.6 RBC-2.60* Hgb-8.7* Hct-25.3*
MCV-97 MCH-33.5* MCHC-34.4 RDW-16.6* RDWSD-58.4* Plt ___
___ 07:54AM BLOOD Plt ___
___ 07:54AM BLOOD ___ PTT-36.1 ___
___ 05:15AM BLOOD Ret Aut-3.2* Abs Ret-0.08
___ 07:54AM BLOOD Glucose-138* UreaN-7 Creat-0.8 Na-140
K-3.8 Cl-104 HCO3-22 AnGap-14
___ 07:54AM BLOOD ALT-20 AST-47* AlkPhos-181* TotBili-4.8*
___ 07:54AM BLOOD Albumin-3.7 Calcium-9.1 Phos-3.4 Mg-1.4*
___ 05:15AM BLOOD Hapto-<10*
Brief Hospital Course:
___ yo M with history of HTN, HLD, type 2 diabetes, alcoholic
cirrhosis, EtOH abuse 2 months in remission, presenting with
palpitations, found to be in narrow complex regular SVT,
transferred to ICU on esmolol gtt.
#CORONARIES: unknown
#PUMP: EF 66%
#RHYTHM: sinus
#Tachycardia / palpitations
Patient presenting with several episodes of palpitations at
home. EKG showing regular narrow complex tachycardia, likely
consistent with atrial tachycardia vs. nodal re-entrant
tachycardia. No telemetry strips available showing transition,
but converted to sinus prior to arrival to CCU. Patient does
note significant anxiety with these episodes, however, rates are
faster than would expect from anxiety alone. History of
withdrawal symptoms, but per patient, no recent alcohol use but
does endorse significant coffee intake which was new for him,
and likely the underlying cause for his new arrhythmia. ___ had a
brief run of what was likely Atrial Tachycardia on ___, and as
such was transitioned from Nadolol to Sotalol with close QTc
monitoring and no prolongation. Given this, ___ was discharged on
Sotalol with Cardiology and PCP follow ___ should be
considered for ablation in the future if ___ has another run of
re-entrant tachycardia, though Sotalol and avoiding caffeine may
be sufficient.
#Anemia
Patient with anemia, which appears to be stable from outside
hospital (~9) but down from a year ago (per atrius record Hgb
12.2). Per atrius records patient does have history of upper GI
bleed. Brown stool in ED but mildly guaiac positive. No overt
signs of bleeding. Patient has significant alcohol history so
marrow suppression is possible, but other counts are normal. CBC
remained stable while inpatient, and patient should have CBC
check as outpatient, though no clear signs of bleeding while the
patient was in the hospital.
#Alcoholic cirrhosis
#Cholestasis
Patient with extensive alcohol abuse history, and per report,
cirrhosis had been diagnosed. ___ notes a hospitalization with
intubation in the setting of jaundice at ___ in ___.
Elevated tbili on admission. No abd tenderness. RUQUS notable
for splenomegaly, trace ascites. ___ was continued on his home
lactulose, rifaxamin, and his LFTs were trended while ___ was
inpatient. ___ should continue to follow with hepatology as an
outpatient for management of his cirrhosis.
#DMII
Metformin held while inpatient, started on HISS. Restarted
Metformin on discharge.
#HTN
Per patient, no longer on antihypertensive, but recently filled
HCTZ and amlodipine and metoprolol. Discharged off of these
medications with stable BPs. Please trend BP as outpatient and
consider adding back on antihypertensives as needed.
#Gout
Continued home allopurinol
TRANSITIONAL ISSUES:
======================
[] Please obtain EKG at first follow up for QTc monitoring while
on Sotalol: Discharge QTc 460
[] Please obtain CBC at first follow up to ensure Anemia stable
[] Please ensure that the patient has follow up with hepatology
for cirrhosis
[] Please monitor patient's blood pressure: HCTZ, amlodipine and
metoprolol all held in setting of normotension off of these
medications as well as starting Sotalol
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lactulose 15 mL PO DAILY
2. Omeprazole 20 mg PO BID
3. Rifaximin 550 mg PO BID
4. Allopurinol ___ mg PO DAILY
5. Propranolol 10 mg PO BID
6. Furosemide 20 mg PO DAILY
7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation as
needed
8. Metoprolol Tartrate 50 mg PO BID
9. Hydrochlorothiazide 25 mg PO DAILY
10. MetFORMIN (Glucophage) 500 mg PO BID
11. Benzonatate 100 mg PO TID
12. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Sotalol 80 mg PO BID
RX *sotalol 80 mg 1 tablet(s) by mouth Twice daily Disp #*60
Tablet Refills:*0
2. Allopurinol ___ mg PO DAILY
3. Benzonatate 100 mg PO TID
4. Furosemide 20 mg PO DAILY
5. Lactulose 15 mL PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Omeprazole 20 mg PO BID
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
AS NEEDED
9. Rifaximin 550 mg PO BID
10. Tiotropium Bromide 1 CAP IH DAILY
11. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until you follow up
with your primary care doctor or cardiologist
12. HELD- Metoprolol Tartrate 50 mg PO BID This medication was
held. Do not restart Metoprolol Tartrate until you follow up
with your primary care doctor or cardiologist
13. HELD- Propranolol 10 mg PO BID This medication was held. Do
not restart Propranolol until you follow up with your primary
care doctor or cardiologist
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
====================
Re-entrant tachycardia
Secondary Diagnosis:
=====================
Anemia
Cirrhosis
Hypertension
Diabetes II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were here because of palpitations and a fast heart rate
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- You were given medications to slow your heart rate.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
Followup Instructions:
___
|
10774499-DS-7
| 10,774,499 | 24,095,157 |
DS
| 7 |
2160-10-14 00:00:00
|
2160-10-16 14:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Fevers/chills
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ male with a history of HTN, paroxysmal afib,
OSA, gout, renal insufficiency, and HTN who presented with
fevers
and chills s/p prostate biopsy yesterday.
Patient underwent an uneventful prostate biopsy yesterday with
Dr. ___. He received cipro and gentamicin prior to the
procedure. Overnight he says that he started to experience
significant chills and says he had a fever. Describes some minor
rectal bleeding overnight as well. Then this morning he states
that the rigors continued and his temp was elevated to 103.
Denies SOB, CP, N/V, dysuria, hematuria at this time. Voiding
appropriately.
Past Medical History:
HTN x 4+ years
Atrial fibrillation -- one episode in ___ with RVR to 120s,
spontaneously resolved, currently rate controlled with atenolol
GERD
Heavy EtOH use (currently less so)
Social History:
___
Family History:
Significant for HTN.
Physical Exam:
Gen: No acute distress, alert & oriented
CHEST: no tachypnea, regular rate
BACK: Non-labored breathing, no CVA tenderness bilaterally
ABD: Soft, non-tender, non-distended, no guarding or rebound
EXT: Moves all extremities well.
Pertinent Results:
___ 07:45AM BLOOD WBC-7.0 RBC-3.88* Hgb-11.8* Hct-35.6*
MCV-92 MCH-30.4 MCHC-33.1 RDW-11.5 RDWSD-38.9 Plt ___
___ 07:15AM BLOOD WBC-7.8 RBC-4.07* Hgb-12.6* Hct-38.1*
MCV-94 MCH-31.0 MCHC-33.1 RDW-11.6 RDWSD-39.4 Plt ___
___ 07:15AM BLOOD Glucose-105* UreaN-11 Creat-1.2 Na-138
K-4.1 Cl-105 HCO3-21* AnGap-12
___ 11:20AM BLOOD Glucose-120* UreaN-7 Creat-1.4* Na-135
K-4.1 Cl-98 HCO3-20* AnGap-17
___ 11:20 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ 0132 ON
___ -
___.
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
___ 11:16 am URINE ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 CFU/mL.
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
Mr. ___ was admitted to the Urology service under Dr.
___. He was started on Meropenem and approval was obtained
from ID. His fever curve improved daily. Overnight on the first
day he spiked a fever to 103 but no further fevers after this
isolated episode. Urine and blood cultures were positive for
___ to Cipro. Repeat blood and urine cultures were
obtained after proper treatment. Urine culture was negative and
blood cultures no growth to date at the time of discharge.
Patient did well on the appropriate antibiotics and was
discharged on PO cipro x 10 days. He will follow up as
scheduled.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol Dose is Unknown PO DAILY
2. Atenolol 100 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Multivitamins 1 TAB PO DAILY
5. Aspirin 325 mg PO DAILY
6. Tamsulosin 0.4 mg PO QHS
7. Albuterol Sulfate (Extended Release) Dose is Unknown PO
Frequency is Unknown
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Ciprofloxacin HCl 500 mg PO Q12H
3. Albuterol Sulfate (Extended Release) 4 mg PO Q12H
4. Allopurinol ___ mg PO DAILY
5. Atorvastatin 80 mg PO QPM
Do not take this med while taking the antibiotic prescribed
(Ciprofloxacin)
6. Aspirin 325 mg PO DAILY
7. Atenolol 100 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Infection after prostate biopsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Resume your pre-admission/home medications except as noted.
ALWAYS call to inform, review and discuss any medication changes
and your post-operative course with your primary care doctor.
-___ should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-Call your Urologist's office to schedule/confirm your follow-up
appointment AND if you have any questions.
-If prescribed; always complete the full course of antibiotics
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 2 weeks or until
otherwise advised. Light household chores/activity and leisurely
walking/activity is OK and should be continued. Do NOT be a
couch potato
-Tylenol should be your first-line pain medication. A narcotic
pain medication has been prescribed for breakthrough pain ___.
-Max daily Tylenol (acetaminophen) dose is THREE to FOUR grams
from ALL sources
AVOID lifting/pushing/pulling items heavier than 10 pounds (or
3 kilos; about a gallon of milk) or participate in high
intensity physical activity (which includes intercourse) until
you are cleared by your Urologist in follow-up.
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room.
Followup Instructions:
___
|
10774541-DS-17
| 10,774,541 | 28,106,752 |
DS
| 17 |
2153-08-31 00:00:00
|
2153-09-01 09:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bloody diarrhea
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy
History of Present Illness:
This is a ___ man who presents for the evaluation of
bloody stools. He carries a diagnosis of "ulcerative proctitis"
made in ___ in ___. His original presentation was non-painful
bloody stools. Since that time, he has been taking Mesalamine
Enemas daily for maintenance therapy. Since his first diagnosis,
he has had two flares, both of which presented with non-painful
bright red blood per rectum. On each occasion, he discussed with
his doctors in ___ who prescribed him Rifaximin, and his
symptoms resolved in 5 days.
On this occasion, the patient first noticed bloody stools 14
days
ago. He conferred with his doctors in ___, and was prescribed
rifaximin, which he took from ___ through this past ___
without relief. Over the last ___ days, he has had innumerable
small volume bloody stools per day. No fevers or chills. No
abdominal pain. No nausea or vomiting, but has had poor appetite
in the last 2 3 days. No cardiopulmonary symptoms.
Past Medical History:
Ulcerative Colitis
Social History:
___
Family History:
Noncontibutory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: ___ 2318 Temp: 98.1 PO BP: 126/79 R Sitting HR: 98 RR:
18 O2 sat: 100% O2 delivery: Ra
GENERAL: NAD, lying comfortably in bed
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema. No rashes.
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Physical Exam at Discharge:
PHYSICAL EXAM:
Vitals: Temp: 98.1 PO BP: 120/78 HR: 79 RR: 18 O2 sat: 99% O2 RA
GENERAL: Alerted, oriented x 3. Pleasant, lying in bed
comfortably.
HEENT: Normocephalic. Sclera anicteric and without injection.
Oral MMM, clear oropharynx without exudates.
CARDIAC: Regular rate, rhythm. S1 S2 audible. No m/g/r.
LUNGS: CABL, no c/w/r.
ABDOMEN: Bowel sounds in all four quadrants, soft NTND, no
rebound tenderness or guarding. No organomegaly.
EXTREMITIES: Warm, well perfused, no lower extremity edema. Cap
refill <2s.
SKIN: No significant rashes.
NEUROLOGIC: A&Ox3, no focal neuro deficits.
Pertinent Results:
___ 08:30PM GLUCOSE-107* UREA N-7 CREAT-1.2 SODIUM-137
POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-25 ANION GAP-15
___ 08:30PM estGFR-Using this
___ 08:30PM ALT(SGPT)-14 AST(SGOT)-19 LD(LDH)-258* ALK
PHOS-113 TOT BILI-0.5
___ 08:30PM ALBUMIN-3.9 CALCIUM-9.6 PHOSPHATE-3.7
MAGNESIUM-1.6 IRON-27*
___ 08:30PM calTIBC-395 FERRITIN-14* TRF-304
___ 08:30PM CRP-16.0*
___ 08:30PM WBC-5.7 RBC-4.85 HGB-10.9* HCT-35.6* MCV-73*
MCH-22.5* MCHC-30.6* RDW-16.7* RDWSD-43.7
___ 08:30PM NEUTS-46.0 ___ MONOS-17.3* EOS-7.2*
BASOS-0.9 IM ___ AbsNeut-2.63 AbsLymp-1.61 AbsMono-0.99*
AbsEos-0.41 AbsBaso-0.05
___ 08:30PM PLT COUNT-258
___ 05:10AM BLOOD WBC-14.6* RBC-4.73 Hgb-10.9* Hct-35.7*
MCV-76* MCH-23.0* MCHC-30.5* RDW-18.9* RDWSD-46.5* Plt ___
___ 05:10AM BLOOD Glucose-141* UreaN-19 Creat-1.0 Na-138
K-4.8 Cl-97 HCO3-28 AnGap-13
___ 05:10AM BLOOD Calcium-9.2 Phos-5.5* Mg-2.2
Brief Hospital Course:
Mr. ___ is an otherwise healthy ___ with a history of
ulcerative proctitis diagnosed in ___, on maintenance
mesalamine, presenting with 2 weeks of bloody diarrhea
consistent with severe ulcerative colitis flare. Has failed IV
steroid management. Hemodynamically stable. S/p remicade x1 on
___. Still with some blood in the stool and decreasing
frequency of bowel movements.
ACUTE ISSUES:
===============
#Bloody diarrhea
#UC Flare
On admission, the patient complained of approximately 10 bloody
bowel movements per day, anemia (Hgb nadir 9.6), and CRP 16.
UC flare confirmed on flexible sigmoidoscopy on ___, with
diffuse continuous erythema, granularity, friability, exudate
and small ulcers with spontaneous bleeding, concerning for
severe UC flare. Our infectious colitis workup was negative, as
all stool testing was negative for any parasitic or bacterial
infections. We trialed the patient on high-dose IV steroids,
however he continued to have upwards of 5 bloody bowel movements
per day. Quantiferon gold negative, and hepatitis B Ab positive.
At this time per gastroenterology recommendations, we started
the patient on IV Remicade on ___. Given the high risk of
colectomy in patients who fail IV steroid therapy, we contacted
her colorectal surgery colleagues so that they would be able to
meet Mr. ___ in the event that he would need a colectomy.
There is no surgical intervention indicated at this time. On day
of discharge, ___ the patient reported that his bowel
movement frequency had decreased to 1 time per day and that it
was "only with a couple drops of blood. At the time of
discharge, he will be sent home on prednisone 40 mg p.o. daily
with a taper plan as outlined in the discharge instructions. He
will need to see gastroenterology in ___ weeks and will also
need to be set up for Remicade IV as an outpatient.
# Iron deficiency anemia
During the hospitalization was noted that the patient was
slightly anemic with a H/H of 10.9/35.7. We initially were
concerned about acute GI bleed losses secondary to the bloody
diarrhea. This is the most likely source of the patient's
anemia. As we have significantly decreased the amount of blood
in the patient's stool, we suspect that this will improve. There
is no evidence of hemodynamic instability. The patient has not
required any blood products throughout stay. It may be
worthwhile for the patient to pursue IV iron infusions as an
outpatient given ferritin 14.
# Transitional issues
Patient will need follow-up with gastroenterology and PCP
Patient will need to be set up for IV Remicade infusions as an
outpatient
Please check CBC to ensure resolution of the anemia, and
consider iron supplementation/infusion as outpatient. Discharge
Hgb 10.9
We would recommend vaccination for influenza yearly as well as
pneumococcus influenza.
- Patient at increased risk of colorectal cancer, screening TBD
by GI and PCP
___ on ___:
The Preadmission Medication list is accurate and complete.
1. Mesalamine (Rectal) ___AILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
2. PredniSONE 40 mg PO DAILY
Take 4 pills for 3 days, then 3 pills for 3 days, than 2 pills
for 3 days and then 1 pill for 3 days
RX *prednisone 10 mg 4 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Ulcerative colitis
Discharge Condition:
Return to his baseline functional status. No limits on
ambulation. Thought content processes clear and at baseline,
patient verbalized an understanding of his diagnosis and
treatment plan.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
-Bloody diarrhea, abdominal pain
WHAT HAPPENED IN THE HOSPITAL?
-We performed a flexible sigmoidoscopy, looking at your colon
which showed a flare of your ulcerative colitis
-We tried intravenous steroids, however this did not decrease
the inflammation in your colon
We then had gastroenterology recommend using infliximab to help
decrease your inflammation.
WHAT SHOULD YOU DO AT HOME?
-Please keep your follow-up appointments with your PCP and
gastroenterologist
Please continue taking her prednisone as prescribed
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
10774619-DS-8
| 10,774,619 | 22,990,451 |
DS
| 8 |
2175-08-09 00:00:00
|
2175-08-09 13:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Percocet
Attending: ___.
Chief Complaint:
right sided weakness, aphasia
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Pt is a ___ year old man w/ history of prior CVA ___ year ago w/
residual R eye vision loss, CAD s/p CABG and bare metal stent,
HTN, HLD who was transferred from ___ with new R sided
weakness and aphasia on ___.
The patient's wife reports that she heard the patient roll out
of bed around 0400 on ___. Last known well was at midnight
prior. Patient's wife described that patient was unable to
effectively stand up, remaining on his knees. He responded to
questions with one word responses, but appeared to comprehend,
according to his wife.
EMS was called and pt was brought to ___ where he was
seen to have R facial droop, R hemibody weakness, and aphasia
with NIHSS of 5. He was deemed not to be a tPA candidate and
underwent NCHCT and CTA ___, the former of which showed old
infarcts and latter which was unremarkable. Per documentation,
pt's aphasia and R sided weakness improved somewhat in OSH ED,
although wife does not believe this. Due to concern that pt may
be an interventional candidate, pt was transferred to ___ for
further evaluation.
Pt's stroke risk factors include longstanding hx of HTN, HLD,
and heart disease w/ prior MI and placement of BMS on DAPT. Of
note, pt had a stroke ___ year ago with residual loss of vision in
R eye. At that time, was also seen on imaging to have other area
of cerebral infarct but wife unaware of any prior neurovascular
event. He has a remote history of smoking (40+ years ago) and no
family history of strokes.
Past Medical History:
Hypertension
Hyperlipidemia
Prior CVA ___ yr ago w/ residual loss of vision in R eye/CRAO
CAD s/p CABG in ___ and BMS placement in ___ on DAPT
Gout
Benign Prostatic Hypertrophy
Social History:
___
Family History:
Noncontributory
Physical Exam:
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to person and place.
Able to speak fluently in ___ and ___, although with
thickened accent in ___ and few paraphasic errors. Able to
name high frequency objects. Repetition intact. Minimal
dysarthria. Able to follow most midline and appendicular
commands.
- Cranial Nerves: R pupil 4mm, minimally reactive, L pupil
4->2mm brisk. Right fundus with paucity of vessels, with loss of
vision (no light perception) on visual acuity testing. Left eye
with right hemianopsia and incomplete left upper
quadrantanopsia. Very subtle right facial weakness and asymmetry
on smile, which improved with emotional smile. Hearing intact
bilaterally. Palate elevation symmetric. SCM/trapezius ___.
Tongue protrusion midline.
- Motor: Normal bulk, paratonia present. No tremor or
asterixis.
[___]
L 5 5 5 5 5 5 5 5 5 5 5
R 5- 5 5 5- 4+ 5- 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 3 2+ 1 0
R 2+ 3 2+ 1 0
Plantar response flexor bilaterally.
- Sensory: Slightly decreased sensation to LT, PP and vibration
over
RUE/RLE. On half of trials, extinction to DSS on right hemiside.
- Coordination: No dysmetria with finger to nose testing on LUE.
Significant dysmetria on RUE.
- Gait: Deferred.
Pertinent Results:
LABS:
___ 07:30PM GLUCOSE-99 UREA N-21* CREAT-1.1 SODIUM-141
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-25 ANION GAP-12
___ 07:30PM ALT(SGPT)-14 AST(SGOT)-20 LD(LDH)-194
CK(CPK)-134 ALK PHOS-73 TOT BILI-0.6
___ 07:30PM CK-MB-2 cTropnT-<0.01
___ 07:30PM ALBUMIN-3.9 CHOLEST-126
___ 07:30PM %HbA1c-5.2 eAG-103
___ 07:30PM TRIGLYCER-72 HDL CHOL-62 CHOL/HDL-2.0
LDL(CALC)-50
___ 07:30PM TSH-0.58
___ 07:30PM WBC-9.2 RBC-3.95* HGB-13.5* HCT-39.2* MCV-99*
MCH-34.2* MCHC-34.4 RDW-13.1 RDWSD-47.6*
___ 07:30PM ___ PTT-27.6 ___
___ 06:53AM LACTATE-1.9
___ 06:45AM GLUCOSE-104* UREA N-29* CREAT-1.3* SODIUM-140
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-23 ANION GAP-15
___ 06:45AM ALT(SGPT)-16 AST(SGOT)-24 CK(CPK)-131 ALK
PHOS-71 TOT BILI-0.3
___ 06:45AM cTropnT-<0.01
___ 06:45AM CK-MB-3
___ 06:45AM ALBUMIN-4.0
___ 06:45AM ASA-NEG ETHANOL-37* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 06:45AM WBC-7.3 RBC-3.86* HGB-13.4* HCT-39.3*
MCV-102* MCH-34.7* MCHC-34.1 RDW-13.1 RDWSD-48.7*
___ 06:45AM NEUTS-77.7* LYMPHS-13.6* MONOS-7.5 EOS-0.3*
BASOS-0.4 IM ___ AbsNeut-5.67 AbsLymp-0.99* AbsMono-0.55
AbsEos-0.02* AbsBaso-0.03
___ 06:45AM ___ PTT-26.7 ___
IMAGING:
CTA ___ & Neck w/ and w/o contrast ___:
IMPRESSION:
1. Suggestion of acute infarct upper posterior right cerebellum.
2. Suggestion of small acute infarct in the left
parietal/occipital lobe with area of ischemic penumbra. MRI
brain recommended
3. Findings consistent with early subacute left thalamic
infarct.
4. Chronic right PCA distribution infarct.
5. Significant atherosclerotic narrowing bilateral vertebral
arteries at their origins and V4 segments. Moderately narrowed
proximal basilar artery. Moderately attenuated left P3 segment.
6. Approximately 45% narrowing left proximal ICA. Moderate
narrowing right supraclinoid ICA. Moderate narrowing single
right M2 branch.
MR ___ w/o contrast ___:
IMPRESSION:
1. Acute to early subacute moderately extensive infarcts in the
left PCA
distribution, right cerebellum, and an additional punctate
infarct left
cerebellum.
2. Few punctate foci of microhemorrhage in the right cerebellum,
follow-up
___ CT within 24 hours recommended.
3. Chronic right occipital lobe infarct.
4. Moderate brain parenchymal atrophy..
5. Inflammatory changes of the paranasal sinuses as described
above.
CT ___ w/o Contrast ___:
IMPRESSION:
1. No evidence of interval intraparenchymal hemorrhage.
2. Multiple parenchymal hypodensities within the left PCA
distribution and
right cerebellum. The punctate infarct in the left cerebellum
identified on MR is not well visualized the current study.
3. Overall these lesions are stable in size and appearance as
compared to the prior MR, but have increased in size as compared
to the ___ CT dated ___.
4. No new regions suspicious for infarct identified.
5. Chronic infarct in the right occipital lobe again identified.
Echocardiogram on ___:
The left atrial volume index is normal. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF = 60%). However, the apex is hypokinetic with focal
akinesis. No masses or thrombi are seen in the left ventricle.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The 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. Moderate (2+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Brief Hospital Course:
Mr. ___ is a ___ year old with history of HTN, HLD, CAD s/p
CABG and bare metal stent, and prior CVA with acute monocular
vision loss (suspected CRAO) who was admitted to the Neurology
stroke service with aphasia and right-sided weakness and found
to have multifocal ischemic infarcts in posterior circulation
territories (R cerebellum, L occipital and L thalamus). Given
its location in multiple posterior circulation territories, we
feel his stroke was mostly due to a proximal source e.g. cardiac
embolism from apical ventricular akinesis as visualized on echo.
For that reason, we will start him on Apixaban for
anticoagulation. His deficits improved greatly prior to
discharge. He still had significant R-sided motor dyscordination
with minimal speech impairment at time of discharge. He will
continue rehab at a rehab center.
His stroke risk factors include the following:
1) Intracranial atherosclerosis of both anterior and posterior
circulation.
2) Hyperlipidemia: well controlled on Atorvastatin 80mg with
LDL 50
3) Hypertension
4) Cardiac disease - CAD, abnormal cardiac wall motion.
An echocardiogram showed apical areas of hypokinesis and
akinesis. No thrombus was visualized, though the study was
limited.
During his stay, he also had urine and blood cultures sent
after developing a self-limiting acute episode of confusion.
Urine culture was negative and final blood culture results
pending at time of discharge. He remained afebrile without other
changes in mental status and further infectious workup was not
pursued. He also exhibit symptoms of depression, for which he
was started on Fluoxetine 10mg daily.
Transitional issues:
- Anticoagulation: He is being discharged on both Aspirin 325mg
daily and Plavix 75mg daily. On ___ (2 weeks after stroke),
he should START Apixaban 5mg PO BID, REDUCE his Aspirin dose to
81mg daily, and STOP Plavix. Apixaban prior authorization was
initiated on ___ and should be processed within 24 hours.
- HTN: His anti-hypertensive regimen was reduced during his
admission. He was maintained on Metoprolol 25mg BID and
Valsartan 160mg BID prior to discharge. His Valsartan-HCTZ is to
be resumed on discharge, and his Metoprolol dose may be
increased as indicated with BP monitoring.
- Depression: He exhibited symptoms of depression after his
stroke. He was started on Fluoxetine 10mg PO daily on ___.
Please INCREASE his dose to 20mg PO daily on ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Clopidogrel 75 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Allopurinol ___ mg PO DAILY
4. valsartan-hydrochlorothiazide 320-25 mg oral DAILY
5. Terazosin 2 mg PO QHS
6. Terazosin 1 mg PO QHS
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Gabapentin Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Apixaban 5 mg PO BID
Start taking this medication on ___.
2. FLUoxetine 10 mg PO DAILY
Increase to 20mg daily on ___.
3. Metoprolol Tartrate 25 mg PO BID
4. Aspirin 81mg mg PO DAILY
5. Allopurinol ___ mg PO DAILY
6. amLODIPine 5 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Terazosin 2 mg PO QHS
9. Terazosin 1 mg PO QHS
10. valsartan-hydrochlorothiazide 320-25 mg oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of difficulty speaking
and weakness resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Hypertension
- High cholesterol
- Heart disease
We also started on a new medication, Fluoxetine, to treat
symptoms of depression. Depression is very common after a
stroke, and you should follow up with your PCP about how best to
manage this moving forward.
We are changing your medications as follows:
- Start taking Apixaban (Eliquis) 5mg twice daily on ___.
- When you start Apixaban
(1) DECREASE your dose of Aspirin from 325mg daily to
81mg daily.
(2) STOP taking Clopidogrel (Plavix)
- Continue taking Fluoxetine 10mg daily. Increase your dose to
20mg daily on ___.
- We reduced your blood pressure medications while you were
admitted. Your doctor ___ increase/resume your doses as
indicated to keep your blood pressure under good control.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10774729-DS-12
| 10,774,729 | 25,298,231 |
DS
| 12 |
2158-06-02 00:00:00
|
2158-06-06 20:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
pollen and ragweed / phenazopyridine
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo male with metastatic prostate cancer on zytiga/prednisone
and muscle-invasive bladder cancer s/p cystoprostatectomy who
presents with 2 days of worsening back pain.
Per patient, he has been experiencing dull, aching back pain for
the last ___ weeks. He initially felt the pain was improved with
advil and Tylenol, though states the effects of the pain
medication seemed to be wearing off over the last week. Two days
ago, he felt the pain became debilitating in the morning, to the
poin that he couldn't move or get out of bed ___ pain. Described
as ___ over his mid-lower back "at the waist-line" with
radiation down b/l anterior legs. He called an ambulance to
bring him to the hospital. Denies any recent trauma. Denies any
bowel or bladder incontinence, numbness or tingling of
extremities, weakness, F/C, abd pain, N/V/diarrhea. Does endorse
constipation, last BM the day prior to ED visit.
In the ED, initial vitals: Pain ___, 97.9, 55, 124/66, RR 19,
100% RA. Labs significant for WBC 9.1, Hgb 9.8.
CTAP with contrast showed:
1. Diffuse demineralization of the bones with acute superior
endplate compression fracture at L4.
2. Sclerotic lesion at the L5 vertebral body concerning for
metastatic disease.
3. Similar pattern and size of retroperitoneal and bilateral
pelvic lymphadenopathy.
4. Aneurysmal dilation of the infrarenal abdominal aorta
measuring 3.2 x 3.0 cm. Mildly dilated left and right common
iliac arteries. Extensive atherosclerosis.
5. Status post cystectomy and prostatectomy with neobladder
which appears uncomplicated.
6. Cholelithiasis without evidence of cholecystitis.
Patient given Tylenol/oxycodone and lidocaine patch with some
relief. Patient admitted to medicine for additional management.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Metastatic prostate cancer who is now ___ years s/p robot-assisted
laparoscopic radical cystectomy and ileal conduit urinary
diversion on ___. Started on zytiga/prednisone ___
with
no change in PSA. Receives q3monthly Lupron injections, last
given ___.
PAST MEDICAL HISTORY:
HTN, Hypercholesterolemia, Colonic polyps, GERD, COPD, active
tobacco use
Social History:
___
Family History:
Diabetes, CVA, no FH of prostate/bladder cancer
Physical Exam:
Admission Physical Exam:
========================
Vitals: 24 HR Data (last updated ___ @ 130)
Temp: 97.7 (Tm 97.7), BP: 147/71, HR: 61, RR: 18, O2 sat:
95%, O2 delivery: RA
Fluid Balance (last updated ___ @ 245)
GENERAL: Lying comfortably in bed, NAD
HEENT: Clear OP without lesions or thrush
EYES: PERRL, anicteric
NECK: supple, no JVD
RESP: No increased WOB, no wheezing, rhonchi or crackles
___: RRR, no murmurs
GI: soft, non-tender, no rebound or guarding, urostomy site
C/D/I
draining clear yellow urine
EXT: no edema, warm
SKIN: dry, no obvious rashes
MSK: no tenderness to palpation of spine, negative SLR b/l
NEURO: alert, fluent speech. ___ strength in b/l ___, sensation
intact to fine touch in b/l ___
ACCESS: PIV
Discharge Physical Exam:
========================
Vitals: ___ 0718 Temp: 98.0 PO BP: 131/76 HR: 58 RR: 18 O2
sat: 93% O2 delivery: Ra
GENERAL: Lying comfortably in bed, NAD, less pain with sitting
up
than prior
HEENT: No nasal discharge, Mouth clear OP without lesions or
thrush, poor dentition
EYES: Pupils equal and round, anicteric
RESP: Breathing non-labored, CTAB
___: RRR, no murmurs
GI: soft, non-tender, no rebound or guarding, urostomy site
C/D/I
draining clear yellow urine
EXT: no edema, warm
SKIN: dry, no obvious rashes
MSK: some TTP over L4-L5 area, mild
NEURO: alert, fluent speech. normal strength in b/l ___,
sensation
grossly intact
Pertinent Results:
Admission Labs:
===============
___ 04:20PM BLOOD WBC-9.1 RBC-2.84* Hgb-9.8* Hct-28.4*
MCV-100* MCH-34.5* MCHC-34.5 RDW-12.8 RDWSD-46.8* Plt ___
___ 04:20PM BLOOD Neuts-73.3* Lymphs-16.6* Monos-7.4
Eos-1.8 Baso-0.2 Im ___ AbsNeut-6.68* AbsLymp-1.51
AbsMono-0.67 AbsEos-0.16 AbsBaso-0.02
___ 04:20PM BLOOD Glucose-100 UreaN-17 Creat-0.8 Na-137
K-4.2 Cl-103 HCO3-20* AnGap-14
Imaging:
========
CT Abd/Pelvis ___:
1. Diffuse demineralization of the bones with acute superior
endplate
compression fracture at L4.
2. Sclerotic lesion at the L5 vertebral body concerning for
metastatic
disease, more conspicuous compared with prior.
3. Similar pattern and size of retroperitoneal and bilateral
pelvic
lymphadenopathy.
4. Aneurysmal dilation of the infrarenal abdominal aorta
measuring 3.2 x 3.0 cm. Mildly dilated left and right common
iliac arteries. Extensive
atherosclerosis.
5. Status post cystectomy and prostatectomy with neobladder
which appears
uncomplicated.
6. Cholelithiasis without evidence of cholecystitis.
MRI L-SPINE W & W/O CONT ___. Anterior wedging of L4 vertebral body with associated
abnormal marrow
signal and enhancement suggests compression fracture likely
secondary to
underlying metastatic disease.
2. Diffuse marrow signal abnormality involving L5 vertebral body
and extending
to the posterior element with associated enhancement may suggest
metastatic
disease.
3. Additional findings as described above
Discharge Labs:
===============
___ 08:38AM BLOOD WBC-5.7 RBC-2.93* Hgb-10.1* Hct-30.2*
MCV-103* MCH-34.5* MCHC-33.4 RDW-12.9 RDWSD-48.0* Plt ___
___ 08:38AM BLOOD Glucose-92 UreaN-15 Creat-0.9 Na-139
K-4.1 Cl-103 HCO3-21* AnGap-15
___ 08:38AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.9
___ 10:10AM BLOOD PSA-19.5*
Brief Hospital Course:
Mr. ___ is a ___ yo male with metastatic prostate
cancer on zytiga/prednisone and muscle-invasive bladder cancer
s/p cystoprostatectomy who presented with acute worsening of
subacute back pain, found to
have L4 compression fracture, likely due to metastatic disease
in the lumbar spine.
# Back Pain ___ Pathologic L4 Compression fracture
# Lumbar spine metastasis
Presented with acute on chronic back pain and was found to have
an L4 compression fracture on CT. He had no neurologic deficits
suggestive of cord compression. MRI showed abnormal marrow
signal in L4 and L5 suggestive of metastatic disease, likely the
cause of the fracture. Radiation oncology was consulted and
started a 10 fraction treatment for palliation. MRI also showed
some disc bulging, and there was some concern from radiation
oncology that this could be the cause of back pain. Neurosurgery
was consulted for this and per discussion, they felt he would be
unlikely to have symptoms from this. Pain was controlled with
Tylenol, oxycodone 10 mg Q3H, transitioned to oxycontin 30 mg
Q12H with additional PRN oxycodone for breakthrough. Pain was
well controlled prior to discharge. ___ was consulted,
recommended home with home ___. Started calcium/vitamin D
supplementation.
# Constipation
Likely in the setting of opioids as above. Started on aggressive
bowel regimen.
# Metastatic prostate cancer
PSA was downtrending at 19.5. Continued home zytiga, prednisone.
Outpatient followup scheduled.
# HTN
Continued home amlodipine, atenolol
# HLD
Continued home statin
# COPD
# Active tobacco use
Continued albuterol PRN, Spiriva, was not interested in quitting
smoking at this time, previously declined
nicotine lozenges/patch.
# GERD
Continued home omeprazole
# Allergies
Continued home loratadine
Transitional Issues:
============
[] He will need prescriptions for oxycontin and oxycodone at
oncology followup ___
[] Monitor for constipation on chronic opioids
[] ___ was consulted, recommended home with home ___
[] Radiation to be completed, 10 fractions
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Loratadine 10 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Pravastatin 40 mg PO QPM
6. abiraterone 1000 mg oral DAILY
7. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
8. Tiotropium Bromide 1 CAP IH DAILY
9. PredniSONE 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
3. Calcium Carbonate 1000 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
RX *oxycodone 5 mg ___ tablet(s) by mouth three times a day Disp
#*30 Tablet Refills:*0
6. OxyCODONE SR (OxyCONTIN) 30 mg PO Q12H
RX *oxycodone [OxyContin] 30 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*14 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO BID
8. Senna 17.2 mg PO BID
9. Vitamin D 1000 UNIT PO DAILY
10. abiraterone 1000 mg oral DAILY
11. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
12. Amlodipine 10 mg PO DAILY
13. Atenolol 50 mg PO DAILY
14. Loratadine 10 mg PO DAILY
15. Omeprazole 20 mg PO DAILY
16. Pravastatin 40 mg PO QPM
17. PredniSONE 5 mg PO DAILY
18. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
L4 compression fracture
Metastasis to L4 L5
Back pain
Constipation
Secondary:
Prostate cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came in with severe back pain. We found that you had a
compression fracture (area of collapse) in your spine, likely
caused by spread of your cancer to the lumbar spine. We treated
you with pain medication and your pain improved. You also
started radiation for your pain. You will have 10 sessions in
total.
When you go home, please:
- watch out for leg weakness, numbness, tingling, tingling in
the area between your legs, inability to hold your stool in,
inability to urinate. These would be signs of compression of the
spinal cord which is an emergency.
- let Dr. ___ know if your pain gets out of control
at home or if you have any new symptoms, or cannot have a bowel
movement with the medicines you are taking.
- see below for medicines and followup appointments.
It was a pleasure taking care of you, and we wish you the best,
Your ___ Team
Followup Instructions:
___
|
10774872-DS-5
| 10,774,872 | 27,838,414 |
DS
| 5 |
2167-02-10 00:00:00
|
2167-02-11 15:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
morphine / Lipitor / Lipitor / Pravachol
Attending: ___
Chief Complaint:
acute right face and arm numbness and weakness and decreased
speech output
Major Surgical or Invasive Procedure:
Left internal carotid stent placement
History of Present Illness:
The patient is a ___ year old right handed woman with a
history of hyperlipidemia, HTN, ___ disease type I,
previous
stress cardiomyopathy (resolved), SVT s/p ablation in ___ and
recent admission (___) for acute stroke ___ left carotid
stenosis who presents as a transfer from ___ in ___
for
acute right face and arm numbness and weakness and decreased
speech output concerning for recurrent stroke.
Ability to obtain history is limited by decreased speech output
from patient, who is acutely anxious and tearful during exam.
Per
report, she was in her usual state of health until 8:30am this
morning when she developed acute numbness and heaviness on the
right side of her body, beginning in the right arm and then
traveling to the right side of her face. Leg was not involved.
Around this time, she noticed that her speech seemed "slowed",
though she did not have difficulty understanding what others
were
saying to her. She called ___ and was brought to an OSH in ___. She was transferred to ___ ED for further
evaluation.
Of note she was admitted to ___ Stroke service from
___
for acute stroke ___ sympatomatic left carotid stenosis. On
___
and ___ she had several minutes of right hand and forearm
numbness. On ___ she had four minutes of right hand and
forearm
numbness radiating to the right face. She was taken to ___ and then tranferred to ___ on ___.
MRI showed three small L posterior frontal subacute infarcts (in
MCA/ACA watershed) and also R posterior mesial parietal lesion
(could be distal small PCA stroke). MRA showed three problems in
the left ICA: (1) kinking after the bifurcation that causes a
moderate degree stenosis; (2) about 1cm more distally there is
at
least a 80% calcified stenosis; (3) another 1 cm distally there
is a concentric calcification that stretches to the skull base;
this last concentric calcification does not cause any moderate
or
high grade stenosis. MRA also showed atherosclerotic lesion at L
vertebral artery origin. Carotid ultrasound rated the stenosis
at
80-99%. TTE showed normal EF of 60% and no intracardiac clot or
PFO. She was seen by Vascular Surgery who decided to hold off on
intervention (were considering CEA vs. carotid stent vs.
connecting the ECA to the ICA). Ultimately decided to maximize
her medical management by adding Plavix to her home Aspirin. She
was followed by Hematology for this given her history of vWD.
Crestor 40mg (maximal dose) was continued. Her antihypertensive
meds were decreased slightly (continued amlodipine 5mg daily but
decreased lisinopril to 10mg daily) to optimize perfusion distal
to the lesions.
Neuro and General ROS: unable to obtain
Past Medical History:
PMHx:
1. Hypertension
2. Hyperlipidemia
3. ___ Disease (Type 1)
4. Symptomatic left carotid stenosis, per HPI
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GENERAL EXAM:
- Vitals: 97.9 88 144/95 20 99% RA
- General: Awake, cooperative, acutely anxious and tearful
- HEENT: NC/AT
- Neck: Supple, no carotid bruits appreciated. No nuchal
rigidity
- Pulmonary: CTABL
- Cardiac: RRR, no murmurs
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
NEURO EXAM:
- Mental Status: Awake, alert, oriented x 3. Speech is hesitant,
with decreased verbal fluency and speech output but able to
speak
in short sentences when encouraged. Language is fluent with
intact repetition and comprehension. Normal prosody. There were
no paraphasic errors. Able to name both high and low frequency
objects. Speech was not dysarthric. No evidence of apraxia or
neglect.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
- Motor: Normal bulk, tone throughout. +Right arm pronator
drift.
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 4+ 5 5 5
R 4+ 5 4+ 4+ ___ 4- 4+ 4- 4- 5 5 5
- Sensory: Decreased sensation to pinprick over right arm and
leg. No extinction to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
- Coordination: No intention tremor, no dysdiadochokinesia
noted.
No dysmetria on FNF or HKS bilaterally.
- Gait: Not tested.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T97.7, BP 95-121/65-75, P58-82, RR10-15, 96-98% on ra
NEURO: Awake, alert, oriented to person, place and time. Speech
once again fluent without dysarthria, slowness, or increased
effort. Naming intact to high/low frequency objects. pupils
symmetric and reflexive to light, EOMI, visual fields full.
Strength is ___ bilaterally in UEs and IP, gastrocs 4+ R and
Left, no pronator drift, no longer w/ giveway weakness.
Pertinent Results:
ADMISSION LABS:
===============
___ 12:10PM BLOOD WBC-9.4 RBC-4.70 Hgb-14.7 Hct-43.5 MCV-93
MCH-31.3 MCHC-33.8 RDW-12.9 Plt ___
___ 12:10PM BLOOD ___ PTT-33.8 ___
___ 06:33AM BLOOD Glucose-96 UreaN-7 Creat-0.7 Na-140 K-3.9
Cl-108 HCO3-26 AnGap-10
___ 06:33AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.9
___ 12:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
===============
___ 06:25AM BLOOD WBC-8.6 RBC-2.96* Hgb-9.4* Hct-27.1*
MCV-92 MCH-31.7 MCHC-34.7 RDW-12.9 Plt ___
___ 06:25AM BLOOD ___ PTT-27.6 ___
___ 06:25AM BLOOD Glucose-95 UreaN-5* Creat-0.6 Na-141
K-4.0 Cl-109* HCO3-24 AnGap-12
___ 06:25AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.8
RELEVANT STUDIES:
=================
NCHCT/CTA/CTP (___):
- NCHCT: No acute intracranial abnormality.
- CT PERFUSION: Small area of slightly increased MTT and
slightly decreased blood flow and blood volume in the left
posterior parietal lobe (CTP maps, im 9) concerning for acute
ischemia/infarction, likely new since recent MR of ___ from
OSH.
- CTA HEAD AND NECK: Patent major intracranial arteries.
Atherosclerotic changes in the left cervical internal carotid
artery over a long segment with contour irregularity, possible
small foci of ulcerated plaques and circumferential
calcification and non-calcified atherosclerotic plaques, with
focal maximum narrowing of approximately 70-80%.
- CT NECK: A small nodule in the left lobe of the thyroid,
measuring approximately 6 mm. Correlate with ultrasound.
- MR ___ (___):
1. Redemonstration of three punctate subacute infarcts in the
left parietal deep white matter in an identical distribution to
the outside examination from ___ faintly seen on
ADC sequence.
2. No new focus of slowed diffusion to suggest acute infarct.
3. Previously seen linear band of slowed diffusion in the
posterior right
parietal lobe on outside study is no longer seen and may have
represented
artifact.
4. Unchanged, single, nonspecific focus of left parietal
subcortical white matter T2/FLAIR hyperintensity, not associated
with slowed diffusion.
- CAROTID STENTING (___):
1. Left internal carotid artery stenosis measuring 65% per
NASCET criteria involving a long segment, however, the majority
of the entire cervical ICA. This has been stented with two
separate stents to good resolution to now 13% stenosis of the
left ICA. There was some reactive vasospasm to the Spider
distal embolic protection device within the distal cervical ICA
that periodically caused worsening of her exam; however, with
antispasmodic agents, her exam markedly improved and is now at
her baseline.
2. No evidence of thromboembolic complications.
Brief Hospital Course:
HOSPITAL COURSE: ___ is a ___ year old woman with a
history of ___ disease type 1, hypertension,
hyperlipidemia, and recent admission to the Neurology Stroke
service for several small left-sided strokes and one small
right-sided stroke in the setting of severe left ICA stenosis
(unable to stent or perform carotid endarterectomy due to
complex anatomy), who re-presented to an outside hospital with
acute right face and arm numbness and weakness (similar to last
admission) and decreased speech speed/fluency (new, unexplained
symptoms) concerning for recurrent stroke.
Pt was put on heparin gtt while awaiting neurosurgery
recommendations. Exam had functional decreased speech fluency
and giveway weakness, otherwise stable subtle right upper motor
neuron weakness pattern (similar to last admission). Repeat MRI
showed very small progression of prior left-sided infarcts, and
no new areas of injury. Pt most likely had mild hypotensive
episode causing decreased perfusion resulting in progression and
return of prior symptoms. Pt did not have a recurrence of her
prior stroke symptoms after admission, and her speech and muscle
weakness symptoms resolved spontaneously after discussing with
pt the contribution stress often has to physical symptoms.
Neurosurgery was consulted and gave the pt a second opinion
regarding invasive management of carotid artery
stenosis/calcification, the likely cause of her original stroke.
Per Neurosurgery recs she was switched from heparin drip to
aspirin 325/Plavix 150 for 3 days prior to going to the OR for
stent placement in her left ICA. Pt is now stable and doing well
post-op. Presenting symptoms have completely resolved.
TRANSITIONAL ISSUES:
====================
- Pt being discharged on ASA 325/Plavix 75, to be continued at
least until pt follows up in clinic with neurosurgeon, Dr.
___, in 4 weeks.
- Pt has f/u appt w/ Dr. ___ of ___
Neurology-Stroke
- Pt has f/u appt w/ Dr. ___ at the Hematology
Coagulation clinic for further evaluation and tx of her ___
___ disease
- Pt was placed back on her home anti-hypertensive meds prior to
discharge, in order to prevent carotid hyperperfusion (common
issue after CEAs or stents as carotid sinuses lose ability to
autoregulate BP resulting in HA)
- On imaging of the carotid pt was found incidentally to have a
6mm nodule/nodules in the thyroid of unclear significance.
Should f/u w/ PCP and get ___ routine thyroid ultrasound for
further workup.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Rosuvastatin Calcium 40 mg PO DAILY
3. Amlodipine 5 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Rosuvastatin Calcium 40 mg PO DAILY
4. Amlodipine 5 mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Lisinopril 20 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
L ICA stenosis
Multiple L sided subacute strokes
Type 1 ___ disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of ___ at ___.
___ came back to us because ___ had a repeat episode of your
prior stroke symptoms of right hand/arm/face numbness and
tingling. Head imaging showed ___ had some minor progression of
your known pre-existing strokes. After discussing your options
with the Neurology Stroke Service, Vascular Surgery, and
Neurosurgery, ___ opted to undergo stent placement in your left
carotid artery to hopefully prevent any future strokes. ___ are
doing well after surgery and are safe to go home.
To further decrease your risk of stroke, ___ are now on a high
dose of daily aspirin, and on a daily regimen of Plavix. ___
should continue taking both of these medications daily, as well
as the blood pressure medications ___ were on previously, until
___ follow-up in clinic with Dr. ___ Neurosurgery.
Please call his office (see below) to make an appointment with
him for 4 weeks from today.
Please note the medication changes and follow-up appointments
scheduled for ___, as detailed below.
Followup Instructions:
___
|
10775154-DS-17
| 10,775,154 | 21,826,114 |
DS
| 17 |
2117-12-24 00:00:00
|
2117-12-24 18:51:00
|
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 periprosthetic femur fracture
Major Surgical or Invasive Procedure:
___: ___ L periprosthetic femur fracture
History of Present Illness:
___ female presents after a fall. The patient was
washing dishes, when she fell backwards, landing on her bottom.
Since that time, she has had left leg pain and inability to move
her left leg. No paresthesias or other injury. Previous femoral
fracture in ___. Wears leg braces at baseline
Past Medical History:
Polio
L femur ___ ___
Social History:
___
Family History:
NC
Physical Exam:
Discharge Exam:
Gen: NAD, AOx3
CV: RRR
Resp: CTAB
Abd: Soft, NT/ND
Extrem:
LLE:
Incision c/d/I, no erythema/drainage
SILT s/s/sp/dp/t nerve distributions
Fires ___
2+ ___ pulses
Foot wwp, good cap refill
Pertinent Results:
___ 10:40PM BLOOD WBC-9.5 RBC-4.09 Hgb-12.9 Hct-40.4
MCV-99* MCH-31.5 MCHC-31.9* RDW-12.2 RDWSD-44.4 Plt ___
___ 10:40PM BLOOD Glucose-124* UreaN-15 Creat-0.4 Na-140
K-4.2 Cl-102 HCO3-21* AnGap-21*
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left periprosthetic femur fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for ___ L femur fracture, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touch down weight bearing in the left lower extremity, and will
be discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine in 2 weeks post-op. 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:
Vitamins only
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QHS
Start: Today - ___, First Dose: Next Routine Administration
Time
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*35 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left periprosthetic femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- touch down weight bearing left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___ 2
weeks in the ___ 14 days post-operation for
evaluation. Call ___ to schedule appointment upon
discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Weight bearing as tolerated left lower extremity
Treatments Frequency:
Primary dressing has been changed. ___ change dressing on an as
needed basis. Staples will be removed at 2 week follow up visit.
Followup Instructions:
___
|
10775471-DS-5
| 10,775,471 | 29,921,377 |
DS
| 5 |
2126-11-09 00:00:00
|
2126-11-09 15:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Antihistamines - Alkylamine / Antihistamines - Ethylenediamine /
Bisphosphonates / shellfish derived / hydrochlorothiazide /
hydroxyzine / iodine / Iodine and Iodide Containing Products /
Keflex / latex / desloratadine / Macrodantin / nickel /
nitrofurantoin / Quinolones / Sulfa (Sulfonamide Antibiotics) /
Generic metoprolol
Attending: ___.
Chief Complaint:
Left lateral chest pain in the setting of AAA.
Major Surgical or Invasive Procedure:
1. Blood pressure optimization
2. spinal drain attempt x 2
History of Present Illness:
Patient is a ___ y/o female who presented to an OSH with a
several hour episode of left lateral chest pain. A CT revealed
an expanding 7 cm thoraco-abdominal aortic aneurysm. A CT done
several months prior at OSH for mid-sternal pain revealed a TAA
of 6.7 cm. She was transferred to ___ for evaluation.
Past Medical History:
Past Medical History:
-TAA diagnosed "few months ago" allegedly measured 6.7cm on CTA
Chest
-CAD s/p stent ___
-Ulcerative colitis
-pAfib
-HTN
-HLD
-Right nephrolithiasis
Past Surgical History:
-Coronary stent placement ___
-bilateral knee replacement ___
-Left ankle surgery
-"back and shoulder" surgeries
Social History:
___
Family History:
Family History:
no known family hx of vascular disease
Physical Exam:
Vitals: 121/79 66 16 95%/RA
General: alert and oriented x3, seated comfortably in chair,
NAD
HEENT: normocephalic, skin anicteric, MMM
CV: RRR
Lungs: breathing unlabored
ABd: soft, non-tender - no palpable mass appreciated
Extremities: warm and well perfused bilaterally. Palpable ___
pulses bilaterally
Pertinent Results:
Labs-----------
___ 04:33AM BLOOD WBC-10.8* RBC-2.82* Hgb-8.3* Hct-26.2*
MCV-93 MCH-29.4 MCHC-31.7* RDW-14.5 RDWSD-49.4* Plt ___
___ 04:33AM BLOOD Plt ___
___ 04:33AM BLOOD Glucose-94 UreaN-28* Creat-1.5* Na-138
K-5.4 Cl-105 HCO3-24 AnGap-9*
___ 10:22AM BLOOD CK(CPK)-187
___ 01:09AM BLOOD CK-MB-6 cTropnT-0.02*
___ 04:33AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.0
Imaging------------------
CTA CHEST Study Date of ___ 12:54 AM
___ CVICU-B ___ 12:54 AM
CTA CHEST ; CTA ABD & PELVIS Clip # ___
Reason: known descending thoracic aortic aneurysm, pre-op
planning known descending thoracic aortic aneurysm, pre-op
planning ___ PMH of CAD s/p stent, pAfib (on Aspirin), HTN, HLD,
known thoracic aortic aneurysm p/w chest pain CTA shows 7 cm TAA
Contrast: OMNIPAQUE Amt: 80
IMPRESSION:
1. Fusiform aneurysmal dilatation of the descending thoracic
aorta, measuring
up to 7.1 x 6.9 cm in axial dimension, with a large amount of
eccentric mural
thrombus which narrows the lumen by approximately 50%.
2. Ectasia of the abdominal aorta, with the suprarenal aorta
measuring up to
2.8 cm in diameter and the infrarenal aorta measuring up to 2.9
cm in
diameter.
3. 2.2 cm saccular aneurysm of the right internal iliac artery
at the iliac
bifurcation.
4. Mild right hydronephrosis, with tapering at the ureteropelvic
junction,
suggestive of UPJ obstruction.
5. Severe compression fracture of the L1 vertebral body with
kyphoplasty
changes. Severe compression fracture of the T12 vertebral body.
Moderate
compression fractures of the T9 and L2 vertebral bodies.
Brief Hospital Course:
The patient was admitted to the ICU for BP control and
monitoring while she was evaluated for possible surgical
intervention. Her chest pain improved with a decrease in her
blood pressure. Due to a number of reasons, the patient's
thoracic aneurysm was determined to be one that could not be
repaired with an endovascular approach -- current grafts were
not amenable to her difficult anatomy and tortuosity made all
theoretical approaches not feasible. Furthermore, all available
grafts contained nickel, to which the patient was allergic.
These concerns were discussed with the patient and her family.
The patient declined consideration of open repair, and elective
open repair was not recommended given complexity of her anatomy
and likelihood of complications.
The patient presented to the hospital with a MOLST form
confirming DNR/DNI status. Numerous conversations with the
patient and her family members were had during her
hospitalization to confirm her code status. All conversations
emphasized that aneurysm rupture, without attempt at repair,
would result in death. She understands very clearly and
expressed her comfort with the decision not to repair
the aneurysm, "I'll stick with what I've got".
The patient was transitioned from IV BP control to an oral
regimen with the assistance of vascular medicine. Her home
medications have been altered to bring patient to a goal SBP of
less than 130. Patient will require follow up with her home
cardiologist for BP monitoring and medication management.
She encouraged to call the vascular surgery office with any
further questions.
Patient is discharged to a short term rehab in stable condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mesalamine ___ 800 mg PO BID
2. amLODIPine 5 mg PO DAILY
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. Valsartan 160 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Aspirin 81 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
3. Losartan Potassium 100 mg PO DAILY
4. Metoprolol Succinate XL 200 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
6. amLODIPine 10 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Mesalamine ___ 800 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Symptomatic Thoraco-abdominal aortic aneurysm,
Hypertension
Secondary: paroxysmal AFIB, CAD s/p stenting,
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you at ___. You were
admitted after an episode of chest pain. Your evaluation
included monitoring of your known thoracic abdominal aortic
aneurysm. Your pain resolved with lowering of your blood
pressure. As discussed, repair of this aneurysm is not advised
at this time, however, it is important to maintain good blood
pressure levels and to have your cardiologist follow your blood
pressure medication changes. Your discharge paperwork with
outline these medication changes.
Please follow up with your cardiologist within one week of your
discharge from the hospital. It will also be important to touch
base with your PCP with ___ couple of weeks of discharge from the
hospital.
Followup Instructions:
___
|
10775507-DS-3
| 10,775,507 | 28,647,341 |
DS
| 3 |
2170-03-17 00:00:00
|
2170-03-20 18:51:00
|
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with h/o T2Dm, genotype 1A HCV,
who has failed tx with harvoni and interferon and HCC in the
setting of cirrhosis, who is currently inactive on the
transplant list due to concern of progression of HCC. He p/w 5d
of nausea, subjective fevers/chills, and abdominal fullness,
nausea and vomiting x1 today. He states that his symptoms
started on ___ with with body aches, nausea more than
usual, and NBNB vomiting x1 today after eating a meal. He also
endorses headache and worsening of his symptoms with activity.
He initially thought he had the flu and took ibuprofen but it
didn't help. He presented to the ED this past evening because he
felt that something was "just not right". He otherwise denies
unintentional weight loss, diarrhea, constipation, abdominal
pain, recent travel, new or unusual foods.
In the ED, initial VS were: 100.5, 98, 194/89, 16, 98% RA
Labs showed: WBC 8.9 with neutrophil predominance, plt 108.
mild elevation of LFTs
Imaging as below
Received: Zofran and 1L NS
Transfer VS were: 97.8, 86, 156/97, 14, 98% RA
Hepatology was consulted and recommended admit to ET for
monitoring.
Past Medical History:
___
Bipolar disorder
Type 2 DM
Hepatitis C: genotype 1 failed Harvoni
HTN
Cirrhosis
Left ankle surgery
Social History:
___
Family History:
Family history of colon CA? in mother but passed away of COPD
Father: MI around age ___
Siblings: healthy
Physical Exam:
==================
ADMISSION PHYSICAL
==================
VS - 98.8, 177/91, 87, 18, 96% RA
GENERAL: well appearing man in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM
CARDIAC: RRR, S1/S2, ___ murmurs, gallops, or rubs
LUNG: CTAB, ___ wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, mild RUQ tenderness, ___ appreciable
hepatosplenomegaly
EXTREMITIES: WWP, ___ edema, 2+ DP pulses bilaterally
NEURO: CN II-XII grossly intact
==================
DISCHARGE PHYSICAL
==================
VS: 99.0 PO 163/89 89 16 97 RA
GENERAL: well appearing man in NAD
HEENT: EOMI, PERRL, anicteric sclera, MMM
CARDIAC: RRR, S1/S2, ___ murmurs, gallops, or rubs
LUNG: CTAB, ___ wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, ___ TTP, ___ appreciable
hepatosplenomegaly
EXTREMITIES: WWP, ___ edema, 2+ DP pulses bilaterally
NEURO: CN II-XII grossly intact
Pertinent Results:
=========================
ADMISSION/DISCHARGE LABS
=========================
___ 04:44AM BLOOD WBC-5.9 RBC-4.58* Hgb-14.1 Hct-41.1
MCV-90 MCH-30.8 MCHC-34.3 RDW-12.7 RDWSD-41.4 Plt Ct-97*
___ 08:38PM BLOOD WBC-8.9# RBC-4.90 Hgb-15.3 Hct-44.1
MCV-90 MCH-31.2 MCHC-34.7 RDW-12.3 RDWSD-40.6 Plt ___
___ 08:38PM BLOOD Neuts-73.9* Lymphs-15.4* Monos-8.6
Eos-1.5 Baso-0.3 Im ___ AbsNeut-6.56*# AbsLymp-1.37
AbsMono-0.76 AbsEos-0.13 AbsBaso-0.03
___ 04:44AM BLOOD Glucose-164* UreaN-15 Creat-0.9 Na-141
K-3.8 Cl-104 HCO3-28 AnGap-13
___ 08:38PM BLOOD Glucose-216* UreaN-14 Creat-0.8 Na-139
K-3.8 Cl-104 HCO3-23 AnGap-16
___ 04:44AM BLOOD ALT-97* AST-53* AlkPhos-106 TotBili-1.4
___ 08:38PM BLOOD ALT-118* AST-70* AlkPhos-112 TotBili-1.4
___ 04:44AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.4*
___ 04:44AM BLOOD AFP-148.9*
HCV VIRAL LOAD (Final ___:
3,010,000 IU/mL.
============
IMAGING
============
CT Abd/PElv ___:
IMPRESSION:
1. ___ acute intra-abdominal process.
2. Cirrhotic liver with a stable segment VI ablation cavity.
3. Stable portal vein thrombosis adjacent to the ablation
cavity, and within the left portal vein, better evaluated on the
recent MR. ___ evidence of new portal vein thrombosis.
4. Sequela of portal hypertension include gastroesophageal
varices and splenomegaly.
___ ABD US:
IMPRESSION:
___ tumor thrombus seen on MRI can be visualized by ultrasound
however is
surrounded by large arterial branches. While biopsy can be
attempted, it may ultimately not be feasible.
Brief Hospital Course:
___ male with PMHx genotype 1A HCV (s/p treatment
failure), T2DM, HCC s/p RFA who presents with 5 days of malaise,
nausea, and one day of vomiting. CT abdomen and pelvis negative
for acute intraabdominal process; LFTs at or below baseline.
Symtpoms are most likely secondary to acute viral
gastroenteritis, possibly norovirus. Patient tolerated PO intake
well and discharged with instruction to stay well hydrated and
advance diet slowly. ___ medical interventions.
====================
TRANSITIONAL ISSUES
====================
[] Blood cultures, urine culture, HCV VL, and Norovirus results
pending on discharge
[] Patient should follow up with Liver Clinic social worker to
discuss getting a note to work less than full time
[] Patient should have appointment scheduled for liver biopsy to
evaluate for recurrent ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. ARIPiprazole 30 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Glargine 42 Units Breakfast
Glargine 42 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Discharge Medications:
1. Ondansetron ODT 4 mg SL Q8H:PRN nausea
RX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*30 Tablet Refills:*0
2. ARIPiprazole 30 mg PO DAILY
3. Glargine 42 Units Breakfast
Glargine 42 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
4. Losartan Potassium 100 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Viral Gastroenteritis
Secondary Diagnosis:
Type II Diabetes Mellitus
Genotype 1A HCV cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Discharge Instructions:
Mr. ___,
You were hospitalized because you were having nausea and
vomiting. While you were here, we checked labs and they were all
normal. You also had a CT scan of your abdomen which did not
show any causes of your symptoms. We think your symptoms are due
to a viral illness that will get better on its own.
You can take a medication called ondansetron (dissolve under
your tongue) every 8 hours as needed for nausea. Please make
sure you are drinking plenty of water when you go home to stay
well hydrated.
It was a pleasure meeting and taking care of you while you were
in the hospital.
-Your ___ Team
Followup Instructions:
___
|
10775646-DS-20
| 10,775,646 | 25,486,476 |
DS
| 20 |
2129-01-31 00:00:00
|
2129-01-31 17:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
metformin / lisinopril / ACE Inhibitors
Attending: ___.
Chief Complaint:
Fatigue, chest tightness
Major Surgical or Invasive Procedure:
L anterior chest wall port placement ___
History of Present Illness:
___, ___, with history of breast cancer s/p
lumpectomy and RT, pAF on coumadin, recently admitted to ___ for
chest pain, now presents after being referred in for new acute
myeloid leukemia.
The patient initially presented to ___ on ___ after experiencing
an episode of chest tightness and pressure at home. This
occurred at rest, radiated to her jaw and neck. It was
associated with mild lightheadedness, shortness of breath, and
diaphoresis. Her pain improved without intervention. She had
similar episodes in the past with periods of AFib. However,
given concern for cardiac etiology, her daughter brought her to
the ED for evaluation. On presentation to the ED she was noted
to be leukopenic to 2K. Per the patient's daughter, her WBC had
been 4K several months prior at a PCP ___.
During her ___ admission, the patient underwent a nuclear stress
test that was normal and had negative cardiac enzymes.
Hematology was consulted for her leukopenia. Dr ___ a
bone marrow biopsy on ___. Shortly thereafter the patient was
discharged home given clinical stability. Preliminary smear
review from the peripheral blood and marrow aspirate showed
leukopenia, but no blasts. On ___, preliminary FISH showed a
significant population of myeloid blasts (67%), later seen on a
concentrated smear. The immunophenotype was potentially
concerning for APML, however preliminary FISH was negative for
PML/RARA. She was referred to this facility for evaluation and
treatment. The bone marrow is currently undergoing FISH and PCR
testing.
On arrival to the ED, the patient denies any acute complaints,
no chest pain, no shortness of breath. No bleeding, though some
bruising at phlebotomy sites. She was anxious on arrival to the
ED but rapidly quieted. EKG noted grouped sinus beats, no AFib.
After discussion of her preliminary diagnosis (AML, possibly
APML), she was consented for ATRA administration to start this
evening.
Past Medical History:
breast cancer s/p lumpectomy and RT (___)
post-operative DVT (___), on warfarin
s/p bunionectomy (___)
paroxysmal AFib, on warfarin
anxiety
depression
s/p C section ___ years ago)
Social History:
___
Family History:
No malignancy history per patient
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.1, 126/70, 69, 18, 95% RA
GENERAL: NAD, comfortable
HEENT: anicteric sclera, no oral lesions
CARDIAC: irregular, ? respiratory variation, no murmurs
LUNG: clear to auscultation, no wheezes or rhonchi
ABD: +BS, soft, NT/ND, no rebound or guarding
EXT: No lower extremity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: Warm and dry, without rashes
DISCHARGE PHYSICAL EXAM:
Vitals: Tc 98.1, Tm 98.5 BP 96/66 HR 75 RR 18 Sp02 98% RA Wt
195.5<-195.0
General: Well appearing, no acute distress
HEENT: MMM, OP clear, no oral lesions
CV: RRR, nl S1 S2, no murmurs/rubs/gallops
Chest: clear to auscultation bilaterally
Abd: obese, soft, nontender, nondistended, normoactive bowel
sounds, no appreciable hepatosplenomegaly
Ext: WWP, no edema
Skin: no rash, R brachial PICC, no erythema or induration or
bleeding at ___ site, no induration or mass; L anterior chest
port mild erythema and tenderness to palpation, no discharge or
induration
Neuro: AAOx3, no anxiety, mood is good
Pertinent Results:
ADMISSION LABS:
___ 05:00PM BLOOD WBC-1.3* RBC-2.94* Hgb-9.4* Hct-28.4*
MCV-97 MCH-32.0 MCHC-33.1 RDW-17.9* RDWSD-62.7* Plt ___
___ 05:00PM BLOOD Neuts-6* Bands-0 Lymphs-91* Monos-2*
Eos-0 Baso-1 ___ Myelos-0 AbsNeut-0.08*
AbsLymp-1.18* AbsMono-0.03* AbsEos-0.00* AbsBaso-0.01
___ 05:00PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-3+
Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL
Ovalocy-2+ Burr-1+ Acantho-OCCASIONAL
___ 05:00PM BLOOD ___ PTT-35.3 ___
___ 05:00PM BLOOD ___ 05:00PM BLOOD Glucose-78 UreaN-19 Creat-1.0 Na-136
K-4.3 Cl-103 HCO3-23 AnGap-14
___ 05:00PM BLOOD ALT-22 AST-27 LD(LDH)-231 AlkPhos-76
TotBili-0.6 DirBili-0.2 IndBili-0.4
___ 05:00PM BLOOD Albumin-4.0 Calcium-9.4 Phos-2.7 Mg-2.1
UricAcd-4.4
PERTINENT INTERVAL LABS:
___ 12:00AM BLOOD QG6PD-8.6
___ 12:00AM BLOOD Ret Aut-2.5* Abs Ret-0.06
___ 12:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-POSITIVE
___ 05:00PM BLOOD CRP-13.0*
___ 12:00AM BLOOD HCV Ab-NEGATIVE
DISCHARGE LABS:
___ 10:11AM BLOOD WBC-2.0* RBC-2.41* Hgb-8.4* Hct-25.9*
MCV-108* MCH-34.9* MCHC-32.4 RDW-22.5* RDWSD-87.9* Plt ___
___ 10:11AM BLOOD Neuts-23.1* Lymphs-71.3* Monos-5.1
Eos-0.0* Baso-0.5 AbsNeut-0.45* AbsLymp-1.39 AbsMono-0.10*
AbsEos-0.00* AbsBaso-0.01
___ 12:00AM BLOOD ___
___ 12:00AM BLOOD Glucose-131* UreaN-12 Creat-0.7 Na-140
K-3.7 Cl-110* HCO3-21* AnGap-13
___ 12:00AM BLOOD LD(LDH)-188
___ 12:00AM BLOOD Calcium-8.9 Phos-4.5 Mg-2.4 UricAcd-5.4
MICROBIOLOGY:
C Diff Negative ___
IMAGING:
CXR ___: No acute intrathoracic process.
CXR ___: In comparison with the study of ___, the
patient has taken a better inspiration. Continued enlargement
of the cardiac silhouette with minimal central vascular
congestion. Right PICC line is stable. No evidence of acute
focal pneumonia.
TTE ___
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF = 65%). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. The left
ventricular inflow pattern suggests impaired relaxation. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
___ CT HEAD W/O CONTRAST No hemorrhage, infarction or
fracture.
___: CT SINUS 1. Well-aerated paranasal sinuses. 2. Dental
disease of the remaining mandibular teeth.
___: LIJ Port-a-cath
Successful placement of a single lumen chest power Port-a-cath
via the left internal jugular venous approach. The tip of the
catheter terminates in the right atrium. The catheter is ready
for use.
PATHOLOGY
___ SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY (CONSULT
SLIDES ___;FROM ___
PROCEDURE ___: ACUTE PROMYELOCYTIC
LEUKEMIA, SEE NOTE.
Note: Flow cytometry studies performed at ___,
___, demonstrated that 67% of cells in the aspirate are positive
for CD13, CD33, CD117, CD15 (variable), CD38 (moderated)and CD64
(partial dim), and are negative for CD34, ___, and Mo2. In
addition, cytogenics revealed the presence of a t
(15;17)(p24;q12) translocation and a "PML-RARA"signal by FISH
analysis. This results confirm the diagnosis of acute
promyelocytic leukemia.
Bone marrow cytogenetics ___
Every metaphase bone marrow cell examined appeared to be
karyotypically normal. No cells were found with the previously
observed translocation involving chromosomes 15 and 17 that is
diagnostic of acute promyelocytic leukemia. However, FISH has
demonstrated the presence of a small population of PML/RARA
positive interphase cells with segmented nuclei.
FISH: 6.5% of the interphase bone marrow cells examined had an
abnormal probe signal pattern consistent with the PML/RARA gene
rearrangement brought about by the t(15;17)(q24;q21) diagnostic
of acute promyelocytic leukemia. These cells had segmented
nuclei.
Bone marrow immunophenotyping ___
10-color analysis with linear side scatter vs. CD45 gating was
used to evaluate for leukemia. The sample viability done by
7-AAD is 96%. CD45-bright, low side-scatter gated lymphocytes
compris approximately 60% of total analyzed events. B cells
comprise approximately 6% of lymphoid-gated events. No abnormal
events are identified in the "blast gate." CD34 positive blast
cells comprise <0.5% of total gated events.
INTERPRETATION
Diagnostic immunophenotypic features of involvement by leukemia
are not seen in specimen. Correlation with clinical and
cytogenetic findings and morphology (see separate pathology
report ___ is recommended. Flow cytometry
immunophenotyping may not detect all lymphomas as due to
topography, sampling or artifacts of sample preparation.
Brief Hospital Course:
Ms. ___ is a ___ year old female, ___, with
history of breast cancer s/p lumpectomy and RT, paroxysmal afib
on chronic anticoagulation with warfarin, recently admitted to
___ for chest pain, found to have APML, treated with ATRA and
arsenic.
# APML: The patient initially presented to OSH with chest pain.
There, she was found to be anemic and leukopenic. Per outside
report of bone marrow biopsy, preliminary review of peripheral
blood and marrow aspirate showed leukopenia, but no blasts. ___
preliminary FISH showed myeloid blasts (67%), phenotype
concerning for APML however prelim FISH negative for PML/RARA,
per report final karyotype positive for APML. The patient was
started on ATRA (___). She was started on arsenic on
___. She was treated with prednisone during her therapy
which was tapered and ultimately discontinued. She was started
on atovaquone, acyclovir, and allopurinol for prophylaxis.
Allopurinol was discontinued as uric acid remained stable.
During hospitalization, the patient had no evidence of TLS or
DIC. Aresnic dosing was monitored with telemetry and frequent
ECGs. The patient had some QTc prolongation for which arsenic
was held x1 day. She otherwise completed a ___ of
ATRA/arsenic. Negative bone marrow from ___. Her ANC was
450 on day of discharge, so she was discharged on ciprofloxacin
ppx. The patient should follow-up with hematology/oncology for
further management.
# Paroxysmal Atrial Fibrillation: The patient had a history of
pAF on rate control with metoprolol and anticoagulation with
warfarin. The patient was found to have intermittent episodes of
RVR during her admission. The patient's metoprolol was
uptitrated to 100mg PO TID. Due to persistent episodes of RVR,
the patient was evaluated by cardiology who suggested addition
of flecainide for rhythm control. This medication was not
started as it was found to be category X interaction with ATRA,
which the patient would require for a long period of time for
treatment of her APML. The patient's warfarin was initially held
due to thrombocytopenia. She was restarted on home regimen
warfarin with lovenox bridge (80mg subcutaneous BID). The
patient's aspirin was held on admission due to bleeding risk but
was continued prior to discharge. The patient's atorvastatin
80mg PO qday was held due to concern for LFT abnormalities with
ATRA and arsenic. The patient should f/u with oncology for
consideration of restarting this medication.
# Diarrhea: The patient had some episodes of loose stool. She
was evaluated with c diff studies x2 which were negative. The
patient was managed symptomatically with loperamide and this
resolved prior to discharge.
# Elevated transaminases: The patient was found to have mildly
elevated LFTs intermittently during her admission. She was
evaluated with hepatitis serologies which were negative for
active infection. Transaminitis was thought to be secondary to
NAFLD vs. medication side effect. The patient should f/u with
oncology and outpatient providers for further management.
# Depression/anxiety: The patient's citalopram 10mg PO qday was
held due to concern for worsening QTc prolongation with arsenic.
The patient should f/u with oncology to determine whether this
medication can be restarted. The patient was continued on home
wellbutrin SR 150mg PO qday. Her anxiety greatly improved on
0.25mg clonazepam twice daily and she was discharge on this
medication.
# Diabetes: The patient's glipizde was held and she was started
on ISS while hospitalized. After discharge, the patient should
restart home glipizide. She was prescribed glucometer and given
teaching to monitor blood sugar post-discharge.
# Dry eyes: The patient was started on artificial tears.
# Memory loss: While hospitalized, the patient and family
reported that the patient had memory loss. This was found to be
chronic in nature, unchanged over the past several years. The
patient should follow up with outpatient providers for further
evaluation and management.
Transitional Issues:
- f/u with oncology for further management of APML
- f/u with cardiology/PCP for further management of atrial
fibrillation
- discharged on Coumadin home regimen as verified with PCP
___: ___ 1mg daily ___ 2mg daily ___ 3mg daily
- repeat INR to be drawn by ___ and faxed to PCP ___ ___
CODE: Full (presumed)
COMMUNICATION: ___ (Daughter, ___) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE 5 mg PO BID
2. Atorvastatin 80 mg PO QPM
3. Citalopram 10 mg PO DAILY
4. BuPROPion (Sustained Release) 150 mg PO BID
___ MD to order daily dose PO DAILY16
6. Metoprolol Tartrate 100 mg PO BID
7. Aspirin 81 mg PO DAILY
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE 5 mg PO BID
2. Atorvastatin 80 mg PO QPM
3. Citalopram 10 mg PO DAILY
4. BuPROPion (Sustained Release) 150 mg PO BID
___ MD to order daily dose PO DAILY16
6. Metoprolol Tartrate 100 mg PO BID
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth every 8 hours Disp
#*90 Tablet Refills:*0
2. ClonazePAM 0.25 mg PO BID
RX *clonazepam 0.25 mg 1 tablet(s) by mouth twice daily Disp
#*30 Tablet Refills:*0
3. Ranitidine 150 mg PO DAILY
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth once daily Disp
#*30 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. GlipiZIDE 5 mg PO BID
6. BuPROPion (Sustained Release) 150 mg PO BID
7. Enoxaparin Sodium 90 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 80 mg subcutaneous every 12 hours
Disp #*30 Syringe Refills:*0
8. Metoprolol Tartrate 100 mg PO TID
RX *metoprolol tartrate 100 mg 1 tablet(s) by mouth three times
daily Disp #*90 Tablet Refills:*0
9. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*28 Tablet Refills:*6
10. ___ MD to order daily dose PO DAILY16
1mg on ___ 2mg on ___ 3mg on ___
11. Outpatient Lab Work
___ and CBC/differential on ___.
Please fax results to ___. Phone: ___
Fax: ___ ICD 10: I48.0; ICD 10: ___.41
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary: acute promyelocytic leukemia, sinus arrhythmia, atrial
fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for allowing us to participate in your care at ___.
You were admitted to the hospital for treatment of your
leukemia. You were found to have acute promyelocytic leukemia.
You were treated with ATRA and arsenic and your blood counts
improved. After discharge you should continue to follow up with
your oncologist for further management. You were started on new
medications to protect you against infections including
ACYCLOVIR and CIPROFLOXACIN. You should continue to take these
medications until discussing with your oncologist. Do not start
taking the ATRA medication until instructed by your oncologist.
While in the hospital, you were also found to have fast heart
rates associated with atrial fibrillation. We treated you with
an increased dose of your metoprolol. We are discharging you on
an injected medicine, enoxaparin, while your coumadin levels
(INR) come back to therapeutic range. Do not stop taking
enoxaparin until you are instructed to do so by your primary
care doctor.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10776078-DS-14
| 10,776,078 | 25,852,519 |
DS
| 14 |
2143-01-12 00:00:00
|
2143-01-12 18:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Iodine-Iodine Containing / steroids
Attending: ___.
Chief Complaint:
L-sided weakness and confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with history of
metastatic melanoma s/p HD IL-2 with multiple oligo-metastatic
recurrences (including brain) s/p multiple resections,
ipilimumab
and cyberknife now with new poorly differentiated spindle cell
neoplasm of right parietal brain likely gliosarcoma s/p
resection
who presents with left-sided weakness.
The patient was seen by Neuro/Onc two days ago for follow-up and
was noted to have increasing weakness of the left arm and leg as
well as a visual field defect on the left. An MRI for radiation
planning on the same day revealed disease recurrence at the
surgical margins in the right parietal lobe. The patient was
started on dexamethasone 4mg daily and celocoxib 200mg BID as
well as keppra. The patient and family report that over the past
2 weeks she has had worsening left-sided weakness, which had
previously been much improved after tumor resection. She
presented to the ED because the weakness has now worsened to the
point that it is difficult for her to walk and she has fallen
multiple times. She endorses headache and feeling dizzy upon
standing. The patient's husband also reports that the patient
often seems unaware of things going on to her left side. She
denies any other new complaints.
On arrival to the ED, initial vitals were 97.4 70 167/85 18 98%
RA. Exam was notable for left-sided neglect, right-sided
nystagums, and decreased left-sided strength. Labs were notable
for WBC 11.5, H/H 9.___.5, Plt 253, Na 143, K 3.3, BUN/Cr
___, and UA with large leuks, positive nitrite, and 45 WBCs.
Urine culture was sent. Head CT showed increase in edema and
mass
effect from the right temporoparietal mass causing progression
of
leftward midline shift and increase in effacement of the
interpeduncular cistern. She had an acute mental status change
at
23:30 where she became more somnolent, head CT without change
from earlier, and she had improved in mental status after ___
minutes. Dr. ___ was consulted who recommended 10mg IV dex x 1,
increasing dex to 4mg BID, consideration of more urgent
radiation, and no need to contact Neurosurgery regarding brain
imaging. Patient was given dexamethasone 10mg IV. Prior to
transfer vitals were 98.0 65 156/75 16 98% RA.
On arrival to the floor, patient has no acute issues or
concerns.
She denies fevers/chills, night sweats, vision changes,
dizziness/lightheadedness, shortness of breath, cough,
hemoptysis, chest pain, palpitations, abdominal pain,
nausea/vomiting, diarrhea, hematemesis, hematochezia/melena,
dysuria, hematuria, and new rashes.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- Resection of a right arm primary melanoma in ___ and was
found
to have metastatic disease in ___.
- Treated with High-dose interleukin-2 with complete remission.
- Developed recurrence in the mesentery of the jejunum in ___
and underwent proximal jejunum mesenteric mass resection in
___.
- Enrolled in ECOG protocol 4697 on HLA-A2 positive arm in
___.
- In ___, she was found to have brain metastases and
underwent total surgical resection at ___. She had
dural enhancement in the surgical cavity on follow up MRI, and
the neurosurgeon performed a second CNS surgery on ___ to
identify the underlying pathology with no tumor being found. She
received CyberKnife radiation therapy to the tumor bed in
___.
- She restarted ECOG protocol 4697 on ___, completing 13
cycles in ___.
- In ___, follow up torso CT revealed a growing subcarinal
soft tissue density mass and several new subcutaneous lesions
with FDG avidity. She underwent suprapubic and subcarinal mass
resections on ___ with pathology revealing melanoma.
- She underwent a re-do right thoracotomy with pneumolysis;
resection of a middle mediastinal mass on ___.
- She began ipilimumab expanded access protocol ___ on
___.
- On ___ she had surveillance MRI A/P which showed new
1.6cm
enhancing lesion within the anterior superior right acetabulum.
This lesion was concerning for metastatic disease. On ___
she
underwent cyberknife to this lesion. On ___ outside MRI
pelvis showed minimal decrease in size of treated acetabular
lesion. Chronic nonspecific posterior rectal wall thickening.
- ___: CT chest & MRI abdomen/pelvis - ___
- ___: CT chest showed 1-cm internal mammary node that was
slightly larger than on prior scans. Also seen was a lesion in
the vicinity of the aortic arch that may be a pericardial recess
that had slowly enlarged since ___ from 1.5 cm to 3.5 cm MRI
A&P
with ___ plan for PET/CT scan.
- ___: Admission with symptomatic right parietal lesion
s/p right craniotomy for tumor resection on ___. Presented at
OSH with left neglect and left visual field cut. CT head at OSH
showed right parietal lesion with vasogenic edema, and
transferred to ___.
>> ___: MRI brain showed large right inferior parietal lobe
mass with extensive vasogenic edema, leftward shift and right
uncal herniation.
>> ___: CT torso w/o contrast showed new enlarged right
thoracic outlet lymph node and moderate increase in left upper
internal mammary adenopathy.
>> ___: Right craniotomy for tumor resection.
PAST MEDICAL HISTORY:
- Metastatic Melanoma, as above
- CKD
- OSA
- Hypothyroidism
- Hypercholesterolemia
- Hypertension
- Osteoarthritis
- s/p tonsillectomy
Social History:
___
Family History:
Father died at age ___ from brain tumor. Mother
died at ___ from natural causes Sister with ___ and breast
cancer. Son with Down's syndrome.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 97.4, BP 129/79, HR 62, RR 20, O2 sat 94% RA.
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, positive bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, responds appropriately to questions but gives
mostly one word answers, CN II-XII intact. Left-sided neglect.
Right looking nystagmus. Moves all extremities. ___ left upper
and lower extremity strength. Sensation to light touch intact.
Able to name president and simple arithmetic. Able to state ___
backwards.
SKIN: No significant rashes.
DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM: Temp: 97.4 (Tm 98.2), BP: 134/82 (100-147/60-82),
HR: 86
(75-106), RR: 18, O2 sat: 97% (96-97), O2 delivery: RA GENERAL:
in no distress, woman lying in bed comfortably
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, crackles at bases, no
wheezes or rhonchi.
ABD: Soft, non-tender, non-distended, positive bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox4, responds appropriately to questions. CN II-XII
intact. Left-sided neglect. Moves all extremities. ___ left
upper
and lower extremity strength. Sensation to light touch intact.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS
___ 07:46PM BLOOD WBC-11.5* RBC-3.30* Hgb-9.9* Hct-31.5*
MCV-96 MCH-30.0 MCHC-31.4* RDW-14.7 RDWSD-51.3* Plt ___
___ 07:46PM BLOOD Neuts-61.2 Lymphs-10.3* Monos-10.0
Eos-16.9* Baso-0.7 Im ___ AbsNeut-7.01* AbsLymp-1.18*
AbsMono-1.15* AbsEos-1.94* AbsBaso-0.08
___ 07:46PM BLOOD Glucose-103* UreaN-21* Creat-1.4* Na-143
K-3.3* Cl-104 HCO3-23 AnGap-16
___ 06:55AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.4
___ 07:40PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 07:40PM URINE Blood-TR* Nitrite-POS* Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 07:40PM URINE RBC-4* WBC-45* Bacteri-MOD* Yeast-NONE
Epi-5 TransE-<1
___ 07:40PM URINE Mucous-RARE*
PERTINENT INTERVAL LABS
___ 09:45AM URINE Color-Yellow Appear-Clear Sp ___
___ 09:45AM URINE Blood-TR* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*
___ 09:45AM URINE RBC-2 WBC-64* Bacteri-NONE Yeast-NONE
Epi-2
___ 09:45AM URINE Hours-RANDOM Creat-100 TotProt-96
Prot/Cr-1.0*
___ 07:30AM BLOOD TSH-0.26*
___ 07:30AM BLOOD Free T4-1.7
DISCHARGE LABS
___ 04:24AM BLOOD WBC-8.4 RBC-3.47* Hgb-10.4* Hct-32.5*
MCV-94 MCH-30.0 MCHC-32.0 RDW-15.5 RDWSD-52.8* Plt ___
___ 04:24AM BLOOD Glucose-109* UreaN-28* Creat-0.9 Na-141
K-3.4* Cl-107 HCO3-19* AnGap-15
___ 04:24AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.2
MICROBIOLOGY
___ 7:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Piperacillin/Tazobactam test result performed by ___
___.
Cefepime test result confirmed by ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- 32 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING AND STUDIES
___ CT HEAD W CON
Mild interval increase in edema and mass effect from the right
temporoparietal mass. There is now approximately 13 mm of
leftward midline shift (previously 11 mm), and effacement of the
interpeduncular cistern has likely increased. The remainder of
the basilar cisterns appear patent however. Mass effect on the
right lateral ventricle is similar.
___ CT HEAD W CON
Overall unchanged findings when compared with study performed 4
hours prior with a edema and mass effect from right temporal
parietal mass and 12 mm of leftward midline shift with
effacement of the interpeduncular cistern and right lateral
ventricle.
___ EEG
This telemetry captured no pushbutton activations. It showed a
normal background in wakefulness but with prominent focal
slowing in the right posterior quadrant, suggesting a
subcortical dysfunction there, possibly structural in origin.
There was minimal slowing on the left. There were a few sharp
waves near the right hemisphere slowing, but no overtly
epileptiform abnormalities or repetitive discharges. There were
no electrographic seizures.
___ EEG
This telemetry captured no pushbutton activations. It showed a
normal waking background over the left hemisphere but prominent
focal slowing
over the right hemisphere, as on the previous recording. The
right hemisphere slowing indicates a large area of subcortical
dysfunction. Recording cannot specify the etiology, but vascular
disease is among the common causes at this age. Structural
lesions are also possible. There were no epileptiform features
or electrographic seizures.
___ PICC LINE REPLACEMENT
Successful placement of a right 45 cm basilic approach double
lumen PowerPICC with tip in the cavoatrial junction. The line
is ready to use.
Brief Hospital Course:
Ms. ___ is a ___ female with history of
metastatic melanoma s/p HD IL-2 with multiple oligo-metastatic
recurrences (including brain) s/p multiple resections,
ipilimumab and cyberknife now with new metastatic lesion
(melanoma vs poorly differentiated spindle cell neoplasm likely
gliosarcoma) in right parietal brain s/p resection who presented
with
left-sided weakness.
# Left-Sided Weakness due to Cerebral Edema
Patient had sub-acute decline over the last 2 weeks due to
worsening disease. Head CT showed increased edema and worsening
midline shift. She was given IV dexamethasone 10mg x1 and her
home dexamethasone was uptitrated to dexamethasone 4mg PO q6h,
eventually tapered to q12h. In addition, she was given a
bevacizumab infusion on ___ to control cerebral edema.
Initially planned for 6 weeks of radiation given pathology of
previously resected brain lesion was likely gliosarcoma.
However, later revised to likely metastatic melanoma and she
received 5 fractions total (___). Her course was c/b
mechanical fall towards her left side after attempting to stand
from chair unassisted on ___. Staff was present seconds later,
she denied head trauma, and she had no exam changes. Throughout
the hospital course her mental status and strength returned to
baseline though with persistent though improving left-sided
neglect. She was continued on keppra and celecoxib at home
doses. Upon discharge, her dex was further tapered to 4mg in AM
and 2mg in afternoon, with plans to continue decrease at
appointment on ___ w neuro-onc.
# Toxic Metabolic Encephalopathy
She initially presented with increased somnolence and difficulty
with days of the week backwards, likely ___ increasing cerebral
edema as above but also may have an element of toxic metabolic
encephalopathy in the setting of UTI. EEG with no e/o seizures
but did show non-specific slowing c/w encephalopathy. Mental
status improved throughout hospitalization and she was back at
her baseline by discharge.
# ESBL UTI
Positive UA, culture results showing E coli, ESBL. Treated w
10-day course of meropenem 500 mg IV Q6H (___).
# Metastatic Melanoma
On re-eval by path, right parietal brain lesion is a new
melanoma met rather than previously thought poorly
differentiated spindle cell neoplasm/probable gliosarcoma. She
received ___ fractions of radiation while inpatient.
# Leukocytosis
Likely secondary to steroids vs. infection. Improved after
initiation of IV antibiotics.
CHRONIC ISSUES:
===============
# Stage III CKD: Baseline Cr 1.2-1.3. Remained at baseline while
in-house.
# Anemia: At baseline. No evidence of bleeding.
# Hypothyroidism: ___ ___ 0.18, re-checked while inpatient
and was still low at 0.26 w normal (1.7) free T4. Can be
discussed as transitional issue, reassuring htat FT4 is within
normal limits. Her home levothyroxine was continued.
TRANSITIONAL ISSUES:
====================
[] Patient discharged w PICC to continue chemotherapy on
___.
[] Follow-up with Dr. ___ ___ for Bevacizumab infusion
scheduling
[] Dexamethasone (steroid) tapered upon discharge to 4mg in AM
and 2mg in afternoon. She will remain at this dose until her
appointment w her neuro-oncologist on ___, when this will
likely be tapered further.
[] MRI in 1 month and neurology follow-up
[] Follow-up with Radiation oncology
[] Recheck ___ as an outpatient in approx. 6 weeks to ensure
patient is at correct dose of synthroid
[] Patient worked with our physical therapists who recommended
discharge to rehab given L-sided weakness and neglect, and need
for 24 hour supervision. We educated her and her husband on the
importance of rehab and why it would be better and safer than
home. However, she chose to return home and get services in the
house. Her husband promised he would be able to provide 24 hour
supervision that patient needs. She is at increased risk of
falls and other injuries because of this.
CODE: Full Code (presumed)
EMERGENCY CONTACT/HCP: ___ (husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Atorvastatin 40 mg PO QPM
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Famotidine 20 mg PO DAILY
5. LevETIRAcetam 1000 mg PO BID
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Senna 8.6 mg PO BID:PRN constipation
8. Dexamethasone 4 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Celecoxib 200 mg oral BID
11. Prochlorperazine 10 mg PO ASDIR nausea/vomiting
12. Mirtazapine 15 mg PO QHS
13. temozolomide 150 mg oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Bevacizumab (Avastin) 500 mg IV Days 1 and 15. ___
and ___
(5 mg/kg (Weight used: Actual Weight = 94.8 kg BSA: 2.02 m2))
*Dose before rounding 474 mg
3. Dexamethasone 4 mg PO QAM
4. Dexamethasone 2 mg PO EVERY AFTERNOON
5. Docusate Sodium 200 mg PO BID
6. Famotidine 20 mg PO DAILY
7. LevETIRAcetam 1000 mg PO BID
8. Senna 8.6 mg PO BID
9. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
RX *sodium chloride 0.9 % 0.9 % 10 ml IV once a day Disp #*30
Milliliter Refills:*0
10. Atorvastatin 40 mg PO QPM
11. Celecoxib 200 mg oral BID
12. Levothyroxine Sodium 125 mcg PO DAILY
13. Mirtazapine 15 mg PO QHS
14. Multivitamins 1 TAB PO DAILY
15. Prochlorperazine 10 mg PO ASDIR nausea/vomiting
16. HELD- temozolomide 150 mg oral DAILY This medication was
held. Do not restart temozolomide until Dr. ___ you that
you should.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
L-sided body weakness and neglect
Metastatic melanoma
Cerebral edema
Toxic metabolic encephalopathy
Multi-drug resistant urinary tract infection
SECONDARY DIAGNOSIS:
====================
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ was a pleasure caring for you at ___.
You came to the hospital because you were feeling confused and
weak on the left side of your body.
While you were in the hospital, we found that there was some
swelling in your brain that was causing this weakness. We gave
you steroids to help with the swelling, and chemotherapy and
radiation to help reduce the bad effects the cancer was causing
on your body.
We also found that you had a urinary tract infection and treated
you with antibiotics.
You worked with our physical therapists who recommended you
attend rehab to get stronger prior to going home. We educated
you and your husband on the importance of rehab and why it would
be better and safer than home. Instead, you chose to go home and
get therapy in your house. As we discussed with you and your
husband, you will need 24 hour supervision because of your motor
limitations, and your husband agreed he would be able to provide
this.
When you leave the hospital, please follow up with all of your
scheduled appointments (listed below), and continue to work with
your in-home services and take your medications.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10776100-DS-19
| 10,776,100 | 20,962,183 |
DS
| 19 |
2189-03-12 00:00:00
|
2189-03-23 20:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo male with Hx of nonobstructive CAD, HTN, HL and chronic
cough/DOE of unknown etiology presents with syncope. The patient
was walking to ___ game, became lightheaded and sat down.
When he stood back up, he felt lightheaded, syncopized and hit
his face on the ground. He denies any CP, SOB, dizziness,
palpitations prior to the event. He denies any loss of urine or
bowel control, shaking or post-ictal period. Patient reports
DOE and lighheadedness that has been progressive over the past
few years. He has seen a pulmonologist and cardiologist as an
outpatient without a clear diagnosis. Cardiac cath showed
non-obstructive CAD last year and ECHO showed normal LVEF
without significant valvular disease.
In the ED, initial VS: 99 80 138/82 18. The patient was given
Asa 81 mg and 1 liter of IVF. EK showed nsr with twi/std V1-v3,
likely lvh CT head negative for intracranial bleed. CXR with
moderate cardiomegaly, mild pulm edema. Patient was seen and
evaluated by OMFS. Lasix given for O2 sat of 92% on RA. Vitals
prior to transfer: afeb 72 134/78 23 92% on RA.
On the medical floor, the patient denied any palpitations, chest
pain, changes to his shortness of breath, or changes to his
cough. He also denied any pain in his face or neck, headaches,
blurry vision, changes to his vision, tinnitus.
Past Medical History:
Nonobstructive CAD
HTN
HLD
Chronic cough and dyspnea on exertion of unclear etiology
Social History:
___
Family History:
Mother with ___ (died in ___. Father with renal cancer
(died in ___. Denies FH of stroke, sudden death, pulmonary
disease, clotting disorder.
Physical Exam:
On Admission:
VS - 98, 116/78, 108, 20, 95%RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - PERRLA, EOMI, sclerae anicteric, swollen ___ lac
sutured and c/d/i, teeth with splint, MMM, no tongue lesions
NECK - supple, no JVD
LUNGS - bibasilar crackles
HEART - PMI displaced laterally, irregularly irregular, nl
S1-S2, diastolic murmur lowdest over pulmonic area
ABDOMEN - +BS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout
On Discharge:
PHYSICAL EXAM:
VS - 97.6 (max 98.8), 125/75 (max 134/90 - 117/78), 52, 18,
95%RA
GENERAL - sleeping comfortably, well-appearing man in NAD, no
difficulty breathing, non-diaphoretic, appropriate
HEENT - pupils equally round and reactive to light00,
extraoccular movements intact, sclerae anicteric, swollen ___,
___ laceration sutured and clean, dry and intact, teeth with
splint, moist mucous membranes, no tongue lesions
NECK - supple, JVP not visualized at 30 degrees
LUNGS - bibasilar crackles, no accessory muscle use, no wheezes
or rhonchi or rales
HEART - PMI displaced laterally, regular rate and rhythm, normal
S1-S2, diastolic murmur loudest over pulmonic area
ABDOMEN - normoactive bowel sounds, soft, non-tender,
nondistended; no masses, no hepatosplenomegaly, no
rebound/guarding
EXTREMITIES - warm and well perfused, no cyanosis, clubbing or
edema, 2+ peripheral pulses (radials, DPs)
NEURO - awake, awake and oriented x 3, CNs II-XII grossly
intact, muscle strength ___ throughout
Pertinent Results:
ADMISSION VITALS:
___ 07:30PM GLUCOSE-89 UREA N-20 CREAT-0.7 SODIUM-142
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15
___ 07:30PM CK(CPK)-250
___ 07:30PM cTropnT-0.01
___ 07:30PM CK-MB-7 proBNP-431*
___ 07:30PM WBC-11.9* RBC-5.27 HGB-15.2 HCT-46.3 MCV-88
MCH-28.9 MCHC-32.9 RDW-14.6
___ 07:30PM NEUTS-83.0* LYMPHS-10.7* MONOS-4.8 EOS-0.8
BASOS-0.7
___ 07:30PM PLT COUNT-196
RELEVANT LABS:
___ 07:30PM BLOOD CK-MB-7 proBNP-431*
___ 07:30PM BLOOD cTropnT-0.01
___ 07:30AM BLOOD CK-MB-5 cTropnT-<0.01
___ 11:05AM BLOOD D-Dimer-1492*
DISCHARGE LABS:
___ 08:00AM BLOOD WBC-6.4 RBC-5.66 Hgb-16.1 Hct-49.3 MCV-87
MCH-28.5 MCHC-32.7 RDW-14.3 Plt ___
___ 08:00AM BLOOD Glucose-124* UreaN-24* Creat-0.8 Na-136
K-3.9 Cl-99 HCO3-25 AnGap-16 Calcium-9.0 Phos-3.5 Mg-1.7
IMAGING:
CT HEAD W/O CONTRAST Study Date of ___
IMPRESSION: No acute intracranial process.
Fracture/dislocation of the left TMJ better seen on concurrently
performed CT facial bones.
CHEST RADIOGRAPH PERFORMED ON ___
IMPRESSION: Cardiomegaly with pulmonary edema.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Study Date of
___
IMPRESSION:
1. Fracture of the left mandibular neck and dislocation of the
left
mandibular head from the temporomandibular joint.
2. Fracture of the anterior maxilla at the anterior inferior
nasal spine and involving the frontal maxillary incisors.
3. Absent mandibular incisor.
MANDIBLE RADIOGRAPH PERFORMED ON ___ (TEETH (PANOREX FOR
DENTAL)
FINDINGS: Total of eight images of the mandible which include
two Panorex images were provided. As seen on CT scan, there is
a displaced fracture through the left mandibular neck. No
additional fractures of the mandible seen. The known fracture
through the anterior inferior nasal spine of the anterior
maxilla is better assessed on CT with disruption of the central
maxillary incisors and right lateral incisor. The left
mandibular central incisor is absent. Please refer to report
from CT of the facial bones for further details.
TTE (Complete) Done ___
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity size
and regional/global systolic function are normal (LVEF >55%).
There is no ventricular septal defect. The right ventricular
cavity is mildly dilated with borderline normal free wall
function. The ascending aorta is mildly dilated. The aortic arch
is mildly dilated. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. The mitral valve
leaflets are elongated. Mild (1+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. Significant
pulmonic regurgitation is seen. There is no pericardial
effusion.
IMPRESSION: normal regional and global left ventricular systolic
function. Mild aortic regurgitation. Elongated and thickened
mitral leaflets without meeting criteria for mitral valve
prolapse. The right ventricle is mildly dilated with borderline
systolic function, mild tricuspid regurgitation and probably
moderate pulmonic regurgitation. There is moderate pulmonary
hypertension present.
CTA CHEST W and W/O ___
IMPRESSION:
1. Relatively acute segmental pulmonary embolus in a left lower
lobe
segmental artery with chronic appearing linear filling defect in
a right lower lobe segmental artery. The hemodynamic
significance of a clot of this small size is uncertain.
2. Cardiomegaly with enlargement of the main and right
pulmonary artery
consistent with pulmonary hypertension.
3. Increased subpleural interstitial opacities with basilar
traction
bronchiectasis compatible with known fibrotic interstitial lung
disease with accompanying likely reactive lymphadenopathy.
Brief Hospital Course:
Mr. ___ is a ___ year old male with history of nonobstructive
CAD, HTN, HL and chronic cough/DOE of unknown etiology who
presented with syncope leading to fall and facial lacerations
and fractures.
ACTIVE ISSUES:
# Syncope: Mr. ___ presented with an episode of syncope while
walking that was preceded by lightheadedness. He denied
dizziness, headache, changes to vision, nausea, diaphoresis.
He has had past episodes (~2/month) of lightheadedness which
resolved with sitting down but no history of syncope. Initial
concern was for cardiogenic cause. ECG on admission showed
sinus rhythm with frequent premature atrial contractions at 65
with a RBBB, t wave inversions throughout precordium and
inferior limb leads, a left anterior fascicular block, 1mm ST
depression in V2. An ECHO was down which showed mild RV
dilation with borderline function, moderate RA dilation, ___
___, normal LV size and function, 1+ AR/MR ad moderate
pulmonary hypertension with significant pulmonary regurgitation.
The patient was evaluated by cardiology, who felt that the
episode was unlikely to be secondary to arrhythmia and more
likely related to decreased cardiac output in the setting of
exercise and pulmonary fibrosis. Should this occur again, a
reveal monitor could be considered. The patient was given full
dose aspirin, metoprolol and atorvastatin 80 mg due to concern
for acute coronary syndrome, however he ruled out with two
negative troponins and one CK-MB. The patient was monitor on
telemetry for 24 hours without event. Our differential further
included neurocardiogenic, orthostatic, , and neurologic. It is
possible that this was an orthostatic event because it occured
after he went from sitting to standing and the patient reported
low PO intake prior to the event. Considering his ECHO findings
of pulmonary hypertension, it is more likely that the syncope
was related to decreased cardiac output in the setting of
pulmonary hypertension and pulmonic and tricuspid valve
regurgitation. A CTA was performed due to concern for pulmonary
embolism and a small pulmonary embolism was found that was
unlikely to be hemodynamically compromising or related to
syncopal episode.
# Pulmonary Embolism: CT Chest revealed a pulmonary embolism in
the lower lobe segmental artery with chronic appearing linear
filling defect in a right lower lobe segmental artery after a
D-Dimer returned at 1428. The patient is stable,
non-diaphoretic in no acute distress. He reports no chest pain,
changes to his baseline shortness of breath or changes to cough
or difficulty breathing. This is most likely not associated
with the syncope (above) because it is not a massive PE. The
patient was started on enoxaparin 90 mg SC Q12H and warfarin 5
mg PO/NG. He has been referred to his primary care physician ___.
___ in ___, ___ for monitoring of his INR (goal 2.0 - 3.0)
and management of his anti-coagulation therapy. He is scheduled
to see Dr. ___ on ___ at 2:15PM. Dr. ___ is aware
of the need to monitor the INR and his office has confirmed the
ability to do this.
# Dyspnea and cough: Patient has crackles on exam, and CXR
revealing cardiomegaly and pulmonary edema. CTA chest revealed
increased subpleural interstitial opacities with basilar
traction bronchiectasis compatible with known fibrotic
interstitial lung disease with accompanying likely reactive
lymphadenopathy. Considering his chronic cough and dyspnea on
exertion for ___ years, this may be idiopathic pulmonary fibrosis,
although honeycombing was not appreciated on CT scan. Also on
the differential is right sided heart failure secondary to
pulmonary disease (cor pulmonale). He was given Furosemide 20
mg PO/NG DAILY and his in's and out's were monitored with daily
weights. There was no change from his baseline admission
crackles during his inpatient stay. He should follow up out
patient with his pulmonologist about the latest CT and CXR
findings.
# left subcondylar fracture: During the syncopal event, Mr.
___ fell and hit his jaw and face on the ground. He was seen
by oro-maxilla facial surgery; he has stable, reproducible
occlusion, with no jaw deviation and at the time did not require
to be placed in maxillo-mandibular fixation. He will continue
on full liquid diet for two-four weeks. While he refused to
return to ___ to see a ___ oral surgeon that we could
schedule, we have strongly encouraged him to follow-up with his
local oral surgeon upon return home within 2 weeks, especially
for possible MMF if noted jaw deviation or change in occlusion.
