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10804747-DS-11	10,804,747	20,366,455	DS	11	2148-12-02 00:00:00	2148-12-03 15:45:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lithium / Wellbutrin / Seroquel Attending: ___ Chief Complaint: Left trimalleolar ankle fracture status post-syncope mechanical fall Major Surgical or Invasive Procedure: Re-alignment of left ankle fracture History of Present Illness: As per HPI by admitting MD: ___ female history of COPD on 5 L O2, A. fib (on baby aspirin only), unstable angina who presents with left ankle pain status post syncopal fall earlier today. The patient was ambulating to the bathroom without her oxygen when she started feeling lightheaded and dizzy and passed out. Uncertain whether she hit her head. Unable to ablate on her left ankle after the fall. Denies numbness or tingling distally. On evaluation, patient was treated for hypotension and hypoxia. Patient was placed back on her 5 L of oxygen improved to normal. For blood pressure, steadily increased. Patient states that her blood pressure is always low. Ankles 2+ pulses. Of note, +UA in ED which was treated with Macrobid for 5 days, starting on ___. Past Medical History: PAST MEDICAL HISTORY: - Pulmonary hypertension with an estimated TR gradient of 32-42 mmHg on TTEs done ___ and ___ measured PASP 42 mmHg on ___ - Right ventricular dilation, hypertrophy and basal hypokinesis of free wall (TTE ___ improved on TTE ___ - Chronic diastolic heart failure/HFpEF (EF >55%) - Depression and anxiety, s/p ECT - Bipolar disorder with history of suicidal ideation - Anorexia nervosa - Hypothyroidism - COPD, O2 dependent, on 5L - GERD - Pernicious anemia - Osteoporosis - Spinal stenosis - Right-sided peripheral neuropathy the right leg - History of DVT PAST SURGICAL HISTORY: - Laparoscopy converted to open sigmoid resection with rectopexy for grade 3 sigmoid OCL and fecal incontinence in ___ - Appendectomy in ___ - C-sections x2 in ___ and in ___ - Carpal tunnel release ___ years ago Social History: ___ Family History: - Mother: emphysema - Sister: O2 dependent - No relevant cardiac history including premature coronary artery disease, cardiomyopathies, arrhythmias or sudden cardiac death Physical Exam: ADMISSION PHYSICAL EXAM Vitals: 24 HR Data (last updated ___ @ 006) Temp: 98.0 (Tm 98.7), BP: 95/60 (92-135/58-84), HR: 76 (76-85), RR: 18 (___), O2 sat: 88% (88-97), O2 delivery: 5lnc Fluid Balance (last updated ___ @ 2201) Last 8 hours Total cumulative -140ml IN: Total 60ml, PO Amt 60ml OUT: Total 200ml, Urine Amt 200ml Last 24 hours Total cumulative -140ml IN: Total 60ml, PO Amt 60ml OUT: Total 200ml, Urine Amt 200ml Physical exam: Gen: NAD, AxOx3 Card: RRR, no m/r/g Pulm: CTAB, no respiratory distress Abd: Soft, non-tender, non-distended, normal bs. Wounds: c/d/i Ext: No edema, warm well-perfused. Cast on L foot/leg. DISCHARGE PHYSICAL EXAM VITALS: ___ ___ Temp: 97.6 PO BP: 106/67 R Lying HR: 70 RR: 18 O2 sat: 93% O2 delivery: 5l GENERAL: Elderly female lying comfortably in bed. In no acute distress. HEENT: Normocephalic, atraumatic. Poor dentition. NECK: Supple. JVP just above the clavicle. CARDIAC: RRR with normal S1 and S2. No murmurs/rubs/gallops. LUNGS: Normal respiratory effort. Scattered wheezes, bibasilar inspiratory crackles over the bases. No rhonchi. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: Left foot in brace. No lower extremity edema. Left great toe without swelling or erythema. Mild TTP over MTP joint. FROM with minimal pain. NEURO: Alert and interactive. CN II-XII grossly intact. Moves all extremities. SKIN: warm, dry, no rashes Pertinent Results: ADMISSION LABS ___ 06:47AM BLOOD WBC-10.4* RBC-4.12 Hgb-13.2 Hct-40.9 MCV-99* MCH-32.0 MCHC-32.3 RDW-15.1 RDWSD-55.3* Plt ___ ___ 01:54AM BLOOD WBC-13.0* RBC-3.82* Hgb-12.3 Hct-38.0 MCV-100* MCH-32.2* MCHC-32.4 RDW-15.3 RDWSD-55.9* Plt ___ ___ 01:54AM BLOOD Neuts-72.7* Lymphs-16.5* Monos-7.4 Eos-2.5 Baso-0.3 Im ___ AbsNeut-9.48* AbsLymp-2.15 AbsMono-0.96* AbsEos-0.32 AbsBaso-0.04 ___ 06:47AM BLOOD Plt ___ ___ 05:01AM BLOOD ___ PTT-24.6* ___ ___ 01:54AM BLOOD Plt ___ ___ 06:47AM BLOOD Glucose-107* UreaN-17 Creat-1.1 Na-144 K-3.5 Cl-104 HCO3-24 AnGap-16 ___ 01:54AM BLOOD Glucose-113* UreaN-23* Creat-1.3* Na-140 K-3.7 Cl-105 HCO3-23 AnGap-12 ___ 01:54AM BLOOD CK(CPK)-54 ___ 07:30PM BLOOD cTropnT-0.02* ___ 05:36AM BLOOD cTropnT-0.02* ___ 05:36AM BLOOD cTropnT-0.01 ___ 01:54AM BLOOD cTropnT-0.02* ___ 01:54AM BLOOD CK-MB-3 ___ 06:47AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.2 DISCHARGE LABS ___ 07:11AM BLOOD WBC-10.9* RBC-4.22 Hgb-13.5 Hct-42.6 MCV-101* MCH-32.0 MCHC-31.7* RDW-15.0 RDWSD-55.9* Plt ___ ___ 07:11AM BLOOD Plt ___ ___ 07:11AM BLOOD Glucose-112* UreaN-17 Creat-0.8 Na-143 K-4.0 Cl-106 HCO3-24 AnGap-13 ___ 07:11AM BLOOD Phos-4.8* Mg-2.2 ___ 07:15AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.3 Imaging ___ L tib fib xray Trimalleolar fracture. ___ CXR IMPRESSION: Stable chronic diffuse interstitial abnormalities without pulmonary edema or focal consolidation. Although no acute or other chest wall lesion is seen, conventional chest radiographs are not sufficient for detection or characterization of most such abnormalities. If the demonstration of trauma or other soft tissue abnormality involving the chest wall is clinically warranted, the location of any referable focal findings should be clearly marked and imaged with either bone detail radiographs or Chest CT scanning. ___ CT head 1. No acute findings. 2. Advanced brain parenchymal atrophy, most severe at the frontal lobes. ___ CT C spine 1. No acute findings.. 2. Degenerative changes cervical spine. 3. Suggestion of centrilobular emphysema, mild biapical scarring versus mild pulmonary edema. ___ L ankle xray Status post splinting of the known trimalleolar fracture with similar alignment. No new fracture. ___ CT LLE Trimalleolar fracture as described above. There is depression of a 5 mm portion of the posterior tibial plafond articular surface. There is also mild widening of the medial ankle mortise. ___ CT Torso 1. No traumatic injury identified within the chest, abdomen, or pelvis. No fracture identified. 2. Increased pulmonary interstitial scarring with associated ground-glass opacities and upper lobe predominant emphysematous changes compared to study of ___. No focal consolidations identified. 3. Partially calcified 1 cm right renal artery aneurysm. ___ 2d echo The left atrium is normal in size. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is normal left ventricular wall thickness with a small cavity. There is normal regional and global left ventricular systolic function. Left ventricular cardiac index is depressed (less than 2.0 L/min/m2). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Diastolic function could not be assessed. The right ventricular free wall is hypertrophied. Mildly dilated right ventricular cavity with moderate global free wall hypokinesis. There is abnormal interventricular septal motion c/w right ventricular pressure and volume overload. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a mildly dilated descending aorta. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is mild [1+] mitral regurgitation. The tricuspid valve leaflets are mildly thickened. There is moderate [2+] tricuspid regurgitation. There is SEVERE pulmonary artery systolic hypertension. There is a very small circumferential pericardial effusion. IMPRESSION: Mildly dilated right ventricle with moderate systolic dysfunction and evidence of pressure/volume overload. Small left ventricular with normal global systolic function. Moderate tricuspid regurgitation. Severe pulmonary hypertension. Compared with the prior TTE (images reviewed) of ___ , the degree of pulmonary hypertension has worsened and a very small pericardial effusion is seen. Syncope and pericardial effusion are both poor prognostic signs in pulmonary hypertension. Brief Hospital Course: Ms. ___ is a ___ year old female with past medical history notable for chronic diastolic heart failure/HFPEF, chronic hypoxic respiration failure (on 5L O2), mild to moderate PASP, RV dysfunction, depression and anxiety, bipolar disorder, hypothyroidism, GERD, and history of DVT (not current on AC) who was admitted to ___ after left ankle fracture, transferred to medicine for evaluation of the etiology of her fall. ACUTE PROBLEMS: ================ #Fall Etiology of current fall likely related to hypoxia in setting of ambulating without supplemental O2. Despite this, patient does report numerous falls over the past several months, some of which occur while wearing O2. She notes feeling unsteady on her feet and has required wheelchair intermittently. Orthostatics were negative. Telemetry without events and EKG unchecked from prior. Prior TTE with RV dysfunction and elevated PASP, repeat TTE on ___ shows worsening of her pHTN, but otherwise is stable. ___ was consulted and recommended discharge back to rehab. #Left ankle fracture #Left toe pain Evaluated in ED by ortho and s/p now non-operative management with a splint. Also describes left toe pain. Likely sustained an injury during her fall. She was started on standing acetaminophen 1000mg Q8h, and oxycodone PRN for pain ___ reviewed). ___ consulted as above. She will follow up with Ortho trauma in 1 week. #Chronic hypoxic respiratory failure Patient typically requires 5L O2 as outpatient. Etiology likely multifactorial with contribution from pulmonary hypertension and HF. Repeat TTE on ___ showed worsening of her severe pHTN. The patient was stable at her baseline currently while inpatient. She was continued on Fluticasone-Salmeterol, Duoneb PRN, albuterol PRN, and guaifenesin. #Dysphagia Previously been recommended to have a dysphagia diet. Team had planned for SLP eval and modified diet however she states she would like to continue a chopped and moist diet (rather than ground). She declined a SLP eval. She accepts the risk of aspiration and knows she could suffer from choking, pneumonia/infection and possibly even death, she even notes she is DNR/DNI and understands she would not be intubated or resuscitated if this happened. #Chronic heart failure with preserved EF #Pulmonary hypertension Does not appear to be in decompensated HF currently. JVD just above clavicle at 60 degrees. Resumed home torsemide upon discharge. Continued home metoprolol. TTE as noted above. ___ (resolved) Mild ___ with Cr up to 1.3 from baseline of 1.0. Improved to 1.1 after 1L LR and was trending down at the time of discharge. CHRONIC ISSUES: ================= #Depression #Bipolar disorder Patient describes history of psychosis for which she was previously on anti-psychotic and was transitioned to risperidone many years ago. She was continued on Risperidone 1.5mg QHS, Clonazepam 0.5mg TID, Sertraline 175mg daily and Bentroprine 0.5mg daily. #GERD: Continued on home omeprazole 20mg BID #Hypothyroidism: Continued on home levothyroxine TRANSITIONAL ISSUES: ==================== [] follow up pain control: discharged on Oxycodone 5mg PO q6hrs PRN [] follow up with ortho: scheduled as above [] if swallowing declines, consider repeat SLP eval-- patient wants to stay on chopped diet and declined SLP eval while inpatient [] follow up with pulmonary team and repeat echo as needed as an outpatient * CODE: DNR/DNI PCP notified of discharge Time spent: 55 minutes Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Benztropine Mesylate 0.5 mg PO DAILY 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY 4. GuaiFENesin ER 600 mg PO Q12H 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Oxybutynin 5 mg PO BID 7. Nitroglycerin Patch 0.1 mg/hr TD Q24H 8. Simvastatin 20 mg PO QPM 9. Systane (PF) (peg 400-propylene glycol (PF)) 0.4-0.3 % ophthalmic (eye) TID 10. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation BID 11. Docusate Sodium 100 mg PO BID 12. RisperiDONE 1.5 mg PO QHS 13. Sertraline 175 mg PO DAILY 14. melatonin 5 mg oral QHS 15. Omeprazole 20 mg PO BID 16. multivitamin with iron 1 tablet oral DAILY 17. Super B/C (B-complex with vitamin C) 150 mg oral DAILY 18. TraMADol 50 mg PO BID 19. Torsemide 20 mg PO DAILY 20. ClonazePAM 0.5 mg PO TID 21. Potassium Chloride 20 mEq PO DAILY 22. Metoprolol Succinate XL 25 mg PO DAILY 23. cranberry 450 mg oral DAILY 24. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q4H:PRN GI upset 25. Calcium Carbonate 500 mg PO TID:PRN GI upset 26. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - First Line 27. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal dryness 28. TraMADol 50 mg PO DAILY:PRN Pain - Moderate 29. Nicotine Polacrilex 2 mg PO Q1H:PRN smoking cessation 30. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 31. Senna 8.6 mg PO QHS:PRN Constipation - First Line 32. GuaiFENesin 10 mL PO Q4H:PRN cough 33. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 34. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 35. Bisacodyl ___AILY:PRN Constipation - Second Line 36. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 37. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB/wheeze 38. Clotrimazole 1 TROC PO QID:PRN mouth discomfort Discharge Medications: 1. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate RX oxycodone 5 mg 1 capsule(s) by mouth every six (6) hours Disp #28 Capsule Refills:0 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 4. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q4H:PRN GI upset 5. Aspirin 81 mg PO DAILY 6. Benztropine Mesylate 0.5 mg PO DAILY 7. Bisacodyl ___AILY:PRN Constipation - Second Line 8. Calcium Carbonate 500 mg PO TID:PRN GI upset 9. ClonazePAM 0.5 mg PO TID 10. Clotrimazole 1 TROC PO QID:PRN mouth discomfort 11. cranberry 450 mg oral DAILY 12. Docusate Sodium 100 mg PO BID 13. Fluticasone Propionate NASAL 1 SPRY NU DAILY 14. GuaiFENesin ER 600 mg PO Q12H 15. GuaiFENesin 10 mL PO Q4H:PRN cough 16. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB/wheeze 17. Levothyroxine Sodium 50 mcg PO DAILY 18. melatonin 5 mg oral QHS 19. Metoprolol Succinate XL 25 mg PO DAILY 20. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - First Line 21. multivitamin with iron 1 tablet oral DAILY 22. Nicotine Polacrilex 2 mg PO Q1H:PRN smoking cessation 23. Nitroglycerin Patch 0.1 mg/hr TD Q24H 24. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 25. Omeprazole 20 mg PO BID 26. Oxybutynin 5 mg PO BID 27. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 28. Potassium Chloride 20 mEq PO DAILY 29. RisperiDONE 1.5 mg PO QHS 30. Senna 8.6 mg PO QHS:PRN Constipation - First Line 31. Sertraline 175 mg PO DAILY 32. Simvastatin 20 mg PO QPM 33. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal dryness 34. Super B/C (B-complex with vitamin C) 150 mg oral DAILY 35. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation BID 36. Systane (PF) (peg 400-propylene glycol (PF)) 0.4-0.3 % ophthalmic (eye) TID 37. Torsemide 20 mg PO DAILY 38. TraMADol 50 mg PO BID 39. TraMADol 50 mg PO DAILY:PRN Pain - Moderate Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left trimalleolar ankle fracture status post-syncope mechanical fall Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: NON-weight bearing in lower extremity, in a splint . Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital due to a mechanical fall that caused a closed left ankle fracture . Your fracture was re-aligned by the orthopedic team and this was managed non-operatively in a splint. You are not allowed to bear weight on your left lower extremity until you are followed up in clinic. After your ankle fracture was stable your etiology of syncope (loss of consciousness) was further worked up by the medicine team. You were also found to have a positive urinary tract infection and treated with the antibiotic macrobid. Please take for 5 days as prescribed , starting on ___. With proper pain management you are ready to be discharged home to continue your recovery with the following instructions. You should take your pain medication as directed to stay ahead of the pain. If the pain medication is too sedating take half the dose and notify your physician. * 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 if pain worsen despite pain medication, there is bleeding or discharge from the wound or your temperature is greater than 101.1 degree Fahrenheit Followup Instructions: ___
10804747-DS-8	10,804,747	26,246,594	DS	8	2147-04-12 00:00:00	2147-04-12 13:58:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lithium / Wellbutrin / Seroquel Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old lady with history of HFpEF, mild to moderate pulmonary artery systolic hypertension, chronic hypoxic respiratory failure (multifactorial- COPD, ?old interstitial pneumonitis and WHO Group 2 pulmonary hypertension) on 3L NC at home, DVT on warfarin, who presents for evaluation of dyspnea. At baseline she uses 3L NC oxygen and occasionally walks with a walker at her assisted living facility. She says that she generally does not walk very much and is not very active, preferring to use her computer all day, but is able to perform all ADL's independently. She is unable to estimate how far she is able to walk on a good day; prior cardiology notes document ___ class III symptoms. Around three weeks ago she developed a cough productive of sputum and worsening shortness of breath associated with low grade temperatures ~ ___. No chills, no sick contacts, no other URI symptoms. Her dyspnea is worse when she is sitting up and also when she lies down- she is unable to lie flat but is unable to say if this has really changed. She has not noticed increased lower extremity edema or weight gain. She currently denies any new chest pain. Her other complaint is that when she nods her head or extends it backwards she develops dizziness which is described as a room spinning sensation. No tinnitus, ear fullness, vision changes, focal weakness. Not triggered when she moves her head side to side; not particularly worse when getting up from bed. This has never happened in the past. She says that she has not been eating or drinking much recently due to dysphagia and heartburn; this has been evaluated by GI and thought ___ ___ dysmotility. Regarding her cardiac and pulmonary history (extracted from OMR)- she was admitted to ___ in ___ for elective laparoscopic sigmoid colectomy, complicated by ___ blood loss and hemodynamic instability. During workup for elevated cardiac markers, echocardiogram demonstrated hyperdynamic left ventricle (EF >75%) and dilated, hypokinetic RV with abnormal septal motion consistent with RV pressure/volume overload, as well as moderately elevated pulmonary artery systolic pressure (TR gradient ___ mm Hg). Of note, a prior echo showed similar findings, and there was concern for acute or acute on chronic pulmonary embolism. Right heart catheterization was performed in ___, which demonstrated only mild pulmonary hypertension with PA ___ (23), normal filling pressures and cardiac output. In ___, she presented to ___ ED with chest pain and had a negative PMIBI examination. Her most recent TTE from ___ actually demonstrated normal global and regional biventricular systolic function w/ moderate pulmonary hypertension (PASP 42 mmHg), improved RV function compared to ___. Her most recent set of PFTs are from ___, with FEV1/FVC 86%, FEV1 107% (1.58). Previously in ___ FEV1/FVC 84%, FEV1 99%, DLCO 45%. It is thought that the etiology of her chronic hypoxemic respiratory failure and right ventricular dysfunction is multifactorial, related to COPD, pulmonary hypertension, and HFpEF. In ED initial VS: HR 98 BP 103/49 RR 24 85% 4L NC Exam: Diffuse wheezing Labs: (1) WBC 7.3 Hgb 12.1 Plt 298, 62% neutrophils, 1% bands (2) INR 3.9, PTT 38.7 (3) Troponin 0.05, ___ 5, BNP 14014 (4) vBG ___ Patient was given: - Albuterol neb x 1, ipratropium neb x 1, methylprednisolone 125 mg - Pip/tazo 4.5 g - Vancomycin 1 mg - Magnesium sulfate 2gm Imaging notable for: CXR- Patchy left basilar opacity, concerning for pneumonia in the correct clinical setting. VS prior to transfer: 97.3 HR 80 BP 96/55 94% on BiPAP ___ On arrival to the MICU, she confirms the history as above. REVIEW OF SYSTEMS: (+) Per HPI Past Medical History: 1. Mild to moderate pulmonary hypertension with an estimated TR gradient of ___ mmHg on echocardiograms done ___ and ___. Right heart catheterization ___ with PASP 42 mmHg. 2. Right ventricular dilation, hypertrophy and basal hypokinesis of free wall (TTE ___. Improved RV function on TTE ___. 3. Chronic diastolic heart failure/HFpEF (EF >55% on TTE ___. 4. Chronic atypical chest pain. Negative PMIBI ___. 5. Chronic hypoxic respiratory failure on 3L O2 (multifactorial). 6. Esophageal dysmotility Social History: ___ Family History: - Mother: emphysema - Sister: O2 dependent - No relevant cardiac history including premature coronary artery disease, cardiomyopathies, arrhythmias or sudden cardiac death Physical Exam: ADMISSION PHYSICAL EXAM ======================= 97.6, 85, 113/60, 19, 93%/6L NC GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Crackles at bilateral bases L>R, expiratory wheezing anteriorly CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, ___, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE PHYSICAL EXAM ======================= Afebrile, SBPs ___, P ___, RR 18, 92 on 4L Alert oriented NAD HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD Lungs clear to auscultation bilaterally with no wheezing or crackles No JVD No ___ ___ Pertinent Results: ADMISSION LABS ============== ___ 11:37PM BLOOD ___ ___ Plt ___ ___ 11:37PM BLOOD ___ ___ ___ ___ 11:37PM BLOOD ___ ___ ___ Tear ___ ___ 11:37PM BLOOD ___ ___ ___ 11:37PM BLOOD Plt ___ Plt ___ ___ 11:37PM BLOOD ___ ___ ___ 11:37PM BLOOD CK(CPK)-451* ___ 11:37PM BLOOD ___ ___ 11:37PM BLOOD ___ ___ 11:37PM BLOOD ___ ___ 11:44PM BLOOD ___ ___ Base XS--3 MICRO ===== Urine Culture (___): negative MRSA Screen (___): negative Sputum Culture (___): cancelled IMAGES ====== CXR (___): Patchy left basilar opacity, concerning for pneumonia in the correct clinical setting. TTE (___): IMPRESSION: Dilated right ventricle with moderate global hypokinesis and pressure/volume overload. Normal left ventricular systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of ___, the right ventricle is dilated and hypokinetic with signs of pressure/volume overload. Brief Hospital Course: Ms. ___ is a ___ year old lady with history of HFpEF, mild to moderate pulmonary artery systolic hypertension, chronic hypoxic respiratory failure (multifactorial- COPD, possible interstitial pneumonitis and WHO Group 2 pulmonary hypertension) on 3L NC at home, DVT on warfarin, who is admitted to the ICU for hypoxemic respiratory failure found to have pneumonia and right heart failure. ================= ACTIVE ISSUES ================= # Hypoxemic respiratory failure/Pneumonia: Pt p/w patchy left basilar opacity in setting of cough and low grade temperatures, concerning for pneumonia. She has resided in nursing home for greater than ___ years, which places her at risk for resistant organisms. She has not improved with levofloxacin in outpatient setting. Antibiotics were broadened to vancomycin/ceftazidime/azithromycin (___), vancomycin was discontinued when MRSA swab returned negative. Likely respiratory distress worsened by baseline pulmonary hypertension, COPD and HFpEF. Pt was gently diuresed out of c/f pulmonary edema and also received a prednisone 40 mg burst (___) out of concern for COPD exacerbation given wheezes on exam. She will require slow prednisone taper 10mg daily to start in AM ___ to complete her taper in addition to indefinite azithromycin. TTE showed RV volume overload, discussed below. # Right Heart Strain. Pt p/w new TWI in inferior leads as well as ___, rightward axis in addition to an elevated BNP, all c/f TV strain iso known pulmonary HTN. TTE showed e/o right heart volume overload, no sign of new ischemic changes and mild admission troponin of 0.05 ___. Etiology of right heart strain is unclear as it is out of proportion for underlying pulmonary hypertension. As discussed, ischemia is unlikely and PE is unlikely given that pt presented supratherapeutic on warfarin. Cardiology was consulted and recommneded starting 10 mg torsemide. The patient has follow up scheduled with cardiology. # ___: Pt presented with ___ likely ___ given sodium avid urine lytes. Improved with IVF. # Supratherapeutic INR: In setting of decreased PO intake d/t esophageal dysmotility, also possible drug interaction as she was recently on levofloxacin. Warfarin was held while patient was supra therapeutic and resumed while hospitalized. INR was 2.1 on discharge. Coumadin will be resumed at 3mg daily. =============== CHRONIC ISSUES =============== # Esophageal dysmotility: Per GI, nonspecific dysmotility and would attempt treatment for spasm, with suggestion for SL nitro prior to meals. After TTE could consider this w/ close monitoring of BP as well as swallow evaluation. # Hypothyroidism: Continue home levothyroxine. # Depression/anxiety: Continue home sertraline and clonazepam # Constipation: Continue home linzess 290 mcg daily, senna 2 tabs every 3 days. ==================== TRANSITIONAL ISSUES ==================== CODE: DNR/DNI HCP: ___ (son) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Nitroglycerin Patch 0.1 mg/hr TD Q24H 2. Warfarin 3 mg PO DAILY16 3. ClonazePAM 1 mg PO QHS 4. Benztropine Mesylate 0.5 mg PO DAILY 5. Levothyroxine Sodium 50 mcg PO DAILY 8pm 6. TraMADol 50 mg PO TID 7. Loxapine Succinate 30 mg PO DAILY 8. Oxybutynin 5 mg PO BID 9. Symbicort ___ mcg/actuation inhalation BID 10. Furosemide 40 mg PO BID 11. Omeprazole 20 mg PO BID WIHT LUNCH AND DINNER 12. Fluticasone Propionate NASAL 1 SPRY NU DAILY 13. Sertraline 150 mg PO DAILY 14. Linzess (linaclotide) 290 mcg oral daily 15. Aspirin 81 mg PO DAILY 16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP for up to 3 doses 17. Senna 8.6 mg PO QHS:PRN constipation 18. ClonazePAM 0.25 mg PO DAILY 2PM 19. ClonazePAM 0.5 mg PO DAILY 20. Docusate Sodium 100 mg PO DAILY 21. Simvastatin 20 mg PO QPM 22. RisperiDONE 1 mg PO DAILY 23. Systane Gel (artificial tears(hypromellose);<br>peg ___ glycol) ___ % ophthalmic TID Discharge Medications: 1. Azithromycin 250 mg PO Q24H continue until you ___ with your pulmonologist 2. GuaiFENesin ER 600 mg PO Q12H 3. ___ Neb 1 NEB NEB Q6H:PRN wheezing take PRN for wheezing or shortness of breath 4. Nicotine Patch 14 mg TD DAILY 5. PNEUMOcoccal ___ polysaccharide vaccine 0.5 ml IM NOW X1 6. PredniSONE 10 mg PO DAILY Duration: 3 Days 7. Torsemide 10 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Benztropine Mesylate 0.5 mg PO DAILY 10. ClonazePAM 1 mg PO QHS 11. ClonazePAM 0.25 mg PO DAILY 2PM 12. ClonazePAM 0.5 mg PO DAILY 13. Docusate Sodium 100 mg PO DAILY 14. Fluticasone Propionate NASAL 1 SPRY NU DAILY 15. Levothyroxine Sodium 50 mcg PO DAILY 8pm 16. Linzess (linaclotide) 290 mcg oral daily 17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP for up to 3 doses 18. Omeprazole 20 mg PO BID WIHT LUNCH AND DINNER 19. Oxybutynin 5 mg PO BID 20. RisperiDONE 1 mg PO DAILY 21. Senna 8.6 mg PO QHS:PRN constipation 22. Sertraline 150 mg PO DAILY 23. Simvastatin 20 mg PO QPM 24. Symbicort ___ mcg/actuation inhalation BID 25. Systane Gel (artificial tears(hypromellose);<br>peg ___ glycol) ___ % ophthalmic TID 26. TraMADol 50 mg PO TID 27. Warfarin 3 mg PO DAILY16 28. HELD- Loxapine Succinate 30 mg PO DAILY This medication was held. Do not restart Loxapine Succinate until you discuss with PCP 29. HELD- Nitroglycerin Patch 0.1 mg/hr TD Q24H This medication was held. Do not restart Nitroglycerin Patch until discuss with PCP - soft BPs on discharge Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Pneumonia COPD exacerbation Right heart failure, RV Strain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. ___, It was a pleasure taking care of you during your recent admission to ___. You were admitted with shortness of breath which was likely due to a combination of pneumonia, COPD exacerbation and fluid in your lungs. You were treated with Antibiotics, steroids and diuretics and you improved. You were started on an oral diuretic which you should continue on discharge. It is important that you follow up with your cardiologist and pulmonologist after discharge We wish you the best, Your ___ care team Followup Instructions: ___
10804747-DS-9	10,804,747	24,231,179	DS	9	2147-07-04 00:00:00	2147-07-15 18:50:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lithium / Wellbutrin / Seroquel Attending: ___. Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ female pt w/ hx of HFpEF, mild to moderate pulmonary artery systolic hypertension, chronic hypoxic respiratory failure (multifactorial- COPD, ?old interstitial pneumonitis, WHO Group 2 pulmonary hypertension) on 3L NC at home, RV hypokinesis but preserved LFEF (>60% per ___ TTE), DVT (x1 in 1960s, x2 Picc-associated in arm ___ on warfarin, presenting with CP. On ___, chest pain woke her from sleep ~0600. The pain was midsternal and radiated to the right jaw. States she vomited x2 this am, denies blood in vomit, denies N/D. Denies recent fevers/chills. Of note, she states that she has been feeling increasingly SOB over the last ___. (She says that this might be attributable to the fact that she has been forgetting to wear and/or turn on her O2). She states that her current SOB is worse than baseline. She received nitroglycerin and full dose of aspirin prior to arrival to ___ ED. She arrived on her home nitro patch, but this was removed d/t low BPs. In the ED initial vitals were: Temp 98.4 HR 88 BP 100/60 RR 18 94% on Nasal Cannula EKG: no ischemic changes per ED read. On this writer's read, low voltage of V1 concerning for poor test v poor R wave progression Labs/studies notable for: BMP wnl Trop-T 0.02 H&H ___ with MCV 90 WBC 9.7 with 73.6% PMN Past Medical History: 1. Mild to moderate pulmonary hypertension with an estimated TR gradient of 32-42 mmHg on echocardiograms done ___ and ___. Right heart catheterization ___ with PASP 42 mmHg. 2. Right ventricular dilation, hypertrophy and basal hypokinesis of free wall (TTE ___. Improved RV function on TTE ___. 3. Chronic diastolic heart failure/HFpEF (EF >55% on TTE ___. 4. Chronic atypical chest pain. Negative PMIBI ___. 5. Chronic hypoxic respiratory failure on 3L O2 (multifactorial). 6. Esophageal dysmotility Social History: ___ Family History: - Mother: emphysema - Sister: O2 dependent - No relevant cardiac history including premature coronary artery disease, cardiomyopathies, arrhythmias or sudden cardiac death Physical Exam: ADMISSION GENERAL: Frail-appearing woman in NAD. Mood, affect appropriate. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, but intermittent pursed lip breathing. Ronchi all fields, crackles at bases. Some mild dyspnea at end of sentences. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: Round ecchymosis 7cm diameter on L thigh. Round ecchymosis 1cm diameter dorsal side of R hand. PULSES: Distal pulses palpable and symmetric NEURO: Face grossly symmetric, moving all limbs w/ purpose against gravity. Low amplitude resting tremor. DISCHARGE VITALS: 98.5 PO 87 / 50 R Lying 78 18 90 4L GENERAL: Cachectic, NAD. Mood, affect appropriate. HEENT: MMM. Tongue pink and without exudate; no signs thrush. CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops appreciated. LUNGS: Intermittent pursed lip breathing. Ronchi in all fields, crackles at bases. Some mild dyspnea at end of sentences. ABDOMEN: Soft, NTND. EXTREMITIES: No c/c/e. PULSES: Distal pulses palpable and symmetric NEURO: Face grossly symmetric, moving all limbs w/ purpose against gravity. Low amplitude resting tremor. Pertinent Results: ___ 07:26AM BLOOD WBC-8.5 RBC-3.58* Hgb-10.0* Hct-32.9* MCV-92 MCH-27.9 MCHC-30.4* RDW-17.1* RDWSD-57.2* Plt ___ ___ 12:00PM BLOOD Neuts-73.6* Lymphs-17.5* Monos-6.4 Eos-1.9 Baso-0.3 Im ___ AbsNeut-7.13*# AbsLymp-1.69 AbsMono-0.62 AbsEos-0.18 AbsBaso-0.03 ___ 10:25AM BLOOD ___ ___ 07:26AM BLOOD Glucose-98 UreaN-13 Creat-0.9 Na-145 K-4.1 Cl-104 HCO3-28 AnGap-13 ___ 09:30AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 07:26AM BLOOD Mg-2.3 ___ NUCLEAR STRESS FINDINGS: The images are adequate but limited due to soft tissue attenuation and subdiaphragmatic activity. Left ventricular cavity size is normal. Rest and stress perfusion images reveal a moderate, medium-sized, fixed anteroseptal defect from the apex to the mid ventricle which does not completely improve with attenuation correction but is still favored to be artifact given the EF of 78%. Gated images reveal mild hypokinesis in the region of the above defect. The calculated left ventricular ejection fraction is 78%. IMPRESSION: 1. No reversible perfusion defects. 2. Normal left ventricular cavity size and normal ejection fraction. Compared to the prior study on ___ there is no change. ___ CHEMICAL STRESS INTERPRETATION: This ___ woman with COPD and pHTN was referred to the stress lab for evaluation of chest discomfort. There was baseline NSSTTWs on her resting ECG. She was infused with 0.142mg/kg/min of dipyradimole over 4min. There was no reported chest, neck, back, or arm discomfort thoughout the study. There were no ST segment deviations during infusion or recovery. The rhythm was sinus with no ectopy. Appropriate hemodynamic response to the infusion and recovery. The dipyridamole was reversed with 125 mg of aminophylline IV. IMPRESSION: No angina or ST segment changes during dipyridamole infusion. Nuclear report sent separately. SIGNED: ___ ___ TTE IMPRESSION: Dilated right ventricle with moderate global hypokinesis and pressure/volume overload. Normal left ventricular systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of ___, the right ventricle is dilated and hypokinetic with signs of pressure/volume overload. ___ TTE IMPRESSION: Normal global and regional biventricular systolic function. Moderate pulmonary hypertension. TTE demonstrating normal global and regional biventricular systolic function w/ moderate pulmonary hypertension (PASP 42 mmHg), improved RV function compared to ___. ___ PFTs: FEV1/FVC 86%, FEV1 108% (1.56). [Previously in ___ FEV1/FVC 86%, FEV1 108% \| ___ FEV1/FVC 84%, FEV1 99%, DLCO 45%.] ___: STRESS ECHO IMPRSSION: No angina type symptoms or ischemic EKG changes. PMIBI results normal by report. ___ (per written records; report not found): R heart cath demonstrated only mild pulmonary HTN with PA ___ (23), normal filling pressures and cardiac output Brief Hospital Course: SUMMARY: ___ female pt w/ HFpEF (EG >60% per ___ TTE & RV hypokinesis), mild to moderate pulmonary artery systolic HTN, COPD on home O2 (___), DVT (x1 in 1960s, x2 in arm ___ on warfarin, here w/ chest pain c/f unstable angina. She underwent nuclear perfusion scan and pharmacologic stress test on ___, which were both grossly normal. #ANGINA: Concern for cardiac in origin given acute onset, pain radiating to jaw, association with N/V. No ECG changes or trop leak. No evidence of pneumonia, costochonrdritis; therapeutic on warfarin making PE unlikely. Not c/w pt's GERD pain. However, nuclear test showing no heart motion abnormality or filling defect. No angina or ST segment changes during stress test. Continued home ASA 81, simvastatin 20. #SUPRATHERAPEUTIC INR: Given dose-reduced warfarin (2mg) on ___ for INR 2.8. On ___, INR 3.4. Not reversed. Held dose ___ pm. Please recheck on ___ and dose adjust in consult with a physician as appropriate. #URINARY HESITANCY: Required straight cathx1 in context of receiving benztropine (was on her med list from prior discharge; pt does not actually take at home) Chronic, stable # COPD: Overall stable. Recent PFTs similar to ___. On home oxygen ___ and home medications. # Hx DVTs: Patient reports 1 spontaneous DVT many years ago and then PICC-associated DVTs in approximately ___. Continued home warfarin # recent hx thrush w/current mouth pain: Wrote for nystatin swish and spit # Esophageal dysmotility # Chronic constipation: Continue home meds, including omeprazole, maalox, bisacodyl, tums, docusate, senna # Bipolar Disorder: Continue home medications: -clonazepam QAM, 2pm, QHS; risperidone; sertraline # hypothyroidism - home levothyroxine # derm: on home doses of -aquaphor, bengay # GU - on home oxybutynin # HEENT -on home Flonase, guaifenisen, sodium nasal spray, artificial tears # pain -home tramadol >30 minutes on discharge planning/coordination of care. TRANSITIONAL ISSUES [ ] HOLDING WARFARIN ___ for supratherapeutic INR on ___. Restart as needed, or discuss discontinuation with PCP/hematologist given >3 months out past ___-associated DVT [ ] consider optimizing primary prevention of CAD with higher-dose statin [ ] continue to follow Coumadin dosing ___ INR 3.4; holding ___ dose) [ ] see Cardiology to follow-up on stress test performed ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. ClonazePAM 1 mg PO QHS 3. ClonazePAM 0.25 mg PO DAILY 2PM 4. ClonazePAM 0.5 mg PO DAILY 5. Docusate Sodium 100 mg PO DAILY 6. Fluticasone Propionate NASAL 1 SPRY NU DAILY 7. Levothyroxine Sodium 50 mcg PO DAILY 8pm 8. Omeprazole 20 mg PO BID WIHT LUNCH AND DINNER 9. RisperiDONE 1 mg PO DAILY 10. Senna 17.2 mg PO QHS:PRN constipation 11. Sertraline 150 mg PO DAILY 12. TraMADol 50 mg PO TID 13. Warfarin 3 mg PO DAILY16 14. Torsemide 10 mg PO DAILY 15. Linzess (linaclotide) 290 mcg oral before breakfast 16. Nitroglycerin Patch 0.1 mg/hr TD Q24H 17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP for up to 3 doses 18. Oxybutynin 5 mg PO BID 19. Simvastatin 20 mg PO QPM 20. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation BID 21. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing 22. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 23. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN GI upset 24. Aquaphor Ointment 1 Appl TP Frequency is Unknown dry scabs on ears 25. Bisacodyl 10 mg PR QHS:PRN constipation 26. Calcium Carbonate 500 mg PO TID:PRN GI upset 27. Levalbuterol Neb 0.63 mg NEB Q6H:PRN sob 28. Loratadine 10 mg PO DAILY 29. melatonin 3 mg oral QHS 30. Milk of Magnesia 30 mL PO DAILY:PRN constipation 31. Multivitamins 1 TAB PO DAILY 32. Nicotine Polacrilex 2 mg PO Q1H:PRN smoking cesation 33. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal dryness 34. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN wheeze 35. Systane Gel (artificial tears(hypromellose);<br>peg 400-propylene glycol) 0.4-0.3 % ophthalmic TID 36. Bengay Cream 1 Appl TP BID:PRN neck pain 37. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 38. GuaiFENesin ER 600 mg PO Q12H 39. TraMADol 50 mg PO DAILY:PRN Pain - Moderate 40. GuaiFENesin 10 mL PO Q4H:PRN cough 41. Anbesol (benzocaine) (benzocaine) 20 % mucous membrane QID:PRN 42. magnesium citrate ___ bottle oral DAILY:PRN Discharge Medications: 1. Aquaphor Ointment 1 Appl TP DAILY dry scabs on ears 2. Magnesium Citrate 4 oz oral DAILY:PRN constipation 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 4. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN GI upset 5. Anbesol (benzocaine) (benzocaine) 20 % mucous membrane QID:PRN 6. Aspirin 81 mg PO DAILY 7. Bengay Cream 1 Appl TP BID:PRN neck pain 8. Bisacodyl 10 mg PR QHS:PRN constipation 9. Calcium Carbonate 500 mg PO TID:PRN GI upset 10. ClonazePAM 1 mg PO QHS 11. ClonazePAM 0.25 mg PO DAILY 2PM 12. ClonazePAM 0.5 mg PO DAILY 13. Docusate Sodium 100 mg PO DAILY 14. Fluticasone Propionate NASAL 1 SPRY NU DAILY 15. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 16. GuaiFENesin ER 600 mg PO Q12H 17. GuaiFENesin 10 mL PO Q4H:PRN cough 18. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing 19. Levalbuterol Neb 0.63 mg NEB Q6H:PRN sob 20. Levothyroxine Sodium 50 mcg PO DAILY 8pm 21. Linzess (linaclotide) 290 mcg oral before breakfast 22. Loratadine 10 mg PO DAILY 23. melatonin 3 mg oral QHS 24. Milk of Magnesia 30 mL PO DAILY:PRN constipation 25. Multivitamins 1 TAB PO DAILY 26. Nicotine Polacrilex 2 mg PO Q1H:PRN smoking cesation 27. Nitroglycerin Patch 0.1 mg/hr TD Q24H 28. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP for up to 3 doses 29. Omeprazole 20 mg PO BID WIHT LUNCH AND DINNER 30. Oxybutynin 5 mg PO BID 31. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN wheeze 32. RisperiDONE 1 mg PO DAILY 33. Senna 17.2 mg PO QHS:PRN constipation 34. Sertraline 150 mg PO DAILY 35. Simvastatin 20 mg PO QPM 36. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal dryness 37. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation BID 38. Systane Gel (artificial tears(hypromellose);<br>peg 400-propylene glycol) 0.4-0.3 % ophthalmic TID 39. Torsemide 10 mg PO DAILY 40. TraMADol 50 mg PO TID 41. TraMADol 50 mg PO DAILY:PRN Pain - Moderate 42. HELD- Warfarin 3 mg PO DAILY16 This medication was held. Do not restart Warfarin until your INR is checked on ___ and is not supratherapeutic, or take a lower dose as recommended by your doctor. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Angina Pulmonary hypertension Chronic diastolic heart failure (HFpEF) History of upper extremity DVT 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 were in the hospital because you had pain in your chest. WHAT HAPPENED IN THE HOSPITAL? ============================== In the hospital, your doctors took ___ picture of your heart. It showed that your heart moves normally, and that your heart is able to perform well under stress. WHAT SHOULD I DO WHEN I GO HOME? ================================ When you go home, you should continue to take your medications as prescribed. You should also make sure to follow up with your care providers as scheduled. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team #NEW MEDS: none #CHANGED MEDS: none #DICONTINUED MEDS: none #HELD MEDS: Warfarin Discharge weight: 129.19 lb Discharge creatinine: 0.9 Code status: DNR/DNI Followup Instructions: ___
10804768-DS-11	10,804,768	25,038,576	DS	11	2140-02-28 00:00:00	2140-02-28 17:04:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: adalimumab / apremilast / bupropion / cefaclor / ceftriaxone / hydromorphone / nitrofurantoin / Sulfa (Sulfonamide Antibiotics) Attending: ___ Chief Complaint: abnormal LFTs Major Surgical or Invasive Procedure: EGD ___ History of Present Illness: ___ female with a history of plaque psoriasis, alcohol abuse, who presented to ___ with abnormal LFTs, referred to ___ for further management. Patient reports that she has been feeling "under the weather" for the past month, with mild cold-type symptoms including fatigue, sneezing, congestion, coughing with clear sputum, which most of her office has had. She also noticed dark urine (light brown in color), increased abdominal bloating, and changes in bowel habits (stool more mucus-y) during this time. She also reports increased leg swelling for the past 2 weeks. Of note, she was recently tried on apremilast (Otezla) for treatment of plaque psoriasis - she reports taking this for 1 month, then stopping it 1 month prior to this presentation due to GI side effects with N/V. She presented for routine PCP appointment about 1 week ago, at which time she was found to have elevated LFTs. Pt denies prior h/o liver disease of LFT abnormalities. She was referred in for an U/S, which was concerning for possible portal vein thrombosis. She received CT scan which was negative for portal vein thrombosis. Outside ED Labs: patient with bilirubin 2.7, alk phos 249, ALT 27, AST 131, INR 1.37. At that point, she was noted to be tender in right upper quadrant, no encephalopathy, and was transferred to ___. In terms of ETOH use, patient reports drinking close to 4 drinks daily (range ___, either wine or mixed drink. She has had increased ETOH intake for the past 4 months. Prior to that was drinking 1 glass of wine per day, though she notes that ___ year ago she had a period of time where she had increased life stress and was drinking more heavily before she saw a therapist and cut down on ETOH. Last ETOH drink ___. In the ED initial vitals: 97.8, 101, 112/70, 18, 98% RA - Exam notable for: +TTP in RUQ, abdominal distension. trace pitting edema. no jaundice, no asterixis - Labs notable for: 7.6 12.4 170 >-----< 37.2 137 ___ AGap=13 ------------< 4.0 23 0.6 ALT: 19 AST: 111 AP: 218 Tbili: 2.4 INR: 1.8 - negative serum tox - hep B immune, hep A neg, HCV neg - AMA, ___, anti smooth muscle ab: negative - Imaging notable for: CXR - Hypoinflated lungs with bibasilar atelectasis. No focal consolidation identified. OSH RUQ U/S with Doppler: 1. findings c/w PVT likely iso cirrhosis. hepatomegaly and surface contour lobulation. mild splenomegaly. diffuse parenchymal heterogeneity. superimposed hepatitis cannot be excluded. focal mass not identified. 2. gallbladder has been removed. slight prominence of extrahepatic ductal system without intrahepatic ductal dilatation is nonspecific and probably reflects the chronic post CCY state. 3. minimal perihepatic free fluid is nonspecific and could reflect actue hepatitis or portal HTN. OSH CT A/P with con: 1. diffusely enlarged heterogenous liver with heterogenous peripheral enhancement. 2. minimal pelvic ascites. 3. no e/o portal venous thrombosis. - Liver Consult: Differential broad for acute liver injury. Based on AST:ALT pattern concern is for alcoholic hepatitis vs drug induced liver injury. Will send broad workup, trend LFTs and decide if liver biopsy is warranted. - Acute hepatitis panel: HAV, HBV, HCV, ___, AMA, ___, Ceruloplasmin, alpha1 antitrypsin, CMV, EBV, Serum tox including acetaminophen level -Second opinion on CT imaging -Given INR of 1.8, Vit K challenge 5mg iv x 3 doses -___ DF based on T bili 2.2 and ___ of 19.8 is 35.8(>32), if confirmed alc hep, may benefit from steroids, please send CXR and UA, rule out potential sources of infection -Admit to ET service with Dr ___ as attending - Patient was given: venlafaxine, vit K 10 PO, oxycodone 5 x2, topical betamethasone Upon arrival to floor, patient reports history above. Otherwise she does not have active complaints. Denies f/c, SOB, CP, dysuria. Past Medical History: Plaque psoriasis Anxiety ?Depression ETOH use s/p CCY s/p "back surgery" x2 ectopic pregnancy s/p salpingectomy Social History: ___ Family History: ETOH abuse in mother, maternal grandfather, maternal aunts. Dad with DM. Maternal grandfather had cirrhosis ___ ETOH. Physical Exam: ADMISSION PHYSICAL EXAMINATION: =============================== VS: 98.3PO, 114 / 73L Sitting, 91, 18, 97 Ra GENERAL: NAD HEENT: AT/NC, EOMI, anicteric sclera, MMM NECK: supple HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: mild distended, +BS, tympanitic, mildly tender in RUQ without guarding EXTREMITIES: no pitting ___, trace soft tissue edema bl PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose. no asterixis. SKIN: warm and well perfused, scattered red plaques with scale DISCHARGE PHYSICAL EXAMINATION: =============================== VS: 24 HR Data (last updated ___ @ 748) Temp: 98.4 (Tm 98.5), BP: 103/68 (103-118/64-72), HR: 91 (91-97), RR: 18, O2 sat: 93% (93-95), O2 delivery: Ra, Wt: 190.4 lb/86.37 kg GENERAL: NAD HEENT: AT/NC, EOMI, anicteric sclera, MMM NECK: supple HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: mildly distended but soft, +BS, tender hepatomegaly with mildly ttp in RUQ without guarding EXTREMITIES: trace soft tissue edema bl, non pitting PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose. no asterixis. SKIN: warm and well perfused, scattered red plaques with scale Pertinent Results: ADMISSION LABS ============== ___ 01:18AM BLOOD WBC-8.3 RBC-3.27* Hgb-11.7 Hct-35.1 MCV-107* MCH-35.8* MCHC-33.3 RDW-15.3 RDWSD-61.1* Plt ___ ___ 01:18AM BLOOD Neuts-71.3* Lymphs-17.8* Monos-8.2 Eos-1.8 Baso-0.7 Im ___ AbsNeut-5.89 AbsLymp-1.47 AbsMono-0.68 AbsEos-0.15 AbsBaso-0.06 ___ 01:30AM BLOOD ___ PTT-40.8* ___ ___ 01:18AM BLOOD Glucose-75 UreaN-4* Creat-0.6 Na-137 K-4.1 Cl-102 HCO3-23 AnGap-12 ___ 01:18AM BLOOD ALT-19 AST-109* AlkPhos-211* TotBili-2.2* ___ 01:18AM BLOOD Lipase-29 ___ 11:15AM BLOOD Calcium-8.0* Phos-3.6 Mg-1.8 ___ 01:18AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-NEG ___ 01:18AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE ___ 01:18AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 01:18AM BLOOD ___ ___ 01:18AM BLOOD HCV Ab-NEG DISCHARGE LABS ============== ___ 06:52AM BLOOD WBC-7.3 RBC-3.15* Hgb-11.3 Hct-34.1 MCV-108* MCH-35.9* MCHC-33.1 RDW-15.5 RDWSD-61.7* Plt ___ ___ 06:52AM BLOOD ___ PTT-41.4* ___ ___ 06:52AM BLOOD Glucose-109* UreaN-5* Creat-0.6 Na-139 K-3.5 Cl-103 HCO3-25 AnGap-11 ___ 06:52AM BLOOD ALT-16 AST-87* AlkPhos-185* TotBili-1.0 ___ 06:52AM BLOOD Albumin-2.8* Calcium-8.0* Phos-2.4* Mg-2.1 IMAGING/STUDIES =============== ___ Imaging ABDOMEN (SUPINE & ERECT IMPRESSION: No evidence of small-bowel obstruction or ileus. EGD ___ Grade I varices in distal esophagus, 1 cord, nonbleeding. Portal hypertensive gastropathy in fundus and body Brief Hospital Course: ___ female with a history of plaque psoriasis, alcohol use disorder, anxiety, who presented to ___ with abnormal LFTs c/f alcoholic hepatitis ACTIVE ISSUES ============= # Abnormal LFTs # Alcoholic hepatitis Presented with RUQ pain as well as n/v/poor PO, found to have newly elevated LFTs with AST>>ALT. Presentation most likely ___ alc hep, given otherwise negative work up. While Apremilast can lead to asymptomatic transaminitis during treatment, less likely to lead to sx this far out. Infectious work up negative with CXR unremarkable, UA clean, EBV/CMV negative. Autoimmune w/u showing negative AMA, ___. A1AT and ceruloplasmin wnl. Lipase unremarkable. Underwent EGD ___ given retching, unclear hx of liver disease, and no prior hx of EGD. OSH U/S c/f PVT but f/u CT negative. No known hx of cirrhosis but OSH ___ read of CT with evidence of nodular liver, portal hypertension, splenomegaly, and EGD with grade I varices, portal hypertensive gastropathy all suggestive of cirrhosis. NJT was placed with EGD and TF were started. DF was 37.8 on admission, but steroids were deferred given rapid improvement with supportive therapy. Started on PO PPI bid and standing Zofran. Given IV vit K challenge x 3d given elevated INR. Given ongoing n/v and abdominal pain and no BM for 3 days, was ordered for KUB which was unremarkable. Patient was discharged after tolerating PO and cycled TF at goal # ETOH use Reported alcohol intake of 4 drinks (wine/cocktails) daily. Inconsistent reports but possibly with increased ETOH intake for the past 4 months. No clear precipitant, but pt had reported using ETOH to "self medicate" in past. Pt appeared motivated to stop drinking. Last drink was ___ with no signs of withdrawal. Placed on CIWA protocol and consulted SW CHRONIC ISSUES =============== # Plaque psoriasis - Continued on home betamethasone topical # Anxiety / depression - Continued on home venlafaxine. TRANSITIONAL ISSUES: =================== Discharge DF 17.1 [] Continue tube feeds until clinically improved (preliminary recs for ___ [] New diagnosis of cirrhosis - patient should be referred to hepatology and followed as appropriate [] Should receive ongoing counseling and possibly psych referral for alcohol cessation/self-medication []Please consider treatment for alcohol cessation/abuse and consider topomax and on-demand naltrexone. # CODE: Presumed FULL # CONTACT: ___ Relationship: ___ Phone: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Venlafaxine XR 37.5 mg PO DAILY 2. Betamethasone Dipro 0.05% Lot. 1 Appl TP BID 3. Multivitamins 1 TAB PO DAILY 4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 [Miralax] 17 gram/dose 17 g by mouth once a day Refills:0 3. Senna 8.6 mg PO BID RX sennosides [Senna Lax] 8.6 mg 1 by mouth once a day Disp #30 Tablet Refills:0 4. Thiamine 100 mg PO DAILY RX thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a day Disp #60 Tablet Refills:*0 5. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 6. Betamethasone Dipro 0.05% Lot. 1 Appl TP BID 7. Multivitamins 1 TAB PO DAILY 8. Venlafaxine XR 37.5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY - Alcoholic Hepatitis - Alcohol Use Disorder SECONDARY - Plaque psoriasis - Major Depressive Disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you were having abdominal pain and vomiting. WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - You were monitored for alcoholic hepatitis. - You were given supportive care and a feeding tube to help you recover. - You improved and were ready to leave the hospital. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Please take all of your medications as prescribed and go to your follow up appointments with your doctors ___ below) - Weigh yourself every morning, before you eat or take your medications. Call your doctor if your weight increases by more than 3 pounds - Please maintain a low salt diet and monitor your fluid intake - Seek medical attention if you have new or concerning symptoms or you develop It was a pleasure participating in your care. We wish you the best! - Your ___ Care Team Followup Instructions: ___
10805203-DS-3	10,805,203	22,054,032	DS	3	2189-04-15 00:00:00	2189-04-15 16:37:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Cipro / Keflex Attending: ___. Chief Complaint: Agitation/Somnolence Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ female with history of dementia, hereditary colon cancer syndrome. retinal melanoma colon cancer x3 breast cancer x1 who presents with agitation. The patient's daughter is at bedside and provides history as patient is somnolent. The patient's daughter reports that over the past few days the patient has been increasingly agitated. She was recently diagnosed with UTI and started on antibiotics yesterday afternoon. Yesterday evening at about 9:30 ___ she was noted to be speaking to inanimate objects. Her husband was also concerned that she had decreased ostomy output therefore he brought her to the emergency department. The patient initially presented to ___ where a CT head showed a mass with significant vasogenic edema without significant mass-effect the patient was transferred to twice daily and see for neurosurgical evaluation. While in the emergency department the patient was agitated. At ___ she was given 5 mg Zyprexa x2. At the emergency department at twice daily MC she received 5 mg Zyprexa IV x2 in addition to lorazepam 0.5 mg IV x3. The patient is currently arousable but cannot provide additional history. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: -Alzheimer's dementia -Hereditary cancer syndrome - increased risk for colon and breast cancer. -Breast cancer diagnosed at age ___ status post left mastectomy - Colon cancer diagnosed first at age ___ and subsequently age ___ and then at age ___ status post total colectomy with end ileostomy - Retinal melanoma treated with intraocular radiation Social History: ___ Family History: Multiple family members with colon cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.9 116/74 72 18 99/RA GENERAL: Somnolent, restless EYES: Anicteric, pupils 2mm, minimally responsive to light ENT: Ears and nose without visible erythema, masses, or trauma. CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear on anterior auscultation. Poor cooperation/ GI: Abdomen soft, ostomy in place in mid abdomen with small hernia. Soft stool in bag. 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: Somnolent. Does not track or opens eyes to voice. PSYCH: unable asses DISCHARGE PHYSICAL EXAM: T 97.6, BP 152 / 63, HR 79, RR 18, O2sat 91 on RA General: restless, agitated HEENT: sclera anicteric, conjunctiva normal, eyes tracking appropriately PULM: lungs clear to auscultation throughout CV: patient not cooperative with examination of the precordium GI/GU: abdomen soft, patient not cooperative with remainder of abdominal exam MSK: moving all extremities, strength grossly normal SKIN: no rashes noted Neuro: Restless. Responds to questioning with word-salad, incomprehensible but fluent speech. Incomprehensibly ruminating about the "meaning" and pointing at her legs repeatedly PYSCH: unable to assess Pertinent Results: ADMISSION LABS: ___ 05:08AM BLOOD WBC: 8.9 RBC: 4.90 Hgb: 14.5 Hct: 44.3 MCV: 90 MCH: 29.6 MCHC: 32.7 RDW: 13.8 RDWSD: 46.___ ___ 05:08AM BLOOD Glucose: 129* UreaN: 22* Creat: 0.7 Na: 143 K: 7.2* Cl: 111* HCO3: 21* AnGap: 11 ___ 05:08AM BLOOD ALT: 17 AST: 46* CK(CPK): 153 AlkPhos: 60 TotBili: 0.7 ___ 05:08AM BLOOD Lipase: 111* ___ 05:17AM BLOOD Lactate: 1.7 K: 4.3 ___ 05:08AM BLOOD TSH: 0.99 ___ 05:08AM BLOOD Albumin: 4.5 Calcium: 8.9 Phos: 4.3 Mg: 3.3* DISCHARGE LABS: ___ 09:00AM BLOOD WBC-10.7* RBC-4.88 Hgb-14.3 Hct-44.1 MCV-90 MCH-29.3 MCHC-32.4 RDW-13.4 RDWSD-44.3 Plt ___ ___ 09:00AM BLOOD Glucose-142* UreaN-8 Creat-0.4 Na-144 K-4.3 Cl-109* HCO3-25 AnGap-10 ___ 09:00AM BLOOD Calcium-8.8 Phos-2.3* Mg-2.0 IMAGING: CT head/brain wo con Accession Number(s): ___ Date / Time of Exam: ___ 02:30:06 Reason for Study: altered mental status Interpretation Location: PACSWKS2 Axial CT scans of the head obtained from the base to the vertex without contrast enhancement. Reformatted coronal and sagittal images also generated. Brain and bone windows reviewed. Age related involutional changes bilaterally. Focal areas of intra-axial low attenuation in the adjacent left frontal and parietal lobes. Differential diagnosis includes acute cerebral infarct and metastatic disease. No intracranial hemorrhage or midline shift. No hydrocephalus. Bone windows demonstrate no significant osseous abnormality. Imaged paranasal sinuses and mastoid air cells are clear. IMPRESSION: Focal areas of intra-axial low attenuation in the adjacent left frontal and parietal lobes. ? Acute cerebral infarcts vs metastatic disease. Brain MRI without and with IV gadolinium recommended for further evaluation. - CT HEAD WITH CONTRAST (___): Solitary, rim-enhancing lesion within the posterior left parietal lobe measuring 3.0 x 3.1 x 3.3 cm, with surrounding vasogenic edema. Given its internal fluid density, findings may be compatible with abscess, however differential consideration of metastasis or high-grade primary malignancy cannot be excluded. Recommend further evaluation with dedicated MRI head with without contrast for characterization. - MRI BRAIN ___: 1. Solitary mass with irregular rim enhancement in the inferior left parietal lobe concerning for glioblastoma. A solitary metastasis is less likely given the highly irregular morphology. Diffusion characteristics are not supportive of an infarct or bacterial abscess. 2. Moderate surrounding edema with mild effacement of the atrium of the left lateral ventricle but no shift of midline structures. - TTE ___: Poor image quality. Bileaflet mitral valve prolapse without large vegetation in oneview. Mildly thickened aortic valve without clear vegetation in one view. Endocarditis cannot beexcluded on the basis of the study, however given poor image quality. TEE would be necessary toexclude endocarditis. Small hypertrophied, dynamic left ventricle. No prior TTE available forcomparison. - EEG ___: This is an abnormal continuous ICU monitoring study due to the presence of 18 brief electrographic seizures arising from the left parietal region, with involvement of the left posterior temporal region, lasting ___ minutes in duration without any consistent clinical change in behaviors. Interictally, broad-based sharp waves are seen in the left parietal and posterior temporal region, or more broadly over the left hemisphere, indicative of potentially epileptogenic cortex in these regions. Mild attenuation of activity with bursts of slowing are seen over the left hemisphere, indicative of a structural lesion causing focal cerebral dysfunction. Diffuse slowing of the background is consistent with a mild to moderate encephalopathy, which is nonspecific in etiology, and can be associated with toxic/metabolic disturbances and medication effects. - ___ EEG: This continuous ICU monitoring study was abnormal due to: 1) Frequent independent sharp waves seen in the left > right temporal regions, at times occurring in pseudoperiodic runs at ___ Hz. These findings are indicative of underlying focal and epileptogenic areas. 2) There was mild focal slowing over the left temporal region, and focal slowing over the right temporal region, suggesting focal cerebral dysfunction. 4) Generalized background slowing consistent with a mild encephalopathy, non-specific with regards to etiology. There were no push button events. Compared to the prior day's recording, there was no significant change. Brief Hospital Course: SUMMARY: ___ is a ___ year old woman with a history of dementia, and multiple malignancies (including melanoma) admitted with acute AMS, found to have likely new intracranial malignancy c/b focal seizures. Surgical, radiation, and medical management of mass were not within ___ and patient was managed conservatively with focus on seizure suppression and improvement in mental status. Pt discharged with all PO meds and regular diet despite high aspiration risk, per ___. Pt discharged on hospice to ___. HOSPITAL COURSE: # Goals of Care: Per discussions at family meetings this hospitalization, the patient's treatment goals are now comfort-focused. All medications will be PO and directed towards comfort, as below. The patient was discharged on ___ ___ with hospice. # Malignant Intracranial Mass: Patient admitted with acute onset mental status changes in the setting of subacute decline. NCHCT with left parietal 3x3cm mass. As patient initially could not tolerate MRI for agitation, CT brain with contrast demonstrated hyperenhancement of mass concerning for possible abscess and she was subsequently started on CTZ/MTZ/vancomycin. However, after MRI performed with MAC anesthesia, imaging was more consistent with a malignancy (possibly GBM) with mass effect of surrounding tissues, but without midline shift or signs of herniation. Neurosurgery consulted and reviewed at neuro tumor board. After discussion with patients family, it was determined that surgical options, chemotherapy, or radiation were not within patients goals of care, and she was instead started on dexamethasone to decrease brain swelling at the direction of neurology. Mass was felt to be cause of seizures (see below). Patient was eventually tapered down to 1mg dexamethasone BID, which she will continue indefinitely after discharge. # Seizures: EEG monitoring demonstrated frequent focal electrographic seizures origination from left parietal lobe. She was started on keppra and lacosamide with eventual seizure suppression. These medications were converted to oral and she will need to continue these indefinitely aftter discharge. Of note, if the patient is unable to take keppra and lacosamide (see toxic-metabolic encephalopathy below), can try clonazepam wafers instead. # Toxic-metabolic encephalopathy: Multifactorial. Patient with baseline dementia. UTI diagnosed 1 day prior to admission (which may have lower seizure threshold) and metabolic encephalopathy may have been contributing factor. Seizures additionally contributed early in hospital course, as did delirium from hospital setting and steroid use. After seizures suppressed, UTI treated, EEG leads, tubes and restraints were removed efforts were made to improve her delirium with ___ olanzapine, frequent reorientation and family bedside presence and patients condition improved. SLP evaluation revealed high risk of aspiration and inattention to many food boluses; however, per GOC the patient was discharged on a regular diet. SLP recommended thin liquids rather than thickened liquids as an option for comfort and improved hydration. The patient was also discharged on oral medications. # Hypernatremia: patient initially hypernatremic iso dehydration/oliguria. Resolved with increased rate of IVFs prior to discharge. Remained eunatremic on day of discharge after 1 day of discontinuation of all IVFs and IV medications. # Urinary Retention: patient with ongoing urinary retention. Foley was ultimately removed, per ___ discussion. Patient required straight caths for comfort when urine >750 on serial bladder scans (q6-8 hrs). # Thrush: initially got IV fluconazole iso difficulty swallowing, but ultimately tolerated nystatin swish (continue for comfort) Transitional Issues: ==================== - regular diet with thin liquieds despite high aspiration risk, per GOC - all meds PO, including anti-epileptic medications, which are indicated to control seizures for comfort - if patient unable to take oral lacosamide and keppra, can try clonazepam wafers (0.5 mg BID) - if possible, please try to give medications when family is around (patient tolerates oral medications better in the presence of family). She does best with medications crushed in a magic cup Code status: Comfort focused care, DNR/DNI Time spent coordinating discharge > 30 minutes Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cephalexin 500 mg PO Q8H 2. Nitrofurantoin (Macrodantin) 100 mg PO BID Discharge Medications: 1. ClonazePAM 0.5 mg PO BID:PRN If unable to take AEDs Please provide wafer. Give BID PRN when patient not otherwise taking anti-epileptics RX clonazepam 0.5 mg 1 tablet(s) by mouth twice a day Disp #10 Tablet Refills:*0 2. Dexamethasone Oral Soln (0.1mg/1mL) 10 mL ORAL BID if a crushed pill format is available, this might be better tolerated than the oral formulation 3. LACOSamide 100 mg PO BID 4. LevETIRAcetam Oral Solution 750 mg PO Q12H 5. Nystatin Oral Suspension 5 mL PO QID 6. OLANZapine (Disintegrating Tablet) 5 mg PO QPM 7. Ramelteon 8 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: - Intracranial Mass - Seizures - Toxic-metabolic encephalopathy - Hypernatremia - Urinary Retention - Difficulty Swallowing 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. ___ and ___, You were admitted to the hospital with confusion. We found a mass in the brain. We had a family meeting and it was decided that treatment of this mass with chemotherapy, radiation, or surgery would not be within your goals of care. We did treat the swelling around the mass in the brain with some steroids, as we discussed in the goals of care meeting. Additionally, we found evidence of seizure activity in the brain. The seizure activity was treated with anti-epileptic medications. While in the hospital, you had difficulty swallowing. Although the risk of aspiration is high, it was decided in another family meeting that part of optimizing comfort would include allowing you to eat a regular diet and take medications by mouth rather than by IV. You are now being discharged to ___ to focus on spending time with your family. It was a pleasure taking care of you. - Your ___ Care team Followup Instructions: ___
10805306-DS-14	10,805,306	28,145,388	DS	14	2156-01-25 00:00:00	2156-01-25 15:17:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Incarcerated ventral hernia Major Surgical or Invasive Procedure: Incisional Hernia Repair with Mesh History of Present Illness: ___ p/w incarcerated incisional bowel containing umbilical hernia Past Medical History: PMH: HTN H. pylori Polycythemia PSH: --s/p cystoscopy, laser lithotripsy and L ureteral stent placement for L kidney stone on ___ --Hx of perianal fistula drained in ___ Health Maintenance: Colonoscopy-never had one PSA in ___ Social History: ___ Family History: Mother died at age ___ ___ from "old age." Father died at ___ ___ from stroke; hx of ETOH abuse 2 brothers-health described as "good." Unaware of any other family history. Physical Exam: GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress. HEAD: normocephalic. EYES: PERRL, EOMI. Fundi normal, vision is grossly intact. EARS: External auditory canals and tympanic membranes clear, hearing grossly intact. NOSE: No nasal discharge. THROAT: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition. NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly. CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits. LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds. ABDOMEN: Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses. Abdominal lap sites c/d/I. MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait. BACK: Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm. EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities. LOWER EXTREMITY: Examination of both feet reveals all toes to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity; examination of both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity. NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal. SKIN: Skin normal color, texture and turgor with no lesions or eruptions. Pertinent Results: ___ 06:00AM GLUCOSE-115* UREA N-17 CREAT-0.7 SODIUM-139 POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-26 ANION GAP-14 ___ 06:00AM CALCIUM-9.3 PHOSPHATE-3.2 MAGNESIUM-2.1 ___ 06:00AM WBC-6.6 RBC-5.43 HGB-16.1 HCT-46.6 MCV-86 MCH-29.7 MCHC-34.5 RDW-13.2 RDWSD-41.0 ___ 06:00AM PLT COUNT-226 ___ 06:00AM ___ PTT-26.2 ___ ___ 07:54PM LACTATE-1.9 ___ 07:48PM GLUCOSE-137* UREA N-20 CREAT-0.9 SODIUM-140 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-25 ANION GAP-15 ___ 07:48PM estGFR-Using this ___ 07:48PM ALT(SGPT)-19 AST(SGOT)-21 ALK PHOS-93 TOT BILI-1.0 ___ 07:48PM ALBUMIN-4.4 ___ 07:48PM WBC-7.8 RBC-5.61 HGB-16.3 HCT-47.8 MCV-85 MCH-29.1 MCHC-34.1 RDW-13.0 RDWSD-40.5 ___ 07:48PM NEUTS-79.2* LYMPHS-15.2* MONOS-4.8* EOS-0.0* BASOS-0.3 IM ___ AbsNeut-6.17* AbsLymp-1.18* AbsMono-0.37 AbsEos-0.00* AbsBaso-0.02 ___ 07:48PM PLT COUNT-223 Brief Hospital Course: The patient presented to Emergency Department on ___. Upon arrival to ED, the acute care surgery service was consulted. Given findings, the patient was taken to the operating room for repair of umbilical hernia repair. There were no adverse events in the operating room; please see the operative note for details. Pt was extubated, taken to the PACU until stable, then transferred to the ward for observation. Neuro: The patient was alert and oriented throughout hospitalization; pain was managed with 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 IVF. Over the next few hours, the diet was advanced sequentially to a Regular diet, which was well tolerated. Patient's intake and output were closely monitored ID: The patient's fever curves were closely watched for signs of infection, of which there were none. 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: 1. Simvastatin 20mg QD Discharge Medications: 1. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate RX oxycodone 5 mg 5 tablet(s) by mouth every six (6) hours Disp #6 Tablet Refills:0 2. Simvastatin 20mg QD Discharge Disposition: Home Discharge Diagnosis: Incarcerated Ventral Hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. JP Drain Care: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). Maintain suction of the bulb. Note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. You may shower; wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: ___
10805461-DS-40	10,805,461	20,178,114	DS	40	2147-05-30 00:00:00	2147-06-03 16:27:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Heparin Agents / Cefazolin / Nelfinavir / Morphine / vancomycin / Nafcillin / Valium Attending: ___. Chief Complaint: Hypotension at HD Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. ___ is a ___ female with PMH of ESRD on MWF HD, cardiomyopathy, severe pHTN, and HIV on HAART ___: CD4 410) who presents to the ED for evaluation of hypotension. She was last in her USOH until today at ___ when she experienced hypotension to ___'s over ___ along with light-headedness/AMS. Dialysis was near the end. She was brought to the ED for evaluation and had SBP improve to 90's by arrival and was A+Ox3. In the ED, initial VS were 99.6 100 95/60 18 98% 3L. ED ECG was read as SR ___ changes. Labs revealed a lactate of 1.6. There was concern for pneumonia given report of cough with sputum, baseline immunosuppression, and recent admission for pneumonia. She received 2LNS, ipratropium and albuterol nebs, meropenem 500mg IV, and midodrine 10mg. She reportedly had not received midodrine post HD today. Her blood pressures recovered to the 80's and 90's systolic. She was admitted to the medical floor for monitoring. Vitals prior to transfer were 98.1, 110, 21, 92/63, 100%3LNC. On arrival to the medical floor, VS98.9, 106/60, 101, 20, 98%3LNC. She reports cough with sputum production but no fevers/chills, no pain, no nausea/vomiting, no fatigue or light-headedness. The cough has never stopped since her last presentation to the hospital, although she has remained afebrile since previous discharge. ROS: per HPI, 10 pt ROS neg except for above. Past Medical History: -HIV ___: CD4 410) -ESRD on HD MWF -HTN -severe pHTN -Cardiomyopathy ___ LVEF 31%, severe MR/TR -Lymphocytic interstitial pneumonitis (LIP) followed by Dr. ___ at ___ ___ -anemia of chronic disease -AVNRT diagnosed at ___ -vaginal bleed s/p conization -HCV - untreated -Asthma/COPD on home O2 -h/o MSSA bacteremia and vertebral osteomyelitis . PAST SURGICAL HISTORY -C-section -R knee surgery -Ovarian cysts removed Social History: ___ Family History: Her mother is living in her ___ and had a stroke, hypertension and diabetes. Her uncle died of kidney disease. She never met her father. Her sister was killed in a motor vehicle crash. Her children are healthy. Her daughter has a single kidney. Physical Exam: Physical Exam on Presentation: Vitals-98.9, 106/60, 101, 20, 98%3LNC General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD, right tunneled SC line is without surrounding erythema or tenderness Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, No MRG Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, left extremity with intact incision from fistula revision, palpable thrill and bruit auscultated Neuro- CNs2-12 intact, motor function grossly normal DISCHARGE PHYSICAL EXAM Vitals: afebrile satting 98% on 2L General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, moonshaped facies Neck- supple, JVP not elevated, no LAD, right tunneled SC line is without surrounding erythema or tenderness Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, No MRG Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, left extremity with intact incision from fistula revision, palpable thrill and bruit auscultated Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: Lab Results on Presentation: ___ 10:22AM BLOOD WBC-2.4* RBC-3.94* Hgb-10.5* Hct-36.7 MCV-93 MCH-26.7* MCHC-28.7* RDW-19.2* Plt Ct-66* ___ 10:22AM BLOOD Neuts-40.8* Lymphs-46.4* Monos-7.9 Eos-4.5* Baso-0.4 ___ 10:22AM BLOOD Plt Ct-66* ___ 10:49AM BLOOD ___ PTT-42.5* ___ ___ 10:22AM BLOOD Glucose-81 UreaN-10 Creat-3.7# Na-143 K-3.8 Cl-104 HCO3-27 AnGap-16 ___ 10:22AM BLOOD ___ ___ 06:15AM BLOOD Calcium-8.1 Phos-4.7*# Mg-1.9 ___ 10:24AM BLOOD Lactate-1.6 Imaging: Radiology Report CHEST (PORTABLE AP) Study Date of ___ 12:41 ___ FINDINGS: Single frontal view of the chest was obtained. There has been interval placement of a right-sided large-bore central venous catheter which terminate in the right atrium. The cardiac and mediastinal silhouettes are stable. There is stable prominence of the perihilar vasculature which may be due to vascular congestion as well as bibasilar opacities which could relate to atelectasis and scarring, underlying infection or aspiration is not excluded. Old right-sided rib fractures are again seen. Radiology Report CT CHEST W/CONTRAST Study Date of ___ 6:02 ___ IMPRESSION: 1. Bilateral lower lobe bronchial wall thickening is consistent with acute infectious bronchitis, most likely bacterial given the patient's relatively high CD4 count. 2. Increased size and number of mediastinal lymph nodes and axillary lymph nodes. 2. Moderate splenomegaly and liver morphology in keeping with known chronic liver disease. ECG: Cardiovascular Report ECG Study Date of ___ 10:30:52 AM Sinus tachycardia. Possible left atrial abnormality. Diffuse non-specific ST-T wave abnormalities that are most marked in the inferior and anterolateral leads. Compared to the previous tracing of ___ wave abnormalities are slightly more marked. Cannot rule out ischemia. Clinical correlation and repeat tracing are suggested. Cardiovascular Report ECG Study Date of ___ 12:09:52 AM Sinus rhythm. Possible left atrial abnormality. Diffuse non-specific ST-T wave abnormalities that are most marked in the anterolateral leads. Compared to tracing #1 no diagnostic change. CT CHEST WITH IV CONTRAST FINDINGS ___ LUNGS AND AIRWAYS: The airways are patent to the subsegmental level. There is moderate-to-severe upper lobe predominant centrilobular emphysema. There is mild to moderate bronchial wall thickening, more prominent in both lower lobes (representative image 5:166). Bibasilar dependent atelectasis, right worse than left, is present but there is no focal consolidation concerning for pneumonia. Of note, localized left lower lobe scarring is unchanged from prior exam. Trace bilateral pleural effusion is unchanged. MEDIASTINUM: A right-sided tunneled line ends in the right atrium. Compared with prior exam, there has been mild interval worsening of mediastinal and axillary lymphadenopathy. For example, a subcarinal lymph node measuring 16 mm in short axis diameter (3:28) was 9 mm in the previous exam. Also numerous lymph nodes in both axillae, more prominently in the left, appear new or increased in size and conspicuity from the previous exam. For example, an 18 x 11 mm lymph node in the left axilla (3:15) was only 15 x 8 mm and had a predominantly fatty hilum in ___. Multiple thoracic wall lymph nodes in the left subpectoral region (significant image 3:8 and 3:9) ranging up to 16 x 8 mm, are also more conspicuous than in the previous exam. Otherwise, the thyroid gland is unremarkable. The heart is not enlarged. The aorta is normal in caliber. The pulmonary artery is increased in caliber, measuring up to 38 mm of diameter, suggestive of pulmonary hypertension. Trace pericardial fluid is physiologic. There is no esophageal wall thickening or hiatal hernia. This study is not tailored for the assessment of subdiaphragmatic structures. Allowing for limitations of the truncated imaging frame: Moderate splenomegaly is again seen and the nodular contour of the liver is compatible with known chronic liver disease. OSSEOUS STRUCTURES: There are no lytic or blastic lesions concerning for malignancy. Hardware from anterior lower cervical spinal fixation construct is unremarkable. IMPRESSION: 1. Bilateral lower lobe bronchial wall thickening is consistent with acute infectious bronchitis, most likely bacterial given the patient's relatively high CD4 count. 2. Increased size and number of mediastinal lymph nodes and axillary lymph nodes. 2. Moderate splenomegaly and liver morphology in keeping with known chronic liver disease. Brief Hospital Course: BRIEF HOSPITAL COURSE ======================= Ms. ___ was admitted to the hospital for hypotension at HD. She also had worsening cough from her previous presentation with pneumonia. She underwent several dialysis sessions in house and her blood pressure was intermittently low at dialysis without symptoms. CT chest showed acute bronchitis and she was started on a course of ceftriaxone, azithromycin, and prednisone. Her midodrine was increased and her dialysis goal weight was increased from 63 to 65kg in an effort to limit hypotension. ACTIVE ISSUES =============== #Hypotension at HD: Ms. ___ BP dropped to the 30's systolic at HD 2 days prior per nephrology report. She received a repeat session and received her midodrine prior to and then during as well with stable blood pressures. At time of discharge, she was stable on the floor with SBP ___ which is her baseline. She was continued on this regimen of midodrine. - ___ consider increasing midodrine as needed in the future. #Bronchitis / COPD exacerbation: Diagnosis of bronchitis (felt to be bacterial) on her CT scan in setting of COPD. Previous team had low suspicion for resistant organisms despite recent course of meropenem and patient clinically looked well, as such was started on prednisone burst and azithromycin x 5 days (finished while inpatient). #Pneumonia: Diagnosed on a previous admission and had finished her course of meropenem while inpatient. CHRONIC ISSUES ================ #HIV ___: CD4 410): Continued home HAART regimen. #ESRD on HD MWF: Continued HD at BI, and increased midodrine. Also continued home meds. #severe pulmonary hypertension: Continued home sildenafil. #Cardiomyopathy ___ LVEF 31%, severe MR/TR. Most recent echo has normalized, with EF 55%. Continued aspirin and low sodium diet. #Lymphocytic interstitial pneumonitis (LIP): Continued ___ NC. #HCV - Untreated, last seen by Dr. ___ ___ and she did not want treatment at that time, was later deemed to not be a liver-kidney transplant candidate given comorbidities. Consider GI/liver referral after discharge for new combination oral therapy. #Asthma/COPD on home O2: Treated for bronchitis as above, otherwise continued oxygen, albuterol, and ipratropium. TRANSITIONAL ISSUES ==================== - Code status: Full code. - Emergency contact: ___, daughter, ___. - Studies pending on discharge: Blood cultures x2 from ___ - Please check an AM cortisol level when patient is off steroids. - UNABLE TO CONFIRM CORRECT HOME MEDICATIONS. Patient reported that dialysis list was incorrect, however pharmacy was closed for the holiday and HCP was not aware of med list. PCP's office was contacted several different days w/o response. As such, she was discharged on her dialysis list of medications. Please do accurate med rec on next visit. - A copy of this discharge summary was faxed to Dr. ___ office at ___. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 325 mg PO Q6H:PRN pain 2. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN shortness of breath, wheeze 3. Aspirin 81 mg PO DAILY 4. Cinacalcet 30 mg PO 2X/WEEK (MO,FR) 5. Etravirine 200 mg PO BID 6. LaMIVudine 50 mg PO DAILY 7. Pantoprazole 40 mg PO Q24H 8. Pregabalin 25 mg PO QHS 9. Raltegravir 400 mg PO BID 10. Sildenafil 50 mg PO TID 11. Tenofovir Disoproxil (Viread) 300 mg PO ___ 12. Thiamine 100 mg PO DAILY 13. Epoetin Alfa 0 UNIT IV PER HD 14. Nephplex Rx (vit B cmplex ___ ox) ___ mg-mg-mcg-mg oral daily 15. QUEtiapine Fumarate 50 mg PO QHS 16. Lactulose 15 mL PO BID 17. Ipratropium Bromide Neb 1 NEB IH Q2H:PRN shortness of breath, wheeze 18. Midodrine 20 mg PO QMOWEFR 19. Venofer (iron sucrose) 0 units INJECTION PER RENAL Discharge Medications: 1. Acetaminophen 325 mg PO Q6H:PRN pain 2. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN shortness of breath, wheeze 3. Aspirin 81 mg PO DAILY 4. Cinacalcet 30 mg PO 2X/WEEK (MO,FR) 5. Etravirine 200 mg PO BID 6. Ipratropium Bromide Neb 1 NEB IH Q2H:PRN shortness of breath, wheeze 7. Lactulose 15 mL PO BID 8. LaMIVudine 50 mg PO DAILY 9. Pantoprazole 40 mg PO Q24H 10. QUEtiapine Fumarate 50 mg PO QHS 11. Raltegravir 400 mg PO BID 12. Sildenafil 50 mg PO TID 13. Tenofovir Disoproxil (Viread) 300 mg PO ___ 14. Thiamine 100 mg PO DAILY 15. Midodrine 15 mg PO QMOWEFR 16. Epoetin Alfa 0 UNIT IV PER HD per nephrology. 17. Nephplex Rx (vit B cmplex ___ ox) ___ mg-mg-mcg-mg oral daily 18. Pregabalin 25 mg PO QHS 19. Venofer (iron sucrose) 0 units INJECTION PER RENAL per nephrology. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Hypotension, Bronchitis Secondary: End-stage Renal disease, HIV Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital because of low blood pressure at dialysis. Also, we found that your cough is likely due to acute bronchitis. While in the hospital, we worked with the kidney doctors to ___ your blood pressure up during dialysis. We also gave a you a treatment of steroids and antibiotics for your bronchitis. Your blood pressure stayed stable and your bronchitis began to improve. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: ___
10805699-DS-21	10,805,699	22,941,683	DS	21	2132-02-11 00:00:00	2132-02-11 17:49:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim / Cipro / morphine Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: cysto, ureteroscopy, ureteral stent History of Present Illness: PCP: ___ (___) . CC: R sided abd pain . HPI/EVENTS: ___ F h/o obesity, DM2, sarcoidosis, chronic LBP admitted with increasing R sided abd pain over the past two days. Reports pain occurred in RUQ/R flank - which worsened over the past 2 days. Associated with N/V, poor PO intake, but denies fever/chills. Felt that pain was similar to appendicitis many years ago, however, able to tolerate PO more recently. Had BM yesterday. Due to increasing pain came to ED for evaluation. In ED, vitals sign stable 98.4 70 146/63 18 99%. WBC 9.4, but Cr increased to 1.9 (from baseline 1.1). U/A negative. RUQ U/S showed cholelithiasis no cholecyctitis. Abd CT showed 8mm proximal right ureteral stone w/ evidence of hydronephrosis. Urology was consulted and plan was for stent placement. Received toradol 30 mg IV, tylenol, flomax, and 2L IVF NS bolus. Immediately brought to OR for ureter stenting. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. A 10 pt review of sxs was otherwise negative. Past Medical History: # HTN # Obesity # DM2 - renal/ peripheral neuropathy last Hgb A1C 6.2 (___) - s/p R toe amputation ___ # sarcoidosis - hypercalcemia # nephrolithiasis - KUB ___: Skeletal: Two small calcifications project over the lower pole left kidney. No definite calcifications visualized over the right renal shadow region # OSA - ? CPAP # Chronic LBP - scoliosis, sciatica (L leg) # compression fx (Lumbar) - MRI Lumbar ___: Severe rotational scoliosis convex to the patient's left. Multilevel degenerative changes without significant progression compared to prior study. Wedge compression deformity again demonstrated superior endplate of the L2 vertebral body # OA Social History: ___ Family History: Positive for Diabetes on maternal side. F deceased from colon CA. M alive - diabetes, ESRD Physical Exam: Vital Signs: 97.8 53 107/55 15 96% RA glucose: . GEN: NAD, obese, lying in bed EYES: PERRL, EOMI, conjunctiva clear, anicteric ENT: moist mucous membranes, no exudates NECK: supple CV: RRR s1s2 nl, no m/r/g PULM: CTA, no r/r/w GI: normal BS, R flank pain, otherwise NT/ND, no HSM EXT: warm, no c/c/e SKIN: no rashes NEURO: alert, oriented x 3, answers ? appropriately, follows commands, non focal PSYCH: appropriate ACCESS: PIV FOLEY: absent Pertinent Results: LABS: SEE BELOW # WBC 9.4, BUN 39, Cr 1.9, U/A <1 WBC 0 RBC, ___ neg OTHER DATA: # Abd CT (___): 8 mm obstructing stone within the proximal right ureter causing mild right hydronephrosis. Multiple bilateral nonobstructing stones. # RUQ U/S (___): Cholelithiasis. Multiple nonobstructing renal stones measuring up to 1.1 cm with mild hydronephrosis. Brief Hospital Course: ASSESSMENT & PLAN: ___ F h/o obesity, DM2, sarcoidosis, chronic LBP admitted with increasing R sided abd pain - found to have obstructing R ___ ureteric stone. # Abd pain/flank pain: Ms. ___ was admitted with abdominal/flank pain attributed to obstructing 8mm ___ ureteric stone. This was associated with ___, Cr 1.9 (from 1.1). There were no other pathology on CT scan or RUQ u/s or any evidence of infection (nl WBC, afebrile, U/A unremarkable). Urology brought her to operating room semi-urgently to perform a cystoscopy, uretreroscopy, laser lithotripsy, and ureteral stent placement. Reportedly, the urology team felt good about eliminating most of the stone burden in the R ureter/kidney. After the procedure, her pain was much improved and did not require any pain medications. She is scheduled to get stent removed in 9 days time. While the stent is in place, she should continue to take the flomax. She understands to take a single dose of antibiotics the morning of the stent removal. She received a single dose of abx periprocedurally, but did not require any antibiotics thereafter. # DM2: well controlled, with complications (renal/neuropathy). She was maintained on insulin sliding scale. Given that she was NPO for most of the day, both the lantus and metformin were held. # HTN: controlled. Cont ASA, atenolol, losartan, amlodipine # Sarcoidosis: outpt methotrexate, leukovorin # cLBP: cont ultram #CONSULTS: urology #CODE STATUS: [X]full code []DNR/DNI Medications on Admission: - Aspirin 81 mg Oral Tablet, 1 tab po qd - atenolol 100 mg daily - losartan 50 mg daily - amlodipine 10 mg daily - Insulin glargine 56u QAM - Insulin Lispro SS - Metformin 1000mg BID - trospium 20 mg daily - tramadol 50-100 mg Q4h PRN pain - methotrexate 15 mg SQ Q1 wk - leucovorin 15 mg Q1wk 10h after MTX - latanoprost 0.005 % 1gtt both eyes QHS - triamcinolone 0.1 % Topical Cream, Apply to affected area BID - CETIRIZINE HCL (CETIRIZINE ORAL), once daily - ERGOCALCIFEROL, VITAMIN D2, (VITAMIN D ORAL), 2000mg ___ Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Atenolol 100 mg PO DAILY 3. Glargine 56 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 5. Losartan Potassium 50 mg PO DAILY 6. TraMADOL (Ultram) 50-100 mg PO Q4H:PRN pain 7. Tamsulosin 0.4 mg PO HS RX tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #30 Capsule Refills:0 8. Aspirin 81 mg PO DAILY 9. Cetirizine 10 mg PO DAILY 10. Leucovorin Calcium 15 mg PO 1X/WEEK (MO) 11. MetFORMIN (Glucophage) 1000 mg PO BID 12. Methotrexate 15 mg SC 1X/WEEK (MO) 13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 14. trospium 20 mg oral Daily 15. Vitamin D ___ UNIT PO DAILY 16. Amoxicillin-Clavulanic Acid ___ mg PO ONCE Duration: 1 Dose please take in the morning of ___ (on the day of stent removal) RX amoxicillin-pot clavulanate 875 mg-125 mg 1 Tabket by mouth ONCE Disp #1 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Nephrolithiasis Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure looking after you, Ms. ___. As you know, you were admitted with abdominal, right flank pain and was found to have an obstructing kidney stone. This stone was removed by lithotripsy and a stent was placed in the ureter. You should follow up with urology to have stent removed on ___. Please take a single dose of augmentin (antibiotic to be used instead of cipro - due to your allergy) on the morning of the ___, the day of the stent removal. (see prescription). Please continue with the flomax (tamsulosin) while the stent is in place. If you have any concerns about your recent procedure or questions about the stent, feel free to call Dr. ___ office (___). Followup Instructions: ___
10806596-DS-8	10,806,596	28,761,867	DS	8	2163-09-30 00:00:00	2163-09-30 13:42:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Left pilon fracture Major Surgical or Invasive Procedure: External fixator to left ankle History of Present Illness: ___ female presents with the above fracture s/p mechanical fall down stairs. She had pain in the left ankle, inability to bear weight, and deformity. She went to ___ and was transferred to ___. Past Medical History: Hx of breast cancer s/p mastectomy RA Anxiety S/p L THA Social History: ___ Family History: NC Physical Exam: Gen: middle-aged female in no acute distress Neuro: alert and interactive CV: palpable DP pulses bilaterally Pulm: no respiratory distress on room air LLE: in ankle external fixator, SILT: ___, fires ___, pins sites without erythema or drainage Pertinent Results: NONE Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have left pilon fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for external fixation left pilon fracture which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is non-weight-bearing in the left lower extremity, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Anastrozole 1 mg PO DAILY 2. LORazepam 0.5 mg PO Q4H:PRN anxiety Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth every 12 hours as needed for constipation Disp #20 Capsule Refills:0 3. Enoxaparin Sodium 40 mg SC Q24H RX enoxaparin 40 mg/0.4 mL 40 mg subcutaneous daily Disp #14 Syringe Refills:0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg ___ tablet(s) by mouth every ___ hours as needed for pain Disp #50 Tablet Refills:0 5. Senna 8.6 mg PO QHS RX sennosides [senna] 8.6 mg 1 tablet by mouth nightly as needed for constipation Disp #20 Tablet Refills:0 6. Anastrozole 1 mg PO DAILY 7. LORazepam 0.5 mg PO Q4H:PRN anxiety 8.Crutches Diagnosis: left pilon fracture Length of Need: 13 months Prognosis: good Discharge Disposition: Home With Service Facility: ___ ___: Left pilon fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - non-weight-bearing left lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox daily for 2 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet Followup Instructions: ___
10806634-DS-20	10,806,634	26,948,347	DS	20	2130-07-15 00:00:00	2130-07-15 19:21:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Pravachol Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ pt with past history of CAD (has never had stents), Htn who presents with CP. She has a history of "chest heaviness" on exertion for years. She will walk, feel CP, stop and sit and the pain improved and then she walks and feels the pain again. Last night she wasnt feeling right while laying in bed, denies CP but didnt feel quite right and then today felt chest heaviness when laying in bed. Her children told her to come to the hospital. Per report she had a positive stress echo in ___ (ST depressions with WMA) and declined cath at that time. Vitals in ED were 99.6 63 200/89 20 99% Labs significant for Na 136, BUN/Cr 95/0.8, H&H 13.8/40.2, WBC 6.1 without left shift. INR 0.9, Troponin T <0.01. Pt took 81mg ASAx2 at home then x2 again in ED. Exam was significant for no chest pain, no respiratory distress, regular HR. CXR was negative for acute cardiopulm process. EKG showed NSR with <1mm STE in inferior leads, TWI in V2-V6. VS Pt was given ASA on xfer to the floor were: 98.3 56 141/85 16 99% RA . On arrival to the floor she is chest pain free and feels well. She made it clear she does not want any invasive procedures, that she would be ok with medication as treatment only. Past Medical History: - CAD (positive stress echo ___ w/ ___epressions and WMA, but patient refuses cardiac catheterization) - HTN - HLD - GERD - Anxiety - Vitamin D deficiency - Macular degeneration c/b legal blindness R eye Social History: ___ Family History: Noncontributory Physical Exam: ADMISSION: VS:50 kg 187/74 50 100%RA GENERAL: NAD, AxOx3. HEENT: no elev JVP. PERRL, EOMI. MMM CARDIAC: bradycardic, no murmur LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. EXTREMITIES: trace edema lower ext. DISCHARGE: VS: 97.5 141/58 52 18 100%RA Wt: 50.7KG GENERAL: NAD, AxOx3. HEENT: no elev JVP. PERRL, EOMI. MMM CARDIAC: bradycardic, no murmur LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. EXTREMITIES: no edema lower ext. Pertinent Results: ADMISSION LABS: ___ 02:55PM BLOOD WBC-6.1 RBC-4.43 Hgb-13.8 Hct-40.2 MCV-91 MCH-31.3 MCHC-34.4 RDW-12.8 Plt ___ ___ 02:55PM BLOOD Neuts-55.7 ___ Monos-9.2 Eos-4.7* Baso-1.0 ___ 02:55PM BLOOD Glucose-95 UreaN-20 Creat-0.8 Na-136 K-4.0 Cl-104 HCO3-22 AnGap-14 ___ 03:10PM BLOOD cTropnT-<0.01 TREND LABS: ___ 03:10PM BLOOD cTropnT-<0.01 ___ 01:12AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 06:40AM BLOOD CK-MB-2 cTropnT-<0.01 DISCHARGE LABS: ___ 06:40AM BLOOD WBC-6.3 RBC-4.16* Hgb-12.5 Hct-38.6 MCV-93 MCH-30.0 MCHC-32.4 RDW-13.1 Plt ___ ___ 06:40AM BLOOD Glucose-86 UreaN-19 Creat-0.8 Na-141 K-4.3 Cl-107 HCO3-24 AnGap-14 ___ 06:40AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1 ___ 06:40AM BLOOD CK-MB-2 cTropnT-<0.01 CXR ___: No acute cardiopulmonary process. COPD. Brief Hospital Course: ___ woman with known CAD presented with worsening chest pain concerning for unstable angina. ACTIVE ISSUES: # Chest pain: EKG showed T-wave inversions in anterior and lateral leads. No prior EKG here for comparison. Cardiac enzymes negative x 3. Patient is not interested in aggresive care such as PCI, so managed medically. Started isosorbide mononitrate to optimize medical management. Continued home ASA 81mg, metoprolol, losartan. Given her documented allergies to statins held off on starting any statin. CHRONIC ISSUES: # HTN: Initial SBP 200s in ED, down to SBP 120-140 on the floor. Continued home metoprolol, losartan, started imdur as above. # HLD: Continued home ezetimibe. # GERD: Continued lansoprazole. # Anxiety: Continued home citalopram. TRANSITIONAL ISSUES: - consider statin (pt has documented allergy to pravachol, may tolerate another statin). Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Citalopram 10 mg PO DAILY 3. Losartan Potassium 100 mg PO DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY 5. lansoprazole 15 mg oral daily 6. Phenazopyridine 100 mg PO DAILY 7. Ezetimibe 10 mg PO DAILY 8. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral daily 9. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Citalopram 10 mg PO DAILY 3. Ezetimibe 10 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral daily 7. Phenazopyridine 100 mg PO DAILY 8. Lansoprazole 15 mg ORAL DAILY 9. Isosorbide Mononitrate 20 mg PO BID RX isosorbide mononitrate 20 mg 1 (One) tablet(s) by mouth twice a day Disp #60 Tablet Refills:*0 10. Metoprolol Succinate XL 25 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Chest pain Unstable angina Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, It was a pleasure participating in your care at ___. You were admitted to the hospital with chest pain, which resolved on its own. We have added a new medication to help with your recurrent chest pain (see list below). Please continue taking all of your other medications as you have been. Please follow up with your primary care Dr. ___ in the next week. Followup Instructions: ___
10806859-DS-19	10,806,859	25,336,602	DS	19	2119-05-28 00:00:00	2119-05-30 11:06:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Worsening left testicular pain and swelling Major Surgical or Invasive Procedure: ___ drainage of hydrocele ___ History of Present Illness: Mr. ___ is a ___ yo male with h/o HFrEF, CAD s/p CABG, CKD, BPH, and urinary retention requiring chronic intermittent catheterization last seen on ___ for L epididymo-orchitis who presents with progressive L testicular pain and swelling. He was seen in the ED on ___ and a scrotal ultrasound showed left epididymal orchitis with a reactive, possibly complex hydrocele. Urine culture negative at the time. He was started on a course of ciprofloxacin, which he has been compliant with. He was seend by Dr. ___ urologist, for increasing scrotal swelling and tightness on ___, and his cipro course was extended. Today, patient returns to the ED with progressively worsening pain that increases with movement, cramps through the groin, and swelling of the scrotum. He also states that over the last week he has had chills during the night, but no frank fevers. He denies any recent right testicular pain or swelling. No recent sexual contacts. Pt. has been sexually active with his wife only ___. No h/o STIs and his wife has not had any STIs either. No dysuria (straight caths), but pt. does endorse a episode of thick white penile discharge several weeks that spontaneously resolved and has not reoccurred. In the ED, initial vitals: 98.2 67 110/64 18 100% RA - Exam notable for: large firm left testicle without substantial ttp - Labs notable for: WBC 13.9 (83%N), Cr 1.4 (baseline), lactate 1.5. UA clear. - Imaging notable for: Scrotal U/S with right testicular torsion with features of necrosis and persistent left epididymorchitis, complex, septated left hydrocele. - Pt given: 400mg IV cipro - Vitals prior to transfer: 98.1 69 118/60 18 99% RA ROS: No fevers or weight changes. No nausea or vomiting. He endorses chronic constipation. No dysuria or hematuria. Past Medical History: Congestive Heart Failure (LVEF 34% ___ ischemic CM) CAD s/p 4 vessel CABG (___) HTN HLD Chronic Kidney Disease (not endorsed by pt, but noted on review of OMR labs; baseline Cr 1.6-1.7; unclear etiology) Abdominal Aortic Aneurism (max diameter 3.2cm) Neurogenic Bladder (started after lumbar laminectomy; managed with intermittent self catheterizations) Constipation (started after lumbar laminectomy) BPH Spinal Stenosis Lumbar laminectomy (___) Social History: ___ Family History: Mother - died age ___ of ___ Father - died age ___ of prostate cancer Significant coronary disease in his family. Physical Exam: EXAM ON ADMISSION: Vitals- Tc 97.1 BP 135/60 HR 76 RR 18 O2 99%RA wt 72.2kg General- pleasant and alert, lying in bed no acute distress HEENT- Sclerae anicteric, MMM Neck- supple Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1 and S2, III/VI holosystolic murmur Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly Back- no CVA tenderness, well-healed scar over central mid-back from laminectomy Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal GU- Scrotum: significantly swollen and indurated L scrotum, TTP; no R scrotum TTP, no R scrotal swelling; No redness, skin intact Penis: no penile discharge, no skin lesions EXAM ON DISCHARGE: Vitals- Tm 100.9 Tc 98.2 BP 110-139/56-94 HR ___ RR 18 O2 100%RA A and O x3. Remainder of exam unchanged. Pertinent Results: ==================LABS ON ADMISSION===================== ___ 08:55AM BLOOD WBC-13.9* RBC-2.74* Hgb-8.0* Hct-24.5* MCV-89 MCH-29.2 MCHC-32.7 RDW-14.8 RDWSD-48.4* Plt ___ ___ 08:55AM BLOOD Neuts-83.4* Lymphs-7.5* Monos-7.7 Eos-0.6* Baso-0.2 Im ___ AbsNeut-11.57* AbsLymp-1.04* AbsMono-1.07* AbsEos-0.09 AbsBaso-0.03 ___ 08:55AM BLOOD Glucose-93 UreaN-24* Creat-1.4* Na-140 K-4.4 Cl-103 HCO3-23 AnGap-18 ___ 07:13AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.0 ___ 09:03AM BLOOD Lactate-1.5 ___ 12:00PM URINE Color-Straw Appear-Clear Sp ___ ___ 12:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG =================LABS ON DISCHARGE====================== ___ 07:00AM BLOOD WBC-7.9 RBC-2.76* Hgb-7.8* Hct-24.1* MCV-87 MCH-28.3 MCHC-32.4 RDW-14.0 RDWSD-44.5 Plt ___ ___ 07:00AM BLOOD Glucose-96 UreaN-15 Creat-1.2 Na-138 K-4.3 Cl-100 HCO3-23 AnGap-19 ___ 07:00AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.2 ===================IMAGING=============================== PRIOR Scrotal US ___ 1. Left epididymo-orchitis. 2. Equivocally increased vascularity within the right testicle, most likely reactive. 3. Complex bilateral hydroceles, highly septated on the left, and may represent a pyocele. Scrotal US ___ 1. Findings compatible with missed right testicular torsion with features of necrosis. 2. Persistent left epididymorchitis, complex, septated left hydrocele. Pyocele is not excluded. Scrotal US ___ Right testicular torsion with necrosis and early liquefaction. Left testicular epididymo- orchitis with associated pyocele. Ultrasound-guided L Hydrocele Drainage ___ FINDINGS: Left scrotal multi-septated extratesticular fluid collection, suggestive underlying pyocele. Torsed/necrotic right testicle. Please refer to ultrasound performed ___ for more detail. IMPRESSION: Successful US-guided drainage of a suspected left scrotal pyocele. CXR ___ Comparison with the study ___, there is little change. Again there isenlargement of the cardiac silhouette with tortuosity of the aorta. However,no evidence of acute pneumonia, vascular congestion, or pleural effusion. =====================OTHER RESULTS====================== URINE CULTURE (Final ___: NO GROWTH. *FINAL REPORT ___ Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by PANTHER System, APTIMA COMBO 2 Assay. Validated for use on Urine Samples by the ___ Microbiology Laboratory. Performance characteristics on urine samples were found to be equivalent to those of FDA- approved TIGRIS APTIMA COMBO 2 and/or COBAS Amplicor methods. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae by PANTHER System, APTIMA COMBO 2 Assay. Validated for use on Urine Samples by the ___ Microbiology Laboratory. Performance characteristics on urine samples were found to be equivalent to those of FDA- approved TIGRIS APTIMA COMBO 2 and/or COBAS Amplicor methods. GRAM STAIN (Final ___: 2+ ___ 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. URINE CULTURE (Final ___: NO GROWTH. Blood Culture, Routine (Final ___: NO GROWTH. Brief Hospital Course: ___ with h/o CHF, CAD s/p CABG, CKD, BPH, and urinary retention requiring chronic intermittent catherizations last seen on ___ for L epididymo-orchitis presents with progressive L testicular pain and swelling and found on scrotal US to have persistent L epididymo-orchitis in addition to new R testicular torsion w/ necrosis. #Left epididymo-orchitis The patient was started on ciprofloxacin by his outpatient urologist on ___. He presented on ___ to ___ for increased tenderness and swelling. A scrotal ultrasound showed persistent left epididymo-orchitis, with complex, septated left hydrocele c/f possible pyocele. ___ guided biopsy of L testicular fluid collection was c/w hydrocele (WBCs 33, fluid culture negative). Urine chlamydia and gonorrhea negative. Given that he was not improving clinical with cipro and continued to have leukocytosis and fevers, he was transitioned to amp-sulbactam IV on ___. His fevers decreased and WBC started to decline. His physical exam and symptoms, however, remained unchanged. We suspect this represents chronic epididymo-orchitis. Urology was involved and deferred any surgical intervention given high risk of total loss of left testicle. He was transitioned to amox-clav at discharge for prolonged antibiotic course of 4 weeks. He was encouraged to continue wearing supportive underwear as well as icing and elevating the scrotum as much as possible. # Right testicular torsion with necrosis The patient was asymptomatic and his right testicle nontender on exam. It is unclear how long he has had torsion, but given that he remained asymptomatic, surgery was deferred. # Transitional Issue - ABX: Augmentin 875mg twice a day ___ for 4 week course) - CONTACT: ___ (daughter) ___ - CODE STATUS: Full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Carvedilol 25 mg PO BID 3. Ciprofloxacin HCl 500 mg PO Q12H 4. Furosemide 20 mg PO BID 5. Ramipril 10 mg PO DAILY 6. Tamsulosin 0.4 mg PO DAILY 7. Acetaminophen 325-650 mg PO Q6H:PRN pain 8. Aspirin 81 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Milk of Magnesia ___ mL PO DAILY 11. Senna 8.6 mg PO BID Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Carvedilol 25 mg PO BID 5. Docusate Sodium 100 mg PO BID 6. Furosemide 20 mg PO BID 7. Milk of Magnesia ___ mL PO DAILY 8. Ramipril 10 mg PO DAILY 9. Senna 8.6 mg PO BID 10. Tamsulosin 0.4 mg PO DAILY 11. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Please continue until ___. RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth twice daily Disp #50 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Left epididymo-orchitis Right testicular torsion with necrosis and liquefaction Secondary: Heart failure with reduced ejection fraction Coronary artery disease Benign prostatic hypertrophy Urinary retention requiring intermittent catheterization Constipation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You were admitted to the ___ for worsening left testicular swelling and pain despite having been on antibiotics since ___. We think that this swelling is likely due to an infection. We drained some of the fluid from your scrotum, and the fluid looked clear and did not look like pus. Based on this information, your urologist, Dr. ___ not want to proceed with surgery at this time, given that you have an active infection and the increased risk of spreading the infection to the other testicle. You received antibiotics while here, and you should continue taking the antibiotics until ___. In addition, we performed an ultrasound of your scrotum, and we found that there is dead tissue in your right testicle. You did not have any pain on that side, and Dr. ___ that we leave it alone. It was a pleasure taking care of you. We wish you all the best. Sincerely, Your ___ Medicine Team Followup Instructions: ___
10807041-DS-8	10,807,041	24,636,815	DS	8	2161-10-14 00:00:00	2161-10-15 07:09:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: carbidopa / carbidopa / levodopa Attending: ___. Chief Complaint: fall, subdural hematoma Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ y/o male with a history of ___ disease w/ ___ body dementia (poor baseline mental status), HTN, and depression who presents s/p a fall at home, transferred from ___ for subdural hematomas. History obtained from ___. Patient unable to provide history and family not available/reachable by phone. The patient sustained an unwitnessed fall on ___ with his home health aide and wife nearby. He had a presumed headstrike given a new laceration, though unclear if he had LOC. Of note, the patient has had multiple falls over the past few years and noted by his family to have a decline in functional status over the last couple of months. Per other notes, he has been more confused, fatigued and difficult to arouse in the mornings. He initially presented to ___ where vitals were notable for BP 220/110, HR 70, 95% on RA. He had an eyebrow laceration that was sutured. Labs were notable for WBC 7.3, H/H 12.6/37.8, plt 159. CT scan showed bilateral subdural hematomas, prompting transfer to ___ for neurosurgical evaluation. His aspirin was held and he was given IV metoprolol and labetalolol for BP control prior to transfer. In the ED, initial vitals: Temp ___ BP 189/96 HR 70 RR 17 100% on RA Exam notable for: None documented Labs notable for: Na 139, BUN/Cr ___, WBC 9.3, H/H 12.6/38.4, plt 163, INR 1.1, VBG 7.41/52 Imaging notable for: - CXR: No focal consolidation, pleural effusion or pneumothorax. Pt given: IM olanzapine 2.5 mg x4, IV keppra 500mg x2, PR acetaminophen, 1L NS Consults: - Trauma surgery: repeat head CT given somnolence, trauma surgery will perform tertiary survey - Neurosurgery: No neurosurgical intervention recommended. Goal BP <160, hold aspirin, Keppra 500mg BID x 7 days for seizure ppx Vitals prior to transfer: Temp 98.2 BP 136/91 HR 62 RR 16 94% on RA Upon arrival to the floor, the patient is unable to provider further history. REVIEW OF SYSTEMS: Unable to obtain ___ mental status Past Medical History: Hypertension ___ disease Transient ischemic attack (___) Hallucintations Depression OSA Prostate cancer s/p prostatectomy Tonsillectomy Appendectomy Hernia repair Knee surgery Social History: ___ Family History: Non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: Temp ___ BP 180/82 HR 76 RR 23 99% on 2L NC GENERAL: Elderly male in NAD. Lying comfortably in bed. Eyes closed for exam. Mumbling, minimal communication. HEENT: Laceration over right eyebrown, periorbital ecchymosis on the right. MMM. CV: RRR with normal S1/S2, no murmurs, gallops, or rubs PULM: Normal respiratory effort. CTAB over anterior chest without wheezes, rales or rhonchi. GI: Soft, NT/ND, normaoctive BS. No guarding or masses. EXTREMITIES: Warm, well perfused. No ___ edema or erythema. NEURO: Eyes closed, responds to voice. Left pupil 1-2mm, minimally reactive. Cannot open right ___ pain. Moves all extremities. Unable to participate further in the exam. DISCHARGE PHYSICAL EXAM: ======================== VITALS: 24 HR Data (last updated ___ @ 512) Temp: 98.9 (Tm 98.9), BP: 170/80 (___), HR: 81 (81-171), RR: 20 (___), O2 sat: 81% (81-95) GENERAL: Elderly male in NAD. Sleeping and not responding to voice. HEENT: periorbital ecchymosis which is resolving on the right. MMM. PULM: Normal respiratory effort. Unable to auscultate posterior lung fields GI: Soft, NT/ND. No grimacing to palpation. EXTREMITIES: Warm, well perfused. NEURO: Sleepy and not rousable to voice. Pertinent Results: ADMISSION LABS: =============== ___ 10:00AM BLOOD WBC-9.3 RBC-4.11* Hgb-12.6* Hct-38.4* MCV-93 MCH-30.7 MCHC-32.8 RDW-13.6 RDWSD-46.3 Plt ___ ___ 10:00AM BLOOD Neuts-70.6 Lymphs-16.9* Monos-9.1 Eos-2.7 Baso-0.3 Im ___ AbsNeut-6.57* AbsLymp-1.57 AbsMono-0.85* AbsEos-0.25 AbsBaso-0.03 ___ 10:00AM BLOOD ___ PTT-25.4 ___ ___ 10:00AM BLOOD Glucose-93 UreaN-23* Creat-0.9 Na-139 K-3.9 Cl-96 HCO3-28 AnGap-15 ___ 10:15AM BLOOD ___ pO2-30* pCO2-52* pH-7.41 calTCO2-34* Base XS-5 ___ 10:15AM BLOOD O2 Sat-48 MICROBIOLOGY: ============= __________________________________________________________ ___ 7:35 pm BLOOD CULTURE 2 OF 2. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 10:54 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 8:17 am BLOOD CULTURE 2 OF 2. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 8:11 am BLOOD CULTURE 1 OF 2. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. IMAGING/STUDIES: ================ CXR ___: IMPRESSION: Limited views of the lungs secondary to the patient position and overlying facial structures obscuring the lung apices. Within the limits of the study, no new focal consolidation. No pleural effusion. No large pneumothorax. CT Head ___: IMPRESSION: The study is substantially limited by motion artifact. No significant change of the Left frontal, right frontotemporal, and Left tentorial extra-axial hemorrhage - mostly subdural. No new bleed or rebleed, or herniation syndrome. CXR ___: IMPRESSION: Increased prominence of the right infrahilar region could represent crowding of vessels, lymph nodes and possibly a pneumonia. If patient is able to tolerate, recommend lateral chest radiograph for further evaluation. ___ - ___: IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. DISCHARGE LABS: =============== ___ 09:38AM BLOOD WBC-8.1 RBC-3.60* Hgb-11.1* Hct-34.5* MCV-96 MCH-30.8 MCHC-32.2 RDW-14.4 RDWSD-49.7* Plt ___ ___ 09:07AM BLOOD Glucose-83 UreaN-20 Creat-0.7 Na-146 K-3.4* Cl-109* HCO3-26 AnGap-11 ___ 09:07AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.8 Brief Hospital Course: SUMMARY: ======== Mr. ___ is a ___ y/o male with a history ___ body dementia (poor baseline mental status) c/b parkinsonism, HTN, and depression who presents s/p a fall at home, transferred from ___ for subdural hematomas. Evalauted by neurosurgery and ACS who opted for non-operative management. Started on Keppra for a 7 day course for seizure prophylaxis. Patient was encephalopathic on admission felt to be in the setting of his bleeds and his baseline dementia. Made NPO including medications and blood pressure initially managed with IV Hydralazine. Patient was severely agitated on admission requiring wrist restraints to prevent him from pulling at IV/telemetry. He required Olanzipine for control of his agitation, and also received IV acetaminophen and Dilaudid for pain control. Throughout admission, pain and agitation improved and he no longer required olanzapine or IV pain medication or narcotic pain medication, no longer required soft wrist restraints or mitts. ACUTE ISSUES: ============= #Goals of care Given patient's complex medical situation and unclear goals of care, a family meeting with all of patient's HCPs present (primary and ___ alternates) was held. The family requested to minimize interventions that could be contributing to delirium. We discussed limiting time on IVs by trying to move towards PO medications. We discussed the risks of moving toward PO medications and liquids by mouth; specifically, the risk of aspiration and potential for worsened hypertension without IV medications. The family understood this risk and wished to proceed with PO attempts. We discussed minimizing night time interruptions by holding vital sign checks. We discussed that in doing so, patient's BP may be high with no interventions applied. We discussed the increase risk of elevated blood pressures in patients with brain bleeds. The family understood these risks and saw the benefit of minimizing interruptions. In line with this, we held vital signs overnight. We discussed nutrition, with the family stating that food is a pleasure to the patient and that food by mouth was their preference with the understanding of risk. They did not wish to proceed with a feeding tube after weighing the risks and benefits. The patient remains DNR/DNI - family ideally would like patient to undergo trial of rehab to see how he is able to progress, but may ultimately elect to pursue hospice care for the patient. In line with ultimate goal of outpatient care facility, the patient was transitioned to a PO medication regimen. On day of discharge, patient was intermittently accepting PO nutrition and medications. #S/p fall #Subdural hematomas #Facial laceration s/p repair The patient sustained an unwitnessed fall, likely with headstrike given new laceration, unknown if had LOC. Work up notable for bilateral subdural hematomas. Evaluated by neurosurgery who recommended monitoring, particularly given stable imaging from OSH to here. Mental status had been declining recently per family. Patient was acutely agitated on admission felt to be in the setting of delirium, his bleeds, and baseline dementia. He was placed in wrist restraints and mitts to prevent pulling at IV and telemetry wires. Patient also complained of pain, so standing IV acetaminophen was ordered and supplemented with low dose IV dilaudid. He was started on Keppra 500mg IV BID for seizure ppx with plan to complete a 7 day course. However, given concern that this was contributing to patient agitation, he was transitioned to Depakote for both seizure ppx and delirium, with neurosurgery approving the transition. Prior to discharge patient was without need for restraints for >24 hours. #Recurrent falls #Confusion, declining mental status ___ disease, ___ body dementia Reportedly having worsening mental status and recurrent falls recently at home. Most likely this represents progression of his underlying ___ body dementia and associated parkinsonism. Differential also included worsening mental status due to chronic SDH in the setting of recurrent falls, medication induced, or infection. Falls felt to be less likely due to orthostasis, arrhythmia, or seizures. Rivastigmine was held during this admission initially due to inability to take PO medications. Rivastigmine was not reinitiated on discharge as patient was unable to swallow capsules and capsules could not be crushed. Could consider starting a rivastigmine patch moving forward. #Concern for dysphagia Per family, patient had progressive difficulty communicating at home, was nonverbal on admission but improved to occasional coherent responses with mostly mumbling noises to questioning. Speech and swallow evaluated the patient and felt he was unsafe to take po , even medications, so home meds were initially held with patient NPO. However, in line with family/___ meeting detailed above, the patient was reinitiated on a full, thickened liquid diet with PO medications crushed prior to discharge. #Hypertension Patient with autonomic instability ___ LBD w/ parkinsonism. On 3 antihypertensive medications at home with family reporting SBP in 200's on regular basis. After ___, neurosurgery recommendations for SBP<160. To this end, trialed IV medications (hydral, enalaprilat) and TD Clonidine patch to control pressures, with limited success. Patient reinitiated on home medication PO losartan and started on PO labetolol/amlodipine for additional control after PO medications reinitiated. Intravenous antihypertensive medications were stopped > 24 hours prior to discharge. #Pneumonia Given rising leukocytosis on ___ and worsening mental status, infectious work up was repeated and notable for possible PNA. Patient received 7 day course of CTX and doxy for PNA without respiratory symptoms/increased O2 requirements. #Flu exposure Pt's roommate in the hospital was diagnosed with the flu (lab confirmed) after having been in the same room with the patient for several hours. As a result, the patient was started on flu prophylaxis with Tamiflu (___1 ___. #Hypokalemia Recurrently hypokalemic, requiring frequent repletion throughout admission. Started on standing 40 mEq potassium at discharge. Will need to be closely followed after discharge for this. #Hypernatremia #Free water deficit Patient was noted to have hypernatremia with free water deficits calculated and repleted throughout his hosptialization. On day of discharge this was improved without need for free water deficit repletion for ~3 days. #Prolonged QTc Unclear chronicity/etiology, around 500 ms throughout most of admission. Avoided medications with QT-prolonging effect. #Normocytic anemia Mild anemia, unknown baseline. Low concern for other sources ofbleeding. #Hypercarbia Noted on admission. No known pulmonary disease and lungs CTAB over anterior chest. Felt to be possibly secondary to poor mental status. Improved on subsequent VBG. #Depression Held home citalopram in setting of prolonged QTc on admission. TRANSITIONAL ISSUES: ==================== [] Patient's home metoprolol and HCTZ were held. Home losartan was initiated prior to discharge. Labetolol, amlodipine, Clonidine initiated. BP regimen should be monitored as outpatient. [] Patient's citalopram held given long QTc. An alternative agent may be appropriate to initiate in the outpatient setting. [] Patient's aspirin held indefinitely given brain bleed. [] Patient's tamsulosin, vitamin D, omeprazole held given desire to decrease number of PO medications. If patient's PO abilities improve, these medications could be reinitiated. [] Patient discharged on 40 mEq oral potassium daily - recommend checking BMP ___ times/week and adjusting standing potassium as necessary. [] Patient with dysphagia; however, taking PO medications and limited liquids as patient is able per family's wishes. Should monitor respiratory status as increased risk for aspiration. #CONTACTS: HCP: ___ (wife), ___ ___, ___ ___ Alt HCP: ___ (son), ___ ___, ___, cell 9, ___, cell ___ #CODE STATUS: DNR/DNI, confirmed, MOLST signed on ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Vitamin D ___ UNIT PO DAILY 3. Citalopram 40 mg PO DAILY 4. Hydrochlorothiazide 25 mg PO DAILY 5. Losartan Potassium 100 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. rivastigmine tartrate 4.5 mg oral BREAKFAST 8. Tamsulosin 0.4 mg PO QHS 9. TraZODone 25 mg PO QHS 10. rivastigmine tartrate 4.5 mg oral DINNER 11. Omeprazole 20 mg PO DAILY 12. Artificial Tears GEL 1% 1 DROP BOTH EYES Q6H 13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS Discharge Medications: 1. amLODIPine 10 mg PO DAILY 2. Bisacodyl ___AILY:PRN Constipation - Second Line 3. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QFRI 4. Divalproex Sod. Sprinkles 250 mg PO QHS 5. Labetalol 200 mg PO BID 6. OSELTAMivir 30 mg PO DAILY Duration: 9 Days Last day ___. 7. Potassium Citrate 40 mEq PO DAILY Hold for K > 4.5 8. Artificial Tears GEL 1% 1 DROP BOTH EYES Q6H 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. Losartan Potassium 100 mg PO DAILY 11. rivastigmine tartrate 4.5 mg oral BREAKFAST 12. rivastigmine tartrate 4.5 mg oral DINNER 13. TraZODone 25 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Subdural Hematomas Subarachnoid Hemorrhage ___ Body Dementia Encephalopathy Hypertension Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___ ___. WHY WERE YOU IN THE HOSPITAL? - You were admitted to the hospital because you had a fall at home and were found to have bleeding around your brain WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? -You were evalauted by our neurosurgeons who felt that non-operative management was the best course of action for you. Per your family, this is also in line with your desired care. -We monitored you closely for signs of worsening bleeding. We gave you medications through your IV when you were unable to take medications by mouth. -You were very confused because of your injury. Your confusion made you agitated. We gave you medications to help with this and minimized interventions that could be contributing with improvement. -We worked closely with your family to come up with a plan of care that we felt would be most consistent with your goals to promote quality of life going forward. WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL? - Continue to take all your medicines as prescribed below. - Show up to your appointments as listed below. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
10807423-DS-19	10,807,423	20,073,035	DS	19	2119-03-28 00:00:00	2119-03-28 18:03:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: R ankle fracture dislocation, open Major Surgical or Invasive Procedure: ORIF R ankle and I&D ___ History of Present Illness: Chief Complaint: ankle pain Reason for Orthopedics Consult: management of open fracture HISTORY OF PRESENT ILLNESS: Patient is a ___ yo male previously healhty presenting w/ fall from 6 feet, from ladder. Patient landed on LLE w/ forced eversion and subsequent open fracture/dislocation. Denies head strike or LOC. Denies neck pain, back pain, chest pain, abd pain. Denies pelvic or thigh pain. Was emergently reduced in ED under conscious sedation. In the ED, initial vitals were 77 160/60 16 100%. Per the ED, the patient's exam did not show evidence of neurovascular symptoms. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, neck or back pain. Denies cough, shortness of breath, chest pain. Denies nausea, vomiting, diarrhea, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. PAST MEDICAL HISTORY: none MEDICATIONS: none ALLERGIES: NKDA SOCIAL HISTORY: Denies alcohol, drugs, smoking PHYSICAL EXAM: GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: C-spine is non-tender to palpation LUNGS: Clear to auscultation bilaterally CV: Regular rate and rhythm, ABD: soft, non-tender, non-distended, PELVIS: stable EXT: open fracture/likely dislocation of LLE at level of distal tibia. +DP. Unable to assess. Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. ___ Labs: pending Images: ASSESSMENT & PLAN: ___ yo male w/ type II open fracture/dislocation of distal tib/fib. 1. Ancef 2g, tetanus 2. Imaging 3. Admit to ___ for surgical repair 4. Preop labs Past Medical History: none Social History: ___ Family History: not contributory Physical Exam: AFVSS NAD RLE: dressing c/d/i ___ intact dp/t ___ Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have right ankle open fracture dislocation and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for R ankle I&D and ORIF, which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patients home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to 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 NWB in the right lower extremity, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge. Medications on Admission: none Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC QHS Start: Today - ___, First Dose: Next Routine Administration Time RX enoxaparin 40 mg/0.4 mL 1 syringe at bedtime Disp #14 Syringe Refills:0 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth q3hrs Disp #80 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: R ankle fracture dislocation 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 lovenox 40mg daily for 2 weeks WOUND CARE: - No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - 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: NWB R ankle Danger Signs: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Followup Instructions: ___
