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10785913-DS-22
| 10,785,913 | 21,330,219 |
DS
| 22 |
2138-10-13 00:00:00
|
2138-10-18 15:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
penicillamine / captopril
Attending: ___.
Chief Complaint:
gait difficulties
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year-old man with history of PAD/PVD, CKD,
COPD, subclavian artery stenosis status post bypass on the left,
carotid and vertebral artery stenoses, prior ACA aneurysm,
presenting with acute onset gait disturbance. His symptoms
started around 4 ___ yesterday when he noticed that when he
looked
to the right, he would lean towards the left, and vice versa.
This was more prominent when he was walking. As long as he
keeps
his head still he can walk without swaying to either side. He
denies any sensation of room spinning, and describes his
sensation is more like unable to find balance. He also complains
of "skipping vision," which he describes as having segments of
vision when scanning horizontally or vertically. Both his gait
and vision problems have remained constant and the severity is
since onset. Patient denies recent illness, trauma to neck or
head, changes in medication or diet, or recent travel history.
The patient feels nauseous at times but has never vomited since
onset of symptoms.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention.
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 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:
anemia, BPH, chronic kidney disease, COPD, colon polyps, DJD,
hyperlipidemia, hypertension, kidney stones, lung mass,
peripheral vascular disease, and Peyronie disease, L subclavian
artery stenosis
PAST SURGICAL HISTORY:
1. Status post left percutaneous nephrolithotomy x 5.
2. Status post VATS plus thoracotomy plus right upper lobe
wedge
resection for lung mass.
3. Status post cervical spine surgery.
4. Status post arthroscopic repair, meniscus tear, right knee.
5. Status post arthroscopic repair, ACL tear and meniscus tear,
left knee.
6. Status post left common carotid artery to subclavian artery
bypass graft.
7. Status post left ureteroscopy, laser lithotripsy, and left
ureter stent placement.
8. Status post left neck cyst excision.
Social History:
___
Family History:
Positive for diabetes in his grandmother, positive for
hypertension in his mother, positive for CAD in his grandmother,
positive for brain tumor in his father. No other family history
of malignancies.
Physical Exam:
ADMISSION:
Vitals: T 98.1 P 81 BP 110/61 R 18 SpO2 99% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation. Able to relate history without difficulty. Attentive,
able to name ___ backward without difficulty. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were no paraphasic errors. Pt was able to name both high and low
frequency objects. Speech was not dysarthric. Able to follow
both
midline and appendicular commands. 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: end gaze nystagmus that extinguish on either
horizontal gaze, EOMI otherwise, head thrust test without
corrective saccades in both directions
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. Mild drift without
pronation on left upper extremity. No adventitious movements,
such as tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory: Light touch and pinprick RLE > LLE (70%), LUE > RUE
(90%. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was flexor bilaterally. Positive suprapatellar
reflex bilaterally
-Coordination: No intention tremor, on FTN pass points L>R, on
HTS equal mild impairment bilaterally,
-Gait: Romberg positive, the patient feels unbalanced upon
standing but is able to stand in place after a few seconds, gait
exam is deferred due to significant unsteadiness
DISCHARGE:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Abdomen: soft, ND
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented. 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
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.
III, IV, VI: EOMI w/o end gaze nystagmus, no ocular dysmetria,
smooth saccades
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Bilateral rebound.
No adventitious movements.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory: Light touch intact. No proprioceptive deficits in
bilateral fingers and bilateral great toes. No extinction to
DSS.
-Coordination: No intention tremor, terminal tremor L>R w/ FNF,
mildly slowed RAM and less smooth movements on left. Difficulty
marching in place but did not veer to a particular direction.
-Gait: wide based gait, feels less off balance
Pertinent Results:
___ 02:35PM BLOOD WBC-7.8 RBC-4.63 Hgb-15.0 Hct-45.6
MCV-99* MCH-32.4* MCHC-32.9 RDW-14.3 RDWSD-51.8* Plt ___
___ 02:35PM BLOOD Neuts-64.9 ___ Monos-9.5 Eos-3.6
Baso-0.8 Im ___ AbsNeut-5.07 AbsLymp-1.62 AbsMono-0.74
AbsEos-0.28 AbsBaso-0.06
___ 06:00AM BLOOD ___ PTT-29.5 ___
___ 02:35PM BLOOD Glucose-110* UreaN-26* Creat-1.9* Na-140
K-5.0 Cl-100 HCO3-25 AnGap-15
___ 06:00AM BLOOD ALT-12 AST-16 LD(LDH)-154 CK(CPK)-76
AlkPhos-44 TotBili-0.5
___ 06:00AM BLOOD GGT-19
___ 06:00AM BLOOD CK-MB-4 cTropnT-<0.01
___ 02:35PM BLOOD Calcium-10.5* Phos-3.5 Mg-2.0
___ 06:00AM BLOOD TotProt-5.6* Albumin-3.6 Globuln-2.0
Cholest-120
___ 06:00AM BLOOD VitB12-241
___ 06:00AM BLOOD %HbA1c-5.3 eAG-105
___ 06:00AM BLOOD Triglyc-106 HDL-48 CHOL/HD-2.5 LDLcalc-51
___ 06:00AM BLOOD TSH-4.3*
___ 06:00AM BLOOD T4-5.0
___ 06:00AM BLOOD CRP-5.5*
___ 06:00AM BLOOD Trep Ab-NEG
___ 06:00AM BLOOD SED RATE- 2
___ 03:30PM URINE Color-Straw Appear-Clear Sp ___
___ 03:30PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 03:30PM URINE RBC-1 WBC-1 Bacteri-FEW* Yeast-NONE
Epi-<1
___ 3:30 pm URINE **FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ CT head w/o contrast
IMPRESSION:
No acute intracranial process. Mild small vessel disease. If
there is
further concern for acute stroke consider MRI to better assess.
___ MRI head w/o contrast
IMPRESSION:
1. Evidence of mass, hemorrhage or infarction.
2. Absent flow void in the intracranial left vertebral artery.
___ MRA brain/neck
IMPRESSION:
1. Unchanged less than 3 mm aneurysm arising from the A1 segment
of the right anterior cerebral artery.
2. Patent left common carotid to left subclavian artery shunt.
Unchanged.
3. Patent left subclavian artery with unchanged pre and post
anastomotic
subclavian segments stenoses.
4. Unchanged severely attenuated left vertebral artery with
retrograde flow at upper ___ retrograde flow of the left
vertebral artery.
5. There is about 50% stenosis at the left internal carotid
artery origin.
___ MRI head w/ & w/o contrast
IMPRESSION:
Within the limitations of the study, no perfusion abnormalities
are seen,
there is no evidence of hypoperfusion on the left cerebellar
hemisphere.
Brief Hospital Course:
Mr. ___ is a ___ year old male with PAD/PVD, CKD, COPD,
subclavian artery stenosis status post bypass on the left,
carotid and vertebral artery stenoses, and prior ACA aneurysm
who is admitted to the Neurology stroke service with acute onset
ataxia/ disequilibrium likely secondary to flow dependent
posterior circulation symptoms. History notable for sensation of
disequilibrium that is worsened with movement and inability to
track smoothly with his eyes in all directions. Presenting exam
notable for negative head thrust test, positive Romberg, past
pointing on finger-to-nose greater on the left than right,
equally impaired heel-to-shin bilaterally. His initial NCHCT did
not show obvious acute infarct or hemorrhage. MRI brain showed
no mass or infarct, and MRA head/neck demonstrated patent left
common carotid to left subclavian artery shunt, unchanged
severely attenuated left vertebral artery with retrograde flow
distally, and 50% left ICA stenosis. MR perfusion did not
demonstrate hypoperfusion in left cerebellum or any other
perfusion abnormality.
Given positional of disequilibrium and no apparent strokes on
imaging and severe vasculopath, concerned flow-dependent
phenomena, such as intracranial small vessel disease or
subclavian steal syndrome. His symptoms were likely brought on
by dehydration with recent poor PO intake and increased alcohol
intake prior to presentation.
Symptoms did not seem affected by holding cilostazol but did
improve with IVF, discharged home with orthostasis precautions
and close follow-up.
#disequilibrium, c/f flow dependent phenomenon:
-Recommend ___ PO fluid intake daily, decrease or obtain from
alcohol use, and daily compression stockings to prevent
orthostasis
-Will follow-up in stroke neurology clinic
-___ recs for home with outpatient ___
#significant vasculopathy w/ PAD/PVD s/p carotid-subclavian
bypass, multiple iliac and femoral stents
-Continue ASA 81 mg PO daily
-Continue cilostazol 100 mg PO BID
-Continue atorvastatin 40 mg PO nightly
#HTN:
-Continue metoprolol succinate 100mg daily, PCP could consider
decrease if BP would tolerate
#prior tobacco use, quit ___ yrs ago
-Continue bupropion XL 300 mg daily
-Continue nicotine patch daily
His stroke risk factors include the following:
1) DM: A1c 5.3%
2) severely stenotic intra- and extra-cranial arteries
3) Hyperlipidemia: well controlled on atorvastatin 40mg with LDL
51
4) BMI not consistent with obesity
5) No reported concern for or known diagnosis of sleep apnea
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented? (X) Yes (LDL = 51) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (X) Yes - () No [if
LDL if LDL >70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? (X) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (X) No - (X) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
4. Aspirin 81 mg PO DAILY
5. ammonium lactate ___ % topical BID dry skin
6. Atorvastatin 40 mg PO QPM
7. BuPROPion XL (Once Daily) 300 mg PO DAILY
8. Cilostazol 100 mg PO BID
9. imiquimod 5 % topical 3X/WEEK back of hands for dry skin
10. Ketoconazole Shampoo 1 Appl TP ASDIR face, chest, abdomen
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. comp.stocking,knee,long,medium 20 psi miscellaneous DAILY
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
3. ammonium lactate ___ % topical BID dry skin
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. BuPROPion XL (Once Daily) 300 mg PO DAILY
7. Cilostazol 100 mg PO BID
8. imiquimod 5 % topical 3X/WEEK back of hands for dry skin
9. Ketoconazole Shampoo 1 Appl TP ASDIR face, chest, abdomen
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Tamsulosin 0.4 mg PO QHS
12. Tiotropium Bromide 1 CAP IH DAILY
13. Vitamin D 1000 UNIT PO DAILY
14.Outpatient Physical Therapy
ATAXIA FOLLOWING UNSPECIFIED CEREBROVASCULAR DISEASE ___.___
Outpatient physical therapy, no activity restrictions
___, ___
Discharge Disposition:
Home
Discharge Diagnosis:
flow-dependent ataxia in setting of dehydration and severe left
vertebral artery stenosis from significant intracranial &
extracranial atherosclerotic diseases
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 instability resulting
from decreased blood flow to certain areas of your brain in the
setting of dehydration and abnormal blood vessels. 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 for prolonged periods of time can result in
a variety of symptoms.
Although you did not have a stroke on imaging, you are at
increased risk of stroke, so we assessed you for medical
conditions that might raise your risk of having stroke. We found
no risk factors that would benefit from changes in your
medications. However, as your symptoms are likely secondary to
decrease blood flow, we recommend that you take precautions to
prevent recurrent symptoms:
Use 20psi compression stockings (up to knee) daily
Ensure ___ liters of fluid intake daily
Take caution to prevent dehydration
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:
___
|
10786070-DS-17
| 10,786,070 | 29,532,197 |
DS
| 17 |
2112-12-17 00:00:00
|
2112-12-18 23:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache accompanied by nausea, vomiting, and syncope.
Major Surgical or Invasive Procedure:
___ EVD placement
___ Left Vertebral artery aneurysm Pipeline Embolization
History of Present Illness:
___ yo male with worsening HA since ___ after doing
pushups at the gym. Since then his HAs have waxed and waned.
Today the HA suddenly got worse to a ___ and he developed
nausea. He pulled over his car and then passed out and
bystanders called EMS. He was brought to ___ where Head
CT
showed SAH in the basal cisterns and CTA revealed a possible
aneurysm distal to the ___. He was then transported to
___ for
Neurosurgical evaluation. He continues to c/o headache and
dizziness. He states his nausea is improved and he has no visual
deficits.
Past Medical History:
None
Social History:
___
Family History:
Reports no sudden deaths or 1st degree relatives with known
aneurysms.
Physical Exam:
On Discharge:
AOx3, following commands, fluent speech
CN II-XII intact
Motor: No drift
___ strength in upper and lower extremities bilaterally
Sensation intact to light touch
Groin: c/d/I no hematoma
scalp: EVD incision well healed, sutures/staples removed
Pertinent Results:
CT HEAD W/O CONTRAST Study Date of ___ 7:54 ___
IMPRESSION:
1. Interval placement of a right frontal approach EVD
terminating near the
third ventricle, with expected hemorrhage and air along the
tract.
2. Ventriculomegaly, slightly increased from 4 hours earlier
worrisome for
hydrocephalus.
3. Subarachnoid hemorrhage and intraventricular hemorrhage
layering within the lateral and fourth ventricles.
CT HEAD W/O CONTRAST Study Date of ___ 3:33
IMPRESSION:
1. EVD in place but with slight interval increase in hemorrhage
rounding the EVD tract in the right frontal lobe. Close
attention on follow-up.
2. Status-post left vertebral artery basilar artery pipeline.
3. Bilateral occipital horn and fourth ventricle
intraventricular hemorrhage is overall stable in appearance.
4. Slight interval decrease in the size of the ventricles.
EMBO TRANSCRANIAL Study Date of ___ 7:55 ___
IMPRESSION:
Successful pipeline embolization of left vertebral artery
dissecting aneurysm.
No thromboembolic complications.
CTA HEAD W&W/O C & RECONS Study Date of ___ 1:27 ___
IMPRESSION:
1. Position of ventriculostomy catheter and the overall size of
the
ventricular system are stable.
2. Focus of intraparenchymal hemorrhage along the proximal EVD
tract and
hemorrhage in the occipital horns of the right lateral
ventricles, fourth
ventricle, and basal cisterns are no worse compared to prior
study and the
extra-axial hemorrhages may even show a slight decrease in size.
3. The status post pipeline embolization of left vertebral
artery dissecting aneurysm without evidence of new aneurysms.
No stenosis or occlusion involving the circle of ___ and its
major branches.
CT HEAD W/O CONTRAST Study Date of ___ 6:06 AM
IMPRESSION:
1. Stable position of the right frontal ventriculostomy catheter
and
hemorrhage along the catheter tract. Stable ventricle size and
configuration.
2. Minimally increased intraventricular blood could be secondary
to
redistribution or interval manipulation of the ventricular
drain.
CTA HEAD W&W/O C & RECONS Study Date of ___ 9:22 AM
IMPRESSION:
1. Status post pipeline embolization of the left vertebral
artery dissecting aneurysm without evidence of new aneurysm
formation.
2. Although bolus timing is suboptimal, there is no evidence of
vasospasm.
3. Unchanged position of right frontal ventriculostomy catheter
and stable
size and configuration of the ventricular system.
4. Stable intraparenchymal hemorrhage along the catheter course
and layering dependently within the lateral ventricles, without
evidence of new hemorrhage.
CT HEAD W/O CONTRAST Study Date of ___ 4:20 AM
IMPRESSION:
Stable right frontal ventriculostomy catheter. Similar size
size/configuration of the ventricular system from examination of
___.
ABDOMEN (SUPINE & ERECT) Study Date of ___ 5:27 AM
IMPRESSION:
Nonobstructive bowel gas pattern.
CT HEAD W/O CONTRAST Study Date of ___ 4:26 AM
IMPRESSION:
1. Interventricular hemorrhage in the left occipital horn of the
lateral
ventricle is similar in size but increased in density since
___.
2. Stable size and configuration of the ventricular system from
___.
3. Stable right frontal ventriculostomy catheter and posterior
fossa stent
from ___.
CT HEAD W/O CONTRAST Study Date of ___ 8:49 AM
IMPRESSION:
1. When compared to the ___ 05:20 CT head without
contrast, the
previously described right frontal approach ventriculostomy
catheter has been removed. There is a new small hyperdense foci
trailing the the pathway of the now removed ventriculostomy
catheter that likely represents intraparenchymal hemorrhage
status post catheter removal. Additionally, the surrounding
vasogenic edema of the right frontal lobe has mildly increased
and is associated with mild effacement of the adjacent sulci and
right lateral ventricle. However, there is no evidence of
midline shift.
CT head ___:
Re-demonstrated is sequelae of prior ventriculostomy catheter in
the right
frontal lobe including linear hyperdensity along the catheter
tract with
surrounding white matter hypodensity. No evidence of new focus
of hemorrhage or appreciable interval change in comparison to
prior study from ___. Otherwise, there is no
evidence of new hemorrhage elsewhere, acute infarction, edema or
mass effect. The basal cisterns are patent. There is no shift
of the normally midline structures. Stent in the distal left
vertebral artery is re-identified. Mild prominence of the
ventricles and sulci is unchanged.
Brief Hospital Course:
Patient was transferred to ___ Neurosurgery ICU from OSH after
presenting with headache, found to have SAH in basal cisterns
and CTA revealed Left vertebral artery dissecting aneurysm.
#Aneurysm: He was taken to the angio suite for pipeline stent of
Left vertebral aneurysm and EVD placement with Dr. ___ on
___. He was started on Aspirin and Brilinta. He was started
on Nimodipine 60q4 for vasospasm prevention x21 days. CTA was
negative for spasm on ___ and ___ and Transcranial dopplers
were consistently negative for vasospasm. He was intermittently
bolused to maintain euvolemia. He remained neurologically intact
throughout his hospitalization, with headaches and neck pain.
EVD clamp trial was initiated twice and eventually tolerated.
EVD was removed on ___. Post pull head CT showed small
hemorrhage along the catheter tract without evidence of
hydrocephalus. He was transferred to the floor in stable
condition. Head CT ___ was stable. He was seen and evaluated
by the physical therapy team who recommended dispo to home with
outpatient ___ and he was given a script for this at discharge.
Staples and sutures from EVD were removed prior to discharge.
#CV: HR baseline in ___, dips to ___ while sleeping,
asymptomatic. No intervention required.
#GI: c/o abdominal distention with n/v, KUB negative for ileus
on ___. Symptoms improved and he was able to tolerate PO diet.
At the time of discharge he was tolerating a regular diet,
ambulating without difficulty, afebrile with stable vital signs.
Nimodipine prescription was faxed to his pharmacy ahead of his
discharge to ensure availability on day of discharge. He will
continue nimodipine for the full 21 days.
Medications on Admission:
Zyrtec
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Artificial Tears ___ DROP BOTH EYES Q6H
3. Aspirin 81 mg PO DAILY
Do NOT stop this medication unless directed by your neurosurgeon
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*3
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Calcium Carbonate 500 mg PO QID:PRN Gi Upset
6. Docusate Sodium 100 mg PO BID
7. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % 1 patch daily Disp #*30 Patch Refills:*0
8. NiMODipine 60 mg PO Q4H Duration: 5 Days
9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*60 Tablet Refills:*0
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 8.6 mg PO BID:PRN constipation
12. TiCAGRELOR 90 mg PO BID
Do NOT stop this medication unless directed by your neurosurgeon
RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth Twice daily
Disp #*60 Tablet Refills:*3
13.Outpatient Physical Therapy
Subarachnoid hemorrhage from Vertebral artery dissecting
aneurysm
Discharge Disposition:
Home
Discharge Diagnosis:
left vertebral artery aneurysm dissection
Subarachnoid hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Activity
· You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours to avoid
bleeding from your groin.
· Heavy lifting, running, climbing, or other strenuous
exercise should be avoided for ten (10) days. This is to prevent
bleeding from your groin.
· You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
· Do not go swimming or submerge yourself in water for five
(5) days after your procedure.
· You make take a shower.
Medications
· Resume your normal medications and begin new medications
as directed.
· It is very important to take the medication your doctor
___ prescribe for you to keep your blood thin and slippery.
This will prevent clots from developing and sticking to the
stent.
· You may use Acetaminophen (Tylenol) for minor discomfort
if you are not otherwise restricted from taking this medication.
Care of the Puncture Site
· Keep the site clean with soap and water and dry it
carefully.
What You ___ Experience:
· Mild tenderness and bruising at the puncture site (groin).
· Soreness in your arms from the intravenous lines.
· Mild to moderate headaches that last several days to a few
weeks.
· Fatigue is very normal
· 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
puncture site.
· Fever greater than 101.5 degrees Fahrenheit
· Constipation
· Blood in your stool or urine
· 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
Followup Instructions:
___
|
10786767-DS-18
| 10,786,767 | 23,182,291 |
DS
| 18 |
2166-05-17 00:00:00
|
2166-05-17 12:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
progressive weakness and numbness
Major Surgical or Invasive Procedure:
-C2-T1 POSTERIOR DECOMPRESSION FUSION INSTRUMENTATION AUTOGRAFT
ALLOGRAFT add-on for ___
History of Present Illness:
Mr. ___ is a ___ old right-handed man with a past medical
history of hyperlipidemia and restless leg syndrome who presents
with progressive weakness and numbness for the past 2 months.
Since ___, Mr. ___ has noticed a numbness in his hands
and feet. This came on gradually and has progressed over time to
involve his arms up to the level of his shoulders and his legs
up to his thighs. He also reports a sensation of numbness over
his chest and abdomen. He denies tingling. There is no bowel or
bladder incontinence. He does have occasional dribbling, thought
related to his prostate and this has been present for years
without change in severity recently. About two weeks ago, he
presented to neurology at ___ with new complaints of
generalized weakness. He was having difficulty walking and this
has progressed to requiring a cane to walk. He also reports arm
weakness which came on about the same time. He denies any
history of trauma or falls. He denies back pain. He has a
history of right sided sciatica related to a bulging disc but
this has not been an issue for him for some time. His
neurologist has done an extensive work-up including normal B12,
negative RPR, lyme, HIV and HCV. A1C was mildly elevated at 6.9.
He also had EMG-NCS which showed electrophysiologic evidence for
generalized polyneuropathy, sensory-motor, axonal-demyelinating,
moderate in severity. Given progression of his symptoms and
concern for GBS, he was sent to ___ urgently for MRI spine and
neurology admission. On neuro ROS, the pt denies headache, loss
of vision, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. Denies
parasthesiae. No bowel
or bladder incontinence or retention. MRI of c-spine on ___
showed severe spinal canal narrowing and myelomalacia.
Past Medical History:
Hyperlipidemia
Restless leg syndrome
Prostate cancer, low grade, followed by urology
Social History:
___
Family History:
Patient adopted, unknown family history.
Physical Exam:
ADMISSION Physical Exam:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, poor dentition
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No ___ edema.
Skin: erythema over dorsal feet bilaterally
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact comprehension. Normal
prosody. There were no paraphasic errors. Pt was able to name
both high and low frequency objects. Able to read without
difficulty. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Pt was able to register 3
objects and recall ___ at 5 minutes. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal tone throughout. LEFT pronator drift. No
adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___ ___
L 4+ 5- 4 54 5- ___ 4+ 4+ 5 4
R 4+ 5- ___ 4+ 4+ 5 4
-Sensory: No deficits to light touch. Impaired pinprick in arms
and legs bilaterally. Decreased sensation more proximally in the
arms and legs. Proprioception impaired in the toes and fingers,
intact at ankles and wrists. Vibration absent at the toes,
ankles, knees. Vibration with 8 sec latency at clavicles
bilaterally. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2 2 3 1
R 3 2 2 3 1
+ pec jerks bilaterally
Plantar response was upgoing bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Wide-based, short stride with cane. Romberg positive.
Pertinent Results:
ADMISSION LABS
___ 06:00AM BLOOD WBC-7.6 RBC-4.89 Hgb-15.2 Hct-45.0 MCV-92
MCH-31.1 MCHC-33.8 RDW-12.7 RDWSD-42.9 Plt ___
___ 06:00AM BLOOD ___ PTT-27.4 ___
___ 06:00AM BLOOD Glucose-103* UreaN-20 Creat-0.7 Na-143
K-3.8 Cl-108 HCO3-25 AnGap-14
___ 06:00AM BLOOD TotProt-6.8 Calcium-9.2 Phos-3.3 Mg-2.2
DIAGNOSTIC STUDIES
MRI cervical and thoracic spine ___:
IMPRESSION:
1. Multilevel multifactorial cervical spondylosis spanning C2-C3
through C5-C6 resulting in severe spinal canal narrowing,
flattening the cord and multilevel severe bilateral neural
foraminal narrowing.
2. There is abnormal C4 cord signal, which may represent
myelomalacia versus edema.
3. A 2.5 cm lesion of the right adrenal gland medial limb,
incompletely
characterize. This could represent an adenoma. Definitive
evaluation could be performed with MRI adrenal mass protocol.
4. Partially imaged on lumbar spine scout images is a 2.0 cm T2
hypointense lesion within the bladder lumen. Further evaluation
with ultrasound or CT could be performed.
RECOMMENDATION(S): 2.5 cm right adrenal gland lesion for which
definitive
evaluation with MRI adrenal mass protocol is recommended.
EMG ___:
IMPRESSION:
Abnormal study. There is electrophysiologic evidence for (a)
moderate, chronic and ongoing, neurogenic process(es) most
prominently affecting the lower extremities.
The findings are consistent with a length-dependent sensorimotor
polyneuropathy with primarily axonal features. In this setting,
a left
lumbosacral polyradiculopathy cannot be excluded.
In addition, there is evidence for a moderate median neuropathy
at the left wrist, as in carpal tunnel syndrome.
Finally, the findings support a mild chronic C7 radiculopathy on
the left. A mild chronic left C6 radiculopathy cannot be
excluded.
There is no definite evidence for a generalized disorder of
motor neurons or their axons.
Note that the needle examination may not have captured all
changes related to the presenting syndrome given the timing of
the study (<3 months) in relation to symptom onset.
Brief Hospital Course:
Patient was admitted for progressive symptoms of weakness and
sensory changes. On examination he was found to have profound
upper and lower extremity weakness in a mixed upper and lower
motor pattern, with distal>proximal sensory loss in all
modalities and hyperreflexia. Imaging of his cervical and
thoracic spinal cord showed multilevel degenerative changes with
disc herniation and cord compression at multiple levels, with
cord signal changes felt to reflect compressive myelomalacia. An
EMG was performed, which showed sensory/motor polyneuropathy
with predominantly axonal features, greater in lower
extremities, consistent with cervical compressive myelopathy. It
also showed cervical and possible lumbar radiculopathy. An MRI
lumbar spine was also performed, which showed multilevel
degenerative changes with prominent neuroforaminal narrowing.
For treatment, he was started on tizanidine 2mg BID for muscle
spasm which helped significantly with his stiffness. He was also
placed in a soft cervical collar. Spine was consulted for
possibility of surgical intervention. On multidisciplinary team
discussion it was recommended for patient to undergo surgical
decompression, and he was taken to OR on ___ for fusion
laminectomy.
Incidental findings:
- 2.5cm R adrenal lesion
- 2cm bladder lesion - bladder ultrasound showed enlarged
prostate but no bladder lesion.
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 ___ heparin 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:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. rOPINIRole 0.5 mg PO BID
3. Ibuprofen Dose is Unknown PO PRN headache
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. rOPINIRole 0.5 mg PO BID
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC BID
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*42 Tablet Refills:*0
7. Senna 8.6 mg PO BID:PRN constipation
8. Tizanidine 2 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cervical stenosis with multilevel disc herniation and cord
compression
Compressive myelopathy
Multilevel lumbrosacral spondylosis with radiculopathy
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:
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:
1)Weight bearing as tolerated.2)Gait,balance training.3)No
lifting >10 lbs.4)No significant bending/twisting.
Treatments Frequency:
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.
Followup Instructions:
___
|
10786789-DS-20
| 10,786,789 | 22,835,574 |
DS
| 20 |
2126-01-17 00:00:00
|
2126-01-20 14:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
vertigo
Major Surgical or Invasive Procedure:
Nil
History of Present Illness:
The pt is a ___ ___ right handed man without significant PMH
or vascular risk factor presented here with vertigo since this
morning.
The interview was conducted with the help of his daughter as he
can speak ___ a little.
He noted that at 3 am when he woke up to use the bathroom he
felt
that he is so dizzy: the room was spinning around him, this
sensation remained the same even with closed eyes.
He also felt that he was very nauseous, he stood up and as he
was
scared to have a fall he held on the furniture to avoid falling.
After he urinated as he still felt dizzy he called his daughter
and after 30 min when the daughter arrived he started throwing
up, They called ___ and came here to ED. he threw up 2 more
times
and after he received Zofran his nausea subsided but he still
had
the vertigo.
He noted that he still has the vertigo which is now hours after
it started.
He said that positional changes does not make any difference but
changing position from flat to standing makes it worse.
His dizziness improved with Meclizine.
He denies having headache, loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention, no
recent ear infection or trauma to his head.
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:
none
Social History:
___
Family History:
There is no history of seizures, developmental disability,
learning disorders, migraine headaches, strokes less than 50,
neuromuscular disorders, or movement disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 97.1, HR:68 regular, RR:14, BP: 132/83 he is not
orthostatic O2sar:100 RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Full range of motion OR decreased neck rotation and
flexion/extension.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Calves SNT bilaterally.
Skin: no rashes or lesions noted.
Neurological examination:
- Mental Status:
ORIENTATION - Alert, oriented x3
The pt. had good knowledge of current events.
SPEECH
Able to relate history without difficulty.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors.
Speech was not dysarthric.
NAMING Pt. was able to name both high and low frequency objects.
READING - Able to read without difficulty
ATTENTION - Attentive, able to name ___ backward without
difficulty.
REGISTRATION and RECALL
Pt. was able to register 3 objects and recall ___ at 5 minutes.
COMPREHENSION
Able to follow both midline and appendicular commands
There was no evidence of apraxia or neglect
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Blinks to
threat bilaterally. Funduscopic exam reveals no papilledema,
exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal pursuits and
saccades
V: Facial sensation intact to light touch. Good power in muscles
of mastication.
VII: No facial weakness, facial musculature asymmetric flat NLF
on the right
VIII: Hearing intact to ___ bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with normal velocity movements.
- Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
SAbd SAdd ElF ElE WrE FFl FE IO HipF HipE KnF KnE AnkD ___
L 5 5 ___ ___ 5 5 5 5 5 5 5
R 5 5 ___ ___ 5 5 5 5 5 5 5
- Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout in UE and ___. No
extinction to DSS.
- DTRs:
BJ SJ TJ KJ AJ
L ___ 2 1
R ___ 2 1
There was no evidence of clonus.
___ negative. Pectoral reflexes absent.
Plantar response was flexor bilaterally.
- Coordination: No intention tremor, normal finger tapping. No
dysdiadochokinesia noted. No dysmetria on FNF or HKS
bilaterally.
- Gait: Good initiation. ___, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
DISCHARGE EXAM: unchanged
Pertinent Results:
ADMISSION LABS
___ 04:55PM ALT(SGPT)-14 AST(SGOT)-17 LD(LDH)-186
CK(CPK)-150 ALK ___ TOT ___
___ 04:55PM ___ cTropnT-<0.01
___ 04:55PM ___
___ 04:55PM ___
___ 04:55PM ___ HDL ___
LDL(CALC)-69
___ 11:10AM URINE ___ SP ___
___ 11:10AM URINE ___
___
___
___ 07:43AM ___ ___
___ 05:15AM ___
___ 05:10AM ___ UREA ___
___ TOTAL ___ ANION ___
___ 05:10AM ___ this
___ 05:10AM ___
___ 05:10AM ___
___
___ 05:10AM ___
___
___ 05:10AM PLT ___
CT HEAD ___
No acute intracranial abnormality. MRI would be more sensitive
for vestibular nerve pathology.
CTA head + neck ___. No evidence for dissection.
2. Minimal intracranial atherosclerosis without hemodynamically
significant stenosis.
3. No intracranial hemorrhage or mass effect.
MRI head w/o contrast ___
No acute infarct or intracranial hemorrhage.
Brief Hospital Course:
The pt is ___ ___ man previously healthy
without any vascular ___ who presents with acute onset
vertigo: room spinning sensation which did not disappear after
closing eyes, started at 3 am accompanied by severe nausea,
vomiting and feeling unsteady. It has been with the patient now
for 5 hours, constantly without any interruption with the same
intensity. He noted that the vertigo is getting worse with
standing. He denied other neurologic symptom such as focal
weakness or numbness, double vision, blurred vision or
difficulty in hearing, focal numbness or weakness, change in his
voice or difficulty in swallowing. He denied any trauma to his
head or ear, recent infection, recent travel or any changes in
his life style. He is not taking any medications and he never
experienced these symptoms before. Neurologic exam revealed
intact cranial nerve (except for ?possible right NLF flattening,
intact motor, sensory and coordination exam. DDX for his
symptoms includes vestibulo basilar insufficiency v/s
vestibulopathy.
Given ? of possible R NLF flattening, and the constant duration
of the symptoms, the patient was admitted for MRI to rule out
stroke. MRI showed no stroke. MRI did show intracranial
atherosclerosis, so he was continued on a low dose ASA at
discharge. LDL and A1C were wnl. The patient's vertigo improved
with medication and did not recur. Since he did not have a PCP,
he was set up with a new PCP at ___. He will also follow
up with Stroke in 1 month.
Code Status: Full
TRANSITIONAL ISSUES
- the patient was set up with a new PCP appt since he did not
yet have a PCP
- follow up with stroke neurology in 1 month
Medications on Admission:
none
Discharge Medications:
1. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Vertigo
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 ___ Neurology. You were
hospitalized for new symptoms of vertigo and nausea, and we were
concerned that you may have had a stroke. We obtained an MRI of
your brain, and it showed NO new stroke. We also found no
evidence of bleeding, tumors or other abnormalities. We checked
blood tests for diabetes and high cholesterol and all of these
tests returned negative.
To prevent further stroke, we ask that you take a small or
"Baby" aspirin daily. You can buy this over the counter.
Continue to live a healthy lifestyle and with a healthy diet and
exercise. Be sure to follow up with your appointments listed
below.
Followup Instructions:
___
|
10786862-DS-10
| 10,786,862 | 26,181,237 |
DS
| 10 |
2188-01-21 00:00:00
|
2188-01-22 18:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Iodinated Contrast Media - IV Dye /
shellfish derived / titanium / fish oil / Gadolinium-Containing
Contrast Media / hydroxyzine
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ F h/o left hip replacement ___
presenting with n/v/d and right sided abdominal pain since ___ am
on ___.
The patient was discharged from ___ recently to rehab,
where she recovered well and was discharged home on ___
(___). She felt very fatigued all day ___ and did eat
during the day because she didn't have an appetite. Her
boyfriend brought her ___ takeout on ___ night and she
nibbled on that. The following morning at 10AM the patient
developed acute abdominal pain associated with non-bloody
diarrhea and non-bloody emesis. She denies fevers, chills, sick
contacts. No recent antibiotic exposure other than the routine
intra-op antibiotics for hip replacement surgery ___. Her only
abdominal surgery was a tubal ligation many years ago.
In the ED, initial vitals: ___, T 98.2, HR 113, BP 154/55, RR
18, O2 97% RA
***Glucose 30
Exam: appears uncomfortable, abdomen soft, mildly distended with
generalized tenderness, guaiac positive brown to orange stool
Labs were significant for WBC 6.9 with PMN 91%. Normal LFTs.
Normal lipase. Lactate 3.9 initially which trended down with
fluids to 2.0. U/A with only 4 WBC and few bacteria, neg nit.
Imaging was not done.
In the ED, she received
___ 20:16 IV Morphine Sulfate 4 mg
___ 20:16 IV Ondansetron 4 mg
___ 20:16 IVF 1000 mL NS 1000 mL
___ 21:51 PO Acetaminophen 1000 mg
___ 23:49 IVF 1000 mL NS 1000 mL
___ 23:49 PO Ibuprofen 600 mg
___ 08:45 IV Ondansetron 4 mg
___ 11:19 PO Aluminum-Magnesium Hydrox.-Simethicone 30 mL
___ 11:19 PO Acetaminophen 1000 mg
___ 11:19 IV Metoclopramide 10 mg
___ 11:19 PO Donnatal 10 mL
___ 11:19 PO Lidocaine Viscous 2% 10 mL
___ 11:25 IH Albuterol Inhaler 2 PUFF
___ 11:26 SC Enoxaparin Sodium 40 mg
She was monitored in ED observation unit but unfortunately had
ongoing abdominal pain and inability to tolerate PO so was
admitted for pain control and treatment. Of note, she spiked
temp to 102.1 on night of ___.
Vitals prior to transfer: Pain 0, T 98.8, HR 84, BP 130/81, RR
16, O2 97% RA
Currently, the patient just finished a tuna sandwich and has
some nausea during interview. No emesis. She also has urge to
defecate and has to excuse herself to bathroom.
Past Medical History:
Asthma - severe.
GOUT
HLD
ASEPTIC NECROSIS OF BONE-right hip
ESOPHAGEAL REFLUX
Osteoarthritis
FAMILY HISTORY OF cerebral aneurysm
Obesity
Impaired fasting glucose
Neuropathy
ARTHRALGIA - ANKLE / FOOT
Hypertension, essential
Vitamin D deficiency
Hypertriglyceridemia
Sleep apnea - does not tolerate CPAP due to anxiety
Fibromyalgia
Carpal tunnel syndrome
Lumbar disc disease
Lung nodule
Colonic adenoma
s/p tubal ligation
s/p L hip replacement at ___ in ___ by Dr. ___
___ History:
___
Family History:
Sister with ovarian cancer
Mother and MGM with brain aneurysms. Genetic has been done on
the rest of the family and has been neg per pt report.
Physical Exam:
ADMISSION
VS: 99.5, 114/86, 86, 18, 96% RA
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, tender to palpation over right side with guarding but
no rebound. Normoactive bowel sounds. NO tympany.
EXTREM: Warm, well-perfused, no edema. Well healed surgical scar
on L hip.
NEURO: CN II-XII grossly intact, motor function grossly normal
DISCHARGE
VS: 99.2 103/65 90 18 96RA
24h 1820/300
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l no w/r/r
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, Tender in RLQ, no rebound, (+) BS
EXTREM: Warm, well-perfused, no edema. Well healed surgical scar
on L hip, incision mildly erythematous & boggy.
NEURO:AAO3, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 08:25PM BLOOD WBC-6.9# RBC-4.23 Hgb-11.7 Hct-36.7
MCV-87 MCH-27.7 MCHC-31.9* RDW-13.9 RDWSD-43.7 Plt ___
___ 08:25PM BLOOD Neuts-91.6* Lymphs-4.8* Monos-2.5*
Eos-0.4* Baso-0.1 Im ___ AbsNeut-6.28* AbsLymp-0.33*
AbsMono-0.17* AbsEos-0.03* AbsBaso-0.01
___ 08:25PM BLOOD ___ PTT-26.4 ___
___ 08:25PM BLOOD Glucose-146* UreaN-20 Creat-0.8 Na-135
K-7.1* Cl-102 HCO3-21* AnGap-19
___ 08:25PM BLOOD ALT-18 AST-47* AlkPhos-70 TotBili-0.2
___ 08:25PM BLOOD Lipase-39
___ 08:25PM BLOOD Albumin-4.0
___ 08:36PM BLOOD Lactate-3.9* K-4.3
___ 10:51PM BLOOD Lactate-2.0
RELEVANT LABS:
___ 09:43PM BLOOD Lactate-1.2
___ 09:51AM BLOOD ALT-19 AST-20 LD(LDH)-185 AlkPhos-64
TotBili-0.2
___ 12:24AM URINE Color-Yellow Appear-Hazy Sp ___
___ 12:24AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR
___ 12:24AM URINE RBC-2 WBC-4 Bacteri-FEW Yeast-NONE Epi-6
TransE-<1
DISCHARGE LABS:
___ 05:27AM BLOOD WBC-5.2 RBC-3.46* Hgb-9.5* Hct-30.2*
MCV-87 MCH-27.5 MCHC-31.5* RDW-13.8 RDWSD-43.7 Plt ___
___ 05:27AM BLOOD Glucose-116* UreaN-12 Creat-0.8 Na-140
K-4.3 Cl-104 HCO3-27 AnGap-13
___ 05:27AM BLOOD Calcium-9.7 Phos-3.4 Mg-2.0
MICROBIOLOGY:
___ URINE CULTURE: MIXED BACTERIAL FLORA ( >= 3 COLONY
TYPES), CONSISTENT WITH FECAL CONTAMINATION.
___ STOOL CULTURE: **FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI
0157:H7 FOUND.
___ BLOOD CULTURE X2: NEGATIVE ON DAY OF DISCHARGE, PRELIM
___ STOOL C. DIF: NEGATIVE
___ STOOL NOROVIRUS PCR: POSITIVE FOR TYPE II**
Relevant Imaging/Studies
___ U.S., TRANSVAGIN
Normal pelvic ultrasound. No cause for right lower quadrant
pain is
appreciated.
___ ABD & PELVIS W/O CON
1. Mild stranding in the mesenteric fat with prominent lymph
nodes may reflect mild mesenteric panniculitis.
2. Normal appendix. No evidence of diverticulitis.
3. Postoperative seroma in the subcutaneous tissues of the left
hip at site of prior hip replacement.
___ (SUPINE & ERECT
Normal bowel gas pattern. No evidence of pneumoperitoneum.
Brief Hospital Course:
Ms. ___ is a ___ F h/o left hip replacement ___
presenting with sudden onset n/v/d and right sided abdominal
pain secondary to Norovirus and post-infectious IBS.
ACTIVE ISSUES
#N/V/D: Stool studies, including C. dif were initially negative.
Norovirus PCR was later checked and positive. She initially
received cipro/flagyl, however, these were discontinued as there
was low suspicion for bacterial infection. She did have CT
abdomen/pelvis, which showed "Mild stranding in the mesenteric
fat with prominent lymph nodes may reflect mild mesenteric
panniculitis." Surgery was consulted gievn this finding, but
there was no recommended surgical option. Pelvic US was limited,
but did not show any ovarian/pelvic pathology that could be
contributing to persistent RLQ cramping pain. Given negative
imaging, we attributed RLQ pain to post-infectious irritable
bowel syndrome. She was given Rx for dicyclomine. On discharge,
RLQ and frequency of diarrhea had significantly improved.
#S/p L hip repair: She completed course of enoxaparin DVT ppx
for post left hip repair. CT a/p showed small seroma at hip
incision, however, wound was evaluated by ortho and deemed to be
healing appropriately. She continued PRN oxycodone for pain.
CHRONIC ISSUES
#Fibromylagia: She continued duloxetine and gabapentin 900 mg
PO/NG TID
#Asthma: She continued home inhalers, PRN albuterol
TRANSITIONAL ISSUES:
-Held HCTZ on discharge given normotension; Consider restarting
as outpatient
-Given CT findings, would recommend repeat CT and/or follow-up
with Gastroenterology
-S/p L hip repair: completed enoxaparin. has f/u ___.
-Please continue eval of anemia
-CODE STATUS: Full, confirmed
-CONTACT: Sister/HCP ___ ___, cell
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC DAILY
4. Acetaminophen 1000 mg PO Q8H
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH DAILY
6. Famotidine 10 mg PO DAILY:PRN indigestion
7. Vitamin D 5000 UNIT PO DAILY
8. artificial saliva (yerbas-lyt) 2 spray mucous membrane BID
9. Ibuprofen 600 mg PO Q8H:PRN pain
10. DULoxetine 60 mg PO DAILY
11. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
12. Fluticasone Propionate NASAL 2 SPRY NU DAILY
13. Gabapentin 900 mg PO TID
14. ammonium lactate 12 % topical BID:PRN dry skin
15. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
16. Allopurinol ___ mg PO DAILY
17. fenofibrate micronized 200 mg oral DAILY
18. Montelukast 10 mg PO DAILY
19. Hydrochlorothiazide 25 mg PO DAILY
20. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID
21. coenzyme Q10 100 mg oral DAILY
22. Sarna Lotion 1 Appl TP QID:PRN itching
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Allopurinol ___ mg PO DAILY
4. DULoxetine 60 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH DAILY
7. Gabapentin 900 mg PO TID
8. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
9. Montelukast 10 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
11. Sarna Lotion 1 Appl TP QID:PRN itching
12. DICYCLOMine 20 mg PO QID
RX *dicyclomine 20 mg 1 tablet(s) by mouth QID PRN Disp #*30
Tablet Refills:*0
13. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide 2 mg 1 capsule by mouth QID PRN Disp #*30 Capsule
Refills:*0
14. ammonium lactate 12 % topical BID:PRN dry skin
15. artificial saliva (yerbas-lyt) 2 spray mucous membrane BID
16. coenzyme Q10 100 mg oral DAILY
17. Docusate Sodium 100 mg PO BID
Hold if having diarrhea
18. Famotidine 10 mg PO DAILY:PRN indigestion
19. fenofibrate micronized 200 mg oral DAILY
20. Ibuprofen 600 mg PO Q8H:PRN pain
21. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID
22. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Norovirus infection
Post-infectious irritable bowel syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care of you at the ___
___. You were admitted for nausea,
vomiting, diarrhea, which we believe is from an infection called
Norovirus. Your symptoms improved prior to discharge. You had a
CT scan of your abdomen, which showed some inflammation of the
tissue in your abdomen as well as some enlarged lymph nodes.
These are most likely from your infection, but we cannot
absolutely rule out processes, such as mesenteric panniculitis
and inflammatory bowel disease. We have made you an appointment
with a GI doctor so that you may follow-up regarding this. Your
abdominal pain and diarrhea should continue to improve. Please
try to avoid dairy products for the next week, as lactose
intolerance is common after the infection that you had.
I have written you a prescription for a medication called
dicyclomine, which may help with the cramping.
Please follow-up with your PCP, orthopedist and
gastroenterologist as listed below.
We wish you all the best,
Your ___ team
Followup Instructions:
___
|
10787013-DS-7
| 10,787,013 | 21,643,759 |
DS
| 7 |
2166-08-07 00:00:00
|
2166-08-10 12:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Fever, shortness of breath
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ yo F w/ hx of chronic SOB of unclear etiology (CXR suggestive
of interstitial lung disease and hyperinflation, PFTs remotely
reportedly normal), anxiety/depression, chronic pain syndrome
presenting from home with cough starting 3 days prior to
admission, dyspnea and fever to 102 day prior to admission, with
fatigue, found to have influenza A.
She reports that for the past 4 days she has had worsening
cough, largely non-productive, shortness of breath starting 2
days later, and generalized fatigue, with sore throat on day of
admission. In conjunction with these symptoms she has had fever
(potentially to 102 at home), some lightheadedness, and 2
episodes of non bloody, non bilious post-tussive emesis, with
some associated nausea. Notes she continues to eat and hydrate
well. She has been using Advair twice daily at home but without
significant relief. She denies CP (including pleuritic CP),
palpitations, pre-sycnope or syncope, dizziness, headaches,
abdominal pain, dysuria, changes in BMs. Patient did not receive
flu vaccines this year, as has had bad reactions ever since H1N1
vaccine.
In the ED, temp of 99.8 with RR 24, )2 saturations of 93-95% on
RA, ambulatory sat 92-96%, in no distress. Other VSS. Influenza
A testing was positive, and the patient was started on
oseltamivir, albuterol/ipratropium nebs, and given 500cc NS.
Past Medical History:
#Chronic SOB (no formal Dx of COPD)
- PFTs at OSH in ___ reprotedly normal
#Anxiety/Depression: on home benzodiazepines
#Chronic Pain: home regimen includes oxycodone, gabapenitin
#Aortic sclerosis
- EF 65%, concentric LV hyperterophy
#GERD
- EGD ___ hiatal hernia, gastritis,
#Hematuria
- dx ___ w/ microhematuria; in ___, concern for bladder
cancer, patient unaware of this
- clear studies for last ___ years with urology in ___
- NOTE: PATIENT IS UNAWARE OF POSSIBLE DX OF BLADDER CANCER
#Macular degeneration
#Nocturnal leg movements
#Osteoporosis
#s/p I&D ORIF of L. distal radius and ulna Fx (___)
#S/p L. transfemoral intramedullary nail (___)
#S/p R hip fracture in ___
#S/p R wrist fracture in ___
Social History:
___
Family History:
Non-contributory to current presentation in this ___ year old
patient.
Father - pancreatic cancer
Sister - brain cancer
Husband - pancreatic cancer
Mother - DM
Physical ___:
ADMISSION PHYSICAL EXAM:
====================
VS - 95% on RA, RR 24, HR 81
Gen - very pleasant, elderly F; appears younger than stated age;
no distress, breathing comfortably on room air, speaking in full
sentences
HEENT - pinpoint pupils, dry MMM, no OP lesions
Cor - RRR no MRG
Pulm - respiratory rate 24; mild accessory muscle use; diffuse
expiratory wheezing
Abd - soft, non-tender, non-distended, normal bowel sounds '
Skin - multiple sebhorreic keratoses, mostly on her back
Extrem - warm, no edema, DP pulses 2+, hammer toes bilaterally
DISCHARGE PHYSICAL EXAM:
====================
VS: Tm 98.6, HR 70-75, BP 139-175/54-68, RR 18 (28 on my check),
O2 93-97%RA
Gen: very pleasant, elderly woman, lying in bed. NAD, speaking
in full word sentences
HEENT: PERRL, left ptosis similar to prior, MMM, no OP lesions
Neck: supple, no LAD noted
CV: RRR, no murmurs, rubs, gallops
Lungs: Minimal diffuse expiratory wheezing, without rhonchorous
sounds, and improved from prior exams, with intermittent wet
cough during exam and interview. Without significant prolonged
expirations this morning
Abd: soft, mild epigastric tenderness (similar to yesterday),
without rebound or guarding, non-distended, normal bowel sounds
GU: no Foley
Skin: multiple sebhorreic keratoses, mostly on her back
Ext: warm, no edema, hammer toes bilaterally
Neuro: PERRL, EOMI, symmetric palate elevation, tongue midline,
___ shoulder shrug, hearing intact to snaps bilaterally,
sensation to LT intact in ___, facial muscles symmetric with
activation, some mild L ptosis at rest (unchanged). Strength
exam deferred, sensation to light touch in distal extremities
intact. No paraphasic errors, answering all questions
appropriately.
Pertinent Results:
==== ADMISSION LABS ====
___ 03:30PM BLOOD WBC-11.2*# RBC-4.05* Hgb-12.3 Hct-36.8
MCV-91 MCH-30.3 MCHC-33.3 RDW-13.6 Plt ___
___ 03:30PM BLOOD Neuts-53.7 ___ Monos-5.6 Eos-0.5
Baso-0.6
___ 03:30PM BLOOD Glucose-101* UreaN-18 Creat-0.6 Na-129*
K-4.1 Cl-95* HCO3-20* AnGap-18
___ 03:30PM BLOOD ALT-38 AST-58* AlkPhos-68 TotBili-0.6
___ 03:30PM BLOOD Albumin-4.1
___ 03:36PM BLOOD Lactate-1.1 K-3.7
___ 05:20PM URINE Color-Straw Appear-Clear Sp ___
___ 05:20PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:20PM URINE RBC-1 WBC-1 Bacteri-MOD Yeast-NONE Epi-<1
___ 05:20PM URINE Hours-RANDOM Creat-43 Na-LESS THAN K-23
Cl-LESS THAN
___ 06:30PM OTHER BODY FLUID FluAPCR-POSITIVE *
FluBPCR-NEGATIVE
==== DISCHARGE LABS ====
___ 04:30AM BLOOD WBC-15.2* RBC-3.86* Hgb-11.5* Hct-34.3*
MCV-89 MCH-29.9 MCHC-33.7 RDW-13.6 Plt ___
___ 04:30AM BLOOD Glucose-122* UreaN-11 Creat-0.4 Na-133
K-3.9 Cl-94* HCO3-27 AnGap-16
==== MICROBIOLOGY ====
___ BLOOD CULTURES: pending
==== IMAGING ====
___ EKG: NSR at 77; PVCs and ___ AVB; no other change from
prior.
___ CXR (PA/Lat):
No focal consolidation to suggest pneumonia.
___ CXR (PORTABLE):
1. Interval resolution of mild interstitial edema since
___.
2. No acute cardiopulmonary process.
Brief Hospital Course:
___ yo F w/ hx of chronic SOB of unclear etiology (CXR suggestive
of interstitial lung disease and hyperinflation, PFTs remotely
reportedly normal), anxiety/depression, chronic pain syndrome
presenting from home with fever, cough and dyspnea, found to
have influenza A by PCR testing, which is very accurate.
Although she has diffuse bronchospasm, she is without
respiratory distress or oxygen requirement.
ACUTE PROBLEMS:
====================
#INFLUENZA A:
Patient presented with worsening of her chronic SOB and new wet
intermittently productive cough, with fatigue, nausea and fevers
to 102, found to have Influenza A on influenza testing in the
setting of not receiving the flu shot this year as she is
allergic to the new formulations since the swine flu versions
(gets anaphylactoid reaction). She did not have contacts who
would require prophlyaxis. Patient treated with oseltamivir, as
well as supportive care with tylenol, nebulizer therapy and prn
1L O2 for patient comfort, as well as
guaifenesin-dextromethorphan for congestion and productive
cough. Patient slowly improved over time, and remained afebrile.
A CXR was done on admission and when patient's WBC rose (see
discussion below), without evidence of concomitant bacterial
pneumonia. Patient was evaluated by ___, who recommended rehab
following acute hospitalization.
#ANEMIA:
Patient initially with normal H/H, downtrended over course of
hospital stay in the setting of receiving IV fluid support.
Retic count low, potentially related to inflammatory bone marrow
suppression from acute infection. LDH, haptoglobin, and tbili
were within normal limits, less concerning for hemolysis. Will
need follow up as an outpatient to determine need for further
workup.
#HYPONATREMIA:
Patient presented with hyponatremia in the setting of infection
and poor PO intake, with Na down to 129. Urine studies with UNa
<10, consistent with hypovolemic hyponatremia. Patient improved
with IVF.
#LEUKOCYTOSIS:
Patient initially with mild leukocytosis to 11, with normal
differential, which downtrended initially, and then began to
uptrend during treatment of influenza, with preferential
lymphocytosis. Per daughter, patient has a history of
leukocytosis, previously worked up at the ___, and
reportedly nothing to be concerned about, but has had high white
counts which are reportedly her normal. Patient's WBC was 15.2
on discharge. Deferred further workup to outpatient setting, as
patient clinically was improving.
CHRONIC ISSUES:
=====================
#ANXIETY/DEPRESSION/CHRONIC PAIN:
Stable, continued home clonazepam (reduced to 0.25mg),
citalopram 15mg, gabapentin 300mg qHS. Given stable on this
regimen, patient was discharged on reduced dose of clonazepam
#HYPERTENSION:
Patient's home med, telmisartan 80mg, not on formulary, so
started on equivalent dose of losartan while in house.
Discharged on home medication.
#GERD/gastritis:
Stable, continued home PPI. Given risk for all types of
fractures in the elderly on a PPI, consider transitioning to H2
blocker for treatment of GERD symptoms in the setting of
patient's history of fractures.
#HEMATURIA (microscopic):
***NOTE: Patient unaware of possible diagnosis of bladder
cancer, per family request please do not mention.
Per daughter, no history of bladder cancer (some concern years
ago, but no signs currently that she does or did have bladder
cancer). Deferred further discussion and workup to outpatient
setting.
#OSTEOPOROSIS: Given the numerous previous fractures and
relatively well preserved mobility, consideration should be
given for drug treatment once she returns to her usual care.
TRANSITIONAL ISSUES:
=================
#Tamiflu for 5 day course total, first day ___, last dose
evening of ___ (patient has one dose left to take)
#Continue guaifenesin-dextromethorphan for symptomatic treatment
of cough
#Continue decreased clonazepam at 0.25mg every evening, as
patient remained stable on this regimen while in hospital, and
can cause falls/confusion in elderly
#Given concern for fractures with PPI, consider transition to H2
blocker as an outpatient
#Given patient allergy to bisphosphonates, consider prolia
(denosumab) as an outpatient
#Outpatient follow up with urology for microscopic hematuria
#Outpatient follow up for patient's leukocytosis.
#Code: FULL (confirmed w/ daughter ___
#Emergency Contact: ___ (daughter, HCP) ___
___ (daughter/HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
3. Benzonatate 100 mg PO TID (instructed not to take if taking
Robitussin DM)
4. ClonazePAM 0.5 mg PO QHS
5. Citalopram 15 mg PO DAILY
6. Gabapentin 300 mg PO QHS
7. Ropinirole 1.5 mg PO QPM
8. Aspirin 81 mg PO DAILY
9. esomeprazole magnesium 40 mg oral daily GERD/gastritis
10. Micardis (telmisartan) 80 mg oral QAM
11. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral QAM
12. Citracal + D (calcium phosphate-vitamin D3) 250 mg calcium-
250 unit oral QAM
13. Acetaminophen 650 mg PO QAM
14. Acetaminophen 650 mg PO QHS:PRN pain
15. Lidocaine 5% Patch 1 PTCH TD QAM
16. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
Discharge Medications:
1. Acetaminophen 650 mg PO QAM
2. Aspirin 81 mg PO DAILY
3. Citalopram 15 mg PO DAILY
4. ClonazePAM 0.25 mg PO QHS
5. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
6. Gabapentin 300 mg PO QHS
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Ropinirole 1.5 mg PO QPM
9. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
This is a new medication to treat your cough.
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 5 mL by mouth
every 6 hours as needed Refills:*0
10. OSELTAMivir 75 mg PO Q12H Duration: 1 Dose
This is a new medication to treat your flu. Last dose evening of
___
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth twice
daily Disp #*1 Capsule Refills:*0
11. Acetaminophen 650 mg PO QHS:PRN pain
12. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
13. Benzonatate 100 mg PO TID
14. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral QAM
15. Citracal + D (calcium phosphate-vitamin D3) 250 mg calcium-
250 unit oral QAM
16. Esomeprazole Magnesium 40 mg ORAL DAILY GERD/gastritis
17. Micardis (telmisartan) 80 mg oral QAM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
-Influenza A
-Hyponatremia
Secondary Diagnoses:
-Anemia
-Anxiety/depression
-Osteoporosis
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your recent hospital
stay at the ___. You came in
with worsening cough and shortness of breath with a fever, and
were found to have influenza (the flu). You were treated with
tamiflu and a small amount of supplemental oxygen, and were
given nebulizer treatments and cough medicine. We got an image
of your lungs, and they were clear of any other infection. You
slowly began to improve, and the physical therapists who
evaluated you felt you would benefit from rehab until your
strength improves.
Your medications are listed below for you, including your
tamiflu medication which you have one more dose to take (last
dose on ___. The physician at your rehab will follow up
with you at the rehab, and arrange future follow up with your
regular primary care doctor.
We wish you the best with your health.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10787105-DS-9
| 10,787,105 | 25,696,888 |
DS
| 9 |
2121-01-20 00:00:00
|
2121-01-21 21:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
assault
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
This patient is a ___ year old male with no pertinent history who
presents as a transfer after being assaulted a few hours ago.
Per EMS, the pt was found under a bridge near water in ___. Pt
was transferred for ophthalmology evaluation given
hyphema. The patient had no imaging prior to arrival.
Past Medical History:
None
Social History:
___
Family History:
N/C
Physical Exam:
Admission Physical Exam:
HR: 116
Constitutional: agitated, thrashing about
HEENT: L eye: hyphema with question of irregular pupil (vs
fake out from hyphema), numerous facial abrasions
In C-collar. Airway is intact
Chest: Spontaneous bilateral breath sounds. Abrasion to the
R chest wall.
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender, Nondistended
Extr/Back: Palpable radial pulses. No deformity of UEs ___
bilaterally
Skin: No rash
Psych: agitated
___: No petechiae
Discharge Physical Exam
VS:98.2 PO HR 53, BP 140/86, RR 20, 100% RA
Gen: Awake, alert, sitting up in bed. Pleasant and interactive.
HEENT: left eye ecchymosis, left cheek swelling. Right pupil 8
mm non reactive, Left pupil 7 mm non reactive. EOMI. Mucus
membranes pink/moist. teeth intact. Neck supple, trachea
midline.
CV: bradycardic, regular rhythm
Pulm: Clear to auscultation bilaterally
Abd: Soft, non-tender, non-distended.
Ext: Warm and dry. 2+ ___ pulses. no edema
Neuro: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 07:48AM GLUCOSE-89 UREA N-10 CREAT-0.9 SODIUM-141
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-23 ANION GAP-17
___ 07:48AM LIPASE-159*
___ 07:48AM CALCIUM-9.3 PHOSPHATE-3.4 MAGNESIUM-2.1
___ 07:48AM TRIGLYCER-221*
___ 07:48AM WBC-9.9 RBC-4.91 HGB-14.9 HCT-44.7 MCV-91
MCH-30.3 MCHC-33.3 RDW-12.7 RDWSD-41.7
___ 07:48AM NEUTS-53.1 ___ MONOS-8.6 EOS-0.5*
BASOS-0.2 IM ___ AbsNeut-5.23 AbsLymp-3.67 AbsMono-0.85*
AbsEos-0.05 AbsBaso-0.02
___ 07:48AM PLT COUNT-235
___ 07:48AM ___ PTT-35.8 ___
___ 06:15AM TYPE-ART TIDAL VOL-500 PEEP-5 O2-100 PO2-576*
PCO2-26* PH-7.48* TOTAL CO2-20* BASE XS--1 AADO2-112 REQ O2-30
INTUBATED-INTUBATED
___ 06:15AM O2 SAT-99
___ 03:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 03:45AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 02:48AM GLUCOSE-110* LACTATE-1.9 NA+-145 K+-4.3
CL--104 TCO2-26
___ 02:42AM UREA N-9 CREAT-1.1
___ 02:42AM LIPASE-544*
___ 02:42AM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 02:42AM WBC-12.5* RBC-4.90 HGB-15.1 HCT-45.1 MCV-92
MCH-30.8 MCHC-33.5 RDW-12.5 RDWSD-41.8
___ 02:42AM PLT COUNT-244
___ 02:42AM ___ PTT-33.1 ___
___ 02:42AM ___
Imaging:
___: CT C-spine:
1. Mild widening of the anterior C6/C7 disc space with mild
anterior wedging of C7, concerning for ligamentous injury and
anterior compression fracture of C7. Recommend correlation with
physical examination. If clinically indicated, a cervical spine
MRI may be obtained for further evaluation.
2. Mild multilevel degenerative changes as described.
3. Paranasal sinus disease as described.
___: CT Head:
1. No acute intracranial hemorrhage.
2. Left periorbital hematoma with left orbital floor fracture
with findings
concerning for left inferior rectus muscle concerning for
entrapment.
Recommend correlation with ophthalmologic exam.
3. Right nasal bone fracture.
___: CXR:
No acute cardiopulmonary process.
___: CT Chest/ABD/Pelvis:
No evidence of acute injury in the torso. Bibasilar
atelectasis.
___: CT SINUS/MANDIBLE/MAXIL:
1. Left orbital floor fracture, minimally displaced.
2. Nonspecific mild enlargement of left inferior rectus muscle
relative to
right, concerning for entrapment. Recommend correlation with
ophthalmologic exam.
3. Question left maxillary sinus anterior wall nondisplaced
fracture.
4. Minimally displaced right nasal bone fracture.
5. Left periorbital preseptal soft tissue hematoma.
___: MRI Cervical Spine:
1. Redemonstration of anterior wedging of the C7 vertebral body
with widening of the intervertebral disc space at C6-7 with no
internal or surrounding high signal, likely secondary to remote
injury or congenital etiology.
2. No evidence for ligamentous or cervical spinal cord injury.
3. Degenerative changes at C5-7, as described above, resulting
in
mild-to-moderate spinal canal stenosis and severe bilateral
neural foraminal stenosis.
Brief Hospital Course:
Mr. ___ is a ___ year-old male who presented to ___ as a
transfer after being assaulted and was found to have a left
hyphema. Imaging also revealed a L maxillary sinus anterior wall
fracture as well as a R nasal fracture. CT c-spine was
remarkable for intervertebral disc widening at C6-7 and an MRI
C-spine was obtained which showed that the widening of the
intervertebral disc space at C6-7 was most likely congenital and
not traumatic. The patient was admitted to the Trauma Service
for further medical care.
On HD1, Ophthalmology was consulted. No surgical intervention
was necessary. It was recommended that the patient have the
head of the bed elevated to allow inferior settling of the clot,
be placed on bed rest with bathroom privileges to minimize risk
of rebleed, and avoid bending, lifting, and valsalva maneuvers.
He was also started on eye drop medication. The Plastic Surgery
service was consulted for the patient's facial fractures and no
further intervention was needed.
The remainder of the ___ hospital stay is summarized by
systems below:
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with acetaminophen and
oxycodone.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient tolerated a regular diet. Patient's
intake and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*50 Tablet Refills:*0
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
RX *dorzolamide-timolol 22.3 mg-6.8 mg/mL 1 drop twice a day
Refills:*0
3. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID
RX *erythromycin 5 mg/gram (0.5 %) 1 application four times a
day Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
5. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
RX *prednisolone acetate 1 % 1 drop four times a day Refills:*0
6. Atropine Sulfate Ophth 1% 1 DROP LEFT EYE BID
RX *atropine 1 % 1 drop in the left eye twice a day Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
1. Left eye hyphema
2. left eye corneal abrasion
3. Left orbital floor fracture
4. Right nasal bone fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the Acute Care Trauma Surgery service on
___ with multiple facial injuries. You had CT scan imaging
that showed a left orbital floor fracture, right nasal bone
fractures, left corneal abrasion, and blood in your left eye.
You were seen and evaluated by the ophthalmology (eye) team that
recommended multiple eye drops as listed below and close follow
up. You were also seen by plastic surgery for your facial
fractures. There is nothing surgical to do for your fractures at
this time. Please note the instructions listed below and follow
up in the plastic surgery outpatient clinic as scheduled below.
======================================================
Instructions for Eye injury:
-Continue Prednisolone acetate 1% four times per day to LEFT EYE
-Continue Atropine 1% twice a day to LEFT EYE
-Continue Cosopt twice a day to LEFT EYE
-Continue erythromycin ointment three times per day to left eye
-Avoid bending, lifting, valsalva maneuvers
==============================================
Instructions for facial fractures:
Please maintain sinus precautions as noted below:
- No using straws, sneeze with mouth open, no sniffing, no
smoking, keep head elevated on several pillows when lying down.
- Soft or blenderized diet x 2 weeks
- Keep cool pack to face for first 48 hours.
=======================================================
General Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until your follow-up appointment.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10787427-DS-10
| 10,787,427 | 28,402,850 |
DS
| 10 |
2144-08-21 00:00:00
|
2144-08-26 15:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
left facial droop, left sided weakness,
"difficulty speaking"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old LEFT-handed gentleman with a history
of
hypertension and prior TIA ___ years ago, who presented to our ED
this morning from ___, with left sided weakness and
left facial droop, and difficulty clearing his throat and
speaking.
He went to bed at 09:30pm last night and was in his usual state
of health. He woke up this morning at around 5:30 am with
difficulty speaking, reports it was a difficulty pronouncing and
no word finding difficulty. He had a left facial droop, left arm
and leg weakness, as well as numbness on the left side of his
face and arm.
He was taken to the ED at ___.
At ___, Head CT was done and did not show acute infarct. He
received Aspirin 325mg PO. His initial labs were all within
normal limit.
He was transferred to our ED for further evaluation.
In the ED, he reports some improvement in his left arm strength,
and states that he initially was unable to lift it and that now
he can move it better.
On neuro ROS, the pt reports a very slight headache, but no loss
of vision, blurred vision, diplopia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties
comprehending
speech. 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.
Last well seen: 21:30 on ___
Paged: 08:15am on ___
Neurology by bedside: 08:17am
Head CT, head/neck CTA reviewed within 20 minutes of
presentation.
___ SS obtained at 08:20= 7
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 2
5a. Motor arm, left: 1
5b. Motor arm, right: 0
6a. Motor leg, left: 1
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 0
10. Dysarthria: 1
11. Extinction and Neglect: 1
Past Medical History:
History of TIA ___ years ago, presented with dysarthria and left
sided weakness to ___. He reports MRI was
normal, and he was not started on any medications at the time.
HTN
Social History:
___
Family History:
Negative for strokes, heart disease, or hypercoagulable
disorders
Physical Exam:
Physical Exam:
T 98.4 HR 45 BP128/96 RR16 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is dysarthric but fluent with
intact repetition and comprehension. Normal prosody. There
were
no paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to read without difficulty. Able to
follow both midline and appendicular commands. The pt. had good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation.
III, IV, VI:EOMI without nystagmus. Normal saccades.
V: Facial sensation decreased on the left side to light,
pinprick
and cold sensation.
VII: Left facial droop, with left orbicularis oculi weakness as
well.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically. Gag reflex is hard to
elicit but ultimately present.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue is deviated to the left.
Motor:
Normal bulk and tone, no rigidity or bradykinesia.
Left:
Delt ___, ___ ___, Tri ___, wrist extensors 4+/5, wrist flexors
___. Grip ___, Spread 4+/5, IP ___, Quad ___, Ham ___, TA ___,
___ ___, Gastroc ___
Right:
Delt ___, ___ ___, Tri ___, Grip ___, Spread ___, IP ___, Quad
___, Ham ___, TA ___, ___ ___, Gastroc ___
Pronator drift on the Left.
Sensory: Decreased on the left to light touch, vibration,
temperature, pinprick, and impaired proprioception in upper
extremity only. Lower extremities are equally sensitive.
He has agraphestesia and asteretognosis on the left. He has
extinction on DSS on the left.
Reflexes:
DTRs
Right: ___ 2 Tri 2 ___ 2 Patellar 2 Achilles 1 Toes
downgoing
Left: ___ 2 Tri 2 ___ ___chilles 1 Toes
upgoing
Cerebellar: no Dysdiadochokinesia, no dysmetria on the right,
and
dysmetria is appropriate to degree of weakness on the left.
-Gait: Not attempted. Patient lying down and trying to optimize
cerebral blood flow.
Pertinent Results:
___ 04:50AM BLOOD WBC-6.3 RBC-4.56* Hgb-14.8 Hct-43.5
MCV-96 MCH-32.4* MCHC-33.9 RDW-13.1 Plt ___
___ 08:15AM BLOOD WBC-7.9 RBC-4.87 Hgb-15.6 Hct-46.5 MCV-96
MCH-32.0 MCHC-33.5 RDW-13.4 Plt ___
___ 04:50AM BLOOD Plt ___
___ 08:15AM BLOOD Plt ___
___ 08:15AM BLOOD ___ PTT-25.7 ___
___ 04:50AM BLOOD Glucose-85 UreaN-13 Creat-0.7 Na-141
K-3.5 Cl-106 HCO3-24 AnGap-15
___ 08:15AM BLOOD UreaN-22*
___ 08:15AM BLOOD CK(CPK)-128
___ 08:15AM BLOOD cTropnT-<0.01
___ 08:15AM BLOOD CK-MB-3
___ 04:50AM BLOOD %HbA1c-5.5 eAG-111
___ 04:50AM BLOOD Triglyc-75 HDL-58 CHOL/HD-3.1 LDLcalc-108
___ 04:50AM BLOOD TSH-3.4
___ 08:33AM BLOOD Comment-GREEN TOP
___ 08:33AM BLOOD Glucose-103 Na-143 K-3.7 Cl-103
calHCO3-26
ECHO:
The left atrium is moderately dilated. The right atrium is
moderately dilated. A secundum type atrial septal defect is
present (identified with intravenous saline contrast at rest).
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets are moderately thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is borderline pulmonary artery systolic
hypertension.
IMPRESSION: Secundum atrial septal defect. Biatrial enlargement.
Normal left ventricular wall thickness and cavity size with
preserved global biventricular systolic funciton. Mildly dilated
aortic root, ascending aorta, and aortic arch. Borderline
pulmonary artery systolic hypertension.
MRI:
There is an acute infarct identified in the right middle
cerebral
artery posterior division territory. The infarct involves the
right frontal
cortex in the surrounding subcortical region. There is no
evidence of blood
products seen in this region. There is no mass effect, midline
shift or
hydrocephalus. Following gadolinium, no abnormal enhancement is
seen.
IMPRESSION: Acute partial right middle cerebral artery
territorial infarct.
No evidence of hemorrhagic transformation or significant mass
effect. No
enhancing brain lesions.
CT:
CT HEAD: There is a questionable area of low attenuation
involving the right
frontal subcortical white matter which is suspicious for acute
stroke.
Otherwise, the gray-white matter is preserved elsewhere. The
basal cisterns
are patent. There is no evidence of midline shift or mass
effect. No
hemorrhage products are identified.
There is mild mucosal thickening of the ethmoid air cells.
Minimal mucosal
thickening of the maxillary sinuses is also noted. The
remaining paranasal
sinuses and mastoid air cells are clear.
CTA HEAD AND NECK: There is a three-vessel arch. The origin of
the common
carotid and vertebral arteries appear patent. The common
carotid, cervical
ICA, and vertebral arteries are patent.
The cavernous carotid arteries are very tortuous bilaterally.
There is no
significant narrowing. The anterior and middle cerebral
arteries are patent.
The V4 segments of the vertebral arteries are patent. The
basilar artery is
within normal limits. The posterior cerebral arteries are
patent. The
posterior communicating arteries are prominent.
There is mild oligemia in the right frontal lobe with truncation
of the distal
branches of the superior division of the rigth MCA.
the proximal right and left ICAs measure both 9.6 mm, and the
distal right and
left distal ICAs measure 5.3 mm and 4.5 mm. According to NASCET
criteria,
there is no stenosis.
There are multilevel degenerative changes of the cervical spine,
most severe
at C5-C6 and C6-C7 with sclerosis of the endplates and disc
space narrowing.
IMPRESSION:
1. Subtle area of low attenuation in the right frontal
subcortical white
matter with associated oligemia and truncation of the distal
branches of the
superior division of the right MCA concerning for an acute
infarct. An MRI
could be helpful for further evaluation.
2. No evidence of aneurysm or arteriovenous malformation in the
head or neck.
Brief Hospital Course:
patient is a ___ year old left handed man who developed left arm
numbness shortly after moving his bowels. Able to walk without
difficulty though his wife noted that his speech was slurred.
She drove him to ___.
States that his arm and hand became weaker and he was unable to
lift it but after several minutes he regained strength. Mild
right sided headache. Had a similar episode of left sided
weakness and slurred speech ___ years ago and was investigated at
___ (records unavailable at this time). Denies CP, palpitations.
On exam, awake, alert and oriented. Speech is fluent with mild
dysarthria. Able to read. Provides a coherent, detailed
narrative. Full eye movements. No field cuts. Left facial
weakness with mild weakness of left eye closure. No drift. No
weakness but slower FFM on left. Markedly decreased PP,
temperature on left face, arm, chest but normal vibs, JPS.
He was admitted in stroke service and we performed multiple
tests to find the cause of the symptom.
In MRI: He was found to have Ischemic infarction in right middle
cerebral artery territory.
Cardiac ECHO showed a secundum type ASD with biatrial
enlargement and he was started on coumadin for further events
prevention.
In risk factor management his LDL was 108 and he was started on
statin.
We noticed significant improvement in his neuro exam including
left facial droop and left side ___ hospital stay.
In ___ evaluation the patient was evaluated as safe to discharge
home
Medications on Admission:
Lisinopril 10mg(?) PO daily
Zantac daily
Multivitamins
ASA 81 mg daily
Discharge Medications:
1. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*2
2. Multivitamins 1 TAB PO DAILY
3. Ranitidine 150 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
RX *simvastatin 20 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*2
5. Warfarin 5 mg PO DAILY
RX *Coumadin 5 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Stroke: Ischemic infarction in right middle cerebral artery
territory.
Secondary Diagnoses:
Secundum Atrial Septal Defect
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurological Exam at Discharge: Slow RAMs on left. Decreased
pinprick on left upper extremity, most notable on dorsum of left
hand. Mild agraphesthesia on left (1 mistake with identifying
coins).
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurological Exam at Discharge: Slow RAMs on left. Decreased
pinprick on left upper extremity, most notable on dorsum of left
hand. Mild agraphesthesia on left (1 mistake with identifying
coins).
Discharge Instructions:
You presented to the hospital with symptoms of left facial
weakness, slurred speech and left upper extremity numbness and
weakness. You had an MRI, which showed that you had a stroke on
the right side of your brain (resulting in your left sided
symptoms). To evaluate for cause of your stroke, you had an
Echocardiogram, which showed you have a hole in your heart,
called an atrial septal defect. For this reason and because you
had the stroke while on Aspirin, we will start you on a blood
thinner called Coumadin. While on this medication, you will need
to get blood levels monitored to make sure you are in a
therapeutic range. The first level should be checked ___ at your PCP ___. You should continue taking Aspirin daily
until your Coumadin level is within a therapeutic range and then
you can stop taking the Aspirin.
In addition, you had cholesterol levels checked and your LDL
was slightly elevated at 108. You were started on a medication
called Simvastatin for this.
Followup Instructions:
___
|
10787788-DS-15
| 10,787,788 | 28,121,322 |
DS
| 15 |
2168-11-11 00:00:00
|
2168-11-11 20:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Fiber / Gemfibrozil / Atorvastatin Calcium / Haldol
Attending: ___.
Chief Complaint:
shortness of breath, cough
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
This is a ___ year-old Male with PMH significant for
oxygen-dependent COPD (with multiple prior admissions for
respiratory infections) with active tobacco use, hypertension,
chronic HCV infection, hyperlipidemia, depression and BPH who
presents 1-day of change in sputum production and cough.
Patient awoke at 3 AM the morning of admission with productive
cough and resting shortness of breath. He notes potentially a
recent mild URI with sore throat and clear nasal congestion in
the preceding days. He then attempted to use his nebulizers
twice (combivent) with minimal relief and then called EMS. He
denies chills, nightsweats or fevers. He has no recent sick
contacts and lives alone. He continues to smoke up to 1.5 packs
per day. He had some fleeting substernal chest pain in the AM
upon awakening, but this was non-radiating and subsided within
minutes. He has no strong cardiac history. He had no diaphoresis
or nausea.
Of note, the patient presented to his PCP, ___, on
___ with sore throat and dysphagia complaints and worsening
exertional dyspnea. Dr. ___ was concerned that given recent
corticosteroid use that he could have candidal esophagitis, and
an EGD was recommended. In addition, Dr. ___ was planning to
setup home oxygen, but did not feel he was acutely
decompensated.
In the ED, initial VS 97.8 103 117/88 28 99% 3L NC. Labs were
notable for WBC 11.7 without neutrophilia. Trop-T < 0.01.
Creatinine 1.2. VBG 7.37/50/53. A CXR was obtained. Patient was
dosed Prednisone 60 mg PO x 1, Azithromycin 500 mg PO x 1 and
received albuterol and ipratropium nebulizer treatments.
On arrival to the floor, patient is coughing intermittently but
is non-toxic appearing.
Past Medical History:
COPD
HTN
Hep C
HLD
H/o gabapentin and aspirin overdose in ___
H/o language difficulty episode in ___, unsure if hospitalized
multiple hospitalizations for pneumonia in ___,
___
Spiculated lung nodule, monitored, stable, nonactive on PET scan
H/o Hepatitis B, cleared
Candidal esophagitis in ___ w/incompleted treatment
"Lazy bowel syndrome" causing chronic constipation
Depression
Hernia repair x 2
BPH
Renal cysts
Chronic sinusitis
Deviated septum repair x 2
Scoliosis
Cataracts
H/o syphilis, gonorrhea
H/o positive PPD
Social History:
___
Family History:
Breast cancer (maternal), alcoholism, depression, suicide.
Brother died in ___ of asthma attack.
Physical Exam:
ADMISSION EXAM:
.
VITALS: 97.4 134/68 110 26 98% 2L NC
GENERAL: Appears in no acute distress. Alert and interactive.
Thin-appearing.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes dry without visible plaques or exudates.
NECK: supple without lymphadenopathy. JVP not elevated.
___: Distant heart sounds, regular rate and rhythm, without
murmurs, rubs or gallops. S1 and S2 normal.
RESP: Barrel-chested. Bilateral inspiratory wheezing noted
without rhonchi or crackles. Stable inspiratory effort without
labored breathing.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength ___ bilaterally, sensation grossly
intact. Gait deferred.
.
DISCHARGE EXAM: unable to peform, patient left AMA
Pertinent Results:
ADMISSION LABS:
.
___ 07:45AM BLOOD WBC-11.7* RBC-5.12 Hgb-15.3 Hct-46.4
MCV-91 MCH-29.8 MCHC-32.9 RDW-13.2 Plt ___
___ 07:45AM BLOOD Neuts-57.7 Lymphs-16.4* Monos-5.7
Eos-19.0* Baso-1.1
___ 07:45AM BLOOD Glucose-123* UreaN-23* Creat-1.2 Na-140
K-3.9 Cl-101 HCO3-30 AnGap-13
___ 07:45AM BLOOD cTropnT-<0.01
___ 08:08AM BLOOD ___ Temp-36.6 Rates-/35 O2 Flow-4
pO2-53* pCO2-50* pH-7.37 calTCO2-30 Base XS-1 Intubat-NOT INTUBA
Comment-NASAL ___
.
MICROBIOLOGY DATA: None
.
IMAGING:
___ Pulmonary/PFT - FEV1 44% of predicted. FEV1/FVC 66% of
predicted. Ratio moderately to severely reduced. Significant
increase in FVC following inahled bronchodilator therapy.
Consistent with obstructive deficit, with RAD component.
Compared to ___, FEV1 has increased by 37%.
.
___ CHEST (PORTABLE AP) - The lungs are severely
hyperinflated, consistent with emphysematous changes. These
changes are more pronounced at the apices. There is minimal, if
any, pulmonary edema, which is slightly improved from the prior
exam. There is no focal airspace consolidation, pleural
effusion, or pneumothorax.
The cardiomediastinal silhouette is normal.
Brief Hospital Course:
IMPRESSION: ___ with a PMH significant for oxygen-dependent COPD
(with multiple prior admissions for respiratory infections) with
active tobacco use, hypertension, chronic HCV infection,
hyperlipidemia, depression and BPH who presents 1-day of change
in sputum production and cough.
.
# Acute on chronic, mild COPD exacerbation - Known chronic COPD
attributed to chronic tobacco use. Managed as an patient with
inhaled corticosteroids, long-acting beta-agonist,
anticholinergic, nebs and leukotriene inhibitor. Recently there
was a plan to start home oxygen therapy. Recent PFTs show FEV1
44% (Gold's stage III) but improved from prior. Now presenting
with worsening dyspnea, increasing cough with change in sputum,
but CXR is reassuring - overall consistent with mild-moderate
acute on chronic COPD exacerbation with unclear trigger. Some
recent URI symptoms to support infectious concerns. EKG
reassuring without elevated cardiac biomarkers. Pulmonary
embolism another potential etiology, but less likely. WBC
minimally elevated. ABG demonstrates mild hypercarbia above
baseline. Required 2L nasal cannula for supplemental oxygen
which was weaned quickly. With nebulizer treatment, Prednisone
60 mg PO and Azithromycin 250 mg PO, the patient improved. He
opted to leave AGAINST MEDICAL ADVICE the evening of admission
after a full discussion of the risks of worsening hypoxemia and
his need for further medical treatment. He fully understood the
implications and favored leaving.
.
# Hypertension - Essential hypertension. Recent PCP visits
document moderate control. Minimal elevation on admission.
Baseline creatinine 1.0-1.2 without known nephropathy. Continued
HCTZ-triamterene combination.
.
# Chronic HCV infection - History of positive HCV antibody. In
___, HCV viral load 20 million. LFTs normal. No evidence of
synthetic dysfunction. RUQ ultrasound in ___ without focal
lesions in the liver (no prior biopsy). Seen by Liver clinic
without initiation of therapy given PTSD/depression concerns.
.
# Hyperlipidemia - LDL 40 in ___. Continued on statin.
.
# Depression, PTSD - Mood appeared stable. No current
anti-depression treatment. Continued amitryptiline given PTSD
history.
.
# PVD - History of infrarenal atherosclerosis, AAA (small focal
area of dissection on MR imaging) and intermittent claudication.
Denied current symptoms. Continued ASA.
.
# BPH - Symptoms controlled. Continued doxazosin, finasteride.
.
TRANSITIONAL CARE ISSUES:
1. Left AGAINST MEDICAL ADVICE on the evening of admission;
encouraged to call PCP's office to schedule follow-up in ___
days.
2. Discharged with Prednisone 60 mg PO x 4-days and Azithromycin
250 mg PO x 4-days. Patient took portable oxygen tank in the
room.
3. Strongly discouraged further tobacco smoking.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Albuterol Inhaler ___ PUFF IH Q4 TO 6 HOURS wheezing, dyspnea
3. Amitriptyline 50 mg PO DAILY
4. ammonium lactate *NF* 12 % Topical to arms and legs twice
daily
5. Atorvastatin 80 mg PO DAILY
6. Doxazosin 2 mg PO BID
7. Finasteride 5 mg PO HS
8. Fluticasone Propionate NASAL 2 SPRY NU BID
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. formoterol fumarate *NF* 12 mcg Inhalation BID
11. Gabapentin 800 mg PO HS
12. Gabapentin 600 mg PO QPM
13. Gabapentin 600 mg PO QAM
14. Ipratropium Bromide Neb 1 NEB IH Q6H wheezing
15. Albuterol-Ipratropium ___ PUFF IH Q4-6 HOURS wheezing,
dyspnea
16. Montelukast Sodium 10 mg PO HS
17. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
18. Tiotropium Bromide 1 CAP IH DAILY
19. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
20. urea *NF* 40 % Topical applied to heels at bedtime
21. Aspirin 325 mg PO DAILY
22. Ensure *NF* (food supplement, lactose-free) 1 can Oral TID
23. Loratadine *NF* 10 mg Oral DAILY
24. magnesium hydroxide *NF* 400 mg (170 mg) Oral DAILY
25. Ranitidine 150 mg PO BID
Discharge Medications:
1. Outpatient Lab Work
___ HEALTH ID: ___
OXYGEN CONCENTRATOR AND PORTABLE 2 LPM CONTINUOUS USE FOR ALL
ACTIVITY FOR HOME USE, DIAGNOSIS: COPD. Oxygen saturations at
88% on RA at rest ___. Objective to keep oxygen saturation
above 92%. Lengths of need: 12 months
2. PredniSONE 60 mg PO DAILY Duration: 5 Days
RX *prednisone 20 mg 3 tablet(s) by mouth DAILY Disp #*4 Tablet
Refills:*0
3. Azithromycin 250 mg PO Q24H Duration: 4 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth DAILY Disp #*4
Tablet Refills:*0
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
5. Amitriptyline 50 mg PO DAILY
6. Aspirin 325 mg PO DAILY
7. Atorvastatin 80 mg PO DAILY
8. Doxazosin 2 mg PO BID
9. Finasteride 5 mg PO HS
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
11. Fluticasone Propionate NASAL 2 SPRY NU BID
12. formoterol fumarate *NF* 12 mcg INHALATION BID
13. Gabapentin 800 mg PO HS
14. Gabapentin 600 mg PO QPM
15. Gabapentin 600 mg PO QAM
16. Ipratropium Bromide Neb 1 NEB IH Q6H wheezing
17. Loratadine *NF* 10 mg Oral DAILY
18. Montelukast Sodium 10 mg PO HS
19. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
20. Ranitidine 150 mg PO BID
21. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
22. urea *NF* 40 % Topical applied to heels at bedtime
23. Albuterol Inhaler ___ PUFF IH Q4 TO 6 HOURS wheezing,
dyspnea
24. Albuterol-Ipratropium ___ PUFF IH Q4-6 HOURS wheezing,
dyspnea
25. ammonium lactate *NF* 12 % Topical to arms and legs twice
daily
26. Ensure *NF* (food supplement, lactose-free) 1 can Oral TID
27. magnesium hydroxide *NF* 400 mg (170 mg) ORAL DAILY
28. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Acute on chronic mild-moderate COPD exacerbation
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 Internal Medicine service at ___
___ on ___ regarding management
of your mild to moderate COPD exacerbation. Unfortunately you
decide to leave AGAINST MEDICAL ADVICE. We were able to hand you
prescriptions for antibiotics and steroids before you left.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If 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 an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
Followup Instructions:
___
|
10788420-DS-14
| 10,788,420 | 27,142,274 |
DS
| 14 |
2160-07-17 00:00:00
|
2160-07-19 15:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Percocet / Darvocet-N 100
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Esophagogastric endoscopy ___
Endoscopic ultrasound ___
History of Present Illness:
This is a ___ year old female ___s Witness with a family
history of polyposis who undergoes screening colonoscopies every
___ years who presents with weakness for 3 months, anemia, and an
oozing gastric lesion discovered on EGD today without
intervention.
The patient reports feeling progressively weak and short of
breath with exertion since ___, treated for asthma exacerbation
by PCP without improvement. She presented to her PCP ___ for
acute worsening of physical function for the past 7 days, CBC at
that time showed a crit drop from 38 one year prior to 29. The
patient was referred to ___ endoscopy where EGD today showed
active oozing blood from a lesion in the gastric cardia that
could not be further characterized, mass vs. gastritis vs. varix
could not be differentiated. Patient was transferred to ___
for further management/evaluation of this lesion.
She reports fleeting chest pain, one episode last night and one
episode shortly before EGD today, lasting less than 10 seconds,
nonexertional, no associated nausea, shortness of breath, or
pain radiating down arms or into neck. Otherwise denies abd
pain, nausea/vomiting, denies fever/chills.
In the ED initial vitals were 98.4 74 138/92 18 99%. Labs were
notable for H/H 9.4/28.2 with MCV 75, WBC 5.2 with 6.9% eos,
down from 12.9% ___. INR 1.0. Stool was brown with bright red
blood attributed to menses. She was evaluated by GI and patient
reinforced that she does not want blood even if her life
depended on it, and GI felt most appropriate in ICU for close
monitoring prior to repeat EGD. She was given IV protonix and
transferred to the ICU.
On arrival to the MICU, patient continues to feel fatigued, no
abd pain, no lightheadedness, no diarrhea.
Past Medical History:
Gets screening colonoscopy ___ years for family history of
polyposis, last colonoscopy ___ with 11 polyps, one tubular
adenoma.
Asthma
Allergic rhinitis
Obesity
Basal cell carcinoma
Premenopause
Stress incontinence
Atrial septal defect
Left ventricular hypertrophy
Hypothyroidism
Sigmoid diverticulitis
Ovarian cyst: 3cm, simple.
Iron deficiency anemia due to chronic blood loss NOS
Hypertriglyceridemia
Symptomatic PVCs
Social History:
___
Family History:
Per patient- mother with ulcerative colitis s/p partial
colectomy, developed pancreatic cancer ___ and passed ___,
sister and maternal cousin with polyposis syndrome, sister had
30 polyps at one colonoscopy, cousin had >100, per patient
sister and maternal cousin had "stomach removed for a growth," ___
years ago, no further complications.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: T: 98.1 BP 155/92 HR 65 RR 18 O2 98%RA
General- Alert, oriented, no acute distress
HEENT- Conjunctiva pink, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, PMI not displaced, normal S1 + S2,
no murmurs, rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- palmar creases pigmented, warm, well perfused, 2+ pulses,
no clubbing, cyanosis or edema
Neuro- CNs2-12 intact, motor function grossly normal
PHYSICAL EXAM ON DISCHARGE:
Vitals: Tm 98, BP 101/53 (101-134/53-87), HR 50 (50-108), RR 18,
SaO2 98% RA
General: caucasian woman, appears stated age, resting
comfortably in bed, NAD, AAOx3, cooperative with exam
HEENT: mucous membranes moist, OP without lesions/thrush.
Neck: No JVD
CV: RR, no ectopy or murmurs.
Lungs: CTABL, no w/r/r
Abdomen: soft, NT/ND, BS+
Ext: WWP, no edema
Neuro: CN II-XII grossly intact, MAE
Skin: No obvious rashes or lesions
Pertinent Results:
LABS ON ADMISSION:
___ 11:35PM HCT-26.8*
___ 06:55PM GLUCOSE-90 UREA N-12 CREAT-0.7 SODIUM-141
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-27 ANION GAP-11
___ 06:55PM estGFR-Using this
___ 06:55PM ALT(SGPT)-13 AST(SGOT)-19 ALK PHOS-48 TOT
BILI-0.3
___ 06:55PM ALBUMIN-4.1
___ 06:55PM URINE HOURS-RANDOM
___ 06:55PM URINE UCG-NEGATIVE
___ 06:55PM WBC-5.2 RBC-3.77* HGB-9.4* HCT-28.2* MCV-75*
MCH-24.9* MCHC-33.2 RDW-15.2
___ 06:55PM NEUTS-67.0 ___ MONOS-4.8 EOS-6.9*
BASOS-0.8
___ 06:55PM PLT COUNT-223
___ 06:55PM ___ PTT-29.5 ___
___ 05:49AM BLOOD WBC-5.1 RBC-4.07* Hgb-9.9* Hct-30.9*
MCV-76* MCH-24.3* MCHC-31.9 RDW-15.6* Plt ___
___ 11:33AM BLOOD Hct-28.2*
___ 06:00AM BLOOD WBC-4.4 RBC-3.77* Hgb-9.1* Hct-28.3*
MCV-75* MCH-24.1* MCHC-32.2 RDW-15.2 Plt ___
___ 05:49AM BLOOD ___ PTT-29.5 ___
___ 05:49AM BLOOD Glucose-94 UreaN-11 Creat-0.7 Na-140
K-4.1 Cl-107 HCO3-26 AnGap-11
___ 06:00AM BLOOD Glucose-90 UreaN-9 Creat-0.8 Na-141 K-4.1
Cl-105 HCO3-28 AnGap-12
___ 05:49AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.2
___ 06:00AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.2
LABS ON DISCHARGE:
___ 06:00AM BLOOD WBC-4.7 RBC-3.79* Hgb-9.2* Hct-28.4*
MCV-75* MCH-24.4* MCHC-32.5 RDW-15.4 Plt ___
MICROBIOLOGY:
MRSA screening: negative
IMAGING:
EGD (___):
Medium hiatal hernia. There was a 2cm raised inflammatory area
in the cardia. This area was not bleeding. It is consistent with
inflammatory polyp with erosion secondary to prolapsing within
the hiatal hernia, but an isolated gastric varix cannot be
excluded. Polyp in the antrum
There was diffuse erythema, granularity, and nodularity in the
stomach, consistent with gastritis.There was erythema and
granularity in D1, consistent with duodenitis. Otherwise normal
EGD to third part of the duodenum.
EUS (___):
-No esophageal varices noted
-There was a 3-4cm inflammatory area in the cardia and extending
into the proximal body. This area was not bleeding. Biopsies
were not taken due to recent bleeding.
-Small Polyp in the antrum
On EUS, the inflammatory region seen on EGD appeared mucosal
with mild thickening of the mucosal layer [EUS layer 1] noted at
site in the cardia of most inflammation.
No adjacent lymphadenopathy noted.
There was no doppler flow to suggest vascularity/gastric varix
Otherwise normal upper eus to second part of the duodenum
Abdominal CT with IV contrast (___):
FINDINGS:
The bases of the lungs are clear. The visualized heart and
pericardium are
unremarkable.
CT abdomen: The liver enhances homogeneously without focal
lesions or
intrahepatic biliary dilatation. The gallbladder is unremarkable
and the
portal vein is patent. The pancreas, spleen and adrenal glands
are
unremarkable. The kidneys present symmetric nephrograms and
excretion of
contrast with no pelvicaliceal dilation or perinephric
abnormalities.
The stomach is decompressed precluding evaluation of wall
thickness; however, there is no evidence of an extrinsic mass.
The small bowel are unremarkable. The colon is within normal
limits. The appendix is visualized and there is no evidence of
appendicitis. The intraabdominal vasculature is unremarkable.
There is no mesenteric or retroperitoneal lymph node enlargement
by CT size criteria. No ascites, free air or abdominal wall
hernia is noted.
CT pelvis: The urinary bladder is unremarkable. The uterus is
normal in
size. There are left ovarian cysts measuring up to 3 cm. The
right ovary is normal in size. There is no pelvic free fluid.
There is no inguinal or
pelvic wall lymphadenopathy.
Osseous structures: No lytic or sclerotic lesions suspicious for
malignancy is present. Degenerative changes of the thoracic
spine are noted.
IMPRESSION:
1. No extrinsic mass adjacent to the stomach. Stomach is
decompressed
precluding evaluation of the stomach wall.
2. Left ovarian cysts are physiologic if the patient is
premenopausal. If
postmenopausal, these could be further evaluated with pelvic
ultrasound.
Brief Hospital Course:
___ F Jehovah's Witness with hiatal hernia and 3 months of
progressive weakness presents s/p EGD that showed oozing blood,
admitted to ICU for close monitoring for potential intervention
in the context of declining blood products for religious
reasons.
Acute Issues:
=============
#UGIB: Appears to have been chronic, with Hct fall from 38 to 28
over the past year. Became more symptomatic in the past 3
months. EGD at ___ reportedly showed mild oozing
from bulbous fold vs varix in gastric cardia, and an antral
polyp that was biopsied. Initially admitted to ___ here in
context of unknown rate of blood loss with inability to give
blood products. She was started on IV PPI and serial hct checks.
GI obtained repeat EGD in house, showing an inflammatory lesion
in cardia, not actively bleeding, and an antral polyp. As she
was hemodynamically stable, she was switched to PO Pantropazole
40mg BID, sucralfate, and was transferred to the medical floor.
She had an EUS which showed the inflammatory cardiac lesion to
be mucosal. Biopsies were not taken due to history of bleed. An
abdominal CT was obtained to rule out an extrinsic mass
compressing the stomach, and this was negative. Plan is to
repeat EGD and biopsy as an outpatient 10 days following
discharge with ongoing PO PPI treatment. Her Hct and vital signs
remained stable throughout her stay. She did not have any BMs
while in house, to demonstrate any blood in stool or to provide
a sample for stool H Pylori testing.
#Anemia: Due to chronic GIB, per above. Reportedly had Ferritin
5 and Iron 44 at ___ ___. Patient was started on Fe
supplementation with IV and PO.
Chronic Issues:
===============
# Asthma: home inhalers and singulair were continued.
# Hypothyroidism: levothyroxine was continued.
Transitional Issues:
====================
- Repeat EGD with biopsy in 10 days post discharge (scheduled
with Dr ___ on ___ @ 9:30am)
- Pt is a Jehovah's witness and cannot take blood products.
- She reportedly has had a negative H Pylori test at the OSH. We
were unable to obtain a stool sample for testing. This may need
to be obtained outpatient.
- Repeat iron studies in few months to assess need for ongoing
supplementation.
- Consider pelvic ultrasound to evaluate incidental finding of
left ovarian cysts seen on CT scan
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Montelukast Sodium 10 mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob/wheeze
5. budesonide-formoterol 160-4.5 mcg/actuation Inhalation BID
6. Cetirizine 10 mg Oral Daily:PRN allergies
7. Vitamin D 1000 UNIT PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Sumatriptan Succinate 50 mg PO Q2H:PRN Headache
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob/wheeze
2. budesonide-formoterol 160-4.5 mcg/actuation Inhalation BID
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Montelukast Sodium 10 mg PO DAILY
5. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth twice a day Disp #*60 Tablet Refills:*0
6. Cetirizine 10 mg Oral Daily:PRN allergies
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Sumatriptan Succinate 50 mg PO Q2H:PRN Headache
10. Vitamin D 1000 UNIT PO DAILY
11. Docusate Sodium 100 mg PO BID constipation
12. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL 10 ml by mouth four times a day Disp
#*1 Bottle Refills:*0
13. Ferrous Sulfate 325 mg PO TID
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
three times a day Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
# Upper gastrointestinal bleed
Secondary Diagnoses:
# Asthma
# Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted for further evaluation of a possible bleeding
site in your stomach. You had another endoscopy, which showed a
patch of inflammation that may have been the cause of your slow
bleeding. You also had an ultrasound of your stomach wall,
which showed the same inflamed area as being superficial.
Please start the following medications:
1. Ferrous sulfate (iron) 325mg three times a day
2. Pantoprazole 40mg twice a day
3. Sucralfate 1g four times a day
Thank you for allowing us to be part of your care.
Followup Instructions:
___
|
10788434-DS-13
| 10,788,434 | 22,518,634 |
DS
| 13 |
2174-07-01 00:00:00
|
2174-07-01 22:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
pollen / house dust / pet dander / shellfish derived
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
laparoscopic cholecystectomy ___
History of Present Illness:
___ is a ___ year old man with PMHx notable for
Asthma and prior ICA aneurysm s/p embolization who presented to
___ with ___ episode of sudden onset
abdominal pain in the last 2 weeks. He reports that the pain is
in a band-like distribution in the epigastric region and
radiates to the back. He reports that he has otherwise been
feeling well. He notes that the first episode was 2 weeks ago
while stuck in traffic and lasted for ___ minutes. He reports
that he did not seek care as it resolved prior to getting out of
traffic.
He reports that this episode he at pizza the night before. He
reports that the pain was present at 0700 on the day of
admission. Given the pain he presented for evaluation. He
reports that he does not drink any alcohol. At the OSH he was
evaluated and found to have mild elevation in his LFTs, normal
T.Bili, mild elevation in LFTs. He was transfer to ___ ED for
management of possible gallstone pancreatitis.
In the ___ ED his LFTs were mildly elevated to the ___
with normal Alk Phos and normal TBili. His RUQUS did not show
any intra or extra hepatic biliary dilation. He was seen by
surgery who recommended admission to medicine for evaluation of
the biliary tree.
Upon arrival to the floor the patient feels well and is
abdominal pain free. He denies fever, chills, nausea, vomiting
or any other symptoms.
ROS: A ten point ROS was conducted and was negative except as
above in the HPI.
Past Medical History:
Asthma
Obesity
HLD
Embolization of ICA aneurysm
Social History:
___
Family History:
His mother and father are both living and he is unaware of any
medical problems in the family.
Physical Exam:
Admission Physical Exam:
Vitals: 98.1 PO, 130 / 74, 63, 18, 100 RA
Gen: NAD, lying in bed, pleaseant
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
CV: RRR, no murmur
PULM: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
GU: No foley cathater
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. Fluent speech, no facial droop.
Psych: Full range of affect
DISCHARGE PHYSICAL EXAM:
Tm 98.6, Tc 98.2, HR 55, BP 122/67, RR 18, O2 98%RA
Gen: pleasant man standing up in NAD
HEENT: NCAT, MMM, EOMI
CV: RRR, no m/r/g, normal S1S2
Chest: CTAB, normal depth and effort of breathing
Abd: three laparoscopic port site dressings c/d/i. Appropriately
tender to palpation. Non-distended.
Ext: no c/c/e, DP pulses 2+ bilaterally
Neuro: A&Ox3, no focal neuro deficits
Pertinent Results:
ADMISSION LABS:
___ 12:40PM BLOOD WBC-9.6 RBC-5.29 Hgb-13.9 Hct-43.7 MCV-83
MCH-26.3 MCHC-31.8* RDW-14.0 RDWSD-41.3 Plt ___
___ 12:40PM BLOOD Neuts-64.2 ___ Monos-7.3 Eos-2.5
Baso-0.2 Im ___ AbsNeut-6.18* AbsLymp-2.45 AbsMono-0.70
AbsEos-0.24 AbsBaso-0.02
___ 12:40PM BLOOD ___ PTT-26.9 ___
___ 12:40PM BLOOD Glucose-102* UreaN-13 Creat-1.0 Na-139
K-4.4 Cl-103 HCO3-26 AnGap-14
___ 12:40PM BLOOD ALT-61* AST-95* AlkPhos-118 TotBili-0.3
___ 12:40PM BLOOD Lipase-764*
___ 12:40PM BLOOD Albumin-4.4
DISCHARGE LABS:
___ 06:08AM BLOOD WBC-7.1 RBC-5.16 Hgb-13.7 Hct-42.7 MCV-83
MCH-26.6 MCHC-32.1 RDW-13.7 RDWSD-41.0 Plt ___
___ 06:08AM BLOOD Glucose-83 UreaN-8 Creat-1.0 Na-139 K-4.2
Cl-102 HCO3-27 AnGap-14
___ 06:08AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.2
LIPASE TREND:
___ 12:40PM BLOOD Lipase-764*
___ 07:00PM BLOOD Lipase-35
MICROBIOLOGY:
BCx ___ x2: pending
IMAGING:
RUQ u/s ___:
IMPRESSION:
Echogenic liver consistent with steatosis. Other forms of liver
disease including steatohepatitis, hepatic fibrosis, or
cirrhosis cannot be excluded on the basis of this examination.
Mild splenomegaly. No nodularity to the liver is seen. Highly
echogenic liver, however, limits evaluation for a focal lesion.
Cholelithiasis without evidence of acute cholecystitis. No
intra or extrahepatic duct dilation.
MRCP ___:
IMPRESSION:
1. Normal pancreas.
2. No biliary dilatation or choledocholithiasis.
3. Mild left hydronephrosis with transition at the UPJ, likely
longstanding given timely excretion of contrast.
4. Cholelithiasis.
5. Moderate hepatic steatosis (fat fraction 12.9%).
PATHOLOGY:
Gallbladder ___: report pending
Brief Hospital Course:
This is a ___ year old man with PMHx notable for Asthma and prior
ICA aneurysm s/p embolization who presented to ___
___ with ___ episode of sudden onset abdominal pain in the
last 2 weeks.
Acute Pancreatitis: Unclear etiology. Denies Etoh use, and no
recent medication changes. He has mild elevation in AST/ALT that
may be related to biliary process but normal alk phos and T.
Bili with a RUQUS that does not show any intra or exta hepatic
biliary dilation. Seen by Acute Care Surgery in the ED who
recommended evolution of biliary tree prior to CCY.
The patient had an MRCP that showed a normal pancreas,
cholelithiasis, and no biliary dilatation or
choledocholithiasis. Lipase downtrended to the normal range on
hospital day 2. The patient was then transferred to the Acute
Care Surgery service for cholecystectomy.
The patient went to the operating room on ___ for
laparoscopic cholecystectomy. For full details of the procedure,
please see the Operative Report. The patient tolerated the
procedure well. After an uneventful stay in the PACU, he was
transferred to the floor.
In the postoperative period, the patient's pain was
well-controlled on oral pain medication. On the night following
his operation, the patient experienced difficulty in emptying
his bladder. A post-void residual bladder scan was done with
significant retention of urine. The patient underwent one-time
bladder catheterization and was given a dose of tamsulosin.
Later on postoperative day 1, the patient successfully voided
with minimal post-void residual. He stated that he had no
further issues with urination.
The patient was discharged later on postoperative day 1. At the
time of discharge, the patient was doing well, afebrile with
stable vital signs. The patient was tolerating a regular diet,
ambulating, voiding without assistance, and pain was
well-controlled on oral pain medications. The patient was
discharged home without services. He was given prescriptions for
acetaminophen and oxycodone. The patient was instructed to call
the Acute Care Surgery Clinic for a follow-up appointment. The
patient and his family received discharge teaching and follow-up
instructions. They verbalized their understanding with the
discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Loratadine 10 mg PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/Wheeze
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/Wheeze
2. Aspirin 81 mg PO DAILY
3. Loratadine 10 mg PO DAILY
4. Acetaminophen 1000 mg PO Q8H pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth every ___ hours
Disp #*40 Tablet Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every ___ Disp #*20
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
gallstone pancreatitis
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 gallstone pancreatitis.
Your imaging did not show any concerning blockages, so you were
transferred to the surgery service to have your gallbladder
removed. You tolerated this procedure well and it is now safe
for you to go home.
Please follow-up at the ___ Surgery clinic. Details
listed below.
You should take Tylenol (acetaminophen) for pain. We are also
giving you a prescription for oxycodone for pain that is not
controlled with Tylenol.
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.
Followup Instructions:
___
|
10788481-DS-10
| 10,788,481 | 21,304,772 |
DS
| 10 |
2177-05-04 00:00:00
|
2177-05-04 17:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Non-operative Managment
History of Present Illness:
___ w/ h/o sigmoid adenoca s/p sigmoid colectomy in ___ c/b
incisional hernia s/p laparoscopic repair w/ mesh by Dr.
___ presents with one day of severe nausea/vomiting and
abdominal pain. He reports that he ate a regular solid
breakfast this morning and then approxiamately 1 hour after
developed severe nausea and vomiting. He reports >10 episodes of
bilious, non-bloody emesis since this time. In addition he has
had some mild ___ pain that has been getting
gradually worse. He has not passed flatus in the last 24 hours
however did have 2 loose watery bm's today. He denies any
urinary symptoms, fevers/chills, chest pain, or sob.
Past Medical History:
HTN
DMII x ___ years; last A1c was 7.1% in ___
HL
Gynecomastia on left
Colon Ca diagnosed in ___ s/p sigmoidectomy
incisional ventral wall hernias s/p repair in ___
Social History:
___
Family History:
33 of his family members died in the ___; no knowledge of their
medical histories
Physical Exam:
PE:
T:98.8 HR:50 BP:150/76 RR:18 O2sat:96 RA
Gen: A&Ox3, NAD
Card: bradychardic, reg rhythm, no m/r/g, nl s1s2
Resp: CTAB
Abd: obese, soft, non-tender, non-distended, no masses, previous
surgical incisions well-healed
Ext: CCE
Pertinent Results:
___ 07:40AM BLOOD WBC-7.3 RBC-4.54* Hgb-13.6* Hct-42.6
MCV-94 MCH-29.9 MCHC-31.9 RDW-13.3 Plt ___
___ 07:40AM BLOOD Glucose-131* UreaN-13 Creat-1.1 Na-143
K-3.7 Cl-102 HCO3-28 AnGap-17
___ 07:40AM BLOOD ALT-17 AST-21 AlkPhos-37* TotBili-2.1*
DirBili-0.5* IndBili-1.6
___ CT Abd/Pelvis
Small bowel obstruction with dilated loops of small bowel,
fecalized contents and relatively abrupt transition in the left
lower abdomen. There is no definite evidence of ischemia. There
is no free air or free fluid. Bowel mucosa appears relatively
normally enhancing. Distal loops of small bowel are collapsed.
The descending and sigmoid colon are mostly empty.
Brief Hospital Course:
Patient was admitted to the ___ Surgery Service on ___ from
the Emergency Department. Please refer to the HPI for details of
his initial presentation. Patient's CT scan with oral and IV
contrast in the ED showed a complete bowel obstruction. He was
treated with non-operative managment.
She was kept NPO with IV fluid resusciation. He also has had a
NGT placed and placed on low intermittent wall suction. He
underwent serial abdominal. On the morning of hosptial day 2,
the patient's NGT had low output. At that time, his NGT was
clamped. The clamp trial was well tolerated, and the patient's
NGT was discontinued. He was started on clear liquids, which he
tolerated without n/v. His diet was then advanced to sips, which
were well-tolerated. He was then advanced to clears while
awaiting return of bowel function. On hosptial day 3, the
patient had flatus and his diet was advanced as tolerated. He
also had BMx2. At the time of discharge, the patient was not
complaining of any abdominal distention or pain, and he had a
normal abdominal exam. He was tolerating a regular diabetic diet
and his bowel function had returned.
Medications on Admission:
finasteride 5', glimepiride 8', simvastatin 20', doxazosin 4',
vitamin D2, lisinopril 5mg', metformin 1000mg'', omeprazole
20mg', aspirin 81mg'
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Chloraseptic Throat Spray 1 SPRY PO PRN NG tube irriation
3. Doxazosin 4 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. glimepiride 8 mg ORAL DAILY
6. Lisinopril 5 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Omeprazole 20 mg PO DAILY
9. Simvastatin 20 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:
Mr. ___
You were admitted for management of your small bowel
obstruction.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Followup Instructions:
___
|
10788481-DS-11
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| 11 |
2180-06-01 00:00:00
|
2180-06-01 14:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year old man with history of type 2 diabetes
mellitus, hypertension, hyperlipidemia, who presents with left
leg redness and swelling.
The patient states he has had increasing redness, pain, and
swelling in his left lower extremity over the past 3 to 4 days.
He started having fevers and chills yesterday morning when he
came home from exercising at the gym (swimming in a pool).
Axillary temperature at the time was 39C. He subsequently
complained of headache and left ear pain. He denies previous ear
infections. He reports a left front tooth extraction 3 months
ago, for which he took ___ antibiotics. At home, he has
been taking Tylenol and a multi-symptom cold medicine with
relief. (Last dose Tylenol 1am ___
Last night, abrupt progression of his left lower extremity
swelling brought him into the ED. He denies recent trauma to the
leg, does not report any recent skin breaks. No history of blood
clots. Not taking blood thinners.
On review of systems, other than pertinent positives above, he
reports associated nausea. No shortness of breath, wheezing. No
chest pain, palpitations. No lightheadedness, vertigo, tinnitus,
or hearing changes. Chronic vision changes with age. No
vomiting, constipation, diarrhea. No dysuria. No
tingling/numbness/shooting pains of the extremities.
Past Medical History:
PAST MEDICAL HISTORY:
Type 2 diabetes mellitus
Hypertension
Hyperlipidemia
Benign prostatic hypertrophy
History of chickenpox as a child
PAST SURGICAL HISTORY:
Left lower tooth extraction 3 months ago
Bladder cancer s/p left hydrocelectomy ___
Colon cancer s/p sigmoidectomy ___
Social History:
___
Family History:
All 33 of his family members died in the WWII; no knowledge of
their medical histories
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
VITAL SIGNS: 99.5 138 / 61 74 18 98 RA
GENERAL: no acute distress, sitting comfortably in bed, pleasant
HEENT: NCAT, moist mucous membranes, Pinnae non-erythematous
bilaterally. ___ not yet examined.
NECK: supple
CARDIAC: RRR, no MRG
LUNGS: CTAB
ABDOMEN: Soft, non-tender, non-distended, normoactive bowel
sounds, no organomegaly
EXTREMITIES: Warm, well-perfused, 2+ ___ pulses
NEUROLOGIC: AAOx3, moves all extremities equally, sensation and
strength in lower extremities b/l
SKIN: moderately-well demarcated erythema of the left lower
shin,
skin shiny, warm to touch, non-pustulent, with prominent
varicose
veins. No rash visible on the head.
PHYSICAL EXAM ON DISCHARGE:
===========================
VITAL SIGNS: T 98.4 BP 112 / 75 HR 74 RR 18 O2Sat 96% Ra
GENERAL: no acute distress
HEENT: PERRLA, EOMI, MMM, ___ unable to be visualized ___
cerumen.
NECK: supple, no LAD
CARDIAC: RRR, no MRG
LUNGS: CTAB
ABDOMEN: normoactive bowel sounds, soft, NDNT, no organomegaly
EXTREMITIES: moves all extremities equally, no cyanosis or
rashes
NEUROLOGIC: AAOx3, CN II-XII, walks with limp secondary to leg
pain.
SKIN: well-demarcated circumferential erythema with petechiae
and edema of the left lower extremity from below the knee to the
ankle. Warm to the touch, non-pruritic.
Pertinent Results:
NOTABLE LABS ON ADMISSION ___:
==================================
WBC 15.5
Hgb 12.9, Hct 38.3
Plt 121
PTT 28.8, INR 1.4
Na 135, K 4.9, Cl 97, HCO3 21, BUN 20, Cr 1.2
AG 17
%HbA1c 8.2
Blood culture: PENDING
NOTABLE LABS ON DISCHARGE ___:
==================================
WBC 10.3 Hgb 12.1 Hct 37.___
Glucose 176 UreaN 27 Creat 1.2 Na 143 K 5.5 Cl 105 HCO3 24 AnGap
14
Repeat Whole Blood K+ 4.4
Calcium 8.7 Phos 3.4 Mg 1.8
IMAGING:
==========
ECG (___): sinus rhythm, PR prolongation, normal axis. No ST
changes, Q waves.
Tib/Fib X-ray (___): Soft tissue swelling over the anterior
tibia
with no subcutaneous gas or bony erosion.
CXR (___): Possible right lower lobe pneumonia vs atelectasis.
Brief Hospital Course:
Mr. ___ is an ___ year old man with a PMH of type 2 diabetes
mellitus, hypertension, hyperlipidemia, who presented from home
to the ED with left lower extremity cellulitis and fever.
ACUTE ISSUES:
# Acute LLE Cellulitis:
Patient presented with 1 day of left lower extremity redness,
swelling and pain, associated with subjective fever and chills.
___ was negative for evidence of DVT. Given history DM and
physical exam (well-demarcated erythema, warmth, shiny skin),
cellulitis was diagnosed and patient was started on Clindamycin.
This was switched to Cephalexin given high likelihood of Group A
Strep infection (no pustules suggestive of staph or pseudomonal
infection). Infection was monitored and Tylenol was given for
fever. Over the following ___, patient spiked fevers to 101.5F
and showed evidence of worsening swelling/erythema, so he was
broadened to IV vancomycin on the ___ day of hospitalization.
Patient remained afebrile over the next ___ and subjectively
felt much improved with clinical improvement of left leg exam as
well. He was afebrile at discharge, pain was controlled with
Tylenol, vital signs were stable, and patient was tolerating PO.
IV Vancomycin was switched to Clindamycin 450mg PO q6hr for a
projected 7 day course (last day ___.
CHRONIC ISSUES:
# Headache and Ear Pain:
Patient reported shooting pains on the left side of his head for
1 month, not associated with motor or sensory deficits or vision
changes. He reports no prodrome or recent upper respiratory
infection reported. TM exam limited by cerumen. The etiology is
unclear, but seems most consistent with trigeminal neuralgia.
Exam and history were inconsistent with more serious causes such
as Herpes Zoster or Temporal Arteritis. Further cleaning and
external ear canal and exam ___ deferred for outpatient
follow-up.
#Type II Diabetes Mellitus: Metformin was continued, Glimepiride
was held. Patient was placed on a humalog ISS while in the
hospital. A repeat HgA1c was sent to evaluate DM disease
severity (last 9.3), found to be 8.2.
#Hypertension: Doxasozin and Lisinopril were continued.
#Hyperlipidemia: Simvastatin 20mg was continued.
#Benign Prostatic Hypertrophy: Finasteride and Doxazosin were
continued.
TRANSITIONAL ISSUES
[ ] complete 7d course Clindamycin (last ___
[ ] f/u with PCP for management of diabetes, consider starting
insulin glargine.
[ ] f/u with PCP for ear wax removal and evaluation of
trigeminal neuralgia-like pain
[ ] Patient had elevated K+ on morning of discharge, which
resolved on repeat whole blood potassium lab. Follow-up BMP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Doxazosin 4 mg PO HS
3. Lisinopril 20 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Simvastatin 20 mg PO QPM
6. Aspirin 81 mg PO DAILY
7. glimepiride 8 mg oral DAILY
Discharge Medications:
1. Clindamycin 450 mg PO Q6H Cellulitis Duration: 4 Days
Start taking on ___ at 6:00AM. Take 3 pills every 6hours. Last
day ___.
RX *clindamycin HCl 150 mg 3 capsule(s) by mouth every six (6)
hours Disp #*48 Capsule Refills:*0
2. Aspirin 81 mg PO DAILY
3. Doxazosin 4 mg PO HS
4. Finasteride 5 mg PO DAILY
5. glimepiride 8 mg oral DAILY
6. Lisinopril 20 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
- You were admitted for fever, and redness / swelling in your
left leg which was due to a skin infection called cellulitis.
WHAT HAPPENED IN THE HOSPITAL?
- We gave you IV antibiotics to treat your infection.
- We monitored your blood for any signs of bacteria in your
bloodstream. There were none.
- When your leg infection improved, we stopped your IV medicine
and gave you antibiotics to take by mouth at home.
WHAT SHOULD YOU DO AT HOME?
- Please follow up with your primary care doctor within ___
weeks.
- Continue to take your antibiotics for 4 days (last day
___.
- Please take all other medications as directed.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
10788481-DS-9
| 10,788,481 | 25,973,778 |
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| 9 |
2174-11-28 00:00:00
|
2174-12-02 17:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
Blood transfusions
History of Present Illness:
___ with h/o HTN, DMII, HL, colon ca s/p sigmoidectomy who
presents with melena. He was in his USOH until 3 days ago when
he noticed that he was passing very dark stools. He has had 1
episode of melena each day for the past 3 days, including today.
No h/o GI bleed since colon ca diagnosed ___ yrs ago (s/p
sigmoidectomy). He denies any BRBPR. No abd pain. He does
endorse nausea but no vomiting - he has been eating less the
past 3 days, last meal was at 5 ___ last night. He has had
associated fatigue and dizziness for the past few days. Also,
his blood sugar has been much higher than usual - in the 300s.
He does endorse 1 episode of chest pressure, at rest a few days
ago that lasted a short time. No CP since then. He walked
himself to the ED today with his wife.
.
In the ED, initial VS 98.1 117 (improved to 64 after fluids,
blood) 144/69 18 100% on RA. Rectal exam revealed dark,
guaiac+ stool. NG lavage was negative. Labs showed BUN 52 with
normal Cr, Hct of 29.2 (down from 43 in ___, and normal
coags. EKG was without signs of ischemia. He was given 1L NS,
10U humalog for bs of 334, and 2U PRBCs. GI was consulted who
felt there was no indication for emergent endoscopy and
recommended pantoprazole gtt (received 80 mg bolus and gtt at 8
mg/hr).
.
Currently, the patient feels well. He denies abd pain. His last
bm was this AM. He has had many colonoscopies - last in ___,
which showed 1 polpy - but never an EGD. He denies recent NSAID
and ASA use. No h/o alcoholism or recent EtOH.