# anterion nasal spine fracture / dentoalveolar fracture with
intrusion of teeth #7,8,9 - upon obtaining verbal and written
consent, anesthetised with 5ml 2% Lidocaine with 1:100,000 epi,
teeth #6,7, and 8 repositioned and splinted; repeated panoramic
x-ray. Recommend to keep splint for 2 weeks. Patient informed of
poor
prognosis for these teeth and that they might require root canal
treatment or possible extraction in the future. Require close
follow-up with oral surgeon, liquid diet and meticulous oral
hygiene. Mr. ___ has had the option to follow up with Dr.
___, consulting oral surgeon, at her clinic at ___,
___, ___, ___ however he has
refused and will see his home oral surgeon within two weeks.
# HTN: While inpatient he was normotensive. We continued home
aliskiren with hydrochlorothiazide and changed diltiazem to a
beta blocker while in house. He will continue his home
medications at discharge.
INACTIVE ISSUES:
# Hyperlipidemia: stable while in house. Continue on home meds.
TRANSITIONAL ISSUES:
# ANTICOAGULATION: Mr. ___ will need to be followed by his
home PCP's office for management of anticoagulation for the
pulmonary embolism. The patient was started on enoxaparin 90 mg
SC Q12H and warfarin 5 mg PO/NG. He has been referred to his
primary care physician ___ in ___, ___ for monitoring of
his INR (goal 2.0 - 3.0) and management of his anti-coagulation
therapy. He is scheduled to see Dr. ___ on ___ at
2:15PM. Dr. ___ is aware of the need to monitor the INR and
his office has confirmed the ability to do this.
# ORAL LACERATION AND FRACTURE MANAGEMENT: Mr. ___ will need
to follow up closely with an oral surgeon about the facial
fractures he obtained during his syncopal event. He has refused
to return to ___ to see Dr. ___ in her Oral Surgery
Clinic because it is too far from him home. He has confirmed
that he will see his local oral surgeon in ___ within 2
weeks and that he already has an appointment with them in 10
days. We have strongly counseled him about follow up with his
oral surgeon to avoid any complications.
# ?INTERSTITIAL PULMONARY FIBROSIS: Mr. ___ was told to follow
up with his pulmonologist about his chronic cough and dyspnea on
exertion. CTA of the chest suggested that this may be an
interstitial process and he will need management.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. ___-hydrochlorothiazide *NF* 150-25 mg Oral daily
2. Diltiazem Extended-Release 180 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
Discharge Medications:
1. aliskiren-hydrochlorothiazide *NF* 150-25 mg Oral daily
2. Diltiazem Extended-Release 180 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Warfarin 5 mg PO DAILY16
RX *Coumadin 2.5 mg 1 Tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Enoxaparin Sodium 90 mg SC Q12H
RX *enoxaparin 100 mg/mL inject 90 mg every 12 hours Disp #*14
Syringe Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: pulmonary embolism
Secondary: syncope, pulmonary hypertension, pulmonary
regurgitation, anterior nasal fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___, It was a pleasure taking care of you at ___
___. You came in with an episode of
fainting. You were seen by our cardiology team, who felt that
it was not likely due to your heart. You had a CT scan of the
chest that found a small clot in your lung. You are being
treated for this clot with lovenox and warfarin. You will need
to have your blood level (___) monitored for the warfarin
treatment and follow up with /your primary care physician
regarding dosing on ___.
The CT also showed some chronic lung disease that you may follow
up with as an oupatient with your pulmonologist.
You also hit your face when you fainted and broke your nasal
spine. You will need to follow up with your oral surgeon. You
will also need to be on a liquid diet and keep your mouth
meticulously clean. You will need to splint for two weeks.
Followup Instructions:
___
|
10776104-DS-17
| 10,776,104 | 26,447,208 |
DS
| 17 |
2182-11-21 00:00:00
|
2182-11-21 15:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
HOSPITALIST ATTENDING ADMISSION H&P
Pt seen / examined at 0700
.
CC: EtOH intoxication / EtOH withdrawl / pancreatitis
.
PCP: ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M, PMH of EtOH abuse with hx of withdrawal seizures, IVDU,
pancreatitis (presumed EtOH), chronic HCV, who p/w EtOH
intoxication. Pt does not recall HPI, and HPI is based on ED
report. Pt was brought in by EMS sleeping on concrete sidewalk
with empty bottle of Listerine.
.
On arrival to the ED, he was noted to be hypothermic, but
otherwise hemodynamically stable. He underwent unremarkable
Head CT and PCXR. His bloodwork was notable for EtOH level 486,
lipase 217, + urine tox for barbituates, as well as multiple
metabolic derangements, including serum lactate 5.1, K 9.1
(hemolyzed, repeat K 4.4), HCO3 13, AG 40, CBC 51.3, as well as
elevated transaminases / alk phos, but normal T. bili and CPK
595, but Cr 0.9. In the ED he was initally placed in
OBSERVATION, but due to concern for EtOH withdrawal, he was
placed on Valium PRN CIWA, and received approximately total of
60mg of Valium. He also received IV morphine for pain.
.
On arrival to the floor, patient reports feeling more sober,
although he admits to still being quite intoxicated. He is c/o
epigastric abdominal pain and is requesting IV pain medication.
The abdominal pain is associated with nausea and vomiting, but
does not radiate, is constant, dull, but severe. With regards
to his EtOH history, he reports that he started drinking at the
age of ___, alcoholism runs in the family (both parents) and that
he currently drinks on a daily basis, will drink any alcohol.
Last recalls being sober in ___. He does report hx of
EtOH withdrawal seizures and has been intubated once in the
past. He has been to several different detox / addiction
treatment programs / facilities in the past. He expresses
interest in attempting sobriety again and agrees to S/W consult.
.
ROS: 10 point ROS negative except as noted above in HPI
Past Medical History:
-EtOH abuse with h/o withdrawal seizures
- h/o IVDU
-pancreatitis
-HCV
Social History:
___
Family History:
+ FH of alcoholism in both parents
Physical Exam:
ADMISSION PHYSICAL EXAM:
===============================
VS: 98.6, 142/84, 102, 18, 98% on RA
Pain: ___
Gen: NAD, anxious, non-diaphoretic, disheveled
HEENT: EOMI, + nystagmus, anicteric, MMM, + tongue fasiculations
CV: RRR, no murmurs
Lungs: CTAB
Abd: soft, + epigastric TTP, NABS
Ext: WWP
Neuro: AAOx3, + tremulous
Mood: stable, appropriate
.
Pertinent Results:
ADMISSION LABS:
=====================
___ 10:00AM BLOOD WBC-4.2 RBC-5.12 Hgb-17.5 Hct-51.3
MCV-100* MCH-34.1* MCHC-34.1 RDW-15.1 Plt ___
___ 10:00AM BLOOD Glucose-117* UreaN-15 Creat-0.9 Na-137
K-9.1* Cl-93* HCO3-13* AnGap-40*
___ 10:00AM BLOOD ALT-103* AST-271* CK(CPK)-595*
AlkPhos-134* TotBili-0.5
___ 10:00AM BLOOD Lipase-217*
___ 10:00AM BLOOD Albumin-4.7 Calcium-8.1* Phos-6.0* Mg-2.1
___ 10:00AM BLOOD Osmolal-427*
___ 10:00AM BLOOD ASA-NEGATIVE ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:40AM BLOOD K-4.4
___ 10:10AM BLOOD Lactate-5.1*
___ 11:55PM BLOOD Lactate-4.7*
___ 10:40AM BLOOD ___ Temp-37 pO2-58* pCO2-43 pH-7.24*
calTCO2-19* Base XS--8 Intubat-NOT INTUBA
___ 11:55PM BLOOD ___ pO2-57* pCO2-29* pH-7.37
calTCO2-17* Base XS--6
___ 10:50AM URINE bnzodzp-POS barbitr-POS opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
MICROBIOLOGY:
==================
___ Urine Culture - NO GROWTH (FINAL)
___ Blood Culture - NGTD, final PENDING
.
IMAGING:
==================
___ CT Head
IMPRESSION:
1. No acute intracranial abnormality.
2. Dysconjugate alignment of the globes is noted. However, this
may be a transient finding at the time of the scan. Correlate
with physical examination.
.
___ PCXR
IMPRESSION:
No acute cardiopulmonary process.
.
Brief Hospital Course:
___ yo M with polysubstance abuse, including EtOH abuse and IVDU,
also PMH of HCV and pancreatitis, p/w EtOH intoxication and
acute pancreatitis.
.
# Acute pancreatitis
Presumed EtOH pancreatitis. Would correlate to his elevated
EtOH level of >400. Lipase was > 3 ULN and his epigastric
abdominal pain were c/w diagnosis of acute pancreatitis. BISAP
score was low, at 2 (impaired mental status, 2 SIRS
criteria),although the 2 points could also be attributed to EtOH
withdrawal. He responded well to medical management with bowel
rest, IVF's and IV supportive medications. He tolerated a trial
of clears and his diet was successfully advanced to regular, low
fat diet prior to discharge. He did report pain at times, but
appeared quite comfortable and was tolerating a regular diet
without n/v/d. The patient was not discharged with any pain
medication given his addiction/alcohol history and the risk for
misuse.
.
# Abd pain:
Most likely from pancreatitis. He denied N/V, hematemesis, but
he is at risk for gastritis / esophagitis / M-W tear from his
EtOH intake. Pt was given PPI during admission. Diet advanced to
regular without complication.
.
# EtOH intoxication / abuse, EtOH withdrawal
Initially with high BZD requirement in the ED and initially
during admission. He was placed on MVI, thiamine and folate.
He was seen by Social Work who provided pt with multiple
resources and options for housing and addiction/sobriety
treatment. He was slowly tapered on CIWA / BZD's and did not
require any benzos for withdrawal in the days prior to
discharge. He was discharged with prescriptions for thiamine and
folate. He was given a transportation pass and pt states that
his mother was arranging for him to get transportation back down
to the ___ where pt states he will present himself to
___ for treatment.
.
# h/o IVDU
Pt reports he is known HCV positive. He reports a recent HIV
test and is DECLINING repeat HIV test at ___. He has no
murmur or stigmata of IE. Blood culture negative. Seen by ___ as
above.
.
# Thrombocytopenia / Pancytopenia
Plt# has dropped significantly during admission, although he was
likely very hemoconcentrated on admission. Also, he has
previously had plt # quite low as well, and now has
pancytopenia,so could be all due to chronic marrow suppression
from EtOH use. However, 4T score is 5, so sent HIT Ab, but
returned negative. Heparin SQ was held for DVT PPx and he
received Arixtra instead for DVT PPx.
.
Transitional issues
1.pt encouraged to find and maintain good report with PCP. He
states he will present to the ___ clinic down the ___
2.Pt will need ongoing intensive resources for addiction/ETOH
abuse. SW was extensively involved and provided him with
multiple resources and options for ongoing treatment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol Intoxication
Alcohol Withdrawal
Pancytopenia
Acute Pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to the hospital with alcohol intoxication and
alcohol withdrawal, so you were admitted for treatment of
alcohol withdrawal with medications. You were also found to
have acute pancreatitis, likely due to your alcohol intake. You
were treated conservatively with bowel rest, IV fluids and
supportive medications with good improvement.
.
You worked with the social work team to help you with resources
for shelter and sobriety. Please be sure to follow up with these
resources that have been given to you and abstain from alcohol
and substance use.
Followup Instructions:
___
|
10777078-DS-5
| 10,777,078 | 24,828,086 |
DS
| 5 |
2156-08-15 00:00:00
|
2156-09-06 10:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
L3-4 laminotomies and discectomy
History of Present Illness:
___ w/h/o chronic back pain p/w ___ weeks of intractable back
pain with radiation into his right lower extremity. Patient
states that this occurred after bending down to pick up a napkin
___ weeks ago. Since that time he has tried multiple
interventions to no avail. He has tried oxycodone, vicodin,
valium, lidocaine patches, and a recent epidural injection. He
denies any numbness, paresthesias, bowel or bladder symptoms, or
saddle anesthesia. He has been able to ambulate short distances
to use the restroom. No fevers, chills, chest pain, or shortness
of breath.
Past Medical History:
Bipolar disease
Social History:
___
Family History:
Denies
Physical Exam:
Vitals: AVSS
General: anxious male in obvious pain, lying on stretcher
Mental Status: AOx3
Sensory UE
C5(Ax) C6(MC) C7(Mid fngr) C8(MACN) T1(MBCN) T2-L2 Trunk
R + + + + + +
L + + + + + +
Sensory ___
L2(Groin) L3(Leg) L4(Knee) L5(Grt Toe) S1(Sm toe) S2(Post Thigh)
R + + + + + +
L + + + + + +
Motor UE
C5 C6 C7 C8 T1
R ___ 5 5
L ___ 5 5
Motor ___
L2 L3 L4DP L5/SG S1/SP S1-2/T
R ___
L ___
Reflexes
Bicep(C4-5) BR(C5-6) Tricep(C6-7) Patellar(L3-4) Ach(L5-S1)
R 1+ 1+ 1+ 1+ 1+
L 1+ 1+ 1+ 1+ 1+
Straight Leg Raise Test: positive elicitation of pain
___: negative
Babinski: downgoing
Clonus: not present
Perianal sensation: intact
Rectal tone: intact
Estimated Level of cooperation: good
Estimated Reliability of Exam: good
Pertinent Results:
___ 03:45PM BLOOD WBC-10.6 RBC-4.99 Hgb-13.6* Hct-42.1
MCV-84 MCH-27.2 MCHC-32.2 RDW-12.9 Plt ___
___ 03:45PM BLOOD Neuts-86.0* Lymphs-9.0* Monos-4.5 Eos-0.2
Baso-0.3
___ 05:45PM BLOOD Glucose-139* UreaN-19 Creat-1.2 Na-137
K-4.8 Cl-99 HCO3-29 AnGap-14
___ 03:45PM BLOOD Glucose-120* UreaN-32* Creat-1.6* Na-136
K-5.1 Cl-102 HCO___ AnGap-17
Brief Hospital Course:
Mr. ___ was admitted to the service of Dr. ___ for a
lumbar discectomy. He was informed and consented and elected to
proceed. Please see Operative Note for procedure in detail.
Post-operatively he was given antibiotics and pain medication.
His bladder catheter was removed POD 3 and his diet was advanced
without difficulty. He was able to work with physical therapy
for strength and balance. He was discharged in good condition
and will follow up in the Orthopaedic Spine clinic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LaMOTrigine 150 mg PO QAM
2. LaMOTrigine 125 mg PO QPM
Discharge Medications:
1. LaMOTrigine 150 mg PO QAM
2. LaMOTrigine 125 mg PO QPM
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl 5 mg ___ tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
4. Diazepam 5 mg PO Q6H:PRN spasm
RX *diazepam 5 mg 1 tablet by mouth every six (6) hours Disp
#*90 Tablet Refills:*0
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every four (4)
hours Disp #*100 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
L3-4 disk degeneration and
herniation.
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: Laminotomies and
discectomy L3-4
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
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.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually ___ days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Followup Instructions:
___
|
10777285-DS-11
| 10,777,285 | 22,963,655 |
DS
| 11 |
2169-12-28 00:00:00
|
2169-12-28 16:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Flexeril / Percocet / Rituxan / trazodone / Treanda / Sulfa
(Sulfonamide Antibiotics) / mold,trees
Attending: ___.
Chief Complaint:
Pancreatic cyst
Major Surgical or Invasive Procedure:
___:
1. Exploratory laparoscopy.
2. Robot-assisted minimally invasive distal pancreatectomy and
splenectomy.
3. Regional lymphadenectomy of common hepatic artery, superior
mesenteric artery, and left gastric artery in patient with
lymphoma.
4. Intraoperative ultrasound.
5. Placement of fiducials.
History of Present Illness:
Mrs ___ is a ___ year old female with a 6.8 cm cystic lesion in
the tail of the pancreas incidentally found in ___. FNA of the
lesion is suspicious for adenocarcinoma. We had an extensive
discussion with the patient and her family regarding the
pathology and management. We discussed the risks and benefits
of
a robotic distal pancreatectomy and splenectomy including, but
not limited to, worsening diabetes, conversion to open
procedure,
and pancreatic leak. We encouraged the patient to attempt
weight
loss prior to surgery. The CT torso was negative for metastatic
disease. Surgery will be scheduled in the next few weeks
Past Medical History:
morbid obesity (BMI 43), HTN, DM, hypothyroidism, GERD,
recurrent UTIs, stage III CKD, CLL (followed by Dr. ___, on
___ and receives gamma globulin infusions for
hypogammaglobulinemia and occasional respiratory infections),
history of diarrhea with unremarkable EGD and c-scope; possible
multiple sclerosis
Social History:
___
Family History:
She has a maternal cousin, who had pancreatic cancer, as well as
family relatives with breast cancer.
Physical Exam:
Prior to discharge:
VS: 98.5, 80, 142/84, 18, 98% RA
GEN: Anxious with NAD
CV: RRR, no m/r/g
PULM: Diminished on bases
ABD: Obese, laparoscopic incisions open to air and c/d/i. LLQ JP
drain to bulb suction with minimal serosanguinous output. Site
covered with drain sponge with serosanguinous stains.
EXTR: Warm, no c/c/e
Pertinent Results:
BLOOD:
___ 05:45AM BLOOD WBC-21.3* RBC-4.04 Hgb-11.5 Hct-36.2
MCV-90 MCH-28.5 MCHC-31.8* RDW-14.2 RDWSD-46.6* Plt ___
___ 09:48AM BLOOD WBC-18.2* RBC-3.99 Hgb-11.2 Hct-36.2
MCV-91 MCH-28.1 MCHC-30.9* RDW-14.6 RDWSD-48.7* Plt ___
___ 06:06PM BLOOD Glucose-147* UreaN-8 Creat-0.6 Na-138
K-4.0 Cl-103 HCO3-27 AnGap-12
___ 06:10AM BLOOD Glucose-163* UreaN-6 Creat-0.6 Na-140
K-3.9 Cl-102 HCO3-28 AnGap-14
___ 05:45AM BLOOD ALT-14 AST-14 LD(LDH)-227 AlkPhos-159*
TotBili-0.4
___ 06:10AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.7
URINE:
___ 03:50PM URINE RBC-5* WBC-17 Bacteri-MOD Yeast-NONE
Epi-3 TransE-1
___ 09:25PM URINE RBC-5* WBC-12* Bacteri-FEW Yeast-OCC
Epi-4
___ 10:35AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 09:25PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
___ 03:50PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
OTHER:
___ 03:30PM ASCITES Amylase-67
___ 11:07AM ASCITES Amylase-83
PATHOLOGY:
Common hepatic artery lymph node: Pending
Brief Hospital Course:
The patient scheduled for elective distal pancreatectomy and
splenectomy was admitted for glycemic control day prior her
surgery. The patient's blood sugar was managed with insulin gtt
and ___ was called for consult. On ___, the patient
underwent robot-assisted minimally invasive distal
pancreatectomy
and splenectomy, golden fiducials placement, which went well
without complication (please see the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor NPO, on IV fluids, on insulin gtt,
with a foley catheter, and Dilaudid PCA for pain control. The
patient was hemodynamically stable.
Neuro: The patient received Dilaudid PCA with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications. Patient developed
severe headache and medicine was consulted. Patient was treated
with coffee and Ibuprofen. She was off Clonazepam post op and it
was restarted when she tolerated PO. Patient's headache improved
after Klonopin was restarted.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient was required supplemental O2 post op to
maintain her O2 sats within normal limits. Post op CXR revealed
low lung volume and atelectasis. Good pulmonary toilet, early
ambulation and incentive spirrometry were encouraged throughout
hospitalization. Patient was able to wean off supplemental O2,
repeat CXR demonstrated improvement in aeration compared to
prior.
GI: Post-operatively, the patient was made NPO with IV fluids.
Diet was advanced when appropriate, which was well tolerated.
Patient's intake and output were closely monitored, and IV fluid
was adjusted when necessary. Electrolytes were routinely
followed, and repleted when necessary. JP drain was removed
prior to discharge as amylase level and output were low.
GU: The patient has a history of UTI. Her UA was sent secondary
to elevated WBC. UA was borderline and patient was treated for
UTI with Cipro x 5 day base on her history. Urine culture was
negative.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. The patient had elevated
WBC though to be secondary to splenectomy and CLL. Wound were
evaluated daily and no signs or symptoms of infection were
noticed. The patient received post splenectomy vaccines prior to
discharge.
Endocrine: The patient with history of poor controlled diabetes
was admitted day prior her scheduled operation for blood sugar
control. Her blood glucose was 500s on admission. She was
started on insulin gtt and endocrinology was consulted. Post
operatively patient was managed with insulin gtt, which was
weaned off on POD 1. Patient was managed with long and short
acting insulin during hospitalization. Dose of the long acting
insulin and sliding scale insulin were titrated prior to
discharge, patient's blood sugars remained within normal level.
She was advised to follow up with ___ and was provided with
contact information in order to schedule a follow up.
Hematology: As above. The patient's complete blood count was
examined routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diabetic 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:
acrivastine-pseudoephedrine [Semprex-D]
Semprex-D 8 mg-60 mg capsule
1 (One) capsule(s) by mouth twice a day (Prescribed by Other
Provider) ___
Recorded Only ___,
___
acyclovir
acyclovir 400 mg tablet
1 (One) tablet(s) by mouth once a day (Prescribed by Other
Provider) ___
Recorded Only ___,
___
nr clonazepam [Klonopin]
Klonopin 0.5 mg tablet
2 (Two) tablet(s) by mouth twice a day (Prescribed by Other
Provider) ___
Recorded Only ___,
___
___ [Vytorin ___
Vytorin 10 mg-20 mg tablet
1 (One) tablet(s) by mouth at bedtime (Prescribed by Other
Provider) ___
Recorded Only ___,
___
hydrochlorothiazide
hydrochlorothiazide 25 mg tablet
1 (One) tablet(s) by mouth twice a day (Prescribed by Other
Provider) ___
Recorded Only ___,
___
___ [Imbruvica]
Imbruvica 140 mg capsule
3 (Three) capsule(s) by mouth at bedtime (Prescribed by Other
Provider) ___
Recorded Only ___,
___
nr immune globulin (human) (IgG) [___ S/D]
Dosage uncertain (Prescribed by Other Provider) ___
Recorded Only ___,
___
nr insulin aspart [Novolog Flexpen]
Novolog Flexpen 100 unit/mL subcutaneous
___ times daily sliding scale (Prescribed by Other Provider)
___
Recorded Only ___,
___
insulin detemir [Levemir]
Levemir 100 unit/mL subcutaneous solution
___t bedtime (Prescribed by Other Provider)
___
Recorded Only ___,
___
levothyroxine
levothyroxine 100 mcg tablet
1 (One) tablet(s) by mouth once a day (Prescribed by Other
Provider) ___
Recorded Only ___,
___
metformin
metformin 500 mg tablet
1 (One) tablet(s) by mouth once a day in am plus 2 tabs in pm
(Prescribed by Other Provider) ___
Recorded Only ___,
___
methenamine hippurate
methenamine hippurate 1 gram tablet
1 (One) tablet(s) by mouth once a day (Prescribed by Other
Provider) ___
Recorded Only ___,
___
metoprolol succinate [Toprol XL]
Toprol XL 25 mg tablet,extended release
1 (One) tablet(s) by mouth at bedtime (Prescribed by Other
Provider) ___
Recorded Only ___,
___
pantoprazole
pantoprazole 20 mg tablet,delayed release
1 tablet(s) by mouth twice a day ___
Modified ___,
___ 60 Tablet 3 ___
paroxetine HCl
paroxetine 40 mg tablet
1 (One) tablet(s) by mouth once a day (Prescribed by Other
Provider) ___
Recorded Only ___,
___
valsartan [Diovan]
Diovan 320 mg tablet
1 (One) tablet(s) by mouth once a day (Prescribed by Other
Provider) ___
Recorded Only ___,
___
nr vitamin D
Dosage uncertain (Prescribed by Other Provider) ___
Recorded Only ___,
___
* OTCs *
aspirin [Adult Low Dose Aspirin]
Adult Low Dose Aspirin 81 mg tablet,delayed release
1 (One) tablet(s) by mouth once a day (Prescribed by Other
Provider) ___
Recorded Only ___,
___
Lactobacillus acidophilus [Probiotic]
Probiotic 10 billion cell capsule
1 (One) capsule(s) by mouth once a day (Prescribed by Other
Provider) ___
Recorded Only ___,
___
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*5 Tablet Refills:*0
3. ClonazePAM 1 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*80 Tablet Refills:*0
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Pantoprazole 40 mg PO Q12H
11. Paroxetine 40 mg PO DAILY
12. Semprex-D (acrivastine-pseudoephedrine) ___ mg oral BID
13. Senna 8.6 mg PO BID
14. Valsartan 320 mg PO DAILY
15. Vytorin ___ (___) ___ mg oral QHS
16. Hydrochlorothiazide 25 mg PO DAILY
17. Aspirin 81 mg PO DAILY
18. Lactobacillus acidophilus 10 billion cell oral DAILY
19. Levemir 30 Units Breakfast
Levemir 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Mucinous cystic neoplasm with ovarian-type stroma and mild
dysplasia.
2. Poor controlled diabetes mellitus
3. Urinary tract infection
4. Headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner 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.
.
___ 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.
.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
Followup Instructions:
___
|
10777579-DS-5
| 10,777,579 | 26,089,478 |
DS
| 5 |
2164-05-21 00:00:00
|
2164-05-21 19:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
fatigue, lower extremity swell, bilateral lower extremity DVTs
Major Surgical or Invasive Procedure:
IVC filter placement
History of Present Illness:
___ with recent diagnosis of metastatic adenocarcinoma of
unknown primary with metastatic disease to liver, spine, chest,
and pelvis based on PET scan dated ___ that presented with
leg pain and swelling to ___. He was found to have
bilateral DVTs. He is also undergoing radiotherapy (1600cGy to
date) to the sacrum with doses on ___. The
patient's wife called radiation oncology and was concerned about
progressive fatigue and drowsiness in addition to poor PO
intake.
The patient was seen in the ___ ED. Initial VS were T 98 HR 88
RR 20 BP 125/71 pOx 98 % RA.
His main compliants were fatigue, poor po intake, and RLL
pain/swelling/redness.
Physical exam revealed a thin male with non-focal
cardiopulmonary examination. There was left leg swelling and
discoloration with intact neurovascular structures. Patient was
AAOx3.
___ was performed showing extensive bilateral lower extremity
DVTs (see ___ records for full report).
Labs were performed:
Recent labs dated ___ were used for comparison
- WBC 19 (prior 19.8) Hgb 12.3 (prior 13.9) MCV 98.3 MCH 32.7
MCHC 33.3 Plt 89 (recent platelets 276) RDW 13
Diff N85.2(H)
- Na 130 (L) K 4.4 Cl 89 (L) HCO3 28 Glc 148(H) BUN 116(H) Cr
1.96 (recent 1.3, with baseline ~ 0.9) (H) Ca 8.7 Albumin 3.3 TP
6.9 Tbili 0.66 ALP 300 (H) ALT 48 (H) AS T 46 (H)
There was concern that the patient needed further work-up given
acute renal failure and imaging of the CNS before
anti-coagulation was initiated. He was transferred to ___ Main
campus for further-work and consideration of IVC filter if
indicated. VS on transfer were not given.
In the ___ ED, initial VS were 14:06 (unable) 97.5 88 115/62
18 95% ra. Dr. ___ was paged and advised MRI brain to
determine if anticoagulation vs. IVC filter were needed. The
patient was given morphine IV for pain. Exam was significant for
patient being AAOx2-3 and somewhat confused. VS on transfer:
___ 117/64 16 95%
Past Medical History:
PAST MEDICAL HISTORY:
- Desmoplastic atrophic melanoma (___)
- Adenocarcinoma of unknown primary (___)
- Hypertension
PAST SURGICAL HISTORY:
- S/p rotator cuff surgery (___)
- Cataract surgery on his left eye in ___
PAST ONCOLOGIC HISTORY:
-desmoplastic atrophic melanoma (4.9 mm in thickness, ___
level IV without evidence of ulceration) s/p local excision and
sentinel lymph node biopsy from the right jugular lymph node
performed by Dr. ___ on ___
-0.5 mm thick melanoma from his left ___ level
III, s/p radiation of his face 15 treatments using electron beam
in ___
-S/p 12-week course of adjuvant interferon, ending ___
-He was recently seen by Dermatology and a biopsy was performed
on ___, of a central upper chest lesion, which was found
to be a poorly differentiated adenocarcinoma. Immunostaining was
not entirely specific to the site of origin and the differential
included
aerodigestive tract including lung, esophageal, gastric,
pancreatic, or biliary.
-PET (___) Diffuse visceral, soft tissue, and osseous
metastatic disease involving chest, abdomen and pelvis, new
since ___ CT exam. No focal FDG uptake is noted within
the esophagus. Large, partially necrotic lesions in the liver,
but disease primary can not be determined. The lack of abnormal
esophageal uptake argues against an esophageal primary.
-undergoing radiotherapy (1600cGy to date) for metastatic
disease to the sacrum
Social History:
___
Family History:
There is no family history of melanoma or pancreatic cancer. His
father died from a glioblastoma multiforme at age ___. His
mother died at age ___ from a subdural hematoma. He has a
brother who is alive and well.
Physical Exam:
Admission:
Vitals - T: 98 BP: 88/53 HR: 80 RR: 16 02 sat: 98%
Admit weight: 156.5, Height 69 in
General: thin, elderly male in NAD, somnolent
HEENT: PERRL, anicteric sclerae, nose clear, OP clear
Neck: anterior cervical LAD, no JVD
CV: RRR, S1/S2 normal, no MRG, non-displaced PMI
Lungs: adequate air entry/chest expansion,
Abdomen: +BS, S/NT/ND, palpable mass in LUQ
GU: Foley placed
Ext: overall warm and well perfused, left lower extremity with
1+ edema and erythema, right lower extremity with vein
engorgement/no edmea or erythema, 2+ lower extremity pulses
bilaterally
Neuro: AAOx2.5, somnolent, CNII-XII intact, ___ upper and lower
extremity strength bilaterally, no asterixis
Skin: scattered skin nodules on torso
.
Discharge:
Vitals - 97.7, 102/52, 105, 20, 92% RA
General: chronically ill appearing, picking at things with his
hands while he sleeps; oriented when he is awake and
concentrates, but overall inattentive
HEENT: OP clear
Neck: anterior cervical LAD, no JVD
CV: RRR, S1/S2 normal
Lungs: CTAB anteriorly
Abdomen: hypoactive bowel sounds, moderate distention, mild TTP
diffusely
Ext: ___ pitting edema bilateral and symmetric, worse since
admission, ___ ___
Pertinent Results:
LABS:
___ 08:00PM BLOOD WBC-17.8* RBC-3.50* Hgb-12.2* Hct-33.8*
MCV-97 MCH-34.9*# MCHC-36.1*# RDW-12.8 Plt Ct-97*#
___ 06:45AM BLOOD WBC-19.8* RBC-3.34* Hgb-10.9* Hct-32.5*
MCV-97 MCH-32.7* MCHC-33.5 RDW-13.2 Plt ___
___ 06:35AM BLOOD WBC-20.4* RBC-3.16* Hgb-10.0* Hct-30.9*
MCV-98 MCH-31.6 MCHC-32.4 RDW-14.2 Plt Ct-49*
___ 08:00PM BLOOD ___ PTT-26.8 ___
___ 06:35AM BLOOD ___ PTT-37.4* ___
___ 08:00PM BLOOD ___
___ 06:45AM BLOOD ___ 06:35AM BLOOD ___ 08:00PM BLOOD Glucose-105* UreaN-101* Creat-1.6* Na-133
K-4.1 Cl-97 HCO3-24 AnGap-16
___ 06:20AM BLOOD Glucose-107* UreaN-86* Creat-1.3* Na-136
K-4.3 Cl-99 HCO3-26 AnGap-15
___ 06:35AM BLOOD Glucose-104* UreaN-30* Creat-0.9 Na-141
K-4.2 Cl-106 HCO3-26 AnGap-13
___ 08:00PM BLOOD ALT-44* AST-43* LD(___)-561* CK(CPK)-67
AlkPhos-251* TotBili-0.7
___ 06:35AM BLOOD ALT-84* AST-130* LD(___)-851*
AlkPhos-448* TotBili-1.1
___ 08:00PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:20AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:20AM BLOOD Lipase-13
___ 08:00PM BLOOD Albumin-2.9* Calcium-7.8* Phos-3.6 Mg-2.5
___ 06:35AM BLOOD Albumin-2.6* Calcium-8.5 Phos-3.8 Mg-1.9
___ 08:00PM BLOOD Hapto-160
___ 06:32PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:32PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 06:32PM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
TransE-<1
___ 06:32PM URINE CastGr-3* CastHy-2*
___ 06:32PM URINE Mucous-RARE
___ 06:32PM URINE Hours-RANDOM UreaN-1120 Creat-98 Na-<10
K-56 Cl-10
___ 06:32PM URINE Osmolal-611
.
MICRO:
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT no growth
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT no growth
___ URINE URINE CULTURE-FINAL INPATIENT no
growth
.
STUDIES:
___ CXR
The new pulmonary nodules are noted in the upper, left lower and
right lung fields, and correspond to pulmonary nodules
demonstrated on the PET/CT from ___, with potentially
no substantial difference in size, although the comparison is
limited. No definite new consolidations demonstrated to suggest
the reason for interval development of leukocytosis. There is
no pleural effusion or pneumothorax.
MRI HEAD ___
Multiple small foci of increased signal predominantly cortically
based, best seen on the diffusion imaging without surrounding
edema. Given these imaging characteritics, these are most
consistent with embolic infarcts, new since the prior exam.
However given the clinical history, recommend a repeat MRI with
contrast if possible after resolution of acute renal failure for
more definitive evaluation of possible metastatic disease.
CT CHEST non con ___
New subtle opacity in the right lower lobe, potentially caused
by pneumonia. Known adenocarcinoma with extensive bilateral
lung metastases, several larger nodules, as well as mediastinal
lymphadenopathy. Known lytic and sclerotic bone lesions.
Renal U/S ___:
No evidence of hydronephrosis or nephrolithiasis. Duplex
configuration of the right kidney.
Partially seen hepatic and splenic hilum metastasis.
Prostatomegaly.
AORTIC U/S ___:
No evidence of abdominal aortic aneurysm. Atherosclerotic
plaques seen without significant stenosis.
TTE ___:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). The estimated cardiac index
is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. On
apical 4-chamber views (clips 58,59, 71, 72, and on RV inflow
views), there is an echodense and highly mobile structure
(measuring 0.9 x 1.1cm) about 2 cm inferior to the tricuspid
valve which may be highly redundant chordae and prominent
papillary muscle- however, a right ventricular mass/thrombus
cannot be excluded. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved biventricular cavity size and hyperdynamic
global/regional systolic function. Mild pulmonary artery
systolic hypertension. Possible right ventricular thrombus/mass
(see text).
___ FDG TUMOR IMAGING (PET)
Diffuse visceral, soft tissue, and osseous metastatic disease
involving chest, abdomen and pelvis, new since ___ CT
exam. No focal FDG uptake is noted within the esophagus.
Large, partially necrotic lesions in the liver, but disease
primary can not be determined. The lack of abnormal esophageal
uptake argues against an esophageal primary.
Brief Hospital Course:
___ with recent diagnosis of metastatic adenocarcinoma (of
likely pancreatic [vs. biliary] etiology given tumor markers)
with metastatic disease to liver, spine, chest, and pelvis based
on PET scan dated ___ who presented for DVT but was found
to have numerous other issues during his hospitalization. More
specifically, he was found to have hypotension due to
hypovolemia, pneumonia (treated successfully with a 7 day course
of levofloxacin), acute renal failure (prerenal in nature,
responsive to fluids), hypovolemic hyponatremia (resolved with
fluids), and labs suggestive of DIC without any evidence of
bleeding.
For the patient's adenocardinoma, PET scan showed diffuse
visceral, soft tissue, and osseous metastatic disease involving
chest, abdomen, and pelvis, new since ___ CT exam.
Palliative chemotherapy was considered, but given the patient's
very poor functional status (initially ECOG performance status
3, progressed to ECOG performance status 4), this was ultimately
not pursued. He had extensive pain, especially in his lower
extremities due to B/L DVTs and resultant edema. MRI showed
emboli in the brain of uncertain etiology, but patient's mental
status did start to decline, likely secondary to delerium,
medication effect (from narcotics), and emboli. Patient was
initially full code, but after several conversations between
him, his wife (and HCP), the oncology team, and palliative care,
it was decided that we would focus on his comfort and not on
extending his life. He was transitioned to hospice and made
DNR/DNI.
DVT was initially treated with IV heparin and then an IVC filter
was placed to decrease the risk of PE. (Patient may have
already had a PE, but we did not do a CTA chest, so there is no
radiographic evidence of PE.) He was transitioned to ___,
and the Lovenox was discontinued at the request of the patient's
wife when the focus of his care was shifted to comfort.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiloride HCl 5 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
5. Bisacodyl 5 mg PO DAILY:PRN constipation
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Morphine Sulfate (Concentrated Oral Soln) 5 mg SL Q4H:PRN
pain or breathlessness
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 5 mg by mouth
every four (4) hours Disp ___ Milliliter Refills:*0
2. Lorazepam 1 mg PO Q6H:PRN anxiety
RX *lorazepam 1 mg 1 mg by mouth every six (6) hours Disp #*16
Tablet Refills:*0
3. atropine *NF* 2 drops SL q4H:prn secretions
RX *atropine atropine 1 % drops (0.125 mg) 2 drops SL every
four (4) hours Disp ___ Milliliter Refills:*0
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 10 mg 1 tablet PO/PR daily Disp #*10 Tablet
Refills:*2
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*2
6. Senna 2 TAB PO BID constipation
RX *sennosides [senna] 8.6 mg 2 tablets by mouth twice a day
Disp #*60 Tablet Refills:*2
7. Acetaminophen 650 mg PO Q8H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*2
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 3 mL IH every six
(6) hours Disp ___ Milliliter Refills:*2
9. QUEtiapine Fumarate 25 mg PO QHS
RX *quetiapine 25 mg 1 tablet(s) by mouth at bedtime Disp #*15
Tablet Refills:*2
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 17 g by mouth daily Disp
#*10 Pack Refills:*3
11. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN dyspnea
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 neb IH every six
(6) hours Disp #*40 Unit Refills:*2
12. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth Q3H Disp #*50
Tablet Refills:*0
RX *hydromorphone 2 mg ___ tablet(s) by mouth Q3H Disp #*150
Tablet Refills:*2
13. Fentanyl Patch 25 mcg/h TD Q72H
RX *fentanyl 25 mcg/hour 1 patch Q72H Disp #*1 Transdermal Patch
Refills:*0
RX *fentanyl 25 mcg/hour 1 patch Q72H Disp #*10 Transdermal
Patch Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: metastatic adenomacarcinoma, likely from pancreas
Secondary: DVT, embolic lesions in the brain, DIC
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Dr. ___,
___ were admitted to the hospital with metastatic
adenocarcinoma, likely from your pancreas. ___ were also found
to have bilateral deep vein thromboses. ___ were initially
treated with anticoagulation, and an IVC filter was placed to
decrease the risk of blood clots traveling to your lung. We
discussed the possibility of palliative chemotherapy for the
cancer, but ultimately this was thought to not be the best
treatment option for ___. Instead, ___ and your family decided
to pursue hospice, and ___ will be discharged to an inpatient
hospice program.
Followup Instructions:
___
|
10777749-DS-9
| 10,777,749 | 25,925,387 |
DS
| 9 |
2126-03-12 00:00:00
|
2126-03-12 13:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
see discharge summary
___
History of Present Illness:
HPI(4): Ms. ___ is a ___ female with metastatic ER+
breast CA, hx of SBO, PE on warfarin who presents with abdominal
pain. Patient notes acute onset of abdominal pain 1 day PTA
which was sharp, cramping, located in the upper quadrants.
Patient reports she does not like giving pain a number but feels
it is very severe. Last BM yesterday although small, has not
passed gas since yesterday. Had on episode of NBNB emesis when
EMS arrived at her home and once this AM. Denies f/c. Patient
was
discharged from ___ two days ago after presenting with the
same
complaint. CT showed partial SBO and large stool burden. ACS
felt
presentation more c/w with constipation therefore patient placed
on aggressive bowel regimen with relief of symptoms. She reports
she did not have these medications at home until yesterday.
Patient reports she feels mildly short of breath, worse when
pain
becomes more severe. Otherwise no CP, flank pain, fevers, has
chronic mild LLE swelling.
Per chart review, patient also had a prolonged admission in
___ for SBO that required venting g-tube placement.
Hospital course was complicated by PNA, bacteremia, and PE for
which she was placed on warfarin. GOC were only briefly broached
with patient at that time. Oncologist is Dr. ___.
___: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Metastatic breast CA
Hx of SBO
PE on warfarin
Social History:
___
Family History:
No FH of malignancy
Physical Exam:
ADMISSION EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: resting in bed, appears uncomfortable, moderate
distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: hypoactive BS, distended, mildly TTP throughout, no masses
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs, trace ___ edema in left
leg
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
VITALS: 98.3 98/68 86 18
GENERAL: Alert and in no apparent distress aox3
soft abdomen, slightly distended no tenderness to palpation
MENTATION: alert and cooperative.
Pertinent Results:
BCx (___): neg x 2
UCx (___): neg
CT A/P (___):
1. Small-bowel obstruction with decompressed small bowel loops
in
the pelvis although no definite transition point identified.
The
obstruction may be partial or early complete. No
pneumoperitoneum, pneumatosis, or abnormal bowel wall
enhancement.
2. Small volume ascites limits assessment soft tissue
nodularity/masses.
3. Trace bilateral pleural effusions.
4. Extensive osseous sclerotic lesions in the right sacrum, left
hip, and spine appear stable. No acute fracture.
___ 05:46AM BLOOD WBC-4.1 RBC-3.20* Hgb-9.4* Hct-30.7*
MCV-96 MCH-29.4 MCHC-30.6* RDW-15.0 RDWSD-52.8* Plt ___
___ 09:30AM BLOOD Glucose-123* UreaN-26* Creat-0.4 Na-141
K-4.5 Cl-100 HCO3-27 AnGap-14
___ 09:30AM BLOOD ALT-14 AST-15 AlkPhos-127* TotBili-0.2
___ 09:55AM BLOOD 25VitD-23*
___ 05:46AM BLOOD CEA-19.6*
Test Result Reference
Range/Units
CA ___ 85 H <38 U/mL
Final Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with new line// new left PICC 43
cm ___
___ Contact name: ___: ___
IMPRESSION:
In comparison with the study of earlier in this date, there is
an placement of
a left subclavian PICC line that extends to the lower SVC.
Otherwise, little
change.
___, MD electronically signed on SAT ___
12:09 ___
Brief Hospital Course:
___ female with metastatic ER+ breast CA, hx of SBO
(prior venting G-tube removed recent admission), PE on warfarin,
hx C.diff who presents with abdominal pain.
#Abdominal pain:
#Small bowel obstruction:
Initial CT ___ c/f SBO, unclear whether related to metastatic
breast CA or adhesions from prior radiation. Possibly
contribution from constipation given opiate use and missed doses
of bowel regimen. She was felt to be improving and then ordered
and regular diet after which she had worsening symptoms and
distension. NG tube was reinserted and connected to intermittent
suction initially and patient puled it out overnight again and
refused to have it re-inserted. ACS followed. TPN initiated on
___ due to concern for malnutrition. She remained on bowel
regimen. She began moving bowels and passing gas.
Need for long term TPN unclear as she seems to tolerate PO diet,
but that she chooses to eat small quantities and is not eager to
eat more.
# Hypoxia:
#acute on chronic hypoxic respiratory failure
#likely multifactorial from splinting, atelectasis and now
concern for
#aspiration vs HCAP: resolved
Patient at baseline 2L requirement, likely in setting of some
atelectasis and known pulmonary emboli.
# Pulmonary emboli:
Diagnosed during ___ admission. Discharged on Coumadin
(unable to afford lovenox), which is being managed by PCP. INR 2
on admission, but Coumadin was held this admit as there were
possible procedures. Ultimately she remained on lovenox 50mg
BID sc for her PE treatment. GIven that she will be discharged
to rehab, and they can help sort out if long term lovenox will
be an issue because of payment, we opted to treat with lovenox
because of malignancy. If she is unable to afford lovenox, then
Coumadin can be initiated with appropriate bridge using lovenox.
# Metastatic ER+ breast cancer:
Metastatic to bone. On doxil (monthly) and exemestane. Last
doxil dose was ___.
- Continue home exemestane
- continue tylenol and home MS ___ 60mg q12h with dilaudid IV
PRN severe pain for cancer-related pain
- f/u with Dr. ___ as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Exemestane 25 mg PO DAILY
2. Morphine SR (MS ___ 60 mg PO Q12H
3. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
4. Furosemide 40 mg PO DAILY:PRN leg swelling
5. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
6. Vitamin D ___ UNIT PO 1X/WEEK (___)
7. Warfarin 5 mg PO DAILY16
8. Cyanocobalamin 100 mcg PO DAILY
Discharge Medications:
1. Alteplase 1mg/2mL ( Clearance ie. PICC, tunneled access
line, PA ) 1 mg IV ONCE MR1 Duration: 1 Dose
use if needed to clear PICC
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
gerd
3. Bisacodyl ___AILY constipation
4. Enoxaparin Sodium 50 mg SC Q12H
5. Senna 8.6 mg PO BID
6. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
7. Vitamin D ___ UNIT PO 1X/WEEK (___)
8. Furosemide 20 mg PO DAILY
9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
10. Cyanocobalamin 100 mcg PO DAILY
11. Exemestane 25 mg PO DAILY
12. Morphine SR (MS ___ 60 mg PO Q12H
RX *morphine [MS ___ 60 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*30 Tablet Refills:*0
13. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
small bowel obstruction
health care acquire pneumonia
Hypoxia
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. ___,
You were admitted to ___ due to small bowel obstruction for
which you needed a nasogastric tube and we gave you nutrition
though an Iv route. You were also seen by surgery during the
hospital stay
You were also treated for pneumonia with a course of
antibiotics.
Followup Instructions:
___
|
10777944-DS-10
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| 10 |
2154-12-02 00:00:00
|
2154-12-02 12:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
___
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
___ Right Suboccipital craniotomy for tumor resection
History of Present Illness:
___ is a ___ year old female with no significant PMH
who presents with complaints of a headache for the past couple
months. She usually takes IBP, Tylenol, or excedrin with some
relief. Last night, the headache worsened and she was unable to
sleep or get comfortable and it persisted this morning. She also
endorses dizziness with the headache this morning. She presented
to ___ where she was given a migraine cocktail with no
benefit. NCHCT was completed and showed an abnormality in the
cerebellum so MRI brain was completed that revealed a cerebellar
lesion. She was transferred to ___ for neurosurgical
evaluation. She has also noticed worsening vision over the past
couple of months especially with fine print. If she closes one
of
her eyes, her vision seems to improve. She states the vision is
worse in her left eye than her right eye. She denies nausea or
vomiting.
Past Medical History:
None
PSHx:
C-section x 2, cholecystectomy, tonsillectomy, foot surgery,
vein
stripping
Allergies:
NKDA
Social History:
___
Family History:
Non-contributory
Physical Exam:
O: T: 97.9 °F HR: 73 RR: 18 BP: 130/88 SPO2: 99
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Coordination: normal on finger-nose-finger
EXAM ON DISCHARGE:
Patient is alert and oriented to person, place and time
Face symmetrical, tongue midline.
PERRL, EOMI
No pronator drift
MAE ___
Incision is clean, dry and intact
Pertinent Results:
Please refer to OMR for reports.
Brief Hospital Course:
#Right Cerebellar Lesion
Mrs. ___ was admitted for further work up of her new
cerebellar lesion on ___.
On HD 2 a CTA/V was obtained for operative planning. A CT torso
was also obtained and showed 2.1 cm dominant follicle within the
left ovary. She underwent a pre-operative work-up in
anticipation for surgery. On ___ the patient underwent
right suboccipital craniotomy for tumor resection. Physical
therapy and occupational therapy evaluated her for disposition
planning and recommended rehab. The patient had a rehab bed and
was discharged on ___.
#Blurred vision
On ___, the patient complained of blurred vision. She was
evaluated by Ophthalmology later that evening who recommended a
new prescription for her glasses.
#Chest Pain
On ___, the patient experienced a sensation of chest tightness.
An EKG was obtained which was stable. Cardiac enzymes were sent
and were negative. Cardiology was consulted and recommended
outpatient sleep study.
#Nausea
The patient complained of nausea and was managed with Zofran,
Reglan, and a scopolamine patch. Daily EKG for QTc monitoring
was obtained.
Medications on Admission:
None.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
GI upset/GERD
3. Dexamethasone 4 mg PO Q8H Duration: 6 Doses
This is dose # 1 of 4 tapered doses
4. Dexamethasone 3 mg PO Q8H Duration: 6 Doses
This is dose # 2 of 4 tapered doses
Tapered dose - DOWN
5. Dexamethasone 2 mg PO Q8H Duration: 6 Doses
This is dose # 3 of 4 tapered doses
Tapered dose - DOWN
6. Dexamethasone 1 mg PO Q8H Duration: 6 Doses
This is dose # 4 of 4 tapered doses
Tapered dose - DOWN
7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
8. Diazepam 5 mg PO Q6H:PRN neck pain/muscle spasm
9. Docusate Sodium 100 mg PO BID
10. Famotidine 20 mg PO BID
11. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
12. Glucose Gel 15 g PO PRN hypoglycemia protocol
13. Heparin 5000 UNIT SC BID
14. HydrALAZINE ___ mg IV Q6H:PRN SBP>160
15. Insulin SC
Sliding Scale
Fingerstick QACHS, HS
Insulin SC Sliding Scale using HUM Insulin
16. Morphine Sulfate ___ 15 mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
17. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
18. Senna 17.2 mg PO QHS
19. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cerebellar lesion
Cerebral edema
Chest pain
Blurry vision
Nausea
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:
Surgery
You underwent surgery to remove a brain lesion from your
brain.
Please keep your incision dry until your sutures are removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10777944-DS-11
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| 11 |
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2155-01-30 17:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ PMH of High grade anaplastic meningioma (s/p resection in
the
posterior fossa in ___ undergoing radiotherapy) who
presents with dyspnea on exertion, found to have acute PE,
admitted to oncology for further care
Patient has had worsening dyspnea on exertion over the last 7
days but none prior. She noted SOB with minimal exertion as well
as the sensation of a fast heart rate with exertion and cough in
the morning (non productive). She denied any chest pain, fever,
or chills. She denied any immobility, long travel, tobacco use,
or personal history of blood clots. She noted that radiation
therapy has been ongoing without any issues.
Today, while she was working with ___ she was noted to have low
O2
sat was low with exertion. Accordingly, rad onc physicians
ordered CTA at ___ which revealed bilateral segmental and
subsegmental pulmonary emboli. She was transferred to ___ for
further evaluation. She was started on a heparin drip without a
bolus prior to transfer.
In the ED, initial vitals: 98.1 66 126/81 18 94% RA. LAbs
included WBC of 12.3, normal Hgb, normal plt, BNP 279, trop
<0.01, CHEM wnl, coags wnl. CT head did not show any e/o
intracranial hemorrhage and showed stable post-surgical changes.
Patient was continued on IV heparin as a result. Cardiology was
consulted given question of septal bowing and rec'd against
intervention aside from heparin. Rec'd TTE/duplex.
On arrival to the floor she noted that she had right sided
headache which is common for her and unchanged from her
baseline.
She noted that she had no new neurologic symptoms associated
with it. She reported feeling confident that it is her unchanged
daily headache which she has chronically.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
___ Headaches started
___ Dizziness started
___ Head CT showed right posterior fossa extra-axial mass
___ Brain MRI showed right posterior fossa extra-axial mass
___ Resection by Dr. ___: Anaplastic meningioma, WHO Grade III
___ Brain MRI
___ - Started radiation
PAST MEDICAL HISTORY:
-C-section x 2
-Cholecystectomy
-Tonsillectomy
-Foot surgery
-Vein stripping
Social History:
___
Family History:
FAMILY HISTORY:
Father with MI at unknown age. No family history of blood clots.
Father had bone/bladder/liver cancer
Physical Exam:
Vitals: 97.9
PO 105 / 66 68 17 95 RA
GENERAL: Lying comfortably in bed, no acute distress, adult
friend at bedside
EYES: PERRLA
HEENT: Oropharynx clear, moist mucous membranes
NECK: supple
LUNGS: CTA b/l no wheezes/rales/rhonchi, occasional dry cough,
normal RR, speaks in full sentences
CV: RRR no m/r/g, no edema, distal perfusion intact
ABD: Soft, NT, ND, NABS
GENITOURINARY: no foley
EXT: warm, well perfused, no deformity, no assymetry
SKIN: warm, dry, no rash
NEURO: AOx3, fluent speech, CNII-XII intact without focal
deficits, strength ___ in all 4 extremities
Pertinent Results:
___ 06:32AM BLOOD WBC-12.4* RBC-4.58 Hgb-12.7 Hct-38.9
MCV-85 MCH-27.7 MCHC-32.6 RDW-17.6* RDWSD-54.4* Plt ___
___ 06:41AM BLOOD WBC-12.9* RBC-4.80 Hgb-13.2 Hct-40.9
MCV-85 MCH-27.5 MCHC-32.3 RDW-17.9* RDWSD-55.0* Plt ___
___ 05:20PM BLOOD WBC-12.3* RBC-4.85 Hgb-13.6 Hct-44.0
MCV-91 MCH-28.0 MCHC-30.9* RDW-18.0* RDWSD-60.4* Plt ___
___ 05:20PM BLOOD Neuts-88* Bands-1 Lymphs-4* Monos-7 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-10.95* AbsLymp-0.49*
AbsMono-0.86* AbsEos-0.00* AbsBaso-0.00*
___ 06:45AM BLOOD ___ PTT-75.5* ___
___ 06:41AM BLOOD Glucose-117* UreaN-17 Creat-0.5 Na-143
K-4.5 Cl-103 HCO3-24 AnGap-16
___ 05:20PM BLOOD Glucose-105* UreaN-16 Creat-0.5 Na-140
K-3.9 Cl-100 HCO3-24 AnGap-16
___ 05:20PM BLOOD cTropnT-<0.01 proBNP-279*
___ 06:41AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.3
STUDIES:
CTA ___:
IMPRESSION:
1. Bilateral segmental and subsegmental pulmonary emboli.
Straightening of the interventricular septum suspicious for
right
heart strain.
2. Multifocal predominately subpleural and basal parenchymal
changes are nonspecific in appearance. The distribution is not
typical for pulmonary edema or infection, potentially is could
reflect a drug reaction or very early interstitial lung disease.
Recommend clinicalcorrelation short-term follow-up with repeat
CT
chest in 3 months.
CT head ___:
IMPRESSION:
1. No evidence of intracranial hemorrhage, as clinically
questioned. No acute intracranial abnormality.
2. Stable posterior fossa postsurgical changes.
echo
The left atrial volume index is normal. There is mild symmetric
left ventricular hypertrophy with normal cavity size. Regional
left ventricular wall motion is normal. Left ventricular
systolic function is hyperdynamic (EF>75%). The estimated
cardiac index is high (>4.0L/min/m2). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Doppler parameters are most consistent with
normal left ventricular diastolic function. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. No mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with hyperdynamic systolic function.
Normal right ventricular cavity size and systolic function. No
valvular abnormalities or pathologic flow identified
___ negative
Brief Hospital Course:
___ PMH of High grade anaplastic meningioma (s/p resection in
the
posterior fossa in ___ undergoing radiotherapy) who
presents with dyspnea on exertion, found to have acute PE.
#Acute pulmonary embolism:
#symptomatic tachycardia and dyspnea:
Patient with some relative immobility over the past few weeks
and
is likely hypercoaguable ___ malignancy as main predisposing
factors. CT head negative for bleed in ED so continued on IV
heparin, NSGY did not feel recent surgery was contraindication
for anticoagulation.
Cardiology consulted in the ED for septal bowing on ED ECHO and
declined
intervention, but rec'd continued anticoagulation. Official echo
and ___ unrevealing. She remained stable on IV heparin and thus
was transitioned to ___ lovenox ___ which she appeared to
tolerate well. She was provided with supportive care for
exertional tachypnea and tachycardia.
#High grade anaplastic meningioma (s/p resection in the
posterior
fossa in ___ undergoing radiotherapy). Pt continued her
daily XRT sessions while admitted. Radiation oncology
recommended trying to taper her dexamethasone and recommended
2mg QAM and 1mg Q2pm for now. Further taper per outpt XRT. She
was started on ca, vit D, and Bactrim for pcp ___.
#HSV ulcer on the buttock and presumed in the mouth. Dermatology
was consulted and performed a smear confirming HSV. She was
given acyclovir during admission and transitioned to Valtrex on
dc for 7 days.
#Chronic Headaches
While patient had headaches during admission was consistent with
typical
daily headaches without any new change in symptoms or neurologic
changes. Head CT on admit without bleeding. Provided symptomatic
tx per outpt regimen.
#Leukocytosis
Likely related to stress of PE, as is without fever/chills or
symptoms suggestive of infection. Alternatively may be ___
chronic dexamethasone.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diazepam 5 mg PO Q6H:PRN neck pain/muscle spasm
2. Docusate Sodium 100 mg PO BID
3. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
4. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN Pain -
Moderate
5. Citalopram 20 mg PO DAILY
6. Dexamethasone 2 mg PO Q12H
7. Meclizine 25 mg PO Q6H:PRN dizzyness
8. Tamsulosin 0.4 mg PO QHS
9. Topiramate (Topamax) 25 mg PO QHS
10. TraZODone 25 mg PO QHS:PRN insomnia
11. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
12. Esomeprazole 20 mg Other DAILY
Discharge Medications:
1. Calcium Carbonate 500 mg PO BID
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 1
tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0
2. Diazepam 5 mg PO Q6H:PRN neck pain/muscle spasm
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 70 mg SC Q12H
RX *enoxaparin 80 mg/0.8 mL 80 mg SC twice a day Disp #*60
Syringe Refills:*0
5. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
7. ValACYclovir 1000 mg PO Q12H Duration: 7 Days
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
8. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*0
9. Dexamethasone 2 mg PO QAM
10. Dexamethasone 1 mg PO DAILY AT 1400
RX *dexamethasone 1 mg ___ tablet(s) by mouth twice a day Disp
#*90 Tablet Refills:*0
11. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN Pain -
Moderate
12. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
13. Citalopram 20 mg PO DAILY
14. Esomeprazole 20 mg Other DAILY
15. Meclizine 25 mg PO Q6H:PRN dizzyness
16. Tamsulosin 0.4 mg PO QHS
17. Topiramate (Topamax) 25 mg PO QHS
18. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
pulmonary embolism
h.o meningioma s/p craniotomy on XRT
herpes simplex
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for evaluation of shortness of breath and
found to have pulmonary emboli. For this, you were started on IV
heparin and converted to lovenox injections which you will need
to take indefinitely.
In addition, you had a stable headache during admission.
However, should you have a worsened headache or any new findings
such as weakness, nausea, vomiting, tingling, please seek
attention.
You were also found to have a new herpes rash on your skin for
which you were started on antivirals to take for 7 days.
You were started on calcium, vitamin D to protect your bones
while on steroids and Bactrim (an antibiotic to prevent PCP
___ while on steroids. Please discuss with your oncology
team when you may stop these medications.
Your steroids were downtitrated to dexamethasone 2mg in the
morning and 1mg at 2pm. Please discuss further changes with your
radiation team.
Followup Instructions:
___
|
10778034-DS-14
| 10,778,034 | 27,569,558 |
DS
| 14 |
2149-08-30 00:00:00
|
2149-09-04 10:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
New word finding difficulty
Major Surgical or Invasive Procedure:
___ Blood patch for spinal headache
History of Present Illness:
___ yo M recently diagnosed with a 10mm ___ aneurysm at
OSH. Patient was evaluated today in the ___ clinic with
Dr. ___. In clinic today patient reports new word finding
difficulty starting ___ and worsening each day since. He is
also reporting headache. He states he has been having ongoing
headaches which ultimately lead to the workup resulting in
finding of aneurysm. Recently at OSH had LP and patient reports
since then his headache has been worse. It is worst when
standing
and sitting but resolving when lying done. He was sent to the ED
for workup of new word finding difficulty, admission to
neurosurgery service and possibility of blood patch for ?spinal
headaches.
Past Medical History:
Recently treated with 21 day course of doxycycline for Lyme
disease
Social History:
History of smoking 1 to 1 & ___ pack ppd history, quit 30 days
ago, denies drug or ETOH use
Physical Exam:
O: T:98.2 BP: 140/98 HR:73 R 16 O2Sats 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ bilaterally EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Word finding difficulty
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: mild dysmetria on R finger-nose-finger,
On discharge:
AAO x 3, PERRL, EOMs intact
Improved word finding difficulty, but speech slowing/hesitancy
persists.
Improved balance on ambulation
No pronator drift
Strength and sensation full throughout
Pertinent Results:
___ 09:15PM BLOOD WBC-9.3 RBC-4.79 Hgb-13.9 Hct-42.0 MCV-88
MCH-29.0 MCHC-33.1 RDW-13.1 RDWSD-42.0 Plt ___
___ 05:50AM BLOOD WBC-6.8 RBC-4.67 Hgb-13.6* Hct-40.7
MCV-87 MCH-29.1 MCHC-33.4 RDW-13.2 RDWSD-41.7 Plt ___
___ 04:30PM BLOOD WBC-8.8 RBC-5.00 Hgb-14.6 Hct-44.0 MCV-88
MCH-29.2 MCHC-33.2 RDW-13.2 RDWSD-42.5 Plt ___
___ 09:15PM BLOOD Neuts-33.0* Lymphs-53.2* Monos-8.3
Eos-4.7 Baso-0.6 Im ___ AbsNeut-3.05 AbsLymp-4.94*
AbsMono-0.77 AbsEos-0.44 AbsBaso-0.06
___ 04:30PM BLOOD Neuts-33.1* ___ Monos-8.6 Eos-5.6
Baso-0.6 Im ___ AbsNeut-2.90 AbsLymp-4.54* AbsMono-0.75
AbsEos-0.49 AbsBaso-0.05
___ 09:15PM BLOOD ___ PTT-29.3 ___
___ 09:15PM BLOOD Glucose-114* UreaN-14 Creat-1.1 Na-141
K-3.6 Cl-103 HCO3-24 AnGap-18
___ 05:50AM BLOOD Glucose-93 UreaN-20 Creat-1.1 Na-138
K-4.1 Cl-105 HCO3-24 AnGap-13
___ 04:30PM BLOOD Glucose-94 UreaN-17 Creat-1.0 Na-139
K-4.0 Cl-102 HCO3-26 AnGap-15
___ 05:50AM BLOOD Calcium-9.4 Phos-4.9* Mg-2.0
___ 04:30PM BLOOD Calcium-9.6 Phos-4.0 Mg-2.1
___ 09:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ CT head without contrast
5 x 6 mm aneurysm of the left distal internal carotid artery as
seen on
outside hospital MRA. No hemorrhage.
___ MR head with and without contrast
1. No acute intracranial infarct or hemorrhage is seen.
2. Stable 5 mm aneurysm involving the left supraclinoid ICA.
___ EEG
Normal EEG in wakefulness and in sleep. There were no focal
abnormalities or epileptiform features.
___ CT head without contrast
1. No intra cerebral hemorrhage.
2. Stable 2 mm aneurysm of the left distal internal carotid
artery.
Brief Hospital Course:
Mr. ___ was admitted to the Neurosurgery service on ___ after
he was seen in ___ clinic and there was concern for new
word finding difficulties and cognitive processing issues. He
was also known to have an approximate 10mm left ophthalmic
segment aneurysm. The patient was admitted to the inpatient
ward for ongoing management and observation. Neurology was
consulted to assist in evaluating the patient's neurologic
function and before any neurosurgical intervention is
undertaken.
At the time of admission, the patient had an unrelenting
headache with presented as a spinal headache, i.e., worsening
upon rising from a supine position, nausea. The pain
service/anesthesia was consulted for their assessment and
possible intervention with a blood patch as the patient
underwent a recent lumbar puncture at an outside hospital.
On ___, the patient as assessed by anesthesia and subsequently
underwent the blood patch procedure. There were no
complication. After the procedure, the patient still had a
headache but was improved from prior.
At the recommendation of Neurology, the Infectious Disease
service was consulted to further evaluate Mr. ___ for any
condition that could be contributing to his current symptoms.
At their recommendations, a serum RPR with prozone effect and
cryptococcal antigen were sent for analysis. Those results were
pending at the time of the patient's discharge. An EEG was
completed to also rule out seizures as a source of his speech
and cognitive issues. EEG results were normal.
As Mr. ___ symptoms slowly resolved, he was discharged home
in the care of his girlfriend on ___ with planned return on
___ for a cerebral angiogram. Prior to his discharge, he was
loaded with Plavix and aspirin (Plavix 150mg x 3 days then 75mg
daily) with planned pipeline embolization of his aneurysm on
___.
At the time of discharge, Mr. ___ was afebrile,
hemodynamically and neurologically stable. Per his discharge
instructions, the patient will be followed closely by the
Neurosurgery service.
Medications on Admission:
Tylenol, ibuprofen PRN
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
capsule(s) by mouth every six (6) hours Disp #*45 Capsule
Refills:*0
3. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Clopidogrel 150 mg PO DAILY Duration: 3 Days
Take 150mg on ___ and ___, then one tablet (75mg) daily
thereafter.
RX *clopidogrel 75 mg Take tablet(s) by mouth as directed Disp
#*30 Tablet Refills:*0
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Left ICA aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ neurosurgery service for further
work-up of your memory issues and cognitive issues. You were
seen by Neurology and Infectious Disease to assist in this
work-up.
You are now being discharged home with planned return on ___
and ___ of next week. You also have a follow-up with
Cognitive Neurology as listed below.
To be clear, you will be taking 150mg (two 75mg tablets) daily
on ___ and ___. Then, you will take one tablet (75mg daily)
thereafter. During this time, you should also take 325mg of
aspirin daily as well.
You have been given a short supply of Fioricet for your
headaches. It may cause drowsiness, so do not drive or operate
heavy machinery while taking it.
Followup Instructions:
___
|
10778034-DS-16
| 10,778,034 | 28,078,318 |
DS
| 16 |
2149-09-22 00:00:00
|
2149-09-22 17:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old male known to Neurosurgery for
recent diagnosis of unruptured left ICA ophthalmic segment
aneurysm, currently ___ s/p pipeline stent-mediated
embolization. Hospital course was significant only for anxiety,
and he was discharged home in stable condition on POD#2. The
aneurysm was originally identified on MRI at an OSH in early
___ performed for a variety of complaints, including
headache, speech hesitancy and word-finding difficulties,
myalgias, cognitive slowing, and fatigue. EEG and LP were also
performed during this workup.
Past Medical History:
Lyme Disease
Left ICA aneurysm, s/p pipeline embolization (___)
Social History:
___
Family History:
Non-contributory
Physical Exam:
On discharge:
AAO x 3, PERRL, EOMI, smile symmetrical, no pronator drift.
Strength and sensation full throughout.
Pertinent Results:
___ 12:20PM BLOOD WBC-6.7 RBC-4.82 Hgb-14.2 Hct-42.9 MCV-89
MCH-29.5 MCHC-33.1 RDW-13.4 RDWSD-43.5 Plt ___
___ 12:20PM BLOOD Neuts-40.9 ___ Monos-9.4 Eos-4.0
Baso-0.7 Im ___ AbsNeut-2.73 AbsLymp-3.01 AbsMono-0.63
AbsEos-0.27 AbsBaso-0.05
___ 01:19PM BLOOD ___ PTT-29.9 ___
___ 12:20PM BLOOD Glucose-84 UreaN-15 Creat-1.1 Na-141
K-4.1 Cl-103 HCO3-27 ___ CT head without contrast:
1. No evidence of infarction or hemorrhage.
2. 6 mm hyperdensity abutting the supraclinoid left ICA,
compatible with known aneurysm with increased density suggesting
thrombosis and no evidence of enlargement or bleeding.
3. Sinus disease, as described above.
Brief Hospital Course:
Mr. ___ was admitted to the Neurosurgery service for further
management of his headaches. A CT head was performed while the
patient was in the ED and showed no acute hemorrhage. He was
started on steroids and gabapentin to reduce his headache pain
and left facial tingling.
On the following morning, Mr. ___ continued to have his
headache, but it was much better controlled. He was discharged
home with prescriptions for a Medrol dosepack and gabapentin.
As advised by Neurology, he was instructed to not take more than
three doses (per week) of Fioricet or Tylenol for his headaches
due to concerns of rebound headaches.
Per his discharge instructions, Mr. ___ should follow up with
Dr. ___ Dr. ___ previously
scheduled.
At the time of discharge, Mr. ___ was afebrile,
hemodynamically and neurologically intact.
Medications on Admission:
ASA 325mg daily, Plavix 75mg daily, APAP PRN, Fioricet PRN,
Famotidine 20mg BID, Ativan
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain/Fever
Take as instructed by your Neurologist.
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache
Take as instructed by your Neurologist.
3. Aspirin 325 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Gabapentin 300 mg PO QHS
RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*1
6. Lorazepam 0.5 mg PO Q8H:PRN Anxiety
7. Famotidine 20 mg PO BID
8. Methylprednisolone 10 mg PO BID Duration: 2 Doses
See package insert for tapering the dose.
This is dose # 2 of 6 tapered doses
RX *methylprednisolone 4 mg Taper tablets(s) by mouth as
directed Disp #*1 Dose Pack Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Headaches
Left ICA aneurysm s/p pipeline embolization
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ Neurosurgery service for further
evaluation of your headache. Your non-contrast head CT was
stable and showed no new signs of bleeding. You were kept
overnight for observation. As you remained neurologically
stable, you are being discharged home with the following
instructions.
- As instructed by your Neurologist, do not take more than one
dose of either Fioricet or Tylenol three times during the week.
If you do, you are risk for rebound headaches.
- You are being discharged on a Medrol dosepack which could help
in diminishing your headache symptoms.
- You are also being started on Gabapentin at the recommendation
of Neurology. This is used to help treat your left facial
tingling and headaches.
- If you have any questions or concerns, you may call the
Neurosurgery office or your Neurologist.
Followup Instructions:
___
|
10778294-DS-15
| 10,778,294 | 28,560,614 |
DS
| 15 |
2169-11-24 00:00:00
|
2169-11-28 21:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Gallstone pancreatitis
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy
History of Present Illness:
Mr. ___ is a ___ year old gentleman with no past medical
history who initially presented to an OSH with acute onset of
abdominal pain. He was found to have acute gallstone
pancreatitis and transferred to ___ for ERCP.
He reports that for 10 days he has been having intermittent,
acute, severe abdominal pain up to ___ in severity which has
waxed and waned on a daily basis. He reports that the abdominal
pain is located on the left side and radiates centrally over the
epigastrium. It is associated with a burning sensation over his
back. He first presented to the ED at an OSH last ___ where
labs and imaging were unremarkable and he was sent home. He was
given a regular diet on ___ after drinking only liquids at
the request of the ED. When eating a regular diet he had acute
worsening of identical symptoms so he presented again to OSH ED
on ___. He again had a negative work up so was sent home.
On ___ he drank only honey water and reports he had no
abdominal pain, nausea or vomiting during that time. Wife
restarted foods on ___, chicken noodle soup and 2 hours later
had acute onset worsening abdominal pain. The abdominal pain is
not associated with nausea, vomiting, diarrhea. He has not had
melena, hematochezia, fevers or chills. After the last episode
on ___ he again went to the OSH where work up revealed lipase
of >400 and RUQ US showed gallstones. He was then transferred to
___ ED for evaluation and potential ERCP.
In our ED, initial vitals were: pain ___, 98.6, 72, 133/88, 18,
99%RA. Labs were notable for a lipase of 106 (though lipase at
OSH was >400), LFTs with TBili of 1.7, otherwise within normal
limits and stable from OSH. He was given IVFs, IV Unasyn and one
dose of IV Dilaudid. Unasyn was given because OSH RUQ US showed
mild gallbladder thickening which could be consistent with
cholecystitis.
Past Medical History:
None
Social History:
___
Family History:
No family history of gallstone, pancreatitis or GI issues
Physical Exam:
Vitals: Temp 98.6, HR 81, BP 133/70, RR 18, 98%RA
General: Pleasant gentleman in no acute distress, alert and
oriented
HEENT: Sclera anicteric, moist mucous membranes
Lungs: Clear to auscultation bilaterally, non-labored breathing
CV: Regular rate and rhythm
Abdomen: Soft, non-distended, appropriately tender incisionally
Ext: Warm, well perfused, peripheral pulses intact
Pertinent Results:
OSH Labs / Imaging:
7.8 > 16.___ < 276
128 91 7
-------------< 98
3.6 28 0.8
T.Bili 1.6
AST / ALT - ___
RUQ US ___: - normal liver, multiple gallstones, no
pericholecystic fluid, borderline gallbladder thickness
MRCP ___:
1. Cholelithiasis. There is minimal gallbladder wall edema,
but not a
specific finding for cholecystitis. This may be secondary to
inflammation,
but may can also be seen in the setting of third spacing.
2. Conventional pancreas and biliary duct anatomy.
3. Duodenal diverticulum likely arising from the third portion
of the
duodenum. While this is near the ampulla, it is unclear whether
this is
actually causing significant mass effect upon the biliary tree.
ERCP ___:
-Duodenal diverticulum
-The scout film was normal.
-The bile duct was deeply cannulated with the sphincterotome.
Contrast was injected and there was brisk flow through the
ducts. Contrast extended to the entire biliary tree.
-The CBD was 4mm in diameter. No definite filling defects were
identified in the CBD and CHD.
-Opacification of the gallbladder was incomplete. The left and
right hepatic ducts and all intrahepatic branches were normal.
-Given rise in bilirubin, a biliary sphincterotomy was made with
a sphincterotome. The biliary tree was swept with a 9-12mm
balloon starting at the bifurcation. A small amount of sludge
was removed. The CBD and CHD were swept repeatedly.
-The final occlusion cholangiogram showed no evidence of filling
defects in the CBD. Excellent bile and contrast drainage was
seen endoscopically and fluoroscopically.
-The pancreatic duct was partially filled with contrast and
visualized proximally. The course and caliber of the duct was
normal with no evidence of filling defects, masses, chronic
pancreatitis or other abnormalities.
-Otherwise normal ercp to third part of the duodenum
Brief Hospital Course:
Mr. ___ presented on ___ with acute onset of
abdominal pain,. He was found to have acute pancreatitis,
thought to be secondary to gallstone etiology. He was admitted
to the ___ service for MRCP/ERCP. MRCP on
___ was without biliary dilation or choledocholithiasis. He
had an ERCP on ___ with a sphincterotomy performed. He was
transferred to the Acute Care Surgery service after a
laparoscopic cholecystectomy was performed on ___. Please
see the 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. He was provided a regular diet 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. His pain level was
routinely assessed and well controlled at discharge with an oral
regimen as needed.
On ___, he was discharged home and instructed to follow up
in ___ clinic in two weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
You may not drive while taking Oxycodone pain medication
RX *oxycodone 5 mg 1 tablet(s) by mouth every four hours Disp
#*60 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
Hold for loose stools
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Gallstone pancreatitis, cholelithiasis
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure treating you during this hospitalization. You
were admitted to ___ with abdominal pain and found to have
gallstone pancreatitis. An MRCP was performed and showed
cholelithiasis (stones in the gallbladder) and a duodenal
diverticulum likely arising from the third portion of the
duodenum. You also had an ERCP. Sludge was removed from the
gallbladder and a sphincterotomy was performed.
You were then 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 call the Acute Care Surgery clinic at ___ to
schedule a follow-up appointment in 2 weeks.
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.
Best wishes,
Your ___ surgical team
Followup Instructions:
___
|
10778651-DS-14
| 10,778,651 | 22,928,951 |
DS
| 14 |
2184-10-16 00:00:00
|
2184-10-16 11:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a hx of asthma, HTN, HLD and recent
rectal bleed ___ internal hemorrhoids (___) who presented to
the ED today with a 3 week hx of cough, nausea and anorexia.
Since the beginning of the month, he endorses a cough with clear
sputum and wheezing, dyspnea with activity, nausea, decreased
appetite, and constipation. After his initial cough, wheezing,
and nausea, he was unable to take his long-acting medication
regularly, only was taking his ___. He has lost 10lb in the
past 3 weeks, but weight has been stable since one week prior to
admission. He denies fever, hemoptysis, night sweats. Denies CP,
orthopnea, leg swelling, abdominal pain, or diarrhea. He had
rectal bleeding that resolved one week ago, was diagnosed with
internal hemorrhoids by PCP. Started on a Prednisone taper by
his PCP and has required IVF for dehydration and weight loss.
Reports a negative CXR 1 week ago and lab work. No smoking hx or
chemical exposure. He has a dog at home (for ___ years), no recent
renovation, construction or dust/environmental exposures. He has
no sick contacts or recent travel. He has had several asthma
exacerbations since ___, requiring prednisone taper. Of
note, he is unable to tolerate peak flow measurements secondary
to passing out (vasovagal).
In the ED, initial vitals: T:97.4 HR:96 BP:121/67 RR:22 SaO2
99%/ra
Exam notable for diffuse wheeze, rhonchi, use of excessory
muscles, no focal lung findings. Labs notable for WBC 12.5, BUN
32, lactate 4->8.8->9, VBG ___. Flu swab was negative.
CXR did not reveal an acute process. CTA chest performed to r/o
PE; no PE, dissection or infiltrate, notable only for multiple
rib lesions likely to be healing fractures. Received only 1L
documented IVF, in addition to multiple duonebs with improvement
in symptoms. Also received 125mg of solumedrol and 4.5mg zosyn,
vanc.
EKG: Heart Rate: 91 Rhythm: Sinus Intervals: Normal
Past Medical History:
HTN
HLD
Colonic adenoma
Vitiligo
Cataracts
Lattice degeneration of peripheral retina
Asthma
Social History:
___
Family History:
Father with DM
Physical Exam:
Admission physical exam:
Vitals- 98.3 166/117 96 22 100% on 2L
GENERAL: Caucasian middle aged man, speaking in full sentences,
alert oriented, but in mild respiratory distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, though distant breath
sounds, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes
NEURO: CN II-XII intact, PERRLA, moving all extremities, full
strength
Discharge physical exam:
VITALS: 98.5, 130s-150s/70s-80s, 60s-70s, ___, 100% on RA
GENERAL: Caucasian middle aged man, speaking in full sentences,
alert oriented, no acute distress, appearing comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Scattered wheezes with rhonchi bilaterally, but good air
movement
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes
NEURO: CN II-XII intact, PERRLA, moving all extremities, full
strength
Pertinent Results:
Admission labs:
___ 02:35PM BLOOD WBC-12.5* RBC-5.57 Hgb-17.1 Hct-47.8
MCV-86 MCH-30.7 MCHC-35.7* RDW-12.8 Plt ___
___ 02:35PM BLOOD Neuts-83.9* Lymphs-12.4* Monos-3.3
Eos-0.2 Baso-0.2
___ 02:35PM BLOOD Glucose-112* UreaN-32* Creat-1.0 Na-139
K-3.4 Cl-100 HCO3-23 AnGap-19
___ 02:35PM BLOOD Albumin-4.1 Calcium-10.0 Phos-1.7* Mg-1.8
___ 02:48PM BLOOD Lactate-4.0*
CXR: No acute cardiopulmonary abnormality.
Chest CTA:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mild mucus plugging and bronchial wall thickening within the
subsegmental left lower lobe branches consistent with small
airways disease.
3. Multiple subacute for healing rib fractures as described
above. Clinical correlation with previous trauma history is
recommended.
CT abdomen/pelvis:
1. Fat containing left-sided inguinal hernia with a 3.2 cm soft
tissue lesion most consistent with a hematoma.
2. Small hiatal hernia.
3. No pneumoperitoneum or evidence of ischemic bowel.
4. Mildly enlarged prostate with a 1.6 cm hyperenhancing lesion
within the peripheral zone of the left posterolateral mid
prostate. Correlation with PSA and clinical history is
recommended.
Brief Hospital Course:
NARRATIVE:
___ with a history of asthma, HTN, HLD, recent rectal bleed ___
internal hemorrhoids (___), who presented to the ED with a 3
week hx of cough, wheeze, nausea with vomiting, and anorexia. He
was found to have apparent asthma exacerbation with lactatemia,
and was admitted to the ICU for close monitoring. Lactatemia
resolved with IVF resuscitation. Asthma symptoms improved with
prednisone and nebulizers in addition to home inhalers and home
antihistamines. In the ICU, he was started on pantoprazole for
possible GERD/gastritis symptoms, with improvement in nausea.
Overall, his symptoms steadily improved throughout his hospital
stay and he felt well enough to go home and pursue outpatient
followup as necessary. While no obvious cause of his initial
symptoms were found, I think it is possible that he suffered a
viral illness with both GI and respiratory symptoms, or
experienced an aspiration event during his bout of nausea with
vomiting that triggered an asthma exacerbation.
PROBLEMS:
# SOB/ Cough: Differential includes viral URI vs asthma
exacerbation vs acute bronchitis, CAP, including atypical
organisms. No evidence of consolidation on chest radiograph to
suggest bacterial pneumonia. History of acute onset and poor
compliance with long acting asthma medications as well as
initial wheezing on exam consistent with asthma exacerbation.
Unclear what his trigger was, possibly viral infection vs
environmental exposure vs GERD or an aspiration pneumonitis in
setting of vomiting. He received one dose 125mg solumedrol in ED
and was much improved with steroids and nebulizers. Continued
steroid taper as prescribed by his PCP, starting with 60mg
prednisone. Continued asthma medications:
Fluticasone-Salmeterol, montelukast, and nebulizers. Of note,
most recent PFTs do not seem consistent with asthma diagnosis,
and he may benefit from full PFTs/Pulmonology referral.
# Nausea/vomiting
# Weight loss: While potentially all part of a viral process,
ten pound weight loss in past three works is dramatic, and
possibly not explained solely by anorexia and poor po intake.
Should consider possibility of underlying gastritis/PUD,
malignancy, HIV, particularly if without clinical improvement.
He does not have risk factors for HIV. TSH was normal at 1.2.
- If fails to completely improve, would pursue further workup
and early GI referral for endoscopy
# Elevated lactate: Likely in the setting of dehydration from
anorexia (reports poor PO and weight loss) and insensible
losses, causing underlying increased sympathetic tone, and
further exacerbated by type B lactic acidosis secondary to
albuterol nebs. Lactate trended down with IVF resuscitation.
# Leukocytosis: Afebrile but with elevated WBC on admission, in
setting of prednisone taper prescribed by outpatient PCP.
Infectious workup was negative. WBCs trended to normal after
IVF, suggestive of hemoconcentration.
# Hypertension: continued home lisinopril-HCTZ
# Hyperlipidemia: continued home simvastatin
TRANSITIONAL ISSUES:
# Outpatient GI followup recommended if symptoms including
weight loss do not entirely and quickly resolve, given
antecedant nausea/vomiting he may very well have an upper GI
process.
# Further workup for weight loss, including HIV testing if this
does not entirely resolve.
# Code status: FULL CODE
Billing: > 30 minutes spent coordinating his discharge from the
hospital.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 40 mg PO DAILY
2. PredniSONE 10 mg PO DAILY
Tapered dose - DOWN
3. Hydrocortisone Acetate Suppository ___ID
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Ibuprofen 800 mg PO Q8H:PRN pain
6. Simvastatin 40 mg PO DAILY
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze, sob
8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze, sob
9. Fexofenadine 180 mg PO DAILY
10. Sildenafil 20 mg PO X2 PRN ED
11. lisinopril-hydrochlorothiazide ___ mg oral daily
12. Montelukast 10 mg PO DAILY
Discharge Medications:
1. Citalopram 40 mg PO DAILY
2. Fexofenadine 180 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze, sob
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze, sob
6. Hydrocortisone Acetate Suppository ___ID
7. lisinopril-hydrochlorothiazide ___ mg oral daily
8. Montelukast 10 mg PO DAILY
9. Sildenafil 20 mg PO X2 PRN ED
10. Simvastatin 40 mg PO DAILY
11. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*3
12. PredniSONE 60 mg PO DAILY Duration: 2 Weeks
Tapered dose - DOWN
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma exacerbation
Lactic acidosis
Malaise
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with nausea, vomiting which progressed to
cough, shortness of breath, and fatigue. You were diagnosed
with and treated for an asthma exacerbation as well as
dehydration. You had imaging of your chest and abdomen which
was negative. You steadily improved with IV fluids, antacids,
and asthma treatment. Please see a Pulmonologist in follow up,
and consider having an upper endoscopy to further evaluate your
GI symptoms.
Followup Instructions:
___
|
10778686-DS-13
| 10,778,686 | 21,267,966 |
DS
| 13 |
2124-04-04 00:00:00
|
2124-04-06 10:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L flank and abdominal pain
Major Surgical or Invasive Procedure:
Left ureteroscopy with laser lithotripsy
History of Present Illness:
Patient is a ___ male with a history of BPH, HTN, and
depression who presents with an obstructing left ureteral stone.
Patient states that the pain started earlier this morning around
11 am continued to progress in nature. The pain is sharp and is
located in the LLQ. He has never experienced pain like this
before. Denies past kidney stones. Denies fevers, chills, N/V,
dysuria, hematuria, and incomplete emptying.
Past Medical History:
DEPRESSION
GOUT
HEALTH MAINTENANCE
H/O DIVERTICULITIS
Surgical History (Last Verified ___ by ___, MD):
VASECTOMY
Social History:
___
Family History:
n/a
Physical Exam:
WdWn male, NAD, AVSS
Interactive, cooperative
Abdomen soft, Nt/Nd
No CVA tenderness
Lower extremities w/out edema or pitting and no report of calf
pain
Pertinent Results:
___ 04:36PM BLOOD WBC-11.1* RBC-4.43* Hgb-14.2 Hct-40.7
MCV-92 MCH-32.1* MCHC-34.9 RDW-12.5 RDWSD-42.3 Plt ___
___ 12:00PM BLOOD Glucose-105* UreaN-20 Creat-1.8* Na-139
K-4.6 Cl-102 HCO3-28 AnGap-9*
___ 04:36PM BLOOD Glucose-153* UreaN-24* Creat-1.4* Na-138
K-4.2 Cl-102 HCO3-22 AnGap-14
Brief Hospital Course:
Mr. ___ was admitted from the ED for nephrolithiasis
management with a known obstructing left proximal ureteral
stone. He underwent cystoscopy, left URS with laser
lithotripsy, and left stent placement the following morning.
He tolerated the procedure well and recovered in the PACU before
transfer to the general surgical floor. See the dictated
operative note for full details.
After the procedure, the patients pain was controlled with oral
pain medications, tolerating regular diet, ambulating without
assistance, and voiding without difficulty.
Patient was explicitly advised to follow up as directed as the
indwelling ureteral stent must be removed and or exchanged. He
also was instructed to follow up with his PCP for ___ creatinine
check within the next week in order to get clearance to restart
his Lisinopril and indomethacin.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. BuPROPion 100 mg PO BID
3. Indomethacin 75 mg PO BID PRN Pain - Mild
4. Tamsulosin 0.4 mg PO QHS
5. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*30 Capsule Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every 4 hours
as needed for pain Disp #*10 Tablet Refills:*0
4. BuPROPion 100 mg PO BID
5. Tamsulosin 0.4 mg PO QHS
6. TraZODone 50 mg PO QHS:PRN insomnia
7. HELD- Indomethacin 75 mg PO BID PRN Pain - Mild This
medication was held. Do not restart Indomethacin until your
kidney function normalizes
8. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do
not restart Lisinopril until your kidney function normalizes and
as directed by your primary care physician
___:
Home
Discharge Diagnosis:
Left ureteral stone
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent (if there is one).
-You may notice the passing of several small stone fragments in
the urine.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-For pain control, try TYLENOL FIRST, then take the narcotic
pain medication as prescribed if additional pain relief is
needed.
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No major activity restrictions
Followup Instructions:
___
|
10778867-DS-10
| 10,778,867 | 26,181,654 |
DS
| 10 |
2170-04-02 00:00:00
|
2170-04-05 16:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo male with a history of Crohn's disease
s/p multiple bowel surgeries c/b short gut syndrome, ETOH abuse,
and chronic ___ who presents to the ED on ___ after
experiencing worsening chest ___. He has had chest ___ ever
since undergoing a pleurodesis at ___ at ___.
However this ___ has worsened over the past ___ months. He was
admitted in ___ with this ___, and hasn't improved
since then. His ___ is a ___ (usually ___, and
described as a sharp, persistent, pleuritic ___ localized to
the sides of his chest and spine, and occasionally radiates
across the front of the chest. His ___ worsens with movement,
coughing and deep breathing ("almost like a muscle spasm"), and
improves with sitting still. His ___ has intensified to the
point that his activity is severely limited to only essential
activities. He denies SOB, palpitations, lightheadedness, leg
___ or neurological symptoms associated with this sensation.
In the ED, initial vitals: VS 99.1, 126, 117/80, 18, 97%. His
EKG showed ST changes in V1-V4. Labs were significant for INR
1.2, Cr 1.4, Mg 1.4, ALT 115, AST 273, Alk phos 269, troponins
negative x 2, D-dimer 1018, serum ETOH level 372. CXR was
unremarkable.
He was seen by Cardiology on ___, who felt that an acute
coronary syndrome was unlikely given atypical chest ___ and
non-ischemic EKG. They recommended an echo to evaluate for any
wall-motion abnormalities. Echo on ___ showed borderline left
systolic function in the setting of tachycardia. CTA was
negative for pulmonary embolism.
Mr. ___ was kept overnight in obs. On the morning of ___,
patient was tremulous and complaining of headache and anxiety.
He was given a total of 1000 ml IV NS x 6, diazepam 10 mg x 5,
lorazepam 2 mg x 1 for symptomatic management of his alcohol
withdrawal. He was admitted to Medicine for alcohol withdrawal.
Vitals prior to transfer: 101 138/85 20 100% RA. Currently, Mr.
___ is comfortable and without complaints.
With regard to his alcohol history, he drinks an average of
___ pint of liquor per day. His last drink was on the
afternoon of his arrival to the ED on ___. He has experienced
alcohol withdrawal before, but denies a history of withdrawal
seizures.
ROS:
No fevers, chills or night sweats. Endorses unintentional weight
loss over the past few weeks, which he atttributes to poor
appetite. No changes in vision or hearing, no changes in
balance. No cough, no shortness of breath, no dyspnea on
exertion. Chest ___ as described above. Has felt slightly
nauseous since arriving at the hospital. Has a lot of flatus and
chronic diarrhea secondary to short gut syndrome. He produces an
average of ___ bowel movements per day, although reports up to
24 bowel movements per day. His diarrhea is aggravated by
certain foods. No dysuria or hematuria. No hematochezia, no
melena. Had some reflux symptoms a few days ago, and bought OTC
Zantac. No numbness or weakness, no focal deficits. Currently
feeling anxious and tremulous.
Past Medical History:
Crohns disease s/p multiple bowel surgeries
RCC s/p L nephrectomy
Pancreatitis
Osteoporosis
Chronic ___
Depression
Social History:
___
Family History:
Grandfather and sister with alcohol use
Brother with ___ abuse
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- T98.3F. BP 144/101. HR 95. RR 20. O2 sat 99% RA.
General- Alert, oriented, no acute distress, mildly tremulous
Skin - Generalized erythema in face, chest and arms bilaterally.
Feels warm.
HEENT- Sclerae anicteric, MMM
Neck- supple, JVP not elevated
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- Vertical midline scar, soft, NT/ND bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function normal, sensation intact.
DISCHARGE PHYSICAL EXAM:
Vitals-T97.2-98.5 (97.4) BP ___ (135/94). P ___ (64)
RR 18 O2 sat 98-100%RA
General- Alert, oriented, no acute distress, mildly tremulous
Skin - Generalized erythema in face, chest and arms bilaterally.
Feels warm with flushed skin.
HEENT- Sclerae anicteric, MMM
Neck- supple, JVP not elevated
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG. ___ not reproducible by palpation.
Abdomen- Vertical midline scar, soft, NT/ND, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
___ not reproducible by palpation.
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function normal, sensation intact
Pertinent Results:
===============
ADMISSION LABS:
===============
COMPLETE BLOOD COUNT
___ 10:30PM WBC-7.2 RBC-4.67# HGB-16.2# HCT-46.6 MCV-100*
MCH-34.8* MCHC-34.8 RDW-14.1
___ 10:30PM PLT COUNT-200#
___ 10:30PM NEUTS-84.5* LYMPHS-10.2* MONOS-4.6 EOS-0.4
BASOS-0.2
CHEMISTRIES
___ 10:50PM GLUCOSE-115* UREA N-18 CREAT-1.4* SODIUM-138
POTASSIUM-4.6 CHLORIDE-93* TOTAL CO2-31 ANION GAP-19
___ 10:50PM ALBUMIN-4.1 CALCIUM-9.6 PHOSPHATE-3.5
MAGNESIUM-1.4*
COAGS
___ 10:50PM ___ PTT-29.5 ___
LIVER ENZYMES
___ 10:50PM ALT(SGPT)-115* AST(SGOT)-273* CK(CPK)-93 ALK
PHOS-269* TOT BILI-0.7
CARDIAC MARKERS
___ 10:30PM cTropnT-<0.01
___ 10:50PM CK-MB-2
___ 06:30AM cTropnT-<0.01
TOX SCREEN
___ 10:50PM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
URINE
___ 08:30AM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 08:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:30AM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-1
___ 08:30AM URINE MUCOUS-RARE
OTHER LABS
___ 10:50PM LIPASE-25
___ 10:50PM D-DIMER-1018*
=============
HOSPITAL LABS
=============
COMPLETE BLOOD COUNT
___ 07:21AM BLOOD WBC-4.6 RBC-3.91* Hgb-12.9*# Hct-40.1
MCV-102* MCH-33.1* MCHC-32.3 RDW-14.1 Plt ___
___ 06:55AM BLOOD WBC-4.7 RBC-3.51* Hgb-12.0* Hct-35.6*
MCV-101* MCH-34.3* MCHC-33.8 RDW-13.9 Plt Ct-77*
CHEMISTRIES
___ 07:21AM BLOOD Glucose-86 UreaN-16 Creat-1.1 Na-138
K-4.2 Cl-96 HCO3-34* AnGap-12
___ 07:21AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.0*
___ 06:55AM BLOOD Glucose-86 UreaN-14 Creat-1.1 Na-135
K-4.2 Cl-96 HCO3-31 AnGap-12
___ 06:55AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.2
LIVER ENZYMES
___ 07:21AM BLOOD ALT-113* AST-188* AlkPhos-258*
TotBili-1.4
___ 06:55AM BLOOD ALT-83* AST-101* AlkPhos-218* TotBili-0.6
OTHER LABS
___ 07:21AM BLOOD ANCA-NEGATIVE B
=========
IMAGING
=========
EKG (___): Resting sinus tachycardia. Left axis deviation
consistent with left anterior fascicular block. Left atrial
abnormality. Left ventricular hypertrophy. Slow R wave
progression which could be due to left ventricular hypertrophy,
anterior myocardial infarction, cardiomyopathy, etc. Delayed
precordial transition zone. Non-specific ST-T wave changes.
Since the previous tracing of ___ heart rate is faster. R
wave progression is slower. Clinical correlation is suggested.
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
108 148 98 322/406 67 -78 50
EKG (___): Resting sinus tachycardia with atrial premature
beats. Compared to the previous tracing of ___ heart rate is
somewhat faster with atrial ectopy now seen. Multiple
abnormalities are as previously noted with persistent slight ST
segment elevations in leads V1-V2 which are non-diagnostic.
Cannot exclude ischemia. However, these changes have been seen
on multiple previous tracings. Findings may also be seen with
hyperkalemia, drug effect, Brugada type pattern, etc. Clinical
correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
___ 330/419 74 -79 57
Portable CXR (___):
FINDINGS:
The lungs are clear focal opacities concerning for infection.
There is no
evidence of pneumothorax or pulmonary edema. Blunting of the
left costophrenic angle is chronic related to scarring as seen
on the prior CT from ___. The right costophrenic angle
is clear. Numerous surgical clips in the abdomen are imaged. The
heart size is normal.
IMPRESSION:
No evidence of acute cardiopulmonary process.
Echocardiogram (___): The left atrium is normal in size.
Left ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Borderline left ventricular systolic function (in
the setting of tachycardia).
Compared with the report of the prior study (images unavailable
for review) of ___, LV function appears less vigorous.
CTA Chest W&WO Contrast (___):
IMPRESSION:
1. No pulmonary embolism
2. Several age indeterminate compression fractures are new since
___ and
progressed since ___ as described in the body of the report
occurring on a background of demineralization.
3. Hepatic steatosis
4. Left lateral upper lobe/ perifissural pleural thickening,
adjacent scarring and rib changes and metallic densities
apparently representing staples. No thoracic operative report in
the medical record. Recommend correlation with any history of
intervention there.
Brief Hospital Course:
Mr. ___ is a ___ yo male with a history of Crohn's disease
s/p multiple bowel surgeries, ETOH abuse, HTN, chronic pleuritic
chest ___ s/p pleurodesis in ___ who presents to the ED on
___ after experiencing worsening chest ___ for the past few
weeks, found to have ST changes in the precordial leads and
elevated D-dimer. ACS and PE workup was negative. He remained
tachycardic with increasing tremulousness and anxiety, and was
then admitted to Medicine on ___ for ETOH withdrawal.
# Alcohol withdrawal/abuse: Patient has a history of drinking
___ pint of whiskey per day. His last drink was on the day of
admission to the ED. He was noted to be increasingly tremulous,
anxious and nauseous, with tachycardia to the 130s and
hypertension to the 130s. He required diazepam and lorazepam in
the ED for symptom management, and was subsequently admitted for
alcohol withdrawal. On the floor, he was monitored via the ___
protocol. He only required diazepam once during his hospital
stay. He was also given thiamine and folic acid. He expressed a
motivation to quit drinking, so he was seen by Social Work to
identify an appropriate treatment program upon discharge. He was
advised to follow-up with the Discover Program at
___ in ___, which is a day
hospital treatment program that he is willing to attend. Upon
hospital discharge, his symptoms and tachycardia had resolved.
# Chronic chest ___: Patient has had chronic pleuritic chest
___ since his pleurodesis ___ year ago that also worsened with
movement. His ___ worsened over the prior ___ weeks,
accompanied by ___ in his sides and hips and decrease in his
mobility. He was evaluated by cardiology in the ED, who
determined that the chest ___ was unlikely to be coronary in
etiology given atypical presentation, no focal wall motion
abnormalities on echo, and negative troponins. He was also
evaluated for a PE given tachycardia and elevated D-dimer,
although CTA chest was also negative. His chronic chest ___ was
felt to be secondary to chest wall fibrosis s/p pleurodesis.
Patient was previously managing his chest ___ with opioids, but
discontinued in ___. His current home ___ regimen
includes tramadol 100 mg TID and gabapentin 300 mg BID. He had
already established care with the ___. He was
started on lidoderm patch qday and he was encouraged follow-up
with his ___ clinic to further optimize his medications. Upon
hospital discharge, his chest ___ had returned to baseline and
he was much more mobile.
# Transaminitis: Patient had mildly elevated AST/ALT, alk phos
and INR. At his previous hospital admission for pancreatitis, he
was found to have mildly elevated AST, ALT and alk phos. CT
abd/pelvis was notable for hepatic steatosis. Hepatitis panel
was negative and iron studies were not consistent with
hemochromatosis. At this hospitalization, patient only had
intermittent abdominal ___ that appeared to be related to gas.
ANCA was sent to rule out primary sclerosing cholangitis given
history of IBD - ANCA was negative.
# Hypertension: Patient with ETOH abuse and s/p L nephrectomy.
He has a history of hypertension that was treated at his prior
hospitalizations with labetalol. He recently uptitrated his
lisinopril from 20 to 40 mg daily. Patient continued to be
hypertensive to the mid to high 140s/90s, even after symptoms of
alcohol withdrawal subsided. His creatinine was at his baseline
(1.1), so unlikely to be related to underlying renal parenchymal
disease. He likely has essential hypertension. We continued his
home lisinopril without dose adjustment. He may need follow-up
with his PCP for further medication adjustment, and to consider
adding another agent for better blood pressure control.
# Depression: Patient was continued on his home sertraline.
Patient has a therapist, but does not have a psychiatrist. He
was recommended to see Dr. ___ at the ___ for
management of addiction and ___. He intends to follow-up with
the ___ as an outpatient.
Transitional Issues:
[ ] f/u with ___ for further management of
chronic chest wall ___ - likely secondary to fibrosis from
pleurodesis in ___
[ ] contact rehab facilities provided by Social Work for
management of alcohol dependence
[ ] Consider referral to psychiatry for management of his
alcohol dependence and depression
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcitriol 0.75 mcg PO DAILY
2. Cyanocobalamin 1000 mcg IM/SC EVERY 2 WEEKS
3. FoLIC Acid 1 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Mercaptopurine 50 mg PO DAILY
6. Multivitamins ___ TAB PO DAILY
7. TraMADOL (Ultram) 100 mg PO TID
8. Vitamin D 50,000 UNIT PO 10 CAPSULES WEEKLY
9. AndroGel (testosterone) 1 % (25 mg/2.5gram) transdermal bid
10. Diphenoxylate-Atropine 1 TAB PO TID:PRN diarrhea
11. Gabapentin 300 mg PO BID
12. Gabapentin 600 mg PO HS
13. Citracal + D Petites (calcium citrate-vitamin D3) 200 mg
calcium -250 unit oral 2 tablets tid
14. Acetaminophen 1000 mg PO Q8H:PRN ___
15. Ibuprofen 600 mg PO Q12H:PRN ___
16. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN ___
2. Calcitriol 0.75 mcg PO DAILY
3. Diphenoxylate-Atropine 1 TAB PO TID:PRN diarrhea
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 300 mg PO BID
6. Lisinopril 40 mg PO DAILY
7. Mercaptopurine 50 mg PO DAILY
8. Multivitamins ___ TAB PO DAILY
9. Sertraline 50 mg PO DAILY
10. TraMADOL (Ultram) 100 mg PO TID
11. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) ASDIR Daily Disp
#*30 Patch Refills:*0
12. AndroGel (testosterone) 1 % (25 mg/2.5gram) transdermal bid
13. Citracal + D Petites (calcium citrate-vitamin D3) 200 mg
calcium -250 unit oral 2 tablets tid
14. Cyanocobalamin 1000 mcg IM/SC EVERY 2 WEEKS
15. Gabapentin 600 mg PO HS
16. Ibuprofen 600 mg PO Q12H:PRN ___
17. Vitamin D 50,000 UNIT PO 10 CAPSULES WEEKLY
18. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth Daily Disp #*15
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Alcohol withdrawal
Secondary diagnosis:
Transaminitis
Crohn's disease
Chronic chest ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You came to the ___ on ___ with worsening of your chronic
chest ___. You were evaluated by Cardiology, who determined
that your chest ___ was not cardiac in origin. You also had a
CT scan of the chest, which did not show any evidence of a blood
clot to your lungs. You were admitted to the hospital on ___
because you began to withdraw from alcohol. You were treated
with Valium as needed for withdrawal symptoms. You stayed in
the hospital until your withdrawal symptoms subsided. Please
abstain from alcohol, and continue to attend your AA meetings in
___. Please follow-up with one of the rehab facilities
provided by our social work team to continue management of your
alcohol dependence. We also recommend that you continue to
follow up with the ___ clinic for management of your
chronic chest ___. Please keep your appointments as scheduled
and take your medications as prescribed.
We hope you continue to feel better.
- Your ___ Team
Followup Instructions:
___
|
10778867-DS-9
| 10,778,867 | 21,508,628 |
DS
| 9 |
2170-03-05 00:00:00
|
2170-03-10 16:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, nausea/vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M patient w/ h/o alcoholism and Crohn's disease and renal
cell who presents with LLQ abdominal pain that began 3 days ago,
followed shortly after by onset of left back pain. Pain was
described as sharp and constant with no clear relieving or
exacerbating factors. Patient also reported left chest pain that
was sharp in quality and different from the chronic dull pain in
the same region that he has had for the past ___ years s/p tube
drainage for empyema. Abdominal pain became progressively worse
over the next few days which led to his presentation to the
hospital. Also reports decreased appetite and nausea during this
time, but denies vomiting. Has had decreased frequency of
urination and bowel movements, which patient attributes to his
decreased appetite. Of note, patient is a self-reported binge
drinker who reports his last binge episode as taking place on
the day before presentation; reported volume of imbibement was
___ liter of whiskey. Patient denied fever, chills, and recent
weight change. Denies headache, cough, or shortness of breath.
In the ED, initial vs were: Temp: 97.8 HR: 88 BP: 135/109 Resp:
18 O2Sat: 94
Labs were remarkable for neg troponin, lipase 541, ALT 76 AST
97, WBC 15.2, Alk Phos 168, INR 2.5, Cr 2.2, Mg 1.5
Patient was given IV fluids and pain medications
Past Medical History:
Crohn's disease with multiple small bowel resections and
resultant short gut syndrome
Osteoporosis
Renal Cell Carcinoma, s/p left nephrectomy
Social History:
___
Family History:
Grandfather and sister with alcohol use
Brother with ___ abuse
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: Tm 98.8, Tc 98.3, HR 104 (90-100), BP 143/98
(130-140/80-90), RR 18, SaO2 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Breathing comfortably, CTAB
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +BS, soft, nondistended, firm, tenderness to palpation
of LLQ, no rebound or guarding.