10807626-DS-3	10,807,626	24,488,240	DS	3	2175-07-06 00:00:00	2175-07-06 12:23:00	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: ___ presenting with 5 days of worsening abdominal pain, nausea, vomiting and poor appetite. Pain is diffuse but more severe in the right side of her abdomen. She is passing flatus and had a small bowel movement ___ in the morning. Denies fevers, chest pain, SOB, diarrhea. Last colonoscopy was ___ years ago, normal per patient report. Past Medical History: Anemia Aortic Stenosis Atrial Fibrillation Basal Cell Carcinoma Chronic Obstructive Pulmonary Disease Chronic Pain Syndrome Colon and Rectal Cancer Congestive Heart Failure Coronary Artery Disease, history of PCI/stenting Diabetes Mellitus Fractures - Back, Rib, Wrist Hyperlipidemia Hypertension Hypokalemia Metabolic Syndrome Morbid Obesity Peripheral Vascular Disease Pulmonary Hypertension Right Foot Contusion s/p colorectal surgery ___ for rectal CA s/p appendectomy s/p tonsillectomy s/p basal cell excision s/p cesarean section Social History: ___ Family History: Father - died in war at age ___ Mother - died at age ___ Sister - died of rheumatic disease and 3 heart surgeries. Sister - died of ___ rupture Physical Exam: Admission Physical Exam T 97.5 HR 90 BP 111/58 RR 18 SatO2 94% RA Alert and oriented RRR CTA bil Abdomen is soft, tender to palpation on right side, distended Extremities no edema Discharge Physical Exam Vital Signs T 97.8 HR 67 BP 110 / 60 RR 18 SatO2 97%RA GEN: WD, WN in NAD HEENT: NCAT, EOMI, anicteric CV: RRR, PULM: no respiratory distress ABD: soft, NT, ND, no mass, no hernia EXT: WWP, no CCE, no tenderness NEURO: A&Ox3, no focal neurologic deficits Pertinent Results: ___ 06:40AM BLOOD WBC-7.1 RBC-3.21* Hgb-9.8* Hct-32.2* MCV-100* MCH-30.5 MCHC-30.4* RDW-14.9 RDWSD-55.6* Plt ___ ___ 07:10AM BLOOD WBC-6.7 RBC-3.23* Hgb-10.0* Hct-32.1* MCV-99* MCH-31.0 MCHC-31.2* RDW-14.8 RDWSD-54.6* Plt ___ ___ 07:25AM BLOOD WBC-7.1 RBC-3.39* Hgb-10.5* Hct-33.5* MCV-99* MCH-31.0 MCHC-31.3* RDW-14.8 RDWSD-53.8* Plt ___ ___ 06:40AM BLOOD ___ PTT-32.5 ___ ___ 07:10AM BLOOD ___ ___ 07:25AM BLOOD ___ PTT-31.4 ___ ___ 06:40AM BLOOD Glucose-103* UreaN-31* Creat-1.4* Na-143 K-4.4 Cl-108 HCO3-25 AnGap-10 ___ 07:10AM BLOOD Glucose-113* UreaN-35* Creat-1.5* Na-142 K-4.5 Cl-106 HCO3-25 AnGap-11 ___ 07:25AM BLOOD Glucose-94 UreaN-36* Creat-1.5* Na-143 K-4.7 Cl-109* HCO3-20* AnGap-14 ___ 06:40AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.8 ___ 07:10AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.1 ___ 07:25AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.6 CT Abd/pelvis OSH (Wet read by ___ Radiology) - SBO, possible TP in distal jejunum (RLQ, below umbilicus) - Chronic appearing R obstructing hydronephrosis *FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Reported to and read back by ___ @ 2238 ON ___ - ___. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C difficile by the Cepheid nucleic amplification assay. (Reference Range-Negative). Brief Hospital Course: Ms. ___ is a ___ year old female who presents with obstructive symptoms for 5 days. CT from OSH shows proximal dilated and distally decompressed bowel with no clear transition point. The patient was admitted for non-operative management. She was placed on bowel rest with IV fluids, nasogastric tube, and serial abdominal exams. 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. She subsequently experienced increased bowel movements and for this reason a C. difficile test was sent and that returned positive. For this reason she was put on vancomycin on the ___ for a ___uring 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 had venodyne boots were used during this stay. Her warfarin was continued during this hospital course and the INR was appropriately monitored. During this hospital course physical therapy evaluated the patient and it was recommended as Ms. ___ was discharged to rehabilitation. 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: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Warfarin 4 mg PO DAILY16 2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Vitamin D 1000 UNIT PO DAILY 6. Furosemide 40 mg PO DAILY 7. MetFORMIN (Glucophage) 500 mg PO BID 8. Metoprolol Tartrate 50 mg PO TID 9. Ondansetron 4 mg PO Q8H:PRN nausea Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #12 Tablet Refills:0 3. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 2 Weeks RX vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours Disp #44 Capsule Refills:0 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 7. Furosemide 40 mg PO DAILY 8. MetFORMIN (Glucophage) 500 mg PO BID 9. Metoprolol Tartrate 50 mg PO TID 10. Ondansetron 4 mg PO Q8H:PRN nausea 11. Vitamin D 1000 UNIT PO DAILY 12. Warfarin 4 mg PO DAILY16 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Small bowel obstruction Clostridium difficile infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the Acute Care Surgery Service on ___ with abdominal pain and found to have a bowel obstruction. You were given bowel rest, IV fluids, and had a nasogastric tube to help decompress your stomach. You had return of bowel function and therefore the gastric tube was removed and your diet was slowly advanced to regular. You were noted to be having a lot of loose stools. A sample was sent to the lab and it tested positive for clostridium difficile (c. diff). This is a bacterial infection of the intestines that causes diarrhea. You are now doing better, tolerating a regular diet, and ready to be discharged to home to continue your recovery. 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. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: ___
10807873-DS-15	10,807,873	28,211,155	DS	15	2166-08-18 00:00:00	2166-08-19 14:45:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: unknown Attending: ___ Chief Complaint: acute EtOH intoxication and suicidal ideation Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMH MI, CAD, alcohol and cocaine abuse who presented with acute intoxication and SI. Per reports found in public park, unable to ambulate, threatening or trying to hurt himself with a knife. He denies this. He does admit to alcohol use, however reports only a few beers with last drink this ___ am. Denies any cocaine or other drug use. Not willing to discuss SI. Denies HI. Reports some ? sharp and substernal CP and SOB, possibly started several hours prior to ED presentation. He felt nauseated but did not vomit. Trops were 0.02, 0.02, and <0.01 and EKG showed NSR, normal axis. New T wave inversion in V2, isolated 2mm ST elevation in V3. No reciprocal changes. Pt says he had a "lot" of etoh night prior to presentation, and usually drinks several times weekly. This morning in the ED the patient continued to have mild chest pain and was given SL nitro with relief. Psych saw patient and felt that patient had psychiatric contraindication to discharge. ___ and 1:1 observation observation were discontinued as per Psych recs and Psych felt patient could follow up with PCP as an out patient. As patient was leaving for ED, pt stood up, became very lightheaded, diaphoretic, tremulous, nauseated, and vomited several times. No chest pain. He was given 2L IVF, zofran, and ativan. He was reportedly tachycardic and hypertensive. His EKG was wnl. In the ED, initial vital signs were: T 97.6 P 68 BP 126/80 R 18 97% O2 sat. Exam notable for: Not documented. Labs were notable for: Trops 0.02, 0.01, and <0.01. Serum alcohol 316, rest of serum tox negative, Utox negative, WBC 6.0, Hb 14.3, Platelets 308, Cr 2.1 (baseline 2.1), AST 60, ALT 29, t.bili 0.03, albumin 4.2 Patient was given: diazepam 10mg X 2, SL nitro 0.4mg X2, zofran, ativan 1mg, folic acid, thiamine, multivitamin, labetalol 100mg, 2L NS On arrival to the floor patient feels improved but still is mildly tremulous. He has a headache in the middle of his forehead with photophobia, feels "like a bad hangover". No N/V, does not normally get headaches but used to get migraines as a child. This HA does not feel like a migraine. No associated vision changes. Last BM was several days ago. The longest the patient has gone without drinking is 1 week. No history of withdrawal seizures/hallucinations/DTs. Past Medical History: PAST MEDICAL HISTORY: HLD HTN s/p 2x MI with 2 stents s/p 2 CVA's Renal insufficiency PAST PSYCHIATRIC HISTORY: Hospitalizations: denies Current treaters and treatment: denies Medication and ECT trials: denies Self-injury: denies Harm to others: has assaulted neighbor resulting in arrest/jail Access to weapons: denies Social History: B/R in ___ by both parents; Education: graduated high school Occupations/Income: no income, applying for disability Housing: homeless Relationships/children: has at least 1 daughter Social Supports: ___ Family History: N/A Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 163/36 105 18 93% RA FSG 183-200 General: Alert and oriented, lying in bed with eyes closed HEENT: PERRL, NC/AT CV: Distant heart sounds, RRR S1 S2 NMRG Lungs: faint crackles right lower lung base otherwise CTABL Abdomen: soft, NT, ND +BS Neuro: Grossly neurologically in tact DISCHARGE PHYSICAL EXAM: Telemetry: NSR except for 26 beats/4 seconds of V.tach Vitals: 140s-160s/36 105 18 93% RA FSG 183-200 General: Alert and oriented, lying in bed with eyes closed HEENT: PERRL, NC/AT CV: Distant heart sounds, RRR S1 S2 NMRG Lungs: faint crackles right lower lung base otherwise CTABL Abdomen: soft, NT, ND +BS Neuro: Grossly neurologically in tact Pertinent Results: ADMISSION LABS: ===================== ___ 11:07PM BLOOD WBC-4.5 RBC-4.32* Hgb-14.2 Hct-42.3 MCV-98 MCH-32.9* MCHC-33.6 RDW-14.9 RDWSD-53.6* Plt ___ ___ 11:07PM BLOOD Neuts-54.8 ___ Monos-7.6 Eos-2.0 Baso-0.9 Im ___ AbsNeut-2.45 AbsLymp-1.54 AbsMono-0.34 AbsEos-0.09 AbsBaso-0.04 ___ 11:07PM BLOOD Plt ___ ___ 11:07PM BLOOD Glucose-81 UreaN-23* Creat-2.1* Na-143 K-4.1 Cl-108 HCO3-16* AnGap-23* ___ 11:07PM BLOOD cTropnT-<0.01 ___ 11:07PM BLOOD ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 11:07PM BLOOD GreenHd-HOLD IMPORTANT LABS: ======================== ___ 12:08PM BLOOD ALT-29 AST-60* AlkPhos-118 TotBili-0.3 ___ 04:59AM BLOOD cTropnT-0.01 ___ 12:08PM BLOOD CK-MB-7 ___ 12:08PM BLOOD cTropnT-0.02* ___ 05:50PM BLOOD cTropnT-0.01 DISCHARGE LABS: ======================== ___ 05:40AM BLOOD WBC-3.9* RBC-3.95* Hgb-12.8* Hct-38.0* MCV-96 MCH-32.4* MCHC-33.7 RDW-14.5 RDWSD-51.8* Plt ___ ___ 12:08PM BLOOD Neuts-71.2* ___ Monos-7.2 Eos-0.3* Baso-0.7 Im ___ AbsNeut-4.25# AbsLymp-1.22 AbsMono-0.43 AbsEos-0.02* AbsBaso-0.04 ___ 05:40AM BLOOD Plt ___ ___ 05:40AM BLOOD Glucose-78 UreaN-23* Creat-1.9* Na-139 K-3.9 Cl-103 HCO3-23 AnGap-17 ___ 05:40AM BLOOD Calcium-9.1 Phos-4.0 Mg-1.8 IMAGING: ========================= CXR ___ IMPRESSION: Possible minimal bibasilar atelectasis. Otherwise, no acute pulmonary process identified. EKG: ======================== ___: NSR, normal axis. New T wave inversion in V2, isolated 2mm ST elevation in V3. No reciprocal changes. Unchanged from prior EKGs, no acute ischemic process suspected. Repeat ___: Repeat EKG shows no interval change from previous EKGs. Brief Hospital Course: ___ presents with history of hypertension, hyperlipidemia, and MI X 2 with two stents (unknown if drug eluting) presents with EtOH intoxication, chest pain, and suicidal ideation. His last drink ___ am, unclear how much patient drinks normally. No history of seizures or DTs. Initial EKG showed NSR, normal axis with new T wave inversion in V2, isolated 2mm ST elevation in V3. No reciprocal changes. Trops peaked at 0.02 and downtrended. Repeat EKG ___ was unchanged from baseline EKGs obtained previously and chest pain resolved with diazepam and SL nitro. Patient was treated for alcohol withdrawal with diazapam 10mg for CIWA scores > 10, he was given diazepam X 2 in the ED and X 1 on the floor. Psych saw patient for suicidal ideation and felt that patient had no psychiatric contraindication to discharge. ___ and 1:1 observation observation were discontinued as per Psych recs and Psych recommended follow up with PCP as an out patient. TRANSITIONAL ISSUES: = = = = = ================================================================ - suicidal ideation, no active plan - continue encouraging alcohol abstinence - continue optimization of medical management of CAD, hypertension, and hyperlipidemia - question of whether patient has drug eluting stents and needs dual anti-platelet therapy Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Omeprazole 40 mg PO DAILY 6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Acetaminophen 325 mg PO Q6H:PRN pain 10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain Discharge Medications: 1. Acetaminophen 325 mg PO Q6H:PRN pain RX acetaminophen 325 mg 1 tablet(s) by mouth every 6 hours as needed Disp #30 Tablet Refills:0 2. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Atorvastatin 80 mg PO QPM RX atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #30 Tablet 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. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY RX isosorbide mononitrate 60 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 6. Lisinopril 20 mg PO DAILY RX lisinopril 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 7. Multivitamins 1 TAB PO DAILY RX multivitamin [Men's Multi-Vitamin] 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain RX nitroglycerin 0.4 mg 1 tablet(s) sublingually every 5 minutes as needed Disp #25 Tablet Refills:0 9. Omeprazole 40 mg PO DAILY RX omeprazole 40 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:0 10. Thiamine 100 mg PO DAILY RX thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 11. Metoprolol Succinate XL 50 mg PO DAILY RX metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Alcohol withdrawal Chest pain Secondary diagnosis: Hypertension Hyperlipidemia CAD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___ ___. You were admitted to the hospital for alcohol withdrawal. You were treated for your withdrawal. Continuing to drink alcohol increases your risk for infection, end-organ damage, and death. If you are interested in quitting drinkig please follow up with your primary care provider. Please continue to take your medications as perscribed. It was a pleasure taking care of you. Sincerely, Your ___ team Followup Instructions: ___
10807985-DS-19	10,807,985	21,318,253	DS	19	2137-12-25 00:00:00	2137-12-25 15:56:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Cellulitis, AMS Major Surgical or Invasive Procedure: Intubation ___, Extubation ___ PICC placement EGD ___ History of Present Illness: ___ M hx of EtOH abuse, elevated transaminases, DM2, ?COPD, AFib recently on coumadin who presents as a transfer from ___ after a fall. The patient himself is a poor historian and the history is mainly gathtered from notes and from his primary care Physician's assistant. He was brought to his PCP by his wife on ___ because he had been fatigued for about three weeks and had reportedly had multiple falls. Felt "not himself" and was weak and unable to walk much in the last week. No fevers/chills. Unclear how much or how frequently he was drinking, he says ___ drinks daily. In his PCP's office, he was sleepy and hypoxic to 86%, so he was sent to the ED at ___. In the ED at ___ he had labs, notable for elevated AST/ALT, EToH of 467, ammonia 53, PLTs 53, INR 2.4, negative UA. He had a non-con CT head which showed (read by our neuroradiologists) a chronic subdural hematoma without acute blood. A non-con CT of the abdomen from OSH informally read by our radiologists as fatty, shrunken, nodular, increased venous collaterals (umbilical vein) in the abdomen suggestive of portal hypertension, presence of IVC filter, a partial splenectomy, and findings concerning for lower abdominal/upper pelvic superficial cellulitis. He was given lactulose, 1g of Vancomyin IV and transfered to ___ for further management. Of note he was being treated for bilateral lower extremity cellulitis with doxycycline as an outpatient. In the ED at ___, he was sleepy but arousable, vitals were unremarkable. Labs notable for ETOH >300, INR 2.3, PLTs 31, HCT 31, MCV 122, albumin 2.7, and lactate of 3.0. He was evaluated by neurosurgery who, as above, felt that the OSH CT was c/w a chronic, not acute, subdural hematoma, and recommended no intervention. On transfer to the floor he was in AF, Afebrile, HR 83, 103/57 93% on 3L. ===================MICU TRANSFER==================================== Mr. ___ is a ___ year old gentleman with a history of ETOH abuse, afib recently on coumadin who initially presented ___ as a transfer from ___ after a fall. At ___ he was somnolent and hypoxemic to 86%, found to have elevated LFTs, ETOH 467. NCCT revealed chronic subdural hematoma. A non-con CT of the abdomen from ___ showed fatty, shrunken, nodular liver with increased venous collaterals (umbilical vein) in the abdomen suggestive of portal hypertension, presence of IVC filter, a partial splenectomy. He was given lactulose for AMS and vancomycin given concern for cellulitis prior to transfer. He was transferred to the MICU on ___ for escalating nursing needs in the setting of encephalopathy and increasing 02 requirement. He was treated for hepatic encephalopathy and EtOH withdrawal with phenobarb protocol. Hypoxemic respiratory failure was attributed to aspiration pneumonia and he was treated with Unasyn. He was diuresed ~2L and TTE did not show reduced EF. He was transferred back to the floor ___ with somewhat improved mental status. Since going back to the floor ___ his mental status has worsened, now responsive only to sternal rub. He has been persistently febrile to 102 despite APAP and was broadened to vanc/cefepime/metronidazole for possible GI source given abdominal pain. He has been getting 100g 25% albumin for the past 2 days for volume. Over the past 3 days his 02 requirement has been increasing with RR in the ___ now on non-rebreather. ABG this morning 7.35 44 78. Given concern for volume overload as a component of his worsening respiratory status, he was given 80 mg IV lasix with 600-800cc UOP prior to ICU transfer. On arrival to the MICU, the patient is minimally responsive to sternal rub, tachypneic, saturating 88% on 100 non-rebreather. Given AMS and hypoxemia he was intubated shortly after arrival. Review of systems: Unable to obtain given AMS Past Medical History: PAST MEDICAL HISTORY: - HCV/ETOH cirrhosis - Alcohol abuse - Transaminitis since ___ as above - Atrial fibrillation - on warfarin recently, has sparse cards followup. Report of a recent TTE that looked "OK" - DM2 - COPD: no PFTs - OSA: On 2L home oxygen for the last year. PSurgical Hx: - Tracheostomy in ___ - Partial splenectomy ___ - Partial prostatectomy for prostate Ca - IVC filter ___ after MVA and inability to anticoagulate for AFib in setting of polytrauma and abdominal surgery Social History: ___ Family History: Father died of lung cancer Mother died of neck cancer Physical Exam: ADMISSION: Vitals - 98.1 HR 84 AF, 111/47 RR 14 93% on 3L GENERAL: coughing, appears uncomfortable, tremulous, disheveled, obese, poor hygeine, smells of alcohol. NEURO: AOX2, knows year, knows president. Unable to recount much of his history. Follows commands appropriately. HEENT: AT/NC, conjunctiva red, sclera slightly icteric. Tongue tremor. Significant lacrimation. CARDIAC: irregular rhythm, S1/S2, no murmurs. LUNG: very poor air movement throughout, inspiratory and expiratory wheezes. ABDOMEN: obese, NT. 10-20 cm violaceous patch in RLQ of abdomen. Not warm, non-tender. Flaky skin beneath pannus. EXTREMITIES: Anasarcic, pitting edema in hands and to the knee bilaterally. Woody skin changes in bilateral lower extreities. Bilateral warm erythema with scabs and some dry ulcers in bilateral lower extremities. PULSES: 2+ DP pulses bilaterally NEURO: No pronator drift. Coarse resting tremor bilaterally. + Asterexis. SKIN: small spider angiomata over torso with central flushing under neck. Armpits and chest hairless. DISCHARGE: VS Tmax 98.7 Tc 98.4 HR 75-104 BP 104/57-134/76 RR ___ SpO2 93-96% RA, I/O 24h 520/850+BMx2, 8h 120/300+BMx1, General: Appears well, NAD. AOx2 (not to date). Unable to spell world backwards. Interacting appropriately. Less interactive today. Neck: Unable to appreciate JVD. No supraclavicular adenopathy. CV: No murmurs, irregular. Lungs: clear anteriorly. Abdomen: Soft, obese, large ecchymosis RLQ. No evidence of fluid wave suggestive of ascites. GU: Scrotal edema. Foley in place. Ext: Trace pitting edema. Skin: Spider angiomas on chest, no jaundice. Neuro: Mild asterixis. Otherwise, cranial nerves II-XII grossly intact. Normal UE and ___ strength and sensation bilaterally. Unable to assess gait. Pertinent Results: ADMISSION ___ 05:30PM CK(CPK)-223 ___ 05:30PM IRON-113 ___ 05:30PM calTIBC-192* VIT B12-1680* FERRITIN-1849* TRF-148* ___ 05:30PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE ___ 05:30PM HCV Ab-POSITIVE* ___ 05:30PM ___ ___ 01:10PM LACTATE-3.2* ___ 12:46PM LIPASE-421* ___ 02:38AM ___ PTT-42.7* ___ ___ 01:59AM COMMENTS-GREEN TOP ___ 01:59AM LACTATE-3.4* ___ 01:49AM GLUCOSE-100 UREA N-18 CREAT-1.0 SODIUM-140 POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-27 ANION GAP-18 ___ 01:49AM estGFR-Using this ___ 01:49AM ALT(SGPT)-39 AST(SGOT)-184* ALK PHOS-215* TOT BILI-3.0* ___ 01:49AM ALBUMIN-2.7* ___ 01:49AM ASA-NEG ___ ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 01:49AM WBC-8.2 RBC-2.61* HGB-10.1* HCT-31.9* MCV-122* MCH-38.7* MCHC-31.7 RDW-17.6* ___ 01:49AM NEUTS-75* BANDS-0 LYMPHS-10* MONOS-14* EOS-1 BASOS-0 ___ MYELOS-0 NUC RBCS-2* ___ 01:49AM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-2+ MACROCYT-3+ MICROCYT-1+ POLYCHROM-OCCASIONAL TARGET-2+ HOW-JOL-OCCASIONAL PAPPENHEI-OCCASIONAL ENVELOP-1+ ___ 01:49AM PLT SMR-VERY LOW PLT COUNT-31* ___ 01:49AM RET AUT-2.9 = = = = = = = ======================Imaging=================================== Liver US ___ IMPRESSION: 1. Coarsened liver echogenicity and nodular hepatic contour consistent with cirrhosis. 2. Sequela of portal hypertension including recanalization of paraumbilical vein. Patent hepatic and portal venous vasculature. 3. Dilated common bile duct measuring up to 12 mm without evidence of filling defect or intrahepatic biliary dilatation, however the distal aspect of the duct is not visualized. Sludge in GB also noted. MRCP may be considered if further imaging evaluation is indicated. TTE ___ The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses and cavity size are normal. Left ventricular systolic function is hyperdynamic (EF>75%). Doppler parameters are indeterminate for left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Hyperdynamic left ventricular systolic function without outflow tract obstruction. Mild mitral regurgitation. Normal pulmonary artery systolic pressure. Diastolic function indices are equivocal. CT Head IMPRESSION: 1. Chronic right frontal subdural hematoma causing mild sulcal effacement. No shift of midline structures. 2. Large posterior fossa hypodensity, which may represent an arachnoid cyst ___ cisterna magna. CT Chest IMPRESSION: 1. Right lower lobe bronchi filled with secretions leading to atelectasis. Multifocal bilateral patchy ground-glass and nodular opacities with upper lobe predominance, the possibility of aspiration pneumonia has to be considered. 2. moderate left and small right pleural effusions. 3. Mild dilatation of the main pulmonary trunk and its major branches suggests pulmonary arterial hypertension. 4. Please refer to separately dictated CT abdomen and pelvis report from the same day for full description of subdiaphragmatic findings. CT A/P IMPRESSION: 1. No organized fluid collection to suggest an intra-abdominal abscess. 2. Mild central intrahepatic and mild extrahepatic biliary dilatation without evidence of obstruction. 3. A 2.7 cm round soft tissue mass abutting the tail of the pancreas at the splenectomy bed is thought to represent an accessory spleen. If further confirmation is needed MRI or a nuclear medicine sulfur colloid scan may be obtained. 4. Please refer to separately dictated CT chest report from the same day for full description of intrathoracic findings. CTA CHEST ___: 1. No evidence of pulmonary embolism. 2. Improvement in bibasilar atelectasis. 3. Right lung base ___ nodules are most likely due to aspiration or infection. Mucous plugs are present in the segmental bronchi to the right upper lobe and nonobstructing secretions in the trachea and right main bronchus. Right upper lobe airspace ground-glass infiltrate has increased from previous. 4. Nonspecific lucent lesion in T5 vertebral body which could represent hemangioma but is not specific. MRI can be performed for further characterization as indicated. EGD ___ no varices = = = = ===========================Micro================================ ___ fungal and mycobacterial isolator culture negative to date. C. Diff ___ negative. BAL ___: HSV-1 grew out of culture, CMV antigen detected. BAL ___: yeast ___ 10:10 pm SPUTUM Source: Endotracheal. *FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. YEAST. SPARSE GROWTH. Multiple negative blood cxs Multiple negative urine cxs Negative c diff DISCHARGE: ___ 05:22AM BLOOD WBC-13.0 RBC-2.44* Hgb-9.6* Hct-30.9* MCV-127* MCH-39.3* MCHC-31.1 RDW-15.9* Plt Ct-84* ___ 05:22AM BLOOD Plt Ct-84* ___ 05:22AM BLOOD ___ PTT-67.4* ___ ___ 05:22AM BLOOD Glucose-89 UreaN-13 Creat-0.8 Na-137 K-4.2 Cl-110* HCO3-21* AnGap-10 ___ 05:22AM BLOOD ALT-30 AST-76* LD(LDH)-421* AlkPhos-113 TotBili-2.4* Brief Hospital Course: ___ yo M with PMH of alcohol abuse who presented with encephalopathy, new cirrhosis, and alcohol withdrawal whose hospital course was complicated by slow-to-clear encephalopathy, hypoxemic respiratory failure, and prolonged intubation. Treated for hepatic encephalopathy, alcohol withdrwal, and aspiration/hospital acquired pneumonia. At time of discharge mental status had cleared and he was breathing comfortably on room air. Etiology of the cirrhosis is either alcoholic, ___ HCV, or NAFLD. He will follow up in the ___. # Encephalopathy: Initially thought due to alcohol withdrawal and hepatic encephalopathy. Treated with aggresive lactulose and rifaximina nd a phenobarbitol taper. His encephalopathy, however, was slow to clear and he remained delerious and intermittently agitated, in spite of appropriate treatment for the above conditions. Systemic illness was likely also causing decreased level of arousal. Hypernatremia may also have been contributing. Head CT revealed stable subdural hematoma. Repeated on admission to MICU given dilated pupils, though revealed no change from prior. He was continued on lactulose/rifaximin. His mental status improved significantly on ___. Given his long history of alcohol use, started on oral thiamine supplementation. # Hypoxemic respiratory failure: Concern for possible aspiration in the setting of worsening mental status given productive cough, elevated WBC, and high fevers. VOlume overload may also have contributed in the setting of IVF resuscitation on admission with low albumin and multiple CXRs with vascular congestion. Did not improve with diuresis. TTE with normal LVEF and he remained in persistent Afib with rates in low 100s. Low suspicion for cardiogenic etiologies given absence of valvular disease and adequate rate control. Initially treated with Vanc/Zosyn given concern for aspiration pneumonia in the setting of AMS. He was intubated and remained so for > 7 days given high PEEP requirements and in the setting of persistent altered mental status. Once he was more arousable he still required high levels of PEEP, particularly when sitting upright, though improved while lying flat. Given concern for intrapulmonary shunting, a bubble study was performed, though revealed no evidence of shunt physiology. His respiratory status improved and he was extubated on ___. No microbiologic soure was identified. He had GNRs on a sputum gram stain that did not grow in the culture. He had a BAL that grew HSV-1 and was positive for CMV antigen, but these were not felt to be respiratoy pathogens in his case. He had a positive galactomannan and was briefly treated with voriconazole, but no pathogenic fungi grew from his blood or respiratory cultures. He completed a 14 day course of Meropenem on ___. # Cirrhosis: Diagnosed by labs and OSH CT abdomen/pelvis showing a nodular liver. Chronicity unclear. RUQUS confirmed cirrhotic liver appearance. HCV positive and has an extensive drinking history. HAV negative. HBV non-immune. Started on Lactulose and Rifaximin. Hepatology followed throughout hospital stay. They will see him in the ___ as an outpatient for ongoing monitoring (regular RUQUS, ? treatment of HCV, HBV immunization). EGD on ___ showed no varices. # ___: Presented with creatinine of 1.3 from baseline 0.9-1. Likely secondary to volume depletion. Given history of cirrhosis, important to consider HRS. His renal function improved with albumin resuscitation. # Hypernatremia: Intermittently hypernatremic during hospital stay. Likely from minimal POs (while without NG access) and ongoing loose stools from the lactulose. # Chronic right frontal SDH: Stable on Repeat CT head ___ and ___. # Afib: CHADS2 of 2. INR was 2.4 despite holding Coumadin, most likely representing coagulopathy of liver disease. Will continue to hold Coumadin given this, thrombocytopenia, and SDH. Also, on discussion with wife, coumadin was initiated for planned cardioversion, but patient decided not to undergo cardioversion later, so doesn't really need to be anticoagulated. Rate controlling with metoprolol. Stopped digoxin given fluctuating renal function. In discussion with PCP, decision was made to continue to hold Warfarin at discharge given elevated INR, and no plans for cardioversion (had been off coumadin for years before that). Patient started on Aspirin 81 mg PO QDaily at discharge. # Macrocytic anemia: Most likely due to a combination of alcohol use and splenectomy. B12 normal. Will monitor. Started on B12/folate. # Thrombocytopenia: Likely cirrhosis. He is s/p partial splenectomy. No DIC or TTP based on initial labs. Held heparin for Plt < 50. # Hypoalbuminemia: Likely due to cirrhosis and poor oral intake. Was on TF as he failed initial swallow evaluation. However swallow improved as mental status cleared, pand patient was able to take adequate PO by time of discharge, and TFs were discontinued. TRANSITIONAL: []Code status: Full []Digoxin discontinued []Coumadin discontinued given subdural hematoma and risk for further bleeds given fall risk, patient started on Aspirin 81 mg PO QDaily [] Patient discharged on Lactulose and Rifaximin [] Lasix 40 mg PO QDaily resumed at discharge, will need to consider starting Spironolactone at ___ [] Patient will need Hepatology followup [] Patient will need post-discharge PCP ___ [] Patient will need HBV vaccination [] Patient will need Liver Ultrasound q 6month for surveillance Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation inhalation qd dyspnea 2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation q6H wheeze 3. Digoxin 0.125 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Lisinopril 2.5 mg PO DAILY 6. Metoprolol Succinate XL 100 mg PO DAILY 7. OxyCODONE SR (OxyconTIN) 60 mg PO Q8H 8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 9. Doxycycline Hyclate 50 mg PO Q12H 10. TraZODone 100 mg PO HS 11. Warfarin 3 mg PO DAILY16 12. potassium chloride 10 mEq oral daily 13. Zovirax Ointment 5% 1 appl Other qd 14. Tiotropium Bromide 1 CAP IH DAILY Discharge Medications: 1. Furosemide 40 mg PO DAILY 2. Lisinopril 2.5 mg PO DAILY 3. Metoprolol Succinate XL 100 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Cyanocobalamin 50 mcg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Lactulose 30 mL PO QID 8. Multivitamins 1 TAB PO DAILY 9. Rifaximin 550 mg PO BID 10. Thiamine 100 mg PO DAILY 11. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation inhalation qd dyspnea 12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation q6H wheeze 13. Tiotropium Bromide 1 CAP IH DAILY 14. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth Q8H:PRN Disp #20 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Cirrhosis ___ hospital acquire pneumonia Secondary: atrial fibrillation alcoholic hepatitis diabetes Discharge Condition: Alert and oriented x2 (not to date) Clear and coherent Deconditioned and weak. Unable to stand without assistance. Discharge Instructions: Mr. ___, You were admitted to the hospital because of fatigue and confusion. You were found to have evidence of impaired liver function, a condition called cirrhosis. This was likely the primary reason for your fatigue and confusion, though withdrawal from alcohol may also have been initially contributing. We have started you on two new medications, lactulose and rifaximin, that will help you from becoming confused in the future. While in the hospital, you became quite sick and had worsening difficulty breathing. We transfered you to the medical ICU where you were placed on a breathing machine for more than one week. You improved with treatment for pneumonia, and we think this is probably what caused your breathing trouble. You came to the hopsital on coumadin. You should stop this medication for the time being. We have also stopped your digoxin. You should also continue to hold your lasix, which you were taking before coming to the hospital. We have arranged for you to followup in our ___ here for onging management of your liver disease. It has been a pleasure taking care of you at the ___. -your ___ care team. Followup Instructions: ___
10808090-DS-24	10,808,090	26,346,806	DS	24	2190-11-12 00:00:00	2190-11-12 11:40:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left hip pain Major Surgical or Invasive Procedure: ___ Left hip hemiarthroplasty History of Present Illness: HPI: ___ male with history of lymphoma, hypertension presenting status post mechanical fall onto his left side with associated head strike. No loss of consciousness. Patient complaining of left hip pain. No weakness or numbness in the left lower extremity. No urinary or bowel incontinence. Patient is on aspirin and not anticoagulated. Past Medical History: lymphoma hypercholesterolemia hypertension Gastritis Colonic polys Prostate cancer ___ treated with seed-radiation h/o pulmonary edema and dilated right pulmonary artery BPH s/p TURP appy inguinal hernia repair Social History: ___ Family History: no family history of malignancy Physical Exam: PHYSICAL EXAM ON ADMISSION: Vitals: 98.1 72 115/79 22 93% In mild distress, AOx3 BUE skin clean and intact No tenderness, deformity, erythema, edema, induration or ecchymosis Arms and forearms are soft No pain with passive motion R M U ___ EPL FPL EIP EDC FDP FDI fire 2+ radial pulses LLE skin clean and intact Tenderness left lateral hip.No deformity or shortening. No erythema, edema, induration or ecchymosis. Thighs and legs are soft Pain with external rotation and axial loading. Pelvic is stable. Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire 1+ ___ and DP pulses Left knee stable without joint tenderness, swelling or eccymosis. RLE skin clean and intact no tenderness , deformity, erythema, edema, induration or ecchymosis Thighs and legs are soft No pain with passive motion Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire 1+ ___ and DP pulses PHYSICAL EXAM ON DISCHARGE: A&O x3, calm and comfortable LLE: ___ fire, warm and well-perfused with ___ pulses Incision c/d/i with staples in place Pertinent Results: ___ 05:00AM BLOOD WBC-5.6 RBC-3.29* Hgb-10.3* Hct-28.2* MCV-86 MCH-31.2 MCHC-36.5* RDW-14.1 Plt ___ ___ 05:00AM BLOOD Glucose-94 UreaN-11 Creat-0.9 Na-138 K-3.6 Cl-105 HCO3-26 AnGap-11 Brief Hospital Course: Mr. ___ was admitted to the Orthopaedic Surgery Trauma service from the Emergency Department on ___ for further management of a left femoral neck fracture, including pre-operative work-up. The following day, he was taken to the Operating Room to undergo a left hip hemiarthroplasty. The patient tolerated the procedure well. Please see Operative Report for full details. Post-operatively, the patient was taken to the recovery room before being transferred to the floor for further monitoring and care. He was given Lovenox for DVT prophylaxis. His pain was well controlled with narcotic medications, which were eventually transitioned to oral pain medications. Physical Therapy was consulted, and the patient made gradual progression and was able to ambulate with assistance by the date of discharge. On ___, the patient was transfused 1 unit of packed red blood cells for acute blood loss anemia. He responded well to the transfusion, and his hematocrit increased appropriately. On ___, the patient was in good spirits and expressed readiness for discharge to a rehabilitation facility. His incision was clean, dry, and intact, and he was able to tolerate a regular diet. He was discharged to rehab in stable condition with detailed precautionary instructions as well as instructions regarding follow-up. Medications on Admission: Lipitor 20 mg Tab daily Prandin 1 mg Tab daily Protonix 40 mg Tab daily AZILECT 0.5 mg Tab daily Aspirin 81 mg Chewable Tab daily Verelan ___ 300 mg 24 hr Cap Microzide 12.5 mg Cap daily Lactulose 10 gram/15 mL Oral Soln ___ ml b.i.d. p.r.n. for constipation Altace 5 mg Cap daily Bisacodyl 10 mg Rectal Suppository q.h.s. p.r.n. constipation Miralax 17 gram Oral Powder Packet daily GlycoLax 17 gram (100 %) Oral Powder Packet daily Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 2. repaglinide 2 mg Tablet Sig: 0.5 Tablet PO TIDAC (3 times a day (before meals)). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. AZILECT 0.5 mg Tablet Sig: One (1) Tablet PO daily (). 6. carbidopa-levodopa ___ mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 9. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Syringe Subcutaneous QHS (once a day (at bedtime)) for 2 weeks. 10. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:65 Tablet(s) Refills:0 11. insulin regular human 100 unit/mL Solution Sig: AC+HS Injection ASDIR (AS DIRECTED): Please see printed sliding scale. 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. verapamil 300 mg Capsule, 24hr ER Pellet CT Sig: One (1) Capsule, 24hr ER Pellet CT PO Q24H (every 24 hours). 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold if loose stool. 16. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for constipation: Hold if loose stool. 17. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation: Hold if loose stool. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left 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: Wound Care: - Keep Incision clean and dry. - You can get the wound wet or take a shower starting from 7 days after surgery, but no baths or swimming for at least 4 weeks. - Dry sterile dresssing may be changed daily. No dressing is needed if wound continues to be non-draining. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. Activity: - Continue to be weight-bearing as tolerated on your left leg, with anterior precautions. - Elevate left leg to reduce swelling and pain. Other Instructions - Resume your regular diet. - Please check electroyltes, including phosphorus and magnesium in addition to a Basic Metabolic Panel, and replete appropriately. - 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. Please call the office of Dr. ___ to schedule a follow-up appointment with ___ in 2 weeks at ___. Please follow-up with your primary care physician regarding this admission. Physical Therapy: WBAT LLE with anterior precautions Ambulate twice daily if patient able With Assist: Walker Treatments Frequency: Wound care: Site: Incision Type: Surgical Dressing: Gauze - dry Comment: daily; please overwrap any dressing bleedthrough with ABDs and ACE Followup Instructions: ___
10808090-DS-26	10,808,090	26,313,901	DS	26	2192-10-05 00:00:00	2192-10-07 22:28:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: weakness, fever Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMH notable for Mantle cell lymphoma s/p chemotherapy at ___ (___), hypertension, hyperlipidemia and ___ disease presenting with weakness. The patient states that approximately one hour prior to arrival to the hospital he began feeling weak and could not stand. He previously felt well in the early morning. He denies pain in his legs and does not have any arm weakness. He reports subjective fevers and chills. He denies cough and dysuria. No chest pressure or chest pain. In terms of his Mantle cell lymphoma that patient is currently in remission. His last chemotherapy was in ___. His next PET scan is scheduled for ___. In the ED intial vitals were: 101.1, 95, 125/62, 18, 94% RA - Labs were significant for WBC 5.5 (80% PMN), H/H 12.3/35.9, plt 150, Na 142, K 3.8, Cl 106, HCO3 25, BUN 21, Cr 1.0, glucose 234 and lactate 2.2. UA was unremarkable - Imaging significant for CXR w/ ___ lung volumes but no acute cardiopulmonary process - Patient was given acetaminophen Vitals prior to transfer were: 98.1, 74, 128/55, 16, 95% RA On the floor the patient has no major complaints. He reports feeling leg weakness this afternoon along with fevers and chills. He denies diarrrhea, recent travel and sick contacts. He is accompanied by his son and wife. Past Medical History: Actinic keratosis Mantle cell lymphoma s/p chemotherpay at ___ (___) Hypercholesterolemia Hypertension Gastritis Colonic polys Prostate CA s/p seed-radiation pulm edema w/dilated R pulmonary artery BPH Parkinsons PAST SURGICAL HISTORY: Cataract surgery (___) Ultrasound-guided aspiration of left groin abscess (___) TURP Appendectomy Inguinal hernia repair L hip repair Social History: ___ Family History: No family history of malignancy Physical Exam: ADMISSION PHYSICAL EXAM: Vitals- 97.7 132/69 80 20 99% RA General- well appearing elderaly gentleman in NAD, walker at bedside HEENT- PERRL, conjunctiva normal, mild nasal congestion, OP w/o lesions Neck- supple, no JVD Lungs- fine rales b/l at bases otherwise clear CV- RRR, S1/S2 normal, ___ systolic murmur at ___, no R/G Abdomen- +BS, S/NT/ND, no HSM GU- normal genitalia Ext- WWP, trace ___ edema bilaterally, no clubbing/cyanosis Neuro- CNII-XII intact, ___ upper and lower extremity strength, normal lower extremity sensation DISCHARGE PHYSICAL EXAM: General- well appearing elderaly gentleman in NAD HEENT- PERRL, OP w/o lesions, MMM Neck- supple, no JVD Lungs- fine rales b/l at bases otherwise clear CV- RRR, S1/S2 normal, ___ systolic murmur at ___, no R/G Abdomen- +BS, S/NT/ND, no HSM Ext- WWP, trace ___ edema bilaterally Neuro- grossly intact Pertinent Results: ADMISSION LABS: ___ 04:25PM BLOOD WBC-5.5 RBC-4.00* Hgb-12.3* Hct-35.9* MCV-90 MCH-30.7 MCHC-34.2 RDW-14.5 Plt ___ ___ 04:25PM BLOOD Neuts-80.8* Lymphs-10.6* Monos-6.9 Eos-1.3 Baso-0.3 ___ 04:25PM BLOOD Glucose-234* UreaN-21* Creat-1.0 Na-142 K-3.8 Cl-106 HCO3-25 AnGap-15 ___ 06:40AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.7 ___ 04:25PM BLOOD ALT-16 AST-22 LD(LDH)-168 CK(CPK)-68 AlkPhos-95 TotBili-0.4 DISCHARGE LABS: ___ 06:40AM BLOOD WBC-4.1 RBC-3.75* Hgb-11.6* Hct-33.8* MCV-90 MCH-31.0 MCHC-34.3 RDW-14.4 Plt ___ ___ 06:40AM BLOOD Glucose-92 UreaN-17 Creat-0.9 Na-142 K-3.5 Cl-107 HCO3-24 AnGap-15 ___ 06:40AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.7 PERTINENT LABS: ___ 06:40AM BLOOD TSH-2.8 ___ 04:25PM BLOOD CRP-8.4* ___ 04:25PM BLOOD ESR-19* MICROBIOLOGY: ___ 04:25PM URINE Color-Yellow Appear-Clear Sp ___ ___ 04:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ BLOOD CULTURE Blood Culture, Routine-PENDING CXR ___ FINDINGS: Lung volumes are very low, as seen previously. There is no focal consolidation, pleural effusion or pneumothorax. The aorta is tortuous. Heart size appears slightly smaller than the previous exam. The imaged upper abdomen is unremarkable. IMPRESSION: Low lung volumes but no acute cardiopulmonary process . EKG: ___ Sinus 86, first degree AV block, LAD, T wave inversion in V4 Brief Hospital Course: ___ with PMH notable for Mantle cell lymphoma s/p chemotherapy at ___ (___), hypertension, hyperlipidemia and ___ disease presenting with weakness / fever. #FEVER: Patient reported one isolated fever and sudden onset of generalized weakness with no localizing symptoms other than mild nasal congestion. CXR neg. No leukocytosis. U/A WNL. Mantle cell lymphoma in remission with a recent CT scan in ___ at ___. Patient monitored off anti-pyretics with no recurrent fevers throughout his course. His generalized malaise/weakness resolved. Symptoms may have been secondary to mild, transient viral illness. He did report hip pain, but chronic issue and unchanged. No exam findings to suggest septic joint, no leukocytosis, and ESR/CRP not suggestive of infection. He was evaluated by ___ and arrangements for home ___ were made. Patient will f/u with PCP and oncology. No antibiotics were administered during hospitalization. #DIABETES: Blood sugar on admission in the 240s. He takes multiple medications at home, including metformin which was added within the last month. Humalog sliding scale inpatient, then discharged on home PO meds. No hypoglycemic episodes throughout course. Counseled regarding importance of checking fingerstick when symptomatic, including generalized malaise / weakness, to ensure not hypoglycemic. #HYPERTENSION: Blood pressure WNL on home regimen of Verapamil and Ramipril. #HYPERLIPIDEMIA:Continued Atorvastatin 20 mg PO/NG DAILY. ___ DISEASE: Likely contributed to recent weakness / unsteadiness. No noticeable tremor on exam. Continued Sinemet QID. Will f/u with home ___. TRANSITIONAL ISSUES: # Code: FULL # Emergency Contact: Serg ___ ___ -f/u with PCP and oncologist ___ on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. MetFORMIN (Glucophage) 500 mg PO DAILY 2. Azilect (rasagiline) 1 mg oral daily 3. Januvia (sitaGLIPtin) 100 oral daily 4. Atorvastatin 20 mg PO DAILY 5. Repaglinide 2 mg PO TID W/MEALS 6. Pantoprazole 40 mg PO Q24H 7. Carbidopa-Levodopa (___) 1.5 TAB PO TID 8. Carbidopa-Levodopa (___) 1 TAB PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Ramipril 10 mg PO DAILY 11. Verapamil SR 400 mg PO QHS 12. Acetaminophen w/Codeine 1 TAB PO TID:PRN pain 13. Acyclovir 400 mg PO Q12H 14. Polyethylene Glycol 17 g PO DAILY:PRN constipation 15. Aspirin 81 mg PO DAILY 16. Bisacodyl 10 mg PR HS:PRN constipation Discharge Medications: 1. Acyclovir 400 mg PO Q12H 2. Atorvastatin 20 mg PO DAILY 3. Azilect (rasagiline) 1 mg oral daily 4. Carbidopa-Levodopa (___) 1.5 TAB PO TID 5. Carbidopa-Levodopa (___) 1 TAB PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Pantoprazole 40 mg PO Q24H 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 9. Ramipril 10 mg PO DAILY 10. Verapamil SR 400 mg PO QHS 11. Acetaminophen w/Codeine 1 TAB PO TID:PRN pain 12. Aspirin 81 mg PO DAILY 13. Bisacodyl 10 mg PR HS:PRN constipation 14. Januvia (sitaGLIPtin) 100 oral daily 15. MetFORMIN (Glucophage) 500 mg PO DAILY 16. Repaglinide 2 mg PO TID W/MEALS Discharge Disposition: Home With Service Facility: ___. Discharge Diagnosis: Generalized malaise h/o mantle cell lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr ___, You were admitted to the hospital with an episode of fever and weakness. You may have had a transient viral illness. You were monitored here with no recurrent fevers and were feeling much better prior to discharge. You should follow up with your PCP for further ___. Followup Instructions: ___
10808282-DS-21	10,808,282	27,115,454	DS	21	2123-09-20 00:00:00	2123-09-21 09:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Amoxicillin / Codeine / Latex / Lactose / Shellfish Derived Attending: ___. Chief Complaint: Weakness Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: History of Present Illness: ___ year-old male with history of ESRD on HD, CAD, ___ with resultant cardiac liver chirrosis, RUE fistula s/p multiple revisions presenting today with generalized weakness. The patient is on ___ dialysis sessions. . Per the patient's report he has been in usual state of health for the past several weeks no significant complaints, fevers or otherwise. On ___ the patient decided that he had had enough with dialysis and refused to go. His family asked that a social worker see him at the house, but he was adimant that he would not go to dialysis. On ___ the patient continued to feel fine with no complaints. Late ___ night and into ___ morning the patient developed several episodes of loose stool without abdominal pian, nausea or vomitting. On the morning of admission patient states he "felt terrible", was unable to walk or stand, felt that his legs were going to buckle underneath him. Also felt that he was tremors and unable to hold a cup of tea. He denies any fevers, chills, pain, swelling in his arms or legs, increased abdominal distention or abdominal pain. His mother called and ambulance and he was brought to the ED. . In the ED, initial vs were: 97.9 86 142/86 18 98% RA. Patient was noted to have chronic ulcerations on bilateral knees, over chronic venous stasis. Patient was admitted for dialysis prior to arrival on the floor. HD was uneventful by report. . On the floor, patient's vitals were 97.8, 135/85, 86, 20, 96RA. And he was reporting improvement in his tremor as well as jerking in his legs. He denied any pain or current abdominal symptoms. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, constipation or abdominal pain. No recent change in bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: ESRD on HD ___, anemia, CAD, hypertension, systolic CHF, hypothyroidism, psoriasis, restless leg syndrome, h/o L3 burst fracture, s/p spinal fusion L2-4 ___, h/o MSSA osteomyelitis, h/o MSSA epidural abscess, h/o MSSA paraspinal abscess, h/o MSSA bacteremia. Social History: ___ Family History: Father died of MI in ___ mother alive and well ___; 8 siblings, one of whom has HTN, one who has a cerebral aneurysm; he has no children. Physical Exam: ADMISSION EXAM: Vitals: 97.8, 135/85, 86, 20, 96RA General: very caxcectic man, appears very anxious, Alert, oriented, no acute distress, with a flat yet worried affect appears mildly disheveled. HEENT: Sclera mildly icteric, MMM, oropharynx clear, eczemathous plaque on left ear lobe. Neck: very little supperficial tissue, easily palpable lymphnodes that do not appear enlarged, easily palpable thyroid w/o masses. Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, faint ___ systolic murmur in the precoridum and apex no rubs, gallops Abdomen: grossly distented with easily visulaized epigastric veins, positive fluid wave and distention of the flanks bilaterally. pingpong ball sized errythematous mass in the LUQ with small scar below. + bowel sounds, non-tender. GU: no foley, some errythematous plaques in inguinal area, easily to palpate, non-tender, mobile lymphnodes. No lesions on glans or testees. Ext: very wasted w/ little muscle mass. large protruberent fistula on RUE, Right tunneled line inplace w/o errythema, scaling errythematous plaques on plams, arms bilaterally, chronic venous chagnes in feet and lower extremities with thick finger and toe nails. Neuro: CNs2-12 intact, motor function grossly normal w/ 4+ strenght in all extremities, not able to illict DTRs, no flapping ___, but occasional whole body myoclonic jerking. + rhomberg, pt unwilling to atempt gait testing. No sensory defects noticed, normal FNF. . DISCHARGE EXAM: Vitals: 98, 132/84, 73, 18, 97 RA General: very caxcectic man, NAD, though anxious affect is remarkable HEENT: Sclera mildly icteric, MMM, oropharynx clear, eczemathous plaque on left ear lobe. Neck: very little supperficial tissue, easily palpable lymphnodes that do not appear enlarged, easily palpable thyroid w/o masses. Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, faint ___ systolic murmur in the precoridum and apex no rubs, gallops Abdomen: grossly distented with easily visulaized epigastric veins, positive fluid wave and distention of the flanks bilaterally. pingpong ball sized errythematous mass in the LUQ with small scar below. + bowel sounds, non-tender. Ext: very wasted w/ little muscle mass. large protruberent fistula on RUE, Right tunneled line inplace w/o errythema, scaling errythematous plaques on plams, arms bilaterally, chronic venous chagnes in feet and lower extremities with thick finger and toe nails. Pertinent Results: ADMISSION LABS: ___ 02:00PM BLOOD WBC-6.7 RBC-3.96* Hgb-11.8* Hct-37.0* MCV-93 MCH-29.7 MCHC-31.8 RDW-16.4* Plt ___ ___ 02:00PM BLOOD ___ PTT-36.7* ___ ___ 02:00PM BLOOD Glucose-54* UreaN-34* Creat-5.0* Na-134 K-6.8* Cl-94* HCO3-23 AnGap-24* ___ 07:20AM BLOOD ALT-14 AST-29 CK(CPK)-57 AlkPhos-213* TotBili-0.4 ___ 07:20AM BLOOD Albumin-3.2* Calcium-8.9 Phos-5.5* Mg-2.1 ___ 06:40AM BLOOD TSH-3.2 DISCHARGE LABS: ___ 06:33AM BLOOD WBC-5.9 RBC-3.68* Hgb-10.5* Hct-33.9* MCV-92 MCH-28.5 MCHC-30.9* RDW-15.9* Plt ___ ___ 06:33AM BLOOD Glucose-105* UreaN-31* Creat-5.4# Na-138 K-4.9 Cl-94 HCO3-38* AnGap-11 IMAGING: CXR: FINDINGS: Bilateral pleural effusions persist and are likely increased slightly. Heart size is again noted to be enlarged. Pulmonary vascular engorgement persists and is similar. Lung volumes are low. Linear opacities at the right base appear similar compared to prior and likely represent atelectasis or scarring. Lumbar spine hardware is incompletely imaged. Right-sided dialysis catheter is poorly evaluated on this study, but likely terminates in the low right atrium. Right subclavian stent is again noted. IMPRESSION: Stable cardiomegaly, pulmonary vascular prominence, and bilateral pleural effusions, probably increased somewhat. MICROBIOLOGY: Blood Cultures: Pending Brief Hospital Course: Assessment and Plan: ___ yo male with end stage renal, liver, heart and lung disease along with overlaying depression who was admitted with weakness after missing a dialysis appointment two days prior to admission. Patient recieved dialysis with improvement in his symptoms. Patient was screened by ___ and determined to need short term rehab. #WEAKNESS: PER PCP this is indeed the complaints a man with multiorgan failure and progressive decline over several months. Patient had some improvement in his symptoms with dialysis though there was a singificant contribution of his symptoms by decondidtioning. Patient was seen by physical therapy who recommended that he receive short term rehabilitation to improve his endurance and balance. There were no major metabolic, infectious or hemodynamic causes of his weakness uncovered and the patient was discharged to rehab. Depression and poor coping were felt to play a major contribution to his symptoms and a palliative care consult was placed to discuss long term goals of care. It was determiend that the patient would go to rehab and if continued to have progressive decline a move towards comfort focus care would be made. . #ESRD: Patient missed his scheduled dialysis due to non-compliance per his family's report. He was dialysised according to his normal schedule while and inpatient and had a mild improvement in his symptoms of weakness. Patient continued to recieve all his usual renal medications. . #Systolic CHF: patient has a EF of ___ on last ECHO from ___ and stable cardiac exam. Patient continued onaspirin, lisinopril, metoprolol while in house. . #CHIRRHOSIS: patient with history of cardiac induced cirrhosis from chronic hepatic congestion. Has had infectious as well as autoimmune workup for chirrohsis in the past which were negative. No derangements in his liver function was observed and the patient recieved lactulose to treat any enchilitis that may have been contributing to his depression. . #CHRONIC PAIN: From compression fractures s/p fusion. Will continue home dilaudid at 8 mg BID. . #RESTLESS LEG SYNDROME: Stable, continued home gabapentin and ropinirole. . #HTN: Good systolic pressures at this time, will continue lisinopril. . #HYPOTHYROID: will continue synthroid per home dosing as TSH was not elevated. . #COPD: Lungs clear on exam and CXR w/o no respiratory complaints, will continue titropium and albuterol. . #DEPRESSION: Patient's depression was identified as a major barrier to his longterm care needs, he was continued on his home buproprion and clonazepam. Activating medications including ritalin were entertained, but felt that his underlying cardiac and liver disease percluded its use. . TRANSITIONAL ISSUES: -Primary nephrologist raised issue of future neuro-cognative testing -patient is a full code, but should be reassed as his chronic issues continue to evolve -Palliative care consultation was placed to address future, needs patient still wishes to persue treatment of chronic issues at this time -patinet's blood cultures were pending, but no growth at the time of discharge. Medications on Admission: - albuterol 90mcg ___ puffs Q4hrs - Renal Caps 1mg daily - Betamethasone dipropionate 0.05% Cream daily - bupropion Hcl 150mg daily - clonazepam 1mg daily PRN - Gabapentin 900mg QHS - Hydromorphone 8mg BID - levothyroxine 125mcg daily - lisinopril 5mg daily - metoprolol succinate 100mg daily - mometasone 0.1% lotion BID - ropinirole 0.25mg QHS - sevelamer 2400mg TID - tiotropium 18mcg 2 puffs daily - trazodone 50mg QHS - Vit C 500mg daily - ASA 81mg daily Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q4H (every 4 hours). 2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. betamethasone dipropionate 0.05 % Cream Sig: One (1) Appl Topical BID (2 times a day). 4. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QAM (once a day (in the morning)). 5. clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for anxiety. 6. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 7. hydromorphone 2 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). 8. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 11. mometasone 0.1 % Cream Sig: One (1) Topical BID (2 times a day). 12. ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 13. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 15. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 18. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 19. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 20. nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY - End Stage Renal Disease on a TuThSa dialysis schedule SECONDARY - Systolic heart failure - Anemia - Chronic ascites and cirrhosis from congestive hepatopathy - Compression fractures, s/p L2-4 fusion causing chronic pain - Hypertension - hypothyroidism - restless leg syndrome - psoriasis - Chronic Obstructive Pulmonary Disease - Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted for evaluation of your weakness and difficulty standing. This was felt to be related to missing your dialysis session and a result of your chronic liver, lung, heart and kidney diseases. You were seen by our physical therapists who felt that you would benefit from rehab, Dr. ___ Dr. ___ agreed as did your family. The following changes were made to your medications: -Start Lactulose 30 mL three times a day Followup Instructions: ___
10808292-DS-11	10,808,292	29,980,567	DS	11	2188-04-25 00:00:00	2188-04-25 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: Dyspnea Major Surgical or Invasive Procedure: EKOS catheter placement with tPA administration History of Present Illness: Mr. ___ is a ___ year-old male with PMH significant for HTN, HLD who presents with 2 days of dyspnea and pre-syncope with imaging showing extensive bilateral acute pulmonary embolism and TTE with right heart strain. Patient had recurrent fevers and fatigue and was admitted to ___ 1 week ago. During that hospitalization, he underwent flu testing that was negative and was found to have elevated troponin. He underwent a negative stress test and was discharged after a 3 day hospitalization. After discharge, he continued to have fevers up to ___. Patient awoke on ___ at 2AM to use the restroom and noted dyspnea and lightheadedness. He felt pre-syncopal and lowered himself to the ground. He did not lose consciousness and denied head strike or trauma. He asked his tenant to call EMS and was taken to ___ with CTA findings of bilateral pulmonary emboli. He was started on IV heparin and transferred to ___ for further evaluation. Patient denies any recent travel, immobility, or prior history of VTE. Has had cramping of left calf over last few days and bilateral lower extremity edema. Denies family history of VTE, history of stroke, trauma, malignancy. In the ED at ___, initial vitals were notable: T 98.3 HR 116 BP 133/83 RR 18 SpO2 93%\|2L O2 - Exam notable for: Uncomfortably appearing, dyspneic. No lower extremity edema. - Labs notable for: 14.7 15.9 >----< 208 43.8 137\|100\|14 ----------< 127 5.3\|21\|0.9 Trop T < 0.01 BNP 2729 Lactate 2.2 - Studies notable for: TTE: Dilated right ventricle with severe RV systolic dysfunction c/w PE on chronic pHTN. Small underfilled LV with normal global and regional LV systolic function. Moderate to severe functional TR. Severe pHTN. ___: DVT within posterior tibial veins of left upper calf. ECG: Sinus rhythm with PACs. Tachycardic. S1, Q3. Incomplete RBBB. Borderline LAD. T wave inversions in V1-V4. - Patient was given: + Heparin gtt - Consults Vascular medicine: Recommended catheter-directed thrombolysis and admission to the CCU. Patient was taken to ___ where EKOS catheters were placed and tPA started w/o complication. On arrival to the CCU, patient confirmed the above history. He has had some intermittent L sided pleuritic chest pain and he has had back pain secondary to lying in the hospital bed. He does not currently feel short of breath. ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative. Past Medical History: PAST MEDICAL HISTORY: Cardiac History: - HTN - HLD Other PMH: - Anxiety Social History: ___ Family History: No known family history of VTE. Father with MI in his ___. Physical Exam: ADMISSION PHYSICAL EXAM: ========================== VS: T98.7 HR 114 BP 135/84 RR 36 91% 3L NC GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. EKOS catheters in place through R IJ. CARDIAC: Tachycardic. No murmurs, rubs, or gallops appreciated. LUNGS: Tachypneic, CTAB ABDOMEN: Soft, non-tender, non-distended. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAM: ========================== VS: 24 HR Data (last updated ___ @ 710) Temp: 97.7 (Tm 99.6), BP: 161/89 (145-175/73-99), HR: 75 (67-88), RR: 18, O2 sat: 98% (94-98), O2 delivery: Ra Fluid Balance (last updated ___ @ 701) Last 8 hours Total cumulative -2520ml IN: Total 480ml, PO Amt 480ml OUT: Total 3000ml, Urine Amt 3000ml Last 24 hours Total cumulative -3002ml IN: Total 2998ml, PO Amt 2020ml, IV Amt Infused 978ml OUT: Total 6000ml, Urine Amt 6000ml GENERAL: comfortable, well appearing, obese. in no acute distress HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. CARDIAC: RRR, no murmurs/rubs/gallops LUNGS: CTAB, normal work of breathing on RA ABDOMEN: Soft, non-tender, non-distended. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. Pertinent Results: ADMISSION LABS: ================= ___ 10:35AM BLOOD WBC-15.9* RBC-5.26 Hgb-14.7 Hct-43.8 MCV-83 MCH-27.9 MCHC-33.6 RDW-14.2 RDWSD-42.5 Plt ___ ___ 10:35AM BLOOD Neuts-73.0* ___ Monos-6.7 Eos-0.1* Baso-0.2 Im ___ AbsNeut-11.60* AbsLymp-3.02 AbsMono-1.06* AbsEos-0.01* AbsBaso-0.03 ___ 10:35AM BLOOD ___ PTT-34.3 ___ ___ 07:30PM BLOOD ___ ___ 10:35AM BLOOD Glucose-127* UreaN-14 Creat-0.9 Na-137 K-5.3 Cl-100 HCO3-21* AnGap-16 ___ 10:35AM BLOOD cTropnT-<0.01 ___ 10:35AM BLOOD proBNP-2729* ___ 07:30PM BLOOD Calcium-8.3* Phos-3.3 Mg-2.1 ___ 02:01PM BLOOD Lactate-2.2* NOTABLE INTERVAL LABS: ======================== ___ 09:56AM BLOOD ALT-41* AST-19 LD(LDH)-292* AlkPhos-80 TotBili-0.7 ___ 06:03AM BLOOD %HbA1c-6.0 eAG-126 DISCHARGE LABS: ===================== ___ 05:50AM BLOOD WBC-8.0 RBC-4.57* Hgb-12.7* Hct-39.3* MCV-86 MCH-27.8 MCHC-32.3 RDW-13.9 RDWSD-43.1 Plt ___ ___ 05:50AM BLOOD ___ PTT-75.3* ___ ___ 05:50AM BLOOD Glucose-136* UreaN-11 Creat-0.8 Na-141 K-5.0 Cl-100 HCO3-31 AnGap-10 ___ 05:50AM BLOOD Calcium-9.0 Phos-5.6* Mg-2.2 IMAGING/STUDIES: ==================== BILAT LOWER EXT VEINS Study Date of ___ 11:50 AM DVT suspected within the posterior tibial veins of the left upper calf. Otherwise negative PULMONARY ARTERIOGRAM Study Date of ___ 1:58 ___ FINDINGS: 1. The access right basilic vein was patent and compressible. 2. Basilic Vein approach double-lumen right PICC with tips in the distal SVC. 3. Placement of 6cm EKOS catheter into the left pulmonary artery 4. Placement of 12cm EKOS catheter into the right pulmonary artery For reporting clarification, diagnostic arteriograms were medically necessary to evaluate for anatomy, abnormal vasculature, and the presence or absence of thrombus, active bleeding, pseudoaneurysms, and or arteriovenous fistula. IMPRESSION: Successful placement of a right 41 cm basilic approach single lumen PowerPICC with tip in the distal SVC. The line is ready to use. Technically successful placement of 6cm EKOS catheter into the left pulmonary artery. Technically successful placement of 12cm EKOS catheter into the right pulmonary artery. Both catheters were infused each at a rate of 0.75 milligrams/hour of tPA for a total of 16 hours for a total doses of 24 mg of tPA. Improvement of bilateral mean pulmonary pressures from 56mmHg pre-treatment to 27mmHg post-treatment. CHEST (PORTABLE AP) Study Date of ___ 7:06 ___ Status post bilateral pulmonary artery catheter placements. PICC line terminating in the lower superior vena cava. Otherwise, no significant change. Transthoracic Echocardiogram Report ___ 24:00 Dilated right ventricle with severe RV systolic dysfunction, most c/w acute pulmonary embolism on the background of chronic pulmonary hypertension. Small, underfilled LV with normal global and regional left ventricular systolic function. Moderate to severe functional tricuspid regurgitation. Severe pulmonary hypertension. MICROBIOLOGY: ================= ___ 10:50 am URINE *FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. Brief Hospital Course: Mr. ___ is a ___ year-old male with PMH significant for HTN, HLD who presented with 2 days of dyspnea and pre-syncope found to have extensive bilateral acute submassive pulmonary embolism and TTE with right heart strain. He underwent catheter-directed thrombolysis with significant improvement in symptoms. He was then bridged to warfarin with heparin gtt. #CORONARIES: Unknown #PUMP: EF 60-65%. Severe RV systolic dysfunction with dilated RV. #RHYTHM: sinus tachycardia ACUTE ISSUES: ============= # Acute submassive pulmonary embolism with RV systolic dysfunction: # Acute hypoxic respiratory failure: Patient developed acute bilateral submassive pulmonary embolisms w right heart strain. No recent travel, family history of VTE. Given evidence of severe RV systolic dysfunction, he underwent catheter-directed thrombolysis and initiation of heparin gtt with bridge to warfarin. He was therapeutic on discharge with INR 2.9. DOACs and lovenox avoided due to patient's obesity. He will likely need at least 6 months of anticoagulation with warfarin given BMI. He will be scheduled to follow up with Dr. ___ in vascular medicine. He will be set up with the ___ clinic for INR checks as he plans on transitioning his primary care to ___ his next INR check should be on ___. # Severe pulmonary hypertension # untreated OSA # morbid obesity Likely chronic underlying undiagnosed severe pulmonary hypertension. Potential etiologies include Group 3 given patient's untreated OSA, Group 4 due to possible chronic thromboembolic disease. Should have outpatient follow up for pulmonary hypertension workup and management of OSA. He was care-connected with the sleep medicine clinic so that he can undergo a sleep study and be initiated on CPAP treatment. He also expressed desire to follow with a nutritionist to help him with weight loss and should be referred to one as an outpatient as appropriate. # HTN Had been hypertensive to 150-160s on home lisinopril 5mg. Uptitrated home lisinopril to 20mg daily. # HLD Continued home pravastatin 40mg daily #acute gout flare Pt complaining of acute R MTP pain that he attributes to his gout and for which he takes colchicine PRN. He was loaded with colchicine 1.8mg on ___, with plan to complete 10 day course of colchicine 0.6mg BID to end on ___. #prediabetes A1c 6.0% - he was counseled on exercise and diet for weight loss and should be considered for metformin initiation as an outpatient. TRANSITIONAL ISSUES: ===================== [ ] Discharged with warfarin 5mg daily, INR on ___ was 2.9. He will be setup with the ___ clinic for INR checks. He should have his next INR checked on ___. [ ] He will be followed in vascular medicine clinic with Dr. ___ at ___ for bilateral pulmonary emboli. [ ] Pt with severe underlying pulmonary hypertension. Should undergo outpatient workup with pulmonology. [ ] Pt likely has underlying and untreated OSA. Should have sleep study and initiation. [ ] Pt started on colchicine 0.6mg BID for acute gout flare. Total 10 day course to end on ___. [ ] A1c 6.0% - prediabetic. Recommend nutrition counseling as outpatient for weight loss. Consider initiating metformin [ ] Please continue to titrate antihypertensives, he was discharged with lisinopril 20mg daily. He should have a BMP check along with his INR check a week after discharge. [ ] Patient takes clonazepam 1mg TID as needed for anxiety as prescribed by his current PCP ___ in ___. He last received 90 tabs of clonazepam on ___ per MassPMP check. [ ] Please continue to support smoking cessation efforts #CODE: Full Code (confirmed) #CONTACT/HCP: ___ (father) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY 2. Pravastatin 40 mg PO QPM 3. Nicotine Patch 21 mg/day TD DAILY 4. ClonazePAM 1 mg PO TID:PRN anxiety Discharge Medications: 1. Warfarin 5 mg PO DAILY16 RX warfarin 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Colchicine 0.6 mg PO BID RX colchicine 0.6 mg 1 tablet(s) by mouth twice daily Disp #16 Tablet Refills:0 3. Lisinopril 20 mg PO DAILY RX lisinopril 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 4. ClonazePAM 1 mg PO TID:PRN anxiety 5. Nicotine Patch 21 mg/day TD DAILY 6. Pravastatin 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Submassive pulmonary embolism with right heart strain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you during your stay at ___. WHY WAS I HERE? -You had pulmonary embolisms (blood clots) in both your lungs which was straining your heart WHAT WAS DONE WHILE I WAS HERE? - You were given a powerful blood thinner through special catheters directed to the blood clots in your heart to help break them up - You were started on a blood thinner called warfarin (Coumadin) to help prevent any further clot from forming - You were started on colchicine for your gout flare and will need to continue taking this for another week - You improved and were ready to go home. WHAT SHOULD I DO WHEN I GO HOME? - You should continue to take your blood thinner (warfarin) as directed; you will need to have regular blood checks to help direct the dosing of this medication. You will need to take this for at least 6 months after leaving the hospital. - You will be scheduled with an appointment with Dr. ___ in the ___ Medicine Clinic. - You should see a sleep medicine doctor and wear your CPAP machine. - You should see a ___ and work on weight loss. - You should see a primary care doctor regularly and ___ set you up with a new primary care physician at ___ Associates - If you have any chest pain, shortness of breath, trouble breathing when you are exerting yourself, or any other new or worsening symptoms that concern you - please call your doctor and go to an emergency room. We wish you the best! -Your ___ Care Team Followup Instructions: ___
10808848-DS-12	10,808,848	25,986,133	DS	12	2165-10-28 00:00:00	2165-10-29 16:27:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Splenic cyst Major Surgical or Invasive Procedure: ___: Laparoscopy-assisted splenectomy History of Present Illness: This is a ___ year old lady with left pleuritic chest pain x ___ weeks found on imaging to have 10.3 cm splenic cyst. She originally presented to an OSH after having ___ left pleuritic chest pain. An elevated D-dimer prompted a CTA chest which was negative, but incidentally was found to have a splenic cyst. A CT abdomen with contrast was performed and demonstrated a large splenic cyst measuring 10.3 cm. Surgical consultation recommended transfer to ___ for further management. She has had associated nausea and NB/NB emesis x1. Of note, she reports increased shortness of breath over the past month and has been seen by a cardiologist at ___. Her SOB was attributed to severe mitral regurgitation and she was being planned for surgical repair in ___. She was in ___ hiking about a month ago when her shortness of breath was first noticed, but she was staying in hotels. She has had no other recent travel. Denies fevers, chills, diarrhea, BRBPR, hematemesis, dyspnea, rash, skin changes, or jaundice. Past Medical History: Past Medical History: -Mitral valve prolapse (on quinapril) -Severe mitral regurgitation scheduled for repair in ___ -H. pylori treated ___ -Strongyloides with ivermectin x2 in ___ -Lyme ___ -IBS with chronic constipation since childhood -H/o BRBPR s/p colonoscopy ___ (negative) -Seasonal allergies -Asthma Past Surgical History: -C-section x 1 -Umbilical hernia repair -Ovarian cyst excision (benign per patient) Social History: ___ Family History: There is no celiac sprue, colitis or Crohn's. There is no rheumatoid or lupus, diabetes or thyroid in the family. There is no colon cancer. Her mother has hypertension and osteoarthritis and her father has osteoarthritis. Physical Exam: VS: Temp 98.9, HR 101, BP 129/84, RR 16, SpO2 98% RA GEN: AA&O x 3, NAD, calm, cooperative. HEENT: (-) LAD, mucous membranes moist, trachea midline, EOMI, PERRL. CHEST: Clear to auscultation bilaterally, no increased work of breathing noted. ABDOMEN: Soft, mildly tender to palpation incisionally, non-distended. Incisions: clean, dry and intact without surrounding erythema or fluctuance, closed with staples. EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema. Pertinent Results: SPLENIC ULTRASOUND (___): Complex cystic necrotic mass in the spleen. The differential remains broad including tumor is as well as parasitic cysts. CHEST X-RAY (___): Lungs are grossly clear. There is minimal blunting of the right CP angle, however this area appears unremarkable on the lateral view. Heart size is normal. Bony structures are intact. Brief Hospital Course: Ms. ___ was initially admitted to the Medicine Service on ___ for workup of her left upper quadrant pain that was associated with pleurisy. In her initial evaluation, a chest CTA was performed at an outside hospital, which was negative for a pulmonary embolism, but did show a 10.3 cm heterogeneous LUQ (presumed splenic) mass with internal septation, displacing the tail of pancreas anteriorly. A surgical consult was obtained and the decision was made to transfer the patient to the Acute Care Surgical service for further management. Cardiology and Infectious Disease were also consulted, the former for surgical planning in relation to the patient's severe mitral regurgitation and the latter for question that this mass could be an echinococcal cyst. She was started on albendazole on hospital day 3. The patient was taken to the operating room on ___ for a laparoscopy-assisted splenectomy (please see the Operative Report for further details). The splenic contents were sent for pathology. At the time of discharge, the splenic pathology had returned and was negative for echinococcus, so albendazole was stopped. On the day of discharge, the patient was given post-splenectomy vaccines (Prevnar 13, Menactra and Hib conjugate) and discharged with appropriate follow-up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Quinapril 10 mg PO DAILY Discharge Medications: 1. Quinapril 10 mg PO DAILY 2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain You may not drive while taking Oxycodone pain medication. RX oxycodone 5 mg ___ tablet(s) by mouth every four hours Disp #30 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 4. Levofloxacin 750 mg PO Q24H Duration: 5 Days Please take this medication only if you spike a fever (>100.4 F) at home. RX levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily Disp #5 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Splenic cyst s/p splenectomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ with a cyst in your spleen. While you were here, we removed your spleen and gave you the appropriate post-splenectomy vaccinations. You have now recovered well from your procedure and are ready to continue your recovery at home. Please follow the instructions below to ensure a safe and speedy 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. Additionally, please follow up with your primary care physician within two weeks of discharge. We will send you with a prescription for an antibiotic called levofloxacin. Please take this only if you spike a fever with a temperature greater than 100.4 F. Best wishes, Your surgical team Followup Instructions: ___
10808848-DS-14	10,808,848	27,124,577	DS	14	2169-12-29 00:00:00	2169-12-29 13:11:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: gluten Attending: ___ Chief Complaint: vertigo, abnormal imaging Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ year old right handed woman with a history of metastatic angiosarcoma as well as mitral regurgitation for whom a Neurology consultation is requested due to findings of an acute infarct on MRI. Her history begins yesterday evening. She states she otherwise had a normal day and was able to exercise, go to work, and drive home without any difficulty. She returned home at about 6:30pm. Shortly after walking into the house and putting down her things, she noticed the onset of room spinning vertigo. She describes this as coming on gradually over about 5 minutes. She notes that the vertigo was generally mild and at first she did not think much of it but did feel generally unwell. Vertigo was made worse by head movement, but only for a second or two, and she reports a constant level of mild vertigo. She also experienced a gradual onset of a feeling of tightness in a band across her chest. There was no associated dyspnea. She thought she had not slept enough over the past few days, so lied down on the couch. She asked her husband to go any buy a blood pressure cuff, as she was worried her blood pressure may be too high. When he returned, her symptoms had not abated, so she presented to the ED around 8pm last night. In the ED, she notes that she experienced a few other symptoms, including some nonrhythmic, asynchronous or alternating movements of her limbs, mostly her legs as well as a sensation as if the lights were dimmed, a darkness sensation (she denies a loss of vision), a feeling of tightness in her throat, and occasional nausea without vomiting. She also noted that when undergoing a neurologic exam by the ED team, she felt that the right side of her body felt "colder" when touched compared to the left. Finally she does endorse occasional "difficulty speaking", though clarifies that this was more due to her Initial vital signs in the ED were notable for a BP of 172/103, though subsequent blood pressures have been normal. She underwent a CTA of the chest/abdomen/pelvis, which showed numerous pulmonary metastases, new from earlier this year. She also underwent an MRI of the brain w/ and w/o contrast given concern for metastatic disease. This showed a small acute ischemic stroke in the left mesial temporal lobe, prompting Neurology consult. On my evaluation, she reports that her vertigo has essentially resolved, and she has been able to walk around without any difficulty. Throughout this episode she denies any headache, neck ache, fever, chills, slurred speech, difficulty comprehending or producing speech, confusion, loss of consciousness, tinnitus, hearing loss, dysarthria, dysphagia, facial droop, weakness, or other sensory change. Past Medical History: Past Medical History: -Splenic angiosarcoma -Mitral valve prolapse (on quinapril, followed by Dr. ___ at ___ -Severe mitral regurgitation -H. pylori treated ___ -Strongyloides with ivermectin x2 in ___ -IBS with chronic constipation since childhood -Seasonal allergies -Ovarian cyst (noted incidentally on PET) Surgical History Resection of angiosarcoma diaphragm recurrence Splenectomy Social History: ___ Family History: Maternal grandfather had a stroke in his ___. Both parents have hypertension. Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vitals: T: 98.7 BP: 126/86 HR: 78 RR: 17 SaO2: 97% 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: Normal work of breathing. Cardiac: warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No ___ edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. No dysarthria. Able to follow both midline and appendicular commands. 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 4 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk and tone throughout. No pronator drift. No adventitious movements, such as tremor or asterixis noted. [___] L 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, temperature, vibration, or proprioception throughout. No extinction to DSS. Romberg absent. -Reflexes: [Bic] [Tri] [___] [Pat] [Ach] L 2 2 2 2 2 R 2 2 2 2 2 She did occasional seem to "jump" when reflexes were tested, but this seemed more of a voluntary movement. No pathologic reflexes were present. Plantar response was flexor bilaterally. -Coordination: No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. ___ maneuver not attempted as she is no longer complaining of vertigo. DISCHARGE PHYSICAL EXAM ======================= 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: Normal work of breathing. Cardiac: warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No ___ edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive. Language fluent no paraphasic errors. Able to follow both midline and appendicular commands. -Cranial Nerves: II, III, IV, VI: PERRL 4 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk and tone throughout. No pronator drift. No adventitious movements, such as tremor or asterixis noted. [___] L 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch throughout. No extinction to DSS. -Coordination: No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. Pertinent Results: ADMISSION LABS ============== ___ 07:45PM BLOOD WBC-6.8 RBC-4.03 Hgb-11.9 Hct-35.4 MCV-88 MCH-29.5 MCHC-33.6 RDW-13.9 RDWSD-44.8 Plt ___ ___ 07:45PM BLOOD Neuts-46.2 ___ Monos-12.7 Eos-7.4* Baso-1.2* Im ___ AbsNeut-3.14 AbsLymp-2.18 AbsMono-0.86* AbsEos-0.50 AbsBaso-0.08 ___ 07:45PM BLOOD Plt ___ ___ 07:45PM BLOOD ___ PTT-30.2 ___ ___ 07:45PM BLOOD Glucose-120* UreaN-19 Creat-0.6 Na-138 K-4.2 Cl-99 HCO3-24 AnGap-15 ___ 07:45PM BLOOD ALT-18 AST-33 AlkPhos-82 TotBili-0.3 ___ 07:45PM BLOOD cTropnT-<0.01 ___ 11:49PM BLOOD cTropnT-<0.01 ___ 07:45PM BLOOD Albumin-4.4 DISCHARGE LABS ============== ___ 04:45AM BLOOD WBC-5.3 RBC-3.96 Hgb-11.6 Hct-35.2 MCV-89 MCH-29.3 MCHC-33.0 RDW-13.9 RDWSD-45.5 Plt ___ ___ 04:45AM BLOOD Plt ___ ___ 04:45AM BLOOD Glucose-94 UreaN-12 Creat-0.6 Na-140 K-4.7 Cl-102 HCO3-27 AnGap-11 ___ 04:45AM BLOOD Calcium-9.9 Phos-4.6* Mg-1.9 IMAGING ======= MR HEAD W & W/O CONTRAST Study Date of ___ IMPRESSION: 1. 5 mm diffusion-weighted hyperintense signal in the left medial temporal lobe without evidence of abnormal enhancement, suggesting acute infarct. No findings to suggest intracranial metastatic disease at this time. 2. Focal enlargement of the right trigeminal nerve expanding the right foramina ovale, in retrospect unchanged since examination of ___. This may represent a nerve sheath tumor. Recommend follow-up examination in ___ months to document stability. 3. Additional findings described above. CTA HEAD AND CTA NECK Study Date of ___ IMPRESSION: 1. Known tiny left temporal lobe infarct is not appreciated. 2. Normal head and neck CTA. 3. Possible right trigeminal nerve schwannoma is better assessed on preceding MRI. 4. Lung findings more fully characterized on same day chest CT. CTA CHEST Study Date of ___ IMPRESSION: 1. No pulmonary embolism or acute aortic abnormality. 2. Numerous bilateral pulmonary metastases. 3. Prominent right periaortic lymph nodes, recommend attention on follow-up. ___ TTE IMPRESSION: Mild bileaflet mitral valve prolapse with moderate late systolic mitral regurgitation. Mild symmetric left ventricular hypertrophy with normal cavity size, and regional/global systolic function. Mild tricuspid regurgitation. Compared with the prior TTE ___ , the degree of tricuspid regurgitation is now less. Brief Hospital Course: Ms ___ is a ___ year old woman with a past medical history of splenic angiosarcoma and mitral regurgitation who presented to the ED with vertigo, chest tightness. Found to have new ischemic stroke and pulmonary metastases. #Left medial temoral lobe ischemic stroke: Initial NIHSS was 0. History notable for cycling-like movements of her extremities which were suppressible and resolved prior to Neuro evaluation. Exam remained normal throughout admission and vertigo was resolved by the time of neurology assessment. MRI was initially obtained to evaluate for metastatic disease, and instead showed a small ischemic stroke in the left medial temporal lobe. Vessels were patent with no atherosclerotic burden on CTA imaging. TTE with no thrombus or PFO. Risk factors notable for HbA1c of 5.6, LDL of 116. Etiology concerning for hypercoagulability in setting of malignancy (potentially basilar thrombus that resolved given transient symptoms of brainstem ischemia such as vertigo/nausea, right-sided sensory problems, bilateral leg movements, and odd visual sensations such as dimming of the lights, possibly suggesting a bilateral PCA problem) versus cardioembolic. In that context, it is important that the small ischemic stroke in the left messiah temporal lobe is suggestive of a small embolus that travelled into the left PCA. Per discussion with outpatient oncologist (Dr. ___ ___, decision made to initiate lovenox for secondary stroke prophylaxis. Also initiated atorvastatin 40mg qhs. She will be discharged with a zio patch to monitor for atrial fibrillation. #Splenic angiosarcoma with new pulmonary metastases: Presented with chest tightness of unclear etiology. CTA chest revealed multiple bilateral pulmonary metastases. Outpatient oncologist aware, reviewing scans at sarcoma conference, will see in clinic the next several days to discuss next steps for management. Visited patient prior to her discharge. #HTN: Continued home quinapril. #Hypothyroidism: Continued home ___ thyroid. TRANSITIONAL ISSUES =================== [] initiated lovenox, atorvastatin for stroke management [] f/u Zio patch to monitor for atrial fibrillation, consider transition from lovenox to apixaban if afib identified =============== AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed () No. If no, reason why: 2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not (I.e. bleeding risk, hemorrhage, etc.) 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No. If not, why not? (I.e. bleeding risk, hemorrhage, etc.) 4. LDL documented? (x) Yes (LDL = 116 ) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: () Antiplatelet - (x) Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - (x) No - If no, why not (I.e. bleeding risk, etc.) (x) N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Quinapril 10 mg PO DAILY 2. Thyroid 60 mg PO QAM 3. Thyroid 30 mg PO QPM Discharge Medications: 1. Atorvastatin 40 mg PO QPM RX atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:6 2. Enoxaparin Sodium 60 mg SC BID RX enoxaparin 60 mg/0.6 mL 1 twice a day Disp #60 Syringe Refills:8 3. Quinapril 10 mg PO DAILY 4. Thyroid 60 mg PO QAM 5. Thyroid 30 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Ischemic stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ were hospitalized due to symptoms of vertigo resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed ___ for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: -Hyperlipidemia -malignancy We are changing your medications as follows: -Start Lovenox -start atorvastatin Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If ___ experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to ___ - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___
10808848-DS-15	10,808,848	20,726,077	DS	15	2170-06-22 00:00:00	2170-06-23 07:36:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: gluten Attending: ___ Chief Complaint: dizziness, buzzing sound in ears Major Surgical or Invasive Procedure: none History of Present Illness: ___ female right-handed with a history of metastatic angiosarcoma currently undergoing chemo for metastatic disease, MR, and recent ischemic stroke in ___ felt due to hypercoagulability of malignancy on Xarelto who presented with persistent dizziness since awaking in the morning. Patient says that she was in her usual state of health on ___ other than mild right ear pain that was new. She awoke in the morning with new disequilibrium sensation. She denies any room spinning vertigo but says it feels like she is on a ship. She also noticed a new buzzing in her ears that was not present prior in addition to the continued right ear pain. She feels like she is a pressure behind her ears. Buzzing is constant and does not fluctuate. Disequilibrium has wax and wane but has not completely gone away since it started. It worsens when she changes positions. She said a little bit of nausea but no vomiting. She has been able to walk but just feels like she needs to be more careful when she does. She has not had any falls. She denies any fever or upper respiratory infection symptoms But she did use Afrin due to the ear pressure but without any relief. She has been taking her Xarelto regularly and has not missed any doses. She denies any palpitations. Her chemotherapy was recently put on hold due to a nail infection. She last received chemo about 7 weeks ago. On neuro ROS, pertinent positives in HPI, currently the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, 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, positives in HPI, 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: -Splenic angiosarcoma, recent pulmonary metastatic disease currently on chemotherapy though has been on hold for around 7 weeks -Mitral valve prolapse (on quinapril, followed by Dr. ___ at ___ -Severe mitral regurgitation -H. pylori treated ___ -Strongyloides with ivermectin x2 in ___ -IBS with chronic constipation since childhood -Seasonal allergies -Ovarian cyst (noted incidentally on PET) Surgical HX Resection of angiosarcoma diaphragm recurrence Splenectomy Social History: ___ Family History: Maternal grandfather had a stroke in his ___. Both parents have hypertension. Physical Exam: Admission Physical Exam: Vitals: 96.4, HR 87, BP 114/77, RR16, 98% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx, ___ with good light reflex, no injection or obvious fluid Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Normal work of breathing Cardiac: RRR, warm, well-perfused Abdomen: soft, non-distended Extremities: No ___ edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall ___ at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. Coarse left beating nystagmus with left gaze that does not extinguish, fine right beating nystagmus with right gaze that does extinguish, normal saccades. No skew with cover-uncover, has a corrective saccade with head impulse to the left, VFF to confrontation. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages in right eye was unable to view fundus in the left eye. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ L 5 ___ 5 5 5 5 5 5 5 R 5 ___ 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. Romberg absent. -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. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. Mild left sided rebound, left overshoot with mirroring -Gait: Good initiation. mildly wide based, mildly unsteady. Negative Romberg, attempts tandem gait but has to grab on to the wall Discharge physical exam General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted Pulmonary: Normal work of breathing Cardiac: warm, well-perfused Extremities: No ___ edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, speaking fluently, answering questions appropriately -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. VFF to confrontation. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad Ham TA ___ L 5 ___ 5 5 5 5 5 5 R 5 ___ 5 5 5 5 5 5 -Sensory: No deficits to light touch. Romberg absent. -Coordination: No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF. -Gait: Good initiation. Some difficulty with tandem gait. Pertinent Results: ADMISSION LABS ___ 12:20AM BLOOD WBC-4.9 RBC-3.80* Hgb-10.7* Hct-33.8* MCV-89 MCH-28.2 MCHC-31.7* RDW-15.9* RDWSD-52.2* Plt ___ ___ 12:20AM BLOOD Glucose-117* UreaN-16 Creat-0.6 Na-139 K-4.2 Cl-100 HCO3-25 AnGap-14 ___ 12:20AM BLOOD ALT-17 AST-23 AlkPhos-74 TotBili-0.2 ___ 09:19AM BLOOD Albumin-4.1 Calcium-9.7 Phos-4.2 Mg-1.8 Cholest-127 ___ 09:19AM BLOOD %HbA1c-5.1 eAG-100 ___ 09:19AM BLOOD Triglyc-38 HDL-64 CHOL/HD-2.0 LDLcalc-55 ___ 09:19AM BLOOD TSH-0.06* ___ 09:19AM BLOOD Free T4-0.9* ___ 12:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG MRI BRAIN ___. No acute intracranial abnormality on contrast enhanced MRI brain. 2. Unchanged focal enlargement of the right trigeminal nerve within the foramen ovale since ___, possibly representing a nerve sheath tumor. CTA HEAD AND NECK 1. Normal CTA of the head and neck. 2. No CT evidence of acute intracranial abnormality. Brief Hospital Course: ___ with a history of angiosarcoma s/p splenectomy with metastatic disease to the lungs currently on chemotherapy (last dose ___, prior ischemic stroke in the L mesial temporal region likely due to hypercoagulability of malignancy who presented with new disequilibrium, 'buzzing' in both ears, and ear pressure. Initial concern for stroke given that her history of malignancy and L mesial temporal stroke (that presentation was vertigo, chest tightness, seeing darkness in her vision). Her initial exam had concern for central nystagmus with pathologic gaze evoked nystagmus on the left. However, this time her exam was reassuring without focal findings. CT head and CTA head/neck showed no acute findings. MRI brain showed no acute intracranial abnormality. Her symptoms were likely due to a peripheral process such as vestibular neuritis. She was continued on home medications including xarelto and atorvastatin. Her oncology team was updated. She was ordered for outpatient ___ for peripheral vestibulopathy and gait training. Given the unchanged R CN V enlargement within the foramen ovale seen on previous scans possibly representing nerve sheath tumor, she was advised to f/u with Neurosurgery in clinic. MRI BRAIN ___ 1. No acute intracranial abnormality on contrast enhanced MRI brain. 2. Unchanged focal enlargement of the right trigeminal nerve within the foramen ovale since ___, possibly representing a nerve sheath tumor CT CTA HEAD ___ CT HEAD WITHOUT CONTRAST: There is no evidence of infarction,hemorrhage or edema. Previously seen possible right trigeminal nerve enlargement possibly representing a schwannoma is not well assessed on this study. The ventricles and sulci are normal in size and configuration for age. The visualized portion of the paranasal sinuses, mastoid air cells,and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. CTA NECK: The carotidandvertebral arteries and their major branches appear normal with no evidence of stenosis or occlusion. There is no evidence of internal carotid stenosis by NASCET criteria. Dental amalgam limits assessment of the oropharynx. OTHER: Right chest port catheter noted in partially visualized. The visualized portion of the lungs are essentially clear. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. Normal CTA of the head and neck. 2. No CT evidence of acute intracranial abnormality. TRANSITIONAL ISSUES ------------------- []Given the unchanged R CN V enlargement within the foramen ovale seen on previous scans possibly representing nerve sheath tumor, she was advised to f/u with Neurosurgery in clinic. []Utox pending at time of discharge and needs to be followed up []TSH and free T4 were low during this hospitalization. Would need outpatient follow up. Medications on Admission: Xarelto 20mg Qpm Atorvastatin 40 mg nightly Dexamethasone 4 mg with chemotherapy, Zofran 8 mg p.o. every 8 hours as needed Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. Rivaroxaban 20 mg PO/NG QPM with dinner 3.Outpatient Physical Therapy H81.23 VESTIBULAR NEURITIS Provider ___: ___ Discharge Disposition: Home Discharge Diagnosis: vestibular neuritis dizziness history of angiosarcoma s/p splenectomy history of ischemic stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms ___, You presented to ___ because you were having symptoms of dizziness and a buzzing sound in your ears. While in the hospital, you had a CT scan of your head, which showed no acute stroke. Imaging of your blood vessels was also reassuring. You received a brain MRI which showed no acute findings. It did show an enlargement of one of your nerves, and for this we recommend that you follow up with neurosurgery in clinic after discharge. Overall, the cause for your symptoms is unclear, but is most likely vestibular neuritis. This is an inflammation/viral response in the inner ear which can cause dizziness, ringing in the ears and ear pain. This should gradually improve over time with supportive care. Please make sure you are well hydrated and continue physical activity as tolerated. We have placed an order for outpatient physical therapy. Please try to get this done to make sure your walking is secure. We will keep your medications the same. We also will update your oncologist about this admission. It was a pleasure taking care of you. We wish you the best, Your ___ team Followup Instructions: ___
10808949-DS-8	10,808,949	25,233,419	DS	8	2150-02-11 00:00:00	2150-02-24 15:58:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: naproxen / Plavix / Rofecoxib / fluoxetine Attending: ___. Chief Complaint: Somnolence, fluctuating mental status Major Surgical or Invasive Procedure: None History of Present Illness: The patient presented to ___ at ___ on ___ due to SOB and audible wheezes. The patient has a h/o COPD and is on 2 L NC at home. During this episode of dyspnea, the patient was 96% on his baseline 2L. The patient also c/o slurred speech, which he attributed to a swollen tongue. According to the notes, the patient recently started a new medication, which he said was Chantix three days prior. The patient was also recently diagnosed with Parkinsonism and is on Sinemet at home. The patient was also complaining of increased visual hallucinations at home prior to presentation. At ___, the patient had an ABG that was 7.36/47/142/26 on 4L NC. He was given 125mg Solumedrol, Duoneb, Levaquin 750mg. His saturations remained in the high ___ on 2L NC. During the ED stay at ___, the patient took off all of his EKG leads and wanted to leave, but was easily redirected. By ___, it was reported that the patient's tongue swelling had improved. The patient was transfered to ___ due to altered mental status and neurology consult. During transport, the patient continued to have visual hallucinations and was repsonding to internal stimuli, which the patient says was baseline for him. He was not distressed by these. . At ___, initial VS were 98.8, 112/71, 79, 20, 96% RA. He triggered for 2 episodes of unresponsiveness even to sternal rub. On exam, at first incredibly somnolent, slurred speech, tongue fasciculations, otherwise CN II-XII intact; strength ___ throughout w/e/o L leg foot drop; lungs exp wheezing bilat. ? myoclonic jerks. Awoke spontaneously after minutes. Lactate normal, ABG 7.37/46/62/28. Normal head CT. Utox negative. Given narcan with no change in mental status. . On arrival to the MICU, the patient was initially difficult to arouse. Once awoken, the patient was appropriate, following commands, and logical. The patient says that he doesn't remember much of what happened today, but notes that it started this AM with some SOB and then increasing visual hallucinations. He says that he has had these hallucinations for ___ weeks, which he describes as seeing people whom he knows and he has conversations with. These are nonthreatening hallucinations. The patient also notes some orthostasis, especially dizziness when he arises from bed in the AM. He complains of tremor, both at rest and with movement, which he says has gotten better since starting Sinimet. He denies rigidity or gait disturbance. No urinary symptoms. He notes dry mouth, but little tongue swelling now. . Review of systems: (+) Per HPI, otherwise unable to be elicited by patient Past Medical History: Past Medical History: left foot drop s/p surgery in ___ chronic back pain anxiety depression COPD on 2L NC at home HTN degenerative disk disease Past Surgical History: CABG with aneurysm repair ___ Appendectomy Subclavian stenting ___ knee surgeries ___ Social History: ___ Family History: Mother: ___ disease with ___ Body features Father: killed by a drunk driver, but previously was healthy w/ thyroid disease Sister: thyroid disease Physical Exam: ADMISSION EXAM: Vitals: T: 97.9 BP: 113/61 P: 75 R: 18 O2: 99% RA General: Once arousable, AOx2, no hallucinations now, able to carry on logical conversation HEENT: Sclera anicteric, dry MM, dry tongue, non-swollen, no dysarthria, PERRLA Neck: obese, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: distant breath sounds, end-expiratory wheezes Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, has brace on left foot due to foot drop Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 1+ biceps reflex, unable to elicit other reflexes, gait deferred, finger-to-nose intact, some resting arm and chin tremor, but normal cerebellar function DISCHARGE EXAM: On discharge he is awake and alert, oriented x3, denies hallucinations. Neuro exam intact. Pertinent Results: ADMISSION LABS: ___ 04:27PM BLOOD WBC-7.2 RBC-4.41* Hgb-13.3* Hct-39.2* MCV-89 MCH-30.2 MCHC-34.0 RDW-12.3 Plt ___ ___ 04:27PM BLOOD Neuts-90.9* Lymphs-8.3* Monos-0.3* Eos-0.3 Baso-0.2 ___ 04:27PM BLOOD ___ PTT-32.7 ___ ___ 04:27PM BLOOD Glucose-182* UreaN-24* Creat-1.4* Na-139 K-3.6 Cl-101 HCO3-24 AnGap-18 ___ 04:27PM BLOOD ALT-12 AST-12 AlkPhos-114 TotBili-0.2 ___ 04:27PM BLOOD Lipase-24 ___ 04:27PM BLOOD Calcium-9.4 Phos-1.9* Mg-2.0 ___ 04:27PM BLOOD VitB12-417 ___ 04:27PM BLOOD TSH-0.82 ___ 04:27PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 05:49PM BLOOD Type-ART pO2-62* pCO2-46* pH-7.37 calTCO2-28 Base XS-0 Intubat-NOT INTUBA ___ 04:25PM BLOOD Lactate-2.9* ___ 05:57PM BLOOD Lactate-3.0* ___ 04:23AM BLOOD Lactate-1.8 DISCHARGE LABS: ___ 08:05AM BLOOD WBC-13.2* RBC-4.35* Hgb-13.1* Hct-38.1* MCV-88 MCH-30.2 MCHC-34.4 RDW-12.8 Plt ___ ___ 08:05AM BLOOD Glucose-88 UreaN-23* Creat-1.2 Na-144 K-4.0 Cl-107 HCO3-29 AnGap-12 ___ 08:05AM BLOOD Calcium-9.4 Phos-2.9 Mg-2.0 MICRO DATA: ___ RAPID PLASMA REAGIN TEST: Negative ___ BLOOD CULTURE: No growth IMAGING: ___ CT HEAD W/O CONTRAST No acute intracranial process. ___ CHEST (SINGLE VIEW) Mild bibasilar atelectasis. Low lung volumes. Blunting of the left costophrenic angle may be due to overlying soft tissue although a small left pleural effusion cannot be excluded. No definite focal consolidation. Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: Mr. ___ is a ___ gentleman with COPD, CAD s/p distant CABG, depression, anxiety, smoking, and recent dx of Parkinsonism who presented from ___ for neurological evaluation given increasing somnolence and visual hallucinations. ACTIVE ISSUES: #. AMS with hallucinations: The etiology of his AMS and hallucinations is not clear. His fluctuating consciousness on admission with non-threatening hallucinations could be c/w a neurologic process such as ___ Body dementia although he did not have the characteristic motor findings. The neurology service was consulted and felt his hallucinations were most likely ___ polypharmacy vs hypoxia from his underlying lung disease. His sinemet was discontinued as neurology felt he had no s/sx ___ disease. His alprazolam, loratidine, oxycodone, amitriptyline, and gabapentin were held. His hallucinations resolved and mental status cleared. On discharge, it was recommended that he continue to hold these medications and follow up with his PCP and an outpatient neurologist for further evaluation. CHRONIC ISSUES: # COPD: The patient has a long hx of COPD and is a chronic smoker. He remained at his baseline O2 requirement of 2L throughout hospitalization, and ABG was wnl. he was continued on his home inhalers. # CAD s/p CABG: He was continued on his home ASA and statin. # HTN: He was continued on his home lisinopril and nifedipine. TRANSITIONAL ISSUES - The following medications were discontinued: Sinimet, chantix, ropinirole, alprazolam, loratidine, oxycodone, amitriptyline, and gabapentin. - He was scheduled to follow up with his PCP after discharge. It was recommended that he ask his PCP about referral to a neurologist in his area. Medications on Admission: Aspirin 81mg Qday Bisoprolol and HCTZ ___ Qday Lisinopril 20mg Qday Nifedipine ER 30mg Qday Zocor 20mg QHS Sinemet ___ 1 tab QID Gabapentin 100mg TID Celexa 10mg Qday Amitriptyline 25mg QHS Alprazolam 0.5mg BID Oxycodone 5mg TID Duoneb QID Albuterol 2 puffs Q4hr PRN Symbicort 2 puffs BID Singulair 10mg QHS Loratidine 10mg Qday Fluticasone nasal spray 2 sprays Qday Ropinirole 0.5mg TID Pyridoxine 100mg BID Vitamin B12 500mcg BID Prilosec 20mg Qday Nicotine patch Chantix --> started 3 days ago Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 2. montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every ___ hours as needed for shortness of breath or wheezing. 5. Flonase 50 mcg/Actuation Spray, Suspension Sig: Two (2) sprays Nasal once a day: 2 sprays each nostril once daily. 6. Vitamin B-6 100 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Vitamin B-12 500 mcg Lozenge Sig: One (1) lozenge PO twice a day. 8. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation once a day. 9. Zocor 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. bisoprolol-hydrochlorothiazide ___ mg Tablet Sig: One (1) Tablet PO once a day. 11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. Nifedical XL 30 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 13. Symbicort Inhalation 14. Neurontin 100 mg Capsule Sig: One (1) Capsule PO three times a day. 15. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 16. Nicoderm CQ 21 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal once a day. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Altered mental status due to medication side effect Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ because you were confused and having hallucinations. We believe this happened as a side effect of multiple medications you were taking, including Sinimet, Chantix, Citalopram, ropinirole, and percocet. We stopped these medications while you were in the hospital, and your confusion improved. You were also evaluated by our neurologists while you were in the hospital. The neurologists do not feel that you have ___ disease and recommend that you stop taking Sinimet as it could be contributing to your hallucinations. We recommend that you follow up with a neurologist as an outpatient. Please talk to your primary care provider about setting up an appointment with a neurologist near you. We recommend that you stop the following medications: -STOP Sinimet -STOP Chantix - we recommend you continue using your nicotine patch for smoking cessation -STOP Ropinirole -STOP Citalopram -STOP alprazolam -STOP percocet -STOP amitriptyline We made no other changes to your medications while you were in the hospital. Please continue taking the rest of your medications as prescribed by your outpatient providers. We have scheduled an appointment for you to follow up with your primary care provider. Please see below for your appointment time. It has been a pleasure taking care of you at ___ and we wish you a speedy recovery. Followup Instructions: ___
10808966-DS-11	10,808,966	26,208,995	DS	11	2124-01-01 00:00:00	2124-01-01 20:50:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Cipro / doxycycline / clindamycin Attending: ___. Chief Complaint: episode of aphasia Major Surgical or Invasive Procedure: none History of Present Illness: This was NOT a code stroke. The NIHSS was performed: Date: ___ Time: 00:25 ___ Stroke Scale score was : 2 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 1 5a. Motor arm, left: 0 5b. Motor arm, right: 1 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 0 10. Dysarthria: 0 11. Extinction and Neglect: 0 REASON FOR CONSULTATION: TIA/Stroke HISTORY OF THE PRESENTING ILLNESS: ================================== Eu Critical ___ MRN ___ (AKA ___ MRN ___) is an ___ year old right-handed man with a history of HTN, HLD, and recent PPM placement for symptomatic bradycardia (___) who presents to the ED after an episode of vision loss and difficulty speaking. History is provided by the patient and his wife. Mr. ___ was sitting on the couch at home with his wife earlier this evening (9:30 ___ on ___ watching a ___ when he developed sudden onset vision loss in the right hemi-field. He states that the actor's left eye (but curiously not the rest of his face) suddenly became absent. This lasted for a few seconds and then resolved. There was no diplopia, blurry vision, or other associated symptoms. No headache. He stood up from the couch and realized something "was wrong." His speech was "completely garbled" and he was unable to make a meaningful sentence. According to his wife, he had "trouble getting the words out" but no issues comprehending what she was saying. This lasted longer than the visual symptoms, approximately ___ minutes. His wife called ___. Upon EMS arrival, the patient states he "still felt off" but he was able to speak in full sentences. He was brought to the ___ ED for further evaluation. On ROS, the patient notes 2 prior episodes of visual field loss over the past month or so (since his PPM placement). Interestingly, both of the prior episodes also involved the "left eye of the person on the screen." He has felt "weird" recently - feeling "overall weak" today. This he felt could have been related to a couple mile walk he went on yesterday - the first exercise he has had since his PPM implantation. On further neurological ROS, the patient denies headache, blurred vision, diplopia, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Chronic unsteadiness when walking which has overall improved since his PPM was placed. On general review of systems, the patient 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: - Symptomatic bradycardia with 2:1 AV block s/p dcPPM ___ - Hypertension, BPs at home recently 120-130 mmHg systolic - Prostate cancer s/p cyberknife and hormone therapy (last injection several months ago) - Hyperlipidemia - Nephrolithiasis Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM Vitals: Afebrile, HR 73, BP 150/78, RR 16, Sa 98% RA General: Awake, cooperative, NAD, supine in ED bed HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Normal work of breathing Cardiac: RRR, warm, well-perfused Abdomen: soft, non-distended Extremities: Trace ___ edema. Skin: no rashes or lesions noted. Neurologic Exam: -Mental Status: Alert, oriented to ___, ___, and president. States the date at the ___ not ___. Attentive. Occasional word finding difficulties - "spy plane" instead of "drone." Wife and patient state he would usually know the word "drone." Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to read without difficulty. 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 2.5 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: There is right NLFF and widening of the right palpebral fissure (compared to photo from ___, this is stable). VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk, tone throughout. Subtle right pronation but no drift. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ L 5 ___ 5 ___ 5 5 5 R 5- ___ 5 4+ 5 4+ 5 5 5 -Sensory: 50% decreased pin prick sensation over the right leg compared to the left. Otherwise, no deficits to light touch, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. Romberg absent. -DTRs: ___ brisk, 3+ with bilateral pectoral jerks and crossed adductors. 2+ at the Achilles bilaterally. No clonus. Plantar response was withdrawal bilaterally. -Coordination: No intention tremor. Normal finger-tap bilaterally, perhaps slightly irregular on the right compared to the left. No dysmetria on FNF or HKS bilaterally. -Gait/Station: Good initiation. Narrow-based, normal stride and arm swing. Unable to walk on tip toes. ======== DISCHARGE PHYSICAL EXAM Gen: awake, alert, comfortable, in no acute distress HEENT: normocephalic atraumatic, no oropharyngeal lesions CV: warm, well perfused Pulm: breathing non labored on room air Extremities: no cyanosis/clubbing or edema Neurologic: -MS: Awake, alert, oriented to self, place, time and situation. Easily maintains attention to examiner. Able to say months of the year backwards. Speech fluent, no dysarthria. No evidence of hemineglect. -CN: Gaze congjugate, ___, EOMI no nystagmus, face symmetric, palate elevates symmetrically, tongue midline -Motor: normal bulk and tone. No tremor or asterixis. Delt Bic Tri ECR FEx FFl IO IP Quad Ham TA Gas ___ L 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: intact to LT in bilateral UE and ___, no extinction to DSS -Coordination: finger nose finger intact, no dysmetria -Gait: narrow based, no ataxia or sway Pertinent Results: ___ 08:00AM BLOOD WBC-5.0 RBC-3.89* Hgb-12.8* Hct-36.1* MCV-93 MCH-32.9* MCHC-35.5 RDW-12.9 RDWSD-43.6 Plt Ct-90* ___ 08:00AM BLOOD ___ PTT-28.3 ___ ___ 08:00AM BLOOD Glucose-95 UreaN-14 Creat-0.8 Na-141 K-4.8 Cl-102 HCO3-24 AnGap-15 ___ 08:00AM BLOOD ALT-24 AST-24 LD(LDH)-197 CK(CPK)-42* AlkPhos-71 TotBili-0.7 ___ 08:00AM BLOOD GGT-20 ___ 08:00AM BLOOD TotProt-6.5 Albumin-4.4 Globuln-2.1 Cholest-126 ___ 08:00AM BLOOD %HbA1c-4.6 eAG-85 ___ 08:00AM BLOOD Triglyc-176* HDL-29* CHOL/HD-4.3 LDLcalc-62 ___ 08:00AM BLOOD TSH-2.9 ___ 08:00AM BLOOD CRP-0.7 ___ 10:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG =========== IMAGING STUDIES CTA Head/neck 1. No evidence of masses, hemorrhage or infarction. 2. 12 mm left upper lobe pulmonary nodule. 3. 8 mm calcified right thyroid nodule. RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule bigger than 8mm, a follow-up CT in 3 months, a PET-CT, or tissue sampling is recommended. See the ___ ___ Society Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ Thyroid nodule. No follow up recommended. Absent suspicious imaging features, unless there is additional clinical concern, ___ College of Radiology guidelines do not recommend further evaluation for incidental thyroid nodules less than 1.0 cm in patients under age ___ or less than 1.5 cm in patients age ___ or ___. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. ___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR Incidental Findings Committee". J ___ ___ ___ 12:143-150. CXR- no acute cardiopulmonary process Brief Hospital Course: ___ year old right-handed man with a history of HTN, HLD, and recent PPM placement who presents to the ED after an episode of vision loss and difficulty speaking concerning for TIA vs. stroke. #TIA: on exam initially patient was noted to have right sided weakness in an UMN pattern and decreased pin prick sensation, iso episode of aphasia was concerning for possible left MCA syndrome. On re-assessment these findings were no longer present. While in hospital vision changes and aphasia did not recur. Given recent placement of pacemaker cardiology interrogated the pacemaker and found it was functioning normally without any episodes of a fib. MRI brain was cleared by cardiology given pacemaker placement, but unfortunately unable to be completed as inpatient due to inability for cardiology coverage on weekend to complete MRI. TTE also unable to be performed due to no weekend availability, and not felt to be critical given prior TTE in ___ that was unrevealing. Risk factors were notable for LDL 62 and HgbA1c of 4.6. He was continued on atrova 20mg QHS and started on aspirin 81mg after load of 325mg. He was discharged with Zio patch. #Symptomatic bardycardia s/p pacemaker placement: Pacemaker interrogated and found to be functioning normally without any episodes of a fib or other arrhythmias. TTE also unable to be performed due to no weekend availability, and not felt to be critical given prior TTE in ___ that was unrevealing. #Thrombocytopenia: plts were notably low to 100s on presentation, looking at OSH records patient's platelets have been in 120s-80s from ___. Transitional issues ================ []Discharged on Aspirin 81mg daily []Follow up with Neurology []Neurology: discharged with zio patch []PCP: consider referral to hematology for thrombocytopenia AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed () No. If no, reason why 2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not (I.e. bleeding risk, hemorrhage, etc.) 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No. If not, why not? (I.e. bleeding risk, hemorrhage, etc.) 4. LDL documented? (x) Yes (LDL =63 ) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [x ] LDL-c less than 70 mg/dL 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given in written form? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? () Yes - (x) No. If no, why not? -> patient at baseline functional status 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - If no, why not (I.e. bleeding risk, etc.) (x) N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 20 mg PO QPM 2. LORazepam 1 mg PO QHS:PRN sleep 3. ___ (omega-3 acid ethyl esters) 2 caps oral BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. LORazepam 1 mg PO QHS:PRN sleep 4. Lovaza (omega-3 acid ethyl esters) 2 caps oral BID Discharge Disposition: Home Discharge Diagnosis: Transient Ischemic Attack (TIA) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were hospitalized due to symptoms of vision loss and difficulty speaking resulting from an Transient Ischemic Attack (TIA) aka "mini stroke" , a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. TIAs can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: -High blood pressure -Hyperlipidemia We are changing your medications as follows: -Start taking aspirin 81mg daily Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___
10809510-DS-11	10,809,510	23,155,010	DS	11	2133-08-03 00:00:00	2133-08-03 15:18:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Oxycodone Attending: ___ Chief Complaint: Bilateral lower extremity weakness, intradural mass Major Surgical or Invasive Procedure: ___ (ORTHO/Dr. ___ L5-S1 laminectomy w/ interbody and posterior fusion ___ C7-T1 laminectomies for intradural tumor resection (Neurosurgery/Dr. ___ History of Present Illness: This is a ___ female who has had 3 months of progressively worsening neurological symptoms involving the bilateral lower extremities. She first noticed a foot drop on the left approximately three months ago and has since had increasing difficulty walking due to bilateral leg weakness, requiring the use of a walker, and over the last 3 weeks she has been wheelchair-bound. She has also had difficulty urinating and urinary incontinence over the last two days. She has been incontinent of small volumes and feels as if she has fullness in her lower abdomen. No fecal incontinence however she has had to manually disimpact herself in order to have bowel movements over the past 2 weeks. She has progressive numbness in her legs and torso. She was seen and evaluated in the ER and MRI Lumbar spine demonstrated L5-S1 stenosis. She underwent L5-S1 laminectomy and instrumented fusion with Orthopedics on ___. Postoperatively the patient had no improvement in her symptoms. MRI C and T Spine were performed ___ that demonstrated a large intradural mass posterior to the body of T1 displacing the spinal cord to the left and causing significant spinal cord compression. Neurosurgery was consulted for intradural mass. Past Medical History: Prior history of EtOH abuse, had a history of breast cancer removed at "2 cells", denies chemo or active cancer. Previously diagnosed with HTN and DM however pt feels these have resolved and stopped taking medication. Social History: ___ Family History: Non-contributory Physical Exam: ON ADMISSION: PHYSICAL EXAM: O: T: 98.7 BP: 118/68 HR: 101 R: 18 O2Sats: 96% RA Gen: WD/WN, comfortable, NAD. HEENT: normocephalic, atraumatic. poor dentition Neck: Supple. Abd: Distended, firm, nontender Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q H AT ___ G R 5 5 5 5 5 3 3 2 0 0 0 L 5 5 5 5 5 3 4- 2 0 0 0 Sensation: decreased to light touch from the level of T3 down and absent from the mid thigh down. Decreased perianal sensation. Reflexes: B T Br Pa Ac Right 1+ 1+ 1+ 3+ 0 Left 1+ 1+ 1+ 3+ 0 Proprioception absent Toes mute on the right and upgoing on the left 2 beats clonus on the left, no clonus on the right No Hoffmans Rectal exam normal sphincter control. There is stool in the vault. ======================================================= ON DISCHARGE: Continued paresthesias in bilateral ___, worse below the knee. Decreased sensation to light touch from the level of T3 down. Small area of swelling L inferior incision. Staples. Soft c-collar for comfort. Motor: IP Q H AT ___ G R 4+ 5 4 5 5 5 L 5 5 4+ 5 5 5 Cervical incision is intact without erythema or drainage Pertinent Results: Please refer to OMR for pertinent imaging and lab results. Brief Hospital Course: Ms. ___ presented to the ED on ___ with complaints of progressive lower extremity weakness and was initially admitted to the Ortho Spine service for further management. During her stay she was transitioned to the neurosurgery service for findings of a T1 intradural extramedullary mass. #Lumbar stenosis: On arrival to the ED the patient had bilateral lower extremity weakness which she reported had been progressive. MRI revealed stenosis and the patient was taken urgently to the OR with orthopedic spine for L5-S1 laminectomy and fusion with Dr. ___. A drain was left in place. On post-op exam the patient's strength did not improve and an MRI of the cervical and thoracic spine was obtained which demonstrated T1 intradural mass. Neurosurgery was consulted for management. The patient self d/c'd her drain from her lumbar spine surgery and a Lumbar wound vac was placed by orthopedics. #T1 intradural extramedullary mass Neurosurgery was consulted for MRI findings of T1 intradural mass after she underwent an L5-S1 laminectomy and fusion without improvement of her bilateral lower extremity weakness. She went to the OR on ___ for tumor resection and tolerated the procedure well. She was extubated in the OR and transferred to the PACU for recovery. Neurologically her lower extremity weakness had improved and she was transferred to the neuro stepdown unit for ongoing evaluation. Post-operatively she received a 1L fluid bolus for tachycardia to the 120's. A small area of swelling on the left inferior aspect of her incision was noted when the dressing was removed. There was no open areas or active drainage from the site. Post-op MRI demonstrated full resection of the mass and final pathology is pending. Her ___ weakness continued to improve. #Anemia Post-operatively her Hgb and Hct had dropped to 6.4 and 19.5 Se was asymptomatic however she was given 1 unit of PRBCs for downtrending labs. Her Hgb and Hct responded well and trended up. #ID Blood cultures obtained on admission showed Gram positive rods and final culture grew P. Acnes. Because the patient remained afebrile with normal WBC throughout her hospital stay it was felt that it was likely a contaminant. Repeat blood cultures from ___ and ___ are negative to date. Urine Culture was negative. #Elder Services Elder services was consulted for reported neglect at home. Social work was also involved for additional support. At the time of discharge she was voiding on her own, tolerating a regular diet, ambulating with a walker, afebrile with stable vital signs. Medications on Admission: ACETAMINOPHEN-CODEINE - acetaminophen 300 mg-codeine 30 mg tablet. ___ tablet q6h PRN Pain Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY 3. Calcium Carbonate 500 mg PO TID:PRN heartburn 4. Dexamethasone 4 mg PO Q12H Duration: 4 Doses This is dose # 1 of 3 tapered doses 5. Dexamethasone 3 mg PO Q12H Duration: 4 Doses This is dose # 2 of 3 tapered doses 6. Dexamethasone 2 mg PO Q12H Duration: 4 Doses Start: After 3 mg Q12H tapered dose This is dose # 3 of 3 tapered doses 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 8. Diazepam 2 mg PO Q8H:PRN muscle spasm 9. Docusate Sodium 100 mg PO BID 10. Famotidine 20 mg PO BID 11. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 12. Glucose Gel 15 g PO PRN hypoglycemia protocol 13. Heparin 5000 UNIT SC BID 14. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 15. Senna 8.6 mg PO BID 16. TraMADol 50 mg PO Q6H:PRN pain 17. TraZODone 25 mg PO HS:PRN insomnia Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: T1 Intradural tumor Lumbar stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Discharge Instructions Spinal Fusion Surgery Your Cervical dressing may come off on the second day after surgery. ** Your Lumbar wound is dressed with a Prevena Wound vac which should stay in place for 7 days until ___. After that a dry sterile dressing should stay in place until follow up with Dr. ___. Your Cervical incision is closed with staples. You will need staple removal. Your Lumbar incision is closed with Sutures and you will need suture removal. Do not apply any lotions or creams to the site. Please keep your incision dry until removal of your staples/sutures. Please avoid swimming for two weeks after staple/suture removal. Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity Soft cervical collar is for comfort only. We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You may take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. No driving while taking any narcotic or sedating medication. No contact sports until cleared by your neurosurgeon. Do NOT smoke. Smoking can affect your healing and fusion. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc until cleared by your neurosurgeon. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. When to Call Your Doctor at ___ for: Severe pain, swelling, redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit New weakness or changes in sensation in your arms or legs. Followup Instructions: ___
