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10822967-DS-14
| 10,822,967 | 23,415,665 |
DS
| 14 |
2110-11-05 00:00:00
|
2110-11-05 14:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
SOB, PE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH of Stage IIIC testicular tumor (substantial component of
choriocarcinoma as well as yolk sac and teratoma w/ CNS mets,
s/p
Left radical orchiectomy and 4 cycles BEP), who presented with
SOB, found to have PE on outpatient staging scans, admitted for
trial of anticoagulation given high risk of bleeding
As per review of notes patient has had improvement in malignant
burden with chemotherapy, on re-staging scans done on day of
admission, which incidentally identified PE, ? of right atrial
thrombus, and iliac thrombi concerning for ___ syndrome.
Patient was referred to ED afterward, for STAT imaging and
discussion of anticoagulation.
In the ED, initial VS were: 97.1 109 132/82 16 100% RA. WBC 3.3,
Hgb 10.2, plt 490, BNP 46, Trop <0.01, coags/chem wnl, UA with
high specific gravity, but few bacteria.
CT head with IV contrast revealed decrease in size of right
frontal lesion and no large hemorrhage. As per discussion with
Dr
___, patient is at risk for bleeding given known hemorrhage
seen on MRI from ___. In taking into account patient's
significant clot burden, Dr ___ that the benefits of
anticoagulation exceed the risks, and therefore warranted
anticoagulation. In order to minimize risk of bleeding,
recommended more narrow therapeutic range and no boluses with
initiation or rate changes to prevent overshooting.
Pt reports that he had periods of immobility ___ malaise with
chemotherapy but no long car rides or flights. He denied tobacco
use. He denied leg swelling or chest pain. He noted that he had
shortness of breath with climbing stairs 2 weeks ago but it has
gradually improved. He noted that he is asymptomatic at rest.
Endorsed palpitations with exertion. Patient noted that he was
without any recent neurologic abnormalities including
vision/hearing changes, gait imbalance, speech abnormalities.
Past Medical History:
PAST ONCOLOGIC HISTORY:
As per last clinic note by Dr ___:
___: Admitted to ___ after developing
symptomatic anemia. Also had approx ___ months of left
testicular
pain and 1 month of headaches. At ___, transfused 4 units
PRBCs, had capsule endoscopy showing jejunal bleeding, and
enteroscopy with clips placed to the lesion. He was planned for
a
bowel resection, but CT torso showed multiple metastases to
lungs
and periaortic lymph nodes as well as a 5.2 cm testicular mass.
Also noted to have a right cephalic vein thrombosis due to
peripheral IV. Transferred to ___.
-___: Admitted to ___. Admission hCG 292,820, AFP 145.9,
LDH 434.
-___: Urgent left radical orchiectomy, path showed
malignant
NSGCT with 40% choriocarcinoma, 30% teratoma, 20% embryonal
carcinoma, and 10% yolk sac tumor, with extensive tumor necrosis
and lymphatic vascular invasion.
-___: CT and MRI head showed dominant right frontal lobe
mass with edema and hemorrhage, suggestion of additional
parenchymal punctate metastases in left parietal lobe vs.
subacute infarct, areas of leptomeningeal enhancement concerning
for metastases, single right temporal bone metastasis and
possible tiny left parietal bone metastasis, acute/subacute
infarct in right parietal lobe.
-___: MRI spine showed possible artifact vs. small LM met
around C6-C7.
-___: Follow-up head CT/MRI showed new punctate right
cerebellar infarction, possibly embolic, increased vasogenic
edema and ongoing hemorrhage, but he remained asymptomatic.
-___: TTE showed possible PFO, which could have allowed
embolism from RUE DVT to brain, but no intra-cardiac thrombi
seen.
-___: C1D1 BEP (bleo 30 units D1,8,15; etoposide 100 mg/m2
D1-5; cisplatin 20 mg/m2 D1-5 of a 21-day cycle)
-___: C2D1 BEP
-___: C3D1 BEP"
PAST MEDICAL HISTORY:
Erupted Wisdom tooth
Testicular cancer as above
Social History:
___
Family History:
Grandmother died ___ liver cancer
Physical Exam:
PHYSICAL EXAM:
Vitals: 98.3 PO 130 / 82 93 20 99 ra
GENERAL: sitting in bed, appears comfortable, smiling,
talkative,
NAD
EYES: PERRLA, anicteric
HEENT: OP clear, MMM, CNII-XII intact without deficits
NECK: supple, normal ROM
LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR, speaks in
full sentences
CV: RRR has systolic murmur at left sternal border, normal
distal
perfusion without edema
ABD: soft, NT, ND, normoactive BS
GENITOURINARY: no foley
EXT: normal muscle bulk/tone, no assymetrical swelling
SKIN: warm, dry, no rash
NEURO: AOx3, fluent speech, CNII-XII intact without deficits,
strength ___ in all extremities, gross sensation intact
throughout, gait normal, pronator drift negative, finger to nose
normal b/l
ACCESS:port in left chest is accessed with dressing c/d/I
PSYCH: Normal mood, insight, judgment, affect
DISCHARGE EXAM
VS: T97.4, BP 114/75, HR95, RR18, 99% RA
GENERAL: sitting in bed, appears comfortable, NAD
EYES: PERRLA, anicteric
HEENT: OP clear, MMM, CNII-XII intact without deficits, moon
facies
NECK: supple, normal ROM
LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR, speaks in
full sentences
CV: RRR has systolic murmur at left sternal border, normal
distal
perfusion without edema
ABD: soft, NT, ND, normoactive BS
EXT: normal muscle bulk/tone, no asymmetrical swelling
SKIN: warm, dry, no rash
NEURO: AOx3, fluent speech, CNII-XII intact without deficits,
strength ___ in all extremities, gross sensation intact
throughout, pronator drift negative, finger to nose fast and
smooth bilaterally
ACCESS: port in left chest is accessed with dressing c/d/I
PSYCH: Normal mood, insight, judgment, affect
Pertinent Results:
ADMISSION LABS
===============
___ 08:14PM BLOOD WBC-3.3* RBC-3.79* Hgb-10.2* Hct-32.1*
MCV-85 MCH-26.9 MCHC-31.8* RDW-16.7* RDWSD-51.3* Plt ___
___ 08:14PM BLOOD Glucose-134* UreaN-12 Creat-0.9 Na-140
K-4.4 Cl-100 HCO3-25 AnGap-15
___ 06:33AM BLOOD Calcium-9.7 Phos-6.3* Mg-1.9
IMPORTANT INTERVAL LABS
========================
___ 12:10AM BLOOD Heparin-0.79*
___ 06:33AM BLOOD HCG-30
___ 07:45AM BLOOD HCG-31
___ 07:48AM BLOOD 25VitD-16*
DISCHARGE LABS
================
___ 05:51AM BLOOD WBC-6.4 RBC-3.79* Hgb-10.1* Hct-32.8*
MCV-87 MCH-26.6 MCHC-30.8* RDW-16.2* RDWSD-51.5* Plt ___
___ 05:51AM BLOOD Glucose-91 UreaN-15 Creat-1.0 Na-145
K-4.7 Cl-106 HCO3-25 AnGap-14
MICRO
====
NONE
IMAGING
========
___ CT abd/pelvis
1. Marked interval decrease size of the in numerous nodules in
the lung bases and the large left para-aortic retroperitoneal
lymph node consistent with disease response. No new or
enlarging metastatic foci.
2. Nonocclusive thrombus within the left common iliac vein and
external iliac vein and a configuration raising concern for
___ syndrome.
3. Postsurgical changes in the subcutaneous tissues of the low
anterior left pelvis, including a 1.7 cm fluid collection, which
could represent a
postoperative seroma or abscess. Correlate clinically for
evidence of
infection.
___ CT chest W/contrast
Pulmonary emboli involving the left upper lobe pulmonary artery
standing into the segmental and subsegmental branches the left
upper lobe and left lower lobe pulmonary artery. Note that this
is not dedicated pulmonary embolism study.
Filling defect also noted within the right atrium concerning for
clot within the atrium. Correlation with echocardiography is
recommended.
Multiple bilateral pulmonary metastasis.
Please refer to dedicated report on abdomen which has been
dictated
separately.
___ CT HEAD
1. Interval decrease in size of peripherally enhancing right
frontal lobe
lesion which measures 2.2 x 2.3 cm on this study, previously
measuring 4.3 x 3.2 cm with decreased surrounding vasogenic
edema. No internal hemorrhagic component is visualized within
this lesion.
2. Previously visualized left parietal and right occipital lobe
lesions are not visualized on the current CT.
3. No acute large territory infarction or intracranial
hemorrhage.
___ TTE
The left atrial volume index is normal. A probable mass is seen
in the right atrium, measuring 0.9 x 1.4 cm (clips 7, 73, 74).
It appears relatively immobile and well-circumscribed. The site
of attachment cannot be determined due to suboptimal image
quality. . Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). The
estimated cardiac index is normal (>=2.5L/min/m2). The diameters
of aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. No mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___, a
probable right atrial mass is seen, as described above
___ ___: Negative
___ MRI Head
1. Interval improvement in the hemorrhagic parenchymal and
suspected
leptomeningeal disease burden from ___ MRI.
2. No interval metastasis are identified.
3. 10 mm enhancing lesion in the right parietal calvarium is
nonspecific and unchanged from prior examinations.
Brief Hospital Course:
___ PMH of Stage IIIC testicular tumor (substantial component of
choriocarcinoma as well as yolk sac and teratoma w/ CNS mets,
s/p Left radical orchiectomy and 4 cycles BEP), who presented
with SOB, found to have PE on outpatient staging scans, admitted
for trial of anticoagulation given high risk of bleeding
#Acute DVT/PE
#Question of ___ Syndrome: On staging CT found PE,
possible of right atrial thrombus, and iliac thrombi concerning
for ___ syndrome. PE was submassive without hemodynamic
abnormalities, trop and BNP wnl. CT head with IV contrast
revealed decrease in size of right frontal lesion s/p
chemotherapy and no large hemorrhage. It was decided given high
clot burden benefits of anticoagulation outweighed risk of
bleeding. He was monitored on heparin with neuro checks without
any significant changes. Repeat MRI brain with interval
improvement in masses and no evidence of recurrent hemorrhage.
He was transitioned to lovenox for anticoagulation. Xa level was
initially supratheraputic and dose was decreased. Repeat anti-Xa
was 0.79. He was felt safe for discharge on lovenox at a dose of
80mg BID
#Right Atrial Mass: CT with evidence of possible right atrial
thrombus. TTE showed non mobile circumscribed mass that was not
typical for thrombus. To better assess mass he was scheduled for
cardiac MRI with contrast to help differentiate as would be
something to follow over time w/response. He will follow up as
an outpatient for cardiac MRI.
#Stage IIIC testicular tumor (substantial component of
choriocarcinoma as well as yolk sac and teratoma w/ CNS mets,
s/p Left radical orchiectomy and 4 cycles BEP)
Staging scans show improvement in malignant burden s/p
chemotherapy. Tumor markers are still elevated. Primary
oncologist Dr. ___ during hospitalization and his
case was discussed during tumor board. He will follow up as an
outpatient for consideration of second line therapies including
TI-CE. Also ongoing discussion with ___ re: potential for SCT
and involvement with rad onc for SRS/CyberKnife. He was
continued on home keppra and PPI. His dexamethasone was tapered
off during hospitalization.
-hcg done on day of admission remains detectable at 31 from 30
on ___ and ___, respectively
#Anemia/Leukopenia
Likely ___ BM suppression in setting of malignancy and
chemotherapy. At time of discharge patient's hbg was stable at
10.
Transitional issues
=====================
#New medications
- Lovenox 80mg BID
- Vitamin D 50,000 given ___
#Medications stopped
- Dexamethasone
- Pantoprazole
[ ] vit D def, given 50,000 units PO vit D ___ x8 to 12 weeks,
follow up at PCP/Primary Onc discretion
[ ] Monitor Weight/renal fuunction as an outpatient, if
increasing or decreasing dramatically would check Xa level and
adjust dose of enoxaparin.
[ ] cardiac MRI as an outpatient to characterize RA mass,
ordered but has not been scheduled yet
[ ] repeat TTE if delay in cardiac MRI at discretion of Dr.
___.
[ ] follow up SRS vs WBRT
#HCP/Contact: mother ___ is his HCP ___
#Code: FULL confirmed on admission
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dexamethasone 0.5 mg PO EVERY OTHER DAY
2. LevETIRAcetam 500 mg PO Q12H
3. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
4. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 80 mg/0.8 mL 80 mg sc twice a day Disp #*60
Syringe Refills:*0
2. LevETIRAcetam 500 mg PO Q12H
3. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
4. Vitamin D ___ UNIT PO 1X/WEEK (FR,SA)
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth weekly Disp #*7 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
==================
Acute Pulmonary Embolism
Right atrial mass
Secondary Diagnosis
======================
Stage IIIC testicular tumor with metastasis to brain
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 ___ at ___.
WHY WAS I IN THE HOSPITAL?
- ___ were in the hospital because imaging found a clot in your
left leg at around the area of the groin which then traveled to
the lung.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- ___ were given a blood thinner called LOVENOX (low molecular
weight heparin) to prevent the clots from getting bigger.
- We performed an ultrasound of the heart called and
Echocardiogram. We found a very small mass within your heart in
the area called the Right Atrium. It is unclear if this
represents part of a blood clot or could be related to your
cancer.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- ___ will be giving yourself these LOVENOX shots twice a day
- ___ will have the level of this medicine in your blood checked
periodically
- ___ will need to have an MRI of your heart to help
characterize the very small mass in your heart. Alternatively,
if this is delayed ___ have a repeat Echocardiogram to
monitor it over time. This will be left to the discretion of Dr.
___.
- Continue to take all your medicines
- Follow up with Dr. ___
- ___ have other follow up appointments which are listed
below
IF ___ DEVELOP NEW HEADACHES, THIS COULD BE A SIGN OF BLEEDING
IN THE BRAIN. CALL YOUR ONCOLOGIST AND DETERMINE THE NEED TO
PRESENT TO THE EMERGENCY DEPARTMENT FOR BRAIN IMAGING.
PLEASE review your medication list as your prescriptions have
changed.
We wish ___ the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10823095-DS-10
| 10,823,095 | 21,083,485 |
DS
| 10 |
2143-02-21 00:00:00
|
2143-02-21 20:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH IDDM, CHF (EF30-35% ___ with pacemaker in place,
sleep apnea, obesity, and Graves Disease presented with nausea,
vomiting, and diarrhea for 3 days. He had URI symptoms one week
ago, then 3 days prior to admission began to have nausea and
vomiting (about 1 episode daily) followed by watery diarrhea
___ episodes daily) no melena/hematochezia. He had 2 episodes
of diarrhea and vomiting night prior to admission and once
morning of admission. Patient reported whole body fatigue and
weakness without chest pain, shortness of breath, swelling of
arms/legs. He works at a hotel and his coworker was sick with a
similar illness but continued to go to work. His sugars have
been running in the 400s despite compliance with ISS. Review of
systems is otherwise negative for abdominal pain or fever. En
route to ED, patient had brief episodes of shortness of breath
lasting less than 5 seconds which quickly resolved without
intervention.