Msk: Tenderness to palpation along spine and left flank.
Ext: 2+ L DP pulse, 1+ R DP pulse pulses, no clubbing, cyanosis
or edema
Skin: Tanned skin
DISCHARGE PHYSICAL EXAM:
Vitals: Tm 99.1/Tc 99, HR 94, BP 160/100 (150-180/90-100), RR
18, SaO2 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Breathing comfortably, CTAB
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +BS, soft, nondistended, firm, nontender, no rebound or
guarding, no hepatomegaly
Msk: Tenderness to palpation along spine and left flank
Ext: 2+ L DP pulse, 1+ R DP pulse, no clubbing, cyanosis or
edema
Skin: Tanned skin, large eecchymosis along left hip
Pertinent Results:
ADMISSION LABS:
___ 01:00PM BLOOD WBC-15.2*# RBC-4.76 Hgb-16.4 Hct-49.0
MCV-103* MCH-34.5* MCHC-33.6 RDW-13.4 Plt ___
___ 01:00PM BLOOD Neuts-92.6* Lymphs-2.8* Monos-3.8 Eos-0.7
Baso-0.1
___ 01:31PM BLOOD ___ PTT-40.4* ___
___ 01:00PM BLOOD Glucose-90 UreaN-32* Creat-2.2* Na-129*
K-5.6* Cl-84* HCO3-32 AnGap-19
___ 01:00PM BLOOD ALT-76* AlkPhos-168* TotBili-0.7
___ 01:00PM BLOOD Lipase-541*
___ 01:00PM BLOOD Albumin-4.7 Calcium-9.5 Phos-4.8*#
Mg-1.5*
___ 01:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:17PM BLOOD Lactate-1.7 K-5.0
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-7.2 RBC-3.64* Hgb-12.7* Hct-37.3*
MCV-103* MCH-34.8* MCHC-33.9 RDW-12.8 Plt ___
___ 05:40AM BLOOD Glucose-118* UreaN-10 Creat-1.0 Na-133
K-3.2* Cl-90* HCO3-32 AnGap-14
___ 05:40AM BLOOD ALT-70* AST-81* AlkPhos-149* TotBili-1.8*
___ 05:40AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.2*
OTHER LABS:
___ 05:55AM BLOOD calTIBC-248* VitB12-1115* Folate-GREATER
TH Hapto-65 TRF-191*
___ 05:55AM BLOOD Triglyc-94
___ 05:55AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
Micro: blood and urine cx negative, RPR negative
IMAGING:
___ CT A/P:
1. Mild stranding and indistinctness of the pancreatic head
compatible with acute pancreatitis.
2. Mesenteric nodal mass is grossly unchanged from exam in
___.
3. No signs of acute bowel inflammation.
4. Hepatic steatosis.
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with a past medical
history significant for Crohn's disease and alcohol abuse who
presented with abdominal/back pain and nausea/vomiting, found to
have an elevated lipase/LFTs and CT imaging consistent with
pancreatitis.
# PANCREATITIS: Abdominal/back pain with elevated lipase and
evidence of pancreatic stranding on CT was consistent with acute
pancreatitis, likely due to alcohol. Of note, mercaptopurine
(which patient takes for Crohn's disease) is also rarely
associated with pancreatitis. Patient's BISAP score on
admission was 1, consistent with mild disease. Patient was
treated conservatively with IV fluids, pain medications, and
bowel rest. His diet was gradually advanced and he was weaned
to oral pain medications.
# ALCOHOL ABUSE/WITHDRAWAL: Patient was maintained on a CIWA
protocol for alcohol withdrawal and required intermittent
diazepam for the first two hospital days. Social work was
consulted and patient declined additional outpatient or
inpatient supports for substance abuse. He has a weekly
therapist, a new sponsor, and attends AA meetings daily.
Patient was instructed to avoid alcohol on discharge.
# HYPERTENSION: Patient was relatively hypertensive on home
lisinopril. Initially, his hypertension was associated with
tachycardia and was likely related to alcohol withdrawal. He
remained hypertensive to 150-160s/90-100s and required prn doses
of labetalol. Consider uptitration of lisinopril or addition of
a second antihypertensive medication as an outpatient.
# HYPOGLYCEMIA: His hospital course was complicated by
hypoglycemia to 45, likely related to poor oral intake in the
setting of probable underlying liver disease. He was
transiently maintained on a D5 infusion and his glucose
normalized.
# ELEVATED INR: INR was elevated to 2.5 on admission. Patient
was given a small dose of vitamin K and his INR normalized.
Unclear if the elevated INR was related to nutritional
deficiency or liver disease.
# ELEVATED LIVER ENZYMES: AST/ALT and alk phos were mildly
elevated during hospitalization. CT A/P was notable for hepatic
steatosis, which may be related to alcohol use. Hepatitis panel
was negative and iron studies were not consistent with
hemochromatosis. Consider additional outpatient work-up for
elevated liver enzymes. Patient was instructed to abstain from
alcohol use.
TRANSITIONAL ISSUES:
- Patient was advised to abstain from alcohol.
- Patient was relatively hypertensive on home lisinopril (BP
150-160s/90-100s). Consider uptitrating lisinopril or adding an
additional antihypertensive medication.
- Patient was negative for HBsAb and requires vaccination for
hepatitis B.
- Consider additional work-up for elevated liver enzymes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcitriol 0.75 mcg PO DAILY
2. Vitamin D 50,000 UNIT PO EVERY OTHER DAY
3. Diphenoxylate-Atropine 1 TAB PO TID:PRN diarrhea
4. FoLIC Acid 1 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Mercaptopurine 50 mg PO DAILY
7. AndroGel (testosterone) 1 % (25 mg/2.5gram) transdermal bid
8. Multivitamins 1 TAB PO DAILY
9. TraMADOL (Ultram) 100 mg PO TID
10. Gabapentin 300 mg PO BID
11. Gabapentin 600 mg PO HS
12. Cyanocobalamin 1000 mcg IM/SC EVERY 2 WEEKS
13. Vitamin D 100,000 UNIT PO EVERY OTHER DAY
14. Citracal + D Petites (calcium citrate-vitamin D3) 200 mg
calcium -250 unit oral 2 tablets tid
Discharge Medications:
1. Calcitriol 0.75 mcg PO DAILY
2. Cyanocobalamin 1000 mcg IM/SC EVERY 2 WEEKS
3. FoLIC Acid 1 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Mercaptopurine 50 mg PO ONCE Duration: 1 Dose
6. Multivitamins 1 TAB PO DAILY
7. TraMADOL (Ultram) 100 mg PO TID
8. Vitamin D 50,000 UNIT PO EVERY OTHER DAY
9. AndroGel (testosterone) 1 % (25 mg/2.5gram) transdermal bid
10. Diphenoxylate-Atropine 1 TAB PO TID:PRN diarrhea
11. Gabapentin 300 mg PO BID
12. Gabapentin 600 mg PO HS
13. Vitamin D 100,000 UNIT PO EVERY OTHER DAY
14. Citracal + D Petites (calcium citrate-vitamin D3) 200 mg
calcium -250 unit oral 2 tablets tid
15. Acetaminophen 1000 mg PO Q8H:PRN pain
16. Ibuprofen 600 mg PO Q12H:PRN pain
17. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % (700 mg/patch) Apply to painful area Daily
Disp #*15 Patch Refills:*0
18. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 gram by mouth daily
prn Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
- Pancreatitis
- Hypoglycemia
- Elevated INR
Chronic isues:
- Alcohol abuse
- Chest pain
- Macrocytic anemia
- Crohn's 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 for
abdominal pain and were diagnosed with pancreatitis, likely from
alcohol use. We treated you with pain medications, fluids, and
bowel rest. Your symptoms improved and we discharged you home.
It will be very important for you to avoid alcohol after your
discharge.
Take care, and we wish you the best.
Sincerely,
Your ___ medicine team
Followup Instructions:
___
|
10778904-DS-11
| 10,778,904 | 26,267,542 |
DS
| 11 |
2187-12-24 00:00:00
|
2188-02-16 11:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
penicillin
Attending: ___.
Chief Complaint:
RUQ pain, fatigue, anorexia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Sister ___ is a ___ yo female with PMH significant for HTN,
obesity, newly diagnosed cholangiocarcinoma found to have
worsening leukocytosis on pre operative labs with some nausea
and anorexia.
Her initial prsentation was to ___ on ___ where she
presented with RUQ pain, nausea, early satiety. She was noted to
have abnormal LFTs and leukocytosis. She was diagnosed initially
with acute cholecystitis and treated with Cipro/Flagyl. She then
had MRI imaging showing a 15.8x7.5x8.1cm lesion in the right
liver extending towards the gallbladder. She had biopsy which
showed cholangiocarcinoma. She was recently seen in ___
clinic on ___. Treatment plan was established as
preoperative Y90 embolization followed by surgical resection.
Today patient notes worsening RUQ pain over the past few weeks.
She has not had any fevers/chills at home but has had decreased
oral intake and increased thirst.
In the ED, initial vitals were: 8 98.1 130 133/84 18 96% RA
- Labs were significant for WBC of 31.2. LFTs were at her most
recent baseline.
- Imaging revealed known cholangiocarcinoma in segment 4 of the
liver. Gallbladder noted to have wall thickening and gallstones.
There was concern for acute cholecystitis and MRI was
recommended for further evaluation.
- The patient was given Morphine for pain, Zofran for nausea.
She was additionally given Levofloxacin 750mg, Flagyl 500mg and
2L IVF.
Vitals prior to transfer were: 4 97.3 78 123/70 18 100% Nasal
Cannula.
Upon arrival to the floor, she complains of mild persistent RUQ
pain and feeling cold (thermostat set at ___ in room).
Past Medical History:
Cholangiocarcinoma
Obesity
HTN
Gallstones
?Neuropathy - tingling in toes
Social History:
___
Family History:
Sister- breast cancer ___
Father- prostate cancer
3 brothers - prostate cancer
1 brother - brain aneurysm (her only living sibling)
Niece- breast cancer ___ (s/p mastectomy b/l, alive)
Pat GM - breast ca ___
Sister & mother died cardiac disease (___, ___)
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals: 97.8 | 141/80 | 87 | 20 | 100%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, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Obese, non-distended, normal bowel sounds, soft,
tenderness to palpation of epigastrium and RUQ, equivocal ___
sign, no rebound.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3. Fluent speech. No gross focal deficit.
DISCHARGE PHYSICAL EXAM
========================
VS: Tc 97.9 Tm 98.6, BP: 149/41, HR 94-107, RR ___, 97% RA
General: Sleeping but arousable. Alert, oriented, no acute
distress.
HEENT: Sclera anicteric, MMM, EOMI
Neck: Supple, JVP not elevated, no LAD
CV: RRR, normal S1, S2, no m/r/g
Lungs: Slight wheezing appreciated in L upper lobe, R lung bases
Abdomen: Obese, tenderness to palpation of RUQ, no rebound, no
guarding, no ___, hepatomegaly at 15cm below the diaphragm,
palpable spleen, soft, non-distended.
Skin: no jaundice noted
GU: No foley
Ext: Warm, well perfused, 2+ pulses
Neuro: AOx3. Fluent speech. No gross focal deficit
Pertinent Results:
ADMISSION LABS
=
=
=
=
================================================================
___ 10:10AM BLOOD WBC-29.0*# RBC-3.96 Hgb-10.5* Hct-34.6
MCV-87 MCH-26.5 MCHC-30.3* RDW-14.8 RDWSD-47.4* Plt ___
___ 07:35PM BLOOD WBC-31.2* RBC-3.82* Hgb-10.3* Hct-33.1*
MCV-87 MCH-27.0 MCHC-31.1* RDW-14.9 RDWSD-47.2* Plt ___
___ 10:10AM BLOOD Neuts-89* Bands-3 Lymphs-2* Monos-6 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-26.68* AbsLymp-0.58*
AbsMono-1.74* AbsEos-0.00* AbsBaso-0.00*
___ 10:10AM BLOOD Plt Smr-HIGH Plt ___
___ 07:35PM BLOOD ___ PTT-27.7 ___
___ 07:35PM BLOOD Plt ___
___ 07:35PM BLOOD Glucose-135* UreaN-11 Creat-1.0 Na-135
K-4.3 Cl-96 HCO3-26 AnGap-17
___ 07:35PM BLOOD ALT-17 AST-34 AlkPhos-197* TotBili-0.7
DirBili-0.4* IndBili-0.3
___ 07:35PM BLOOD Lipase-12
___ 07:35PM BLOOD Albumin-2.9* Calcium-9.0 Phos-4.0 Mg-1.9
___ 07:35PM BLOOD LtGrnHD-HOLD
___ 07:44PM BLOOD Lactate-1.4
___ 05:39AM BLOOD GGT-73*
DISCHARGE LABS
=
=
=
=
================================================================
___ 05:00AM BLOOD WBC-30.2* RBC-3.25* Hgb-8.7* Hct-28.4*
MCV-87 MCH-26.8 MCHC-30.6* RDW-15.3 RDWSD-48.8* Plt ___
___ 05:00AM BLOOD Neuts-90.7* Lymphs-3.0* Monos-4.0*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-27.37* AbsLymp-0.91*
AbsMono-1.22* AbsEos-0.03* AbsBaso-0.07
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD Glucose-76 UreaN-11 Creat-0.8 Na-141
K-3.7 Cl-104 HCO3-26 AnGap-15
___ 05:00AM BLOOD ALT-19 AST-39 AlkPhos-203* TotBili-0.5
___ 05:00AM BLOOD Calcium-8.4 Phos-4.1 Mg-1.9
___ 07:44PM BLOOD Lactate-1.4
IMAGING/TESTING:
=========================================
MRCP ___
1. Limited exam. The large hepatic mass has increased in size,
as described above. Additionally, there are more necrotic
changes. 2. Unchanged appearance of the gallbladder. The
distention and focal wall thickening is related to the mass.
The gallbladder wall distant to the mass is normal, suggesting
there is no acute cholecystitis.
3. Interval increase in the amount of perihepatic and
pericholecystic fluid.
4. Stable periportal lymphadenopathy.
US Liver/Gallbladder ___
1. Stable appearance of moderately distended gallbladder.
Diffuse wallm thickening with a more pronounced focus along the
fundus raises concern for tumor infiltration.
2. Re-demonstrated hepatic parenchymal mass with probable
surrounding
satellite lesions.
3. Splenomegaly, measuring up to 17.2 cm.
CXR ___
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous
structures are intact.
ECG ___
Sinus tachycardia. Prominent voltage in leads I and aVL
suggesting left
ventricular hypertrophy. Delayed R wave transition and low
precordial lead voltage. Compared to the previous tracing of
___ the rate has increased.There is variation in precordial
lead placement. Otherwise, no diagnostic interim change.
MICRO:
=========================================
Close
___ 7:35 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 9:21 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
___ yoF w/ h/o obesity, htn, and recent diagnosis of
cholangiocarcinoma presenting w/ increased RUQ pain,
leukocytosis, and anorexia.
ACTIVE ISSUES
==========
#RUQ Pain/Leukocytosis: On admission, pt had elevated Alk phos
at 197, w/ LFTs WNL, suggesting biliary or infiltrative
etiology. Ddx include cholesystitis, cholelethiasis,
choledocolithiasis, cholangitis, and SIRS response from
progressing cholangiocarcinoma. RUQ u/s showed moderately
distended gallbladder, diffuse wall thickening, and more
pronounced focus along the fundus raising concerns for tumor
infiltration. As pt was not febrile on admission, was relatively
well appearing, did not have a significantly elevated total
bili, and U/S finding did not significantly inflammed
gallbladder , cholecystitis and cholangitis were less likely.
Though, given her cholangiocarcinoma and possibility of ductal
obstruction, empiric ciprofloxacin 400mg IV q12hr, Metronidazole
500 mg IV q8hr were started, and an MRCP was done for further
evaluation. The MRCP showed an enlarged hepatic mass w/ more
necrotic changes, gallbladder w/ gallstones but w/out evidence
of acute cholecystitis, biliary duct w/out evidence of
cholangitis, and an increase in the amount of perihepatic and
pericholecystic fluid. Oncology was consulted for the progressed
cholangiocarcinoma and recommended no change to pt's original
cholangiocarcinoma treatment plan. The pt will receive Y90
embolization followed by surgical resection. Blood culture was
pending at time of discharge.
#Tachycardia: Pt had sinus tachycardia in the 90-110's while
in-pt, and responded to 500cc fluid boluses. H&H was stable, w/
no signs of bleeding. SBPs were in the 112-114, w/ increases to
the 150's with ambulation. Cause is likely multifactoral-- RUQ
pain, anxiety, hypovolemia from poor PO intact, and SIRS
response to her underlying malignancy. Pt's home Lasix 20mg
daily was held since admission given her leukocytosis and
tachycardia and was restarted at time of discharge on ___.
Vitals were stable at the time of discharge.
# Dyspnea: The pt had increased work of breathing in mornings w/
intermittent coughing w/out sputum production. Lungs were clear
to auscultation. CXR on admission was negative. Echo ___ years
prior showed no systolic dysfunction per pt report. Satting well
on room air. Pt has baseline shortness of breath at home,
contributed to by body habitus. Her breathing improves
throughout the day. At time of discharge, pt's breathing was
baseline with good O2 sat on room air.
# Cholangiocarcinoma: Advanced stage given multiple satellite
lesions. Found to have increased in size on MRCP. Oncology was
consulted and recommended no change to pt's original treatment
plan. Pt will be seen ___ clinic and receive Y90
embolization followed by surgical resection.
CHRONIC ISSUES
===========
Hypertension: Home lasix 20mg PO daily was restarted at time of
discharge. Held while in pt given leukocytosis and tachycardia.
TRANSITION ISSUES
============
- f/u on blood cultures
- f/u with ___ clinic ___ for scheduled Y90
radioembolization
- ?establishment of care with a ___ PMD (pt's previous PMD
was in ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
3. Polyethylene Glycol 17 g PO DAILY
4. Furosemide 30 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
3. Polyethylene Glycol 17 g PO DAILY
4. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Disposition:
Expired
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Cholangiocarcinoma
SECONDARY DIAGNOSES
Gallstones
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___ on
___ for worsening pain in the right upper region of your
abdomen. We started you on antibiotics in case your worsening
pain was due to a bacterial infection and did an MRI of your
gallbladder, biliary tract, as well as other surrounding
structures. The MRI showed that there was a slight enlargement
of the cholangiocarcinoma mass in your liver. The oncology team
was consulted and recommended no change to your original
cholangiocarcinoma treatment plan. You will still have the Y90
radiation on ___, followed by surgical removal of
the tumor mass. We have stopped your antibiotics.
It was a pleasure taking care of you at ___. If you have any
questions about the care you received, please do not hesitate to
ask.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10779064-DS-16
| 10,779,064 | 20,445,698 |
DS
| 16 |
2183-06-08 00:00:00
|
2183-06-09 17:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
prasugrel / clopidogrel
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___
Right and left heart catheterization
DES (expedition) to LCXp
DES X2 (expedition) to RCAp
Intra-aortic balloon pump placement
History of Present Illness:
___ with history of Hodgkins lymphoma s/p radiation brought in
by EMS s/p fall from standing with chest pain. Patient stated he
was nauseated, had chest pressure and felt faint. Per ED note,
duration of pain was 2 hrs. EKG showed RBBB, right axis
deviation with ST elevations in inferior and lateral leads. He
was taken to the cath lab, started on levophed for hypotension
to the ___, given morphine for pain, and balloon pump was placed
with 1:1 settings. SBP improved to 100s with levophed.
In the cath lab, patient was found to have ulcerative disease in
the LCx and additional lesion in the RCA which was felt to be
culprit lesion. Received 1 DES to LCx and 2 DES to RCA. Failed
attempts through R radial, angioseal w arterial line to R groin,
central line in L groin. Levophed was able to be weaned off
while he remains on balloon pump upon tranfer to CCU.
On arrival to the floor, patient feels well - reports that he
awoke this AM at 0500 with need to use the bathroom. He felt
nauseated but didn't vomit. When he got out of bed with the
intent to go to the bathroom he fell and the next thing he
remembers is getting water splashed on his face by his wife who
witnessed his fall. He denied chest pain. He did feel short of
breath and slightly wheezy. They called an ambulance. He
continues to feel slightly short of breath and thinks he
aspirated the chewable aspirin administered this AM.
Past Medical History:
1. CARDIAC RISK FACTORS: None
2. CARDIAC HISTORY:
-None
3. OTHER PAST MEDICAL HISTORY:
-Hodgkins Lymphoma: treated with 6mo chemo/RT in ___, stage III
to groin, neck and chest. tx'd at ___
-low normal BP at baseline (110/80)
Social History:
___
Family History:
Mother deceased ___ malignancy to lung/stomach/liver. Father
deceased ___ cva vs seizure. Siblings healthy. No family
history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
Admission physical exam:
VS: 98.0 ABP 102/69 NBP ___ 109 26 100/6L NC
General: well appearing, thin well nourished Caucasian male,
lying in bed, no resp distress
HEENT: PERRL, HEENT, EOMI, OP wo lesions
Neck: supple
CV: RRR, S1/S2 intact, no murmurs
Lungs: diffuse anterior wheezes and occ rhonchi, aortic balloon
pump audible
Abdomen: soft, NT/ND, no organomegaly
GU: Foley in place
Ext: cool, clammy, distal pulses intact, moving all ext, R
groin oozing
Neuro: AOx3, CN II-XII grossly intact
Discharge physical exam:
Afeb, HR 80-90's SR, RR 18 BP 90-110/60, O2 sat 98 RA, pulsus
6cm
HEENT: eyes with mild injection of sclera, JVD 4 cm above
clavicle
Chest: clear bilateral with dec right base
CV: RRR no murmurs
Abd: soft NT
Ext: no edema
Skin: macular rash almost cleared from chest, arms and back.
Macular/papular rash in groin and medial thigh area greatly
improved with mild macular scattered lesions and dec itching.
Pertinent Results:
ADMISSION LABS:
___ 07:30PM PLT COUNT-305
___ 07:08PM ___ COMMENTS-GREEN TOP
___ 07:08PM LACTATE-2.0
___ 07:00PM CREAT-1.0 SODIUM-139 POTASSIUM-4.7
CHLORIDE-101
___ 07:00PM CK(CPK)-4939*
___ 07:00PM CK-MB-483* MB INDX-9.8* cTropnT-8.39*
___ 07:00PM MAGNESIUM-2.1
___ 07:00PM PTT-44.2*
___ 07:09AM UREA N-20 CREAT-1.2
___ 07:09AM estGFR-Using this
___ 07:09AM LIPASE-37
___ 07:09AM cTropnT-<0.01
___ 07:09AM CHOLEST-302*
___ 07:09AM TRIGLYCER-134 HDL CHOL-84 CHOL/HDL-3.6
LDL(CALC)-191*
___ 07:09AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 07:09AM PH-7.38 COMMENTS-GREEN TOP
___ 07:09AM GLUCOSE-148* LACTATE-3.4* NA+-141 K+-4.9
CL--99 TCO2-25
___ 07:09AM HGB-17.7 calcHCT-53 O2 SAT-74 CARBOXYHB-2 MET
HGB-0
___ 07:09AM freeCa-1.08*
___ 07:09AM WBC-12.0* RBC-5.52 HGB-17.5 HCT-52.1* MCV-94
MCH-31.6 MCHC-33.5 RDW-13.0
___ 07:09AM PLT COUNT-355
___ 07:09AM ___ PTT-25.9 ___
___ 07:09AM ___
OTHER LABS:
___ 07:00PM BLOOD CK(CPK)-4939*
___ 02:03AM BLOOD CK(CPK)-3301*
___ 07:00PM BLOOD CK-MB-483* MB Indx-9.8* cTropnT-8.39*
___ 02:03AM BLOOD CK-MB-211* MB Indx-6.4* cTropnT-5.32*
___ 08:14AM BLOOD cTropnT-2.35*
___ 07:08PM BLOOD Lactate-2.0
IMAGING/STUDIES:
TTE ___ @0950
The left atrium is normal in size. 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%). The number of aortic valve leaflets cannot
be determined. The mitral valve leaflets are structurally
normal. The mitral valve leaflets are not well seen. Mild (1+)
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is a small anterior
pericardial effusion. The effusion is echo dense, consistent
with blood, inflammation or other cellular elements. There are
no echocardiographic signs of tamponade.
IMPRESSION: Extremely poor technical quality study. Left
ventricular function is probably low normal, a focal wall motion
abnormality cannot be fully excluded. The right ventricle is not
well seen. Mild mitral regurgitation. Small, echodense anterior
pericardial effusion without tamponade. Pulmonary artery
systolic pressure could not be determined.
TTE ___ @1209
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 40%) secondary to
akinesis of the inferior and infero-lateral walls. The LV apex
and ___ wall could not be visualized due to
suboptimal apical views. Anterior wall contractility is
preserved. Right ventricular chamber size is normal. with mild
global free wall hypokinesis. The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is a very
small pericardial effusion located along the LV apex and distal
anterior wall without evidence of tamponade.
Compared with the prior study (images reviewed) of ___,
image quality is improved (although not optimal) allowing
identification of inferior and infero-lateral wall motion
abnormalities with overall mildly depressed global systolic
function. Normal right ventricular size with mild depressed
systolic function. Mild mitral regurgitation.
CXR ___
The tip of intra-aortic balloon pump is approximately 2.5 cm
below the roof of
the aortic arch. The patient is in moderate-to-severe pulmonary
edema. The
heart size is normal. There is no mediastinal widening. Small
amount of
bilateral pleural effusion is most likely present.
CXR ___ @___
There is interval improvement of interstitial pulmonary edema
that is still
present, mild to moderate. Intra-aortic balloon pump tip is
currently more
proximal than on the prior study approximately 1 cm below the
roof of the
ascending aorta. The heart size and mediastinum are unchanged.
ECHO ___: The left atrium is elongated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is severe global left ventricular
hypokinesis (LVEF = ___. No masses or thrombi are seen in
the left ventricle. There is no aortic valve stenosis. No aortic
regurgitation is seen. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Dilated left ventricle with severe global systolic
dysfunction in the setting of tachycardia.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
----------
SPECIMEN SUBMITTED: SKIN, RIGHT MEDIAL THIGH
Procedure date Tissue received Report Date Diagnosed
by
___. ___
DIAGNOSIS:
Skin, right medial thigh (A):
Superficial and predominantly perivascular lymphocytic
infiltrate with eosinophils, sparse neutrophils with
karyorrhexis and red blood cell extravasation with mild upper
dermal edema most consistent with hypersensitivity reaction (see
comment).
No fungal organisms seen on a PAS stain.
Bacterial organisms seen within a hair follicle (tissue Gram
stain performed)
Multiple tissue levels examined.
Comment. Sections show epidermis with focal spongiosis and mild
patchy basal vacuolar change with rare dyskeratotic
keratinocytes. There is minimal intraepidermal inflammation and
changes of erythema multiforme / ___ are
not seen in this biopsy. There is a predominantly perivascular
mononuclear infiltrate with eosinophils, associated with mild
upper dermal edema. Neutrophils are present but sparse with some
karyorrhexis. Red blood cell extravasation is prominent. Some
vascular lumina are dilated, contain neutrophils and are lined
by reactive appearing endothelium. However, no acute vasculitis
is appreciated in the multiple tissue levels examined. Overall,
the histologic features favor a hypersensitivity reaction such
as to a drug.
------------------
CTA CHEST W&W/O C&RECONS, NON-CORONARYStudy Date of ___
Contrast: OMNIPAQUE Amt: 100
FINDINGS:
CT of the thorax: The airways are patent to the subsegmental
level. There is
no mediastinal, hilar or axillary lymph node enlargement by CT
size criteria.
The heart, pericardium and great vessels are within normal
limits. No hiatal
hernia or other esophageal abnormality is seen. The thyroid is
enlarged with
multiple nodules, consistent with multinodular goiter.
The lung parenchyma demonstrates patchy ground-glass opacities
bilaterally
with interlobular septal thickening and bilateral pleural
effusions and
adjacent compressive atelectasis. In the clinical setting of a
recent
myocardial infarction, this is most consistent with congestive
heart failure.
No pneumothorax is present.
CTA thorax: The aorta and main thoracic vessels are well
opacified. The
aorta demonstrates normal caliber through the thorax without
intramural
hematoma or dissection. The pulmonary arteries are opacified to
the segmental
level. There is no filling defect to suggest pulmonary
embolism. No
arteriovenous malformation is seen.
Abdomen: Although this study is not designed for assessment of
intra-abdominal structures, the visualized solid organs, stomach
and bowel are
unremarkable.
Osseous structures: No significant abnormality seen within the
visualized
osseous structures.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Bilateral patchy ground-glass opacities with bilateral
pleural effusions
consistent with congestive heart failure.
3. Multinodular goiter.
PORTABLE CHEST RADIOGRAPH ___
COMPARISON: ___ radiograph.
FINDINGS: Cardiac silhouette is normal in size. Pulmonary
vascular
congestion is accompanied by mild-to-moderate pulmonary edema as
well as
bilateral small-to-moderate pleural effusions. Biapical
scarring is
unchanged.
DISCHARGE LABS:
___ 07:05AM BLOOD WBC-14.4* RBC-4.35* Hgb-13.4* Hct-39.8*
MCV-92 MCH-30.9 MCHC-33.8 RDW-12.7 Plt ___
___ 07:05AM BLOOD Neuts-67.0 Lymphs-14.8* Monos-7.9
Eos-9.7* Baso-0.7
___ 07:05AM BLOOD Glucose-93 UreaN-19 Creat-0.9 Na-134
K-4.9 Cl-97 HCO3-29 AnGap-13
___ 07:05AM BLOOD ALT-83* AST-71* AlkPhos-123
___ 04:00PM BLOOD Calcium-8.8 Phos-4.5 Mg-2.5
___ 06:01AM BLOOD T3-128
___ 06:14AM BLOOD T4-5.8
___ 06:14AM BLOOD TSH-5.2*
___ 06:14AM BLOOD Cortsol-30.1*
Brief Hospital Course:
___ with history of lymphoma s/p radiation brought in by EMS s/p
fall from standing with chest pain found to have inferolateral
STEMI, s/p cardiac catheterization ___ with DESx2 to RCA
(likely culprit lesion) and DESx1 to LCx, with subsequent
allergic reaction likely to Prasugrel.
ACTIVE DIAGNOSES
# STEMI: ___ be related to radiation induced coronary disease
given patient's age and lack of any cardiac risk factors.
Checked lipid panel and HgbA1c to risk stratify. Cholesterol
high at 302 and LDL 191. HgbA1c was 5.6%.
Cardiac cath on arrival revealed ulcerated lesion in LCx and
ostial chronic RCA lesion. The LCx was treated with DES but due
to continued hemodynamic instability the RCA treated with DES
x2. IABP was placed and levophed weaned prior to arrival in
unit. Proper balloon placement was confirmed by CXR. Lactate
was rechecked later on ___, decreased from 3.4 to 2.0. Trops
and CKMB were elevated after cath and PCI but downtrended.
Pt was started on ASA 325mg, prasugrel 10mg daily and Integrilin
gtt 2mcg/kg/min x 18hrs. Heparin gtt was started since IABP was
in place. Heparin gtt was started without bolus and at half
normal rate since multiple antiplatelets were on board, goal PTT
50-60. Betablocker and ACEI were held ___ HoTN. Atorvastatin
80mg daily given.
TTE was checked post-procedurally which showed inferior and
infero-lateral wall motion abnormalities with overall mildly
depressed global systolic function. Normal right ventricular
size with mild depressed systolic function. Mild mitral
regurgitation. Given hemodynamic improvement IABP and heparin
were d/c'd. Continued to have exertional SOB/orthopnea so echo
repeated on ___ w/ similar findings except new mild pulm artery
HTN. Low dose beta blocker started for cardioprotection and rate
control from sinus tach (see below). Allergic reaction (see
below) was felt to be ___ Prasugrel. He was switched to
Clopidogrel but rash was not improving so he was switched to
Ticagrelor (In the future, if needed, Ticlopidine would be
another option but there is a chance of cross reactivity). He
was started on low dose lisinopril and SL nitro prn. He was also
referred to cardiac rehab.
# Persistent mild hypotension/sinus tachycardia: Was
persistently with SBPs ___ and HRS 110s-120s, intermittently
febrile. Warm, perfusing. Was not felt to be cardiogenic.
Extensive infectious, endocrinologic workup as well as negative
PE scan. Was felt to most likely be related to his drug allergic
reaction (see below). At discharge his BPs were ___, HR
___.
# SOB: Dyspnea was present at completion of catheterization/PCI
and persisted upon admission to CCU. Continued through much of
his hospitalization but resolved before discharge. Most likely
related to systolic dysfunction/volume overload, with on/off
orthopnea and dyspnea on exertion. CXR's with waxing/waning mild
pulmonary edema. Pulmonary consult was obtained, who felt it was
not consistent with allergic pneumonitis or bronchospasm. Had a
negative PE-CT. Improved with intermittent low-dose IV lasix
boluses. Resolved at discharge. It could be that because of his
prior chest radiation his lymphatics have difficulty clearing
interstitial/alveolar fluid.
# Allergic reaction: Likely from Prasugrel and/or Plavix.
Manifested with persistent mild hypotension/sinus tachycardia,
diffuse pruritic morbilliform papules and dusky macules in the
groin areas. He also had some mild blurry vision and rising LFTs
and eosinophilia. Dermatology was consulted: biopsy consistent
with drug hypersensitivity without SJS. Allergy was consulted
and felt there was concern for DRESS (though time to onset of <2
weeks was not classic) but his kidney/pulmonary function were
not impaired so steroids were not started (were hesitant to
start steroids anyway after STEMI unless absolutely necessary).
Ophthalmology was consulted and they did not see any evidence of
ocular SJS, only dry eyes. They recommended artificial tears.
Dermatology recommended clobetasol and hydrolated petrolatum. He
also discharged on clobetasol, benadryl, fexofenadine, and
camphor-menthol. At discharge his symptoms were improved.
# Low TSH: Subclinical. T4/T3 nml. Did have multinodular goiter
incidentally seen on CT chest. This should be followed up as
his prior chest radiation puts him at risk for thyroid cancer.
CHRONIC DIAGNOSES
# Lymphoma: Inactive. S/p treatment ___ yrs ago at ___.
TRANSITIONAL ISSUES
- He will follow up with cardiology here
- He will follow up with allergy in 1 week
- He was referred to cardiac rehab
- He should not be started on steroids without first speaking
with a cardiologist.
- Multinodular goiter needs evaluation: he is at risk for
thyroid cancer
- He did not have any hypothyroid symptoms but his low TSH
should be followed to see if his subclinical hypothyroidism
becomes clinical.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *aspirin 325 mg one tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
2. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
3. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Metoprolol Succinate XL 37.5 mg PO DAILY
RX *metoprolol succinate 25 mg 1.5 tablet extended release 24
hr(s) by mouth daily Disp #*45 Tablet Refills:*2
5. Sarna Lotion 1 Appl TP BID:PRN rash
RX *camphor-menthol [Anti-Itch (menthol/camphor)] 0.5 %-0.5 %
apply to rash as needed Disp #*1 Bottle Refills:*0
6. Nitroglycerin SL 0.4 mg SL PRN chest pain
7. Outpatient Lab Work
Please check Chem-7, LFT's and CBC with diff with results to Dr.
___ at ___. at ___
ICD-9:
8. TiCAGRELOR 90 mg PO BID
RX *ticagrelor [Brilinta] 90 mg one tablet(s) by mouth twice a
day Disp #*30 Tablet Refills:*2
9. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN eye
redness/itching
10. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
11. DiphenhydrAMINE 50 mg PO Q6H:PRN itching
12. Fexofenadine 180 mg PO BID
RX *fexofenadine 180 mg one tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
ST elevation myocardial infarction
Acute systolic heart failure
Allergic rash
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 at ___.
You were admitted with chest pain and a heart attack. A cardiac
catheterization showed blockages in your right coronary artery
and left circumflex artery and drug eluting stents were used to
open the artery and keep them open. You will need to take
aspirin and clopidogrel (plavix) every day without fail for at
least one year and possibly longer to prevent the stents from
clotting off and causing another heart attack. Do not stop
taking aspirin and clopidogrel or miss any doses unless Dr.
___ that it is OK to do so.
Your heart is weaker after the heart attack but the muscle will
likely recover somewhat over time. It is important to take all
your medicines to help the muscle recover as much as possible.
Talk to Dr. ___ you are not tolerating some of your
medicines.
Because your heart is weaker, you may retain fluid. Weigh
yourself every morning before breakfast and record the weight.
Call Dr. ___ your weight increases more than 3 pounds in 1
day or 5 pounds in 3 days. You also have to follow a low sodium
diet. Information about this has been given to you.
You had a rash that we think was from one of your medicines,
clopidogrel and prasugrel and we treated the symptoms with
benedryl, famotidinem, ranitidine and creams. Please write down
these medicines and never take them again.
Followup Instructions:
___
|
10779159-DS-14
| 10,779,159 | 22,684,840 |
DS
| 14 |
2180-09-26 00:00:00
|
2180-09-26 19:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Vicodin
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
paracentesis
History of Present Illness:
___ yo G5P4 with h/o roux-en-Y gastric bypass and h/o SBO
requiring reoperation now s/p IVF embryo transfer on ___ who
presents as a transfer from ___ with
?ectopic pregnancy. Of note, patient was previously transferred
from ___ on ___ for abdominal pain in the setting of
early pregnancy. At that time she underwent pelvic ultrasound
and
MRI showing twin intrauterine gestation, ovarian
hyperstimulation syndrome, and no bowel pathology. She was
discharged home with PO acetaminophen and rest.
Prior to her previous presentation on ___, she had undergone an
uncomplicated embryo transfer at ___ on ___.
She had a positive pregnancy test. She was feeling well until
___ when she started feeling unwell. On ___ night
___ she began to feel somewhat bloated with generalized
abdominal pain. Mild nausea, no vomiting. She was passing gas
and having
BMs. Denied cramping or vaginal bleeding. She presented to
___. Given her extensive surgical history and need
for GI evaluation with MRI, she was transferred to ___. She
underwent MRI, which showed no bowel pathology and findings
consistent with OHSS.
She was discharged home where she has been taking acetaminophen
and ibuprofen without being able to control her pain. She
reports diffuse abdominal tenderness and bloating. She has mild
nausea, no emesis. She can eat, but states her appetite is
decreased. No bowel movement for 5 days, but is passing flatus.
Denies fevers, chills, CP, SOB, vaginal bleeding, calf pain. She
has received IV morphine x 2 in the ED with some improvement in
her pain.
Past Medical History:
PMH: obesity, anemia
PSH: Roux-en-Y gastric bypass, c/s x 1, bilateral tubal
ligation, abdominoplasty
POBHx: SVD x 3, c/s x 1
PGynhx: infertility ___ tubal ligation. Denies STIs. Denies abnl
Paps.
Social History:
Lives with her three children. Denies tobacco, alcohol, drugs.
Originally from ___.
___:
Admission Physical Exam:
VS: 98.2 69 118/50 18 100% RA
___: Comfortable, well-appearing
CV: RRR
Lungs: CTAB
Abdomen: Well healed vertical midline scar and abdominoplasty
scar. Mildly distended, mildly tender diffusely, no point
tenderness, no rebound or guarding.
Ext: nontender, no edema
Discharge physical exam
Vitals: VSS
Gen: NAD, A&O x 3
CV: RRR
Resp: no acute respiratory distress
Abd: soft, appropriately tender, no rebound/guarding, incision
c/d/i
Ext: no TTP
Pertinent Results:
___ 09:30AM GLUCOSE-74 UREA N-4* CREAT-0.4 SODIUM-133
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-22 ANION GAP-11
___ 09:30AM CALCIUM-8.7 PHOSPHATE-2.9 MAGNESIUM-1.7
___ 09:30AM WBC-8.7 RBC-3.88* HGB-7.4* HCT-24.8* MCV-64*
MCH-19.2* MCHC-30.0* RDW-16.9*
___ 09:30AM PLT COUNT-360
___ 06:00AM GLUCOSE-68* UREA N-3* CREAT-0.5 SODIUM-136
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-21* ANION GAP-12
___ 06:00AM ALT(SGPT)-30 AST(SGOT)-52*
___ 06:00AM ALBUMIN-3.3* CALCIUM-8.6 PHOSPHATE-3.1
MAGNESIUM-1.7
___ 06:00AM WBC-9.3 RBC-3.99* HGB-7.6* HCT-25.7* MCV-64*
MCH-19.0* MCHC-29.6* RDW-16.9*
___ 06:00AM PLT COUNT-352
___ 06:00AM ___ PTT-26.0 ___
___ 06:00AM ___
___ 12:00AM URINE UCG-POSITIVE
___ 12:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:45PM GLUCOSE-77 UREA N-4* CREAT-0.4 SODIUM-134
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-17* ANION GAP-14
___ 09:45PM ALT(SGPT)-29 AST(SGOT)-53* ALK PHOS-130* TOT
BILI-0.2
___ 09:45PM ALBUMIN-3.2*
___ 09:45PM ___ 09:45PM WBC-10.0 RBC-3.75* HGB-7.3* HCT-24.5* MCV-65*
MCH-19.4* MCHC-29.8* RDW-16.9*
___ 09:45PM NEUTS-73.4* ___ MONOS-4.3 EOS-0.9
BASOS-0.3
___ 09:45PM PLT COUNT-321
IMAGING:
PELVIC ULTRASOUND ___:
FINDINGS: 2 intrauterine gestational sacs are seen, with mean
sac
diameters corresponding to 6 weeks 1 day and 5 weeks 6 days,
which corresponds satisfactorily with the menstrual dates of 6
weeks 1 days. The uterus is normal. The ovaries are enlarged,
with multiple follicles, consistent with ovarian
hyperstimulation. A moderate to large amount of pelvic free
fluid
is increased compared to ___.
IMPRESSION: 1. 2 intrauterine gestational sacs, with size =
dates. No evidence of ectopic pregnancy.
2. Enlarged ovaries with multiple follicles, consistent with
ovarian hyperstimulation. 3. Mildly increased pelvic free fluid.
MRI ABDOMEN ___:
1. No evidence of small bowel obstruction.
2. Enlarged ovaries with multiple follicles and small amount of
ascites, consistent with ovarian hyperstimulation.
3. Two gestational sacs seen with in the right and left
endometrial canal.
4. Fluid within the endometrial canal and surrounding decidual
reaction, likely related to recent implantation.
PELVIC ULTRASOUND ___: The uterus is enlarged anteverted and
measures 11.3 x 6.9 x 7.3 cm cm. The bilateral ovaries are
enlarged containing multiple follicles measuring 7.1 x
6.9 x 4.6 on the right and 8.6 x 4.3 x 7.1 cm on the left.
Normal arterial and venous waveforms are present within the
bilateral ovaries. There is moderate volume pelvic free fluid.
Two gestational sacs are seen in the right and left endometrium
measure 6 and 5 mm respectively. There is a large amount
of anechoic appearing fluid within the endometrial cavity. .
IMPRESSION: 1. Enlarged ovaries containing multiple follicles as
well as moderate volume pelvic free fluid, consistent with
ovarian hyperstimulation.
2. Two gestational sacs seen in the right and left endometrial
canal.
3. Endometrial fluid likely related to recent implantation.
Brief Hospital Course:
On ___, Ms. ___ was admitted to ___ service after
presenting with abdominal pain concerning for OHSS. Her pain was
controlled with IV dilaudid, PO tylenol and oxycodone. She was
put on a bowel regimen as she had not had a bowel movement in 5
days and had a bowel movement.
On ___ after consulting with interventional radiology,
patient had a paracentesis. 1500 cc of fluid was drained. Her
pain improved after the paracentesis.
She was noted to have anemia and started on iron. Her hct
remained stable at around ___ at time of discharge.
By HD# 1, she was tolerating a regular diet, ambulating
independently, and pain was controlled with oral medications.
She was then discharged home in stable condition with outpatient
follow-up scheduled.
Medications on Admission:
PNV
Discharge Medications:
1. Prenatal Vitamins 1 TAB PO DAILY
2. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*1
3. Acetaminophen ___ mg PO Q6H:PRN pain
do not exceed 4g in 24 hrs
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*50 Tablet Refills:*1
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*50 Tablet Refills:*1
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
may cause drowsiness. take with stool softener
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
ovarian hyperstimulation syndrome
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 presenting with
symptoms concering for ovarian hyperstimulation syndrome. You
had a paracentesis done. You have recovered well 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.
___ instructions:
* Take your medications as prescribed.
* 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.
* You may eat a regular diet.
* You may walk up and down stairs.
Call your doctor for:
* fever > 100.4F
* 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
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No tub baths for 6 weeks.
* If you have steri-strips, leave them on. They will fall off on
their own or be removed during your followup visit.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
10779244-DS-21
| 10,779,244 | 22,516,615 |
DS
| 21 |
2171-07-26 00:00:00
|
2171-07-27 20:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with h/o depression, anxiety, psoriasis, HTN,
HLD, and T2DM on Metformin presented to the ED with c/o
abdominal
pain, nausea and vomiting. She reports that the abdominal pain
started on ___. The pain was initially described as intense
pressure, in the epigastric area, radiated to the sides and
back,
was intermittent, improved with Ibuprofen and had no clear
association with food however she notes she has not had much of
an appetite. She also reports associated nausea and non-bloody
vomiting. The pain became progressively more constant so she
went
to urgent care and referred to the ED for further evaluation.
She
denies any fever, SOB, diarrhea, BRBPR, dysuria or polyuria.
Past Medical History:
PMH/PSH:
T2DM
Depression
Anxiety
Psoriasis
Hypertension
Hyperlipidemia
Social History:
___
Family History:
no FH of diabetes
Physical Exam:
VS: reviewed
GEN: Appearing mildly anxious, no acute distress
HEENT: Oropharynx dry
NECK: Supple, no JVD
CV: Tachycardic, regular rhythm, no m/r/g
RESP: Left decreased breath sounds at base, L>Right mid to lower
posterior field crackles, otherwise no wheezes or rhonchi
GI: Soft, no ttp, no distension, no guarding or rebound
SKIN: warm, well perfused
NEURO: AOX3, ___ upper and lower extremity muscle strength
PSYCH: Anxious, affect and mood congruent
Pertinent Results:
Admission labs:
___ 12:15PM WBC-16.1* RBC-3.89* HGB-11.1* HCT-32.6*
MCV-84 MCH-28.5 MCHC-34.0 RDW-13.9 RDWSD-42.5
___ 12:15PM LIPASE-48
___ 12:15PM ALT(SGPT)-5 AST(SGOT)-5 ALK PHOS-72 TOT
BILI-0.2
___ 12:15PM LIPASE-48
___ 03:17PM GLUCOSE-293* UREA N-4* CREAT-0.6 SODIUM-134*
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-12* ANION GAP-22*
___ 05:30PM Beta-OH-4.9*
Call out labs:
___ 08:55PM GLUCOSE-186* UREA N-2* CREAT-0.4 SODIUM-132*
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-20* ANION GAP-12
___ 09:07PM LACTATE-0.8
___ 09:07PM ___ PO2-33* PCO2-39 PH-7.37 TOTAL CO2-23
BASE XS--3
___ 08:55PM Beta-OH-0.9*
HIDA scan:
IMPRESSION: Normal hepatobiliary scan.
CXR:
IMPRESSION:
PICC line terminating in the superior vena cava. Persistent
interstitial
pulmonary edema. Minor suspected left basilar atelectasis.
Brief Hospital Course:
Summary:
___ h/o depression, anxiety, psoriasis, HTN, HLD, and T2DM on
metformin p/w 2 days of abdominal pain, nausea and vomiting as
well as resp failure. Workup revealed leukocytosis,
hyperglycemia, metabolic acidosis with ketonuria and an anion
gap and cxr showed opacities concerning for CAP. Started on
insulin drip and IVF. Anion gap resolved. Treated for CAP.
Developed mild pulm edema and dyspnea after fluids which
improved.
ISSUES
===============
# T2DM
# AG metabolic acidosis
# Diabetic ketoacidosis
Patient initially with hyperglycemia, metabolic acidosis with
ketonuria and an anion gap. Initially thought to be from
cholecystitis, but abd pain resolved, HIDA neg, ACS signed
off. Received IVF, insulin drip and anion gap closed, elevated
BOH resolved wnl.
# Hypoxic respiratory failure
# Multifocal PNA vs pneumonitis
While in ED, patient noted to be increasingly tachypneic and
hypoxic requiring 4L NC. CTA chest notable for multifocal
bilateral ground-glass and nodular opacities with associated
bronchial wall thickening c/f possible pneumonia. Patient was
vomiting so may have had aspiration. No underlying lung
disease.
Patient with increased O2 requirement overnight ___, cardiac
workup with EKG and trops neg. Repeat CXR showed pulm edema,
likely ___ large fluid bolus tx for dka. No fever, sputum, CAP
less likely than pulm edema due to fluid overload with possible
mild diastolic dysfunction. Treated for CAP with abx x5days (CTX
and Axithro). IVF d/c'd. TTE to workup pulm edema/possible
diastolic dysfunction. Referred to sleep clinic as patient has
signs/sx of OSA.
# Abdominal pain
Patient presented with RUQ pain in setting of dieting, initially
concerning for cholecystitis.
RUQ u/s shows echogenic liver c/w steatosis and cholelithasis
w/o
sonographic evidence of suggest cholecystitis. In ED, surgery
evaluated patient, can not rule out acute cholecystitis but DKA
complicates clinical assessment as abdominal pain and nausea
could be secondary to this. HIDA was negative. Abd pain
resolved. ACS signed off. Rec outpatient f/u with Dr. ___
___
possible elective chole.
# Anxiety/Depression- Continued celexa and Wellbutrin. EKG for
Qtc monitoring (esp if she continues getting Zofran. Ativan prn
nausea and anxiety while in ICU.
CHRONIC ISSUES
===============
# HTN
# HLD
- Holding Lisinopril for now
- Holding metoprolol for now
- Holding simavastatin, fishoil, fenofibrate for now
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion 250 mg PO QAM
2. Citalopram 40 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Simvastatin 10 mg PO QPM
7. Multivitamins 1 TAB PO DAILY
8. flaxseed oil 1,000 mg oral DAILY
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Melatin (melatonin) 3 mg oral qHS
11. BuPROPion (Sustained Release) 150 mg PO QPM
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Fenofibrate 145 mg PO DAILY
3. Glargine 16 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR
Up to 10 Units QID per sliding scale Disp #*6 Syringe Refills:*0
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. BuPROPion (Sustained Release) 150 mg PO QPM
6. BuPROPion 250 mg PO QAM
7. Citalopram 40 mg PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. flaxseed oil 1,000 mg oral DAILY
10. Lisinopril 20 mg PO DAILY
11. Melatin (melatonin) 3 mg oral qHS
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
-----------------
DKA
CAP
Hypertriglyceridemia
SECONDARY DIAGNOSIS
-------------------
Hypertension
Hyperlipidemia
Anxiety/Depression
Discharge Condition:
Stable
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did I come to the hospital?
- You were admitted to the ICU at ___ because you
developed a condition cause Diabetic Ketoacidosis. This occurs
when your blood sugar is high. You also had shortness of breath
that is likely from a pneumonia.
What happened while I was in the hospital?
When you arrived at the hospital your blood sugar and
triglyceride levels were very high. You were given insulin to
bring these both down. You were also given fenofibrate, another
medication to control your triglyceride levels. You had
shortness of breath and were given oxygen as well as antibiotics
for potential pneumonia. Scans of your stomach showed some
gallstones, which may have contributed to your pain. You were
continued on your home medications for anxiety and depression
What should I do once I leave the hospital?
- Take your medications as prescribed and follow up with your
doctor appointments as listed below.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10779248-DS-3
| 10,779,248 | 20,097,280 |
DS
| 3 |
2143-08-26 00:00:00
|
2143-08-27 04:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered Mental Status, Facial Droop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ RH male with history of HTN and HLD who
presents after an episode of altered mental status followed by
left facial droop.
Patient was in his usual state of health until approximately 2
weeks prior to presentation when he received a glucocorticoid
injection in his back as treatment for chronic back pain. Since
then patient has felt general malaise and has noted weight gain
in a Cushingoid distribution as well as intermittent headaches.
More recently he had developed a throat infection that was being
treated first with Amoxicillin, then with Azithromycin and
finally with Augmentin.
On the day of presentation he was eating at a restaurant/bar
that
he frequents when he had a change in cognition, becoming
progressively more difficult to engage. The time from symptom
start to peak was approximately one minute. This lasted
approximately 2 minutes during which the patient sat upright
with
his eye open. The bartender called EMS as well as the patient's
son. Upon EMS arrival patient had become much more responsive
and
did not want to be brought to the hospital; however his friends
and son insisted. Of note, after the patient became more
responsive, his son noted a left facial droop that lasted
approximately 45 minutes.
Upon arrival to the ED, Mr. ___ was nearly back to
baseline.
Head/Neck CT/CTA was performed and showed a completely occluded
right vertebral artery from its origin to the C3/4 level. No
intracranial abnormality was found.
On ROS Mr. ___ denies neck pain, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Hypertension
Hyperlipidemia
Traumatic Brain Injury and Subdural Hematoma
Social History:
___
Family History:
No family history of seizures, learning disabilities,
developmental delay, stroke or any other neurologic problem
Physical Exam:
Admission Physical Exam:
T98.4 HR: 86 BP: 165/92 Resp: 14 SpO2: 100%
General: Awake, cooperative, NAD.
HEENT: NCAT, no scleral icterus noted, MMM
Neck: Supple, No nuchal rigidity
Pulmonary: nl WOB, lungs CTAB
Cardiac: normal rate, regular rhythm, no murmur
Abdomen: non-distended, soft, non-tender
Extremities: warm and well-perfused
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert and oriented to ___
Month Day. ___ registration and recall. able to say ___
backwards
but with some difficulty, names high and low frequency objects.
follows commands briskly. intact repetition.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezius and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk and tone No pronator drift bilaterally.
No adventitious tremor noted
Delt Bic Tri WrE FE IO IP Quad Ham TA ___
L 5 ___ 4+ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-Sensory: No deficits to light touch throughout. No extinction
to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor or dysmetria FNF
-Gait: Good initiation. Narrow-based, normal stride and arm
swing.
=
=
=
=
=
================================================================
Discharge Physical Examination:
no significant changes from admission exam
Pertinent Results:
___ 07:25PM PTT-59.0*
___ 01:30PM CHOLEST-263*
___ 01:30PM %HbA1c-5.6 eAG-114
___ 01:30PM TRIGLYCER-109 HDL CHOL-104 CHOL/HDL-2.5
LDL(CALC)-137*
___ 01:30PM PTT-53.5*
___ 08:50PM GLUCOSE-92 UREA N-13 CREAT-0.9 SODIUM-143
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-28 ANION GAP-17
___ 08:50PM estGFR-Using this
___ 08:50PM cTropnT-<0.01
___ 08:50PM proBNP-375*
___ 08:50PM WBC-4.9 RBC-3.53* HGB-11.9* HCT-35.9*
MCV-102* MCH-33.8* MCHC-33.2 RDW-14.0
___ 08:50PM NEUTS-59.7 ___ MONOS-6.3 EOS-1.4
BASOS-0.5
___ 08:50PM ___ PTT-29.0 ___
___ 08:50PM PLT COUNT-254
___ 08:40PM URINE HOURS-RANDOM
___ 08:40PM URINE HOURS-RANDOM
___ 08:40PM URINE UHOLD-HOLD
___ 08:40PM URINE GR HOLD-HOLD
___ 08:40PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:40PM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 08:40PM URINE HYALINE-5*
___ 08:40PM URINE MUCOUS-RARE
Echocardiogram (___) IMPRESSION: No LV thrombus, PFO or ASD.
Normal global and regional biventricular systolic function.
MRI Brain (___) IMPRESSION:
No acute infarct mass effect or hydrocephalus. Mild brain
atrophy and small vessel disease.
EEG (___) IMPRESSION:
This is a normal routine EEG in the awake and asleep states. No
focal or epileptiform features were seen. Frequent episodes of
leg jerks were not associated with any significant EEG change.
CTA Head Neck (___) IMPRESSION:
Occlusion of the right vertebral artery from its origin to the
level of
C3/4. Contrast is seen in a diminutive right vertebral artery
superior to C3/4 from retrograde filling from the left vertebral
artery. Intracranial vessels remain opacified.
Brief Hospital Course:
Patient was admitted after episode of altered mental status and
possible left facial droop. Evaluation in the ED revealed
complete occlusion of the right vertebral artery, which raised
concern for embolic TIAs in the posterior circulation at an
etiology of the patient's complaints. The patient was therefore
started on Heparin gtt. MRI after admission showed no acute
strokes and Heparin gtt was discontinued. Transthoracic
echocardiogram was performed to assess the possibility of
cardioembolic TIA. No intracardiac thrombus or valve pathology
was identified. Also in the differential was seizure. Thus, EEG
was performed. This study was normal as well. Another
possibility is that he had a presyncopal event (although this
would not explain the left facial droop witnessed by his son).
Atorvastatin was increased to 40mg daily given elevated LDL 137.
Aspirin 81mg daily was added to his medical regimen and should
be continued going forward. Clopidogrel 75mg was added to his
medical regimen, but can be discontinued in 2 months if the
patient remains stable. Hemoglobin A1c was within normal range
at 5.6%
Medications on Admission:
Losartan 100mg daily
Atorvastatin 20mg daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*5
2. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
4. Losartan Potassium 100 mg PO DAILY
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN moderate to
severe pain
Discharge Disposition:
Home
Discharge Diagnosis:
Transient Ischemic Attack
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of altered mental status
and a possible facial droop that may have resulted from a
TRANSIENT ISCHEMIC ATTACK (TIA), a condition in which a blood
vessel providing oxygen and nutrients to the brain is briefly
blocked by a clot. It is also possible however that your
symptoms were due to PRE-SYNCOPE, a condition in which blood
supply to the brain becomes globally decreased. This can happen
for a variety of reasons. The brain is the part of your body
that controls and directs all the other parts of your body, so
decreased blood supply to the brain can result in a variety of
symptoms.
TIA can have many different causes, so we assessed you for
medical conditions that might raise your risk of having a TIA.
This is important because TIAs can be a harbinger of a Stroke,
in which permanent damage to the brain occurs. In order to
prevent future TIAs/strokes, we plan to modify those risk
factors.
Your risk factors are:
High Blood Pressure
High Cholesterol
To prevent PRE-SYNCOPAL episodes in the future. Please maintain
adequate hydration and try not to over-exert yourself
We are changing your medications as follows:
NEW
Clopidogrel 75mg daily, to reduce the risk of future
TIAs/Strokes this will be discontinued after 2 months
Aspirin 81mg daily, to reduce the risk of future TIAs/Strokes
INCREASED
Atorvastatin 40mg daily, to reduce the risk of future
TIAs/Strokes
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
10779535-DS-7
| 10,779,535 | 28,807,232 |
DS
| 7 |
2163-09-20 00:00:00
|
2163-09-20 22:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / iodinated IV dye / fenofibrate / Sulfa
(Sulfonamide Antibiotics) / contrast dye / shellfish derived
Attending: ___
Chief Complaint:
Lower extremity edema, left lower extremity cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx decompensated cirrhosis (child ___ B; decompensated with
portal hypertension, bleeding from esophageal varices status
post banding, hepatic encephalopathy and volume overload), HTN,
HLD, CAD, T2DM, BPH, migraine, depression who presents with LLE
pain, redness, and swelling. He was seen in liver clinic today,
where he was thought to be volume overloaded with bilateral
lower extremity edema, with skin breakdown LLE. Per hepatology
note, sent to ED for admission and tx for cellulitis, and
diuresis with Lasix/albumin.
Today reports 3 weeks of worsening leg edema, skin blisters LLE,
warmth. No fevers or chills. Reports he gets chest discomfort
and dyspnea while walking > 1 block, which is stable over
months. No abd pain, nausea, vomiting, diarrhea. Worsening ___
edema; per hepatology notes, there may be some dietary
indiscretion when his wife cooks. Notes he takes baths with
water immersion of his feet.
In the ED, initial VS were: 98.2 78 127/45 18 96% RA
Exam notable for: ___ with 2+ edema to knees bilat; LLE with
? cellulitis vs stasis dermatitis. Labs showed: Lactate:2.0,
WBC 7.8, Cr 1.2 Imaging showed: CXR with No consolidation, RUQ
US: Patent hepatic vasculature. No focal lesions, within the
limits of the examination.
Consults: hepatology
Patient received: 1gm Vancomycin IV
Transfer VS were: 98.8 67 140/65 14 98% RA
On arrival to the floor, patient reports no complaints aside
from discomfort in his left lower extremity when putting weight
on the leg.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI, also with intermittent diarrhea over the last few
months
Past Medical History:
1. Significant coronary artery disease.
2. Hypertension.
3. Recurrent seizures.
4. COPD.
5. Cervical epidural steroid injection.
6. Cataracts.
7. Status post malignant colonic polyp removal.
8. Alcohol abuse.
9. Diabetes.
10. BPH.
11. Anxiety, depression.
12. Migraines.
13. Hypercholesterolemia.
14. ALLERGIES: Penicillins / iodinated IV dye / fenofibrate /
Sulfa
(Sulfonamide Antibiotics) / contrast dye / shellfish derived
Social History:
___
Family History:
He has multiple family members with alcoholism. His brother is
alcoholic. His another brother died from alcoholic cirrhosis.
He has siblings who live in ___ in ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
================================
VS: 98.4PO 137/67 71 18 97 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: mildly distended, nontender in all quadrants
EXTREMITIES: 3+ pitting edema bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose. No
asterixis
SKIN: warm and well perfused. Numerous small, round lesions in
the right lower extremity with minimal drainage. No purulence,
no induration. With surrounding area of erythema, warmth and
tenderness on the calf, outlined with skin marker
DISCHARGE PHYSICAL EXAM:
================================
VS: 98.1 134/75 59 18 98 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
NECK: supple, no LAD, no JVD but +HJR
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: softly distended, RUQ tenderness to deep palpation
otherwise non tender, skin with scattered brown macules
EXTREMITIES: trace pitting edema bilaterally to the knees,
+outlined erythema on the left shin with scattered blisters,
right shin also with darkening
NEURO: A&Ox3, moving all 4 extremities with purpose. No
asterixis
Pertinent Results:
ADMISSION LABS:
=====================
___ 07:55PM BLOOD WBC-7.8 RBC-4.13* Hgb-13.3* Hct-40.6
MCV-98 MCH-32.2* MCHC-32.8 RDW-12.5 RDWSD-44.7 Plt ___
___ 07:55PM BLOOD Neuts-64.8 ___ Monos-9.7 Eos-3.6
Baso-1.0 Im ___ AbsNeut-5.03 AbsLymp-1.60 AbsMono-0.75
AbsEos-0.28 AbsBaso-0.08
___ 07:55PM BLOOD ___ PTT-31.0 ___
___ 07:55PM BLOOD Glucose-209* UreaN-13 Creat-1.2 Na-139
K-4.5 Cl-101 HCO3-25 AnGap-13
___ 07:55PM BLOOD ALT-29 AST-35 AlkPhos-105 TotBili-1.3
___ 06:33AM BLOOD Calcium-9.3 Phos-3.0 Mg-1.9
___ 07:55PM BLOOD Albumin-3.9
___ 07:23AM BLOOD %HbA1c-7.8* eAG-177*
___ 08:08PM BLOOD Lactate-2.0
DISCHARGE LABS:
=====================
___ 06:54AM BLOOD WBC-8.1 RBC-4.08* Hgb-13.1* Hct-39.0*
MCV-96 MCH-32.1* MCHC-33.6 RDW-12.0 RDWSD-42.0 Plt ___
___ 06:54AM BLOOD ___ PTT-31.6 ___
___ 06:54AM BLOOD Glucose-219* UreaN-15 Creat-1.1 Na-138
K-4.4 Cl-98 HCO3-27 AnGap-13
___ 06:54AM BLOOD ALT-24 AST-28 LD(LDH)-260* AlkPhos-87
TotBili-2.3* DirBili-0.5* IndBili-1.8
___ 06:54AM BLOOD Albumin-3.7 Calcium-9.7 Phos-2.9 Mg-1.8
MICROBIOLOGY:
======================
___ Blood Cx - NGTD, pending
IMAGING:
======================
___ ABDOMINAL U/S:
Patent hepatic vasculature. No focal lesions, within the limits
of the examination.
___ CXR:
There is no consolidation. There are no pleural effusions. The
heart is normal in size. The aorta is atherosclerotic. The
trachea is midline. The visualized osseous structures are
unremarkable.
Brief Hospital Course:
SUMMARY:
================
___ hx decompensated cirrhosis (child ___ B; decompensated with
portal hypertension, bleeding from esophageal varices status
post banding, hepatic encephalopathy and volume overload
presenting with LLE pain, swelling and redness concerning for
cellulitis.
ACTIVE ISSUES:
================
# LLE SWELLING and
# ?CELLULITIS:
Patient p/w worsening LLE pain, swelling, and redness with
blistering. He was given 40mg IV Lasix for two days in addition
to his spironolactone, and then transitioned back to his home
dose of Lasix 40mg qd with an increase in his spironolactone
from 50mg to 100mg daily. His exam was concerning for possible
cellulitis with MRSA involvement (history of MRSA skin
infections) given that pt had some weeping blisters and has had
MRSA skin infections in the past. However, he also has
chronic-looking skin changes that may indicate underlying venous
stasis changes. He was treated with vancomycin in-house, to
improvement of his erythema. He was continued on doxycycline BID
for a total of a 7-day course of antimicrobial therapy. His
final day of therapy will be ___.
# ETOH CIRRHOSIS:
Child's ___ B, complicated by bleeding varices, hepatic
encephalopathy, and volume overload. Possibly due to dietary
indiscretion at home (Pt has his wife's family cooking for them
oftentimes, and it is generally salty food). Nutrition consulted
and provided recommendations for low salt intake. His edema
improved after 2 doses of active diuresis with 40mg IV
furosemide + albumin. He was transitioned to an oral diuretic
regimen of 40mg furosemide/100mg spironolactone (increased from
50mg spironolactone that he had previously been on).
- Continued on home propranolol for variceal bleed PPx
- Continued on home HE regimen
# DIARRHEA:
Pt with some complaints of on and off diarrhea for several
months. It was not bothersome during his hospital stay, so a C.
diff was not checked.
CHRONIC/STABLE ISSUES:
===========================
# CORONARY ARTERY DISEASE:
- Home antihypertensives as below
- Consider starting a statin as outpatient (has possibly not
been on it due to cirrhosis, but if he has not had adverse
reactions likely could tolerate a low to moderate intensity
statin).
# HISTORY OF DIABETES:
- Followed by ___ Associates
- ___ = 7.8
- D/c on home insulin regimen, no changes made:
U-500 insulin sliding scale (no standing insulin)
Pre-meal blood sugar, units
(B = breakfast, D = dinner)
< 70 - B 0, D 0
< 80 - B 20, D 15
< 90 - B 30, D 25
< 100 - B 40, D 35
100-150 - B 65, D 50
151-200 - B 70, D 55
201-250 - B 75, D 60
251-300 - B 80, D 65
301-350 - B 85, D 70
351-400 - B 90, D 75
401-450 - B 95, D 80
> 450 - B 100, D 85
# HYPERTENSION:
- Home enalapril and imdur
# SEIZURE DISORDER:
- Home lamotrigine
# COPD:
- Home Prozac and aricept
# ANEMIA, BASELINE:
- Home iron supplements
# GERD:
- Home pantoprazole
# BPH:
- Home oxybutynin
TRANSITIONAL ISSUES:
========================
#CODE: Full (confirmed)
#CONTACT: wife ___ ___
#DISCHARGE WEIGHT: 101.6kg
[ ] MEDICATION CHANGES:
- Added: Doxycycline (___ therapy ___
- Changed: Spironolactone (50mg -> 100mg daily)
[ ] DISCHARGE CREATININE:
- Creatinine 1.1 on ___.
[ ] FOLLOW UP LABS:
- Please obtain chem10 on ___. Please fax results to the
___ at ___, attn: Dr. ___.
[ ] LOW SODIUM DIET:
- Encouraged Pt to reduce his sodium intake to 2g daily.
- Nutrition consulted for further evaluation.
[ ] MRSA SKIN INFECTIONS:
- Pt with a reported history of multiple MRSA skin infections in
the past. Consider a decontamination regimen with chlorhexidine
baths for Pt.
[ ] DIABETES MELLITUS:
- Pt had reported some hypoglycemia while on his home regimen of
U-500. However, he felt comfortable returning on same.
- Please consider downtitrating his insulin regimen, or giving
him doses of long-acting insulin, to prevent
hyperglycemia/hypoglycemia.
[ ] CARDIAC RISK FACTORS:
- Pt is currently not taking a statin, reasons are unclear
- If tolerates, consider starting on Atorvastatin 80mg QHS
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
2. Donepezil 5 mg PO QHS
3. Enalapril Maleate 20 mg PO DAILY
4. Vitamin D ___ UNIT PO QMONTHLY
5. FLUoxetine 60 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. LamoTRIgine 75 mg PO DAILY
8. Montelukast 10 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL Q15MIN PRN chest pain
10. Oxybutynin 15 mg PO QHS
11. Pantoprazole 40 mg PO Q24H
12. Pregabalin 50 mg PO BID
13. Propranolol 10 mg PO TID
14. Spironolactone 50 mg PO DAILY
15. Cetirizine 10 mg PO DAILY
16. Ferrous Sulfate 325 mg PO BID
17. Multivitamins 1 TAB PO DAILY
18. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using U500 InsulinMax Dose Override
Reason: U500 insulin
19. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN itching
20. DiphenhydrAMINE 25 mg PO Q6H:PRN rash
21. Glucose Tab ___ TAB PO PRN hypoglycemia
22. Albuterol 0.083% Neb Soln 1 NEB IH Q4-6H sob, wheezing
23. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
24. Lidocaine 5% Ointment 1 Appl TP TID:PRN pain
25. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
26. Clotrimazole Cream 1 Appl TP BID to groin
27. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H Duration: 11 Doses
Final day of therapy through ___.
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*11 Tablet Refills:*0
2. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
3. Albuterol 0.083% Neb Soln 1 NEB IH Q4-6H sob, wheezing
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
5. Cetirizine 10 mg PO DAILY
6. Clotrimazole Cream 1 Appl TP BID to groin
7. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
8. DiphenhydrAMINE 25 mg PO Q6H:PRN rash
9. Donepezil 5 mg PO QHS
10. Enalapril Maleate 20 mg PO DAILY
11. Ferrous Sulfate 325 mg PO BID
12. FLUoxetine 60 mg PO DAILY
13. Furosemide 40 mg PO DAILY
14. Glucose Tab ___ TAB PO PRN hypoglycemia
15. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using U500 InsulinMax Dose Override
Reason: U500 insulin
16. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
17. LamoTRIgine 75 mg PO DAILY
18. Lidocaine 5% Ointment 1 Appl TP TID:PRN pain
19. Montelukast 10 mg PO DAILY
20. Multivitamins 1 TAB PO DAILY
21. Nitroglycerin SL 0.4 mg SL Q15MIN PRN chest pain
22. Oxybutynin 15 mg PO QHS
23. Pantoprazole 40 mg PO Q24H
24. Pregabalin 50 mg PO BID
25. Propranolol 10 mg PO TID
26. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
27. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN
itching
28. Vitamin D ___ UNIT PO QMONTHLY
29.Outpatient Lab Work
L03.90: Cellulitis
Please obtain chem10 on ___. Please fax results to the
___ at ___, attn: Dr. ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Left lower extremity swelling
Concern for cellulitis
SECONDARY DIAGNOSES:
History of cirrhosis, Child ___ class B; decompensated by
esophageal variceal bleeding, hepatic encephalopathy, and volume
overload
History of coronary artery disease
Hypertension
Seizure disorder
History of chronic obstructive pulmonary disease
History of diabetes
Benign prostatic hyperplasia
History of anxiety
Anemia, stable
Gastroesophageal reflux
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at the ___
___.
WHY WAS I SEEN IN THE HOSPITAL?
- You were having worsening left leg pain, redness, and
swelling.
WHAT DID WE DO WHILE YOU WERE IN THE HOSPITAL?
- We gave you water pills through the IV ("Lasix") to reduce
your swelling.
- We gave you antibiotics through the IV to treat your
infection.
- We gave you pills to complete your antibiotic course.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- Please take all your antibiotics as prescribed.
Followup Instructions:
___
|
10779535-DS-8
| 10,779,535 | 28,379,044 |
DS
| 8 |
2164-03-04 00:00:00
|
2164-03-04 17:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / iodinated IV dye / fenofibrate / Sulfa
(Sulfonamide Antibiotics) / contrast dye / shellfish derived /
cyclobenzaprine / vancomycin
Attending: ___
Chief Complaint:
left lower extremity redness and swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a h/o EtOH cirrhosis c/b
esophageal varices, undergoing serial band ligation, who
presented for outpatient EGD /colon today, referred to ED for
LLE
wounds.
EGD /colon was performed ___ without complications. 3 bands
were
placed. 2 colonic polyps removed. Also noted to have rectal
varix. While there, pt was noted to have LLE wound c/f
recurrent
cellulitis (h/o MRSA cellulitis in past) with worsening erythema
x 4 days, pain, and drainage from punctate ulcers. He says he
has had recurrent skin ulcerations and lesions for years.
He reports an injury one month ago where he injured the right
side of his chest after reaching out with an outstretched arm to
grab something. After 2 weeks of right chest wall pain, he was
evaluated at ___ locally, where he says X-Ray and
CT were normal, was diagnosed with a "sprain." He has had the
same level of pain since then. He is taking Percocet. It is
worth with movement, and located in the right lower chest and
right upper quadrant.
He denies fever, chills, chest pain, diarrhea, constipation,
dysuria, hematuria, wheezing. He reports chronic headache.
In the ED, initial VS were: 98.7, HR 75, BP 118/60, RR 18, 96%
RA
- He was given 1g IV Vanco, Omeprazole, Sucralfate, and home
meds
- RUQUS showed no ascites
On arrival to the floor, patient reports above story, no new
complaints.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
- EtOH Cirrhosis
- CAD
- HTN
- Seizures
- COPD
- Cataracts
- H/o malignant colon polyps
- DMT2
- BPH
- Anxiety, depression.
- Migraines
- HLD
Social History:
___
Family History:
He has multiple family members with alcoholism. His brother is
alcoholic. His another brother died from alcoholic cirrhosis.
He has siblings who live in ___ in ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: T 100.2, BP 122 / 64, HR 72, RR 18, 94% RA
GENERAL: NAD, chronically ill appearing, resting in bed.
Significant right chest wall pain with movement of that area.
HEENT: AT/NC, sclera mildly icteric, MMM
NECK: supple
CV: RRR
PULM: CTAB, no wheezes
GI: abdomen soft, nondistended. Mild TTP in RUQ, not rigid.
EXTREMITIES: 1+ ___ edema bilat
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric, no asterixis
DERM: LLE with warmth and erythema about ___ of the way up the
leg, scattered pustules. Demarcated the area with a pen. He
also
has multiple punctate ulcerations throughout his body surface.
DISCHARGE PHYSICAL EXAM:
=========================
VS:
24 HR Data (last updated ___ @ 1422)
Temp: 99.3 (Tm 99.3), BP: 132/66 (106-134/61-68), HR: 59
(53-59), RR: 18 (___), O2 sat: 94% (92-96), O2 delivery: Ra,
Wt: 220.68 lb/100.1 kg
GENERAL: No acute distress. Breathing comfortably on RA.
HEENT: AT/NC, sclera mildly icteric. Moist mucus membranes, JVP
~9 cm.
Heart: RRR, normal S1 and S2
Lungs: soft crackles RLL otherwise clear
Abdomen: abdomen soft, nontender to palpation, mildly distended.
Normal bowel sounds
EXTREMITIES: trace to 1+ ___ edema bilat otherwise warm and
symmetric without erythema
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric, no asterixis
Pertinent Results:
ADMISSION / PERTINENT LABS:
==============================
___ 07:58PM BLOOD WBC-10.9* RBC-4.32* Hgb-14.0 Hct-41.3
MCV-96 MCH-32.4* MCHC-33.9 RDW-11.6 RDWSD-40.7 Plt Ct-85*
___ 07:58PM BLOOD Neuts-69.6 Lymphs-15.4* Monos-11.5
Eos-2.5 Baso-0.6 Im ___ AbsNeut-7.58* AbsLymp-1.68
AbsMono-1.25* AbsEos-0.27 AbsBaso-0.06
___ 07:58PM BLOOD ___ PTT-30.1 ___
___ 07:58PM BLOOD Glucose-171* UreaN-17 Creat-1.3* Na-135
K-4.7 Cl-101 HCO3-20* AnGap-14
___ 07:58PM BLOOD ALT-21 AST-32 AlkPhos-79 TotBili-3.8*
DirBili-1.0* IndBili-2.8
___ 07:58PM BLOOD Lipase-19
___ 02:44AM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:58PM BLOOD Albumin-3.6 Calcium-9.4 Phos-2.4* Mg-1.6
___ 01:05PM BLOOD Osmolal-290
___ 08:15PM BLOOD Lactate-2.2*
DISCHARGE LABS:
=====================
___ 06:15AM BLOOD WBC-5.9 RBC-3.56* Hgb-11.6* Hct-34.6*
MCV-97 MCH-32.6* MCHC-33.5 RDW-12.9 RDWSD-45.1 Plt ___
___ 06:15AM BLOOD Glucose-216* UreaN-31* Creat-1.5* Na-138
K-5.0 Cl-102 HCO3-23 AnGap-13
___ 06:20AM BLOOD ALT-13 AST-24 LD(LDH)-199 AlkPhos-95
TotBili-1.3
___ 06:15AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.2
MICROBIOLOGY:
==================
___ 11:25 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).
___ 10:49 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
URINE STUDIES:
================
___ 10:57PM URINE Color-Yellow Appear-Clear Sp ___
___ 10:57PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-150* Ketone-TR* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 10:57PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 02:22PM URINE Hours-RANDOM UreaN-627 Creat-131 Na-33
Cl-<20
___ 01:48PM URINE Hours-RANDOM UreaN-517 Creat-95 Na-<20
TotProt-23 Prot/Cr-0.2
___ 01:48PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:48PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
IMAGING:
=============
___ Imaging LIVER OR GALLBLADDER US
IMPRESSION:
Patent main portal vein in the portal venous system with
appropriate direction of flow. Main portal is patent, but
appears to demonstrate slow flow, unclear whether this is
technical or real.
Splenomegaly.
No ascites.
___ Imaging CHEST (PA & LAT)
FINDINGS:
There is mild pulmonary vascular congestion. No focal
consolidation is seen. There is no pleural effusion or
pneumothorax. Cardiac and mediastinal silhouettes are stable.
IMPRESSION:
Mild pulmonary vascular congestion.
___HEST W/O CONTRAST
FINDINGS:
BASE OF NECK: Partially visualized thyroid is within normal
limits
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or
hilar adenopathy.
HEART AND VASCULATURE: The heart is normal size. No
pericardial effusion. Mild coronary artery disease. Mild
calcifications of the aortic valve. Mild atherosclerotic
calcifications of the thoracic aorta.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Mild dependent atelectasis. Mildly more
confluent
consolidative change at the right greater than left lung base
may represent developing pneumonia versus atelectasis. The
airways are centrally patent.
ABDOMEN: Mildly nodular liver contour consistent with history
of cirrhosis. Mild perihepatic ascitic fluid. Splenomegaly
with the spleen measuring 15.9 cm. Small hiatal hernia.
Cholelithiasis.
BONES: No rib fractures. No acute osseous process.
IMPRESSION:
1. No evidence of rib fractures.
2. Mildly more confluent consolidative change at the right
greater than left lung base are most consistent with
atelectasis..
3. Finding secondary to known cirrhosis.
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
Increased consolidation of the right lung base concerning for
pneumonia. Mild pulmonary edema.
___ Imaging CHEST (PA & LAT)
IMPRESSION:
Comparison to ___. The patient has developed mild to
moderate
pulmonary edema. In addition, there is a new parenchymal
opacity at the right lung bases, with a location highly
suggestive of aspiration. No pleural effusions. Stable
borderline size of the cardiac silhouette.
Brief Hospital Course:
Information for Outpatient Providers: ___ man with a h/o EtOH
cirrhosis c/b esophageal varices, undergoing serial band
ligation (most recent ___ and recurrent soft tissue
infections (h/o MRSA), who presented for outpatient EGD /colon
on ___, referred to ED for LLE wounds concerning for
cellulitis. Hospital course complicated by intermittent fevers
while on broad spectrum antibiotics and acute kidney injury.
# Cellulitis
Tender erythematous, tender swelling up to ___ of left lower
extremity, with slight leukocytosis (10.9). Skin on shins were
covered with multiple excoriated lesions with broken skin.
Likely due to venous insufficiency, poor wound healing (T2DM),
and broken skin due to scratching and chronic itch. Patient was
treated with vancomycin for 7 days with great improvement ___
- ___. Vancomycin was discontinued on ___ out of concern for
drug-induced fever, and patient was transitioned to doxycycline
on ___ to complete a 14 day course on ___.
Cellulitis improved while on antibiotics, with significant
reductions in erythema, warmth, and tenderness. Initial
leukocytosis resolved after day 1 of treatment and has remained
normal.
# Hypoxia: Patient developed some shortness of breath and
hypoxia on ___, requiring intermittent supplemental oxygen (1L)
and nebulizer treatments, with patient complaining of chest
tightness and dyspnea, particularly in the setting of receiving
supplemental albumin. CXR was initially significant for lower
right lobe consolidation vs. effusion, and pulmonary edema. He
was given IV Lasix and briefly treated with vancomycin,
ceftazidine, and flagyl, until repeat CXR showed resolution of
the consolidation most consistent with pulmonary edema/effusion
on ___. Patient was breathing comfortably on room air by ___.
# Fever - Patient spiking intermittent fevers every day since
___. Antibiotics were broaded vancomycin, ceftriaxone, and
flagyl, with repeat CXR initially concerning for
hospital-acquired PNA. However, persistent, intermittent fevers
continued despite broad antibiotic coverage. Resolution of
radiographic signs with diuresis made a fever due to PNA less
likely. Out of concern for drug reaction causing fever (patient
noted a reaction to vancomycin), all antibiotics were
discontinued on ___ and doxycycline was started on ___. His
fevers resolved and vancomycin was added to him adverse reaction
list.
# Right chest wall and RUQ pain: Most likely costocondritis, as
very tender to palpation. No evidence of rib fractures on CT. No
tachycardia or hypoxia to suggest PE. Treated with Tylenol,
lidocaine patch. At time of discharge this pain had resolved.
# ___: Patient presented with a Cr of 1.3 that has progressively
trended up to 2.0 on ___. Patient had a likely prerenal iso of
NPO for EGD/Colonoscopy, but ___ did not respond to fluid
resuscitation with 25% albumin, nor did it improve with
diruesis. Muddy brown fragements possibly seen on urine
sediment. Low urine chloride suggesting dehydration. Nephrology
consulted on ___ and did not have further recommendations since
his creatinine had improved to 1.6 then 1.5 at time of
discharge. His spironolactone was held in the setting ___
with potassium of 5.0. Recommend repeat labs in one week prior
to resumption of his spironolactone.
# Diarrhea. Has intermittent diarrhea at baseline has complained
of this during hospital stay. C. diff negative. Stool O+P and
cultures also negative. Possibly secondary to antibiotics and
resolved by the time of discharge.
# Esophageal varices, s/p banding ___: patient was continued
on his home pantoprazole and sucralfate. Propranolol was reduced
to BID given low blood pressures initially and increased back to
TID at time of discharge. He will continue his sucralfate until
he completes a 2 week course on ___.
# HTN: patient's Enalapril 10mg BID was held on admission and
discharge secondary to systolic BP 100-110.
TRANSITIONAL ISSUES:
=========================
- New Meds:
* doxycycline 100mg PO BID for cellulitis, last dose on ___
* Clobetasol Propionate 0.05% Cream BID (this is replacing
triamcinolone)
- Stopped/Held Meds:
* Spironolactone 50mg daily was held in the setting ___
(discharge Cr 1.5 from baseline 1.3) and potassium 5.0 prior to
discharge. Please resume if repeat labs are improved.
* Enalapril 10mg BID was held in the setting of hypotension /
normotension with systolic blood pressure in the 100s-110s.
* Oxycodone 5mg as needed, you did not need this medication
while inpatient. You can continue to use it as needed at home.
- Changed Meds: none
- Post-Discharge Follow-up Labs Needed:
*Patient was given a prescription for repeat labs on ___
___
-consider outpatient sleep study: per patient, he often wakes up
at night. does not know if he snores (wife sleeps in a separate
bedroom). Denies headaches in AM. Reports that often falls
asleep during the day, multiple times.
-f/u w/ PCP/GI/Cards re: furosemide prescriptions: ___ (home
nurse, ___ needs clarification as to who should be
prescribing him furosemide (has been getting it from his PCP).
- f/u with PCP and dermatology for managing chronic itchiness /
prurigo nodularis. Scratching seemed to be the primary cause of
patient's cellulitis. He was discharged with Clobetasol cream.
Can consider Carafate if etiology of itching seems to be
secondary to elevated bilirubin.
- f/u with PCP ___: diabetes control, patient discharged on home
diabetic regimen.
- patient discharged with home ___ for complex medication
management.
#CODE: Full (confirmed)
#CONTACT: wife ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Donepezil 5 mg PO QHS
2. DiphenhydrAMINE 25 mg PO Q6H:PRN rash/itching
3. LamoTRIgine 75 mg PO DAILY
4. Lotrimin AF (miconazole nitrate) 2 % topical BID
5. Pregabalin 50 mg PO BID
6. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain -
Severe
7. Pantoprazole 40 mg PO Q24H
8. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB/wheeze
9. FLUoxetine 60 mg PO DAILY
10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
11. Vitamin D ___ UNIT PO MONTHLY
12. Cetirizine 10 mg PO DAILY
13. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
14. Enalapril Maleate 10 mg PO BID
15. Ferrous Sulfate 325 mg PO DAILY
16. Furosemide 40 mg PO DAILY
17. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
18. Montelukast 10 mg PO DAILY
19. Multivitamins 1 TAB PO DAILY
20. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
21. oxybutynin chloride 15 mg oral DAILY
22. Propranolol 10 mg PO TID
23. Spironolactone 100 mg PO DAILY
24. Triamcinolone Acetonide 0.1% Cream 1 Appl TP ASDIR
25. HumuLIN R U-500 (Conc) Kwikpen (insulin regular hum U-500
conc) 500 unit/mL (3 mL) subcutaneous BID
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
RX *clobetasol 0.05 % apply to rash (red spots) twice a day
Refills:*0
3. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*11 Tablet Refills:*0
4. Sucralfate 1 gm PO Q6H Duration: 14 Days
RX *sucralfate 1 gram 1 tablet(s) by mouth every 6 hours Disp
#*18 Tablet Refills:*0
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
6. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB/wheeze
7. Cetirizine 10 mg PO DAILY
8. DiphenhydrAMINE 25 mg PO Q6H:PRN rash/itching
9. Donepezil 5 mg PO QHS
10. Ferrous Sulfate 325 mg PO DAILY
11. FLUoxetine 60 mg PO DAILY
12. Furosemide 40 mg PO DAILY
13. HumuLIN R U-500 (Conc) Kwikpen (insulin regular hum U-500
conc) 500 unit/mL (3 mL) subcutaneous BID
14. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
15. LamoTRIgine 75 mg PO DAILY
16. Lotrimin AF (miconazole nitrate) 2 % topical BID
17. Montelukast 10 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
20. oxybutynin chloride 15 mg oral DAILY
21. Pantoprazole 40 mg PO Q24H
22. Pregabalin 50 mg PO BID
23. Propranolol 10 mg PO TID
24. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
25. Vitamin D ___ UNIT PO MONTHLY
26. HELD- Enalapril Maleate 10 mg PO BID This medication was
held. Do not restart Enalapril Maleate until your blood pressure
and labs are checked and you see your doctor
27. HELD- OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN
Pain - Severe This medication was held. Do not restart
OxyCODONE--Acetaminophen (5mg-325mg) until your blood pressure
improves
28. HELD- Spironolactone 50 mg PO DAILY This medication was
held. Do not restart Spironolactone until you have repeat labs
done and your liver doctor tells you to resume this medication
29.Outpatient Lab Work
DATE: ___
Diagnosis: Anemia (D64.9), ___ (N17.9)
LABS: Na, K, Cl, Bicarb, BUN, Cr, CBC
Please fax results to: Dr. ___ ___ AND Dr. ___
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Cellulitis
Secondary:
Acute Kidney Injury on chronic kidney disease
Alcoholic cirrhosis
Prurigo nodularis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___.
WHY WERE YOU HERE?
You were admitted to the hospital because you had an infection
of the skin in your left leg and your kidney function was lower
than normal.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
While you were in the hospital, we treated your skin infection
with antibiotics. We also treated the rib pain you were
experiencing. You continued to have fevers but they stopped when
we stopped your antibiotic called vancomycin.
You also developed some injury to your kidneys. We monitored
your kidney function and it got better.
We evaluated the rash on your body, and diagnosed you with
prurigo nodularis, a skin rash caused by constant scratching,
usually in a person who frequently feels very itchy.
WHAT SHOULD YOU DO WHEN YOU GET HOME?
1) Please follow up at your outpatient appointments.
2) Please take your medications as prescribed.
3) You need to have your labs checked in one week.
3) We are holding your spironolactone until you have your labs
rechecked and your doctor says you can start taking it again.
4) You were also discharged with an antibiotic for your leg
infection called doxycycline. You should take doxycycline 100mg
twice a day (once in the morning and once at night) until
___.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10780367-DS-4
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| 4 |
2165-01-20 00:00:00
|
2165-01-23 15:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Feveres, chills
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram
History of Present Illness:
Mr. ___ is a ___ year old male with a history of aortic
insufficiency, asthma, GERD, iron deficiency anemia,
hyperlipidemia, hypertension, osteoporosis and BPH who presents
with fever and positive blood cultures drawn in the outpatient
setting.
Mr. ___ symptoms began one week prior to presentation. He
initially presented to PCP ___ with a 6 day history of fevers,
chills and soaking night sweats. He reports temperatures at home
of 100.5 and was taking advil for symptom management. During his
outpatient visit CXR was obtained without evidence of focal
infiltrates and unremarkable UA with no growth on subsequent
urine culture. His labwork at that time demonstrated no
leukocytosis (slight leftward shift on differential), stable
microcytic anemia and chemistry. CRP elevated to 43.3
Regarding other localizing symptoms patient denies symptoms of
URI including cough, rhinorrhea, dysuria, nausea, vomiting,
diarrhea. Additionally no headache, neck stiffness,
palpitations.
Blood cultures drawn ___ subsequently grew gram positive
clusters and pairs in ___ bottles prompting Mr. ___ to be
instructed to present to the emergency department.
In the ED, initial vitals: T97.1 HR98 BP157/82, 99%RA
- Exam notable for: No remarkable exam finding per ED team
- Labs notable for: wBc 4.4 with slight left shift, Hgb 12.1
(stable since ___, Normal coags, Chemistry stable from prior,
LFTs WNL, lactate 1.2
- Imaging notable for: No repeat imaging ordered
- Pt given: 1g IV Vancomycin
On the floor, the patient corroborates the above history. He
also
denies any recent weight loss. He has tooth teeth that he thinks
needs to be extracted, however he is unsure if he has been told
these teeth are infected.
Past Medical History:
Aortic Inusfficiency
Asthma, Mild intermittent
GERD
Iron Deficiency Anemia
HLD
HTN
Osteoporosis
BPH
Chronic Low Back pain
Trochanteric Bursitis
Social History:
___
Family History:
Aunt with liver cancer (had chemical exposures),
sister with ovarian cancer (deceased).
Physical Exam:
ADMISSION EXAM:
===============
VITALS: ___ Temp: 99.3 PO BP: 125/76 HR: 79 RR: 18 O2
sat: 97% O2 delivery: Ra
GENERAL: AOx3, NAD, mildly flushed
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Mucous
membrane
moist, no obvious dental issues
NECK: No cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate. No murmurs appreciated
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
BACK: No spinous process tenderness. no CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, has hernia present
with increased abdominal pressure when sitting.
EXTREMITIES: No edema, warm, well perfused. Has large bunyon on
let foot, corn on right foot, no ulcers present.
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation. No ataxia, dysmetria, disdiadochokinesia.
DISCHARGE EXAM:
===============
GENERAL: AOx3, NAD, mildly flushed
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Mucous
membrane
moist, no obvious dental issues. Did not evaluate for ___
spots.
NECK: No cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate. ___ systolic ejection
murmur, ___ blowing diastolic murmur heard when patient leans
forward.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
BACK: No spinous process tenderness. no CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, has hernia present
with increased abdominal pressure when sitting.
EXTREMITIES: No edema, warm, well perfused. Has large bunyon on
let foot, corn on right foot, no ulcers present. Small blue
lesions on right middle fingernail which may represent nailbed
hemorrhages. No osloer nodes.
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation. No ataxia, dysmetria, disdiadochokinesia.
Pertinent Results:
ADMISSION LABS:
===============
___ 12:28PM BLOOD WBC-4.1 RBC-4.69 Hgb-11.9* Hct-36.7*
MCV-78* MCH-25.4* MCHC-32.4 RDW-15.0 RDWSD-41.9 Plt ___
___ 12:28PM BLOOD Neuts-76.4* Lymphs-15.7* Monos-7.3
Eos-0.2* Baso-0.2 Im ___ AbsNeut-3.15 AbsLymp-0.65*
AbsMono-0.30 AbsEos-0.01* AbsBaso-0.01
___ 12:00PM BLOOD ___ PTT-26.1 ___
___ 12:28PM BLOOD UreaN-23* Creat-1.1 Na-138 K-4.3 Cl-99
HCO3-23 AnGap-16
___ 12:28PM BLOOD ALT-19 AST-26 LD(LDH)-212 AlkPhos-98
TotBili-0.6
___ 12:28PM BLOOD Calcium-8.5 Phos-3.4 Mg-2.3
___ 04:35AM BLOOD calTIBC-270 ___ Ferritn-158 TRF-208
___ 12:28PM BLOOD CRP-43.3* PSA-0.8
PERTINENT STUDIES:
=================
___ Cardiovascular ECHO
The left atrial volume index is mildly increased. 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. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). There is a mild resting left
ventricular outflow tract obstruction. The right ventricular
cavity is mildly dilated with normal free wall contractility.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. The aortic arch is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are structurally normal.
There is no mitral valve prolapse. No mass or vegetation is seen
on the mitral valve. Trivial mitral regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve. The end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery diastolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: No definite vegetations or pathologic valvular flow
identified. Mild symmetric left ventricular hypertrophy with
normal cavity size, and hyperdynamic regional/global systolic
function. Mild resting left ventricular outflow tract
obstruction. Mild aortic regurgitation. Pulmonary artery
diastolic hypertension.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis, and
transesophageal echocardiography is warranted.
Compared with the prior study (images reviewed) of ___,
there is now pulmonary artery diastolic hypertension.
**** TEE ****
MICRO:
======
___ 1:40 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 1:30 pm BLOOD CULTURE #2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 5:55 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 10:10 am BLOOD CULTURE #2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 4:35 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 12:00 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM POSITIVE COCCUS(COCCI).
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
481-___
___.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
__________________________________________________________
___ 12:00 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM POSITIVE COCCUS(COCCI).
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
__________________________________________________________
___ 12:28 pm BLOOD CULTURE SET #2.
Blood Culture, Routine (Preliminary):
VIRIDANS STREPTOCOCCI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by ___. ___ (___)
___ @
11:10.
__________________________________________________________
___ 12:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 12:28 pm BLOOD CULTURE BLOOD CULTURE X 2.
Blood Culture, Routine (Preliminary):
VIRIDANS STREPTOCOCCI.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
VIRIDANS STREPTOCOCCI
|
CEFTRIAXONE-----------<=0.12 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.12 S
PENICILLIN G---------- 0.12 S
VANCOMYCIN------------ 0.5 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by ___. ___ (___)
___ @
9:21 AM.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
DISCHARGE LABS:
===============
___ 09:00AM BLOOD WBC-3.2* RBC-4.37* Hgb-11.0* Hct-34.2*
MCV-78* MCH-25.2* MCHC-32.2 RDW-14.8 RDWSD-42.4 Plt ___
___ 09:00AM BLOOD Glucose-131* UreaN-24* Creat-1.0 Na-141
K-3.9 Cl-103 HCO3-23 AnGap-15
___ 04:35AM BLOOD LD(LDH)-183 TotBili-0.4
___ 12:00PM BLOOD ALT-20 AST-26 AlkPhos-107 TotBili-0.5
___ 09:00AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.3
Brief Hospital Course:
Mr. ___ is a ___ year old male with a history of aortic
insufficiency, asthma, GERD, iron deficiency anemia,
hyperlipidemia, hypertension, osteoporosis and BPH who presents
with fever, night sweats and positive blood cultures drawn in
the outpatient setting. Pt was found to have strep viridans
bacteremia, without evidence of vegetations or abscess on TEE or
TTE, cleared blood cultures on ___ on Ceftriaxone 2mg IV daily.
ACUTE ISSUES:
=============
#Streptococcus Viridans Bacteremia:
The patient presented to his outpatient clinic with fevers and
night sweats for one week. Blood cultures were drawn which grew
gram positive cocci in chains and pairs and the patient was sent
to the ED. He was admitted to the medicine service and started
on Vancomycin for broad coverage. His blood cultures speciated
to pan sensitive Streptococcus Viridans, and he was changed to
ceftriaxone (Day 1 of ceftriaxone was ___. The course for the
patient's bacteremia was thought to be from oral flora given
that he had a planned tooth removal, though his oral exam was
normal and he was having no dental symptoms. Given his prolonged
bacteremia, he had a TTE which showed no valvular vegetation,
however the suspicion was high enough that he got a TEE. The
image quality on the TEE was sub-optimal, however no vegetations
were identified. Given the sub-optimal image quality as well the
patient's abnormal valve, he was still thought to be very high
risk for endocarditis and was therefore discharged with the plan
to complete a 6 week course of IV Ceftriaxone. A PICC line was
placed and the patient was discharged with plan to complete this
course as an outpatient.
Agent & Dose: Ceftriaxone 2g q24h
Start Date: ___
Projected End Date: ___
Lab monitoring: WEEKLY CBC with differential, BUN, Cr, AST, ALT,
Total Bili, ALK PHOS, CRP
#Thrombocytopenia
#Anemia:
The patient was found to have a mild anemia and thrombocytopenia
on admission. These were thought to be related to systemic
inflammation in the setting of bacteremia, however iron studies
and hemolysis labs were sent. Hemolysis labs were negative, but
the patient was found to be iron deficient with a Fe/TIBC ratio
of approximately 10%. The patient should be worked up for iron
deficiency anemia as an outpatient, and in particular should
have a colonoscopy as his recent colonoscopy did not have
sufficienct prep. He should also be started on oral iron
supplementation after the clearance of his active infection.
CHRONIC ISSUES:
===============
#Hypertension: Continued on home Nifedipine and Lisinopril while
in patient
#Hyperlipidemia: Continued home Simvastatin
#Osteoporosis: Continued home Alendronate, dosed weekly on
___
#BPH: Continued tamsulosin, finasteride
#Mild Intermittent Asthma: Occasionally uses Albuterol, not
currently taking Fluticasone
TRANSITIONAL ISSUES:
====================
[ ] Antibiotics: Agent & Dose: Ceftriaxone 2g q24h, Start Date:
___, Projected End Date: ___
[ ] Labs:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
WEEKLY: CBC with differential, BUN, Cr, AST, ALT, Total Bili,
ALK
PHOS, CRP
[ ] Patient should have continued workup for iron deficiency
anemia: Recommend repeating CBC and iron studies upon resolution
of acute infection with iron supplementation if indicated and
colonoscopy
[ ] All questions regarding outpatient parenteral antibiotics
after discharge should be directed to the ___
R.N.s at ___ or to the on-call ID fellow when the
clinic is closed.
#Code status: Full Code
#Health care proxy/emergency contact: ___
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. Alendronate Sodium 70 mg PO QSUN
4. NIFEdipine (Extended Release) 60 mg PO DAILY
5. Ranitidine 150 mg PO BID
6. Simvastatin 40 mg PO QPM
7. HYDROcodone-Acetaminophen (5mg-325mg) 2 TAB PO Q12H PRN Pain
- Moderate
8. Aspirin 81 mg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
10. Albuterol Inhaler 2 PUFF IH BID PRN asthma
11. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. CefTRIAXone 2 gm IV Q 24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 Grams IV Daily
Disp #*28 Intravenous Bag Refills:*0
2. Albuterol Inhaler 2 PUFF IH BID PRN asthma
3. Alendronate Sodium 70 mg PO QSUN
4. Aspirin 81 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. HYDROcodone-Acetaminophen (5mg-325mg) 2 TAB PO Q12H PRN Pain
- Moderate
7. Lisinopril 5 mg PO DAILY
8. NIFEdipine (Extended Release) 60 mg PO DAILY
9. Ranitidine 150 mg PO BID
10. Simvastatin 40 mg PO QPM
11. Tamsulosin 0.4 mg PO QHS
12. Vitamin D ___ UNIT PO DAILY
13.Outpatient Lab Work
WEEKLY: CBC with differential, BUN, Cr, AST, ALT, Total Bili,
ALK, PHOS, CRP
ICD-10: I33.0 Acute and subacute infective endocarditis
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Streptococcus viridans bacteremia
- Endocarditis (meeting criteria by bacterial species, splinter
hemorrhages, predisposing condition, fevers)
- Aortic insufficiency
Secondary diagnosis:
- Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were having fevers and night sweats at home
- You were found to have a bacteria that was growing in you
blood
WHAT WAS DONE WHILE YOU WERE HERE?
- The infection in your blood was treated with antibiotics
- We monitored the infection and found out the exact bacteria
that was causing your infection
- We got two imaging tests of your heart to make sure the
infection was not growing on any of the heart valves
- We did not see any infection on the heart valves
- You were seen by our infectious disease specialists who
recommended a 6 week course of antibiotics through your IV
- You had a large IV line placed called a ___ line for these
antibiotics
WHAT SHOULD I DO WHEN I LEAVE?
- Please take all of your medications as prescribed
- Please follow up with your doctors as we arranged for you
- Please get weekly blood tests until your antibiotics are
finished. Please take the prescription to any of the ___
affiliates for lab testing, so they are available in our system
It was a pleasure to care for you during your hospitalization.
- Your ___ team
Followup Instructions:
___
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2120-06-21 16:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
rectal pain, diarrhea
Major Surgical or Invasive Procedure:
flexible sigmoidoscopy ___
History of Present Illness:
___ h/o multiple myeloma (well-controlled, diagnosed ___, on
revlimid/dexamethasone), CAD with MI ___ s/p PTCA in ___ and PCI
in ___ (for STEMI), HTN, HLD, and gout p/w progressive rectal
pain and nonbloody diarrhea x 1 week. Patient reports that
symptoms began about 10 days prior to presentation with rectal
pain, urgency for bowel movements and tenesmus. Pain was
constant and improved with sleep. Had associated loose bowel
movements up to 5 times a day without any blood. There were
times he felt he had to have a movement but only gas came out.
Denied any nocturnal symptoms, fevers, chills, night sweats,
nausea or vomiting. No prior episodes. No recent travel or sick
contacts. No unusual contacts. No urinary symptoms. No family or
personal history of IBD. Given symptoms he presented to his PCP
who performed initially performed a KUB showing stool. He was
given Senna/Colace which did not help symptoms. He re-presented
and PCP performed anoscopy which showed inflammed hemorrhoidal
tissue, and given his discomfort, he was sent to the ED for
evaluation.
In the ED, initial vital signs were 98.0, 103/57, 72, 20, 99%
RA. In the ED, exam showed no clear fissures, prostate non-boggy
and non-tender, no thrombosis palpable, and no ___
fluctulance, induration, or erythema. Rectal mucosa was
edematous and erythematous with mucous in the vault. CT
abdomen/pelvis was performed and demonstrated rectal enhancement
suggestive of proctocolitis. Labs significant for normal WBC
count but 85% PMN, plats 63 (from 124), Hct 41.3, creatinine 1.4
(in ___ was 1.2). He was given dilaudid for pain control and
started on IV cipro/flagyl. Transfer vital signs were 98.9,
100/67, 70, 16, 100% RA.
On arrival to the floor, pt appeared tired and uncomfortable,
still with pain and BM urgency.
Past Medical History:
-HYPERTENSION
-HYPERCHOLESTEROLEMIA
-ASTHMA, UNSPEC
-GOUT, UNSPEC
-CORONARY ARTERY DISEASE, s/p PTCA (___), Stent (___)
-RADICULOPATHY - LUMBOSACRAL L5 RIGHT
-OBESITY UNSPEC
-Blepharitis
-Orbital cellulitis
-Multiple myeloma
-Depression
-Low tension glaucoma
ONCOLOGIC HISTORY:
___- lytic lesions on shoulder xray; SIEP with monoclonal
free light chains of the kappa type with decreased levels of
IgA, IgG, and IgM. Testing for free light chains in the serum
revealed a free kappa light chain level of 4018 mg/L (normal
3.3-19.4 mg/L), free lambda light chain level of 1.33 mg/L
(normal 5.71-26.3 mg/L), with a kappa lambda ratio of 3021.05.