.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, abdominal pain, vomiting, diarrhea,
constipation, BRBPR, hematochezia, dysuria, hematuria.
Past Medical History:
HTN
DMII x ___ years; last A1c was 7.1% in ___
HL
Gynecomastia on left
Colon Ca diagnosed in ___ s/p sigmoidectomy
incisional ventral wall hernias s/p repair in ___
Social History:
___
Family History:
33 of his family members died in the ___; no knowledge of their
medical histories
Physical Exam:
On admission:
VS - 98.0 80 154/62 18 100% on RA
GENERAL - NAD, obese, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD, no carotid bruits
LUNGS - CTAB, unlabored
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - obese, no epigastric tenderness, NABS, soft/NT/ND
EXTREMITIES - WWP, varicose veins on L ___, no c/c/e
NEURO - A&Ox3, EOMI, full strenth in ___, nl gait
ACCESS: 2 PIVs
.
On discharge:
Stable vital signs. No abd pain.
Pertinent Results:
On admission:
.
___ 10:25AM BLOOD WBC-13.1* RBC-3.26*# Hgb-10.1*#
Hct-29.2*# MCV-90 MCH-30.9 MCHC-34.5 RDW-13.3 Plt ___
___ 10:25AM BLOOD ___ PTT-28.0 ___
___ 10:25AM BLOOD Glucose-334* UreaN-52* Creat-1.2 Na-137
K-4.5 Cl-101 HCO3-23 AnGap-18
___ 10:25AM BLOOD CK-MB-5 cTropnT-<0.01
___ 05:15PM BLOOD CK-MB-3 cTropnT-0.06*
___ 09:30PM BLOOD cTropnT-<0.01
___ 05:35AM BLOOD cTropnT-<0.01
.
Colonoscopy:
Impression: Angioectasia in the Distal descending colon (thermal
therapy)
Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
Recommendations: AVM is the possible source of melena. No
Colitis, polyps noted.
Because of the poor quality of prep, and history of sigmoid
Cancer and multiple adnomas in the past, patient would need
screening colonoscopy in another year.
Monitor for any further bleed today. Trend Hct. If stable, could
be discharged home tomorrow.
Advance diet as tolerated.
.
EGD:
Impression: Normal mucosa in the esophagus
Thickening of gastric folds in the stomach body and fundus
(biopsy)
Erythema, submucosal hemorrhages in the duodenal bulb compatible
with Mild duodenitis
Medium hiatal hernia
Polyp in the stomach body (biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations: Follow-up biopsy results
The findings do not account for the symptoms
Recommend prepping tonight for colonoscopy tomorrow.
.
On discharge:
___ 05:05AM BLOOD WBC-7.5 RBC-3.31* Hgb-10.4* Hct-29.6*
MCV-90 MCH-31.4 MCHC-35.1* RDW-14.3 Plt ___
___ 05:05AM BLOOD Glucose-128* UreaN-12 Creat-1.0 Na-144
K-4.0 Cl-107 HCO3-26 AnGap-15
Brief Hospital Course:
Hospitalization Summary:
___ with h/o HTN, DMII, HL, colon ca s/p sigmoidectomy who
presents with melena.
.
# Melena: Patient presented with reports of 3 days of melena.
Hct was 29.2 on admission (down from a baseline of 42). He was
tachycardic in the ED and rectal showed melana. He was
transfused 2 Units PRBCs and Hct stabilized ~ 29. He had an EGD
on ___, which was mostly normal - showed mild duodenitits and
biopsies were taken. He then had a colonscopy on ___, which
showed an AVM -> this was argon coagulated. He had no further
episodes of melana and was hemodynamically stable upon
discharge. Recommendations are for a short-course of omeprazole
and for repeat colonoscopy in ___ year for cancer screening
because of poor quality of the prep.
.
# NSTEMI: On admission, patient reported that he had had 1
fleeting episode of chest pain 3 days PTA. Troponins were
checked and trend was 0.01, 0.06, 0.01, 0.01. EKG showed no
ischemic changes and patient was chest pain free. He was started
on a baby aspirin at discharge and should have a stress test as
an outpatient.
.
# Thrombophlebitis: Developed thrombophlebitis at site of old IV
in R antecubital fossa. There was small cellulitic component 2
days prior to discharge, which was much improved on the day of
discharge. Warm compresses were used.
.
# Hyperglycemia/DMII: Was maintained on SSI during admission and
was restarted on metformin and glimepiride on discharge.
.
# Hydrocele: Patient requested urology outpt f/u for this, which
was arranged. He did have 1 episode of penile bleeding - ?
trauma. Hematuria was found on U/A and should be repeated.
.
# HTN: Continued doxazosin.
.
# HL: Continued simvastatin 20 mg qday.
.
# BPH: Continued finasteride 5 mg qday.
.
Transitional Issues:
- outpatient stress test
- f/u for hematuria and hydrocele
- f/u GI biopsies
- repeat Hct to ensure stabilization
- repeat Cscope in ___ year for routine cancer screening
- Code status was Full Code
- Communication was with wife ___ ___
___ on Admission:
Metformin 1000 mg BID
Glimepiride 8 mg qday
Doxazosin 4 mg qday
Finasteride 5 mg qday
Simvastatin 20 mg qday
Vitamin D 50,000U qweek
Discharge Medications:
1. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
2. glimepiride 4 mg Tablet Sig: Two (2) Tablet PO once a day.
3. doxazosin 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO at bedtime.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
melena - colonic angioectasia
NSTEMI
mild duodenitis
.
Secondary:
Diabetes Mellitus
Benign prostatic hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at the ___
___. You were admitted for melena (dark stool). You
received 2 blood transfusions in the Emergency Department. We
watched your blood counts closely and they stabilized. You had
an EGD that showed mild irritation in your duodenum (otherwise
normal) and a colonoscopy that showed an angioectasia (malformed
blood vessel) that may account for your symptoms - this was
treated with laser therapy. You also had possible evidence of
coronary heart disease so we started a baby aspirin per day -
you will need a stress test as an outpatient. Dr. ___ will
help to arrange this. For your urinary problems, we have
arranged urology follow-up.
.
We made the following changes to your medications:
We STARTED aspirin 81 mg per day
We STARTED omeprazole 20 mg per day for 4 weeks
.
Your follow-up appointments are listed below.
Followup Instructions:
___
|
10788552-DS-12
| 10,788,552 | 20,623,860 |
DS
| 12 |
2120-03-31 00:00:00
|
2120-04-26 23:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Ceftin / coconuts / Strawberry
Attending: ___.
Chief Complaint:
headache, fever, ? seizures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
ADMIT NOTE
___
___
___ yo F with epidermoid cyst s/p resection in ___ who was seen
in Dr. ___ today for evaluation of worsening and more
frequent headaches over the past 2 months. The headache involve
the entire head and occur 3 to 4 times per week. On two
occassions (___, she has had episode of flash of light
followed by leg weakness and slouching to the floor. For the
last week, she has had fevers and headache, particularly at
night.
Her outpatient work-up today included sleep-deprived EEG and
LP. Her CSF WBC was grossly elevated and she was sent to the ED
for admission and IV antibiotics.
In the ED: T 99.5, HR 119, BP 104/75 RR 18 O2: 100% RA. She was
started on vancomycin and pip-tazobactam. SHe developed red man
syndrome to vancomycin.
Currently, she is sleeping comfortably. Denies any current
headache.
Past Medical History:
migraine
h/o bell's palsy (___)
s/p D&C
s/p tonsillectomy
s/p tubal ligation twice
s/p C-section ___
s/p drainage of an epidermoid cyst and placement of a Rickham
catheter by ___, M.D. on ___, cyst aspiration
(about 20 cc) via ___ by Dr. ___ on
___, and status post resection of the epidermoid cyst by
Dr. ___ on ___.
Social History:
___
Family History:
Her parents, sister, brother, daughter, and son are healthy.
Physical Exam:
T 98.2 P 68 BP 99/60 RR 18 O2Sat 98% RA
GENERAL: lying in bed sleeping--> awake and alert, mentating
clearly, wrapped in sweatshirt and blankets
Eyes: NC/AT, PERRL, EOMI, no scleral icterus noted
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
Neck: supple, no JVD appreciated
Respiratory: Lungs CTA bilaterally without R/R/W
Cardiovascular: Reg S1S2, no M/R/G noted
Gastrointestinal: soft, NT/ND, no masses or organomegaly noted.
Skin: no rashes or lesions noted. No pressure ulcer
Extremities: No C/C/E bilaterally, 2+ radial, DP and ___ pulses
b/l.
Lymphatics/Heme/Immun: No cervical, supraclavicular
lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
No foley catheter/tracheostomy/PEG/ventilator support/chest
tube/colostomy
Psychiatric:
ACCESS: [x]PIV
Pertinent Results:
___ 06:35PM WBC-10.0 RBC-4.59 HGB-14.1 HCT-42.2 MCV-92
MCH-30.8 MCHC-33.4 RDW-11.8
___ 06:35PM NEUTS-59.3 ___ MONOS-4.4 EOS-2.2
BASOS-1.3
___ 06:35PM PLT COUNT-358
___ 12:30PM CEREBROSPINAL FLUID (CSF) PROTEIN-73*
GLUCOSE-48 LD(LDH)-27
___ 12:30PM CEREBROSPINAL FLUID (CSF) WBC-515 RBC-20*
POLYS-38 ___ ___ 10:15PM URINE UCG-NEGATIVE
___ 10:15PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 10:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 06:35PM GLUCOSE-96 UREA N-9 CREAT-0.7 SODIUM-139
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-25 ANION GAP-13
___ 06:48PM LACTATE-1.5
___ MRI: Stable post operative changes with a right parietal
approach
ventriculostomy catheter, tip terminating within the resection
cavity in the pineal region. There is minimal enlargement of the
ventricles as compared to the prior study. There is no increase
in the mass effect on the aqueduct of Sylvius. No abnormal
leptomeningeal enhancement. Periphery of the resection cavity
shows restricted diffusion which represents residual neoplasm.
Brief Hospital Course:
___ yo F with epidermoid cyst s/p resection in ___ with
worsening and more frequent headaches, ? seizure episodes,
fevers, + inflammatory CSF.
# Meningitis: History was not typical of bacterial meningitis
and inflammation was thought perhaps secondary to effects of
residual tumor seen on MRI. However her hardware in CSF placed
her at higher risk for a bacterial process. She was started on
empiric vancomycin /pip-tazo for a total 2 week IV course. She
received a PICC line and was sent home with ___ services.
# Headaches/? seizures: continued topiramate, lamotrigine, no
evidence of seizure activity
# Epidermoid cyst: s/p resection but MRI reveals residual tumor.
Neurosurgery consulted but no acute intervention.
# Fever: No clear source and likely related to CNS process.
Blood/urine cultures unrevealing. No acute process on CXR.
Medications on Admission:
vicodin prn migraine
ibuprofen prn
topiramate
lamotrigine
lorazepam prn prior to procedures
Discharge Medications:
1. lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO twice a day:
Take 50mg twice a day for two weeks, then 75mg twice a day for
two weeks,
then 100 twice a day for two weeks, then 125 twice a day for two
weeks, then 150 twice a day.
Disp:*360 Tablet(s)* Refills:*2*
2. topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for Pain/headache .
4. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 2 weeks: 1000mg q12 for
two weeks, last day of doses ___.
Disp:*24 grams* Refills:*0*
5. piperacillin-tazobactam 4.5 gram Recon Soln Sig: One (1)
Intravenous every eight (8) hours for 2 weeks: last doses on day
of ___.
Disp:*189 grams* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Meningitis - possibly bacterial
Seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a headache and neck stiffness. You
additionally had two episodes of loss of consciousness that were
concerning for seizure. You had a lumbar punture which showed
an elevated white count, which can be a sign of infection or
inflammation. As you have had a cyst in this region and have
instrumentation we are concerned about possible infection. You
will have an extended course of antibiotics, both Vancomycin and
Zosyn for two weeks. About a few weeks after this you will see
Dr. ___ in clinic and he will check you for signs of this
infection as well.
Additionally you have evidence on EEG of a proprensity towards
seizure and since you have had lesions in your brain and seizure
we will start you on seizure medication. You are already on a
medication that we use for seizures and we will slowly titrate
this medication up to a therapuetic dose.
You were placed on
Vancomycin - you will stop on ___
Zosyn - you will stop on ___
We are increasing your lamictal, you are currently on 50mg qhs,
but we have written you a taper to increase over the next ___
wees to a total dose of 200mg twice a day. If you have any rash
you need to call your doctor (___) and let him know.
Followup Instructions:
___
|
10788599-DS-5
| 10,788,599 | 26,117,965 |
DS
| 5 |
2134-06-16 00:00:00
|
2134-06-20 10:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
Sinusitis
Major Surgical or Invasive Procedure:
Abscess I&D by ENT
___ placement
History of Present Illness:
___ yo M transferred from ___ for sinusitis.
Per report, patient started to have left sided facial pain on
___, and was started on antibiotics of amoxicillin, on ___
___, and also received ibuprofen, tramadol and guaifenison.
Pain worsened. There is also left eye swelling and
odynophagia/dysphagia. He had N/V on ___ and ___. He
developed fever to 103 and went to ___. Nasal
drainage was noted. He had negative rapid strep. CT scan showed
extensive left paranasal sinus disease without abscess or
intraorbital inflammation. Patient received Tylenol and 1 g of
ceftriaxone. Patient is transferred here for further ENT
evaluation.
Initial VS in the ED: pain 10 T99.8 HR105 BP133/88 RR22 O2Sat
95% RA
Exam notable for A&Ox3, normal extraocular movements, left
periorbital swelling and erythema. Labs notable for WBC 9.0, Hgb
13.1, Hct 40.6, Plt 207, neutrophils 85.2%, lymphocytes 7.1%, Na
134, K 4.0, Cl 95, Bicarb 29, BUN 17, Crt 0.8, Glucose 133,
Lactate 1.5. Patient was given morphine 5 mg IV x2,
hydromorphone IV 1 mg x2, zofran IV x 1, ibuprofen 800 mg x 1,
Ampicillin-sulbactam IV, NS 150 cc/hr. Blood cultures x2 were
sent. ENT was consulted but will plan to see patient in the
morning and ENT asked the primary team to contact them in AM.
VS prior to transfer: Temp: 100.3 °F (37.9 °C) (Oral), Pulse:
104, RR: 16, BP: 151/67, O2Sat: 96, O2Flow: ra, Pain: 10, and 20
gauge R AC IV
I reviewed records from ___. Confirmed documentation
of neg rapid strep.
On arrival to the medicine floor, the patient was in NAD, mildly
tachycardic, complaining of facial pain. He denied any sick
contacts, or any recent travel, aside from going to ___
last week. No swimming in salt or freshwater recently. He did
endorse fatigue. At 4:00am on ___, pt began having worsening
secretions which he was not tolerating well, no reports of
wheezing or SOB. Given Dexamethason 10mg IV x1. At 4:10am,
patient developed substantial soft palate edema and the
posterior pharynx was unable to be visualized. His VS were
stable (tachycardia in the 100s) on the floor, no signs of
tachypnea, CTAB with no stridor or wheezes. There was a concern
for possible eventual respiratory compromise 2/t swelling and
MICU was called for possible intubation and transfer to MICU.
On arrival to the MICU, c/o dysphagia and osynophagia. Denies
SOB, wheezing, or any issues with his bretahing.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 101.9 155/95 109 19 98%RA
General: Alert, oriented, no acute distress
HEENT: Swollen R side of face with a R swollen eyelid and
echymoses, R swollen neck; sclera anicteric/pink conj; swollen
soft palate (R>L), unable to visualize posterior pharynx;
significant erythema, swelling and tenderness to anterior sinus;
EOMI and PERRL, no pain with EOM. No decrement to visual acuity
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi, or stridor
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3, CN II-XII w/out deficit
DISCHARGE PHYSICAL EXAM:
VS:Tc 98.2 BP 112/74 P 74 RR 18 Sat 96% RA
General: pleasant, young gentleman, NAD
HEENT: EOMI, no pain with extraocular movement, caked buildup on
tongue edges, decreased from yesterday, scrapes off without
blood, not clumpy
Neck: No tenderness, no LAD, no swelling, no erythema
Lungs: CTAB, no wheezes or crackles
Chest: irregular, tachycardic to 112 no m/r/g
Abdomen: Soft, nontender, nondistended. BS+
Extremities: Warm and well perfused, no clubbing, cyanosis, or
edema
Neuro: moving all extremities spontaneously
Pertinent Results:
ADMISSION LABS:
___ 08:20PM BLOOD WBC-9.0 RBC-4.76 Hgb-13.1* Hct-40.6
MCV-85 MCH-27.5 MCHC-32.3 RDW-12.4 Plt ___
___ 08:20PM BLOOD Neuts-85.2* Lymphs-7.1* Monos-7.3 Eos-0.2
Baso-0.2
___ 08:20PM BLOOD Plt ___
___ 05:13AM BLOOD ___ PTT-29.8 ___
___ 08:20PM BLOOD Glucose-133* UreaN-17 Creat-0.8 Na-134
K-4.0 Cl-95* HCO3-29 AnGap-14
___ 05:13AM BLOOD Calcium-8.6 Phos-1.6* Mg-1.9
___ 08:32PM BLOOD Lactate-1.5
___ 05:23AM BLOOD Lactate-1.2
DISCHARGE LABS:
___ 04:36AM BLOOD WBC-11.3* RBC-4.52* Hgb-12.6* Hct-38.2*
MCV-85 MCH-27.9 MCHC-33.0 RDW-12.9 Plt ___
___ 04:36AM BLOOD Plt ___
___ 04:36AM BLOOD Glucose-113* UreaN-19 Creat-0.9 Na-141
K-4.0 Cl-103 HCO3-30 AnGap-12
___ 04:36AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.3
IMAGING:
___: CT head and sinus non-con OSH
No intracranial abnl, extensive L paranasal sinus disease. Some
soft tissue inflammation lies anterior to the L maxillary sinus
w/out evidence of abscess. Does make note of reflection of
extension of inflammation or infection through the haversian
canal system.
___: TTE
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is no pericardial effusion.
___: CT sinus non-con
Since the prior study from ___ the overall extent
of sinus disease is unchanged. Again seen is complete
opacification of the left maxillary sinus, left ethmoidal air
cells and left frontal and sphenoid sinus. There is mucosal
thickening involving the right maxillary sinus and right
ethmoidal air cells. Again seen is nasal cavity opacification
which appears somewhat polypoid on the left. The ostiomeatal
unit appears patent now on the right but is still opacified on
the left. The anterior skull base and lamina papyracea are
intact. The orbits are intact. The nasal septum is deviated to
the left with a bony spur. The visualized portions of the brain
are unremarkable.
MICRO:
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ 8:54 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
Brief Hospital Course:
Mr. ___ is ___ who initially presented with sinusitis found
to have retropharyngeal abscess s/p sinus surgery by ENT whose
course has been c/b MSSA and GNR bacteremia and atrial
fibrilliation with RVR.
# maxillary sinusitis w/ parapharyngeal abscess and periorbital
Cellulitis: Pt presented w/ high fever. Clinical and CT e/o
bacterial sinusitis. No clear e/o abscess or erosion of bone on
CT scan. Given no effect of amoxicillin, it was changed to
unasyn IV when he arrived at ___. Given likely bacterial
sinusitis, and tolerating small amounts of fluid and secretions,
steroids were intially held. When the patient began to develop
worsening edema on the medicine floor, there was concern for
impending respiratory compromise and he was transferred to the
MIUC. He was given Dexamethasone x1. ENT recommended CT
Head/Orbits/Neck to assess for complications/extension of his
infection. ENT evalatuation in the MICU confirmed that the
airway was patent. They also recommended consulting
Opthalmology. We continued Unasyn and added Vancomycin for MRSA
coverage. The patient responded after a few hours, did not have
a fever except for his initial fever on arriving at the MICU.
Imaging ___ revealed bulging of the parapharyngeal space, ENT
repeated needle aspiration w/ ___ pus drainage, which was sent
for cultures. ENT drained in OR ___, put in pinrose drain, then
removed when drainage decreased. Nasal cultures taked during
procedure grew MSSA. The patient was ultimately switched to
daily ertapenum and instructed to continue ertapenum until
___, at which point he was instructed to start Augmentin
for another 14 days. He was also discharged on peridex mouth
wash, as per ENT recs, as well as sinus precautions for 2 weeks
ending ___ (no snorting, blowing nose, etc for risk of
epistaxis). Pt will followup with ENT as outpatient. He had been
on IV morphine and oxycodone for pain management, was discharged
with 20 5mg oxycodone.
# polymicrobial bacteremia: Pt's blood culture ___ grew MSSA in
1 of 2 tubes. He had a TTE at this point, which was negative.
___ blood cultures grew GNRs. Pt initially put on IV Unasyn,
changed ___ to Zosyn for psuedomonas coverage given new GNR.
Per ID recs, pt to finish 14 day course with 5 more days of IV
ertapenem 1mg ___ get infusion at ___ (stop
___. After he will transition to PO Augmentin for 14 days,
following up with PCP.
# AFib with RVR: After placement of PICC line, patient became
tachycardic to 180s was, given metoprolol 5mg x2 and Diltiazem
10mgx4, remained in 120-140, put on Diltiazem drip. Tachy
started after PICC line placed, PICC was pulled back out of
cocnern for myocardial irritation, with no effect. HR continued
to be high in 100-120s and the patient was also started on PO
metoprolol 50q6. Given this persistent tachycardia, the patient
was going to get cardioverted, as per Cardiology
recommendations. However, before getting cardioverted, the
patient spontaneously converted. Per cardiology, no indication
for longterm anticoagulation. The patient was discharged on
12.5mg Q8 metoprolol and, as per Cardiology, the patient was
also set up with Holter monitor.
# Thrush: After pt started IV Zosyn, he developed cakey white
growth on tongue, likely thrust. Was started on mystatin was
which improved growth. Thrush likely ___ antibiotics, however we
recommend an HIV test as an outpatient, which pt said he would
be willing to do.
# lung nodule: incidental 6mm lung nodule on CT. Followup as
outpatient.
Transitional Issues:
- The patient was found to have incidental 6mm lung nodule on
CT; this should ber followed up as an outpatient.
- The patient will be getting daily Ertapenum infusions at
___ he will need to continue until ___, at which
point he will be transitioned to PO Augmentin.
- The patient was discharged on 12.5 mg metoprolol q8h; please
monitor his heart rates and blood pressures as an outpatient.
- The patient was discharged with ___ of Hearts holter
monitor; this will need to be followed up as an outpatient.
Medications on Admission:
no home medications
Discharge Medications:
1. Metoprolol Tartrate 12.5 mg PO Q 8H
please hold for HR<60, and SBP<100.
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
every 8 hours Disp #*30 Tablet Refills:*0
2. ertapenem *NF* 1 g IV ONCE Duration: 1 Doses Reason for
Ordering: transitioning to outpatient
RX *ertapenem [Invanz] 1 gram 1 gram daily Disp #*5 Bag
Refills:*0
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL HS
RX *chlorhexidine gluconate [Peridex] 0.12 % 15 mL daily Disp
#*1 Bottle Refills:*0
4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 14 Days
Please take 1 pill twice daily by mouth starting on
___
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet by mouth twice daily Disp #*28 Tablet Refills:*0
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
please hold for RR<12, altered mental status
RX *oxycodone 5 mg 1 tablet(s) by mouth every six hours Disp
#*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Sinusitis
Parapharyngeal Abscess
polymicrobial Bacteremia
Lung nodule
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___,
___ was a pleasure taking care of you during your admission to
the ___. You were admitted for sinusitis and while here, found
to have multiple abscesses in your cheek and nose, as well as
infection that spread to your blood. You were started on IV
antibiotics, and our ENT team drained the pus from your
abscesses in the OR. You have been recovering well from the
infection, no longer have fevers, and the redness and swelling
in your face have resolved.
You did have an episode of elevated heart rate, and we are not
clear why this occurred. We gave you medications to lower your
heart rate and eventually it spontaneously became normal. We are
sending you home with a heart monitor which will help determine
if your heart has additional any irregular rhythms. It is very
important that you followup with your PCP.
- You were put on sinus precautions for 2 weeks ending ___
- this means that you should not snort anything, blow your nose,
etc which may cause your nose to bleed.
Please see below for medication instructions:
Continue IV Ertapenem once/day infusion at ___, stop ___.
START Oral antibiotic Augmentin ___, LAST DAY ___
Continue Peridex mouth wash, STOP ___
Continue Metoprolol 12.5mg every 8 hours.
In addition, your CT scan showed a 6mm nodule in your lungs, you
should follow up with this, as well as the results of your
Holter Monitor, in the outpatient setting with your PCP.
Followup Instructions:
___
|
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2124-02-28 20:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
morphine / Keflex
Attending: ___.
Chief Complaint:
trauma:
C2 lamina fracture
humeral head fracture (acute on chronic)
left ___ rib fracture non displaced
pubic rami fracture.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ year old female with history notable for
multiple (~20) fractures, osteoporosis, and degenerative
cervical
spine disease, who presents with neck pain after fall. The
patient tripped on a carpet and fell at her assisted living
facility earlier this evening. She sustained lacerations to her
head and left wrist, and was brought in to the ED for
evaluation.
The patient does complain of midline neck pain at the base of
the
skull; the pain does not radiate into either arm. She does have
pain at baseline in her left shoulder, and of note, is scheduled
for a left shoulder replacement in 3 weeks.
She denies any numbness or tingling in her hands or feet and has
no new weakness.
The patient reports that she has been told she has severe
degenerative disease of her cervical spine and should wear a
cervical collar for protection.
Past Medical History:
CKD
- Osteoporosis
- Anemia
- Dysphagia
- Cervical radiculopathy
- Polyneuropathy
- Frequent falls
- Hx Basal cell carcinoma
- Hx Lentigo maligna
- Hx Squamous cell carcinoma of skin
- Hx Ankle fracture
- Hx Humerus fracture, proximal w/ shoulder arthroplasty ___
Social History:
___
Family History:
Mother with facial cancer. Didn't know her father. Sister
healthy.
Physical Exam:
Upon admission: ___
PE: 98.4 83 160/115 18 95% RA
In stretcher, appears comfortable
left frontal scalp laceration sutured with underlyign eechymosis
left orbital eechymosis
No obvious bony skull deformities
PERRL
no hemoTM
septum midline, no deviation
Mild neck tenderness around C2-C3 without stepoffs
Trachea midline
CN ___ intact
No sternal deformities, TTP left chest wall tenderness with deep
inspiration, no crepitus
Abd soft, NT/ND, midline scar noted, no hernias
left pelvic eechymosis
Pelvis stable
b/l hematomas over dorsum of hands
right knee hematoma
motor ___ throughout
gross sensation preserved
No step offs of back, some mild TTP between shoulders
Physical examination upon discharge: ___
vital signs: 99.1, hr=89, bp=125/50, rr-18, 96% room air
General: NAD, soft collar in place
CV: ns1, s2, -s3, -s4, + Grade ___ systolic murmur, ___ ICS,
LSC, RSB
LUNGS: clear
ABDOMEN: soft, non-tender
EXT: No pedal edema, ecchymosis right knee, mild swelling,,
ecchymosis upper ext. bil., mild edema right wrist
NEURO: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___ 06:50AM BLOOD WBC-9.8 RBC-2.71* Hgb-8.2* Hct-24.9*
MCV-92 MCH-30.3 MCHC-33.0 RDW-14.3 Plt ___
___ 09:10PM BLOOD Hct-25.9*
___ 08:57AM BLOOD WBC-11.7* RBC-3.04* Hgb-9.1* Hct-27.7*
MCV-91 MCH-30.0 MCHC-32.9 RDW-14.2 Plt ___
___ 04:35PM BLOOD WBC-10.3# RBC-4.45 Hgb-13.4 Hct-39.9
MCV-90 MCH-30.0 MCHC-33.6 RDW-13.9 Plt ___
___ 04:35PM BLOOD Neuts-69.3 ___ Monos-6.4 Eos-2.5
Baso-0.5
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD ___ PTT-26.4 ___
___ 06:50AM BLOOD Glucose-96 UreaN-10 Creat-0.8 Na-138
K-4.2 Cl-106 HCO3-23 AnGap-13
___ 08:57AM BLOOD CK(CPK)-55
___ 06:40AM BLOOD Lipase-22
___ 09:10PM BLOOD CK-MB-3 cTropnT-<0.01
___ 08:57AM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:50AM BLOOD Calcium-7.9* Phos-2.3* Mg-1.9
___: cat scan of the head:
1. Moderate subgaleal hematoma along the left frontal area with
small
supraorbital hematoma and associated laceration. Intact globes.
2. Possible nondisplaced transverse fracture through
right-sided lamina of C2.
3. No intraparenchymal hemorrhage.
___: cat scan abdomen and pelvis:
1. 3.5 cm hematoma within the left anterior subcutaneous tissue
at the level of left iliac crest without underlying fracture.
Punctate foci of hyperdensity is suspicious for pseudoaneurysm
or small blush of active extravasation.
2. No solid organ injury. No retroperitoneal hematoma.
3. Multiple chronic fractures as described above.
4. Buckling of right anterior third through fifth ribs is of
indeterminate age.
5. Mild intrahepatic and moderate to severe extrahepatic
biliary duct
dilatation with moderate pancreatic duct dilatation. Clinical
and laboratory correlation is recommended. Recommend ERCP/MRCP
for further evaluation.
___: cat scan of the chest:
1. 3.5 cm hematoma within the left anterior subcutaneous tissue
at the level of left iliac crest without underlying fracture.
Punctate foci of hyperdensity
is suspicious for pseudoaneurysm or small blush of active
extravasation.
2. No solid organ injury. No retroperitoneal hematoma.
3. Multiple chronic fractures as described above.
4. Buckling of right anterior third through fifth ribs is of
indeterminate age.
5. Mild intrahepatic and moderate to severe extrahepatic
biliary duct
dilatation with moderate pancreatic duct dilatation. Clinical
and laboratory correlation is recommended. Recommend ERCP/MRCP
for further evaluation.
___: cat scan of the c-spine:
. Possible nondisplaced fracture of the right C2 lamina.
2. Multilevel degenerative changes with stable mild
anterolisthesis of C4 on C5.
3. Stable bilateral apical pleural-parenchymal scarring.
___: bilateral forearm:
Subtle cortical irregularity of the distal left ulna raises
concern for
nondisplaced fracture. No definite acute fracture seen
elsewhere.
3 mm radiopaque structure projecting over the mid shaft of the
left radius could represent a retained foreign body.
Chronic changes including suggestion of prior trauma at the
distal right
radius and ulna and osteoarthritic changes of the bilateral
wrists, as above, better assessed on the dedicated wrist
radiographs.
___: right knee:
Questionable lucency involving the lateral patella on the AP
and oblique
views, not well assessed on the lateral view. Sunrise view may
further assess the patella.
Prominent prepatellar soft tissue swelling/ possible hematoma.
___: left humerus x-ray:
Chronic fracture of the proximal left humerus with possible
acute component seen on the Y-view. Findings could be further
assessed on CT or MRI if clinical concern for such.
___: CXR
No acute intrathoracic process seen.
___: bil. wrist x-ray:
Right scapholunate dissociation. Marked degenerative changes of
both wrists.
Difficult to exclude nondisplaced ulnar fracture as noted on
forearm
radiographs. No definite acute fracture seen elsewhere.
Brief Hospital Course:
___ year old female admitted to the hospital after a mechanical
fall from standing. There reportedly was no loss of
consciousness. She sustained a C2 lamina fracture,left humeral
head fracture (acute on chronic), left ___ rib fractures,non
displaced, and a pubic rami fracture. The patient was made NPO
upon admission and underwent imaging.
Because of her injuries, she was evalutated by the Ortho-Spine
service for a minimally displaced bilateral laminae fractures of
C2. She had a normal neurologic examination. Based on these
findings, this injury was treated conservatively with cervical
collar immobilization for 2 weeks and a follow-up visit. The
Orthopedic service was consulted for pelvic and humeral
fracture. They determined that the patient had an old proximal
humerus fracture and a non-displaced verticle rim patella
fracture. Neither injury required surgical repair and both were
treated in a non-operative manner. The left shoulder injury was
managed in a sling for comfort with advance ROM and AROM as
tolerated.
The patella was not braced as the patient was not having pain
with active
extension. The patient's rib pain and other bony injuries were
managed with oral analgesia. She was instructed in the use of
the incentive spirometer.
During her hospital course, the patient's vital signs were
stable and she was afebrile. Her pain was controlled with oral
analgesia. She was tolerating a regular diet and voiding
without difficulty. She remained in a soft cervical collar for
neck immobilization. The patient was seen by physical therapy
and recommendations were made for discharge to a rehabilitation
facility.
The patient was discharged on HD # 3 in stable condition.
Appointments for follow-up were made with the Spine, Orthopedic
and acute care service. The patient will also need follow-up
with her primary care provider for findings on cat scan of
biliary dilitation and the need for MRCP/ERCP. Dr. ___
patient's primary care provider, was informed of the need for
additional imaging.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Celecoxib 100 mg oral DAILY
3. Docusate Sodium 100 mg PO BID
4. Fluoxetine 40 mg PO DAILY
5. Gabapentin 800 mg PO TID
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Lorazepam 1 mg PO BID:PRN anxiety
8. Mirtazapine 15 mg PO QHS
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Senna 8.6 mg PO BID:PRN constipation
12. Calcium Carbonate 500 mg PO BID
13. Vitamin D 1000 UNIT PO DAILY
14. Acetaminophen 325-650 mg PO Q6H:PRN pain
15. LOPERamide 2 mg PO BID:PRN loose stools
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Fluoxetine 40 mg PO DAILY
4. Gabapentin 800 mg PO TID
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Lorazepam 1 mg PO BID:PRN anxiety
7. Mirtazapine 15 mg PO QHS
8. Omeprazole 20 mg PO DAILY
9. Senna 8.6 mg PO BID:PRN constipation
10. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
hold for increased sedation, resp. rate <12
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*12 Tablet Refills:*0
11. Acetaminophen 325-650 mg PO Q6H:PRN pain
12. Calcium Carbonate 500 mg PO BID
13. LOPERamide 2 mg PO BID:PRN loose stools
14. Multivitamins 1 TAB PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
16. Celecoxib 100 mg ORAL DAILY
please take with food
17. Heparin 5000 UNIT SC TID
please start on ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Trauma: fall:
C2 lamina fracture
humeral head fracture (acute on chronic)
left ___ rib fracture non displaced
pubic rami fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a fall. You sustained
fractured ribs, pelvis You also sustained a fracture to your
arm. You were seen by physical therapy and recommendations were
made for discharge to a rehabilitation facility to further
regain your strength and mobility.
Followup Instructions:
___
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10789227-DS-13
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| 13 |
2125-03-21 00:00:00
|
2125-03-22 13:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / Keflex
Attending: ___.
Chief Complaint:
Fall, hyponatremia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o F w/ h/o ckd, not on blood thinners, in assisted living,
here after witnessed mechanical fall around 8p. Pt bending over
to adjust fan, fell, hit right side of head and right hip. No
LOC, N/V, vision changes, altered mental status, or amnesia. Pt
currently c/o right sided headache, and right hip pain.
In the ED, initial vitals: 97.8
72 183/74 18 100% RA
Labs were significant for hyponatremia (118), ___ (cr 1.3 from
1, has been as high as 1.7 in past), mild luekocytosis (13.4),
positive U/A
Imaging showed
CT head and cspine neg, plain films hip neg
Able to range right hip well
Cspine clinically cleared
In the ED, she received tylenol, oxycodone 5 mg X 3 over 8
hours, fluoxetine, gabapentin, synthroid
She was fluid restricted for hyponaremia of 118, which improved
to 122 and Cr to 1.2.
Vitals prior to transfer: 98.2 65 140/77 16 96% RA
On floor patient reports no complaints. She has been eating and
drinking okay the past few days and has not felt fatigued, and
has had no change in bladder or bowel habits. She does report
however that she has had been drinking more tea and water
recently. She is very pleasant and is AOX3; is a former ___.
Past Medical History:
- CKD
- Osteoporosis
- Anemia
- Dysphagia
- Cervical radiculopathy
- Polyneuropathy
- Frequent falls
- Hx Basal cell carcinoma
- Hx Lentigo maligna
- Hx Squamous cell carcinoma of skin
- Hx Ankle fracture
- Hx Humerus fracture, proximal w/ shoulder arthroplasty ___
Social History:
___
Family History:
Mother with facial cancer. Didn't know her father. Sister
healthy.
Physical Exam:
ON ADMISSION
VS: T 98.3 145/66 HR 62 RR 18 98 % RA
GEN: Alert, lying in bed, no acute distress
HEENT: dry MM, no cervical LAD, anisocoria noted
NECK: Supple without LAD
PULM: Generally CTA over anterior chest
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender,slight distension, midline scar ___ prior
hysterectomy
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
ON DISCHARGE
PHYSICAL EXAM:
VS: BP 144/66 HR 59 RR 18 97 RA
GEN: Alert, lying in bed, no acute distress
HEENT: moist mucous membranes
NECK: Supple without LAD
PULM: Generally CTA over anterior chest
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender,slight distension, midline scar ___ prior
hysterectomy
EXTREM: Warm, well-perfused, skin tender to touch. LEft lateral
hip tenderness
NEURO: CN II-XII grossly intact, motor function grossly normal
Pertinent Results:
ON ADMISSION
======================
___ 07:30PM GLUCOSE-137* UREA N-11 CREAT-1.3* SODIUM-121*
POTASSIUM-4.7 CHLORIDE-89* TOTAL CO2-24 ANION GAP-13
___ 10:13AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:55PM WBC-13.4* RBC-3.93 HGB-11.9 HCT-34.3 MCV-87
MCH-30.3 MCHC-34.7 RDW-12.5 RDWSD-40.0
ON DISCHARGE
======================
___ 06:05AM BLOOD WBC-9.1 RBC-3.29* Hgb-9.8* Hct-30.3*
MCV-92 MCH-29.8 MCHC-32.3 RDW-12.7 RDWSD-42.0 Plt ___
___ 06:05AM BLOOD Glucose-90 UreaN-23* Creat-1.2* ___
K-4.6 Cl-94* HCO3-27 AnGap-12
___ 06:05AM BLOOD Calcium-9.2 Phos-4.2 Mg-1.9
___ 06:54AM BLOOD TSH-12*
___ 06:54AM BLOOD Free T4-1.0
IMAGING
================================
HIP XRAY
Final Report
INDICATION: ___ with mechanical fall, fell onto right side,
with right hip
pain // fracture
COMPARISON: Prior exam dated ___.
FINDINGS:
AP pelvis and two views of the right hip were provided. There
is left hip
arthroplasty partially imaged which appears aligns normally and
without signs
of hardware failure. Chronic deformities involving the inferior
pubic rami
are again noted. Right hip aligns normally. Vascular
calcification noted.
Bony pelvic ring appears intact. SI joints are symmetric and
normal.
IMPRESSION:
No acute findings.
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with mechanical fall witnessed onto right side,
with right
sided hematoma, no LOC, not on blood thinners
TECHNIQUE: Non-contrast helical multidetector CT was performed.
Soft tissue
and bone algorithm images were generated. Coronal and sagittal
reformations
were then constructed.
DOSE: Total DLP (Body) = 625 mGy-cm.
CT SPINE
COMPARISON: CT cervical spine ___.
FINDINGS:
Mild anterolisthesis of C4 on C5 and retrolisthesis of C6 on C7
is chronic.
No acute fractures are identified. Multilevel degenerative
changes with
anterior osteophytes and disc space narrowing are present and
unchanged.
There is no prevertebral soft tissue swelling.There is no
cervical
lymphadenopathy by size criteria. The visualized thyroid gland
is
unremarkable. Prominent biapical pleural-parenchymal scarring
and
calcifications are unchanged from prior exam. The visualized
aerodigestive
tract is grossly unremarkable. Prominent atherosclerotic
calcification of the
bilateral carotid bifurcations are noted.
IMPRESSION:
1. No acute fracture or traumatic malalignment.
2. Multilevel degenerative changes, unchanged from prior exam.
CT HEAD
Final Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with mechanical fall witnessed onto right side,
with right
sided hematoma, no LOC, not on blood thinners
TECHNIQUE: Contiguous axial images of the brain were obtained
without
contrast.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CT ___.
FINDINGS:
There is no evidence of acute large territorial infarction,
hemorrhage, edema,
or mass effect. Ventricles and sulci are prominent, consistent
with
age-related involutional changes. Periventricular subcortical
white matter
hypodensities are nonspecific but compatible with chronic small
vessel
ischemic changes and unchanged from prior exam.
There is no evidence of fracture. Extensive calcification of
carotid siphons
is present. Partial opacification of right mastoid air cells is
noted. The
visualized portion of the paranasal sinuses,left mastoid air
cells, and middle
ear cavities are clear. Mild right temporal scalp hematoma is
identified
without underlying skull fracture.
IMPRESSION:
1. No acute intracranial abnormality on noncontrast head CT.
Specifically no
intracranial hemorrhage.
CXR
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: ___ year old woman with fall found to have elevated
WBC. // Eval
for cardiopulmonary process
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
The patient is somewhat rotated. The lungs remain
hyperinflated. Biapical
pleural thickening is noted. No new focal consolidation is
seen. No pleural
effusion or pneumothorax is seen. The cardiac and mediastinal
silhouettes are
stable. Partially imaged bilateral humeral prostheses noted.
IMPRESSION:
No acute cardiopulmonary process.
MICRIOBIOLOGY
========================
Allergies: morphine / Keflex
Resident: ___ ___ Intern: ___ ___
Code Status: Do not resuscitate (DNR/DNI) molst in chart
Microbiology Results(last 7 days) ___
__________________________________________________________
___ 10:13 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
___ pleasant year old female s/p recent left hip revision
hemiarthoplasty presents from nursing home with mechanical fall,
found to have profound hyponatremia (118) and likely UTI, and
___. It was determined patient likely had prerenal ___ prior to
admission, and during hospital stay while hyponatremika improved
from 118 to 128 source of hypoantremia remained unclear, with
belief being patient may have suffered from SIADH vs reset
osmostat. Patient discharged on 1 L fluid restriction with plans
for close PCP followup, and her home SSRi was stopped.
HOSPITAL COURSE BY ISSUE
==================
#Hyponatremia: Likely chronic in setting of poor po intake,
possible volume down, and confusion from UTI. initially patient
was fluid restricted for concern siadh. Patient was given 500 cc
boluses but now with ___ improvement 118 on admission to 129,
leading team to believe hypovolemic hyponatremia in setting of
poor po intake after recent hip surgery as cause. However,
patient then subseqeutnly had drop in ___, with urine osmolality
showed ~ 400. AS a result, patient was fluid restricted, with ___
hovering around ~140, with resolution ___ below. Ultimately it
was determined as despite fluid boluses and fluid restriction
and given lack of symptoms, patient may have had a reset
osmostat as well. Her home fluoxetine was stopped, and TSH was
checked at 12 (FT4 1.0); home synthroid was uptitrated to 75 mcg
from 50mcg as a result.
# UTI, leukocytosis: CXR clear. WBC 13.4 on admision, ~ 7 on
___ after treating uti. Patient was on bactrim ___t
___ for unclear reason, switched to cipro in house. patient
afebrile, has some hesitancy symptoms, mild positive u/a.
Leukocytosis now improving. Urince cultures were negative but
given fact patient came in on bactrim and improvement in WBC
continued cipro /17, d7 = ___ given improvement since starting
antibx
___: Cr 1.4 from 1.0 baseline, likely pre renal. It was
believed she ahd a prerenal ATN immediately prior to admission
as while giving her fluidis initially during her stay helped her
___ it worsened her Cr. However, by discharge, Cr had started to
downtrend to 1.2.
# Hypertension: Home lisinopril was held due to ___ above. She
was intermittently hypertensive overnight in the setting of
pain. She recieved oxycodone prn as below.
#Trauma workup s/p mechanical fall: Hip x-rays Negative, no
fractures. Patient s/o ___ left hip hemiarthoplasty (left
hip s/p hip replacement ___ years prior) Pain control with
oxycodone.
# Hx depression: Continued hoem fluoxetine, then stopped ___
possible SIADH above
# Hypothyroid: Continued home synthroid. TSH in house was 12;
however free T4 was wnl. ___ hypothyroidism as possible
etiology of hypoantremia above, patient was uptitrated to 75 mcg
synthroid on d/c.
# Osteoporosis: Continued calcium, vitamin D
# Pain control: Continued home meds save for hydromorphone;
switched to oxycodone prn, can switch back on d/c.
TRANSITIONAL ISSUES
==============================
-Patient to end ciprofloxacin on ___
-Please check ___, Cr at next PCP appointment, ___ on d/c 128,
1.2
-Patient used short term oxycodone in house; she can resume her
prior pain regimen thereafter. Rx short course to last until PCP
followup as patient feared ALF would require rx to fill.
-Patient's home lisinopril discontinued, if Cr returns to normal
on d/c woul restart
-Home synthroid increased to 75 mcg from 50 mcg given TSH of 12
(elevated) and hyponatremia above (however free T4 1). Given
just subclinical hypothyroidism on labs; would recheck TSH and
Free T4 in 3 weeks; if patient hyperthyroid decrease synthroid
back to 50 mcg.
-Patient's home SSRI stopped due to hyponatremia above.
-Patient discharged on 1 L fluid restriction; if patient appears
dry on F/U appointment and ___ improving, would liberalize
restriction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 600 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 600 mg PO TID
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Lorazepam 1 mg PO BID:PRN anxiety
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Senna 8.6 mg PO BID:PRN constipation
10. TraZODone 100 mg PO QHS
11. Vitamin D ___ UNIT PO DAILY
12. Acetaminophen 1000 mg PO Q8H
13. Denosumab (Prolia) 60 mg SC Q6MONTHS
14. Fluoxetine 20 mg PO DAILY
15. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
16. Fiber (calcium polycarbophil) (calcium polycarbophil) 625 mg
oral DAILY
17. Ferrous Sulfate 325 mg PO DAILY
18. Voltaren (diclofenac sodium) 1 % topical BID
19. Sulfameth/Trimethoprim DS 1 TAB PO BID
20. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO DAILY:PRN
pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hypovolemic Hyponatremia
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital because you fell. At the hospital, it
was determined that you had no fractures but your sodium was
very low, and our medical team felt you were dehydrated. In the
hospital we gave your IV fluids and your sodium improved. We ask
that you follow up with your primary care physician to monitor
your sodium level and kidney function. We also also discharging
you with a short taper of oxycodone for pain in your hip; after
this you should go back on the pain regimen your assisted living
facility is giving you. Lastly, we are giving you an antiobiotic
for a possible UTI (you were taking another antibitotic at home
which we changed). This antibiiotic is called ciprofloxacin, and
you will take it until ___.
We wish you all the best!
-You ___ Care Team
Followup Instructions:
___
|
10789227-DS-15
| 10,789,227 | 29,382,611 |
DS
| 15 |
2126-03-26 00:00:00
|
2126-03-28 18:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
morphine / Keflex
Attending: ___.
Chief Complaint:
right rib pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ lives in a nursing home fell from standing while near a
refrigerator onto a chair with her right chest striking the arm
rest. No head strike or loss of consciousness. She had immediate
pain and send to the hospital for evaluation. She was sent to
___ where pan scan revealed right rib fractures ___
and a (very) small pneumothorax. She was transferred to ___
for
further evaluation
Past Medical History:
- CKD
- Osteoporosis
- Anemia
- Dysphagia
- Cervical radiculopathy
- Polyneuropathy
- Frequent falls
- Hx Basal cell carcinoma
- Hx Lentigo maligna
- Hx Squamous cell carcinoma of skin
- Hx Ankle fracture
- Hx Humerus fracture, proximal w/ shoulder arthroplasty ___
Social History:
___
Family History:
Mother with facial cancer. Didn't know her father. Sister
healthy.
Physical Exam:
Physical examination upon admission: ___
98 65 129/63 24 100% 2LNC
NAD, AAOx3
no stigmata of head trauma
stable midface, nontender
trachea midline
breathing well
right chest tender to palpation, no crepitus
RRR
abdomen soft, non-tender non-distended
pelvis stable
extremities non-tender
Physical examination upon discharge: ___:
General: NAD
vital signs: 991, hr=67, bp=96/61, rr=18, 98% room air
CV: ns1, s2, no murmurs
LUNGS: clear
ABDOMEN: hypoactive BS, soft, non-tender
EXT: hyperpigmentation lower ext. bil., + dp bil., no calf
tendernesss bil
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
Hematology
GENERAL URINE INFORMATION Type Color ___
___ 23:09 Straw Clear 1.015
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone
Bilirub Urobiln pH Leuks
___ 23:09 NEG NEG TR NEG NEG NEG NEG 6.5 SM
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
___ 23:09 <1 2 FEW NONE 1 <1
___: ct scan abd and pelvis:
1. Acute fractures involving the right posterior lower ribs 8
through 12 with increasing right lower lobe consolidation likely
a combination of contusion and atelectasis. No visible
pneumothorax.
2. Left lower lobe nodule measures 13 mm, follow-up CT in 3
months advised to ensure stability/resolution.
3. Biliary and pancreatic duct dilation appears appears stable
since ___. If not already performed, MRCP for further
evaluation on a
non-emergent basis can be considered.
4. Additional non-emergent findings as detailed above.
___: CXR:
Small persistent right apical pneumothorax.
___: CXR:
No appreciable change in right apical pneumothorax.Right-sided
effusion has increased when compared to ___, and must
be followed up to ensure stability as there is concern for
hemothorax in the setting of trauma.
RECOMMENDATION(S): Follow-up radiograph is recommended to
ensure stability of right sided a fusion, as there is concern
for hemothorax.
___: left shoulder:
Left shoulder prosthesis without evidence for ___
fracture or
dislocation
___: left knee:
No acute osseous injury of the left knee.
___: chest x-ray:
Heart size and mediastinum are stable. There is no change
apical thickening.
There is left basal the shin. Overall the findings are similar
to previous examination.
___: chest x-ray:
Right apical pneumothorax not clearly delineated and certainly
not enlarged since priors
___: CXR:
In comparison with the study of ___, there is again
scarring at the
apices with no definite pneumothorax. Continued low lung
volumes. Blunting of the costophrenic angles is consistent with
small effusions and underlying compressive atelectasis.
Multiple vertebro-plasties and bilateral shoulder prostheses are
again seen.
The multiple right rib fractures were better seen on a prior CT
examination.
Brief Hospital Course:
___ year old female admitted to the hospital after a mechanical
fall in which she sustained right sided ___ rib fractures and a
small right pneumothorax. She was transferred here for medical
management. Upon admission, the patient was made NPO, given
intravenous fluids, and underwent imaging. Cat scan imaging of
the head and c-spine showed no acute fractures. Additional
imaging of the chest and pelvis showed a small right apical
pneumothorax, 13x8 mm nodule left lower lobe and a 0.7 cm lesion
in left hepatic lobe. These findings will need further
investigation.
During the patient's hospitalization, her vital signs remained
stable and she was afebrile. She was instructed in the use of
the incentive spirometer. Her rib pain was controlled with oral
analgesia. She was tolerating a regular diet and voiding without
difficulty. She was evaluated by physical therapy and
recommendations made for discharge to a rehabilitation facility.
The patient was discharged on HD #5 in stable condition.
(telephone conversation with NP at facility for need to review
current medications)
Medications on Admission:
fluoxetine 20', gabapentin 600''', atrovent neb, Lasix 20',
levoxyl 75', Ativan 1'', omeprazole 20', trazodone 100HS'
Discharge Medications:
1. Acetaminophen 650 mg PO TID
please change to every 6 hours PRN as needed for pain after
___
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezes
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC BID
continue until patient becomes ambulatory
6. Lidocaine 5% Patch 1 PTCH TD QPM
7. Omeprazole 20 mg PO DAILY
8. amLODIPine 5 mg PO DAILY
9. FLUoxetine 20 mg PO DAILY
10. Furosemide 20 mg PO DAILY
11. Gabapentin 600 mg PO TID
12. Ipratropium Bromide Neb 1 NEB IH Q6H
13. Levothyroxine Sodium 50 mcg PO DAILY
14. LORazepam 1 mg PO Q8H:PRN anxiety
15. TraZODone 100 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Trauma: mechanical fall
right sided rib fractures, ___
small right apical pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after a fall in which you
sustained right sided rib fractures and a small collapse of your
right lung. Your vital signs have been stable and you are
preparing for discharge to a rehabilitation center to help
further regain your strength and mobility. You are being
discharged with the following instructions:
Your injury caused right sided_rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
In addition to the rib fracture recommendations, I have included
the following instructions:
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.
*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.
Followup Instructions:
___
|
10789227-DS-9
| 10,789,227 | 24,914,492 |
DS
| 9 |
2123-09-28 00:00:00
|
2123-09-28 19:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / Keflex
Attending: ___.
Chief Complaint:
Fall and Subdural Hematoma
Major Surgical or Invasive Procedure:
___ - 2 layer suture closure of forehead laceration by
plastic surgery using ___ Vicryl and ___ and ___ prolene.
History of Present Illness:
Ms. ___ is a ___ F w/ CKD, history of falls and chronic
back pain along with cervical radiculopathy and polyneuropathy
who presents to the ED s/p fall. The patient notes that in the
week leading up to the fall she had not been eating or drinking
well, as she was very busy with clinic appointments for her
various health issues. She also had denture work on ___
prior to admission (___). She notes significant trouble
falling asleep on the night of ___, and going to the bathroom
around 1AM on ___. She fell asleep on the toilet, falling
forward and hitting the front of her forehead on the ground. She
woke up immediately, and remembers the aftermath of the fall
when she was transported to ___.
On review of systems she denies any anginal hx, pre-syncope or
dizziness prior to the fall. She also denies any chest pain,
shortness of breath, abdominal pain,
dysuria/hematuria/hesitancy, or any fever/chills/rashes.
___ ED course:
- initial vitals: 97.5 55 177/67 18 98% RA
- improving L sided neck tenderness
- complex 4cm laceration to forehead with hematoma
- no other traumatic injuries on body found
- WBC 9, Hct 38, creat 1.2
- CT head: small right frontal subdural hematoma
- CT c-spine: no acute fracture or traumatic malalignment
- 1500cc IVF
- Ketorolac IV, Fluoxetine, Gabapentin, Levothyroxine,
Omeprazole, Loperamide, Lorazepam, Fentanyl
- Neurosurgery: clear for home, no ASA, no need for repeat head
CTs
- Plastic Surgery: requested
- Physical Therapy: recommend short term rehab
ROS: Full 10 pt review of systems negative except for above.
Past Medical History:
CKD
- Osteoporosis
- Anemia
- Dysphagia
- Cervical radiculopathy
- Polyneuropathy
- Frequent falls
- Hx Basal cell carcinoma
- Hx Lentigo maligna
- Hx Squamous cell carcinoma of skin
- Hx Ankle fracture
- Hx Humerus fracture, proximal w/ shoulder arthroplasty ___
Social History:
___
Family History:
Mother with facial cancer. Didn't know her father. Sister
healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==================
VS: 97.5 55 177/67 18 98% RA
Gen: NAD, AAOx3
HEENT: EOMI, PERRLA. Bilateral orbital ecchymoses.
CV: ___ systolic murmur loudest at the ___.
Pulm: CTAB, good respiratory effort.
Abd: Normoactive BS, soft non distended, nontender on deep
palpation.
GU: No foley
Ext: Upper extremities with multiple ecchymoses consistent with
bruising from falls, bilateral lower extremities with pretibial
healed scars. FROM x 4. Right wrist deformity consistent with
old injury.
Skin: No visible rashes.
Neuro: CNII-CNXII, ___ strength upper and lower extremities.
Psych: Alert and oriented x 3.
DISCHARGE PHYSICAL EXAM:
==================
Vitals: 97.8, 148-175/67-84, 56-67, pulse 18, 98% on RA
On recheck: 152/80 BP
Gen: NAD, AAOx3
HEENT: EOMI, PERRLA. Bilateral orbital ecchymoses. Front of
forehead covered with bandage, clean/dry/intact.
CV: ___ systolic murmur loudest at the ___.
Pulm: CTAB, good respiratory effort.
Abd: Normoactive BS, soft non distended, nontender on deep
palpation.
Ext: Upper extremities with multiple ecchymoses consistent with
bruising from falls, bilateral lower extremities with pretibial
healed scars. FROM x 4. Right wrist deformity consistent with
old injury.
Skin: No visible rashes.
Neuro: CNII-CNXII, ___ strength upper and lower extremities.
Psych: Alert and oriented x 3.
Pertinent Results:
ADMISSION LABS:
===========
___ 02:45AM BLOOD WBC-9.4 RBC-4.17*# Hgb-12.4 Hct-38.4
MCV-92# MCH-29.7 MCHC-32.2 RDW-14.1 Plt ___
___ 02:45AM BLOOD ___ PTT-28.0 ___
___ 02:45AM BLOOD Glucose-85 UreaN-17 Creat-1.2* Na-134
K-4.4 Cl-97 HCO3-25 AnGap-16
___ 02:45AM BLOOD Calcium-9.0 Phos-4.4 Mg-1.9
EKG:
====
1st degree AV block, otherwise NSR
OTHER PERTINENT LABS:
===============
___ 07:32AM BLOOD WBC-8.7 RBC-4.13* Hgb-12.0 Hct-37.6
MCV-91 MCH-29.2 MCHC-32.0 RDW-13.9 Plt ___
___ 07:32AM BLOOD UreaN-14 Creat-1.1 Na-137 K-4.7 Cl-99
HCO3-29 AnGap-14
___ 07:32AM BLOOD ___ PTT-26.7 ___
___ 07:32AM BLOOD Phos-2.8# Mg-1.9
MICROBIOLOGY:
==========
Urinalysis - WNL
IMAGING:
======
___: CT HEAD WITHOUT CONTRAST
There is a small right frontal subdural hematoma (2:21),
measuring
approx. 11 by 6 mm in transverse dimension. Prominent
ventricles and sulci
are consistent with age-related involutional change.
Periventricular and deep
subcortical white matter hypodensities are consistent with
chronic small
vessel ischemic disease. The basal cisterns appear patent, and
there is
preservation of gray-white matter differentiation.
No fracture is identified. The mastoid air cells, middle ear
cavities and
visualized paranasal sinuses are clear. The globes are
unremarkable.
IMPRESSION: Small right frontal subdural hematoma.
___: CT C-SPINE WITHOUT CONTRAST
FINDINGS: There is no acute fracture or traumatic malalignment.
Multilevel
degenerative changes are seen throughout the cervical spine,
including
unchanged 3 mm of anterolisthesis of C4 on C5, with disc height
loss, anterior
osteophytosis and endplate sclerosis at multiple levels. There
is no
prevertebral soft tissue swelling. The thyroid gland is
unremarkable. Apical
partially calcified scarring is unchanged.
IMPRESSION: No acute fracture or traumatic malalignment.
Chest XRAY: ___:
Probable background COPD and mild cardiomegaly. No acute
pulmonary process
identified. Biapical pleural/parenchymal thickening noted.
Brief Hospital Course:
Ms. ___ is a ___ F w/ CKD, history of falls and chronic
back pain along with cervical radiculopathy and polyneuropathy
who presents to the ED s/p fall and found to have subdural
hematoma measuring 11mm x 6mm that appears to be ___ fatigue,
poor PO, and potentially deliriogenic medications.
# Subdural Hematoma:
Small right frontal subdural hematoma on admission CT head with
negative CT c-spine. No neurosurgical interventions or repeat
imaging needed per Neurosurgery in ED. Patient also needs no NSG
followup as per the team. Her course remained stable, with no
changes in her neurological function which would have been
indicative of progression of the subdural hematoma. The
neurosurgery service was consulted on ___ in regards to
whether or not patient can be anticoagulated with DVT
prophylaxis - they recommended holding ASA x 1 week from
___ (to ___. After ___, aspirin can be
started if recommended by patient's primary care physician for
cardiac risk reduction. OK for sc heparin for DVT prophylaxis if
needed.
# Mechanical Fall:
Multifactorial - patient on some deliriogenic medications,
fatigued, and with poor PO in the context of busy clinic
appointment schedule. ___ evaluated and recommends short term
rehab. In evaluation of the medication list - patient is on a
number of deliriogenic medications and doses that are above the
recommended level including Lorazepam 1 mg PO BID for anxiety,
which can increase risk of delirium/falls. She is on Trazodone
100mg PO qHS:prn for insomnia, which increased risk for QT
prolongation and for somnolence that may contribute to the
overnight risk of falls. In addition, she is on standing
narcotics for her chronic pain, and these may also contribute to
fall risk. Prior to discharge from ___ a workup for other
causes of patient's fall were performed. EKG indicated ___
degree AV block, but otherwise was within normal limits. In
addition, electrolytes were within normal limits. Her gait was
unstable at times, prompting physical therapy to recommend that
the patient go to short term rehab.
# CKD:
Creatinine of 1.2, at baseline and stable. Patient notes that
she has a history of one of her kidneys not being appropriately
formed and that this is the cause of her CKD. Medications were
renally dosed, and nephrotoxic agents were avoided. Kidney
function monitored throughout hospitalization.
# Cervical Radiculopathy
Patient with continuing back and neck discomfort. Provided
Tylenol, Gabapentin 800 mg PO TID, and Hydrocodone-Tylenol 5mg
PO q8h:prn pain. Discontinued her home Endocet during
hospitalization. Did not exceed 4 grams of Tylenol daily. Held
patient's Celebrex ___ mg oral qd.
# Polyneuropathy
Stable. On Gabapentin 800 mg PO TID.
# Osteoporosis
No fractures seen on imaging. On Vitamin D 1000 UNIT PO DAILY
and Calcium Carbonate 500 mg PO BID.
# Depression/Anxiety
Held Lorazepam 1mg PO BID due to deliriogenic effects. However,
provided patient's home Fluoxetine 40 mg PO DAILY.
#Hypothyroidism
On Levothyroxine Sodium 50 mcg PO DAILY.
#Insomnia
Reduced dose of home TraZODone 100 mg PO HS:PRN insomnia to 25mg
PO HS:PRN insomnia.
#History of Anemia
Continued Ferrous Sulfate 325 mg PO DAILY.
TRANSITIONAL ISSUES:
===============
- Plastic surgery clinic on ___ for removal of sutures
and re-evaluation of forehead laceration
- No Aspirin for a total of 1 week from injury - until ___.
- Please follow up with your primary care physician ___ 2
weeks of discharge.
- Consider discontinuing lorazepam, reducing endocet amount as
able, and trazodone dose to reduce risk for delirium and falls.
- No followup required with neurosurgery
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluoxetine 40 mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Lorazepam 1 mg PO BID
4. Calcium Carbonate 500 mg PO BID
5. Amoxicillin 500 mg PO 4 PILLS ONCE PRIOR TO DENTAL PROCEDURES
6. LOPERamide 2 mg PO BID:PRN diarrhea
7. Multivitamins 1 TAB PO DAILY
8. TraZODone 100 mg PO HS:PRN insomnia
9. Vitamin D 1000 UNIT PO DAILY
10. Gabapentin 800 mg PO TID
11. Celebrex ___ mg oral qd
12. Ferrous Sulfate 325 mg PO DAILY
13. Endocet (oxyCODONE-acetaminophen) ___ mg oral BID
14. Endocet (oxyCODONE-acetaminophen) ___ mg oral qHS
Discharge Medications:
1. Calcium Carbonate 500 mg PO BID
2. Ferrous Sulfate 325 mg PO DAILY
3. Fluoxetine 40 mg PO DAILY
4. Gabapentin 800 mg PO TID
5. Levothyroxine Sodium 50 mcg PO DAILY
6. LOPERamide 2 mg PO BID:PRN diarrhea
7. Multivitamins 1 TAB PO DAILY
8. TraZODone 25 mg PO HS:PRN insomnia
9. Vitamin D 1000 UNIT PO DAILY
10. Acetaminophen 325 mg PO Q4H:PRN pain
11. Amlodipine 5 mg PO DAILY
12. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
Duration: 7 Days
13. Amoxicillin 500 mg PO 4 PILLS ONCE PRIOR TO DENTAL
PROCEDURES
14. Celecoxib 100 mg ORAL QD
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Subdural Hematoma
Mechanical Fall
Secondary:
Chronic Kidney Disease
Cervical Radiculopathy
Polyneuropathy
Osteoporosis
Depression/Anxiety
Hypothyroidism
Insomnia
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. ___,
You came to ___ after having a
fall, hitting your head and sustaining a subdural hematoma (a
small area of bleeding in your brain). You were seen by the
neurosurgery service which found that the area of bleeding was
small, should not affect your activities, and does not require
any follow up with neurosurgery. Because you sustained an injury
to your forehead, you received stitches and will need to go to
the plastic surgery clinic at ___ on either ___ to
have these removed, and for re-evaluation of your head wound. We
found that the most likely cause of your fall was fatigue from
your numerous doctor's appointments, and not eating and drinking
enough. In addition, some of your home medications can
contribute to falls.
You were seen by our physical therapists who recommended you go
to a rehab facility to regain your strength before returning to
assisted living.
It has been a pleasure caring for you here at ___, and we wish
you all the best.
Kind regards,
Your ___ Team
Followup Instructions:
___
|
10789538-DS-20
| 10,789,538 | 25,870,167 |
DS
| 20 |
2122-11-02 00:00:00
|
2122-11-02 19:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
___ 01:00AM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG
___ 12:49AM ___ COMMENTS-GREEN TOP
___ 12:49AM LACTATE-0.8
___ 12:41AM GLUCOSE-98 UREA N-9 CREAT-0.6 SODIUM-140
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-25 ANION GAP-14
___ 12:41AM estGFR-Using this
___ 12:41AM ALT(SGPT)-43* AST(SGOT)-40 ALK PHOS-66 TOT
BILI-0.5
___ 12:41AM LIPASE-14
___ 12:41AM ALBUMIN-3.8 CALCIUM-9.0 PHOSPHATE-4.2
MAGNESIUM-2.0
___ 12:41AM CRP-47.7*
___ 12:41AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 12:41AM WBC-11.5* RBC-4.38* HGB-12.7* HCT-38.6*
MCV-88 MCH-29.0 MCHC-32.9 RDW-12.5 RDWSD-40.3
___ 12:41AM NEUTS-50.0 ___ MONOS-7.6 EOS-1.6
BASOS-0.3 IM ___ AbsNeut-5.74 AbsLymp-4.62* AbsMono-0.87*
AbsEos-0.18 AbsBaso-0.04
___ 12:41AM PLT COUNT-280
___ 12:41AM ___ PTT-30.4 ___
Brief Hospital Course:
=======================TRANSITIONAL
ISSUES==========================
PATIENT LEFT AMA ON ___, understood risks. Discussed at length
return precautions--worsening rash, fevers/chills, dizziness
etc.
#Cellulitis
[ ] Elected to leave AMA on ___
[ ] Given doxycycline 100mg BID for 7 day course for cellulitis
#IVDU
[ ] Continues to use IV meth
#HCV
[ ] Needs outpt treatment
#?Vasculitis
[ ] c/f levamisole vasculitis, f/up ANCA serologies
ACUTE/ACTIVE PROBLEMS:
#cough
#malaise: Sx consistent with URI. DDx levamisole-induced
ANCA-vasculitis. Pt has been smoking cocaine so a direct acute
lung injury is possible. CXR w/o infiltrate. No e/o bacterial
pneumonia. Breathing well on RA. Flu neg. ANCA serologies
pending on AMA.
#left hand cellulitis:
Presented ill appearing poorly defined
border on L hand. Started on Vanc/CTx initially but narrowed to
Cefazolin prior to AMA. Left AMA on ___ despite lack of
improvement in cellulitis and discharged on 7 day course of
doxycycline 100mg BID. Well appearing on AMA.
___:
#EtOH: Numerous substances abused but pt states IVD has been
rare
and not recent. Uses more uppers - inhaled cocaine, meth, as
well
as alcohol; endorses withdrawal prior.
#HCV: needs outpatient f/u for treatment
#psych: continued wellbutrin, risperidone
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL TID
2. RisperiDONE 1 mg PO BID
3. Gabapentin 800 mg PO TID
4. BuPROPion (Sustained Release) 150 mg PO BID
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Capsule Refills:*0
2. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL TID
3. BuPROPion (Sustained Release) 150 mg PO BID
4. Gabapentin 800 mg PO TID
5. RisperiDONE 1 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
IVDU
Discharge Condition:
Mental Status: Clear and coherent.
Discharge Instructions:
You were seen in the hospital for a skin infection on your hand.
You were treated with IV antibiotics and your infection
improved. We recommended you continue IV antibiotics but you
elected to leave against medical advice.
Please take doxycycline 100mg twice daily for 7 days (last day
___
Followup Instructions:
___
|
10789695-DS-14
| 10,789,695 | 28,784,511 |
DS
| 14 |
2145-03-01 00:00:00
|
2145-03-01 12:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
egg / flu shot
Attending: ___.
Chief Complaint:
Right Hip & Thigh Pain
Major Surgical or Invasive Procedure:
Right hip hemiarthroplasty (___)
History of Present Illness:
___ with a history of left hip fracture presents s/p mechanical
slip and fall with right hip pain. She was in her kitchen when
she slipped and lost her balance, ___ on her right hip. No
headstrike or LOC. No preceeding lightheadedness, dizzyness,
SOB, or CP. Complainin only of pain in the right hip and thigh.
Denies pain in other locations.
Past Medical History:
Hypotension previously on medication
Social History:
___
Family History:
Non-Contributory
Physical Exam:
On Admission:
Vitals - 97.5 95 118/81 18 97% RA
General - AAOx3, CAM negative, easily recalls 3 objects,
properly draws a clock
MSK - No pain with ROM of bilateral upper extremities. No pain
wih ROM of left lower extremities
RLE shortened. Skin intact. Pain with any ROM of the hip. Fires
___. SILT DP/SP/S/S. 1+ ___ pulses.
On Discharge
Vitals - T 97.7 BP 125/84 HR 90 RR 18 94% on RA
General - Awake and alert. NAD. Oriented to name, location, and
date.
Wound - Intact over anterolateral right thigh with staples in
place. No erythema, discharge, tenderness to palpation.
Right Lower Extremity
- Skin intact with wound as described above.
- Sensation intact to light touch throughout.
- Fires ___ FHL TA GSC
- (+) DP pulse
Pertinent Results:
CT C spine (___):
No fracture or malalignment
CT Head (___):
No acute intracranial process
CXR (___):
No evidence of acute cardiopulmonary process.
Right Femur X-ray (___):
Impacted right femoral neck fracture.
Right Hip X-ray (___):
Patient is status post right hemiarthroplasty in overall
anatomic alignment and no evidence of hardware abnormality.
___ 05:53AM BLOOD WBC-8.1 RBC-3.52* Hgb-10.6* Hct-33.1*
MCV-94 MCH-30.1 MCHC-32.0 RDW-13.6 Plt ___
___ 08:50PM BLOOD WBC-6.9 RBC-4.45 Hgb-13.8 Hct-42.2 MCV-95
MCH-30.9 MCHC-32.6 RDW-13.5 Plt ___
___ 08:50PM BLOOD Glucose-110* UreaN-14 Creat-1.3* Na-144
K-3.9 Cl-106 HCO3-26 AnGap-16
___ 07:30AM BLOOD Glucose-103* UreaN-14 Creat-1.3* Na-137
K-4.1 Cl-101 HCO3-25 AnGap-15
___ 07:30AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.6
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an isolated right femoral neck fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for right hip hemiarthroplasty,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
right lower extremity with ANTEROLATERAL hip precautions, and
will be discharged on enoxaparin for DVT prophylaxis. The
patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge.
Medications on Admission:
ASA 81 mg po daily
Discharge Medications:
1. Acetaminophen 650 mg PO TID
Never exceed 4000 mg in 24 hours.
2. Calcium Carbonate 500 mg PO TID
3. Docusate Sodium 100 mg PO BID
Do not take if having loose bowel movements.
4. Enoxaparin Sodium 30 mg SC QHS
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 30 mg/0.3 mL 30 mg sc at bedtime Disp #*14
Syringe Refills:*0
5. Vitamin D 400 UNIT PO DAILY
6. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*42 Tablet Refills:*0
7. Aspirin EC 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right Femoral Neck (Hip) Fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
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 enoxaparin (Lovenox) 30 mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- You may bear weight as tolerated to the right leg with
anterolateral hip precautions that the physical therapist has
taught you.
Physical Therapy:
Activity as tolerated
Ambulate at least twice daily if patient able
Pneumatic boots
Right lower extremity: Full weight bearing with ANTEROLATERAL
hip precautions
Left lower extremity: Full weight bearing
Encourage turn, cough and deep breathe q2h when awake
Treatments Frequency:
Wound may remain open to the air without a dressing if the wound
remains dry.
Staples will be removed at the 2 week follow up visit.
Followup Instructions:
___
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10789773-DS-4
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2163-11-07 00:00:00
|
2163-11-08 22:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with a recent diagnosis of
myocarditis/pericarditis. He states that on ___ he
was in a ___ and since that time has had chest "discomfort." He
denies any trauma to the chest, but was seen in ___ and
reportedly diagnosed with myopericarditis. He denies any
preceeding infectious symptoms. He was told to take ibuprofen
and colchicine, and has been doing so since that time. He
self-tapered the ibuprofen and his pain returned, so he
presented to the ED for a second opinion. He had a similar
episode about ___ years ago that resolved on its own. He states he
does not want to take the ibuprofen anymore, he wants this to be
"cured."
.
In the ED, initial VS were: 97.1 134/82 56 20 110% RA. He
received ibuprofen, vicodin, and aspirin for his pain.
Reportedly, a bedside echo was performed which did not show an
effusion. He was admitted to medicine for further evaluation.
.
On the floor, patient reports that he has no pain or other
complaints currently, but would like a cardiology evaluation.
.
Review of systems:
(+) Per HPI. Also reports finding "spots" at the base of his
penis twice in the past month. He picked at them and they
disappeared. He denies that these were painful, has had no new
sexual partners.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
? dx myocarditis/pericarditis
Allergic rhinitis
Social History:
___
Family History:
Denies
Physical Exam:
Vitals: T: 98 BP: 120/80 P: 64 R: 18 O2: 98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Genitals: declined exam
Pulsus ___
Pertinent Results:
Laboratory Findings:
___ 12:48PM BLOOD WBC-4.0 RBC-5.15 Hgb-16.3 Hct-44.0 MCV-86
MCH-31.7 MCHC-37.1* RDW-11.4 Plt ___
___ 12:48PM BLOOD Glucose-76 UreaN-10 Creat-1.1 Na-140
K-4.1 Cl-105 HCO3-28 AnGap-11
___ 06:45AM BLOOD Glucose-83 UreaN-9 Creat-1.0 Na-141 K-4.1
Cl-105 HCO3-28 AnGap-12
___ 12:48PM BLOOD CK(CPK)-174
___ 12:48PM BLOOD CK-MB-9 cTropnT-0.30*
___ 06:45AM BLOOD CK-MB-6 cTropnT-0.17*
___ 06:45AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.0
___ 12:48PM BLOOD D-Dimer-<150
.
Imaging:
CXR ___: PA and lateral views of the chest are provided.
There is no focal
consolidation, pleural effusion or pneumothorax. The lungs are
well expanded.
The cardiomediastinal silhouette is unremarkable.
IMPRESSION: No acute cardiopulmonary process.
.
XRAY L Shoulder ___ views of the left shoulder were
obtained. No evidence of
acute fracture or dislocation is seen. The left
acromioclavicular joint is
intact. The visualized aspect of the upper outer left hemithorax
is
unremarkable.
IMPRESSION: No evidence of acute fracture or dislocation.
.
TTE ___ left atrium is elongated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: No pericardial effusion. Normal global and regional
biventricular systolic function.
Brief Hospital Course:
Mr. ___ is a ___ year old man with a recent diagnosis of
myocarditis. He is presenting with a troponin elevation and
intermittent chest discomfort most consistent with ongoing
myocarditis.
.
# Chest Pain: The patient gave a history of intermittent chest
discomfort for 1.5 months, with a diagnosis of myocarditis at
___ in ___. His pain had not changed
significantly since that time, but the patient had stopped his
ibuprofen and colchicine and it had returned. The patient had
elevated troponins, but no ischemic changes on ECG. Given his
age and the duration of symptoms, his troponin elevation was
felt to be more consistent with ongoing myocarditis than with
ischemia. He underwent TTE, which was essentially normal and
showed no evidence of effusion or focal wall motion
abnormalities; again, this finding made a diagnosis of coronary
disease unlikely. He was also monitored on telemetry and had no
significant arrhythmic events. He did not have any significant
chest discomfort during this admission, and was advised to
resume ibuprofen and colchicine if his pain returns.
Medications on Admission:
ibuprofen 2 tabs BID
colchicine BID
Discharge Medications:
1. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
2. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Discharge Disposition:
Home
Discharge Diagnosis:
Myocarditis/Pericarditis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for chest pain related to
myocarditis/pericarditis, which is inflammation of the heart and
lining around the heart. You had an ultrasound of you heart
which did not show any concerning fluid around the heart. You
can continue to take ibuprofen for chest discomfort as needed.
We made you an appointment with a cardiologist for next week for
further evaluation.
Followup Instructions:
___
|
10789896-DS-6
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2132-05-14 00:00:00
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2132-05-14 10:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Mental status change
Major Surgical or Invasive Procedure:
___: Left burr hole evacuation of a chronic subdural
hematoma
History of Present Illness:
This is a ___ year old female well known to this service who
presents today from ___ after a fall in
the bathroom. She denies hitting her head. Following the fall
she was reported to have slurred speech and was slightly
confused. The patient had a Head Ct which revealed stable left
sided subdural hematoma and was transferred here for further
evaluation and treatment. The patient has a new skin tear on
her
anterior shin from the fall. The family is at the patient's
bedside and reports that the patient is now back at her baseline
mental status.
The patient denies, weakness, numbness, tingling sensation,
hearing or vision disturbance, bowel or bladder dysfunction.
Past Medical History:
PMH: frequent falls, dementia w/ dysarthria/broca's aphasia,
lyme
disease, L hand contracture, hypothyroid
PSH: C3 laminectomy, C5 and C6 fusion/laminectomy from fall and
MVC
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAM (on Admission)
O: T: 97.6 BP: 173/85 HR:71 R:18 O2Sats96% 2 liters
Gen: comfortable
HEENT: Pupils: ___ EOMs:intact
Neck: Supple.
Extrem: Warm and well-perfused.new large skin tear on left
anterior shin
Neuro:
Mental status: Awake and alert, cooperative and pleasant but
does
not follow all aspects of the exam,slightly vague affect
Orientation: Oriented to person only
Recall: unable to perform
Language: Speech fluent
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 patient is antigravity and appears, very
pleasant but does not fully participate in motor exam. No
pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: patient does not participate
Upon discharge:
PERRL, Moves all extremities spontaneously, confused
Pertinent Results:
Blood
___ 03:05AM BLOOD WBC-4.7 RBC-4.20 Hgb-12.9 Hct-38.6 MCV-92
MCH-30.7 MCHC-33.4 RDW-13.4 Plt ___
___ 03:05AM BLOOD Glucose-124* UreaN-11 Creat-0.7 Na-139
K-3.6 Cl-107 HCO3-25 AnGap-11
___ 03:05AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.1
Urine
___ 12:30AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 12:30AM URINE RBC-2 WBC-115* Bacteri-NONE Yeast-NONE
Epi-4
Imaging studies:
CXR ___
FINDINGS: There is an irregularity along the base of the fifth
metacarpal,
suspected to represent a tug lesion associated with enthesopathy
rather than trauma. There is also a bridging osteophyte at the
joint between the medial cuneiform and first metatarsal. A tug
lesion is also noted along the lateral malleolus. Spurring is
likewise noted along the superior margin of the patella. The
bones appear demineralized.
IMPRESSION: Bony demineralization. No evidence of fracture.
Head CT ___
IMPRESSION:
1. Decrease in size of left subdural hematoma with slight
decrease in
rightward shift of the normal midline structures.
2. Expected postoperative pneumocephalus.
3. No evidence of new hemorrhage.
Head CT ___
IMPRESSION: Interval craniotomy with partial evacuation of
subdural
collection, now significantly decreased in size with improved
mass effect and
shift of midline structures.
Brief Hospital Course:
___ year old female with recent admission/discharge for ___
(without intervention at that time) who presented on ___ from
___ after a fall in the bathroom and
question seizure activity. Head CT was stable in comparison to
the Head CT from ___.
#Neuro:
- started Keppra 500mg BID for question seizure. She was made
NPO on ___ and underwent burr hole for subdural hematoma
evacuation on ___. Post-op exam remained stable. Repeat head
CT on day of discharge on ___ was stable with some expected
pneumocephalus, but decreased midline shift.
# ID:
- U/A showing increased WBC, patient placed on Cipro. Culture
showed alpha streptococcus or Lactobacillus sp. She should
continue on this medicaition for 7 days.
# Cardiac:
- patient is being discharged on home doses of Digoxin and
Diltiazem.
# Nutrition:
- Patient takes an adequate oral diet with assistance.
# s/p Fall:
- tib/fib xray not showing Fx.
Patient is being discharged with instructions to follow up with
us in two weeks.
Medications on Admission:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. memantine 10 mg Tablet Sig: One (1) Tablet PO daily ().
6. risperidone 0.25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
7. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
8. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Continue as previously prescribed.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
2. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. memantine 10 mg Tablet Sig: One (1) Tablet PO QD ().
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. levothyroxine 88 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO four times
a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left chronic subdural hematoma with compression
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
General Instructions
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
You may wash your hair with a mild shampoo, we recommend baby
shampoo.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
You have been prescribed Keppra (Levetiracetam), you will not
require blood work monitoring.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101° F.
without contrast.
You will / will not need an MRI of the brain with/ or without
gadolinium contrast.
Followup Instructions:
___
|
10790076-DS-20
| 10,790,076 | 25,587,364 |
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| 20 |
2162-12-07 00:00:00
|
2162-12-10 18:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Rifampin / morphine
Attending: ___.
Chief Complaint:
hypokalemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with a history of primary biliary cirrhosis
complicated by hepatopulmonary hypertension and grade II
esophageal varices who presents with potassium level 2.5 on
routine lab draw (baseline 3.7 on ___. Patient states that
she has been on remodulin, uptitrated weekly since ___.
Since that time, the patient has had poor appetite. She states
that for the past 1.5 months, when she eats, she experiences
loose stools. She denies overt diarrhea, nausea, vomiting,
abdominal pain. No changes in urination.
.
Of note, the patient has been on aldactone since ___, when she
was noted to have some edema at a hepatology visit. On ___,
she called the hepatology office complaining of 4lb weight gain
and ascites, at which point her aldactone dose was increased
from 12.5 mg daily to 25mg daily. Yesterday, her aldactone dose
was increased to 50mg daily (she has not yet taken a dose of
this) because of weight gain/ ___ edema. On call hepatology
fellow received call about critically low K, and recommended
patient go to the ER.
.
In the ED, initial vitals are as follows: 98.8 70 146/80 16 100%
RA. Labs notable for K 2.5. HCO3 is 21 (previously 26 on
___. Hepatology was called, who recommended admission to
medicine. The patient received 60meQ oral potassium and 40meQ
KCl in fluid. Vitals prior to transfer 98.7, 135/66, 60, 18,
99%. Currently, patient has no complaints.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, palpitations, abdominal pain, nausea,
vomiting, constipation, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
-Primary Biliary Cirrhosis
-Hepatopulmonary hypertension diagnosed on cardiac
cath(unresponsive to sildenafil, recently started on remodulin)
-Varices: upper endoscopy in ___ which showed 2 cords of grade
___ varices in the esophagus as well as varices in the fundus.
-Depression
Social History:
___
Family History:
Father: heart disease
Mother: heart disease s/p CABG
Denies family history of gastrointestinal or renal problems
Physical Exam:
Admission Physical Exam:
Vitals - T: 98.3 BP: 107/65 HR: 64 RR: 18 02 sat: 97%RA
GENERAL: Pleasant, well appearing female in NAD
HEENT: Normocephalic, atraumatic. PERRLA/EOMI. MMM. OP clear.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. Prominent
P2
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: Trace edema, 2+ dorsalis pedis/ posterior tibial
pulses. + clubbing
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. NO asterixis. Appropriate. CN ___ grossly intact.
Preserved sensation throughout. ___ strength throughout. ___
reflexes, equal ___. Normal coordination. Gait assessment
deferred
PSYCH: Listens and responds to questions appropriately, pleasant
.
Discharge Physical Exam:
VS: 98.4 103/61 60 16 96%RA
GENERAL: Pleasant, well appearing female in NAD
HEENT: Normocephalic, atraumatic. PERRLA/EOMI. MMM. OP clear.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. ___
systolic flow murmur best heard in ___ intercostal space.
Prominent P2
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, mildly softly distended. No HSM
EXTREMITIES: Trace edema, 2+ dorsalis pedis/ posterior tibial
pulses. + mild clubbing
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. NO asterixis. Appropriate.
Pertinent Results:
Admission Labs ___ 01:07AM:
Glucose-110* UreaN-5* Creat-0.5 Na-142 K-2.6* Cl-111* HCO3-21*
AnGap-13
Albumin-3.2* Calcium-7.8* Phos-3.7 Mg-1.8
Osmolal-291
.
Discharge labs ___ 05:33AM:
WBC-1.9* RBC-3.74* Hgb-11.2* Hct-35.4* MCV-94 MCH-29.9 MCHC-31.6
RDW-16.8* Plt Ct-53*
Glucose-114* UreaN-5* Creat-0.6 Na-139 K-4.2 Cl-113* HCO3-19*
AnGap-11
Calcium-8.0* Phos-3.2 Mg-2.1
Osmolal-285
.
Urine Studies:
Color-Yellow Appear-Clear Sp ___
Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-4* pH-6.5 Leuks-NEG
RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-1 TransE-<1
Mucous-RARE
UreaN-148 Creat-33 Na-138 K-14 Cl-151 Calcium-13.8 HCO3-<5
Osmolal-378
.
CXR ___:
1. Tunneled RIJ line at low SVC.
2. Faint left basilar opacity could represent infection in the
correct
clinical context. Correlate with exam and symptoms.
.
RUQ ultrasound with dopplers:
1. No focal liver lesions.
2. Patent portal vein with forward flow, but huge left gastric
varices and huge splenic varices with a splenorenal shunt.
Findings are consistent with marked portal hypertension.
3. Splenomagaly and small volume ascites.
Brief Hospital Course:
___ year old female with a history of primary biliary cirrhosis
complicated by hepatopulmonary hypertension and grade II
esophageal varices who presents with potassium level 2.5 on
routine lab draw.
.
# Hypokalemia: Patient admitted with asymptomatic hypokalemia
to 2.5 on aldactone therapy. Potassium was repleted, but
continued to decrease following repletion. Hypokalemia likely
due to poor PO intake and several weeks of increasing loose
stools the patient attributes to side effect of remodulin pump.
Transtubular potassium gradient < 3, making type 1 or type 2 RTA
unlikely. The patient's potassium was repleted to normal and
her aldactone was increased to 50 mg daily. She was discharged
to home, with follow up for potassium check on discharge. The
patient should follow up with both hepatology and pulmonology
regarding remodulin therapy and aldactone dosing.
.
# Primary biliary cirrhosis complicated by hepatopulmonary
hypertension and grade II varices. On admission, the patient
complained of slowly increasing abdominal distention. No
abdominal pain. She underwent RUQ ultrasound that showed
significant portal hypertension, without evidence of portal vein
thrombosis. The patient was continued on remodulin, nadalol,
protonix, ursodiol. Aldactone was increased to 50 mg daily as
above.
.
# CODE: Full (confirmed)
===============================================
TRANSITIONAL ISSUES:
Patient should have potassium checked ___ at her
PCP's office
She will be called with an appointment by pulmonary on
discharge.
She should follow up with hepatology as previously scheduled.
Medications on Admission:
Remodulin infusion pump
Nadolol 10 mg daily
Ursodiol 600 mg bid
Protonix 40 mg daily
Megace 1 ml qid
Aldactone 25 mg daily
Discharge Medications:
1. nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. treprostinil sodium 1 mg/mL Solution Sig: 47.5
nanograms/kg/minute Injection INFUSION (continuous infusion).
5. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
6. Outpatient Lab Work
Please check chem 10 on ___. Report results to Dr.
___
7. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1) mL
PO four times a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Hypokalemia
Secondary diagnoses: Hepatopulmonary hypertension, primary
biliary cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
.
You were admitted to the hospital with low potassium found on
routine blood draw. We gave you potassium to return your level
to normal. We performed blood and urine studies, and found that
your potassium is likely low due to poor appetite and loose
bowel movements. You should follow up in primary care clinic
for a potassium check on ___. You will be called with an
appointment with Dr. ___.
.
MEDICATION CHANGES:
INCREASE spironolactone to 50 mg daily
Followup Instructions:
___
|
10790076-DS-21
| 10,790,076 | 27,166,733 |
DS
| 21 |
2163-03-09 00:00:00
|
2163-03-10 21:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Rifampin / morphine / ceftriaxone
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
R ___ removal
L tunneled line placement
History of Present Illness:
Ms. ___ is a ___ female with a complicated past
medical
history including AMA-positive primary biliary cirrhosis with at
least stage 3 fibrosis (LBX ___, which has been complicated
by portal pulmonary hypertension on Treprostinil gtt,
non-bleeding esophageal varices, and ascites who is presenting
with severe abdominal pain.
She developed chills and subjective fevers yesterday, shortly
afterwards she noted insidious onset of diffuse abdominal pain.
She developed diarrhea, small volume and mucousy discharge ___
times overnight accompanied by nausea but not vomiting. She has
been excessively fatigued. No recent sick contacts. The pain
progressed over the daytime today- it is exacerbated by movement
and relents somewhat when still. She noted severe pain during
the drive to the hospital when the car hit roadbumps. She has
had very poor appetite with decreased PO over the past day. She
has held her diuretics. She has no history of SBP per her
report.
With regard to her liver disease, she has has had
diuretic-controlled ascites, and she is currently taking
spironolactone 100 mg daily (along with potassium
supplementation given history of low K.) Her last upper
endoscopy ___ noted two cords of grade ___ varices. She is
on nadolol 10 mg daily. She has never had bleeding esophageal
varices. Her last abdominal U/S ___ was negative for liver
mass lesions. Her main complications has been portal pulmonary
hypertension, which has been severe. She was hospitalized
___ @ ___ for placement of a central caheter and
initiation of treprostinil therapy. She is on a dose escalation
schedule and is currently at 106.5. Her repeat right heart cath
___ noted PASP 45 mmHg (previously 52 mmHg.)
In the ED, initial vs were 100.0F, 93, 95/62, 18. Exam was
significant for exquisite abdominal pain diffusely to palpation.
CT abd/pelvis showed ?peritonitis, ascites, cirrhosis, and a
normal gallbladder. Discussions with liver team raised
possibility of SBP, though a paracentesis could not be performed
due to an inability to find an accessible pocket. She was given
2g ceftriaxone and was admitted.
On arrival to the floor, VS were T99.4 BP93/47 ___ RR18
Sat95RA. She is in pain but feels better while laying still. In
discussion with pharmacy given the plans for dose escalation of
Treprostinil and the need for frequent vital sign checks, she
was transferred to the MICU for close monitoring.
On arrival to the MICU, she stated that abdominal pain continued
and was improved if she remained still.
Review of systems:
(+) Per HPI 10lb weight gain in last ___ weeks
(-) Denies night sweats, recent weight loss. Denies headache.
Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations, or weakness. Denies dysuria,
frequency, or urgency.
Past Medical History:
-Primary Biliary Cirrhosis
-Hepatopulmonary hypertension diagnosed on cardiac
cath(unresponsive to sildenafil, recently started on remodulin)
-Varices: upper endoscopy in ___ which showed 2 cords of grade
___ varices in the esophagus as well as varices in the fundus.
-Depression
Social History:
___
Family History:
Father: heart disease Mother: heart disease s/p CABG. Denies
family history of gastrointestinal or renal problems
Physical Exam:
On Admission:
Vitals: T:98.9 BP:99/60 P:92 R: 18 O2:92% 2LNC
General: Middle aged female alert, oriented, appearing
uncomfortable though in no acute distress
HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, S1 + loud S2, loud systolic murumr
over right upper sternal border.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, diffusely tender with rebound
Ext: warm, well perfused, 2+ pulses, no edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait deferred
Discharge PE:
Vitals: Tc- 98.5, HR 60-70s, BP 90-100s/40-50s, RR 18, 93-98% RA
I/O: 250(PO) + 1548(IV) / 1850 + 4BM
General: pleasant woman, A&Ox3, lying in bed, in NAD
HEENT: Sclera anicteric. MMM.
CARDIAC: RRR, no murmurs
LUNGS: bibasilar rales with inspiratory rales up to the mid
thorax on the R, otherwise clear
CHEST: dressing over R ___ removal site, nontender; L-sided
tunnel line without surrounding erythema, mild tenderness
ABDOMEN: Distended, soft, diffuse mild tenderness to palpation.
+BS.
EXTREMITIES: Trace ___ edema. Warm and well perfused.
NEURO: no asterixis
Pertinent Results:
Admission Labs:
======================
___ 03:29PM BLOOD WBC-5.4# RBC-3.81* Hgb-11.4* Hct-34.1*
MCV-90 MCH-29.8 MCHC-33.3 RDW-16.7* Plt Ct-26*#
___ 03:29PM BLOOD Neuts-90.1* Lymphs-5.9* Monos-3.9 Eos-0
Baso-0.1
___ 07:38PM BLOOD ___ PTT-53.5* ___
___ 03:29PM BLOOD Glucose-90 UreaN-17 Creat-0.9 Na-132*
K-3.4 Cl-105 HCO3-20* AnGap-10
___ 03:29PM BLOOD ALT-36 AST-50* AlkPhos-146* TotBili-3.3*
___ 05:18AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.8
___ 03:29PM BLOOD Albumin-3.0*
CT Abd/pelvis ___:
1. Subtle enhancement of the peritoneal surfaces, raising
concern for
peritonitis in the appropriate clinical setting.
2. Cirrhosis, with recanalization of the umbilical vein and
numerous varices
with ascites consistent with portal hypertension.
3. Unremarkable gallbladder, with note again made of a stone
adjacent to the
gallbladder wall.
RUQ U/S ___:
1. Patent portal vein.
2. Evidence of cirrhosis and small volume ascites.
3. Mild circumferential gallbladder wall thickening, likely
secondary to
third spacing.
4. Massive splenomegaly.
Micro:
bl cx: NGTD
R ___ catheter culture: WOUND CULTURE (Final ___:
No significant growth.
URINE CULTURE (Final ___: NO GROWTH.
Discharge Labs:
======================
___ 08:05AM BLOOD WBC-1.5* RBC-3.41* Hgb-9.9* Hct-30.6*
MCV-90 MCH-29.0 MCHC-32.3 RDW-18.0* Plt Ct-48*
___ 08:05AM BLOOD ___
___ 08:05AM BLOOD Glucose-79 UreaN-13 Creat-1.0 Na-137
K-3.5 Cl-104 HCO3-24 AnGap-13
___ 08:05AM BLOOD ALT-24 AST-37 AlkPhos-105 TotBili-2.6*
___ 08:05AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.1
Brief Hospital Course:
Ms. ___ is a ___ with primary biliary cirrhosis (c/b
portal pulmonary hypertension, ascites and esophageal varices)
who presented with diffuse abdominal pain.
# SBP: Exam initially showing rebound and significant
tenderness, thought to be SBP given her history of cirrhosis and
ascites. There was no evidence of secondary peritonitis seen on
CT abdomen. Lipase was normal. Gall bladder stone is seen on CT,
which could potentially explain RUQ pain but not the diffuse
abdominal pain picture. Tbili decreased, as was Alk phos. All
LFTs decreased but Tbili started to uptrend. No ascites fluid
pocket was seen on U/S, so she was treated empirically with
ceftriaxone and albumin 1.5mg/kg. Fluid resuscitation. Portal
Vein patent. Drug rash ___ with Ceftriaxone, so switched to
therapeutic PO Cipro. Started cipro ppx ___. S/p albumin,
received on days 1 and 3. Restarted diuretics and uptitrated
spironolactone back to home dose of 50 BID. Pt slightly volume
up from MICU stay, so initially diuresed with IV lasix, and
transitioned to PO home lasix of 20 QD. Tramadol for pain
management per patient preference. Abdominal pain improved with
intermittent abdominal pain throughout the hospital stay, which
was controlled with tramadol. Bl cx NGTD.
# ___ with drainage, concern for pocket infection: Nurse
reported drainage from ___ starting ___. Nurses
intermittently reporting purulent drainage from around line.
Skin pink just adjacent to line insertion site; nontender, no
spread of erythema. Concern for tunnel infection. ___ nurse
evaluated and recommended line removal for concern of tunnel
infection. R ___ pulled ___. Remodulin run temporarily
through peripheral line. New tunneled line placed on L by ___
___. R catheter tip sent for culture, which was negative. Pt
put on Vanc ___ for tunnel infection, which was transitioned to
PO doxy + amoxicillin ___. Pt remained afebrile. No
leukocytosis. Bl cx NGTD. Plan for 5d course of ABX total to end
___.
# Primary Biliary Cirrhosis: MELD 17 on adm from 13. Followed by
Dr ___ with plans to place on transplant list once pulmonary
artery hypertension under better control. Home regimen of
ursodiol and nadalol continued. No EGD since ___, will need
one as outpatient.
# Hypotension: BP 80/50s on ___ after remodulin infusion
uptitrated (plan was for biweekly dose uptitration managed by pt
to get to goal drop in pulm pressures in hopes for liver
transplant and this plan confirmed with Dr. ___. Albumin
challenge without much response. Pt asymptomatic. Not much
changed from prior baseline of 90-100s/50-60s, but BPs improved
back to baseline by time of discharge.
# Portal Pulmonary Hypertension: Her repeat right heart cath
___ while on Treprostinil showed PASP 45 mmHg (previously 52
mmHg.) Dr. ___ has stated that his target PASP < 40 mmHG to
reactivate the transplant evaluation. The plan is for her to
gradually increase the dose of Treprostinil. On ___
Treprostinil was increased from 106 to 109 nanograms/kg/minute
as was previously planned and on ___ dose was increased to
111.5, also as planned. Repeat RHC scheduled for ___.
# Acute Kidney Injury: Cr 0.9 from 0.6, likely from volume
depletion as she was also hyponatremic and mildly acidotic with
HCO3 20. Improved with albumin. Diuretics restarted.
# Thrombocytopenia: Likely related to chronic liver disease.
Platelets have ranged ___ in the last 90 days. Trended daily
and remained stable.
Transitional Issues:
- close f/u with Dr. ___. Will need EGD since ___
since last.
- Pt to f/u for repeat RHC in ___. Pt instructed to f/u
with Dr. ___ as previously planned.
- Team recommended against travel until f/u with Dr. ___
pt asked about travel to visit family in ___.
- Pt discharged on SBP ppx with daily cipro.
- Pt discharged with 2 additional days of doxy + amoxicillin for
tunnel infection from R-sided ___.
- Pt with rash after ceftriaxone, so allergies updated.
- labs pending at time of discharge: Bl cultures pending (NGTD
at time of discharge).
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Nadolol 10 mg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Spironolactone 50 mg PO BID
4. Potassium Chloride 15 mEq PO BID Duration: 24 Hours
5. Treprostinil Sodium 109 nanograms/kg/minute IV DRIP INFUSION
(increased from 106.5 on ___
6. Ursodiol 600 mg PO BID
7. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. Nadolol 10 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Potassium Chloride 15 mEq PO BID Duration: 24 Hours
5. Spironolactone 50 mg PO BID
6. Treprostinil Sodium 111.5 nanograms/kg/minute IV DRIP
INFUSION
7. Ursodiol 600 mg PO BID
8. Ciprofloxacin HCl 500 mg PO/NG Q24H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. Lactulose 30 mL PO Q8H:PRN constipation
Titrate to 3 bowel movements daily.
RX *lactulose 10 gram/15 mL (15 mL) 30 mL(s) by mouth every 8
hours Disp #*1 Liter Refills:*0
10. Amoxicillin 500 mg PO Q12H
last day ___
RX *amoxicillin 500 mg 1 tablet(s) by mouth every 12 hours Disp
#*4 Tablet Refills:*0
11. Doxycycline Hyclate 100 mg PO Q12H
last day ___
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every 12
hours Disp #*4 Tablet Refills:*0
12. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
hold for sedation or RR<12
RX *tramadol 50 mg 1 tablet(s) by mouth every 4 hours Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary diagnosis:
Spontaneous bacterial peritonitis
Secondary diagnosis:
Primary biliary cirrhosis with portal pulmonary hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you in the hospital. You were
admitted with abdominal pain. We were unable to remove fluid
from your belly to test for infection, so we treated you for a
presumed infection. You did well with antibiotics and felt even
better after we gave you pain medications and you had reular
bowel movements.
You started to drain pus from around your tunneled line, which
was concerning for an infection in the tunnel. We had the line
on the right removed and you had a new line placed on the left
for your Remodulin infusion.
Please follow-up at the appointments listed below. Please make
an appointment to follow-up with Dr. ___ as planned (___).
Please see the attached list for changes to your medications.
You will complete a course of antibiotics for your soft tissue
infection from the ___ line on the right. These antibiotics
will finish on ___. You will also start an antibiotic called
ciprofloxacin which will help to prevent infections in your
belly in the future; you will take ciprofloxacin long-term.
Followup Instructions:
___
|
10790116-DS-6
| 10,790,116 | 28,616,086 |
DS
| 6 |
2127-11-26 00:00:00
|
2127-11-30 16:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
Intubation, mechanical ventilation.
History of Present Illness:
___ with PMH of COPD/ hypoxemic respiratory failure requiring
intubation (___) and EtOH abuse who presents with acute
hypoxemic respiratory failure. Per report, patient decompensated
at home with SOB and cough. Both him and his wife had a
viral-like illness early in the week with muscle aches/pains,
chills. Patient did not get a flu shot this year. His breathing
worsened throughout the week and would be more labored with
little to no activity. He also became more somnolent as the week
went on and would often fall asleep at his desk. On the night of
admission, his ex-wife found him to be in respiratory distress
and called EMS. His ex-wife also noted that his lower
extremities seemed more swollen. EMS started pt on BIPAP and
brought him to ___. Sats were in the ___ on arrival.
In the ED, initial vs were: ___, 46, 82% cpap. Pt was
intubated in the ED and started on ventilator. Intubation was
difficult and pt was thought to be autoPEEP-ing on ventilator.
Gas was 7.19/70/179/28. Given multiple doses of MDIs and
methylprednisolone 125mcg x1. Blood pressures were high on
arrival. CXR showed bibasilar infiltrates. VBG has a lactate of
2.8. He was given azthromycin and vancomycin. Propofol was
started for sedation. Blood pressure then dropped to 76/48.
Central line was placed and patient was started on levophed.
Given 3.5L IVF. Sedation was switched to midazolam and fentanyl.
Vitals prior to transfer were 100.2, 105, 102/56, 14, 100%
Intubation.
In the ICU, the patient was noted to be volume overloaded, and
echo revealed a depressed EF with global hypokinesis. The
patient was also febrile and CXR revealed evidence of a
pneumonia. He was treated with an 8 day course of antibiotics
for community acquired pneumonia, and a 5 day burst of
prednisone for a COPD exacerbation. He was extubated on ___. His
post-extubation course was complicated by delirium. He was
called out to the floor on ___, but was found to be somnolent
and hypercarbic, so he returned to the ICU.
Over his last 24 hours in the ICU, the patient was diuresed with
40 mg IV lasix x 2. He was negative 1800 cc for 24 hours. His
bicarbonate slowly trended down without further intervention. He
remained delirious, but otherwise had no ICU needs.
On transfer to the floor, the patient was alert, but quite
disoriented. He was able to say that he does not have pain, but
is otherwise nonsensical in his response to questions
(discussing splitting hotel costs in ___).
Past Medical History:
Alcoholism since ___, Denies withdrawal history, denies history
of seizures/ DTs
COPD
Hypertension
DM
CHF (EF 35%)
Social History:
___
Family History:
Mother: ___ Coronary artery disease
Father: ___
Physical ___:
Admission:
Vitals: 107/60, 95, 96% on CMV
General: intubated, sedated.
HEENT: Sclera anicteric, ETT in place
Neck: thick, JVP not visualized
Lungs: Mechanical breath sounds throughout. Crackles at the
bases bilaterally. No wheezes.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Obese, tense. Non-tender, hypoactive bowel sounds
present, no rebound tenderness or guarding
GU: +foley draining cloudy yellow urine
Ext: warm, well perfused, 1+ pulses. 1+ edema to knees
bilaterally. No clubbing or cyanosis. All extremities with
spontaneous movement with the exception of the left. No Babinski
on the LLE, does not withdrawal to pain on the LLE.
Discharge:
GENERAL: alert, calm, following commands, in NAD
HEENT: EOMI, anicteric sclera, moist mucous membranes
NECK: JVP not elevated
CARDIAC: RRR, ___ systolic murmur; no gallops or rubs
LUNG: scattered wheezes in all lung fields. Diffuse rhonchi b/l
unchanged from ytdy.
ABDOMEN: obese, distended but soft, +BS, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: wwp, trace LLE edema
NEURO: AOx3, able to say wks & months backwardsble to give name,
CN ___ grossly intact. No asterixis.
Pertinent Results:
ADMISSION LABS:
___ 02:03AM BLOOD WBC-12.9* RBC-5.00 Hgb-16.3 Hct-50.1
MCV-100* MCH-32.6* MCHC-32.6 RDW-15.6* Plt ___
___ 06:05AM BLOOD Neuts-91* Bands-1 Lymphs-2* Monos-5 Eos-1
Baso-0 ___ Myelos-0 NRBC-2*
___ 06:05AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-2+ Microcy-NORMAL Polychr-1+
___ 02:03AM BLOOD ___ PTT-28.9 ___
___ 06:05AM BLOOD Glucose-199* UreaN-8 Creat-1.0 Na-120*
K-5.2* Cl-92* HCO3-22 AnGap-11
___ 06:05AM BLOOD ALT-16 AST-51* LD(LDH)-252* AlkPhos-98
TotBili-0.8
___ 12:31PM BLOOD CK-MB-9 cTropnT-<0.01
___ 06:05AM BLOOD Albumin-2.9* Calcium-7.1* Phos-2.8 Mg-1.7
___ 03:48AM BLOOD Type-ART Tidal V-450 PEEP-14 FiO2-100
pO2-179* pCO2-70* pH-7.19* calTCO2-28 Base XS--2 AADO2-459 REQ
O2-79 Intubat-INTUBATED
DISCHARGE LABS:
___ 06:35AM BLOOD WBC-8.0 RBC-4.87 Hgb-15.4 Hct-48.4
MCV-99* MCH-31.6 MCHC-31.8 RDW-14.7 Plt ___
___ 06:35AM BLOOD Neuts-73* Bands-0 ___ Monos-5 Eos-1
Baso-0 ___ Myelos-0
___ 07:10AM BLOOD UreaN-15 Creat-0.9 Na-139 K-3.5 Cl-97
HCO3-30 AnGap-16
___ 04:18AM BLOOD ALT-36 AST-54* AlkPhos-102 TotBili-0.5
___ 07:10AM BLOOD Mg-1.7
___ 06:35AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.2
___ 03:55PM BLOOD VitB12-1580*
___ 06:05AM BLOOD Triglyc-132 HDL-53 CHOL/HD-3.2 LDLcalc-89
IMAGING:
___ 12:03 ___ CHEST (PA & LAT)
Cardiomegaly is severe. Mediastinal contours are unchanged,
dilated. There is upper zone redistribution, mild, but no overt
pulmonary edema. Left mid lung opacity is concerning for
infectious process. There is also evidence of bilateral pleural
effusions.
___ 3:39 AM CHEST (PORTABLE AP)
As compared to the prior study obtained on ___ at 7:28
p.m., current study demonstrates interval improvement of
pulmonary edema with only mild vascular engorgement present.
Cardiomegaly and most likely bilateral pleural effusions are
noted. No pneumothorax is seen.
___ CXR:
FINDINGS: Support and monitoring devices are unchanged in
position, and
cardiomediastinal contours are stable. Interval slight
improvement in the extent of pulmonary edema, but similar
pleural effusions, moderate on the left and small on the right.
___
FINDINGS: Endotracheal tube remains in standard position.
Although nasogastric tube terminates in the stomach, the side
port is above the GE
junction level, as communicated by phone to Dr. ___ at 1:15
p.m. on ___ at the time of discovery. Cardiomegaly is
accompanied by improved interstitial edema and resolving
asymmetrical left perihilar opacity which is probably due to
asymmetrical edema. Moderate left pleural effusion and adjacent
left lower lobe atelectasis or consolidation are unchanged.
Worsening opacity at right lung base may reflect dependent edema
accompanied by atelectasis and effusion.
___ CHEST (PORTABLE AP)
FINDINGS: Interval removal of right internal jugular vascular
catheter with no pneumothorax. Stable cardiomegaly with
pulmonary vascular congestion accompanied by worsening
asymmetrical airspace opacity in the left juxtahilar region.
This could reflect asymmetrical edema, but secondary process
such as aspiration or infection is also possible. Persistent
left lower lobe atelectasis with adjacent moderate left pleural
effusion, and unchanged small right pleural effusion.
___ CHEST (PORTABLE AP)
FINDINGS: As compared to the recent study, there has been
slight improvement in the extent of pulmonary edema and improved
aeration at the right lung base. Otherwise, no relevant short
interval change.
___ CXR:
IMPRESSION:
1. Mild cardiomegaly with mild-to-moderate pulmonary edema.
2. Confluent right lower lung opacities may represent edema or
pneumonia.
3. Endotracheal tube is in satisfactory position
___ ECHO:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed (LVEF = 35 %) secondary to hypokinesis of the
interventricular septum, anterior free wall, and apex. The basal
inferior and posterior walls are also hypokinetic. The right
ventricular free wall thickness is normal. The right ventricular
cavity is dilated with depressed free wall contractility. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is a small pericardial effusion. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. There is an anterior space which most
likely represents a prominent fat pad. There are no
echocardiographic signs of tamponade.
Brief Hospital Course:
Mr. ___ is a ___ y/o male with a history of hypertension,
chronic obstructive pulmonary disease, probable alcoholic
cirrhosis, and alcohol abuse/dependence admitted with pneumonia
and hypoxemic respiratory failure.
# Hypoxemic Respiratory Failure: Likely caused by COPD
exacerbation, pneumonia, and CHF exacerbation. Differential
included PNA (bacterial vs aspiration) as CXR showed bibasliar
opacities and has fever to 102. He was treated with a 5 day
course of azithromycin and 7 day course of ceftriaxone.
Additionally, he was treated with a 5 day course of prednisone.
His respiratory status improved and he passed an SBT and was
extubated. He initially was called to the floor on ___ but then
returned to the MICU due to staff concern about patient being
tachypneic. On return, a CXR showed bilateral pulmonary edema,
and he was diuresed with Lasix. He was transferred to the floor
___ satting 93% on 3L oxygen. Over the course of the week he
was slowly weaned off his oxygen as he continued to be diuresed.
By time of discharge he was satting 93% on RA sitting and down
to 89% on RA while walking.
# Congestive heart failure: Per ex-wife, pt has history of CHF
but does not take medication as an outpatient and is
noncompliant with diet. Echo confirmed global cardiac
dysfunction and dilation with an EF of 35%. Etiology not
elucidated on this admission, but probably secondary to
long-term alcoholism although CAD was not ruled out. Admission
weight was 118.3 kgs. He was started on a medication regimen for
heart failure which included BB, ACEi and diuretic, as well as
ASA/statin for presumed CAD tx. Discharge dry weight was 98.6
kgs. Will need f/u w cardiology as an outpatient for
consideration of cardiac catheterization and ongoing management
of congestive heart failure.
# Community acquired pneumonia: Patient has fever to 102 and CXR
which showed bibasilar infiltrates with right hilar fullness/
consolidation. Given azithromycin and vancomycin in ED. He was
treated with a 5 day course of azithromycin and 7 day course of
ceftriaxone. Pt remained afebrile and asymptomatic while
admitted to the floor.
#Toxic metabolic encephalopathy: ___ hospital course
significantly prolonged due to continued delirium s/p
extubation. Pt treated with standing nightly haloperidol 2.5 mg
with 1 mg PO TID for agitation per psychiatry recs. By the time
of discharge patient was no longer delirious, but per ex-wife
report, not quite to baseline with impulsivity. Patient was
counseled on the importance of continuing his medical care and
abstaining from alcohol.
# EtOH abuse: No confirmed history of withdrawal seizures.
Ex-wife states that he has not had any days where he has not
drank EtOH and thus has never withdrawn. He was placed on a
phenobarbital taper to prevent withdrawal seizures. He was given
thiamine and folate to support his nutritional status.
# Cirrhosis: Noted to have cirrhotic liver on last
hospitalization. Unknown if pt has varices or portal
gastropathy. Not known to liver service at ___. LFTs trended
throughout the hospitalization and never uptrended, INR remained
wnl.
# Chronic COPD: Treated for COPD exacerbation during this
admission, given hypercarbia. Now without evidence of
exacerbation, lungs clear. Pt responded well to standing
albuterol and ipratropium nebs. Discharged on appropriate COPD
regimen.
# DM: Takes oral hypoglycemics as an outpatient. Was placed on
insulin sliding scale while hospitalized, but rarely required
insulin.
#Deconditioning. ___ able to walk w/walker after prolonged
hospital course. ___ recommended rehab, but patient without
insurance and wanted to go home. Discharged to home.
#Social/Insurance: Pt is self-pay, self-employed but no insured.
Has elected to not obtain insurance and due to this, was not
eligible for rehab or home services, including home O2 should he
need it. He was instructed to obtain health insurance as soon
as possible as his cardiac workup will be costly (this is part
of the reason cardiac consultation for consideration of
catheterization was deferred this admission).
TRANSITIONAL ISSUES:
--------------------
* requires cardiac workup for new onset congestive heart failure
* social work for etoh abuse
* discharged on CAD/CHF/COPD regimen
* must obtain insurance for further workup and medical care
requirements
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. FoLIC Acid 1 mg PO DAILY
3. Vitamin B Complex 1 CAP PO DAILY
4. Cyanocobalamin 1000 mcg PO Q1MO
5. Jentadueto (linagliptin-metformin) 2.5-500 mg oral BID
6. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q4hr sob
7. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*0
2. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Fluticasone Propionate 110mcg 4 PUFF IH BID
RX *fluticasone [Flovent HFA] 220 mcg 2 puffs inhaled twice per
day Disp #*1 Inhaler Refills:*0
4. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule,extended release 24hr(s) by
mouth at night Disp #*30 Capsule Refills:*0
9. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
10. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
RX *albuterol sulfate 90 mcg ___ puffs inhaled every ___ hours
Disp #*1 Inhaler Refills:*0
11. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
COPD exacerbation
Acute respiratory failure
Acute on chronic congestive heart failure (systolic)
Alcoholism, etoh withdrawal
Toxic metabolic encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with respiratory failure from COPD
exacerbation, heart failure and pneumonia. You were intubated
in the ICU, extubated without issue, and hospitalized for a
prolonged delirium afterwards. You have a new diagnosis of
congestive heart failure, probably from alcoholism, and you
should see a cardiologist in the future for further management.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10790131-DS-7
| 10,790,131 | 24,884,880 |
DS
| 7 |
2134-09-21 00:00:00
|
2134-09-30 22:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
leg swelling, DOE, progressive rash
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Ms. ___ is a ___ year old female with a history of PVD s/p
bilateral iliac stents, HTN, and HLD who presents with bilateral
pedal edema and progressive rash.
According to Ms. ___, she was in her usual state of health
until 2 weeks ago, when, a few hours after she awoke one
morning, she noticed that both of her ankles and feet were more
swollen than normal. The swelling disappeared each night when
she went to bed and re-appeared throughout the day. She began
sleeping with 2 pillows under her feet, because she realized
that it was helping the swelling go down. When her lower
extremities were swollen, her feet hurt. She attributed this
swelling to her "recent sedentary lifestyle" in the setting of
the ___ snowstorms. She states that she was in her house for
approximately ~1 month, without going out much. She denies any
history of CHF, MI, chest pain or diuretic use. Besides a bus
ride from ___ to ___ ___ years ago, she has
never had lower extremity swelling before.
She has also noticed increasing DOE during this time. Even
routine activities, such as making breakfast or walking up the
stairs, made her short of breath and she found herself sitting
down to catch her breath more often. She denies SOB at rest, as
well as any history of COPD, asthma or home O2. However, she is
an active smoker with a 25 pack year history, currently 5 cigs
per day.
Approximately 2 nights before admission, she noticed a rash made
up of small red dots above her right knee. Over the next 2 days,
the rash rapidly spread up her leg towards her left leg, abdomen
and trunk. She states that it has not been oozing or bleeding.
However, it is itchy at night. She also states that she has a
crusting red lesion in her right antecubital fossa that has
"come and gone for the last several years and right now it won't
seem to go away since this other rash started." She also states
that her urine has been dark yellow the past few days. She
denies any fevers, chills, nausea, vomiting, diarrhea, recent
travel, sick contacts, dysuria, hematuria or hematochezia, as
well as any history of psoriasis, lupus or any other autoimmune
diseases. No home medication changes since ___ years ago
(clopidogrel), latest new medication exposures include Fentanyl,
Versed, heparin and protamine during ___ vascular procedure,
last antibiotic use in ___ (amoxicillin), no NSAIDs
or tylenol. She states that she has been fully vaccinated.
Because the swelling and pain in her lower extremities had
persisted and her rash had continued to spread on her torso, she
had her sister (health care proxy, ___ drive her
into the ___ ED.
- Initial vitals in the ED: 0 98.2 99 94/59 20 100%
- Exam notable for: 4+ pitting edema to feet b/l, diffuse
morbilliform rash from dorsum feet to abdomen/back
- Pertinent labs: Na 125, Cl 84, 11.6(80.8%N)>10.9/32.4<263, ALT
157/AST 324, AP 750, albumin 2.4, Cr 0.5.
- Studies/imaging: RUQ U/S
- Patient given: Diphenhydramine 50mg PO
- Vitals on transfer: 0 98.4 87 95/66 13 100% RA
On the floor, Ms. ___ feels "fine" and states that she is
doing well. She wants to figure out what has been happening with
her swelling and rash. Besides her rash, swelling, and DOE, she
has no other complaints at this time.
Past Medical History:
PAST MEDICAL HISTORY:
- PVD s/p bilateral iliac stents and RLE angioplasty
- HTN
- HLD
- Benign uterine mass s/p hysterectomy
- Prior anemia and thrombocytosis worked up by heme/onc here:
neg Jak2 workup and recommended annual CBC
- EtOH abuse: 6 pack/day for ___ years until ___, since then, "3
wine drinks on holidays", no known history of withdrawal or
seizures, hx of alcoholism in father, brothers x2, and sister
PAST SURGICAL HISTORY:
- Right lower extremity angioplasty: ___
- Left external iliac stent: ___
- Right external iliac stent: ___
- Hysterectomy for benign uterine mass: ___
- C-section x 2: ___
Social History:
___
Family History:
- Mother: ___ at age ___, HTN
- Father: HTN, alive at ___
- Sister: HTN
- Sister: Died of lung cancer at age ___, smoker
- PGM: died breast cancer
- MGM: died lung cancer
- MGF: MI, PAD
- Alcoholism: father, brothers x2, sister
- ___ any history of pulmonary embolism, lupus, rheumatoid
arthritis, scleroderma or other autoimmune diseases. No history
of a similar rash or liver disease in the family.