In the ED initial vitals were:
- Labs were significant for VBG 7.4/39, trop <0.01, AG 14, u/a
with glc 1000, ket80, lactate 2.9, WBC 15.2 (differential 88.9)
- Patient was given
___ 10:12 500cc bolus NS
___ 10:12 IV Ondansetron 4 mg
___ 12:54 PO Acetaminophen 1000 mg
___ 12:54 500cc bolus NS
___ 13:19 SC Insulin Lispro 10 UNIT
___ 17:23 SC Insulin Lispro 14 UNIT
___ 17:23 IVF 1000 mL NS 500 mL
Vitals prior to transfer were:
0 98.2 90 111/60 16 100% RA
fs at 1630: 255
On the floor, patient c/o of thirst but otherwise had no
complaints.
Past Medical History:
IDDM
Non ischemic cardiomyopathy, pacer for primary prevention in
___ (EF ___ in ___
chronic systolic CHF
Grave's disease on methimazole
___ cardiac catheterization: no significant CAD
?Sleep apnea
Social History:
___
Family History:
Sister with CABG and another sister with valve replacement.
Mother with heart disease
Physical Exam:
Vitals - 97.8 tm 98.5 110/57 83 16 100%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
moist mm, good dentition
NECK: nontender supple neck, no LAD, flat jvd
CARDIAC: RRR, S1/S2
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, no tenderness throughout, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: grossly intact, moving all extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes. Multiple tattoes, all professional and none recent per
patient
Exam essentially unchanged on discharge
Pertinent Results:
Admission Labs:
___ 09:57AM BLOOD WBC-15.2*# RBC-4.80 Hgb-14.5 Hct-44.7
MCV-93 MCH-30.2 MCHC-32.4 RDW-13.7 Plt ___
___ 09:57AM BLOOD Neuts-88.9* Lymphs-7.3* Monos-3.3 Eos-0.4
Baso-0.1
___ 10:12AM BLOOD ___ PTT-29.1 ___
___ 09:57AM BLOOD Glucose-438* UreaN-29* Creat-1.0 Na-134
K-4.3 Cl-93* HCO3-21* AnGap-24*
___ 09:57AM BLOOD cTropnT-<0.01
___ 09:57AM BLOOD Calcium-10.1 Phos-2.8 Mg-1.8
___ 04:06PM BLOOD ___ pO2-56* pCO2-39 pH-7.40
calTCO2-25 Base XS-0 Intubat-NOT INTUBA
___ 10:03AM BLOOD Lactate-2.9*
Labs on Discharge:
___ 04:52AM BLOOD WBC-8.8 RBC-3.99* Hgb-12.1* Hct-36.9*
MCV-93 MCH-30.4 MCHC-32.9 RDW-13.9 Plt ___
___ 03:27AM BLOOD Neuts-64.0 ___ Monos-6.1 Eos-1.6
Baso-0.2
___ 04:52AM BLOOD Glucose-121* UreaN-22* Creat-0.8 Na-138
K-4.2 Cl-102 HCO3-24 AnGap-16
___ 03:27AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 04:52AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.8
___ 01:51AM BLOOD ___ pO2-185* pCO2-42 pH-7.42
calTCO2-28 Base XS-3 Comment-GREEN TOP
___ 01:51AM BLOOD Lactate-0.9
CXR ___
PA and lateral views of the chest provided. AICD is unchanged
with pacer
pack projecting over left chest wall and lead positioned in the
region of the right ventricle. The cardiomediastinal silhouette
is stable. Lungs are clear. No signs of pneumonia, effusion or
pneumothorax. Bony structures are intact. No free air below the
right hemidiaphragm.
IMPRESSION:
No acute findings.
EKG: Sinus HR103,STE of V1/V2 of 1mm with no reciprocal changes,
LAD, no ST depressions; qtc407. Similar to prior.
Brief Hospital Course:
Mr. ___ is a ___ with a history of non-ischemic
cardiomyopathy EF 35% with PPM, DM2, Graves Disease who presents
with nausea, vomiting, diarrhea and hyperglycemia.
Active Problems:
# Gastroenteritis: 3 days of first n/v, then diarrhea, sick
contact with identical symptoms. Most likely viral
gastroenteritis. Would also consider thyrotoxicosis given h/o
Graves Disease, but less likely as this has been under good
control and symptoms resolved the day after admission. Cardiac
ischemia unlikely as troponin negative x3 and EKG at baseline.
WBC 15 on admission then 8. The morning after admission he was
asymptomatic and tolerating a regular diet.
#Type 2 DM. Last a1c 8.0 ___, c/b retinopathy, uncontrolled on
admission in setting of stress/infection. Received total 24u
insulin in ED for FSG in 400's, then down to 100's overnight.
Started on home lantus and lower dose sliding scale than at home
given readings in 100's. One FSG in 200's prior to discharge.
He was discharged home on his home regimen. He will continue to
check his finger sticks at home and knows to call his PCP if any
readings in the 300's. I spoke with his PCP and ___ arrange
followup with the patient tomorrow or the next day.
Chronic Problems:
# chronic sCHF (LVEF of ___: compensated and does not appear
volume overloaded.
Held diuretics here, will restart on discharge. Maintained on
home BB, spironolactone, losartan.
# Grave's disease. Presented with heart palpitations and fatigue
in ___. TSH was 0.02 with elevated Total T3. Thyroid scan
(___) showed 21.8% homogeneous uptake with TSH 0.03. MMI
since ___. Currently on Methimazole 5 mg qam. Last TFT's
___: TSH 1.15 (.___), t4 8.7(4.5-12.8). Continued
methimazole 5 mg PO DAILY.
# Emergency Contact: ___ (daughter). Her cell phone#
is ___.
Transitional:
- As above PCP ___ arrange followup in ___ days. No changes
to home regimen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Methimazole 5 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Spironolactone 12.5 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. HumaLOG (insulin lispro) 100 unit/mL subcutaneous tid AC
8. Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Losartan Potassium 50 mg PO DAILY
2. Methimazole 5 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Spironolactone 12.5 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Furosemide 40 mg PO DAILY
7. HumaLOG (insulin lispro) 100 unit/mL subcutaneous tid AC
8. Glargine 25 Units Bedtime
Discharge Disposition:
Home
Discharge Diagnosis:
viral gastroenteritis
type 2 diabetes, uncontrolled
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because of nausea, vomiting, and diarrhea.
This was likely from a virus. You should not return to work
until 48 hours after your symptoms have resolved. Your blood
sugar was also high, this was likely caused by the infection.
You should drink plenty of fluids (chicken soup is good) and
because of your high blood sugar you should follow up with your
primary care doctor in the next ___ days.
Followup Instructions:
___
|
10823165-DS-15
| 10,823,165 | 28,177,362 |
DS
| 15 |
2157-01-29 00:00:00
|
2157-01-29 20:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
trauma:
R fronto-parietal SAH
Nasal fracture
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: ___ with hx of chronic alcohol abuse s/p altercation in bar
involving punch to the right face and subsequent fall off bar
stool, hitting back of head on ground with subsequent +LOC.
Event
occurred around 11PM, after 5 alcoholic drinks. Presented to OSH
(___) with initial episode of confusion, vomiting, and
nasal
hematemesis; regained consciousness/awareness around 4am. CT
scan
showed R fronto-temporal SAH as well as potential new C7
transverse process fracture; though CT imaging suggests this is
most likely old, healed injury unrelated to present trauma. Tx
here for neurosurgery and trauma evaluation.
In ___ ED, pt was tachycardic up to 150/160s and tremulous on
initial presentation. Was given 5mg of diazepam with positive
response, HR down to 106 and decreased tremulousness. Currently
primarily complaining of dizziness and coninued nausea; right
eye
pain; tenderness over bridge of nose; right-sided frontal
headache; and left-sided tenderness over bottom ribs.
Past Medical History:
cervical and lumbar HNP; anxiety/panic attacks; PUD; "leaky
valves" followed by cardiologist
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical examination: ___
PHYSICAL EXAM:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck:Hard cervical Collar, Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to
2mm bilaterally. Visual fields are grossly full to
confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger
Physical examination upon discharge: ___:
vital signs:
t=98, hr-87, bp=133/68, rr=18, 96 % room air
General: NAD
HEENT: full EOMI's, sclera anicteric, no cervical
lymphadenopathy
CV: ns1, s2, -s3. -s4
LUNGS: clear
ABDOMEN: soft, non-tender
EXT: no calf tenderness bil., no pedal edema bil., muscle st.
upper ext. +5/+5, lower ext. +5/+5
NEURO: ___ 4mm bil., alert and oriented x 3, speech clear, no
tremors
Pertinent Results:
___ 05:00AM BLOOD WBC-9.9 RBC-5.46 Hgb-15.7 Hct-45.9 MCV-84
MCH-28.7 MCHC-34.1 RDW-14.3 Plt ___
___ 05:00AM BLOOD Glucose-154* UreaN-11 Creat-0.8 Na-140
K-4.6 Cl-103 HCO3-26 AnGap-16
___ 05:00AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___: cat scan of the head:
Unchanged subarachnoid hemorrhage in the right frontotemporal
region. A
possible right temporal intraparenchymal component is also
unchanged.
___: ct of sinus and mandible:
1. Nasal septum fracture with minimal displacement and
rightwards angulation of fracture fragment. Clinical
correlation is recommended.
Brief Hospital Course:
___ year old male admitted to the hospital after he was involved
in an altercation resulting in injuries to his face and head.
Imaging done at an outside hospital showed a right
frontal-temporal SAH, and a nasal fracture. In the emergency
room, the patient was reported to have tachycardia with a heart
rate up to 150/160s. He was given 5mg of diazepam with
effective results. His heart rate decreased to 106 and he became
less tremulous.
He was admitted to the surgical floor where he underwent imaging
of his head which showed an unchanged subarachnoid hemorrhage in
the right frontal-temporal region. Because the patient received
facial bruising, a cat scan of the mandible and maxilla was done
which showed a nasal septum fracture. No immediate intervention
was recommended. The patient was evaluated by Neurosurgery and
placed on a 7 day course of keppra to prevent seizure activity.
His neurological status was closely monitored and he remained
alert and oriented. There was no evidence of tremors.
Out-patient follow- with the Plastic surgery service was
recommended for his nasal fracture. During his hospital stay,
the patient had no difficulty breathing.
In preparation for discharge, the patient was evaluated by
occupational therapy and no cognitive follow-up was indicated.
He was also seen by the social worker who provided him with
out-patient substance abuse programs.
The patient was discharged home on HD #1 in stable condition.
An appointment for follow-up was made with the Neurosurgery
service including a repeat cat scan of the head. No new
injuries were identified on the tertiary examination.
Appointments for follow-up were made with the Neurosurgery and
Plastic surgery service.
Medications on Admission:
Paxil 50mg daily, Clonazepam 0.5mg daily. Omeprazole.
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. ClonazePAM 0.5 mg PO Q8H:PRN anxiety
3. LeVETiracetam 500 mg PO BID
last dose ___
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*13 Tablet Refills:*0
4. Omeprazole 20 mg PO DAILY
5. Paroxetine 20 mg PO QPM
6. Paroxetine 30 mg PO QAM
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma:
right frontal-parietal SAH
Nasal fracture
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted to the hospital after an altercation in which
you were punched in the face. You sustained a small fracture to
your nose and a small bleed in your head. Your cat scan and
vital signs have been stable. You are preparing for discharge
home with the following instructions:
Because of your head injury, please return to the EW with the
following:
*severe headahce
*visual changes
*difficulty speaking
*weakness on one side of your body
*nausea, vomitting
*temperature >101
*drooping in your face
*weakness upper/lower ext
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Followup Instructions:
___
|
10823188-DS-22
| 10,823,188 | 20,163,399 |
DS
| 22 |
2172-06-13 00:00:00
|
2172-06-13 23:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Loose bowel movements
Major Surgical or Invasive Procedure:
Sigmoidoscopy on ___
History of Present Illness:
___ with cerebral palsy, anorexia, depression, asthma presents
with persistent diarrhea.
.
Of note, patient was admitted on ___ for diarrhea with
negative work-up thought to be viral gastroenteritis. C.diff
was negative despite being on Macrobid and 1x dose
ciprofloxacin. Her symptoms improved to a tolerable level prior
to discharge.
.
Since being home, patient reports that the diarrhea persisted
although less in frequency. She has it at least twice a day,
loose, foul-smelling, brown in color. She feels that as soon as
she eat, the food goes right through her and comes out. She has
noticed that she has not been able to take any dairy since this
diarrhea started, because it makes her very bloated and gasy.
She denies recent travel or unusual food. She has never had a
colonoscopy before and there is family history of colon cancer.
Patient is very concerned as she thinks that she has lost about
14 lbs over the last 8 days or so. She said that she tried to
take pepto bismol for the diarrhea, which helps a little bit.
.
Initial VS in the ED: 97.6 80 121/77. Abdominal pain improved
after catheterization. Labs are notable for normal CBC, normal
LFTs, normal chemistry, and negative UA. Patient was given 1 L
NS. VS prior to transfer: 97.6 po, 112/76, 74, 16, 98% RA.
.
On the floor, she reports feeling hungry, but is somewhat afraid
that eating will lead to diarrhea. Has occasional chill and
mild nausea.
Past Medical History:
1) Spastic cerebral palsy since birth, wheelchair bound
2) Asthma
3) Raynaud's syndrome
4) Anorexia/Bulimia
5) Chronic UTIs - patient is straight cathed by aide
6) IBS
7) Eczema
8) H/o osteoporosis?
9) PNA (admitted to ___ for 10 days in ___.
10) Mammoplasty in ___ at ___ c/b ICU stay
Social History:
___
Family History:
Father died of pancreatic cancer at age ___. Mother is ___ and in
federal prison after stealing $20,000 from her. Brother with DM.
Father had heard disease. Also has family history of colon
cancer at old age
Physical Exam:
Physical Exam on Admission:
General: Alert, oriented, slightly uncomfortable
HEENT: Sclera anicteric, mucous membrane dry, 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: cool, 2+ pulses, no clubbing, cyanosis or edema
Neuro: paraplegic, able to move upper extremities.
Physical Exam on Discharge:
VS: T 98.1, BP 116/70, HR 90, RR 18, O2Sat 93% RA, I/O 720/750
Gen: A&Ox3, NAD
HEENT: sclera anicteric, MMM
Neck: supple
Lungs: CTAB, no w/c/r
CV: RRR, normal S1 and S2, no m/r/g
Abd: soft, NT, ND, frequent BS, no rebound, no guarding, no HSM
Ext: cool, 2+ DP pulses, no clubbing or cyanosis or edema
Neuro: paraplegic, ___ contracture (chronic), able to move UE
Pertinent Results:
Labs on admission:
___ 10:04AM BLOOD WBC-5.5 RBC-4.37 Hgb-13.2 Hct-40.4 MCV-92
MCH-30.2 MCHC-32.6 RDW-14.0 Plt ___
___ 10:04AM BLOOD Neuts-59.0 ___ Monos-5.5 Eos-2.2
Baso-0.2
___ 10:04AM BLOOD Glucose-77 UreaN-16 Creat-0.5 Na-143
K-3.8 Cl-104 HCO3-31 AnGap-12
___ 10:04AM BLOOD ALT-14 AST-21 AlkPhos-77 TotBili-0.4
___ 10:04AM BLOOD Lipase-21
___ 10:04AM BLOOD Albumin-4.8
___ 09:50AM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:50AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
___ 09:50AM URINE RBC-0 WBC-5 Bacteri-NONE Yeast-NONE Epi-3
___ 09:50AM URINE Mucous-MANY
___ Stool culture
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
___ blood culture pending
Pertinent Labs:
___ 06:47AM BLOOD IgA-81
___ 06:47AM BLOOD tTG-IgA-3
Labs on discharge:
___ 07:10AM BLOOD WBC-8.2# RBC-3.97* Hgb-11.8* Hct-36.7
MCV-92 MCH-29.7 MCHC-32.2 RDW-14.3 Plt ___
Imaging:
___:
- Abd X ray: An IUD is situated in the mid pelvic region. The
bowel gas pattern is unremarkable though there is moderate fecal
loading in the left hemiabdomen and region of the rectosigmoid.