BM biopsy performed ___ showed Findings consistent with
multiple myeloma with 50% of the cellularity comprised of
monoclonal plasma cells. Cytogenetic studies show 20q- deletion.
Skeletal survey showed multiple small lytic lesions. Calcium was
elevated at 10.5, beta-2 microglobulin 3.1, hg 13.8, creatinine
1.05.
___- started velcade/dexamethasone and zometa; kappa light
chains 5984 mg/L
___- s/p 2 cycles velcade/dexamethasone; kappa light
chains 687 mg/L; velcade held d/t neuropathy
___- kappa light chains increased slightly on dexamethasone
20mg twice weekly; switch to revlimid/ dexamethasone
___- started revlimid/dexamethasone
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.2, 100/62, 74, 18, 98% RA
GENERAL - fatigued-appearing male, appears uncomfortable but NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP clear
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft. TTP to deep palp in lower quadrants and
left quadrant, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
DISCHARGE PHYSICAL EXAM:
VS - 98.1, 97.8, 111-126/70-86, 57-76, 97-99% RA
GENERAL - NAD, significantly more energy and improved mood
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP clear
LUNGS - CTAB, no w/r/r, good air movement, resp unlabored, no
accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, NT/ND, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
Pertinent Results:
___ 07:25PM BLOOD WBC-8.8 RBC-4.08* Hgb-13.9* Hct-41.3
MCV-101* MCH-34.0* MCHC-33.6 RDW-15.8* Plt Ct-63*
___ 07:25PM BLOOD Neuts-85.5* Lymphs-8.3* Monos-4.7 Eos-1.4
Baso-0.1
___ 12:40PM BLOOD ___ PTT-29.5 ___
___ 07:25PM BLOOD Glucose-99 UreaN-18 Creat-1.4* Na-144
K-3.4 Cl-108 HCO3-26 AnGap-13
___ 12:40PM BLOOD ALT-22 AST-24 LD(LDH)-170 AlkPhos-37*
TotBili-1.4
___ 07:25PM BLOOD Calcium-8.9 Phos-1.6* Mg-2.0
Stool studies: ___: Cdiff neg
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
CMV IgG ANTIBODY (Final ___:
NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
___ VIRUS VCA-IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
CMV Viral Load (Final ___:
CMV DNA not detected.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
___ CT:
There is mural thickening of the distal sigmoid colon and rectum
with surrounding inflammatory changes and mucosal
hyperenhancement compatible with proctocolitis. There are no
focal fluid collections or gross evidence of a perianal or
perirectal fistula, though assessment for the former is somewhat
limited on CT. There is no free fluid or free air. The
ischioanal fossa appear unremarkable.
The remainder of the pelvic loops of bowel are within normal
limits. The
prostate is enlarged measuring up to 6.0 x 6.8 cm in greatest
transverse
___. Seminal vesicles are unremarkable. The distal
ureters and bladder are within normal limits. The iliac vessels
appear normal. There are bilateral fat containing inguinal
hernias. No pelvic or inguinal lymphadenopathy.
Osseous structures: There are no lytic or sclerotic osseous
lesions
suspicious for malignancy. Moderate degenerative changes are
visualized in the lumbar spine.
IMPRESSION:
1. Mild proctocolitis involving the distal sigmoid colon and
rectum. No
focal fluid collections or gross evidence of fistula formation.
2. Enlarged prostate.
___ Flexible sigmoidoscopy:
Ulceration, friability and erythema in the descending colon,
sigmoid colon and rectum (biopsy)
Normal mucosa in the transverse colon
Grade 1 internal & external hemorrhoids
Otherwise normal sigmoidoscopy to transverse colon
___ GI biopsies:
A. Transverse colon biopsy: Rare neutrophil or eosinophil in
crypt.
B. Sigmoid colon biopsy: Focal mild active cryptitis.
C. Rectum biopsy: Chronic active colitis with prominent
reactive changes and focal granulation tissue consistent with
ulceration. Additional levels were examined.
___ LEFT KNEE, LOWER EXTREMITY AND FOOT XRAY:
Three views of the left knee show possible small joint effusion,
but no
erosive changes. There are no findings of multiple myeloma.
Two views of the left lower extremity show normal bone
mineralization. There is no evidence of multiple myeloma.
Three views of the left foot show degenerative narrowing and
mild lateral
subluxation of the interphalangeal joint of the first toe. The
bones of the foot are otherwise normal. There are no findings
of multiple myeloma.
Brief Hospital Course:
___ h/o multiple myeloma, CAD with MI ___ s/p PCI ___, HTN, HLD,
and gout p/w progressive perianal pain, nonbloody diarrhea, and
tenesmus x 1 week, found to have new-onset ulcerative colitis,
c/b new-onset Afib/RVR, neutropenia, and likely gout flare.
ACUTE ISSUES:
# perianal pain/diarrhea: Patient received CT ___ that was
consistent with proctocolitis. He underwent a flexible
sigmoidoscopy with biopsies ___ that eventually confirmed
mild ulcerative colitis. He continued to have perianal pain and
diarrhea for 10 more days, despite starting mesalamine PO,
mesalamine enemas, hydrocortisone suppository, and lidocaine,
nitroglycerin, and nifedipine anal creams. The perianal pain
was thought to be due to a separate process, likely an anal
fissure or thrombosed hemorrhoids, but the colorectal surgery
consultants did not believe this warranted an inpatient
operation. Though infectious etiology was also heavily
considered given his immunosuppression with his myeloma, his
stool cultures were all negative for an acute infectious
etiology. He was discharged on mesalamine PO, mesalamine
enemas, lidocaine and nifedipine anal creams, and
senna/colace/miralax with PRN loperamide for
constipation/diarrhea (with preference for looser stool rather
than firmer stool). For pain, he was discharged on tylenol with
a small amount of breakthrough PO dilaudid.
# chest pain/Afib with RVR: On ___, he had an episode of
chest tightness and new-onset Afib with RVR in the setting of
diarrhea and intense perianal pain. He was found to have new
1mm ST depressions in V3-V5 on his EKG, and his troponins peaked
at 0.13 before downtrending. This episode was thought to be
likely due to demand ischemia in setting of Afib/RVR and
pain/diarrhea. He was initially started on hep gtt until
troponins peaked, and given his CHADS2-VASC score of 3, it was
decided that he would likely benefit from anticoagulation for
Afib with coumadin (in addition to his home aspirin). He was
also started on metoprolol tartrate and was discharged on
metoprolol succinate 25mg qdaily. He will have his INR
rechecked two days after discharge and will follow up with his
PCP four days after discharge and his cardiologist soon
thereafter.
# neutropenia: reached a nadir ANC 800 on ___ and ___,
but remained afebrile and asymptomatic. He was placed on
neutropenic precautions, but soon ___ and ANC recovered without
intervention. This may have been due to revlimid, though the
time course also coincided with starting mesalamine and
colchicine (though the latter was just for one day).
# arthritis: s/p injection the week before admission, and has
intermittently had acute episodes that had crystals on previous
arthrocenteses. He underwent an arthrocentesis on ___,
which showed ___ WBC with no crystals but only a 2cc sample.
Given that it could be either gout (with no crystals due to the
small sample amount) or UC-related arthritis, rheumatology
recommended placing him on a steroid taper, starting with
methylprednisolone 40mg IV x 2 days, and tapering prednisone PO
down by 10mg every 2 days. His X-rays were also negative for
fracture. His pain soon resolved significantly. He was
continued on his home allopurinol ___ daily and a prednisone
taper as described above.
# multiple myeloma: has been very well-controlled per Atrius
heme/onc. His revlimid and dexamethasone were hold. His
acyclovir was continued but his bactrim held, per Atrius
heme/onc.
# urinary retention: episode of dysuria and urinary retention
___ that was likely related to anticholinergic effects of
opioids and anesthetics. Though straight cath could not be
passed, a ___ coude catheter was eventually able to be passed
with major relief of symptoms. He passed voiding trial three
days later without any further urinary symptoms.
# ___: Baseline 1.2, admitted at 1.4, but remained for the
majority of the hospitalization at 0.9-1. Likely prerenal given
hypovolemia from diarrhea. He was given IVF as needed.
# HTN: He was mildly hypotensive on admission, likely secondary
to volume depletion, and remained hypotensive to normotensive
throughout his hospitalization.
His atenolol and amlodipine were held throughout his
hospitalization and at discharge, as he is on metoprolol for
Afib rate control and has not been hypertensive in-house.
CHRONIC ISSUES:
# HLD: continued on home simvastatin
# Radiculopathy: continued on home gabapentin
# Depression: continued on home citalopram
# Low tension glaucoma: continued on home brimonidine
TRANSITIONAL ISSUES:
# INR check on W ___ and followed up with PCP on ___
___, and will need to be connected with an ___
clinic
# may uptitrate metoprolol succinate as needed for optimal rate
control
# will need PCP to arrange GI referral for ulcerative colitis
followup
# may restart on bactrim as indicated if restarting high-dose
steroids for myeloma
# may restart amlodipine as needed for hypertension
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrocortisone Acetate Suppository ___ID:PRN
hemorrhoidal pain
2. Lenalidomide 25 mg PO DAILY
stopped on ___
3. zoledronic acid *NF* 4 mg/5 mL Injection unknown
4. HYDROmorphone (Dilaudid) ___ mg PO TID:PRN pain
5. Gabapentin 400 mg PO TID
6. brimonidine *NF* 0.2 % OS BID
7. Allopurinol ___ mg PO DAILY
8. Citalopram 20 mg PO DAILY
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Acyclovir 400 mg PO Q12H
11. Atenolol 50 mg PO BID
hold for SBP<100 or HR<60
12. Aspirin 325 mg PO DAILY
13. Simvastatin 80 mg PO DAILY
14. Amlodipine 5 mg PO DAILY
hold for SBP<100
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Allopurinol ___ mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. Gabapentin 400 mg PO TID
6. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN extreme pain
hold for sedation, respiratory rate <12
RX *hydromorphone 2 mg ___ tablet(s) by mouth every six (6)
hours Disp #*20 Tablet Refills:*0
7. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
9. Lidocaine Jelly 2% 1 Appl TP DAILY
RX *lidocaine [Lidocream] 4 % 1 application three times a day
Disp #*1 Tube Refills:*0
10. Loperamide 2 mg PO QID:PRN diarrhea
RX *loperamide [Lo-Peramide] 2 mg 1 tablet(s) by mouth every six
(6) hours Disp #*60 Tablet Refills:*0
11. Mesalamine 1000 mg PO QID
RX *mesalamine [Pentasa] 500 mg 2 capsule(s) by mouth four times
a day Disp #*120 Capsule Refills:*0
12. Mesalamine (Rectal) 1000 mg PR QAM
RX *mesalamine [Canasa] 1,000 mg 1 Suppository(s) rectally daily
Disp #*30 Suppository Refills:*0
13. Mesalamine Enema 4 gm PR HS
RX *mesalamine [sfRowasa] 4 gram/60 mL 1 Enema(s) rectally at
bedtime Disp #*30 Each Refills:*0
14. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
15. NIFEdipine (bulk) *NF* 1 application TOPICAL TID
RX *nifedipine (bulk) 1 application three times a day Disp #*1
Tube Refills:*0
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by
mouth daily Disp #*1 Bottle Refills:*0
17. PredniSONE 30 mg PO DAILY Duration: 1 Days
___
Tapered dose - DOWN
RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*9 Tablet
Refills:*0
18. PredniSONE 20 mg PO DAILY Duration: 2 Days
___
Tapered dose - DOWN
19. PredniSONE 10 mg PO DAILY Duration: 2 Days
___
Tapered dose - DOWN
20. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
21. Warfarin 2.5 mg PO DAILY16
RX *warfarin 2.5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
22. brimonidine *NF* 0.2 % OS BID
23. Simvastatin 80 mg PO DAILY
24. zoledronic acid *NF* 4 mg/5 mL Injection unknown
25. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
26. Outpatient Lab Work
CBC, ___
ICD-9 427.31
Provider: Dr. ___, ___
Discharge Disposition:
Home
Discharge Diagnosis:
acute ulcerative colitis
anal fissure vs. thrombosed hemorrhoids
atrial fibrillation with rapid ventricular rate
acute gout
neutropenia
multiple myeloma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted for rectal pain and diarrhea, and were found to have
biopsy-proven ulcerative colitis, for which you are taking
mesalamine pills and enemas. You may also have had an anal
fissure or hemorrhoids that were causing you anal pain, for
which you were taking lidocaine and nifedipine creams. You were
also found to have an episode of a fast irregular heartrate
(atrial fibrillation with rapid ventricular rate, for which you
are taking coumadin), a gout flare (for which you are taking
prednisone), and a low white blood cell count (which resolved on
its own and was likely due to your chemotherapy).
Please check your blood work on ___ (bring the
prescription for this with you) and follow up with your
physician ___ on ___.
Medications:
-For anal pain: tylenol (acetaminophen), dilaudid
(hydromorphone) only if absolutely needed, lidocaine and
nifedipine creams as needed
-For ulcerative colitis: mesalamine (pentasa) oral, mesalamine
(rowasa and canasa) enemas
-For constipation/diarrhea: senna, colace, and miralax
(polyethylene glycol) to keep your stool loose; loperamide if
your stool is too loose
-For atrial fibrillation: aspirin, coumadin (warfarin),
metoprolol succinate (instead of atenolol or amlodipine for now,
since your blood pressure was not high in the hospital)
-For your heart since you had chest pain: atorvastatin
-For gout: prednisone (30mg tomorrow ___, 20mg ___, 10mg
___
Followup Instructions:
___
|
10780669-DS-5
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2123-07-11 15:49:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall with multiple rib fractures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o multiple myeloma on dexamethasone and pomalidamide,
a-fib on
Coumadin presenting s/p fall. The patient reports recent
episodes of dizziness, but states that this fall was from
slipping on his kitchen floor. He denies head strike or LOC.
He
fell on the right side and describes ___ to his right side from
the axilla to flank, denies back ___, worsening paresthesias,
radiating ___ to the legs, weakness. He does have neuropathy
in
a stocking-glove distribution at baseline.
ROS: Negative except for as noted in HPI
Past Medical History:
-HYPERTENSION
-HYPERCHOLESTEROLEMIA
-ASTHMA, UNSPEC
-GOUT, UNSPEC
-CORONARY ARTERY DISEASE, s/p PTCA (___), Stent (___)
-RADICULOPATHY - LUMBOSACRAL L5 RIGHT
-OBESITY UNSPEC
-Blepharitis
-Orbital cellulitis
-Multiple myeloma
-Depression
-Low tension glaucoma
ONCOLOGIC HISTORY:
___- lytic lesions on shoulder xray; SIEP with monoclonal
free
kappa light chain level of 4018 mg/L (normal 3.3-19.4 mg/L),
free lambda light chain level 1.33 mg/L, kappa lambda ratio of
3021.05.
___ BM biopsy consistent with multiple myeloma: 50% of the
cellularity comprised of monoclonal plasma cells. Cytogenetic
studies show 20q- deletion.
Skeletal survey showed multiple small lytic lesions.
Calcium was elevated at 10.5, beta-2 microglobulin 3.1, hg 13.8,
creatinine 1.05.
___- started velcade/dexamethasone and zometa; kappa light
chains 5984 mg/L
___- s/p 2 cycles velcade/dexamethasone; kappa light
chains
687 mg/L; velcade held d/t neuropathy
___- kappa light chains increased slightly on dexamethasone
20mg twice weekly; switch to revlimid/ dexamethasone,
___- started revlimid/dexamethasone
___- revlimid/dexamethasone held when admitted for acute
colitis and new Dx UC.
___ opinion ___, no change in Rx recommended
___ Odd Rx wiyh Light chains stable at 375 mg/L
___- Kappa light chains up to 1,330 mg/L, Resumed velcade, SQ
as less neuropathy/decadron
___- add revlimid
___- Rapid response free kappa light chains 160 mg/L; revlimid
d/c'd due to multiple rheumatic complaints
___- after brief chemotherapy holiday, resumed weekly
velcade/dexamethasone
___ MRI T-L spine ___ Possible myeloma lesions T spine,
severe spinal stenosis L3-L5.
___ remained a major problem, followed by Dr ___
service ___.
___- free kappa light chains down to ___- light chains overall relatively stable on every other
week
velcade/Dexamethasone however treatment discontinued as
thrombocytopenia interfered with cardiac evaluation
___- started low dose pomalidomide 1 mg/d x 21 of every 28
days; dexamethasone 20 mg weekly
___- free kappa light chains 638 on
pomalidomide/dexamethasone
___ Admitted FH after falling, hit face, Concussion.
___hains on 1 mg daily pomalidamide, dex
weekly tapering dose.
Social History:
___
Family History:
Brother- kidney cancer
Father- MI
Physical ___:
On Admission:
Vitals: T: 98.4 BP: 102/56 P: 129 R: 38 O2: 97% 2L NC
GENERAL: Alert, oriented, appears uncomfortable
HEENT: Sclera anicteric, MM dry, oropharynx clear
NECK: JVP 7 cm H2O
LUNGS: Scattered rhonchi, otherwise CTAB
CV: Irregular, tachycardic, S1 and S2, no m/r/g
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, no edema
SKIN: senile purpura on bilateral UEs, R flank with large
ecchymosis
NEURO: Grossly intact, moving all extremities
On Discharge:
Vitals: 97.8, 126/90, 107, 18, 96%RA
General: patient lying in bed, appears fatigued.
HEENT: Mucous membranes mildly dry, EOMI, head ATNC, neck supple
without adenopathy
Pulm: bibasilar crackles with severely decreased breathsounds
over right lower lung field but improved since transfer to the
floor.
CV: Regular rhythm, normal S1, S2 no S3, S4, murmurs
Abd: NTND
Ext: WWP, no edema
Neuro: oriented, CN II-XII grossly intact.
Pertinent Results:
ADMISSION / PERTINENT LABS:
___ 09:45PM BLOOD WBC-6.1 RBC-3.86* Hgb-13.6* Hct-40.4
MCV-105* MCH-35.2* MCHC-33.7 RDW-16.6* RDWSD-62.9* Plt ___
___ 09:45PM BLOOD Neuts-56 Bands-2 Lymphs-10* Monos-30*
Eos-1 Baso-1 ___ Myelos-0 AbsNeut-3.54 AbsLymp-0.61*
AbsMono-1.83* AbsEos-0.06 AbsBaso-0.06
___ 09:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 09:45PM BLOOD ___ PTT-26.8 ___
___ 09:45PM BLOOD Glucose-127* UreaN-49* Creat-1.6* Na-139
K-3.9 Cl-104 HCO3-25 AnGap-14
___ 09:45PM BLOOD CK(CPK)-80
___ 09:45PM BLOOD CK-MB-2 cTropnT-0.55*
___ 02:32AM BLOOD CK-MB-2 cTropnT-0.53*
___ 08:55AM BLOOD CK-MB-2 cTropnT-0.46*
___ 04:00PM BLOOD CK-MB-3 cTropnT-0.45*
___ 12:17AM BLOOD CK-MB-2 cTropnT-0.10*
___ 02:32AM BLOOD Calcium-9.7 Phos-3.7 Mg-2.7*
___ 02:43AM BLOOD ___ pH-7.33*
___ 02:43AM BLOOD Lactate-1.3
___ 02:43AM BLOOD freeCa-1.16
IMAGING:
CT CHEST / ABD / PELVIS ___
1. Right mildly displaced ___ posterior rib fractures with
associated
subcutaneous emphysema and pulmonary contusions and atelectasis.
The
additional ___ rib fractures were discussed with ___
___ on the
telephone on ___ at 1040 am.
2. Bilateral ground glass opacities could also reflect
superimposed infection and edema in the appropriate clinical
situation. Correlate with clinical assessment.
3. L1 vertebral body deformity is age-indeterminate, new since
___, but in the absence of prevertebral soft tissue
swelling, this appears more
chronic. No retropulsion of fracture fragments.
4. Multilevel degenerative changes in the spine.
5. Prostatomegaly.
6. Small hiatal hernia.
ECHO ___: The left atrial volume index is moderately
increased. The estimated right atrial pressure is ___ mmHg.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. LV systolic function
appears moderately-to-severely depressed (LVEF = 30%) secondary
to akinesis of the inferior free wall and posterior wall, and
hypokinesis of the inferior septum. Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic arch is mildly dilated. There are
focal calcifications in the aortic arch. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
Chest Xray ___
Comparison to ___, 09:52. As previously mentioned,
the PICC line inserted over the right upper extremity continues
to be misplaced in the right internal jugular vein. The line
needs repositioning. No pneumothorax.
Chest xray ___
Diffuse atelectasis, no consolidation. Pulmonary contusions
improved in comparison to ___.
CXR ___
1. Right lower lobe collapse with minimally increased pleural
effusion. No focal opacities suggestive of pneumonia.
2. Multiple bilateral rib fractures.
BILAT ___ VEINS US ___
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
DISCHARGE / PERTINENT LABS:
___ 05:59AM BLOOD WBC-2.7* RBC-2.59* Hgb-9.0* Hct-28.0*
MCV-108* MCH-34.7* MCHC-32.1 RDW-17.0* RDWSD-64.0* Plt Ct-97*
___ 05:59AM BLOOD ___ PTT-39.0* ___
___ 05:59AM BLOOD Glucose-93 UreaN-11 Creat-0.9 Na-141
K-4.0 Cl-112* HCO3-25 AnGap-8
___ 05:00AM BLOOD CK-MB-4 cTropnT-0.02*
___ 05:59AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9
___ 12:17AM BLOOD TSH-2.3
___ 01:53AM BLOOD FreeKap-750* ___ Fr K/L-62*
___ 12:17AM BLOOD calTIBC-130* Hapto-232* Ferritn-1390*
TRF-100*
Brief Hospital Course:
Mr. ___ is a ___ yo M with a PMHx of HTN, CAD, A-fib (on
Coumadin), ulcerative colitis, multiple myeloma (on
pomalidamide, well controlled), admitted with presyncopal fall
c/b 5 rib fractures, L1 compression fracture, apical
pneumothorax, pulmonary contusions, and a type 2 NSTEMI
requiring trauma-ICU admission.
# Atrial Fibrillation with Rapid Ventricular Response: Pt with
known h/o a-fib on warfarin and amiodarone required transfer to
FICU for AF with RVR to 160s. His AF with RVR was asymptomatic.
Etiology of AFib with RVR likely multifactorial including volume
depletion and ___. Afib was associated with hypotension (SBPs
___. He converted to NSR s/p amiodarone load. He was
continued on amiodarone 300 daily and converted from heparin gtt
to warfarin. On the floor metoprolol 6.25 Q6H was added and he
converted back into sinus rhythm HR ___ with brief episodes
of non-sustained a-fib. Discharged in sinus with cardiology
follow up.
#Hypotension: SBPs initially ___. Likely ___ volume
depletion, exacerbated by RVR. Narcotics may also have
contributed. He had no clinical evidence of sepsis with a
lactate of 0.8. He also has stable H/H and has no evidence of
bleeding. His hypotension resolved by time of ICU transfer back
to floor. On the floor his BP was low/normal (low 100s systolic)
on a beta blocker so an ACE inhibitor was not started.
# Type 2 NSTEMI with chronic systolic heart failure: Patient
with elevated troponin-T on ___ (trop max: 0.53) with
non-specific ST changes, likely secondary to tachycardia, ___,
and surrounding trauma. He was treated with heparin ggt, O2,
___ control, and treatment of his a-fib. His troponin trended
down to a baseline on 0.02 upon discharge. TTE with newly
further reduced EF from 40 to 30%, though unchanged WMA on read.
Started on beta blocker, continued aspirin 81 and did not start
ace inhibitor secondary to low BP as above.
# ___ secondary to rib fractures: Pt endorsing severe ___ in
the setting of rib fractures and possible old L1 fracture.
Improved minimally on dilaudid PCA but confusion with the pump
resulted in drastic swings in ___ control. He improved
significantly on oral long acting morphine TID and short acting
dilaudid Q4H. He was discharged on this regimen with plan to
wean dilaudid first as soon as possible as he improves
functionally with continued ___. His morphine should also be
weaned as tolerated as he continues to improve. He was seen by
neurosurgery during his admission who recommended a TLSO brace
for 6 weeks and follow up with them with repeat CT TL spine.
They will be contacting the patient to set up this appointment
and scan.
# Hypoxia: Pt had O2 requirement on admission. He later was
able to sat in the low ___ on RA. His hypoxia was thought to be
due to atelectasis and splinting. PE was considered but INR was
therapeutic. He improved and was saturating 96-98% on room air
by the time of discharge.
# Cough: patient with chronic cough that is mildly productive.
Suction in the hospital did not remove any sputum/mucus. Serial
chest x-rays during admission were not concerning for pneumonia
and his cough improved with Guaifenesin/codine, pantoprazole,
and albuterol nebulizer as needed.
# Multiple myeloma: Patient with well controlled multiple
myeloma. He was continued on dexamethasone taper (20 once
weekly), Bactrim for pneumocystis prophylaxis, prophylactic
acyclovir, and pomalidomide without complication. He was
scheduled for follow up with his primary oncologist upon
discharge.
# Goals of Care: Pt's code status has been dynamic during
hospitalization with a period of CMO secondary to extreme ___.
He was then transitioned back to full code after prognosis
discussion and better ___ control.
TRANSITIONAL ISSUES:
- Patient discharged on high dose narcotics for ___ control
secondary to rib fractures. Please wean PO dilaudid as tolerated
as he continues to improve functionally and then wean MS contin
as tolerated.
- Please adhere to strict bowel regimen and add laxatives if
needed given constipation on high dose narcotics.
- Please follow up depression and alternative ___ management
medications instead of narcotics. No treatment for depression
initiated while inpatient.
- Discharged with TLSO brace to be worn while out of bed for a
duration of 6 weeks (until ___. Please ensure completion of
repeat T-L spine CT in 4 weeks and follow up with Dr. ___
with Neurosurgery. ___ office to call patient for
scheduling of CT and appointment.
- Discharged off warfarin due to supratherapeutic INR secondary
to amiodarone interaction (INR 3.1 on discharge). PLEASE CHECK
INR WITHIN ___ DAYS OF DISCHARGE. Please start 2.5 mg three
times per week on ___ and ___ when INR < 2.5
and titrate to INR ___.
- PLEASE CHECK CHEM 7 WITHIN ___ DAYS OF DISCHARGE.
- Discharged on amiodarone 300 daily and metoprolol tartrate
12.5 BID. Please monitor HR during recovery. Follow up scheduled
with cardiologist on ___.
- Consider initiation of ACE-inhibitor if BP permits in the
future. Had low-normal BP during admission.
- Follow up scheduled with primary oncologist. Continuing
scheduled pomalidamide on discharge.
EMERGENCY CONTACT:
Name of health care proxy: ___
Relationship: Wife
Phone number: ___
CODE: FULL CODE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Mesalamine 1000 mg PO BID
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
6. OxycoDONE (Immediate Release) 10 mg PO Q4-6H ___
7. Warfarin 5 mg PO 3X/WEEK (___)
8. Finasteride 5 mg PO DAILY
9. Atorvastatin 40 mg PO QPM
10. Amiodarone 200 mg PO DAILY
11. Tizanidine 2 mg PO QHS
12. Vitamin D 1000 UNIT PO QHS
13. Dexamethasone 20 mg PO 1X/WEEK (TH)
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Allopurinol ___ mg PO DAILY
3. Amiodarone 300 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Dexamethasone 20 mg PO 1X/WEEK (TH)
___
7. Finasteride 5 mg PO DAILY
8. Mesalamine 1000 mg PO BID
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Vitamin D 1000 UNIT PO QHS
11. Benzonatate 200 mg PO TID
12. Bisacodyl 10 mg PO BID
13. Chloraseptic Throat Spray 1 SPRY PO Q6H:PRN sore thoart
14. Docusate Sodium 100 mg PO BID
15. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
16. HYDROmorphone (Dilaudid) 4 mg PO Q4H
please wean as tolerated
RX *hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth every
four (4) hours Disp #*83 Tablet Refills:*0
17. Lorazepam 0.5 mg PO QHS:PRN anxiety
RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth QHS:PRN Disp
#*13 Tablet Refills:*0
18. Morphine SR (MS ___ 45 mg PO Q8H
RX *morphine 45 mg 1 capsule(s) by mouth every eight (8) hours
Disp #*43 Capsule Refills:*0
19. Pantoprazole 40 mg PO Q24H
20. pomalidomide 3 mg PO DAILY
21. Senna 17.2 mg PO BID
22. Metoprolol Tartrate 12.5 mg PO BID
23. Fleet Enema ___AILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Rib Fractures and Lumbar Spine L1 Fracture; ___
Atrial Fibrillation with Rapid Ventricular Response
Secondary: Multiple Myeloma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care here at ___
___.
You were admitted to the ___
following a fainting episode in your home where you fell and
fractured multiple ribs and one of your lumbar vertebrae (L1).
Causes of this episode, including those related to your heart,
were ruled out. You were transferred to the ICU for ___
management.
You were then transferred to the oncology medicine service where
we began to transition you to oral medications for ___. During
your course on the oncology floor your heart rate became
dangerously fast and required you return to the ICU. You were
started on a medication called amiodarone which helped to
control your heart rate. However, you did suffer a silent heart
attack. You were treated and recovered without complications.
You were then transferred back to the oncology medicine floor
where your ___ was managed with oral medications and wee
started you on metoprolol, a medication to help your heart rate
stay in a normal range. You were discharged to a rehabilitation
facility for continued healing.
Thank you for choosing ___ for your healthcare needs.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10780669-DS-6
| 10,780,669 | 20,769,615 |
DS
| 6 |
2123-09-17 00:00:00
|
2123-09-17 16:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Depression/psych evaluation
Major Surgical or Invasive Procedure:
R ankle arthrocentesis and intraarticular steroid injection
History of Present Illness:
___ PMH multiple myeloma (currently w/ Stable light chains on 1
mg daily pomalidamide, dex), HTN, HLD, depression, referred in
by PCP for medical and psychiatric evaluation for failure to
thrive.
Pt with hx multiple myeloma, s/p right rib fractures after a
fall, reporting ongoing right rib ___, diffuse lower back ___,
difficulty with ambulation since the fall. Also with ongoing
depression, taking duloxetine and abilify. Decreased energy,
decreased appetite. Not participating with physical therapy.
Denies SI/HI/VH/AH. Per PCP, main concern is failure to thrive
___ depression, with poor activity, very poor eating. Patient
does not really acknowledge any acute reason for being in the
hospital at present, other than his difficulty walking and his
UTI. He does report some depressed mood and poor energy, denies
anhedonia, psychomotor agitation, guilt, difficulty with
concentration. Reports some stinging and intermittent urinary
stream, but no frank dysuria and no hematuria. Reports some
decreased sensation in feet due to chronic neuropathy, says his
legs feel weak when he tries to walk.
Patient was evaluated by psychiatry in the ED and was ___
overnight. He was found to have evidence of a UTI on UA with
mild ___ (cr up to 1.3 from 1.1). Psych recommended overnight to
admit to medicine for eval and they will follow. In the AM the
psych team was called and removed the ___. Patient was
started on PO abx of ciprofloxacin. ___ improved. Patient was
admitted to medicine.
On arrival to the floor, patient reports generally feeling well.
Denies chest ___, SOB, abdominal ___, nausea/vomiting. Reports
intermittent urinary stream still but otherwise doing well.
Reports good diet, fine BMs. Is willing to try to walk while
here in hospital.
Past Medical History:
-HYPERTENSION
-HYPERCHOLESTEROLEMIA
-ASTHMA
-GOUT
-CORONARY ARTERY DISEASE, s/p PTCA (___), Stent (___)
-Ulcerative colitis
-RADICULOPATHY - LUMBOSACRAL L5 RIGHT
-OBESITY UNSPEC
-Blepharitis
-Orbital cellulitis
-Multiple myeloma
-Depression
-Low tension glaucoma
-Afib on Warfarin
-BPH
ONCOLOGIC HISTORY:
___- lytic lesions on shoulder xray; SIEP with monoclonal
free
kappa light chain level of 4018 mg/L (normal 3.3-19.4 mg/L),
free lambda light chain level 1.33 mg/L, kappa lambda ratio of
3021.05.
___ BM biopsy consistent with multiple myeloma: 50% of the
cellularity comprised of monoclonal plasma cells. Cytogenetic
studies show 20q- deletion.
Skeletal survey showed multiple small lytic lesions.
Calcium was elevated at 10.5, beta-2 microglobulin 3.1, hg 13.8,
creatinine 1.05.
___- started velcade/dexamethasone and zometa; kappa light
chains 5984 mg/L
___- s/p 2 cycles velcade/dexamethasone; kappa light
chains
687 mg/L; velcade held d/t neuropathy
___- kappa light chains increased slightly on dexamethasone
20mg twice weekly; switch to revlimid/ dexamethasone,
___- started revlimid/dexamethasone
___- revlimid/dexamethasone held when admitted for acute
colitis and new Dx UC.
___ opinion ___, no change in Rx recommended
___ Odd Rx wiyh Light chains stable at 375 mg/L
___- Kappa light chains up to 1,330 mg/L, Resumed velcade, SQ
as less neuropathy/decadron
___- add revlimid
___- Rapid response free kappa light chains 160 mg/L; revlimid
d/c'd due to multiple rheumatic complaints
___- after brief chemotherapy holiday, resumed weekly
velcade/dexamethasone
___ MRI T-L spine ___ Possible myeloma lesions T spine,
severe spinal stenosis L3-L5.
___ remained a major problem, followed by Dr ___
service ___.
___- free kappa light chains down to ___- light chains overall relatively stable on every other
week
velcade/Dexamethasone however treatment discontinued as
thrombocytopenia interfered with cardiac evaluation
___- started low dose pomalidomide 1 mg/d x 21 of every 28
days; dexamethasone 20 mg weekly
___- free kappa light chains 638 on
pomalidomide/dexamethasone
___ Admitted FH after falling, hit face, Concussion.
___hains on 1 mg daily pomalidamide, dex
weekly tapering dose.
Social History:
___
Family History:
Brother- kidney cancer
Father- MI
Physical ___:
ADMISSION
=========
VS - 97.7 110/59 61 20 100RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, 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. strength ___ and sensation intact
throughout.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Psych: Is long-winded and doesn't recognize social cues
particularly well but is not tangential. Has appropriately
labile affect for stated mood.
DISCHARGE
=========
VS - 97.8 121/63 62 16 99/RA
GENERAL: NAD, pleasant, well-appearing, appropriate
LUNG: Breathing comfortably without use of accessory muscles
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose; ankle with improved edema, erythema,
warmth.
Psych: Annoyed. Affect slightly flat.
Pertinent Results:
ADMISSION
=========
___ 03:45PM BLOOD WBC-2.5* RBC-2.63* Hgb-8.8* Hct-28.5*
MCV-108* MCH-33.5* MCHC-30.9* RDW-18.4* RDWSD-72.1* Plt Ct-78*
___ 03:45PM BLOOD Neuts-47 Bands-2 ___ Monos-21*
Eos-2 Baso-0 Atyps-1* Metas-1* Myelos-0 NRBC-1* AbsNeut-1.23*
AbsLymp-0.68* AbsMono-0.53 AbsEos-0.05 AbsBaso-0.00*
___ 11:45PM BLOOD ___ PTT-30.8 ___
___ 03:45PM BLOOD Glucose-91 UreaN-21* Creat-1.3* Na-141
K-4.5 Cl-106 HCO3-25 AnGap-15
___ 03:45PM BLOOD ALT-18 AST-18 AlkPhos-78 TotBili-1.1
___ 03:45PM BLOOD Albumin-3.1* Calcium-9.7 Phos-3.5 Mg-2.2
___ 03:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:10PM BLOOD Lactate-1.4
___ 08:05PM URINE Blood-MOD Nitrite-POS Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 08:05PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 08:05PM URINE RBC-28* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
___ 08:05PM URINE WBC Clm-MOD Mucous-RARE
___ 08:05PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
PERTINENT
=========
___ 09:10PM BLOOD WBC-1.6* RBC-2.11* Hgb-7.1* Hct-23.1*
MCV-110* MCH-33.6* MCHC-30.7* RDW-18.0* RDWSD-71.3* Plt Ct-50*
___ 09:10PM BLOOD Neuts-33* Bands-1 ___ Monos-21*
Eos-3 Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-0.54*
AbsLymp-0.67* AbsMono-0.34 AbsEos-0.05 AbsBaso-0.00*
___ 06:35AM BLOOD WBC-3.4* RBC-2.80* Hgb-9.3* Hct-29.7*
MCV-106* MCH-33.2* MCHC-31.3* RDW-19.3* RDWSD-72.3* Plt Ct-96*
___ 06:35AM BLOOD Neuts-74* Bands-0 Lymphs-13* Monos-10
Eos-0 Baso-0 Atyps-3* ___ Myelos-0 AbsNeut-2.52
AbsLymp-0.54* AbsMono-0.34 AbsEos-0.00* AbsBaso-0.00*
___ 06:35AM BLOOD CK(CPK)-12*
___ 07:28AM BLOOD ___
MICROBIOLOGY
============
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- <=2 S
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING
=======
CXR: Cardiac silhouette size is normal. Coronary artery stent
is noted. The aorta is mildly tortuous. The mediastinal and
hilar contours are otherwise unremarkable. The pulmonary
vasculature is normal. Lungs are clear. No pleural effusion or
pneumothorax is present. There are mild degenerative changes
noted in the thoracic spine. Chronic bilateral rib fractures
are present.
Ankle XR: No fracture, dislocation or degenerative change seen.
No destructive lytic or sclerotic bone lesions. No radiopaque
foreign body or soft tissue calcification. The ankle mortise is
congruent on these nonstress views. Tiny plantar calcaneal
spur.
EKG: QTc 471 on discharge
DISCHARGE
=========
___ 08:30AM BLOOD WBC-4.2 RBC-3.07* Hgb-10.1* Hct-33.2*
MCV-108* MCH-32.9* MCHC-30.4* RDW-20.3* RDWSD-76.5* Plt ___
___ 01:25PM BLOOD Glucose-97 UreaN-18 Creat-1.1 Na-143
K-3.8 Cl-112* HCO3-25 AnGap-10
___ 01:25PM BLOOD Calcium-9.5 Phos-3.6 Mg-2.2
___ 08:30AM BLOOD ___ PTT-35.3 ___
Brief Hospital Course:
___ PMH multiple myeloma (currently w/ Stable light chains on 1
mg daily pomalidamide, dex), HTN, HLD, depression, referred in
by PCP for medical and psychiatric evaluation for failure to
thrive. NOW MEDICALLY CLEARED FOR TRANSFER TO PSYCH.
#Failure to thrive
#Depression
Patient with inability to walk despite no clear organic cause,
intact strength. Per PCP, is having difficulty with eating, as
well as this abnormal inability to walk following a fall. Per
wife, has difficulty with managing ADLs. Anemic with elevated
MCV. TSH WNL, CPK mildly depressed and steroid taper not c/w
myopathy. Prerenal ___ on admission, possibly ___ poor PO intake
although patient denies. On exam, patient reports feeling
"depressed" occasionally with a largely congruent, restricted
affect; however, affect is reactive and appropriately brightens
at times. Concern for uncontrolled depression with psychosomatic
complications leading to failure to thrive. Per psychiatry
evaluation, appears more c/w an apathy syndrome but
significantly impairing depression cannot be ruled out; psych
also expresses concern for dementia given poor performance on
mental status evaluations. Has no hx of dementia, which would
raise concern for pseudodementia. Treated with the following:
- Wellbutrin 150mg QAM
- Duloxetine 60 mg po daily
- Mirtazapine 7.5 mg po QHS
- Aripiprazole 2.5 mg po daily
Per psych, ECT is not indicated at this time. Plan for discharge
to inpatient ___ psych.
#Pancytopenia
Patient noted to be pancytopenic on ___, with neutropenia.
Discussed with ___ oncology, agree with assessment that this
is likely acute change ___ infection in the setting of chronic
suppression from multiple myeloma. Unlikely Bactrim related
since patient is on it chronically. No other clear precipitating
meds. Fibrinogen elevated so no DIC. Now improved, close to
baseline, no longer neutropenic. Holding pomalidomide for now,
will resume on discharge.
#Ankle ___:
#Gout:
Patient presenting w/ R ankle ___ ___. On exam, ongoing ___ w/
some inflammation. Ankle x ray with no acute fracture or bony
abnormality.
Rheumatology tapped ankle, no purulence, injected steroids.
Didn't see any crystals, though presumed gout given past
aspirates were also negative for crystals despite being
otherwise consistent with gout. Septic arthritis is felt to be
less likely as the aspirate was non-purulent. Improved with
steroid injection, no persistent ___ subsequently. Continued
home Allopurinol ___ mg PO DAILY, started Naproxen 375mg PRN for
repeat ankle ___.
#UTI
Patient with UA on admission c/f UTI. Reporting some dysuria.
Urine culture with resistant klebsiella, sensitive to cipro and
CTX. Started on ___ for treatment (after initial treatment
with CTX). s/p 7 day course given complicated UTI (d1 ___, d7
___.
___
Patient with cr bump to 1.3 on admission from baseline 0.9. S/p
fluids in the ED, with normalization to 1.1. Likely prerenal ___
poor PO intake as described above. Has remained at baseline
subsequently.
#Afib: Patient w/ recent admission ___ for afib w/RVR.
Asymptomatic during this admission, with HR in the ___.
Continued Metoprolol 25 mg po daily, Amiodarone 200 mg po daily,
Warfarin 2.5mg daily, goal INR ___. Warfarin found to be
supratherapeutic on 2.5 daily on ___, should hold until
___ and restart at 2mg daily moving forward, with biweekly
INR checks for dose titration.
#Multiple Myeloma: Currently w/ stable light chains on 1 mg
daily pomalidamide, dex. Continued Dexamethasone, acyclovir,
Bactrim for pneumocystis prophylaxis; held pomalidamide.
#BPH: continued home Finasteride 5 mg po daily, Tamsulosin 0.4
mg po daily
#Constipation: continued Colace, senna, mirilax
#UC: continued mesalamine
TRANSITIONAL ISSUES
===================
-Restart warfarin once INR is in the therapeutic range, likely
___ patient should have INR checked ___ for ongoing
monitoring and warfarin titration.
-Resume pomalidomide; being held while inpatient but can restart
once transferred to psych
-If planning ECT, should get skeletal survey in advance given
underlying MM
-Titration of warfarin, goal INR ___
-Buproprion started during this admission, consider uptitrating
but with caution in the setting of known Afib
-Medication Changes: Mirtazapine 7.5 mg PO QHS started, Naproxen
375 mg PO Q8H PRN gouty flare
CODE STATUS: Full
EMERGENCY CONTACT:
Name of health care proxy: ___
Relationship: Wife
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Allopurinol ___ mg PO DAILY
3. Amiodarone 300 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Dexamethasone 4 mg PO 1X/WEEK (TH)
7. Finasteride 5 mg PO DAILY
8. Mesalamine 1000 mg PO BID
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Vitamin D 1000 UNIT PO QHS
11. Pantoprazole 40 mg PO Q24H
12. pomalidomide 2 mg PO DAILY
13. Metoprolol Tartrate 12.5 mg PO BID
14. Cyanocobalamin 100 mcg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Duloxetine 60 mg PO DAILY
17. ARIPiprazole 7.5 mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Allopurinol ___ mg PO DAILY
3. Amiodarone 200 mg PO DAILY
4. ARIPiprazole 7.5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Cyanocobalamin 100 mcg PO DAILY
8. Dexamethasone 4 mg PO 1X/WEEK (TH)
9. Duloxetine 60 mg PO DAILY
10. Finasteride 5 mg PO DAILY
11. Mesalamine 1000 mg PO BID
12. Metoprolol Tartrate 12.5 mg PO BID
13. Multivitamins 1 TAB PO DAILY
14. Pantoprazole 40 mg PO Q24H
15. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
16. Vitamin D 1000 UNIT PO QHS
17. BuPROPion (Sustained Release) 150 mg PO QAM
18. FoLIC Acid 1 mg PO DAILY
19. pomalidomide 2 mg PO DAILY
20. Mirtazapine 7.5 mg PO QHS
21. Naproxen 375 mg PO Q8H:PRN ankle ___
22. Warfarin 2 mg PO DAILY16
First dose ___. Please check INR prior to starting
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
Depression with failure to thrive
Urinary Tract Infection
Pancytopenia
SECONDARY
Gout flare
Acute kidney injury
Atrial fibrillation
Multiple Myeloma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for choosing to receive your care at ___. You were
admitted for difficulty walking and depressed mood, which we
were concerned was interfering with your ability to function as
you would like to in your day to day life. You were initially on
the medicine service for treatment for a urinary tract
infection, with low blood counts which were likely caused by
this infection. Your blood counts improved with treatment of
your infection. You also had ankle ___ which was evaluated and
found to be consistent with gout, and treated with a joint
injection. You were determined to be medically cleared to go to
psychiatry for ongoing treatment of your depression. Your blood
thinning level (called INR) was high and we stopped your
comumadin/warfarin for a few days.
Moving forward, you should take your medications as prescribed,
and weigh yourself every morning; you should call your MD if
your weight goes up more than 3 lbs.
We wish you the best with your ongoing treatment.
Sincerely,
your ___ care team
Followup Instructions:
___
|
10780669-DS-7
| 10,780,669 | 24,667,059 |
DS
| 7 |
2124-08-05 00:00:00
|
2124-08-05 13:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / clindamycin /
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / trazodone /
hydrochlorothiazide / ACE Inhibitors
Attending: ___
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a pleasant ___ w/ HTN, DL, Afib, CAD w/ recent
NSTEMI, and MM on pomalidomide/dex, who presents w/ flu like
symptoms. History was mainly obtained from his wife due to acute
___ crisis on arrival to ___.
His wife, ___, noted that pt's friend was recently admitted
to
___ w/ influenza and unfortunately died despite aggressive
measures. Funeral was held ___ and "everyone was spreading
the
flu there." She developed the flu and so he was placed on
prophylactic amoxicillin and tamiflu. He did not have any
symptoms until 2 days ago when he developed a cough, chills, no
fevers/sob. He became lightheaded and went to the clinic where
he
was found to have afib w/ rvr and referred to the ED.
In ED, afebrile at ___. HR 120-139. RR 20 and 98% RA. Received 5
mg IV metop at midnight and 4 am, and 12.5 mg ER PO xl at 6 am.
FluA+ CXR c/f PNA started on Vanc (3am), Cefepime 2 gm at 1 am,
tamiflu 8 am, 2.5-3L NS, and several rounds of IV Morphine. Due
to elevated Cr of 3.0, foley placed but traumatic w/ consequent
hematuria.
On arrival to 5S, pt's HR was 150s Afib, SOB, light headed, and
writhing in ___ from the foley catheter. Skin warm but mottled.
The foley bag contained dark red urine w/o clots. Wife and puppy
were at bedside visibly upset. FICU was immediately notified and
the patient received 1 mg IV dilaudid and 0.5 mg IV ativan for
presumptive bladder spasms, as well as 1L LR bolus. Case was
also
discussed w/ urology resident on call. HR improved to 120s with
these measures. His symptoms improved. CXR repeated revealed
worsening PNA. Urology evaluated pt at bedside. Pt was about to
be transferred to CT chest but his HR rose again to the 150s.
Due
to concern for hemodynamic instability in context of worsening
PNA vs pulmonary edema (or a combination of both), pt was
transferred to the FICU for further management.
Past Medical History:
-HYPERTENSION
-HYPERCHOLESTEROLEMIA
-ASTHMA
-GOUT
-CORONARY ARTERY DISEASE, s/p PTCA (___), Stent (___)
-Ulcerative colitis
-RADICULOPATHY - LUMBOSACRAL L5 RIGHT
-OBESITY UNSPEC
-Blepharitis
-Orbital cellulitis
-Multiple myeloma
-Depression
-Low tension glaucoma
-Afib on Warfarin
-BPH
ONCOLOGIC HISTORY:
___- lytic lesions on shoulder xray; SIEP with monoclonal
free
kappa light chain level of 4018 mg/L (normal 3.3-19.4 mg/L),
free lambda light chain level 1.33 mg/L, kappa lambda ratio of
3021.05.
___ BM biopsy consistent with multiple myeloma: 50% of the
cellularity comprised of monoclonal plasma cells. Cytogenetic
studies show 20q- deletion.
Skeletal survey showed multiple small lytic lesions.
Calcium was elevated at 10.5, beta-2 microglobulin 3.1, hg 13.8,
creatinine 1.05.
___- started velcade/dexamethasone and zometa; kappa light
chains 5984 mg/L
___- s/p 2 cycles velcade/dexamethasone; kappa light
chains
687 mg/L; velcade held d/t neuropathy
___- kappa light chains increased slightly on dexamethasone
20mg twice weekly; switch to revlimid/ dexamethasone,
___- started revlimid/dexamethasone
___- revlimid/dexamethasone held when admitted for acute
colitis and new Dx UC.
___ opinion ___, no change in Rx recommended
___ Odd Rx wiyh Light chains stable at 375 mg/L
___- Kappa light chains up to 1,330 mg/L, Resumed velcade, SQ
as less neuropathy/decadron
___- add revlimid
___- Rapid response free kappa light chains 160 mg/L; revlimid
d/c'd due to multiple rheumatic complaints
___- after brief chemotherapy holiday, resumed weekly
velcade/dexamethasone
___ MRI T-L spine ___ Possible myeloma lesions T spine,
severe spinal stenosis L3-L5.
___ remained a major problem, followed by Dr ___
service ___.
___- free kappa light chains down to ___- light chains overall relatively stable on every other
week
velcade/Dexamethasone however treatment discontinued as
thrombocytopenia interfered with cardiac evaluation
___- started low dose pomalidomide 1 mg/d x 21 of every 28
days; dexamethasone 20 mg weekly
___- free kappa light chains 638 on
pomalidomide/dexamethasone
___ Admitted ___ after falling, hit face, Concussion.
___hains on 1 mg daily pomalidamide, dex
weekly tapering dose.
Social History:
___
Family History:
Brother- kidney cancer
Father- MI
Physical ___:
ADMISSION EXAM
==============
Vitals: HR 131 (A fib) BP 100/66, RR 15, 98% on RA
General: awake, alert, lying in bed and agitated, visibly
uncomfortable and moaning, difficulty focusing enough to answer
questions
HEENT: mucous membranes dry
CV: tachycardia, no murmurs/rubs/gallops
PULM: breathing unlabored on RA, with intermittent hacking dry
cough, diffuse rhonchi anteriorly with mild crackles at bases
laterally
ABDOMEN: soft, ND, moderate RLQ TTP and right CVAT, NEURO:
moving all extremities spontaneously
GU: Foley catheter in place with grossly bloody drainage
EXTREMITIES: dry, warm, no edema
DISCHARGE EXAM
==============
VS: Afebrile, HDS
Gen: laying in bed in NAD
HEENT: no scleral icterus, no conjunctival injection, MMM, no
oral lesions
Heart: Irregularly irregular, no m/r/g
Lungs: Poor air movement throughout, scattered coarse rhonchi
R>L
Abd: soft; nontender, nondistended. +BS
Ext: no edema, wwp
Skin: no rashes, no ulcers
Neuro: AOx3, moving all extremities
Psych: appears slightly agitated with interview
Pertinent Results:
ADMISSION LABS:
==============
___ 10:47PM BLOOD WBC-5.4 RBC-3.38* Hgb-12.2* Hct-38.5*
MCV-114* MCH-36.1* MCHC-31.7* RDW-16.3* RDWSD-68.1* Plt Ct-82*
___ 10:47PM BLOOD Neuts-82.1* Lymphs-10.7* Monos-6.4
Eos-0.2* Baso-0.0 Im ___ AbsNeut-4.46# AbsLymp-0.58*
AbsMono-0.35 AbsEos-0.01* AbsBaso-0.00*
___ 11:51PM BLOOD ___ PTT-25.3 ___
___ 10:47PM BLOOD Glucose-101* UreaN-44* Creat-2.9*#
Na-146* K-4.6 Cl-113* HCO3-18* AnGap-20
___ 10:47PM BLOOD CK-MB-3 cTropnT-0.02*
___ 10:47PM BLOOD Albumin-4.4 Calcium-10.3 Phos-3.1 Mg-2.4
___:52AM BLOOD PEP-PND FreeKap-3363* ___ Fr
K/L-336.30* IFE-PND
___ 12:52AM BLOOD PEP-PND FreeKap-3363* ___ Fr
K/L-336.30* IFE-PND
___ 12:52AM BLOOD TSH-5.8*
___ 11:00PM BLOOD Lactate-2.6*
DISCHARGE LABS:
==============
___ 07:23AM BLOOD Glucose-78 UreaN-30* Creat-2.2* Na-147*
K-4.0 Cl-115* HCO3-21* AnGap-15
___ 01:29AM BLOOD ALT-13 AST-17 AlkPhos-54 TotBili-1.3
___ 07:23AM BLOOD Calcium-9.9 Mg-1.9
___ 12:52AM BLOOD PEP-HYPOGAMMAG FreeKap-3363* FreeLam-10.0
Fr K/L-336.30* IgG-119* IgA-9* IgM-<5* IFE-MONOCLONAL
MICRO
UCX ___ NEGATIVE
BCX ___ NEGATIVE
LEGIONELLA URINARY ANTIGEN ___BD/PELVIS ___. A 3 mm stone is identified at the right UVJ causing upstream
mild right
hydroureternephrosis. There is minimally increased right
perinephric
stranding. Surrounding fat stranding is noted at mid right
ureter, at the
level of aortic bifurcation.
2. Multiple nonobstructing stones are identified in bilateral
kidneys.
3. Unchanged subendocardial fat deposition in the left lateral
ventricle may be sequela of old infarct.
4. Enlarged prostate.
CXR ___
Increasing right mid lung, lower lung, and left lower lung
opacities, more
prominent interstitial markings, may represent worsening
pneumonia. Some of the findings may represent edema, as heart
size and pulmonary vascularity have mildly increased since
yesterday. Trace right pleural effusion is new. No sizable
left pleural effusion. No pneumothorax. Stable rib fracture.
RENAL US ___:
1. Previously seen mild right-sided hydronephrosis has resolved.
2. Nonobstructing renal stones bilaterally.
3. Mild cortical increased echogenicity and cortical thinning
suggestive of
medical renal disease.
4. Bladder jets could not be demonstrated due to bladder
decompression around
a Foley catheter.
Brief Hospital Course:
___ h/o of multiple myeloma, paroxysmal a. fib, CAD with recent
nstemi, CKD initially admitted with 10 days of cough, malaise
found to have influenza, ?superimposed pneumonia, ___ on CKD,
and ongoing RVR.
# Severe Sepsis
# Influenza A
# CAP: patient with known flu + status and interval worsening of
respiratory status c/f superimposed pna. He was started on
5-day course of oseltamivir with the addition of vanc/cefepime
for possible superimposed bacterial infection. He completed 6
days of IV abx and will be transitioned to levaquin for
completion of 10 day course given his prolonged respiratory
symptoms.
#Afib RVR: Pt with chronic afib. Developed RVR during this
admission likely ___ sepsis, ___, blood loss, and volume
depletion. He transferred to the FICU and started on metoprolol
which was uptitrated to 12.5mg q6H with good control of HR's. Pt
had been on beta-blockers in the past but per his wife, these
were d/c'ed d/t falls and hypotension. His BP's have remained
stable in the 120's-140's range on this regimen. He will be
discharged on metoprolol XL 50mg qDaily. He was also continued
on home amidoarone.
# ___ on CKD
Pt presented with Cr up to 3.0 from baseline of 1.1. ___ was
felt to possibly due to pre-renal volume depletion, ?component
of ATN ___ hypotension, and possibly progressive MM given
worsening SPEP. Cr improved slowly with IVF's and treatment of
infection per above and leveled off at 2.2 on discharge.
# Hematuria
Pt noted to have significant hematuria i/s/o traumatic foley
placement in context of BPH and asa use. Pt also noted to have
3mm stone at R UVJ on admission with associated hydronephrosis.
Urology was consulted and recommended bladder irrigation which
improved the hematuria. Repeat Renal US was done on ___
showed non-obstructing stones and resolved hydro so no
intervention was needed. Foley was removed on ___ and pt
voided well afterwards.
# MM
Unfortunately free light chains seem to be rising and could be
contributing to his renal failure. Outpatient team considering
ninlaro vs carfilzomib vs daratumumab. Deferred to OP Onc team
to discuss further treatment options. Continued acyclovir and
allopurinol, renally dosed
# Psych: Pt noted to be often agitated and likely depressed. He
was continued on home seroquel, duloxetine 30 daily. Plan for
pt to follow-up with ___ on ___.
# CAD, recent NSTEMI: Continued asa, statin initially held in
s/o sepsis but restarted on discharge.
# UC: cont mesalamine, no active diarrhea
TRANSITIONAL ISSUES:
====================
[ ] Further discussion of tx for progressive MM per above
[ ] Pt will need to discuss with OP ___ for likely poorly
controlled depression and poor appetite.
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Allopurinol ___ mg PO DAILY
3. Amiodarone 300 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Dexamethasone 4 mg PO 1X/WEEK (TH)
7. Duloxetine 30 mg PO DAILY
8. Mesalamine 1000 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Vitamin D 1000 UNIT PO QHS
11. pomalidomide 2 mg PO DAILY
12. Cyanocobalamin 100 mcg PO DAILY
13. QUEtiapine Fumarate 25 mg PO QHS
Discharge Medications:
1. Levofloxacin 750 mg PO Q48H Duration: 4 Days
Stop ___
2. Acyclovir 400 mg PO Q12H
3. Allopurinol ___ mg PO DAILY
4. Amiodarone 300 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Cyanocobalamin 100 mcg PO DAILY
8. Dexamethasone 4 mg PO 1X/WEEK (TH)
9. Duloxetine 30 mg PO DAILY
10. Mesalamine 1000 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. pomalidomide 2 mg PO DAILY
13. QUEtiapine Fumarate 25 mg PO QHS
14. Vitamin D 1000 UNIT PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Influenza A
Community Acquired Pneumonia
Afib with RVR
Acute Kidney Injury
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:
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10780962-DS-21
| 10,780,962 | 26,104,369 |
DS
| 21 |
2155-02-05 00:00:00
|
2155-02-05 11:16:00
|
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 periprosthetic femur fracture
Major Surgical or Invasive Procedure:
Open reduction internal fixation of left periprosthetic femur
fracture
History of Present Illness:
HPI: ___ presents after fall from standing (tripped over walker
per report). She noted immediate Left thigh pain. No HS or LOC.
She complains of Left thigh pain and Right buttock pain.
Past Medical History:
HTN
Osteoporosis
HLD
Social History:
___
Family History:
n/c
Physical Exam:
___ ___ Temp: 99.3 PO BP: 109/57 R Lying HR: 92 RR: 18 O2
sat: 96% O2 delivery: Ra
General: Well-appearing, breathing comfortably
MSK:
LLE:
Asleep this AM
Primary dressing c/d/I
Pertinent Results:
___ 06:00PM BLOOD WBC-8.8 RBC-3.01* Hgb-8.3* Hct-25.3*#
MCV-84 MCH-27.6 MCHC-32.8 RDW-13.2 RDWSD-39.8 Plt ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left periprostetic femur fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF L periprosthetic femur
fracture, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise remarkable for a transfusion of 1U pRBCs
for a Hct of 20. She was also noted to have a new left bundle
branch block but was asymptomatic. She will followup with
cardiology as an outpatient.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touchdown weight bearing in the left lower extremity, and will
be discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
Alendronate 70mg
Quetiapine 25mg
Irbesartan 150mg
Docusaste 100mg
Atorvastatin 20mg
HCTZ 25mg
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth q8hr Disp #*80
Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl [Correctol] 5 mg 2 tablet(s) by mouth once a day
Disp #*60 Tablet Refills:*0
3. Calcium Carbonate 1250 mg PO TID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth three times a day Disp #*90 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Enoxaparin Sodium 30 mg SC Q24H
RX *enoxaparin 30 mg/0.3 mL 30 mg subcutaneous q24hr Disp #*28
Syringe Refills:*0
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4hr Disp #*20 Tablet
Refills:*0
7. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
8. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
once a day Disp #*60 Tablet Refills:*0
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
10. Atorvastatin 20 mg PO QPM
11. QUEtiapine Fumarate 25 mg PO QHS
12. TraZODone 50 mg PO QHS:PRN Insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left periprosthetic femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
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:
-Touchdown Weightbearing to the left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 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.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
touchdown weightbearing to the left lower extremity
Treatments Frequency:
Staples will remain for 2 weeks postoperatively. You may
shower, but please refrain from taking a bath for at least 4
weeks. Incision may remain open to air unless. If draining,
can apply gauze dressing.
Followup Instructions:
___
|
10781100-DS-13
| 10,781,100 | 26,128,575 |
DS
| 13 |
2127-01-18 00:00:00
|
2127-01-23 22:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L sided weakness/decreased sensation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ Critical is a ___ ___ male with a PMHx
of
stroke ___ years ago, incidental finding on imaging), DM, HTN,
HL, and blindness ___ B/L glaucoma, per dtr) who presents with
left hemibody weakness.
He was in his USOH until ___, at which time he
experienced dyspnea treated with an albuterol inhaler. He
subsequently developed nausea, vomiting of "clear liquid,"
chills, and BP 180s/100s. He was treated with 10 minutes of his
wife's O2 NC, and then he was asymptomatic except for ongoing
chills.
On ___, the patient reports that he began to experience
left leg heaviness wherein he could not pick his left leg off
the
floor. Per his daughter, he has bilateral leg and arm
"heaviness." At that time, he started using a wheelchair, and he
continued to use it until the day of presentation due to
inability to lift the leg and inability to bear weight on the
left leg when walking. Prior to this, he would ambulate by
gripping onto objects (due to blindness) and with family member
standing behind him at all times for safetly. On ___, per
his
daughter, he could lift his arms, push on her hands with his
hands and feet, and make tight fists (she volunteered this).
He continued to have chills since ___, and he also had a cough
productive of white sputum; despite a reportedly normal CXR, his
PCP started ___ on ___ is d5/10).
On ___, his daughter noticed that he was not holding
his
plate with his left hand as he normally does while eating lunch;
the patient denied that there was a problem. The patient was
brought to the ED at that time, and per the ED notes, the
patient
reported 2 weeks of progressive weakness in bilateral arms and
legs as well as fatigue. The ED notes also noted some confusion
at the onset of weakness. CXR, UA, chem10, and CBC were normal.
NCHCT was also normal. He was discharged with palliative care
follow-up, and a referral for hpspice was made on ___.
On ___, at 4pm, he experienced left hand and arm
weakness such that both limbs were immobile. This started in the
arm, lasted 10 minutes, and then moved to the leg. The weakness
resolved within 30 minutes.
He was put to bet at 10pm on ___. Per his daughter, he often
doesn't fall asleep right away. Per the patient, he was still
awake at 11:45pm when he once again had left-sided weakness
(again arm then leg), and he rang the bell to call his daughter
who saw that his left side was immobilized again. This improved
such as that he was able to lift his left side antigravity
(unsustained).
Past Medical History:
Type 2 diabetes
hypertension
cataract
legally blind
s/p cholecystectomy
s/p abdominal laceration
Social History:
___
Family History:
multiple daughters with thyroid cancer, breast cancer.
Physical Exam:
General: Awake, cooperative, NAD.
HEENT: NC/AT, R scleral injection, no dentition, eyes shut
Neck: Supple
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted. +Bruising in UE.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history with
some difficulty and perseverates on certain details (e.g., leg
weakness) rather than answering questions. Inattentive, unable
to
name ___ backward but able to name ___ backward. Language exam
limited by ___ and blindness. Language is fluent with
intact repetition and comprehension. Normal prosody. There were
no paraphasic errors. Pt was able to name hand, fingers, thumb,
and nails but unable to name knuckles. Could not test reading
due to vision loss. Speech was 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
neglect.
-Cranial Nerves:
II, III, IV, VI: Unable to test pupillary reaction because
pupils
often roll up, patient unable to/declines to open eyes, and
extremely resists manual eye opening. Pupils move in all
directions to command. No objects, lights, or shadows visible in
either eye.
V: Facial sensation intact to light touch.
VII: +L NLFF.
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. +LUE pronation and drift
(unable to supinate). No adventitious movements, such as tremor,
noted. No asterixis noted.
Delt Bic Tri WrE FE IP Quad Ham TA Gastroc EDB
L 4 4+ ___ 3 3 3 0 1 0
R 5 ___ ___ 5 5 5 5
Of note, symptoms improved over course of interview. Initially
unable to sustain antigravity in LUE (able to do ___ but
subsequently able to sustain antigravity for ___. Initially no
antigravity movement in LLE and subsequenty able to lift LLE
proximally for 5s.
-Sensory: R leg 50% LT cf left (patient said had more sensation
in LUE!) Otherwise LT intact. PP intact in arms, 90% left (cf
right). LUE and LLE 80% temp cf right. Proprioception: intact to
high but not low amplitude movements in all 4 extreme.
Vibratory:
decreased sensation bilaterally until knees (intact at knees).
No
extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 1
R 2 2 2 1 1
Plantar response was flexor on right and mute on left.
-Coordination: No intention tremor. No dysmetria on FNF or HKS
bilaterally (difficult to test due to blindness).
-Gait: Deferred while on bed rest.
DISCHARGE EXAM:
Neurologic:
-Mental Status: Alert, oriented x 3. Language exam
limited by ___ but is fluent with normal prosody.
Intact comprehension. Speech was hypophonic and slightly
dysarthric.
-Cranial Nerves:
II, III, IV, VI: Unable to test pupillary reaction because
pupils
often roll up, patient has difficulty opening eyes and
resists manual eye opening
V: Facial sensation intact to light touch.
VII: Face symmetric with activation
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. +LUE pronation and drift
(unable to supinate). No adventitious movements, such as tremor,
noted..
Delt Bic Tri FFlx IP Quad Ham TA Gastroc
L 4+ 4+ ___ difficult to assess 2 1
R 5 ___ 5 difficult to assess 5 5
-Sensory: Pt reports decreased light touch and pinprick (10%
less) on LUE/LLE compared to Right.
Pertinent Results:
___ 01:47AM WBC-8.6 RBC-5.21 HGB-14.9 HCT-44.8 MCV-86
MCH-28.6 MCHC-33.3 RDW-13.6 RDWSD-42.4
___ 01:47AM NEUTS-40.9 ___ MONOS-8.3 EOS-4.1
BASOS-0.5 IM ___ AbsNeut-3.52 AbsLymp-3.94* AbsMono-0.71
AbsEos-0.35 AbsBaso-0.04
___ 01:47AM PLT COUNT-206
___ 01:47AM ___ PTT-34.0 ___
___ 01:47AM GLUCOSE-276* UREA N-10 CREAT-1.0 SODIUM-138
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-25 ANION GAP-17
___ 01:47AM CALCIUM-9.5 PHOSPHATE-2.1* MAGNESIUM-1.8
___ 01:47AM ALT(SGPT)-20 AST(SGOT)-37 ALK PHOS-63 TOT
BILI-0.6
___ 01:47AM cTropnT-<0.01
CTA Head/Neck (___):
1. Moderate narrowing of the right proximal to mid M1 segment,
right P1, and right P2 segments and moderate to severe narrowing
of the right distal V4 segments, likely related to
atherosclerotic disease.
2. Occlusion of the left distal P1 and P2 segments with
reconstitution of the left P3 and P4 segments with chronic
infarction along the left PCA distribution.
3. Approximately 30% stenosis of the left internal carotid
artery at its bifurcation by NASCET criteria. No evidence of
right internal carotid artery stenosis by NASCET criteria.
4. Age indeterminate lacunar infarctions in the right caudate
and left basal ganglia.
5. Multiple small nodules in a peribronchovascular distribution
in the upper lobes, likely infectious or inflammatory in
etiology.
MRI Brain (___):
1. Study is mildly degraded by motion.
2. Right pons 11 x 7 mm acute to subacute infarct with no
evidence of
hemorrhagic transformation.
3. Findings suggestive of right globe vitreous hemorrhage, as
described. While finding may be related to choroid detachment,
an intra-ocular tumor is
not excluded on the basis of this examination. Recommend
correlation with ophthalmologic exam. If clinically indicated,
contrast-enhanced MRI of the orbits may be obtained.
4. Age-related volume loss with chronic infarct in the left
occipital lobe.
DISCHARGE LABS:
___ 01:52AM %HbA1c-7.9* eAG-180*
Cholesterol 181
Triglycerides 275
HDL 37
LDL 89
Brief Hospital Course:
Mr. ___ is a ___ yo male who was admitted on ___ due to concerns for acute ischemic stroke. He was admitted
with a 3 day history of fluctuating L arm and leg weakness. In
the ER a NCHCT was performed and did not demonstrate an acute
infarction or hemorrhage but was notable for old occipital
stroke. CTA demonstrated significant stenosis of multiple
intracranial arteries likely related to atherosclerotic disease.
Although there was concern for stroke, TPA was not given as it
was deferred by the patient's family. He was started on Aspirin
and admitted to the Neurology service for further workup. An
MRI w/o contrast was performed and demonstrated a right pons 11
x 7 mm acute to subacute infarct without hemorrhagic
transformation. His home Amlodipine of 2.5 mg qDay was
increased to 5 mg qDay due to ongoing high blood pressure.
Closer BP control with SBP 120-150 was recommended along with
improved glucose control with goal 150-180.
He was observed overnight with slight improvement in LUE
strength but persistent LLE weakness. There were no new
symptoms. He was evaluated by ___ who recommended ___ rehab
but family preferred discharge to home with outpatient ___.
Patient was advised to follow up with his PCP regarding
adjustment of his Metformin for better blood sugar control.
Lipid panel was notable after discharge for elevated
Triglycerides, low HDL (37), and normal LDL (89); no medications
for hyperlipidemia were started during this hospital course;
further treatment will be deferred to PCP. Of note, his MRI
demonstrated a R globe vitreous hemorrhage, likely contributing
to pain. This was discussed with ophthalmology who recommended
further evaluation with his primary opthalomogist. Finally, Mr.
___ was on a course of Levofloxacin at the time to
admission for CAP; daughter reported he had completed a 5 day
course so the medication was discontinued.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes -ASA () No
4. LDL documented? (X) Yes (LDL = 89) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (X) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? () Yes - (X) No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet -ASA () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (X) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. MetFORMIN (Glucophage) 500 mg PO DAILY
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
6. Restasis (cycloSPORINE) 0.05 % ophthalmic bid
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*1
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*1
3. Docusate Sodium 100 mg PO DAILY
4. Outpatient Occupational Therapy
5. Outpatient Physical Therapy
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
7. Omeprazole 20 mg PO DAILY
8. Restasis (cycloSPORINE) 0.05 % ophthalmic bid
9. MetFORMIN (Glucophage) 500 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute Ischemic Stroke
Diabetes Mellitus
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
LLE>LUE weakness
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of L sided weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Diabetes
Hypertension
We are changing your medications as follows:
INCREASE AMLODIPINE TO 5 MG DAILY
START ASPIRIN 81 MG DAILY
Please discuss increasing your dose of Metformin with your PCP
___ take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
Followup Instructions:
___
|
10781100-DS-14
| 10,781,100 | 21,539,663 |
DS
| 14 |
2129-05-15 00:00:00
|
2129-05-16 09:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ with a history of T2DM, CVA
(residual LLE weakness), HTN (not on medication), and blindness
who presents with 2 days of dyspnea and fever. Two days ago he
became increasingly weak and developed a low grade fever to
100.2. He had a fall while being helped into bed and hit his
knees on the ground. No headstrike. He also had a cough
productive of yellow sputum. The day of admission, he told her
he felt like he needed to go to the hospital so she checked his
vitals and his oxygen saturation was 88%, prompting
presentation.
In the ED, initial vitals were: 98.5 83 117/58 24 93%
Labs were notable for:
WBC 16.7, lactate 2.7
Tbili 2.3
INR 1.6
CXR showed: Left upper lobe consolidation worrisome for
pneumonia.
Patient was given 1L LR, Azithro, ceftriaxone.
On the floor, patient endorses feeling like he can't get enough
air. Denies chest pain or pain anywhere in his body. No knee
pain. No abd pain, nausea, or vomiting. No leg swelling. No pain
with urination. Is incontinent and wears a diaper. No headache
or dizziness.
Review of systems: Per HPI
Past Medical History:
Type 2 diabetes
hypertension (no longer on medication)
CVA
cataract
?retinal hemorrhage
legally blind
s/p cholecystectomy
s/p abdominal laceration
Social History:
___
Family History:
multiple daughters with thyroid cancer, breast cancer.
Physical Exam:
ADMISSION:
Vital Signs: 97.4PO 133/74 73 18 92 2L
General: Sleeping but arousable. NAD.
HEENT: Sclerae anicteric, MMM
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Crackles in LLL, no wheezes or rhonchi; +cough productive
of yellow sputum
Abdomen: Soft, non-tender, non-distended, no rebound or guarding
DISCHARGE:
VS: 98.2 PO 162 / 85 78 18 93% RA
GENERAL: Elderly man lying in bed with eyes closed, chronically
ill-appearing, intermittent nonproductive cough, in NAD
N: A&OX1 (didn't know month/where he was)
HEENT: Eyes closed with some discharge, MMM, JVP < 10cm
CV: RRR with normal S1 and S2, no murmurs/rubs/gallops
RESP: Breathing comfortably on RA with intermittent coughing,
faint crackles over R anterior thorax
GI: Abd soft, nontender/nondistended
GU: No CVA or suprapubic tenderness
Ext: WWP, no peripheral edema
Pertinent Results:
ADMISSION LABS:
___ 03:20PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 01:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-TR* BILIRUBIN-SM* UROBILNGN-4* PH-5.5
LEUK-NEG
___ 01:50PM URINE RBC-2 WBC-8* BACTERIA-FEW* YEAST-NONE
EPI-1 TRANS EPI-<1
___ 01:46PM LACTATE-2.7*
___ 01:37PM GLUCOSE-161* UREA N-27* CREAT-1.2 SODIUM-142
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-22 ANION GAP-21*
___ 01:37PM ALT(SGPT)-24 AST(SGOT)-48* ALK PHOS-107 TOT
BILI-2.3*
___ 01:37PM LIPASE-49
___ 01:37PM ALBUMIN-3.6 CALCIUM-9.1 PHOSPHATE-4.2
MAGNESIUM-1.4*
___ 01:37PM WBC-16.7* RBC-4.86 HGB-13.9 HCT-42.6 MCV-88
MCH-28.6 MCHC-32.6 RDW-14.6 RDWSD-47.2*
DISCHARGE LABS:
___ 06:52AM BLOOD WBC: 7.2 RBC: 4.57* Hgb: 13.0* Hct: 39.8*
MCV: 87 MCH: 28.4 MCHC: 32.7 RDW: 14.5 RDWSD: 46.___
___ 06:52AM BLOOD Glucose: 190* UreaN: 13 Creat: 0.7 Na:
140 K: 3.9 Cl: 100 HCO3: 26 AnGap: 14
___ 06:52AM BLOOD ALT: 70* AST: 57* LD(LDH): 142 AlkPhos:
178* TotBili: 0.7
___ 06:52AM BLOOD Calcium: 9.0 Phos: 3.6 Mg: 1.9
PERTINENT FINDINGS:
Labs:
ALT/AST ___: 110* 196*
CXR ___
FINDINGS:
There is new focal consolidation in the left mid lung localizing
to the upper lobe. Lungs are otherwise clear. Cardiac
silhouette is within normal limits. Tortuosity of the thoracic
aorta again noted. Hypertrophic changes are identified in the
spine.
IMPRESSION:
Left upper lobe consolidation worrisome for pneumonia.
CXR ___:
IMPRESSION:
Comparison to ___. Increasing parenchymal opacities on
the left,
notably in the left perihilar areas, potentially reflecting
pneumonia of
increasing severity. Stable mild cardiomegaly. Stable
elongation of the
descending aorta. No pleural effusions. No pulmonary edema.
RUQUS ___:
IMPRESSION:
No acute abdominal process. Normal ultrasound appearance of the
liver. No focal hepatic mass. No intra or extrahepatic bile
duct dilation.
Brief Hospital Course:
Mr. ___ is a ___ year old man with a history of T2DM, CVA
(residual LLE weakness), HTN (not on medication), and blindness
who presented with 2 days of dyspnea, cough and fever, found to
have a LUL pneumonia.
#Pneumonia
Patient presented with hypoxia, cough, fever and LUL infiltrate
on CXR. Given no recent hospitalizations, no risk factors for
resistant organisms, was initially treated for CAP with
ceftriaxone/azithromycin. He spiked a fever on to 101.8 on ___
with CXR showing slightly worsened L-sided opacities. He was
broadened to cefepime/vancomycin. It is unclear why he spiked
through his original course but the differential includes
aspiration pneumonitis and viral illness. The team spoke with
his daughter about making him NPO and getting an SLP eval, and
she was clear that this is not within his GOC. He remained
afebrile on his new regimen, was satting in the ___ on room air,
was breathing comfortably on exam, and had a normal WBC. He was
discharged on levaquin to complete a total 8-day course since
being febrile (___).
#LFT abnormalities
AST and ALT were elevated and peaked at ALT 110 AST 196 on ___,
then downtrended to the 70/57 on day of discharge. The etiology
was unclear but differential includes drug toxicity and viral
illness. Abdominal exam remained benign and RUQUS was
unrevealing. CK was normal, making skeletal muscle breakdown
unlikely. He should get followup LFTs with his PCP next week.
#Weakness
Patient had generalized weakness, likely in the setting of
infection. ___ saw ___ and family expressed strong preference for
him to be at home, therefore will go home with home ___ services.
#Coagulopathy
Pt had mildly elevated INR to 1.6, not on anticoagulation.
Likely due to poor PO intake in the setting of illness or
disruption of normal gut flora from antibiotics. He had no
signs/sx of bleeding and was monitored.
#Altered mental status
#Memory impairment
Patient had waxing/waning mental status. Per daughter, at
baseline patient often does not know where he is, what month it
is. States his long-term memory is intact but has poor
short-term memory. He was put on delirium precautions and
monitored.
CHRONIC/RESOLVED ISSUES:
___
Admission Cr 1.2, likely prerenal as patient's daughter states
he had poor PO intake since ___. He was given intermittent fluid
boluses and PO intake was encouraged. His Cr was down to 0.7 on
discharge.
#CVA
He was continued on his home atorvastatin and aspirin.
#Type 2 DM
His home metformin was held and a gentle insulin sliding scale
was started, and his sugars remained well-controlled.
TRANSITIONAL ISSUES:
- New Meds: levofloxacin, last day ___
- Stopped/Held Meds: None
- Changed Meds: none
- Repeat labs (Rx given) at ___ ___ ___
- Patient wants to eat and drink per his personal preference,
aspiration diet is not within goals of care
- Discharge Cr: 0.7
# CODE: DNI/DNR (MOLST on file)
# CONTACT: ___
Relationship: Daughter
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 425 mg PO BID
2. Atorvastatin 10 mg PO QPM
3. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line
4. Aspirin 81 mg PO DAILY
5. Melatin (melatonin) 5 mg oral QHS
6. Acetaminophen 500 mg PO BID
7. Tamsulosin 0.4 mg PO DAILY
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough
9. Loratadine 10 mg PO DAILY:PRN allergies
Discharge Medications:
1. Levofloxacin 500 mg PO Q48H
Last day ___.
RX *levofloxacin 500 mg 1 tablet(s) by mouth every 48 hours Disp
#*2 Tablet Refills:*0
2. Acetaminophen 500 mg PO BID
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First
Line
7. Loratadine 10 mg PO DAILY:PRN allergies
8. Melatin (melatonin) 5 mg oral QHS
9. MetFORMIN (Glucophage) 425 mg PO BID
10. Tamsulosin 0.4 mg PO DAILY
11.Outpatient Lab Work
794.8 ICD 9: Elevated LFTs
BMP, AST/ALT/Tbili/Dbili/Alk phos fax results to ___
___ MD ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
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 had fevers,
shortness of breath, and weakness.
- You were found to have a pneumonia, which is a lung infection.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
- We gave you antibiotics to fight the pneumonia and oxygen to
help you breathe comfortably.
WHAT SHOULD YOU DO WHEN YOU GET HOME?
1) Please follow up at your outpatient appointments.
2) Please take your levofloxacin as prescribed. The last day you
will take it is ___.
WHAT ARE REASONS TO RETURN TO THE HOSPITAL?
- If you feel short of breath.
- If you have a fever.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
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2132-09-06 12:54:00
|
Name: ___ (MD) Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
mirtazapine
Attending: ___.
Chief Complaint:
hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___, ___ speaking, with PMH of Diabetes Type II, ___, CVA
presenting after syncopal episode this AM. Patient reports
taking AM lantus and humalog, then "waiting too long" to eat
something, and then having syncopal episode. He does not
remember circumstances leading up to fall, but was found by his
neighbor who reportedly said he hit his head falling down, was
very confused after fall. She put some sugar in his mouth and he
gradually became less confused over 15 minutes. ___ glucose done
by EMS was 48. No history of shaking/bowel/bladder
incontinence/prodrome. No headache, nausea, vomiting,
aspiration. No focal neurological deficits.
In the ED, initial VS were 97.7 60 140/60 16 98% RA. Received
home meds in the ED. EKG showed RBBB (baseline), no ST changes.
Negative troponin. CT Head/C-spine unremarkable/no acute
process. CXR no acute process. Transfer VS were 64 155/56 18
99%RA.
On arrival to the floor, patient reports that he has no
complaints. He reports that he has had 3 other syncopal episodes
- ___ and ___ and now today ___. He reports
some anxiety and sweating prior to losing consciousness. He is
unsure if he took insulin without eating those other times. He
was found by neighbor each time and awoke and ate something
sweat. He denies associated CP, palpitations, vision changes,
lightheadedness or head strike. He denies fevers/chills,
weakness, numbness, dysuria, cough.
Past Medical History:
DMII ___, on insulin ___
___
BPH
PERIPHERAL VASCULAR DISEASE - status post femoral to dorsalis
pedis graft in ___ and ___
BRANCH RETINAL ARTERY OCCLUSION
s/p CVA in ___ (reports some mild weakness and numbness in
right hand, no other residual deficits)
HTN
HLD
ORTHOSTATIC HYPOTENSION
CKD
INSOMNIA
ANEMIA
ERECTILE DYSFUNCTION
*S/P R HERNIORRHAPHY
NEPHROPATHY
NEUROPATHY
URINARY RETENTION (straight caths ___
GERD
CONSTIPATION
H/O RENAL CALCULUS
H/O DUODENAL ULCER
Social History:
___
Family History:
Anemia, diabetes, stroke, hypertension.
Physical Exam:
Admission Exam:
VS - 97.4, 164/82, 72, 20, 96%RA
GEN - Alert, awake, no acute distress
HEENT - NC/AT, MMM, EOMI, sclera anicteric, OC/OP clear
NECK - supple, no JVD, no LAD
PULM - CTAB
CV - RRR, no m/r/g
ABD - +BS, soft, NT/ND, no guarding or rebound
EXT - WWP, no c/c/e
NEURO - CN II-XII intact, ___ strength BLE/BUE. Intact to light
touch BLE/BUE
Discharge Exam:
VS: afeb, stable, but ~40pt SBP drop from sitting to standing,
asymptomatic
___: In last 24hrs: 182-319; total Humalog 16units, 6units Lantus
qhs
GEN - Alert, awake, no acute distress
PULM - CTAB
CV - RRR, no m/r/g
ABD - +BS, soft, NT/ND, no guarding or rebound
EXT - WWP, no c/c/e
Pertinent Results:
Admission Labs:
___ 01:30PM BLOOD WBC-8.0 RBC-3.80* Hgb-11.0* Hct-33.8*
MCV-89 MCH-29.0 MCHC-32.6 RDW-12.6 Plt ___
___ 01:30PM BLOOD Neuts-83.1* Lymphs-10.3* Monos-5.5
Eos-0.8 Baso-0.2
___ 07:45AM BLOOD ___ PTT-27.6 ___
___ 01:30PM BLOOD Glucose-183* UreaN-27* Creat-1.1 Na-137
K-4.4 Cl-105 HCO3-23 AnGap-13
___ 07:45AM BLOOD Calcium-9.8 Phos-3.0 Mg-1.8
.
Discharge Labs:
___ 08:15AM BLOOD WBC-6.2 RBC-4.05* Hgb-11.9* Hct-35.1*
MCV-87 MCH-29.3 MCHC-33.9 RDW-13.0 Plt ___
___ 08:15AM BLOOD Glucose-226* UreaN-29* Creat-1.2 Na-135
K-4.2 Cl-100 HCO3-26 AnGap-13
___ 08:15AM BLOOD Calcium-8.8 Phos-2.7 Mg-2.1
.
Cardiac Enzymes:
___ 01:30PM BLOOD cTropnT-<0.01
___ 07:45AM BLOOD CK-MB-5 cTropnT-<0.01
.
Micro:
Blood culture x2 - PENDING
.
Imaging:
___ CT Head without contrast: IMPRESSION: No acute intracranial
process. Chronic changes as above.
.
___ CT C-spine without contrast: IMPRESSION: No evidence of
acute fracture or dislocation.
.
___ CXR: IMPRESSION: Mild bibasilar atelectasis. Mild
cardiomegaly. Otherwise, unremarkable.
Brief Hospital Course:
___, ___ speaking, with PMH of Diabetes Type II, dCHF, CVA
presenting after syncopal episode ___ found to have ___ 48.
Active issues:
# Syncope due to hypoglycemia: Took AM insulin and then no food.
EMS reported ___ 48. Patient reports that this is his ___
syncopal episode in the last week which is highly concerning. On
review of records, pt has had numerous hypoglycemic episodes
that were being managed by education/reduction in insulin dosing
as an outpt. No evidence for cardiac, stroke or seizure based on
history or exam. Patient was maintained on telemetry with no
events. We held his home insulin regimen and home metformin and
initially maintained him on a gentle insulin sliding scale.
Based on humalog need of approximately 16units total daily, pt
was initially started on Lantus 6 units qhs. Attempts were made
to teach patient the sliding scale (with ___ interpreter
present) but he was unable to display adequate understanding. As
a result, we discharged him without a sliding scale and no meal
time insulin but increased his lantus to 10 units qhs. We also
provided the patient with Lantus Solostar that was set to 10
units at time of discharge. We felt that this would ensure less
room for error at home. We instructed patient to not restart
Metformin.
# Orthostasis: Patient with significant orthostasis ___ SBP
drop from sitting to standing) that was not fluid responsive. He
denies any symptoms with his orthostasis. We stopped his
metoprolol and indapamide as this may have contributed to his
orthostasis. He had no rebound tachycardia. We changed his
lisinopril and amlodipine to be dosed in the evening (but did
not change the dose itself). We continued his tamsulosin as pt
has evidence of significant urinary retention requiring
self-cath at home (see below). Finally, consideration for reason
for othrostasis - we considered possible autonomic neuropathy
secondary to progression of his diabetes. However, he has little
other evidence of end-organ damage. We also considered the
diagnosis of ___ disease as pt does have a resting
tremor and shuffling gait.
# BPH/Urinary retention: Patient was monitored for evidence of
retention. The evening of ___, patient's bladder scan was 600 cc
and he was straight cathed. Did not require additional straight
cath during this admission. We continued his home tamsulosin.
# ___: Patient noted to have a bump in his Cr to 1.4 after
episode of urinary retention (see above). ___ have a component
of dehydration - got 1L NS bolus ___. The next morning, Cr had
returned to baseline of 1.2.
Chronic issues:
# HLD: Continued home simvastatin
# GERD: Continued home ranitidine
# HTN/dCHF: Continued home Amlodipine, Lisinopril, ___
81. Amlodipine/Lisinopril now dosed in the evening. D/c'd home
metoprolol and indapamide as above.
# Constipation: Continued home Docusate
Transitional issues:
-EMERGENCY CONTACT: ___ ("relative"): ___ ___
(son):
-Code status: Full (confirmed)
-Consider ___ disease as diagnosis for orthostasis
-Patient needs close follow-up for management of his diabetes.
Despite pt's meticulous records, it is unclear he is taking his
medications properly at home. During admission, pt did not have
a significant insulin requirement and he was discharged on a
significantly reduced regimen. He was unable to demonstrate
understanding of a sliding scale and insulin administration.
-Patient was adamant that he knew how to take his insulin but
was unable to demonstrate this to nursing staff.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Indapamide 2.5 mg PO DAILY
4. Aspart 20 Units Breakfast
Aspart 20 Units Lunch
Aspart 20 Units Dinner
Glargine 28 Units Breakfast
Glargine 28 Units Bedtime
5. Lisinopril 40 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Metoprolol Tartrate 100 mg PO BID
8. Potassium Chloride 10 mEq PO DAILY
9. Simvastatin 20 mg PO DAILY
10. Tamsulosin 0.4 mg PO HS
11. Aspirin 81 mg PO DAILY
12. Docusate Sodium 100 mg PO HS
13. Ranitidine 150 mg PO DAILY
14. valerian root *NF* unknown mg Oral qhs:PRN insomnia
Discharge Medications:
1. Amlodipine 10 mg PO HS
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO HS
5. Lisinopril 40 mg PO HS
6. Ranitidine 150 mg PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. valerian root *NF* 0 mg ORAL QHS:PRN insomnia
Resume home dose
10. Glargine 10 Units Bedtime
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hypoglycemia
Orthostasis
Diabetes Mellitus
Urinary retention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at ___. You were admitted
after you were found unconscious at home. We believe this was
because your blood sugar was very low (it was 48). You reported
that you had taken your insulin but did not eat anything. You
also told us that this was the ___ time you had loss
consciousnss in the last week. This is very concerning because
if you lose consciousness due to low blood sugar you could have
significant brain damage or even die. We stopped your metformin
and reduced the amount of insulin you are taking.
Additionally, we found that your blood pressure drops
significantly when you move from sitting to standing. This
change (called orthostasis) can also lead to loss of
consciousness, though you denied any dizziness. We stopped your
metoprolol and indapamide. You continued to have drops in your
blood pressure. This may be due to progression of your diabetes.
It is very important that you follow up with your primary care
doctor.
Followup Instructions:
___
|
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2144-09-01 00:00:00
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2144-09-01 11:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Neck Pain
Upper Extremity Weakness
Major Surgical or Invasive Procedure:
___ C4-C6
Posterior Cervical Fusion C4-C6
History of Present Illness:
___ male with history of cervical spine stenosis presents status
post ground-level fall. Neuro intact on exam. CT CT and
L-spine without obvious fracture or traumatic malalignment. MRI
C-spine with degenerative stenosis worst at C5-6 also with
likely acute injury contributing to stenosis. Patient with cord
signal change at C5-6. Plan for admission to orthospine.
Past Medical History:
Past Medical History:
-HTN
-HLD
-PVCs
-Gout
-Rheumatoid Arthritis
Past Surgical History:
-Left TKR
-Right THR
-Rotator cuff repair (bilateral)
-Tonsillectomy
-Appendectomy
Social History:
___
Family History:
NC
Physical Exam:
AVSS
Well appearing, NAD, comfortable, facial bruising from fall
BUE: SILT C5-T1 dermatomal distributions
BUE: ___ Del/Tri/Bic/WE/WF/FF/IO
BUE: tone normal, negative ___, 2+ symmetric DTR
bic/bra/tri
All fingers WWP, brisk capillary refill, 2+ distal pulses
BLE: SILT L1-S1 dermatomal distributions
BLE: ___ ___
BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle
All toes WWP, brisk capillary refill, 2+ distal pulses
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as
tolerated.Foley was removed on POD#2. Physical therapy and
Occupational therapy were consulted for mobilization OOB to
ambulate and ADL's.Hospital course was otherwise unremarkable.On
the day of discharge the patient was afebrile with stable vital
signs, comfortable on oral pain control and tolerating a regular
diet.
Medications on Admission:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
5. TraMADol 25 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
5. TraMADol 25 mg PO Q6H:PRN pain
6. Allopurinol ___ mg PO DAILY
7. Diltiazem Extended-Release 120 mg PO DAILY
8. Hydroxychloroquine Sulfate 200 mg PO DAILY
9. Lisinopril 10 mg PO DAILY
10. Pravastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Cervical Stenosis
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:
ACDF:
You have undergone the following operation:Anterior Cervical
Decompression and Fusion.
Immediately after the operation:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit in a car or chair for more than~45 minutes without
getting up and walking around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.
Swallowing:Difficulty swallowing is not
uncommon after this type of surgery.This should resolve over
time.Please take small bites and eat slowly.Removing the collar
while eating can be helpfulhowever,please limit your movement
of your neck if you remove your collar while eating.
Cervical Collar / Neck Brace:If you have been
given a soft collar for comfort, you may remove the collar to
take a shower or eat.Limit your motion of your neck while the
collar is off.You should wear the collar when walking,especially
in public.
Wound Care:Remove the dressing in 2 days.If the
incision is draining cover it with a new sterile dressing.If it
is dry then you can leave the incision open to the air.Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower.Do not soak the incision in a
bath or pool.If the incision starts draining at anytime after
surgery,do not get the incision wet.Call the office at that
time. f you have an incision on your hip please follow the same
instructions in terms of wound care.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions,so plan ahead.You can either have them
mailed to your home or pick them up at the clinic located on
___.We are not allowed to call in narcotic
(oxycontin,oxycodone,percocet) prescriptions to the pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision,take baseline x rays and answer any questions.
___ We will then see you at 6 weeks from the
day of the operation.At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound,or have any questions.
Posterior Cervical Fusion
You have undergone the following operation: Posterior Cervical
Decompression and Fusion
Immediately after the operation:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit in a car or chair for more than~45 minutes without
getting up and walking around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Cervical Collar / Neck Brace:You need to wear
the brace at all times until your follow-up appointment which
should be in 2 weeks.You may remove the collar to take a
shower.Limit your motion of your neck while the collar is
off.Place the collar back on your neck immediately after the
shower.
Wound Care:Remove the dressing in 2 days.If the
incision is draining cover it with a new sterile dressing.If it
is dry then you can leave the incision open to the air.Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower.Do not soak the incision in a
bath or pool.If the incision starts draining at anytime after
surgery,do not get the incision wet.Call the office at that
time.If you have an incision on your hip please follow the same
instructions in terms of wound care.
You should resume taking your normal home
medications
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___ 2.We are not allowed to call in narcotic
prescriptions (oxycontin,oxycodone,percocet) to the pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision,take baseline x rays and answer any questions.
___ We will then see you at 6 weeks from the
day of the operation.At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit,drainage from your wound,or have any questions.
Physical Therapy:
Activity: as tolerated, ___ j when oob, may remove for
hygiene when upright.
Treatments Frequency:
Wound care:
Site: anterior neck
Type: Surgical
Dressing: Gauze - dry
Wound care:
Site: posterior neck
Type: Surgical
Dressing: Gauze - dry
Followup Instructions:
___
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2127-09-02 19:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cortisone / cholesterol med
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with end-stage renal disease on ___
dialysis presenting with a few days of worsening shortness of
breath. After waking this morning he noted that he was almost
unable to breathe and came to the emergency room. He attended
all of his HD sessions this week, but remarked that there was
trouble with his ___ session with establishing/maintaining
access.
He reports taking all of his medications as prescribed over the
past few weeks. He denies any chest pain. He has not felt ill
lately, no fever/cough, no sick contacts. He has had no abd
pain, nausea/vomiting. He does not make urine.
Of note, he was admitted ___ for acute shortness of breath
that was attributed to flash pulmonary edema. Specific etiology
was not identified, he improved with 2L off at HD and starting
imdur 30mg for afterload reduction.
In the ED, initial vital signs were T97.2 BP210/95 HR32 100%
4LNC. Patient was vol overloaded on exam, CXR showed pulm edema.
Labs notable for K 5.5, Cr 7.7, HCO3 20 AG 16.5. He was
transferred to for HD before arriving on the floor.
In HD the patient was feeling well, shortness of breath had
resolved. He was otherwise feeling like his regular self.
Review of Systems:
(+) Per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
-DM type 2
-ESRD on HD (MWF) since ___
-COPD mild-to-moderate airway obstruction
SPIROMETRY
Actual Pred %Pred
FVC 1.75 3.71 47
FEV1 0.98 2.47 ___
MMF 0.41 2.33 18
FEV1/FVC 56 67 85
-CAD with history of MI in ___ in ___, no known treatment
-BPH
-Gout
-Hypertension
-Bilateral cataract extractions
-Diabetic Retinopathy
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: 97.2, 73, 18, 174/68, 100% 3LNC
General: awake, alert, NAD
HEENT: no conjunctival iceterus or pallor, MMM, OP clear
Neck: supple, no JVD or cervical LAD
Lungs: Bibasilar crackles, no wheezes or rhonchi
CV: RRR, normal S1/S2, no rubs
Abdomen: softly distended, nontender, no rebound tenderness or
guarding
Ext: thin, warm, no edema
Access: radiocephalic AVF with mild aneurysmal dilations,
+palpable thrill and audible bruit throughout cardiac cycle
DISCHARGE EXAM
O2 saturation 94-96% RA
Pertinent Results:
___ 07:00AM BLOOD WBC-8.6# RBC-3.87* Hgb-11.9* Hct-36.1*
MCV-93 MCH-30.7 MCHC-32.9 RDW-15.2 Plt ___
___ 07:45AM BLOOD WBC-5.4 RBC-3.41* Hgb-10.0* Hct-31.4*
MCV-92 MCH-29.4 MCHC-31.9 RDW-15.2 Plt ___
___ 07:00AM BLOOD Neuts-67.9 Lymphs-16.8* Monos-3.9
Eos-11.0* Baso-0.4
___ 07:00AM BLOOD ___ PTT-33.9 ___
___ 07:00AM BLOOD Glucose-85 UreaN-51* Creat-7.7*# Na-138
K-5.5* Cl-102 HCO3-20* AnGap-22*
___ 07:45AM BLOOD Glucose-76 UreaN-38* Creat-5.9*# Na-141
K-5.0 Cl-100 HCO3-27 AnGap-19
___ 07:00AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.8*
___ 07:45AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.5
___ 07:10AM BLOOD Lactate-1.0
MICRO
Blood Culture ___
No growth to date
IMAGING
CXR ___
Chest, portable. Bilateral hazy opacities and indistinctness of
the pulmonary
vasculature is consistent with mild pulmonary edema. Emphysema
is also
present. The lungs are otherwise clear. The hilar and
cardiomediastinal
contours are normal. There is no pneumothorax or pleural
effusion.
IMPRESSION:
Pulmonary edema which is mild radiographically. However, given
the background
of emphysema, the edema could be more significant clinically.
ECHO
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is top normal/borderline dilated.
Overall left ventricular systolic function is moderately
depressed (LVEF= 35-40 %) with basl to mid infero-septal,
inferior and infero-lateral hypokinesis. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Moderate (2+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate to severe pulmonary artery systolic hypertension.
There is a very small pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the report of the prior study (images unavailable
for review) of ___, no definite change.
Brief Hospital Course:
___ with CAD DM HTN and ESRD on HD presents with dyspnea and vol
overload.
# Dyspnea: Patient appears vol overloaded on exam, pulm edema on
CXR, likely due to problems with HD on ___, improved with HD
today. It was thought that he flashed during last admission, and
given pressures systolic 210 in ED, possibility that he flashed
again. Crit was stable. Amlodipine increased 5->10mg, Imdur
increased 30->60mg. EKG unchanged. Echo unchanged.
# HTN: Presented with BP 210 in the context of possible flash.
Imdur added for this last admission ___.
- increase amlodipine 5->10mg
- cont carvedilol 25mg BID
- Increase Imdur 30->60mg
- cont losartan 100mg daily
CHRONIC ISSUES:
# COPD: No evidence of exacerbation, no wheezes on exam, no e/o
URI/PNA.
# ESRD: Likely due to HTN and DM, HD ___, per patient reports
issues with HD on ___. Anemia at baseline. Underwent HD as
scheduled, symptoms improved with 3L ultrafiltration.
# CAD: MI ___, no known intervention, no evidence of cardiac
event by history.
# Gout- reduce allopurinol to 100mg daily
# DM: Diet controlled, A1C 5.6 ___
# Depression: Cont citalopram
TRANSITIONAL ISSUES:
- Uptitrated amlodipine and Imdur to 10mg and 60mg respectively.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 5 mg PO DAILY
Hold for SBP <120 or HR<60
3. Aspirin 81 mg PO DAILY
4. Carvedilol 25 mg PO BID
hold for SBP<120 or HR<60
5. Docusate Sodium 100 mg PO BID constipation
6. Losartan Potassium 100 mg PO DAILY
hold for SBP<120
7. Nephrocaps 1 CAP PO DAILY
8. sevelamer CARBONATE 2400 mg PO TID W/MEALS
take with meals
9. Systane *NF* (peg 400-propylene glycol) 0.4-0.3 % ___
10. Albuterol Inhaler 2 PUFF IH Q4-6 HR
11. Hydrocortisone (Rectal) 2.5% Cream ___ TIMES A DAY
rectal pain
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
13. Citalopram 5 mg PO DAILY
14. Budesonide Nasal Inhaler *NF* 90-80 mg Other BID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4-6 HR
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Carvedilol 25 mg PO BID
6. Citalopram 5 mg PO DAILY
7. Docusate Sodium 100 mg PO BID constipation
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1 tablet extended release 24
hr(s) by mouth once daily Disp #*30 Tablet Refills:*0
9. Losartan Potassium 100 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. sevelamer CARBONATE 2400 mg PO TID W/MEALS
12. Budesonide Nasal Inhaler *NF* 90-80 mg OTHER BID
13. Hydrocortisone (Rectal) 2.5% Cream ___ TIMES A DAY
rectal pain
14. Systane *NF* (peg 400-propylene glycol) 0.4-0.3 % ___
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary edema secondary to end stage renal disease
Secondary diagnosis:
Chronic obstructive pulmonary disease
congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at ___
___.
You were admitted with shortness of breath. Your blood pressure
was very high and we think you had extra fluid in your lungs.
You underwent dialysis yesterday and are improved. Your heart
was examined, and it was determined that there is no new
dysfunction- it is unchanged from before.
We increased your blood pressure medications - amlodipine and
imdur. Please resume dialysis as per your regular dialysis
schedule. We have set you up with a new cardiologist (heart
doctor) and pulmonologist (lung doctor). Please see below for
your follow-up appointments.
Followup Instructions:
___
|
10781468-DS-27
| 10,781,468 | 23,523,775 |
DS
| 27 |
2128-08-18 00:00:00
|
2128-08-19 23:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cortisone / cholesterol med
Attending: ___.
Chief Complaint:
Abdominal pain/distension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o male with a history of CAD, sCHF (EF 35-40%), COPD, DM2,
HTN, ESRD on HD (MWF), and recent UGIB secondary to gastric
ulcer s/p embolization left gastric artery and distal
gastroepiploic artery ___, rehospitilizaed ___ for
significant Hct drop (29.4 on ___ -> 17.7 on admission) s/p 2u
of pRBCs with an appropriate bump in hct to 25, now transferred
from home today for hypoxia (84-90% RA), nausea, and abdominal
distension. States he began feeling nauseous around 9 am after
drinking a shake. No abomdinal pain, spitting up saliva, no
blood. No bloody or black stools. No chest pain, baseline
non-productive cough. Last dialysed ___.
Of note, on ___, pt underwent EGD which showed a large clot
in stomach, evidence of ischemic changes in the setting of
recent embolization, and no active bleeding, no interventions.
In the ED initial vitals were: 98.3 68 174/54 18 97% 2L NC
- physical exam O: friction rub, bilateral exp wheeze, dim R
base, mild distension w/o rebound ro guarding, guiac pos brown
stool.
- Labs were significant for lactate 0.8, K 5.5, BUN 37,
creatinine 5.6, bicarb 28, BNP 37876 (previously ___, Hct
30.6 (improved from prior discharge)
- Patient was given zofran
- CT abdomen and pelvis with contrast: Comparison to ___,
interval increase in pleural and pericardial effusions.
Increasing basilar atelectasis. No acute intra-abdominal
abnormalities identified.
- CXR - bilaeral interstitial edema
- EKG - LAFB, unchanged from prior
- Bedside US - small R pleural effusion, B lines, no pericardial
eff, good squeeze
Vitals prior to transfer were: 68 168/72 16 98% Nasal Cannula
On the floor, continues to report nausea, but no other symptoms.
He was discharged from rehab back to home yesterday. Denies
fevers, chills, abdominal pain, diarrhea. +constipation for 3
days. Has been complaint with low salt diet, taking all his
medications, and going to dialysis sessions. Per son, was told
by rehab that his BP has been very elevated the last three days
while in rehab. Does not make any urine.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, shortness of breath, chest
pain, abdominal pain, vomiting, diarrhea, BRBPR, melena,
hematochezia.
Past Medical History:
-DM type 2, diet controlled
-ESRD on HD (MWF) since ___
-COPD mild-to-moderate airway obstruction
SPIROMETRY
Actual Pred %Pred
FVC 1.75 3.71 47
FEV1 0.98 2.47 40
MMF 0.41 2.33 18
FEV1/FVC 56 67 85
-CAD with history of MI in ___ in ___, no known treatment,
EF in ___ ECHO 35-40 % with basl to mid infero-septal, inferior
and infero-lateral hypokinesis.