10809600-DS-21	10,809,600	23,636,380	DS	21	2118-04-09 00:00:00	2118-04-09 15:33:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: CC: dysarthria, right facial weakness, and changes in vision Major Surgical or Invasive Procedure: PEG tube placement History of Present Illness: Mr. ___ is an ___ right-handed man with a history of stroke which affected his left arm and leg, with no apparent residual weakness, HTN, HLD, and DM, presenting with new onset dysarthria, right arm weakness, and changes in his vision. Last night at 2AM, Mr. ___ awoke to use the restroom. He tried to walk to the bathroom, felt as though he was uncoordinated more so than feeling weak. He felt that "something was wrong," that he was imbalanced and could fall to either side. He did not make it to the bathroom but used a chair as a walker to get to the phone. He called ___ and recognized that he had slurred speech, which he states is completely different from his baseline speech. He denies any pain, dizziness, lightheadedness, weakness, numbness, or tingling at that time. He states that he only felt like he was awakening from a deep sleep and noted something felt wrong when trying to walk. EMS arrived shortly after. He was unable to walk to the ambulance as he was worried he would fall. Mr. ___ was brought to ___, where a head CT was done and negative, and he was transferred to ___ for neuro evaluation and workup. OSH states that he awoke with right facial weakness and dysarthria. Mr. ___ denied right facial weakness when asked this AM at ___. He states at ___ he noticed that people looked like they were moving up and down in his vision which he had never experienced this before. He denied any frank diplopia or blurry vision but describes it as objects in his near vision as bouncing up and down, he could not provide further details. Several years ago, Mr. ___ had what he was told was a minor stroke, and he was seen at ___. In that episode, he had arm and leg weakness on his left side. No numbness and tingling, no facial involvement, and no speech impairment. He has since been on Aggrenox ___ mg BID. As of evaluation this morning, he continues to have vision changes of seeing people and objects (now states that they are moving "east and west"), and he says this happens when things are closer to him. He states that he has no trouble comprehending speech, but he continues to have slurred speech. He is afraid to walk due to fear of falls. Mr. ___ denies headache, loss of vision, blurred vision, diplopia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies focal weakness, numbness, parasthesiae. He denies any fever, recent illness, sick contacts, or recent travel. He endorses neck pain from arthritis, as well as arthritis in his left shoulder. Past Medical History: PMH: -DM - states that it is controlled, not on insulin -HTN -HLD -presumed ischemic stroke several years ago - cervical arthritis Social History: ___ Family History: -Uncle with MI in his ___ - Unknown if family history of stroke or neurologic disease Physical Exam: Admission ======== Physical Exam: Vitals: T 99.3 BP 159/70 HR 64 RR 20 General: Awake at the beginning of exam. Drifting to sleep toward the last third of exam, but awakens quickly. Cooperative. Voided urine in clothes. Appears frustrated when trying to state history and will slow down and exhibit much effort to pronounce words. Volume of voice is normal. HEENT: NC/AT, no scleral icterus noted, MMM. Hearing to speech normal. Neck: supple, no nuchal rigidity Pulmonary: breathing comfortably on room air Cardiac: RRR, nl Abdomen: ND Extremities: warm, well perfused Skin: no rashes noted. Small, shallow lesion on left shin. Multiple nevi on back. Neurologic: -Mental Status: Alert, when asked his name, would spell it out but not state it directly, oriented to place, and date. Able to relate history but spoke slowly due to difficulty with pronounciation. Attentive, able to name ___ backward and spell world backward without difficulty. Speech was dysarthric with both lingual and labial difficulty (___, ___, ___, ta). Language is fluent with intact repetition ("Today is a sunny day in ___, "No ifs, ands, or buts") and comprehension. Normal prosody. Pt was able to name both high and low frequency objects (Needed some prompting with hammock). Able to read. Able to follow both midline and appendicular commands. No evidence of neglect. -Cranial Nerves: II, III, IV, VI: PERRL 4 to 2mm and brisk. EOMI. VFF. Drift of right eye with corrective saccades back to center observed, right eye exotropia. Drift at baseline and when trying to focus on something in front of him. V: Facial sensation intact to light touch. VII: No facial droop. Marginally weaker right eyelid. Facial musculature otherwise symmetric. VIII: Hearing to speech intact. IX, X: Patient was able to swallow water without difficulty. XI: strong XII: Tongue protrudes in midline. could not assess tongue strength in cheek, poor effort -Motor: Normal bulk, tone throughout. Pronator drift of right arm observed. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad Ham TA L 5 ___ ___ 5 5 R 5* 5 5* ___ ___ Initially with R delt and R tricep, it was slightly weak at 4+ but with repeat testing, he was able to give full strength. ___ mild decreased strength compared to left. Did not test finger tapping due to time limitations. could not test orbiting due to multiple wires. -Sensory: No deficits to light touch throughout. -DTRs: ___ reflex 3 bl. Bi Tri ___ Pat Ach L ___ 3 0 R ___ 3 0 -Coordination: No intention tremor noted. Slight intention tremor on FNF, with more errors with R hand than L. -Gait: Attempted, but patient unable to get out of bed. ___ up but concerned about falling. Discharge =========== VS: T 98.3; BP 117 / 75; HR 74; RR 18; O2 sat 95% Ra General Exam: Gen: Lying in BED in NAD, awake and appropriately interactive HEENT: NCAT, mucuous membranes moist Lungs: Breathing comfortably on room air, lungs clear to auscultation bilaterally CV: well perfused, regular S1, S2 Abd: peg tube in place with clean/dry/intact dressing, abdomen non-distended, +BS Ext: non-edematous, warm to touch Neuro Exam MS: Speech is dysarthric w slurring. Oriented to self, place, situation. CN: Pupils: R 3.5>2, L 4>2; right NLFF; EOMI without nystagmus; facial sensation intact; tongue deviated to right Motor: RUE: Delt 4; Bic 4+, Tric 4-, WE 3, FF 3 RLE: IP 4, HAM 4, Quad 4, TA 4, Gastroc 4 Left UE and ___: Full ___ throughout proximal and distal Reflexes: UE 3+ bilaterally; patellar 3+ bilateraly, R toe downgoing, L toe upgoing Sensation: grossly intact to light touch Coordination/Gait: Deferred Pertinent Results: Admission ======== ___ 09:08AM BLOOD WBC-7.7 RBC-3.73* Hgb-11.8* Hct-35.1* MCV-94# MCH-31.6 MCHC-33.6 RDW-12.7 RDWSD-43.8 Plt ___ ___ 09:08AM BLOOD Neuts-76.5* Lymphs-13.5* Monos-5.5 Eos-3.4 Baso-0.7 Im ___ AbsNeut-5.86 AbsLymp-1.03* AbsMono-0.42 AbsEos-0.26 AbsBaso-0.05 ___ 09:08AM BLOOD ___ PTT-29.1 ___ ___ 09:08AM BLOOD Plt ___ ___ 09:08AM BLOOD Glucose-123* UreaN-29* Creat-1.2 Na-135 K-5.0 Cl-97 HCO3-25 AnGap-13 ___ 09:08AM BLOOD ALT-13 AST-23 AlkPhos-70 TotBili-0.2 ___ 09:08AM BLOOD Lipase-32 ___ 09:08AM BLOOD cTropnT-<0.01 ___ 09:08AM BLOOD Albumin-4.3 Calcium-9.5 Phos-3.3 Mg-1.9 ___ 09:08AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 09:22AM BLOOD Lactate-1.7 Imaging ====== Chest (PA & LAT) ___: Bilateral calcified pleural plaques suggest prior asbestos exposure. No definite focal consolidation. CTA Head and Neck w/wo ___: 1. No evidence for intracranial hemorrhage or vascular territorial infarction. 2. Dominant left sided vertebrobasilar system with severe calcifications in the distal left V4 segment, without occlusion and with patency of the basilar artery and proximal V4 segment 3. Hypoplastic right vertebral artery with long segment smooth narrowing of the distal V4 segment prior to termination within the right ___. No convincing evidence for dissection. 4. 30% stenosis of the proximal left ICA by NASCET criteria. 5. Moderate calcifications of the bilateral cavernous ICAs. Otherwise, patent intracranial vasculature. MRI HEAD ___ RESULTS: There is moderate-sized acute infarct involving left paramedian pons. Mild chronic small vessel ischemic changes. There is no evidence of hemorrhage, edema, masses, mass effect, midline shift. No hydrocephalus. Moderate generalized brain parenchymal atrophy. Intracranial vascular flow voids are preserved. IMPRESSION: Acute infarct left pons. Brief Hospital Course: Mr. ___ is a ___ RH man w/ h/o HTN, HLD, DM (HbA1C 5.9%), and CAD s/p stent in ___ who presents with new onset dysarthria, vision changes, gait unsteadiness, and R-sided arm and leg weakness. Initial exam notable for bidirectional horizontal gaze-evoked nystagmus, R nasolabial fold flattening, R tongue deviation, pronounced dysarthria in a pseudobulbar pattern, as well as R UE and ___ weakness. Which has been slowly improving. Imaging with CTA of the head and neck showed no evidence for intracranial hemorrhage or vascular territory infarction. MRI with acute LT pontine stroke. Stroke risk factors assess with A1C 5.9% and LDL 64. Etiology of his infarct likely from small vessel atherosclerosis. He was started on secondary prevention measures with clopidogrel and atorvastatin 40mg daily. As he had severe dysphagia and failed swallow study, he had a PEG tube placed on ___ and feeds were starting through it prior to discharge. Physical therapy worked with him throughout admission and recommended he be discharged to acute rehab facility. Transitional issues: Stroke prevention: Continue to take clopidogrel Hypertension: Discharged with metoprolol 100 BID and amlodipine 5 mg daily. Holding combination valsartan-hydrochlorothiazide and Imdur to be resumed as outpatient as tolerated. Hyperlipidemia: Previously on simvastatin, switched to atorvastatin 40 mg daily to avoid interaction with amlodipine Nutrition: PEG tube placed, will need re-evaluation for oral feeds in future. Glucerna 1.5 at 45 ml/hour. 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 = 64) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL ] 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (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 - () No - (x) N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 2. Aspirin EC 325 mg PO DAILY 3. MetFORMIN (Glucophage) 1000 mg PO BID 4. Simvastatin 60 mg PO QPM 5. Dipyridamole-Aspirin 1 CAP PO BID 6. Omeprazole 20 mg PO DAILY 7. Metoprolol Tartrate 100 mg PO BID 8. valsartan-hydrochlorothiazide 160-12.5 mg oral unknown 9. amLODIPine 5 mg PO DAILY Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. Clopidogrel 75 mg PO DAILY Stroke prevention 3. amLODIPine 5 mg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. Metoprolol Tartrate 100 mg PO BID 6. Omeprazole 20 mg PO DAILY 7. HELD- Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY This medication was held. Do not restart Isosorbide Mononitrate (Extended Release) until you see your primary care doctor 8. HELD- valsartan-hydrochlorothiazide 160-12.5 mg oral unknown This medication was held. Do not restart valsartan-hydrochlorothiazide until discussed with your ___ care doctor Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left pons stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You were hospitalized here after you developed difficulty with speech and right arm and leg speech and determined to have an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, in your case, the etiology is likely due to atherosclerotic disease in the blood vessels that provide blood to your brain. The goal will be to maximize your recovery from this stroke and help to prevent you from having another stroke. You will be discharged to acute rehabilitation and you will work with physical therapists for hours a day to help increase your strength. Previously, you were taking Aggrenox to help prevent stroke, but we have changed management and you will no longer take this medication. Instead, you will now take clopidogrel to help reduce your risk of stroke. Also, you will no longer take simvastatin and we have replaced it with atorvastatin as your lipid lowering medication. Please follow up with your primary care physician ___ days after discharge from hospital to update her on your hospitalization. We have scheduled you for a follow up appointment with the stroke clinic with Dr. ___ the date and time is 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: ___
10809600-DS-22	10,809,600	25,103,522	DS	22	2118-04-22 00:00:00	2118-04-22 15:06:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: bleeding from PEG site Major Surgical or Invasive Procedure: PEG tube bolstered and released, one vicryl stitch placed History of Present Illness: ___ year old male with history of stroke recently admitted for L. pons infarct c/b dysphagia s/p PEG tube ___ (Dr. ___ presenting with bleeding around PEG tube. Per patient and living facility, he has been having painless bleeding around the PEG tube site over the last ___ days. Today the amount of bleeding increasing and he was prompted to the ED. The patient was started on Plavix on ___ for stroke prevention. He notes no associated pain with the bleeding. No symptoms of fatigue, lightheadedness, blood in stool or urine, no dark or tarry stools, no new aches or pain. Of note he had been progressing in his swallowing rehab and was to start pureed solids tomorrow. Past Medical History: PMH: -DM - states that it is controlled, not on insulin -HTN -HLD -presumed ischemic stroke several years ago - cervical arthritis Social History: ___ Family History: -Uncle with MI in his ___ - Unknown if family history of stroke or neurologic disease Physical Exam: Physical exam upon admission: ___: T 97.7 HR 74 RR 16 BP 126/55 SatO2 99% RA AAA RRR CTA bil Abd: soft, non tender, non distended. PEG site surrounded with dried blood, no active bleeding, no secreation. Extremities: no edema Physical exam upon discharge: ___ T 99.1 BP 138 / 61 HR 89 RR 19 ___ 96 RA GEN: NAD CV: RRR RESP: CTA bil ABD: soft, non tender, non distended. PEG site surrounded with dried blood, no active bleeding, some oozing from site. Extremities: no peripheral edema Pertinent Results: ___ 07:35AM BLOOD WBC-9.4 RBC-3.47* Hgb-10.7* Hct-33.0* MCV-95 MCH-30.8 MCHC-32.4 RDW-12.4 RDWSD-43.0 Plt ___ ___ 05:00AM BLOOD WBC-13.9* RBC-3.51* Hgb-10.7* Hct-33.3* MCV-95 MCH-30.5 MCHC-32.1 RDW-12.3 RDWSD-42.5 Plt ___ ___ 10:10PM BLOOD WBC-14.9* RBC-3.70* Hgb-11.5* Hct-34.5* MCV-93 MCH-31.1 MCHC-33.3 RDW-12.2 RDWSD-41.4 Plt ___ ___ 07:35AM BLOOD Glucose-106* UreaN-24* Creat-1.0 Na-139 K-4.8 Cl-99 HCO3-23 AnGap-17 ___ 05:00AM BLOOD Glucose-112* UreaN-38* Creat-1.1 Na-137 K-4.8 Cl-97 HCO3-28 AnGap-12 ___ 07:35AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.9 ___ 05:04AM BLOOD Lactate-1.2 ___: CXR: No focal consolidation. Probable small bilateral pleural effusions. Brief Hospital Course: ___ year old male, s/p PEG tube on ___ placement for dysphagia, presenting with bleeding around PEG tube site. Patient reportedly had been bleeding from the PEG site over the last ___ days. Because of the increase in the bleeding, the patient was transferred here for management. His hematocrit upon admission was 33. The patient was made NPO and given intravenous fluids. At bedside, the PEG was adjusted to tamponade bleeding, and no further bleeding was observed for 24 hours. The patient's hematocrit was monitored for 24 hours and remained stable. However, after 24 hours bleeding was again noted and a stitch was placed around a bleeding vessel. After another 24 hours of observation, no vigorous bleeding was noted- only some residual oozing that continues to decrease in quantity. Tube feeds were held after the stitch was placed, but resumed on ___ and he tolerated well without further evidence of bleeding. The patient was discharged on HD #6. His vital signs were stable and he was afebrile. His hematocrit remained stable. His Plavix was held on ___ and should be held until ___ for a total of 7 days. Discharge instructions were reviewed. Medications on Admission: 1. Atorvastatin 40 mg PO QPM 2. Clopidogrel 75 mg PO DAILY Stroke prevention 3. amLODIPine 5 mg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. Metoprolol Tartrate 100 mg PO BID 6. Omeprazole 20 mg PO DAILY 7. HELD- Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY This medication was held. Do not restart Isosorbide Mononitrate (Extended Release) until you see your primary care doctor 8. HELD- valsartan-hydrochlorothiazide 160-12.5 mg oral unknown This medication was held. Do not restart valsartan-hydrochlorothiazide until discussed with your ___ care doctor Discharge Medications: 1. Omeprazole 20 mg PO BID 2. valsartan-hydrochlorothiazide 160-12.5 mg oral DAILY DO NOT RESUME UNTIL SEEN BY PRIMARY CARE PROVIDER 3. amLODIPine 5 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Clopidogrel 75 mg PO DAILY - HOLD UNTIL ___ 6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY DO NOT RESUME UNTIL FOLLOW-UP WITH PCP 7. MetFORMIN (Glucophage) 1000 mg PO BID please monitor blood sugar prior to meals and at bedtime 8. Metoprolol Tartrate 100 mg PO BID hold for systolic blood pressure <100, hr <60 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: bleeding from PEG site Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___ You were admitted to the hospital with bleeding from the PEG site. The area around the PEG tube was pulled back and there has been no further bleeding. There was one stitch placed around the site of bleeding. You have resumed your tube feedings via the PEG and there has been no further bleeding. You are being dishcharged to your rehabilitation facility with 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. Followup Instructions: ___
10809663-DS-20	10,809,663	27,669,905	DS	20	2147-01-06 00:00:00	2147-01-08 17:22:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headache for three days Major Surgical or Invasive Procedure: ___: right craniectomy for IPH ___: Port placement History of Present Illness: ___ year old female, 2-months post-partum, presented to ___ triage with chief complaint of headache with photophobia for three days prior to presentation on ___. The patient was transferred from triage to an ED room, and was found to be obtunded when the ED resident entered the exam room. She was alert in triage at 742am, but on evaluation by ED resident ~10 min later she was nonresponsive with fixed and dilated right pupil. Neurosurgery was consulted. She was intubated for airway protection and taken to STAT CT where she was found to have large right IPH with IVH. Past Medical History: s/p normal vaginal delivery ___ s/p D&Cx3 for TABx3 (confidential) Social History: ___ Family History: unknown Physical Exam: ON ADMISSION: Gen: unresponsive female, HEENT: Pupils: R pupil 7mm NR, L pupil 4mm NR Date and Time of evaluation: 8:02 am ___ Coma Scale: [ ]Intubated [x]Not intubated Eye Opening: [x]1 Does not open eyes [ ]2 Opens eyes to painful stimuli [ ]3 Opens eyes to voice [ ]4 Opens eyes spontaneously Verbal: [x]1 Makes no sounds [ ]2 Incomprehensible sounds [ ]3 Inappropriate words [ ]4 Confused, disoriented [ ]5 Oriented Motor: [ ]1 No movement [ ]2 Extension to painful stimuli (decerebrate response) [x]3 Abnormal flexion to painful stimuli (decorticate response) [ ___ Flexion/ withdrawal to painful stimuli [ ]5 Localizes to painful stimuli [ ]6 Obeys commands __5__ Total ICH Score: GCS [ ]2 GCS ___ [x]1 GCS ___ [ ]0 GCS ___ ICH Volume [x]1 30 mL or Greater [ ]0 Less than 30 mL Intraventricular Hemorrhage [x]1 Present [ ]0 Absent Infratentorial ICH [ ___ Yes [x]0 No Age [ ]1 ___ years old or greater [x]0 Less than ___ years old Total Score: __3____ Neuro: Mental status: unresponsive Orientation/Language: nonverbal. Right pupil 7mm NR, Left pupil 4mm NR Right corneal present. Left corneal absent. midline gaze Right upper extremity extends to noxious Left upper extremity abnormal flexion Bilateral lower extremities extending Sensation: response to noxious stimuli AT DISCHARGE: Vitals: ___ 0713 Temp: 98.1 PO BP: 128/78 Lying HR: 77 RR: 18 O2 sat: 98% O2 delivery: Ra GENERAL: NAD, alert and oriented, depression over right side with large surgical incision now with staples removed; looking well-healed EYES: ptosis/eyelid swelling on right close to symmetrical, right eye down and out w/ mild ptosis, EOMI but R eye limited on sup, inf and lateral gaze. PERRL, cranial nerves otherwise intact without deficits HEENT: MMM. Ulcerations healing on lips. OP clear NECK: supple LUNGS: CTA b/l, no wheezes/rales/rhonchi CV: RRR no m/r/g, normal distal perfusion, ABD: soft, no TP, ND, normoactive BS, no rebound or guarding EXT: warm, normal muscle bulk, no edema SKIN: warm/dry, large surgical incision well approximated on right side of head, no erythema/drainage NEURO: AOx3, fluent speech, ptosis on right w/ anisocoria; otherwise normal cranial nerves ACCESS: PIV, PICC, port Pertinent Results: Admit Labs ___ 08:07AM BLOOD WBC-9.7 RBC-3.35* Hgb-10.8* Hct-33.1* MCV-99* MCH-32.2* MCHC-32.6 RDW-11.9 RDWSD-42.6 Plt ___ ___ 08:07AM BLOOD Neuts-24.2* Lymphs-66.1* Monos-7.8 Eos-1.5 Baso-0.1 Im ___ AbsNeut-2.35 AbsLymp-6.43* AbsMono-0.76 AbsEos-0.15 AbsBaso-0.01 ___ 08:07AM BLOOD Hypochr-NORMAL Anisocy-1+* Poiklo-1+* Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+* Burr-OCCASIONAL Tear Dr-OCCASIONAL ___ 08:07AM BLOOD ___ PTT-22.8* ___ ___ 12:00PM BLOOD ___ ___ 08:07AM BLOOD Glucose-173* UreaN-11 Creat-0.6 Na-141 K-3.2* Cl-104 HCO3-19* AnGap-18 ___ 10:53AM BLOOD Calcium-8.8 Phos-2.1* Mg-1.5* ___ 11:10AM BLOOD ___ ___ 11:10AM BLOOD CEA-1.6 CA125-8 ___ 08:07AM BLOOD Digoxin-<0.4* ___ 08:07AM BLOOD Phenoba-<3* Phenyto-1.2* Lithium-<0.1* Valproa-<3* ___ 08:07AM BLOOD ASA-NEG Ethanol-NEG Carbamz-<2* Acetmnp-NEG Tricycl-NEG ___ 08:17AM BLOOD ___ pO2-50* pCO2-36 pH-7.39 calTCO2-23 Base XS--2 ___ 08:17AM BLOOD O2 Sat-82 ___ MetHgb-0 Imaging Radiology ReportED CODE STROKE ONLY CTStudy Date of ___ 8:10 AM 1. Large right intraparenchymal hemorrhage with surrounding edema, intraventricular extension, and mass effect including effacement of the lateral ventricles, right greater than left, and leftward midline shift measuring up to 15 mm. 2. No underlying aneurysm or arteriovenous malformation visualized. 3. Partially visualized soft tissue in the anterior mediastinum, for which CT chest is recommended for further evaluation, particularly given a possible pleural base mass seen on chest radiograph performed on same day. 4. Right mainstem bronchus intubation. Radiology ReportCT HEAD W/O CONTRASTStudy Date of ___ 12:38 ___ 1. Patient is status post right craniectomy and evacuation of large right frontotempooparietal intraparenchymal hemorrhage with expected postoperative findings. There has been interval decrease in overall mass effect with decrease in leftward midline shift, now measuring 8 mm (previously 15 mm). No suggestion of underlying acute, large territorial infarction. 2. Unchanged small amount of subarachnoid hemorrhage along the posterolateral right cerebral convexity. Radiology ReportCT CHEST W/CONTRASTStudy Date of ___ 5:40 AM FINDINGS: THORACIC INLET: The ET tube and NG tube are in acceptable position. BREAST AND AXILLA : There are no enlarged axillary lymph nodes. MEDIASTINUM: There are no enlarged mediastinal or hilar lymph nodes. The aorta and pulmonary artery are normal in caliber. There is no pleural or pericardial effusion. Heart size is normal PLEURA: There is no pleural effusion LUNG: There is a large mass in the lingula measuring 3.1 x 3.1 cm (602, 96). Multiple additional bilateral pulmonary nodules are seen ranging in size from 16 mm to 18 mm. 2 smaller nodules are seen in the left lower lobe. Some of these the lesions have high-density material within them, which could represent enhancement or could represent calcification. Difference aeration due to presence of intravenous contrast is limited. There is minimal subsegmental atelectasis in the left lung base. BONES AND CHEST WALL : Review of bones is unremarkable. UPPER ABDOMEN: Limited sections through the upper abdomen shows a hypodense lesion in the right lobe of liver measuring 11 mm (2, 46), could represent evidence of calcification or enhancement. IMPRESSION: Multiple bilateral pulmonary masses the largest measuring 3 cm in the lingula, are concerning for metastasis. Some of these lesions have areas of high-density within them which could represent enhancement or calcification. Given the appearance and morphology of the nodules these could represent metastasis from a colon cancer or an ovarian cancer. Small and high-density lesion in the right lobe of liver could also represent a metastasis. The ET tube and the ET tube and NG tube are in appropriate position Radiology ReportMR HEAD W & W/O CONTRASTStudy Date of ___ 4:06 ___ FINDINGS: The patient is status post large right-sided craniectomy. Postsurgical changes are noted including calvarial defect, relatively large subgaleal blood, fluid, and air-containing collection overlying the craniectomy site, and skin/scalp edema. There are intrinsically T1 hyperintense subacute blood products within the right temporal lobe associated with scattered foci of susceptibility-related artifact at the site of the known intraparenchymal hematoma. Serpiginous gyriform enhancement is within range for expected findings given involving hematoma. There is right-sided dural thickening and enhancement likely related to the recent surgery. There is no evidence of focal nodular or mass like enhancement at the site of the hematomas to suggest underlying mass, although note that the degree of postsurgical change, hematoma, and edema somewhat limits sensitivity. Restricted diffusion seen peripheral to the site of the hematoma likely represents devitalized tissue secondary to bleed. There is a separate acute infarction in the medial right occipital lobe in the PCA distribution (6 and 5 image 12). Trace linear FLAIR hyperintense signal along the posterior clivus, right cerebellopontine angle, right anterior temporal pole, right frontal convexity and along the anterior falx may reflect enhancing dural thickening primarily ipsilateral to the hematoma and surgery. There has been interval resolution of right frontal pneumocephalus since prior CT. There is unchanged 7 mm leftward shift of midline structures. There is slight right uncal herniation (13:67 and 100:65). There is mild right cerebral hemispheric sulcal and right lateral ventricular effacement. No ventricular entrapment. IMPRESSION: 1. Status post evacuation of right-sided posterior temporal hematoma with postsurgical changes as described. Restricted diffusion at the margin related to surgery and postoperative change. No definite enhancing nodular lesion is seen no or abnormal vascular structures are identified. 2. Acute right posterior cerebral artery medial occipital infarct likely related to uncal herniation. 3. Mass effect as described above with other postsurgical findings. Radiology ReportCT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONSStudy Date of ___ 11:02 AM IMPRESSION: 1. No definite evidence of malignancy in the abdomen or pelvis. 2. 0.9 cm hyperenhancing lesion hepatic segment VIII is nonspecific but could represent a capillary hemangioma. Metastasis is unable to be completely excluded. 3. Mildly enlarged uterus with hyperenhancement of the junctional zone, likely secondary to recent postpartum state. No uterine or adnexal mass. 4. Redemonstration of multiple pulmonary nodules and masses in the visualized lung bases. Please see dedicated chest CT performed on ___ for more detailed evaluation. adiology ReportPELVIS U.S., TRANSVAGINALStudy Date of ___ 8:19 AM The postpartum uterus is anteverted and enlarged, measuring 8.7 cm x 5.5 cm x 5.2 cm. Atrium measures 6 mm, at the fundus the endometrium is heterogeneous without internal vascularity, this may represent retained products of conception, however no discrete mass is seen. The ovaries are normal. There is a trace amount of free fluid. IMPRESSION: 1. Enlarged postpartum uterus. Heterogeneous endometrium at the fundus may represent retained products of conception, however no discrete mass is seen. 2. Normal ovaries. CT HEAD ___. Status post right craniectomy with evacuation of right-sided posterior temporal hematoma, now with expected postoperative findings. 2. Interval decrease in left for midline shift, now measuring 4.6 mm (previously 8 mm). 3. Interval decrease in frontal region pneumocephalus. 4. Interval resolution of the right cerebral convexity sub arachnoid hemorrhage. 5. Additional findings as described above. MRI HEAD ___. Status post evacuation of right-sided temporal hematoma with postsurgical changes as described. 2. Interval decrease of right temporal intraparenchymal hemorrhage with decreasing mass effect, now measuring 4 mm. 3. Possible new punctate acute/subacute infarct of the right thalamic pulvinar region, correlate clinically. CT HEAD ___. Status post right craniectomy and evacuation of a right-sided temporoparietal intraparenchymal hematoma with expected postoperative changes. Interval decrease in leftward midline shift, now measuring 3 mm. No new intracranial hemorrhage. MRI HEAD ___. Interval decrease and evolution of the right temporal intraparenchymal hemorrhage. Curvilinear areas of enhancement and restricted diffusion likely relate to devitalized tissue/compressive effects secondary to hemorrhage. Evaluation for underlying mass and abnormal enhancement is limited. No discrete mass is visualized. 2. Resolution of mass effect on the ventricular system. No hydrocephalus. Patent basal cisterns. 3. Mildly increasing extra-axial fluid collection in the right middle cranial fossa compatible with arachnoid cyst with mild mass effect on the right temporal lobe. 4. Additional findings as described above. CT HEAD ___. Status post right temporoparietal craniotomy with stable postoperative changes. No increase in cerebral edema in the parietal and occipital lobes. 2. Unchanged 3 mm leftward midline shift. Stable 3. No new intracranial hemorrhage, large territorial infarction, or mass. RUQUS ___. Collapsed gallbladder, therefore inadequately assessed. If there is persistent clinical concern for cholelithiasis or acute cholecystitis, consider repeating the study after fasting for at least 4 hours. 2. Nonvisualization of the appendix. CT ABDOMEN ___. No acute findings in the abdomen or pelvis. 2. 12 mm hyperenhancing lesion in the right hepatic lobe is bigger, suspicious for additional site of metastatic choriocarcinoma. 3. Masses in the imaged lung bases are similar or mildly smaller. CT HEAD ___. Status post right temporoparietal craniotomy with stable postoperative changes. 2. No new areas of hemorrhage or increased mass effect. No evidence of new large territorial infarction. 3. Unchanged 3 mm leftward midline shift. MICRO LABS ================= ___ 11:54 am BLOOD CULTURE Source: Line-PICC. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 12:36 pm URINE Source: ___. FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. ANAEROBIC CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. Test performed only on suprapubic and kidney aspirates received in a syringe. SPOKE WITH ___ ON ___ AT 1440. ___ 4:15 pm BLOOD CULTURE Source: Line-port ( 1 OF 3 ). FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 4:20 pm BLOOD CULTURE Source: Line-port ( 2 OF 3 ). FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 6:10 pm BLOOD CULTURE SET#3. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 12:48 pm URINE Source: ___. FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. DISCHARGE LABS =================== ___ 04:25PM BLOOD WBC-1.0* RBC-3.17* Hgb-9.6* Hct-27.6* MCV-87 MCH-30.3 MCHC-34.8 RDW-12.7 RDWSD-40.5 Plt Ct-48* ___ 04:36AM BLOOD Neuts-33.3* ___ Monos-17.5* Eos-0.0* Baso-0.0 Im ___ AbsNeut-0.42* AbsLymp-0.57* AbsMono-0.22 AbsEos-0.00* AbsBaso-0.00* ___ 04:25PM BLOOD Plt Ct-48* ___ 04:36AM BLOOD Plt Ct-47* ___ 04:36AM BLOOD ___ PTT-24.4* ___ ___ 04:36AM BLOOD Glucose-105* UreaN-31* Creat-0.6 Na-139 K-4.6 Cl-105 HCO3-21* AnGap-13 ___ 04:36AM BLOOD ALT-92* AST-26 LD(LDH)-223 AlkPhos-90 TotBili-0.3 ___ 04:36AM BLOOD Calcium-8.5 Phos-4.0 Mg-1.9 ___ 06:46PM BLOOD mthotrx-<0.04 Brief Hospital Course: PATIENT DISCHARGED WITH HOME SERVICES FOR ___ MEDICATION MANAGEMENT ___ F 3 months postpartum who initially presented to ED with headache, found to have large right intraparenchymal and intravascular hemorrhage (s/p craniectomy and clot evacuation), was subsequently found to have liver/lung lesions and an elevated HCG concerning for metastatic gestational trophoblastic neoplasm, transferred to oncology service for chemotherapy. # Metastatic gestational trophoblastic neoplasm w/ lung/brain/liver lesions: Patient two months post partum with discovery of metastatic choriocarcinoma iso intracranial and liver/lungs mets. Started on etopo/MTX/cisplatin/dactinomycin with plan for at least 8 weeks following an HCG level of zero. HCG down from 150,000 to 2,000 post cycle 1. C2D1 initiated ___ with improvement in HCG to 357. Will need to get readmitted every other week for MTX. TLS labs have been stable. Her brain will likely either be treated with whole brain radiation or CyberKnife and intrathecal chemotherapy (likely post chemotherapy). Repeat MRI with interval improvement, to determine neurosurgical plan in two weeks. Cleared for home by ___ with 24 hour supervision at home. Patient was at high risk for TLS given tumor burden but stable labs on chemotherapy. Elevated LFTs likely attributed to chemo drugs Etoposide vs. MTX, and now improving. Will need to monitor weekly Hcg on ___. 14 day cycles of current chemotherapy regimen to continue with at least two months post-HCG level of zero so likely time course ___ months. Will follow up with radiation oncology outpatient the to determine future WBRT vs cyberknife, and will need repeat MRI at outpatient follow up appointment. On discharge, patient and family were given extensive teaching and a calendar outlining which medications to take on what days. She received 3 cycles of chemotherapy while in house and her methotrexate has been cleared before discharge. # Right intraparenchymal and intravascular hemorrhage (s/p craniectomy and clot evacuation): Improving headache and CN3 palsy with improved swelling. MRI shows improvement in mass effect. Venous infarct in right thalamic pulvinar region. Area is involved in attention/neglect. Demonstrated left neglect and homonomyous hemianopsia. No changes in neuro exam means no need for further work-up. Continued keppra BID for seizure ppx. On ___ pt had one episode of loss of consciousness, urinary incontinence and bilateral upper extremity tremors, after which Keppra was uptitrated to 1000 BID with no further issues. On ___ patient started to c/o headache and nausea/vomiting and increased right temporal swelling was noted. MRI head showed mildly increasing extra-axial fluid collection in the right middle cranial fossa compatible with arachnoid cyst with mild mass effect on the right temporal lobe. Repeat CT head showed status post right temporoparietal craniotomy with stable postoperative changes. No increase in cerebral edema in the parietal and occipital lobes. Unchanged 3 mm leftward midline shift and stable. No new intracranial hemorrhage, large territorial infarction, or mass. Patient received dexamethasone and symptom relief treatment and patient's symptoms resolved. Her anticoagulation was held. On Needs to continue to wear helmet whenever ambulating. Will follow up with neurosurgery for repeat MRI and outpt appt with ___. Should discuss plan to replace skull bone at this time. No platelet goal per neurosurgery. # Unstable gait: Likely secondary to intraparenchymal hemorrhage with subsequent intracranial edema and deconditioning. As per ___, patient was at high risk for deconditioning but with persistent ambulation and working with ___ patient significantly improved. Discharged with 24 hour supervision at home. Will need to continue to wear the helmet whenever out of bed. # Pupil-sparing CNIII palsy: R eye down and out w/ ptosis. Failure to adduct past midline. Pupils are equal and reactive to light, no afferent defect. These findings support nuclear involvement vs chronic CNIII. Neuroophtho endorsed CN III palsy OD and likely CN IV palsy with L homonymous hemianopsia and ataxia. Improved on exam with time and dexamethasone in the setting of resolving intracranial edema. Will follow up with neuroopthalmology for a repeat evaluation. # Anemia: Likely secondary to chemotherapy/malignancy rather than acute blood loss. s/p 1U pRBC during time in ___ ICU and has received transfusions after transferring to the floor. Upon discharge hemolysis labs unremarkable, and with resolved vaginal spotting. She received 1u RBC on the day of discharge. RESOLVED ISSUES ================ # Dysphagia/nutrition # Mucositis Speech and swallow saw patient ___ and approved her for a regular diet. Dysphagia previously secondary to acute insult from IPH and intubation. NGT pulled out. No residual issues. Patient developed mucositis which caused decreased oral intake and TPN has been started. Patient's mucositis has improved and she is able to eat and drink normally on discharge. We discontinue her TPN on discharge. # Neutropenic fever Patient had 1 episode of fever on ___. She was started on cefepime and pan-cultures were obtained. Unclear source and patient had been afebrile since. Cefepime was discontinued on ___ and patient continues to be afebrile. # S/p 3 month Post Partum Patient's breast milk initially thought to be a hazard iso HD MTX. With less frequent pumping and active chemotherapy, the breast milk volume decreased and production eventually stopped. # Orthostatic hypotension Improved with IVF prn for orthostasis ___ poor PO intake, and resolved after more persistent ambulation. It has been resolved. # GERD Hpylori negative. Improved symptoms with ranitidine 150 mg PO BID and tums prn. # Insomnia Patient says pain was what was keeping her up instead of issues with getting to sleep. Improved with pain improvement and able to ambulate. Received ramelteon and trazodone PRN. TRANSITIONAL ISSUES ================== DISCHARGE WT: 51.62 kg (113.8 lb) DISCHARGE HGB: 8.0 DISCHARGE WBC: 1.3 (___ 420) [ ] Please check CBC/diff daily after discharge [ ] Needs to wear helmet at all times while ambulating [ ] Rad Onc outpatient follow up for radiation plans; they want repeat imaging and follow up around the same time as neurosurgery [ ] Please check HCG once a week (next one ___ [ ] once HCG negative, will need at least 8 weeks of therapy as per Dr ___ (2 week cycle with HD MTX and chemo) [ ] On discharge, patient and family were given extensive teaching and a calendar outlining which medications to take on what days. Please ensure compliance as able. [ ] Please ensure that an interpreter is booked for all appointments [ ] Please recheck CT abdomen to monitor hepatic mass as outpatient. Recommended Followup: [ ] Please schedule f/u w/ NSGY first week of ___ (4 weeks post craniectomy) for repeat MRI and outpt appt w/ ___ plan for replacement of skull bone [ ] follow up with neuro-optho Dr. ___ in ___ for repeat exam and dilated fundus examination [ ] Please schedule follow up outpatient with gyn Onc as needed [ ] Neurosurgery follow up appointment pending #HCP/Contact: Husband ___ ___ #Code: presumed FULL This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated. Medications on Admission: prenatal vitamin (unsure if still taking) Discharge Medications: 1. Calcium Carbonate 1000 mg PO QID:PRN heartburn 2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 3. Dexamethasone 4 mg PO BID on days 2,3,9,10 of chemotherapy cycle RX dexamethasone [Decadron] 4 mg 1 tablet(s) by mouth twice a day Disp #8 Tablet Refills:5 4. Docusate Sodium 100 mg PO BID 5. Filgrastim-sndz 300 mcg SC Q24H Duration: 5 Days on days ___ and ___ of chemotherapy cycle RX filgrastim-sndz [Zarxio] 300 mcg/0.5 mL 300 mcg SC once a day Disp #11 Syringe Refills:4 6. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line flush 7. Leucovorin Calcium 15 mg PO Q6H Duration: 18 Doses Start 24 hours after START of methotrexate infusion . RX leucovorin calcium 15 mg 1 tablet(s) by mouth every six (6) hours Disp #18 Tablet Refills:0 8. LevETIRAcetam 1000 mg PO BID RX levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 9. LORazepam 0.5 mg PO Q8H:PRN nausea/insomnia hold for sedation RX lorazepam [Ativan] 0.5 mg 1 tab by mouth every eight (8) hours Disp #30 Tablet Refills:1 10. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID RX alum-mag hydroxide-simeth [Maalox Maximum Strength] 400 mg-400 mg-40 mg/5 mL 5 mL by mouth four times a day Disp #710 Milliliter Milliliter Refills:0 11. Ondansetron 8 mg PO TID on days 2,3,9,10 of chemotherapy cycle, then 8 hours prn RX ondansetron 8 mg 1 tablet(s) by mouth three times a day Disp #35 Tablet Refills:3 12. OxycoDONE Liquid ___ mg PO Q6H:PRN Pain - Moderate RX oxycodone 5 mg ___ tabs by mouth every six (6) hours Disp #10 Tablet Refills:0 13. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting RX prochlorperazine maleate [Compazine] 10 mg 1 tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:3 14. Ranitidine 150 mg PO BID RX ranitidine HCl 150 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 15. Senna 17.2 mg PO BID RX sennosides 8.6 mg 17.2 mg by mouth twice a day Disp #60 Tablet Refills:0 16. Sodium Bicarbonate 1300 mg PO TAKE 1 PRIOR TO MTX CHEMOTHERAPY Please take 1 tab prior to presenting for MTX chemo RX sodium bicarbonate 650 mg 2 tablet(s) by mouth Take one prior to presenting for MTX chemotherapy Disp #30 Tablet Refills:0 17. Sodium Bicarbonate 1300 mg PO ONCE Duration: 1 Dose Take one prior to presenting for MTX chemotherapy. RX sodium bicarbonate 650 mg 2 tablet(s) by mouth once Disp #2 Tablet Refills:*0 18.Rollator Walker Dx: Choriocarcinoma ICD 10: C58 Length of need: 13 months Prognosis: good Discharge Disposition: Home Discharge Diagnosis: Right intraparenchymal hemorrhage with intraventricular hemorrhage Cerebral compression Metastatic gestational trophoblastic neoplasm with metastases to the liver, lungs, and brain Cranial nerve three palsy Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane)(needs to wear helmet while ambulating) Discharge Instructions: Dear Ms ___, WHY DID YOU COME TO THE HOSPITAL? - You had a headache and were found to have bleeding in your brain. WHAT WE DID FOR YOU - You had surgery to remove the blood from the brain which involved removing a piece of the skull - You were found to have a metastatic cancer from your pregnancy that had spread to the brain, liver, and lungs that caused the brain bleed - You were started on chemotherapy and watched carefully to make sure you tolerated it - Your cancer numbers (HCG hormone) came down tremendously with chemotherapy, which is good news - You had an issue with moving your right eye and you saw neuro-ophthalmology for this, but it improved significantly - Your walking was unstable but the physical and occupational therapists worked closely with you and your walking improved - Your swallowing was initially impaired but improved to normal so the feeding tube was removed - You received a blood transfusion for dropping blood counts, likely because of chemotherapy - You were pumping your breast milk but it eventually stopped coming - You received a port placement for chemotherapy - You underwent a CT abdomen which showed 12 mm hyperenhancing lesion in the right hepatic lobe is bigger. - You underwent MRI head and CT head which showed craniotomy post-operative change. WHAT YOU SHOULD DO WHEN YOU LEAVE - Please make sure you are under 24 supervision at all times with walking and with tasks. You are not completely healed yet and cannot do your normal routine without supervision to prevent injury to yourself! - You NEED to wear your helmet every time you get out of bed or are walking inside or outside. Your brain is still very tender and there is risk for bleeding again if you fall or hit your head - You need to follow up regularly in clinic with Dr ___ chemotherapy as well as for inpatient methotrexate every other week - Please take all your medications as prescribed and follow up with all the doctors below It was a pleasure caring for you, we wish you the best!! Sincerely, Your ___ Care Team Followup Instructions: ___
10809830-DS-28	10,809,830	28,710,771	DS	28	2170-03-13 00:00:00	2170-03-13 17:10:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Gentamicin / Diltiazem / Plavix / Sulfa (Sulfonamide Antibiotics) / IV Dye, Iodine Containing / Vancomycin / Ativan / Clindamycin / ciprofloxacin Attending: ___. Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMH CAD (with CABG in ___, multiple PCIs), Afib, HTN, DM, who is presenting with chest pain. This has been occurring intermittently over the last two days. He noticed the pain immediately after getting into an argument with his daughter. He reports substernal pain that radiates to the back. The pain is pleuritic but nonexertional. He has noticed shortness of breath. He denies fever, chills, cough, hemoptysis, abdominal pain, nausea, vomiting. He has chronic history of left leg swelling which is his baseline since he had vein stripping performed in the past. No history of DVT, PE, but has prostate cancer in past. He took aspirin prior to arrival. In the ED initial vitals were: no temp 76 112/55 17 98% RA EKG: SR 79, QTc 471, QRS 150, Qwaves II, III, AVF, AVR, V1-V3. Labs/studies notable for: WBC 10.5, Hgb 11.1, K 5.2, Creat 1.5 INR 1.2, normal LFTS, trop 0.19->0.29, normal MB x2, lactate 1.4. UA showed large leuks, WBC 182, negative nitrate, many bacteria. Exam with nontender prostate. Chest Xray with low lung volume and persistent R hemidiaphragm elevation. Patient was given: Ceftriaxone Vitals on transfer: 98.2 62 120/50 17 97% RA Consulted: Cards was consulted who recommended admit for rising troponin. On the floor the patient had no complaints. ROS: On review of systems, denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Denies recent fevers, chills or rigors. Denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. Coronary artery disease with prior CABG in ___. 2. Abrupt occlusion of a vein graft to the OM in ___ in the setting of brief aspirin discontinuation for prostate biopsy. He has had subsequent multiple PCIs. 3. Atrial fibrillation, currently managed with low-dose amiodarone and dabigatran for thromboembolic prophylaxis. 4. Hypertension. 5. Diabetes mellitus. 6. PMR on chronic prednisone Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; Family history is significant for father who died at age ___ of heart attack and coronary artery disease. His mother died in her ___ of a heart attack and coronary artery disease. He has a brother with lymphoma and sarcoma. Physical Exam: ADMISSION PHYSICAL EXAM VS: 97 110/51 68 20 96% 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 xanthelasma. NECK: Supple with no elevated JVP. CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric DISCHARGE PHYSICAL EXAM Vitals: 98.4 ___ 54-71 ___ 95-100%RA I/O= ___ (8hrs), 480/780 (24hrs) GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP not elevated. CARDIAC: RRR, normal S1, S2. II/VI systolic murmur loudest at RUSB. LUNGS: Very mild crackles at R base. Breathing comfortably without accessory muscle use. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. B/l lower extremities thin. R knee with non-tender swelling around patella. No overlying redness or warmth. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: b/l 2+ DP and ___ Pertinent Results: ADMISSION LABS ___ 01:10PM WBC-10.5# RBC-3.72 HGB-11.1* HCT-35.1* MCV-94 MCH-29.8 MCHC-31.6* RDW-14.5 RDWSD-49.9* ___ 01:10PM NEUTS-83.3* LYMPHS-6.2* MONOS-9.0 EOS-0.7* BASOS-0.3 IM ___ AbsNeut-8.75# AbsLymp-0.65 AbsMono-0.95* AbsEos-0.07 AbsBaso-0.03 ___ 01:10PM PLT COUNT-178 ___ 01:10PM cTropnT-0.19* ___ 01:10PM LIPASE-20 ___ 01:10PM ALT(SGPT)-13 AST(SGOT)-21 CK(CPK)-84 ALK PHOS-99 TOT BILI-0.4 ___ 01:10PM GLUCOSE-215* UREA N-45* CREAT-1.5* SODIUM-138 POTASSIUM-5.2* CHLORIDE-104 TOTAL CO2-22 ANION GAP-17 ___ 02:45PM URINE RBC-20* WBC->182* BACTERIA-MANY YEAST-NONE EPI-1 ___ 02:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG ___ 02:45PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 04:37PM LACTATE-1.4 ___ 06:28PM CK-MB-7 cTropnT-0.29* proBNP-8424* ___ 06:28PM CK(CPK)-69 PERTINENT LABS DURING ADMISSION ___ 01:10PM BLOOD cTropnT-0.19* ___ 06:28PM BLOOD CK-MB-7 cTropnT-0.29* proBNP-8424* ___ 03:11AM BLOOD CK-MB-6 cTropnT-0.19* ___ 06:20AM BLOOD CK-MB-5 cTropnT-0.15* DISCHARGE LABS ___ 06:40AM BLOOD WBC-5.6 RBC-3.55* Hgb-10.4* Hct-34.0* MCV-96 MCH-29.3 MCHC-30.6* RDW-14.4 RDWSD-50.2* Plt ___ ___ 06:40AM BLOOD ___ PTT-30.3 ___ ___ 06:40AM BLOOD Glucose-115* UreaN-44* Creat-1.3* Na-140 K-4.3 Cl-104 HCO3-27 AnGap-13 ___ 06:40AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.1 MICRO URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S STUDIES CXR ___: Low lung volumes and persistent elevation of the right hemidiaphragm. No focal consolidation to suggest pneumonia. No pulmonary edema. TTE ___: LVEF 40-45% Mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction c/w CAD (PDA distribution). Severe mitral regurgitation. Mild pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of ___, the severity of mitral regurgitation has increased and trivial aortic valve stenosis is now present. Regional and global left ventricular systolic function is similar. No aortic regurgitation is seen on the current study. CLINICAL IMPLICATIONS: The patient has severe mitral regurgitation. Based on ___ ACC/AHA Valvular Heart Disease Guidelines, a follow-up echocardiogram is suggested in ___ months. Brief Hospital Course: ___ with ___ CAD s/p CABG and PCIs (10 total, last in ___, Afib on amiodorone, DM, HTN who presents with atypical chest pain admitted for rising troponins. # Atypical Chest Pain. Troponin peaked at 0.29 while in the ED, without recurrence of chest pain symptoms during hospitalization. No significant EKG changes were noted. He was not started on heparin. Repeat TTE showed mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction consistent with CAD in PDA distribution. Also showed severe mitral regurgitation and mild pulmonary artery systolic hypertension. Given increase in severity of mitral regurgitation, follow up echocardiogram recommended in ___ months. He was continued on his home medications ASA, Lisinopril, Furosemide, Metoprolol and Simvistatin. Given his extensive past PCI, in addition to his age, comorbidities and atypical nature of his chest pain symptoms, he did not undergo additional PCI. He was continued on medical management. Troponin downtrended with treatment for UTI and patient remained chest pain free at time of discharge. # UTI. He was noted to have a UA positive for infection, with symptoms of dysuria. Urine culture showed E. coli, resistent to ampicillin, ampicillin/sulbactam, and cefazolin. He was treated with Ceftriaxone IV and switched to cefpodoxime to complete a 10 day course of therapy for complicated UTI on ___. Chronic Issues # Atrial fibrillation. He remained in SR on telemetry during his admission. He was continued on amiodorone and metoprolol. He was taken off apixaban at some point prior to admission by his outpatient cardiologist Dr. ___. This was not restarted during admission. # CKD. Cr remained near baseline 1.3. He was continued on home lasix. # Diabetes mellitus. Home glipizide was held and he was continued on ISS. Transitional Issues * - Repeat TTE done ___ with read pending as of patient's discharge. Given worsening of severe MR, patient will need follow up TTE in ___ months. - To complete 10 day course of cefpodoxime for UTI on ___. - Please follow-up blood culture pending from ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1 Start: ___, First Dose: Next Routine Administration Time 2. Amiodarone 100 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Ferrous Sulfate 325 mg PO DAILY 5. Finasteride 5 mg PO DAILY 6. Furosemide 20 mg PO BID 7. Lisinopril 5 mg PO DAILY 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Simvastatin 20 mg PO DAILY 11. flunisolide 25 mcg (0.025 %) nasal prn congestion 12. GlipiZIDE XL 1.25 mg PO DAILY 13. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 14. Nitroglycerin SL 0.4 mg SL PRN chest pain 15. Vesicare (solifenacin) 10 mg oral daily 16. Vitamin D ___ UNIT PO 1X/WEEK (___) 17. Polyethylene Glycol 17 g PO DAILY:PRN constipation 18. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Amiodarone 100 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Ferrous Sulfate 325 mg PO DAILY 5. Finasteride 5 mg PO DAILY 6. Furosemide 20 mg PO BID 7. Lisinopril 5 mg PO DAILY 8. Nitroglycerin SL 0.4 mg SL PRN chest pain 9. Omeprazole 20 mg PO DAILY 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Simvastatin 20 mg PO DAILY 12. flunisolide 25 mcg (0.025 %) nasal prn congestion 13. GlipiZIDE XL 1.25 mg PO DAILY 14. Vesicare (solifenacin) 10 mg oral daily 15. Vitamin D ___ UNIT PO 1X/WEEK (___) 16. Cefpodoxime Proxetil 200 mg PO Q12H RX cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #15 Tablet Refills:*0 17. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 18. Metoprolol Succinate XL 25 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis - Atypical Angina - Urinary Tract Infection Secondary Diagnosis - Atrial fibrillation - Hypertension - Hyperlipidemia - Diabetes - Prostate Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you during your hospitalization at ___. Briefly, you were hospitalized with chest pain. You were also found to have a UTI and you were started on IV antibiotics. You will continue taking oral antibiotics (Cefpodoxine) until ___. Please weigh yourself every morning, call MD if weight goes up more than 3 lbs. We wish you the best, Your ___ Treatment Team Followup Instructions: ___
10809830-DS-29	10,809,830	27,831,894	DS	29	2170-03-29 00:00:00	2170-03-29 14:13:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Penicillins / Erythromycin Base / Gentamicin / Diltiazem / Plavix / Sulfa (Sulfonamide Antibiotics) / IV Dye, Iodine Containing / Vancomycin / Ativan / Clindamycin / ciprofloxacin Attending: ___. Chief Complaint: R hip fracture Major Surgical or Invasive Procedure: R hip ORIF with DHS History of Present Illness: ___ M with CAD s/p CABG and PCI (on ASA) presents with R hip fracture s/p mechanical fall. He tripped while ambulating with his walker this morning and fell on his right side, with immediate pain about the right hip and inability to ambulate. He denies numbness, tingling, or pain elsewhere. He was initially taken to ___, then transferred to ___ in order to undergo pre-operative evaluation by his established cardiac team. Past Medical History: 1. Coronary artery disease with prior CABG in ___. 2. Abrupt occlusion of a vein graft to the OM in ___ in the setting of brief aspirin discontinuation for prostate biopsy. He has had subsequent multiple PCIs. 3. Atrial fibrillation, currently managed with low-dose amiodarone and dabigatran for thromboembolic prophylaxis. 4. Hypertension. 5. Diabetes mellitus. 6. PMR on chronic prednisone Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; Family history is significant for father who died at age ___ of heart attack and coronary artery disease. His mother died in her ___ of a heart attack and coronary artery disease. He has a brother with lymphoma and sarcoma. Physical Exam: Right lower extremity: - Dsg cdi - Fires ___ - SILT S/S/SP/DP/T distributions - 1+ ___ pulses, WWP Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have R intertrochanteric hip fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for R hip DHS, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is WBAT in the right lower extremity, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up with ___ trauma team per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 100 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Ferrous Sulfate 325 mg PO DAILY 4. Finasteride 5 mg PO DAILY 5. Furosemide 10 mg PO DAILY 6. Lisinopril 5 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Simvastatin 20 mg PO QPM 9. Flunisolide Inhaler 80 mcg/actuation inhalation DAILY:PRN congestion 10. GlipiZIDE XL 1.25 mg PO DAILY 11. Vesicare (solifenacin) 10 mg oral DAILY 12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 13. Metoprolol Succinate XL 25 mg PO DAILY 14. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral DAILY 15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 16. Polyethylene Glycol 17 g PO DAILY 17. Docusate Sodium 100 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Ferrous Sulfate 325 mg PO DAILY 3. Finasteride 5 mg PO DAILY 4. Furosemide 20 mg PO BID 5. GlipiZIDE XL 1.25 mg PO DAILY 6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 7. Lisinopril 5 mg PO DAILY 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Simvastatin 20 mg PO QPM 11. Acetaminophen 1000 mg PO Q8H 12. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 13. Docusate Sodium 100 mg PO BID 14. Enoxaparin Sodium 40 mg SC Q24H RX enoxaparin [Lovenox] 40 mg/0.4 mL 1 syringe sq once a day Disp #24 Syringe Refills:0 15. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #20 Tablet Refills:0 16. Polyethylene Glycol 17 g PO DAILY:PRN constipation 17. Senna 8.6 mg PO BID 18. solifenacin 5 mg oral BID 19. Vitamin D 400 UNIT PO DAILY 20. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 21. Flunisolide Inhaler 80 mcg/actuation inhalation DAILY:PRN congestion 22. Vesicare (solifenacin) 10 mg ORAL DAILY 23. Amiodarone 100 mg PO DAILY 24. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral DAILY 25. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting RX ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #20 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: R hip intertrochanteric fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Weight bearing as tolerated in right lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Lovenox 40mg daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. - If applicable, splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Physical Therapy: Activity: Activity: Out of bed w/ assist Right lower extremity: Full weight bearing, can weight bear as tolerated Left lower extremity: Full weight bearing Encourage turning, deep breathing and coughing qhour when awake. Treatments Frequency: Site: Incision Type: Surgical Dressing: Gauze - dry Comment: on AM of POD 3 by ___, then daily by RN as needed; please overwrap any dressing bleedthrough with ABD's and ACE. Followup Instructions: ___
10809830-DS-30	10,809,830	24,153,916	DS	30	2170-06-15 00:00:00	2170-06-15 19:07:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Gentamicin / Diltiazem / Plavix / Sulfa (Sulfonamide Antibiotics) / IV Dye, Iodine Containing / Vancomycin / Ativan / Clindamycin / ciprofloxacin Attending: ___. Chief Complaint: Lower extremity swelling Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with history of coronary artery disease (s/p CABG ___ and multiple PCIs, last NSTEMI ___ managed medically), afib not on anticoagulation, and CHF with EF 40-45% admitted with CHF exacerbation. The patient's daughter, who is a ___, noticed bilateral progressive lower extremity edema up to the thighs. The patient's wife called his PCP who referred him to the emergency room. The patient's daughter also feels as though he is slightly confused. The patient denies any recent chest pain or shortness of breath. He states that he is complaint with taking 20mg Lasix daily. He denies any change in diet. - In the ED, initial vitals were: T 98.3 HR 82 BP 129/89 RR 18 O2 97%RA - Exam notable for bilateral pitting edema to thighs - Labs notable for mild, chronic anemia, Cr 1.4 at baseline, Na 141, K 5.2, Cl 107, HCO3 23. Trop <0.01 at 1350, BNP 14771 - Imaging notable for CXR with Mild to moderate interstitial edema may be slightly exaggerated due to low lung volumes. - Patient was given 20mg IV Lasix at 1600 - Patient was discussed with primary cardiologist Dr. ___ ___ agrees with admission to CHF service Vitals prior to transfer 97.4 94 134/72 18 96% RA On the floor, patient was stable. Denies SOB. However agrees his BLE look more swollen than usual, L>R (though chronically has been L>R swelling to a lesser extent). ROS: Full 10 pt review of systems negative except for above. (-) Denies fever, chills, night sweats, Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: 1. Coronary artery disease: s/p CABG in ___, s/p multiple PCIs (10 total, last in ___, Last NSTEMI ___ managed medically 2. Abrupt occlusion of a vein graft to the OM in ___ in the setting of brief aspirin discontinuation for prostate biopsy. 3. Atrial fibrillation, currently managed with low-dose amiodarone and dabigatran for thromboembolic prophylaxis. 4. Hypertension. 5. Diabetes mellitus. 6. PMR on chronic prednisone 7. CKD 8. CHF with EF 40-45% 9. Hip fracture s/p repair ___ 10. Recurrent UTIs Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; Family history is significant for father who died at age ___ of heart attack and coronary artery disease. His mother died in her ___ of a heart attack and coronary artery disease. He has a brother with lymphoma and sarcoma. Physical Exam: ADMISSION: Vitals: T: 97.4 BP: 127/70 P: 93 R: 28 O2: 95% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Crackles at bases.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. Presence of significant edema upto knees. L>R DISCHARGE EXAM VS: 97.4 ___ 98-122/83-70 18 100% RA Weight: 64.7 kg ___ yesterday) I/O: ___ last 32 hr General: alert and oriented, NAD, normal affect HEENT: Sclera anicteric, MMM, conjunctivae noninjected Neck: JVP 1 cm above clavicle Lungs: Crackles midway up left lung, right basilar crackles, otherwise no wheezes or rhonchi CV: Regular rate and rhythm, systolic murmur best heard at apex, otherwise no rubs or gallops Abdomen: soft, non-tender, non-distended Ext: Warm, well perfused, 1+ pitting edema in LLE, trace in right Pertinent Results: ADMISSION: ___ 01:50PM BLOOD WBC-5.5 RBC-3.92* Hgb-11.9# Hct-39.4# MCV-101# MCH-30.4 MCHC-30.2 RDW-15.2 RDWSD-56.1* Plt ___ ___ 01:50PM BLOOD Neuts-71.8* Lymphs-16.2* Monos-8.4 Eos-2.6 Baso-0.5 Im ___ AbsNeut-3.93# AbsLymp-0.89* AbsMono-0.46 AbsEos-0.14 AbsBaso-0.03 ___ 01:50PM BLOOD ___ PTT-30.9 ___ ___ 01:50PM BLOOD Glucose-108* UreaN-50* Creat-1.4* Na-141 K-5.2* Cl-107 HCO3-23 AnGap-16 ___ 01:50PM BLOOD Albumin-4.2 Calcium-9.4 Phos-3.9 Mg-2.4 ___ 01:50PM BLOOD ___ ___ 01:50PM BLOOD cTropnT-<0.01 ___ 08:12PM BLOOD cTropnT-<0.01 PERTINENT LABS ___ 07:50AM BLOOD Glucose-90 UreaN-51* Creat-1.1 Na-144 K-4.6 Cl-108 HCO3-27 AnGap-14 ___ 06:10AM BLOOD Glucose-77 UreaN-58* Creat-1.4* Na-145 K-4.2 Cl-106 HCO3-28 AnGap-15 ___ 06:10AM BLOOD ___ ___ 02:39PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 03:39PM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 DISCHARGE LABS ___ 07:00AM BLOOD WBC-8.1 RBC-3.72* Hgb-11.4* Hct-35.9* MCV-97 MCH-30.6 MCHC-31.8* RDW-14.9 RDWSD-52.7* Plt ___ ___ 07:00AM BLOOD Glucose-113* UreaN-61* Creat-1.5* Na-135 K-4.4 Cl-94* HCO3-29 AnGap-16 ___ 08:10AM BLOOD proBNP-6448* ___ 07:00AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.3 MICROBIOLOGY: ___ URINE CULTURES: NEGATIVE ___ BLOOD CULTURE: NEGATIVE IMAGING: ___ CHEST X RAY: Mild to moderate interstitial edema may be slightly exaggerated due to low lung volumes. Persistent elevation of the right hemidiaphragm. ___ LEFT ___: No evidence of deep venous thrombosis in the left lower extremity veins. Biphasic respiratory variation within bilateral common femoral veins compatible with right-sided heart failure. ___ CHEST X RAY: IN COMPARISON WITH THE STUDY OF ___, THERE AGAIN ARE VERY LOW LUNG VOLUMES. CONTINUED ENLARGEMENT OF THE CARDIAC SILHOUETTE, BUT DRAMATIC IMPROVEMENT IN THE DEGREE OF PULMONARY VASCULAR CONGESTION. NO EVIDENCE OF ACUTE FOCAL PNEUMONIA. ___ CT HEAD NON-CON: No acute intracranial abnormality. Brief Hospital Course: BRIEF SUMMARY ============= ___ is an ___ year old man with a history of CAD (s/p CABG ___ and multiple PCIs), afib not on anticoagulation, and ischemic cardiomyopathy (EF 40-45%) who presented with bilateral ___ edema consistent with CHF exacerbation. ACUTE ISSUES ============ # Acute on chronic systolic heart failure: Patient with known ischemic cardiomyopathy with preserved EF. He was grossly volume overloaded on clinical exam with pulmonary edema on chest X ray and an elevated BNP. Decompensation likely occurred in the setting of decreased home Lasix from 20 mg BID to 10 mg per day with doses missed about once per week. Per the patient, these changes had been made to avoid frequent urination after consulting with Dr. ___. He was diuresed with bolus IV Lasix to a dry weight of 64.7 kg. His Lasix was switched to Torsemide 20 mg po daily # Urinary retention: Patient developed urinary retention on ___ and also was noted to have clots in his urine. A Foley was placed with return of clear urine. He had no history of recent urinary trauma. The Foley was removed prior to discharge and Mr. ___ was able to void. He follows with urology (has seen Dr. ___ in the past but primarily follows with Dr. ___ and will follow up following discharge. # Encephalopathy: Mr. ___ developed altered mental status and agitation on ___. An infectious workup (blood/urine cultures and chest X ray) was negative and a CT head was unremarkable. His AMS was thought to be due to urinary retention as it resolved subsequent to resolution of this. While agitated, he was initially treated with Haldol but this had to be avoided ultimately due to QTc prolongation (502 ms). #CAD: s/p CABG in ___ with multiple PCIs. Mr. ___ was chest-pain free and had two negative troponins in the ED. He was continued on his home simvastatin, metoprolol, lisinopril, and aspirin. #Paroxysmal atrial fibrillation: Patient previously on warfarin but now only on aspirin for anticoagulation given his age. Aspirin and amiodarone continued. #DM: Patient's home glipizide was held and he was treated with SSI. #GERD: Patient continued on his home omeprazole. #BPH: Patient continues on his home finsteride 5 mg. He is not on tamsulosin due to hypotension. # Iron deficiency anemia: Patient continued on home ferrous sulfate with bowel regimen. Transitional issues: =============================== -Home Lasix changed to Torsemide 20 mg po daily, home metoprolol switched to carvedilol 6.25 bid for afterload reduction in setting of worsening MR. ___ cardiac regimen unchanged; on home ACE, statin, asa, amiodarone. -Discharge weight 64.7 kg, d/c creatinine 1.5 -Will need follow up with urology after discharge. He has seen Dr. ___ in the past but primarily follows with Dr. ___. Patient had delirium in house ___ urinary obstruction, relieved with foley placement, and had successful voiding trial with d/c of foley prior to discharge - CONTACT: ___ (wife and HCP) ___ Dr. ___ ___ ___ - CODE: Full code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Ferrous Sulfate 325 mg PO DAILY 3. Finasteride 5 mg PO DAILY 4. Furosemide 10 mg PO DAILY 5. GlipiZIDE XL 1.25 mg PO DAILY 6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 7. Lisinopril 5 mg PO DAILY 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Simvastatin 20 mg PO QPM 11. Acetaminophen 1000 mg PO Q8H 12. Bisacodyl 10 mg PO DAILY:PRN constipation 13. Docusate Sodium 100 mg PO BID 14. Polyethylene Glycol 17 g PO DAILY:PRN constipation 15. Senna 8.6 mg PO BID 16. Vitamin D ___ UNIT PO DAILY 17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 18. Flunisolide Inhaler 80 mcg/actuation inhalation DAILY:PRN wheeze/sob 19. Amiodarone 100 mg PO DAILY 20. Tamsulosin 0.4 mg PO DAILY 21. Align (bifidobacterium infantis) 4 mg oral DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Amiodarone 100 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Bisacodyl 10 mg PO DAILY:PRN constipation 5. Docusate Sodium 100 mg PO BID 6. Ferrous Sulfate 325 mg PO DAILY 7. Finasteride 5 mg PO DAILY 8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 9. Lisinopril 5 mg PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Polyethylene Glycol 17 g PO DAILY:PRN constipation 12. Senna 8.6 mg PO BID 13. Simvastatin 20 mg PO QPM 14. Vitamin D ___ UNIT PO DAILY 15. Carvedilol 6.25 mg PO BID 16. Lidocaine 5% Patch 1 PTCH TD DAILY knee pain 17. Torsemide 20 mg PO DAILY 18. Align (bifidobacterium infantis) 4 mg oral DAILY 19. Flunisolide Inhaler 80 mcg/actuation inhalation DAILY:PRN wheeze/sob 20. GlipiZIDE XL 1.25 mg PO DAILY 21. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 22. Tamsulosin 0.4 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnoses: Acute on Chronic Diastolic heart failure Urinary retention Hematuria Encephalopathy Secondary diagnoses: Coronary artery disease Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You were hospitalized at ___ because you had developed worsening swelling in your legs. This was due to your congestive heart failure, which causes excess fluid to build up in your body. We treated you with a medication through your IV to remove this fluid, called Lasix. We have increased the amount of Lasix you should take at home to prevent you from coming back to the hospital. You should weigh yourself every morning, and call your doctor if your weight goes up more than 3 lbs. While you were in the hospital you also had difficult urinating and had some blood in your urine, so a catheter was placed. You should follow up with your urologist after you leave the hospital. You became confused while you were in the hospital; this was likely due to your inability to urinate. It was a pleasure participating in your care. We wish you all the best in the future. Sincerely, Your ___ team Followup Instructions: ___
10809859-DS-10	10,809,859	28,177,364	DS	10	2133-04-29 00:00:00	2133-04-29 12:18:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Amoxicillin Attending: ___. Chief Complaint: R forearm abscesses Major Surgical or Invasive Procedure: ___: Irrigation/debridement of right forearm abscesses History of Present Illness: ___ F->M transgender w hx of IVDU and PCOS who presented to the ___ ED on ___ with multiple right forearm abscesses located on the dorsal wrist and proximal volar forearm. He has had pain his forearm for a week, which acutely worsened over the past 48 hours. He has hx of abscess in his thigh. He states these abscesses are at the site of prior IV injections. Past Medical History: PCOS Iv drug abuse, last use 14 days prior Social History: ___ Family History: NC Physical Exam: PE Easy work of breathing RUE erythematous, painful fluctuant mass over volar forearm just distal to antecubital fossa. Also smaller mass of dorsal radiocarpal joint. decreased sensation to pinprick throughout hand, particularly dorsally at first web space. Fires EPL/FPL/ DIO/Wrist extensor moderate pain with flexion and extension of digits. 2+ radial pulse Pertinent Results: ___ 03:45AM WBC-11.7* RBC-3.51* HGB-11.3* HCT-32.8* MCV-93 MCH-32.2* MCHC-34.5 RDW-12.3 ___ 03:45AM NEUTS-70.4* ___ MONOS-5.9 EOS-1.6 BASOS-0.3 ___ 03:45AM SED RATE-90* ___ 03:45AM CRP-113.8* ___ 03:45AM GLUCOSE-109* UREA N-8 CREAT-0.7 SODIUM-130* POTASSIUM-3.4 CHLORIDE-96 TOTAL CO2-23 ANION GAP-14 ___ 06:35AM ___ PTT-22.4* ___ Brief Hospital Course: Patient was admitted from ___ ED on ___ with presentation of multiple right forearm abscesses, one on right dorsal wrist and one on proximal volar forearm. General Surgery was consulted and recommended Hand Surgery consult. Evaluation by Hand Surgery showed multiple abscesses requiring surgical I&D. While patient was in the ED he was started on IV vancomycin and clindamycin. He was taken to the OR on ___ for I&D of R forearm abscesses. Cultures were sent from the OR. Postoperatively he was extubated and taking the the PACU without any complications. IV vancomycin and clindamycin were continued pending OR cultures, which showed polymicrobial growth. The clindamycin was changed to ciprofloxacin on POD#1 to cover gram negatives. The patient was transitioned to oral bactrim and ciprofloxacin prior to discharge with the plan to complete a ___ course. Pain was controlled with regional block performed preoperatively by the Anesthesia team and ATC Tylenol, PO oxycodone, and IV morphine for breakthrough. The RUE was kept elevated and OT was consulted to fabricate a volar resting orthoplast splint, which was placed on POD#1. ___ drains x 4 (2 in each incision) were removed on POD#3. DVT prophylaxis with SC heparin was given while patient was in house. He was advanced to a regular diet. At the time of discharge, the right forearm incisions were clean and healing with no evidence of further abscesses. Patient was tolerating a diet, voiding, and afebrile. Pain was controlled. The patient was discharged on PO antibiotics with follow-up in Hand Clinic. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin 500 mg 1 tablet(s) by mouth twice a ___ Disp #20 Tablet Refills:0 3. Sulfameth/Trimethoprim DS 1 TAB PO BID RX sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth twice a ___ Disp #20 Tablet Refills:0 4. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth Q3-4 Hours Disp #60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Right forearm abscesses Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Wound Care: - Keep Incision clean and dry. - You can get the wound wet or take a shower starting from 7 days after surgery, but no baths or swimming for at least 4 weeks. - Dry sterile dresssing may be changed daily. No dressing is needed if wound continues to be non-draining. - Any stitches or staples that need to be removed will be taken out at your follow up appointment. Activity: - Elevate right arm to reduce swelling and pain. - Keep splint/dressing clean/dry. Other Instructions - Resume your regular diet. - Avoid nicotine products to optimize healing. Medications - Please complete all antibiotics as prescribed. - Resume your home medications. Take all medications as instructed. - 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. Please follow-up on ___ at the Hand Clinic located at ___, ___, ___ Center, ___ floor. To make an appointment, please call ___ Please follow-up with your primary care physician regarding this admission. Physical Therapy: Keep right upper extremity elevated and splinted OK to come out of splint for range of motion as tolerated No weight bearing restrictions Treatments Frequency: Keep right arm elevated and splinted Daily dressing changes with clean dry gauze Continue antibiotics as prescribed Followup Instructions: ___
10810206-DS-15	10,810,206	25,210,564	DS	15	2137-07-13 00:00:00	2137-07-14 08:48:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: naproxen / Ativan / Percocet / Detrol Attending: ___ Chief Complaint: nausea, dry heaving emesis Major Surgical or Invasive Procedure: None this hospitalization History of Present Illness: This is an ___ year-old Female with a PMH significant for CAD, pulmonary emboli (s/p IVC filter), renal mass, prior TIAs, HTN, HLD, and CHF (EF 40-45%) with recent admission for cholecystitis (complicated by an NSTEMI and Klebsiella bacteremia) in ___ which resolved with antibiotics who now presents with confusion and several days of nausea with dry heaving emesis. She is accompanied by her daughter and son-in-law. . In ___, she presented to ___ with an episode of acute cholecystitis with planned ___ percutaneous cholecystostomy due to positive HIDA scan. On arrival to ___, a repeat RUQ ultrasound showed no obstruction or cholecystitis, so this was deferred and she was treated with IV Unasyn transitioned to Levqauin PO (given documented Klebsiella bacteremia at the time, presumed enteric source). . Her acute concerns revolve around 3-days prior to admission, with the onset of nausea with multiple retching episodes daily - there is little vomitus and she has not had diarrhea or loose stools. She was iniitally concernd that this represented another episode of cholecystitis, which prompted her ED evaluation. She is very unclear of the details and looked to her family for help answering questions. She denies abdominal pain. No recent sick contacts. . During this period, some memory lapses have been more apparent. There has been concern given her poor mental performance, which started about ___ ago when her daughter described an episode of acute delirium attributed to Detrol. Over the few ensuing years, she has been hospitalized for a few fractures and prior cholecystitis, and the family thinks she has become more forgetful. She will sit on the bed at night and ask "how do I get ready for bed?" She confuses her home with a nursing home or hospital. Sometimes she gets lost in her home and mistakes one room for another, asking how to navigate between them. She lives with her daughter and son-in-law, and is dependent for all IADLs - she is still able to wash, dress, and groom herself. Per her family, she has had perhaps 5-episodes of TIAs in the past, some unconfirmed. No major strokes or family history of Alzheimers or dementia of note. . All of these symptoms of memory loss have become more common recently. She is also noting significant fatigue - she apparently had been sleeping from ___ to ___. She otherwise denies recent fevers, chills, diarrhea, dyusuria, hematuria, shortness of breath. She saw her PCP recently who was planning on Neurology referral to work-up this memory loss. . In the ED, initial VS 100.6 88 141/50 18 99% RA. She had minimal abdominal pain and her labs showed only a leukocytosis of 16 (N 84.6%, wihtout bandemia) and hyponatremia to 125. LFTs were normal and RUQ ultrasound showed cholelithiasis without evidence of cholecystitis. Her U/A was positive for 3000 glucose and 30 protein without infection. Lactate 1.4. TSH, vitamin-B12 and folate were normal. Creatinine was 0.8. After 1L of NS x 1 her sodium improved to 129. She was given Zofran 4 mg IV x 1 and admitted to the Medicine service. Past Medical History: MEDICAL & SURGICAL HISTORY: 1. Coronary artery disease (s/p NSTEMI in ___ 2. Diabetes mellitus, type 2 3. Hypertension 4. Klebsiella bacteremia in ___ with episode of acute cholecystitis; improved with antibiotics - did not require percutaneous cholecystostomy tube 5. E.coli bactermia (___) without identifiable source 6. Prior transient ischemic attacks (roughly 2 in the last ___ 7. Left renal mass (4-cm) 8. History of right lower extremity osteomyelitis 9. Osteoarthritis 10. Acute rheumatic fever (age ___ years old) ___. s/p hip replacement in ___ (complicated by DVT/PE and IVC filter) 12. s/p mechanical fall in ___ ___ removal of hardware in her left hip 13. s/p partial hysterectomy (___) 14. s/p three spontaneous vaginal deliveries Social History: ___ Family History: Sister died of CAD. Grandfather and father died of MI. Brother had MI (ages all unknown). Physical Exam: ADMISSION LABS: . VITALS: 100.3 99.7 122/64 92 18 100% RA BG: 309-421 mg/dL I/Os: 1100 \| 1000 GENERAL: Appears in no acute distress. Alert and interactive. Elderly appearing female. HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear. Mucous membranes moist. NECK: supple without lymphadenopathy. JVD not elevated. ___: Regular rate and rhythm, without murmurs, rubs or gallops. S1 and S2 normal. RESP: Clear to auscultation bilaterally without adventitious sounds. No wheezing, rhonchi or crackles. Stable inspiratory effort. ABD: soft, non-tender, non-distended, with normoactive bowel sounds. No palpable masses or peritoneal signs. Negative ___ sign. EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses; right knee osteoarthritic changes, deformity noted. Right leg varicosities. NEURO: awake, oriented to person, read day of month off wall but thought it was ___ unknown year. Knows she is in the hospital but not by name. Knows family members names. ___ of year intact backwards ___, then lost interest. 5 minute recall intact ___ objects. CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait. . DISCHARGE EXAM: . VITALS: 99.1 99.1 142/64 71 20 97% RA BG: 181-289 mg/dL I/Os: 2220 \| 2900 GENERAL: Appears in no acute distress. Alert and interactive. Elderly appearing female. HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear. Mucous membranes moist. NECK: supple without lymphadenopathy. JVD not elevated. ___: Regular rate and rhythm, without murmurs, rubs or gallops. S1 and S2 normal. RESP: Clear to auscultation bilaterally without adventitious sounds. No wheezing, rhonchi or crackles. Stable inspiratory effort. ABD: soft, minimally tender to deep palpation in the RUQ, non-distended, with normoactive bowel sounds. No palpable masses or peritoneal signs. Negative ___ sign. EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses; right knee osteoarthritic changes, deformity noted. Right leg varicosities. NEURO: awake, oriented to person, read day of month off wall but thought it was ___ unknown year. Knows she is in the hospital but not by name. Knows family members names. ___ of year intact backwards ___, then lost interest. 5 minute recall intact ___ objects. CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait. Pertinent Results: ADMISSION LABS: . ___ 05:40PM BLOOD WBC-16.0* RBC-3.86* Hgb-11.2* Hct-32.5* MCV-84 MCH-29.1 MCHC-34.5 RDW-13.3 Plt ___ ___ 05:40PM BLOOD Neuts-84.6* Lymphs-9.7* Monos-5.2 Eos-0.1 Baso-0.3 ___ 05:40PM BLOOD ___ PTT-21.3* ___ ___ 05:40PM BLOOD Glucose-298* UreaN-12 Creat-0.8 Na-125* K-5.3* Cl-87* HCO3-24 AnGap-19 ___ 05:40PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 05:40PM BLOOD Lipase-15 ___ 05:40PM BLOOD ALT-12 AST-36 CK(CPK)-87 AlkPhos-89 TotBili-0.5 ___ 05:40PM BLOOD Albumin-3.6 Calcium-9.9 Phos-2.8 Mg-1.4* ___ 05:40PM BLOOD VitB12-572 Folate-GREATER TH ___ 07:45AM BLOOD %HbA1c-9.3* eAG-220* ___ 05:40PM BLOOD TSH-1.0 . DISCHARGE LABS: . ___ 06:05AM BLOOD WBC-11.2* RBC-3.58* Hgb-10.2* Hct-30.9* MCV-86 MCH-28.6 MCHC-33.1 RDW-13.5 Plt ___ ___ 06:05AM BLOOD Glucose-164* UreaN-9 Creat-0.7 Na-131* K-4.4 Cl-96 HCO3-27 AnGap-12 ___ 06:05AM BLOOD Calcium-9.3 Phos-3.2 Mg-1.8 . URINALYSIS: clear, negative for ___, negative for Nitr, protein 30, glucose 300 . MICROBIOLOGY DATA: ___ Blood culture - E.coli (pan-sensitive) ___ Blood culture - pending ___ RPR serology - non-reactive ___ Urine culture - negative ___ Blood culture (x 2) - pending ___ Blood culture - pending ___ Blood culture - pending ___ Blood culture - pending . IMAGING: ___ LIVER OR GALLBLADDER US - Cholelithiasis without evidence of cholecystitis. The liver echogenicity and echotexture are normal. In the left hepatic lobe, there is a 6 x 4 x 6 mm simple cyst, not significantly changed in size compared to CT from ___. No additional focal liver lesions are seen. There is no intrahepatic biliary duct dilatation. . ___ CHEST (PA & LAT) - No evidence of infection or malignancy. Stable cardiomegaly with no evidence of heart failure. . ___ 2D-ECHO - The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction with inferior and infero-lateral akinesis. The basal inferior wall appears near dyskinetic. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. CAD with prior inferior/infero-lateral MI and moderately reduced LVEF. . ___ CT HEAD WITHOUT CONTRAST - No acute intracranial process. Age-related atrophy, most significant in the midline parasagittal frontal lobes. Less likely this may be a chronic hygroma without mass effect. . ___ CT ABD & PELVIS WITH CO - Uncomplicated cholelithiasis. No evidence for acute cholecystitis. Indeterminate left adrenal lesion which can be further characterized with a wash-in and wash-out CT or MRI when the patient's clinical status has improved. No intra-abdominal abscess or collection identified to correspond to patient's symptom complex. Brief Hospital Course: IMPRESSION: ___ with a PMH significant for CAD, pulmonary emboli (s/p IVC filter), renal mass, prior TIAs, HTN, HLD, and CHF (EF 40-45%) with recent admission for cholecystitis (complicated by an NSTEMI and Klebsiella bacteremia) in ___ which resolved with antibiotics who now presents with worsening confusion and a few months of slow decline in cognitive function with several days of nausea, dry heaving emesis without abdominal pain found to have E.coli bacteremia and leukocytosis. . # E.COLI BACTEREMIA, LEUKOCYTOSIS - Patient presented with non-specific GI complaints, specifically nausea and dry heaving emesis without a biliary component for several days, which was similar to her prior cholecytitis complaints from ___. Her infectious work-up included a CXR, urine and blood cultures which only revealed a positive blood culture (single bottle) speciating pan-sensitive E.coli for which she was treated with IV Unasyn initially and then discharged on IV Cefepime for 14-days, based off of the sensitivity report. The source of her bacteremia was attributed to her biliary tree; likely she develops episodic biliary colic with some inflammation that results in hematogenous spreading of bacteria. Despite the bacteremia, she remained afebrile, without leukocytosis and her mental status appeared at baseline. Her RUQ ultrasound and imaging showed no evidence of acute cholecystitis and her LFTs were reassuring. She was referred to outpatient General Surgery to consider cholecystectomy given her recurrent gram-negative enteric bacteremia with the gall bladder being the likely source. . # HYPONATREMIA - She presented with a sodium of 125, with normal creatinine at 0.7. Baseline sodium 132-134 per our records. She has baseline cognitive impairment, with slow decline over several months without neurologic deficits on admission. Based on her response to fluid administration in the setting of infection, this was likely hypovolemic hyponatremia. She returned to her baseline of 131-134 with fluid resuscitation. . # COGNITIVE DECLINE, PRESUMED DEMENTIA - The patient's baseline mental status decline over several months has been notable, with recent exacerbation per her daughter and son-in-law. Her family offers a history of chronic decline in executive function over the past few years, becoming more pronounced in the recent months, consistent with a dementia. Vascular dementia would seem likely given multiple TIAs in her history. A reversible dementia work-up this admission was reassuring and her head CT imaging was consistent with age-related atrophic changes. She is encouraged to follow-up with Cognitive Neurology as an outpatient. . # DIABETES MELLITUS, TYPE 2 - Patient has no history of retinopathy, neuropathy or chronic kidney disease. Unknown baseline HbA1c. Managed on Metformin therapy and Humilin 70-30 insulin regimen. Blood glucose in the 250-300 mg/dL range this admission with marked glucosuria on admission. We continued her home insulin regimen and resumed her Metformin on discharge. Her HbA1c was 9.3% this admission. . # CORONARY ARTERY DISEASE - Documented coronary disease with prior NSTEMI in ___ surrounding her cholecystitis issues. No active chest pain this admission. EKG on admission reassuring. Cardiac biomarker in the ED was flat. We continued her Aspirin and statin. . # CONGESTIVE HEART FAILURE, DECREASED EF - Last 2D-Echo demonstrated reported LVEF of 40-45% with systolic dysfunction (although no TTE reports in our system). No evidence of volume overload on exam and no CXR evidence of pulmonary congestion this admission. We continued her ACEI, beta-blocker, and Lasix this admission. . # HYPERTENSION, HYPERLIPIDEMIA - Home regimen includes ACEI, beta-blocker and amlodipine, which were continued. Her Pravastatin 80 mg PO daily was also continued. . TRANSITION OF CARE ISSUES: 1. Discharged with Cefepime 2g IV Q12 hours for a total of 14-days with the assistance of ___ and IV services given her E.coli bacteremia. 2. She was scheduled to follow-up with General Surgery regarding possible cholecystectomy given her recurrent bacteremia episodes, likely from an enteric source in the setting of biliary colic and inflammation. 3. She was scheduled with primary care follow-up; at the time of discharge, her surveillance blood cultures were pending but without notable growth. 4. She is encouraged to follow-up with Cognitive Neurology for her chronic dementia concerns. Medications on Admission: HOME MEDICATIONS (confirmed with daughter and son-in-law) 1. Metoprolol succinate 50 mg ER PO daily 2. Lisinopril 20 mg PO daily 3. Potassium chloride 10 mEq PO BID 4. Vicodin ___ mg 2 tablets PO TID PRN pain 5. Pantroprazole 40 mg EC PO daily 6. Pravastatin 80 mg PO daily 7. Humulin 70/30 (30 units SC QAM and QPM) 8. Aspirin 81 mg PO daily 9. Furosemide 40 mg PO daily 10. Amlodipine 5 mg PO daily 11. Metformin 1000 mg PO BID Discharge Medications: 1. cefepime 2 gram Recon Soln Sig: Two (2) grams Injection every twelve (12) hours for 14 days: total of 14-days (started ___, ending ___. Disp:21 doses Refills:0 2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO twice a day. 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. Humulin R 100 unit/mL Solution Sig: Thirty (30) units Injection twice a day. 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush Mid-line, heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above, daily and PRN per lumen. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnoses: 1. Escherichia coli bacteremia . Secondary Diagnoses: 1. Coronary artery disease 2. Diabetes mellitus, type 2 3. Hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Patient Discharge Instructions: . You were admitted to the Internal Medicine service at ___ ___ on ___ regarding management of your blood infection and abdominal complaints. You were found to have a gram-negative enteric organisms in your blood which was treated with IV antibiotics and will continue on these for a total of 14-days. You were feeling well at the time of discharge. You were also discharged with a follow-up appointment with a general surgeon to discuss the possibiility of removing your gallbladder in the near future. . 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. . CHANGES IN YOUR MEDICATION RECONCILIATION: . * Upon admission, we ADDED: START: Ceftriaxone 2 grams IV every 12-hours for 14-days total (started ___, ending ___ . * The following medications were DISCONTINUED on admission and you should NOT resume: DISCONTINUE: Lasix (stop this medication until discussing it with your primary care physician) DISCONTINUE: Vicodin . * You should continue all of your other home medications as prescribed, unless otherwise directed above. Followup Instructions: ___
10810607-DS-23	10,810,607	26,091,872	DS	23	2129-03-19 00:00:00	2129-03-19 15:09:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Prochlorperazine / Sulfa (Sulfonamide Antibiotics) / Meperidine / Indomethacin / Ampicillin Attending: ___. Chief Complaint: Fevers Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F with h/o advanced ___ Disease presenting from her nursing facility due to concern that the patient had increased lethargy and "change in mental status" over the last 24 hours. This was associated with "very poor" po intake and reports that she was feeling weak and noted to be leaning to the left. She had a fever 101.6 recorded at 1pm on the day of admission and she was transferred to the ED for further evaluation. The patient is confused at baseline but able to verbalize her needs. She reportedly was noted to be leaning more to her left. She is incontient of urine and stool. . In the ED, initial vitals 100.0, 85, 133/65, 20, 96%. Labs notable for a white count of 6.7 with 12% bands, an increased BUN, and increased alk phos. Her UA revealed >182 WBCs with large ___ and negative nitrites. She received ceftriaxone 1 gm IV and was admitted to medicine for further management. Vitals prior to transfer: 99.6, 86, 130/87, 96% RA, 20 . Currently, the patient reported feels "ok". She states multiple times that she has ___ disease and appears somewhat confused. She reports that she lives with her Daughter ___ in ___. When prompted, she reports that she has some pain in her abdomen, and points to the b/l lower quadrants and increased urinary frequency. She states that this has been going on for "about a year". She denies burning on urination. . ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, hematuria. Past Medical History: -Advanced Parkinsons Disease -Dementia -HTN -HLD -Spinal stenosis -Depression -s/p left hip replacement Social History: ___ Family History: Non-contributory. Physical Exam: Admission- VS - 96.3, 143/82, 80, 18, 98%RA GENERAL - well-appearing woman in NAD, comfortable, appropriate, lethargic but arousable. HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry mucus membranes, OP with dried orange coating in mouth. NECK - supple, no JVD, no carotid bruits, no cervical LAD LUNGS - CTA bilat anteriorly, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, ___ systolic murmur best heard at that LUSB with mild radiation to the carotid, No other 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), toe nail changes c/w fungal infection SKIN - no rashes or lesions NEURO - lethargic but arousable, A&Ox2, CNs II-XII grossly intact, +hypophonia, sensation grossly intact throughout, +minimal cogwheel rigidity in wrist b/l, +clasp knife spasticity in b/l UE. Discharge- VS - 98.2, 150/82, 84, 16, 98%RA GENERAL - well-appearing woman in NAD, comfortable, appropriate, sleeping but arousable. HEENT - NC/AT, dry mucus membranes but significantly improving, EOMI NECK - supple, no JVD, LUNGS - CTA bilat anteriorly, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, ___ systolic murmur best heard at that LUSB with mild radiation to the carotid (unchanged), No other MRG, nl S1-S2 ABDOMEN - NABS, soft/ND, mildly tender over suprapubic region (similar to prior), no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs), toe nail changes c/w fungal infection NEURO - sleeping but arousable, opens eyes with less prompting than yesterday. Continues to have difficulty with phonation, but is able to mouth her responses. Pertinent Results: Admission- ___ 03:30PM BLOOD WBC-6.7 RBC-4.07* Hgb-12.8 Hct-36.2 MCV-89 MCH-31.4 MCHC-35.4* RDW-13.6 Plt ___ ___ 03:30PM BLOOD Neuts-54 Bands-12* Lymphs-16* Monos-10 Eos-6* Baso-0 Atyps-1* Metas-1* Myelos-0 ___ 03:30PM BLOOD Glucose-94 UreaN-23* Creat-0.7 Na-135 K-3.6 Cl-97 HCO3-27 AnGap-15 ___ 03:30PM BLOOD ALT-10 AST-23 AlkPhos-149* TotBili-0.8 ___ 06:30AM BLOOD Calcium-8.5 Phos-2.3* Mg-1.7 ___ 04:24PM BLOOD Lactate-1.7 Discharge- ___ 05:40AM BLOOD WBC-6.8 RBC-3.96* Hgb-11.9* Hct-35.0* MCV-88 MCH-30.1 MCHC-34.1 RDW-13.0 Plt ___ ___ 05:40AM BLOOD Glucose-112* UreaN-7 Creat-0.5 Na-139 K-3.6 Cl-106 HCO3-28 AnGap-9 ___ 05:40AM BLOOD AlkPhos-97 ___ 05:40AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0 UA- ___ 04:33PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 04:33PM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-LG ___ 04:33PM URINE RBC-6* WBC->182* Bacteri-MOD Yeast-NONE Epi-3 Urine Culture- PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Repeat UA- ___ 11:29AM URINE Color-Straw Appear-Clear Sp ___ ___ 11:29AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG Stool- CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___: FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. Studies- CXR (___) Single erect AP portable view of the chest was obtained. No focal consolidation, pleural effusion, or evidence of pneumothorax is seen. Marked aortic tortuosity is stable. The cardiac size remains upper limits of normal. AXR (___) A single supine image of the abdomen shows a nonspecific bowel gas pattern without evidence of obstruction or ileus. There is no evidence of toxic megacolon. There is no obvious free air, although exam is somewhat limited due to supine positioning. Hardware from a prior spinal fusion of L3 through L5 is present. There are significant degenerative changes at those levels with large osteophytes. A left total hip arthroplasty is in place. There are multiple pelvic phleboliths. Brief Hospital Course: ___ yo F with h/o advanced ___ Disease presenting with fevers and lethargy; found to have UA c/w UTI. # Severe sepsis secondary to UTI Patient presented with AMS and reported suprapubic pain. She was febrile on admission with 12% bands upon admission. The following day, she was noted to be tachycardia and tachypneic. Her UA was significant for >182 WBCs and large ___, and the culture grew Proteus. She was initially treated with ceftriaxone and when culture data returned she was transitioned to cefpodoxime for a planned 10 day course. She has remained hemodynamically stable throughout her admission and has been afebrile for >48 hours prior to discharge. # C diff Patient has had multiple episodes of cdiff since this ___. She has received both po vanco and iv/po flagyl and only recently completed her vanco taper. She was noted to have having loose stools, which were positive for Cdiff toxin. She was started on po vanco and flagyl. Upon discharge, she is to continue po vanco for two weeks following the completion of her cefpodoxime course followed by an additional 2 weeks of Rifaximin. # Atrial fibrillation with rapid ventricular response. On ___, the patient was noted to be tachycardia with sustained rates of 140-150s bpm. An EKG revealed that she was in atrial fibrillation with RVR. Her home metoprolol had been held in the setting of sepsis and the patient likely had high sympathetic tone in the setting of her acute infections. She was given metoprolol 15 mg IV push spread out over multiple doses while her BP was closely monitored and remained stable. She remained in afib with HR ranging from 100-110s for the next few hours and later converted to normal sinus rhythm. # Encephalopathy The patient presented after her caretakers noted she was more confused and less interactive, which was most likely secondary to her acute infection. As her infection cleared, her mental status did as well and she is back at her baseline upon discharge. # Acute Renal Failure Her admission labs were significant for a BUN/Cr of ___ increased from a baseline of about ___. This was most likely due to dehydration and possible poor forward flow in the setting of sepsis, although she remained hemodynamically stable. Following fluid resuscitation, her kidney function improved and is back at her baseline. # ___ Disease Patient has reported h/o advanced ___ disease and has findings c/w this on exam. She had difficulties speaking particularly with phonation in the setting of her sepsis, but this also improved as her infection cleared. She was continued on her home sinemet dose which was confirmed with her outpatient neurologist. # Swallowing difficulties Patient was evaluated by the speech and swallow team during her prior admissions. Their recommendations were followed during this hospitalization as well. # Elevated alkaline phosphatase The patient was noted to have an increased alkaline phosphatase upon admission. Etiology was unclear, the patient did not endorse signs of symptoms of biliary pathology. A GGT was sent and was also elevated. Her alkaline phosphatase trended down throughout her admission course. # HTN The patient's antihypertensives were held on admission in the setting of sepsis. Her metoprolol was restarted after her episode of afib with RVR and lisinopril was restarted when her kidney function improved. # HLD Patient was continued on her home medication (simvastatin). # Depression Patient was continued on her home medication (cymbalta). ================================ Transition of Care ================================ # Antibiotics: -Cefpodoxime 100 mg twice daily until ___. -Vancomycin 125mg by mouth four times a day until ___. -Rifaximin 400mg twice daily. Do not start this until ___ and then continue until ___. # Pending Labs: -Blood cultures from ___ and ___. Both currently have no growth to date. Medications on Admission: -Amantadine 100 mg po qday -Aspirin 325 mg po qday -Calcium carbonate 1000 mg po qday -Cymbalta 60 mg po qday -Lisinopril 20 mg po qday -Multivitamin daily -Vitamin D3 daily (dose not noted) -Simvastatin 20 mg po qpm -Metoprolol 12.5 mg po BID -Carbidopa/levodopa ___ mg po TID and 1 half tab 1hs. -Enablex ___ mg po qday at 8pm -Colace prn daily Discharge Medications: 1. amantadine 100 mg Tablet Sig: One (1) Tablet PO once a day. 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 4. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO qpm. 8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. 9. carbidopa-levodopa ___ mg Tablet Sig: ___ Tablet PO four times a day: Please take 1 tab TID, and 0.5 tab qhs. 10. Enablex ___ mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 11. docusate sodium 50 mg/5 mL Liquid Sig: One (1) dose PO prn as needed for constipation. 12. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Last dose: ___. 13. vancomycin 125 mg Capsule Sig: One (1) Capsule PO four times a day: Last dose: ___. 14. rifaximin 200 mg Tablet Sig: Two (2) Tablet PO twice a day: Please take from ___. 15. Vitamin D Oral Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary: Severe sepsis secondary to acute cystitis Secondary: Atrial fibrillation with rapid ventricular response Clostridium difficile infection ___ disease 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: Ms. ___, It was a pleasure taking part in your care. We hope you continue to feel well. You were admitted because you were seeming more confused and tired at your nursing facility. You were found to have both an infection in your urinary tract as well as in your stool. You were given antibiotics. We also found that your kidneys were slightly injured. This was most likely due to dehydration and your blood worked showed that they improved following IV fluids. Please make the following changes to your medications: -START: Cefpodoxime 100 mg twice daily until ___. This is for the infection in your urinary tract. -START: Vancomycin 125mg by mouth four times a day until ___. This is for the C. diff infection in your stool. -START: Rifaximin 400mg twice daily. Do not start this until ___ and then continue until ___. This is also for the C. diff infection in your stool. Please continue all of your other medications as previously directed. Followup Instructions: ___
10810720-DS-13	10,810,720	21,027,678	DS	13	2176-03-20 00:00:00	2176-03-26 18:00:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: polytrauma s/p MVC Major Surgical or Invasive Procedure: None History of Present Illness: ___ heroin user transferred from OSH s/p unrestrained passenger in rear seat in MVC vs pole at 40-50 mph. GCS 15, HD stable at scene and on arrival. Complaining of back pain and found to have multiple spine fractures, left orbital floor fracture, nasal bone fracture at OSH. Denies numbness or weakness. No saddle anesthesia. No bowel or bladder incontinence. Past Medical History: PMHx: anxiety, osteomyelitis R thumb, chronic bronchitis PSHx: R thumb distal phalanx resection Social History: ___ Family History: noncontributory Physical Exam: PE: 98.2 80 109/70 14 100 HEENT: Periorbital ecchymosis and swelling L>R. L hand: Pain with ROM of the wrist, NVI. Spine exam: TTP over mid thoracic and lumbar spine, no deformity or stepoff. PE on Discharge: VS: 98.8, 75, 110/57, 18, 96%ra HEENT: Left sided facial ecchymosis and swelling CHEST: LS CTAB, TLSO brace on CARD: HRR, normal s1/s2 ABD: soft, NT/ND EXT: LLE in splint, ace wrap. +csm. No pedal edema Pertinent Results: ___ 06:20AM BLOOD WBC-9.4 RBC-4.29 Hgb-11.6* Hct-34.4* MCV-80* MCH-27.0 MCHC-33.7 RDW-16.4* Plt ___ ___ 06:45PM BLOOD WBC-17.3* RBC-4.80 Hgb-13.2 Hct-39.1 MCV-82 MCH-27.6 MCHC-33.9 RDW-16.5* Plt ___ ___ 06:20AM BLOOD Glucose-93 UreaN-13 Creat-0.7 Na-136 K-4.0 Cl-100 HCO3-25 AnGap-15 ___ 06:45PM BLOOD Glucose-106* UreaN-12 Creat-0.8 Na-136 K-4.3 Cl-100 HCO3-23 AnGap-17 ___ 06:20AM BLOOD ALT-168* AST-86* AlkPhos-85 TotBili-1.9* ___ 06:45PM BLOOD ALT-208* AST-108* AlkPhos-100 TotBili-1.4 ___ 06:20AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.7 ___ 06:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG LEFT HAND XRAY Isolated ulnar styloid fracture CXR: Metallic density projects in the right base of neck, correlate for possible foreign body. Otherwise unremarkable. Brief Hospital Course: ___ heroin user transferred from OSH s/p unrestrained passenger in rear seat in MVC vs pole at 40-50 mph. GCS 15, HD stable at scene and on arrival. CT showed compression fxs T7-T11; L2-L4 transverse process fxs, no evidence of listhesis or canal narrowing. Spine consulted who recommended conservative management with TLSO. Also found to have multiple facial fxs and a distal left ulnar styloid fx, Plastics consulted and recommended fractures be managed conservatively, sinus precautions, outpatient follow-up. The patient was admitted for pain management, Physical Therapy consult, social work, and to be fitted for TLSO brace. 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. The TLSO brace was delivered on HD2 and the patient worked with ___. She was cleared for home without services. 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 with the TLSO brace, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. .. Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain RX acetaminophen 325 mg 2 tablet(s) by mouth every six (6) hours Disp #60 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #30 Capsule Refills:0 3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #20 Tablet Refills:0 4. Ibuprofen 600 mg PO Q8H:PRN pain RX ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours Disp #40 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Polytrauma: T7-11 compression fracture L2-4 transverse process fracture left orbit blow out fracture left styloid ulnar fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ after sustaining injuries from a motor vehicle collision. Your injuries included spine fractures, facial fractures, and a left wrist fracture. You were seen by the spine doctors and the plastic surgeons. Your spine injuries were non-operative but require you wear the brace at all times when out of bed. You will need to follow-up in the spine clinic, to determine when the brace can be discontinued. Your facial and wrist fracture may need surgical repair, and you will need to follow-up in the Hand clinic and Plastics clinic for further management of these injuries, once the swelling goes down. 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 SINUS PRECAUTIONS: 1. Take the prescribed medications as directed. 2. Do not forcefully spit for several days. 3. Do not smoke for several days. 4. Do not use straws for several days. 5. Do not forcefully blow your nose for at least 2 weeks, even though your sinus may feel stuffy or there may be some nasal drainage. 6. Try not to sneeze; it will cause undesired sinus pressure. If you must sneeze, keep your mouth open. 7. Eat only soft foods for several days, always trying to chew on the opposite side of your mouth. 8. Do not rinse vigorously for several days. Followup Instructions: ___
10810971-DS-17	10,810,971	21,364,625	DS	17	2139-12-07 00:00:00	2139-12-07 12:42:00	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: Five palliative radiation treatments History of Present Illness: ___ yo F with metastatic stage IV vulvar cancer (with pulmonary mets) s/p radiation to the vulva presents with abdominal pain and constipation. She was recently admitted to the oncology service from ___ to ___ for vulvar pain, which was attributed to painful inguinal lymphadenopathy. X-ray of her hip was unremarkable. She was started on oxycontin 20mg BID for pain control with improvement. During the admission she was seen by Palliative Care, Social work and Physical Therapy. She was also seen by radiation oncology, who began to plan for palliative radiation to the area. On ___ she saw her oncologist as an outpatient and they discussed starting palliative ___. She was planning to start that on ___, after she completes 5 additional palliative raditation treatments that were due to begin today (___). She and her family today report that her pain has not been controlled since discharge. She was vomiting on discharge and has severe pain with sitting in car and becomes lightheaded and nauseated. At home she has been staying in bed, getting out of bed for 10 min at a time to eat. She reports ___ pain from the vulvar mass that she has, worse with sitting (putting pressure on it). She has not had a BM since ___, and before that she had not had a BM in 7 days. In the ED she was stable. She underwent a KUB that showed fecal loading but not bowel obstruction. She had an enema that produced a bowel movement. She was given morphine that she reports was ineffective. She was admitted for pain control. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. No dysuria. Denies arthralgias or myalgias. Ten point review of systems is otherwise negative. Past Medical History: Per Prior notes: Ms. ___ was initially diagnosed with vulvar patchy lichen in ___ in ___, and recently confirmed as squamous vulvar cancer in ___. She initially noticed white patches on the left vulvar area with spots. She was started on clobetasol without any responses. - She was seen by a second GYN provider with ___ biopsy, which showed chronic inflammation and she was continued on lichen's treatment. - She was seen then by a dermatologist and she was prescribed mupirocin to help with the local erythema; however, her local lesion continued to worsen and involved the other side of her vulva. - She was referred to ___. She was seen by Dr. ___ Dr. ___. She received a biopsy on ___, which showed invasive squamous cell carcinoma of the vulva. Subsequently, a staging PET-CT was performed. She was found to have FDG-avid lymph nodes in the groin area as well as pulmonary nodules concerning for pulmonary metastases. After seeing Dr. ___ ___ GYN oncology, she was referred to our radiation oncologist, Dr. ___. - She received radiation therapy from ___ - ___ Other Past Medical History: 1. Hypertension. 2. Hyperlipidemia. 3. GERD. Cardiac catheterization in ___ showed some stenosis, but no need for stenting. Social History: ___ Family History: Father had prostate cancer, but he died of heart attack. Mother had MI. She is the only child. She has two children and five grandchildren who are all healthy. Physical Exam: VSS Gen: Appears comfortable, alert, awake HEENT: EOMI, PERRLA, MMM CV: RRR, no m/g/r Pulm: CTAB, no w/r/r Abd: Soft, LLQ ttp, +borborygmi, no rebound, minimal guarding GU: + 0.5cm white firm nodule at vulvar meatus, also another 2cm firm nodule over left inguinal canal, and a small red patch which pt thinks is another nodule developing, no foley Back: Left back tenderness, no spinal ttp, no buttock ttp Skin: no rashes Extrem: Warm, no edema Neuro: A+Ox3, speech fluent, ___ strenght in bilat ___, affect pleasant Pertinent Results: ___ 10:12AM BLOOD Neuts-80.3* Lymphs-11.2* Monos-5.8 Eos-2.3 Baso-0.4 ___ 10:12AM BLOOD Glucose-140* UreaN-12 Creat-0.9 Na-136 K-3.8 Cl-99 HCO3-30 AnGap-11 ___ 10:12AM BLOOD ALT-40 AST-27 AlkPhos-108* TotBili-0.3 ___ 10:12AM BLOOD Albumin-3.4* ___ 01:00PM BLOOD ___ pO2-31* pCO2-47* pH-7.41 calTCO2-31* Base XS-3 ___ 10:20AM BLOOD Lactate-1.6 Abd xray FINDINGS: Gas and stool seen throughout the length of the colon which is nondistended. There are no air-filled dilated loops of small bowel. No abnormal air-fluid levels or free intraperitoneal air identified on the decubitus film. Degenerative changes seen at the lumbosacral junction. Calcifications in the pelvis compatible with fibroids. IMPRESSION: Nonobstructive bowel gas pattern. Brief Hospital Course: ___ yo F with metastatic stage IV vulvar carcinoma who was admitted with refractory pain from vulvar mass and lymphadenopathy. # Pain: Pt reports that pain has been stable, with no change in character, intensity, pattern. Working with palliative care ___ who met patient on the prior admission) PCA was started, but she did not tolerate. She was switched to a fentanyl patch at 50mcg. This was increased to 62mcg on ___. Decadron was also added, initially at 6mg once, but this seemed to make pt slightly giddy/agitated. This was down titrated to once daily. Five palliative radiation treatments were scheduled and the patient tolerated them well. On discharge, she was much more comfortable. taking several doses of oxycodone 10mg prn and able to sleep through the night. # Constipation: An aggressive bowel regimen was started and she was finally able to stool regularly. # Strep bacteremia: After XRT was started she developed a fever. ___ blood cx grew strep bacteremia. The patient was vehemently opposed to maintaining IV access, so after discussion with her daughter and patient she was started on "palliative" levofloxacin. Unclear source of bacteremia, but given palliative goals this was not investigated further. She did well with no further fevers and was sent home to finish a 10 day course. # Metastatic vulvar cancer: Plan to start ___ once pt's daughter obtains this prescription. Prior approval was being pursued. # Disposition: Upon family's request ___ was enrolled into a hospice program and she will begin that after discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H 2. Aspirin 81 mg PO DAILY 3. Atenolol 100 mg PO DAILY 4. Zolpidem Tartrate 5 mg PO HS 5. Lisinopril 20 mg PO DAILY Discharge Medications: 1. Atenolol 100 mg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Zolpidem Tartrate 5 mg PO HS 4. Aspirin 81 mg PO DAILY 5. Aquaphor Ointment 1 Appl TP TID:PRN apply to vulva RX white petrolatum [Advanced Healing (Petrolatum)] 41 % apply to affected areas three times a day Disp #396 Gram Gram Refills:3 6. Bisacodyl ___AILY RX bisacodyl 10 mg 1 suppository(s) rectally once a day Disp #30 Suppository Refills:3 7. Dexamethasone 1 mg PO DAILY RX dexamethasone 1 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:3 8. Fentanyl Patch 62 mcg/h TD Q72H RX fentanyl 50 mcg/hour 1 patch q3d Disp #10 Patch Refills:1 RX fentanyl [Duragesic] 12 mcg/hour 1 patch q3d Disp #10 Patch Refills:1 9. Lactulose 15 mL PO BID:PRN Constipation RX lactulose 10 gram/15 mL 22.5 cc by mouth twice a day Refills:3 10. Levofloxacin 500 mg PO Q24H RX levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth once a day Disp #4 Tablet Refills:0 11. OxycoDONE (Immediate Release) 10 mg PO Q2H:PRN pain RX oxycodone 10 mg 1 tablet(s) by mouth q2h Disp #150 Tablet Refills:0 12. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 [Laxative PEG 3350] 17 gram/dose 1 powder(s) by mouth once a day Refills:3 13. Prochlorperazine 5 mg PO Q6H:PRN nausea RX prochlorperazine maleate [Compazine] 5 mg 1 tablet(s) by mouth every six (6) hours Disp #40 Tablet Refills:0 14. Senna 8.6 mg PO 4X/DAY RX sennosides [___] 8.6 mg 1 tab by mouth four times a day Disp #120 Tablet Refills:*3 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Vulvar carcinoma Constipation Streptococcal bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for pain and constipation. You were treated with radiation treatments, pain medications and a bowel regimen... Followup Instructions: ___
10811085-DS-10	10,811,085	21,783,677	DS	10	2121-08-09 00:00:00	2121-08-30 15:33:00	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: ___ with history of hysterectomy for uterine cancer and appendectomy who presents with abdominal pain since last night. The pain is periumbilical and was associated emesis last night. She has not passed gas since, but did have a normal BM at the onset of her symptoms. She initially presents to ___ where two CT scans were performed with findings suggestive of SBO. An NGT was placed and the patient transferred to ___ for further evaluation. Past Medical History: Past Medical History: HTN, DM, Past Surgical History: Hysterectomy, appendectomy Social History: ___ Family History: Family History: Non-contributory Physical Exam: Admission Physical Exam: Vitals: 97.5 78 129/59 17 100RA GEN: A&O, NAD CV: RRR PULM: non-labored on RA ABD: obese. ventral hernias palpated. Difficult exam ___ to habitus but the contents are soft and defects of moderate size. She has discomfort to palpation of the hernias but is otherwise soft and non-tender Ext: No ___ edema, ___ warm and well perfused Discharge Physical Exam: 97.9, 93/61, 73, 18, 96% 2L Gen: [x] NAD, [x] AAOx3 CV: [x] RRR, [] murmur Resp: [x] breaths unlabored, [] CTAB, [] wheezing, [] rales Abdomen: [x] soft, [] distended, [] tender, [] rebound/guarding Wound: [] incisions clean, dry, intact Ext: [x] warm, [] tender, [] edema Pertinent Results: ABDOMEN (SUPINE ONLY) Study Date of ___ 1. NG tube terminates within the proximal stomach. 2. Nonspecific nonobstructive bowel gas pattern. Enteric contrast resides within the right colon terminating at the hepatic flexure. Large bowel containing abdominal hernia was better assessed on preceding CT. PORTABLE ABDOMEN Study Date of ___ 1. No abnormally dilated loops of bowel, however no significant change in location of the enteric contrast from the mid transverse colon. 2. The enteric tube tip is not fully captured on this study and the last side-hole is not visualized. PORTABLE ABDOMEN Study Date of ___ 1. Compared to most recent abdominal radiograph dated 7 hours prior, enteric contrast is still within the mid transverse colon. 2. The enteric tube tips is below the level of the diaphragm, however the last side-hole is near the GE junction. Recommend advancement at least 5 cm. LAB DATA: ___ 07:00AM BLOOD WBC-6.0 RBC-4.10 Hgb-11.6 Hct-39.8 MCV-97 MCH-28.3 MCHC-29.1* RDW-19.1* RDWSD-67.9* Plt ___ ___ 07:00AM BLOOD WBC-6.3 RBC-4.12 Hgb-11.5 Hct-40.4 MCV-98 MCH-27.9 MCHC-28.5* RDW-19.6* RDWSD-70.5* Plt ___ ___ 07:08AM BLOOD WBC-7.2 RBC-4.26 Hgb-11.7 Hct-41.4 MCV-97 MCH-27.5 MCHC-28.3* RDW-20.0* RDWSD-71.2* Plt ___ ___ 07:00AM BLOOD Glucose-118* UreaN-14 Creat-0.8 Na-143 K-4.3 Cl-101 HCO3-31 AnGap-11 ___ 07:00AM BLOOD Glucose-96 UreaN-7 Creat-0.7 Na-145 K-3.7 Cl-99 HCO3-33* AnGap-13 ___ 07:08AM BLOOD Glucose-105* UreaN-10 Creat-0.8 Na-144 K-4.0 Cl-100 HCO3-30 AnGap-14 ___ 08:49PM BLOOD Glucose-91 UreaN-11 Creat-0.8 Na-142 K-4.0 Cl-97 HCO3-30 AnGap-15 ___ 07:00AM BLOOD Calcium-10.0 Phos-2.6* Mg-1.9 ___ 07:08AM BLOOD Calcium-10.2 Phos-2.8 Mg-1.9 Brief Hospital Course: Ms. ___ is a ___ yo F history of abdominal hysterectomy who presented to the emergency department from outside hospital on ___ with abdominal pain. She underwent CT scan that was concerning for bowel obstruction. She was made NPO, NGT was placed, and she was admitted to the surgical floor for further management. Contrast was given via NGT and serial xrays were obtained. Contrast transversed the colon and therefore nasogastric tube was removed. She had return of bowel function and diet was gradually advanced to regular. She then worked with physical therapy and they determined she was safe to discharge back home without need for home ___. During this hospitalization, the patient voided without difficulty and ambulated early and frequently. The patient 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. She was afebrile and her vital signs were stable. The patient was tolerating a regular diet, ambulating, voiding without assistance, and her pain was well controlled. The patient was discharged home without services. Discharge teaching was completed and follow-up instructions were reviewed with reported understanding and agreement. Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Furosemide 20 mg PO DAILY 2. Metoprolol Succinate XL 25 mg PO DAILY 3. Januvia (SITagliptin) 15 mg oral DAILY 4. Tradjenta (linaGLIPtin) 5 mg oral DAILY 5. amLODIPine 5 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation ASDIR Discharge Medications: 1. Bisacodyl ___AILY:PRN Constipation - Second Line 2. Polyethylene Glycol 17 g PO DAILY may discontinue when bowel pattern normalizes 3. Senna 8.6 mg PO BID may discontinue when bowel pattern normalizes 4. amLODIPine 5 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Furosemide 20 mg PO DAILY 7. Januvia (SITagliptin) 15 mg oral DAILY 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation ASDIR 10. Tradjenta (linaGLIPtin) 5 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: Partial small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the Acute Care Surgery Service on ___ with abdominal pain and found to have a partial bowel obstruction. You were given bowel rest, IV fluids, and had a nasogastric tube placed to help decompress you bowels. You had several xrays that showed the contrast you drank was able to pass through your intestines. Your diet was gradually advanced which you tolerated well. You are now ready to be discharged home to continue your recovery. 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: ___