Physical Exam:
=========================
ADMISSION PHYSICAL EXAM:
=========================
Vitals: 98.0 97/64 89 ___ 100RA
Weight: 56.5kg
General: Middle-aged woman reclined in bed, comfortable, NAD,
alert and oriented
HEENT: Sclera anicteric, MMM, oropharynx clear, no signs of rash
Neck: supple, JVP not elevated
Lungs: CTAB, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, soft II/XI harsh
systolic murmur at the right sternal border and right clavicle,
rubs, gallops
Abdomen: soft, non-tender, non-distended, +BS, no rebound
tenderness or guarding, no organomegaly, small 1-2cm round mass
noted on lower right back
Ext: Warm, well perfused, ___ pulses not palpable or dopplerable,
no clubbing or cyanosis, ___ pitting edema to the calves, heels
of her feet feel loose and malleable
Skin: impressive morbilliform rash with excoriations spanning
the lower extremities, abdomen, back, and bilateral axilla,
pronounced above the right knee, in the periumbilical area, and
on the left dorsum of her foot, crusting plaque-like rash on
right antecubital fossa
Neuro: CNII-XII intact, speech fluent and intact, moving all 4
extremities with purpose, sensation intact in hands and ankles
=========================
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: 97.9 92/49 89 ___ 95RA
Weight: Pending
Is/Os: - / 500
Is/Os yest: ___ PO 1000 IVF / 2380 void
General: Middle-aged woman reclined in bed, comfortable, NAD,
alert and oriented
HEENT: Sclera anicteric, MMM, oropharynx clear, no signs of rash
Neck: supple, JVP not elevated
Lungs: CTAB, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, II/XI harsh
systolic murmur at the right sternal border and right clavicle,
no rubs or gallops
Abdomen: soft, non-tender, non-distended, +BS, no rebound
tenderness or guarding, no organomegaly, small 1-2cm round mass
noted on lower right back
Ext: Warm, well perfused, no clubbing or cyanosis, ___ pitting
edema to the calves, heels of her feet feel loose and malleable
Skin: extensive maculopapular rash, now lighter than on previous
exams, spanning the lower extremities, abdomen, back, and
bilateral axilla, with some light scaling across the abdomen,
crusting plaque-like rash on right antecubital fossa
Neuro: speech fluent and intact, moving all 4 extremities with
purpose, sensation intact in hands and ankles
Pertinent Results:
===========================
ADMISSION LABS:
===========================
___ 12:10PM BLOOD WBC-11.6* RBC-3.16* Hgb-10.9* Hct-32.4*
MCV-103*# MCH-34.7* MCHC-33.7 RDW-16.1* Plt ___
___ 12:10PM BLOOD Neuts-80.8* Lymphs-13.7* Monos-3.2
Eos-2.1 Baso-0.1
___ 12:44PM BLOOD ___ PTT-28.2 ___
___ 12:10PM BLOOD Plt ___
___ 08:35AM BLOOD Ret Aut-3.8*
___ 12:10PM BLOOD Glucose-117* UreaN-9 Creat-0.5 Na-125*
K-3.4 Cl-84* HCO3-30 AnGap-14
___ 12:10PM BLOOD Albumin-2.4*
___ 08:35AM BLOOD Albumin-2.3* Calcium-7.9* Phos-2.8 Mg-1.7
Iron-95
___ 12:10PM BLOOD Ferritn-985*
___ 12:10PM BLOOD Osmolal-263*
============================
DISCHARGE LABS:
============================
___ 08:09AM BLOOD WBC-7.7 RBC-2.83* Hgb-10.1* Hct-29.6*
MCV-105* MCH-35.6* MCHC-34.1 RDW-16.0* Plt ___
___ 08:09AM BLOOD Plt ___
___ 08:09AM BLOOD ___
___ 08:09AM BLOOD Glucose-87 UreaN-1* Creat-0.4 Na-133
K-3.3 Cl-96 HCO3-29 AnGap-11
___ 08:09AM BLOOD ALT-117* AST-223* LD(LDH)-364*
AlkPhos-553* TotBili-1.4
___ 12:10PM BLOOD proBNP-65
___ 08:09AM BLOOD Albumin-2.2* Calcium-7.8* Phos-2.1*
Mg-1.5*
___ 08:35AM BLOOD calTIBC-99* VitB12-GREATER TH Folate-17.7
___ Ferritn-1039* TRF-76*
___ 12:10PM BLOOD Osmolal-263*
___ 08:35AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HAV-NEGATIVE
___ 12:10PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 08:35AM BLOOD HCV Ab-NEGATIVE
___ 08:35AM BLOOD HERPES 6 DNA PCR, QUANTITATIVE-PND
___ 08:35AM BLOOD ADENOVIRUS PCR-PND
=================
STUDIES/IMAGING:
=================
___ CXR:
IMPRESSION: No acute intrathoracic abnormality
___ RUQ U/S
IMPRESSION:
1. Diffusely echogenic liver suggestive of fatty infiltration.
However, other forms of liver disease including hepatic
fibrosis/ cirrhosis cannot be sonographically excluded.
2. 1 cm simple hepatic cyst. No other are concerning hepatic
lesions
identified.
3. Several layering gallstones. The gallbladder is slightly
enlarged measuring up to 6 cm in transverse diameter, but does
not appear distended and is without other signs of cholecystitis
such as gallbladder wall edema or pericholecystic fluid. CBD
measures 4 mm.
___ EKG: sinus ___ with non-specific t wave changes in
lower leads
Brief Hospital Course:
___ with a history of EtOH abuse, PVD s/p b/l iliac stents, HTN
and HLD who presented from home after 2 weeks of bilateral pedal
edema and ___ days of diffuse rash.
==============
Acute issues:
==============
# Transaminitis: Likely alcoholic cirrhosis. Patient reported a
significant alcohol history (6 beers a day for ___ years). There
was initially concern for drug toxicity/DRESS given concurrent
rash (see below). Hepatitis A/B/C and CMV studies were negative.
EBV, HHV6, and adenovirus were also sent and negative (positive
EBV IgG, negative IgM). She was advised to avoid all further
alcohol and to also limit Tylenol. She was also instructed to
follow up with hepatology. She verbalized understanding of and
agreement with these recommendations.
# Hypotension: Blood pressures remained in ___ systolic,
likely due to underlying cirrhosis. Home amlodipine and
lisinopril were stopped.
# Xerotic eczema: Initially concern for drug toxicity or DRESS
given transaminitis. However, she had no eosinophilia. She was
evaluated by dermatology. They felt that her rash was consistent
with xerotic eczema in the setting of discontinuing her
moisturizer, with stasis dermatitis in lower extremities. She
was advised to avoid hot showers and was started on aquaphor
BID, and triamcinolone 0.1% prn with significant improvement in
her rash.
# Hyponatremia: Likely to underlying liver disease. Urine Na+
was < 10. She was initially diuresed with 10mg IV lasix, but due
to worsening hypotension with SBP in ___, she was bolused with
NS with resolution of hyponatremia.
# Macrocytic anemia: H/H 10.9/32.4 on admission. Likely
secondary to alcohol and liver disease, and/or reticulocytosis.
Ferritin 1039, transferrin 76, TIBC 99, consistent with acute
phase response. B12/folate were within normal limits.
Reticulocyte count 3.8 (3.0 corrected, RPI 2.0), indicative of a
hyperproliferative anemia. LD was elevated in the setting of
transaminitis, but since haptoglobin and bilirubin were normal
there was low suspicion for hemolysis. She had no acute episodes
of bleeding noted. She may require a colonoscopy as an
outpatient to evaluate for blood loss if anemia continues to
worsen.
# DOE: 25 pack year smoker not on home O2. Given clear lungs and
lack of JVD, there low suspicion for cardiogenic etiology. ECHO
___ LVEF > 55% without evidence of AS, AR, MR. ___ not
endorsing SOB at rest and DOE appeared to resolve without
intervention.
==================
Chronic issues:
==================
# PVD s/p bilateral iliac stents: Followed by Dr. ___.
Continued home clopidogrel 75mg PO and aspirin 81mg PO daily
# HTN: SBPs usually runs 130s/80s per pt. Held home amlodipine
and lisinopril in setting of recent hypotension
# HLD: Continued home atorvastatin 10mg PO daily
# CODE: Full (confirmed)
# CONTACT: Sister, ___ ___
======================
Transitional issues:
======================
- needs follow up in liver clinic (scheduled for ___
- amlodipine and lisinopril stopped due to hypotension
- has a rash consistent with eczema. Advised to moisturize twice
a day and to avoid steroids. Also discharged with triamcinolone
cream. ___ need outpatient dermatology if failing to improve
- noted to have systolic murmur on exam. Would consider repeat
echo
- would consider colonoscopy to evaluate for blood loss
- advised to avoid all alcohol
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN pruritus
RX *triamcinolone acetonide 0.1 % Apply to rash three times a
day Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Elevated LFTs, rash
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came in because you had a rash and swelling. While you were
in the emergency department they found that some of your liver
tests were not normal. This is probably why you developed the
swelling.
We have scheduled you an appointment to follow up with the
hepatologists (liver doctors). You should also avoid all alcohol
in order to prevent more damage to your liver. You should also
avoid tylenol, and if you do take it should make sure not to
take more than 2g a day.
The dermatologists think your rash is from eczema. You should
avoid hot showers, and you apply moisturizer at least twice a
day. We are also discharging you with a cream you can use for
itching.
It was a pleasure taking care of you, and we are happy you are
feeling better!
Followup Instructions:
___
|
10790860-DS-10
| 10,790,860 | 29,525,186 |
DS
| 10 |
2201-06-28 00:00:00
|
2201-06-28 23:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with h/o PMH significant for CAD (s/p PCI and stent in
___, atrial fibrillation (on coumadin), hypertension,
diastolic CHF (EF 55% on echo ___, and recent MICU
admission (___) with hypoxemic respiratory failure
requiring intubation, peg, and trach ___ CHF/ARDS/MRSA HCAP
complicated by septic shock, now presenting to the ED with
complaints of dyspnea with exertion and at rest and orthopnea
uanble to lay flat. He endorses a possible weight loss over the
last month or so do to eating pureed foods only and also
endorses swelling in his legs that is unchanged from baseline
and resolves with elevation of his legs. His weight on discharge
from last admission in ___ was 88 kg. He does endorse a chronic
cough with sputum production that he believes has been present
for months and is relatively unchanged. He endorses transient
chest pain 2 days ago that spread diffusely across his chest
that he attributes to new ___ he has been doing. Denies any
radiation of the pain and currently denies chest pain. He denies
fevers, chills, or med noncompliance. Per ED records, he stated
that he would want intubation if needed. He was being treated
for PNA with levofloxacin at his rehab facility, and had been
discharged with PICC and ___ to complete a 14-day course
for HCAP on ___.
In the ED, initial vitals were: 97.7 80 104/58 26 97% 10L NRB.
The patient was then placed on BIPAP for 2 hours and able to
tolerate 3L NC though continued to be tachypneic to the ___'___.
Exam/labs were notable for: bibasilar crackles, JVD, WBC 16.9
(though questionably elevated since ___, Trop of 0.07, and BNP
12212. Imaging showed opacities consistent with pulmonary edema
vs pneumonia. The patient was given one dose of cefepime and
vancomycin for HCAP as well as 40 mg IV lasix for CHF with
little response and given an additional 80 mg IV lasix prior to
transfer to the CCU team.
In addition blood cultures were drawn and foley placed. He
denied worsening dyspnea and was oxygenating adequately, but
continued to have a RR 30. He was transfered to the CCU team for
ongoing respiratory distress in the setting of known diastolic
CHF (EF 55%).
On transfer, vitals were: Temp 98.5 HR 61 BP 107/68 RR 38 96% 3L
On arrival to the CCU, afebrile BP: 128/53 P:80 R:30 O2: 91% 3L
NC
Denies chest pain, chest pressure, or palpitations. Endorses
bilateral lower extremity weakness that is unchanged from
baseline secondary to deconditioning. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, hematoschezia, or
changes in bowel habits. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
- CAD s/p PCI to LAD in ___ (90% LAD stenosis)
- AF with h/o RVR on coumadin
- Atrial tachycardia with sick sinus syndrome status post
dual-chamber ___ pacemaker
- h/o SVTs on holter ___
- ___ Diverticulosis with LGIB s/p hemicolectomy complicated by
a
prolonged hospitalization with VAP, ARDS requiring tracheostomy,
acute renal failure with uremic encephalopathy requiring CVVH,
poor PO intake requiring PEG placement, and atrial fibrillation
with RVR, all now completely resolved
- Moderate TR on last echo (___)
- Moderate pulmonary HTN on last echo (___)
- PVD
- bilateral carotid disease (___)
- HTN
- HLD
- h/o Basal cell carcinoma s/p mohs resection
Social History:
___
Family History:
His mother passed away at the age of ___ from reported old age.
His father deceased at the age of ___ with a history of cancer
(type unknown).
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
=========================
Vitals- T: afebrile BP: 128/53 P:80 R:30 O2: 91% ___ NC
General: patient appears in NAD, no accessory muscle use though
tachypneic. Appears stated age. Non-toxic appearing.
HEENT: normocephalic, atraumatic. PERRL. EOMI. Oropharynx with
moist mucous membranes. JVP elevated (~___), trach scar on neck,
midline
CV: RRR. II/VI holosystolic murmur best heard at the ___
Chest: chest pain non-reproducible on palpation
Respiratory: Bibasilar crackles bilaterally without wheezing,
rhonchi. Diffuse crackles in upper lung fields R> L
Abdomen: soft, non-tender, non-distended with normoactive bowel
sounds, PEG in place
Extremities: R. arm with PICC in place, c/d/i
distally; 2+ distal pulses bilaterally with trace edema to the
bialteral mid-chins
Derm: skin appears intact with no significant rashes or lesions
Neuro: alert and oriented to self, place and time. Motor and
sensory function are grossly normal. Patient with ___ strenght
in lower extremities, ___ in upper extremities, left wrist
weakness (secondary to previous injury).
PHYSICAL EXAM ON DISCHARGE:
=====================
Vitals- 97.3 (98) 109/46 (100-110s/40-60) 64 (60s) 21 100% RA
I/O: ___ (24h)
General: patient appears in NAD, no accessory muscle use though
tachypneic. Appears stated age. Non-toxic appearing.
HEENT: Right ptosis (chronic). Oropharynx is dry. No JVD. Trach
scar on neck, healing well.
CV: Rate in the ___, rhythm is regular. II/VI holosystolic
murmur best heard at the ___
Lungs: Bibasilar crackles without wheezing, Left worse than
right.
Abdomen: soft, non-tender, non-distended with normoactive bowel
sounds, PEG in place
Extremities: R. arm with PICC in place, c/d/i distally; 2+
distal pulses bilaterally with trace edema to the bialteral
mid-chins
Derm: no pressure ulcers, blanchable erythema of sacrum, chronic
venous stasis of lower legs
Neuro: alert and oriented to self, place and time. Motor and
sensory function are grossly normal. Patient with ___ strenght
in lower extremities, ___ in upper extremities, left wrist
weakness (secondary to previous injury).
Pertinent Results:
LABS ON ADMISSION:
===============
___ 12:20PM BLOOD WBC-16.9* RBC-2.46* Hgb-7.3* Hct-22.7*
MCV-92 MCH-29.7 MCHC-32.2 RDW-17.0* Plt ___
___ 12:20PM BLOOD Neuts-83.3* Lymphs-9.0* Monos-6.4 Eos-1.2
Baso-0.2
___ 12:20PM BLOOD Plt ___
___ 11:46PM BLOOD ___ PTT-40.7* ___
___ 12:20PM BLOOD Glucose-126* UreaN-29* Creat-1.4* Na-132*
K-4.1 Cl-98 HCO3-25 AnGap-13
___ 12:20PM BLOOD Calcium-8.2* Phos-2.4*# Mg-1.9
INTERIM LABS:
================
___ 04:05AM BLOOD WBC-15.0* RBC-2.46* Hgb-7.0* Hct-22.3*
MCV-91 MCH-28.3 MCHC-31.2 RDW-16.9* Plt ___
___ 03:27AM BLOOD WBC-16.5* RBC-2.20* Hgb-6.0* Hct-20.0*
MCV-91 MCH-27.4 MCHC-30.1* RDW-17.2* Plt ___
___ 03:21AM BLOOD WBC-14.0* RBC-3.10* Hgb-8.9* Hct-28.0*
MCV-90 MCH-28.6 MCHC-31.7 RDW-16.6* Plt ___
___ 05:40AM BLOOD WBC-12.8* RBC-2.93* Hgb-8.8* Hct-27.4*
MCV-93 MCH-29.9 MCHC-32.0 RDW-16.6* Plt ___
___ 03:48AM BLOOD WBC-17.3* RBC-3.07* Hgb-8.7* Hct-28.5*
MCV-93 MCH-28.2 MCHC-30.4* RDW-16.8* Plt ___
___ 05:53AM BLOOD WBC-16.6* RBC-3.20* Hgb-9.5* Hct-30.0*
MCV-94 MCH-29.7 MCHC-31.7 RDW-16.8* Plt ___
___ 04:05AM BLOOD ___ PTT-39.1* ___
___ 03:27AM BLOOD ___ PTT-37.8* ___
___ 03:00PM BLOOD ___ PTT-38.9* ___
___ 03:21AM BLOOD ___ PTT-38.9* ___
___ 05:40AM BLOOD ___
___ 03:48AM BLOOD ___
___ 05:53AM BLOOD ___
___ 03:56PM BLOOD Glucose-102* UreaN-25* Creat-1.3* Na-137
K-4.5 Cl-101 HCO3-26 AnGap-15
___ 03:00PM BLOOD Glucose-105* UreaN-30* Creat-1.3* Na-139
K-3.3 Cl-97 HCO3-32 AnGap-13
___ 03:21AM BLOOD Glucose-107* UreaN-37* Creat-1.5* Na-139
K-2.9* Cl-97 HCO3-31 AnGap-14
___ 05:40AM BLOOD Glucose-179* UreaN-53* Creat-1.6* Na-144
K-4.2 Cl-106 HCO3-29 AnGap-13
___ 03:48AM BLOOD Glucose-136* UreaN-48* Creat-1.2 Na-145
K-3.7 Cl-108 HCO3-29 AnGap-12
___ 05:53AM BLOOD Glucose-170* UreaN-53* Creat-1.4* Na-148*
K-3.4 Cl-107 HCO3-32 AnGap-12
___ 03:00PM BLOOD LD(LDH)-307* TotBili-0.7
___ 03:27AM BLOOD calTIBC-159* Ferritn-823* TRF-122*
___ 07:10AM BLOOD Vanco-31.1*
___ 05:53AM BLOOD Vanco-29.6*
LABS ON DISCHARGE:
================
STUDIES:
=========
EKG (___): Baseline artifact. Sinus rhythm. Left ventricular
hypertrophy. Diffuse
ST-T wave abnormalities, most likely related to left ventricular
hypertrophy
but cannot rule out underlying myocardial ischemia. Compared to
the previous
tracing of ___ the patient is now in sinus rhythm. Lateral
ST-T wave
abnormalities are more prominent. Clinical correlation is
suggested.
CXR (___):
Interval increase in bilateral, right greater than left,
pulmonary opacities,
which given history, likely due to slight asymmetric pulmonary
edema, however,
superimposed infectious process is not excluded. Small right
pleural effusion
and possible trace left pleural effusion.
CXR (___): In comparison with the study of ___, there is
little change in the diffuse
bilateral pulmonary opacification. Although much of this may
merely reflect
severe pulmonary edema, in the appropriate clinical setting
superimposed
pneumonia would have to be considered.
CXR (___): Dual lead left-sided pacer is unchanged in
position. Right subclavian PICC
line is also unchanged in position. Stable appearance to the
lungs with a
diffuse airspace process involving the right lung and left lower
lung with
relative sparing of the left upper lung. Findings could be
consistent with
asymmetric pulmonary edema and/or multifocal pneumonia. Clinical
correlation
is advised. Left mediastinal and cardiac contours are stable.
No
pneumothorax. Probable layering bilateral effusions, right
greater than left.
TTE ___:
This study was compared to the prior study of ___.
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV
free wall hypokinesis. Abnormal septal motion/position
consistent with RV pressure/volume overload.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate (2+) MR.
___ VALVE: Normal tricuspid valve leaflets. Tricuspid
leaflets do not fully coapt. Moderate to severe [3+] TR. Severe
PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The right
ventricular cavity is moderately dilated with mild global free
wall hypokinesis. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. 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 mildly thickened. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. The tricuspid valve leaflets fail to fully coapt. Moderate
to severe [3+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Symmetric LVH with normal global and regional left
ventricular systolic function. Dilated right ventricle with mild
global systolic dysfunction. Mild aortic regurgitation. Moderate
mitral regurgitation. Moderate to severe functional tricuspid
regurgitation. Severe pulmonary hypertension.
NUTRITION:
Patient with PEG and was receiving tube feeds at
rehab. Nutrition increased feeds to meet 100% of estimated
nutrition needs. Tube feeds tolerated at goal - residuals noted.
SLP eval deferred ___ d/t decreased alertness, repeat SLP eval
planned for today. Will follow up w/ SLP eval results and adjust
nutrition recommendations prn.
RECOMMENDATIONS:
- Follow up w/ SLP eval for diet advancement
- Continue w/ tube feeds as ordered
- Residual checks q4hrs, hold feeds if greater than 200 mL
- Replete lytes prn
- Please check updated weight
MICROBIOLOGY:
===================
URINE CULTURE (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
Mr. ___ is an ___ with h/o PMH significant for CHF (LVEF>55%),
CAD, atrial fibrillation (on Coumadin), and recent ___ MICU
admission with hypoxemic respiratory failure requiring
intubation, peg/trach ___ CHF/ARDS/MRSA HCAP c/b septic shock,
who presented with dyspnea, orthopnea with continued
leukocytosis, absence of fevers, and asymmetric crackles on exam
concerning for CHF exacerbation vs. pneumonia.
#HYPOXIA. Patient with oxygen requirement of ___ NC and CXR
concerning asymmetric pulmonary edema R>L in setting of know
diastolic heart failure, concern for aspiration, and recent HCAP
infection vs poor respiratory reserve s/p ARDS. History of
weight gain, dyspnea, orthopnea, and BNP support CHF
exacerbation. Additionally, his history of recent MRSA HCAP, and
leukocytosis support PNA. Patient was sent to the CCU for
worsening dyspnea and placed on NIPPV. After aggressive
diuresis, patient's oxygen requirement subsequently decreased
and on the floor was weaned to room air with no dyspneic
symptoms.
#ACUTE DECOMPENSATED DIASTOLIC CHF (EF 55%). Etiology may be
secondary to underlying PNA. Had evidence of CHF exacerbation on
exam with evidence of diffuse crackles on exam R> L lower and
respiratory distress as above, however difficult to interpret
given poor lung parenchyma. Patient's asymmetric pulmonary edema
was also thought to be possibly be secondary to acute MR in the
setting of previously known CAD. Echo obtained showed evidence
of 2+MR. ___ was continued with Lasix bolus and gtt until
___ developed. He was then transitioned to torsemide 20 mg with
adequate diuresis and appeared euvolemic on exam with residual
bibasilar crackles.
#HCAP BACTERIAL PNEUMONIA: Patient was previously discharged on
___ in ___ to complete a 14-day course (last dose of
vanc/meropenem was ___. In addition the patient was
started on vanc and Zosyn on ___ at outside facility for
concern of increasing oxygen requirement. The patient was
continued on vanc and cefepime during hospitalization to
complete total 10 day course. Flagyl was added ___ for
better anaerobic coverage. Patient completed a 7 day course of
vanc, cefepime and Flagyl on ___.
#ANEMIA OF CHRONIC DISEASE:. Patient presented with a decreased
Hct with previous history of GI bleed. Hg/Hct trended. He had no
obvious source of bleeding (no hemoptysis, hematemesis, melena,
hematochezia with negative guaiac stools). He received 1u pRBC
on ___. Anemia work-up was notable for a decreased iron with
an increased ferritin consistent with anemia of chronic disease.
Patient's H/H continued to be stable.
#h/o ATRIAL FIBRILLATION: CHADS-Vasc = 5 (heart failure,
hypertension, age x 2, PAD). He presented in sinus rhythm with a
supratherapeutic INR. Warfarin was held but was continued on
amiodarone and metoprolol. Warfarin was restarted on ___ and
was therapeutic on discharge.
#ACUTE ON CHRONIC KIDNEY DISEASE: Baseline creatinine of 1.1 in
___ however was elevated to 1.6. BUN/creatinine ratio consistent
with pre-renal etiology in the setting of diastolic heart
failure with aggressive Lasix diuresis. Cr improved with
increased free water flushes and serum creatine came to
baseline.
# CAD: Pt with CAD s/p PCI to LAD in ___. He was continued on
ASA 81 and metoprolol.
# HLD: Last lipid panel on ___ was normal. He was continued
on atorvastatin 80.
# HTN: Was normotensive while on the floor and was continued on
metoprolol.
TRANSITIONAL ISSUES:
-Full code
-Daily weights. Discharge weight: 74.5 kg
-Patient was started on torsemide 20 from home dose of Lasix 40
mg PO BID. Please adjust per volume status.
-Patient failed video swallowing study. NPO for now. Further
management deferred to speech/swallow at rehab
-Discharge creatinine: 1.4
-Discharge H/H: 9.9/___.1. Anemia of chronic disease; will need
to monitor
-INR supratherapeutic at 3.5; decreased warfarin to 1 mg daily
on ___.
-Hypernatremia: d/c Na at 147. Continue flushes with 50cc q6h
with D5W.
-Recheck lytes, INR, and CBC on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 100 mg PO DAILY
2. Aspirin (Buffered) 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID:PRN
swab mouth
5. Cyanocobalamin 1000 mcg PO BID
6. Docusate Sodium 100 mg PO BID
7. Famotidine 20 mg PO DAILY
8. Potassium Chloride 20 mEq PO DAILY
9. Metoprolol Tartrate 37.5 mg PO QID
10. Acetaminophen 650 mg PO Q8H:PRN pain
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Acetylcysteine Inhaled For interventional pulmonary use
only ___ mL NEB Q6H
14. Ipratropium-Albuterol Neb 1 NEB NEB BID
15. Furosemide 40 mg PO BID
16. Ferrous Sulfate 325 mg PO DAILY
17. saccharomyces boulardii 250 mg oral BID
18. Vancomycin 1000 mg IV ONCE
19. Piperacillin-Tazobactam 2.25 g IV Q6H
20. Levofloxacin 750 mg PO ONCE
21. Potassium Chloride Replacement (Critical Care and Oncology)
PO Sliding Scale
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Amiodarone 100 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO BID
5. Docusate Sodium 100 mg PO BID
6. Famotidine 20 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Ipratropium-Albuterol Neb 1 NEB NEB BID
9. Metoprolol Tartrate 37.5 mg PO QID
10. Torsemide 20 mg PO DAILY
11. Aspirin (Buffered) 81 mg PO DAILY
12. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID:PRN
swab mouth
13. Ondansetron 4 mg PO Q8H:PRN nausea
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Fluticasone Propionate NASAL 2 SPRY NU DAILY
16. Warfarin 1 mg PO DAILY16
17. saccharomyces boulardii 250 mg oral BID
18. Potassium Chloride 20 mEq PO EVERY OTHER DAY Duration: 24
Hours
Hold for K > 5
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnois:
acute exacerbation of heart failure with preserved ejection
fraction
health-care associated pneumonia
Secondary Diagnosis:
atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were found to have increased fluid
in your lungs that was causing you be short of breath. You were
treated with diuretics to help remove the fluid from your lungs
and given oxygen to help you breath. Your chest x-ray also
showed an infection, for which you were treated with
antibiotics. Your oxygen requirements subseqently decreased and
are now breathing comfortably on room air.
Given that you have a weak heart (heart failure), please weight
yourself everyday. If your weight increases by 3 pounds, please
notify an MD immediately.
Please follow up with the appointments listed below.
Wishing you the best of health,
Your ___ team
Followup Instructions:
___
|
10791626-DS-4
| 10,791,626 | 27,355,488 |
DS
| 4 |
2141-11-30 00:00:00
|
2141-11-30 14:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lescol
Attending: ___.
Chief Complaint:
Delirium
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an ___ woman with hypertension,
recurrent UTIs with recent antibiotic treatment, depression,
dementia, urinary incontinence, and anemia who was brought in ED
due to increasing lethargy, confusion, decreased energy, and
decreased appetite. The patient had a recent hospitalization at
___ from ___ due to fatigue and altered mental status,
at that time found to have a UTI for which she treated with
bactrim and was discharged to assisted living facility on ___.
Per her daughter ___, the patient became more lethargic
since discharge and more confused than her baseline. This
morning, her assisted living facility called an ambulance as she
was unresponsive.
She has history of multiple recurrent UTIs, typically with
pan-sensitive E. coli in the past, her last course of
ciprofloxacin having been a week before her prior admission. She
normally does not have dysuria with UTIs but rather gets more
confused.
During her hospitalization between ___, she had an episode
of hyperactive delirium with agitation and combative behavior
for which she received IM/IV Haldol and the dose of her
Risperidone was increased from 1mg to 1.5 mg. She was discharged
on a 10 day course of bactrim as her prior urine cultures had
been urine sensitive.
At baseline the patient is often only oriented to self but able
to carry on a conversation, and is able to describe how she is
feeling. She generally is not oriented to living in ___ but
thinks that she lives in ___, where she lived previously.
At baseline she does not know year or date.
Review of systems was notable for constipation.
Denies fevers, chills. No CP, SOB, cough. No dysuria. No
diarrhea, nausea, vomiting.
A UA was positive with WBCs; The urine culture from ___
was found to grow enteroccus and she was give ceftriaxone and
normal saline. Cardiac enzymes were negative and EKG was normal.
She was hyperkalemic from a hemolyzed specimen, her lactate was
elevated at 2.2, and her creatinine was elevated from her
baseline of 1.2 but otherwise labs wnl.
Past Medical History:
Anemia
Dementia (moderate)
Depression
Anxiety
Glaucoma
Hiatal hernia
Hyperlipidemia
HTN
Recovered tobacco abuse
Urinary incontinence
Frequent UTI
S/p cataracts
Social History:
___
Family History:
Noncontributory.
Physical Exam:
Admission exam:
Vitals: T: 99.4 BP: 120/52 P:78 R:20 O2:97%
General: Alert, oriented to self only, no acute distress but
somewhat agitated
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: sleepy during interview, oriented only to self, CNs
II-XII grossly intact, sensation grossly intact throughout.
Expressed paranoia about daughter wanting to get rid of her and
thinking that her treaters were trying to give her a bacterial
infection.
Discharge exam:
Vitals: T: 98.5 BP: 148/74 P: 70 R: 20 O2: 99% on RA 97% on RA
General: Alert, oriented to self, no acute distress, tired
Skin: No rashes or lesions
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; second toe overlapping first toe on both feet (chronic)
Neuro: Pleasant affect, cooperative with interview/exam,
oriented only to self, moving all extremities symmetrically, CN
grossly intact.
Pertinent Results:
CBC:
Admission: ___ 11:30AM BLOOD WBC-5.4 RBC-5.14 Hgb-12.0
Hct-37.8 MCV-74* MCH-23.4* MCHC-31.7 RDW-16.4* Plt ___
Diff: ___ 11:30AM BLOOD Neuts-64.1 ___ Monos-7.1
Eos-3.1 Baso-0.6
Discharge: ___ 07:00AM BLOOD WBC-4.3 RBC-4.69 Hgb-10.8*
Hct-34.2* MCV-73* MCH-23.1* MCHC-31.7 RDW-16.5* Plt ___
Electrolytes:
Admission: ___ 11:30AM BLOOD Glucose-98 UreaN-15 Creat-1.5*
Na-139 K-6.9* Cl-105 HCO3-25 AnGap-16
___ 06:00AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.9
Discharge: ___ 07:00AM BLOOD Glucose-103* UreaN-13
Creat-1.2* Na-142 K-4.2 Cl-106 HCO3-25 AnGap-15
___ 07:00AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.0
Lactate: ___ 11:50AM BLOOD Lactate-2.2* K-5.6*
Urine:
___ 01:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 01:00PM URINE RBC-2 WBC-25* Bacteri-FEW Yeast-NONE
Epi-<1 TransE-<1
___: URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. ___
MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S <=2 S
NITROFURANTOIN-------- <=16 S <=16 S
TETRACYCLINE---------- =>16 R =>16 R
VANCOMYCIN------------ 1 S 2 S
___: URINE CULTURE (Final ___: <10,000
organisms/ml.
___: Blood cultures pending, NGTD
IMAGING:
CXR ___: IMPRESSION: No acute cardiopulmonary abnormality.
Moderate size hiatal hernia. Persistent widening of the
superior mediastinum could reflect mediastinal lipomatosis or an
enlarged thyroid gland. Consider further evaluation with chest
CT.
___: CT Head without contrast:
IMPRESSION:
1. No acute intracranial process.
2. Chronic small vessel ischemic disease.
Brief Hospital Course:
___ year old woman with hypertension, recurrent UTIs, depression,
dementia, urinary incontinence, and anemia who is readmitted
after a recent hospitalization for UTI due to fatigue and
confusion, with UCx from ___ growing Enterococcus.
# Delirium: Recently admitted on ___ for multifactorial
delirium due to UTI, constipation, and dehydration. She was
discharged on ___ with PO Bactrim (treating for presumed
pan-sensitive E. coli because the relocation to the hospital
setting appeared to be contributing to her delirium. However,
she became more lethargic and confused at her assisted living
and was readmitted on ___. At the time of her readmission,
the UCx came back from ___ positive for Enterococcous. She
was initially started on vancomycin; when sensitivities returned
she was transitioned to IV ampicillin and then PO augmentin the
day prior to discharge. Dehydration was also thought to be
contributing to delirium, as evidenced by mildly elevated
lactate (2.2) and creatinine (1.4) on admission; she was given 2
L of fluid and good PO intake was encouraged. Her benztropine
was held due to concerns for contributing to confusion and
urinary retention. AM dose of risperidone (added at last
admission due to agitation) was discontinued. Aggressive bowel
regimen was continued (senna, colace, bisacodyl) as constipation
was thought to be contributing to delirium. Other causes of
delirium were ruled out, with a negative head CT, normal
electrolytes. Her delirium improved significantly with
treatment of the UTI and dehydration; she was initially very
agitated and suspicious on ___ but by ___ she had
returned to her baseline, with no agitation.
.
# UTI: Urine culture from ___ grew out Enterococcus,
vancomycin started ___, transitioned to IV ampicillin on
___ per sensitivities, to PO Augmentin ___. Blood
culture also drawn, pending, NGTD at time of discharge. Note UCx
from admission ___ grew <10,000 bx but UA had been positive.
The patient did well with treatment of the UTI, with improvement
in her delirium (per above). No dysuria, hematuria, frequency,
or other urinary symptoms throughout hospital course.
.
# Depression/Anxiety: Initially very agitated on ___, likely
delirium rather than chronic psychiatric conditions. Pt had been
on benztropine for extrapyramidal side effects (foot tapping per
daughter); likely contributing to confusion and urinary
retention, so was held without evidence of extrapyramidal side
effects.
.
#Constipation: Continued colace, senna and Miralax. Received
bisacodyl suppository on day of discharge due to not having had
BM in 3 days.
.
# Hypertension: SBP consistently elevated to 170s-180s despite
continuing home amlodipine 10 mg daily, so metoprolol succinate
25 mg daily was initiated, with good SBP response.
.
# Dementia: Continued Donezepil. Back to baseline at time of
discharge: oriented only to self, but conversational and able to
respond appropriately to questions.
.
# Anemia: Continued iron supplementation. Stable.
.
# Goals of care: Full code confirmed. Contact is daughter ___
___, Home phone: ___, Cell phone: ___
.
# Transitions:
1) Blood cultures from ___ pending, NGTD
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver discharge
summary.
1. Amlodipine 10 mg PO DAILY
2. Benztropine Mesylate 0.5 mg PO HS
3. Calcium Carbonate 500 mg PO TID
4. Docusate Sodium 100 mg PO BID
5. Donepezil 10 mg PO HS
6. Ferrous Sulfate 325 mg PO DAILY
7. Risperidone 1 mg PO 1 TABLET AT 7 ___ DAILY
8. Venlafaxine XR 150 mg PO DAILY
9. Vitamin D 400 UNIT PO DAILY
10. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 10 Days
day one ___
11. Risperidone 0.5 mg PO QAM
12. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Calcium Carbonate 500 mg PO TID
3. Docusate Sodium 100 mg PO BID
4. Donepezil 10 mg PO HS
5. Ferrous Sulfate 325 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
7. Risperidone 1 mg PO 1 TABLET AT 7 ___ DAILY
8. Venlafaxine XR 150 mg PO DAILY
9. Vitamin D 400 UNIT PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
11. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
Last dose on ___.
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth Every 12 hours Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Urinary tract infection
Delirium
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure participating in your care at ___. You were
admitted to the hospital with a urinary tract infection which
made you feel confused. We found that you had a different type
of bacteria in your urine than you have had previously, which is
why the originial antibiotic you were taking did not work. You
will continue the new antibiotics called Augmentin for a total
of 10 days, with the last dose on ___.
You also had elevated blood pressure during your hospital stay,
so a new blood pressure medication called metoprolol was
started. If you notice any lightheadedness, confusion, or low
blood pressure, this medication should be stopped.
Followup Instructions:
___
|
10791653-DS-15
| 10,791,653 | 20,702,017 |
DS
| 15 |
2189-01-26 00:00:00
|
2189-01-27 08:55:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dry mouth, poor appetite
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ F pt with PMH of chronic pancreatitis who
presents with poor intake and dry mouth. She initially presented
to get a CT scan for Dr. ___ and told him that she had
been feeling unwell and she was referred to the ED. She says
that since ___, she has had dry mouth, and unable to drink a
lot of fluids. Her blood sugars were also rising from 160s to
400s over the last 2 days. She began having increasing thirst in
the last couple days and noticed she was urinating frequently.
She just returned 2 days ago from ___ where she was there for
a 5 day trip. For the past 4 days or so she has also had a dry
cough, but denies fevers, chills, sweats, productive cough or
SOB. Because her BG was high, she only took 10mg of prednisone
on ___ and took none today. She reports 5lb wt loss over the
last week and 10lbs over the last month. Last night she also had
loose, watery, ___ diarrhea that looked like "my food."
She denies any n/v/abdominal pain.
In the ED, initial vitals: 97.6 76 121/51 16 100%. On
examination, she appears frail, A&O x 3, EOMI, PERRL, Grade I/VI
systolic murmur RUSB, CTAB no wheezes, Abd ___,
___, Ext no edema. Neg Romberg. Normal strength upper
and lower extremities. ECG showed old LBBB. Labs were notable
for Na to 123, Glucose 418, AG 14, lactate 2.9, LFT's wnl, WBC
20.8, Hct 34.8. CXR was done which was unremarkable. CTAP done
showed pulmonary nodules but no acute ___ process.
UA showed 1000 glucose but no ketones, otherwise negative. She
was given 6 units of insulin x1 at 7pm.
Pt is a Mental Status: a&ox3, Lines & Drains: #18 RAC, Fluids: 2
LNS bolus. Vitals prior to transfer: 97.6 66 113/53 16 100%.
Currently, she feels improved and feels that her mouth is less
dry. No other current complaints.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Diabetes ___ type 2, diagnosed at age ___
- Autoimmune pancreatitis
- mildly abnormal kappa lambda ratio along with her hyperIgG
gammaglobulinemia
- Osteopenia
- HLD
- B12 defeiciency
- Hypothyroidism
- s/p TAH
- allergic rhinitis
- GERD
- LBBB
- left neck mass
- benign parotid gland resection
- psoriatic arthritis
- IgA deficiency
- C. diff colitis
- chronic pancreatitis: previous GI history in detail - ___,
with ___ watery, non bloody, BM's and wt loss. At first she was
diagnosed with C diff diarrhea but the symptoms continued after
treatment. suspected of celiac as well. Diagnosed with chronic
pancreatitis was supported by an abnormal fecal fat content and
an atrophized pancreas demonstrated on an MRCP, MRE and EUS. The
MRIs also demonstrated a dilated irregular pancreatic duct and a
mild narrowing of the distal CBD with no proximal dilatation.
There is no previous history of acute pancreatitis or alcohol
consumption.
The suspicion of celiac disease was due to the pathological
findings of areas with villous shortening in duodenal biopsies,
with infiltration of the mucosa with PMN and lympocytes.
Serology
testing was negative for tTG and anti DGP, but IgA was also low
(<4).
The patient was started treatment with ZENPEP and encouraged to
keep a gluten free diet.
Social History:
___
Family History:
Mother STROKE
Father MYOCARDIAL INFARCTION died at age ___
Brother DIABETES ___
Physical Exam:
Admission:
VS - Temp 98.0F, BP 108/48, HR 76, RR 18 , ___ 100% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, mildly dry MM,
OP clear
NECK - supple, no thyromegaly, no LAD, no JVD
HEART - RRR, nl ___, ___ systolic murmur LUSB
LUNGS - good air movement, faint crackles R base, no wheezes or
rales
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions, + skin tenting
NEURO - awake, A&Ox3, CNs ___ grossly intact, moving all
extremities, gait deferred
Discharge:
Afebrile, normotensive
GENERAL - NAD, comfortable, appropriate
HEENT - MMM, OP clear
HEART - RRR, nl ___, ___ systolic murmur LUSB
LUNGS - good air movement, CTAB
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no edema
Pertinent Results:
Admission labs:
___ 05:00PM BLOOD ___
___ Plt ___
___ 05:00PM BLOOD ___
___
___ 05:00PM BLOOD ___
___
___ 05:00PM BLOOD ___
___ 05:00PM BLOOD ___
___ 05:00PM BLOOD ___
___ 05:43PM BLOOD ___
Discharge labs:
___ 06:30AM BLOOD ___
___ Plt ___
___ 06:30AM BLOOD ___
___
Imaging:
CXR ___:
FINDINGS:
PA and lateral views of the chest. The lungs remain clear of
consolidation.
Bilateral calcified granulomas and calcified left hilar lymph
nodes are again seen. The cardiomediastinal silhouette is within
normal limits. Osseous and soft tissue structures are
unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
CTAP ___:
IMPRESSION:
1. Chronic pancreatitis, without acute inflammation or masses.
2. Cholelithiasis.
3. Bibasilar pulmonary opacities may represent aspiration or
early infection.
Micro:
Blood cultures ___ pending
___ 05:10PM BLOOD COCCIDIOIDES ANTIBODY,
___
Brief Hospital Course:
Brief Course:
Ms. ___ is a ___ F pt with PMH of chronic pancreatitis who
presents with poor intake and dry mouth, found to have
hyperglycemia and dehydration, likely secondary to recent
corticosteroid use.
#. Hyperglycemia: Pt with DM type 2, poorly controlled currently
likely due to recent prednisone use, most recent A1c 7.0. At
home, pt is only on Metformin BID. Pt has UA with 1000 glucose
but no ketones, pH from VBG is 7.31, and no AG acidosis. Pt was
hydrated and given insulin in house and her glucose control. She
was restarted on the corticosteroids per GI recs, and was
discharge on Lantus insulin with a sliding scale while on
prednisone. She was given instructions to call if BG
persistently high.
#. Leukocytosis: Most likely ___ recent steroids vs. infection.
Pt with ___ cough, nd pulmonary nodules seen on CT
(see below), though CXR clear. No other localizing symptoms.
Blood cultures were sent and pending on discharge. Her WBC was
trended and decreased but remained elevated likely secondary to
corticosteroids. See below re: ground glass nodules.
#. Ground glass nodules in lungs: Seen in lung views of CTAP.
New since ___, as above, thought most likely infectious in
etiology. CXR was clear. Recent travel to ___ and could
considered coccidomycosis; less likely given region are other
fungal etiologies such as histoplasmosis and blastomycosis.
Other ddx includes bacterial infection, though syx not
consistent with PNA given ___ cough and afebrile.
Other etiologies considered include pneumoconioses or
malignancy. Sent coccidioides serology, which was pending on
discharge. Given afebrile and pt feeling well, pt was not
started on empiric treatment.
# Chronic autoimmune pancreatitis: Pt sees Dr. ___, Dr.
___ Dr. ___ her chronic diarrhea and autoimmune
pancreatitis. ESR done grossly elevated in ___. Pt has been
on prednisone for 2.5 weeks for planned 3 week course then taper
prior to admission. However, she had ___ 1 day
prior for hyperglycemia as above. Contacted her outpatient
providers via email on patient's admission. Her prednisone was
continued with treatment for hyperglycemia as above. She was
seen briefly by GI who recommended start to taper steroids and
for her to ___ with Dr. ___ as previously scheduled
for EUS on ___.
# Weight loss: possibly ___ poor po intake from infection as
discussed above vs. malignancy vs. chronic pancreatitis. CTAP
ordered by Dr. ___ during this admission showing no
mass, though continued pancreatic duct abnormality. Nutrition
saw her and she recommended supplementation in house. She will
required close ___ with her outpatient providers.
#. Hyponatremia: Likely pseudohyponatremia ___ hyperglycemia and
hypovolemia. She corrected with IVF's and treatment of
hyperglycemia.
#. Hypothyroidism: Continued Levothyroxine 112mcg daily
TRANSITIONAL CARE:
1. CODE: FULL
2. CONTACT: Husband ___
3. ___ studies:
- Blood cultures sent on admission
- coccidomycosis by immunodiffusion
4. ___:
- PCP
- GI as previously scheduled
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. azelastine *NF* 137 mcg NU HS
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Flovent 110mcg 2 PUFF IH BID
with spacer
5. Levothyroxine Sodium 112 mcg PO DAILY
6. Creon 12 3 CAP PO TID W/MEALS
7. Losartan Potassium 50 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Omeprazole 40 mg PO DAILY
10. PredniSONE 30 mg PO DAILY
___ had discontinued this medication 1 day prior to admission
Tapered dose - DOWN
11. Simvastatin 20 mg PO DAILY
12. teriparatide *NF* 20 mcg/dose - 600 mcg/2.4 mL Subcutaneous
daily
13. Acetaminophen ___ mg PO Q6H:PRN pain
14. Vitamin D3 *NF* (cholecalciferol (vitamin D3)) 2,000 unit
Oral daily
15. Glucosamine *NF* (glucosamine sulfate) 500 mg Oral daily
16. vitamins A,C,& ___ *NF* Oral daily
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
3. Creon 12 3 CAP PO TID W/MEALS
4. Flovent 110mcg 2 PUFF IH BID
with spacer
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Levothyroxine Sodium 112 mcg PO DAILY
7. Losartan Potassium 50 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Simvastatin 20 mg PO DAILY
10. azelastine *NF* 137 mcg NU HS
11. Glucosamine *NF* (glucosamine sulfate) 500 mg Oral daily
12. teriparatide *NF* 20 mcg/dose - 600 mcg/2.4 mL Subcutaneous
daily
13. Vitamin D3 *NF* (cholecalciferol (vitamin D3)) 2,000 unit
Oral daily
14. vitamins A,C,& ___ *NF* 0 ORAL DAILY
15. PredniSONE 30 mg PO DAILY
___ had discontinued this medication 1 day prior to admission
Tapered dose - DOWN
RX *prednisone 10 mg ___ tablet(s) by mouth daily Disp #*13
Tablet Refills:*0
16. Glargine 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [One Touch Ultra Test] Check blood
glucose QACHS (4 times daily) Disp #*50 Unit Refills:*0
RX *insulin glargine [Lantus] 100 unit/mL SQ injection 5 Units
before BED Disp #*100 Unit Refills:*0
RX *insulin lispro [Humalog] 100 unit/mL Up to 7 Units per
sliding scale QACHS Disp #*3 Vial Refills:*1
RX *lancets [One Touch SureSoft Lancing Dev] For use
monitoring blood sugar QACHS Disp #*50 Unit Refills:*0
RX *insulin ___ [Insulin Syringe] 30 gauge x
___ For insulin administration QACHS Disp #*60 Syringe
Refills:*0
17. Dex4 Glucose *NF* (dextrose;<br>glucose) 4 gram Oral PRN
FSBG < 70
Take 4 tablets for blood glucose < 70 and recheck fingerstick in
15 minutes.
RX *glucose [Dex4 Glucose] 4 gram 4 tablet(s) by mouth As
directed Disp #*100 Tablet Refills:*0
18. traZODONE 25 mg PO HS:PRN insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*7 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hyperglycemia
Hyponatremia
Dehydration
Cough
Secondary:
Diabetes ___
Chronic pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during this admission. You
were admitted for dehydration, low sodium and high blood sugars.
You were given fluids and improved. Your CT scan showed no
pancreatic mass. However, it did show some pulmonary nodules,
which could suggest infection. Given your recent travel to
___, we were concerned about a specific type of fungal
infection and sent tests for this.
We restarted the prednisone to complete the three week course
that your doctors had ___. You were started on insulin to
prevent high blood sugars while you are on the steroids. Please
discuss the need for continued prednisone when you see Dr.
___.
Your prednisone will finish on ___ (20 mg daily until ___,
then 10 mg daily until ___. While you are taking the
steroids, please stop taking metformin and check your blood
sugar four times a day: before breakfast, before lunch, before
dinner, and before bedtime. You should use the sliding scale
(see printout) to determine how much humalog insulin
(___) you will need to ___ each time you
check your blood sugar. In addition, you will take 5 units of
glargine insulin (___) before bed each night. On
___, you can stop taking insulin and begin taking metformin
again.
You should monitor how you are feeling for side effects while
using insulin. Very high or very low blood sugars can both cause
you to feel poorly. If you feel shaky, sweaty, nauseous, or
lightheaded please check your blood sugar to be sure that it is
not too high or too low. If your blood sugar is less than 70,
you should take dextrose tablets as directed to raise it and
___ your blood sugar after ___ minutes to make sure it
has improved. If you find that your blood sugar is routinely
(e.g. more than once a day) too low (< 70) or too high (> 350),
please call your PCP ___ office to discuss
adjustments to your regimen.
Please see the attached medication list.
Followup Instructions:
___
|
10791751-DS-20
| 10,791,751 | 24,897,947 |
DS
| 20 |
2178-06-19 00:00:00
|
2178-06-19 09:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right groin pain, ruptured R iliac aneurysm
Major Surgical or Invasive Procedure:
___: Diagnostic cystoscopy, Evacuation and repair of right
hypogastric artery aneurysm and Ligation of feeding lumbar
arteries to right hypogastric artery aneurysm
History of Present Illness:
The patient is a ___ year-old male with history of open AAA
repair in ___ at ___ s/p rupture with EVAR repair and L
hypogastric coiling in ___. He was transferred to ___ ED from
___ on ___ with severe right groin
pain since 5 am that day and a non-contrast CT scan (creatinine
elevated to 1.96) that was concerning for a ruptured 11cm Right
common iliac artery aneurysm. Patient reported chronic pain in
his right groin for the past ___ year but on the day of
presentation it was so severe that it woke him up from sleep at
5am. He described the pain as sharp and radiating all the way
down to his right foot and was made worse with movement or when
touched. He denied dizziness, lightheadedness, chest pain, back
pain, increased SOB, abdominal pain, nausea, vomiting, bloody
urine, pain with urination, urinary frequency or urgency. On
presentation to the OSH the patient was hemodynamically stable
with HR 90's to low 100's and SBP's 150's to 180's. He remained
stable during transfer; vitals on arrival to ___ ED were T
97.8, HR 113, BP 172/81, RR 20, SPO2 90% on 3L.
Past Medical History:
PNA ___ ago, Shingles, COPD/emphysema on home O2 ___ yrs
(progressively worse)
PSHx: symptomatic AAA s/p open repair in ___, bilateral groin
hernias s/p repair ___ and ___
Social History:
___
Family History:
no known h/o anueurysmal disease
Physical Exam:
PHYSICAL EXAM ON ADMISSION
Vitals: T 97.8, HR 113, BP 172/81, RR 20, SPO2 90% on 3L
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
PHYSICAL EXAM ON DISCHARGE
Vitals: T 98.6, HR 90, BP 136.63, RR 21, SPO2 94% on 2L
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, mild tenderness around the para-median surgical site.
Staples in place; surgical incision looks healthy with no signs
of infection or discharge. BS ++
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 04:34AM BLOOD WBC-5.4 RBC-2.87* Hgb-8.2* Hct-25.1*
MCV-87 MCH-28.7 MCHC-32.8 RDW-15.1 Plt ___
___ 01:25AM BLOOD ___ PTT-28.8 ___
___ 04:34AM BLOOD Glucose-101* UreaN-27* Creat-1.5* Na-144
K-3.8 Cl-103 HCO3-33* AnGap-12
___ 04:34AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.1
IMAGING
___: CTA CHEST W&W/O C&RECONS,CTA ABD & PELVIS
Aortobiormoral graft with interval enlargement of the aneurysm
sac and with peripheral pooling of contrast compatiblewith an
endoleak, likely type 2. Possible contribution from ___.
Enlarged aneurysm in the pelvis, more clearly seen on prior
examination, likely arising from the right internal iliac
artery, and mostly thrombosed. Contrast within the sac likely in
retrograde fashion from internal iliac branches. Enlarged
previously coiled left internal iliac artery with contrast in
it. Hyperdensity in the left external iliac vein. Given
arterial phase
contrast in a venous structure, these findings could represent
fistulization. The level of fistulization, however, is not
clearly seen, potentially obscured at level of left internal
iliac artery coils. New bilateral hydroureteronephrosis, likely
from mass effect of the pelvic
aneurysm.
Brief Hospital Course:
The patient presented to ___ ED as above. He was started on a
nicardipine drip to maintain SBP < 140 and admitted to the ICU
for close monitoring. Vascular surgery was consulted after
initial evaluation who suggested a CTA CHEST W&W/O C&RECONS,CTA
ABD & PELVIS (___) that confirmed the presence of an
enlarged right internal iliac artery anuerysmal sac with
evidence of peripheral contrast, compatible with a type 2
endoleak. There was also bilateral hydroureteronephrosis likely
from mass effect of the pelvic aneurysm. Urology was taken on
board both for the CT findings as well as for a traumatic foley
placement in the ED. They recommended preoperative ureteral
stent placement on the right side to aid surgical dissection
during aneurysm repair. Please see operative notes for more
details; briefly, once the patient was in the OR, a cystoscopy
was performed that revealed an elevated bladder neck with
anterior displacement by the aneurysm; the angulation of the
scope proved too difficult for ureteral stent placement, so that
portion of the procedure was abandoned. At this point Vascular
surgery took over and performed an evacuation and repair of
right hypogastric artery aneurysm and ligation of feeding lumbar
arteries to right hypogastric artery aneurysm. Urology was
called back in to inspect the right ureter after the aneurysm
had been opened and decompressed. They identified the right
ureter which was quite baggy from chronic obstruction, but no
gross violation was identified. Since urology was satisfied and
felt that no drain was necessary, the incision was closed
primarily.
The patient was then taken to the ICU intubated in stable
condition. There he was rescucitated with crystalloids, 2UPRBC
and ___ and was extubated on POD1. He remained stable overnight
so he was transferred to the Vascular ICU on POD2; after he had
a bowel movement his diet was progressed to clears and he was
transitioned from bed to chair and weaned on to a nasal cannula.
On POD3 the patient had an episode of dyspnea and desatuared; he
improved with chest ___, 4L on NC and nebs. Over POD4 and 5 the
patient was ambulated, restarted on all his home medicines
(including Lasix) and was switched to PO pain meds. Per urology
he was given a voiding trial on POD4 which he passed
successfully. At the time of discharge on POD5 the patient was
making adequate urine, maintaining SPO2 of 95-100% on ___ of
oxygen (takes 3L at home) and tolerating a regular diet. His
urine, that had frank hematirua initially, has been
progressively clearing. The patient is going to rehab and will
follow up with Urology and Vascular Surgery in the coming weeks.
He has also been asked to follow up with his PCP for review of
his BP and COPD medications.
Medications on Admission:
Amlodipine 2.5mg daily
Procrit 10,000 units every 2 weeks (next ___
Pravastatin 40mg daily
Metoprolol 25mg daily
Folic acid 1mg daily
Furosemide 10mg daily (leg swelling)
Iron 65mg daily
B12 500mg daily
Calcium + D
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 2.5 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Metoprolol Tartrate 25 mg PO TID
5. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
6. Pravastatin 40 mg PO HS
7. Furosemide 20 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Cyanocobalamin 500 mcg PO DAILY
10. Calcium Carbonate 1250 mg PO HS:PRN CKD
11. Vitamin D 400 UNIT PO DAILY
12. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
13. Fluticasone Propionate 110mcg 2 PUFF IH BID
14. Ipratropium Bromide Neb 1 NEB IH Q6H
15. Epoetin Alfa 4000 UNIT SC QMOWEFR CKD
16. Senna 1 TAB PO BID:PRN constipation
17. Docusate Sodium 100 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Large Right hypogastric artery aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance with walker at
baseline.
Discharge Instructions:
During this hopsital admission we changed your blood pressure
medication. You were taking Metoprolol tartarate 25mg one tablet
a day at home. We have switched you to Metoprolol succinate 25mg
one tablet three times a day. We also started you on Albuterol,
Ipratropium bromide and Fluticasone to improve your breathing.
Please follow-up with your PCP next week to review these
changes.
During this hospital admission you were given 4000 units of
Procrit. When you visit your PCP next week please remind him to
give you the remaining dose.
During this hospital admission you experienced blood in your
urine. We expect your urine to clear up in the next few days but
expect to see some discoloration of your urine for the next few
days. However, if you notice frank blood in your urine please
call the office at ___ or come to the ED.
WHAT TO EXPECT:
1. It is normal to feel weak and tired, this will last for ___
weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
Wear loose fitting pants/clothing (this will be less
irritating to incision)
Elevate your legs above the level of your heart with ___
pillows every ___ hours throughout the day and at night
3. It is normal to have a decreased appetite, your appetite will
return with time
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
Take all the medications you were taking before surgery,
unless otherwise directed
Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
You should get up every day, get dressed and walk, gradually
increasing your activity
You may up and down stairs, go outside and/or ride in a car
Increase your activities as you can tolerate- do not do too
much right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower (let the soapy water run over incision, rinse
and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area
CALL THE OFFICE FOR : ___
Frank blood in urine.
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your leg or the
ability to feel your leg
Temperature greater than 101.5F for 24 hours
Bleeding from incision
New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
___
|
10791751-DS-22
| 10,791,751 | 25,906,041 |
DS
| 22 |
2179-04-07 00:00:00
|
2179-04-10 16:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R hypogastric a. aneurysm s/p previous open repair
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with multiple cormorbidities, known AAA and right
hypogastric aneurysms most recently s/p open repair of the
latter who now presents with expanding right hypogastric
aneurysm. For unclear reasons, the patient was referred for a CT
at an OSH whereupon he was found to have this enlarging aneurysm
and transferred to ___. Given his history here at
___, the patient was again transferred to ___ for further
management.
Here the patient continues to deny abdominal pain. He actually
is 'feeling pretty good' and is uncertain as to why he underwent
the CT scan. He denies back pain, chest pain or worsening
dyspnea as he has underlying COPD. He denies weakness,
near-fainting or falling.
Of note, the patient was recently admitted to the Vascular
Surgery service in ___ of this year with complaints of
lower back pain. He was found to have interval enlargement of
his AAA with a known type II endoleak. After much consideration
of his complex history, the patient and team had elected to
proceed with conservative management.
Past Medical History:
PAST MEDICAL HISTORY: AAA (s/p repair x2), R hypogastric
aneurysm (s/p repair), COPD/emphysema (on home ___ home O2
24hrs/day), PNA, shingles
PAST SURGICAL HISTORY: bilateral groin hernias s/p repair ___
and ___, open repair of symptomatic AAA ___ at ___, EVAR +
coiling of L hypogastric a. for ruptured AAA ___, repair of
R hypogastric artery aneurysm
Social History:
___
Family History:
No known h/o anueurysmal disease
Physical Exam:
On admission:
PE: VS:Temp: 97.6 HR: 90 BP: 154/87 Resp: 22 O(2)Sat: 96 Normal
___: in no acute distress, thin, malnourished white Caucsian
male
HEENT: sclera anicteric, mucus membranes moist, no ___
cyanosis or nasal flaring. NC in place. Hypertrophied anterior
scalenes
CV: regular rate, rhythm. No appreciable murmurs, rubs, gallops
Pulm: no wheezes, ronchi or rales.
Abd: protuberant with well-healed midline and paramedian
incisions. Non-tender in all four quadrants. No pulsaltile
masses.
MSK: warm, well perfused. all distal pulses palpable.
Neuro: alert, oriented to person, place, time
On discharge:
Vitals: 97.9, 65, 107/54, 20, 96% RA 3L NC
Gen: NAD, AAOx3
CV: RRR
Pulm: CTAB, no resp distress, stable on 3L supplemental O2
Abd: Soft, NT/ND, no rebound/guarding
Ext: WWP no c/c/e
Pertinent Results:
CT ABD & PELVIS WITH CONTRAST ___:
IMPRESSION:
1. No significant change from ___. The abdominal
aortic aneurysmal sac, the right internal iliac artery aneurysm
sac and the left iliac artery aneurysm sac are all unchanged.
Areas of endoleak are similar. A few foci of contrast in the
abdominal aortic aneurysm sac are newly apparent, but this may
be related to contrast timing is unlikely to explain an eight
point hematocrit decrease.
2. Acute/subacute compression fracture of T12 with 2 mm
retropulsion into the spinal canal has developed since from ___. Correlate with
clinical exam.
3. Bilateral hydronephrosis, right slightly worse than left,
unchanged from ___
Brief Hospital Course:
Mr. ___ was admitted to the Vascular Surgery service with HPI
as stated above. The report of his scan from OSH arrived with
him and reads as follows:
___ CT non-contrast:
EVAR of infrarenal AAA. very large residual aneurysm sac 11.2cm
maximum dimension. Aneurysmal promience suprarenal aorta 5cm
maximum dimension. Left hypogastric art coil embolized. Residual
sac 5cm im maximum dimension.
Extremely large right hypogastric aneurysm 12cmx10cm max
dimension.
He was admitted to the CVICU due to bed placement and was noted
to be stable. His hematocrit was 29 and he was not felt to have
a bleed. He was monitored overnight and his vitals were stable.
Acute concern was raised when AM labs on HD#2 were reported as
a hematocrit drop from 28.6 to 20.4, but given his stability,
the crit was felt to be in error and, when repeated, yielded a
value of 27.2.
He underwent CT scan of the abdomen and pelvis that noted no
significant change in aneurysm size from the previous CT scan on
___. The abdominal aortic aneurysmal sac, the right
internal iliac artery aneurysm sac and the left iliac artery
aneurysm sac were all unchanged. Areas of endoleak were similar.
A few foci of contrast in the abdominal aortic aneurysm sac are
newly apparent, but this may be related to contrast timing is
unlikely to explain an eight point hematocrit decrease.
The patient was determined to be sufficiently stable for
transfer to the floor.
His hospital course was otherwise unremarkable except for a
potassium of 5.9; he received insulin and D50 and his potassium
recovered to an appropriate level.
On HD#3, he was voiding with creatinine at 1.9 (baseline), his
hematocrit was stable, his O2 requirements were stable, he
tolerated a regular diet, and he was stabilized on his home
meds. Discussion was had with the patient and continued
conservative management of his condition was determined to be
the most appropriate measure.
He is discharged from the hospital with appropriate information,
warnings, and plans for follow-up with his PCP on HD#3,
___.
Medications on Admission:
MEDICATIONS AT HOME: amlodipine 2.5', procrit 10,000U, folate
1',
lasix 20', metoprolol 25''', pravastatin 40', Ca/VitD3, VitB12
500', FeSO4 325'
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Metoprolol Tartrate 25 mg PO TID
3. Pravastatin 40 mg PO DAILY
4. Epoetin Alfa 4000 UNIT SC QMOWEFR
5. FoLIC Acid 1 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Cyanocobalamin 500 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
R hypogastric a. aneurysm s/p previous open repair
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were seen for concern that you aneurysm might be worsening;
on repeat evaluation with radiologic imaging, it was determined
that it has not enlarged from the previous time it was
evaluated.
You will be discharged to your previous place of residence. You
should follow up immediately if you have any newly worsening
pain in your groin, thigh, leg, or foot, if you develop sudden
weakness or lose sensation in your lower extremity, or if you
have any additional concerning symptoms.
Please keep all follow-up appointments previously scheduled.
You do not need to follow up specially for this visit.
Please resume taking all home medicines you were taking before
this hospitalization.
You may immediately resume your regulat diet.
You may immediately resume your regular level of activity.
Review the warning signs above and below. It is especially
important to immediately return to the emergency department if
you have an increase in abdominal pain at or near the site of
the aneurysm, cold leg or foot, decreased sensation or strength
in your foot/leg/thigh, sudden abdominal or back pain, or any
other concerning symptoms.
Followup Instructions:
___
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2112-07-18 15:32:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
morphine
Attending: ___
Chief Complaint:
Left frontal IPH
Major Surgical or Invasive Procedure:
___ L frontal craniotomy for tumor resection
History of Present Illness:
Ms. ___ is an ___ woman with atrial fibrillation
on Coumadin (INR 3.5 at OSH), found to have confusion and
difficulty speaking today, therefore was taken to the ED. The
OSH
performed a NCHCT and subsequently found a left frontal IPH with
significant vasogenic edema and a second focus of edema in the
right parietal lobe. The patient was given vitamin K and
transferred to ___ for further evaluation of the IPH. The
patient was admitted to the ___ for further evaluation and
work-up.
Past Medical History:
PMHx:
Cataracts
Hypertension
Atrial fibrillation on Coumadin with no missed doses
Social History:
___
Family History:
Family Hx:
unknown
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
Neuro:
Mental status: Awake and alert, cooperative with exam
Orientation: Oriented to person, can provide location when given
choices and correct year when given choices
Language: Expressive aphasia. Receptive language intact. No
dysarthria.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1
mm bilaterally.
III, IV, VI: Extraocular movements notable for baseline left
strabismus
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift.
Sensation: Intact to light touch.
Coordination: +dysmetria on finger-nose-finger.
PHYSICAL EXAMINATION ON DISCHARGE:
Exam:
Opens eyes: [X]spontaneous [ ]to voice [ ]to noxious
Orientation: [X]Person [ X]Place [X]Time
(Patient has expressive aphasia, answers orientation questions
with choices)
Follows commands: [ ]Simple [X]Complex [ ]None
Pupils: Right 2mm R Left 2mm R
EOM: [X]Full [ ]Restricted
Face Symmetric: [X]Yes [ ]NoTongue Midline: [X]Yes [ ]No
Pronator Drift: [X]Yes (R subtle drift) [ ]No
Speech Fluent: [ ]Yes [X]No - expressive aphasia
Comprehension intact [ ]Yes [X]No ? some receptive deficits
Motor:
TrapDeltoidBicepTricepGrip
Right5 4 554
Left 5 5 5 5 4
IPQuadHamATEHLGast
Wound:
[X]Clean, dry, intact
[ ]Abnormal
[ ]Steris [ ]Suture [X]Staples [ ]None
Pertinent Results:
Please see OMR for pertinent lab and imaging results.
Brief Hospital Course:
#Intracranial lesions
The patient was admitted to the ___ on ___ for further
work-up of the left frontal IPH. She underwent a MRI which
showed a left frontal underlying lesion and a right temporal
lesion. She underwent a CT of the abdomen and pelvis which
showed a 3.1cm soft tissue density. CT of the torso showed right
lung nodules, a left thyroid nodule and mildly enlarged lymph
nodes. On ___, the patient remained neurologically stable on
examination. She underwent pre-operative work-up in anticipation
for undergoing surgery the following day. On ___, the patient
was taken to the operating room and underwent a left frontal
craniotomy or resection of tumor. A subgaleal drain was left in
place. Post-operatively, she recovered in the PACU and was later
transferred to the ___. Post op MRI revealed expected post op
changes. She was started on a dexamethasone taper.
Neuro-Oncology, Radiation Oncology and Hematology Oncology were
all consulted and patient was scheduled for follow up. On ___,
the subgaleal JP drain was removed without any issues. She
remained stable and continued to recover post-operatively.
#Tachycardia- Post-operatively the patient was tachycardic. She
received PRN hydral and Lopressor in PACU with good effect. When
she transferred to the ___ her HR remained WNL.
#Hypotension: She had an episode of hypotension (SBP 60's) in
the restroom, repeat SBP was 150. She was noted to have a
negative fluid balace and was given an IV fluid bolus and her
Lasix was held. EKG was stable. Cardiac enzymes were flat. Her
potassium was repleted. Hypotension was resolved.
#Leukocytosis: On ___ her WBC were elevated at 21. She
continues on decadron however infectious work-up was remarkable
for positive UA. She was started on Ceftriaxone for UTI. Urine
cultures was negative on final and her Ceftriaxone was
discontinued on ___. Blood cultures from ___ were negative and
cultures from ___ are still pending. WBC uptrended to 22, she
remained afebrile and clinically stable. CXR negative for
pneumonia. Her WBC began trending down ___ to 20.2.
#Right shoulder dislocation
___ overnight patient had more difficulty moving right arm, RN
heard a pop when patient was ambulating to the bathroom. Xray
confirms R shoulder dislocation. Ortho was consulted. Right
shoulder reduced at beside, Xrays inconclusive, CT showed no
fracture. Ortho recommended a sling prn for comfort and f/u in
two weeks.
#Dispo
She was evaluated by ___ and OT who recommended acute rehab.
Follow-up appointments and treatment plans for obtained from
neuro onc, radiation onc, and heme onc to prepare patient for
discharge to rehab.
Medications on Admission:
Medications prior to admission:
Coumadin 2.5mg BID
lisinopril 40mg daily
atenolol 25mg BID
simvastatin 10mg daily
amlodipine 10mg daily
Lasix 40mg daily
clonazepam (unknown dose)
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
2. Dexamethasone 2 mg PO Q12H Duration: 4 Doses
This is dose # 4 of 5 tapered doses
3. Dexamethasone 2 mg PO Q12H Duration: 2 Doses
This is dose # 5 of 5 tapered doses
Tapered dose - DOWN
4. Docusate Sodium 100 mg PO BID
5. Famotidine 20 mg PO BID
6. Heparin 5000 UNIT SC BID
7. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
8. LevETIRAcetam 500 mg PO BID
9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
10. Senna 17.2 mg PO QHS
11. amLODIPine 10 mg PO DAILY
12. Atenolol 50 mg PO BID
13. Simvastatin 10 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Intracranial lesions
Thyroid lesion
Lung lesion
R shoulder dislocation
Discharge Condition:
Mental Status: Confused - sometimes.
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 staples are removed
on POD 10.
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.
* You will need to follow up with Orthopedic surgery in 2
weeks for your shoulder dislocation. Continue to wear your sling
for comfort until this appointment.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Please follow-up with your PCP/ Oncologist:
-Repeat CT Chest in 6-months (from ___ to monitor Right
lung nodules and mildly enlarged hilar lymph nodes & prominent
mediastinal lymph nodes.
-Dedicated Thyroid ultrasound for further evaluation of 3.3 x
2.6 cm left thyroid lobe lesion.
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hypoglycemia
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ yo F who PVD, HTN, HLD, Type II diabetes presented to ___
___
after she was found by her children unresponsive in bed. Per
patient and ___ notes, patient was discharged from rehab 3
days
ago after R femoral to AT bypass on ___. Patient currently
living at home with husband.
Per patient since discharge from rehab 3 days prior she has been
feeling tired, lethargic, has note had PO intake in the last ___
days. He husband and family were over for dinner, she felt
tired,
went to take a nap and she be woken up in her bed, therefore
family called ___.
Per family from the ___ notes, she lost significant amount
of weight since her first admission. Upon arrival to the ___
___
her FSBG was 40's. She was treated with an amp D50, 3L IVF.
At ___, in addition to low FSBG, she was found to be
in acute renal failure with elevated Cr 3.9 and K+ 6.9. When
patient was discharged from BI to rehab Cr was 0.6. Upon
discharge she was started on several new medications including
lisinopril 10 mg, metformin and glipizide as above and Bactrim
DS
BID.
Additionally during her admission for AT bypass, after the
procedure on ___, there was concern for a cellulitis of the
right lower extremity above the ankle and patient was treated
with cipro/flagyl/vancomycin and discharged on Bactrim DS daily.
In the ___, initial vitals 98.4 F HR 100 132/80 RR 18 100% RA
Labs were notable for negative UA, UCx pending
WBC 14 K
hgb 7.7
plt 417
CK 44 CRP 100.3
Na+ 139 K+ 5.8 Bicarb 15 BUN 87 Cr 2.9 Glucose 48
Repeat K+ 5.4
Patient was treated with ___
Vitals upon transfer 98.0 F HR 101 117/49 RR 21 100% RA
Upon arrival to the floor patient was alert and oriented times
2.
She was somewhat of a poor historian and could only recount some
of the history of the past 2 days. She notes that she has not
eaten since discharge two days ago. She feels incredibly
fatigued. She denies pain.
Past Medical History:
PMH:
- DM 2, hypertension, hyperlipidemia, PVD
PSH:
- RLE angiogram
- Achilles tendon surgery
Social History:
___
Family History:
Diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.0 PO 125/64 HR 91 RR 18 94% RA
GENERAL: NAD, A&O2X, inattentive, cannot complete ___ backwards
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, thrush on tongue
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
GU: Foley in place draining pinkish urine
EXTREMITIES: no cyanosis, clubbing, or edema
R Leg-- well healing incinsion from groin to ankle on the medial
aspect of the leg. Warm, well perfused. No drainage from wound
site. Sensation intact. Dopplerable pulses. Gangerous ___ and
___
digits on the foot. Redness around the ankle with some
associated
warmth.
PULSES: 2+ DP pulses bilaterally
NEURO: moving all 4 extremities with purpose, ___ ___ strength
DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM:
VS: 98.3 PO 156 / 71 L Lying 83 18 96 RA
GENERAL: NAD, A&O3X, attention improved from yesterday.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, thrush on tongue
NECK: supple, no LAD, no JVD
HEART: regular rate and rhythm, no murmurs, gallops, or rubs
LUNGS: Left lower lobe crackles, right lunch clear, no wheezes,
rales, rhonchi bilaterally
ABDOMEN: nondistended, nontender, no rebound/guarding, bowel
sounds present. No suprapubic tenderness. No hepatosplenomagaly.
EXTREMITIES: R Leg-- well healing incision from groin to ankle
on the medial aspect of the leg. Warm, well perfused. No
drainage from wound site. Sensation intact. Gangrenous ___
and ___ digits on the right foot, with no associated pain or
tenderness.
Pertinent Results:
ADMISSION LABS:
===============
___ 05:03PM GLUCOSE-135* UREA N-39* CREAT-0.9 SODIUM-141
POTASSIUM-3.7 CHLORIDE-118* TOTAL CO2-14* ANION GAP-13
___ 05:03PM CALCIUM-6.0* PHOSPHATE-1.5* MAGNESIUM-1.5*
___ 05:03PM PTT-150*
___ 11:28AM ___ PO2-56* PCO2-33* PH-7.36 TOTAL
CO2-19* BASE XS--5
___ 11:28AM LACTATE-1.5
___ 11:10AM GLUCOSE-121* UREA N-61* CREAT-1.6*#
SODIUM-138 POTASSIUM-5.2* CHLORIDE-109* TOTAL CO2-18* ANION
GAP-16
___ 11:10AM ALT(SGPT)-23 AST(SGOT)-21 ALK PHOS-66 TOT
BILI-0.3
___ 11:10AM ALBUMIN-3.2* CALCIUM-8.5 PHOSPHATE-2.5*
MAGNESIUM-2.2
___ 11:10AM WBC-11.3* RBC-2.48* HGB-7.4* HCT-24.2* MCV-98
MCH-29.8 MCHC-30.6* RDW-15.9* RDWSD-56.4*
___ 11:10AM NEUTS-84.8* LYMPHS-5.8* MONOS-6.9 EOS-0.8*
BASOS-0.3 IM ___ AbsNeut-9.59* AbsLymp-0.66* AbsMono-0.78
AbsEos-0.09 AbsBaso-0.03
___ 11:10AM PLT COUNT-389
___ 11:10AM ___ PTT-64.3* ___
___ 09:24AM URINE HOURS-RANDOM CREAT-58 SODIUM-39 TOT
PROT-60 PROT/CREA-1.0* albumin-2.3 alb/CREA-39.7*
___ 09:24AM URINE OSMOLAL-502
___ 09:24AM URINE UHOLD-HOLD
___ 01:08AM K+-5.4*
___ 12:00AM GLUCOSE-48* UREA N-87* CREAT-2.9*# SODIUM-139
POTASSIUM-5.8* CHLORIDE-109* TOTAL CO2-15* ANION GAP-21*
___ 12:00AM estGFR-Using this
___ 12:00AM CK(CPK)-44
___ 12:00AM TSH-2.8
___ 12:00AM CRP-100.3*
___ 12:00AM URINE UHOLD-HOLD
___ 12:00AM WBC-14.0* RBC-2.58* HGB-7.7* HCT-25.3* MCV-98
MCH-29.8 MCHC-30.4* RDW-15.9* RDWSD-57.0*
___ 12:00AM NEUTS-88.4* LYMPHS-3.2* MONOS-6.2 EOS-0.5*
BASOS-0.2 IM ___ AbsNeut-12.36* AbsLymp-0.45*
AbsMono-0.86* AbsEos-0.07 AbsBaso-0.03
___ 12:00AM PLT COUNT-417*
___ 12:00AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 12:00AM URINE RBC-3* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
MICRO
=====
IMAGING:
========
+ ___ CXR
Heart size and mediastinum are stable. Diffuse interstitial
opacities are
bilateral, new and concerning for interstitial pulmonary edema.
No definitive pleural effusion is seen. No discrete focal
consolidation to suggest infectious process present but right
lower lobe is slightly more consolidative than the rest of the
lungs does potentially might represent infectious process.
Followup of the patient 4 weeks after completion of antibiotic
treatment is recommended and that particular case scenario.
DISCHARGE LABS
===============
___ 07:25AM BLOOD WBC-8.6 RBC-2.60* Hgb-7.9* Hct-24.8*
MCV-95 MCH-30.4 MCHC-31.9* RDW-15.0 RDWSD-51.5* Plt ___
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD Glucose-176* UreaN-9 Creat-0.5 Na-135
K-3.7 Cl-100 HCO3-23 AnGap-16
___ 07:25AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.8
___ 07:25AM BLOOD
Brief Hospital Course:
Ms. ___ is an ___ year old woman with a past medical history
of PVD, HTN, HLD, Type II diabetes with a recent femoral to AT
bypass (___) who presents after being found minimally
responsive at home with hypoglycemia (glucose ___ and was found
to have acute kidney injury, new onset paroxysmal atrial
fibrillation, and urinary retention. Her hospital course is as
follows:
#Paroxysmal atrial fibrillation was rate controlled with
metoprolol, anticoagulated with heparin and transitioned to
apixaban (Plavix was stopped and aspirin reduced to 81mg after
discussion with Dr. ___, will be sent home with aspirin
and apixaban for long term anticoagulation.
#Urinary retention developed post operatively from unclear
etiology, failed spointaneous voiding trials ultimately
requiring foley. Completed a 3 day course of ceftriaxone therapy
for UTI, no growth on urine cultures, will not continue
antibiotics at home. Patient will follow up with urology.
#Diabetes was managed with glargine and an insulin sliding
scale, will be managed with glargine and metformin at home.
Glipizide was stopped.
#Acute kidney injury likely developed from poor PO intake in the
setting of metformin/lisinopril/bactrim use, resolved with
fluids.
#Right femoral to AT bypass incision continued to heal nicely,
did not require further intervention by vascular surgery.
Finished aspirin/Plavix; aspirin was dose reduced to 81mg when
apixaban was started.
#Dry gangrene of right ___ digits remained unchanged from
baseline and required no intervention.
TRANSITIONAL ISSUES:
-Please see medication list for changes or additions to
medications.
-Consider seeing GI as outpatient to evaluate weight loss and
anemia.
-Continue to monitor medication compliance, home blood sugar
checks, appetite, food intake, and weight at home. Please call
___ if your blood sugars remain elevated above 180.
-Please check Basic metabolic panel at first PCP appointment
-___ seek emergency care if any falls at home given new
anticoagulation (blood thinning) medications.
CODE: Full
CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. GlipiZIDE 5 mg PO BID
5. Lisinopril 10 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Pantoprazole 40 mg PO Q24H
8. Sulfameth/Trimethoprim DS 1 TAB PO BID
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Glargine 25 Units Dinner
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR
25 Units before Breakfast Disp #*2 Syringe Refills:*0
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Senna 17.2 mg PO QHS:PRN constipation
5. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
7. Atorvastatin 40 mg PO QPM
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
hypoglycemia
Acute kidney injury
Atrial fibrillation
SECONDARY DIAGNOSIS:
Type 2 diabetes
Dry gangrene
Peripheral vascular disease
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___!
You came to the hospital because you had a low blood sugar and
you were very dehydrated. Your diabetes medications (glipizide
and metformin) were stopped and you were given fluids. You will
be started on new medications for your diabetes when you go
home, including an injectable insulin pen.
You developed some difficulty urinating and were sent home with
a catheter in your bladder. You will follow up with a urology
specialist in approximately one week who will remove the
catheter and evaluate your ability to urinate. You were also
treated with antibiotics for a urinary tract infection and got
better.
You were discovered to have an irregular heart rate called
"atrial fibrillation". You were started on a medicine called
apixaban to prevent the risk of stroke associated with this
abnormal heart rhythm.
Now that you are going home please be sure to follow-up with
your urologist, primary care doctor, and please remember to take
all your home medications.
We wish you the best,
- Your ___ Team
Dear Ms. ___,
It was a pleasure caring for you at ___!
You came to the hospital because you had a low blood sugar and
you were very dehydrated. Your diabetes medications (glipizide
and metformin) were stopped and you were given fluids. You will
be started on new medications for your diabetes when you go
home, including an injectable insulin pen.
You developed some difficulty urinating and were sent home with
a catheter in your bladder. You will follow up with a urology
specialist in approximately one week who will remove the
catheter and evaluate your ability to urinate. You were also
treated with antibiotics for a urinary tract infection and got
better.
You were discovered to have an irregular heart rate called
"atrial fibrillation". You were started on a medicine called
apixaban to prevent the risk of stroke associated with this
abnormal heart rhythm.
Now that you are going home please be sure to follow-up with
your urologist, primary care doctor, and please remember to take
all your home medications.
We wish you the best,
- Your ___ Team
Followup Instructions:
___
|
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|
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|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Abdominal pain, nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old M with cholangiocarcinoma s/p whipple in ___
followed by adjuvant chemo/radiation which completed in ___, ventral hernia s/p repair in ___ and inguinal hernia
s/p repair 2 weeks ago with acute on chronic abdominal pain,
nausea, and vomiting.
Pt reports nausea, vomiting and periumbilical abdominal pain
since ___ of this year. He has had 8lbs of weight loss in the
past two months. His appetite has been poor and he has felt
fatigued. However, in the past 3 days he says that his vomiting
has been multiple times per day, including in the ER where he
was noted to have bilious vomiting. This is an increase from
1/week vomiting he had prior. No blood in vomitus. Bowel
movements two days ago. Normal per report. He says that his
periumbilical abdominal pain has also worsened. ___ at the time
of interview. He has been taking oxcycodone and vicodin given to
him post operatively from his recent surgeries.
He presented to ___ and was sent to ___ ED.
There he had a CT which showed no obstruction. A fluid
collection was seen near the site of his recent hernia repair.
He was seen by surgery and admitted to the medical service for
___ care.
Past Medical History:
cholangiocarcinoma s/p whipple
s/p ventral hernia repair
s/p inguinal hernia repair
HTN
DM2
Social History:
___
Family History:
Father died from complications of DM1
Mother living but has hx breast cancer, bt mastectomies
Physical Exam:
On admission:
================
Vitals: 98.2 183/84 75 16 100%RA\
Gen: NAD, gaunt appearing
HEENT: moist mm, no scleral icterus
CV: rrr, no r/m/g
Pulm: clear b/l
Abd: midline scar, no tenderness to palpation, soft,
nondistended, +bs; R inguinal surgical site with clean dressing
no erythema; no bulge or tenderness
Back: no cva tenderness
Ext: no edema
Neuro: alert and oriented x 3
On discharge:
================
Vitals: AF/98.2, 140s-170s/60s-70s, 60s-70s, ___, 100% on RA;
eating well
Gen: NAD, gaunt appearing
Eyes: EOMI, sclearae anicteric
HEENT: MMM, OP clear
CV: RRR, no MRG
Pulm: CTA ___
Abd: midline scar, no tenderness to palpation, soft,
nondistended, +BS; R inguinal surgical site with clean dressing
no erythema; no bulge or tenderness
Back: No cva tenderness. No kyphosis.
Ext: WWP, no edema, no rash, no arthritis
Neuro: AAOx3
GU: No foley
Pertinent Results:
ON ADMISSION:
================
___ 08:45PM GLUCOSE-111* UREA N-17 CREAT-0.8 SODIUM-142
POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-23 ANION GAP-13
___ 08:49PM LACTATE-0.9
___ 08:45PM LIPASE-6
___ 08:45PM ALT(SGPT)-31 AST(SGOT)-19 ALK PHOS-97 TOT
BILI-1.0
___ 08:45PM ALBUMIN-3.8 CALCIUM-9.0 PHOSPHATE-3.6
MAGNESIUM-1.7
___ 08:45PM WBC-5.4 RBC-3.72* HGB-10.8* HCT-31.1* MCV-83
MCH-29.1 MCHC-34.9 RDW-14.1
___ 08:45PM PLT COUNT-210
___ 08:45PM NEUTS-76.5* LYMPHS-16.6* MONOS-4.5 EOS-1.8
BASOS-0.7
CT Abdomen/Pelvis (prelim):
1. No evidence of obstruction. Patient is status post Whipple
with trace
pneumobilia noted within the liver. Additional trace amount of
free fluid is noted about the liver and tracking inferiorly
along the right pericolic gutter.
2. Right inguinal fluid and air filled rim enhancing structure
with overlying subcutaneous inflammatory changes, findings
concerning for an abscess.
AFTER ADMISSION:
================
CT Abdomen/Pelvis (final read ~12 hours after prelim read):
1. New or more extensive, difficult to compare given
differences in acquisition, soft tissue density extending from
the pancreatic head bed and extending posteriorly to the
retroperitoneum encasing the celiac and superior mesenteric
arteries as well as portal vein. This is concerning for
recurrent
tumor.
2. Patient is status post Whipple with trace pneumobilia noted
within the liver. Additional trace amount of free fluid is noted
about the liver and tracking inferiorly along the right
pericolic gutter, decreased since prior examination dated ___.
3. Right inguinal fluid and air filled structure with overlying
subcutaneous inflammatory changes may reflect postoperative
changes status post recent hernia repair with a residual seroma.
An abscess in the absence of pain at the site is felt unlikely.
Brief Hospital Course:
ISSUES THIS HOSPITAL STAY
# Recurrent cholangiocarcinoma: Recurrence suggested by findings
on abdominal CT from admission.
# Abdominal pain, nausea, vomiting: Attributed to problem #1
above. Improved with conservative measures (oxycodone, zofran,
IVF). Advanced diet to regular on ___.
# Recent hernia repairs: Stable on imaging. Incisions CDI
without signs of hernia recurrence.
# Anemia: Hct remained at his outpatient baseline. Etiology
likely multifactorial (chronic blood loss, anemia of
inflammation, prior chemo).
# HTN: Hypertensive while here, but attributed to pain. He was
asymptomatic, so opted to observe, witholding directed treatment
as his pressures will likely improve as his disease progresses
or he undergoes chemotherapy.
# DM : Continued home Lantus and SSI.
NARRATIVE
___ with cholangiocarcinoma s/p Whipple and chemoradiation in
___, recent ventral and inguinal hernia repairs, who presented
with acute on chronic abdominal pain, nausea, vomiting. His
symptoms improved with conservative therapy (short course of
bowel rest, some IV fluids, PO oxycodone, and IV Zofran), and
his diet was advanced. His pain regimen was uptitrated; he was
placed on Oxycontin q12h for improved long term control, along
with oxycodone 5mg q4h as needed for breakthrough. He was also
put on a bowel regimen.
Unfortunately, his abdominal CT scan showed likely recurrence of
cancer. I discussed his case with the oncology fellow ___
___ and had email correspondence with Dr ___. He
underwent restaging chest CT, and outpatient followup was
arranged. A palliative care consult was also obtained this
admission, since he was not sure if he wanted to pursue
chemotherapy or focus only on symptoms. They made some
recommendations for pain management.
TRANSITIONAL
# Likely recurrent cancer: Has outpatient followup arranged.
# Code status: He was full code while here. Will need to be
discussed with primary providers as his goals of care change.
# Contact: ___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 20 mg PO DAILY
2. Glargine 6 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. Creon 12 2 CAP PO TID W/MEALS
4. Lorazepam 0.5 mg PO Q6H:PRN anxiety
5. Megestrol Acetate 400 mg PO DAILY
Discharge Medications:
1. Creon 12 2 CAP PO TID W/MEALS
2. Escitalopram Oxalate 20 mg PO DAILY
3. Lorazepam 0.5 mg PO Q6H:PRN anxiety
4. Glargine 6 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN abdominal pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*84
Tablet Refills:*0
6. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*120 Tablet Refills:*3
7. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*180 Capsule Refills:*3
8. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*90 Packet Refills:*3
9. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 2 tablets by mouth twice daily
Disp #*360 Tablet Refills:*3
10. OxyCODONE SR (OxyconTIN) 10 mg PO Q8H
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth every 8
hours Disp #*84 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses
- Recurrent cholangiocarcinoma (most likely)
- Nausea with vomiting
- Periumbilical abdominal pain
Secondary diagnoses: Diabetes, hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain and nausea with vomiting.
Your workup revealed recurrence of your cancer. You were treated
with pain and nausea medicine and you got somewhat better. You
are being discharged with close followup with Oncology.
Followup Instructions:
___
|
10792141-DS-8
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|
2161-07-31 14:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a a ___ y/o F PMH HTN, hypothyroidism who presented
to ___ on ___ with fever and confusion. As per the
patient's husband, she has been in her normal state of health
until ___. She had an episode of vomiting on ___ and has had
poor PO intake throughout the rest of the week. The patient has
been lethargic, reporting to her husband that her head felt
"like cotton candy." On ___ ___ patient was acutely confused,
behaving strangely, and not speaking coherently while at dinner.
That night, her husband noted that she felt extremely warm to
the touch. She was taken by husband to ___ on
___, where she was noted to have a fever to 101.8.
Of note, patient had recent travel history to ___
during the first week of ___, where she went hiking. Denies
tick bites or rashes. No sick contacts. The patient is exposed
to young children (grand children).
Past Medical History:
- HTN
- Hypothyroidism
- Dyslipidemia
- Epigastric hernia
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION EXAM
Vital Signs: 99.1 PO 133/79 84 18 94 3L
General: Alert, aphasic, unable to assess orientation, no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRLA,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Aphasic, follows commands but often requires multiple
prompts, CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes throughout, No myoclonus,
gait deferred.
************
DISCHARGE EXAM
General: Alert, awake, aphasic, unable to assess orientation,
no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRLA,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, PEG tube in place with binder, mild tenderness
to palpation. Non-distended, bowel sounds present, no
organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro:
-Mental Status: Awake, alert, unable to assess orientation
status due to aphasia. Follows midline and appendicular
commands, but often requires multiple prompts to do so. Speech
is fluent, but only able to string together ___ word phrases. At
times is irritable and does not comply with exam. Able to
answer yes/no questions appropriately. Cannot repeat sentences
or name objects. No dysarthria.
- CN: ___ 3>2, EOMI, gaze conjugate. Subtle R nasolabial fold
flattening. Facial sensation intact to light touch. Tongue
midline.
- Motor: normal bulk and tone. Muscle strength difficult to
assess due to motor impersistence but moves all extremities
antigravity and against resistance. 2+ biceps, brachioradialis,
quadriceps and Achilles reflexes.
- Sensation: withdraws to tickle in bilateral ___, unable to
assess specific sensory modalities
- Gait: Normal initiation. Narrow base. Normal stride length and
arm swing. Stable without sway
Pertinent Results:
ON ADMISSION:
___ 07:10PM WBC-7.4 RBC-4.60 HGB-13.5 HCT-40.4 MCV-88
MCH-29.3 MCHC-33.4 RDW-17.0* RDWSD-54.5*
___ 07:10PM NEUTS-74.6* LYMPHS-12.5* MONOS-11.6 EOS-0.0*
BASOS-0.5 IM ___ AbsNeut-5.48 AbsLymp-0.92* AbsMono-0.85*
AbsEos-0.00* AbsBaso-0.04
___ 07:10PM ALBUMIN-3.7
___ 07:10PM proBNP-479*
___ 07:10PM ALT(SGPT)-25 AST(SGOT)-31 ALK PHOS-58 TOT
BILI-0.7
___ 07:10PM GLUCOSE-96 UREA N-12 CREAT-0.5 SODIUM-126*
POTASSIUM-4.1 CHLORIDE-91* TOTAL CO2-23 ANION GAP-16
___ 07:34PM LACTATE-1.3
ON DISCHARGE:
___ 06:05AM BLOOD WBC-7.9 RBC-3.36* Hgb-9.9* Hct-30.0*
MCV-89 MCH-29.5 MCHC-33.0 RDW-18.6* RDWSD-58.7* Plt ___
___ 06:05AM BLOOD Glucose-81 UreaN-16 Creat-1.7* Na-137
K-3.4 Cl-98 HCO3-27 AnGap-15
___ 06:05AM BLOOD Calcium-8.7 Phos-4.3 Mg-1.8
___ 05:40AM BLOOD Glucose-108* UreaN-16 Creat-1.5* Na-141
K-3.5 Cl-98 HCO3-30 AnGap-17
Brief Hospital Course:
#HSV Encephalitis: Patient presented with fever, nausea/vomiting
and a mixed, predominantly receptive (posterior) aphasia. Workup
was notable for acute hyponatremia (detailed below), OSH LP
revealing lymphocytic pleocytosis with some RBCs (Tube 1: WBC
17, RBC 1 / Tube 2: WBC 9, RBC 58 / Prot 40/ Gluc 68 / 11%
neutrophils, lymphocytes 78%, 11% monocytes]. CSF HSV was
pending at time of transfer to ___. Head CT revealed L
temporal lobe hypodensity, and follow up MRI/MRA brain and neck
revealing T2 and FLAIR hyperintensity and slow diffusion in the
left mesial temporal lobe, extending to the insula, most
consistent with herpes encephalitis. EEG on the night of
admission revealed continuous focal slowing and periodic
epileptiform discharges in the left temporal region, no
electrographic seizures. However, patient exhibited continuous
automatisms of both hands, suggestive of focal seizures.
Despite that no seizures were seen on the scalp EEG, mesial
temporal seizures may not always have a scalp correlate. Given
imaging, LP and clinical findings consistent with encephalitis,
patient was started on Acyclovir empirically on ___. Patient
was also placed on continuous EEG monitoring and started on
Keppra 1500mg BID for treatment of events concerning for
seizure. Patient had gradual improvement in her neurologic exam
over next few days with the above interventions. On ___,
patient's OSH LP resulted as positive for HSV-1 in the CSF. Her
aphasia improved, particularly her comprehension; she was able
to follow midline and appendicular commands by ___. Patient was
started on Acyclovir with plans to complete 21 day course per ID
recommendations. However, when patient developed ___ from likely
Acyclovir-induced ATN (see below), was changed from Acyclovir to
Valacyclovir. Plan will be to continue Valacyclovir through
___ per ID recommendations. Patient did have waxing and
waning mental status during hospitalization. At times, patient
was alert and following midline and appendicular commands; at
other times, was somnolent and not following commands. On ___,
patient was hooked up to cvEEG monitoring to determine if
patient was actively seizing while somnolent, which revealed no
electrographic or clinical seizures. Given improved renal
function on ___, keppra dose was increased to 500mg BID.
Patient was continued on Valcyclovir and Keppra 500mg BID at
discharge.
#Left Temporal PLEDS: On admission to ___ patient was noted to
have continuous automatisms of both hands, suggestive of focal
seizures. EEG revealed continuous focal slowing, left temporal >
parasagittal PLEDs. She was placed on continuous EEG monitoring
and started on Keppra 1500mg BID for treatment of events
concerning for seizure. She had no further events concerning for
seizure and PLEDS resolved. Patient was removed from continuous
EEG monitoring on ___. Per Epilepsy recommendations, patient
will continue Keppra for at least 6 months, with further
treatment course to depend on how she does clinically moving
forward. Patient was discharged on renally dosed keppra, 250mg
BID, with further dosing regimen to be potentially adjusted as
renal function improves.
#Severe Protein Calorie Malnutrition:
After transfer from ICU, patient was noted to have poor PO
intake. Per nutrition evaluation on ___, patient was not close
to meeting nutritional needs (30%) with PO intake alone. Dobhoff
was placed and tube feeds started to initiate enteral feeds,
however patient did not tolerate Dobhoff well as it was a source
of agitation and delirium. Patient pulled out dobhoff despite
being placed on soft restraints. Surgery team was consulted to
consider PEG, and after extensive discussions with Nutrition,
family and surgical team, decision made to pursue PEG. Patient
had PEG placed on ___ and tolerated procedure well without
complications. She was started on tube feeds 24 hours post PEG
on ___. She had an abdominal binder in place, and it is critical
to keep this abdominal binder in place moving forward to
minimize chances of patient pulling out tube and creating a
surgical emergency.
#Acute Kidney Injury:
Patient developed acute kidney injury on ___ (Creatinine was
2.2 from 1.1 earlier in hospitalization) that was likely
secondary to IV acyclovir given associated crystallization
deposition vs renal hypoperfusion (poor PO intake and diarrhea).
Nephrology consult was obtained to assist with management. Renal
ultrasound was negative for hydronephrosis. Patient was started
on IVF with ___ NS as volume challenge and to treat
hyponatremia, but Creatinine remained persistently elevated in
1.7-2.0 range. After discussions with renal team, this injury
was likely ATN and should gradually downtrend. Patient will
follow up with renal team as outpatient with repeat labs.
#Yeast Esophagitis: On ___ patient had PEG performed as detailed
above, where it was noted that patient had yeast esophagitis.
Patient was started on Fluconazole with plans to complete 2 week
course, through ___.
#Acute Hyponatremia: Patient presented with sodium 126 (baseline
137-139 per outpatient PCP ___. Urine/serum studies on
admission were consistent with SIADH (high urine Na, urine Osms,
euvolemic clinically). Patient was started on 3% saline drip and
monitored closely with serial neurologic checks. Her sodium
gradually improved to 131-132 by ___. Given overall clinical
improvement, 3% saline was discontinued on ___ and she was
transitioned to PO salt tabs. Diet was advanced after passing
speech/swallow to regular solids/thin liquids on ___. Her
sodium increased to 143-145 on ___ and her PO salt tabs were
discontinued on ___. Her sodium improved to 138-139 on ___.
She was continued on half normal saline prior to initiation of
tube feeds. This was not continued upon discharge.
#Fever: Patient continued to spike fevers throughout hospital
course. Multiple sets of cultures were sent in-house serially
and OSH cultures were followed as well. This was notable for ___
blood cultures positive for Bacillus (non anthracis species) at
OSH ED, but repeat and serial cultures during ___
___ were negative. Patient did have diarrhea on
___ for which stool cultures including C Diff, culture and
B. cereus were sent. ID team was consulted and was closely
involved with management. On ___, the patient spiked a fever to
103.0; chest x-ray demonstrated a small left opacity concerning
for pleural effusion vs. atelectasis which enlarged on repeat
chest x-ray on ___. On ___, the patient also desaturated to
the high ___ and required oxygen by nasal cannula. On
urinalysis, the patient was also noted to have many bacteria and
45 WBC. The patient's fever in the setting of pleural effusion
was concerning for health care-associated pneumonia, so per ID
recommendations, on ___ the patient was started on vancomycin
and piperacillin/tazobactam, which was continued through ___.
Patient completed treatment course and remained clinically
stable. She did not spike further fevers during hospitalization.
#Diarrhea: Starting on ___ patient developed loose stool over
last 24 hours. Etiology unclear, differential included non
infectious diarrhea (particularly adverse effect from Acyclovir,
seen in minority of cases) vs C Diff vs viral gastroenteritis.
Stool cultures were negative for C diff, B cereus,
Campylobacter, Shigella, and Salmonella. Diarrhea gradually
resolved.
#Hypokalemia: Found to have low potassium during hospital
course, requiring daily repletion. Diarrhea had resolved at this
point; patient not on diuretics. No evidence of RTA. Thought to
be possibly due to medications, including acyclovir or zosyn,
which have been reported to cause hypokalemia. Patient was
started on PO potassium supplementation and potassium returned
in normal ranges. Potassium remained stable after PO potassium
was discontinued.
TRANSITIONAL ISSUES:
1) continue Valacyclovir through ___ per ID recommendations
2) Repeat BMP in 1 week to trend Cr, K and Na. Will follow up
with Nephrology later this month as well.
3) If/when renal function improves, can adjust Keppra as needed.
Did not have any electrographic seizures. Discharged on Keppra
500mg BID
4) Continue to monitor oral intake closely. Monitor caloric
intake. Encourage ensure supplementation with meals.
5) Will follow up with Renal and Neurology upon discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Losartan Potassium 25 mg PO DAILY
3. amLODIPine 10 mg PO DAILY
4. Levothyroxine Sodium 150 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever, pain
2. Fluconazole 200 mg PO Q24H
RX *fluconazole 200 mg 1 tablet(s) by mouth daily Disp #*12
Tablet Refills:*0
3. Heparin 5000 UNIT SC BID
4. LevETIRAcetam 500 mg PO BID
5. Ranitidine 150 mg PO BID
6. ValACYclovir 1000 mg PO Q12H
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth once a day Disp
#*11 Tablet Refills:*0
7. Aspirin 81 mg PO DAILY
8. Levothyroxine Sodium 150 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Herpes Simplex Type 1 Encephalitis
Discharge Condition:
Stable
Discharge Instructions:
Dear Ms. ___,
You were admitted to hospital for confusion, fever, and
difficulty with speech. We sent off a number of tests to look
for the cause, and this revealed that you had a condition called
HSV encephalitis. You also had an MRI and CT of your head, which
was consistent with this condition. We started you on Acyclovir,
an IV medication used to treat this condition. You had gradual
improvement in your speech after starting the medication, with
the help of physical therapy. During your hospitalization, you
also were started on Keppra to treat possible seizures, likely
from the HSV. Later on, you developed injury to your kidney,
which most likely was from the Acyclovir. For this reason, you
were changed from Acyclovir to Valacyclovir. You were seen by
the kidney doctors and your ___ function gradually improved
with this regimen. You will go to rehab facility, and then will
see both the kidney and neurology doctors in follow up.
Followup Instructions:
___
|
10792610-DS-13
| 10,792,610 | 24,350,711 |
DS
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2188-10-01 00:00:00
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2188-10-01 20:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
SHORT OF BREATH
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ w/recent-onset atrial fibrillation, now p/w 3 days
progressive shortness of breath and chest pressure/severe
dyspnea on awakening this morning. Daughter called EMS, who
found her tachypneic into the mid ___, hypoxic to low ___ on
room air, and mildly hypertensive. EMS started CPAP & brought
her to the ED.
.
In the ED on arrival, O2 sat 95/RA, RR ___. Denied recent
coughing, sputum production or fever. On exam she had peripheral
edema plus bilateral pleural effusions (confirmed on CXR). CBC
wnl, Trop-T <0.01 proBNP: 1821 lactate 3.1. EKG showed atrial
fibrillation. Received 20 mg IV lasix (800 cc uop) and 81 mg
ASA. No NTG because BP was 100 systolic at the time (per ED
attending note). Transfer VS 98.6 77(afib) 118/70 RR27 97%/4L
NC.
.
On arrival to the floor, pt ___ only and defers all
questions to her daughter. Daughter ___ describes about
4 months of exertional fatigue and SOB - a few stairs or 100 ft
walking will exhaust her to the point of needing to sit down
huffing and puffing. Also has a dry cough, very occasionally
productive of yellow sputum. No reported weight gain but neither
pt nor daughter know her usual weight. Clothing/shoes fit
unchanged.
.
Daughter says pt saw her PCP 3 weeks ago and was started on a
new medication temporarily (no plan for refill), finished 3 days
ago. Unsure whether lasix or not. Had been fine on ___ after
last dose. Outpatient notes also refer to pradaxa use, but pt's
daughter says she is only taking 2 medications, aspirin and
atenolol (recently increased to 2 50-mg tabs per day), nothing
else. Confirms that she is not taking either pradaxa or
synthroid at this time.
.
Regarding her chest pressure sensation - this morning was the
first episide. Tightness was the prominent sensation. Couldn't
catch her breath. No nausea, vomiting or diaphoresis. All
symptoms resolved with supplemental oxygen in the ambulance en
route. Denies chest pain, SOB, and abdominal pain.
Past Medical History:
Atrial fibrillation (diagnosed ___
Anxiety/Depression (not taking prescribed citalopram)
Hypothyroidism (not taking prescribed synthroid)
Hypertension (increased atenolol 50 mg -> 100 mg 2 weeks ago)
Possible TIA ___ yr ago (per outpatient clinic notes)
Social History:
___
Family History:
No known hx heart failure or MI.
Physical Exam:
ADMISSION EXAM
VS 98.3 135/100 74 22 96/2L (92-94/RA) 87.9 kg
GEN calm elderly female lying in bed in NAD
HEENT NCAT MMM EOMI OP clear, JVD 5+ sternal angle
PULM coarse breathing and coarse apical breath sounds, dull
breath sounds bilaterally (L basilar, R ___ up). No wheeze or
focal rhonchi.
CV heart sounds largely obscured by coarse breathing,
irregularly irregular when pt asked to hold breath, difficult to
assess for murmur (cannot r/o)
ABD obese soft normoactive bowel sounds, no r/g, no HSM
EXT WWP 2+ pulses palpable bilaterally, 1+ pitting edema to
mid-calf equal bilaterally
NEURO AOX2 (hospital, name), answers questions only indirectly,
CN2-12 intact, strength ___ throughout. gait not assessed.
SKIN no ulcers or lesions
.
DISCHARGE EXAM
VS 98.1 120-150S/60-80s HR 90-100 RR 20 O2 96/RA (97/RA
ambulatory) Wt 85.8 kg
GEN calm elderly female sitting up fully dressed NAD
HEENT NCAT MMM EOMI OP clear, JVD 3+ sternal angle
PULM CTAB no r/r/w. coarse breathing and bibasilar dullness
resolved
CV irregularly irregular HS, no murmur
ABD obese soft normoactive bowel sounds
EXT WWP 2+ pulses palpable bilaterally, no pedal/ankle edema
NEURO AOX2 (hospital, name), makes good eye contact and answers
questions appropriately thru translator, CN2-12 intact, strength
___ throughout. gait stable
Pertinent Results:
ADMISSION LABS
___ 07:45AM BLOOD WBC-9.7 RBC-4.94 Hgb-14.4 Hct-44.4 MCV-90
MCH-29.2 MCHC-32.5 RDW-13.6 Plt ___
___ 07:45AM BLOOD Neuts-80.7* Lymphs-14.9* Monos-3.1
Eos-0.7 Baso-0.5
___ 07:45AM BLOOD ___ PTT-35.6 ___
___ 07:45AM BLOOD Glucose-153* UreaN-21* Creat-0.7 Na-143
K-4.4 Cl-108 HCO3-23 AnGap-16
.
OTHER PERTINENT LABS
___ 07:45AM BLOOD proBNP-1821*
___ 06:20AM BLOOD CK-MB-1 cTropnT-<0.01
___ 03:52PM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:45AM BLOOD cTropnT-<0.01
___ 07:45AM BLOOD TSH-8.0*
___ 06:00AM BLOOD Free T4-1.4
___ 07:51AM BLOOD Lactate-3.1*
___ 04:07PM BLOOD Lactate-1.6
___ 06:00AM BLOOD Cholest-156 Triglyc-107 HDL-50
CHOL/HD-3.1 LDLcalc-85
.
DISCHARGE LABS
___ 06:00AM BLOOD Glucose-118* UreaN-33* Creat-0.8 Na-143
K-3.8 Cl-105 HCO3-23 AnGap-19
___ 06:00AM BLOOD ___ PTT-38.1* ___
___ 06:00AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.0
.
MICRO
URINALYSIS
___ ADMISSION UA
Color-Straw Appear-Clear Sp ___ Blood-NEG Nitrite-NEG
Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG
pH-5.0 Leuks-NEG
.
___ REPEAT UA
Color-YELLOW Appear-Hazy Sp ___ Blood-TR Nitrite-POS
Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0
Leuks-LG RBC-1 WBC-27* Bacteri-MANY Yeast-NONE Epi-1 TransE-<1
.
___ URINE CULTURE (Preliminary):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
GRAM NEGATIVE ROD #2. 10,000-100,000 ORGANISMS/ML.
___ BLOOD CULTURES X2 - NGTD
___ URINE CULTURE - NGTD
.
IMAGING
.
___ CXR
FINDINGS: There is diffuse hazy opacification of the lungs,
compatible with edema. There are suspected small bilateral
pleural effusions. No pneumothorax is seen. No definite
consolidation to suggest pneumonia is seen. There is mild
cardiomegaly.
IMPRESSION: Findings consistent with pulmonary edema.
.
STUDIES
.
ADMISSION EKG atrial fibrillation at 92 bpm, no ST/Tw changes
.
___ TTE
The left atrium is dilated. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF 65%). There is considerable beat-to-beat
variability of the left ventricular ejection fraction due to an
irregular rhythm/premature beats. There is no ventricular septal
defect. The right ventricular free wall is hypertrophied. The
right ventricular cavity is dilated with depressed free wall
contractility. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
There is an anterior space which most likely represents a
prominent fat pad.
.
PENDING STUDIES (___ TO CALL PCP ___ RESULTS)
___ URINE CULTURE
___ URINE CULTURE (PRELIM GNR)
Brief Hospital Course:
___ w/recent-onset atrial fibrillation and hypertension admitted
with 3 days of progressive dyspnea which evolved to acute chest
pressure and inability to catch a breath upon awakening, found
to have pulmonary edema and diastolic heart failure; symptoms
improved with diuresis.
.
# ACUTE PULMONARY EDEMA/Acute DIASTOLIC HEART FAILURE (EJECTION
FRACTION 55%)
History of several months minimal exercise tolerance and DOE
building to an acute episode of acute pulmonary edema on the
morning of admission was very suggestive of clinical diagnosis
CHF. Suspicion was for arrhythmia-induced heart failure
(recent-onset afib) and/or hypertension rather than ischemic
disease, as pt had no hx chest pain/pressure before this morning
and cholesterol panel well wnl. We initially suspected the
medication she had run out of last week was a diuretic, but it
turned out to be pradaxa (see PCP NP note in OMR). Pt responded
well to low-dose lasix and felt well within ___ of admission
without SOB, wheeze or chest discomfort. O2 requirement also
resolved. Dry weight unknown. Based upon weights here, suspect
dry weight ~190-193 lbs (NOTE: admission weight of 193 lbs was
logged *after* 1L diuresis and symptomatic relief in ED). As for
underlying reason for cardiomyopathy - B12/folate all checked
1.5 mos ago by PCP and were wnl. TSH elevated but fT4 wnl. TTE
was reviewed with cardiologist, who felt TTE findings of
preserved EF but dilated LA, thickened LV, and hypokinetic RV
were altogether suggestive of diastolic heart failure from
uncontrolled hypertension-induced cardiomyopathy. Home atenolol
dose was increased (from 50 BID to ___ qAM/50 qPM) and
atorvastatin started to complete medical management of CAD in
the event there is a component of ischemic cardiomyopathy. Lasix
20 PO QD, K repletion also started. Initiation of ACEI for
better BP control and treatment of possible ischemia disease was
deferred to PCP and cardiology ___ (arranged) to make sure
volume status and lytes/renal function remain stable.
.
# RECENT ONSET ATRIAL FIBRILLATION
Noted at ___ office within the past month; given hx fatigue
and DOE going back several months plus minimal prior medical
care, suspect arrhythmia may date back to onset of fatigue
symptoms ___ mos ago. Atenolol increased (for BP effect given
dCHF).
Discussed topic of anticoagulation w/pt's PCP. There was some
confusion about whether she had been on anticoagulation at home;
___ NP confirmed that pt had taken pradaxa but only for 1
month starting ___. Increased ASA to 325 mg and defer
re-initiation of pradaxa (vs warfarin) to PCP/Cardiologst (PCP
is ___. ___ consult evaluated the pt and felt she was not a
fall risk.
.
# CHEST PAIN
Pt reported chest pressure sensation on the morning of
admission. Most likely related to acute pulmonary edema. No
associated anginal symptoms of N/V/diaphoresis. CP resolved with
supplemental O2. Cardiac enzymes negative x3. TTE showed no
evidence of focal hypokinesis (although difficult to r/o given
poor echo windows.)
.
# HX HYPERTENSION
Chronically on atenolol for HTN, recently increased to 50 mg BID
when afib diagnosed. BPs 120-150s/60-80s here. Increased
atenolol after TTE showed features consistent with
hypertension-induced cardiomyopathy and there was a short run of
WCT noted on tele (although suspect Afib with aberrancy rather
than NSVT). Lasix 20 mg PO QD started. Would consider starting
___ as additional antihypertensive agent in this pt
w/newly-diagnosed ___ also at risk for CAD.
.
# URINARY TRACT INFECTION
Pt had UA/UCx sent on arrival from the ED and foley placed for
uop moniting in setting of CHF. Initial UA clean, but UCx grew E
coli and another yet-unspeciated GNR. Since this might reflect
colonization rather than infection, repeat UA was sent - it was
grossly positive. Pt reported no urinary symptoms. Started cipro
500 q12h BID x 3d for uncomplicated cystitis. Additional urine
culture (to determine dominant species/antibiotic sensitivity at
time of positive UA) pending at discharge. Will communicate
final urine culture data and any necessary antibiotic change to
patient via her PCP.
.
# HX HYPOTHYROIDISM
Pt previously on synthroid. Script refilled at PCP ___ 1.5 mos
ago at which time her TSH was found to be slightly elevated at
4.3. Now elevated at 8.0 but fT4 wnl at 1.4. Family reports pt
not taking synthroid at this time, unclear why. Defer decision
regarding whether to restart synthroid to PCP ___.
.
# HX DEPRESSION
Pt defers most questions to daughter, so it was difficult to
assess psychological status and mood directly. Appetite good,
slept well. PCP has prescribed celexa but family reports pt is
not currently taking it. Defer restarting celexa to outpatient
PCP.
.
# MED NONCOMPLIANCE
Suspect discrepancies between PCP notes and meds actually taking
at home may be attributable to either communication gap (since
pt ___ only and family ___ speaking)
and/or inability to procure meds, for logistical/financial
reasons. ___ arranged to oversee medication education and
complaince. PCP ___.
.
# DEMENTIA
Pt was AOX2 on arrival (name, hospital) and inattentive.
Daughter confirmed baseline MS and PCP uncovered notes from last
PCP (dating back to before ___ which document need for
re-orientation and occasional inattentive childlike behavior
in-office but no formal mental status exam. Defer further
evaluation and counseling to outpatient ___.
.
TRANSITIONAL ISSUES
.
1. ___ LABS (NA, K) TO BE CHECKED AT PCP ___ APPTS ___
STARTED ON LASIX, K REPLETION.
2. CHECK VOLUME STATUS/WEIGHTS, ADJUST PO LASIX PRN.
3. CONSIDER STARTING ANTICOAGULATION (PRADAXA VS WARFARIN)
4. WILL NEED CK AND LFTS CHECKED IN 1 MONTH (STARTED STATIN)
5. ADDRESS ANY ___ ISSUES ___ TO CHECK WEIGHT/BP/HR &
MEDICATION COMPLIANCE). ENSURE ___ RECEIVING AND REFILLING
MEDICATIONS REGULARLY AND UNDERSTAND THEIR INDICATIONS.
6. REVISIT NEED FOR THYROID REPLACEMENT.
7. REASSESS DEPRESSION/DEMETIA ISSUES, RESTART SSRI PRN.
8. CARDIOLOGY ___ FOR ___ MEDICAL MANAGEMENT ARRANGED.
9. URINE CULTURE DATA PENDING - WE WILL CALL PCP ___
Medications on Admission:
ATENOLOL 50 MG BID
ASPIRIN 81 MG QD
PRADAXA (took for 1 month starting ___
CITALOPRAM 20 MG QD (NOT TAKING)
SYNTHROID 25 MCG QD (NOT TAKING)
MECLIZINE 12.5 MG TID PRN DIZZINESS (NOT TAKING)
Discharge Medications:
1. atenolol 50 mg Tablet Sig: AS DIRECTED Tablet PO BID (2 times
a day): 100 MG 8AM (2 TABS)
50 MG 8PM (1 TAB).
Disp:*90 Tablet(s)* Refills:*0*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Klor-Con M20 20 mEq Tablet, ER Particles/Crystals Sig: One
(1) Tablet, ER Particles/Crystals PO once a day.
Disp:*30 Tablet, ER Particles/Crystals(s)* Refills:*0*
5. Outpatient Lab Work
AT PRIMARY CARE OFFICE, ARRIVE 1 HOUR BEFORE APPOINTMENT.
.
LAB: DRAW CBC, BMP, INR - RESULT TO ___. ___
6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
7. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
NEW-ONSET DIASTOLIC HEART FAILURE, LVEF 55%
HYPERTENSION
HYPOTHYROIDISM
DEMENTIA
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to the hospital for fluid overload.
In the emergency room, we found that ___ were retaining fluid in
your lungs and your legs. This suggested heart failure. ___
responded well to lasix, a water pill. An echocardiogram
(ultrasound of your heart) showed that your heart failure is
most likely from high blood pressure.
Your labs also showed a urinary tract infection. We started ___
on three days of antibiotics.
We also saw that your thyroid function was low. Your daughter
said ___ are NOT taking synthroid pills at home.
We spoke with your doctor Dr. ___ wants to see ___ in
clinic this week. If your daughter ___ is your primary
caregiver, she should go with ___ to this appointment. It is
very important that your doctor and your daughter discuss which
medications ___ need to take and why. ___ have multiple serious
medical conditions which are treatable, but only if ___ take
your medications regularly.
We made the following changes to your medications:
STARTED LASIX, ONE 20 MG PILL EVERY MORNING. DO NOT SKIP DOSES.
STARTED POTASSIUM SUPPLEMENT, TAKE ONE 20 MG TABLET DAILY.
STARTED ATORVASTATIN, TAKE 40 MG DAILY.
STARTED CIPROFLOXACIN (ANTIBIOTIC), TAKE 1 TAB EVERY 12 HOURS
FOR 3 DAYS.
INCREASED ASPIRIN TO ONE 325 MG PILL DAILY.
INCREASED ATENOLOL TO 100 MG (2 TABS) IN THE MORNING AND 50 MG
(ONE TAB) IN THE EVENING.
For your heart failure:
1. ___ should weigh yourself every morning and write down your
weight. Take the log with ___ to every appointment with Dr.
___. If ___ gain more than 3 lbs over your weight of 193
lbs (measure here today), call Dr. ___.
2. Do not skip doses of lasix.
3. Eat a low-salt diet (total less than 2 grams per day). Be
careful: spice mixes and canned/prepared/restaurant food contain
large amounts of salt.
Please talk to Dr. ___ have concerns about not being
able to pick up or pay for your medications. They may be able to
help.
Finally, a visiting nurse ___ come to your home on a regular
basis to check your weight, review your medications, and discuss
diet and medication management with ___ and your family. The
nurse can serve as a liaison to your doctor and answer questions
___ have after ___ leave the hospital.
Followup Instructions:
___
|
10792610-DS-17
| 10,792,610 | 24,548,323 |
DS
| 17 |
2191-11-04 00:00:00
|
2191-11-04 17:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Facial Droop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of afib on aspirin, dementia with psychosis and
prior right thalamic hypertensive hemorrhage in the setting of
rivaroxaban who presents with report of worsening left facial
droop at noon yesterday per nursing home. Per daughter, she has
a chronic mild left facial droop since her bleed in addition to
mild left arm and leg weakness and the patient is at baseline to
her.
In the ED, initial vitals: 98.4 76 118/64 15 98% RA. Code
stroke was called. Left facial droop was similar to prior ICH
stroke. ED discussed with EMS and nursing facility and patient's
mental status is at baseline. Patient is ___ speaking
only. She was combative in ED which is her baseline. Neurology
was consulted. Her CT head shows significant atrophy and small
vessel disease, right>left. Most likely, UTI causing transient
worsening of prior stroke symptoms. She was given 1L IVF and
ceftriaxone IV for UTI. Her lactate continued to rise and she
was therefore sent for CT abdomen and pelvis which did not show
an abdominal process.
Received 1.5L IVF and CTX.
On arrival to the MICU, pt agitated in restrains and swearing
back in ___ to every question. Unable to do ROS due to
mental status.
Past Medical History:
Atrial fibrillation (diagnosed Febrary ___
Anxiety/Depression
Hypothyroidism
Hypertension
R thalamic hemorrhagic stroke ___
Anxiety/Depression
dCHF
CAD
HLD
Social History:
___
Family History:
No known history of heart failure or MI.
Physical Exam:
ADMISSION:
Vitals: P:138 R:22 18 O2:95%
GENERAL: agitated, swearing constantly, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
CV: irregular, tachycardia
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: no edema
NEURO: unable to assess given pt not cooperative
DISCHARGE:
ADMISSION:
Vitals: Afebrile, 60 in AFib, 101/68, 19, 98% on RA
GENERAL: agitated, swearing frequently, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
CV: irregular, tachycardia
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: no edema
NEURO: unable to assess given pt not cooperative
-Mental Status: Alert, combative initially, oriented to self,
hospital but not date (baseline). Answers some questions
appropriately when her daughter asks (eg Why are you here? How
do you feel?). Will not name. Will not repeat. Will stick out
tongue to command.
-Cranial Nerves:
Pupils ___ bialterally, does not blink to threat on the left
(baseline per daughter). Looks to both side of the room. Does
have a mild left facial droop.
-Motor: Will not do formal motor testing but resist strongly in
both arms, L is a bit weaker at the delt and tricep. Will only
lift legs to tickling so at least 3 at the IP, Ham.