-BPH
-Gout
-Hypertension
-Bilateral cataract extractions
-Diabetic Retinopathy
-Hemmorhoids
-blindness
Social History:
___
Family History:
No history of kidney disease, heart disease, DM
Physical Exam:
ADMISSION EXAM:
=========================
Vitals - T: 96.6 BP: 170/60 HR: 67 RR: 16 02 sat: 100% on 2L NC
General: Thin, fatigued but alert, oriented, no acute distress
HEENT: Normalocephalic/atraumatic, surgical L pupil, R pupil
RRL, dry MM, OP clear
Neck: supple, JVD 10cm
Lungs: crackles in bilateral bases L>R, no wheezes/rhonchi, no
use of accessory muscles
CV: Regular rate and rhythm, ___ holosystolic murmur best heard
at ___, no rubs/gallops
Abdomen: soft, non-tender, hypoactive sounds, no rebound
tenderness or guarding
Ext: Warm, well perfused, 1+ pulses, no clubbing or cyanosis, 1+
edema in b/l ankles. R arm fistula with good thrill/bruit
Skin: No rashes or lesions
Neuro: A&O x 3, CNs III-XII grossly intact, +mild asterixis,
sensation to light touch intact throughout, ___ strength in the
extremities while lying in bed.
DISCHARGE EXAM:
=========================
Vitals- Pre HD weight 57kg (last post 55kg) 97.7 174/54
(141-184/45-60) 72 18 92-93% 0.5L NC, 91% 2LNC this am
Ambulatory sat 87% on RA, 94% on 1LNC
Orthostatics: Seated BP 163/69 P 69
Standing BP 141/45 P 72
General: Thin gentleman, resting comfortably at HD
HEENT: Anicteric, surgical L pupil, R pupil RRL, MMM, OP clear
Neck: supple, no appreciable JVD or LAD
Lungs: anterior exam with clear breath sounds
CV: Regular rate and rhythm, ___ systolic murmur best heard at
RUSB, LUSB, no rubs/gallops
Abdomen: soft, NTND, + BS
Ext: Warm, well perfused, 1+ pulses, no clubbing or cyanosis, no
peripheral diseases. R arm fistula accessed
Skin: No rashes or lesions
Neuro: CN III-XII grossly intact
Pertinent Results:
ADMISSION LABS:
=========================
___ 11:59PM SODIUM-136 POTASSIUM-5.0 CHLORIDE-94*
___ 11:59PM FREE T4-1.3
___ 05:07PM LACTATE-0.8
___ 04:50PM GLUCOSE-110* UREA N-37* CREAT-5.6*#
SODIUM-133 POTASSIUM-5.5* CHLORIDE-91* TOTAL CO2-28 ANION GAP-20
___ 04:50PM ALT(SGPT)-10 AST(SGOT)-34 LD(LDH)-348*
CK(CPK)-90 ALK PHOS-100 TOT BILI-0.3
___ 04:50PM LIPASE-21
___ 04:50PM cTropnT-0.05*
___ 04:50PM CK-MB-1 ___
___ 04:50PM CALCIUM-9.2 PHOSPHATE-3.7 MAGNESIUM-2.4
___ 04:50PM TSH-5.0*
___ 04:50PM CRP-7.4*
___ 04:50PM WBC-6.6 RBC-3.19* HGB-9.5* HCT-30.6* MCV-96
MCH-29.9 MCHC-31.2 RDW-16.1*
___ 04:50PM NEUTS-75.9* LYMPHS-14.1* MONOS-4.7 EOS-5.1*
BASOS-0.2
___ 04:50PM ___ PTT-23.5* ___
___ 04:50PM PLT COUNT-226
PERTINENT LABS:
=========================
___ 09:45AM BLOOD WBC-5.1 RBC-3.44* Hgb-10.2* Hct-33.1*
MCV-96 MCH-29.6 MCHC-30.8* RDW-15.8* Plt ___
___ 08:45AM BLOOD WBC-4.6 RBC-3.29* Hgb-9.4* Hct-31.6*
MCV-96 MCH-28.6 MCHC-29.8* RDW-15.7* Plt ___
___ 07:00AM BLOOD Glucose-63* UreaN-43* Creat-6.6* Na-138
K-5.2* Cl-96 HCO3-27 AnGap-20
___ 06:21AM BLOOD Glucose-90 UreaN-34* Creat-6.0*# Na-136
K-4.9 Cl-97 HCO3-29 AnGap-15
___ 07:00AM BLOOD cTropnT-0.05*
___ 06:21AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.2
DISCHARGE LABS:
==========================
___ 06:12AM BLOOD WBC-5.6 RBC-3.39* Hgb-9.7* Hct-32.1*
MCV-95 MCH-28.8 MCHC-30.3* RDW-16.1* Plt ___
___ 06:12AM BLOOD Glucose-100 UreaN-38* Creat-6.1*# Na-136
K-5.1 Cl-97 HCO3-29 AnGap-15
___ 06:12AM BLOOD Calcium-9.5 Phos-1.6* Mg-2.3
MICROBIOLOGY:
===========================
Blood culture ___ NGTD
IMAGING:
===========================
CXR ___ IMPRESSION: Increasing pulmonary edema, increasing
pleural effusions with
increasing consolidations in the lower lungs concerning for
atelectasis versus
pneumonia.
CT Abd/Pelvis ___:
FINDINGS: Small bilateral pleural effusions have increased in
size compared to the prior exam. There is adjacent compressive
atelectasis. Otherwise, the bases of lungs are clear. Note is
also made of slight interval increase in pericardial effusions.
Note is made of mild pulmonary edema at the bases of the lungs.
The liver is normal without evidence of focal lesions or
intrahepatic biliary ductal dilatation. The gallbladder is
normal. The portal vein is patent. The splenic vein is patent.
The spleen is homogenous and normal in size. The adrenal glands
bilaterally are normal. The pancreas is normal without evidence
of focal lesions or pancreatic duct dilatation.
The stomach, duodenum and small bowel are normal without
evidence of wall thickening or obstruction. No retroperitoneal
or mesenteric lymphadenopathy. Diffuse mesenteric haziness is
unchanged compared to the prior exam.
CT PELVIS: The prostate is enlarged. The urinary bladder is
normal. There is no pelvic or inguinal lymphadenopathy. There
is a trace amount of pelvic free fluid.
OSSEOUS STRUCTURES: No lytic or blastic lesions concerning for
malignancy are identified.
IMPRESSION:
1. Interval increase in bilateral pleural effusions and
pericardial effusion, with mild pulmonary edema seen at the
imaged lung bases.
2. No acute intra-abdominal abnormalities.
ECHO ___
Conclusions
The left atrium is mildly 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. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the basal
___ of the inferior septum and inferior walls. The remaining
segments contract normally (LVEF = 45 %). The estimated cardiac
index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
Right ventricular chamber size and free wall motion are normal.
[Intrinsic right ventricular systolic function is likely more
depressed given the severity of tricuspid regurgitation.] 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. Mild-moderate (___)
mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a very small circumferential pericardial
effusion without echocardiographic signs of tamponade.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction most c/w CAD. Mild-moderate mitral
regurgitation most likely due to papillary muscle dysfunction.
Severe pulmonary artery hypertension. Moderate tricuspid
regurgitation.Increased PCWP.
Compared with the prior study (images reviewed) of ___,
global left ventricular systolic function is improved. The
severity of tricuspid regurgitation and the estimated PA
systolic pressure are now higher. The pericardial effusion is
minimally larger.
CXR ___
IMPRESSION:
1. Significant improvement of pulmonary edema. Stable moderate
cardiomegaly.
2. Worsening opacity at the left base may reflect atelectasis.
Pneumonia is felt less likely but cannot be completely excluded
in the appropriate clinical setting.
3. Small right pleural effusion is smaller and moderate left
pleural effusion is unchanged.
Brief Hospital Course:
Mr. ___ is a ___ yo male with a history of CAD, sCHF (EF
35-40%), COPD, DM2, ESRD on HD (___) who is presenting from home
after he developed N/V and abdominal pain as well as hypoxia and
O2 requirement.
ACTIVE ISSUES:
================================
# Hypoxia in setting of pulmonary edema ___ CHF, ESRD: Patient
appeared volume up with worsening pleural effusions on imaging.
Also had episode of N/V so concern for possible aspiration
event. Patient is on home ___ HD schedule, however in setting
of persistent hypertension reported at rehab, may have element
of flash pulmonary edema. He had no notable EKG changes and
stable Troponin at 0.05 suggesting this is not ACS. Patient
does have history of COPD as well. No evidence of PNA on
imaging and patient does not give good history for infectious
process. Some thought that patient has established new dry
weight given several recent hospitalizations and poor PO intake.
Patient had significant volume removed during his scheduled HD
sessions while in house. His oxygenation improved and he was
able to wean off of supplemental O2. Dry weight now
approximately 55kg.
# Nausea/Vomiting: Patient had CT abdomen which did not show
any obstruction or acute intraabdominal pathology. Patient has
known gastritis, ischemic injury from recent left gastric artery
and distal gastroepiploic artery embolization. He additionally
reported no recent bowel movements on admission. He was started
on aggressive bowel regimen and initially received Zofran for
nausea. His N/V did not recur during this admission. He
continued PPI and Carafate.
# Pericardial Effusion: On CT abdomen, noted interval increase
in pleural effusion and pericardial effusion. Overnight no
pulsus was noted. Patient does not have any evidence of
hemodynamic compromise suggesting that this has been a rapidly
accumulately pericardial effusion, moreover, last ECHO from ___
notes small effusion as well. Likely secondary to uremia and/or
CHF/volume overload. Patient was dialyzed as above. TTE showed
no sign of tamponade. He had slightly elevated TSH but normal
Free T4.
# Hypertension: per son, BP were elevated >170 during last three
days while at rehab but in review of recent admissions, BP
appears to be in 150s systolic. Outpatient readings showing
systolics in 120s. Patient's Amlodipine was uptitrated on
admission. He was continued on all of his home medications.
His Imdur was additionally uptitrated as tolerated. Patient did
show some evidence of orthostasis so further uptitration of
Imdur was deferred to outpatient setting.
CHRONIC ISSUES:
====================================
# ESRD: On ___ HD. Nephrology followed patient throughout
admission. He received HD per his home schedule with goal of
removing ___ per session as tolerated. Based on inpatient HD
appears that new dry weight is truly around 55kg as compared to
prior (59kg). Patient additionally received IV iron, EPO in HD.
He was continued on Nephrocaps and Sevelamer initialy as well
as started on a low phos, low K diet. His phos was persistently
low, likely nutritional, so diet was liberalized and patient's
Sevelamer was held. He additionally required some PO phos
repletion.
# Coronary Artery Disease: with history of MI in ___ in ___,
no known treatment, EF in ___ ECHO 35-40 % with basal to mid
infero-septal, inferior and infero-lateral hypokinesis. Repeat
ECHO this admission showing slightly improved systolic function
but worsening pulmonary hypertension. Patient was referred to
Cardiology during last admission but never made outpatient
follow up. He continued home ASA and Carvedilol, Losartan.
# Diabetes: Diet controlled.
# Chronic Obstructive Pulmonary Disease: Patient continued
Albuterol and Flovent in house as well as supplemental O2 as
above.
# Ophtho: Systane not available so patient received Artificial
tears. Resumed home medications at discharge.
# Gout: Continued home allopurinol dosed for HD
TRANSITIONAL ISSUES:
===================================
- please follow up phos level and restart Sevelamer as needed
- Uptitrate Imdur as tolerated in outpatient setting
- New dry weight ~55kg
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB, wheeze
3. Amlodipine 5 mg PO DAILY
4. Carvedilol 25 mg PO BID
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Losartan Potassium 100 mg PO DAILY
7. Nephrocaps 1 CAP PO DAILY
8. TraMADOL (Ultram) 50 mg PO Q6H:PRN breakthrough pain
9. Bisacodyl ___ID:PRN constipation
10. Budesonide 90 mcg/actuation INHALATION 1 PUFF BID
11. Docusate Sodium 100 mg PO BID
12. olopatadine 0.1 % ophthalmic BID both eyes
13. Polyethylene Glycol 17 g PO DAILY
14. Systane (peg 400-propylene glycol) 0.4-0.3 % ophthalmic QID
15. Sucralfate 1 gm PO TID
16. sevelamer CARBONATE 800 mg PO TID W/MEALS
17. Pantoprazole 40 mg PO Q12H
18. Aspirin 81 mg PO DAILY
19. Allopurinol ___ mg PO EVERY OTHER DAY
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB, wheeze
2. Allopurinol ___ mg PO EVERY OTHER DAY
3. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Aspirin 81 mg PO DAILY
5. Bisacodyl ___ID:PRN constipation
6. Carvedilol 25 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
9. Losartan Potassium 100 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. Pantoprazole 40 mg PO Q12H
12. Polyethylene Glycol 17 g PO DAILY
13. Sucralfate 1 gm PO TID
14. Acetaminophen 650 mg PO Q6H:PRN pain
15. Budesonide 90 mcg/actuation INHALATION 1 PUFF BID
16. olopatadine 0.1 % ophthalmic BID both eyes
17. Systane (peg 400-propylene glycol) 0.4-0.3 % ophthalmic QID
18. TraMADOL (Ultram) 50 mg PO Q6H:PRN breakthrough pain
19. Phosphorus 500 mg PO BID Duration: 1 Day
RX *sod phos,di & mono-K phos mono [K-Phos-Neutral] 250 mg 2
tablet(s) by mouth twice a day Disp #*2 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Pulmonary Edema
Systolic CHF exacerbation
ESRD
Secondary: Hypertension
CAD
COPD
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 participating in your care at ___
___. You were admitted because of
shortness of breath, abdominal pain and nausea. You were found
to have significant fluid in your lungs. You underwent multiple
sessions of dialysis to remove some of this fluid.
Additionally, your blood pressure medications were increased to
better control your blood pressure. Please continue to attend
your regular ___ dialysis sessions and
follow up with the appointments as listed below.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the very best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10781468-DS-31
| 10,781,468 | 25,682,245 |
DS
| 31 |
2132-01-09 00:00:00
|
2132-01-09 19:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cortisone / cholesterol med / Carafate
Attending: ___
Chief Complaint:
AMS, Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ old legally blind male with a CAD s/p MI ___ in
___, HFrEF (EF 45%, septal and inferior wall hypokinesis),
___, ESRD on HD (___)- last dialysis session ___, COPD
(no O2 requirement), h/o stroke with left-sided sensory deficits
and diabetes mellitus, type II with micro and macrovascular
manifestations who presented to the ED today after a recent trip
to ___ - returned 2 weeks ago - with slowly progressive
confusion and weakness. According to the patients son, the
patient was treated with a course of steroids for possible
infection vs COPD exacerbation. The patient also reported
new-onset tremors. He denied fevers but stated that he had a
chronic cough. The patient was given insulin and dextrose,
duonebs, calcium gluconate and IVF with subsequent improvement
in
repeat K. He was not emergently dialyzed but was evaluated by
nephrology in the ED.
In the ED, initial vitals: 97, 124, 139/40, 16, 100% 2L
- Labs notable for: VBG CO2 63, K 7.6 -> 3.9 with medical
intervention
- Imaging notable for:
CXR:
Lower lung volumes with increased interstitial markings can be
seen with inflammation and/or infection.
CT Head w/o Contrast:
No intracranial hemorrhage
Pt given: 10u regular insulin, dextrose 25g, 2g calcium
gluconate, duonebs, 1L IVF with repeat K of 3.9 prior to
transfer to the floor.
Vitals prior to transfer: 97, 68, 139/40, 16, 100% 2L
Upon arrival to the floor, the patient is very somnolent.
Answers in yes/no questions and falls asleep during the
interview. Spoke to daughter (___) who reports that the patient
has slowly worsened since returning from ___.
REVIEW OF SYSTEMS:
Limited by mental status. Denies fevers, chills, nausea,
vomiting, CP, SOB, abdominal pain. +productive cough
Past Medical History:
-DM type 2, diet controlled
-ESRD on HD (MWF) since ___
-COPD mild-to-moderate airway obstruction
SPIROMETRY
Actual Pred %Pred
FVC 1.75 3.71 47
FEV1 0.98 2.47 40
MMF 0.41 2.33 18
FEV1/FVC 56 67 85
-CAD with history of MI in ___ in ___, no known treatment,
EF in ___ ECHO 35-40 % with basl to mid infero-septal, inferior
and infero-lateral hypokinesis.
-BPH
-Gout
-Hypertension
-Bilateral cataract extractions
-Diabetic Retinopathy
-Hemmorhoids
-blindness
Social History:
___
Family History:
No history of kidney disease, heart disease, DM
Physical Exam:
ADMISSION PHYSICAL
==================
VITALS: T-98.2PO, BP-159/62, P-70, RR-18, O2sat 95% 2L
General: Somnolent but arousable, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Diffuse crackles and coarse breath sounds, no wheezes or
rhonchi
Abdomen: Soft, obese, non-tender, non-distended, bowel sounds
present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ DPs, no clubbing, cyanosis or
edema,
RUE fistula, +thrill/bruit
Skin: Warm, dry, no rashes or notable lesions.
Neuro: Oriented to self and place, arousable but falls asleep
quickly, handgrip symmetric, dorsiflexion symmetric bilaterally,
due to mental status cannot assess cranial nerves or sensation
DISCHARGE PHYSICAL
==================
VITALS: 97.5 146/56 72 20 96% RA
General: Lying in bed in no acute distress, keeps eyes closed
HEENT: Sclerae anicteric, MMM
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB on anterolateral auscultation
Abdomen: Soft, non-tender, non-distended, bowel sounds
present, no rebound or guarding
Ext: Warm, well perfused, no clubbing, cyanosis or edema, RUE
fistula, +bilateral big toe ingrown toenails
Skin: Warm, dry, no rashes or notable lesions.
Neuro: Alert and oriented, interactive, linear thinking
Pertinent Results:
ADMISSION LABS
==============
___ 12:13PM BLOOD WBC-5.8 RBC-4.12* Hgb-12.4*# Hct-39.8*#
MCV-97 MCH-30.1 MCHC-31.2* RDW-15.0 RDWSD-53.5* Plt ___
___ 12:13PM BLOOD Neuts-68.6 ___ Monos-8.6 Eos-2.9
Baso-0.3 Im ___ AbsNeut-3.97 AbsLymp-1.11* AbsMono-0.50
AbsEos-0.17 AbsBaso-0.02
___ 02:35PM BLOOD Glucose-190* UreaN-21* Creat-4.7* Na-143
K-4.3 Cl-98 HCO3-22 AnGap-23*
___ 02:35PM BLOOD CK(CPK)-107
___ 02:35PM BLOOD Calcium-9.1 Phos-3.6 Mg-2.0
___ 12:32PM BLOOD ___ pO2-28* pCO2-63* pH-7.33*
calTCO2-35* Base XS-3 Comment-K ADDED @
___ 12:32PM BLOOD Lactate-2.0 K-7.6*
___ 02:39PM BLOOD K-3.9
MICRO/PERTINENT LABS
====================
Blood Cultures ___: CoNS ___ bottles
Blood Cultures ___: Pending, No Growth To Date
Blood Cultures ___: Pending, No Growth To Date
Blood Cultures ___: Pending, No Growth To Date
RPR ___ Non Reactive
Malaria Antigen ___ Negative
Parasite Smear Negative x3
___ 04:50AM BLOOD ALT-7 AST-15 LD(LDH)-277* AlkPhos-123
TotBili-0.3
___ 04:50AM BLOOD Vit___-___* Folate->20
___ 04:50AM BLOOD TSH-1.8
___ 04:50AM BLOOD Cortsol-14.7
IMAGING
=======
CT Head w/o Contrast ___
FINDINGS:
No evidence of acute infarction,hemorrhage,edema,or mass effect.
Periventricular and subcortical white matter hypodensity is
nonspecific,
likely sequelae of chronic small vessel ischemic disease and/or
prior insult. Chronic right parietal infarct is noted.
Bilateral, symmetric prominence of the ventricles and sulci
indicates cortical volume loss. Atherosclerotic calcifications
seen within the intracranial ICAs.
No evidence of fracture. The visualized portion of the
paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable other than
bilateral lens replacements.
IMPRESSION:
No intracranial hemorrhage.
CXR PA/LAT ___
Lower lung volumes with increased interstitial markings can be
seen with
inflammation and/or infection.
CXR Portable ___
In comparison with the study of ___, there is again
enlargement of the cardiac silhouette with prominence of
indistinct pulmonary markings suggestive of elevated pulmonary
venous pressure. There is a more focal area of opacification at
the right base, which in the appropriate clinical setting could
represent developing aspiration/pneumonia. Retrocardiac
opacification most likely represents atelectatic changes.
DISCHARGE LABS
==============
___ 07:00AM BLOOD WBC-5.0 RBC-3.67* Hgb-10.8* Hct-35.3*
MCV-96 MCH-29.4 MCHC-30.6* RDW-13.8 RDWSD-49.5* Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-96 UreaN-22* Creat-5.4*# Na-141
K-4.5 Cl-95* HCO3-28 AnGap-18
___ 07:00AM BLOOD Calcium-9.0 Phos-4.8* Mg-2.2
___ 06:31AM BLOOD Triglyc-117 HDL-32* CHOL/HD-4.8
LDLcalc-98 LDLmeas-102
___ 04:50AM BLOOD TSH-1.8
Brief Hospital Course:
Mr. ___ is a ___ old male with a CAD s/p MI ___ in
___, HFrEF (EF 45%, ___, ESRD on HD (___)- last
dialysis session ___ prior to arrival, COPD (no O2
requirement), h/o stroke with left-sided sensory deficits and
diabetes mellitus, type II with micro and macrovascular
manifestations who presented with weakness, tremors, and
confusion in the setting of hyperkalemia of 7.6 found to have
right base pneumonia; with course complicated by findings of
acute-subacute strokes.
ACUTE ISSUES
============
# Toxic Metabolic Encephalopathy
# Community Acquired Pneumonia
Patient presented with increasing confusion, cough. Patient had
recent trip to ___ and had returned 2 weeks prior to
presentation to the hospital. On admission, he was found to be
hyperkalemic, hypercarbic, and hypoxic upon arrival and needed
12 L of supplemental oxygen to maintain saturation rates in the
___, as well as medical treatment for hyperkalemia as per below.
CT head in the emergency department did not show any evidence of
acute hemorrhage. A chest x-ray showed signs of infection versus
inflammation. His presenting symptoms were thought to be
multifactorial in the setting of metabolic derangements and
possible pneumonia. He completed a 5 day course for CAP and had
significant interval improvement in his mental status. Blood
culture returned Coagulase Negative Staph, thought to be
contaminant. Remaineder of work up for toxic metabolic
encephalopathy, inclusive of: Malaria antigen and smears were
negative ×3. CK, B12, folate, TSH, cortisol were found to be
within normal limits. Patient's home dose of gabapentin was held
in the setting of end-stage renal disease as well as altered
mental status and discontinued on discharge. Given persistence
of altered mental status, a MRI Brain was obtained which
demonstrated new acute-subacute strokes - however, the locations
of these strokes was not felt to explain his persistent
encephalopathy. Eventually, Mr. ___ mental status cleared
and his personality returned to baseline prior to discharge.
# Acute Stroke: MRI brain during admission showed acute/subacute
strokes in right postcentral gyrus and left occipital lobe.
Etiology of strokes thought possibly MCA/PCA watershed vs.
embolic effect. Neurology was consulted and patient underwent
stroke work up with A1c, Lipids, CTA Head and Neck and TTE. CTA
head and neck was without e/o dissection, large vessel
occlusion, flow limiting stenosis, or aneurysm formation within
the great vessels of the head or neck. TTE demonstrated moderate
pericardial effusion, pHTN, and diastolic dysfunction without
thrombus. His LDL was found to be 102, A1C 6.6%, TSH 1.8.
Neurology recommended discharge with Holter to evaluate for any
occult arrhythmia and recommended initiation of ASA and Plavix
for stroke prevention.
# Hyperkalemia
# ESRD on HD ___
Once the patient arrived to the hospital, he was found to have a
potassium of 7.6 with peaked T waves, treated medically with
insulin, dextrose, albuterol, and IV fluids. Initially, the
differential for the patient's hyperkalemia was thought to be in
adequate/suboptimal hemodialysis, medication induced
hyperkalemia, increased tissue catabolism, and a derangement in
the RAS system. His hyperkalemia subsequently resolved and his
gabapentin and losartan were held. He continued to receive
hemodialysis sessions per his outpatient schedule was placed on
a low potassium renal based diet.
# Hypoxia
# Hypercapnia
The patient has a history of COPD but does not use supplemental
oxygen at home. Upon arrival he was found to be hypercapnic with
PCO2 of 63 on VBG and a PO2 in the ___. Repeat VBG revealed a
PO2 of greater than 100 and a PCO2 of 35 on 2 L. He was
initially continued on ___ L of supplemental oxygen during his
hospitalization but was successfully weaned off and was stable
on room air. His initial respiratory derangements were thought
to be likely in the setting of his community-acquired pneumonia.
# Hypertension. He was continued on his home dose of isosorbide
mononitrate. Initially his losartan was held in the setting of
hyperkalemia, however was eventually restarted during his
hospitalization.
# Diabetes, Type II. He was placed on an insulin sliding scale.
CHRONIC ISSUES
==============
# COPD. He was continued on his regimen of inhaled
corticosteroid, long-acting beta agonist, long-acting muscarinic
antagonist.
# GERD. He is continued on his home PPI.
# CAD. He is continued on his home carvedilol.
TRANSITIONAL ISSUES
===================
[] TTE on ___ noted moderate sized pericardial effusion
without echogenic evidence of tamponade. Recommend repeat TTE in
1 month for interval follow up to ensure clinical stability
[] ___ monitor provided to patient on discharge to
monitor for any arrhythmia given acute/subactue strokes
[] Initiated on ASA and continued on Plavix for stroke
prevention. Recommend clinically monitoring for signs of acute
blood loss given past history of GIB on ASA/Dipyridamole.
[] Will need Neurology follow up (appointment not yet scheduled
at the time of discharge)
[] Recommend outpatient follow up with Podiatry for toenail
maintenance
[] Underwent HD on ___, will resume regular outpatient HD
on ___ starting on ___
CODE STATUS: Full, confirmed
HCP: ___ (Son) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
2. Nephrocaps 1 CAP PO QHS
3. Omeprazole 40 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. sevelamer CARBONATE 800 mg PO TID W/MEALS
6. albuterol sulfate 90 mcg inhalation Q4H:PRN Wheezing
7. Allopurinol ___ mg PO DAILY
8. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN Dry
eyes
9. Budesonide Nasal Inhaler 90 mcg/actuation nasal BID
10. Gabapentin 100 mg PO QAM Itch
11. Meclizine 12.5 mg PO Q12H:PRN Dizziness
12. Tiotropium Bromide 1 CAP IH DAILY
13. Carvedilol 25 mg PO BID
14. Losartan Potassium 25 mg PO DAILY
15. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. albuterol sulfate 90 mcg inhalation Q4H:PRN Wheezing
4. Allopurinol ___ mg PO DAILY
5. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN Dry
eyes
6. Budesonide Nasal Inhaler 90 mcg/actuation nasal BID
7. Carvedilol 25 mg PO BID
8. Clopidogrel 75 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
11. Losartan Potassium 25 mg PO DAILY
12. Nephrocaps 1 CAP PO QHS
13. Omeprazole 40 mg PO BID
14. sevelamer CARBONATE 800 mg PO TID W/MEALS
15. Tiotropium Bromide 1 CAP IH DAILY
16. HELD- Meclizine 12.5 mg PO Q12H:PRN Dizziness This
medication was held. Do not restart Meclizine until you discuss
with your primary care doctor
17.Rehabilitation Services
ICD10: H___
Please provide patient with Walking cane
Prognosis: Good
Duration of Need: 99 days
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
=================
Community-acquired pneumonia
Toxic metabolic encephalopathy
Acute Stroke
Hyperkalemia
Hypercarbia
Hypoxia
Secondary Diagnoses
===================
History of stroke
Hypertension
GERD
COPD
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 in the hospital!
Why was I admitted to the hospital?
-You came to the hospital because you were very lethargic,
confused, and were having difficulty breathing
What happened while I was admitted to the hospital?
-You were found to have pneumonia and were started on
antibiotics to treat it
-The potassium in your blood was very high and you were given
medications to lower it
-You continued getting hemodialysis while in the hospital
-You got imaging of your brain which showed new strokes in your
brain
-Your lab numbers were closely monitored and you were continued
on your home medications
What should I do after I leave the hospital?
-Please continue taking all of your medications as prescribed,
details below
-Keep all of your appointments as scheduled
-Continue to attend your hemodialysis sessions according to your
schedule
We wish you the very best!
Your ___ Care Team
Followup Instructions:
___
|
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2132-09-15 19:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cortisone / Carafate / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old gentleman with history most notable for HFpEF (LVEF
62% ___, ESRD on MWF HD, CAD w/ cath ___ , who presents
with chest pain and productive cough. His other medical issues
are notable for COPD, CVA with residual L sided weakness, BPH,
hypertension, and legal blindness.
Patient is not the best historian and daughter ___ assisted
with
history.
Mr. ___ reports chest pain x 4 days, constant, associated
with
cough with productive sputum. He was laying down when the pain
started. He initially tried his inhaler which helped at first,
and waited 2 days to come to the hospital because he thought the
pain would improve. He says the 4 aspirin he received in the
ambulance made him feel better. No shortness of breath, pain
with
inspiration, or fevers.
Of note patient was recently admitted from ___ for
hospital acquired pneumonia, with course complicated by type II
NSTEMI. At that time, he was initially treated with ceftriaxone
and azithromycin, then broadened to vanc/cefepime in setting of
SBP in ___. Ultimately completed total 7 day course. He reports
that he still has not recovered from his PNA and is very
fatigued. He was also seen by cardiology in the ED, thought to
have demand ischemia in setting of acute illness hence no
further
intervention was performed.
He had a repeat CXR on ___ which demonstrated resolution of
PNA.
In the ED, initial vitals: 98.6 HR 70 BP 161/61 SpO2 95% RA
- Exam notable for : "chronically ill appearing, lungs clear,
RRR"
- Labs were notable for:
WBC 5.5 Hgb 9.8 Plt 134
136 | 96 | 6
--------------- Anion gap = 12
4.1 | 28 | 2.7
- Imaging: Possible left lower lobe pneumonia. Mild
cardiomegaly. Possible pulmonary arterial hypertension.
- Patient was given: Vancomycin 1 gm + cefepime 2 gm
- Consults: none
- Decision was made to admit to Medicine for pneumonia
- Vitals prior to transfer were
On arrival to the floor,
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative less otherwise noted in the HPI.
Past Medical History:
- HFpEF (EF 62% in ___
- DM type 2, diet controlled
- ESRD on HD (MWF) since ___
- COPD mild-to-moderate airway obstruction
- CAD with history of MI in ___ in ___, no known treatment,
EF in ___ ECHO 35-40 % with basl to mid infero-septal, inferior
and infero-lateral hypokinesis.
- BPH
- Gout
- Hypertension
- Bilateral cataract extractions
- Hemmorhoids
- Legally Blind ___ Diabetic Retinopathy
- Peripheral Vascular Disease
Social History:
___
Family History:
Denies family history of stroke or heart disease.
Mom died at ___, was healthy.
Dad died at ___, unknown cause.
Half-brother died at ___ in a war.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: ___ 1558 Temp: 97.4 PO BP: 177/64 HR: 66 RR: 18 O2 sat:
94% O2 delivery: RA
GENERAL: Pleasant, lying in bed comfortably
HEENT: NC/AT, EOMI, pupils nonreactive
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: CTAB, diffuse expiratory wheezes, no crackles appreciated
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, fistula on right forearm w/ palpable
thrill and bruit, no lower extremity edema, moves all 4
extremities with purpose
PULSES: 2+ radial pulses, 2+ DP pulses
NEURO: Alert, oriented, pupils nonreactive, cranial nerves
otherwise intact, motor and sensory function grossly intact
SKIN: No significant rashes
DISCHARGE PHYSICAL EXAM:
VITALS: ___ 0629 Temp: 98.2 PO BP: 174/60 HR: 74 RR: 18 O2
sat: 97% O2 delivery: RA
GENERAL: comfortably lying in bed receiving HD
HEENT: NC/AT, EOMI, pupils nonreactive
CARDIAC: chest wall nontender, Regular rate and rhythm, no
murmurs, rubs, or gallops
LUNG: CTAB, no crackles appreciated, no use of accessory muscles
ABD: Normal bowel sounds, soft, nontender, nondistended
EXT: Warm, well perfused, no lower extremity edema, moves all
four extremities with purpose
PULSES: 2+ radial pulses
NEURO: Alert, oriented to person place and year, pupils
nonreactive, cranial nerves otherwise intact, motor and sensory
function grossly intact
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS:
___ 03:40AM BLOOD WBC-5.5 RBC-3.38* Hgb-9.8* Hct-32.6*
MCV-96 MCH-29.0 MCHC-30.1* RDW-14.8 RDWSD-52.9* Plt ___
___ 03:40AM BLOOD Neuts-54.4 ___ Monos-9.3 Eos-5.3
Baso-0.7 Im ___ AbsNeut-3.00 AbsLymp-1.64 AbsMono-0.51
AbsEos-0.29 AbsBaso-0.04
___ 03:40AM BLOOD Glucose-79 UreaN-6 Creat-2.7*# Na-136
K-4.1 Cl-96 HCO3-28 AnGap-12
___ 03:40AM BLOOD CK(CPK)-52
___ 03:40AM BLOOD CK-MB-<1
___ 03:40AM BLOOD cTropnT-0.09*
___ 09:50AM BLOOD CK-MB-1 cTropnT-0.12*
___ 04:58PM BLOOD CK-MB-1 cTropnT-0.10*
___ 08:17AM BLOOD Calcium-9.4 Phos-4.9* Mg-2.3 Iron-48
___ 08:17AM BLOOD calTIBC-109* Ferritn-1205* TRF-84*
___ 03:45AM BLOOD Lactate-0.8
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-5.1 RBC-3.20* Hgb-9.3* Hct-30.5*
MCV-95 MCH-29.1 MCHC-30.5* RDW-14.8 RDWSD-51.3* Plt ___
___ 06:50AM BLOOD Neuts-57.0 ___ Monos-11.1
Eos-7.9* Baso-0.4 Im ___ AbsNeut-2.88 AbsLymp-1.18*
AbsMono-0.56 AbsEos-0.40 AbsBaso-0.02
___ 06:50AM BLOOD Glucose-83 UreaN-15 Creat-4.5*# Na-135
K-4.0 Cl-94* HCO3-30 AnGap-11
___ 06:50AM BLOOD Calcium-9.5 Phos-4.2 Mg-2.1
MICRO:
___ 3:40 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 9:50 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 9:27 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
IMAGING REPORTS:
___ CXR (PA & LAT)
IMPRESSION:
Possible left lower lobe pneumonia.
Mild cardiomegaly. Possible pulmonary arterial hypertension.
Brief Hospital Course:
BRIEF SUMMARY:
___ year old gentleman with history most notable for HFpEF (LVEF
62% ___, ESRD on MWF HD, CAD w/ cath ___ , COPD, hx of CVA
w/ residual L. sided weakness, and legal blindness who presents
with chest pain and productive cough.
ACTIVE ISSUES:
# LLL Pneumonia
The patient reported chest pain for 4 days and cough with
associated productive sputum. Of note, he was recently admitted
from ___ for hospital acquired pneumonia, with course
complicated by type II NSTEMI. Follow-up CXR on ___ showed
resolution of the PNA. CXR on admission ___ showed a
possible left lower lobe PNA. He was started on
Vancomycin/cefepime on ___ and transitioned to Azithromyin +
Augmentin ending ___. Speech and swallow eval suspected
oropharyngeal dysphagia characterized by prolonged oral
manipulation of chewable solids and overt s/s of aspiration with
thin liquids. Recommended downgrading his diet to soft solids
with nectar thick liquids with medications given whole in
applesauce.
# Troponin elevation
The patient reported chest pain for 4 days. EKG was unchanged
from prior EKG in ___, and troponins remained stable (.09, .12,
.10, .10). The elevation was likely due to his ESRD causing an
inability to clear the troponins + demand in setting of
underlying infection.
CHRONIC ISSUES:
# ESRD
- Continued MWF hemodialysis
# HFpEF: Euvolemic
- Continue carvedilol 25 mg BID
- Losartan was increased to 50 mg qd
- patient not a candidate for spironolactone due to HD
# History of CAD
- Continue ASA, plavix
- Continue isosorbide mononitrate XR 90 mg qd
# Hypertension
Poorly controlled in the setting of ESRD.
- Continue losartan, carvedilol
# Normocytic anemia
Stable at baseline, no evidence of bleed. Suspect related to
ESRD. Should consider EPO as an outpatient
- iron studies, CTM
# COPD
No increased sputum production or increased SOB to suggest acute
exacerbation
- continue Spiriva qd
- albuterol inhaler q6h prn
# Peripheral vascular disease
Per outpatient notes ___, holding off revascularization
given medical comorbidities, managing symptomatically with pain
control.
- on DAPT
- Gabapentin was discontinued due to confusion.
# CVA
- Cont ASA
- Cont clopidogrel 75 mg qd
# Gout
- Cont allopurinol ___ mg qd
# Diabetes
Last A1c ___. Patient reports he does not take any
medications for diabetes.
TRANSITIONAL ISSUES:
====================
[ ] End date of augmentin ___ for total 7 day course
[ ] Increased losartan dose to 50 mg daily for systolic BPs in
180-200s. On d/c SBP 130-170. Please titrate as necessary.
[ ] Please repeat CT chest in ___ weeks to look for structural
causes for recurrent pneumonia/exclude malignancy
[ ] Speech and swallow recommended downgrading his diet to soft
solids with nectar thick liquids with medications given whole in
applesauce.
[ ] Home gabapentin discontinued due to concern for worsening
sedation
[ ] It is unclear if he ever got ___ of Hearts from discharge
___. Indication at that time was arrhythmia given
acute/subacute strokes; please follow up if this was not
completed
[ ] Please continue risk/benefit discussion of statin
[ ] Please continue goals of care discussion as an outpatient;
patient full code during this admission
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Carvedilol 25 mg PO BID
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 300 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
8. Losartan Potassium 25 mg PO DAILY
9. Omeprazole 40 mg PO BID
10. sevelamer CARBONATE 800 mg PO TID W/MEALS
11. Tiotropium Bromide 1 CAP IH DAILY
12. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN Dry
eyes
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN wheezing/SOB
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q24H
RX *amoxicillin-pot clavulanate [Augmentin] 500 mg-125 mg 1
tablet(s) by mouth daily Disp #*1 Tablet Refills:*0
2. Losartan Potassium 50 mg PO DAILY
RX *losartan 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Omeprazole 40 mg PO DAILY
4. Allopurinol ___ mg PO DAILY
5. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN Dry
eyes
6. Aspirin 81 mg PO DAILY
7. Carvedilol 25 mg PO BID
8. Clopidogrel 75 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN wheezing/SOB
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
13. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Bacterial pneumonia
- Toxic-metabolic encephalopathy
Secondary diagnosis:
- Chronic diastolic heart failure
- CAD s/p IMI
- Hypertension
- COPD
- Severe PVD
- Anemia of CKD
- Prior left occipital & right post-central gyrus infarcts
- Gout
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
- You were admitted for chest pain and cough.
WHAT HAPPENED IN THE HOSPITAL?
- A chest x-ray showed that you have pneumonia.
- You received antibiotics to treat your pneumonia.
- You continued to receive Hemodialysis for your kidney disease.
- Your EKG and labs showed that your chest pain was unlikely to
be due to a heart attack, so you received a lidocaine patch for
pain relief.
WHAT SHOULD YOU DO AT HOME?
- Take your medications as prescribed.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Here are recommendations from our swallow specialists: You may
benefit from eating soft foods with thickened liquids, with
assistance while eating. We have given you a handout on
thickening liquids.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
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|
2132-09-18 14:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cortisone / Carafate / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ with PMH of HFpEF (LVEF 62% ___, ESRD on MWF HD, CAD w/
cath ___, COPD, right parietal lobe CVA, and legal blindness,
who was discharged yesterday ___ following treatment of LLL PNA
and presents today with an episode of loss of consciousness
lasting several minutes.
Patient receives 24 hour health aide and part of hx was
retrieved
from supervisor of health aide via phone. Supervisor states that
his aide arrived this morning and found him to be in a normal
state. At some point during the morning while he was laying in
bed, she tried to arouse him but found him to be unresponsive.
The aide then called her supervisor and 911, by the time
paramedics arrived, patient was awake and responsive again. Per
EMS, upon arrival pt alert and oriented, initial BP 90/56, HR
___, c/o dizziness, lower back pain and was transported to ___
ED. No evidence of head-strike. It is unclear if patient had any
presyncopal symptoms, a prodrome period, incontinence, or a
post-ictal state, as pt denies anything happens and could not
get
in touch with his aide from earlier.
Upon arrival to the ED, patient does not recall the event, did
not have any complaints, and was unclear as to why he was in the
ED. His vital signs were notable for BP of 156/66, he was alert
and oriented with an otherwise normal exam and his electrolytes
were within normal limits with the rest of his labs stable at
his
baseline: Hgb 10.1 (baseline ___. Plt 137 (baseline 100s-140),
Cr 3.3). Chest xray also showed improvements in his left
basilar
opacity.
He was admitted to the floor with stable vital signs. Upon
arrival to floor, patient continues to deny the episode of LOC.
Patient's son is at bedside and states that Mr. ___ had been
improving compared to his admission from ___. He did not
witness the LOC but denies any previous episodes.
Patient denies any CP, SOB, chills, fevers, n/v/d, dizziness,
lightheadedness. According to family, patient did not receive
any
of his medications today.
Past Medical History:
HFpEF (EF 62% in ___
ESRD (on HD MWF since ___
DM type 2, diet controlled, last A1c 5.3%
CAD with history of MI in ___ in ___, no known treatment
COPD
BPH
Gout
HTN
PVD
GERD
CVA (residual L-sided weakness)
Legally blind ___ diabetic retinopathy
Hemorrhoids
Social History:
___
Family History:
Denies family history of stroke or heart disease.
Mom died at ___, was healthy.
Dad died at ___, unknown cause.
Half-brother died at ___ in a war.
Physical Exam:
On admission
VITALS: Temp 97.9, BP 161/62, HR 68, RR 16, O2 98% on 2L
GENERAL: Alert and interactive. In no acute distress. ___
primary language but also speaks some ___.
___: NCAT. Eyes closed during exam, legally blind. Dry MM, no
evidence of tongue-biting.
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes or rhonchi,
faint crackles at base. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Right AVF with
palpable thrill. Pulses DP/Radial 2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash. bilateral excoriations of
extensor surface of left lower legs.
NEUROLOGIC: CNs ___ and 6 not assessed as patient is legally
blind, CN ___ intact. ___ strength throughout. Normal
sensation. AOx3.
Discharge exam
Vitals: 97.9,189 / 66, 78, 16, 95 RA on ___ @0729
General: Sleepy, no acute distress, asking about his son
___ anicteric
Neck: supple, JVP not elevated
Lungs: CTAB, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, distant S1 + S2, no murmurs, rubs,
gallops, faint S3
Abdomen: soft, NTND, bowel sounds present, no rebound tenderness
or guarding, no organomegaly
Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema
Skin: No rashes/lesions
Neuro: Sleepy but answers questions appropriately, asking about
son, moving all extremities
Pertinent Results:
Imaging
CXR (___)
Patchy opacities in the lung bases, improved compared to the
prior exam, in particular the left basilar opacity. Findings
could reflect atelectasis with resolving left lower lobe
pneumonia. Small bilateral pleural effusions.
Non-con Head CT (___):
1. No acute intracranial abnormality.
2. Chronic right parietal lobe infarct, unchanged.
3. Chronic sequelae of age-related involutional changes and
probable small
vessel ischemic disease.
TTE ___
The left atrial volume index is mildly increased. The right
atrium is mildly enlarged. There is no evidence for an atrial
septal defect by 2D/color Doppler. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with a normal cavity size. There is normal regional
and global left ventricular systolic function. Quantitative 3D
volumetric left ventricular ejection fraction is 57 %. There is
a mild (peak 10 mmHg) resting left ventricular outflow tract
gradient with a 18 mm Hg (peak) mid-left ventricular cavity
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 diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets are mildly thickened
with no mitral valve prolapse. There is mild to moderate [___]
mitral regurgitation. The tricuspid valve leaflets are mildly
thickened. There is mild to moderate [___] tricuspid
regurgitation. There is SEVERE pulmonary artery systolic
hypertension. There is a moderate loculated pericardial effusion
located adjacent to the posterior left ventricle (trivial to
none seen elsewhere). There are no 2D or Doppler
echocardiographic evidence of tamponade. In the presence of
pulmonary artery hypertension, typical echocardiographic
findings of tamponade physiology may be absent.
Compared with the prior TTE (images reviewed) of ___ ,
there is a mild left ventricular outflow tract and mid cavitary
gradient seen; the other findings are similar.
Brief Hospital Course:
PATIENT SUMMARY:
================
___ with PMH of HFpEF (LVEF 62% ___, ESRD on ___ HD, CAD w/
cath ___, COPD, right parietal lobe CVA, and legal blindness,
who was discharged ___ following LLL PNA and presented on ___
after home aid found him difficult to rouse, concerning for LOC.
ACUTE ISSUES:
==============
#Unresponsive, ?LOC
Patient was reportedly unresponsive for 2 min while laying in
bed. Given patient was unresponsive for up to ___ minutes, this
could have been an unwitnessed seizure followed by a witnessed
postictal unresponsive state particularly given his known
previous infarct in R parietal lobe, which could predispose him
to a seizure. However, unclear whether he had episode of
incontinence. Given patient is currently asymptomatic, EEG was
thought to have low utility and not obtained.
Thought to be less likely cardiac syncope given episode occurred
at rest and not with exertion. ECG was normal and troponin
similar to previous admission. No significant valvular disease
on most recent TTE in ___ repeat TTE on ___ was unchanged
from prior. Initially held home carvedilol given concern it
contributed to hypotension/bradycardia following the LOC
episode, but restarted due to hypertension (SBP as high as 191).
Patient was orthostatic on the floor. BP changed from 171 / 68
lying to 127 / 49 standing with HR increasing from 67 to 76.
However, episode occurred while patient was lying down.
Non-con Head CT only showed chronic right parietal lobe infarct
and was negative for acute abnormality. He was monitored on
telemetry for arrhythmia. Unresponsive episode was most likely
deep sleep.
# LLL Pneumonia
Patient was recently admitted ___ for chest pain and cough
and found to have LLL pneumonia. He was started on
Vancomycin/cefepime on ___ and transitioned to Azithromyin +
Augmentin (last dose of augmentin received on ___. Also
admitted from ___ for HAP which was complicated by type II
NSTEMI during his admission. CXR on ___ showed improved LLL
opacity. During this admission, patient was asymptomatic,
afebrile, without cough/SOB/CP. Per speech and swallow recs on
prior admission, diet was kept to soft solids, nectar thick
liquids.
# Troponin elevation: Troponin remained elevated but stable
through previous admission ___ (.09, .12, .10, .10).
Troponin was stable at 0.09 which is similar to previous
admission and likely ___ ESRD causing an inability to clear the
troponins. Low suspicion for acute coronary process.
#Pruritis: Patient complained of R leg pruritus, could be uremic
pruritis. Patient is allergic to cortisone, was offered sarna
cream.
CHRONIC ISSUES:
===============
# ESRD: continued MWF hemodialysis, last dialysis ___. Continued
home-med sevelamer CARBONATE 800 mg PO TID W/MEALS and renal
diet (low K and P).
# HFpEF: Patient is euvolemic with EF 62% in ___, 57% on repeat
TTE on ___. Home carvedilol was initially held given concern for
hypotension/bradycardia and patient being orthostatic on the
floor, but restarted on given patient was hypertensive.
Continued Losartan Potassium 50 mg PO/NG DAILY.
# History of CAD and MI in ___: Continued ASA, Plavix,
isosorbide mononitrate
# Hypertension: Poorly controlled in the setting of ESRD. Was
hypertensive on the floor but orthostatic (BP drops from 170s to
120s from lying to standing). Continued losartan and restarted
home carvedilol given hypertension.
# Normocytic anemia: Stable at baseline, no evidence of bleed.
Suspect related to ESRD.
# COPD: continued tiotropium qd
# Peripheral vascular disease: Per outpatient notes ___,
holding off revascularization given medical comorbidities,
managing symptomatically with pain control. Patient continued
his dual anti-platelet therapy. Gabapentin was discontinued
given concern it could contribute to confusion.
# Hx of CVA with residual L sided weakness: Continued ASA and
clopidogrel 75 mg qd
# Gout: Continued allopurinol ___ mg qd
# Diabetes: Last A1c ___. Patient reports he does not
take any meds for diabetes.
#GERD: continued home omeprazole 40mg PO daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN Dry
eyes
3. Aspirin 81 mg PO DAILY
4. Carvedilol 25 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
8. Losartan Potassium 50 mg PO DAILY
9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN wheezing/SOB
10. sevelamer CARBONATE 800 mg PO TID W/MEALS
11. Tiotropium Bromide 1 CAP IH DAILY
12. Omeprazole 40 mg PO DAILY
13. Amoxicillin-Clavulanic Acid ___ mg PO Q24H
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN Dry
eyes
3. Aspirin 81 mg PO DAILY
4. Carvedilol 25 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
8. Losartan Potassium 50 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN wheezing/SOB
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
12. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
--------------------
Unresponsive episode
SECONDARY DIAGNOSES
Hypertension
Pneumonia
Elevated Troponin
HFpEF
ESRD
CAD s/p MI
COPD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care here at ___.
Why was I admitted?
-------------------
You were found unresponsive by your home aid. You were brought
to the hospital to make sure this was not caused by a medical
problem like a seizure or abnormal heart rhythm.
What happened to me in the hospital?
- You received the last dose of your scheduled antibiotic (for
pneumonia) here on ___.
- You were monitored on telemetry. No new arrhythmias were
found.
- You received hemodialysis on ___.
- An ultrasound of your heart was performed. This looked similar
to the last heart ultrasound you had in ___.
- An x-ray of your chest showed improvement of the pneumonia for
which you were recently admitted.
- A CT scan of your head was performed and found to be normal.
What should I do when I leave the hospital?
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Please take your medications as prescribed and follow up with
any upcoming primary care physician ___.
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
10781468-DS-35
| 10,781,468 | 29,724,351 |
DS
| 35 |
2132-11-01 00:00:00
|
2132-11-02 05:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cortisone / Carafate / Statins-Hmg-Coa Reductase Inhibitors /
lisinopril
Attending: ___.
Chief Complaint:
Hypotension, AMS
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Mr. ___ is an ___ year old male with PMH of HFpEF (LVEF 62%
___, ESRD on ___ HD, COPD, right parietal lobe CVA, and
legal blindness who presents to the emergency department with
altered mental status and found to be hypotensive.
Patient developed acute onset confusion at approximately ___
today. He does not remember the incident. Prior to this, patient
had nausea/vomiting approximately one week ago for which he was
seen in the ED that has subsequently resolved. He does report
that he has not been eating or drinking very much recently in
general, although he is not able to identify why. His son
brought
him to his PCP's office where he was found to be hypotensive to
BP 70/40, with HR 67. He was subsequently transferred to ED.
The patient reports he has had mild shortness of breath and dry
cough over the past week. He states this is a chronic problem
for
him, although it has been worse than usual over the past week.
He
denies fever/chills, orthopnea, chest pain, and palpitations. Of
note, per PCP documentation, patient wishes to return home to
___ as he feels he will be dying soon and would prefer to
die in ___.
Of note, patient had admission from ___ - ___ for similar
presentation, without clear etiology determined. He was treated
for pneumonia that admission. Anti-HTN were briefly held,
however
restarted once his SBP went to ~190.
In the ED, patient was initially found to be hypotensive to
___ at triaged but BP improved to 110s/50s upon being seen
in
the ED. Patient son states the patient has been coughing
recently. He received 1L of NS and was started on a
ceftriaxone/azithromycin for possible pneumonia.
In the ED, initial VS were: T 9.7, HR 63, BP 65/29 (in triage),
RR 16, SpO2 99% RA
Exam notable for patient moaning, responds to name
ECG: ___, TWI in V6
Labs showed:
-CBC: WBC 5.4->4.9, HGB 12.4->11.4, PLT 92->97
-CHEM: BUN 14, Cr 3.9
-TropT 0.07->0.07, MB <1
-Lactate 1.9
Imaging showed:
CXR
Left lung base opacities likely represent atelectasis, and
although unlikely,pneumonia cannot be excluded in the correct
clinical setting. No edema or effusion.
CT HEAD W/O CONTRAST
-No evidence of acute infarct, hemorrhage, or other acute
intracranial
process. If there is strong suspicion for stroke, MR would be
more sensitive To the detection of acute infarct.
-Stable appearance of multiple chronic infarcts.
-Global age advanced involutional changes.
-Confluent periventricular and deep white matter hypodensities
are nonspecific But likely represent sequela of chronic small
vessel ischemic disease.
Patient received: IV ceftriaxone 1g, IV azithromycin 500mg, 1L
NS, carvedilol 25mg, lisinopril 10mg, omeprazole 20mg
Transfer VS were: T 98.1, HR 69, BP 144/47, RR 15, SpO2 100% RA
On arrival to the floor, patient reports his shortness of breath
has improved. He is not coughing. He complains of itchiness,
particularly in his back.
Past Medical History:
HFpEF (EF 62% in ___
ESRD (on HD MWF since ___
DM type 2, diet controlled, last A1c 5.3%
CAD with history of MI in ___ in ___, no known treatment
COPD
BPH
Gout
HTN
PVD
GERD
CVA (residual L-sided weakness)
Legally blind ___ diabetic retinopathy
Hemorrhoids
Social History:
___
Family History:
Denies family history of stroke or heart disease.
Mom died at ___, was healthy.
Dad died at ___, unknown cause.
Half-brother died at ___ in a war.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, slightly dry MM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema. R forearm fistula
with +thrill and +bruit
PULSES: 2+ radial pulses bilaterally
NEURO: AO X 3, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
GENERAL: Legally blind, hard of hearing, chronically
ill-appearing and thin, laying in bed, in NAD
HEENT: AT/NC, anicteric sclera, MMM
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
GI: Abdomen soft, mildly distended, nontender in all quadrants,
no rebound/guarding
EXTREMITIES: Venous stasis changes in the ___ bilaterally. (+)
TTP
over the heels bilaterally, no visible lesions or induration. No
cyanosis, clubbing, or edema. R forearm fistula with palpable
thrill and audible bruit
NEURO: AOx3, moving all 4 extremities with purpose, face grossly
symmetric
DERM: Warm and well-perfused, several healing excoriations over
bilateral lower extremities and shoulders
Pertinent Results:
ADMISSION LABS:
===============
___ 05:54PM BLOOD WBC-5.4 RBC-4.20* Hgb-12.4* Hct-40.8
MCV-97 MCH-29.5 MCHC-30.4* RDW-15.2 RDWSD-53.8* Plt Ct-92*
___ 05:54PM BLOOD Plt Ct-92*
___ 06:02PM BLOOD Glucose-94 UreaN-14 Creat-3.9* Na-141
K-4.2 Cl-98 HCO3-29 AnGap-14
___ 06:02PM BLOOD ALT-9 AST-18 CK(CPK)-53 AlkPhos-69
TotBili-0.3
___ 05:54PM BLOOD cTropnT-0.07*
___ 06:02PM BLOOD cTropnT-0.07*
___ 12:06AM BLOOD cTropnT-0.06*
___ 06:02PM BLOOD Albumin-3.1* Calcium-8.9 Phos-2.9 Mg-2.2
___ 06:07PM BLOOD ___ pO2-26* pCO2-52* pH-7.40
calTCO2-33* Base XS-4 Intubat-NOT INTUBA
___ 05:58PM BLOOD Lactate-1.9
DISCHARGE LABS:
===============
___ 09:05AM BLOOD WBC-4.9 RBC-3.73* Hgb-11.0* Hct-35.2*
MCV-94 MCH-29.5 MCHC-31.3* RDW-15.2 RDWSD-51.6* Plt Ct-87*
___ 09:05AM BLOOD Plt Ct-87*
___ 09:05AM BLOOD Glucose-71 UreaN-30* Creat-5.7* Na-139
K-5.6* Cl-99 HCO3-27 AnGap-13
___ 09:05AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.2
STUDIES:
========
___ HCT
IMPRESSION:
1. No evidence of acute infarct, hemorrhage, or other acute
intracranial
process. If there is strong suspicion for stroke, MR would be
more sensitive to the detection of acute infarct.
2. Stable appearance of multiple chronic infarcts.
3. Global age related involutional changes.
4. Confluent periventricular and deep white matter hypodensities
are
nonspecific but likely represent sequela of chronic small vessel
ischemic
disease.
Brief Hospital Course:
___ with legal blindness, partial deafness, and history of HFpEF
(EF 57% in ___, ESRD on MWF HD, COPD, right parietal lobe
ischemic infarct of unclear etiology, CAD complicated by MI in
___ (treated in ___, diet-controlled T2DM, pulmonary
hypertension, and recurrent hospitalizations for confusion over
the past year who presents with altered mental status and
hypotension thought secondary to over-dialysis in a
preload-dependent state. His altered mental status and
hypotension resolved with IVF resuscitation and conservative
volume management during HD. He was discharged home with home
___.
ACUTE ISSUES:
============
#Encephalopathy
Patient's encephalopathy likely occurred in the setting of
hypotension. Per his family, he has had episodes of confusion at
time, often after dialysis sessions. Other etiologies for AMS
were unlikely: he did not present with uremia, his VBG
demonstrated chronic hypercarbia with chronically retained CO2
(pH 7.4), and HCT showed no acute disease. There were also no
signs of acute infection. Once normotensive, he remained alert
and oriented x3, calm, and conversational throughout this
admission.
#Hypotension
#Hypovolemia
#LV outflow tract obstruction
On the day of admission, patient developed acute-onset confusion
and was brought to his PCP's office where he was noted to have
BP 70/40. He presented to the ED, where he was given 1L IVF
without evidence of volume overload. Consequently, the etiology
of his hypotension was likely due to overdialyzation and severe
intravascular volume depletion (outpatient dialysis center
recently lowered his estimated dry weight from 58.6kg on ___ to
54.5kg on ___, exacerbated by poor oral intake, autonomic
dysfunction causing chronic orthostasis, polypharmacy including
multiple anti-hypertensives, and preload- and
afterload-dependent left ventricular outflow tract obstruction
(with known mid-cavitary gradient seen on echo in ___.
Infectious work-up was negative. Per recommendations from Renal
HD, patient's estimated dry weight is now 55.5-56kg; he was
trialed on dialysis over several sessions at this weight with
improved blood pressures and mental status and without evidence
of volume overload. In order to optimize preload and cardiac
output, patient's home imdur was discontinued. Patient was also
normotensive throughout this admission, so his home losartan was
discontinued in order to lessen left ventricular outflow
obstruction. He was continued on carvedilol 25mg twice daily to
allow for increased diastolic filling time and to minimize the
mid-cavitary gradient. He was orthostatic per his vitals but
asymptomatic.
#Pruritus
Patient presented with severe pruritus that has been acutely
worse in the setting of gabapentin recently being stopped for
concern for confusion. He was restarted on gabapentin 300mg
daily with resolution of his pruritus and no concurrent
confusion. He was also continued on sarna lotion.
#Subacute-on-chronic cough
#COPD
Patient reports a chronic cough and shortness of breath that has
gotten somewhat worse over the past week prior to admission.
There was low suspicion for PNA and pulmonary edema given lack
of findings on serial CXR's. Patient has a history of cough
induced by ACE-inhibitors but is not currently taking one. He
was continued on home tiotropium daily and given duonebs PRN.
Please consider titrating his COPD medications as an outpatient;
he is currently on an albuterol inhaler PRN and tiotropium daily
at home and may benefit from ___ given progressive symptoms.
#?Depression
#Risk of severe protein-calorie malnutrition
Family reports patient has had depressed mood, hopelessness, and
decreased oral intake at home. Patient was seen by Nutrition,
who recommended nutritional supplementation four times a day.
Please consider initiating low-dose remeron 7.5mg qHS for
depression and as an appetite stimulant.
CHRONIC ISSUES:
===============
#ESRD on HD (MWF)
He was continued on nephrocaps daily. Given low phosphorus on
this admission, sevelamer was held on discharge.
#CAD
Reported history of MI in ___, treated in ___ with unknown
intervention. Has also had h/o NSTEMI, recorded here in ___ at
that time, underwent coronary angiogram without significant CAD.
- continued ASA/Plavix; please consider narrowing to Plavix only
given no known indication for dual anti-platelet therapy
- discontinued imdur given likely not having anginal symptoms
and trying to avoid preload reduction
- not on a statin due to prior rhabdomyolysis
#PAD
- continued ASA/Plavix as above
#Hx of right parietal lobe infarct, unclear etiology
- continued ASA/Plavix as above
- not on a statin due to prior rhabdomyolysis
#Gout
- continued allopurinol ___ daily
#T2DM, diet-controlled
Last A1c 5.3% in ___. Patient reports he does not take any
medications.
#GERD
- continued home omeprazole 40mg daily; please consider changing
omeprazole to pantoprazole given black box warning for
concurrent use of clopidogrel and omeprazole
TRANSITIONAL ISSUES:
====================
- Please continue to monitor volume status with new estimated
dry weight of 55.5-56kg
- Please continue to monitor blood pressures and mental status
with more conservative volume management at dialysis and
following discontinuation of losartan and imdur
- Continued ASA/Plavix; consider narrowing to Plavix monotherapy
given unclear indication
- Please consider titrating COPD medications; patient is
currently on an albuterol inhaler PRN and tiotropium daily at
home and may benefit from ___ given progressive symptoms
- Please consider initiating low-dose remeron 7.5mg qHS for
depression and as an appetite stimulant
- Please consider changing omeprazole to pantoprazole given
black box warning for concurrent use of clopidogrel and
omeprazole
MEDICATION CHANGES:
===================
STOP isosorbide mononitrate
STOP losartan
STOP sevelamer unless your doctor tells you to restart it
START nephrocaps 1 cap daily
CHANGE gabapentin to 300mg daily
Weight on discharge (new estimated dry weight): 55.5-56kg
Contact: ___ (son), ___ ___
(daughter), ___
Full code
>30 minutes were spent in discharge planning and coordination of
care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 100 mg PO DAILY
2. Allopurinol ___ mg PO QPM
3. Carvedilol 25 mg PO BID
4. sevelamer CARBONATE 800 mg PO TID W/MEALS
5. Clopidogrel 75 mg PO DAILY
6. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
7. Aspirin 81 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. Losartan Potassium 50 mg PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Artificial Tear Ointment 1 Appl BOTH EYES PRN dryness
Discharge Medications:
1. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0
2. Sarna Lotion 1 Appl TP QID itch
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % apply four
times a day as needed Refills:*0
3. Gabapentin 300 mg PO DAILY
RX *gabapentin 300 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
4. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
shortness of breath
5. Allopurinol ___ mg PO QPM
6. Artificial Tear Ointment 1 Appl BOTH EYES PRN dryness
7. Aspirin 81 mg PO DAILY
8. Carvedilol 25 mg PO BID
9. Clopidogrel 75 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Omeprazole 40 mg PO DAILY
12. Tiotropium Bromide 1 CAP IH DAILY
13. HELD- sevelamer CARBONATE 800 mg PO TID W/MEALS This
medication was held. Do not restart sevelamer CARBONATE until
you talk with your doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Encephalopathy ___ hypotension and hypovolemia
SECONDARY DIAGNOSES:
====================
Pruritus
ESRD
COPD
CAD
PAD
Hx of right parietal lobe infarct
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You were confused and were found to have a low blood pressure.
What did you receive in the hospital?
- We believe your confusion was caused by low blood pressure.
- We believe your low blood pressure was caused by too much
fluid being taken from your body at dialysis. We spoke with your
outpatient kidney doctor to target a dry weight that is higher.
We trialed that higher weight at several dialysis sessions in
the hospital, and your blood pressures and mental state remained
normal.
- We also stopped some medications that we believe might be
worsening your low blood pressure.
- We restarted gabapentin in order to help with your itching.
What should you do once you leave the hospital?
- Please continue to monitor your blood pressures and talk with
your kidney doctor if you are still having low blood pressures
or confusion after dialysis.
- Please work with physical therapy at home to get stronger.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10781468-DS-36
| 10,781,468 | 25,031,695 |
DS
| 36 |
2132-12-18 00:00:00
|
2132-12-19 17:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cortisone / Carafate / Statins-Hmg-Coa Reductase Inhibitors /
lisinopril
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with legal blindness, partial deafness, and history of HFpEF
(EF 57% in ___, ESRD on ___ HD, COPD, right parietal lobe
ischemic infarct of unclear etiology, CAD complicated by MI in
___ (treated in ___, diet-controlled T2DM, pulmonary
hypertension, with multiple recent admissions presents from
dialysis after witnessed LOC.
Of note patient had admission ___ for similar episode where
he was laying in bed and then had possible lost consciousness
for
several minutes. On that admission full workup was obtained
including telemetry for 24 hrs, ECHO, head CT. Ultimately no
cause was found and he was discharged.
He was then again admitted from ___ for AMS in the
setting
of dialysis. This was felt to be from possible over dialysis and
with fluids given back and less aggressive dialysis he improved
and was discharged.
The patient is a difficult historian but appears he was
coughing
frequently then vomited. About 20 minutes later has the episode
of LOC. Per ED he was noted to not be breathing but otherwise
had
a pulse (waiting to speak with dialysis center to obtain more
details) patient does not remember the episode.
Past Medical History:
HFpEF (EF 62% in ___
ESRD (on HD MWF since ___
DM type 2, diet controlled, last A1c 5.3%
CAD with history of MI in ___ in ___, no known treatment
COPD
BPH
Gout
HTN
PVD
GERD
CVA (residual L-sided weakness)
Legally blind ___ diabetic retinopathy
Hemorrhoids
Social History:
___
Family History:
Denies family history of stroke or heart disease.
Mom died at ___, was healthy.
Dad died at ___, unknown cause.
Half-brother died at ___ in a war.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 97.4 182/63 64 16 95% RA
GENERAL: Alert and oriented x3. Frequently closes eyes during
conversation. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
Discharge Exam:
24 HR Data (last updated ___ @ 558)
Temp: 97.7 (Tm 98.2), BP: 177/69 (144-177/48-69), HR: 70
(62-70), RR: 18 (___), O2 sat: 96% (94-98), O2 delivery: Ra
GENERAL: Alert and oriented x3. Frequently closes eyes during
conversation. In no acute distress.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
Pertinent Results:
Admission Labs:
___ 02:55PM BLOOD WBC-8.0 RBC-4.07* Hgb-12.3* Hct-39.2*
MCV-96 MCH-30.2 MCHC-31.4* RDW-17.1* RDWSD-59.1* Plt ___
___ 02:55PM BLOOD Plt ___
___ 07:00AM BLOOD ___ PTT-31.0 ___
___ 02:55PM BLOOD Glucose-156* UreaN-19 Creat-3.2*# Na-136
K-5.6* Cl-94* HCO3-25 AnGap-17
___ 02:55PM BLOOD ALT-11 AST-44* CK(CPK)-86 AlkPhos-105
TotBili-0.3
___ 02:55PM BLOOD Albumin-3.6 Calcium-8.7 Phos-2.7 Mg-2.3
Pertinent Interval Labs:
___ 06:15AM BLOOD WBC-3.8* RBC-3.58* Hgb-10.9* Hct-34.1*
MCV-95 MCH-30.4 MCHC-32.0 RDW-16.2* RDWSD-56.4* Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD Glucose-81 UreaN-23* Creat-4.7*# Na-135
K-5.3 Cl-94* HCO3-29 AnGap-12
___ 06:15AM BLOOD Calcium-8.4 Phos-4.4 Mg-2.2
Dialysis:
___ yesterday, will adjust EDW to 57 kg - no UF as pre-HD
weight is below EDW
Transthoracic Echo:
IMPRESSION: No structural cardiac cause of syncope identified.
Normal left ventricular wall
thickness with normal cavity size and mild systolic dysfunction
c/w CAD in an RCA distribution with
hyperkinesis of the remaining segments and an overall
hyperdynamic ejection fraction. Mild apical
intra-cavitary gradient. Mild mitral regurgitation. Mild
tricuspid regurgitation. Moderate to severe
pulmonary artery systolic hypertension. Large, mostly posterior,
loculated pericardial effusion without
echocardiographic evidence of tamponade.
CT Head:
IMPRESSION:
No acute intracranial abnormality.
Brief Hospital Course:
___ yo M PMHx HFpEF (EF 57% in ___ with legal blindness,
partial deafness, ESRD on MWF HD, COPD, right parietal lobe
ischemic infarct of unclear etiology, CAD s/p MI in ___
(treated in ___, diet controlled T2DM, pulmonary
hypertension and 2 recent admission for AMS/syncopal episodes
one of which was related to dialysis who presents from dialysis
___ for a witnessed syncope likely secondary to
over-dialysis. Syncope workup pending.
ACUTE ISSUES:
#Syncope: likely ___ hypovolemia I/s/o dialysis
#Pericardial Effusion without evidence of tamponade.
Hypovolemia appears most likely given that he just had dialysis
was lower than his dry body weight by .___ and has recent
syncopal event soon after dialysis. Patient has demonstrated
here evidence of orthostatic hypotension however it is unclear
if this is the etiology of his syncope as he was lying in
dialysis bed. Arrhythmia: will monitor on tele, previous
episodes of syncope did not reveal arrhythmia.
Work up included an echocardiogram, telemetry and an
echocardiogram as there was a report of a mild outflow tract
obstruction on last echo. Echo was unchanged except for an
enlarged pericardial effusion without tamponade physiology. He
will require follow up with cardiology as an outpatient for this
finding. Infectious disease was consulted to comment on
likelihood of Tb as etiology for effusion. Very low likelihood
of Tb as patient is not systemically ill, without weight loss,
fevers etc. Per ___ ___ dialysis records patients last
ppd was in ___ and was + 15mm, CXR here without evidence of Tb.
He had 2 rounds of dialysis while inpatient and tolerated them
well. 57kg was used as his dry weight at dialysis and his
outpatient dialysis center was informed of this. Cardiology
recommended considering adding midodrine as a medication to be
taken at dialysis.
#Orthostatic Hypotension:
On measurement after dialysis 138/50 flat, 105/61 after 1 minute
standing after 3 minutes standing 92/61. Potential contributor
is
the carvedilol however it appears unlikely to cause such a
profound drop in pressure. Patient has demonstrated labile blood
pressure while here, he possibly has a degree of autonomic
dysregulation.
We attempted to drop his coreg to 12.5mg BID however his blood
pressures remained elevated to borderline urgency range. We will
discharge on home doseage. We Encouraged usage of compression
stockings.
#HTN:
-continue carvedilol as above, consider dose decrease for
orthostasis (as above), mitigating risk of worsening resting
systolic HTN.
===============
CHRONIC ISSUES:
===============
#ESRD on HD
-HD MWF
-Continue nephrocaps
#Heart Failure with preserved ejection fraction
imdur and losartan were stopped during last admission due to
hypotension.
#DM2
Manages with diet as outpatient, Last A1c 5.3% in ___.
Patient
reports he does not take any medications.
Plan:
-ntd
#CAD s/p MI ___
Not on statin due to prior episodes of rhabdo
-clarify with patient if on Clopidogrel as an outpatient.
-Continue ASA
#COPD
-Continue spirivia and albuterol while in house
#Gout
-Allopurinol ___ mg PO every other day per HD dosing guidelines
=============
CORE MEASURES
=============
#CODE: Full code
#CONTACT: ___ (son), ___ ___
(daughter), ___
Transitional Issues
==============
[ ] Latent Tb workup: pt with hx of ppd +15mm in ___ per ___
___ Dialysis. Please confirm that subsequent ppd vs IGRA
testing has been performed and is negative. If it has not,
please test for tb and consider patient for treatment of latent
Tb.
[ ] Cardiology follow up, working to schedule an appointment,
number provided to call.
[ ] Continue to assess need for Coreg at current dose.
Challenging balance between hypertension and orthostasis. Please
continue to monitor for orthostatic symptoms and hypertension.
[ ] reinforcement regarding importance of slow changes in
position from laying flat to seated/standing
[ ] 57kg is weight to be used as dry weight at dialysis. Our
nephrologists spoke with ___.
[ ] Consider using midodrine 5mg at dialysis if hypotensive.
[ ] Please clarify that patient is not to be on Plavix (patient
reported outpatient physician advised him to stop taking.
Refused medication inpatient)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO QPM
2. Aspirin 81 mg PO DAILY
3. Carvedilol 25 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 300 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Tiotropium Bromide 1 CAP IH DAILY
8. Nephrocaps 1 CAP PO DAILY
9. Sarna Lotion 1 Appl TP QID itch
10. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
shortness of breath
11. Artificial Tear Ointment 1 Appl BOTH EYES PRN dryness
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
shortness of breath
2. Allopurinol ___ mg PO QPM
3. Artificial Tear Ointment 1 Appl BOTH EYES PRN dryness
4. Aspirin 81 mg PO DAILY
5. Carvedilol 25 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Gabapentin 300 mg PO DAILY
8. Nephrocaps 1 CAP PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Sarna Lotion 1 Appl TP QID itch
11. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Syncope secondary to excessive fluid removal at dialysis
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 while you were admitted at
___,
Why was I admitted to the hospital?
-You had an episode of loss of consciousness while at dialysis
What happened while I was in the hospital?
-We performed several tests to determine why you lost
consciousness (passed out) including lab work, heart monitoring,
and blood pressure checks
-We performed dialysis and adjusted your dialysis parameters.
What should I do when I go home?
-Continue taking all of your medications as prescribed
-Use caution when standing from a seated or lying position.
Followup Instructions:
___
|
10781561-DS-9
| 10,781,561 | 23,533,521 |
DS
| 9 |
2187-11-10 00:00:00
|
2187-11-10 16:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Norvasc / Penicillins / Lipitor / Lisinopril
Attending: ___
Chief Complaint:
Fever, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a ___ s/p renal transplant p/w 3 days of fever, shortness
of breath, and tremors. Pt states he normally has a baseline
hand tremor from tacrolimus, however he has felt chills over the
past few days and has been shaking. His wife documented two
fevers at home of 103.2 and 102.4. He also has experienced
shortness of breath with minimal cough. Reports overall
malaise, decreased PO intake, and fatigue. Denies diarrhea,
nausea, vomiting, dysuria. Wife states his daughter recently
caught a cold and was around the patient 2 days before. Of
note, patient has known chronic allograft nephropathy on
cellcept and prograf. He also has had very difficult to control
hypertension and remains on multiple medications.
In the ED, initial vital signs were 102.1 79 183/77 16 97% RA.
Labs showed a relative leukocytosis 9.8 from 2.2 with a left
shift. Creatinine was 2.9 from 2.0 with a K of 5.9 EKG was
noted to show a NSR at 80. No ST elevations/depressions, No
peaked T waves. CXR showed a retrocardiac pneumonia. Renal
ultrasound was unremarkable. Pt was given 1L IVF, levofloxacin
750 mg and tylenol for the fever and sent to the ___
service.
ROS: per HPI, denies night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- ESRD due to diabetic nephropahty, a solitary kidney, and 2
episodes of nephrolithiasis complicated by obstruction and ___
s/p a living-related renal transplant from his daughter on
___
- Type II Diabetes
- Hypertension
- Hypercholesterolemia
- Gout
- cataracts
- OSA
- s/p back surgery in ___
Social History:
___
Family History:
Mr. ___ parents died in their ___ (father with esophageal
cancer, mother old age). He has 3 sisters and 3 brothers. One
sister has DM and a signel kidney, 1 brother had ___ at age
___ and now has CAD. The other siblings are well. The other ___xcept one daughter has polycystic ovaries and
is pre-diabetic.
Physical Exam:
ADMISSION EXAM:
Vitals- 98.9, 124/76 ___ rr16, 97ra
General- alert and oriented, mild rigors present
HEENT- sclera anicteric
CV- regular rate and rhythm, normal S1 S2, no murmurs
Lungs- Rhonchi heard in RML, no crackles ausculated
Abdomen- obese, normal bowel sounds, soft, nontender,
nondistended, no rebound, unable to palpate liver margin
Ext- venous stasis changes noted with 2+ bilateral pitting edema
Neuro- no asterixis.
DISCHARGE EXAM:
Vitals- 97.8-98.2, 137-147/68-73, p66-71, rr20, 98ra, 142-162fs
General- middle aged gentleman sitting in chair in no acute
distress
HEENT- sclera anicteric
CV- regular rate and rhythm, normal S1 S2, no murmurs
Lungs- clear to auscultation, no wheezes or rales, egophany LML
LLL
Abdomen- obese, normal bowel sounds, soft, nontender,
nondistended, no rebound
Ext- venous stasis changes noted with 2+ bilateral pitting edema
Neuro- no asterixis, alert and oriented to person, place, and
time
Pertinent Results:
ADMISSION LABS:
___ 08:15AM BLOOD WBC-9.8# RBC-2.92* Hgb-8.7* Hct-26.8*
MCV-92 MCH-29.9 MCHC-32.5 RDW-13.6 Plt ___
___ 08:15AM BLOOD Neuts-89.2* Lymphs-5.1* Monos-5.4 Eos-0.1
Baso-0.1
___ 08:15AM BLOOD ___ PTT-29.6 ___
___ 08:15AM BLOOD Glucose-170* UreaN-65* Creat-2.9* Na-130*
K-5.9* Cl-103 HCO3-15* AnGap-18
___ 08:15AM BLOOD ALT-23 AST-23 AlkPhos-73 TotBili-0.7
___ 08:15AM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.3 Mg-1.9
___ 06:15AM BLOOD calTIBC-178* Ferritn-219 TRF-137*
___ 06:56AM BLOOD tacroFK-7.0
DISCHARGE LABS:
___ 09:25AM BLOOD WBC-3.6* RBC-3.17* Hgb-9.4* Hct-28.7*
MCV-91 MCH-29.5 MCHC-32.6 RDW-13.7 Plt ___
___ 09:25AM BLOOD ___ PTT-30.2 ___
___ 09:25AM BLOOD Glucose-149* UreaN-80* Creat-3.0* Na-133
K-4.5 Cl-104 HCO3-17* AnGap-17
___ 09:25AM BLOOD Calcium-8.7 Phos-4.9* Mg-2.2
URINE:
___ 10:10AM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:10AM URINE Blood-SM Nitrite-NEG Protein-600
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:10AM URINE RBC-5* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0 TransE-<1
___ 10:10AM URINE CastHy-6*
___ 10:10AM URINE Mucous-RARE
___ 10:10AM URINE Hours-RANDOM Creat-152 Na-12 K-44 ___ urine culture - mixed, likely contamination
___ blood culture - pending, no growth to date
___ VRE swab - negative
___ ECG
Sinus rhythm. Normal tracing. Compared to the previous tracing
of ___ no change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
78 158 92 ___
___ CXR
FINDINGS: The lungs are well expanded. A dense retrocardiac
opacity is
present, which is confirmed with a prominent spine sign in the
lateral view. Otherwise, no other focal opacities are
identified. There might be small bilateral pleural effusions.
There is no pneumothorax. Cardiomediastinal and hilar contours
are unremarkable.
IMPRESSION: Left lower lobe pneumonia. Repeat after treatment
to document resolution.
___ Renal US
No hydronephrosis. Patent renal vasculature with normal
resistive indices.
Brief Hospital Course:
___ with ___ s/p kidney transplant in ___ with chronic
allograft nephropathy, HTN, HL presented with 3 days of fever,
chills, dyspnea, and CXR findings consistent with pneumonia.
# Pneumonia, community acquired. Classic fever, chills, dyspnea,
with LLL pneumonia on CXR. Patient initially started with IV
levofloxacin 750mg q48h (renal dosing) in the ED ___. On the
floor, he continued to have worsening dyspnea and Tmax 101. He
was broadened to vancomycin/cefepime, ___. Clinically
improved ___ with no further fevers. On ___, he was
transitioned to levofloxacin 500mg PO q24hr. He will have 6 more
doses to end on ___, for 9 day course, longer given
immunosuppression. On day of discharge, he was afebrile, with no
leukocytosis, normal O2 sats, and no dyspnea.
# Volume overload. Some element of acute on chronic renal
disease, Cr 2.9 up from baseline 2.0. Patient was assessed as
having pre-renal component in the ED and received 1L IVF. He
became more short of breath and improved after IV furosemide
60mg on the floor. There may be component of chronic allograft
nephropathy (seen on biopsy ___. His valsartan was stopped.
His torsemide was increased to 40mg PO BID. His leg edema was
improved on discharge.
# Non-anion gap metabolic acidosis. Most likely related to
kidney transplant. Mechanisms include type 4 RTA due to
tacrolimus, hyperkalemia, and tubular dysfunction. Bicarbonate
low at ___, baseline low ___. He was started on sodium
bicarbonate 650mg PO BID and his bicarbonate was 17 on day of
discharge.
# Hyperkalemia. Likely from acute on chronic kidney diseaase. No
EKG changes. Improved to normal after insulin, furosemide, and
kayexalate. It was 4.5 on discharge day. Valsartan was stopped.
# S/p renal transplant, living donor renal transplant ___. He
was continued on MMF 500 PO BID and tacrolimus 1.5mg PO q12hr.
#Hypertension. Well controlled. He was continued on labetalol,
hydralazine, and clonidine patch. Valsartan 40mg held. Torsemide
increased to 40mg BID. BP on discharge was 137-147/68-73.
#DM. Stable. Continue humalog 10 units B/L/D/QHS. Continue NPH
25 q AM and 25 at lunch
#Hyperlipidemia. Continue statin.
### TRANSITIONAL ISSUES ###
1) Continue levofloxacin 500mg PO q24hr x 6 more days, to end on
___.
2) Valsartan was stopped. Patient's BP was normal and K was high
on admission. We have increased his diuretic.
3) Torsemide increased to 40mg PO BID.
4) Added sodium bicarbonate 650mg PO BID for low bicarbonate
likely from CKD.
5) Weekly electrolyte lab checks faxed until his visit with Dr.
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 800 mg PO TID
2. Tacrolimus 1.5 mg PO Q12H
3. HydrALAzine 50 mg PO TID
4. Torsemide 60 mg PO DAILY
5. Allopurinol ___ mg PO DAILY
6. Mycophenolate Mofetil 500 mg PO BID
7. Pravastatin 10 mg PO EVERY OTHER DAY
8. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QWED
9. Valsartan 40 mg PO DAILY
10. Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Humalog 10 Units Bedtime
NPH 20 Units Breakfast
NPH 25 Units Lunch
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QWED
3. HydrALAzine 50 mg PO TID
4. Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Humalog 10 Units Bedtime
NPH 20 Units Breakfast
NPH 25 Units Lunch
5. Labetalol 800 mg PO TID
6. Mycophenolate Mofetil 500 mg PO BID
7. Pravastatin 10 mg PO EVERY OTHER DAY
8. Tacrolimus 1.5 mg PO Q12H
9. Torsemide 40 mg PO BID
RX *torsemide 20 mg 2 tablet(s) by mouth twice a day Disp #*40
Tablet Refills:*1
10. Sodium Bicarbonate 650 mg PO BID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day
Disp #*40 Tablet Refills:*1
11. Levofloxacin 500 mg PO Q24H Duration: 7 Days
___
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*6
Tablet Refills:*0
12. Outpatient Lab Work
Please check chem 10 and tacrolimus level once a week on
___ and fax results to Dr. ___ ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
1) Pneumonia, community-acquired
2) Acute on chronic kidney disease
3) Lower extremity edema
SECONDARY:
1) Status post kidney transplant.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure to take care of you at ___
___. You were admitted to the hospital because of
shortness of breath and fever. You were found to have a
pneumonia which we are treating with antibiotics. You also have
a low bicarbonate level, likely from your kidney disease, which
we will treat with a sodium bicarbonate pill. Lastly, you had
some increased swelling in your legs. We have increased your
torsemide to 40mg twice a day.
1) You will need to continue with the antibiotic levofloxacin
500mg daily through ___.
2) Please take sodium bicarbonate 650mg PO twice a day for your
low bicarbonate level.
3) Please take torsemide 40mg PO twice a day to treat your leg
edema.
4) Please have weekly labs faxed to Dr. ___ your
visit.
Followup Instructions:
___
|
10781581-DS-13
| 10,781,581 | 29,316,620 |
DS
| 13 |
2182-01-05 00:00:00
|
2182-01-08 16:17:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lactose
Attending: ___
___ Complaint:
Pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o lung CA (adeno Ca involving visceral pleura - T2a)
s/p bilateral wedge resections (___) sent in by Dr.
___ SOB x6 days. He states thats for the past 6 days he
has been feeling more fatigued with decreased appetite and
progressively worsening SOB. Found to have PNA on CXR in the
office today. Denies fevers/chills, leg swelling, calf swelling,
abdominal pain or chest pain. Patient has been intermittently
tachycardic over the past several months, including pre-op. Of
note, he had an EKG ___ that showed diffuse PR depressions
and ST elevations, at which time he had no chest pain. TTE was
performed the same day that showed no pericardial effusion. No
h/o clots. Also had CTA in the past week showing no pericardial
effusion or PE and no PNA or endobronchial lesions.
.
In the ED, initial VS were:
T 98.7 HR 122 BP 158/78 RR 20 O2 Sat 95%
CXR showed RLL PNA. Blood cultures were obtained and he was
given Ceftriaxone 1g iv x1 and Azithromycin 500mg po x1.
.
On the floor, initial VS were:
T 97.4 BP 141/90 HR 108 RR 18 O2 sat 90% RA
Past Medical History:
Hyperlidemia
Hypertension
Diabetes
Psoriatic arthritis on methotrexate
lactose intolerance
BPH
PSH: B/l knee replacement
S/P VATS RUL ___
Social History:
___
Family History:
Mother- died of ___ age ___
Father- MI age ___, died age ___
Siblings- sister died of lung cancer ___, another sister is
leukemia survivor.
Physical Exam:
Admission Exam:
VS - T 98.7 HR 122 BP 158/78 RR 20 O2 Sat 95%
GENERAL - Well appeaing man in NAD
HEENT - NCAT, MMM, thyroid non-tender, no palpable masses
NECK - JVP 5cm above the RA
LUNGS - CTAB, no increased WOB, bronchial breathsounds in the
mid R lung, mild egophany, no wheezes, rales or rhonchi.
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, NTND, no rigidity, rebound or guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - A/Ox3, CN II-XII grossly intact, non focal
.
Discharge Exam:
VS: T ___ BP 115-140/70-80 HR 94-100s (94) RR 18 O2 Sat 99% RA
GENERAL - Well appeaing man in NAD
HEENT - NCAT, MMM, thyroid non-tender, no palpable masses
NECK - JVP 5cm above the RA
LUNGS - CTAB, no increased WOB, no wheezes, rales or rhonchi
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, NTND, no rigidity, rebound or guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - A/Ox3, CN II-XII grossly intact, non focal
Pertinent Results:
Admission Labs:
___ 05:14PM BLOOD WBC-9.9 RBC-4.81 Hgb-13.5* Hct-40.8
MCV-85 MCH-28.1 MCHC-33.1 RDW-13.6 Plt ___
___ 05:14PM BLOOD Neuts-84.6* Lymphs-9.8* Monos-5.0 Eos-0.3
Baso-0.3
___ 06:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
___ 05:14PM BLOOD Glucose-156* UreaN-17 Creat-0.8 Na-141
K-3.8 Cl-100 HCO3-29 AnGap-16
___ 05:14PM BLOOD Calcium-10.1 Phos-3.9 Mg-1.7
___ 06:00AM BLOOD TSH-0.94
___ 06:00AM BLOOD Free T4-1.3
___ 05:29PM BLOOD Lactate-1.2
Discharge Labs:
___ 06:50AM BLOOD WBC-9.7 RBC-4.31* Hgb-12.2* Hct-36.5*
MCV-85 MCH-28.4 MCHC-33.5 RDW-14.1 Plt ___
___ 06:50AM BLOOD Neuts-78.0* Lymphs-15.1* Monos-5.3
Eos-1.3 Baso-0.3
___ 06:50AM BLOOD Glucose-129* UreaN-11 Creat-0.7 Na-143
K-3.9 Cl-105 HCO3-29 AnGap-13
CXR (___):
1. New right lower lobe perihilar opacity consistent with a
pneumonia.
Recommend follow up CXR in 4 weeks after completion of
antibiotic therapy to ensure resolution.
2. Stable post-surgical changes.
.
EKG (___):
Sinus tachycardia. Delayed R wave progression is likely a normal
variant.
Compared to the previous tracing of ___ no significant
difference.
Brief Hospital Course:
Priamry Reason for Admission: ___ y/o man with recent b/l wedge
resections for Lung Ca presenting with SOB and new consolidation
concerning for PNA also with persistent tachycardia of unknown
etiology.
.
Active Problems:
.
# PNA: Given recent hospitalization for >48h, he met criteria
for HCAP. As such, he was started on Vanc/Cefepime/Levofloxacin.
He remained afebrile throughout his course and sputum cultures
were notable only for oropharyngeal flora. At the time of
discharge, with WBC count had normalized and he was clinically
improved. He was ambulated twice, and both times maintained O2
Sat >95% on RA with ambulation. After 2d of HCAP antibiotics, he
was discharged on 10 day course of Levofloxacin given rapid
improvement and clinically non-toxic appearance. His recent CTA
from ___ showed no endobronchial lesions, making our
suspicion for post-obstrucitve PNA low. CT surgery and Pulm were
both notified of the patient's admission and agreed with his
plan of care.
.
# Tachycardia: Pt was noted to be persistently tachycardic
throughout his course. Of note, he has been intermittently
tachycardic for the past several months. He had a notable EKG
during an office visit with his cardiologist, Dr. ___
showed diffuse PR depressions and ST elevations concerning for
pericarditis. A TTE was obtained the same day as the abnormal
EKG and showed no effusion or other evidnce of pericarditis. EKG
on admission showed only sinus tachycardia without ST or PR
segment changes. He was monitored on telemetry overnight and was
consistently tachycardic from 100-120s. TSH and FT4 were normal.
On HD #1, he was started on Metoprolol with improvement in his
HR to the ___. On the day of discharge, he was ambulated and had
an increase in his HR to the 100s, which promptly returned to
the ___ with rest. He will follow up with his cardiologist.
.
Chronic Problems:
.
# DM: His BG was well controlled throughout his course.
- hold oral medications while hospitalized
- ISS
- diabetic diet
.
# HTN: His BP was well controlled throughout his course.
- cont home lisinopril
.
# HLD
- cont home atorvastatin
.
# Psoriatic Arthritis
- Cont home Methotrexate (___)
.
Transitional Issues: He was d/c'ed home with PCP and ___
___. He will also follow up with Pulmonology and CT surgery.
Medications on Admission:
1. oxycodone-acetaminophen ___ mg: ___ Tablets PO Q4H prn for
pain.
2. metformin 500 mg Tablet Sig: One (1) Tablet PO BID
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. fenofibrate micronized 200 mg Capsule Sig: One (1) Capsule PO
once a day.
5. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
7. methotrexate sodium 2.5 mg Tablet Sig: One (1) Tablet PO once
a week.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
9. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
10. glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Lactaid 3,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO three times a day: before meals with dairy.
Discharge Medications:
1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol succinate 50 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*
6. methotrexate sodium 2.5 mg Tablet Sig: Eight (8) Tablet PO
every ___.
7. fenofibrate micronized 200 mg Capsule Sig: One (1) Capsule PO
qday ().
8. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Lactaid 3,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO three times a day: before meals.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Community Acquired Pneumonia
Secondary Diagnosis:
Sinus Tachycardia
Lung Cancer s/p bilateral wedge resections
DM2
HLD
HTN
Psoriasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure caring for you at the ___
___. You were admitted for pneumonia. For this we
started you on antibiotics. We also checked your heart and found
that it is beating fast, though we found no other problems with
your heart. For this, we started you on a medication called
Metoprolol, which will help to slow your heart rate. We feel you
are safe to return home.
During this hospitalization, we made the following changes to
your medications:
STARTED Metoprolol 50mg by mouth once a day
STARTED Levofloxacin 750mg by mouth once a day for 8 days
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
10781714-DS-12
| 10,781,714 | 20,807,736 |
DS
| 12 |
2154-10-23 00:00:00
|
2154-10-23 10:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
aspirin / divalproex sodium / doxepin / sildenafil / topiramate
Attending: ___
Chief Complaint:
Bilateral SDH
Major Surgical or Invasive Procedure:
___: Left burrhole for ___ evacuation
___: Left craniotomy for ___ evacuation
History of Present Illness:
___ y/o Male who presented with a complaint of worsening
headaches
over the last week. He has a history of migraine headaches,
which
he normally takes Imitrex for. This headache was not relieved by
Imitrex and his wife felt he was having slow speech, so he went
to an Urgent care today who recommended follow up with a
Neurologist in 6 weeks. His headache continued to worsen so he
presented to ___ where a CTA head and neck were done, which
showed bilateral chronic SDH with an acute component on the left
and ~9.5mm MLS. Neurosurgery was then consulted.
The patient recalls falling on ice a couple days after
___,
but cannot remember if he hit his head. He cannot recall any
other recent trauma. He takes Coumadin for a history of PEs ___
years ago. INR 4.1 today.
Past Medical History:
PMHx:
-Hypercholesterolemia
-Migraines
-CAD
-Coronary angioplasty
-Asthma
-Erectile dysfunction
-Raynaud's
-PMH PE
-GERD
-HTN
-SCC scalp/neck
Social History:
___
Family History:
Non-contributory.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
T: 97.8 BP: 128/79 HR: 65 R 14 O2Sats 99% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ EOMs full
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to 4-3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift.
Sensation: Intact to light touch.
PHYSICAL EXAMINATION ON DISCHARGE:
Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious
Orientation: [x]Person [x]Place [x]Time
Follows Commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL 4-3mm
EOM: [x]Full [ ]Restricted
Face Symmetric: [ ]Yes [x]No: Slight right nasolabial fold
flattening that activates symmetrically
Tongue Midline: [x]Yes [ ]No
Pronator Drift: [x]Yes [x]No
Speech Fluent: [x]Yes [ ]No
Comprehension Intact: [x]Yes [ ]No
Motor:
Deltoid Bicep Tricep Grip
Right 5 5 5 5
Left 5 5 5 5
IP Quad Ham AT ___ ___
Right5 5 5 5 5 5
Left5 5 5 5 5 5
[x]Sensation intact to light touch
Incision:
[x]Clean, dry, intact
Pertinent Results:
Please see OMR for pertinent lab and imaging results.
Brief Hospital Course:
___ who 1 week of worsening headaches, and CT findings of
bilateral SDH, with acute component on left.
#Bilateral Subdural Hematoma
The patient presented to the ED on ___ with complaints of a
headache. He underwent a CT of the head which shows bilateral
chronic SDH with an acute component on the left with 9.5mm
midline shift. The patient's INR was elevated upon arrival and
received a total of 4 units of FFP and Vitamin K and his repeat
INR was 1.3. He was admitted to the ___ for close neurologic
monitoring. He underwent a pre-operative evaluation in
anticipation for surgery the following day. Patient went to the
OR on ___ for Left Burr hole for subdural hematoma
evacuation with a left sided subdural drain placed
intraoperativly. The surgery went as planned with no
complications. Please refer to operative report in OMR for
further intraoperative details. A post operative CT scan was
obtained and demonstrated decrease size in left SDH and
decreased MLS. CT also demonstrated acute blood component on
right subdural which was not seen in prior CT. Due to concern of
right subdural expansion, it was determined that the drain was
no longer needed on the left, and therefore the drain was
removed. He remained stable and was later transferred to the
___ for further monitoring. A repeat NCHCT was obtained in the
morning of ___ which was stable. His has continued to improve
and ___ was consulted. NCHCT on ___ showed an increase in the
left-sided subdural hematoma. NCHCT was repeated on ___ showed
an increase in the bilateral subdural hematomas. Patient was
taken to the OR on ___ for a left craniotomy for subdural
hematoma evacuation. The procedure was uncomplicated. Please see
separately dictated operative report by Dr. ___
further details. A subdural JP drain was left in place. Patient
was extubated and transferred to the PACU to recover. He was
transferred to the ___ postoperatively for close neurologic
monitoring. A repeat NCHCT was obtained on ___ due to concern
for increasing confusion and was stable in comparison to the
NCHCT on ___. While in ___, the patient experienced a transient
episode of aphasia which self-resolved. Neurology was consulted
who recommended EEG and MRI, both of which were negative for
seizure or infarct. Keppra was increased and symptoms did not
recur. Slight redness was noted around the patient's incision;
he was started on Keflex on ___ for a 7 day course. He remained
neurologically stable for the remainder of his hospitalization.
#Hypertension
Patient was started on a nicardipine drip postoperatively for
hypertension. He was restarted on his home nifedipine on ___,
and the nicardipine drip was discontinued.
#Fever
Patient febrile to 102. Urinalysis was negative. Urine culture
was negative. Blood cultures were negative. Chest x-ray showed
atelectasis, but was negative for pneumonia. LENIs were
negative. His WBC was trending down as of ___.
#Urinary retention
He failed voiding trial and foley had to be inserted by Urology
on ___. It is to remain in place for 7 days prior to another
voiding trial. Tamsulosin was continued for urinary retention.
Foley was removed on ___ for voiding trial; the patient was able
to void without difficulty.
#Dispo planning
The patient was re-evaluated by ___ on ___ in anticipation
for discharge to rehab on ___.
Medications on Admission:
Atorvastatin 40mg daily; Nifedipine 60mg daily; Imitrex ___
daily PRN; Albuterol 90 mcg/actuation 2 puff PRN; Fluticasone 50
mcg/actuation ___ sprays PRN; Metronidazole 0.75% gel BID;
Coumadin 5 mg ___ tabs daily; Nitroglycerin 0.4 mg SL PRN
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
3. Cephalexin 500 mg PO Q12H Duration: 7 Days
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC BID
6. LevETIRAcetam 1000 mg PO BID
7. Nystatin Oral Suspension 5 mL PO TID
8. Senna 17.2 mg PO HS
9. Tamsulosin 0.4 mg PO DAILY
10. Atorvastatin 40 mg PO QPM
11. NIFEdipine (Extended Release) 60 mg PO DAILY
12. Sumatriptan Succinate 100 mg PO DAILY:PRN give at onset of
migraine
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bilateral subdural hematoma with cerebral compression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Surgery
You underwent a surgery called a craniotomy to have blood
removed from your brain.
Please keep your sutures along your incision dry until they
are removed.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
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DS
| 13 |
2154-10-27 00:00:00
|
2154-10-27 17:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
aspirin / divalproex sodium / doxepin / sildenafil / topiramate
Attending: ___
Chief Complaint:
RUE weakness, slurred speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old male who initially presented to
the Emergency Department on ___ with complaints of a
worsening headache over the previous week. He was on warfarin at
the time of presentation for a history of pulmonary embolism
approximately ___ years ago. CT of the head revealed bilateral
acute on chronic subdural hematomas, left greater than right,
with rightward midline shift, rightward subfalcine herniation,
and left-sided uncal herniation. Patient was admitted to the
Neurosurgery Service for further evaluation and management.
Patient subsequently underwent left burr hole for evacuation of
the left-sided acute on chronic subdural hematoma on ___.
Patient returned to the operating room on ___ for a left
craniotomy for evacuation of the left-sided acute on chronic
subdural hematoma in the setting of a worsened CT of the head on
___. Patient was eventually discharged to ___ on ___ in stable condition.
Patient returned to the Emergency Department on ___ as a
transfer from an outside facility with slurred speech, right
facial droop, and right hand numbness. CT of the head at the
outside facility showed stability of the patient's bilateral
acute on chronic subdural hematomas. Patient's Keppra was
increased and he was discharged back to ___.
Patient returns to the Emergency Department today on ___
from ___ with complaints of
slurred
speech and worsening right hand weakness. Patient notes that he
has not be able to write and eat with his right hand over the
past few days as he had previously been able to.
Past Medical History:
PMHx:
-Hypercholesterolemia
-Migraines
-CAD
-Coronary angioplasty
-Asthma
-Erectile dysfunction
-Raynaud's
-PMH PE
-GERD
-HTN
-___ scalp/neck
-S/p left burr hole (___)
-S/p left craniotomy (___)
Social History:
___
Family History:
Non-contributory.
Physical Exam:
-------------
On admission:
-------------
Vital Signs: T 97.5F, HR 92, BP 130/71, RR 16, O2Sat 94% room
air
General: Well dressed, well nourished. Comfortable, no acute
distress.
HEENT: PERRL. EOMs intact.
Extremities: Warm and well perfused.
Neurologic:
Mental Status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech slightly slurred. Good comprehension.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength ___ throughout with the exception of the right
grip, which is 4+/5. No drift.
Sensation: Intact to light touch.
-------------
On discharge:
-------------
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift [ ]Yes [x]No
Speech Fluent: [x]Yes [ ]No - speech slightly slurred
Comprehension intact [x]Yes [ ]No
Motor:
Deltoid BicepTricepGrip
Right 5 4+ 4+ 4+
Left 5 5 5 5
IPQuadHamATEHLGast
[x]Sensation intact to light touch
Wound:
[x]Clean, dry, intact
Pertinent Results:
Please see OMR for pertinent results.
Brief Hospital Course:
___ who presented on ___ with slurred speech and RUE weakness
with known bilateral acute on chronic SDH. NCHCT showed slight
increase in right SDH and stable left SDH. He was admitted for
further monitoring and workup.
He was admitted to the TSICU. MRI with and without contrast was
done, which was negative for acute infarcts. He remained
neurologically stable and was discharged back to rehab on ___.
Medications on Admission:
- acetaminophen 325-650mg by mouth every six hours as needed for
pain
- atorvastatin 40mg by mouth once daily in the evening
- bisacodyl 10mg by mouth once daily as needed for constipation
- cephalexin 500mg by mouth every 12 hours for seven days
___ through ___
- docusate sodium 100mg by mouth twice daily
- heparin 5000 units subcutaneous twice daily
- levetiracetam 1250mg by mouth twice daily
- nifedipine extended release 60mg by mouth once daily
- nystatin oral suspension 5mL by mouth three times daily
- senna 17.2mg by mouth once daily at bedtime
- sumatriptan succinate 100mg by mouth once daily as needed for
migraine headaches
- tamsulosin 0.4mg by mouth once daily
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath, wheezing
2. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
3. Atorvastatin 40 mg PO QPM
4. Cephalexin 500 mg PO Q12H Duration: 1 Day
Last dose evening of ___.
5. Docusate Sodium 100 mg PO BID:PRN Constipation
6. Heparin 5000 UNIT SC BID
7. LevETIRAcetam 1250 mg PO BID
8. NIFEdipine (Extended Release) 60 mg PO DAILY
9. Sumatriptan Succinate 100 mg PO DAILY:PRN Migraine
10. Tamsulosin 0.4 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___ -
Discharge Diagnosis:
Bilateral ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Brain Hemorrhage without Surgery
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10781985-DS-20
| 10,781,985 | 22,939,090 |
DS
| 20 |
2154-03-10 00:00:00
|
2154-03-10 18:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
weight gain, increasing abdominal girth, oliguria
Major Surgical or Invasive Procedure:
Tunneled dialysis line placement
initiation of dialysis followed by six dialysis sessions
EGD
History of Present Illness:
___ year-old male with recurrent minimal change disease, h/o
laryngeal CA s/p laryngectomy, DMII, and HTN who was referred to
the ED by his outpatient nephrologist due to rising creatinine
in the setting of recurrent nephrotic syndrome despite high dose
prednisone.
.
In late ___ he noted increased lower extremity edema and
increasing proteinuria with prot/cr > 5 gram/day. He was started
on 60 mg prednisone daily on ___ and 40 mg of lasix daily.
Despite this treatment he continued to have worsening edema and
increased his lasix to bid. His baseline creatinine usually is
0.7. On ___ he was found to have a creatinine rise to
2.4 and repeat labs have shown continued elevation of creatinine
on ___ up to 4.3 and on ___ up to 6.5.
.
He states he feels poorly. He has had increasing abdominal
distension and feels like there is a hardness near his
umbilicus. He denies nausea or vomiting. No itching, confusion,
or dyspena. He does admit to a 20 pound weight gain and lower
extremity edema. His wife accompanies him and states he has had
relapsing episodes of minimal change disease every year or two
since ___ when he was first diagnosed. He states he was briefly
on dialysis in ___, but during recurrences he has not had as
severe renal injury and usually responds to steroids quickly and
is back to his baseline within a month. No recent NSAID use. He
does report his po intake has been a little less then usual.
.
In the ED his BUN was 159 and his creatinine was 5.8. Potassium
was midly elevated at 5.6. Albumin was 2.0. A foley was placed
and he had 150 cc urine output.
.
On The floor he continues to complian of abdominal distension as
well as being hungry from being NPO.