There is no definite sign of free air along the liver edge on
the left lateral decubitus view. Bony structures are intact.
IMPRESSION:
IUD noted. No signs of ileus or obstruction. Moderate fecal
load in the left colon.
___
- Sigmoidoscopy: Poor preparation, obscuring view of sigmoid
colon.
Mucosa:Normal mucosa was noted in the anus, and rectum. Cold
forceps biopsies were performed for histology at the rectum.
Impression: Normal mucosa in the anus, and rectum (biopsy).
Otherwise normal sigmoidoscopy to proximal sigmoid colon.
Other studies:
___
- Pathology: rectal biopsy, pending
Brief Hospital Course:
___ with cerebral palsy, anorexia, depression, asthma presents
with persistent diarrhea.
# Osmotic diarrhea/loose stool. Based on history, symptom
started after presumed viral gastroenteritis. Since then, she
has been unable to tolerate dairy products and has been having
loose bowel movements associated with eating. She has no travel
history or unusual food ingestion to suggest new infectious
etiology. Her stool cultures have been negative. Malignancy
seems somewhat unlikely given the short course of changes.
Sigmoidoscopy was an unremarkable study but under poor prep as
she declined the tap water enema. Biopsy is pending at this
time. It is possible that she is experiencing a post-viral IBS.
Her IgA and anti-TTG are normal. Patient was instructed to
start a dairy free diet at this time with balking agent and
antimotility agent for symptom control.
# Weight loss. See above for GI work up. Possibly significant
fluid loss given the loose bowel movement and decreased oral
intake given fear of loose bowel movement. Albumin is normal
although half life is long and may not reflect the acute change.
It should be kept in mind that she has history of anorexia
and bulemia, and this needs to be monitored closely in the
outpatient setting.
# Possible vaginal yeast infection. Mild pruritis. Recently
had an yeast infection. No obvious discharge noted on
external exam. Pelvic exam was not performed. Dr. ___
the fluconazole 100 mg daily x 7 days into her regular pharmacy.
She was recommended to have a formal pelvic exam once she
returns to her PCP.
Chronic issue:
# Cerebral palsy. She had a Foley catheter while in the
hospital. She was continued on home diazepam, tizanidine,
nitrofurantoin, doxepine, and tramadol.
Transitional Issue:
# Code status: full
# Pending:
- pathology of the rectal biopsy
- blood culture
# Follow up:
- PCP and ortho (already scheduled prior to this admission)
- patient was recommended to follow up with GI as needed
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Ascorbic Acid ___ mg PO BID
2. Diazepam 15 mg PO Q12H:PRN anxiety, muscle spasm
hold if sedated or RR < 12
3. Tizanidine 6 mg PO TID
4. Sertraline 100 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID PRN SOB,
wheeze
6. Nitrofurantoin (Macrodantin) 100 mg PO DAILY
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing
8. Calcium Carbonate 600 mg PO TID
9. Doxepin HCl 20 mg PO IN AM
10. Doxepin HCl 10 mg PO IN ___
11. HydrOXYzine 25 mg PO TID PRN itchy
12. TraMADOL (Ultram) 100 mg PO TID PRN pain
hold if sedated or RR < 12
13. Vitamin D 400 UNIT PO TID
14. esomeprazole magnesium *NF* 40 mg Oral BID
Discharge Medications:
1. Ascorbic Acid ___ mg PO BID
2. Calcium Carbonate 600 mg PO TID
3. Diazepam 15 mg PO Q12H:PRN anxiety, muscle spasm
hold if sedated or RR < 12
4. Doxepin HCl 20 mg PO AT NOON
5. Doxepin HCl 10 mg PO AT 20:00
6. HydrOXYzine 25 mg PO TID PRN itchy
7. Nitrofurantoin (Macrodantin) 100 mg PO DAILY
8. Sertraline 100 mg PO DAILY
9. Tizanidine 6 mg PO TID
10. TraMADOL (Ultram) 100 mg PO TID PRN pain
hold if sedated or RR < 12
11. Vitamin D 400 UNIT PO TID
12. Loperamide 2 mg PO BID PRN frequent bowel movement
RX *Anti-Diarrhea 2 mg 1 tab by mouth twice a day Disp #*60
Tablet Refills:*0
13. Esomeprazole Magnesium *NF* 40 mg ORAL BID
14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID PRN
SOB, wheeze
15. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing
16. Psyllium Wafer 1 WAF PO DAILY
RX *Metamucil 1 tab by mouth daily Disp #*30 Tablet Refills:*0
17. Fluconazole 100 mg PO Q24H Duration: 7 Days
Dr. ___ will call this in for you.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
- Osmotic diarrhea
- Weight loss
Secondary diagnoses:
- cerebral palsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___
because of persistent diarrhea and concern of 14 lb weight loss.
While in the hospital, we resent your stool, which has not
shown any signs of infection. The gastroenterologist performed
a sigmoidoscopy which did not find the cause for your frequent
bowel movement, although the study was not done under proper
preparation. We ask you to avoid dairy at this time given it
seems to cause some of your symptoms. We also ask that you use
a medicine to help slow down the movement of your bowels on an
as needed basis. It will be very important for you to see
gastroenterology in the outpatient setting for further work-up.
Your weight loss may be the result of your recent frequent bowel
movement and decreased intake. It is very important to continue
taking in adequate amount of nutrients to support your overall
health. The medication mentioned above will help to improve
some of your symptoms. If you continue to lose weight despite
the management of your frequent bowel movement, you will need to
seek additional assistance from your primary care physician.
Please note the following changes to your medications:
- Start loperamide. This will help to slow down your bowel
movements.
- Start metamucil. This will help to bulk up the stool and
prevent loose stool.
- Start fluconazole. Dr. ___ will call it in for you for the
possible yeast infection.
Followup Instructions:
___
|
10823188-DS-26
| 10,823,188 | 21,810,634 |
DS
| 26 |
2174-12-15 00:00:00
|
2174-12-16 09:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / ciprofloxacin
Attending: ___.
Chief Complaint:
cough, fevers, myalgias, malaise
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ presenting from home with fever, cough, dyspnea, myalgias.
Symptoms began yesterday. States she is not tolerating p.o.'s.
Fever to 101 at home. She denies nausea, vomiting, or diarrhea.
She has a chronic indwelling Foley catheter. States she does not
feel safe going home.
She was in ___ for a week checking on her business. She is
the
half owner of ___ there. While in ___ her aide ___
was sick. She returned from ___ on the ___ and began feeling
sick 2 days ago. + Cough x ___ days. + fever. + Diffuse body
aches. + Dry heaves. No n/v. Dry cough. + sob. No chest pain. No
slurred speech. No new focal weakness. Increased sensation of
feet being cold. Pt became hypotensive with SBP = 90s after
receiving home medications.
.
In ER: (Triage Vitals: 8 102.1 103 110/71 18 96% RA )
Meds Given:
IVF 1000 mL NS 1000 mL
Acetaminophen 1000 mg
OSELTAMivir 75 mg
IVF 1000 mL NS
Doxepin HCl 10 mg
Naproxen 500 mg
Tizanidine 8 mg
TraMADOL (Ultram) 50 mg
Diazepam 10 mg ___
___ Propionate NASAL ___ Dose
IVF 1000 mL NS 1000 mL
Fluids given: as above 3L
Radiology Studies:___
consults called: none
.
PAIN SCALE: ___ diffuse aches.
Past Medical History:
1) Spastic cerebral palsy since birth, wheelchair bound with
chronic foley
2) Asthma
3) Raynaud's syndrome
4) Anorexia/Bulimia
5) Chronic UTIs
6) IBS
7) Eczema
8) H/o osteoporosis?
9) PNA (admitted to ___ for 10 days in ___.
10) Mammoplasty in ___ at ___ c/b ICU stay
Family History:
Father died of pancreatic cancer at age ___, had CAD. Mother is
___ and in federal prison after stealing $20,000 from her.
Brother with DM. Also has family history of colon cancer at old
age, +family h/o prostate cancer.
Physical Exam:
1. VS T = 98.0 P 76 BP = 120/75 RR 18 O2Sat on ___99% RA_
GENERAL: Thin female laying in bed. She is speaking in full
sentences.
Nourishment: good
Mentation: alert, speaking in full sentences.
2. Eyes: [] WNL
EOMI without nystagmus, Conjunctiva: clear
3. ENT [] WNL
[X] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____
cm
4. Cardiovascular [X] WNL
[X] Regular [] Tachy [] S1 [] S2 [] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[+] Edema RLE 2+
[+] Edema LLE 2+
[X] Vascular access [] Peripheral [] Central site:
5. Respiratory [ X]WNL
[X] CTA bilaterally - limited ability of pt to move
6. Gastrointestinal [ ] WNL
[X] Soft [-] Rebound [] No hepatomegaly [X] Non-tender []
Tender
[] No splenomegaly
[X] Non distended [] distended [] bowel sounds Yes/No []
guiac: positive/negative
Supra-pubic catheter c/d/i
7. Musculoskeletal-Extremities [] WNL
[ ] Tone WNL [X]Upper extremity strength ___ and symmetrical [
]Other:
[ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica
[
] Other:
8. Neurological [] WNL
[X] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN
II-XII intact [X] Normal attention [ ] FNF/HTS WNL []
Sensation
WNL [ ] Delirious/confused [ ] Asterixis Present/Absent [ ]
Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [] WNL
[X] Warm [X] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
10. Psychiatric [] WNL
[X] Appropriate - sometimes she appears suspicious [] Flat
affect
[] Anxious [] Manic [] Intoxicated [] Pleasant [] Depressed []
Agitated [] Psychotic
Pertinent Results:
___ 01:45PM PLT COUNT-223#
___ 01:45PM NEUTS-81.1* LYMPHS-8.7* MONOS-7.8 EOS-2.0
BASOS-0.4
___ 01:45PM WBC-4.3# RBC-3.55* HGB-10.7* HCT-31.2*
MCV-88# MCH-30.1 MCHC-34.2 RDW-14.5
___ 01:45PM estGFR-Using this
___ 01:45PM GLUCOSE-95 UREA N-9 CREAT-0.5 SODIUM-133
POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-25 ANION GAP-15
___ 02:00PM OTHER BODY FLUID FluAPCR-POSITIVE *
FluBPCR-NEGATIVE
___ 02:01PM LACTATE-1.0
___ 02:01PM ___ COMMENTS-GREEN TOP
___ 02:40PM URINE RBC-1 WBC-7* BACTERIA-FEW YEAST-NONE
EPI-0
___ 02:40PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
___ 02:40PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:40PM URINE GR HOLD-HOLD
___ 02:40PM URINE UHOLD-HOLD
___ 02:40PM URINE HOURS-RANDOM
___ 02:40PM URINE HOURS-RANDOM
___ 3:57 pm URINE TAKEN FROM ___.
URINE CULTURE (Preliminary):
ENTEROBACTER AEROGENES. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
CITROBACTER FREUNDII COMPLEX. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER AEROGENES
| CITROBACTER FREUNDII
COMPLEX
| |
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 8 I <=1 S
CEFTRIAXONE----------- 8 R <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
OTHER BODY FLUID VIRAL, MOLECULAR FluAPCR FluBPCR
___ 14:00 POSITIVE *1 NEGATIVE
Brief Hospital Course:
___ with hx of 1) Spastic cerebral palsy since birth, wheelchair
bound with chronic foley 2) Asthma 3) Raynaud's syndrome
4)Anorexia/Bulimia 5) Chronic UTIs 6) IBS who presented from
home with fever, cough, dyspnea, myalgias. Fever to 101 at
home. She denies nausea, vomiting, or diarrhea. She has a
chronic indwelling Foley catheter. She was in ___ for a week
checking on her business. She is thehalf ___ of ___
there. While in ___ her aide ___
was sick. She returned from ___ on the ___ and began feeling
sick 2 days prior to presentation. + Cough x ___ days. + fever.
+ myalgias. In ER: 102.1 103 110/71 18 96% RA. Found to have
flu positive PCR. Given fluids, oseltamivir, nsaids, and home
meds. UA and cx sent, blood cx sent. CXR negative. Admitted.
.
INFLUENZA
- managed supportively with IVF/NAIDS/APAP
- continued tamiflu for planned 5 dd course
- cxr negative for PNA
Neutropenia (relative and transient) likely due to influenza,
resolved
.
? UTI
followed clinical exam, symptoms, culture data. Given chronic
catheter wanted to ensure true e/o infection not just
colonization prior to treatment - there remained no fruther
fevers from presentation, she remained hemodynamically stable.
There was minimal pyuria on UA (repeated this and culture after
replacement of urinary catheter), she denied dysuria. Suspect
bacterial colonization only (asymptomatic bactiuria), no clinial
evidence on exam or by syptoms of cystitis/UTI.
.
CEREBRAL PALSY
Continued home meds for spasticity
.
ASTHMA: Continued fluticasone
.
DEPRESSION:
continued sertraline 100 mg daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diazepam 10 mg PO Q8H:PRN muscle spasm
2. Doxepin HCl 20 mg PO Q NOON
3. Doxepin HCl 10 mg PO HS
4. HydrOXYzine 25 mg PO BID
5. Naproxen 500 mg PO Q12H
6. NexIUM (esomeprazole magnesium) 40 mg oral BID
7. Sertraline 100 mg PO DAILY
8. Tizanidine 8 mg PO TID
9. TraMADOL (Ultram) 100 mg PO TID
10. zafirlukast 20 mg ORAL BID
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Medications:
1. Diazepam 10 mg PO Q8H:PRN muscle spasm
2. Doxepin HCl 20 mg PO Q NOON
3. Doxepin HCl 10 mg PO HS
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. HydrOXYzine 25 mg PO BID
7. Naproxen 500 mg PO Q12H
8. NexIUM (esomeprazole magnesium) 40 mg oral BID
9. Sertraline 100 mg PO DAILY
10. Tizanidine 8 mg PO TID
11. TraMADOL (Ultram) 100 mg PO TID
12. Acetaminophen (Liquid) 1000 mg PO Q6H:PRN pain/fever
13. zafirlukast 20 mg ORAL BID
14. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat
15. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL ___ mL by mouth every
six (6) hours Refills:*0
16. OSELTAMivir 75 mg PO Q12H
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth twice a
day Disp #*3 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Influenza A
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Ms. ___,
You were admitted due to influenza infection. Your symptoms
improved with treatment. You should rest at home for at least 5
more days as you continue to recover from your infection.