10811369-DS-4	10,811,369	23,582,528	DS	4	2180-11-21 00:00:00	2180-11-21 18:50:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: acetylcysteine / tramadol Attending: ___. Chief Complaint: Acute hepatitis Major Surgical or Invasive Procedure: none History of Present Illness: This is a ___ with a PMH of anxiety, migraines, and depression c/b 2 previous APAP overdoses, most recently 1 month ago presents with RUQ pain and vomiting. GERD symptoms began this past ___ when she had 2 glasses of wine at a coworkers event. Yesterday, she began feeling more nauseated to the point she was unable to sleep. She had a headache and took 2 tabs of extra-strength Tylenol. The patient notes difficult family situation, but denies intentional overdose. She denies sick contacts or recent travel. She started birth control 2 weeks ago. She has been taking sertraline and trazodone as well, which were recently started. She complains of RUQ/R flank pain with nausea and vomiting. The nausea/vomiting is new. The R flank pain has come and gone since her last discharge. She endorses increasing fatigue and decreased appetite with weight loss. She denies fevers or chills. She denied melena and hematochezia. She endorses acid reflux symptoms, epigastric pain, and a band like pain around her rib cage. She endorses non-productive cough. At last admission, patient reported taking approximately 60-70 tablets of acetaminophen 500 mg over the course of the day (30,000 to 35,000 mg) in addition to consuming alcohol. The day prior to the overdose, she took 10 tablets of klonopin 0.5 mg. AST/ALT peaked in 500s. She was given NAC x3 per guidelines w/ down-trending LFTs after 3 doses. Her INR was elevated to 1.3, but downtrended to 1.1 prior to discharge. ALT 145 and AST 64 at the time of discharge. VS prior to transfer: 99.0 62 116/47 16 100% RA In ED initial VS: 97.8 117 ___ 100% RA Labs significant for: ALT: 1721->ALT: 2711 AST: 1706->AST: 2889 2711 Tbili: 1.5->1. INR 1.7 -> 1.8, APAP level negative Patient was given: ___ 05:45 IV Ondansetron 4 mg ___ 05:51 IVF NS 1000 mL ___ 06:57 IV Ketorolac 30 mg ___ 07:47 IVF NS 1000 mL ___ 11:01 IV DiphenhydrAMINE 50 mg ___ 11:07 IV Ondansetron 4 mg ___ 11:07 IV DRIP Acetylcysteine (IV) ___ mg ordered) ___ 13:00 IV Ondansetron 4 mg ___ 13:01 IVF NS ___ Not Stopped ___ 13:58 IV DRIP Acetylcysteine (IV) (3750 mg ordered) Started 62.5 mL/hr ___ 16:00 IVF NS 1000 mL ___ 16:07 IVF NS 150 mL/hr ___ 16:07 PO Omeprazole 40 mg Imaging notable for: echogenic liver on RUQUS Consults: Psych recommended ___ Hepatology recommended hydration and NAC protocol, trend LFTs, chem 10, INR, lactate q4, neuro exam and accuchecks q2 if LFTs rising quickly. VS prior to transfer: 98.0 66 103/54 15 100% RA REVIEW OF SYSTEMS: 11pt ROS negative unless noted above Past Medical History: PAST PSYCHIATRIC HISTORY: History of symptoms as reported by patient are noted above. Has one previous suicide attempt by Tylenol ingestion ___ years ago, after which she was hospitalized. This was her only psychiatric hospitalization. ___ provides medications and psychotherapy. She currently takes sertraline when she notices premenstrual symptoms starting up until her period starts, as well as clonazepam as needed for anxiety, and denies any other medication trials. -Access to weapons: Denies PAST MEDICAL HISTORY: Elevated LFTs following overdose Depression - 2 previous suicide attempts, most recently with Tylenol overdose. Acute hepatitis ___ Tylenol ingestion Migraines Social History: ___ Family History: FAMILY PSYCHIATRIC HISTORY: Denies known family history of mental illness, substance abuse, suicide attempts Physical Exam: ================================= EXAM ON ADMISSION ================================= VITALS: 99.5 66 126/68 13 100%RA GENERAL: Alert, oriented, appears uncomfortable with dry heaves 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 Chest: R side/rib cage TTP to palpation ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: no apparent rashes or jaundice NEURO: II-XII intact, strength preserved ___ ___ ================================= EXAM ON DISCHARGE ================================= VS: 98.6, HR 83, BP 97/65, RR 18, 100%RA General: alert, oriented, no acute distress Eyes: Sclera anicteric Resp: clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops GI: soft, mildly tender in RUQ, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly MSK: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact, motor function grossly normal Pertinent Results: ============================== LABS ON ADMISSION ============================== ___ 05:45AM BLOOD WBC-8.5 RBC-4.06 Hgb-12.6 Hct-36.8 MCV-91 MCH-31.0 MCHC-34.2 RDW-13.9 RDWSD-45.8 Plt ___ ___ 05:45AM BLOOD Neuts-75.4* Lymphs-14.4* Monos-6.5 Eos-2.7 Baso-0.6 Im ___ AbsNeut-6.39* AbsLymp-1.22 AbsMono-0.55 AbsEos-0.23 AbsBaso-0.05 ___ 07:11AM BLOOD ___ PTT-24.9* ___ ___ 05:45AM BLOOD Glucose-94 UreaN-10 Creat-0.8 Na-138 K-4.3 Cl-102 HCO3-19* AnGap-17 ___ 05:45AM BLOOD ALT-1721* AST-1706* AlkPhos-82 TotBili-1.5 ___ 05:45AM BLOOD Lipase-33 ___ 07:43PM BLOOD Calcium-8.2* Phos-2.0* Mg-1.8 Iron-122 ___ 07:43PM BLOOD calTIBC-246* ___ TRF-189* ___ 05:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ============================== LFT TREND ============================== ___ 05:45AM BLOOD ALT-1721* AST-1706* AlkPhos-82 TotBili-1.5 ___ 12:35PM BLOOD ALT-2711* AST-2889* AlkPhos-66 TotBili-1.0 ___ 07:43PM BLOOD ALT-4851* AST-5679* AlkPhos-64 TotBili-0.9 ___ 01:50AM BLOOD ALT-4806* AST-5193* AlkPhos-59 TotBili-0.8 ___ 09:08AM BLOOD ALT-4472* AST-3937* LD(LDH)-2931* AlkPhos-67 ___ 04:30PM BLOOD ALT-4135* AST-2346* LD(LDH)-1263* AlkPhos-66 TotBili-1.0 ___ 10:20PM BLOOD ALT-3454* AST-1432* AlkPhos-65 TotBili-1.0 ___ 05:50AM BLOOD ALT-2812* AST-800* LD(LDH)-350* AlkPhos-59 TotBili-0.8 ___ 04:26PM BLOOD ALT-2653* AST-501* AlkPhos-66 TotBili-0.8 ___ 06:45AM BLOOD ALT-1682* AST-192* LD(LDH)-169 AlkPhos-60 TotBili-0.4 ============================== PERTINENT INTERVAL LABS ============================== ___ 07:43PM BLOOD calTIBC-246* ___ TRF-189* ___ 05:50AM BLOOD Ferritn-1469* ___ 10:20PM BLOOD Triglyc-108 ___ 07:43PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG ___ 12:35PM BLOOD HAV Ab-POS* IgM HAV-NEG ___ 07:43PM BLOOD AMA-NEGATIVE ___ 12:35PM BLOOD Smooth-NEGATIVE ___ 12:35PM BLOOD ___ ___ 07:43PM BLOOD IgG-1076 IgA-153 IgM-98 ___ 04:30PM BLOOD HIV Ab-NEG ___ 04:30PM BLOOD HIV1 VL-NOT DETECT ___ 07:43PM BLOOD HCV Ab-NEG ============================== LABS ON DISCHARGE ============================== ___ 06:45AM BLOOD WBC-5.4 RBC-3.24* Hgb-10.1* Hct-29.7* MCV-92 MCH-31.2 MCHC-34.0 RDW-14.6 RDWSD-48.8* Plt ___ ___ 06:45AM BLOOD Glucose-130* UreaN-3* Creat-0.5 Na-140 K-4.2 Cl-110* HCO3-20* AnGap-10 ___ 06:45AM BLOOD ALT-1682* AST-192* LD(LDH)-169 AlkPhos-60 TotBili-0.4 ============================== MICROBIOLOGY: ============================== - HSV negative - EBV serologies - pending - CMV serologies - IgM negative, IgG positive - ___ blood culture - STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL MORPHOLOGIES. - ___ urine culture - pending ============================== IMAGING ============================== # ___ CXR FINDINGS: Low bilateral lung volumes. There is no focal consolidation, pleural effusion or pneumothorax identified. The size of the cardiac silhouette is within normal limits. IMPRESSION: No focal consolidation. # ___: RUQ U/S IMPRESSION: 1. Echogenic liver with no focal lesions identified. Echogenic liver is most likely from steatosis. More advanced liver disease including hepatitis, hepatic fibrosis, and cirrhosis cannot be excluded on this study. Please note that imaging findings related to acute hepatitis related to drug overdose are nonspecific. 2. No sonographic evidence of acute cholecystitis or cholelithiasis. 3. No ascites. Brief Hospital Course: ___ year old woman with a PMH of acetaminophen overdose, depression, anxiety, migraines, who presented with 2 days of RUQ pain, found to have acute hepatitis. =========================== ACUTE ISSUES ADDRESSED =========================== # Acute Hepatitis: Patient presenting with abdominal pain and nausea, and found to have acute hepatitis with hepatocellular pattern. ALT/AST peaked at ~5000, and also noted to have synthetic dysfunction w/ INR up to 2.3. She was seen by toxicology and hepatology. Patient only reported taking 2 Tylenol in past several weeks, and had recently started sertraline, trazodone, and an OCP. Also with recent ingestion of mushrooms (at restaurant), though after consultation, felt to be unlikely to contribute given no reported cases of hepatitis from mushroom ingestion from restaurants. Liver ultrasound with Doppler with patent hepatic vasculature. CMV IgM negative (positive IgG), hepatitis serologies with no signs of acute infection, HSV negative. EBV serologies and urine copper pending at time of discharge. Though cause was unclear, patient was empirically treated with NAC for possible acetaminophen toxicity, with improvement in her LFTs and INR. Her sertraline, OCP, and trazodone were held on discharge, as possible that this may have been a drug reaction. # GPC Bacteremia - Patient found to have GPCs in blood cultures from ___. She was started on vancomycin. These speciated to coag negative staph, and felt very likely to be a contaminant. Surveillance cultures no growth at time of discharge. =========================== CHRONIC ISSUES ADDRESSED =========================== #Depression/Anxiety: Patient was followed by psychiatry given previous history of Tylenol toxicity. She was felt to be stable, with no suicidal ideation endorsed. Her sertraline and trazodone were held on admission as some possibility that could be related to hepatitis. Patient was discharged with therapy appointment scheduled on ___ and to continue her clonazepam. =========================== TRANSITIONAL ISSUES =========================== [] Sertraline, trazodone, and OCP held at time of discharge given unclear etiology of hepatitis. If restarted, should be done with one medication at a time and LFT monitoring [] Discharged with close ___ follow up and direct discussion with outpatient provider [] Should have repeat LFTs at PCP appointment next week [] EBV serologies and 24 hour copper pending at time of discharge, to be followed by inpatient team [] Found to have mild anemia (discharge Hgb 10.1). Should have recheck, and consider iron studies and further workup if persists. [] Hepatitis serologies show immunity to Hep A and Hep B # Code - Full (presumed) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Sertraline 50 mg PO DAILY 2. TraZODone 50 mg PO QHS:PRN insomnia 3. ClonazePAM 0.5 mg PO QHS 4. Sprintec (28) (norgestimate-ethinyl estradiol) 0.25-35 mg-mcg oral DAILY Discharge Medications: 1. ClonazePAM 0.5 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: # Acute hepatitis SECONDARY DIAGNOSIS # Depression/anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure to be a part of your care team at ___ ___. You were admitted to the hospital with stomach pain, and we found that your liver tests were very high. We do not know exactly what caused this to happen, but they started to get better. Please see below for your medications and follow up appointments. Again, it was very nice to meet you, and we wish you the best. Sincerely, Your ___ Care Team Followup Instructions: ___
10811920-DS-24	10,811,920	27,645,791	DS	24	2161-09-08 00:00:00	2161-09-08 15:06:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Aspirin / Penicillins / Toradol Attending: ___. Chief Complaint: right neck swelling and pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ female with chronic abdominal pain, N/V, diarrhea, with self-diagnosis of acute intermittent porphyria (which was dismissed by heme/onc) presenting with acute on chronic abdominal pain as well as worsening of right neck swelling and pain. Pt recently had thyroid ultrasound as outpatient ___ showing cyst in right thyroid. She notes increased swelling and pain at right side of neck. Per pt, she is due for outpatient biopsy of that cyst. Denies difficulties breathing. . Also reports acute on chronic abdominal pain, worse in LLQ, associated with N/V and nonbloody diarrhea. States that this is usual pattern for her pain. No recent sick contacts, recent travel, or antibiotic use. She has a self-diagnosis of acute intermittent porphyria which was never substantiated. She has had previous hospitalizations ___ to ___ for similar symptoms treated with IV dilaudied; heme/onc consult at that time did not feel pt had AIP. She was also hospitalized ___ with abodminal pain with negative work-up. Suspicion raised for drug-seeking behavior. . In the ED, initial VS: 99.2 94 140/90 16 100% ra. She underwent bore scope that showed no vocal cord edema. Soft tissue x-rays of neck that was largely unremarkable. She received 4mg iv zofran, 10mg iv prochlorperazine, 10mg reglan, 4mg iv morphine, 12.5mg iv promethazine. Past Medical History: 1. ? Porphyria- negative work-up in ___ 2. Irritable bowel syndrome. 3. History of anemia. 4. Endometriosis status post SLAP. 5. Total abdominal hysterectomy and bilateral salpingo-oophorectomy. 6. Allergic rhinitis. 7. History of abnormal gastric emptying. 8. Bronchitis. Social History: ___ Family History: Mother with ? porphyria Physical Exam: VS - 97.8 128/80 76 18 100%RA GENERAL - Alert, interactive, well-appearing in NAD HEENT - PERRL, EOMI, sclerae anicteric, dry MM, OP clear NECK - Supple, right sided neck swelling and pain on palpation HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - NABS, soft, diffusely tender on palpation, voluntary guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact . VS - 98.7, 97.7, 132/78, 93, 16, 100% RA GENERAL - Alert, interactive, well-appearing in NAD HEENT - MMM, OP clear NECK - Supple, right sided neck swelling and pain on palpation, appears decreased from admission HEART - RRR, nl S1-S2, no MRG LUNGS - CTAB ABDOMEN - Soft, nondistended, diffusely minimally TTP without rebound, voluntary guarding, distractable EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - no rashes or lesions, port site without any surrounding erythema NEURO - awake, A&Ox3, no focal neuro defcitis Pertinent Results: ___ 04:00AM BLOOD WBC-6.0 RBC-3.72* Hgb-10.2* Hct-31.6* MCV-85 MCH-27.4 MCHC-32.2 RDW-15.0 Plt ___ ___ 04:00AM BLOOD Plt ___ ___ 04:00AM BLOOD Glucose-90 UreaN-6 Creat-0.7 Na-143 K-3.9 Cl-111* HCO3-26 AnGap-10 ___ 04:00AM BLOOD ALT-7 AST-13 AlkPhos-68 TotBili-0.4 ___ 04:00AM BLOOD TSH-0.46 . . . . DIAGNOSITIC STUDIES: NECK SOFT TISSUES X-RAY ___: IMPRESSION: Mild leftward deviation of the trachea above the thoracic inlet similar to prior x-ray from ___. Otherwise, unremarkable examination . THYROID U/S ___: IMPRESSION: 1. Large 4.3 cm right thyroid cyst. 2. 1.8 and 1.7 cm partially cystic, partially solid left thyroid gland nodules with possible microcalficiation, recommend further workup with FNA. Brief Hospital Course: # Acute on chronic abdominal pain: Pt with acute on chronic abdominal pain, N/V, and diarrhea, which is exactly the same as previous flares. Had recent one day admission for exact pain on ___. Has diagnosis of IBS but per pt, also reports question of acute intermittent porphyria that has not been substantiated. On percocet and fentanyl patch at home and per recent discharge summary from Dr. ___ has narcotic contract with Dr. ___ PCP. Lab results were reassuring. Patient's pain was controlled with IV morphine and IV zofran during her stay with improvement in pain. She was able to eat and drink without difficulty and was transitioned back to PO pain medications. # Thyroid cyst: Pt with recent thyroid ultrasound showing right sided cyst. Neck film showed mild leftward deviation of the trachea above the thoracic inlet similar to prior x-ray from ___. Otherwise, unremarkable examination. Patient had no difficulty speaking or breathing. TSH was normal at 0.46. On hospital day 3, reported question of difficulty swallowing and a repeat thyroid u/s was performed which showed essentially no change from previous ultrasound the week prior for the right cystic lesion, but did show evidence of two partially cystic, partially solid left thyroid gland nodules with possible microcalficiation. Patient will require outpatient follow-up for FNA. # Acute intermittent porphyria: Per heme/onc consult in ___, pt does not carry diagnosis of AIP. She has portacath that was used previously for IV hematin infusions. Attempted to reach Dr. ___ arranging for removal of portacath, but Dr. ___ was not available. Patient will need to follow-up removal of this portacath with the PCP. TRANSITIONAL ISSUES: # thyroid cyst - will require FNA for left small nodules with microcalcifications # portacath - please consider removal Medications on Admission: Percocet ___ 2 tabs q4-6h prn Oxycodone 10mg 1tab q6H pain Klonopin 2mg qhs Folic acid 1mg daily Nexium 40mg BID Ca+2/vit D 600/400 daily Fentanyl patch 100 mcg q72h Zofran ODT q12H Discharge Medications: 1. clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)) as needed for Insomnia. 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 5. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every twelve (12) hours as needed for nausea. 6. Percocet ___ mg Tablet Sig: Two (2) Tablet PO every ___ hours as needed for pain. 7. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 8. Calcium 600 with Vitamin D3 600 mg(1,500mg) -400 unit Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Acute on chronic abdominal pain Complex thyroid cyst 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 ___ for acute on chronic abdominal pain. All of your lab tests were reassuring. You were treated with IV pain medications and anti-nausea medications and improved. Your diet was advanced and you were able to tolerate a regular diet without difficulty. Your neck swelling was monitored throughout your hospital stay. It was likely due the cyst seen on ultrasound. A neck x-ray showed no change from previous in ___. Your thyroid stimulatory hormone was normal and a repeat ultrasound was performed which showed a large right thyroid cyst essentially unchanged from your previous ultrasound and a left sided complex thyroid nodule that has concerning features and will likely require a biopsy. Please follow-up with your endocrinologist as planned on ___. We have made no changes to your medications. Followup Instructions: ___
10811920-DS-26	10,811,920	23,987,965	DS	26	2161-11-12 00:00:00	2161-11-13 10:40:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ___ Allergies: Aspirin / Penicillins / Toradol Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ year-old female with a history of chronic abdominal pain of unknown etiology, narcotics dependence/abuse on a narcotics contract, multiple readmissions for the same abdominal pain presents with several days of abdominal pain. Of note, she presented with similar abdominal pain on ___, was admitted, and discharged on ___. Over the last ___ days, she has had worsening of abdominal pain associated with nausea/vomiting, fevers to 100, anorexia, diffuse myalgias, and rigors. Her previous course was also complicated by a staph epidermis bacteremia, presumed to be from her port-a-cath, which was subsequently removed. In the ED, initial vital signs were 97.9 104 143/95 16 100%. She was given 2L NS, 4 mg IV dilaudid, zofran, reglan, prochloperazine, and her normally prescribed fentanyl patch. CT scan of the abdomen was normal and labs were unremarkable. On transfer, vitals were HR 100, O2 sat 100, BP129/78, temp 98.0. Of note, she has had previous hospitalizations ___ to ___ for similar symptoms treated with IV dilaudied; heme/onc consult at that time did not feel pt had AIP. She was also hospitalized ___ with abodminal pain with negative work-up. Suspicion raised for drug-seeking behavior at that time. She was also hospitalized on ___ with the same symptoms. Past Medical History: 1. Self -reported Porphyria- also carries diagnosis of porphyria that has not been substantiated (see heme/onc note from ___ in ___). Evidence strongly suggests she does not have porphyria. 2. Irritable bowel syndrome. 3. History of anemia. 4. Endometriosis status post SLAP. 5. Total abdominal hysterectomy and bilateral salpingo-oophorectomy. 6. Allergic rhinitis. 7. History of abnormal gastric emptying. 8. Bronchitis. 9. Thyroid Cyst 10. GERD 11. Anxiety 12. Opioid abuse and dependence on narcotics Contract - HISTORY OF DRUG SEEKING ___ Social History: ___ Family History: Mother with ? porphyria Physical Exam: Discharge PE: Vitals: 98.2 130/84 94 20 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft,non-distended, mildly tender to palpation, bowel sounds present, no rebound tenderness Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: ___ 09:30AM BLOOD WBC-8.6 RBC-3.76* Hgb-9.9* Hct-31.6* MCV-84 MCH-26.3* MCHC-31.3 RDW-15.1 Plt ___ ___ 09:30AM BLOOD Glucose-91 UreaN-15 Creat-1.0# Na-141 K-4.2 Cl-104 HCO3-23 AnGap-18 ___ 09:30AM BLOOD ALT-12 AST-19 AlkPhos-113* TotBili-0.3 ___ 06:35AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.5* CT ABD/PELVIS 1. Mildly prominent fluid along the small bowel, but no evidence for dilatation, obstruction, or volvulus on this examination. 2. New mild pancreatic ductal dilatation of uncertain significance particularly given lack of pancreatic enzyme elevation; it is possible that the ductal caliber fluctuates; if there are recurrent or persistent symptoms, follow-up ultrasound could be considered in the future. Brief Hospital Course: ___ year-old female with chronic abdominal pain and narcotics dependence with drug-seeking begavoir presenting with abdominal pain. # Abdominal Pain: Patient's abdominal pain similar to her previous flares. Once she arrived on the floor, we stopped all IV dilaudid and explained we would only give her the normal dose of oxycodone ___ q4 PRN) per her narcotics contract with her PCP (available through ___ records). Her nausea was controlled with IV zofran PRN and PO hydroxyzine per her home regimen. Her CT scan of the abdomen was negative for any acute process, but did show mild pancreatic ductal dilation that may be reactive. This finding is likely insignficiant, but should be followed up by her PCP. She was admitted for 1.5 days until she was able to tolerate full PO. No other pain medications were given other than those stated in her narcotics contract. # Drug Seeking Behavoir and Possible Withdrawl: Based on patient's long history of repeated admissions and history of receiving opiates from multiple providers around the city, she has obvious drug seeking tendencies. Her repeated admissions may be her withdrawing from opiates because she finished her monthly allotment early. Our suspicions were raised to her PCP ___ letter and email. Patient has an appointment to see Dr. ___ on ___. The team proposed that there should be a care plan initiated when the patient presents to the Emergency room in an attempt to break the patient's cycle of repeated admissions. (i.e. bringing her pill bottles in with her). # Anemia: Hct at baseline, which seems to be around 30. No evidence of acute bleed. Iron studies on last admission showed iron deficiency anemia; iron was written for, but patient not taking. # Anxiety: Continued clonazepam. . # History of staph bacteremia: Likely from portacath which has since been removed. Patient treated with IV vancomycin and subsequent negative blood cultures. Patient afebrile, and suspicion for bacteremia was extremely low. Transitional Issues: Follow-up of pancreatic ductal findings on CT scan, could consider endoscopic ultrasound. Potential initiation of care plan for hospital admission and narcotics administration. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Atrius. 1. Clonazepam 2 mg PO QHS:PRN sleep 2. OxycoDONE (Immediate Release) ___ mg PO Q4-Q6 H PRN: pain 3. Fentanyl Patch 100 mcg/hr TP Q72H 4. HydrOXYzine 50 mg PO TID:PRN Nausea 5. NexIUM NF (esomeprazole magnesium) 40 mg Oral BID 6. fluticasone NF 50 mcg/actuation NU QD 7. phenobarb-hyoscy-atropine-scop NF 16.2-0.1037 -0.0194 mg Oral TID With meals 8. Calcarb 600 With Vitamin D NF (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit Oral QD 9. Ondansetron 4 mg PO QD Discharge Medications: 1. Clonazepam 2 mg PO QHS:PRN sleep 2. Fentanyl Patch 100 mcg/hr TP Q72H 3. OxycoDONE (Immediate Release) ___ mg PO Q4-Q6 H PRN: pain 4. Calcarb 600 With Vitamin D NF (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit Oral QD 5. fluticasone NF 50 mcg/actuation NU QD 6. Ondansetron 4 mg PO QD 7. phenobarb-hyoscy-atropine-scop NF 16.2-0.1037 -0.0194 mg Oral TID With meals 8. NF (esomeprazole magnesium) 40 mg ORAL BID 9. HydrOXYzine 50 mg PO TID:PRN Nausea Discharge Disposition: Home Discharge Diagnosis: Abdominal Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were seen in the hospital because of your chronic abdominal pain. A CT scan of your abdomen did not show any acute process and all of your labs were normal. We made no changes to your medications. Followup Instructions: ___
10811920-DS-28	10,811,920	25,103,682	DS	28	2162-01-04 00:00:00	2162-01-04 20:23:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Aspirin / Penicillins / Toradol Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ year-old female with history of chronic abdominal pain of unknown etiology, narcotics dependence/abuse on a narcotics contract,and multiple readmissions for the same abdominal pain who presents with worsening abdominal pain, nausea, and vomiting. Symptoms began ___ days ago when the pain woke her up in the middle of the night. Pain is all over her entire abdomen but worse in the LLQ. Pt reports pain as constant and crampy with a "tightness." She compares it to past menstrual type pain (she is post-menopausal). Also reports nonbloody emesis (yellow and green) and nonbloody diarrhea--5 times a day, started green but turned black. Per pt, has black diarrhea often. Also reports subjective fevers (99.9), chills, dizziness, headache. Denies chest pain, SOB, cough, dysuria, photophobia. She reports her son and grandson having "cold symptoms" about 1 week ago. Patient was admitted 1 month ago for this same type of pain and workup was negative. In the ED, initial VS were T 98.6, P 78, BP 132/91, RR 16, O2Sat 100%RA. Pain ___. Labs were significant for lipase 172 & bicarb 18 with anion gap 14. Preliminary read of CT abd/pelvis showed increasing common bile duct and main pancreatic duct diameter and new intrahepatic biliary dilatation which per radiology was sometimes present on prior CT imaging and sometimes not. Patient was given dilaudid 1mg IV x 4, zofran & metoclopramide. Vital signs on transfer were T 98.9, P 84, RR 16, BP 113/73, O2Sat 100%RA, Pain: ___. Past Medical History: She has had previous hospitalizations ___ to ___ for similar abd pain symptoms treated with IV dilaudid; heme/onc consult at that time did not feel pt had AIP. She was also hospitalized ___ with abdominal pain with negative work-up. Suspicion raised for drug-seeking behavior at that time. She was also hospitalized ___, ___, and ___ with the same symptoms. 1. Self-reported porphyria - carries diagnosis of porphyria that has not been substantiated (see heme/onc note from ___ in ___). Evidence strongly suggests she does not have porphyria. 2. Irritable bowel syndrome. 3. History of anemia. 4. Endometriosis status post SLAP. 5. Total abdominal hysterectomy and bilateral salpingo-oophorectomy. 6. Allergic rhinitis. 7. History of abnormal gastric emptying. 8. Bronchitis. 9. Thyroid Cyst 10. GERD 11. Anxiety 12. Opioid abuse and dependence on narcotics Contract - HISTORY OF DRUG SEEKING ___ Social History: ___ Family History: Mother with ? porphyria. Physical Exam: Admission: VS: 98.3 121/74 79 18 100RA GEN: A+Ox3, NAD, was laying in bed flat not in acute distress, discomfort or pain. Reported ___ pain only when asked about otherwise looked very comfortable HEENT: NCAT. EOMI. PERRL. MMM. Reported neck tenderness because of enlarged thyroid and lymph node assessment was limited. no JVD. neck supple. visible and palpable right thyroid enlargement CV: RRR, normal S1/S2, no murmurs, rubs or gallops. LUNG: CTAB, no wheezes, rales or rhonchi ABD: soft, not distended, no rebound or guarding, reported tenderness overall the abdomen more prominent at LLQ though when pressed with same intensity with the stethoscope she did not report pain and did not grimace, +BS. negative for HSM. EXT: W/WP, no edema, no C/C. 2+ ___ pulses bilaterally. SKIN: W/D/I NEURO: CNs II-XII intact. ___ strength in U/L extremities. sensation intact to LT. cerebellar fxn intact (FTN, HTS). gait WNL. PSYCH: appropriate affect Discharge: VS: 98.8 ___ 18 100RA GEN: A+Ox3, NAD, was laying in bed flat not in acute distress, discomfort or pain. Reported ___ pain only when asked about otherwise looked very comfortable HEENT: NCAT. EOMI. PERRL. MMM. Reported neck tenderness because of enlarged thyroid and lymph node assessment was limited. no JVD. neck supple. visible and palpable right thyroid enlargement CV: RRR, normal S1/S2, no murmurs, rubs or gallops. LUNG: CTAB, no wheezes, rales or rhonchi ABD: soft, not distended, no rebound or guarding, reported tenderness overall the abdomen more prominent at LLQ though when pressed with same intensity with the stethoscope she did not report pain and did not grimace, +BS. negative for HSM. EXT: W/WP, no edema, no C/C. 2+ ___ pulses bilaterally. SKIN: W/D/I NEURO: CNs II-XII intact. ___ strength in U/L extremities. sensation intact to LT. cerebellar fxn intact (FTN, HTS). gait WNL. PSYCH: appropriate affect Pertinent Results: Admission labs: =============== ___ 01:50AM BLOOD WBC-8.1 RBC-4.71 Hgb-12.3 Hct-39.4 MCV-84 MCH-26.1* MCHC-31.2 RDW-15.6* Plt ___ ___ 01:50AM BLOOD Neuts-63.1 ___ Monos-3.4 Eos-3.2 Baso-0.5 ___ 01:50AM BLOOD Plt ___ ___ 01:50AM BLOOD Glucose-106* UreaN-12 Creat-1.1 Na-138 K-4.1 Cl-106 HCO3-18* AnGap-18 ___ 01:50AM BLOOD ALT-7 AST-16 AlkPhos-101 TotBili-0.5 ___ 01:50AM BLOOD Lipase-172* ___ 01:50AM BLOOD Albumin-4.6 Calcium-9.5 Phos-3.7 Mg-2.0 Discharge labs: =============== ___ 05:45AM BLOOD WBC-7.8 RBC-3.86* Hgb-10.1* Hct-32.4* MCV-84 MCH-26.2* MCHC-31.2 RDW-15.6* Plt ___ ___ 01:50AM BLOOD Neuts-63.1 ___ Monos-3.4 Eos-3.2 Baso-0.5 ___ 05:45AM BLOOD Glucose-73 UreaN-9 Creat-1.0 Na-140 K-4.2 Cl-107 HCO3-24 AnGap-13 ___ 01:50AM BLOOD ALT-7 AST-16 AlkPhos-101 TotBili-0.5 ___ 01:50AM BLOOD Lipase-172* ___ 05:45AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.6 Imaging: ======== IMPRESSION: 1. Increasing mild common bile duct and main pancreatic duct dilation. Note is made of normal LFTs and mild lipase elevation. Given the that the CBD has waxed and waned over the past few CTs from this year and the pancreatic duct has increased, potential etiologies include intermittently obstructing stone, papillary stenosis, or sphincter of Oddi dysfunction. An MRCP should be performed soon if acute symptoms persist. If symptoms are intermittent, consider a non-emergent MRCP with secretin. 2. RLQ fluid mentioned on preliminary report is likely within the cecal tip. 3. Moderate to severe multilevel lumbar spine disc herniations and canal stenosis. Brief Hospital Course: ___ year-old female with history of chronic abdominal pain and narcotics dependence presenting with abdominal pain and nausea/vomiting, similar to prior episodes, dramatically improved overnight with dramatic improvement in oral intake. # Abdominal Pain/Nausea: Unclear etiology but does not appear to have acute pathology as CT abd/pelvis is without appendicitis, colitis, diverticulitis. Given symptoms, elevated lipase and CT findings, most concerning for possible pancreatitis. Due to diffuse nature of abdominal pain and particularly LLW and how it can often represent severe and potentially life-threatening disease, we considered mesenteric ischemia and infarction, ruptured abdominal aortic aneurysm, diffuse peritonitis, and intestion obstruction. However, due to her presentation, labs, and imaging, we were not concerned about these pathologies except mesenteric ischemic/infarction which is discussed below. Also, because she is a woman, we considered OB/GYN pathologies however, pt is s/p hysterectomy and bilateral salpingo-oophorectomy so unlikely. Given her nausea, vomiting, and report of loose stools, viral gastroenteritis is possible. Cannaboid hyperemesis syndrome is also possible, though patient reports only using marijuana every week and not at heavy doses. Cocaine induced abdominal vasospasm is another consideration, though unclear when she last used cocaine per patient and Utox in ___. Overall, her abdominal pain similar to her previous flares. For the pain, she was on oxycodone ___ q4 PRN) per her narcotics contract with her PCP (available through Atrius records). For nausea, she was on zofran and PO hydroxyzine per her home regimen. Of note, a prior CT scan has shown mild pancreatic ductal dilation that may be reactive which is also seen on this admission's CT. Per radiology, this is sometimes seen and sometimes not. Consider MRCP with secretin as outpatient since symptoms are intermittent (please see results section) # Elevated Lipase: Elevated lipase to 172. This is new and in prior admissions for similar presentations (abdominal pain), it has been low in the ___ and ___. First thought was toward pancreatitis especially w/ mild pancreatic ductal dilation, unsure if new however per radiology this has been find intermittently on prior CT's. Her signs and symptoms did not fit the classical picture of pancreatitis however Of note, older studies have shown that CTs can miss acute pancreatitis up to 30% of the time. That being said, etiology is unclear. Lipase can be elevated for a large number of reasons other than pancreatitis. About 12% percent of patients admitted to the hospital with non-pancreatic abdominal pain have an elevated serum lipase. Other conditions associated with an elevated lipase include renal failure, acute cholecystitis, bowel obstruction or infarction, duodenal ulceration, pancreatic tumor, DKA, HIV, macrolipasemia, celiac, trauma, idiopathic, drugs. Her Cr is slightly up but likely secondary to volume depletion. As above, bowel obstruction/infarction possible but unlikely. # Drug seeing behavior: During prior admission, question was raised as to whether her repeated admissions may be her withdrawing from opiates. She has a narcotic contract in Atrius records. During admission, we avoided IV opioids as much as possible (was given in the ED, none while on the medical floor as she received only the opioid medications per her narcotic contract while on the floor). # Reported seizure: Patient reported seizure about 6 weeks prior to admission. Reportedly witnessed by boyfriend and son and being found "lying on the floor" wetting herself with minimal tongue bite along with jerky body movements which lasted about ___ minutes. No recall of event. On exam, she has a non-focal neuro exam and was neurologically stable throughout her hospital stay. We continued her home anti-seizure medication as inpatient. # Neck fullness: Has an anterolateral neck nodule. Most likely thyroid given movement with swallowing and lcoation. Patient reports she is being evaluated by endocrinology. She reports that she will have a biopsy done on ___. Transitional issues: - She was not provided with any narcotics on discharge - F/U right anterolateral neck nodule work up - If abd pain persists please order a MRCP with secretin test Medications on Admission: 1. clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)) as needed for sleep. 2. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Transdermal every ___ (72) hours. 3. oxycodone 10 mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain: please do not drive or operate heavy machinery while taking this medication; avoid alcohol. 4. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) Nasal once a day. 5. Zofran 4 mg Tablet Sig: One (1) Tablet PO once a day. 6. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 7. hydroxyzine HCl 50 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea. 8. Calcarb 600 With Vitamin D 600 mg(1,500mg) -200 unit Tablet Sig: One (1) Tablet PO once a day. 9. phenobarb-hyoscy-atropine-scop 16.2-0.1037 -0.0194 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain: with meals. 10. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Medications: 1. Clonazepam ___ mg PO QHS:PRN insomnia or anxiety 2. Fentanyl Patch 100 mcg/hr TP Q72H hold for sedation 3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain please hold if sedated or RR < 10 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY 5. Ondansetron 4 mg PO DAILY:PRN nausea/vomiting 6. esomeprazole magnesium NF 40 mg Oral twice a day 7. HydrOXYzine 50 mg PO TID:PRN nausea 8. Calcarb 600 With Vitamin D NF (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit Oral once daily 9. phenobarb-hyoscy-atropine-scop NF 16.2-0.1037 -0.0194 mg Oral three times a day pain: with meals 10. LeVETiracetam 500 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: abdominal pain Reported Seizure Thyromegaly 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 for abdominal pain, nausea and vomiting. This was managed by pain control based on your narcotic contract in addition to IV anti-emetics that were transitioned to your oral regimen. You also received IV fluids. We did not make changes in your medication list. Please continue taking them the way you were taking prior to admission. Please follow with your appointment as illustrated below with your primary care physician ___ ___. Please make sure to follow-up regarding neck swelling with your doctor as well. Followup Instructions: ___
10812035-DS-5	10,812,035	23,931,867	DS	5	2159-07-07 00:00:00	2159-07-08 22:24:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: adhesive tape / Shellfish / fish / Vancomycin / Penicillins Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/Crohn's presents with abdominal pain. Pt reports that she has been having abd pain and diarrhea for 1 month. She was seen in GI clinic ___ and prescribed Humiria but her insurance has not approved it yet. Her pain increased over the last week. Pain is now constant located over her entire abdomen, worse in epigastric and RLQ. She also has loose stool with small amounts of blood in it, although this has been attributed to internal hemorrhoids recently seen on sigmoidoscopy on ___. Sigmoidoscopy was c/w mildly active colitis, with path showing cryptitis, but no granulomas. . In ED pt given morphine and zofran. CT scan showed inflammation, unchanged from prior. On arrival to floor pt reports epigastric and RLQ pain. She was concerned that pain was not just related to food, but constant. And epigastric pain is similar to when she developed severe gastritis and ulcers from steroids. She attempted to increased PPI to BID with only short term relief. No nausea currently. Last antibiotic course was approximately 1 month ago with a 2 week course of PO Bactrim for hidradenitis. . She inquires about being discharged to home today if it is safe. It is her ___ year anniversary today, and she would like to spend it with her husband outside of the hospital. She also reports that she is concerned that we will need to start steroids, as she has had significant side effects in the past, with severe weight gain and steroid psychosis. . ROS: +as above, otherwise reviewed and negative Past Medical History: Crohn's Disease dx ___ Ankylosing Spondylitis Fibromylagia Social History: ___ Family History: no history of IBD Physical Exam: Admit Exam: Vitals: T:98.9 BP:121/77 P:88 R:18 O2:98%ra PAIN: 5 General: nad Lungs: clear CV: rrr no m/r/g Abdomen: bowel sounds present, soft, tender epigastrium and RLQ Ext: no e/c/c Skin: no rash Neuro: alert, follows commands . Discharge Exam: Similar to above, without major change, except pain improved with PO pain control. Rated ___. Otherwise AVSS and benign abd exam with mild TTP as above. . Pertinent Results: Recent Imaging ===================== CT Abd/Pelvis ___ IMPRESSION: 1. Wall thickening and surrounding inflammatory changes involving the terminal ileum and cecum. increased since the prior study, with prominence of adjacent lymph nodes, suggesting acute Crohn's flair. Mucosal enhancement can not be assessed given lack of IV contrast. No drainable collection seen at this time. No free air. . . PA/lat CXR ___ FINDINGS: Frontal and lateral views of the chest were obtained. There is minimal right basilar atelectasis without frank focal consolidation. No pleural effusion or pneumothorax is seen. There is continued slight prominence of the interstitial markings, stable since the prior study, most likely chronic. Cardiac and mediastinal silhouettes are stable. The hilar contours are stable. IMPRESSION: No acute cardiopulmonary process. . . Flex Sig ___ Impression: Grade 1 internal hemorrhoids Petechiae and erythema in the rectum, sigmoid colon and distal descending colon compatible with mild inflamatory bowel disease (biopsy) Otherwise normal sigmoidoscopy to splenic flexure . Biopsy Pathology ___ Focal active cryptitis. No well developed changes of chronic colitis are seen. The differential diagnosis includes infection, drug effect, early inflammatory bowel disease, etc. No granulomas seen. Clinical correlation is needed. . . Admission Bloodwork: ===================== ___ 03:25PM BLOOD WBC-15.8* RBC-4.16* Hgb-12.1 Hct-38.3 MCV-92 MCH-29.2 MCHC-31.7 RDW-13.1 Plt ___ ___ 03:25PM BLOOD Neuts-77.7* Lymphs-17.5* Monos-2.7 Eos-1.3 Baso-0.8 ___ 03:25PM BLOOD Glucose-87 UreaN-7 Creat-0.6 Na-140 K-4.1 Cl-104 HCO3-24 AnGap-16 ___ 03:25PM BLOOD ALT-17 AST-16 AlkPhos-81 TotBili-0.3 ___ 03:25PM BLOOD Albumin-3.8 ___ 03:25PM BLOOD Lipase-31 ___ 03:25PM BLOOD CRP-85.6* ___ 03:25PM BLOOD ESR-49* . Discharge Bloodwork ===================== ___ 06:25AM BLOOD WBC-12.7* RBC-3.66* Hgb-10.7* Hct-33.7* MCV-92 MCH-29.3 MCHC-31.9 RDW-13.2 Plt ___ ___ 06:25AM BLOOD Glucose-89 UreaN-5* Creat-0.6 Na-139 K-3.9 Cl-108 HCO3-24 AnGap-11 . Urine Studies ===================== ___ 03:30PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 03:30PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG ___ 03:30PM URINE RBC-3* WBC-2 Bacteri-FEW Yeast-NONE Epi-3 ___ 03:30PM URINE UCG-NEGATIVE . Brief Hospital Course: ___ w/Crohn's presents with abdominal pain concerning for Crohn's flare. . ACTIVE ISSUES: ====================== # Abdominal pain: Pt had noted worsening upper abdominal pain and had doubled her home PPI dose under instruction by her outpt GI physician. However, her pain then continued to worsen. Although she does not have evidence of upper GIB by sx's or lab values, her symptoms warrant an EGD. She was seen by GI consult, and they recommended expedited outpt EGD, increased PPI to high-dose BID, and PO PRN opiates for pain control. . # Crohn's Disease: Although pt presents with worsening abdominal pain, the location of the pain is more c/w upper abdomen, and possibly unrelated to her Crohn's disease. She has recent sigmoidoscopy (___) with biopsy, confirming active colitis. She has leukocytosis. She also has elevated ESR and CRP vs baseline, and her CT scan is c/w active Crohn's inflammation. However, she does not endorse worsening diarrhea, bloody stools, cramping lower abdominal pain, or fevers/chills. Her elevated ESR/CRP may also be explained by exacerbation of her other autoimmune diseases. As such, while she may certainly be having active Crohn's flare, it may not be worsening. She is on mesalamine as outpatient and is awaiting Humira approval. She does not want to be on systemic steroids due to previous side effects. She was seen by GI consult, and they recommended continuing mesalamine, adding 2 weeks of Cipro/Flagyl, and to obtain Humira ASAP. PACT Pharmacist was able to assist in obtaining more information re: Humira script, and prior authorization will be obtained by outpt GI office. . . CHRONIC ISSUES: ===================== # Fibromyalgia: continued home meds . . TRANSITIONAL ISSUES: ===================== 1. trial of high dose PPI and outpt EGD to w/u abdominal pain 2. awaiting prior authorization approval of Humira. Outpt GI Dr. ___ to complete. 3. complete 2 weeks of antibiotics 4. PENDING STUDIES AT TIME OF DISCHARGE: NONE . . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Mesalamine ___ 4800 mg PO DAILY 2. clindamycin phosphate 1 % topical BID 3. Diphenoxylate-Atropine 2 TAB PO Q6H:PRN diarrhea 4. Cyanocobalamin 1000 mcg IM/SC Q1MO 5. Apri (desogestrel-ethinyl estradiol) 0.15-30 mg-mcg oral daily 6. Diazepam 10 mg PO HS:PRN restless legs 7. Omeprazole 20 mg PO BID 8. Cyclobenzaprine 10 mg PO HS:PRN muscle spasms Discharge Medications: 1. Cyclobenzaprine 10 mg PO HS:PRN muscle spasms 2. Diazepam 10 mg PO HS:PRN restless legs 3. Diphenoxylate-Atropine 2 TAB PO Q6H:PRN diarrhea 4. Mesalamine ___ 4800 mg PO DAILY 5. Apri (desogestrel-ethinyl estradiol) 0.15-30 mg-mcg oral daily 6. clindamycin phosphate 1 % topical BID 7. Cyanocobalamin 1000 mcg IM/SC Q1MO 8. Diazepam ___ mg PO PRN per psychiatrist 9. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL (1:1,000) injection PRN allergic reaction 10. Ranitidine 75 mg PO PRN heartburn 11. Omeprazole 40 mg PO BID RX omeprazole 40 mg 1 capsule,delayed ___ by mouth twice daily Disp #60 Capsule Refills:0 12. Ciprofloxacin HCl 500 mg PO Q12H Duration: 2 Weeks RX ciprofloxacin 500 mg 1 tablet(s) by mouth every 12 hours Disp #28 Tablet Refills:0 13. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 2 Weeks RX metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp #42 Tablet Refills:0 14. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain RX hydromorphone 2 mg 1 tablet(s) by mouth every 6 hours Disp #40 Tablet Refills:0 15. Ondansetron 4 mg PO Q8H:PRN nausea RX ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp #42 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: abdominal pain Crohn's Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with abdominal pain. Your CT scan did show signs concerning for acute Crohn's flare. ___ d/w the GI consult service, you were felt to be stable for discharge to home. Some medication adjustments were made. You will need an outpatient EGD (upper endoscopy) which Dr. ___ ___ will schedule for you. . Please take your medications as listed. . Please see your physicians as listed. . Followup Instructions: ___
10812219-DS-12	10,812,219	29,229,484	DS	12	2115-01-20 00:00:00	2115-01-21 20:20:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: codeine Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: ___ with hx of acquired TTP with severe ADAMTS13 deficiency, recent MICU course s/p pheresis (last session ___, low dose Rituximab therapy (final dose ___, on steroid taper, who is presenting with fevers (as high as 104 with home oral thermometer), headache, myalgias, nausea, and a "red jelly" diarrhea for 2 days. All symptoms started with a headache. This morning she also noted left sided groin pain, and had a very dark soft stool. She has a new cough for one day which is non-productive, described as a tickle in her throat. She also reports night sweats for about a month which she attributes to her steroids. She denies urinary symptoms. She also endorses memory issues since her hospitalization last month, as well as some visual hallucinations (spiders crawling), which she thinks are all due to steroids. She denies vomiting. She states that four people at work have called out sick in the past week for similar symptoms. She was discharged on ___ after seizure induced by TTP, she required pRBC transfusion and exchange pheresis, no head bleed at that time. Last dose Rituximab on ___, last pheresis ___. She has been on steroids since her ___ admission, and is currently tapering at 30mg prednisone daily. In the ED, initial VS were 102.5, 115, 115/59, 20, 98% RA Exam notable for Tachycardia, regular rhythm, rate 110. CTAB. Diffuse tenderness to abdominal palpation, worse in suprapubic and RUQ, no peritoneal signs. Tender to both groins bilaterally without masses, erythema or drainage. Labs showed WBC 8.6, Hb 12.7, Plt 237, K 4.2 Cr. 0.8. lactate 1.8, UA trace leuk, neg nitrites, 1WBC, tr bld w/ 2RBC Imaging showed Liver Or Gallbladder Us 1. 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. 2. No cholelithiasis. CXR PA/LAT No acute cardiopulmonary abnormality Received Vanc IV, cefepime 2gm IV, Zofran 4mg IV, Tylenol IV 1000mg, NS 1L bolus Patient's oncologist (Dr. ___ was contacted, no signs of TTP per labs or reason for OMED/BMT service, likely viral infection, but wants to cover with IV antibiotics and admit to medicine while awaiting blood culture results. Transfer VS were 98.3, 99, 110/70, 20, 98% RA On arrival to the floor, patient reports minimal improvement in her symptoms. Says her Tylenol is wearing off and feels like she has a fever again. Other notable HPI/ROS discussed above. Past Medical History: PAST MEDICAL HISTORY: - TTP (treated in ___ in ___ -- plasmapheresis for several months - HTN - Left leg surgery Social History: ___ Family History: Unknown Physical Exam: ADMISSION PHYSICAL ================= VS: 102.6, 91/60, 109, 18, 99 Ra GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: Tachycardic, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, tender in all quadrants, moreso in LLQ, no rebound/guarding, no hepatosplenomegaly. Groin tender bilaterally, no notable lymphadenopathy. Mild tenderness to percussion of CVA bilaterally. EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, CN II-XII intact, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes Rectal: Chaperoned by RN. No hemorrhoids, minimal stool in rectal vault, no blood. DISCHARGE PHYSICAL ================ VITALS: 97.5 94 / 60 78 18 98 ra GENERAL: well developed female resting in bed. NAD. HEENT: normocephalic atraumatic. PERRL. Sclera anicteric. No cervical LAD. CV: RRR. Normal S1 and S2. No MGR. RESP: nonlabored respirations. no adventitious sounds. GI: soft, nondistended, nontender to palpation MSK: moving all four extremities spontaneously, no lower extremity edema SKIN: no rashes Pertinent Results: ADMISSION LABS: ============== ___ 10:42AM BLOOD WBC-8.6 RBC-3.90 Hgb-12.7 Hct-38.3 MCV-98 MCH-32.6* MCHC-33.2 RDW-13.2 RDWSD-47.3* Plt ___ ___ 10:42AM BLOOD Neuts-77.1* Lymphs-9.8* Monos-8.1 Eos-3.5 Baso-0.6 Im ___ AbsNeut-6.62* AbsLymp-0.84* AbsMono-0.70 AbsEos-0.30 AbsBaso-0.05 ___ 01:01AM BLOOD Hypochr-1+* Anisocy-1+* Poiklo-NORMAL Macrocy-1+* Microcy-NORMAL Polychr-NORMAL ___ 01:01AM BLOOD Ret Aut-1.4 Abs Ret-0.05 ___ 10:42AM BLOOD Glucose-89 UreaN-12 Creat-0.8 Na-137 K-5.5* Cl-96 HCO3-23 AnGap-18* ___ 01:01AM BLOOD ALT-350* AST-297* LD(___)-490* AlkPhos-202* DirBili-0.8* ___ 10:42AM BLOOD Calcium-8.6 Phos-4.2 Mg-2.1 ___ 01:01AM BLOOD Hapto-235* ___ 10:49AM BLOOD Lactate-1.8 K-4.2 PERTINENT LABS: ============== ___ 10:42AM BLOOD ALT-224* AST-302* LD(___)-1019* AlkPhos-119* TotBili-0.8 ___ 08:00AM BLOOD ALT-340* AST-193* LD(___)-425* AlkPhos-214* TotBili-2.3* ___ 07:58AM BLOOD ALT-257* AST-109* LD(___)-297* AlkPhos-211* TotBili-2.0* ___ 03:15PM BLOOD ALT-269* AST-107* LD(___)-240 AlkPhos-206* TotBili-1.1 ___ 10:42AM BLOOD Hapto-218* DISCHARGE LABS: ============== ___ 07:40AM BLOOD WBC-9.8 RBC-4.15 Hgb-13.4 Hct-41.3 MCV-100* MCH-32.3* MCHC-32.4 RDW-13.1 RDWSD-48.1* Plt ___ ___ 07:40AM BLOOD Glucose-77 UreaN-11 Creat-0.5 Na-143 K-4.5 Cl-103 HCO3-23 AnGap-17* ___ 07:40AM BLOOD ALT-212* AST-51* LD(___)-244 AlkPhos-214* TotBili-0.5 ___ 07:40AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.3 MICROBIOLOGY: ============== Time Taken Not Noted Log-In Date/Time: ___ 10:57 pm URINE 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. ___ 10:50 am BLOOD CULTURE SET#2. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 10:42 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 10:29 am URINE FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING/STUDIES: ============== ___ RUQUS IMPRESSION: 1. 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. 2. No cholelithiasis. ___ CXR IMPRESSION: No acute cardiopulmonary abnormality. Brief Hospital Course: Patient summary statement for admission ___ year old female with past medical history of acquired TTP severe ADAMTS13 deficiency, recent admission ___ with TTP flare requiring pheresis, Rituximab and steroids, admitted ___ with diarrhea and fever of unclear etiology, workup negative for cause, off antibiotics and afebrile for 72 hours, able to be discharged home # Sepsis secondary viral enteritis NOS # Diarrhea Patient presented with 2 days of fever, myalgias, diarrhea and was found to be tachycardic and hypotensive in the emergency department. Given her immunosuppressed state she was felt to be at high risk for serious infection and was started on empiric antibiotics for infection of unknown source and volume resuscitated. Given diarrhea and recent sick contacts at work, there was suspicion for a viral enteritis. Remainder of workup including chest xray and RUQ ultrasound were negative for acute processes. Urine culture was negative and blood cultures remained without growth. She had one episode of nausea and vomiting after admission, but otherwise had a rapid return to her baseline health. Antibiotics were discontinued and patient remained stable and without issue. At time of discharge infectious stool studies were pending. # Elevated LFTs # Hepatic Steatosis Patient with previously noted LFTs that were attributed to drug effect from keppra, who was admitted with elevated LFTs including AST, ALT, alk phos and tbili, all elevated from recent baseline. RUQ ultrasound was only notable for echogenic liver consistant with steatosis but unable to exclude steatohepatitis, hepatofibrosis, or cirrhosis. LFTs rapidly improved with her clinical condition and were felt to have related to her acute illness / viral enteritis, with underlying chronic abnormal liver parenchyma secondary to likely steatosis. At discharge ALT 212 AST 51, AP 214 Tbili 0.5. Would consider rechecking LFTs to ensure normalization as an outpatient. If remain at recent baseline (elevated from normal) would consider additional workup and/or referral to a hepatologist given ultrasound abnormalities described above that were unable to exclude a more serious chronic process. # TTP # Chronic steroids Patient with history of TTP with recent admission and ICU stay in ___ for recurrent TTP episode that required pheresis, rituximab and prednisone. She had been prednisone 30mg prior to admission. Hospital course was notable for patient reporting that secondary to steroid side effects (anxiety, hallucinations) she planned to "stop all steroids immediately" after discharge. Per discussion with Dr. ___ managing her TTP as outpatient) we proposed a taper to the patient as a less risky alternative (although one that still carried risks of TTP recurrence). Patient was able to verbalize understanding of risks, including TTP and death, and agreed to a taper--team tapered her dose to 20mg on ___, to take until ___, then 10mg ___ and ___, then can stop. Platelets remained stable. Admission otherwise notable for initiation of PCP ppx with ___ given her prolonged steroid course, which was stopped when above taper plan was devised. Patient discharged with close PCP and hematology ___. Would recheck CBC at ___ to ensure stability--patient is high risk for complications. # Hallucinations and Insomnia During recent admission, patient ahd been started on zyprexa for these symptoms, which were thought to relate to prednisone side effects. Given plan to taper and stop steroids as outpatient, would ___ with patient after taper to discontinue zyprexa. #HTN Patient endorsed not taking Hctz since her discharge last month. Held this admission and blood pressures remained appropriate. Can reassess restarting at ___. # ADD Held Adderall during admission. TRANSITIONAL ISSUES [] Prednisone taper: 10mg ___, then stop [] F/u CBC, LFTs within 1 week after discharge Code Status: Full ___ (Mother) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 30 mg PO DAILY 2. OLANZapine 5 mg PO DAILY 3. Glucosamine (glucosamine sulfate) 500 mg oral DAILY 4. FoLIC Acid 5 mg PO DAILY 5. cranberry 400 mg oral DAILY 6. garlic extract ___ mg oral DAILY 7. Hydrochlorothiazide 25 mg PO DAILY 8. Amphetamine-Dextroamphetamine XR 20 mg PO DAILY Discharge Medications: 1. PredniSONE 10 mg PO ONCE Duration: 1 Dose 2. cranberry 400 mg oral DAILY 3. FoLIC Acid 5 mg PO DAILY 4. garlic extract ___ mg oral DAILY 5. Glucosamine (glucosamine sulfate) 500 mg oral DAILY 6. OLANZapine 5 mg PO DAILY 7. HELD- Amphetamine-Dextroamphetamine XR 20 mg PO DAILY This medication was held. Do not restart Amphetamine-Dextroamphetamine XR until you see your PCP 8. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was held because your blood pressure was low. Do not restart Hydrochlorothiazide until you see your PCP ___: Home Discharge Diagnosis: # Sepsis secondary viral enteritis NOS # Diarrhea # TTP # Chronic steroids # Elevated LFTs # Hepatic Steatosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, It was a pleasure to take care of you at ___. WHY WAS I HERE? You were admitted to the hospital because you had a fever and you are taking medications that suppress your immune system. WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL - You were treated with antibiotics. - Blood cultures and urine cultures were drawn and showed no signs of a bacterial infection. We think you likely had a viral infection that got better on its own. - Your blood pressure was low when you presented and you were given fluids through your IV. - Your prednisone dose was weaned. WHAT SHOULD I DO WHEN I GET HOME? 1) Follow up with your Primary Care Doctor. 2) Follow up with a Hematologist (Blood Doctor) 3) Take your medications as prescribed. 4) Your last dose of prednisone is tomorrow. Please take 10mg once tomorrow, then follow up with your doctors. We wish you the best! Your ___ Care Team Followup Instructions: ___
10812396-DS-4	10,812,396	25,312,759	DS	4	2173-10-06 00:00:00	2173-10-07 11:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: Sore throat, hoarse voice Major Surgical or Invasive Procedure: None History of Present Illness: ___ history of daily alcohol use, HTN who presents with two weeks of sore throat and hoarse voice. He has been experiencing a change in his voice ("lost his voice") for approximately two weeks. He acutely presented after having an episode of choking when laying flat. In terms of his bowel movements, he does have a history of hemorrhoids but in past has only had blood on toilet paper. Had two episodes of BRBPR with significant amount (~200cc) of blood in toilet bowel, first time this has happened. Has been having diarrhea x ___ weeks. In the ED, initial vitals were: 98.9 116 150/90 18 96% RA - Exam notable for: Lungs CTAB, heart RRR, no throat pain, white coating on the tongue. - Labs notable for: Stable Hb/Hct at 15.4/43.5. K initially low and then repleted. - Imaging was notable for: none - Consults: ENT consulted, thought bacterial vs fungal pharyngitis, recommended fluconazole and levofloxacin x 14 days with PPI. GI curbsided, no plans to scope at this point. - Events: patient had two episodes of BRBPR, stable Hb/Hct, tachycardic to 160s with ambulation. - Patient was given: IV thiamine, LR, potassium/magnesium repletion, diazepam for CIWA, fluconazole 200mg per ENT recs, levofloxacin 750mg. Upon arrival to the floor, patient reports that his two main complaints are: - Change in voice, hoarse voice that occurred abruptly ~13 days ago associated with minor soreness of throat. - Bloody bowel movements. Has a history of hemorrhoids but in past only had blood on toilet paper; significantly more blood on this occasion. - He also notes that for weeks he has been having night sweats, where he wakes up with varying degrees of sweat soaking in his shirt in the AM. Otherwise has intermittent chills, denies fevers, nausea, vomiting, shortness of breath, chest pain. Past Medical History: - Hypertension - Alcohol use disorder Social History: ___ Family History: Mother has DM, father has HTN. Physical Exam: ADMISSION EXAM: Vitals: 98.5 156 / 84 92 18 98 RA General: alert, oriented, no acute distress HEENT: sclera anicteric, MMs slightly dry. Large amount of white plaque covering the tongue and in the oropharynx. Neck: supple, JVP not elevated, no LAD Lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE EXAM: 98.2 PO 148 / 82 83 20 98 ra General: alert, oriented, no acute distress HEENT: sclera anicteric, MMs slightly dry. Large amount of white plaque covering the tongue and in the oropharynx. Neck: supple, 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, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, no edema Pertinent Results: ================ ADMISSION LABS ================ ___ 09:27PM BLOOD WBC-8.8 RBC-4.58* Hgb-15.5 Hct-44.3 MCV-97 MCH-33.8* MCHC-35.0 RDW-13.0 RDWSD-46.6* Plt ___ ___ 09:27PM BLOOD Neuts-72.8* Lymphs-14.9* Monos-10.6 Eos-0.5* Baso-0.7 Im ___ AbsNeut-6.39* AbsLymp-1.31 AbsMono-0.93* AbsEos-0.04 AbsBaso-0.06 ___ 09:27PM BLOOD Plt ___ ___ 07:55AM BLOOD ___ PTT-27.4 ___ ___ 09:27PM BLOOD Glucose-126* UreaN-10 Creat-0.7 Na-138 K-3.0* Cl-96 HCO3-24 AnGap-21* ___ 03:20PM BLOOD ALT-88* AST-155* AlkPhos-115 TotBili-1.7* DirBili-PND ___ 09:27PM BLOOD Mg-1.8 ================= DISCHARGE LABS ================= ___ 06:50AM BLOOD WBC-6.8 RBC-4.47* Hgb-15.5 Hct-43.7 MCV-98 MCH-34.7* MCHC-35.5 RDW-12.5 RDWSD-45.3 Plt ___ ___ 07:55AM BLOOD Neuts-68.1 ___ Monos-10.2 Eos-0.9* Baso-0.6 NRBC-0.2* Im ___ AbsNeut-5.49 AbsLymp-1.55 AbsMono-0.82* AbsEos-0.07 AbsBaso-0.05 ___ 06:50AM BLOOD Plt ___ ___ 07:55AM BLOOD ___ PTT-27.4 ___ ___ 06:50AM BLOOD Glucose-87 UreaN-10 Creat-0.6 Na-136 K-3.8 Cl-96 HCO3-25 AnGap-19 ___ 06:50AM BLOOD ALT-73* AST-87* AlkPhos-110 TotBili-1.4 ================== IMAGING ================== RUQ Ultrasound ___: 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: SUMMARY: ___ history of daily alcohol use, HTN who presents with pharyngitis and BRBPR. ACUTE ISSUES: # Pharyngitis: Patient presents with white plaque on tongue and in mouth consistent with pharyngitis, fungal vs bacterial. Underlying malignancy cannot be excluded and patient does have a significant smoking history. Likely source of patient's symptoms including sore throat and hoarse voice. Will assess for HIV given findings of pharyngitis, night sweats, and diarrhea. ENT was consulted and recommended levofloxacin 750mg, fluconazole 200mg daily x 14 days (d1 = ___. HIV testing was negative. Patient will f/u with ENT as outpatient. # BRBPR: History of hemorrhoids, has not bled for months. In ED had two episodes of BRBPR (200cc in toilet bowl) with tachycardia on ambulation to the 160s. Patient was admitted and subsequently hemodynamically stable with stable Hb/Hct. He was discharged with plan to f/u as outpatient. # Transaminitis: Patient was found to have elevated ALT/AST with elevated Tbili in the setting of extensive alcohol use. RUQ ultrasound showed steatisus. Hepatitis serologies were sent and showed negative HepC and HBs-Ab positive with HBs-Ag negative. # Alcohol use: Daily EtOH use with ___ drinks per day. Connected in the ED with social work who provided with outpatient resources. Patient was kept on CIWA scale with diazepam PRN CHRONIC ISSUES: # HTN: Continue home amlodipine TRANSITIONAL ISSUES: - Will complete 14-day course of fluconazole 200mg daily and levofloxacin 750mg daily (last day ___ - F/u with ENT in clinic for scope to assess for malignancy - Consider referral to GI for scope to assess cause of BRBPR - HIV and hepatitis serologies pending, consider referral to hepatology - Patient counseled on importance of alcohol cessation # Code status: Full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. TraZODone 50 mg PO QHS 3. Tretinoin 0.025% Cream 1 Appl TP QHS Discharge Medications: 1. Fluconazole 200 mg PO Q24H Duration: 13 Days RX fluconazole 200 mg 1 tablet(s) by mouth daily Disp #11 Tablet Refills:0 2. Levofloxacin 750 mg PO Q24H Duration: 13 Days RX levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #11 Tablet Refills:0 3. amLODIPine 10 mg PO DAILY 4. TraZODone 50 mg PO QHS 5. Tretinoin 0.025% Cream 1 Appl TP QHS Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Pharyngitis Gastrointestinal bleed Alcohol use disorder SECONDARY DIAGNOSIS: Hypertension 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 ___ due to a change in your voice. You were found to have an infection in your throat with either bacteria or fungus. You were seen by our ENT doctors and started on both antifungal and antibiotic medications. After you leave the hospital: - Please take all your doses of the new medications as prescribed - It is very important that you follow up with your PCP and with the ENT doctors in ___. Appointments are listed below. - You will need further testing for your liver, throat, and for your GI tract. Please work with your outpatient doctors to get these tests We wish you all the best! - Your ___ care team Followup Instructions: ___
10812790-DS-7	10,812,790	22,767,916	DS	7	2117-04-28 00:00:00	2117-04-29 20:36:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim Attending: ___. Chief Complaint: Fever, Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old gentleman with history of HIV on ART and warm autoimmune hemolytic anemia who presents as transfer from OSH with dyspnea and anemia. Patient has had headache, shortness of breath with exertion, and productive cough for the last week. His SOB is worsened by exertion. Reports fever for last 3 days (up to ___ at home). Denies chest pain. Patient feels symptoms are similar to those prompting admission in ___ however less severe. He has not had chills, abdominal pain, n/v/d, no dysuria. No recent sick contacts. No travel. Given his symptoms he presented to ___ for evaluation. There he was found to have hct 18.4. Given fever and cough he was treated with CTX and clinda. CXR reportedly without consolidation or acute process. In the ED, initial vitals were: 98.9 94 107/67 16 97% RA Labs notable for: hgb 6.3 hct 20.3 MCV 112, normal WBC and plts, elevated retic count 8.3, LDH 460, hapto <10, UA bacteria, large leuks, neg nitrate, neg , trop <0.01 ECG sinus 90, NA, NI, sub mm st depressions in V4-v5 Patient was given: 1LNS, difficult crossmatch, awaiting blood transfusion. heme onc consulted and recommended: add on peripheral smear, likely rituxan not taking effect yet and warm hemolytic anemia, start steroids at 1mg/kg. Vitals prior to transfer: 81 98/54 19 96% RA On the floor, patient is feeling better. He is not currently experiencing fevers. No SOB at rest. He feels overall better than he did when admitted in ___. No other new medication changes. ROS as above, otherwise negative. Past Medical History: - CKD - T2DM - HIV - calcium phosphate renal stones - OSA Social History: ___ Family History: No known history of kidney disease. His mother had diabetes. His father died at a young age from an accident. Physical Exam: ================================ ADMISSION PHYSICAL EXAM ================================ 99.8 PO 107 / 52 91 20 96 ra General: Alert, oriented, very pleasant gentleman in NAD HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, holosystolic flow murmur, no rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley , no CVA tenderness Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. ================================ DISCHARGE PHYSICAL EXAM ================================ Vitals: T 98.6, BP 109-115/74-82, P 74-82, RR 20, O2:98-100% General: Alert and oriented x 3, NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no cervical LAD Lungs: Good air movement. Decreased bibasilar rales, no wheezing. CV: RRR normal S1 + S2, Holosystolic flow murmur, no rubs or gallops Abdomen: Soft, NT, ND, BS+, no rebound or guarding Ext: WWP, 2+ pulses, No CCE. Neuro: CNII-XII intact, Normal strength and sensation. Pertinent Results: =========================== LABS =========================== ADMISSION LABS =========================== ___ 11:00PM BLOOD WBC-9.3# RBC-1.82* Hgb-6.3* Hct-20.3* MCV-112* MCH-34.6* MCHC-31.0* RDW-15.9* RDWSD-62.7* Plt ___ ___ 11:00PM BLOOD Neuts-61.6 ___ Monos-6.7 Eos-2.5 Baso-0.2 Im ___ AbsNeut-5.75# AbsLymp-2.60 AbsMono-0.62 AbsEos-0.23 AbsBaso-0.02 ___ 11:00PM BLOOD ___ PTT-40.6* ___ ___ 11:00PM BLOOD Glucose-120* UreaN-43* Creat-2.9# Na-138 K-5.1 Cl-104 HCO3-22 AnGap-17 ___ 11:00PM BLOOD ALT-16 AST-39 LD(LDH)-460 AlkPhos-52 TotBili-1.2 ___ 11:00PM BLOOD cTropnT-<0.01 ___ 11:00PM BLOOD Albumin-3.9 Iron-26* DISCHARGE LABS =========================== ___ 11:00PM BLOOD calTIBC-208* Hapto-<10* Ferritn-460* TRF-160* ___ 05:38AM BLOOD WBC-7.6 RBC-2.69* Hgb-9.0* Hct-29.6* MCV-110* MCH-33.5* MCHC-30.4* RDW-16.2* RDWSD-65.3* Plt ___ ___ 04:53PM BLOOD ___ PTT-35.0 ___ ___ 05:38AM BLOOD Ret Aut-8.6* Abs Ret-0.23* ___ 05:38AM BLOOD Glucose-104* UreaN-30* Creat-1.7* Na-141 K-4.1 Cl-105 HCO3-24 AnGap-16 ___ 05:38AM BLOOD LD(LDH)-310* ___ 05:38AM BLOOD Hapto-38 =========================== IMAGING =========================== CXR ___: FINDINGS: The cardiomediastinal silhouette is normal. The hila and bilateral pulmonary vasculatures are normal. There is a right lower lobe ill-defined hazy opacities with air bronchogram. No pneumothorax. No fractures. IMPRESSION: Right lower lobe pneumonia. Brief Hospital Course: ___ year-old male with a history of HIV, CKD, T2DM, nephrolithiasis, and warm autoimmune hemolytic anemia s/p recent steroid burst and 4 wks of rituxan who presents from an OSH with dyspnea, headache, fevers for the last week, found to have a hemolytic anemia (Hgb 6.3, haptoglobin <10, LDH 450) and CXR findings c/f RLL PNA. He was given one unit of PRBCs and one dose of Prednisone 70 mg with improvement in his symptoms and appropriate increase in Hgb. Heme/onc saw him and felt the hemolysis was likely related to the infection and Dapsone he was taking for PCP ppx, rather than recurrence of his warm AIHA. His dapsone was changed to Atovaquone for PCP ppx, and he was treated with ceftriaxone and azithromycin for CAP per ID team. On admission he also had a positive UA with WBC >182, but the patient was asymptomatic, and would be covered by ceftriaxone. Also on admission patient had a mild ___ with Cr of 2.9 from baseline 1.6-1.8. His respiratory symptoms improved over the next couple days and his labs improved with an increase in Hgb and decrease in Cr back to baseline. He was discharged with CAP coverage per ID: Cefpodoxime for remaining 7-day abx course (Day ___ finishing ___ and Azithromycin x 5 days (Day ___ finishing ___ and with plans for follow up with PCP and hematologist within 1 week to check a CBC. Discharge diagnoses: Community acquired pneumonia, complicated by worsened hemolytic anemia HIV, complicated with autoimmune hemolytic anemia type II diabetes Hypertension Acute on chronic renal disease # Hemolytic anemia: Warm autoimmune hemolytic anemia recently diagnosed during ___ admission (s/p rituxan x4), presented with hemolytic anemia with Hgb 6.3, retic count 8.3. Given early on in course of rituxan, heme/onc favored hemolysis in setting of infection (UTI vs PNA) vs dapsone, less likely refractory WAHA, rec'd d/c dapsone and start on atovaquone, consider TCR rearrangement study. Hgb/Hct responded appropriately to 1u pRBC transfusion on ___. Peripheral smear findings c/f spherocytes and reticulocytes c/w hemolysis. Hgb remained stable. # Pneumonia: Patient presented with fevers, shortness of breath, and with RLL opacity on CXR. As patient immunocompromised ___ HIV and tx, with recent 4-week course of rituximab and ___ hospital stay, differential included CAP and HCAP. Given mild symptoms, ID favored CAP coverage w/7-days of ceftriaxone (may switch to cefpodoxime on discharge) plus 5-days of azithromycin. Improved clinically. # Acute on chronic kidney disease: Cr 2.9 on admission from baseline 1.6-1.8, likely secondary to pre-renal azotemia and hemolytic anemia. Patient also thought to have post obstructive uropathy secondary to BPH during last admission, started on finasteride. Imaging showed enlarged left kidney with persistent, severe left calyceal dilation with layering echogenic debris and new debris in the bladder concerning for infection. Atrophic and echogenic right kidney. He is scheduled to f/u with urology on ___ needs bladder cancer eval per ID. Will give additional IVF, ensure all meds renally dosed. Cr improved to 1.7 back to baseline. # T2DM: last HgbA1c was 5.0 on ___, but patient has poorly controlled glycemia in setting of steroids. He is s/p one dose of 70 mg prednisone on ___. Will need close follow up with PCP for blood glucose monitoring. # HIV: CD4 count 102, HIV PCR undetected. Pt reports adherence to HAART regimen. EBV viral load <200 on ___. Continued home HAART regimen and switched PCP prophylaxis from ___ to Atavaquone as above. ======================= TRANSITIONAL ISSUES ======================= -MUST HAVE CBC within 1 week (heme/onc to arrange follow up next week) -Cefpodixime until ___ -Azithromycin until ___ -Changed HIV medications per ID recs -Needs follow up with hematology/oncology for further anemia management -Needs follow up with nephrology and urology for further work-up of obstructive uropathy. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Darunavir 800 mg PO DAILY 2. Etravirine 200 mg PO DAILY 3. RiTONAvir 100 mg PO DAILY 4. Dapsone 100 mg PO DAILY 5. Finasteride 5 mg PO DAILY 6. FoLIC Acid 5 mg PO DAILY 7. Acetaminophen 500 mg PO Q4H:PRN pain 8. Aspirin 81 mg PO DAILY 9. DiphenhydrAMINE 25 mg PO Q8H:PRN allergies 10. Loratadine 10 mg PO DAILY 11. Vitamin D ___ UNIT PO 1X/WEEK (___) 12. LaMIVudine 150 mg PO DAILY 13. Repaglinide 0.5 mg PO TIDAC Discharge Medications: 1. Atovaquone Suspension 1500 mg PO DAILY RX atovaquone 750 mg/5 mL 10 mL by mouth daily Refills:0 2. Azithromycin 250 mg PO Q24H RX azithromycin 250 mg 1 tablet(s) by mouth daily Disp #2 Tablet Refills:0 3. Cefpodoxime Proxetil 400 mg PO Q12H RX cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp #18 Tablet Refills:0 4. Etravirine 200 mg PO BID 5. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 6. Acetaminophen 500 mg PO Q4H:PRN pain 7. Aspirin 81 mg PO DAILY 8. Darunavir 800 mg PO DAILY 9. DiphenhydrAMINE 25 mg PO Q8H:PRN allergies 10. Finasteride 5 mg PO DAILY 11. LaMIVudine 150 mg PO DAILY 12. Loratadine 10 mg PO DAILY 13. RiTONAvir 100 mg PO DAILY 14. Vitamin D ___ UNIT PO 1X/WEEK (___) Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================ Hemolytic anemia SECONDARY DIAGNOSIS ================= Pneumonia Type 2 Diabetes Mellitus Chronic Kidney Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ with difficulty breathing and fevers for the last week. It as found that you had low red blood cell counts (anemia) as well as a picture of your chest that showed a lung infection (pneumonia). You were given a unit of blood with improvement in your symptoms and blood counts. The blood doctors saw ___ and ___ that the anemia was a result of the infection and possibly one of the medications you were taking and not because you had a recurrence of the blood disease you have been being treated for (warm autoimmune hemolytic anemia). Therefore the steroids that you were given in the emergency room were not continued. The infection doctors saw ___ and agreed with treatment for the pneumonia with antibiotics through the arm at first, then with pills. You improved significantly and were discharged with pills to continue treating the infection. You will need to take these pills for the next several days as prescribed. You will also need to follow up with 2 doctors: your primary care doctor ___, ___ and the hematologist that you have been seeing for your anemia (Dr. ___, ___. Since it's the weekend, we cannot schedule these for you, but we have contacted them. Please follow up with them to schedule an appointment. You should also follow up with your kidney and urinary tract doctors as ___. It was a pleasure taking care of you and we wish you all the best! -Your ___ Care Team Please call to schedule an appointment with your primary care doctor, ___, ___ *You should be getting a call from your hematologist's office, but if you do not hear from them by ___, please call them: Dr. ___ ___ Followup Instructions: ___
10812790-DS-8	10,812,790	29,409,645	DS	8	2118-05-30 00:00:00	2118-05-30 14:49:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim Attending: ___. Chief Complaint: fevers, shortness of breath, diarrhea Major Surgical or Invasive Procedure: Lumbar puncture on ___ History of Present Illness: ___ y/o M with complex PMHx of HIV (last CD4 of 100 in ___ on ART, SLE complicated by AIHA s/p rituximab, CKD stage III with chronic left hydronephrosis and not felt to have SLE nephritis who p/w ___ weeks of fevers and worsening left posterior chest pain with SOB. Pt was seen with son at bedside who provided additional history and translation as needed. Pt has been feeling unwell for the last ___ weeks with dry cough, progressive SOB, fevers and intermittent HAs. He was seen by PCP who recommended supportive care. Pt developed worsening SOB and DOE with poor appetite, diarrhea and was brought in by family to the ED. Pt denies any confusion or visual challenges, he often gets HA with fevers and denies any HA at the time of my exam. Denies any abd pain but has had intermittent dysuria without hematuria. No BRBPR and no ___ edema. Pt has chronic bilateral hand rash that is stable for some years and is followed by rheum for SLE. Pt reports that chest pain is over left posterior chest wall, worse with inspiration though present at all times for the last few days. Denies any sick contacts, no recent Abx exposures and denies any sputum or hemoptysis with cough. Denies any falls, weakness or LH but does report intermittent "beating" in ears bilaterally Past Medical History: HIV on ART, last CD4 ~100 in ___ SLE on hydroxychloroquine Warm autoimmune hemolytic anemia s/p steroids, rituxan CKD stage III, hx of atrophic right kidney and chronic left hydronephrosis Diet controlled DM Nephrolithiasis OSA on CPAP (poor compliance) Social History: ___ Family History: No known history of kidney disease. + DM and colon cancer Physical Exam: ADMIT Physical Exam VS Tm 100.9 BP 118/68 HR 74 RR 18 Sats 96% RA GENERAL: Alert and in no apparent distress, warm EYES: Anicteric ENT: small ulcerated lesion on base of right tongue, otherwise clear and dry MM CV: Heart regular, no murmur RESP: Crackles noted on inspiration over LLL > RLL GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly intact SKIN: dry scaling rash with scale over bilateral hands NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, FNF intact bilaterally PSYCH: pleasant, appropriate affect Discharge exam VITALS: T 98.6 BP 133/80 HR 70 RR 18 97% RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round CV: Heart regular, no murmur RESP: CTAB GI: Abdomen soft, obese, non-distended, non-tender to palpation. Bowel sounds present. No HSM NEURO: moving all four extremities, no asymmetry PSYCH: pleasant, appropriate affect Pertinent Results: ___ 08:20AM BLOOD WBC-6.7 RBC-2.93* Hgb-8.6* Hct-27.7* MCV-95 MCH-29.4 MCHC-31.0* RDW-14.2 RDWSD-49.3* Plt ___ ___ 05:40PM BLOOD WBC-12.5# Abs CD4-201 ___ 12:00AM BLOOD Glucose-102* UreaN-48* Creat-2.9* Na-135 K-4.7 Cl-98 HCO3-22 AnGap-15 ___ 08:00AM BLOOD Glucose-98 UreaN-37* Creat-1.8* Na-146* K-4.5 Cl-107 HCO3-18* AnGap-21* ___ 12:00AM BLOOD LD(LDH)-264* ___ 08:05PM CEREBROSPINAL FLUID (CSF) TNC-2 RBC-39* Polys-0 ___ ___ 07:25PM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-78* Polys-3 ___ Mesothe-3 ___ 07:25PM CEREBROSPINAL FLUID (CSF) TotProt-37 Glucose-82 ___ 7:25 pm CSF;SPINAL FLUID Source: LP. *FINAL REPORT ___ CRYPTOCOCCAL ANTIGEN (Final ___: CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). Test performed by Lateral Flow Assay. Results should be evaluated in light of culture results and clinical presentation. Renal U/S IMPRESSION: 1. Interval progression of severe left renal caliceal dilation, which contain debris, concerning for worsening obstruction at the level of the left renal pelvis. 2. Stable left lower pole renal stone. 3. Bladder containing echogenic debris. 4. Atrophic right kidney with echogenic parenchyma, unchanged. CT Chest IMPRESSION: 1. Confluent left lower lobe opacity compatible with bacterial pneumonia. 2. Nodular opacity in the right upper lobe may represent infection or focal atelectasis. 3. Hepatic steatosis. Brief Hospital Course: ___ complex PMhx including HIV (last CD4 100, VL undetectable per PCP), CKD stage III, SLE and warm AIHA who p/w ___ weeks off fevers, HA, worsening SOB and acute onset diarrhea, found to have new LLL PNA and acute on chronic renal failure. Acute LLL PNA, immunocompromised host with CD4 201: Pt presented with fevers, pleuritic chest pain and cough. CT chest revealed LLL PNA and pt was treated empirically with Ceftriaxone/Doxycycline for presume CAP. Fevers/HA resolved and symptoms improved rapidly on CAP coverage. Pt was seen by ID who recommended resp isolation for TB ruleout though it was felt to be unlikely. Pt had significant difficulty providing sputums and ultimately, pt was ruled out with a single negative sputum and TB nucleic acid...? Pt was transitioned to Cefpodoxime & Doxycycline to complete a 7 day course. HIV on ARVs: Pt is followed by ___ for his HIC and has had undetectable VL though CD4 of 201. He had a serum Crypto Ag sent during admission that returned weakly positive at 1:2. He denied any prior history of Crypto infection and PCP was unaware of prior serum Crypto Ag. Pt had a underwent LP on ___ that was negative of PMNs and CSF Crypto PCR was negative. - Per ID recommendations, he was started on fluconazole 400 mg daily x 12 months Pt was continued on his home ARV regimen and is scheduled for close follow up with his PCP. Acute on chronic renal failure: Pt presented with ___ in setting of diarrhea and fevers. He was seen by renal and underwent additional work up including Renal u/s that showed acute on chronic dilation of the left kidney. This has been evaluated by urology in the past and felt to be draining appropriately. There was no evidence of acute GN and pt was treated with aggressive IVF resuscitation. Fortunately, his renal function returned to baseline and he is scheduled for close urology follow up given his acute on chronic left kidney calyx dilation. Acute diarrhea: resolved, all stool Cx were negative for growth Hx of AIHA: hgb stable at baseline, no acute issues while admitted. Hx of SLE: continued home hydroxychloroquine, no evidence of acute glomerulonephritis. >30 minutes were spent providing and coordinating care for this patient on day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. RiTONAvir 100 mg PO DAILY 2. Darunavir 800 mg PO DAILY 3. Dapsone 100 mg PO DAILY 4. Hydroxychloroquine Sulfate 200 mg PO DAILY 5. Tamsulosin 0.4 mg PO QHS 6. LaMIVudine 150 mg PO DAILY 7. Etravirine 200 mg PO BID 8. Loratadine 10 mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Acyclovir 800 mg PO Q12H 2. Cefpodoxime Proxetil 400 mg PO Q12H RX cefpodoxime 200 mg 2 tablet(s) by mouth every 12 hours Disp #6 Tablet Refills:0 3. Doxycycline Hyclate 100 mg PO Q12H RX doxycycline hyclate 100 mg 1 capsule(s) by mouth every 12 hours Disp #3 Capsule Refills:0 4. Fluconazole 400 mg PO DAILY RX fluconazole 200 mg 2 tablet(s) by mouth daily Disp #30 Tablet Refills:0 5. Aspirin 81 mg PO DAILY 6. Dapsone 100 mg PO DAILY 7. Darunavir 800 mg PO DAILY 8. Etravirine 200 mg PO BID 9. Hydroxychloroquine Sulfate 200 mg PO DAILY 10. LaMIVudine 150 mg PO DAILY 11. Loratadine 10 mg PO DAILY 12. Multivitamins 1 TAB PO DAILY 13. RiTONAvir 100 mg PO DAILY 14. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Community acquired pneumonia cryptococcal infection Acute on chronic renal failure 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 fevers, shortness of breath and diarrhea. You were found to have worsening renal function which improved with IV fluids and a pneumonia. Your fevers improved with antibiotics. One of your blood tests was mildly positive for a fungal infection therefore you were also started on antifungal medication. Thank you for allowing us to participate in your care Your ___ team Followup Instructions: ___
10812798-DS-15	10,812,798	23,131,167	DS	15	2121-05-28 00:00:00	2121-05-29 18:44:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillin G / Lithium / dicloxacillin / escitalopram Attending: ___. Chief Complaint: Anemia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ y/o woman with h/o CVA and vascular dementia (has lived in ___ since ___, GI bleed in ___ in setting of warfarin use, chronic iron deficiency anemia, presenting from ___ with worsening anemia and guaiac-positive stool. History was obtained from ___ notes; patient unable to confirm due to dementia. Per records, patient's Hgb has been down-trending since at least ___ (9.1 ___ -> 7.4 ___ -> 6.4 ___. She has not had any overt bleeding but stool was guaiac positive. She was started on ferrous sulfate and omeprazole was increased to 20 BID. However, Hgb continued to drop and decision was made to transfer patient to ___ for GI evaluation, with agreement from patient's daughter/HCP. In the ED, initial VS were: 98.5 84 121/49 17 99% RA Exam notable for: pallor, looks ill, NAD, obese abdomen, increased BS, no tenderness, + occult blood test (stool) Labs showed: Hgb 6.8, WBC 12.4, lactate 1.3 Consults: GI - PPI BID, clears, NPO at MN for possible EGD pending discussion with family 20:35 verbal consent was received from her daughter (___) to give PRBC (1 unit), daughter could not recall if her mother had colonoscopy or EGD before. Patient received: IVF, IV pantoprazole 40, 1u RBC Transfer VS were: 97.7 82 138/67 24 98% RA On arrival to the floor, patient reports she feels well. No pain, nausea, lightheadedness, or dyspnea. Past Medical History: Vascular dementia c/b mood and behavior disturbances CVA ___ L-sided hemiparesis DVT ___, warfarin discontinued to GI bleed in ___ Iron deficiency anemia CAD HTN Hypothyroidism Hyperlipidemia DJD Depression Idiopathic peripheral neuropathy Slow transit constipation Social History: ___ Family History: non-contributory Physical Exam: ADMISSION PHYSICAL EXAM VS: reviewed, afebrile and hemodynamically stable General: elderly woman lying comfortably in bed in NAD. HEENT: NC/AT. No icterus or injection. MMM. CV: ___. ___ mid-systolic murmur heard best at ___ c/w AS. Resp: Non-labored, CTAB. Abd: Soft, NDNT, no palpable HSM or masses. GU: No suprapubic tenderness. Extr: Warm. LLE larger than RLE, no erythema or edema. Neuro: Alert, interactive, oriented to self and "doctor" but otherwise confused. DISCHARGE PHYSICAL EXAM General: Pleasant, elderly woman lying comfortably in bed in NAD. HEENT: NC/AT. No icterus or injection. MMM. CV: Irregularly irregular rhythm. III/VI mid-systolic murmur heard best at ___ c/w AS. Resp: Non-labored, CTAB. Abd: Soft, mildly tender RUQ, nondistended, no palpable HSM or masses. Pertinent Results: ADMISSION LABS ============== ___ 04:00PM BLOOD WBC-12.4* RBC-2.98* Hgb-6.8* Hct-22.8* MCV-77# MCH-22.8 MCHC-29.8* RDW-17.2* RDWSD-47.5* Plt ___ ___ 04:00PM BLOOD Neuts-75.4* Lymphs-17.1* Monos-5.7 Eos-0.8* Baso-0.4 Im ___ AbsNeut-9.36* AbsLymp-2.13 AbsMono-0.71 AbsEos-0.10 AbsBaso-0.05 ___ 09:34AM BLOOD ___ PTT-26.1 ___ ___ 04:00PM BLOOD Glucose-141* UreaN-30* Creat-0.6 Na-143 K-4.8 Cl-106 HCO3-25 AnGap-12 ___ 04:00PM BLOOD ALT-6 AST-9 LD(LDH)-143 AlkPhos-167* TotBili-<0.2 ___ 04:00PM BLOOD Albumin-2.8* Iron-15* ___ 09:34AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.3 ___ 04:00PM BLOOD calTIBC-280 VitB12-744 Hapto-276* Ferritn-37 TRF-215 ___ 04:00PM BLOOD TSH-3.3 ___ 06:10PM BLOOD Lactate-1.3 STUDIES ======= CT A/P ___ 1. Large right pleural effusion with compressive atelectasis. 2. No evidence of active extravasation. 3. Heterogeneous enhancement and mural thickening with nodular mucosa of the ascending colon from the ileocecal valve is concerning for underlying mass with possible ulceration. 4. Suspected acute non-occlusive thrombus within the splenic vein. Evidence for chronic splenic infarcts. Patent SMV and portal vasculature. 5. Heterogeneous thickened endometrium measuring 15 mm in thickness is concerning for malignancy. Correlate with pelvic ultrasound. 6. Chronic occlusion of the right internal iliac artery. Moderate narrowing just distal to the origin of the right common iliac artery. 7. Paget's disease in the pelvic bones 8. Gallbladder fundal adenomyomatosis. Brief Hospital Course: Ms. ___ is a ___ year-old female with advanced vascular dementia, h/o GIB on warfarin in ___, presenting with subacute/chronic anemia and guaiac-positive stool concerning for slow GI bleeding, found to have colonic mass on CT of abdomen, with decision made to focus on palliation. ACUTE ISSUES ============ # Subacute GI Bleed with Microcytic Anemia # Weight Loss # Colonic Mass Admitted from ___ with guaiac positive stools and Hb drop since ___. Per our records and ___ ~50 pound weight loss in past ___ years. Started on pantoprazole. Maroon and black stools here. No known h/o EGD or colonoscopy. s/p 1U pRBC this admission. Attempted to prep for colonoscopy, but unsuccessful. CT A/P showed mass of ascending colon/cecum and multiple sites of thrombosis in abdomen. Decision made to focus on palliation. Chronic Issues ============== # Atrial Fibrillation Rate controlled. Poor candidate for anticoagulation given prior GIB, current c/f GIB. Monitored on telemetry. # Vascular dementia H/o significant mood & behavioral disturbances. Continued on home trazodone, ramelteon and delirium precautions. # History of CVA Discontinued home lisinopril given stable blood pressures and desire to minimize unnecessary medications. # Hypothyroidism TSH stable. Continued home levothyroxine at same dose. # Idiopathic peripheral neuropathy Continued home gabapentin 100mg BID + 200mg QHS. #Chronic left heel ulcer Continued home collagenase ointment. TRANSITIONAL ISSUES =================== [ ] MOLST filled out indicating DNR/DNI/DN transfer except for comfort. [ ] Palliative care per primary team at ___. [ ] Discharged on morphine 5mg q1h prn for pain/dyspnea/distress. [ ] Discontinued all non-symptomatic medications given focus on palliation. #CODE: DNR/DNI (confirmed by MOLST) #CONTACTS: Daughters: ___ - ___ ___ - ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO BID 2. Collagenase Ointment 1 Appl TP DAILY 3. Ferrous Sulfate 325 mg PO DAILY 4. Gabapentin 100 mg PO BID 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Lisinopril 5 mg PO DAILY 7. melatonin 3 mg oral QHS 8. Bengay Cream 1 Appl TP BID 9. Omeprazole 20 mg PO BID 10. Polyethylene Glycol 17 g PO DAILY 11. TraZODone 100 mg PO QHS 12. Bisacodyl ___AILY:PRN constipation 13. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO BID:PRN heartburn 14. Ondansetron ODT 4 mg PO Q8H:PRN nausea 15. TraZODone 25 mg PO Q6H:PRN agitation 16. Gabapentin 200 mg PO QHS Discharge Medications: 1. Benzonatate 100 mg PO TID:PRN cough 2. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN cough, sore throat 3. GuaiFENesin ___ mL PO Q6H:PRN cough 4. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 5 mg PO Q1H:PRN Pain or respiratory RX morphine concentrate 100 mg/5 mL (20 mg/mL) 5 mg by mouth q1h Refills:0 5. Sodium Chloride Nasal ___ SPRY NU QID:PRN dryness 6. Acetaminophen 650 mg PO BID 7. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO BID:PRN heartburn 8. Bengay Cream 1 Appl TP BID 9. Bisacodyl ___AILY:PRN constipation 10. Collagenase Ointment 1 Appl TP DAILY 11. Gabapentin 100 mg PO BID 12. Gabapentin 200 mg PO QHS 13. Levothyroxine Sodium 100 mcg PO DAILY 14. melatonin 3 mg oral QHS 15. Omeprazole 20 mg PO BID 16. Ondansetron ODT 4 mg PO Q8H:PRN nausea 17. Polyethylene Glycol 17 g PO DAILY 18. TraZODone 25 mg PO Q6H:PRN agitation 19. TraZODone 100 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES ================= GI Bleed, Presumed Due to Colonic Mass Acute Blood Loss Anemia Severe Malnutrition SECONDARY DIAGNOSES =================== Atrial Fibrillation Thrombocytosis Vascular Dementia H/o Stroke Hypothyroidism Idiopathic Peripheral Neuropathy Chronic Left Heel Ulcer Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at ___. WHY WAS I IN THE HOSPITAL? - You came to the hospital because you were having bleeding with your bowel movements. WHAT HAPPENED TO ME IN THE HOSPITAL? - We gave you a unit of blood. - We watched your blood counts. - We did a CT scan of your abdomen which showed the source of your bleeding in your colon, but that it wasn't something we could fix with a colonoscopy. - We decided not to do a colonoscopy. - We cleaned up your medication list to make sure everything we were giving you was helping you feel better. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines. Your doctors at your ___ ___ continue to care for you and address your concerns. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
10813295-DS-8	10,813,295	22,053,636	DS	8	2124-11-22 00:00:00	2124-11-22 17:54:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / morphine Attending: ___. Chief Complaint: Abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: ___: Intubation (extubated later that day) History of Present Illness: ___ is an ___ PMH Afib, uterine CA s/p radical hysterectomy and radiation, recurrent SBOs s/p ex lap for lysis of adhesions and small bowel resection in ___, cholecystectomy w subsequent RNY hepaticojejunostomy, who presented to OSH for abdominal pain and was found to have an obstructive bile duct concerning for cholangiocarcinoma. Initial vitals at ___ with BP 168/87, 100% room air. Physician ___: ___ presents with severe epigastric pain radiating toward her back x ___ hours. She reports that the pain is tearing in character and accompanied by intense nausea. She has had prior SBOs, but this feels much more severe. Per EMS she had a differential in blood pressure between her arms... Increasing somnolence and continued nausea. Concern for airway risk... Placing OGT (NGT placed by nursing with minimal return after initial placement." She was acutely vomiting and was intubated for airway protection. Was given Zosyn at 2204 (preventative, was afebrile) and 2L NS. Labs with Cr 1.1, CO2 24, WBC 8.9, Hb 11.6, lactate 0.9. Arrived to ___ intubated and sedated on fentanyl and midazolam, CMV FiO2:40% PEEP:5 RR:20 Vt:450. She was extubated on ___ without complications. The ___ team discussed the case with the ERCP team. They felt the the lesion would not be amenable to stenting due to its location. They recommended consulting ___, who recommended against acute intervention. Hepatology recommended further evaluation of the lesion with MRCP. Her symptoms resolved with NGT decompression. She was stable and transferred to the Medicine floor on ___. Past Medical History: PMH: 1. Uterine cancer s/p surgery and radiation 2. Radiation enteritis 3. Chronic diarrhea of unknown etiology 4. Recurrent SBO 5. Anemia 6. Asthma 7. Generalized anxiety disorder . PSH: 1. TAH 2. Lap ccy c/b CBD injury 3. Hepatectomy/RNY hepaticoJ 4. SBO/LOA in distant past Social History: ___ Family History: Diabetes mellitus Crohn's disease squamous cell cancer in mouth -> father cancer (unknown location) -> mother cancer (unknown location) -> siblings Physical Exam: ADMISSION EXAM (FICU): VITALS: 73 137/86 14 100% intubated GENERAL: intubated, awake, responding appropriately to commands, answers yes/no questions HEENT: Sclerae anicteric, OGT and ETT in place, +oral secretions NECK: supple LUNGS: Ventilator breath sounds CV: Distant heart sounds, Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: no significant rashes NEURO: following commands, moving all extremities spontaneously ACCESS: PIVs DISCHARGE EXAM: Vitals: T: 97.8, BP: 154/84, HR: 72, RR: 18, O2: 94% RA; I/O: 1252/1050 GENERAL: Alert, appears uncomfortable EYES: Anicteric, pupils equally round ENT: Oropharynx without visible lesion, erythema or exudate CV: NS1/S2, RRR 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. MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS: ___ 07:55PM TYPE-ART TEMP-37 RATES-16/ TIDAL VOL-400 PEEP-5 O2-40 PO2-130* PCO2-33* PH-7.43 TOTAL CO2-23 BASE XS-0 AS/CTRL-ASSIST/CON INTUBATED-INTUBATED ___ 03:07PM GLUCOSE-97 UREA N-19 CREAT-0.9 SODIUM-137 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-22 ANION GAP-11 ___ 03:07PM estGFR-Using this ___ 03:07PM ALT(SGPT)-37 AST(SGOT)-60* LD(LDH)-202 ALK PHOS-86 TOT BILI-1.1 ___ 03:07PM ALBUMIN-3.4* CALCIUM-7.9* PHOSPHATE-3.3 MAGNESIUM-1.8 ___ 03:07PM WBC-7.0 RBC-3.49* HGB-10.8* HCT-32.3* MCV-93 MCH-30.9 MCHC-33.4 RDW-14.5 RDWSD-49.1* ___ 03:07PM PLT COUNT-138* ___ 03:07PM ___ PTT-29.4 ___ ___ 06:58AM cTropnT-0.02* ___ 01:54AM URINE HOURS-RANDOM ___ 01:54AM URINE UHOLD-HOLD ___ 01:54AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 01:54AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 01:54AM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 01:54AM URINE MUCOUS-RARE* ___ 01:49AM ___ PO2-32* PCO2-39 PH-7.37 TOTAL CO2-23 BASE XS--3 ___ 01:49AM LACTATE-1.6 ___ 01:41AM GLUCOSE-129* UREA N-19 CREAT-0.9 SODIUM-138 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-19* ANION GAP-14 ___ 01:41AM estGFR-Using this ___ 01:41AM ALT(SGPT)-26 AST(SGOT)-56* CK(CPK)-99 ALK PHOS-99 TOT BILI-1.2 ___ 01:41AM LIPASE-26 ___ 01:41AM CK-MB-2 cTropnT-0.04* ___ 01:41AM ALBUMIN-3.6 CALCIUM-7.9* PHOSPHATE-2.3* MAGNESIUM-1.7 ___ 01:41AM WBC-9.0 RBC-3.37* HGB-10.5* HCT-31.7* MCV-94 MCH-31.2 MCHC-33.1 RDW-14.2 RDWSD-48.6* ___ 01:41AM NEUTS-84.6* LYMPHS-7.0* MONOS-7.2 EOS-0.0* BASOS-0.4 IM ___ AbsNeut-7.62* AbsLymp-0.63* AbsMono-0.65 AbsEos-0.00* AbsBaso-0.04 ___ 01:41AM ___ PTT-26.1 ___ ___ 01:41AM PLT COUNT-125* ___ 06:58AM BLOOD cTropnT-0.___ 01:41AM BLOOD CK-MB-2 cTropnT-0.04* MICROBIOLOGY: - ___ Blood cx: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. - ___ Urine cx: Negative - ___ Urine cx: Negative - ___ Blood cx: pending - ___ Blood cx: pending - ___ Blood cx: pending IMAGING: - ___ CXR: IMPRESSION: 1. There is volume loss/infiltrate at the bases 2. Endotracheal tube tip is approximately 4.5 cm above the carina. ___ CXR: IMPRESSION: Upper enteric tube tip terminates in the distal gastric body. ___ CXR: IMPRESSION: Compared to chest radiographs ___ and ___. Regions of peribronchial opacification in the lower lobes, stable on the left, increased on the right could be due to acute aspiration, atelectasis and/or pneumonia. Upper lungs clear. No pulmonary edema. Heart size top-normal. Pleural effusions small if any. Nasogastric drainage tube passes into a nondistended stomach and out of view. ___ MRCP: IMPRESSION: 1. 0.8 cm intraductal stone just proximal to the hepaticojejunostomy, with upstream biliary duct dilatation, likely due to stricture at the anastomosis. 2. Left-sided cholangitis. 3. Persistent severe attenuation of the left portal vein with associated hepatic perfusional abnormalities DISCHARGE LABS: ___ 07:50AM BLOOD WBC-3.8* RBC-3.05* Hgb-9.6* Hct-28.5* MCV-93 MCH-31.5 MCHC-33.7 RDW-14.1 RDWSD-47.9* Plt ___ ___ 07:45AM BLOOD Neuts-46.1 ___ Monos-9.9 Eos-5.9 Baso-0.7 Im ___ AbsNeut-1.26# AbsLymp-1.01 AbsMono-0.27 AbsEos-0.16 AbsBaso-0.02 ___ 07:50AM BLOOD Plt ___ ___ 07:50AM BLOOD Glucose-94 UreaN-6 Creat-0.7 Na-144 K-4.0 Cl-106 HCO3-26 AnGap-12 ___ 07:50AM BLOOD ALT-25 AST-36 AlkPhos-137* TotBili-0.3 ___ 07:45AM BLOOD ALT-20 AST-32 AlkPhos-136* TotBili-0.4 ___ 07:10AM BLOOD ALT-19 AlkPhos-107* TotBili-0.4 ___ 01:41AM BLOOD Lipase-26 ___ 07:50AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.7 ___ 02:40AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG ___ 02:40AM BLOOD AFP-5.3 ___ 02:40AM BLOOD HCV Ab-NEG Brief Hospital Course: # Cholangitis with intraductal stone # Intrahepatic Biliary Dilatation # Transaminitis # Elevated alk phos Patient presented to OSH with abdominal pain and nausea and was intubated for airway protection in the setting of nausea and somnolence. She was started on zosyn due to evidence of an intrahepatic biliary ductal dilatation with concern for obstruction vs. malignancy. Upon arrival to ___, ERCP reviewed her outside imaging and did not think ERCP would be helpful given how central the mass was in the left lobe. They believed there were limited options for stenting (could only use plastic stent). They recommended ___ consult for drainage given that there was a risk for infection to develop. ___ was consulted and did not believe there was immediate need for intervention. The patient was continued on zosyn and transferred to Medicine. Hepatology recommended an MCRP for better characterization of the mass/stricture. MCRP showed abnormal enhancement of left lobe of liver and cholangitis with 0.8 cm intraductalstone. Given her lack of ongoing symptoms and fevers, the cholangitis was may be a chronic issue - it may be due to secondary biliary cirrhosis from multiple bouts of cholangitis. She has chronically elevated alk phos and mild transaminitis and chronic radiographic changes of her liver. ___ recommended against any acute intervention due to her lack of symptoms/significant lab abnormalities. Hepatology recommended continuing treatment for acute cholangitis with a 14-day course of antibiotics, she was discharged on Augmentin to complete 14 day course of antibiotics. They also recommended starting ursodiol. She will be presented at Liver Tumor Conference to discuss the possibility of future interventions. # Recurrent small bowel obstruction The patient has a history of recurrent SBOs, with presentation of abdominal pain, nausea, vomiting, that has improved with decompression. Initially, given CT imaging findings concerning for biliary duct dilatation, there was a concern for ongoing cholangitis or biliary obstruction contributing to her clinical picture. Given significant improvement with decompression alone, it is likely that some part of her symptoms were related to small bowel obstruction. # Intubated for airway protection Patient was noted to be more somnolent and nauseated per OSH note and was intubated for airway protection. ED report differs somewhat ("acutely vomiting"). Given that ERCP and ___ were not able to intervene immediately and the patient's respiratory status was stable, the patient was extubated on ___. # Troponinemia Patient presented with positive troponins in setting of normal renal function. She has a history of atrial fibrillation and is not on anticoagulation, but has no known history of heart failure. Troponemia thought to be secondary to demand ischemia and down-trended from 0.04 to 0.02. # Blood culture contaminant She was initially treated with vancomycin when a blood culture returned with GPCs. Vancomycin was stopped when the culture resulted as coagulase negative Staph (___). # Thrombocytopenia Platelets were consistently in the 120s-130s, with prior labs at ___ showing a baseline in the 180s-200s. She had no evidence of active bleeding. This was thought to be due to underlying infection (possible cholangitis). # Atrial fibrillation Per the FICU team, she had an episode of afib with RVR in the 130s. Not on anticoagulation. CHADS VASC score elevated in the setting of age, sex, gender. ___ lists atrial fibrillation as a known problem, but it is unknown what workup and options have been discussed in the past. Afib with RVR resolved with treatment of SBO and cholangitis. She was monitored on telemetry for 48 hours after transfer to medicine and maintained in normal sinus rhythm. # Anxiety - Continue buspirone 20 mg PO BID - Continue sertraline 25 mg PO daily Transitional issues: Pending future decisions re: interventions, anticoagulation should be discussed with the patient as outpatient with PCP. Will need to discuss with liver team as outpatient regarding future procedures planned. -Repeat CBC, chemistries as outpatient -Follow-up appointment with liver clinic and PCP ___ on ___: The Preadmission Medication list is accurate and complete. 1. BusPIRone 20 mg PO BID 2. Famotidine 40 mg PO DAILY 3. Vitamin D 1000 UNIT PO DAILY 4. Sertraline 25 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Thera-M ( m u l t i v i t - i r o n - F A - c a l c i u m - m i n s ; < b r > m ultivitamin,tx-iron-Ca-FA-min;<br>multivitamin,tx-iron-minerals) ___ mg oral DAILY 7. magnesium 250 mg oral BID 8. Cyanocobalamin Dose is Unknown PO 3X/WEEK (___) Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H cholangitis RX amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 tablet(s) by mouth twice daily Disp #18 Tablet Refills:0 2. Ursodiol 300 mg PO BID RX ursodiol 300 mg 1 capsule(s) by mouth twice daily Disp #30 Capsule Refills:0 3. Cyanocobalamin 100 mcg PO 3X/WEEK (___) 4. Aspirin 81 mg PO DAILY 5. BusPIRone 20 mg PO BID 6. Famotidine 40 mg PO DAILY 7. magnesium 250 mg oral BID 8. Sertraline 25 mg PO DAILY 9. Thera-M ( m u l t i v i t - i r o n - F A - c a l c i u m - m i n s ; < b r > m ultivitamin,tx-iron-Ca-FA-min;<br>multivitamin,tx-iron-minerals) ___ mg oral DAILY 10. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Cholangitis with intraductal stone Intrahepatic biliary ductal dilatation Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, You were admitted to the hospital for severe abdominal pain, nausea, and vomiting with concern for acute cholangitis. At ___ ___, you were intubated for airway protection. A CT of your abdomen showed dilatation of the ducts in your liver and you were transferred to ___ to have an MRCP and to be evaluated by the Liver and Interventional Radiology teams for a potential intervention. Your abdominal pain, nausea, and vomiting resolved with decompression by an NG tube, so this was likely due to a small bowel obstruction. It is possible there was some contribution from cholangitis. You were treated with antibiotics for possible cholangitis, which you should continue as an outpatient. The MRCP showed abnormal enhancement of left lobe of liver, enlarged ducts in the liver, and a stone at the junction of the main liver duct and the small intestine. The enlarged ducts and abnormal liver function tests may be due to chronic recurrent bouts of cholangitis. Due to your lack of symptoms and relatively stable lab results, the Liver and Interventional Radiology teams decided against any acute intervention. However, they would like to discuss you further at the Liver Tumor Conference next week and decide on a plan to try to prevent recurrences of cholangitis. Take care, Your ___ medical team Followup Instructions: ___
10813365-DS-18	10,813,365	22,345,559	DS	18	2129-01-29 00:00:00	2129-01-30 14:19:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Rash, hearing loss Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: Mr. ___ is a ___ year-old man with a history of HIV presenting with a 4 month history of a peeling rash on his palms and soles and difficulty hearing. He reports that he presented to his PCP 4 months prior to admission with peeling rashes on his hands and feet along with a headache, and his PCP advised him to use a lotion and a salt rub. Over the course of the 4 months, his rashes have worsened, and he identifies nothing that has helped reduce them. The rash is mildly tender to touch, but not exquisitely so. Advil has helped to alleviate his headache, which he describes as intermittent and pressure-like, with radiation down his neck and into his shoulders. He also has experienced increased difficulty hearing, as voices now sound muffled and he has a constant ringing sensation in both ears. He denies any exposures to new substances. He denies penile discharge, dysuria, or rashes on other bodily locations. He mentions that he presented to his ID doctor 1 week PTA who was quite concerned that he may have syphilis. Although the history is unclear, it seems that his ID doctor ordered an RPR which was highly reactive at 1:256, but was unable to perform an LP for CSF VDRL to confirm the diagnosis of neurosyphilis. He was then referred to the ED by either his PCP or ID doctor for further workup. In the ED, initial vitals were T 97.2, HR 116, BP 154/94, RR 19, O2Sat 100% RA. Exam notable for desquamating red rash on palms and soles, neurologically intact. Labs notable for RPR highly reactive at 1:256, CSF with 300-475 WBCs and elevated protein to 170. Chemistries, CBC, and UA were unremarkable. CT head demonstrated no definite evidence of mass effect or abscess. The patient was given fioricet x2, penicillin G x2, ceftriaxone 2g, vancomycin 1 g, 2L NS, and 1mg Ativan. Decision was made to admit for further treatment for likely neurosyphilis. Pre-transfer vitals were T 98.4, HR 90, BP 158/80, RR 16, O2Sat 100% RA. On the floor, he is lying comfortably on his bed waiting for his dinner. He complains of a headache but has no other issues. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies cough or shortness of breath. Denies chest pain. Denies nausea, vomiting, diarrhea, or abdominal pain. No recent change in bowel or bladder habits. No dysuria or penile discharge. Past Medical History: - HIV (___): He previously took Truvada and another antiretroviral drug but discontinued these ___ years ago due to an insurance issue. He is planning to restart HAART with his ID doctor soon after discharge. - MRSA cellulitis (___) - Questionable gamma-globulin deficiency as a child, was born with PNA and scarlet fever, remembers getting "shots" for it. After the age of ___ years, he does not remember it being an issue. Social History: ___ Family History: Parents and siblings alive and healthy. No h/o malignancies, HTN, DM that he is aware of. Physical Exam: Admission Physical Exam: ======================== VS: 98.2 131/76 84 19 100%RA Gen: Middle-aged man sitting comfortably on his bed in NAD HEENT: NCAT. EOMI. Neck: supple, 1cm palpable and rubbery anterior chain nodes bilaterally. No pain on neck flexion CV: RRR, no murmurs/rubs/gallops Pulm: CTAB, no crackles or wheezes Abd: soft, non-tender, non-distended. No rebound or guarding Ext: WWP, no ___ edema Skin: Blotchy, mildly erythematous rash over abdomen. Erythematous, scaling rash on bilateral palms and soles Neuro: A/Ox3. Hearing intact to finger rub bilaterally. Normal gait. Discharge Physical Exam: ======================== VS: 98.3 116/69 81 20 98% RA Gen: Middle-aged man sitting comfortably on his bed in NAD HEENT: NCAT. EOMI. Neck: supple, 1cm palpable and rubbery anterior chain nodes bilaterally. No pain on neck flexion CV: RRR, no murmurs/rubs/gallops Pulm: CTAB, no crackles or wheezes Abd: soft, non-tender, non-distended. No rebound or guarding Ext: WWP, no ___ edema Skin: Blotchy, mildly erythematous rash over abdomen. Erythematous, scaling rash on bilateral palms and soles Neuro: A/Ox3. Hearing intact to finger rub bilaterally but softer on left. Normal gait. Pertinent Results: Admission Labs: =============== ___ 02:50AM BLOOD WBC-5.2 RBC-4.87 Hgb-13.7 Hct-41.2 MCV-85 MCH-28.1 MCHC-33.3 RDW-13.2 RDWSD-41.2 Plt ___ ___ 02:50AM BLOOD Neuts-57.1 ___ Monos-8.4 Eos-2.5 Baso-0.8 Im ___ AbsNeut-2.99 AbsLymp-1.61 AbsMono-0.44 AbsEos-0.13 AbsBaso-0.04 ___ 02:50AM BLOOD ___ PTT-28.6 ___ ___ 02:50AM BLOOD WBC-5.2 Lymph-31 Abs ___ CD3%-82 Abs CD3-1314 CD4%-23 Abs CD4-375 CD8%-55 Abs CD8-891* CD4/CD8-0.42* ___ 02:50AM BLOOD Glucose-134* UreaN-15 Creat-0.9 Na-136 K-3.6 Cl-99 HCO3-27 AnGap-14 ___ 06:45AM BLOOD ALT-8 AST-14 LD(LDH)-127 AlkPhos-76 TotBili-0.2 ___ 06:45AM BLOOD Albumin-3.8 Calcium-9.1 Phos-4.1 Mg-2.1 Discharge Labs: =============== ___ 06:03AM BLOOD WBC-6.2 RBC-4.99 Hgb-14.1 Hct-42.5 MCV-85 MCH-28.3 MCHC-33.2 RDW-13.6 RDWSD-42.0 Plt ___ ___ 06:03AM BLOOD Glucose-89 UreaN-10 Creat-0.7 Na-141 K-4.1 Cl-103 HCO3-32 AnGap-10 ___ 06:03AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.2 Micro: ====== Serum HIV Viral Load ___: Pending RPR ___: Nonreactive CSF Viral Culture ___: No enterovirus isolated CSF Culture ___: ___ no PMNs and no organisms; bacterial and fungal cultures NG; AFB cultures pending CSF HIV Viral Load ___: Pending CSF Cryptococcal Antigen ___: Negative CSF VDRL: Reactive 1:64 Blood Cultures x2 ___: Pending, NGTD Studies: ======== CT Head w/ contrast: 1. No definite evidence of mass effect or abscess. Please note contrast MRI of the brain is more sensitive for the evaluation of intracranial mass or abscess. 2. Paranasal sinus disease as described. Brief Hospital Course: ___ year-old man with a history of HIV (not on HAART) presenting with a 4-week history of scaling, erythematous rash on his bilateral palms and soles along with bilateral tinnitus and difficulty hearing in the setting of a reactive RPR, most concerning for tertiary syphilis. # Syphilis: Tertiary syphilis is the most likely cause for the scaling rash on his palms and soles along with headache and tinnitus (auditory nerve involvement). RPR was reactive at his PCP's office and reactive 1:256 in-house, and CSF VDRL was reactive 1:64. HSV meningitis ruled out with negative CSF HSV PCR, so empiric acyclovir d/c'ed on HD2. Bacterial meningitis unlikely given ___ut initially treated with vanc/ceftriaxone, which were d/c'ed on HD2 when CSF cell counts and ___ were not c/w bacterial meningitis (473 WBCs with lymphocytic predominance, no organisms or PMNs on ___. PICC inserted on ___ for two-week antibiotic course. Neurosyphilis treated with IV Penicillin G 4 million units q4h x14 days (___), and pt was discharged to a SNF to finish antibiotic course. Pt will require neuro exams and LP with CSF-VDRL q3 months to assess response to treatment. Pt was informed to tell all close contacts that they need to be treated for syphilis with a single dose of benzathine penicillin G 2.4 million units IM. If penicillin allergic, doxycycline 100mg BID x14 days is an alternative regimen. # HIV: Not currently on HAART, but has plan to initiate HAART as outpatient with ID. CD4 count currently 375, viral load pending on discharge. Was seen by SW consult due to concerns about patient having trouble affording medications. Pt said that when he was at risk for losing his job as well as his medication coverage, he stopped taking antiretrovirals because he knew that taking them intermittently would be risky. His insurance situation is now stable, and he will be able to take his medication consistently. # Tobacco Abuse: Pt given tobacco cessation counseling and a nicotine patch while in-house and upon discharge. Transitional Issues: - Penicillin G Potassium 4 Million Units IV Q4H, Duration: 14 Days (___). Will only need 4am, 8am, and 12pm doses on ___. - Will require neuro exam and LP with CSF-VDRL q3 months to assess response to treatment. - F/u HIV viral load and consider restarting HAART. - Consider further STD workup, including urine GC and chlamydia. - Please ensure regular STD screening. - Patient informed to tell all close contacts that they need to be treated for syphilis with a single dose of benzathine penicillin G 2.4 million units IM. If penicillin allergic, doxycycline 100mg BID x14 days is an alternative regimen. - ___ stay anticipated to be <30 days # Code status: Full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ibuprofen Dose is Unknown PO Frequency is Unknown Discharge Medications: 1. Ibuprofen 400 mg PO Q6H:PRN pain 2. Acetaminophen 650 mg PO Q4H:PRN headache 3. Nicotine Patch 21 mg TD DAILY 4. Penicillin G Potassium 4 Million Units IV Q4H Duration: 14 Days Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Tertiary syphilis Secondary: HIV Tobacco abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You presented to ___ with several months of rash on your hands, headaches, and hearing loss. You were found to have neurosyphilis and were started on a two-week course of IV penicillin. You were discharged to a facility that can help you complete your IV antibiotics. You should follow up with your PCP after discharge from the skilled nursing facility to restart HAART for your HIV. Thank you for allowing us to participate in your care. Sincerely, Your ___ Care Team Followup Instructions: ___
10813632-DS-20	10,813,632	28,201,230	DS	20	2151-11-11 00:00:00	2151-11-11 11:58:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Subarachnoid Hemorrhage Major Surgical or Invasive Procedure: ___ Diagnostic cerebral angiogram ___ Right frontal EVD ___ Diagnostic cerebral angiogram History of Present Illness: ___ y/o male with PMH significant for HTN, Hyperlipidemia, and DM who was transferred from ___ with a subarachnoid hemorrhage. Per his daughter, the patient developed sudden onset nausea and vomiting yesterday around 11AM. He then took a nap. He awoke this morning and was extremely confused. He complained of a headache and continued with nausea with possible vomiting. He was brought to ___ and underwent a non-contrast head CT which showed a subarachnoid hemorrhage. He was transferred to ___ for further evaluation. Past Medical History: Hypertension; Hyperlipidemia; DM Social History: ___ Family History: No family history of aneurysm. Physical Exam: Exam on Admit: T: 97.8 BP: 148/66 HR: 95 RR: 20 O2Sats 96% RA Gen: Lying in bed, drowsy. Awakens and opens eyes to name. ___: 3-2mm bilaterally. Extrem: Warm and well-perfused. Neuro: Mental status: Drowsy but awakens to name. ___ to person, place, but stating it is ___. Language: Speech fluent with good comprehension and repetition. No dysarthria or paraphasic errors. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift. Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally. On Discharge: alert and oriented to person, place and time. MAE ___ no prontator drift Incision is clean, dry and intact. Pertinent Results: ___ 10:44PM BLOOD WBC-10.1 RBC-4.13* Hgb-12.7* Hct-36.9* MCV-89 MCH-30.7 MCHC-34.4 RDW-13.2 Plt ___ ___ 03:57AM BLOOD WBC-12.0* RBC-4.13* Hgb-12.6* Hct-36.9* MCV-89 MCH-30.6 MCHC-34.3 RDW-13.3 Plt ___ ___ 03:57AM BLOOD ___ PTT-24.3* ___ ___ 10:44PM BLOOD Glucose-207* UreaN-18 Creat-1.0 Na-143 K-4.8 Cl-111* HCO3-23 AnGap-14 ___ 03:57AM BLOOD Glucose-161* UreaN-18 Creat-1.0 Na-144 K-4.3 Cl-112* HCO3-23 AnGap-13 ___ 10:44PM BLOOD Calcium-8.3* Phos-3.8 Mg-1.7 ___ 03:57AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.3 CTA NECK W&W/OC & RECONS ___ CT HEAD W/O CONTRAST ___ 1. Improved ventriculomegaly and slightly increased blood within the left lateral ventricle related to ventriculostomy placement. No evidence of new hemorrhage. 2. Mild mucosal thickening of the left maxillary and paranasal sinuses. CXR ___: As compared to the previous radiograph, the monitoring and support devices have been removed. The lung volumes have returned to normal. Borderline size of the cardiac silhouette without pulmonary edema. No pneumonia. No pleural effusions. MRI C-Spine ___: 1. Right paracentral disc protrusion at C5-C6 level, causing slightly flattening the right ventral aspect of the cervical spinal cord, without causing abnormal cord signal. 2. Other mild multilevel degenerative changes as detailed above. MRI Brain ___: 1. No significant interval change in subarachnoid hemorrhage and intraventricular hemorrhage accounting for differences in technique. No new hemorrhage. 2. Interval decrease in ventricular size with resolution of previously noted hydrocephalus. 3. Scattered foci of T2/FLAIR signal hyperintensity in the periventricular, subcortical, and deep white matter which are nonspecific but a patient of this age most likely reflects the sequela of chronic small vessel ischemic disease. CT Head ___: 1. Interval decrease in previously seen subarachnoid and intraventricular hemorrhage. 2. Right ventriculostomy tube was partially withdrawn between ___ and ___, with its tip still within the lateral aspect of the right lateral ventricle. No hydrocephalus. 3. Moderate chronic small vessel ischemic changes. CT Head: ___: IMPRESSION: 1. No significant change in the size of the lateral and third ventricles following clamping of the EVD. 2. Tip of the EVD has been further withdrawn, now terminating immediately lateral to the right lateral ventricle Brief Hospital Course: ___ year-old male presented to OSH with N/V, HA, confusion and found on CT scan to have diffuse subarachnoid hemorrhage with intraventricular extension. Mr. ___ was transfered to ___ for further evaluation. While in the ED, Mr. ___ became sommulent and was intubated at that time. An external ventriculostomy drain was placed without difficulty and maintained at 15cm H2O. Mr. ___ was loaded with Keppra 1gm and continued on Keppra BID. Mr. ___ was admitted to the ICU on the Neurosurgery Service for further care and management. On ___ Mr. ___ underwent a diagnostic angiogram which was negative for aneurysm. Mr. ___ was started on Nimodipine 60mg Q4H and Simvastatin 80mg daily prophylactically for vasospasm. Mr. ___ blood pressure was strictly maintained SBP <130 preangiography, but was liberalized post-angiography to SBP 100-160. On ___ Mr. ___ neurologic exam was intact and he was successfully extubated. A preliminary report of the CSF specimen collected on ___ showed no mincroorganism growth. A repeat NCHCT was performed on ___ which revealed edistribution and slight increase in subarachnoid hemorrhage, with increased blood in the left lateral ventricle in the sellar cistern. Transcranial dopplers were completed. On ___, patient remained intact. His EVD remained open at 15. TCDs were also completed. On ___ Patient remained neurologically stable. CSF culture has shown no growth to date. TCS were completed and no vasospasm was appreciated. On ___, patient was febrile overnight to 101.3. Cultures were sent and he was started on vanc/zoysn empirically. TCDs showed slightly high L ACA, but no vasospasm. CSF was sent and CXR was negative. On ___ he remained stbale clinically. His Tmax was 102.2 On ___ patient remained stable, he recieved intermittent IVF boluses to keep I/Os equal to positive. On ___ the patient the patient c/o headache and pain meds were changed. He received a 500cc IVF bolus. On ___ he underwent an angiogram that was negative and his left groin was angiosealed. On ___ he had a Head CT which was stable and then his EVD was clamped. He toelrated the clamping well into the evening of ___. On ___, the patient's EVD was removed. Physical therapy and occupational therapy were consulted. On ___, The intravenous fluid was discontinued. The arterial line was discontinued. The patient was deemed ready for transfer to the floor when a bed was available. ___, the patient continued to be stable. His nimodipine was discontinued and he was discharged home. Medications on Admission: Metformin 1000mg BID; Glipizide ER 10mg BID; Simvastatin 80mg QD; Lisinopril 20mg PO daily; ASA 325mg PO daily; Vitamin D3 2,000 unit tablet daily Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN pain RX butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:0 2. Bisacodyl 10 mg PO/PR DAILY constipation 3. Docusate Sodium 100 mg PO BID constipation 4. Famotidine 20 mg PO BID 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 7. Senna 8.6 mg PO BID constipation 8. Simvastatin 80 mg PO QPM 9. MetFORMIN (Glucophage) 1000 mg PO BID 10. GlipiZIDE XL 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: SAH (aneurysmal negative) Cerebral vasospasm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Subarachnoid Hemorrhage Surgery/ Procedures: You had a diagnostic cerebral angiogram to coil the aneurysm. You may experience some mild tenderness and bruising at the puncture site (groin). Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. You make take a shower. No driving while taking any narcotic or sedating medication. If you experienced a seizure while admitted, you must refrain from driving. Medications Resume your normal medications and begin new medications as directed. Please do NOT take any blood thinning medication (Aspirin, Plavix, Coumadin) until cleared by the neurosurgeon. You have been discharged on a medication to lower your cholesterol levels. We recommend that you continue this medication indefinitely. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: Mild to moderate headaches that last several days to a few weeks. Difficulty with short term memory. 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 incision site or 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 Call ___ and go to the nearest Emergency Room if you experience any of the following: Sudden numbness or weakness in the face, arm, or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headaches with no known reason Followup Instructions: ___