Past Medical History:
- Type II Diabetes with opthalmic complication
- Minimal change disease with a relapsing course, usually
steroid-responsive
- Essential Benign Hypertension
- Hypercholesterolemia
- Liver hemangioma
- Iron deficiency anemia
- Diverticulosis
- Pulmonary nodule
- Gynecomastia
- Hematuria
- Low back pain, facet arthropathy
- Cancer of the larynx
- Insomnia
- Urinary retention
- Spinal stenosis, unspecified site
- Pulmonary nodule
- Colonic adenoma
- Gait abnormality
Social History:
___
Family History:
He denies a family history of kidney disease. His mother had
diabetes. His brother had prostate cancer. No family history of
CAD and HTN.
Physical Exam:
ADMISSION EXAM
Vitals: T 98.3 BP 180/90 P 64 RR 18 Sat 100% on TM
General: Elderly male in NAD. Alert and approriate.
HEENT: Sclera anicteric, MMM, oropharynx clear, artificial
laryngeal device in place
Lungs: Breathing comfortably, mildly rhoncherous breath sounds
otherwise CTAB
CV: RRR, no MRG
Abdomen: +BS, soft, tenderness to palpation over his mid lower
abdomen.
Ext: warm, 2+ pitting edema of his lower extremities, no
asterixis.
.
DISCHARGE EXAM
VS: T 98.7 BP 127/63 HR 69 RR 18 O2 100 RM
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, moderate anasarca
Neck: supple, tracheal stoma
Lungs: CTAB
Chest: tunnel line dressing clean/dry/intact
CV: Irregular rate and rhythm, no murumurs/rubs/gallops
Abdomen: soft, tender to superficial and deep palpation in left
quadrants, distended, hyperactive bowel sounds present, no
rebound tenderness or guarding, no organomegaly, well-healed
scar from enteral feeding, resonant to percussion
GU: no foley
Lower Ext: warm, well perfused, DP not appreciated bilaterally,
no clubbing, no cyanosis, increased pitting pedal edema (L=R),
edema tracks up ___ calf bilaterally (pitting is R>L)
Neuro: motor and sensory functions grossly normal
Pertinent Results:
ADMISSION LABS
___ 02:21PM GLUCOSE-141* UREA N-159* CREAT-5.8*#
SODIUM-136 POTASSIUM-5.6* CHLORIDE-105 TOTAL CO2-17* ANION
GAP-20
___ 02:21PM ALT(SGPT)-28 AST(SGOT)-36 ALK PHOS-67 TOT
BILI-0.1
___ 02:21PM ALBUMIN-2.0* CALCIUM-7.8* PHOSPHATE-7.4*
MAGNESIUM-2.4
___ 02:21PM WBC-8.0# RBC-4.76 HGB-11.5* HCT-36.8* MCV-77*
MCH-24.1* MCHC-31.2 RDW-16.5*
___ 02:21PM NEUTS-92.2* LYMPHS-5.1* MONOS-2.2 EOS-0.3
BASOS-0.1
___ 02:21PM PLT COUNT-213
___ 02:21PM LIPASE-94*
.
Blood Studies:
___ 06:09AM BLOOD ___ PTT-30.6 ___
___ 02:25PM BLOOD ___ PTT-31.1 ___
___ 09:30PM BLOOD ___
___ 09:30PM BLOOD ___ 06:20AM BLOOD Ret Aut-0.6*
___ 06:10AM BLOOD Ret Aut-0.6*
___ 07:08AM BLOOD ALT-16 AST-15 AlkPhos-49 TotBili-0.3
___ 09:30PM BLOOD LD(LDH)-398* TotBili-0.3
___ 07:08AM BLOOD Lipase-61*
___ 06:09AM BLOOD TotProt-4.4* Albumin-2.9* Globuln-1.5*
Calcium-8.0* Phos-8.2* Mg-2.6
___ 01:03PM BLOOD calTIBC-99* Ferritn-175 TRF-76*
___ 09:30PM BLOOD Hapto-259*
___ 06:10AM BLOOD VitB12-1131* Folate-11.1
___ 06:09AM BLOOD PEP-HYPOGAMMAG IgG-380* IgA-265 IgM-29*
IFE-NO MONOCLO
___ 12:37PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 12:37PM BLOOD HCV Ab-NEGATIVE
___ 04:33PM BLOOD ___ pO2-48* pCO2-34* pH-7.32*
calTCO2-18* Base XS--7 Comment-GREEN TOP
___ 03:44PM BLOOD Lactate-1.1
___ 07:00PM HEPARIN DEPENDENT ANTIBODIES -- NEGATIVE PF4
HEPARIN ANTIBODY BY ___
.
Urine studies:
___ 10:30PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO
___ 10:30PM URINE Hours-RANDOM UreaN-542 Creat-91 Na-28
K-59 Cl-42 TotProt-1500 Prot/Cr-16.5*
___ 05:06PM URINE Hours-RANDOM UreaN-675 Creat-96 Na-26
K-44 Cl-24 TotProt-1430 Phos-54.8 Prot/Cr-14.9*
___ 01:55PM URINE Mucous-OCC
___ 01:55PM URINE CastHy-___*
___:55PM URINE RBC-26* WBC-122* Bacteri-FEW Yeast-NONE
Epi-3 TransE-2
___ 05:52PM URINE Blood-MOD Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 01:55PM URINE Blood-LG Nitrite-NEG Protein->600
Glucose-150 Ketone-TR Bilirub-SM Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:55PM URINE Color-Red Appear-Hazy Sp ___
___ 02:21PM estGFR = 12 if ___ (mL/min/1.73
m2)
.
DISCHARGE LABS
___ 01:14PM BLOOD Hct-24.8*
___ 06:36AM BLOOD WBC-6.3 RBC-3.26* Hgb-8.4* Hct-24.6*
MCV-76* MCH-25.8* MCHC-34.1 RDW-16.5* Plt ___
___ 06:36AM BLOOD Glucose-193* UreaN-54* Creat-5.1*# Na-136
K-3.8 Cl-98 HCO3-29 AnGap-13
.
MICRO:
___ URINE
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ BLOOD CULTURE x2
Blood Culture, Routine (Final ___:
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final ___:
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
___ BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ SEROLOGY/BLOOD
HELICOBACTER PYLORI ANTIBODY TEST (Final ___: NEGATIVE BY
EIA.
___ BLOOD CULTURE
Blood Culture, Routine (Pending):
___ BLOOD CULTURE x3
Blood Culture, Routine (Pending):
___ BLOOD CULTURE x2
Blood Culture, Routine (Pending):
___ URINE
URINE CULTURE (Final ___:
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.
10,000-100,000 ORGANISMS/ML..
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
_________________________________________________________
STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- <=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- <=0.25 S
NITROFURANTOIN-------- 128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
.
IMAGING:
Cardiovascular ECG ___:
Sinus rhythm. Occasional premature atrial contractions. Poor R
wave
progression suggests anteroseptal myocardial infarction of
indeterminate
age. Low QRS voltages in the limb leads. No previous tracing
available for
comparison.
.
Chest (PA and Lat) ___:
IMPRESSION: Small bilateral pleural effusions. Hyperinflation.
Otherwise,
unremarkable exam.
ECG ___:
Sinus rhythm with atrial premature depolarizations. Borderline
low QRS voltage in the limb leads. Non-diagnostic repolarization
abnormalities. Compared to the previous tracing of ___ there
is no significant change.
Duplex Doppler Abdomen/Pelvis ___:
IMPRESSION:
1. Minimally elevated resistive indices in the bilateral renal
parenchymal
arteries, otherwise normal renal ultrasound and Doppler.
2. Tiny left lower pole simple renal cyst.
Renal Ultrasound ___:
IMPRESSION:
1. Minimally elevated resistive indices in the bilateral renal
parenchymal
arteries, otherwise normal renal ultrasound and Doppler.
2. Tiny left lower pole simple renal cyst.
ECG ___:
Sinus rhythm with premature atrial complexes. Borderline Q-T
interval
prolongation. Non-specific ST segment flattening in the lateral
and high
lateral leads. Baseline artifact in lead V1 marring
interpretation of
potential bundle-branch block pattern and ischemia. Compared to
the previous tracing of ___ the findings are similar.
___ Ultrasound Guide for Vascular Access ___:
IMPRESSION: Uncomplicated placement of a 23-cm tip-to-cuff
tunneled dialysis line with the distal tip at the right atrium.
The line is ready to use.
Portable Abdomen ___:
SUPINE AND UPRIGHT ABDOMINAL RADIOGRAPHS: A few loops of
gas-distended bowel are noted in the right abdomen, but there is
no dilated bowel or suspicious air-fluid levels. There is
overall non-obstructive bowel gas pattern. No evidence of free
air is noted underneath the right hemidiaphragm. The visualized
lung bases are grossly unremarkable. The patient is status post
lumbar posterior spinal fusion.
IMPRESSION: No evidence of small bowel obstruction.
Chest (Portable AP) ___:
IMPRESSION:
Patchy retrocardiac opacity and left base atelectasis, new
compared with
___. The possibility of an associated pneumonic infiltrate
cannot be
excluded.
GI Biopsy (1 jar) ___:
Pending
Renal Ultrasound with Renal Artery Doppler ___:
IMPRESSION:
1. No hydronephrosis. Stable simple left renal cyst.
2. No evidence of renal artery stenosis bilaterally. The main
renal vein is patent bilaterally. Resistive indices of the
intraparenchymal arteries are again noted to be minimally
elevated.
Brief Hospital Course:
___ year-old male with recurrent minimal change disease, diabetes
Type II, and hypertension here with nephrotic syndrome and
worsening ___ despite high dose prednisone therapy with minimal
response to IV solumedrol now on dialysis. Hospitalization
complicated by anemia, thrombocytopenia, UTI, bacteremia.
.
# Acute renal failure/Recurrent nephrotic syndrome: The patient
has had 2 or 3 prior episodes of nephrotic syndrome, caused by
minimal change disease, which had previously been responsive to
steroids. During this relapse of nephrotic syndrome, he was on
PO prednisone 60 mg daily for 14 days prior to being admitted,
yet he was not responding to the PO prednisone. Upon admission,
he was transitioned from PO prednisone 60 mg daily to IV
solumedrol 125 mg daily. His creatinine initially trended down
with IV solumedrol but it then reached a plateau that was
elevated at baseline at ~5 up from baseline of ~1 in ___.
Mild ATN may have contributed to ___. Because patient failed to
regain renal function on solumedrol, hemodialysis was initiated
with plans to continue on discharge. He was transitioned from
Solumedrol IV to Prednisone 60mg which he will likely require
for several months with no taper. Patient was started on
nephrocaps and low K diet. He was also treated with PPI, and
Bactrim was started for prevention of Pneumocystis pneumonia.
.
#Anemia: On admission, hct was 36.8. The patient has a history
of iron-deficiency anemia, on iron supplementation. He also has
a history of gastritis which was previously evaluated by
endoscopy. The patient had an MCV of 74 which is consistent with
microcytic anemia with a possible iron-deficient etiology. Fe
studies showed anemia of chronic disease possibly from a renal
etiology. Retic count was 0.6, indicating that a component of
the patient's anemia is caused by his kidneys not producing
enough EPO in the setting of CKD or his bone marrow not
responding to the EPO. GNR bacteremia (see below) may have also
contributed to anemia. During admission, hct trended down.
Transfusion threshold was hct 25 and he required 2 units of
pRBCs over the admission. He had guaiac positive stool x1. Given
history of gastritis, there was concern for possible UGIB. An
EGD showed that the patient has mild gastritis but no active
source of bleeding. Gastric biopsy results pending at time of
discharge. He will f/u with GI as outpatient for possible
colonoscopy and EUS to evaluate the possible lipoma in the
second part of his duodenum.
.
#Thrombocytopenia: Platelets trended down from baseline 200 to
nadir of 89. The dx included infection, HIT, hemodialysis, DIC,
TTP-HUS, and post-transfusion purpura. In setting of GNR
bacteremia and low reticulocyte count, it is likely that his
bone marrow was being suppressed. Initially, heparin sq was
held, but HIT type 2 antibody test was negative. At that time,
heparin SQ and for dialysis line were re-started. No extensive
bruising, has no hematuria, has no bloody diarrhea and normal
hemolysis labs. Normal FDP fibrinogen coagulation panel. On
d/c, platelets were 167.
.
#UTI, bacterial: U/A was indicative of infection. Urine culture
showed Klebsiella pneumoniae which was pan sensitive. At this
time, the foley was pulled. Patient was initially treated with
Cipro, but was then transitioned to cepfepime --> ceftriaxone
given bacteremia (see below).
.
#Bacteremia: On ___, blood cultures grew out GNRs, found to be
klebsiella, pan sensitive as organism in the urine. Thus,
source of bacteremia was UTI. First neg blood culture on ___.
The patient has been on ceftriaxone 1 g Q24h to treat this
infection. The patient will need to be on antibiotics to treat
his bacteremia until ___ for a 2 week course. On d/c, he will
switch from ceftriaxone to Ceftazadime per HD protocol (1g after
HD).
.
#Hypertension, benign: The patient has a history of essential
Hypertension. His increase in volume status was likely
contributing to his elevated BP as SBPs were better controlled
after dialysis sessions. Patient was well controlled on
hydralazine 25mg q6h in house, but was transitioned to
amlodipine 5mg qd as it is more feasible for him to take a daily
drug at home. Will need to continue to titrate amlodipine as
needed.
.
#Diabetes, type II, uncontrolled, without complications: Blood
glucose was difficult to control in the setting of high dose
steroids as above. Initially, he was managed with Lantus in the
morning in addition to insulin sliding scale. However, sugars
were still elevated and ___ was consulted--recommended
changing to NPH and helped with sliding scale. He will need to
f/u with ___ as outpatient as glucose will be particularly
difficult to control when prednisone is tapered.
.
#Hypercholesterolemia: Continued home simvastatin 40 mg PO
daily.
.
#GERD: Temporarily on IV PPI when ?UGIB, then transitioned back
to home omeprazole 20mg qd.
.
TRANSITIONS OF CARE:
-please transfuse 1 unit pRBCs on ___ with HD (Hct was
24.8 on last check here on ___
-ceftazadime 1g after HD, last day = ___ (14 day course total
for Klebsiella UTI/bacteremia)
-check CBC weekly and transfuse if hct <25
-urine culture from ___ +for Stenotrophomonas (10,000-100,000
organisms/mL) which was sensitive to Bactrim, and Klebsiella
(10,000-100,000 organisms/mL) sensitive to
ceftriaxone/ceftazidime; if patient has urinary symptoms, please
repeat U/A
-consider uptitrating amlodipine if needed
-continue to adjust insulin
-gastric biopsy results pending at time of d/c
-will likely need ___ f/u as outpatient, this needs to be
scheduled by PCP
-___ patient should follow up with the Gastroenterology
department in 3 to 4 weeks to assess timing for colonoscopy and
evaluation of lipoma by EUS.
-Per wife, patient has had progression of hearing loss. This
should be further evaluated as an outpatient.
-code status: FULL
Medications on Admission:
Insulin Glargine 15 units EVERY MORNING
Lisinopril 10 mg PO DAILY (held recently)
Glipizide 2.5 mg Extended Rel 24 hr ___ tab po qday
Prednisone 60 mg po daily (since ___
Furosemide 40 mg po daily
Ferrous Sulfate 325 mg po twice a day
Metformin 1,000 mg Oral Tablet ___ tablet bid (held recently)
Aspirin 81 mg po daily
Cholecalciferol 1,000 unit po daily
Simvastatin 40 mg po every evening
Colace 100 mg po bid
Multivitamin daily
Omeprazole 20 mg po daily
MILK OF MAGNESIA ORAL 30 milliliters po hs prn
CALCIUM-CHOLECALCIFEROL 600 MG (1,500)-200 UNIT 1 tablet twice
daily
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Ten (10) Subcutaneous qam: Please take 10 U in the
morning; take 6 U on mornings of dialysis.
13. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous before meals as needed: please see insulin sliding
scale.
14. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
15. glycerin (adult) Suppository Sig: One (1) Suppository
Rectal PRN (as needed) as needed for constipation.
16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. ceftazidime 1 gram Recon Soln Sig: One (1) Intravenous per
HD for 5 days: please administer after HD, last day ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Nephrotic syndrome/acute kidney injury
Urinary tract infection
Bacteremia
Anemia
.
Secondary:
Diabetes
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
.
It was a pleasure taking part in your medical care. You were in
the hospital because your kidneys were not working well. We
tried IV steroids to help your kidneys but unfortunately you
still required dialysis. You will continue to have dialysis in
rehab and then as an outpatient. You should call your
nephrologist, Dr. ___, to schedule an appointment after
discharge.
.
You also had a urinary tract infection and an infection in your
blood. We treated you with IV antibiotics. You should continue
the antibiotics to complete a 2 week course on days that you get
dialysis.
.
You were also noted to be anemic. You had a small amount of
blood in your stool so you underwent an EGD to rule out bleeding
from you upper GI tract. This showed gastritis (irritation of
the stomach) but no bleeding. You should follow up with Dr.
___ gastroenterologist, as scheduled below to discuss
repeating a colonoscopy.
.
We have made multiple changes to your medications. Please see
the updated list below.
.
Please attend the follow up doctor's appointments as scheduled
below.
.
We wish you all the best!
Followup Instructions:
___
|
10781985-DS-22
| 10,781,985 | 26,944,176 |
DS
| 22 |
2156-11-11 00:00:00
|
2156-11-11 12:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male with PMH of laryngeal cancer s/p tracheostomy,
DM II, minimal change disease on chronic prednisone and
discharge from ___ yesterday for coag-negative staph UTI and
bacteremia presenting from home with fevers up to 102 and
diffuse weakness. He presented on ___ with 1 week of urinary
retention and weakness, was admitted to ___ for septic shock,
required vasopressors and stress dose steroids, was on
ceftriaxone, cefepime and then vancomycin and nafcillin. ID was
consulted and he was discharged on 6 week course of Vancomycin
via ___ line for presumed endocarditis, TTE was negative and he
was high risk for TEE given his tracheostomy. He reports
feeling well when he left, developed loose stools starting last
night, had 3 episodes of loose stools that he reports are soft
but not watery. His ___ saw him today and he had a fever of
102, felt weak and unable to ambulate normally. ___ was
concerned for bleeding and possible erythema at ___ site. Sent
to ___ ED, temp 100.6, CXR was initially read as concerning
for RLL consolidation, he was given cefepime and continued on
vancomycin and admitted.
He says he feels weak currently. Has been urinating frequently
with small amounts. He reports having back pain over the last
few months that is unchanged, had an MRI of lumber spine on
___ showing new L2-L3 disc herniation with central canal
stenosis and mass effect on the conus medullaris. Denies
headache, SOB, cough, CP, abdominal pain, n/v, dysuria, rash,
easy bruising or bleeding.
Ten point review of systems otherwise negative.
Past Medical History:
- Cancer of the larynx s/p tracheostomy
- Type II Diabetes with opthalmic complication
- Minimal change disease with a relapsing course, usually
steroid-responsive, on chronic prednisone.
- Essential Benign Hypertension
- Hypercholesterolemia
- Liver hemangioma
- Iron deficiency anemia
- Diverticulosis
- Pulmonary nodule
- Gynecomastia
- Hematuria
- Low back pain, facet arthropathy
- Insomnia
- Urinary retention
- Spinal stenosis, unspecified site
- Pulmonary nodule
- Colonic adenoma
- Gait abnormality
Social History:
___
Family History:
He denies a family history of kidney disease. His mother had
diabetes. His brother had prostate cancer. No family history of
CAD and HTN.
Physical Exam:
Admission Physical Exam:
VS: T 98.5 HR 65 BP 133/70 RR 18 100% RA
Gen: NAD, resting comfortably in bed
HEENT: EOMI, PERRLA, MMM, OP clear, tracheostomy with speech
valve
CV: RRR nl s1s2 no m/r/g
Resp: CTAB no w/r/r
Abd: Soft, NT, ND +BS
Ext: no c/c/e, PICC line site with small amount of blood but
without erythema, tenderness or drainage
Neuro: CN II-XII intact, ___ strength throughout
Back: No spinal or paraspinal tenderness
discharge:
Vitals: 98.9 125/76 p74 RR18 98%ra
General: Alert and oriented x 3. NAD.
Lungs: CTAB, moving air well and symmetrically
HEENT: Laryngectomy site c/d/i, able to speak. PEERL. EOMI
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
EXT: No edema or cyanosis
PICC site RUE without swelling erythema or induration. dressing
c/d/i
Pertinent Results:
___ 09:40AM GLUCOSE-144* UREA N-11 CREAT-0.9 SODIUM-138
POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14
___ 09:40AM ALT(SGPT)-64* AST(SGOT)-33 LD(LDH)-284* ALK
PHOS-69 TOT BILI-0.6
___ 09:40AM WBC-7.4# RBC-4.29* HGB-11.2* HCT-36.0* MCV-84
MCH-26.1* MCHC-31.2 RDW-15.8*
___ 09:40AM PLT COUNT-167
___ 10:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 10:15AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
CXR PA & L ___:
IMPRESSION:
No acute cardiopulmonary process.
DISCHARGE LABS:
___ 05:59AM BLOOD WBC-4.7 RBC-3.90* Hgb-10.2* Hct-32.4*
MCV-83 MCH-26.2* MCHC-31.6 RDW-15.0 Plt ___
___ 05:59AM BLOOD Neuts-62.5 ___ Monos-9.7 Eos-1.2
Baso-0.4
___ 05:59AM BLOOD Glucose-104* UreaN-12 Creat-0.7 Na-139
K-3.7 Cl-104 HCO3-27 AnGap-12
___ 05:59AM BLOOD ALT-41* AST-21 AlkPhos-53
___ 11:21PM BLOOD HBsAg-NEGATIVE
___ 11:21PM BLOOD HIV Ab-NEGATIVE
___ 05:59AM BLOOD Vanco-14.1
___ 11:21PM BLOOD HCV Ab-NEGATIVE
Brief Hospital Course:
___ year old male with PMH of laryngeal cancer s/p tracheostomy,
DM II, minimal change disease on chronic prednisone and
discharge from ___ ___ for coag-negative staph UTI and
bacteremia presenting from home with fevers up to 102 and
diffuse weakness.
#ID: Coag-negative staph UTI and bacteremia with presumed
endocarditis on 6 week course of vancomycin via ___ line.
Febrile to 102 but without focal symptoms. Had some loose stools
but not diarrhea. No cough or other URI symproms with an
unremarkable chest xray. No voiding symptoms. Urine No signs of
pneumonia or other localizing signs of infection. Urine Cx
negative and Blood cx with no growth by discharge. His vanc
trough was 10.1 prior to discharge and so appropraite dose
increases were made. He was afebrile throughout his hospital
stay with no new symptoms. His Vancomycin trough was 14.1 prior
to discharge and vancomycin increased to 1500mg q12 hours. Next
trough to be checked by ___ and faxed to Dr. ___. He will
complete a ___s previously planned, with ID follow
up.
#GU: Hx of BPH. Negative urine culture
Continued flomax and finasteride
#Renal: Minimal change disease on chronic prednisone, creatinine
at baseline.
Continued prednisone 10 mg daily
#CV: HTN, HL: continued amlodipine, lisinopril and aspirin
#DM II: Continued lantus and lispro sliding scale
TRANSITIONAL ISSUES:
Mild elevation of transaminases. Hep serologies negative. Trend
to resolution.
Close follow up with ID (Dr. ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vancomycin 1000 mg IV Q 12H
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID
8. PredniSONE 10 mg PO DAILY
9. Rosuvastatin Calcium 10 mg PO DAILY
10. Tamsulosin 0.4 mg PO HS
11. Vitamin D 1000 UNIT PO DAILY
12. Finasteride 5 mg PO DAILY
13. diclofenac sodium 0.1 % OPHTHALMIC TID
14. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Lisinopril 10 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID
9. PredniSONE 10 mg PO DAILY
10. Rosuvastatin Calcium 10 mg PO DAILY
11. Tamsulosin 0.4 mg PO HS
12. Vancomycin 1500 mg IV Q 12H
RX *vancomycin 750 mg 1500 mg iv every twelve (12) hours Disp
#*126 Vial Refills:*0
13. Vitamin D 1000 UNIT PO DAILY
14. diclofenac sodium 0.1 % OPHTHALMIC TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Fever
Secondary
Staph epidermis bacteremia
Diabetes Mellitus
Minimal change disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was ___ caring for you here at ___. You came in
because of fevers. We repeated tests to check for infection and
you did not have a new infection.
Your fevers are resolved and you are ready to go home.
Followup Instructions:
___
|
10781985-DS-26
| 10,781,985 | 20,663,875 |
DS
| 26 |
2159-11-01 00:00:00
|
2159-11-01 17:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lower abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo M with cervical stenosis s/p
decompression,
lumbar stenosis s/p laminectomy and fusion, laryngeal cancer s/p
radiation and now with trach, bladder and bowel dysfunction with
chronic urinary overflow, HTN, DM and BPH presents with
abdominal
pain of one week.
The patient reports for the past week he has been having lower
abdominal pain and increasing distention. He reports he was also
initially having urinary retention with some overflow
incontinence. Two days ago he began having fevers, chills,
sweats
and rigors. He was also having nausea but no vomiting. He
reports
that he has had urinary retention leading to an infection in the
past. He has not had shortness of breath, chest pain, cough or
diarrhea. He is complaining of constipation, although he notes
he
has constipation at baseline.
In the ED, initial vitals were: T 103.6 HR 139 BP 119/94 RR 19
O2
Sat 96% RA
- Exam notable for:
Distended belly, enlarged bladder that appears to be
heterogenous, no pleural effusions, no significant
hydronephrosis
noted on point-of-care ultrasound, no apparent pericholecystic
fluid or distention of gallbladder or gallstones noted on
point-of-care ultrasound. Heart appears to be hyperdynamic
without any pericardial effusion
- Labs notable for:
WBC 13.7, Hgb 10.9, Plt 108, Cr 1.5, HCO3 21, Gap 19, CK 595,
Trop .13, CK-MB 5, Lacate 2.8
UA w/ 120 RBCs, many bacteria, 143 WBCs
- Imaging was notable for:
CT Head:
1. Exam is mildly degraded by motion. Within this limitation,
there is no acute intracranial abnormality. Specifically no
intracranial hemorrhage or large territory infarct.
CXR:
A left basilar opacity is unchanged from priors, may be due to
scarring or atelectasis. No new focal consolidation.
- Patient was given:
NS 1000 mL
IV Acetaminophen IV 1000 mg
Piperacillin-Tazobactam 4.5 g
IV Vancomycin 1000 mg
NS 1000 mL
Magnesium Sulfate 2 gm
Piperacillin-Tazobactam 4.5 g
Upon arrival to the floor, patient reports that he feels much
better after a foley was placed in the ED. He is no longer
having
fevers, chills or abdominal pain.
Past Medical History:
- Cancer of the larynx s/p tracheostomy and XRT, c/b recurrence,
s/p salvage laryngectomy and tracheo-esophageal prosthesis
- Type II Diabetes Mellitus c/b retinopathy & neuropathy
- Minimal change disease, on chronic prednisone.
- Hypertension
- Hypercholesterolemia
- Liver hemangioma
- Iron deficiency anemia
- Diverticulosis
- Spinal stenosis, cervical and lumbar, s/p laminectomy &
fusion
- Low back pain, facet arthropathy
- Urinary retention
- Pulmonary nodule
- Colonic adenoma
- Gait abnormality
Social History:
___
Family History:
His mother had diabetes. His brother had prostate cancer. No
family history of CAD and HTN.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: T 98.7 BP 119/67 HR 86 RR 18 HR 98 Ra
General: Well appearing, pleasant gentleman in NAD
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB, no wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
DISCHARGE PHYSICAL EXAM:
VS: 98.5 132 / 68 80 17 98RA
GENERAL: Well developed, well nourished male laying comfortably
in bed, NAD. Pleasant and cooperative with exam and interview.
HEENT: Sclera anicteric, speech valve in place over tracheostomy
LUNGS: Clear to auscultation bilaterally, no w/r/r
HEART: RRR, normal S1/S2, no murmurs, rubs, or gallops.
ABDOMEN: NABS, soft/NT/ND
EXTREMITIES: WWP
NEURO: awake, A&Ox3
Pertinent Results:
ADMISSION LABS
=======================
___ 03:40AM BLOOD WBC-13.7*# RBC-4.52*# Hgb-10.9*#
Hct-36.2*# MCV-80* MCH-24.1* MCHC-30.1* RDW-16.8* RDWSD-47.8*
Plt ___
___ 03:40AM BLOOD Neuts-94.6* Lymphs-2.6* Monos-2.2*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-12.94*# AbsLymp-0.36*
AbsMono-0.30 AbsEos-0.00* AbsBaso-0.03
___ 11:45AM BLOOD ___ PTT-37.4* ___
___ 03:40AM BLOOD Glucose-110* UreaN-21* Creat-1.5* Na-142
K-4.1 Cl-102 HCO3-21* AnGap-19*
___ 03:40AM BLOOD ALT-22 AST-52* CK(CPK)-595* AlkPhos-67
TotBili-1.1
___ 03:40AM BLOOD CK-MB-5
___ 03:40AM BLOOD cTropnT-0.13*
___ 06:20AM BLOOD CK-MB-4
___ 06:20AM BLOOD cTropnT-0.38*
___ 11:40AM BLOOD cTropnT-0.26*
___ 03:40AM BLOOD Albumin-3.1* Calcium-8.9 Phos-3.4 Mg-1.2*
___ 03:43AM BLOOD Lactate-2.8*
___ 06:26AM BLOOD Lactate-1.8
DISCHARGE LABS
================================
___ 06:40AM BLOOD WBC-2.1* RBC-3.64* Hgb-9.1* Hct-30.3*
MCV-83 MCH-25.0* MCHC-30.0* RDW-17.0* RDWSD-51.3* Plt ___
___ 06:40AM BLOOD Glucose-128* UreaN-18 Creat-0.8 Na-144
K-4.2 Cl-109* HCO3-24 AnGap-11
___ 06:40AM BLOOD Calcium-8.1* Phos-1.9* Mg-1.6
MICROBIOLOGY
=====================
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Blood cultures negative at time of discharge
IMAGING
==============
CXR ___
IMPRESSION: A left basilar opacity is unchanged from priors,
may be due to scarring or atelectasis. No new focal
consolidation.
CT head w/o contrast ___. Exam is mildly degraded by motion. Within this limitation,
there is no
acute intracranial abnormality. Specifically no intracranial
hemorrhage or large territory infarct.
2. Additional findings described above.
Brief Hospital Course:
Mr. ___ is a ___ yo M with cervical stenosis s/p
decompression, lumbar stenosis s/p laminectomy and fusion,
laryngeal cancer s/p radiation and now with trach, bladder and
bowel dysfunction with chronic urinary overflow, HTN, DM and BPH
presents with fevers, abdominal pain and urinary retention found
to have sepsis likely secondary to E. coli UTI.
#Sepsis secondary to E. coli UTI
Patient presented with one week history of increasing abdominal
pain and urinary retention with a two day history of
fevers/chills/rigors. Patient was noted to be febrile and
tachycardic in the ED with a leukocytosis to 13.7 and lactate of
2.8. UA was notable for 143 whites and many bacteria and urine
culture with >100,000 cfu of pansensitive E. coli. He was given
IVF and started on antibiotics (initially vancomycin and zosyn
in the ED, transitioned to cefepime on the floor and narrow to
ciprofloxacin when sensitivities were available). He had a Foley
placed for urinary retention but it was removed on ___ with
small voids but overall good ability to empty his bladder. He
will be discharged without a Foley but with plans for close
follow up with his urologist (see below). He will complete a 7
day course of ciprofloxacin 500mg BID that will finish on ___.
#Urinary retention
Review of old records show that he has some level of chronic
retention likely secondary to BPH with some component of bladder
dysfunction secondary to long standing DM. He had a foley
catheter placed, which was discontinued 24 hours before
discharge. He was able to void after discontinuation of the
foley, however PVR were 200-300cc. Review of his urology records
show that PVRs in this range were not atypical for him, and we
opted to send him home without a Foley catheter with close
urology follow up. We continued his tamsulosin and finasteride
while inpatient. Patient was on mirabegron as outpatient,
however this was not on formulary and was held on admission. He
can restart this as an outpatient.
#Type II NSTEMI
Patient with troponin leak on admission that peaked at 0.38. In
the absence of EKG changes and symptoms, it was felt that this
was likely type II NSTEMI in the setting of sepsis. He was
maintained on his rosuvastatin and aspirin.
#Leukopenia
Patient noted to be leukopenic with WBC 2.1 on discharge. WBC
trended from 13.7 on admission --> 4.1 --> 2.4 --> 2.1. Review
of previous records showed that patient had a history of
leukopenia when getting vancomycin in the past. We suspect that
his downtrending WBC was likely secondary to cefepime and should
nadir and recover after discontinuation (___). We have
arranged for blood to be drawn the day after discharge (___)
in order to assess his WBC. The results should be faxed to his
new PCP, ___ at ___ (fax number ___.
___
Patient presented with Cr 1.5, which is above baseline 0.88. on
review on records baseline Cr ~ .88. We suspected that this was
likely prerenal in the setting of sepsis, and it responded well
to fluids. At time of discharge, his Cr was 0.8.
#T2DM
Last Hgba1c 7.6, on glargine 11 qam, Humalog 3,3,3 with sliding
scale. We continued glargine and SSI while inpatient.
#Minimal change disease
Continued prednisone 15
#HTN
Lisinopril was held in the setting of sepsis and ___. With
resolution of these problems, lisinopril was reinitiated at his
home dose (40mg PO daily).
#GERD
Continued omeprazole
TRANSITIONAL ISSUES
=====================
[]Leukopenia - patient noted to have downtrending WBC while
admitted, suspected secondary to cefepime. CBC to be checked on
the day after discharge (___) with results to be sent to Dr.
___ at ___ (fax number ___.
[]Urinary retention - will need to be further addressed on
outpatient basis. Close follow up with urology was made at time
of discharge.
HCP -
Name of health care proxy: ___
Relationship: wife
Phone number: ___
Code status - full (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 11 Units Breakfast
Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. PredniSONE 15 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Rosuvastatin Calcium 10 mg PO QPM
5. Tamsulosin 0.4 mg PO QHS
6. Finasteride 5 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Aspirin 81 mg PO DAILY
11. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
12. Omeprazole 20 mg PO DAILY
13. Myrbetriq (mirabegron) 25 mg oral DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*6 Tablet Refills:*0
2. Glargine 11 Units Breakfast
Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Aspirin 81 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Myrbetriq (mirabegron) 25 mg oral DAILY
10. Omeprazole 20 mg PO DAILY
11. PredniSONE 15 mg PO DAILY
12. Rosuvastatin Calcium 10 mg PO QPM
13. Tamsulosin 0.4 mg PO QHS
14. Vitamin D 1000 UNIT PO DAILY
15.Outpatient Lab Work
ICD 10 - D72.819
CBC, Chem 7
Please send results to Dr. ___ at ___ (fax number
___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
===================
UTI
Urinary retention
Secondary Diagnoses
=====================
Leukopenia
___
Iron deficiency anemia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ from ___.
WHY WAS I ADMITTED?
===========================
- You were admitted because you had lower abdominal pain that we
believe was caused by a urinary tract infection.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
=============================================
- We treated your urinary tract infection with antibiotics.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
=================================================
- Take all of your medications as prescribed.
- Follow up with your doctors as listed below.
It was a pleasure caring for you!
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
10781985-DS-27
| 10,781,985 | 23,741,419 |
DS
| 27 |
2161-06-11 00:00:00
|
2161-06-13 07:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
facial pain, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ man with history of laryngeal
cancer s/p tracheostomy, prostate cancer s/p XRT/ADT, minimal
change disease on chronic prednisone, DMII, HTN, HLD presenting
with fever and facial pain.
The patient reports that he was in his usual state of health
until two days prior to admission when he developed right
periorbital swelling and pain. No pain with ocular movements and
no changes in vision. No facial injury or trauma. His wife also
noted erythema around his right eye, and reported that the
patient was more lethargic. He then developed fevers to 101-102
at home. He applied cold compresses to his right eye, which
helped somewhat. He also reports rhinorrhea. He denies any
cough, shortness of breath, abdominal pain, nausea, vomiting,
diarrhea, dysuria.
The patient initially presented to urgent care, where his
temperature was noted to be 100.3 and BP 99/57. He was referred
to the ED for further evaluation.
Of additional note, per review of the patient's Atrius records,
the patient has chronic pancytopenia. On ___, labs notable
for WBC 4.1, Hb 9.5, plt 98. PSA on ___ was 0.0.
In the ED, vitals: 97.9 82 133/53 20 100% RA
Exam notable for: Erythema around the right orbit. No
ophthalmoplegia. Pupils equal round reactive.
Labs notable for: WBC 2.6, Hb 8.8, plt 72, LDH 279, hapto 222,
fibrinogen 464, INR 1.2
Imaging: CXR, CT orbits
Consults: Heme/Onc re: pancytopenia
Patient given: Unasyn 3 g IV
On arrival to the floor, the patient reports that his
periorbital pain is improved although he still has mild
tenderness to palpation. He otherwise feels well and has no
acute complaints.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Cancer of the larynx s/p tracheostomy and XRT, c/b recurrence,
s/p salvage laryngectomy and tracheo-esophageal prosthesis
- Type II Diabetes Mellitus c/b retinopathy & neuropathy
- Minimal change disease, on chronic prednisone.
- Hypertension
- Hypercholesterolemia
- Liver hemangioma
- Iron deficiency anemia
- Diverticulosis
- Spinal stenosis, cervical and lumbar, s/p laminectomy &
fusion
- Low back pain, facet arthropathy
- Urinary retention
- Pulmonary nodule
- Colonic adenoma
- Gait abnormality
Social History:
___
Family History:
His mother had diabetes. His brother had prostate cancer.
Physical Exam:
Admission exam
VITALS: 98.8 144/74 78 20 100 RA
GENERAL: Alert and in no apparent distress, well appearing
EYES: Anicteric, pupils equally round; right periorbital
swelling
and erythema with tenderness over medial maxillary sinus
ENT: Ears and nose without visible erythema, masses, or trauma.
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. S/p tracheostomy.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs; right lower extremity
brace
SKIN: No rashes or ulcerations noted; no bruising or petechiae
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Very pleasant, appropriate affect
Patient examined on day of discharge.
Pertinent Results:
Admission labs
___ 04:45PM BLOOD WBC-2.6* RBC-3.70* Hgb-8.8* Hct-29.3*
MCV-79* MCH-23.8* MCHC-30.0* RDW-17.9* RDWSD-51.2* Plt Ct-72*
___ 04:49PM BLOOD ___ PTT-29.8 ___
___ 04:45PM BLOOD Glucose-202* UreaN-19 Creat-1.0 Na-140
K-4.2 Cl-105 HCO3-23 AnGap-12
___ 04:45PM BLOOD ALT-14 AST-26 LD(LDH)-279* AlkPhos-51
TotBili-0.4
Discharge labs
___ 06:38AM BLOOD WBC-1.7* RBC-3.11* Hgb-7.6* Hct-24.8*
MCV-80* MCH-24.4* MCHC-30.6* RDW-17.7* RDWSD-50.8* Plt Ct-89*
___ 06:38AM BLOOD Glucose-78 UreaN-13 Creat-0.8 Na-143
K-3.9 Cl-107 HCO3-24 AnGap-12
Imaging
======================
CXR ___
FINDINGS:
AP upright and lateral views of the chest provided.
Lungs are clear without focal consolidation, large effusion,
pneumothorax or signs of edema. The cardiomediastinal
silhouette appears stable. Aortic knob calcifications again
noted. Partially visualized spinal fusion hardware is noted in
the upper lumbar spine. Imaged bony structures are intact.
IMPRESSION:
No signs of pneumonia.
CT orbits ___
FINDINGS:
The globes are intact. Status post bilateral lens replacement
surgery. The orbits are intact, with normal appearing orbital
fat. The extraocular
muscles, optic nerve and optic arteries/veins are within normal
limits.
There is mild right periorbital soft tissue swelling without
significant
preseptal component. Findings may reflect a mild periorbital
cellulitis. No retrobulbar inflammation.
There is no facial bone fracture. Pterygoid plates are intact.
There is no mandibular fracture and the temporomandibular joints
are anatomically aligned.
There is mild thickening of the bilateral anterior ethmoid air
cells and
maxillary sinuses, extending into the right frontal sinus. The
sphenoid
sinuses are clear. There is under pneumatization of the
bilateral mastoid air cells.
IMPRESSION:
Findings suggest mild right periorbital cellulitis.
Micro
==============================
Blood Cx NGTD x2 at time of discharge
Brief Hospital Course:
Mr. ___ is a ___ man with history of laryngeal
cancer s/p tracheostomy, prostate cancer s/p XRT/ADT, minimal
change disease on chronic prednisone, DMII, HTN,
HLD presenting with fever and facial pain.
ACUTE/ACTIVE PROBLEMS:
# Periorbital cellulitis:
Patient presenting with fever and right periorbital swelling and
erythema. CT demonstrates right periorbital soft tissue
swelling, as well as thickening of the bilateral anterior
ethmoid air cells and maxillary sinuses, extending into the
right frontal sinus. He was started on unasyn with improvement
in his facial pain and swelling. ENT was consulted given fever
on ___ despite antibiotics and concern for fungal sinusitis.
Bedside nasal scope performed and sinuses appeared normal w/o
signs of infection or invasive fungal infection. He then
remained afebrile for > 24h and was transitioned to PO augmentin
to complete a total 7 day course.
# Pancytopenia:
Unclear etiology but this is not new, and patient is followed by
Atrius heme/onc for this and for his laryngeal cancer and
prostate cancer. There may be some acute on chronic component
due to marrow suppression in setting of acute illness as above.
CHRONIC/STABLE PROBLEMS:
# Minimal change disease: Baseline Cr 0.8-0.9
- Continued home prednisone
# DMII:
- Continued Lantus plus hISS
# HTN:
- Continued amlodipine
# HLD:
- Continued statin
# GERD:
- Continued omeprazole
# Prostate cancer s/p XRT/Lupron:
- Continued tamsulosin
> 30 mins spent on discharge planning
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. PredniSONE 12.5 mg PO DAILY
7. Rosuvastatin Calcium 10 mg PO QPM
8. Tamsulosin 0.8 mg PO QHS
9. Vitamin D ___ UNIT PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Myrbetriq (mirabegron) 25 mg oral DAILY
13. amLODIPine 10 mg PO DAILY
14. Glargine 11 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tab-cap by mouth twice a day Disp #*10 Tablet Refills:*0
2. Glargine 11 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Aspirin 81 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Myrbetriq (___) 25 mg oral DAILY
10. Omeprazole 20 mg PO DAILY
11. PredniSONE 12.5 mg PO DAILY
12. Rosuvastatin Calcium 10 mg PO QPM
13. Tamsulosin 0.8 mg PO QHS
14. Vitamin D ___ UNIT PO DAILY
15. HELD- amLODIPine 10 mg PO DAILY This medication was held.
Do not restart amLODIPine until discussed with PCP.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# pre-septal orbital cellulitis
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 privilege to care for you at the ___
___. You were admitted with a skin infection under
your eye that required treatment with IV antibiotics. You
responded nicely and it is now safe to transition to antibiotics
taken by mouth. It is very important that you finish the full
prescription to prevent the infection from coming back.
Note that we are holding your amlodipine on discharge as your
blood pressure is well controlled without the need for multiple
medications. Your PCP ___ continue to monitor this on your
follow up appointment.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
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2182-11-20 11:18:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
___:
1. Thoracic laminectomy of T1, T2, T6, T7.
2. Transpedicular / Costovertebral decompression bilaterally at
T1-T2 with diskectomy.
3. Transpedicular / Costovertebral decompression left side T6-T7
with
diskectomy.
4. Posterior spinal arthrodesis T1-T8.
5. Posterior spinal instrumentation T1 through T8.
History of Present Illness:
___ with chronic low back pain and 2 months of progressive BLE
weakness, numbness, and tingling, transferred from OSH for
Orthopaedic spine evaluation after MRI revealed L1-2 paracentral
disc herniation. No recent trauma. No bowel or bladder
incontinence.
Past Medical History:
Denies
Social History:
___
Family History:
NC
Physical Exam:
AVSS
Well appearing, NAD, comfortable
Incision c/d/i
BLE: SILT L1-S1 dermatomal distributions
BLE: 4+/5 ___
BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle
All toes WWP, brisk capillary refill, 2+ distal pulses
Pertinent Results:
___ 04:40AM BLOOD WBC-11.3* RBC-3.93* Hgb-11.2* Hct-33.3*
MCV-85 MCH-28.5 MCHC-33.6 RDW-12.4 RDWSD-37.4 Plt ___
___ 09:55PM BLOOD Neuts-58.4 ___ Monos-7.2 Eos-3.2
Baso-0.4 Im ___ AbsNeut-4.44 AbsLymp-2.31 AbsMono-0.55
AbsEos-0.24 AbsBaso-0.03
___ 04:40AM BLOOD Plt ___
___ 04:45AM BLOOD Glucose-128* UreaN-21* Creat-0.7 Na-138
K-4.3 Cl-101 HCO3-25 AnGap-16
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with oral pain medication when tolerating PO
diet. Foley was removed on POD#2. Physical therapy and
Occupational Therapy was consulted for mobilization OOB to
ambulate and ADL's. Hospital course was otherwise unremarkable.
On the day of discharge the patient was afebrile with stable
vital signs, comfortable on oral pain control and tolerating a
regular diet.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
please take while taking narcotic pain medication
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
please do not operate heavy machinery,drink alcohol or drive
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 3 hours Disp
#*75 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
5. Bisacodyl 10 mg PO DAILY
6. Diazepam 5 mg PO Q6H:PRN pain or spasm
may cause drowsiness
RX *diazepam 5 mg 1 Tab by mouth every six (6) hours Disp #*25
Tablet Refills:*0
7. Rolling Walker
Dx: s/p Thoracic Decompression/Fusion
Prognosis:Good
___ Months
Discharge Disposition:
Home
Discharge Diagnosis:
Thoracic disc herniation w/ myelopathy
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 have undergone the following operation: Thoracic
Decompression With Fusion
Immediately after the operation:
Activity: You should not lift anything greater than 10 lbs for 2
weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
Rehabilitation/ Physical Therapy:
___ times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can
tolerate. Limit any kind of lifting.
Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
Brace: You may have been given a brace. This brace is to be worn
when you are walking. You may take it off when sitting in a
chair or while lying in bed.
Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
You should resume taking your normal home medications.
You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment for 2 weeks after
the day of your operation if this has not been done already.
At the 2-week visit we will check your incision, take baseline
X-rays and answer any questions. We may at that time start
physical therapy.
We will then see you at 6 weeks from the day of the operation
and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
-Weight bearing as tolerated
-No lifting >10 lbs
-No significant bending/twisting
Treatments Frequency:
Change dressing every day; ok to shower with replacement of a
dry dressing once wound is patted dry after showering.
Remove the dressing in ___ days. If the incision is draining
cover it with a new sterile dressing. If it is dry then you can
leave the incision open to the air. Once the incision is
completely dry (usually ___ days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call
the office.
Followup Instructions:
___
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2189-07-21 16:39:00
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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:
___ ex lap, SBR, anastomosis
History of Present Illness:
___ is a ___ year old female with a history of HTN and
umbilical hernia who presented to the ED w/ a <1 day hx of
acute onset
periumbilical pain and increase in size of umbilical hernia. She
says she has never had these sx before, and her hernia was first
noted on an MRI last ___. She first noted an umbilical bulge in
___, but did not have any pain. O/n she had sudden onset pain,
which she initially attributed to food poisoning after having
ate
some clams. She subsequently had one episode of emesis after
which her pain transiently improved and subsequently presented
to
the ED for further evaluation. We were consulted for c/f
incarcerated umbilical hernia.
Past Medical History:
HTN
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 97.4 HR: 83 BP: 170/112 Resp: 18 O(2)Sat: 99 room air
Normal
Constitutional: She looks mildly uncomfortable
HEENT: Extraocular muscles intact
Mucous membranes are moist
Chest: Clear to auscultation
Cardiovascular: No murmur
Abdominal: There is some discoloration over the umbilicus
with a firm swelling in that area but also some induration
that spreads superiorly and to the right from the umbilicus.
The hernia does not is easily; however I did not push very
hard because it is been out now for at least ___ hours.
GU/Flank: No costovertebral angle tenderness
Extr/Back: No calf tenderness or edema
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mentation
Pertinent Results:
___ 07:35AM BLOOD WBC-5.3 RBC-3.80* Hgb-9.3* Hct-30.0*
MCV-79* MCH-24.5* MCHC-31.0* RDW-17.6* RDWSD-51.0* Plt ___
___ 02:09PM BLOOD WBC-8.1 RBC-5.20 Hgb-12.9 Hct-39.2
MCV-75* MCH-24.8* MCHC-32.9 RDW-17.6* RDWSD-47.4* Plt ___
___ 02:09PM BLOOD Neuts-86.4* Lymphs-10.2* Monos-2.8*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-7.02* AbsLymp-0.83*
AbsMono-0.23 AbsEos-0.02* AbsBaso-0.02
___ 07:35AM BLOOD Glucose-100 UreaN-9 Creat-0.6 Na-143
K-3.5 Cl-102 HCO3-30 AnGap-11
___ 02:09PM BLOOD ALT-12 AST-17 AlkPhos-91 TotBili-0.4
___ 07:35AM BLOOD Calcium-8.8 Phos-2.1* Mg-2.2
___: cat scan abdomen and pelvis:
Small-bowel obstruction secondary to an umbilical hernia
containing short
segment of small bowel. Adjacent fluid in the hernia sac though
no altered enhancement of the bowel wall or specific findings to
suggest ischemia.
2. Fibroid uterus and tubular left adnexal structure likely
correlating with structure on previous pelvic ultrasound thought
to be consistent with
hydrosalpinx.
Brief Hospital Course:
___ year old female admitted to the hospital with abdominal pain.
Upon admission, the patient was made NPO, given intravenous
fluids, and underwent imaging. The patient was noted to have a
small-bowel obstruction secondary to an umbilical hernia
containing a short segment of small bowel. A ___ tube
was placed for bowel decompression. The patient was taken to
the operating room where she underwent an exploratory
laparotomy, jejunal resection, and repair of multiple
incarcerated umbilical and ventral hernias. The operative course
was stable with a 10cc blood loss. The patient was extubated
after the procedure and monitored in the recovery room.
The post-operative course was stable. After removal of the
___ tube and return of bowel function, the patient was
started on clear liquids and advanced to a regular diet. The
patient was discharged home on POD #6. Her vital signs were
stable and she was afebrile. She was ambulatory and voiding
without difficulty. Her surgical pain was controlled with oral
analgesia. Discharge instructions were reviewed and questions
answered. A follow-up appointment was made in the acute care
clinic.
Medications on Admission:
HYDROCHLOROTHIAZIDE - hydrochlorothiazide 25 mg tablet. 1
Tablet(s) by mouth once a day
HYDROMORPHONE - hydromorphone 2 mg tablet. One tablet(s) by
mouth every 6 hours as needed for back and leg pain.
LOSARTAN [COZAAR] - Cozaar 100 mg tablet. Take one pill by
mouth Tablet(s) by mouth once a day
NAPROXEN - naproxen 500 mg tablet. One tablet(s) by mouth three
times per day as needed for hip pain Take with food.
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
1,000 unit capsule. One capsule(s) by mouth once daily.
CHONDROITIN SULFATE A [CHONDROITIN SULFATE] - Chondroitin
Sulfate 250 mg capsule. 1 capsule(s) by mouth daily as needed
for right hip pain
GLUCOSAMINE SULFATE - glucosamine sulfate 500 mg tablet. 1
tablet(s) by mouth daily as needed for hip pain
NAPROXEN - naproxen 250 mg tablet. 1 (One) tablet(s) by mouth
three times a day as needed for right hip pain - (OTC)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
may continue for ___ days, then take as needed for pain
2. Docusate Sodium 100 mg PO BID
hold for loose stool
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
5. Hydrochlorothiazide 25 mg PO DAILY
6. Losartan Potassium 100 mg PO DAILY
7. Tamsulosin 0.4 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:
You were admitted to the hospital with abdominal pain. You
underwent a cat scan which showed a small bowel obstruction
related to an internal hernia. You were taken to the operating
room where you underwent a small bowel resection. You are
slowly recovering from your surgery and preparing for discharge
home with the following instructions:
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 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red aroudn the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before that that's okay).
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing r 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.
Ove the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 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.
After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluitds and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
IF you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
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:
___
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2114-07-18 14:20:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ambien
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Successful OCT-guided PCI of RCA stent restenosis with
drug-eluting stent
History of Present Illness:
===================================================
MEDICINE ___ ADMISSION NOTE
Date of admission: ___
====================================================
PCP: ___
CC: chest pain
HISTORY OF PRESENT ILLNESS:
Mr. ___ is an ___ year old M w/ ___ CAD s/p CABG ___ at
___, DMII, smoking, CVA ___ and ___ who presents with chest
pain and left-sided paresthesias.
The patient had onset of left-sided chest pain last night before
going to bed. It persisted this morning but resolved some time
between this morning and now. The patient is unclear as to when.
He denies any associated nausea, shortness of breath,
diaphoresis, radiation. The patient also complains of
intermittent left-sided paresthesias. He says he feels a
numb-like sensation in his entire left arm and left leg. He
reports he "cannot remember" how long these symptoms last
(minutes versus hours versus days) and he cannot remember for
how
long the symptoms have been going on. He does report that he had
left-sided weakness as a result of his stroke in ___. He is on
Eliquis. Smokes 1 pack every 3 days.
Got two nitro and an ASA from EMS. Last record of stress ___
(also sees providers at ___ Last cards visit at ___ E's
___, echo ___. Last cath ___. Importantly, his PCP
records document these intermittent paresthesias which have been
present at least ___.
In the ED, initial VS were: 97.6 74 144/67 18 96% RA.
Exam notable for: Regular rate and rhythm, 2+ radial pulse, 4+/5
strength in distal left hand and foot, sensation intact distally
Labs showed: Plt 132, Cr 1.3, BUN 21, HCO3 21, trops neg x 3,
Glucose 341, UA with 1000 glucose.
Imaging showed: CXR: No acute cardiopulmonary process.
Patient received: NS IVF, 10U SC insulin, 0.4 mg SLNG, Nitro
gtt,
Heparin gtt, 4 mg IV Morphine.
Cards was consulted for acute worsening of chest pain. This
evening noted to develop more pain and EKG showed lateral ST
depressions. On evaluation patient noted to have severe chest
pain and appeared diaphoretic. Nitro drip started and
uptitrated.
Repeat EKG with ongoing dynamic changes. Heparin drip started
and
repeat troponins obtained.
Transfer VS were: 98.7 64 139/65 26 97% Nasal Cannula
On arrival to the floor, patient reports that his chest pain is
improved. Wants to go to sleep and does not want to talk.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
DMII
HTN
CAD s/p CABG in ___
HLD
AFib on coumadin
?Depression versus smoking cessation
BPH
GERD
Social History:
___
Family History:
Notable for coronary artery disease in the mother
who passed away of stroke in her ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.9 159 / 70 ___
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: irregularly irregular, S1/S2, no murmurs, gallops, or
rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VITALS: 98.1 158/78 - 189/83, 55-60, 18 96% RA
TELEMETRY: afib
GENERAL: NAD, sleeping
HEENT: AT/NC, EOMI, MMM
NECK: supple, no JVD
HEART: irregularly irregular, S1/S2, no murmurs, gallops, or
rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 02:30PM BLOOD WBC-7.1 RBC-4.86 Hgb-12.8* Hct-41.0
MCV-84 MCH-26.3 MCHC-31.2* RDW-14.5 RDWSD-44.3 Plt ___
___ 02:30PM BLOOD Neuts-76.8* Lymphs-17.2* Monos-4.1*
Eos-1.3 Baso-0.3 Im ___ AbsNeut-5.46 AbsLymp-1.22
AbsMono-0.29 AbsEos-0.09 AbsBaso-0.02
___ 02:30PM BLOOD ___ PTT-27.5 ___
___ 02:30PM BLOOD Plt ___
___ 02:30PM BLOOD Glucose-509* UreaN-23* Creat-1.2 Na-139
K-4.4 Cl-98 HCO3-28 AnGap-13
___ 04:00PM BLOOD ___ pO2-22* pCO2-54* pH-7.39
calTCO2-34* Base XS-4
PERTINENT LABS/TRENDS:
trop trend:
.01-->.01-->.01-->.34 (with CK-MB 41) --> 1.72 (with CK-MB 45)
DISCHARGE LABS:
___ 12:39AM BLOOD Glucose-341* Lactate-1.8
___ 12:55PM BLOOD Hct-43.6 Plt ___
___ 08:00AM BLOOD WBC-8.7 RBC-4.53* Hgb-12.1* Hct-38.2*
MCV-84 MCH-26.7 MCHC-31.7* RDW-14.7 RDWSD-45.2 Plt ___
___ 12:38AM BLOOD Neuts-59.7 ___ Monos-6.1 Eos-1.9
Baso-0.3 Im ___ AbsNeut-5.29 AbsLymp-2.83 AbsMono-0.54
AbsEos-0.17 AbsBaso-0.03
___ 12:55PM BLOOD Plt ___
___ 07:15PM BLOOD Plt ___
___ 12:55PM BLOOD UreaN-15 Creat-1.1 K-4.0
___ 12:38AM BLOOD CK(CPK)-54
ECHO ___:
Findings
Patient unable to tolerate complete study. Suboptimal subcostal
views.
LEFT ATRIUM: Mildly increased LA volume index.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. The IVC
was not visualized. The RA pressure could not be estimated.
LEFT VENTRICLE: Mild regional LV systolic dysfunction. No
resting LVOT gradient.
RIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV
free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild to moderate (___) MR.
___ VALVE: Normal tricuspid valve leaflets. Mild to
moderate [___] TR. Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - poor subcostal views. Suboptimal
image quality - patient unable to cooperate.
Conclusions
The left atrial volume index is mildly increased. The right
atrium is moderately dilated. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the
inferior wall. There is mild hypokinesis of the remaining
segments (LVEF = 40-45 %). The right ventricular cavity is
moderately dilated with mild global free wall hypokinesis. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild to moderate (___) mitral regurgitation is
seen. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with normal cavity size and mild
regional systolic dysfunction involving the RCA territory.
Moderate right ventricular cavity dilation with mild global
hypokinesis. Mild to moderate mitral regurgitation.
Cath report ___:
Coronary Anatomy
Dominance: Right
* Left Coronary Artery: Known ___ chronically occluded based on
prior cath reports and therefore not
engaged.
* Right Coronary Artery: The RCA is with diffuse mild-moderate
disease throughout; there is a widely
patent mid stent.
There is a 90% stent restenosis in the Distal RCA immediately
prior to the bifurcation. The lesion has a
TIMI flow of 3. This lesion is further described as focal. An
intervention was performed on the Distal RCA
with a final stenosis of 0%. There were no lesion complications.
* LIMA-LAD
Widely patent graft.
The left subclavian demonstrated severe tortuosity; there was no
pressure gradient on catheter pullback
to the aorta.
* SVG-OM
50% distal graft body lesion.
* SVG-RPDA
Known occluded and therefore not engaged.
Interventional Details
A 6 ___ AL-0.75 guide provided excellent support. Heparin was
given and a therapeutic ACT
confirmed. We crossed easily to the distal vessel with a
Prowater wire and predilated with a 2.0mm balloon at 12 atm in
order to facillitate intravascular OCT imaging to establish
sizing and mechanism of stent failure. IVOCT demonstrated distal
neointimal hyperplasia and proximal severe neoatherosclerosis;
the reference vessel diameter was ~2.6mm proximally. We
predilated further with a 2.5mm balloon at 16 atm, deployed a
2.5x15mm Resolute Onyx drug-eluting stent at 18 atm and
post-dilated throughout including the overlap zone with the
prior stent using a 2.75mm NC balloon up to 25 atm. Final
angiography with no residual, no dissection, and normal flow.
Notably, the patient had developed confusion and agitation
during the procedure, and subsequently also chest pain following
ballon predilatation that resolved after stent placement and
with IV nitroglycerin administration. He left the cath lab in
hemodynamically stable condition.
Intra-procedural Complications: None
Impressions:
Successful OCT-guided PCI of RCA stent restenosis with
drug-eluting stent
Recommendations
Aspirin 81 mg daily indefinitely
Clopidogrel for minimum 12 months
Follow up with Dr. ___
___ CXR:
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
Mr. ___ is an ___ year old M w/ ___ CAD s/p CABG ___ at
___, DMII, smoking, CVA ___ and ___ who presents with chest
pain and left-sided paresthesias now s/p successful OCT-guided
PCI of RCA stent restenosis with drug-eluting stent.
On admission, patient had trop leak (from <.01) to 0.34 with
CK-MB 41. He also had dynamic changes on ECG and asymptomatic
bradycardia with HRs in the ___. We held the metoprolol in this
setting. His cath successfully re-vascularized RCA stent with
DES. We consulted his primary cardiologist who agreed with dual
anti-coagulation therapy following PIONEER trial for afib with
PCI. We started him on Plavix and rivaroxaban 15mg, and we
discontinued the aspirin. His heart rate improved after the
revascularization, remaining mostly in the ___. We continued to
hold metoprolol. We continued high dose statin given his
significant coronary artery disease. He also had an echo, which
showed LVEF 40-45%.
TRANSITIONAL ISSUES:
Weight: 84.0 kg
Cr: 1.1
Hct: 43.6
Platelets: 127
K: 4.0
CK-MB: 45*
Trop: 1.72
Dipstick glucose: 1000
MEDICATIONS ADDED PER PIONEER PROTOCOL:
Clopidogrel 75 mg PO DAILY
Rivaroxaban 15 mg PO DINNER
MEDICATIONS DISCONTINUED:
Aspirin
Eliquis
MEDICATIONS HELD:
Metoprolol (given bradycardia)
-Please consider restarting metoprolol, which was held in the
setting of bradycardia
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Finasteride 5 mg PO DAILY
2. Valsartan 320 mg PO DAILY
3. BuPROPion 75 mg PO DAILY
4. Phenazopyridine 100 mg PO TID:PRN bladder discomfort
5. Metoprolol Tartrate 25 mg PO BID
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. Senna 17.2 mg PO DAILY
9. amLODIPine 5 mg PO DAILY
10. Apixaban 5 mg PO BID
11. Atorvastatin 80 mg PO QPM
12. Ferrous Sulfate 325 mg PO DAILY
13. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Severe
14. Omeprazole 20 mg PO BID
15. Aspirin 81 mg PO DAILY
16. alfuzosin 10 mg oral DAILY
17. silodosin 8 mg oral DAILY
18. TraZODone 50 mg PO QHS:PRN insomnia
19. Chlorthalidone 25 mg PO DAILY
20. Vitamin D ___ UNIT PO DAILY
21. Furosemide 20 mg PO DAILY
22. Glargine 56 Units Breakfast
23. Lubiprostone 24 mcg PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
2. Rivaroxaban 15 mg PO DINNER PIONEER trial
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth at dinner
Disp #*30 Tablet Refills:*3
3. Glargine 56 Units Breakfast
4. alfuzosin 10 mg oral DAILY
5. amLODIPine 5 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. BuPROPion 75 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Ferrous Sulfate 325 mg PO DAILY
10. Finasteride 5 mg PO DAILY
11. Furosemide 20 mg PO DAILY
12. Lubiprostone 24 mcg PO DAILY
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Omeprazole 20 mg PO BID
15. Phenazopyridine 100 mg PO TID:PRN bladder discomfort
16. Senna 17.2 mg PO DAILY
17. silodosin 8 mg oral DAILY
18. TraZODone 50 mg PO QHS:PRN insomnia
19. Valsartan 320 mg PO DAILY
20. Vitamin D ___ UNIT PO DAILY
21. HELD- Metoprolol Tartrate 25 mg PO BID This medication was
held. Do not restart Metoprolol Tartrate until you speak to your
cardiologist.
22. HELD- OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Severe This medication was held. Do not restart OxyCODONE
(Immediate Release) until you speak to your primary care
physician.
Discharge Disposition:
Home
Discharge Diagnosis:
NSTEMI
Discharge Condition:
Mental status: clear and coherent
Ambulatory status: with assistance
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I ADMITTED TO THE HOSPITAL?
==================================
You were admitted to the hospital because you had chest pain.
You were found to have had a heart attack. Your heart arteries
were examined (cardiac catheterization) which showed a blockage
of one of the arteries. This was opened by placing a tube called
a stent in the artery. You were given medications to prevent
future blockages. You improved considerably and were ready to
leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
===================================================
-You must stop smoking. It's the number one most important thing
you could do for your health. Please speak to your doctor about
new treatment options to help you quit.
-It is very important to take your rivaroxaban and clopidogrel
(also known as Plavix) every day. You will no longer take
aspirin.
-These two medications keep the stents in the vessels of the
heart open and help reduce your risk of having a future heart
attack. They also reduce your risk of stroke given your afib.
-If you stop these medications or miss ___ dose, you risk causing
a blood clot forming in your heart stents, and you may die from
a massive heart attack.
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Seek medical attention if you have new or concerning symptoms
or you develop chest pain, swelling in your legs, abdominal
distention, or shortness of breath at night.
Thank you for allowing us to be involved in your care, we wish
you all the best!
-Your ___ Care Team
Followup Instructions:
___
|
10782600-DS-15
| 10,782,600 | 26,198,281 |
DS
| 15 |
2171-06-24 00:00:00
|
2171-06-24 15:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Red dot EKG electrode
Attending: ___.
Chief Complaint:
right sided chest pain and SOB
Major Surgical or Invasive Procedure:
___
Right pleural pigtail catheter placement
History of Present Illness:
Patient is a ___ who presented to the ED complaining of
acute onset right sided chest pain and shortness of breath.
Patient reports that he was at home eating when around midnight
he had sudden right sided, sharp, non-radiating chest pain
particularly around the inner aspect of his right chest. Chest
pain has pleuritic component with worsened pain on deep
inspiration. He says his pain is relieved with leaning forward
and worse with lying flat. The pain was persistent, and he
attempted to take a warm shower and took some magnesium to help
relax his muscles, which he says helped. He went to sleep around
4am, then woke up two hours later with continued chest pain and
shortness of breath, for which he came to the ED today for
evaluation. He denies any history of trauma. He has never had
similar symptoms in the past, though he does state that he has a
history of panic attacks that are more characterized by sweats
and anxiety rather than shortness of breath and chest pain.
On evaluation in the ED, he was breathing 100% on room air, he
was mildly tachycardic but normotensive, his labs were
unremarkable, and EKG sinus rhythm without concerning findings.
He had an ultrasound done by the ED which they found concerning
for R sided pneumothorax, and subsequent chest xray showed
findings equivocal for pneumothorax, so per radiology
recommendations he had an inspiratory and expiratory xray done
which showed a small to moderate right-sided pneumothorax
without
evidence of mediastinal shift, though this pneumothorax was most
remarkable on expiratory film and minimal on inspiratory film.
Past Medical History:
asthma as a child
Social History:
___
Family History:
mother with sleep apnea, prior ablation. No other significant
family history.
Physical Exam:
Vitals: T 98.2; HR 70; BP 136/71; RR 18; SPO2 100% RA (also on
nonrebreather, but when taken off at bedside patient breathing
100% RA)
GEN: Well appearing. Mild distress and anxiety.
HEENT: NCAT, EOMI, sclera anicteric
CV: HDS
PULM: Some mild shortness of breath without use of accessory
muscles. Conversing comfortably. Inspiratory breath sounds equal
bilaterally. Patient with pain on deep inspiration. Mild pain
with palpation to right anterior chest wall around rib 3 at the
mid clavicular line.
ABD: soft, nontender, nondistended
EXT: Warm, well-perfused
NEURO: A&Ox3, no focal neurologic deficits
Pertinent Results:
___ 11:37AM WBC-7.9 RBC-5.42 HGB-16.8 HCT-46.1 MCV-85
MCH-31.0 MCHC-36.4 RDW-13.3 RDWSD-40.9
___ 11:37AM ___ PTT-29.7 ___
___ 11:37AM GLUCOSE-97 UREA N-19 CREAT-0.9 SODIUM-141
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-22 ANION GAP-15
___ CXR :
Small to moderate sized right pneumothorax without evidence of
tension.
___ CXR :
In comparison with the study of ___ the, the in the
residual right
apical pneumothorax would be extremely small.
No evidence of acute pneumonia, vascular congestion, or pleural
effusion.
Brief Hospital Course:
Mr. ___ was evaluated by the Thoracic Surgery service in
the Emergency Room and admitted to the hospital for further
management of his right spontaneous pneumothorax. A right
pleural pigtail catheter was placed and there was full expansion
of his right lung on chest xray without an air leak.
Following transfer to the Surgical floor the tube remained on
waterseal for 24 hours and his room air saturations were 98%. He
had no air leak or chest pain. After undergoing a successful
clamp trial on ___ his pigtail catheter was removed and his
post pull chest xray was stable, without evidence of a
pneumothorax.
He was discharged to home on ___ and will follow up with
Dr. ___ week with a chest xray prior to his appointment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
Discharge Disposition:
Home
Discharge Diagnosis:
Spontaneous right pneumothorax
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 a collapsed right lung
and required placement of a chest drain to evacuate the air. The
tube has been removed and your chest xray is stable. You are now
redy for discharge.
* The chest dressing may be removed in 48 hrs. If there is any
drainage or redness at the site please call Dr. ___ at
___.
* You may shower with the dressing in place.
* Continue to eat well and stay well hydrated.
* If you develop any shortness of breath, chest pain, chills,
fevers > 101 or any new symptoms that are concerning, call Dr.
___ at ___.
* You should refrain from all contact sports for 4 weeks and
avoid heavy lifting > 10 lbs and straining for 2 weeks.
Followup Instructions:
___
|
10782997-DS-2
| 10,782,997 | 29,095,157 |
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| 2 |
2188-11-05 00:00:00
|
2188-11-25 14:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pain
Major Surgical or Invasive Procedure:
chest tube
bronchoscopy ebus biopsy pleurX placement
History of Present Illness:
___ w/ recent diagnosis of right-sided lung mass
presenting with chest pain, shortness of breath, cough, hip
pain.
History is aided by his daughter who helps translate to ___.
Mr. ___ has had a dry cough for over a month. He went to his
PCP
who gave symptomatic treatments, but it did not improve. Over
the past 2 weeks, he has had increasing shortness of breath as
well as dyspnea with exertion. He would have bouts of coughing,
worse at night and not allowing him to sleep with associated
left-sided chest pain. That pain is not pleuritic, and no
hemoptysis. He had a CT chest which showed a right hilar mass
with right upper lobe obstruction as well as concern for pleural
metastatic lesions. He was admitted to ___ on ___
for one night and was treated with steroids, Robitussin, and
albuterol. His family says he did not receive ABX, and that he
had steroids for a few days after discharge. His breathing
improved slightly, but then became more difficult.
He had an appointment with IP on the day of admission to discuss
next steps (bronch with biopsy), but because he had left
shoulder
and right hip pain, he was referred to the ER. He states that
his left shoulder pain is worse with coughing but does not limit
his range of motion, and not worse with shoulder movement. It
is
sharp, non-radiating, and up to ___ in severity. For his "hip"
pain, he describes this as a 2-inch band between his buttock and
anterior iliac crest, worse with coughing, but does not limit
movement, is not worse with walking, not associated with a limp.
There is no numbness or tingling.
ROS: Positive for insomnia, 15 lb weight loss, fatigue, poor
appetite. Pertinent positives and negatives as noted in the
HPI.
All other systems were reviewed and are negative.
Vitals in the ER: 99.4 95 141/105 20 97% RA
There, the ___ received: Azithromycin 500mg, Ceftriaxone 1g,
and 1L NS, Morphine 4mg IV
Past Medical History:
Tobacco use disorder
GERD
Lung mass
Social History:
___
Family History:
No family hx of lung CA
Physical Exam:
ADMISSION EXAM:
VITALS: (see eFlowsheet)
GENERAL: Alert and in no apparent distress, smiling at times,
thin.
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular rate; normal perfusion, no appreciable JVD
RESP: Symmetric breathing pattern with no stridor. Breathing is
non-labored
GI: Abdomen soft, non-distended, no hepatosplenomegaly
appreciated.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, normal muscle tone. Left shoulder has no
point
tenderness, and retains full range of motion.
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, gait normal, sensation to light touch grossly
intact
PSYCH: normal thought content, logical thought process,
appropriate affect
DISCHARGE EXAM:
VS: 97 131/90 105 20 95 RA
GEN: middle aged man, sitting in bed, NAD. speaking in full
sentences, no coughing.
Eyes: anicteric, non-injected
HEENT: MMM, grossly nl OP
CV: RRR nl S1/S2 no g/r/m
Chest: decreased BS at bases. Right apex with bronchial BS and
egophany. No significant rales or wheezing. Speaking in full
sentences with EWOB. Right TPC capped and bandage CDI Slight TTP
over bandage site.
Abd: soft, NT/ND, NABS.
EXT: WWP, no edema
Psych: calm and appropriate.
Pertinent Results:
ADMISSION LABS
--------------
___ 06:15PM BLOOD WBC-19.0* RBC-6.16* Hgb-13.1* Hct-41.3
MCV-67* MCH-21.3* MCHC-31.7* RDW-15.2 RDWSD-33.6* Plt ___
___ 06:15PM BLOOD Neuts-76.4* Lymphs-9.2* Monos-9.9 Eos-1.4
Baso-0.6 Im ___ AbsNeut-14.53* AbsLymp-1.76 AbsMono-1.89*
AbsEos-0.27 AbsBaso-0.11*
___ 06:15PM BLOOD ___ PTT-25.8 ___
___ 06:15PM BLOOD Glucose-103* UreaN-21* Creat-0.8 Na-136
K-3.5 Cl-93* HCO3-27 AnGap-16
___ 06:15PM BLOOD ALT-16 AST-20 AlkPhos-79 TotBili-1.0
___ 06:15PM BLOOD Albumin-3.8
___ 05:59AM BLOOD Phos-3.4 Mg-2.0
___ 06:28PM BLOOD Lactate-1.6
IMAGING
-------
CXR - IMPRESSION:
Re-demonstrated right perihilar opacity extending into the right
upper lobe, consistent with known right upper lobe mass. Small
right pleural effusion. In comparison with scout image from
prior chest CT from ___, there has likely been no
significant interval change; although, it is difficult to
exclude a subtle consolidation at the right mid to lower lung.
Pelvis X-ray IMPRESSION: No acute fracture or definite
concerning osseous lesion. Please note that cross-sectional
imaging, in particular MRI is more sensitive in detecting
osseous metastases.
- CT CHEST
1. Large right hilar mass measures 9 x 6.9 x 6.8 cm partially
obstructing the right main pulmonary bronchus and lobar branches
causing postobstructive partial collapse of the right upper
lobe, and postobstructive ground-glassopacities in the right
middle lobe. There is also significant narrowing of the distal
right main pulmonary artery and its lobar branches as well as
the superior pulmonary veins. The mass invades into the
mediastinum. 2. Nodular interlobular septal thickening in the
right middle and lower lobes is concerning for postobstructive
inflammatory/infection process, local lymphangitic spread or
vascular congestion. 3. Worsening moderate right pleural
effusion and rim enhancing
collections/masses in the medial aspect of the right middle lobe
are highly
concerning for pleural implants. 4. Bilateral adrenal masses are
highly suspicious for metastasis. 5. New hypoattenuating lesion
in the left subscapularis muscle, which may represent additional
metastatic disease.
6. Unchanged small pericardial effusion, which is concerning for
a malignant effusion.
- MRI BRAIN
1. Multiple punctate enhancing and nonenhancing foci are seen in
the right
cerebellar hemisphere and both cerebral hemispheres, likely
representing
metastatic lesions.
- CXR (___): Small right pleural effusion has increased
despite indwelling right pleural drainage catheter. Small apical
pneumothorax unchanged. Right upper lobe largely collapsed
around right hilar mass. Moderate cardiomegaly stable. Left lung
clear.
- TTE (___): The left atrial volume index is normal. 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 65%. There is no resting left ventricular outflow
tract gradient. Mildly dilated right ventricular cavity with
normal free wall motion. There is abnormal interventricular
septal motion. The aortic sinus is mildly dilated with normal
ascending aorta diameter for gender. The aortic arch diameter is
normal. The aortic valve leaflets (3) appear structurally
normal. There is no aortic valve stenosis. There is trace aortic
regurgitation. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse. There is trivial mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is mild [1+] tricuspid regurgitation. There is
mild pulmonary artery systolic hypertension. There is a small
pericardial effusion. There are no 2D or Doppler
echocardiographic evidence of tamponade.
- PET SCAN:
1. There is an FDG avid right upper lobe necrotic mass with
associated hilar, mediastinal, and axillary lymphadenopathy,
moderate right pleural effusion, and pleural nodularity,
compatible with known lung cancer. Right lateral approach
drainage catheter remains in situ.
2. There is diffuse metastatic disease involving the
musculature, multiple
bones, and bilateral adrenal gland nodule/masses, as described
in detail above.
DISCHARGE LABS
___ 06:03AM BLOOD WBC-10.7* RBC-5.37 Hgb-11.4* Hct-36.2*
MCV-67* MCH-21.2* MCHC-31.5* RDW-15.0 RDWSD-35.1 Plt ___
___ 06:03AM BLOOD Plt ___
___ 06:03AM BLOOD ___ PTT-31.2 ___
___ 06:03AM BLOOD Glucose-92 UreaN-14 Creat-0.6 Na-138
K-4.8 Cl-101 HCO3-25 AnGap-12
___ 06:03AM BLOOD ALT-28 AST-43* LD(LDH)-495* AlkPhos-61
TotBili-0.5
___ 06:03AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.1
___ 06:15PM BLOOD Albumin-3.8
Brief Hospital Course:
Mr ___ is a ___ year old man admitted with
post-obstructive pneumonia from RUL mass, now diagnosed as Stage
IV NSCLC with brain, adrenal mets, and pleural/pericardial
effusions.
# Stage IV NSCLC:
# Malignant Pleural Effusion
# Pericardial Effusion, presumed malignant
# Suspected Brain metastasis:
# Malignant Pleural Effusion: ___ was admitted after
outpatient imaging demonstrated large lung mass with associated
pleural effusion. He underwent thoracentesis; cytology from
pleural fluid showed NSCLC (likely adeno). IP was consulted and
he subsequently underwent EBUS with biopsy and placement of a
tunneled pleurex catheter. ___ was initially bothered by
pain at ___ site, but this improved with symptomatic treatment,
time, and frequent draining of pleural fluid. ___ experience
coughing spells initially with the TPC, but this improved
significantly POD#1, and continued to improve thereafter with
pain control, and pleural draining. Given that CT imaging had
noted pericardial effusion, TTE performed for evaluation, which
demonstrated small effusion without evidence of tamponade.
Hematology was initially consulted, but later recommended
instead outpatient follow-up in ___ clinic.
___ had originally been scheduled for outpatient PET/CT for
staging, but given that he could not be discharged prior, this
was performed inpatient. PET/CT was notable for diffuse
metastatic disease involving the musculature, multiple bones,
and bilateral adrenal glands. Regarding brain metastasis,
___ had a normal neurologic exam, without neuro symptoms,
and no edema of concerning features seen on brain MR.
___ had also complained of some intermittent aching pains
that corresponsed with MSK/bony mets seen on imaging. He was
dicharged with pain medications and instructions to its use,
with the understanding that pain symptoms would have be
addressed with underlying cancer treatment and multidisciplinary
plan. ___ family expressed concern that ___ was unable
to get out of bed, but he was observed multiple times ambulating
laps around the hospital floor.
Given persistent fatigue and poor appetite, ___ was started
on dexamethasone prior to discharge (NOT for brain met
indication). This seemed to help his self reported symptoms. By
day of discharge, ___ was tolerating a regular diet, with
significant improvement (near total resolution) of coughing,
ambuilating independently in halls, capable by RN assessment of
performing home ADLs, pain adequately controlled, and without
neurologic symptoms.
He was seen by the ___ oncology social work for assistance
in the home. ___ was set up for frequent home ___ to assist
with TPC management, dressing changes, and symptom assessment.
He was discharged with intent to follow-up with IP and
multidiciplnary thoracic clinic to establish care plan.
# Sepsis
# Post-obstructive pneumonia (tachycardia, leukocytosis):
___ was noted to have pneumonia on CXR on admission. He was
started on ceftriaxone and azithromycin on ___, with WBC count
trending down, flagyl was later added. Blood cultures were
negative. He was eventually transitioned to cefpodoxime and
metronidazole.
# Microcytic Anemia: MCV < 70. Stable. Consider Hb
electrophoresis and iron panel after discharge.
Time spent coordinating discharge > 30 minutes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
5. Nicotine Patch 21 mg/day TD DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
2. Dexamethasone 4 mg PO DAILY
RX *dexamethasone 4 mg 1 tablet(s) by mouth DAILY Disp #*7
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*28 Capsule Refills:*0
4. MetroNIDAZOLE 500 mg PO/NG Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
5. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*0
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth Q6H PRN Disp #*16 Tablet
Refills:*0
7. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
8. Nicotine Patch 21 mg/day TD DAILY
9. Omeprazole 20 mg PO DAILY
10. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until you talk to your oncologist
11. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until you talk to
your oncologist
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
NSLC lung cancer, stage IV
post obstructive pneumonia
sepsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your recent
hospitalization. You came to the hospital with pain and were
found to have pneumonia. You were treated with antibiotics and
your condition improved. You were diagnosed with lung cancer and
had a drain placed to remove fluid around your lungs. You
completed your PET scan while you were hospitalized.
Medication changes:
- Cefpodoxime: 200mg twice a day for 7 days (an antibiotic)
- Metronidazole: 500mg three times a day for 7 days (an
antibiotic)
- oxycodone 5mg tablets, every 6 hours AS NEEDED for pain
- Dexamethasone: 4mg daily. This is a medication to help cancer
related symptoms and help your appetite.
- docusate: an anti-constipation med. Take this when you are
taking oxycodone
Stop taking your aspirin and hydrochlorothiazide until you speak
to your oncologist.
You should try to drink ensures regularly with each meal after
you leave the hospital to keep up your nutrition.
Please take all medications as prescribed and keep all scheduled
doctor's appointments. Seek medical attention if you develop a
worsening or recurrence of the same symptoms that originally
brought you to the hospital, experience any of the warning signs
listed below, or have any other symptoms that concern you.
It was a pleasure taking care of you!
Your ___ Care Team
Followup Instructions:
___
|
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2153-07-04 21:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ woman with a history of
diverticulitis (x ___ who presents with three days of lower
abdominal pain that has persisted despite a 24 hr course of PO
Augmentin as an outpatient.
Three days ago, patient noted the onset of lower abdominal pain
associated with chills (no fevers), malaise, and bloating.
Episode felt similar to prior episodes of diverticulitis. On
___, she was seen at her PCP's office and started PO Augmentin.
She reports that this typically improves her sypmtoms in 12
hours; however, symptoms persisted and she additionally
developed constipation (no BM since yesterday) and decreased PO
intake (only able to eat toast this AM, had been eating normally
prior). She was seen again on ___, and as pain had no
improved, and there was some concern for peritoneal signs (pain
with walking), she was sent to the hospital for
imaging/management.
Of note, patient reports 5 prior episodes of divertiuculitis,
starting in ___. She cannot tolerate PO cipro/flagyl due to
stomach cramping, vomiting, and joint pain and she has been
hospitalized twice for IV cipro/flagyl. She has never seen a
surgeon. Last episode ___, managed on PO augmentin.
In the ED, initial VS at 10:06am were pain 5, 97.7, 64, 128/64,
16, 99% RA. Patient was made NPO and received an unknown amount
of IVF. She received IV Cipro/Flagyl, toradol, and morphine.
Initial labs were notable for a mild leukocytosis (11.1),
preserved renal function, a normal lactate, and 40 urinary
ketones. She underwent CT abd/pel, which was limited by lack of
enteric contrast and paucity of mesenteric fat but showed
sigmoid diverticulitis on prelim read. No fluid collection or
free air. A rectal exam showed trace positive guaiac stool.
VS prior to transfer VS were 98.6 70 110/64 98% RA.
On arrival to the floor, patient reports crampy abdominal
discomfort, no fever/chills, no N/V, diarrrhea, no BM since
yesterday, no urinary symptoms.
Past Medical History:
- Diverticulitis
- Frozen Shoulder
- Iron deficiency
- Pseudoangiomatous stromal hyperplasia of breast
- Pre-eclampsia
- Acute myocarditis (EF normalized at 60% as of ___
- Vasovagal Syncope (possible plan for Reveal device)
Social History:
___
Family History:
Melanoma, breast, and ovarian cancer (no colon cancer).
Physical Exam:
ADMISSION EXAM:
.
VS - 98.6 ___ 16 98% RA
General: middle aged woman, NAD, does appear midly uncomfortable
HEENT: PEERLA, slightly dry mucous membranes, oropharynx clear
Neck: supple, no LAD
CV: RRR, nl S1/S2
Lungs: CTABL, some crackles that clear w/cough
Abdomen: + BS, diffuse abdominal tenderness on deep palpation
(LLQ, periumbilical, RLQ), normal bowel sounds, no rebound,
guarding.
GU: no foley
Back: no spinal tenderness, does complain of abdominal pain with
assesment of CVA tenderness.
Ext: WWP, no edema
Neuro: CN ___ intact. strength grossly normal
Skin: no rashes
.
DISCHARGE EXAM:
.
VS - 98.6 ___ 16 98% RA
General: middle aged woman, NAD, resting comfortably in bed
HEENT: PEERLA, MMM, oropharynx clear
Neck: supple, no LAD
CV: RRR, nl S1/S2
Lungs: CTABL
Abdomen: + BS, NTND, does complain of some discomfort on deep
palpation of lower quadrants, no HSM
GU: no foley
Ext: WWP, no edema
Neuro: CN ___ intact. strength grossly normal
Skin: no rashes
Pertinent Results:
ADMISSION LABS:
.
___ 01:41PM URINE UCG-NEGATIVE
___ 01:41PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 01:41PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:41PM URINE RBC-5* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-9 TRANS EPI-<1
___ 01:41PM URINE HYALINE-1*
___ 01:41PM URINE MUCOUS-OCC
___ 11:51AM ___ COMMENTS-GREEN TOP
___ 11:51AM LACTATE-1.3 K+-3.9
___ 11:40AM GLUCOSE-86 UREA N-10 CREAT-0.7 SODIUM-135
POTASSIUM-5.7* CHLORIDE-98 TOTAL CO2-27 ANION GAP-16
___ 11:40AM estGFR-Using this
___ 11:40AM CALCIUM-9.3 PHOSPHATE-3.7 MAGNESIUM-2.1
___ 11:40AM WBC-11.1* RBC-4.17* HGB-12.3 HCT-34.4* MCV-83
MCH-29.6 MCHC-35.8* RDW-13.5
___ 11:40AM NEUTS-79.4* LYMPHS-14.2* MONOS-5.2 EOS-0.8
BASOS-0.4
___ 11:40AM PLT COUNT-247
.
IMAGING:
.
___ CTA/P noncon: The examination is somewhat limited by
lack of oral contrast and paucity of intra-abdominal fat.
Within these limitations, there are findings suggesting
acute diverticulitis involving the sigmoid colon without
drainable fluid
collection or free air.
.
DISCHARGE LABS:
.
___ 07:05AM BLOOD WBC-6.6 RBC-4.26 Hgb-12.1 Hct-36.0 MCV-84
MCH-28.4 MCHC-33.7 RDW-13.6 Plt ___
___ 07:05AM BLOOD Plt ___
___ 07:05AM BLOOD Glucose-71 UreaN-9 Creat-0.6 Na-140 K-4.0
Cl-102 HCO3-25 AnGap-17
___ 07:05AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.9
Brief Hospital Course:
Ms. ___ is a ___ woman with a history of
diverticulitis (x ___ who presents with three days of lower
abdominal pain that has persisted despite a 24 hr course of PO
Augmentin as an outpatient.
.
ACUTE ISSUES:
.
# Diverticulitis: on presentation, patient afebrile, mild
leukocytosis (11), tolerating PO fluid and food intake fairly
well. Abdomen exam and imaging consistent with diverticulitis
uncomplicated by abscess or perforation. Symptoms of lower
abdominal pain/cramping c/w prior episodes of diverticulitis;
this was patient's second. Admitted for not improved after 24hrs
of PO Augmentin. Started instead on PO clindamycin and
ciprofloxacin with improvement in subjective symptoms by
patient. On discharge she was still tolerating oral intake will
(placed on a clear liquid diet for a few days until abdominal
pain entirely, though she was tolerating a normal diet at home),
and felt well, with no fever. Set up with outpatient follow up
with colorectal surgery to consider surgical management of
diverticulitis (though per PCP's notes, disease has been in
sigmoid, hepatic, and splenic flexures).
.
# Ketones/AG acidosis: p/w ketones in urine, mild AG. Likely
starvation ketosis secondary to decreased PO intake day of
intake. Resolved during admission with improved PO intake.
.
CHRONIC ISSUES:
.
# Anemia: h/o iron deficiency, monitored by PCP (likely ___
fibroid bleeding). Mildly anemic on admission, resolved on day
of discharge with no intervention. Continued multivitamin.
.
#H/o Acute myocarditis: EF normalized at 60% as of ___.
Continued aspirin, metoprolol.
.
#Exercise-induced Asthma: continued albuterol MDI.
.
FOLLOW UP:
.
# Patient scheduled to see surgeon for discussion of surgical
management of diverticulitis given this is her ___ or ___
recurrence at the age of ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Aspirin 81 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Acetaminophen 650 mg PO Q6H:PRN pain
6. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
7. Clindamycin 450 mg PO Q8H
RX *clindamycin HCl 300 mg 1.5 capsule(s) by mouth q8hrs Disp
#*27 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
# PRIMARY: Diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at the ___
___. You were admitted for an episode of
diverticulitis. Abdominal imaging showed diverticulitis, no
signs of abscess. You were treated with a combination of the
oral antibiotics ciprofloxacin and clindamycin. You will take
these for 6 days following discharge (total 7 days). You should
eat a clear liquid diet for ___ days, until abdominal discomfort
resolves. At that point you can slowly advance your diet to
normal.
We are scheduling you with a follow up with colerectal surgery
to discuss the option of colon resection to treat recurrent
diverticulitis.
Followup Instructions:
___
|
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2156-06-20 23:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Cipro / Flagyl
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of Takutsobo's myocarditis who presents with
central CP and SOB since ___. Came on gradually. Patient with
recent stressor of new DM diagnosis, hasn't started metformin
yet. Feels taxed and that she would be SOB with exertion. No leg
swelling. No history of PE. Took 81 mg Aspirin at home. No
fevers, chills, abdominal pain, nausea vomiting, diarrhea. Last
Echo was done ___ year ago with EF of 55%, 40% during last attack
___ years ago.
In the ED initial vitals were: 98.3 78 124/80 16 99% RA
EKG: sinus 73, no ste, NI, ___
Labs/studies notable for:
Trop-T: 0.14
proBNP: 139
normal Chem 7, except gluc 228
WBC 10.1; N:72.3 L:20.7 M:5.7 E:0.7 Bas:0.4 ___: 0.2
Absneut: 7.32
CXR negative
Patient was given:
___ 14:20 PO Aspirin 243 mg
___ 17:42 IV Heparin 3100 UNIT
___ 17:42 IV Heparin Started 600
Vitals on transfer: 98.9 111/64 69 17 99%RA
On the floor she endorses "2.5"/10 substernal chest pressure.
Earlier, it had intermittently peaked at ___ per hour
lasting ___ minutes at most. Symptom onset at 0930 on ___
reminiscent of the chest pressure she felt during her stress
cardiomyopathy previously, but overall lower in intensity. She
endorsed associated fatigue and diaphoresis. Symptoms are worse
when sitting up and with exertion. She endorses a mild frontal
headache.
She reports a complicated urinary tract infection in ___
which took 1.5 months to clear up, but she is now asymptomatic.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes - she notes that she was prescribed but has not yet
started taking metformin
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- Stress cardiomyopathy vs acute myocarditis in ___ (EF
normalized at 60% as of ___
- Stress cardiomyopathy in ___ (normal stress echo in ___
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
- Diverticulitis
- Frozen Shoulder
- Iron deficiency
- Pseudoangiomatous stromal hyperplasia of breast
- Pre-eclampsia
- Vasovagal Syncope - had been frequent, but no episodes since
___
- s/p fibroid removal
- Exercise induced asthma
Social History:
___
Family History:
Melanoma, breast, and ovarian cancer (no colon cancer).
Father MI in ___, paternal uncle CABG in ___, paternal
grandfather MI in ___. Sister and niece w/ mitral valve prolapse
Physical Exam:
ADMISSION PHYSICAL EXAM
====================
VS: 98.0 120/82 64 16 100%RA
GENERAL: WDWN in NAD. Oriented x3. Nervous affect.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: No elevated JVP
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 PHYSICAL EXAM
=====================
VS: T 98.9 BP 93-103/60-69 HR ___ SpO2 97% RA
GENERAL: Thin, alert, no distress. Anxious affect.
HEENT: No conjunctival injection or icterus. No xanthelasma.
NECK: No JVD
CV: RRR, normal S1, S2. No m/r/g. No thrills or lifts. PMI in
___ ICS @ MCL. 2+ radial and DP pulses.
RESP: Unlabored. CTAB.
ABD: Soft, ND, NT. Normal BS.
EXT: Warm, no edema.
Pertinent Results:
ADMISSION LABS
==============
CBC:
___ 02:25PM BLOOD WBC-10.1*# RBC-4.20 Hgb-12.0 Hct-36.3
MCV-86 MCH-28.6 MCHC-33.1 RDW-12.5 RDWSD-39.6 Plt ___
Diff:
___ 02:25PM BLOOD Neuts-72.3* ___ Monos-5.7
Eos-0.7* Baso-0.4 Im ___ AbsNeut-7.32* AbsLymp-2.10
AbsMono-0.58 AbsEos-0.07 AbsBaso-0.04
Chem:
___ 02:25PM BLOOD Glucose-228* UreaN-20 Creat-0.7 Na-136
K-4.1 Cl-101 HCO3-24 AnGap-15
___ 04:25AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.3
CARDIAC MARKERS
===================
___ 02:25PM BLOOD proBNP-139
___ 02:25PM BLOOD CK-MB-4 cTropnT-0.14*
___ 08:30PM BLOOD CK-MB-4 cTropnT-0.06*
___ 04:25AM BLOOD CK-MB-3 cTropnT-0.01
___ 01:30PM BLOOD CK-MB-4 cTropnT-0.01
DISCHARGE LABS
===================
___ 04:25AM BLOOD WBC-6.9 RBC-4.23 Hgb-12.0 Hct-36.1 MCV-85
MCH-28.4 MCHC-33.2 RDW-12.9 RDWSD-39.5 Plt ___
___ 04:25AM BLOOD Glucose-93 UreaN-16 Creat-0.6 Na-139
K-4.1 Cl-104 HCO3-26 AnGap-13
IMAGES & STUDIES
====================
ECGStudy Date of ___ 1:27:01 ___
Clinical indication for EKG: R79.89 - Other specified abnormal
findings of
blood chemistry
Sinus rhythm. Poor R wave progression, probably normal variant.
Compared to
the previous tracing of ___, there is no significant
diagnostic change.
TRACING #1
ECGStudy Date of ___ 4:44:44 ___
Clinical indication for EKG: R79.89 - Other specified abnormal
findings of
blood chemistry
Sinus rhythm. Compared to the previous tracing, there is no
significant
diagnostic change.
TRACING #2
ECHO ___
Conclusions
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses are
normal. Overall LV systolic function is moderately-to-severely
depressed (LVEF = 30%) secondary to extensive apical hypokinesis
with focal apical dyskinesis. The basal segments are
hyperdynamic. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. The right
ventricular free wall thickness is normal. Right ventricular
chamber size is normal with focal hypokinesis of the apical free
wall. The diameters of aorta at the sinus, ascending and arch
levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___, a
similar configuration of extensive severe apical hypokinesis
with hyperdynamic basal segments is present.
CHEST XRAY (PA & LAT) ___
FINDINGS:
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous
structures are intact.
No free air below the right hemidiaphragm is seen.
Brief Hospital Course:
___ with h/o recurrent stress cardiomyopathy (normal stress echo
in ___, newly diagnosed DM2, HTN, admitted for 1 day of
intermittent chest pain in setting of recent psychosocial stress
and elevated troponin and was diagnosed with recurrent stress
CMP. TTE found depressed EF (30%) and extensive severe apical
hypokinesis with hyperdynamic basal segments similar to prior
episode of stress CMP in ___. Troponin was 0.14 at presentation
and down-trended to 0.01 at discharge. Vital signs remained
stable throughout admission. Patient was chest pain free at
discharge though with continuing fatigue. She was discharged on
her prior cardiac regimen with close PCP and cardiology
___.
TRANSITIONAL ISSUES:
#STRESS CMP: Discharged on prior ASA, metoprolol, and
irbesartan.
***EF 30% this admission, down from 55% in ___.
#STATIN: Not on statin prior to admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. irbesartan 37.5 mg oral DAILY
2. Aspirin 81 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
5. Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
2. Aspirin 81 mg PO DAILY
3. irbesartan 37.5 mg oral DAILY
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
-Stress cardiomyopathy
Secondary Diagnoses:
-Hypertension
-Diabetes mellitus type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why you were admitted: chest pain
What we did for you:
- We did blood tests and an echo (heart ultrasound) that showed
you had another episode of stress cardiomyopathy (heart weakness
from stress)
- We gave you medications to protect your heart
Instructions for when you go home:
- Please follow up with primary care doctor and cardiologist
within 2 weeks. See below for phone numbers and details.
- Take all of your medications as prescribed.
- Call your primary care doctor or cardiologist or return to the
hospital if you have more chest pain, shortness of breath, or
any of the other symptoms below.
We wish you a speedy recovery!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
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|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Flexeril
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ y/o M with h/o CLL s/p recent rituximab and
dose of GCSF, malignant pleural effusion, AVR, Enterococcal
bacteremia, and empyema necessitans ___ Enterococcal seeding s/p
___ window and course c/b by recurrent C. difficile with
recent completion of a course of oral vancomycin presenting with
1 week of generalized weakness.
Patient notes that over the past week he has had worsening
weakness. He has not been able to get out of bed for the most
part, only got out twice in the past week. The weakness is all
over, and not in a specific part of his body. He states that he
has had this weakness before when he was anemic and had c diff,
but it hasn't been so sustained. He reports that for the past 4
weeks he has been getting weekly infusions of rituximab. Patient
reports that the morning prior to admission he had an
appointment
with his oncologist. He reports that she did a blood test and
was
concerned about this. He was also found to be hypotensive to the
___. He states that his doctor spoke with Dr. ___
ultimately decision was made to come to the ED.
He also describes some intermittent productive cough. He has not
noted any fevers. He has no nausea, vomiting, or chills. He does
not note any changes with regards to his urination. He has no
complaints of abdominal pain. No diarrhea or constipation.
On review of records, patient was last admitted to ___ from
___ with acute hypoxic respiratory failure ___ an
acute hemothorax. He improved after a chest tube placement. He
was also found to have Enterococcus faecium bacteremia and
ultimately completed a 14 day course of IV vancomycin.
In the ED:
Initial vital signs were notable for: T 97.8, HR 91, BP 106/45,
RR 16, 98% RA
Exam notable for:
-Nontoxic-appearing, good mentation, non-tachycardic
-Cladgett window dressing in place, soaked with pus, purulent
odor, moderate surrounding erythema, no soft tissue crepitus
-Lung sounds diminished particularly in the lower fields
Labs were notable for:
- CBC: WBC 12.2 (84%n), hgb 8.8, plt 131
- Lytes:
138 / 93 / 18 AGap=12
------------- 68
4.9 \ 33 \ 0.7
- lactate 1.7
Studies performed include: CT chest with contrast with no
substantial change from prior.
Consults: Thoracic surgery was consulted to evaluate the ___
window site, which appeared generally well without erythema and
fluctuance. Drainage expected from ___ window. Recommend
frequent dressing changes.
Patient was given: ___ 21:23 PO/NG rOPINIRole 1.5 mg
Vitals on transfer: T 97.3, HR 76, BP 101/40, RR 16, 98% 2L NC
Upon arrival to the floor, patient recounts history as above. He
is happy to have some food.
Past Medical History:
- CLL recently on ibrutinib; complicated by multiple recurrent
malignant pleural effusions. **Primary hematologist is Dr.
___ ___, ___ ___
Cancer Care in ___
- Severe AS s/p bioAVR ___
- CAD s/p CABG ___ (LIMA to LAD, reverse saphenous vein
to diagonal branch, marginal branch, and RCA)
- Atrial fibrillation/flutter, likely due to chronic pleural
effusion s/p multiple DCCV, briefly on sotalol, amiodarone,
stopped due to hypothyroidism, on apixiban
- Psoriasis
- Insomnia
- BPH
- Prior TIA (right leg weakness and numbness)
- Chronic low back pain
- Cataract surgery
- Iron deficiency anemia
- Possible HFpEF, isolated TTE with EF 40% possibly from
tachyarrhythmia, now recovered
- ? Pericardial constriction on TTE in the past
- ___ ___ admission for flutter with RVR, mixed shock,
enterococcus bacteremia, and pleural effusion/hemothorax s/p
VATS
___
- ___ ___ admission from ___ for management of left
empyema
necessitans and E. Faecalis bacteremia likely due to seeding of
his thorax due to prior hospitalization in ___ s/p CT-guided
core-biopsy of distended left lower pleura ___ which grew
enterococcus, s/p left chest limited thoracotomy, rib resection,
and ___ window on ___, s/p redo thoracotomy, evacuation
of hematoma, hemostasis, and ___ window on ___.
Cultures
of pleural fluid grew E. faecalis and intraoperative tissue
culture grew enterococcus. Planned for treatment of prosthetic
AVR endocarditis in addition to his empyema. Discharge
antibiotics: ampicillin 2mg IV Q4 and ceftriaxone 2mg IV Q12
(start date ___ - end date ___.
Social History:
___
Family History:
Father died secondary to MI aged ___. Mother died secondary to
cancer.
Physical Exam:
Admission Physical Exam:
========================
VITALS: T 98.2, HR 77, BP 105/59, RR 20, 94% 1L NC
GENERAL: Thin appearing male in NAD. Alert and oriented, though
at times will repeat himself.
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, soft holosystolic murmur best heard at LUSB,
no S3, no S4. No JVD.
RESP: Lung sounds with poor air movement bilaterally, diminished
at bases. Dressing in place over window on L chest wall c/d/I.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength generally
diminished, but symmetric bilaterally in all limbs. No lower
extremity edema
SKIN: Erythmatous rash on back of neck
NEURO: Alert, oriented, CN ___ intact. Globally weak, but with
prompting has ___ strength in proximal and distal muscle groups
of upper and lower extremities. Symmetric.
PSYCH: pleasant, appropriate affect
Discharge Physical Exam:
========================
VITALS: see Eflowsheets
GENERAL: Thin appearing male in NAD. Alert and oriented, though
appears quite fatigued
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular. No JVD.
RESP: Dressing in place over window on L chest wall c/d/i with
no
drainage noted.
GI: Abdomen soft, non-distended
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength generally
diminished, but symmetric bilaterally in all limbs. No lower
extremity edema
SKIN: no obvious rashes
NEURO: Alert, oriented, CN ___ intact. Globally weak
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission Labs:
===============
___ 04:50PM BLOOD WBC-12.2* RBC-3.13* Hgb-8.8* Hct-29.4*
MCV-94 MCH-28.1 MCHC-29.9* RDW-18.4* RDWSD-60.0* Plt ___
___ 04:50PM BLOOD Neuts-84.0* Lymphs-9.9* Monos-4.1*
Eos-0.6* Baso-0.7 Im ___ AbsNeut-10.25* AbsLymp-1.21
AbsMono-0.50 AbsEos-0.07 AbsBaso-0.09*
___ 04:50PM BLOOD Glucose-68* UreaN-18 Creat-0.7 Na-138
K-4.9 Cl-93* HCO3-33* AnGap-12
___ 07:25AM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.5 Mg-2.3
Imaging:
========
CT Chest:
1. No substantial change in size in moderate left posterior
chest wall empyema containing foci of air, fluid density and
soft tissue likely reflecting components of malignancy,
collection appears slightly decreased, but persistent.
Superimposed acute infectious process is difficult to exclude.
2. Within the visualized intact lungs, there is no additional
area of
consolidative opacity to indicate pneumonia. Overlying
collapsed lung in the left lower lobe was present on the prior
study and demonstrates somewhat high enhancement, likely
reflecting atelectasis.
3. Previously demonstrated loculated fluid within the major
fissure of the
right lung as well as several other smaller loculated effusions
are
substantially decreased in size compared to the prior study.
4. Cholelithiasis in a collapsed gallbladder. Partially imaged
spleen appears enlarged.