-Sensory: Reponds to touch throughout
-DTRs:
Bi Tri ___ Pat Ach
L ___ 2 0
R ___ 2 0
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FTN on the right, Does not
perform on the left
-Gait: Does not walk
Pertinent Results:
LABS:
===========
___ 03:45PM ___ PTT-33.4 ___
___ 03:45PM PLT COUNT-163
___ 03:45PM WBC-8.0 RBC-5.25 HGB-16.8* HCT-49.5* MCV-94
MCH-32.0 MCHC-33.9 RDW-14.6
___ 03:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:52PM GLUCOSE-88 NA+-141 K+-6.2* CL--105 TCO2-24
___ 03:52PM CREAT-0.8
___ 07:30PM URINE BLOOD-NEG NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-4* PH-6.5 LEUK-MOD
___ 07:30PM URINE RBC-1 WBC-5 BACTERIA-MANY YEAST-NONE
EPI-0
___ 07:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 10:35PM ___ PTT-34.4 ___
___ 10:35PM NEUTS-63.4 ___ MONOS-6.6 EOS-1.1
BASOS-0.8
___ 10:35PM WBC-8.2 RBC-5.01 HGB-16.6* HCT-46.7 MCV-93
MCH-33.1* MCHC-35.5* RDW-13.4
___ 10:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 10:35PM cTropnT-<0.01
___ 10:35PM GLUCOSE-99 UREA N-19 CREAT-0.7 SODIUM-145
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-33* ANION GAP-12
___ 10:46PM LACTATE-3.0* K+-4.9
DISCHARGE:
============
___ 09:13AM BLOOD WBC-8.3 RBC-5.11 Hgb-16.4* Hct-47.8
MCV-94 MCH-32.1* MCHC-34.2 RDW-13.5 Plt ___
___ 10:35PM BLOOD cTropnT-<0.01
___ 03:45PM BLOOD cTropnT-<0.01
___ 09:56AM BLOOD Lactate-2.0
IMAGING:
=============
___ CT HEAD
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Confluent periventricular and subcortical white matter
hypodensities,
greater on the right, are more pronounced since ___ - ___
represent
progressive chronic small vessel ischemic disease, but in the
appropriate
clinical setting, underlying acute ischemia is not entirely
excluded. MR is more sensitive for the detection of acute
ischemia. Findings discussed with Dr. ___ at 420 pm.
3. Chronic left sphenoid sinus opacification.
___ CXR
Patient is rotated to the left. The lungs are grossly clear
without focal consolidation or effusion. Enlarged main pulmonary
artery is as seen on prior CT scan. Cardiac silhouette also
appears moderately enlarged although not dramatically changed
given differences in technique and positioning. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
___
CT ABD
IMPRESSION:
1. No CT evidence of acute abdominal or pelvic process.
2. 1.2 cm hypodensity in the interpolar region of the left
kidney with soft tissue attenuation in this contrast enhanced
exam is indeterminate and should be further evaluated by
ultrasound on a nonemergent basis.
3. Moderate to severe cardiomegaly we significant contribution
from the right cardiac chambers.
4. Mild dependent pulmonary edema in the lung bases.
Brief Hospital Course:
___ with history of afib on aspirin, dementia with psychosis and
prior right thalamic hypertensive hemorrhage in the setting of
rivaroxaban who presents with report of worsening left facial
droop concerning for stroke. She was ultimately felt to be at
baseline neurocognitive status per family, Neurology, and MICU
team without acute medical disease and was discharged back to
___.
# Concern for Stroke: Pt with hx of right thalamic hypertensive
hemorrhage in ___ while taking rivaroxaban. There was concern
for new stroke given "L facial droop" which led to patient's
admission. CT head shows significant atrophy and small vessel
disease, right>left. At ED patient was evaluated by neurology
and after exam and discussion with pt's daughter and nursing
facility, it was determined that pt has had mild chronic left
facial droop and weakness since prior stroke and current exam is
at baseline. Patient demonstrated no further concern for focal
neurological deficit.
# Asymptomatic Bacteriuria: UA concerning for UTI with mod
___, pos nitrite, many bacteria but only 5 WBC. Also noted to
be foul smelling. Given CTX at ED. Past urine culture data
notable for pan-S e.coli and pan-S proteus except for cefazolin.
Patient was initially placed on ceftriaxone but this was
discontinued in MICU as this was felt to be colonization.
# Elevated Lactate: Lactate has been elevated and uptrending
from 3 to 4.7 in ED despite starting CTX. Surprising lactate
continued to go up despite CTX for UTI. No abdominal process on
CT. CXR unremarkable for pulm infection. Lactate improved
without any intervention to improve perfusion.
# Atrial Fibrillation: Given hemorrhagic stroke while on
rivaroxaban, plan on discharge in ___ was to hold rivaroxaban
for 3 months and restart if no further events. Pt has not yet
followed up with neurologist and has not restarted rivaroxaban.
has been on full dose ASA. Patient was continued on home
metoprolol and diltiazem and will need to follow with Dr.
___ discuss restarting rivaroxaban as outpatient
# Agitated Dementia: Patient with known dementia with agitated
psychotic features at baseline agitated at ED swinging at staff.
Per family/nursing facility, patient's behavior at baseline. CT
head notable for chronic small vessel ischemic disease, and
possibly vascular dementia. has had a hx of late latent syphilis
w/ +RPR, +serum VDRL. Negative CSF VDRL. Completed IM penicillin
course in ___. UA showed positive ___ but
no WBC indicating chronic colonization without acute infection.
Patient remained at her baseline mental status throughout this
hospitalization but RPR was repeated.
CHRONIC MEDICAL ISSUES:
# Anxiety/Depression: Continue home seroquel, traz, divaloprex
# CAD: Cont home asp, metop, trop negX2, and EKG showed only
atrial fibrillation
# Chronic diastolic heart failure: no signs of exacerbations,
continue home diuretics
# Hypothyroidism: continue home levothyroxine
# CKD: Patient with known CKD presented without acute kidney
injury
# Communication: ___ (daughter, ___
# Code: Full Code confirmed with HCP
# Disposition: SNF
TRANSITIONAL ISSUES:
- Patient has not followed up with Dr. ___
since her bleed in ___. She needs to make an appointment as
soon as available to discuss the possibility of restarting
Rivaroxaban as planned.
- Urine culture and repeated RPR testing pending at time of
discharge
- ___ yo patient with dementia is still Full Code in discussion
with family
- Communication: ___ (daughter, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Diltiazem Extended-Release 120 mg PO DAILY
3. Divalproex (DELayed Release) 500 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Furosemide 40 mg PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Metoprolol Tartrate 100 mg PO BID
8. Potassium Chloride 20 mEq PO DAILY
9. QUEtiapine Fumarate 25 mg PO BID
10. Acetaminophen 650 mg PO Q6H:PRN pain, fever
11. Albuterol 0.083% Neb Soln 1 NEB IH Q8H:PRN dyspnea, cough
12. Guaifenesin 10 mL PO Q4H:PRN cough
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Senna 8.6 mg PO BID:PRN constipation
15. Senna 17.2 mg PO QHS
16. Vitamin D 50,000 UNIT PO QMONTH on the ___
17. TraZODone 25 mg PO QAM
18. QUEtiapine Fumarate 50 mg PO QHS
19. TraZODone 12.5 mg PO Q4H:PRN agitation
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q8H:PRN dyspnea, cough
2. Aspirin 325 mg PO DAILY
3. Diltiazem Extended-Release 120 mg PO DAILY
4. Divalproex (DELayed Release) 500 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Furosemide 40 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Metoprolol Tartrate 100 mg PO BID
9. QUEtiapine Fumarate 25 mg PO BID
10. QUEtiapine Fumarate 50 mg PO QHS
11. Senna 8.6 mg PO BID:PRN constipation
12. Senna 17.2 mg PO QHS
13. TraZODone 25 mg PO QAM
14. TraZODone 12.5 mg PO Q4H:PRN agitation
15. Acetaminophen 650 mg PO Q6H:PRN pain, fever
16. Guaifenesin 10 mL PO Q4H:PRN cough
17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
18. Potassium Chloride 20 mEq PO DAILY
19. Vitamin D 50,000 UNIT PO QMONTH on the ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
Left Facial Droop
Elevated Lactate
Baseline Agitation
Atrial Fibrillation with Rapid Ventricular Response
Asymptomatic Bacteriuria
SECONDARY:
Chronic Heart Failure with Preserved Ejection Fraction
Anxiety/Depression
Hypothyroidism
Hypertension
Tertiary Syphilis status-post Penicillin course
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because your
face was drooping and this was concerning for a stroke. You
were evaluate by our Neurology team, Emergency medicine
physicians, and ___ Care unit. We determined that you did
not have a stroke, you did not have an infection, and you did
not have any other life-threatening process. In discussion with
your daughter, you were discharged back to your nursing home for
further care. Best of luck to you in your future health.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10792661-DS-21
| 10,792,661 | 29,781,533 |
DS
| 21 |
2190-03-06 00:00:00
|
2190-03-26 18:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vicodin
Attending: ___.
Chief Complaint:
Syncopal fall
Major Surgical or Invasive Procedure:
Left lower extremity ORIF of bimalleolar tib/fib fracture
History of Present Illness:
Patient is a ___ female with PMH of chronic HepC, alcohol abuse
(4 drinks per day, last drink on the evening PTA, no history of
withdrawl seizures), and hypertension with recent episodes of
LOC who presents to the hospital after a witnessed fall on the
night of admission. Patient awoke from sleep around 1230AM to go
to the bathroom and drink water. She left her bed and in the
hallway on the way to the restroom, fell. She injured her ankle
on the way down and reports not hitting her head. This was
witness by her boyfriend. ___ the event she does not
recall experiencing tunnel vision, tachycardia, or feeling
flushed. She reports it happened rather suddenly and only
remembers the impact. The witness reports that she lost
consciousness for 10 seconds and then came to. Patient knows
that she did not feel herself after coming to and reports that
it took several minutes but less than one hour for her to feel
mentally normal. She did not lose control of her bowel or
bladder. She did not hit her head on the way down. She has no
other pain aside from her ankle, which she injured during her
fall. Regarding the fall history she had a few episodes similar
to this a few years ago, and again a few in the past month. She
had one a few days PTA and the one that occured on night of
admission. The previous episodes were similar to this one in the
shaking, LOC, and duration of recovery. She does not feel that
these are related to her alcohol consumption.
Past Medical History:
1. Hypertension.
2. History of hepatitis C.
3. Chronic alcohol abuse (1 pint of rum daily).
4. Tobacco use (about one pack a day for ___ years).
5. Anxiety.
6. Depression.
7. History of polysubstance abuse with heroin use and minimal
cocaine use at age ___, none currently.
8. History of one ectopic pregnancy.
9. History of appendectomy.
10. History of cellulitis secondary to cat bite.
11. Recurrent syncope - seen by cards
Social History:
___
Family History:
Her ___ son has reported palpitations, but no syncope,
as has her ___ son. She has four brothers and two
sisters without knowledge of any medical problems. Her father
died of a myocardial infarction at age ___.
Her mother died of an unknown cause at age ___ while at an
assisted living facility. She denies any family history of
significant problems with surgeries.
per interview: no family history of seizure disorder
Physical Exam:
Physical Exam on Admission:
VS - VS T96, HR88, BP160/72, RR18, O2sat 99%RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA but consricted to pinpoint, EOMI, sclerae
anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, ___ systolic ejection murmur
heard best at the RUSB, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, liver span estimated at 10cm and
palpable 1-2cm below lower costal margin, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
on RLE, LLE wrapped in a cast with intact sensation on all toes
distal to cast and brisk capillary refill
SKIN - no rashes or lesions
LYMPH - no cervical, LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, intact
sensation to light touch on all toes on left foot, intact motor
strength in toes of left foot, gait exam deferred
PHYSICAL EXAM ON DISCHARGE:
Vitals: T99.5F, BP105/61, HR:95, RR:18, O2sat:96%RA
Exam otherwise unchanged from admission
Pertinent Results:
Lab Results on Admission:
___ 04:20AM BLOOD WBC-4.8 RBC-3.12* Hgb-11.7* Hct-33.6*
MCV-108*# MCH-37.5* MCHC-34.7 RDW-12.8 Plt Ct-87*#
___ 04:20AM BLOOD Neuts-41.6* Lymphs-49.7* Monos-4.4
Eos-3.9 Baso-0.5
___ 05:39AM BLOOD ___ PTT-38.2* ___
___ 04:20AM BLOOD Glucose-98 UreaN-18 Creat-0.9 Na-135
K-3.4 Cl-97 HCO3-21* AnGap-20
___ 07:40AM BLOOD ALT-78* AST-130* LD(LDH)-155 AlkPhos-55
TotBili-1.8*
___ 04:20AM BLOOD cTropnT-<0.01
___ 07:40AM BLOOD Albumin-3.8 Calcium-8.2* Phos-2.6*
Mg-0.9*
___ 07:40AM BLOOD VitB12-725 Folate-14.8
___ 07:40AM BLOOD Osmolal-262*
Studies:
___ ECG: Normal sinus rhythm. Q wave in leads V1-V2 and only a
tiny R wave in lead V3. Compared to the previous tracing of
___ the changes are similar to those seen at that time and
may be related to altered lead placement. Consider prior
anterior wall myocardial infarction. No other diagnostic
abnormality.
___ Tib/Fib AP/lateral left: IMPRESSION: Slightly displaced
fractures of the distal fibula and medial malleolus with
associated widening of the medial ankle mortise.
___ CXR: IMPRESSION: No acute cardiac or pulmonary process.
___ Lower Extremity Fluoro: FINDINGS: Comparison is made to
previous study from ___. There has been interval
placement of a lateral fibular fracture plate fixating an
obliquely oriented fracture just extending into the tibiotalar
joint. There is also a cerclage band and percutaneous pin as
well as an interfragmentary screw in the distal tibia. The
previously identified widening of the medial ankle mortise has
improved since the prior study. The total intraservice
fluoroscopic time was 25.0 seconds.
Labaratory Results on Discharge:
___ 07:00AM BLOOD WBC-4.2 RBC-2.13* Hgb-8.1* Hct-22.8*
MCV-107* MCH-38.2* MCHC-35.6* RDW-13.5 Plt Ct-85*
___ 07:00AM BLOOD Glucose-105* UreaN-7 Creat-0.6 Na-128*
K-3.9 Cl-93* HCO3-25 AnGap-14
___ 06:55AM BLOOD ALT-49* AST-72* AlkPhos-65 TotBili-2.1*
___ 07:00AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.4*
___ 06:50AM BLOOD Osmolal-259*
Brief Hospital Course:
Primary Reason for Hospitalization: Patient is a ___ female
with PMH of alcohol dependence, chronic Hep C and episodes of
syncope who presented from home after a syncopal fall without
head injury resulting in ankle fracture. She was taken to the OR
for ORIF. He fall was likely a result of vasovagal syncope in
the setting of heavy alcohol consumption and volume depletion.
.
ACUTE CARE:
1. Left ankle fracture: Imaging revealed a bimalleolar tib/fib
fracture of the left extremity. Orthopedics was consulted in the
ED and the patient underwent an ORIF of the left lower extremity
on the day of admission. Per orthopedics, patient was provided
with Lovenox for DVT PPx. She was discharged with PCP ___,
home lovenox, and ___ services.
.
2. Fall: Etiology of patient's fall was likely vasovagal syncope
in the setting of volume depletion from heavy alcohol use. She
drinks up to four rum beverages nightly. Intoxication with
alcohol is also a possibility. Cardiac causes are unlikely as
echo is normal and EKG shows no arrhythmia. She is followed as
an outpatient by a cardiologist and was suggested to not drink
alcohol at home.
.
3. Hypertension: The patient was provided with her home
medication of Lisinopril throughout her hospital course. Her
pressures remained initially elevated likely due to pain,
anxiety post-op, and possible alcohol withdrawal, though the
pressures normalized with systolics in the 100s at the end of
her course.
.
4. Pyuria: The patient noted that she recently stopped taking
bactrim for UTI 3 days prior to admission. Based on preliminary
urinalysis at ___ indicating pyuria and few bacteria, the
patient received 2 days of Cipro during inpatient stay. Based on
a negative urine culture and lack of clinical findings, the
antibiotic course was stopped. The white blood cell count did
not elevate throughout the hospital course, and the patient had
only a single and intermittent temperature elevation to 100 that
quickly subsided.
.
5. Hyponatremia: The patient presented with a normal serum
sodium of 135, which gradually trended down to 126. The patient
received multiple fluid boluses with normal saline due to
suspected volume depletion on arrival. The patient's serum osms
revealed a hypotonic hyponatremia that appeared to be
unresponsive to fluid boluses. On clinical examination on ___,
the patient appeared euvolemic with continued hyponatremia of
126, and it was hypothesized that hyponatremia may be a result
of SIADH or hypothyroidism, though hypothyroidism less likely
due to normal prior TSH level. The patient was then fluid
restricted to 1.5L and urine and serum lytes were rechecked on
the evening of ___. Sodium trended up on ___ to 128, and
patient continued to be fluid restricted. On discharge,
patient's sodium was 129.
.
6. Calcium/Magnesium/Phosphate Levels: Patient's calcium
gradually trended up from 8.2 to 8.6, Magnesium trended from .9
to 2.5 with Magnesium supplementation throughout the hospital
course. Phosphate trended up from 2.6 to 3.3 with phosphate
repleted throughout the hospital course. Patient was asked to
supplement her magensium on discharge with daily oral Magnesium
Oxide.
.
CHRONIC CARE:
.
1. Alcohol Abuse: The patient notes that she suffered from
chronic alcoholism and notes that she has recently started
seeing a therapist to address her psych needs. As such, the
patient was provided with folic acid/thiamine. In lieu of
potential alcohol withdrawal as an inpatient, the patient was
placed on a CIWA scale and monitored for alcohol withdrawal with
Diazepam administration. The CIWA scale monitoring was
terminated due to not scoring. Social work contined to follow
the patient throughout the course and noted that she had taken
the first steps in overcoming her alcohol, and that no further
consulation needed at this time. She will be following up with
her PCP about her alcohol and cigarette consumption.
.
2. Anemia: The patient's HCT trended down from initial
presentation of 33.6 to 24.2 on ___, s/p ORIF. However,
basline may be around ___, due to likelihood of hypovolemia
due to alcohol consumption. Given the macrocytosis, both B12 and
folate levels were checked and found to be normal. Stool was
guiac negative.
.
3. GERD/ chronic choking spells: The patient notes chronic
gagging issues being followed up by otolaryngology. The patient
was continued on her home medication of omeprazole throughout
the hospital course.
.
4. Nicotine Dependence: The patient is ___ pack-year smoker, and
noted continued cravings in the hospital. The patient received a
nicotine patch and intermittent nicotine lozenges with positive
effect. Tha patient noted that she would follow up with her
primary care physician regarding smoking cessation.
.
TRANSITIONS IN CARE:
1. ___: Patient was instructed to ___ with her PCP
and with orthopedic surgery following discharge.
2. MEDICATION CHANGES: Patient was started on magnesium
supplements, lovenox injections, and morphine for pain control.
Medications on Admission:
Lisinopril 30mg PO daily
omeprazole 20mg PO daily
Flonase prn nasal congestion
Multivitamin
MG and Ca supplement
Aspirin 81mg PO daily
Discharge Medications:
1. lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
6. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain: do not take more than 4 pills
daily.
Disp:*20 Tablet(s)* Refills:*0*
7. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous at bedtime for 2 weeks.
Disp:*14 doses* Refills:*0*
11. morphine 15 mg Tablet Sig: 0.5 Tablet PO every six (6) hours
as needed for pain: Do not drive or operate machinery while
using this medication.
Disp:*15 Tablet(s)* Refills:*0*
12. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. calcium 500 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Left lower extremity tibial and fibular fracture
Secondary: Anemia
Syncope
Discharge Condition:
Left lower extremity aircast post open reduction and internal
fixation of tibial/fibular fracture.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care. You were admitted to
the ___ for a fall after fainting, leading to a fracture of
the tibia and fibula bones on the left leg. You underwent a
surgical procedure for your fracture with a cast placed on the
leg, and you were treated for electrolyte abnormalities.
Please make the following changes to your medications:
1. START Morphine sulfate 15mg tabs, take ___ tablet every 6
hours as needed for pain
2. START magenesium oxide supplements, 1 tablet every day
3. START Lovenox, one subcutaneous injection at bedtime, for 2
weeks
Please take all other medications as previously prescribed.
Please avoid alcohol, especially while taking morphine sulfate
for pain.
Please do not drive or operate heavy machinery while taking
morphine sulfate.
Please keep your ___ appointments
Followup Instructions:
___
|
10793093-DS-8
| 10,793,093 | 22,053,003 |
DS
| 8 |
2122-01-24 00:00:00
|
2122-01-25 11:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
HMED Admission Note
___
CC: altered mental status
Major Surgical or Invasive Procedure:
___ Bronchoscopy with biopsy
History of Present Illness:
============================================
PCP: Dr. ___: Dr. ___
Radiation ___: Dr. ___: Dr. ___
============================================
.
___ year old woman with > 100 pack year smoking history, chronic
bronchitis, and rheumatoid arthritis on methotrexate, who
presents with new metastatic CA. Pt was being evaluated at ___
Neurology due to complaints of dizziness and ataxia. An
outpatient MRI of the ___ done on ___ revealed numerous
lesions in the ___ concerning for metastatic disease. Her
primary care physician arranged for CT chest/abdomen/pelvis on
___ which revealed pulmonary nodules with suspected primary
lung CA. She was feeling dizzy so she was urged to go to the ER
but she refused. Her family came to see her, and she was found
incontinent of stool with a stove on and reportedly left
unattended (per ED report). She was initially brought to the ___
ED and had a CT ___ that did not show acute bleed or mass
effect. She was given Keppra for seizure prophylaxis given
evidence of lesions on ___ imaging and concern for a seizure at
home. She was then transferred to the ER at ___ for
evaluation as she gets her primary care at ___ and will be
followed by ___ Oncology.
In the ED here, pt with stable vitals. She was alert and
oriented x 3. Labs were remarkable for pyuria and microscopic
hematuria (ongoing issue for pt). She was given 1gm of CTX and
admitted for further care. Pt reports dizziness but denies
headache, nausea, vomiting. No loss of consciousness. No fevers
or chills. No back pain or other episodes of incontinence. No
dyspnea beyond her baseline or chest pain.
ROS: 10 point ROS negative except as noted above
Past Medical History:
# HTN
# Hyperlipidemia
# PAD s/p aortofemoral bypass
# Chronic bronchitis
# Nephrolithiasis
# Rheumatoid Arthritis, on methotrexate
# Chronic pyuria
Social History:
___
Family History:
Mother and father both had CAD. Unknown family history of
malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM
============================
Vitals: 98.1, 93, 127/56, 18, 94%RA
Gen: NAD
HEENT: NCAT, no cervical or supraclavicular LAD
CV: rrr, no r/m/g
Pulm: clear b/l
Abd: soft, nt/nd
Ext: skin tears on L anterior and posterior shin
Neuro: alert and oriented x 3, CN ___ intact, no pronator
drift, ___ strength in ___ proximally and distally though
sensation intact
.
DISCHARHE PHYSICAL EXAM
============================
VS: AF, 98.1, 140/71, 75, 18, 93% on RA
AMFS: 183
Gen: thin, elderly female, sitting in chair
Pain: zero out of 10
HEENT: anicteric, MMM
Neck: + right cervical lymphadenopathy
CV: RRR, no murmur
Lungs: CTAB/L, + dry cough
Abd: soft, NT, ND, NABS
Ext: palpable pulses, no edema
Skin: no jaundice, no rash, 3 small superficial wounds on RLE
Neuro: AAOx2, fluent speech, + ataxic gait, interactive, answers
?'s appropriately.
Mood: stable, appropriate
.
Pertinent Results:
ADMISSION LABS:
=================
___ 01:50AM BLOOD WBC-9.6 RBC-3.32* Hgb-11.1* Hct-34.2*
MCV-103* MCH-33.3* MCHC-32.3 RDW-15.9* Plt ___
___ 01:50AM BLOOD Glucose-113* UreaN-23* Creat-0.8 Na-135
K-3.1* Cl-100 HCO3-20* AnGap-18
___ 12:45PM BLOOD Mg-1.7
___ 06:19AM BLOOD Lactate-1.3
___ 04:30AM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:30AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-2* pH-6.5 Leuks-LG
___ 04:30AM URINE RBC-22* WBC->182* Bacteri-MOD Yeast-RARE
Epi-0
___ 04:30AM URINE CastHy-4*
.
MICROBIOLOGY:
=================
___ Urine Culture #1
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 ORGANISMS/ML..
.
___ Urine Culture #2
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 ORGANISMS/ML..
.
___ Blood cultures x 2 sets: No growth, FINAL.
.
.
IMAGING:
=============
___ CT Chest/Abdomen/Pelvis (outpatient study at ___
___ MRI)
IMPRESSION:
- 1.3 cm mass in the superior segment of the right lower lobe
compatible with lung carcinoma.
-Necrotic mass in the left hilum extending inferiorly but most
likely represents necrotic adenopathy although primary lung
carcinoma is not ruled out. 3 mm Lung nodule compatible with
metastatic lesion. Left hilar adenopathy.
- Stable left adrenal nodule compatible with adrenal adenoma.
-No new 8 mm cystic lesion in the pancreatic tail.
- Extensive sclerotic changes in the lower thoracic and upper
lumbar spine these most likely represent progression of
degenerative disc disease.
- Infrarenal AAA.
.
___ MR ___ study at ___
IMPRESSION:
1. Innumerable small ring-enhancing lesions are identified
throughout the ___. Lesions are identified throughout the
cerebral hemispheres, throughout the cerebellum and in the
brainstem. The largest lesions measure approximately 2 cm. The
majority of the lesions however measure less than 1 cm. These
are too numerous to count. Several of these lesions demonstrate
increased signal in DWI. Imaging finds are most suspicious for
widespread intracranial metastases. Lymphoma is a consideration
but is felt to be less likely. In addition, given the
restricted diffusion in several of these lesions infection is a
consideration but this is felt to be much less likely.
.
___ PA/LAT CXR
IMPRESSION:
1. No focal consolidation concerning for pneumonia.
Interstitial prominence reflects acute or chronic edema.
2. Infrahilar nodular opacity, should be correlated with prior
imaging. Left hilar fullness concerning for lymphadenopathy.
3. Sclerotic lower vertebral bodies are concerning for
malignancy.
.
___ MRI Spine (C/T/L)
IMPRESSION:
1. No obvious focal enhancing mass like lesions in spine. Foci
of increased signal intensity with marrow edema pattern in the
lower thoracic vertebral bodies from T9-T12 and at L3 and L4
levels, may relate to type ___ ___ marrow edema pattern, likely
secondary to degenerative changes along with the areas of
sclerosis, better seen on the recent CT study. However,
metastatic involvement in these foci, is difficult to assess due
to slightly limited assessment of any subtle enhancement within,
due to artifacts on the precontrast T1 weighted sequence and
lack of fat sat post-contrast
sequences. Close followup as needed to assess for any interval
change. Correlate with radionuclide studies as needed.
2. Multilevel degenerative disc and joint disease of the entire
spine. The most notable level of disease is at T12-L1 where a
disc herniation causes moderate spinal canal stenosis and
deforms the very distal thoracic spinal cord. No cord signal
abnormality.
3. Multilevel degenerative disc and joint disease cause neural
foraminal stenosis throughout the lumbar spine, detailed above.
4. Several cerebellar metastases, incompletely imaged but seen
on recent prior MR ___ study.
5. Left hilar mass, as seen on recent outside CT. Right lower
lobe 1.2 cm disease may be focal atelectasis or a nodule.
Please correlate with recent CT chest.
6. Left adrenal 2.3 cm mass, incompletely characterized.
Correlation with outside studies would be helpful.
.
___ PCXR
IMPRESSION:
As compared to the previous radiograph, the patient has
undergone left lower lobe biopsy. There is a minimal post
biopsy opacity in the retrocardiac lung region. No pneumothorax
is visualized. Moderate cardiomegaly. Mild elongation of the
descending aorta.
.
___ Bronchoscopy
Impression: FFB introduced via size 4 ___ LMA. Airway
inspection notable for endobronchial lesion in the LLL basilar
segments.
21 gauge ___ needle used to perform TBNA of the LLL lesion.
Thereafter endobronchial biopsies performed of the LLL lesion.
Fluoroscopy used for assistance. Hemostasis achieved prior to
completion of procedure.
- flexible bronchoscopy - transbronchial needle aspiration -
endobronchial biopsy - fluoroscopy
none
.
PATHOLOGY:
===============
___ Cytology FNA
POSTIVE for malignant cells, consistent with small cell
carcinoma
.
___ Tissue biopsy
SMALL CELL CARCINOMA
-immunohistochemical stain shows the tumor cells to express
TTF-1 synaptophysin, and chromogranin (weak, focal)
-A Mib-1/Ki-67 proliferation marker is positive in approximately
85% of tumor cells
-Tumor necrosis and extensive crush artifact is present
.
Brief Hospital Course:
___ yo F with HTN, HLD, RA, PAD, significant tobacco history, p/w
new lung mass and ___ masses discovered on w/u of her ataxia,
now confirmed to have metastatic small cell lung cancer.
.
# Bowel incontinence: This is a new symptom, although patient
reportedly was brought in from home covered in feces. Currently
without any other focal neuro findings on exam, and has intact
rectal tone, but given this new symptom, and risk for spinal
mets, did obtain MRI of the entire spine to evaluate for spinal
lesions. She is already on systemic steroids for her ___
lesions. MRI spine without spine mets and no cord compression.
Suspect that her incontinence may be due to weakness limiting
her ability to get to the commode / BR in a timely fashion.
.
# Small cell lung cancer with ___ mets, with ataxia
Patient was started on systemic steroids for her ataxia, likely
from her ___ metastases. She had an MRI ___ (see above)
that did not show any clear spinal lesions concerning for spinal
mets. Her neurologic symptoms remained stable, although without
significant improvement. She underwent bronchoscopy with
biopsy, with pathology concerning small cell lung cancer. She
was seen by Radiation-Oncology and started on whole ___ XRT,
with 2 sessions received as an inpatient, and will continue 3
more sessions (___) to complete a total of 5 sessions.
Following completion of her XRT sessions, her decadron can be
tapered, reducing the dose by half every 3 days. She will
follow-up with Dr. ___ of ___ Oncology for
discussion and likely initiation of chemotherapy on ___.
.
# Hyperglycemia: no history of DM. Currently elevated BS likely
steroid-induced. Her blood sugars have been mainly in the
200's. Given that she has no history of DM2, is insulin naive
and will be weaned off her steroids soon, will use just gentle
PRN units of short-acting insulin for BS >300.
.
.
# HTN: BP suboptimal, but likely due to high dose steroids, will
continue home dose lisinopril for now. Can uptitrate lisinopril
as needed.
# HLD: continue home statin
# RA: She is on weekly methotrexate (25mg IM qweek) and
leucovoroin at baseline. Per d/w her ___, since she
is currently on dexamethasone, which will control her RA
symptoms, can hold off on continuing methotrexate at this time.
Furthermore, if she is to initiate chemotherapy for her lung
cancer, MTX can also continue to be held. .
# PAD, s/p bypass: continue full dose ASA
.
# FEN: Regular diet
# DVT PPx: HSQ
# Code: Full Code (confirmed)
# Contact: ___, HCP / nephew, ___ (cell),
___
.
TRANSITIONAL ISSUES:
1. Complete WBXRT sessions #3 - #5, scheduled for ___
2. Steroid taper after completing XRT sessions, can reduce dose
by half every 3 days
3. follow-up with Dr. ___ on ___ for discussion and
likely initiation of chemotherapy
4. Consider resuming methotrexate and leuocovorin once she
completes her steroid taper
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Simvastatin 80 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Methotrexate 25 mg IM 1X/WEEK (WE)
5. Nitrofurantoin (Macrodantin) 50 mg PO HS
6. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheeze
7. PredniSONE 5 mg PO DAILY
8. Acetaminophen 500 mg PO Q8H:PRN pain
9. Omeprazole 20 mg PO DAILY
10. Caltrate 600+D Plus Minerals (Ca-D3-mag
___ 600 mg
calcium- 800 unit-40 mg oral daily
11. Aspirin 325 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Fluticasone Propionate NASAL 1 SPRY NU DAILY
14. Alendronate Sodium 70 mg PO Frequency is Unknown
15. leucovorin calcium 25 mg oral every ___
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Simvastatin 80 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Lisinopril 5 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheeze
9. Caltrate 600+D Plus Minerals (Ca-D3-mag
___ 600 mg
calcium- 800 unit-40 mg oral daily
10. Alendronate Sodium 70 mg PO QMON
11. Acetaminophen 650 mg PO Q6H:PRN pain
12. Heparin 5000 UNIT SC TID
13. Dexamethasone 4 mg PO Q6H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Small cell lung cancer with ___ metastases
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after a fall at home and also
with recent outpatient imaging showing ___ and lung masses
concerning for advanced cancer. You underwent bronchoscopy with
biopsy which confirmed lung cancer. You were started on
steroids and radiation therapy for the cancer in your ___.
You will complete a course of radiation therapy. You will see
Dr. ___ in ___ ___ for follow-up to discuss
chemotherapy.
.
Please follow-up with your physicians as listed.
.
Please take your medications as listed.
.
Followup Instructions:
___
|
10793179-DS-12
| 10,793,179 | 23,637,057 |
DS
| 12 |
2188-11-22 00:00:00
|
2188-11-23 05:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine
Attending: ___.
Chief Complaint:
RUQ Pain, cholecystitis
Major Surgical or Invasive Procedure:
Laparoscopic cholecystectomy
History of Present Illness:
Mrs. ___ is a ___ s/p lap sleeve gastrectomy in ___ with
Dr. ___ presents to the ED with 6 hours of post-prandial
RUQ pain. Pain was sudden onset with associated nausea, and has
subsided since being in the ED. Patient reports similar episodes
of pain prior to her lap sleeve gastrectomy and has discussed
lap ___ with Dr. ___ in the past. She reports she last saw
him in ___ of this year when he instructed her to report to the
ED should she have these symptoms again. She denies fevers,
chills,or vomiting.
Past Medical History:
borderline hypertension (not on medication), h/o superficial
blood clot secondary to knee surgery ___ years ago, varicose
veins, osteoarthritis, hepatic steatosis, cholelithiasis,
vitamin D deficiency, hyperuricemia
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM
Vitals:
Temp 98 HR 73 BP 155/86 RR 16 O2 100% RA
General: well appearing female in NAD
HEENT: NCAT, EOMI
Cardiac: RRR, no m/r/g
Pulm: CTAB, non-labored breathing
GI: soft, +RUQ tenderness, non-distended, no rebound/guarding,
-___ sign
Extremities: no CCE
Neuro: A&Ox3, no focal weakness, gross sensation intact
Psych: cooperative, appropriate affect
DISCHARGE EXAM
Vitals 97.4 123/75 66 18 96% on 2LNC
General: Awake, alert, and in no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, neck
supple,
CV: Regular rate and rhythm, extremities well perfused
Lungs: No respiratory distress
Abdomen: Soft, slightly tender, dressings covering incision
sites are in place, clean, dry, and intact
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema, no
calf pain
Neuro: Gross sensation intact
Pertinent Results:
___ 02:39AM BLOOD WBC-9.6 RBC-4.52 Hgb-13.4 Hct-41.5 MCV-92
MCH-29.6 MCHC-32.3 RDW-13.3 RDWSD-45.0 Plt ___
___ 02:39AM BLOOD Neuts-72.8* Lymphs-14.5* Monos-9.3
Eos-2.4 Baso-0.6 Im ___ AbsNeut-7.00* AbsLymp-1.40
AbsMono-0.90* AbsEos-0.23 AbsBaso-0.06
___ 02:39AM BLOOD Plt ___
___ 03:10AM BLOOD ___ PTT-30.6 ___
___ 02:39AM BLOOD Glucose-102* UreaN-22* Creat-0.8 Na-142
K-3.9 Cl-104 HCO3-26 AnGap-16
___ 02:39AM BLOOD ALT-210* AST-322* AlkPhos-126*
TotBili-0.7
___ 04:55AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.0
___ 05:30AM BLOOD Lactate-1.1
___ 04:55AM BLOOD WBC-5.5 RBC-4.50 Hgb-13.4 Hct-40.8 MCV-91
MCH-29.8 MCHC-32.8 RDW-13.7 RDWSD-45.9 Plt ___
___ 04:55AM BLOOD Plt ___
___ 04:55AM BLOOD Glucose-86 UreaN-9 Creat-0.6 Na-141 K-3.8
Cl-105 HCO3-23 AnGap-17
___ 04:55AM BLOOD ALT-307* AST-179* AlkPhos-150*
TotBili-0.8
Brief Hospital Course:
The patient was admitted to the ___ service from the
Emergency Department on ___ for treatment of abdominal
pain (RUQ). The patient underwent laparoscopic cholecystectomy
on ___, which went well without complication (Please
refer to the Operative Note for details). After a
brief,uneventful stay in the PACU, the patient arrived on the
floor tolerating clears, on IV fluids, and oral pain meds for
pain control. The patient was hemodynamically stable.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early, was adherent incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin during this hospital stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
Omeprazole
Discharge Medications:
1. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN Pain
- Moderate
RX *oxycodone-acetaminophen 5 mg-325 mg 1 (One) tablet(s) by
mouth every six (6) hours Disp #*40 Tablet Refills:*0
2. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Laparoscopic cholecystectomy:
Ms. ___, it was a pleasure to have taken care of you at
our service at the ___. You
were admitted to the hospital with symptomatic gall stones and
an incarcerated umbilical hernia. You were taken to the
operating room and had your gallbladder removed laparoscopically
and your umbilical hernia was also removed simultaneously. You
tolerated the procedure well and are now being discharged home
to continue your recovery with the following instructions.
Please follow up in the Surgery clinic at the appointment
listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower. Please keep the umbilical tension
bandage (the brown bandage) on for ___ days. 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
Followup Instructions:
___
|
10793324-DS-22
| 10,793,324 | 26,790,247 |
DS
| 22 |
2146-08-15 00:00:00
|
2146-08-15 11:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncopy
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is an ___ yo M who is ___ speaking with ___
significant for malignant gastric ulcer s/p gastrectomy/LOA,
draining gastrostomy tube, feeding J-tube, HTN, GERD, and BPH
who was recently discharged from ___ ___. He presents
after falling at home fall. Patient's wife reports she was
helping him get to bathroom with ___, his legs gave out and
he fell onto knees. He did not hit his head or lose
conscioussness. He no precipitating chest pain or shortness of
breath, although he did feel lightheaded and had "blurred
vision" prior to fall. His last bowel movement was today at 11
am and was solid with no blood. UA from rehab yesterday showed
no evidence of a UTI. His WBC on ___ was 12 which was slightly
increased from 11 which was his WBC at discharge in late ___.
Of note, his K was between ___ during his last hospital stay in
late ___. His only complaint of R knee pain currently. He
denies having a headache, focal numbness/weakness, abdominal
pain, N/V, and fever.
In the ED, initial vital signs were T 97 P ___ BP 81/53 R O2
sat. 96%. Patient had an EKG which showed sinus tachycardic,
with no acute S-T changes and slightly peaked T-waves. CT head
showed no acute intracranial processes. CXR showed a focal
opacity in mid left lung field which may represent infection vs
inflamation vs contusion. His K was found to be 5.7 and he was
given calcium bicarb, 1 amp of D50, and insulin. He receieved 2L
of IVF. His X-rays of his pelvis and R knee did not show
fractures.
On the floor, his vitals were stable and he was resting
comfortably.
Review of Systems:
(+) per HPI.
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
ANEMIA
GASTROESOPHAGEAL REFLUX
HYPERTENSION
HYPERCHOLESTEROLEMIA
OSTEOARTHRITIS
ELEVATED PSA
GYNECOMASTIA
MEMORY LOSS
SENSORINEURAL HEARING LOSS
CHRONIC KIDNEY DISEASE
stage 3 GASTRIC CANCER status post subtotal distal gastrectomy
with loop gastrojejunostomy
PPD POSITIVE
Functional gastric outlet obstruction
Social History:
___
Family History:
NC
Physical Exam:
Admission Physical Exam:
Vitals- 98, 135/84, 108, 20, 100 RA
General: alert and oriented, no acute distress
HEENT: Slightly dry mucus membranes, EOMI, clear oropharynx
Neck: soft, no JVP
CV: fast, normal S1&S2, no murmurs
Lungs: clear to ascultation bilaterally
Abdomen: soft, non-tender, non-distended, G and J tube dressing
is c/d/i
GU: no CVA tenderness
Ext: pulses 2+ throughout, no c/c/e
Neuro: CNII-XII grossly intact, no gross motor deficits
Skin: warm, dry, no rashes
.
Discharge Physical Exam:
Vitals: 98.4, 94, 101/51, 20 97% RA
General: alert and oriented, no acute distress
HEENT: Slightly dry mucus membranes, EOMI, clear oropharynx
Neck: soft, no JVP
CV: RRR, normal S1&S2, no murmurs
Lungs: clear to ascultation bilaterally
Abdomen: soft, non-tender, non-distended, G and J tube dressing
is c/d/i, G-tube to gravity drainage. J-tube capped.
GU: no CVA tenderness
Ext: pulses 2+ throughout, no c/c/e
Neuro: CNII-XII grossly intact, no gross motor deficits
Skin: warm, dry, no rashes
Pertinent Results:
___ 02:15PM BLOOD WBC-19.9*# RBC-5.31# Hgb-14.7# Hct-44.8#
MCV-84 MCH-27.7 MCHC-32.8 RDW-14.7 Plt ___
___ 02:15PM BLOOD Glucose-185* UreaN-78* Creat-2.1*# Na-137
K-5.7* Cl-101 HCO3-22 AnGap-20
___ 02:15PM BLOOD Calcium-8.7 Phos-7.7*# Mg-3.8*
___ 07:00AM BLOOD WBC-10.4 RBC-4.45* Hgb-12.2* Hct-36.7*
MCV-83 MCH-27.4 MCHC-33.2 RDW-15.0 Plt ___
___ 07:00AM BLOOD Glucose-116* UreaN-40* Creat-1.1 Na-139
K-3.7 Cl-107 HCO3-21* AnGap-15
___ 07:00AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.4
___ UPPER GI:
IMPRESSION: Contrast remaining in the stomach at 20 minutes
which could be technical in nature as the patient was unable to
postion prone. These
findings were discussed with Dr. ___ by Dr. ___ at 11:55 on ___ by telephone. At this time, the decision was made
to leave the gastrostomy tube clamped and obtain a followup
abdominal radiograph in 2 hours to monitor the transit of
contrast. The patient was instructed to remain upright in the
interim to reduce the risk of aspiration.
___ KUB:
IMPRESSION: Satisfactory passage of contrast through the
gastrojejunal
anastomosis. The clamp on the gastrojejunostomy tube should be
removed.
Brief Hospital Course:
Mr. ___ is an ___ yo M who is ___ speaking with PMH
significant for malignant gastric ulcer s/p gastrectomy/LOA,
draining gastrostomy tube, feeding J-tube, HTN, GERD, and BPH
who was recently discharged from ___ ___ who presents
after falling at home fall.
# S/P Fall with lightheadness: The patient reports that he did
not hit his head when he fell. Head CT in the ER was
unremarkable. He has R knee pain, but X-ray in the ER revealed
no fracture. His light headness and vision changes are most
likely secondary to hypovolemia due to his Cr elevation. Other
causes of his lightheadness included infection and changes due
to cancer.
- IVF
- BC and UC
- trend WBC
- Urine lytes --> pre-renal etiology
- Trend lactate
- Repeat labs
- ___ consult
# Hyperkalemia: most likely due to CKD. During his last hospital
stay in ___ his K ranged from ___. He has slight peaking of his
T-waves on admission but otherwise remains asymptomatic. He
received insulin, calcium, and glucose in the ER.
- Continue to trend
# Gastric cancer s/p gastrectomy with G and J tubes: ___ not be
getting enough fluids through his J-tube
- Will consult nutrition
- Thrombocytosis was noted on admission, this could be secondary
to malignancy, will continue to trend
- will continue lansoprazole
- will continue tube feeds
- clears for comfort
# HTN: Well controlled.
- will continue to monitor.
The patient was transferred to Surgical Oncology service on
___. The KUB was obtained on ___ demonstrated bowel gas
pattern is essentially within normal limits. The patient was
kept NPO with IV fluids, he tube feed was restarted at goal.
G-tube was continued to gravity drainage. The patient was
hemodynamically stable.
Neuro: The patient remained stable from neurological stand
point. Pain was controlled with Roxicet prn via J-tube.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Hyperkalemia
resolved with proper hydration.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was continued on tubefeed during
hospitalization. Formula was changed to provide better
hydration. Patient was evaluated by speech and swallow and diet
was advanced to sips. G-tube was kept to gravity drainage as
patient continued to have intermittent nausea/vomiting. PICC
line was placed for possible IV hydration. The patient's nausea
improved prior discharge and patient was able to tolerate sips
without any issues. On ___ patient underwent upper GI study
with contrast, which demonstrated delayed stomach emptying.
Prior discharge, patient was able to tolerate G-tube clamping
trails during ambulation or sitting up right.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. WBC tranded down after
proper hydration and remained within normal limits.
Endocrine: No issues.
Hematology: 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 with walker.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating sips and
tubefeed at goal, ambulating, voiding without assistance, and
pain was well controlled. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. Bisacodyl 10 mg PR HS:PRN constipation
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. Lidocaine 5% Patch 1 PTCH TD DAILY
5. Metoclopramide 5 mg PO Q6H
6. Ondansetron 4 mg IV Q8H:PRN nausea
7. OxycoDONE-Acetaminophen Elixir ___ mL PO Q4H:PRN pain
8. Jevity 1.2 Cal (lactose-free food with fiber) 1800 ml/day
Oral 75 ml/hr
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
3. Metoclopramide 5 mg PO Q6H
4. Ondansetron 4 mg IV Q8H:PRN nausea
5. OxycoDONE-Acetaminophen Elixir ___ mL PO Q4H:PRN pain
RX *oxycodone-acetaminophen [Roxicet] 5 mg-325 mg/5 mL ___ by
mouth every four (4) hours Disp #*500 Milliliter Refills:*0
6. Acetaminophen 650 mg PO Q8H:PRN pain, fever
7. Docusate Sodium 100 mg PO BID
8. Senna 1 TAB PO HS:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Dehydration
2. Acute renal injury
3. Delayed gastric emptying
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(___).
Discharge Instructions:
You were admitted to the surgery service at ___ for
dehydration and possible gastric outlet obstruction. You have
done well and are now safe to return in Rehab to complete your
recovery with the following instructions:
.
Please call Dr. ___ office at ___ if you have any
questions or concerns.
.
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.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
.
G-tube: Keep to garvity drainage, can capped during ambulation
if tolerated.
.
J-tube: Flush with 30 cc of tap water ___ 6 hours. Monitor for
signs and symptoms of infection or dislocation.
Followup Instructions:
___
|
10793407-DS-5
| 10,793,407 | 21,089,345 |
DS
| 5 |
2166-11-27 00:00:00
|
2166-11-27 22:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
foot pain
Major Surgical or Invasive Procedure:
___ - debridement, podiatry
___- right ___ toe amputation
___- Right ___ toe closure
History of Present Illness:
___ w/ hx afib on eliquis, T2DM, HTN, CKD3, hep C s/p treatment,
OSA p/w right foot plantar ulcer w/ concern for infection.
Patient has hx of right foot dorsal ulcer. 2 days ago
developed
pain of dorsal foot radiating to ankle a/w erythema/edema
progressing over days.
C/o fevers to 100.9F at home, chills, decreased PO intake,
dizziness with urination. No nausea/vomiting. No syncope. Has
taken oxycodone 5mg and Tylenol for the pain without relief.
ED contacted podiatry. Per podiatry, wound looks infected w/
periph edema, streaking, odor, tender to palp. Patient will
neeed formal washout in the OR and IV abx. Patient has been
tentatively added on for the OR on ___ for an I&D. Likely will
need eliquis held. Rec NPO at MN. IV abx.
I reviewed VS, meds, labs, orders, imaging, old records, EKG.
VS - afebrile, HR 90 max, RR 20 max, max BP 167/92.
On imaging of right foot, xray showed no fx or erosions, does
show DJD, ___ toe PIP amputation, subcutaneous gas over plantar
foot at the bases of ___ digits, correlated with ulcer site.
Labs reviewed. Mild thrombocytosis plt 130, left shift with abs
neutrophilia. Cr 1.0 currently. BCx x2 pending. Creatinine
baseline is 1.3.
Patient is s/p IV dilaudid, vanc 1g @ 1332, amp/sulbactam 3g @
1507, LR 150 cc/h.
I reviewed outpt notes - had spoken to his orthopedist on day of
admit - the patient had tried to return to work last week but
foot became more painful and he was not able to bear weight. He
was noting pain, swelling, and discharge.
Past Medical History:
Atrial fibrillation
Neuropathy, peripheral
Obesity
Leukocytoclastic vasculitis likely ___ Hep C
Chronic pain
CKD (chronic kidney disease) stage 3
Chronic hepatitis C without hepatic coma - apparent cure
Chronic gout of foot
Type 2 diabetes mellitus without complication, with long-term
current use of insulin
Lattice degeneration of left retina
OSA (obstructive sleep apnea)
PVD w/ severe tibial disease
charcot arthropathy
plantar foot ulcer right
amputation of ___ toe, left foot d/t osteomyelitis
arthroplasty ___ toe for hammertoe, was later amputated due to
ischemia
Social History:
___
Family History:
Mother Alive ___ - Type II
Sister Alive ___ - Type II
Physical Exam:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Right third toe with second PIP amputation, left second toe
amputation
SKIN: Right foot ulcer with associated swelling discharge and
odor
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
Exam on discharge:
VS: 97.9 HR: 170/84 HR: 61 18 92 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric
CV: RRR, no murmur, no S3, no S4. No JVD.
RESP: Clear B/L on auscultation, good air entry
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK:s/p multiple toe amputations.
SKIN: Right surgical scar- currently with dressing that is
C/d/I.
Pertinent Results:
___ 01:00PM GLUCOSE-95 UREA N-16 CREAT-1.0 SODIUM-139
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-27 ANION GAP-12
___ 01:00PM WBC-9.2 RBC-4.70 HGB-14.4 HCT-44.0 MCV-94
MCH-30.6 MCHC-32.7 RDW-13.5 RDWSD-46.2
___ 01:00PM NEUTS-78.9* LYMPHS-10.1* MONOS-9.7 EOS-0.8*
BASOS-0.2 IM ___ AbsNeut-7.28* AbsLymp-0.93* AbsMono-0.89*
AbsEos-0.07 AbsBaso-0.02
CT ___
IMPRESSION:
1. Patient is status post plantar surface of third and fourth
interphalangeal
space debridement with adjacent soft tissue swelling, edema, and
foci of air
tracking along the plantar surface and fourth metatarsal.
Unclear if findings
represent infection or changes from debridement.
2. Degenerative changes at the head of the third metatarsal and
cuneiforms
appear chronic in nature.
CXR: ___
IMPRESSION:
No previous images. The cardiac silhouette is within normal
limits.
Indistinctness of engorged pulmonary vessels is consistent with
elevated
pulmonary venous pressure. Bibasilar opacifications most likely
represent
atelectatic changes. No definite acute focal consolidation.
TTE ___
Suboptimal image quality. Mildly dilated ascending aorta. Mild
symmetric LVH with normal cavity size and global biventricular
systolic function. NO vavluar pathology or pathologic flow
identified.
MICRO:
___ 1:25 pm TISSUE Site: TOE RIGHT ___ TOE BONE.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary):
Susceptibility testing requested per ___ ___
___.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SECOND MORPHOLOGY.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
CLINDAMYCIN-----------<=0.25 S <=0.25 S
ERYTHROMYCIN----------<=0.25 S <=0.25 S
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- 4 R 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S <=1 S
VANCOMYCIN------------ 1 S <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 1:17 pm SWAB Site: FOOT RIGHT FOOT FLUID SWAB.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
VIRIDANS STREPTOCOCCI. RARE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
Susceptibility testing performed on culture # ___
___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 7:25 pm 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).
Brief Hospital Course:
___ w/ hx afib on eliquis, T2DM w/ peripheral neuropathy w/
chronic right foot ulcer/charcot arthropathy/toe amputations,
PVD, HTN, gout, CKD3, hep C s/p treatment, OSA p/w right foot
infection and concern for sepsis.
#Right foot infection with concern for aggressive infection
#Sepsis
#PVD
The patient presented with right foot pain and concern for
aggressive infection. He was seen by podiatry and underwent
debridement on ___. He was started on broad spectrum
antibiotics (Vanco ___ Zosyn ___ Clinda
___. He went to the OR for ___ toe amputation on ___
and the wound was ultimately closed on ___. The patient was
also seen by vascular surgery and had an angiogram which showed
adequate flow to the foot for wound healing. He will follow with
vascular surgery as an outpatient. He was followed by the ID
service who recommended treatment for osteomyelitis. Based on
his culture data, he was discharged on Daptomycin 650mg daily
and ertapenem 1mg daily with a planned 6 week course. He will
follow up with ___ clinic. He will remain non-weightbearing to
his right foot and has follow up scheduled with podiatry. He
should have daily betadine dressing changes. The patient was
provided a prescription for oxycodone for pain on discharge. PMP
was reviewed and he was counseled on risks of opiate use.
# Afib with RVR
#?Junctional rhythm
On ___ noted to have wide complex rhythm on telemetry.
Cardiology was consulted and it was felt that this rhythm
represents conversion from Afib to wide rhythm to sinus. ___ be
exacerbated by increased burden of afib in setting of infection
and high dose of Sotalol. Sotalol was discontinued. The patient
had an episode of afib with RVR requiring IV metoprolol and Iv
diltiazem. He then converted to sinus rhythm and remains in
sinus rhythm on discharge. HIs Elequis was held for procedures
and he was bridged with heparin per cardiology recommendations
given CHADS2=2 CHADS2vAsc=3 and low risk of bleeding. The
patients Elequis was resumed prior to discharge. ASA was
discontinued.
#HTN
The patient was initially hypotensive in the setting of sepsis.
With improvement in infection, his BP improved and his home
medicaitons were resumed.
#Mild thrombocytopenia
Patient with thrombocytopenia in setting of sepsis. Should have
repeat CBC at PCP follow up.
#CKD stage 3, at baseline now
Creatine stable at 0.9 on discharge.
#T2DM w/ peripheral neuropathy w/ chronic right foot ulcer
FSBS well controlled on Lantus alone. The patient will be
discharged on reduced dose lantus but advised to follow his
sugars and increase Lantus at home if sugars remain elevated.
#gout
Continued home allopurinol
#OSA
Should have outpatient sleep study
Transitonal issues:
- Sotalol and ASA discontinued- patient to follow up with his
cardiologist
- Outpateint follow up with podiatry,
- ERTAPEMEN: WEEKLY: CBC with differential, BUN, Cr, AST, ALT,
Total Bili, ALK PHOS, CRP
DAPTOMYCIN: WEEKLY: CBC with differential, BUN, Cr, CPK
- Discharged on lower dose Lantus- please trend sugars and
increase to home dose if sugars elevated
- Patient provided with limited script of increased dose of
Oxycodone in setting of post-surgical pain.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN BREAKTHROUGH
PAIN
2. Allopurinol ___ mg PO DAILY
3. clomiPHENE citrate 50 mg oral ___
4. Atorvastatin 10 mg PO QPM
5. zaleplon 5 mg oral QHS:PRN
6. Lisinopril 5 mg PO DAILY
7. Bumetanide 0.5 mg PO DAILY
8. Apixaban 5 mg PO BID
9. Sotalol 160 mg PO DAILY
10. Metoprolol Tartrate 50 mg PO BID
11. Aspirin 81 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Glargine 30 Units Bedtime
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right toe osteomyelitis
Sepsis
Atrial fibrillation with rapid rate
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(crutches)
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you during your admission to
___. You were admitted with an infection of your right ___
toe. You were seen by the podiatry team and had an amputation of
your ___ toe. You will continue daily dressing changes. The
vascular surgeons did testing that showed you have adequate
blood flow to your foot. We have scheduled outpatient follow up
with the vascular surgery team. You were seen by the infectious
disease doctors and they recommended long term intravenous
antibiotics to treat a possible bone infection. You had a PICC
line placed for these antibiotics. It is important that you do
not put weight on your right foot. You have been prescribed an
increased dose of your oxycodone. Opiate pain medications can
cause constipation, respiratory depression, can be addictive and
can cause death. It is important that you take the lowest
effective dose for the shortest time possible.
While you were in the hospital, you also had an abnormal heart
rhythm. You had an ultrasound of your heart (Echo) which showed
normal cardiac function. Your sotalol was stopped. You should
follow up with your cardiologist.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10793648-DS-21
| 10,793,648 | 21,096,798 |
DS
| 21 |
2171-02-20 00:00:00
|
2171-02-20 09:21:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / OxyContin
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
pericardiocentesis ___
History of Present Illness:
Ms. ___ is a ___ year old transferred from OSH w/pericardial
effusion found on CT which was associated with early tamponade
physiology and pleural effusions. She presented to ___
___ this afternoon for increasing dyspnea and nausea x 1
week. Additionally, she noted ankle edema, and continued chest
pain. Ms. ___ had presented for chest pain to ___
approximately 1 week ago where she ruled out for an MI and was
discharged home with GERD treatment. Upon presentation to the
OSH today, she was found on CT to have a large pericardial
effusion with pleural effusion as well as axillary
lymphadenopathy. Cardiology saw her at the OSH and recommened
transfer for possible pericardial window.
Seen by cards at OSH and sent for poss pericardial window.
h/o breast CA s/p bilat mastectomy, per report adenopathy on CT
scan.
Diagnosis: pericardial effusion
ED Course (labs, imaging, interventions, consults): Upon arrival
in the ED from ___, initially pt was tachy to 150,
RR 23, BP 132/56, 97% on 4L NC (92% on 2L on admission) with a
pulsus of 20mmHg. EKG was obtained which demonstrated sinus
tachycardia. Cardiology and Cardiac Surgery were consulted.
Cardiac surgery recommended window in the morning. Bedside echo
demonstrated RA and RV collapse. Cardiology took Ms. ___ for
an urgent pericardiocentesis.
.
In pericardiocentesis, the RV was initially sampled and
following this Ms. ___ was hypotensive to SBPs in the ___.
Levophed was initiated, the pericardial effusion was drained for
500cc of a bloody effusion.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers or rigors but
espouses chills. She denies exertional buttock or calf pain. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, palpitations, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes - , Dyslipidemia - ,
Hypertension -
2. OTHER PAST MEDICAL HISTORY:
Bilateral stage I lobular carcinoma (see below)
goiter, which is being followed
Basal cell cancer ___ years ago
.
PSH:
Tonsillectomy at age ___ and a cholecystectomy at age ___, rotator
cuff surgery at ___ and knee surgery at age ___.
.
ONCOLOGIC HISTORY:
1. ___: Multiple suspicious areas on breast MRI.
Bilateral
breast biopsy demonstrated invasive lobular carcinoma.
2. ___: Underwent bilateral mastectomy for what appeared
to
be multifocal disease in both breasts and had negative sentinel
lymph node biopsy. The right breast had a lesion staged as T1b
and was grade II, ER positive, PR negative, HER-2 negative,
grade
II. The left breast lesion was T1C M0, ER/PR positive,
HER-2/neu
negative without lymphovascular invasion and grade II. BRCA ___
testing negative.
3. ___: Oncotype DX assay revealed a recurrence score of
21, which was in the intermediate risk group. The patient
declined enrollment in the ___ trial because she did not
want
chemotherapy. Started on Arimidex. The last bone mineral
density scan in ___ revealed osteopenia at the left femoral
neck
Social History:
___
Family History:
A brother who was diagnosed with breast cancer at age ___,
metastatic disease at age ___. She has a sister who was
diagnosed
with breast cancer at age ___ and died at age ___ from metastatic
disease. She has another sister recently diagnosed with breast
cancer in ___. Genetic testing for BRCA 1 or 2 mutations was
performed and was negative.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
.
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVD at 3cm above clavicle at 90 degrees
CARDIAC: Hyperdynamic precordium, PMI located in ___ intercostal
space, midclavicular line. tachycardic but regular rhythm,
normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Decreased breath sounds
at bilateral bases, +egophony at bases, LLB > LLB, ___ sign
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: trace ___ pitting edema, No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx3, CNII-XII intact, ___ strength biceps, triceps,
wrist, knee/hip flexors/extensors, 2+ reflexes biceps,
brachioradialis, patellar, ankle.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Pertinent Results:
LABS ON ADMISSION:
.
___ 05:10PM BLOOD WBC-11.4* RBC-4.34 Hgb-13.7 Hct-39.2
MCV-90 MCH-31.6 MCHC-35.0 RDW-12.7 Plt ___
___ 05:10PM BLOOD Neuts-83.2* Lymphs-11.7* Monos-4.5
Eos-0.1 Baso-0.5
___ 05:10PM BLOOD ___ PTT-22.7* ___
___ 05:10PM BLOOD Glucose-131* UreaN-26* Creat-1.3* Na-135
K-5.3* Cl-102 HCO3-18* AnGap-20
___ 09:20PM BLOOD CK(CPK)-45
___ 09:20PM BLOOD CK-MB-3 cTropnT-0.04*
___ 09:20PM BLOOD Calcium-8.6 Phos-4.5 Mg-2.4
.
REPORTS
CT TORSO ___ 11:29 AM
1. Extensive mediastinal, supraclavicular and hilar
lymphadenopathy with mass effect on to the adjacent veins, but
without occlusion.
2. Interval decrease of pericardial effusion, in keeping with
the recent
pericardial drainage.
3. Interval increase of loculated pleural effusions, left
greater than right. New subtotal collapse of the left lower
lobe. Reticulonodular opacities in the lower lobes raise concern
for lymphangitic carcinomatosis.
4. Heterogeneously enhancing right thyroid nodule, concerning
for metastasis.
5. No definite evidence of intra-abdominal or intra-pelvic
metastatic
disease. Likely geographic hepatosteatosis.
PERICARDIAL FLUID Procedure Date of ___
POSITIVE FOR MALIGNANT CELLS,
consistent with metastatic adenocarcinoma (see note).
Note: The current specimen shows similar findings to the
prior pericardial fluid specimen (___-___, ___, which
was reviewed for comparison.
___ Tissue: pericardium. ___ ___.
Pericardial fluid, cell block:
Positive for Malignant Cells.
Consistent with metastatic poorly differentiated carcinoma.
Note: The tumor cells are immunoreactive for CK7, B72.3, ___,
and focally positive for mammoglobin. They are negative for
CK20, CEA, Leu-M1 (background staining of neutrophils and
macrophages), GCDFP, ER, PR, Calretinin, and WT-1. Mucicarmine
staining is negative. These findings support metastasis from
breast origin. See cytology (___).
CXR AP ___
IMPRESSION:
1. Placement of a right Pleurx catheter with interval decrease
in size of a large right pleural effusion. Tiny right basilar
pneumothorax.
2. Unchanged appearance of left retrocardiac opacity, which may
represent
severe atelectasis or consolidation.
3. Unchanged small left pleural effusion
ECHO ___
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is low normal (LVEF 50-55%). Right ventricular chamber
size and free wall motion are normal. The ascending, transverse
and descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque t.. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is a moderate sized pericardial
effusion. The pericardium may be thickened. No right atrial
diastolic collapse is seen.
No pericardial effusion after surgical drainage.
.
Brain MRI ___:
Preliminary ReportIMPRESSION:
1. Small left sphenoid wing meningioma without evidence of
extension into the optic canal.
2. No additional intra- or extra-axial lesions.
3. Acute-on-chronic sinus disease as detailed above.
Brief Hospital Course:
HOSPITAL SUMMARY:
___ year old female PMHx Breast cancer s/p bilateral mastectomy
who presented w SOB, found to have pericardial effusion with
tamponade, s/p pericardial window, also with L pleural effusion
s/p pleurex placement, both cytology samples returning positive
for adenocarcinoma, course complicated by hypoxia thought to be
secondary to cancer lymphangitic pulmonary burden, now s/p
initiation of taxol.
# Pericardial effusion: On admission, found to have effusion
with tamponade physiology; s/p drainage of pericardial effusion
on ___ complicated by RV puncture and transient need for
levophed (~3 minutes). Pericardial window performed ___.
Final cytology report with malignant cells consistent with
breast adenocarcinoma.
# Atrial Fibrillation - First noted following pericardial
window, felt to be secondary to pericardial irritation; no
evidence of PE on CTA chest (although not protocoled for PE).
Initiated on amiodarone and metoprolol, converted to normal
sinus rhythm with occasional episodes of A fib. Pt has been well
controlled on this regimen, although difficult to tolerate due
to pressures, so metoprolol dose was decreased to 6.25mg. She
should continue on this dose, which she tolerates well.
Amiodarone has just been decreased from 200mg tid after 2 weeks
to 200mg bid, which shold continue for 4 weeks and then 200mg
daily until further recommendations by Cardiology.
# Pleural Effusions - During hospital stay, noted to have
enlarging R pleural effusion, on ___ underwent tap, with
conversion to pleurex on ___. Final cytology report with
malignant cells consistent with breast adenocarcinoma. Patient
underwent daily drainage of pleurex (about 500cc daily) until
___. She had reaccumulating L sided effusion, and had
pleurex placed on that side on ___, draining 1L of fluid.
She should continue to have effusions drained every other day
(alternating), no more than 1L at a time. Please see attached
directions for details. Pt will f/u with Interventional
Pulmonology team on ___ for suture removal of L pleurex
cathether.
# RUE DVT: In setting of RUE edema, RUE ultrasound demonstrated
nonocclusive clot around R PICC line; after discussion w primary
oncologist, patient was started on therapeutic lovenox (planned
duration = lifelong given ongoing onc issues)
# Hypoxia: Patient with hypoxia throughout stay, initially
requiring 6LNC and face mask, thought to be multifactorial in
setting of pleural effusions, pulmonary edema, and lymphangitic
spread of tumor to lungs. Of note, patient was never officially
ruled out for pulmonary embolism (had CT chest w contrast that
was not protocoled for PE), but as this would not change
management (already on therapeutic lovenox as above) CT PE was
not obtained. TTE did not demonstrate shunt (PFO). With
diuresis, drainage of R pleural effusion, patient resp status
improved, but not to baseline. Initiated taxol for presumed
tumor burden component. At transfer to floor, patient satting
90-93% on 5L nasal canula, occasionally using humidified air via
shovel mask for comfort. She had increased O2 requirement to
6LNC on ___ which may have been from small PTX after L
pleruex placement or increased R infiltrate which was possibly
pneumonia, fluid or lymphangitic spread. This most likely
represented a component of lymphangitic spread but since pna
couldn't be ruled out, she will complete a 5 day course of
Levofloxacin.
# Hyponatremia: Sodium ranged from 125-130, initally thought to
be hypovolemic in setting of intravascular depletion (had low
albumin, lots of third-spaced fluids). It did not however,
respond well to hydration. She was then placed on fluid
restriction due to concern for SIADH with normalization of her
sodium. She should continue on a 1200ml fluid restricted diet.
# UTI: Ucx ___ grew pan-sensitive E. coli for which the patient
was treated w IV ceftriaxone (d1= ___ treated for 7-day
course.
# Breast Cancer s/p b/l mastectomy (Her 2 negative, ER/PR
positive) - She was continued on anastrozole, and as discussed
above, started taxol chemotherapy while inpatient. HER 2 status
is pending. She will continue to follow with Dr ___
return for chemo next week.
.
#Hallucinations: Pt developed visual hallucinations during ICU
stay. At that time she had received Ativan, so it was thought
that this was potentially a side effect from ativan. Would
avoid benzos as possible in the future.
Medications on Admission:
anastrozole 1mg daily
Discharge Medications:
1. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours).
4. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO TID (3
times a day).
5. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day:
start ___ and continue this dose for 4weeks, then change to
once daily.
7. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
___ MLs PO QID (4 times a day) as needed for gerd.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
12. morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
13. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12HR ().
14. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 3 days.
15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
16. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metastatic Breast Cancer
Malignant Pericardial Effusion/cardiac tamponade
Malignant Pleural Effusion
Atrial Fibrillation
Deep venous Thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital due to SOB and were found to
have fluid around your heart (pericardial effusion) as well as
in your lungs. These were drained, with a procedure "window" to
continue to empty the pericardial effusion done. The fluid in
these was found to be malignant and consistent with metastatic
breast cancer, so you were started on chemotherapy to control
this, which is called Taxol and you will receive this weekly on
3 weeks and then have one week off. While you were in the
hospital you also developed an abnormal heart rhythm (atrial
fibrillation) and have been started on medications for this, as
well as a DVT (clot) in your upper extremity) for which you were
started on a blood thinner and a UTI that was treated for 7 days
with antibiotics.
Followup Instructions:
___
|
10794086-DS-20
| 10,794,086 | 21,383,659 |
DS
| 20 |
2174-05-07 00:00:00
|
2174-05-07 15:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PSYCHIATRY
Allergies:
Penicillins / morphine
Attending: ___.
Chief Complaint:
"I am beside myself..."
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a very pleasant ___ yo male with reported hx of
anxiety and
depression, no prior psych hospitalizations or SA, who presented
to ___ ED with worsening anxiety in the setting of possible
eviction from his apartment after reportedly making a suicidal
statement to a staff member of his PCP's office.
.
Per the ED Consultation note by ___, psychiatric nurse
___, Mr. ___ reported feeling increasingly anxious
during the past month after learning that his landlord was
planning on evicting him from his apartment due to his excessive
accumulation of collections. On the day prior to presentation,
he experienced a "terrible night" with insomnia and severe
anxiety, which he had difficulty characterizing. He called his
PCP, ___, who has been concerned about him as
well. She reported that he called the doctor's emergency line
endorsed SI and "hallucinations" to a staff member in the form
of hearing foot steps in his apartment and sensing "a presence,"
which was new for this patient. She recommended that the patient
come to the ED for further evaluation.
.
Per collateral obtained in the ED, Dr. ___ reported
that Mr. ___ has been difficult to treat as he is very anxious
and ruminative and has not improved on anxiolytics or SSRI's.
She has atempted to refer him for outpatient psych treatment but
he has either been resistant or not followed through. She said
that he lives alone and manages somewhat but more recently he
has not been functioning well, not sleeping, and he may be
hoarding.
.
Mr. ___ reported that he has been very anxious especially
since last ___ when his landlady asked him to leave his
apartment. He describes himself as a "collector" and reported an
accumulation of objects that have become a fire hazard. He
denied any paranoia. Mr. ___ reported that suicidal thoughts
popped into his head last night. He describes suicide as both a
"cowardly and bravery" act. He reports that he would not act on
this thoughts because of his family and intellectual pursuits.
.
ED Course: The patient was in good behavioral control throughout
his ED course
Past Medical History:
PSYCHIATRIC HISTORY:
- Dx: Anxiety, Depression
- Prior Hospitalizations: none
- SA/SIB: denies
- Medication Trials: ___
- Current psychiatrist/therapist: none
PAST MEDICAL HISTORY: Per OMR
- Hyperglycemia since ___
-LBP/spinal stenosis S/P fusion at L4 in ___,
-hyperlipidemia
- eczema, seborrheic dermatitis
- allergic rhinitis
- COPD, childhood asthma
- BPH
- HLD
- CRI
- TIA ___
- Diverticulosis
Dr. ___ MD - ___ PCP ___
Social History:
SUBSTANCE ABUSE HISTORY: Mr. ___ reports that he does not
drink regularly, but says that he has been more "tempted" during
this period of anxiety. He
reports that he drank more in the past in the context of "broken
romances." He reports no use of illicits or tobacco.
SOCIAL HISTORY: Mr. ___ grew up in ___ with one older
brother. This
brother passed away in ___ when jogging due to a congenital
heart defect. The patient describes himself as a "very sick
child" who suffered from asthma and had multiple medical
hospitalizations. Reports that some of this was "psychosomatic"
which cost him one year of college. He never married and never
had children. He attended and graduated from ___
where
he studied ___. He reports that he knows about 6 or 7
languages. Mr. ___ worked with ___ as part of
the ___ department working with classified intelligence and
research. He is retired and spends his days reading newspapers
and keeping up with world events. He describes himself as a
___ He has a sister-in-law and niece whom he is very close
to who live locally. He says that he does not want to impose
upon them with his problems. He currently lives alone in
___.
Family History:
Denies
Physical Exam:
O:98.5 57 152/76 16 100%RA
A/B: Appears younger than stated age, well-nourished,
well-hydrated, dressed in shorts and sweater with adequate
hygiene, calm, cooperative, pleasant with interviewer, no
psychomotor retardation or agitation noted.
S: normal rate, volume, and prosody.
M: "okay."
A: euthymic, mood-congruent, appropriate
TP: slightly circumstantial but redirectable, mostly linear,
goal
and future oriented
TC: Denies SI/HI, AVH
C: alert and oriented x3.
I: Fair
J: Fair
On day of discharge, patient was ambulatory and able to perform
ADL's without assistance. As noted above, he denied SI/HI,
affect was bright, appropriate, with no evidence of psychosis.
He was future oriented and stated that he was looking forward to
returning home to his books and watching television, planned on
attending a barbecue at friend___ this weekend.
Pertinent Results:
___ 02:10PM GLUCOSE-88 UREA N-22* CREAT-1.3* SODIUM-141
POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-21* ANION GAP-15
___ 02:10PM estGFR-Using this
___ 02:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 02:10PM URINE HOURS-RANDOM
___ 02:10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 02:10PM WBC-5.2 RBC-4.06* HGB-13.1* HCT-37.9* MCV-93
MCH-32.3* MCHC-34.6 RDW-12.8
___ 02:10PM NEUTS-68.0 ___ MONOS-8.5 EOS-2.7
BASOS-1.4
___ 02:10PM PLT COUNT-259
___ 02:10PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 02:10PM URINE RBC-<1 WBC-0 BACTERIA-FEW YEAST-NONE
EPI-0
___ 02:10PM URINE HYALINE-4*
___ 02:10PM URINE MUCOUS-RARE
Brief Hospital Course:
A/P: This is a very pleasant ___ year old gentleman, history of
anxiety with hoarding behaviors, depression, no psychiatric
hosptializations or prior suicide attempts who presents to ___
with worsening anxiety in the setting of possible eviction from
his home after reportedly telling a staff member at his PCP's
office that he was suicidal.
Axis I: Genera;ozed anxiety disorder, mood disorder NOS, r/o
adjustment disorder, r/o MDD
Axis II: deferred
Axis III: HTN, HLD, COPD, chronic lower back pain, h/o
hyperglycemia
Axis IV: limited psychosocial supports, possible eviction from
apartment
Axis V: GAF= 50
#. Anxiety disorder NOS: Per PCP, confirmed by patient, Mr.
___ suffers from baseline anxiety that has worsened in the
last several months in the setting of possible eviction from his
apartment. According to LMR, the patient has been on trials of
Zoloft in the past but has been noncompliant, d/c'ing the
medication because he did not believe he needed it. The pt did
not recall prior side effects with the Zoloft. He has recently
been placed on BuSpar, but stopped because he did not understand
that the medication took weeks to work.
- Given potential risks of drug-drug interactions, we
discontinued BuSpar. We also discontinued alprazolam, zolpidem.
- After discussion of the risks and benefits, initiated
mirtazapine 7.5 mg po qhs to target anxiety and insomnia.
Recommend titrating up as tolerated for symptoms of anxiety and
depression.
- The patient has received a list of referrals for outpatient
psychotherapy from his PCP. We encouraged the patient to
follow-up with an outpatient therapist; of note, he declined our
referral to a therapist.
- The patient attended few groups, given his short
hospitalization but maintained good behavioral control.
-During his hospitalization a family meeting was held with he
and his sister in law who is his primary support. His main
stress of moving was discussed in addition to his anxiety and
safety. His sister in law felt that he was at his baseline and
did not have safety concerns at this time. She will continue to
assit with the moving process. Mr. ___ already has a service
in place that will assist with packing and moving. He is
interested in becoming more involved with other social
activities and perhaps attending community centers. He was
provided information for the ___.
-Through out hospitalization, there was no sign of suicidal
ideation, plan or intent, the patient strongly requested
discharge and felt that this level of care was unnecessary for
him. He was open to engaging in therapy and continuing a trial
of mirtazapine. He was future oriented and looking forward to
activities this weekend. He feels that he will eventually
successfully move. He is aware of emergency resources and feels
able to utilize them in the future if needed if his mood should
worsen or if suicidal thoughts should occur. There was no
evidence of psychosis during this admission. A MOCA was
completed where he scored ___ missing items on visuospatial
categories. He appeared to be appropriately caring for himself,
but endorses that his apartment is quite cluttered. ___ referral
sent for Home Safety Evaluation as the state of his apartment is
unknown and he is being asked to leave.
#. Mood Disorder NOS: patient described being depressed given
his recent social stressors, but stated that his anxiety has
been far more debiliating. Affect was euthymic with full range,
and per his report does not seem to meet full criteria for
depressive episode.
- ___ folate, B12, and TSH WNL.
- We continued his home pyridoxine, folic acid
- Initiated mirtazapine as above
#. Safety: At this time, patient is at low risk for suicide.
Risk factors include male sex, advanced age, single status, and
recent acute psychosocial stressors. However, the patient has
consistently denied suicidality and collateral via his PCP
confirms the patient's story. Denies access to firearms. He does
not appear to be depressed and has numerous protective factors:
he is intelligent, educated, introspective, and able to seek
help when in distress, and has a supportive family. He lacks a
history of prior suicide attempts or psychiatric
hospitalizations.
#. COPD: Stable, no complaints.
- Continued Fluticasone 110 mcg 2 puffs bid
- Continued albuterol prn
#. HTN: history of HTN, on lisinopril. Slightly hypertensive
during admission, however, given Cr- 1.3 with HR= 50's, we
deferred titration of antihypertensives to PCP, whom he will see
per discharge instructions.
#. HLD: continued simvastatin at home dose.
#. Allergic Rhinitis: continued nasal fluticasone at home does.
#. Legal/Safety: The patient was admitted on a ___ and
declined to sign a CV. He maintained his safety throughout his
hospitalization on 15 minute checks. He was discharged prior to
the expiration of his ___ as he did not meet court
commitment criteria and appeared safe and appropriate for
outpatietn follow up.
#. Dispo: Discharge to home with follow-up with his PCP,
___, and ___ per discharge instructions.
Medications on Admission:
ALBUTEROL SULFATE 2 puffs(s) inhaled q ___ hr prn
ALPRAZOLAM 0.25 mg tablet 1 Tablet(s) by mouth tid prn
BUSPIRONE 5 mg tablet 1 tablet(s) by mouth twice a day
FLUTICASONE 2 spray(s) intranasally once a day
FLUTICASONE 110 mcg 2 puffs inhaled twice a day
Folbic 2.5 mg-25 mg-2 mg tablet 1 Tablet(s) by mouth once a day
LISINOPRIL 2.5 mg tablet 1 Tablet(s) by mouth daily
PRAVASTATIN - 20 mg tablet 1 Tablet(s) by mouth once a day
ZOLPIDEM [AMBIEN] - 10 mg tablet 1 Tablet(s) by mouth
Nightly/PRN
Medications - OTC
ASPIRIN - 81 mg tablet,delayed release 1 Tablet(s) by mouth
daily
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3]
DOCUSATE SODIUM 100 mg capsule Capsule(s) by mouth
MULTIVITAMIN
Miralax 17 gram Oral Powder Packet 1 packet by mouth daily/PRN
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Aspirin EC 81 mg PO QHS
3. Cyanocobalamin ___ mcg PO QHS
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. FoLIC Acid 2.5 mg PO QHS
7. Lisinopril 2.5 mg PO HS
8. Mirtazapine 7.5 mg PO HS
RX *mirtazapine 15 mg 0.5 (One half) tablet(s) by mouth at
bedtime Disp #*15 Tablet Refills:*0
9. Multivitamins 1 TAB PO QHS
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Pravastatin 20 mg PO HS
12. Pyridoxine 25 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Axis I: Generalized anxiety disorder, mood disorder NOS, r/o
adjustment disorder, r/o MDD
Axis II: deferred
Axis III: HTN, HLD, COPD, chronic lower back pain
Axis IV: limited psychosocial supports, possible eviction from
apartment
Axis V: GAF= 50
Discharge Condition:
O:98.5 57 152/76 16 100%RA
A/B: Appears younger than stated age, well-nourished,
well-hydrated, dressed in shorts and sweater with adequate
hygiene, calm, cooperative, pleasant with interviewer, no
psychomotor retardation or agitation noted.
S: normal rate, volume, and prosody.
M: 'okay.'
A: euthymic, mood-congruent, appropriate
TP: slightly circumstantial but redirectable, mostly linear,
goal
and future oriented
TC: Denies SI/HI, AVH
C: alert and oriented x3.
I: Fair
J: Fair
On day of discharge, patient was ambulatory and able to perform
ADL's without assistance. As noted above, he denied SI/HI,
affect was bright, appropriate, with no evidence of psychosis.
He was future oriented and stated that he was looking forward to
returning home to his books and watching television, planned on
attending a barbecue at ___ this weekend.
Discharge Instructions:
You should discontinue your Buspar and Ambien
You should start taking Remeron/Mirtazepine ___ tab by mouth at
bedtime
For severe anxiety you may take Xanax 0.25mg as needed.
Continue your other medications as previously prescribed
-Please follow up with all outpatient appointments as listed -
take this discharge paperwork to your appointments.
-Please continue all medications as directed.
-Please avoid abusing alcohol and any drugs--whether
prescription drugs or illegal drugs--as this can further worsen
your medical and psychiatric illnesses.
-Please contact your outpatient psychiatrist or other providers
if you have any concerns.
-Please call ___ or go to your nearest emergency room if you
feel unsafe in any way and are unable to immediately reach your
health care providers.
*It was a pleasure to have worked with you, and we wish you the
best of health.*
Followup Instructions:
___
|
10794465-DS-5
| 10,794,465 | 29,711,159 |
DS
| 5 |
2183-03-16 00:00:00
|
2183-03-16 18:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
transient R arm/leg weakness and numbness
Major Surgical or Invasive Procedure:
CT/CTA: 1. No evidence for acute intracranial abnormalities.
2. Limited evaluation of the V1 segment of the right vertebral
artery due to
streak artifact from concentrated contrast in the adjacent
veins. Otherwise,
normal CTA of the head and neck.
3. Bilateral thyroid nodules measuring up to 1.4 cm on the
right.
RECOMMENDATION(S): MRI would be more sensitive for an acute
infarction, if
clinically warranted.
Recommend thyroid sonography, if not previously performed
elsewhere
MRI Brain without contrast: 1. Study is mildly degraded by
motion.
2. No acute infarct, intracranial hemorrhage or mass effect.
3. Stable sinus disease as described above.
ECG: Sinus bradycardia. Early repolarization pattern. T wave
inversion in leads I, aVL, and V5-V6 likely secondary to left
ventricular hypertrophy. Ischemia cannot be excluded and
clinical correlation is suggested (of note, no chest pain and
trop negative without concern for trop leak or MI). No previous
tracing available for comparison.
Echo with saline contrast - no ASD/PFO, EF>55%, no thrombus
History of Present Illness:
Mr. ___ is a ___ right handed man with a past
medical
history of hypertension and kidney stones who presents as a
transfer from OSH following 2 events of transient right sided
numbness/weakness and unclear CT finding of Right dense MCA
Sign.
The evening of ___ at 930pm, Mr. ___ was sitting at the
table
and feeling well when he noticed onset of "numbness and
heaviness" in his right arm. He was concerned that he was
unable
to move his right arm, but reportedly did so without difficulty.
It is unclear if this symptom came on suddenly or gradually, but
after a short period of time he noticed a similar feeling of
numbness and heaviness in his right leg (primarily thigh).
After
a short period of time it then involved his Right face.
Additionally, he feels that his right lip was "shaking", but no
other part of him was.
He attempted to get up to walk, but his right leg felt "heavy"
and when he stood, he had to lean against a table as he felt it
would be unable to bear his weight.
This entire event took ___ minutes and then spontaneously
resolved. There were no witnesses to this event and no
associated symptoms. When his daughter heard about it, she was
concerned for stroke and had the patient present to an OSH ED.
There, after getting a bed, he reports another similar episode.
This episode lasted only a "few seconds" before resolving and
unlike his previous event involved only his right leg. His leg
suddenly felt heavy. While he was able to move it, he endorses
that it was weaker than baseline. Unfortunately, he did not
tell
his daughter (who was sitting next to him) about this event, so
it went unwitnessed. He has never had event like this prior in
his life.
At OSH ED, he subsequent underwent NCHCT which was read as Right
dense MCA sign. He was subsequently transferred to ___ for
further evaluation.
Otherwise of note, for the past 1 week, Mr. ___ has reported
intermittent episodes of vertigo. He describes them as room
spinning and like the "floor is coming up". These symptoms are
unpredictable, but tend to occur with activity. He has had
approximately 10 episodes over the past week. With one of these
episodes, he lost his balance and ended up falling against a
table. There are no associated symptoms with these episodes.
ROS is positive for
- posterior occipital headaches (2 week history, sharp "hard
headache", with pounding component, + nausea. Tends to occur
after midday and toward the evening. No recent head trauma or
neck jerking.
Past Medical History:
- Hypertension
- Nephrolithiasis
- prior excisional biopsy of lesion ? of skin cancer "small
tumor"
Social History:
___
Family History:
- No known family neurologic history.
Physical Exam:
97.9 58 153/92 16 97%
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Able to read without difficulty. Speech was not
dysarthric (per his daughter). Able to follow both midline and
appendicular commands. Had some trouble with 2 step commands
("point to the door after pointing to the ceiling", but examined
at 330am) Attentive, able to name ___ backward with one error
that he self corrects. Pt. was able to register 3 objects and
recall ___ at 5 minutes. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch, pinprick in all
distributions.
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline and deviates side to side w/o
difficulty.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5
R ___ ___ ___ 5 5 5 5-
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
- Plantar response was flexor bilaterally.
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout. No extinction to DSS. Specifically,
no evidence of sensory loss or change in C2 distribution
bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally. No cerebellar rebound or
overshoot.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent.
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>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Discharge Exam:
Tm/Tc 97.5, SBP 130s, HR 50-70, RR 18, SpO2>96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple.
Pulmonary: regular respirations
Abdomen: nondistended
Extremities: no edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: (Without translator present)Alert, appropriately
regards, Follows simple one step commands in ___
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. 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 and ___
strength in upper and lower distributions, bilaterally
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5
R ___ ___ ___ 5 5 5 5
-DTRs:
Bi Pat Ach
L 2 2 1
R 2 2 1
Patellar responses brisk bilaterally
- Plantar response was flexor bilaterally.
-Sensory: No deficits to light touch in all four extremities
-Coordination: No intention tremor, no dysmetria with voluntary
movement
-Gait: Narrow-based, normal stride
(Overall: normal neuro exam, unchanged from admission)
Pertinent Results:
___ 05:45PM BLOOD WBC-6.2 RBC-5.30 Hgb-16.3 Hct-47.8 MCV-90
MCH-30.8 MCHC-34.1 RDW-14.0 Plt ___
___ 05:45PM BLOOD ___ PTT-30.5 ___
___ 05:45PM BLOOD Glucose-105* UreaN-14 Creat-0.8 Na-142
K-3.9 Cl-110* HCO3-24 AnGap-12
___ 05:45PM BLOOD ALT-26 AST-22 AlkPhos-68 TotBili-0.9
___ 05:45PM BLOOD Albumin-4.4 Calcium-9.6 Phos-3.2 Mg-2.0
Cholest-205*
___ 05:45PM BLOOD %HbA1c-5.7 eAG-117
___ 05:45PM BLOOD Triglyc-522* HDL-37 CHOL/HD-5.5
LDLmeas-115
___ 05:45PM BLOOD TSH-4.4*
___ 05:45PM BLOOD T3-126 Free T4-1.5
Brief Hospital Course:
Impression/Plan:
Mr. ___ is a ___ right handed man with a past
medical
history of hypertension and kidney stones who presents as a
transfer from OSH following 2 events of transient right sided
numbness/weakness (one ___ minutes, and one lasting seconds) and
unclear CT finding of Right dense MCA Sign which was not found
on CT/CTA done here. MRI ultimately was clean without evidence
of stroke, bleed, or amyloid.
The nature of Mr. ___ events are somewhat unusual. His
distribution of Arm--> Leg --> face makes for an unlikely
___ ___. Suspicion for seizures is quite low despite
his report of R lip twitching with the event. He does have a
vascular risk factor in uncontrolled hypertension. Given clean
MRI and CT/CTA, TIA is the most likely diagnosis for his
transient unilateral numbness and weakness. Migraine with aura
is unlikely given that the symptoms did not precede a headache
and given absence of other migrainous headache features (now
denying nausea, photophobia/phonophobia).
He will be discharged on ASA 81 mg and Simvastatin 20 mg daily
for stroke risk modification. His stroke etiology remains
cryptogenic. (no intracranial/cervical atherosclerotic disease,
no evidence of hypertensive intracranial disease, MRI negative
for diffusion restriction, TTE normal).
# NEURO:
- Distributed stroke information packet and note in the chart
- MRI Head - negative for stroke/amyloid/bleed
- CTA Head and neck - clean vasculature
- Assess stroke risk factors with fasting lipid panel (LDL 115),
TSH (mildly elevated at 4.4) and HbA1c (normal at 5.7)
- Start Aspirin 81mg
- Start low dose Simvastatin 20 mg for mildly elevated LDL of
115
- Non focal exam with good independent ambulation so no need for
outpatient ___
# ___:
- Telemetry negative for Afib
- Rule out MI with CEs - trop <0.01
- Allow BP to autoregulate with goal SBP < 180 (goal SBP
140-180s)
- Hydralazine 10 mg IV Q6H PRN SBP > 180
- Reportedly was on lisinopril /HCTZ but has not refilled in
several months - will follow up on this as an outpatient
- TTE negative for thrombus with EF >55%, no ASD/PFO.
# PULM:
- CXR deferred as lungs CTA b/l
.
# ENDO:
- HbA1c 5.7
- Finger sticks QID and Insulin sliding scale with a goal of
normoglycemia - without issue this admission
- Bilteral thyroid nodules will require outpatient follow up
- TSH mildly elevated at 4.4, normal fT4/T3
# Toxic/Metabolic:
- LFTs unremarkable
- Urine tox negative
.
# GIS:
- PRN laxatives - no issue this admission
.
# F/E/N:
- tolerated regular Diet after passing nursing swallow
.
# PPx:
- SC heparin
- Bowel regimen
.
#DISPO:
- Code Status: Full
- daughter ___: ___
All of the above was discussed with the covering physician and
___ prior to discharge.
Medications on Admission:
None
Discharge Medications:
1. Aspirin 81 mg PO Q24H
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*5
2. Simvastatin 20 mg PO QPM
RX *simvastatin 20 mg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*5
Discharge Disposition:
Home
Discharge Diagnosis:
TIA (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 admitted with short-lived (seconds to minutes long)
right arm and leg numbness and weakness that then completely
resolved. CT and MRI imaging showed clean vessels and no
evidence of a stroke. You most likely had a transient ischemic
attack (which is a blockage of an artery going to your brain
that resolves before it becomes a full stroke). It will be
important to control your blood pressure and to take aspirin 81
mg and simvastatin 20 mg daily. Aspirin and simvastatin were
started to decrease your future risk of stroke.
Your thyroid studies were mildly abnormal here and you were
found to have thyroid nodules on your CT scan - this will be
important to follow up at ___
with your regular doctor.
You received an ultrasound of your heart (echocardiogram with
bubble study) to complete your stroke work up. This was normal
(no ASD/PFO, EF>55%, no thrombus).
It will also be important to quit smoking to decrease your
future risk of stroke.
Finally, please follow up with your regular doctor and
neurologist at ___ - controlling
your blood pressure and cholesterol is important for preventing
a stroke.
Followup Instructions:
___
|
10795168-DS-22
| 10,795,168 | 29,147,566 |
DS
| 22 |
2200-12-08 00:00:00
|
2200-12-08 17:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / spironolactone
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M PMH of HFrEF ___ CRT-D, COPD, dilated ascending aorta, GERD
___ ___ Funduplication presenting with hip pain. He notes
that two days ago, he had vomiting. He does not know if he had
difficulty breathing during that time. He really came to the
hospital because he had worsening hip pain. He was diagnosed
with arthritis as an outpatient and takes intermittent oxycodone
at home.
However denies chest pain, no fevers, chills, abdominal pain,
vomiting or diarrhea.
Patient also says c/o of R hip/groin pain of 6 months duration,
which has worsened in the past 3 weeks. Unable to lift leg up
without pain and worsened by humidity. Has been followed by
orthopedics X-ray showed arthritis.
Endorses urinary frequency and urgency. Patient denies history
of asthma, but has a smoking history and uses inhaler at home.
He denies cough productive of mucus or blood. Recently admitted
for heart failure exacerbation with overdiuresis and ___.
In the ED, he was afebrile but was hypotensive to 82/56. Labs
were notable for ___ and a leukocytosis. He was given 500 cc LR,
60 mg prednisone, cefepime, vanco, and Duonebs. Imaging was
notable for a right lower lobe focal consolidative and ground
glass opacity, suspicious for pneumonia. BPs remained in the
___, so he was sent to the MICU.
Upon arrival, he complained of no cough or shortness of breath.
His main concern is his hip pain.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
Past medical history:
- Heart failure with recovered ejection fraction, dilated
cardiomyopathy
- Left bundle branch block ___ CRT-D
- Hyperlipidemia
- Dilated ascending aorta
- GERD, ___ fundoplication
- Nephrolithiasis
- Diverticulosis
- h/o cognitive and memory problems (seen by Dr. ___ and by
___ in ___, attributed to "HIV infection"- though HIV
reportedly negative and false positive test)
Social History:
___
Family History:
Pt claims that all of his family had "heart attacks" diabetes,
and HTN. Doesn't know exact family members these were in. Denies
family history of any kind of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 98 HR 75 BP ___ RR 15 SPO2 92% RA
GEN: Well-appearing middle aged man in NAD
HEENT: PERRL. EOMI. Dry MM
NECK: JVP not visible at 90 degrees.
CV: RRR. Nl s1/s2. No m/r/g.
RESP: Bibasilar crackles (R>L). Otherwise CTAB. Breathing
comfortably.
GI: soft, non-tender, non-distended, normoactive BS
MSK: No lower extremity edema
SKIN: Warm, cap refill brisk
JOINTS: Tender over R posterior hip joint with no erythema or
swelling.
NEURO: AOX3. Moves all extremities.
DISCHARGE PHYSICAL EXAM
=======================
VITALS: 24 HR Data (last updated ___ @ 1436)
Temp: 97.8 (Tm 98.0), BP: 95/69 (87-109/52-77), HR: 62
(60-88), RR: 18 (___), O2 sat: 92% (92-95), O2 delivery: RA,
Wt: 180.56 lb/81.9 kg
GEN: NAD
NECK: No JVD o/e
CARDIAC: rrr, no g/m/r, no lower extremity edema
LUNGS: Bilateral crackles inspiratory worse in dependent
regions,
no wheeze
ABD: distended, NT
EXT: wwp, no edema
NEURO: A&Ox3
Pertinent Results:
ADMISSION LABS
=======================
___ 10:56PM BLOOD WBC-15.3* RBC-5.45 Hgb-16.7 Hct-49.8
MCV-91 MCH-30.6 MCHC-33.5 RDW-13.3 RDWSD-43.8 Plt ___
___ 10:56PM BLOOD Neuts-74.7* Lymphs-14.7* Monos-9.4
Eos-0.5* Baso-0.2 Im ___ AbsNeut-11.40* AbsLymp-2.24
AbsMono-1.44* AbsEos-0.08 AbsBaso-0.03
___ 10:56PM BLOOD ___ PTT-32.0 ___
___ 10:56PM BLOOD Glucose-89 UreaN-31* Creat-3.4*# Na-134*
K-7.2* Cl-93* HCO3-23 AnGap-18
___ 10:56PM BLOOD cTropnT-<0.01
___ 10:56PM BLOOD proBNP-78
___ 10:56PM BLOOD Calcium-8.9 Phos-5.6* Mg-1.9
___ 08:54AM BLOOD WBC-14.7* RBC-5.15 Hgb-15.8 Hct-46.5
MCV-90 MCH-30.7 MCHC-34.0 RDW-13.0 RDWSD-42.8 Plt ___
___ 03:15AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.7
___ 08:14AM BLOOD WBC-12.1* RBC-4.71 Hgb-14.5 Hct-42.9
MCV-91 MCH-30.8 MCHC-33.8 RDW-12.9 RDWSD-43.4 Plt ___
___ 08:14AM BLOOD Glucose-122* UreaN-24* Creat-1.1 Na-141
K-3.7 Cl-102 HCO3-26 AnGap-13
___ 08:14AM BLOOD ALT-21 AST-33 AlkPhos-67 TotBili-0.4
___ 08:14AM BLOOD Calcium-8.9 Phos-2.3* Mg-2.3
=============
DISCHARGE LABS
==============
___ 08:04AM BLOOD WBC-9.6 RBC-5.51 Hgb-16.8 Hct-50.2 MCV-91
MCH-30.5 MCHC-33.5 RDW-13.0 RDWSD-43.5 Plt ___
___ 08:04AM BLOOD Glucose-191* UreaN-16 Creat-0.9 Na-136
K-4.1 Cl-98 HCO3-26 AnGap-12
===========
MICRO
=============
___ 5:10 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
BLOOD CX ___: NGTD
=================
IMAGING TESTS
================
CXR ___
FINDINGS:
Cardiac size is mildly enlarged, unchanged. Left chest
pacemaker device is again seen with tips terminating in stable
position. No focal consolidation. No pneumothorax or large
pleural effusion. No pulmonary edema.
IMPRESSION:
No acute cardiopulmonary process
CT chest w and w/o contrast ___:
No evidence of pneumonia or acute cardiopulmonary process.
HEART AND VASCULATURE: The ascending thoracic aorta is ectatic
measuring 4.1 cm. The heart, pericardium, and great vessels are
within normal limits based on an unenhanced scan. No pericardial
effusion is seen. A left chest pacemaker device is seen with
leads terminating in stable position.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal
lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is bibasilar atelectasis, right greater
than left. There are stable paraseptal emphysematous changes at
the bilateral lung apices. A calcified granuloma is again seen
in the posterior left lower lobe, unchanged. A focal area of
scarring in the Left upper lobe is unchanged dating back to ___
(03:38). Otherwise, lungs are clear without masses or areas of
parenchymal opacification. The airways are patent to the level
of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
ABDOMEN: There is A small paraesophageal hernia. Punctate
calcifications are seen within the spleen. A 1.9 cm hypodense
lesion is seen in the upper pole of the right kidney, compatible
with A simple cyst. Otherwise, included portion of the
unenhanced upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no
acute fracture.
IMPRESSION:
No evidence of pneumonia or acute cardiopulmonary process.
Brief Hospital Course:
=================
BRIEF SUMMARY
=================
Mr. ___ is a ___ M with PMH of HFrEF ___ CRT-D, COPD,
dilated ascending aorta, GERD ___ Nissen Fundoplication who
presented to ED with 3 weeks of worsening hip/groin pain in
setting of 6 months of arthritis. Of note was seen in heart
failure clinic ___ with symptoms of dizziness and imbalance
(of several months), not improved with torsemide or Entresto.
Their plan was to continue torsemide 20 daily, decrease Entresto
to ___ low dose BID, continue carvedilol 25 BID, and hold
eplerenone at least until next visit. In the days leading up to
his presentation to the ED he had joint pain, he was also
vomiting. He said that he was having the sensation of reflux and
was using a tongue depressor to induce vomiting. In the ED, he
was afebrile but was hypotensive to 82/56. Labs were notable for
Cr 3.4 and a leukocytosis to 15.3. He was given 500 cc LR, 60 mg
prednisone, cefepime, vanco, and Duonebs. Imaging was notable
for a right lower lobe focal consolidative and ground glass
opacity, suspicious for pneumonia. BPs remained in the ___,
so he was admitted to the MICU. In the MICU, his Cr improved to
2.0 with fluids suggesting a prerenal etiology of his ___. CT
chest had no evidence of pneumonia so antibiotics were
discontinued. Never required pressors. He was transferred to the
floor where h he was diuresed with IV Lasix. He was planned to
transition to his home PO torsemide and discharged with close
cardiology follow up.
==================
TRANSITIONAL ISSUES
===================
[] Euvolemic at discharge weight. Please check weight and assess
volume status at follow-up and adjust diuretic regimen
accordingly
[] Home ivabradine was held this admission. HRs ___ at
discharge. Please consider whether to resume as outpatient.
[] Please check electrolytes in 1 week, given on torsemide.
[] Patient's hypotension on admission thought to be in part from
home Vicodin use. Please continue to monitor home opioid use.
[] He self-induced emesis prior to admission due to what he
describes as reflux symptoms. He is ___ Nissen fundoplication.
If he is having recurrence of reflux symptoms, consider
follow-up with his surgeon and GI team
*discharge diuretic: torsemide 20mg daily
*discharge Creatinine: 0.9
*discharge weight 172.8 lbs
=================
ACUTE ISSUES
=================
#HFrEF:
History of HFrEF (lowest LVEF ~26%, now 50% ___. Weight on
admission was close to dry weight of 180-185 pounds. On exam he
appeared hypervolemic with crackles, orthopnea and abd
distention. Diuresed with IV Lasix to symptomatic improvement.
He was continued on Entresto, home carvedilol, and his home
torsemide was started on day of discharge ___. Discussed with
patient and outpatient cardiologist option to keep in house for
an additional day for monitoring, and instead decision made to
discharge with close follow up. On day of discharge he appeared
euvolemic without peripheral edema or JVD. ___ CRT-D device was
interrogated on ___ and found to have normal pacer function. LV
output was increased.
___
Presented with creatinine 3.4 from baseline 1.2. In the MICU,
his Cr improved to 2.0 with IV fluids suggesting a prerenal
etiology of his ___. On day of discharge his creatinine was 0.9.
#R hip/groin pain
His pain had been subacutely worsening in the setting of
osteoarthritis. He was treated with oxycodone 5 mg every 4 hours
as needed. He was also given Tylenol 1 g every 8 hours.
#Aspiration pneumonitis/GERD
Was given IV antibiotics in the emergency department given
concern for pneumonia. However, given history of emesis, lack of
evidence of pneumonia on CT on ___, and no clinical worsening
after removal of antibiotics, the thought is that his overall
picture was most consistent with aspiration pneumonitis. He
self-induced emesis prior to admission due to what he describes
as reflux symptoms. However, he is ___ Nissen fundoplication. If
he is having recurrence of reflux symptoms, he should follow-up
with his surgeon to assess for recurrence and whether or not
there is
truly reflux (pH test) vs. dysphagia. Home omeprazole was
continued.
===================
CHRONIC ISSUES
=================
#HLD: Continued home aspirin and atorvastatin
#COPD: Continued home albuterol and Flovent PRN
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. CARVedilol 25 mg PO BID
4. Omeprazole 20 mg PO DAILY
5. Tizanidine 2 mg PO BID:PRN pain
6. Torsemide 20 mg PO DAILY
7. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Moderate
8. Flovent Diskus (fluticasone) 50 mcg/actuation inhalation
BID:PRN
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
10. ivabradine 2.5 mg oral BID
11. Entresto (sacubitril-valsartan) ___ mg oral BID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
RX *albuterol sulfate 90 mcg 2 puff IH every 4 hours as needed
Disp #*1 Inhaler Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*10
Tablet Refills:*0
3. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth once a day Disp #*10
Tablet Refills:*0
4. CARVedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*20
Tablet Refills:*0
5. Entresto (sacubitril-valsartan) ___ mg oral BID
RX *sacubitril-valsartan [Entresto] 24 mg-26 mg 1 tablet(s) by
mouth twice a day Disp #*20 Tablet Refills:*0
6. Flovent Diskus (fluticasone) 50 mcg/actuation inhalation
BID:PRN
RX *fluticasone propionate [Flovent Diskus] 50 mcg 1 INH IH
twice a day Disp #*1 Disk Refills:*0
7. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*10
Capsule Refills:*0
8. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth twice a day as needed
for pain Disp #*10 Tablet Refills:*0
9. Tizanidine 2 mg PO BID:PRN pain
RX *tizanidine 2 mg 1 tablet(s) by mouth twice per day as needed
for pain Disp #*14 Capsule Refills:*0
10. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth once a day Disp #*10
Tablet Refills:*0
11. HELD- ivabradine 2.5 mg oral BID This medication was held.
Do not restart ivabradine until you talk with you cardiology
doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- Aspiration pneumonitis
- ___
- Right hip and groin pain
Secondary diagnosis
- HFrEF
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 taking care of you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because your blood pressure
was low.
WHAT WAS DONE IN THE HOSPITAL?
- We think that your low blood pressure was due to your home
vicodin.
- We gave you antibiotics for a possible pneumonia but that was
stopped because your chest CT did not show any sign of lung
infection.
- We gave you medicine to help remove excess fluid in your body
from your heart failure.
-Your pacemaker device was checked and found to be working
normally.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- Take all your medications as prescribed.
- Follow up with your primary care doctor.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10795239-DS-11
| 10,795,239 | 26,780,833 |
DS
| 11 |
2181-05-26 00:00:00
|
2181-05-26 11:20:00
|
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 hip pain
Major Surgical or Invasive Procedure:
___: Left total hip arthroplasty
History of Present Illness:
The patient is a ___ female with a history of severe
left hip pain due to osteonecrosis. She was scheduled for
elective total hip arthroplasty, however fell and sustained a
fracture of the femoral neck. She was then
admitted urgently.
Past Medical History:
Left Hip AVN
Cirrhosis: Hep B and Hep C
Portal hypertension
Diabetes mellitus type 2, on insulin, c/b retinopathy
Hypertension, benign
Hypothyroidism
Thrombocytopenia (baseline PLT ___
Peripheral neuropathy
Inflammatory arthropathy from HBV/HCV
Osteoarthritis
Glaucoma
Social History:
___
Family History:
Father fell in the BR and died after. Her mother died of some
pain after an injection? Sister with breast cancer per OMR.
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Foley replaced ___ at 1300
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision healing well with staples
* Scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 07:25AM BLOOD WBC-4.1 RBC-2.61* Hgb-8.5* Hct-26.1*
MCV-100* MCH-32.4* MCHC-32.4 RDW-19.6* Plt Ct-41*
___ 07:35AM BLOOD WBC-5.4 RBC-2.60* Hgb-8.6* Hct-25.4*
MCV-98 MCH-33.2* MCHC-33.9 RDW-19.9* Plt Ct-47*
___ 07:40AM BLOOD WBC-5.1 RBC-2.32* Hgb-7.9* Hct-24.0*
MCV-104* MCH-34.1* MCHC-32.9 RDW-19.1* Plt Ct-61*
___ 03:20PM BLOOD WBC-5.2 RBC-2.66* Hgb-8.9* Hct-26.7*
MCV-101* MCH-33.4* MCHC-33.2 RDW-19.3* Plt Ct-72*
___ 07:10AM BLOOD WBC-4.7 RBC-2.65* Hgb-8.9* Hct-26.7*
MCV-101* MCH-33.7* MCHC-33.5 RDW-20.0* Plt Ct-72*
___ 11:50PM BLOOD WBC-5.8 RBC-2.80* Hgb-9.1* Hct-28.3*
MCV-101* MCH-32.6* MCHC-32.3 RDW-19.5* Plt Ct-84*
___ 07:15PM BLOOD WBC-5.7 RBC-3.00* Hgb-10.0* Hct-30.6*
MCV-102* MCH-33.2* MCHC-32.6 RDW-19.5* Plt Ct-93*#
___ 06:24AM BLOOD WBC-4.4 RBC-2.73*# Hgb-9.1*# Hct-28.1*#
MCV-103*# MCH-33.2* MCHC-32.3 RDW-17.8* Plt Ct-24*
___ 08:10AM BLOOD WBC-3.4* RBC-1.87* Hgb-6.8* Hct-21.0*
MCV-112* MCH-36.3* MCHC-32.3 RDW-15.2 Plt Ct-22*
___ 10:10AM BLOOD WBC-3.5* RBC-2.17* Hgb-7.9* Hct-24.2*
MCV-112* MCH-36.5* MCHC-32.6 RDW-16.3* Plt Ct-23*
___ 11:30AM BLOOD WBC-3.2* RBC-2.22* Hgb-8.1* Hct-24.6*
MCV-111* MCH-36.4* MCHC-32.9 RDW-15.5 Plt Ct-25*
___ 11:30AM BLOOD Neuts-64.4 ___ Monos-5.5 Eos-2.2
Baso-0.2
___ 07:25AM BLOOD ___
___ 09:08AM BLOOD ___
___ 07:40AM BLOOD ___ PTT-26.5 ___
___ 07:10AM BLOOD ___ PTT-28.2 ___
___ 07:25AM BLOOD Glucose-113* UreaN-76* Creat-1.8* Na-126*
K-4.8 Cl-96 HCO3-20* AnGap-15
___ 07:35AM BLOOD Glucose-112* UreaN-67* Creat-1.9* Na-130*
K-5.0 Cl-99 HCO3-17* AnGap-19
___ 07:40AM BLOOD Glucose-153* UreaN-61* Creat-1.7* Na-129*
K-5.2* Cl-99 HCO3-19* AnGap-16
___ 08:15AM BLOOD ALT-21 AST-19 AlkPhos-66 TotBili-0.4
___ 10:10AM BLOOD ALT-24 AST-23 LD(LDH)-214 AlkPhos-81
TotBili-0.3
___ 07:25AM BLOOD Calcium-8.0* Phos-4.9* Mg-1.9
___ 07:35AM BLOOD Calcium-8.0* Phos-4.2 Mg-1.8
___ 07:40AM BLOOD Calcium-8.1* Phos-3.9 Mg-1.7
___ 08:15AM BLOOD VitB12-219* Folate-15.1
___ 10:10AM BLOOD calTIBC-286 Ferritn-244* TRF-220
___ 10:16AM BLOOD PTH-71*
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service
through the emergency room after a fall on ___. On
___ she was taken to the operating room for above
described procedure. Please see separately dictated operative
report for details. The surgery was uncomplicated and the
patient tolerated the procedure well. Patient received
perioperative IV antibiotics.
Postoperative course was remarkable for the following:
1. Thrombocytopenia- Hematology consulted pre-op. She was
transfused 1 bag of platelets pre-op and an additional bag
intra-op.
2. Anemia - Per Hematology recommendations, patient was
transfused 2u PRBCs the day before surgery Hct 21.0 -> 28.1. She
was transfused one unit PRBC's intra-op for blood loss anemia.
On POD2, Hct 24.0, asymptomatic -> Transfused 1u PRBCs to keep
Hct > 25.
3. Cirrhosis- hepatology was consulted to manage Hepatitis B and
C.
4. Hematology co-management
5. Urinary retention - The foley was removed on POD#2 and the
patient was unable to void. Straight cath x 1. Patient was
unable to void again on POD3, bladder scanned for > 500cc, foley
was replaced on ___ at 1300. Please DC FOLEY ___ at 6AM and
REPEAT VOIDING TRAIL.
Otherwise, pain was initially controlled with a PCA followed by
a transition to oral pain medications on POD#1. The patient
received lovenox for DVT prophylaxis (renally dose) starting on
the morning of POD#1 to bridge to Coumadin. The surgical
dressing was changed on POD#2 and the surgical incision was
found to be clean and intact without erythema or abnormal
drainage. The patient was seen daily by physical therapy. Labs
were checked throughout the hospital course and repleted
accordingly. At the time of discharge the patient was tolerating
a regular diet and feeling well. The patient was afebrile with
stable vital signs. The patient's hematocrit was acceptable and
pain was adequately controlled on an oral regimen. The operative
extremity was neurovascularly intact and the wound was benign.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity with posterior precautions.
Walker or two crutches at all times for 6 weeks.
Ms ___ is discharged to rehab in stable condition.
Medications on Admission:
1. Lumigan *NF* (bimatoprost) 0.03% ___ HS
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. Furosemide 40 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Hydroxychloroquine Sulfate 200 mg PO BID
7. Ketoconazole Shampoo 1 Appl TP ASDIR
8. Lactulose 30 mL PO TID
9. Levothyroxine Sodium 88 mcg PO DAILY
10. Lisinopril 20 mg PO DAILY
11. Omeprazole 20 mg PO BID
12. Ranitidine 150 mg PO BID
13. Sertraline 25 mg PO DAILY
14. Spironolactone 50 mg PO DAILY
15. Zolpidem Tartrate 5 mg PO HS
16. Insulin - 70/30 18 Units Breakfast, 70/30 22 Units Bedtime
17. Procardia XL 90 mg Oral DAILY
Discharge Medications:
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. Furosemide 40 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Hydroxychloroquine Sulfate 200 mg PO BID
6. Insulin - 70/30 18 Units Breakfast, 70/30 22 Units Bedtime
7. Levothyroxine Sodium 88 mcg PO DAILY
8. Omeprazole 20 mg PO BID
9. Procardia XL 90 mg ORAL DAILY
10. Sertraline 25 mg PO DAILY
11. Spironolactone 50 mg PO DAILY
12. Zolpidem Tartrate 5 mg PO HS
13. Acetaminophen 500 mg PO Q6H:PRN fever, pain
14. Docusate Sodium 100 mg PO BID
15. Enoxaparin Sodium 30 mg SC DAILY to bridge to warfarin *STOP
when INR > 2.0 x 24hrs*
16. Senna 1 TAB PO BID
17. Lumigan *NF* (bimatoprost) 0.03% ___ HS
18. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
19. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg Take ___ tablets by mouth every 4 hours Disp
#*25 Tablet Refills:*0
20. Warfarin 5 mg PO DAILY16
Goal INR ___
21. Ketoconazole Shampoo 1 Appl TP ASDIR
22. Lactulose 30 mL PO TID - Patient was not taking as directed.
___ restart as needed for daily BM.
23. Lisinopril 20 mg PO DAILY - Patient was not taking as
directed. ___ restart as needed for HTN. Hold for K > 5.0.
24. Ranitidine 150 mg PO BID - Patient was not taking as
directed. Restart as needed for reflux.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left hip fracture
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:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining. Any stitches or staples that need to be
removed will be taken out by the visiting nurse (___) or rehab
facility two
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in four (4) weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for four (4)
weeks to help prevent deep vein thrombosis (blood clots). If
you were taking aspirin prior to surgery, you may resume you
pre-operative dose while taking lovenox. ___ STOCKINGS x 6
WEEKS.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed by the visiting
nurse or rehab facility in two (2) weeks.
11. ___ (once at home): Home ___, dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
12. ACTIVITY: Weight bearing as tolerated with walker or 2
crutches at all times for six weeks. Posterior precautions. No
strenuous exercise or heavy lifting until follow up appointment.
Mobilize frequently.
Physical Therapy:
LLE WBAT
Posterior hip precautions x 3 months
Walker or 2 crutches AAT x 6 weeks
Mobilize
Treatment Frequency:
Dry sterile dressing dailu as needed for drainage
Wound checks
Ice
TEDs x 6 weeks
Labs - Check CBC 2x/week.
- Goal HCT > 21, PLT > 10
*Patient has baseline thrombycytopenia (PLT ___
Staple removal POD14, replace with steristrips
Voiding trial - REMOVE FOLEY ___ at 6am and repeat voiding
trial
Followup Instructions:
___
|
10795434-DS-29
| 10,795,434 | 29,968,792 |
DS
| 29 |
2177-07-23 00:00:00
|
2177-07-26 16:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Polysporin / Latex / Hydrochlorothiazide
Attending: ___.
Chief Complaint:
R neck pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a very pleasant ___ with h/o dementia, C3-C4
spondylosis, HTN, GERD who presents with neck pain. Pt has
impaired memory ___ dementia and does not recall details of her
previous work-up for her chronic neck pain. Per OMR, has a h/o
C3-C4 cervical spondylosis with degenerative changes. She is
followed by Dr. ___ in neurology, who has recommended soft
cervical collar and low dose tizanidine, however she does not
like the soft collar and is reluctant to take pain medication
other than tylenol or ibuprofen. She does use heating pads
which help somewhat. Her pain was severe this AM and she was
having difficulty performing her ADLs. She lives with her
daughter, but her daughter is currently out of town. She
presented to the ED for evaluation.
In the ED, initial VS were 98.8 88 173/70 20 100%. Physical
exam was notable for a palpable supraclavicular mass with a
palpable thrill. Labs were notable for K 2.4. She had a CTA
neck which showed small fusiform stable aneurysm of the right
subclavian artery, stable since ___. She received 40 meq PO
and 40meQ IV over 4hours, diazepam 2.5mg x1, tylenol ___. She
was admitted to the floor for evaluation of hypokalemia.
Upon transfer to the floor, vitals were T 98.5F, BP 177/88, HR
76, R 18, O2-sat 100% RA She describes the neck pain as
right-sided, sharp, worse with neck rotation. The pain does not
radiate to her arms. Denies numbness/tingling of extremities.
Has occasional occipital HA. Denies visual changes,
lightheadedness, dizziness. She notes LBP that is chronic.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- Hypertension
- Mild diastolic dysfunction
- GERD
- History of asbestos exposure
- Cataracts
- Migraine
- H/o rheumatic fever
- Carpal tunnel
- Osteoarthritis
- Chronic kidney disease
- Spinal stenosis
- Myelodysplastic Syndrome
Social History:
___
Family History:
Mother, Father passes away in ___ from stroke.
Physical Exam:
VS - Temp 98.5F, BP 177/88, HR 76, R 18, O2-sat 100% RA
GENERAL - pleasant, well-appearing elderly female in NAD,
comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
adentulous
NECK - palpable 2-3cm supraclavicular mass with palpable thrill,
no JVD, R lateral neck mildly TTP
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact
Pertinent Results:
Admission Labs:
___ 01:00PM BLOOD WBC-6.7 RBC-4.27 Hgb-11.3* Hct-34.7*
MCV-81* MCH-26.4* MCHC-32.5 RDW-13.5 Plt ___
___ 01:00PM BLOOD Glucose-110* UreaN-11 Creat-0.8 Na-141
K-2.4* Cl-98 HCO3-30 AnGap-15
___ 01:00PM BLOOD cTropnT-<0.01
Imaging:
NON-CONTRAST HEAD CT: There is no evidence of hemorrhage, edema,
mass, mass effect, or infarction. The ventricles and sulci are
normal for a patient of this age. There is mild hyperostosis
frontalis interna. No fracture is identified. The visualized
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear.
CTA, HEAD AND NECK: There is a 14 mm x 20 mm fusiform aneurysm
of a tortuous right subclavian artery immediately after the
takeoff from the brachiocephalic trunk. There has been no
significant change from a prior CTA chest in ___. There is no
thrombosis or intraluminal defect. There is no dissection. The
aneurysm abuts the right lobe of the thyroid. The thyroid is
heterogeneously enhancing with a small left nodule. This was
better evaluated on recent thyroid ultrasound. The carotid and
vertebral arteries and their major branches are patent without
evidence of stenosis. The carotids are normal in size and
caliber. There is no evidence of intracerebral aneurysm
formation or other vascular abnormality.
There is no lymphadenopathy. The soft tissues are normal. The
airway is
patent. The bilateral pleural scarring in the lung apices is
stable.
Degenerative changes in the cervical spine with mild disc space
narrowing are stable.
IMPRESSION:
1. Small fusiform stable aneurysm of the right subclavian artery
immediately after the takeoff from the brachiocephalic trunk. No
thrombosis, intraluminal defect, or dissection. If clinically
warranted, could follow with ultrasound to assess for interval
change in the long run.
2. Heterogeneously enhancing thyroid with possible small
left-sided nodule
was better evaluated on recent ultrasound.
3. No acute intracranial process.
4. Stable pleural scarring at the lung apices.
5. Stable degenerative changes of the cervical spine.
Brief Hospital Course:
Primary reason for hospitalization:
___ with h/o dementia, C3-C4 spondylosis, HTN, GERD who
presents with R-sided neck pain and found to have hypokalemia.
Active issues:
# Hypokalemia: Resolved with PO potassium chloride. Pt had very
low K on admission (2.4), unclear etiology. She is not taking
diuretics or other medications that would promote loss of K.
She has no recent h/o N/V to account for GI losses. Recommend
repeat K measurement within 1 week as outpatient to ensure it is
stable within normal range.
# Cervical spondylosis: Pt presented with R sided neck pain that
is consistent with her chronic pain ___ known cervical
spondylosis. (However due to her dementia she does not always
recall that her pain is chronic.) Per OMR, her neurologist and
PCP have recommended soft collar but she does not like wearing
it. Her neurologist has also recommended tizanidine, but she is
reluctant to take it. She had no UE weakness, no s/sx cord
compression. She was given standing tylenol for pain and again
encouraged soft collar. Also spoke with pt's family about
encouraging use of soft collar at home.
Chronic issues:
# HTN: Pt was hypertensive on admission in setting of pain and
not taking home medications, returned to normal on her home
atenolol, amlodipine, and moexepril.
# GERD: Pt c/o mild epigastric pain on HD#2, per OMR she is
followed for chronic GERD. Described her pain as c/w her
typical GERD pain. Her pain resolved on her home pantoprazole
and sucralfate.
# Depression: Stable on home citalopram.
# Dementia: Stable, pt lives with daughter who is currently out
of town but has son and grandchildren who check on her
regularly. Per ___ eval, she can ambulate independently.
Transitional issues:
- No medication changes during this hospitalization. She was
encouraged to use soft collar at home to treat her pain ___
cervical spondylosis.
- She is scheduled to follow up in ___ clinic. She
should have repeat K measured within 1 week of discharge to
ensure it is stable within normal range.
- She maintained full code status throughout hospitalization.