10814338-DS-20	10,814,338	26,420,995	DS	20	2184-02-05 00:00:00	2184-02-05 19:12:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Hickory Attending: ___. Chief Complaint: Acute liver failure, alcoholic hepatitis Major Surgical or Invasive Procedure: ___ - EGD History of Present Illness: ___ is a ___ year-old woman with a history of alcohol use disorder, fatty liver disease (MELD-Na 35, DF 106.6, drinks 1 pint vodka per day ), depression, hypertension, who presents with worsening RUQ pain and found to be in acute liver failure. She initially presented to and was transferred from ___ ___ for abnormal liver tests. Patient states that since ___ she has had increasing RUQ pain radiating to the right flank. She states it is sharp ___ pain, worse with movement but continues at rest. She has had multiple episodes of vomiting, but no hematemesis or coffee ground. no change in stools, no f/c/cp/sob and she denies any abdominal distention. In the ED initial vitals: 98.3 102 125/57 18 100% RA Patient was given: diazepam per CIWA protocol, IV morphine, home gabapentin, albumin, lactulose, vitamin K, 40 mEq IV potassium, MVI, thiamine. Hepatology was consulted and noted that the patient had a distended abdomen but not fluid that they could tap. Upon arrival to the floor, the patient reports that she has right shoulder and back pain. She adds that she also has suprapubic tenderness. Notes that she takes all of her psych meds because she is a "psycho" and that if she doesn't take them, she hears voices and has anxiety. Last drink ___. Was constipated but had a large BM just before I met her. REVIEW OF SYSTEMS: (+) Exertional dyspnea (but not active chest pain), light headedness (-) Fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. All other 10-system review negative in detail. Past Medical History: - HTN - GERD - Depression & anxiety - Bipolar disorder - Schizophrenia - Alcohol use disorder - Gastric bypass surgery ___ years ago Social History: ___ Family History: - Mother with ovarian tumor - Father with prostate cancer Physical Exam: ADMISSION PHYSICAL EXAM ====================== VS: 98.2 PO 160 / 93 103 18 96 RA GENERAL: NAD, AOx3 but falling asleep during exam but easy to redirect and wake up. Pleasant. HEENT: AT/NC, EOMI, PERRL, sclera icteric, pink conjunctiva, MMM, poor dentition NECK: Tender but supple neck, no LAD, no JVD HEART: Tachycardia, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, epigastric and RUQ tenderness, suprapubic tenderness, no rebound/guarding, +hepatomegaly with nodularity EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, no asterixis SKIN: warm and well perfused, jaundiced, palmar erythema, no spider angiomas, scattered ecchymosis DISCHARGE PHYSICAL EXAM ====================== PHYSICAL EXAM: VS: T 97.5, BP 122/75 HR 91 RR 18 O2 94% RA GENERAL: NAD, AOx3. Pleasant. HEENT: AT/NC, EOMI, PERRL, sclera icteric, MM NECK: supple neck, no LAD, no JVD HEART: Regular rate and rhythm, nl S1/S2, no m/r/g LUNGS: CTAB, no wheezes/rales/rhonchi ABDOMEN: +BS, mildly distended without fluid wave, soft, no tenderness to palpation. EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities. Soft, tender 1x1 superficial mass inferior to R deltoid smaller, no ecchymoses, erythema. PULSES: 2+ DP pulses bilaterally SKIN: warm and well perfused, no spider angiomas, scattered ecchymosis, jaundiced. Pertinent Results: _______________________ ADMISSION LABS: ___ 01:20AM BLOOD WBC-5.3 RBC-3.25* Hgb-9.3* Hct-25.5* MCV-79* MCH-28.6 MCHC-36.5 RDW-23.8* RDWSD-58.3* Plt ___ ___ 01:20AM BLOOD Neuts-62.6 ___ Monos-11.2 Eos-0.9* Baso-0.4 NRBC-0.6* Im ___ AbsNeut-3.34 AbsLymp-1.31 AbsMono-0.60 AbsEos-0.05 AbsBaso-0.02 ___ 01:20AM BLOOD ___ PTT-37.6* ___ ___ 07:11PM BLOOD ___ 02:50AM BLOOD Glucose-82 UreaN-9 Creat-1.1 Na-126* K-3.2* Cl-87* HCO3-24 AnGap-18 ___ 02:50AM BLOOD ALT-110* AST-564* AlkPhos-398* TotBili-10.8* DirBili-6.6* IndBili-4.2 ___ 02:50AM BLOOD Lipase-37 ___ 03:38PM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 11:55AM BLOOD Albumin-4.0 Calcium-9.1 Phos-1.1* Mg-1.5* ___ 11:45AM BLOOD calTIBC-198* Ferritn-635* TRF-152* ___ 11:55AM BLOOD PTH-159* _______________________ PERTINENT LABS: ___ 11:45AM BLOOD calTIBC-198* Ferritn-635* TRF-152* ___ 07:20AM BLOOD PTH-241* ___ 11:45AM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Negative HAV Ab-Positive IgM HAV-Negative ___ 11:45AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE ___ 02:48PM BLOOD CRP-56.0* ___ 11:45AM BLOOD ___ ___ 11:45AM BLOOD IgG-2330* IgA-428* IgM-436* ___ 02:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 11:45AM BLOOD HCV Ab-Negative ___ 01:27AM BLOOD Lactate-4.9* K-3.2* ___ 11:58AM BLOOD Lactate-2.9* ___ 05:34PM BLOOD Lactate-2.1* ___ 02:50AM BLOOD ALT-110* AST-564* AlkPhos-398* TotBili-10.8* DirBili-6.6* IndBili-4.2 ___ 11:55AM BLOOD ALT-116* AST-562* AlkPhos-385* TotBili-11.8* ___ 07:11PM BLOOD ALT-106* AST-540* LD(LDH)-442* AlkPhos-341* TotBili-12.8* ___ 07:20AM BLOOD ALT-98* AST-470* AlkPhos-320* TotBili-12.8* ___ 07:50AM BLOOD ALT-82* AST-360* AlkPhos-284* TotBili-14.7* ___ 12:45AM BLOOD ALT-77* AST-297* LD(___)-373* AlkPhos-270* TotBili-16.3* ___ 07:30AM BLOOD ALT-77* AST-289* AlkPhos-270* TotBili-17.0* ___ 08:25AM BLOOD ALT-69* AST-221* AlkPhos-257* TotBili-18.3* ___ 08:05AM BLOOD ALT-67* AST-208* AlkPhos-260* TotBili-20.6* ___ 07:40AM BLOOD ALT-54* AST-163* LD(LDH)-319* AlkPhos-223* TotBili-23.7* ___ 08:00AM BLOOD ALT-42* AST-123* AlkPhos-166* TotBili-20.4* ___ 07:50AM BLOOD ALT-42* AST-131* AlkPhos-161* TotBili-20.2* ___ 07:50AM BLOOD ALT-41* AST-132* AlkPhos-148* TotBili-23.9* ___ 07:20AM BLOOD ALT-43* AST-142* AlkPhos-148* TotBili-26.2* ___ 08:30AM BLOOD AST-147* AlkPhos-161* TotBili-28.9* ___ 08:05AM BLOOD ALT-53* AST-150* LD(___)-271* AlkPhos-169* TotBili-28.7* ___ 07:45AM BLOOD ALT-50* AST-140* AlkPhos-146* TotBili-25.0* ___ 08:00AM BLOOD ALT-58* AST-140* AlkPhos-147* TotBili-22.1* ___ 07:40AM BLOOD ALT-67* AST-147* AlkPhos-151* TotBili-20.5* _______________________ DISCHARGE LABS: ___ 07:40AM BLOOD WBC-9.3 RBC-3.10* Hgb-9.3* Hct-28.2* MCV-91 MCH-30.0 MCHC-33.0 RDW-31.5* RDWSD-99.1* Plt ___ ___ 07:40AM BLOOD Plt ___ ___ 07:40AM BLOOD Glucose-127* UreaN-15 Creat-0.6 Na-133 K-4.4 Cl-98 HCO3-21* AnGap-18 ___ 07:40AM BLOOD ALT-67* AST-147* AlkPhos-151* TotBili-20.5* ___ 07:20AM BLOOD ALT-83* AST-168* AlkPhos-156* TotBili-18.8* _______________________ IMAGING/STUDIES: ___ LIVER OR GALLBLADDER US W/ DUPLEX: 1. Markedly limited evaluation by poor sonographic penetration, particularly of the liver. 2. Markedly echogenic and heterogeneous liver compatible with steatosis and/or hepatitis. 3. Patent main portal vein with to and fro flow. Impending thrombosis is a concern. 4. Right lower quadrant ascites with echogenic debris raising the possibility peritonitis. ___ Imaging US ABD LIMIT, SINGLE ORGAN: Limited grayscale ultrasound images of the abdomen were obtained. Images demonstrate only a trace volume of fluid in the right lower quadrant. No adequately sized pockets of ascites fluid were identified suitable for percutaneous drainage. ___ Imaging CTA CHEST: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Diffuse bilateral ground-glass opacities associated with airspace nodules could be due to atypical infection or pulmonary edema. Please correlate clinically. 3. Trace right-sided pleural effusion. 4. Mildly enlarged main pulmonary artery could be related to pulmonary artery hypertension. 5. Limited evaluation of the upper abdomen shows diffuse severe hepatic steatosis. ___ EGD No esophageal varices ___ RUQ US No evidence of ascites. ___ CXR No new regions of airspace disease as described. ___ US MSK SHOULDER RIGHT 1.9 x 0.8 x 2.2 cm fluid collection is identified in the subcutaneous fat of left lateral arm, possibly an old hematoma given the low level internal echoes. Brief Hospital Course: Ms. ___ is a ___ year-old woman with a history of alcohol use disorder, fatty liver disease (admission MELD-Na 35, DF 106.6, Child's Class C), depression and hypertension who presented as transfer from ___ with abdominal pain and elevated liver enzymes, found to be in acute liver failure secondary to alcoholic hepatitis. ACUTE ISSUES: ==================================================== #Alcoholic hepatitis: #Hyperbilirubinemia: #Coagulopathy: Patient has history of heavy alcohol consumption. She also had a history of fatty liver disease. ___ tried to tap ascites but could not find a fluid pocket (RUQ US x 2 without fluid). All infectious and autoimmune work up were negative. RUQ ultrasound with Doppler was without evidence of portal vein thrombosis. An EGD on ___ was without evidence of esophageal varices. She was given one dose of steroids, but then developed pneumonia (which was treated), so the steroids were stopped. Her total bilirubin and DF began to increase on ___ (peak Tbili = 28.9 on ___ and so patient was restarted on steroid trial on ___ with significant clinical improvement and decrease in Tbili. Patient was discharged with plan for alcohol abstinence and total 28-day course of prednisone (discharged on D5 of steroids) and will follow up with liver clinic on ___. #Healthcare Associated Pneumonia: Patient became hypoxic on ___. CTA negative for PE but did show bilateral pulmonary edema, likely volume overload in setting of large amount of IV albumin that patient received. Her first fever of the admission was on ___, at which time she was started on ceftriaxone and azithromycin. MRSA screen positive. She was broadened to vanc/cefepime/azithromycin for healthcare associated pneumonia on ___. She was narrowed to levofloxacin on ___ and completed 7-day course on ___ without issue. ___: Patient presented with Cr of 1.7. It improved to Cr 0.6 after albumin challenge. #Severe Malnutrition: Albumin on presentation <3. Secondary to alcohol use disorder. She was given Ensure shakes to supplement meals. She was also given thiamine and multivitamin supplementation. She had good nutrition for duration of stay. #Hepatic Encephalopathy. The patient presented altered with asterixis. Significant improvement with lactulose and rifaximin. # CHRONIC ISSUES: ======================================================= #Anemia of chronic inflammation: The patient presented with Hb of 9.3, which has been stable throughout admission. Iron studies showed normal iron, low TIBC and transferrin, very elevated ferritin. #Hypertension: Her home valsartan was held initially because of low blood pressures, but it was restarted on ___ when the patient became hypertensive. #Psych: The patient was seeing psych at ___. She was continued on her home aripiprazole 5 mg daily and prn clonidine (with bp holding parameters). Mirtazapine 30 mg QHS was held per psych recommendation given that patient only takes intermittently at home and had no issues during hospitalization. #GERD: Continued home omeprazole. ==================================================== TRANSITIONAL ISSUES ==================================================== [ ] Please follow up CBC, Chem7, LFTs, and INR at next liver appointment [ ] Will be discharged with 40mg daily until ___ and will be on day 11 of steroids on ___. Plan to prescribe refills at that time for completion of 28-day trial on ___. Discharge Tbili: 18.8 Discharge Cr: 0.6 Discharge weight: 87 kg #CODE STATUS: FULL CODE #CONTACT/HCP: ___ ___, friend/proxy ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Valsartan 80 mg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Gabapentin 800 mg PO QID 4. Daily-Vite (multivitamin) 1 tablet oral DAILY 5. Sucralfate 1 gm PO QID 6. ARIPiprazole 5 mg PO DAILY 7. CloNIDine 0.2 mg PO TID as needed for anxiety and auditory hallucinations 8. Vitamin D ___ UNIT PO DAILY 9. Mirtazapine 30 mg PO QHS 10. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 2. HydrOXYzine 25 mg PO Q6H:PRN Itching RX hydroxyzine HCl 25 mg 1 tablet by mouth Up to 4 times a day every 6 hours Disp #120 Tablet Refills:3 3. Lactulose 30 mL PO BID RX lactulose 20 gram/30 mL 30 mL by mouth Twice daily Refills:3 4. Miconazole Powder 2% 1 Appl TP TID:PRN rash RX miconazole nitrate 2 % For rash Three times daily as needed Disp #30 Spray Refills:3 5. PredniSONE 40 mg PO DAILY RX prednisone 20 mg 2 tablet(s) by mouth daily Disp #6 Tablet Refills:0 6. Rifaximin 550 mg PO BID RX rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth Twice a day Disp #30 Tablet Refills:3 7. Sarna Lotion 1 Appl TP QID:PRN Itching (hyperbilirubinemia) RX camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % For itching As needed Refills:0 8. Simethicone 40-80 mg PO QID:PRN gas pain RX simethicone [Gas Relief] 80 mg 1 tablet by mouth Take up to 4 times daily as needed Disp #120 Tablet Refills:3 9. TraMADol 25 mg PO Q6H:PRN Pain - Moderate RX tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six (6) hours Disp #10 Tablet Refills:0 10. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days stop date: ___ RX zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth daily Disp #4 Capsule Refills:0 11. ARIPiprazole 5 mg PO DAILY 12. CloNIDine 0.2 mg PO TID as needed for anxiety and auditory hallucinations 13. Daily-Vite (multivitamin) 1 tablet oral DAILY 14. Ferrous Sulfate 325 mg PO DAILY 15. Gabapentin 800 mg PO QID 16. Mirtazapine 30 mg PO QHS 17. Omeprazole 20 mg PO DAILY 18. Sucralfate 1 gm PO QID 19. Valsartan 80 mg PO DAILY 20. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: - Alcoholic hepatitis, complicated by Hyperbilirubinemia and Coagulopathy Secondary Diagnosis: - Healthcare Associated Pneumonia - Severe malnutrition - Acute Kidney Injury (resolved) - Hepatic encephalopathy (resolved) 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 were you admitted? ================================================= - You were transferred here from ___ because you had belly pain and your liver tests were abnormal. - These problems are due to your history of alcohol use, which has severely damaged your liver. What was done in the hospital? =================================================== - You had an ultrasound of your liver, which showed that there was no fluid around your liver. - You had a fever while hospitalized and so we gave you IV antibiotics to treat an infection in your lungs (pneumonia). - We also started you on a 28-day course of steroids, which has improved your liver function. What do you need to do? =============================================== - You will be discharged to a nursing home. - It is very important that you NEVER drink alcohol again. - Please follow up with your liver doctor as shown below. Please also follow up with your primary care provider. - Please take your medications as prescribed. Sincerely, Your ___ Care Team Followup Instructions: ___
10814412-DS-9	10,814,412	28,253,758	DS	9	2146-08-06 00:00:00	2146-08-09 18:36:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right ankle fracture Major Surgical or Invasive Procedure: ORIF ___ ___ History of Present Illness: ___ with right ankle fracture. Patient slipped two days ago and presented to an outside hospital. She was found to have a bimal ankle fracture there. Surgery was offered but patient refused. Went to PCP today who referred to an orthopaedic surgeon. She saw him in clinic and was referred to the ED for ortho evaluation for surgery. Patient denies any numbness/tingling. Does take any medications. Past Medical History: none Social History: ___ Family History: nc Physical Exam: ___ fire +SILT SPN/DPN distributions +foot warm and well-perfused Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have R ankle fx and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for R ankle orif, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is tdwb in RLE, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up in two weeks with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: oxycodone Discharge Medications: 1. Acetaminophen 650 mg PO Q6H pain 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 3. Enoxaparin Sodium 40 mg SC QHS Duration: 14 Days Start: Today - ___, First Dose: Next Routine Administration Time RX enoxaparin 40 mg/0.4 mL 40 mg sc at bedtime Disp #14 Syringe Refills:0 4. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #75 Tablet Refills:*0 5. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: R ankle fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Instructions After Orthopedic Surgery - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. Medicines - Resume taking your home medications unless specifically instructed to stop by your surgeon. Please talk to your primary care doctor within the next ___ weeks regarding this hospitalization and any changes to your home medications that may be necessary. - Do not drink alcohol, drive, or operate machinery while you are taking narcotic pain relievers (oxycodone/dilaudid). - As your pain lessens, decrease the amount of narcotic pain relievers you are taking. Instead, take acetaminophen (also called tylenol). Follow all instructions on the medication bottle and never take more than 4,000mg of tylenol in a single day. - If you need medication refills, call your surgeon's office 3-to-4 days before you need the refill. Your prescriptions will be mailed to your home. - Please take Lovenox for 2 weeks to help prevent the formation of blood clots. Constipation - Both surgery and narcotic pain relievers can cause constipation. Please follow the advice below to help prevent constipation. - Drink 8 glasses of water and/or other fluids like juice, tea, and broth to stay well hydrated. - Eat foods that are high in fiber like fruits and vegetables. - Please take a stool softener like docusate (also called colace) to help prevent constipation while you are taking narcotic pain relievers. - You may also take a laxative such as senna (also called Senokot) to help promote regular bowel movements. - You can buy senna or colace over the counter. Stop taking them if your bowel movements become loose. If your bowel movements continue to stay loose after stopping these medications, please call your doctor. Incision - Please return to the emergency department or notify your surgeon if you experience severe pain, increased swelling, decreased sensation, difficulty with movement, redness or drainage at the incision site. - You can get the wound wet/take a shower starting 3 days after surgery. Let water run over the incision and do not vigorously scrub the surgical site. Pat the area dry after showering. - No baths or swimming for at least 4 weeks after surgery. - Your staples/sutures will be taken out at your 2-week follow up appointment. No dressing is needed if your wound is non-draining. - You may put an ice pack on your surgical site, but do not put the ice pack directly on your skin (place a towel between your skin and the ice pack), and do not leave it in place for more than 20 minutes at a time. Activity TDWB RLE Followup Instructions: ___
10814670-DS-21	10,814,670	20,879,907	DS	21	2143-10-21 00:00:00	2143-10-21 11:23:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: lisinopril Attending: ___. Chief Complaint: R hip pain Major Surgical or Invasive Procedure: ___: Right hip hemiarthroplasty. History of Present Illness: ___ w/ hx as below including L hip fx s/p ORIF in ___ s/p fall w/ R hip fracture. Patient tripped while using his walker and landed on his right side. He complains of pain in his R hip with a shortened and externally rotated RLE. He denies any head strike or LOC. Past Medical History: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 ___ Diabetes Hyperlipidemia Hypertension Seborrheic dermatitis Cataracts Social History: ___ Family History: NC Physical Exam: Physical Exam: 98.1 65 134/80 18 100% Gen: alert, no distress ENT: EOMI, OP clear CV: regular rate Resp: non-labored breathing Abd: soft, nontender, nondistended Ext: nontender over midline c-spine, nontender chest wall, stable pelvis, TTP R groin but otherwise nontender in RLE with no crepitus or deformity, RLE is shortened and rotated externally, well perfused with 2+ DP pulse, other extremities atraumatic and nontender except for distal radius and thenar eminance of R hand although intrinsic hand movements are all fully intact and the hand is well perfused Neuro: ___ strength throughout except for R hip and knee which were not tested ___ pain, sensation intact Skin: warm and dry, no open lesions, multiple areas of ecchymosis Pertinent Results: ___ 12:15PM GLUCOSE-193* UREA N-15 CREAT-1.0 SODIUM-140 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15 ___ 12:15PM estGFR-Using this ___ 12:15PM WBC-8.1 RBC-4.02* HGB-12.7* HCT-38.4* MCV-96 MCH-31.7 MCHC-33.1 RDW-12.6 ___ 12:15PM NEUTS-74.5* LYMPHS-15.6* MONOS-6.3 EOS-2.8 BASOS-0.8 ___ 12:15PM PLT COUNT-206 ___ 12:15PM ___ PTT-27.4 ___ Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have right hip 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 WBAT in the right lower extremity, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. Lovastatin NF 40 mg Oral daily 3. MetFORMIN (Glucophage) 1000 mg PO BID 4. Metoprolol Tartrate 50 mg PO BID 5. Tamsulosin 0.4 mg PO HS 6. Aspirin EC 81 mg PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Aspirin EC 81 mg PO DAILY 3. Lovastatin NF 40 mg Oral daily 4. Metoprolol Tartrate 50 mg PO BID 5. Tamsulosin 0.4 mg PO HS 6. Acetaminophen 650 mg PO TID 7. Enoxaparin Sodium 40 mg SC DAILY 8. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 9. Multivitamins 1 CAP PO DAILY 10. Vitamin D 400 UNIT PO DAILY 11. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain RX oxycodone 5 mg 2.5 tablet(s) by mouth q4 hours Disp #40 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: R 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 lovenox 40mg daily for 2 weeks WOUND CARE: - You can get the wound wet/take a shower starting 3 days after your surgery. You may wash gently with soap and water, and pat the incision dry after showering. - No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. ACTIVITY AND WEIGHT BEARING: - Weight Bearing as tolerated Physical Therapy: Weight Bearing as tolerated Treatments Frequency: Dry sterile dressing to wound daily. Followup Instructions: ___
10814713-DS-7	10,814,713	23,020,238	DS	7	2141-01-08 00:00:00	2141-01-18 09:28:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: vitamin C / Compazine Attending: ___ Chief Complaint: weakness Major Surgical or Invasive Procedure: none History of Present Illness: ___ year-old ___ speaking woman with dementia, h/o CAD s/p PCI ___ yrs ago on plavix, and recently hospitalized at ___. ___ with new diagnosis of afib now presents with 3 days of generalized weakness. Her daughter reports that for the last 3 days she has been weak with poor po intake. She has been complaining of full body pain. On the day of presentation, she also had 1 episode of nonbloody nonbilious vomiting and one episode of nonbloody diarrhea. They were monitoring her vital signs at home, and her heart rates were within normal limits. No fevers. She became more agitated yesterday, for which they gave her remeron. She subsequently slept all day but then refused to move. This concerned her daughter, who then brought her to the ED. In the ED, initial vitals: 98.8 88 120/60 24 97%. On exam she was moaning frequently and unable to provide much history. Labs were notable for leukocytosis to 15, ___ with Cr 3.4 (unknown baseline), Na 128, lactate 2.6, bicarb 19. UA was positive for large ___ and ___ bacteria, 4 WBC. CXR showed gross volume overload. A BNP was checked which was 11,000. Given a tender abdominal exam, she underwent CT A/P which showed no acute process. During her ED stay, she converted to afib with RVR in the 160s. Her BPs dropped to the ___ systolic with MAPs in the 60-65 range. She was loaded with 0.5mg IV digoxin. Her rates were in the 140s upon transfer. During her stay she desatted to the ___ on RA and was on NRB for a few hours, then back on 4L NC prior to transfer. She was also given zofran and droperidol for nausea, and vanc and zosyn for presumed UTI. On transfer, vitals were: 128 118/64 18 94% 4L Nasal ___ On arrival to the MICU, the patient is complaining of full body pain. She did not know why she was in the hospital. Her daughter reports that she was hospitalized at ___ E___ 1.5 months ago for afib with RVR. They treated her with amio and then digoxin, however, she did not tolerate these medications due to nausea and sedation. She is apparently very sensitive to any medications. Since then, she has not been taking medications for afib. She has a new cardiologist named Dr. ___ at ___. The daughter reports that they were told her echo at ___ looked okay. Past Medical History: Dementia CAD s/p stent ___ years ago, on ASA and plavix Afib with RVR diagnosed ___, not on meds ? diabetes (on glipizide) Social History: ___ Family History: No heart disease, cancer, or DM Physical Exam: Admission Exam: General- elderly ___ woman moaning in pain, grabbing at lines and tubes HEENT- PERRL, EOMI, MMM Neck- unable to assess due to pt movement CV- tachycardic, irregular, no m/g/r appreciated Lungs- CTAB, however lung exam limited due to lack of cooperation with exam Abdomen- does not appear to withdraw to pain GU- no foley Ext- warm, well perfused, trace ___ pitting edema b/l Neuro- AAOx1, MAEE, unable to cooperate with neuro exam however no lateralizing signs, good strength Patient expired Pertinent Results: Admission labs: ___ 08:00PM BLOOD WBC-15.6* RBC-4.14* Hgb-11.8* Hct-37.1 MCV-90 MCH-28.5 MCHC-31.9 RDW-16.8* Plt ___ ___ 08:00PM BLOOD Neuts-52 Bands-3 Lymphs-13* Monos-9 Eos-0 Baso-0 Atyps-22* ___ Myelos-0 Promyel-1* ___ 08:00PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-NORMAL Ovalocy-1+ Acantho-1+ ___ 03:07AM BLOOD ___ PTT-33.8 ___ ___ 08:00PM BLOOD Glucose-58* UreaN-62* Creat-3.4* Na-128* K-4.8 Cl-102 HCO3-19* AnGap-12 ___ 08:00PM BLOOD ALT-16 AST-24 CK(CPK)-16* AlkPhos-133* TotBili-1.2 ___ 03:07AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.9 ___ 08:00PM BLOOD Albumin-2.3* ___ 04:13AM BLOOD %HbA1c-PND ___ 08:09PM BLOOD Lactate-2.6* Micro: ___ 2:55 am Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. Respiratory Viral Culture (Pending): Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. ___ 10:15 pm URINE URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD Imaging: CXR: Pulmonary edema with possible superimposed pneumonia at the right lung base. Followup post-diuresis is advised to further assess. CT A/P: 1. Mildly dilated gallbladder with gallstones, but no other signs of cholecystitis such as gallbladder wall thickening or pericholecystic fluid. 2. Moderate right and small left pleural effusions with adjacent atelectasis. 3. Multiple small peripheral hypodensities in the spleen consistent with infarcts. Brief Hospital Course: ___ with h/o dementia, CAD, afib presents with 3 days of weakness and full body pain, found to have afib with RVR, hypoxia, and UTI. # Hypoxia: Briefly on NRB in the ED, so was admitted to MICU. In MICU, was 94% on 4LNC and no longer required NRB. CXR findings most c/w pulmonary edema, possibly exacerbated by RVR. Does have h/o CAD and cardiomegaly on CXR which make heart failure more likely. However, with leukocytosis, AMS, and body aches, it was difficult to rule out pneumonia or a viral process. Other etiologies include PE but no obvious risk factors. Received vanc and zosyn in ED. Flu swab was negative. Pt was started on a lasix drip for pulmonary edema. She was called out to the regular cardiology floor. She was treated empirically with antibiotics for PNA and diuresed, with resolution of her hypoxia, but with no improvement in her overall condition, and decline in her mental status and with continued pauses on telemetry (see below). # Afib with RVR: She was hospitalized in ___ with afib and has been off rhythm control since then due to not tolerating side effects. Difficult to say if afib was triggered by hypoxia or if RVR precipitated fluid overload, thus leading to hypoxia. On metoprolol 25 BID at home. She was dig loaded in ED, and this was continued in the MICU. She remained in RVR in the 140s, so metoprolol was added. However, following this, the pt began having sinus conversion pauses up to 6 seconds long with likely tachy brady syndrome. EP was consulted, who recommended monitoring for now and starting low dose metoprolol to control tachycardia. Pt was transferred to the ___ team where she continued to have tachy/bradycardia. Her condition continued to decline. # Leukocytosis: UTI is positive. Cannot exclude pneumonia based on CXR. s/p vanc and zosyn in ED. Pt received one dose of cefepime in unit, then changed to CTX. Antibiotics were later discontinued as her condition deteriorated, and as she was comfort measures only (see above). # ___: Given RVR and fluid overload on CXR this was likely ___ due to poor forward flow, i.e. cardiorenal injury. She was diuresed with lasix, but continued to decline. # Hyponatremia: Resolved. Most likely hypervolemic due to congestive heart failure versus hypovolemic with poor po intake, vomiting, and diarrhea. # AMS: This appeared to be a subacute process per the pt's daughter with gradual worsening since her recent hospitalization in ___. Multiple potential sources including infection (UTI vs PNA), hypoxia, uremia from ___, hyponatremia, hypoglycemia. In the unit, she remained confused and agitated, improved with zyprexa. On the floor, she was initially delerious, and then became increasingly less responsive. # Thrombocytopenia: Given patient's age, anemia, and atypical cells, we suspect she may have a component of myelodysplastic syndrome, undiagnosed. Baseline platelet count unknown. No active bleeding. # CAD/dCHF: Troponins negative. Continued home atorvastatin, asa, plavix. Metoprolol was restarted at half home dose due to sinus pauses. Echo showed hyperdynamic global systolic function; dilated right ventricle with preserved systolic function; septal flattening consistent with RV volume overload; at least moderate pulmonary artery hypertension. After extensive discussion with the Patient's family, Palliative Care and the Cardiology team, Patient was made CMO, was seen by Hospice, and expired peacefully on ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Metoprolol Tartrate 50 mg PO BID 3. GlipiZIDE XL 2.5 mg PO DAILY 4. Pantoprazole 20 mg PO Q12H 5. Docusate Sodium 100 mg PO DAILY:PRN constipation 6. Clopidogrel 75 mg PO DAILY 7. Atorvastatin 80 mg PO DAILY 8. DiphenhydrAMINE 25 mg PO HS:PRN insomnia 9. Fluoxetine 10 mg PO DAILY Discharge Medications: Patient expired Discharge Disposition: Expired Discharge Diagnosis: Atrial fibrillation Acute Kidney Injury Discharge Condition: Deceased Discharge Instructions: Dear Ms. ___ family, Your mother presented with a fast heart rate, kidney failure, and volume overload (fluid in the heart, lungs, and tissues). Unfortunately we were not able to reverse this with medical therapy and she passed away comfortably on hospice. Unfortuantely, it is unclear what caused this initially. Followup Instructions: ___
10814901-DS-21	10,814,901	29,757,019	DS	21	2174-09-30 00:00:00	2174-10-12 05:45:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dizziness Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ year old man with hypertension referred to the ED from his outpatient neurologist due to uncontrolled hypertension and episodic dizziness. Mr. ___ states that he has had approximately 4 episodes of dizziness over the past 2 weeks. The first episode occurred while visiting someone in a hospital. He was riding the elevator down towards the lobby when he noted the sudden-onset of a sensation that "everything started shaking." The doors of the elevator opened and the "room felt like it was shaking." He held on to a gurney outside of the elevator while waiting for the episode to subside. It lasted approximately 1 minute. He was "fine" for the next week without any additional episodes. Then, last week, while he was delivering mail for work, he noticed that he was "veering towards the left." He was pushing a hand cart full of mail and felt as though he had "no control" over the cart. He would pause, and try again to push the cart straight, but it would repeatedly veer towards the left. He kept hitting the wall on his left hand side. This persisted for roughly 1 hour and then resolved. There was no associated double vision, voice changes, or weakness. He has had 2 additional episodes of "dizziness" over this time period though he does not recall the precise details of these other events. He has felt a "fog" - like "when you're hung over" - upon wakening in the morning. He has had a "tinge" of a bitemporal headache over this time period but no thunderclap headache and no nausea, vomiting, or blurred vision. It was the incident with the hand cart that prompted him to see his PCP. He was evaluated by his PCP in ___ yesterday afternoon. BP there was 140/90 according to the patient. BP at home is usually 140 - 160/80 - 90. He was referred to Dr. ___ neurological evaluation given his episodic unsteadiness. At Dr. ___, his SBP was > 200 mmHg. Dr. ___ referred the patient to the ED for further neurological evaluation, including MRI. Past Medical History: Hypertension Cervical spine surgery (possibly discectomy) C5-C7 ___ Social History: ___ Family History: Father had throat and colon cancer. One brother had kidney cancer, the other brother with prostate cancer. No family history of stroke. Physical Exam: ADMISSION PHYSICAL EXAM ======================== Vitals: T 96.5, HR 66, BP 171/120, RR 18, Sa 95% RA (initial BP 204/117, peak 230/130) 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: CTAB Cardiac: RRR, warm, well-perfused Abdomen: soft, non-distended Extremities: Left > right pitting edema, 2+ Skin: no rashes or lesions noted. Neurologic Exam: -Mental Status: Alert, oriented. 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. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2 mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages. V: Facial sensation intact to light touch. VII: Very mild facial asymmetry limited to the mouth. Facial musculature activates symmetrically. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ L 5 ___ 5 ___ 5 5 5 R 5- ___ 5 ___ 5 5 5 -Sensory: Decreased sensation to pin prick in C 5 - 7 dermatomes, left more than right. No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout otherwise. No extinction to DSS. Romberg absent. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response was flexor bilaterally. -Coordination: No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. No overshoot with mirroring. Unterberger negative. -Gait/Station: Good initiation. Narrow-based, normal stride and arm swing. Slightly antalgic. Able to walk tandem for a few steps, albeit with difficulty. DISCHARGE PHYSICAL EXAM ====================== Gen - well appearing gentleman in NAD Resp - breathing comfortable on room air CV - RRR -Mental Status: Alert, oriented. 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. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2 mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages. V: Facial sensation intact to light touch. VII: Very mild facial asymmetry limited to the mouth. Facial musculature activates symmetrically. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ L 5 ___ 5 ___ 5 5 5 R 5- ___ 5 ___ 5 5 5 -Sensory: Decreased sensation to pin prick in C 5 - 7 dermatomes, left more than right. No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout otherwise. No extinction to DSS. Romberg absent. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response was flexor bilaterally. -Coordination: No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. No overshoot with mirroring. Unterberger negative. -Gait/Station: Good initiation. Narrow-based, normal stride and arm swing. Slightly antalgic. Able to walk tandem for a few steps, albeit with difficulty. Pertinent Results: ___ 02:03PM BLOOD WBC-6.8 RBC-4.85 Hgb-14.9 Hct-44.3 MCV-91 MCH-30.7 MCHC-33.6 RDW-12.6 RDWSD-41.4 Plt ___ ___ 02:03PM BLOOD Glucose-104* UreaN-15 Creat-0.9 Na-144 K-3.7 Cl-102 HCO3-27 AnGap-15 ___ 02:03PM BLOOD ALT-26 AST-25 AlkPhos-72 TotBili-0.6 ___ 02:13PM BLOOD Calcium-9.2 Phos-3.3 Mg-2.2 Cholest-207* ___ 02:13PM BLOOD %HbA1c-6.0 eAG-126 ___ 02:13PM BLOOD Triglyc-809* HDL-25* CHOL/HD-8.3 LDLmeas-84 IMAGING ======= MRI There are multiple areas of slow diffusion with associated FLAIR hyperintensity in the right splenium of the corpus callosum, left parietal white matter and in the left external capsule. Findings suggestive of subacute infarction. There is a small hyperintense focus in the right frontal lobe on diffusion weighted image without corresponding definite hypointensity on ADC map and FLAIR hyperintensity, likely representing subacute to chronic infarct. There are multiple chronic lacunar infarction in the bilateral corona radiata. There is chronic infarction in the right cerebellum. There is no evidence of hemorrhage, edema, masses, mass effect, or midline shift. The ventricles and sulci are normal in caliber and configuration. There is minimal mucosal thickening of the ethmoid air cells, otherwise the paranasal sinuses are clear. The mastoid air cells are clear. The orbits and globes appear normal. No abnormal marrow signal. IMPRESSION: 1. Multiple areas of subacute infarction in the right splenium of the corpus callosum, left parietal white matter, and in the left external capsule. No large vascular distribution infarct is identified. 2. Small subacute to chronic infarction in the right frontal white matter. 3. Scattered chronic infa infarction rct in the bilateral corona radiata, and in the right cerebellum. 4. No hemorrhage or mass. TTE IMPRESSION: Mild to moderate symmetric left ventricular hypertrophy with normal cavity size and regional/global biventricular systolic function. Mildly dilated thoracic aorta. No significant valvular disease detected. No structural cardiac source of embolism (e.g.patent foramen ovale/atrial septal defect, intracardiac thrombus, or vegetation) seen. Brief Hospital Course: Summary Statement =================== This is a ___ year old man with poorly controlled hypertension referred to the ED after multiple episodes of unsteadiness, including a 60 minute period during which he was repeatedly veering towards the left. Pt was found to be quite hypertensive with systolic blood pressures > 200 and MRI revealed multiple chronic lacunar strokes w/o new acute infarct to explain his symptoms. Transitional Issues ===================== [ ] Please continue to uptitrate patients blood pressure medications, we did not want to increase too drastically given report that patient has had systolic blood pressures 140s-160s at home. We did increase the carvedilol to 25mg BID. [ ] Please make sure pt has a neurology appointment set up (pt is atrius pt and cannot be arranged for him) [ ] Pt encouraged this admission to reconsider using CPAP for his OSA [ ] Of note patient has evidence of bilateral ventricular hypertrophy on a TTE [ ] Pt's LDL and A1c were pending at discharge, please follow-up [ ] Pt was discharged with a Ziopatch to look for evidence of atrial fibrillation Pt presented w/ multiple episodes of unsteadiness, room shaking and one episode where he noted veering to the left for ~ 1 hour. Pt was admitted for blood pressure control and MRI. MRI revealed multiple chronic lacunar infarcts, likely due to his uncontrolled hypertension, but no acute infarcts that would have explained his symptoms. Overall impression is that his transient symptoms are likely in the setting of uncontrolled hypertension as well given slightly vague non-stereotyped features. He had an TTE which was notable for ventricular hypertrophy but otherwise without concerning features. Pt will be discharged with a Zio patch to investigate for atrial fibrillation. Blood pressure this admission was labile but SBP range was between SBP 160-190 even after increase in carvedilol. Elected not to increase medications further given pt notes that he normally has SBPs in 140s-160s. However, he will most certainly require further titration of his medications as an outpatient. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. CARVedilol 12.5 mg PO QAM 2. CARVedilol 6.25 mg PO QPM 3. Gabapentin 100 mg PO TID 4. Hydrochlorothiazide 25 mg PO DAILY 5. Losartan Potassium 50 mg PO DAILY 6. TraMADol 50 mg PO ___ WEEKLY Discharge Medications: 1. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:3 2. Atorvastatin 40 mg PO QPM RX atorvastatin 40 mg 1 tablet(s) by mouth QPM Disp #30 Tablet Refills:3 3. CARVedilol 25 mg PO BID RX carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:*3 4. Gabapentin 100 mg PO TID 5. Hydrochlorothiazide 25 mg PO DAILY 6. Losartan Potassium 50 mg PO DAILY 7. TraMADol 50 mg PO ___ WEEKLY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis =================== Hypertensive Urgency 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 due to transient episodes of dizziness and unsteadiness as well as your high blood pressure. There was some concern that you had a stroke. You had an MRI which showed evidence of previous small strokes likely due to your high blood pressure. However there was not any evidence of a new stroke to explain your symptoms. We think this is all likely due to your high blood pressure and it will be important to continue to work on this with your primary care physician. We also recommend that you reconsider have your obstructive sleep apnea treated, as this will be important to help control your blood pressure as well. You also had an echocardiogram (ultrasound) of your heart which was largely normal, though shows some evidence of hypertension and enlarged heart muscles (called ventricular hypertrophy). We increased one of your blood pressure medications called Carvedilol to 25mg two times per day, started you on an aspirin, as well as a statin medication for cholesterol. Please take your blood pressure at least ___ daily if possible and record in a notebook to bring to your primary care appointment. Please continue to take all of your medications and go to all of your appointments. - Your ___ neurology team Followup Instructions: ___
10814905-DS-7	10,814,905	26,021,073	DS	7	2123-04-10 00:00:00	2123-04-10 12:15:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: IV Contrast Attending: ___. Chief Complaint: right flank pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ hx of stage IIB pancreatic CA treated with FOLFOX then gem/abraxane for PD in LN, recently completed ___ cycle, also underwent cyberknife ___. She presents to BI with rt flank pain for the past two days. Is intermittent, when having episode of pain is sever, ___ feels like wrenching/twisting inside. sometimes also having dull pain at R ant subcostal margin. She also had some nausea w/ emesis x 2 of stomach contents. No hematemsis or bilious contents. no other pain. states she did not take MSIR at home because it causes bad constipation. Currently BM are regualr. No fever/chills. No cough, SOB. No back pain. No numbness/focal weakness or HA. In ___ she underwent CT abdomen that was concerning for progressive disease now with fat stranding of pancreas, vasculature involvement as well as questionable liver met. Also had UA with gross hematuria but pt currently has menses. Pt referred to BI for heme/onc eval and pain treatment and planning. In ___ ___ intiial VS 17:48 3 98.7 94 121/76 16 97% RA she was given 4mg morphine w/ significant improvement in pain and IV zofran and 1L NS REVIEW OF SYSTEMS: GENERAL: No fever, chills, night sweats, recent weight changes. HEENT: No mouth sores, odynophagia, sinus tenderness, rhinorrhea, or congestion. CARDS: No chest pain, chest pressure, exertional symptoms, or palpitations. PULM: No cough, shortness of breath, hemoptysis, or wheezing. GI: as above. GU: No dysuria, hematuruia or frequency. MSK: No arthritis, arthralgias, myalgias, or bone pain. DERM: Denies rashes, itching, or skin breakdown. NEURO: No headache, visual changes, numbness, paresthesias, focal weakness, or neurologic symptoms. HEME: No bleeding or clotting Past Medical History: PAST ONCOLOGIC HISTORY: per OMR Pancreatic cancer stage IIB (T3N1M0) - ___ Initially presented about three weeks ago with upper back pain and was prescribed naproxen and flexeril. Shortly after starting the new medications she developed jaundice and pruritus and was found to have abnormal liver function tests and was sent to the ___ emergency room and then transferred to ___. - ___ Admission to ___ - ___ ERCP showed a 2 cm stricture in the mid-common bile duct for which a plastic biliary stent was placed. Brushings were taken which returned negative. - ___ Underwent CTA abdomen, which show a partially necrotic pancreatic head/neck mass, abnormal appearing peripancreatic lymph nodes measuring up to 1.5 cm, tumor abutment of the portal splenic confluence and SMV involvement over a 180 degree circumference with encasement/narrowing of the GDA. CA ___ on ___ was 438. Her bilirubin on admission was 9.6 but after stent placement has trended down to 1.7. - ___ Initial Pancreatic MDC visit - ___ ERCP cytology revealed pancreatic adenocarcinoma - ___ ERCP exchange of plastic stent for metal. EUS report says, "A 2.5cm ill-defined mass was again noted in the head/neck of the pancreas. The mass was hypoechoic and heterogenous in echotexture. The borders of the mass were irregular and poorly defined. The mass was seen abutting the portal vein, porto-splenic confluence and the superior mesenteric vein. This was suspicious for vascular invasion by the mass. CBD stent was seen in situ. Successful placement of fiducials were placed." - ___ FOLFIRINOX C1D1 at full dose. Complicated by febrile neutropenia and colitis. Admitted to ___. D15 dose not given. - ___ C1D1 FOLFOX6 + Neulasta - ___ C2D1 FOLFOX6 + Neulasta - ___ CT torso showed no metastatic disease and stable disease to response in the pancreatic mass, but possible progression in the LNs. - ___ C1D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 D1,8. D15 held for low counts - ___ Start CK - ___ Complete CK with 2400 cGy - ___ C2D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 D1,8,15 - ___ PLT 83. Reduce gemcitabine to 750 mg/m2 starting D8 of this cycle. - ___ C2D15 chemo held for pancytopenia. - ___ C3D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 D1,8,15 - ___ C3D15 chemo held for cytopenias - ___ C4D1 gemcitabine 750 mg/m2 Abraxane 100 mg/m2 D1,8,15, delayed for patient preference - ___ C4D15 dose of gem/Abraxane given, pt unable to make her D8 visit PAST MEDICAL HISTORY: Obesity, depression/anxiety, status post C-section ___ Social History: ___ Family History: Paternal GM with urinary CA. Maternal GF with melanoma. No FHx of GI or pancreatic malignancies. Physical Exam: ADMISSIOn PHYSICAL EXAM: General: NAD VITAL SIGNS: 97.6 124/78 99 18 100%RA HEENT: MMM, no OP lesions Neck: supple, no JVD CV: RR, NL S1S2 no S3S4 or MRG PULM: CTAB ABD: BS+, soft, mild ttp R lat subcostal margin, no masses or hepatosplenomegaly EXT: warm well perfused, no edema, no CVA tenderness, no spinal tenderness SKIN: No rashes or skin breakdown NEURO: alert and oriented x 4, ___, EOMI, no nystagmus, face symmetric, no tongue deviation, full hand grip, shoulder shrug and bicep flexion, full toe dorsiflexion and hip flexion against resistance bilateral, sensation intact to light touch, no clonus DISCHARGE PHYSICAL EXAM: General: NAD VITAL SIGNS: 98.1 120s/60s ___ 100s 18 98% RA HEENT: MMM, no OP lesions Neck: supple, no JVD CV: RR, NL S1S2 no S3S4 or MRG PULM: CTAB ABD: BS+, soft, no tendereness of abdomen or spine/flanks on exam, no masses or hepatosplenomegaly EXT: warm well perfused, no edema, no CVA tenderness, no spinal tenderness SKIN: No rashes or skin breakdown NEURO: alert and oriented x 4, ___, EOMI, no asterixis, ___ strength throughout Pelvic: no signs of rectal bleeding but red blood is coming from the vagina Pertinent Results: IMAGING: CT abdomen/pelvis - ___ ___ Pneumobilia is present in association with a stent across the metallic common bile duct, which is unchanged in position. The liver demonstrates fatty infiltration. There is a new hypodense lesion measuring low attenuation adjacent to the gallbladder fossa within segment V of the liver measuring overall 37 x 18 mm in axial ___, suggestive of focal fatty infiltration although a metastasis is hard to exclude . A right adrenal nodule which previously measured 22 x 19 mm in axial ___ and now measures up to 22 x 18 mm , very similar in size. The left adrenal is unremarkable. A few small hypodense foci in the each at kidney are too small to characterize but unchanged and doubtful in clinical significance. No stones are identified. There has very mild bilateral hydronephrosis, greater on the right than left, but unchanged and not necessarily pathological; there is no indication of an obstructing lesion. The spleen appears mildly enlarged, measuring up to 15.0 cm in length; p reviously it measured 13.1 cm. An ill-defined pancreatic mass in the head narrows the main portal vein to a greater than degree before, although probably still slightly patent, suggesting underlying progression of tumor. The tumor is infilrative and irregular in shape, and accordingly difficult to measure precisely, but appears slightly increased; it now contains a small amount of gas which may be associated with necrosis but likely from the stent lumen. There is also new stranding about the pancreas as well as ill-defined fluid or infiltration of the right anterior pararenal space. The body and tail of the pancreas show similar ductal dilatation. The pancreatic duct again measures 6 mm in diameter. Tumor invo lvement of the celiac axis and common hepatic artery hasincreased and it may be that the artery is now occluded with collaterals, although not optimally delineated non-angiographic technique. Central mesenteric lymph nodes appear mildly more prominent particularly with regard to number but not enlarged by size criteria. The duodenum appears partly encased but there is noobstruction. The colon is unremarkable. Pelvis: A small quantity of ascites is present in the pelvic cul-de-sac. The uterus is mildly enlarged with minimally uneven outer cont our, particularly posteriorly, possibly reflectingf ibroids. There is a a left-sided involve are cyst measuring up to 26 x 17 mm in axial ___, respectively. In the right lower quadrant, there is a small nodule, probably a lymph node measuring 10 mm in length, previously 7 mm. An additional tiny nodule measures 4 mm, not apparent before but quite small.Mild atherosclerotic calcification is present. Bones: There are no suspicious lytic or blastic bone lesions. The bones appear de mineralized. MRI ___ liver at BID IMPRESSION: 1. Segment V hepatic lesion seen on prior CT is compatible with increased focal fat deposition on a background of diffuse hepatic steatosis. No suspicious liver lesion detected. 2. 2.7 cm pancreatic head mass with worsening moderate compression of the proximal main portal vein and a small nonocclusive thrombus in the narrowed segment, new since ___. 3. Mild splenomegaly and trace perihepatic ascites suggest portal hypertension. 3. 1.7 cm right adrenal adenoma. 4. Gallbladder sludge. Brief Hospital Course: Ms ___ is a ___ yr old female with hx stage IIB pancreatic cancer s/p cyberknife and most recently ___ C4D1 abraxane who presents with acute R flank pain and imaging concerning for progressive disease w/ worsening vascular involvement (portal vein narrowing further, possibly complete celiac artery occlusion) found also to have Hct drop in the setting of menses. Anemia - Hct drop initially likely ___ hemodilution as no reason clinically to suspect internal bleeding at that time (and subsequently no evidence of such on MRI) however drop was noteworthy. Underlying baseline anemia likely ___ chemo, though recent clinic visit had noted worsening anemia and considered etiologies; at that time iron 14 (ferritin 54 and TIBC 342 suggests possibly superimposed iron deficiency). Pt also currently menstruating during this admission with heavy flow. She stated her last period was ___ months ago and she has a history of heavy periods. She may just be perimenopausal and having irregular periods however she noted being told she had a history of fibroids at one point (s/p Csection in ___ but subsequently told she did not have them. Pelvic ultrasound was done which showed only one small fibroid and nothing else unusual. Overall Hct stable with slight further downtrend which stabilized. Hemolysis labs and smear were unremarkable. There was no evidence of GI bleeding (in fact the patient had constipation) and on pelvic exam it was clear the blood was coming from the vagina rather than the rectum. Given the iron studies suggestive of iron deficiency along with the evidence of active blood loss she was started on iron supplementation. By the time of discharge her menstrual flow had subsided. She was instructed to see her OB/gyn the week after discharge for complete speculum exam. Heavy/abnormal menstrual bleeding - see anemia above. ultrasound showed no evidence of cancer or thickened endometrial stripe or sizeable fibroid. After brief discussion with OB/gyn, it was felt that she should return on an outpatient basis to have an endometrial biopsy or at least consideration of such by a gynecologist. The gyn team said it is sometimes the case that a sizeable Hct drop can occur simply from abnormal menstrual bleeding, as above. Her TSH was normal at 1.3. Pancreatic cancer - clinical picture and imaging as above concerning for progressive disease and possible new liver met (fatty infiltration on read but met hard to exclude, however MRI done at ___ showed fatty focus rather than metastatic disease), ___ slowly rising. worsening vascular involvement of tumor on imaging as well - specifically portal vein narrowing and almost complete occlusion of celiac artery. Poor prognosis as she has completed 6mo chemo (FOLFOX + gem/abraxane) and has had cyberknife w/ steadily progressive disease. As noted, liver lesion however appears to be fatty and nonmalignant per MRI. Abd pain - likely ___ pancreatic cancer, possibly compressing celiac plexus.She was started on MS contin 15mg BID with excellent effect and went home with this and with prn MSIR 7.5mg po as needed. She can follow up in the pain clinic if she wishes to puruse a celiac plexus block in the future if her pain is poorly controlled. Portal vein thrombus - new, small, nonocclusive thrombus noted on MRI noted compared to ___. Pt likely warrants anticoagulation but given the sizeable Hct drop and heavy menstrual flow, this was not initiated at this time. Her outpatient oncologist is aware of this and can start anticoagulation if Hct stabilizes or at his discretion. Constipation - significant issue during this hospital stay but finally had BM before discharge. sent home on standing colase, senna, dulcolax, miralax, with mg citrate and suppositories prn. Likely exacerbated by the uptitration of pain meds and addition of PO iron. TRANSITIONAL ISSUES: - Portal vein thrombus, though small/nonocclusive as above - needs f/u with gynecology for consideration of endometrial biopsy, pt aware Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lorazepam 0.5 mg PO Q6H:PRN nausea, vomiting 2. Docusate Sodium 100 mg PO BID 3. Magnesium Citrate 150 mL PO BID PRN constipation 4. Senna 8.6 mg PO BID:PRN constipation 5. Morphine Sulfate 7.5 mg IM Q6H:PRN pain Discharge Medications: 1. Docusate Sodium 200 mg PO BID RX docusate sodium [Colace] 100 mg 2 capsule(s) by mouth twice a day Disp #80 Capsule Refills:0 2. Lorazepam 0.5 mg PO Q6H:PRN nausea, vomiting 3. Magnesium Citrate 150 mL PO BID PRN constipation 4. Senna 17.2 mg PO BID constipation RX sennosides [senna] 8.6 mg 2 capsules by mouth twice a day Disp #80 Capsule Refills:0 5. Bisacodyl 10 mg PO DAILY RX bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #60 Tablet Refills:0 6. Ferrous Sulfate 325 mg PO BID RX ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 7. Ondansetron 4 mg PO Q8H:PRN nausea RX ondansetron 4 mg ___ tablet(s) by mouth every 8 hours as needed Disp #45 Tablet Refills:0 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by mouth daily prn Disp #30 Packet Refills:0 9. Prochlorperazine 10 mg PO Q6H:PRN nausea RX prochlorperazine maleate [Compazine] 10 mg 1 tablet(s) by mouth every 6 hours as needed Disp #45 Tablet Refills:0 10. Morphine Sulfate ___ 7.5-15 mg PO Q4H:PRN pain RX morphine 15 mg ___ tablet(s) by mouth every 4 hours as needed Disp #60 Tablet Refills:0 11. Morphine SR (MS ___ 15 mg PO Q12H dont drive or use alcohol with this RX morphine 15 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 12. Lactulose 30 mL PO DAILY:PRN constipation RX lactulose 20 gram/30 mL 30 mL by mouth daily if needed Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Pancreatic cancer Iron Deficiency Anemia 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. We did a CT scan which showed question of a liver lesion concerning for cancer but our MRI suggested it was just an area of focal fat deposit. We started you on long acting morphine for pain, to be taken twice a day, with short acting morphine pills to be used in addition to this throughout the day. Your blood counts were dropping and this was likely due to heavy vaginal bleeding from your period. However given the degree of bleeding we did an ultrasound which actually didn't show any significant fibroids. We started you on iron supplementation. make sure to take the iron with food and use the medications to prevent constipation (take colase and senna and dulcolax every day) and if you develop constipation you should ALSO use miralax that day. it is ok if you need to use the miralax every day. Actually I would recommend you just use the miralax daily to prevent a bad situation with constipation and use a SECOND dose if you are constipated. It is important that you see a gynecologist within ___ weeks after discharge. Your bleeding was signficant and given your age, you will need a biopsy of the inside lining of the uterus at some point to make sure there is no evidence of cancer. Our ultrasound didn't suggest cancer, but anyone over ___ with abnormal bleeding like this should have it investigated further just to be safe. I know you don't have a gynecologist so if your primary care doctor cannot get you in to see a gynecologist in the next ___ weeks please call OUR gynecologists (information is below) and make an appointment to come to ___. It is important to follow up on this. If you bleeding gets worse again please call your doctor immediately. In the future if you have worsening pain, talk to Dr. ___ ___ You should make an appointment to be seen in our pain clinic to consider a nerve block near your tumor which would numb some of the nerves affected by the tumor likely responsible for causing the pain. You can call ___ and ask for the next available appointment with Dr. ___. For pain, use the long acting morphine twice a day (it is called MS CONTIN) and use the short acting morphine (MS ___, ___ sulfate) during the day if you have extra pain. These meds have similar names so it can be confusing so pay attention to this on the bottle. Followup Instructions: ___
10815292-DS-2	10,815,292	29,052,052	DS	2	2166-06-26 00:00:00	2166-06-27 10:25:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Penicillins / Iodinated Contrast Media - IV Dye Attending: ___. Chief Complaint: expedited workup of progressive dysarthria and ataxia Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: ___ is a ___ year-old right-handed woman with history of anxiety, HTN, HLD, DM, COPD (chronic smoker) followed by ___ at ___ Neuro since ___ who presents with worsening ataxia and dysarthria. In ___ her son remarked on her dysarthria and left facial droop, and wondered if she had had a stroke. However, in retrospect she and her family agree that these symptoms came on gradually. Due to ongoing family turmoil, she was not evaluated until several months later, at which point her most bothersome symptoms were left-sided weakness and dysarthria. She had an MRI of the brain which was negative for stroke and an EMG which reportedly showed myotonia, and was referred to ___ in ___. At that clinic visit, she was noted to have dysarthria, mild appendicular ataxia and inability to walk in tandem. An initial workup consisting of a myelopathy evaluation and paraneoplastic panel in the serum was sent and reportedly notable only for low B12, for which she was started on cyanocobalamin. She returned today for a swallowing evaluation and was found to have significant progression of her deficits, with more pronounced dysarthria, appendicular ataxia, and left sided weakness. Her video swallow showed penetration of thin liquids but she was cleared for an unrestricted diet. Since her prior clinic visit, she has fallen twice. Once was a fall after making a turn too briskly at the bank; the other was when kicking laundry down the stairs and becoming tangled up with it. She denies loss of consciousness. She has also had some episodes of coughing on thin liquids but no frank choking. Her dysarthria is worse. She has noticed weakness of her left arm and has dropped things a couple times. She has been having progressive difficulty performing her activities of daily living. On arrival in the ED she was noted to have sinus tachycardia and received a bolus of 500 cc of normal saline. She also has a history of childhood/familial muscle cramps (unclear formal diagnosis) that is likely unrelated to the current presentation. She complains of stiffness and muscle cramps since birth which worsen in the cold, with delayed muscle relaxation. She admits to balance issues and clumsiness in her teenage years. Past Medical History: - HTN - HLD - DM - COPD - anxiety - spastic dysarthria - hereditary myotonic syndrome Social History: ___ Family History: Mother: deceased age ___ heart, COPD, diabetes, Father: deceased age ___ diabetes mellitus, bladder cancer with mets to liver She has 7 brother and sisters who are healthy. Paternal family history of myotonia: She has a pertinent family history of similar muscle cramping problems in multiple relatives. For example her father, brother, son, niece and sister get cramping of their eyes when they rubbed her eyes and are unable to open them. In addition, she has a great nephew, which is her sister's daughter's son who has been diagnosed with a sodium channel genetic abnormality (sodium channel gene problem in the SCN4A.) Pedigree appears consistent with AD disorder. Physical Exam: General: Overweight woman who appears stated age, sitting in chair, NAD. Obese trunk with minimal cutaneous fat on arms and legs. HEENT: No scleral icterus or injection. Moist mucus membranes. Neck: Supple, multiple subcentimeter lymph nodes noted in posterior cervical chain with one 1.5 cm lymph node in left supraclavicular area. There is a left-sided, asymmetric non-tender soft tissue mass at the nape of the neck. Pulmonary: Normal work of breathing. Vesicular breath sounds bilaterally, no wheezes or crackles appreciated. Cardiac: S1/S2 appreciated, RRR. Abdomen: Obese, soft, nontender, nondistended Extremities: no lower extremity edema Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty and recite pedigree across multiple generations without difficulty. Attentive to ___ backwards. Language is fluent and intact to naming of high and low frequency objects, repetition long and complex phrases, and comprehension. There were no paraphasic errors. Encoded 3 objects and recalled ___ at 5 minutes. The pt. had good knowledge of current events. There was no evidence of neglect. There is dysarthria, spastic speech with lingual > labial > palatal dysarthria and slowing of all phonemes. -Cranial Nerves: I: Olfaction not tested. II: Pupils round and reactive to light with physiologic anisocoria, R ___ and L 4.5-2.5. VFF to confrontation with finger counting. III, IV, VI: EOMI. There is saccadic breakdown in horizontal gaze, more prominent on leftward gaze. There are several beats of low amplitude right rotary nystagmus on rightward gaze and left rotary nystagmus on leftward gaze but none in primary position. Saccades are hypometric in all directions of gaze. V: Facial sensation intact to light touch, pinprick in all distributions. VII: Left nasolabial fold flattening, slow to activate and excursion is not as full. There is intermittent widening of the left palpebral fissure, but frontalis is not involved. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. Gag is present bilaterally XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline, and is equal ___ strength bilaterally as evidenced by tongue-in-cheek testing. -Motor: Increased bulk symmetrically throughout. Spastic catch in legs bilaterally. Left pronation without drift. No tremor or asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 4+ 5 4+ ___ 5 4+ 5 4+ 5 5 5 5 R ___ ___ ___ 5 5 5 5 5 - DTRs: Bi Tri ___ Pat Ach L 3 2 3 3 2 R 3 2 3 3 2 - Plantar response was flexor bilaterally. - Jaw jerk present. No grasp. - Sensory: No deficits to light touch, pinprick in upper extremities. There is hyperesthesia to pinprick in bilateral lower extremities from mid-thigh. Vibration and proprioception are intact in great toes bilaterally. No extinction to DSS. - Coordination: There is dysmetria on L>R FNF. Finger tapping is markedly slowed and inaccurate on the L>R. L HKS is significantly dysmetric, R relatively preserved. L toe tapping is slow with irregular cadence. - Gait: Able to rise to a standing position without pushing off. Good initiation. Gait is wide based but steady. Turn is slow with multiple steps, but is off balance. Cannot walk in tandem. On Romberg testing she has difficulty standing with feet together and eyes open. Pertinent Results: LABS ___ 03:00PM BLOOD WBC-9.4 RBC-4.36 Hgb-13.0 Hct-38.5 MCV-88 MCH-29.8 MCHC-33.8 RDW-12.1 RDWSD-38.7 Plt ___ ___ 03:00PM BLOOD Neuts-67.8 ___ Monos-6.9 Eos-1.7 Baso-0.4 Im ___ AbsNeut-6.35* AbsLymp-2.14 AbsMono-0.65 AbsEos-0.16 AbsBaso-0.04 ___ 03:00PM BLOOD Glucose-211* UreaN-12 Creat-0.9 Na-143 K-3.6 Cl-103 HCO3-26 AnGap-18 ___ 03:00PM BLOOD Glucose-211* UreaN-12 Creat-0.9 Na-143 K-3.6 Cl-103 HCO3-26 AnGap-18 ___ 03:00PM BLOOD Albumin-4.5 Calcium-9.9 Phos-2.8 Mg-2.5 ___ 03:00PM BLOOD ALT-17 AST-19 AlkPhos-119* TotBili-0.3 ___ 03:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 05:20AM BLOOD SPINOCEREBELLAR ATAXIA TYPE 3-PND ___ 07:00PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-1 ___ ___ 07:00PM CEREBROSPINAL FLUID (CSF) TotProt-42 Glucose-72 ___ 07:00PM CEREBROSPINAL FLUID (CSF) PARANEOPLASTIC AUTOANTIBODY EVALUATION, CSF-PND ************ IMAGING MR head w/wo contrast ___ IMPRESSION: 1. Somewhat motion limited exam. Within that limitation, no acute intracranial process. 2. There is atrophy of the cerebellum, slightly disproportionate to the degree of age related mild cerebral atrophy. CT chest ___ IMPRESSION: 1. No evidence of malignancy in the chest. 2. Moderate atelectasis bilaterally. CT abdomen/pelvis ___ IMPRESSION: 1. No acute intra-abdominal process. No evidence of malignancy in the abdomen or pelvis. Brief Hospital Course: Patient was admitted from clinic for expedited workup of worsening dysarthria and ataxia as well as spastic hemiparesis of the left concerning for a progressive cerebellar degenerative process. Of note, she also has a personal and family history of myotonia and cramps in the extremities and eyelids. She underwent MRI brain with/without contrast which showed marked cerebellar atrophy, left worse than right, but no abnormal enhancement. She underwent lumbar puncture; cell count and protein were bland. Numerous studies were sent including CSF cytology, CSF and serum paraneoplastic panel, as well as genetic testing for spinocerebellar ataxia type 3. She will be followed up in clinic to review final results of these studies. She was found to have a pan-sensitive E coli UTI which was treated with 3 days of Bactrim DS. She was evaluated by Physical Therapy who felt she was safe to discharge home with home ___ and a cane. She was encouraged to enroll in DriveWise or similar service to assess driving capability if needed. Transitional issues: [ ] F/U CSF paraneoplastic panel and serum spinocerebellar ataxia type 3 analysis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Simvastatin 40 mg PO QPM 3. bisoprolol-hydrochlorothiazide ___ mg oral DAILY 4. Imipramine 100 mg PO BID 5. Imipramine 25 mg PO QHS 6. MetFORMIN (Glucophage) 500 mg PO QAM 7. MetFORMIN (Glucophage) 1000 mg PO QHS 8. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation BID 9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, sob 10. TRIAzolam 0.25 mg PO QHS:PRN anxiety 11. Cyanocobalamin 500 mcg PO DAILY 12. GlipiZIDE XL 5 mg PO DAILY Discharge Medications: 1. Striaght cane Diagnosis: progressive ataxia of unclear etiology Prognosis: good Level of need: 13 months 2. Aspirin 81 mg PO DAILY 3. bisoprolol-hydrochlorothiazide ___ mg oral DAILY 4. Imipramine 100 mg PO BID 5. Imipramine 25 mg PO QHS 6. Simvastatin 40 mg PO QPM 7. TRIAzolam 0.25 mg PO QHS:PRN anxiety 8. Cyanocobalamin 500 mcg PO DAILY 9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, sob 10. MetFORMIN (Glucophage) 500 mg PO QAM 11. MetFORMIN (Glucophage) 1000 mg PO QHS 12. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation INHALATION BID 13. GlipiZIDE XL 5 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Progressive dysarthria and ataxia of unclear etiology Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted from clinic for symptoms of progressive worsening slurred speech and gait instability. We performed an extensive evaluation including an MRI of your brain, which showed a degenerative process of your cerebellum (the "cauliflower" of the brain which controls the coordination of your body) and a lumbar puncture, which is a test in which we sampled a small amount of cerebrospinal fluid. The preliminary results of that showed no evidence of acute infection. The final results will take some time to return; you will follow up with Dr. ___ in her office to review the final results. You were also found to have a urinary tract infection while you were here. We treated you with a 3 day course of an antibiotic called Bactrim. You do not need further treatment for this. While you were here, we also had our physical therapist perform an evaluation. They felt that you were able to safely ambulate with the help of an assistive device (cane) as well as climb stairs. We will arrange for a home therapist to visit and work with you in your home environment to provide specific strategies and tips to remain safe at home. If there is a concern for driving, we recommend you participate in DriveWise, which is a program at ___ that offers an evaluation of your ability to continue driving. It was a pleasure taking care of you. We wish you the best. Sincerely, Your ___ Care Team Followup Instructions: ___
10815532-DS-13	10,815,532	22,723,348	DS	13	2184-04-07 00:00:00	2184-04-08 10:15:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: Blood in urine Major Surgical or Invasive Procedure: R sided thoracentesis. History of Present Illness: Mr. ___ is a ___ male with history of metastatic prostate cancer s/p left PCNU placement on ___ for left-sided hydronephrosis secondary to bulky lymphadenopathy who presents for hematuria. He underwent PCNU placement on ___ and had been doing well at home. His output from the PCNU slowly cleared and was a normal clear yellow for several days. However, the day prior to admission his urine output changed from clear yellow to dark red. He denies any trauma or dislodgement of the PCNU. His ___ noticed the change and his vitals were notable for BP 100/62 and HR 110. His ___ recommended him to go the ED for further evaluation. On arrival to the ED, initial vitals were 97.8 105 120/80 18 98% RA. Labs were notable for WBC 7.2, H/H 11.837.9, Plt 337, Na 132, Cl 91, BUN/Cr ___, lactate 1.6, and UA with large blood, large lueks, negative nitrite, WBC > 182, RBC > 182, and bacteruria. ___ was consulted who recommended CTA abdomen for further evaluation which showed correct position of PCNU with possible blood products in the bladder. Patient was given ceftriaxone 1g IV, morphine 4mg IV x 2, and 2L NS. Prior to transfer, vitals were 98.7 114 113/60 18 96% RA. On arrival to the floor, the patient reports a poor appetite which is chronic. He notes generalized fatigue for several months. Also reports pain in his pelvis/groin on the left. He reports that since the PCNU he has not had any urine output via his urethra however today had a small amount of leakage He denies fevers/chills, headache, dizzinesss/lightheadedness, shortness of breath, cough, chest pain, flank pain, nausea/vomiting, diarrhea, and dysuria. Past Medical History: Arthritis Coronary Artery Disease Diabetes Mellitus Type II Diabetic Neuropathy Gout Hypertension Metastatic Prostate Cancer s/p Lupron, Bicalutamide, and radiation Mitral Regurgitation Mitral Valve Prolapse Social History: ___ Family History: Father ___ in ___ Physical Exam: Discharge exam VS 97.5 90-100s/60-70 90-100 18 91% RA In 660 out ___ yesterday Heart- RRR S1 and S2 normal. No MRG Lungs- CTAB, no crackles or wheezes Abdomen-Soft NT ND Extremities-No edema. Neuro: ___ strength throughout, though notably weaker in LLE (per pt chronic). Pt with difficulty fully closing left eyelid dysconjugate extraocular gaze though movements are coordinated, PERRLA, no tremor/asterixis, left facial droop left TM with fullness, dullness Pertinent Results: ___ 02:20PM BLOOD WBC-7.2 RBC-4.69 Hgb-11.8* Hct-37.9* MCV-81* MCH-25.2* MCHC-31.1* RDW-14.9 RDWSD-43.1 Plt ___ ___ 07:20AM BLOOD WBC-5.9 RBC-4.29* Hgb-10.5* Hct-34.3* MCV-80* MCH-24.5* MCHC-30.6* RDW-16.0* RDWSD-45.1 Plt ___ ___ 02:20PM BLOOD Glucose-128* UreaN-16 Creat-1.0 Na-132* K-4.1 Cl-91* HCO3-25 AnGap-20 ___ 07:20AM BLOOD UreaN-15 Creat-0.8 Na-138 K-4.2 Cl-100 HCO3-28 AnGap-14 ___ 08:09AM BLOOD ALT-8 AST-15 AlkPhos-106 TotBili-0.2 ___ 10:50AM BLOOD proBNP-712* ___ 07:57AM BLOOD PSA-72* ___ 02:33PM BLOOD Lactate-1.___hest IMPRESSION: 1. Right middle and lower lobe pneumonia. 2. Mild focal interstitial pulmonary edema in the medial lingula. 3. Bilateral layering nonhemorrhagic moderate-to-large pleural effusions. 4. Unchanged multifocal sclerotic osseous metastases. 5. Unchanged fusiform ascending thoracic aortic dilation measuring 4.1 cm. In the absence of imaging prior to this, ___ year follow-up chest CT is recommended to ensure stability. 6. New mediastinal lymphadenopathy is likely reactive. 7. Unchanged 16 mm left adrenal nodule. RECOMMENDATION(S): In the absence of imaging prior to this, ___ year follow-up chest CT is recommended to ensure stability of a 4.1 cm ascending thoracic aortic aneurysm. MRI head IMPRESSION: 1. Postcontrast examination is severely limited secondary to patient motion. Within this confine: 2. Apparent 8 mm lesion in the left internal auditory canal with likely postcontrast enhancement. Possible asymmetric enhancement of the left tympanic and mastoid segments of the facial nerve. There is new T2 hyperintense signal/opacification of pneumatized left petrous apex and the mastoid air cells. It is uncertain whether this lesion represents leptomeningeal disease or extension of from an osseous lesion. No abnormality is noted in the internal auditory canal on nondedicated sequences on prior MRI of ___. 3. Recommend dedicated temporal bone CT for further evaluation of the osseous structures. 4. Numerous scattered calvarial lesions consistent with metastatic disease. The occipital lesion has a soft tissue component that extends to the dura and the scalp. There is also suspicion for extension of the right orbital roof lesion into the anterior cranial fossa. RECOMMENDATION(S): Temporal bone CT is recommended for further evaluation of the left temporal bone. Brief Hospital Course: ___ M with metastatic prostate cancer and PCNU presented with hematuria, now resolved, found to have Klebsiella UTI, pleural effusions, and multiple skull based mets with new finding of auditory canal lesion of unclear etiology. # Bells palsy/peripheral L ___ nerve palsy # auditory canal lesion # numerous osseous/skull mets ___ nerve palsy somewhat chronic (present last 4 months), overall MRI with finding of new auditory canal lesion w/ enhancement c/f possible extension of osseous lesion vs leptomeningeal disease. Ct temporal bone however now suggests possibly cholesteatoma as appears to be soft tissue lesion rather than osseous lesion, with extension into the auditory canal effacing the bone covering the facial nerve, so seems possible explanation for facial palsy, and further likely to explain his more recent left ear fullness and reported hearing loss. ENT evaluated and felt very unlikely cholesteatoma, more likely metastatic lesion. Per Dr. ___, ___ for ___ sessions of CK to the lesion. He also suggested starting steroids, so 4mg dex daily was started on ___, with plan to taper or continue per direction of radiation oncology, and he has follow up with Dr. ___ ___ at which time they can also be stopped. Note that brain MRI showed numerous scattered calvarial lesions consistent with metastatic disease. Of great importance, he must continue supportive care for facial nerve palsy - artificial tears and ointment nightly, and at night needs to tape the eye shut. The radiation oncology department in ___ (Dr. ___, should contact the patient about scheduling/timing of radiation) # New large bilateral non-hemorrhagic pleural effusions - cytology positive for malignant cells per pathologist. There was nothing clinically or initially radiographically (serial CXR) to suggest infectious process - pt without fever, cough, leukocytosis, and pleural fluid cultures not convincing for infectious process. However ultimately because pleural fluid cytology was not completely consistent with prostate cancer, we did a chest CT to evaluate for a possible other malignancy, such as lung cancer for example, which did not reveal other malignant process but did suggest pt had right sided pneumonia, therefore he was treated with a course of 5 days of levoflox ___ - ___ given noteworthy radiographic appearance, however clinically not consistent with infection. His pleural effusion may also be CHF related though more likely malignant driver given positive cytology. Pt with history of CHF but no recent echo in our system, BNP 700s but no prior for comparison. Clinically otherwise he did not seem to be in heart failure, no ___ edema. Very possible that with time his cardiac function is worsening, however given low BPs in the 80-90 range systolic (back to ___ every time we initiated low dose metop or resumed home Lasix) we had to hold Lasix/metop regardless, could consider re-eval with ECHO but likely would not change management given overall prognosis and hypotension limiting reintroduction of cardiac meds. ___ for 1.1 L out via ___ on ___ with reaccumulation on CXR and more dyspnea though comfortable, IP repeated tap on ___, for 1.7L out with sx improvement. Has f/u with IP for consideration of pleurex on ___, ctyo from both taps pending at ___. Holding Lasix due to low blood pressures and generally low appetite/poor PO intake. # Gross Hematuria - Resolved. Source of hematuria likely from invasion of bladder by prostate ca. # Metastatic Prostate Cancer: Continue Tamoxifen. Plans for ongoing Enzalutamide treatment as outpatient, has f/u with Dr. ___ ___. Dr. ___ was able to secure enzalutamide for him from specialty pharmacy and it will be delivered to his house, should be started right away at rehab. # Hypotension - borderline, overall running low during this admission, pt with history of heart failure, no recent echo in our system, s/p MVR with annular ring, last echo ___ with EF 55%. Pt asymptomatic. Suspect that decr po intake also contributed to BP in ___ range at times, compounded by Lasix use. Improved somewhat after small amt albumin on ___ post ___. No e/o bleeding or systemic infection (UTI on cipro well treated it seemed, and clinical picture not consistent with true pneumonia). Held Lasix as BPs in low ___ and went to ___ when tried to reintroduce. Also held metoprolol for similar reason - tried dose reduction to 12.5mg BID but again SBP went to low ___. At rehab, he should weigh himself daily (DC weight 161 lbs) and if weight goes up more than 3 pounds consider 10mg po Lasix. # Klebsiella UTI - CTX started on admit ___, changed to cipro as pan sensitive. Completed 10d course ___. # Constipation - addressed ultimately w miralax, Colace, senna. # Type II Diabetes: Per patient, no longer taking Janumet. Humalog ISS while admitted but did not require much even after steroids initiated so stopped insulin sliding scale. # CAD/Hypertension: - Continued aspirin - holding metop as above due to hypotension # Depression - Continued citalopram # Weakness - likely due to progressive cancer, deconditioning w/ hospitalizations, no back pain or particularly pronounced bilateral lower ext issues to suggest cord compression. Will optimize nutrition, ___ recommending rehab, pt agrees to rehab. # Severe protein calorie malnutrition - poor appetite likely due to malignancy, deconditioning, comorbidities. Initiating steroids as above seemed somewhat helpful. Nutrition followed, pt declined offer for dobhoff with enteral feeds. EMERGENCY CONTACT HCP: ___ (friend) ___ TRANSITIONAL ISSUES: - continue dexamethasone until sees Dr. ___ on ___ but likely should stop at that point - Of great importance, he must continue supportive care for facial nerve palsy - artificial tears and ointment nightly, and at night needs to tape the eye shut. - When enzalutamide arrives to his house (friend will deliver to rehab) pt should start this right away. - please weigh patient daily and if weight goes up more than ___ pounds would give ___ Lasix po. discharge weight was 73.4 kg/161.9 lbs - Pt needs to go to interventional pulm apt ___ for pleural effusion follow up - pt needs radiation therapy ___, Dr. ___ ___ to the auditory canal lesion Greater than 30 minutes were spent on planning and execution of this discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 20 mg PO DAILY 2. Colchicine 0.6 mg PO DAILY:PRN gout 3. Furosemide 20 mg PO DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Tamoxifen Citrate 10 mg PO DAILY 6. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 7. Aspirin 81 mg PO DAILY 8. Vitamin D 5000 UNIT PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Vitamin B Complex 1 CAP PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Artificial Tear Ointment 1 Appl LEFT EYE QHS 3. Artificial Tears ___ DROP BOTH EYES Q6H dry eyes 4. Dexamethasone 4 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Levofloxacin 750 mg PO DAILY Duration: 2 Days 7. OxyCODONE (Immediate Release) 5 mg PO Q3H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth every 3 hours as needed Disp #5 Tablet Refills:*0 8. Polyethylene Glycol 17 g PO DAILY 9. Senna 8.6 mg PO BID 10. Aspirin 81 mg PO DAILY 11. Citalopram 20 mg PO DAILY 12. Colchicine 0.6 mg PO DAILY:PRN gout 13. Multivitamins 1 TAB PO DAILY 14. Tamoxifen Citrate 10 mg PO DAILY 15. Vitamin B Complex 1 CAP PO DAILY 16. Vitamin D 5000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Hematuria-likely from bladder invasion Bilateral pleural effusion Klebsiella Urinary infection. Calvareal(skull) Lesions-likely from malignancy Discharge Condition: Stable Alert oriented Needs help with transfer, able to ambulate with walker Discharge Instructions: Dear ___, IT was a pleasure taking care of you at ___. You were admitted as you had blood in your urine. This is most likely from the invasion of your urinary bladder by prostate cancer. We discussed with urology and although it may appear alarming, it does not cause your body's blood counts to drop significantly and will continue for a while. You also had your R sided lung drained. You still have some fluid left and at this time, we are waiting on the lab results as to the cause of this fluid accummulation. You may need to get his done again in the future. During this admission we found several brain lesions in the skull and your brain which required help from Neurology and Neuro-oncologists. Followup Instructions: ___
10815532-DS-14	10,815,532	23,088,000	DS	14	2184-05-04 00:00:00	2184-05-05 07:06:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: Left lower extremity weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ male with history of metastatic prostate cancer s/p left PCNU placement on ___ for left-sided hydronephrosis secondary to bulky lymphadenopathy who presents from clinic with chief complaint of lower extremity weakness for evaluation of cord compression. Patient recently admitted to OMED ___ to ___ with heamturia which was likely from invasion of bladder by prostate cancer and was resolved at time of discharge. He had brain imaging due to chronic seventh nerve palsy which showed concern for auditory canal lesion as well as multiple calvarial lesions consistent with metastatic disease. Radiation Oncology was consulted with plan for CK to the lesion. He also had large bilateral pleural effusions which were tapped several times with cytology positive for malignant cells. He was discharged to ___. Since discharge he was seen by IP on ___ where her underwent therapeutic right thoracentesis with removal of 1250cc. On ___, the patient presented to radiation simulation for planned SRT mapping for left IAC lesion but refused to have follow-up MRI brain. He was noted at that time to have profound lower extremity weakness that had progressively worsened in the last 2 weeks. An MRI Spine was ordered for ___ to accompany the MRI brain needed for RT planning. Unfortunately, on ___, the patient refused the scan. Dr. ___ requested that he be admitted directly for inpatient imaging following previously scheduled thoracentesis on ___. This morning, the thoracentesis was ultimately deferred (to allow re-accumulation for planned TPC placement). He had a CXR which showed increased moderate to large right pleural effusion and moderate left pleural effusion. He was referred directly to the ER. Patient reports bilateral lower extremity weakness (left worse than right) for the past five to seven days. Has been using a walker but for the past two days has felt too weak to get out of bed. Has been trying to participate in ___ at rehab but found difficult. Also notes pain across lower back. He denies lower extremity numbness and urine/stool incontinence. He also endorses poor PO intake due to poor appetite and dislike of the food at rehab. He reports 40 pound weight loss over the past ___ months. On arrival to the ED, initial vitals were 97.4 110 ___ 95% on 6L. Exam notable for normal strength/sensation in lower extremities and intact rectal tone. Labs were notable for WBC 6.8, H/H 9.7/35.1, Plt 373, Na 136, Cl 95, CO2 17, BUN/Cr 95/17, and lactate 3.5. No imaging obtained. Patient was given oxycodone 5mg PO and 1L NS. Vitals prior to transfer were 113 115/76 26 89% 2.5L. On arrival to the floor, the patient reports ___ lower abdominal pain which is chronic. He notes constipation but just had a bowel movement. He notes intermittent dizziness and mild shortness of breath. Patient denies fevers/chills, headache, vision changes, cough, chest pain, palpitations, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: - Abnormal rectal exam in ___. The PSA obtained at that time was 32. - ___ the patient underwent prostate biopsy, which showed ___ cores positive for adenocarcinoma, highest ___ score 4+5. The transrectal US showed a mass in the left pelvic area and the patient was referred for MRI. - ___ MRI showed tumor extending through the prostatic base into the seminal vesicles greater to the left where there was extension beyond the seminal vesicles into the pelvic sidewall. The left pelvic mass measured approximately 5.8x4.5x4cm. The prostate was described as rotated and deviated to the left. Invasion of the hypogastric neurovascular bundle was described with encasement of the sciatic nerve. The distal ureter resulted dilated with left hydronephrosis. Left pelvic lymphadenopathy up to 2.3 was also described, as well as 1.4 retroperitoneal lymphadenopathy to the left of the aortic bifurcation. - ___ patient was started on Casodex - ___ CT guided biopsy of the L pelvic sidewall mass. Pathology examination consistent with metastatic prostate cancer. - ___ start Lupron - ___ to ___ XRT - Lupron # 4 ___ - Lupron # 5 ___ - Discontinued Lupron ___ - PSA rose from <0.1 in ___ to 6.4 in ___, started Bicalutamide - ___: PSA started to rise again, 1.9 in ___ in ___ - ___: Bone scan without mets, CT Torso with some retroperitoneal lymphadenopathy (stable). PSA up to 2.8. - ___: Switch to nilutamide 150mg daily - ___: Rise in PSA, started on Lupron monthly - ___: L-sided PCNU for hydronephrosis ___ lymphadenopathy - ___ to ___ admitted to OMED with heamturia which was likely from invasion of bladder by prostate cancer and was resolved at time of discharge. MRI Brain showed numerous scattered calvarial lesions, known occipital lesion with soft tissue component that extended to dura and scalp, right orbital roof lesion, and a 8 mm lesion in the left IAC with some enhancement. There was associated asymmetric enhancement of the left tympanic and mastoid segments of the facial nerve. There was a question of whether this represented the cause of the patient's known left facial palsy. He was evaluated by radiation oncology, who recommended stereotactic hypofractionated radiotherapy to the IAC lesion with a palliative intent. He also had large bilateral pleural effusions which were tapped several times with cytology positive for malignant cells. He was discharged to ___. - ___, the patient presented to radiation simulation for planned SRT mapping for left IAC lesion (with the hope it would provide palliative improvement in facial palsy). He was noted at that time to have profound lower extremity weakness that had progressively worsened in the last 2 weeks. An MRI Spine was ordered for ___ to accompany the MRI Brain needed for RT planning. Unfortunately, on ___, the patient refused the scan despite calls from his radiation oncologist and medical oncologist. Dr. ___ requested that he be admitted directly for inpatient imaging following previously scheduled thoracentesis on ___. This morning, the thoracentesis was ultimately deferred (to allow re-accumulation for planned TPC placement). He was referred directly to the ER. PAST MEDICAL HISTORY: - Arthritis - Coronary Artery Disease s/p CABG x 2(LIMA to LAD, SVG to OM) in ___ - Diabetes Mellitus Type II c/b neuropathy - Gout - Hypertension - Hyperlipidemia - Metastatic Prostate Cancer s/p Lupron, Bicalutamide, and radiation - Mitral Regurgitation s/p MVR with ___ II annuloplasty ring in ___ - Mitral Valve Prolapse - Bell's Palsy - Thoracic Aneurysm Social History: ___ Family History: His mother had CHF. His father is deceased and had coronary artery disease. Physical Exam: ADMISSION PHYSICAL EXAM: VS: Temp 97.5, BP 98/64, HR 113, RR 16, O2 sat 96% on 2.5L. GENERAL: Pleasant man, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: Tachycardic, regular rhythm, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, decreased breath sounds at bases bilaterally. ABD: Normal bowel sounds, soft, mild LLQ tenderness to palpation, nondistended, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, trace bilateral lower extremity edema, no erythema or tenderness. BACK: Left nephrostomy tube draining brown urine. Diffuse lower back mild tenderness to palpation. NEURO: Alert, oriented, good attention and linear thought, left facial droop and left ear with fullness. ___ ___ strength (L>R). SKIN: No significant rashes. DISCHARGE PHYSICAL EXAM: VS: T 97.5 BP 102/68 HR 110 RR 20 O2 4LNC GENERAL: Chronically ill appearing; tired. No acute distress. HEENT: Anciteric. Dense left facial palsy. OP clear. CARDIOVASCULAR: RRR. No MRG. PULMONARY: Mildly increased WOB. Absent breathsounds over halfway up both lung bases. No crackles or wheeze. GASTROINTESTINAL: Nondistended, soft, NT. No HSM. No rebound or guarding. NEURO: Alert, oriented x3. Dense left sided facial palsy. Tracks in all four quadrants. PERLL. Symmetric palate. Normal sensation in all 4 extremities. Normal Bilateral upper extremity strength. RLE- ___ proximal strength. LLE ___ proximal strength. Preserved distal strength. MSK: No edema. Diminished bulk. SKIN: No significant rashes Pertinent Results: ADMISSION LABS: =============== ___ 04:50PM BLOOD WBC-6.8 RBC-4.09* Hgb-9.7* Hct-35.1* MCV-86 MCH-23.7* MCHC-27.6* RDW-17.7* RDWSD-55.3* Plt ___ ___ 01:11PM BLOOD Glucose-96 UreaN-17 Creat-0.8 Na-134 K-4.5 Cl-95* HCO3-17* AnGap-27* ___ 01:11PM BLOOD Calcium-9.6 Phos-4.4 Mg-1.9 ___ 07:59AM BLOOD PSA-333* ___ 01:22PM BLOOD Lactate-3.5* DISCHARGE LABS: =============== ___ 08:00AM BLOOD WBC-4.9 RBC-4.28* Hgb-10.0* Hct-33.4* MCV-78* MCH-23.4* MCHC-29.9* RDW-17.1* RDWSD-47.7* Plt ___ ___ 09:15AM BLOOD ___ PTT-43.7* ___ ___ 08:00AM BLOOD Glucose-152* UreaN-25* Creat-0.6 Na-137 K-4.2 Cl-100 HCO3-28 AnGap-13 ___ 08:00AM BLOOD PSA-353* ___ 07:59AM BLOOD Lactate-1.0 IMAGING: ======== ___ Imaging CHEST (PORTABLE AP) In comparison with the study of ___, there again are layering bilateral pleural effusions, more prominent on the right, with associated compressive basilar atelectasis. Known osseous metastatic disease is again seen. ___ Imaging CT ___ W/O CONTRAST 1. Diffuse extensive metastases involving essentially all imaged bones. 2. No evidence of compression fractures. 3. The epidural soft tissue encroaching on the spinal canal at T12 and L3 are best evaluated by prior MRI, however within the limitations of CT do not appear worse. 4. Degenerative disc disease with disc bulging at L4-5 encroaching on the right L5 nerve root. ___ Imaging CHEST (PORTABLE AP) 1. Layering moderate to large bilateral pleural effusions, right greater than left. More accurate quantification could be performed with upright lateral radiograph or CT chest. 2. Known osseous metastatic disease. ___ Imaging MR HEAD W & W/O CONTRAS 1. Progression of osseous metastatic disease with enlargement of a mass encroaching on the right frontal bone and medial right orbit. 2. Progression of an osseous lesion involving the sphenoid bone and lateral portion of the clivus with extension into the posterior nasopharynx on the right and into the right cavernous sinus. 3. Definite progression of multiple calvarial metastases since ___. These lesions appear new since the study of ___. 4. Unchanged enhancement in the left internal auditory canal suggesting leptomeningeal disease. ___ Imaging MR ___ & W/O CONT 1. Diffuse extensive metastases involving essentially all imaged bones. 2. Wedging of the T12 vertebral body with epidural soft tissue extending into the spinal canal and deforming at the distal spinal cord. 3. Expansion of the left pedicle at L3 with intraspinal epidural soft tissue arising from the pedicle and the posterior margin of the vertebral body. This encroaches on the left L3 nerve root. ___ Imaging CHEST (PA & LAT) Increased moderate to large right pleural effusion and moderate left pleural effusion and increased bibasilar atelectasis when compared to ___ study. Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION ___ year old man with metastatic prostate cancer with widespread bony involvement and malignant effusions who is admitted with increasing lower extremity weakness, found to have T12 disease approaching spinal cord. Now undergoing XRT. ACTIVE PROBLEMS: # Lower Extremity Weakness # Back pain: Weakness likely from extensive metastatic prostate cancer burden including expansion L3 pedical with encroaching of the nerve root. He deferred further orthopedic evaluation or intervention and declinced prophylactic TLSO brace. Planned to under 5 fractions XRT to T11-S1. First of five fractions received on ___. Patient had progressive weakness and given rising PSA, it was felt he was not responding to his therapy for prostate cancer. We deferred his last XRT session on ___ due to patient preference. He was started on dexamethasone 4mg po q6 hours. Tapering down every few days to 4mg poq12 hours on discharge. ___ continue taper dose by half every 5 days per patient comfort if needed. # Metastatic Prostate Cancer: Recently found to have recurrence with retroeritoneal disease causing urinary outflow obstruction requiring PCN. Also with malignant effusions and widespread bony metastatic burden. PSA on admission elevated to 333 from 72 on ___. Continued to rise inhouse. He was recently started enzalutamide early ___. However, cancer continued to progress, and it is felt he is unlikely to have good response to enzalutamide at this point. Therefore, he was made DNR/DNI and we decided to pursue hospice. We did continue the enzalutamide and tamoxifen, however, as he had the medication already and he seemingly tolerated it well. Follow up with Dr. ___ as needed. # Peripheral Left ___ Nerve Palsy # Auditory Canal Lesion # Numerous Calvarial Mets: Patient with several month history of seventh nerve palsy. MRI recently found new auditory canal lesion with enhancement c/f possible extension of osseous lesion vs. leptomeningeal disease. Plan had been for SBRT but deferred given recent developments. We used artificial tears as needed and ensured to maintain left eye shut while sleeping # Bilateral Malignant Pleural Effusions/Respiratory Distress: Patient with bilateral pleural effusions. Right effusion tapped x 3 with malignant cells prior to admission. He remained mildly symptomatic with stable O2 requirement. Plan had been to defer tunneled pleural catheter placement as outpatient. Given increasing symptoms and goals of ___, we asked IP to evaluate for TPC placement in house. Unfortunately, his INR was too eleveted to safely undergo procedure. He does have a follow up appointment in ___ clinic IF he wishes to attempt repeat procedure after repletion with vitamin K. # Coagulaopathy: Developed marked coagulopathy during admission. Possibly from nutritional deficit vs possible liver metastatic involvement (no documented liver disease, however). We started him on vitamin K 5mg po daily x3 days prior to discharge. # Anion-Gap Metabolic Acidosis: Elevated lactate to 3.5 on admission. Resolved. # Hypotension: Hypotensive of admission. Lasix and metoprolol were held and it resolved. Likely from poor PO intake. # Enterococcus UTI: Patient with positive urine culture from rehab prior to admission. Finished 10 day course of augmentin ___. Repeat urine culture negative, persistent pyuria likely related to PCN. # Constipation: Continued bowel reigmen # CAD/Hypertension - Continued aspirin - Holding anti-hypertensives # Depression: Continued citalopram # Severe Protein Calorie Malnutrition: Poor appetite likely due to malignancy, deconditioning, comorbidities. # Mitral Regurgitation s/p MVR with ___ II annuloplasty ring in ___ FEN: Regular, Encourage PO, Replete Electrolytes PRN scales PPX: Heparin SC BID ACCESS: PIV CODE: Full Code COMMUNICATION: Patient EMERGENCY CONTACT HCP: ___ (friend) ___ DISPO: Inpatient Hospice TRANSITIONAL ISSUES: - Continue vitamin K 5mg po x2 more doses - ___ with IP IF feasible and appropriate for patient to pursue tunneled pleural catheter - ___ complete his current enzalutamide and/or tamoxifen if feasible. However, unlikely to have positive result at this point Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Artificial Tear Ointment 1 Appl LEFT EYE QHS 3. Artificial Tears ___ DROP BOTH EYES Q6H:PRN dry eyes 4. Docusate Sodium 100 mg PO BID 5. OxyCODONE (Immediate Release) 5 mg PO Q3H:PRN Pain - Moderate 6. Polyethylene Glycol 17 g PO DAILY 7. Aspirin 81 mg PO DAILY 8. Citalopram 20 mg PO DAILY 9. Colchicine 0.6 mg PO DAILY:PRN gout 10. Multivitamins 1 TAB PO DAILY 11. Vitamin B Complex 1 CAP PO DAILY 12. Vitamin D 5000 UNIT PO DAILY 13. Tamoxifen Citrate 10 mg PO DAILY 14. Bisacodyl ___AILY:PRN constipation 15. Milk of Magnesia 30 mL PO DAILY:PRN constipation 16. Calcium Carbonate 1250 mg PO QPM 17. Xtandi (enzalutamide) 160 mg oral DAILY 18. Amoxicillin-Clavulanic Acid ___ mg PO BID 19. OxyCODONE SR (OxyconTIN) 20 mg PO QAM 20. OxyCODONE SR (OxyconTIN) 10 mg PO QPM 21. Saccharomyces boulardii 250 mg oral BID 22. Senna 17.2 mg PO BID 23. Acetaminophen 650 mg PO QHS 24. Enoxaparin Sodium 40 mg SC DAILY Discharge Medications: 1. Dexamethasone 4 mg PO Q8H RX dexamethasone 2 mg 2 tablet(s) by mouth q8 hours Disp #180 Tablet Refills:0 2. Pantoprazole 40 mg PO Q24H 3. Phytonadione 5 mg PO DAILY Duration: 2 Doses RX phytonadione (vitamin K1) [Mephyton] 5 mg 1 tablet(s) by mouth daily Disp #2 Tablet Refills:0 4. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Moderate 5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 6. Acetaminophen 650 mg PO QHS 7. Artificial Tear Ointment 1 Appl LEFT EYE QHS 8. Artificial Tears ___ DROP BOTH EYES Q6H:PRN dry eyes 9. Aspirin 81 mg PO DAILY 10. Bisacodyl ___AILY:PRN constipation 11. Calcium Carbonate 1250 mg PO QPM 12. Citalopram 20 mg PO DAILY RX citalopram 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 13. Colchicine 0.6 mg PO DAILY:PRN gout 14. Docusate Sodium 100 mg PO BID 15. Milk of Magnesia 30 mL PO DAILY:PRN constipation 16. Multivitamins 1 TAB PO DAILY 17. OxyCODONE SR (OxyconTIN) 20 mg PO QAM RX oxycodone 10 mg 1 tablet(s) by mouth qam Disp #30 Tablet Refills:0 RX oxycodone 20 mg 1 tablet(s) by mouth qpm Disp #30 Tablet Refills:*0 18. OxyCODONE SR (OxyconTIN) 10 mg PO QPM 19. Polyethylene Glycol 17 g PO DAILY 20. Saccharomyces ___ 250 mg oral BID 21. Senna 17.2 mg PO BID 22. Tamoxifen Citrate 10 mg PO DAILY 23. Vitamin B Complex 1 CAP PO DAILY 24. Vitamin D 5000 UNIT PO DAILY 25. Xtandi (enzalutamide) 160 mg oral DAILY Discharge Disposition: Extended ___ Facility: ___ Discharge Diagnosis: - Metastatic prostate cancer - Lumbar metastatic disease with associated leg weakness - Calvarial/Intra-auditory canal metastatic disease with left facial never paralysis - Likely malignant bilateral pleural effusions. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, It has been a pleasure taking ___ of you at ___ ___. You were admitted for increasing weakness in your legs. You were found to have progression of your prostate cancer in your lower spine, likely causing your weakness. You also have some fluid building around your lung, as well. We were hoping to drain the fluid off your lung, unfortunately your blood is too think for this procedure to be done safely. Given the progression of your cancer, we talked with you and Dr. ___ we all decided that transitioning to an inpatient hospice ___ would help meet your needs best in the coming days. We wish you all the best, Your ___ Team Followup Instructions: ___
10816667-DS-21	10,816,667	25,407,448	DS	21	2148-11-08 00:00:00	2148-11-08 20:25:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: -shortness of breath - leg swelling Major Surgical or Invasive Procedure: none History of Present Illness: ___ with history of HTN, T2DM c/b Stage V CKD with nephrotic range proteinuria (planning to start dialysis soon), dyslipidemia, legal blindness with hx of acute angle closure glaucoma and diabetic retinopathy, and anemia, who presents with 2 days of worsening dyspnea superimposed on several months of worsening ___ swelling and ascending anasarca. She was admitted to ___ back on ___ with worsening b/l lower extremity swelling presumably due to worsening CKD ___ T2DM. She was diuresed in the hopsital and discharged home on Torsemide 20 mg daily. Since then she has still developed worsening lower extremity edema b/l and diffuse anasarca throughout the abdomen. She notes that she is currently ___ pounds above her normal weight. She has also had progressive dyspnea on exertion, having to pause to catch her breath after climbing ___ stairs. A contributing factor is also the heaviness and weakness she experiences in her lower extremities due to the swelling. In the past two days, she has developed dyspnea at night while lying down in bed which has prevented her from sleeping at night. She has two-pillow orthopnea, and has occasional dyspnea at rest as well. She has an occasional dry cough, but no sputum production or recent fevers, no sick contacts. Given her inability to sleep at night ___ SOB she came to the ED. - In the ED, initial vitals were: T 98.8 HR 92 BP 206/110 RR 18 O2 100% RA - Exam was notable for: "Coarse breath sounds bilaterally, no crackles or wheezing. Bilateral pitting edema with some non-purulent blistering and chronic skin changes" - Labs were notable for: WBC 7.2 Hgb 7.4 Plt 387 Cr 5.3 BUN 58 Ca 7.3 pro-BNP 10,000 - Studies were notable for: CXR 1. Small right pleural effusion. 2. No evidence of pulmonary edema or focal consolidation. - The patient was given: Lasix 100 mg On arrival to the floor, she feels comfortable lying in bed, with minimal shortness of breath. SBP in the 190s, but denies any headaches. She denies any current nausea, vomiting, decreased appetite, or diffuse pruritis. However, she has had uremic symptoms in the past. She has been feeling more fatigued recently but also attributes this to the shortness of breath and feeling of heaviness from her diffuse swelling. She describes a pressure and tightness around her chest that is also new. Denies palpitations or lightheadedness. Her EF is 59% (last TTE ___. She has no hx of cirrhosis or impaired liver function. In terms of her CKD history, she first developed albuminuria in ___, with progression to nephrotic range in ___. Creatinine has been rising since ___, most notably from 2.3 in ___ to ~4s in ___. She met with nephrology on ___, with whom she discussed dialysis and kidney transplant options. Past Medical History: DMII, complicated by retinopathy, neuropathy, nephropathy CKDV Hypertension Dyslipidemia Acute angle glaucoma multiple eye surgeries Social History: ___ Family History: Mother Living ___ DIABETES TYPE II Father ___ ___ HYPERTENSION, PERIPHERAL ARTERY DISEASE MGM Deceased DIABETES TYPE II Physical Exam: ========================= ADMISSION PHYSICAL EXAM: ========================= VITALS: Temp: 98.8 (Tm 98.8), BP: 196/89, HR: 84, RR: 17, O2 sat: 98%, O2 delivery: RA GENERAL: Alert and interactive. In no acute distress. HEENT: R pupil 3mm, L pupil 2mm. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Soft inspiratory crackles in the L lower lung base. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds. Distended abdomen. Non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis. 2+ pitting edema b/l. Non-bleeding ulcerations b/l in the lower legs. SKIN: Warm. Cap refill <2s. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. ___ strength throughout. Normal sensation. ======================== DISCHARGE PHSYICAL EXAM ======================== GENERAL: Alert and interactive. In no acute distress. Wearing sunglasses at baseline (legally blind). HEENT: R pupil 3mm, L pupil 2mm. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: CTAB. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds. Mildly distended abdomen. Non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis. 1+ pitting edema b/l. Non-bleeding ulcerations b/l in the lower legs. SKIN: Warm and well-perfused. NEUROLOGIC: AOx3. Face symmetric except changes noted above. Moving all 4 limbs spontaneously. Normal sensation. Pertinent Results: ADMISSION LABS: ================ ___ 04:34AM BLOOD WBC-7.2 RBC-2.65* Hgb-7.4* Hct-23.4* MCV-88 MCH-27.9 MCHC-31.6* RDW-13.2 RDWSD-43.1 Plt ___ ___ 04:34AM BLOOD ___ PTT-30.8 ___ ___ 08:15AM BLOOD ___ ___ 08:15AM BLOOD Ret Aut-1.4 Abs Ret-0.04 ___ 04:34AM BLOOD Glucose-273* UreaN-58* Creat-5.3* Na-139 K-3.9 Cl-104 HCO3-24 AnGap-11 ___ 08:15AM BLOOD ALT-17 AST-20 LD(LDH)-350* CK(CPK)-851* AlkPhos-131* TotBili-<0.2 ___ 08:15AM BLOOD CK-MB-5 cTropnT-0.08* ___ 04:34AM BLOOD ___ ___ 04:34AM BLOOD Calcium-7.3* Phos-4.5 Mg-1.9 ___ 08:15AM BLOOD Hapto-282* PERTINENT INTERVAL LABS: ======================== ___ 06:24AM BLOOD calTIBC-198* Ferritn-66 TRF-152* ___ 06:43AM BLOOD WBC-6.9 RBC-2.34* Hgb-6.6* Hct-20.5* MCV-88 MCH-28.2 MCHC-32.2 RDW-13.4 RDWSD-42.7 Plt ___ ___ 08:40PM BLOOD Hgb-8.8* ___ 06:43AM BLOOD cTropnT-0.09* IMAGING: ========= ___ CXR PA/LAT: IMPRESSION: 1. Small right pleural effusion. 2. No evidence of pulmonary edema or focal consolidation. MICRO: ======= none DISCHARGE LABS: ================ ___ 06:23AM BLOOD WBC-7.6 RBC-2.95* Hgb-8.3* Hct-25.5* MCV-86 MCH-28.1 MCHC-32.5 RDW-13.4 RDWSD-41.5 Plt ___ ___ 06:53AM BLOOD Glucose-83 UreaN-82* Creat-7.2* Na-140 K-4.2 Cl-99 HCO3-26 AnGap-15 ___ 06:53AM BLOOD Calcium-7.8* Phos-6.2* Mg-2.1 Brief Hospital Course: ================== PATIENT SUMMARY ================== ___ with history of HTN, T2DM c/b Stage V CKD with nephrotic range proteinuria (planning to start dialysis soon), dyslipidemia, legal blindness with hx of acute angle closure glaucoma and diabetic retinopathy, and anemia, who presented with 2 days of worsening dyspnea superimposed on several months of worsening ___ swelling and ascending anasarca. She was diuresed with IV Lasix to good effect, with neg -12 L fluid balance and 15 lb weight loss, accompanied by resolution of her shortness of breath and improvement ___ swelling. She was discharged on her home dose of PO torsemide 30 mg. ==================== ACUTE/ACTIVE ISSUES ==================== # Dyspnea, resolved # Volume overload # Lower extremity edema # CKDV Most likely secondary to CKDV. Sx of chronic volume overload with progression to lungs now, despite being on torsemide 30 mg PO daily at baseline. Myocardial ischemia was ruled out, given normal ECG, nl CK-MB, and Trop 0.08 (not concerning I/s/o CKD). On presentation, she had no symptoms of uremia, and labs did not show acidemia or hyperkalemia. She had discussed the options of dialysis and transplant with ___ nephrology recently. However, given that volume overload was her primary symptom, the decision was made to diurese her and defer dialysis until AV fistula placement could be arranged. She was diuresed with 100 mg IV Lasix BID and 5 mg metalozone daily with resolution of SOB and improvement of anasarca. On her date of discharge on ___, her fluid balance was net -12 L and her weight was 198.19 lbs, down 15 lbs from admission. Given her brisk diuresis, she was discharged on her home dose of PO torsemide 30 mg with instructions for close follow up if her swelling worsens. # Hypertensive urgency # Long-term hypertension management On presentation, initial BPs in the ED were concerning for hypertensive urgency with SBP to 200s, likely worsened from volume overload. She denied any headaches. She was started on PO labetalol, which was gradually uptitrated to 400 mg TID. Before her discharge, she was transitioned to carvedilol 12.5 mg BID to reduce medication frequency (legally blind and receives meds in blisterpacks). # Renal osteodystrophy She has secondary hyperparathyroidism related to her kidney disease. Phosphate was elevated throughout admission, max 6.3. She was placed on Sevelamer 1600 mg TID with meals and her diet was phosphorus-restricted. Her home calcitriol and Vitamin D supplements were held, and nephrology recommended that she not restart them until P < 5.5 # Anemia Initially thought to be secondary to renal disease I/s/o dec EPO. She had started iron as an outpatient. However, given her subsequent Hb drop (8.3 on ___ to 6.6 on ___, other etiologies were considered: occult bleed (GI) vs hemolytic process. Her Iron studies were consistent with iron-deficiency anemia, guaiac was negative, and hemolysis labs unremarkable. Unclear etiology, but Hb improved after transfusion and remained stable >7.9 throughout the rest of admission. # DMII Most recent A1c 8.8%. Home regimen is insulin glargine 30 U daily with a sliding scale. She notes her glucose levels have been higher lately, in the 200s. Was initially hypoglycemic at night on her home regimen, which was subsequently adjusted to 10 u glargine nightly, with 3 u Humalog + sliding scale each meal. Her glucose levels were well controlled and she was discharged on this regimen. # Transplant surgery consultation Transplant surgery was consulted, and the decision was made to preserve R arm for future fistula placement for dialysis. She will follow up with them outpatient. ======================= CHRONIC/STABLE ISSUES ======================= # Nutrition Pt noted confusion over balancing diet requirements and restrictions for both diabetes and chronic kidney disease. Nutrition consulted and provided education to patient. She will be set up with a dietician from the ___ Diabetes team for outpatient followup # Wound care Pt with likely venous stasis ulcers, but has been treating them with alcohol wipes daily. Wound care consulted, and recommended washing LEs with disposable wash clothes and foam cleanser, with application of Soothe and ___ moisturizers to bilat LLE & feet BID # Glaucoma Her home medications were continued, as below: - brimonidine 0.2% eye drops 1 drop each eye TID - dorzolamide-timolol ==================== TRANSITIONAL ISSUES ==================== MEDICATION CHANGES: [] Carvedilol 12.5 mg BID was added to her antihypertensive regimen, as her SBP was initially in the 160-180s [] Calcitriol and Vitamin D were stopped given her high phosphorus. We recommend holding these until phosphorus is < 5.5 [] Her insulin regimen is now 10 units Lantus nightly, with 3 units Humalog + Humalog sliding scale with each meal [] She was started on Sevelamer 1600 mg TID with meals to help control her phosphate levels. MONITORING: [] Repeat electrolytes and CBC (last Hb 8.3) within 5 days of discharge [] Please follow up on blood pressures within 1 week of discharge. Nephrology recommends to continue amlodipine 10 mg daily and titrate her new carvedilol for goal average BP 140/90 [] Please follow up her blood glucose levels within 1 week of discharge [] Please ensure that the patient is weighing herself daily. Nephrology wants her to contact them if she experiences weight gain or loss exceeding 3 lbs in one day, or 5 lbs over one week. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO QPM 2. Torsemide 30 mg PO DAILY 3. Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 4. Atorvastatin 40 mg PO QPM 5. brimonidine 0.2 % ophthalmic (eye) TID 6. Calcitriol 0.25 mcg PO 3X/WEEK (___) 7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID 8. Aspirin 81 mg PO QPM 9. Vitamin D 1000 UNIT PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. CARVedilol 12.5 mg PO BID Hypertension RX carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:2 2. sevelamer CARBONATE 1600 mg PO TID W/MEALS RX sevelamer carbonate 800 mg 2 tablet(s) by mouth three times a day with meals Disp #180 Tablet Refills:2 3. Torsemide 30 mg PO/NG DAILY Start: Upon Arrival RX torsemide 20 mg 1.5 (One and a half) tablet(s) by mouth once a day Disp #45 Tablet Refills:2 4. Ferrous Sulfate 325 mg PO EVERY OTHER DAY RX ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth every other day Disp #15 Tablet Refills:2 5. Glargine 10 Units Bedtime Humalog 3 Units Breakfast Humalog 3 Units Lunch Humalog 3 Units Dinner RX insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL (3 mL) AS DIR 10 Units before BED; Disp #1 Syringe Refills:2 RX insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR 3 Units before BKFT; 3 Units before LNCH; 3 Units before DINR; Disp #1 Syringe Refills:2 6. amLODIPine 10 mg PO QPM RX amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:2 7. Aspirin 81 mg PO QPM RX aspirin 81 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:2 8. Atorvastatin 40 mg PO QPM RX atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:2 9. brimonidine 0.2 % ophthalmic (eye) TID 10. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID 11. Multivitamins 1 TAB PO DAILY RX multivitamin 1 capsule(s) by mouth once a day Disp #30 Tablet Refills:2 12. HELD- Calcitriol 0.25 mcg PO 3X/WEEK (___) This medication was held. Do not restart Calcitriol until your renal doctor tells you it is safe to restart. 13. HELD- Vitamin D 1000 UNIT PO DAILY This medication was held. Do not restart Vitamin D until your renal doctor tells you it is safe to restart. Discharge Disposition: Home Discharge Diagnosis: - volume overload secondary to chronic kidney disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted for shortness of breath and increased swelling in your legs and belly. What was done for me while I was in the hospital? - We gave you diuretics (water pills) to help you release the extra fluid in your body which was causing your shortness of breath and swelling. We also noticed your blood pressures were high and gave you a new medication to help keep your blood pressure under control. By the end of your hospital stay, you were no longer short of breath and the swelling had improved. What should I do when I leave the hospital? The Nephrology team recommends the following: - Please weigh yourself every day - Contact the ___ clinic if you notice a weight gain of over 3 pounds over a 24 hour period, or a weight loss of over 3 pounds in a 24 hour period. Please also contact them if, over the course of a whole week, you lose or gain more than 5 pounds - Drink water and other liquids when you are thirsty, but try not to drink too much more than 1 liter per day (about two regular sized water bottles). We also have the following recommendations: -Please go to your follow up appointments as scheduled in the discharge papers. Most of them already have a specific date & time set. If there is no specific time specified, and you do not hear from their office in ___ business days, please contact the office to schedule an appointment. - Please monitor for new/or worsening symptoms (worsening swelling, shortness of breath, uncontrollable itching, nausea/vomiting, or confusion). If you do not feel like you are getting better or have any other concerns, please call your doctor to discuss or return to the emergency room. -Please note any new medications in your discharge worksheet -Your appointments are as below Sincerely, Your ___ Care Team Followup Instructions: ___
10816667-DS-23	10,816,667	24,119,839	DS	23	2149-02-12 00:00:00	2149-02-13 16:46:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: lower extremity wounds Major Surgical or Invasive Procedure: None History of Present Illness: ___ female with hypertension, hyperlipidemia, type 2 diabetes complicated by diabetic retinopathy and stage V CKD who presents with 10 days of foul smelling lesions on her bilateral lower extremities. She recently had an AV fistula placed but has not started dialysis. She was recently seen in ___ clinic and was diagnosed with elephantiasis nostra verrucosa from chronic venous stasis and was recommended to wear compression stockings and elevation. The lesions became more diffuse and foul-smelling starting on the ___, and have progressed since then. No redness, pain, or fevers. She has been dressing them by herself with paper towels at home. She denies chest pain, shortness of breath, orthopnea, PND, and notes that her weight has actually decreased. In the ED, initial vital signs notable for blood pressure 158/77 and she was satting 98% on room air. Physical exam notable for wartlike lesions on the bilateral lower calves that are tan-colored. Legs were not noted to be swollen or tense and she had strong ___ pulses. Labs were notable for BUN of 99 and creatinine 7.0. Hemoglobin was 7.2 with normal platelets and white count. proBNP was 26,578. She received torsemide 100 mg, carvedilol 25 mg, insulin 4 units, potassium chloride ___ M EQ and insulin 6 units. Chest x-ray showed mild pulmonary vascular congestion without frank edema. Dermatology consult was requested, as well as renal consult who stated she was stable from a renal standpoint. Vitals on transfer notable for blood pressure of 165/74. On the floor, she states she is feeling well and has been able to perform most tasks at home. She is most bothered by the smell and increase in blisters that suddenly appeared on her lower legs. Past Medical History: Diabetes mellitus type 2 complicated by retinopathy, neuropathy, nephropathy Chronic kidney disease stage V Hypertension Dyslipidemia Acute angle glaucoma Multiple eye surgeries Social History: ___ Family History: Mother Living ___ DIABETES TYPE II Father ___ ___ HYPERTENSION, PERIPHERAL ARTERY DISEASE MGM Deceased DIABETES TYPE II Physical Exam: ADMISSION PHYSICAL ================== VITALS: T 98.4 BP 165/74 HR 78 RR 18 O2 sat 97 RA GENERAL: Alert and interactive. In no acute distress. EYES: NCAT. Wearing sunglasses. Sclera anicteric and without injection. ENT: MMM. Thyroid is normal in size and texture, no nodules. No cervical lymphadenopathy. JVP 7cm. 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, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. MSK: Lower extremities with signs of chronic venous ulceration with diffuse tissue edema and swelling. SKIN: Warm. Skin findings as above. PSYCH: appropriate mood and affect DISCHARGE PHYSICAL ================== VS: ___ 1519 Temp: 99.3 PO BP: 142/62 L Sitting HR: 69 RR: 20 O2 sat: 97% O2 delivery: RA GENERAL: Alert and interactive. In no acute distress. EYES: NCAT. Wearing sunglasses. Sclera anicteric and without injection. ENT: MMM. No cervical lymphadenopathy. 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: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. MSK: Lower extremities wrapped. No swelling noted above the wraps on upper calves. SKIN: Warm and well perfused. PSYCH: appropriate mood and affect Pertinent Results: INITIAL LABS ============ ___ 12:30AM BLOOD WBC-7.0 RBC-2.46* Hgb-7.0* Hct-22.3* MCV-91 MCH-28.5 MCHC-31.4* RDW-14.3 RDWSD-46.7* Plt ___ ___ 12:30AM BLOOD Neuts-72.7* Lymphs-12.5* Monos-11.0 Eos-2.8 Baso-0.6 Im ___ AbsNeut-5.10 AbsLymp-0.88* AbsMono-0.77 AbsEos-0.20 AbsBaso-0.04 ___ 06:50AM BLOOD ___ PTT-27.3 ___ ___ 12:30AM BLOOD Glucose-218* UreaN-102* Creat-7.3* Na-137 K-3.7 Cl-99 HCO3-24 AnGap-14 ___ 12:30AM BLOOD Calcium-8.0* Phos-5.6* Mg-2.3 MICROBIOLOGY ============ None IMAGING ======= CXR (___): Mild pulmonary vascular congestion without frank edema. OTHER LABS ============== ___ 12:30AM BLOOD ___ ___ 07:29AM BLOOD calTIBC-205* Ferritn-803* TRF-158* DISCHARGE LABS ============== ___ 09:15AM BLOOD WBC-6.9 RBC-2.54* Hgb-7.2* Hct-22.7* MCV-89 MCH-28.3 MCHC-31.7* RDW-13.9 RDWSD-45.6 Plt ___ ___ 09:15AM BLOOD Glucose-124* UreaN-98* Creat-7.2* Na-142 K-3.7 Cl-100 HCO3-26 AnGap-16 ___ 09:15AM BLOOD Calcium-7.8* Phos-5.5* Mg-2.2 Brief Hospital Course: TRANSITIONAL ISSUES =================== [ ] Discharge Hgb 7.2 - recheck stability at follow up [ ] Discharge Cr 7.2 and BUN 98 (on HD) [ ] Weight on discharge 79.4kg which is EDW [ ] BP noted to be elevated during this hospitalization in 140s-160s; please recheck as outpatient and uptitrate anti-hypertensives if necessary. [ ] Patient determined to have elephantiasis nostra verrucose secondary to chronic venous stasis. Evaluated by Dermatology who recommended conservative management with excellent wound care regimen with help of ___ consisting of the following: - Leg elevation - Apply vaseline, Xeroform, then wrap the legs in gauze, then wrap with Ace bandage for compression - Please ensure that patient has adequate perfusion to her distal extremities and toes with compression wrapping - Change dressings daily - Continue cleaning skin with gentle wound cleanser or burrow's solution daily if oozing (acts as a drying agent) Patient has dermatology follow-up. [ ] Patient with discharge weight on 79.4kg. She is concerned about losing too much weight as this weight is much lower than her scale at home. Please continue to monitor weight. [ ] Patient with significant anemia of chronic disease likely in setting of CKD. She recently received IV iron and has been continued on oral iron. ___ benefit from EPO. [ ] Patient with severe peripheral neuropathy. Has podiatry follow-up. BRIEF HOSPITAL COURSE ===================== Mrs. ___ is a ___ year old woman with chronic kidney disease ___ HTN/diabetes awaiting dialysis initiation and chronic venous stasis who presented with worsening lower extremity swelling and malodorous weeping determined to have chronic elephantiasis nostra verrucose managed with IV diuresis and excellent wound care. There was no sign of infection. There was no immediate indication for HD during admission. ACTIVE ISSUES ============= # Elephantiasis nostra verrucosa Mrs. ___ presented with ten days of foul-smelling and weeping lower extremity wounds. She was evaluated by dermatology and nephrology, who recommended conservative wound care management consisting of leg elevation, daily application of Vaseline then xeroform then wrap in gauze followed by ACE bandage for compression. She was given intravenous diuretics with clinical improvement and discharged with home ___ in place. Weight on discharge 79.4kg. Will follow up with dermatology as an outpatient. CHRONIC ISSUES ============== # CKD-Stage V Patient at baseline Cr of 6.9-7.5 during admission. No indication for more urgent initiation of HD at this point. She was continued on her home medications and scheduled for outpatient follow-up with nephrology for initiation of intermittent hemodialysis through her maturing RUE fistula. She has vein mapping scheduling in 1 month. #Type II Diabetes Complicated by diabetic retinopathy and nephropathy. She was discharged on her home glycemic regimen. #CODE: Full (presumed) #CONTACT: ___ (mother) ___ >30 min spent on discharge planning including face to face time Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 2. CARVedilol 25 mg PO BID 3. dorzolamide-timolol 22.3-6.8 mg/mL right eye BID 4. amLODIPine 10 mg PO DAILY 5. Artificial Tears ___ DROP BOTH EYES Q6H:PRN dry eyes 6. Atorvastatin 40 mg PO QPM 7. Ferrous Sulfate 325 mg PO EVERY OTHER DAY 8. Torsemide 100 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe 11. sevelamer HYDROCHLORIDE 1600 mg oral TID W/MEALS 12. Glargine 10 Units Bedtime Humalog 3 Units Breakfast Humalog 3 Units Lunch Humalog 3 Units Dinner Insulin SC Sliding Scale using HUM Insulin 13. Aspirin 81 mg PO DAILY 14. MetOLazone 5 mg PO 3X/WEEK (___) 15. Calcitriol 0.25 mcg PO 3X/WEEK (___) 16. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Glargine 10 Units Bedtime Humalog 3 Units Breakfast Humalog 3 Units Lunch Humalog 3 Units Dinner Insulin SC Sliding Scale using HUM Insulin 2. amLODIPine 10 mg PO DAILY 3. Artificial Tears ___ DROP BOTH EYES Q6H:PRN dry eyes 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 7. Calcitriol 0.25 mcg PO 3X/WEEK (___) 8. CARVedilol 25 mg PO BID 9. dorzolamide-timolol 22.3-6.8 mg/mL right eye BID 10. Ferrous Sulfate 325 mg PO EVERY OTHER DAY 11. MetOLazone 5 mg PO 3X/WEEK (___) 12. Multivitamins 1 TAB PO DAILY 13. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe 14. sevelamer HYDROCHLORIDE 1600 mg oral TID W/MEALS 15. Torsemide 100 mg PO DAILY 16. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ====================== Elephantiasis nostra verrucose Chronic Venous Stasis SECONDARY DIAGNOSIS ====================== Chronic Kidney Disease Diabetes Chronic anemia, multifactorial Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory Discharge Instructions: Dear Ms. ___, WHY WERE YOU ADMITTED TO THE HOSPITAL? - Your leg wounds were leaking foul smelling fluid WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? - You were seen by the Dermatology team who recommended specific care for your wounds. There was no sign of infection - You will go home with visiting nursing care for your wounds. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Please weigh yourself every morning when you wake up if possible. If you weight increases by more than 3 pounds in one day, then please call your doctor. - You will have a visiting nurse come to your home to help with dressing changes. - Take all of your medications as prescribed (listed below) - Follow up with your doctors as listed below Please see below for more information on your hospitalization. It was a pleasure taking part in your care here at ___. We wish you all the best, - Your ___ Care Team Followup Instructions: ___