Discharge Labs:
===============
___ 07:50AM BLOOD WBC-7.3 RBC-2.85* Hgb-8.0* Hct-27.2*
MCV-95 MCH-28.1 MCHC-29.4* RDW-18.3* RDWSD-61.8* Plt ___
___ 07:50AM BLOOD Glucose-74 UreaN-17 Creat-0.7 Na-143
K-4.5 Cl-97 HCO3-37* AnGap-9*
___ 07:50AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.1
Brief Hospital Course:
Mr. ___ is a ___ y/o M with h/o CLL s/p recent rituximab and
dose of GCSF, malignant pleural effusion, AVR, Enterococcal
bacteremia, and empyema necessitans ___ Enterococcal seeding s/p
___ window and course c/b by recurrent C. difficile with
recent completion of a course of oral vancomycin who presented
with 1 week of generalized weakness.
ACUTE/ACTIVE PROBLEMS:
# Weakness
Patient presented with generalized weakness in the setting of
CLL with recent Rituximab treatment, malignant pleural
effusions.
Broad infectious workup was negative - blood cultures were
negative, UA was negative, and repeat C diff testing was
negative. CT of the chest revealed persistent effusions, though
decreased on the right. Pneumonia was unable to be fully
excluded given the presence of effusions but he had no
respiratory symptoms suggestive of this. He was evaluated by
thoracic surgery who felt that the ___ window was healing
well without any sign of infection.
Overdiuresis was considered as a cause of weakness but
creatinine was normal and orthostatics were negative, making
this unlikely.
Digoxin level was normal. TSH was elevated at 16, though T3 and
T4 levels were normal and TSH was improved from prior level of
85, at which time levothyroxine dose had been increased.
He denied any symptoms of depression.
He was seen by physical therapy who recommended home ___
# Blood in stool: had one episode of small amount of blood
coating stool. No external hemorrhoids were visualized on exam
but thought likely internal hemorrhoidal bleeding secondary to
irritation from frequent loose stools. Could consider
colonoscopy as an outpatient depending on overall goals of care,
though he likely would not be a candidate for treatment if any
cancer were found. This was discussed with patient and his wife
# ___ c diff - Currently on PO vanc taper. C diff testing
was negative here. Continued PO vancomycin taper (currently at
125mg every other day)
CHRONIC/STABLE PROBLEMS:
# Anemia of chronic disease and malignancy: Hg was at baseline
# Hypothyroid:
- continue home levothyroxine
# AFib: continued home digoxin 0.125mg Q48h. Level was checked
and was normal. Continued home apixaban
# GERD: continued home ranitidine
# Coronary artery disease s/p CABG: continued home ASA 81mg and
simvastatin
# Restless legs: continued home gabapentin and ropinirol
# Chronic diastolic heart failure: appeared euvolemic on exam.
Continued home torsemide
> 30 minutes spent on discharge coordination and planning
Transitional Issues:
====================
- needs repeat TSH check in several weeks
- continue vancomycin taper per ID (currently 125mg every other
day, to decrease to every third day on ___
- could consider outpatient colonoscopy
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Digoxin 0.125 mg PO EVERY OTHER DAY
4. Gabapentin 300 mg PO QHS
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Ramelteon 8 mg PO QHS insomnia
8. Ranitidine 150 mg PO DAILY
9. rOPINIRole 1 mg PO QPM
10. Simvastatin 40 mg PO QPM
11. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
12. Apixaban 5 mg PO BID
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Torsemide 20 mg PO DAILY
15. Vancomycin Oral Liquid ___ mg PO EVERY OTHER DAY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Apixaban 5 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Digoxin 0.125 mg PO EVERY OTHER DAY
6. Gabapentin 300 mg PO QHS
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Ramelteon 8 mg PO QHS insomnia
11. Ranitidine 150 mg PO DAILY
12. rOPINIRole 1 mg PO QPM
13. Simvastatin 40 mg PO QPM
14. Torsemide 20 mg PO DAILY
15. Vancomycin Oral Liquid ___ mg PO EVERY OTHER DAY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Weakness, Failure to thrive
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came into the hospital because you were feeling weak. We did
many tests but did not find any signs of infection. The thoracic
surgeons also saw you and thought that your chest incision was
healing well.
Your weakness may be from your cancer and your low blood counts.
It will be important to follow up with your oncologist Dr.
___ leaving the hospital.
Please continue to follow the vancomycin taper as previously
recommended by Dr. ___.
It was a pleasure taking care of you, and we are happy that
you're feeling better.
Followup Instructions:
___
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2138-09-06 00:00:00
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2138-09-08 13:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
thiopental
Attending: ___.
Chief Complaint:
Back Pain, Leg Weakness
Major Surgical or Invasive Procedure:
___ 1. T5 to T6 tumor resection after
2. T4 to T5 and superior T6 laminectomies bilaterally,
3. transpedicular resection of T5 vertebral body/vertebrectomy
4. placement of anterior expandable cage and OI material
5. T3 to T7 fusion using pedicle screws, ___ rods,
crosslinks,
6. allograft placement
7. Drain placement
History of Present Illness:
Mr. ___ is a ___ male with history of
metastatic renal cell carcinoma to ___ s/p nephrectomy and XRT to
the thoracic spine currently undergoing close monitoring and
Zometa who presents with back pain and right leg weakness.
Patient reports initially thoracic spine pain improved after
radiation treatments. However about one week ago noticed
worsening thoracic spine pain and decreased mobility. Patient
attributed to aggressive ___ sessions however pain continued.
Patient was placed on decadron 4mg TID and repeat imaging showed
stable lesion however now with hetergenous component suggestive
of hemorrhage vs. necrosis with significant stenosis. He also
has
had difficulty with ambulating and feels right leg weaker than
left. He has needed to use his cane as well as balance against a
wall when walking. He had to use a shower chair in the shower
rather than being able to stand. He has been taking Tylenol with
Advil in the morning and oxycodone 5mg at night for the pain. He
also notes bilateral foot tingling. Per report, was planned for
surgery on ___. Denies bowel/bladder incontinence.
On arrival to the ED, initial vitals were 98.3 65 140/83 16 99%
RA. Exam was notable for mild T6 tenderness to palpation, ___
strength RLE, ___ strength LLE, slight decreased sensation in
left lower extremity, normal perianal sensation and rectal tone,
and positive clonus bilaterally. Labs were notable for WBC 10.2,
H/H 12.2/38.1, Plt 258, INR 1.0, Na 143, K 4.2, and BUN/Cr
32/1.3. Neurosurgery was consulted who recommended CTA of
___
for surgical planning, decadron 4mg q8h, ISS/Pepcid, and
admission to ___. Discussed with ___ for appropriate
admission disposition who stated plan for surgery on ___ is
not definite. Patient was given morphine 4mg IV x 2,
dexamethasone 4mg PO, and 1L LR. Prior to transfer vitals were
97.8 74 128/76 18 99% RA.
On arrival to the floor, patient reports ___ back pain. He
denies fevers/chills, night sweats, headache, vision changes,
dizziness/lightheadedness, shortness of breath, cough,
hemoptysis, chest pain, palpitations, abdominal pain,
nausea/vomiting, diarrhea, hematemesis, hematochezia/melena,
dysuria, hematuria, and new rashes.
Past Medical History:
- Hyperlipidemia
- Obesity
- Left Eye Strabismus s/p repair at age ___
- Left cheekbone fracture and repair due to a car accident in
___
PAST ONCOLOGIC HISTORY:
Mr. ___ underwent screening chest CT on ___ (due to
his
extensive smoking history) revealing a 2.8 cm right lower lobe
mass and two small stable right and left lung nodules. He had a
PET scan on ___ revealing mild FDG avidity in the right
lower lobe mass as well as a 6.7 cm left renal mass. There was
also a 9 x 18 mm soft tissue density in the left posterior
lateral T5 vertebral body with bony erosion. He had a biopsy of
the bone lesion on ___ at ___ revealing
malignant cells consistent with a renal primary. Tumor cells
were
positive for renal cell cancer antigen and PAX8 and negative for
TTF-1 and P40. Focally, some features were suggestive of clear
cell renal cell carcinoma.
He was referred to ___ to discuss biopsy of the lung mass and
treatment for metastatic RCC. He underwent EUS on ___ for
biopsy of the RLL mass. This revealed malignant cells,
consistent
with low-grade neuroendocrine tumor. He had a left radical
laparascopic nephrectomy on ___ ___.
Pathology revealed a 7 cm clear cell RCC, ___ grade 3 to
focal 4. He developed new mid thoracic back pain after surgery.
Chest CT ___ revealed significant growth in the lesion
involving the T5/T6 vertebral body with invasion of the spinal
canal. Radiation oncology was consulted. Thoracic spine MRI on
___ showed significant cord displacement by tumor (but no
cord compression). He began dexamethasone and 10 fractions of
radiation on ___, completed ___.
Social History:
___
Family History:
Unknown as he is adopted.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: Temp 97.6, BP 160/84, HR 70, RR 18, O2 sat 99% RA.
GENERAL: Pleasant man, in no distress, lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Decreased sensation on right foot. Decreased strength
right leg with decreased range of motion.
SKIN: No significant rashes.
DISCHARGE PHYSICAL EXAM:
========================
VS: 98.0 PO 112 / 71 74 18 99 RA
GENERAL: Pleasant man, in no distress, lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Improved sensation on right and left foot. Improved
strength in R leg to ___ from ___ and improved ROM around hip,
knee, and ankle joint.
SKIN: No significant rashes. Back bandage without drainage,
pain.
Pertinent Results:
ON ADMISSION
===========================================
___ 12:58PM BLOOD WBC-10.2*# RBC-4.23* Hgb-12.2* Hct-38.1*
MCV-90 MCH-28.8 MCHC-32.0 RDW-13.1 RDWSD-42.7 Plt ___
___ 12:58PM BLOOD Glucose-103* UreaN-32* Creat-1.3* Na-143
K-4.2 Cl-108 HCO3-23 AnGap-16
___ 12:58PM BLOOD Calcium-9.5 Phos-3.3 Mg-2.4
RADIOLOGY
===========================================
MRI SPINE ___
EXAMINATION: MR ___ ANDW/O CONTRAST ___ MR SPINE
INDICATION: ___ year old man with metatatic RCC-- known lesion
at T6, s/p XRT in ___, initially with improvement in pain;
now worsening pain, leg heaviness and balance difficulties. Will
take oral benzodiazepines before scan secondary to
claustrophobia// evaluate for cord compression evaluate for
cord compression
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR
technique, followed by axial T2 imaging. This was followed by
sagittal and axial T1 images obtained after the uneventful
intravenous administration of 10 mL of Gadavist contrast agent.
COMPARISON: CT chest from ___ and MRI from ___.
FINDINGS:
Again seen is the expansile mass at T5 and T6 demonstrating
hyperintense
signal on T2 weighted imaging, intrinsically hypointense on T1
weighted
imaging. As previously, there is enhancement of the mass after
contrast
administration. However, compared to prior exam, the
enhancement is
heterogeneous and specifically not avidly enhancing in the areas
of
hypointensity on T2 weighted imaging, which may represent areas
of necrosis or hemorrhage (12:25). The overall size of the mass
is grossly unchanged, measuring 4.8 x 3.8 cm, previously 4.8 x
3.5 cm at the similar slice (08:25). Persistent mass effect on
the spinal cord with encasement of the right aspect of the
spinal cord, severe narrowing of the spinal canal and
displacement of the spinal cord to the left is overall
unchanged. Specifically, the epidural component of the soft
tissue results in severe spinal canal narrowing with compression
of the spinal cord (12:24). There is no definite cord signal
change.
The mass continues to involve the pedicle of T5 vertebral body
in the facet and lamina with extension to the right fifth rib.
Lobulated soft tissue extension into the neural foramina with
mass-effect on the spinal cord, mildly displacing it to the left
is persistent and overall not significantly changed from prior
exam (02:28).
Extra cortical soft tissue breakthrough is again noted. New
since prior exam, there is increased pulmonary parenchymal
consolidation abutting the area of soft tissue mass, which is
enhancing on postcontrast images in the paraspinal right lower
lobe (12:27), concerning for metastatic extension.
As previously, there is compression deformity at T5 vertebral
body, compatible with pathologic fracture.
8 mm focus of hyperintensity on T2 and T1 weighted imaging at
T11 is likely a hemangioma, unchanged from ___.
The remaining vertebral body alignment, vertebral body height
and disc spaces are mostly preserved. No other focal bone
marrow lesion is seen.
The remainder of the spinal cord is preserved in caliber. No
signal
abnormality is seen elsewhere. Incidental note is made of 1.4 cm
right upper pole renal cyst, unchanged from prior exam.
IMPRESSION:
1. Lobulated, expansile enhancing mass at T5 and T6 with
epidural component, severely narrowing the spinal canal,
exerting mass effect on the spinal cord with near complete
effacement of the CSF, not significantly changed from ___. However, the enhancement is now heterogeneous, which may
represent necrosis or hemorrhage within the mass.
2. Enhancing pulmonary parenchymal consolidation abutting the
extramedullary component of the above described metastatic
disease, concerning for pulmonary extension. CT chest may be
obtained for further evaluation.
CTA CHEST ___
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with T6 metastatic RCC having worsening pain x1
week// ?
change in known T6 metastatic RCC; please perform CTA T spine w/
thin cuts
through T6
TECHNIQUE: Axial multidetector CT images were obtained through
the thorax
after the uneventful administration of intravenous contrast.
Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal
intensity
projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 866 mGy-cm.
COMPARISON: MR ___ from ___hest from ___
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified
to the
subsegmental level without filling defect to indicate a
pulmonary embolus. The thoracic aorta is normal in caliber
without evidence of dissection or
intramural hematoma. The heart, pericardium, and great vessels
are within
normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No pathologically enlarged
axillary, hilar, or mediastinal lymph nodes are seen.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is re-demonstration of a pulmonary mass in
the right
lower lobe that measures 2.7 x 1.7 cm, which is not
significantly changed when compared to prior study. Fibrotic
changes are seen in the right lower lung adjacent to expansile
T5 lesion compatible with post radiation changes. No new
pulmonary nodules or masses are visualized. The airways are
patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
ABDOMEN: The liver, gallbladder, and spleen are unremarkable.
The pancreas is
unremarkable. The bilateral adrenal glands are of normal size
and shape.
Multiple well-circumscribed hypodensities are seen in the right
kidney,
characterized as simple cysts on previous imaging. The left
kidney is
surgically absent. The imaged portion of the GI tract is
unremarkable.
BONES: There is re-demonstration of a soft tissue/lytic
metastatic lesion
centered about the T5 vertebral body and lateral arch with
encroachment on the spinal cord, that measures 3.9 x 3.9 x 4.3
cm, which appears slightly larger in size compared in comparison
to prior.
IMPRESSION:
1. Slight interval increase in size of expansile, lytic mass
centered about the T5 vertebral body.
2. Unchanged appearance of right lower lobe pulmonary lesion.
3. No new pulmonary masses, osseous lesions, or
lymphadenopathyidentified.
PRE OP CXR ___
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old man with renal cell carcinoma, known
pulmonary mets, here w/spine metastasis and symptoms of cord
compression.// pre-op for spine decompression Surg: ___
(spine decompression)
COMPARISON: Chest CT ___
FINDINGS:
PA and lateral views of the chest provided.
There is no focal consolidation, pleural effusion, pneumothorax.
3.1 cm
retrocardiac none nodular opacity is best seen on lateral
projection and
corresponds to the right lower lobe mass seen on CT..
Cardiomediastinal
silhouette is within normal limits
IMPRESSION:
No acute intrathoracic process. Known right lower lobe mass is
better
evaluated on recent chest CT.
___ x-ray ___
Postsurgical appearances are demonstrated with trans pedicle
screws,
longitudinal rods and vertebral body spacer. Skin staples are
seen. Surgical clips are seen. No additional hardware is
identified on this single projection. T5 bone destruction and
and/or debridement changes are evident.
IMPRESSION:
Spinal fixation hardware. No additional hardware is seen apart
from surgical clips.
on discharge
___ 08:15AM BLOOD WBC-7.7 RBC-3.03* Hgb-8.9* Hct-27.4*
MCV-90 MCH-29.4 MCHC-32.5 RDW-13.9 RDWSD-45.1 Plt ___
___ 08:15AM BLOOD Glucose-85 UreaN-25* Creat-1.0 Na-139
K-4.6 Cl-106 HCO3-23 AnGap-15
Brief Hospital Course:
Mr. ___ is a ___ male with history of
metastatic renal cell carcinoma to ___ s/p nephrectomy and XRT to
the thoracic spine currently undergoing
close monitoring and Zometa who presents with back pain and
right leg weakness and reduced sensation. Patient had T5-6 tumor
resection, T4-6 decompression post T3-8 fusion, T5 cage, and
anterior T4-6 fusion on ___ with JP drain. Jp drain was pulled
___ and patient was discharged to rehab with oncology,
neurosurgery, and radiation oncology follow up.
# Back Pain:
# Right Leg Weakness ___ T5 spinal metasis: Patient with known
T5/6 mass with epidural component, severely narrowing the spinal
canal, exerting mass
effect on the spinal cord with near complete effacement of the
CSF presented with back pain, weakness in RLE>LLE, and reduced
sensation in b/l ___. No bowel/bladder incontinence. Pain was
ongoing in spite of patient receiving dexamethasone 4mg TID over
x3 doses, however, pain and weakness improved with loading dose
of dexamethasone 10mg and then dexamethasone 6mg q6h, with some
improvement in lower extremity and sensation, but given that
patient's symptoms are in spite of previous XRT, decision was
made to pursue definitive treatment with neurosurgical
decompression. Patient had T5-6 tumor resection, T4-6
decompression post T3-8 fusion, T5 cage, and anterior T4-6
fusion on ___ with JP drain, and was subsequently transferred
to the neurosurgery service. His dexamethasone was weaned off
with last dose ___. Patient has been maintained on
dexamethasone taper, and JP drain was pulled POD#4 on ___, and
he was discharged ___ to rehab, with plan for NSGY follow up
___ for suture removal.
# Metastatic RCC: Not currently on chemotherapy. Patient with
T5/6 metastatic lesion.
Follow-up with outpatient radiation-oncologist, Dr. ___
___
Follow-up with outpatient Oncologist, Dr. ___ for
___
Follow up with Dr. ___ in 2 and 6 weeks for suture removal
and repeat visit and thoracic C T respectively
# Stage II/III CKD: Cr 1.3 on admission which is at baseline. Cr
1.0 on D/C. Was stable.
# Anemia: No evidence of active bleeding. Of note patient had
hgb drop of 12 to 9 pre and post surgery.
# Hyperlipidemia: Continued home simvastatin
TRANSITIONAL ISSUES
=
=
=
================================================================
-Follow-up with outpatient radiation-oncologist, Dr. ___
___
-Follow-up with outpatient Oncologist, Dr. ___ for
___
-Follow up with Dr. ___ for suture removal
and in 6 weeks with Dr. ___ repeat visit and thoracic CT.
These appointments are not yet booked. Please have rehab call
___ to make these.
-Please recheck CBC in one week given patient's drop of hgb 12
to 9 pre and post surgery to ensure patient does not have
worsening anemia.
-Patient started on multivitamin w/ minerals as he is on Zometa;
would check calcium and albumin at next visit with oncologist
and consider calcium supplementation if calcium low (on d/c
Calcium 7.8, albumin 3, corrected 8.6)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Senna 8.6 mg PO BID:PRN constipation
3. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
4. Simvastatin 40 mg PO QPM
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. Dexamethasone 4 mg PO Q8H
7. LORazepam 0.5-1 mg PO QHS:PRN insomnia
8. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right leg weakness secondary to T5-T6 renal metastasis to spine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Discharge Instructions
Spinal Fusion
Surgery
Your dressing may come off on the second day after surgery.
Your incision is closed with staples or sutures. You will need
suture/staple removal.
Do not apply any lotions or creams to the site.
Please keep your incision dry until removal of your
sutures/staples.
Please avoid swimming for two weeks after suture/staple
removal.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
*** You must wear your brace at all times when out of bed. You
may apply your brace sitting at the edge of the bed. You do not
need to sleep with it on.
*** You must wear your brace while showering.
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your activity
at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc
until cleared by your
neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if you
are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs.
Followup Instructions:
___
|
10783654-DS-21
| 10,783,654 | 23,973,278 |
DS
| 21 |
2158-06-17 00:00:00
|
2158-06-18 10:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
Paracentesis - ___
Endoscopy - ___
History of Present Illness:
___ male with a history of ___ years of chronic alcohol
and IV drug abuse presenting from OSH with abdominal pain,
nausea and vomiting.
His sister called a wellness check on him yesterday evening
since he was not picking up his phone for the past ___ years, and
he was taken to ___ from where he was transferred
to ___ for further management.
The HPI was obtained from patient who is a poor historian and
seems altered and also with collateral from his sister who has
been estranged until recently and does not have much information
about his current health problems.
Per patient: he has had one 1 week of abdominal pain, nausea,
continuous vomiting. Patient reports he quit drinking more than
a week ago due to the discomfort and pain. He denies fever,
chills, blood in the urine or stool. Has not had a BM in more
than a couple of days. Had nausea and vomiting, but reports no
hematemesis. He says his vomit is brown, but denies ever
throwing
up blood or having and EGD. He denies ever having his belly
tapped.
Per sister: Patient lives in ___ with a roommate who is a IV
drug user. He is actively drinking about 1 bottle of vodka a
day. she does not know when his last drink was. She says that
his current behavior is different from his baseline when he is
not drinking. She thinks his belly is much more distended than
usual. She says he does not have PCP, ___, does not
take any meds other than Klonopin that he buys from the street.
She is not aware of him having prior EGDs, hx of HE, SBP,
varices.
In the ED, initial vitals were:
Today 02:21 T 97.8, HR 95, BP 102/64, RR 18, O2 94% RA
- Exam notable for: Mild scleral icterus, Distended abdomen,
tender to palpation diffusely.
- Labs notable for: Cr 1.7, Tbili 4, INR 2.4, ALT 15, AST 46,
Lipase 45
- Imaging was notable for:
Liver Or Gallbladder US ___
1. Cirrhosis without focal hepatic lesion.
2. Large ascites.
Chest (Pa & Lat) ___
Bibasilar opacities are increased from prior, concerning for
multifocal infection.
Paracentesis in the ED shows:
ASCITES ANALYSIS TNC RBC Polys
___ 09:13 196* 71* 29*
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
Not known by sister or patient
Social History:
___
Family History:
Unknown by patient
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 97.6 91/44 84 18 95 RA
HEENT: atraumatic, normocephalic, EOMI, PERRL, icteric sclera
General: cachectic, anxious looking, asking for food, A&O3
Lungs: bilateral basilar crackles
Heart: Regular rate and rhythm, no murmurs, rubs or gallops
Abdomen: very distended and tense, tender to palpation
throughout, + fluid wave, no rebound or guarding
Extremities: no edema, 2+ peripheral pulses
GU: no Foley
Neuro: moving all 4 extremities with purpose, CN II-XII intact,
+asterixis.
Skin: Warm and well perfused, no excoriations or lesions, no
rashes, not jaundiced.
DISCHARGE PHYSICAL EXAM:
========================
VS: T 98.3, BP 88-97/61-63, HR 82-89, RR 18, Spo2 100/RA
General: NAD. Lying comfortably in bed. Cachectic.
HEENT: sclera anicteric. MMM. Poor dentition.
Lungs: CTAB, no W/R/C
Heart: RRR, S1+S2, II/VI systolic murmur noted. No rubs or
gallops.
Abdomen: Soft, non-distended, no TTP or guarding. Normoactive
BS.
Extremities: No ___ edema or erythema.
Neuro: A&Ox3, no asterixis. Moves all extremities.
Skin: Warm and well perfused, not jaundiced.
Pertinent Results:
ADMISSION LABS:
================
___ 05:20AM BLOOD WBC-6.8 RBC-2.67* Hgb-9.5* Hct-29.6*
MCV-111* MCH-35.6* MCHC-32.1 RDW-14.4 RDWSD-55.8* Plt ___
___ 05:20AM BLOOD Neuts-61.0 ___ Monos-11.1 Eos-1.8
Baso-0.6 Im ___ AbsNeut-4.17 AbsLymp-1.66 AbsMono-0.76
AbsEos-0.12 AbsBaso-0.04
___ 05:20AM BLOOD Glucose-105* UreaN-30* Creat-1.7* Na-145
K-3.7 Cl-105 HCO3-23 AnGap-17*
___ 05:20AM BLOOD ALT-15 AST-46* AlkPhos-52 Amylase-48
TotBili-4.0* DirBili-2.4* IndBili-1.6
___ 05:20AM BLOOD Albumin-2.3*
___ 03:34PM BLOOD Calcium-7.9* Phos-3.6 Mg-1.7
PERTINENT LABS/MICRO:
======================
___ 05:20AM BLOOD Lipase-45
___ 03:34PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS*
___ 03:34PM BLOOD HIV Ab-NEG
___ 05:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:34PM BLOOD HCV Ab-POS*
___ 03:34PM BLOOD HBV VL-NOT DETECT HCV VL-NOT DETECT
___ 03:34PM BLOOD HIV1 VL-NOT DETECT
___ 05:45AM BLOOD Lactate-2.0
___ 09:13AM ASCITES TotPro-1.9 Glucose-111
___ 09:13AM ASCITES TNC-196* RBC-71* Polys-29* Lymphs-16
___ Mesothe-5* Macroph-50* Other-0
___ 04:28PM ASCITES TNC-214* RBC-80* Polys-5* Lymphs-24*
___ Mesothe-3* Macroph-68* Other-0
___ 02:40PM ASCITES TNC-169* RBC-196* Polys-1* Lymphs-35*
___ Mesothe-4* Macroph-60*
___ 04:51PM URINE Hours-RANDOM Creat-360 Na-<20
___ 04:51PM URINE Mucous-RARE*
___ 04:51PM URINE CastGr-6* CastHy-41*
___ 04:51PM URINE RBC-1 WBC-9* Bacteri-FEW* Yeast-NONE
Epi-1 TransE-<1
___ 04:51PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-SM* Urobiln-4* pH-5.5 Leuks-NEG
___ 04:51PM URINE Color-DkAmb* Appear-Hazy* Sp ___
___ 04:01PM URINE Color-Amber* Appear-Cloudy* Sp ___
___ 04:01PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-SM* Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:01PM URINE RBC-2 WBC-3 Bacteri-FEW* Yeast-NONE
Epi-<1
MICRO:
___ BCx: No growth
___ Peritoneal fluid: No growth
___ Urine culture: No growth
___ Peritoneal fluid: No growth
___ BCx x2: No growth
___ Urine culture: No growth
___ Peritoneal culture: No growth
DISCHARGE LAB:
==============
___ 05:15AM BLOOD WBC-8.0 RBC-2.65* Hgb-9.3* Hct-27.5*
MCV-104* MCH-35.1* MCHC-33.8 RDW-13.9 RDWSD-52.8* Plt ___
___ 05:15AM BLOOD Glucose-100 UreaN-20 Creat-1.0 Na-133
K-3.9 Cl-93* HCO3-26 AnGap-14
___ 05:15AM BLOOD ALT-16 AST-41* LD(LDH)-197 AlkPhos-48
TotBili-3.3*
___ 05:15AM BLOOD Albumin-3.0* Calcium-8.1* Phos-3.5 Mg-1.7
PERTINENT IMAGING:
==================
___ EGD:
Mild to moderate esophagitis
No varices noted
Mild erythema in the antrum
Otherwise normal EGD to third part of the duodenum
___ CXR:
Bibasilar opacities are increased from prior, concerning for
multifocal
infection.
___ RUQ US:
1. Cirrhosis without focal hepatic lesion.
2. Large-volume ascites.
___ Abd xray:
Nonspecific bowel gas pattern, without evidence of ileus or
obstruction.
Ascites.
___ CXR:
Bibasilar pneumonia, slightly worsened on the right and slightly
improved on the left.
___ Abd Xray:
Again seen are mildly distended loops of central small bowel
filled with air measuring up to 4.1 mm, stable in appearance as
compared to prior exam. Partial small-bowel obstruction cannot
be ruled out.
Brief Hospital Course:
___ with a history of chronic alcohol and IV drug abuse
presenting from outside hospital with abdominal pain, nausea and
vomiting, concerning for alcohol hepatitis and decompensated
alcoholic cirrhosis.
# Decompensated cirrhosis
# Hepatic Encephalopathy
Denies having any history of cirrhosis or its complications.
MELD-Na 27 on admission. Childs Class C. RUQ showed cirrhosis
and large volume ascites without other hepatic lesions or PVT.
Likely due to ETOH. HepBs Ab positive (VL neg) and HepC Ab
positive (VL neg). During this admission, his cirrhosis was
decompensated by hepatic encephalopathy and ascites, likely d/t
infection (see below) and ongoing EtOH consumption. S/p large
volume paracentesis on ___ (5L removed) and on ___ (6L removed)
- no evidence of SBP on these taps. HE resolved with lactulose
and rifaximin. Subsequently started refusing lactulose but
continued to have ___ daily, in spite of the med
non-adherence. Pt had EGD on ___, which showed esophagitis
without varices. No signs of bleeding throughout admission.
MELD-Na of 24 on discharge. Given prescriptions for lactulose
30mg TID, rifaximin 550mg BID (goal ___ BMs/day). Also given
furosemide 20mg and spironolactone 50mg daily to control
ascites. Will establish care with Dr ___ in ___
here at ___, and will likely need a paracentesis as an
outpatient in the next few weeks.
# Severe Malnutrition:
History of alcohol abuse and now, cirrhosis. He appeared
cachetic on exam. Nutrition
consulted and recommended 3000 calories daily, which patient was
not able to maintain while admitted. Recommended Dobhoff
placement with tube feeds, but patient repeatedly declined this.
Furthermore, would not have insurance coverage for tube feeds as
an outpatient. Recommend Ensure Enlive TID with meals and
strongly encouraged PO intake (while adhering to low salt diet).
# Vomiting/Abdominal pain:
Had several episodes of bilious, non-bloody vomiting along with
burning abdominal pain and distention. KUB without obvious
obstruction or ileus. EGD showed mild-moderate esophagitis.
Symptoms overall improved with standing Zofran and omeprazole.
Symptoms resolved with second large volume paracentesis.
Continue Omeprazole 40 mg daily. Zofran stopped.
# ETOH Abuse: Reports last drink was two weeks prior to
admission. Did not score on CIWA while admitted. Given thiamine
and multivitamin.
# Community Acquired Pneumonia: Pt was having ongoing coughing
and was found to have an infiltrate on CXR. s/p 5 days of
ceftriaxone and azithromycin with resolution of symptoms.
# Anemia: Likely combination of EtOH cirrhosis and alcohol
toxicity. Stable. Given thiamine and multivitamin.
TRANSITIONAL ISSUES
===================
[ ] Follow-up with Dr ___ in ___, will need
paracentesis in ___ weeks.
[ ] Declined feeding tube and tube feeds, despite
recommendations from nutrition. Additionally, per case
management, pt's insurance (largely through the ___ would not
cover outpatient tube feeds.
[ ] Needs PCP at ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg One tablet(s) by mouth Once a day Disp #*30
Tablet Refills:*0
2. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg One tablet(s) by mouth Once a day Disp #*30
Tablet Refills:*0
3. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 mL by mouth Three times a day
Disp #*1800 Gram Refills:*0
4. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg One capsule(s) by mouth Once a day Disp
#*30 Capsule Refills:*0
5. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg One tablet(s) by mouth Twice a
day Disp #*60 Tablet Refills:*0
6. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg One tablet(s) by mouth Once a day Disp
#*30 Tablet Refills:*0
7. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg One tablet(s) by mouth Once
a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Decompensated alcoholic cirrhosis
Alcoholic hepatitis
Community-acquired pneumonia
SECONDARY DIAGNOSES:
Alcohol use disorder
IV drug use
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
WHY WERE YOU ADMITTED TO THE HOSPITAL?
You were having belly pain, nausea, vomiting, and were unable to
eat.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had your belly drained twice.
- You had an endoscopy (camera put into your stomach) to look
for any evidence of bleeding - you had no bleeding or enlarged
blood vessels, but you did have some irritation in your
esophagus (tube connecting mouth to stomach). This can be the
result of reflux.
- We discussed putting a feeding tube in so we could provide you
with an adequate amount of nutrition, but you chose not to have
this done.
- You had a pneumonia, and were given antibiotics to treat it.
- You were treated for alcohol withdrawal.
- You had an injury to your kidneys which was preventing your
kidneys from working as well as they should - this was fixed and
your kidneys were functioning well by the time you left the
hospital.
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
- Do not drink alcohol! It will kill you.
- It is very, very important that you continue to eat 3 meals a
day, with Ensure (if you are able to get Ensure from the store)
at each meal. You goal is to eat 3000 calories every day. If you
are not able to do this, you will be continually asked by our
liver team to accept a feeding tube and nutrition through the
tube.
- Please try to minimize how much salt your are taking in with
your diet. The goal is for less than 2g (= 2000mg) of salt per
day. This will prevent fluid re-accumulation in your belly.
- You will take all of your medicines as prescribed.
- You will get another paracentesis (drainage of the fluid in
your belly) in the next few weeks.
- You will see a liver doctor in the office here at ___.
- You will need to start seeing a primary care doctor. You can
do that at the ___ in ___.
Followup Instructions:
___
|
10783706-DS-4
| 10,783,706 | 24,570,151 |
DS
| 4 |
2172-07-10 00:00:00
|
2172-07-10 14:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Penicillins
Attending: ___.
Chief Complaint:
jaundice
Major Surgical or Invasive Procedure:
ERCP with removal of multiple stones and pus
History of Present Illness:
___ w/Afib, biliary adenocarcinoma with prior stent presents
with jaundice. Pt reports sx started 1 week ago with malaise,
then yesterday developed dark urine, pruritis and jaundice.
Denies nausea or abd pain. She started taking Cipro at home for
the last week, which has helped in the past when she developed
jaundice, but no relief this time. She presented to ___ this
evening and was found to be in atrial fibrillation with RVR to
140s. She was given Lopressor 2.5 mg x 2 with improvement in HR
to 100s. She received Cipro/Flagyl and was transferred to ___
when bili was found to be 9.
In ED pt given Toprol 25mg, 2.5mg IV metoprolol, 1Lns. ERCP
notified.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
HTN
Afib
cellophane maculopathy
cataracts
ADENOCARCINOMA BILIARY
jaundice ___ - ercp showing extrinsic mass, stent and some
improvement. Brushings and bx negative for malignancy. ercp and
CT x 2 - neg for clear malignancy; ___ - pt opted to stop
monitoring given overall health wishes ; ___ recurrence of
cholangitis-adenocarcinoma found on cytology
Social History:
She lives in a house by herself. She cleans her own house. She
never married. She does not have any children. She and her
brother were never close and she is not very close to her nieces
and nephews. She has many friends but she also helps them. She
is retired ___. She was a social smoker < 1 pk per week and
she quit in her ___.
ETOH: [] No [+] Yes- very rarely
Drugs: none
Lives: [X] Alone [] w/ family [ ] Other:
>65
ADLS:
Independent of ADLS: [ X]dressing [ X]ambulating [ X]hygiene [
X]eating [ X]toileting
She walks with poles when she goes hiking but otherwise walks
independently.
IADLS:
Independent of IADLS: [ X]shopping [ X] accounting [ x]telephone
use [ X]food preparation. She cleans her own house.
At baseline walks: [X ]independently [ ] with a cane [
]wutwalker
[ ]wheelchair at ___
H/o fall within past year: []Y [X]N- last fell ___ years ago.
Visual aides [ ]Y [X]N
Dentures [ ]Y [X ]N
Family History:
Her father died of an MI at age ___. He was a smoker. Her mother
died at ___ of PNA/dementia but also had heart disease.
Her cousin died of liver cancer.
Physical Exam:
Vitals: T:97.7 BP:122/86 P:123 R:18 O2:97%ra
PAIN: 0
General: nad
EYES: anicteric
Lungs: clear
CV: irreg irreg no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Pertinent Results:
___ 05:25PM GLUCOSE-76 UREA N-25* CREAT-1.1 SODIUM-139
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-18* ANION GAP-21*
___ 05:51PM LACTATE-1.7
___ 05:25PM ALT(SGPT)-127* AST(SGOT)-110* ALK PHOS-388*
TOT BILI-10.1*
___ 05:25PM LIPASE-57
___ 05:25PM ALBUMIN-4.2
___ 05:25PM WBC-6.6 RBC-4.74 HGB-14.7 HCT-45.0 MCV-95
MCH-31.0 MCHC-32.7 RDW-16.3* RDWSD-56.6*
___ 05:25PM NEUTS-66.0 ___ MONOS-10.2 EOS-0.9*
BASOS-0.5 IM ___ AbsNeut-4.34 AbsLymp-1.39 AbsMono-0.67
AbsEos-0.06 AbsBaso-0.03
___ 05:25PM PLT COUNT-266
___ 05:25PM ___ PTT-40.9* ___
RUQ US IMPRESSION
1. Findings consistent with patient's known biliary system and
carcinoma including large hepatic mass with intrahepatic biliary
ductal dilatation. For better comparison with recent MRI, CT or
MRI can be considered if clinically warranted.
2. Common bile duct stent in place, which appears to contain
echogenic debris within.
ERCP ___:
Impression: The scout film showed evidence of the previously
placed metal biliary stent.
Evidence of a previous sphincterotomy was noted in the major
papilla.
Cannulation of the biliary duct was successful and deep with a
balloon using a free-hand technique.
Contrast medium was injected resulting in opacification.
The biliary tree was swept with a balloon starting at the top
of the metal stent.
A large amount of pus, sludge and one stone were removed. The
CBD and CHD were swept repeatedly until no further stones,
sludge or pus were seen.
The intrahepatics were filled, but great care was taken to
minimize the amount of contrast injected. The right system
appeared patent. A mild stricture involving the left hepatic
duct was noted.
A ___ Fr x 5 cm double pigtail was placed successfully into the
left system.
Excellent bile and contrast drainage was seen endoscopically
and fluoroscopically.
Otherwise normal ercp to third part of the duodenum
Day of Discharge Labs:
___: WBC-6.6 RBC-4.22 Hgb-13.1 Hct-40.1 Plt ___
Glucose-59* UreaN-26* Creat-1.1 Na-140 K-4.5 Cl-108 HCO3-22
AnGap-15
LFTs during hospitalization:
___ 05:25PM BLOOD ALT-127* AST-110* AlkPhos-388*
TotBili-10.1*
___ 06:58AM BLOOD ALT-94* AST-76* AlkPhos-323* TotBili-9.4*
___ 07:05AM BLOOD ALT-72* AST-60* AlkPhos-283* TotBili-8.9*
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ w/Afib, biliary adenocarcinoma with
prior stenting presented with jaundice and malaise.
# Biliary Obstruction with cholangitis: ___ adenocarcinoma and
occluded stent. S/p ERCP on ___ with removal of multiple
gallstones and pus. She tolerated the procedure well without
immediate complications. She was continued on ciprofloxacin.
LFTs trending slowly down as of the day of discharge, ERCP team
OK with her going home, recommended checking LFTs in 2 weeks to
confirm that they have normalized. She will need to follow-up
in clinic with Dr. ___ in ___ months for evaluation and
removal of plastic stent placed during this admission.
# Afib with rapid ventricular rate without evidence of
decompensated cardiac function: Xarelto was briefly held for her
procedure (x2 days). Her HR was elevated in the 110s-120s and
remained so despite resolution of her cholangitis with stenting.
Discussed her case with her primary cardiologist, Dr. ___,
on ___. He initially recommended ___ with possible
cardioversion on ___, but due to scheduling limitations this
was not feasible. Instead, EP fellow, Dr. ___, arranged
for ___ with possible cardioversion to be performed at ___
___ (closer to patient's home) on ___, and
communicated this with Dr. ___. Patient is to be called this
weekend with final details re: schedule. She was advised to
remain NPO after midnight on ___ night and to continue taking
her Xarelto (to be restarted tonight, ___. Her dose of Toprol
XL was increased to 50 mg QHS from 25 mg QHS. Her home dose of
amiodarone was continued at 200 mg PO QHS.
# HTN: continued home lisinopril
# Code status: DNR/DNI
# CONTACT: HCP, ___
___ than 30 minutes were spent on patient evaluation and
discharge planning today.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO QPM
2. Ciprofloxacin HCl 500 mg PO Q12H prn jaundice
3. Vitamin D 800 UNIT PO DAILY
4. Lisinopril 7.5 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO QPM
6. Rivaroxaban 15 mg PO QPM
Discharge Medications:
1. Amiodarone 200 mg PO QPM
2. Lisinopril 7.5 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO QPM
4. Rivaroxaban 15 mg PO QPM
5. Vitamin D 800 UNIT PO DAILY
6. Ciprofloxacin HCl 500 mg PO Q12H prn jaundice
7. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
Take for 3 ___ days, then stop.
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Biliary obstruction
Cholangitis
Biliary adenocarcinoma
Atrial fibrillation with RVR
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Abd: soft, nontender, BS+, tolerating normal diet without
symptoms
Cards: normal BP, HR 110s-120s, irregularly irregular, no m/r/g,
2+ pulses in upper and lower extremities bilaterally, no JVD, no
___ edema
Lungs: CTAB, no increased WOB or accessory muscle use
Neuro: AAOx4, moving all four extremities
Discharge Instructions:
You were admitted for jaundice to undergo an ERCP procedure.
You had an ERCP on ___ with removal of multiple gallstones and
pus. You were started on antibiotics for a possible bile duct
infection.
1) Atrial fibrillation:
- Restart your Xarelto tonight.
- Take Toprol XL (metoprolol succinate) 50 mg by mouth every
night
- Follow-up at ___ on ___, for
possible cardioversion
- You will be called by the Cardiology team at ___ this
weekend to make specific arrangements
- You also have an appointment scheduled with Dr. ___ as
described below:
Department: CARDIOVASCULAR ___
When: ___ at 3:20 ___
With: ___
Building: ___
Campus: ___ Best Parking: ___
2) Jaundice
- You should take ciprofloxacin 500 mg twice daily for 3 ___
days.
- You will need to have your liver function checked in 2 weeks,
with the results sent to your primary care physician and GI
physician.
- If any abdominal pain, fever, jaundice, gastrointestinal
bleeding please call ERCP fellow on call ___.
- You will require a repeat ERCP with removal of plastic stent
and reevaluation in ___.
Followup Instructions:
___
|
10783916-DS-14
| 10,783,916 | 28,017,219 |
DS
| 14 |
2136-05-26 00:00:00
|
2136-05-28 20:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache and double vision
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o male who was transferred from an outside hospital after a
CT at the outside hospital revealed a large super sellar mass.
Patient was at a ___ facility for detoxing from opioids and
Heroin. He developed a sudden onset, sharp, left temporal
headache 4 days ago, which was ___ and unresponsive to pain
medication. Accompanied by nausea, vomiting, abdominal pain.
Head CT revealed a large super sellar mass. He was transferred
here for further evaluation.
He complaints of diplopia, photophobia and left eye drop for a
week. He also noticed poor nocturnal vision which caused him
difficulty driving at night a week ago. He states he has little
libido for almost ___ years, and seldom has morning erection. His
noticed his has had less body hair in the last ___ years. In
terms of his energy level, he states since he was ___ years old,
his energy level is only half of what he had at age of ___. He
has chronic constipation. His body weight has been stable. On
specific questioning, he denies any swelling, heat or cold
intolerance, any change in size of his shoes or wedding ring,
dysphagia, voice changes, or galactorrhea.
As per his wife, he has had some personality changes and bizarre
behavior in the past year to the point where he has committed
some minor robberies that are out of character for him. He
states he is feeling confused sometimes, losses his train of
thought easily.
Past Medical History:
PMH: Anemia, Depression, Herniated disc, Inguinal hernia repair,
polysubstance abuse
PSH: L inguinal hernia repair, T&A, L ankle arthroplasty,
vasectomy
Social History:
___
Family History:
brother has intracranial aneurysm and testicular cancer. Father
has prostate cancer. Mother had DM who was expired at age of ___.
Denies pituitary or thyroid disorder.
Physical Exam:
PHYSICAL EXAM:
T:98.3 BP:144 /83 HR:58 R16 O2Sats 97 RA
Gen: WD/WN, comfortable, NAD.
HEENT:
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: A&O x 3, lethargic, losses train of thought
easily.
Orientation: Oriented to person, place, and date.
Recall: poor
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Left pupil 4mm midpoint and nonreactive, right 3mm reactive
Difficult to assess visual fields due to ptosis of left eye and
pt's blurry vision
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII:Left ptosis. Remainder of facial strength and sensation
intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
ON DISCHARGE:
PHYSICAL EXAM:
Vital signs stable, afebrile
Gen: WD/WN, comfortable, NAD.
HEENT: Ptosis of L eye resolved
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: A&O x 3, lethargic, losses train of thought
easily.
Orientation: Oriented to person, place, and date.
Recall: poor
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Visual field testing demonstrates a R sided field deficit
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII:Left ptosis. Remainder of facial strength and sensation
intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
MR HEAD W & W/O CONTRAST ___
Large lobulated mass lesion, involving the clivus, sella,
suprasellar region and extending into the left side of the
middle cranial fossa, as described above. A hemorrhagic
component with subacute blood products is
noted in the left-sided component of the lesion. There is edema
in the medial left temporal lobe. Encasement of the cavernous
carotid segments on both sides without luminal thrombosis. Mass
seen to extend into the cavernous sinuses on both sides. Lesion
in proximity to the basilar artery without clear plane of
separation on some images. Mass effect on the optic chiasm.
Infundibulum not seen separately.
Possibilities include an aggressive pituitary macroadenoma,
meningioma or a clival chondrosarcoma, lymphoma, mets,
plasmacytoma, etc; accurate
characterization of the origin of the lesion is limited given
the size.
However, very high prolactin levels per the endocrinology team
favor an
invasive macro-adenoma.
CTA HEAD/NECK ___
Non contrast head CT: 5.5 x 4 cm predominantly hyperdense sellar
mass with adjacent bony destruction eroding into the sphenoid
sinuses and superior nasopharynx.
CT angiogram: This mass surrounds the left common carotid
artery, which appears widely patent; the right common carotid
artery courses along the periphery of this mass and demonstrates
wall irregularity, concerning for invasion. All major
intracranial vasculature appears patent, owever the right A1
segment of the anterior cerebral artery is thin and wispy. A
prominent artery arising from the right middle cerebral artery
irculation and coursing along the right temporofrontal convexity
may course directly into the superior sagittal sinus, suggestive
of arteriovenous communication.
CT HEAD W/O CONTRAST ___
No significant change in large central skull base mass centered
in the sella with destruction of adjacent structures.
Brief Hospital Course:
Mr. ___ was admitted to the neurosurgery service on ___
___nd MRI showed a large sellar mass. The patient was
seen in the emergency room and seen to have a Left CN III palsy
and was admitted to the neurosurgical intensive care unit.
A CTA was performed and endocrine was consulted for the
pituitary mass. Patient was started on levothyroxine and
cabergoline. The patient was deemed stable enough in the
evening of ___ for transfer to the neurosurgical stepdown unit
___- Patient was seen to have improving exam, no longer had
paradoxical L pupil and was now appropriately reactive. Patient
still have L eye ptosis and was complaining of blurry and double
vision. A neuro-ophtho consult was requested for visual field
testing.
___ - pt reported a ___ headache, there was concern for
hemorrhage, and thus a head CT was performed. There was no
change in the CT findings compared to the previous imaging
study.
___ - Pt was initiated on a steroid taper. Neuro-ophthomology
visual field testing was performed which showed a Right-upper
field hemianopsia. Chronic pain service was consulted for
management of pain medications, and their recommendations were
followed.
___ - Pt continued to improve. Tolerated Cabergoline full dose
again. Pain controlled on CPS's recs. Made ready for discharge
with close follow up by endorine, neurosurgery,
neuro-ophthamology and a new PCP.
Medications on Admission:
Cymbalta 60' xanax 1'''
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Tizanidine 2 mg PO TID
RX *tizanidine 2 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD DAILY
RX *lidocaine 5 % (700 mg/patch) Apply to painful area once a
day Disp #*30 Transdermal Patch Refills:*0
4. Senna 1 TAB PO BID
5. Levothyroxine Sodium 50 mcg PO DAILY
RX *levothyroxine [Levothroid] 50 mcg 1 tablet(s) by mouth Daily
Disp #*30 Tablet Refills:*0
6. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
7. Gabapentin 100 mg PO TID
RX *gabapentin 100 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
8. Duloxetine 60 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. DiphenhydrAMINE ___ mg PO QHS:PRN insomnia
11. CloniDINE 0.1 mg PO TID
RX *clonidine 0.1 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
12. cabergoline *NF* 1.0 mg Oral ___ Reason
for Ordering: treatment of prolactinoma
RX *cabergoline 0.5 mg 2 tablet(s) by mouth ___,
___ Disp #*24 Tablet Refills:*0
13. ALPRAZolam 1 mg PO TID:PRN anxiety
14. Bisacodyl 10 mg PO/PR DAILY
15. Dexamethasone 2 mg PO AS INSTRUCTED
Tapered dose 4 tabs 3 times a day, then 3 tabs 3 times a day,
then 2 tabs 2 times a day then 1 tab twice a day until seen by
physician
___ *dexamethasone 2 mg As instructed tablet(s) by mouth As
instructed Disp #*60 Tablet Refills:*0
16. Famotidine 20 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Pituitary Tumor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace) &
Senna
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Follow-Up Appointment Instructions
Please return to the office in ___ days. This appointment can
be made with the Physician ___ or Nurse Practitioner.
Please make this appointment by calling ___. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
You will need to see Neuro-ophthamology to have your vision
re-evaluated. They will call you with an appointment.
You will need to follow up with endocrinology with Dr.
___. You should hear from the office in a few days with
an appointment. If you do not hear from them by early next
week, please call at ___
The Brain Tumor Clinic is located on the ___ of ___,
in the ___ Building, ___ floor. Their phone number is
___. Please call if you need to change your
appointment, or require additional directions.
You will need an MRI of the brain with/ or without gadolinium
contrast. If you are required to have a MRI, you may also
require a blood test to measure your BUN and Cr within 30 days
of your MRI. This can be measured by your PCP, however please
make sure to have these results with you, when you come in for
your appointment.
Followup Instructions:
___
|
10783934-DS-21
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| 21 |
2124-04-28 00:00:00
|
2124-04-30 17:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / shellfish derived
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH LVH/SVT s/p ablation x2 who presents with syncope
on day of admission. He was at work this evening and felt
palpitations, then felt the room spinning, and then lost
consciousness. He did hit the back of his head, denies any bowel
or bladder incontinence or tongue biting. No jerking or
seizure-like activity reported by onlookers. He has only
syncopized once previously, many years ago. He does, however
report a long history of palpitations for which he has been
followed for many years now. During the interview he reports
still feeling "foggy", nauseous and lightheaded after LOC but
describes monitoring over years where he was initially told he
had HCM and was maintained on cardizem from ___ and
discontinued due to leg cramping. He was later told by a
different cardiologist that he has "SVT" and ablation was
attempted in ___ and ___. ECHO done years ago is reported by
the patient to have LVH and "something wrong with his
pressures". PPM has been recommended to him on multiple
occasions, but he reports being scared to do it. He does not
recall when he last saw his cardiologist, but saw his PCP last
month for the first time and was started on paxil.
He reports maternal side with multiple family members dying at
young age due to various heart problems, arrythmias and "valve
issues". He has many family members with ___. He reports
increases in palpitations when he bends over, exerts himself,
and often experiences tingling in hands and feet when he has
these episodes.
In the ED, initial vitals were 0 98.0 98 142/89 99% RA. Upon
arrival to the ED he was reportedly weak, lightheaded, nauseous.
He reported occasional palpitations that corresponded with PVCs
on monitor. He received IVF and labs essentially normal except
for bicarb 34. EP was alerted in the ED. Attempts to retrieve
records from ___, where patient has received his
medical care, were made, however hospital is without EMR and
they will be unable to access medical records warehouse over the
weekend such that cardiology and ablation reports are
unavailable.
Upon transfer, vitals were 97.8 89 133/90 18 100% RA.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes -, Dyslipidemia -,
Hypertension -
2. CARDIAC HISTORY:
- SVT s/p ablation x2, adenosine
3. OTHER PAST MEDICAL HISTORY:
- anxiety
- MVA with SDH and subsequent anisocoria
Social History:
___
Family History:
Significant maternal family history of arrythmias, sudden
cardiac death, valvular disease. Paternal history of CHF.
Physical Exam:
Admission exam:
VS: T= 97.7 BP=147/102 HR= 60 RR= 20 O2 sat= 100%RA
General: young male in NAD, speaking full sentences, somewhat
anxious appearing, pleasant, answers questions appropriately
HEENT: pupils anisocoric (baseline), MMM, OP clear, small mildly
tender swelling on right occiput c/w history of trauma without
ecchymosis or drainage
Neck: soft, supples, JVD at
CV: RRR, S1, S2, S4 gallop, no murmurs or rubs
Lungs: CTAB, no wheezes, rales, or rhonchi, good air movement
Abdomen: soft, NT, ND, BS+
GU: no foley
Ext: warm, well-perfused, no cyanosis, clubbing, or edema
Neuro: AxOx3, CN2-12 intact, strength ___ throughout, sensation
intact to light touch throught, reflexes symmetric 2+ throughout
Skin: warm, capillary refill <2s
PULSES: 2+ radial and DP, ___
Discharge exam:
VS: 98.0 | 112/66 | 57 | 18 | 99%RA
Telemetry- Avg HR ___, though did have two episodes of sinus
brady to ___
GENERAL: AA OX3 NAD, breathing comfortably
HEENT: NCAT. PERRLA, EOMI, MMM. Sclera anicteric, no
conjunctival pallor. OP clear, trachea midline, no thyromegaly
or cervical LAD.
NECK: Supple, with JVP flat without evidence of HJR. Carotids
benign bilaterally.
CARDIAC: S1/S2 without MGR. PMI non-enlarged, non-displaced. No
parasternal or subxiphoid heaves, precordial thrills, or
palpable pulsations in the 3LICS.
LUNGS: Lungs CTAPB without WRR. Resp unlabored, no accessory
muscle use.
ABDOMEN: Soft, NT, ND. BS + X4, No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominal bruits.
EXTREMITIES: No CCE or edema. No femoral bruits. L femoral
access site unremarkable.
SKIN: No concerning lesions.
Pertinent Results:
Admission labs:
___ 04:01PM BLOOD WBC-5.8 RBC-4.43* Hgb-14.3 Hct-40.3
MCV-91 MCH-32.3* MCHC-35.5* RDW-12.4 Plt ___
___ 04:01PM BLOOD Glucose-93 UreaN-10 Creat-0.8 Na-144
K-3.9 Cl-102 HCO3-34* AnGap-12
___ 04:01PM BLOOD Calcium-9.7 Phos-3.1 Mg-2.1
___ 06:10AM BLOOD TSH-1.5
Discharge labs:
___ 06:05AM BLOOD WBC-5.3 RBC-4.32* Hgb-13.8* Hct-39.6*
MCV-92 MCH-32.1* MCHC-35.0 RDW-12.4 Plt ___
___ 06:05AM BLOOD Glucose-94 UreaN-9 Creat-0.9 Na-140 K-4.1
Cl-102 HCO3-30 AnGap-12
___ 06:05AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.1
Pertinent studies:
TTE:
The left atrial volume is normal. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Quantitative (biplane) LVEF = 67 %. Transmitral
and tissue Doppler imaging suggests normal diastolic function,
and a normal left ventricular filling pressure (PCWP<12mmHg).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
NCHCT: no acute intracranial process
Brief Hospital Course:
Mr. ___ is a ___ with history of recurrent syncopal episodes
who presents with syncope. He reports that he has LVH and a
history of SVT which has been ablated. He says that multiple
family members have had arrythmias and required pacemakers and
has been told that he needs a pacemaker. Mr. ___ was admitted
to ___ for observation. He was noted to be in NSR on tele
throughout his 2 day stay. He went into asymptomatic sinus
bradycardia to the high ___ at night but otherwise no
arrythmias on tele. EKG and echocardiogram were completely
normal. We contacted his cardiologist, who reports that he has
NOT had an ablation. He has had EP studies in the past for this
problem but they have not found any arrhythmias to ablate. Per
his description of the syncopal event, it appears that his
episodes are most likely vasovagal syncope. He was started on
midodrine 2.5mg BID to improve peripheral alpha constriction. He
will follow up with Dr. ___ attending physician ___ 6
weeks for uptitration of midodrine as needed.
Of note, pt reported head injury with fall. His NCHCT was
negative for acute process.
Transitional issues:
-uptitrate midodrine to improve vasovagal episodes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Paroxetine 20 mg PO DAILY
2. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
Discharge Medications:
1. Paroxetine 20 mg PO DAILY
2. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
3. Midodrine 2.5 mg PO BID
RX *midodrine 2.5 mg 1 tablet(s) by mouth Twice daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Neurocardiogenic syncope
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 fainted. This
episode was likely due to a malfunction of the system in your
body that maintains normal blood pressure on standing. We
started a medicine called midodrine that should help with this.
You can also purchase support house that help the blood in your
veins get back to your heart.
Followup Instructions:
___
|
10784239-DS-11
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| 11 |
2147-05-27 00:00:00
|
2147-05-29 11:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Demerol / Penicillins / Amoxicillin / Sulfa (Sulfonamide
Antibiotics) / fentanyl
Attending: ___.
Chief Complaint:
nausea, emesis, epigastric pain
Major Surgical or Invasive Procedure:
endoscopy with polypectomy
History of Present Illness:
___ with history of invasive breasat ductal carcinoma (ER/PR
positive, HER-2/neu negative, on Taxotere/cytoxan every 3 wks)
s/p partial mastectomy with left axillary sentinel lymph node
biopsy and GERD and chronic dyspepsia, p/w nausea, vomiting and
epigastric pain for 5 days.
.
Pt is s/p a cycle of taxotere/cytoxan last week, followed by
neulasta/dexamethasone on ___. Pt endorses nausea w/
epigastric abdominal pain, ___ at its worse, non-radiating,
associated w/ reflux, minimally relieved w/ tums. Pt reports
chronic nausea and dyspepsia related to chemo/neulasta, that
usually improves on its own, though this episode has been
persistent. She reports poor PO intake, w/ non-biliary,
non-bloody emesis with. She had a brief episode of CP lasted
5min over the weekend, while moving dryer, non-radiating and
self-limited. Otherwise, no f, diarrhea, melena. Has chronic
constipation, occasional chills.
.
In the ED, initial vitals: T 96.9, HR 99, BP 126/69, RR 18, O2
99% RA. Labs: wbc 22.3 (pmn 79%), lactate 2.9, bun/cr ___, UA
neg nitr/leuk, alt 51, ast 33, ap 127. Meds given: dilaudid 1mg
iv x1, zofran 4mg iv x1, reglan 10mg iv x1, morphine 5mg iv x1,
ativan 2mg x1.
Vitals prior to transfer: T 99, HR 90, RR 18, BP 142/73, O2 99%
RA.
.
Currently, pain is ___, continues to have nausea.
.
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[ ] Fever [x] Chills [ ] Sweats [x ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[x ] 5 lbs. weight loss over 5 days
Eyes
[x] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT [x] All Normal
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat
[] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [x] All Normal
[ ] Shortness of breath [ ] Dyspnea on exertion [ ] Can't
walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum
[ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [x] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ]
Chest Pain [ ] Dyspnea on exertion [ ] Other:
GI: [] All Normal
[ ] Nausea [] Vomiting [x] Abd pain [] Abdominal swelling [
] Diarrhea [ x] Constipation [ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [x ] Reflux
[ ] Other:
GU: [x] All Normal
[ ] Dysuria [ ] Incontinence or retention [ ] Frequency
[ ] Hematuria []Discharge []Menorrhagia
SKIN: [x] All Normal
[ ] Rash [ ] Pruritus
MS: [] All Normal
[ x] Joint pain [ ] Jt swelling [ x] Back pain [ ] Bony
pain
NEURO: [] All Normal
[x ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [x ] Dizziness/Lightheaded [
]Vertigo [ ] Headache
ENDOCRINE: [] All Normal
[ ] Skin changes [x ] Hair changes [ ] Heat or cold
intolerance [ ] loss of energy
HEME/LYMPH: [x] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
Past Medical History:
1. Breast Cancer:
She noted a mass involving her left breast in ___,
while visiting her primary care doctor. Her most recent
mammogram was performed in ___, which was reportedly normal.
The patient underwent bilateral breast mammogram on ___ at ___, which revealed heterogeneously dense breast
parenchyma, a 1.3 cm irregular mass was seen in the lateral
aspect of the left breast. Same day ultrasound described this
mass as being solid and irregular, without any associated
microcalcifications. Right breast was remarkable for 1.6 cm oval
isodense nodule without any discrete margins, consistent with a
hamartoma or fibroadenoma. There were no abnormal-appearing
lymph nodes involving the left axilla. Ultrasound-guided core
needle biopsy was performed of the left breast mass at the 1
o'clock position. This revealed an 8-mm grade 2 invasive ductal
carcinoma, ER/PR positive, HER-2/neu negative with a ratio of
1.0 on FISH. Current treatment: Taxotere/cytoxan every 3 wks
with neulasta on d2 -> radiation.
Status post left breast wire-localized partial mastectomy with
left axillary sentinel lymph node biopsy performed on ___
2. Obesity
3. Urinary stress incontinence
4. Right shoulder pain secondary to injury, for which physical
therapy has allowed resolution of symptoms
5. Gastritis
6. GERD
7. Depression
8. Anxiety
9. Constipation
10. Cervical polyp
11. History of atypical chest pain, which has been evaluated by
her primary care physician. The patient reports that she had an
EKG performed recently, which was negative. However, we do not
have this report for our review available at this time. She
reports that likely these chest pains are due to anxiety or
reflux.
12. Diminished hearing in the left ear
13. Osteomyelitis of the right foot, for which IV vancomycin
was needed many years ago following stepping on a sewing needle.
14. Mononucleosis
Social History:
___
Family History:
1. She has distant family members on both sides with breast
cancer.
2. No relatives with ovarian cancer.
3. Mom with bipolar disorder.
4. Father died at ___ from renal cell carcinoma, also had basal
cell carcinoma.
5. Paternal grandmother with basal cell carcinoma.
Physical Exam:
VS - Temp 97.5F, BP 143/77, HR 92, R 19, O2-sat 98% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - soft/ND, no masses or HSM, and no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII intact, muscle strength ___
throughout, nl fnf
Pertinent Results:
.
MICRO:
HELICOBACTER PYLORI ANTIBODY TEST (___): NEGATIVE BY EIA.
.
IMAGING:
Abdominal US: ___
IMPRESSION: Unremarkable abdominal ultrasound.
EGD: ___
Esophagus: Normal
Stomach: Normal mucosa (bx wnl)
Duodenum: Normal duodenum
___: ___
Grade 1 internal & external hemorrhoids
Otherwise normal colonoscopy to cecum and terminal ileum
.
___ 12:00PM BLOOD WBC-43.4* RBC-4.12* Hgb-11.5* Hct-34.3*
MCV-83 MCH-27.9 MCHC-33.5 RDW-16.6* Plt ___
___ 09:15AM BLOOD WBC-UNABLE TO RBC-UNABLE TO Hgb-UNABLE
TO Hct-UNABLE TO MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO
RDW-UNABLE TO Plt Ct-UNABLE TO
___ 08:30AM BLOOD WBC-34.4*# RBC-4.50 Hgb-12.3 Hct-37.8
MCV-84 MCH-27.3 MCHC-32.5 RDW-16.0* Plt ___
___ 03:00PM BLOOD WBC-22.3*# RBC-4.97 Hgb-13.6 Hct-40.6
MCV-82 MCH-27.4 MCHC-33.5 RDW-15.9* Plt ___
___ 12:00PM BLOOD Neuts-PND Lymphs-PND Monos-PND Eos-PND
Baso-PND
___ 08:30AM BLOOD Neuts-40* Bands-26* Lymphs-8* Monos-4
Eos-1 Baso-0 Atyps-1* Metas-11* Myelos-6* Promyel-3* NRBC-1*
___ 03:00PM BLOOD Neuts-79* Bands-0 Lymphs-8* Monos-4 Eos-0
Baso-0 ___ Metas-2* Myelos-7*
___ 12:00PM BLOOD I-HOS-DONE
___ 08:30AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-1+
___ 09:15AM BLOOD Glucose-95 UreaN-4* Creat-0.9 Na-137
K-4.8 Cl-103 HCO3-19* AnGap-20
___ 03:00PM BLOOD ALT-51* AST-33 AlkPhos-127* TotBili-0.5
___ 01:04PM BLOOD Lactate-1.1
___ 03:09PM BLOOD Lactate-2.9*
.
___ CXR:
IMPRESSION: Bibasilar right-greater-than-left atelectasis.
Early right
cardiophrenic angle infiltrate cannot be entirely excluded.
.
___ KUB:
IMPRESSION:
No evidence of ileus or obstruction. Scattered stool seen
through the colon.
.
Microbiology: blood, urine, c.diff=negative
.
EGD ___:
ession: Normal mucosa in the esophagus
Streaks of erythema in the antrum compatible with gastritis
(biopsy)
Polyps in the fundus and body (biopsy)
Normal mucosa in the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations: Continue BID PPI, anti-emetics. Add Carafate
for symptomatic control
Additional notes: The attending was present for the entire
procedure. The patient's home medication list is appended to
this report. FINAL DIAGNOSES are listed in the impression
section above. Estimated blood loss = zero. Specimens were taken
for pathology as listed above
Brief Hospital Course:
ASSESSMENT & PLAN: ___ with history of invasive breasat ductal
carcinoma (ER/PR positive, HER-2/neu negative, on
Taxotere/cytoxan every 3 wks) s/p partial mastectomy with left
axillary sentinel lymph node biopsy, GERD, and gastritis p/w
nausea, vomiting and epigastric pain for 5 days.
.
#. Nausea, vomiting, abdominal pain: Pt w/ chronic dyspepsia and
GERD. LFTs wnl, abdominal exam benign. Prior EGD ___
unremarkable and ___ ___ notable for grade 1 int/ext
hemorrhoids. Serum Hpylori ab test neg in ___. No sign of
acute abdomen during admission. However, pt did have a
significant leukocytosis with elevated lactate. KUB/CXR not
revealing. Ddx included PUD, gastritis, esophagitis. She was
treated symptomatically with standing zofran, PO compazine, IV
ativan, PO prn zyprexa, with monitoring of her QTC as well as
BID IV PPI. Stools were ordered for guaiac and she was offered a
GI cocktail. GI was consulted and EGD was performed on ___
revealing gastritis and benign appearing gastric polyps that
were sent for biopsy. Results are still PENDING at the time of
discharge.
Final regimen includes omeprazole 40mg BID x21 days, sulcralfate
1gm QID x21 days. Pt may then resume her regular PPI dosing
after this time.
.
#. Leukocytosis: Pt with a significant leukocytosis during
admission. She remained afebrile with negative, blood, urine,
and stool cultures. CXR and KUB were not suggestive of infection
or obstruction. She reported dysuria x1 and UCX x3 was
contaminated. Therefore, she was treated for a UTI with 3 days
of cipro with good effect. The oncology service followed along
with the patient and evaluated her peripheral blood smear. The
oncology service also felt that pt's marked leukocytosis was a
reaction to her dexamethasone and neulasta taken prior to
admission. Her leukocytosis improved on the day of DC.
.
#dysuria/urinary tract infection-Serial Ucx with contaminated
flora. Pt with dysuria that resolved with 3 days of cipro
therapy.
.
#. Invasive breasat ductal carcinoma: Oncology followed the
patient during admission. She will follow up upon discharge. She
was given pain medication and anti-emetic therapy.
. .
FEN: regular diet
.
DVT PPx: hep SC TID
.
Lines: PIV
.
CODE: FULL
Medications on Admission:
-lorazepam 0.5 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for insomnia/anxiety.
-omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
-Dilaudid 2 mg Tablet Sig: ___ Tablets PO every four (4) hours
as needed for pain.
-Zofran 8 mg Tablet Sig: One (1) Tablet PO twice a day as needed
for nausea.
-prochlorperazine maleate 5 mg Tablet Sig: ___ Tablets PO every
six (6) hours as needed for nausea.
-nystatin 100,000 unit/mL Suspension Sig: One (1) dose PO four
times a day as needed for thrush.
-chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) mL
Mucous membrane twice a day as needed for mouth sores.
Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
-polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1)
Powder in Packet PO DAILY (Daily) as needed for constipation.
-promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for nausea.
Discharge Medications:
1. Ativan 0.5 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for nausea.
2. Dilaudid 2 mg Tablet Sig: ___ Tablets PO every four (4) hours
as needed for pain.
3. Zofran 8 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for nausea.
4. prochlorperazine maleate 5 mg Tablet Sig: ___ Tablets PO
every six (6) hours as needed for nausea.
5. nystatin 100,000 unit/mL Suspension Sig: One (1) PO once a
day as needed for thrush.
6. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for c.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. promethazine 25 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for nausea.
9. sucralfate 1 gram tablet Sig: One (1) tablet PO QID (4 times
a day) for 20 days.
Disp:*80 tablet(s)* Refills:*0*
10. omeprazole 40 mg capsule,delayed ___ Sig: One (1)
capsule,delayed ___ PO twice a day for 20 days.
Disp:*40 capsule,delayed ___ Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
breast cancer
gastritis-epigastric pain with nausea and vomiting
leukocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with nausea, vomiting, and abdominal pain
after your most recent cycle of chemotherapy. For this, you were
treated with IV fluids and medications for pain and nausea and
your symptoms improved. You underwent an endoscopy that showed
gastritis and polyps. You had a biopsy taken of the polyps that
is still PENDING at the time of discharge. In addition, you were
found to have an very elevated white blood cell count that was
thought to be due to your neulasta injection. This improved
during admission.
.
Medication changes:
1. Increase omeprazole to 40mg twice a day for 21 days
2. start sulcralfate 1gm 4 times a day for 21 days
3. Continue clotrimazole trouches for 7 more days
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
___
|
10784345-DS-11
| 10,784,345 | 20,890,047 |
DS
| 11 |
2155-05-05 00:00:00
|
2155-05-06 08:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Bactrim / Dapsone / clindamycin / Sulfa (Sulfonamide
Antibiotics)
Attending: ___.
Chief Complaint:
High-grade SBO
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ year old female with history of HIV on ARVs,
HCV, prior SBOs, presenting with one day of crampy diffuse
abdominal pain, nausea, vomiting. Last night, the pain came on
fairly suddenly, mostly on the right side of her abdomen, where
she has previously had pain for an SBOs in the past. The pain
then progressed to fairly diffuse. Since she has previously had
SBO's that would last only a few hours at a time sometimes not
requiring hospitalization, she thought she might be able to
sleep it off. However, this morning, she developed nausea and
vomited. Since the pain began, she has had 2 bowel movements,
yesterday and this morning. Both were soft, nonbloody. Has not
passed gas since yesterday. No hematemesis. No fevers, chills,
sweats,
chest pain, trouble breathing. Has never had surgery for any of
her SBOs. These all started when she was young after she had a
neuroblastoma removed from her abdomen, and then a few years
later developed appendicitis requiring exploratory laparotomy.
Her last SBO requiring hospitalization was about ___ years ago.
Had a colonoscopy 7 or ___ years ago after a GI physician
___ 1 given her recurrent SBOs, reportedly it was
normal.
Past Medical History:
Past Medical History:
Anemia, Allergies, Hypertension, heart murmur, neuroblastoma,
hepatitis C, kidney disease, hypothyroid, HIV ___ blood
transfusion (CD4 520; 41%; VL UD) on Triumeq, endometriosis,
nephrolithiasis, CKD, prior SBOs
Past Surgical History:
Excision of neuroblastoma ___
Appendectomy ___
CCY (per record, but pt does not recall this operation)
Social History:
___
Family History:
Mother- precancerous skin lesions
Father- HLD
___
PGF- ___, hypothyroidism
Physical Exam:
Admission Physical Exam:
Vitals: 98.1 | 77 | 153/98 | 16 | 100% RA
GEN: A&Ox3, 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: Midline scar c/w prior surgical history, soft, mildly
distended, diffusely tender to palpation, primarily L mid
abdomen, no rebound or guarding, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Neuro: non-focal
Discharge Physical Exam:
VS: T: 98.4 PO BP: 124/85 L Lying HR: 62 RR: 16 O2: 98% Ra
GEN: A+Ox3, NAD
HEENT: MMM
CV: RRR
PULM: CTA b/l
ABD: soft, mildly distended, non-tender to palpation. No rebound
or guarding
EXT: wwp, no edema b/l
Pertinent Results:
IMAGING:
___: CT Abdomen/Pelvis:
1. High-grade small bowel obstruction with fecalization of loops
of distal
small bowel adjacent to a transition point in the right mid to
lower abdomen
with a small volume of surrounding free fluid.
2. 5 cm pelvic endometrioma, increased in size compared to prior
exam.
3. Bilateral tubular cystic structures in the pelvis, likely
hydrosalpinges
which may be related to the patient's history of endometriosis.
___: KUB:
Several dilated loops of small bowel, confirmatory of the recent
CT scan. NG
tube within the stomach.
___: KUB:
Radiographic signs of ileus, although partial small bowel
obstruction cannot
be excluded. There is no radiopaque contrast seen throughout
the GI tract.
___: KUB:
Resolving small bowel obstruction.
LABS:
___ 03:16PM LACTATE-1.3
___ 10:18AM URINE UCG-NEGATIVE
___ 10:18AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:18AM URINE BLOOD-SM* NITRITE-NEG PROTEIN-100*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD*
___ 10:18AM URINE RBC-23* WBC-46* BACTERIA-FEW* YEAST-NONE
EPI-0
___ 10:18AM URINE MUCOUS-RARE*
___ 08:28AM GLUCOSE-111* UREA N-22* CREAT-1.3* SODIUM-141
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-27 ANION GAP-15
___ 08:28AM ALT(SGPT)-16 AST(SGOT)-22 ALK PHOS-83 TOT
BILI-0.5
___ 08:28AM LIPASE-21
___ 08:28AM ALBUMIN-4.8
___ 08:28AM WBC-9.9 RBC-4.25 HGB-14.1 HCT-38.1 MCV-90
MCH-33.2* MCHC-37.0 RDW-12.2 RDWSD-39.4
___ 08:28AM NEUTS-84.4* LYMPHS-8.1* MONOS-6.4 EOS-0.5*
BASOS-0.2 IM ___ AbsNeut-8.35* AbsLymp-0.80* AbsMono-0.63
AbsEos-0.05 AbsBaso-0.02
___ 08:28AM PLT COUNT-181
Brief Hospital Course:
Ms. ___ is a ___ year old female with history of HIV on ARVs,
HCV, prior SBOs all conservatively managed who presented this
admission with diffuse abdominal pain, nausea and vomiting. She
had a CT abd/pel showing a high-grade small bowel obstruction.
The patient was admitted to the Acute Care Surgery service and
was managed conservatively with NPO/IVF/NGT, ARBF. A Gastroview
contrast KUB series was performed to aid in diagnosis and
treatment of SBO.
On HD3, the patient's KUB demonstrated that the gastroview
passed into the colon, indicating resolving SBO. The patient
had multiple loose bowel movements. A c.diff was sent which was
negative. The patient's diet was advanced from clears to
regular which was well-tolerated. IVF were discontinued.
The patient was alert and oriented throughout hospitalization.
She remained stable from a cardiovascular and pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet and early ambulation were encouraged throughout
hospitalization. The patient received subcutaneous heparin and
___ dyne boots were used during this stay and was encouraged to
get up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral
DAILY
2. Levothyroxine Sodium 175 mcg PO 6X/WEEK (___)
3. olopatadine 0.1 % ophthalmic (eye) ASDIR
4. Vitamin D 1000 UNIT PO DAILY
5. FoLIC Acid 0.8 mg PO DAILY
6. Docusate Sodium 50-100 mg PO DAILY:PRN Constipation
7. ALPRAZolam 0.25 mg PO QHS:PRN insomnia
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
2. ALPRAZolam 0.25 mg PO QHS:PRN insomnia
3. Docusate Sodium 50-100 mg PO DAILY:PRN Constipation
4. FoLIC Acid 0.8 mg PO DAILY
5. Levothyroxine Sodium 175 mcg PO 6X/WEEK (___)
6. olopatadine 0.1 % ophthalmic (eye) ASDIR
7. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral
DAILY
8. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with a
small bowel obstruction. This bowel obstruction was managed
conservatively without surgery. You had a nasogastric tube
placed to help decompress your bowels and were initially
restricted from eating to promote bowel rest. You had oral
contrast and abdominal x-ray imaging taken which showed that the
contrast passed all the way through your colon, indicating that
the bowel obstruction resolved. You also had return of bowel
function, and the nasogastric tube was removed. Your diet was
gradually advanced and you are now tolerating a regular diet.
You are now ready to be discharged home.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10784356-DS-23
| 10,784,356 | 21,780,862 |
DS
| 23 |
2123-12-21 00:00:00
|
2123-12-23 14:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / latex / ACE Inhibitors
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Right and Left heart catheterization with SWAN placement
History of Present Illness:
Ms. ___ is a ___ woman with moderate-persistent
asthma, hypertension, depression, anxiety, PTSD, panic disorder
w/ agoraphobia, thalassemia trait, and recent admission for
cholecystitis s/p cholecystectomy who presented as a transfer
from ___ for new reduced LVEF of 15% and symptoms of CHF.
The patient's current symptoms began approximately two months
ago
(___) with dyspnea and mild chest pain on exertion. At
her prior baseline she was able to walk several blocks without
shortness of breath but at onset of symptoms was unable to walk
more than the length of her family room without needing to stop
and catch her breath. The episodes of dyspnea have also been
associated with substernal chest pain without radiation that
improves with rest. She has never had chest pain symptoms at
rest. She initially felt that these symptoms were related to her
asthma so she began to use her inhalers more but with little
benefit.
She was then admitted to ___ from ___ with
cholecystitis and underwent cholecystectomy. During the
hospitalization she was complaining of dyspnea for which she
underwent CTA-PE. The study was negative for PE but showed a
moderate pericardial effusion and cardiomegaly. Of note, CXR at
___ from ___ showed a normal-sized cardiac silhouette.
She later presented to her doctor at ___ with the complaint
of
persistent dyspnea and chest pain on exertion. She also began to
develop significant b/l ___ edema, orthopnea, and PND. Workup
included a chest Xray that again showed new cardiomegaly. A TTE
was performed on ___ and showed a new LVEF of 15% (prior
normal
in ___ with LV hypokinesis, moderate MR, and mild-mod TR.
Given
the findings on echo and her constellation of symptoms, she was
directed to the ___ ED for management of CHF and evaluation
for
the etiology of new cardiomyopathy.
In the ED, initial vitals: 97.8, 110, 116/74, 16, 100% RA
- Exam notable for:
Resp: diffuse crackles/wheezing, normal work of breathing
CV: Regular rate and rhythm, +SEM, 2+ distal pulses. Capillary
refill less than 2 seconds.
MSK: 2+ pitting edema bilaterally
- Labs notable for: Hgb 9.6, normal BMP, neg trop, proBNP 2186,
lactate 2.1, AST 47, Tbili 1.8, INR 1.6, flu neg.
- Imaging notable for:
CXR: Severe cardiomegaly. No gross signs for pneumonia or edema
On the floor, the patient is not experiencing chest pain or
dyspnea while resting in bed. She has been unable to lay flat
due
to dyspnea for ___ weeks and has also experienced PND during
this
time. For the past two weeks she has developed significant ___
edema making ambulation difficult. She has not had any abdominal
pain or distension. She has not experienced fevers, chills, or
night sweats but has had a dry cough intermittently during this
time. She has not had any viral-like illnesses over the past
year
that she can recall. She has not used IV drugs, consumed
alcohol,
or any illicit substances. She is not sexually active and has
tested negative for HIV in the past. She has not taken any new
medications preceding her development of dyspnea. She denies any
chest pain with exertion prior to the past 2 months. She has had
no rashes or tick bites. She has had back pain and knee
osteoarthritis but no history of autoimmune disease such as
lupus.
Past Medical History:
- moderate-persistent asthma
- hypertension
- depression, anxiety, PTSD, panic disorder w/ agoraphobia
- thalassemia trait
- s/p Hysterectomy including cervix
- Degenerative joint disease of knee s/p TKR
- Severe glaucoma in R eye
- Diverticulosis
- Chronic LBP w/ sciatica
Social History:
___
Family History:
No family history of heart disease, CAD, or
stroke. No known family history of autoimmune disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI (has
strabismus), neck supple, JVP elevated to 4cm above clavicle, no
LAD
CV: Regular rate and rhythm, distant heart sounds, +S3,
holosystolic murmur heard best at apex. PULSUS < 6mmHg
Lungs: good air movement, no wheezes, rales at bilateral bases
w/
R>L
Abdomen: Soft, obese, non-tender, non-distended, absence of
fluid
wave or shifting dullness, bowel sounds present, no
organomegaly,
no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, 2+ pitting edema from feet
to below the knee bilaterally
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
DISCHARGE PHYSICAL EXAM
=======================
General: ___ adult woman in NAD
HEENT: NCAT, sclerae anicteric, EOMI w/ strabismus
NECK: JVP ~11 at 90 degrees on right
CV: RRR, normal S1/S2, no m/r/g, distant heart sounds
Lungs: Bibasilar crackles, no increased work of breathing
Abdomen: Soft, non-tender, non-distended, normoactive BS
Ext: Warm, no edema, DP pulses 2+ bilaterally
Neuro: A&Ox3, mentating well
Pertinent Results:
ADMISSION LABS
==============
___ 08:30PM BLOOD WBC-5.9 RBC-4.69 Hgb-9.6* Hct-32.8*
MCV-70* MCH-20.5* MCHC-29.3* RDW-16.8* RDWSD-41.1 Plt ___
___ 08:30PM BLOOD Neuts-38.9 ___ Monos-6.1 Eos-6.2
Baso-0.7 NRBC-0.3* Im ___ AbsNeut-2.31 AbsLymp-2.84
AbsMono-0.36 AbsEos-0.37 AbsBaso-0.04
___ 08:30PM BLOOD ___ PTT-24.7* ___
___ 08:30PM BLOOD Plt ___
___ 08:30PM BLOOD Glucose-95 UreaN-11 Creat-0.9 Na-137
K-4.9 Cl-100 HCO3-23 AnGap-14
___ 08:30PM BLOOD ALT-25 AST-47* AlkPhos-93 TotBili-1.8*
DirBili-0.4* IndBili-1.4
___ 08:30PM BLOOD proBNP-2168*
___ 08:30PM BLOOD cTropnT-<0.01
___ 08:30PM BLOOD Albumin-3.5 Calcium-8.7 Phos-3.9 Mg-1.5*
___ 08:30PM BLOOD Lactate-2.1*
PERTINENT LABS
==============
___ 06:20AM BLOOD ___ 10:00AM BLOOD Lipase-37
___ 08:30PM BLOOD proBNP-2168*
___ 08:30PM BLOOD cTropnT-<0.01
___ 06:20AM BLOOD cTropnT-<0.01
___ 12:14AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:20AM BLOOD calTIBC-377 Ferritn-29 TRF-290
___ 06:20AM BLOOD %HbA1c-5.8 eAG-120
___ 06:20AM BLOOD Triglyc-77 HDL-18* CHOL/HD-5.4 LDLcalc-65
___ 06:01AM BLOOD Osmolal-269*
___ 02:25AM BLOOD Osmolal-264*
___ 06:20AM BLOOD TSH-0.94
___ 07:46AM BLOOD Cortsol-13.3
___ 06:30AM BLOOD Cortsol-12.2
___ 06:30AM BLOOD HCG-8
___ 08:25AM BLOOD HCG-9
___ 06:20AM BLOOD ___
___ 06:10AM BLOOD PEP-POLYCLONAL IgG-1865* IgA-363 IgM-90
___ 05:55AM BLOOD FreeKap-66.5* ___ Fr K/L-2.75*
___ 06:20AM BLOOD HIV Ab-NEG
___ 04:46AM BLOOD Digoxin-0.7
___ 05:30AM BLOOD Digoxin-0.9
___ 06:01AM BLOOD Digoxin-1.8*
___ 08:30PM BLOOD Lactate-2.1*
___ 12:39AM BLOOD Lactate-2.4*
___ 07:35AM BLOOD Lactate-1.0
___ 01:32PM BLOOD Lactate-2.5*
___ 12:18PM BLOOD Lactate-0.8 K-4.4
___ 10:44AM BLOOD K-5.8*
___ 06:19AM BLOOD K-6.2*
___ 09:27AM BLOOD K-6.0*
___ 09:27AM BLOOD K-6.0*
___ 04:50PM BLOOD Hgb-9.0* calcHCT-27 O2 Sat-74
___ 08:11AM BLOOD O2 Sat-56
___ 03:40PM BLOOD Hgb-14.4 calcHCT-43 O2 Sat-65
___ 08:47AM BLOOD O2 Sat-61
___ 04:17PM BLOOD O2 Sat-68
___ 09:00AM BLOOD O2 Sat-65
___ 06:12PM BLOOD O2 Sat-71
___ 09:19AM BLOOD O2 Sat-69
___ 04:39PM BLOOD O2 Sat-69
___ 09:00AM BLOOD O2 Sat-70
___ 12:55AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:55AM URINE Blood-TR* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.5 Leuks-NEG
___ 12:55AM URINE RBC-<1 WBC-2 Bacteri-FEW* Yeast-NONE
Epi-10
___ 12:55AM URINE CastHy-9*
___ 05:41AM URINE Hours-RANDOM UreaN-191 Creat-43 Na-27
___ 11:19AM URINE Hours-RANDOM TotProt-4
___ 05:41AM URINE Osmolal-198
___ 11:19AM URINE U-PEP-NO PROTEIN
___ 02:00PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
DISCHARGE LABS
==============
___ 07:37AM BLOOD WBC-5.4 RBC-5.49* Hgb-11.2 Hct-37.6
MCV-69* MCH-20.4* MCHC-29.8* RDW-17.2* RDWSD-40.3 Plt ___
___ 07:37AM BLOOD Plt ___
___ 07:37AM BLOOD Glucose-87 UreaN-22* Creat-0.8 Na-132*
K-5.2 Cl-95* HCO3-25 AnGap-12
___ 07:37AM BLOOD Calcium-10.2 Phos-4.4 Mg-2.0
IMAGING/REPORTS
=================
CHEST X RAY (___)
FINDINGS:
AP portable upright view of the chest. The heart is markedly
enlarged. No
focal consolidation, large effusion or pneumothorax is seen.
Evaluation is
slightly degraded due to subtle motion artifact on the single
view provided.
No large effusion or pneumothorax is seen. Mediastinal contour
is
unremarkable. Imaged bony structures are intact.
IMPRESSION:
Severe cardiomegaly. No gross signs for pneumonia or edema. If
there is
further concern, recommend repeat exam with dedicated PA and
lateral with more
optimized technique.
TTE (___)
CONCLUSION:
The left atrium is mildly dilated. The right atrium is mildly
enlarged. There is mild symmetric left ventricular hypertrophy
with a moderately increased/dilated cavity. Overall left
ventricular systolic function is severely depressed secondary to
global contractile dysfunction with regional variation as well
as direct ventricular interaction with a pressure/volume
overloaded right ventricle. The visually estimated left
ventricular ejection fraction is 15%. There is no resting left
ventricular outflow tract
gradient. Moderately dilated right ventricular cavity with
depressed free wall motion. Intrinsic right ventricular systolic
function is likely lower due to the severity of tricuspid
regurgitation. There is abnormal interventricular septal motion
c/w right ventricular pressure and volume overload. The aortic
sinus diameter is normal for gender with mildly dilated
ascending aorta. The aortic arch is mildly dilated. The aortic
valve leaflets (3) appear structurally normal. There is no
aortic valve stenosis. There is trace aortic regurgitation. The
mitral valve leaflets are mildly thickened with no mitral valve
prolapse.
There is SEVERE [4+] mitral regurgitation. The tricuspid valve
leaflets are mildly thickened. There is SEVERE [4+] tricuspid
regurgitation. There is moderate pulmonary artery systolic
hypertension. In the setting of at least moderate to severe
tricuspid regurgitation, the pulmonary artery systolic pressure
may be UNDERestimated. There is a small pericardial effusion.
There are no 2D or Doppler echocardiographic evidence of
tamponade. In the presence of pulmonary artery hypertension,
typical echocardiographic findings of tamponade physiology may
be absent.
TTE (___)
CONCLUSION:
The left atrial volume index is moderately increased. The right
atrium is moderately enlarged. The estimated right atrial
pressure is >15mmHg. There is mild symmetric left ventricular
hypertrophy with a moderately increased/dilated cavity. There is
SEVERE global left ventricular hypokinesis. No thrombus or mass
is seen in the left ventricle. The visually estimated left
ventricular ejection fraction is ___. Due to severity of
mitral regurgitation, intrinsic left ventricular systolic
function likely is lower. Left ventricular cardiac index is
depressed (less than 2.0 L/min/m2). Diastolic function could not
be assessed. Mildly dilated right ventricular cavity with
moderate global free wall hypokinesis. Intrinsic right
ventricular systolic function is likely lower due to the
severity of tricuspid regurgitation. The aortic valve leaflets
(3) appear structurally normal. There is no aortic valve
stenosis. There is no aortic regurgitation. The mitral valve
leaflets are mildly thickened with no mitral valve prolapse.
There is a central jet of moderate to severe [3+] mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is SEVERE [4+] tricuspid regurgitation. In the
setting of at least moderate to severe tricuspid regurgitation,
the pulmonary artery systolic pressure may be UNDERestimated.
There is a small to moderate loculated pericardial effusion.
There are no 2D or Doppler echocardiographic evidence of
tamponade.
IMPRESSION: 1) Severe global LV systolic dysfunction with minor
variation in contractility suggestive of diffuse cardiomyopathic
process. Cardiac output appears depressed and judging from
systolic arterial pressure SVR is significantly elevated for
this heart. 2) Moderate to severe central mitral regurgitation
likely due to annular dilation ___ I). 3) Moderate RV
hypokinesis in setting of mild RV dilation, severe tricuspid
regurgitation and likely severe RA pressure overload. 4) Small
to moderate loculated (largely inferolaterally located) serous
pericardial effusion without signs of tamponade.
Compared with the prior TTE (images reviewed) of ___ ,
the left ventricular systolic function is now improved. The size
of the pericardial effusion is likely similar.
CHEST X RAY (___)
IMPRESSION:
There has been interval placement of a right internal jugular
Swan-Ganz
catheter whose tip projects in the region of the AP window and
may possibly be
within the left main or a left upper lobe pulmonary artery.
There is
atelectasis at the left lung base. No pleural effusion,
pneumothorax or right
lung consolidation. The size of the cardiomediastinal
silhouette is enlarged
but unchanged.
LEFT AND RIGHT HEART CATHETERIZATION (___)
Coronary Anatomy
Coronary Description
The left main, left anterior descending, circumflex and right
coronary artery have no angiographically significant coronary
abnormalities. Right dominant system.
Complications: There were no clinically significant
complications.
Findings
Elevated left and right heart filling pressures.___ ___
catheter sutured and left in place for
continuous hemodynamic monitoring.
No angiographically apparent coronary artery disease.
CHEST X RAY (___)
IMPRESSION:
The ___ catheter is unchanged with its tip in the left
main pulmonary
artery. Cardiomediastinal silhouette is enlarged but unchanged.
Lungs
continue to be low volume. There is stable minimal blunting of
the left
costophrenic sulcus. No pneumothorax.
CHEST X RAY (___)
IMPRESSION:
The tip of a ___-Ganz catheter projects over the proximal left
pulmonary
artery. Unchanged cardiopulmonary findings. No pneumothorax.
CHEST X RAY (___)
IMPRESSION:
Right-sided ___ catheter is unchanged in position.
Cardiomediastinal
silhouette is enlarged but unchanged. Small left pleural
effusion stable.
Mild pulmonary vascular congestion is stable. No pneumothorax.
No new
consolidations.
CHEST X RAY (___)
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Swan-Ganz catheter tip projects over the bifurcation of the main
pulmonary
artery. Moderate cardiomegaly unchanged. No mediastinal
widening or
pneumothorax. Combination of left lower lobe atelectasis and at
least a small
left pleural effusion stable. No pneumothorax.
CARDIAC MRI (___)
IMPRESSION: Severely dilated left ventricle with severe global
hypokinesis. Early and late stripe of mid-wall gadolinium
enhancement
in the basal septum, c/w non-ischemic cardiomyopathy. Severely
depressed right ventricular systolic function. Functional mitral
and
tricuspid regurgitation suggested due to dilated annulus.
Moderate to
severe mitral regurgitation. Small circumferential pericardial
effusion.
MICROBIOLOGY
=============
___ 8:30 pm BLOOD CULTURE #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:25 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:55 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
Ms. ___ is a ___ woman with moderate-persistent
asthma, hypertension, depression, anxiety, PTSD, panic disorder
w/ agoraphobia, thalassemia trait, and recent admission for
cholecystitis s/p cholecystectomy (path with chronic
cholecystitis) who presented as a transfer from ___ for
cardiomyopathy w/ reduced LVEF of 15% and symptoms of CHF, with
course complicated by decompensated cardiogenic shock requiring
dobuatmine from ___.
CORONARIES: Anatomy uncertain, no prior cath or stress tests
PUMP: EF ___, severe global LV systolic dysfunction, moderate
to severe MR, moderate RV hypokinesis, severe TR, small to
moderate pleural effusion
RHYTHM: NSR w/1st degree AV block
# Acute systolic decompensated heart failure (HFrEF, LVEF 15%)
# Cardiogenic shock
Patient presented with newly diagnosed heart failure (EF 15% on
initial TTE,
diffuse systolic dysfunction) with acute decompensation. Initial
differential included ischemic heart disease (moderate risk and
typical angina, but clean coronaries on LHC) vs infiltrative
disease (SFLC ratio 2.75, elevated serum IgG, but SPEP/UPEP not
suggestive) vs. HTN (mild LVH likely ___ long-standing poorly
controlled HTN) vs. myocarditis (given pericardial effusion, CP
not ___ CAD) vs malnutrition (low thiamine on admission). TSH
and iron panel WNL, HIV and ___ negative. A1C 5.8. Lipid panel
notable for HDL 18, LDL 65. SPEP w/polyclonal
hypergammoglobulinemia, no M-spike. UPEP w/o protein. Thiamine
was low but no other signs of malnutrition. She was initially
diuresed with Lasix IV boluses to which she diuresed
effectively. On ___ (hospital day 2) she developed cardiogenic
shock likely in the setting of carvedilol initiation. She
required dobuatmine for ionotropic support. She underwent RHC
and swan placement to help optimize medications. Unfortunately,
she was unable to tolerate ___ due to hyperkalemia. She
was started on hydralazine for afterload reduction. She was
started on digoxin for ionotropic support and the dobuatmine was
weaned off. Once she was euvolemic beta blocker was added. She
underwent cardiac MRI on ___ and the final read is pending
at time of discharge. Her final heart failure regimen on
discharge is Lasix PO 10mg every other day, metoprolol succinate
12.5mg daily, digoxin 0.125mg daily.
# ___
Creatinine uptrended during hospitalization to peak 1.5 likely
___ overdiuresis and ACE-I initiation. Diuresis held and the
patient was given back fluids and the creatinine improved to her
baseline of 0.8 - 0.9.
# Hyperkalemia
Potassium increased to ___ requiring multiple doses of insulin,
kayexalate, calcium. The etiology was thought to be secondary to
ACE-I initiation. K improved after discontinuing ___. A
prescription of Valtessa was sent to the patient's pharmacy for
prior authorization to help control hyperkalemia so that she can
be trialed on ___ as an outpatient.
# Hyponatremia.
The patient developed hyponatremia to high 127 after aggressive
diuresis. Patient was asymptomatic. This was thought to be
secondary to hypovolemia. The sodium improved with gentle fluid
resuscitation.
# Pericardial effusion.
Patient noted to have a new moderate pericardial effusion. There
was no echocardiographic or clinical signs (normal pulsus) of
tamponade. Effusion remained stable during hospitalization on
repeat TTE.
# Borderline elevated bHCG
Slightly elevated to 9 (equivocal) in setting of hysterectomy.
Level remained stable on re-check.
# Microcytic anemia
Known history of thalassemia minor with Hgb at recent baseline,
though labs also were consistent with iron deficiency. S/p IV
iron x4 days. Started oral iron on ___.
# Moderate-persistent asthma
- Standing duonebs
- Home Fluticasone-Salmeterol Diskus (250/50)
# Anxiety, depression, PTSD, and panic disorder
Followed by psychiatry at ___.
- Continued sertraline, buspirone, gabapentin, nortryptiline
- Discontinued prazosin iso HFrEF and need for competing
afterload reduciton
# Severe glaucoma in R eye.
- Continued ophthalmic drops, but held methazolamide iso
hyperkalemia, re-started at discharge
# Chronic LBP w/ sciatica.
- Continued home tizanidine, methacarbamol, gabapentin
TRANSITIONAL ISSUES:
NEW MEDICATIONS:
Digoxin 0.125 mg PO/NG DAILY
HydrALAZINE 100 mg PO/NG Q8H
Iron Polysaccharides Complex ___ mg PO EVERY OTHER DAY
Metoprolol Succinate XL 12.5 mg PO DAILY
Multivitamin
Thiamine (had low thiamine level on admission)
Furosemide 10 mg PO/NG DAILY
DISCONTINUED MEDICATIONS:
Hydrochlorothiazide 25 mg PO DAILY
Prazosin 1 mg PO TID
DISCHARGE WEIGHT:
CREATININE at DISHCARGE: 0.8
HEART FAILURE MEDICATION REGIMEN:
Digoxin 0.125 mg PO/NG DAILY
HydrALAZINE 100 mg PO/NG Q8H
Metoprolol Succinate XL 12.5 mg PO DAILY
Furosemide 10 mg PO/NG DAILY
[ ] Follow-up final cardiac MRI read (pending at time of
discharge)
[ ] Follow-up prior authorization for valtessa to use for
management of ACE-I induced hyperkalemia
[ ] Patient should have BMP drawn at follow-up for evaluation of
stable renal function and to assess stability of sodium and
potassium levels
[ ] Please ensure that patient follows-up with her
ophthalmologist for her advanced glaucoma
[ ] Check iron studies and CBC in 3 to 6 months (By ___
and consider stopping iron supplementation if iron studies
return to normal
[ ] Check digoxin level
[ ] ___ not started due to hyperkalemia - consider
starting low dose with concurrent Valtessa once approved;
similarly did not start MRA due to hyperkalemia
[ ] Consider up-titration of beta blocker as tolerating
[ ] Consider evaluation for ICD based on EF<35%
[ ] Consider heart transplant evaluation
[ ] Patient had significant urinary output to low doses of Lasix
Please follow-up weights and symptoms of
dehydration/overdiuresis as patient may need to go to every
other day dosing
Health care proxy chosen: Yes
Name of health care proxy: ___: Son
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
2. BusPIRone 45 mg PO BID
3. Sertraline 200 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Hydrochlorothiazide 25 mg PO DAILY
6. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
7. Bimatoprost 0.03% Ophth (*NF*) 1 drop Other QHS
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
9. Prazosin 1 mg PO TID
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
11. Methazolamide 50 mg PO TID
12. HydrOXYzine 25 mg PO TID:PRN pruritis
13. Tiotropium Bromide 1 CAP IH DAILY
14. Cetirizine 10 mg PO DAILY
15. Methocarbamol 750 mg PO QID:PRN back pain
16. Tizanidine 2 mg PO BID
17. Tizanidine 4 mg PO QHS
18. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
19. Gabapentin 600 mg PO TID
Discharge Medications:
1. Digoxin 0.125 mg PO DAILY
RX *digoxin 125 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Furosemide 10 mg PO DAILY
RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth Daily
Disp #*15 Tablet Refills:*0
3. HydrALAZINE 100 mg PO Q8H
RX *hydralazine 100 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*90 Tablet Refills:*0
4. Iron Polysaccharides Complex ___ mg PO EVERY OTHER DAY
RX *polysaccharide iron complex [Ferric ___ 150 mg iron 1
capsule(s) by mouth every other day Disp #*15 Capsule Refills:*0
5. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
daily Disp #*15 Tablet Refills:*0
6. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 capsule(s) by mouth daily Disp
#*30 Capsule Refills:*0
7. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
10. Bimatoprost 0.03% Ophth (*NF*) 1 drop Other QHS
11. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
12. BusPIRone 45 mg PO BID
13. Cetirizine 10 mg PO DAILY
14. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
15. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
16. Gabapentin 600 mg PO TID
17. HydrOXYzine 25 mg PO TID:PRN pruritis
18. Methazolamide 50 mg PO TID
19. Methocarbamol 750 mg PO QID:PRN back pain
20. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
21. Sertraline 200 mg PO DAILY
22. Tiotropium Bromide 1 CAP IH DAILY
23. Tizanidine 2 mg PO BID
24. Tizanidine 4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Acute systolic decompensated heart failure (HFrEF, LVEF 15%)
# Cardiogenic shock
# ___
# Hyperkalemia
# Hyponatremia.
# Pericardial effusion.
# Microcytic anemia, chronic
# Moderate-persistent asthma
# Anxiety, depression, PTSD, and panic disorder
# Severe glaucoma in R eye.
# Chronic LBP w/ sciatica.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you had shortness of
breath and you were found to have extra fluid in your body. Your
heart was found to be functioning lower than normal which is the
cause of the extra fluid.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were started on new medications to help support your heart
and remove the extra fluid. You will continue some of these very
important medications when you leave the hospital.
- You had a procedure called a cardiac catheterization in order
to look at the arteries in your heart and to look at the
pressures inside your heart and lungs.
- You had an MRI of your heart to help us figure our why your
heart is not beating as strong as it should. The results of the
MRI are not back yet and you will receive the results at your
follow-up appointment.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10784423-DS-17
| 10,784,423 | 29,616,692 |
DS
| 17 |
2132-07-13 00:00:00
|
2132-07-13 19:51:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shock
Major Surgical or Invasive Procedure:
R groin CVL
Arterial line
PICC Placement
History of Present Illness:
Mr. ___ is a ___ year old male with past medical history
significant for CVA resulting in significant deficits ultimately
requiring trach/PEG, atrial fibrillation on DOAC, hypertension,
hyperlipidemia, and DM who presented to ___ in shock and is
admitted to ICU for ongoing management of shock.
Per family, patient was in his usual state of health up until
the morning. He has lived at ___ in ___ over the past
___ years after a CVA resulting in trach/peg. Has been
non-verbal since then but able to communicate with hand signals.
Has ___ on trach mask over this period of time. Family notes one
episode of isolated fever last week which resolved on its own
without any treatment. Since then, patient has been stable per
the son. Patient had worsening mental status with
unresponsiveness and fever prompting EMS call and arrival to ED.
He had IO placed in the field.
In the ED, patient was persistently hypotensive. He received 4L
of IVF without improvement in pressures and was started on
norepinephrine, epinephrine, vasopressin, and phenylephrine. He
was started on broad coverage antibiotics with vanc/zosyn for
unclear bacterial infection and po vanc/iv flagyl for possible
c. diff given diarrhea in ED.
In the ED,
- Initial Vitals: T 40.4, HR 120, BP 59/32, RR 25%, 87% trach
- Labs:
CBC: WBC 6.0, Hgb 10.0, Plt 131
Chem: Na 153, Cl 115, HCO3 20, BUN 55, Cr 2.4
VBG: 7.29/44
Lactate: 8.4
- Imaging:
CXR: Retrocardiac opacity, potentially atelectasis, with
pneumonia also possible given the clinical history. Trace left
pleural effusion.
- Interventions: 4L IVF, pressors and antibiotics per above,
stress dose steroids, and 1g IV calcium chloride
Upon arrival to ICU, patient is on ventilator. Not responding to
vocal stimuli or tracking.