Followup Instructions:
___
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2177-05-22 12:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / ciprofloxacin
Attending: ___
Chief Complaint:
Flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of spastic cerebral palsy who is bedbound
with a chronic Foley, asthma, collagenous colitis and IBS who
presents for fever, left flank pain, suprapubic pain. This
reminds her of prior UTIs. She feels unwell overall. She has
been having increased sediment and cloudy urine. Her visiting
nurse changed the Foley several days ago. She was hypotensive
with EMS and then
improved.
Has had previous hospitalizations here for UTIs, most recently
with pan-sensitively ecoli and klebciella. Hx of
ceftriaxone-resistant enterobacter in ___, as well as multiple
hospitalizations for presumed UTIs with mixed flora.
In the ED, initial vitals were: 98.9, HR 101, BP 123/75, RR 18,
98% RA
- Exam notable for: Mild suprapubic tenderness. Left CVA
tenderness.
- Labs notable for:
*CBC WBC 10.9, Hgb 12.0, Hct 37.4, Plt 357
*lytes
139 / 103 / 4
------------- 100
4.9 \ 22 \ 0.4
Lactate:1.2
*U/a with lg lueks, positive nitr, trace protein, 18 WBCs, few
bacteria
- Imaging was notable for a chest x-ray with no acute
cardiopulmonary process identified.
- Patient was given:
___ 04:29 PO Oxycodone-Acetaminophen (5mg-325mg) 1 TAB
___ 05:03 IVF NS ( 1000 mL ordered)
___ 05:03 IV CefePIME 2 g ___
___ 05:11 PO Oxycodone-Acetaminophen (5mg-325mg) 1 TAB
___ 05:41 IV Vancomycin
___ 08:00 PO TraMADol 50 mg
Upon arrival to the floor, patient reports continued suprapubic
pain as well as neck pain and feeling unwell and feverish.
Denies chest pain, SOB, abdominal pain, n/v. Has had diarrhea
recently,
pt feels this is from her IBS-D.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
1) Spastic cerebral palsy since birth, wheelchair bound with
chronic foley
2) Asthma
3) Raynaud's syndrome
4) Anorexia/Bulimia
5) Recurrent UTIs
6) Collagenous colitis and IBS
7) Eczema
8) H/o osteoporosis
9) PNA (admitted to ___ for 10 days in ___
10) Mammoplasty in ___ at ___ c/b ICU stay
Social History:
___
Family History:
Father died of pancreatic cancer at age ___, had CAD. Mother has
just gotten out of prison after stealing $20,000 from her.
Brother with DM. Also has family history of colon cancer at old
age, +family h/o prostate cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
Vitals: 98.1, 123/82, 85, 17, 94 RA %
General: alert, oriented, appears mildly uncomfortable
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, kurnigs negative
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. Contractures and limited ROM evident in both forearms.
Neuro: CNs2-12 intact, motor function at baseline with
contractures and limited ROM per her CP
Derm: Erythematous, raised area over sacral area, R>L. No broken
skin. Painful to touch.
DISCHARGE PHYSICAL EXAM
=========================
Vitals: 98.9 BP 155/89 HR 77 RR 18 97% on Ra
General: NAD. Appears chronically ill.
HEENT: NC/AT. Sclera anicteric, MMM.
Neck: Supple.
Lungs: Normal respiratory effort. CTAB without wheezes, rales or
rhonchi over anterior chest.
CV: RRR with normal S1 and S2. No murmurs, rubs, or gallops.
Abdomen: Soft, non-distended. Mild TTP over suprapubic region,
improved from yesterday. + Left-sided CVA tenderness.
GU: Foley in place.
Ext: Contractures and limited ROM evident in both arms. RLE is
internally rotated and lengthened (chronic issue). Warm, well
perfused. No erythema or edema.
Neuro: A&Ox3. Motor function is at her baseline, limited by
contractures.
Skin: No obvious rashes.
Mood: Normal mood and affect.
Pertinent Results:
ADMISSION LABS
================================
___ 04:45AM BLOOD WBC-10.9* RBC-4.51 Hgb-12.0 Hct-37.4
MCV-83 MCH-26.6 MCHC-32.1 RDW-15.6* RDWSD-47.3* Plt ___
___ 04:45AM BLOOD Neuts-69.1 ___ Monos-8.1 Eos-1.6
Baso-0.4 Im ___ AbsNeut-7.52*# AbsLymp-2.21 AbsMono-0.88*
AbsEos-0.17 AbsBaso-0.04
___ 04:45AM BLOOD Plt ___
___ 07:07AM BLOOD Glucose-100 UreaN-4* Creat-0.4 Na-139
K-4.9 Cl-103 HCO3-22 AnGap-19
___:07AM BLOOD Calcium-9.5 Phos-4.2 Mg-2.2
___ 04:51AM BLOOD Lactate-1.2
DISCHARGE LABS
================================
___ 08:15AM BLOOD WBC-6.1 RBC-3.92 Hgb-10.4* Hct-33.0*
MCV-84 MCH-26.5 MCHC-31.5* RDW-15.9* RDWSD-48.4* Plt ___
___ 08:15AM BLOOD Glucose-114* UreaN-5* Creat-0.3* Na-144
K-3.6 Cl-107 HCO3-24 AnGap-17
PERTINENT LABS
================================
___ 04:45AM URINE Blood-TR Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 04:45AM URINE Color-Straw Appear-Hazy Sp ___
___ 04:45AM URINE RBC-2 WBC-18* Bacteri-FEW Yeast-NONE
Epi-<1 TransE-<1
MICROBIOLOGY
================================
___ urine culture: Gram negative rods (likely fecal
contaminant)
___ blood culture x2: No growth (final)
STUDIES
================================
Chest X-ray (___): No acute cardiopulmonary process
Brief Hospital Course:
Ms. ___ is a ___ y/o female with a history of spastic
cerebral palsy who is bedbound with a chronic Foley complicated
by recurrent UTIs who presented with fever, left flank pain,
suprapubic pain, and cloudy urine. She was diagnosed with a
urinary tract infection.
#Complicated Urinary Tract Infection: Patient presented with
suprapubic pain and fever. Urinalysis showed positive ___
and few bacteria concerning for UTI. Urine culture grew gram
negative rods, though this may have been a fecal contaminant.
She was started on cefepime (given history of prior resistant
organisms) x 2 days before switching to PO cefpoxodime on
discharge. The patient is scheduled to complete an 8 day course
of cefpoxodime (end date ___.
#Cerebral Palsy / AMS: Patient had an episode of somnolence
while being on her home medications. Her hydroxyzine was halved
to 12.5 mg BID and her tizanidine was also halved to 4 mg TID.
She returned to her baseline cognitive function and did not have
another episode following this change. At discharge, we resumed
her home dosages at the patient's request, though we instructed
her to follow-up with PCP for further discussion.
#Nutrition: Patient seen by nutrition. Supplemental Ensure
Enlive shakes were started.
No other changes were made to her home medications.
Transitional Issues:
====================
[ ] Continue cefpoxodime 200 mg BID x 8 days
[ ] Follow-up on management of multiple sedating medications
# CODE: DNR/ok to intubate (confirmed)
# CONTACT: ___, friend, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diazepam 10 mg PO Q8H:PRN muscle spasms
2. Doxepin HCl 10 mg PO NOON
3. Doxepin HCl 20 mg PO HS
4. Esomeprazole 40 mg Other QPM
5. Esomeprazole 80 mg Other NOON
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. HydrOXYzine 25 mg PO BID
8. LOPERamide 2 mg PO QID:PRN Diarrhea
9. Sertraline 100 mg PO NOON
10. Tizanidine 8 mg PO TID
11. TraMADol 50 mg PO BID:PRN Pain - Moderate
12. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
13. Acetaminophen 650 mg PO Q6H
14. zafirlukast 20 mg oral BID
15. Rivaroxaban 10 mg PO DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H UTI
2. Acetaminophen 650 mg PO Q6H
3. Diazepam 10 mg PO Q8H:PRN muscle spasms
4. Doxepin HCl 10 mg PO NOON
5. Doxepin HCl 20 mg PO HS
6. Esomeprazole 80 mg Other NOON
7. Esomeprazole 40 mg Other QPM
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. HydrOXYzine 25 mg PO BID
10. LOPERamide 2 mg PO QID:PRN Diarrhea
11. Rivaroxaban 10 mg PO DAILY
12. Sertraline 100 mg PO NOON
13. Tizanidine 8 mg PO TID
14. TraMADol 50 mg PO BID:PRN Pain - Moderate
15. zafirlukast 20 mg oral BID
16. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
#Complicated urinary tract infection
Secondary:
#Cerebral palsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why you were here:
- You were admitted due to fever and abdominal pain
- You were diagnosed with a urinary tract infection (infection
in your bladder)
What we did:
- During your hospitalization, you were treated with intravenous
antibiotics (cefepime)
- You also saw a nutritionist who recommended you start ensure
supplement shakes and carnation shakes
What you need to do when you go home:
- Please take the cefpoxodime (antibiotic) 1 tablet two times a
day for 8 more days
- Continue drinking supplemental nutritional shakes
Your medications and follow up appointments are listed below. We
think some of your medications may be making you sleepy. You
should discuss this further with Dr. ___ avoid any sedating
medicines when you are already tired.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
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2170-09-05 16:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Seldane / Synthroid / Ceftin / erythromycin base / codeine
Attending: ___.
Chief Complaint:
Right basal ganglia hemorrhage presented from OSH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with PMH of HTN, hypothyroidism who
was transferred from an OSH for management of acute onset LT
facial droop, hemiparesis, slurred speech and RT gaze preference
in the setting of RT basal ganglia hemorrhage.
Per OSH report patient was in her usual state of health until
about 2:15 pm when she was walking in the yard and slumped over
/ fell to the LT (this was reported as witnessed). Per EMS
witnessed fall with headstrike. On arrival to OSH she was
hypertensive to 160s, found to have significant left sided
paresis, rightward gaze, dysarthria, and a right sided basal
ganglia hemorrhage on imaging.
Past Medical History:
HTN
Hypothyroidism
Social History:
___
Family History:
Non- contributory
Physical Exam:
===============
ADMISSION EXAM:
===============
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck in hard cervical
collar
___: RRR, no M/R/G
Pulmonary: clear anteriorly as patient immobilized
Abdomen: Soft
Extremities: Warm
Neurologic Examination:
MS: Awake, alert, oriented to person and date. Unable to relate
history without difficulty as severely limited by dysarthria.
Attentive, able to name ___ backward without minor difficulty.
Speech is dysarthric but intact repetition, and intact verbal
comprehension. Able to register 3 objects and recall ___ at 5
minutes.
Cranial Nerves: PERRL 3->2.5mm brisk. Blinks to threat
bilaterally. EOM with forced RT gaze deviation. V1-V3 without
deficits to light touch bilaterally. Marked LT facial droop.
Hearing intact to finger rub bilaterally. Tongue midline.
Motor: Normal bulk and tone. No tremor or asterixis. RT upper
and
lower extremities full strength. LT hemiplegia worse in her
upper
extremity (___) than her lower (___)
Sensory: No deficits to light touch, pin, + exinction to DSS.
DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response extensor on LT, Flexor on RT.
Gait deferred.
===============
Discharge Exam:
===============
Essentially unchanged except for improved dysarthria, now
minimal.
Pertinent Results:
Pertinent Labs:
___ 05:06PM BLOOD WBC-10.3* RBC-4.67 Hgb-13.7 Hct-42.1
MCV-90 MCH-29.3 MCHC-32.5 RDW-13.3 RDWSD-43.8 Plt ___
___ 05:06PM BLOOD Neuts-79.9* Lymphs-12.3* Monos-4.8*
Eos-1.9 Baso-0.6 Im ___ AbsNeut-8.22* AbsLymp-1.26
AbsMono-0.49 AbsEos-0.19 AbsBaso-0.06
___ 05:06PM BLOOD ___ PTT-27.0 ___
___ 05:06PM BLOOD Glucose-117* UreaN-19 Creat-0.9 Na-138
K-4.3 Cl-102 HCO3-27 AnGap-13
___ 05:06PM BLOOD ALT-16 AST-22 AlkPhos-127* TotBili-0.3
___:06PM BLOOD Albumin-4.0 Calcium-9.2 Phos-3.0 Mg-2.1
___ 09:12AM BLOOD WBC-9.6 RBC-4.09 Hgb-12.1 Hct-37.2 MCV-91
MCH-29.6 MCHC-32.5 RDW-13.8 RDWSD-45.4 Plt ___
___ 09:12AM BLOOD Glucose-139* UreaN-17 Creat-0.6 Na-135
K-4.2 Cl-100 HCO3-23 AnGap-16
___ 09:12AM BLOOD Calcium-8.4 Phos-4.2 Mg-1.9
Pertinent Imaging:
___ CXR
IMPRESSION:
Compared to chest radiographs since ___, most
recently ___. Persistent peribronchial opacification
at the lung bases could be atelectasis or early pneumonia,
increased since ___. Upper lungs clear. Normal
postoperative cardiomediastinal silhouette. Right pleural
effusions small if any.
CT brain on ___:
IMPRESSION:
1. There is acute parenchymal hematoma centered on right basal
ganglia, stable in size, with mildly more apparent adjacent
edema.
___ CTA Head and CTA Neck
IMPRESSION:
1. Extensive calcified and noncalcified plaque causing severe
stenosis of the cavernous segments of bilateral internal carotid
arteries, right greater than left. There are superimposed areas
of non opacification, which is likely related to severe stenosis
given overall patency distally, and felt less likely to
represent complete occlusion.
2. Severe stenosis of the proximal third of the basilar artery
immediately
distal to the vertebral artery confluence .
3. Slight irregularity of the left M1 segment of the middle
cerebral artery, likely atherosclerotic disease, without
significant stenosis.
4. Moderate stenosis of left vertebral origin.
5. No CT evidence of acute cortical infarction, hemorrhage, mass
effect, or midline shift. However, if there is clinical concern
for an acute cortical infarction, MRI is a more sensitive means
for further evaluation.
6. Nonspecific periventricular subcortical white matter
hypodensities, with a hypodense focus within the left basal
ganglia which may represent prominent perivascular space versus
old lacunar infarct.
7. Small layering bilateral pleural effusions, left greater than
right.
___ CXR
IMPRESSION:
Blunting of the bilateral posterior costophrenic angles suggests
small pleural effusions. No focal consolidation to suggest
pneumonia.
___ ECG
Sinus rhythm. Inferior myocardial infarction, age indeterminate.
Anterior
ST segment elevations, probably due to normal early
repolarization, although ischemia cannot be excluded. Compared
to the previous tracing of ___ segment
elevations are no longer seen which could be consistent with
evolution of an inferior myocardial infarction. Anterior ST
segment elevations are also now less prominent.
___ ECHO
IMPRESSION: Mild regional systolic dysfunction c/w CAD. No
cardiac source of embolism identified.