10816667-DS-25	10,816,667	24,128,174	DS	25	2149-04-20 00:00:00	2149-04-21 08:21:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Major Surgical or Invasive Procedure: - ___: Tunneled HD line removal - ___: Temporary HD line placement - ___: Tunneled HD line placement attach Pertinent Results: ADMISSION LABS: ___ 10:22AM BLOOD WBC-14.3* RBC-2.74* Hgb-7.8* Hct-25.8* MCV-94 MCH-28.5 MCHC-30.2* RDW-15.9* RDWSD-54.2* Plt ___ ___ 10:22AM BLOOD Neuts-90.5* Lymphs-1.5* Monos-3.8* Eos-0.0* Baso-0.1 Im ___ AbsNeut-12.96* AbsLymp-0.21* AbsMono-0.54 AbsEos-0.00* AbsBaso-0.02 ___ 10:22AM BLOOD ___ PTT-25.7 ___ ___ 10:22AM BLOOD Glucose-362* UreaN-67* Creat-5.5* Na-134* K-4.5 Cl-97 HCO3-21* AnGap-16 ___ 10:22AM BLOOD ALT-17 AST-22 AlkPhos-67 TotBili-0.6 ___ 10:22AM BLOOD Albumin-2.7* Calcium-7.4* Phos-3.8 Mg-1.6 ___ 10:22AM BLOOD Beta-OH-<0.2 ___ 07:10AM BLOOD Free T4-1.3 ___ 07:10AM BLOOD TSH-4.6* DISCHARGE LABS: ___ 12:50 12.0* 2.80* 8.0* 26.2* 94 28.6 30.5* 15.4 51.8* 527* ___ 12:50 1691 23 3.1* 134* 4.1 92* 29 13 ___ 12:50 8.5 2.4* 1.8 MICRO: __________________________________________________________ ___ 10:52 am BLOOD CULTURE Source: Line-dialysis. Blood Culture, Routine (Pending): No growth to date. __________________________________________________________ ___ 9:57 am BLOOD CULTURE 2 OF 2. Blood Culture, Routine (Pending): No growth to date. __________________________________________________________ ___ 7:06 am BLOOD CULTURE 1 OF 2. Blood Culture, Routine (Pending): No growth to date. __________________________________________________________ ___ 10:00 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 6:02 am BLOOD CULTURE 1 OF 2. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 10:15 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 7:21 am BLOOD CULTURE 1 OF 2. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 11:34 pm BLOOD CULTURE Source: Venipuncture. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 11:34 pm BLOOD CULTURE Source: Venipuncture. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 10:03 am BLOOD CULTURE 2 OF 2. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 6:42 am BLOOD CULTURE 1 OF 2. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 9:22 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 7:20 am BLOOD CULTURE 1 OF 2. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 7:30 am BLOOD CULTURE 2 OF 2. FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. Susceptibility testing performed on culture # ___ ___. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by ___, MD (___) ___ @ 9:02 AM. __________________________________________________________ ___ 7:05 am BLOOD CULTURE 1 OF 2. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 7:01 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 8:46 am BLOOD CULTURE 2OF2. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 7:15 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. FINAL SENSITIVITIES. 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-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ @ 0410 ON ___ - ___. GRAM POSITIVE COCCI IN CLUSTERS. ___ 7:15 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. FINAL SENSITIVITIES. 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-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ @ 0410 ON ___ - ___. GRAM POSITIVE COCCI IN CLUSTERS. ___ 5:30 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. Susceptibility testing performed on culture # ___ (___). Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. ___ 9:28 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. FINAL SENSITIVITIES. 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-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by ___ @13:12 (___). ___ 7:08 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. Susceptibility testing performed on culture # ___ (___). Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. ___ 10:09 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. Susceptibility testing performed on culture # ___ ___. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. ___ 7:10 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. Susceptibility testing performed on culture # ___ ___. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. ___ 12:16 pm BLOOD CULTURE 2 OF 2. FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. Susceptibility testing performed on culture # ___ ___. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. ___ 11:32 am BLOOD CULTURE 3 OF 3. FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. Susceptibility testing performed on culture # ___ ___. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by ___ (___) AT 2224 ON ___. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. ___ 10:22 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. FINAL SENSITIVITIES. 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-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by ___ (___) AT 2125 ON ___. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. IMAGING: TTE ___ IMPRESSION: Mildly dilated right ventricle with moderate to severe tricuspid regurgitation and moderate pulmonary hypertension. Ascites. Echocardiographic evidence for diastolic dysfunction with elevated PCWP. Very small pericardial effusion with exaggerated respiratory variation in tricuspid inflow velocities but no evidence of 2D evidence of tamponade. No valvular vegetations EMR 2853-P-IP-OP (O___) Name: ___ MRN: ___ Study Date: ___ 0:00:00 p. ___ seen. No 2D echocardiographic evidence for endocarditis. Normal left ventricular systolic function. Compared with the prior TTE (images reviewed) of ___ , very small pericardial effusion is seen, there is significantly more tricuspid regurgitation, moderate pulmonary hypertension is present. ___ Imaging RENAL U.S. 1. No hydronephrosis bilaterally. 2. 2 mm nonobstructive stone in the lower pole the right kidney. 3. Small amount of layering debris is seen within the urinary bladder. ___HEST W/O CONTRAST 1. Right lower lobe rounded consolidative opacity and additional opacity in the right middle lobe and left upper lobe, with surrounding ground-glass opacity, which are concerning for multifocal infection. 2. New prominent subcentimeter mediastinal lymph nodes, which are most likely reactive. 3. Partially distended urinary bladder with symmetric circumferential thickening, similar to prior. Findings may reflect cystitis in the appropriate clinical setting. 4. Diffuse anasarca. 5. Retroperitoneal and bilateral inguinal lymphadenopathy, which is unchanged compared to ___. ___BD & PELVIS W/O CON 1. Right lower lobe rounded consolidative opacity and additional opacity in the right middle lobe and left upper lobe, with surrounding ground-glass opacity, which are concerning for multifocal infection. 2. New prominent subcentimeter mediastinal lymph nodes, which are most likely reactive. 3. Partially distended urinary bladder with symmetric circumferential thickening, similar to prior. Findings may reflect cystitis in the appropriate clinical setting. 4. Diffuse anasarca. 5. Retroperitoneal and bilateral inguinal lymphadenopathy, which is unchanged compared to ___. ___ Cardiovascular Transesophageal Echo Final Report No discrete vegetation or abscess seen. Mild-moderate mitral regurgitation with normal leaflet morphology. Moderate tricuspid regurgitation with normal leaflet morphology. Moderate pulmonary artery systolic hypertension. Very small circumferential pericardial effusion. ___ Imaging US CHEST WALL SOFT TISS 1. No evidence of drainable fluid collection within left chest. 2. Interval decrease in size of a linear, hypoechoic tract within the subcutaneous tissues, likely sequela of prior tunneled hemodialysis catheter removal. 3. Partially occlusive thrombus within the left internal jugular vein, better assessed on the dedicated venous study. ___ Imaging BILAT UP EXT VEINS US Partially occlusive thrombus within the left internal jugular vein. No other thrombus identified. ___ Imaging LIVER OR GALLBLADDER US 1. No evidence of hepatic lesions. 2. No intra or extrahepatic biliary dilatation. Brief Hospital Course: TRANSITIONAL ISSUES =================== [ ] She will need ___ weeks of total antibiotic therapy for her infection, Projected End Date: ___ [ ] please assess volume to see if torsemide dose is appropriate- the dose was decreased after restarting HD because of some lightheadedness after HD. [ ] patient with tunneled line associated left internal jugular clot, please continue to assess duration of ___, ___ likely be 3 months with end date ___ [ ] PLEASE OBTAIN WEEKLY CRP, CBC with differential, BUN, Cr and fax to ATTN: ___ CLINIC - FAX: ___ [ ] consideration of CAD evaluation given troponin elevation while inpatient [ ] patient to lay down and rest post dialysis to ensure not lightheaded [ ] please adjust insulin as needed [ ] recheck CBC within 1 week to ensure no leukocytosis and monitor for infectious symptoms [ ] please change tunneled line dressing daily SUMMARY ======= This is a ___ w/ history of DM2, ESRD, retinopathy, neuropathy, HTN, HLD, chronic lymphedema and secondary elephantiasis, who presented for fistulogram after being discharged 2 days prior for a routine admission for HD initiation and was found to be hypoxic and febrile to 103. The patient was subsequently found to have MSSA bacteremia which was presumed to be from her tunneled HD line. She underwent removal of her HD line on ___ with placement of temporary HD line on ___. Both a TTE and TEE were w/out endocarditis, but with new TR and pHTN. Cultures continued to be positive until ___ and she has continued to have fevers. Given that the patient continued to have fevers in spite of clearing her cultures, this raised concern for an additional locus of infection. She underwent further work up which was ultimately notable for a U/S of her left IJ showing a partially occlusive thrombus for which she was started on Heparin drip then apixaban. ACUTE/ACTIVE HOSPITAL ISSUES ============================ # Tunneled HD Line Infection # MSSA Bacteremia # Fevers The patient presented with fevers, malaise, purulent drainage from her tunneled line. Her initial admission blood cultures grew MSSA and she was started on Cefazolin (narrowed from Cefazolin/Vancomycin which was started on admission). She underwent removal of her tunneled HD line on ___ with placement of temporary HD line on ___. Both a TTE and TEE were without endocarditis, but did show new TR and pHTN. The patient continued to grow positive blood cultures positive until ___ and she started to have fevers on ___ and ultimately deveresced on ___. Given persistent fevers, her new temporary HD line was pulled on ___. Given that the patient continued to have fevers in spite of clearing her cultures, this raised concern for an additional locus of infection. A U/S of her left IJ showed a partially occlusive thrombus for which she was started on Heparin gtt. Given lack of another new infectious source, it was thought that her ongoing fevers were likely from the clot. Ultimately the patient was discharged on apixaban 2.5mg PO BID after approval from her nephrologist. The patient was discharged on Cefazolin with HD with likely 6 week course to end ___. #ESRD, CKD Stage V Prior to discharge from her last hospitalization, the patient had HD arranged for ___ at ___. Per renal/transplant the patient's fistula may take up to 12 weeks to mature. As above, the patient underwent removal of her tunneled HD line on ___ and placement of temporary HD line on ___. She then underwent removal of her temporary HD line on ___ given persistent bacteremia and fevers. She had a line/HD holiday until her cultures cleared and she was afebrile. She ultimately had a left tunneled HD line placed on ___. She was continued on Torsemide 80mg and Metolazone 5mg PO QD on non HD days. She was continued on Sevelamer 1600 TID. # Left IJ Thrombus The patient was found to have a left IJ thrombus on ___ on U/S of AV fistula graft. This was where her prior temporary HD catheter had been. There was concern that this could be contributing to her persistent fevers and thus she was treated with IV heparin gtt while inpatient. Ultimately the patient was discharged on apixaban 2.5mg PO BID for anticoagulation. #Anemia Aranesp was continued with HD while inpatient and she was continued on ferrous sulfate QOD. She intermittently required HgB transfusions while inpatient. #Type II NSTEMI The patient had an elevated troponin (higher than previous baseline) on admission. She had no chest pain and no EKG changes. Troponins since down trended. This was thought to be most likely type 2 NSTEMI in setting of increased demand/infection, with contribution from renal disease impairing clearance. She was continued on ASA and Atorvastatin. #Type II Diabetes The patient's insulin regimen was changed during her last admission, with improved control while in hospital but per patient has still been running high at home. Her home lantus and humalog doses were increased and she was continued on a sliding scale insulin while inpatient. ################ >30 minutes spent on discharge planning and care coordination on the day of discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Artificial Tears ___ DROP BOTH EYES Q6H:PRN dry eyes 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 6. Calcitriol 0.25 mcg PO 3X/WEEK (___) 7. CARVedilol 25 mg PO BID 8. dorzolamide-timolol 22.3-6.8 mg/mL right eye BID 9. Ferrous Sulfate 325 mg PO EVERY OTHER DAY 10. Multivitamins 1 TAB PO DAILY 11. sevelamer HYDROCHLORIDE 1600 mg oral TID W/MEALS 12. Vitamin D 1000 UNIT PO DAILY 13. Torsemide 100 mg PO DAILY 14. Glargine 12 Units Bedtime Humalog 4 Units Breakfast Humalog 4 Units Lunch Humalog 6 Units Dinner 15. MetOLazone 5 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. CeFAZolin 3 g IV POST HD (SA) 3. CeFAZolin 2 g IV POST HD (___) 4. Glargine 18 Units Bedtime Humalog 10 Units Breakfast Humalog 10 Units Lunch Humalog 10 Units Dinner Insulin SC Sliding Scale using HUM Insulin 5. Torsemide 80 mg PO DAILY RX torsemide 20 mg 4 tablet(s) by mouth once a day on ___ Disp #120 Tablet Refills:0 6. amLODIPine 10 mg PO DAILY RX amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 7. Artificial Tears ___ DROP BOTH EYES Q6H:PRN dry eyes 8. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 9. Atorvastatin 40 mg PO QPM RX atorvastatin 40 mg 1 tablet(s) by mouth daily at night Disp #30 Tablet Refills:0 10. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 11. Calcitriol 0.25 mcg PO 3X/WEEK (___) RX calcitriol 0.25 mcg 1 capsule(s) by mouth daily 3X/WEEK (___) Disp #30 Capsule Refills:0 12. CARVedilol 25 mg PO BID RX carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 13. dorzolamide-timolol 22.3-6.8 mg/mL right eye BID 14. Ferrous Sulfate 325 mg PO EVERY OTHER DAY RX ferrous sulfate [Iron (ferrous sulfate)] 325 mg (65 mg iron) 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 15. MetOLazone 5 mg PO DAILY RX metolazone 5 mg 1 tablet(s) by mouth once a day on ___ Disp #30 Tablet Refills:0 16. Multivitamins 1 TAB PO DAILY RX multivitamin 1 capsule(s) by mouth once a day Disp #30 Capsule Refills:0 17. sevelamer HYDROCHLORIDE 1600 mg oral TID W/MEALS RX sevelamer HCl 800 mg 2 tablet(s) by mouth three times a day with meals Disp #90 Tablet Refills:0 18. Vitamin D 1000 UNIT PO DAILY RX ergocalciferol (vitamin D2) 50 mcg (2,000 unit) 1 capsule(s) by mouth once a day Disp #30 Capsule Refills:0 19.Outpatient Lab Work ___ PLEASE OBTAIN WEEKLY CRP, CBC with differential, BUN, Cr and fax to ATTN: ___ CLINIC - FAX: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: MSSA Bacteremia Catheter Associated Bloodstream Infection Left Internal Jugular Vein Septic Thrombus Secondary Diagnoses: End Stage Renal Disease Anemia Pulmonary Hypertension Type II NSTEMI Elephantiasis nostra verrucose Type II Diabetes Hyperlipidemia Hypertension Glaucoma Nutrition Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? ========================== - You were admitted to the hospital because you were having fevers and pus coming out of your dialysis line which was concerning for an infection of your dialysis line. WHAT HAPPENED TO ME IN THE HOSPITAL? ======================================= - You were found to have bacteria in your blood - You were given IV antibiotics to treat the infection in your blood - You were seen by the infectious disease doctors - Your dialysis line was removed and you had a new one placed once your cultures were negative. Unfortunately, your cultures again became positive and this new line had to also be removed. - You had an endoscopic ultrasound done of your heart to look for a heart infection. This showed no heart infection. - You had an ultrasound done of your neck to look for other sources of bacteria that could lead to your blood cultures continuing to be positive. This showed a blood clot that may have been infected. You were started on a blood thinner for this. - You eventually had a new dialysis line placed and underwent dialysis successfully WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Continue to take all your medicines and keep your appointments. - Please weigh yourself daily and contact your doctor if your weight goes up or down by more than 3 lbs in a day or 5 pounds in a week We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
10816916-DS-4	10,816,916	26,290,158	DS	4	2154-08-11 00:00:00	2154-08-12 19:22:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Erythromycin Base / Biaxin / Cipro / prednisone Attending: ___. Chief Complaint: STEMI Major Surgical or Invasive Procedure: ___ Cardiac Catheterization Coronary angiography: right dominant LMCA: No significant stenosis LAD: No significant stenosis LCX: No significant stenosis RCA: Distal RCA obstruction s/p Two DES to Distal RCA lesions. History of Present Illness: ___ with history of HLD who presented via EMS for inferior STEMI, now s/p 2 DES to distal RCA. Pt reports that she was in her USOH until this AM. She felt well and helped her son with ___, which she tolerated without any symptoms. Upon coming in the house she developed sudden onset SOB. She describes severe air hunger without chest pain and called her son who called ___. By the time EMS arrived she has begun to feel substernal chest pain ___ without radiation or associated nausea or diaphoresis. An EKG showed ST elevations in II, III, AVF with reciprocal ST depressions in the precordial leads. She was taken to ___ where CODE STEMI was activated. She was loaded with ticagrelor and taken to cath lab where PCI showed distal RCA occlusion which was stented with 2 DES. She tolerated the procedure well. Post cath EKG showed resolution of ST elevations with new Q wave in lead III, LAD and PRWP. On arrival to the CCU, the patient is interactive, oriented and comfortable. Of note, patient reports increased stress associated with tremors (no SOB or chest pain) in the setting of recently moving homes. REVIEW OF SYSTEMS: (+) mild ___ edema with prolonged rest, stress (-) exertional chest pain or dyspnea Past Medical History: - Chronic early repol in V1 (per patient history) - HLD (intolerant of statins ___ myalgias) - OA - s/p appendectomy - s/p Left knee replacement Social History: ___ Family History: No family history of early MI, cardiomyopathy, SCD Father - ___ cancer Sister - stomach cancer at ___ Sister - pancreatic cancer at ___ Sister - uterine cancer Has been considered for familial cancer syndrome workup but deferred given age. Physical Exam: ADMISSION PHYSICAL EXAM: Gen: Pleasant, calm, NAD. HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple, No LAD. JVP 1cm above clavicle at 30 degrees. CV: RR, normal rhythm, normal S1,S2. No m/r/g LUNGS: CTAB. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT, ND. No HSM. EXT: WWP, NO CCE. Full distal pulses bilaterally. No femoral bruits. Right femoral artery sheath in place. Non tender. Trace ___ edema. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. CN ___ grossly intact. Preserved sensation throughout. ___ strength throughout. FNF normal. DISCHARGE PHYSICAL EXAM: Eyes: (Conjunctiva and lids: WNL) PERRL Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and palette: WNL) Neurologic: Attentive, Follows simple commands, Responds to: Unknown (i.e. not assessed), Movement: Not assessed, Tone: Not assessed, Cranial Nerves: intact Neck: (Right carotid artery: No bruit), (Left carotid artery: No bruit), (Jugular veins: JVP, 1cm above clavicle at 30 deg) Back / Musculoskeletal: (Chest wall structure: WNL) Respiratory: (Effort: WNL), (Auscultation: WNL) Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1: WNL, S2: WNL, S3: Absent, S4: Absent) Abdominal / Gastrointestinal: (Bowel sounds: WNL) Femoral Artery: (Right femoral artery: R femoral access sheath in place without bleeding or hematoma) Extremities / Musculoskeletal: (Muscle strength and tone: WNL), (Dorsalis pedis artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+), (Extremity details: trace) Skin: ( WNL) Pertinent Results: CARDIAC ENZYMES: ___ 02:27PM BLOOD CK-MB-16* MB Indx-10.4* cTropnT-0.77* ___ 05:39PM BLOOD cTropnT-1.15* ___ 05:10AM BLOOD CK-MB-21* MB Indx-7.9* cTropnT-0.72* ___ 04:22PM BLOOD CK-MB-10 MB Indx-5.8 cTropnT-0.42* ADMISSION LABS: ___ 11:00AM BLOOD WBC-6.7 RBC-4.33 Hgb-13.8 Hct-40.9 MCV-94 MCH-31.8 MCHC-33.7 RDW-14.0 Plt ___ ___ 05:10AM BLOOD Neuts-62.8 ___ Monos-7.1 Eos-5.5* Baso-0.6 ___ 11:00AM BLOOD ___ PTT-25.4 ___ ___ 02:27PM BLOOD Glucose-132* UreaN-17 Creat-0.6 Na-137 K-4.0 Cl-104 HCO3-22 AnGap-15 ___ 02:27PM BLOOD Calcium-8.7 Phos-3.2 Mg-2.1 CARDIAC RISK STRATIFICATION: ___ 11:00AM BLOOD %HbA1c-6.0* eAG-126* ___ 02:27PM BLOOD Cholest-258* Triglyc-138 HDL-49 CHOL/HD-5.3 LDLcalc-181* DISCHARGE LABS: ___ 07:50AM BLOOD WBC-5.1 RBC-4.15* Hgb-13.1 Hct-39.7 MCV-96 MCH-31.7 MCHC-33.1 RDW-13.8 Plt ___ ___ 07:50AM BLOOD Glucose-146* UreaN-15 Creat-0.7 Na-141 K-4.0 Cl-103 HCO3-27 AnGap-15 ___ 07:50AM BLOOD ALT-22 AST-35 LD(LDH)-250 AlkPhos-51 TotBili-1.6* ___ 07:50AM BLOOD Albumin-4.1 Calcium-9.6 Phos-3.5 Mg-2.2 STUDIES: + CXR: Heart size is normal. Ascending aortic dilatation is suspected. Lungs are clear. There is no pleural effusion or pneumothorax. + EKG: ___: NSR @ 78bpm. NA, NI. 4mm in STE in lead III > II. With reciprocal ST depression in anterior leads. ___: NSR @ 100bpm. NA. LAD. Resolution of ST elevations. PRWP + CARDIAC CATH: Coronary angiography: right dominant LMCA: No significant stenosis LAD: No significant stenosis LCX: No significant stenosis RCA: Distal RCA obstruction s/p Two DES to Distal RCA lesions. Brief Hospital Course: ___ with history of HLD who presented via EMS for inferior STEMI, now s/p 2 DES to distal RCA. # CORONARIES: RCA with 2 DES. No other vessels. # PUMP: # RHYTHM: NSR #) STEMI: History of HLD. Developed sudden onset SOB and substernal chest pain. EKG with 4mm STE in III>II. Concern that some reciprocal changes may represent posterior infarct. Taken immediately to cath lab with successful PCI of two DES to distal RCA. On arrival to the CCU from cath lab the patient is without SOB/chest pain and in comfortable. She was monitored for 24 hours following catheterization without an evidence of hemodynamic instability or arrhythmic disturbances. - aspirin 81 daily - ticagrelor 180 BID - metop 12.5 BID, with plan to uptitrate as needed. - Will start atorvastatin 80mg daily. - restart home valsartan 160mg as tolerated. #) Dilated Ascending Aorta: Seen on CXR. No complaints of back pain or any discomfort. Blood pressures concordant between arms. TTE without evidence of aortic dilatation. # CODE: DNR/DNI (confirmed) # ICU consent: Done Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Valsartan 160 mg PO DAILY 2. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal ___ and ___ 3. Diclofenac Sodium ___ 75 mg PO BID 4. Atorvastatin 10 mg PO DAILY 5. Lorazepam 1.5 mg PO HS:PRN insomnia 6. NexIUM (esomeprazole magnesium) 20 mg oral qd Discharge Disposition: Home Discharge Diagnosis: ___ elevation MI s/p two drug eluting stents to Right Coronary Artery Disease Hyperlipidemia Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ was a pleasure meeting ___ and taking care of ___ during your hospital stay. ___ were admitted after having a heart attack. A heart artery called the right coronary artery was found to be blocked and two drug eluting stents were placed to open the blockage. ___ have done well since the procedure and are ready to go home. ___ are on two new medicines to help the stent stay open and prevent another heart attack, Aspirin and Ticagrelor. Do not stop taking these medicines or miss any doses unless Dr. ___ it is OK to do so. ___ will see Dr. ___ cardiologist in ___ in about a month who will check another echocardiogram to see if the heart has recovered. ___ will be able to go to cardiac rehab after that appt. Followup Instructions: ___
10816940-DS-18	10,816,940	27,690,963	DS	18	2124-09-17 00:00:00	2124-09-18 05:42:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___ Chief Complaint: cough/dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is an ___ year old female w/ h/o HTN, mild asthma, glaucoma, arthritis, and early Alzheimer's who presents with cough and dyspnea. She reports that her symptoms initially began around ___ with sneezing and she then developed productive coughing, chills, sore throat, and some body aches. She does have some sick contacts in the family. Denies chest pain, nausea, vomiting or diarrhea. General body aches, headache, +ST. +sick contacts. She did get a flu shot. Denies h/o CHF. In the ED initial vitals were: 99.0 54 183/60 24 98% RA. Labs significant for Hct 33.8, eos 5.5, Cr 2 (baseline 1.8) with BUN 44. Trop was flat and lactate 0.6. A flu swab was obtained and was negative. Blood cx were obtained. In the ED, ambulatory sats were noted to be 88% but a CXR showed no acute cardiopulmonary abnormality. She received ipratropium/albuterol nebs and gentle IVF's. Given her ambulatory hypoxia, she was admitted for further management. VS upon transfer: 99.3 105 140/72 25 98% RA. On the floor, Ms. ___ had a very significant productive cough, which is the most bothersome symptom for her. She also mentioned that she frequently falls on her face and breaks her glasses; she attributes this to "balance issues". She also frequently finds streaks of blood in her stool and says this has happened for "years". She reports having had 4 total colonoscopies but does not remember when her last one was. Past Medical History: ___ DISEASE (questionable, reportedly had a test that was negative for the disease) HYPERTENSION ARTHRITIS EARLY ALZHEIMER'S GLAUCOMA HYSTERECTOMY HAND OPERATION HIP REPLACEMENT Social History: ___ Family History: Patient unsure Physical Exam: PHYSICAL EXAM ON ADMISSION: Vitals - 99.2 150/70 72 20 97 ra GENERAL: NAD but coughing significantly. Appearing younger than stated age. HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, NECK: nontender supple neck CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: Reduced breath sounds with rales and rhonchi audible without the stethoscope. Coughing frequently, sounds productive. ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema NEURO: Conversing appropriately and able to give a history. Moving all extremities well. Gait not assessed. SKIN: warm and well perfused, no excoriations or lesions, no rashes PHYSICAL EXAM ON DISCHARGE: Vitals: 98.4 (98.4) 139/70 (134-154/70-74) 70 (45-84) 20 96% RA (96-100% RA) General: alert, oriented, no acute distress HEENT: Sclera anicteric, moist mucous membranes, oropharynx clear Lungs: mild scattered wheezing heard bilaterally CV: RRR, normal s1/s2, no m/r/g Abdomen: soft, nontender to palpation, bowel sounds + Ext: Warm, well perfused, no edema in feet bilaterally Neuro: grossly intact Pertinent Results: LABS ON ADMISSION: ============== ___ 02:45PM BLOOD WBC-4.6 RBC-3.83* Hgb-11.5* Hct-33.8* MCV-88# MCH-30.0 MCHC-33.9 RDW-13.8 Plt ___ ___ 02:45PM BLOOD Neuts-61.6 Lymphs-17.4* Monos-14.8* Eos-5.5* Baso-0.7 ___ 04:10PM BLOOD ___ PTT-29.5 ___ ___ 02:45PM BLOOD Glucose-120* UreaN-44* Creat-2.0* Na-138 K-4.7 Cl-101 HCO3-25 AnGap-17 ___ 06:15AM BLOOD ALT-13 AST-22 AlkPhos-45 TotBili-0.3 ___ 02:45PM BLOOD proBNP-458 ___ 02:45PM BLOOD cTropnT-<0.01 ___ 06:15AM BLOOD Albumin-3.9 Calcium-8.8 Phos-3.1 Mg-2.0 ___ 02:50PM BLOOD Lactate-0.6 LABS ON DISCHARGE: ============== ___ 07:04AM BLOOD WBC-6.1 RBC-3.35* Hgb-10.0* Hct-29.8* MCV-89 MCH-29.8 MCHC-33.5 RDW-13.7 Plt ___ ___ 07:04AM BLOOD Glucose-114* UreaN-43* Creat-2.0* Na-139 K-4.2 Cl-105 HCO3-24 AnGap-14 ___ 07:04AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.9 MICROBIOLOGY: ====================== ___ Influenza A/B both negative by PCR ___ 2:45 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___ 11:45 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. Respiratory Viral Culture (Final ___: TEST CANCELLED, PATIENT CREDITED. Refer to respiratory viral antigen screen and respiratory virus identification test results for further information. Respiratory Viral Antigen Screen (Final ___: Positive for Respiratory viral antigens. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Respiratory Virus Identification (Final ___: POSITIVE FOR RESPIRATORY SYNCYTIAL VIRUS (RSV). Viral antigen identified by immunofluorescence. Reported to and read back by ___ ___ 1120. ___ 6:15 am URINE OLD# ___. URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. STUDIES: =============== ECGStudy Date of ___ 5:20:56 ___ Sinus rhythm. Left axis deviation. Borderline left atrial abnormality. Delayed R wave transition. Non-specific ST segment flattening. Left ventricular hypertrophy. No previous tracing available for comparison. CHEST (PA & LAT)Study Date of ___ 3:50 ___ IMPRESSION: No acute cardiopulmonary abnormality. Brief Hospital Course: ___ w/ h/o HTN, mild asthma, glaucoma, arthritis, and early Alzheimer's who presents with a 1-week history of cough, dyspnea, chills, sneezing, nasal congestion, and sore throat. Presented to ___ on ___, admitted for ambulatory sats of 88%. CXR negative but RSV+ so presumed to have viral URI. Treated with benzonatate, guaifenesin, cepachol lozenges for symptomatic relief of cough. Given standing duonebs and then transitioned to MDI w/ spacer. Respiratory status improved as a result and no longer hypoxic on ambulation or rest. Also found to have dysuria while in-house, urine cx preliminarily suggest E Coli; prescribed 3d course of bactrim. #Dyspnea/Dry cough: ___ RSV infection, which also likely caused asthma exacerbation. Pt's other sx of chills, sneezing, nasal congestion, and sore throat consistent with RSV. CXR unremarkable and flu swab negative; low suspicion for bacterial process. On repeat ambulatory sat, patient 91-94% on room air. Given benzonatate, guaifenesin, cepachol lozenges for symptomatic relief. Treated with combivent inhaler with spacer to optimize asthma treatment. # Dysuria: c/w patient's prior bouts of cystitis. UA revealed 13 WBCs and few bacteria. Urine cx appears to be growing E Coli. Due to renal function, Bactrim SS BID x 3d. Urine cx to be followed up at PCP ___. # CKD: seen in ___ clinic at ___, no acute intervention recommended. Baseline Cr 1.8, has ranged from 1.8-2.2 throughout admission, varying with fluid status. Patient encouraged to increase PO PO intake. #Glaucoma: continued on brimonidine, dorzolamide/timolol, and lumigan (took own meds). #HTN: continued on aliskiren and amlodipine. #Hx of Falls: patient reports not having fallen in over a year. In the past, when she has fallen at home, there was no prodrome and no LOC. No workup as per PCP. She lives alone and has no services. Seen by ___ inpatient. Independent for ADLs and for IADLs. Pt does participate in regular physical activity including walking in the park across from her house. She drives and has the Ride to get to appts. Performance Orientated Mobility Assessment score of 23 is consistent with low risk for falls; patient demonstrated ability to vary speed, step over and around obstacles and complete higher level balance activities without LOB. From ___ standpoint, patient was safe for home d/c. Will followup with home ___. #Hx of blood in stool: per patient, has occurred for years and this is also noted in her ___ nephrology note from ___. On ___, colonoscopy showed diverticulosis and internal hemorrhoids. TRANSITIONAL ISSUES: - F/u with PCP ___ 7 days - Continue bactrim to complete 3day course (ending ___ - F/u urine cx sensitivities - Combivent with spacer to relieve asthma exacerbation during viral illness - Will need f/u regarding asthma and titration of meds in future - Followup with home ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 2.5 mg PO DAILY 2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID 3. Lumigan (bimatoprost) 0.01 % ophthalmic daily 4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 5. Aliskiren 300 mg PO DAILY Discharge Medications: 1. Amlodipine 2.5 mg PO DAILY 2. Lumigan (bimatoprost) 0.01 % ophthalmic daily 3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID 4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 5. Aliskiren 300 mg PO DAILY 6. Sulfameth/Trimethoprim SS 1 TAB PO BID Duration: 3 Days RX sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by mouth twice daily Disp #4 Tablet Refills:0 7. Benzonatate 100 mg PO TID RX benzonatate 100 mg 1 capsule(s) by mouth three times daily as needed Disp #30 Capsule Refills:0 8. Guaifenesin ___ mL PO Q6H:PRN cough RX guaifenesin 100 mg/5 mL 10 liquid(s) by mouth every 6 hours as needed Disp #473 Milliliter Milliliter Refills:0 9. Cepastat (Phenol) Lozenge 1 LOZ PO Q2H:PRN sore throat RX phenol [Cepastat] 14.5 mg 1 lozenge every 2 hours as needed Disp #30 Lozenge Refills:0 10. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN shortness of breath RX ipratropium-albuterol [Combivent Respimat] 20 mcg-100 mcg/actuation 1 puff inhalation every 6 hours as needed Disp #1 Inhaler Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: - RESPIRATORY SYNCYTIAL VIRUS infection - Asthma - Urinary Tract Infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were seen at ___ because of cough and shortness of breath. Your chest x-ray was normal. You were found to have a viral respiratory infection (RSV), which likely triggered your asthma. You were treated with medications to relieve your cough, and were given an inhaler with a spacer to help your asthma. At time of discharge, your cough had improved and your blood oxygen levels were normal. Also, because you experienced some burning on urination, you were treated with a 3-day course of antibiotics for a urinary tract infection. Please call your primary care doctor after discharge to schedule an appointment to be seen within 7 days. It wss our pleasure taking care of you. We wish you all the best! Sincerely, Your ___ Team Followup Instructions: ___
10816993-DS-5	10,816,993	23,142,822	DS	5	2158-01-18 00:00:00	2158-01-18 17:06:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ___ S/D Attending: ___ ___ Complaint: Rash Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ ___ woman w/ PMH of dermatomyositis, currently on MMF, hydroxychloroquine, prednisone 15 mg daily who presented with worsening rash. Patient reports that her rash began to worsen around a week or 2 ago. She noticed it on her thighs, upper arms, and around her face -in particular, her cheeks and her eyelids. She notes that these areas are new. The rash is very itchy, and at times painful as well -it is severe enough that she has trouble sleeping at night. She believes she may have had a fever the night prior to presentation as well. She has not noted any weakness. She has no trouble standing up from a seated position or reaching over her head. She is able to confirm that she is currently taking MMF twice a day, hydroxychloroquine once a day, and prednisone 15 mg every day. She otherwise has no recent changes to her medications. On review of records, patient was last seen by rheumatology on ___. At this time, it was noted that she had proximal muscle weakness, active rash, and an elevated CPK. They discussed re-challenging with rituximab. However, it appears that the patient did not receive this. In the ED: Initial vital signs were notable for: T 97.3, HR 80, BP 150/92, RR 17, 100% RA Exam notable for: Blanching maculopapular rash over the cheeks, upper eyelids, chest, knees. No intraoral involvement, involvement of the palms or soles. ___ strength with bilateral upper and lower extremities including the knee, hip, ankle, elbow. Labs were notable for: - CBC: WBC 4.1 (31%n, 47% l, 16%m), hgb 11.7, plt 220 - Lytes: 139 / 101 / 12 AGap=12 -------------- 91 5.5 \ 26 \ 0.5 - CRP 3.7 - CK: 1060-> 908 - lactate 0.9 Patient was given: ___ 14:30 PO/NG PredniSONE 30 mg ___ 15:27 IVF NS 1000 mL Per ED, case was discussed with rheumatology attending, who recommended the patient's prednisone be increased to 30 mg daily. Vitals on transfer: T 98.9, HR 70, BP 161/100, RR 16, 100% RA Upon arrival to the floor, patient recounts history as above. She describes an extremely itchy rash currently. Past Medical History: - dermatomyositis - abdominal pain - anemia - back pain - GERD - headache - hypertension - migraines - osteoarthritis Social History: ___ Family History: Sister with IBD and colon cancer (___) Both parents died from MI- Mother (___) Maternal aunt and sister - DM Maternal cousin - ___ issues Physical Exam: ON ADMISSION: VITALS: T 99.1, HR 84, BP 160/75, RR 18, 96% Ra GENERAL: Alert and in no apparent distress, ambulating independently in room EYES: Anicteric, pupils equally round ENT: Erythematous scaly rash on eyelids, cheeks. 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 on room air. 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: Facial rash as above. Several areas of erythematous, blanching, maculopapular rash noted, including bilateral lateral thighs, knees, elbows, upper arm, upper chest NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent. ___ strength in bilateral upper and lower proximal and distal muscle groups. Steady gait. PSYCH: pleasant, appropriate affect ==================================== VITALS: ___ 0828 Temp: 98.9 PO BP: 127/84 R Lying HR: 84 RR: 16 O2 sat: 99% O2 delivery: ra Dyspnea: 0 RASS: 0 Pain Score: ___ GENERAL: Alert and in no apparent distress, appears comfortable, conversant EYES: Anicteric ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate. Moist mucus membranes. CV: RRR, no murmur, no S3, no S4. 2+ radial pulses bilaterally RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored on room air. GI: Abdomen soft, non-distended, mildly tender in RLQ, non-tender in epigastric region. Bowel sounds present. GU: No suprapubic fullness or tenderness to palpation, no Foley MSK: Moves all extremities, no joint tenderness of hands, knees or ankles. SKIN: Improved, mildly erythematous, maculopapular rash over face including nasolabial folds. Resolved rash on neck and anterior chest. Patch on right lateral thigh and patch on left thigh improved, mildly erythematous. Scars on right thigh. Slightly erythema over dorsum of both hands over MCP joints and DIP joints, both knees and elbows. No rash of axilla/abdomen/back. NEURO: Alert, oriented x3, face symmetric, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect Pertinent Results: LABS ON ADMISSION: ___ 12:53PM BLOOD WBC-4.1 RBC-4.30 Hgb-11.7 Hct-37.4 MCV-87 MCH-27.2 MCHC-31.3* RDW-14.6 RDWSD-46.2 Plt ___ ___ 12:53PM BLOOD Neuts-31.6* ___ Monos-16.2* Eos-4.4 Baso-0.5 Im ___ AbsNeut-1.29* AbsLymp-1.92 AbsMono-0.66 AbsEos-0.18 AbsBaso-0.02 ___ 12:53PM BLOOD Glucose-91 UreaN-12 Creat-0.5 Na-139 K-5.5* Cl-101 HCO3-26 AnGap-12 ___ 12:53PM BLOOD CK(CPK)-1060* ___ 08:40AM BLOOD ALT-40 AST-43* CK(CPK)-752* AlkPhos-52 TotBili-0.6 ___ 08:40AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.8 ___ 12:53PM BLOOD CRP-3.7 ___ 07:40AM BLOOD IgG-1153 IgA-239 IgM-61 ___ 01:20PM BLOOD Lactate-0.9 ___ 12:53PM URINE Color-Straw Appear-Hazy* Sp ___ ___ 12:53PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR* ___ 12:53PM URINE RBC-<1 WBC-2 Bacteri-NONE Yeast-NONE Epi-21 ___ 12:53PM URINE Mucous-RARE* ========================================== LABS ON DISCHARGE: ___ 06:55AM BLOOD WBC-7.3 RBC-4.60 Hgb-12.7 Hct-39.9 MCV-87 MCH-27.6 MCHC-31.8* RDW-14.5 RDWSD-46.0 Plt ___ ___ 07:20AM BLOOD Glucose-80 UreaN-21* Creat-0.5 Na-139 K-4.3 Cl-101 HCO3-22 AnGap-16 ___ 07:20AM BLOOD ALT-60* AST-54* AlkPhos-47 TotBili-0.7 ___ 06:55AM BLOOD CK(CPK)-376* ___ 07:40AM BLOOD IgG-1153 IgA-239 IgM-61 ___ 01:20PM URINE Color-Yellow Appear-Clear Sp ___ ___ 01:20PM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR* ___ 01:20PM URINE RBC-1 WBC-2 Bacteri-FEW* Yeast-NONE Epi-<1 ========================================== MICROBIOLOGY: Urine culture ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Blood culture ___: No growth (final) ========================================== IMAGING: CHEST X-RAY ___: No acute cardiopulmonary abnormality. Unchanged appearance of the cardiomediastinal silhouette. Brief Hospital Course: Ms. ___ is a ___ ___ woman with dermatomyositis (on mycophenolate, hydroxychloroquine, prednisone 15 mg daily) who presented with 1 week of worsening rash, consistent with acute dermatomyositis flare. ACUTE/ACTIVE PROBLEMS: # Acute flare of dermatomyositis: She presented with worsening rash in several areas, including her face, neck, chest, and legs. She had no evidence of weakness on exam. CK was elevated to 1060 on admission, but steadily decreased and was down to 376 prior to discharge. It was slightly decreased from ___ (was 1300). Her disease is refractory to mycophenolate, hydroxychloroquine, and prednisone 15 mg daily. Prednisone was increased from 15mg to 40mg daily. Rheumatology was consulted and felt her disease is prednisone responsive, but this is not a long term solution for controlling her disease. She requires aggressive therapy, so she was started on Rituximab. She has had prior adverse effects to methotrexate and has contraindication to azathioprine. She got 1st dose of Rituximab 1g at week 0 (given on ___ and will need another dose at week 2. The major problem would be trying to get second dose, since it is extremely expensive and rheum specialty pharmacy was trying to find charitable donation to cover the cost. She was continued on home hydroxychloroquine 200mg daily and mycophenolate 1500mg BID. She was discharged on Prednisone 30mg daily. She was started on prophylactic Bactrim SS daily for PCP prophylaxis while high dose Prednisone and calcium/vitamin D to prevent steroid-induced osteoporosis. Rheumatology will be scheduling outpatient follow up with Dr. ___ for her ___ injection of Rituximab. # Dysphagia: She reported dysphagia with solids, which could be related to her dermatomyositis. SLP recommended soft solids and thin liquids, but no aspiration was noted. # Dyspnea on exertion: She specified dyspnea if she walks for prolonged periods like 20 minutes or more, not with mild, brief exertion. CXR ___ showed no abnormalities. # Social situation # Homelessness # Lack of insurance: She was recently evicted from housing on ___. Her children are currently staying with family. ___ is involved but she has a good relationship with them. She has a probation officer. Social work was heavily involved. Financial services saw her and working to enroll in ___ and hopefully should have insurance in two weeks. # Nausea: # Epigastric pain: Side effects of Rituximab include ___ with nausea and her nausea began on ___, so this seemed most likely to be a side effect. She had no vomiting. She was given 1L of IV fluids and PRN Zofran and Maalox. Her epigastric pain and nausea had resolved by the day of discharge. # Bilateral hip pain: This "bone pain" was new as of ___, with tenderness on exam without overlying skin changes, but may have been a side effect of Rituximab (arthralgias can be side effect). This pain resolved prior to discharge. CHRONIC/STABLE PROBLEMS: # Hypertension: She was normotensive and she was continued on home diltiazem 180mg daily and lisinopril 20mg daily. # GERD: She had some epigastric pain and tenderness, that seemed worse after getting Rituximab and she was continued on omeprazole. Her symptoms had improved prior to discharge. # Constipation: She was treated with Senna, Colace, Miralax. TRANSITION OF CARE ISSUES: - I made her an appointment with Dr. ___ office at 10:30 AM on ___ for follow up (___). She may need to reschedule this if she still doesn't have insurance then. She wants to switch to a PCP here or ___, so may need to cancel appointment, but on day of discharge, she told me she'd go to her existing appointment. - She is still waiting on getting Mass Health Limited. This is going to impact her ability to get follow up with her PCP and rheumatology, particularly for the Rituximab injection. Check if applies: [ X ] Ms. ___ is clinically stable for discharge today. The total time spent today on discharge planning, counseling and coordination of care today was greater than 30 minutes. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diltiazem Extended-Release 180 mg PO DAILY 2. Hydroxychloroquine Sulfate 200 mg PO DAILY 3. Lisinopril 20 mg PO DAILY 4. mycophenolate mofetil 1500 mg oral BID 5. Omeprazole 20 mg PO DAILY 6. PredniSONE 15 mg PO DAILY 7. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP DAILY 8. Calcium Carbonate 500 mg PO DAILY 9. Docusate Sodium 100 mg PO DAILY Discharge Medications: 1. Polyethylene Glycol 17 g PO DAILY 2. Sarna Lotion 1 Appl TP QID:PRN itching 3. Senna 8.6 mg PO BID 4. 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 5. Vitamin D 1000 UNIT PO DAILY 6. PredniSONE 30 mg PO DAILY RX prednisone 10 mg 3 tablet(s) by mouth Daily Disp #45 Tablet Refills:0 7. Calcium Carbonate 500 mg PO DAILY 8. Diltiazem Extended-Release 180 mg PO DAILY RX diltiazem HCl 180 mg 1 tablet(s) by mouth Daily Disp #14 Tablet Refills:0 9. Docusate Sodium 100 mg PO DAILY 10. Hydroxychloroquine Sulfate 200 mg PO DAILY RX hydroxychloroquine 200 mg 1 tablet(s) by mouth Daily Disp #14 Tablet Refills:0 11. Lisinopril 20 mg PO DAILY RX lisinopril 20 mg 1 tablet(s) by mouth Daily Disp #14 Tablet Refills:0 12. mycophenolate mofetil 1500 mg oral BID RX mycophenolate mofetil 500 mg 3 tablet(s) by mouth twice a day Disp #84 Tablet Refills:0 13. Omeprazole 20 mg PO DAILY RX omeprazole 20 mg 1 capsule(s) by mouth Daily Disp #14 Capsule Refills:0 14. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP DAILY RX triamcinolone acetonide 0.025 % Apply thin layer to affected area Daily Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Dermatomyositis flare Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were hospitalized with a flare of dermatomyositis. Your prednisone was increased to 30mg daily and you were continued on your existing doses of mycophenolate and hydroxychloroquine. You had your first infusion of Rituximab on ___. You will need another infusion in 2 weeks. Rheumatology will contact you regarding follow up. You are being started on calcium and vitamin D supplementation to help prevent steroid-induced osteoporosis. You are also being started on an antibiotic called Bactrim to help prevent rare causes of pneumonia that can occur if you're on high doses of steroids (like the prednisone) for long periods of time. It is extremely important to follow up with your primary care doctor and rheumatologist in the next several weeks to make sure that your dermatomyositis is controlled, because the potential complications can be very severe. We understand that right now you do not have insurance and it is difficult to pay for care, but hopefully you will be set up with Mass Health soon. Our social worker talked with you about shelters you can stay in. Do not hesitate to contact your doctors' offices if you have questions. Followup Instructions: ___
10816993-DS-6	10,816,993	24,483,786	DS	6	2158-03-07 00:00:00	2158-03-19 18:40:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ___ S/D Attending: ___. Chief Complaint: Hand pain Major Surgical or Invasive Procedure: EGD History of Present Illness: Ms. ___ is a ___ ___ speaking female with history of dermatomyositis with recent admission for flare (on MMF, HCQ, prednisone, and rituximab), who is presenting with finger pain. Patient is interviewed with ___ phone interpreter. She states that she first developed finger pain 3 days ago, and it has become increasingly severe. It is located in the joints of her right hand, especially the middle finger. She notes that she is no longer able to make a fist. This has been associated with new sores on her joints. She also notes that the rash on her right thigh is worse, with a few openings that she has noticed. No fevers. Facial rash has gotten better, and muscle aches have also improved, though still some pain on right side. Patient also reports that she has been feeling lightheaded, and the morning of admission felt weak while in the shower and fell back, hitting her head on the faucet. Continues to have headache, which is now throughout her head. Dizziness has since resolved. She notes that insurance continues to be an issue, and that she has run out of some of her medications. She notes that she still does not have housing, Per review of records, was admitted in ___ for flare of her dermatomyositis. Her dose of steroids was increased at that time, and she was given a dose of rituximab. They had planned to give her a second dose as an outpatient, but have been unable to get insurance authorization. Started tapering her steroids on ___ (reduced dose from 30mg at time of discharge to 15mg). Past Medical History: - dermatomyositis - abdominal pain - anemia - back pain - GERD - headache - hypertension - migraines - osteoarthritis Social History: ___ Family History: Sister with IBD and colon cancer (___) Both parents died from MI- Mother (___) Maternal aunt and sister - DM Maternal cousin - ___ issues Physical Exam: ADMISSION EXAM VITALS: T 98.7, HR 76, BP 130/81, RR 18, 99% 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. L leg painful to palpation SKIN: Gottron's papules over finger joints, with ulceration over R ___ finger MCP. Heliotrop rash. R upper leg with hyperpigmented rash with three small, nondraining openings. NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: ************** ADMISSION LABS ************ - CBC: WBC 5.5, hgb 11.7, plt 227 - Lytes: 142 / 107 / 9 AGap=15 ------------- 120 4.3 \ 20 \ 0.5 - CK 324 - CRP 3.4 ************ DISCHARGE LABS ************** ___ 03:18PM BLOOD WBC-4.9 RBC-4.81 Hgb-13.0 Hct-41.6 MCV-87 MCH-27.0 MCHC-31.3* RDW-14.5 RDWSD-45.8 Plt ___ ___ 03:18PM BLOOD Glucose-134* UreaN-15 Creat-0.7 Na-137 K-5.0 Cl-102 HCO3-23 AnGap-12 ___ 03:18PM BLOOD Calcium-9.9 Phos-2.9 Mg-2.0 ************** IMAGING ************ CT ADBEOMEN/PELVS W/ ___ 1. No acute abdominopelvic process. 2. Sheet-like calcifications in the subcutaneous fat of the flanks and gluteal regions are compatible with dermatomyositis, progressed from ___. Brief Hospital Course: ___ yo recently homeless F w/ dermatomyositis (on prednisone & CellCept) who presented w/ right hand swelling and an ulcerative lesion. Given prednisone burst and Remicade with dramatic improvement in her symptoms. She then developed epigastric abdominal pain and associated poor PO; EGD showed gastritis, presumed to be steroid induced based on timing of onset. The gastritis improved with several days of acid suppression and supportive care. #DERMATOMYOSITIS FLARE The patient presented with acute onset of hand swelling and ulceration, and ulceration over an old lesion on her thigh. This was likely a flare of her known dermatomyositis. New lesions are compatible with dermatomyositis as well. She was seen by rheumatology and received a rituximab infusion with considerable improvement in her hand pain and resolution of the ulcer. She was continued on her home MMP and Plaquinel. Her home prednisone was briefly increased too, but as below, she developed gastritis and the dose was adjusted downward again. Continues TMP-SMX, VitD/calcium, and PPI while on prednisone. #GASTRITIS Likely steroid-induced gastritis based on EGD findings abd timing of onset after an increase in prednisone dose. CT unremarkable for alternate cause of her pain. She was treated with omeprazole 20 mg BID, ranitidine 150 mg daily, carafate, and standing antiemetics. Symptoms improved with several days of supportive care. She is discharged on a BID PPI for now. #PLANTAR FASCITIS Patient developed severe pain on of her plantar fascia. Exam c/w plantar fasciitis. Checked with rheum to make sure this isn't an obscure sign of her rheumatologic disease, but they confirmed that it probably isn't). Unfortunately, cannot give NSAIDs with her recovering gastritis. She was taught stretching exercises (pulling the forefoot cephalad with the leg in extension using a folded bedsheet). Giving a short course of PRN Ultram to help with pain, as she will have to do significant ambulation in the setting of homelessness. #Homelessness Discharged with instructions from social work about how to get placement in a family shelter. Discharging physician gave her ___ personal gift of funds to hopefully support her in a transition to stable housing. TRANSITIONAL ISSUES*** 1) Ongoing adjustment of prednisone to balance disease control with steroid side effects. 2) wean antacids, antiemetics, and analgesics as she continues to spontaneously recover from her gastritis and her plantar fasciitis. 3) Continue to assist her in transition to a stable housing situation and offer ongoing support to this homeless mother of three. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diltiazem Extended-Release 180 mg PO DAILY 2. Docusate Sodium 100 mg PO DAILY 3. Hydroxychloroquine Sulfate 200 mg PO DAILY 4. Lisinopril 20 mg PO DAILY 5. mycophenolate mofetil 1500 mg oral BID 6. Omeprazole 20 mg PO DAILY 7. Sarna Lotion 1 Appl TP QID:PRN itching 8. Senna 8.6 mg PO BID 9. Polyethylene Glycol 17 g PO DAILY 10. Calcium Carbonate 500 mg PO DAILY 11. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP DAILY 12. Vitamin D 1000 UNIT PO DAILY 13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 14. PredniSONE 15 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX acetaminophen [Acetaminophen Extra Strength] 500 mg 2 tablet(s) by mouth three times a day Disp #180 Tablet Refills:1 2. Ondansetron 8 mg PO TID RX ondansetron 8 mg 1 tablet(s) by mouth three times a day Disp #21 Tablet Refills:0 3. Ranitidine 150 mg PO DAILY RX ranitidine HCl 150 mg 1 capsule(s) by mouth once a day Disp #7 Capsule Refills:0 4. TraMADol 50 mg PO Q6H:PRN Foot pain RX tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 5. Vitamin D 1000 UNIT PO DAILY 6. Omeprazole 20 mg PO BIDAC RX omeprazole 20 mg 1 capsule(s) by mouth BIDAC Disp #60 Capsule Refills:1 7. PredniSONE 20 mg PO DAILY RX prednisone 20 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:1 8. Calcium Carbonate 500 mg PO DAILY RX calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:1 9. Diltiazem Extended-Release 180 mg PO DAILY RX diltiazem HCl 180 mg 1 capsule(s) by mouth once a day Disp #30 Capsule Refills:1 10. Docusate Sodium 100 mg PO DAILY RX docusate sodium 100 mg 1 capsule(s) by mouth once a day Disp #30 Capsule Refills:1 11. Hydroxychloroquine Sulfate 200 mg PO DAILY RX hydroxychloroquine 200 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:1 12. Lisinopril 20 mg PO DAILY RX lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:1 13. mycophenolate mofetil 1500 mg oral BID RX mycophenolate mofetil 500 mg 3 tablet(s) by mouth twice a day Disp #180 Tablet Refills:1 14. Polyethylene Glycol 17 g PO DAILY 15. Sarna Lotion 1 Appl TP QID:PRN itching RX camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % Apply to itchy skin every six (6) hours Refills:5 16. Senna 8.6 mg PO BID RX sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:1 17. Sulfameth/Trimethoprim SS 1 TAB PO DAILY RX sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tab-cap by mouth once a day Disp #30 Tablet Refills:1 18. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP DAILY RX triamcinolone acetonide 0.025 % Apply to skin rash once a day Refills:1 19. Vitamin D 1000 UNIT PO DAILY RX ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:1 Discharge Disposition: Home Discharge Diagnosis: Dermatomyositis with acute exacerbation Gastritis Plantar fasciitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were in the hospital for dermatomyositis. The disease flared up and caused damage to your hands. You were treated with prednisone and rituximab and got better. Unfortunately you got gastritis. This was probably a side effect of getting extra prednisone. We did an upper endoscopy, which did not show anything else besides the gastritis. Please take extra antacid and nausea medicine for a week while the gastritis heals. You also developed pain in your foot. This is probably plantar fasciitis. Plantar fasciitis is a benign but annoying condition. Stretch the foot out and walk around like normal. Take Tylenol for the pain three times a day. Before walking a long way, take tramadol (a stronger pain medicine). For placement in a family shelter, please go to: ___ Office - ___ ___ (south of ___) ___ ___ ********* Traducción al español (por ___ médico) Ud estubo ___ hospital por dermatomiositis. ___ se inflamó y causó daños en las manos. Recibió tratamiento con prednisona y rituximab y Ud mejoró. Luego, tuvo inicio de gastritis. Este fue ___ un efecto secundario de obtener prednisona extra. Hicimos una endoscopia, que no mostró ___ más aparte ___. Por favor, tome medicamentos antiácidos y para las náuseas ___ una semana ___. Usted también desarrolló dolor ___ pie. Esto es ___ ___ plantar (plantar fasciitis). ___ plantar es una condición ___. Estira el pie y camina como normal. Tome acetaminophen para el dolor tres veces al día. Antes de caminar mucho, tome tramadol (un medicamento para el dolor más ___. También ___ recientemente. Para ___ colocación en un ___ para las familias: ___ Office - ___ ___ ___ de ___) ___ ___ Followup Instructions: ___
10817631-DS-10	10,817,631	25,587,982	DS	10	2152-09-29 00:00:00	2152-09-28 14:53:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ man with history of CAD s/p CABG, HTN, HLD, DMII, multiple myeloma s/p auto SCT currently on pomalidomide/daratumumab presenting with weakness. The patient has a history of multiple myeloma s/p auto SCT (___). He was initially on Revlimid, then Ninlaro, and now initiated ___ on pomalidomide/daratumumab/dexamethasone. The patient and his wife report that he has progressively become weaker over the past several months, but it has been worse in the past several weeks. He also notes that he has had drenching sweats for over a year but this has also gotten worse recently. He reports that his blood sugars have been labile since initiating the dexamethasone, sometimes in the 300-400s, but also low in the ___. About 3 weeks ago, the patient got up in the night to urinate and feel extremely weak. His wife found him lying on the floor in the bathroom. He was taken to BID-M on ___. There, he was found to have febrile neutropenia and acute on chronic anemia. ID was consulted and he underwent extensive infectious evaluation including blood and urine cultures, sputum culture, Flu/RSV swab; Lyme, Anaplasma, Babesia, Erlichia negative; CT abdomen/pelvis; TTE without vegetations. The patient was given vancomycin/cefepime empirically for 10 days and defervesced. His hospital course was complicated by an acute gout flare for which he received prednisone and colchicine. He was discharged on ___. The patient saw his oncologist Dr. ___ on ___. The plan at that time was to hold Bactrim/acyclovir prophylaxis, hold aspirin given worsened thrombocytopenia, resume atenolol, and to hold pomalidomide. However, the patient took a dose on ___. At home, he continued to feel extremely weak. He denies any fevers at home, but noted ongoing drenching sweats. His wife reports that she went to the supermarket and returned 45 minutes later and found her husband on the floor. The patient reports that he was sitting in a recliner and attempted several times to stand but felt extremely weak and repeatedly fell back into the recline. On his final attempt to stand he rocked forward and fell out of the chair. He denies any loss of consciousness. He denies any antecedent symptoms such as chest pain, palpitations, dizziness or lightheadedness. He felt too weak to prop himself up, and when his wife returned she called EMS. He was taken to ___, where he was febrile to 100.5. He was give IV vancomycin, IV cefepime, oral vancomycin for potential C. diff, and 1 unit pRBCS. He was transferred to ___ for further care. The patient additionally notes that he developed a dry cough while at ___ but denies any shortness of breath. No abdominal pain, nausea, vomiting. He had a few loose stools several days prior to admission this has been ongoing related to chemotherapy. He has a rash on his forehead due to his use of ___ for his actinic keratosis but no other rashes or lesions. No dysuria. No known sick contacts. In the ED, vitals: Tmax 102.7 80 122/66 16 98% RA Exam notable for: CTAB no WRR, unlabored breathing Labs notable for: WBC 5.5, Hb 7.9, plt 94, INR 1.6; trop 0.07->0.04, MB 3->2; UA with glucosuria Imaging: CXR Patient given: Magnesium 2 gm IV, insulin 6 units, Tylenol 1 gm, erythromycin eye ointment In our ED, he was noted to have left eye lid with scant purulent appearing discharge. No pain or redness in the eye. Started on erythromycin ointment for presumed bacterial conjunctivitis On arrival to the floor, the patient reports that he feels fatigued but otherwise has no complaints. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Hypertension Dyslipidemia Diabetes (type II with retinopathy) BPH Colon Polyps s/p polypectomy Lung Nodule (right side- stable) Basal cell CA Diverticulosis Multiple myeloma Social History: ___ Family History: Mother and father died of CAD in their ___ Physical Exam: ADMISSION VITALS: 99.7 125 / 80 67 18 94 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 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. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: Rash on forehead NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: Very pleasant, appropriate affect GENERAL: Alert and in no apparent distress EYES: Anicteric sclera ENT: Oropharynx without visible lesion, erythema or exudate. CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored. GI: Abdomen is soft, non-distended, non-tender to palpation. MSK: Neck supple, moves all extremities SKIN: Crusted rash on face extending across midline NEURO: Alert, oriented, speech fluent PSYCH: Pleasant, appropriate affect Pertinent Results: ADMISSION ___ 11:30PM BLOOD WBC-5.5 RBC-2.86* Hgb-7.9* Hct-25.5* MCV-89 MCH-27.6 MCHC-31.0* RDW-16.2* RDWSD-51.4* Plt Ct-94* ___ 11:30PM BLOOD Neuts-70.7 ___ Monos-7.7 Eos-0.2* Baso-0.2 Im ___ AbsNeut-3.89 AbsLymp-1.08* AbsMono-0.42 AbsEos-0.01* AbsBaso-0.01 ___ 11:30PM BLOOD ___ PTT-26.8 ___ ___ 11:30PM BLOOD Glucose-182* UreaN-13 Creat-0.9 Na-136 K-4.3 Cl-102 HCO3-23 AnGap-11 ___ 11:30PM BLOOD CK(CPK)-857* ___ 05:51AM BLOOD ALT-7 AST-19 LD(LDH)-96 CK(CPK)-109 AlkPhos-65 TotBili-0.9 ___ 11:30PM BLOOD CK-MB-3 cTropnT-0.07* ___ 11:30PM BLOOD Calcium-9.6 Phos-3.5 Mg-1.2* Iron-40* ___ 08:48AM BLOOD PEP-PND FreeKap-134.6* FreeLam-1.3* Fr K/L-103.5* ___ 11:30PM BLOOD calTIBC-120* Ferritn-1101* TRF-92* ___ 07:30AM BLOOD Cortsol-17.7 ___ 11:30PM BLOOD TSH-3.4 ___ 11:38PM BLOOD Glucose-178* Lactate-1.0 IMAGING - CT Head (___): CT head that did not show acute hemorrhage, mass, territorial infarct. - CT chest (___) 1. Multiple lucent lesions scattered throughout the axial skeleton are concerning for myelomatous involvement. Several of the lesions including dominant lesions in the T6 and T7 vertebral bodies, which were not FDG avid on the prior PET-CT appear grossly unchanged. A probable lesion in the medial aspect of the right clavicle, appears new from PET-CT ___ and is concerning for new or worsening myelomatous involvement. 2. Small pulmonary nodules measure up to 2 mm, not definitely seen on PET-CT ___, possibly due to poor resolution. Recommend ___ month interval follow-up to assess for stability. 3. Assessment is moderately limited by respiratory motion, but no definite evidence of pneumonia or bronchitis. - CT sinus (___) 1. There is moderate mucosal thickening of the bilateral ethmoid air cells and left maxillary sinus with partial opacification of the left maxillary sinus which may represent sinus disease in the appropriate clinical setting. 2. There is opacification of the left infundibulum. 3. Polypoid soft tissue in the left maxillary sinus may represent sinus polyposis. 4. The bilateral orbits are unremarkable. ___ 07:05AM BLOOD WBC-3.4* RBC-2.61* Hgb-7.3* Hct-23.2* MCV-89 MCH-28.0 MCHC-31.5* RDW-15.4 RDWSD-49.4* Plt Ct-87* ___ 07:05AM BLOOD Glucose-93 UreaN-12 Creat-1.1 Na-136 K-3.4* Cl-100 HCO3-29 AnGap-7* ___ 07:05AM BLOOD Mg-1.4* Brief Hospital Course: Mr. ___ is a ___ man with history of CAD s/p CABG, HTN, HLD, DMII, multiple myeloma s/p auto SCT currently on pomalidomide/daratumumab presenting with weakness and fever. #Fever #Sinusitis Patient recently was admitted to BID-M for neutropenic fever with extensive evaluation without source identification. Patient was treated with 10 day course of empiric vancomycin/cefepime. He re-presented with recurrent fever. No clear localizing signs or symptoms of infection other than cough and possible conjunctivitis. CXR was without focal infiltrate. CT chest showed no pneumonia. CT sinus showed possible sinusitis. Patient did have loose stools prior to admission, but they were self-limiting. Infectious disease and oncology were consulted to help advise investigation and management. Patient was treated with empiric broad spectrum antibiotics with IV vancomycin, IV cefepime, and IV metronidazole, then transitioned to PO levofloxacin and flagyl on ___ once it was determined that he likely had viral URI +/- superimposed bacterial conjunctivitis/sinusitis. He remained stable on this regimen and was discharged on levofloxacin and metronidazole to complete a 14-day total course on ___. # Acute metabolic encephalopathy Delirium, febrile effects related to immunotherapy versus infection. Infectious workup and management as above. His encephalopathy resolved with the aforementioned treatment. # Multiple myeloma # Anemia/thrombocytopenia: Currently receiving treatment with daratumumab/pomalidomide. Intention had been to hold pomalidomide, but patient took 2 doses since recent discharge. Held daratumumab/pomalidomide but per Atrius onc. He will see his oncologist Dr. ___ on ___ to discuss resuming therapy. He received 1 U pRBC for symptomatic anemia and Hgb <7. # CAD s/p CABG # Demand ischemia: Patient with mild troponin elevation on admission, likely represents mild demand in setting of acute illness. Patient is asymptomatic and EKG was without acute ischemic changes. His home cardiac medications were resumed. # DMII: Labile blood sugars in setting of recent dexamethasone use. His home medications were resumed # Weakness # Fall Patient with global weakness in setting of febrile illness, labile blood sugars, and multiple myeloma on new immunotherapy regimen. ___ worked with the patient, and his mobility progressed to where they felt he would be safe to return home with home ___. # Conjunctivitis (viral versus bacterial): Patient had scant purulent discharge in left eye in ED and started on erythromycin. He completed 7 days of erythromycin ointment. # Gout: No evidence of acute flare. Mr. ___ was seen and examined on the day of discharge and is clinically stable for discharge today. The total time spent today on discharge planning, counseling and coordination of care was greater than 30 minutes. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Colchicine 0.6 mg PO DAILY 2. Nateglinide 120 mg PO TIDAC 3. pomalidomide 2 mg oral DAILY 4. Dexamethasone 20 mg PO 1X/WEEK (___) 5. fluorouracil 5 % topical DAILY 6. Omeprazole 20 mg PO DAILY 7. colestipol 5 gram oral DAILY 8. Cyanocobalamin 1000 mcg PO DAILY 9. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 10. Glargine 22 Units Bedtime 11. FoLIC Acid 1 mg PO DAILY 12. magnesium chloride 64 mg oral BID 13. Lisinopril 10 mg PO DAILY 14. Atenolol 25 mg PO DAILY 15. Atorvastatin 20 mg PO QPM 16. Aspirin 81 mg PO DAILY 17. Fish Oil (Omega 3) 1000 mg PO DAILY 18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain Discharge Medications: 1. Benzonatate 200 mg PO TID Cough RX benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #30 Capsule Refills:1 2. GuaiFENesin ER 1200 mg PO Q12H RX guaifenesin [Mucus-ER MAX] 1,200 mg 1 tablet(s) by mouth twice a day Disp #28 Tablet Refills:1 3. LevoFLOXacin 750 mg PO DAILY RX levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #8 Tablet Refills:0 4. MetroNIDAZOLE 500 mg PO/NG Q8H RX metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #24 Tablet Refills:0 5. Multivitamins W/minerals 1 TAB PO DAILY RX multivitamin,tx-minerals 1 tablet(s) by mouth once a day Disp #90 Tablet Refills:*3 6. Aspirin 81 mg PO DAILY 7. Atenolol 25 mg PO DAILY 8. Atorvastatin 20 mg PO QPM 9. colestipol 5 gram oral DAILY 10. Cyanocobalamin 1000 mcg PO DAILY 11. Dexamethasone 20 mg PO 1X/WEEK (___) 12. Fish Oil (Omega 3) 1000 mg PO DAILY 13. FoLIC Acid 1 mg PO DAILY 14. Glargine 22 Units Bedtime 15. Lisinopril 10 mg PO DAILY 16. magnesium chloride 64 mg oral BID 17. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 18. Nateglinide 120 mg PO TIDAC 19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain 20. Omeprazole 20 mg PO DAILY 21. HELD- fluorouracil 5 % topical DAILY This medication was held. Do not restart fluorouracil until your oncologist tells you to 22. HELD- pomalidomide 2 mg oral DAILY This medication was held. Do not restart pomalidomide until your oncologist tells you to Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Febrile illness Acute metabolic encephalopathy Multiple myeloma Anemia and thrombocytopenia CAD s/p CABG Demand ischemia Diabetes mellitus Weakness Fall Conjunctivitis Essential hypertension Hyperlipidemia Gout Actinic keratosis: 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: Mr. ___, You were admitted to ___ with an infection. We treated you for a respiratory infection, and your symptoms improved. We would like you to complete a 14-day course of antibiotics to help clear this up. Your oncologist would like to see you in clinic on ___. Followup Instructions: ___
10817631-DS-11	10,817,631	23,330,902	DS	11	2152-10-15 00:00:00	2152-10-15 14:57:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: HYPERCALCEMIA ___ MULTIPLE MYELOMA PROGRESSION Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old man with relapsed multiple myeloma with multiple recent admissions for fevers, cough, and weakness who is admitted from the ED with persistent weakness and falls. Recently admitted ___ to ___ on HMED with weakness and neutropenic fever. He was treated with Vancomycin, cefepime, and metronidazole before transitioning to po levofloxacin and flagyl with planned completion on ___. No source definitively identified but thought viral URI +/- superimposed bacterial conjunctivitis/sinusitis. Course otherwise notable for encephalopathy and weakness. His daratumumab / pomalidomide / dexamethasone were held. He had a similar hospitalization at ___ from ___ to ___. He apparently was considering SNF placement, but reportedly could not be discharged to SNF due to chemotherapy. Since discharge home he has remained extremely weak, with severe difficult ambulating around his home. He has had two additional falls over the weekend, last yesterday. Also notes frequent night sweats with a FSBG of 44 this am. He otherwise denies headaches. No known fevers and his cough has resolved. No visual changes. No dysphagia or odynophagia. No CP, SOB or cough. He had a day of nausea with emesis x2 last week but none since. Appetite is very poor but is tolerating po. No abdominal pain. He notes frequent urination but no dysuria. He had four episodes of diarrhea yesterday. Because of severe weakness and inability to get out of his chair this morning, he presented to ___. Past Medical History: Hypertension Dyslipidemia Diabetes (type II with retinopathy) BPH Colon Polyps s/p polypectomy Lung Nodule (right side- stable) Basal cell CA Diverticulosis Multiple myeloma Social History: ___ Family History: Mother and father died of CAD in their ___ Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 98.0 HR 67 BP 122/58 RR 18 SAT 96% O2 on RA GENERAL: Pleasant chronically ill appearing man sitting up in bed in no distress EYES: Anicteric sclerea, PERLL, EOMI; ENT: Dry MM. Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Decreased bulk NEURO: Alert, oriented, CN III-XII intact, motor and sensory function grossly intact, FTN intact SKIN: Excoriation/scabs over forehead and nose LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE PHYSICAL EXAM: VS: T 98.8 BP 138/54 HR 74 R 18 O2Sat 99 RA GENERAL: Pleasant chronically ill appearing man sitting up in bed in no distress, alert, oriented to self, place, and situation. EYES: Anicteric sclerea, PERLL, EOMI; ENT: Dry MM. Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Decreased bulk NEURO: Alert, oriented to self, place, situation, time SKIN: Skin type II. Scattered scaly, erythematous plaque with hemorrhagic crust on forehead, well healing. ACCESS: PIV Pertinent Results: ADMISSION LABS: ___ 06:51PM CALCIUM-13.7* PHOSPHATE-3.5 MAGNESIUM-0.9* ___ 06:51PM WBC-4.7 RBC-2.84* HGB-8.1* HCT-26.0* MCV-92 MCH-28.5 MCHC-31.2* RDW-15.8* RDWSD-50.5* ___ 06:51PM GLUCOSE-58* UREA N-12 CREAT-1.0 SODIUM-136 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-28 ANION GAP-6* ___ 06:30AM BLOOD FreeKap-269.3* FreeLam-1.1* Fr K/L-244.8* b2micro-17.3* ___ 12:40PM BLOOD PEP-ABNORMAL B IgG-4791* IgA-11* IgM-<5* ___ 12:40PM BLOOD TotProt-10.3* Calcium-12.7* Phos-3.6 Mg-2.0 DISCHARGE LABS: ___ 06:20AM BLOOD WBC-5.9 RBC-2.67* Hgb-7.8* Hct-24.3* MCV-91 MCH-29.2 MCHC-32.1 RDW-17.0* RDWSD-53.7* Plt ___ ___ 06:20AM BLOOD Glucose-88 UreaN-10 Creat-0.9 Na-137 K-3.9 Cl-102 HCO3-24 AnGap-11 ___ 06:20AM BLOOD Calcium-8.8 Phos-4.8* Mg-1.5* PERTINENT IMAGING: MRI HEAD W/ W/O CONTRAST ___ 1. No acute infarcts, mass effect or hydrocephalus. 2. No enhancing brain lesions or leptomeningeal enhancement. 3. Marrow signal abnormalities at the clivus and upper cervical spine is a nonspecific finding and could indicate marrow infiltrative process from myeloma or marrow hyperplasia. Brief Hospital Course: Mr. ___ is a ___ year old man with relapsed multiple myeloma with multiple recent admissions for fevers, cough, and weakness who was admitted with persistent weakness and falls in the setting of profound hypercalcemia, hypomagnesemia, and AMS. His calcium normalized after dexamethasone and pamidronate, and his mental status also improved over the course of the hospitalization. TRANSITIONAL ISSUES: [] Follow up with Dr. ___ on ___ for further treatment of multiple myeloma [] Check Calcium, Blood Glucose, Magnesium on ___ [] Check Hgb on ___, transfuse for hgb<7 (required 1u prbcs on ___ [] Follow up on blood sugars; discharged on glargine 10u at bedtime (home dose was 22u, dose reduced to low morning blood glucose close to discharge); discharged on home metformin; home nateglinide held on discharge, can be restarted by outpatient provider [] Follow up about re-starting atenolol (held in the setting of low heart rates and low pressures) [] Started on acyclovir ppx # HYPERCALCEMIA OF MALIGNANCY: # HYPOMAGNESEMIA: # ENCEPHALOPATHY Patient had hypercalcemia in setting of relapsed multiple myeloma. His corrected calcium on admission was 15.1. He was given Pamidronate 90mg IV as well as dexamethasone 40mg for four days. On discharge, it was 10.2 when corrected for albumin. His mental status on admission was altered as he made several comments not consistent with his environment. His mental status improved with correction of calcium. A complete work up including, TSH, RPR, B12, and MRI was done with consultation of neurology and everything was within in normal limits. On discharge, mental status was clear. # HYPOGLYCEMIA ___ STEROID TAPER # DMII Patient initially had symptomatic hypoglycemia, then was hyperglycemic in the setting of dexamethasone. With insulin titration, had some low blood sugars. On discharge his insulin regimen is 10 units of lantus at night (takes 22 units of lantus at home prior to admission). His fasting BG on the morning of discharge was 88. Metformin held during hospitalization, will be continued on discharge. Nateglinide 120 mg PO TIDAC held during hospitalization and on discharge, can be started by PCP. # HEMATURIA Patient complained of blood in urine with no other urinary symptoms. He had no discoloration of urine, but on exam he had gross blood at the end of the meatus. He has not been catheterized this hospitalization. A UA showed moderate blood in urine with glucose ~300. On the following day his symptoms resolved. # BRADYCARDIA During his 4 day steroid regimen, his HR dropped to 30's and 40's. Upon completion of steroid course, his HR resumed to the the ___. The etiology of this was most likely ___ atenolol and recent dexamethasone course. His home atenolol was held on discharge and can be restarted in outpatient setting. # MULTIPLE MYELOMA He is s/p Auto-SCT (___) with newly relapsed disease and now s/p cycle 1 of Dex/Pomalidomide/Daratumumab. He received dexamethasone 40mg for 4 days in the hospital. Plan, per Dr. ___, is to resume Dex/Pomalidomide/Daratumumab as outpatient with Dr. ___ ___. CHRONIC ISSUES: # CAD sp CABG # S/p CEA # HLD # HTN His home ASA 162mg daily, home lisinopril, and home atorvastatin were continued in the hospital. # Skin cancer He had been using topical ___ x3 weeks and was on a break when he was admitted. We monitored his skin and he had no concerning lesions. Can be followed up in outpatient setting. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 162 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Cyanocobalamin 1000 mcg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Benzonatate 200 mg PO TID:PRN Cough 7. Fish Oil (Omega 3) 1000 mg PO DAILY 8. Multivitamins W/minerals 1 TAB PO DAILY 9. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 10. LevoFLOXacin 750 mg PO DAILY 11. MetroNIDAZOLE 500 mg PO/NG Q8H 12. Atenolol 12.5 mg PO DAILY 13. colestipol 5 gram oral DAILY 14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain 15. magnesium chloride 64 mg oral BID 16. Nateglinide 120 mg PO TIDAC 17. Lisinopril 10 mg PO DAILY 18. fluorouracil 5 % topical DAILY 19. Glargine 22 Units Bedtime 20. Acetaminophen 650 mg PO Q12H:PRN Pain - Mild/Fever Discharge Medications: 1. Acyclovir 400 mg PO Q12H RX acyclovir 400 mg 1 capsule(s) by mouth twice a day Disp #60 Tablet Refills:*0 2. Glargine 10 Units Bedtime 3. Acetaminophen 650 mg PO Q12H:PRN Pain - Mild/Fever 4. Aspirin 162 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Benzonatate 200 mg PO TID:PRN Cough 7. colestipol 5 gram oral DAILY 8. Cyanocobalamin 1000 mcg PO DAILY 9. Fish Oil (Omega 3) 1000 mg PO DAILY 10. FoLIC Acid 1 mg PO DAILY 11. Lisinopril 10 mg PO DAILY 12. magnesium chloride 64 mg oral BID 13. MetFORMIN XR (Glucophage XR) 1000 mg PO BID Do Not Crush 14. Multivitamins W/minerals 1 TAB PO DAILY 15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain 16. Omeprazole 20 mg PO DAILY 17. HELD- Atenolol 12.5 mg PO DAILY This medication was held. Do not restart Atenolol until you see your pcp 18. HELD- Nateglinide 120 mg PO TIDAC This medication was held. Do not restart Nateglinide until you see your primary care doctor. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: HYPERCALCEMIA ___ MULTIPLE MYELOMA PROGRESSION Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___ ___ ___. WHY WAS I IN THE HOSPITAL? - You were admitted for high calcium levels and confusion. WHAT HAPPENED TO ME IN THE HOSPITAL? - You were given a medication and some fluids to decrease your calcium. - You had some low blood sugars after we took you off the steroid and we titrated your medications to fix your sugars WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
10818031-DS-20	10,818,031	29,324,388	DS	20	2189-07-25 00:00:00	2189-07-25 17:15:00	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: ___: ___ History of Present Illness: ___ with 2 weeks of lower pelvic pain/pressure. Seen by her Ob-Gyn with pelvic U/S showing "cysts." Patient's symptoms became worse over the past ___ days with increasing focal LLQ tenderness, - flatus/BM, fevers/chills, poor appetite and increasing abd distention. Seen at OSH (___) and CT A/P obtainined which was "normal" per patient. Seen by her Ob-Gyn again recently with labs showing leukocytosis and CT scan performed showing LBO with sigmoid volvulus. Past Medical History: PMhx: Omphalocele, SBO PShx: Omphalocele reduction, CCY, C-section X 2 Social History: ___ Family History: No GI malignancy/IBD Physical Exam: On admission: PE: 101.6 112 119/72 18 99% A+OX3 RRR CTAB Distended, focal peritonitis on LLQ with guarding rectal exam WNL, guiac negative, no masses felt no c/c/e On discharge: ___ Gen: awake, alert, NAD HEENT: MMM CV: RRR Pulm: Nonlabored breathing Abd: soft, appropriately tender, nondistended. ostomy pink, +gas / stool. incision opened at middle aspect with serosanguinous drainage, no erythema/induration. Ext: no ___ Pertinent Results: ___ 05:00AM BLOOD WBC-15.6* RBC-2.76* Hgb-8.9* Hct-27.2* MCV-99* MCH-32.3* MCHC-32.8 RDW-13.7 Plt ___ ___ 04:00AM BLOOD WBC-16.0* RBC-2.84* Hgb-9.2* Hct-28.3* MCV-100* MCH-32.3* MCHC-32.4 RDW-13.8 Plt ___ ___ 04:55AM BLOOD WBC-14.5* RBC-2.92* Hgb-9.1* Hct-29.5* MCV-101* MCH-31.1 MCHC-30.7* RDW-13.9 Plt ___ ___ 05:35AM BLOOD WBC-14.2* RBC-2.96* Hgb-9.7* Hct-29.9* MCV-101* MCH-32.6* MCHC-32.3 RDW-13.4 Plt ___ ___ 05:25AM BLOOD WBC-15.4* RBC-3.22* Hgb-10.4* Hct-31.9* MCV-99* MCH-32.2* MCHC-32.4 RDW-13.3 Plt ___ ___ 08:02AM BLOOD WBC-16.4* RBC-3.51* Hgb-11.6* Hct-35.1* MCV-100* MCH-33.0* MCHC-33.0 RDW-13.2 Plt ___ ___ 01:21AM BLOOD WBC-16.8* RBC-3.71* Hgb-11.9* Hct-36.6 MCV-99* MCH-32.0 MCHC-32.5 RDW-13.0 Plt ___ ___ 06:15PM BLOOD WBC-16.5* RBC-3.74* Hgb-12.1 Hct-36.9 MCV-99* MCH-32.3* MCHC-32.7 RDW-13.0 Plt ___ ___ 05:00AM BLOOD Plt ___ ___ 04:00AM BLOOD Plt ___ ___ 04:55AM BLOOD Plt ___ ___ 04:00AM BLOOD Glucose-85 UreaN-9 Creat-1.2* Na-140 K-4.0 Cl-105 HCO3-29 AnGap-10 ___ 04:55AM BLOOD Glucose-128* UreaN-9 Creat-1.3* Na-138 K-3.5 Cl-102 HCO3-27 AnGap-13 ___ 05:35AM BLOOD Glucose-115* UreaN-11 Creat-1.4* Na-134 K-3.4 Cl-99 HCO3-27 AnGap-11 CT A/P: LBO ___/ sigmoid volvulus with ascites ___ 04:00AM BLOOD Calcium-7.9* Phos-3.5 Mg-1.7 ___ 04:55AM BLOOD Calcium-7.9* Phos-3.1 Mg-1.9 ___ 06:26PM BLOOD Lactate-0.9 Brief Hospital Course: he patient was admitted to the Acute Care Surgical Service on ___ for a sigmoid volvulus and went to the OR for a ___ procedure. The procedure went well without complication (reader referred to the Operative Note for details). Of note, there was purulent fluid in the abdomen for which cultures were sent and the patient was placed on antibiotics (see below). After a brief, uneventful stay in the PACU, the patient arrived on the floor in good condition. Neuro: The patient received a dilaudid PCA 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 spirometry 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. The patient received ostomy teaching and the ostomy was pink at the time of discharge. ID: The patient had purulent fluid noted at the time of the operation and a perforation was suspected. She was placed on broad spectrum antibiotics post-operatively and when tolerating a PO diet was switched to augmentin for a total of one week course. On POD5, she noted increasing drainage from her wound, and there was mild associated erythema. Two staples were removed and purulent fluid was expressed and cultures were sent. The wound is being packed wet to dry. She was discharged on a one week total course of augmentin. 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. She will follow up with the ___ clinic in two weeks. Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice daily Disp #4 Tablet Refills:0 2. Acetaminophen 1000 mg PO Q6H:PRN pain 3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth every four hours for pain Disp #40 Tablet Refills:0 4. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #60 Capsule Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: large bowel onstruction ___ sigmoid voluvlus s/p ex-lap sigmoid colectomy and ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. Monitoring Ostomy output/ Prevention of Dehydration: Keep well hydrated. Replace fluid loss from ostomy daily. Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. Try to maintain ostomy output between 1000mL to 1500mL per day. If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. Please follow up with ACS and your primary care within two weeks as scheduled for you. See below. Followup Instructions: ___
10818910-DS-25	10,818,910	28,136,223	DS	25	2146-06-06 00:00:00	2146-06-06 17:46:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: nausea, vomiting, increased ostomy output Major Surgical or Invasive Procedure: None. History of Present Illness: ___ hx Crohn's s/p colectomy with ostomy, hysterectomy, oophorectomy. She presents as transfer from ___ with acute onset of nausea, vomiting, abdominal pain, and increased ostomy output. She was in her USOH until ___, when she developed worsening abdominal discomfort just beneath the umbilicus and in the RLQ. The pain worsened, but she was able to eat dinner as normal. She went to sleep, but was awakened from sleep with severe abdominal pain, nausea, and vomiting. She had been warned by her surgeon that she would likely develop a small bowel obstruction one day (she is an ___ - cardiac/neuro). Would have come to ___, but couldn't drive herself. EMS took her to ___. She was given morphine/zophran, IVF which improved her symptoms. Subsequently KUB was performed which showed no perforation. She was offered transfer to ___ for evaluation because her surgical care is here, which she accepted. In the ED, initial VS 97.0 78 105/69 19 99% RA - Patient reported her pain, nausea and vomiting had resolved in the ED; she also noted ostomy output was decreased. - Exam notable for soft, nondistended abd, diffuse ttp most significant in the bilateral lower quadrants. - Labs notable for normal CBC, normal chemistry, normal LFTs, CRP 1.0. - ECG showed NSR with one PAC. - CTAP was concerning for early or partial SBO (full report below). - Surgery and GI were consulted; admission to Medicine was recommended for serial abdominal exams. On arrival to the floor, she endorses the above. Denies chest pain, dizziness, shortness of breath or numbness/tingling. No fever or chills. Patient denies recent travel, no sick contacts and no foreign food ingestions. Of note, patient states she has hx of Crohn's. Initially dx'ed with UC. However, has had oral ulcers and lesions throughout the GI tract. However, bx has never been definitively positive for Crohn's. However, GI has treated her as crohn's. She has hx of colectomy. Reason for this is an episode of toxic megacolon. She states that she was in hospital for Crohn's flare when she developed "massive hemorrhage from below," passed out, woke with colectomy. ================== 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: Past Medical History: - indeterminate colitis (Crohn's vs UC) - hx of DVT - GERD - lupus anticoagulant antibody - back pain - ___ asthma - gestational diabetes. Past Surgical History: - colectomy and ileostomy - hysterectomy - L oophorectomy for symptomatic ovarian cyst - R oophorectomy for symptomatic ovarian cyst - multiple exploratory laparotomies with LOA Social History: ___ Family History: adopted, unknown Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals: 97.9 PO 96 / 56 71 16 99 RA Genl: tired but nontoxic, NAD HEENT: PERRL, no icterus, MMM Cor: RRR NMRG Pulm: CTAB Abd: soft, nondistended. midline incisions, healed. ostomy with bag in place containing flatus and watery output. minimal ttp greatest just below umbilicus and RLQ. Neuro: AOX3 MSK: extr wwp without edema DISCHARGE PHYSICAL EXAM: ======================== Vitals: Tc 98.1 Tm 98.8 BP 109/52 (___) HR ___ RR 18 O2sat 100% RA , 24 hr I/O: 1655/115 (ostomy 115 cc) 8 hr I/O: ___ General: tired, NAD, resting comfortably in bed HEENT: PERRL, no icterus, MMM Cor: RRR No M/R/G Pulm: Nonlabored breathing. CTAB Abd: soft, nondistended. midline incisions, healed. Ostomy with bag in place containing flatus and ___ output. No longer ttp in lower abdomen. No rebound or guarding. Neuro: A&OX3 EXTREMITIES: wwp without edema, clubbing, or cyanosis Pertinent Results: ADMISSION LABS: ======================== ___ 07:00AM URINE ___ ___ 07:00AM URINE ___ ___ 07:00AM URINE ___ ___ 07:00AM URINE GR ___ ___ 07:00AM URINE ___ SP ___ ___ 07:00AM URINE ___ ___ ___ ___ 07:00AM URINE ___ ___ ___ 07:00AM URINE ___ ___ 05:15AM ___ UREA ___ ___ TOTAL ___ ANION ___ ___ 05:15AM ___ this ___ 05:15AM ALT(SGPT)-11 AST(SGOT)-22 ALK ___ TOT ___ ___ 05:15AM ___ ___ 05:15AM ___ ___ 05:15AM ___ ___ 05:15AM ___ ___ ___ 05:15AM ___ ___ IM ___ ___ ___ 05:15AM PLT ___ MICROBIOLOGY: ======================== STOOL CONSISTENCY: WATERY Source: Stool. ___ 11:12 am) MICROSPORIDIA STAIN (Final ___: NO MICROSPORIDIUM SEEN. CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN. C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference ___. FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. 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. Cryptosporidium/Giardia (DFA) (Final ___: NO CRYPTOSPORIDIUM OR GIARDIA SEEN. IMAGING: ======================== CT ABD & PELVIS w/contrast (___): IMPRESSION: 1. Status post total colectomy and right lower quadrant ileostomy with prominent ___ small bowel loops within the pelvis and a gradual transition to collapsed loops in the right lower quadrant, findings concerning for an early or partial small bowel obstruction. No discrete transition point. 2. Normal small bowel wall thickness and enhancement. 3. Small amount of nonhemorrhagic free fluid within the pelvis. KUB (supine and erect) (___): FINDINGS: Multiple surgical clips are again demonstrated throughout the abdomen, better visualized on the CT examination from ___. A normal bowel gas pattern is demonstrated. There is no free air. The lung bases are clear. IMPRESSION: Normal bowel gas pattern. No radiographic evidence of bowel obstruction or ileus. KUB (supine and erect) (___): FINDINGS: There is a paucity of bowel gas throughout the abdomen. There are no abnormally dilated ___ loops of small and large bowel. A right lower quadrant ostomy is noted. There is no free intraperitoneal air. Osseous structures are unremarkable. Multiple semi circular surgical clips are seen over the abdomen. IMPRESSION: Examination is limited by paucity of bowel gas. No ___ loops of dilated small or large bowel to indicate bowel obstruction. PERTINENT & DISCHARGE LABS: ========================== ___ 06:31AM BLOOD ___ ___ Plt ___ ___ 10:15PM BLOOD ___ ___ Plt ___ ___ 05:41AM BLOOD ___ ___ Plt ___ ___ 07:45AM BLOOD ___ ___ Plt ___ ___ 07:20AM BLOOD ___ ___ Plt ___ ___ 06:33AM BLOOD ___ ___ Plt ___ ___ 07:35AM BLOOD ___ ___ Plt ___ ___ 07:45AM BLOOD ___ ___ ___ ___ 07:20AM BLOOD ___ ___ Im ___ ___ ___ 06:33AM BLOOD ___ ___ ___ ___ 07:35AM BLOOD ___ ___ Im ___ ___ ___ 06:31AM BLOOD Plt ___ ___ 10:15PM BLOOD Plt ___ ___ 05:41AM BLOOD Plt ___ ___ 07:45AM BLOOD Plt ___ ___ 07:20AM BLOOD Plt ___ ___ 06:33AM BLOOD Plt ___ ___ 07:35AM BLOOD Plt ___ ___ 06:31AM BLOOD ___ ___ ___ 05:41AM BLOOD ___ ___ ___ 07:45AM BLOOD ___ ___ ___ 07:20AM BLOOD ___ ___ ___ 06:33AM BLOOD ___ ___ ___ 07:35AM BLOOD ___ ___ ___ 06:31AM BLOOD ___ ___ 05:41AM BLOOD ___ ___ 07:45AM BLOOD ___ ___ 07:20AM BLOOD ___ ___ 06:33AM BLOOD ___ ___ 07:35AM BLOOD ___ Brief Hospital Course: Ms. ___ is a ___ female with ___ hx Crohn's s/p colectomy with ostomy, hysterectomy, oophorectomy. She presented as transfer from ___ with acute onset of nausea, vomiting, lower abdominal pain, and increased ostomy output. #Partial Small Bowel Obstruction: On admission, the patient was nauseous and had pain and tenderness in her LLQ>RLQ. Her labs were notable for a CBC wnl, chem10 wnl, lipase wnl, LFTs wnl, bland UA. CRP 1.0. She had a CT abdomen/pelvis which revealed a prominent ___ small bowel loops within the pelvis and a gradual transition to collapsed loops in the right lower quadrant, which was c/f an early or partial small bowel obstruction. Pt's SBO was likely related to intraabdominal adhesions from her many prior abdominal surgeries, although a contribution from gastroenteritis was considered given that patient had increased, watery ostomy output. Patient was initially made NPO for bowel rest and started on IVF. Her nausea was controlled with IV ondansetron. Her nausea progressively improved, and her abdominal pain and tenderness resolved. Her diet was progressively advanced to clear sips, and ultimately to a full, regular diet including her PO medications, at which point mIVF were discontinued. Patient was tolerating regular, full diet on discharge. Of note, patient had several infectious studies as part of a workup for gastroenteritis, which were all negative, including C diff, Salmonella, Shigella, Campylobacter, Yersinia, E. coli: 0157:H7, Cryptosporidium, Giardia, Cyclospora, and microsporidium, O&P. Guaiac neg x1 on ___. #Leukopenia: Patient became leukopenic during admission w/WBC 2.8 on ___ from 6.1 on ___. She remained leukopenic throughout the remainder of her hospitalization with WBC 2.7 at time of discharge on ___. We initially considered that this was dilutional b/c of mild decrease in all counts at first, however, draws from the ___ line consistently demonstrated leukopenia, while other counts have normalized. Considered that leukopenia was ___ to infection, although it has been persistent regardless of pt's improvement in clinical status, and negative infectious ___. Also considered that it might be related to her home ___, which was held iso leukopenia. Have sent labs for thiopurine metabolites to assess for this possibility. #Crohn's disease: Patient's ___ was held in the setting of leukopenia as above. Labs for thiopurine metabolites are pending at the time of discharge. Initially received IV ondansetron for nausea as above, which was changed to home PO ondansetron as patient's nausea improved and she tolerated PO intake. ___ asthma: Patient did not have any symptoms during hospitalization. Was continued on home albuterol inhaler. #Hx of PVCs: Pt's home atenolol was held while NPO and restarted prior to discharge. #GERD: Held patient's home omeprazole while NPO, but restarted once tolerating PO. #Estrogen supplementation: Held estradiol 1mg daily while NPO, was restarted once tolerating full diet for discharge. TRANSITIONAL ISSUES: ==================== - Patient was persistently leukopenic, WBC ___ range, during admission. ___ was held and labs for thiopurine metabolites are pending. Please check CBC at PCP ___ to evaluate restarting ___. - Code status: full - HCP: ___, Husband ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea 2. Atenolol 12.5 mg PO BID 3. Estradiol 1 mg PO DAILY 4. Mercaptopurine 25 mg PO BID 5. Ondansetron 4 mg PO Q6H:PRN nausea 6. Pantoprazole 20 mg PO Q12H Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea 2. Estradiol 1 mg PO DAILY 3. Ondansetron 4 mg PO Q6H:PRN nausea 4. Pantoprazole 20 mg PO Q12H Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: ================= Partial Small Bowel Obstruction Leukopenia SECONDARY DIAGNOSES: ================= Crohn's disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted with nausea, vomiting, lower abdominal pain, and increased ostomy output. You had CT imaging of your abdomen which were concerning for partial small bowel obstruction. Your small bowel obstruction is likely related to scarring from your previous abdominal surgeries. We also considered that you may have had a gastroenteritis that may have contributed, although all of your infectious studies were negative. We treated you with "bowel rest" meaning that we waited for your symptoms to improve before having you eat, and in the interim, we gave you IV fluids. Over the course of a few days, your nausea improved, and you were gradually progressed from a liquid to a full, regular diet. Of note, your WBC was persistently low during your hospitalization, and because of this, we had to stop your ___ as this can be associated with a low WBC count. Please make sure that you talk to your gastroenterologist before starting to take ___. We have made the following appointments for you: # Appointment at your PCP's office with Dr. ___ on ___ at 11:00 AM at ___ floor, ___ # Gastroenterology will call you to schedule an appointment. If you have not heard from them within 2 business days following discharge, please call their office at ___. It was a pleasure taking care of you! We wish you all the best! Your team at ___ Followup Instructions: ___
10819462-DS-7	10,819,462	25,434,274	DS	7	2181-09-15 00:00:00	2181-09-15 16:20:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Back pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of HTN, chronic renal insufficiency, asthma, OSA, and GERD, who presented to ED with worsening low back pain. Patient was in usual state of health until about 5 days ago, when he reports he woke up with left-sided lower back pain. He initially reports just discomfort, but over the next day the pain progressed to a sharp, stabbing pain unlike any pain he has had before. The pain is mainly in the left sacral area, but does not radiate down into the leg left. He denies any preceding injury or trauma. He also denies any fevers, chills, lower extremity weakness/numbness/tingling, urinary retention or bowel dysfunction. Does report two month history of slight urine leaking when he goes to the bathroom. He has no known history of malignancy and denies any history of IVDU. States he recently had his prostate checked by his PCP and was told everything was normal. States he was initially able to work, but over the past few days has progressive difficulty ambulating due to pain. The pain is not constant, and will improve when he is still for a period of time, but is exacerbated when he first gets up and when he walks around. Saw his PCP two days ago, and was prescribed naproxen and cyclobenzaprine. States he took naproxen but without relief of pain, and therefore presented to ED for evaluation yesterday. In the ED, initial vitals were 98.6 61 124/84 14 98% RA. On exam, he had no TTP along the midline of the back or in the left paraspinal area. Did have pain with left leg raise, with pain most prominent in the sacral area. No labs done. He had x-rays of the lumbo-sacral spine, hip, and pelvis which were negative for fracture. Pain initially treated with toradol and diazepam. He subsequently received oxycodone-acetaminophen and IV hydromorphone. Plan was to trial him on oral pain medication this morning, but patient was having difficulty walking due to pain that was not adequately controlled on oral medication. Therefore, he is being admitted for pain control and possible further work-up. Vitals prior to transfer 97.6 63 126/84 18 96% RA. On arrival to the floor, patient states he is comfortable, with no significant back pain while at rest. Review of sytems: (+) Per HPI. (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain, tightness, or palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel habits. No dysuria. No arthralgias or myalgias other than back pain as above. Past Medical History: Hypertension Obesity OSA (unable to tolerate CPAP) Asthma GERD Chronic renal insufficiency (Cr 1.4-1.6 in ___ system) Arthritis Club feet Prior foot and knee surgeries Social History: ___ Family History: CAD in uncle, grandfather. Mother had lung cancer. Father had leukemia. Physical Exam: ADMISSION EXAM: VS: 97.9 140/92 66 22 99% RA, weight 149.7 kg GENERAL: obese but otherwise well appearing male, resting in bed, NAD HEENT: PERRL, EOMI, sclera anicteric, MMM, OP clear NECK: supple, no cervical LAD, unable to assess JVP due to body habitus CARDIAC: RRR, no r/m/g LUNGS: CTAB, no wheezing/rales/rhonchi ABDOMEN: obese, soft, NT, ND, no organomegaly, no guarding/rebound, normoactive bowel sounds EXTREMITIES: warm, well-perfused, 2+ pulses, no edema NEURO: CN II-XII grossly intact, strength ___ throughout, sensation grossly intact to light touch, Patellar reflexes 2+ and symmetric bilaterally, Achilles reflexes diminished but symmetric bilaterally, down-going toes, back pain in left sacral area upon lifting left leg to 40 degrees but no pain with lifting right leg, (normal rectal tone per attending Dr. ___ ___ BACK: no mid-line tenderness to palpation, no TTP along paraspinal muscles in lumbar area SKIN: no rashes or jaundice, back slightly diaphoretic PSYCH: calm, appropriate affect DISCHARGE EXAM: VS: 97.9 113/78 74 20 100% RA GENERAL: obese but otherwise well appearing male, resting in bed, NAD HEENT: sclera anicteric, MMM, OP clear NECK: supple, unable to assess JVP due to body habitus CARDIAC: RRR, no r/m/g LUNGS: CTAB, no wheezing/rales/rhonchi ABDOMEN: soft, NT, ND, no guarding/rebound, normoactive bowel sounds EXTREMITIES: warm, well-perfused, 2+ pulses, no edema BACK: no midline tenderness to palpation, straight leg raise on left elicited back pain at about 40 degrees NEURO: strength ___ lower ext, sensation grossly intact to light touch low extremities, Patellar reflexes 2+ and symmetric bilaterally, down-going toes Pertinent Results: ADMISSION LABS: ___ 03:25PM BLOOD WBC-6.7 RBC-5.28 Hgb-16.4 Hct-49.0 MCV-93 MCH-31.1 MCHC-33.5 RDW-14.2 Plt ___ ___ 03:25PM BLOOD Neuts-67.8 ___ Monos-6.7 Eos-4.0 Baso-0.9 ___ 03:25PM BLOOD ___ PTT-35.0 ___ ___ 03:25PM BLOOD Glucose-90 UreaN-18 Creat-1.5* Na-139 K-4.3 Cl-99 HCO3-30 AnGap-14 ___ 03:25PM BLOOD Calcium-9.4 Phos-4.0 Mg-2.0 DISCHARGE LABS: ___ 07:30AM BLOOD Glucose-79 UreaN-18 Creat-1.3* Na-134 K-4.1 Cl-97 HC___ AnGap-12 IMAGING: L-spine x-ray ___: There is minimal leftward convex curvature, but no spondylolisthesis. The vertebral body heights and interspaces appear preserved with minimal anterior osteophyte formation among levels. There is no evidence for fracture, dislocation or bone destruction. IMPRESSION: Very mild degenerative changes. Hip/Pelvic x-ray ___: There is no evidence for fracture, dislocation or bone destruction. The hip joint spaces are preserved. The mineralization appears within normal limits. Bilaterally, there is a convex contour to the femoral head-neck junction with an appearance that may reflect a pre-disposition to femoroacetabular impingement in the appropriate clinical setting, but correlation with physical findings and time course of symptoms is suggested. IMPRESSION: No evidence of fracture. Findings which may relate to a pre-disposition to femoroacetabular impingement, for which correlation with clinical presentation and findings is recommended. MR arthrography may be helpful to assess further if clinically indicated. MRI L-spine ___: From T11-12 to L3-4, mild degenerative disc disease and minimal bulging seen. At L4-5, disc bulging and a left-sided disc herniation extends inferiorly to the left lateral recess of L5 and could result in irritation of left L5 nerve root. At L5-S1 level, mild degenerative disc disease seen. The distal spinal cord and paraspinal soft tissues are unremarkable. IMPRESSION: Left-sided disc herniation at L4-5 level extending inferiorly ___ could result in irritation of left L5 nerve root. Mild degenerative changes at other levels. Brief Hospital Course: ___ with history of HTN, chronic renal insufficiency, asthma, OSA, and GERD, who presented with worsening back pain. Was neurologically intact but found to have a left-sided disc herniation at L4-5 level, likely causing an L5 radiculopathy. ACTIVE ISSUES: # Lumbar radiculopathy: Patient presented with 5 day history of worsening back pain, without clear antecedent trauma. He had no red flag symptoms and was neurologically intact. Due to the severity of his pain and difficulty ambulating due to pain, he was admitted for pain control and ___ evaluation. X-rays of the L-spine, hip, and pelvis were negative for fracture. MRI of L-spine showed left-sided disc herniation at L4-5 level extending inferiorly, possibly causing irritation of the left L5 nerve root. Was felt that lumbar radiculopathy was most likely etiology of his pain. While x-rays showed pre-disposition to femoroacetabular impingement, location of current pain not c/w this diagnosis. His pain was reasonably controlled with standing acetaminophen and tramadol. Was initially on IV hydromorphone, and transitioned to oxycodone 10 mg PO Q4H prn pain prior to discharge. Was evaluated by ___, and will continue outpatient ___ on discharge. Will follow-up with PCP and pain clinic, and if pain not improving with conservative therapy may benefit from referral to Ortho-Spine. # Hypertension: BP intermittently elevated during the hospitalization, in setting of acute pain. Continued home moexipril-hydrochlorothiazide. If BP remains elevated once acute pain resolves, may need uptitration of home antihypertensive regimen. CHRONIC ISSUES: # CKD Stage 3: Last Cr in our system was 1.4-1.6. Per notes, attributed to adverse effect of antibiotic therapy after patient treated for empyema in ___. Cr was stable this admission, ranging 1.3-1.5. Avoided NSAIDs. # Asthma/Seasonal allergies: Stable. Continued home Advair, albuterol inhaler as needed. Continued fluticasone nasal spray, fexofenadine as needed. # GERD: Stable. Continued home omeprazole. TRANSITIONAL ISSUES: #If pain does not continue to improve with conservative management, would refer patient to Ortho-Spine. #Hip x-rays show pre-disposition to femoroacetabular impingement. If patient develops hip pain in future would consider this diagnosis and refer to Ortho. #BP intermittently elevated in hospital. If BP control does not improve with improved pain control, may need uptitration of antihypertensives. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 2. Astepro NF (azelastine) 0.15 % (205.5 mcg) NU BID 3. Fexofenadine 60 mg PO DAILY:PRN allergy symptoms 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY 5. Aspirin 81 mg PO DAILY 6. Moexipril 15 mg PO DAILY 7. Hydrochlorothiazide 25 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB/wheezing 10. Naproxen Dose is Unknown PO Frequency is Unknown 11. Cyclobenzaprine Dose is Unknown PO Frequency is Unknown Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB/wheezing 2. Aspirin 81 mg PO DAILY 3. Fexofenadine 60 mg PO DAILY:PRN allergy symptoms 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. Hydrochlorothiazide 25 mg PO DAILY 7. Moexipril 15 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Acetaminophen 1000 mg PO TID RX acetaminophen 500 mg 2 tablet(s) by mouth three times a day Disp #180 Tablet Refills:0 10. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 11. Senna 1 TAB PO BID:PRN constipation RX sennosides [senna] 8.6 mg 1 cap by mouth twice a day Disp #60 Capsule Refills:0 12. TraMADOL (Ultram) 50 mg PO QID RX tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #90 Tablet Refills:0 13. Astepro NF (azelastine) 0.15 % (205.5 mcg) NU BID 14. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain RX oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:*0 15. Outpatient Physical Therapy Left sided L5 radiculopathy ICD-9: 722.10 (Displacement of lumbar intervertebral disc without myelopathy) Evaluation and Treatment Discharge Disposition: Home Discharge Diagnosis: Primary: lumbar radiculopathy, herniated disc Secondary: hypertension, chronic kidney disease 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 part in your care during your admission to ___. You were admitted to the hospital with severe pain in the lower left side of your back. An MRI showed that you have a herniated disc, which is likely irritating the L5 nerve root and causing your back pain. This type of pain is called a lumbar radiculopathy. We gave you pain medication, had you work with physical therapy, and your pain improved. You are now stable for discharge home, but you will need to continue working with physical therapy as an outpatient. You may continue to take acetaminophen, tramadol, and oxycodone as needed for your pain. These medications can cause constipation, so it is important you drink plenty of fluids and eat a high fiber diet. You can also take an over-the-counter stool softener, such as docusate sodium, to help prevent constipation, as well as a medication called senna. You should follow-up with your primary care doctor, and we have also set you up to see a pain specialist. Please discuss with your primary care doctor about whether you should see an Orthopedic specialist if your back pain does not continue to improve. Followup Instructions: ___
10819468-DS-10	10,819,468	28,511,056	DS	10	2170-04-12 00:00:00	2170-04-13 18:28:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Lactulose Attending: ___. Chief Complaint: Umbilical hernia Major Surgical or Invasive Procedure: umbilical hernia repair with mesh ___ History of Present Illness: ___ ETOH Cirrhosis (Child A) c/b esophageal varicies, splenomegaly, and HRS gets HD via RUE AVF MWF. Patient has h/o umbilical hernia in the past, and over several years, this hernia has been getting larger. Currently the hernia interferes with his ADLs. Patient notes that he has difficulty ambulating and sitting down due to the size of the hernia. Additionally, he states that he is more constipated. No f/c, tolerating regular diet and passing flatus still. Last C-scope in ___ with small diverticula seen. Patient on prior imaging has trace ascites and has never required a paracentesis before. Patient recently lost PCP care and was seen by his hepatologist who instructed him to come into the ED for further evaluation of this hernia. Past Medical History: 1. Multiple admissions to ___ for upper and lower GI bleeds. --___: transfused 9U PRBC, 8U FFP and 10U plts. No noted varices on EGD ___. Thought to be secondary to erosive esophagitis. --___: OSH transfused 14U PRBC, 1U FFP and 2Uplts. Gastropathy noted on EGD at ___. 2. EtOH cirrhosis: acute EtOH hepatitis in ___ (was not started on corticosteroids due to GI bleed, UTI and ___ was started on pentoxyphyline to prevent HRS with a planned 4 week course from ___ (last day ___ negative hepatitis A, B and C serologies. Complicated by GI bleeds as above in the past (but no varices), and possible history of HRS. 3. CKD: Cr baseline around 3.0. Was HD-dependent via RUE fistula until ___. Diagnosis was multifactorial from ATN +/- NSAIDs +/- HRS. He resumed HD (MWF) in ___ after recurrent HRS/ATN. 4. MRSA bacteremia ___ treated with vancomycin 5. EtOH abuse with h/o seizures in the setting of heavy alcohol consumption 6. Gastroesophageal Reflux Disease 7. MVA ___: Right femur fracture with ___ placement, pelvic fracture 8. Asthma Social History: ___ Family History: Mother - ___ ___ alcoholic liver disease Father - ___ ___ colon cancer, diagnosed in his ___. No other family history of colon cancer. Physical Exam: 98.6 88 107/47 18 100% ra NAD, A+OX3 No jaundice RRR CTAB RUE - aneurysmal AVF + thrill Soft, large multilobulated umbilical hernia, able to be reduced very slowly at bedside however recurs again, no cellulitis/induration to suggest strangulation. No evidence of ascites on examination mild edema b/l Labs: CBC: 6.6/17.3/197, repeat Hct 17 Chem: ___ Coag: ___ lactate: 1.3 ___ Pertinent Results: ___ 10:45AM BLOOD WBC-6.6 RBC-1.85# Hgb-5.7# Hct-17.3# MCV-93 MCH-30.7 MCHC-32.9 RDW-21.2 Plt ___ ___ 06:50AM BLOOD WBC-7.8 RBC-2.86* Hgb-9.0* Hct-26.2* MCV-92 MCH-31.4 MCHC-34.3 RDW-18.6* Plt ___ ___ 06:50AM BLOOD Plt ___ ___ 06:40AM BLOOD ___ PTT-35.4 ___ ___ 06:50AM BLOOD Glucose-93 UreaN-29* Creat-4.2* Na-130* K-3.9 Cl-95* HCO3-23 AnGap-16 ___ 07:15AM BLOOD ALT-11 AST-23 AlkPhos-138* TotBili-1.4 ___ 06:50AM BLOOD Albumin-2.8* Calcium-8.6 Phos-2.8 Mg-1.6 ___ 06:45AM BLOOD calTIBC-170* Ferritn-1038* TRF-131* ___ 6:00 pm SPUTUM Source: Expectorated. *FINAL REPORT ___ GRAM STAIN (Final ___: ___ PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. Brief Hospital Course: ___ y.o. male with ETOH Cirrhosis (Child A) and HRS admitted to Dr. ___ service with reducible umbilical hernia. No evidence of strangulation. Hct was low and repeat was 17. 2 units of PRBC were transfused. Hct increased to 26. Hepatology was consulted and on ___, they performed an EGD noting severe esophagitis with ulcerations, moderate erosive antral gastritis and duodenitis suggestive of chemical gastritis, NSAIDs induced. Misoprostol, Carafate and bid omeprazole was started per hepatology recommendations. HCT remained stable. H. pylori was negative. He was instructed on multiple occasions to not take NSAIDS (takes after HD for headache/malaise). Instructed to take tylenol (no more than 2grams per day). 0n ___ he was dialyzed then went to the OR for umbilical hernia repair with mesh. Surgeon was Dr. ___. Please refer to operative notes for details. A CXR was done the next day on ___ for fever. A right, partially, loculated pleural effusion and bibasilar atelectasis was noted. The right mid and lower lobes were concerning for infiltrate. Blood cultures were sent and then he was started on Levaquin. Blood cultures were pending. UA and urine culture were negative. Repeat CXR was unchanged on ___. Diet was advanced and tolerated. IV omeprazole was switched to oral. He was passing flatus and had a BM. Incision was intact without redness or drainage. An abdominal binder was placed on him. He was ambulating independently and felt well enough to go home on ___ after his dialysis session. Follow up appointment with Dr. ___ was set for ___. Visiting nurse services were arranged to follow him at home. He will f/u with Dr. ___ in ___ and at that time plans for f/u EGD will be determined. Medications on Admission: Lasix 80", Metoprolol ER 25", Midodrine 5 on HD days, Nadolol 20', omeprazole 40', nephrocaps 1', rifaximin 550" (on hold), Tums, sodium bicarb 650", thiamine 100' All: NKDA Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain / fever do not take more than 3000mg per day 2. Benzonatate 100 mg PO QID:PRN cough RX benzonatate 100 mg 1 capsule(s) by mouth every six (6) hours Disp #56 Capsule Refills:0 3. Calcium Carbonate 500 mg PO BID Tums 4. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:1 5. Furosemide 80 mg PO BID 6. Midodrine 5 mg PO QMOWEFR 7. Misoprostol 200 mcg PO QIDPCHS RX misoprostol 200 mcg 1 tablet(s) by mouth four times a day Disp #28 Tablet Refills:0 8. Nadolol 20 mg PO DAILY 9. Nephrocaps 1 CAP PO DAILY 10. Omeprazole 40 mg PO BID increased dose for gastritis finding RX omeprazole 40 mg 1 capsule,delayed ___ by mouth twice a day Disp #60 Capsule Refills:2 11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #40 Tablet Refills:0 12. Sucralfate 1 gm PO QID RX sucralfate 1 gram/10 mL 10 ml Suspension(s) by mouth four times a day Disp #300 Milliliter Refills:0 13. Levofloxacin 250 mg PO DAILY pneumonia on dialysis days, take after dialysis RX levofloxacin 250 mg 1 tablet(s) by mouth once a day Disp #6 Tablet Refills:0 14. Thiamine 100 mg PO DAILY 15. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath/wheeze RX albuterol ___ puffs inh every four (4) hours Disp #1 Inhaler Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: ESRD Umbilical hernia Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr. ___ office office ___ if you have any of the following: temperature of 101 or greater,chills, nausea, vomiting, increased pain, abdominal bloating, incision redness/bleeding/drainage, constipation or diarrhea -no heavy lifting/straining (do not lift anything heavier than 10 pounds) DO NOT TAKE ANY MOTRIN/ADVIL/IBUPROFEN/ALEVE OR NSAIDS (non-steroidal anti-infammatory medication) You may take tylenol for headache or malaise after dialysis, but no more than 2000mg per day. -you may shower, but no tub baths or swimming -do not apply powder/lotion or ointment to incision -no driving while taking pain medication -continue your usual hemodialysis schedule Followup Instructions: ___
10819468-DS-11	10,819,468	27,637,934	DS	11	2170-05-05 00:00:00	2170-05-05 17:48:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lactulose Attending: ___. Chief Complaint: nausea, vomiting, weakness Major Surgical or Invasive Procedure: none History of Present Illness: ___ with PMH ETOH Cirrhosis (Child A) c/b esophageal varicies, splenomegaly, and HRS (HD via RUE AVF MWF) with recent admission for anemia and umbilical hernia repair with mesh ___, course complicated by PNA. He is now presenting with nausea, vomiting and weakness. Since discharge, from ___ on ___, he has attended one HD session on ___. Subsequently he had "black diarrhea" and felt weak for a few days and did not return for dialysis. His diarrhea resolved within 3 days and turned brown in color. Also, one week ago, he started having nausea, non-bloody vomiting (last emesis ___ and poor po intake. He also had increased itchiness and swelling of lower extremities, right more than left, that is worse than his baseline. During that time he did not have abdominal pain, fever/chills, chest pain or SOB. Still producing good amounts of yellow urine. He did miss his appointment for suture removal from umbilical hernia repair. He was prompted to come to ED by HD unitl as he missed multiple HD sessions. He also resumed drinking vodka ___, last drink was 15 hours ago. He was previously sober since ___, but was tempted to drink because he was home alone. Of note, he has had prior alcohol withdrawal seizures. On arrival to ED his vitals were 98.1 135/59 114 20 98%RA. ___ dopplers were negative for DVT. He received Diazepam 5mg po x1. Initial labs notable for WBC 3.1, HCT 25, PLT 43, Na 125, Cr 3.2. Urinalysis with moderate blood, bacteria, 2wbc, no nitrities or leuk est. He was evaluated by nephrology prior to admission. On the floor, he denies complaints. Initial vitals are 97.9 146/64 107 20 95RA. Review of Systems: (+) as per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain,constipation, BRBPR, hematochezia, dysuria, hematuria. Past Medical History: ETOH Cirrhosis (Child A) HRS (baseline Cr 3.0) requiring HD MWF Started HD in ___ and then on and off dialysis, had been off dialysis from ___ and then restarted treatment in ___ Erosive esophagitis portal gastropathy barretts ETOH abuse (not on txp list) MRSA bacteremia ___ treated with vancomycin seizures ___ ETOH abuse asthma umbilical hernia - mesh repair ___ MVA ___: pelvix fx and Right femur fracture with ___ placement Social History: ___ Family History: Mother - ___ ___ alcoholic liver disease Father - ___ ___ colon cancer, diagnosed in his ___. No other family history of colon cancer. Physical Exam: Admission Physical Exam: Vitals- 97.9 146/64 107 20 95RA. General: Alert, oriented, no acute distress, sitting up in bed HEENT: mild scleral icterus, dry oral mucosa. Neck: supple, JVP not elevated CV: Sinus tachycardia, no m/r/g. Lungs: Decreased aeration at right base. Dullness to percussion ___ way up right lung field. Left side with good aeration. No crackles or wheezesl. Abdomen: Vertical incision site with sutures in place, no discharge or erythema. Abd is soft, NT/ND, +BS. Hepatomegaly 3-4cm below costal margin. + splenomegaly. No ascites. No guarding or rebound. Ext: warm, 1+ edema on right to mid shin, trace on left lower ext, skin erythematous with chronic skin changes. No asterixis Access: RightUE fistula with palpable thrill, and bruit Discharge Physical Exam: Vitals- TM 99.9 104-127/55-63 ___ 18 99RA 80.7KG i/o: nr General: Alert, oriented, no acute distress HEENT: mild scleral icterus, dry oral mucosa. Neck: supple, JVP not elevated CV: RRR, no m/r/g. Lungs: Decreased aeration at right base. Dullness to percussion ___ way up right lung field. Left side with good aeration. No crackles or wheezesl. Abdomen: Vertical incision sutures removed, no discharge or erythema. Abd is soft, NT/ND, +BS. Hepatomegaly 3-4cm below costal margin. + splenomegaly. No ascites. No guarding or rebound. Ext: warm, 1+ edema on right to mid shin, trace on left lower ext, skin erythematous with chronic skin changes. No asterixis Access: RightUE fistula with palpable thrill, and bruit Pertinent Results: ADMISSION LABS: ___ 09:10AM BLOOD WBC-4.0 RBC-3.08* Hgb-9.6* Hct-26.6* MCV-87 MCH-31.1 MCHC-36.0* RDW-15.9* Plt Ct-UNABLE TO ___ 09:10AM BLOOD Neuts-74.5* Lymphs-13.8* Monos-8.9 Eos-2.5 Baso-0.2 ___ 09:10AM BLOOD Glucose-108* UreaN-62* Creat-3.2* Na-125* K-3.4 Cl-83* HCO3-26 AnGap-19 ___ 09:10AM BLOOD ALT-24 AST-73* LD(LDH)-489* AlkPhos-253* TotBili-2.0* DirBili-0.9* IndBili-1.1 ___ 09:10AM BLOOD Albumin-3.8 DISCHARGE LABS: ___ 08:29AM BLOOD WBC-3.9* RBC-2.77* Hgb-8.5* Hct-25.3* MCV-91 MCH-30.7 MCHC-33.7 RDW-16.3* Plt Ct-60* ___ 07:20AM BLOOD ___ PTT-34.1 ___ ___ 08:29AM BLOOD Glucose-97 UreaN-65* Creat-3.7* Na-136 K-3.2* Cl-98 HCO3-26 AnGap-15 ___ 08:29AM BLOOD Albumin-3.2* Calcium-8.5 Phos-1.3* Mg-1.7 URINE ___ 11:41AM URINE Color-Yellow Appear-Clear Sp ___ ___ 11:41AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 11:41AM URINE RBC-16* WBC-2 Bacteri-FEW Yeast-NONE Epi-0 TransE-<1 ___ 08:49PM URINE pH-7 Hours-24 Volume-800 UreaN-343 Creat-74 ___ 03:33PM URINE Hours-RANDOM UreaN-352 Creat-86 Na-19 K-14 Cl-LESS THAN ___ 03:33PM URINE Osmolal-229 ___ 08:49PM URINE 24Creat-592 ___ URINE CULTURE (Final ___: NO GROWTH. =============================================== IMAGING: ___ ___: The right common femoral, superficial femoral, popliteal, peroneal, and posterior tibial veins all demonstrate normal compressibility, flow and augmentation were appropriate. There is normal phasicity in bilateral common femoral veins. A 4.0 x 1.6 x 1.0 cm ___ cyst is noted in the right popliteal fossa. Soft tissue edema is seen in the subcutaneous tissues. 1) No evidence of deep venous thrombosis in the right lower extremity. 2) ___ cyst. 3) Soft tissue edema. CXR: ___: Stable large right pleural effusion with associated atelectasis of the right lower lobe; please note, infection in this area cannot be entirely excluded. EKG: Sinus tachycardia with RBBB. Brief Hospital Course: ___ with PMH ETOH Cirrhosis (Child A) c/b esophageal varicies, splenomegaly, and HRS (HD via RUE AVF MWF) with recent admission for umbilical hernia repair with mesh ___, course complicated by PNA, now representing with n/v and weakness in setting of being off HD x 2.5 weeks. # Nausea/Vomiting: Although he presented for nausea/vomiting, no episodes during this admission. Most likely his nausea/vomiting was caused by his alcohol consumption just prior to admission. No evidence of infection (specifically no SBP or UTI), GI bleed, uremia or hepatic encephalopathy. # Hyponatremia: He presented with Na to 125 without evidence of mental status changes. This improved with fluid restriction. Etiology ___ poor po intake, vomiting and chronic renal/liver disease. # ESRD/HD: He is known CKD stage 5 who has been off-and-on dialysis since ___. Last HD session was ___ and his BUN/Cr was remarkably stable at his baseline. Still producing good urine. Also no asterixis, fluid overload, or mental status changes consistent with uremia. 24 urine collection obtained, which showed creatinine clearance of 11. He was restarted on dialysis ___ and will resume home dialysis schedule of MWF. #Alcoholism: He has a history of alcohol abuse with prior alcohol withdrawal related seizures. Was previously sober for 3 months, however resumed drinking prior to this admission. He was kept on CIWA, but did not actively withdraw. He was continued on thiamine. CHRONIC ISSUES: # H/o Eophageal Varices/Gastritis: stable, he continued home meds (omeprazole, sucralfate/misoprostol). # Alcoholic Cirrhosis : Child A. There was no indication for SBP prophylaxis during this admission. Small ascites present. He was kept on nadalol and started on spironolactone. # Thrombocytopenia: stable at baseline ___ splenomegaly and liver disease. Given PLT <50, he was not anticoagulated with heparin. PLT to 43, within previous baseline. # Anemia: stable, secondary to ESRD. TRANSITIONAL ISSUES: -full code -Liver follow-up in 1 month with next EGD in 2 months. -Current alcohol use precludes liver transplant. -f/u with outpt Nephrologist, continue outpt HD -re-check his plt # to assess for stability or improvement in his thrombocytopenia -consider repeat CXR to re-evaluate the right sided pleural effusion and atelectasis seen on PCXR on ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H:PRN pain / fever do not take more than 3000mg per day 2. Benzonatate 100 mg PO QID:PRN cough 3. Calcium Carbonate 500 mg PO BID Tums 4. Docusate Sodium 100 mg PO BID 5. Furosemide 80 mg PO BID 6. Midodrine 5 mg PO QMOWEFR 7. Misoprostol 200 mcg PO QIDPCHS 8. Nadolol 20 mg PO DAILY 9. Nephrocaps 1 CAP PO DAILY 10. Omeprazole 40 mg PO BID increased dose for gastritis finding 11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 12. Sucralfate 1 gm PO QID 13. Levofloxacin 250 mg PO DAILY pneumonia on dialysis days, take after dialysis 14. Thiamine 100 mg PO DAILY 15. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath/wheeze Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain / fever 2. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath/wheeze 3. Benzonatate 100 mg PO QID:PRN cough 4. Furosemide 80 mg PO BID 5. Misoprostol 200 mcg PO QIDPCHS 6. Nadolol 20 mg PO DAILY 7. Nephrocaps 1 CAP PO DAILY 8. Omeprazole 40 mg PO BID 9. Sucralfate 1 gm PO QID 10. Thiamine 100 mg PO DAILY 11. Calcium Carbonate 500 mg PO BID 12. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 13. Midodrine 5 mg PO QMOWEFR used as needed for hypotension at dialysis 14. Spironolactone 25 mg PO DAILY RX spironolactone 25 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*3 Discharge Disposition: Home Discharge Diagnosis: End stage renal disease Hepatorenal syndrome Alcohol Withdrawal Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you while you were admitted to ___. You were admitted because of nausea, vomiting and weakness. You had numerous blood tests which showed that your body still requires hemodialysis for proper functioning. You were restarted on hemodialysis with the plan to continue on an outpatient basis. Your next session will be ___ at your regular dialysis unit. You were also monitored closely to prevent severe alcohol withdrawal. You did not show signs of this. Followup Instructions: ___