Past Medical History:
-CVA
-Atrial fibrillation
-Hypertension
-Hyperlipidemia
-Type 2 DM
Social History:
___
Family History:
Unknown
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
GEN: respiratory distress
EYES: right > left, minimally responsive
HENNT: NC/AT. trach
CV: tachycardia, normal S1 and S2
RESP: course breath sounds bilaterally
GI: distended, no bowel sounds
MSK: no lower extremity edema
SKIN: wounds on buttocks
NEURO: left arm/leg with minimal movement
PSYCH: unable to assess
=======================
DISCHARGE PHYSICAL EXAM
=======================
VS: T98.6, HR 88, BP 108/56, RR 18, O2 97% 40% trach mask
GEN: Awaking somewhat to stimulation today, tracks observer
intermittently with eyes
EYES: right > left, minimally responsive
HENNT: NC/AT. trach
CV: tachycardia, normal S1 and S2
RESP: course breath sounds bilaterally
GI: somewhat distended, soft and no guarding to deep palpation
MSK: no lower extremity edema, some edema in the upper thighs
still
SKIN: wounds on buttocks
NEURO: left arm/leg with minimal movement
Pertinent Results:
==============
ADMISSION LABS
==============
___ 09:47PM BLOOD WBC-6.0 RBC-3.06* Hgb-10.0* Hct-33.2*
MCV-109* MCH-32.7* MCHC-30.1* RDW-16.1* RDWSD-65.0* Plt ___
___ 09:47PM BLOOD Neuts-63.9 ___ Monos-9.3 Eos-0.0*
Baso-0.3 NRBC-0.7* Im ___ AbsNeut-3.82 AbsLymp-1.48
AbsMono-0.56 AbsEos-0.00* AbsBaso-0.02
___ 09:47PM BLOOD Plt ___
___ 09:56PM BLOOD ___ PTT-45.5* ___
___ 09:47PM BLOOD Glucose-378* UreaN-55* Creat-2.4* Na-153*
K-3.9 Cl-115* HCO3-20* AnGap-18
___ 09:47PM BLOOD ALT-30 AST-61* AlkPhos-25* TotBili-0.2
___ 09:47PM BLOOD Albumin-2.1* Calcium-7.5* Phos-1.0*
Mg-1.8
___ 09:57PM BLOOD Type-CENTRAL VE pO2-77* pCO2-44 pH-7.29*
calTCO2-22 Base XS--4
___ 09:57PM BLOOD Lactate-8.4*
___ 09:57PM BLOOD O2 Sat-91
==============
DISCHARGE LABS
==============
___ 03:53AM BLOOD WBC-4.1 RBC-2.46* Hgb-8.0* Hct-26.9*
MCV-109* MCH-32.5* MCHC-29.7* RDW-15.2 RDWSD-60.6* Plt ___
___ 03:53AM BLOOD ___ PTT-36.0 ___
___ 03:53AM BLOOD Glucose-131* UreaN-22* Creat-0.7 Na-146
K-4.1 Cl-107 HCO3-30 AnGap-9*
___ 03:53AM BLOOD ALT-95* AST-260* AlkPhos-61 TotBili-0.2
___ 03:17AM BLOOD ALT-85* AST-291* AlkPhos-58 TotBili-0.3
___ 04:01AM BLOOD ALT-68* AST-194* AlkPhos-56 TotBili-0.4
___ 04:02AM BLOOD ALT-59* AST-120* AlkPhos-57 TotBili-0.4
___ 04:00AM BLOOD ALT-56* AST-100* LD(LDH)-240 AlkPhos-60
TotBili-0.4
___ 04:08AM BLOOD ALT-59* AST-93* LD(LDH)-220 AlkPhos-35*
TotBili-0.5
___ 03:53AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.4
___ 05:45AM BLOOD VitB12-987* Folate->20 Hapto-46
___ 06:19PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS*
___ 06:19PM BLOOD HCV Ab-NEG
============
MICROBIOLOGY
============
___ 4:10 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ ___ per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
Piperacillin/Tazobactam test result performed by ___
___.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SECOND
MORPHOLOGY.
SENSITIVITIES: MIC expressed in MCG/ML
PSEUDOMONAS AERUGINOSA
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ 2 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ <=1 S
-------
URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in MCG/ML
ENTEROCOCCUS SP.
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
==================
IMAGING/PROCEDURES
==================
___ CXR
Retrocardiac opacity, potentially atelectasis, with pneumonia
also possible given the clinical history. Trace left pleural
effusion.
___ KUB
Moderate gas is distension of the stomach with a gastrostomy
tube in place. No evidence of bowel obstruction. No large
pneumoperitoneum given limitation of a supine abdominal
radiograph.
___ CT Ab/Pelvis w/ contrast
1. The colon is decompressed, which makes evaluation of the wall
difficult. However, pericolonic fat stranding is noted and
although it is nonspecific, colitis of the ascending colon
cannot be entirely excluded.
2. Dilated common bile duct measuring up to 13 mm, with cut off
at the level of the pancreatic head. The main pancreatic duct
is also dilated with a similar cutoff point. No discrete mass
is seen. Sphincter stenosis or choledocholithiasis also cannot
be excluded. MRCP could be performed for more complete
assessment.
3. 3.2 cm fusiform infrarenal abdominal aortic aneurysm with
focal area of
plaque ulceration.
4. Please refer to the separately dictated concurrent CTA chest
report for a description of thoracic findings.
___ CTA Chest
1. No evidence of pulmonary embolism or aortic abnormality.
2. Widespread bronchiolar inflammation is likely indicative of
small airway inflammation and is usually seen in the setting of
smoking history or severe allergies.
3. Trace bilateral pleural effusions.
4. Status post tracheostomy with minimal intraluminal
secretions.
5. Please refer to separately dictated report of CT abdomen and
pelvis for
description of the subdiaphragmatic findings.
___ CT head
1. No acute intracranial hemorrhage.
2. Large area of chronic encephalomalacia of the right frontal
and temporal lobes.
___ TTE
The left atrial volume index is normal. The right atrium is
mildly enlarged. There is no evidence for an atrial septal
defect by 2D/color Doppler. The right atrial pressure could not
be estimated. There is mild symmetric left ventricular
hypertrophy with a normal cavity size. There is normal regional
left ventricular systolic function. Overall left ventricular
systolic function is low normal. The visually estimated left
ventricular ejection fraction is 50-55%. Left ventricular
cardiac index is low normal (2.0-2.5 L/min/m2). There is no
resting left ventricular outflow tract gradient. No ventricular
septal defect is seen. Diastolic parameters are indeterminate.
Normal right ventricular cavity size with low normal free wall
motion. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. There is trace aortic regurgitation. The mitral valve
leaflets are
mildly thickened with no mitral valve prolapse. There is trivial
mitral regurgitation. The tricuspid valve leaflets appear
structurally normal. There is mild [1+] tricuspid regurgitation.
There is mild pulmonary artery systolic hypertension. There is a
trivial pericardial effusion.
IMPRESSION: Low-normal biventricular systolic function. Mild
tricuspid regurgitation Mild pulmonary hypertension.
___ CXR
Mild cardiomegaly with pulmonary vascular congestion and a left
pleural
effusion.
___ Portable Abdomen
IMPRESSION: No evidence of ileus or bowel obstruction.
___ ___ Confirmation
FINDINGS:
1. The accessed vein was patent and compressible.
2. Basilicvein approach double lumen right PICC with tip in the
distal SVC.
IMPRESSION:
Successful placement of a right 42 cm basilic approach double
lumen PowerPICC ith tip in the distal SVC. The line is ready
to use.
___ RUQ Ultrasound
IMPRESSION:
1. Unremarkable appearance of the liver and no biliary
dilatation.
2. A small right pleural effusion is noted.
Brief Hospital Course:
=======
SUMMARY
=======
Mr. ___ is a ___ year old male with past medical history
significant for CVA resulting in significant deficits ultimately
requiring trach/PEG, atrial fibrillation on DOAC, hypertension,
hyperlipidemia, and DM who presented to ___ in shock and is
admitted to ICU for ongoing management of shock. His shock was
thought to be related to sepsis from a urinary tract infection.
He improved after an extended antibiotic course. His hospital
stay was complicated by dependency on a ventilator which
resolved with repeated boluses of IV Lasix. He was also found to
have elevated transaminases likely secondary to drug injury.
=============================
IMPORTANT TRANSITIONAL ISSUES
=============================
[ ] Please continue to monitor his LFTs, initially on a daily
basis. AST was 96 on discharge and AST was 260. Alk Phos and
bilirubin were normal. He developed a transaminitis around ___
that is possibly related to piperacillin/tazobactam, as it
improved somewhat when he was transitioned to meropenem.
[ ] Please continue meropenem 500mg IV q8hrs for a 7-d course
for hospital-associated pneumonia due to pseudomonas resistant
to piperacillin/tazobactam. Final day of the 7d course would be
___.
[ ] Would continue active diuresis with boluses of 20mg IV
Lasix. He had a small increase in his BUN on ___ after diuresis
which may indicate developing ___ and ___, but would
continue to shoot for net negative until that time.
[ ] Needs follow-up with vascular surgery in ___ year for AAA of
3.2cm.
[ ] Neurology has placed referral for patient to be seen as an
outpatient. Please ensure that he has follow-up within 1 month
of discharge.
ACUTE ISSUES
===============
#Acute on chronic respiratory failure
He was initially on trach mask at his facility and placed on a
ventilator after admission. He received significant volume
resuscitation and was almost 10L positive and was not able to be
weaned off the ventilator. He was diuresed with boluses of 20mg
IV Lasix or 40mg IV Lasix and on ___ was able to remain on
trach mask persistently without evidence of distress. Notably,
he was found to have a new RUL and RLL infiltrates concerning
for aspiration, and sputum culture grew pseudomonas resistant to
piperacillin/tazobactam. He was initially on pip/tazo before
this culture resulted and then switched to meropenem on ___ for
a planned course ending ___.
#Transaminitis
Hepatocellualr LFT elevation possibly in the setting of
antibiotic use including unasyn and zosyn. He was converted to
meropenem as his pseudomonas pneumonia was found to be zosyn
resistant and LFTs showed improvement on ___.
#Shock
#Enterococcus UTI
Presented with elevated SvO2, WBC, and fever consistent for
septic shock. Likely also component of hypovolemia given his
electrolytes at time of presentation and aggressively fluid
resuscitated. Treated in the ED with four pressors, stress dose
steroids, and broad spectrum antibiotic coverage. Etiology of
sepsis likely urinary source with urine growing enterococcus,
vanc and amp/sulbactam sensitive. He completed an extended
course of treatment for the enterococcus UTI that completed on
___. The last time that he required vasopressors was ___.
# Altered mental status
# R arm jerking
At baseline able to make hand-gestures to communicate and is
alert. Initially unresponsive here and with R arm jerking.
Loaded with keppra ___. R arm jerking activity is new per family
in setting of sepsis. Per neurology resident, epileptiform
discharges may have been misinterpreted and per his read there
are no discharges on EEG. No evidence of seizures on EEG, just
diffuse slowing in area of prior major stroke. Mental status
still not improved to baseline by the time of discharged, likely
related to delirium and toxic metabolic encephalopathy from
pneumonia. Neurology plan to see him as an outpatient and would
like to continue keppra at least until that time. Unable to
obtain MRI due to the fact that his trach is likely not
compatible.
#Hypernatremia
Likely in setting of poor PO intake and ongoing diarrhea.
Increased free water flushes temporarily and his hypernatremia
improved.
# Coagulopathy
# Thrombocytopenia
Platelets had nadir of 26 on ___. Suspect related severe sepsis.
Fibrinogen was relatively low in setting of sepsis. Automated
smear with normal RBCs and no schistocytes. Heme suspects
etiology likely related to sepsis. Platelets subsequently
returned to normal.
___ on CKD
#Hyperchloremia
Unclear of baseline, Cr up to 2.4 in setting of prolonged
hypotension. Improved s/p IVF. Per records, baseline 1.0 in
___. Hyperchloremia likely ___ RTA. Cr was down to 0.7 on
discharge.
# DM
Elevated BGs at time of presentation in setting of sepsis and
recently starting steroids as outpatient. Does not appear to be
on any anti-glycemics as outpatient. Maintained on insulin
sliding scale here and typically only needed sliding scale once
daily.
# Macrocytic anemia
Unclear of baseline. Concerns for nutritional deficiencies vs.
possible liver dysfunction. Folate and B12 found to be normal.
CHRONIC ISSUES
===============
# AF
Held anticoagulation. in setting of low platelets. Amio IV
loaded and transitioned to PO amio. Apixaban resumed ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg NG DAILY
2. Scopolamine Patch 1 PTCH TD Q72H
3. Metoprolol Tartrate 25 mg NG Q6H
4. PredniSONE 10 mg NG DAILY Blisters/itching
5. Acetaminophen 650 mg NG Q6H:PRN Pain - Mild/Fever
6. Atorvastatin 20 mg NG QPM
7. Atropine Sulfate 1% 1 DROP SL Q8H:PRN Secretions
8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
9. Docusate Sodium 100 mg PO/NG BID
10. Bisacodyl ___AILY:PRN Constipation - Second Line
11. Apixaban 5 mg NG BID
12. Hyoscyamine 0.125 mg SL TID
13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
14. Senna 8.6 mg NG DAILY:PRN Constipation - First Line
Discharge Medications:
1. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
2. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
3. Glucose Gel 15 g PO PRN hypoglycemia protocol
4. Insulin SC
Sliding Scale
Fingerstick Q6H
Insulin SC Sliding Scale using HUM Insulin
5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
6. LevETIRAcetam 1000 mg PO BID
7. Meropenem 500 mg IV Q8H
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
9. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
10. Senna 17.2 mg PO BID:PRN Constipation - First Line
11. Amiodarone 200 mg PO DAILY
12. Apixaban 5 mg PO BID
13. Atorvastatin 20 mg PO QPM
14. Docusate Sodium 100 mg PO BID
15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute on chronic hypoxic and hypercarbic respiratory failure
requiring mechanical ventilation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Mr. ___,
Why was I hospitalized?
- You had low blood pressure related to a serious infection
- Your thinking was not clear and it was harder than normal to
wake you up
What happened when I was in the hospital?
- We treated you with antibiotics for serious infections in your
urinary tract and in your lungs
- We used a breathing machine (ventilator) to support your
breathing
- We temporarily used medications to help support your blood
pressure
- We gave you medications to help you urinate a lot to remove
extra fluid that had gone to your lungs
What should I do when I leave the hospital?
- Continue taking all of your medications as prescribed
- You will be seen by the doctors at your facility who will help
manage your care.
It was a pleasure caring for you here while you were
hospitalized.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
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10784877-DS-21
| 10,784,877 | 22,253,744 |
DS
| 21 |
2170-02-07 00:00:00
|
2170-02-13 23:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
LLQ abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ on Lovenox for DVT, with metastatic non-small cell lung
cancer currently on chemotherapy (last session ___, hx of
cervical cancer s/p TAH/BSO and pelvic radiation, with multiple
prior SBOs s/p ex-lap/LOA ___, now transfered from OSH with
abdominal pain and nausea. Pt reports gradual onset of LLQ
abdominal pain, sharp and non-radiating, which progressed in
severity over the ensuing hours. This was accompanied by nausea
without emesis. She reports baseline constipation with last
bowel movement yesterday. Denies flatus for the last 24 hours.
Denies associated fevers, chills, or hematochezia.
Mrs ___ presented to ___ where a CT A/P
was interpreted as concerning for small bowel obstruction.
Given her prior care at ___, she was transfered here for
further management.
Past Medical History:
PMH: cervical ca s/p TAH/USO/radiation c/b radiation enteritis;
Metastatic non-small cell lung ca with mets to brain and R ___
femur getting maintenence pemetrex and s/p whole brain radiation
carboplatin/pemetrexed cycle 15 completed ___ Attention
deficit hyperactive disorder, seizure d/o, upper extremity DVT
.
PSH: s/p ex-lap w/LOA ___ for SBO, s/p total abdominal
hysterectomy and unilateral salpingo-oophorectomy ___, s/p
unilateral salpingo oophorectomy ___, s/p appendectomy, s/p R
knee lateral meniscus repair
Social History:
___
Family History:
- Father with diabetes, coronary artery bypass, percutaneous
interventions, heart disease clinically evident by ___ or ___
- Mother with breast cancer, dying at ___
Physical Exam:
EXAM ON ADMISSION:
Vitals: 97.6 95 124/75 14 98%
GEN: Initially appears quite uncomfortable but then markedly
improves after IV analgesia. Alert, oriented x3. NGT in place.
HEENT: No scleral icterus. Mucous membranes dry.
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, nondistended. LLQ tenderness vastly improves with
analgesics. No R/G. No masses. Midline incisions well-healed.
RECTAL: Increased tone. No masses. No gross blood. Heme-occult
positive.
EXT: Warm without ___ edema.
Exam On Discharge:
VS: 97.6 112/64 69 20 97% on RA
GEN: resting comfortably in bed. Alert, oriented x3.
HEENT: No scleral icterus. Mucous membranes dry.
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, nondistended. LLQ tenderness vastly improves with
analgesics. No R/G. No masses. Midline incisions well-healed.
EXT: Warm without ___ edema.
Pertinent Results:
On Admission:
___ 12:20AM BLOOD WBC-2.4*# RBC-2.82* Hgb-9.5* Hct-30.2*
MCV-107* MCH-33.6* MCHC-31.4 RDW-14.7 Plt ___
___ 12:20AM BLOOD ___ PTT-38.3* ___
___ 12:20AM BLOOD Glucose-95 UreaN-8 Creat-0.6 Na-136 K-3.6
Cl-100 HCO3-26 AnGap-14
___ 12:20AM BLOOD Calcium-6.0* Phos-2.8 Mg-1.7
___ 06:00AM BLOOD Lipase-10
Discharge Labs:
___ 06:00AM BLOOD WBC-2.2* RBC-2.63* Hgb-9.1* Hct-27.7*
MCV-105* MCH-34.6* MCHC-32.9 RDW-14.6 Plt ___
___ 06:00AM BLOOD ___ PTT-33.7 ___
___ 06:00AM BLOOD Glucose-120* UreaN-5* Creat-0.7 Na-142
K-3.6 Cl-105 HCO3-33* AnGap-8
___ 06:00AM BLOOD Calcium-8.1* Phos-3.6 Mg-1.6
Imaging:
CT OF THE ABDOMEN WITH IV CONTRAST: Included views of the lung
bases
demonstrate minimal dependent atelectasis and emphysema. There
is no
pericardial or pleural effusion. The heart size is normal. A
cardiac
pacemaker lead projects into the right atrium.
The liver, gallbladder, adrenal glands, kidneys, spleen, stomach
are normal. Mild dilation of the pancreatic ducts, measuring up
to 4 mm in diameter (5:119) is unchanged since the ___
and ___ CT examinations. No obstructing mass is
detected. There is no intrahepatic bile duct dilation. The
abdominal aorta, celiac trunk, SMA, and ___ are patent and
normal in caliber.
CT OF THE PELVIS WITH IV CONTRAST: Again seen is abnormal
peritoneal
thickening throughout the lower pelvis with obliteration of fat
planes between small and large bowel and the bladder (5:312),
unchanged since ___, but progressed since the
___ CT examination. Multiple intrapelvic fiducial
seeds and surgical clips are present. No underlying mass is
detected. There is no neighboring lymphadenopathy. The bladder
is partially collapsed (5:333). The cecum demonstrates mildly
increased wall hyperemia without thickening and is fluid-filled.
The neighboring intrapelvic distal ileum appears mildly
distended with a large amount of fluid, but is not dilated. The
distal colon contains a moderate amount of stool.
OSSEOUS STRUCTURES: There is no acute fracture. There are no
bony lesions
concerning for malignancy or infection.
IMPRESSION:
1. No small-bowel obstruction. Multiple loops of fluid-filled
ileum and
cecum demonstrating mild wall hyperemia may reflect mild
enteritis.
2. Diffuse intrapelvic peritoneal thickening, with obscuration
of neighboring fat planes, progressed since ___ but unchanged
since ___, which may represent a combination of
radiation fibrosis and post-surgical scarring/inflammation. No
underlying mass or neighboring lymphadenopathy is detected.
Given history of malignancy in this region, continued attention
to this region on followup imaging is recommended.
3. Unchanged persistent mild dilation of the pancreatic ducts,
possibly from ampullary stenosis given lack of an obstructing
mass.
Brief Hospital Course:
___ w/ Stage IV NSCLC w/ brain mets on chemotx, hx cervical CA
s/p TAH/BSO and radiation tx, on Lovenox for DVT, s/p ex-lap,
LOA ___ for SBO, who presented to OSH initially with LLQ
abdominal pain.
#ABDOMINAL PAIN: The patient has a history of bowel obstruction
and was transferred from an outside hospital with a CT scan
concerning for small bowel obstruction. The scan was reviewed
with radiology, and there was no definitive evidence of
obstruction. She was made n.p.o. and an NG tube was placed with
concern for possible partial small bowel obstruction. She was
admitted to the surgical service. There was minimal NG tube
output and so the tube was clamped. The patient continued to had
flatus and her pain improved somewhat, so the tube was removed.
She was transferred to the oncology service for further
management and started on clears that were well tolerated. The
pain was suprapubic and left lower quadrant and not where the
patient typically has pain with her prior SBO's (epigastic).
Moreover, the patient had not past stool for almost a week with
an increase use of narcotic pain meds. She was started on an a
aggressive bowel regime, and after passing multiple small hard
pieces of fecal material her pain started to resolve. She
started to pass copious amounts of soft stool with good
resolution of her pain. She was discharged on a good bowel
regime.
#. metastatic lung CA: She was continued on maintenance
pemetrexed.
.
# DVT: continued enoxaparin at her home dose.
.
# ADHD: cont methylphenidate at her home dose.
Medications on Admission:
VitB12, Lovenox 60 SQ, Folic acid 1, Lorazepam 2 Q6H PRN,
Methylphenidate 54, Dexamthasone (___), Mirtazapine 15
HS, Omeprazole 20, Ondansetron 4 Q6H PRN, Oxycodone 5 Q6H PRN,
Cetirizine 10 PRN, Colace 100'', Senna 17.2'', Urea cream PRN
Discharge Medications:
1. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. lorazepam 2 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety or insomnia.
4. methylphenidate 54 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO QAM (once a day (in the morning)).
5. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for nausea.
8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
9. Tylenol ___ mg Tablet Sig: ___ Tablets PO every six (6) hours
as needed for pain.
10. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
non-small cell lung cancer
constipation
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
abdominal pain. This pain is now much better. Please continue
to take stool softeners regularly. Please follow up in clinic
tomorrow for your already existing appointments.
Medication Changes:
Please continue to take all medications as prescribed, including
colace and senna
Followup Instructions:
___
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10784877-DS-22
| 10,784,877 | 23,751,418 |
DS
| 22 |
2170-03-09 00:00:00
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2170-03-10 09:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
febrile neutropenia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with history of metastatic non-small cell lung
cancer currently on chemotherapy (last session ___, hx of
cervical cancer s/p TAH/BSO and pelvic radiation, with multiple
prior SBOs s/p ex-lap/LOA ___, now transferred from OSH with
fevers and chills.
The patient was in her usual state of health until yesterday
morning when she developed fevers, sweats, back pain and overall
sense of feeling unwell. She contacted her oncologist who
recommended she go to the closest ED given she has febrile
neutropenia. She presented to OSH where she was febrile to
101.6. Labs there demonstrated neutropenia in addition to UTI.
Cultures were drawn from her port and peripherally. She was
started on vancomycin and ceftazidime and transferred to ___
for further management.
In terms of her malignancy, she has had a complex course
including multiple rounds of chemotherapy, whole brain
irradition and surgeries. Recently, she was found to have a RUL
anterior segment chest mass and was started on a docetaxel, for
palliative purposes.
In the ED, initial VS were T- 97.6, HR- 79, BP- 82/55, RR- 16,
SaO2 95% on room air. Labs pertinent for WBC 1.8 (neutrophils
18) and lactate 0.8. She received morphine for pain control and
was given 2L NS with improvement in her blood pressure. On
transfer to the FICU, BP 101/55.
On arrival to the MICU, patient's VS, were T- 98.7, HR- 83, BP-
103/61, RR- 20, SaO2- 100% on RA. Patient felt somewhat better
and was comfortable.
Past Medical History:
1. Cervical ca s/p TAH/USO/radiation c/b radiation enteritis
2. Metastatic non-small cell lung ca with mets to brain and R
___ femur getting maintenence pemetrex and s/p whole brain
radiation carboplatin/pemetrexed cycle 15 completed ___, now
on docetaxal q3 weeks starting on ___
3. Attention deficit hyperactive disorder
4. Seizure d/o
5 Upper extremity DVT
PSH: s/p ex-lap w/LOA ___ for SBO, s/p total abdominal
hysterectomy and unilateral salpingo-oophorectomy ___, s/p
unilateral salpingo oophorectomy ___, s/p appendectomy, s/p R
knee lateral meniscus repair
Social History:
___
Family History:
- Father with diabetes, coronary artery bypass, percutaneous
interventions, heart disease clinically evident by ___ or ___
- Mother with breast cancer, dying at ___
Physical Exam:
Admission Physical Exam:
Vitals: T- 98.7, HR- 83, BP- 103/61, RR- 20, SaO2- 100% on RA
General: Alert, oriented, no acute distress, appears older than
stated age
HEENT: Sclera anicteric, dry mucous membranes, EOMI. Port in
place.
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
tenderness to palpation, no rebound or guarding. positive b/l
flank tenderness (L>R)
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
.
DISCHARGE PHYSICAL EXAM:
VS T 98.5 BP 102/60 HR 72 RR 18 SaO2 97% RA
I/O: 8 hr sips/550; 24 hr 1550/1600
GEN: well appearing middle aged female
PULM: CTABL, no wheezes, rales/ronchi
CV: S1/S2 RRR no MRG
BACK: very mild bilateral CVA tenderness
ABDOMEN: Soft non tender NABS
NEURO: CN II-XII intact and symmetric, Motor ___ in upper/lower
extremities sensation to light touch intact and symmetric.
Pertinent Results:
ADMISSION LABS:
___ 12:15AM BLOOD WBC-1.8*# RBC-2.68* Hgb-8.9*# Hct-28.6*
MCV-107* MCH-33.3* MCHC-31.1 RDW-15.0 Plt ___
___ 12:15AM BLOOD Neuts-18* Bands-2 Lymphs-55* Monos-25*
Eos-0 Baso-0 ___ Myelos-0
___ 12:15AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Tear
Dr-OCCASIONAL
___ 12:15AM BLOOD Glucose-118* UreaN-7 Creat-0.5 Na-139
K-3.6 Cl-104 HCO3-25 AnGap-14
___ 04:46AM BLOOD Albumin-2.8* Calcium-7.4* Phos-2.2*
Mg-1.5*
___ 12:40AM BLOOD Lactate-0.8
___ 05:09AM URINE Color-Straw Appear-Clear Sp ___
___ 05:09AM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 05:09AM URINE RBC-1 WBC-15* Bacteri-FEW Yeast-NONE
Epi-0
.
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-4.7# RBC-3.11* Hgb-10.2* Hct-32.4*
MCV-104* MCH-32.7* MCHC-31.3 RDW-15.1 Plt ___
___ 06:00AM BLOOD Neuts-66 Bands-2 Lymphs-14* Monos-11
Eos-0 Baso-1 ___ Metas-5* Myelos-1*
___ 06:00AM BLOOD Glucose-93 UreaN-4* Creat-0.5 Na-140
K-4.2 Cl-102 HCO3-30 AnGap-12
___ 06:00AM BLOOD Calcium-9.0 Phos-4.0 Mg-1.7
___ 06:00AM BLOOD Vanco-18.9
.
URINALYSIS
___ 05:09AM URINE Color-Straw Appear-Clear Sp ___
___ 05:09AM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 05:09AM URINE RBC-1 WBC-15* Bacteri-FEW Yeast-NONE
Epi-0
MICROBIOLOGY:
___ BLOOD CULTURE PENDING
___ Legionella Urinary Antigen - negative
___ BLOOD CULTURE PENDING
___ URINE CULTURE- MIXED BACTERIAL FLORA ( >= 3 COLONY
TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
___ BLOOD CULTURE-PENDING
___ BLOOD CULTURE PENDING
IMAGING:
# CXR ___ Right mid lung field opacity likely within the
left upper lobe which is new since the previous study and may
represent developing infiltrate.
# Renal US ___
Mild bilateral pelvocaliectasis. No ultrasound evidence for
pyelonephritis.
# CT Head ___
A small focal area of hyperattenuation involving right lateral
pons at the site of patient's known metastatic focus is new
since ___ CT exam; however faintly seen on prior CT Head
study of ___. This may relate to minimal blood products
or mineralization. Additional metastatic lesions within left
cerebellum and medial right temporal lobe are better assessed on
___ MR exam. Correlate with MR if not CI as clinically
needed. No large hemorrhage or mass effect.
# MR ___ & W/O CONTRAST ___
FINDINGS: High signal is again seen in the L5 vertebral body,
imaged upper sacrum, and imaged medial pelvic bones on T1- and
T2-weighted images, suggesting fatty replacement, such as may be
seen with prior radiation therapy. Slightly heterogeneous
marrow signal in other lumbar and lower thoracic vertebral
bodies is similar to ___. There is no evidence of an
epidural or intrathecal mass. The conus medullaris terminates
at T12-L1, and it appears unremarkable.
Vertebral body height and alignment is preserved.
The L2-3 level is unremarkable.
At L3-4, there is mild-to-moderate right facet arthropathy,
without evidence of neural impingement.
At L4-5, there is moderate right and milder left facet
arthropathy, as well as a minimal disc bulge, without evidence
of neural impingement.
At L5-S1, there is minimal facet arthropathy without evidence of
nerve root impingement.
IMPRESSION:
1. No evidence of metastatic disease in the lumbar spine.
2. Mild lumbar degenerative disease without evidence of neural
impingement.
Brief Hospital Course:
___ female with history of metastatic non-small cell carcinoma
(currently on chemotherapy), cervical cancer, DVT who presents
with febrile neutropenia and hypotension.
.
ACTIVE ISSUES:
.
#. Neutropenic Fever - ___ was 200 at admission. Likely source
was considered urinary, based on OSH UA results, and eventual
cultures from OSH which were pan-sensitive klebsiella
pneumoniae. Given left CVA tenderness and degree of fever, she
was clinically diagnosed with pyelonephritis. The patient was
started on vancomycin and ceftazidime for febrile neutropenia
and transferred to ___ for further management. Renal US
showed mild bilateral pelvocaliectasis with no ultrasound
evidence for pyelonephritis, although again, pyelo was diagnosed
clinically. Upon arrival to ___, she was initially in the ICU
for relative hypotension. However, she stabilized within 24
hours of hospitalization here and was called out the floor,
where she continued to improve, with clinical improvement in her
back pain, defervescence and clinical stability. Because of
chest xray findings, she was continued on vanc/ceftaz to
complete an 8 day course for HCAP, then to be transitioned to
Cipro for completion of her 14 day treatment course for
pyelonephritis.
.
# Hospital Acquired Pneumonia: Although the patient was
asymptomatic from a respiratory perspective, her CXR showed RML
pneumonia, and due to her recent hospitalization just 4 weeks
ago, the patient was continued on the Vancomycin and Ceftazidime
that had been started at OSH on ___. She was discharged with
IV antibiotics, to be completed on ___.
.
# Pyelonephritis: This was diagnosed clinically based on
positive urine cultures from OSH, along with fever and CVA
tenderness. For her pan sensitive klebsiella, she was treated
with vanc/ceftaz (providing coverage for HCAP as above) with the
plan to transition her to ciprofloxacin for completion of a 14
day course once finished with IV antibiotics. Her outpatient
neurologist, Dr. ___, was contacted during her
hospitalization given the risk of seizure threshold lower with a
medication such as Cipro, and he felt it was safe for her to
complete a course of Cipro.
#. Hypotension - Pt was hypotensive on admission, likely
secondary to urosepsis vs dehydration in the setting of recent
illness, requiring brief ICU stay. Her BP improved s/p 2L NS in
the ED and was 103/61 on transfer out of the FICU.
.
CHRONIC ISSUES:
.
#. Non-small cell carcinoma- patient currently on docetaxel q3
weeks for palliative purposes. Last dose received on ___.
Followed by Dr. ___ at ___, who continued to follow the
patient while in house.
.
# Left Leg Numbness: patient reported months of posterior left
leg numbness in thigh extending to posterior calf. She had an
MRI of L spine, which was unrevealing for etiology. Discussed
with patient's outpatient neurologist Dr. ___ does not
feel any further imaging is indicated at this time. She will be
referred for outpatient physical therapy and will follow with
Dr. ___ as an outpatient.
#. DVT- patient had left upper extremity DVT ___. She was
continued on enoxaparin daily in the setting of active
malignancy.
.
# Headache: patient reports bifrontal headaches and has been
requiring increasing dose of narcotic medication to control
pain. CT Brain reflects stable metastatic disease without mass
effect, hemorrhage or new lesions. Her neuro exam was non-focal.
She will follow with Dr. ___ as an outpatient
#. GERD- continued PPI
.
TRANSITIONS OF CARE:
# CODE: Full, confirmed
# She will need to complete an 8 day course of IV antibiotics,
last dose ___, then transition to PO Cipro from ___ for
treatment of pyelonephritis.
# Pt is being referred to outpatient physical therapy for
continued work with her left leg.
Medications on Admission:
1. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
DAILY
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. lorazepam 2 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety or insomnia.
4. methylphenidate 54 mg Tablet Extended Rel 24 hr Sig: One (1)
tablet Extended Rel 24 hr PO QAM (once a day (in the morning)).
5. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
capsule, Delayed Release(E.C.) PO once a day.
7. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for nausea.
8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
9. Tylenol ___ mg Tablet Sig: ___ Tablets PO every six (6) hours
as needed for pain.
10. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
12. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Discharge Medications:
1. ceftazidime 2 gram Recon Soln Sig: Two (2) gram Injection Q8H
(every 8 hours) for 4 days: last dose ___.
Disp:*qs gram* Refills:*0*
2. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours): last dose ___.
Disp:*qs gram* Refills:*0*
3. Cipro 500 mg Tablet Sig: One (1) Tablet PO every twelve (12)
hours for 6 days: From ___.
Disp:*12 Tablet(s)* Refills:*0*
4. enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg
Subcutaneous DAILY (Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for nausea.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
13. metronidazole 0.75 % Gel Sig: One (1) Appl Vaginal HS (at
bedtime) for 4 days.
Disp:*4 applicators* Refills:*0*
14. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: Three
(3) ML Intravenous Q8H (every 8 hours) as needed for line flush.
Disp:*qs ML(s)* Refills:*0*
15. heparin, porcine (PF) 10 unit/mL Syringe Sig: Five (5) ML
Intravenous PRN (as needed) as needed for line flush: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen. .
Disp:*qs ML(s)* Refills:*0*
16. heparin lock flush (porcine) 100 unit/mL Syringe Sig: Five
(5) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port: When de-accessing port, flush with 10 mL Normal Saline
followed by Heparin as above per lumen. .
Disp:*qs ML(s)* Refills:*0*
17. lorazepam 2 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety, insomnia.
18. methylphenidate 54 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
primary diagnosis:
pyelonephritis, urinary tract infection
hospital acquired pneumonia
non small cell lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital because you
had a kidney infection and you were also found to have
pneumonia. You were started on antibiotics and your symptoms
improved. You will need to continue IV antibiotics through ___,
and then transition to oral antibiotics until ___.
Please make the following changes to your medications:
1. START vancomycin 1 gram IV every 12 hours, last dose ___. START Ceftazidime 2 gram IV every 8 hours, last dose ___. START ciprofloxacin 500 mg every 12 hours by mouth after IV
antibiotics are completed. You should take ciprofloxacin from
___.
4. START metronidazole 0.75 % Gel 1 Applicator Vaginal at
bedtime for 4 days.
Followup Instructions:
___
|
10784943-DS-18
| 10,784,943 | 26,669,344 |
DS
| 18 |
2161-04-17 00:00:00
|
2161-04-17 13:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Celexa / house dust / ragweed
pollen
Attending: ___
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with past medical history
of Crohn's, fibromyalgia, hypertension, hyperlipidemia, prostate
cancer, carotid dissection, subarachnoid hemorrhage who presents
for evaluation of cough and hypoxemia.
Patient was in his usual health until about 3 days ago. States
his wife was sick at home with a cold. He developed clear
rhinorrhea, postnasal drip, and a cough. He denies any chest
pain
or shortness of breath. However, he said that the postnasal drip
and coughing at night became intolerable, and he has been unable
to sleep lying flat as a result. He denies any orthopnea or PND.
He denies any worsening peripheral edema. He presented to urgent
care at ___ for evaluation of upper respiratory
symptoms. He was noted to be hypoxemic with an oxygen saturation
91% on room air.
Of note EKG showed a new left bundle branch block. He denies any
chest pain or exertional shortness of breath. He was transferred
to our ___ for further evaluation. Presently, he denies any
significant symptoms. He denies chest pain or shortness of
breath. Otherwise feels well.
Past Medical History:
-Crohn's disease
-seen by Neurology in the past for atypical face and head pain
(possibly musculoskeletal headaches), responding to prozac per
OMR
-polyarthralgia, possibly due to parvovirus infection
-hyperlipidemia
Social History:
___
Family History:
Notable for father with coronary disease. No history of stroke,
migraine, or other neurologic disease.
Physical Exam:
Gen: NAD, sitting up in bed
ENT:slight unable to visualize posterior oropharynx MallamPati
score of 3, nc in place
Cardiovasc: RRR, ___ systolic murmur loudest in the right upper
sternal border, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs mild
rhonchorous sounds.
GI: soft, NT, ND, BS+
Skin: No visible rash. No jaundice.
Neuro: AAOx3. CN grossly intact
Psych: Full range of affect
Pertinent Results:
CXR ___ Patchy opacity in the left lower lobe is suspicious for
pneumonia.
CTA chest ___
1. No evidence of pulmonary embolism or aortic abnormality.
2. The study is moderately limited by respiratory motion
artifact. Within these limitations, there is atelectasis and/or
scarring in the right lung base as well as in the lingula.
3. No focal consolidation.
4. Nonobstructing left renal calculi measuring up to 4 mm.
5. Diverticulosis without evidence of acute diverticulitis.
___ Echo: LV EF 70% no gross valvular pathology
Brief Hospital Course:
Mr. ___ is a ___ male with past
medical history of Crohn's, fibromyalgia, hypertension,
hyperlipidemia, prostate cancer, carotid dissection,
subarachnoid
hemorrhage who presents for evaluation of cough and hypoxemia.
#Acute on ?Chronic hypoxic respiratory failure
#Pneumonia/allergic rhinitis
Patient presenting with cough in the setting of post nasal drip
and hypoxemia. Found to be hypoxic with room air at rest
saturation of 90% in room air with ambulation saturation of 86%
requiring ___ L with ambulation to maintain saturations above
90%. CT scan of the chest was performed that was notable
for atelectasis without pneumonia and PE, however the study was
limited by respiratory motion artifact. Patient underwent an
echocardiogram that was grossly normal cardiac etiology to
hypoxia is unlikely. Chest x-ray showed possible left lower
lobe
pneumonia. In the context of CT scan with diagnostic
limitations
treated patient for a community-acquired pneumonia with Levaquin
and low dose steroids.
The etiology and chronicity of patients symptoms is unclear. It
is likely that the patient has a chronic respiratory.
alternative treatments have been tried and failed improving his
symptoms of hypoxia including nebs and antibiotics. Patient
requires home and portable oxygen to improve hypoxia-related
symptoms.
#LBB: EKG with new findings of LBBB. No
other EKGs for comparison except in ___ when he was in sinus
rhythm. No obvious acute process. Likely slowly progressive
degenerative disease involving the conduction system. Discussed
patient case with electrophysiology who thought that
left bundle appearance was not concerning for ischemia. Patient
was asymptomatic nor has he had any symptoms of dyspnea on
exertion shortness of breath or evidence of heart failure on
exam. Echo within nml limits. No additional workup warranted
35 minutes spent on patient care and discharge preparation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 240 mg PO DAILY
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Atorvastatin 40 mg PO QPM
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Vitamin D 800 UNIT PO DAILY
6. FLUoxetine 20 mg PO DAILY
7. Loratadine 10 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
11. Ranitidine 150 mg PO BID:PRN indigestion
12. Mesalamine 800 mg PO TID
Discharge Medications:
1. Fexofenadine 60 mg PO BID
RX *fexofenadine 60 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
2. GuaiFENesin-Dextromethorphan 5 mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 5 ml by mouth
every six (6) hours Refills:*0
3. LevoFLOXacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
4. PredniSONE 20 mg PO DAILY hypoxia
RX *prednisone [Deltasone] 20 mg 1 tablet(s) by mouth once a day
Disp #*4 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Diltiazem Extended-Release 240 mg PO DAILY
8. FLUoxetine 20 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. Levothyroxine Sodium 75 mcg PO DAILY
11. Mesalamine 800 mg PO TID
12. Omeprazole 20 mg PO DAILY
13. Vitamin D 800 UNIT PO DAILY
14.home oxygen
Date of service ___
Concentrator and portable tanks via nasal cannula 2 LPM
ICD 10: Bronchitis
___: 7mo
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to the hospital for cough. You were found a
pneumonia and treated with antibiotics which she will continue
home. Your oxygen levels were also low while in the hospital.
You will be discharged home with oxygen and home health services
to monitor your oxygen saturation. Please limit use of the
oxygen 2 L when walking you do not require any oxygen at rest.
You are also found to have EKG changes of a left bundle branch
block. You underwent an ultrasound of your heart that was
unremarkable. You should follow-up with your primary care
physician.
Followup Instructions:
___
|
10785214-DS-13
| 10,785,214 | 29,152,197 |
DS
| 13 |
2204-08-22 00:00:00
|
2204-08-22 15:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Worsening Renal Function
Major Surgical or Invasive Procedure:
None (had L3-4 laminotomy / discectomy on ___, but this was
on previous admission)
History of Present Illness:
___ with h/o BPH, HTN, CAD s/p PCI, mild distant CVA, and spinal
stenosis s/p L3-4 laminotomy discectomy on ___ presenting
with asymptomatic worsening renal function (2.8 from 1.1 four
days prior). During hospitalization ___, there was a question
of Vtach in PACU (deferred to outpatient cardiology workup), and
patient received IV fluids for episodes of hypotension. Feels
no complaints besides phlegm in throat, denies urinary
retention, fever, chills, nausea, vomiting, diarrhea, chest
pain, or SOB. In the ED, BP 91/56 but otherwise VSS, labs
notable for Cr 2.4, BUN 39, HCT 34.5, Plt 136 and a FeNa of
0.14%. Bladder scan showed decompressed bladder. Ultrasound of
the kidneys showed mild fullness of the left collecting system
with no stones or hydronephrosis, a 0.8 cm left angiomyolipoma,
and an enlarged prostate. UA was unremarkable with no
eosinophils. Received 1L NS, BP improved to 130/79 prior to
transfer, and received another 1L on the floor before holding
further fluids due to concerns of wheezing.
This AM, patient has no complaints. Reports not drinking enough
water at times because he sometimes gets incontinent at night if
he drinks too much from urgency.
Past Medical History:
HTN
CAD s/p stent
spinal stenosis
peripheral neuropathy
arthritis
thrombocytopenia
mild stroke ___
right medial meniscus surgery
L3-4 laminotomy / discectomy on ___
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.6 133/73 86 16 96%RA
General: NAD, resting comfortably in bed.
HEENT: anicteric sclerae, soft neck, MMM
CV: RRR nl S1/S2, no m/r/g
Lungs: excellent air movement, no crackles or rhonchi
Abdomen: soft, nontender, bs+, no suprapubic tenderness
Back: small incision covered with clean dressing in back, mild
tenderness to palpation, no surrounding warmth or erythema
Ext: no edema
Neuro: AOx3, speech fluent, ___ strength in major muscle groups
of upper and lower extremities
DISCHARGE PHYSICAL EXAM:
98.7, 112-134/61-73, 79-86, 94-98% RA, 1000/800
Exam otherwise unchanged.
Pertinent Results:
ADMISSION LABS:
___ 03:50PM BLOOD WBC-9.6 RBC-3.58* Hgb-11.9* Hct-34.5*
MCV-96 MCH-33.2* MCHC-34.4 RDW-14.1 Plt ___
___ 03:50PM BLOOD Glucose-92 UreaN-39* Creat-2.4*# Na-137
K-4.2 Cl-105 HCO3-23 AnGap-13
___ 03:50PM BLOOD Calcium-9.5 Phos-2.8 Mg-2.6
DISCHARGE LABS:
creatinine was 0.9 on the morning of discharge.
Micro: None
Images:
RENAL U.S. ___. Mild fullness of the left collecting system with no stones
or
hydronephrosis.
2. 0.8 cm echogenic lesion suggesting an angiomyolipoma;
however occasionally renal cell carcinoma may be appear
echogenic so follow-up ultrasound is suggested for surveillance
in ___ months. Recommendation discussed with ___ on ___.
3. Enlarged prostate.
Brief Hospital Course:
___ with h/o BPH, HTN, CAD s/p PCI, mild distant CVA, and spinal
stenosis s/p L3-4 laminotomy discectomy on ___ presenting
with asymptomatic ___ (2.8 from 1.1 four days prior).
# Acute Kidney Injury: likely pre-renal given BUN/Cr elevation
and FeNa <1%, possibly from poor PO intake s/p recent surgical
procedure and fear of being incontinent at night. Cr improved
significantly after fluids and was back down to 0.9 on the day
of discharge (from 2.8 on admission). Renal ultrasound showed
no evidence of obstruction, though an angiolipoma was noted that
could be followed up with an ultrasound in ___ months to rule
out renal cell carcinoma. Darifenacin was held since this may
be worsening ___. Gabapentin was renally dosed, and valsartan
was held until GFR resolved. Outpatient echo could be considered
as an outpatient given mild concerns for volume overload after
fluid boluses (though wheezing resolved spontaneously within an
hour).
# CAD s/p stent: asymptomatic, continued on Atenolol 25 mg Oral
Daily, Atorvastatin 40 mg PO DAILY, Clopidogrel 75 mg PO DAILY,
and Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY.
We inquired into whether the patient has taken aspirin before
and he stated that he is not taking aspirin and believes his
cardiologist told him not to take it. It was confirmed with his
son that he was not taking aspirin, and we asked his son to
re-visit this issue with the patient's cardiologist in a timely
fashion.
# Normocytic Anemia: Stable from prior in our system. Iron
studies are not present. Iron studies could be considered as an
outpatient.
# Thrombocytopenia: Stable since ___. Unclear etiology.
# Hypertension: Initially his valsartan was held in the setting
of ___. On discharge after ___ resolved he went to rehab on
prior regimen of Amlodipine 5 mg PO DAILY, though Valsartan 160
mg PO BID.
# BPH: enlarged prostate on Renal US, continued on Finasteride 5
mg PO DAILY
and Tamsulosin 0.4 mg PO BID
# Depression: asymptomatic, continued on Fluoxetine 20 mg PO
DAILY and Mirtazapine 7.5 mg PO HS
# Neuropathic Pain: asymptomatic, continued on Gabapentin 400 mg
PO DAILY (initially renal-adjusted to 300mg PO daily), TraMADOL
(Ultram) 50 mg PO Q6H:PRN pain, and Oxycodone PRN for
breakthrough pain
# GERD: asymptomatic, continued on ranitidine 300 mg PO DAILY
# s/p discectomy: Orthopedic service was notified of patient's
admission
# HCM: Continued on Vitamin D 800 UNIT PO DAILY
TRANSITIONAL ISSUES:
# Code: DNR/DNI
# Communication: son ___ ___
# *******Will need ultrasound follow-up in ___ months of
echogeneic kidney lesion that is considered likely an
angiomyolipoma but very rarely a small renal cell carcinoma
# Aspirin could be considered as an outpatient, we asked the
patient's son to follow up with the patient's ___ cardiologist
about this in a timely fashion.
# Iron studies could be considered as an outpatient.
# If in ___ in the future, darifenacin and valsartan can be held
and gabapentin can be renally dosed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. darifenacin *NF* 15 mg Oral qd
5. Docusate Sodium 100 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Fluoxetine 20 mg PO DAILY
8. Gabapentin 400 mg PO DAILY
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
11. Mirtazapine 7.5 mg PO HS
12. Nitroglycerin SL 0.4 mg SL PRN chest pain
13. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
14. Ranitidine 300 mg PO DAILY
15. Tamsulosin 0.4 mg PO BID
16. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
17. Valsartan 160 mg PO BID
18. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Fluoxetine 20 mg PO DAILY
7. Gabapentin 400 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Milk of Magnesia 30 mL PO Q6H:PRN constipation
10. Mirtazapine 7.5 mg PO HS
11. Nitroglycerin SL 0.4 mg SL PRN chest pain
12. Ranitidine 300 mg PO DAILY
13. Tamsulosin 0.4 mg PO BID
14. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
15. Vitamin D 800 UNIT PO DAILY
16. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
17. Valsartan 160 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
acute kidney injury due to dehydration
SECONDARY:
recent lumbar discectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted with worsening kidney function, which rapidly corrected
with IV fluids. You were observed and found to be able to
maintain good kidney function on your own. Please continue to
drink whenever you are thirsty.
Followup Instructions:
___
|
10785214-DS-14
| 10,785,214 | 21,784,562 |
DS
| 14 |
2205-08-18 00:00:00
|
2205-08-19 22:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an ___ with h/o BPH, HTN, CAD s/p PCI, mild distant CVA,
and spinal
stenosis s/p L3-4 laminotomy discectomy who presents with
dyspnea on exertion and subacute weight gain.
Over last ___ months, patient has been having more shortness of
breath on exertion when walking around with his walker,
especially on ramps and steps. Denying orthopnea and PND, not
sure if legs more swollen. No recent infections or changes in
diet. Notes dry weight is 205-210, lately has been 225. At his
PCP ___ ___ he was 228, ___ was 215. Denies any recent chest
pain, but has had intermittent nausea, not clearly tied to
exertion. Recent med changes include initiation of celecoxib for
back pain 2 months ago, and trospium 1 month ago for
incontinence.
On ___ he was at the ___ seniors. Was engaging
in activitites and started to feel very unwell.- BP was 96/50,
O2 was 78, improved after rest. He initially refused to be
brought to ER but then agreed.
In the ED intial vitals were: 98.8 79 137/77 20 96% 2L Nasal
Cannula. Labs were significant for BNP 1306, trop<.01,
creatinine 1.6 (baseline 1), and negative UA. Patient was given:
Furosemide 20mg IV x1 with rapid improvement in symptoms. Vitals
on transfer: 98.8 74 103/57 18 96% RA. On the floor patient
reports major improvement in his symptoms. BNP is elevated,
trops neg x1.
He is not on ASA for unclear reasons. Of note, per prior ___
notes DOE has been anginal equivalent in the past. His Cath his
is as follows:
___: Cx stent
___: LAD DES
___: DES/LAD ostium DES, mid-LAD stent
Had nml perfusion on stress in ___. Last saw cards at ___ ___ yr
ago where there were no cardiac concerns. Spoke with Dr. ___,
___ cardiologist this AM, recommended low threshold for cath.
Past Medical History:
HTN
CAD s/p stent
spinal stenosis
peripheral neuropathy
arthritis
thrombocytopenia
mild stroke ___
right medial meniscus surgery
L3-4 laminotomy / discectomy on ___
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION:
VS: T=98.3 BP=149/83 HR=76 RR=20 O2 sat= 95RA
GENERAL: in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP up to earloabe at 45 degrees
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. soft II/VI ?holosystolic murmur. No
thrills, lifts. No S3 or S4 appreciated
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. ___ breath sounds at
bases
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: 2+ pitting edema up to bottom of knees bilaterally.
No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 1+ DP pulses
DISCHARGE:
Vitals: 98.5 139/97 76 20 93-94% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP at lower ___ neck at 45 deg, no LAD or carotid
bruits
Lungs: CTAB
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.
Trace edema at ankles
Skin: No rashes.
Neuro: Grossly nml strength/sensation and cranial nerves
Pertinent Results:
ADMISSION LABS:
___ 07:36PM PLT COUNT-101*
___ 07:36PM NEUTS-57.7 ___ MONOS-6.1 EOS-4.9*
BASOS-0.8
___ 07:36PM WBC-6.5 RBC-3.76* HGB-12.8* HCT-37.0* MCV-98
MCH-33.9* MCHC-34.5 RDW-13.2
___ 07:36PM CALCIUM-9.1 PHOSPHATE-2.6* MAGNESIUM-2.3
___ 07:36PM cTropnT-<0.01 proBNP-1306*
___ 07:36PM estGFR-Using this
___ 07:36PM GLUCOSE-87 UREA N-33* CREAT-1.6* SODIUM-137
POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-27 ANION GAP-10
___ 10:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 10:22PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:22PM URINE GR HOLD-HOLD
___ 10:22PM URINE UHOLD-HOLD
___ 10:22PM URINE HOURS-RANDOM
___ 10:22PM URINE HOURS-RANDOM
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-4.9 RBC-4.02* Hgb-13.4* Hct-38.9*
MCV-97 MCH-33.4* MCHC-34.5 RDW-13.1 Plt ___
___ 08:15AM BLOOD Glucose-109* UreaN-23* Creat-1.2 Na-138
K-3.9 Cl-103 HCO3-25 AnGap-14
___ 08:15AM BLOOD Calcium-10.0 Phos-2.6* Mg-2.4
IMAGING:
EKG ___: Sinus rhythm. Prolonged P-R interval. Left
bundle-branch block. Prolonged Q-T interval. Compared to the
previous tracing of ___ no definite change.
CXR ___: IMPRESSION: Streaky right basilar opacities, probably
due to atelectasis,
associated with an eventration of the right hemidiaphragm.
Stable nodular
focus projecting over the left mid lung.
TTE ___: Conclusions
The left atrium is moderately dilated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is low normal (LVEF 50%). Mechanical dyssynchrony with
LBBB activation sequence is present. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no left ventricular outflow obstruction
at rest or with Valsalva. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. There are focal calcifications in the aortic arch. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of ___ the findings are similar. Left
ventricular dyssynchrony appears similar.
Carotid US ___: (Preliminary): no stenosis
Brief Hospital Course:
___ with h/o BPH, HTN, CAD s/p DES to LAD/diag ___, TIA ___,
and spinal stenosis s/p L3-4 laminotomy discectomy on ___ who
presents with dyspnea on exertion consistent with e/o new CHF.
#Congestive Heart Failure: Subacute, diastolic. Seems to be
somewhat subacute to chronic based on increased weight over
several months, without acute worsening on ___, now
significantly improved symptomatically after diuresis. No known
dx of CHF. No e/o RWMA to suggest worsening coronary dx. Cox-2
inhibitor may have been contributing as well, re. fluid
retention. No infectious sx or EKG changes to suggest ACS,
myocarditis, and trops neg x2. Valves unchanged on TTE. Pt is
not anemic and had nml TSH in ___. Suspect this is a
longstanding process. Diuresed with IV lasix boluses with good
effect, transitioned to PO diuretic with plan for cards ___ as
outpt. Felt that presentation not convincing for worsened
coronary disease for cause. Given chronicity of symptoms,
deferred decision re stress test vs left heart cath to the outpt
setting but likely low yield. Continued nitrate, CCB, switched
atenolol to metoprolol. ___ improved with diuresis.
#Acute Kidney Injury: Elevated from baseline around 1, peaked at
1.6, down to 1.2 at discharge. Likely ___ cardiorenal in the
setting of volume overload from CHF, trended down with diuresis.
Held valsartan at discharge given soft blood pressures after
restarting this medication.
#CAD s/p stent: See CHF as above. Unclear why not on ASA, PCP
and cardiologist unsure. Continued clopidogrel (unclear why
still on it, possibly for CAD secondary prophylaxis). Restarted
ASA 81 mg. Switched omperazole to H2 blocker prn per PCP
___.
# ?TIAs: Pt with possible TIA-like symptoms recently, does have
a h/o stroke. TTE and carotid US both neg. This symptom, if it
recurs, can worked up in the outpt setting.
#Overactive Bladder/BPH: Continued flomax, trospium (did not
receive in house bc of lack of supply, pt did not have his own
meds)
Transition issues:
- Started on 40 PO lasix daily
- Started on aspirin
- Started on docusate
- Tylenol with codeine stopped as not clearly being prescribed
it and already on tramadol
- Switched atenolol for metoprolol (atenolol renally cleared)
- Switched esomeprazole for ranitidine prn (PCP ___
- Held Diovan given low blood pressures after it was restarted,
consideration for restarting at a lower dose as an outpt can be
assessed at PCP ___
- Stopped celebrex (thought to have possibly contributed to
sodium retention)
- Would suggest checking electrolytes at followup PCP
appointment to assess for need of repletion
- Discharged with home ___ and ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Valsartan 160 mg PO BID
3. Tamsulosin 0.4 mg PO BID
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Atorvastatin 40 mg PO DAILY
6. Lorazepam 1 mg PO HS:PRN insomnia
7. NexIUM (esomeprazole magnesium) 20 mg oral Daily
8. Amlodipine 5 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
10. Mirtazapine 7.5 mg PO HS
11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
12. Senna 8.6 mg PO BID:PRN constipation
13. trospium 60 mg oral Daily
14. celecoxib 100 mg oral BID prn pain
15. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN pain
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Mirtazapine 7.5 mg PO HS
6. Senna 8.6 mg PO BID:PRN constipation
7. Tamsulosin 0.4 mg PO BID
8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
9. Aspirin 81 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
13. Lorazepam 1 mg PO HS:PRN insomnia
14. Ranitidine 150 mg PO DAILY:PRN reflux
15. trospium 60 mg oral Daily
16. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Acute on chronic diastolic heart failure
Secondary:
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure caring for you at ___. You were admitted for
shortness of breath and found to be in heart failure (meaning
you had too much fluid in your body). You were given a diuretic
to help remove this excess fluid. You should followup with your
PCP and cardiologist, and eat a low sodium diet (never more than
2g in a day)
You did not have any symptoms or tests that were concerning for
a stroke.
Several medication adjustments were made. Please see the
accompanying sheet for details. Of note, please do not take the
celecoxib (Celebrex) any longer. You were started on aspirin.
Also, your blood pressure was a little low after taking the
Diovan so it was stopped. You and your PCP can decide if to
restart it. Please do not take the Tylenol with codeine any
longer as your pain was controlled with Tylenol (without
codeine) and tramadol.
Followup Instructions:
___
|
10785344-DS-10
| 10,785,344 | 28,358,492 |
DS
| 10 |
2149-03-29 00:00:00
|
2149-03-30 11:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
paresthesias
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old woman with a history of stroke in
___ (L sided numbness and weakness which is now much improved),
sarcoid (affecting her lungs and eyes), asthma, p/w an episode
of presyncope, chest pain, and tingling in her L face, L hand,
and R foot.
The patient was walking out of a store at 1:30 ___ when she had
an episode of presyncope. She was normal and then suddenly she
had a feeling of "wham" and she started to fall but caught
herself on the door. She did not pass out or lose conciousness
or fall to the floor. She was able to get herself together and
walk out of the store, but overall felt a bit discombobulated
and somewhat lightheaded, no vertigo. She noted that her vision
seemed a bit blurry. She leaned against a wall for a while and
then collected herself and went about her day. However, the
whole rest of the day she felt strange and "not like myself".
Around 5 ___ she started to note some chest pressure which was
somewhat similar to pains she has had before with her asthma
exacerbation, although there was no associated SOB. At the same
time she noted some tingling in her bilateral hands but much
more pronounced on the L than the R, and some tingling in her R
foot. The tingling in her hands was mostly in her L hand
affecting all the fingers and extending into her palm. The
tingling in the R hand was milder and just in the tips of her
fingers. This tingling has been persistant until time of
evaluation. The tingling in the R foot involved all 5 toes but
was only present for ___ minutes before resolving.
She continued to have the L hand tingling and chest pain for the
rest of the day. At 11 ___ she noted onset of lips and face
tingling, so she decided to come to the ED.
Past Medical History:
- h/o stroke in ___ seen at ___. Reportedly cryptogenic. Per
patient she presented with a L leg dragging, L hand and L face
numbness, and L hand weakness. She recovered her strength well
in rehab afterwards.
- sarcoid diagnosed in ___. Affecting her lungs and eyes.
Recently not active per patient
- asthma, with recent hospitalization.
- she is being worked up for possible carpal tunnel syndrome for
chronic wrist pain and grip weakness
Social History:
___
Family History:
P grandmother with stroke.
Father MI at ___ yo
Mother MI at ___ yo, CHF
Brother type 2 diabetes
Other siblings - many with hyperlipidemia, hypertension
Physical Exam:
Admission Exam:
VS 97.0 72 144/78 16 98%
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus
Pulmonary: non labored
Abdomen: Soft, obese
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status -
Awake, alert, oriented x 3. Attention to examiner easily
attained
and maintained. Concentration maintained when recalling months
backwards. Recalls a coherent history. Structure of speech
demonstrates fluency with full sentences, intact repetition, and
intact verbal comprehension. Content of speech demonstrates
intact naming (high and low frequency) and no paraphasias.
Normal
prosody. No dysarthria. Verbal registration and recall ___. No
evidence of hemineglect
- Cranial Nerves -
I. not tested
II. Equal and reactive pupils (3 to 2 mm). On fundoscopic exam,
optic disc margins were sharp. Visual fields were full to finger
wiggling.
III, IV, VI. smooth and full extraocular movements without
diplopia or nystagmus.
V. facial sensation was intact, muscles of mastication with full
strength
VII. face was symmetric with full strength of facial muscles
VIII. hearing was intact to finger rub bilaterally.
IX, X. symmetric palate elevation and symmetric tongue
protrusion with full movement.
XI. SCM and trapezius were of normal strength and volume.
Elevates the L shoulder less than the R in the setting of L
shoulder muscular spasm.
- Motor -
Muscule bulk and tone were normal. There is moderate L sided
pronator drift. There is + muscle spasm near the L shoulder
blade.
Delt Bic Tri ECR FExt FFlx IP Quad Ham TA Gas
L 5 5 5 5* 5* 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5
*There is L sided motor impersistance and some give way weakness
with testing, although max strength on the L was full.
- Sensation -
Decreased to pinprick on the entire palm of the R hand, and the
entire palm and dorsum of the L hand, returnts to normal several
cm above the wrist.
Intact to proprioception at the great toes.
- DTRs -
Bic Tri ___ Quad Gastroc
L 1 0 1 1 0
R 1 0 1 1 0
Plantar response mute bilaterally.
- Cerebellar -
No dysmetria with finger to nose testing bilaterally. Good speed
and intact cadence with rapid alternating movements.
- Gait -
Normal initiation. Narrow base. Normal stride length and arm
swing. Stable without sway. No Romberg.
****************
Discharge Exam:
Vitals stable
Alert, awake, speech fluent and appropriate.
Cranial nerves: PERRL, EOMI, intact sensation to light
touch/pinprick throughout V1-V2 though complaining of tingling
in the lips. Face symmetric.
Motor: No pronator drift. Good strength bilaterally, both
proximally and distally.
Sensory: intact to light touch and pinprick throughout.
Good coordination and gait.
Pertinent Results:
Admission Labs:
___ 01:20AM BLOOD WBC-7.6# RBC-4.69 Hgb-11.6* Hct-37.9
MCV-81* MCH-24.8* MCHC-30.7* RDW-15.2 Plt ___
___ 01:20AM BLOOD Neuts-47.9* Lymphs-43.2* Monos-6.5
Eos-1.8 Baso-0.6
___ 01:33AM BLOOD ___ PTT-32.9 ___
___ 01:20AM BLOOD Glucose-95 UreaN-19 Creat-1.0 Na-139
K-4.3 Cl-100 HCO3-34* AnGap-9
___ 01:20AM BLOOD ALT-20 AST-19 AlkPhos-71 TotBili-0.3
Relevant Labs:
___ 01:20AM BLOOD cTropnT-<0.01
___ 08:55AM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:55AM BLOOD %HbA1c-6.1* eAG-128*
___ 08:55AM BLOOD Cholest-231* Triglyc-68 HDL-72
CHOL/HD-3.2 LDLcalc-145*
UA/UTox negative
Stox negative
Imaging:
CT head ___: No acute intracranial abnormality.
CXR ___: No acute cardiopulmonary abnormality. Stable
borderline cardiomegaly.
ECG ___: Sinus bradycardia. Compared to the previous tracing
the rate is slower.
MRI/MRA of brain (prelim): No significant abnormality is seen
except for mild sequela of chronic small vessel ischemic
disease.
Brief Hospital Course:
Ms. ___ is a ___ F with h/o prior stroke ___ (reported
history of L sided weakness/numbness), sarcoidosis (in
remission) who presented with L facial, bilateral hand and right
foot tingling in setting of increased social stressors, feeling
off/presyncopal and chest pressure. She was admitted to stroke
service to rule out stroke given her past history. Her MRI did
not show any acute ischemia and her cardiac work up was also
negative. Her symptoms improved on its own, and patient reported
increased stressors at home which may have contributed to this
episode - including her son, who is struggling with alcoholism,
recently moving back with her. She also witnessed one of her
nephews having a grand mal seizure the day before this event
occurred, which made her more worried.
However, she was found to have hyperlipidemia during the work
up, so she was started on atorvastatin and baby aspirin given
her reported history of past stroke in ___. She was asked to
follow up in stroke clinic.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
prn wheezing
4. Cetirizine 10 mg oral daily
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
prn wheezing
4. Cetirizine 10 mg oral daily
5. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
6. Atorvastatin 20 mg PO DAILY
RX *atorvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: paresthesias, hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital with tingling
of your left face, both hands and right foot. MRI did not show
any stroke and we do not think you had a mini-stroke or TIA.
However, given that you had a small stroke in ___, we do
recommend starting a baby aspirin (81 mg daily) as well as
atorvastatin (Lipitor) for your high cholesterol.
We will have our stroke clinic call you with a follow up
appointment.
Followup Instructions:
___
|
10785570-DS-19
| 10,785,570 | 29,904,158 |
DS
| 19 |
2159-08-06 00:00:00
|
2159-08-07 11:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zestril / Calcium Channel Blockers / Dilaudid (PF)
Attending: ___
Chief Complaint:
Nausea, vomitting, diarrhea and abdominal pain x 2days
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ yo female with a history of alcohol-induced
pancreatitis (___), reflux esophagitis, incisional hernia,
DMII, and HepB, who presents with nausea, vomitting, abdominal
pain, and diarrhea x 2days.
Per patient, she started having a pint of rum daily since her
sister passed away in ___. She had a brief period of 4 days
for which she attempted to stop drinking but restarted last
___. One day prior to admission (___), she developed
severe nausea, frequent dark colored/nonbilious vomitting, and a
___ abdominal pain localized in the epigastric region and
RUQ, worsening on palpation. Her abdominal pain persisted
throughout the day, spreading to the LLQ and her back. She
noticed that the emesis that was initially dark colored, had
gradually become nonbloody and nonbilious, but with no change in
frequency (once every couple of hours). In addition, she
reported having shortness of breath and mild chest pain with
each episode of vomitting, such that she thought she was "having
seizure". At night, she developed diarrhea w/ small amount of
red blood noted on the tissue, but no active GI bleeding.
Overnight, the abdominal pain worsened and woke her up multiple
times. Despite her symptoms, patient continued to drink for the
past two days, reporting having improved pain but worsened
vomitting and diarrhea with drinking. Because her symptoms were
similar to the previous episode of pancreatitis, patient was
concerned for recurrent alcohol-induced pancreatitis and came to
___ ED today for further evaluation and management.
Of note, patient endorsed having an unintended weight loss of 15
lb since ___, as well as decreased appetite (minimal food intake
since ___, last meal baked potato yesterday AM). Patient
also reported having throat pain (due to reflux), headache, and
worsened shooting pain (?myalgia) from her ankle to upper thigh
bilaterally. Otherwise, patient denied fevers, chills and night
sweats. She has no recent change in diet, no traveling outside
of the US, and no sick contact.
In the ED, initial vs were: 98.4 125 148/99 16 97%. Labs were
remarkable for K 5.2, ALT 121, AST 326, Lip 66, Cr 1.3, lactate
4, INR 1.1, HCT 41.8. RUQ US showed No ascites. Small amount of
nonspecific pericholecystic fluid without gallbladder wall
thickening or stone/sludge. No sonographic ___ sign.
Patient was given thiamine, tramadol, lorazepam, ondansetron,
and folic acid before transferred to ___.
On the floor, vs were: T98 P92 BP160/90 R20 O2 sat 99% on RA.
Patient appeared to be uncomfortable but stable and not in acute
distress.
Past Medical History:
HCV, HBV, HTN, GERD, DM, OSA, gout, arthritis, asthma, sleep
apnea,hypothyroidism, anemia, h/o heroine/EtOH abuse,
hypercholesterolemia
___ Laparoscopic transverse colectomy
TAH
Tubal ligation
R knee surgery
Rotator cuff x2
R foot surgery
Back lipoma
Social History:
___
Family History:
- Mother (___) alive.
- Brother has had gallstones
- sister with metastatic cancer to breast, chest, and lungs.
deceased.
- mother's sister with breast cancer
- father's sister with gastric cancer
- no additional family history of cardiac diseases, lung
diseases (COPD, asthma), renal diseases, hypertension, or
diabetes.
Physical Exam:
Admissions Physical Exam:
VS: T98 P92 BP160/90 R20 O2 sat 99% on RA
General: patient appears to be stated age. slightly
uncomfortable, but non-stressed.
HEENT: NC/AT. PERRL. EOMI. Throat clear.
Neck: supple. thyroid gland non-palpable. no lymphadenopathies.
CV: slightly tachycardia (~108), regular rhythm. nl S1 and S2.
no murmurs, rubs, or gallops
RESP: CTAB. no wheezes, rales, rhonchi.
Abdomen: soft w/o masses, non distended. no rebound tenderness
but guarding when palpating epigastric region and RUQ. +BS
appreciated at all 4 quarants. liver edge was not palpated due
to patient's pain. no costovertebral tenderness.
Extremities: warm and well perfused. capillary refill <2sec. no
clubbing, cyanosis, or edema. normal range of motion. 2+ radial
and DP pulses.
Derm: no rash noted.
Neuro: CN II-XII grossly intact. upper extremities 3+/5
strength. lower extremities ___ strength.
Discharge Physical Exam:
Vitals: Tc:98.4 BP 158/90 P72 R18 O2 Sat 100% on RA. ___ pain
24hr I 840+208 O: 1225/BMx2
General: slightly uncomfortable. non-distressed. frustrated with
her pain. asked for pain meds.
HEENT: NC/AT. Throat clear.
Neck: supple. thyroid gland non-palpable. no lymphadenopathies.
CV: RRR. nl S1 and S2. no murmurs, rubs, or gallops
RESP: CTAB. no wheezes, rales, or rhonchi.
Abdomen: soft w/o masses, non distended. No rebound tenderness
and guarding when palpating. (however, patient continued to
report ___ pain in RUQ radiating to the back, RLQ, and
paraumbilical region.) + BS. no spider angiomata
Extremities: warm and well perfused. capillary refill <2sec. no
clubbing, cyanosis, or edema. normal range of motion. 2+ radial
and DP pulses. no Asterixis. no palmar erythema noted.
Pertinent Results:
ADMISSION LABS:
___ 12:15PM ___ PTT-31.0 ___
___ 12:15PM PLT COUNT-183
___ 12:15PM NEUTS-59.4 ___ MONOS-6.1 EOS-0.6
BASOS-1.1
___ 12:15PM WBC-5.7 RBC-4.49 HGB-13.6 HCT-41.8 MCV-93#
MCH-30.4 MCHC-32.6 RDW-15.3
___ 12:15PM ETHANOL-NEG
___ 12:15PM ALBUMIN-3.9 CALCIUM-9.2 PHOSPHATE-2.5*
MAGNESIUM-2.0
___ 12:15PM LIPASE-66*
___ 12:15PM ALT(SGPT)-121* AST(SGOT)-326* ALK PHOS-99 TOT
BILI-0.6
___ 12:15PM estGFR-Using this
___ 12:15PM GLUCOSE-237* UREA N-13 CREAT-1.3* SODIUM-136
POTASSIUM-5.2* CHLORIDE-97 TOTAL CO2-23 ANION GAP-21*
___ 12:21PM LACTATE-4.0*
___ 12:21PM ___ COMMENTS-GREEN TOP
___ 04:46PM LACTATE-1.6
___ 08:45PM HBsAg-NEGATIVE HAV Ab-POSITIVE
___ 08:45PM CALCIUM-8.4 PHOSPHATE-1.6* MAGNESIUM-2.0
___ 08:45PM GLUCOSE-199* UREA N-12 CREAT-1.3* SODIUM-138
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
IMAGING STUDIES:
___ ECG
Sinus rhythm with ventricular ectopy. No major change from
previous tracing.
___ LIVER OR GALLBLADDER US
IMPRESSION:
1. Small amount of nonspecific pericholecystic fluid without
gallbladder wall thickening or stone/sludge. No sonographic
___ sign elicited.
Otherwise, no ascites seen.
___ CHEST (PORTABLE AP)
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Normal size of the cardiac silhouette. No pleural
effusions. No parenchymal opacities. No pulmonary edema. Mild
tortuosity of the thoracic aorta.
___ CT ABDOMEN W/CONTRAST
IMPRESSION:
1. Fat stranding surrounding the head and uncinate process of
the pancreas in keeping with acute pancreatitis.
2. Fat deposition within the liver, with a possible recanalized
paraumbilical vein, early portal hypertension due to cirrhosis
cannot be excluded.
3. Two focal areas of colonic thickening/polyps as described
above,
colonoscopy is recommended for further evaluation.
___ ABDOMEN (SUPINE & ERECT)
IMPRESSION: Two supine frontal and a left decubitus frontal
view are
submitted, compared to ___:
Formed stool is present in an otherwise normal appearing colon
from the
hepatic flexure to the rectum, where there is stool containing
oral contrast agent. There is no small bowel distention. No
free intraperitoneal gas. There is no intra-abdominal mass
effect, though this is not excluded by this examination.
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-5.9 RBC-3.77* Hgb-11.6* Hct-35.9*
MCV-95 MCH-30.6 MCHC-32.2 RDW-15.9* Plt ___
___ 07:20AM BLOOD Plt ___
___ 07:40AM BLOOD ___ 07:20AM BLOOD
___ 07:20AM BLOOD Glucose-190* UreaN-12 Creat-1.0 Na-138
K-3.9 Cl-102 HCO3-29 AnGap-11
___ 07:20AM BLOOD ALT-41* AST-76* AlkPhos-85 TotBili-0.4
___ 07:20AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.8
Brief Hospital Course:
Ms. ___ is a ___ yo female with a history of
alcohol-induced pancreatitis (___), reflux esophagitis,
incisional hernia, DMII, and HepB, who presents with nausea,
vomitting, abdominal pain, and diarrhea x 2days.
#VOMITTING: patient initially had non-bloody and non-billious
vomitting. Patient's lipase, AST, ALT were elevated (AST:ALT
was 2:1) suggesting alcohol use in the setting of pancreatitis.
Patient underwent CT scan, which confirmed pancreatitis.
Patient was managed with bowel rest and intravenous fluids. She
was discharged on a low fat diet. She was also advised to stop
drinking alcohol as this was thought to be the trigger for her
most recent episode.
#DIARRHEA - Patient was thought to have diarrhoe secondary to
EtOH induced pancreatitis. C. Diff culture was negative.
Patient had no diarrhea, hematochezia, or melena during her
hospital course. Her electrolytes were low secondary to
diarrhea initially but was K and Mg repleted. On discharge,
patient was stable with normal electolytes.
#ABDOMINAL PAIN: Patient presented with RUQ pain radiating to
the back, consistent with pancreatitis. Diabetic gastroparesis
was also on the differential given patient's history of DM and
but her HbA1c was 6.6. Patient was given IV morphine and
oxycodone for pain control during her hospital course and was
kept NPO for 5 days. Patient's symptoms improved with bowel
rest. On discharge, patient was able to walk around with no
discomfort. There was subjective pain, but no rebound
tenderness or guarding on abdominal exams. Three days of
oxycodone was given for her pain until her follow up appointment
with GI.
#EtOH ABUSE: patient was evaluated via CIWA scale. Thiamine and
folate supplement was given during ___ hospital course.
Patient was also assessed by social works and nutrition. On her
discharge, patient showed no signs of withdrawl with >96hrs of
EtOH free.
#TRANSAMINITIS: Patient initially presented with elevated ALT
and AST in the ratio of 2:1 concerning for transaminitis. Given
her hostory of hepatitis B and hepatitis C, recurrent hepatitis
in the setting of pancreatitis was concerning. Patient had
negative HsBAg, indicating no active Hepatitis B. However, her
HCV viral load was high (8,606,711 IU/mL), which will be
followed by PCP after her discharge. Over the course of her
hospitalization, AST and ALT had gradually trended down as she
was clinically improving.
#DIC: The AM lab on her HD#2 showed elevated INR (2.2), as well
as low platelets, concerning for DIC. Fibrinogen level was
below normal. Patient was monitored closely with AM and ___ labs
following fibrinogen trends and on her HD#4, fibrinogen level
returned to normal. In addition, both INF and platelets were
improving. Overall, DIC was resolved prior to the discharge.
#ACUTE RENAL INJURY: patient had mildly elevated creatinine
(1.3) when she was admitted. Given her 2 days history of
vomitting and diarrhea w/ decreased food intake, pre-renal ___
was high on the differential. Over her hospital course, patient
was maintained on IVF and her creatinine returned to baseline on
HD#3.
Transition Issues:
#ATRIAL TACHYCARDIA : Followed by Dr ___. As this puts her
at high risk of an embolus. She was given rivaroxiban and
metoprolol while she was hospitalized.
#ASTHMA/OSA: no episodes of SOB during this hospitalization.
She was given albuterol nebs and flonase.
#HYPOTHYROIDISM: her TSH was elevated. She was given her home
dose of levothyroxine. ___ need to updose levothyroxine if
continue to have elevated TSH. Please check TSH in one month's
time.
#dHF: her home meds valsartan and spironolactone was on hold
when she was hospitalized. Consider restart home meds once
symptoms completely resolved.
#Patient due for colonoscopy screening this year
#please ensure GI follow up
#please f/u hepatitis C viral load in GI ___ clinic
#please f/u pending blood cultures
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 100 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Rivaroxaban 20 mg PO DAILY
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
6. Betamethasone Dipro 0.05% Cream 1 Appl TP BID:PRN itch
7. NexIUM (esomeprazole magnesium) 40 mg oral daily
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. GlipiZIDE XL 10 mg PO BID
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. spironolacton-hydrochlorothiaz 50-50 mg oral daily
12. Valsartan 160 mg PO QAM
13. Valsartan 80 mg PO QPM (___)
14. Glargine 45 Units Bedtime
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Levothyroxine Sodium 150 mcg PO DAILY
RX *levothyroxine 150 mcg 1 tablet(s) by mouth once daily Disp
#*30 Tablet Refills:*0
3. Metoprolol Tartrate 100 mg PO BID
4. Rivaroxaban 20 mg PO DAILY
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
please try to use less medication as time goes on
RX *oxycodone 5 mg 1 capsule(s) by mouth every 6 hours Disp #*36
Tablet Refills:*0
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
7. Betamethasone Dipro 0.05% Cream 1 Appl TP BID:PRN itch
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. GlipiZIDE XL 10 mg PO BID
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. NexIUM (esomeprazole magnesium) 40 mg oral daily
12. spironolacton-hydrochlorothiaz 50-50 mg oral daily
13. Valsartan 160 mg PO QAM
14. Valsartan 80 mg PO QPM (___)
15. Glargine 45 Units Bedtime
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pancreatitis
Early portal hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Miss ___,
It was a pleasure having you here at the ___
___. You were admitted with vomitting, diarrhoea and
abdominal pain. You had CT imaging of your abdomen and found to
have pancreatitis. You were managed with bowel rest and
intravenous fluids. You were transitioned to a low fat diet.
You tolerated diet well. You were discharged with oxycodone to
control your pain. Please keep your follow-up appointments
below. Please also try to maintain a low fat diet and avoid
alcohol as much as possible as this can trigger your
pancreatitis.
Followup Instructions:
___
|
10785570-DS-23
| 10,785,570 | 25,503,241 |
DS
| 23 |
2161-05-05 00:00:00
|
2161-05-05 18:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zestril / Calcium Channel Blockers / Dilaudid (PF) /
ciprofloxacin / clindamycin
Attending: ___.
Chief Complaint:
eye pain, visual disturbance, abnormal MRI results
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ yr old female with left-sided
infiltrating ductal carcinoma, grade III with significant
lymphovascular involvement. She is status post four cycles of
chemotherapy and recently completed radiotherapy in ___.
history Also hx of atrial arrhythmia, chronic hepatitis C and
ETOH abuse. She was referred to ED after MRI at ___ earlier
today showed innumerable brain metastases and extensive
leptomeningeal disease.
Patient reports that about 2 weeks ago she started having L
sided
HA and pain over the L side of her face, also now having pain in
her L eye. Reports pains as sharp and stabbing. Is using
percocet
w/ some relief. She also began noting some L blurry vision and
double vision and was due for her regular biannual eye exam so
she waited. Was told at the exam last ___ she had ___ nerve
palsy
and was referred for MRI. Denies any numbness or extremity
weakness, in fact says her strength is better than after chemo,
now she is able to get up from her knees or the ground on her
own
which she couldnt do few weeks ago. Denies any fever/chills,
back
pain, bowel/bladder incontinence, confusion or balance
disturbance. Does have tingling in her R foot but this has been
present for some time, not new.
Initial VS in ED 17:33 8 98.0 70 232/92 18 100% 4L Nasal Cannula
VS prior to transfer ___ 80 197/90 16 99% RA
MRI reviewed admitted for initiation of dexamethasone ,
evaluation for other sites of disease and emergency radiation
therapy.
In ED pt was given 10mg IV dex at 10pm, labetalol 10mg IV at
945pm, labetalol 200mg PO
BP improved to 180s on arrival to floor. Denies any chest pain,
lightheadedness or SOB. cont to have HA states she didnt get any
pain meds in ED
Past Medical History:
PAST MEDICAL HISTORY:
obstructive sleep apnea (does not use cpap)
asthma
hypertension
hearing impairement left ear
GERD
hypothyroidism
gout
paroxysmal atrial tachycardia
atypical lobular hyperplasia
adenomatous polyps
diabetes c/b diabetic retinopathy
hepatitis C
renal insufficiency
shoulder pain status post rotator cuff repair
recurrent episodes of alcoholic pancreatitis
PAST SURGICAL HISTORY:
left shoulder arthroscopy with subacromial decompression;
rotator cuff repair; tendinosis (___),
right shoulder arthroscopy; arthtroscopic biceps tenotomy and
open rotator cuff repair right shoulder;
arthoecopic subacromial decompression and biceps tendinosis
right shoulder (___),
right hand carpal tunnel release endoscopic right hand
tenosynovectomy (___),
right hand flexor tenosynovectomy and trigger release third
digit (___),
right terminal duct excision breast (___),
repair of herniorrhaphy incarcerated epigastric excision of
necrotic tissue (___),
laparoscopic assisted transverse colectomy ___ ___
Social History:
___
Family History:
son, uncle and cousin with h/o cocaine use
- Mother (___) alive.
- Brother has had gallstones
- sister with metastatic cancer to breast, chest, and lungs.
deceased.
- mother's sister with breast cancer
- father's sister with gastric cancer
- no additional family history of cardiac diseases, lung
diseases (COPD, asthma), renal diseases, hypertension, or
diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD, morbidly obese, pleasant
VITAL SIGNS: 98.3 180/92 73 20 98%RA
HEENT: MMM, no OP lesions no ulcers or thrush
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no palpable masses
LIMBS: No edema, full ROM
SKIN: No rashes or skin breakdown
NEURO: pupils reactive to light L larger, bilat cateracts, face
symmetric, no nystagmus, medial deviation of L eye and unable to
laterally deviate, pt gets nauseated w/ this
L eye w/ L inf field cut, R eye fields intact
strength ___, sensation intact to light touch
FTN/HTS testing intact
did not assess gait
DISCHARGE PHYSICAL EXAM:
VS: 97.9 150s-170s/70s-90s ___ 96-99% RA
I/O 300/150+
FSGs 173-247
General: NAD, morbidly obese, pleasant
HEENT: MMM, no OP lesions no ulcers or thrush
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no palpable masses
LIMBS: No edema, full ROM
SKIN: No rashes or skin breakdown
NEURO: not hallucinating at this time, PERRL, bilat cateracts,
face
symmetric, no nystagmus, medial deviation of L eye and unable to
laterally deviate L eye, pt feels pain with extraocular eye
movements, strength ___ bilaterally in extremities, sensation
intact to light touch, FTN/HTS testing intact, did not assess
gait
Pertinent Results:
ADMISSION LABS:
-----------------
___ 06:46PM BLOOD WBC-5.9 RBC-3.57* Hgb-11.1* Hct-33.8*
MCV-95# MCH-31.1 MCHC-32.8 RDW-13.6 RDWSD-46.5* Plt ___
___ 06:46PM BLOOD Neuts-62.6 ___ Monos-9.0 Eos-1.5
Baso-0.3 Im ___ AbsNeut-3.69 AbsLymp-1.54 AbsMono-0.53
AbsEos-0.09 AbsBaso-0.02
___ 06:46PM BLOOD ___ PTT-33.8 ___
___ 07:40AM BLOOD Creat-1.4*
___ 07:40AM BLOOD estGFR-Using this
___ 06:46PM BLOOD GreenHd-HOLD
DISCHARGE LABS:
-----------------
___ 08:10AM BLOOD WBC-9.9 RBC-3.43* Hgb-10.7* Hct-32.6*
MCV-95 MCH-31.2 MCHC-32.8 RDW-13.7 RDWSD-47.7* Plt ___
___ 08:10AM BLOOD Neuts-87.8* Lymphs-5.3* Monos-4.8*
Eos-0.0* Baso-0.1 NRBC-0.2* Im ___ AbsNeut-8.69*
AbsLymp-0.53* AbsMono-0.48 AbsEos-0.00* AbsBaso-0.01
___ 08:10AM BLOOD Plt ___
___ 08:10AM BLOOD Glucose-185* UreaN-32* Creat-1.2* Na-132*
K-4.4 Cl-100 HCO3-24 AnGap-12
___ 08:10AM BLOOD estGFR-Using this
___ 07:30AM BLOOD ALT-32 AST-38 AlkPhos-85 TotBili-0.2
___ 08:10AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.3
MICRO:
---------------
Blood culture ___ no growth
EKG:
--------------
___ Sinus rhythm. Normal ECG. Compared to the previous tracing
of ___ no significant change except for a slightly slower
rate.
IMAGING:
---------------
MRI brain and orbits ___
IMPRESSION:
1. Innumerable intracranial metastasis from patient's known
breast cancer. No midline shift is seen. Asymmetric dural
thickening along the left tentorium in keeping with
leptomeningeal carcinomatosis with large tumor deposit along the
left tentorium possibly invading the left cerebellar hemisphere.
2. Tumor deposits along multiple cranial nerves including left
internal
auditory canal, left abducens nerve, right trigeminal nerve and
left optic canal as described above.
MRI brain without contrast ___
IMPRESSION:
1. Normal brain MRA.
2. Please refer to separate dictation of an MRI of the brain and
orbits
performed concurrently for brain findings.
CXR ___
No acute intrathoracic process.
CT CHEST WITH CONTRAST ___
IMPRESSION:
Subpleural opacities in the anterior left hemi thorax, likely
represent post treatment changes from left breast cancer.
No new suspicious pulmonary nodules, lymph nodes or bony lesion
suggest
metastatic disease in the thorax.
CT ABD PELVIS W CONTRAST ___
No evidence of intra-abdominal metastases.
BONE SCAN ___
IMPRESSION: Increased radiotracer uptake in the thoracic spine
which
correlates with degenerative disease seen on CT. No evidence of
osseous
metastatic disease.
Brief Hospital Course:
Ms ___ is a ___ yr old female with history of breast
cancer s/p L mastectomy and axillary LND, 4 cycles chemotherapy
and adjuvant XRT who presented with left ___ nerve palsy, found
to have innumerable brain mets on MRI. Patient received 5 cycles
of whole brain radiation during her admission and was started on
steroids. There was no change in her ___ nerve palsy with
consistent paralysis of her left lateral gaze. With regards to
her pain control regimen, she was seen by palliative care team.
Her pain was mainly due to headache and retro-orbital pain. Her
opiod regimen was adjusted to standing MS ___ 15 mg q12 hours
and PRN ___ morphine. She also received tylenol. Her pain control
was good prior to discharge. She was also noted to have some
intermittent hallucinations / agitation which were thought
likely secondary to her steroids. She was started on olanzapine
2.5 mg daily. There was a family discussion regarding
disposition. It was determined that given her brain mets and
risk for resumption of alcohol consumption at home, that she be
discharged to a facility where she could receive assistance and
be more closely monitored.
Please see below for discussion of individual issues:
#L ___ nerve palsy - Due to brain mets. Patient received 5
cycles of whole brain radiation during her admission and was
started on steroids. There was no change in her ___ nerve palsy
with consistent paralysis of her left lateral gaze. Patient is
on steroid taper (dexamethasone taper (8 mg q12 hours ___, 4mg
q12 hours ___, 2 mg q12 hours ___, 1mg q12 hours
___, 0.5 mg q12 hours ___, 0.5 mg daily ___,
then off). Patient does not need specific follow up with
radiation oncology.
# L breast cancer with diffuse metastasis and leptomeningeal
disease, s/p mastectomy, chemotherapy, radiation. Likely having
recurrence with intracranial lesions as noted above. Patient
received whole brain radiation as noted above and was started on
dexamethasone with taper upon discharge. Patient's pain regimen
was adjusted per palliative care recs - MS contin 15mg Q12h,
7.5-15mg PO morphine Q3h PRN plus acetaminophen. Staging work
up negative for metastasis to thorax/abdomen/bones.
# Agitation/hallucinations: Patient was noted have visual
hallucinations while on dexamethasone and was intermittently
anxious and agitated with house staff. Patient was started on
dexamethasone taper as noted above and started on zyprexa 2.5 mg
daily.
#HA - secondary to mets as above. Patient's opioid regimen was
adjusted per palliative care recs with improvement in her pain.
# Difficulty swallowing: Unclear etiology, however may be ___ to
metastatic disease in the brain. Patient was seen by speech and
swallow and diet was adjusted per their recommendations to thin
liquids, ground solids.
# ___: Mild creatinine elevation likely pre-renal given poor PO
in take and confusion. Creatinine was 1.2 on day of discharge.
#HTN - patient with intermittently elevated BPs while in house.
Per patient BPs often run high 150-170s. Pain / steroids may
have been contributing. She was continued on her home
amlodipine and valsartan.
# Diabetes mellitus. Patient's Glipizide was held while in
house. Lantus was increased to 40U QHS (from home dose 30U)
while on steroids. Patient was also on humalog sliding scale.
FSBS were in 100s to low 200s prior to discharge. Recommend
careful monitoring of blood sugars after discharge as will
require titration of insulin regimen as steroids are tapered.
# Hx ETOH abuse - on daily disulfiram at home, was held while
inpt as no
access to ETOH in hospital.
# Chronic hepatitis C - continued home lamivudine treatment.
LFTs wnl.
# Hx Atrial arrhythmia: was in NSR on admission. Previously was
tried on
anticoagulation with a novel anticoagulant, however,
discontinued the medication as she felt like she was
experiencing adverse effects. She was on full-dose aspirin for
stroke prophylaxis at home and carvedilol for rate control.
Aspirin discontinued in setting of brain mets. Carvedilol held
while in house, will discharge on lower dose given adequate rate
control and blood pressure while in house.
# Chronic pain left breast - residual since radiation -
continued
pain control as above with MS ___ and ___ morphine and
tylenol. Held ibuprofen due to bleeding risk.
# Chronic shoulder pain s/p rotator cuff surgery - gave meds for
pain control as above, tylenol, held ibuprofen due to bleeding
risk.
# Depression: continued on sertraline.
# Conjunctivitis: Continued with erythromycin ointment &
artificial tears.
Transitional Issues:
===============================
[] continue dexamethasone taper (8 mg q12 hours ___, 4mg q12
hours ___, 2 mg q12 hours ___, 1mg q12 hours
___, 0.5 mg q12 hours ___, 0.5 mg daily ___,
then off)
[] continue pain management with tylenol, standing MS ___ and
___ morphine, adjust dose as needed
[] f/u with PCP (Dr. ___ on ___ and oncologist Dr.
___ on ___
[] titrate insulin regimen as appropriate with steroid taper
[] Patient with evidence of dysphagia - per speech and swallow
diet changed to: Ground (dysphagia); Thin liquids
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation Q6H:PRN
SOB , wheeze
2. Carvedilol 25 mg PO BID
3. Disulfiram 250 mg PO DAILY
4. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QHS
5. esomeprazole magnesium 40 mg oral daily
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. GlipiZIDE XL 10 mg PO DAILY
8. Ibuprofen 800 mg PO Q8H:PRN pain
9. Glargine 30 Units Bedtime
10. LaMIVudine 100 mg PO DAILY
11. Levothyroxine Sodium 150 mcg PO DAILY
12. nystatin 100,000 unit/gram topical BID
13. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO TID:PRN pain
14. Sertraline 100 mg PO DAILY
15. Aspirin 325 mg PO DAILY
16. Acetaminophen 325 mg PO Q6H
17. Amlodipine 5 mg PO DAILY
18. Valsartan 160 mg PO BID
19. Aquaphor Ointment 1 Appl TP BID
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H
2. Amlodipine 5 mg PO DAILY
3. Aquaphor Ointment 1 Appl TP TID:PRN dry skin
4. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QHS
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. LaMIVudine 100 mg PO DAILY
8. Levothyroxine Sodium 150 mcg PO DAILY
9. Sertraline 100 mg PO DAILY
10. Valsartan 160 mg PO BID
11. Artificial Tears ___ DROP BOTH EYES DAILY
12. Morphine SR (MS ___ 15 mg PO Q12H
Hold for sedation or RR < 12
RX *morphine [MS ___ 15 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*30 Tablet Refills:*0
13. Morphine Sulfate ___ 7.5 mg PO Q6H:PRN pain
Give for breakthrough pain, hold for sedation or RR < 12
RX *morphine 15 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*30 Tablet Refills:*0
14. Docusate Sodium 100 mg PO BID
15. OLANZapine (Disintegrating Tablet) 2.5 mg PO DAILY
agitation/anxiety/hallucinations
16. Senna 8.6 mg PO BID
17. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation Q6H:PRN
SOB , wheeze
18. Carvedilol 6.25 mg PO BID
19. Disulfiram 250 mg PO DAILY
20. esomeprazole magnesium 40 mg oral daily
21. nystatin 100,000 unit/gram topical BID
22. Dexamethasone 8 mg PO Q12H Duration: 1 Dose
RX *dexamethasone 2 mg ASDIR tablet(s) by mouth ASDIR Disp #*28
Tablet Refills:*0
23. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
1. ___ Nerve Palsy
2. Metastatic breast cancer
Secondary Diagnosis:
1. Diabetes
2. Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
It was a pleasure caring for you during your admission to ___
___. You were admitted for
evaluation and management of cancer with brain involvement. You
were given whole brain radiation and steroids to help alleviate
your symptoms. You will need to continue the steroids after
discharge, but the dose will be slowly decreased. Follow up
appointments have been scheduled with your primary care
physician as well as your oncologist. Please take your
medications and keep your follow up appointments as scheduled.
We wish you all the best.
- Your ___ Team
Followup Instructions:
___
|
10785764-DS-19
| 10,785,764 | 20,565,392 |
DS
| 19 |
2153-07-03 00:00:00
|
2153-07-04 14:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
___ Angio
History of Present Illness:
___ with hx of Afib, recurrent GI Bleeds of unknown etiology who
presents with BRBPR. The patient had a bowel movement around
7:30 this morning that was loose with a little blood in it. He
had another BM around 9:30 that was deep red/maroon with clots.
The patient has a history of multiple GI bleeds over the last
___ years. He estimates that he has had ___ bleeding events
in his life, about 4 of which have required hospitalizeations.
His last bleed was in ___ while on a cruise and
reportedly required transfusion of 4 units of pRBCs and 3 units
of FFP. He has had an extensive workup including multiple
colonoscopies, capsule endoscopy, nuclear scans, all of which
have not identified a bleed.
In the ED, the patient denied dizziness or lightheadedness.
Denies abdominal pain, nausea, vomiting, constipation, diarrhea,
chest pain, SOB.
The patient is followed by Dr. ___ here at ___, who has a
recommendation for CTA in the event of further bleeds. See OMR
note ___.
In the ED, initial vitals initially 98, HR 45, 157/84, RR 20,
98%RA. Exam notable for rectal with dark red blood with clots,
guaiac positive, no external hemorrhoids noted. Labs notable for
normal chem 7, WBC 8.8, Hgb 13.7 (which subsequently dropped to
9.4). INR 1. GI and ___ consulted in the ED. Patient was also
given 100mg Metoprolol XR in ED. A patient was developing
worsening tachycardia, decision made to have patient undergo CTA
which was notable for active extravasation at the hepatic
flexure. Patient was taken the ___ suite for ateriogram and
possible emblolization.
In the ___ suite, initially saw active extrav. again in R colon,
but the vessel going there was tortuous and think that may have
dissected with wire during approach. No embolization was
completed, but no further extravasation was appreciated. Early
in the procedure, shortly after receiving sedation, the patient
dropped pressures to the ___ systolic. He was reportedly
asymptomatic. Gave IVF, 2U pRBCs, LIJ and BPs resolved.
On transfer from ___ suite, patient reportedly HD stable.
On arrival to the MICU, patient resting comfortable in bed in
NAD. HD stable.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
1. Cardiac Risk factors: - diabetes, + dyslipidemia, -
hypertension
2. CABG: none
3. PCI: none
4. Pacing: none
-diverticulosis
-history of gastrointestinal bleeds
-angioectasia
Social History:
___
Family History:
Mother w/ diverticular disease. No cardiac disease except father
with CHF deceased at ___. Mother deceased at ___.
Physical Exam:
ADMISSION PE:
Vitals: Afebrile, HR 96, BP 131/88; RR 14, SaO2 95%
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: irregularly irregular rhythm, normal S1 S2, no murmurs,
rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No rashes, lesions noted
NEURO: A&Ox3. RLE in brace post ___ procedure, pulses stable.
DISCHARGE PE:
Vitals: Temp 98.0, BP 117/85, HR 85, RR 18, O2 sat 97% RA
Tele: Bump to 130s overnight (temporary) with rate in 90-100s
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Very faint bibasilar crackles L>R
CV: Irregularly irregular, regular rate, no murmurs
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rash
Neuro: CN2-12 grossly intact, moving all extremities
Pertinent Results:
ADMISSION LABS:
___ 11:30AM BLOOD WBC-8.8# RBC-4.61 Hgb-13.7 Hct-41.0
MCV-89 MCH-29.7 MCHC-33.4 RDW-13.0 RDWSD-41.9 Plt ___
___ 11:30AM BLOOD Neuts-72.2* Lymphs-15.3* Monos-10.3
Eos-0.7* Baso-0.6 Im ___ AbsNeut-6.39* AbsLymp-1.35
AbsMono-0.91* AbsEos-0.06 AbsBaso-0.05
___ 11:30AM BLOOD ___ PTT-25.9 ___
___ 11:30AM BLOOD Glucose-116* UreaN-19 Creat-0.8 Na-141
K-4.3 Cl-108 HCO3-21* AnGap-16
___ 11:30AM BLOOD ALT-41* AST-26 AlkPhos-58 TotBili-0.4
___ 11:30AM BLOOD Albumin-3.8
___ 02:00AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.9
___ 11:36AM BLOOD Hgb-14.6 calcHCT-44
___ 11:36AM BLOOD Lactate-1.4
HEMATOCRIT TREND:
___ 11:30AM BLOOD WBC-8.8# RBC-4.61 Hgb-13.7 Hct-41.0
MCV-89 MCH-29.7 MCHC-33.4 RDW-13.0 RDWSD-41.9 Plt ___
___ 05:15PM BLOOD WBC-10.4* RBC-3.11*# Hgb-9.4*# Hct-28.0*#
MCV-90 MCH-30.2 MCHC-33.6 RDW-13.1 RDWSD-43.0 Plt ___
___ 08:45PM BLOOD WBC-12.4* RBC-4.18*# Hgb-12.7*#
Hct-37.5*# MCV-90 MCH-30.4 MCHC-33.9 RDW-13.3 RDWSD-43.4 Plt
___
___ 02:00AM BLOOD WBC-15.8* RBC-3.95* Hgb-11.9* Hct-36.1*
MCV-91 MCH-30.1 MCHC-33.0 RDW-13.5 RDWSD-44.5 Plt ___
___ 07:57AM BLOOD WBC-14.0* RBC-3.92* Hgb-11.9* Hct-35.3*
MCV-90 MCH-30.4 MCHC-33.7 RDW-13.7 RDWSD-44.6 Plt ___
___ 03:49AM BLOOD WBC-8.7 RBC-3.59* Hgb-10.8* Hct-32.8*
MCV-91 MCH-30.1 MCHC-32.9 RDW-13.8 RDWSD-45.8 Plt ___
___ 12:53PM BLOOD WBC-10.0 RBC-3.66* Hgb-11.1* Hct-33.2*
MCV-91 MCH-30.3 MCHC-33.4 RDW-13.9 RDWSD-45.8 Plt ___
___ 05:10AM BLOOD WBC-9.3 RBC-3.49* Hgb-10.5* Hct-32.0*
MCV-92 MCH-30.1 MCHC-32.8 RDW-14.0 RDWSD-46.5* Plt ___
DISCHARGE LABS:
___ 05:10AM BLOOD WBC-9.3 RBC-3.49* Hgb-10.5* Hct-32.0*
MCV-92 MCH-30.1 MCHC-32.8 RDW-14.0 RDWSD-46.5* Plt ___
___ 05:10AM BLOOD Glucose-82 UreaN-8 Creat-0.8 Na-140 K-3.5
Cl-107 HCO3-27 AnGap-10
___ 05:10AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.0
MICRO:
IMAGING:
CTA:
1. Active extravasation at the hepatic flexure consistent with
acute to GI bleed. Extensive colonic diverticulosis without
evidence of acute
diverticulitis.
2. Cholelithiasis without acute cholecystitis.
3. 1.7 cm indeterminate left renal lesion for which further
evaluation with
non urgent renal ultrasound is recommended.
4. Partially imaged 4.0 x 3.6 cm cyst adjacent to the
pericardium may
represent a pericardial cyst. This could be further assessed by
dedicated
chest CT or MRI.
5. Large prostate gland.
6. Large urinary bladder diverticulum.
___ MESENTERIC ANGIOGRAM
1. Conventional superior mesenteric arterial anatomy.
2. Possible active extravasation arising from a small tortuous
second order
branch of the middle colic artery supplying the hepatic flexure.
Occlusion of
this vessel was noted during wire manipulation.
3. No active extravasation identified at completion of
procedure. No embolics
were administered.
4. Successful placement of left internal jugular approach
triple lumen
central venous catheter.
IMPRESSION:
1. Possible active extravasation initially identified at the
hepatic flexure,
supplied by a branch of the middle colic artery. This branch
was noted to
occlude during the procedure.
2. No active extravasation at completion of procedure. No
embolics were
administered.
3. Successful placement of left internal jugular approach
triple lumen
central venous catheter. The line is ready to use.
Brief Hospital Course:
___ with hx of Afib, recurrent GI Bleeds of unknown etiology who
presents with BRBPR s/p CTA without embolization with ___.
#Gastrointestinal bleeding, presumed diverticular: Patient
presented with large bowel movement and clots. He has a history
of multiple GI bleeds over the last ___ years. He estimates
that he has had ___ bleeding events in his life, about 4 of
which have required hospitalizeations. He has had an extensive
workup including multiple colonoscopies, capsule endoscopy,
nuclear scans, all of which have not identified a bleed. Exam in
ED notable for rectal with dark red blood with clots, guaiac
positive, no external hemorrhoids noted. Labs notable for Hgb
13.7 (which subsequently dropped to 9.4). Patient underwent CTA
which was notable for active extravasation at the hepatic
flexure. Patient was taken the ___ suite for arteriogram. In the
___ suite, initially saw active extrav. again in R colon, but the
vessel going there was tortuous and there was question of spasm
vs dissection with wire. No embolization was completed but
extravasation stopped. Patient did drop SBPs to ___ and was
given IVF and 2units PRBCs. Patient was transferred to ICU and
had stable BP and H/H. He was transferred to medical floor where
h/h remained stable. Colorectal surgery evaluated the patient
for consideration of elective colectomy, but he preferred to
follow up further as an outpatient.
#AFIB - His home Metoprolol and Dilt were started at lower,
short acting doses initially given hemodynamic instability.
After his pressures stablized, these were restarted. He had one
episode of Afib with RVR during which he was hemodynamically
stable. This likely occurred because he was on lower doses of
dilt which were spaced q8 hours. It resolved with 5 IV metop x2
and did not recur.
CHRONIC ISSUES:
#HTN - home losartan was held in setting of acute bleed.
#GERD - continued home omeprazole 20mg qD
#Insomnia - continued home trazodone PRN
==========================
TRANSITIONAL ISSUES:
==========================
[ ] Recurrent GI bleeds: He will need to follow up closely with
colorectal surgery for consideration of elective partial or
total colectomy.
[ ] Recommend checking a blood count at next PCP visit as pt
continued to have small amounts of dark red blood in his stool
at discharge.
[ ] Incidental Finding: Partially imaged 4.0 x 3.6 cm cyst
adjacent to the pericardium may represent a pericardial cyst.
This could be further assessed by dedicated chest CT or MRI.
[ ] Incidental Finding: 1.7 cm indeterminate left renal lesion
for which further evaluation with non-urgent renal ultrasound is
recommended.
[ ] Discharge hemoglobin: 10.5.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO DAILY
2. Diltiazem Extended-Release 180 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. TraZODone 50-100 mg PO QHS:PRN insomnia
6. Metoprolol Tartrate 100 mg PO TID
Discharge Medications:
1. Diltiazem Extended-Release 180 mg PO DAILY
2. Metoprolol Tartrate 100 mg PO TID
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. TraZODone 50-100 mg PO QHS:PRN insomnia
6. Losartan Potassium 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
lower gastrointestinal bleed
SECONDARY DIAGNOSES:
hypertension
atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___:
You were admitted to ___ because you had bleeding in your
stool. You had an special CT scan that showed you were bleeding
from a certain part of your colon. You needed two blood
transfusions. The bleeding stopped on its own. You were seen by
colorectal surgery who recommended that you follow up with Dr.
___ as an outpatient if you are interested in surgery to
remove your colon. Your blood counts were stable prior to
discharge.
Please call Dr. ___ office at ___ to schedule an
appointment. If any questions arise, you can schedule a follow
up appointment with Dr. ___ at ___.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure to care for you!
Your ___ team
Followup Instructions:
___
|
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