Medications on Admission:
-atenolol 50 mg Tab 1 Tablet(s) by mouth Twice daily
-amlodipine 10 mg Tab 1 Tablet(s) by mouth once a day
-citalopram 20 mg Tab Oral 1.5 Tablet(s) Once Daily
-Restasis 0.05 % Eye Dropperette Ophthalmic 1 Dropperette(s) 1
drop in each eye, twice daily
-moexipril 15 mg Tab 1 Tablet(s) by mouth twice a day
-One Daily Multivitamin Tab Oral 1 Tablet(s) Once Daily
-pantoprazole 40 mg Tab, Delayed Release 1 tablet by mouth twice
a day
-sucralfate 100 mg/mL Oral Susp 10 ml by mouth four times a day
___ hour before meals and at bedtime
-tizanidine 2 mg Tab Oral ___ Tablet(s) Twice Daily
-ergocalciferol (vitamin D2) 400 unit Tab 1 Tablet(s) by mouth
once a day
-Calcium Carbonate 500 mg Chewable Tab 1 Tablet(s) by mouth
three times a day
- Aspirin 81 mg Tab, Delayed Release 1 Tablet(s) by mouth once a
day
-Tylenol ___ mg Tab as needed
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every ___
hours as needed for pain.
2. atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. Restasis 0.05 % Dropperette Sig: One (1) drop Ophthalmic
twice a day: 1 drop each eye twice daily.
5. moexipril 15 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. sucralfate 100 mg/mL Suspension Sig: Ten (10) mL PO four
times a day: 30 minutes before meals and at bedtime.
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
10. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Hypokalemia
Cervical spondylosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ because your potassium level was low.
We gave you potassium supplement by mouth and your level
returned to normal.
You also had neck pain, which is likely due to your arthritis in
your neck. You had a CT scan of your neck which showed chronic
arthritis and an aneurysm of a blood vessel which has been
stable for over ___ years. You should have periodic ultrasound to
monitor the aneurysm.
We recommend that you continue wearing your soft collar both at
night and during the day to improve your neck pain.
We made no changes to your medications while you were in the
hospital. Please continue taking all of your medications as
prescribed by your outpatient providers.
We have scheduled an appointment for you to follow up in the
___ clinic at ___. Please see below for your
appointment time.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It has been a pleasure taking care of you at ___ and we wish
you a speedy recovery.
Followup Instructions:
___
|
10795434-DS-31
| 10,795,434 | 27,393,389 |
DS
| 31 |
2178-10-28 00:00:00
|
2178-10-29 18:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Polysporin / Latex / Hydrochlorothiazide
Attending: ___.
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ dementia who presents from home because patient has been
less willing to walk, eat, drink, or take meds. Patient has had
subacute decline over the past several months with increased
fatigue, weight loss, decreased appetite, refusal to take
certain medications, and unwillingness to get out of bed. Also
newly incontinent of urine. On day of admission, pt complained
of neck and shoulder pain, which is chronic, but was unwilling
to take tylenol. Daughter, ___, who lives with patient feels
she has become deconditioned and needs a higher level of care,
at least temporarily.
Initial VS in the ED: 98.6 94 181/68 18 98% Labs notable for K
2.7, Mg 1.6, P 2.2, normal creatinine. Patient was given 800mg
MgOxide, 40mEq PO K, 40mEq IV K, 2 packets neutraphos, 1L IVF.
Past Medical History:
1. Hypertension
2. Mild diastolic dysfunction
3. Reflux esophagitis (GERD) and dyspepsia
4. History of asbestos exposure, chronic interstitial lung
disease
5. Cataracts
6. Migraine headaches
7. History of rheumatic fever
8. Carpal tunnel
9. Osteoarthritis
10. Chronic kidney disease
11. Spinal stenosis
12. Myelodysplastic syndrome
Social History:
___
Family History:
Mother, Father passes away in ___ from stroke.
Physical Exam:
ADMISSION/DISCHARGE Physical Exam:
98.4 ___ 18 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Good air movement bilaterally, +dry crackles at bases b/l
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non ttp, nondistended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
___ 05:15PM BLOOD WBC-7.4 RBC-3.97* Hgb-9.9* Hct-32.5*
MCV-82# MCH-24.9*# MCHC-30.5* RDW-16.4* Plt ___
___ 05:15PM BLOOD Glucose-157* UreaN-14 Creat-0.8 Na-142
K-2.7* Cl-96 HCO3-31 AnGap-18
___ 05:15PM BLOOD ALT-6 AST-17 LD(LDH)-181 CK(CPK)-37
AlkPhos-82 TotBili-0.3
___ 05:15PM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:15PM BLOOD Albumin-3.4* Calcium-9.1 Phos-2.2* Mg-1.6
___ 07:45AM BLOOD WBC-5.5 RBC-3.72* Hgb-9.4* Hct-30.7*
MCV-82 MCH-25.2* MCHC-30.6* RDW-16.5* Plt ___
___ 07:45AM BLOOD Glucose-83 UreaN-8 Creat-0.6 Na-140 K-4.0
Cl-102 HCO3-27 AnGap-15
___ 07:45AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:45AM BLOOD Calcium-8.5 Phos-1.8* Mg-1.6 Iron-___ 07:45AM BLOOD calTIBC-146* Ferritn-190* TRF-112*
CXR: IMPRESSION:
Chronic fibrotic changes with bilateral calcified pleural
plaques compatible with asbestosis, similar compared to the
prior exam. No new areas of focal consolidation identified.
Brief Hospital Course:
___ with dementia here with FTT and hypokalemia.
ACTIVE ISSUES:
# Failure to thrive: Subacute decline over the past several
months consistent with progressive dementia. Family denies
worsening depression and pt has no localizing symptoms to
suggest acute process. UA with protein but otherwise negative.
D/c Ranitidine, will receive soon follow up with Dr. ___. She
will go home until then. ___ cleared her for home with 24hr care.
# Electrolyte abnormalities: Likely due to poor PO. Repleted
CHRONIC ISSUES:
# Normocytic hypochronic Anemia: Hgb down from 11.7 in ___ to
9.9. Possible due to iron deficiency given other nutrient
deficiencies and near microcytic MCV. Iron studies show anemia
of chronic disease.
# HTN: Decreased to 154 from admission 190's. Cnt BB, CCB, ACE
# Depression: Cnt citalopram
# GERD: Perhaps the cause of her abdominal discomfort on
admission, not present on re-exam this AM. LFTs normal. Cnt PPI
and sucralafate. We discontinued ranitidine during this
admission due to concerns for its anticholinergic effects in
light of her worsening dementia.
TRANSITIONAL ISSUES:
-F/u with Dr. ___ for further about subacute detioration
and FTT
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Moexipril 15 mg PO BID
hold for sbp<100
3. Calcium Carbonate 500 mg PO TID
4. Atenolol 50 mg PO BID
hold for sbp<100, hr<55
5. Amlodipine 10 mg PO DAILY
hold for sbp<100
6. cycloSPORINE *NF* 0.05 % ___ BID
7. Ranitidine 150 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Sucralfate 1 gm PO QID
10. Pantoprazole 40 mg PO Q12H
11. Aspirin 81 mg PO DAILY
12. Citalopram 30 mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atenolol 50 mg PO BID
5. Calcium Carbonate 500 mg PO TID
6. Citalopram 30 mg PO DAILY
7. Moexipril 15 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Vitamin D ___ UNIT PO DAILY
11. cycloSPORINE *NF* 0.05 % ___ BID
12. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
advancing dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
You were admitted to ___ for
care of advancing dementia. You will need further outpatient
management to help better care for you at home. It is very
important that you follow up with Dr. ___ ___ at 10am (see contact information below).
Followup Instructions:
___
|
10795482-DS-13
| 10,795,482 | 27,489,172 |
DS
| 13 |
2175-07-12 00:00:00
|
2175-07-12 13:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Motrin
Attending: ___.
Chief Complaint:
N/V abdominal pain
Major Surgical or Invasive Procedure:
___ Laparoscopic cholecystectomy
History of Present Illness:
Ms. ___ is a ___ year old woman with obesity and
cholelithiasis who presented to the ED with one week of
abdominal pain, nausea, and vomiting. Of note she had presented
to primary care clinic in ___ with epigastric pain and at
that time had elevation of her transaminases and alk phos,
although bili was not reported. She underwent negative viral
hepatitis work-up and LFTs subsequently
improved. At that time she also had an ultrasound showing a 1.3
cm gallstone. Her recent symptoms began approximately one week
ago. Since that time she has had waxing and waning abdominal
pain, nausea, and vomiting. The abdominal pain has been across
the upper abdomen and has been as high as ___ at times. The
vomit has mostly been watery in appearance, although she notes
that once or twice it appeared that there was some slight
pinkish tinge without any consumption of pink or red foods. She
denies any change to her bowel movements. No fevers, dyspnea, or
chest pain. She reports dehydration, dizziness, and thirstiness.
She also reports some increased urinary frequency, although
without
other urinary symptoms. Overall the symptoms had improved
slightly in recent days, but when they then worsened again today
she sought care at the ED.
In the ED, initial VS were AF ___
98-100% RA, exam notable for diffuse abdominal tenderness. Labs
were notable for ___, ALT 430, AST 133, Alk Phos 157,
Tbili 4.9, DBili 3.2, WBC 19.4. CT showed acute
pancreatitis, intrahepatic and cystic ductal dilitation without
filling defects identified, and distended gallbladder without
gallbladder wall thickening. While in the ED she was seen by ACS
and the case was discussed with the ERCP team. Patient was given
fluids, zosyn, morphine ,an Zofran and was admitted to medicine
for further management. She reports mild improvemen in her
symptoms with these therapies.
ROS: As per HPI, and 10 point ROS completed and otherwise
negative.
Past Medical History:
iron deficiency anemia
asthma
migraines
mood disorder nos
neuropathy
obesity
cholelithiasis
Social History:
___
Family History:
-unknown (adopted)
Physical Exam:
Admission Exam:
Vital signs reviewed in flowsheet. (see HPI)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, diffuse TTP worst in upper
abdomen, overall symmetric. no bowel sounds heard
MSK: No joint erythema or swelling
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: T 98.6 HR 112 BP 112/75 RR 20 89%RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, moderately tender to palpation
in RUQ, incisions C/D/I
MSK: No joint erythema or swelling
Pertinent Results:
===========================================
Admission Data
___ 08:10PM BLOOD WBC: 19.4* RBC: 5.16 Hgb: 13.7 Hct: 43.5
MCV: 84 MCH: 26.6 MCHC: 31.5* RDW: 15.0 RDWSD: 45.___
___ 08:10PM BLOOD Neuts: 83.9* Lymphs: 7.3* Monos: 7.9 Eos:
0.1* Baso: 0.2 Im ___: 0.6 AbsNeut: 16.25* AbsLymp: 1.42
AbsMono: 1.52* AbsEos: 0.02* AbsBaso: 0.03
___ 08:10PM BLOOD ___: 10.6 PTT: 27.1 ___: 1.0
___ 08:10PM BLOOD Glucose: 166* UreaN: 12 Creat: 0.7 Na:
137
K: 5.1 Cl: 98 HCO3: 23 AnGap: 16
___ 08:10PM BLOOD ALT: 428* AST: 133* AlkPhos: 157*
TotBili:
4.9* DirBili: 3.2* IndBili: 1.7
___ 08:10PM BLOOD ___: ___
___ 08:10PM BLOOD Albumin: 4.4
___ 09:46PM BLOOD Lactate: 1.0
CT prelim read
1. Acute pancreatitis with small amount of ascites in the
retroperitoneum,
layering against the left lateroconal fascia.
2. New mild intrahepatic ductal dilation, marked dilation of the
cystic duct,
measuring 13 mm and mild dilation of the common bile duct
measuring 10 mm. No
filling defects are seen. No definite ampullary mass is
identified.
3. Mildly distended gallbladder with a 1.2 cm stone within. No
gallbladder
wall thickening.
===========================================
Brief Hospital Course:
Ms. ___ is a ___ year-old woman who initially presented with
nausea, vomiting, and abdominal pain, found with have
pancreatitis. A CT in the ED showed marked dilation of the
cystic duct and mild dilation of the CBG with no filling
defects, most consistent with gallstone pancreatitis. ERCP
initially planned a procedure, but an MRCP on HD#2 showed a
normal CBD and pancreatic duct, consistent with the stone
passing. She was therefore treated conservatively with IVF and
pain meds. She had high fevers, and completed a 5 day course of
ampicillin-sulbactam out of concern for cholangitis. Her diet
was slowly advanced, and by HD#4 she was on an oral pain regimen
and eating a regular diet. Her course was complicated by
hypoxia, caused by splinting. With incentive spirometry, her O2
saturations markedly improved. Her LFTs completely normalized,
and her leukocytosis resolved. On HD#5, the patient was taken
for a cholecystectomy. Please see operative report for details.
She tolerated the procedure well and was extubated upon
completion. She was subsequently taken to the PACU for recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced on the morning of
POD1 to regular, which she tolerated without abdominal pain,
nausea, or vomiting. She was voiding adequate amounts of urine
without difficulty. She was encouraged to mobilize out of bed
and ambulate as tolerated, which she was able to do
independently. Her pain level was routinely assessed and well
controlled at discharge with an oral regimen as needed.
On ___ she was discharged home with scheduled follow up in
___ clinic on ___.
Medications on Admission:
OCPs
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN Headache
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
take acetaminophen regularly to keep on top of your pain
3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
do not drive a car while taking this medication
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every ___
hours Disp #*15 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Gallstone Cholecystitis
Acute Cholecystectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital on ___ with abdominal
pain and found to have gallstone pancreatitis. You were given
antibiotics and your labs were monitored. Once your abdominal
pain resolved, you were taken to the operating room and had your
gallbladder removed laparoscopically. You are now doing better,
tolerating a regular diet, pain is better controlled, and you
are ready to be discharged to home to continue your recovery
from surgery.
Please note the following discharge instructions:
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.
Followup Instructions:
___
|
10795503-DS-7
| 10,795,503 | 26,171,310 |
DS
| 7 |
2183-01-10 00:00:00
|
2183-01-11 19:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / morphine / simvastatin /
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
orthostatic hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F with PMH orthostatic hypotension and iron-deficiency
anemia presenting with worsening lightheadedness when standing
up and dyspnea on exertion. She notes symptoms have worsened
over past week, becomes LH when standing up or lying down, and
worsening heart racing and shortness of breath after walking
short distances. Has felt cold the past day, no fevers, no chest
pain/pressure, no abdominal pain, n/v/d, dysuria. Underwent
colonoscopy/EGD ___ for iron-deficiency anemia without any
significant findings. No falls or syncope. Has had issues with
orthostatic hypotension for several years now, on florinef since
then. Symptoms have worsened over the past month-has had to
receive IVF for orthostatic sx 4 times in the past month. Blood
pressure has responded to fluids in those circumstances. Has
been drinking plenty of fluids, urinating fine. No diarrhea,
nausea/vomiting. Had not been wearing compression stockings.
In the ED, initial vitals: 97.9 99 123/77 19 96% RA.
Orthostatic vitals: 131/99 (lying), 116/76 (Sitting), 109/52
(Standing). Repeat s/p 1L NS: 143/74 (Laying Down), 108/69
(Sitting), 84/54 (Standing)
Past Medical History:
GERD
OSA
orthostatic hypotension
Social History:
___
Family History:
Colon cancer in brother, sister, mother
Physical ___:
ADMISSION PHYSICAL EXAM
======================
Vitals: 98 146/80 88 18 95RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, no
LAD, no JVD. Noted to have mild anisicoria, L pupil slightly
larger. unsure if chronic.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no cyanosis or edema
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
DISCHARGE PHYSICAL EXAM
======================
VS - Tmax 98.7 Tc 98.1 HR 76 BP 145/84 RR 02 sat 96% on RA
Orthostatics: lying down BP 145/78 HR 69 to sitting 120/78 HR
69 to standing BP 100/66 HR 69
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, pale conjunctive, mild anisicoria, L
pupil slightly larger. Pupils reactive with no APD
NECK: no LAD, no JVD.
Lungs: Good aeration bilaterally. Lungs clear to auscultation
bilaterally without adventitious sounds
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, no cyanosis or edema. Wearing
compression socks
Skin: Without rashes or lesions
Neuro: A&Ox3. Mild anisicoria as above. Other cranial nerves
intact. Moves all extremities symmetrically and spontaneously.
Otherwise, grossly intact.
Pertinent Results:
ADMISSION LAB RESULTS
====================
___ 08:13PM BLOOD WBC-8.7 RBC-4.14 Hgb-10.3* Hct-34.2
MCV-83 MCH-24.9* MCHC-30.1* RDW-15.0 RDWSD-45.5 Plt ___
___ 08:13PM BLOOD Neuts-63.8 ___ Monos-9.1 Eos-2.4
Baso-0.6 Im ___ AbsNeut-5.53 AbsLymp-2.04 AbsMono-0.79
AbsEos-0.21 AbsBaso-0.05
___ 08:13PM BLOOD ___ PTT-30.0 ___
___ 08:13PM BLOOD Glucose-90 UreaN-22* Creat-1.1 Na-136
K-4.7 Cl-102 HCO3-21* AnGap-18
___ 08:19PM BLOOD Lactate-1.7
___ 08:13PM BLOOD cTropnT-<0.01
___ 11:50PM BLOOD cTropnT-<0.01
PERTINENT LAB RESULTS
===================
___ 08:10AM BLOOD Cortsol-32.2*
___ 07:26AM BLOOD Cortsol-25.3*
___ 06:50AM BLOOD Cortsol-7.2
___ 07:30AM BLOOD Cortsol-5.3
ACTH: 10 (Reference range: ___ pg/mL)
DISCHARGE LAB RESULTS
====================
___ 06:50AM BLOOD WBC-7.1 RBC-3.78* Hgb-9.5* Hct-31.7*
MCV-84 MCH-25.1* MCHC-30.0* RDW-14.9 RDWSD-45.5 Plt ___
___ 06:50AM BLOOD Glucose-95 UreaN-16 Creat-0.9 Na-142
K-4.0 Cl-107 HCO3-22 AnGap-17
IMAGING
======
___ CXR:
The lungs are well expanded and clear. No focal consolidations.
No pulmonary
edema. Stable enlargement of the cardiomediastinal silhouette.
The rounded
retrocardiac opacity likely represents a hiatal hernia. No
pleural effusion.
No pneumothorax.
MICROBIOLOGY
============
___ Urine Culture: mixed bacterial flora
___ Blood Culture: pending
Brief Hospital Course:
___ y/o F with long history of orthostatic hypotension and
iron-deficiency anemia presenting with lightheadedness,
dizziness and DOE found to have orthostatic hypotension.
#Orthostatic Hypotension: The patient has a two year history of
orthostatic hypotension without clear etiology, with worsening
of sx over last month requiring multiple visits to ED/UC for IVF
despite use of florinef. She appeared hypovolemic on exam and
endorsed thirst, making hypovolemia a likely cause of her
orthostatic hypotension. There was low suspicion for cardiac
etiology given lack of cardiac history, negative troponins x 2,
and reassuring ECG. No recent ECHO on file. Her oxygen
saturation remained above 94% with ambulation. Repeat
orthostatics on ___ showed lying BP of 150/90, standing
128/78. he was given a total of 4L of IVF, and her orthostatic
hypotension resolved after IVF. As per new guidelines about
supine hypertension, positive orthostatics include systolic BP
drop >30 and diastolic drop >20. Patient does not meet criteria
for orthostatic hypotension. We arranged follow up with ___
Autonomics (Neurology) for further workup of her orthostasis.
Of note, AM cortisol level ___ was low at 5.3, but it was
normal (7.2) when it was checked the morning of 11.29. She
responded appropriately to the cosyntropin stimulation test
(7.2-->25.3-->32.2). ACTH level was normal at 10 (reference
range ___ pg/mL). She does not have primary or secondary
adrenal insufficiency.
#Dyspnea on Exertion: She has been having increasing dyspnea on
exertion since ___ but states that it has been worse over the
past month, and particularly the past week as she has begun to
notice dyspnea with minimal exertion. As above, there is low
suspicion for cardiac etiology. She may have other respiratory
pathology contributing to progressive dyspnea including a mass
not visualized on CXR or pulmonary HTN given history of OSA. She
presents with anemia, however her Hgb is consistent with her
baseline iron-deficiency anemia. Ambulatory O2 saturation
remains in mid to high ___. It would be beneficial to obtain a
TTE as an outpatient. Further consideration of outpatient PFTs
and a non-contrast CT of the chest may also be helpful. ___
evaluated the patient and recommended outpatient physical
therapy.
TRANSITIONAL ISSUES
===================
#Orthostasis
- The patient should follow up with ___ Neurology
(specifically ___ who specializes in autonomic
neurology) for further management of her orthostatic
hypotension.
- Consider discontinuing fludricortisone (since it does not
appear to be effective), and consider starting midodrine 2.5mg
TID for orthostatic hypotension. Patient would need close blood
pressure monitoring for supine hypertension given that she is
also on Adderall.
#Shortness of Breath
- It may be beneficial to obtain a CT of the chest and PFTs to
further evaluate the patient's shortness of breath.
- The patient should get an echocardiogram to evaluate cardiac
function or pulmonary hypertension given persistent shortness of
breath.
- Patient should begin outpatient physical therapy
# CODE STATUS: Full code (confirmed)
# CONTACT: ___ (daughter, ___,
___ (daughter, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Sertraline 150 mg PO DAILY
3. Simvastatin 20 mg PO QPM
4. Fludrocortisone Acetate 0.1 mg PO DAILY
5. Amphetamine-Dextroamphetamine XR 20 mg PO DAILY
Discharge Medications:
1. Amphetamine-Dextroamphetamine XR 20 mg PO DAILY
2. Fludrocortisone Acetate 0.1 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Sertraline 150 mg PO DAILY
5. Simvastatin 20 mg PO QPM
6.Outpatient Physical Therapy
ICD-10 code: ___ deconditioning. Please evaluate and treat
for deconditioning and persistent shortness of breath.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
- Orthostatic hypotension secondary to adrenal insufficiency
Secondary Diagnosis
- Anemia
- OSA
- GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized at ___.
Why did you come to the hospital?
=========================
- You were admitted to the hospital for worsening of your
orthostatic hypotension
What did we do for you?
=================
- We gave you IV fluids to increase your blood pressure.
- We tested your cortisol level, which was normal.
What do you need to do?
==================
- It is important that you follow-up with your outpatient doctor
for further management of your orthostatic hypotension. You
already have an appointment scheduled for ___
- It is important that you get an ultrasound of your heart
(echocardiogram), pulmonary function tests, and a CT of your
chest as an outpatient.
- You should follow up with ___ Neurology (appointment
information below)
- Please note you have both a PCP appointment and ___ capsule
endoscopy on ___, please call your PCP to verify if you should
get your endoscopy that morning.
It was a pleasure caring for you. We wish you the best!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10795507-DS-19
| 10,795,507 | 22,969,909 |
DS
| 19 |
2196-01-05 00:00:00
|
2196-01-05 16:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Indocin / Proventil
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
spinal injection
History of Present Illness:
___ yo F longstanding h/o follicular lymphoma previously tx w/
XRT, Rituxan/Fludarabine, Leukeran, on Rituxan p/w back pain.
Pt was in ___ when pain started and slowly progressed over the
course of 1 week. She had acute worsening on ___ and ___
went to ED in ___ where she was given tizanidine/percocet and an
XRay of the spine was done. Pain is predominantly right sided
on the lower back, intermittent, at it's worse ___, worsened
w/ changes in position, walking. She denies midline tenderness,
fevers chills, urinary/bowel inc, urinary frequency, h/a, vision
changes. She does endorse some parasthesia in her ___. She had
difficulty ambulating w/ cane (baseline) b/c pain. She had one
epsiode of nausea/emesis ___ percocet last night.
In the ED, VS: T97.5, HR 89, BP 142/115, RR 16, O2 93% RA. Labs
notable for dirty UA, Cr 2.5, WBC 8.8. CXR showed posterior
mediastinal mass. CT torso showed enlarged node adjacent to the
aortic bifurcation. She received nitrofurantoin 100mg, tylenol
___, morphine 2.5mg.
Currently, pt states pain is okay when she's not moving and that
she feels drowsy b/c of the narcotics in the ED.
ROS: 12 point review of system also + for few pound weight loss,
poor po (per niece), constipation. Otherwise negative.
Past Medical History:
Oncologic history:
Follicular lymphoma:
- in ___ presented with stage I follicular lymphoma with two
large left supraclavicular nodes, which were excised; negative
staging workup included a bone marrow examination and CT scan of
the chest, abdomen and pelvis with no other evidence for
disease.
- received radiation therapy to the left supraclavicular area
with curative intent.
- remained in a continuous complete remission until ___ when
she developed weight loss and fatigue with decreased appetite.
CT showed no adenopathy. Colonoscopy revealed a polyp with a
benign biopsy. Noted to be anemic and a bone marrow aspirate and
biopsy revealed diffuse infiltration by the known follicular
lymphoma grade III,
accounting for 70% of bone marrow involvement.
- was treated with rituximab and fludarabine for four cycles
from ___ and ___.
- had complete normalization of her anemia and remained in
complete remission until ___ when she presented with
increasing shortness of breath with fatigue. She was noted to
have a large left pleural effusion; underwent a diagnostic and
therapeutic thoracentesis, the results of which did reveal a
small population of monoclonal
B cells consistent with the patient's known follicular lymphoma.
- was started on chlorambucil and prednisone. She also required
oxygen support and periodic thoracentesis. Her pleural effusion
completely resolved by ___.
- follow-up CT in ___ continued to show no evidence for
adenopathy but note was made of a thyroid nodule, this was
biopsied, but did not show any significant abnormality.
- continued on chlorambucil until ___ when she was noted for
worsening anemia and an elevated MCV. It was not clear whether
this was related to her chlorambucil treatment, disease or
hemolysis or
any vitamin deficiency. This was evaluated with Dr. ___. By
report, her hemolysis workup was negative and a CT scan was
done,
which revealed essentially no evidence for adenopathy but with
mild splenomegaly and a small left pleural effusion.
- because of the concern for hemolysis, she was started on a
prednisone with a taper in mid ___. Coming off the
chlorambucil and receiving prednisone, her hematocrit recovered
from 28.3 to 39.8 on ___ her MCV, however, did remain
elevated.
.
Non-oncologic history:
1. atrial fibrillation: never on warfarin, on disopyramide
2. glaucoma
3. rotator cuff injury ___
Social History:
___
Family History:
father: pancreatic cancer
Physical Exam:
VS: T 98.3, BP 125/56, HR 86, O2 93% RA
Gen: NAD
HEENT: dry mm, OP clear, sclera anicteric
Neck: supple, no thyromegaly
CV: RR, no mrg
Pulm: CTAB, no wrr
Abd: +BS, soft, mildly distended, NT, no guarding/rebound
GU: No CVAT
Spine: No midline tenderness
Ext: no edema
Neuro: Pt sleepy, but responds appropriately to questions and
follows commands; CN2-12 intact; Sensation to LT intact
throughout, no saddle anesthesia; Strength 4+/5 in ___ bl,
___ R/L knee/hip ext/flex, ___ foot ext/flex; unable to illicit
patellar reflex; downgoing toes
Pertinent Results:
___ 08:35AM ___ PTT-25.1 ___
___ 08:35AM PLT COUNT-178
___ 08:35AM NEUTS-84.4* LYMPHS-10.8* MONOS-2.9 EOS-1.8
BASOS-0.2
___ 08:35AM WBC-8.8# RBC-4.08* HGB-13.1 HCT-38.9 MCV-95
MCH-32.0 MCHC-33.7 RDW-13.8
___ 08:35AM ALBUMIN-4.1 CALCIUM-10.0 PHOSPHATE-5.3*
MAGNESIUM-2.2
___ 08:35AM cTropnT-<0.01
___ 08:35AM LIPASE-37
___ 08:35AM ALT(SGPT)-15 AST(SGOT)-26 ALK PHOS-64 TOT
BILI-0.6
___ 08:35AM estGFR-Using this
___ 08:35AM GLUCOSE-118* UREA N-46* CREAT-2.5*#
SODIUM-135 POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-26 ANION GAP-19
___ 08:49AM LACTATE-1.8
___ 01:25PM URINE WBCCLUMP-OCC MUCOUS-RARE
___ 01:25PM URINE HYALINE-8*
___ 01:25PM URINE RBC-11* WBC-113* BACTERIA-FEW YEAST-NONE
EPI-10 TRANS EPI-3
___ 01:25PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-LG
___ 01:25PM URINE COLOR-Yellow APPEAR-Hazy SP ___
CT torso:
IMPRESSION:
1. Multilevel thoracolumbar degenerative changes without
evidence of
compression fracture.
2. 2.5 x 1.8 cm lymph node adjacent to the aortic bifurcation,
likely
unrelated to patient's acute presentation, is increased since
___ and suspicious for recurrent disease, given
history of lymphoma. This could be further evaluated with
PET-CT or short interval follow-up.
3. Tiny ___ and nodular ground-glass opacities
predominantly in the left lower lobe are nonspecific but
compatible with aspiration, particularly in the setting of oral
contrast seen within the esophagus.
4. Right lower lobe basal segmental collapse. Small left
pleural effusion with adjacent compressive atelectasis, likely
accounting for abnormality on chest radiograph.
5. Large fecal load.
6. 3.2-cm right thyroid lobe nodule, similar to prior.
CXR:
FINDINGS: PA and lateral views of the chest were provided. On
the lateral
view there is a convex opacity arising posteriorly partially
overlapping with the lower thoracic vertebral bodies which is
new from prior exams and is concerning for a posterior
mediastinal mass. Otherwise the lungs are clear.
Cardiomediastinal silhouette is normal. Bony structures appear
intact. No free air below the right hemidiaphragm. Degenerative
spurring is noted anteriorly in the thoracic spine.
IMPRESSION: Findings concerning for a posterior mediastinal mass
with convex opacity overlapping with the mid-to-lower T-spine,
new from prior exam. Correlation with CT advised.
.
MRI T+L spine:
IMPRESSION:
1. Diffusely abnormal bone marrow signal. Lymphomatous
infiltration cannot be excluded.
2. Indeterminate focal signal abnormalities in the L1 and L5
vertebral
bodies, without evidence of pathologic fractures. These
correspond to lucent areas on the ___ torso CT, not
significantly changed compared to the ___pparent stability suggests non-aggressive etiology, but
followup could be considered.
3. Multilevel degenerative disease in the thoracic and lumbar
spine.
Moderate spinal canal stenosis and severe right neural foraminal
narrowing at L4-5.
4. 4-mm indeterminate T2 hypointense lesion in the right
kidney. Diagnostic considerations include a hemorrhagic cyst,
but a solid lesion cannot be excluded. If clinically warranted,
this could be characterized by renal protocol MRI.
5. No evidence of discitis, osteomyelitis, or epidural
collection, within the limits of non-contrast MRI.
.
___:
IMPRESSION:
1. There is interval appearance of bilateral layering pleural
effusions, left greater than right, with associated bibasilar
airspace disease. Although this may represent compressive
atelectasis, aspiration and/or pneumonia should also be
considered. No evidence of pulmonary edema. No pneumothorax.
Overall, cardiac and mediastinal contours are stable.
Degenerative changes in the thoracic spine. No acute bony
abnormality appreciated.
.
UCX-mixed flora
Brief Hospital Course:
Pt is a ___ y.o female with h.o lymphoma, afib who presented with
back pain and ARF. Pt then developed afib with RVR.
.
#lower back pain-Likely musculoskeletal due to lumbosacral
degenerative changes. There were no neurologic red flags or
signs of cord compression. Imaging did not suggest infection or
cord compression. No evidence of pyelonephritis. Imaging did
reveal a small hemorrhagic renal cyst and "diffuse lymphomatous
infiltration". However, this was not thought to be the cause of
her pain. She was initially treated with oxycodone, lidocaine
patch, and standing tylenol with minimal effect. Therefore, the
pain service evaluated the patient and performed a spinal
injection on ___ with good effect and decrease in pain.
Physical therapy evaluated the patient and felt that pt would
benefit from rehab.
- cont ___, tylenol, low dose oxycodone, lidocaine ptch
.
#afib with RVR developed ___. Pt only with minimal response to
IV metoprolol and PO metoprolol. She was then given IV diltiazem
and converted over to 90mg QID PO diltiazem. She was continued
on her home regimen of aspirin and disopyramide. Due to poor
control, she was briefly added on metoprolol 25mg TID, but
spontaneously became controlled to HR 60-70s. Her metoprolol
was stopped with continued good effect. She is still on dilt
QID, however, i suspect her heart rate will improve itself as
she clinically improves. she may not need any nodal agents once
she recovers
- recommend tele/close HR monitoring and Dilt adjustment as
needed
.
#hypoxemia/acute diastolic CHF-likely due to acute pulmonary
edema from IVF and from afib with rvr. Improved with HR control
and rate control. Lasix 20mg IV ___ per day worked well,
putting out ___ of fluid. Would assess her volume status and
diuresis as needed. ___ benefit from low dose lasix on
discharge from rehab.
.
#acute renal failure- Prerenal on admission. Improved with IVF.
.
#h.o lymphoma with ?recurrence-issue of recurrence raised on new
imaging, with lymphadenopathy and renal cyst (see report above).
Thought not to be the cause of pain/current presentation as
discussed with Dr. ___. Discussed with pt and her HCP. Pt
will required follow up in oncology for this, given possibility
of recurrence
.
#constipation-improved with agressive bowel regimen. continued
on discharge.
.
FEN: reg, low sodium
.
DVT PPx: hep SC TID
.
CODE: FULL
.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/CaregiverwebOMR.
1. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown
2. Disopyramide Phosphate 150 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral bid
6. Aspirin 81 mg PO DAILY
7. FoLIC Acid 2 mg PO DAILY
8. Ibuprofen 400 mg PO Q8H:PRN pain
9. Cyclobenzaprine 10 mg PO TID:PRN pain
10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Disopyramide Phosphate 150 mg PO BID
3. FoLIC Acid 2 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Multivitamins 1 TAB PO DAILY
6. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral bid
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Acetaminophen 1000 mg PO TID
9. Diltiazem 90 mg PO Q6H
hold for SBP <100 or HR <60 and notify MD.
10. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
11. Lidocaine 5% Patch 1 PTCH TD DAILY
12. Docusate Sodium 100 mg PO BID
13. Polyethylene Glycol 17 g PO DAILY:PRN c
14. Senna 1 TAB PO BID:PRN c
15. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*12 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
spinal disc herniation/degenerative changes
atrial fibrillation with RVR
back pain
acute diastolic chf exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for evaluation of back pain. You underwent a
CT scan and an MRI that showed disc disease and arthritis of
your back. For this, you were evaluated by the pain doctors who
performed ___ injection into your back with good effect and
relief of your pain. In addition, you had difficult to control
atrial fibrillation and were started on new medications
(diltiazem and metoprolol). Please follow up closely with your
oncologist to further monitor your lymphoma. You may need more
adjustment of her heart rate medications, and your water pill.
.
New medications:
1.diltiazem
Followup Instructions:
___
|
10795507-DS-20
| 10,795,507 | 29,247,508 |
DS
| 20 |
2196-04-28 00:00:00
|
2196-04-29 07:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Indocin / Proventil
Attending: ___.
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F w/ PMH of NHL (s/p 2 cycles of rituxan treatment in
___ who presents with cough. Pt reports symptoms started 1
week prior with cough and shortness of breath. She called her
PCP's office who recommended she go tot he hospital but she was
concerned about getting the flu so instead had a cxr performed
at her assisted living apartment, and she was started on
cefpodoxime on ___ which continues to take.Denies fevers,
chills, sore throat, sinus congestions, muscle aches, headaches,
stiff neck, skin rashes, swollen lymph nodes. She reports some
mild orthopnea with one additional pillow use, but no pnd. She
complains of getting "winded" just walking from the stretcher to
the bed today. She denies any history of lung disease, but did
have a pleural effusion in the past ___ her lymphoma but no
recurrences of this. She reports sick contacts at her assited
living.
On the day of admission she reported feeling overall worse and
felt like she now needed to go to the emergency room.
On arrival to the ED her VS were: 97.6 68 153/60 24 100% 2L
Nasal Cannula. She was complaining of cough and received
tessalon perles and a dose of IV levofloxacin. A CXR was
performed and final read was pending at the time of admission.
ROS: occasional fast heart rate when her breathing gets labored,
+cough. per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
NHL- getting rounds of rituxan multiple times a year, last
treatment ___
Aplastic anemia
Squamous cell skin cancer
h/o atrial fibrillation
glaucoma
s/p rotator cuff injury
squamous cell cancer of the finger s/p skin graft from arm on
___
Social History:
___
Family History:
mother: pancreatic cancer
Father- h/o MI (at age ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.9, 168/37, 70, 96%2L at rest
GENERAL - elderly caucasian woman in NAD, lying in bed
comfortable appearing.
HEENT - NC/AT, blotching to the skin on her face. MMM,
Oropharynx with erythematous blotches on her hard palate without
signs of vesicles, plaques or exudate present. PERRLA, EOMI,
sclerae anicteric, MMM,
NECK - supple, no thyromegaly, no JVD
HEART - ___ systolic murmur heard best at the RUSB, no
appreciable rubs or gallops
LUNGS - musical sounding wheezes throughout with coarse rhonchi
present in the right base
ABDOMEN - soft, nontender nondistended, normoactive bowel sounds
EXTREMITIES - WWP, Left index figner with sutures on the dorsal
surface, intact and well healed. difficult to feel radial pulse
SKIN - multiple SKs ont he skin
NEURO - awake, A&Ox3, CNs II-XII grossly intact, no pronator
drift, following commands, strength grossly ___. Gait deferred.
Sensation grossly intact.
DISCHARGE PHYSICAL EXAM:
Tc 97.3 BP 132/62 HR 76 RR 20 95% RA (94% on RA with ambulation)
GENERAL - elderly caucasian woman in NAD, lying in bed
comfortable appearing.
HEENT - NC/AT, blotching to the skin on her face. MMM,
Oropharynx with erythematous blotches on her hard palate without
signs of vesicles, plaques or exudate present. PERRLA, EOMI,
sclerae anicteric, MMM,
NECK - supple, no thyromegaly, no JVD
HEART - ___ systolic murmur heard best at the RUSB, no
appreciable rubs or gallops
LUNGS - Crackles at the left base
ABDOMEN - soft, nontender nondistended, normoactive bowel sounds
EXTREMITIES - WWP, Left index figner with sutures on the dorsal
surface, intact and well healed. has dissolable sutures
SKIN - multiple SKs ont he skin
NEURO - awake, A&Ox3, CNs II-XII grossly intact, no pronator
drift, following commands, strength grossly ___. Gait deferred.
Sensation grossly intact.
Pertinent Results:
Labs on Admission:
___ 11:45AM BLOOD WBC-7.6 RBC-3.60* Hgb-11.4* Hct-34.9*
MCV-97 MCH-31.5 MCHC-32.5 RDW-12.6 Plt ___
___ 11:45AM BLOOD Neuts-81.1* Lymphs-13.5* Monos-4.3
Eos-0.8 Baso-0.2
___ 11:45AM BLOOD Glucose-93 UreaN-25* Creat-1.1 Na-141
K-4.4 Cl-103 HCO3-26 AnGap-16
___ 08:00AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.7
MICROBIOLOGY:
___ 12:14PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
___ 11:30 am Influenza A/B by ___
Source: Nasopharyngeal aspirate.
**FINAL REPORT ___
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
___ Blood cultures x 2 PND
___ 10:36 am URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
IMAGING:
ECG Study Date of ___ 12:21:14 ___
Sinus rhythm. Diffuse non-specific repolarization abnormalities.
Compared to the previous tracing of ___ cardiac rhythm is
now sinus mechanism.
CHEST (PA & LAT) Study Date of ___ 2:03 ___
IMPRESSION:
1. Reticular opacity projecting over the right superior
paramediastinal
region, possibly an infectious focus. Recommend further
evaluation with an AP lordotic radiograph. This finding and
recommendation was discussed with Dr. ___ by Dr.
___ at 9:54 p.m. via telephone on the day of the study.
2. Interval near-complete resolution of bibasilar opacities
seen on the prior radiograph from ___
CHEST (APICAL LORDOTIC ONLY) Study Date of ___ 12:27 AM
FINDINGS: Technically limited examination. As compared to the
previous film from ___, the pre-described opacity
in the right medial areas of the right lung have resolved. On
the current image, there is no evidence of pneumonia. Normal
size of the cardiac silhouette. No pulmonary edema. No
evidence of pneumothorax.
TTE (Complete) Done ___ at 11:40:32 AM FINAL
Findings
This study was compared to the report of the prior study (images
not available) of ___.
LEFT ATRIUM: Mild ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Suboptimal technical quality, a focal LV wall motion abnormality
cannot be fully excluded. Mildly depressed LVEF. Beat-to-beat
variability on LVEF due to irregular rhythm/premature beats. No
resting LVOT gradient.
RIGHT VENTRICLE: Dilated RV cavity. Normal RV systolic function.
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 mitral annular calcification. Mild (1+) MR.
___ VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: The rhythm appears to be atrial fibrillation.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
mildly depressed (LVEF= 40-45 %). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. The right
ventricular cavity is dilated with normal free wall
contractility. 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. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the report of the prior study (images unavailable
for review) of ___, left ventricular systolic function has
declined.
CHEST (PA & LAT) Study Date of ___ 10:14 AM
IMPRESSION:
1. Increasing atelectasis in the right lower lobe. Stable small
left pleural effusion with adjacent atelectasis.
2. No evidence of pulmonary edema.
Labs on Discharge and Relevant Labs:
___ 07:35AM BLOOD WBC-5.0 RBC-3.65* Hgb-12.0 Hct-36.0
MCV-99* MCH-32.9* MCHC-33.3 RDW-13.3 Plt ___
___ 07:35AM BLOOD Glucose-71 UreaN-22* Creat-1.4* Na-143
K-4.3 Cl-106 HCO3-30 AnGap-11
___ 07:35AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.7*
Brief Hospital Course:
___ yo F w/ PMH of aplastic anemia and NHL s/p rituxan treatment
presents with cough and shortness of breath concerning for
pneumonia despite treatment.
# Acute Systolic Congestive Heart Failure: The patient had
findings of intermittent opacities on her CXR; she was treated
with a 5 day course of Levoquin in ___. However, she continued
to have impressive desaturations while walking into the ___ on
RA; as such, an ECHO was performed, which showed a new decrease
in her EF from 60% to a newly low 40%. One day in ___ she
received 20 mg IV Lasix; the next day 40 mg IV Lasix. With these
medications, her Cr rose from 1 to 1.4, and stayed there on
discharge; however, she was then able to walk with normal
saturations on room air. As such, she was discharged with 20 mg
Furosemide Daily, and a plan to have her rehab physicians
recheck her electrolytes in 3 days time from her discharge to
ensure stability of her creatinine, as well as a recheck of her
oxygenation and volume status.
Of note, a pulmonary embolism was on the differential given that
she had a history of PE and ___ filter placement in ___
she has not been anticoagulated since that time, but given her
improvements with diuresis, PE was felt to be less likely.
# Atrial fibrillation: On admission, the patient was in sinus
rhythm, but did convert to atrial fibrillation, and then back to
sinus, during her hospitalization. Her CHADS2 score is currently
2 for age and heart failure; the patient and myself extensively
discussed the approximately 4% risk of stroke annually with her
risk factors with paroxysmal atrial fibrillation. The patient
elected to further discuss this issue with her new cardiologist
and primary care physician. She was continued on her home
Diltiazem, Disopyramide, and ASA 81 mg Daily.
# NHL - s/p rituxan in ___. She should continue to follow-up
with oncology per their instruction. She was never pancytopenic
while in ___.
#CODE STATUS: full code (confirmed with patient)
#CONTACT: ___ ___
TRANSITIONAL ISSUES:
- Please recheck O2 saturation, volume status, and a CHEM-10 on
___, and have this forwarded to her rehabilitation
physician.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. FoLIC Acid 2 mg PO DAILY
3. Diltiazem 90 mg PO QID
hold for sbp<100 or hr<60
4. Disopyramide CR 150 mg PO Q12H
hold for sbp<100 or hr<60
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
6. Fish Oil (Omega 3) 1000 mg PO BID
7. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral daily
8. Multivitamins 1 TAB PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Diltiazem 90 mg PO QID
hold for sbp<100 or hr<60
3. Disopyramide CR 150 mg PO Q12H
hold for sbp<100 or hr<60
4. Fish Oil (Omega 3) 1000 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Multivitamins 1 TAB PO DAILY
8. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral daily
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Furosemide 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Community Acquired Pneumonia
- Systolic Heart Failure
- Atrial Fibrillation
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 in the
hospital. You were admitted because you had been having symptoms
of pneumonia which did not respond to the oral antibiotics you
were taking. You receieved a dose of IV antibiotics in our
emergency department, and improved on the oral version of this
antibiotic.
However, you continued to have shortness of breath, and had
drops in your oxygen upon walking. We performed an ultra-sound
of your heart, which showed that your heart is not squeezing as
well as it did several years ago, concerning for possible
"heart failure."
We started you on medications to cause you to urinate, which can
help in heart failure, and your breathing improved. You will be
taking a pill that will cause you to urinate to keep you from
developing shortness of breath.
We also noted that you were in an irregular heart rhythm known
as "atrial fibrillation." We had a long discussion about the
risks and benefits of starting a blood thinner; your risk of
stroke every year is around 4%. We decided to allow you to speak
with your primary care doctor and cardiologist (whom you have an
appointment with) about starting these kinds of medications.
Followup Instructions:
___
|
10795612-DS-10
| 10,795,612 | 28,124,139 |
DS
| 10 |
2134-11-18 00:00:00
|
2134-11-18 13:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Right bimalleolar ankle fracture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old otherwise healthy female who fell from standing
4 days ago while walking with her walker at home. She did not
appreciate any immediate deformity and was able to ambulate with
minimal pain thereafter. She was seen by her visiting home nurse
who subsequently wrapped her right lower extremity with an ACE
wrap. The morning of presentation she had pain/difficulty
bearing
weight. She was taken to ___ for further evaluation.
ROS: No chest pain, shortness of breath, headache, vision
change,
abdominal pain, no weakness outside of H&P
Past Medical History:
- Osteoarthritis at multiple sites including hands, r hip, both
knees
- HTN
- Osteoporosis
- Chronic Bronchitis per family (they note frequent mild cough,
and phlegm, has been followed by PCP for this)
- severe bunions b/l
Social History:
___
Family History:
Family Hx: Various family members with RA. A sister with
possible
thyroid cancer, o/w the patient is unaware of any strokes, heart
disease or DM in family.
Physical Exam:
T-99 HR-105 BP-133/71 RR-16 SaO2-97% RA
A&O x 3
Calm and comfortable
RLE skin clean and intact w/ marked ecchymosis and edema about
bilateral malleoli.
Tender about medial malleolus
Thighs and legs are soft
No pain with passive motion
Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire
1+ ___ and DP pulses
Pertinent Results:
___ 01:30PM WBC-8.9 RBC-4.47 HGB-13.1 HCT-39.2 MCV-88
MCH-29.3 MCHC-33.4 RDW-13.6
___ 01:30PM NEUTS-80.3* LYMPHS-12.4* MONOS-5.8 EOS-1.1
BASOS-0.4
___ 01:30PM PLT COUNT-173
___ 01:30PM ___ PTT-28.6 ___
___ 01:30PM GLUCOSE-157* UREA N-28* CREAT-0.8 SODIUM-136
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-25 ANION GAP-13
___ 01:30PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 01:30PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-LG
Brief Hospital Course:
Ms. ___ was admitted to the Orthopedic service on ___
for a right ankle fracture after being evaluated and treated
with closed reduction in the emergency room. After carefully
reviewing her X-rays, it was decided to that her injury would be
treated non-operatively. She was made weight bearing as
tolerated in her RLE. She was initially placed in a short
Aircast boot, but was unable to tolerate its weight and had
difficulty with ambulation. Consequently, the Aircast boot was
discontinued and she was fitted with a right fiberglass short
leg walking cast that was applied on HOD #4.
An admission urinalysis revealed a UTI, so she was started on
empiric ciprofloxacin. She had completed a 3-day course of IV
and PO ciprofloxacin , when the results of the urine culture and
sensitivities revealed the causative organism, E.coli, was
ciprofloxacin resistant. She was immediately begun on IV Unasyn,
to which the strain of E.coli was sensitive. She will be
continued on PO Augmenin to complete a 10-day course.
During her hospital stay, Ms. ___ developed some delirium,
which peaked on HOD #3, when she presented with confusion and
agitation. Psychiatry was consulted and recommended
discontinuation of anticholinergics, abstaining from narcotic
medications and continued treatment of her UTI, which they
agreed was the likely cause of her acute mental status change.
By the time of discharge, she had shown significant improvement
in her mental status. She awas awake, alert and oriented to
herself, her location in the hospital, the month and year.
She had adequate pain management and worked with physical
therapy while in the hospital. The remainder of her hospital
course was uneventful and Ms. ___ is being discharged to
rehab in stable condition. She will follow-up in 2 weeks with
repeat X-rays of her Right ankle.
Medications on Admission:
Lisinopril 5 mg qd
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*240 Tablet(s)* Refills:*2*
2. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for Pain for 2 weeks.
Disp:*60 Tablet(s)* Refills:*1*
3. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q24HR () for 2 weeks.
Disp:*14 syringes* Refills:*0*
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as
needed for Constipation.
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
8. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. zolpidem 5 mg Tablet Sig: ___ Tablet PO QHS (once a day (at
bedtime)) as needed for Insomnia.
10. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
11. diphenhydramine HCl 25 mg Tablet Sig: 0.5-2 Tablets PO Q6H
(every 6 hours) as needed for Insomnia/Pruritis.
12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
13. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Cepacol Sore Throat ___ mg Lozenge Sig: One (1) Mucous
membrane twice a day as needed for dry throat.
15. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 10 days.
16. haloperidol lactate 5 mg/mL Solution Sig: 0.5 mg Injection
BID (2 times a day) as needed for delirium/confusion.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right ankle fracture
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Activity:
- Continue to be weight bearing as tolerated on your right leg
- You should not lift anything greater than 5 pounds.
- Elevate right leg to reduce swelling and pain.
- Do not remove the brace and keep the brace dry.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
- If you have questions, concerns or experience any of the below
danger signs then please call your doctor at ___ or go
to your local emergency room.
Physical Therapy:
RLE: WBAT in Aircast Boot
Followup Instructions:
___
|
10795686-DS-11
| 10,795,686 | 20,392,462 |
DS
| 11 |
2158-06-12 00:00:00
|
2158-06-13 15:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vicodin / Tetracyclines / nickel / zinc
Attending: ___.
Chief Complaint:
Abdominal pain, nausea/vomiting, diarrhea
Major Surgical or Invasive Procedure:
___ EGD
___ Colonoscopy
History of Present Illness:
___ w/ h/o GERD, IBS, tension headaches (occipital neuralgia)
p/w
abdominal pain, n/v/d. Started on ___, w/ intermittent
watery ___, dark diarrhea, as frequent as ___ episodes
a
day, improved to ___ episodes daily with imodium. Last diarrhea
this AM ___, slightly more formed than prior. Also endorsed
frequent nausea and dry heaving with about ___ episodes of
emesis
a day, worse with eating, preventing her from eating. Last
emesis
this AM, yellowish in color, ___. Endorses diffuse
abdominal pain radiating to back in a band around her ___,
dull, max ___ worse with with vomiting. After her colonoscopy
in ___, she endorsed more crampy abdominal pain, which she
believed was worsened by her heparin injections. Seen by
multiple
providers for the symptoms including outpatient GI at ___,
where reportedly testing for C. diff, Salmonella, Shigella
negative, as well as negative H. pylori, Sjogren's antibody.
Seen in ___ on ___, where she had negative RUQUS and
CT A/P. Seen in ED again on ___ and admitted, discharged
yesterday. During that admission, nuclear stress test was
performed and EKG/troponins obtained for possible cardiac
etiology given associated chest pressure (substernal, ___,
nonradiating, nonexertional, nonpleuritic, not associated with
food), although patient has never had h/o MI. Her chest
discomfort resolved, with 3 negative trops, EKG with mild TWI in
___, and stress test was wnl. Etiology believed not to be
cardiac. EGD showed gastritis, and colonoscopy was normal except
for microscopic lymphocytic and focal collagenous colitis,
biopsies pending for both. Labs from that admission were notable
for normal WBC 6.3, normal lipase 35, and normal LFTs.
In the ED: Initial vital signs were notable for: T 97.4 BP
145/73 HR 77 RR 18 O2 100% on RA. Labs were notable for:
Negative
urine tox, Normal urinalysis, Lactate 1.3, Trop < 0.01, Chem7
with glucose 65, otherwise WNL, INR 1.3, CBC WNL (hb 12.8, WBC
7.3), Patient was given 1L LR. GI was consulted and given
outpatient GI's diagnosis of lymphocytic collagenous colitis
based on recent colonoscopy, agreed with admission for symptom
control. Vitals on transfer: T 97.4 BP 145/73 HR 77 RR 18 O2
100% on RA
Upon arrival to the floor, patient endorsed ___ abdominal pain,
___ headache. Says she's only had 1 formed movement in last
month.
Recalls no changes in diet except an ___ chicken she
and
her husband bought on ___. She has never had intolerance of
dairy products or gluten. Her stool has been more ___
lately but not more greasy. She took Flagyl recently prescribed
by outpt GI at ___ and a 3 day course of azithromycin from
___ but no other antibiotics in the last 6 months. She
frequently feels dizzy with head movement even when lying in
bed.
Has recently been feeling faint even when sitting, endorses
orthostasis. She frequently wakes at night with palpitations and
now recently with diarrhea. Denies dysuria or urinary retention.
Previously walked independently without walker but her husband
has been assisting her more recently given fear of falling.
Denies fevers/chills, SOB.
REVIEW OF SYSTEMS: positives as per HPI
Past Medical History:
Microscopic colitis
Tension headaches
GERD
Fibromyalgia
Irritable bowel syndrome
Anxiety
Social History:
___
Family History:
Mother: GI issues, unspecified, diarrhea
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
VITALS: 97.7, BP 128 / 80, HR 77, RR 18, O2 97 RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. Sclera anicteric and without injection.
NECK: Supple
CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: CTAB. No wheezes, rhonchi or rales. No increased WOB.
ABDOMEN: Hypoactive bowels sounds, non distended, diffusely
tender to palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, ___ pitting edema in
anterior shins ___ bilaterally, 2+ pitting edema in ankles
bilaterally. 2+ distal pulses
SKIN: WWP. No rash.
NEUROLOGIC: Alert, answering questions appropriately, moves all
extremities
DISCHARGE PHYSICAL EXAM:
=========================
___ Temp: 97.6 PO BP: 104/57 HR: 57 RR: 18 O2 sat:
100%
O2 delivery: RA
GENERAL: Alert, NAD.
HEENT: MM dry, PERRL.
CARDIAC: RRR. Nl S1 and S2. No murmurs/rubs/gallops.
LUNGS: CTAB.
ABDOMEN: NT/ND.
EXTREMITIES: No edema.
SKIN: No rashes
NEUROLOGIC: AOx3
Pertinent Results:
ADMISSION LABS:
================
___ 02:15PM BLOOD ___
___ Plt ___
___ 02:15PM BLOOD ___
___ Im ___
___
___ 02:15PM BLOOD ___ ___
___ 02:15PM BLOOD ___
___
___ 02:15PM BLOOD ___
___ 02:15PM BLOOD cTropnT-<0.01
___ 02:15PM BLOOD ___
DISCHARGE LABS:
==================
___ 06:25AM BLOOD ___
___ Plt ___
___ 06:25AM BLOOD ___
___
___ 06:25AM BLOOD ___
STUDIES:
=========
___ Abd XR
Nonobstructive bowel gas pattern.
___ CT
No acute abnormalities identified within the abdomen pelvis
specifically, no findings to suggest inflammatory bowel disease.
Brief Hospital Course:
Ms ___ ___ F w/ PMH significant for GERD, IBS, who
presented
with diarrhea. She has had ___ months of persistent watery
diarrhea, N/V, poor PO intake, and weight loss. She was
initially seen at ___ where she was found to have C Diff
infection and colonoscopy with biopsy concerning for microscopic
colitis. She was then transferred to ___ for further care.
Here she underwent treatment for the C Diff with a 14 day course
of PO vancomycin and colitis with PO budesonide. She did have
persistence of symptoms initially despite treatment, and
underwent an extensive workup for the cause of her diarrhea,
which was overall unremarkable. Slowly her symptoms began to
resolve, and at the time of discharge, she had improving PO
intake and dramatic improvement in her diarrhea.
ACUTE ISSUES:
=============
#Diarrhea
#Microscopic Colitis
#Nonsevere C. difficile infection, resolved
Patient initially presented with ___ months of persistent watery
diarrhea, N/V, poor PO intake. Biopsy from ___
demonstrated microscopic colitis, and she was treated with PO
budesonide. CDiff ___ testing was also positive, so patient
underwent PO vanco for full ___ompleted on ___.
Initially she did not have resolution of symptoms despite
treatment, and underwent further workup including endoscopy and
colonoscopy (normal mucosa, normal biopsies), CT enterography
(no evidence of SB Crohn's), and extensive laboratory workup
which was negative. Slowly her symptoms began to improve. She
will continue budesonide 9 mg daily at discharge. She will
continue loperamide 2 mg PRN to titrate to ___ bowel movements
daily. She will continue Pantoprazole 40mg BID. She will have
close outpatient GI follow up, where her steroids will be
titrated down (based on the final pathology reads of her various
mucosal biopsies).
#Hypernatremia
#DI
Na+ was fluctuating > 150 throughout admission, which was
initially believed to be due to diarrhea. She later underwent
desmopressin challenge testing which was positive for
nephrogenic DI, of unclear cause (patient has no history of this
and was taking no medication that is classically implicated).
She was encouraged to take in 3 L free water scheduled
throughout the day. Na stabilized with this and increased PO
intake. She will follow up with Dr ___ as an outpatient.
#Gastritis
#GERD
Patient with gastritis on initial OSH upper endoscopy and has
been maintained on oral PPI. Repeat endoscopies in house
revealed resolution of this gastritis. She will continue PPI at
discharge.
#Severe Protein Malnutrition
Patient with weight loss, poor PO intake over the last few
months, likely due to the above GI symptoms and poor PO intake.
She had a dobhoff placed and received tube feeds. The dobhoff
was later removed and as the patient began to tolerate PO. At
discharge, she was tolerated meals better, but will need close
follow up to ensure adequate intake and nutrition.
CHRONIC ISSUES:
===============
#Tension headaches
Continued Methocarbamol 500 mg PO QID:PRN.
TRANSITIONAL ISSUES:
=====================
PCP TRANSITIONAL ISSUES:
[ ] Help transition patient to get new PCP in ___
[ ] F/u patient's PO intake to ensure adequate nutrition;
consider outpatient Nutrition consult
[ ] F/u patient's diarrhea. She should be titrated loperamide to
___ bowel movements a day
[ ] please ensure she has had bloodwork done (and that Dr.
___ has assessed her Na)
RENAL
[ ] F/u electrolytes in 1 week ___ or ___. Patient
frequently hypernatremic due to DI, and may require increased
free water intake (patient provided script, to be performed at
lab near home, and results faxed to Dr ___
GI
[ ] F/u pathology read of biopsy sent over from ___
(reportedly previously showed microscopic colitis). Patient will
be given script to complete 1 month of budesonide. Please
titrate steroids as tolerated
[ ] Pantoprazole: patient to take 40 mg BID of pantoprazole for
next month, then 40 mg qD for 1 month, the 20 mg daily ongoing.
Please continue to assess need for this medication
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D ___ UNIT PO DAILY
2. Estrogens Conjugated 1 gm VG EVERY 3 DAYS
3. Multivitamins 1 TAB PO DAILY
4. IBgard (peppermint oil) 90 mg oral BID
5. Bifidobacterium infantis 4 mg oral DAILY
6. ___ D (calcium ___ D3) 2 tabs oral
BID
7. melatonin 5 mg oral QHS:PRN
8. Riboflavin (Vitamin ___ 100 mg PO BID
9. Methocarbamol 500 mg PO QID:PRN muscle spasm
10. Polyethylene Glycol Dose is Unknown PO DAILY constipation
11. Lidocaine 5% Ointment 1 Appl TP PRN Pain
12. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Budesonide 9 mg PO DAILY
RX *budesonide 9 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide 2 mg 1 tablet by mouth four times a day Disp
#*120 Capsule Refills:*0
3. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
4. Simethicone 80 mg PO QID:PRN gas
RX *simethicone 80 mg 1 tablet by mouth four times a day Disp
#*120 Tablet Refills:*0
5. Bifidobacterium infantis 4 mg oral DAILY
6. ___ D (calcium ___ D3) 2 tabs
oral BID
7. Estrogens Conjugated 1 gm VG EVERY 3 DAYS
8. IBgard (peppermint oil) 90 mg oral BID
9. Lidocaine 5% Ointment 1 Appl TP PRN Pain
10. melatonin 5 mg oral QHS:PRN
11. Methocarbamol 500 mg PO QID:PRN muscle spasm
12. Multivitamins 1 TAB PO DAILY
13. Riboflavin (Vitamin ___ 100 mg PO BID
14. Vitamin D ___ UNIT PO DAILY
15.Outpatient Lab Work
ICD Nephrogenic Diabetes Insipidus (N25.1) ___ (Na, Cl, K,
HCO3, CR, BUN, GLUC) Contact: Dr. ___ Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Diarrhea
Microscopic Colitis
C Diff Colitis
Gastritis
GERD
Nephrogenic Diabetes Insipidus
Severe Protein Malnutrition
Secondary:
Tension Headaches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure caring of you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because of diarrhea, nausea,
and weight loss over the last few months
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were treated for C Diff infection with oral antibiotics
and you were given steroids for microscopic colitis, a type of
inflammation in your colon
- You received extensive testing for the cause of your diarrhea,
which was all negative.
- you had an endoscopy and a colonoscopy
- you saw the GI and Renal teams while you were in the hospital
- you were diagnosed with a salt problem called diabetes
insipidus (which causes high sodium levels)
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please follow up with the ___ clinic here at ___
(appointment below)
- Please follow up with the ___ clinic here at ___
(appointment below)
- please continue to drink sufficient water per the
recommendation of the kidney doctors
- please make sure you get a follow up with your new PCP
- ___ sure to let us know if you experience worsening diarrhea,
vomiting, poor food intake, worsening dry mouth, or excessive
urination
- please get your bloodwork checked on ___ or ___ of next
week. Dr. ___ office at ___ will follow up the results.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10795993-DS-12
| 10,795,993 | 24,741,277 |
DS
| 12 |
2151-11-21 00:00:00
|
2151-11-21 14:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
FEVER of 102 for several hours with abdominal pain. Wife found
him lethargic and febrile.
Major Surgical or Invasive Procedure:
Placement of interventional radiology guided drain of abscess in
gall bladder fossa.
History of Present Illness:
This patient is a ___ year old male with a history of
cholangiocarcinoma, IDDM, HTN, hypercholesterolemia who presents
from OSH with a FEVER of 102 since this am, with abdominal pain.
When patient woke up from a nap, wife found him lethargic and
febrile. He had a cholecystectomy here on ___. No imaging done
at OSH. At OSH he was given tylenol ___, caftriaxone,
vancomycin and IVF 1L. He denies nausea, vomiting, diarrhea.
Past Medical History:
Cholangiocarcinoma -- recent dx as noted above
Cholelithiasis
HTN
HL
NIDDM
Nephrolithiasis
GERD
PSHx:
s/p appendectomy
s/p left hand amputation ___ to industrial accident
Social History:
___
Family History:
No family hx of pancreatic CA. Father with esophageal issues
(unknown)
Physical Exam:
Gen: NAD, laying in bed, patient seems a bit sad, but talkative
when asked questions and cooperative. Wife at bedside.
HEENT: EOMI, PERRL, (-) LAD.
Chest: No cyanosis, no accessory muscle use or labored
breathing.
Heart--Regular rate and rhythm, no ecotpic heart sounds, heaves
or thrills.
Lungs--Clear to auscultation bilaterally, no adventitious
sounds.
Abdomen: Somewhat firm, non-tender, non-distended, incicion
clean/dry and intact.
Extremities/MSK: No edema, pulses palpable throughout, MAE. Left
hand amputation.
Neurologic: No focal deficits.
Pertinent Results:
___ 04:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 04:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
___ 04:00PM URINE RBC-36* WBC-3 BACTERIA-FEW YEAST-RARE
EPI-<1
___ 04:00PM URINE GRANULAR-1*
___ 04:00PM URINE MUCOUS-RARE
___ 04:57AM GLUCOSE-324* UREA N-20 CREAT-0.9 SODIUM-134
POTASSIUM-4.8 CHLORIDE-96 TOTAL CO2-18* ANION GAP-25*
___ 04:57AM ALT(SGPT)-27 AST(SGOT)-90* ALK PHOS-223* TOT
BILI-1.3
___ 04:57AM WBC-7.9 RBC-2.87* HGB-8.8* HCT-26.0* MCV-91
MCH-30.8 MCHC-34.0 RDW-14.0
___ 11:32PM LACTATE-0.9
___ 11:20PM GLUCOSE-301* UREA N-23* CREAT-0.8 SODIUM-133
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-23 ANION GAP-17
___ 11:20PM cTropnT-<0.01
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment. On ___ the patient was brought to
the ED of ___ for the chief complaint listed above. He was
transferred to the ICU and on ___bdomen and
pelvis which showed 1. 5.4 cm air-containing, fluid collection
within the gallbladder fossa worrisome for abscess, especially
with the provided clinical history. Otherwise, a biloma from a
bile leak should also be considered. 2. Pneumobilia from recent
surgery. 3. New splenomegaly. On ___ Mr. ___
underwent a successful bedside ultrasound demonstrated a thick
walled fluid collection measuring approximately 10 x 3.5 cm. The
ultrasound guided drainage of the gallbladder fossa fluid
collection, yielded 105 mL of bile tinged purulent material,
which was sent for culture. The patient tolerated the procedure
well and a routine drainage catheter was placed, the procedure
was without complication (reader referred to the Operative Note
for details). After a brief, uneventful stay in the PACU, the
patient arrived in the ICU where his vital signs were monitored
around the clock for signs of resolving or continuing sepsis. He
was given IV antibiotics, Vancomycin and Zosyn, pain medications
Fentanyl and Dilaudid, norepinephrine and phenylephrine and
fluid boluses along with packed red blood cells as needed to
treat his infection, provide adequate pain control, support
blood pressure, increase urine output for adequate renal
function and to maintain normal cardiac function respectively.
After he became hemodynamically stable, he was transferred the
floor NPO, on IV fluids and antibiotics, with a foley catheter,
and with adequate pain control. The abscess was cultured and
yielded mixed bacterial types (>=3) without anaerobes.
Antibiotic treatment was begun and with positive effect.
Neuro: The patient received with good effect and adequate pain
control. When tolerating oral intake, the patient was
transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: 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.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Wound care consisted
of daily incision and pigtail catheter insertion site inspection
and dressing changes. The drainage bag was checked daily. His
antibiotics were changed prior to discharge to Ceftriaxone 2g IV
q24h and Metronidazole 500mg PO BID. He was tolerating his
medications prior to discharge.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: 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
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:
1. Glimepiride 8 QHS
2. Tradjenta 5mg qdaily
3. Omeprazole 40mg qdaily
4. Pravastatin 20mg qdaily
5. Aspirin ___ 81mg qdaily
6. Colace 100mg BID
7. Miralax 17 gm q daily
8. Losartan-HCTZ 50-12.5mg qdaily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
4. Mirtazapine 7.5 mg PO HS
5. Omeprazole 40 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
7. Pravastatin 20 mg PO DAILY
8. Docusate Sodium (Liquid) 100 mg PO BID
9. CeftriaXONE 2 gm IV Q24H
10. GlipiZIDE 5 mg PO DAILY
11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
12. CeftriaXONE 2 gm IV Q24H 3 weeks
13. Losartan Potassium 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Gall bladder fossa abscess.
Discharge Condition:
Patient able to ambulate and transfer, but may need assistance.
Has adequate family support and will be sent home with services.
Mental status: AA&O x 4, person, place, year, situation.
Performs ADLs with assistance, ambulates to restroom or commode.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Followup Instructions:
___
|
10795993-DS-9
| 10,795,993 | 21,233,759 |
DS
| 9 |
2151-10-17 00:00:00
|
2151-10-17 20:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
HMED OVERNIGHT ADMISSION NOTE
PCP: ___ MD
CC: ___, fatigue
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
___ with history of chronic transaminitis who had a recent
admission for obstructive jaundice s/p stent placement presents
with fatigue x48 hours.
Per his report, he was doing well at home prior to symptoms
developed. 1 day prior to presentation he noted that he was more
tired than usual during his ___ mile daily walk. Given this he
was slightly concerned. He also noted some jaundice. He was
adviced to present to the ED for further evaluation.
Upon presentation to the ED, initial vitals were: 0 98.2 76
154/72 16 98%. His labs showed transaminitis. He was admitted
for ERCP evaluation in the AM.
Currently, he feels somewhat improved.
ROS: Per HPI. He denies fevers, chills, nausea, vomiting,
diarrhea, constipation, cough, shortness of breath, DOE, chest
pain, headache, abdominal pain, anorexia, constipation, diarrhea
or other symptoms.
Past Medical History:
# chronic transaminitis -- thought to be cholangiocarcinoma vs.
chronic inflammation, currently undergoing work up
# s/p appendectomy
# nephrolithiasis
# HTN, benign
# DMII
# HLD
# s/p left hand amputation ___ to industrial accident
# GERD
Social History:
___
Family History:
No family hx of pancreatic CA. Father with esophageal issues
(unknown)
Physical Exam:
Admission physical examination:
General: well appearing male, no apparent distress
Vitals: 98.4 168/80 69 18 98RA
Pain: ___
HEENT: mild icteric sclera
CV: rr, nl rate, no r/g/m
Lungs: CTAB
Abd: soft, nontender, nondistended, positive bowel sounds
Ext: warm, well perfused, no edema, left hand missing
Skin: bronzed, difficult to tell if secondary to skin tone or
juandice
Neuro: CNII-XII intact, pleasant
Psych: pleasant
Pertinent Results:
___ 08:15PM BLOOD WBC-5.4 RBC-3.97* Hgb-12.8* Hct-36.1*
MCV-91 MCH-32.4* MCHC-35.5* RDW-13.6 Plt ___
___ 08:15PM BLOOD Neuts-70.4* ___ Monos-7.7 Eos-2.5
Baso-0.4
___ 08:15PM BLOOD ___ PTT-29.4 ___
___ 08:15PM BLOOD Glucose-274* UreaN-18 Creat-0.9 Na-134
K-4.1 Cl-99 HCO3-28 AnGap-11
___ 08:15PM BLOOD ALT-180* AST-383* AlkPhos-326*
TotBili-2.9* DirBili-1.8* IndBili-1.1
___ 08:15PM BLOOD Albumin-4.0
___ 08:15PM BLOOD Lipase-30
___ 08:29PM BLOOD Lactate-1.3
___ 08:30PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-1000 Ketone-NEG Bilirub-SM Urobiln-2* pH-5.5 Leuks-NEG
___ 08:30PM URINE RBC-7* WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
.
.
CTA PANCREAS:
Exam is limited by noninclusion of the lung bases and superior
liver on
arterial and portal venous phase.
Single, noncontrast phase evaluation of the lung bases
demonstrate no
suspicious lung lesions. Mild at emphasis at the lingula and
left lung base
is noted. Normal appearance of the Gadavist small hiatal hernia
is noted.
Stomach is distended with water.
11 mm cyst at the hepatic dome is stable from comparison.
There is moderate bilateral intrahepatic biliary dilatation. No
___ is seen
in the intrahepatic bile ducts to the level of the hepatic duct
confluence.
After that point the common bile duct stent is present. There
is soft tissue
density surrounding the right hepatic artery in the portal
hepatis and
surrounding the common bile duct. The left hepatic artery
appears uninvolved.
There is marked enlargement of a gastroduodenal-adrenal artery
node which
becomes confluent with a portacaval node. The portacaval node
measures 1.8 x
1.0 cm which is increased from 7 x 14 mm on ___.
Gastroduodenal artery
noted currently measures 2.3 x 11 mm, previously the 1.8 x 0.6
cm. The celiac
trunk and superior mesenteric artery are free of disease. The
portal vein is
abutted by soft tissue in the porta hepatitis (3B: 56). The
superior
mesenteric vein and splenic veins are uninvolved as is the
superior mesenteric
artery.
Normal appearance of the pancreas. The spleen is borderline
enlarged at 12.6
cm. Normal appearance of the bilateral adrenals. Kidneys
demonstrate
bilateral subcentimeter hypodensities which are too small to
characterize but
most likely represent simple cysts.
Small and large bowel are unobstructed. No focal bowel wall
thickening is
seen.
The gallbladder is hydropic with gallbladder wall thickening and
gallstones as
well as a in erosion at the fundus which is new from comparison.
The aorta is normal in caliber. There is no retroperitoneal
adenopathy other
than previously described at the porta hepatis. Osseous
structures
demonstrate degenerative changes without suspicious lesion
identified.
IMPRESSION:
1. Exam is technically limited by noninclusion of the complete
liver on
post-contrast phases, however there is no evidence of metastatic
spread.
2. Ill-defined soft tissue ___ at the porta abuts the portal
vein and
encases the right hepatic artery as described above.
3. Enlarged portacaval and gastroduodenal artery nodes.
4. Moderate intrahepatic biliary dilation.
5. Chronically hydropic gallbladder with stones and marked
gallbladder wall
thickening and a new erosion at the fundus likely due to chronic
cholecystitis.
.
.
EUS:
___: A 1.39 x 1.3 cm ill-defined ___ was noted at the middle
bile duct adjacent to the porta hepatis. The ___ was hypoechoic
and heterogenous in echotexture. The borders of the ___ were
irregular and poorly defined. This is suspicious for
cholangiocarcinoma.
FNA was performed of the ___. Color doppler was used to
determine an avascular path for needle aspiration. A 25-gauge
needle with a stylet was used to perform aspiration. Six needle
passes were made into the ___. Aspirate was sent for cytology.
Vessels [Venous structures]: The ___ did not invade the portal
vein.
Bile duct: The bile duct was imaged at the level of the
porta-hepatis , head of the pancreas and the ampulla. This
measured 7 mm in diameter. This contained a biliary stent. There
was ___ hypoechoic areas in close proximity to the porta
___.
There was a 1.19 cm x 1.22 cm hypoechoic round malignant
appearing lymph node in the porta hepatis in close proximity to
the ___. FNA was performed. Two needle passes were made into
the lymph node. Aspirate was sent for cytology.
Several other smaller round hypoechoic malignant appearing nodes
were noted near the bile duct ___.
Otherwise normal upper eus to second part of the duodenum
.
___ 07:20AM BLOOD WBC-4.2 RBC-3.43* Hgb-11.1* Hct-31.4*
MCV-92 MCH-32.4* MCHC-35.4* RDW-13.7 Plt ___
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD Glucose-171* UreaN-13 Creat-0.8 Na-139
K-3.6 Cl-104 HCO3-28 AnGap-11
___ 06:40AM BLOOD ALT-151* AST-322* AlkPhos-485*
TotBili-9.4*
___ 07:20AM BLOOD ALT-130* AST-280* AlkPhos-473*
TotBili-7.2*
Brief Hospital Course:
___ with chronic transaminitis s/p stent placement currently
undergoing work up of etiology presents with obstructive
jaundice.
.
#BILE DUCT OBSTRUCTION / PRESUMED CHOLANGIOCARCINOMA: He
underwent ERCP with bile duct stent exchange. The previously
demonstrated stricture was noted to be worse. Brushings were
obtained that returned with atypical cells. He underwent EUS
the following day given the worsening stricture. A 1.3cm ___
was noted at the porta hepatis, concerning for
cholangiocarcinoma. A biopsy was obtained with results pending
at the time of discharge. Hepatobiliary surgery (Dr. ___ was
consulted. A CTA pancreas protocol was obtained that
demonstrated a ___ at the porta hepatis abutting the portal
vein and encasing the right hepatic artery with enlarged
portacaval and gastroduodenal artery nodes but no evidence of
metastasis. He will follow up with Dr. ___ week to
determine if he is a candidate for surgical resection.
Depending on the biopsy results and if he is a surgical
candidate, consider placement of metal stent. His bilirubin
trended down following the procedure but was not yet normal at
the time of discharge. He will follow up with his primary care
physician to trend LFT.
# HYPERTENSION: His hypertension medications were discontinued
in the past due to normotension. His blood pressure was trended
during the hospitalization and he was noted to be between
130s-150s systolic.
# DMII: He was maintained on an insulin sliding scale while an
inpatient and his home medication restarted at discharge.
# Anemia: His hematocrit was at baseline in the mid thirties.
There was no clinically evidence of acute bleeding. Recommend
further outpatient evaluation.
.
# Thrombocytopenia: His platelet cound was at baseline in the
low 100s. Recommend further outpatient evaluation. Consider MDS
on differential.
# Hematuria: His UA was abnormal with microscopic hematuria.
Recommend repeat UA as outpatient.
.
# HLD: Continued on Pravastatin.
.
# Hiccups: Following CT abdomen he reported hiccups. Physical
maneuvers as well as baclofen, reglan, and chlorpromazine were
used.
.
TRANSITIONAL:
-___ biopsy pending at discharge
-IgG subclasses pending at discharge
-repeat UA as noted to have microscopic hematuria on UA
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Omeprazole 40 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Pravastatin 20 mg PO DAILY
4. saxagliptin *NF* 5 mg Oral qAM
He reports he is on an additional oral antiglycemic. He is
unsure of the name or the dose.
Discharge Medications:
1. saxagliptin *NF* 5 mg Oral qAM
2. Pravastatin 20 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Bile duct obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care. You were admitted
to ___ with jaundice due to bile duct obstruction. You
underwent ERCP with exchange of the biliary stent. Your liver
function tests are improving but not yet normal at the time of
discharge. You were scheduled for follow up with your primary
care physician to trend these labs.
You were noted to have a small ___ near the common bile duct.
This ___ was biopsied, which is pending at the time of
discharge. You had a CT scan of your abdomen to determine the
extent of the ___. You will follow up with Dr. ___ to discuss
this further.
Followup Instructions:
___
|
10796004-DS-2
| 10,796,004 | 24,001,494 |
DS
| 2 |
2110-02-12 00:00:00
|
2110-02-16 18:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
___ male past medical history significant for
cholelithiasis presents with abdominal pain. The evening prior
to admission, the patient had taken some laxatives, and then
began having abdominal pain in his epigastrium down to his
umbilicus. He states he has had pain similar to this in the past
which has been associated with cholelithiasis. Patient denies
nausea, vomiting, fevers, chills, dysuria, hematuria, chest
pain, shortness of breath. Patient states his pain was initially
___. He also states the pain was worse while riding in a car on
the way to the hospital.
In the ED, initial vitals were 97.5 85 135/80 18 97% RA. Exam
showed mild tenderness to palpation without rebound or guarding
in the epigastrium. Labs showed lactate 2.4, total bilirubin
3.2, AP 193, ALT 756, AST 597, WBC 10.2K. She received 1 liter
NS, ciprofloxacin 400 mg x 1, metronidazole 500 mg x 1,
ketorolac 30 mg IV x 1. CT A/P preliminarily showed
intrahepatic and extrahepatic biliary ductal dilatation raising
the possibility of choledocholithiasis given the reported
history of cholelithiasis, though no radiopaque stones are seen,
and possible small focus of epiploic appendagitis adjacent to
the descending colon. UA showed pyuria, culture pending.
Currently, the patient reports ___ pain in his epigastric area
after taking pain medication. There is no current nausea,
fevers or chills.
Review of systems:
10 pt ROS negative other than noted
Past Medical History:
Cholelithiasis
Social History:
___
Family History:
Maternal grandmother with diabetes
Physical Exam:
ADMISSION EXAM:
Vitals: T not available 140/88 85 18 96 RA
GEN: Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MMM.
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, moderately tender in epigastrium and RUQ,
non-distended, + bowel sounds. + ___ sign.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash.
Neuro: non-focal.
PSYCH: Appropriate and calm.
DISCHARGE EXAM:
VS: 98.5PO 131/81 91 18 100% on RA
GEN: Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MMM.
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, moderately tender in epigastrium and RUQ,
non-distended, + bowel sounds. + ___ sign.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash.
Neuro: non-focal.
PSYCH: Appropriate and calm.
Pertinent Results:
ADMISSION LABS
--------------
___ 01:00AM BLOOD WBC-10.2* RBC-5.82 Hgb-15.3 Hct-44.7
MCV-77* MCH-26.3 MCHC-34.2 RDW-13.2 RDWSD-35.4 Plt ___
___ 01:00AM BLOOD Neuts-86.3* Lymphs-9.5* Monos-3.4*
Eos-0.1* Baso-0.4 Im ___ AbsNeut-8.78* AbsLymp-0.97*
AbsMono-0.35 AbsEos-0.01* AbsBaso-0.04
___ 01:00AM BLOOD Glucose-122* UreaN-11 Creat-1.0 Na-135
K-5.6* Cl-99 HCO3-24 AnGap-18
___ 01:00AM BLOOD ALT-756* AST-597* AlkPhos-193*
TotBili-3.2*
___ 01:00AM BLOOD Albumin-5.0
___ 01:06AM BLOOD Lactate-2.4* K-4.5
IMAGING
-------
ERCP ___:
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.
Multiple filling defects consistent with stones 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.
A biliary sphincterotomy was made with a sphincterotome.
There was no post-sphincterotomy bleeding.
The biliary tree was swept with a multi 3V plus 15mm single
lumen extraction balloon starting at the bifurcation. Multiple
stones and sludge were removed.
The CBD and CHD were swept repeatedly until no further stones
were seen.
The final occlusion cholangiogram showed no evidence of filling
defects in the CBD.
Excellent bile and contrast drainage was seen endoscopically
and fluoroscopically.
Otherwise normal ercp to third part of the duodenum
CT A/P on admission:
1. Intrahepatic and extrahepatic biliary ductal dilatation raise
the
possibility of choledocholithiasis given the reported history of
cholelithiasis, though no radiopaque stones are seen. Recommend
ERCP or MRCP for further evaluation.
2. Equivocal small focus of epiploic appendagitis adjacent to
the descending colon.
RECOMMENDATION(S): Intrahepatic and extrahepatic biliary ductal
dilatation raise the possibility of choledocholithiasis given
the reported history of cholelithiasis, though no radiopaque
stones are seen. Recommend ERCP or MRCP for further evaluation.
MICROBIOLOGY
------------
___ 2:00 am URINE Site: NOT SPECIFIED
GRAY TOP HOLD # ___ ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS
--------------
___ 08:00AM BLOOD WBC-6.8 RBC-4.96 Hgb-12.9* Hct-37.8*
MCV-76* MCH-26.0 MCHC-34.1 RDW-12.7 RDWSD-34.8* Plt ___
___ 08:00AM BLOOD Glucose-97 UreaN-15 Creat-1.1 Na-139
K-4.5 Cl-105 HCO3-25 AnGap-14
___ 08:00AM BLOOD ALT-476* AST-178* LD(LDH)-234
AlkPhos-170* TotBili-5.2*
Brief Hospital Course:
___ male past medical history significant for
cholelithiasis presents with abdominal pain, with imaging and
lab findings concerning for choledocholithiasis.
# Bile duct obstruction
# Transaminitis
# Abdominal pain: labs showied obstructive pattern, CT A/P
suggested choledocholithiasis. Mild leukocytosis was present.
Patient underwent ERCP and spincheterotomy with removal of
stones. He received IV fluids after, diet was advanced after
being left NPO overnight. He tolerated a full diet. He will be
on ciprofloxacin for total five days. He will need to avoid
aspirin and ibuprofen for five days and was instructed of this.
His bilirubin uptrended on the day of discharge and he was
instructed to have his LFTs checked on ___ at his PCP's office.
He will follow up with his PCP.
# Pyuria: UA positive, no reported urinary symptoms. Urine
culture was negative.
TRANSITIONS OF CARE
-------------------
# Follow-up: patient's bilirubin uptrended on the day of
discharge and he was instructed to have his LFTs checked on ___
at his PCP's office. He will follow up with his PCP.
# Code status: Full, confirmed
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*8 Tablet Refills:*0
3.Outpatient Lab Work
Please get AST, ALT, total bilirubin, alkaline phosphatase
checked on ___
Discharge Disposition:
Home
Discharge Diagnosis:
Bile duct obstruction
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 for abdominal pain. You were found to have a
bile duct obstruction and you underwent ERCP, which helped to
relieve this obstruction. You are being treated with five days
of antibiotics and should avoid taking aspirin, ibuprofen,
Advil, Motrin, naproxen, Aleve, or Midol for five days.
Please have your liver function tests checked on ___. A
prescription will be provided for this.
It is important that you continue to take your medications as
prescribed and follow up with your appointments as listed below.
Followup Instructions:
___
|
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| 18 |
2139-08-09 00:00:00
|
2139-08-10 12:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
DVT
Major Surgical or Invasive Procedure:
NA
History of Present Illness:
This is a ___ year old woman with a h/o of anti-phospholipid
syndrome, MI, CKD stage IV, COPD, GIB, with two prior PEs/DVTs
in past on coumadin who awoke with small volume hemoptysis. She
presented to ___ ED where she found to have left
lower extremity DVT and INR of 1.9. A perfusion scan was
performed which showed small new left lower lobe defect. No
ventilatory imaging was done. She was given a heparin bolus and
transferred to the ___ ED. She is admitted to medicine for
heparin drip and management of anticoagulation.
She denied associated CP, SOB, syncope, lightheadedness, change
in mental status during episodes of hemoptysis. She brought up
less than 10cc of dark red clot, stating that it was enough to
"stain several tissues." She denied lower extremity swelling,
pain, or erythema. She denied bleeding symptoms such as
nosebleeds, gum or skin discoloration. There were no new
medications or changes in her intake of green vegetables
recently.
Per patient report, her first episode of DVT/PE occurred ___
years ago. She was placed on coumadin for one year. On
stopping coumadin, she had a second episode of DVT/PE and has
been on coumadin since that time, except during a
hospitalization ___) for medical management of
diverticulitis in ___. She was on levaquin then and her
coumadin was d/ced during the admission. On ___ her INR was
1.0. The most recent INR 2.7 was performed in mid ___. Her
coumadin is managed by Dr ___) and she
was taking 5mg QHS with goal INR of 2.0-3.0 on admission.
Past Medical History:
Anti-phospholipid Syndrome
Obesity BMI 45
COPD
HTN
MI
CHF
DVT
PE
CKD
Bronchitis
Anxiety
Depression
Diverticulitis
Social History:
___
Family History:
Non-contributory
Physical Exam:
VS 97.6 54 ___ 97%RA
General- well appearing, laying in bed
HEENT- NCAT,oropharynx clear
Neck- No JVD, no LAD
Lungs- Decreased breath sound in the lung bases, breathing
comfortably on room air
CV- RRR, distant heart sounds
Abdomen- Obese, soft, non-tender, non-distended. No masses or
hernias palpable.
GU- no foley
Ext- Warm, well perfused. DP + bilaterally. No clubbing,
cyanosis or edema.
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
___ 02:30PM BLOOD ___ PTT-69.0* ___
___ 07:40AM BLOOD ___ PTT-82.6* ___
___ 07:40AM BLOOD ___ PTT-57.6* ___
___ 10:10AM BLOOD ___ PTT-82.2* ___
___ 10:10AM BLOOD WBC-3.9* RBC-3.75* Hgb-11.3* Hct-33.2*
MCV-89 MCH-30.0 MCHC-33.9 RDW-14.2 Plt ___
.
___ 04:25PM BLOOD ACA IgG-3.4 ACA IgM-42.5*
.
___ 10:10AM BLOOD Glucose-104* UreaN-43* Creat-2.4* Na-144
K-5.3* Cl-110* HCO3-25 AnGap-14
.
ECHO ___
Suboptimal image quality. The left atrium is mildly dilated. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is probably mildly depressed (LVEF= 50 %). In some
views, the inferior wall appears hypokinetic. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The left ventricular inflow
pattern suggests impaired relaxation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion
.
Lower extremity US ___
IMPRESSION:
1. Occlusive thrombus is seen extending from the left proximal
superficial femoral vein through the popliteal vein. Evaluation
of the calf veins is limited and while some flow is seen in the
posterior tibials, the peroneal veins are not visualized, and
further extension of thrombosis into the calf cannot be
completely ruled out.
2. No evidence of deep venous thrombosis in the right lower
extremity.
.
Chest CT w/o contrast ___
IMPRESSION:
1. No definitive evidence of abnormality to explain patient's
hemoptysis.
2. Bronchial wall thickening and centrilobularnodules might be
consistent
with known history of smoking, representing respiratory
bronchiolitis.
3. Pulmonary nodules as described that given the patient's
history and
symptoms, should be reassessed in three to six months for
assessment of
stability, unless previous chest CTs will be available for
comparison.
.
EKG ___
Sinus rhythm. Non-specific anterolateral ST segment changes. No
previous
tracing available for comparison.
Brief Hospital Course:
___ year old woman with a h/o of MI, CKD stage IV, COPD, hx of
GIB, antiphospholipid syndrome with two prior PEs/DVTs in past
on coumadin who presented to OSH with hemoptysis and found to
have LLE DVT.
# Recurrent DVT/PE: Patient with APLS and LLE DVT. Throughout
the hospitalization, she was breathing comfortably and satting
well on room air. On admission, she was found to have borderline
subtherapeutic INR of 1.9. OSH US revealed presence of large,
nearly occlusive LLE DVT. The patient is unable to take lovenox
given Cr of 2.5 so she was treated with a heparin drip to goal
PTT of 80-100. Admission EKG showed some T wave inversions on
lateral leads with no other signs of acute heart strain. TTE
showed no signs of right heart strain. Troponins were negative.
BNP was modestly elevated at 1000. Repeat LENIS confirmed large
LLE clot but chronicity/acuity could not be determined given the
clot is occlusive. Non contrast chest CT was performed without
evidence of pulmonary infarct(unable to undergo CTPA given CKD).
Bronchial thickening concerning for bronchitis was noted, a
possible source for hemoptysis. In light of the OSH perfusion
scan, chest CT findings, stable respiratory status and lack of
CP/tachycardia/tachypnea at time of hemoptysis, there is low
suspicion that she has PE. Her low volume hemoptysis was quite
possibly secondary to bronchial inflammation and coughing while
anticoagulated.
During her hospitalization, the patient was evaluated by
Hematology who did not recommend increasing coumadin to achieve
INR goal of ___ given hemoptysis of yet unknown etiology, and
recommended continuing coumadin for goal INR 2.0-3.0 with IV
heparin bridge. They did not recommend an IVC filter which would
be pro-thrombotic and would worsen any chronic DVT formation.
# CKD, stage IV: Cr ranged from 2.3 - 2.5 during this admission.
She was continued on home sodium bicarb and calcitriol.
#COPD: Her respiratory status was stable throughout the
admission. She was breathing comfortably and satting well on
room air. She was given home albuterol as needed.
#HTN: Patient was continued on home lisinopril and metoprolol.
#Depression: Patient was continued on home citalopram and
buspirone.
#Anxiety: Patient was continued on home ativan prn.
#HLD: Patient was continued on home simvastatin.
#Pulmonary nodule: A 6mm nodule visualized on CT. This will
require repeat imaging in ___ months.
Transitional Issues:
The patient was discharged with instructions to continue
warfarin 5mg QD and to follow up with her PCP Dr ___ on
___ for INR monitoring and further management of her
anticoagulation. Follow up was arranged with her outpatient
Hematologist, Dr ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 60 mg PO DAILY depression
2. CloniDINE 0.1 mg PO BID HTN
3. Lisinopril 5 mg PO DAILY HTN
4. Calcitriol 0.25 mcg PO DAILY
5. Aspirin 81 mg PO DAILY CAD
6. Vitamin D 3000 UNIT PO DAILY
7. Metoprolol Tartrate 75 mg PO BID
8. Simvastatin 20 mg PO DAILY
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
10. Sodium Bicarbonate 650 mg PO TID
11. Warfarin 5 mg PO DAILY
12. Lorazepam 1 mg PO HS:PRN anxiety
13. BusPIRone 15 mg PO TID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. BusPIRone 15 mg PO TID
3. Calcitriol 0.25 mcg PO DAILY
4. Citalopram 40 mg PO DAILY depression
5. Lisinopril 5 mg PO DAILY HTN
6. CloniDINE 0.1 mg PO BID HTN
7. Lorazepam 1 mg PO HS:PRN anxiety
8. Simvastatin 20 mg PO DAILY
9. Sodium Bicarbonate 650 mg PO TID
10. Vitamin D 3000 UNIT PO DAILY
11. Warfarin 5 mg PO DAILY DVT
12. Aspirin 81 mg PO DAILY CAD
13. Metoprolol Tartrate 75 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
1. Deep Venous thrombosis
2. Hemoptysis
3. Pulmonary nodule
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___, it was a pleasure taking care of you during
your hospitalization at ___. You were admitted due to
coughing up blood and concern of a clot in your lungs. Your
blood levels of coumadin were found to be slightly lower than
desired and you were put on a medication, IV heparin, to keep
more clot from forming while your coumadin levels were brought
back to normal. Ultrasound studies of your legs showed a clot
in a vein in your left leg however it is unlcear when they may
have formed. Imaging of your chest did not show any evidence of
mass that could explain why you coughed up blood, but we did see
some thickening of airways (bronchitis) which might explain
coughing up blood. We also found a small nodule in your lungs
for which you should have follow up imaging in three to six
months through your primary care doctor to ensure no concerning
changes in the size of the nodule. Please have your INR
rechecked on ___ and dose of coumadin
adjusted. Please also follow up closely with your hematologist
to discuss further strategies and options for preventig future
clots.
Followup Instructions:
___
|
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| 19 |
2142-05-20 00:00:00
|
2142-05-20 15:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Intracranial hemmorrhage
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o female on Coumadin for afib developed a headache on ___
morning at 11:30am while at dialysis. Headache came on suddenly
in the occipital lesion and has remained constant. Patient has
had diplopia and nausea with dry heaves but no vomiting. She was
transferred to ___ from ___ and CT consistent with
cerebellar hemorrhage with mass effect and elevated INR,
reversed
here. Followed in ICU, now stable for transfer to floor and
further evaluation with neuro-oncology.
On ___, episode of shaking, likely partial siezure, started on
Keppra and repeated head CT, and also started on Dex 4mg Q6. MRI
showed multiple mets.
On arrival to the floor, patient was somnolent though oriented
and in no distress.
Past Medical History:
Anti-phospholipid Syndrome
Obesity BMI 45
COPD
HTN
MI
CHF
DVT
PE
CKD
Bronchitis
Anxiety
Depression
Diverticulitis
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:PHYSICAL EXAM:
General: NAD
VITAL SIGNS: VSS
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to self and hospital.
DISCHARGE EXAM:
VS: 97.5 Axillary 103 / 54 R Lying 94 16 94 RA
CV: RR, NL S1S2 no S3 S4 MRG
PULM: exp wheezing on the left more than the right. insp
crackles on the base
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
Neuro: Mental status: Awake and alert, cooperative with exam,
normal affect.
Orientation: Oriented to self and hospital.
Language: hypo-phonic and deliberate, but clear
Pertinent Results:
LABS
=============
___ 02:01AM GLUCOSE-126* UREA N-34* CREAT-5.2* SODIUM-136
POTASSIUM-4.9 CHLORIDE-94* TOTAL CO2-29 ANION GAP-18
___ 02:01AM estGFR-Using this
___ 02:01AM CALCIUM-9.0 PHOSPHATE-2.5* MAGNESIUM-2.2
___ 02:01AM WBC-5.7 RBC-2.74* HGB-9.3* HCT-29.4* MCV-107*
MCH-33.9* MCHC-31.6* RDW-15.9* RDWSD-62.0*
___ 02:01AM NEUTS-87.6* LYMPHS-6.3* MONOS-5.6 EOS-0.0*
BASOS-0.0 IM ___ AbsNeut-5.02 AbsLymp-0.36* AbsMono-0.32
AbsEos-0.00* AbsBaso-0.00*
___ 02:01AM PLT COUNT-174
___ 02:01AM ___ PTT-25.2 ___
___ 11:41PM GLUCOSE-124* UREA N-32* CREAT-5.2*#
SODIUM-137 POTASSIUM-5.1 CHLORIDE-95* TOTAL CO2-31 ANION GAP-16
___ 11:41PM estGFR-Using this
___ 11:41PM URINE HOURS-RANDOM
___ 11:41PM URINE HOURS-RANDOM
___ 11:41PM URINE UHOLD-HOLD
___ 11:41PM URINE GR HOLD-HOLD
___ 11:41PM WBC-6.1# RBC-2.84* HGB-9.5* HCT-30.7*
MCV-108*# MCH-33.5*# MCHC-30.9* RDW-16.0* RDWSD-63.4*
___ 11:41PM NEUTS-85.7* LYMPHS-7.2* MONOS-6.4 EOS-0.0*
BASOS-0.0 IM ___ AbsNeut-5.24 AbsLymp-0.44* AbsMono-0.39
AbsEos-0.00* AbsBaso-0.00*
___ 11:41PM PLT COUNT-186
___ 11:41PM ___ PTT-29.8 ___
___ 11:41PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 11:41PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.5*
LEUK-MOD
___ 11:41PM URINE RBC-10* WBC-38* BACTERIA-FEW YEAST-NONE
EPI-3
___ 11:41PM URINE HYALINE-14*
___ 11:41PM URINE AMORPH-RARE
___ 11:41PM URINE WBCCLUMP-FEW MUCOUS-OCC
___ 08:10AM BLOOD WBC-16.2* RBC-3.19* Hgb-10.7* Hct-33.2*
MCV-104* MCH-33.5* MCHC-32.2 RDW-14.8 RDWSD-57.2* Plt ___
___:01AM BLOOD Neuts-87.6* Lymphs-6.3* Monos-5.6
Eos-0.0* Baso-0.0 Im ___ AbsNeut-5.02 AbsLymp-0.36*
AbsMono-0.32 AbsEos-0.00* AbsBaso-0.00*
___ 08:10AM BLOOD Plt ___
___ 08:10AM BLOOD Glucose-110* UreaN-74* Creat-4.6* Na-129*
K-5.8* Cl-91* HCO3-19* AnGap-25*
___ 07:35AM BLOOD LD(LDH)-395*
___ 08:10AM BLOOD Calcium-8.1* Phos-4.4 Mg-2.4
___ 10:50AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative
___ 11:41PM BLOOD LtGrnHD-HOLD
___ 08:10AM BLOOD
MICRO:
==========
NONE
IMAGING:
=============
___ Imaging L-SPINE (AP & LAT)
Diffuse osteopenia and radiodense material throughout the large
bowel obscures the view of the lumbar spine and severely limit
evaluation for fracture.
Multilevel degenerative changes are noted in the lumbar spine.
___HEST W/CONTRAST
Extensive left hilar mass with likely vascular and potential
bronchial
invasion. 2 cm left upper lobe satellite nodule and cavitated
right lung
nodule. Small bilateral pleural effusions. Extensive mucous
retention. No
evidence of pneumonia. A left adrenal mass likely reflect
metastatic disease.
___ Imaging CHEST (PORTABLE AP)
In comparison with the study ___, there again is
substantial
enlargement of the cardiac silhouette with moderate pulmonary
edema that has
not decreased since the prior examination. In view of the
extensive pulmonary
changes and cardiomegaly, it is impossible to exclude the
possibility of
superimposed pneumonia in the appropriate setting, especially in
the absence
of a lateral view.
___ Imaging CT HEAD W/O CONTRAST
Unchanged hemorrhagic right cerebellar hemisphere mass with
severe
posterior fossa mass effect.
___ Imaging MR HEAD W & W/O CONTRAS
1. Multiple enhancing FLAIR hyperintense intraparenchymal
lesions in bilateral
cerebral and cerebellar hemispheres some of which demonstrates
slow diffusion
and hemorrhage, the largest corresponding to the previously seen
lesion in the
right cerebellar hemisphere. These are most likely in keeping
with
intracranial metastatic disease.
2. The right cerebellar lesion has surrounding vasogenic edema
causing
partially effacement of the fourth ventricle. However, there is
no definite
evidence of obstructive hydrocephalus.
3. Findings of small vessel ischemic disease in age-related
involutional
changes.
___ Imaging CHEST (PORTABLE AP)
PULMONAR CONGESTION
___ Imaging CT HEAD W/O CONTRAST
1. 4.1 x 3.6 cm right cerebellar hemorrhage, resulting in
effacement of the fourth ventricle, cisterna magna and
quadrigeminal plate cistern, as well as 4 mm downward herniation
of the right cerebellar tonsil.
2. Supratentorial hydrocephalus with possible transependymal CSF
flow.
3. 0.8 cm faintly hyperdense lesion in the right corona radiata
with mild
surrounding edema, concerning for a mass.
4. Moderate-sized hypodensity in the anterior left temporal lobe
is not well evaluated due to motion artifact. It may represent
vasogenic edema, sequela of prior contusion, or infarction of
indeterminate age.
5. Evidence of chronic right maxillary sinusitis with osseous
remodeling, as well as mild secretions in the right maxillary
sinus.
Brief Hospital Course:
___ ESRD on HD, h/o HCC, APLS with prior DVT/PE and GI bleeding,
h/o CAD, COPD, presenting with posterior fossa hemorrhage with
mass effect. During her hospital stay received steroid dosing
and was started on radiation therapy.
# Metastatic Sm Cell cancer:
presented with newly diagnosed brain metastasis and was
diagnosed with small cell lung cancer by biopsy of a met in the
liver. CT chest ontained on ___ at ___ revealed an
extensive 7 x 3 cm left hilar mass with likely bronchial
invasion and bilateral pleural effusion likely the primary
malignancy. Ms. ___ stated that she would be interested in
life prolonging interventions. Brain metastases would take
priority, and as such she was referred to radiation for
consideration of palliative radiation. Her tumor is likely from
the lung given tumor markers and lung mass. Oncology service did
not recommend chemotherapy given low functional score and
prognosis. She was started on palliative whole brain radiation
for a total of 5 session starting on ___. last session was
completed on ___ without complications. The patient will
continue with 4mg dexamethasone bid and keppra for seizure
prophylaxis indefinitely. She was discharged to rehab to
transition to hospice.
# Acute on Chronic diastolic CHF (resolved) - she presented with
evidence of fluid overload on admission CXR. She underwent
dialysis on the second day of admission with 2.9L fluid removal.
Since then the patient has been euvolumic on her normal
___ dialysis. Her last EF was 50% in ___bnormality and her cardiobiomarker were
negative during this admission. continued her home metoprolol
and lisinopril
# Low back pain: Her pain was well controlled on po dilaudid.
# Posterior fossa hemorrhage: the patient has significant
cerebella hemorrhage with mass effect while on Coumadin for AFIB
likely from brain mets manifested as intentional tremor. Upon
arrival to ___ her INR was elevated to 4.5 and was thus
reversed with Vitamin K and FEIBAT. The patient does not have
headache or other signs or symptoms of increased intracranial
pressure. Does not have evidence of midline shift. Her bleeding
was treated conservatively. She received radiation therapy
during her hospital stay. See above. Neurosurgery saw the
patient and the patients poor prognosis and life expectancy of 7
months to live the patient has declined Neurosurgical
intervention. We started her on Keppra and dex (see above). We
continued her home buspirone and citalopram for anxiety.
# Afib - held her anticoagulation for IPH, rate control with
home diltiazem and metoprolol
# HLD - Continued home atorvastatin
# COPD - On chronic steroids, held her prednisone. During her
hospital stay her shortness of breath was treated
symptomatically with advair, spiriva, ___ prn.
# UTI: the patient was treated with ceftriaxone ___
___.
# ESRD: the patient is dependent on dialysis (MWF) with no
complications.
# APLS with prior DVT/PE. We held her Coumadin during admission.
TRANSITIONAL ISSUES:
==============================
- being discharged after completing her radiation therapy to
rehab. From there, she will transition to hospice
- will continue on dexamethasone and keppra for brain mets
indefinitely
- no indication for chemotherapy given her poor performance
status, comorbidities and prognosis
- nystatin can be stopped with thrush resolves
CODE STATUS:
- DNR/DNI
Name of health care proxy: ___
___: Son
Phone number: ___
Date on form: ___
Proxy form in chart: ___
Filed on Date: ___
Comments: Alternative HCP: ___ in-law)
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. BusPIRone 15 mg PO TID
3. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
shortness of breath
4. Citalopram 40 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. GuaiFENesin ER 600 mg PO Q12H
7. Multivitamins 1 TAB PO DAILY
8. Warfarin 7 mg PO DAILY16
9. Zolpidem Tartrate 5 mg PO QHS
10. Atorvastatin 10 mg PO QPM
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Diltiazem Extended-Release 240 mg PO DAILY
Discharge Medications:
1. BusPIRone 15 mg PO TID
2. Citalopram 40 mg PO DAILY
3. GuaiFENesin ER 600 mg PO Q12H
4. Tiotropium Bromide 1 CAP IH DAILY
5. Diltiazem Extended-Release 240 mg PO DAILY
6. Senna 8.6 mg PO BID contipation
7. Polyethylene Glycol 17 g PO DAILY
8. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
shortness of breath
9. LevETIRAcetam 500 mg PO BID
10. Dexamethasone 4 mg PO BID
11. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
12. Bisacodyl 10 mg PO/PR DAILY:PRN contipation or BM < 1 per 2
days
13. Docusate Sodium 100 mg PO BID
14. Famotidine 20 mg PO Q24H
15. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth up to every three
hours as needed for Disp #*30 Tablet Refills:*0
16. LORazepam 0.5 mg PO Q6H:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth up to every six hours as
needed for Disp #*30 Tablet Refills:*0
17. Insulin SC
Sliding Scale
Fingerstick Q12H
Insulin SC Sliding Scale using REG Insulin
18. Metoprolol Tartrate 50 mg PO TID
19. Nephrocaps 1 CAP PO DAILY
20. ___ ___ UNIT PO Q8H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Metastatic small cell lung cancer
# Acute on Chronic diastolic CHF
# Posterior fossa hemorrhage
# Afib
# HLD
# UTI
# COPD
# ESRD
# APLS with prior DVT/PE
# Supratherapeutic INR
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear ___ was a pleasure taking care of you at the ___.
You were admitted because of a bleeding inside the brain. This
occurred as a result of tumors that have spread from your lung
to the brain. Because of your bleeding, we stopped your warfarin
and gave you medication to counteract your bleeding tendency.
Also we gave you steroids to reduce the swelling around the
tumors in your brain. You were started on radiation therapy to
shrink the brain tumors. You will continue the discussion with
your primary oncologist regarding what further treatment options
are available. During your stay, you were diagnosed with a urine
tract infection and you were treated with a short course of
antibiotics. Also we continued your home medication and resumed
you dialysis as scheduled.
Please take you medication as prescribed below and keep your
appointments.
It was a pleasure taking care of you at the ___.
We wish you all the best.
Your ___ team.
Followup Instructions:
___
|
10797056-DS-16
| 10,797,056 | 26,570,017 |
DS
| 16 |
2183-10-21 00:00:00
|
2183-10-21 21:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ bipolar/schizoaffective disorder who presents with a
multiple day history of abdominal pain. Her pain started on
___ and has been localized to the right side. She denies
any
fevers or chills, but has had several episodes of emesis. Denies
dysuria or vaginal discharge.
Past Medical History:
PSYCHIATRIC HISTORY (INCLUDE PRIOR HOSPITALIZATIONS, OUTPATIENT
TREATMENTS, MEDICATION/ECT HISTORY, RESPONSE TO TREATMENT,
HISTORY OF HOMICIDAL/SUICIDAL/ASSAULTIVE BEHAVIOR):
- Dx: Schizoaffective Disorder, Bipolar type.
- Multiple past hospitalizations, last reported at ___ in
late
___ after last psychotic decompensation. Unclear past med
trials, currently only receiving Clozaril through ___ (monthly blood draws).
- Psychopharm: Dr. ___ ___
- Therapist: ___ ___
- No known past SA, SIB. Reports of assult while acutely
psychotic.
PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES,
OR OTHER NEUROLOGIC ILLNESS): Denies.
Social History:
___
Family History:
FAMILY PSYCHIATRIC HISTORY: "Mother and grandma both crazy,"
unknown diagnoses.
Physical Exam:
Gen: Alert and oriented
Neck: No palpable adenopathy
Resp: CTAB
CV: Regular rate and rhythm
Abd: Soft, nontender, nondistended
Ext: WWP, pulses intact
Pertinent Results:
___ 02:45PM GLUCOSE-182* UREA N-23* CREAT-1.4*
SODIUM-130* POTASSIUM-4.0 CHLORIDE-88* TOTAL CO2-25 ANION
GAP-21*
___ 02:45PM ALT(SGPT)-22 AST(SGOT)-15 ALK PHOS-113* TOT
BILI-0.7
___ 02:45PM LIPASE-19
___ 03:52PM LACTATE-1.5
___ 02:45PM WBC-20.6*# RBC-3.95 HGB-11.9 HCT-35.9 MCV-91
MCH-30.1 MCHC-33.1 RDW-13.9 RDWSD-46.5*
Brief Hospital Course:
Ms. ___ was admitted to the hospital on ___ with
abdominal pain. CT scan revealed inflammation, perforated
appendicitis with abscess, and functional ileus. She was made
NPO and given IV fluids as well as IV cipro and flagyl. ___ was
consulted, but they did not see a clear area to place a drain.
She remained nauseated for several days. After multiple days of
persistent nausea and absence of bowel function, she had a
repeat CT scan performed on ___, which showed that the abscess
had decreased in size to 2.6 x 2.1 cm and had become more
organized. She began passing flatus, and had a bowel movement.
Her diet was advanced to clears, and eventually to a regular
diet, which she tolerated well. She continued passing flatus.
Her antibiotics and medications were changed to PO, which she
tolerated well. Her WBC count trended down to normal, and she
remained afebrile. When she was tolerating a regular diet and
had return of bowel function, she was discharged home on ___.
She will continue the course of cipro and flagyl for a total of
two weeks, and will follow-up in ___ clinic in 2 weeks.
Also of note, endometrial thickening was seen on her initial CT
scan, which should be evaluated by OBGYN with an ultrasound.
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PR ONCE Duration: 1 Dose
RX *bisacodyl [Dulcolax (bisacodyl)] 10 mg 1 suppository(s)
rectally once a day Disp #*20 Suppository Refills:*0
5. Clozapine 275 mg PO QHS
6. Divalproex (EXTended Release) 750 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
8. Ipratropium Bromide MDI 2 PUFF IH QID
9. Levothyroxine Sodium 88 mcg PO DAILY
10. Lisinopril 2.5 mg PO DAILY
11. Lorazepam 0.5 mg PO Q4H:PRN anxiety
12. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*15 Tablet Refills:*0
13. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*30 Capsule Refills:*0
14. Simvastatin 10 mg PO QPM
15. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
perforated appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the surgery service at ___ for evaluation
of the abdominal pain. You were found to have perforated
appendicitis. You were started on antibiotics and you pain
improved. You are now safe to return home to complete your
recovery with the following 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.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Followup Instructions:
___
|
10797056-DS-18
| 10,797,056 | 27,347,093 |
DS
| 18 |
2184-09-25 00:00:00
|
2184-09-25 12:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
appendicitis
Major Surgical or Invasive Procedure:
___ - x-lap, lysis of adhesions, appendectomy
History of Present Illness:
___ yo F with history of 2 bouts of perforated appendicitis for
whom interval appendectomy was unable to be performed due to
"scheduing issues" presents with 5 days of obstipation and
intermittent abd pain. Last BM last flatus 1 week ago. Last
ate/drank fluid 36 hours ago. Vomiting multiple times in last 24
hours. Emesis was green, non bloody. Denies fevers/chills, no
dysuria.
Past Medical History:
PMH:
Diabetes
Hypertension
Bipolar/schizoaffective disorders
Hypothyroidism
COPD
Ruptured appendicitis managed conservatively
PSH:
Tonsillectomy as a child
Social History:
___
Family History:
FAMILY PSYCHIATRIC HISTORY: "Mother and grandma both crazy,"
unknown diagnoses.
Physical Exam:
Afebrile, VSS
General: well appearing, NAD
HEENT: normocephalic, atraumatic, no scleral icterus
Resp: breathing comfortably on room air
CV: regular rate and rhythm on monitor
Abdomen: soft, NT, ND, erythema improved, wound vac in place on
midline incision, holding suction
Brief Hospital Course:
The patient was admitted for acute appendicitis. She went to the
OR for open appendectomy and lysis of adhesions. The procedure
occurred without complication, for more information about the
procedure please refer to the operative report. The patient was
transferred to the PACU in the immediate post operative period,
and when appropriate, the patient was transferred to the floor.
The patient's course was complicated by ileus and wound
infection. For the first few days of her post operative course,
she refused all care from medical staff. We contacted her
brother, her health care proxy and psychiatry who declared
patient did not have capacity to refuse care. After negotiation
with the patient utilizing her brother, she was amenable to care
and was able to be appropriately rehydrated. She then had return
of bowel function. She was noted to have cellulitis and a wound
infection, thus wound was opened and wet to dry dressings were
placed. She was set up for home VAC dressing which was placed on
___. She was initially on meropenum, then transitioned to
Bactrim for intra-abdominal contamination with resistant
enterobacter species and wound infection. She was discharged on
bactrim. At the time of discharge, the patient was urinating and
stooling normally, pain was controlled with oral pain
medication, and the patient was out of bed to ambulate without
assistance. The patient was discharged home with plan to follow
up with Acute Care Surgery in clinic in 2 weeks.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation
aerosol inhaler. ___ puffs(s) by mouth every four (4) to six
(6)
hours as needed for cough/wheezing/shortness of breath
CLOZAPINE - clozapine 100 mg tablet. 2 Tablet(s) by mouth at
bedtime For a total of 275mg every night. - (Prescribed by
Other
Provider: Dr. ___ Dose adjustment - no new Rx)
CLOZAPINE - clozapine 25 mg tablet. 3 Tablet(s) by mouth HS For
a
total dose of 275mg. - (Prescribed by Other Provider: Dr.
___ Dose adjustment - no new Rx)
DIVALPROEX [DEPAKOTE] - Depakote 250 mg tablet,delayed release.
3
Tablet(s) by mouth at bedtime - (Prescribed by Other Provider)
IPRATROPIUM BROMIDE [ATROVENT HFA] - Atrovent HFA 17
mcg/actuation aerosol inhaler. 2 puffs INH every ___ hours
LEVOTHYROXINE - levothyroxine 88 mcg tablet. 1 tablet(s) by
mouth
daily
METFORMIN - metformin 500 mg tablet. 1 tablet(s) by mouth twice
a
day Please schedule appointment with Dr. ___.
SIMVASTATIN - simvastatin 10 mg tablet. 1 tablet(s) by mouth
daily at bed time
Medications - OTC
ASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet,delayed
release (___) by mouth daily
PSYLLIUM HUSK [METAMUCIL] - Metamucil 0.52 gram capsule. ___
capsule(s) by mouth daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
3. Aspirin 81 mg PO DAILY
4. Clozapine 275 mg PO QHS
5. Divalproex (EXTended Release) 750 mg PO DAILY
6. Ipratropium Bromide MDI 2 PUFF IH Q6H
7. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
take until ___
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*4 Tablet Refills:*0
8. levothyroxine 88 mcg tablet. 1 tablet(s) by mouth daily
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth Q4 hours Disp #*25
Tablet Refills:*0
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
appendicitis
wound infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Discharge Instructions:
You were admitted to the hospital for acute appendicitis. You
underwent surgery for your appendicitis and the scars in your
belly. Your course was complicated by wound infection, but you
are now safe to be discharged home. Please follow the following
instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*change your wound vac every ___ and ___ for
the first week, followed by every ___ and ___ the second
week provided the cellulitis has improved.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, detach your wound vac from the machine and
clamp it prior to showering. If possible, only shower on the
dates your home nurse is changing your wound vac.
*You have 3 staples, they will be removed at your follow-up
appointment.
Followup Instructions:
___
|
10797086-DS-19
| 10,797,086 | 26,452,976 |
DS
| 19 |
2129-07-01 00:00:00
|
2129-07-01 17:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with medical history notable for
HIV with non-compliance with anti-retroviral therapy,
polysubstance abuse who presents with concern for pre-syncope,
cough, and fever.
Per patient, last ___ he noticed a fever. Over the past week
he has developed increasing cough and mild shortness of breath,
denies wheezing. He has also noticed increased diarrhea, watery,
non-bloody/non-melanotic. He reports decreased po intake and has
been feeling nauseous, denies vomiting. He denies
lightheadedness/dizziness, headache, neck pain, CP/palp,
dysuria, joint/MSK pain, swelling. He denies sick contacts.
Of note, he reports increased stressors over the past year
including problems with finances. He has not been compliant with
his HIV medications for at least ___ year, which he attributes to
being depressed and anxious. Over the past few weeks his
financial situation has become significantly worse and he has
been very stressed by trying to figure out how to deal with
this. He has not been eating for the past few weeks because he
has not had money to feed himself. He reports smoking meth x2
nights ago to help "get me out of a situation" and also endorses
recently injecting meth for the same reason. He has also been
taking increased amounts of caffeine pills to try to stay awake.
He is worried about being a burden on his sister
In ___ initial VS: 97.8 147 ___ 17 98% RA
Triggered for tachycardia - ECG with sinus tachy
-Exam: not recorded
-Patient was given: 30cc/kg NS, vanc/zosyn
-Imaging notable for:
CXR (___)
IMPRESSION: Right middle lobe and upper lobe consolidation
concerning for pneumonia. Follow-up to resolution is
recommended.
VS prior to transfer: 103 135 97/58 30 92% RA
On arrival to the MICU, patient reports feeling nervous about a
job he is supposed to go to tomorrow and is anxious to find
coverage. He reports feeling really hungry and thirsty.
Past Medical History:
HIV (previously on stribild)
Basal cell carcinoma on back
Syphillis
Social History:
___
Family History:
Denies family history of cardiac problems.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: 98.1, 106, 102/69, 27, 100%/3L
GENERAL: Alert, oriented, anxious, diaphoretic
HEENT: PERRL, EOMI sclera anicteric, MMM, oropharynx clear,
adentulous
NECK: supple, JVP not elevated, no LAD
LUNGS: decreased breath sounds on right, tachypneic, no
accessory muscle use, speaking in full sentences
CV: tachycardic, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, mild-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: x4 erythematous, patches over upper back
NEURO: AAOx3, moves all extremities spontaneously
DISCHARGE PHYSICAL EXAM
=======================
VS: 98.1 128 / 76 89 18 95 Ra
GENERAL: Alert, oriented, lying in bed, NAD
HEENT: PERRL, EOMI sclera anicteric, MMM, OP clear
NECK: supple, no JVD
LUNGS: right sided crackles mild lung, clear breath sounds on
left, no wheezes; good inspiratory effort
CV: RRR, S1 + S2 present, no murmurs, rubs, gallops
ABD: SNTND, +BS, no rebound/guarding
EXT: WWP, 2+ pulses, no clubbing, cyanosis or edema
SKIN: x3 erythematous patches over upper back; x 1 path on left
thigh (pt states are chronic and has been told they are BCC)
NEURO: AAOx3, moves all extremities spontaneously
Pertinent Results:
ADMISSION LABS:
==============
___ 05:20PM BLOOD WBC-20.1*# RBC-3.97* Hgb-10.1* Hct-30.5*
MCV-77*# MCH-25.4* MCHC-33.1 RDW-15.6* RDWSD-43.6 Plt ___
___ 05:20PM BLOOD Neuts-86* Bands-8* Lymphs-3* Monos-3*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-18.89*
AbsLymp-0.60* AbsMono-0.60 AbsEos-0.00* AbsBaso-0.00*
___ 05:20PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-3+ Polychr-NORMAL
___ 05:26PM BLOOD ___ PTT-33.6 ___
___ 05:20PM BLOOD WBC-20.1*# Lymph-3* Abs ___ CD3%-45
Abs CD3-273* CD4%-10 Abs CD4-58* CD8%-30 Abs CD8-178*
CD4/CD8-0.33*
___ 05:20PM BLOOD Glucose-116* UreaN-21* Creat-1.3* Na-122*
K-3.6 Cl-86* HCO3-22 AnGap-18
___ 05:20PM BLOOD ALT-37 AST-61* AlkPhos-211* TotBili-0.8
___ 05:20PM BLOOD Lipase-27
___ 05:20PM BLOOD Albumin-2.7* Calcium-8.0* Mg-1.6
___ 09:14PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-12
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:30PM BLOOD Lactate-2.5*
___ 05:20PM BLOOD WBC-20.1*# Lymph-3* Abs ___ CD3%-45
Abs CD3-273* CD4%-10 Abs CD4-58* CD8%-30 Abs CD8-178*
CD4/CD8-0.33*
IMAGES:
=======
CXR (___): Right middle lobe and upper lobe consolidation
concerning for pneumonia. Follow-up to resolution is
recommended.
CXR (___): Re-demonstrated is a dense consolidation
involving the right middle lobe and right upper lobe. Patchy
opacities at both lung bases may reflect additional foci of
infection or atelectasis. There are small bilateral pleural
effusions. No pneumothorax is identified. The size of the
cardiac silhouette is within normal limits.