Brief Hospital Course:
___ is a ___ woman with medical history of HTN and
___ transferred from OSH from management of of acute
onset LT facial droop, hemiparesis, slurred speech and RT gaze
preference in the setting of RT basal ganglia hemorrhage. On
neurologic examination NIHSS of 11. NCHCT with large RT basal
ganglia IPH. Etiology likely hypertensive. She will be
discharged to rehab with stroke neurology follow up in ___.
- We increased her home valsartan from 160 to 240mg daily.
- Scheduled for repeat MRI in 2 months (___)
#Hemorrhagic Stroke
Patient presented from OSH with hemorrhagic stroke seen in R
basal ganglia. Her BP was controlled <160 with Nicardipine gtt
and Hydralazine. Repeat CT on ___ and ___ concerning for
slightly increased surrounding edema w/ bleed stable. Due to
facial weakness, patient required NGT placement on ___ with
tube feed started. Passed swallow evaluation to pureed diet on
___ and video swallow showed no overt aspiration on ___ so
upgraded to ground diet with thin liquids.
#Musculoskeletal
Following fall, patient was placed on C-collar and received
Tylenol for pain control. MRI C-Spine w/o contrast was performed
on ___ due to concern for associated spinal injury. X-Ray of R
ankle was performed on ___
******************
Transitional Issues:
- MRI ordered for 2 months. Please call ___ to schedule
MRI in ~2 months. Approximately ___. Has stroke
neurology follow-up in ___.
- Valsartan increased to 240mg DAILY. Please monitor and ensure
aggressive long-term control of her hypertension.
*******************
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
4. 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
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 160 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Heparin 5000 UNIT SC BID
5. HydrALAZINE ___ mg IV Q6H:PRN SBP < 160
6. Insulin SC
Sliding Scale
Fingerstick q6h
Insulin SC Sliding Scale using HUM Insulin
7. Morphine Sulfate 0.5-1 mg IV Q6H:PRN Pain - Moderate
8. Senna 8.6 mg PO BID:PRN Constipation
9. Valsartan 240 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right Basal Ganglia Hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of left facial droop,
left-sided weakness, and slurred speech resulting from a BRAIN
BLEED in an area of the brain called the basal ganglia. It
results in condition where the blood vessel providing oxygen and
nutrients to the brain are no longer able to do so. The brain is
the part of your body that controls and directs all the other
parts of your body, so damage to the brain from being deprived
of its blood supply can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- High blood pressure
We are changing your medications as follows:
- Increased your valsartan to 240mg per day.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Followup Instructions:
___
|
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2149-07-29 08:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Primary Care Physician: ___
CC: left leg swelling
Reason for admission: Bilateral pulmonary emboli, fever and
tachycardia
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
This is a ___ old Female with PMH significant for obesity
(s/p gastric bypass surgery), hirsutism, ADHD, hypertension,
chronic normocytic anemia and chronic low back pain (on chronic
narcotics) with degenerative disc disease now s/p anterior
lumbar interbody fusion L5-S1 with iliac crest bone graft on
___ and posterior fusion on ___ without complications
now admitted with evidence of venous thromboembolic disease,
fever and tachycardia.
___ notes that since discharge from the hospital following
spinal surgery she has been doing well at home with her parents.
She has been mobilizing with a walker and ambulating
post-surgery. She has had adequate pain control with dilaudid
PO. Her diet as been stable and she had no complaints until ___
days prior to admission when she developed left lower extremity
calf pain that was crampy, achy and dull. This was intermittent
and worse with ambulation. She saw the orthopedic surgery NP on
___ who increased her pain medication. She continued to have
pain in her left calf and was referred for outpatient ___ which
was positive for DVT and she was referred to the ___ ED. She
did not receive prophylactic anticoagulation post-op.
She has no personal history of blood clots, but her father had a
DVT in the past.
ED course:
- initial VS: 101.6 124 112/67 18 100% RA
- Labs notable for WBC 11.6, Hgb 11.6, plt 579; creatinine 0.8
- U/A negative, lactate 3.4 to 2.5, UCG negative; INR 1.1
- Bilateral LENIs and CTA chest obtained
- Blood and urine cx's obtained
- Heparin gtt started with bolus
- Morphine 5 mg IV and acetaminophen 1g PO x 1 given
- Bedside Echo with ? small pericardial effusion per ED staff
- She received 3L NS x 1
- Ortho spine was consulted
On arrival to the MICU, she appears mildly diaphoretic but
stable.
REVIEW OF SYSTEMS: See HPI for pertinent details. Denies fevers
or chills at home; no nightsweats. No headaches or visual
changes. No chest pain or difficulty breathing. No notable upper
respiratory symptoms or cough. Denies nausea and emesis or
abdominal pain. No loose stools or diarrhea, constipation or
other changes in bowel habits. No dysuria or hematuria. No new
rashes, lesions or ulcers. No extremity swelling, athralgias or
joint complaints. No pertinent weight loss or gain, change in
dietary habits.
Past Medical History:
PAST MEDICAL HISTORY:
- Chronic low back pain, sciatica (on chronic narcotics)
- Chronic normocytic anemia
- Seasonal allergic rhinitis
- Obesity (s/p gastric bypass surgery)
- Hirsutism
- Hypertension
- Benign breast lesion
- ADHD
PAST SURGICAL HISTORY:
- Low back surgery (see above)
- Gastric bypass surgery (___)
- Right rotator cuff surgery (___)
- Cholecystectomy (___)
Social History:
___
Family History:
The patient denies a history of premature cardiac disease such
as MI, arrhythmia or sudden cardiac death. Father had an
unprovoked DVT. No family history of clotting disorder. Family
history of colon cancer and testicular cancer in her brother.
Physical Exam:
ADMISSION EXAM
===============
Vitals: 101.2 110/69 107 10 95% RA
General: patient appears in NAD. Appears stated age. Non-toxic
appearing. Mildly diaphoretic.
HEENT: normocephalic, atraumatic. PERRL. EOMI. Oropharynx with
no notable lesions, plaques or exudates. Good dentition. Neck
supple. No lymphadenopathy. No JVP elevation.
___: Sinus tachycardic with normal rhythm. No murmurs, audible
rubs. S1 and S2 noted.
Respiratory: demonstrates unlabored breathing. Clear to
auscultation bilaterally without adventitious sounds such as
wheezing, rhonchi or rales.
Abdomen: soft, non-tender, non-distended with normoactive bowel
sounds; midline abdominal incision is clean, well-approximated
and without erythema or drainage; steristrips on LLQ incision
which is also clean.
Back: midline lumbar incision is clean, well-approximated
without erythema or drainage; no L-spine point tenderness.
Extremities: warm, well-perfused distally; 2+ distal pulses
bilaterally with no cyanosis, clubbing or peripheral edema;
posterior left calf with some pain to palpation; equivocal
___ sign.
Derm: skin appears intact with no significant rashes or lesions
Neuro: alert and oriented to self, place and time. Cranial
nerves II-XII are intact. Normal bulk and tone. Motor and
sensory function are grossly normal. DTRs 2+ throughout. Gait
deferred.
DISCHARGE EXAM:
=======================
VSS, afebrile, mild tachycardia
General: Well appearing female, NAD
HEENT: MMM, NCAT, PERRL, sclera anicteric
CV: regular rhythm, tachycardic, no m/r/g
Lungs: CTAB
Abd: soft, NTP, ND, NABS
Ext: No edema, no erythema, no pain with palpation
Neuro: grossly intact
Pertinent Results:
ADMISSION LABS
===============
___ 05:30PM BLOOD WBC-11.6* RBC-4.08* Hgb-11.6* Hct-34.9*
MCV-86 MCH-28.4 MCHC-33.2 RDW-14.6 Plt ___
___:30PM BLOOD Neuts-74.3* ___ Monos-4.7 Eos-2.5
Baso-0.3
___ 05:30PM BLOOD Plt ___
___ 01:32AM BLOOD ___ PTT-93.6* ___
___ 05:30PM BLOOD Glucose-91 UreaN-8 Creat-0.8 Na-137 K-3.4
Cl-97 HCO3-28 AnGap-15
___ 05:30PM BLOOD cTropnT-<0.01 proBNP-32
___ 05:30PM BLOOD Calcium-9.4 Phos-4.3 Mg-1.9
___ 06:43PM BLOOD Lactate-3.4*
___ 10:17PM BLOOD Lactate-2.5*
DISCHARGE LABS
==============
___ 05:23AM BLOOD WBC-7.6 RBC-3.17* Hgb-8.9* Hct-27.2*
MCV-86 MCH-28.1 MCHC-32.7 RDW-14.4 Plt ___
___ 05:23AM BLOOD ___ PTT-38.1* ___
___ 05:23AM BLOOD Glucose-79 UreaN-7 Creat-0.6 Na-142 K-3.9
Cl-107 HCO3-27 AnGap-12
___ 05:23AM BLOOD Calcium-8.6 Phos-4.6* Mg-2.0
MICROBIOLOGY
=============
___ Blood culture (x 2) - pending
___ Urine culture - pending
ECG (___): Sinus tachycardic to 129 bpm. Normal axis with
normal intervals. S1Q3T3. Low voltage. R-wave progression is
reassuring. No RV strain pattern. TWI noted in lead III. No
ischemic changes.
IMAGING STUDIES
================
___ L-SPINE (AP & LAT) - In comparison with study of ___,
there have been posterior and anterior fusions with interbody
spacer at L5-S1. No evidence of hardware-related complication or
change from previous study.
___ ___ DUP EXTEXT BIL (MAP - Deep vein thrombosis noted
within the left lower extremity from the popliteal vein through
the calf. The thrombus is non-occlusive in the popliteal vein
and
occlusive in the peroneal and posterior tibial veins. No DVT
noted within the right lower extremity.
___ CTA CHEST W&W/O C&RECON - Bilateral pulmonary emboli
most notable involvement the left lower lobe. Small opacities in
the lower lobes could represent atelectasis versus infarction.
No signs of right heart strain.
Echo ___:
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Regional left ventricular wall motion is normal.
Transmitral and tissue Doppler imaging suggests normal diastolic
function, and a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: Normal biventricular regional/global systolic
function. High cardiac index. No clinically significant valvular
abnormalities.
EKG ___: Sinus tachycardia. Poor R wave progression.
Non-specific inferior and precordial T wave flattening. Compared
to tracing #2 the ventricular rate is faster.
CXR ___:
The lung volumes are normal. Normal size of the cardiac
silhouette. Normal appearance of the hilar and mediastinal
structures. Normal structure and transparency of the lung
parenchyma. No opacities, no pleural effusions. No pneumonia, no
pulmonary edema.
Brief Hospital Course:
___ old female with history significant for hypertension,
chronic normocytic anemia and chronic low back pain (on chronic
narcotics) with degenerative disc disease now s/p anterior
lumbar fusion L5-S1 on ___ and posterior fusion on
___ who presented with pulmonary embolism and deep venous
thrombosis, fever and tachycardia.
ACTIVE ISSUES
-------------
# Acute venous thromboembolic disease: The patient presented
several weeks post-spinal surgery with lower extremity DVT and
bilateral pulmonary emboli. Not hypoxemic during admission. No
RV strain or evidence of RV collapse on CTA chest imaging or
echocardiogram. Was started on heparin gtt on admission, then
was transitioned to lovenox and warfarin. Was a provoked DVT
with recent surgery, and thus will need 3 months of
anticoagulation. The patient should take lovenox until her
warfarin is between ___. She should follow up with her PCP and
___ clinic.
# Tachycardia: The patient presented with sinus tachycardia
initially to the 130s-140s. Likely due to PE vs. pleuritic chest
pain. The patient also had a fever intermittently during
admission, which may have contributed. No evidence of infection.
Her thromboembolism was treated as above, she was given IV fluid
boluses, and her pain was controlled with decrease in her heart
rate.
# Fevers: The patient had fevers intermittently during
admission, likely due to thromboembolic disease. No evidence of
infection. No consolidation on chest imaging, negative blood and
urine cultures. Spinal surgery incisions not concerning for
infection. Her fevers were treated with tylenol.
CHRONIC ISSUES:
# Hypertension: The patient's hydrochlorothiazide was held
during admission given hemodynamic concerns. Should follow up
with PCP about restarting.
# Chronic low back pain: Recent spine surgery. Pain was
controlled. Was seen by ___ who recommended discharge home with
___.
# Chronic normocytic anemia: Stable during admission without
bleeding concerns. Had low ferritin levels of 12, and received
one dose of IV iron during admission. Possibly poor absorption
of iron due to gastric bypass. Should follow up with PCP.
TRANSITIONAL ISSUES
====================
- Check INR on ___ and fax results to PCP office and
___ clinic
- Continue anticoagulation for at least 3 months for provoked
DVT
- ___ consider outpatient thrombophilia evaluation
- Ensure age appropriate screening for cancer as outpatient
- Monitor INR for goal ___
- ___ require IV iron infusions for low iron levels and history
of gastric bypass
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 600 mg PO TID
2. Hydrochlorothiazide 25 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H
4. Cyclobenzaprine 5 mg PO Q6H:PRN pain or muscle spasm
5. Docusate Sodium 100 mg PO BID
6. HYDROmorphone (Dilaudid) 8 mg PO Q4H:PRN breakthrough pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Cyclobenzaprine 5 mg PO Q6H:PRN pain or muscle spasm
RX *cyclobenzaprine 5 mg one tablet(s) by mouth Q6hr-prn Disp
#*28 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg one tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
5. HYDROmorphone (Dilaudid) 8 mg PO Q4H:PRN breakthrough pain
RX *hydromorphone 8 mg one tablet(s) by mouth Q4hr-prn Disp #*42
Tablet Refills:*0
6. Outpatient Lab Work
Labs: ___, PTT and INR
ICD9 code: ___.1 Pulmonary embolism
Please fax labs to: ___ ___
and Dr. ___ ___
7. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 5 mg one tablet(s) by mouth daily Disp
#*14 Tablet Refills:*0
8. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 80 cc SC Q12 Disp #*14 Syringe
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pulmonary embolism
DVT
Secondary:
Recent spinal surgery
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your stay. You were
admitted for a blood clot in your leg and in your lung. You were
put on anticoagulation, and will need to be on anticoagulation
for at least three months. You are being discharged on lovenox
and warfarin. You will need to take lovenox until your INR is
between ___. Please have your INR checked on ___ and faxed to
your PCP office at ___. Please follow up with your
primary care physician and the ___ clinic after discharge.
We wish you the best!
Your ___ care team
Followup Instructions:
___
|
10823878-DS-16
| 10,823,878 | 25,032,072 |
DS
| 16 |
2163-03-02 00:00:00
|
2163-03-02 19:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
complete heart block, congestive heart failure
Major Surgical or Invasive Procedure:
Temporary Pacing Wire
Permanent Pacemaker
History of Present Illness:
___ is a ___ year old woman with history of
hypertension, hypothyroid, GERD, anxiety, pneumonia, restrictive
lung disease, coronary artery disease, on Coumadin for atrial
fibrillation who presents with several days of shortness of
breath. She called ___ because of tachypnea to the 30's and ___'s
and was found by EMS to have a peripheral sat in the ___ and RR
in the ___. Placed on CPAP and transported to ___. There
she was found to have a RLL opacity on x-ray and was given
vancomycin and zosyn for recent stays in rehab and . Her BNP was
found to be 2413 and she was given fluid prior to knowledge of
CHF and then 40mg IV Lasix. She was discovered to have a new
RBBB and then Second Degree Type 1 heart block. Finally she had
UA concerning for a UTI. She was then brought to ___ via
medflight.