10819799-DS-27	10,819,799	25,829,369	DS	27	2150-06-24 00:00:00	2150-06-24 20:31:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Keflex / Neurontin Attending: ___. Chief Complaint: confusion Major Surgical or Invasive Procedure: Foley catheter insertion and removal History of Present Illness: ___ yo M with DM2, h/o CVA, HTN, presenting with altered mental status since yesterday evening. . Per ___, patient was found on the floor around 9 p.m. yesterday, confused, agitated, unable to stand. He had last been seen 15 minutes, at which time he was calm, confused. At baseline, he is oriented to self and place and intermittently to time. He has a history of chronic leg pain. Per family, patient is oriented to place at baseline, knows family, who president is, not always oriented to date. . In the ED, initial vital signs were T 98.4, HR 96, BP 125/65, RR 18, Sat 97%/RA. Per ED report, EKG showed SR 89,Q waves in inf leads c/w prior, no acute ST changes. CT head was limited by motion artifact but showed no obvious bleed. The patient was given no medications. . On the medical floor, the patient was confused and did not respond appropriately to questions. . REVIEW OF SYSTEMS: unable to obtain secondary to altered mental status Past Medical History: # DM2 on insulin # CVA in early ___ with residual speech hesitancy, mild L weakness # HTN # Chronic venous insufficiency # discogenic LBP s/p distant spinal surgery x 2 # obesity # h/o EtOH abuse # Dyslipidemia # left toe ulcer s/p Percutaneous angioplasty of left popliteal artery, tibial-peroneal trunk, and anterior tibital artery. Social History: ___ Family History: DM in twin brother. Physical Exam: Vital signs: T 97.8, HR 85, BP 160/85, RR 18, O2 Sat 95%/RA Gen: Confused. Oriented only to self. Agitated. HEENT: NC/AT. Anicteric sclerae. Moist mucous membranes. OP clear. Neck: Supple. Resp: Normal respiratory effort. CTAB. CV: RRR. Normal s1 and s2. No M/G/R. Abd: +BS. Soft. NT/ND. No rebound or guarding. Ext: Warm and well-perfused. Radial and DP pulses 2+ bilaterally. Markedly tender to palpation of left tibia. Neuro: Exam limited by mental status. Oriented only to self. PERRL. EOMI. Face symmetric. Palate elevates symmetrically. Tongue protrudes in midline. Strength assessment limited by patient cooperation, but no asymetry noted. . Discharge exam: Vital signs: T 97.8 BP 148/70 HR 64 RR 20 Sat 98%/RA Gen: NAD Neck: Supple. Resp: Normal respiratory effort. CTAB. CV: RRR. Normal s1 and s2. No M/G/R. Abd: +BS. Soft. NT/ND. No rebound or guarding. Ext: Warm and well-perfused. No edema. Alert. Oriented to self, ___, family. Pupils equal. Right pupil round and reactive. Left pupil slightly irregular and reactive. EOMI. Facial movement normal. Tongue protrudes in midline. Strength ___ throughout bilateral upper extremities and RLE. In LLE, strength at ___ for hip flexion, and ___ for plantarflexion and dorsiflexion, with movement limited by weakness and pain (chronic). Pertinent Results: Admission labs: ___ 09:30AM BLOOD WBC-10.9 RBC-4.54* Hgb-12.4* Hct-39.3* MCV-87 MCH-27.2 MCHC-31.4 RDW-15.0 Plt ___ ___ 09:30AM BLOOD ___ PTT-32.0 ___ ___ 09:30AM BLOOD Glucose-172* UreaN-31* Creat-1.3* Na-138 K-4.9 Cl-100 HCO3-27 AnGap-16 ___ 09:30AM BLOOD ALT-13 AST-18 CK(CPK)-153 AlkPhos-72 TotBili-0.3 ___ 11:23PM BLOOD Calcium-8.7 Phos-3.6 Mg-2.5 . Urinalysis: ___ 11:30AM URINE Color-Yellow Appear-Clear Sp ___ ___ 11:30AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 11:30AM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 ___ 11:30AM URINE CastHy-7* . Micro: URINE CULTURE ___: NO GROWTH. Blood culture ___: pending . Reports: . EKG ___: Sinus rhythm. There are non-diagnostic Q waves in the inferior leads. Compared to the previous tracing of ___ there is no significant change. . CT head w/o contrast ___: Severely limited exam due to motion. Within that limitation, there are no large areas of acute hemorrhage or definite area of acute infarction. The area of prior infarction in the left occipital lobe has not significantly changed. Area of prior infarction in the left inferior temporal lobe is not well seen. No obvious fractures identified. . CXR PA and lateral ___: Low lung volumes. Mildly prominent pulmonary vascular engorgement, no signs of overt pulmonary edema. No focal opacities concerning for pneumonia. . Pelvis/hip x-rays ___: No fracture. Severe osteoarthritis, right hip. . Left knee/tibia/fibula ___: No acute fracture identified, although images of the knee are suboptimal. No knee effusion. Extensive vascular calcifications are noteworthy. Equivocal old avulsion fracture involving the medial malleolus and probable incidental plantar and posterior calcaneal spurs. Ankle mortise congruent with talus. IMPRESSION: No acute fracture. Brief Hospital Course: ___ yo M with h/o CVA, DM2, HTN, presenting with altered mental status. # Delirium: The patient presented with confusion and agitation, along with a fall. CT head was limited by motion artifact but did not show a large bleed. No infectious cause of the patient's delirium was identified. However, the patient was found to be in urinary retention, relieved with a Foley catheter. It was noted that the patient's medication list included Percocet, tramadol, and trazodone, and these were held. The patient's mental status improved to his prior baseline. He has chronic moderate left lower extremity weakness, but there were no new neurologic deficits. # s/p Fall: The patient sustained an unwitnessed fall at ___. CT head was severely limited due to motion but did not show any acute abnormalities. Imaging of the bilateral hips and left tibia/fibia were negative for fracture. MI was ruled out with serial cardiac enzymes. # Urinary retention: The patient was found to be retaining urine, with 600 cc of urine in his bladder. A Foley catheter was placed. Terazosin was changed to tamsulosin, and finasteride was started. The Foley was removed on ___. The patient was able to void, and post-void residual was 0 just prior to discharge. # Gross hematuria: On ___, the patient was noted to have some bleeding around his Foley catheter, as well as some blood in the urine. This was presumed to be related to pulling at the catheter, although no pulling was directed observed. The patient's urine went from red to pink, and the catheter was removed. The hematuria had completely resolved prior to discharge. # Acute kidney injury: The patient presented with creatinine 1.3. This was felt to be of pre-renal etiology. Diuretics and lisinopril were intially held. As the patient's creatinine improved, lisinopril was restarted. With this treatment, the patient's creatinine improved to 1.0. Lasix can be restarted at reduced dose (20 mg daily) after discharge. The patient's volume status should be monitored closely to avoid dehydration or fluid overload. # DM2: The patient was not eating well on arrival, so his home insulin regimen was stopped, and he was placed on an insulin sliding scale. He had blood sugars in the low 200s on this regimen, so NPH was added. He was discharged on NPH 10 units QAM and 5 units QPM. His insulin can titrated as needed at the ___. # HTN: The patient was felt to be volume-depleted on admission, so lisinopril, furosemide, and atenolol were held. The patient was treated with IV fluids, with normalization of his volume status. Atenolol and lisinopril were restarted. Furosemide was held. Lasix can be restarted at reduced dose (20 mg daily) after discharge. The patient's volume status should be monitored closely to avoid dehydration or fluid overload. # h/o stroke: Plavix was initially held, but was subsequently restarted. There was no evidence of a new stroke, as the patient's mental status and neurologic exam returned to its previous baseline. # Chronic lower extremity pain: Percocet and tramadol were held in the setting of altered mental status, and the patient was started on standing Tylenol ___ mg TID. # Pressure ulcer: The patient was noted to have a stage 2 decubitus pressure ulcer. A Mepilex dressing was placed. He will need frequent repositioning. # Communication: Healthcare proxy is daughter ___ ___ # Code status: FULL CODE, per healthcare proxy ___ on ___: calcium 500 mg with D 1 tablet by mouth daily atenolol 25 mg daily furosemide 40 mg daily lisinopril 15 mg daily Plavix 75 mg daily sertraline 75 mg daily simvastatin 40 mg daily docusate 100 mg BID tramadol 50 mg TID PRN terazosin 2 mg QHS acetaminophen 650 mg TID PRN bisacodyl 10 mg PR PRN Compro 25 mg suppository PRN fleet enema PRN milk of magnesia 30 mL PRN constipation Percocet ___ Q8H PRN pain senna 8.6 mg BID PRN constipation trazodone 25 mg PRN agitation Novolin 70-30 40 units QAM and 20 units QPM Novolog sliding scale Discharge Medications: 1. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 2. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. sertraline 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 8. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal once a day as needed for constipation. 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. lisinopril 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 11. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. NPH insulin human recomb 100 unit/mL Suspension Sig: as directed Subcutaneous twice a day: Give 10 units in the morning and 5 units before dinner. 14. Novolog 100 unit/mL Solution Sig: as directed Subcutaneous as directed: Please use attached sliding scale. 15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: delirium urinary retention gross hematuria . Secondary: diabetes mellitus 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: You came to the hospital with confusion. There was no evidence of infection. You were found to be retaining urine, and a Foley catheter was placed. You were started on medications called tamsulosin and finasteride for urinary retention. We were able to remove the Foley catheter, and you were able to urinate without difficulty. . You were thought to be a little dehydrated, so you were given IV fluids and furosemide (diuretic) was held. It will be restarted at a lower dose at the ___. . You had some blood in your urine, which was thought to be related to the Foley catheter. The catheter was removed, and the blood in your urine resolved. . There are some changes to your medications: START finasteride for urinary symptoms. START tamsulosin for urinary symptoms. DECREASE furosemide to 20 mg daily. STOP terazosin STOP Percocet STOP tramadol STOP trazodone STOP Novolin 70/30 and START NPH (not 70/30) 10 units in the morning and 5 units before dinner. USE attached Novolog insulin sliding scale. Followup Instructions: ___
10819799-DS-28	10,819,799	23,262,517	DS	28	2150-07-12 00:00:00	2150-07-12 16:47:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Keflex / Neurontin Attending: ___. Chief Complaint: Confusion, agitation Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with a history of hypertension, type II diabetes, dyslipidemia, CVA in ___ with residual speech hesitancy and mild left-sided weakness, and baseline dementia (per records, oriented to person and place, often not oriented to date/time) who presents from ___ where he is a long term care resident with increased confusion. His only active complaint is painful legs. Of note, patient was recently admitted from ___ for confusion and similar symptoms and was found to be retaining urine and had a UTI. In the ED, initial vs were: T 98.2, HR 79, BP 170/66, RR 14, O2 sat 94% RA. Labs were notable for WBC of 11.4 (79% PMNs, no bands), Hct 34.6 (baseline mid-30s), creatinine 1.1 (baseline), lactate 2.3, and U/A with > 182 WBCs, ___, -nitrates. Legs were noted to be swollen (R > L) and tender to palpation (spontaneous void of 400 cc foul-smelling urine). Imaging was notable for head CT with no evidence of acute intracranial process (preliminary read), clear CXR (preliminary read), and bilateral lower extremity ultrasound negative for DVT (preliminary read). Patient was given 1g IV meropenem for UTI given his cephalosporin allergy to Keflex and history of UTI with Proteus resistant to cipro and Bactrim. Also received acetaminophen for pain. He became agitated in the ED prior to transfer and was given olanzapine 5 mg IM and droperidol 5 mg iv. Vitals on transfer were T 99.2, HR 64, BP 159/60, RR 18, O2 sat 98% on RA. On the floor, he was somnolent and would open eyes briefly but not answering questions. Past Medical History: - Type II diabetes mellitus on insulin - CVA in early ___ with residual speech hesitancy, mild L weakness - Hypertension - Chronic venous insufficiency - Discogenic LBP s/p distant spinal surgery x 2 - Obesity - History of alcohol abuse - Dyslipidemia - Left toe ulcer s/p Percutaneous angioplasty of left popliteal artery, tibial-peroneal trunk, and anterior tibital artery Social History: ___ Family History: Per records, has a twin brother also with diabetes. Physical Exam: Admission Physical Exam: Vitals: T: 98.3 BP:111/48 P: 74 R: 20 O2: 93% on RA General: somnolent, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: chronic venous stasis changes Neuro: patient somnolent and would open eyes briefly to sternal rub, Pupils equal, round and reactive to light. EOMI. No obvious facial movement normal. Discharge PE: Vitals: Tm: 98.8 Tc: 97.5 P: 75 (68-92) BP: 148/57 (108-142/50-70) RR: 18 SpO2: 95% RA General: alert, oriented to person, place ("hospital"), date and month but not year HEENT: MMM Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, + wheezes at R lung base 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: 1+ pitting edema to knees, blue-brown discoloration of BLEs c/w chronic venous stasis changes Neuro: speech hesistancy, PERRL, pain to light touch over BLEs Pertinent Results: Hematology: ___ 06:35AM BLOOD WBC-7.2 RBC-4.18* Hgb-11.3* Hct-37.1* MCV-89 MCH-27.0 MCHC-30.4* RDW-15.1 Plt ___ ___ 06:55AM BLOOD WBC-13.5* RBC-3.98* Hgb-10.7* Hct-34.5* MCV-87 MCH-27.0 MCHC-31.1 RDW-15.0 Plt ___ ___ 10:10AM BLOOD WBC-11.4* RBC-4.08* Hgb-11.5* Hct-34.6* MCV-85 MCH-28.1 MCHC-33.1 RDW-14.7 Plt ___ Chemistries: ___ 10:10AM BLOOD Neuts-71.9* ___ Monos-3.8 Eos-3.1 Baso-0.7 ___ 06:35AM BLOOD Glucose-179* UreaN-25* Creat-1.0 Na-141 K-4.4 Cl-106 HCO3-28 AnGap-11 ___ 06:55AM BLOOD Glucose-198* UreaN-29* Creat-1.0 Na-138 K-4.7 Cl-107 HCO3-26 AnGap-10 ___ 10:10AM BLOOD Glucose-176* UreaN-31* Creat-1.1 Na-138 K-5.0 Cl-101 HCO3-26 AnGap-16 Other: - Blood culture ___: Pending - Urine culture ___: (prelim) GNRs >100,000 Imaging: CXR ___: FINDINGS: The lungs are low in volumes, giving appearance of vascular crowding. No focal consolidation is seen with mild retrocardiac atelectasis. There is no pneumothorax. No pleural effusion is identified. The heart is top normal in size. IMPRESSION: Low lung volumes without evidence of acute process. Vascular ___ venous studies ___: IMPRESSION: No DVT with non-visualization of the right calf veins. CT Head ___: IMPRESSION: There is no evidence of hemorrhage, edema, mass, mass effect, or infarction. Severe periventricular white matter changes suggest chronic small vessel ischemic disease. The white matter changes are more extensive in the tracts of the left brain, causing ex vacuo dilatation of the left lateral ventricle. Otherwise, there is preservation of gray-white matter differentiation. The basal cisterns appear patent. Prominent sulci and ventricles are consistent with age-related atrophy. There is no evidence of fractures. The paranasal sinuses, mastoid air cells and middle ear cavities are clear. Atherosclerotic vascular calcifications are more prominent in the vertebral arteries and carotid siphons. IMPRESSION: No evidence of acute intracranial process. Brief Hospital Course: Patient is a ___ y/o M with PMH of hypertension, type II diabetes, dyslipidemia, CVA in ___ with residual speech hesitancy and mild left-sided weakness, and baseline dementia who initially presented from ___ with confusion/agitation and was found to have a UTI, now with improved orientation and alertness. #Confusion/ agitation: Was likely toxic-metabolic encephalopathy in the setting of his UTI. His somnolence on arrival to the floor was likely related to receiving droperidol and olanzapine in the ED. Upon discharge, he was alert, oriented x3. His tramadol, amitripyline and sertraline were initially held but restarted when his confusion improved. His trazadone was held. His UTI was treated as below. #UTI: UA consistent UTI. WBC increased to 13 and improved to 7.2 upon discharge. His dysuria improved with treatment. He was initially treated with meropenem as he has cephalosporin allergy (unknown effect) and hx of proteus UTI resistant to bactrim/cipro. However, he has received augmentin in the past and prior proteus senstive to ampicillin. He was transitioned to amoxicillin-clavulonic acid upon discharge for 5 more days for a total 7 day course for complicated UTI. # DM2: relatively at goal. Continued home insulin regimen and diabetic diet. # HTN: well controlled. He was restarted on home lasix, atenolol, lisinopril. # h/o stroke: baseline speech hesistancy. He was continued on his home plavix. # Chronic lower extremity pain: complains of chronic pain. No DVT on US. He was continued on his home tramadol and tylenol ___ mg TID. #CODE: Full (confirmed with HCP, daughter ___ ___ on Admission: Preadmission medications listed are correct and complete. Information was obtained from ___ records. 1. Furosemide 20 mg PO DAILY 2. Finasteride 5 mg PO DAILY 3. Acetaminophen 650 mg PO TID 4. NPH 10 Units Breakfast NPH 5 Units Dinner Insulin SC Sliding Scale using Novolog Insulin 5. TraMADOL (Ultram) 50 mg PO TID 6. Amitriptyline 25 mg PO HS 7. traZODONE 12.5 mg PO BID:PRN agitation 8. Calcium Carbonate 500 mg PO DAILY 9. Clopidogrel 75 mg PO DAILY 10. Sertraline 75 mg PO DAILY 11. Simvastatin 40 mg PO DAILY 12. Docusate Sodium 100 mg PO BID 13. Tamsulosin 0.4 mg PO HS 14. Senna 1 TAB PO BID:PRN constipation 15. Lisinopril 15 mg PO DAILY 16. Milk of Magnesia 30 mL PO DAILY:PRN constipation 17. Bisacodyl ___AILY:PRN constipation 18. Fleet Enema ___AILY:PRN constipation 19. Atenolol 25 mg PO DAILY Hold for SBP<100, HR< 60 Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Bisacodyl ___AILY:PRN constipation 3. Atenolol 25 mg PO DAILY Hold for SBP<100, HR< 60 4. Calcium Carbonate 500 mg PO DAILY 5. Clopidogrel 75 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Finasteride 5 mg PO DAILY 8. Furosemide 20 mg PO DAILY 9. NPH 10 Units Breakfast NPH 5 Units Dinner Insulin SC Sliding Scale using HUM Insulin 10. Lisinopril 15 mg PO DAILY 11. Senna 1 TAB PO BID:PRN constipation 12. Simvastatin 40 mg PO DAILY 13. Tamsulosin 0.4 mg PO HS 14. TraMADOL (Ultram) 50 mg PO TID 15. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 16. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 17. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days For 5 more days, last day ___ 18. Amitriptyline 25 mg PO HS 19. Fleet Enema ___AILY:PRN constipation 20. Milk of Magnesia 30 mL PO DAILY:PRN constipation 21. Sertraline 75 mg PO DAILY 22. traZODONE 12.5 mg PO BID:PRN agitation Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: UTI Associated diagnoses: delirium ___ toxic-metabolic encephalopathy in the setting of UTI Secondary diagnoses: Diabetes type 2, HTN, s/p CVA, dementia, chronic venous stasis 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 because of confusion that was noted at ___. You were found to have a urinary tract infection. Your infection was treated with intravenous antibiotics. Your signs of infection have now improved and your mental status is improved to baseline. After discharge from the hospital you will take oral antibiotics. Followup Instructions: ___
10819799-DS-31	10,819,799	27,969,861	DS	31	2150-10-01 00:00:00	2150-10-04 19:56:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Keflex / Neurontin Attending: ___. Chief Complaint: vomiting Major Surgical or Invasive Procedure: ___ guided percutaneous cholecystostomy tube exchange ___. History of Present Illness: ___ h/o dementia, chronic cholecystitis s/p perc chole tube with plan for elective lap chole p/w vomiting. Pt is a poor historian and has trouble remembering why he came to the hospital. When asked if it was due to nausea and vomiting pt said yes. Pt said vomit was yellowish, which was confirmed by nursing home note. Nausea began last night. Per ___ home facility, patient was eating breakfast this morning, then vomited his undigested food and pills. He then vomited again before and During lunch. refused clear liquids after lunch. His vomit was described as yellow, then clear. No blood. Pt denies fevers, chills, cp, sob, diarrhea, changes to urinary habits. At home, 8am vitals: 123/59, 82, 97.3, 18, 96% RA. At 10am: 182/65, 77, 97.1, 92% RA. . In the ED, VS 96.8 78 148/58 18 97%. On exam, alert + oriented to place and person, not time, Cardiac-rrr, Lungs-ctab, Abdomen-soft nt nd, perc chole tube well healed without erythema/exudate and draining bile well. Labs significant for CHEM-7 and CBC unchanged from prior. LFTs and lipase, u/a --> no uti, cxr --> lungs clear, surgery c/s --> ruq u/s to ensure tube is draining, ruq u/s --> unable to visualize tube, per surg, tube study in am to confirm chole tube is in place. . On arrival to the floor, VS 97.3, 163/66, 79, 18, 97% RA. Pt denies nausea or abd pain and has no c/o. Past Medical History: - Type II diabetes mellitus on insulin - CVA in early ___ with residual speech hesitancy, mild L weakness - Hypertension - Chronic venous insufficiency - Discogenic LBP s/p distant spinal surgery x 2 - Obesity - History of alcohol abuse - Dyslipidemia - Left toe ulcer s/p Percutaneous angioplasty of left popliteal artery, tibial-peroneal trunk, and anterior tibital artery Social History: ___ Family History: Per records, has a twin brother also with diabetes. Physical Exam: ADMIT: VITALS: 97.3 163/66 79 18 97% RA GENERAL: elderly male, NAD HEENT: PERRL, EOMI LUNGS: CTAB HEART: RRR, normal S1 S2, no MRG ABDOMEN: Soft, TTP over drain site. mild erythema around drain but no pus or weeping. abd discomfort with palpation diffusely. neg murphys sign, NABS. chole drain tubing cracked and leaking bile EXTREMITIES: No c/c/e. healed abrasian over right foot dorsum with steri-strips intact. chronic venous stasis changes in ___ skin with hyperpigmentation and superficial ulceration over right shin. ___ TTP. NEUROLOGIC: A+OX3 D/C: Vitals: Tm 98.4, Tc 98.0, P 68 (61-80), BP 132/50 (132-150/50-70), RR 18, 96%RA GENERAL: Alert, interactive, well-appearing Caucasian gentleman in NAD HEENT: PERRLA, sclerae anicteric, OP clear HEART: RRR, nl S1-S2, no MRG LUNGS: Crackles at both bases bilaterally. ABDOMEN: NABS, soft/NT/ND, no masses or HSM. Perc chole tube site is mildly erythematous without warmth or tenderness to palpation. Tube is leaking bile externally. EXTREMITIES: WWP, chronic venous stasis changes present. Dressing on dorsum of R foot is clean/dry/intact. Has steristripped wound on dorsum of R foot that is healing well. Tender to palpation. NEURO: awake, A&Ox2 (not oriented to time), CNs II-XII grossly intact Pertinent Results: ___ 05:35PM PLT COUNT-224 ___ 05:35PM NEUTS-73.5* ___ MONOS-3.7 EOS-2.7 BASOS-0.5 ___ 05:35PM ALBUMIN-3.9 ___ 05:35PM ALBUMIN-3.9 ___ 05:35PM ALT(SGPT)-25 AST(SGOT)-18 ALK PHOS-119 TOT BILI-0.2 ___ 05:35PM estGFR-Using this ___ 05:35PM GLUCOSE-156* UREA N-34* CREAT-1.3* SODIUM-139 POTASSIUM-5.3* CHLORIDE-104 TOTAL CO2-22 ANION GAP-18 ___ 05:44PM LACTATE-1.3 ___ 06:35PM URINE MUCOUS-RARE ___ 06:35PM URINE HYALINE-8* ___ 06:35PM URINE RBC-3* WBC-31* BACTERIA-NONE YEAST-NONE EPI-6 ___ 06:35PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD ___ 06:35PM URINE COLOR-Yellow APPEAR-Hazy SP ___ Time Taken Not Noted Log-In Date/Time: ___ 10:48 pm URINE FINAL REPORT ___ URINE CULTURE (Final ___: YEAST. 10,000-100,000 ORGANISMS/ML.. Blood Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. OF TWO COLONIAL MORPHOLOGIES. Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___. ___ @ 2245, ___. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. ___ 5:30 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. Brief Hospital Course: ___ h/o dementia, chronic cholecystitis s/p percutaneous cholecystostomy tube with plan for elective lap cholecystectomy presents with vomiting. ACTIVE ISSUES: # Broken cholecystostomy tube: Interventional radiology replaced his tube on ___, and surgery will see his as outpatient for elective cholecystectomy. He had no abdominal pain, fevers, or leukocytosis during admission and vital signs were stable. # STAPHYLOCOCCUS, COAGULASE NEGATIVE cultured from blood: The patient was on vancomycin briefly and then antibiotics were discontinued once coag neg staph grew suggestive of contaminant. He remained hemodynamically stable with no leukocytosis on discharge. INACTIVE ISSUES: # Type II diabetes: The patient was continued home insulin regimen # History of CVA: The patient was continued on Plavix. # Hypertension: The patient was continued on his home medications. # Low back pain: The patient was continued on tramadol and amitriptyline. # Dementia: The patient was continued on trazodone as needed for agitation as well as sertraline. # BPH: continued Finasteride and tamsulosin. TRANSITIONAL ISSUES: - Will need general surgery follow-up for percutaneous cholecystostomy tube - Urine culture showed 10,000-100,000 colonies of yeast, patient was asymptomatic Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver. 1. magnesium carbonate NF 400 mg Miscellaneous BID 2. Docusate Sodium 100 mg PO BID 3. Senna 1 TAB PO HS 4. Simvastatin 40 mg PO HS 5. Clopidogrel 75 mg PO DAILY 6. TraMADOL (Ultram) 50 mg PO TID 7. traZODONE 25 mg PO TID:PRN agitation 8. NPH 10 Units Breakfast NPH 5 Units Bedtime 9. Finasteride 5 mg PO DAILY 10. Lisinopril 15 mg PO DAILY 11. Furosemide 20 mg PO DAILY 12. Amitriptyline 25 mg PO HS 13. Sertraline 75 mg PO DAILY 14. Bisacodyl 10 mg PR HS:PRN constipation 15. Calcium Carbonate 500 mg PO DAILY 16. Metoprolol Succinate XL 25 mg PO DAILY 17. Acetaminophen 650 mg PO TID:PRN pain 18. Tamsulosin 0.4 mg PO HS Discharge Medications: 1. Acetaminophen 650 mg PO TID:PRN pain 2. Amitriptyline 25 mg PO HS 3. Bisacodyl 10 mg PR HS:PRN constipation 4. Clopidogrel 75 mg PO DAILY 5. Calcium Carbonate 500 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Finasteride 5 mg PO DAILY 8. Furosemide 20 mg PO DAILY 9. NPH 10 Units Breakfast NPH 5 Units Bedtime 10. Lisinopril 15 mg PO DAILY 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Senna 1 TAB PO HS 13. Sertraline 75 mg PO DAILY 14. Simvastatin 40 mg PO HS 15. Tamsulosin 0.4 mg PO HS 16. TraMADOL (Ultram) 50 mg PO TID:PRN pain hold for sedation or RR<10 17. traZODONE 25 mg PO TID:PRN agitation 18. magnesium carbonate NF 400 mg Miscellaneous BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: cholecystitis Type II diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you during your hospitalization at ___. You were admitted because of nausea and vomiting. Your biliary drain was replaced because it was broken and leaking. You improved over the course of the hospitalization and were discharged back to ___. Please follow up with your primary care doctor within the next week. Followup Instructions: ___
10819799-DS-33	10,819,799	29,187,647	DS	33	2151-01-13 00:00:00	2151-01-14 20:52:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Keflex / Neurontin Attending: ___. Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: ___ hx of dementia, A&Ox1 at baseline, recent laparoscopic cholecystectomy for chronic cholecystitis presenting with change in mental status. Patient was transferred from ___ ___ ___ where he lives. At 8am staff noticed that he wasn't talking, wouldn't eat. He is also twitching all limbs intermittently. Touching his lowers legs which are normally exquisitely tender does not elicit any pain today. Patient had normal vitals and a FSBS of 158. He was transferred here for further evaluation. The patient was recently discharged on ___ s/p cholecystectomy for chronic cholecystitis. He aslo had percutaneous cholecystostomy tube placement (___) and acute cholecystitis following replacement of tube (___). The previous hospital course was complicated by ileus and atrial fibrillation. He spontaneously converted to NSR, the patient was discharged with warfarin for one month and lopressor for rate control with cardiology follow up. At the time of discharge, the patient had erythema around his umbilicus. The incision was opened and some purulent drainage was seen. The wound was packed with wet to dry packing and the patient will continue on PO Bactrim for a total course of 7 days. In the ED, initial vital signs were T98.1 P77 BP118/47 RR26 97%/RA. A+Ox1. Labs reveal Na of 127, K of 5.7, Cr 1.6 from baseline 0.6. Patient was given kayexalate 60 grams x 1. CXR with no acute cardiopulmonary processes (final read pending). On the floor, T 98.3, 118/54, 81, 22, 98% RA. Patient has no complaints. On ROS he denies, CP, dysuria, dyspnea, constipation, diarrhea, N/V/D, fever, sweats, chills, headache, pain. Past Medical History: - Type II diabetes mellitus on insulin - CVA in early ___ with residual speech hesitancy, mild L weakness - Hypertension - Chronic venous insufficiency - Discogenic LBP s/p distant spinal surgery x 2 - Obesity - History of alcohol abuse - Dyslipidemia - Left toe ulcer s/p Percutaneous angioplasty of left popliteal artery, tibial-peroneal trunk, and anterior tibital artery Social History: ___ Family History: Per records, has a twin brother also with diabetes. Physical Exam: ADMISSION PHYSICAL EXAM Vitals- T 98.3, 118/54, 81, 22, 98% RA General- Alert, oriented only to person, no place, year, month, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, 2 cm surgical wound that is open and mildly erythematous, two 1 cm surgical scars in RUQ that are clean and healing well GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal, episode of non-responsiveness during exam with twitching Discharge O: VS 98.2 98 127-162/40-64 ___ 18 98%RA General: Sleeping in NAD. Neuro: A&O x2 to self and place. Neck: No JVD at 45 degrees and flat. No lymphadenopathy Cardiovascular: RRR. Normal S1 and S2. No m/g/r. Respiratory: CTAB with no wheezes, crackles, or rhonchi. Abdomen: Soft, NTND, no signs of infection of open incision. Extremities: Bilateral venous stasis. Warm with distal pulses. Pertinent Results: ADMISSION LABS ___ 12:00PM BLOOD WBC-12.7* RBC-3.76* Hgb-10.0* Hct-31.7* MCV-84 MCH-26.6* MCHC-31.5 RDW-14.0 Plt ___ ___ 12:00PM BLOOD Neuts-64.4 ___ Monos-4.5 Eos-2.9 Baso-0.6 ___ 12:00PM BLOOD ___ PTT-33.6 ___ ___ 12:00PM BLOOD Glucose-145* UreaN-24* Creat-1.6* Na-129* K-5.7* Cl-94* HCO3-28 AnGap-13 ___ 12:00PM BLOOD ALT-23 AST-26 AlkPhos-101 TotBili-0.2 ___ 12:00PM BLOOD Albumin-3.3* ___ 12:18PM BLOOD Lactate-1.1 K-5.6* Micro: ___ 12:00 pm BLOOD CULTURE 2 OF 2. Blood Culture, Routine (Pending): ___ 2:47 pm URINE FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 1:34 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). Discharge: ___ 09:25AM BLOOD WBC-8.0 RBC-3.74* Hgb-10.0* Hct-31.6* MCV-85 MCH-26.6* MCHC-31.5 RDW-13.9 Plt ___ ___ 09:25AM BLOOD Glucose-187* UreaN-17 Creat-1.2 Na-133 K-4.3 Cl-98 HCO3-26 AnGap-13 ___ 09:25AM BLOOD Calcium-8.3* Phos-3.4# Mg-2.4 ___ Cardiovascular ECG Sinus rhythm. Non-specific anterolateral ST-T wave abnormalities. Compared to the previous tracing of ___ no diagnostic interval change. ___ Radiology CHEST (PORTABLE AP) IMPRESSION: Haziness at right costophrenic angle, cannot exclude small pleural effusion. Otherwise, no focal consolidation. ___ Radiology CHEST (PA & LAT FINDINGS: As compared to the previous radiograph, there is no relevant change. Low lung volumes. No acute changes. Borderline size of the cardiac silhouette. Borderline diameter of the vascular hilar structures. Known areas of hypoventilation at both lung bases. No larger pleural effusions. The study and the report were reviewed by the staff radiologist. ___ Neurophysiology EEG IMPRESSION: Abnormal EEG due to the slow disorganized background. This indicates a widespread encephalopathy. Medications, metabolic disturbances, and infection are among the common causes. There were no areas of prominent focal slowing, and there were no epileptiform features Brief Hospital Course: This is a ___ yo M with history of dementia (A&O x 1 to self baseline), DM2, and status post laparoscopy cholecystectomy on ___ who was transferred from his nursing home with an acute confusional state and limb shaking movements. # AMS: Patient presenting with acute change in mental status- difficulty swallowing pills, twitching legs, and lack of normal leg pain. Differential diagnosis included infection, stroke, electrolyte abnormality, hypoglycemia. Labs were notable for elevated WBC of 12.7, sodium of 129, Cr of 1.6, potassium 5.7. Infectious work up was negative- normal UA, no acute processes on CXR and white blood cell count decreased to 9 without intervention. Patient also finished 7 day course of ciprofloxacin for surgical incision. Hyponatremia was mild at 129 and unlikely to cause altered mental status, this improved with IVF. On exam, the patient was noted to have one episode of twitching with decreased level of responsiveness concerning for seizure. He did not have any focal abnormalities, making stroke very unlikely. An EEG was performed to look for seizure, however there was no evidence of seizure. The patient was treated with IVF for dehydration evident on exam and lab abnormalities. His sodium improved to 133, Cr 1.2 (baseline) and K 4.3 with IVF suggesting dehydration, likely secondary to furosemide and decreased PO fluids. The patient is now better than his baseline, and is oriented to self and place (BID hospital). # Acute renal failure - Patient presenting with acute renal failure with Cr of 1.6 up from baseline of ___. After 2L IVF, the Cr improved to 1.2. Etiology most likely prerenal. BUN/Cr=15, FEUrea 43%. Urine electrolytes difficult to interpret in setting of furosemide, however given complete clinical picture appears to be pre-renal. Patient had a foley for decreased urine output and bladder scan showing >440 cc. Foley drained 600 cc, making post renal unlikey. Patient was able to pass voiding trial. Furosemide discontinued and lisinopril held while in ___. His furosemide was for venous stasis, and he was therefore prescribed graduated compression stockings in lieu of furosemide. # Hyponatremia: Patient presented with hyponatremia of 129 that is down from recent value of 136. He appeared to be hypovolemic on exam aside from lower extremity edema secondary to chronic venous stasis, most likely caused by decreased effective circulating volume secondary to furosemide. This improved to 133 with with IVF hydration consistent with hypovolemic hyponatremia. ECHO in ___ (LVEF>50%). # Hyperkalemia: 5.7 on admission without any EKG changes. Most likely caused by ___ and ___. Resolved after IV fluid challenge. # Diarrhea: New onset of watery diarrhea (> 4 BM) after admission in the setting of finishing bactrim for wound infection two days prior, concerning for C difficile colities. C. difficile testing was negative. Patient has baseline fecal incontinence. # Leukocytosis: Patient presented with mild leukocytosis of 12.7 down from 13.3 on recent discharge. He finished a course of ciprofloxacin on the day prior to admission for a surgical wound infection. Surgery evaluated and felt his wound looked improved. There was no other evidence of infection; normal chest x-ray, clean UA. Blood cultures pending on discharge. Leukocytosis resolved, may have been hemoconcentration. # Anemia: Patient with anemia that is new but stable, s/p surgery. No evidence of acute bleeding. ___ be followed up by primary care physician. # Afib: Patient developed atrial fibrillation in ___ period of last admission. He spontaneously converted to NSR prior to planned cardioversion. He was discharged on coumadin with cardiology follow up. CHADS2 score of 5 and subtherapeutic INR of 1.7 with past history of prior stroke. Patient was in normal sinus rhythm on presenation. He was monitored on telemetry and stayed in sinus rhythm. He was bridged with IV heparin weight based until INR therapeutic. He received 3.5mg of warfarin daily here. Metoprolol 50 mg BID was continued. Previous echo in ___ EF>50% no significant valvular disease Transitional Issues: - discontinued furosemide - recommend elevation and compression stockings for venous stasis - blood cultures pending Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 40 mg PO DAILY 2. NPH 10 Units Breakfast NPH 5 Units Bedtime 3. Clopidogrel 75 mg PO DAILY 4. Lisinopril 15 mg PO DAILY 5. Simvastatin 40 mg PO QHS 6. TraMADOL (Ultram) 50 mg PO TID:PRN pain hold for sedation, RR<10 7. Acetaminophen 650 mg PO TID:PRN pain 8. Metoprolol Tartrate 50 mg PO BID 9. Warfarin Dose is Unknown PO DAILY16 10. Finasteride 5 mg PO DAILY 11. Senna 1 TAB PO HS 12. Sertraline 75 mg PO DAILY 13. Amitriptyline 25 mg PO HS 14. Calcium Carbonate 500 mg PO DAILY 15. Docusate Sodium 100 mg PO BID 16. magnesium carbonate NF 400 mg Miscellaneous BID 17. Tamsulosin 0.4 mg PO HS 18. Bisacodyl 10 mg PR HS:PRN constipation Discharge Medications: 1. Acetaminophen 650 mg PO TID:PRN pain 2. Amitriptyline 25 mg PO HS 3. Calcium Carbonate 500 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Finasteride 5 mg PO DAILY 7. NPH 10 Units Breakfast NPH 5 Units Bedtime 8. Metoprolol Tartrate 50 mg PO BID 9. Senna 1 TAB PO HS 10. Sertraline 75 mg PO DAILY 11. Simvastatin 40 mg PO QHS 12. Tamsulosin 0.4 mg PO HS 13. TraMADOL (Ultram) 50 mg PO TID:PRN pain hold for sedation, RR<10 14. Warfarin 3.5 mg PO DAILY16 15. Bisacodyl 10 mg PR HS:PRN constipation 16. magnesium carbonate NF 400 mg Miscellaneous BID 17. Lisinopril 15 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Dehydration, Acute renal failure, Hyponatremia, Confusion Secondary: Dementia, Atrial Fibrillation Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. ___, It was a pleasure taking care of you during your hospitalization. You were admitted to ___ with confusion and a high white count. There was no signs of infection and your white count decreased. You also had electrolyt abnormalities (low sodium and high potassium). We gave you intravenous fluids and stopped your Lasix and this resolved. We think that you were dehydrated. Medications: Please stop taking furosemide Lasix) Followup Instructions: ___
10819799-DS-36	10,819,799	20,385,993	DS	36	2153-04-04 00:00:00	2153-04-04 18:01:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Keflex / Neurontin Attending: ___. Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is an ___ with past medical history of CVA ___ with residual speech hesitancy, Type 2 DM, PVD and recent admission for AMS believed to be secondary to medications who presented from ___ with altered mental status, fevers, and new hypoxia to SaO2 85% on room air. Per nursing at ___, the patient was found to be agitated and confused. That evening, he became febrile to ___ in the setting of continued agitation, confusion, and muscle twitching. In addition, he does not have a history of aspiration or nursing concern for aspiration. The morning of admission, in addition to the above symptoms he developed hypoxia to 85% and was placed on 2L. At that point, he was transferred to ___ for further care. In the ED, initial vitals were 102.4 93 90/46 97% 6L. Exam was notable for pt being non-verbal but following commands, diaphoretic, coarse breath sounds. Labs notable for negative influenza A/B PCR, WBC 18.0 with 83.6% PMNs, H/H 11.4/34.3, plts 159, Na 136, K 5.3, HCO3 25, BUN 56, Cr 2.0 from baseline 0.6, LFTs WNL, lactate 1.7, INR 4.0, UA with 1 WBC and negative ___ and nitrites. Blood cx x 2 and urine cx sent. Pt received 3L NS, Levofloxacin 500mg IV x 1, Ceftriaxone 1g IV x 1, Azithromycin 500mg IV x 1, Vancomycin 1g IV x 1, Tylenol ___ PR x 1. In the ED, pt was hypotensive to SBP 70's to 80's, with low reading of 72/50. A right IJ CVL was placed, and pt was started on levophed with improvement in BP to 100-150/50-70. Past Medical History: - Type II diabetes mellitus on insulin - CVA in early ___ with residual speech hesitancy, mild L weakness - Hypertension - Chronic venous insufficiency - Discogenic LBP s/p distant spinal surgery x 2 - Obesity - History of alcohol abuse - Dyslipidemia - Left toe ulcer s/p Percutaneous angioplasty of left popliteal artery, tibial-peroneal trunk, and anterior tibital artery Social History: ___ Family History: Per records, has a twin brother also with diabetes. Physical Exam: ADMISSION: Vitals- 98.4 88 155/55 (on levophed 0.03) 19 94% on 4L NC GENERAL: Somnolent, oriented x 2, no acute distress HEENT: Sclera anicteric, MMM NECK: supple, RIJ CVL LUNGS: crackles at the bases bilaterally, no rhonchi CV: Distant sounds, 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, ostomy with light brown stool in RLQ EXT: Warm, well perfused, no clubbing, cyanosis or edema SKIN: No evidence of open wounds or cellulitis NEURO: Moves all 4 extremities DISCHARGE: VS: 98.2 148/61 82 18 99RA GENERAL: Awake and interactive, upright in bed HEENT: MMM, sclera anicteric NECK: Supple PULM: Distant crackles at the bases bilaterally, though overall relatively clear CV: Irregular, (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended, bowel sounds present, RLQ ostomy with stool output EXTREM: Warm, well perfused, no clubbing, cyanosis or edema SKIN: No evidence of open wounds or cellulitis NEURO: Moves all 4 extremities, expressive aphasia Pertinent Results: ADMISSION: ___ 04:40AM BLOOD WBC-18.0# RBC-4.15 Hgb-11.4* Hct-34.3* MCV-83 MCH-27.5 MCHC-33.2 RDW-15.6* Plt ___ ___ 04:40AM BLOOD Neuts-83.6* Lymphs-12.6* Monos-3.3 Eos-0.3 Baso-0.2 ___ 04:40AM BLOOD ___ PTT-42.7* ___ ___ 04:40AM BLOOD Glucose-262* UreaN-56* Creat-2.0* Na-136 K-5.3* Cl-101 HCO3-25 AnGap-15 ___ 04:40AM BLOOD ALT-22 AST-18 AlkPhos-85 TotBili-0.3 ___ 04:40AM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.6 Mg-2.1 DISCHARGE: ___ 05:57AM BLOOD WBC-10.8 RBC-3.88* Hgb-10.5* Hct-31.7* MCV-82 MCH-27.2 MCHC-33.2 RDW-15.3 Plt ___ ___ 05:57AM BLOOD Glucose-136* UreaN-19 Creat-0.8 Na-134 K-4.1 Cl-99 HCO3-23 AnGap-16 ___ 05:57AM BLOOD ___ PTT-47.0* ___ ___ 05:57AM BLOOD Calcium-8.1* Phos-2.0* Mg-1.7 IMAGING: ___ CXR Low lung volumes, with bibasilar atelectasis, greater on the right, however, left basilar pneumonia cannot be excluded. Stable cardiomegaly. ___ CT Head 1. No acute intracranial hemorrhage. 2. Multifocal encephalomalacia in left cerebral hemisphere and right pons consistent with prior infarct. 3. Mucosal thickening of left maxillary and anterior ethmoidal air cells. Brief Hospital Course: Mr. ___ is an ___ with history of history of stroke (___) with residual speech deficits, dementia, diabetes mellitus, and atrial fibrillation who presented with altered mental status and hypoxia, found to have sepsis likely secondary to pneumonia. ACUTE ISSUES #Septic shock, pneumonia Presenting from ___ with hypoxemia and altered mental status, found to have possible pneumonia on CXR with leukocytosis. He was hypotensive in the ED requiring pressors and several IV fluid boluses. His blood pressure quickly stabilized overnight. His antibiotic regimen was narrowed during his MICU stay, initially vancomycin, cefepime, and azithromycin, and later to azithromycin and cefpodoxime for seven day total antibiotic course. #Altered mental status/Encephalopathy Thought to be most likely secondary to the patient's infection with possible contribution of his many medications which are known to cause altered mental status in the elderly. His gabapentin was downtitrated and recommendations were made to be judicious about the use of some of his medications which can cause mental status changes. #Acute kidney injury Patient found to have creatinine of 2.2 on admission from baseline of 0.6. Patient received significant rehydration with improvement of his creatinine to near baseline. Creatinine on discharge 0.8. #Atrial fibrillation complicated by supratherapeutic INR Patient with history of AF and elevated CHADS2 score 5. On warfarin for anticoagulation and metoprolol for rate control. Presenting with INR of 4.0, which remained elevated during his hospitalization. The patient's warfarin was held and his INR was trended. INR remains elevated on discharge without signs of bleeding. #Diabetes mellitus He was continued on his home insulin regimen. #CHF He was continued on his home metoprolol and lisinopril. #Hypertension He was continued on his home metoprolol and lisinopril. HCTZ was held at time of discharge for planned restart at ___. #History of CVA He was continued on his home clopidogrel. #CAD/Hyperlipidemia He was continued on his home simvastatin. #Chronic back Patient with history of back pain s/p spinal surgery. His pain regimen has been downtitrated recently given presentation of altered mental status before. His home tramadol and gabapentin was held during his hospitalization and restarted upon discharge. #BPH He was continued on his home finasteride. #Depression and dementia He was continued on his home sertraline and desipramine. His home trazodone was restarted upon discharge. TRANSITIONAL ISSUES -Please trend INR and restart warfarin at home doses once INR <3. Warfarin dosing may require adjustment given concurrent use of antibiotics. -Consider downtitrating many of the patient's sedating medications to prevent altered mental status. -Patient was largely restarted on his home antihypertensive regimen, though HCTZ was still held at discharge. This can be restarted at ___ once his blood pressures have stabilized. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 3. Bisacodyl ___AILY:PRN constipation 4. Clopidogrel 75 mg PO DAILY 5. Desipramine 50 mg PO QHS 6. Docusate Sodium 100 mg PO BID 7. Finasteride 5 mg PO DAILY 8. Hydrochlorothiazide 25 mg PO DAILY 9. Lisinopril 60 mg PO DAILY 10. Metoprolol Tartrate 50 mg PO DAILY 11. Milk of Magnesia 30 mL PO DAILY:PRN constipation 12. Prochlorperazine 25 mg PR Q12H:PRN nausea 13. Senna 8.6 mg PO DAILY:PRN constipation 14. Sertraline 150 mg PO DAILY 15. TraZODone 25 mg PO HS:PRN if first, smaller dose, does not work 16. TraZODone 12.5 mg PO HS:PRN sleep 17. TraMADOL (Ultram) 25 mg PO Q8H:PRN pain 18. Simvastatin 20 mg PO DAILY 19. Warfarin 6 mg PO DAILY16 20. Amlodipine 10 mg PO DAILY 21. Gabapentin 400 mg PO BID 22. Desipramine 25 mg PO QAM 23. 70/30 10 Units Breakfast 70/30 5 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 3. Amlodipine 10 mg PO DAILY 4. Bisacodyl ___AILY:PRN constipation 5. Clopidogrel 75 mg PO DAILY 6. Desipramine 50 mg PO QHS 7. Docusate Sodium 100 mg PO BID 8. Finasteride 5 mg PO DAILY 9. Gabapentin 200 mg PO BID 10. 70/30 10 Units Breakfast 70/30 5 Units Dinner Insulin SC Sliding Scale using HUM Insulin 11. Lisinopril 60 mg PO DAILY 12. Metoprolol Tartrate 50 mg PO DAILY 13. Milk of Magnesia 30 mL PO DAILY:PRN constipation 14. Senna 8.6 mg PO DAILY:PRN constipation 15. Sertraline 150 mg PO DAILY 16. Simvastatin 20 mg PO DAILY 17. Azithromycin 250 mg PO Q24H Please continue through ___ for total of seven days of antibiotics. 18. Cefpodoxime Proxetil 400 mg PO Q12H Please continue through ___ for total of seven days of antibiotics. 19. Desipramine 25 mg PO QAM 20. Warfarin 6 mg PO DAILY16 21. Hydrochlorothiazide 25 mg PO DAILY 22. Prochlorperazine 25 mg PR Q12H:PRN nausea 23. TraMADOL (Ultram) 25 mg PO Q8H:PRN pain 24. TraZODone 25 mg PO HS:PRN if first, smaller dose, does not work 25. TraZODone 12.5 mg PO HS:PRN sleep Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Pneumonia Severe sepsis Atrial fibrillation, supratherapeutic INR Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. ___, You were admitted from ___ with low oxygen levels and confusion. You were found to have a pneumonia causing a low blood pressure. You were cared for in the ICU initially, but became well enough to go to the medical floor. Please continue taking antibiotics as directed. You warfarin levels (INR) were found to be very high during your admission, possible because of your illness. Please monitor your INR blood test and restart the warfarin as directed. Followup Instructions: ___
10819930-DS-11	10,819,930	26,920,336	DS	11	2120-01-14 00:00:00	2120-01-15 17:21:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Imitrex / Nexium Attending: ___. Chief Complaint: RUQ Pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with hx of chronic abdominal pain, migraines, and relapsing/remitting MS who presents with acute on chronic RUQ abdominal pain concerning for symptomatic cholelithiasis. . Pt has had chronic abdominal pain for past several months and has been worked up extensively by gastroenterology. She has been ruled out for celiac disease and had a recent EGD showing gastritis, though biopsies were all normal and negative for HPylori. Pt was started on a PPI but discontinued it when the medication was making her nauseous - also on dicyclamine per GI. Pt had a recent CCK HIDA scan which was normal as well as a normal abd CT. . She has been without pain recently until 2 days ago (___ morning), when she again developed RUQ crampy, sharp pain, similar to prior episodes. It started in the morning and resolved somewhat allowing her to attempt to eat THaksgiving dinner (which consisted of a fair amount of cheese). She states that while prior episodes resolved after a few hours, this one has not. After dinner, however, she developed pain ___ later and then she began to vomit 90-120min later and has not been able to keep down food since. She tried a couple other times and had the same experience with worsening pain followed by vomiting. Pain is always in the epigastrium/RUQ and is similar in location to prior episodes. She has mild constipation, but denies diarrhea, fevers, chills, melana, hematochezia, rash, cough, sick contacts. Additionally, she did note that her urine seemed a bit dark yesterday. . In the ED, initial VS:98.8 63 149/92 16 100%. LFTs and Lipase normal. RUQ U/S showed stones in gallbladder and possible stone in cystic duct. ACS was consulte regarding symptomatic cholelithiasis but said would like input from GI for other reasons for pain before commiting to surgery and requested admission to medicine for a GI consult. Pt was given zofran 4mg iv at 0130 and dilaudid 1mg iv at 0130. pt given another dilaudid 1mg iv at 0520 Temp - 98.2 oral, HR - 59, BP - 102/67, RR - 16, O2 Sat - 100% room air Past Medical History: Multiple Sclerosis (Dx ___ L numbness most normal presentation) Migraines Anxiety/Panic attacks Chronic Abd Pain (since beginning ___ Lactose Intolerance Social History: ___ Family History: Mother with ovarian cyst and ?breast CA and s/p CCY and fibromyalgia Uncle with Type ___ DM Physical Exam: ADMISSION PHYSICAL EXAM: VS - Temp 96.9F, BP 104/64, HR 64, R 16, O2-sat 100% RA GENERAL - obese, well-appearing in NAD, slightly uncomfortable HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no cervical LAD LUNGS - CTA bilat ant, no r/rh/wh, good air movement, resp unlabored HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/TTP in RUQ, slightly worse with inspiration, 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 ___ grossly intact, muscle strength ___ throughout, sensation grossly intact throughout DISCHARGE PHYSICAL EXAM: VS: 98.9 98.2 118/76 72 14 100%RA GEN: obese, NAD, laying in bed comfortable HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no cervical LAD LUNGS - CTA bilat ant, no r/rh/wh, good air movement, resp unlabored HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/mildly TTP in RUQ, slightly worse with deep inspiration, no masses or HSM, no rebound/guarding. Exam unchanged from prior. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions NEURO - awake, A&Ox3 Pertinent Results: ADMISSION LABS: ___ 01:10AM BLOOD WBC-6.7 RBC-4.10* Hgb-13.2 Hct-38.5 MCV-94 MCH-32.1* MCHC-34.2 RDW-12.4 Plt ___ ___ 01:10AM BLOOD Neuts-73.5* ___ Monos-4.0 Eos-1.9 Baso-0.2 ___ 05:10AM BLOOD ESR-10 ___ 01:10AM BLOOD Glucose-116* UreaN-8 Creat-0.6 Na-138 K-4.1 Cl-105 HCO3-22 AnGap-15 ___ 01:10AM BLOOD ALT-15 AST-24 LD(LDH)-184 AlkPhos-63 TotBili-0.2 ___ 01:10AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.0 ___ 01:10AM BLOOD CRP-1.7 CA125-16 ___ 01:53AM BLOOD Lactate-2.4* DISCHARGE LABS: ___ 07:50AM BLOOD WBC-4.0 RBC-3.91* Hgb-13.1 Hct-36.6 MCV-94 MCH-33.5* MCHC-35.8* RDW-12.3 Plt ___ ___ 07:50AM BLOOD Glucose-119* UreaN-7 Creat-0.7 Na-138 K-3.7 Cl-103 HCO3-25 AnGap-14 RADIOLOGY: HIDA Scan - IMPRESSION: Normal hepatobiliary study. LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___ 1:16 AM FINDINGS: The liver appears normal in echotexture with no focal liver lesions identified. The gallbladder demonstrates gallstones, but there is no evidence of gallbladder wall thickening or surrounding pericholecystic fluid. No sonographic ___ sign was elicited. Overall, findings suggest cholelithiasis without any specific signs for cholecystitis. The common bile duct measures 0.3 cm and is within normal limits. The main portal vein is patent. There is no free fluid. There appears to be a small stone within the cystic duct. IMPRESSION: 1. Cholelithiasis without specific signs for cholecystitis. 2. Stone noted within the cystic duct. Brief Hospital Course: Ms. ___ is a ___ yo F w chronic intermittent right upper quadrant abdominal pain most clinically consistent w symptomatic cholelithiasis. . #Right Upper Quadrant Pain- The current presentation is most clinically consistent with symptomatic cholethiasis. A right upper quadrant ultrasound confirmed the presence of stones in the gallbladder (the largest measuring 1.2cm) including a stone in the cystic duct but showed no evidence of acute cholecystitis. General Surgery evaluated the patient a felt that considering her ultrasound did not show acute cholecystitis that a cholecystectomy did not have to be emergently performed. GI was also consulted and recommended that a HIDA scan be ordered. They also felt her symptoms could be due to irritable bowel syndrome and recommended that we continue her on Dicyclomine 10mg three times per day. They recommended that further workup occur as an out patient. Her pain was controlled with Acetaminophen, Toradol and Tramadol. Her diet was slowly advanced from NPO to full liquids as tolerated. HIDA scan was performed and was unremarkable. The patient was discharged on ___ with plans to f/u with her GI physician ___ and with surgery for possible elective CCY. #Migraines- The patient has a known history of migraines in the past. We continued Amitriptyline 25 mg prn to be used for headaches while she was in the hosptial. #Transitional- 1) Need for outpatient cholecystectomy to be addressed with surgery Medications on Admission: AMITRIPTYLINE - 25 mg daily as needed for migraine/MS ___ DICYCLOMINE - 10 mg three times a day RANITIDINE HCL - 150 mg BID Discharge Medications: 1. dicyclomine 10 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. amitriptyline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) as needed for headache. 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea for 4 days: Please do not drive a car or operate heavy machinery until you know how compazine affects you. Disp:12 Tablet(s) Refills:0 5. tramadol 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for pain for 3 days: Please do not drive a car or operate heavy machinery if taking tramadol. Disp:3 Tablet(s) Refills:0 6. Tylenol ___ mg Tablet Sig: ___ Tablets PO three times a day for 3 days. Disp:18 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Abdominal pain Secondary Diagnosis: 2. Migraines Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, It was a pleasure taking care of you at ___ ___. You were admitted to the hosptial with abdominal pain. An ultrasound of your abdomen showed that there a stones in your gallbladder but none that were causing a blockage and inflammation that could explain your abdominal pain. You had a HIDA scan of your gallbladder performed which was normal. We recommend you keep your appointment with Dr. ___ on ___ for further work up of this problem. Note the following changes to your home medication regimen: 1) Please START Tramadol 50mg at night as needed for pain until you follow-up with your Gastroenterologist on ___. 2) Please START Compazine 5mg 3 times daily as needed for nausea until you follow-up with your Gastroenterologist on ___. 3) Please START Acetaminophen (tylenol) every 8 hours as long as pain persists. See below for instructions regarding follow-up care: Followup Instructions: ___
10819935-DS-4	10,819,935	25,355,672	DS	4	2183-06-07 00:00:00	2183-06-07 21:31:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Motrin / Penicillins / Tylenol Attending: ___. Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: ___ hx of bipolar, IVDU many years ago on suboxone presents after being found unresponsive tonight by his sister. He has had 3 days of N/V and took a dose of his trazadone tonight because he wanted to sleep. He was then found unresponsive by sister. Last seen well at 1330 ___. Family reported to EMS patient has been drinking large quantities of soda with little water past few days. Per EMS, pupils dilated and alert to name only. En route to ED, however, pinpoint pupils. Was given narcan without change. Meds in patient's room included trazodone, alprazolam, codeine, abilify, omeprazole. At ___ his initial BP 90/s HR 116. He was altered and slurring his speech. He was found to have BUN/Cr of 95/6.4, Na of 116, Lactate 5.8 and lipase 414. AST 80, ALT 106, TBili 2.8, Dbili 1.16 He was given 2L NS bolus over 30 min at 2300, and 1L NS bolus at ~0030, as well as 40mEq PO K zofran. He was transferred here because there were no ICU beds at ___. In the ED, initial vs were: 98.4 98 122/75 20 94% RA. He was initially asymptomatic. He denied taking any other substances and denied SI or intentional overdose. He had no complaints and denied nausea, fever, pains. He appeared dehydrated but otherwise had an unremarkable exam including a benign abdomen. He received maintenance NS. Na 125 up from 116 at OSH. While in the ED he became altered, pulling at lines and foley and not answering questions or following commands. He was given 2mg Ativan and 5mg Haldol and placed in mechanical restraints. Head CT w/out did not show any acute findings including cerebral edema. He was given zofran for nausea, and started on empiric cipro/flagyl for concern of abdominal process. RUQ u/s was obtained with no acute findings. On the floor, patient is somnolent. He is unable to correctly answer most questions and falls asleep during questioning and exam. He briefly became hypoxic to ___ requiring addition of low flow nasal canula. Past Medical History: Polysubstance abuse (clonazepam, oxycodone, IVDU) Bipolar Disorder Past psych admissions PTSD ADHD GERD Chronic back pain Knee surgery Left shoulder surgery Sleep terrors Social History: ___ Family History: NC Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.5 p78 105/43 R13 96% on RA then to 80%s. Improved to 97% on 4L NC General: Disheveled male, NAD, very somnolent HEENT: Pupils reactive, equal 3->2mm bilaterally, tongue protrudes midline, atraumatic Neck: No LAD, supple and freely mobile Lungs: Bilateral air entry CV: S1, S2 regular. Pulses 2+ throughout Abdomen: Soft, nontender throughout to deep palpation. Nonperitoneal. GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Recent lab draw needle sites but no obvious track marks Neuro: A+Ox2 (knows name, location - "hospital," not month or year) Skin: erythematous rash over face and neck. DISCHARGE PHYSICAL EXAM: VS: 98.2, 105/65, 70, 20, 98% RA General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, No MRG Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal, normal finger-to-nose test, no asterixis Pertinent Results: LABS: On Admission: ___ 03:03PM BLOOD Glucose-112* UreaN-86* Creat-5.7* Na-125* K-5.3* Cl-74* HCO3-30 AnGap-26* ___ 02:50AM BLOOD WBC-12.3* RBC-4.51* Hgb-13.7* Hct-39.0* MCV-86 MCH-30.3 MCHC-35.1* RDW-11.8 Plt ___ ___ 02:50AM BLOOD Neuts-81.6* Lymphs-9.4* Monos-8.5 Eos-0.2 Baso-0.3 ___ 02:50AM BLOOD ___ PTT-28.9 ___ ___ 02:50AM BLOOD Glucose-101* UreaN-80* Creat-5.7* Na-125* K-3.2* Cl-72* HCO3-36* AnGap-20 ___ 02:50AM BLOOD ALT-80* AST-73* AlkPhos-55 TotBili-2.1* ___ 02:50AM BLOOD Lipase-104* ___ 09:39AM BLOOD Calcium-7.6* Phos-6.8* Mg-2.1 ___ 06:14AM BLOOD Osmolal-289 ___ 03:04AM BLOOD Lactate-2.3* On discharge: ___ 06:33AM BLOOD Glucose-97 UreaN-74* Creat-3.5* Na-135 K-4.4 Cl-94* HCO3-33* AnGap-12 ___ 06:33AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.0 Misc: ___ 12:35PM BLOOD Glucose-118* UreaN-86* Creat-4.6* Na-125* K-3.1* Cl-82* HCO3-33* AnGap-13 ___ 03:14AM BLOOD ALT-73* AST-48* LD(LDH)-196 AlkPhos-54 TotBili-0.7 ___ 06:14AM BLOOD Lipase-93* ___ 10:44PM BLOOD Lactate-1.0 ___ 06:40AM BLOOD WBC-9.5 RBC-4.50* Hgb-13.5* Hct-39.9* MCV-89 MCH-30.1 MCHC-33.9 RDW-11.8 Plt ___ MICROBIOLOGY: ___ URINE CULTURE (Final ___: <10,000 organisms/ml. ___ Blood cx pending x2 IMAGING: ___ CT head w/out: No acute intracranial process. No evidence of cerebral edema. ___ RUQ u/s: no acute abnormalities ___ Renal US: No hydronephrosis. Slightly increased echogenicity of the renal parenchyma suggesting medical renal disease. Normal renal vasculature. Brief Hospital Course: ___ with history of Bipolar disorder, polysubstance abuse, PTSD who presented with altered mental status in setting of recent GI illness, hyponatremia, renal failure and psychoactive medication use. ACTIVE ISSUES BY PROBLEM: # Toxic-metabolic Encephalopathy: Likely secondary to symptomatic hyponatremia and renal failure in addition to medication effects. CT head was negative with no focal neurological findings. Urine tox screen only positive for benzos, which he is prescribed. With gradual normalization of his electrolytes, his mental status improved back to baseline. # Hyponatremia: Likely hypovolemic with solute losses from vomiting with GI illness combined with large volumes of intake with low solute. His sodium levels corrected on their won with resumption of normal diet and fluid intake. Na on discharge was 135. He should have his electrolytes rechecked at his follow up PCP ___ # Acute kidney injury: Nephrology consulted who believed that his original kidney injury was from severe dehydration in the setting of acute nause/vomiting and that he also likely developed from ATN. They expected his renal function to likely make a full recovery. He was allowed a regular diet without fluid restriction for management and his creatinine trended down to 3.4 on discharge. His Cr should be rechecked at his next PCP appointment and if Cr has not returned to normal, can consider referral to nephrology. TRANSITIONS OF CARE: - Hyponatremia: should have Na checked at follow up visit to PCP to ensure it has remained normal after discharge - Renal failure: Cr decreased from 6.4->3.4 on discharge and is expected to keep falling. Should have repeat Cr rechecked at visit with PCP. If renal function does not fully recover, can consider referral to nephrology. - No medication changes were made except holding his terbinafine given his decreased renal function - FULL CODE this admission Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. QUEtiapine extended-release 300 mg PO QHS 2. TraZODone 400 mg PO HS 3. Aripiprazole 50 mg PO HS 4. ALPRAZolam 1 mg PO TID 5. CloniDINE Dose is Unknown PO Frequency is Unknown 6. Buprenorphine-Naloxone (2mg-0.5mg) Dose is Unknown SL Frequency is Unknown Discharge Medications: 1. ALPRAZolam 1 mg PO BID 2. Amphetamine Salt Combo (dextroamphetamine-amphetamine) 5 mg oral daily 3. Aripiprazole 20 mg PO HS 4. Buprenorphine-Naloxone (8mg-2mg) 3 TAB SL DAILY 5. CloniDINE 0.2 mg PO TID 6. TraZODone 300 mg PO HS Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Hyponatremia Acute kidney injury Acute encephalopathy Secondary diagnoses: Attention deficit disorder Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr ___, It was a pleasure taking care of you at ___! You were admitted to the hospital with severe confusion, low sodium and kidney failure. We believe that the stomach bug you had caused you to throw up too much sodium and get dehydrated, then affecting your kidneys. You sodium is now back to normal and your kidneys are continuing to improve. We expect you to make a full recovery. Once you go home, continue to eat plenty of food and drink when you are thirsty, avoiding just plain water if able. Do not take anymore drugs other than those you are prescribed! Followup Instructions: ___
10819935-DS-6	10,819,935	24,995,393	DS	6	2184-05-09 00:00:00	2184-05-09 20:56:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Motrin / Penicillins / Tylenol Attending: ___. Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: Endotracheal Intubation History of Present Illness: ___ with PMH of Anxiety, substance abuse, bipolar disorder, polysubstance abuse and IVDU presented to ___ with altered mental status. Per report, the pt had not been feeling well over the past three days, becoming increasingly agitated. His mother came home over the past couple of days noting noting items around the house in disarray, although her son did not recall making such changes. Per a friend's report, he has been injecting suboxone daily. On presentation at the OSH, he was agitated and combative. On exam, he was diaphoretic, tachycardic to 140s, normotensive, febrile to 104.5. There was no report of clonus or rigidity. Labs were significant for a WBC 19 (88 PMNs), Na 125, K 2.8, Cl 74, HCO3 36, AST 316, TB 1.2, DB 0.36, CK > 20k, lactate of 3.3, UA with large blood. Trops were 0.116. Salicylates and tylenol level was negative. Non-contrast head CT was negative. He had a tonic-clonic seizure, was given 6mg ativan for seizure and concern for serotonin syndrome, and was intubated for airway protection. He was not actively cooled, but was given PR tylenol. He was also given 1 dose of vanc/CTX, and 1200cc fluid bolus. He was then transferred to ___. In the ___, initial vitals: 100.0 (Tmax 100.8) 117 131/76 23 99% and intubation. On exam, he was flushed and diaphoretic, pupils were 1mm and reactive, no hyperreflexia, no clonus, no rigidity. His labs were notable for WBC 18.1, INR 1.3, Na 130, K 2.6, Cl 82, HCO3 34, Cr 1.5, Mg 2.7, Phos 4.6, ALT 79, AST 697, LDH 1089, CK ___, lactate 1.8, trop 0.03. UA positive for blood. Serum tox was positive for acetaminophen level of 6 and for BZDs. Initial ABG showed pH 7.52, pCO2 44. CSF was sampled to rule out meningitis: 1 WBC, 1 RBC, Protein 17, Glucose 93. CXR showed opacities in the right middle lobe. EKG showed normal QRS and QTc. He was given 2L LR and K was repleted. He was admitted to the MICU for further monitoring. On arrival to the MICU, the patient is intubated and sedated. He is hemodynamically stable. IVF initiated. Past Medical History: Polysubstance abuse (clonazepam, oxycodone, IVDU) Bipolar Disorder Past psych admissions PTSD ADHD GERD Chronic back pain Knee surgery Left shoulder surgery Sleep terrors Social History: ___ Family History: family history remarkable for ulcer disease in mother, s/p gastrectomy Physical Exam: Admission Exam: Vitals- T:99.9 (rectal), BP: 123/78, P: 100, O2: 100% on CMV FiO2 50%, 450 Vt, RR 16, PEEP 5. GENERAL: Intubated, sedated, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Tachycardic, regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, hypoactive bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: Multiple track marks in the bilateral antecubital fossa, red/warm/dry skin. Erythematous rash all over, flushed. Areas of induration in left antecubital region and right anterior shin. Neuro: Cranial nerve reflexes intact (pupils 2mm and sluggish, corneals intact). Discharge Exam: Vitals- 98.2 127/79 90 18 95%RA GENERAL: Middle aged male, NAD, lying in bed HEENT: Sclera anicteric, dry MM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: lungs CTAB CV:regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, hypoactive bowel sounds present, no rebound tenderness or guarding EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: Multiple track marks in the right antecubital fossa, red/warm/dry skin. Neuro: Hearing decreased in left ear, CN ___ otherwise intact, AO x3 Pertinent Results: ___ 02:48AM TYPE-ART RATES-20/ TIDAL VOL-500 PEEP-5 O2-100 PO2-203* PCO2-44 PH-7.52* TOTAL CO2-37* BASE XS-12 AADO2-460 REQ O2-79 -ASSIST/CON INTUBATED-INTUBATED ___ 02:55AM PLT SMR-NORMAL PLT COUNT-310 ___ 02:55AM ___ PTT-32.8 ___ ___ 02:55AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL ___ 02:55AM NEUTS-89.8* LYMPHS-6.0* MONOS-2.9 EOS-1.1 BASOS-0.1 ___ 02:55AM WBC-18.1* RBC-5.12 HGB-15.7 HCT-42.6 MCV-83 MCH-30.6 MCHC-36.8* RDW-12.7 ___ 02:55AM ASA-NEG ETHANOL-NEG ACETMNPHN-6* bnzodzpn-POS barbitrt-NEG tricyclic-NEG ___ 02:55AM TSH-0.37 ___ 02:55AM TRIGLYCER-135 ___ 02:55AM ALBUMIN-4.0 CALCIUM-8.7 PHOSPHATE-4.6* MAGNESIUM-2.7* ___ 02:55AM cTropnT-0.03* ___ 02:55AM LIPASE-22 ___ 02:55AM ALT(SGPT)-79* AST(SGOT)-697* LD(LDH)-1809* ___ ALK PHOS-68 TOT BILI-0.8 ___ 02:55AM GLUCOSE-121* UREA N-19 CREAT-1.5* SODIUM-130* POTASSIUM-2.6* CHLORIDE-82* TOTAL CO2-34* ANION GAP-17 ___ 03:09AM LACTATE-1.8 ___ 03:09AM COMMENTS-GREEN TOP ___ 03:30AM URINE RBC-2 WBC-7* BACTERIA-FEW YEAST-NONE EPI-0 ___ 03:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 03:30AM URINE COLOR-Red APPEAR-Hazy SP ___ ___ 03:30AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* POLYS-6 ___ MACROPHAG-2 ___ 03:30AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 03:30AM URINE HOURS-RANDOM ___ 03:30AM CEREBROSPINAL FLUID (CSF) PROTEIN-17 GLUCOSE-93 ___ 07:08AM PLT COUNT-245 ___ 07:08AM WBC-15.9* RBC-4.48* HGB-13.7* HCT-37.7* MCV-84 MCH-30.6 MCHC-36.4* RDW-12.8 ___ 07:08AM CALCIUM-7.8* PHOSPHATE-3.1 MAGNESIUM-2.4 ___ 07:08AM ALT(SGPT)-98* AST(SGOT)-746* ___ ___ ALK PHOS-60 TOT BILI-1.0 ___ 07:08AM GLUCOSE-126* UREA N-20 CREAT-1.7* SODIUM-135 POTASSIUM-2.5* CHLORIDE-93* TOTAL CO2-32 ANION GAP-13 ___ 10:47AM freeCa-1.03* ___ 10:47AM LACTATE-1.2 ___ 10:47AM TYPE-ART TEMP-37.8 ___ TIDAL VOL-480 PEEP-5 O2-50 PO2-90 PCO2-49* PH-7.45 TOTAL CO2-35* BASE XS-8 -ASSIST/CON INTUBATED-INTUBATED ___ 12:37PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 03:23PM ___ PTT-37.6* ___ ___ 03:23PM CALCIUM-7.7* PHOSPHATE-2.5* MAGNESIUM-2.3 ___ 03:23PM ALT(SGPT)-101* AST(SGOT)-792* LD(___)-1898* ALK PHOS-55 ___ 03:23PM GLUCOSE-101* UREA N-22* CREAT-1.9* SODIUM-137 POTASSIUM-3.4 CHLORIDE-101 TOTAL CO2-26 ANION GAP-13 ___ 05:34PM LACTATE-1.0 ___ 05:34PM TYPE-ART PO2-124* PCO2-42 PH-7.43 TOTAL CO2-29 BASE XS-3 ___ 05:34PM LACTATE-1.0 RUQ US 1. Redemonstration of 2 hepatic hemangiomas, unchanged. 2. Small bilateral pleural effusions. ECHO: Normal regional and global biventricular systolic function. Normal diastolic function. No pathologic valvular abnormalities. CXR: Residual mild pulmonary vascular congestion/interstitial edema, improved from ___. Trace right pleural effusion. Discharge Labs: ___ 05:35AM BLOOD WBC-11.1* RBC-3.72* Hgb-10.9* Hct-32.3* MCV-87 MCH-29.2 MCHC-33.6 RDW-12.9 Plt ___ ___ 05:35AM BLOOD Glucose-101* UreaN-22* Creat-2.0* Na-140 K-4.0 Cl-99 HCO3-34* AnGap-11 ___ 05:35AM BLOOD ALT-137* AST-133* ___ 05:48AM BLOOD Calcium-8.1* Phos-2.4* Mg-1.8 Iron-22* ___ 05:48AM BLOOD calTIBC-135* Ferritn-418* TRF-104* ___ 03:32AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HAV-NEGATIVE ___ 04:04AM BLOOD HIV Ab-NEGATIVE ___ 03:32AM BLOOD HCV Ab-NEGATIVE Brief Hospital Course: ___ yo M with history of polysubstance abuse, IVDU, anxiety, depression, presents after acute agitation and seizure thought to be due to a sympathomimetic overdose and is now s/p intubation/extubation with ___ and rhabdomyolysis. # Acute encephalopathy: Presenting with agitation at ___ (reports of needing to be restrained by 5 security guards), Pt had evidence of sympathetic overdrive with fever, tachycardia, diaphoresis, and agitation, hypoactive bowel sounds. Toxicology was consulted. Patient has reportedly made dimethyltryptamine, which is a psychedelic medication that contains serotonin and melatonin analogs. Clembuterol was also a consideration given the patients hypokalemia and tachycardia, but less likely given there is no hypocalcemia or hyperglycemia. The patient also takes alprazolam at baseline and could have been experiencing BZD withdrawal. Seratonin syndrome was also on the differential given the use of multiple serotonergic medications including trazadone. Tylenol levels were negative. He was treated supportively with benzodiazepines and IVF while in the ICU. He self extubated and was transferred to the floor where he was restarted on his home alprazolam. He did not experience any more agitation after floor transfer. He has had 2 similar presentations in the past where drug use has been suspected but he has firmly denied any drug use before his current presentation. # Seizures: Pt had generalized tonic-clonic seizure at OSH. It was most likely provoked ___ high fever and severe electrolyte abnormalities (hyponatremia). The pt has no clinical evidence of ongoing seizures. CT head negative at OSH. EEG here did not demonstrate any seizures or seizure focus. He was maintained on ativan per CIWA protocol and as substitution for his xanax. He did not have any recurrence of seizures. # Rhabdomyolysis: CK elevated at OSH and rising on presentation to ___. Possible etiologies include fever, NMS, prolonged time of immobility, and seizure. He was treated aggressively with fluid resuscitation until CK trended to less than 5K. He required multiple doses of IV lasix to help with diuresis due to pulmonary edema. # ___: Baseline of 1.0 and presented with Cr of 1.5 which trended up to 2.8. This was thought to be due to ATN and rhabdomyolysis. His Cr trended down with fluid resuscitation and it was 2.0 on discharge. #H/o drug use: Patient firmly denies any recent drug use, but presentation was concerning for possible overdose of a sympathomimetic (amphetamine, bath salt, etc.). SW saw the patient and offered resources, but patient was not interested in a halfway house or rehab center. #Anemia: normocytic, downtrending Hct since arrival. Retic count was low and ferritin high, so thought to be due to anemia of inflammation. Should be followed as outpatient. #Anxiety/Depression: Continue home Xanax, Abilify, Clonidine; Did not continue Trazadone, as this medication was also implicated in patient's last similar presentation in ___. Unsure at this point if it was causative, but due to multiple seratonin modulating drugs, recommended that the patient stop taking trazadone. #Superficial thrombophlebitis:Clot was seen in the cephalic vein of the RUE on US. Patient initially started on heparin and warfarin in the ICU but this was stopped on the floor as the patient was asymptomatic. Transitional Issues: -Patient firmly denies drug use in the days preceding this admission, as well as the previous admissions for similar presentations. There is no clear evidence to confirm the presence or absence of drug use (sympathomimetics, bath salts) during these admissions. -Cr 2.0 on discharge and should be checked on ___ for resolution of the ___ -Patient endorsed SI ("I wish I had never woken up"). He has no intent to harm himself, no plan, and no firearm. Please monitor for depression and continued SI. -Trazadone discontinued on this admission in case these repeated cases of agitation and sympathetic stimulation were due to seratonin syndrome. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 1 mg PO QID:PRN anxiety 2. ARIPiprazole 20 mg PO DAILY 3. Buprenorphine-Naloxone (8mg-2mg) 3 TAB SL DAILY 4. CloniDINE 0.2 mg PO TID 5. TraZODone 300 mg PO QHS:PRN insomnia 6. Adderall (dextroamphetamine-amphetamine) 30 mg oral TID 7. Prazosin 2 mg PO QHS Discharge Medications: 1. ALPRAZolam 1 mg PO QID:PRN anxiety RX alprazolam 1 mg 1 tablet(s) by mouth four times daily Disp #4 Tablet Refills:*0 2. ARIPiprazole 20 mg PO DAILY 3. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY 4. CloniDINE 0.2 mg PO TID 5. Prazosin 2 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Primary: Acute encephalopathy Respiratory Failure Rhabdomyolysis Acute Kidney Injury Pulmonary Edema Secondary: Anxiety Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital because you were confused and agitated. You needed to be put on the breathing machine because you had a seizure. You also developed some muscle breakdown and injured your kidneys. At this time we do not know what caused this series of events, but we think it is possible you may have taken some type of drug. We understand that you deny any drug use, but if you are consuming or injecting any type of drug, we want you to understand that you could seriously damage your health, which would include kidney failure and even death. Please follow up with your other providers for continued management of your other health issues. Sincerely, Your ___ Team Followup Instructions: ___
10819991-DS-16	10,819,991	27,823,541	DS	16	2114-11-05 00:00:00	2114-11-05 16:14:00	Name: ___ Unit ___: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: ___ Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Increasing event frequency ? seizures Major Surgical or Invasive Procedure: None History of Present Illness: HPC: ___ with a PMH of a significant head injury with loss of consciousness < age ___, a febrile seizure age ___ and functional dysphagia on swallow assessment in ___ presents from neurology clinic after escalating episodes of possible seizures and had further episodes today including in the ___. The patient has had escalating events over the past 3 weeks. He was in his usual state of health until ___ after a night of drinking and having fun he woke up feeling hungover and "out of it" and noted problems with his memory and developed a headache and took ibuprofen for this. Then on ___ he had a prolonged episode when he was unable to speak at all save making some sounds. He was able to understand and follow commands. He was transported to ___ and en route he had an episode in the back of the car when he was unaware and became stiff, eyes rolled back and head and all 4 limbs were shaking which lasted for a few minutes and afterwards felt tired but was not confused or disoriented. He still was unable to speak after this episode. He has ___ tongue biting or incontinence which has been consistent throughout all his episodes. His mutism lasted for perhaps ___ hours and resolved. He had workup for a stroke with a CT head which was normal and HIV and syphilis were both negative and normal prolactin. He was discharged on Keppra 500mg bid the following day. On ___ he had tremors of all 4 limbs on and off and was aware with these and again presented to ___ and this was felt due to anxiety and was prescribed rectal diazepam with a plan for an outpatient EEG and MRI. On ___ he had shaking intermittently with a feeling of tightness in his neck and went back to the ___ and at that point they attempted an MRI but he had an episode in the scanner with partial awareness and shaking of all 4 limbs for roughly 1 minute was given benzos and the scan was aborted. He felt back to his normal after 2 minutes with ___ clear post-ictal period. Again ___ tongue-biting or incontinence. He then had an o/p EEG on ___ when he captured an episode during photic stimulation and the report was normal. He also had an MRI head which we do not have the images or the report for which apparently per the patient showed "post seizure changes". He saw his PCP ___ ___ and was referred to neurology. He was seen by a neurologist Dr ___ who felt he may have had 1 epileptic and other non-epileptic events and Keppra was increased to 1500mg bid and clonazepam added. He then had a period without any events but continued tremors until he had a further episode on ___ when his room-mate heard noises from his room and per documentation "saw him thrashing around in the bed" shaking all 4 limbs and lips turned blue/white per his room-mate who gave him rectal diazepam. 911 was called and he again presented to ___. He had labs taken including CMP which were normal and was discharged. On ___ out of fear of him having another seizure, he self-increased his clonazepam to 2mg bid and had tremors and shakes but ___ events. By ___ he had run out of clonazepam. He then saw his PCP ___ ___ and plans were then to have an ambulatory EEG on ___. Since then, he had 2 episodes yesterday with him shaking uncontrollably at roughly 7pm and was unresponsive but trying to talk but his teeth were clenched making a vibrating sound. This lasted 3.5 minutes again with a very short period before he was back to his normal self. He then had a syncopal episode that evening after micturating and fell and hit the bathroom scale.. He had a further episode this morning at 06:30 which was preceded by a tingling feeling all over which was present with some of his other episodes and again lasted for ___ minutes with 2 minutes until he was back to normal. He had a further event en route to his neurology appointment with ___ ___ after he wanted to transfer his care to our system. She found him encephalopathic and sent him to ___ ___ for admission. Here, he had a further episode in the ___ with possibly a slight preceding tingling and then becoming stiff and high frequency shaking of all 4 limbs but only lasted ___ with ___ significant post-ictal period. He currently "feels like shit" and notes a persistent left temporal throbbing headache without nausea or vomiting but present photo/phonophobia. He feels the Keppra makes him feel "out of it". His partner also states that he has had some episodes of staring when he would be walking and then stare straight ahead and be unresponsive and this would last for a few minutes. He has also been doing psychotherapy. He had hypoglycaemia in the ___ with an initial ___ ___ and then dropped to ___ had an amp of D50 and then dropped to 54 and had another amp. He still has a left temporal headache. He notes that he has been very stressed since he started a new job as a ___ for a small ___ in ___ which is very deadline driven ad has 4 bosses who are very exacting. Since the start of his symptoms he has been doing work at home but actually had a seizure during a client call. He feels his mood is not depressed but is low. He feels his memory has been impaired since starting Keppra. He vomited on the first day back at work possibly due to anxiety but not since. He has been finding it hard to get to sleep and has slept restlessly since his last event overnight and is scared to fall asleep. He also notes bilateral tinnitus 2 days ago which has settled. He has chronic manageable dysphagia. He endorses occasional chest pain and diarrhoea. On neuro ROS, the pt denies loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. ___ bowel or bladder incontinence or retention. On general review of systems, the pt denies recent fever or chills. ___ night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies palpitations. Denies nausea, vomiting, constipation or abdominal pain. ___ recent change in bowel or bladder habits. ___ dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: PMH: - Functional dysphagia felt on swallow assessment ___ to be a learned behaviour - Chronic headaches worse with increased setress now ___ days per week - Febrile seizure age ___ none since - Head injury age ___ falling off a ___ with LOC age <___ - Chronic right hearing loss - ___ h/o meningitis or encephalitis Social History: ___ Family History: Family Hx: Mother - T2DM Maternal great great uncle had seizures and died from this An aunt had a stroke in old age Father - Does not know Sibs - many adn all are well Children - none There is ___ history of developmental disability, learning disorders, migraine headaches, strokes less than 50, neuromuscular disorders, dementia or movement disorders. Physical Exam: Physical Exam on admission: Vitals: T:97.6 P:73 R:16 BP:116/63 SaO2:99% RA General: Awake, cooperative, appears anxious and tremulous. HEENT: NC/AT, ___ scleral icterus noted, MMM, ___ lesions noted in oropharynx. ___ evidence of tongue bites. Neck: Supple, ___ carotid bruits appreciated. ___ nuchal rigidity. Full range of motion. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, ___ M/R/G noted Abdomen: soft, slight suprapubic tenderness, ND, normoactive bowel sounds, ___ masses or organomegaly noted. Extremities: ___ C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Calves SNT bilaterally. Skin: ___ rashes or lesions noted ave old tattoos. Neurological examination: - Mental Status: ORIENTATION - Alert, oriented x 4 The pt. had good knowledge of current events. SPEECH Able to relate history without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were ___ 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 ___ evidence of apraxia or neglect but had soe initial confusion regarding sides but was normal. - Cranial Nerves: I: Olfaction not tested. II: PERRL 6.5 to 4mm and brisk. VFF to confrontation. Funduscopic exam reveals ___ papilledema, exudates, or hemorrhages. III, IV, VI: EOMI with bilateral endgaze nystagmus. Normal pursuits and saccades. V: Facial sensation intact to light touch. Good power in muscles of mastication. VII: ___ facial weakness, facial musculature symmetric although he speaks out of the left side of his mouth more and states this is chronic with a logstanding "twisted lip". VIII: Hearing intact to finger-rub on left and absent chronically on the right. 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. ___ pronator drift bilaterally. Bilateral postural tremor noted. ___ asterixis noted. SAb SAdd ElF ElE WrE FFl FE IO HipF HipE KnF KnE AnkD ___ L 5 5 ___ ___ 5 ___ ___ R 5 5 ___ ___ 5 ___ ___ - Sensory: ___ deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout in UE and ___ save decreasd sensation to temperature and pinptick in the left lateral calf and decreased vibration in the left great toe . ___ extinction to DSS. - DTRs: BJ SJ TJ KJ AJ L ___ 2 1 R ___ 2 1 There was ___ evidence of clonus. ___ negative. Plantar response was flexor bilaterally. - CoordinationSlight bilateral action tremor, normal finger tapping. ___ dysdiadochokinesia noted. ___ dysmetria on FNF or HKS bilaterally. - Gait: Gait was stable on standing and Romberg testing without sway but very unstable when walking. EXAM ON DISCHARGE: T 98.7 BP 107/65 (lying) -> 114/62 (standing) HR 52 (lying) -> 92 (standing) RR 18 O2sat 100% Gen: NAD, comfortable Resp: nonlabored MS: alert, oriented, conversing appropriately Pertinent Results: Laboratory Data: Bloods: 139 99 12 72 AGap=16 ------------< 4.2 28 1.0 Ca: 9.2 Mg: 2.1 P: 4.0 ALT: 23 AP: 60 Tbili: 0.5 Alb: 4.6 AST: 38 LDH: Dbili: TProt: ___: Lip: Comments: ALT: Hemolysis Falsely Elevates Alt AST: Hemolysis Falsely Elevates Ast. Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative 98 7.6 14.1 203 40.8 N:52.2 L:41.6 M:4.2 E:1.0 Bas:0.9 Urine: UA negative Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative Benzodiazepine EKG ___ Sinus bradycardia. A-V conduction delay. Voltage may be appropriate for age. ___ previous tracing available for comparison. TRACING #1 Read by: ___ ___ Axes Rate PR QRS QT/QTc P QRS T 52 226 92 436/422 44 70 21 CXR ___ FINDINGS: The lungs are clear. There is ___ pleural effusion, pneumothorax or focal airspace consolidation. The cardiac and mediastinal contours are normal. The hilar structures are unremarkable. IMPRESSION: Normal chest radiograph. CT Head ___ FINDINGS: There is ___ evidence of hemorrhage, edema, mass, mass effect, or large vascular territory infarction. The ventricles and sulci are normal in size and configuration. The basal cisterns are patent. There is preservation of gray-white matter differentiation. ___ fracture is identified. The visualized paranasal sinuses and mastoid air cells are clear. Cerumen is incidentally noted in the bilateral middle ear canals. The soft tissues are unremarkable. IMPRESSION: ___ acute intracranial abnormality. TTE ___ Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.3 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.5 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.5 m/s Left Atrium - Peak Pulm Vein D: 0.5 m/s Left Atrium - Peak Pulm Vein A: 0.4 m/s < 0.4 m/s Right Atrium - Four Chamber Length: 4.8 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.4 cm Left Ventricle - Fractional Shortening: 0.47 >= 0.29 Left Ventricle - Ejection Fraction: 60% to 65% >= 55% Left Ventricle - Lateral Peak E': 0.16 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.10 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 8 < 15 Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Ascending: 2.8 cm <= 3.4 cm Aorta - Arch: 2.3 cm <= 3.0 cm Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 1.67 TR Gradient (+ RA = PASP): 15 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. ___ ASD by 2D or color Doppler. Normal IVC diameter (<=2.1cm) with >50% decrease with sniff (estimated RA pressure ___ mmHg). LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). TDI E/e' < 8, suggesting normal PCWP (<12mmHg). ___ resting or Valsalva inducible LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. ___ 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). ___ AS. ___ AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. ___ MVP. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. ___ PS. Physiologic PR. PERICARDIUM: ___ pericardial effusion. Conclusions The left atrium is elongated. ___ atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is ___ left ventricular outflow obstruction at rest or with Valsalva. 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. There is ___ aortic valve stenosis. ___ aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is ___ mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is ___ pericardial effusion. IMPRESSION: Normal biventricular size and function. ___ clinically significant valvular disease is seen. ___ prior exams for comparison. Brief Hospital Course: ASSESSMENT: ___ with a PMH of a significant head injury with loss of consciousness < age ___, a febrile seizure age ___ and functional dysphagia on swallow assessment in ___, who presented from neurology clinic after several non-stereotyped episodes of possible seizures, with escalating frequency despite increasing doses of AEDs. The patient has had multiple episodes with varying semiologies including staring, convulsion-like and a prolonged episode of mutism with varying degrees of awareness and ___ clear post-ictal period. He has also had significant escalation of symptoms despite a significant dose of anti-convulsant. He has ___ clear post-ictal period and given significant anxiety, previous functional symptoms and significant stress at least some of these events may well be non-epileptic in nature. He was admitted to the epilepsy service for EEG LTM and medication adjustment. On examination, orthostatic hypotension was documented on a couple of occasions. On neuro exam, pt had a slight bilateral postural tremor and mental status was normal apart from significant anxiety. CN examination revealed bilateral endgaze nystagmus and chronic right decreased hearing and he speaks out of the left side of his mouth more although face on examination is symmetric and states this is chronic with a longstanding "twisted lip". Gait was stable on standing and Romberg testing without sway but very unstable when walking. Several of pt's episodes of unresponsiveness and body stiffening were observed by MDs and captured on video EEG. There was ___ EEG change with any of those movements, also ___ significant changes on telemetry except for occasional mild sinus tachycardia. Interictal EEG was also completely benign without epileptiform discharges. When interviewed after one of those events, pt admitted to dissociative features, i.e., being "sort of conscious" during the event but "in a far away place"; he knew who had been in the room and what they had said to him. Therefore, a diagnosis of psychogenic nonepileptic seizures is most appropriate for these events. Levetiracetam was weaned off during this admission, and at this point, we do not see any indication for antiepileptics. Pt was counseled extensively about physical manifestations of stress, and the need to get help to reduce his stress level, e.g., through therapy or relaxation techniques. He seemed receptive to this message. He also met extensively with social work. The diagnosis of PNES was communicated to pt's neurologist, Dr. ___ she ___ have close follow-up with him. Pt also indicated that he will make an appointment with his therapist to discuss. Unrelated to the above episodes of unresponsiveness, pt had a couple of witnessed syncopal events, and had orthostatism documented on a couple of occasions. He had a benign cardiac exem and telemetry. EKG only showed mildly bradycardic sinus arrhythmia with borderline ___ AV block and early repolarization changes, within normal limits for a young athlete. TTE was benign. Pt was evaluated by cardiology, who concurred that a diagnosis of vasovagal syncope is most appropriate. After discussion with his PCP ___ was provided with support stockings and a trial of midodrine 5 mg BID. Pt will f/u with Dr. ___ week. Pt was evaluated by ___, and was deemed safe for discharge home, with a planned home safety evaluation. He was given education about syncope precautions. Pt expressed the desire to stop his other medications (clonazepam and citalopram) as he didn't think they were helping, so these were held during the admission. Medications on Admission: Medications: Keppra 1500mg bid Clonaxepa,m 0.5mg bid Citaloram 20mg HS Diazepam PR PRN Discharge Medications: 1. Midodrine 5 mg PO BID RX midodrine 5 mg 1 tablet(s) by mouth twice daily Disp #60 Tablet Refills:*0 2. Outpatient Physical Therapy Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: 1: Vaso-vagal syncope 2: Stress reaction/ non-epileptic events. 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 characterization of episodes of sudden unresponsiveness and shaking. We discovered that your events are of two different types: on the one hand, you have fainting spells that are caused by an overactive autonomic nervous system; this is a common problem that many young people have; on the other hand, you have episodes of unresponsiveness that are stress reactions. Some other terms that people use for these events are PNES (psychogenic non-epileptic seizures) or pseudoseizures. Fortunately, your events do not have any brain wave changes on the EEG, and thus they are not epileptic seizures. You do not need to take a seizure medication. We discussed your two problems with your PCP, ___, and with your neurologist, Dr. ___. Dr. ___ trying a medication called midodrine to keep your blood pressure up in order to keep him from fainting. You should try to avoid situations that can provoke fainting, such as prolonged standing or running in the heat, hot showers, and dehydration. She would like you to call her office to schedule a follow up next week. Dr. ___ also like you to call her office to schedule follow up next week. Please also call ___ to schedule an appointment with Mrs. ___, your therapist. We recommend that you work with her on relaxation techniques and lifestyle changes that can diminish your stress level. Your only new medication is midodrine. We stopped the levetiracetam (Keppra) seizure medication because we do not think you need it. At your request, we also stopped the citalopram (Celexa) and clonazepam (Klonopin). It was a pleasure taking care of you in the hospital. Followup Instructions: ___
10820044-DS-7	10,820,044	25,001,669	DS	7	2171-08-22 00:00:00	2171-08-22 15:43:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: PCI with 1 DES placed to RCA (___) History of Present Illness: Mrs. ___ is a ___ year-old woman with a history of hypertension, hyperlipidemia, current smoker, and atrial fibrillation (on apixaban) who presented to the ED with acute onset shortness of breath. She says that at about 3 am she had sudden onset shortness on breath upon waking and presented to ___ for evaluation. She was also complaining of some vague symptoms, feeling somewhat strange but is unable to specify specific symptoms. Patient reports that she exercises 2x week, usually on the bike, and has not experienced recent chest pain or abnormal shortness of breath while exercising. She has noticed over the last two weeks that her heart rates on the bike will get up to the 170s whereas prior to that her max rate would be ___. She notably denied any new palpitations, lightheadedness, chest discomfort, orthopnea, peripheral edema, or PND. She has a chronic cough but no fever or chills (although notes she did have a temperature to 100.3 at ___. She reports that she had PFTs several years ago and was not diagnosed with COPD. Her chronic cough is productive of sputum at baseline but there has been no increased sputum or change in color. No recent immobilization, surgeries, travel, or unilateral leg swelling. About 1 month ago she did have some intermittent palpitations that lasted about 1 minute and improved with diltiazem and metoprolol. She has been on metoprolol for several years and the diltiazem was added about one month ago. At ___ her CXR demonstrated atypical right sided vascular congestion with an elevated troponin of 0.13. She was also noted to be in atrial fibrillation with a new left bundle branch block. She got aspirin, Lasix 20 IV, started on heparin drip. Past Medical History: - Atrial fibrillation - Hypertension - Hyperlipidemia - Peripheral Vascular disease - Tobacco use disorder - Anxiety - R colectomy due to cecal volvulus - R nephrectomy due to malignancy - Partial hip replacement - Chronic low back pain Social History: ___ Family History: Positive family history for CAD; her mother had CAD, but died in her ___. No history of DM. Brother has AF. Physical Exam: ADMISSION EXAM: VS: ___ 1711 Temp: 98.2 PO BP: 140/79 HR: 122 RR: 20 O2 sat: 96% O2 delivery: ra Dyspnea: 3 RASS: 0 Pain Score: ___ GENERAL: No acute distress, sitting up in bed HEENT: Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. No JVD. CARDIAC: Tachycardic. Irregular. No murmurs, rubs, or gallops. no thrills or lifts. LUNGS: No chest wall deformities or tenderness. Mildly increased work of breathing. Bibasilar crackles. No wheezes. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. Vertical incision scar in the mid abdomen. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Peripheral pulses not palpable. DISCHARGE EXAM: Temp: 97.7 (Tm 98.8), BP: 115/70 (90-148/60-81), HR: 71 (58-107), RR: 16 (___), O2 sat: 96% (82-100), O2 delivery: RA HEENT: JVP not elevated Lungs: Normal work of breathing. Decreased breath sounds at bases b/l. No wheezing, rales or ronchi CV: Tachycardia, irregular, no m/r/g Abdomen: Soft, ND. Non-tender to palpation throughout Ext: Trace pitting edema bilaterally. DP pulses 2+ and equal b/l Pertinent Results: ADMISSION LABS: ___ 07:58AM BLOOD WBC-15.0* RBC-3.98 Hgb-12.9 Hct-39.1 MCV-98 MCH-32.4* MCHC-33.0 RDW-13.3 RDWSD-48.1* Plt ___ ___ 07:50AM BLOOD ___ PTT-143.5* ___ ___ 07:58AM BLOOD Glucose-144* UreaN-15 Creat-1.1 Na-145 K-4.8 Cl-102 HCO3-22 AnGap-21* ___ 05:45AM BLOOD ALT-18 AST-37 AlkPhos-90 TotBili-1.0 ___ 07:58AM BLOOD cTropnT-0.16* proBNP-6871* ___ 05:45AM BLOOD Calcium-10.0 Phos-2.9 Mg-2.1 DISCHARGE LABS: ___ 08:45AM BLOOD WBC-9.4 RBC-4.12 Hgb-13.4 Hct-41.7 MCV-101* MCH-32.5* MCHC-32.1 RDW-13.3 RDWSD-49.6* Plt ___ ___ 08:45AM BLOOD ___ ___ 08:45AM BLOOD Glucose-96 UreaN-20 Creat-0.9 Na-142 K-5.1 Cl-107 HCO3-18* AnGap-17 ___ 08:45AM BLOOD Phos-3.4 Mg-2.0 STUDIES: ___ EKG: NSR, normal intervals, no ischemic ST changes changes or TWIs ___ EKG: Afib with new LBBB, negative Sgarbossa Nuclear Stress Test ___: FINDINGS: Left ventricular cavity size is normal, with an end-diastolic volume of 82 mL. Rest and stress perfusion images reveal a moderate, partially reversible inferolateral defect. Gated images reveal global hypokinesis. The calculated left ventricular ejection fraction is 48%. IMPRESSION: 1. Moderate, partially reversible inferolateral defect. 2. Low ejection fraction calculated at 48% and global hypokinesis. TTE ___: EF 54%. IMPRESSION: Suboptimal image quality.Normal left ventricular cavity size with mild regional systolic dysfunction most consistent with single vessel coronary artery disease (PDA distribution). Mild pulmonary artery systolic hypertension. Mild mitral regurgitation. Coronary Angiogram ___: The coronary circulation is right dominant. Heavily calcified vessels. LM: The Left Main, arising from the left cusp, is a large caliber vessel and is normal. This vessel bifurcates into the Left Anterior Descending and Left Circumflex systems. LAD: The Left Anterior Descending artery, which arises from the LM, is a large caliber vessel. There is a 30% stenosis in the proximal and mid segments. The ___ Diagonal, arising from the proximal segment, is a small caliber vessel. The Septal Perforator, arising from the proximal segment, is a small caliber vessel. The ___ Diagonal, arising from the mid segment, is a medium caliber vessel. There is a 50% stenosis in the proximal segment. Cx: The Circumflex artery, which arises from the LM, is a large caliber vessel. There is a 60% eccentric and stenosis in the ostium and proximal segment. The Obtuse Marginal, arising from the proximal segment, is a medium caliber vessel. The Inferior lateral of the OM, arising from the proximal segment, is a medium caliber vessel. RCA: The Right Coronary Artery, arising from the right cusp, is a large caliber vessel. There is a 50% stenosis in the proximal segment. There is a 90% stenosis in the distal segment extneding into the posterolateral segment. The Acute Marginal, arising from the proximal segment, is a small caliber vessel. The Right Posterior Descending Artery, arising from the distal segment, is a medium caliber vessel. There is a 70% stenosis in the proximal segment. The Right Posterolateral segment, arising from the distal segment, is a medium caliber vessel. There is a 90% stenosis in the ostium. The Inferior lateral of the RV, arising from the mid segment, is a medium caliber vessel. Brief Hospital Course: Mrs. ___ is a ___ year old woman with a history of atrial fibrillation (previously on apixaban) who presented to the ED with acute onset shortness of breath presenting with an NSTEMI, HFpEF exacerbation and Afib with RVR. Found to have new basal-inferior hypokinesis on echo, and reversible inferolateral defect on stress test. She had PCI with DES to distal RCA. TRANSITIONAL ISSUES: [] This patient is being discharged on dual antiplatelet therapy AND anticoagulation (for atrial fibrillation). Please monitor for bleeding. [] Please discontinue aspirin in one month (___) [] Pt had stent placed and MUST CONTINE PLAVIX. DO NOT DISCONTINUE THIS MEDICATION WITHOUT TALKING TO A CARDIOLOGIST. [] This pt would benefit from ___ if blood pressures can tolerate. [] Pt presented in acute heart failure, please continue to monitor volume status. [] Pt will need repeat TTE in ___ months to evaluate EF. [] PLEASE ENCOURAGE SMOKING CESSATION [] DISCHARGE WEIGHT 59.8 kg(131.83 lb) [] DISCHARGE CREATININE 0.9 ACUTE ISSUES: #NSTEMI On presentation, patient reported acute shortness of breath with no chest pain. Troponin peaked at 0.16 and EKG showed new LBBB block. She had an echocardiogram which showed new basal-inferior hypokinesis and EF 54%. Pharmacologic nuclear stress test showed a reversible inferolateral defect. PCI (___) was performed and showed two vessel disease (LCx and RCA) with a drug eluting stent placed to distal RCA. She is now on triple therapy with ASA, clopidogrel and rivaroxaban (for atrial fibrillation). ASA can be discontinued in 1 month. Please continue clopidogrel for ___ year. #Afib with RVR Patient initially presented with Afib and rates as high as 150bpm. She did not experience palpitations or chest pain but felt "off". She converted to normal sinus rhythm on metoprolol and diltiazem. Sotalol was started once she was in sinus rhythm, but then discontinued due to prolonged Qtc >500ms. We continued metoprolol and diltiazem for rate control and felt that she does not require antiarrhythmic control for now since the Afib with RVR was likely due to a new ischemic event as above. She remained in sinus rhythm on those two rate control agents and anticoagulation was changed from apixiban to rivaroxaban 20mg for anticoagulation due to stent placement. #HFpEF with newly reduced EF Patient initially presented with volume overload and was diuresed with IV Lasix 20mg. Echo in ___ was notable for preserved EF and echo on this admission showed newly reduced to EF ___ in the setting of new ischemic event as above. She required minimal diuresis and dry weight at discharge was 59.8 kg (131.83 lb) with Cr of 0.9. She did not require oral maintenance diuresis while inpatient. CHRONIC ISSUES: #Smoking Cessation Continued nicotine patch daily Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LORazepam 0.5 mg PO BID:PRN anxiety 2. TraMADol 50-100 mg PO Q4H:PRN Pain - Moderate 3. Gabapentin 400 mg PO TID 4. Apixaban 5 mg PO BID 5. Metoprolol Tartrate 50 mg PO BID 6. magnesium hydroxide 200 mg oral DAILY 7. Simvastatin 20 mg PO QPM 8. Diltiazem Extended-Release 240 mg PO DAILY 9. minoxidil 5 % topical BID 10. Aspirin 81 mg PO DAILY 11. FoLIC Acid 0.4 mg PO DAILY 12. Vitamin D 4000 UNIT PO DAILY 13. Timolol Maleate 0.5% 1 DROP BOTH EYES BID 14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS Discharge Medications: 1. Atorvastatin 80 mg PO QPM RX atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Clopidogrel 75 mg PO DAILY DO NOT STOP TAKING THIS MEDICATION. RX clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 3. Metoprolol Succinate XL 100 mg PO DAILY RX metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 4. Nicotine Patch 21 mg/day TD DAILY RX nicotine 21 mg/24 hour apply one patch daily Disp #28 Each Refills:0 5. Rivaroxaban 20 mg PO DINNER RX rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 6. Aspirin 81 mg PO DAILY 7. Diltiazem Extended-Release 240 mg PO DAILY 8. FoLIC Acid 0.4 mg PO DAILY 9. Gabapentin 400 mg PO TID 10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 11. LORazepam 0.5 mg PO BID:PRN anxiety 12. magnesium hydroxide 200 mg oral DAILY 13. minoxidil 5 % topical BID 14. Timolol Maleate 0.5% 1 DROP BOTH EYES BID 15. TraMADol 50-100 mg PO Q4H:PRN Pain - Moderate 16. Vitamin D 4000 UNIT PO DAILY 17.Outpatient Physical Therapy cardiac rehab 410.71 18.Outpatient Physical Therapy cardiac rehab 410.71 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: NSTEMI Secondary diagnosis: Atrial Ribrillation with RVR Acute Diastolic Heart Failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ was a pleasure taking care of you at the ___ ___! - You were admitted to the hospital because you had shortness of breath. - You were found to have had a heart attack. Your heart arteries were examined (cardiac catheterization) which showed a blockage of one of the arteries. This was opened by placing a tube called a stent in the artery. - You were given medications to prevent future blockages. WHAT SHOULD YOU DO WHEN YOU GO HOME? - It is very important to take your aspirin and clopidogrel (also known as Plavix) every day. - These two medications keep the stents in the vessels of the heart open and help reduce your risk of having a future heart attack. - If you stop these medications or miss ___ dose, you risk causing a blood clot forming in your heart stents and having another heart attack - You were also on a blood thinner called Apixaban to help prevent a stroke, due to atrial fibrillation. We changed this blood thinner to one called Rivaroxaban (Xarelto) because this is more suitable in patients who have had a stent. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team Followup Instructions: ___
10820114-DS-13	10,820,114	24,563,575	DS	13	2197-09-08 00:00:00	2197-09-10 09:51:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Lisinopril Attending: ___ Chief Complaint: fever Major Surgical or Invasive Procedure: Fluoro-guided lumbar puncture History of Present Illness: Pt with Stage IV Follicular Lymphoma and prostate CA treated with one cycle of Bendamustine and Rituxan (R on ___ who presents to the ER with fever to 103 and rigors. The patient reports having a cough after his first dose of Bendamustine on ___ which was productive of white sputum. CXR ___ was negative for acute process, and his cough has resolved without any therapy. The patient was supposed to have his second cycle of chemotherapy on ___ (by his report), but was dehydrated; he was given IVF in clinic as well as Ceftriaxone 1g IV for presumed UTI. He also received his first dose of Rituxan. He was discharged on Cipro 500mg PO BID for 14 days; UA since that time shows no evidence of infection. The patient is not the best historian, but reports feeling "just awful" for the past few days. He denies any dysuria, diarrhea, pain, cough, sick contacts, or focal symptoms concerning for a focus of infection. He does not have a port. His temperature on the evening of ___ was elevated and the next day reached a max of 103.4. He states that he has neck and head soreness that accompanied his cough but this has since subsided. . Vitals in the ER: 99.8 106 131/61 16 95% RA Pt received Cefepime 2g IV, Tylenol ___ PO, and 2L IVF. . REVIEW OF SYSTEMS: (+) Per HPI; constipation (-) Denies 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 nausea, vomiting, diarrhea, abdominal pain. Denies dysuria, arthralgias or myalgias. Denies rashes or skin changes. All other ROS negative . Past Medical History: ONCOLOGIC HISTORY Mr. ___ is a ___ gentleman with a history of newly diagnosed follicular lymphoma with bulky lymphadenopathy, both above and below the diaphragm. Did have a PET scan on ___, which revealed extensive disease with bulky lymphadenopathy above and below the diaphragm as well as some splenomegaly and osseous involvement. Also, upon initial presentation, he did have a question of some muscle wasting, fatigue and sweat. His oncologist then had decided to monitor him off treatment with plan for repeat PET scan in approximately a month from his prior one. However, the patient called two weeks ago to report new/worsening pain in left shoulder, chest and axilla region. They repeated a CT scan of his torso, which revealed some further progression of his disease and also the patient reported feeling somewhat more fatigued with some worsening night sweats as well as some ongoing poor appetite and it was decided that they would initiate treatment. He did have a bone marrow biopsy as part of staging of his disease, which revealed extensive involvement of his lymphoma. - ___ C1 D1 Bendamustine - Rituxan ___ Past Medical History: 1. Gout. 2. Hypertension. 3. Obstructive sleep apnea. 4. Hx. Supraventricular tachycardia. 5. Prostate cancer. 6. CKD 7. Diastolic Dysfunction Past Surgical History: 1. Procedure on his right elbow. 2. Procedure on his left knee. Social History: ___ Family History: His older brother had ___ lymphoma and his younger brother had colon cancer. Physical Exam: Vitals: T98.2 bp 132/70 HR 81 RR 18 SaO2 96 RA GEN: NAD, awake, alert HEENT: supple neck, dry mucous membranes, no oropharyngeal lesions; eyes have puffy appearance which is chronic, heridetary 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: flat affect, cooperative Vital signs stable, afebrile Pertinent Results: ADMIT LABS: -------------------- ___ 09:30PM LACTATE-1.0 ___ 09:26PM GLUCOSE-122* UREA N-14 CREAT-1.4* SODIUM-134 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-24 ANION GAP-14 ___ 09:26PM WBC-5.1 RBC-3.85* HGB-11.0* HCT-33.4* MCV-87 MCH-28.5 MCHC-32.9 RDW-14.6 ___ 09:26PM NEUTS-65 BANDS-2 ___ MONOS-7 EOS-2 BASOS-0 ATYPS-3* METAS-1* MYELOS-0 ___ 09:26PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL ___ 09:26PM PLT SMR-LOW PLT COUNT-81* ___ 09:26PM ___ PTT-29.5 ___ ___ 09:10PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 09:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 09:10PM URINE RBC-5* WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 09:10PM URINE HYALINE-28* ___ 09:10PM URINE MUCOUS-MANY . DISCHARGE LABS: ------------------ ___ 10:15AM BLOOD WBC-2.1* RBC-2.78* Hgb-7.7* Hct-24.4* MCV-88 MCH-27.8 MCHC-31.7 RDW-14.7 Plt ___ ___ 10:15AM BLOOD Neuts-66.4 ___ Monos-8.7 Eos-1.9 Baso-0.1 ___ 10:15AM BLOOD Plt ___ ___ 10:15AM BLOOD ___ PTT-33.2 ___ ___ 10:15AM BLOOD Glucose-162* UreaN-11 Creat-1.1 Na-137 K-3.9 Cl-105 HCO3-25 AnGap-11 ___ 10:15AM BLOOD ALT-50* AST-25 LD(LDH)-119 AlkPhos-85 TotBili-0.4 ___ 10:15AM BLOOD Albumin-3.0* Calcium-8.6 Phos-2.6* Mg-2.0 . MICRO: ___ B D Glucan NEGATIVE ___ Galactomannan NEGATIVE ___ and ___ Adenovirus PCR NEGATIVE ___ Mycoplasma pneumo IgG POSITIVE, IgM NEGATIVE ___ EBV NEGATIVE CSF: ___ CMV, EBV, HSV negative ___ 11:00AM CEREBROSPINAL FLUID (CSF) WBC-9 RBC-4400* Polys-36 ___ Monos-15 Eos-1 ___ 11:00AM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-5725* Polys-44 ___ Monos-15 Eos-1 ___ 11:00AM CEREBROSPINAL FLUID (CSF) TotProt-56* Glucose-70 . IMAGING: CXR - no acute intrathoracic process . ___ CT CHEST: IMPRESSION: 1. No obvious evidence of active infectious or inflammatory process in the neck or chest. No evidence of pneumonia. 2. Significant decrease in size of bilateral axillary lymph nodes which no longer meet CT size criteria for pathological enlargement. Interval increase in the degree of minimal fat stranding surrounding lymph nodes likely represents post-treatment change. 3. A single focus of minimally enlarged lymph nodes in the IIb cervical station on the right with minimal fat stranding, also likely represents post-treatment change given the morphologic similarity to the changes in the axillary lymph nodes. . ___. No obvious evidence of active infectious or inflammatory process in the neck or chest. No evidence of pneumonia. 2. Significant decrease in size of bilateral axillary lymph nodes which no longer meet CT size criteria for pathological enlargement. Interval increase in the degree of minimal fat stranding surrounding lymph nodes likely represents post-treatment change. 3. A single focus of minimally enlarged lymph nodes in the IIb cervical station on the right with minimal fat stranding, also likely represents post-treatment change given the morphologic similarity to the changes in the axillary lymph nodes. . ___ CHEST IMPRESSION: Small bilateral pleural effusions with bibasilar consolidations concerning for pulmonary edema or pneumonia. . ___ ___ No evidence of deep vein thrombosis in the right lower extremity. ___ CT ABD PELVIS 1. No acute intra-abdominal pathology identified. 2. Interval development of new small bilateral pleural effusions with associated subsegmental atelectasis. For further details of the chest, please refer to dedicated report of CT chest done same day. 3. Slight interval improvement in retroperitoneal, periportal and inguinal lymphadenopathy. 4. Other chronic findings such as mild splenomegaly as above. . ___ CT CHEST IMPRESSION: 1. Small bilateral pleural effusions and residual dependent pulmonary edema, new since ___. 2. No evidence of intrathoracic infection. 3. No central adenopathy. Left axillary adenopathy improved since ___. 4. Probable anemia. . ___ CT HEAD 1. No evidence of acute intracranial abnormalities. 2. Moderate diffuse ventricular enlargement, out of proportion of sulcal enlargement. This could reflect cerebral atrophy with central predominance. Alternatively, this could reflect communicating hydrocephalus. If subependymal lymphomatous involvement or other intracranial lymphomatous involvement is highly suspected, then further evaluation would be best performed by MRI. MRI would also be more sensitive for intracranial infection. 3. 6 x 4 mm sclerotic lesion in the outer table of the left parietal bone at the vertex most likely represents an osteoma. Given the history of lymphoma, follow-up could be obtained to assess stability. . ___ CT SINUS 1. A single right middle ethmoid air cell contains mild aerosolized secretions, which is in the absence of associated fluid is a nonspecific finding with regard to the possibility of acute sinusitis. No fluid in the paranasal sinuses to clearly suggest acute sinusitis. 2. Mild mucosal thickening in the paranasal sinuses indicates mild chronic inflammation. . ___ MR HEAD No evidence of mass, mass effect or abnormally enhancing lesions. . Brief Hospital Course: ___ with PMH HTN, h/o SVT, stage IV follicular lymphoma and prostate CA presents wtih fevers to 102 for 2 days and neck pain with cough. . #Fever and rigors - Pt presented with fevers to 102-103, and with headache, neck pain, drenching nightsweats and poor PO intake. Extensive infectious work-up was undertaken for bacterial, viral, and fungal causes without any positive tests. Headache/neck pain was not thought to be meningitis, as pt was tender on lateral posterior neck and tender on scalp in occipital area, without any visual disturbances. Pt was empirically treated with vanc/unasyn, evetually on vanc/zosyn/levofloxacin/tamiflu. Pt underwent extensive imaging including CT head, neck, chest, abd, pelvis which were only notable for ventriculomegaly in head. Subsequent MRI was negative for acute hydrocephalus or other evidenec of acute disease. As culture data returned, vanc/zosyn/tamiflu were stopped. Pt underwent LP, for ? lymphoma in brain without any abnormalities concerning for infection or lymphoma. Pt seemed to defervesce spontaneously. At discharge, it is thought that pt likely had a viral infection, which caused his illness. . In the setting of getting IVF for fevers and poor PO intake, pt developed some pulm edema requiring O2, but was given 40iv lasix with complete resolution of O2 requirement. . # Pancytopenia: Pt's pancytopenia is attributed to his acute viral illness. Outpatient team may recheck CBC and consider BM biopsy is this does not resolve within ___ weeks of discharge. . #Stage IV Follicular Lymphoma s/p ___ C1 D1 Bendamustine and Rituxan ___. Pt did not receive any chemotherapy while hospitalized. . #Prostate CA - ___ 6, no active treatment at this time. Pt was continued on flomax. . #CKD III with mild Cr elevation (Cr 1.2 -> 1.4): Losartan was stopped on admission due to worsening Cr and was not resumed as pt's SBPs were in 100-120s and metoprolol was increased for SVT. . #Hx of SVT - Pt had episode of SVT in 130-150s which terminated spontaneously. Pt only minimally symptomatic and HD stable. Metoprolol was incrased from 25mg po xl to 75 po xl. . TRANSITION ISSUES: # The following medications were stopped, please consider whether they need to be restarted: losartan stopped bc SBPs in 100-120s and metoprolol dose was increased for SVT, ASA stopped for thrombocytopenia. # Metoprolol was increased rfom 25xl to 75xl for SVT Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Losartan Potassium 50 mg PO DAILY 3. Allopurinol ___ mg PO DAILY 4. Metoprolol Succinate XL 25 mg PO HS 5. Multivitamins 1 TAB PO DAILY 6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 7. sildenafil NF 100 mg Oral daily PRN sex 8. Aspirin 81 mg PO DAILY 9. Tamsulosin 0.8 mg PO HS 10. albuterol sulfate NF 90 mcg/actuation Inhalation q4 PRN dyspnea 11. Vitamin D 1000 UNIT PO DAILY 12. Ciprofloxacin HCl 500 mg PO Q12H starting ___ for 14 days Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #10 Tablet Refills:0 4. Tamsulosin 0.8 mg PO HS 5. Vitamin D 1000 UNIT PO DAILY 6. albuterol sulfate NF* 90 mcg/actuation Inhalation q4 PRN dyspnea 7. Ondansetron 8 mg PO Q8H:PRN nausea 8. Metoprolol Succinate XL 75 mg PO DAILY RX metoprolol succinate 25 mg 3 tablet extended release 24 hr(s) by mouth daily Disp #90 Tablet Refills:0 9. Sildenafil NF* 100 mg ORAL DAILY PRN sex ___. Levofloxacin 750 mg PO DAILY please stop taking this medication after ___ RX levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #3 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Fever of unknown origin 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 high fevers, headaches, neck pain, and overall because you were feeling unwell. We initially placed you on several antibiotics and tested your blood for several infections. None of these tests showed the specific infection you may have. We also took several CT scans of your head, neck, chest, and abdomen, none of which showed anything concerning for infection. Because of an abnormality on your CT head, we also got an MRI of your head and performed a lumbar puncture, which were all reassuring. We think you had a viral illness, from which your body is slowly recovering. Followup Instructions: ___
10820114-DS-16	10,820,114	26,397,856	DS	16	2199-11-06 00:00:00	2199-11-08 11:14:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Lisinopril Attending: ___. Chief Complaint: Fever, Inability to urinate Major Surgical or Invasive Procedure: None History of Present Illness: In brief, Mr. ___ is a ___ y/o M with PMHx of NHL in remission, 3+3 ___ Prostate cancer under surveillance by Urology, penile implant (___), SVT and dCHF who presented to ___ ED with urinary retention and fevers to ___ F since ___. No prior history of AUR or nephrolithiasis, one prior UTI and episode of prostatitis. Foley placed with minimal return. CT Abd/Pelvis reveals 2 mm non-obstructing stone in Rt kidney without hydronephrosis and no other intra-abdominal or intra-pelvic process. U/A revealed pyuria, Urine culture reveals GNR, patient started on empiric Abx with IV Ceftriaxone. Past Medical History: Past Medical History: 1. Gout. 2. Hypertension. 3. Obstructive sleep apnea. 4. Hx. Supraventricular tachycardia. 5. Prostate cancer. 6. CKD 7. Diastolic Dysfunction Past Surgical History: 1. Procedure on his right elbow. 2. Procedure on his left knee. Social History: ___ Family History: His older brother had ___ lymphoma and his younger brother had colon cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VS - 98.7 138/64 69 12 97%RA General: well appearing male in NAD, laying comfortably in bed HEENT: NC/AT, PERRL, EOMI, anicteric sclera, MOM, oropharynx without edema, erythema, exudate Neck: supple, no JVD, no bruits CV: Regular rate, nl S1 S2, no M/R/G Lungs: CTAB, no W/R/R Abdomen: Soft, tenderness to deep palpation in the suprapubic region, no other tenderness, no rebound, no masses, no HSM, normal BS GU: no CVA tenderness, foley in place, mild irritation of penile tip at foley insertion, FC draining turbid yellow urine Ext: warm, well perfused, 2+ peripheral pulses, no edema Neuro: A&Ox4, SILT bilaterally ___, no gross motor deficits Skin: no rashes / lesions DISCHARGE PHYSICAL EXAM: VS - 98.7 130/66 72 20 99%RA General: well appearing male in NAD, laying in bed HEENT: PERRL, EOMI, anicteric sclera, MOM, oropharynx without edema, erythema, exudate Neck: supple, no JVD CV: Regular rate, nl S1 S2, no M/R/G Lungs: CTAB, no W/R/R Abdomen: Soft, tenderness to deep palpation in the suprapubic region, no other tenderness, no rebound, normal BS GU: no discharge or irritation of penis, Clear yellow urine in urinal at bedside Ext: warm, well perfused, 2+ peripheral pulses, no edema Neuro: alert and oriented, no gross deficits Pertinent Results: ADMISSION STUDIES LABS ___ 07:00PM BLOOD WBC-9.3# RBC-3.89* Hgb-11.3* Hct-36.6* MCV-94# MCH-29.0 MCHC-30.9* RDW-14.6 RDWSD-50.4* Plt Ct-83* ___ 07:00PM BLOOD Neuts-75.1* Lymphs-7.0* Monos-16.8* Eos-0.6* Baso-0.2 Im ___ AbsNeut-6.99* AbsLymp-0.65* AbsMono-1.57* AbsEos-0.06 AbsBaso-0.02 ___ 07:00PM BLOOD Glucose-97 UreaN-10 Creat-1.3* Na-135 K-5.0 Cl-100 HCO3-23 AnGap-17 ___ 07:00PM BLOOD PSA-107.3* ___ 10:36PM BLOOD Lactate-1.4 ___ 08:20AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 08:20AM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG ___ 08:20AM URINE RBC-10* WBC->182* Bacteri-FEW Yeast-NONE Epi-1 ___ 08:20AM URINE CastHy-3* ___ 08:20AM URINE WBC Clm-FEW Mucous-RARE IMAGING ___ CT ABD AND PELVIS W/O CONTRAST IMPRESSION: 2 mm non-obstructing right renal calculus. No hydronephrosis. DISCHARGE STUDIES LABS ___ 06:35AM BLOOD WBC-5.1 RBC-3.85* Hgb-11.0* Hct-34.9* MCV-91 MCH-28.6 MCHC-31.5* RDW-14.2 RDWSD-46.5* Plt ___ ___ 06:35AM BLOOD Glucose-106* UreaN-11 Creat-1.2 Na-138 K-3.7 Cl-104 HCO3-26 AnGap-12 MICRO ___ 9:15 pm BLOOD CULTURE x 2; pending at discharge ___ 8:20 am URINE CULTURE (Final ___: ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: ___ y/o M with PMHx of NHL in remission, 3+3 ___ Prostate cancer under surveillance by Urology, penile implant (___), SVT and ___ who presented on ___ with urinary retention and fevers to ___ F since ___, likely secondary to complicated UTI. ACTIVE ISSUES # UTI, complicated. Urine Cx positive for E Coli, Imaging reveals non-obstructing renal calculus without hydonephrosis. Urology intially advised broad spectrum antibiotic coverage of pseudomonas and enterococcus. Started on IV Ceftriaxone pending urine culture results, which revealed pan sensitive E. Coli. Transitioned to PO Cipro for a 10 day course of treatment. # Urinary Obstruction w/ mild ___. Unclear etiology but improved with foley placement. CT abdomen unimpressive for other clear etiology. Has known prostate cancer being monitored. Patient voided successfully after foley was removed. Continued home flomax. Follow up with Dr ___ in ___ weeks to discuss further BPH management. CHRONIC ISSUES # Hypertension. Controlled with home meds. # H/O SVT. Controlled on home metoprolol. # Gout. No evidence of exacerbation, controlled on home allopurinol. TRANSITIONAL ISSUES - Patient will take Ciprofloxacin 500 mg BID from ___ for complicated UTI - Patient should follow up with Dr ___ on ___ ___ at 8:30 AM) to discuss further BPH management (eg. TURP) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Tamsulosin 0.4 mg PO QHS 3. Gabapentin 300 mg PO TID 4. Metoprolol Succinate XL 75 mg PO DAILY 5. Albuterol Inhaler 2 PUFF IH Q4H:PRN Wheezing, SOB Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN Wheezing, SOB 2. Aspirin 81 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Metoprolol Succinate XL 75 mg PO DAILY 5. Tamsulosin 0.4 mg PO QHS 6. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #20 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: - E. coli UTI with sepsis - Dehydration Secondary: - Follicular lymphoma s/p 6 cycles of R-bendamustine - Prostate cancer - Gout - Hypertension - S/P 2-piece penile prosthesis ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital because you had a fever and some urinary retention. You were found to have a urinary tract infection which likely caused these symptoms. You were treated with intravenous antibiotics and then transitioned to oral antibiotics which you should continue for 10 more days. Please follow up with your primary care physician and urologist at the appointments scheduled for you (see below). It was a pleasure meeting and taking care of you while you were in the hospital. -Your ___ Team Followup Instructions: ___
10820164-DS-15	10,820,164	22,927,079	DS	15	2152-12-06 00:00:00	2152-12-07 18:53:00	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 and diarrhea Major Surgical or Invasive Procedure: ERCP (___): Biliary stent removal History of Present Illness: ___ yo M with PMH of HCV with cirrhosis and HCC s/p liver transplant ___ currently with fibrosing cholestatic HCV on Sofosbuvir and focal aneurysmal dilation of hepatic artery per ___ liver biopsy who p/w fever, abdominal pain, and diarrhea. Has a blood transfusion ___ for anemia attributed to ribavirin therapy. He subsequently developed diarrhea at home which he had throughout ths weekend. Denies melena and hematochezia. Associated with generalized abdominal pain worst in RLQ and fevers/chills to 103. Patient denies N/V, CP, and SOB. He has not made any recent changes to his diet, traveled, or been around anyone with a GI illness. Patient has no history of CMV infection. In the ED initial vitals were 102.2, 117, 148/93, 16, 100% RA. Initial labs remarkable for Cr of 2, AP of 143, H/H of 8.2/25.2, and Plt of 99. Lactate was 2.3. CXR was unremarkable. Patient was given Tylenol for fever and started on empiric antibiotics with ciprofloxacin and Flagyl per hepatology fellow. HCV and CMV sent. On the floor initial vital signs were 97.2, 88, 115/62, 20, 98% RA. Patient reports mild chills and lower abdominal pain but he is otherwise without symptoms at this time. Past Medical History: - Chronic HCV with HCC s/p transplant in ___ - Fibrosing cholestatic HCV - Grade I esophageal varices per ___ EGD - Hypertension - Chronic kidney disease, stage III with baseline Cr ___ - GERD - Schatzki's ring - Hiatal hernia - Gastritis and duodenitis - Osteoporosis Social History: ___ Family History: Lung cancer in mother. Physical Exam: ADMISSION EXAM VS: 97.2, 88, 115/62, 20, 98% RA General: ___ male, AAOx3, NAD HEENT: Sclera anicteric, PERRLA, EOMI, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD CV: RRR, nl S1/S2, no MRG Lungs: CTAB, no wheezes/rales/rhonchi Abdomen: Soft, RLQ tenderness, ___, no rebound/guarding, mild splenomegaly, RUQ scar GU: Deferred Ext: Warm, ___, no cyanosis/clubbing/edema Neuro: CN ___ grossly intact Skin: No concerning lesions DISCHARGE EXAM VS: 98.1, 64, 126/80, 18, 100% RA General: ___ male, AAOx3, NAD HEENT: Sclera anicteric, PERRLA, EOMI, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD CV: RRR, nl S1/S2, no MRG Lungs: CTAB, no wheezes/rales/rhonchi Abdomen: Soft, mild RUQ tenderness, no rebound/guarding, RUQ scar Ext: Warm, ___, no cyanosis/clubbing/edema Neuro: CN ___ grossly intact Pertinent Results: ADMISSION LABS ___ 10:27AM BLOOD ___ ___ Plt ___ ___ 10:27AM BLOOD ___ ___ ___ 10:27AM BLOOD ___ ___ ___ 10:27AM BLOOD ___ ___ ___ 10:27AM BLOOD ___ ___ 10:27AM BLOOD ___ ___ 06:10AM BLOOD ___ ___ 10:33AM BLOOD ___ ___ 02:16PM URINE ___ Sp ___ ___ 02:16PM URINE ___ ___ ___ 02:16PM URINE ___ DISCHARGE LABS ___ 05:57AM BLOOD ___ ___ Plt ___ ___ 05:57AM BLOOD ___ ___ ___ 05:57AM BLOOD ___ ___ ___ 05:57AM BLOOD ___ ___ ___ 05:57AM BLOOD ___ ___ 05:57AM BLOOD ___ ___ 05:57AM BLOOD ___ MICROBIOLOGY All other blood, urine, stool cultures NEGATIVE or PENDING on discharge Blood Culture, Routine (___): PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML ___________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S CMV viral load (___): CMV DNA detected, less than 137 IU/mL. HCV viral load (___): ___ NOT DETECTED. IMAGING RUQ US (___): 1. Status post liver transplant with no concerning liver lesions. Right lobe hemangioma is again noted. 2. Patent hepatic vasculature. It is worth noting that the previously visualized focal aneurysm up to 7 mm on CT torso from ___ at the anastomosis of the hepatic arteries and is not visualized on today's study due to overlying bowel gas. Further evaluation of this region may be with a dedicated CT scan with contrast. CXR (___): Unremarkable chest radiographic examination. ENDOSCOPY ERCP (___): The previously placed plastic biliary stent was seen in the right upper quadrant on the scout film. Erythema, congestion and granularity in the first and second parts of the duodenum compatible with duodenitis. Previous plastic biliary stent in the major papilla. This was removed successfully using a snare. Cholangiogram was not performed during this procedure. Brief Hospital Course: ___ yo M with PMH of HCV with cirrhosis and ___ s/p liver transplant ___ currently with fibrosing cholestatic HCV on Sofosbuvir and focal aneurysmal dilation of hepatic artery per ___ liver biopsy who p/w fever, abdominal pain, and diarrhea. ACTIVE ISSUES # Fever and diarrhea: Symptoms began after a blood transfusion. Presentation was somewhat concerning for CMV colitis. CMV viral load revealed detectable virus but not enough to be quantified, arguing against CMV colitis. C. diff colitis considered but C. diff toxin assay was negative. Patient was started on vancomycin and ciprofloxacin on admission. Flagyl was added given concern for diverticulitis. Blood cultures grew ___ Pseudomonas for which vancomycin was discontinued and ciprofloxacin and Flagyl were continued. Treatment resulted in significant improvement in his symptoms. ID was consulted and they recommended a 14 day course of antibiotics. Patient has a PICC placed for outpatient IV antibiotic therapy. He subsequently underwent ERCP for removal of a previously placed biliary stent given that it is a nidus for infection. The procedure was successful and was remarkable only for mild duodenitis. Patient was discharged on a 14 day course of ciprofloxacin IV and Flagyl PO. # ___ on CKD: Stage III with baseline Cr ___. Cr was slightly elevated at 2.0 on admission. Likely ___ in the setting of volume depletion due to the diarrhea for which patient was treated with gentle IV fluids. Cr returned to baseline the next day confirming suspicion for ___. Home Epoeitin and vitamin D were continued in hospital. CHRONIC ISSUES # Cirrhosis: Due to chronic HCV infection. Complicated by ___. Patient underwent liver transplant in ___ but has since developed fibrosing cholestatic disease. Being managed with ___ and sofosbuvir (study drug) and tacrolimus and MMF for immunosuppression. Childs class A. MELD is ___. Patient was continued on home sofosbuvir and ribavirin was added per the study protocol. Tacrolimus was continued. Home interferon and MMF were held due to sepsis in the setting of immunosuppression. Prophylactic Bactrim was continued. Patient was discharged on his ___ regimen with the exception of interferon which patient will discuss restarting on ___ with Dr. ___ week. # Anemia: Baseline anemia due to chronic disease and ribavirin. The patient received 2 units pRBCs on ___ and bumped appropriately. Hct remained stable subsequently. # Esophageal varices: Grade I per ___ EGD. Not on nadolol. # Hypertension: Stable. Continued metoprolol. TRANSITIONAL ISSUES - Discharged on 14 day course of ciprofloxacin IV and Flagyl PO - ___ held on discharge - If recurrent diarrhea should undergo colonoscopy to check for CMV ulcers per ID - Monitor CBC while on ribavirin given risk for worsening anemia - ___ with PCP scheduled - ___ with Liver Clinic scheduled Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Tartrate 50 mg PO BID 2. Mycophenolate Mofetil 500 mg PO BID 3. Ondansetron 4 mg PO Q6H:PRN nausea/vomiting 4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 5. Peginterferon ___ 135 mcg SC 1X/WEEK (WE) 6. Bactrim ___ mg oral DAILY 7. Tacrolimus 2 mg PO Q12H 8. Epoetin Alfa 60,000 units SC 1X/WEEK (___) 9. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Epoetin Alfa 60,000 units SC 1X/WEEK (___) 2. Metoprolol Tartrate 50 mg PO BID 3. Ondansetron 4 mg PO Q6H:PRN nausea/vomiting 4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #20 Tablet Refills:0 5. Tacrolimus 2 mg PO Q12H 6. Vitamin D 1000 UNIT PO DAILY 7. Sofosbuvir Study Med 400 Mg ORALLY ONCE A DAY Duration: 24 Weeks 8. Bactrim ___ mg oral DAILY 9. Mycophenolate Mofetil 500 mg PO BID 10. Ciprofloxacin 400 mg IV Q12H RX ciprofloxacin in D5W 400 mg/200 mL 400 mg IV every twelve (12) hours Disp #16 Vial Refills:0 11. Ribavirin 200 mg PO DAILY RX ribavirin 200 mg 1 tablet(s) by mouth DAILY Disp #30 Capsule Refills:0 12. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #24 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Infectious enterocolitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you while you were a patient at ___. You came to us with fevers and diarrhea. Blood cultures revealed that this was likely due to an infection in your blood. We treated you with antibiotics which resulted in significant improvement in your symptoms. You will be discharged with several more days of IV and oral antibiotics. We continued you on all pf your liver medications with the exception of interferon which you should NOT take until following up in with Dr. ___ on ___. While you were here we also removed your biliary stent. The procedure went well without complications. Please be sure to take all of your medications as listed below. Please keep all of your ___ appointments. Followup Instructions: ___