NOTABLE LABS:
=============
___ 07:20AM BLOOD TSH-5.8*
___ 12:44PM BLOOD Acetmnp-NEG
___ 05:40AM BLOOD HIV1 VL-4.5*
___ 07:20AM BLOOD FLUORESCENT TREPONEMAL ANTIBODY
(FTA-ABS)-PND
___ 05:40AM BLOOD B-GLUCAN-PND
MICRO:
======
Blood culture (___): no growth
Urine culture (___): no growth
Legionella (___): negative
Stool culture (___): C.diff negative, culture negative few PMNs
Sputum (___): contaminated
B-glucan (___): pending
PRP w/ check for Proszone (___): Reactive ___
MRSA screen (___): negative
DISCHARGE LABS:
==============
___ 08:15AM BLOOD WBC-6.1 RBC-3.85* Hgb-9.7* Hct-30.9*
MCV-80* MCH-25.2* MCHC-31.4* RDW-16.3* RDWSD-46.5* Plt ___
___ 08:15AM BLOOD Glucose-81 UreaN-12 Creat-0.6 Na-137
K-4.7 Cl-100 HCO3-26 AnGap-16
___ 08:15AM BLOOD ALT-36 AST-55* AlkPhos-193* TotBili-0.3
___ 08:15AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9
___ 08:15AM BLOOD HIV GENOTYPING-PND
Brief Hospital Course:
Mr. ___ is a ___ with PMH of HIV not on ART (CD4 58 this
admission) who presented with fever, cough and diarrhea found to
have right upper and middle lobe pneumonia.
# Right Middle & Upper Lobe Pneumonia:
Patient presented with fever, tachycardia, leukocytosis, severe
cough and hypotension requiring pressors briefly, initially
admitted to the MICU. CXR notable for focal right upper and
middle lobe consolidations. Initially dosed with
Vancomycin/Zosyn/Azithromycin ___ given severity of
presentation, but was narrowed to cefepime/azithromycin and
completed a 5 day course for community acquired pneumonia.
Patient significantly improved early on in hospital course and
quickly called out from MICU to medical floor. MRSA swab
negative. Urine legionella and streptococcal antigen negative.
Unable to identify pathogen given contaminated sputum. Did not
suspect PCP or other opportunistic infection (CD4 count 58)
given focal consolidation on CXR and quick clinical improvement.
# Diarrhea, resolved:
Patient reported loose stool prior to admission. Cdiff negative.
Differential included gastroenteritis vs effect of IV meth abuse
and caffeine pill abuse prior to admission. Stool studies
negative.
# HIV:
Patient has been non-adherent to ART therapy; ___ VL <20, CD4
537. Formerly on Stribild. This admission, CD4 count was 58 with
elevated VL. Resistance panel ordered inpatient. Started on
Stribild on discharge with prescription for TMP-SMX for PCP ppx
and ___ for MAC ppx. Discharged with close PCP follow
up.
# Microcytic Anemia:
Chronic per OMR since ___. No signs/symptoms of bleeding.
Transitional issue to consider EGD/Colonscopy.
# Polysubstance abuse
# Social Stressors:
Patient reported increased stressors over the past year
including problems with finances and problems with mood. He has
not been compliant with his HIV medications for at least ___
year, which he attributes to being depressed and anxious. Over
the past few weeks his financial situation has become
significantly worse. Current housing situation is complex; has
been staying illegally at a warehouse. He reports using meth
prior to admission during an encounter with financial
incentives. Urine tox screen was positive for amphetamines.
Patient also reports abuse of caffeine pills prior to admission.
Social work consulted to provide resources. Patient was
discharged to sister's home and has sister and friend who will
help provide housing and social assistance for the first few
days after discharge. Has paid rent up until ___ of ___ at
warehouse.
# History Syphilis:
Per outpatient records, last treated for latent titer 1:256
___ bicillin x 3. Last RPR 1:32 ___, down from 1:64 in
___. RPR this admission 1:16 which may represent serofast or
may be a latent infection. FTA-Ab pending on discharge.
# ___, Resolved:
Initial Cr 1.3, decreased to 0.6 with IVF. Likely pre-renal in
setting of sepsis.
# Hyponatremia, resolved:
Likely hypovolemic in the setting of illness, decreased po
intake, improved with IVF.
TRANSITIONAL ISSUES:
===================
- HIV Management: Discharged to restart Stribild and discharged
on TMP-SMX for PCP ppx and ___ for MAC ppx
- Resistance HIV panel sent this admission
- FTA Ab, stool microspora, and beta glucan pending on discharge
- Please assist patient with social resources.
- RPR titer 1:16, unclear whether this is a serofast or
inadequately treated active infection
- TSH 5.8 inpatient, please repeat outpatient
- Mild transaminitis while inpatient, improved. Please recheck
LFTs outpatient.
- Patient has history of basal cell carcinomas on his back,
please help patient reconnect with Dermatology
- Normocytic anemia; likely needs EGD/Colonoscopy outpatient for
further evaluation
- Follow up chest x-ray in 6 weeks to evaluate resolution
pneumonia
# Communication: HCP ___ (sister) ___
# Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Azithromycin 1200 mg PO 1X/WEEK (TH)
RX *azithromycin 600 mg 2 tablet(s) by mouth once per week
___ Disp #*10 Tablet Refills:*0
2. Stribild 1 TAB PO DAILY
RX *elviteg-cobi-emtric-tenofov DF [Stribild] 150 mg-150 mg-200
mg-300 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
3. 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
Discharge Disposition:
Home
Discharge Diagnosis:
Right middle lobe pneumonia
HIV
Diarrhea, resolved
Polysubstance abuse
Acute kidney injury, resolved
Malnutrition
Hyponatremia, resolved
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to be part of your care.
You were admitted to the hospital because you were having fever
a severe cough and diarrhea. You were found to have an infection
of your right lung. Your infection was quite severe and you were
monitored in the ICU. You received IV antibiotics and your
breathing improved significantly. Your diarrhea also improved.
We were concerned that you haven't been taking your
antiretroviral medication for some time. We checked a viral load
which was high and you have a low CD4 count (58).
WHAT TO DO NEXT:
- Please take your medicines as prescribed:
-- Bactrim 1 tablet daily
-- Azithromcyin 2 tablets one time per week (___)
-- Stribild daily
- You need to take the Bactrim and azithromycin until your CD4
count recovers (likely for a few months).
- Please follow up with your doctor at ___ as
scheduled.
- If you experience fevers, chills, vomiting, worsening
diarrhea, a rash, or any concerning symptoms please call ___
___. ___.
- Please not to stop taking Stribild once you start taking this
medicine. If you have questions or concerns, call ___
___.
We wish you the best!
Your ___ Care Team
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
10797125-DS-4
| 10,797,125 | 28,263,348 |
DS
| 4 |
2169-01-14 00:00:00
|
2169-01-14 13:33:00
|
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 wrist pain
Left distal radius fracture/DRUJ injury
Major Surgical or Invasive Procedure:
___: Left distal radius ORIF, DRUJ fixation
History of Present Illness:
Mrs. ___ is a ___ yo female, otherwise healthy, who
presented s/p fall with significantly displaced and irreducible
left distal radius fracture from OSH. Patient was running and
tripped, falling on outstretched left hand. No headstrike or
LOC. Patient is right-hand dominant. She was seen at an outside
hospital, and transferred given the complexity of the fracture
for orthopedic evaluation. Mild numbness over medial and ulnar
distribution. She denied any other location of pain. Last meal
was eggs/coffee at 5:30am. Pt works as a ___.
Past Medical History:
Left DRFx (x2 as child)
Social History:
___
Family History:
Non-contributory
Physical Exam:
Exam on presentation:
Temp: 97.3 HR: 64 BP: 129/90 Resp: 18O2 Sat: 97
GENERAL: NAD, comfortable, AAOx3
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
NECK: no midline tenderness, supple, full ROM
CARDIAC: RRR, S1/S2,
LUNG: CTAB, no wheeze
ABDOMEN: soft, ND, nontender in all quadrants, no
rebound/guarding
BACK: no tenderness to palpation of the cervical, thoracic,
lumbar spine region
EXTREMITIES:
L upper extremity: deformity of the left distal radius, TTP.
0.5cm abrasion over left ulnar styloid region. Full painless
AROM/PROM of shoulder and wrist. +EPL/FPL/DIO (index) fire;
+SILT axillary/radial/median/ulnar nerve distributions; +Radial
pulse
B/L lower extremity: Abrasion over L knee. NTTP. Compartments
soft. +SILT SPN/DPN/TN/saphenous/sural. ___ pulses, foot warm
and well-perfused
Exam at discharge:
VS: AVSS
GEN: WDWN man in NAD
LUE: WWP, SILT m/r/u, moving fingers
Pertinent Results:
___ 04:20PM GLUCOSE-100 UREA N-17 CREAT-0.8 SODIUM-142
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-24 ANION GAP-17
___ 04:20PM estGFR-Using this
___ 04:20PM WBC-6.0 RBC-3.83* HGB-12.7 HCT-37.7 MCV-99*
MCH-33.0* MCHC-33.5 RDW-13.2
___ 04:20PM NEUTS-73.2* ___ MONOS-6.6 EOS-0.4
BASOS-0.3
___ 04:20PM ___ PTT-24.7* ___
___ 04:20PM PLT COUNT-238
Brief Hospital Course:
The patient was directly transferred from an OSH and was
evaluated by the orthopedic surgery team. The patient was found
to have left distal radius fracture/DRUJ injury and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for Left distal radius ORIF, DRUJ
fixation, which the patient tolerated well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patients 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 was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is non weight-bearing in the left
upper extremity. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours
Disp #*60 Capsule Refills:*0
3. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*60
Capsule Refills:*0
4. Acetaminophen 325 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg 1 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left distal radius fracture/DRUJ injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- Non weight-bearing left upper extremity
- Sling for comford
Followup Instructions:
___
|
10797854-DS-12
| 10,797,854 | 22,175,577 |
DS
| 12 |
2151-09-03 00:00:00
|
2151-09-03 18:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Zoloft / Motrin / clonidine
Attending: ___
Chief Complaint:
Found wandering
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with past medical history (per OMR) of mood disorder,
cognitive disorder, personality disorder, DMII, and HTN who was
BIBA wandering and confused, found to be agitated and
hyperthermic, admitted to the MICU for altered mental status. He
was found by EMS shirtless, wandering, and confused. He
reportedly was picking at things in the air. He was speaking and
moving spontaneously but he was not directable. In the ED:
- Initial VS were: T 99.0 HR 100 BP 180/64 RR 18 SpO2 97%
- On exam he was confused, moving all extremities equally, and
appeared to picking at something in front of him. He had
abrasions on his face and arm.
- The staff found several pills on his person: 3 pills thought
to be 10mg oxycodone, 1 pill thought to be quetiapine 200mg, and
2 pills thought to be dextroamphetamine 20mg
- Labs were notable for WBC 16.8, H/H 10.6/32.1, Cr 1.1, UTox
positive for methadone and oxycodone, STox negative
- CT head was negative for acute process but limited by motion
artifact
- CXR showed left ___ and ___ lateral rib fractures
- He spiked a fever to 104.8 with BP 187/81
- LP was attempted but was unsuccessful by multiple operators
given patient movement, but suspicion for calcified spine
- He was given empiric vancomycin 1g, ceftriaxone 2g, and
acyclovir 700mg
- He was very agitated during his ED course and was given 15mg
Haldol and 6mg Lorazepam with little effect
- Given his continued encephalopathy, he was admitted to the
MICU for monitoring
On arrival to the MICU, he is in 4-point soft restraints. He is
somnolent but not agitated and redirectable.
Review of systems:
Unable to obtain because of altered mental status.
Past Medical History:
Obtained from OMR and prior notes:
- Multiple prior diagnosses, including mood d/o, cognitive d/o,
personality d/o, PSA, psychotic d/o, anxiety d/o
- Reported h/o fabricating sx
- Multiple prior hospitalizations, last ___ for
self-reported
psychotic sx that resolved immediately on admission
- DM II
- Hypertension
- H/o CVA
- H/o seizures? (on Keppra)
Social History:
___
Family History:
Unable to obtain.
Physical Exam:
On Admission:
Vitals: T 97.8 HR 87 BP 199/87 HR 19 SpO2 100% on RA
GENERAL: Somnolent but arousable to loud voice and sternal rub,
speaks with slurred speech, no acute distress
HEENT: Sclera anicteric, MMM, edentulous, small abrasion on
forehead and nose
NECK: supple, JVP not elevated, no LAD
LUNGS: Poor effort but clear to auscultation bilaterally
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, normoactive bowel sounds,
no rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Dry, abrasions on face as noted
NEURO: Face is symmetric, does not cooperate with CN
examination, moves all 4 extremities spontaneously and to pain
but does not cooperate with motor/cerebellar examination, normal
muscle bulk and tone, 2+ patellar reflexes bilaterally,
downgoing Babinski bilaterally, no clonus
On Discharge:
Vitals - 99.0 155/92 75 18 96%RA
General - no acute distress, sitting in bed comfortably, not
diaphoretic
HEENT- 1 x 1 cm abrasion over L frontal bone, 1.5 cm irregular
laceration over nasal bridge, Sclera anicteric, PERRL 3-4mm
bilaterally, MMM, oropharynx clear
Neck - supple, JVP not elevated, no LAD
Chest - ttp over L lateral chest wall without palpible step-off
or overlying skin change
Lungs - Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV - regular, normal S1 + S2, no murmurs, rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU - no foley
Ext - warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro - CNs2-12 intact, motor function grossly normal
Pertinent Results:
On Admission:
___ 12:06PM BLOOD WBC-16.8* RBC-3.87* Hgb-10.6*# Hct-32.1*#
MCV-83# MCH-27.4 MCHC-33.0 RDW-14.0 RDWSD-41.3 Plt ___
___ 12:06PM BLOOD Neuts-87.9* Lymphs-3.2* Monos-7.3
Eos-0.8* Baso-0.2 Im ___ AbsNeut-14.81* AbsLymp-0.54*
AbsMono-1.23* AbsEos-0.13 AbsBaso-0.03
___ 06:55PM BLOOD ___ PTT-24.9* ___
___ 11:55AM BLOOD Glucose-195* UreaN-23* Creat-1.1 Na-133
K-5.8* Cl-100 HCO3-22 AnGap-17
___ 06:55PM BLOOD ALT-13 AST-31 LD(LDH)-296* CK(CPK)-562*
AlkPhos-67 TotBili-0.5
___ 06:55PM BLOOD Albumin-3.4* Calcium-8.6 Phos-2.5*
Mg-1.2*
___ 07:05PM BLOOD ___ pO2-47* pCO2-50* pH-7.36
calTCO2-29 Base XS-1
___ 07:05PM BLOOD Lactate-1.3
Imaging/Studies:
___ CT Head Without Contrast
No acute intracranial process on this study which is very
limited secondary to patient motion artifact.
___ CXR Portable
1. Findings concerning for left fifth and sixth lateral rib
fractures. No pneumothorax.
2. Mild left basal atelectasis.
3. Numerous calcific densities abutting the right humeral neck,
question tendinopathy Correlate for pain.
Microbiology:
___ UCx - negative
___ BCx x2 - pending
Discharge Labs:
___ 08:20AM BLOOD WBC-6.7 RBC-3.87* Hgb-10.5* Hct-31.7*
MCV-82 MCH-27.1 MCHC-33.1 RDW-13.8 RDWSD-40.2 Plt ___
___ 06:55PM BLOOD Neuts-82.6* Lymphs-8.7* Monos-7.6
Eos-0.5* Baso-0.2 Im ___ AbsNeut-13.90* AbsLymp-1.47
AbsMono-1.28* AbsEos-0.08 AbsBaso-0.04
___ 08:20AM BLOOD Glucose-146* UreaN-7 Creat-0.7 Na-136
K-4.1 Cl-100 HCO3-26 AnGap-14
___ 08:20AM BLOOD CK(CPK)-135
___ 08:20AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.0*
___ 11:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:05PM BLOOD ___ pO2-47* pCO2-50* pH-7.36
calTCO2-29 Base XS-1
___ 07:05PM BLOOD Lactate-1.3
Brief Hospital Course:
This is a ___ with a history of mood and personality disorder
presenting with fevers, hypertension, and encephalopathy
secondary to toxidrome.
Active Issues:
# SIRS
He met SIRS criteria on admission given leukocytosis and fevers.
Considering infectious causes, UA did not suggest infection. He
has encephalopathy so meningitis/encephalitis is possible, but
he has no nuchal rigidity and is predominantly encephalopathic,
so meningitis is less likely. CXR shows no pulmonary infiltrate.
His abdominal examination is benign. Besides small superficial
facial abrasions, he has no skin lesions or concern for
cellulitis. LP was attempted multipe times without success
secondary to patient anatomy and poor cooperation. He was
started on empiric vancomycin, ceftriaxone, and acyclovir. Urine
cultures returned negative but blood cultures showed no growth
at the time of discharge. Antibiotics were discontinued prior to
transfer to the floor. The patient remained afebrile and
hemodynamically stable. He was discharged off antibiotics.
# Encephalopathy
His encephalopathy was initially felt to be secondary to either
a sepsis or toxidrome. Infectious casues are detailed above.
Considering toxidrome, his symptoms could be anti-cholinergic,
serotonin syndrome (but no clonus), sympathomimetic (but no
hyperreflexia or rigidity), or opioid overdose (although his CNS
depression was only after antipsychotics and benzodiazepines in
the ED). His symptoms improved without further benzodiazepines.
He was found to have capacity by psychiatry and left against
clinical recommendations. Of note, he was found to have two rib
fractures and discharged with a lidocaine patch for pain
management.
Chronic Issues:
# Hypertension
He has a documented history of hypertension, and was
hypertensive on arrival, but quickly downtrended to 114/65. He
again became hypertensive on the floor but this was managed with
home Lisinopril and labetalol. He was discharged on his home
antihypertensive regimen of Lisinopril and Metoprolol.
# History of seizures
Medication review on OMR shows that he filled a prescription for
Keppra 1000mg BID on ___. This was continued during his
admission.
# Chronic pain
Medication review on OMR shows that he filled a prescription for
gabapentin 900mg TID on ___ and oxycodone 5mg q6h:prn on ___.
This was continued during his admission.
TRANSITIONAL ISSUES:
- Patient is being discharged on his home medications except
for: Amaryl, Oxycodone, Olanzapine, Omeprazole and Tramadol.
Please reassess the need for these medications in the outpatient
setting.
- Mr. ___ is being discharged with Lidocaine patches for
pain.
- Mr. ___ had hypertension during his admission but this
resolved with his home medications.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 900 mg PO TID
2. LeVETiracetam 1000 mg PO BID
3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
4. ClonazePAM 1 mg PO 0.5 TABLET IN MORNING AND 1 IN EVENING
5. Pregabalin 300 mg PO BID
6. Amitriptyline 50 mg PO QHS
7. Simvastatin 40 mg PO QPM
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN SOB
9. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Ranitidine 150 mg PO BID
12. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. ClonazePAM 1 mg PO 0.5 TABLET IN MORNING AND 1 IN EVENING
RX *clonazepam 0.5 mg 1 tablet(s) by mouth twice daily Disp #*14
Tablet Refills:*0
2. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Simvastatin 40 mg PO QPM
4. Ranitidine 150 mg PO BID
5. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN SOB
6. Pregabalin 300 mg PO BID
7. Gabapentin 900 mg PO TID
8. LeVETiracetam 1000 mg PO BID
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice
daily Disp #*30 Tablet Refills:*0
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Amitriptyline 50 mg PO QHS
11. Aspirin 81 mg PO DAILY
12. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*15 Tablet Refills:*0
13. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) Apply patch once
daily Disp #*30 Patch Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Toxidrome, Rib Fractures
Secondary Diagnosis: Hypertension, Type 2 Diabetes Mellitus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted at ___ after being found
down confused by authorities. You were placed in the ICU with a
fever and high white count that was felt to be due to substances
you ingested. You received antibiotics but all of the diagnostic
tests were negative for infection so these were stopped. You
were also found to have two broken ribs which did not require
any surgical intervention. You improved with medications and
were discharged at your request.
Several medications were stopped at the time of discharge. These
include AMARYL, Oxycodone, Olanzapine, Omeprazole and Tramadol.
Please discuss the need for these medications with your Primary
Care Physician. PLEASE BE SURE TO FOLLOW-UP WITH YOUR PRIMARY
CARE DOCTOR ON ___ AT 8:45AM.
It was a privilege to participate in your care.
Best,
Your ___ Team
Followup Instructions:
___
|
10797885-DS-13
| 10,797,885 | 20,865,551 |
DS
| 13 |
2186-12-27 00:00:00
|
2186-12-27 11:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of ATLL presents from ___ clinic for evaluation
of somnolence.
Regarding the patient's malignancy, he was diagnosed with HTLV-1
associated Adult T cell lymphoma in ___ and was subsequently
lost to follow up. On ___, the patient presented to ___
for dry gangrene of his right great and second toe and underwent
R popliteal and peroneal artery angioplasty.
During that hospitalization, the patient was incidentally found
to have multiple, diffuse purple-colored nodules on his back,
chest and abdomen. Dermatology was consulted and biopsy
confirmed ATLL. CT imaging showed diffuse LAD. He was
subsequently discharged with close heme/onc follow up.
The patient has been living at rehab since discharge and had
previously been doing well and was mentally sharp per his wife.
Last night, the patient was in his usual state of health when he
went to sleep, however, upon awakening this morning, he was slow
to respond and lethargic, easily falling asleep.
He went to his scheduled ___ appointment where he was found to
have normal vital signs and was AAO x1-2 (person and month). He
was without complaint or focal symptoms.
Per the patient's wife who is at bedside, she states that over
the last few days he seemed tired but himself. Then, this
morning, when she went to visit him he just seemed "out of it",
holding his spoon eating cereal but not completing the task.
In the ED, initial vitals were notable for:
T 98.1 HR 110 BP 124/67 R 18 SpO2 97% RA
labs were notable for:
Normal Chem10 and LFTs
WBC 10.7 Hgb 8.8
Lactate 1.8
Trop 0.03
Patient received:
___ 14:50 IV CefTRIAXone
___ 15:11 IV CefTRIAXone 1 gm
___ 17:22 IVF NS ( 1000 mL ordered)
Imaging was notable for:
___ CT Head W/O Contrast
1. No acute intracranial abnormality. Specifically, no evidence
of a cute territorial infarction, hemorrhage, or mass. Please
note MRI is more sensitive for the detection of acute infarct.
2. Unchanged appearance of chronic left-sided basal ganglia and
right frontal lobe encephalomalacia, likely sequelae of prior
infarcts.
___ Chest (Pa & Lat)
IMPRESSION:
No acute cardiopulmonary process. Known bilateral pulmonary
nodules were better seen on recent prior chest CT.
Currently, both the patient and wife feel that he is doing
better. The patient has no fevers or chills. No chest pain,
dyspnea or palpitations. No abd pain. No n/v/d. No dysuria. No
pain in his foot.
The patient notes dysphagia but no sore throat for the last 2
days. Also, has been complaining of bilateral jaw pain for the
last 2 days.
ROS: 10 point review of systems discussed with patient and
negative unless noted above
Past Medical History:
PAST ONCOLOGIC HISTORY:
Patient was seen in ___ ___. At that
time he was referred for a leukocytosis with a white blood cell
count of ___ for over a year, with about 60-65%
lymphocytes. Peripheral blood flow cytometry was obtained that
was consistent with a CD4 positive, CD5 bright, cytoplasmic CD25
positive, CD8, CD56, and CD57 negative process. TCR gene
rearrangement was clonal and suggestive of a T-cell leukemia.
At
that time he also had an HTLV ___ antibody which was repeatedly
reactive and confirmed by Western blot. Other relevant tests at
that time was in neuron-specific enolase which was normal at
4.9,
and HIV 1 which was negative. Additionally, he had significant
weakness and some muscle spasms around that time and a diagnosis
of tropical spastic paresis was invoked. He has also had
"multiple strokes" c/b decreased mobility one of which in the L
basal ganglia. He states his PCP is in ___ and ___ was
supposed to follow
with a neurologist at ___.
___: Admitted for nonhealing R toe gangrene s/p
percutaneous angioplasty of the popliteal artery and peroneal
artery. During hospitalization noted to have diffuse nodular
rash
c/f cutaneous leukemia. Heme/onc consulted (noting history
below)
and he underwent derm biopsy of a nodule c/w ATLL (see path
below). CT Torso revealed diffuse adenopathy and visceral
involvement (see below). History given during that admission:
"More recently, he has suffered a 60 pound weight loss over the
past 6 months. Per his wife, she attributes this to his strokes
rather than anything else. He also has noted a profound skin
rash which is characterized by nodules throughout his body
mostly
on his back that has started at the end of ___. Patient
does
not remember receiving a diagnosis of leukemia, nor does his
wife. Per ___, the hematologist who diagnosed him a few
years ago, there were multiple attempts to contact the patient
and get him back in for follow-up after the second visit, but
these were unsuccessful. Additionally, he also tried to get him
to the ___ for a trial, but this was also unsuccessful as his
calls were not returned."
PAST MEDICAL HISTORY:
HTN
HLD
DM2
CVA
PVD c/b R toe gangrene
Social History:
___
Family History:
He denies a history of hematologic or ___ medical issues
Physical Exam:
ADMISSION PHYSICAL EXAM:
====================================
VITALS: T 98.7 BP 108/66 HR 102 R 18 SpO2 97 Ra
GENERAL: Chronically ill appearing, no acute distress
HEENT: Dry mucous membranes, white discolored tongue. No lesions
or erythema. Bilateral hard, fixed masses by TMJ
EYES: anicteric, PERRL
NECK: 1cm hard, circular nodule under right angle of jaw
RESP: CTAB, no increased WOB
___: RRR no MRG
GI: soft, NTND no HSM
EXT: warm, no edema 1+ DP pulse R foot. Dry gangrene R great
toe with circular ulcer ___ toe
SKIN: multiple, diffuse purple nodules with surrounding
erythema on chest flank and back. L Biopsy site with dried blood
without erythema (Image uploaded to ___)
NEURO: PERRL, EOMI, mild, R facial droop (Chronic). Uvula
midline. Moving all 4 extremeties.
ACCESS: PIV
DISCHARGE PHYSICAL EXAM:
====================================
98.3 PO BP: 114/66 HR: 81 RR: 18 O2 sat: 99% O2 delivery: RA
GENERAL: Chronically ill appearing, no acute distress, pleasant
HEENT: MMM, clear OP. Bilateral hard, fixed posterior cervical
and parotid masses, significantly improved compared to prior,
nontender currently. Also submandibular 1-2cm hard LAD.
Dentures in place. No facial swellilng. Temporal wasting
EYES: anicteric, PERRL
RESP: CTAB, no R/R/W
CV: RRR, no R/M/G
GI: S/NT/ND, no hepatosplenomegaly
EXT: warm, no edema, 1+ ___ pulse bilaterally. Dry gangrene R
great toe with circular ulcer ___ toe without surrounding
erythema, tenderness, or drainage
SKIN: multiple, diffuse purple nodules with surrounding
erythema and scaling on chest, flank, and back, to ~2cm in
diameter for largest, slightly raised, much improved compared to
prior. A few have skin sloughing, exposing pink underlying skin
without tenderness, warmth, or erythema. Sacral decubitus ulcer
at location of former skin nodule, nontender, without drainage.
NEURO: mild, right-sided facial droop. Able to lift bilateral
legs off bed.
MSK: +cachexia
Pertinent Results:
ADMISSION LABS
===============================
___ 05:35AM BLOOD WBC-10.7* RBC-3.06* Hgb-8.7* Hct-27.7*
MCV-91 MCH-28.4 MCHC-31.4* RDW-13.1 RDWSD-43.3 Plt ___
___ 10:30AM BLOOD Neuts-70.7 Lymphs-16.7* Monos-8.9 Eos-2.4
Baso-0.4 Im ___ AbsNeut-7.55* AbsLymp-1.79 AbsMono-0.95*
AbsEos-0.26 AbsBaso-0.04
___ 10:30AM BLOOD ___ PTT-25.1 ___
___ 10:30AM BLOOD ___
___ 10:30AM BLOOD Ret Aut-2.1* Abs Ret-0.06
___ 05:35AM BLOOD Glucose-185* UreaN-14 Creat-0.9 Na-138
K-5.0 Cl-96 HCO3-30 AnGap-12
___ 10:30AM BLOOD ALT-15 AST-14 AlkPhos-70 TotBili-0.3
___ 10:30AM BLOOD LD(LDH)-437*
___ 10:30AM BLOOD Lipase-11
___ 12:30PM BLOOD cTropnT-0.03*
___ 05:35AM BLOOD Calcium-9.8 Phos-4.0 Mg-1.9
___ 12:35PM BLOOD Lactate-1.8
RELEVANT LABS
===============================
___ 04:40PM BLOOD WBC-6.7 RBC-2.52* Hgb-7.2* Hct-23.3*
MCV-93 MCH-28.6 MCHC-30.9* RDW-14.8 RDWSD-48.8* Plt ___
___ 04:40PM BLOOD Neuts-72* Bands-0 Lymphs-16* Monos-7
Eos-2 Baso-3* ___ Myelos-0 AbsNeut-4.82
AbsLymp-1.07* AbsMono-0.47 AbsEos-0.13 AbsBaso-0.20*
___ 06:27AM BLOOD G6PD-NORMAL
___ 04:40PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 10:30AM BLOOD Hapto-557*
___ 06:27AM BLOOD calTIBC-187* Ferritn-280 TRF-144*
___ 10:30AM BLOOD TSH-11*
___ 06:27AM BLOOD TSH-6.6*
___ 06:27AM BLOOD T4-6.0 T3-61*
RELEVANT MICRO
===============================
___ 10:30AM BLOOD HBsAg-POSITIVE* HBsAb-NEG HBcAb-POS*
___ 10:30AM BLOOD HIV Ab-NEG
___ 10:30AM BLOOD HCV Ab-NEG
___ 07:20PM BLOOD HBV VL-DETECTED
___ 12:00AM BLOOD HBV VL-NOT DETECT
___ 06:40AM BLOOD HBV VL-NOT DETECT
___ BLOOD CULTURES X2: NO GROWTH
___ BLOOD CULTURES X2: NO GROWTH
___ BLOOD CULTURES X2: NGTD
___ PICC TIP CULTURE: NO GROWTH
___ URINE CULTURE
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
___ URINE CULTURE
Culture workup discontinued. Further incubation showed
contamination
with mixed fecal flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
___ URINE CULTURE
URINE CULTURE (Final ___: NO GROWTH.
___ URINE CULTURE
URINE CULTURE (Final ___: NO GROWTH.
___ URINE CULTURE
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ~1000 CFU/mL.
RELEVANT RADIOLOGY
===============================
___ CT ABD/PELVIS WITH CONTRAST
1. Patient known with acute T-cell lymphoma. Multiple hepatic
ypodensities, heterogeneous aspect of the right iliac bone and
left inguinal adenopathy. These findings are concerning for
metastatic disease.
2. Bilateral adrenal nodules, they are nonspecific although
likely due to
lymphoma.
3. Skin lesions.
4. For intrathoracic findings, please refer to separately
dictated CT chest performed on the same day.
___ CT CHEST WITH CONTRAST
1. Bilateral axillary and right hilar lymphadenopathy.
2. Multiple diffuse solid and sub-solid nodules in both lobes,
most of which are in a peribronchial distribution, likely
representing metastatic disease.
3. Skin lesions. Correlation with physical findings suggested.
4. Please refer to same day CT abdomen and pelvis report for
subdiaphragmatic findings.
___ CT HEAD WITHOUT CONTRAST
No evidence of acute intracranial process. Unchanged chronic
left basal
ganglia infarct with volume loss. Interval appearance of
probably chronic
additional small right frontal lobe infarcts.
___ CT HEAD WITHOUT CONTRAST
1. No acute intracranial abnormality. Specifically, no evidence
of a cute
territorial infarction, hemorrhage, or mass. Please note MRI is
more
sensitive for the detection of acute infarct.
2. Unchanged appearance of chronic infarcts.
___ CT NECK WITH CONTRAST
1. Extensive bilateral cervical lymphadenopathy including
numerous necrotic nodes measuring up to 2.3 cm by 1.4 cm in the
right level Ib station, with involvement of the bilateral
parotid and right submandibular glands.
2. Several nodules in the imaged lung apices measuring up to 9
mm are bigger from ___.
3. Differential considerations include malignancy or infection,
including
tuberculosis.
4. No definite impingement or obstruction of the aerodigestive
tract.
5. The cervical lymphadenopathy causes mass-effect on otherwise
patent
bilateral internal jugular veins.
___ BILATERAL UPPER EXTREMITY VENOUS ULTRASOUND
1. Mildly enlarged lymph nodes surrounding the right internal
jugular vein
without significant compression. No suggestion of deep venous
thrombosis in the right internal jugular vein.
2. Grossly enlarged lymph nodes adjacent to the left internal
jugular vein
cause severe compression. No suggestion of deep venous
thrombosis or complete occlusion.
___ PET
1. Diffuse FDG avid lymphadenopathy including abnormally
enlarged
and necrotic nodes in the cervical, axillary, mediastinal,
hilar,
retroperitoneal, and inguinal chains, consistent with metastatic
disease.
2. Numerous FDG avid pulmonary nodules and liver lesions.
3. Innumerable FDG avid cutaneous nodules, most prominently in
the torso
posteriorly.
4. Foci of increased activity involving the lumbar spine,
notably in the body of L5.
5. Malpositioned left PICC line terminating in the azygos vein.
___ CT CHEST WITHOUT CONTRAST
1. No focal consolidations concerning for pneumonia.
2. Small bilateral pleural effusions with subjacent passive
atelectasis are similar to PET-CT ___.
3. Innumerable bilateral pulmonary nodules, hilar
lymphadenopathy, axillary lymphadenopathy, and cutaneous nodules
all similar to ___.
4. Malpositioned PICC in the azygos vein, as before.
5. Numerous hepatic lesions are re-demonstrated, better assessed
on PET-CT.
DISCHARGE LABS
===============================
___ 06:58AM BLOOD WBC-15.9* RBC-3.46* Hgb-10.3* Hct-32.8*
MCV-95 MCH-29.8 MCHC-31.4* RDW-17.5* RDWSD-54.9* Plt ___
___ 06:58AM BLOOD Neuts-83* Bands-0 Lymphs-11* Monos-3*
Eos-0 Baso-0 ___ Myelos-2* Other-1* AbsNeut-13.20*
AbsLymp-1.75 AbsMono-0.48 AbsEos-0.00* AbsBaso-0.00*
___ 06:58AM BLOOD ___ PTT-25.6 ___
___ 06:58AM BLOOD Glucose-118* UreaN-10 Creat-0.9 Na-143
K-5.9* Cl-103 HCO3-32 AnGap-8* ***moderately hemolyzed sample
___ 06:58AM BLOOD ALT-17 AST-32 LD(LDH)-388* AlkPhos-117
TotBili-0.3
___ 06:58AM BLOOD Albumin-3.3* Calcium-9.6 Phos-3.7 Mg-2.0
UricAcd-2.5*
Brief Hospital Course:
===================
SUMMARY
===================
___ with progressive ATLL who presents after recent discharge to
rehab with progressive lethargy, found to have an UTI. During
this admission, he was initiated onto mini-CHOP for treatment of
his progressive ATLL with good symptomatic response.
===================
ACUTE ISSUES
===================
#Adult T-cell lymphoma
Patient was diagnosed with ATLL in ___ and was not treated
previously. During this admission, he was noted to have
bilateral cervical lymphadenopathy and submandibular nodules,
which were initially quite tender, as well as diffuse skin
nodules which are nontender. PET scan this admission showed
diffuse lymphadenopathy most prominently in cervical region,
multiple nodules in lungs and liver, diffuse cutaneous nodules,
and increased uptake near lumbar spine including body of L5.
Ultrasound before mini-CHOP showed severe external compression
of the left jugular vein without thrombosis. CT neck did not
show any impingement upon the aerodigestive tract. HTLV1
positive. Initiated onto mini-CHOP on ___ (C1D1). Tolerated
well. ANC nadir 4,800 on growth factor support. Main side-effect
otherwise has been constipation which was treated with a strong
bowel regimen. Symptomatically, bilateral cervical and
submandibular lymphadenopathy shrunk significantly and became
nontender. Skin nodules also shrunk.
#Hepatitis B
HBsAb negative, HBsAg positive, HBcAb positive. VL detectable at
<1.3 log IU/mL just before initiation of chemotherapy. AST/ALT
normal this admission. No known history of treatment or
resistance and as such started on entecavir 0.5mg daily. Weekly
viral load afterwards were undetectable.
#Isolated systolic HTN
#Labile blood pressures
Patient noted to have isolated systolic hypertension and labile
blood pressures in general. This may be due to autonomic
dysfunction from ?___ disease (see below). As such,
blood pressure goals were made liberal.
#UTI
#Toxic metabolic encephalopathy
Presented with somnolence from his oncology appointment. UA
showed large leuks, 176 WBCs. Urine culture was unfortunately
contaminated. Treated with ceftriaxone with rapid improvement in
mental status back to baseline. Received ~2 week course. Repeat
UA after treatment was clean.
===================
CHRONIC ISSUES
===================
#T2DM
At home is on glipizide and metformin. Put on insulin sliding
scale while in-house.
#Right toe gangrene
#Peripheral vascular disease
Patient recently underwent angioplasty by vascular surgery.
Extremity is warm and toe does not appear to have drainage or
other signs of infection. Continued on aspirin 325mg,
clopidogrel 75mg, and atorvastatin 80mg (see below).
#History of stroke
#History of ___
Per notes, patient's wife states right sided facial droop is at
baseline for him. In addition, has noted involvement of his
basal ganglia in prior CVAs and demonstrates occasional
spasticity and stiffness. Saw neurologist in the past who made
diagnosis of ___ disease; possible that baseline
cognitive dysfunction related to ___. Was not on
___ treatment upon admission. CT in ED on admission was
without acute process.
#Thrush
Given nystatin rinse. Initially had odynophagia, improved with
nystatin.
#BPH
Treated with home tamsulosin.
#Hyperlipidemia
Atorvastatin held in the setting of chemotherapy. Restarted once
chemotherapy finished.
#HCP/CONTACT: ___ (Wife) ___
#CODE STATUS: full
===================
TRANSITIONAL ISSUES
===================
[] Hepatitis B: please check viral loads weekly
[] Atorvastatin: please stop before receiving cycle 2 of R-CHOP,
in case patient develops LFT abnormalities of unclear etiology.
[] ___ disease: it is unclear if the patient has
___ disease. Please consider re-evaluation and treatment
if within goals of care.
[] R toe gangrene: please follow up with Podiatry and Vascular
appointments.
[] Hypertension: please consider being liberal with BP goals as
patient appeared to have labile blood pressures this admission.
[] TSH: mildly elevated in the setting of infection. Consider
repeating as an outpatient.
[] Access: please consider placement of port for access.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Ferrous Sulfate 325 mg PO DAILY
4. GlipiZIDE 5 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. TraZODone 25 mg PO QHS
9. Ascorbic Acid ___ mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate
2. Acyclovir 400 mg PO Q12H
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
4. Docusate Sodium 100 mg PO BID
5. Entecavir 0.5 mg PO DAILY
6. Heparin 5000 UNIT SC BID
7. Glargine 2 Units Bedtime
Humalog 2 Units Breakfast
Humalog 2 Units Lunch
Humalog 2 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. Nystatin Oral Suspension 10 mL PO QID
9. Pantoprazole 40 mg PO Q12H
10. Polyethylene Glycol 17 g PO QHS
11. Senna 8.6 mg PO BID:PRN Constipation - First Line
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. Aspirin 325 mg PO DAILY
14. Atorvastatin 80 mg PO QPM
15. Clopidogrel 75 mg PO DAILY
16. Tamsulosin 0.4 mg PO QHS
17. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
#Adult T-cell lymphoma
#Labile blood pressure
#Isolated systolic hypertension
#Hepatitis B
#UTI
#Toxic metabolic encephalopathy
SECONDARY DIAGNOSES
#T2DM
#Right toe gangrene
#Peripheral vascular disease
#History of stroke
#History of ___
#Thrush
#BPH
#Hyperlipidemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure taking care of you at the ___
___!
WHY WERE YOU ADMITTED TO THE HOSPITAL?
You were seen in the oncology (cancer medicine) clinic, and you
were found to be very sleepy.
WHAT HAPPENED IN THE HOSPITAL?
- You were found to have a urinary tract infection (UTI). For
this, you were treated with IV antibiotics.
- You started receiving treatment for your cancer (adult T-cell
leukemia/lymphoma) with a chemotherapy regimen called mini-CHOP.
You tolerated this regimen well.
- You were diagnosed with hepatitis B and started on treatment
for this as well.
WHAT SHOULD YOU DO ONCE YOU LEAVE THE HOSPITAL?
- Please take your medications as prescribed and attend your
doctor's appointments.
- You will need to return to clinic to see Dr. ___
your ___ cycle of chemotherapy. Please see below for the
schedule.
We wish you all the best!
Your ___ Care Team
Followup Instructions:
___
|
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|
2155-05-26 17:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy
History of Present Illness:
___ yo F w/ prior h/o cholelithiasis in ___ that did not have
any
further episodes of biliary colic and did not require her to do
anything about it, who developed nausea, vomiting throughout the
last day, hasn't been able to tolerate any food or liquids, and
says her vomit is nonbilious, nonbloody. She also endorses
chills
throughout the last day but otherwise had been in her usual
state of health prior. She ate dinner about 2 hours before the
pain hit its most severe point, which started and peaked after
dinner.
Past Medical History:
PMH: DM, HTN, h/o cholelithiasis on u/s in ___
PSH: 2 c-sections
Social History:
___
Family History:
noncontributory
Physical Exam:
PE:
VS: 97.2 92 131/71 16 100% RA
Gen: NAD in bed
CV: rrr, no m/r/g
P: CTAB no coughs or wheezes
Abd: RUQ tender, some pain on inspiration on RUQ, no masses or
gallbladder palpable, no jaundice
Ext: WWP, no edema, 2+ pulses
Discharge Physical Exam:
VS: 98.3, 88, 120/79, 18, 100%
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+) BS x 4 quadrants, soft, mildly tender to palpation
incisionally, non-distended. Incisions: clean, dry and intact,
dressed and closed with steristrips.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
Pertinent Results:
___ 07:00AM BLOOD WBC-8.3 RBC-4.39 Hgb-12.3 Hct-34.6
MCV-79* MCH-28.0 MCHC-35.5 RDW-14.2 RDWSD-40.3 Plt ___
___ 03:36PM BLOOD WBC-10.3* RBC-4.66 Hgb-13.2 Hct-36.4
MCV-78* MCH-28.3 MCHC-36.3 RDW-14.2 RDWSD-39.7 Plt ___
___ 07:00AM BLOOD Glucose-184* UreaN-12 Creat-0.9 Na-136
K-3.1* Cl-99 HCO3-28 AnGap-12
___ 03:36PM BLOOD Glucose-269* UreaN-13 Creat-0.9 Na-136
K-3.2* Cl-95* HCO3-27 AnGap-17
___ 03:36PM BLOOD ALT-66* AST-45* AlkPhos-58 TotBili-0.4
___ 07:00AM BLOOD Calcium-8.9 Phos-2.5* Mg-1.9
___ 03:36PM BLOOD Albumin-4.2 Calcium-9.8 Phos-2.8 Mg-1.7
___ 03:48PM BLOOD Lactate-2.2*
___: gallbladder US
1. Cholelithiasis. Gallbladder distended but not hydropic. No
sonographic
___. Findings are overall not consistent with acute
cholecystitis.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot
be excluded on the basis of this examination.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission ultra-sound revealed distended gallbladder with
cholelithiasis. The patient underwent laparoscopic
cholecystectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
tolerating sips, on IV fluids, and IV analgesia for pain
control. The patient was hemodynamically stable.
.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
..
Medications on Admission:
___: lantus 44 units qhs, chlorthalidone 25 mg qd, lisinopril 20
mg qd, metformin, sertraline, prazosin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. Glargine 44 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
4. Chlorthalidone 25 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10798458-DS-16
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|
2186-04-23 10:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain, nausea, vomitting
Major Surgical or Invasive Procedure:
___ - exploratory laparotomy, lysis of adhesions, and
cecopexy
History of Present Illness:
___ with hx of colonic volvulus s/p exlap, detorsion, and
appendectomy ___ ___ presenting from PCP with worsening
abdominal pain, distention, nausea and vomiting. She had been in
her normal state of health until 1 month ago when she started to
have vague abdominal pain. She had a work-up by her PCP in the
outpatient setting and underwent a CT scan on ___ which
showed ascending colitis. 2 nights ago, she started to have
persistent, crampy right lower quadrant pain with associated
nausea vomiting x4. Since the onset of symptoms, she has had
poor PO intake, subjective fevers, and chills. Last BM and
flatus this morning. She initially saw her PCP who referred her
to the ED for further evaluation. Last colonscopy was ___ years
ago and a polyp was removed. Surgery was consulted for further
evaluation.
Past Medical History:
PMH: asthma, mitral vlave prolapse, hypothyroidism
PSH:
- ORIF of right lateral and medial malleolar fractures ___
___
-Trans-canal excision of glomus tympanicum tumor ___
___
- bilateral salpingo-oopherectomy ___ ___
- exlap with adhesiolysis, reduction of small bowel volvulus and
appendectomy ___ ___
- excision of right cheek nevus with layered closure ___
___
Social History:
___
Family History:
Aunt - breast cancer
Mother - lymphosarcoma
___
Physical Exam:
Admission Physical Exam:
Vitals: 99.2 99 148/86 16 100%RA
GEN: AOx3, NAD
HEENT: No scleral icterus, mucus membranes moist, NGT in place
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, distended, tympanitic, RLQ tenderness, no rebound or
guarding
GU: foley in place
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 98.4, 76, 132/54, 16, 100% RA
Gen: Alert, sitting up in bed with husband at bedside.
HEENT: No deformity. Neck supple, trachea midline.
CV: RRR
Pulm: Clear to auscultation bilaterally.
Abd: Soft, mildly tender incisionally as anticipated,
non-distended. Active bowel sounds x 4 quadrants. Midline
abdominal incision CDI with steri strips.
Ext: Warm and dry. 2+ ___ pulses.
Neuro: A&Ox3. Moves all extremities equal and strong. Speech is
clear and fluent.
Pertinent Results:
___ 05:40AM BLOOD WBC-7.0 RBC-4.15 Hgb-12.1 Hct-36.9 MCV-89
MCH-29.2 MCHC-32.8 RDW-14.3 RDWSD-46.0 Plt ___
___ 05:45AM BLOOD WBC-6.4 RBC-4.08 Hgb-11.9 Hct-36.4 MCV-89
MCH-29.2 MCHC-32.7 RDW-14.2 RDWSD-45.7 Plt ___
___ 05:40AM BLOOD WBC-5.2 RBC-3.98 Hgb-11.6 Hct-35.6 MCV-89
MCH-29.1 MCHC-32.6 RDW-14.2 RDWSD-46.3 Plt ___
___ 04:50AM BLOOD WBC-4.0 RBC-4.58 Hgb-13.5 Hct-40.4 MCV-88
MCH-29.5 MCHC-33.4 RDW-14.4 RDWSD-46.0 Plt ___
___ 07:12PM BLOOD WBC-3.4* RBC-4.14 Hgb-12.1 Hct-36.7
MCV-89 MCH-29.2 MCHC-33.0 RDW-14.5 RDWSD-46.9* Plt ___
___ 06:40AM BLOOD WBC-2.7* RBC-3.82* Hgb-11.2 Hct-34.3
MCV-90 MCH-29.3 MCHC-32.7 RDW-14.6 RDWSD-47.4* Plt ___
___ 04:25AM BLOOD WBC-4.2 RBC-3.43* Hgb-10.1* Hct-31.2*
MCV-91 MCH-29.4 MCHC-32.4 RDW-14.5 RDWSD-47.9* Plt ___
___ 06:10AM BLOOD WBC-5.0 RBC-4.10 Hgb-12.1 Hct-36.9 MCV-90
MCH-29.5 MCHC-32.8 RDW-14.6 RDWSD-47.8* Plt ___
___ 05:30AM BLOOD WBC-8.2 RBC-4.67 Hgb-13.7 Hct-40.9 MCV-88
MCH-29.3 MCHC-33.5 RDW-14.3 RDWSD-45.7 Plt ___
___ 09:45PM BLOOD WBC-8.5 RBC-5.31* Hgb-15.5 Hct-45.6*
MCV-86 MCH-29.2 MCHC-34.0 RDW-14.0 RDWSD-43.9 Plt ___
___ 05:40AM BLOOD Glucose-117* UreaN-5* Creat-0.7 Na-136
K-4.5 Cl-101 HCO3-26 AnGap-14
___ 05:45AM BLOOD Glucose-121* UreaN-6 Creat-0.6 Na-136
K-4.4 Cl-100 HCO3-28 AnGap-12
___ 05:40AM BLOOD Glucose-128* UreaN-6 Creat-0.6 Na-133
K-4.2 Cl-98 HCO3-31 AnGap-8
___ 04:50AM BLOOD Glucose-113* UreaN-6 Creat-0.6 Na-137
K-4.2 Cl-97 HCO3-29 AnGap-15
___ 07:12PM BLOOD Glucose-132* UreaN-6 Creat-0.6 Na-136
K-4.1 Cl-98 HCO3-28 AnGap-14
___ 06:40AM BLOOD Glucose-145* UreaN-9 Creat-0.6 Na-133
K-3.7 Cl-99 HCO3-29 AnGap-9
___ 04:25AM BLOOD Glucose-161* UreaN-13 Creat-0.7 Na-134
K-3.5 Cl-102 HCO3-26 AnGap-10
___ 06:10AM BLOOD Glucose-92 UreaN-14 Creat-0.9 Na-132*
K-3.8 Cl-98 HCO3-26 AnGap-12
___ 05:30AM BLOOD Glucose-98 UreaN-11 Creat-0.9 Na-130*
K-4.1 Cl-94* HCO3-27 AnGap-13
___ 09:45PM BLOOD Glucose-111* UreaN-13 Creat-0.8 Na-127*
K-4.2 Cl-87* HCO3-28 AnGap-16
___ 05:40AM BLOOD Calcium-8.8 Phos-3.7 Mg-1.9
___ 05:45AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.0
___ 05:40AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9
___ 04:50AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.5
___ 07:12PM BLOOD Calcium-8.6 Phos-3.3 Mg-1.9
___ 06:40AM BLOOD Calcium-7.8* Phos-2.1* Mg-1.7
___ 04:25AM BLOOD Calcium-8.1* Phos-2.1*# Mg-2.0
___ 06:10AM BLOOD Calcium-8.0* Phos-4.5 Mg-2.0
___ 05:30AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.9
___ 10:26PM BLOOD Lactate-1.5
___ Chest PA and LAT: 1. No acute cardiopulmonary process.
2. Partially imaged gaseous distention of small bowel.
___ CT A/P: 1. Complete small bowel obstruction with a
transition point in the lower central abdomen. Wall edema and
intraperitoneal free fluid is concerning for developing bowel
ischemia. Surgical consultation is advised.
2. Indeterminate left adrenal nodule. Noncontrast CT can be
obtained obtained for further evaluation.
___ CXR:
1. No acute cardiopulmonary process.
2. Partially imaged gaseous distention of small bowel.
___ Abd Xray: Dilated loops of small and large bowel most
likely representing postoperative ileus. If there is clinical
concern for a small bowel obstruction, CT abdomen pelvis may be
obtained.
Brief Hospital Course:
Ms ___ is ___ yo F who was admitted to the Acute Care Surgery
Service on ___ with abdominal pain, nausea, and vomitting.
She had a CT scan that showed a high grade bowel obstruction and
a nasogastric tube was place. She continued to have obstructive
symptoms despite gastric decompression. On ___ informed
consent was obtained and she was taken to the operating room for
an exploratory laparotomy, lysis of adhesions, and a cecopexy.
Please see operative report for details. Patient was extubated,
taken to the PACU until stable, then transferred to the floor
for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with an epidural
managed by the acute pain service and then transitioned to oral
pain medication once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. On POD1, the NGT
was removed, therefore, the diet was advanced sequentially to a
Regular diet. On POD4 she had an episode of nausea and vomitting
therefore the nasogastric tube was replaced. On POD5 she had a
repeat CT abdomen/pelvis that was unremarkable. On POD7 her NG
tube was removed and she was able to tolerate a regular diet
without nausea or vomittng. Patient's intake and output were
closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. Follow up appointments were
scheduled.
An incidental finding of A 10 x 14 mm left adrenal nodule was
seen on CT scan.
Medications on Admission:
fluticasone-salmeterol 500-50 Q12, albuterol q4-6 PRN,
fluticasone 220 2 inh Q12, levothyroxine 25', olanzapine 2.5',
nortriptyline 30 qPM, latanoprost 1 drop both eyes QPM,
hyoscyamine Q4prn, lorazepam 0.5'' prn, vit C, Vit B12,
multivitamin
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth Q4H PRN Disp #*30
Tablet Refills:*0
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Levothyroxine Sodium 25 mcg PO DAILY
7. OLANZapine (Disintegrating Tablet) 2.5 mg PO QHS
8. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth
daily Disp #*48 Packet Refills:*0
9. albuterol q4-6 PRN
10. fluticasone 220 2 inh
11. nortriptyline 30 qPM
12. hyoscyamine Q4prn
13. lorazepam 0.5'' prn
14. vit C
15. Vit B12, multivitamin
Discharge Disposition:
Home
Discharge Diagnosis:
High-grade small-bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___ and
underwent exploratory laparotomy, lysis of adhesions, and
cecopexy. You are recovering well and are now ready for
discharge. Please follow the instructions below to continue your
recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
10798524-DS-7
| 10,798,524 | 26,229,464 |
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| 7 |
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|
2134-01-22 20:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of HTN, HLD, DM2, presented to OSH with rigors,
malaise, and CT Head was read as having ring enhancing lesions
on CT.
The patient's symptoms developed over past 5 days. Initially
developed rigors on ___, headache, joint pains, and today has a
new cough. No meningismus or photosensitivity. Friend was
concerned he was more confused. He presented to ___
ED on ___ and was febrile there to 102, tachy to 112. CT head
was read as having 3 ring enhancing lesions concerning for
abscess so he was referred to ___ for neurosurgery evaluation.
Also, CXR showed RUL consolidation. Of note, he travelled to
___ for 3 weeks in ___ without any healthy symptoms
there.
Past Medical History:
CAD
HLD
HTN
Hypothyroidism
DMII
Depression
Diverticulosis
Social History:
___
Family History:
Non-contributory
Physical Exam:
====================
ADMISSION PHYSICAL EXAM
====================
Vital Signs: 100.0 126/73 103 18 94 RA
General: Alert, oriented, no acute distress
HEENT: Pupils asymmetric, R approx. 4mm, L 3mm, equally
reactive
CV: tachycardic, S1, S2, no murmurs
Lungs: R crackles at base, L lung clear
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: slight dysmetria to FNF b/l, muscle strength ___ all
extremities,
====================
ADMISSION PHYSICAL EXAM
====================
Vital Signs: Tmax 98.8, 101-116/58-74, 73-86, 18, 97% RA
General: Alert and oriented, no acute distress
HEENT: Pupils asymmetric, R approx. 4mm, L 3mm, equally reactive
CV: RRR, normal S1, S2, no murmurs
Lungs: R crackles at base, L lung clear
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Muscle strength ___ all extremities,
Pertinent Results:
=====================
LABS
=====================
ADMISSION
=====================
___ 11:31PM BLOOD WBC-13.1* RBC-4.08* Hgb-12.6* Hct-37.3*
MCV-91 MCH-30.9 MCHC-33.8 RDW-12.7 RDWSD-42.4 Plt ___
___ 11:31PM BLOOD Neuts-85.5* Lymphs-8.4* Monos-5.1
Eos-0.0* Baso-0.2 Im ___ AbsNeut-11.24* AbsLymp-1.10*
AbsMono-0.67 AbsEos-0.00* AbsBaso-0.02
___ 11:31PM BLOOD ___ PTT-29.8 ___
HOSPITALIZATION
=====================
___ 03:45PM BLOOD WBC-9.7 Lymph-12* Abs ___ CD3%-69
Abs CD3-803 CD4%-54 Abs CD4-627 CD8%-16 Abs CD8-189*
CD4/CD8-3.32*
___ 03:45PM BLOOD ANCA-NEGATIVE B
___ 09:35AM BLOOD HIV Ab-Negative
DISCHARGE
=====================
___ 07:50AM BLOOD Glucose-138* UreaN-18 Creat-0.8 Na-134
K-4.5 Cl-95* HCO3-28 AnGap-16
___ 07:50AM BLOOD WBC-5.8 RBC-3.85* Hgb-12.0* Hct-35.6*
MCV-93 MCH-31.2 MCHC-33.7 RDW-13.2 RDWSD-44.7 Plt ___
=====================
IMAGING
=====================
MRI BRAIN ___:
1. No concerning enhancing lesions identified. No evidence of
an intracranial
abscess.
2. Chronic microangiopathy. Global atrophy.
Brief Hospital Course:
Key Information for Outpatient ___ with CAD, DM2,
HTN, HLD, Hypothyroidism, presents with 5 days of fever,
malaise, mild confusion, originally transferred from OSH as CT
Head was read as having ring enhancing lesions concerning for
intracranial abscess. On transfer patient was seen by neuro
surgery, who recommended getting a brain MRI to better
characterize the lesions. Brain MRI here showed no lesions and
re-read of OSH Head CT was unremarkable. CXR, however, was
notable for RUL consolidation and patient was started on empiric
antibiotics which were narrowed to Levofloxacin on ___ when the
urine legionella antigen came back positive. Patient improved
over the next day and remained afebrile. He was discharged with
PCP follow up.
TRANSITIONAL ISSUE:
- 14-day course of levofloxacin
- Recommend cognitive evaluation
- Please follow up pending work up (toxoplasma, histoplasma,
strep pneumo antigen, and cysticercus)
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY
Your last dose will be on ___ for a total of 14 days of
antibiotic treatment
RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*11
Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- RUL legionella pneumonia
- Hyponatremia
Secondary:
- Diabetes mellitus type II
- Hypertension
- Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital because you had several days of fever,
tiredness, and headaches. At the other hospital in ___,
there was some concern on the head pictures (CAT scan) that you
might have an infection in your brain, so you were transferred
to ___ for consultation with
the brain surgeons. They recommended that you have another
picture (MRI) of your brain, which showed that you did NOT have
an infection in your brain. A picture of your lungs (chest
x-ray) however did show that you have a lung infection
(pneumonia), which was treated with an antibiotic, levoquin. You
will need to take this medication for the next ___ days for a
total course of 14 days. Your last dose will be on ___.
Please follow up with your primary care doctor ___ below for
appointment) to ensure that the pneumonia has resolved.
We wish you all the best!
-Your ___ Care Team
Followup Instructions:
___
|
10798756-DS-18
| 10,798,756 | 29,002,696 |
DS
| 18 |
2125-10-05 00:00:00
|
2125-10-05 15:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
prednisone
Attending: ___.
Chief Complaint:
CC: headache
Major ___ or Invasive Procedure:
LP with fluoroscopic guidance on ___
History of Present Illness:
HPI:
___ yo F with severe O2 dependent COPD who presents with concern
for meningitis. Pt with global headache x 2 weeks. She reports
photophobia associated with headache. Also endorses neck
stiffness over the past few days. Pt also reported diplopia with
lateral gaze towards both directions. She saw her PCP today who
recommended that she go to the ED for evaluation given concern
for meningitis.
Pt sent to ___ where she had a CT head without evidence
of hemorrhage, an LP performed with opening pressure of 10 mmHg,
WBC of 32 (3 N, ___, Glucose 99, Protein >600. Case was
discussed with neurology who recommended transfer to ___ for
further workup. Pt started on acyclovir on transfer. Pt seen by
neurology in ___ ED and felt to have likely viral meningitis.
Less likely encephaligits. Acyclovir recommended to continue
until viral testing at ___ was resulted.
On arrival to the floor, pt with continued headache, neck
stiffness. Denies fevers or chills. Lives with husband, daughter
in law and 2 grandchildren aged ___ and ___. No one has been sick
at
home. No recent travel. No recent immune suppression or steroid
use.
ROS: As above. Denies lightheadedness, dizziness, sore throat,
sinus congestion, chest pain, heart palpitations, shortness of
breath, cough, nausea, vomiting, diarrhea, constipation, urinary
symptoms, muscle or joint pains, focal numbness or tingling,
skin
rash. The remainder of the ROS was negative.
Past Medical History:
h/o Chiari malformation per pt
COPD on 2L NC at home
Asthma
hyperlipidemia
OSA
GERD
HTN
Social History:
___
Family History:
FAMILY HISTORY:
No family history of neurological illness.
Physical Exam:
ADMISSION EXAM:
VS - 98.0 129/70 96 20 92 3LNC
GEN - NAD, lying in bed
HEENT - no sinus tenderness, EOMI
NECK - mild rigidity w/ pain with flexion and turning left/right
CV - rrr, no r/m/g
RESP - clear bl
ABD - soft, nt/nd, +bs
EXT - no edema
SKIN - no rashes
NEURO - alert and oriented x 3, no focal deficits
PSYCH - calm
Pertinent Results:
___ 01:11AM BLOOD WBC-9.0 RBC-4.35 Hgb-14.0 Hct-41.2 MCV-95
MCH-32.2* MCHC-34.0 RDW-12.4 RDWSD-43.0 Plt ___
___ 06:18AM BLOOD WBC-6.1 RBC-3.92 Hgb-12.3 Hct-37.3 MCV-95
MCH-31.4 MCHC-33.0 RDW-12.7 RDWSD-44.2 Plt ___
___ 01:11AM BLOOD Neuts-61.6 ___ Monos-8.6 Eos-2.1
Baso-0.6 Im ___ AbsNeut-5.54 AbsLymp-2.40 AbsMono-0.77
AbsEos-0.19 AbsBaso-0.05
___ 05:45AM BLOOD ___ PTT-30.8 ___
___ 01:11AM BLOOD Glucose-109* UreaN-13 Creat-0.6 Na-141
K-4.2 Cl-101 HCO3-27 AnGap-13
___ 06:30AM BLOOD Glucose-102* UreaN-15 Creat-1.2* Na-144
K-5.9* Cl-102 HCO3-33* AnGap-9*
___ 06:18AM BLOOD Glucose-90 UreaN-16 Creat-0.8 Na-143
K-4.6 Cl-100 HCO3-31 AnGap-12
___ 06:18AM BLOOD LD(LDH)-261*
___ 06:18AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.0
___ 06:30AM BLOOD TSH-16*
___ 06:18AM BLOOD CRP-18.2*
___ 06:18
SED RATE
Test Result Reference
Range/Units
SED RATE BY MODIFIED 53 H < OR = 30 mm/h
___
THIS TEST WAS PERFORMED AT:
___ ___ ___
___
___ 06:18
QUANTIFERON-TB GOLD
Test Result Reference
Range/Units
QUANTIFERON(R)-TB GOLD NEGATIVE NEGATIVE
Negative test result. M. tuberculosis complex
infection unlikely.
___ 06:18
ANGIOTENSIN 1 - CONVERTING ___
Test Result Reference
Range/Units
ANGIOTENSIN-1-CONVERTING 11 ___ U/L
ENZYME
___ 08:39AM CEREBROSPINAL FLUID (CSF) TNC-5 RBC-299*
Polys-8 ___ ___ 08:39AM CEREBROSPINAL FLUID (CSF) TNC-6* RBC-795*
Polys-13 ___ ___ 08:39AM CEREBROSPINAL FLUID (CSF) TotProt-52*
Glucose-50
___ 08:39
TB - PCR
Test Result Reference
Range/Units
SOURCE: CSF
MTB COMPLEX, PCR,NON RESP NOT DETECTED
___ 8:39 am CSF;SPINAL FLUID Site: LUMBAR PUNCTURE
Source: LP TUBE # 3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take ___ weeks to grow..
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Test performed by Lateral Flow Assay.
Results should be evaluated in light of culture results
and clinical
presentation.
MR HEAD W & W/O CONTRAST Study Date of ___ 6:39 ___
IMPRESSION:
1. Diffuse pachymeningeal enhancement and slightly low position
of the
cerebellar tonsils indicates possibility of intracranial
hypotension.
Correlate with clinical history of lumbar puncture.
Inflammatory conditions or infection are less likely. With
primary differential considerations including sequela recent
lumbar puncture, intracranial hypotension and
infection/inflammation.
2. Of note, enhancement and FLAIR hyperintensity extends along
the anterior border of the internal auditory canals is due to
dural enhancement.
3. No evidence of intracranial hemorrhage or infarction.
MR ___ SCAN WITH CONTRAST Study Date of ___ 6:39 ___
IMPRESSION:
1. Partially degraded study due to motion artifact.
2. Mild dural enhancement at the foramen magnum and slightly low
position of the cerebellar tonsils to the other with the finding
seen on the brain MRI could indicate intracranial hypotension in
proper clinical settings.
3. Mild multilevel degenerative changes of the cervical spine
with
superimposed congenital shortening of the pedicles results in
mild-to-moderate canal narrowing most significant at C5-C6 where
there is mild
flattening/remodeling of the cord without definite evidence of
abnormal cord signal.
4. Patchy cord signal abnormality on STIR images is likely
artifactual
relating to volume averaging due to motion.
CT torso ___ IMPRESSION:
1. No evidence for malignancy or lymphadenopathy in the abdomen
and pelvis
2. Diverticulosis without evidence for diverticulitis.
3. Status post cholecystectomy.
Sub cm nodules are seen within the right lung. No evidence of
lymphadenopathy.
Severe centrilobular emphysema.
Brief Hospital Course:
Patient is a ___ with COPD on 2L home O2 presenting with
headache
and concern for sarcoid v. TB v. fungal meningitis and found to
have ___.
#Headache concerning for meningitis with high CSF protein:
CSF from ___ suggestive of aseptic meningitis.
Unfortunately there was not enough sample to send viral studies.
She was transferred here for further mgmt. She was admitted to
the hospitalist service where we stopped acyclovir on ___. She
had an MRI of the head and C spine on ___ which shows low CSF.
Neurology followed the patient and recommended repeat LP. LP
attempted on ___ AM was unsuccessful, so ___ did this on ___
___. The protein was mildly elevated at 52, but other studies
were largely unremarkable, though final culture of AFB and
routine culture were not finalized at the time of discharge.
Cryptococcal Ag negative as was Quant gold and ACE level. CT
torso looking for sarcoid or malignancy is negative for both
given IV contrast study only. She did have increased
inflammation markers with ESR 50 and CRP 18. Ultimately, this
was thought to be a possible mild viral encephalitis of unclear
etiology, which will take time to recover. She was given pain
management initially with Dilaudid ___ PO and Tylenol and
Flexaril. None of these was very effective, so Dilaudid was
tapered off. On the day prior to discharge, she was trialed on
Toradol (but could not continue secondary to IV burning) as well
as Topomax and Reglan. I explained that steroids would be
effective, but she was very adamantly against this since she has
had bad reactions to prednisone for lung disease in the past.
Her headache had improved on discharge but not resolved. She was
given Rx for Trazodone for insomnia (which she said also helped
her headache) as well as Topomax. She could not see ___
Neurology given she is an ___ patient, so will see a
neurologist near her in follow-up for these studies.
#Acute renal failure - resolved. Her Cr was as high as 1.4, but
resolved to 0.8
Unclear etiology. Possibly mild hypovolemia, possible
contribution of acyclovir nephrotoxicity. We initially held her
home furosemide and lisinopril but these were restarted on
discharge.
#Ear ache - this was present on ___, mild, with no trauma.
There was no abnormality seen on exam, so this may be related to
headache. She will continue meds for headache, but if not
improved, was advised to see her PCP to discuss if any
additional wok-up may be needed.
#COPD - stable -Continue oxygen supplementation with goal O2 sat
> 91%
-Albuterol PRN; Advair in place of Symbicort
#Hypothyroidism - TSH on repeat is 16 and T3 is mildly low,
consistent with mild hypothyroidiem v. euthyroid sick. She
should continue on her current dose of Synthroid and follow-up
with her PCP for recheck LFTs 2 weeks after discharge. She
continued levothyroxine 25 mcg daily.
#GERD
-Continue omeprazole
#Psych
-Continue fluoxetine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Levalbuterol Neb 1.25 mg NEB Q4H:PRN wheeze/shortness of
breath
3. Lisinopril 5 mg PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
5. FLUoxetine 60 mg PO DAILY
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Docusate Sodium 100 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY
9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
10. Levothyroxine Sodium 25 mcg PO DAILY
11. Omeprazole 40 mg PO BID
12. Acetaminophen 500 mg PO BID:PRN Pain - Mild
13. Citracal + D Slow Release (calcium carb and citrate-vitD3)
600 mg calcium- 500 unit oral DAILY
Discharge Medications:
1. Topiramate (Topamax) 50 mg PO DAILY PRN headache
RX *topiramate 50 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
2. TraZODone 25 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth nightly
Disp #*15 Tablet Refills:*0
3. Acetaminophen 500 mg PO BID:PRN Pain - Mild
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
5. Citracal + D Slow Release (calcium carb and citrate-vitD3)
600 mg calcium- 500 unit oral DAILY
6. Docusate Sodium 100 mg PO BID
7. FLUoxetine 60 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Levalbuterol Neb 1.25 mg NEB Q4H:PRN wheeze/shortness of
breath
10. Levothyroxine Sodium 25 mcg PO DAILY
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. Lisinopril 5 mg PO DAILY
13. Omeprazole 40 mg PO BID
14. Polyethylene Glycol 17 g PO DAILY
15. Symbicort (___-formoterol) 160-4.5 mcg/actuation
inhalation BID
Discharge Disposition:
Home
Discharge Diagnosis:
Probable viral encephalitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
We admitted you to the hospital for a severe headache and neck
pain. While you were here, we repeated your spinal tap to see if
you may have an infection that needs specific medicine.
Although not all of the tests were final at the time of
discharge, this headache appears to be in the setting of a viral
encephalitis, which should heal with time.
It was a pleasure to participate in your care,
Your ___ team
We wish you the best,
___ Medicine
Followup Instructions:
___
|
10798867-DS-16
| 10,798,867 | 25,737,074 |
DS
| 16 |
2170-05-13 00:00:00
|
2170-05-13 17:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Diabetic ketoacidosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with hx of HIV (last VL undetectable,
CD4 104) c/b CNS toxoplasmosis and seizures, CAD s/p stenting,
HTN, HLD, vitiligo who presents with decreased appetite,
fatigue,
weakness, polyuria/polydypsia since the beginning of ___ ___s chest pain, SOB for the last 1.5wks.
Mr. ___ was feeling well until the beginning of ___. He
said that he began experiencing polyuria and polydipsia, as well
as progressive fatigue, diffuse weakness, dec appetite, and
myalgias. He then began experiencing CP and SOB ~1.5wks ago. He
says that these sxs only occurred after walking ___ and
resolved after resting for 1min. Describes CP as midsternal,
feels like heartburn, nonradiating; also resolves after burping.
Last instance of CP was at 6AM this morning. Over the last
1.5wk,
also endorses nausea, but denies vomiting/diarrhea. Mr. ___
also noted visual hallucinations over the last 1.5wks (eg
"squirrels running around inside"). His wife notes slurred
speech. Denies any recent falls, any fevers, any travel or sick
contacts.
In the ED,
- Initial Vitals: Temp 98.0degF | HR 88 | BP 120/60 | RR 16 |
93%
___
- Exam: A&Ox3
- Labs:
CBC: WBC 3.6, HCT 39.4, PLT 240, diff: 51.5% PMNs, 31.8%
lymphocytes
BMP: Na 131 (corrected 140-144), K 5.1, Cl 93, HCO3 11, BUN 26,
Cr 1.8, AG 27, glucose 651
Ca ___, phos 4.4, Mg 2.2
Troponin <0.01
VBG: pH 7.23/pO2 30/ pCO2 36
Lactate 1.9
UA: glucose 1000, ketone 80, protein 30, trace blood. Neg
nitrites, leuks
- Microbiology: blood x2/urine cx pending
- Imaging:
CXR ___: wnl
- EKG:
___: NSR with rate 91. Nml axis. Intervals wnl. No signs c/f
current ischemia. Broad P wave in lead II c/w LAH.
- Consults: none
- Interventions: 324mg ASA, 2L NS, started insulin gtt
Past Medical History:
HIV - dx ___, had been on and off ART during course. In
___,
presented to ___ with AMS, CD4=4, VL=36,587. Found to have CNS
toxo. Started toxo tmnt, azithro MAC ppx, and restarted ART
CAD s/p stenting - Had first MI ___ ago and received 1 stent.
Had another MI ___ ago, another stent was placed
Treated TB - reports that he received a full year of treatment
for this
HTN
HLD
vitiligo
depression
Social History:
___
Family History:
patient denies any FHx of DM
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.4degF | HR 95 | BP 113/81 | RR 28 | 99% ___
GEN: tired-appearing man lying in bed.
EYES: PERRLA, EOMI.
HENNT: NCAT. Mouth very dry. No oral lesions. No thyroid
enlargement or tenderness.
CV: RRR, nml S1/S2. No m/g/r.
RESP: Nml WOB, lungs clear to auscultation b/l.
GI: Obese abdomen. Normoactive BS. No ttp.
MSK: Moving all extremities spontaneously.
SKIN: Diffuse vitiligo
NEURO: A&Ox3. CNII-XII intact. Strength U/LEs ___ throughout.
Sensation intact b/l. Reflexes 2+ throughout.
PSYCH: Depressed mood, endorsing vague SI, but no plan, and no
HI.
DISCHARGE PHYSICAL EXAM:
VS: 98.0 96/69 79 18 96 Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: 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: slightly blunted affect
Pertinent Results:
ADMISSION LABS
=====
___ 11:45AM BLOOD WBC-3.6* RBC-4.23* Hgb-12.9* Hct-39.4*
MCV-93 MCH-30.5 MCHC-32.7 RDW-15.7* RDWSD-52.9* Plt ___
___ 11:45AM BLOOD Neuts-51.5 ___ Monos-13.1*
Eos-1.1 Baso-1.1* Im ___ AbsNeut-1.85 AbsLymp-1.14*
AbsMono-0.47 AbsEos-0.04 AbsBaso-0.04
___ 11:45AM BLOOD Plt ___
___ 05:45PM BLOOD ___ PTT-22.7* ___
___ 05:45PM BLOOD WBC-3.5* Lymph-38 Abs ___ CD3%-64
Abs CD3-849 CD4%-7 Abs CD4-98* CD8%-53 Abs CD8-703*
CD4/CD8-0.14*
___ 11:45AM BLOOD Glucose-651* UreaN-26* Creat-1.8* Na-131*
K-5.1 Cl-93* HCO3-11* AnGap-27*
___ 05:45PM BLOOD ALT-8 AST-9 LD(LDH)-173 AlkPhos-115
TotBili-0.2
___ 11:45AM BLOOD cTropnT-<0.01
___ 05:45PM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:44AM BLOOD cTropnT-<0.01
___ 11:45AM BLOOD Calcium-10.4* Phos-4.4 Mg-2.2
___ 06:51PM BLOOD calTIBC-273 Ferritn-619* TRF-210
___ 05:45PM BLOOD %HbA1c-16.9* eAG-438*
___ 05:44AM BLOOD TSH-1.1
___ 12:41PM BLOOD ___ pO2-105 pCO2-31* pH-7.22*
calTCO2-13* Base XS--13 Comment-ADDED TO G
___ 07:38PM BLOOD ___ pO2-28* pCO2-43 pH-7.26*
calTCO2-20* Base XS--8
___ 01:23PM BLOOD Glucose-591* Lactate-1.9 Na-133 K-4.7
Cl-102
___ 06:25PM BLOOD Lactate-2.1*
CXR ___: No acute intrathoracic process.
NCHCT ___: Hyperdense foci in left cerebellum and within both
cerebral hemispheres are likely sequela of prior toxoplasmosis
infection. However, in absence of any prior CT, a follow-up CT
can be obtained to exclude associated hemorrhage.
TTE ___: The left atrial volume index is normal. There is mild
symmetric left ventricular hypertrophy with a normal
cavity size. There is normal regional and global left
ventricular systolic function. The visually estimated left
ventricular ejection fraction is 55-60%. There is no resting
left ventricular outflow tract gradient. Tissue
Doppler suggests a normal left ventricular filling pressure
(PCWP less than 12mmHg). Normal right ventricular
cavity size with normal free wall motion. The aortic sinus is
mildly dilated with normal ascending aorta
diameter for gender. The aortic arch is mildly dilated. 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 trivial mitral
regurgitation. The tricuspid valve leaflets appear
structurally normal. There is physiologic tricuspid
regurgitation. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with normal
cavity size and regional/global biventricular systolic function.
Mild thoracic aortic dilatation.
DISCHARGE LABS:
___ 06:55AM BLOOD WBC-3.0* RBC-3.65* Hgb-10.8* Hct-34.4*
MCV-94 MCH-29.6 MCHC-31.4* RDW-15.9* RDWSD-54.4* Plt ___
___ 05:45AM BLOOD Glucose-212* UreaN-8 Creat-1.1 Na-136
K-4.7 Cl-101 HCO3-23 AnGap-12
___ 05:45AM BLOOD Calcium-9.4 Phos-3.9 Mg-1.6
Brief Hospital Course:
Mr. ___ is a ___ with hx of HIV (last VL undetectable, CD4
104) c/b CNS toxoplasmosis and seizures, CAD/PCI, HTN, HLD,
vitiligo, admitted with DKA and encephalopathy, thought possibly
due to new onset T1DM (from prior T2DM).
# DKA:
# History of T2DM with possible progression to T1DM
Patient admitted with polyuria/polydipsia, nausea, weakness,
fatigue, dyspnea, encephalopathy with visual hallucinations,
found to be in DKA: on admission BG 651, pH 7.22 on VBG, AG 27,
urine glucose and ketones present. He had a prior history of
T2DM, though presentation concerning for T1DM. he was initially
managed with an insulin drip, transitioned to subcutaneous when
gap closed. After transfer to the floor, he continued to have
insulin regimen titrated by the ___ diabetes service with
intent to establish care with them after discharge. Anti-GAD,
IA2, islet cell antibodies were pending at time of discharge. He
was seen by the diabetic nurse educator and was able to self
administer insulin.
# HIV
# History of toxoplasmosis: Patient previously self discontinued
HAART prior to admission. CD4 count 94, though in setting of
acute systemic illness. ART restarted in ICU and continued on
the floor. Brain imaging without evidence of new toxoplasmosis
infection or other concerning features. He was continued on
TMP/SMX.
# Possible Distal RTA: bicarb persistently low after resolution
of DKA, but eventually recovered. Urine lytes suggestive of RTA.
VBG pH 7.3, labs most suggestive of possible distal RTA.
Possibly related to HIV medications or other.
# Depression: No active SI/HI, but suggestion of passive SI with
his discontinuation of ART. Would suggest non-urgent psychiatric
evaluation.
# ___: Resolved with DKA treatment.
# HTN: Normotensive. Not on any home medications for HTN.
# HLD: Continued home atorvastatin.
TRANSITIONAL ISSUES:
[ ] ___ to contact patient at rehab to schedule follow-up. If
appointment not made, please call ___.
[ ] F/U Anti-GAD, IA2, islet cell Ab after discharge.
[ ] continue insulin / diabetes teaching and education
[ ] please schedule patient for infectious disease appointment
after discharge.
[ ] Continue ART.
[ ] would suggest repeat urine lytes and pH in a few weeks. If
persistently altered, would suggest evaluation for RTA.
[ ] consider psych evaluation after discharge.
Time spent coordinating discharge > 30 minutes
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Nicotine Patch 14 mg/day TD DAILY
2. Dolutegravir 50 mg PO DAILY
3. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Aspirin 81 mg PO DAILY
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Medications:
1. Glargine 45 Units Breakfast
Humalog 16 Units Breakfast
Humalog 16 Units Lunch
Humalog 16 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. Nicotine Patch 14 mg/day TD DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Dolutegravir 50 mg PO DAILY
6. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
7. Sulfameth/Trimethoprim DS 1 TAB PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Diabetes
DKA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for diabetic ketoacidosis. You were treated
with IV fluids and insulin. Your blood sugar improved. You will
need to continue insulin for glycemic control. ___ recommended
rehab.
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:
___
|
10799304-DS-15
| 10,799,304 | 21,292,678 |
DS
| 15 |
2130-02-23 00:00:00
|
2130-02-23 20:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
Thoracentesis
History of Present Illness:
___ with a history of previous TBI, tobacco use, and HepC who
was admitted to the neurosurgery service from OSH yesterday. He
initially presented to ___ with worsening back
pain, lower extremity weakness over the past week, with
occasional urinary/stool incontinence over the past week. He
was found to have severe T10 compression fracture with a
surrounding soft tissue densities causing severe cord
compression. There was also a T11 lesion suspicious for a
metastasis. A followup CT torso showed a diffuse metastatic
burden, with pulmonary, pleural, nodal and hepatic mets noted
with large left upper lobe perihilar mass encasing the
bronchovascular structures and obstructing the left superior
pulmonary vein. He was subsequently transferred to ___ ED
where he received 10mg IV dexamethasone and was admitted to the
neurosurgery service for consideration of decompressive surgery.
Since admission, the patient was seen by hematology oncology who
recommended continued steroids, thoracentesis, and tissue
biopsy. He was transferred to medicine for consideration of
palliative approaches to relieving impingement. IP is involved
and performed a thoracentesis. Thoracics was consulted re:
tissue acquisition.
Past Medical History:
-traumatic brain injury- from closed head injury in ___
-seizure disorder (post-traumatic)
-depression
-Hepatitis C
-alcohol abuse
-hypercholesterolemia
-Diverticulitis
-DVT
-?LUL infiltrate on ___ x ray
-Renal lesion seen on CT scan with MRI pending
Social History:
___
Family History:
hodgkins lymphoma and gallbladder cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.2 BP 98-130/60-80 HR 100-120 Sat98RA RR18
pulsus: 7mmHg checked on left arm
GEN: thin male laying comfortably flat on his back
HEENT: MMM, no cervical adenopathy, PERRL
NECK: supple without JVD appreciated
CARDS: tachycardic but regular
PULM: CTAB no RRW
ABD: lower quadrant tenderness appreciated
EXT: WWP 2+ DPPT pulses
NEURO: AAOx1 (had just recieved morphine from thoracentesis), ___
strength ___ bilaterally, sensation to light touch was symmetric
bilaterally, Gait was not test
Discharge:
Not getting vital signs
GEN Alert and oriented x2-3, NAD, thin, appears older than
stated age
HEENT Left pupil larger than right but equally reactive
PULM Decreased breath sounds with crackles at bases
CV Tachycardic, regular, normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
GU foley in place
SKIN no ulcers or lesions
Pertinent Results:
___ OPERATIVE REPORT:
PROCEDURE: T11 full laminectomy and partial facetectomy with
partial tumor resection.
DESCRIPTION OF PROCEDURE: The patient was taken to the
operating room emergently and ___, intubated, turned
in the prone position with appropriate chest bolsters.
Prepped and draped for a mid upper lumbar lower thoracic
incision. After an appropriate time-out, an incision was
made with a 10 blade. Neuro monitoring was done throughout
the case with SSEPs. MEPS were not able to be performed
because of the seizure history. Dissection was taken down
along both sides of the laminar margin using monopolar
periosteal and 2 cerebellar self-retaining retraction. The x-
ray was obtained for localization of the appropriate level
and then a ___ x-ray was obtained further into the case as a
___ 4 was placed into the T11 vertebral body space
itself. These are saved in the record. The spinous process
and lamina were removed using an Adson double-action rongeur
and a Leksell and these were sent for permanent pathology.
The thecal sac overlying the conus region and the dura was
completely intact and decompressed fully in this area as
ligamentum flavum was also removed and the high-speed drill
and Leksell and 2, 3, and 4 mm Kerrisons were used to
decompress laterally, primarily on the right, allowing
access to the anterior canal space. Soft tissues were
visible and able to be removed using a pituitary rongeur, and
nerve hook, as well as down pushing ___ curettes were
able to be used to push tissue forward and explore the
anterior space in the canal. It was appreciated on alignment
by the x-ray that bone fragments were not anteriorly
compressing this region any further because of realignment in
the positioning in the operating room. This was also
appreciated under direct vision,
looking into that area on the right side, and as well on the
left side, that there was no ongoing compression of the conus
region. The small amount of what appeared to be tumor or
disk material was able to be removed and sent for
pathological analysis separately as well. Copious irrigation
with bacitracin saline was used and hemostasis was obtained
using the bipolar or Gelfoam soaked in thrombin as needed,
and then the retractors were removed and the wound was closed
using interrupted layers of Vicryl and a running ___ nylon
suture for skin, staples for skin. Dressings were placed,
and the patient was turned carefully back in the supine
position, awakened, extubated, taken to recovery room for
further care.
___, M.D. ___
PATHOLOGY:
___
DIAGNOSIS:
Anterior T11 tissue, T11 Decompression (A):
Metastatic adenocarcinoma, moderately to poorly differentiated,
see note.
Note: Tumor cells are positive for TTF-1, CK7, ___ and
negative for CK20 consistent with lung origin.
DIAGNOSIS:
Pleural fluid (___):
POSITIVE FOR ADENOCARCINOMA. Likely of lung origin.
Tumor cells are positive for CK7 and TTF-1, but
negative for p63, CK20, Pax-2 and CDX2.
IMAGING:
OSH imaging on ___:
MRI Thoracic: Severe cord compression due to severe compression
fracture of T10 with breakthrough of the posterior cortex and
with abnormal prevertebral and anterior epidural soft tissue
which could represent either hematoma, or tumor. No cord
hemorrhage is identified with cord edema is present at this
level. Additional lesion T11 suspicious for metastasis. Large
right pleural effusion with parietal pleural soft tissue lesions
consistent with metastasis.
Chest/abdomen CT: Diffuse pulmonary, pleural, nodal and hepatic
metastases with large left upper lobe perihilar mass encasing
the bronchovascular structures and obstructing the left superior
pulmonary vein, probable left upper lobe primary bronchogenic
carcinoma, less likely but not excluded mesothelioma. Severe T10
compression fracture with surrounding soft tissue density,
probable pathologic fracture with ___
and anterior cord compression. Left renal posterior perinephric
mass which may represent an implant rather than a primary renal
malignancy. Probable intrahepatic malignant soft tissue implant.
(transcribed from CT ab/pelvis report from ___ at ___
___ emergency department) showed diffuse pulm, pleural and
hepatic mets w/ LUL perihilar mass c/w bronchogenic carcinoma
CHEST (PORTABLE AP)Study Date of ___ 6:31 ___
FINDINGS: There is a large right-sided pleural effusion. There
are multiple bilateral pulmonary masses, the largest of these
are in the left upper lobe,although there are many scattered
smaller masses. Old rib fractures are seen in the left lung.
There is hazy vasculature, predominantly on the right. There are
multiple gas-filled loops of small and large bowel.
Impression: metastatic disease.
___ CT HEAD
IMPRESSION:
Encephalomalacia of the right temporal, right frontal, and left
frontal lobes. No acute large territorial infarction or mass
effect. MRI would be more sensitive for evaluation of
metastatic disease.
___ ECHO:
Overall left ventricular systolic function is normal (LVEF>55%).
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 borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
___ CTA CHEST:
IMPRESSION:
1. New left segmental pulmonary embolism.
2. Increasing narrowing of the left main pulmonary artery, as
well as new
near-complete obliteration of the left anterior segmental
pulmonary artery, from the adjacent mediastinal mass.
3. Extensive and increasing pleural deposits, mediastinal masses
(including new extension into the right mainstem bronchus) and
pulmonary nodules consistent with metastatic disease.
4. Partial loculation of the right-sided pleural effusion as
well as
increasing left-sided pleural effusion.
5. Progressive compression of the T11 vertebral body with
adjacent soft
tissue/hematoma impressing upon the thecal sac.
6. Stable multifocal ground-glass opacities left greater than
right which are nonspecific but could be seen in aspiration or
infection.
___ CXR:
FINDINGS: In comparison with study of ___, there is probably
little overall change. Extensive effusion with volume loss and
possible pleural metastases again seen on the right. Probable
pleural metastases and healed rib fractures on the left as well.
An area of suggested increased opacification in the left upper
zone could possibly represent a superimposed consolidation.
There is an unusual appearance to the distal clavicle, which may
reflect a previous fracture with some bony resorption. The
acromioclavicular joint is essentially within normal limits.
ADMISSION LABS:
___ 12:28AM BLOOD WBC-15.8* RBC-5.04 Hgb-14.9 Hct-44.6
MCV-89 MCH-29.5 MCHC-33.3 RDW-13.6 Plt ___
___ 12:28AM BLOOD ___ PTT-34.0 ___
___ 12:28AM BLOOD Glucose-127* UreaN-11 Creat-0.7 Na-134
K-4.1 Cl-95* HCO3-29 AnGap-14
___ 07:00PM BLOOD CK(CPK)-33*
___ 10:40AM BLOOD ALT-15 AST-17 LD(LDH)-328* AlkPhos-114
TotBili-0.2
___ 07:00PM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:21AM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:45AM BLOOD CK-MB-2
___ 10:40AM BLOOD TotProt-5.4* Albumin-3.2* Globuln-2.2
Calcium-9.1 Phos-2.4* Mg-1.8 UricAcd-2.4*
___ 10:40AM BLOOD PSA-1.3
Discharge Labs:
Labs were no longer checked after patient was made CMO on
___.
MICROBIOLOGY:
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:17 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to hematology for a quantitative white blood cell
count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
___ with history of tobacco use admitted to neurosurgery on
___ with t10 pathologic compression fracture causing severe
symptomatic cord compression with CT evidence of diffuse mets of
likely lung source.
Active Issues:
# GOALS OF CARE: Patient has waxing/waning mental status
therefore brother is HCP in making decisions. Per discussion
with ICU attending/resident, palliative care team and pts
brother/HCP, it was felt that it would be futile to intubate him
with his progressive malignancy and extremely poor prognosis
with likely less than 6 months of survival. HCP feels we should
treat his pain and agrees that intubation/resusucitation given
the prognosis would be unkind. Care will focus on comfort.
Patient is being discharged to ___ facility.
# DISTANT, DIFFUSE METASTATIC LESIONS: Primary lesion was
initially unknown. Pathology was sent on both pleural fluid and
on recovered tissue from the patient's spinal surgery and both
demonstrated likely lung adenocarcinoma. Imaging shows distant
and diffuse metastasis. The problems below all stem from the
patient's metastatic lung cancer. Repeat imaging completed for
other reasons during the patient's hospitalization showed
continuing progression of disease. The patient's current
function status makes chemotherapy undesirable. Radiation
Oncology does not see a role for irradiating mediastinal tumor.
Based on overall prognosis and goals of care the patient and his
family elected hospice care.
# SEVERE T10 SPINAL CORD COMPRESSION: Radiation oncology was
consulted, and would recommend surgical decompression prior to
initiation of radiation therapy. Given these recommendations,
Neurosurgery agreed to take the patient for decompression at
T10/T11. See operative report above in results section. Support
brace has been made if the patient becomes ready for
mobilization. Pain control with oxycontin, oxycodone, IV
morphine as needed.
# PULMONARY EMBOLISM: After tachycardia increased on ___, the
patient went for CTA and pulmonary embolism was discovered, as
was progression of tumor crushing pulmonary artery. Patient
unable to undergo MRI with anesthesia given poor respiratory
statsus. In consultation with Heme/Onc, decision made to
anticoagulate patient with conservative heparin, however due to
agitation patient pulled out his IV lines and was unable to
reach therapeutic levels. After goals of care was discussed as
per above, decision was made to stop anticoagulation.
# MALIGNANT PLEURAL EFFUSION: Exudative and consistent with
malignancy. Patient has undergone two thoracenteses to drain
pleural fluid. Unfortunately, due to delirium, he removed both
of those tubes. Interventional Pulmonology was justifiably
hesistant to consider further drainage of pleural fluid, which
was continued to be monitored.
# SINUS TACHYCARDIA: Perhaps related to his cancer burden and
increased catecholamine state, as well as the left PA
compression, which worsened according to follow-up imaging of
chest. Some control has been achieved via metoprolol (HR 120s),
but patient likely needs tachycardia to provide cardiac output
in setting of tumor compressing pulmonary artery.
# HYPOXIA: Likely multifactorial. See above. Patient has
extensive tumor burden throuoghout lungs and a recurring pleural
effusion. Pulmonary embolism discovered on ___ also be
contributing. He was treated for 8 days with vanc/cefepime for
hospital acquired pneumonia, which improved lung function
somewhat, but he slowly decompensated over his hospitalization.
Transitional Issues:
-Code Status: DNR/DNI, CMO
-CONTACT: brother ___ (___) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LeVETiracetam 500 mg PO TID
2. Nortriptyline 25 mg PO HS
3. Methocarbamol 500 mg PO BID pain
4. TraMADOL (Ultram) 50 mg PO BID
Discharge Medications:
1. LeVETiracetam 500 mg PO TID
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Bisacodyl 10 mg PO DAILY
4. Clotrimazole Cream 1 Appl TP BID tinea pedis (feet)
5. Dexamethasone 2 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Gabapentin 100 mg PO BID
8. Guaifenesin-CODEINE Phosphate 5 mL PO Q4H cough
9. Lidocaine 5% Patch 1 PTCH TD DAILY
10. Metoprolol Tartrate 50 mg PO BID
11. Morphine Sulfate ___ mg IV Q2H:PRN pain, dyspnea
RX *morphine 100 mg/4 mL ___ mg Q2H Disp #*1 Vial Refills:*0
12. Ondansetron 4 mg IV Q8H:PRN NV
13. OxycoDONE Liquid ___ mg PO Q3H:PRN pain
14. Oxycodone SR (OxyconTIN) 50 mg PO Q12H
15. Polyethylene Glycol 17 g PO DAILY constipation
16. Scopolamine Patch 1 PTCH TD ONCE Duration: 1 Doses
17. Senna 1 TAB PO BID constipation
18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Lung adenocarcinoma
Pulmonary embolism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you in the hospital. You were
admitted because of severe back pain. You were found to have a
cancer pressing on the nerves of your back as well as the
vessels in your lungs. Your breathing worsened and you were also
found to have a blood clot in your lung vessel. After much
discussion with you, your brother ___, the palliative care
team, and the medical staff it was decided to focus your care on
making you comfortable.
Please take oxycontin, oxycodone, and IV morphine as needed for
pain. We also started you on a scopolamine patch and guaifensin
to help manage your secretions. You may continue to take keppra
for seizure prevention and metoprolol to prevent uncomfortable
palpitations. You may also take stools softeners to prevent
constipation which can be uncomfortable.
Followup Instructions:
___
|
10799337-DS-23
| 10,799,337 | 27,599,562 |
DS
| 23 |
2145-01-16 00:00:00
|
2145-01-19 19:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ y/o M with COPD (FEV1/FVC 79% predicted,
mild-moderate), active smoker, DM2, CAD (s/p stenting in ___
who presented with shortness of breath and cough. Sx started
after the patient visited his nephew who had a URI 6 days PTA.
No sputum production. He has associated bilateral lower rib pain
exacerbated by coughing. Started taking doxycycline at home
without relief of symptoms 5 days ago. No recent travel,
surgeries or lower extremity swelling. No fever or chills.
.
In the ED, initial VS: 98.4 96 111/65 36 97%. Given solumedrol
125mg, azithromycin 500mg PO, albuterol/ipratropium and tessalon
pearls. CXR showed No acute intrathoracic process. Ambulatory
sats were 88%. Lactate elevated at 3.9. Most recent set of
vitals: 98-93-121/72 18 96%RA.
Past Medical History:
- COPD (takes advair 100/50 2 puffs BID, ~10 exacerbations since
diagnosis ___ ago)
- DM2 (metformin)
- GERD (takes pantoprazole 80mg BID; reportedly had aspiration
event requiring hospitalization ___ ago and subsequently
increased dose, no episodes since)
* Cardiac Risk Factors: (+)Diabetes, (-)Dyslipidemia,
(-)Hypertension
* Percutaneous coronary intervention today showed anatomy as
follows:
95% stenosis of mid-LAD and 60% of distal-LAD.
Social History:
___
Family History:
Mother had ovarian cancer, several uncles with stomach cancer.
No CAD, DMII or known lung disease.
Physical Exam:
VS - GENERAL - NAD, slightly diaphoretic, appropriate
HEENT - NC/AT, PERRLA, EOMI, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - decreased I/E ratio, breath sounds distant, no wheezing,
rhonchi or crackles
HEART - distant heart sounds, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
Laboratory Results:
___ 03:06PM BLOOD WBC-11.0 RBC-4.65 Hgb-14.2 Hct-42.5
MCV-92 MCH-30.6 MCHC-33.5 RDW-12.9 Plt ___
___ 03:06PM BLOOD Neuts-66.8 ___ Monos-4.2 Eos-4.4*
Baso-0.8
___ 03:06PM BLOOD Glucose-154* UreaN-16 Creat-0.8 Na-137
K-4.9 Cl-102 HCO3-26 AnGap-14
___ 04:30AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.2
___ 05:52PM BLOOD ___ pO2-41* pCO2-52* pH-7.32*
calTCO2-28 Base XS-0 Comment-GREEN TOP
___ 03:18PM BLOOD Lactate-3.9* K-4.7
Studies:
.
CXR - FRONTAL CHEST RADIOGRAPH: The heart size is normal. The
hilar and
mediastinal contours are within normal limits. There is no
pneumothorax,
focal consolidation, or pleural effusion. No bony abnormalities
are detected.
IMPRESSION: No acute intrathoracic process.
Brief Hospital Course:
Mr. ___ is a ___ yyear old gentleman with COPD, DM2 and CAD
who presented on ___ with a COPD exacerbation.
.
#. COPD exacerbation: The patient developed sore throat and
subsequent cough/SOB after an encounter with a family member who
had a URI. In the emergency department the patient was given
solumedrol 125mg, azithromycin 500mg PO, albuterol/ipratropium
and tessalon pearls. A CXR showed no acute intrathoracic
process. Ambulatory sats were 88%. The patient was admitted to
the medicine floor where he was continued on azithro, steroids,
and nebulizer therapy. The patient was noted to have a severe
cough, especially at night, although was otherwise improving.
Given Tesslon pearls and Guaifenesin-codeine with some
improvement in cough. On HOD #2 the patient was ready for
discharge with plans to complete a 5 day course of azihro and a
5 day course of prednisone as an outpatient. Also given a short
course of opiates to be used at night to help reduce cough.
.
#. CAD: The patient has a history of CAD with 95% stenosis of
mid-LAD and 60% of distal-LAD, s/p 2 overlapping stents ___.
In house the patient's ECG was without ST/T changes and he had
no active chest pain. Continued on home aspirin, rosuvastatin,
lisinopril, plavix. Is not on a BBlocker which could be
considered as an outpatient, unless his reactive airways disease
is sensitive to beta-blockade. This can be discussed with his
PCP at ___.
.
#. DM2: The patient's DMII was poorly controlled in house most
likely due to steroid administration. BSs measured between
300-400. Was maintained on a sliding scale and metformin held.
Discharged with script for short acting insulin on a sliding
scale to be used while on prednisone. Pt is comfortable with
this plan, as he already checks his blood sugars 4 times daily,
and his girlfriend is insulin dependent and he helps her with
her insulin injections.
.
#. Smoking Cessation - The patient was continued on Chantix in
house. He has recently reduced his smoking from 5ppd to ___
ppd. Counseled on continued tapering of his smoking.
.
#. GERD: Continued pantoprazole
.
Transitional Issues:
1) Not on Spiriva. Per HCP notes this is due to HA on spiriva.
Patient given ipratropium in house without adverse effect. ___
want to retry spiriva.
2) Not on BBlocker for CAD. ___ want to consider as o/p, unless
the reactive airway disease component of his lung pathology is
too sensitive to beta-blockade.
Medications on Admission:
CLOPIDOGREL 75 mg daily
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg BID
GLYBURIDE - 2.5 mg daily
LISINOPRIL - 10 mg daily
METFORMIN - 1,000 mg BID
NITROGLYCERIN - 0.4 mg PRN
PANTOPRAZOLE - 40 mg BID
VARENICLINE [CHANTIX] - 1 mg dialy
ASPIRIN 81mg daily
CRESTOR 10mg qHS
Discharge Medications:
1. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days: Please continue for 2 additional days to
complete a ___isp:*2 Tablet(s)* Refills:*0*
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for SOB/wheezing.
Disp:*1 bottle* Refills:*2*
3. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. varenicline 1 mg Tablet Sig: One (1) Tablet PO daily ().
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED) for 4 days: Please refer to
provided sliding scale for home insulin coverage.
Disp:*1 Bottle* Refills:*0*
11. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
12. benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day) as needed for cough.
Disp:*30 Capsule(s)* Refills:*2*
13. oxycodone 5 mg Tablet Sig: One (1) Tablet PO at bedtime:
Take at night prior to going to sleep to help prevent cough.
Disp:*7 Tablet(s)* Refills:*0*
14. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
15. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
16. nebulizer & compressor Device Sig: One (1)
Miscellaneous With albuterol: Diagnosis: COPD.
Disp:*1 Device* Refills:*0*
17. insulin lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous QACHS for 3 days: Please refer to sliding
scale for dosing regiment.
Disp:*4 mL* Refills:*0*
18. insulin syringe,safetyneedle 0.5 mL 30 x ___ Syringe Sig:
One (1) syringe Miscellaneous QACHS for 3 days.
Disp:*15 syringes* Refills:*0*
19. oxycodone 5 mg Tablet Sig: One (1) Tablet PO at bedtime for
6 days: Do not drink, drive or operate heavy machinery while
taking this medication.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: COPD exacerbation
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 due to an exacerbation of your chronic
obstructive lung disease (COPD). In the hospital you were
treated with steroids and antibiotics. Your symptoms have since
improved and you will be able to complete your treatment course
on an out-patient basis.
See below for changes to your home medication regimen:
1) Please CONTINUE Prednisone 40mg daily for 2 additional days
2) Please CONTINUE Azithromycin 250mg daily for 2 additional
days
3) Please START Oxycodone 5mg at night as needed for cough
4) Please check your blood sugar 4x daily and REFER TO insulin
sliding scale for insulin coverage
**It is very important that you continue to decrease the amount
that you smoke as this will help prevent future
hospitalizations**
See below for instructions regarding ___ care:
Followup Instructions:
___
|
10799337-DS-24
| 10,799,337 | 23,262,511 |
DS
| 24 |
2146-07-31 00:00:00
|
2146-08-05 10:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
According to the Emergency Department, the patient is a ___ with
CAD, COPD, R knee pain w/ prior arthroscopic surgery presents
with CC of dyspnea and chest tightness. He was here at ___ for
an outpt MRI, had MRI which included IV contrast and shortly
after MRI was completed felt sudden onset of dyspnea. He also
felt a sensation of tightness across his chest. He was
transferred to the ED for further evaluation.
He denies any frank chest pain. He states that he feels wheezy
like his COPD exacerbations. He does still smoke, but has cut
down to 0.5ppd. He was supposed to have a MIBI next week; since
the patient cannot walk and a MIBI cannot be done over the
weekend, he was admitted to medicine for remainder of cardiac
ruleout in midst of COPD exacerbation.
In the ED, initial vs were 0 97.3 104 146/72 24 96% 8L. The
patient's d-dimer was greater than 500, so he was sent for a
CTA, which was negative for a pulmonary embolism. He received
Duonebs, morphine, 20mg prednisone, and a nicotine patch.
Caadiac biomarkers were within normal limits. The patient had
been ordered a stress test by his PCP the day before he reported
to the Emergency Department. Vitals on Transfer: Today ___ 130/68 22 94%
On the floor patient is NAD.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies palpitations. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias. Ten point review of systems is otherwise negative.
Past Medical History:
1. Coronary artery disease with drug-eluting stent x2 to his LAD
in
___ ___s an angioplasty in ___
2. Right knee pain status post knee steroid injection with no
relief
3. COPD
4. Diabetes mellitus type 2, on insulin, uncontrolled.
5. Gastroesophageal reflux
6. Hypertension
7. Hypercholesterolemia
8. Tobacco abuse.
9. BPH
Social History:
Country of Origin: ___
Marital status: Divorced
Name of ___
___: Yes, Description: daughter-age ___
Lives with: ___
Lives in: Apartment
Work: ___
Sexual activity: Present
Sexual orientation: Female
Sexual Abuse: Denies
Domestic violence: Denies
Tobacco use: Yes, smoking cessation counseling provided
Tobacco Use Comments: recent reduction to 10 cigs/day
Alcohol use: Past
Alcohol use comments: h/o ___ drinks/setting now rarely
Recreational drugs (marijuana, heroin, crack, pills or other):
Denies
Exercise: None
Family History:
The patient's mother died of ovarian cancer at ___. several
uncles with stomach cancer. No CAD, DMII or known lung disease
Physical Exam:
ADMISSION:
Vitals: 98.5 136/81 HR 94 rr 2 satting 95% on 4L
General: Alert, oriented, no acute distress, obese
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD large neck
Lungs: Some scattered wheezes ___
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, 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: AOX3 no focal CN deficits.
DISCHARGE:
VS 97.9 128/70 87 20 100%2L
General: Alert, oriented, no acute distress, obese
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not distended, no LAD, large neck
Lungs: significantly improved expiratory wheezes bilaterally now
very subtle, distant lung sounds
CV: distant heart sounds. regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: obese, 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: Tan
Neuro: AOX3 no focal CN deficits.
Pertinent Results:
ADMISSION:
___ 12:10AM BLOOD WBC-15.4*# RBC-4.75 Hgb-14.5 Hct-43.8
MCV-92 MCH-30.6 MCHC-33.1 RDW-13.2 Plt ___
___ 12:10AM BLOOD Neuts-87.2* Lymphs-9.5* Monos-1.6*
Eos-1.1 Baso-0.6
___ 12:10AM BLOOD ___ PTT-29.5 ___
___ 12:10AM BLOOD Glucose-167* UreaN-17 Creat-0.8 Na-135
K-4.5 Cl-100 HCO3-25 AnGap-15
___ 12:10AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.8
___ 12:10AM BLOOD D-Dimer-776*
___ 10:51AM BLOOD %HbA1c-7.8* eAG-177*
TROPONINS:
___ 12:10AM BLOOD cTropnT-<0.01
___ 09:24AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-47
OTHER RELEVANT:
___ 09:24AM BLOOD WBC-9.9 RBC-4.90 Hgb-15.0 Hct-44.6 MCV-91
MCH-30.7 MCHC-33.7 RDW-13.3 Plt ___
___ 03:25PM BLOOD Glucose-309* UreaN-20 Creat-0.8 Na-130*
K-4.7 Cl-98 HCO3-24 AnGap-13
___ 03:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 12:11PM URINE Hours-RANDOM Creat-146 Albumin-1.0
Alb/Cre-6.8
DISCHARGE:
___ 05:20AM BLOOD Glucose-80 UreaN-15 Creat-0.6 Na-140
K-4.1 Cl-101 HCO3-30 AnGap-13
___ 05:20AM BLOOD Calcium-8.7 Phos-5.5* Mg-2.5
STUDIES:
___ CTA CHEST:
FINDINGS: The thyroid is normal and symmetric in appearance.
The aorta and major branches are patent and normal in caliber
without acute aortic pathology. The heart and pericardium are
unremarkable with multiple coronary stents noted. There is no
pathologic enlargement of mediastinal, hilar or axillary lymph
nodes with multiple prominent lymph nodes noted in the
mediastinum measuring up to 8 mm in the lower paratracheal
stations bilaterally and in the hila measuring up to 8 mm in the
right hilum. Although this study is not tailored for
subdiaphragmatic evaluation, the imaged upper abdomen is
unremarkable.
Assessment of the pulmonary arterial tree is somewhat limited
due to extensive respiratory motion and slightly limited bolus
timing without evidence of large or central pulmonary embolus.
The trachea is patent; however there is some flattening of the
mainstem bronchi bilaterally which could reflect bronchomalacia.
Minimal basal atelectasis is seen in the motion degraded lungs.
Two mm right apical (2:10), 5 mm right fissural (2:50) and 4 mm
right major fissure (2:51) nodules are unchanged. The imaged
osseous skeleton is unremarkable without suspicious lytic or
blastic bony lesion. Mild degenerative changes are noted.
IMPRESSION:
1. Slightly limited examination due to respiratory motion
without evidence of large or central pulmonary emboli.
2. Multiple pulmonary nodules are unchanged since ___ for
which no further followup is required.
3. Flattening of the mainstem bronchi; may be seen in
bronchomalacia.
___ P-MIBI:
IMPRESSION:No myocardial perfusion defect or wall motion
abnormality at the level of exercise achieved. LVEF 48%.
STRESS:
IMPRESSION: Possible Regadenoson-induced anginal symptoms with
no ischemic ST segment changes. Appropriate hemodynamic response
to the Regadenson infusion. Nuclear report sent separately
___ 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 thickness, cavity size, and
global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size is top
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. Mild to moderate
(___) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is high normal. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity sizes with preserved global biventricular systolic
function. Mild-moderate mitral regurgitation.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
___ MR RIGHT KNEE:
IMPRESSION:
1. Tear of the body of the medial meniscus, with associated
severe
degenerative disease in the medial compartment (complete loss of
articular cartilage).
2. Areas of cartilage loss in the patellofemoral, medial and
lateral
compartments.
3. Small-to-moderate-sized joint effusion with synovitis.
Brief Hospital Course:
The patient is a ___ man with a history of CAD and COPD
who is presenting with dyspnea and hypoxia most likely due to
COPD exacerbation.
ACTIVE ISSUES:
# COPD Exacerbation: Evidenced by extensive smoking history,
bilateral wheezes with decreased air movement and prolonged
expiratory phase on exam, and lack of evidence of other
convincing causes. CAD with anginal equivalent from transient
ischemia considered, though no EKG changes, troponins negative,
and pMIBI negative for inducible ischemia on ___. CHF with
increased pulmonary pressures considered and still possible,
though CXR and CTA do not reveal any notable interstitial or
pulmonary edema, no crackles on exam, also unchanged echo though
notable for mitral regurgitation. In consultation with
pulmonology, treated with optimal COPD therapy including
standing duonebs, azithromycin, and prednisone course. Slowly
improved on this regimen and by time of discharge ambulating
well without daytime requirement for O2 (see below for OSA). He
was discharged on a prednisone taper, home nebulizer with
ipratropium (did not tolerate tiotropium) and albuterol, and
guaifenesin, and counseled on critical importance of smoking
cessation, provided with nicotine replacement.
# DIABETES MELLITUS: The patient is insulin-dependent. In the
setting of steroids, his blood sugar has been more elevated
requiring extra doses of humalog and increase in home glargine.
Discharged on his home regimen given the tapering dose of
prednisone.
# Mitral regurgitation: No evidence of acute congestive heart
failure, though it is possible that the MR is contributing to
increase pulmonary pressures and contributing to delay in
symptomatic improvement. Increased his lisinopril from 10 to
20mg to optimize afterload reduction.
# Knee pain: Musculoskeletal, without any exam evidence of
erythema, asymmetric warmth, fevers, chills, or other concerns
for infectious etiology. History of steroid injection with no
relief in the past. Discharged on tylenol and short course of
oxycodone.
# OSA: No prior sleep study, however frequent overnight
desaturations to mid-low ___ required overnight O2 therapy. He
will need an outpatient sleep study to further evaluate. In the
mean time, he was set up with home oxygen therapy, 2L to be used
nocturnally.
# TOBACCO ABUSE: Counseled daily on cessation therapy and its
importance for his long-term prognosis. Nicotine patch and prn
lozenges provided while hospitalized, discharged with this
regimen as well.
CHRONIC ISSUES:
# CAD: Continued home aspirin, Plavix, and atorvastatin
# BPH: Continued home tamsulosin.
# GERD: Continued home pantoprazole therapy.
TRANSITIONAL:
- outpatient pulmonology follow-up recommended
- started nocturnal home O2 2L
- will need outpatient sleep study
- recommend outpatient ___ rehab
- further outpatient management for MSK knee pain
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath or
wheezing
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath or wheezing
3. Atorvastatin 40 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. GlyBURIDE 2.5 mg PO DAILY
8. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. Lisinopril 10 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. nebulizer & compressor *NF* use every ___ hours as needed
Miscellaneous q4-6h
12. Nitroglycerin SL 0.4 mg SL PRN chest pain
13. Pantoprazole 40 mg PO Q12H
14. Tamsulosin 0.8 mg PO HS
15. vardenafil *NF* 20 mg Oral as needed
16. Aspirin 81 mg PO DAILY
17. Cetirizine *NF* 10 mg Oral daily
Discharge Medications:
1. Oxygen
2 Liters Oxygen by nasal cannula for nocturnal use. Please
evaluate for concentrator if able. Patient will follow-up with:
Name: ___ MD
Location: HEALTHCARE ASSOCIATES
___
Address: ___, ___
Phone: ___
Fax: ___
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath or wheezing
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. Pantoprazole 40 mg PO Q12H
11. Tamsulosin 0.8 mg PO HS
12. Acetaminophen 1000 mg PO Q8H
13. Bisacodyl 10 mg PO DAILY
14. Bisacodyl ___AILY:PRN constipation
15. Docusate Sodium 100 mg PO BID
16. Guaifenesin ER 1200 mg PO Q12H
RX *guaifenesin 600 mg 2 tablet extended release(s) by mouth
twice daily Disp #*28 Tablet Refills:*0
17. Ipratropium Bromide Neb 1 NEB IH Q6H
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 NEB INHALED Every
6 hours Disp #*30 Vial Refills:*0
18. Nicotine Lozenge 2 mg PO Q2H:PRN nicotine craving
RX *nicotine (polacrilex) 2 mg 1 Lozenge every 2 hours Disp #*30
Gum Refills:*2
19. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour (28)-14 mg/24 hour (14)-7 mg/24 hour
(14) Apply patch daily to complete nicotine patch taper Disp #*1
Box Refills:*0
20. OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN knee pain
RX *oxycodone 10 mg 1 tablet(s) by mouth Every 4 hours Disp #*15
Tablet Refills:*0
21. Polyethylene Glycol 17 g PO DAILY
22. PredniSONE 30 mg po daily Duration: 3 Days
RX *prednisone 10 mg 3 tablet(s) by mouth daily Disp #*9 Tablet
Refills:*0
23. PredniSONE 20 mg po daily Duration: 3 Days Start: After 30
mg tapered dose.
RX *prednisone 10 mg 2 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
24. PredniSONE 10 mg po daily Duration: 3 Days Start: After 20
mg tapered dose.
RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
25. Senna 1 TAB PO BID
26. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath or
wheezing
27. Cetirizine *NF* 10 mg Oral daily
28. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
29. GlyBURIDE 2.5 mg PO DAILY
30. MetFORMIN (Glucophage) 1000 mg PO BID
31. vardenafil *NF* 20 mg Oral as needed
32. Ipratropium Bromide MDI 2 PUFF IH Q6H
RX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 2 PUFFS
INHALED Every 6 hours Disp #*1 Inhaler Refills:*2
33. Nebulizer
Nebulizer and compressor. Please dispense portable nebulizer for
patient. Diagnosis: COPD (ICD-9: 496.0).
PCP ___ ___
Location: HEALTHCARE ASSOCIATES
___
Address: ___, ___
Phone: ___
Fax: ___
34. Outpatient Pulmonary Rehab
Diagnosis: COPD
Outpatient provider (pulmonology): DRS ___
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
COPD exacerbation
SECONDARY DIAGNOSIS:
Probable Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your hospitalization.
You were admitted on ___ after developing worsening shortness
of breath. You underwent an extensive evaluation including
physical exams, lab tests, imaging tests, and a heart stress
test. Based on these results, your symptoms are most likely due
to your lung disease called COPD.
You were seen by the Lung specialists and are being treated with
a course of steroids, antibiotics, and breathing treatments to
help open up your airways.
You also had low oxygen levels mostly while you are sleeping at
night. This is probably due to a condition called Obstructive
Sleep Apnea. You need to have a Sleep Study done as an
outpatient, but in the mean time you will be given Oxygen to use
each night.
The most important action you can take to improve your lung
health and breathing along with helping to prevent other serious
medical problems is to STOP SMOKING. This is critical for your
health.
Please be sure to follow-up at the appointments listed below.
We wish you the best of luck!
Followup Instructions:
___
|
10799337-DS-26
| 10,799,337 | 25,535,022 |
DS
| 26 |
2152-02-08 00:00:00
|
2152-02-08 16:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Jardiance / Invokana
Attending: ___.
Chief Complaint:
Dyspnea and chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with past medical history
significant for CAD s/p ___ 3 (2 to LAD in ___, 1 to first
diag in ___, IDDM, and COPD who presents to the emergency
department with dyspnea and chest pain.
He was in his usual state of health until 10 days ago when he
developed dyspnea and chest pain that is substernal
pressure-like and radiates to the back.
Patient states it became acutely worse last night and he is
unable to get up or move around secondary to the pain and
shortness of breath. Patient is been treating himself with nitro
with improvement as well as with inhalers with some improvement.
In the ED, initial vitals:
- Exam notable for: No positive pertinents. Negative pertinents
include. Normal S1, S2, regular rate and rhythm, no
murmurs/rubs/gallops, 2+ peripheral pulses bilaterally
Pulmonary: Clear to auscultation bilaterally
- Labs notable for:
BNP 58
Chem panel- unremarkable other than elevated glucose 313
Trop < 0.01 x 2
CBC unremarkable
VBG: with pH 7.45, pCO2 43, lactate 2.8
- Imaging notable for:
CTA C/A/P ___
1. No evidence of acute aortic abnormality or pulmonary filling
defect.
2. No acute process in the abdomen or pelvis.
3. Moderate centrilobular emphysematous changes. No evidence of
pneumonia.
CXR ___
No acute cardiopulmonary process.
- Pt given:
0.4mg SL nitroglycerin
IV methylprednisolone 60mg
Insulin lispro 12U
- Vitals prior to transfer:
HR 90 BP 149/74 RR 18 O2 Sat 96% RA
On the floor, patient reports continued discomfort. He describes
stabbing chest pain in the left front of his chest and in his
back which has been ongoing for one month. He reports this pain
is very similar to the pain he felt in the past when he had
stents placed. His partner ___ cautions that despite
normal troponin in the past as well as normal EKG, he was still
found to have intervenable lesions in his heart. Per Dr.
___ note, most recent catheterization on ___
was done because of recurrent chest pain which showed that the
LAD stent was patent, but there was a new 90% stenosis in a
small inferior sub-branch of the first obtuse marginal branch,
which was not large enough for coronary intervention. His chest
pain seems to be improved with nitroglycerin but he is now
taking the nitroglycerin ___ times per day to alleviate the
chest pressure (and he has been doing this for one month).
Together, they report that he has had progressive weakness over
the last month with chest discomfort. He works in ___
but has been unable to work for several weeks. His dyspnea and
fatigue on exertion have progressed to the point where he cannot
run errands or leave the house. He is able to walk to the
bathroom and can walk around the house. He does not use any kind
of walking aid.
He does not weigh himself but on admission here, his weight is
about 20 pounds higher than he expected (he was 270 pounds one
year ago and now ___, beforehand he was 282 on ___. On review of his OMR weights, though, it does seem that
his weight is around 270-290 over the last few years. He has
noticed increased swelling in his legs. He sleeps with one
pillow on his side and is generally able to lay flat. He does
report some paroxysmal nocturnal dyspnea. He has a significant
history of smoking (5 packs per day from ___ to ___ but has
since quit smoking. He does not use oxygen at home. He has been
using his nebulizer regularly at home every 6 hours and reports
good compliance.
Of note, overnight his sugars are very elevated and he is very
thirsty, drinking a lot of water.