Of note, she recently had an ED visit ___ for a sudden fall
after feeling weak all over.
In the ED initial vitals were: 99.6 40 155/41 18 96% NIV:
PS 8/ PEEP +5/ FiO2 50%
EKG: complete heart block, atrial rate 84, narrow complex
ventricular rate 40
Labs/studies notable for: no leukocytosis, INR 2.1 on Coumadin,
peripheral VBG 7.34/40/___; trop T 0.04 U/A contaminated
specimen;
Patient was given: 1gm Calcium Gluconate.
In the ED, the repeat EKG was found to have complete heart
block. She was given calcium gluconate to try to counteract her
home calcium channel blockers. Initially on BiPAP she was weaned
to 3lL NC.
Vitals on transfer:
T:99.6, HR:40, BP:155/41, RR:18 O2:96% BiPAP
On arrival to the CCU: Patient confirmed some of the above
history. She appeared stable. Plans for a temporary wire were
put into place.
REVIEW OF SYSTEMS:
Positive per HPI.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- Coronaries - history of prior heart attack
- Pump - Bedside echo shows roughly appropriate EF
- Rhythm - Complete heart block, history of Afib and Lyme
3. OTHER PAST MEDICAL HISTORY
HTN,
Gastro Reflux,
Hyperlipidemia,
Hypertension,
Pneumonia,
anxiety,
HYPOTHYROIDISM ,
LYME,
restrictive lung disease
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T:98.4 BP:138/54 HR:39 RR:16 O2:92% on 3L NC
GENERAL: Well developed, well nourished in NAD. Oriented x2 (did
not not know president or month). Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP elevated to 12cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Bradycardic. Normal S1, S2. No murmurs, rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Crackles Bilaterally.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Cool. No clubbing, cyanosis.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses 1+ palpable and symmetric.
LABS AND MICROBIOLOGY: Reviewed in OMR.
DISCHARGE PHYSICAL EXAMINATION:
VS: AF 130s/160s/60s ___ 93-94% 2LNC
GENERAL: In no acute distress
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. No JVP elevation. Pacemaker site mildly tender,
otherwise cdi, no erythema/swelling.
CARDIAC: RRR. Normal S1, S2. No murmurs, rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Inferior crackles
bilaterally.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: No clubbing, cyanosis.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses 1+ palpable and symmetric.
Pertinent Results:
ADMISSION LABS
=============
___ 09:30PM BLOOD WBC-8.6 RBC-3.68* Hgb-11.0* Hct-34.4
MCV-94 MCH-29.9 MCHC-32.0 RDW-14.6 RDWSD-49.8* Plt ___
___ 09:30PM BLOOD Neuts-66.2 Lymphs-15.1* Monos-15.3*
Eos-1.9 Baso-0.8 Im ___ AbsNeut-5.72 AbsLymp-1.30
AbsMono-1.32* AbsEos-0.16 AbsBaso-0.07
___ 09:30PM BLOOD ___ PTT-36.0 ___
___ 09:30PM BLOOD Glucose-108* UreaN-25* Creat-1.7* Na-140
K-4.6 Cl-106 HCO3-19* AnGap-20
___ 09:30PM BLOOD ALT-24 AST-32 LD(LDH)-214 AlkPhos-49
TotBili-0.3
___ 09:30PM BLOOD TSH-3.8
___ 09:37PM BLOOD ___ pO2-21* pCO2-40 pH-7.34*
calTCO2-23 Base XS--4
___ 09:37PM BLOOD Lactate-1.1
___ 09:37PM BLOOD O2 Sat-30
___ 09:20PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 09:20PM URINE Blood-SM Nitrite-POS Protein-600
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 09:20PM URINE RBC-8* WBC->182* Bacteri-MOD Yeast-NONE
Epi-7
PERTINENT LABS
=============
___ 06:20AM BLOOD ___ PTT-34.8 ___
___ 02:39PM BLOOD Glucose-112* UreaN-22* Creat-1.6* Na-141
K-4.3 Cl-109* HCO3-21* AnGap-15
___ 04:13AM BLOOD Glucose-93 UreaN-20 Creat-1.4* Na-141
K-4.3 Cl-109* HCO3-19* AnGap-17
___ 04:29AM BLOOD Glucose-95 UreaN-15 Creat-1.1 Na-141
K-3.8 Cl-107 HCO3-22 AnGap-16
___ 06:20AM BLOOD Glucose-90 UreaN-16 Creat-1.2* Na-141
K-4.0 Cl-107 HCO3-21* AnGap-17
___ 09:30PM BLOOD cTropnT-0.04*
___ 09:30PM BLOOD TSH-3.8
___ 09:37PM BLOOD Lactate-1.1
STUDIES/IMAGING
==============
CXR ___
FINDINGS:
AP portable upright view of the chest. Elevation of the right
hemidiaphragm
is noted. Lung volumes are low limiting assessment. The mid
upper lungs
appear well aerated. There is lower lung atelectasis. The
heart appears
top-normal in size. The aorta is unfolded and calcified. No
large effusion
or pneumothorax. No overt signs of edema. No convincing
evidence for
pneumonia. Bony structures are intact.
TTE ___
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is ___ mmHg. Normal left
ventricular wall thickness, cavity size, and global systolic
function (3D LVEF = 63 %). The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened (?#). The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild [1+] mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Mild mitral
regurgitation. Mild pulmonary artery systolic hypertension.
Increased PCWP.
CXR ___
FINDINGS:
There is a pacing wire in place with the lead taking a slightly
unusual course
in the right ventricle. There is no pneumothorax. Lung volumes
have
increased however, there is persistent bibasilar atelectasis.
Heart is
top-normal in size. There is no pleural effusion.
IMPRESSION:
Temporary pacing wire lead takes an unusual course in the right
ventricle,
recommend cardiac echo to evaluate its exact position. No
pneumothorax.
EP PROCEDURE ___
Successful implantation of a ___ dual chamber pacemaker
with His-bundle pacing. There were no complications.
CXR ___
IMPRESSION:
Comparison to ___. The external pacemaker was removed.
The patient
has received a permanent left pectoral pacemaker. The leads are
in expected
position. There is no pneumothorax. The lateral radiograph
only shows small
dorsal pleural effusion. No pulmonary edema. Mild fluid
overload. No
pneumonia.
DISCHARGE LABS
=============
___ 07:15AM BLOOD WBC-9.9 RBC-3.47* Hgb-10.1* Hct-32.1*
MCV-93 MCH-29.1 MCHC-31.5* RDW-14.6 RDWSD-49.1* Plt ___
___ 09:30PM BLOOD Neuts-66.2 Lymphs-15.1* Monos-15.3*
Eos-1.9 Baso-0.8 Im ___ AbsNeut-5.72 AbsLymp-1.30
AbsMono-1.32* AbsEos-0.16 AbsBaso-0.07
___ 07:15AM BLOOD ___ PTT-39.6* ___
___ 07:15AM BLOOD Glucose-90 UreaN-14 Creat-0.9 Na-143
K-3.7 Cl-107 HCO3-26 AnGap-14
___ 07:15AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.0
Brief Hospital Course:
Patient is a ___ year old woman with HTN, HLD, hypothyroidsm,
known secondary degree heart block type 1, GERD, HFpEF and
restrictive lung disease who presented with several days of
worsening shortness of breath, found to be in complete heart
block.
# CORONARIES: Clear per most recent cath in ___
# PUMP: EF >55% on ___, 63% on this admisison
# RHYTHM: resolved complete heart block
#COMPLETE HEART BLOCK
#CARDIOGENIC SHOCK
#HISTORY OF LYME DISEASE
Patient with history of lyme and babesia with prior temporary
pacemaker. She may also have age related conduction disease.
From records, it appears as though permanent pacemaker has been
considered for several years and unclear why not placed. Patient
initially presented to OSH in cardiogenic shock, peripheral O2
sat of 30 requiring Bipap, cool extremities. Patient was
transferred to the ___ CCU for monitoring and placement of
temporary pacemaker. Patient remained HD stable s/p placement
of temporary pacemaker. After an infectious work-up (patient
had received broad spectrum abx at OSH for ?PNA , initially was
on 2g CTX until Lyme serologies returned NEG (including IgG),
asymptomatic Ecoli bacteriuria), patient had dual chamber
pacemaker placed by EP without complications. She received 3
days Vancomycin.
#ACUTE RESPIRATORY FAILURE
#ACUTE ON CHRONIC HFpEF (LVEF 63%)
Initially on BiPAP in the ED, likely acute pulmonary edema iso
complete heart block. Resolved upon arrival to the CCU, patient
on 3L NC. Patient continued to improve s/p temorary/permanent
pacemaker placements. TTE ___: Normal biventricular cavity
sizes with preserved regional and global biventricular systolic
function. Mild mitral regurgitation. Mild pulmonary artery
systolic hypertension. Increased PCWP. Patient on Lasix 20mg
daily at home per last discharge summary. Lasix was held
throughout admission given appearance of euvolemia with adequate
pacing.
#UTI
UA showed >182 WBCs, POS Nitrite. Patient, however, denied any
symptoms consistent with cystitis. UCx from ___ showing
Ecoli, sensitivities from last month with Ecoli resistant to
CTX, sensitive to augmentin/macrobid/carbapenem. UCx on this
admission showing similar Ecoli, sensitive to
AMPICILLIN/SULBACTAM. Patient was started on unasyn ___,
plan for 7day course for complicated cystitis. Abx regimen at
time of discharge: augmentin (D1 ___ for 7 day course (last
day ___
___
Patient baseline creatinine 0.9, elevated to 1.7 on admission.
Most likely from poor forward flow in the setting of complete
heart block. Cr improved to baseline with adequate pacing.
#ANTICOAGULATION
Patient on Coumadin, possibly in setting of atrial fibrillation,
notes mentioning Afib at ___. Patient was initially
given ___ (home dose 4mg), decreased to 1.5mg qd given
supratherapeutic INR in setting of ongoing abx.
Chronic Problems
----------------
#HTN
- Increased home amlodipine to 10mg
- Lisinopril initially held iso ___ as above, restarted at 10mg
on discharge.
#HYPOTHYROIDISM
- Continued home levothyroxine
#MOOD DISORDER
-Initially held home paroxetine given prolonged QTc, restarted
at lowered dose (10mg) prior to discharge
#CONCERN FOR PNA
Outside hospital concerned for pneumonia on CXR. Given
vancomycin and zosyn as has had recent rehab stays. Repeat CXR
here read was not concerning. Rapid improvement with Lasix and
lack of fever or white count makes infection less likely.
Patient was treated with CTX transiently for ?lyme, unasyn for
cystitis as above.
TRANSITIONAL ISSUES
=================
[] clarify indication for anticoagulation
[] PPM interrogation if will need continued coumadin
[] increase Paxil as tolerated (started lower dose given qtc
prolongation)
[] needs Coumadin adjusted when finished with abx course.
Recommend daily INR if possible and dosing by level. Discharge
warfarin 1.5mg (was on 4mg warfarin as home dose)
[] QTc on discharge: 494
[] on augmentin for UTI to complete 7 day course (___)
[] On lisinopril at 10mg, titrate up as necessary for HTN
[] Held Lasix on discharge given patient appeared euvolemic. If
patient is gaining weight, consider restarting Lasix 20mg
[] Discharge weight: 65.8kg
# CODE: FULL
# CONTACT/HCP: ___, SON&HCP
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Simvastatin 20 mg PO QPM
2. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
3. PARoxetine 40 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
7. Cyanocobalamin 1000 mcg PO DAILY
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. Potassium Chloride 10 mEq PO DAILY
12. Ferrous Sulfate 325 mg PO BID
13. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation 2
inhilations BID
14. LORazepam 0.5 mg PO QHS:PRN insomnia
15. Warfarin 4 mg PO DAILY16
16. Lisinopril 20 mg PO DAILY
17. amLODIPine 5 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
2. amLODIPine 10 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. PARoxetine 10 mg PO DAILY
5. ___ MD to order daily dose PO DAILY16
6. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
7. Cyanocobalamin 1000 mcg PO DAILY
8. Ferrous Sulfate 325 mg PO BID
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Levothyroxine Sodium 88 mcg PO DAILY
11. LORazepam 0.5 mg PO QHS:PRN insomnia
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Potassium Chloride 10 mEq PO DAILY
15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
16. Simvastatin 20 mg PO QPM
17. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation 2
inhilations BID
18. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until told by your doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
==============
Complete heart block
Complicated cystitis
Secondary Diagnoses
================
Acute kidney injury
Hypertension
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:
Dear ___,
You were admitted to the hospital because you were having
difficulties breathing. You had an electrocardiogram (ECG),
which showed that your heart was beating abnormally due to
blocked conduction (complete heart block). You had a pacemaker
placed in order to maintain your heart rate.
You had a urine test which showed the presence of bacteria. You
received antibiotics to treat this infection. You Coumadin dose
was adjusted while you were on antibiotics.
It is important that you take all your medications and follow-up
with your doctors as listed below.
It was a pleasure taking care of you!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10824195-DS-11
| 10,824,195 | 22,565,229 |
DS
| 11 |
2130-08-13 00:00:00
|
2130-08-22 07:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
LLQ Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
In brief, this patient is a ___ with a h/o chronic DVT's and
PE's from ___ syndrome on warfarin, iliac stents, IVC
filter, pancreatitis, depression, who presented with LLQ pain
for 1 day. Patient was lying down on ___ night (___) when he
noted a gradual onset of ___ LLQ pain. Pain is described as
sharp and radiating to the back. It is made worse by sitting up,
standing, or movement. It is not worsening or getting better.
Patient endorses loss of appetite with diminished PO intake. He
had a bowel movement yesterday morning without change in pain
symptoms. He denies n/v, hematuria, change in urine,
hematochezia, fevers, chills.
Pt was just admitted from ___ for vasovagal event from
LLE pain and was found to be subtherapeutic on his warfarin,
bridged with heparin gtt and discharged to rehab with lovenox
bridge. He required dilaudid and oxycodone during that admission
to control his pain. He initially had improvement in his pain
after leaving rehab and his PCP was starting to wean his
oxycodone. However, his pain acutely worsened 1 day prior to
admission and he presented to the ED. His INR has been
subtherapeutic for the past 2 months.
In the ED, initial vital signs were: 97.9 74 124/87 18 100% RA
- Exam was notable for: negative testicular exam.
- Labs were notable for: INR 2.9, UA negative for infection.
- Imaging: CT abd/pelvis negative for abdominal process but
showing resolution of previously noted thrombus about the IVC
filter and unchanged chronic non-occlusive thrombus within the
left common/external iliac vein stent. LENIs showed nearly
completely occlusive thrombus in the left mid and distal
femoral vein as well as the popliteal and gastrocnemius veins
- The patient was given: 2L NS, morphine 4mg x1, dilaudid 0.5mg
x2, dilaudid 1mg x1.
Upon arrival to the floor, patient complained of ___ LLQ
pain.