10820804-DS-7	10,820,804	25,118,663	DS	7	2138-08-13 00:00:00	2138-08-13 18:38:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Keflex / cephalexin / clindamycin / sulfamethoxazole / ibuprofen Attending: ___ Chief Complaint: Right neck/shoulder pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ male with cardiac history notable for CABG (LIMA to LAD, SVG to OMI, SVG, to L-PDA), multiple stents, CHB s/p pacemaker implantation, paroxysmal AF (s/p MAZE, not on anti-coagulation), ESRD (HD ___, DM2, and HTN presented for severe right sided neck pain c/b episode of his typical angina symptoms while in the ED. Patient initially here for right neck pain for the last 3 days after sleeping on a pillow uncomfortably. Prescribed cyclobenozprine by his PCP but this did not help. Pain radiates up right shoulder to right-posterior neck. No headache or dizziness. While walking to his bed in the ED, he developed sudden onset of left-sided chest pain that is sharp and worse with breathing. Patient put on oxygen and felt better. Pain similar to prior presentation w/ MI. Past Medical History: - Multi-vessel CAD - s/p 3v-CABG (LIMA-LAD, SVG-OM, SVG-LPDA) in ___ + MAIZE procedure - DES to RCA ___ DEX x 2 to LAD and LCx (___) - PAF initially on warfarin but stopped after MAZE in ___ - Hypertension - Diabetes mellitus, type 2 - Diabetic nephropathy - ESRD, on HD ___) since ___ - Obesity - Former smoker, quit ___ ago. - Asthma, on prn inhalers - Partial thyroidectomy in ___ - Depression ___ - R toe amputation due to frostbite Social History: ___ Family History: Mother: HTN, DM, CAD No FH of early MI, arrhythmia, cardiomyopathies, sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.3 78 145/68 18 100 RA GEN: AAOx3. Uncomfortable but in no distress. Appears stated age. NEURO: CNIII-XII intact. Full strength upper and lower extremities. Gait stable. No sensory deficits. Speech normal. HEENT: Flexion and extension of head normal, rotation limited by severe pain. No obvious deformity. Tender to palpation over right trapezius. CARD: ___ systolic murmur most prominent over right sternal border. Regular rate, rhythm. PULM: Distant breath sounds but otherwise clear to auscultation. ABD: Soft, non-tender, non-distended. DISCHARGE PHYSICAL EXAM: Vitals: 98.4 64 (64-78) 129/67 (129-169/58-68) 16 97% RA GEN: AAOx3. Comfortable in NAD. Appears stated age. HEENT: neck ROM improved today. + Spurling test. No obvious deformity. less TTP on right trapezius. CARD: ___ systolic murmur most prominent over right sternal border, radiating to carotids. Regular rate, rhythm. PULM: Distant breath sounds but otherwise clear to auscultation. ABD: Soft, non-tender, non-distended. Pertinent Results: PERTINENT STUDIES: CXR (___): Lungs are hyperinflated, but clear. Heart size top-normal. No pulmonary edema or pleural effusion. Previous vascular congestion has resolved. Transvenous right atrial right ventricular pacer leads in standard placements. CXR (___): Bibasilar opacities may represent atelectasis, however, superimposed pneumonia cannot be excluded in the appropriate clinical setting. C-SPINE X-RAY NON-TRAUMA (___) Degenerative changes. Straightening of the normal cervical lordosis. Patient's head is tilted toward the right. SHOULDER X-RAY NON-TRAUMA (___) 1. No fracture or dislocation. 2. Findings suggest rotator cuff calcific tendinitis. 3. Mild acromioclavicular degenerative change. ADMISSION LABS: ___ 03:00AM BLOOD WBC-12.7* RBC-3.70* Hgb-11.0* Hct-34.7* MCV-94 MCH-29.7 MCHC-31.7* RDW-13.6 RDWSD-47.1* Plt ___ ___ 03:00AM BLOOD Neuts-65.2 ___ Monos-9.3 Eos-2.8 Baso-0.2 Im ___ AbsNeut-8.29# AbsLymp-2.81 AbsMono-1.18 AbsEos-0.36 AbsBaso-0.02 ___ 03:00AM BLOOD Plt ___ ___ 10:10AM BLOOD ___ ___ 03:00AM BLOOD Glucose-294* UreaN-66* Creat-6.5# Na-138 K-6.0 Cl-95* HCO3-21* AnGap-22* ___ 03:00AM BLOOD cTropnT-0.04* ___ 10:10AM BLOOD Calcium-9.8 Phos-6.7* Mg-2.1 ___ 06:17AM BLOOD K-5.7* ___ 03:12AM URINE Color-Straw Appear-Clear Sp ___ ___ 03:12AM URINE Blood-TR* Nitrite-NEG Protein-100* Glucose-300* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 03:12AM URINE RBC-2 WBC-4 Bacteri-FEW* Yeast-NONE Epi-0 PERTINENT LABS: ___ 06:05AM BLOOD WBC-9.4 RBC-3.44* Hgb-10.4* Hct-32.7* MCV-95 MCH-30.2 MCHC-31.8* RDW-13.7 RDWSD-47.1* Plt ___ ___ 06:05AM BLOOD Glucose-92 UreaN-40* Creat-5.1# Na-141 K-4.6 Cl-95 HCO3-31 AnGap-15 ___ 03:00AM BLOOD cTropnT-0.04* ___ 10:10AM BLOOD CK-MB-4 cTropnT-0.08* ___ 06:20PM BLOOD CK-MB-4 cTropnT-0.14* ___ 06:05AM BLOOD CK-MB-3 cTropnT-0.16* ___ 10:10AM BLOOD CK-MB-3 cTropnT-0.14* DISCHARGE LABS: ___ 06:05AM BLOOD WBC-9.4 RBC-3.44* Hgb-10.4* Hct-32.7* MCV-95 MCH-30.2 MCHC-31.8* RDW-13.7 RDWSD-47.1* Plt ___ ___ 06:05AM BLOOD Plt ___ ___ 06:05AM BLOOD Glucose-92 UreaN-40* Creat-5.1# Na-141 K-4.6 Cl-95 HCO3-31 AnGap-15 ___ 10:10AM BLOOD CK-MB-3 cTropnT-0.14* ___ 06:05AM BLOOD Calcium-9.9 Phos-6.2* Mg-2.0 MICRO: ___ CULTURE-FINALEMERGENCY WARD Brief Hospital Course: ___ male with significant cardiac history notable for CABG (LIMA to LAD, SVG to OMI, SVG, to L-PDA), multiple stents, CHB s/p PPM (___), paroxysmal AF (s/p MAZE ___, not on anti-coagulation), ESRD (HD ___, IDDM2, HTN presented for worsening right shoulder/neck pain and admitted for episode of stable angina that occurred while in ED. # Neck Pain: He presented initially for severe neck pain, unresponsive to outpatient trial of cyclobenzaprine. Pain improved with lidocaine patch and acetaminophen. Spurling sign positive. C-spine x-ray demonstrated degenerative changes. No other evidence of emergent cause for his symptoms. Improved overnight and felt more comfortable the following day. Advised to treat with Tylenol at home until further PCP follow up. # Demand ischemia: Patient did not initially have chest pain upon arrival to ED. Experienced one episode of his baseline stable angina while ambulating in ED. Subsequent EKG showed evidence of ST elevation in aVR, however diffuse ST depressions in precordial leads were suggestive of global demand ischemia rather than acute infarction. His troponins were initially rising and peaked at 0.14 (likely related to ESRD than true ischemic episode). CKMB was stable throughout at 4. Completely asymptomatic throughout admission. Carvedilol, atorvastatin, ASA, Plavix, and Imdur were continued. # ESRD: Hemodialyzed ___ (-2800 cc). Continued regular home medications. # Leukocytosis: Borderline elevated WBC on admission which returned to baseline. Attributed to demarginalization in the setting of pain response. CHRONIC ISSUES: #Anemia: Remained stable. #Type 2 IDDM: Continued insulin sliding scale. #HTN: Continued home amlodipine. Mildly elevated BPs in 130s-140s so increased carvedilol to 12.5 mg BID. #Asthma: continued home albuterol nebs and fluticasone #GERD: continued home pantoprazole. TRANSITIONAL ISSUES ====================== [] Consider titrating BP medications given systolic pressure 140s throughout admission. [] Consider d/c Plavix as he is >30 months since PCI (___) and risk of bleeding given ESRD. [] Will need follow up regarding ongoing MSK neck/shoulder pain #CODE: full (confirmed) #CONTACT: HCP: ___ (son) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Glargine 40 Units Lunch Glargine 40 Units Bedtime Insulin SC Sliding Scale using Novolog Insulin 2. Pantoprazole 40 mg PO Q24H 3. Renagel 2400 mg oral TID W/MEALS 4. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY 5. Furosemide 80 mg PO DIALYSIS-OFF DAYS 6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 7. Fluticasone Propionate 110mcg 2 PUFF IH BID 8. Carvedilol 6.25 mg PO BID 9. amLODIPine 5 mg PO BID 10. Nitroglycerin Patch 0.2 mg/hr TD Q24H 11. Clopidogrel 75 mg PO DAILY 12. coenzyme Q10 100 mg oral DAILY 13. Aspirin 81 mg PO DAILY 14. Atorvastatin 20 mg PO QPM 15. Nephrocaps 1 CAP PO DAILY Discharge Medications: 1. Acetaminophen 500 mg PO Q4H 2. Carvedilol 12.5 mg PO BID RX carvedilol 12.5 mg 1 tablet(s) by mouth twice daily Disp #60 Tablet Refills:*0 3. Glargine 40 Units Lunch Glargine 40 Units Bedtime Insulin SC Sliding Scale using Novolog Insulin 4. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 5. amLODIPine 5 mg PO BID 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 20 mg PO QPM 8. Clopidogrel 75 mg PO DAILY 9. coenzyme Q10 100 mg oral DAILY 10. Fluticasone Propionate 110mcg 2 PUFF IH BID 11. Furosemide 80 mg PO DIALYSIS-OFF DAYS 12. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY 13. Nephrocaps 1 CAP PO DAILY 14. Nitroglycerin Patch 0.2 mg/hr TD Q24H 15. Pantoprazole 40 mg PO Q24H 16. Renagel 2400 mg oral TID W/MEALS Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: ------------------ Stable Angina Musculoskeletal neck/shoulder pain Degenerative changes of cervical spine Secondary Diagnoses: -------------------- - Hypertension - Diabetes mellitus, type 2 - Diabetic neuropathy - End Stage Renal Disease - Obesity - Asthma 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. Why were you in the hospital? - You had right-sided neck and shoulder pain. - 1 episode of chest pain in the ER. What was done for you in the hospital? - We checked lab tests that did not show any injury to your heart. - We took x-rays of your neck and shoulder. - You were given medications to help manage your neck pain. - You received your scheduled hemodialysis. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below). - Follow up with your doctors as listed below. - Seek medical attention if you have new or concerning symptoms or you develop chest pain, swelling in your legs, abdominal distention, or shortness of breath at night. It was a pleasure participating in your care. We wish you the best! - Your ___ Care Team Followup Instructions: ___
10821855-DS-17	10,821,855	24,041,295	DS	17	2185-07-02 00:00:00	2185-07-03 14:09:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: UTI, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with a history of two intracerebral aneurysms s/p clipping ___, HTN, IDDM, stage IV sacral decub who was advised to present to the ED due to abnormal labs. Approximately 5 days ago her ___ was taking her vitals and noted her temperature to be "very low." She was told it was as low as ___. She then presented to ___ for further evaluation. At the time she endorsed abdominal pain, nausea, and flank pain. She was discharged on PO Cipro for UTI. She received a call yesterday which said "please return to the hospital asap as you have an infection that necessitates IV antibiotics." She was unaware of further details. Records from ___ reveal +E.coli UTI by culture with sensitivity to Zosyn, imipenem, meropenem, and cefepime only. Positive blood cultures noted at ___ "several days later". She presented to ___ ED rather than returning to ___. In the ED, initial vitals were: Pain 10 T 98.4 HR 70 BP 129/65 RR 18 96% RA Exam was notable for an obese woman lying in bed. Sacral decubitus site clean and dry without erythema. Lungs clear. Abdomen soft and tender. Labs notable for WBC 9.4 Hgb 11.3 Hct 34.6 Plt 257. Chemistry notable for glucose 221 and otherwise WNL. Lactate 1.5. UA with large leuk, neg nitrite, many bacteria. She received: diazepam 5 mg x2 PO, Cefepime 2g IVx1, Percocet PO x1 for shoulder pain sustained on ambulance ride She is admitted for further management of UTI/Pyelo. Vitals on transfer: Pain 10 T 98.6 HR 74 BP 144/61 RR 18 97% RA On the floor, she appears comfortable. Review of systems is notable for a several week history of abdominal pain and nausea. She feels that her abdomen has significantly increased in size during this time. She also endorses brown vaginal discharge, prominent at night. She endorses constipation, denies diarrhea. She denies chest pain, dyspnea, headache, arthralgias, myalgias. Past Medical History: paraplegia s/p MVA - ___ syringomyelia DMII CVA Brain aneurysm neuropathy hypothyroidism HTN HLD Depression Urgency incontinence GERD HCV Ischial Decubitus ulcer Social History: ___ Family History: Mother: ___, DM, Stroke Father: ___, DM, CAD Physical Exam: ADMISSION PHYSICAL EXAM: Vital Signs: 99.0 152/50 72 18 98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD. Seborrheic dermatitis of the face CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, diffusely tender throughout, most notably in the RUQ GU: Chronic indwelling foley draining clear urine. + paraspinal muscle tenderness though no overt flank pain Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Alert and oriented x3, paraplegic DISCHARGE PHYSICAL EXAM: VS: 98.9/98.6 116-125/49-53 ___ 18 96% RA General: Alert, comfortable appearing, NAD HEENT: sclera anicteric, conjunctivae noninjected, erythematous macular rash with some scale in patches on her face CV: Heart sounds distant. Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Poor effort but otherwise clear to auscultation bilaterally Abdomen: soft, nondistended, mild ttp in lower quadrants bilaterally, no rebound, guarding, or rigidity GU: Chronic indwelling foley draining clear urine. Ext: Warm, well perfused Neuro: Alert and interactive, paraplegic Pertinent Results: ADMISSION LABS: ___ 05:50PM BLOOD WBC-9.4 RBC-3.98 Hgb-11.3 Hct-34.5 MCV-87 MCH-28.4 MCHC-32.8 RDW-14.6 RDWSD-46.1 Plt ___ ___ 05:50PM BLOOD Neuts-63.5 ___ Monos-6.8 Eos-2.5 Baso-0.2 Im ___ AbsNeut-5.93 AbsLymp-2.49 AbsMono-0.64 AbsEos-0.23 AbsBaso-0.02 ___ 05:50PM BLOOD Neuts-63.5 ___ Monos-6.8 Eos-2.5 Baso-0.2 Im ___ AbsNeut-5.93 AbsLymp-2.49 AbsMono-0.64 AbsEos-0.23 AbsBaso-0.02 ___ 05:50PM BLOOD Glucose-221* UreaN-9 Creat-0.6 Na-139 K-3.8 Cl-101 HCO3-26 AnGap-16 ___ 05:03AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0 ___ 05:03AM BLOOD ALT-17 AST-14 AlkPhos-111* TotBili-0.3 ___ 05:25PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 05:25PM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-6.5 Leuks-LG ___ 05:25PM URINE RBC-2 WBC-22* Bacteri-MANY Yeast-NONE Epi-2 TransE-<1 PERTINENT LABS: ___ 05:03AM BLOOD %HbA1c-8.4* eAG-194* ___ 09:32PM URINE Color-Straw Appear-Clear Sp ___ ___ 09:32PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG DISCHARGE LABS: ___ 07:04AM BLOOD WBC-7.1 RBC-3.88* Hgb-11.2 Hct-34.7 MCV-89 MCH-28.9 MCHC-32.3 RDW-14.5 RDWSD-46.7* Plt ___ ___ 07:04AM BLOOD Glucose-314* UreaN-17 Creat-0.6 Na-135 K-4.2 Cl-96 HCO3-26 AnGap-17 ___ 07:04AM BLOOD Calcium-9.0 Phos-4.3 Mg-1.8 ___ 07:04AM BLOOD ALT-17 AST-13 AlkPhos-102 TotBili-0.2 MICROBIOLOGY: ___ 5:50 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). Isolated from only one set in the previous five days. Reported to and read back by ___ AT 10:05 ON ___. Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___. ___ @ 6PM ON ___. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. IMAGING: ___ RUQ US: 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. ___ Transvaginal pelvic US: Very limited exam. Thickened, mildly heterogeneous endometrium (11 mm) for which further evaluation is recommended with endometrial biopsy for tissue sampling. Brief Hospital Course: ___ is a ___ with a history of paraplegia secondary to a MVA, IDDM, intracerebral aneurysms s/p clipping, stage IV sacral decubitous ulcer, chronic indwelling Foley with recurrent UTIs and a history of cleared HCV infection (s/p IFN and ribavirin) who presented with migratory abdominal pain, post-menopausal vaginal bleeding, and MDR UTI. Investigations/interventions: # Urinary tract infection: Presented with hypothermia and rigors. Cultures at ___ grew MDR E. coli (sensitive to cefepime, Zosyn, ertapenem, and amikacin). She was transferred to ___ where ID was consulted. She completed a 7 day course of cefepime. If she has further UTIs, consider restarting suppressive fosfomycin # Abdominal pain: Patient presented with acute on chronic abdominal pain and report of alternating constipation and diarrhea. Pain improved with laxatives but did not completely resolve, IBS suspected. # possible cirrhosis: Pt with history of HepC cleared s/p prior treatment. During this admission the workup of abdominal pain included RUQ U/S which showed a coarsed nodular liver. Her LFTs were normal. A HCV viral load was ordered at was pending at time of discharge. An appointment with hepatology was scheduled on discharge. # Post-menopausal vaginal bleeding: She reported 3 months of vaginal bleeding. A transvaginal US found endometrial thickening (11 mm). She was set up with a gynecology appointment at discharge for follow up for endometrial biopsy. # Insulin dependent diabetes mellitus: Despite her Hgb A1c 8.4, she endorsed poorly controlled blood sugars with highs in the 300-400s and frequent hypoglycemic events as well at home. She took irregular and inconsistent amounts of humulin throughout the day. During this admission, BGs were very difficult to control ___ diabetes service was consulted. She declined followup with ___ stating that she preferred a more local endocrinology provider. She would ideally be scheduled with a local provider at her followup visit. Transitional issues: - Patient was discharged on lantus 36 units in the morning and 40 units at night with Humalog 25 units with meals plus Humalog sliding scale. She was advised to have endocrinology followup - Patient was treated with a 7 day course of cefepime for MDR UTI - If patient continues to have UTIs, ID recommended re-starting suppressive therapy with fosfomycin and considering GU imaging - Patient with 3 months vaginal bleeding and endometrial thickening on US; she is schedule for gyn follow up - Patient found to have steatosis/possible fibrosis on RUQ US and was scheduled for hepatology follow up; an HCV VL was pending on discharge - CODE: full - CONTACT: ___ (roommate, HCP): ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 1200 mg PO QHS 2. Levothyroxine Sodium 75 mcg PO DAILY 3. Lisinopril 5 mg PO DAILY 4. Omeprazole 20 mg PO BID 5. Pravastatin 80 mg PO QPM 6. Humalog 75 Units Breakfast Humalog 75 Units Lunch Humalog 75 Units Dinner 7. Methadone 10 mg PO DAILY 8. Diazepam ___ mg PO TID 9. Gabapentin 1200 mg PO QAM 10. Gabapentin 900 mg PO QPM 11. FLUoxetine 20 mg PO DAILY 12. Docusate Sodium 100 mg PO BID 13. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q4-6H:PRN pain Discharge Medications: 1. Diazepam ___ mg PO TID 2. Docusate Sodium 100 mg PO BID 3. Gabapentin 1200 mg PO QHS 4. Levothyroxine Sodium 75 mcg PO DAILY 5. Lisinopril 5 mg PO DAILY 6. Omeprazole 20 mg PO BID 7. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q4-6H:PRN pain 8. Pravastatin 80 mg PO QPM 9. FLUoxetine 20 mg PO DAILY 10. Gabapentin 1200 mg PO QAM 11. Gabapentin 900 mg PO QPM 12. Methadone 10 mg PO DAILY 13. Glargine 36 Units Breakfast Glargine 40 Units Bedtime Humalog 25 Units Breakfast Humalog 25 Units Lunch Humalog 25 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX insulin glargine [Lantus] 100 unit/mL AS DIR 36 Units before BKFT; 40 Units before BED; Disp #4 Vial Refills:0 RX insulin lispro [Humalog] 100 unit/mL AS DIR Up to 20 Units QID per sliding scale 25 Units before LNCH; Units QID per sliding scale 25 Units before DINR; Disp #4 Vial Refills:0 RX insulin syringe-needle U-100 [BD Insulin Syringe ___ 29 gauge x ___ use to administer insulin as directed Disp #100 Syringe Refills:1 14. Ketoconazole 2% 1 Appl TP BID:PRN rash RX ketoconazole 2 % apply to rash on face twice daily Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnoses: Urinary tract infection Abdominal pain Endometrial thickening Post-menopausal vaginal bleeding Secondary diagnoses: IDDM hypertension paraplegia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, You were hospitalized at ___ because you had a urinary tract infection requiring treatment with antibiotics through an IV. You also had abdominal pain and had an ultrasound of your liver which showed fat deposition and possibly some fibrosis (scarring). This was likely unrelated to your abdominal pain but you should follow up with a liver doctor because of this finding. An appointment is listed below. Your abdominal pain improved with treatment of your constipation. You also had been having vaginal bleeding. An ultrasound showed thickening of the lining of your uterus (this lining is called the endometrium). You should follow up with gynecology for an endometrial biopsy. An appointment is listed below. Lastly, your insulin medications have been changed. You should follow up with the diabetes doctors as below. It was a pleasure participating in your care. We wish you all the best in the future. Sincerely, Your ___ team Followup Instructions: ___
10821892-DS-19	10,821,892	20,918,371	DS	19	2185-03-25 00:00:00	2185-03-30 14:49:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: epinephrine / Augmentin Attending: ___. Chief Complaint: Fevers and lower abdominal pain Major Surgical or Invasive Procedure: Ultrasound-guided drainage of abscesses History of Present Illness: ___ G1P1 with h/o bilateral TOAs in ___ s/p ___ guided drainage and course of abx who presents to ED with lower abd pain and fever to 102. States recovered well from TOAs in ___ and the day before admission started to have lower abdominal pain, constant, ___. Had nausea and vomiting. Did not have vaginal discharge, changes in bowel/bladder habits, or dysuria. Re: course in ___, was admitted to GYN for PID/bilateral TOAs. Initially started on gent/clinda. Underwent bilateral ___ guided drainage. ID was consulted who changed abx to zosyn then unasyn. Discharged home with course of augmentin, but stopped course early ___ hives. During this course, was ? bowel etiology s/p CT scan and ACS consult to thought etiology more likely gynecologic. The preliminary read on the ___ pelvic ultrasound was: Complex bilateral adnexal collections with tubular appearance and internal echoes suggestive of pyosalpinges are new compared to the prior study of ___. Past Medical History: POB/GYNH: - ___ s/p LTCS. - Denies hx of STIs, abnormal Pap tests. - LMP approx 2 weeks ago. - Sexually active with husband only. - Endorses dypareunia since c-section ___ years ago. - Also reports recent yeast infections after intercourse. PMH: - Ventricular bigeminy PSURGH: LTCS All: latex -> rash, epinephrine -> palpitations Social History: ___ Family History: Denies hx of breast, ovary, uterine, colon cancers. Physical Exam: Afebrile. General: appears well, not diaphoretic as on admission CV: RRR Resp: bibasilar crackles c/w atelectasis Abd: soft, non-tender, non-distended. minimal tenderness to palpation. Ext: no edema Skin: no rashes Pertinent Results: ___ 07:35AM BLOOD WBC-10.2 RBC-4.08* Hgb-12.7# Hct-39.4 MCV-97 MCH-31.0 MCHC-32.2 RDW-13.3 Plt ___ ___ 07:30AM BLOOD WBC-7.7 RBC-3.28* Hgb-10.1* Hct-32.6* MCV-100* MCH-30.8 MCHC-31.0 RDW-13.5 Plt ___ ___ 08:10AM BLOOD WBC-12.1* RBC-3.32* Hgb-10.1* Hct-32.5* MCV-98 MCH-30.6 MCHC-31.2 RDW-13.6 Plt ___ ___ 04:45AM BLOOD WBC-14.7* RBC-3.63* Hgb-11.3* Hct-35.1* MCV-97 MCH-31.1 MCHC-32.2 RDW-13.2 Plt ___ ___ 07:15AM BLOOD WBC-15.7* RBC-3.91* Hgb-12.1 Hct-37.6 MCV-96 MCH-30.9 MCHC-32.1 RDW-13.5 Plt ___ ___ 09:50PM BLOOD WBC-13.1# RBC-4.18 Hgb-13.1 Hct-40.4 MCV-97 MCH-31.4 MCHC-32.5 RDW-13.4 Plt ___ ___ 07:35AM BLOOD Neuts-75.9* Lymphs-17.3* Monos-6.0 Eos-0.4 Baso-0.3 ___ 07:30AM BLOOD Neuts-68.8 ___ Monos-8.7 Eos-0.9 Baso-0.4 ___ 08:10AM BLOOD Neuts-85.9* Lymphs-9.0* Monos-4.0 Eos-1.0 Baso-0.1 ___ 04:45AM BLOOD Neuts-90.3* Lymphs-6.4* Monos-2.2 Eos-1.0 Baso-0.1 ___ 07:15AM BLOOD Neuts-89.6* Lymphs-6.8* Monos-2.9 Eos-0.6 Baso-0.1 ___ 09:50PM BLOOD Neuts-88* Bands-2 Lymphs-5* Monos-5 Eos-0 Baso-0 ___ Myelos-0 ___ 09:50PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 07:35AM BLOOD Plt ___ ___ 07:35AM BLOOD ___ PTT-34.1 ___ ___ 07:30AM BLOOD Plt ___ ___ 08:10AM BLOOD Plt ___ ___ 08:10AM BLOOD ___ PTT-33.9 ___ ___ 04:45AM BLOOD Plt ___ ___ 04:45AM BLOOD ___ PTT-34.6 ___ ___ 07:15AM BLOOD Plt ___ ___ 07:15AM BLOOD ___ PTT-34.2 ___ ___ 09:50PM BLOOD Plt Smr-NORMAL Plt ___ ___ 07:35AM BLOOD ___ ___ 08:10AM BLOOD ___ ___ 04:45AM BLOOD ___ ___ 07:15AM BLOOD ___ ___ 07:35AM BLOOD ESR-88* ___ 04:45AM BLOOD Glucose-95 UreaN-10 Creat-0.7 Na-135 K-3.3 Cl-106 HCO3-20* AnGap-12 ___ 09:50PM BLOOD Glucose-92 UreaN-11 Creat-0.7 Na-138 K-3.4 Cl-103 HCO3-21* AnGap-17 ___ 07:35AM BLOOD Calcium-8.7 Phos-3.4# Mg-1.8 ___ 04:45AM BLOOD Calcium-8.5 Phos-1.7# Mg-1.7 ___ 10:40PM URINE Color-Yellow Appear-Clear Sp ___ ___ 10:40PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-SM ___ 10:40PM URINE RBC-<1 WBC-18 Bacteri-FEW Yeast-NONE Epi-6 Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service for treatment of suspected bilateral tuboovarian abscesses. She was febrile the day of admission to 103.0. She was empirically started on unasyn and doxycycline, which was then changed to ceftriaxone and flagyl based on culture results from her prior tuboovarian abscesses. Chlamydia and gonorrhea testing performed on admission were negative. A pelvic ultrasound done the day of admission showed bilateral pyelosalpinges. By pelvic ultrasound, there was not sufficient fluid to aspirate, so a CT was performed on hospital day two to better evaluate fluid collections and the presence of pelvic abscesses. The CT revealed bilateral pyosalpinges and 7 cm pelvic abscess. She underwent an ultrasound-guided aspiration of 110ccs from the abscess and placement of a drain on hospital day two, which drained 40cc. The gram stain of the fluid from her abscess showed gram negative rods, but bacteria did not grow for sensitivities. Blood cultures taken during the admission were also negative. On hospital day three the drain fell out, and a follow up ultrasound showed insufficient fluid for aspiration. On hospital day three she had a repeat pelvic ultrasound showing fluid collection and 65cc was aspirated. She had an isolated fever to 101.3, but had shown significant clinical improvement. Her last fever was 101.1 on hospital day four (___). She was transitioned to a PO regimen of metronidazole and levofloxacin. She continued to remain afebrile on hospital day five. Although the plan was to monitor her vitals and symptoms for a 48-hour time period, the patient chose to leave against medical advice on hospital day 5. During her hospitalization she was also noted to have a prolonged INR of 2.0 on hospital day one, which was thought to be due to the imflammatory reaction caused by her pelvic infection. She was given vitamin K and monitored closely for bleeding. Her follow up INRs were 1.2-1.4's. Medications on Admission: - Clotrimazole-betamethasone 1 %-0.05 % topical cream. Apply to rash once daily x one week. Discharge Medications: 1. Levofloxacin 500 mg PO Q24H RX levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #14 Tablet Refills:0 2. MetRONIDAZOLE (FLagyl) 500 mg PO TID RX metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #42 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: tubo-ovarian abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecology service for bilateral tuboovarian abscesses. You were treated with antibiotics. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns at ___. Please follow the instructions below. You should continue to take oral antibiotics - levofloxacin once daily and metronidazole three times daily up until surgery date, will discuss if needed post-op. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___
10821939-DS-21	10,821,939	25,285,253	DS	21	2147-11-02 00:00:00	2147-11-02 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: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS ============== ___ 12:21PM BLOOD WBC-9.5 RBC-4.70 Hgb-16.0 Hct-46.8 MCV-100* MCH-34.0* MCHC-34.2 RDW-12.5 RDWSD-46.3 Plt ___ ___ 12:21PM BLOOD Neuts-84.0* Lymphs-5.8* Monos-7.7 Eos-1.6 Baso-0.4 Im ___ AbsNeut-7.98* AbsLymp-0.55* AbsMono-0.73 AbsEos-0.15 AbsBaso-0.04 ___ 12:21PM BLOOD ___ PTT-26.7 ___ ___ 12:21PM BLOOD Glucose-100 UreaN-106* Creat-1.9* Na-131* K-5.8* Cl-88* HCO3-25 AnGap-18 ___ 12:21PM BLOOD Albumin-4.0 Calcium-10.1 Phos-5.3* Mg-2.4 ___ 12:21PM BLOOD ALT-16 AST-22 AlkPhos-113 TotBili-0.8 ___ 12:21PM BLOOD Lipase-44 ___ 12:21PM BLOOD proBNP-4881* ___ 12:21PM BLOOD cTropnT-0.04* ___ 07:17PM BLOOD CK-MB-3 cTropnT-0.02* PERTINENT STUDIES ================= ___ CT Torso 1. Status post left pneumonectomy, esophagectomy, and gastric pull-through. 2. Emphysema and evidence of chronic small airway disease in the right lung. 3. No evidence of recurrent malignancy in the chest. 4. No acute process or evidence malignancy in the abdomen or pelvis. 5. Cholelithiasis. 6. Heavy colonic stool burden. DISCHARGE LABS =============== ___ 07:20AM BLOOD WBC-7.2 RBC-3.62* Hgb-12.5* Hct-37.2* MCV-103* MCH-34.5* MCHC-33.6 RDW-13.1 RDWSD-49.8* Plt ___ ___ 07:20AM BLOOD Glucose-94 UreaN-45* Creat-1.1 Na-141 K-5.8* Cl-102 HCO3-27 AnGap-12 ___ 07:20AM BLOOD Calcium-9.2 Phos-2.4* Mg-2.2 Brief Hospital Course: ===================== TRANSITIONAL ISSUES ===================== [] Adjust diuretic as needed given poor PO intake. Home diuretic changed to PRN dosing only if patient has weight gain given presentation with profound intravascular volume depletion. [] Consider interventions to increase appetite. Patient reports "acid taste" that makes eating unpleasant, but on PPI [] Consider uptitrating lisinopril as tolerated. Lisinopril held on admission iso ___ and symptomatic hypotension, restarted at much lower dose of 5 mg [] Repeat CBC and chemistry panel in 1 week, particularly Cr given ___ on presentation [] Ensure that patient is up-to-date with all preventative vaccinations and screenings [] Review if constipation still present and address accordingly Discharge wt: 105 lb Discharge Cr: 1.1 ===================== ASSESSMENT AND PLAN: ===================== Mr. ___ is an ___ year-old man with a history of HTN, HLD, HFrEF (EF 30%, severe 4+ MR, 4+ TR), prior stomach and esophageal adenocarcinoma s/p resection and chemoradiation ___ years ago now in remission, pulmonary HTN, prior L pneumonectomy for childhood bronchiectasis, hypothyroidism, and atrial fibrillation, who presents with weakness, profound weight loss, hypotension, and ___, likely ___ poor PO intake and intravascular volume depletion. He received 2L IVF in the ED w/ symptomatic improvement of weakness and dizziness. His torsemide was held iso likely intravascular volume depletion. He was then encouraged to increase PO intake without repeat episodes of weakness or dizziness. His lisinopril was held and then restarted at a low dose in the setting of symptomatic hypotension. At discharge, his BPs were stable and Cr had normalized. CORONARIES: No significant CAD. PUMP: EF 34%, 4+ MR, 4+ TR RHYTHM: atrial fibrillation =============== ACTIVE ISSUES: =============== # Dehydration, malnutrition # ___ The patient presents with subacute to chronic weight loss in the setting of poor PO intake, which ultimately led to his current presentation. +orthostatics VS ___, likely intravascular volume depletion given poor PO intake and patient symptomatically improving after 2L of IV fluids in the ED. No evidence of recurrence of malignancy on EGD from ___, however this is something to consider given his profound weight loss, decreased PO intake, continued reflux sx through lansoprazole, difficulty w/ TEE, and esophageal cancer hx x2. Possibly some component from GERD given acid reflux sensation. The patient does not appear volume overloaded, thus making cardiorenal syndrome or a heart failure exacerbation less likely. We consulted nutrition and adjusted his diet accordingly. Notably, then recommended tube feeds if within goals of care of the patient, which we did not pursue. Her underwent CT torso to evaluate for esophageal abnormalities given his hx of gastric/esophageal cancer with recent weight loss and poor PO intake, which was not concerning for any abnormality. We held home torsemide, initially held lisinopril iso ___ and symptomatic hypotension, and restarted lisinopril at low dose prior to discharge. # HFrEF (last EF 34%): The patient has HFrEF that appears stable at this time. There is no clinical evidence of volume overload and BNP is lower than prior heart failure exacerbation. We held his home diuretic while giving IVF for intravascular volume depletion and restarted him on his home dose but PRN given his poor PO intake. We encouraged PO intake to replete his volume status. Lisinopril was initially held iso ___ and symptomatic hypotension, and later restarted lisinopril at low dose prior to discharge for afterload reduction. Metop was reduced as lisinopril was uptitrated to keep him hemodynamically stable. We continued home ASA and statin for primary prevention. He was euvolemic at discharge. # Elevated troponin, resolved Likely type II NSTEMI in the setting of dehydration and poor PO intake. No evidence of coronary disease on recent cardiac cath make type I NSTEMI unlikely. Trop downtrended after peak at 0.04. ================ CHRONIC ISSUES: ================ # Atrial fibrillation Home metop reduced as lisinopril restarted per above. We did not start anti-coagulation per family and patient discussion with outpatient cardiologist # Hypothyroidism Continued home levothyroxine # COPD Continued home inhalers # GERD Continued home lansoprazole Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Cyanocobalamin 1000 mcg PO DAILY 3. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 4. Levothyroxine Sodium 112 mcg PO DAILY 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Simvastatin 5 mg PO QPM 7. Ipratropium Bromide MDI 2 PUFF IH TID 8. Torsemide 20 mg PO DAILY 9. Lisinopril 40 mg PO DAILY 10. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing Discharge Medications: 1. Multivitamins W/minerals 1 TAB PO DAILY 2. Lisinopril 5 mg PO DAILY RX lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 3. Metoprolol Succinate XL 25 mg PO DAILY RX metoprolol succinate 25 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 4. Torsemide 20 mg PO DAILY:PRN weight gain more than 3 pounds RX torsemide 20 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:*0 5. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing 6. Aspirin 81 mg PO DAILY 7. Cyanocobalamin 1000 mcg PO DAILY 8. Ipratropium Bromide MDI 2 PUFF IH TID 9. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 10. Levothyroxine Sodium 112 mcg PO DAILY 11. Simvastatin 5 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================== ___ SECONDARY DIAGNOSIS ==================== HFrEF Atrial fibrillation Hypothyroidism COPD GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? ========================================== - You came to the hospital because you were feeling weak. You were admitted to the hospital because you had kidney injury, probably from not eating and drinking enough. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? =============================================== - You received a lot of intravenous (IV) fluid because you were dehydrated. You felt a lot better after you were rehydrated. - We adjusted your medicines to hopefully prevent you from getting dehydrated again. Most importantly, you should take your water pill (torsemide) only when your weight goes up - A CT scan was done but did not show any abnormal findings in you chest or abdomen WHAT SHOULD I DO WHEN I GO HOME? ==================================== - Your discharge weight: 105 pounds. Weigh yourself when you get home from the hospital without clothes. This will be your baseline weight. - If your weight is more than 3 pounds above your baseline (105 lbs) in the morning when you weigh yourself, take 20 mg of your torsemide. You should continue to check your weight every morning and take torsemide again if your weight is still more than 3 pounds above 105 lbs. - You should continue to take your medications as prescribed. - If you are experiencing new or concerning chest pain that is coming and going you should call the heartline at ___. If you are experiencing persistent chest pain that isn't getting better with rest or nitroglycerin you should call ___. - You should also call the heartline if you develop swelling in your legs, abdominal distention, or shortness of breath at night. - You should attend the appointments listed below. - Weigh yourself every morning, call your doctor if your weight goes up more than 5 lbs. - Take over-the-counter Senna and Miralax to prevent constipation and call your PCP if you are having trouble with bowel movements. We wish you the best! Your ___ Care Team Followup Instructions: ___
10821939-DS-22	10,821,939	21,608,018	DS	22	2147-12-16 00:00:00	2147-12-16 20:06:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS =============== ___ 02:35PM BLOOD WBC-6.8 RBC-4.61 Hgb-15.8 Hct-47.8 MCV-104* MCH-34.3* MCHC-33.1 RDW-15.1 RDWSD-58.6* Plt ___ ___ 02:35PM BLOOD Neuts-84.0* Lymphs-6.4* Monos-8.6 Eos-0.1* Baso-0.3 Im ___ AbsNeut-5.73 AbsLymp-0.44* AbsMono-0.59 AbsEos-0.01* AbsBaso-0.02 ___ 02:35PM BLOOD Glucose-99 UreaN-46* Creat-1.5* Na-127* K-6.6* Cl-87* HCO3-22 AnGap-18 ___ 12:37AM BLOOD ___ pO2-53* pCO2-59* pH-7.27* calTCO2-28 Base XS-0 Comment-GREEN TOP ___ 04:05PM BLOOD K-5.6* INTERIM LABS ============ ___ 09:40PM BLOOD ___ ___ 07:28AM BLOOD ___ Folate-18 ___ 07:28AM BLOOD Osmolal-281 ___ 03:50PM BLOOD CRP-10.8* ___ 07:40AM BLOOD ___ pO2-34* pCO2-58* pH-7.33* calTCO2-32* Base XS-2 Comment-GREEN TOP ___ 06:24AM BLOOD ___ pO2-29* pCO2-56* pH-7.37 calTCO2-34* Base XS-3 Comment-GREEN TOP DISCHARGE LABS =============== ___ 07:40AM BLOOD WBC-5.3 RBC-3.65* Hgb-12.4* Hct-38.1* MCV-104* MCH-34.0* MCHC-32.5 RDW-14.8 RDWSD-57.1* Plt ___ ___ 07:40AM BLOOD ___ PTT-28.9 ___ ___ 07:40AM BLOOD Glucose-84 UreaN-37* Creat-1.1 Na-134* K-4.1 Cl-90* HCO3-30 AnGap-14 ___ 07:40AM BLOOD ALT-41* AST-49* AlkPhos-120 TotBili-0.7 ___ 07:40AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.9 REPORTS ========= ___ IMPRESSION: Increased opacity at the right lung base appears new from prior study dated ___, suspicious for aspiration/pneumonia in the appropriate clinical setting. ___ IMPRESSION: Moderate global biventricular systolic dysfunction. At least moderate to severe mitral and tricuspid regurgitation. Moderate to severe pulmonary hypertension. Brief Hospital Course: ASSESSMENT AND PLAN: ==================== Mr. ___ is an ___ year old male with HFrEF (EF 30%), severe MR and TR, pulmonary HTN, atrial fibrillation not on AC, HTN, HLD, a history of stomach and esophageal adenocarcinoma status post resection and chemoradiation in remission ___ years), and remote L pneumonectomy for bronchiectasis in childhood; he presented from home to the ED for dyspnea, fatigue, and poor PO intake. He was found to have a right basilar pneumonia, was well as acute kidney injury and signs of fluid overload. His weight on admission was 115 pounds on admission; this is increased from his last recorded weight of 105 pounds on ___. His pneumonia was treated with IV antibiotics for 5 days. He underwent several days of IV diuresis, as well as 1.5L-2L oral fluid restriction, with significant improvement in clinical status. TRANSITIONAL ISSUES ==================== [] His lisinopril was held prior to admission for ___. This was restarted at discharge at 2.5mg daily, to help prevent cardiac remodeling in Heart Failure. [] This patient is not on spironolactone, which has been shown to have a mortality benefit for symptomatic heart failure. His PCP or cardiologist should consider whether this might be a useful medication for him. [] He was discharged on 20mg of Torsemide daily. He has instructions to weigh himself daily, and to contact his PCP cardiologist if his weight fluctuates by more than 3 pounds from his ideal weight. [] His discharge weight was 107 pounds. He will weigh himself daily in the morning. If his weight reaches over 110 pounds (an increase of 3 pounds) or drops to under 104 pounds (a decrease of 3 pounds), he should call his doctor to make adjustments to his diuretics. [] He should continue to discuss the possibility of venous-access valve replacement with his cardiologist. [] His PCP should see him within 4 days to assess the following: -BUN/CR (last 37/1.1) -Na (last 134) -K+ (last 4.1) -weight (last 107.8 pounds). [] His B12 level was very high in-hospital. For this reason, his B12 supplementation was stopped. His PCP should consider whether to restart this supplement. [] He should take stool softeners for constipation at home as needed. # CODE STATUS: FULL CODE (confirmed) # CONTACT: Name of health care proxy: ___ Relationship: wife Phone number: ___ Cell phone: ___ ACUTE ISSUES: ============= # Heart Failure with Reduced EF Last EF: 34%. Severe mitral and tricuspid regurgitation. His MR and TR have been severe and progressive, and he is undergoing outpatient workup with Dr. ___ transcatheter mitral valve replacement. He presented with an elevated BNP, hyponatremia, and 10 pound weight gain since last admission, indicative of likey fluid overload. Per patient report, he was noting taking his diuretics at all, and was drinking fluids aggressively, as he was told to avoid dehydration. He was treated in-hospital with IV lasix and a fluid restriction of 1.5 to 2L daily. With this regimen, he was able to diurese close to 1L of additional fluid per day. Upon discharge, he will continue on daily diuresis of PO Torsemide 20mg daily, and will continue on a fluid restriction of 2L. He has strict instructions to call his PCP/Cardiologist if his weight fluctuates by more than 3 pounds (up or down) from his discharge weight of 107 lbs, in order to make adjustments to his diuretic regimen. #Community acquired pneumonia #?Aspiration pneumonia Presented with dyspnea x5 days, likely secondary to both worsening heart failure and R lung opacity noted on chest Xray. There is some concern for aspiration given location and his esophageal resection. Bedswide speech and swallow without any concerns. He was treated with a 5 day course of ceftriaxone/azithromycin for presumed aspiration pneumonia. #Atrial Fibrillation Not on anticoagulation. His metoprolol was initially held, and he developed tachycardia to the 130's. His metoprolol was restarted with good effect. # Combined Respiratory and metabolic acidosis Patient presented with a venous pH of 7.27, pCO2 59, bicarb 22 and lactate 3.1. His acidosis was likely secondary to his acute kidney injury, lactic acidosis, incomplete respiratory compensation due to underlying lung disease and pneumonectomy. His acid-base status improved with diuresis. # ___ Patient presented with a creatinine of 1.5, from baseline 0.9. Given his volume status, the etiology is likely cardiorenal. His creatinine improved with diuresis, back to baseline. Discharge BUN/CR: 37/1.1. # Hyponatremia Patient presented with hyponatremia to 126, likely hypoosmotic, hypervolemic hyponatremia due to CHF. It improved daily with diuresis, although there is likely a chronic component. Discharge sodium: 134. # Hyperkalemia -Initially with serum K 6.6, however whole blood K 5.6 on recheck. No peaked T-waves on ECG. Likely elevated in the setting of ___, responsive to IV diuresis. Spironolactone was held (although it is noted that he has not been taking this since last hospitalization. Discharge K: 4.1 CHRONIC/RESOLVED ISSUES: ====================== # Hypothyroidism - continued home Levothyroxine Sodium ___ M-F and 224 ___ and ___ # COPD - continued home inhalers # GERD - continued home lansoprazole # Moderate pulmonary artery hypertension on TTE ___ # Restrictive lung disease Followed by Dr. ___ seen ___. Restrictive lung disease secondary to past pneumonectomy with fairly well compensated obstructive airway disease and likely intermittent aspiration. Last PFTs with FEV1 and vital capacity 0.99 and 1.52 (37 and 41% predicted respectively). FEV1 to vital capacity ratio is 65% (91% predicted). He was continued on home albuterol 2 puffs TID and Atrovent 2 puffs TID . . . Time in care: >30 minutes in discharge-related activities on the day of discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Aspirin 81 mg PO DAILY 2. Cyanocobalamin 1000 mcg PO DAILY 3. Levothyroxine Sodium 112 mcg PO DAILY 4. Simvastatin 5 mg PO QPM 5. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Ipratropium Bromide MDI 2 PUFF IH TID 8. Torsemide 20 mg PO DAILY:PRN weight gain more than 3 pounds 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 11. Levothyroxine Sodium 112 mcg PO 2X/WEEK (___) Discharge Medications: 1. Lisinopril 2.5 mg PO DAILY RX lisinopril 2.5 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 2. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days RX zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth once a day Disp #14 Capsule Refills:0 3. Torsemide 20 mg PO DAILY RX torsemide 20 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:*0 4. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing 5. Aspirin 81 mg PO DAILY 6. Ipratropium Bromide MDI 2 PUFF IH TID 7. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 8. Levothyroxine Sodium 112 mcg PO DAILY 9. Levothyroxine Sodium 112 mcg PO 2X/WEEK (___) 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Multivitamins W/minerals 1 TAB PO DAILY 12. Simvastatin 5 mg PO QPM 13. HELD- Cyanocobalamin 1000 mcg PO DAILY This medication was held. Do not restart Cyanocobalamin until you see your PCP ___: Home With Service Facility: ___ Discharge Diagnosis: FINAL DIAGNOSIS ================= Heart Failure with Reduced Ejection Fraction Acute Kidney Injury Pneumonia SECONDARY DIAGNOSES ==================== Mitral Regurgitation Tricuspid Regurgitation Esophageal Resection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You came to the hospital because you were having shortness of breath, fatigue, and decreased appetite. You were diagnosed with a pneumonia, and volume overload. WHAT HAPPENED TO ME IN THE HOSPITAL? - Your pneumonia was treated with antibiotics through an IV. - Your weight was up significantly from your last hospitalization. For this reason, you were started on medications to remove excess fluid from your body. - With the medications, your weight decreased, and your overall status improved. - You were feeling better, and you were ready to leave the hospital. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Weigh yourself as soon as you get home from the hospital, and record this weight. This is your goal weight, as you are feeling good at this weight. -Continue to weigh yourself each day, before you eat and before you take your medications. -If your weight increases by more than 3 pounds from your goal weight at any point, you may need to increase your diuretic dose because you are holding on to too much water. You should call your cardiologist if this happens. -If your weight decreased by more than 3 pounds from your goal weight at any time, and you are feeling dizzy, weak, or lightheaded, you may need to decrease your diuretic dose because you are losing too much water. You should call your cardiologist if this happens. -Please drink only when you are thirsty, and do not force yourself to drink. You should drink about 2L of fluid each day. -You should take stool softeners at home so that you have a bowel movement every few days. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
10821939-DS-23	10,821,939	21,615,317	DS	23	2148-01-07 00:00:00	2148-01-08 10:42:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Major Surgical or Invasive Procedure: none attach Pertinent Results: ADMISSION LABS ============== ___ 05:35PM BLOOD WBC-5.3 RBC-4.32* Hgb-14.8 Hct-46.3 MCV-107* MCH-34.3* MCHC-32.0 RDW-15.6* RDWSD-62.2* Plt ___ ___ 05:40AM BLOOD WBC-4.5 RBC-4.18* Hgb-14.2 Hct-44.9 MCV-107* MCH-34.0* MCHC-31.6* RDW-15.7* RDWSD-61.7* Plt ___ ___ 05:35PM BLOOD Plt ___ ___ 05:40AM BLOOD ___ PTT-31.2 ___ ___ 05:40AM BLOOD Plt ___ ___ 06:45AM BLOOD ___ PTT-28.6 ___ ___ 05:35PM BLOOD Glucose-99 UreaN-32* Creat-1.4* Na-144 K-4.7 Cl-99 HCO3-30 AnGap-15 ___ 05:40AM BLOOD Glucose-98 UreaN-36* Creat-1.3* Na-144 K-4.4 Cl-98 HCO3-33* AnGap-13 ___ 04:55PM BLOOD Glucose-140* UreaN-39* Creat-1.3* Na-144 K-3.9 Cl-97 HCO3-32 AnGap-15 ___ 06:45AM BLOOD Glucose-125* UreaN-41* Creat-1.4* Na-145 K-5.2 Cl-100 HCO3-31 AnGap-14 ___ 05:35PM BLOOD cTropnT-0.04* ___ 05:35PM BLOOD ___ ___ 05:40AM BLOOD Calcium-9.8 Phos-4.9* Mg-2.1 Iron-86 ___ 04:55PM BLOOD Calcium-9.2 Phos-4.3 Mg-2.1 ___ 06:45AM BLOOD Calcium-9.7 Phos-4.4 Mg-2.2 INTERVAL LABS ================ ___ 06:45AM BLOOD WBC-5.7 RBC-3.84* Hgb-13.0* Hct-41.2 MCV-107* MCH-33.9* MCHC-31.6* RDW-15.9* RDWSD-62.6* Plt ___ ___ 06:45AM BLOOD ___ PTT-28.6 ___ ___ 05:40PM BLOOD Glucose-95 UreaN-37* Creat-1.3* Na-143 K-4.8 Cl-99 HCO3-36* AnGap-8* ___ 12:45PM BLOOD Glucose-130* UreaN-53* Creat-2.6* Na-143 K-5.5* Cl-99 HCO3-31 AnGap-13 ___ 07:29PM BLOOD Glucose-99 UreaN-56* Creat-2.3* Na-145 K-4.9 Cl-99 HCO3-31 AnGap-15 ___ 06:40AM BLOOD Glucose-108* UreaN-58* Creat-2.3* Na-144 K-5.4 Cl-98 HCO3-29 AnGap-17 ___ 12:45PM BLOOD Calcium-9.1 Phos-6.5* Mg-2.3 ___ 07:29PM BLOOD Calcium-10.1 Phos-5.6* Mg-2.4 ___ 06:40AM BLOOD Calcium-9.8 Phos-5.6* Mg-2.3 DISCHARGE LABS ============== ___ 06:40AM BLOOD WBC-7.5 RBC-3.42* Hgb-11.9* Hct-37.6* MCV-110* MCH-34.8* MCHC-31.6* RDW-16.4* RDWSD-65.6* Plt ___ ___ 07:06AM BLOOD ___ PTT-27.2 ___ ___ 06:26AM BLOOD Glucose-100 UreaN-60* Creat-2.2* Na-146 K-4.9 Cl-102 HCO3-27 AnGap-17 IMAGING ======= ___ CXR IMPRESSION: Status post left pneumonectomy an esophagectomy with gastric pull-through, with similar postoperative appearance. Slight blunting of the right costophrenic angle is similar to possibly slightly improved. No definite new focal consolidation. ___ CXR IMPRESSION: 1. Status post left pneumonectomy and esophagectomy with gastric pull-through, with similar postoperative appearance. 2. Unchanged opacity at the right lung base, most consistent with atelectasis or aspiration/pneumonia in the appropriate clinical setting. Otherwise, there is no evidence of new focal consolidation within the right hemithorax. Brief Hospital Course: Mr. ___ is an ___ y/o M w/ PMH of HFrEF (EF 30%), severe MR and TR, pulmonary HTN, atrial fibrillation not on AC, HTN, HLD, h/o stomach and esophageal adenocarcinoma s/p resection and chemoradiation in remission ___ years), and remote L pneumonectomy for bronchiectasis in childhood who presented ___ with intermittent dyspnea, weight loss and ___, improving with diuresis but then diuresis was held iso relative hypotension and developed ATN ___ poor PO intake because of dietary restrictions for aspiration risk. ___ was initially recommended to have a feeding tube however patient had declined. ___ was discharged on ___ with TMVR eval outpatient on ___, and discharged on diet recommendation of pureed/nectar pre-thickened liquids in the time being until ___ is evaluated by speech and swallow as an outpatient. ___ was also noted to have a superficial thrombophlebitis in the right arm which is treated with heat packs and was newly started on apixaban this admission for Afib stroke prophylaxis. TRANSITIONAL ISSUES =================== [ ] Lisinopril 2.5mg was held secondary to ___, and home diuretics were also stopped due to relative hypotension / ___. [ ] Patient to complete swallowing evaluation including VEES in the Speech and Swallow Department as an outpatient. The inpatient ___ team has arranged this appointment and the patient has the information to call to confirm. [ ] Per ENT: will require follow up in ___ clinic. Please call ___ upon discharge to arrange f/u with Dr. ___. [ ] Please ensure R arm superficial thrombophlebitis is improving with warm compress. Note ___ is on apixaban 2.5mg BID for stroke prophylaxis for Afib. [ ] New Medications: - apixaban 2.5mg BID. previously denied anticoagulation for stroke prophylaxis but was open to it this admission. ACTIVE ISSUES ============= # HFrEF # Severe MR ___ has HFrEF with 4+ MR, pHTN, and TR and is currently undergoing outpatient workup with Dr. ___ transcatheter mitral valve replacement. His pulmonary symptoms with which ___ presented are more likely due to his severe MR and pHTN. The patient responded well to IV diuresis for 2 days and then was euvolemic ___. Given that fact and had poor PO intake (due to aspiration risk) and relative hypotension, no further diuresis was given since ___ held iso relative hypotension. ___ developed ___ (ATN) ___ for which ___ was cautiously given fluid and improved creatinine. ___ was euvolemic on discharge. His evaluation for TMVR was deferred to the outpatient setting, given his clinical euvolemia and patient desire to return home. ___ has close follow-up with Cardiology that was arranged while in house. Discharge Cr 2.2, Discharge weight 101.1 lb. Not any diuretics upon discharge. # Dysphagia Patient has had long standing dysphagia, secondary to R vocal cord paralysis which is chronic issue for him since esophagectomy. During this admission, the patient had repeated evaluations by Speech and Swallow who initially had limited his diet to NPO but then subsequently, after visualization, agreed with advancing diet. ENT performed a laryngoscopy and reported that the vocal cords approximate well even with L vocal cord paralyzed, and recommended BID PPI. # ___ Possibly in the setting worsening heart failure as above vs to lisinopril which was restarted during his last admission. Cr responded well to IV diuresis for 2 days and then was euvolemic ___. Given that fact and had poor PO intake (due to aspiration risk) and relative hypotension, no further diuresis was given since ___ held iso relative hypotension. ___ then developed an ___ (ATN) ___ for which ___ was cautiously given fluid and improved creatinine. Discharge Cr was 2.2. # Weight loss / FTT Likely due to worsening heart failure and poor PO intake. ___ does have a history of malignancy, however CT CAP ___ without evidence of malignancy. Low concern at this time. # Atrial fibrillation CHAD2VASC 5 Patient's beta blockade was adjusted throughout this hospitalization, with blood pressures that were sensitive to the escalating doses, and thus his lisinopril was held. Discharged on metop succinate 25 mg daily. #Superficial thrombophlebitis R arm Patient has a marked off superficial thrombophlebitis on Right lower arm from IV site. Treated with warm compress and plan for re-evaluation on follow up. Note ___ was newly started on apixaban 2.5mg for Afib dosing which is not ideal for VTE dosing. CHRONIC ======= # Macrocytosis Vit B12 previously greater than essay. Folate was wnl. Patient denies ETOH use. Likely due to poor nutrition. # Hypothyroidism Patient was continued on home levothyroxine ___ M-F, 224 ___ and ___. # GERD Continued home lansoprazole. Also recommended by ENT for help with vocal cord dysfunction. # CODE STATUS: FULL CODE # CONTACT: Name of health care proxy: ___ Relationship: wife Phone number: ___ Cell phone: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing 2. Aspirin 81 mg PO DAILY 3. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 4. Levothyroxine Sodium 112 mcg PO DAILY 5. Levothyroxine Sodium 112 mcg PO 2X/WEEK (___) 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Simvastatin 5 mg PO QPM 9. Torsemide 20 mg PO DAILY 10. Ipratropium Bromide MDI 2 PUFF IH TID 11. Zinc Sulfate 220 mg PO DAILY 12. Lisinopril 2.5 mg PO DAILY 13. Famotidine 40 mg PO QHS 14. Mirtazapine 7.5 mg PO QHS 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. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing 3. Aspirin 81 mg PO DAILY 4. Famotidine 40 mg PO QHS 5. Ipratropium Bromide MDI 2 PUFF IH TID 6. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 7. Levothyroxine Sodium 112 mcg PO DAILY 8. Levothyroxine Sodium 112 mcg PO 2X/WEEK (___) 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Mirtazapine 7.5 mg PO QHS 11. Multivitamins W/minerals 1 TAB PO DAILY 12. Simvastatin 5 mg PO QPM 13. Zinc Sulfate 220 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================== # Heart Failure with Reduced Ejection Fraction # Chronic Obstructive Pulmonary Disease SECONDARY DIAGNOSIS =================== # Malnutrition # Chronic Dysphagia # Gastrointestinal Reflux Disease # R Arm Superficial Thrombophlebitis 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 hospitalized? ======================== You were admitted to the hospital with worsening shortness of breath. What happened to me while I was here? ======================================= You had a chest xray which showed extra fluid in the lung. You received intravenous Lasix to help get the fluid out. Your medications for heart rate and blood pressure were adjusted. You were seen by the ENT team and the Swallowing team for evaluation of your swallowing ability. Your vocal cords are intact. You are still at in increased risk of aspiration and choking, however. You were evaluated by the nutrition team who made recommendations about your diet. You had a superficial blood clot on your right arm, it is not worrisome if you take your new medicine apixaban which is primarily used for your atrial fibrillation. What should I do when I go home? ================================== Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Please make sure that you take all of your medications and that you go to all of your appointments. Please contact speech and swallow in below information to confirm appointment for test. We wish you the best! Your ___ care team Followup Instructions: ___
10822122-DS-2	10,822,122	25,252,686	DS	2	2145-07-29 00:00:00	2145-07-29 12:57:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: L hip pain Major Surgical or Invasive Procedure: L hip aspiration by ___ (___) History of Present Illness: ___ with PMH hx IVDU (on methadone), s/p L hip replacement ___ (at ___), HTN, and asthma p/w worsening L hip pain. Following hip replacement, pt was in rehab until ___. Has been walking with walker. Was initially on oxycodone 5mg q8h following surgery, but has since run out of her prescription. Had a fall 1 month ago, slipped on ice outside her home. Reportedly went to ___ after the fall and was told something may be broken, went to see her orthopedic surgeon at ___ on ___ and was told hip has fracture that will heal without intervention. She states that pain has become increasingly severe, and she has been unable to ambulate for the last 2 days due to pain. Not currently taking anything for pain at home other than usual methadone; states no relief from advil or tylenol. Methadone dose is 120mg daily; pt already received dose today prior to admission (confirmed with Ed ___, Habit Opco, ___ Pt denies new trauma, fevers, chills, joint swelling, warmth near joint, bleeding, abdominal pain, N/V. Pt denies recent IVDU. In the ED, initial vital signs were: 10 98.2 68 150/89 16 97% Labs were notable for normal WBC. X ray L hip: on prelim read: total left hip prosthesis appears intact without evidence of loosening or fracture. In ED pt was given 1L IVF, 30mg toradol without relief, 1mg dilaudid with mild relief; still unable to ambulate. On Transfer Vitals were: 97.5 68 161/92 18 97% RA. Past Medical History: -Arthritis s/p L hip replacement ___ -HTN -Asthma -Blind in R eye secondary to trauma -Chronic back pain -Abdominal hernia s/p surgery -hx narcotic abuse, on methadone maintenance Social History: ___ Family History: Sister and son with DM. Physical Exam: On admission: Vitals- 97.9 156/85 68 18 98% General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding GU- no foley Ext- Scar over L lateral pelvis; L anterior and lateral thigh and hip tender to palpation; Pt unable to actively flex L leg at hip; pain with passive motion at L hipo; warm, well perfused, no clubbing, cyanosis or edema On discharge: Vitals- 98.8 129/73 73 18 99%RA General- Alert, oriented, NAD HEENT- Sclera anicteric, MMM, oropharynx clear Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, systolic murmur best heart at L ___ intercostal space radiating to carotid Abdomen- obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding GU- no foley Ext- Scar over L lateral pelvis; L lateral pelvis/flank tender to palpation; unable to actively flex L leg at hip; able to tolerate some passive L hip flexion without pain Pertinent Results: ==================== Labs: ==================== ___ 08:50AM BLOOD WBC-6.5 RBC-3.94* Hgb-11.3* Hct-37.2 MCV-94 MCH-28.7 MCHC-30.4* RDW-17.7* Plt ___ ___ 08:50AM BLOOD Neuts-52.4 ___ Monos-5.3 Eos-3.0 Baso-0.9 ___ 10:00AM BLOOD ___ PTT-32.8 ___ ___ 10:00AM BLOOD ESR-50* ___ 08:50AM BLOOD Glucose-91 UreaN-14 Creat-0.8 Na-134 K-8.3* Cl-101 HCO3-25 AnGap-16 ___ 08:50AM BLOOD ASA-NEG* Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 10:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 08:05AM BLOOD WBC-6.3 RBC-4.07* Hgb-11.7* Hct-38.0 MCV-93 MCH-28.7 MCHC-30.7* RDW-16.9* Plt ___ ___ 08:05AM BLOOD Glucose-91 UreaN-31* Creat-1.1 Na-135 K-4.6 Cl-102 HCO3-25 AnGap-13 ==================== Micro: ==================== ___ blood cultures: negative ___ blood cultures: negative ___ 3:00 pm JOINT FLUID LEFT HIP . GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ACID FAST SMEAR (Final ___: SPECIMEN NOT PROCESSED DUE TO: QUANTITY NOT SUFFICIENT. Reported to and read back by ___. ___ @ 1745 ON ___. TEST CANCELLED, PATIENT CREDITED. ACID FAST CULTURE (Final ___: SPECIMEN NOT PROCESSED DUE TO: QUANTITY NOT SUFFICIENT. Reported to and read back by ___ @ 1745 ON ___. TEST CANCELLED, PATIENT CREDITED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ANAEROBIC CULTURE (Final ___: NO GROWTH. ==================== Imaging: ==================== HIP UNILAT MIN 2 VIEWS LEFT Study Date of ___ 8:54 AM FINDINGS: Patient is status post left total hip prosthesis with non-cemented femoral stem. The femoral head component appears symmetrically seated within the acetabular component. Several plates and associated screws and a wire mesh type device also noted securing the acetabulum. There is no periprosthetic lucency to suggest loosening and no osteolysis is detected. No significant heterotopic ossification is noted. There is irregularity and cortical disruption of the left iliopectineal line and left inferior pubic ramus, possibly from prior trauma or related to surgery but margins appear sclerotic. IMPRESSION: Total left hip prosthesis appears intact without evidence of loosening or fracture. No prior for comparison. Irregularity and cortical disruption of the left iliopectineal line and left inferior pubic ramus, possibly from prior trauma or related to surgery but margins appear sclerotic. Brief Hospital Course: ___ with PMH hx IVDU (on methadone), s/p L hip replacement ___ (at ___), HTN, and asthma who presented with worsening L hip pain. # L hip pain, s/p L hip replacement ___: Xray negative for acute fracture. Per ortho, pt with healing L ramus fracture on xray. Despite lack of fever of leukocytosis, L hip aspiration performed ___ to rule out infection, particularly given history of IVDU. No growth to date from joint or blood cultures. Pt continues to have pain with activity and unable to weight bear on L ___. Pain being treated with tylenol, oxycodoen, lidocaine patch, and gabapentin, in addition to home methadone. Tizanidine was prescribed as recommended by Pain Service but discontinued after pt developed asymptomatic hypotension (SBP 80). Ortho recommended weight bearing as tolerated. She continued to work with ___ daily. Pt to follow up with ortho as outpt. # Hypotension, likely secondary to pain medications: Pt had an episode of SBP drop to 80, without symptoms, which occured after being started on tizanidine and increased doses of oxycodone. SBP recovered to >90 after 1L NS. Oxycodone was reduced and tizanidine was discontinued. Amlodipine was also discontinued and lisinopril dose reduced. HCTZ dose being reduced on discharge, as pt complaining of polyuria. # H/o IVDU: Pt denies recent use. On methadone 120mg daily as outpt (confirmed with clinic). Utox and serum tox negative. QTc 434 on ___. Was continued on home methadone 120mg daily. # HTN: Pt was continued on home HCTZ and lisinopril. Amlodipine was held after pt had an episode of hypotension (SBP 80), and lisinopril dose was reduced from 40mg to 20mg daily. HCTZ dose being reduced on discharge, as pt complaining of polyuria. Also continued on home aspirin. # Asthma: Was treated with albuterol neb prn. Transitional issues: -Gabapentin dose may be uptitrated to 600mg TID as tolerated -Pt to follow up with ortho at ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 25 mg PO DAILY 2. Lisinopril 40 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. albuterol sulfate 90 mcg/actuation inhalation unknown 5. Methadone 120 mg PO DAILY 6. Amlodipine 10 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Methadone 120 mg PO DAILY 3. Acetaminophen 1000 mg PO TID 4. Docusate Sodium 100 mg PO BID 5. Polyethylene Glycol 17 g PO DAILY constip 6. Senna 8.6 mg PO BID constip 7. albuterol sulfate 90 mcg/actuation inhalation unknown 8. Lidocaine 5% Patch 1 PTCH TD QAM hip 9. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain 10. Famotidine 20 mg PO BID 11. Gabapentin 300 mg PO TID 12. Lisinopril 20 mg PO DAILY 13. Hydrochlorothiazide 12.5 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: L hip pain s/p L hip replacement History of IVDU HTN Asthma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, It was a pleasure to care for you. You were hospitalized due to hip pain. We were concerned your about the possibility of infection causing the left hip pain, and so interventional radiology withdrew fluid from the joint. The joint fluid and other tests did not show any evidence of infection. You have a follow up appointment with Dr. ___. Please take your medications as prescribed and attend your follow up appointments. Followup Instructions: ___
10822122-DS-3	10,822,122	29,536,759	DS	3	2145-09-07 00:00:00	2145-09-07 11:18:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: nuts Attending: ___. Chief Complaint: L Hip Pain, R Leg Numbness Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMH hx IVDU (on methadone), s/p L hip replacement ___ (at ___), HTN, and asthma, with recent admission ___ for hip pain, who presents with worsened hip pain and L leg numbness. Following hip replacement in ___, pt was in rehab until ___. Was initially on oxycodone 5mg q8h following surgery, but then ran out of medication. Had a fall in ___, slipped on ice outside her home. Reportedly went to ___ after the fall and was told something may be broken, went to see her orthopedic surgeon at ___ on ___ and was told hip has fracture that will heal without intervention. Pain increased to the point she was unable to ambulation. Was admitted in ___ and given analgesics. On that admission, there was initialy concern for infection, but blood and joint fluid cultures were negative. On discharge, went to ___. Was discharged home ___ and has since been on tylenol and gabapentin for pain (in addition to mathadone). 3 days ago L hip pain increased, which has prevented ambulation; she had been ambulation with walker at home. Reports pain over L low back, buttocks, and thigh. She also reports R leg numbness. Pt denies new trauma, fevers, chills, SOB, dysuria, diarrhea, feeling lightheaded. She reports intermittent nausea over last 2 weeks without emesis. In the ED, initial vital signs were:98.4 90 161/85 20 96%. Labs were notable for WBC 6.5, ESR 63, CRP 3.0. Patient was given diazpema 5mg po, ketorolac 30mg IV, oxycodone-aceaminophen x multipls doses, morphine 5mg IV x2, and percocet. Was also given home meds: aspirin, HCTZ 25, lisinopril 40, gabapentin, methadone 120mg daily. Pt was evaluated by ortho who felt hip xray appeared unchanged from priors obtained one month ago, without evidence of hardware loosening or acute fracture. Felt no acute surgical intervention needed at this time. Pt was admitted for pain control and placement. On Transfer Vitals were: Today ___ 77 160/99 16 98% RA Past Medical History: -Arthritis s/p L hip replacement ___ -HTN -Asthma -Blind in R eye secondary to trauma -Chronic back pain -Abdominal hernia s/p surgery -hx narcotic abuse, on methadone maintenance Social History: ___ Family History: Sister and son with DM. Physical Exam: On admission: Vitals- 98.0 150/90 79 16 99%RA General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, +systolic murmur Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding GU- no foley Ext- Scar over L lateral pelvis without erythema or drainage; L anterior and lateral thigh, L buttocks, and L lower back tender to palpation; pt unable to actively flex L leg at hip; no pain with passive flexion of L hip; no clubbing, cyanosis or edema; sensation to light touch intact on ___ bilaterally . On discharge: VS: 98.6/97.5 92 148/87 18 96% RA GEN: Seated in chair, mildly uncomfortable ___ pain HEENT: Sclera anicteric, MMM, oropharynx clear RESP: CTABL, no w/r/r CV: RR, S1+S2, systolic crescendo murmur throughout precordium ABD: SNTND, normoactive BS EXT: Scar over L hip well-healing without surrounding erythma, exquisitely tender over L trochanter. NEURO: no sensation to light touch on R lateral thigh, distal strength and sensation intact Pertinent Results: Admission Labs ============== ___ 10:18AM BLOOD WBC-6.5 RBC-3.91* Hgb-11.2* Hct-36.4 MCV-93 MCH-28.6 MCHC-30.7* RDW-17.5* Plt ___ ___ 07:30AM BLOOD WBC-5.0 RBC-3.80* Hgb-11.2* Hct-35.8* MCV-94 MCH-29.5 MCHC-31.3 RDW-17.2* Plt ___ ___ 10:18AM BLOOD Neuts-54.3 ___ Monos-6.4 Eos-2.8 Baso-0.4 ___ 10:18AM BLOOD ESR-63* ___ 10:18AM BLOOD Glucose-104* UreaN-10 Creat-0.8 Na-141 K-3.7 Cl-101 HCO3-32 AnGap-12 ___ 07:30AM BLOOD Glucose-83 UreaN-19 Creat-1.0 Na-136 K-4.4 Cl-100 HCO3-28 AnGap-12 ___ 07:30AM BLOOD CK(CPK)-44 ___ 03:30PM BLOOD CK(CPK)-44 ___ 07:30AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 03:30PM BLOOD CK-MB-3 cTropnT-<0.01 ___ 10:18AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.6 ___ 07:30AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.8 ___ 10:18AM BLOOD CRP-3.0 ___ 07:58PM URINE Color-Yellow Appear-Clear Sp ___ ___ 07:58PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-SM Urobiln-4* pH-6.0 Leuks-TR ___ 07:58PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-4 ___ 07:58PM URINE CastHy-4* ___ 07:58PM URINE Mucous-FEW . . Imaging ======= HIP UNILAT MIN 2 VIEWS LEFT Study Date of ___ 10:29 AM FINDINGS: AP pelvis and multiple views of the left hip were provided. In comparison with the prior exam, there are again noted to be fractures involving the left inferior pubic ramus and left acetabulum, which appears similar in overall alignment from prior exam. The left hip prosthesis is also similarly positioned although given the findings of the acetabular fracture, compromise of the hardware is a strong concern. Please correlate clinically and consider CT to further assess. Alternatively, if there are prior imaging studies to assess the postoperative appearance of this left hip arthroplasty that would be helpful for overall assessment. . TTE (Complete) Done ___ at 3:42:54 ___ The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality due to body habitus. Left and right ventricular systolic function are probably normal, a focal wall motion abnormality cannot be excluded. Mild mitral regurgitation. Unable to assess pulmonary artery systolic pressure. . . Discharge Labs ============== No labs gathered since admission. Brief Hospital Course: ___ with PMH hx IVDU (on methadone), s/p L hip replacement ___ (at ___), HTN, and asthma, with recent admission ___ for hip pain, who presents with worsened L hip pain and R leg numbness. . Acute Issues ============= # L hip pain, R thigh numbness: S/p L hip replacement ___, with reported intermittent severe pain since. Had admission ___ with negative infectious workup including joint fluid and blood cultures. Ongoing pain may be secondary to prior fractures. Secondary gain thought also possible. Infection less likely given no fevers, normal WBC and symptoms similar to prior presentation with negative infectious workup. ESR elevated on admission, but similar to prior. Evaluated by ortho, who did not recommend acute surgical intervention. Pain treated with tylenol and oxycodone. Also continued on home gabapentin. R thigh pain/numbness deemed due to nerve injury that occured in operative period, as has been an issue since that time. Discharged with short course of oxycodone. . # EKG changes: Pt with biphasic T waves in precordial leads on admission. However, lack of chest pain, negative cardiac enzymes, and lack of wall motion abnormalities on echo made acute ischemia/infarction is unlikely. Asymptomatic throughout admission. . # Nausea: Pt reported intermittent nausea for weeks prior to admission. ___ be secondary to opiate use or constipation. Cardiac ischemia considered unlikely, per above. Pt did not have emesis during admission and appeared to have good po intake. Was treated with bowel regimen and discharged with this for duration of oxycodone prescription. . . Chronic Issues ============== # H/o IVDU: Pt denied recent use. On methadone 120mg daily as outpt, which was continued during admission. QTc was not prolonged. . # HTN: Continued on lisinopril and HCTZ. . # Asthma: Stable. Treated with albuterol prn. . . Transitional issues =================== - Please continue to wean off oxycodone as tolerated - Code: Full - Emergency Contact: sister ___ (___) ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Methadone 120 mg PO DAILY 3. Acetaminophen 650 mg PO Q8H:PRN pain 4. Docusate Sodium 100 mg PO BID 5. Polyethylene Glycol 17 g PO DAILY constip 6. Senna 8.6 mg PO BID constip 7. albuterol sulfate 2 puffs inhalation BID prn shortness of breath 8. Gabapentin 300 mg PO TID 9. Lisinopril 20 mg PO DAILY 10. Hydrochlorothiazide 12.5 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. albuterol sulfate 2 puffs inhalation BID prn shortness of breath 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #14 Capsule Refills:0 5. Gabapentin 300 mg PO TID RX gabapentin [Neurontin] 300 mg 1 capsule(s) by mouth three times a day Disp #90 Capsule Refills:0 6. Hydrochlorothiazide 12.5 mg PO DAILY 7. Lisinopril 20 mg PO DAILY 8. Methadone 120 mg PO DAILY 9. Polyethylene Glycol 17 g PO DAILY constip RX polyethylene glycol 3350 17 gram 1 packet by mouth daily Disp #7 Packet Refills:0 10. Senna 8.6 mg PO BID constip RX sennosides [senna] 8.6 mg 1 capsule by mouth twice a day Disp #14 Capsule Refills:0 11. Ibuprofen 400 mg PO Q8H:PRN pain RX ibuprofen 400 mg 1 tablet(s) by mouth q8h:prn Disp #90 Tablet Refills:0 12. Lidocaine 5% Patch 1 PTCH TD QAM RX lidocaine 5 % (700 mg/patch) Apply one patch, remove after 12 hours QAM:prn Disp #30 Unit Refills:0 13. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth q4h:prn Disp #28 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: -L hip pain status/post L hip replacement Secondary: -History of IV drug use -HTN -Asthma 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 to care for you. You were hospitalized due to hip pain. You were evaluated by orthopedics, who did not recommend a surgical intervention. Imaging of your hip was similar to prior imaging. You were given medications for pain control. Please take your medication as prescribed, and attend your follow up appointments. Thank you for allowing us to be part of your care. Followup Instructions: ___
10822122-DS-4	10,822,122	21,384,244	DS	4	2145-10-28 00:00:00	2145-10-30 10:48:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: nuts Attending: ___ Chief Complaint: Hip/back pain status-post fall Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ F with a PMH notable for left total hip arthroplasty ___ and h/o IVDU on methadone, presenting status-post fall off rolling walker earlier today found to have ___. The patient states that she has been home-bound since her last hospitalization over 1 month ago and went out today for the first time. She was heading to the courthouse to watch her sons trial, assisted by her friends. She ascended the courthouse steps and then sat down on her rolling walker at the top of the steps. Her friend then began to roll her walker while the patient was seated, wheels hit a crack in the sidewalk, then patient fell backward hitting her posterior head and left hip. No loss of consciousness. She has had ongoing left sided hip pain that radiates down to her knee as well as exacerbation of her chronic back pain. She also has posterior head pain. No new paresthesias in extremities, no visual changes, no loss of strength, no neck pain. Of note, the patient has a history of frequent hospital admissions for L hip pain control ever since her L hip replacement last fall. She was most recently hospitalized at ___ ___ for pain control, treated with oxycodone 5mg Q4H PRN. She was discharged with a short course but has not had oxycodone since. She continues to take methadone 120mg QAM, as well as gabapentin 300mg TID. She does not take Tylenol at home, but does take ___ tablets of ibuprofen daily as needed for pain. She has not had increased dosing of her ibuprofen lately. She has been staying well hydrated ("I chew ice all day long") and has not had any changes to her diet. No nausea or vomiting lately. No recent illnesses. In the ED, initial vs were: 97.4, 53, 109/67, 20 94% RA. Labs were remarkable for creatinine 2.2 up from baseline 0.9 for which the patient reportedly received 1L NS bolus and also had urinary electrolytes tested. Unclear of the timing between IVF and urine lytes. CBC revealed chronic anemia, slightly worsened thrombocytopenia at 116, normal ___ ct. Patient was given morphine 5mg IV and well as oxycodone 10mg PO 2.5 hours later. Per patient report, she was unable to void on the bedpan, so a Foley was placed. She has not had any difficulty voiding at home recently. Vitals on Transfer: T 98.1, HR 54, RR 16, BP 116/64, O2 96% RA, pain ___. On the floor, VS were: T 98.4 P 55 BP 111/72 R 20 O2 sat 100% RA. The patient is asking for pain medication. Past Medical History: -Arthritis s/p L hip replacement ___ -HTN -Asthma -Blind in R eye secondary to trauma -Chronic back pain -Abdominal hernia s/p surgery -hx narcotic abuse, on methadone maintenance since ___. ___ clinic at ___, on RN home delivery service through ___. -Hepatitis C Social History: ___ Family History: Mom: CAD Dad: deceased, unknown cause Sister: ___, DM Son: DM Physical ___: ADMISSION EXAM: Vitals: T 98.4 P 55 BP 111/72 R 20 O2 sat 100% RA General: Obese ___ female moaning/wincing with every turn in bed, alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, unable to assess JVD given body habitus, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, SEM loudest at ___. Abdomen: obese, soft, non-distended, bowel sounds present, no rebound tenderness, no organomegaly. Tenderness to palpation mostly on left side with voluntary guarding. Pt very jumpy with examination and winces with minimal pressure on skin. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. Trace edema on b/l ankles. Pt has exquisite tenderness to palpation of left hip and grimaces with light palpation of skin. Able to internally and externally rotate hip although she does grimace with external rotation. Skin: No rashes or lesions. Well healed scar on L anterior shin and L hip. Neuro: CN ___ intact. Strength ___ in b/l upper extremities. 4+/5 strength in right knee flex/ext. ___ in left knee flex/ext. ___ strength in plantar flexion and dorsiflexion b/l. DISCHARGE EXAM: Tm 98.5, Tc 98.4, BP 115/75, HR 54, RR 20, O2 100% RA General: Obese woman sitting in bed in NAD Ext: Tenderness to light palpation of left hip, good ROM and 4+/5 strength in left hip strength. Pertinent Results: ADMISSION LABS: ___ 03:30PM BLOOD WBC-6.2 RBC-3.55* Hgb-11.1* Hct-35.9* MCV-101# MCH-31.3 MCHC-31.0 RDW-17.2 Plt ___ ___ 03:30PM BLOOD Neuts-53.8 ___ Monos-4.5 Eos-4.2* Baso-0.7 ___ 03:30PM BLOOD ___ PTT-30.6 ___ ___ 03:30PM BLOOD Glucose-102* UreaN-47* Creat-2.2# Na-137 K-4.4 Cl-103 HCO3-26 AnGap-12 ___ 02:46PM URINE Color-Straw Appear-Clear Sp ___ ___ 02:46PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 02:46PM URINE Hours-RANDOM UreaN-326 Creat-61 Na-78 K-11 Cl-66 ___ 02:46PM URINE Osmolal-323 DISCHARGE LABS: ___ 06:50AM BLOOD WBC-4.2 RBC-3.42 Hgb-10.6* Hct-34.5* MCV-101* MCH-31.0 MCHC-30.7* RDW-17.1* Plt ___ ___ 06:50AM BLOOD Glucose-123* UreaN-41* Creat-1.3* Na-140 K-4.3 Cl-105 HCO3-25 AnGap-14 IMAGING: Lumbo-sacral spine xrays ___: No fracture or malalignment in the lumbosacral spine, noting that the lumbosacral junction is not well assessed due to overlying soft tissues. Pelvis and femur xrays ___: No significant interval change of left total hip arthroplasty with additional orthopedic hardware in place. Left superior and inferior pubic rami and acetabular fractures are all similar when compared to prior without significant callus formation. No acute fracture. Brief Hospital Course: Ms. ___ is a ___ F with a history of left total hip arthroplasty ___ and history of intravenous drug use on methadone, who presented status-post fall off rolling walker found to have prerenal acute kidney injury. ACTIVE DIAGNOSES: # Pre-renal acute kidney injury: Labs on admission were notable for Cr 2.2 up from baseline of 0.9. HCTZ, lisinopril, and ibuprofen were all held. She was treated with 2L normal saline and her creatinine the following day was 1.3. She was sent home with instructions to remain OFF hydrochlorothiazide but to restart lisinopril and to use Tylenol for pain control rather than ibuprofen. She has follow up with her PCP ___ 1 week, at which time repeat Chem-7 should be checked to ensure return to baseline kidney function. # Acute on chronic hip and back pain: The patient had fallen backwards from a seated position off her rolling walker, while a friend was pushing her up an incline. Plain film x-rays in the ED of her L/S spine and left hip were negative for fracture. Her neurologic exam was intact so head imaging was not obtained. Her pain was controlled with standing Tylenol. The patient was instructed to restart lisinopril on discharge, but STOP taking HCTZ and ibuprofen. CHRONIC, INACTIVE DIAGNOSES: # Hypertension: Well controlled, even while holding ACEi and HCTZ. She was discharged OFF of hydrochlorothiazide given her dehydration on admission, but was instructed to restart lisinopril. BP and chemistries should be rechecked by PCP next week. She was continued on aspirin 81mg daily. # Asthma: No exacerbations. She should continue using albuterol as needed. TRANSITIONAL ISSUES: -STOP hydrochlorothiazide -STOP ibuprofen -START acetaminophen 500mg QID:PRN pain -Repeat chem-7 at PCP ___ appt -___ pt to stay well hydrated -Last dose of methadone given 8:00am on ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. albuterol sulfate 2 puffs inhalation BID prn shortness of breath 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 300 mg PO TID 5. Hydrochlorothiazide 12.5 mg PO DAILY 6. Lisinopril 20 mg PO DAILY 7. Methadone 120 mg PO DAILY 8. Senna 8.6 mg PO BID constip 9. Ibuprofen 400 mg PO Q8H:PRN pain Discharge Medications: 1. albuterol sulfate 2 puffs inhalation BID prn shortness of breath 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 300 mg PO TID 5. Methadone 120 mg PO DAILY 6. Senna 8.6 mg PO BID constip 7. Acetaminophen 500 mg PO Q6H:PRN pain 8. Lisinopril 20 mg PO DAILY 9. Outpatient Lab Work Please draw Na, K, Cl, HCO3, BUN, Cr on ___ and fax to Dr. ___ at ___. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: -Acute Kidney Injury -Dehydration -Acute on chronic back and left hip pain SECONDARY: -Hepatitis C -Hypertension -Osteoarthritis status-post left hip replacement -History of narcotic abuse, now on methadone 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 to care for you at ___. You were admitted after falling off your walker. X-rays of your hip and back were normal and did not show breaks in the bones. We treated your pain with Tylenol. Your labwork in the ER showed worsening kidney function. We treated you with IV fluid and your kidneys improved greatly. That means that you were dehydrated, likely worsened by the use of your blood pressure medication called hydrochlorothiazide (HCTZ) and also by the use of ibuprofen. It will be very important for you to drink plenty of fluid throughout the day (At least 8 glasses of water daily). STOP taking hydrochlorothiazide and ibuprofen. Use Tylenol (also called acetaminophen) for pain control instead of ibuprofen. Do not take more than 2000mg of Tylenol per day. Please ___ with your primary care doctor on ___ (see appointment information below). You will need repeat blood work checked at that visit. We wish you all the best, Your ___ Team Followup Instructions: ___
10822122-DS-7	10,822,122	26,296,201	DS	7	2146-07-11 00:00:00	2146-07-11 16:03:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: nuts Attending: ___. Chief Complaint: Left hip pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with history of bilateral hip replacements (___) with multiple admission for hip/back pain following surgery since then, IV drug use currently on methadone maintenance who presents with worsening left hip pain for two days as well as fevers, chills, and sweats. She reports a temperature to ___ yesterday, and despite being afebrile today, has had chills and nightsweats. She reports not having tried anything for pain. She reports being hospitalized at ___ two to three weeks ago for asthma exacerbation and has had some ongoing wheezing. In the ED initial vitals were 98.6 84 166/96 16 96%/RA. Orthopedics was consulted for extreme tenderness on exam; it was felt that the pain was greatest with hip flexion >60 degrees and internal/external rotation thus making it less likely that it was a septic joint. Labs were remarkable for a normal CBC without leukocytosis, normal chemistries, CRP, and UA. The patient was given morphine 5mg and ipratropium-albuterol nebs and admitted for futher evaluation. On the floor, the patient reports ongoing hip pain. Past Medical History: -Arthritis s/p L hip replacement ___ -Hypertension -Asthma -Blind in R eye secondary to trauma -Chronic back pain -Abdominal hernia s/p surgery -Narcotic abuse, on methadone maintenance since ___. ___ clinic at ___, on ___ home delivery service through ___. -Hepatitis C virus Social History: ___ Family History: Mother with CAD. Father (deceased) from unknown cause. Sister with asthma and diabetes and a son with diabetes. Physical Exam: EXAM ON ADMISSION: =================== Vitals: 97.4 89 22 98%RA, patient not tolerating BP measurement GENERAL: NAD, in bed HEENT: NCAT, MMM, poor dentition NECK: Supple without LAD CARDIAC: RRR, S1/S2, SEM at RUSB/LUSB LUNG: Scattered expiratory wheezes, otherwise clear ABDOMEN: Soft, non-tender, non-distended EXTREMITIES: no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII grossly intact MSK: patient refusing MSK exam given discomfort EXAM ON DISCHARGE: ================== Vitals: 98.0, BP 138/84, HR 73, RR 20, 100% RA GENERAL: NAD, in bed HEENT: NCAT, MMM, poor dentition NECK: Supple without LAD CARDIAC: RRR, S1/S2, SEM at LUSB LUNG: CTAB, no wheezes, or rhonci, adequate air movement CTAB ABDOMEN: Soft, non-distended, mild tenderness to palpation diffusely EXTREMITIES: minimal lower extremity edema PULSES: 2+ DP pulses bilaterally MSK: patient with hip pain with abjuction, adduction, flexion on hip; pain with light palpation over left hip Pertinent Results: LABS ON ADMISSION: ================== ___ 11:37PM BLOOD WBC-4.5 RBC-3.47* Hgb-11.8* Hct-35.6* MCV-103* MCH-34.0* MCHC-33.2 RDW-16.5* Plt Ct-97* ___ 09:25AM BLOOD ___ PTT-31.8 ___ ___ 09:25AM BLOOD Glucose-106* UreaN-10 Creat-1.0 Na-139 K-3.4 Cl-101 HCO3-26 AnGap-15 ___ 11:37PM BLOOD CRP-4.3 ___ 11:43PM BLOOD Glucose-120* Na-139 K-3.6 Cl-108 calHCO3-25 ___ 11:43PM BLOOD Hgb-11.8* calcHCT-35 ___ 03:12AM BLOOD SED RATE-PND ___ 12:30AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 12:30AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-TR Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 12:30AM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-4 LABS ON DISCHARGE: ================== ___ CXR: IMPRESSION: In comparison with the study of ___, there again is enlargement of the cardiac silhouette with mild elevation of pulmonary venous pressure. There is suggestion of some coalescence of opacification at the right base, which is not definitely seen on the lateral view. Nevertheless, in the appropriate clinical setting, this could represent a developing consolidation. IMAGING: ======== ___ CTAP IMPRESSION: 1. No acute intra-abdominal process. 2. Mildly prominent distal common bile duct just prior to the ampulla is nonspecific but could be evaluated via MRCP or a nonemergent basis, if hepatobiliary pathology is suggested. 3. Prior left hip fracture with hardware fixation, and total hip arthroplasty. 4. Hepatic steatosis. ___ Hip: IMPRESSION: Status post left hip total arthoplasty and fracture fixation with no sign of hardware complication or new fracture. Brief Hospital Course: ___ ___ history of total left hip arthroplasty ___ with multiple admission for hip/back pain following surgery including recent admissions ___, and ___, distant hx of IVDU currently on methadone maintenance (with concern for narcotic dependence/abuse) who was admitted for recurrent left hip pain. #Acute on chronic left hip pain s/p hip total arthroplasty: Patient initially presented with acute on chronic hip pain. Given patient's report of fever initially on admission there was some concern for septic joint however she did not have leukocytosis, did not have any documented fevers in the hospital and joint exam was not consistent with septic joint. Additionally her CRP level was completely normal. X-ray of her left hip and pelvis did not show any evidence of fracture or hardware complication She was seen by orthopedics consult service who felt her exam was not consistent with septic joint and recommended against arthrocensis or other imaging. She was asked to follow up in the speciality orthopedics clinic for further management. For pain control she was treated with ibuprofen, tylenol, lidocaine patch and her home methadone dose. She was also treated with oxycodone 5 mg Q8 hours as needed for pain as well as ultram 50 mg Q6 hours PRN for pain as these were her home medications prescribed for limited amount of time by her PCP. ___ worked with that patient while in the hospital and felt she was back at her baseline prior to discharge. She was discharged with limited 5 day supply of oxycodone and ultram to continue until follow up with her PCP for further determination of pain regimen at that time. In addition orthopedics follow up with Dr. ___ scheduled. # COPD # Acute on chronic COPD: likely triggered by acute bacterial pneumonia # Pneumonia: Acute bacterial pneumonia likely health care associated Patient developed cough and shortness of breath during hospital course with diffuse expiratory wheezing and dyspnea in setting of known asthma as well as smoking history. She does not carry a formal history of COPD though presumed based on symptoms and extensive smoking history. CXR obtained showing evidence of focal developing RLL opacity on ___. Patient initially started on treatment for asthma exacerbation however given lack of improvement of symptoms care was escalated to that of COPD exacerbation with addition of azithromycin to inahled ipratropium-albuterol nebulizers and 40 mg PO prednisone for 5 day course. Lastly when CXR revealed developing pneumonia in setting of recent hospitalization within the last few weeks at ___ patient was started on IV ceftriaxone and once clinically improved to PO levofloxacin to complete total 7 day treatment course for HCAP. Patient also continued on inhaled fluticasone throughout hospital course. It was thought that patient would benefit from pulmonary follow up for evaluation and treatment of her COPD and asthma given her recent hospitalizations for this issue. She was started on advair prior to discharge and it was thought that further consideration for starting agent such as tiotropium could be made. #Hypertension complicated by orthostatic hypotension Antihypertensive medications including lisinopril and amlodipine continued. Patient noted to be orthostatic with HCTZ and atenolol so these were held. The patient remained persistently orthostatic by vital signs with endorsement of feeling lightheaded and dizzy with standing so amlodipine was decreased to 5 mg and lisinopril decreased to 20 mg daily. The patient was no longer orthostatic by vital signs prior to discharge. #Mild elevation of pulmonary venous pressure on CXR Patient had noted mild elevation of pulmonary venous pressure on CXR could be indication of underlying COPD/asthma as well as OSA. Ms. ___ had multiple episodes of shortness of breath particularly while sleeping. She did endorse daytime fatigue as well and it was thought that given her body habitus and episodes of shortness of breath particularly while sleeping that she could benefit from OSA work up. #History of IVDU with plan for Methadone Taper Per patient's outpatient notes she is undergoing methadone taper. Per discussion with ___ Healthcare and Habit Opco patient confirmed to be on methadone taper 5mg every week. She is administered methadone by ___ healthcare and prescribed it by habit OPCO. She was tapered to 35 mg methadone dose on ___ with plan to decrease to 30 mg on ___. She was provided with prescription for 5 day supply of methadone. #Constipation Ms. ___ was noted to be constipated during her hospital course in the setting of methadone and oxycodone use as above. She was given senna/colace, miralax, and PO and PR dulcolax that with resolution of her constipation prior to discharge. She was discharged with miralax and senna prior to discharge to prevent constipation in the future. #Tobacco Abuse Patient encouraged to quit smoking in the setting of her recurrent hospitalizations for COPD and asthma exacerbations recently. She was placed on nicotine patch throughout her hospital course. # Code: Full # Emergency Contact: ___ ___ Transitional Issues: ===================== -Medications started during this hospitalization: Advair -Medications stopped or changed during this hospitalization: Lisinopril decreased to 20 mg, amlodipine decreased to 5 mg, atenolol and hydrochlorothiazed stopped. fluticasone stopped (advair started in its place) -Patient started on Advair discus this hospitalization for COPD; consider starting further agents such as tiotropium -Consider restarting patient's atenolol and hydrochlorothiazide pending patient's blood pressure on follow up and resolution of her orthostatic symptoms -Patient noted to be thrombocytopenic from unclear etiology. She should have repeat CBC on follow to assess for stabilization/improvement of her platelet -Methadone taper--should continue with planned taper to decreased at 5 mg each week. Patient's should decrease to 30 mg methadone on ___. -consider need to continue oxycodone 5 mg Q8 hours pending severity of patient's hip pain and ultram 50 mg Q8 hours for pain. Given limited 5 day supply until follow up. -Patient should likely have PFT testing in the outpatient setting for diagnosis and management of her presumed -Consider sleep study for questionable OSA Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Methadone 40 mg PO DAILY 5. Lisinopril 40 mg PO DAILY 6. Acetaminophen 1000 mg PO TID pain 7. Gabapentin 400 mg PO TID 8. CloniDINE 0.3 mg PO BID 9. Tizanidine 2 mg PO TID Discharge Medications: 1. Acetaminophen 1000 mg PO TID pain 2. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath RX albuterol sulfate 90 mcg 1 mcg inhaled every four (4) hours Disp #1 Inhaler Refills:3 3. Citalopram 40 mg PO DAILY 4. CloniDINE 0.3 mg PO BID 5. Docusate Sodium 100 mg PO BID 6. Furosemide 20 mg PO DAILY 7. Gabapentin 300 mg PO TID 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Omeprazole 20 mg PO DAILY 10. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN severe pain RX oxycodone 5 mg 1 capsule(s) by mouth every eight (8) hours Disp #15 Capsule Refills:0 11. TraMADOL (Ultram) 50 mg PO ___ TABS PO TID PRN MODERATE TO SEVERE PAIN moderate to severe pain RX tramadol 50 mg 1 tablet(s) by mouth every eight (8) hours Disp #15 Tablet Refills:0 12. Amlodipine 5 mg PO DAILY RX amlodipine 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:1 13. Aspirin 81 mg PO DAILY 14. Duloxetine 60 mg PO DAILY 15. Methadone 35 mg PO DAILY Will be continued at 35 mg dose until ___ and then decreased to 30 mg. RX methadone 5 mg 7 tablets by mouth once a day Disp #28 Tablet Refills:0 16. Cepastat (Phenol) Lozenge 2 LOZ PO Q4H:PRN cough 17. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID COPD RX fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1 INH inhaled twice a day Disp #1 Disk Refills:3 18. Calcium Carbonate 500 mg PO TID 19. Hydrocortisone Oint 2.5% 1 Appl TP BID 20. LOPERamide 2 mg PO 2 CAPS INITIALLY THEN 1 CAP PO AFTER EACH LOOSE STOOL UP TO 8 MAX DAILY 21. Naproxen 500 mg PO Q12H 22. Lisinopril 20 mg PO DAILY RX lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:1 23. Vitamin D 1000 UNIT PO DAILY 24. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 [Miralax] 17 gram/dose 17 grams by mouth once a day Refills:2 25. Senna 8.6 mg PO BID:PRN constipation RX sennosides [___] 8.6 mg 1 tab by mouth twice a day Disp #60 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Chronic obstructive pulmonary disease exacerbation Asthma Healthcare Associated Pneumonia Orthostatic hypotension Secondary: Hypertension Arthritis s/p L hip replacement ___ Blind in R eye secondary to trauma Chronic back pain Abdominal hernia s/p surgery Narcotic abuse, on methadone maintenance since ___. ___ clinic at ___, on RN home delivery service through ___. Habit OPCO prescribes methadone Hepatitis C virus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure being involved in your care. You were admitted to the hospital for hip pain. Our evaluation of the hip did not show any evidence of new injury, fracture, or infection. You were noted to have shortness of breath and difficulty breathing and were treated for worsening of your chronic obstructive pulmonary disease (COPD) from longtime smoking and asthma. We also felt that you were in the early stages of developing a pneumonia so we treated you with antibiotics. We strongly recommend that you quit smoking to prevent future infections in your lungs and the need to be hospitalized. We started you on an inhaler called Advair that is very important for you to take every day regardless of if you feel short of breath. Your blood pressure was low and you also had dizziness with standing. Because of this we decreased your blood pressure medications to lisinopril 20 mg and amlodipine 5 mg. We stopped your medications for blood pressure called atenolol and hydrochlorothiazide. Sincerely, Your ___ Team Followup Instructions: ___
10822193-DS-20	10,822,193	23,542,322	DS	20	2178-11-15 00:00:00	2178-11-19 08:33:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: fever, pain Major Surgical or Invasive Procedure: ___: Cystoscopy, Left Ureteral Stent Placement, Left Retrograde Pyelogram History of Present Illness: ___ with left side 0.9mm obstructing left proximal ureteral stone with sepsis now s/p urgent cystoscopy, Left Ureteral Stent Placement, Left Retrograde Pyelogram Past Medical History: Two prior C-sections Social History: ___ Family History: No Family History currently on file. Physical Exam: WdWn female, NAD, AVSS Interactive, cooperative Abdomen soft, Nt/Nd Flank pain improved Lower extremities w/out edema or pitting and no report of calf pain Pertinent Results: ___ 07:45AM BLOOD WBC-12.1* RBC-3.76* Hgb-10.8* Hct-34.5 MCV-92 MCH-28.7 MCHC-31.3* RDW-12.7 RDWSD-42.0 Plt ___ ___ 06:02AM BLOOD WBC-14.9* RBC-4.04 Hgb-11.6 Hct-36.1 MCV-89 MCH-28.7 MCHC-32.1 RDW-12.7 RDWSD-41.3 Plt ___ ___ 12:30AM BLOOD WBC-17.6* RBC-4.31 Hgb-12.4 Hct-38.1 MCV-88 MCH-28.8 MCHC-32.5 RDW-12.5 RDWSD-40.7 Plt ___ ___ 12:30AM BLOOD Neuts-85.9* Lymphs-7.2* Monos-4.6* Eos-1.4 Baso-0.2 Im ___ AbsNeut-15.14* AbsLymp-1.27 AbsMono-0.82* AbsEos-0.25 AbsBaso-0.04 ___ 07:45AM BLOOD Glucose-98 UreaN-16 Creat-0.9 Na-144 K-4.1 Cl-106 HCO3-24 AnGap-14 ___ 06:02AM BLOOD Glucose-128* UreaN-15 Creat-0.9 Na-146 K-3.9 Cl-109* HCO3-23 AnGap-14 ___ 12:30AM BLOOD Glucose-117* UreaN-19 Creat-1.0 Na-139 K-4.7 Cl-102 HCO3-21* AnGap-16 ___ 5:09 am URINE Site: CYSTOSCOPY LEFT RENAL PELVIC URINE FOR CULTURE. *FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. ~300 CFU/mL. Cefepime MIC OF <=2 MCG/ML test result performed by Microscan. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- S CEFTAZIDIME----------- 4 S CEFTRIAXONE----------- =>64 R CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: Ms. ___ was admitted to urology for nephrolithiasis management with a known 0.9mm obstructing left proximal ureteral stone and presenting with fever, tachycardia; sirs. She was immediately started on IV antibiotics and tolerated the procedure well and recovered in the PACU before transfer to the general surgical floor. See the dictated operative note for full details. Overnight, the patient was hydrated with intravenous fluids and received appropriate perioperative prophylactic antibiotics. On POD1, catheter was removed. At discharge on POD1, patients pain was controlled with oral pain medications, tolerating regular diet, ambulating without assistance, and voiding without difficulty and without fever for over 24hrs. She was explicitly advised to follow up as directed as the indwelling ureteral stent must be removed and or exchanged. Medications on Admission: NONE Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Cephalexin 500 mg PO Q6H Duration: 9 Days RX cephalexin 500 mg ONE capsule(s) by mouth Q6HRS Disp #36 Capsule Refills:0 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg ONE capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 4. Phenazopyridine 200 mg PO TID:PRN bladd pain Duration: 3 Days RX phenazopyridine 100 mg ONE TAB by mouth Q8HRS Disp #9 Tablet Refills:0 5. Senna 8.6 mg PO BID 6. Tamsulosin 0.4 mg PO DAILY RX tamsulosin 0.4 mg ONE capsule(s) by mouth DAILY Disp #30 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: SIRS: fever, + Urinalysis, leukocytosis, pain, tachycardia Surgeon's Preop Diagnosis: Left Ureteral Calculus, obstructing Findings: large left proximal ureteral stone Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent. -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -Do not lift anything heavier than a phone book (10 pounds) -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume your pre-admission/home medications EXCEPT as noted. You should ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. HOLD ASPIRIN and aspirin containing products for one week unless otherwise advised. -IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. For pain control, try TYLENOL FIRST, then ibuprofen, and then take the narcotic pain medication as prescribed if additional pain relief is needed. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -You MAY be discharged home with a medication called PYRIDIUM that will help with the "burning" pain you may experience when voiding. This medication may turn your urine bright orange. -You may be given prescriptions for a stool softener and/or a gentle laxative. These are over-the-counter medications that may be health care spending account reimbursable. -Colace (docusate sodium) may have been prescribed to avoid post-surgical constipation or constipation related to use of narcotic pain medications. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative. -Senokot (or any gentle laxative) may have been prescribed to further minimize your risk of constipation. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks and while Foley catheter is in place. Followup Instructions: ___
10822372-DS-22	10,822,372	22,180,093	DS	22	2195-04-11 00:00:00	2195-04-11 19:23:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Cough, SOB Major Surgical or Invasive Procedure: None History of Present Illness: ___ woman with h/o restrictive lung disease, massive hiatal hernia, reactive airway disease, remote breast ca, HTN, osteoporosis/arthritis, and dementia presents with SOB and cough. the pt is unable to provide significant history because of her dementia. Per her husband and ___ note from ___ clinic yesterday she has had several days of worsening dyspnea, cough and chills. She was sent in from clinic with the concern for pneumonia vs asthma exacerbation. She uses 3L O2 at home intermittently. . In the ED, initial VS: 98.0 107 130/48 26 87% on RA (improved to 95% on 3L nc). Labs revealed WBC of 11.2 w/ left-shift. EKG showed ST at 111, otherwise unremarkable. I reviewed CXR with ED rads resident -> massive hiatal hernia, probably some consolidation lateral to hernia on R; possibly with consolidation/atelectasis/effusion on L as well -> no overt volume overload. In the ED, she was given 125 mg IV methylpred, 1g ceftriaxone, 500 mg azithro, and nebs. . On the floor, VS 98.1 126/68 91 34 (for which she triggered) and 96% on 4L. She speaks in full sentences, does appear tachypneic, but is not in any distress. She is very pleasant, oriented, but has short-term memory loss and repeats questions. She isn't coughing at present. States her diarrhea hasn't been severe or watery. No abd pain at present. . REVIEW OF SYSTEMS: Denies night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, chest pain, abdominal pain, vomiting, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: R breast cancer - stage II, s/p lumpectomy/XRT/tamoxifen x ___ years; off all therapy x ___ yrs Asthma - as a child, reports of 'reactive airway dz' in ___ Restrictive and obstructive lung disease - followed by pulm, on 3L home O2 (FEV1 is 0.39 (49% predicted), FVC 0.56 (39% predicted) with a FEV1/FVC ratio of 0.70.) Glaucoma Large Hiatal Hernia HL Dementia Osteoporosis Arthritis H/O DEEP VENOUS THROMBOPHLEBITIS S/P APPENDECTOMY S/P HYSTERECTOMY S/P TONSILLECTOMY Social History: ___ Family History: Reviewed and noncontributory Physical Exam: ADMISSION EXAM: VS - 97.4 ___ 96-100% on 4L GENERAL - Alert, interactive, tachypneic but not in distress; A&Ox1; repeats questions frequently HEENT - pupils reactive, EOMI, MMM, OP clear NECK - Supple, no JVD, no carotid bruits HEART - RRR, nl S1-S2, harsh ___ systolic murmur heard best at RUSB LUNGS - tachypneic, expiratory wheezes, very poor air movement throughout ABDOMEN - NABS, soft/NT/ND EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout . Discharge Exam: VS - 98.0 118-137/40-56 60-80s 20 93% on 3L UOP 300cc/8hrs GENERAL - Alert, interactive, not in distress; A&Ox1; repeats questions frequently HEENT - pupils reactive, EOMI, MMM, OP clear NECK - Supple, no JVD, no carotid bruits HEART - RRR, nl S1-S2, harsh ___ systolic murmur heard best at RUSB LUNGS - not tachypneic, minimal coarse breath sounds, productive cough, good air movement throughout ABDOMEN - NABS, soft/NT/ND EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout Pertinent Results: ADMISSION LABS: ___ 06:05PM WBC-11.2 RBC-4.09* HGB-12.6 HCT-35.5* MCV-87 MCH-30.7 MCHC-35.4* RDW-13.0 ___ 06:05PM NEUTS-88.9* LYMPHS-6.7* MONOS-4.0 EOS-0.2 BASOS-0.2 ___ 06:05PM PLT COUNT-195 ___ 06:05PM GLUCOSE-126* UREA N-12 CREAT-0.6 SODIUM-140 POTASSIUM-3.5 CHLORIDE-94* TOTAL CO2-36* ANION GAP-14 ___ 06:05PM estGFR-Using this ___ 06:05PM proBNP-188 ___ 06:05PM CALCIUM-9.9 PHOSPHATE-2.7 MAGNESIUM-1.7 ___ 06:12PM LACTATE-1.6 . UA: ___ 10:50PM URINE Color-Yellow Appear-Clear Sp ___ ___ 10:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG . DISCHARGE LABS: ___ 07:45AM BLOOD WBC-10.7 RBC-3.88* Hgb-11.8* Hct-34.0* MCV-88 MCH-30.5 MCHC-34.8 RDW-13.0 Plt ___ ___ 07:45AM BLOOD Glucose-89 UreaN-22* Creat-0.6 Na-144 K-4.6 Cl-99 HCO3-40* AnGap-10 ___ 07:45AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.3 . Micro: ___ Urine legionella negative ___ blood cultures NGTD on discharge . Imaging: ___ ECG: Sinus tachycardia. Non-specific repolarization abnormalities. Compared to the previous tracing of ___ the findings are simlilar. . ___ CXR FINDINGS: Frontal and lateral radiographs of the chest show new opacities in the right mid lung consistent with pneumonia. The pulmonary vasculature is mildly engorged. Evaluation of the lung bases is limited due to low inspiratory lung volumes and a massive but stable hiatal hernia. The lung apices are well aerated without pneumothorax. Rightward deviation of the trachea is unchanged. The mediastinal and hilar contours are within normal limits and unchanged. The cardiac silhouette cannot be assessed. The thoracic spine is kyphotic with severe degenerative changes. Large, dense calcifications are noted in the bilateral breasts, unchanged from diagnostic mammogram of ___. IMPRESSION: 1. Pneumonia of the right lung. 2. Stable massive hiatal hernia. . ___ ECHO The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF 75%). There is no left ventricular outflow obstruction at rest or with Valsalva. Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is mild aortic valve stenosis (valve area 1.7 cm2). The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of ___, mild aortic stenosis is now present. Brief Hospital Course: ___ woman with h/o restrictive and obstructive lung disease, massive hiatal hernia, remote breast ca, HTN, osteoporosis/arthritis, and mild dementia presents with SOB and cough, found to have a PNA. . # Pneumonia: She presented with cough, SOB, elevated WBC count to 13.0, and right sided consolidation on her chest xray. She did not have significant health care exposure so we initiated treatment with ceftriaxone azithromycin for CAP. She did well and was transitioned to cefpodoxime and azithromycin for a planned seven day course. . # Asthma and Restrictive: She has a history of asthma and an ill defined restrictive lung disease that may be related to her massive hiatal hernia. She had prominent wheezing on presentation so she was started on ipratropium and albuterol nebulizers as well as prednisone. Her respiratory status significantly improved prior to discharge. She was continued on her nebulizers and her prednisone will be tapered off slowly (30mg daily for several days until ___, then 20mg for 2 days, then 10mg for 2 days, then off). . # Aortic stenosis: She had a significant ___ murmur loudest at the RUSB that was not previously noted. She underwent an echocardiogram which showed mild aortic stenosis. . CHRONIC ISSUES: . # HTN: continued hydrochlorathiazide 25 mg qday and blood pressures were well controlled. . # Dementia: continued donepezil 10 mg qday. . # GERD: continued omeprazole 20 mg qday. . # HL: continued pravastatin 10 mg qday. . # Osteoporosis: Ca + D continued. . TRANSITIONAL ISSUES: -Blood cultures are pending at time of discharge Medications on Admission: DONEPEZIL [ARICEPT] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth qday FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs(s) inhaled twice a day Rinse mouth after use. To be used with spacer. HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth daily IPRATROPIUM BROMIDE - 0.2 mg/mL (0.02 %) Solution - 1 vial(s) nebulized ___ times daily OLOPATADINE [PATADAY] - (Prescribed by Other Provider) - 0.2 % Drops - once a day OMEPRAZOLE [PRILOSEC] - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth daily PRAVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth daily - No Substitution TRIAMCINOLONE ACETONIDE [NASACORT AQ] - 55 mcg Aerosol, Spray - 2 sprays each nostril daily . Medications - OTC BISACODYL - (OTC) - 5 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth qday as needed for PRN for constipation CHOLECALCIFEROL (VITAMIN D3) - (OTC) - 1,000 unit Capsule - 0.5 (One half) Capsule(s) by mouth daily GLUCOSAMINE-CHONDROIT-VIT C-MN [GLUCOSAMINE CHONDROITIN MAXSTR] - 500-400 mg Capsule - 3 Capsule(s) by mouth daily MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth daily Discharge Medications: 1. donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff Inhalation BID (2 times a day). 3. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation three times a day. 5. olopatadine 0.2 % Drops Sig: One (1) Ophthalmic once a day as needed for Allergy symptoms. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. triamcinolone acetonide 55 mcg Aerosol, Spray Sig: Two (2) Nasal once a day. 9. cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO twice a day for 2 days. Disp:8 Tablet(s) Refills:0 10. azithromycin 500 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. Disp:2 Tablet(s) Refills:0 11. prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day for 7 days: Please take 3 tabs until ___, then 2 tabs for two days, then 1 tab for two days, then stop. Disp:15 Tablet(s) Refills:0 12. dextromethorphan-guaifenesin ___ mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. Disp:50 ML(s) Refills:0 13. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. 14. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: 0.5 Capsule PO once a day. 15. glucosamine-chondroit-vit C-Mn Oral 16. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnoses: Pneumonia Asthma exacerbation Secondary Diagnoses: Asthma Restrictive lung disease Hiatal Hernia Dementia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear ___ was a pleasure taking part in your medical care. You were in the hospital because you had pneumonia. You were treated with IV antibiotics and you got much better. We switched to oral antibiotics. You should continue to take these for two more days. We also started steroids for your asthma. . Medication Recommendations: Please START: -Cefpodoxime for 400 mg twice daily two more days -Azithromycin 500 mg daily for two more days -Albuterol nebulizer every 6 hours as needed for shortness of breath -Guafenesin/dextromethorphan every six hours as needed for cough -Prednisone 30 mg until ___, then 20 mg for two days then 10 mg for two days then stop in the following order: ___: 30mg ___: 30mg ___: 30mg ___: 20mg ___: 20mg ___: 10mg ___: 10mg Followup Instructions: ___
10822532-DS-5	10,822,532	25,566,527	DS	5	2123-02-17 00:00:00	2123-02-17 22:49:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Trauma: fall from ladder L cerebellopontine angle hemorrhage Subgaleal hematoma L ribs fxs ___ tiny L ptx L1-L2 transverse process fx R buttocks hematoma Major Surgical or Invasive Procedure: None History of Present Illness: ___ M h/o CVA w/ RIGHT sided motor deficits on Plavix, HTN, DM was taking down Christmas lights when he fell 10 feet from a ladder. Per report he struck his head and had + LOC. Vomited multiple times at scene. At ___ ED was collared as a precaution. CT scanning revealed a small LEFT cerebelllar-pontine angle hemorrhage for which Neurosurgery was consulted. He also had rib fractures and lumbar spine fractures for which Orthopedics was consulted. Past Medical History: - CVA ___: w/ RIGHT sided deficits: arthralgias, facial droop, hand weakness (s/p LEFT carotid stent, on Plavix) - Seizures - HTN - Type II diabetes Social History: ___ Family History: NC Physical Exam: PHYSICAL EXAMINATION: upon admission: ___ Temp: 96 HR: 103 BP: 200/100 Resp: 26 O(2)Sat: 100% on 2 L Normal Constitutional: General appearance: The patient arrives boarded and collared and is in no acute distress. The GCS is 15. Head: The scalp shows a small occipital laceration. HEENT: The extraocular muscles are intact and the pupils both constrict to light. Neck: There is no C-spine tenderness or step off. Upper extremities: The upper extremities show no trauma. Thorax: The chest wall is nontender. Lungs: The lungs are clear and symmetrical. Heart: The heart sounds are crisp. Abdomen: soft, scaphoid, and nontender. Spine: There is no thoracic or lumbar spine tenderness. Hips and pelvis: The pelvis is stable and the hips are nontender. Lower extremities: no long bone signs but he has deep abrasions on both anterior knees. Back: NT Neurological: The patient moves all 4 extremities equally but is weak on the right (which is old). Physical examination upon discharge: ___ vital signs: t=98, hr=72, bp=142/67, room air sat 97% room air General: Reclining in bed, NAD CV: Ns1, s2, -s, -s4 LUNGS: clear ABDOMEN: soft, non-tender EXT: feet cool, + dp bil, no calf tendernes bil SKIN: Ecchymotic area right hip, abrasions knees bil. NEURO: speech slow, slurred, alert and oriented x 3, no tremors Pertinent Results: CONSULTS: - Neurosurgery: no emergent neurosurgical intervention; reviewed repeat head CT with no acute changes - Ortho/spine re L1-2 transverse process fx: corset for comfort. No weight bearing or activity restrictions ___ 05:00AM BLOOD WBC-7.3 RBC-3.46* Hgb-10.2* Hct-29.4* MCV-85 MCH-29.5 MCHC-34.7 RDW-14.7 Plt ___ ___ 06:00PM BLOOD Hct-30.0* ___ 10:47AM BLOOD Hct-29.8* ___ 01:00PM BLOOD WBC-14.4* RBC-4.57* Hgb-14.1 Hct-39.5* MCV-87 MCH-30.9 MCHC-35.8* RDW-14.5 Plt ___ ___ 05:00AM BLOOD Plt ___ ___ 05:00AM BLOOD ___ PTT-26.7 ___ ___ 11:47PM BLOOD ___ ___ 05:00AM BLOOD Glucose-100 UreaN-18 Creat-1.0 Na-138 K-4.5 Cl-104 HCO3-25 AnGap-14 ___ 05:00AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.0 ___: head cat scan: Tiny focus of extra-axial hemorrhage in the left cerebellopontine angle. Large posterior subgaleal hematoma with soft tissue laceration. No acute fracture. Old areas of encephalomalacia in the left ACA and MCA territories. ___: cat scan of the c-spine: IMPRESSION: Degenerative changes as stated with small disc osteophytes indenting the thecal sac. No acute fracture or malalignment. Left carotid stent in place. ___: cat scan of the abdomen and pelvis: IMPRESSION: 1. Large hematoma in the right low back/buttock region with active bleeding. 2. Acute fractures in the left posterior rib cage at ribs 9 through 12, segmental at the twelfth rib. Tiny associated left pneumothorax and left low lung contusion. 3. Fractures involving the left L1 and L2 transverse processes, non-displaced. ___: cat scan of the head: IMPRESSION: 1. Previously seen tiny focus of hemorrhage in the left cerebellopontine angle is not well visualized on this exam and may be due to evolution of blood. No evidence of new hemorrhage. No new acute infarction. 2. Old area of encephalomalacia in the left frontal brain is unchanged. ___: chest x-ray: FINDINGS: In comparison with study of ___, there is little change in the appearance of the heart and lungs. No evidence of pneumothorax, acute pneumonia, or vascular congestion. On this study and the prior one, there appears to be some narrowing of the tracheal air column at the level of the clavicles. This raises the possibility of true tracheal narrowing. Ifthere is no clinical explanation for this appearance, CT of the trachea could be considered. Brief Hospital Course: ___ year old gentleman admitted to the acute care service after falling off a ladder and stricking his head. Upon admission, he was made NPO, given intravenous fluids, and underwent radiographic imaging. The head cat scan showed a bleed in the cerebellopontine angle. He also sustained left sided ___ rib fractures, a left L1-L2 transverse process fracture, and a tiny left pneumothorax. As a result of the fall, he also sustained a buttock hematoma. Because of his injures, the Neurology and orthopedic services were consulted. Neurosurgery recommended neurological assessments and a repeat head cat scan. Orthopedics recommended a corset for comfort for the L1-L2 transverse process fracture. He was admitted to Trauma-SICU overnight for monitoring of his vital signs and neurological assessment. Because of the buttocks hematoma, his hematocrits were followed and found to be stable. Per neurosurgery recommendations, he underwent a repeat head CT the morning after admission to follow any change in the cerebellar-pontine angle hematoma; there was no change and they were in agreement with restarting the patient's Plavix. He was mentating appropriately and restarted on his oral home medications as well as oral pain control. He was felt to be stable for transfer out to the surgical floor on HD#2. He was transferred to the surgical floor on HD #2. Social services met with his family and provided support. His vital signs are stable. His hematocrit has stabilized at 29. His oxygen saturation has been stable at 98% on room air. He is tolerating a regular diet. He was evaluated by physical and occupational therapy and recommendations made for discharge home with ___ services. He was dischaged home with planned follow-up in the acute care clinic. Of note: CXR did show narrowing of trachea, at the level of the clavicle, no resp. compromise noted. Primary care provider ___. Medications on Admission: - plavix 75mg daily - keppra 500mg bid - metformin 850mg bid - citalopram 40mg daily - viagra 50mg PRN Discharge Medications: 1. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 4. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours): may cause drowsiness, avoid driving while on this medication. Disp:25 Tablet(s) Refills:0 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): ___ monitor blood sugars. 8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: hold for loose stools. 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 11. Lipitor 80 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home With Service Facility: ___ ___: Trauma: fall L cerebellopontine angle hemorrhage Subgaleal hematoma L ribs fxs ___ tiny L ptx L1-L2 transverse process fx R buttocks hematoma Discharge Condition: Mental Status: Clear and coherent ( speech slow) Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after you fell off a ladder. You did hit your head and sustain loss of consciousness. You sustained a small bleed in your head, rib fractures, fractures of parts of your spinal column, and a collapsed left lung. You also sustained a bruise to your right buttock. You were monitored in the intensive care unit after your fall. You were seen by the Spine and Neurology service. You did not require any surgery for your injuries. You are now preparing for discharge home with the following instructions: Your injury caused left sided rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ) Please report: shortness of breath difficulty breating chills/sweats congested cough Please report: increased pain and swelling right buttock weakness *dizziness Please apply bacitracin ointment to the abrasions on your knees daily and as needed ___ wear corset for comfort Followup Instructions: ___

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