Past Medical History:
COPD not on home oxygen
CAD with drug-eluting stent x2 to his LAD in ___ ___s
an angioplasty in ___
Type 2 diabetes on insulin, complicated by neuropathy
Hypertension
BPH
ED
OSA
Colonic adenoma
GERD
Hand arthritis
Right knee pain status post knee steroid injection with no
relief
H/O VARICOSE VEINS
H/O TOBACCO ABUSE
H/O STOMACH ULCER
Social History:
___
Family History:
The patient's mother died of ovarian cancer at
___. several ucles with stomach cancer. No CAD, DMII or known
lung
disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 98.4 BP 135 / 62 HR 104 RR 18 O2 Sat 92 Ra
General: Alert, oriented, no acute distress
HEENT: MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not
elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Lungs: Clear to auscultation bilaterally, no wheezes or crackles
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
Ext: Warm, well perfused, mild edema in lower extremities
bilaterally but non-pitting
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, moves all extremities with purpose
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 1341)
Temp: 98.3 (Tm 98.5), BP: 135/56 (101-135/56-77), HR: 85
(81-116), RR: 18 (___), O2 sat: 91% (91-95), O2 delivery: 1.5L
(1L-1.5L), Wt: 293.65 lb/133.2 kg
General: Alert, oriented, no acute distress
HEENT: MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not
elevated
CV: distant heart sounds Regular rate and rhythm, normal S1 +
S2,
no murmurs
Lungs: reduced air movement. No wheeze. No crackles
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
Ext: Warm, well perfused, mild edema in lower extremities
bilaterally but non-pitting. Decreased hair on ___ from mid shins
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, moves all extremities with purpose
Pertinent Results:
ADMISSION LABS:
___ 05:28PM BLOOD WBC-9.9 RBC-4.77 Hgb-14.4 Hct-42.3 MCV-89
MCH-30.2 MCHC-34.0 RDW-12.9 RDWSD-41.6 Plt ___
___ 05:28PM BLOOD Neuts-65.8 ___ Monos-7.3 Eos-4.3
Baso-0.9 Im ___ AbsNeut-6.51* AbsLymp-2.10 AbsMono-0.72
AbsEos-0.43 AbsBaso-0.09*
___ 05:28PM BLOOD Glucose-313* UreaN-14 Creat-0.8 Na-135
K-4.6 Cl-96 HCO3-24 AnGap-15
___ 05:28PM BLOOD proBNP-58
___ 05:28PM BLOOD cTropnT-<0.01
___ 05:28PM BLOOD Calcium-9.2 Phos-2.8 Mg-1.9
PERTINENT LABS:
___ 08:50PM BLOOD cTropnT-<0.01
___ 07:56AM BLOOD ALT-15 AST-12 LD(LDH)-172 AlkPhos-72
TotBili-0.2
___ 07:36AM BLOOD %HbA1c-10.5* eAG-255*
___ 01:07AM BLOOD Triglyc-210* HDL-32* CHOL/HD-3.5
LDLcalc-37
___ 05:28PM BLOOD TSH-1.3
DISCHARGE LABS:
___ 07:55AM BLOOD WBC-9.3 RBC-4.55* Hgb-13.5* Hct-40.5
MCV-89 MCH-29.7 MCHC-33.3 RDW-13.2 RDWSD-42.5 Plt ___
___ 07:55AM BLOOD Glucose-264* UreaN-20 Creat-0.9 Na-137
K-4.8 Cl-99 HCO3-28 AnGap-10
___ 07:55AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.0
IMAGING/RESULTS:
CXR ___:
No acute cardiopulmonary process
CTA CHEST AND ABDOMEN ___:
1. No evidence of acute aortic abnormality or pulmonary
embolism.
2. No acute process in the abdomen or pelvis.
3. Moderate centrilobular emphysematous changes. No evidence of
pneumonia.
TTE ___:
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color Doppler. There is normal
left ventricular wall thickness with a normal cavity size. There
is normal regional and global left ventricular systolic
function. Quantitative biplane left ventricular ejection
fraction is 53 %. There is no resting left ventricular outflow
tract gradient. Tissue Doppler suggests a normal left
ventricular filling pressure (PCWP less than 12mmHg). Normal
right ventricular cavity size with normal free wall motion. The
aortic sinus diameter is normal for gender with normal ascending
aorta diameter for gender. The aortic arch diameter is normal.
The aortic valve leaflets (3) appear structurally normal. There
is no aortic valve stenosis. There is no aortic regurgitation.
The mitral valve leaflets appear structurally normal with no
mitral valve prolapse. There is trivial mitral regurgitation.
The tricuspid valve leaflets appear structurally normal. There
is physiologic tricuspid regurgitation. The pulmonary artery
systolic pressure could not be estimated. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes and regional/global biventricular systolic
function. No valvular pathology or pathologic flow identified.
Indeterminate pulmonary artery systolic pressure. Compared with
the prior TTE ___, there is no obvious change, but the
suboptimal image quality of the studies precludes definitive
comparison.
CARDIAC PERFUSION PHARM ___:
Limited evaluation secondary to motion. No new perfusion defect
compared to prior study in ___. Mild fixed inferior wall defect
secondary to attenuation, similar to prior exam from ___.
Normal wall motion. Ejection fraction at 48% is unchanged.
Brief Hospital Course:
ASSESSMENT & PLAN:
=====================
Mr. ___ is a ___ male with past medical history
significant for CAD x 4 stents (last to LAD in ___, IDDM, and
COPD who presents to the emergency department with dyspnea and
chest pain. P-MIBI during hospitalization was stable from prior.
Chest pain improved with initiation of Imdur.
ACUTE/ACTIVE PROBLEMS:
#Chest pain
#CAD
Patient presents with one month of chest tightness accompanied
by progressive dyspnea and fatigue. Trops/BNP wnl. Has been
taking SL nitro ___ daily for one month. Last cor angio was in
___, which showed a patent LAD stent was patent and 90%
stenosis of small inferior sub-branch of the first obtuse
marginal branch, which was too small for coronary intervention.
P-MIBI during hospitalization notable for mild fixed inferior
wall defect secondary to attenuation, similar to prior exam from
___. Given known non-intervenable CAD and ongoing chest pain,
patient was started on Imdur which was uptitrated to 60mg daily.
Chest pain improved on this regimen. He remained on his home
atorvastatin 40mg, lisinopril 20mg, metoprolol succinate 25mg,
and aspirin 81mg daily.
#Nocturnal hypoxemia
#OSA
#COPD
Patient presents with one month of chest tightness accompanied
by progressive dyspnea and fatigue. Initially treated for COPD
exacerbation w/ steroids for three days without change in
clinical status. Given lack of improvement, course was
discontinued early. Pt states that he is unable to tolerate his
home CPAP due severe fluctuations in flow of air. He was started
on nocturnal O2 at 2L NC while in hospitalized and will continue
on this regimen until he follows up with Dr. ___. He remained
on home advair BID, duoneb Q6h, fluticasone nasal spray. Patient
will need outpatient pulmonology follow up and repeat PFTs.
# Diabetes, Type 2, uncontrolled:
On Lantus 70U at night as well as Lispro with meals (up to 40U
daily) and metformin 1000mg BID. BGs initially poorly controlled
during hospitalization due to steroids. Steroids were d/c per
above. ___ consulted and adjusted insulin accordingly:
Glargine 30 Units Breakfast, Glargine 50 Units Bedtime, and
Humalog 13 units with meals. Patient also remained on Humalog
sliding scale. He was restarted on metformin at time of
discharge.
CHRONIC/STABLE PROBLEMS:
========================
# GERD:
Remained on home pantoprazole 40mg daily
# BPH: Well-controlled
On Tamsulosin 0.8mg daily
# Seasonal allergies: on cetirizine 10mg daily
Transitional Issues:
========================
[] Consider uptitration of Imdur pending chest pain
[] Will need further evaluation with outpatient pulmonology for
COPD and OSA
[] Discharged on nocturnal O2 until he can be evaluated for OSA
- will need adjustment to home CPAP machine settings
[] Continue uptitration of insulin as needed
[] Continue DM education
#CODE: Full code
#CONTACT: Name of health care proxy: ___
___: Girlfriend/friend
Phone number: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Cetirizine 10 mg PO DAILY
3. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL
subcutaneous TID W/MEALS
4. Glargine 70 Units Bedtime
5. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. Hydrochlorothiazide 25 mg PO DAILY
10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
11. Lisinopril 20 mg PO DAILY
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Metoprolol Succinate XL 25 mg PO DAILY
14. metroNIDAZOLE 0.75 % topical BID
15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
16. Pantoprazole 40 mg PO Q24H
17. Tamsulosin 0.8 mg PO QHS
Discharge Medications:
1. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Lidocaine 5% Patch 2 PTCH TD QPM pain
RX *lidocaine 5 % apply to chest/back daily Disp #*30 Patch
Refills:*0
3. Glargine 30 Units Breakfast
Glargine 50 Units Bedtime
Humalog 13 Units Breakfast
Humalog 13 Units Lunch
Humalog 13 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus U-100 Insulin] 100 unit/mL AS DIR
30 Units before BKFT; 50 Units before BED; Disp #*1 Vial
Refills:*0
RX *insulin lispro [Humalog U-100 Insulin] 100 unit/mL AS DIR 13
units before meals Disp #*1 Vial Refills:*0
4. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Cetirizine 10 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
11. Lisinopril 20 mg PO DAILY
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Metoprolol Succinate XL 25 mg PO DAILY
14. metroNIDAZOLE 0.75 % topical BID
15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
16. Pantoprazole 40 mg PO Q24H
17. Tamsulosin 0.8 mg PO QHS
18.Home O2
___
___
ID#: ___
Dx: ___.02
Concentrator, 999 days
For 2L NC 8 hours overnight
Overnight O2: 86 on RA
For home use
Discharge Disposition:
Home
Discharge Diagnosis:
Chest pain
COPD
OSA
Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization!
WHY WERE YOU ADMITTED?
- You were having chest pain and shortness of breath.
WHAT HAPPENED DURING YOUR HOSPITALIZATION?
- You had a test to evaluate the blood supply to your heart
which was stable from before.
- You were started on a medication to help with your chest pain.
- You insulin was adjusted due to high blood sugars.
- You were started on supplemental oxygen overnight due to low
O2. You should continue wearing 2L of O2 at night until you see
Dr. ___.
WHAT SHOULD YOU DO ONCE YOU LEAVE THE HOSPITAL?
- Pick up your new prescriptions tomorrow between 9am and 2pm.
- Continue to wear 2L of O2 at night until you can have your
CPAP adjusted.
- Continue to take all of your medications as prescribed.
- Follow up with your PCP, ___, and pulmonologist in
the next couple of weeks.
Again, it was a pleasure.
All the best,
Your ___ Team
Followup Instructions:
___
|
10799565-DS-20
| 10,799,565 | 29,668,009 |
DS
| 20 |
2159-01-18 00:00:00
|
2159-01-19 14:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Arm swelling
Major Surgical or Invasive Procedure:
paracentesis with drainage of 1L ascetic fluid ___
History of Present Illness:
Ms. ___ is a ___ female with a PMH notable for PBC,
portal hypertension with prior variceal banding, and Sjogren's
syndrome who presents to the ED after evaluation in clinic for
swelling of left arm and ascites.
The patient moved to ___ a few years ago
and came up to visit her family around mid ___. Prior to
coming here, she noticed having progressively worsening
abdominal swelling and weight gain (115 lbs to 127 lbs today in
clinic). She also has been getting short of breath with moderate
exertion, walking a few blocks. She recently developed left
upper arm swelling. Due to these combination of issues, she was
scheduled to see her Liver doctor, ___, on ___. In
clinic, she was referred for an upper extremity ultrasound that
showed an extensive blood clot, for which she was sent to the ED
for further evaluation.
In the ED, she had a CTA that, on preliminary read, showed
bilateral acute PE in the lateral segment of the right middle
lobe, the right lower lobe anterior basilar segment, and the
medial basilar segment of the left lobe. There was suggestion of
right heart strain with equivocal flattening of the septum.
There was also small bilateral layering effusions.
The Hepatology Service and MASCOT Service were consulted.
Hepatology recommended abdominal US with Doppler to assess new
onset ascites and diagnostic paracentesis to work up her news
ascites. MASCOT recommended no advanced intervention given the
high risk of bleeding with portal gastropathy and clinical
stability. She was started on a heparin drip in the ED. Her
vitals were within normal limits, HR ___, BP 130s/70s, O2
sat 98-100% on RA.
On arrival to the floor, patient reports feeling well with no
symptoms at rest.
Review of systems: as per HPI, otherwise negative
Past Medical History:
PAST MEDICAL HISTORY:
- Primary Biliary Cirrhosis (complicated by portal hypertension
with esophageal varices banded prophylactically, portal
gastropathy)
- Sjogren's Syndrome
- Scleroderma
- Anxiety
- Osteoporosis
- History of Pyoderma Gangrenosum
Social History:
___
Family History:
FAMILY HISTORY:
One of 11 siblings. One Brother with UC. Sister with MS. ___
with ___. Father died in ___ of a heart attack. Mother had
angina, but died of "old age."
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: T 98.3, BP 147/78, HR 91, RR 16, O2 SAT 95% on RA
General: Alert, oriented, no acute distress, wearing sunglasses
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: Diminished breath sounds bilaterally left greater than
right, bibasilar crackles, clear at the top, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, distended, bowel sounds sluggish, no
organomegaly, no rebound or guarding
GU: No Foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; lower legs appear symmetric in size
Skin: Left knee on the lateral aspect has a large circular scar
Neuro: Grossly nonfocal.
DISCHARGE PHYSICAL EXAM:
Vitals:T 98.5 BP 121/57 HR 80 RR 18 O2sat 99% RA
Gen: sitting up, well-appearing, sociable, wearing sunglasses.
HEENT: PERRLA, EOMI, no lymphadenopathy, thyromegaly, neck
supple, no palpable cords, no carotid bruit.
CV: RRR, no MGR, nl S1, mildly prominent S2 over LUSB.
Lungs: mildly decreased breath sounds isolated to R lower lung
field, notably no crackles, otherwise clear to auscultation,
equal breath sounds throughout.
Abdomen: Mild distention, mild periumbilical tenderness in
midline to 3cm above umbilicus and near paracentesis site. Faint
dullness to percussion inferior to umbilicus and laterally at
level of umbilicus, resonant above umbilicus. Paracentesis site
C/D/I, no erythema or edema.
MSK: 7 cm cord palpated LUE medially near axilla without point
tenderness. Full ROM all four extremities. L arm mildly
edematous throughout compared to R arm, notably no erythema.
Extremities: distal extremities cool/dry to touch with moderate
erythema distal to PIPs. Radial and dorsalis pedis pulses 2+
bilaterally.
Neuro: CN II-XII intact, sensation intact/equal in distal
extremities, strength ___ throughout. No facial drooping, no
slurred speech.
Pertinent Results:
ADMISSION / PERTINENT LABS:
=============================
___ 02:05PM BLOOD CK-MB-10 MB Indx-3.7 proBNP-359*
cTropnT-0.02*
___ 07:25AM BLOOD CK-MB-5 cTropnT-0.04*
___ 09:41AM BLOOD ALT-23 AST-49* LD(LDH)-386* AlkPhos-129*
TotBili-0.5
___ 07:25AM BLOOD ALT-21 AST-46* AlkPhos-125* TotBili-0.4
___ 09:41AM BLOOD WBC-4.2 RBC-3.37* Hgb-9.7* Hct-32.2*
MCV-96# MCH-28.8# MCHC-30.1* RDW-21.7* RDWSD-75.2* Plt ___
___ 07:25AM BLOOD WBC-3.5* RBC-3.26* Hgb-9.4* Hct-31.3*
MCV-96 MCH-28.8 MCHC-30.0* RDW-21.2* RDWSD-73.4* Plt ___
___ 09:41AM BLOOD ___
___ 04:45PM BLOOD ___ PTT-110.3* ___
___ 07:25AM BLOOD ___ PTT-57.6* ___
___ 08:30AM STOOL Blood-NEGATIVE
___ 07:45AM BLOOD calTIBC-387 VitB12-493 Folate-12
Ferritn-89 TRF-298 Iron-31
URINE STUDIES:
=================
___ 10:37PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 10:37PM URINE RBC-2 WBC-0 Bacteri-FEW Yeast-NONE Epi-<1
___ 10:37PM URINE Color-Straw Appear-Clear Sp ___
ASCITIC STUDIES:
================
___ 09:10AM ASCITES WBC-96* RBC-645* Polys-8* Lymphs-9*
___ Mesothe-8* Macroph-75* Other-0
___ 09:10AM ASCITES TotPro-0.9 LD(LDH)-55 Amylase-40
Albumin-0.5
MICROBIOLOGY:
================
___ 9:10 am PERITONEAL FLUID
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH. (___)
ANAEROBIC CULTURE (Preliminary): NO GROWTH. (___)
IMAGING:
===========
UE DUPLEX U/S ___:
Left upper extremity deep venous thrombosis within the left
external jugular,
subclavian, axillary, and brachial veins.
CTA CHEST ___:
1. Bilateral acute pulmonary emboli within the pulmonary
arterial branches
supplying the lateral segment of the right middle lobe, the
right lower lobe
anterior basilar segment and the medial basilar segment of left
lower lobe.
2. Equivocal flattening of the interventricular septum and mild
right
ventricular dilation raise the possibility of right heart
strain. Recommend
echocardiogram for further evaluation.
3. Small bilateral layering pleural effusions.
4. Cirrhotic hepatic morphology. Moderate ascites is partially
imaged.
5. Dilated esophagus containing air and fluid. Correlation with
any dysphagia is recommended and consider GI consultation/
endoscopy for further assessment.
BILATERAL ___ U/S ___:
Limited evaluation of the right posterior tibial veins. No
evidence of deep venous thrombosis in the right or left lower
extremity veins.
CTA ABD/PELVIS ___:
IMPRESSION:
1. Cirrhotic liver. Nonocclusive thrombus within the main,
right, and left portal veins. Moderate volume ascites.
2. Small bilateral pleural effusions, right greater than left.
3. Diffuse wall thickening of the stomach, small bowel and colon
is suggestive of portal gastropathy/enteropathy/colopathy.
ECHOCARDIOGRAM ___:
1. Cirrhotic liver. Nonocclusive thrombus within the main,
right, and left portal veins. Moderate volume ascites.
2. Small bilateral pleural effusions, right greater than left.
3. Diffuse wall thickening of the stomach, small bowel and colon
is suggestive of portal gastropathy/enteropathy/colopathy.
DISCHARGE LABS:
====================
___ 07:50AM BLOOD WBC-3.8* RBC-3.34* Hgb-9.6* Hct-32.0*
MCV-96 MCH-28.7 MCHC-30.0* RDW-21.2* RDWSD-73.4* Plt ___
___ 07:50AM BLOOD ___ PTT-33.3 ___
___ 07:50AM BLOOD Glucose-90 UreaN-8 Creat-0.6 Na-137 K-4.0
Cl-100 HCO3-24 AnGap-17
___ 07:50AM BLOOD ALT-22 AST-47* AlkPhos-126* TotBili-0.4
___ 07:50AM BLOOD Calcium-7.9* Phos-3.0 Mg-1.9
CARDIOLIPIN ANTIBODIES (IGG, IGM)
Test Result Reference
Range/Units
CARDIOLIPIN AB (IGG) <14 GPL
Value Interpretation
----- --------------
< or = 14 Negative
15 - 20 Indeterminate
21 - 80 Low to Medium Positive
>80 High Positive
Test Result Reference
Range/Units
CARDIOLIPIN AB (IGM) <12 MPL
Value Interpretation
----- --------------
< or = 12 Negative
13 - 20 Indeterminate
21 - 80 Low to Medium Positive
>80 High Positive
BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)
Test Result Reference
Range/Units
B2 GLYCOPROTEIN I (IGG)AB <9 <=20 SGU
B2 GLYCOPROTEIN I (IGM)AB <9 <=20 SMU
B2 GLYCOPROTEIN I (IGA)AB 10 <=20 ___
IGG SUBCLASSES 1,2,3,4
Test Result Reference
Range/Units
IMMUNOGLOBULIN G SUBCLASS 1 ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 2 ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 3 58 ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 4 43 ___ mg/dL
IMMUNOGLOBULIN G, SERUM ___ mg/dL
Brief Hospital Course:
Mrs. ___ was admitted to ___ from the ED where she was
referred after being seen in GI clinic with a c/o L arm
swelling. In the ED, she was found to have an extensive LUE DVT
on U/S and chest CTA revealed bilateral pulmonary emboli in the
RML, RLL, and LLL with evidence of R heart strain as well as
large volume ascites identified incidentally - a new development
for Mrs. ___.
Throughout her course, Mrs. ___ remained hemodynamically
stable and had adequate O2 saturations on room air - she did not
require supplemental O2 at any time. She remained afebrile and
was not c/f infection. To address chest CTA findings in the ED,
Mrs. ___ had an echocardiogram done on ___ which notably
showed no evidence of RV strain, though mild 1+ mitral
regurgitation and mild pulmonary artery systolic HTN was found,
the latter c/w her PEs.
Due to the unusual nature of an UE DVT being the source of her
PEs, a bilateral lower extremity U/S was ordered which was
negative, increasing suspicion of a possible new rheumatologic
or malignant cause vs a combination of her existing
rheumatologic Hx and cirrhosis as the etiology of her acute
widespread thrombosis. An abdominal U/S with Doppler on ___
revealed an obstruction in the L portal vein. Confirmatory CTA
of the abdomen and pelvis on ___ showed nonocclusive thrombi in
the L, R, and main portal veins, suggesting acute decompensation
of her cirrhosis possibly due to impaired flow through the
portal venous system.
Rheumatology and hematology were consulted and recommended a
workup for antiphospholipid Ab syndrome which was negative at
discharge, but the lupus antibody could not be drawn because of
heparin administration. Hematology further recommended genetic
testing for hypercoagulability syndromes including FVL and
prothrombin ___ and her PCP in ___ will connect
her with a hematologist in ___.
A diagnostic and therapeutic paracentesis on ___ collected 1L of
peritoneal fluid. Hematologic, chemical, and preliminary
microbiologic analyses of her ascites were consistent with
portal hypertension-related ascites and were not concerning for
SBP. Her nausea and bloating improved following paracentesis but
mild Sx returned with reaccumulation of ascites.
On the floor, she was started on a heparin drip that was
eventually titrated to 500 units to achieve a therapeutic PTT,
at which point she was transitioned to 5mg PO warfarin on ___
and ___ with a target INR between 2.5-3. On ___ her ___ rose as
expected to 2.2 and her warfarin was reduced to 3mg - her
heparin was stopped on ___ before d/c and she was sent home on
2.5mg warfarin daily with an INR of 3.1. She was given
prescriptions for outpatient labs to monitor her INR and will be
seen by the ___ on ___ for follow up of her
INR. Her PCP, ___ in ___ better in ___, will
be following her INR regularly once she returns to ___. Once
her anticoagulation regimen was titrated appropriately it was
felt that in the absence of respiratory Sx, stable ambulatory O2
sats and vitals it was safe to begin 20 mg furosemide and 50 mg
spironolactone daily beginning ___ and was d/c'd on these meds.
Her Nadolol continued to be held for now and will be restarted
at the discretion of her hepatologist.
Considering Mrs. ___ continued improved daily with respect
to her vitals, physical exam, and subjective report, and
considering adequate anticoagulation, reassuring laboratory and
imaging studies, she was felt to be adequately improved and
stable for discharge on ___.
TRANSITIONAL ISSUES:
- patient discharged on warfarin 2.5 mg daily for treatment of
DVT/PE. She will have INR monitor by hepatology while she is in
___ and management will be transitioned to her PCP in ___
when she returns. INR on day of discharge 3.1.
- Nadolol held during admission due to pulmonary embolism. Can
restart in one week when she follows up with hepatology per
their discretion.
- patient will need ongoing monitoring for new onset ascites
after discharge - Mrs. ___ is followed by a hepatologist in
___ - Dr. ___ ___.
- patient will need work up for transplant when she follows up
with hepatology in ___. MELD on discharge 19. Child ___ 9,
remains grade B on discharge.
- Please refer patient to hematology after she returns to
___ for work up of clotting disorders in the setting of
unprovoked DVT/PE.
- IgG Subclasses 1,2,3,4 and Beta-2 Glycoprotein 1 Antibodies
(IgA, IgM, IgG) normal, Cardiolipin Antibodies (IgG, IgM)
pending on discharge.
- patient with mildly elevated LFTs (ALT: 22, AST: 47, AP: 126,
Tbili: 0.4), mild stable anemia with normal iron studies, normal
B12/folate studies (9.6 & 32) and leukopenia (3.8) on discharge.
Please repeat labs at next follow up appointment.
# CODE: FULL
# CONTACT: ___ (daughter, main contact, ___, ___
___ (HCP, husband, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 7.5 mg PO DAILY
2. Nadolol 20 mg PO DAILY
3. Ursodiol 300 mg PO TID
4. AzaTHIOprine 50 mg PO DAILY
5. Venlafaxine 25 mg PO DAILY
6. Pantoprazole 40 mg PO DAILY
7. PrednisoLONE Acetate 0.12% Ophth. Susp. 2 DROP LEFT EYE DAILY
8. Denosumab (Prolia) 60 mg SC Q6MONTH
9. Vitamin D ___ UNIT PO 1X/WEEK (WE)
10. polyvinyl alcohol 1.4 % ophthalmic Q2H:PRN
11. CarafATE (sucralfate) 100 mg/mL oral TID
Discharge Medications:
1. amLODIPine 5 mg PO DAILY Raynaud syndrome
___ cause leg swelling ___ weeks after starting amlodipine.
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Spironolactone 50 mg PO DAILY
RX *spironolactone 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Warfarin 2.5 mg PO DAILY16 DVT/PE/portal vein thrombosis
Duration: 1 Dose
RX *warfarin 2.5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
RX *warfarin 1 mg 1 tablet(s) by mouth as instructed Disp #*30
Tablet Refills:*0
5. AzaTHIOprine 50 mg PO DAILY
6. CarafATE (sucralfate) 100 mg/mL oral TID
7. Denosumab (Prolia) 60 mg SC Q6MONTH
8. Pantoprazole 40 mg PO DAILY
9. polyvinyl alcohol 1.4 % ophthalmic Q2H:PRN
10. PrednisoLONE Acetate 0.12% Ophth. Susp. 2 DROP LEFT EYE
DAILY
11. PredniSONE 7.5 mg PO DAILY
12. Ursodiol 300 mg PO TID
13. Venlafaxine 25 mg PO DAILY
14. Vitamin D ___ UNIT PO 1X/WEEK (WE)
15. HELD- Nadolol 20 mg PO DAILY This medication was held. Do
not restart Nadolol until ___ follow up with your liver doctor
16.Outpatient Lab Work
Date: ___
Dx: pulmonary embolism with acute core pulmonale (I26.0)
Labs: INR, ___
Please fax results to ___, MD at ___ and
___ MD at ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- LUE DVT, b/l PE, nonocclusive thrombi in L, R, main portal
veins
- Ascites
SECONDARY DIAGNOSES:
- Primary biliary cirrhosis c/b portal HTN and esophageal
varices c/b
- Sjogren's syndrome
- Scleroderma (systemic sclerosis)
- Normocytic anemia
- Osteoporosis
- Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to ___ for
arm and abdominal swelling. ___ were found to have clots in your
lungs, left arm and small clots in your liver vessels and fluid
accumulation in your abdomen.
WHAT WAS DONE WHILE ___ WERE HERE:
- L arm Doppler ultrasound which identified a deep venous
thrombosis (DVT, a blood clot)
- Chest CT angiography which found bilateral clots in your lungs
- L and R leg Doppler U/S to look for leg DVTs, which was
negative
- Abdominal Doppler ultrasound to look for the cause of your new
abdominal fluid accumulation which found obstructed blood flow
in one liver vessel.
- CT angiogram of abdomen and pelvis which found small clots in
your liver vessels that were non-occlusive.
- Echocardiogram to assess your heart function, which was normal
- Diagnostic/therapeutic paracentesis which drained 1L of fluid
from your abdomen. Preliminary results were normal and not
concerning for infection.
- Anticoagulation with heparin and transition to warfarin
(Coumadin) to decrease the likelihood of blood clot formation.
- Iron/B12/folic acid/stool guaiac studies - all normal.
WHAT ___ NEED TO DO WHEN ___ LEAVE HERE:
- Be seen in ___ clinic at ___ the week of your
discharge to have your INR checked and have genetic testing done
for clotting disorders.
- Follow up with Dr. ___ to have your INR checked regularly
and to be connected to a hematologist in ___.
Establish a regular time schedule to check your INR with Dr.
___ return.
- Do not fly for at least 1 week after discharge! Wear
compression stockings on the plane and avoid alcohol or
sedatives before flying. Try to get up and walk around once per
hour and move your feet up and down (like pressing on the gas)
while seated.
It was a pleasure taking care of ___, we wish ___ the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10799662-DS-17
| 10,799,662 | 22,254,535 |
DS
| 17 |
2155-06-19 00:00:00
|
2155-06-19 21:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
Fiducial placement
History of Present Illness:
___ year-old female with metastatic neuroendocrine tumor (primary
location unknown) s/p 6 prior TACE procedures who presents to
the ER with nausea, vomiting, and abdominal pain. The patient
recently underwent an octreotide scan on ___ which showed,
"Improved but persistent radiotracer uptake within the liver.
Greatest degree of uptake corresponds with hepatic dome lesion
also seen on recent MRI." She Received an increased dose of
Octreotide from 40mg to 50mg q 3weeks on ___ which is used to
manage her disease. The following evening, she experienced
intense RUQ pain which radiated to the right shoulder. It was
dulled by oxycodone and not assodicated with diarrhea. She has
never had this kind of reaction with octreotide. The pain
subsided but on the morning of admission, she was nauseous and
had multiple episodes of non-bloody vomiting and dry heaves
after breakfast. There was no associated skin flushing, hot
flashes, or diarrhea. She went to the ER by which time her
symptoms were improving. She is scheduled to begin planning for
cyberknife treatment tomorrow; this is a patient of Drs.
___ and ___
Vitals in the ER: 98.6 78 140/76 16 100%.
Pt received ZOfran 4mg IV, Morphine 5mg IV, and 2L NS.
REVIEW OF SYSTEMS:
(+) Per HPI; constipation, intermittant palpitations for months
(-) Denies fever, rigors, recent weight loss or gain. Denies
headache, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure, or
weakness. Denies dysuria, arthralgias or myalgias. Denies rashes
or skin changes. All other ROS negative
Past Medical History:
Oncologic History: Patient p/w acid reflux/heartburn and RUQ
discomfort symptoms in ___. She was treated symptomatically and
EGD was negative per report. Other symptoms developed such as
flushing and tachycardia. Evaluation for transaminitase in
___ demonstrated liver masses. Biopsy showed
neuroendocrine tumor.
Despite extensive evaluation with octreotide scan and PET, no
primary site was found. She has had an excellent symptomatic
response to depot octreotide, which was initiated ___.
She continues to receive octreotide injections at 40 mg q3weeks.
For localized therapy to the liver the patient has now undergone
6 prior TACE procedures.
TACE #1 on ___ to right sided lesions with excellent
response by imaging. Her course was complicated by
nausea/vomiting, fatigue and RUQ pain.
TACE #2 on ___ to target left sided liver lesions. She
tolerated this procedure much better than the first (drug
eluting
beads were used) with no vomiting, less nausea and less acute
pain.
Tace #3 was delivered on ___ for residual disease in the
right lobe of the liver, also using drug eluting beads. In the
setting of onging transplant evaluation, a VATS procedure (by
Dr.
___ was performed on ___ to assess a 1.2 cm RUL
pulmonary nodule that was determined to be adenocarcinoma in
situ.
Tace #4 on ___ using selective right liver lobe
branches and drug eluting beads. Her post Tace course was
notable
for RUQ pain, fatigue, and wt loss.
Tace #5 on ___ which she tolerated well except for some
mild nausea.
Tace #6 on ___ that was complicated by severe RUQ pain and
nausea.
PMHx:
- Lumbar disc disease, status post L4-L5 disc surgery in ___,
disc decompression in ___
- Cervical stenosis status post dilation, D&C in ___.
- Anxiety
- Insomnia
- Last colonoscopy ___ years ago
- Mammogram ___
- Cardiac stress test ___ years ago that was unrevealing per pt
report
- Episode of spontaneous right breast secretions approximately
___
years ago, underwent testing including brain imaging at ___, was
told it was 'normal for her brain' but might cause problems
should she want to have more children
- HCV and HBV and HIV negative ___
- Lung Adenocarcinoma In Situ s/p VATS ___
Social History:
___
Family History:
Verified.
Father: Died from emphysema.
Mother: Died from emphysema.
Maternal aunt: lung cancer at age ___. Smoker.
Maternal first cousin: bilateral retinoblastoma.
2 paternal aunts with unknown cancer.
Physical Exam:
Vitals: T 97.8 bp 145/80 HR 69 RR 16 SaO2 98 RA
GEN: NAD, awake, alert
HEENT: supple neck, dry mucous membranes, no oropharyngeal
lesions
PULM: normal effort, CTAB
CV: RRR, no r/m/g/heaves
ABD: soft, NT, ND, bowel sounds present
EXT: normal perfusion
SKIN: warm, dry
NEURO: AOx3, no focal sensory or motor deficits
PSYCH: calm, cooperative
Pertinent Results:
___ 05:15PM LACTATE-1.5
___ 05:05PM GLUCOSE-120* UREA N-6 CREAT-0.5 SODIUM-134
POTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-24 ANION GAP-20
___ 05:05PM ALT(SGPT)-21 AST(SGOT)-44* ALK PHOS-260* TOT
BILI-0.7
___ 05:05PM LIPASE-25
___ 05:05PM ALBUMIN-4.6
___ 05:05PM WBC-9.0# RBC-4.56 HGB-13.2 HCT-39.7 MCV-87
MCH-28.9 MCHC-33.1 RDW-13.1
___ 05:05PM NEUTS-82.0* LYMPHS-12.9* MONOS-4.0 EOS-0.7
BASOS-0.3
___ 05:05PM ___ PTT-29.8 ___
___ 05:05PM PLT COUNT-280
___ 05:05PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___
RUQ Ultrasound:
1. Nodular heterogeneous liver with multiple masses, consistent
with the history of known metastatic neuroendocrine tumor.
Patent hepatic vasculature.
2. Contracted gallbladder with a large central stone.
3. Prominent common bile duct, which measures 9 mm, unchanged
from the prior MRI.
4. No evidence of ascites.
CXR ___: PA and lateral views of the chest provided. Chain
suture again noted in the right upper lung at the site of prior
wedge resection. The lungs are clear. No signs of pneumonia or
CHF. No pleural effusion or pneumothorax. The
cardiomediastinal silhouette is normal. The imaged osseous
structures are intact. No free air is seen below the right
hemidiaphragm.
___: US: Technically successful ultrasound -guided fiducial
seeds placement into large
left hepatic lobe mass.
Brief Hospital Course:
___ yoF with metastatic neuroendocrine tumor s/p TACE x 6, on
octreotide who presents with nausea/vomiting and abdominal pain.
# Nausea, vomiting, abdominal pain: Her symptoms of acute onset
of nausea, vomiting, and abdominal pain resolved by the time of
admission. Her diet was advanced without complication. It was
felt to perhaps be related to passage of a gallstone as she has
known cholelithiasis. LFTs, however, were at baseline and
symptoms did not recur. She also recently increased her dose of
octreotide and perhaps her symptoms were related.
# Metastatic neuroendocrine tumor of the liver: S/p TACE x6 and
currently listed for transplant. She underwent fiducial
placement during admission in preparation for Cyberknife. She
will continue outpatient octreotide.
# Low back pain with history of lumbar disc disease and s/p
laminectomy: Continued on oxycontin and oxycodone for pain
TRANSITIONAL ISSUES:
- Underwent fiducial placement while inpatient in preparation
for Cyberknife
- Urine culture pending at the time of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 300 mg PO DAILY:PRN constipation
2. Fluticasone Propionate NASAL 1 SPRY NU BID
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
4. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
5. Senna 2 TAB PO BID:PRN constipation
6. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Octreotide Acetate *NF* 50 mg INJECTION Q3 WEEKS
last dose ___
10. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Docusate Sodium 300 mg PO DAILY:PRN constipation
2. Fluticasone Propionate NASAL 1 SPRY NU BID
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
4. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
5. Polyethylene Glycol 17 g PO DAILY
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. Senna 2 TAB PO BID:PRN constipation
8. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. Octreotide Acetate *NF* 50 mg INJECTION Q3 WEEKS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Abdominal pain
Nausea with vomiting
Neuroendocrine tumor in liver, s/p TACE
Cholelithiasis
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 to the hospital due to nausea, vomiting and abdominal
pain. Your symptoms resolved on admission and the cause of your
symptoms is not entirely clear, but may be related to gallstones
or to your octreotide. You had fiducial placement while you
were in the hospital in preparation for Cyberknife.
Followup Instructions:
___
|
10799704-DS-13
| 10,799,704 | 21,821,320 |
DS
| 13 |
2132-06-29 00:00:00
|
2132-06-29 17:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Celebrex
Attending: ___.
Chief Complaint:
cough, dyspnea
Major Surgical or Invasive Procedure:
___: Bronchoalveolar Lavage with transbronchial biopsies
History of Present Illness:
Pt is a ___ yo F w/ pmh of HTN, recurrent sinusitis, chronic
occipital/cervical headaches who presented with 2 months of
nonproductive cough and one week of worsening dyspnea. Pt notes
that her cough started 2 months ago ___ ___ and she went to see
her PCP who started on cough suppressants. She improved for a
short time but continued to have the "nagging cough." She then
went back to her PCP ___ ___ but no clear etiology found. As
of the weekend prior to presentation ___ addition to her chronic
and unchanging cough she noticed that she was having increasing
SOB with exertion, having to stop to rest as she was walking her
inclined road. She also had an episode of feeling lightheaded
and "dizzy" when getting up too fast from the chair or if she
walked too fast. She also notes that she had PNA ___ times a few
years ago.
She denies having any chest pain, palpitations, no fever,
no chills, no change ___ wt, no fatigue- except for SOB. Overall
she remains very active. She then came to the ED because her
daughter was getting worried about her progressive shortness of
breath.
___ the ED she presented acutely short of breath and
"triggered" for hypoxia ___ the upper ___. Her initial vitals
were 98.2 115 170/66 28 91%. She had duoneb w/ good effect. CXR
was clear and CT-A showed no PE and no dissection. It did show
peripheral ground glass and nodular opacities with extensive
mediastinal and bilateral hilar lymphadenopathy. She was given
ceftriaxone and azithromycin. She noted that she developed a
rash prior to having the antibiotics this afternoon.
On the floor, pt sitting up ___ bed and appeared comfortable.
She was able to speak ___ full sentences. Her vitals were: ___
Family History:
No lung disease, Mother colon ___, father- stomach ___. No cardiac
hx
Physical Exam:
Physical Exam on admission:
VS: 99.1 130/75 (110's-150's/60's-90's) p 99 rr 20 97% on 2L
GENERAL: Well-appearing ___ NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: crackles bilaterally halfway up her back, no
ronchi/rales/wheezes, good air movement, resp unlabored
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: erythematous, blanchable rash on trunk and upper tigh, no
facial involvement- non-itching (improved since admission per
patient).
LYMPH: One cervical right-sided lymph node
NEURO: Awake, A&Ox3 (forgetful), CNs II-XII grossly intact,
muscle strength ___ throughout, sensation grossly intact
throughout, DTRs 2+ and symmetric
Physical Exam on discharge:
VS: Tmax 99.2 BP 117/68 (100;s-130's/50's-90's) p (80's-100's)
rr 18; 98%2L NC
GENERAL: Well-appearing ___ NAD, comfortable, appropriate.
HEENT:MMM, no elevated JVP.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: Scattered expiratory rhonchi at bilateral bases. good air
movement, resp unlabored
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: erythematous, blanchable papulomacular rash on trunk,
chest, abdomen and upper tigh, no facial involvement
LYMPH: One cervical right-sided lymph node
NEURO: Awake, A&Ox3
Pertinent Results:
Labs on admission:
___ 05:35PM BLOOD Glucose-119* UreaN-14 Creat-1.3* Na-140
K-4.2 Cl-102 HCO3-26 AnGap-16
___ 07:15AM BLOOD Glucose-109* UreaN-10 Creat-1.2* Na-141
K-4.0 Cl-103 HCO3-30 AnGap-12
___ 07:30PM BLOOD ALT-16 AST-17 LD(LDH)-212 AlkPhos-82
TotBili-0.4
___ 05:35PM BLOOD proBNP-559
___ 05:35PM BLOOD cTropnT-<0.01
___ 05:35PM BLOOD Calcium-9.1 Phos-4.2 Mg-2.2
___ 05:35PM BLOOD D-Dimer-2336*
CBC w/ diff:
___ 09:57PM BLOOD WBC-3.6* RBC-3.66* Hgb-12.0 Hct-35.5*
MCV-97 MCH-32.7* MCHC-33.8 RDW-12.7 Plt ___
___ 09:57PM BLOOD Neuts-43.0* Bands-0 Lymphs-16.6*
Monos-1.0* Eos-38.8* Baso-0.6
___ 07:15AM BLOOD WBC-7.9# RBC-3.47* Hgb-11.1* Hct-33.3*
MCV-96 MCH-32.0 MCHC-33.4 RDW-12.9 Plt ___
___ 07:15AM BLOOD Neuts-51.5 Bands-0 Lymphs-8.1* Monos-2.3
Eos-37.9* Baso-0.3
___ 07:00AM BLOOD WBC-7.9 RBC-3.59* Hgb-11.2* Hct-35.0*
MCV-98 MCH-31.2 MCHC-32.0 RDW-12.7 Plt ___
___ 07:00AM BLOOD Neuts-35.4* Bands-0 Lymphs-12.1*
Monos-2.0 Eos-49.9* Baso-0.5
___ 06:40AM BLOOD WBC-7.6 RBC-3.58* Hgb-11.4* Hct-35.1*
MCV-98 MCH-31.8 MCHC-32.4 RDW-12.6 Plt ___
___ 06:40AM BLOOD Neuts-32* Bands-1 Lymphs-6* Monos-4
Eos-55* Baso-1 Atyps-1* ___ Myelos-0
___ 06:29AM BLOOD WBC-10.7 RBC-3.88* Hgb-12.5 Hct-38.7
MCV-100* MCH-32.3* MCHC-32.4 RDW-12.9 Plt ___
___ 06:29AM BLOOD Neuts-59 Bands-0 Lymphs-2* Monos-2
Eos-36* Baso-1 ___ Myelos-0
___ 06:55AM BLOOD WBC-8.0 RBC-3.52* Hgb-11.3* Hct-34.1*
MCV-97 MCH-32.0 MCHC-33.1 RDW-12.7 Plt ___
___ 06:55AM BLOOD Neuts-66 Bands-0 Lymphs-8* Monos-3
Eos-21* Baso-2 ___ Myelos-0 NRBC-1*
___ 06:30AM BLOOD WBC-11.4* RBC-3.16* Hgb-10.1* Hct-30.9*
MCV-98 MCH-31.8 MCHC-32.6 RDW-12.9 Plt ___
___ 06:30AM BLOOD Neuts-40.7* Lymphs-12.8* Monos-1.2*
Eos-44.7* Baso-0.6
Labs on discharge:
___ 06:30AM BLOOD Glucose-106* UreaN-16 Creat-1.1 Na-137
K-3.6 Cl-102 HCO3-29 AnGap-10
___ 06:30AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.4
Rheumatologic testing:
___ 07:30PM BLOOD ESR-30*
___ 07:30PM BLOOD ANCA-NEGATIVE B
___ 07:30PM BLOOD ___
___ 07:30PM BLOOD CRP-67.2*
Microbiology:
ASPERGILLUS ANTIGEN 0.1
Fungitell (tm) Assay for (1,3)-B-D-Glucans
Results Reference Ranges
------- ----------------
<31 pg/mL Negative Less than
60 pg/mL
___ 7:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:26 am URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
BRONCHIAL LAVAGE ___
Polys 10* 0 - 0 %
PERFORMED AT ___ LAB
Lymphocytes 10* 0 - 0 %
PERFORMED AT ___ LAB
Monos 24* 0 - 0 %
PERFORMED AT ___ LAB
Eosinophils 44* 0 - 0 %
Basophils 1* 0 - 0 %
Macrophage 11* 0 - 0 %
___ 5:20 pm TISSUE EBUS TBNA LEVEL 4R.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Time Taken Not Noted ___ Date/Time: ___ 8:24 pm
BRONCHOALVEOLAR LAVAGE RIGHT LOWER LOBE BAL.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
~9000/ML Commensal Respiratory Flora.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our ___
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
Time Taken Not Noted ___ Date/Time: ___ 8:20 pm
BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
YEAST.
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: ___, FMC-7,
Kappa, Lambda, and CD antigens 2, 3, 4, 5, 7, 8, 10, 16, 19, 20,
23, 45, 56.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
B cells comprise 18% of lymphoid-gated events, are polyclonal,
and do not express aberrant antigens.
T cells comprise 80% of lymphoid gated events, express mature
lineage antigens.
INTERPRETATION
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by non-Hodgkin B-cell
lymphoma are not seen ___ specimen. Correlation with clinical
findings is recommended. Flow cytometry immunophenotyping may
not detect all lymphomas due to topography, sampling or
artifacts of sample preparation. Review of the cytospin reveals
extensive contamination with peripheral blood. Please correlate
with pending cytology report
Imaging:
CTA chest with and without contrast ___:
IMPRESSION: Multiple peripherally based ground-glass opacities,
some
demonstrating small nodular components, with associated
extensive mediastinal and bilateral hilar lymphadenopathy. These
findings suggest an interstitial lung disease with features of
non-specific interstitial pneumonitis but also possibly
organizing or eosinophilic forms of interstitial pneumonia.
Relative short-term progression of opacities on the chest
radiographs suggests an inflammatory-predominant process rather
than fibrosis, which is also suggested by predominance of ground
glass opacity. A ___xamination could be
considered to assess for stability/improvement of
lymphadenopathy and opacities noting discete nodules
Brief Hospital Course:
___ yo F w/ pmh of HTN, recurrent sinusitis, chronic
occipital/cervical headaches who presented with worsening
dyspnea and cough, found have esosinophilia with groundglass
opacities and extensive mediastinal and hilar lymphadenopathy on
CT scan.
# Cough/SOB/Pneumonitis/Eosinophilia: Pt was found on chest CT
to have bilateral ground glass opacities with multiple nodular
components and extensive mediastinal and bilateral hilar
lymphadenopathy ___ conjunction with a moderate absolute
eosinophilia. Differential diagnosis was broad and included
eosinophilic pneumonia, fungal or parasitic infections, as well
as vasculitic disroders ___ or Wegener's
granulomatosis) or less likely malignancy (lymphoma or
leukemia). Pt was stable from a respiratory standpoint with
oxygen sats ___ the high 90's on 2L NC. To further investigate
her SOB/cough, CT findings and impressive peripheral
eosinophilia, she underwent Bronch with LN and RLL biopsies on
___ by the interventional pulmonology team. Bronch cell count
again showed a eosinophilic predominance with 44% eosinophils.
After the procedure she was started on prednisone 30 mg
(increased to 60 mg daily at discharge) as well as atovaqoune
1500 mg daily for PCP ___ (given allergy to Bactrim) for
a likely diagnosis of eosinophilic pneumonia. After steroids
were started she was able to be weaned off oxygen, satting ___
the mid 90's on ambulation.
ANCA and ___ were negative, although pulm still felt that
ANCA-negative ___ was a possibility given her chronic
sinusitis. At the time of discharge her aspergillus serologies
were negative. Her flow cytometry was also NOT consistent with
lymphoma. She will follow- up ___ the ___ clinic for further
work-up.
# Rash- Patient had a diffuse erythematous blanching rash on her
trunk and proximal thighs concerning for a drug rash that
developed after she was ___ the ED. The potential etiologies for
the rash included iodine or antibiotic allergy, as well as ___
to her eosinophilia. She was maintained on benadryl,
fexofenadine, famotidine with symptomatic relief. At the time
of discharge her rash was much improved on po steroids.
Inactive Issues:
# Hypertension: Contniued losartan 25 mg daily
# GERD: continued omeprazole 20 mg daily
# Hyperlipidemia- continued simvastatin 40 mg qhs
# Anxiety: continued buspar 10 mg tid
Transitional Issues:
-Pt will have close follow-up with her PCP and pulmonary team
-At the time of discharge multiple tests were pending including
LN and RLL biopsies, cytology, strongyloides antibody and final
BAL cultures.
-Pt was instructed to not take celebrex as she is at an
increased risk of GI bleed given her steroid use
Medications on Admission:
ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth weekly Take on
empty stomach with large glass of water; remain upright >30
minutes after taking
BUSPIRONE - (Prescribed by Other Provider: psychiatric) - 10 mg
Tablet - 1 Tablet(s) by mouth three times a day
CODEINE-GUAIFENESIN - 100 mg-10 mg/5 mL Liquid - ___ tsp(s) by
mouth every 6 hours as needed for cough 250 ml
COLCHICINE [COLCRYS] - 0.6 mg Tablet - 1 Tablet(s) by mouth
twice
a day
FLUOXETINE [PROZAC] - (Prescribed by Other Provider: ___
___) - Dosage uncertain
FLUTICASONE - 50 mcg Spray, Suspension - 1 spray each nostril
twice a day intranasal
KETOCONAZOLE - 2 % Cream - apply as directed 2 x daily
LOSARTAN - 25 mg Tablet - 1 Tablet(s) by mouth daily
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth daily
TRAZODONE - (Prescribed by Other Provider: psychiatry) - 50 mg
Tablet - ___ Tablet(s) by mouth at bedtime
Medications - OTC
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth daily
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 WITH D] - (Prescribed
by Other Provider) - Dosage uncertain
LORATADINE - (Prescribed by Other Provider) - Dosage uncertain
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - 20 mg Tablet, Delayed
Release (E.C.) - 1 Tablet(s) by mouth daily
Discharge Medications:
1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
2. buspirone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. codeine-guaifenesin ___ mg/5 mL Syrup Sig: ___ MLs PO Q6H
(every 6 hours) as needed for cough.
4. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day.
5. fluoxetine Oral
6. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal BID (2 times a day).
7. ketoconazole 2 % Cream Sig: One (1) as directed Topical twice
a day.
8. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. trazodone 50 mg Tablet Sig: ___ Tablets PO HS (at bedtime)
as needed for insomnia.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. calcium carbonate-vitamin D3 Oral
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
14. loratadine Oral
15. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ml PO DAILY
(Daily) for 4 weeks.
Disp:*qs ml* Refills:*0*
16. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
Disp:*30 Capsule(s)* Refills:*0*
17. prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
18. Guaifenesin AC ___ mg/5 mL Liquid Sig: ___ ml PO every
six (6) hours as needed for cough.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Pulmonary Ground Glass Opacities
Peripheral Eosinophilia
Mediastinal and bilateral hilar lymphadenopathy
Rash
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for a cough and you were
found to have abnormal deposits ___ the lungs. Your blood counts
also showed a large number of a type of cell called eosinophils.
You underwent a bronchoscopy to help diagnose your lung
condition, and blood tests were sent to determine the cause of
your condition. You were started on steroids ___ the hospital,
and you will follow up with your lung specialists regarding your
lung function on the steroids.
You also developed a rash which may be related to your lung and
blood conditions. You will be following up with a pulmonologist
(lung specialist) and a allergy specialist who specializes ___
conditions related to eosinophils ___ the blood. You will be
discharged with oxygen that you can use at home while your lungs
recover with steroid therapy.
The following changes were made to your home medications:
- Prednisone 60 mg daily was STARTED
- Atovaquone 1500 mg daily was STARTED
- Diphenhydramine 25 mg every six hours as needed for itching
STARTED
PLEASE DO NOT TAKE ANY NON-STEROIDAL ANTI-INFLAMMATORY
MEDICATIONS (INCLUDING CELEBREX) AS YOU ARE AT AN INCREASED RISK
OF GASTROINTESTINAL BLEEDING
Followup Instructions:
___
|
10799704-DS-14
| 10,799,704 | 24,281,198 |
DS
| 14 |
2132-12-16 00:00:00
|
2132-12-19 12:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Celebrex
Attending: ___.
Chief Complaint:
several falls, concern for stroke
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old right-handed woman with h/o HTN, HL,
prior pontine infarct, and eosinophilic pneumonia, who presents
with falls, unsteady gait.
The patient has poor memory at baseline, and some information is
obtained from her daughter.
The patient reports that she fell on ___ while walking
outside in ___. She denies any warning symptoms of
dizziness, lightheadedness, unsteadiness, but suddenly she
quickly fell to the ground. States that she fell forward. She
did not lose consciousness or hit her head. She was assisted by
passers-by to her feet, and was
able to walk with her normal gait, continuing on to her
destination. She denies any associated neurologic symptoms.
The patient's daugther reports that she also fell 3 additional
times in the past week. She thinks the falls occurred on
different days, and that the last was on ___. The patient is
currently denying these falls, though she apparently described
them to others. She does not like to share information that she
feels will worry her children, or risk her own independence.
The patient is now feeling well, and her only other compliant is
blurry vision. She had trouble seeing the letters in her puzzle
while waiting in the ED, and is still having blurred vision.
She denies any double vision, slurred speech, numbness,
tingling,
focal weakness, hand clumsiness, N/V, vertigo, hearing changes.
Her daughter reports that her memory has been progressively
declining for the past ___ year or so, worse over the past ___
months. She had a set-back when she was hospitalized in ___. She
had ___ for short time after that, but is generally very
resistant to accepting help. She can handle all her ADLs, but
her
daughter's only concern is medications. She ambulates without
cane or walker. She has not gotten lost, left stove on, etc.
ROS:
(+) falls
(-) headache, loss of vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty,
difficulties producing or comprehending speech, focal weakness,
numbness, parasthesiae, bowel or bladder incontinence or
retention.
No fever, chills, night sweats, recent weight loss/gain, cough,
shortness of breath, chest pain or tightness, palpitations,
nausea, vomiting, diarrhea, constipation or abdominal pain.
Past Medical History:
-stroke ___, records indicate she had symptoms consistent with
pontine infarct but MRI was negative, fully recovered
-eosinophilic pneumonia, ___
-HTN
-HL
-depression and anxiety
-chronic neck and back pain
-recurrent sinusitis
Social History:
___
Family History:
No lung disease, Mother colon ___, father- stomach ___. No cardiac
hx
Physical Exam:
Physical Exam on Admission:
Vitals: T: 97.6 P: 75 R: 16 BP: ___ SaO2:94/RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Knows President after some
prompting. Able to relate history without difficulty.
Attentive,
able to name ___ forward without difficulty but has trouble with
backwards. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes ___ with
category
clue). There was no evidence of apraxia or neglect. Cannot
describe any current events, except knows that ___ is running
for ___.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation with red
pin.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch, cold.
VII: No facial droop, upper and lower facial musculature full
strength and symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with normal quick lateral
movements.
-Motor: Increased tone in bilateral lower extremities
symmetrically. No pronator drift bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
Intact cortical sensory modalities (graphethesia).
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 2 0
R 2+ 2+ 2+ 2 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
No overshoot or rebound on mirroring task with bilateral upper
extremities.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing
but appears to be leaning to the right, and veers off to the
right consistently. Romberg absent (sway but similar with eyes
open). Unable to walk in tandem, falls toward the right.
Physical Exam on Discharge:
afebrile, hemodynamically stable
bradykinetic finger tapping with decrement, R>L, as well as with
rapid alternating movements
intention tremor with finger to nose
gait is narrow based, slight shuffling, decreased arm swing on
R>L, + retropulsion
Pertinent Results:
Labs on Admission:
___ 04:10PM WBC-5.5 RBC-4.07* HGB-13.4 HCT-40.1 MCV-99*
MCH-33.1* MCHC-33.5 RDW-12.1
___ 04:10PM NEUTS-58.0 ___ MONOS-4.3 EOS-9.6*
BASOS-0.7
___ 04:10PM ___ PTT-51.2* ___
___ 04:10PM GLUCOSE-110* UREA N-17 CREAT-1.1 SODIUM-140
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-30 ANION GAP-13
___ 07:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-LG
___ 07:45PM URINE RBC-2 WBC-11* BACTERIA-NONE YEAST-NONE
EPI-1
Relevant Labs:
___ 05:15AM BLOOD %HbA1c-5.8 eAG-120
___ 05:15AM BLOOD Triglyc-185* HDL-70 CHOL/HD-2.7
LDLcalc-81
___ 05:15AM BLOOD TSH-3.1
Imaging:
Non contrast head CT
No acute intracranial process. Diffuse volume loss and
confluent white matter hypodensities commonly due to chronic
small vessel disease, these findings have progressed since ___
MRI head w/o contrast and MRA head/neck
1. No infarct or hemorrhage.
2. Mild atheromatous disease of the bilateral A1 segments of
the anterior
cerebral arteries and M1 segment of the right middle cerebral
artery without evidence of stenosis, aneurysm, or arteriovenous
malformation.
3. Non-visualization of the origins of the vertebral arteries,
which could be related to stenosis of either of them or could be
technical.
4. Sinus disease as described.
TTE
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Overall left ventricular systolic function is
normal (LVEF 60%). Right ventricular chamber size and free wall
motion 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. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
Brief Hospital Course:
___ year old right-handed woman with h/o HTN, HL, prior pontine
infarct, and eosinophilic pneumonia, who presents with falls,
unsteady gait.
# NEURO: On initial presentation in the ED, physical exam showed
evidence of truncal ataxia. In combination with history of
falls, there was concern for subacute small vessel infarct, with
R cerebellar, or possibly basis pontis or cerebellar peduncle
localization. Stroke risk factors were checked, HbA1c 5.8 and
LDL 81. TTE did not show thrombus or PFO. MRI brain ruled out
ischemic infarct.
On morning after admission, above findings on exam were no
longer present. Additional history included decreased
smell/taste over the last several years. In regards to falls,
no presyncopal symptoms, not falling left or right. States that
she falls forward and feels unsteady on her feet. Exam
significant for bradykinesia-- slowed finger tapping and
decrementation. Also, intention tremor on finger to nose. Gait
is narrow based with decreased arm swing. + steping on
retropulsion. Currently, her symptoms and physical exam are
suggestive of Parkinsonism. As symptoms are quite mild, did not
start Sinemet prior to discharge. She will follow up in
neurology clinic and at that time will discuss initiation of
Rasagiline for slowing progression of symtpoms. However, she
will first have to stop fluoxetine.
In terms of memory decline, there is concern for dementia
possibly related to Parkinsonism. MRI brain shows moderate
bilateral subcortical and periventricular white matter disease
that suggests she may have a component of vascular dementia.
She has been scheduled for testing with her psychiatrist this
month.
# Cardiac: No aberrant rhythms on telemetry. TTE wnl as above.
# ID: UA neg, CXR with no pneumonia
TRANSITIONS OF CARE:
- will consider Rasagiline for slowing progression of
Parkinsonian syptoms on follow up (however, will need to stop
fluoxetine first)
- will f/u in neurology clinic
Medications on Admission:
BUSPIRONE - buspirone 10 mg tablet. 1 Tablet(s) by mouth three
times a day - (Prescribed by Other Provider: psychiatric)
FLUOXETINE - fluoxetine 40 mg capsule. 1 capsule(s) by mouth
once
a day - (Prescribed by Other Provider)
FLUTICASONE - fluticasone 50 mcg/actuation Nasal Spray, Susp. 1
spray each nostril twice a day intranasal
LOSARTAN - losartan 25 mg tablet. 1 Tablet(s) by mouth daily
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1
Capsule(s) by mouth daily
PREDNISONE - prednisone 2.5 mg tablet. 3 tablet(s) by mouth
daily
SIMVASTATIN - simvastatin 40 mg tablet. 1 Tablet(s) by mouth
daily
TRAZODONE - trazodone 50 mg tablet. ___ Tablet(s) by mouth at
bedtime - (Prescribed by Other Provider: psychiatry)
TRIAMCINOLONE ACETONIDE - triamcinolone acetonide 0.1 % Topical
Cream. apply to affected areas twice a day Dispense Fougera
brand, 16 ounce container
Medications - OTC
ASPIRIN - aspirin 81 mg tablet,delayed release. 1 Tablet(s) by
mouth daily
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 WITH D] - Dosage
uncertain - (Prescribed by Other Provider)
CAMPHOR-MENTHOL [SARNA ANTI-ITCH] - Sarna Anti-Itch 0.5 %-0.5 %
Lotion. apply to affected areas of itching q 1 hour as needed
for
itching
DIPHENHYDRAMINE HCL - diphenhydramine 25 mg capsule. 1
Capsule(s)
by mouth every six (6) hours as needed for itching -
(Prescribed
by Other Provider: inpatient team)
LORATADINE - Dosage uncertain - (Prescribed by Other Provider)
Discharge Medications:
1. BusPIRone 10 mg PO TID
2. Fluoxetine 40 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Losartan Potassium 25 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. PredniSONE 7.5 mg PO DAILY
7. Simvastatin 40 mg PO DAILY
8. traZODONE ___ mg PO HS:PRN insomnia
9. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) dose
unknown Oral QD
10. Sarna Lotion 1 Appl TP QID:PRN pruritis
11. DiphenhydrAMINE 25 mg PO Q6H:PRN pruritis
12. Loratadine *NF* 10 mg Oral per home dose
13. Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
mild movement disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with frequent falls. We were
worried that you had a stroke, so we admitted you for further
work up. An MRI of your brain showed that you DID NOT have a
new stroke which is reassuring. An ultrasound of your heart was
normal.
We did find that you had some slowed movements in your hands as
well as some increased stiffness in your arms. Also, your
walking was slightly off balance. We think that these may be
early signs of a movement disorder which can be contributing to
your gait. Therefore, we would like you to follow up in
neurology outpatient clinic. Also, you should try to decrease
your intake of benadryl and loratidine as that can make you
drowsy and contribute to gait imbalance.
We have not made any changes to your medications.
It was a pleasure taking care of you, we wish you all the best!
Followup Instructions:
___
|
10800175-DS-15
| 10,800,175 | 24,112,348 |
DS
| 15 |
2175-10-28 00:00:00
|
2175-10-28 23:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Chief Complaint: Dyspnea
Reason for MICU transfer: Hypoxemia
Major Surgical or Invasive Procedure:
BiPAP
Right femoral vein central venous catheter placement
History of Present Illness:
___ year old female with a history of breast cancer s/p L breast
mastectomy ___ years ago), squamous cell carcinoma of the
larynx s/p radiation and chemotherapy ___ years ago), and COPD
on home 4L who p/w acute SOB, transferred to MICU for NIPPV and
hypotension.
Patient reports mild difficulty breathing before falling asleep
on ___ night (one day prior to admission) as compared to
her baseline. At 2AM, she woke up to use the bathroom and
recalls acute shortness of breath while walking back to bed. The
patient's daughter woke to assist her mother and found the
patient gasping for air in the bathroom, unable to speak in full
sentences. Her daughter immediately called ___. The patient does
not recall her time in the bathroom. She continued to have
labored breathing for ~10mins until EMS and her second daughter
arrived, at which time she became more interactive and began to
feel better.
The patient denies recent CP, ___ swelling, cough. No fevers,
chills, nausea, vomiting, chest pain or pressure, or LOC. No
sick contacts, recent travel or environmental changes, abdominal
pain or indigestion, diarrhea, constipation, urinary symptoms,
rashes/lesions/bruises.
In the ED, she was afebrile, tachycardic to 125, and tachypneic
to 22. Her blood pressure was 108/90. O2 Sat 97% on bipap.
Initial labs were remarkable for leukocytosis of 16.2 (86%PMNs),
Trop 0.01, and proBNP 148. UA was negative. EKG shows a sinus
tachycardia with normal or L-axis. CXR initially revealed
increased interstitial markings of pulmonary edema and
undifferentiated L-sided perihilar opacity. Subsequent CTA
showed heterogeneous spiculated mass (5.3cm) in the LLL with
multiple additional masses at the right apices and mediastinum
as well as collapse of the RLL with small pleural effusion. No
evidence of PE on CTA. The patient desaturated with
downtitration of her bipap and was ultimately transferred to the
ICU for NIPPV.
Overnight in the MICU, the patient's pressure dropped to 76/48
for which a R femoral CVL was placed and Levophed started. She
required pressors for 8 hours, which were discontinued when her
BP stabilized. The patient continued albuterol and ipratropium
nebs as well as methylprednisolone for COPD exacerbation.
Ceftriaxone and azithromycin were given out of concern for
potential pneumonia. She was weaned off bipap overnight. The
MICU team placed a femoral central line and a urethral foley,
both of which will be removed prior to transfer to the floor.
She was given crystalloid for low urine output this morning.
Follow up CXRs confirmed a lung mass, now with resolving
pulmonary edema and no evidence of consolidation.
Of note, patient reports progressive dysphagia over the past ___
years with difficulty swallowing both liquids and solids. She
has tolerated a diet of ground solids/thin liquids since then
with frequent choking. No recent changes in swallowing. As noted
above, she has a history of squamous cell carcinoma of the
larynx s/p radiation and chemotherapy in ___ for T3N0M0
___ ago). In ___, a biopsy of the right vocal cord due to
leukoplakic lesion showed keratosis with dysplasia per Atrius
records. The patient also reports a history of GERD treated with
omeprazole, which may contribute to her presentation. Lastly,
she endorses a ___ pound weight loss within the past year,
which she attributes to physical difficulty with swallowing. SLP
evaluation on ___ reveals high aspiration risk for liquids
and solids with recommendation that patient remain NPO with ice
chips.
Upon transfer to the floor, the patient is able to speak clearly
and appears alert and oriented. History is confirmed with the
patient and her two daughters.
Past Medical History:
Breast Ca s/p mastectomy
Throat Ca s/p chemo and radiation
COPD on home 4L
GERD
Thyroid Disease
Hx Singles & post-Shingles Pain
Social History:
___
Family History:
No family history of clotting disorders, hypertension, diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97.9 BP: 99/70 P: 118 R: 12 O2: 99% on BiPap
GENERAL: Alert, oriented, sharp and attempting to converse,
cachectic
HEENT: Sclera anicteric, pupils symmetric, BiPap mask on face
NECK: thin, JVP not appreciated
LUNGS: Poor air movement bilaterally, diminished breath sounds R
lower lung field
CV: Tachycardic, regular, no r/g/m
ABD: Soft NT ND +BS
EXT: Warm, well perfused, no edema
SKIN: No mottling, lesions
NEURO: Face symmetric, moving all four extremities on command
DISCHARGE PHYSICAL EXAM:
General: AOx3, thin, frail-appearing woman with 4L O2 per nasal
canula, in NAD
HEENT: NCAT, EOMI, PERRL. Sclera anicteric, conjunctiva pink.
MMM. OP clear, edentulous
Neck: Supple, no LAD
Lungs: Diminished air movement bilaterally with diffuse
crackles, increased at the right base. Prolonged expiratory
phase. No wheezing.
CV: RRR, normal S1/S2, no m/g/r
Abdomen: NABS, soft, nondistended, nontender, no HSM
GU: no foley
Ext: WWP, 2+ peripheral pulses, no edema
Neuro: AOx3. MAEE. Grossly normal strength and sensation.
Pertinent Results:
ADMISSION LABS:
___ 03:20AM BLOOD WBC-16.7* RBC-3.56* Hgb-9.8* Hct-32.5*
MCV-91 MCH-27.5 MCHC-30.2* RDW-13.2 RDWSD-43.1 Plt ___
___ 03:20AM BLOOD Neuts-86* Bands-3 Lymphs-4* Monos-3*
Eos-3 Baso-1 ___ Myelos-0 AbsNeut-14.86*
AbsLymp-0.67* AbsMono-0.50 AbsEos-0.50 AbsBaso-0.17*
___ 03:20AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear
Dr-OCCASIONAL
___ 03:20AM BLOOD Glucose-189* UreaN-21* Creat-0.8 Na-132*
K-5.6* Cl-97 HCO3-27 AnGap-14
___ 03:20AM BLOOD cTropnT-0.01
___ 03:20AM BLOOD proBNP-148
___ 03:20AM BLOOD Calcium-9.4 Phos-5.4* Mg-1.9
___ 03:31AM BLOOD ___ pO2-34* pCO2-87* pH-7.19*
calTCO2-35* Base XS-1
___ 03:31AM BLOOD Lactate-1.1 K-5.1
___ 06:01AM BLOOD O2 Sat-87
IMAGING:
___ CXR: IMPRESSION:
1. Diffusely increased interstitial markings may reflect
interstitial
pulmonary edema.
2. Left-sided perihilar opacity is incompletely evaluated on
this study, and may represent pneumonia, hilar lymphadenopathy,
or lung parenchyma lesion. CT of the chest with contrast could
be performed for further evaluation. At the time of her proving
this chest x-ray interpretation S CT at already been performed
that demonstrated a left lung mass
___ CTA CHEST: IMPRESSION:
1. No evidence of pulmonary embolism to the segmental level.
Assessment for subsegmental pulmonary embolism is limited
secondary to respiratory motion.
2. A 5.3 cm heterogeneous spiculated mass is present in the
left lower lobe. A smaller 2.2 cm mass is present at the right
apex, as well as a 7 mm spiculated nodule. These findings are
concerning for malignancy, with
satellite lesions.
3. Low-density conglomerate nodal masses in the mediastinum and
bilateral hila are concerning for metastatic disease.
4. Diffuse interstitial septal thickening and ground-glass
likely reflects a background of pulmonary edema, however diffuse
lymphangitic spread of tumor could also have this appearance.
5. Collapse of the large portion of the right lower lobe with
small adjacent pleural effusion.
#CXR ___
In comparison with the study ___, there is little change.
Pulmonary
vascularity is now essentially within normal limits. The left
infrahilar mass
seen on CT is better visualized on the current study. No
evidence of acute
focal pneumonia.
#VIDEO SWALLOW STUDY:
Barium passes freely through the oropharynx and esophagus
without evidence of
obstruction. There was aspiration with thin and nectar thick
liquids. There
was penetration with puree. Substantial amount of oropharyngeal
residue was
noted.
IMPRESSION:
Aspiration with thin and nectar thick liquid and penetration
with puree.
DISCHARGE LABS:
=====================
___ 05:58AM BLOOD WBC-12.7* RBC-3.41* Hgb-9.3* Hct-29.9*
MCV-88 MCH-27.3 MCHC-31.1* RDW-13.2 RDWSD-42.8 Plt ___
___ 06:07AM BLOOD Glucose-115* UreaN-31* Creat-0.6 Na-139
K-3.6 Cl-102 HCO3-26 AnGap-15
MICROBIOLOGY:
========================
___ 9:53 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
___ 11:38 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
Brief Hospital Course:
___ year old female with a distant history of breast cancer s/p
mastectomy and SCC of the larynx s/p radiation and chemotherapy,
progressive dysphagia, and COPD on home 4L who p/w acute SOB.
Initially in MICU for NIPPV and hypotension. Transferred to
floor for further management of dyspnea, dysphagia, and
pulmonary nodules on CTA.
#ACUTE RESPRIATORY DISTRESS with HYPERCARBIA
The patient has a longstanding diagnosis of COPD requiring 4L O2
for one year. Her acute episode of SOB in the setting of chronic
lung disease raises suspicion of a COPD exacerbation,
potentially triggered by an aspiration event given her
progressive dysphagia over the past several years (detailed
below). Pneumonia is another possibility based on the patient's
chronic aspiration, baseline lung compromise, and white count of
16.7 on admission, though less likely in the absence of cough
and fever. CTA was negative for PE. She was given empiric
treatment for CAP with ceftriaxone/azithromycin. Transitioned to
cefpodoxime/azithromycin to complete 7 day course. She was also
empirically treated for COPD exacerbation with
methylprednisolone, 4 days total started on admission. On
transfer out of the ICU her respiratory status was at baseline
and she had no further respiratory complaints.
# Shock
She has a transient pressor requirement upon admission in the
setting of BiPAP. This was felt to be obstructive from positive
pressure ventilation. Unlikely cardiogenic, hypovolemic or
obstructive based on examination and data. Pressors were quickly
weaned.
#Dysphagia: The patient has a history of squamous cell carcinoma
of the larynx s/p radiation and chemotherapy in ___ for
T3N0M0. High concern for compromised oropharyngeal function ___
chemoradiation. Swallow study confirms weak base of tongue,
decreased laryngeal elevation and hyoid excursion, and swallow
delay, all likely due to post-radiation changes. High aspiration
risk with solids>liquids. Patient does not wish to pursue a
feeding tube (either NGT or PEG) and is willing to accept some
risk of aspiration. Enacted SLP recommendations:
- PO diet: nectar-thick full liquid diet, including runny purees
- Meds via non-oral means is most reliable; however, could also
be crushed in nectar-thick liquids
- Aspiration precautions: Upright with all PO, two dry
swallows/sip, cough/re-swallow after every ___ sips
She was discharged on nectar thick liquid diet with plan for
home swallow therapy and plan to transition to swallow therapy
at ___.
#Lung masses: CTA on admission revealed multiple lung masses
concerning for malignancy. Though these masses do not provide a
clear explanation for the patient's acute episode, they likely
play a role in her chronic dyspneic presentation and may
contribute to her overall lung compromise at baseline. The
patient's recent weight loss of ___ pounds and smoking history
increases concern for malignancy, which would require further
work up. Patient's family expresses desire for further work up
of lung lesions, but concern for risk of intubation with
bronchoscopy. Instead, they would prefer an approach to
transdermal biopsy. ___ consulted, and recommended biopsy once
patient's acute dyspnea had resolved with treatment. Patient's
PCP was contacted and agreed to coordinate outpatient lung
biopsy.
#Hypotension: Patient's BP decreased to 76/45 on admission after
bipap was initiated. Now resolved. The initiation of bipap
combined with likely hypovolemia ___ low intake may have led to
compromised cardiac output and blood pressure.
- Continue monitoring with telemetry
- Treatment for suspected infection as above
#Diarrhea:
Patient had 2 days of diarrhea with mild leukocytosis on day of
discharge. She was otherwise asymptomatic. Suspect
antibiotic-associated diarrhea worsened by liquid-only diet; C.
diff stool assay sent and was pending at time of discharge.
Patient given a prescription for oral metronidazole to take in
case this turns positive. Inpatient team will be in contact with
the patient to instruct her whether or not to take
metronidazole.
TRANSITIONAL ISSUES:
======================
-Pneumonia: will complete course of 7 days of antibiotics
(cefpodixime and azithromycin), final day ___.
-Dysphagia:
Patient evaluated by speech and language pathology and
nutritionist. Reviewed diet and appropriate thickness of
liquids. Also reviewed
various nectar thick nutritional supplement options and provided
information on where and how to obtain them.Reviewed ways to add
calories to diet. Patient given contact information for
scheduling outpatient swallowing therapy.
-Lung masses, need for biopsy:
Have been in contact with patient's PCP ___, who is
aware of her need for ___ lung biopsy. PCP ___ coordinate
___ biopsy as an outpatient so that the results will be
sent to her.
-Diarrhea:
Patient had 2 days of diarrhea with mild leukocytosis on day of
discharge. She was otherwise asymptomatic. Suspect
antibiotic-associated diarrhea worsened by liquid-only diet; C.
diff stool assay sent and was pending at time of discharge.
Patient given a prescription for oral metronidazole to take in
case this turns positive. Inpatient team will be in contact with
the patient to instruct her whether or not to take
metronidazole.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Unknown
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Ipratropium Bromide Neb 1 NEB IH Q6H
4. Levothyroxine Sodium 112 mcg PO DAILY
5. HYDROmorphone (Dilaudid) ___ mg PO Q8H:PRN pain
6. Gabapentin 600 mg PO BID
7. Gabapentin 300 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Sertraline 100 mg PO DAILY
Discharge Medications:
1. Outpatient Physical Therapy
Rolling Walker
Diagnosis: pneumonia, COPD, and possible lung cancer
Prognosis: Good
Length of need: ___ year
___: ___
2. Gabapentin 600 mg PO BID
3. Gabapentin 300 mg PO DAILY
4. Ipratropium Bromide Neb 1 NEB IH Q6H
5. Levothyroxine Sodium 112 mcg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Sertraline 100 mg PO DAILY
8. Azithromycin 250 mg PO Q24H
RX *azithromycin 250 mg 1 tablet(s) by mouth Q24H Disp #*2
Tablet Refills:*0
9. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*4 Tablet Refills:*0
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
11. HYDROmorphone (Dilaudid) ___ mg PO Q8H:PRN pain
12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Unknown
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
===========================
Aspiration pneumonia
COPD exacerbation
New diagnosis of left lung mass
Oropharyngeal dysphagia
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 meeting you and taking ___ of you during your
admission at ___. You were
admitted to the hospital after developing severe shortness of
breath at home. You were taken by ambulance to the hospital and
placed on a breathing mask to help with shortness of breath, and
you were treated for a pneumonia and exacerbation of COPD
(chronic obstructive pulmonary disease). A CT scan of the chest
was done and showed a mass in the left lung which is concerning
for possible cancer. Your primary ___ doctor, ___, is
aware of our concern regarding this mass and will help you
schedule an appointment to have a biopsy of this mass done as an
outpatient.
You will need to take 2 more days of antibiotics (azithromycin
and cefpodoxime, final day ___
You had several days of diarrhea while in the hospital.
Sometimes diarrhea can be caused by antibiotics, and this could
be worsened since your diet is liquid-only. However there is
also an infectious form of diarrhea called "C diff diarrhea"
caused by a bacteria. We sent a stool sample to test for this
infection, however the results are not available at this time.
We have given you a prescription for metronidazole, which is the
antibiotic treatment for C diff diarrhea. We will call you and
let you know the results of the stool sample test, and if you
have C diff we will have you fill this prescription and take the
metronidazole.
You were evaluated by the speech and language pathology team,
and had a video swallowing study which showed that you
"aspirated" food and liquids, which means that some of the foods
passed into your windpipe. This can increase your risk of
pneumonia, and so we recommend thickened-liquid diet, and have
swallowing therapy as an outpatient. You should call to schedule
an appointmet for swallowing therapy, and the phone number is
___.
We wish you the best of health!
Your ___ Team
Followup Instructions:
___
|
10800175-DS-17
| 10,800,175 | 25,805,670 |
DS
| 17 |
2175-12-17 00:00:00
|
2175-12-18 08:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
Intubation
Central line placement
History of Present Illness:
___ year old female with a history of breast cancer s/p L breast
mastectomy ___ years ago), squamous cell carcinoma of the
larynx s/p radiation and chemotherapy ___ years ago), and COPD
on home 4L, and recent admission (___/) for aspiration
pneumonitis/COPD exacerbation who presents with sudden onset
dyspnea since this afternoon. She reports that she may have
aspirated on yogurt and this feels like prior COPD
exacerbations. She denied recent travel.
In the ED, initial vitals: 98.5 128 ___ 96% 4L NC.
Exam notable for RR 30, tachycardia, decreased breath sounds
bilaterally.
Labs notable for WBC 16.9 with 89.7%, lactate 1.5, calcium 10.9.
Imaging revealed CXR with spiculated left lower lobe mass.
Prominent
background interstitial markings as well as complete collapse of
the right lower lobe and right apical consolidation are all
unchanged. There is likely a small right pleural effusion. No
pneumothorax is seen. CTA revealed no PE.
She received 3L NS, IV methylprednisolone,
vanco/cefepime/levofloxacin. She initially improved, but
desaturated to ___ and became cyanotic. Sats improved with PPV,
however, due to increased work of breathing, she was intubated
(*Note, she was DNI, however, decided with family that she
wanted to be intubated). She was started on levophed for SBP
77/50.
On transfer, vitals were: 98.4 90 99/53 16 99% ett.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Multiple lung nodules on CT concerning for malignancy (___)
Breast Ca s/p mastectomy
Throat Ca s/p chemo and radiation
COPD on home 4L
GERD
Thyroid Disease
Hx Singles & post-Shingles Pain
Social History:
___
Family History:
No family history of clotting disorders, hypertension, diabetes.
Physical Exam:
On Admission:
GENERAL: Intubated, sedated, chronically ill appearing
HEENT: Sclera anicteric, MMM
NECK: supple, JVP not elevated, no LAD
LUNGS: Decreased bretah sounds at right base, wheezing
throughout
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Warm, well-perfused
On Discharge:
Vitals- 97.6 (98.6) 121/66 (121/66-135/65) 104 (100-109) 20
(___) 100% 4L NC (98-100% 4L NC).
General- Alert, oriented, no acute distress. Cachectic and
chronically ill appearing, sitting comfortably in bed.
HEENT- Sclerae anicteric, MMM, edentulous
Lungs- Decreased breath sounds at the bases, scattered wheezes,
no rales, ronchi
CV- Borderline tachcyardic, regular rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding,
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- motor function grossly normal
Skin: New faint macular blanching rash on abdomen, no rash on
extremities, chest
Pertinent Results:
On Admission:
___ 03:19AM BLOOD WBC-29.2*# RBC-2.69* Hgb-7.2* Hct-24.3*
MCV-90 MCH-26.8 MCHC-29.6* RDW-14.9 RDWSD-48.4* Plt ___
___ 03:19AM BLOOD Neuts-96.2* Lymphs-1.4* Monos-1.5*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-28.09*# AbsLymp-0.42*
AbsMono-0.44 AbsEos-0.00* AbsBaso-0.03
___ 03:19AM BLOOD Glucose-175* UreaN-22* Creat-0.8 Na-139
K-4.6 Cl-106 HCO3-28 AnGap-10
___ 03:19AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.2
___ 04:55PM BLOOD ___ pO2-52* pCO2-57* pH-7.39
calTCO2-36* Base XS-7
On Discharge:
___ 11:22AM BLOOD WBC-10.2*# RBC-3.71* Hgb-9.9* Hct-33.2*
MCV-90 MCH-26.7 MCHC-29.8* RDW-15.2 RDWSD-48.3* Plt ___
___ 05:30AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Tear Dr-OCCASIONAL
___ 05:30AM BLOOD Ret Aut-1.8 Abs Ret-0.05
___ 11:22AM BLOOD Glucose-148* UreaN-20 Creat-0.7 Na-141
K-3.2* Cl-102 HCO3-25 AnGap-17
___ 05:30AM BLOOD LD(LDH)-154 TotBili-0.1
___ 03:19AM BLOOD proBNP-227
___ 11:22AM BLOOD Calcium-9.7 Phos-1.6* Mg-1.7
___ 05:30AM BLOOD calTIBC-179* Ferritn-390* TRF-138*
Microbiology:
___ Urine culture - negative
___ Sputum culture - extensive contamination
___ Respiratory viral culture - negative
___ MRSA screen - negative
___ Blood culture - no growth to date
Imaging:
___ CXR
Spiculated left lower lobe mass is re- demonstrated. Right
apical opacity is again seen. There is persistent blunting of
the right costophrenic angle, small pleural effusion and
atelectasis. No definite new focal consolidation is identified.
___ CTA
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Slight interval increase in the dominant spiculated mass in
the left lower lobe measuring 4.1 x 4.0 cm.
3. Unchanged spiculated mass at the right apex measuring 1.4cm.
Confluent hilar lymphadenopathy. No changed in right lower lobe
collapse.
4. Diffuse septal thickening with nodular opacities bilaterally
measuring up to 5 mm concerning for lymphangitic spread with
metastatic nodules.
Cardiology:
EKG ___:
Sinus tachycardia. Tall peaked P waves with rightward P wave
axis consistent with right atrial abnormality and in the context
of low limb lead voltage suggests pulmonary pathology. Compared
to the previous tracing of ___ the rate has slowed. Clinical
correlation is suggested.
Brief Hospital Course:
___ year old female with a history of newly diagnosed invasive
squamous cell carcinoma likely lung primary, remote history of
breast and laryngeal cancer, and COPD on 4L home O2 who
presented with acute respiratory distress.
ACTIVE ISSUES
# Mixed Respiratory Failure
She had both hypoxia, hypercapnea and tachypnea leading to
intubatioy. Etiology most likely multifactorial, including 1)
Bilateral GGOs concerning for pulmonary edema vs infection, 2)
Aspiration pneumonitis/pneumonia, and 3) COPD exacerbation. She
was treated for COPD exacerbation with IV methylprednisolone,
duonebs initially, then transitioned to PO prednisone. She was
also started on inhaled fluticasone and tiotropium. She was
treated for HCAP with vanco/cefepime/levoquin initially, but
deescalated to levofloxacin on ___. Sputum culture revealed
was contaminated. Viral respiratory screen was negative.
Investigation for pulmonary edema including BNP, which was
normal. She was extubated on ___ and transferred to the floor.
She remained stable on home oxygen of 4L. Physical therapy saw
the patient and believed she had returned to her baseline
functional status. She was discharged home with home ___ and
family support. She will complete Levofloxacin on ___.
# Aspiration
Prior evaluation has shows aspiration on all food consistencies.
She is at risk for recurrent respiratory distress and failure
because of her aspiration. However, the patient has determined
multiple times and documented in OMR that she accepts the risks
of aspiration and does not want a feeding tube. We have
discussed with the patient and family (daughters) that she will
likely always be aspirating, and we can modify but not eliminate
this risk. The patient has elected to eat with nectar thick
liquids and pureed solids, accepting the risk of aspiration. She
is DNR/DNI, but ok for NIPPV.
# Squamous Cell Carcinoma, Likely Lung Primary
Leftu lng mass biopsy results from outpatient biopsy done ___
showed moderately differentiated SCC. In discussion with the
pulmonary pathologist, it was felt that this was most likely a
lung primary. Patient and family will discuss with her PCP after
discharge seeing an oncologist as an outpatient. She may need
PET CT and Brain MRI for further evaluation/staging. We did
discuss with her and her family that given her chronic diseases,
chemotherapy options may be limited.
# Normocytic Anemia
She received 1u pRBCs for Hgb of 6.9 on ___. She had no
evidence of bleeding and very low reticulocyte count, so anemia
was attributed to chronic illness and frequent phlebotomy in the
setting of poor marrow response.
TRANSITIONAL ISSUES
- Started on tiotropium for severe COPD
- Last day of levofloxacin for HCAP is ___. Her dosing for
renal function is q48h, so she is due for one more dose on ___.
- Lung biopsy done as outpatient resulted as squamous cell
carcinoma, most likely lung primary. Consider PET CT and Brain
MRI with referral to oncology as an outpatient.
- Giver her severe COPD and chronic aspiration, along with
baseline functional status, would recommended outpatient
referral to palliative care to continue symptom management.
- Despite known aspiration on all food consistencies, the
patient reiterated her wish to continue to eat accepting the
risk of aspiration.
- Code: DNR/DNI, OK for non-invasive positive pressure
ventilation
- Contact: ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Levothyroxine Sodium 112 mcg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Sertraline 100 mg PO DAILY
5. Gabapentin 600 mg PO BID
6. Gabapentin 300 mg PO DAILY
7. HYDROmorphone (Dilaudid) ___ mg PO Q8H:PRN pain
8. Ipratropium Bromide Neb 1 NEB IH Q6H
9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Unknown
Discharge Medications:
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Gabapentin 600 mg PO BID
3. Gabapentin 300 mg PO DAILY
4. HYDROmorphone (Dilaudid) ___ mg PO Q8H:PRN pain
5. Levothyroxine Sodium 112 mcg PO 6X/WEEK (___)
6. Levothyroxine Sodium 224 mcg PO 1X/WEEK (___)
7. Omeprazole 20 mg PO DAILY
8. Sertraline 100 mg PO DAILY
9. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
10. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN shortness of
breath
11. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 CAP
INH daily Disp #*30 Capsule Refills:*0
12. Levofloxacin 500 mg PO ONCE Duration: 1 Dose
Take on ___.
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth once
Disp #*1 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Recurrent aspiration
COPD exacerbation
New diagnosis of squamous cell carcinoma in lung (source
unclear)
Secondary:
Multiple lung nodules on CT concerning for malignancy
Chronic obstructive lung 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:
Dear. Ms. ___,
It was a pleasure taking part in your care at ___. You were
admitted becaue of low oxygen at home. You needed to have a
breathing tube to help you breathe. We found that one of the
lobes of your right lung was collapsed, which was most likely a
result of aspiration into that area. You were also treated with
antibiotics for possible pneumonia and steroids for possible
COPD exacerbation contributing to your symptoms. We were able to
take the breathing tube out quickly and you were stable on your
home oxygen of 4 Liters.
We discussed with you, as have prior physicians, that you
continue to apsirate will all food types. You wish to continue
to eat, and to reduce the risk of aspiration as much as we are
able, you can eat liquids that are nectar-thickened and pureed
foods.
You also had a biopsy of the mass in your left lung as an
outpatient, and the results showed cancer. This is most likely
lung cancer, and given that you have multiple spots in both
lungs, it is advanced. You should talk to your primary care
physician after discharge who will refer you to an oncologist.
The oncologist will discuss any further imaging that is
necessary. They will also discuss how to progress going forward,
but we did discuss with you that given your other illnesses,
chemotherapy options may be limited.
You were seen by physical therapy, who felt you were at your
baseline physical activity level and safe to return home with
your daughter and physical therapy at home.
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
10800264-DS-19
| 10,800,264 | 27,605,746 |
DS
| 19 |
2183-05-08 00:00:00
|
2183-05-10 14:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
15 months of episodic fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ GOPO with PMHx of migraines began experiencing fevers and
joint pain starting in ___, treated for meningitis in
___ and placed on long term steriods with taper that ended
in ___ with resolution of symptoms which have returned and
progressed since ___.
___ experienced similar symptoms to her current presentation
with fever, lower extremity join pain in the lower back, hips,
knees, and ankles bilaterally, and night sweats. Providers
initially diagnosed her with Lyme. She was treated serially, per
the patient's recall, with doxycycline, azithromycin,
clindamycin, and penicillin. Joint pain and fever persisted. In
___, she woke up in the middle of the night with symptoms
that were very different from her current presentation including
neck stiffness and terrible headaches. She went to ___
___, where she was diagnosed and treated for meningitis. At
that time she was also placed on steroids, and her symptoms
resolved quickly. The steroids were tapered in ___ and the
patient has been in her ususal state of health from ___
through ___.
In ___, symetric lower back, knee, hip, and ankle joint
pains, with nocturnal fevers and night sweats returned. Pain is
throbbing and has progressed to ___ severity that forces her to
lie down and stop moving. Fevers have crescendoed, peaking at a
highest temperature of 104. Acetaminophen use has broken the
fevers and improved the pain somewhat. Patient denies any
agrivating factors including pain worse in the mornings, in the
cold, with ambulation, or at night. 7 days prior to presentation
she would have episodes consisting of joint pain, and then feels
chills lasting ___ minutes. She would notice her temperature
increased, lasting about 90 minutes, followed by sweating for
several hours. These eppisodes have been occurring up to four
times per day.
Patient endorses associated symptoms of non productive cough
since last week, 10 pound unitnentional weight loss in 2 weeks,
and periodically pain when it is cold outside and she takes deep
breaths. Menstrual cycle ___ days. Patient denies any new
medications. Patient endorses being bitten by tick in ___.
The tick was not saved and was on the skin for unknown duration.
No other contact with animals: cats, dogs, bats, birds, spiders,
mosquitos. The patient traveled to ___ in ___, but has not
had any other travel within or outside of the ___. The
patient had one sick contact, a nephew with croup.
In the ED intial vitals were: Tc 98.8oF, HR 124, BP 137/76, RR
16, and SpO2 98% on RA. The ED began an infection r/o and the
patient was admitted to medicine for a broader workup of her
fevers and joint pain.
ROS (+)
Unintentional weight loss 8 pounds of past several weeks,
headaches of different nature than her migraines, cough
accompanying her episodes, nausea without vomiting, nail
pitting, dry mouth,
ROS(-)
dyspnea on exertion, chest pain, abdominal pain, BRBPR, melena,
diarrhea, constipation, dysuria, hematuria, rashes
Past Medical History:
1. Migraines with visual aura.
2. GERD
3. Roasacea
Social History:
___
Family History:
1. Paternal Grandfather - CVA
2. Grandmother - osteoarthritis
3. ___ Grandfather - MI , ___.
4. Mom - "irregular heart rhythm", BCC, SCC
5. Dad - HTN, HLD, osteoarthritis
6. Sister - healthy.
7. Family history of thyroid disease: Grandmother, 2 Aunts, 2
Cousins
8. No history of DM1
Physical Exam:
ADMISSION PHYSICAL EXAM:
------
Vitals: Tc 98.7oF, HR 78, BP 108/60, RR 18, SpO2 99% on RA
Exam:
General: alert, oriented to person, place, and time, NAD, lying
comfortably in bed, well groomed and wearing a hospital gown
HEENT: clear sclera, no conjunctivitis or icterus, MMM, no oral
lesions, single soft mobile painless lymph node in the right
submandibular sector
Heart: RRR, nl. S1 and S2, no M/R/G, <2 second capillary refill
Pulmonary: CTAB, good aeration throughout, no increased work of
breathing
Abdomen: +BS, S/NT/ND, no hepatomegaly, splenomegaly with spleen
tip to 2 fingerbreadths below the costal margin, no masses
Extremities: +pulses, no edema, warm, pitting on fingernails
noted, no clubbing, no ___ nodes, no ___ lesions, no
splinter hemmhorages
Neuro: CN II-XII intact, no pronator drift, 2+ reflexes
bilaterally, ___ strength bilaterally
DISCHARGE PHYSICAL EXAM: (UNCHANGED)
------
Vitals: Tm 99.2, Tc98.1, 107/57 85 20 99/RA I/O:brp
Exam:
General: alert, oriented to person, place, and time, NAD, lying
comfortably in bed, well groomed and wearing a hospital gown
HEENT: clear sclera, no conjunctivitis or icterus, MMM, no oral
lesions, no cervical/axillary LAD.
Heart: RRR, nl. S1 and S2, no M/R/G, <2 second capillary refill
Pulmonary: CTAB, good aeration throughout, no increased work of
breathing
Abdomen: +BS, S/NT/ND, no hepatomegaly, splenomegaly with spleen
tip to 2 fingerbreadths below the costal margin, no masses. No
palpable inguinal nodes.
Extremities: +pulses, no edema, warm, pitting on fingernails
noted, no clubbing, no ___ nodes, no ___ lesions, no
splinter hemorrhage
Pertinent Results:
ADMISSION LABS:
----------
___ 05:45AM BLOOD WBC-8.4 RBC-4.63 Hgb-13.4 Hct-41.0 MCV-89
MCH-28.9 MCHC-32.6 RDW-14.3 Plt ___
___ 05:45AM BLOOD Neuts-74.0* ___ Monos-6.3 Eos-0.4
Baso-0.6
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD Glucose-100 UreaN-7 Creat-0.7 Na-134
K-4.0 Cl-95* HCO3-25 AnGap-18
___ 05:45AM BLOOD ALT-18 AST-19 LD(LDH)-205 AlkPhos-110*
TotBili-0.3
___ 05:45AM BLOOD Albumin-4.2 Calcium-9.1 Phos-2.3* Mg-2.0
UricAcd-2.8
___ 07:05PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE IgM
HBc-NEGATIVE
___ 07:05PM BLOOD HIV Ab-NEGATIVE
___ 07:05PM BLOOD HCV Ab-NEGATIVE
___ 06:10AM BLOOD Lactate-1.0
___ 08:09AM URINE Color-Straw Appear-Clear Sp ___
___ 08:09AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 01:32AM URINE Hours-RANDOM Creat-85 TotProt-12
Prot/Cr-0.1
___ 08:09AM URINE UCG-NEGATIVE
DISCHARGE LABS:
------
___ 07:40AM BLOOD WBC-5.9 RBC-4.02* Hgb-11.7* Hct-35.8*
MCV-89 MCH-29.0 MCHC-32.6 RDW-13.8 Plt ___
___ 07:40AM BLOOD Glucose-89 UreaN-5* Creat-0.5 Na-136
K-4.3 Cl-100 HCO3-28 AnGap-12
IMAGING:
-------------
CXR ___
FINDINGS:
PA and lateral views the chest were viewed. The cardio
mediastinal contours
are normal. Mild prominence of the left hilum corresponds to
the abnormality
seen on recent CT. The lungs are well-expanded and clear
without focal
consolidation concerning for pneumonia.
IMPRESSION:
No acute cardiopulmonary process.
-----
CTAP ___
CT ABDOMEN:
The lung bases appear unremarkable.
There are two liver hypodensities, which are too small to
characterize, the
largest measuring 7 mm within the caudate lobe (2:12). The
spleen is mildly
enlarged and measures 13.5 cm. The gallbladder, pancreas,
kidneys, adrenal
glands appear unremarkable.
There are enlarged porto-caval, retroperitoneal and periaortic
lymph nodes,
the largest in the right retroperitoneal region measures 1.3 x
2.3 cm (short x
long axis, 2:30). The largest in the portacaval region measures
1.2 cm in
short axis (2:22).
The abdominal aorta and major arterial branches appear
unremarkable without
dissection, aneurysm or flow-limiting stenosis. The small bowel
and colon
appear unremarkable.
CT PELVIS:
The uterus and bladder appear unremarkable. There are a few
follicles within
the left and right ovaries. There are no enlarged pelvic lymph
nodes. There
is a 9 mm left-sided Bartholin's cyst.
OSSEOUS STRUCTURES:
There are no suspicious lytic or sclerotic bone lesions.
IMPRESSION:
1. Splenomegaly with spleen measuring up to 13.5 cm.
2. Enlarged retroperitoneal, portocaval and periaortic lymph
nodes for which
percutaneous biopsy would be difficult; recommend endoscopic
ultrasound for
sampling to exclude lymphoma.
----
TTE ___
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Transmitral and tissue
Doppler imaging suggests normal diastolic function, and a normal
left ventricular filling pressure (PCWP<12mmHg). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. No masses or
vegetations are seen on the aortic valve. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. No mass or vegetation is seen
on the mitral valve. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: No echocardiographic evidence of endocarditis.
Normal regional and global biventricular systolic function. No
evidence of endocarditis.
Brief Hospital Course:
___ GOPO PMHx migraines with visual aura presents with episodic
fevers of unknown origin which are becoming more frequent.
------
ACTIVE ISSUES:
# FUO/ PARA-AORTIC LYMPHADENOPATHY / SPLENOMEGALY: Unknown
etiology, could represent splenic lymphoma resulting in FUO, but
differential remains broad including autoimmune (sarcoid),
malignancy (Hodgkin Lymphoma, splenic lymphoma), and less likely
infectious processes (subacute bacterial endocarditis).
Malignancy remains less likely in the setting go normal LDH and
normal uric acid. Hematology-oncology team agreed to meet with
the patient to discuss their explicit reasoning: Need lymph node
biopsy, specifically sub diaphragmatic given the higher
diagnostic yield and likelihood that a node from this location
will be needed for definitive diagnosis.
- Surgery consulted, who expressed concern that the need to
excise retroperitoneal lymph nodes may necessitate conversion of
laparoscopic to open procedure. It remains the explicit position
of the hematology-oncology team that the patient requires
retroperitoneal lymph node biopsy in order to establish a
definitive diagnosis which would not be otherwise possible.
- APAP 1000qd PRN:fever
- Naproxen 250 q8 PRN:fever
- Flexeril 10mg tid PRN:pain
# ISOLATED PROTEINURIA: RESOLVED. Spurious previous lab value
given new spot Protein:Creatinine ratio 0.1.
# TOBACCO CESSATION: Counseled patient to stop tobacco use.
Patient refused nicotine patch, 21mg qd
------
CHRONIC ISSUES:
#MIGRAINES: STABLE. Recommended that the patient stop home
Fioricet.
----
TRANSITIONAL ISSUES:
# SURGICAL EXCISION AND BIOPSY - TO BE SCHEDULED FOR WEEK OF ___
# HEME-ONC FOLLOWUP
# RHEUMATOLOGY FOLLOWUP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN fever
2. Cyclobenzaprine 10 mg PO TID:PRN joint pains
3. Pantoprazole 40 mg PO Q24H
4. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN migraines
5. etodolac 400 mg oral BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN fever
2. Cyclobenzaprine 10 mg PO TID:PRN joint pains
3. Pantoprazole 40 mg PO Q24H
4. Docusate Sodium 100 mg PO BID
5. Naproxen 250 mg PO Q8H:PRN FEVER
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
(Prescribed 10 tablets)
Discharge Disposition:
Home
Discharge Diagnosis:
FEVERS OF UNKNOWN ORIGIN
RETROPERITONEAL LYMPHADENOPATHY
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 ___. You were admitted
for expedited workup of your fevers of unknown origin. You
underwent a CT scan of your abdomen and pelvis which revealed
enlarged lymph nodes in your belly. An excisional biopsy of
these nodes is highly recommended by the hematology-oncology
team. The plan remains that you will return for surgery to
excise these nodes for pathologic analysis. The surgery office
will contact you with appointment details on ___.
Followup Instructions:
___
|
10800407-DS-17
| 10,800,407 | 20,111,460 |
DS
| 17 |
2140-03-11 00:00:00
|
2140-03-25 13:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Abdominal pain, nausea, and vomiting
Major Surgical or Invasive Procedure:
___ line placement
History of Present Illness:
Per colorectal surgery consult note:
HPI: This is a ___ year old female w/ prior chron's colitis
refractory to medications requiring total abdominal colectomy
with end-ileostomy back in ___ who presents to the ED with one
day of nausea, and lack of ostomy output concerning for sbo.
Colorectal surgery to evaluate patient for further management.
She was in her usual state of health till yesterday 2pm when se
started with some nausea. She noticed around 5 pm her ileostomy
stop abruptly having output. Denies prior episodes. She endorses
having a parastomal hernia after 2 months of her colectomy but
denies having any prior issues regarding this in the past.
Upon exam, VSS. NAD, exam with soft abdomen. Slightly tender
deep
palpation to RLQ. Parastomal hernia of aprox 15-20cm.
Non-reducible. Ostomy is pink. Digitalized with return of scant
bloody output. Not able to reach fascia. Non-peritoneal exam.
Labs witl slight elevated lactate. No white count.
Past Medical History:
Ulcerative colitis dx ___
IBS
GERD
SVT s/p ablation ___
S/p hemorroidectomy ___
Spinal stenosis
Nephrolithiasis
B/L knee replacement ___
CCY ___
Umbilical hernia repair ___
Social History:
___
Family History:
No known fhx of crohn's or ulcerative colitis.
Physical Exam:
General: doingwell, tolerating a regular diet
VSS
Neuro: A&OX3
cardio/pulm; no chest pain or shortness of breath
Abd: soft non distended, non tender
Pertinent Results:
___ 05:36AM BLOOD WBC-8.6 RBC-3.59* Hgb-10.8* Hct-34.5
MCV-96 MCH-30.1 MCHC-31.3* RDW-13.5 RDWSD-48.2* Plt ___
___ 05:01AM BLOOD WBC-8.8 RBC-3.41* Hgb-10.4* Hct-32.6*
MCV-96 MCH-30.5 MCHC-31.9* RDW-13.4 RDWSD-46.8* Plt ___
___ 04:56AM BLOOD WBC-7.7 RBC-3.54* Hgb-10.7* Hct-33.6*
MCV-95 MCH-30.2 MCHC-31.8* RDW-13.2 RDWSD-46.5* Plt ___
___ 06:27AM BLOOD WBC-6.9 RBC-3.85* Hgb-11.9 Hct-36.7
MCV-95 MCH-30.9 MCHC-32.4 RDW-13.4 RDWSD-47.1* Plt ___
___ 06:15AM BLOOD WBC-8.4 RBC-3.89* Hgb-11.8 Hct-37.4
MCV-96 MCH-30.3 MCHC-31.6* RDW-13.5 RDWSD-48.1* Plt ___
___ 06:40AM BLOOD WBC-6.7# RBC-3.82* Hgb-12.0 Hct-36.6
MCV-96 MCH-31.4 MCHC-32.8 RDW-13.4 RDWSD-47.3* Plt ___
___ 06:10AM BLOOD WBC-4.0 RBC-3.96 Hgb-12.0 Hct-38.3 MCV-97
MCH-30.3 MCHC-31.3* RDW-13.5 RDWSD-48.5* Plt ___
___ 07:18AM BLOOD WBC-3.6* RBC-4.14 Hgb-12.8 Hct-39.5
MCV-95 MCH-30.9 MCHC-32.4 RDW-13.6 RDWSD-47.9* Plt ___
___ 05:36AM BLOOD Glucose-96 UreaN-15 Creat-0.7 Na-140
K-4.5 Cl-106 HCO3-25 AnGap-9*
___ 05:01AM BLOOD Glucose-114* UreaN-15 Creat-0.7 Na-143
K-3.8 Cl-106 HCO3-26 AnGap-11
___ 04:56AM BLOOD Glucose-122* UreaN-12 Creat-0.8 Na-143
K-3.5 Cl-106 HCO3-26 AnGap-11
___ 06:40AM BLOOD Glucose-102* UreaN-14 Creat-0.8 Na-142
K-3.6 Cl-104 HCO3-25 AnGap-13
___ 06:10AM BLOOD Glucose-109* UreaN-18 Creat-0.8 Na-142
K-3.5 Cl-104 HCO3-28 AnGap-10
___ 06:10AM BLOOD Glucose-129* UreaN-18 Creat-0.8 Na-143
K-4.2 Cl-104 HCO3-27 AnGap-12
___ 07:18AM BLOOD Glucose-150* UreaN-18 Creat-0.9 Na-144
K-4.4 Cl-106 HCO3-26 AnGap-12
___ 11:15AM BLOOD Glucose-160* UreaN-15 Creat-1.0 Na-142
K-4.9 Cl-106 HCO3-22 AnGap-14
___ 05:36AM BLOOD Calcium-7.9* Phos-2.9 Mg-2.0
___ 05:01AM BLOOD Calcium-7.8* Phos-3.2 Mg-2.1
___ 04:56AM BLOOD Calcium-7.5* Phos-3.4 Mg-2.1 Iron-64
___ 06:27AM BLOOD Calcium-7.3* Phos-2.4* Mg-2.3
___ 06:15AM BLOOD Calcium-7.4* Phos-2.8 Mg-1.9
___ 06:40AM BLOOD Calcium-7.7* Phos-2.7 Mg-2.0
___ 06:10AM BLOOD Calcium-8.0* Phos-2.4* Mg-2.0
___ 07:18AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.9
Brief Hospital Course:
Mrs. ___ was admitted to the inatpeint colorectal surgery
with a bowel obstruction. SHe was managed conservatively. The
ngt was removed when she had adequate ostomy output. She
received a pic line and tpn during her admission. She was able
to avoid surgery and was discharged home tolerating a regular
diet.
Medications on Admission:
albuterol,areds eye drops ,fluticasone 50 mcg/actuation nasal
spray, Aspirin 81 mg ', loperamide 2mg
Discharge Medications:
1. fluticasone 50 mcg/actuation nasal Other
2. Aspirin 81 mg PO DAILY
3. LOPERamide 4 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for a small bowel obstruction.
You were given bowel rest and intravenous fluids and a
nasogastric tube was placed in your stomach to decompress your
bowels. Your obstruction has subsequently resolved after
conservative management. You have tolerated a regular diet, are
passing gas and your pain is controlled with pain medications by
mouth. You may return home to finish your recovery.
If you have any of the following symptoms please call the
office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities.
Good luck!
Followup Instructions:
___
|
10800455-DS-9
| 10,800,455 | 27,423,616 |
DS
| 9 |
2140-06-07 00:00:00
|
2140-06-08 10:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
mechanical fall with jaw pain
Major Surgical or Invasive Procedure:
___: ORIF mandibular symphysis fracture and closed
reduction of mandibular subcondylar fracture
History of Present Illness:
___ is a ___ w/ hx of pituitary tumor s/p resection
now w/ adrenal insufficiency on prednisone who is presenting
here to the ED ~2 days after tripping and falling, for which we
were consulted. She says she tripped and fell on her chin, -LOC,
and she denies any lightheadedness and/or dizziness,
chest pain, SOB, or palpitations at that time. She notes some
worsening jaw pain and thus presented to an OSH where a CT head,
max/fac and C-spine were obtained which showed b/l mandibular
fx's and was txfr'ed here for further management.
Past Medical History:
PMHx: pituitary tumor s/p resection now w/ adrenal insufficiency
on prednisone, developmental delay, HTN, HLD, hypothyroidism
PSHx: resection of pituitary tumor
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
VS - 96.7 72 150/102 18 98% RA
Gen - NAD
HEENT - PERRL, L jaw mildly deformed and swollen, ttp, no blood
in nares, mouth, or ears, no C-spine ttp, full passive neck ROM
w/ no pain
CV - RRR
Pulm - non-labored breathing, no resp distress
Abd - soft, non distended, nontender
MSK & extremities/skin - no leg swelling observed b/l, R ___ toe
swollen, ecchymotic and discolored w/ no ttp, no T or L-spine
ttp
or bony stepoffs
FAST - inadequate hepatorenal and splenorenal views, ?trace
pericardial effusion
Discharge Physical Exam:
VS: T: 98.3 PO BP: 147/76 L Lying HR: 63 RR: 18 O2: 96% RA
GEN: A+Ox3, NAD
HEENT: mild bilateral lower third facial swelling, eloplastic
chin dressing cdi.
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, non-tender to palpation
EXT: wwp, no edema b/l
Pertinent Results:
IMAGING:
___: Mandibular x-ray (Panorex):
Fracture of the body of the mandible seen on preceding CT is not
as well seen on the current study, possibly in part related to
overlying external artifact.
Nondisplaced fracture of the right mandibular ramus.
___: Pelvis X-ray:
No fracture or malalignment.
___: right foot x-ray:
1. No fracture or malalignment.
2. Mild-to-moderate degenerative changes.
___: CXR (pre-op):
No acute intrathoracic process.
___: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST:
1. Plate and screw fixation of the comminuted fracture through
the
parasymphyseal regions of the mandible, with overall improved
anatomic
alignment.
2. No significant change in the nondisplaced oblique fracture
through the
right mandibular ramus.
3. Unchanged expansile lesion in the sella turcica which
extends into the
sphenoid sinuses and right middle cranial fossa.
LABS:
___ 07:30PM GLUCOSE-95 UREA N-20 CREAT-0.8 SODIUM-142
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-24 ANION GAP-15
___ 07:30PM WBC-8.8 RBC-4.48 HGB-14.3 HCT-40.3 MCV-90
MCH-31.9 MCHC-35.5 RDW-13.4 RDWSD-43.8
___ 07:30PM NEUTS-56.3 ___ MONOS-5.1 EOS-4.2
BASOS-0.5 IM ___ AbsNeut-4.95 AbsLymp-2.96 AbsMono-0.45
AbsEos-0.37 AbsBaso-0.04
___ 07:30PM PLT COUNT-272
___ 07:30PM ___ PTT-29.0 ___
Brief Hospital Course:
___ is a ___ w/ hx of pituitary tumor s/p resection
now w/ adrenal insufficiency on prednisone who presented to
___ with worsened jaw pain about 2 days after a mechanical
fall. She initially went to an OSH where a CT head, max/fac and
C-spine were obtained which showed b/l mandibular fx's and was
transferred to ___ for further management. She was evaluated
by the Oral Maxillofacial Surgery (___) service who determined
her injuries would require surgery. She was admitted to the
Acute Care Surgery/Trauma service.
While in the hospital, she was noted to be hypertensive (SBP in
low 200s) and she received IV hydralazine. She also had atrial
fibrillation with RVR and she received IV metoprolol and IV
diltiazem. Blood pressure and heart rate normalized. A TTE was
done which showed normal global biventricular cavity size and
systolic function, mild mitral regurgitation and trivial
pericardial effusion.
On HD3, the patient was taken to the operating room by ___
where she underwent ORIF mandibular symphysis fracture and
closed reduction of mandibular subcondylar fracture. This
procedure went well (reader, please refer to operative note for
further details). After remaining hemodynamically stable in the
PACU, the patient was transferred to the surgical floor. She
received IV cefazolin post-operatively.
The patient's diet was advanced to full liquids which she
tolerated and IVF were discontinued. 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 with acetaminophen. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
pravastatin 40 mg tablet oral
1 tablet(s) Once Daily
bisoprolol fumarate
1 tablet(s) 2.5/6.25 once daily
levothyroxine 100 mcg capsule oral
1 capsule(s) Once Daily
prednisone 1 mg tablet oral
3 tablet(s) Once Daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
swish and spit
RX *chlorhexidine gluconate 0.12 % swish and spit 15 mL twice a
day Disp #*420 Milliliter Refills:*0
3. Docusate Sodium (Liquid) 100 mg PO BID:PRN Constipation -
First Line
4. bisoprolol-hydrochlorothiazide 2.5-6.25 mg oral DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Pravastatin 40 mg PO QPM
7. PredniSONE 3 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
-Right subcondylar fracture
-Left mandibular parasymphysis fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with a broken jaw after a
fall. You were taken to the operating room by the Oral
Maxillofacial Surgery team and had your jaw repaired. This
surgery went well and you were later advanced to a full-liquid
diet. Please remain on a full-liquid consistency diet until
your follow-up appointment with the surgeon.
You are now ready to be discharged home to continue your
recovery. Please note the following discharge instructions:
Please maintain meticulous oral hygiene with twice daily
brushing
and by using the prescribed mouthrinse twice daily. Rinse with
warm salt water after meals.
Please do not smoke while your surgical sites are healing.
Smoking will significantly affect the healing and affect your
sinuses.
Please do not drive while taking narcotic medications as these
medications can slow your reaction time and be sedating. If you
feel you do not need this narcotic medication, then you may take
tylenol only.
No strenuous activity or heavy lifting greater than 10 lbs for
the next 6 weeks.
Please maintain a strict non-chew full liquid diet for 4 weeks
or
until advised otherwise by your surgeon. A diet package will be
provided to you for helpful ideas of liquid meals.
Take stool softeners as needed to prevent constipation. Keep
your stools loose to prevent bearing down or straining.
You have stiches in your mouth. These will dissolve on their own
within ___ weeks.
Call your doctor or go to the nearest ER for the following:
- Fevers > ___
- Increased pain, redness, swelling of the wound
- Drainage, pus from the wound
- If 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.
-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.
Contact ___ oral surgery with questions about care of this
patient at any time ___, ask the operator to page the
Oral Surgery resident on call.
Please refer to the provided jaw surgery instruction sheet for
further details regarding post-operative care.
Followup Instructions:
___
|
10800546-DS-7
| 10,800,546 | 25,150,796 |
DS
| 7 |
2198-03-20 00:00:00
|
2198-03-20 15:55:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left leg swelling, foul smelling discharge from left foot ulcer
Major Surgical or Invasive Procedure:
1. Right groin percutaneous access.
2. Aortogram with left lower extremity runoff.
3. Contralateral third order selective catheterization.
4. Left superficial femoral artery angioplasty and stent.
5. Right groin Perclose.
History of Present Illness:
___ year old woman with multiple medical problems including
bilateral unprovoked PE's on coumadin s/p IVC filter placement
at outside hospital, CAD s/p MI ___ ___ s/p RCA stent, diabetes
on home insulin complicated by lower extermity ulcers, presents
with worsening lower extremity ulcers with foul discharge.
The patient has suffered chronic leg ulcers for approximately
six months. She is followed by Vascular Surgery who had
previously recommended bypass grafting to reduce the impact of
her significant PVD and resulting venous stasis ulcers. She is
under evaluation for this procedure, but ___ the interim her
wounds have become larger and began weeping purulent drainage.
She also has noted increased ___ edema. ___ ___ her Lasix was
increased to reduce edema, which has not been effective. She
has been treating her wounds with sulfsaladine and wound care,
but has not been on antibiotics. She wraps her legs daily and
notes significant weeping discharge; at night she puts her leg
___ a plastic bag and collects at least ___ cup fluid by morning.
Per the patient's report, a wound culture was positive for
Pseudomonas at some point ___ the last few months, although this
is not available ___ our system.
She notes that the worsening infection has led to difficulty
walking due to weakness. A few days ago she couldn't climb the
steps ___ her house without significant assistance due to
weakness of the leg. She denies lightheadedness or dizziness,
and she did not feel that the leg would give way. Rather, she
felt that she was too weak to maintain her balance while
climbing the steps. She did not have this same sensation when
walking with her cane on flat surfaces. The day of admission
she couldn't walk up the steps even with the support of one of
her sons. She called her PCP's coverage who recommended she
come to the ED. She denies fever, chills, nausea, vomiting.
Her ___ weekly ___ has not noted fever or hypotension.
Of note, ___ ___ of this year she was admitted for
hyperglycemia and was noted to be hypotensive. Her
anti-hypertension regimen was held at that time, including
Lasix. Only the Lasix and lisinopril have been restarted. Her
insulin regimen was increased at that time.
She presented to the ED due to this worsening leg pain that
inhibits her ambulation. On arrival, initial vitals were 99.9
125/54 70 18 98% RA. She was noted to have significant dark
blue-green drainage from her leg wounds. She was unable to
weight bear. She was provided vancomycin and ceftazidime as
well as Percocet for pain. Her lactate was noted to be 3.0,
although she had no anion gap metabolic acidosis. Her Cr was
worse than baseline at 1.9, and her anemia at the low end of her
baseline at 8.2/26.7. She had a leukocytosis to 11.6 despite
being afebrile. INR 2.5, on chronic coumadin for h/o PE. She
was admitted for IV ABX and potential vascular workup.
On arrival to the floor, she complains of no pain or discomfort.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, dyspnea or
wheezing. Denies chest pain, chest pressure, palpitations.
Denies constipation, abdominal pain, diarrhea, dark or bloody
stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes.
Past Medical History:
PAST MEDICAL HISTORY:
Diabetes mellitus type 2
Hypertension
Peripheral vascular disease
Open wounds on the legs that are not healing
Peripheral neuropathy
Hyperthyroidism
History of pulmonary embolism, on warfarin
Urinary incontinence
Coronary artery disease s/p stent
Chronic anemia (baseline 30)
Chronic kidney disease (baseline 1.5)
PAST SURGICAL HISTORY:
Hysterectomy ___
Partial thyroidectomy
Cholecystectomy ___
Cataract surgery bilaterally
Removal fibroadenoma of right breast
Cardiac stent placement
Skin grafts to ___ (didn't take)
Social History:
___
Family History:
Mother died ___ her ___ due to complications of Alzheimer's
disease. Father had tuberculosis
Physical Exam:
PHYSICAL EXAM on admission:
Vitals: 99.4 111/53 69 20 100% RA FSBS 185
GENERAL: NAD, awake and alert
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, OP clear, good dentition
NECK: nontender and supple, no LAD, no JVD, no thyromegaly
CARDIAC: RRR, nl S1 S2, ___ systolic murmur
LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding, no HSM
EXT: warm and well-perfused, no cyanosis or clubbing. 2+
pitting edema b/l ___: ___ pulses not palpable b/l
NEURO: CN II-XII tested and intact, strength ___ ___ UEs not
tested ___ ___, sensation grossly normal
SKIN: UEs warm and well-perfused. ___ significant edema
and chronic stasis changes. LLE has eroded, weeping area of
ulceration that is circumferential and spans 10cm length along
the leg. There is an area of black eschar on the superior
aspect of the posterior leg. Remainder of large area of lesion
is granulation tissue with round ulcerations. Signficant
drainage onto gauze bandage. 2+ pitting edema superior to area
of erosion.
PHYSICAL EXAM on discharge:
Vitals: Tc 98.6 Tmax 98.7, BP 112/48 (100-130'/40-70'), HR 78
(50-70's), RR 13 Sat 96-100%. FSBG ranging 141-272
GENERAL: NAD, awake and alert
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, OP clear, good dentition
NECK: nontender and supple, no LAD, no JVD, no thyromegaly
CARDIAC: RRR, nl S1 S2, ___ systolic murmur
LUNG: CTAB, no rales, no accessory muscle use, reduced air entry
with reduced vocal fremitus at left lung base > right lung base
(but reduced on both sides), no wheeze or rhonchi
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding, no HSM
EXT: warm, no cyanosis or clubbing. 1+ pitting edema b/l ___
> R
PULSES: ___ pulses not palpable right side, left side was hard
to assess given it was bandaged
NEURO: CN II-XII tested and intact, strength ___ ___ UEs not
tested ___ ___, sensation grossly normal
SKIN: upper extremities warm and well-perfused. lower
extremities exhibit edema and chronic stasis changes. Left
lower extremity had eroded, weeping area of ulceration that is
circumferential and spans 10cm length along the leg with no
frank pus. There is still an area of black eschar on the
superior aspect of the posterior leg. Remainder of large area
of lesion is granulation tissue that is improving compared to
prior. 1+ pitting edema superior to area of erosion.
GU: on foley
Pertinent Results:
Admission Labs:
===============
___ 01:50PM BLOOD WBC-11.6* RBC-2.89* Hgb-8.2* Hct-26.7*
MCV-93 MCH-28.4 MCHC-30.8* RDW-12.4 Plt ___
___ 01:50PM BLOOD Neuts-84.1* Lymphs-10.2* Monos-4.2
Eos-1.3 Baso-0.2
___ 01:50PM BLOOD ___ PTT-35.1 ___
___ 01:50PM BLOOD Glucose-277* UreaN-50* Creat-1.9* Na-137
K-5.0 Cl-101 HCO3-24 AnGap-17
___ 01:50PM BLOOD proBNP-778*
___ BLOOD CRP 274.2*
___ BLOOD ESR 126*
Interim labs:
==============
___ 07:00AM BLOOD WBC-13.3* RBC-2.86* Hgb-8.4* Hct-27.1*
MCV-95 MCH-29.4 MCHC-31.1 RDW-12.8 Plt ___
___ 07:00AM BLOOD Glucose-179* UreaN-21* Creat-1.1 Na-142
K-4.9 Cl-108 HCO3-28 AnGap-11
Discharge labs:
===============
___ 06:14AM BLOOD WBC-9.7 RBC-2.88* Hgb-8.5* Hct-26.9*
MCV-93 MCH-29.4 MCHC-31.5 RDW-13.2 Plt ___
___ 06:14AM BLOOD Neuts-73.5* ___ Monos-4.8 Eos-2.8
Baso-0.4
___ 06:14AM BLOOD ___ PTT-32.1 ___
___ 06:14AM BLOOD Glucose-121* UreaN-12 Creat-1.0 Na-140
K-4.5 Cl-107 HCO3-28 AnGap-10
___ 07:45AM BLOOD ALT-26 AST-47* LD(LDH)-226 AlkPhos-93
TotBili-0.3
___ 06:14AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.0
___ BLOOD CRP-86.8*
___ BLOOD ESR 123*
Micriobilogy:
=============
___ blood culture negative
___ urine culture: mixed bacterial flora
___ urine culture: no growth
___ urine legionella antigen negative
___ 8:52 am SPUTUM Source: Induced.
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ MRSA screen negative
___ Deep tissue swab
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
TISSUE (Preliminary):
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture..
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE
GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
ENTEROCOCCUS SP..