Past Medical History:
Complete VTE history difficult to corroborate
-___ Syndrome in ___
-DVTs, more than 10 per patient report
-PEs x ___ per patient report
-Review of clotting history per discharge summary ___ and
Heme-Onc note ___: First DVT ___ after knee surgery -> 6
months Coumadin -> off anticoagulation until ___ with no VTE ->
___ gets another DVT -> ___ LLE DVT -> 6 months Coumadin -> On
pradaxa and aspirin subsequently but still got a PE -> receives
CIV/EIV stent ___ -> on Coumadin which he self-discontinued in
___ -> ___ develops extensive DVT extending throughout L
internal iliac, femoral, popliteal, and gastroc veins ->
thrombolysis, IVC filter in ___ and back on Coumadin ->
___ L femoral vein clot as well as IVC clot -> discharged
on Coumadin-> LLE pain and admission in ___ with INR of
1.1, ___ showed decreased clot burden -> lovenox and aspirin
bridge to Coumadin -> admitted ___ with distal
extension of his LLE DVT and near complete occlusion of LLE
veins by ___ (sparing common femoral vein)-> discharged on
Coumadin with goal INR of 2.5 - 3.5 per previous Heme-Onc
consult in ___
-Left knee injury at age ___ s/p multiple surgeries (most recent
___
-PTA of left iliac veins. Stented with 18x90 mm Wallstent with
proximal stent into distal IVC and overlapped with 14x 3 Smart
stent into left distal EIV ___.
-ORIF L tib/fib fracture, left meniscus tear
-Evacuation of abdominal hematoma after football injury at age
___
-Gout, symptoms occur in his ___ toes typically
Social History:
___
Family History:
No h/o clotting disorder or DVT.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 97.7, 118/66, 60, 16, 96% RA
GENERAL: Alert, oriented, uncomfortable, lying in hospital bed
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: Supple, JVP not elevated, no LAD
RESP: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABD: +BS, soft, nondistended, tender to palpation in LLQ
without rebound, guarding. No hepatomegaly. + CVA tenderness. No
palpable masses.
GU: no foley
EXT: warm, well-perfused, LLE with non-pitting edema > RLE and
with multiple varicosities and venous stasis changes. RLE
appears normal.
NEURO: CNs2-12 intact, motor function grossly normal
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
================================================================
DISCHARGE PHYSICAL EXAM
Vitals: 97.9, 118/66, 85, 18, 98% RA
Exam:
GENERAL - Alert, interactive, well-appearing in mild distress
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB
ABDOMEN - NABS, soft/ND, no masses or HSM. Tenderness to light
palpation in left lower quadrant without guarding or rebound. +
CVA tenderness. Well-healed scar above umbilicus
GU: no foley
EXT: warm, well-perfused, LLE with non-pitting edema > RLE and
with multiple varicosities and venous stasis changes. RLE
appears normal.
MSK: Tenderness to palpation in muscle over the left ASIS. Pain
with passive flexion of left hip. Patient will not tolerate
internal rotation of left hip. Full range of motion at right hip
joint. No increased warmth or erythema. No rash.
NEURO: CNs2-12 intact, motor function grossly normal
Pertinent Results:
==========================
ADMISSION LABS
==========================
___ 07:40PM ___ PTT-38.8* ___
___ 07:40PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 07:40PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 07:40PM URINE AMORPH-RARE
___ 02:51PM LACTATE-2.1*
___ 02:40PM GLUCOSE-97 UREA N-23* CREAT-0.9 SODIUM-137
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-20* ANION GAP-20
___ 02:40PM ALT(SGPT)-22 AST(SGOT)-22 ALK PHOS-42 TOT
BILI-0.7
___ 02:40PM LIPASE-25
___ 02:40PM ALBUMIN-4.6 CALCIUM-9.5 PHOSPHATE-3.4#
MAGNESIUM-2.2
___ 02:40PM WBC-6.3 RBC-4.42* HGB-13.2* HCT-37.1* MCV-84
MCH-29.9 MCHC-35.6 RDW-13.6 RDWSD-41.4
___ 02:40PM NEUTS-75.1* LYMPHS-15.1* MONOS-7.4 EOS-1.4
BASOS-0.5 IM ___ AbsNeut-4.74 AbsLymp-0.95* AbsMono-0.47
AbsEos-0.09 AbsBaso-0.03
___ 02:40PM PLT COUNT-236
==========================
DISCHARGE LABS
==========================
___ 07:33AM BLOOD WBC-4.1 RBC-4.12* Hgb-12.2* Hct-35.1*
MCV-85 MCH-29.6 MCHC-34.8 RDW-13.6 RDWSD-41.6 Plt ___
___ 07:33AM BLOOD Glucose-95 UreaN-17 Creat-1.1 Na-135
K-4.0 Cl-104 HCO3-22 AnGap-13
___ 07:33AM BLOOD Calcium-8.9 Phos-4.7* Mg-2.1
___ 07:50AM BLOOD Lactate-1.4
___ 07:33AM BLOOD ___ PTT-39.7* ___
==========================
IMAGING:
==========================
___ CT Abdomen and Pelvis with contrast-
1. No evidence of diverticulitis or other acute intra-abdominal
process.
2. Resolution of previously noted thrombus about the IVC filter.
Chronic
non-occlusive thrombus within the left common/external iliac
vein stent
appears unchanged. No new venous thrombosis is otherwise
identified.
3. Hepatic steatosis.
___ unilateral ___-
1. Partially occlusive thrombus in the proximal femoral vein and
nearly
completely occlusive thrombus in the mid and distal femoral vein
as well as the popliteal and gastrocnemius veins. On prior
exam, DVT was partially occlusive, which may suggest interval
worsening.
2. The left common femoral vein and the left peroneal veins are
patent. The posterior tibial veins were not seen.
3. Superficial thrombophlebitis of the left calf is similar to
prior.
___ Pelvic and Sacroiliac X ray-
Minimal spurring at the femoral head neck junction of both
proximal femora. Clinical correlation is requested, as this
configuration can be seen in association with symptoms of
femoroacetabular impingement. Otherwise, no fracture or hip
osteoarthritis detected on this AP view.
Sacrum and SI joints are within normal limits on this view.
Note made of mild to moderate narrowing of the presumptive L4/5
lumbar spine disc space, not fully evaluated on this
examination.
Brief Hospital Course:
==================================
PRIMARY REASON FOR ADMISSION:
==================================
This is a ___ with a history of chronic DVT's and PE's from
___ syndrome on warfarin, iliac stents, IVC filter,
pancreatitis, depression, who presented with LLQ pain radiating
to the back for 1 day.
===================================
ACTIVE ISSUES:
===================================
# Abdominal pain: While in the hospital patient's physical exam
was notable for LLQ tenderness to palpation without rebound or
guarding with CVA tenderness. Vital signs were normal throughout
the hospital stay. The patient received CT Abdomen and pelvis
with contrast showing resolution of previously noted IVC filter
thrombus and no change in chronic non-occlusive thrombus in left
common/external iliac vein stent without evidence of acute
intra-abdominal process. Laboratory evaluation was significant
for a mildly elevated lactate which down trended to normal after
one day and was otherwise normal. He was maintained initially on
IV dilaudid in addition to his oral oxycodone and tapered slowly
off all IV pain medication. His pain remained a ___ on
discharge.
# Chronic Lumbar Back pain: He also reported new, worsening left
back pain. Pelvic and sacroiliac X-ray demonstrated minimal
spurring at the femoral head neck junction of both proximal
femora. No red-flag warning signs.
===================================
DISCHARGE ISSUES:
===================================
# Recurrent DVT: INR goal 2.5-3.5 on Coumadin 12.5mg WFSu, 10mg
___. INR was supratherapeutic at 4.2 for which patient
was given a diminished dose of 7.5 mg Coumadin on ___. After
discussion with the ___, he received 2.5 mg
___, 5mg ___, with plan to receive 5mg ___ and lab check on
___.
# Chronic normocytic anemia: Hgb is stable and improved from
prior hospitalization. No history of bleeding or signs of
bleeding on exam.
# Depression: Denies SI/HI/AVH currently. Continued home
sertraline 100 mg PO QD
# Homelessness- Patient was seen by case management while
inpatient. Recommendations for shelters were given. Patient
plans to f/u with brother and friends who have allowed him to
stay with them in the past.
===================================
TRANSITIONAL ISSUES:
===================================
- INR was supratherapeutic on discharge. After discussion with
___, he will be given 2.5mg on ___ with plans to
take 5mg on ___ with plans for recheck on ___
- Would benefit from Outpatient Physical Therapy for back pain
(prescription given)
- Discharged with oxycodone 15mg x 12 pills to last until he
sees PCP on ___
- Pelvis xray notable for minimal spurring at the femoral head
neck junction of both proximal femora that could be suggestive
of femoroacetabular impingement
- Would recommend continued pain medication titration or
initiation of narcotic contract in the future
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Gabapentin 800 mg PO QID
4. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
5. Sertraline 100 mg PO DAILY
___ MD to order daily dose PO ASDIR
Discharge Medications:
1. Outpatient Physical Therapy
Outpatient physical therapy. Diagnosis: Low back pain M54.5.
Evaluate and treat.
2. Acetaminophen 500 mg PO Q6H:PRN pain
3. Aspirin 81 mg PO DAILY
4. Gabapentin 800 mg PO QID
5. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
RX *oxycodone 15 mg 1 tablet(s) by mouth every four (4) hours
Disp #*12 Tablet Refills:*0
6. Sertraline 100 mg PO DAILY
___ MD to order daily dose PO ASDIR
Discharge Disposition:
Home
Discharge Diagnosis:
LLQ abdominal pain
Back pain
Deep venous thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It is our pleasure participating in your care here at ___. You
were admitted on ___ with left-sided abdominal and back pain.
Your physical exam, lab results, and CT scan were reassuring and
you received oral and IV pain medication while in the hospital.
You are being discharged on your home pain medication and close
follow up with your PCP.
Your INR was elevated above its target level while here in the
hospital. We decreased the dose of your Coumadin here in order
to compensate. Please take only 5 mg of Coumadin on ___
___ and ___. It is very important you follow up at your
PCP appointment and get your INR checked. The ___
will then adjust your regimen and tell you what dose to take
ongoing.
You were evaluated by physical therapy who felt you may benefit
from outpatient
Again, it was our pleasure participating in your care,
We wish you the best
Your ___ Team
Followup Instructions:
___
|
10824195-DS-12
| 10,824,195 | 22,532,034 |
DS
| 12 |
2130-08-16 00:00:00
|
2130-08-22 08:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old with history of ___ Syndrome on warfarin,
multiple DVTs and PEs s/p CIV/EIV stent placement at ___ in ___
and IVC filter placement at ___ in ___, and depression who
was discharged from ___ today represents to the ED with
tachycardia.
On ___ he presented to ED with with LLQ pain radiating to
the back for 1 day. He was admitted on ___. Extensive
workup did not elucidate an etiology for his pain. CT Abdomen
and pelvis with contrast showed resolution of previously noted
IVC filter thrombus and no change in chronic non-occlusive
thrombus in left common/external iliac vein stent without
evidence of acute intra-abdominal process. ___ of LLE showed
near completely occlusive thrombus in the mid and distal femoral
vein suggesting possible worsening form baseline and extensive
clot distally consistent with prior imaging. Pelvic and
sacroiliac X-ray demonstrated minimal spurring at the femoral
head neck junction of both proximal femora. Laboratory
evaluation was significant for a mildly elevated lactate which
down trended to normal after one day and was otherwise normal.
Pt was discharged ___ with plans for outpatient ___ and PO
oxydocone for pain control.
After discharge, pt presented to ___ for
medications. He states that he had significant dyspnea on
exertion traveling by foot to the clinic. He denies associated
chest pain or presyncope. On arrival, he was told that his HR
was 186. Reapeat in 2 hours was 145. He subsequently called his
PCP's office, and the on-call physician referred him to the ED
for evaluation.
In the ED, initial vital signs were: 98.3 125 129/76 18 95% RA
- Exam was notable for: Pt found to be anxious, abd tender to
palpation in LLQ with hypoactive BS
- Labs were notable for: Normal CBC and Chem 10 from this
morning, repeat CBC in ED with WBC 10.1, H/H ___, plts 205,
INR 3.9, CK 126, troponin <0.01
- UA demonstrated 3 WBC, 31 RBC, neg nitrites, neg leuks
- Imaging: CTA chest limited but did not demonstrate PE or
pneumonia, did demonstrate stable hilar and mediastinal LAD;
- The patient was given: 1L NS, Dilaudid 1mg IV x 1, Oxycodone
15mg PO x 1
- Consults: None
Vitals prior to transfer were: 98 75 115/67 18 96% RA
Upon arrival to the floor, pt is sleeping comfortably. He
denies shortness of breath or chest pain and states that he
feels well overall.
Past Medical History:
Complete VTE history difficult to corroborate
-___ Syndrome in ___
-DVTs, more than 10 per patient report
-PEs x ___ per patient report
-Review of clotting history per discharge summary ___ and
Heme-Onc note ___: First DVT ___ after knee surgery -> 6
months Coumadin -> off anticoagulation until ___ with no VTE ->
___ gets another DVT -> ___ LLE DVT -> 6 months Coumadin -> On
pradaxa and aspirin subsequently but still got a PE -> receives
CIV/EIV stent ___ -> on Coumadin which he self-discontinued in
___ -> ___ develops extensive DVT extending throughout L
internal iliac, femoral, popliteal, and gastroc veins ->
thrombolysis, IVC filter in ___ and back on Coumadin ->
___ L femoral vein clot as well as IVC clot -> discharged
on Coumadin-> LLE pain and admission in ___ with INR of
1.1, ___ showed decreased clot burden -> lovenox and aspirin
bridge to Coumadin -> admitted ___ with distal
extension of his LLE DVT and near complete occlusion of LLE
veins by ___ (sparing common femoral vein)-> discharged on
Coumadin with goal INR of 2.5 - 3.5 per previous Heme-Onc
consult in ___
-Left knee injury at age ___ s/p multiple surgeries (most recent
___
-PTA of left iliac veins. Stented with 18x90 mm Wallstent with
proximal stent into distal IVC and overlapped with 14x 3 Smart
stent into left distal EIV ___.
-ORIF L tib/fib fracture, left meniscus tear
-Evacuation of abdominal hematoma after football injury at age
___
-Gout, symptoms occur in his ___ toes typically
Social History:
___
Family History:
No h/o clotting disorder or DVT.
Physical Exam:
=====================================
ADMISSION PHYSICAL EXAM
=====================================
VITALS - 98.3 74 125/50 20 99% on RA, WT 97.2kg
GENERAL - pleasant, well-appearing, in no apparent distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA
NECK - supple, JVP flat
CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs
or gallops
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
ABDOMEN - normal bowel sounds, soft, TTP in LLQ and LUQ
EXTREMITIES - Left ankle ulcer, no edema
SKIN - without rash
NEUROLOGIC - A&Ox3
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
======================================
DISCHARGE PHYSICAL EXAM
======================================
Vitals: 98.0, 109/65, 62, 18, 97% RA
Exam:
GENERAL - Alert, interactive, well-appearing in no acute
distress
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB
ABDOMEN - NABS, soft/ND, no masses or HSM. Tenderness to deep
palpation in left lower quadrant without guarding or rebound. No
CVA tenderness. Well-healed scar above umbilicus
GU: no foley
EXT: warm, well-perfused, LLE with non-pitting edema > RLE and
with multiple varicosities and venous stasis changes. RLE
appears normal.