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
___ C. difficile DNA amplification assay: Negative for
toxigenic C. difficile by the Illumigene DNA amplification
assay.
Imaging:
========
- left ankle AP, lateral and mortise XRAY ___:
FINDINGS: Four views of the left ankle are provided. There is
persistent mild-to-moderate soft tissue swelling about the
ankle, slightly improved since the previous examination. The
previously described soft tissue defect along the distal
anteromedial tibia is again seen. The cortex is intact with no
evidence of osteomyelitis. The bone mineralization is normal.
There is no periostitis. There are again extensive vascular
calcifications. No soft tissue mineralization. There are
moderate degenerative changes at the talonavicular joint with
large dorsal osseous spurs.
IMPRESSION: Persistent skin ulceration, but no evidence of
osteomyelitis.
- CXR PA and lat ___
Substantial increase ___ size of the right hilus, right
paratracheal tissue to the tracheobronchial angle and the
mediastinum ___ the region of the AP window could be due to new
adenopathy or progressive pulmonary hypertension. Moderate
cardiomegaly is slightly worse and there is new small pleural
effusion on the left side. There are no lung findings to
suggest pneumonia, but there may be several new small nodules ___
the left mid lung. CT scanning, even without contrast agent
would be helpful ___ clarifying these.
- ___ ___:
IMPRESSION: The left greater saphenous is larger than the right
side and is visible from the saphenofemoral junction to the mid
calf region. However, below this is difficult to evaluate due
to the wound and bandages.
- CT chest without contrast ___
IMPRESSION:
1. There is no evidence of mediastinal, supraclavicular or
axillary
lymphadenopathy.
2. Bilateral mild-to-moderate, nonhemorrhagic, posteriorly
layering pleural effusion with accompanying mild atelectasis.
No pneumonia.
3. A 4-mm solid noncalcified nodule ___ the lingula. If patient
has risk
factors, for example, smoking or malignancy, this needs to be
evaluated again at six months to one year. Otherwise, no
followup is indicated.
4. Severe coronary artery disease and enlarged pulmonary artery
suggestive of pulmonary artery hypertension.
- CXR post PICC placement ___
FINDINGS: There is a new left-sided PICC line with tip ___ the
low SVC. There are small bilateral effusions that have
increased ___ size compared to prior. The heart is mildly
enlarged and there is mild pulmonary vascular redistribution.
There is no pneumothorax.
-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 thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Pulmonary
artery hypertension. Aortic valve sclerosis.
Brief Hospital Course:
___ year old woman with multiple medical problems including
bilateral unprovoked PE's on coumadin, IVC filter, CAD s/p MI
s/p RCA stent ___ ___, diabetes on home insulin complicated by
Lower extremity ulcers, presents with worsening ulcers with foul
discharge, had Left SFA stent placed by vascular surgery team on
___, developed fever on ___, discharged ___ stable
condition to rehab with total course of 6 week antibitiocs for a
most likely osteomyelitis.
# Fever: Afebrile over the last ___ days of hospital stay.
Patient initially presented with leukocytosis. She was initially
on vancomycin and ceftazidime on admission to cover broadly
polymicrobial infection for her left lower extremity ulcers that
were having foul smelling copious pus. Her antibiotic regimen
was subsequently switched to vanc/cipro/flagyl on ___. Last
spiked ___ at 0800 (while on vancomycin, ciprofloxacin,
flagyl) and prior was ___ at 102.2F. Given the spike on ___,
her antibiotic regimen was changed to vancomycin IV and zosyn
IV. There was a concern from the beginning for osteomyelitis
given ESR and CRP were very high on admission although probing
was attempted and not successful. MRI of the bone was considered
however given her acute on chronic kidney failure on admission
___ addition to exposure to contrast during her angiography were
strongly considered and MRI was not pursued. Also, bone marrow
biopsy was not perfumed given the concern for poor wound healing
___ an already unhealthy left lower extremity with foul smelling
pus. Standard of care would suggest that bone biopsy and MRI may
be helpful ___ such a case. This was discussed with the patient
and her husband who did not want to pursue this work-up given
risk and benefits. PICC is placed and can be removed after
completing the course of antibiotics. Prior to discharge, CRP
was much lower than admission value with minimal decrease ___ her
ESR. ID team was involved ___ her care who recommended
discharging her on IV vancomycin with weekly trough level ___
addition to IV zosyn 2.25 gram every 6 hours for a total of 6
weeks through ___. She reported chronic intermittent dry
cough that is unchanged from baseline per patient. CT chest was
done to evaluate right mediastinal enlargement seen on CXR
(please see below) which showed bilateral pleural effusion but
no infiltrates to suggest pneumonia. Denied dysuria. No
headache. No other localizing symptoms. Urine culture ___
mixed flora ___ setting of her incontinence but was on foley
catheter during this admission. UA with trace leuks, negative
nitrites, few bacteria. Repeat urine culture didn't show growth.
She will be followed up with ___ clinic. She has weekly
vancomycin trough, CBC with differential, chem 7, LFT, ESR and
CRP to be drawn and faxed to ID nurse at ___.
# Venous ulcers: The patient has chronic venous stasis ulcers,
PVD, and diabetes. She was thought to have a complicated
polymicrobial infection given the appearance of enlargening
ulcerations with frank serosanguinous drainage. Per patient
report, she had pseudomonas + cultures from these ulcers at some
point ___ the last few months. While plain films demonstrated no
evidence of osteomyelitis, ESR and CRP were found to be very
elevated raising suspicion for a deeper process. She was
started on broad spectrum antibiotics with vancomycin,
ceftazidime. Vascular surgery was consulted and she was
transferred to the vascular surgery service. On ___ she
underwent angiogram and stenting of her left SFA. While on the
vascular service, antibtiocs were changed to Vancomycin,
ciprofloxacin and flagyl. Post-operatively, the patient did
well. She remained on bedrest for the appropriate time period.
After bedrest, the patient ambulated without difficulties.
There was no gross hematoma/pseudoaneurysmal formation noted on
physical examination. The patient was tolerating a regular
diet. Wound care team was involved ___ the care. Oxycodone as
needed was used to control pain. She is discharged with ACE wrap
and adaptic dressing as instructed on page 1. She is discharged
on plavix 75 mg daily. After discussing with Dr ___
vascular surgeon, it was reasonably acceptable not to continue
with the aspirin given she is on coumadin as well. She will be
taking plavix 75 mg daily for 1 month along with coumadin for
her PE (please see below). Afterwards, plavix can be switched to
aspirin. She has appointment with vascular surgery ___ 2 weeks.
# Acute on chronic CKD: Resolved. Baseline Cr 1.5, thought to be
due to diabetic nephropathy. Cr 1.9 on admission, may be due to
pre-renal state and infection. The patient was hydrated before
and after her angiogram with a bicarbonate drip. Her creatinine
was stable on discharge and back to ___ prior to discharge.
# Anemia: Her H/H was fairly stable ___ recent trend 25.7-30.4.
She required 1 u PRBC tranfusion on ___ for Hct of 22. Her B12
levels were normal ___ ___ with normal iron studies ___ ___.
FOBT on ___ was negative.
# History of PE: On chronic warfarin for history of PE. Also
has IVC filter. INR therapeutic on admission. Coumadin was being
held since ___ but restarted ___ for INR of 1.8 that dropped
from 2.5 the day prior. She is discharged on coumadin 20 mg
daily at 4pm with INR of 1.6. She will need uptitration of her
coumadin at the rehab based on her INR trend.
# Hypertension: BP currently within normal limits without
anti-hypertensive meds. Several medications were held following
___ admission given hypotension during that stay. Lasix was
restarted for ___ edema and bilateral pleural effusions seen
chest CT but at lower dose compared to her home regimen.
Lisinopril was still held given SBP 100-110's on day of
discharge. On presentation the patient has elevated lactate and
elevated Cr. We continued to hold amlodipine, atenolol,
terazosin (currently on hold since ___ admission).
# T2DM: On insulin regimen at home, was hyperglycemic at ___
admission. We uptitrated her NPH to 9unit ___ the morning and
7unit ___ the evening along with humalog ISS.
# Right mediastinal enlargement: Detected on CXR on admission
which was done given fever and leukocytosis. CT chest without
contrast didn't reveal lymphadenopathy but revealed bilateral
pleural effusions
# Depression: continue home citalopram, mirtazapine
# Hypertyroidism s/p partial thyroidectomy: stable, no
medications
# CAD s/p stent: continue simvastatin. Atenolol on hold.
# Glaucoma: continue Cosopt, Xalatan
# Transitional issues
-CT performed --> A 4-mm solid noncalcified nodule ___ the
lingula. If patient has risk factors, for example, smoking or
malignancy, this needs to be evaluated again
at six months to one year. Otherwise, no followup is indicated.
- Please follow up final report of ___ Deep tissue swab
microbiology
- Please adjust coumadin based on INR
- plavix 75 mg daily for 1 month then switch to aspirin per
vascular surgery. The patient can discontinue plavix and start
aspirin 325 mg PO qD on ___.
- Code: full
- Add lisinopril/norvasc as tolerated by BP
- IV vancomycin and zosyn through ___
- ID and vascular surgery outpatient appointments
- foley to be removed at rehab and do a voiding trial
Medications on Admission:
CITALOPRAM 20 mg daily
FUROSEMIDE 20 mg BID
LISINOPRIL 40 mg daily
MIRTAZAPINE 15 mg QHS
POTASSIUM CHLORIDE 10 mEq daily
SIMVASTATIN 20 mg daily
WARFARIN 12 mg daily
COSOPT ONE QTT EACH EYE AT BEDTIME
XALATAN 0.005% Drops ONE QTT EACH EYE AT BEDTIME
INSULIN [HUMULIN R] 20 u qam and 6 u before supper
NPH INSULIN 6 u qam and 6 q hs
MULTIVITAMIN daily
AMLODIPINE 5 mg daily (on hold for hypotension)
ATENOLOL 50 mg daily (on hold for hypotension)
TERAZOSIN 4mg QHS (on hold for hypotension)
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. dorzolamide-timolol ___ % Drops Sig: One (1) Drop
Ophthalmic QHS (once a day (at bedtime)).
5. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Coumadin 10 mg Tablet Sig: Two (2) Tablet PO once a day: to
be adjusted based on INR.
11. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1)
injection Subcutaneous twice a day: 9unit AM, 7unit ___. adjusted
based on daily FSBG.
12. Humalog 100 unit/mL Solution Sig: One (1) injection
Subcutaneous four times a day: as directed by provided sliding
scale.
13. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months: End date: ___.
14. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO daily ():
through ___.
15. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
16. vancomycin 1,000 mg Recon Soln Sig: One (1) dose Intravenous
twice a day: as directed by trough level through ___.
17. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day:
START DATE: ___
Patient will stop plavix at this date and start aspirin.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- ? lower extremity osteomyelitis
- Left Lower extremity ulcers requiring bedside debridement
-Left SFA stenosis with stent placement
Secondary:
Diabetes
Hypertension
Peripheral vascular disease
Urinary and stool incontinence
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 great pleasure taking care of you. As you know you were
admitted to ___ for left foot
ulcers. Given your fever and high white cell, we provided
antibiotics. We are assuming this is because of underlying bone
infection and therefore 6 weeks of antibiotics are required. A
peripherally inserted central line (PICC) was placed for this
purpose. This can be removed once your antibiotic course is
completed.
Vascular surgery was following with us ___ your care and they
have placed a stent ___ the artery ___ your left thigh (the artery
is called superficial femoral artery). You need to take plavix
for this stent. Please do not discontinue it unless you are told
otherwise by your physician. You will be taking it for 1 month
which will be switched to aspirin afterwards.
We made the following changes ___ your medication list.
- Please START vancomycin 1 gram twice daily through ___
- Please START moxifloxacin 400 mg daily through ___
- Please START plavix 75 mg daily for 1 month as above (end
date: ___
- Please INCREASE your morning NPH to 9 unit. Please increase
your evening NPH to 7 unit. This might be changed based on your
daily finger stick glucose levels
- Please STOP twice daily humalin R insulin injections. You will
be provided with a sliding scale instead.
- Please CONTINUE your coumadin. Dose will be adjusted based on
your INR (coumadin) level
- Please HOLD lisinopril ___ addition to HOLDING amlodipine,
atenolol, terazosin
- Please STOP potassium chloride 19 meq daily
- Please REDUCE lasix from 20 mg twice daily to 20 mg once daily
Please continue taking the rest of your home medications the way
you were taking them at home prior to admission.
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
Medications:
Take Plavix (Clopidogrel) 75mg once daily for a total of 1
month, please do not discontinue this unless you are told
otherwise by your physician as mentioned above
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go to rehab:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart (use ___
pillows or a recliner) every ___ hours throughout the day and at
night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist ___ wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
When you go rehab, you may walk and go up and down stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
Call and schedule an appointment to be seen ___ ___ weeks for
post procedure check and ultrasound
You will have weekly blood draws and results should be faxed to
___ the infectious disease nurse.
Please follow up with your appointments as illustrated below.
Followup Instructions:
___
|
10800637-DS-16
| 10,800,637 | 25,644,047 |
DS
| 16 |
2180-06-12 00:00:00
|
2180-06-12 23:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with reported psychiatric DO, pancreatic insufficiency,
polysubstance abuse (EtOH use) who presented with altered mental
status.
She reports that she has chronic epigastric abdominal pain. Over
the last couple of days she has had worsened abdominal pain,
epigastric, nausea, vomiting (multiple episodes), diarrhea. She
reports blood in both her emesis and diarrhea. She reports
drinking "1 gallon and 1 pint" of vodka per day. She reports a
history of EtOH withdrawal complicated by seizures.
Per the ED and EMS, she as in her usual state of health until
she was at a partial day program where staff were concerned as
she appeared altered. EMS found her with a mostly empty 1.75L
bottle of vodka. At that time she was able to walk to the
ambulance.
Upon arrival to ED, she was obtunded. She was arousable to
painful stimuli and maintaining her airway but not answer simple
questions. Initial vitals were: T 97.8, HR 92, BP 126/86, RR 14,
SvO2 95% RA. She was found to have serum EtOH level of 449 and
transaminitis. Other tox screen negative. RUQ U/S showed (prelim
read) " 1. No acute cholecystitis. 2. Echogenic liver consistent
with fatty liver appeared however other forms of liver disease
cannot be entirely excluded. 3. Dilated CBD in no
choledocholithiasis. However to limited evaluation of the
pancreas for which an underlying obstructing lesion cannot be
entirely excluded." She was given IV fluids and monitored. On
sober reevaluation, she notes some abdominal pain which was
concerning for pancreatitis (per ED). She was admitted for
further evaluation and management.
Currently, she notes ___ abdominal pain and nausea. She reports
that her BAL is usually higher. She feels that she is starting
to withdraw and notes that her symptoms seem similar to prior
episodes of pancreatitis.
ROS: Per above. She endorses abdominal pain, mild SOB, nausea,
vomiting, diarrhea, blood in emesis and stools, mild headache,
tremor, anxiety. She denies chest pain, back pain (at baseline),
fevers, chills, or other symptoms.
She endorses wanted to quit alcohol and is interested in
speaking with a social worker.
Past Medical History:
Back surgery ___, chronic back pain
Depression, history of SI and hospitalizations
Anxiety
Pancreatic insufficiency / pancreatitis
Polysubstance abuse - cocaine, EtOH dependence, narcotics
Hepatitis C virus, genotype 3a
History of EtOH withdrawal with seizure
Insomnia
Social History:
___
Family History:
Adopted - unknown
Physical Exam:
General: No apparent distress, curled into fetal position
Vitals: T 98.0, BP 144/83, HR 88, RR 18, SvO2 98% RA
Pain: ___
HEENT: OP clean, ?thrush - will need reeval
Neck: low JVD
Cardiac: rr, nl rate, no murmur
Lungs: CTAB
Abd: soft, tender with light palp in epigastric area, decreased
bowel sounds, voluntary guarding
Ext: wwp, no edema
Skin: no jaundice, no rashes
Neuro: good attention, AOx3, tremor (extremities and tongue)
Psych: mildy anxious, pleasant
Pertinent Results:
___ 03:15PM BLOOD WBC-4.8 RBC-3.79* Hgb-13.0 Hct-41.2
MCV-109* MCH-34.3* MCHC-31.6 RDW-14.6 Plt ___
___ 03:15PM BLOOD ___ PTT-29.2 ___
___ 03:15PM BLOOD Glucose-103* UreaN-6 Creat-0.6 Na-137
K-3.5 Cl-96 HCO3-23 AnGap-22*
___ 03:15PM BLOOD ALT-115* AST-279* AlkPhos-226*
TotBili-1.1
___ 06:20AM BLOOD ALT-162* AST-440* AlkPhos-232*
TotBili-3.4*
___ 09:00AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.3*
___ 03:15PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:15PM BLOOD VitB12-457 Folate-7.7
___ 04:20PM BLOOD Lactate-1.5
MRCP: IMPRESSION: 1. Dilated common bile duct to 10 mm which
smoothly tapers. No evidence of choledocholithiasis. These
findings most likely represents sphincter of Oddi dysfunction or
papillary stenosis. The main pancreatic duct is normal in
caliber. 2. Marked hepatic signal dropout on out-of-phase
images, compatible with fatty deposition; however, more severe
types of liver disease such as NASH cannot be excluded.
CTAP: IMPRESSION: 1. Again seen is CBD dilatation measuring up
to 1 cm. No definite evidence of choledocholithiasis; however,
an ERCP or MRCP is recommended for further evaluation. 2. Fatty
liver. 3. Note is made of bilateral corpus luteal cysts.
Brief Hospital Course:
___ with polysubstance abuse history who presents with acute
alcohol intoxication and presents with alcohol withdrawal and
epigastric pain.
.
# Acute EtOH intoxication, EtOH dependence and EtOH withdrawal:
Pt had a history of EtOH withdrawal and reports heavy EtOH use.
Her ETOH level was >400 on admission. She was monitored on a
valium CIWA scale and received multiple doses. While in house
she was continued on thiamine, folate and MVI. She was seen by
___ for substance abuse discussion/treatment options. Direct
verbal signout was provided to the patients PCP to organize ___
next day appointment given the patients very high risk for
clinical deterioration due to alcohol at home.
.
# Acute alcoholic hepatitis:
After discussion with ERCP and multiple imaging studies her
transaminitis seems consistent with acute alcoholic hepatitis.
Given this, hepatology was consulted and recommended
conservative management with nutrition.
.
# Epigastric pain:, Nausea with emesis, GI bleed:
The etiology of her pain was not clear. The differential
includes acute alcoholic hepatitis, chronic pancreatitis,
gastritis or other. She was initially treated with bowel rest,
IV fluids and analgesia. Her pain improved and she was able to
tolerate some oral diet and liquid. Her hematocrit was stable
and the bleed was likely secondary to gastritis ___
tear. Her LFTs bumped (see above) but came down over a few days.
She had no clinical signs of bleeding at discharge but her Hct
had slowly drifted down.
- The patient was provided with two days worth of the PO
equivelent of the amount of dilaudid she was receiving in house.
This should be tapered down as an outpatient. She was advised to
continue taking PPi and avoid all alcohol.
.
# Anxiety:
She was continued on her home medication of clonazepam.
.
# HCV: Untreated. This was noted in house and later confirmed by
her ___ PCP.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. ClonazePAM 1 mg PO TID
2. Gabapentin 800 mg PO TID
3. Pancreaze (lipase-protease-amylase) unknown oral ASDIR with
meals
Discharge Medications:
1. ClonazePAM 1 mg PO TID
2. Gabapentin 800 mg PO TID
3. Paroxetine 20 mg PO DAILY
4. Zenpep (lipase-protease-amylase) 15,000-51,000 -82,000 unit
oral ___ caps TID with meals
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth q4 Disp #*20 Tablet
Refills:*0
6. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- Alcoholic Hepatitis
- Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ after you consumed large amounts of
alcohol and developed alcohol induced hepatitis.
Please stop drinking alcohol and seek out additional help.
Followup Instructions:
___
|
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| 14 |
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|
2199-02-01 15:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Left below knee amputation stump infection
Major Surgical or Invasive Procedure:
___: Left below knee amputation revision
History of Present Illness:
___ M s/p recent (___) L ___ revision p/w concerns for wound
infection. Pt states that he went to visit a wound physician in
___ for wound eval, was told that he may have
osteomyelitis based on clinical exam, was transferred to ___
for wound management. Pt denies any acute changes to clinical
status, states that he has no new pain, has not had any recent
fevers, chills, nausea, vomiting, chest pain, SOB, bleeding,
numbness, or tingling. Does report some increased drainage from
stump in the past week, intermittently bloody but mostly serous.
Past Medical History:
-CAD s/p CABG and MV repair, 10'
-DM2
-HTN
-Hyperlipidemia
-PVD
-CVA x2
-MV endocarditis
-Paroxysmal AFib/flutter
-Hypothyroidism
-Diabetic neuropathy
-Cataracts
Recent Surgical History:
___:
1) Ligation of left femoral-peritoneal bypass graft.
2) Resection of pseudoaneurysm at the distal anastomosis with
ligation of distal peroneal artery.
___:
1) Ultrasound-guided access to the right common femoral artery
and placement of a ___ sheath.
2) Selective catheterization of the left external iliac artery.
3) Left lower extremity angiogram
___: Left Below Knee Amputation
Social History:
___
Family History:
Mother died from diabetic complications. Father died of an MI at
age ___. No history of arrhythmias.
Physical Exam:
Physical Exam:
VSS
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: No respiratory distress
ABD: Soft, nondistended, nontender, no rebound or guarding,
Neuro: Grossly intact CN II-XII intact
Ext: No ___ edema, s/p bilat ___. Left below knee amputation
revision site with sutures intact, with small dehiscence
centrally. Mild serosanguinous dressing. Dry eschar noted to the
anterior tibia on the right, no edema, erythema or drainage
noted.
Pertinent Results:
___ 05:02PM BLOOD WBC-10.2* RBC-3.58* Hgb-8.1* Hct-27.2*
MCV-76*# MCH-22.6*# MCHC-29.8* RDW-19.3* RDWSD-53.3* Plt
___
___ 06:10AM BLOOD WBC-9.6 RBC-3.22* Hgb-7.4* Hct-24.4*
MCV-76* MCH-23.0* MCHC-30.3* RDW-19.3* RDWSD-53.2* Plt ___
___ 06:42AM BLOOD WBC-8.9 RBC-3.16* Hgb-6.8* Hct-23.7*
MCV-75* MCH-21.5* MCHC-28.7* RDW-18.7* RDWSD-51.8* Plt ___
___ 07:20AM BLOOD WBC-10.7* RBC-3.22* Hgb-7.1* Hct-24.2*
MCV-75* MCH-22.0* MCHC-29.3* RDW-18.9* RDWSD-51.8* Plt ___
___ 05:02PM BLOOD ___ PTT-28.7 ___
___ 07:20AM BLOOD Plt ___
___ 05:02PM BLOOD Glucose-222* UreaN-30* Creat-1.6* Na-135
K-4.3 Cl-102 HCO3-19* AnGap-18
___ 06:10AM BLOOD Glucose-146* UreaN-28* Creat-1.4* Na-137
K-4.3 Cl-105 HCO3-21* AnGap-15
___ 06:42AM BLOOD Glucose-166* UreaN-29* Creat-1.4* Na-135
K-5.0 Cl-104 HCO3-23 AnGap-13
___ 07:20AM BLOOD Glucose-144* UreaN-27* Creat-1.3* Na-136
K-4.8 Cl-105 HCO3-22 AnGap-14
___ 06:10AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.9
___ 07:20AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.0
___ 06:30AM BLOOD %HbA1c-8.1* eAG-186*
___ 05:02PM BLOOD CRP-73.2*
___ 11:00AM BLOOD Vanco-25.7*
___ 05:10PM BLOOD Lactate-1.9
Brief Hospital Course:
Mr. ___ presented to ___
with an infected ulcer and concern for osteomyelitis on his left
below knee amputation site. There was erythema surrounding the
ulcer and some seropurulent drainage from the ulcer. A wound
culture was taken and he was started on IV antibiotics. The
wound culture showed sparse growth of corynebacterium. When the
erythema improved, the patient was taken to the operating room
for a left below knee amputation revision. For details of the
procedure please see the operative report. The patient tolerated
the procedure well. After a short stay in the PACU the patient
was brought to the vascular surgery floor where he stayed for
the remained of his hospitalization. Post-operatively the
patients pain was controlled with oral pain medication, he
tolerated a regular diet, and he was able to void without issue.
He was found to have a hematocrit of 23.6 and he was transfused
one unit of blood.
The patient was also noted to have some superficial ulcerations
noted to his right leg below knee amputation site, and the
patient requested to have ___
evaluate his prosthetics. ___ came to evaluate the
right leg prosthetic and made some adjustments and
recommendations to make the leg more comfortable for the
patient.
Throughout the patients stay, he was evaluated by physical
therapy. Physical therapy originally recommended he go to a
rehabilitation facility following discharge. Upon discussions
with case management, the patients insurance would not cover any
more days at a facility. After the patients prosthetic was
evaluated and adjusted, physical therapy felt that he could be
discharged home with ___ and ___ services.
Transitional Issues:
- Patient was found to have a UTI with the urine culture growing
yeast. The UTI was asymptomatic. The patient will be discharged
on a course of ciprofloxacin.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 325 mg PO DAILY
2. amLODIPine 7.5 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Finasteride 5 mg PO DAILY
5. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Levothyroxine Sodium 200 mcg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. MetFORMIN (Glucophage) 850 mg PO BID
9. Metoprolol Succinate XL 12.5 mg PO DAILY
10. Tamsulosin 0.4 mg PO QHS
11. Acetaminophen w/Codeine Elixir ___ mL PO Q4H:PRN Pain -
Mild
12. Acidophilus (Lactobacillus acidophilus) 1 capsule oral
2X/WEEK
13. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
14. Docusate Sodium 100 mg PO BID
15. Senna 8.6 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 250 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*14 Tablet Refills:*0
2. Minocycline 100 mg PO BID
RX *minocycline 100 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN for pain on
POD1
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
4. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Acetaminophen w/Codeine Elixir ___ mL PO Q4H:PRN Pain -
Mild
6. Acidophilus (Lactobacillus acidophilus) 1 capsule oral
2X/WEEK
7. amLODIPine 7.5 mg PO DAILY
8. Aspirin 325 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
11. Docusate Sodium 100 mg PO BID
12. Finasteride 5 mg PO DAILY
13. Levothyroxine Sodium 200 mcg PO DAILY
14. Lisinopril 10 mg PO DAILY
15. MetFORMIN (Glucophage) 850 mg PO BID
16. Metoprolol Succinate XL 12.5 mg PO DAILY
17. Senna 8.6 mg PO DAILY
18. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left below knee amputation stump infection
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 ___ for a
left below knee amputation stump infection with concern for
osteomyelitis. You were placed on IV antibiotics and on
___ you were taken to the operating foot for a left
below knee amputation revision.
Here are your discharge instructions:
ACTIVITY:
On the side of your amputation you are to be non weight
bearing for ___ weeks.
You should keep this amputation site elevated when ever
possible.
You may use the opposite leg for transfers and pivots.
No driving until cleared by your Surgeon.
No heavy lifting greater than 20 pounds for the next 3 weeks.
BATHING/SHOWERING:
You may shower when you get home
No tub baths or pools / do not soak your foot for 4 weeks from
your date of surgery
WOUND CARE:
Sutures / Staples may have been removed before discharge. If
they are not, an appointment will be made for you to return for
staple removal.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
CAUTIONS:
If you smoke, please make every attempt to quit. Your primary
care physician can help with this. Smoking causes narrowing of
your blood vessels which in turn decreases circulation.
DIET:
Low fat, low cholesterol / if you are diabetic follow your
dietary restrictions as before
CALL THE OFFICE ___
Bleeding, redness of, or drainage from your below knee
amputation site
New pain, numbness or discoloration of the skin on the
effected stump
Fever greater than 101 degrees, chills, increased redness, or
pus draining from the incision site.
It was a pleasure taking care of you.
- Your ___ Team
Followup Instructions:
___
|
10800948-DS-7
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2194-02-17 15:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Right foot dry gangrene
Major Surgical or Invasive Procedure:
___: Right leg below knee amputation
History of Present Illness:
___ with a history of PVD was recently hospitalized for
endocarditis in Ocotober (no clear etiology) and treated with 7
week of Ceftriaxone. While being treated for endocarditis he
noted that the ___ and ___ toes of his right foot were turning
black. Vascular surgery was consulted but they deferred
intervention due to his endocarditis. He had an angiogram
performed 4 days ago that per report showed an occluded right
pop to DP bypass graft and occluded tibial vessels as well. He
was then sent back home and decided to seek treatment with Dr.
___ in hopes of salvaging his foot. He states that over
the past two weeks the toes have worsened and become "more
black". He states that the tips of his ___ and ___ toes have
become black as well. He has developed a raw erythema that goes
from the MTP joints to the mid foot. He does have pain at rest
and is now unable to ambulate without assistance. There is no
drainage from his foot. He denies fevers and chills. He was
admitted to ___ Vascular Surgery Service under attending Dr.
___. He was given vancomycin, ciprofloxacin, flagyl,
and heparin drip (PTT 60-80) without notable improvement in
right foot gangrene. Noninvasive arterial studies of the legs
were performed and showed no waveforms at the level of the
metatarsals on the right foot. The patient was informed he
required right below knee amputation, to which he agreed and
appropriate consent was signed. He was taken to the operating
room on ___.
Past Medical History:
PMH: Diabetes, hypothyroidism, hypercholesterolemia,
hypertension, CAD
PSH: Popliteal to DP bypass with nonreversed SVG in ___, CABG x
3 with LLE vein
Social History:
___
Family History:
FAMILY HISTORY: Mother died from diabetic complications. Father
died of an MI at age ___. No history of arrhythmias.
Physical Exam:
Discharge day exam:
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: No masses, Trachea midline.
Heart: Abnormal: Irregular rhythm.
Lungs: Clear.
Gastrointestinal: Non distended.
Ext: R ___ incision site clean/dry/itact without erythema or
wound drainage; L ___ toe ulcer clean and dry without erythema
or drainage
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: P.
___ Radial: P.
RLE Femoral: P. Popiteal: P.
LLE Femoral: P. Popiteal: P. DP: D. ___: D.
Pertinent Results:
___ TTE: Well seated mitral annuloplasty ring without
evidence of mitral regurgitation. No discrete vegetations seen.
Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function.
___ lower extremety arterial nonivasive studies: 1. Severe
multilevel outflow obstruction in the right lower extremity
arterial system, moderate to severe at the level of the SFA and
severe at the level of right dorsalis pedis artery. 2. Moderate
outflow obstruction at the level of the SFA on the left.
___ upper extremety vein mapping: Patent bilateral cephalic
and basilic veins with a relatively small diameter of the left
cephalic vein.
Brief Hospital Course:
Mr. ___ was admitted to ___ on ___ with concern of
worsening RLE gangrene. Since he had been treated recently for
endocarditis, an echocardiogram was obtained on admission which
was negative for evidence of vegetations. He was intially
started on a heparin drip and IV antibiotics in an attempt to
salvage the right leg; however the gangrene continued to
progress and Dr. ___ right ___ amputation
(___) and the patient agreed.
Notably also on admission the patient was found to be in atrial
flutter, for which he had previously been treated with coumadin
but stopped due to his preference and concern for bruising. He
was admitted initially to the VICU for observation and telemetry
monitoring.
On ___, Mr. ___ underwent right ___ without
complication. He was maintained on keflex for prophylaxis
postoperatively, given the left third toe ulcer and recent ___.
Postoperatively a cardiology consult was obtained for the
ongoing atrial flutter. Due to his very high stroke risk, it
was recommended that he resume the coumadin which he had stopped
some months prior. Coumadin was re-started with a heparin
bridge.
Notably during this admission his foley catheter was
discontinued twice and he failed two voiding trials. A foley
catheter was replaced and he will be discharged to rehab with
the catheter, with anticipated follow-up at rehab and/or with
his primary care provider or urologist.
A physical therapy consult was obtained and rehab was
recommended. At the time of discharge, Mr. ___ is working
with physical therapy for transfers and ADLs. His pain is
well-controlled and he is tolerating a regular diet. He is
discharged to rehab in stable condition.
Medications on Admission:
levothyroxine 200mcg PO daily, simvastatin 10mg PO daily, asa
81mg PO daily, metoprolol 25mg PO BID, omeprazole 20mg PO daily,
metformin 500mg PO BID, lisinopril 20mg PO daily, vit C 500mg PO
BID, zinc sulfate daily
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 weeks.
11. metformin 500 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
12. metformin 500 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)). Tablet(s)
13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for yeast.
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. insulin glargine 100 unit/mL Solution Sig: ___ (28)
Units Subcutaneous once a day: given in AM.
16. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: 1000-1800 Units Intravenous ASDIR (AS DIRECTED):
goal PTT ___ while INR subtherapeutic.
17. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: Goal
INR ___, titrate dose as needed per MD.
18. Vitamin C Oral
19. zinc Oral
20. Humalog 100 unit/mL Solution Sig: One (1) Unit Subcutaneous
four times a day: Sliding scale for breakfast/lunch/dinner:
BS: Units
71-150: 0
151-200: 8
201-250: 10
251-300: 12
301-350: 14
351-400: 16
>400 call MD
___ scale for bedtime:
BS: Units
71-150: 0
151-200: 0
201-250: 5
251-300: 7
301-350: 9
351-400: 11
>400 call MD.
21. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Dose
at 4 pm daily.
22. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: 1450 (1450) units/hour Intravenous continuous:
Adjust as necessary to achieve goal PTT 60-80.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right foot gangrene
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:
DISCHARGE INSTRUCTIONS FOLLOWING BELOW OR ABOVE KNEE AMPUTATION
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please call our office nurse
if you have any questions. Dial 911 if you have any medical
emergency.
ACTIVITY:
- There are restrictions on activity. On the side of your
amputation you are non weight bearing until cleared by your
Surgeon. You should keep this amputation site elevated when ever
possible.
- You may use the other leg to assist in transferring and
pivots. But try not to exert to much pressure on the amputation
site when transferring and or pivoting. You may keep the knee
immobilizer on at nights for comfort.
Exercise:
- Limit strenuous activity for 6 weeks.
- Do not drive a car unless cleared by your Surgeon.
- Try to keep leg elevated when able.
BATHING/SHOWERING:
- You may shower immediately upon going to the rehabilitation
facility. No bathing. A dressing may cover youre amputation
site and this should be left in place for three (3) days. Remove
it after this time and wash your incision(s) gently with soap
and water. Do not take a bath or go in a pool until directed to
do so by Dr. ___.
WOUND CARE:
- Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
- When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
- Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
MEDICATIONS:
- Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
- Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
CAUTIONS:
- NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
- Avoid pressure to your amputation site.
- No strenuous activity for 6 weeks after surgery.
Followup Instructions:
___
|
10801874-DS-20
| 10,801,874 | 28,009,786 |
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| 20 |
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|
2152-05-31 20:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain, dizziness, changes in vision
Major Surgical or Invasive Procedure:
cardiac cath ___ccess, no interventions
History of Present Illness:
Mr. ___ is a ___ gentleman with PMH of HTN and HLD
who
presents as a transfer from ___ with brief episode of
chest
discomfort and troponin T elevation to 0.04 concerning for
NSTEMI.
Patient reports that he was in his usual state of health until
about one week ago. At that time, he reports experiencing mild
gait instability as well as discomfort in his chest. His
symptoms
acutely worsened on the day prior to presentation, when the
patient reports dizziness "like it took my eyes a little while
to
focus after turning my head" as well as a mild chest discomfort
after dinner. Specifically, he describes the chest discomfort as
a ___, left-sided pressure without radiation and without
worsening with exertion. He had no associated nausea or
vomiting.
The chest discomfort improved after several minutes but has been
intermittently recurring throughout the day for the last week,
lasting about 10 minutes each time. It was improved with laying
down. It had no association with food, and he has not had any
recent fever, chills, cough, rhinorrhea or other URI symptoms.
He
noted it did not seem to be worse with palpation or movement.
However, given these symptoms, the patient presented to
___
for further evaluation.
Of note, the patient has a history of hypertension for which he
is prescribed atenolol, which he hasn't been taking for the last
___ years because he felt that his blood pressure, which causes
dizziness and visual changes when it is elevated, feels normal.
He checks his BP at work very rarely (three times a year). His
systolic BPs have been in the 160s-170s. He also previously had
been treated for HLD but his statin was stopped after his lipids
improved. He previously had an episode of chest discomfort in
___ and presented to ___ at that time, and underwent
exercise stress test which was reportedly normal. He has never
had an echocardiogram. He has not seen his PCP in about ___
years
and was recently notified that his PCP has retired.
Patient presented to ___ for his symptoms, where he was
hemodynamically stable. Labs/studies at ___ notable for
mildly
elevated AST and troponin 0.04 in the absence of chest pain. He
was given full dose ASA and started on a heparin gtt. CXR was
unremarkable.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- History of dyslipidemia
2. CARDIAC HISTORY
- No prior coronary artery disease and no cath prior to this
admission
- No prior echocardiogram
3. OTHER PAST MEDICAL HISTORY
- None
Social History:
___
Family History:
- Maternal grandfather w/ MI in his ___
- Paternal grandfather with MI
- ___ uncle with MI at age ___
- Sister is healthy
- Brother with diabetes
- Two daughters who are healthy
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
======================================
VS: 98.1 BP 158 / 92 HR 75 RR 18 O2 Sat 95 RA
GENERAL: Well developed, well nourished male in NAD. Oriented
x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No xanthelasma.
NECK: Supple. No JVD appreciated.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
MSK: Chest not tender to palpation.
ABDOMEN: Soft, non-tender, non-distended. Normoactive bowel
sounds.
EXTREMITIES: Right radial TR band in place. Warm, well perfused.
No clubbing, cyanosis, or peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM:
==================
VS: ___ ___ Temp: 97.8 PO BP: 148/81 HR: 64 RR: 20 O2 sat:
98% O2 delivery: RA
GENERAL: Well developed, well nourished male in NAD. Oriented
x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No xanthelasma.
NECK: Supple. No JVD appreciated.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: CTAB, no wheezes/crackles
ABDOMEN: Soft, non-tender, non-distended. Normoactive bowel
sounds.
EXTREMITIES: right radial dressing c/d/I with no hematoma/skin
coloration changes
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS:
=====================
___ 02:22AM BLOOD WBC-5.9 RBC-4.76 Hgb-14.4 Hct-43.8 MCV-92
MCH-30.3 MCHC-32.9 RDW-12.9 RDWSD-42.9 Plt ___
___ 03:49AM BLOOD ___ PTT-49.6* ___
___ 02:22AM BLOOD Glucose-107* UreaN-19 Creat-1.0 Na-137
K-5.2 Cl-106 HCO3-20* AnGap-11
___ 02:22AM BLOOD ALT-73* AST-69* CK(CPK)-928* AlkPhos-55
___ 02:22AM BLOOD CK-MB-19* MB Indx-2.0 cTropnT-0.01
___ 02:22AM BLOOD cTropnT-0.02*
___ 08:31AM BLOOD cTropnT-<0.01
___ 02:22AM BLOOD %HbA1c-4.9 eAG-94
___ 08:31AM BLOOD Triglyc-99 HDL-61 CHOL/HD-3.1 LDLcalc-109
___ 02:22AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS:
====================
___ 07:19AM BLOOD WBC-4.4 RBC-4.72 Hgb-14.2 Hct-42.7 MCV-91
MCH-30.1 MCHC-33.3 RDW-13.0 RDWSD-42.3 Plt ___
___ 08:31AM BLOOD ___ PTT-57.7* ___
___ 07:19AM BLOOD Glucose-93 UreaN-17 Creat-0.8 Na-141
K-5.0 Cl-107 HCO3-22 AnGap-12
___ 07:19AM BLOOD ALT-60* AST-42* LD(LDH)-311* CK(CPK)-432*
AlkPhos-62 TotBili-0.7
=====================
TTE ___:
=====================
CONCLUSION: 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 and global left ventricular systolic function.
Quantitative biplane left ventricular
ejection fraction is 62 %. Left ventricular cardiac index is
normal (>2.5 L/min/m2). There is no resting
left ventricular outflow tract gradient. No ventricular septal
defect is seen. There is normal diastolic
function. Normal right ventricular cavity size with normal free
wall motion. The aortic sinus diameter is
normal for gender with normal ascending aorta diameter for
gender. The aortic arch diameter is normal
with a normal descending aorta diameter. There is no evidence
for an aortic arch coarctation. The aortic
valve leaflets (3) appear structurally normal. There is no
aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse. There is
trivial mitral regurgitation. The pulmonic valve leaflets are
not well seen. The tricuspid valve leaflets
appear structurally normal. There is physiologic tricuspid
regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/
global biventricular systolic function. No valvular pathology or
pathologic flow identified. Normal
pulmonary artery systolic pressure. No echocardiographic
evidence for left ventricular diastolic
dysfunction.
CARDIAC CATH ___:
=========================
Findings
No angiographically apparent coronary artery disease.
Recommendations
Primary prevention of CAD and continued risk factor
management.
Brief Hospital Course:
TRANSITIONAL ISSUES:
========================
[] LFTs mildly elevated on admission. Given obesity and hx HLD,
could be due to NAFDL.
Will need follow up LFTs as outpatient to ensure resolution, as
well as liver ultrasound.
[] Please start high intensity statin if LFTs and CK normalizes
on outpatient follow up labs.
[] Patient started on Lisinopril and Metoprolol, please follow
up blood pressures and titrate as needed.
[] Pt presented with NSTEMI and clean coronaries (MINOCA),
unclear whether this was due to hypertensive urgency or type I
NSTEMI - consider cardiac MRI to further work up microvascular
disease.
[] A1C this hospitalization: 4.9%
[] EF on TTE ___: 62%
PATIENT SUMMARY:
=====================
Mr. ___ is a ___ gentleman with ___ of HTN and HLD
who
presents as a transfer from ___ with brief episode of
chest
discomfort and troponin T elevation to 0.04 concerning for
NSTEMI. He is s/p cardiac cath ___ with clean coronaries and
has
remained CP free since that time. It is not entirely clear that
this
patient's clinical picture is entirely explained by NSTEMI with
clean
coronaries. He had elevated troponins and CK (900s) on admission
as well
as transaminitis. While we are treating him as if he had a heart
attack
(as it is very possible he did), if his symptoms persist and CK
remains
elevated, he may need to undergo musculoskeletal testing to make
a more
unifying diagnosis.
CORONARIES: As above, no significant coronary abnormalities on
___
PUMP: TTE ___ with ejection fraction 62 %
RHYTHM: Sinus rhythm
===============
ACTIVE ISSUES:
===============
#Chest pain:
#C/f NSTEMI:
Patient has no known history of CAD, but he has
several risk factors including hypertension and hyperlipidemia
and presents with chest pain and troponin elevation concerning
for Type I NSTEMI. He underwent a cardiac catheterization which
revealed clean coronaries. Etiology of NSTEMI with clean
coronaries could be coronary vasc dysfunction, prinzmetal's
angina, or cardiomyopathy(less likely). Pt had lipid panel WNL,
although
would benefit from statin for secondary prevention as outpatient
(holding off
initiating now given elevated LFTs and CK). Will be discharged
on ASA 81, metoprolol
12.5, lisinopril 10. TTE inpatient showed ejection fraction 62%
with Mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global biventricular systolic function.
#HTN:
Reported history of hypertension for at least the last ___
years, noncompliant with medications (atenolol). Concern for
hypertensive cardiomyopathy, no LVH on EKG. BP 150-160 on
presentation, down to 140s.
Patient was counseled on importance of weight loss and adhering
to medicines.
Reviewed importance of weight loss as method for BP control.
Will discharge on lisinopril, metoprolol.
#Dizziness:
___ be associated with cardiac ischemia; could also be
peripheral
process like BPPV. CTA head/neck without evidence of acute
intracranial process. Currently asymptomatic. No arrhythmic
events on telemetry. Could consider trial of meclizine in future
if symptoms persist.
#HLD: Previously with hyperlipidemia on statin which has since
been discontinued. Lipid panel this admission WNL but pt would
benefit
from high intensity statin as secondary prevention as
outpatient. Held on
initiation this admission given transaminitis and elevated CK.
#Transaminitis.
LFTs mildly elevated on admission, downtrending on discharge but
still elevated (ALT 42 ALT 60). Unclear etiology, possibly
viral. Given obesity and hx HLD, could be due to NAFDL. Will
need follow up LFTs as outpatient to ensure resolution, as well
as liver ultrasound.
Medications on Admission:
None
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
===============
Troponinemia and chest pain concerning for Non ST elevation
Myocardial Infarction with clean coronaries
SECONDARY:
============
transaminitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had chest pain
with elevated cardiac enzymes that was consistent with a heart
attack.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You underwent cardiac catherization, which showed that you did
not have any blockages in the large arteries of your heart.
- You had an ultrasound of your heart performed, which showed
that it was working normally.
- You were noted to have elevated liver enzymes on your labwork,
you should follow up with your primary care physician to repeat
these labs.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- 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.
TO OPTIMIZE YOUR HEART HEALTH AND PREVENT FUTURE HEART ATTACKS:
- Take your new meds: aspirin, metoprolol, lisinopril. Even if
you don't feel that your blood pressure is high, it can still
damage your heart.
-- Weight loss
-- Physical activity: Recommend 150 minutes of moderate
intensity activity per week
-- Healthy diet: Reduce saturated fat, increase fiber intake
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10802063-DS-4
| 10,802,063 | 22,903,350 |
DS
| 4 |
2168-09-19 00:00:00
|
2168-09-25 08:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
motor vehicle accident
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ G2P1 @ ___ s/p MVA at approximately 1545 in which she was
the unrestrained driver and hit her head cracking the
windshield. Denies LOC. Was driving approx. 40mph. Denies trauma
to belly. Denies abdominal pain, cramping/ctx, LOF, VB. +FM, but
less than usual.
___ per pt ___. Receives prenatal care at ___. E___. Missed
most recent PNV, and not sure when most recent visit was. On
suboxone for hx of substance abuse, ___. Denies current
drug, ETOH use. Reported to nurse that she last used opiates
2months ago. Occasionally smokes cigarettes and endorses past MJ
use. Reports otherwise nl prenatal care and is having a boy.
Pt does not know blood type.
Past Medical History:
POb: TAB x 1
PMH: denies other than substance abuse
PSH: denies other than TAB
Social History:
___
Family History:
non-contributory
Physical Exam:
(on admission)
VITALS: T 98.8, HR 100, BP 117/83, RR 17, 100% O2 on RA
rpt HR 93 RR 22 BP 115/73 100% O2 RA
Abrasion on forehead, alert and oriented x 3, does not appear to
be intoxicated
ABDOMEN: soft, NDNT, gravid
FAST exam wnl
FHR 160s
TAUS by myself: posterior placenta, FHR wnl, + active FM,
grossly normal fluid
No vaginal bleeding
Ext NT, no edema
CXR wnl
Pertinent Results:
___ WBC-10.8 RBC-4.42 Hgb-12.1 Hct-35.5 MCV-80 Plt-213
___ WBC-10.1 RBC-3.96 Hgb-10.9 Hct-31.9 MCV-81 Plt-180
___ WBC-13.5 RBC-4.14 Hgb-11.3 Hct-32.9 MCV-80 Plt-206
___ ___ PTT-26.1 ___ ___ ___ PTT-28.3 ___ ___ PTT-28.4 ___ ___ BLOOD FetlHgb-0
___ Glu-86 BUN-5 Cre-0.5 Na-133 K-3.6 Cl-103 HCO3-21
___ ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
___ y/o G2P0 admitted at 33w1d for observation after an MVA. Pt
was initially evaluated and cleared by the emergency department.
She then was transferred to labor and delivery where she
underwent prolonged monitoring. She had no evidence of preterm
labor or abruption. Her cervix was closed/50%. CBC and
coagulation studies were stable and KB was negative. Her fetal
tracing was notable for rare spontaneous decels. MFM was
consulted and performed an ultrasound which revealed no
sonographic evidence of abruption, appropriate fetal growth, and
reassuring testing. She received a course of betamethasone for
fetal lung maturity (complete ___ and the NICU was consulted.
The fetal decelerations resolved and subsequent NSTs were
reactive. She was discharged to home in stable condition on
___.
.
Of note, Ms ___ was continued on her Wellbutrin and Suboxone
as she had been taking. Social services met with the patient
during this admission.
Medications on Admission:
Wellbutrin ER 150mg daily
Suboxone (prescribed by Dr. ___ at ___)
Visteril prn
Discharge Medications:
no medication changes.
Discharge Disposition:
Home
Discharge Diagnosis:
pregnancy at 33 weeks gestation
s/p motor vehicle accident
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital for observation after an MVA.
You were evaluated by the Emergency You had no evidence of
abruption or preterm labor. You underwent close fetal monitoring
and all testing was reassuring. You received a course of
betamethasone for fetal lung maturity (second dose given at noon
on ___
Followup Instructions:
___
|
10802870-DS-5
| 10,802,870 | 20,939,802 |
DS
| 5 |
2113-09-16 00:00:00
|
2113-09-21 11:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
question seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
per Dr. ___ note:
___ is a ___ year old man with history of multiple
concussions who presents with two lifetime episodes concerning
for seizure, most recent one being today, characterized by tonic
stiffening and followed by shaking of all extremities.
As per the patient, he was sitting in the couch this ___, and the
next thing he knows is waking up to see his girlfriend calling
911. As per the patient's ___ was in his USOH this
AM and they had just finished eating tonight as he was sitting
on the couch watching TV. At around ___, she asked him
something but noted that he was not responding. She went over to
him, at which point his body became stiff and then all his
extremities started shaking. His eyes were rolled up and he was
unresponsive to vocal or tactile stimuli. He briefly ceased to
move but then resumed again and the entire episode lasted 5
minutes from the time his girlfriend first saw him. After he
opened his eyes, he seemed very confused and was asking
questions about events that had already occured during the day.
He did not return to baseline for another 30min. There was no
urinary incontinence, although the patient might have bit his
tongue. He reports no aura or preceding discomfort. He endorses
still being "foggy." His right shoulder, s/p surgery in ___, is also hurting more now.
The patient reports that in ___, he had been feeling
dizzy and therefore decided to drive to the hospital. He
describes this feeling of dizziness as lightheadedness, the kind
you get when you stand up too fast. A bystander noted that his
car slowed down, pulled to the side and then hit a pole gently.
He has no recollection of the episode and woke up only in the
ambulance. This event occured in ___ and reportedly ___
at the time was negative. EKG was normal. He did see a
neurologist in ___ but did not have an EEG done.
While he denies any recent trauma, his girlfriend reports that
he told her that he did slip and fall down the stairs on ___
and hit his head. He also has intermittent lightheadedness as
described above, regardless of position. He has had at least 7
concussions since the age of ___ from playing hockey, most
recently in ___. He also tore his right biceps tendon and had
it repaired in ___ and has been on Tramadol for pain.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies 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:
kidney stones,
concussions x7, most recent in ___
R biceps tendon repair in ___
appendectomy
Social History:
___
Family History:
No history of seizures or any neurological problems.
Physical Exam:
ADMISSION EXAM:
Physical Exam:
Vitals: T:98 P: 116 R: 18 BP: 146/83 SaO2: 100% ra
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl.
Abdomen: soft, NT/ND.
Extremities: warm and well perfused. limitation at right
shoulder ROM secondary to pain
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Able to read without difficulty. Speech was not
dysarthric. Able to follow both midline and appendicular
commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 3mm and brisk. VFF to confrontation. Fundoscopic
exam revealed no papilledema although I did not visualize good
venous pulsations.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact grossly.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Limited by decreased ROM at right shouder secondary to
pain. Normal bulk, tone throughout. No pronator drift
bilaterally.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5 5
R UTD ___ ___ 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 1
R 2 2 2 3 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
DISCHARGE EXAM:
Unchanged.
Pertinent Results:
___ 09:59PM BLOOD WBC-8.8 RBC-4.32* Hgb-13.5* Hct-38.8*
MCV-90 MCH-31.2 MCHC-34.7 RDW-12.7 Plt ___
___ 09:59PM BLOOD Neuts-80.3* Lymphs-13.2* Monos-5.2
Eos-1.0 Baso-0.3
___ 09:59PM BLOOD Glucose-89 UreaN-14 Creat-1.2 Na-139
K-3.9 Cl-102 HCO3-30 AnGap-11
___ 09:59PM BLOOD ALT-37 AST-27 AlkPhos-58 TotBili-0.3
___ 09:59PM BLOOD Albumin-4.1 Calcium-8.9 Phos-2.1* Mg-2.4
___ 09:59PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:35AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-POS
IMAGING:
U/S Kidney (___):
The right kidney measures 11.1 cm. The left kidney measures 11.1
cm. There is no hydronephrosis, stones, or masses bilaterally.
Normal cortical echogenicity and corticomedullary
differentiation are seen bilaterally. The bladder is moderately
well distended and normal in appearance.
IMPRESSION:
Normal renal ultrasound.
MRI Brain w/ and w/o (___):
IMPRESSION:
Tiny nonenhancing nonspecific focus of T2/FLAIR signal
hyperintensity in the subcortical white matter of the left
frontal lobe. A few subtle periventricular FLAIR hyperintense
foci.
Slightly increased signal intensity in some of the sulci on the
FLAIR sequence question real/artifactual. No acute infarct or
enhancing lesions. Recommend correlation with EEG and consider
followup as clinically warranted.
MRI Shoulder (___):
1. Increased T2 signal within the anterior aspect of the deltoid
along its origin from the acromion, compatible with a strain.
Mild adjacent acromial marrow edema, but no discrete fracture.
2. Mild to moderate supraspinatus tendinosis and mild
infraspinatus tendinosis. No discrete rotator cuff tear.
3. Mild degenerative changes along the acromioclavicular joint,
including inferior spurring that results in deformity of the
traversing rotator cuff.
4. Mild subacromial-subdeltoid bursitis.
Brief Hospital Course:
___ was admitted in stable condition to the General
Neurology service. He was monitored for 24 hours on video EEG.
He had no clinical or electrographic events concerning for
seizure. However, given his multiple episodes of loss of
consciousness, he was started on levetiracetam for treatment of
seizures. He had no evidence of infectious trigger of seizures;
his urine tox screen was positive for methadone which was
thought to be secondary to his tramadol use prior to admission.
His tramadol was stopped. He was instructed that he should not
drive for at least 6 months. He had an MRI which was notable of
subtle enhancement of L frontal subcortical white matter. He
will follow up in Neurology clinic.
He developed L flank pain and hematuria. This was consistent
with his prior kidney stones. A renal ultrasound did not show
any hydronephrosis. He was discharged with hydration to follow
up with his primary care provider.
For his persistent shoulder pain and associated weakness he
underwent a shoulder MRI which was concerning for a strain in
the deltoid. He was asked to follow up with his orthopedic
surgeon and given a CD of his MRI for that purpose.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Discharge Medications:
1. Ibuprofen 600 mg PO Q8H
2. LeVETiracetam 1000 mg PO BID
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*30 Tablet Refills:*5
3. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO ONCE Duration: 1
Dose
RX *oxycodone-acetaminophen 10 mg-325 mg 1 tablet(s) by mouth
Q6H:PRN Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital because you had an event concerning for
a seizure. You were monitored on EEG and we did not see any
seizures while you were in the hospital. However, because you
have had more than one episode of symptoms concerning for
seizure, we have started an anti-seizure medication, Keppra
(levetiracetam). We have obtained an MRI which did not show any
obvious abnormality which could serve as a seizure focus. The
official interpretation is still pending. However, tramadol is a
medication which can increase the likelihood of seizures. For
this reason we recommend that you stop taking tramadol for your
pain.
Since you had had an episode of loss of consciousness and we are
concerned that you have had a seizure, you should not perform
activities which would pose a risk to yourself or others around
you if you were to have another event. This includes driving,
bathing or swimming alone, operating power tools or heavy
machinery.
We saw that you were having discomfort in your shoulder. We
obtained an MRI of your shoulder which showed a strain. You
should follow up with your orthopedic surgeon to discuss these
findings. Since we have asked you to stop taking the tramadol we
have given you alternative pain medications. You should follow
up with Dr. ___ to discuss your pain control.
While you were here you had the onset of pain in your flank and
blood in your urine, which was similar to the symptoms you have
had with kidney stones in the past. An ultrasound of your kidney
did not show a concerning blockage which would require immediate
surgical intervention. We have encouraged you to drink plenty of
fluids and given you pain medications. You should follow up with
your primary care doctor and urology appointment to discuss
further treatment and prevention of these stones.
Followup Instructions:
___
|
10803413-DS-10
| 10,803,413 | 29,500,350 |
DS
| 10 |
2144-11-29 00:00:00
|
2144-11-30 18:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Demerol / Percodan / Simvastatin / Penicillins
Attending: ___.
Chief Complaint:
throbbing sensation in chest
Major Surgical or Invasive Procedure:
percutaneous vena-tech permanent IVC filter placement
History of Present Illness:
___ female with h/o metastatic pancreatic cancer s/p first
cycle of FOLFIRINOX on ___, DVT/PE on lovenox who presents
with throbbing chest and low back near her coccyx pain.
Sensation started last night. She took some pain meds with
slight relief and went to sleep. This morning still had pain so
called on call oncology fellow who asked her to come in. She had
no SOB/n/v/diaphoresis/f/c/abd pain/leg pain. has not had
symptoms like this before. When she had DVT in the past there
was pain behind both knees, not present now. She has been taking
lovenox as prescribed.
Evaluation in the ED was remarkable for CTA showing a new PE in
LLL subsegmental branch. She is admitted for further workup and
management.
Upon arrival to the floor she reports feeling well. She has had
generalized fatigue the last few days but no other specific
symptoms.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, Denies headache,
rhinorrhea or congestion. Denies cough, shortness of breath, or
wheezing. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain. Denies dysuria, arthralgias or myalgias. Denies
rashes or skin changes. All other ROS negative
Past Medical History:
Past Medical History:
1. Hypercholesterolemia.
2. Osteopenia.
3. History of Meniere's disease.
4. Status post rhinoplasty.
5. Status post left wrist cyst resected in ___.
Social History:
___
Family History:
Family History: The patient's mother is alive at ___ years, but
has suffered a stroke. Her father died at ___ with Alzheimer's
disease, maternal grandmother suffered a stroke. Paternal
grandfather died following an MI. Paternal grandmother had
breast cancer in her ___. Maternal uncle has had a stroke. Her
sister is treated for ___ disease, she has no children.
Physical Exam:
Physical Examination:
vital signs reviewed in bedside chart
GEN: Alert, oriented to name, place and situation. no acute
signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric,
MMM.
Neck: Supple
Lymph nodes: No cervical, supraclavicular or axillary LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. R
chest port no tenderness
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, no hepatosplenomegaly
EXTR: No lower leg edema
DERM: No active rash
Neuro: muscle strength grossly full and symmetric in all major
muscle groups
PSYCH: Appropriate and calm.
Pertinent Results:
==================================
Labs
==================================
___ 07:45AM BLOOD WBC-2.4*# RBC-4.00* Hgb-11.6* Hct-35.7*
MCV-89 MCH-28.9 MCHC-32.4 RDW-15.0 Plt Ct-53*#
___ 07:45AM BLOOD Neuts-17* Bands-7* Lymphs-59* Monos-6
Eos-8* Baso-0 Atyps-1* Metas-1* Myelos-1*
___ 07:45AM BLOOD ___ PTT-34.8 ___
___ 07:45AM BLOOD Glucose-116* UreaN-13 Creat-0.7 Na-136
K-3.8 Cl-101 HCO3-26 AnGap-13
___ 07:45AM BLOOD ALT-72* AST-41* AlkPhos-452* TotBili-1.4
___ 07:45AM BLOOD Albumin-3.1* Calcium-8.6 Phos-1.4* Mg-1.7
==================================
Radiology
==================================
CTA
FINDINGS:
CTA thorax: The aorta and main thoracic vessels are well
opacified. The
aorta demonstrates normal caliber throughout the thorax without
intramural
hematoma or dissection. The pulmonary arteries are opacified to
the
subsegmental level. A filling defect within the left lower lobe
segmental
branch point represents a new pulmonary embolus. There has been
interval
resolution of the right lower lobe pulmonary embolus seen on
prior CTA chest.
CT thorax: There are multiple bilateral new pulmonary nodules
compared to the
CT chest in ___. The largest on the left, in the lower
lobe, is
subpleural and measures 5 x 5 mm (2:38). The largest new nodule
on the the
right is also in the lower lobe and is pleural based, measuring
6 x 10 mm
(2:71). Also noted is mucous plugging of the left lower lobe
bronchus. There
is atelectasis within the lingula and bilateral lower lobes,
without focal
consolidation. No pleural effusion or pneumothorax is seen.
Enlarged right
hilar lymph node measuring up to 11-mm is similar in size
compared to prior
exam. No axillary or mediastinal lymphadenopathy is seen.
Multiple liver metastases appear increased in number, but are
not well
assessed on this exam.
Osseous structures: No focal osseous lesion is identified.
IMPRESSION:
1. New pulmonary embolism involving a left lower lobe segmental
branch point.
Interval resolution of the previously noted right lower lobe
pulmonary embolus
seen in ___. No acute aortic syndrome.
2. Multiple new bilateral pulmonary nodules, concerning for
metastases.
3. Liver metastases appear increased in number, although not
optimally
assessed on this study.
Brief Hospital Course:
The patient was admitted for further management of her new PE.
She did not have lower extremity US on this admission, but given
her h/o DVT, after discussion with primary oncologist,
interventional radiology, and patient and her husband, we
recommended placement of a permanent IVC filter to reduce the
risk of further pulmonary embolism. after the procedure she was
kept on heparin drip overnight. She had no puncture site
bleeding and was transitioned back to Lovenox 70mg BID the next
day. A new prescription was sent to patient assistance and
syringes will be shipped to her house. She received 3 days worth
of Lovenox shots from the inpatient pharmacy to take until she
receives her shipment. She had cytopenias while here which were
resolving on discharge and are presumed due to chemotherapy.
# Dispo:
[x] Discharge documentation reviewed, pt is stable for
discharge.
[x] Time spent on discharge activity was greater than 30min.
[ ] Time spent on discharge activity was less than 30min.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Prochlorperazine 10 mg PO Q6H:PRN nausea
3. Enoxaparin Sodium 70 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
Discharge Medications:
1. Enoxaparin Sodium 70 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 80 mg/0.8 mL 70 mg SC every twelve (12) hours
Disp #*180 Syringe Refills:*0
RX *enoxaparin 80 mg/0.8 mL 70 mg SC every twelve (12) hours
Disp #*7 Syringe Refills:*0
2. Acetaminophen 325-650 mg PO Q6H:PRN pain
3. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
pulmonary embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after having a pounding
sensation in your chest and low back. A CT scan showed a new
pulmonary embolism (blood clot in the lung) despite you being on
Lovenox as treatment for a prior PE. We discussed that placing a
filter into the IVC (one of your main veins bringing blood back
to the heart) may help prevent additional blood clots from
traveling to the lungs, and you had this filter placed on ___.
The filter will remain permanently, and you should alert
healthcare providers before any procedure to access your central
veins.
Followup Instructions:
___
|
10803413-DS-13
| 10,803,413 | 23,609,319 |
DS
| 13 |
2145-10-09 00:00:00
|
2145-10-12 10:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Demerol / Percodan / Simvastatin / Penicillins
Attending: ___.
Chief Complaint:
AMS
Hypoxia
Major Surgical or Invasive Procedure:
Thoracentesis ___
Paracentesis ___
History of Present Illness:
Mrs. ___ is a ___ w/ pancreatic adenocarcinoma with mets to
liver (s/p FOLFIRINOX, mFOLFOX x 7C, most recently on
gemcitabine/Nab-paclitaxel with ___ who presents with
altered mental status and hypoxia.
The husband provided most of the history due to her AMS. He
notes
that the patient last saw Dr. ___ on ___ for C1D13 of
gem/nab-paclitaxel. At the time of that visit it was noted she
had severe cough associated w/ fatigue, dyspnea, and worsening
neuropathy. Cough improved w/ tessalon pearles, MS contin 15mg
BID and oxycodone ___ g q6hrs but it was noted this combination
caused sedation and cognitive changes, specifically noted lack
of
focus and affects on short term memory. They adjusted her
medications and even came off the oxycodone without any changes
in her MS. ___ over the last week she has developed
increased
disorientation, "she didn't perceive the toilet as being a
toilet." She was behaving oddly, thinking that the cat litter
was
a toilet. She seems to have developed "dementia" over the past
week and that the "dementia has taken a quantum leap over the
past 2 days" per the husband.
Husband and patient denied any F/C/N/V. Denied any constipation
or diarrhea. Denied any CP or SOB but he states she appeared
tachypneic last night. He notes she had ___ last night but this
improved today. She does admit to abd pain in her RUQ with
movement.
In the ED, her O2 sats ranged in the upper ___ on RA and
improved
to mid ___ on 3L NC. Her husband noted that her MS improved
significantly. CT Head unremarkable, CTA chest revealed no PE,
larger pleural effusion and new abdominal ascites.
Past Medical History:
Past Medical History:
1. Hypercholesterolemia.
2. Osteopenia.
3. History of Meniere's disease.
4. Status post rhinoplasty.
5. Status post left wrist cyst resected in ___.
6. Metastatic Pancreatic adenocarcinoma
___ presented in early ___
with dyspnea on exertion and was diagnosed with DVT/PE. She
then described abdominal pain, and CT performed on ___
identified a 3.3 x 1.1 cm pancreatic mass encasing the splenic
artery, associated with numerous large metastatic lesions
throughout the liver. Biopsy on ___ confirmed the
finding
of metastatic pancreatic adenocarcinoma. Baseline ___
measured ___ U/mL. She began chemotherapy with FOLFIRINOX
___. Doses were reduced with cycle 2 due to fatigue.
With cycle three she transitioned to mFOLFOX and completed seven
cycles. Following this, CA ___ rose and she developed
increasing fatigue and neuropathy. She transitioned to
gemcitabine ___. With cycle 2 this was dose reduced due to
thrombocytopenia. Surveillance CT ___ showed progression
in the liver, and she transitioned to gemcitabine/nab-paclitaxel
beginning ___ with C1D13 most recently chemo ___.
Social History:
___
Family History:
Family History: The patient's mother is alive at ___ years, but
has suffered a stroke. Her father died at ___ with Alzheimer's
disease, maternal grandmother suffered a stroke. Paternal
grandfather died following an MI. Paternal grandmother had
breast cancer in her ___. Maternal uncle has had a stroke. Her
sister is treated for ___ disease, she has no children.
Physical Exam:
ON ADMISSION
VS: T 98.6 BP 105-128/56-66 Pulse 92-100 RR 18 O2 93 % on RA
GEN: AOx3, NAD
HEENT: PERRLA. dry tongue, moist buccal gutters. No cervical or
supraclavicular LAD.
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, B/L posterior inferior and
superior aspect mild inspiratory crackles.
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no ___
sign
Extremities: 2 + edema.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. ___ strength in U/L extremities B/L.
DTRs 2+ ___.
ON DISCHARGE
VS: T 98.2 BP 110/60 Pulse 92-100 RR 18 O2 93 % on RA
GEN: AOx3, NAD
HEENT: PERRLA. dry tongue, moist buccal gutters. No cervical or
supraclavicular LAD.
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, B/L posterior inferior and
superior aspect mild inspiratory crackles.
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no ___
sign
Extremities: 3 + edema; depression under socks.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. ___ strength in U/L extremities B/L.
DTRs 2+ ___.
Pertinent Results:
ON ADMISSION
___ 10:00AM BLOOD WBC-3.8* RBC-3.86* Hgb-10.6* Hct-33.9*
MCV-88 MCH-27.5 MCHC-31.4 RDW-18.4* Plt ___
___ 10:00AM BLOOD Neuts-39* Bands-1 ___ Monos-33*
Eos-3 Baso-1 ___ Myelos-0
___ 10:00AM BLOOD ___ PTT-52.6* ___
___ 10:00AM BLOOD Glucose-152* UreaN-19 Creat-1.2* Na-134
K-4.2 Cl-99 HCO3-22 AnGap-17
___ 10:00AM BLOOD ALT-21 AST-24 AlkPhos-143* TotBili-0.7
___ 10:00AM BLOOD Albumin-2.8* Calcium-8.8 Phos-3.1 Mg-2.0
ON DISCHARGE
___ 04:50AM BLOOD WBC-7.9 RBC-3.48* Hgb-9.6* Hct-30.6*
MCV-88 MCH-27.7 MCHC-31.5 RDW-18.9* Plt ___
___ 06:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Ellipto-OCCASIONAL
___ 04:50AM BLOOD Plt ___
___ 04:50AM BLOOD Glucose-111* UreaN-17 Creat-0.9 Na-139
K-3.3 Cl-104 HCO3-25 AnGap-13
PLEURAL FLUID (___)
___ 10:10AM PLEURAL WBC-1500* ___ Polys-8* Lymphs-9*
Monos-0 Eos-24* Meso-1* Macro-48* Other-10*
___ 10:10AM PLEURAL TotProt-3.1 Glucose-121 LD(LDH)-204
Albumin-2.0
ASCITIC FLUID (___)
___ 09:41AM ASCITES WBC-278* RBC-244* Polys-9* Lymphs-29*
Monos-0 Eos-1* Macroph-59* Other-2*
___ 09:41AM ASCITES TotPro-3.2 Albumin-1.6
MICROBIOLOGY
___ 10:10 am PLEURAL FLUID
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 9:41 am PERITONEAL FLUID
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
RADIOLOGY
CT HEAD ___
FINDINGS:
There is no hemorrhage, edema, mass effect, or midline shifting.
Prominence of
the ventricles and sulci is indicative of volume loss.
Nonspecific
periventricular and subcortical white matter hypodensities are
likely a
sequela of chronic small vessel ischemic disease. The basal
cisterns are
patent and there is normal gray-white matter differentiation.
No bony abnormalities seen. The paranasal sinuses, mastoid air
cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial process. Global volume loss and sequela
of chronic
small vessel ischemic disease.
The study and the report were reviewed by the staff radiologist.
CTA CHEST ___
FINDINGS:
CHEST: The thyroid is homogeneous. The right chest wall port
catheter tip
terminates in the right atrium. No pathologically enlarged
axillary lymph
nodes are seen. Small mediastinal lymph nodes are not
pathologically
enlarged. The aorta and main pulmonary artery are normal in
caliber and well
opacified with no evidence of dissection or intramural hematoma.
The pulmonary
artery branches are opacified to the segmental level with no
evidence of
pulmonary embolism.
There is a large right-sided pleural effusion with adjacent
atelectasis.
Evaluation of lung parenchyma is limited by low inspiratory
level. The lungs
demonstrate diffuse interstitial changes, some of which may be
representing
underlying interstitial lung disease, but this may represent
rapid progression
of interstitial infiltration which can be seen in pulmonary
edema or
lymphangitic spread of tumor. No evidence of pneumothorax.
ABDOMEN:
The liver demonstrates numerous hypodense lesions, consistent
with metastatic
pancreatic cancer. Left lobe biliary dilatation is again
demonstrated. There
is a large volume of free intraperitoneal fluid, new since the
recent CT from
___. The gallbladder is normal with no radio-opaque
gallstones. The
pancreas is atrophic with no surrounding inflammatory changes.
There is marked
splenomegaly with collateral veins going to the SMV, likely from
splenic vein
thrombosis. The adrenal glands are normal in size and
morphology. The kidneys
enhance symmetrically and display prompt contrast excretion with
simple cysts
bilaterally, off the interpolar region of the right kidney
measuring 6.7 cm,
and a parapelvic cyst of the left kidney.
Small hiatal hernia is noted at the distal esophagus. The
stomach is normal in
caliber. The small bowel is not obstructed. The large bowel
with decompressed
with no evidence of inflammation. The appendix is reportedly
surgically
absent. There is no retroperitoneal or mesenteric
lymphadenopathy by CT size
criteria. Undulation of the peritoneum anteriorly is indicative
of peritoneal
carcinomatosis.
PELVIS: Large volume of free fluid is seen dependently in the
pelvis. Soft
tissue deposits in the pelvis are likely drop metastases. The
distal ureters
and bladder are grossly normal. The uterus and adnexae are
unremarkable. There
is no pelvic side-wall or inguinal lymphadenopathy by CT size
criteria.
VESSELS: The aorta is normal in caliber and its major branches
are patent. An
IVC filter is noted terminating before the level of the renal
veins.
OSSEOUS STRUCTURES: Intraosseous hemangioma of T12 is noted. No
focal lytic or
sclerotic lesions are seen concerning for malignancy or
infection.
IMPRESSION:
1. Larger right pleural effusion and large amount of
intra-abdominal ascites,
new since ___.
2. Evaluation of the lungs is limited by low inspiratory level,
however there
is no evidence of large central pulmonary embolism.
Interstitial opacities
have significantly increased, raising the concern for
lymphangitic spread of
tumor and/or pulmonary edema.
3. Redemonstration of hepatic hypodensities consistent with
metastases with
evidence of peritoneal carcinomatosis.
CTA ABD/PELVIS ___
FINDINGS:
CHEST: The thyroid is homogeneous. The right chest wall port
catheter tip
terminates in the right atrium. No pathologically enlarged
axillary lymph
nodes are seen. Small mediastinal lymph nodes are not
pathologically
enlarged. The aorta and main pulmonary artery are normal in
caliber and well
opacified with no evidence of dissection or intramural hematoma.
The pulmonary
artery branches are opacified to the segmental level with no
evidence of
pulmonary embolism.
There is a large right-sided pleural effusion with adjacent
atelectasis.
Evaluation of lung parenchyma is limited by low inspiratory
level. The lungs
demonstrate diffuse interstitial changes, some of which may be
representing
underlying interstitial lung disease, but this may represent
rapid progression
of interstitial infiltration which can be seen in pulmonary
edema or
lymphangitic spread of tumor. No evidence of pneumothorax.
ABDOMEN:
The liver demonstrates numerous hypodense lesions, consistent
with metastatic
pancreatic cancer. Left lobe biliary dilatation is again
demonstrated. There
is a large volume of free intraperitoneal fluid, new since the
recent CT from
___. The gallbladder is normal with no radio-opaque
gallstones. The
pancreas is atrophic with no surrounding inflammatory changes.
There is marked
splenomegaly with collateral veins going to the SMV, likely from
splenic vein
thrombosis. The adrenal glands are normal in size and
morphology. The kidneys
enhance symmetrically and display prompt contrast excretion with
simple cysts
bilaterally, off the interpolar region of the right kidney
measuring 6.7 cm,
and a parapelvic cyst of the left kidney.
Small hiatal hernia is noted at the distal esophagus. The
stomach is normal in
caliber. The small bowel is not obstructed. The large bowel
with decompressed
with no evidence of inflammation. The appendix is reportedly
surgically
absent. There is no retroperitoneal or mesenteric
lymphadenopathy by CT size
criteria. Undulation of the peritoneum anteriorly is indicative
of peritoneal
carcinomatosis.
PELVIS: Large volume of free fluid is seen dependently in the
pelvis. Soft
tissue deposits in the pelvis are likely drop metastases. The
distal ureters
and bladder are grossly normal. The uterus and adnexae are
unremarkable. There
is no pelvic side-wall or inguinal lymphadenopathy by CT size
criteria.
VESSELS: The aorta is normal in caliber and its major branches
are patent. An
IVC filter is noted terminating before the level of the renal
veins.
OSSEOUS STRUCTURES: Intraosseous hemangioma of T12 is noted. No
focal lytic or
sclerotic lesions are seen concerning for malignancy or
infection.
IMPRESSION:
1. Larger right pleural effusion and large amount of
intra-abdominal ascites,
new since ___.
2. Evaluation of the lungs is limited by low inspiratory level,
however there
is no evidence of large central pulmonary embolism.
Interstitial opacities
have significantly increased, raising the concern for
lymphangitic spread of
tumor and/or pulmonary edema.
3. Redemonstration of hepatic hypodensities consistent with
metastases with
evidence of peritoneal carcinomatosis.
Brief Hospital Course:
___ w/ pancreatic adenocarcinoma with mets to
liver (s/p FOLFIRINOX, mFOLFOX x 7C, most recently on
gemcitabine/Nab-paclitaxel with ___ who presents with
altered mental status and hypoxia.
#AMS: Likely multifactorial from hypoxia to ___ on presentation
and med effect from narcotics. AMS quickly resolved after SaO2
>90% on supplemental O2 and holding oxycodone. D/c'ed on home O2
as below. Narcotics held at discharge.
# Hypoxia: Initially thought to be related to large R. pleural
effusion on presentation and hypoventilation ___ large ascites;
however, after reomval of 3L ascitic fluid and ~250cc pleural
fluid, her pleural effusion resolved with persistence of hypoxia
(89% on 1L NC with ambulation). Pulmonary was subsequently
consulted to eval for gemcitabine toxicity vs. lymphangitic
spread in the setting of diffuse interstitial infiltrates and
GGOs on CTA. Less likely to be cardiogenic edema, as echo showed
75 % EF, <12mm Hg PCWP, and BNP <200. On day of discharge,
patient did not want to remain for further workup for hypoxia.
She was discharged on home O2, and will see interventional
pulmonology and general pulmonology as an outpatient.
# Pleural Effusion: CTA chest on ___ showed large R. pleural
effusion; patient subsequently had a diagnostic thoracentesis on
___ which showed malignant cells on cytology. Effusion
resolved following paracentesis, indicating that fluid likely
from abdominal cavity rather than pleura.
# Ascites: Patient was noted to have distended abdomen on
presentation which limited breathing as above. Diagnostic and
therapeutic paracentesis was performed on ___, which showed no
SBP. Cytology was pending by time of discharge.
#Transitional Issues
-F/U final cytology of pleural fluid and ascites
-F/U with Dr. ___ further treatment options,
goals of care
-F/U with both pulmonology and interventional pulmonology as
below
-Patient will discuss with Dr. ___ whether she would like
repeat paracentesis for abdominal ascites.
-Patient being d/ced with home oxygen in the setting of new
pleural effusion (likely from abdominal ascites) and persistent
hypoxia on RA
-Reassess pain as narcotic analgesia held on discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 60 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
2. Morphine SR (MS ___ 30 mg PO BREAKFAST
3. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
4. Mirtazapine 7.5 mg PO HS
5. Pregabalin 25 mg PO BREAKFAST
6. Pregabalin 50 mg PO QHS
7. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000 unit
oral TID with meals and snacks
8. Lorazepam 0.5 mg PO BREAKFAST
9. Morphine SR (MS ___ 15 mg PO QHS
Discharge Medications:
1. Pregabalin 25 mg PO BREAKFAST
2. Pregabalin 50 mg PO QHS
3. Enoxaparin Sodium 60 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
4. Mirtazapine 7.5 mg PO HS
5. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000 unit
oral TID with meals and snacks
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pancreatic adenocarcinoma
Pleural Effusion
Ascites
Hypoxia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were brought to the hospital because you had an altered
mental status and were feeling short of breath. Your blood
oxygen level was low, which improved after starting you on
supplemental oxygen. Your mental status improved after this, and
after holding your oxycodone. A CAT scan of your stomach and
chest showed that you had fluid around your lung and your
abdomen. We performed a thoracentesis to drain the fluid around
your lung and a paracentesis to drain the fluid around the
abdomen. Your oxygen level improved after the fluid was removed,
but you still required supplemental oxygen. Prelimnary results
of the fluid in your lung are positive for malginant cells.
You were seen by our pulmonologists to determine the cause of
your low oxygen, but you wished to go home before the work-up
was completed. You should wear oxygen at all times until this
issue is resolved. Please follow-up with the interventional
pulmonologists and regular pulmonologists as listed below.
Please follow-up with Dr. ___ as listed below to discuss
further management of your pancreatic cancer.
We wish you all the best!
-Your ___ Care Team
Followup Instructions:
___
|
10803598-DS-15
| 10,803,598 | 27,025,474 |
DS
| 15 |
2137-04-30 00:00:00
|
2137-04-30 21:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / lorazepam
Attending: ___.
Chief Complaint:
Abdominal Pain
Hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with hx HTN, anxiety, and prior history of AFib who
presents with abdominal pain for ___ weeks.
At the end of ___ patient started experiencing constant
abdominal pain near the belly button with an aching sensation.
No
radiation or cramping. Not exacerbated by po intake and not
relieved by BMs. Intermittent bouts of nausea and loose stools.
Abdominal pain worsened through the day to the point where she
was shaking, relieved with ativan. Has not had much po intake
for
1.5 weeks but due to loss of appetite, not due to pain.
Associated with generalized weakness, dizziness when standing,
instability c/b falls x2 (mechanical in nature, no headstrike or
LOC). Reports diarrhea after eating chocolate and also iso
miralax, urinary urgency with accidents, and lots of
bloating/belching/dyspepsia. Has been seen by GI for this
abdominal pain with recommendation for H pylori breath test
which
was performed.
Denies numbness/tingling in LEs, fevers, chills, night sweats,
cough, sore throat, congestion, CP, palpitations, SOB,
orthopnea,
PND, ___ edema, bloody stools, dysuria, hematuria, urinary
frequency.
In the ED...
- Initial VS: T98.2, HR64, BP135/61, RR16, PO299% RA
- Exam notable for: Grossly non-focal. CNs II-XII grossly
intact.
Sensation and motor function of extremities grossly intact. Skin
warm and dry without any rash.
- Labs were notable for: bwc 12.1, hgb 11.9, Cr 1.9, Na 123->126
(WB), K 6, serum Osm 267, AST 46, ALT 17, lactate 1.5, UA
unremarkable; urine Na 29, Osm***
- Studies performed include:
*CT A/P: No acute abdominopelvic pathology, specifically no
evidence of bowel obstruction.
*EKG: NSR rate 60, normal axis and intervals; TWI V1-2, no other
acute ST changes
- Patient was given:
IV Ondansetron 4 mg
IVF NS 500 mL
PO/NG LORazepam .25 mg
Upon arrival to the floor, patient is doing well with improved
abdominal pain and nausea.
Past Medical History:
HTN
Anxiety
Panic disorder
Hx of Afib (___)
CKD
Urinary incontinence
Osteoporosis
Polymyalgia rheumatic
Pseudophakia of both eyes
Social History:
___
Family History:
Sister- ___ skin cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T99.4, BP 105/57, HR 68, RR 18, PO2 98 Ra
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
ENT: Dry MM. No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, distended; non-tender to deep
palpation in all four quadrants
MSK: No spinous process tenderness. No CVA tenderness.
EXT: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+
bilaterally.
NEUROLOGIC: AOx3, no focal deficits
DISCHARGE PHYSICAL EXAM
Vitals: 24 HR Data (last updated ___ @ 842)
Temp: 97.8 (Tm 98.2), BP: 132/66 (126-168/57-75), HR: 64
(63-78), RR: 18, O2 sat: 98% (95-100), O2 delivery: Ra, Wt:
118.83 lb/53.9 kg
GENERAL: Alert, lying comfortably in bed. In no acute distress.
EYES: PERRL. Sclera anicteric and without injection.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: CTAB. No wheezes, rhonchi or rales. No increased work of
breathing.
ABDOMEN: Active bowels sounds, mild distention; tenderness with
deep palpation in epigastrium, no rebound/guarding
EXT: No ___ edema
NEUROLOGIC: AOx3 (difficulty remembering hospital name)
PSYCH: Affect appropriate to situation, states mood is "good".
No
active hallucinations, feelings of depression or anxiety, SI/HI.
Good insight/judgment.
Pertinent Results:
ADMISSION LABS
___ 03:30PM BLOOD WBC-12.1* RBC-3.90 Hgb-11.9 Hct-35.1
MCV-90 MCH-30.5 MCHC-33.9 RDW-13.5 RDWSD-44.0 Plt ___
___ 03:30PM BLOOD Neuts-81.2* Lymphs-11.0* Monos-6.6
Eos-0.6* Baso-0.3 Im ___ AbsNeut-9.86* AbsLymp-1.33
AbsMono-0.80 AbsEos-0.07 AbsBaso-0.04
___ 03:30PM BLOOD Glucose-120* UreaN-19 Creat-1.9* Na-123*
K-6.0* Cl-88* HCO3-22 AnGap-12
___ 03:50PM BLOOD ALT-17 AST-46* AlkPhos-63 TotBili-0.3
___ 03:50PM BLOOD Albumin-4.4
___ 01:40AM BLOOD Calcium-9.8 Phos-3.2 Mg-1.3*
___ 03:50PM BLOOD Osmolal-267*
___ 04:03PM BLOOD Lactate-1.5
___ 07:40PM URINE Osmolal-216
___ 07:40PM URINE Hours-RANDOM Na-29
DISCHARGE LABS
___ 05:55AM BLOOD WBC-9.2 RBC-3.59* Hgb-11.0* Hct-32.8*
MCV-91 MCH-30.6 MCHC-33.5 RDW-13.7 RDWSD-46.0 Plt ___
___ 05:55AM BLOOD Glucose-90 UreaN-15 Creat-1.2* Na-135
K-4.7 Cl-97 HCO3-25 AnGap-13
___ 05:55AM BLOOD Calcium-9.6 Phos-2.3* Mg-1.6
OTHER PERTINENT LABS
Na trend during stay: (___) 123 -> 129 -> 127 -> 131 -> 128 ->
125 -> 126 -> 132 -> 135 (___)
MICRO
URINE CULTURE (Final ___: < 10,000 CFU/mL.
IMAGING
CT A/P without contrast (___)
IMPRESSION: No acute findings to account for reported abdominal
pain.
Brief Hospital Course:
PATIENT SUMMARY STATEMENT
___ yo F with hx HTN and anxiety who presented with abdominal
pain found to have hypotonic hyponatremia, ___ iso hypovolemia,
and waxing-waning delirium iso anxiolytics, improved after IVF,
increased PO intake, and Ativan discontinuation.
ACUTE MEDICAL ISSUES
# Hyponatremia
# Poor PO intake:
Patient initially found to have hyponatremia (Na 123), with labs
suggestive of hypotonic hyponatremia likely iso thiazide
diuretic, poor PO intake, and hypovolemia, with resolution after
IVF and increased PO intake with Ensure supplementation. Sodium
was monitored daily. Na at discharge ___: 135.
# Abdominal pain:
Patient with abdominal pain for the last month in epigastric
region, with unclear etiology. Suspected causes include
PUD/gastritis vs H pylori vs functional dyspepsia. CT scan was
unrevealing. H pylori stool Ag is currently pending. We started
ranitidine, Maalox, and simethicone, which helped improve her
pain.
# AoCKD
Presented with an elevated Cr 1.9, with baseline Cr around
1.4-1.6, likely iso prerenal etiology given poor PO intake. Cr
was monitored daily and improved with IVF and increased PO
intake. HCTZ was discontinued. Cr at discharge: 1.2.
#Tremors
#Anxiety
New onset of tremors likely iso withdrawal to abruptly stopping
Amitriptyline and Perphenazine before admission. Tremors
resolved after restarting these medications, with concurrent
improvement in anxiety. Home Lorazepam was d/c'ed due to ADE of
delirium. Trial of Hydroxyzine for anxiety, which was also
d/c'ed due to delirium. She was evaluated by psych ___, who
recommended switching Perphenazine to Remeron as outpatient with
close monitoring. Mood was good with minimal anxiety at
discharge.
#Delirium
Patient experienced waxing and waning delirium with visual
hallucinations during stay, likely hospital induced + ADE to
anxiolytic meds (lorazepam, hydroxyzine). She was placed on
delirium precautions (frequent reorientation, encouraging
early/frequent mobility to chair with assistance, electrolyte
management, minimizing delirium inducing meds). Delirium
resolved by the time of discharge.
#Fall risk
She has a hx of a recent fall, with deconditioning recently due
to poor PO intake. Given new complaint of R leg pain, XR was
ordered of her R tibia/fibula. Per ___ evaluation recs, she was
discharged to rehab.
# Leukocytosis
# Hx UTI
She was diagnosed with UTI at PCP office, started on Bactrim,
finished ___. Leukocytosis resolved, and she had no
urinary sx at discharge.
CHRONIC MEDICAL ISSUES
# Hx Afib, reportedly no longer a diagnosis:
Continued Metoprolol tartrate 50mg BID
# HTN:
Continued Losartan 100mg daily and Metoprolol tartrate 50mg BID.
Stopped HCTZ 25mg daily due to hyponatremia and ___.
TRANSITIONAL ISSUES
For PCP:
[] Per inpatient psychiatry recommendation, consider
discontinuing Perphenazine for anxiety management and starting
Mirtazapine for anxiety/appetite stimulation (starting at 7.5mg
po qhs) with continuation of Amitriptyline 25mg po qhs.
[] Follow up on H pylori stool testing, which is currently
pending
[] Please continue ranitidine, Maalox, and simethicone until
___ (6 week duration). If no resolution of abdominal
pain, consider need for outpatient EGD.
[] Given hyponatremia and ___, we discontinued HCTZ. Please
monitor BPs and consider if alternative antihypertensive is
required.
>30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sulfameth/Trimethoprim DS 1 TAB PO BID
2. LORazepam 0.5 mg PO BID:PRN anxiety
3. Metoprolol Tartrate 50 mg PO BID
4. Losartan Potassium 100 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE BID
Discharge Medications:
1. Amitriptyline 25 mg PO QHS
2. Perphenazine 2 mg PO QHS
3. Ramelteon 8 mg PO QPM
4. Ranitidine 150 mg PO BID Duration: 5 Weeks
5. Simethicone 40-80 mg PO QID:PRN bloating
6. Losartan Potassium 100 mg PO DAILY
7. Metoprolol Tartrate 50 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
9. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hyponatremia
___
Poor PO intake
Anxiety
Abdominal pain
Risk of falls
Delirium
Hx of UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You initially presented to the hospital for abdominal pain
and a low sodium level. You were also found to have worsening
kidney function (e.g. acute kidney injury). You were admitted
for further evaluation and treatment.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- For your abdominal pain, we performed a CT scan of you
abdomen, which was normal. Given concern for gastritis, we
started you on ranitidine, Maalox, simethicone. We tested you
for H pylori, which is pending. Your abdominal pain improved
with these medications.
- For your low sodium level and acute kidney injury, we
performed blood and urine tests, which showed that you were
dehydrated. Likely, the dehydration was due to you
eating/drinking less than usual and your antihypertensive
medication HCTZ. We stopped your HCTZ. We gave you IV fluids,
supplemented your diet with Ensure/Glucerna shakes. Your kidney
function and sodium level improved with these interventions.
- For your anxiety and tremors, we restarted your home
Amitriptyline and Perphenazine with concern of withdrawal from
abruptly stopping these medications recently. We stopped your
Ativan, since it was causing confusion and falls. We started
Ramelteon, which helps with sleep. Your anxiety improved
throughout your stay with these measures.
- We continued your treatment (Bactrim) for your UTI, which was
completed ___.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please follow-up with your PCP about your anxiety management.
Consider outpatient psychiatry referral from your PCP if anxiety
is not well-managed.
- Please continue eating three meals a day, drinking plenty of
fluid, and supplementing meals with Ensure
- Please continue to take all of your medications as directed
- Please follow up with all the appointments scheduled with
your doctor
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Team
Followup Instructions:
___
|
10803622-DS-14
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2113-12-08 00:00:00
|
2113-12-13 15:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with no significant PMHx who presents to the hospital with
abdominal pain for approximately 4 days, with imaging concerning
for perforated appendicitis. Patient states that he has had
lower abdominal pain for since ___, he describes pain as a
pressure sensation. He has had diarrhea since ___. Endorses
nausea, anorexia, with one episode of emesis on ___, which
prompted his visit to an OSH ED, however he states the ED was
busy and decided to leave the ED AMA. He report significant
improvement in abdominal pain yesterday afternoon, and the pain
returned today. He has had chills and night sweats, but no
fevers.
His only prior surgery is a laparoscopic ventral hernia at ___
___ ___ years ago, and he continues to have chronic pain
from this repair, for which he has seen Dr. ___
times in clinic.
On evaluation in the ED, patient with a low grade temperature to
100.9 but hemodynamically stable. WBC 11.7 and lactate 1.3.
Imaging concerning for perforated appendicitis. with gangrenous
appendix and adjacent 3.9 x 1.5 cm complex fluid collection
concerning for perforation.
Review of systems negative except otherwise noted in the HPI
Past Medical History:
Past medical history:
- Hemorrhoids and anal fissures, rectal pain
Past surgical history:
- Laparoscopic ventral hernia repair (___) by Dr. ___
___ History:
___
Family History:
Cancer in grandfather and great uncle.
Physical Exam:
Admission Physical Exam:
Vitals: Temp 100.9 HR 83 BP 146/64 RR18 PO2 97% RA
Gen: NAD, A/Ox3, resting comfortably in bed
HEENT:PERRLA, EOMI
Lungs: CTAB, not in respiratory distress
CV: RRR
Abd: soft, nondistended, tender in RLQ, no rebound or guarding
Ext: WWP
Discharge Physical Exam:
VS: 98.2 PO 121 / 79 R Lying 73 18 96 Ra
GEN: Awake, alert, pleasant and interactive.
HEENT: PERRL, EOMI. nares patent, mucus membranes pink/moist.
CV: RRR
PULM: Clear to auscultation bilaterally
ABD: Soft, non-tender, non-distended, active bowel sounds.
EXT: Warm and dry. ___ pulses. no edema
NEURO: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 07:49AM BLOOD WBC-6.0 RBC-4.72 Hgb-13.6* Hct-39.5*
MCV-84 MCH-28.8 MCHC-34.4 RDW-11.6 RDWSD-35.3 Plt ___
___ 07:31AM BLOOD WBC-8.2 RBC-5.26 Hgb-15.0 Hct-44.0 MCV-84
MCH-28.5 MCHC-34.1 RDW-11.9 RDWSD-35.7 Plt ___
___ 06:57AM BLOOD WBC-8.4 RBC-4.78 Hgb-14.0 Hct-40.7 MCV-85
MCH-29.3 MCHC-34.4 RDW-11.8 RDWSD-36.6 Plt ___
___ 10:34AM BLOOD WBC-11.6* RBC-4.99 Hgb-14.3 Hct-42.4
MCV-85 MCH-28.7 MCHC-33.7 RDW-12.0 RDWSD-36.6 Plt ___
___ 07:49AM BLOOD Glucose-122* UreaN-7 Creat-0.7 Na-141
K-3.9 Cl-103 HCO3-26 AnGap-12
___ 07:31AM BLOOD Glucose-96 UreaN-12 Creat-0.6 Na-145
K-3.8 Cl-104 HCO3-25 AnGap-16
___ 06:57AM BLOOD Glucose-87 UreaN-12 Creat-0.8 Na-145
K-4.0 Cl-105 HCO3-23 AnGap-17
___ 10:34AM BLOOD Glucose-93 UreaN-10 Creat-0.7 Na-141
K-3.6 Cl-101 HCO3-27 AnGap-13
___ 07:49AM BLOOD Calcium-9.2 Phos-3.8 Mg-1.9
___ 07:31AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.0
___ 06:57AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.9
___ 10:49AM BLOOD Lactate-1.3
___ 02:12PM URINE Color-Straw Appear-CLEAR Sp ___
___ 02:12PM URINE Blood-TR* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-60* Bilirub-NEG Urobiln-NORMAL pH-6.5
Leuks-NEG
___ 2:12 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 2:25 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
Brief Hospital Course:
Mr. ___ is a ___ yo M who presented to the Emergency Department
on ___ with 4 days of abdominal pain, elevated white blood
cell count to 11.6, and CT scan concerning for perforated
appendicitis with abscess. He was hemodynamically stable and
exam consistent with right lower quadrant pain. ___ was consulted
for possible drainage but the collection was too small. He was
made NPO, given IV antibiotics, and admitted to the surgical
floor for monitoring and continued antibiotic treatment. On HD2
his pain was improved and white blood cell count decreased to
8.4 and pain was slightly improved. On HD3, abdominal pain
continued to improve and diet was advanced to clears. On HD4,
abdominal pain was nearly resolved and therefore diet was
advanced to regular and he was transitioned to oral antibiotics
with continued good effect.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services to
complete a course of antibiotics. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
Current medications: None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO BID
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*22 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*33 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute perforated appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the Acute Care surgery clinic with
abdominal pain and were found to have perforated appendicitis.
You were given antibiotics and your pain improved. Your diet was
gradually advanced and you were given oral antibiotics and
continued to feel well. You are now ready to be discharged home
to complete a course of antibiotics.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Followup Instructions:
___
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10804034-DS-24
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2139-01-13 00:00:00
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2139-01-14 20:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headache, chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year-old female with past medical history of CAD with MIx2
and stenting to RCA in ___, T2DM, HTN, and HLD who presents
with 6 days of headache and chest pain. Patient was on a plane
ride from ___ to the ___ straight for 17 hours last ___
and developed a headache on-flight. The pain is in the back of
the head but also involved the top of the head as well. Patient
has sensitivity to light and sound and pain in the neck as well,
especially when moving her neck. Her head felt numb on the sides
and she has general body aches. She also feels very tired and
has been sleeping much more than usual (because of jetlag), but
as per her family when she is awake she is at her baseline
mental status. Patient has had subjective fevers and chills at
home, but did not take her temperature.
She has pain in the chest as well for which she took a prn
nitroglycerin with minimal improvement. The pain has largely
resolved but she is left with a focal chest pain under the right
breast. She points to 4 tender points on her chest wall. No
nasuea or vomiting, no cough or shortness of breath, no
palpitations, no diaphoresis.
In the ED, initial VS: 99.6 80 115/51 16 97% RA. Exam was
notable for clear lungs. Labs were significant for negative
troponin x1. Patient had a CTA showing no PE or aortic
dissection. EKG was significant for sinus rhythm, normal axis,
Q-waves in II, III, aVF, and no signs of ischemia. LP was
recommended to patient to rule out meningitis given headache,
photophobia and neck pain. Patient refused LP. She never was
febrile, hypotensive or hemodynamically unstable while in the
emergency department. Patient was ordered for vancomycin and
ceftriaxone for empiric treatment for meningitis. She received
fentanyl and oxycodone for pain. Vitals on transfer: T98.6,
HR74, RR18, BP 125/74, O2sat:100% RA.
On the floor, patient reports her pain is much improved and
resolved. She still has some neck pain more towards right
trapezius, but is able to move her neck all around. No fevers or
chills. Her chest pain is also better but she still has focal
point of tenderness at under right breast.
ROS:
+ As per HPI
-fever, chills, night sweats, rhinorrhea, congestion, sore
throat, cough, shortness of breath, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
# CAD s/p IMI in ___, s/p stent to RCA in ___
# Diabetes mellitus
# Hypercholesterolemia
# Cataract surgery
# Breast mass biopsy in ___ showing intraductal papilloma
# Status post cholecystectomy
# Carpal Tunnel
# Osteoporosis
Social History:
___
Family History:
No MIs or sudden deaths in the family.
Physical Exam:
Physical exam:
VS - Temp 98.2 F, BP 103/61, HR 73, R 18, O2-sat 100% RA
GENERAL - well appearing woman in no acute distress.
HEENT - NC/AT, right pupil deformed secondary to eye surgical
intervention, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, patient able to complete full flexion of neck and
touch chin to chest (although she reports discomfort when doing
this), no lymphadenopathy
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, S1, S2, ___ SEM
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no clubbing/cyanosis/edema
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
Discharge physical exam:
remained afebrile. vital signs stable. continued to have supple
neck. No headache. Reproducible chest pain at 4 well defined
points on the chest wall anteriorly
Pertinent Results:
Labs:
=====
___ 04:50PM BLOOD WBC-4.2 RBC-4.72 Hgb-13.5 Hct-42.8 MCV-91
MCH-28.7 MCHC-31.7 RDW-13.0 Plt ___
___ 06:00AM BLOOD ___ PTT-29.6 ___
___ 06:00AM BLOOD Glucose-121* UreaN-6 Creat-0.7 Na-140
K-4.3 Cl-105 HCO3-28 AnGap-11
___ 06:00AM BLOOD CK(CPK)-41
___ 06:00AM BLOOD CK-MB-1 cTropnT-<0.01
___ 04:50PM BLOOD cTropnT-<0.01
___ 06:00AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.9
___ 04:50PM BLOOD D-Dimer-911*
Microbiology:
=============
___ blood culture pending
EKG ___:
============
Sinus rhythm. Probable prior inferior Q wave myocardial
infarction. Compared
to the previous tracing of ___, no diagnostic change.
CT head without contrast:
=========================
IMPRESSION:
1. No evidence of acute intracranial process.
2. Small vessel ischemic disease.
CTA chest with and without contrast:
====================================
FINDINGS:
The pulmonary artery appears well opacified without perfusion
defect to
suggest acute pulmonary embolus. The intrathoracic aorta is
normal in caliberwithout evidence of dissection. Heart size is
top normal with trace
pericardial effusion. Coronary artery calcifications are
mild-to-moderate. Great vessels are unremarkable. There are
scattered mediastinal lymph nodes, which do not meet CT criteria
for pathologic enlargement. For example, a pretracheal lymph
node measures 7 mm (3:16). Right hilar lymph nodes measures 9
mm (3:25). A left hilar lymph node measures 7 mm (3:30). No
pathologically enlarged axillary lymph nodes are seen. Basilar
dependent atelectasis is noted. Otherwise, lungs are clear.
The tracheobronchial tree is patent to subsegmental levels.
There is no pneumothorax.
The study is not tailored for subdiaphragmatic evaluation;
however, partially imaged upper abdominal visceral organs are
unremarkable. Small hiatal hernia is present.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is
seen.
IMPRESSION:
No acute aortic syndrome or pulmonary embolus.
Brief Hospital Course:
Ms. ___ is a ___ year-old woman with type 1 DM presented with
headache and chest pain, most likely musculoskeletal after 17
hour long flight from ___. Discharged home without pain,
fever, or leukocytosis.
# Headache: Patient with headache and neck pain following recent
travel from Ethopia (17 hour straight flight), most likely
musculoskeletal in origin. Differential diagnosis includes
vascular cuase (SAH, intracerebral hemorrhage), but no evidence
of bleeding on head CT and patient refused LP. Possibly
secondary to infection. Other possible etiologies of headache
include tension, migraine (although typically would not last
this long). Patient received empiric treatment for meningitis in
ED. Given patient's non-toxic appearance (she is afebrile, well
appearing, not hypotensive/tachycardiac), no leukocytosis, and
given time course of headaches (6 days) - this is very unlikley
to be a bacterial meningitis. Furthermore, patient's headache
and neck pain are much better after only one dose of antibiotics
in the emergency department, which would be unlikely if
bacterial meningitis. Furthermore, patient without nuchal
rigidity on exam. We had long discussion with patient and her
family about risks and benefits of LP. Family and patient
refused LP. Her symptoms have already improved since arrival to
ED and did not recur while monitored on the floor. No further
antibiotics were given during her stay.
# Chest pain: Patient with history of CAD s/p stenting to RCA in
___. No ischemic EKG changes and troponin negative. Patient
with recent long flight and elevated D-dimer, but no CTA of PE.
No aortic dissection. No pneumonia on CXR. Possibly
musculoskeletal in etiology as patient has point tenderness at 4
specific points the patient points and presses on. We continued
home ASA, betablocker, isosorbide.
# CAD: s/p stent in ___. We continued home aspirin, statin,
beta blocker, ACEI.
# Diabetes Mellitus: Last HgbA1c was 7.6 in ___. We
continued home NPH along with ISS humalog. Metformin was held
while inpatient.
# Hypertension: Normotensive while in the hospital. We continued
captopril 25 mg twice daily, isosorbide dinitrate 5 mg twice
daily, metoprolol succinate 50 mg daily.
# HLD: We continued simvastatin 20 mg daily.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
PatientFamily/CaregiverwebOMR.
1. Alendronate Sodium 70 mg PO WEEKLY
2. Captopril 25 mg PO TID
Hold for SBP < 100
3. Isosorbide Dinitrate 5 mg PO TID
Hold for SBP < 100
4. MetFORMIN (Glucophage) 1000 mg PO QAM
5. MetFORMIN (Glucophage) 500 mg PO QPM
6. Metoprolol Succinate XL 50 mg PO DAILY
Hold for SBP < 100, HR < 55
7. Simvastatin 20 mg PO DAILY
8. Aspirin 325 mg PO DAILY
9. NPH 50 Units Breakfast
NPH 25 Units Dinner
Discharge Medications:
1. Alendronate Sodium 70 mg PO WEEKLY
2. Captopril 25 mg PO BID
Hold for SBP < 100
3. Isosorbide Dinitrate 5 mg PO BID
Hold for SBP < 100
4. MetFORMIN (Glucophage) 1000 mg PO QAM
5. MetFORMIN (Glucophage) 500 mg PO QPM
6. Metoprolol Succinate XL 50 mg PO DAILY
Hold for SBP < 100, HR < 55
7. Nitroglycerin SL 0.4 mg SL PRN chest pain
1 tab every 5 minute, max 3 tablets. if pain does not resolve,
please call ___ and go to ER
8. Simvastatin 20 mg PO DAILY
9. Aspirin 325 mg PO DAILY
10. NPH 50 Units Breakfast
NPH 25 Units Dinner
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
-Headache and neck pain, most likely musculoskeletal and
long-travel hours, jet lag, timing differences, less likely
infectious
-Chest pain, most likely musculoskeletal
Secondary Diagnoses:
Diabetes type II
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a great pleasure taking care of you. As you know you were
admitted to ___ because of
headache, being bothered by light, and chest pain.
You had a CT scan of your head which didn't show abnormalities.
Also you had a CT scan of your chest which didn't show disease
in your aorta or a clot in your lung vessel or an infection in
your lungs. Your EKG did not show active heart attack changes.
Your heart enzyme was normal. Doing a spinal tap was offered in
the Emergency Department being concerned about an infection in
the layers covering your brain however you declined this.
Antibiotics were given for a presumed infection however our
suspicion that this is an infection is low.
During your stay your pain resolved. You did not have fever or
elevated white cells. We think your pain is mainly muscular
related to your long-hour travel.
We did not make changes in your medication list. Please continue
taking them the way you were taking at home prior to admission.
Please follow with the appointments as illustrated below.
Followup Instructions:
___
|
10804288-DS-18
| 10,804,288 | 25,790,934 |
DS
| 18 |
2122-08-17 00:00:00
|
2122-08-18 09:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L vision loss
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ yo L-handed woman with history of stroke
without residual deficit, PFO + ASA, epilepsy on LEV (follows
with Neurology, ___ who presents as a transfer from
___ with left eye vision loss.
Yesterday evening she suddenly lost vision in her left eye while
watching TV. She covered each eye and was able to see normally
out of her right eye, but saw only a few spots of light out of
her left eye, otherwise black. This lasted for 30 min before
resolving.
This morning at 0900 she again had sudden onset of painless
vision loss of left eye while watching TV. She then presented to
___, and while there her vision returned after a total
of approx. 45 minutes. Her vision is now at baseline.
She has had no episodes of focal neurologic deficits either
recent nor remote except she remembers having approx. 30 min of
R
arm numbness several years ago.
Headaches - rare, none for ___ months.
Jaw claudication - none
Scalp tenderness - none
weight loss - Curr weight 104lb. Ms. ___ reports 8 lb loss
in
last 6 months, though daughter notes Ms. ___ weight has
been stable at 104 at least since ___, when her daughter
started attending medical appointments with her. Ms. ___
reports relatively poor PO intake, saying "I don't like to
cook".
Past Medical History:
HTN
TIA (chart review shows this occurred in mid ___, pt does not
recall details)
Stroke ___ per chart review, L periventricular by imaging. Pt
and family do not remember this and do not remember any
presenting clinical symptoms
Cerebral microvascular disease
PFO + Atrial septal aneurysm
Epilepsy, focal onset, with post-ictal ___ L paralysis + L
neglect, only seizure ___.
anemia
h/o upper GIB
migraine
osteoporosis
s/p bilateral cataract surgery
anxiety
hypothyroidism
polymyalgia rheumatica
essential tremor
Social History:
___
Family History:
Father d. ___, throat cancer, tremor in ___
Mother d. ___
3 sons, healthy
5 healthy grandchildren.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: T: 98 HR: 74 BP: 124/57 RR: 16 SaO2: 97% RA
General: Awake, cooperative, NAD.
HEENT: no scleral icterus, MMM, no oropharyngeal lesions.
Temporal arteries with good pulses bilaterally, no firmness nor
nodularity of the arteries.
Neck: supple, no carotid bruits.
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: Skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema.
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive to exam. Speech is fluent
with normal grammar and syntax. No paraphasic errors.
Comprehension intact to complex commands. Normal prosody.
-Cranial Nerves: **Prior to Ophthalmology pupillary dilatation**
Pupils 2.5->2. No rAPD. VFF to confrontation OD, OS. EOMI
without
nystagmus. Facial sensation intact to light touch. Face
symmetric
at rest and with activation. Hearing intact to conversation.
Palate elevates symmetrically. ___ strength in trapezii
bilaterally. Tongue protrudes in midline and moves briskly to
each side. No dysarthria.
- Motor: Normal bulk and tone. No drift. Mild right worse than
left postural tremor.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 4+ 5 4+ 5
R 5 ___ ___ 4 5 4 5
-DTRs:
Bi Tri ___ Pat Ach Pec jerk Crossed Adductors
L 3 2 3 2 0
R 3 2 3 2 0
Plantar response was mute bilaterally.
-Sensory: Intact to LT, temp throughout.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait: Normal initiation. Narrow base. Normal stride length and
arm swing. Stable without sway. Negative Romberg.
DISCHARGE PHYSICAL EXAM
Vitals: ___ 0822 Temp: 98.2 PO BP: 154/75 HR: 77 RR: 16 O2
sat: 97% O2 delivery: RA FSBG: 103
General: awake, cooperative, NAD
HEENT: NC/AT, no scleral icterus noted
Pulmonary: breathing comfortably, no tachypnea or increased WOB
Cardiac: skin warm, well-perfused
Abdomen: soft, ND
Extremities: symmetric, no edema
Neurologic:
-Mental Status: Alert, cooperative. Language is fluent with
intact comprehension. Able to follow both midline and
appendicular commands.
-Cranial Nerves: Able to count 2 fingers but not 5 fingers in
OS.
Able to see red color. Able to see light. EOMI
without nystagmus. Facial sensation intact to light touch. R
NLFF. Hearing intact to conversation.
-Motor: No pronator drift bilaterally. Full power in proximal
BLE.
-Sensory: Intact to LT throughout.
-DTRs: ___.
-Coordination: deferred
Pertinent Results:
ADMISSION LABS
___ 12:38PM BLOOD D-Dimer: 763*
___ 12:38PM BLOOD CRP: 0.6
ESR: pending
___ 12:38PM BLOOD ASA: NEG Ethanol: NEG Acetmnp: NEG
Tricycl: NEG
___ 01:00PM URINE Blood: NEG Nitrite: NEG Protein: TR*
Glucose: NEG Ketone: NEG Bilirub: NEG Urobiln: NEG pH: 6.5
Leuks:
NEG
___ 01:00PM URINE RBC: 2 WBC: 1 Bacteri: NONE Yeast: NONE
Epi: <1
___ 01:00PM URINE bnzodzp: NEG barbitr: NEG opiates: NEG
cocaine: NEG amphetm: NEG oxycodn: NEG mthdone: NEG
CT CHEST WITH CONTRAST
No evidence of intrathoracic malignancy.
Large gastric hernia with the majority of the stomach present in
the thoracic cavity, but no features of volvulus or obstruction.
No pneumonia.
The pulmonary truncus is not dilated, but the main pulmonary
arteries are
dilated bilaterally and pulmonary hypertension should be
excluded.
CT ABD/PEL
1. No evidence of intra-abdominal malignancy.
2. No acute abdominal or pelvic pathology.
3. Moderate hiatal hernia with the majority of the stomach
present in the
thorax. No features of volvulus.
4. Simple appearing bilateral ovarian cysts measuring up to 5.3
cm on the left with a small punctate calcification in its
dependent aspect, measures 4.8 cm on the left. If clinically
indicated this may be better characterized with ultrasound.
5. For chest findings reference is made to CT chest report of
the same day.
MRI BRAIN ___. Study is mildly degraded by motion.
2. No acute infarct or intracranial hemorrhage.
3. Global volume loss and extensive chronic microangiopathy
changes.
US LEs ___
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
DISCHARGE LABS
___ 06:00AM BLOOD WBC: 5.1 RBC: 3.16* Hgb: 7.1* Hct: 24.6*
MCV: 78* MCH: 22.5* MCHC: 28.9* RDW: 16.5* RDWSD: 47.0* Plt Ct:
328
___ 06:00AM BLOOD Glucose: 101* UreaN: 18 Creat: 0.9 Na:
142
K: 4.4 Cl: 105 HCO3: 26 AnGap: 11
___ 06:00AM BLOOD Calcium: 8.9 Phos: 4.0 Mg: 2.1
Brief Hospital Course:
Ms. ___ is an ___ left-handed woman with history
notable for prior stroke, PFO, and epilepsy (on levetiracetam)
transferred from ___ with two prolonged episodes of
prolonged vision loss in the left eye, now with persistently
decreased vision. Initial evaluation for
cardioembolism showed absence of AFib on telemetry and
unrevealing BLE U/S and CT of the pelvis in setting of PFO,
while
GCA somewhat less likely with normal CRP and absence of systemic
symptoms. On repeat ophtho evaluation, they noted "clearly
significant
swelling of the retina with hemorrhages, most likely caused by
new wet macular degeneration." She was evaluated in retina
clinic by ophtho and her management will be directed by
ophothalmology. Incidental note also made of microcytic anemia
and low ferritin with stable H&H
consistent with iron-deficiency anemia. PCP was notified.
# Neuro
She was continued on home ASA 81 mg daily, levetiracetam 750mg
bid
and atorvastatin 40 mg daily. Initial question for stroke
evaluated by ___ US, CT A/P without DVT or underlying
malignancy.
# Heme:
- Acute microcytic anemia - Hgb trend 10.1->9.7->7.9->7.5 over
last 6 months. Some melenic stools by history. She was continued
on
IV pantoprazole 40 mg IV BID while inpatient then discharged on
home PPI. She was started on ferrous sulfate 325 mg daily. Plan
for PCP follow up.
- Code status: pFull
- Health Care Proxy: HCP is Son , ___ ___.
Alternate contact, daughter-in-law ___, ___.
Transitional issues
--------------------
[ ] Per Ophthalmology take Preservision AREDS2 one tablet 2x/day
( this contains 10 mg lutein, 2 mg zeaxanthin, 500 mg of vitamin
C, 400 international units of vitamin E, 25 mg of zinc oxide,
and 2 mg of cupric oxide per day) in order to reduce the risk of
severe vision loss
[ ] daily testing of central vision in each eye separately with
an Amsler grid or using straight lines in the environment.
If you notice any sudden loss, distortion or change in vision in
either eye, they should contact your eye doctor as soon as
possible.
[ ] Continue home ASA 81 mg daily, atorvastatin 40 mg daily
[] Continue home levetiracetam 750mg bid
[ ] Acute microcytic anemia - Hgb trend 10.1->9.7->7.9->7.5 over
last 6 months:
Your Hb was low at 7.0 - 7.1 during this admission, you
complained of abnormal (melanotic) stools, we recommended repeat
Hb in 3 days and close follow up with your PCP. Your were
started on ferrous sulfate 325 mg daily.
[ ] Per OT, good potential for home discharge with outpatient
low vision OT services. Will benefit from formal driving
evaluation to progress patient to return to driving. No
additional acute care OT needs at this time.
Discharge Disposition:
Home
Discharge Diagnosis:
Wet macular degeneration
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
You were admitted to ___ due to left eye vision loss. We did
brain imaging and fortunately found no new stroke. Eye doctors
___ and ___ your vision loss was consistent with age
related degeneration in your retina. They recommended close
outpatient follow up with an eye doctor, with daily
antioxidants, and monthly injections inside your eye.
Your hemoglobin was also found to be low, therefore please get a
repeat blood check in 3 days and follow up with your PCP.
You were also evaluated by Occupational therapy who recommended
outpatient low vision OT services. They also suggest that you
will benefit from formal driving evaluation.
Please take the medications as scheduled and follow up with your
eye doctor and PCP.
Thank you
___ Neurology Team
[ ] Per Ophthalmology take Preservision AREDS2 one tablet twice
a day (this contains 10 mg lutein, 2 mg zeaxanthin, 500 mg of
vitamin C, 400 international units of vitamin E, 25 mg of zinc
oxide, and 2 mg of cupric oxide per day) in order to reduce the
risk of severe vision loss
[ ] daily testing of central vision in each eye separately
using straight lines in the environment. If you notice any
sudden loss, distortion or change in vision in either eye, they
should contact your eye doctor as soon as possible.
[ ] Continue home ASA 81 mg daily, atorvastatin 40 mg daily
[ ] Continue home levetiracetam 750mg bid
[ ] Your Hemoglobin was low at 7.0 - 7.1 during this admission,
i.e. you have anemia, you complained of abnormal (melanotic)
stools, we recommended repeat Hb in 3 days and close follow up
with your PCP. Your were started on ferrous sulfate 325 mg
daily.
Followup Instructions:
___
|
10804556-DS-2
| 10,804,556 | 28,696,925 |
DS
| 2 |
2112-11-23 00:00:00
|
2112-11-23 12:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Bicyclist struck by auto
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o LHD gentleman with no significant
past medical history who presents after being struck by a motor
vehicle while cycling earlier today. He was helmeted and does
believe he lost consciousness, as he is unable to recall many of
the details of the crash. He now complains of minor left
shoulder pain when moving his arm, as well as some chest wall
pain. He denies numbness or tingling. He was brought to the BI
ED for further evaluation, where imaging was concerning for a
left scapular fracture, SDH, and 5th rib fracture. The
Orthopaedic Surgery team was consulted for further management of
this possible left scapular fracture. The patient has a
reported
questionable history of shoulder pathology for which he has
worked with Physical Therapy in the past.
Past Medical History:
Depresion
PSH: Tonsillectomy
Family History:
Noncontributory
Physical Exam:
Upon presentation to ___:
AOx3, following commands readily
PEERLA 3 to 2 mm
Face symmetric, tongue Midline, palate elevation symmetric
EOMs intact, visual fields full
Motor:
Limited evaluation of left upper extremity due to pain; left
grip
is full
Otherwise strength is full ___ in all muscle groups
Sensation intact to light touch.
Toes downgoing bilaterally
No Clonus, No Hoffmans
Pertinent Results:
___ 09:10AM GLUCOSE-121* NA+-140 K+-5.0 CL--106 TCO2-23
___ 09:00AM UREA N-24* CREAT-1.0
___ 09:00AM WBC-8.6 RBC-5.02 HGB-15.1 HCT-43.7 MCV-87
MCH-30.0 MCHC-34.5 RDW-12.5
___ 09:00AM ___ PTT-25.6 ___
___ 09:00AM PLT COUNT-276
___ 09:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
CT Head:
IMPRESSION: Small parafalcine subdural hematoma without
significant mass
effect
CT c-spine:
IMPRESSION: No evidence of fracture or malalignment.
CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST:
IMPRESSION:
1. Nondisplaced fracture of the tip of the blade left scapula
without
adjacent hematoma.
2. Probable gallbladder polyp. Further characterization with
ultrasound is
recommended.
Left scapula:
IMPRESSION: Minimally displaced fracture of the inferior tip of
the left
scapula.
Gallbladder ultrasound:
Brief Hospital Course:
He was admitted to the Acute Care Surgery team. Neurosurgery was
consulted for the subdural hemorrhage which was managed non
operatively. Frequent neuro checks and serial exams were
followed closely and remained stable. No seizure prophylaxis was
recommended. He will follow up in 4 weeks for exam and repeat
head CT imaging.
Orthopedics was consulted for the left scapula fracture which
was also managed conservatively with a sling and non weight
bearing. He may actively perform range of motion. He will follow
up in 2 weeks in ___ clinic for exam and repeat imaging.
Incidentally a gallbladder polyp was noted on CT imaging of his
abdomen. A gallbladder ultrasound was performed showing no liver
lesions, no ductal dilatation, common bile duct measuring 5 mm,
no free fluid and multiple gallbladder polyps. It is being
recommended that he have a 6 month follow up of this - this
information was conveyed to the patient prior to discharge.
His pain was controlled with oral narcotics which initially
caused some nausea; Ultram was added along with Tylenol prn. His
home medication was restarted and he tolerated a regular diet.
He was discharged to home with instructions for follow up.
Medications on Admission:
Paxil 15'
Discharge Medications:
1. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
3. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
6. senna 8.6 mg Tablet Sig: ___ Tablets PO once a day as needed
for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Bicyclist struck by auto
Injuires:
1. Parafalcine subdural hematoma
2. Left scapula fracture
3. Gallbladder polyps
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the ___ after being struck by an auot
while on a bicycle. You sustained a small bleeding injury to
your brain that was evalauted by the ___ team. This
injury did not require any operations - you will follow up with
the Neurosurgeon in about 4 weeks where you will have a repeat
head CT scan done.
You also sustained a left scapula fracture that did not reuqire
any operations. A sling for comfort is recommended to. You
should not put full weight on your left arm but you may perform
range of motion exercises.
Also noted on the cat scan of your abdomen was a polyp in your
gallbladder - an ultrasound was done while you were in the
hospital. It is being recommended that you have a 6 month follow
up of this finding with another ultrasound. You will need to
follow up with your primary care doctor after discharge for
further work up of this.
Followup Instructions:
___
|
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