NEURO: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 06:53AM BLOOD WBC-5.2 RBC-4.77 Hgb-14.2 Hct-41.0 MCV-86
MCH-29.8 MCHC-34.6 RDW-13.8 RDWSD-42.5 Plt ___
___ 10:40PM BLOOD ___ PTT-42.1* ___
___ 06:53AM BLOOD Glucose-97 UreaN-13 Creat-1.0 Na-135
K-4.1 Cl-102 HCO3-21* AnGap-16
___ 06:53AM BLOOD Calcium-9.5 Phos-4.9* Mg-2.1
DISCHARGE LABS:
___ 07:45AM BLOOD WBC-4.6 RBC-4.14* Hgb-12.6* Hct-35.8*
MCV-87 MCH-30.4 MCHC-35.2 RDW-13.7 RDWSD-42.6 Plt ___
___ 07:45AM BLOOD ___ PTT-39.1* ___
___ 07:45AM BLOOD Glucose-95 UreaN-16 Creat-0.9 Na-139
K-4.0 Cl-102 HCO3-28 AnGap-13
___ 07:45AM BLOOD Calcium-9.8 Phos-5.4* Mg-2.0
Brief Hospital Course:
=================================
PRIMARY REASON FOR ADMISSION
=================================
Please see Discharge Summary from ___.
Mr. ___ is ___ year old M with history of ___
Syndrome on warfarin, multiple DVTs and PEs s/p CIV/EIV stent
placement at ___ in ___ and IVC filter placement at ___ in
___, and depression who was discharged from ___ ___ s/p
evaluation for LLQ pain and represented to the ED later that day
with tachycardia.
=================================
ACTIVE ISSUES:
=================================
# Sinus tachycardia: Patient reported dyspnea on exertion as he
walked on foot to ___. His heart rate was measured
to be in the 140s-180s and he was sent to ___ for further
evaluation. Workup revealed sinus tachycardia without ischemic
changes, trops negative x2, chest CT was without evidence of
Pulmonary embolism or pneumonia, UA without evidence of
infection. Patient's heart rate came down to the ___ on IV
fluids. His heart rate was monitored on telemetry overnight
without arrhythmia or tachycardia with rates remaining in the
___. At time of discharge he had normal vital signs without
Chest pain, SOB, or light-headedness.
# Vasovagal syncope: The patient had an episode of likely
vasovagal syncope after a blood draw, with head strike and ?
LOC. CT head negative for bleed, orthostatics negative and tele
w/o arrhythmia. He had headache and nausea post-fall, felt to be
related to post-concussive symptoms.
# Abdominal and back pain: As during prior admission, the
patient continued to have abdominal and back pain. He was
maintained initially on IV dilaudid in addition to his oral
oxycodone and quickly tapered off of IV pain medication. His
pain remained a ___ on discharge.
===================================
DISCHARGE ISSUES:
===================================
# Recurrent DVT: INR goal 2.5-3.5. He was given 10 mg on ___
and ___, 7.5 mg on ___, and instructed to take 10mg on ___
and ___ until he has INR check at PCP office on ___.
# Depression: Denies SI/HI/AVH currently. Continued home
sertraline 100 mg PO QD
# Homelessness- Patient was seen by case management while
inpatient. Recommendations for shelters were given.
=================================
TRANSITIONAL ISSUES:
=================================
- Patient should take 7.5mg of Coumadin on ___, then 10mg on
___ and ___ with repeat INR on ___ at ___ appointment
- Would benefit from Outpatient Physical Therapy for back pain
(prescription given during previous admission)
- CTA on ___ showed stable mediastinal and hilar
lymphadenopathy and bilateral pulmonary nodules (stable from
___ for which he should have 3 month follow up imaging.
- Would recommend continued pain medication titration or
initiation of narcotic contract in the future
- Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Gabapentin 800 mg PO QID
4. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
5. Sertraline 100 mg PO DAILY
___ MD to order daily dose PO ASDIR
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
___ MD to order daily dose PO ASDIR
3. Sertraline 100 mg PO DAILY
4. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
5. Gabapentin 800 mg PO QID
6. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
sinus tachycardia
vasovagal syncope
back and abdominal pain
SECONDARY DIAGNOSES:
deep venous thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care here at ___.
During this hospitalization, you were treated and evaluated for
an elevated heart rate. Your lab tests and imaging did not show
evidence of disease in your heart and lungs or a new infection.
You were given IV fluids and pain medication with return of your
heart to a regular rate and rhythm. Please follow up with your
outpatient provider for management of your anti-coagulation
medication and skin ulcer.
Please take 7.5 mg of Coumadin on ___ and then 10mg on ___ and
___. You will need to get your INR checked on ___ when
you come to Healthcare Associates. This is very important to
make sure you are on the right dose of Coumadin.
You also had a fall after getting a blood draw. Imaging of your
head did not show any bleeding but you did have headache and
some nausea that may be from a concussion. Please continue to
monitor these symptoms.
Thank you for allowing us to participate in your care!
--Your ___ care team
Followup Instructions:
___
|
10824195-DS-14
| 10,824,195 | 21,947,256 |
DS
| 14 |
2131-01-03 00:00:00
|
2131-01-03 21:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
LLE swelling/wound
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with ___ syndrome with history of DVTs on warfarin
and chronic substance abuse on methadone who presents with left
leg wound and swelling. Patient has a chronic foot ulcer that
had completely healed and then re-opened a few days ago with
increased pain, redness and swelling. He denies chest pain,
shortness of breath, fevers, nausea, vomiting or other systemic
symptoms. He also notes "Rash" on right foot.
In the ED, initial vitals were: 96.7 86 133/82 16 99% RA
Exam notable for: shallow ulcer on left medial aspect of foot
with surrounding tenderness and erythema without drainage.
palpable cords in mid-calf with mild tenderness on palpation.
edema of the left lower extremity compared to right.
Labs notable for: INR 2.4, P 4.6, Plt 125, Hgb 10.2, lactate
1.4
Imaging notable for:
CT LLE: There is extensive varicose varicose veins throughout
the left leg. There is subcutaneous tissue edema in the left
calf and foot. Skin ulceration is noted at the medial ankle. No
subcutaneous emphysema is identified to suggest necrotizing
fasciitis. No erosive bone changes identified suggestive of
osteomyelitis.
BLE venous dopplers: IMPRESSION: Progression of DVT involving
the duplicated left femoral veins and popliteal vein, now
extending into the common femoral vein. No right lower extremity
deep venous thrombosis.
Patient was given:
___ 17:10 IV Clindamycin 600 mg
___ 17:10 IVF 1000 mL NS 1000 mL
___ 19:23 IV Heparin
___ 22:42 IV Morphine Sulfate 4 mg
Vitals prior to transfer: 98.3 68 131/61 17 99% RA
On the floor, he is in ___ pain in L foot. No other
complaints.
ROS:
As per HPI. Remaining 10-point ROS negative.
Past Medical History:
Complete VTE history difficult to corroborate
-___ Syndrome in ___
-DVTs, more than 10 per patient report
-PEs x ___ per patient report
-Review of clotting history per discharge summary ___ and
Heme-Onc note ___: First DVT ___ after knee surgery -> 6
months Coumadin -> off anticoagulation until ___ with no VTE ->
___ gets another DVT -> ___ LLE DVT -> 6 months Coumadin -> On
pradaxa and aspirin subsequently but still got a PE -> receives
CIV/EIV stent ___ -> on Coumadin which he self-discontinued in
___ -> ___ develops extensive DVT extending throughout L
internal iliac, femoral, popliteal, and gastroc veins ->
thrombolysis, IVC filter in ___ and back on Coumadin ->
___ L femoral vein clot as well as IVC clot -> discharged
on Coumadin-> LLE pain and admission in ___ with INR of
1.1, ___ showed decreased clot burden -> lovenox and aspirin
bridge to Coumadin -> admitted ___ with distal
extension of his LLE DVT and near complete occlusion of LLE
veins by ___ (sparing common femoral vein)-> discharged on
Coumadin with goal INR of 2.5 - 3.5 per previous Heme-Onc
consult in ___
-Left knee injury at age ___ s/p multiple surgeries (most recent
___
-PTA of left iliac veins. Stented with 18x90 mm Wallstent with
proximal stent into distal IVC and overlapped with 14x 3 Smart
stent into left distal EIV ___.
-ORIF L tib/fib fracture, left meniscus tear
-Evacuation of abdominal hematoma after football injury at age
___
-Gout, symptoms occur in his ___ toes typically
Social History:
___
Family History:
No family h/o clotting disorder or DVT
Physical Exam:
ON ADMISSION:
Vitals: Tm 97.8 HR 62 BP 118/71 RR 18 O2 sat 100% RA
General: Alert, oriented, in mild distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. LLE
with quarter-sized ulcer over medial malleolus with surrounding
erythema/warmth over medial shin/calf. Exquisitely tender to
light touch. No crepitus or necrosis. LLE calf also with some
petechiae, as well as varicose veins. RLE with erythematous
macular rash over anteromedial ankle
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
ON DISCHARGE:
Vitals: T 98.0/97.6, BP 109-122/65-69 HR ___ RR 18 95%onRA
General: comfortable appearing, resting in bed, in no acute
distress
HEENT: Sclera anicteric, conjunctivae noninjected
CV: RRR, normal S1 + S2, no murmurs, rubs or gallops
Lungs: CTAB, no wheezes
Abdomen: Soft, non-tender, non-distended
GU: No foley
Ext: Warm, well perfused, 2+ distal/radial pulses. L calf with
prominent distended veins, tender to palpation. L medial ankle
ulcer has granulation tissue and hemorrhagic crust. Minimal
erythema and tenderness.
Pertinent Results:
ON ADMISSION:
___ 03:30PM BLOOD WBC-5.1 RBC-3.75* Hgb-10.2* Hct-31.8*
MCV-85 MCH-27.2 MCHC-32.1 RDW-14.7 RDWSD-45.1 Plt ___
___ 03:30PM BLOOD Neuts-53.2 ___ Monos-13.5*
Eos-4.3 Baso-0.6 Im ___ AbsNeut-2.71# AbsLymp-1.43
AbsMono-0.69 AbsEos-0.22 AbsBaso-0.03
___ 03:30PM BLOOD ___ PTT-36.8* ___
___ 03:30PM BLOOD Ret Aut-2.6* Abs Ret-0.10
___ 03:30PM BLOOD Glucose-94 UreaN-18 Creat-1.0 Na-137
K-3.5 Cl-98 HCO3-29 AnGap-14
___ 03:30PM BLOOD Calcium-9.6 Phos-4.6* Mg-2.2
___ 03:30PM BLOOD Hapto-19*
___ 10:20AM BLOOD calTIBC-306 Ferritn-70 TRF-235
___ 03:44PM BLOOD Lactate-1.4
ON DISCHARGE:
___ 11:45AM BLOOD WBC-4.9 RBC-4.81 Hgb-13.3* Hct-41.2
MCV-86 MCH-27.7 MCHC-32.3 RDW-15.3 RDWSD-47.6* Plt ___
___ 11:45AM BLOOD Glucose-91 UreaN-15 Creat-1.2 Na-136
K-4.4 Cl-99 HCO3-26 AnGap-15
___ 11:45AM BLOOD Calcium-9.9 Phos-4.7* Mg-2.1
___:45AM BLOOD ___
MICROBIOLOGY:
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
___ Blood cultures x 2: negative
IMAGING:
___ Bilat ___ US:
Progression of DVT involving the duplicated left femoral veins
and popliteal vein, now extending into the common femoral vein.
No right lower extremity deep venous thrombosis.
___ CT ___:
1. Patency of the partially imaged left external iliac vein
stent and veins of left lower extremity cannot be assessed due
to suboptimal bolus timing.
2. Subcutaneous tissue edema at of the left calf and foot.
There is skin
ulceration at the medial ankle. No subcutaneous gas.
3. Extensive varicose veins throughout the left leg.
___ CT venogram:
1. Patent IVC and left iliac stent. Minimal mural nonocclusive
thrombus in
the iliac vein appears chronic. There is nonocclusive thrombus
within the left femoral vein, popliteal vein, and posterior
tibial vein.
___ US ankle MSK:
Venous varix, without evidence for focal collection.
Brief Hospital Course:
Mr. ___ is a ___ with h/o ___ syndrome and
multiple DVTs & PEs, on warfarin with inconsistent INR
monitoring, as well as chronic substance use on methadone
presenting with left leg wound and swelling.
# DVT: Throughout admission, he was hemodynamically stable. Left
leg ultrasound showed progression of LLE DVT. He was started on
a heparin drip, and Vascular surgery was consulted but felt that
operative management was not necessary. His warfarin was then
re-initiated, but given subtherapeutic INRs (initially 2.4, and
2.2 at discharge), the heparin drip was continued. Based on
conversations with Heme/Onc and the PCP, the INR goal was set at
2.5-3.5. He was discharged on 7.5mg of Warfarin at a therapeutic
INR of 2.5.
# Cellulitis: He had a non-healing ulcer over the L medial
malleolus. Swab cultures grew GPCs in pairs/chains and was
treated initially with PO Clindamycin. Sensitivities showed
resistance to Clindamycin, so he was transiently on IV
Vancomycin and then transitioned to PO Bactrim and Keflex, then
to doxycycline for the final 2 days of therapy when he had a
transient rise in creatinine. His creatinine returned to
baseline. He completed a 7 day course of antibiotics
(___). There was no concern about arterial etiology
for his nonhealing ulcer given his strong distal pulses.
# Pain/Chronic substance use disorder: Given his DVT and
cellulitis, his pain was managed initially with PO Dilaudid 4mg
Q4hr PRN with IV Dilaudid 0.5-1mg Q4hr for breakthrough pain.
The dilaudid regimen was weaned and transitioned to Oxycodone
5mg Q4hr, and then stopped completely several days prior to
discharge. He was discharged on his home dose of Methadone 70mg
PO QD (confirmed with ___ clinic).
# Thrombocytopenia: Mr. ___ was incidentally found to be
thrombocytopenic (120-140s) without symptoms. This was
monitored.
# Psych: Home Sertraline 200mg, Wellbutrin 150mg, and Risperdal
0.5mg BID were continued during hospitalization. QTc was
monitored and within normal limits.
Transitional issues:
- Anticoagulation: patient should have INR checks 3 times per
week
- An attempt was made to help patient qualify for home INR
monitor (such as Alere or similar) but he cannot qualify while
he is homeless per his insurance company
- warfarin dose at discharge: 7.5 mg
- INR at discharge: 2.5
- Patient discharged on iron for anemia (iron 37, ferritin 70);
consider further workup as an outpatient for occult bleeding (no
bleeding seen this admission)
- CODE: full
- CONTACT: Father ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 800 mg PO QID
___ MD to order daily dose PO ASDIR
3. Sertraline 200 mg PO DAILY
4. nalOXone 4 mg/actuation nasal 1 spray overdose
5. Methadone 70 mg PO DAILY
6. RisperiDONE 0.5 mg PO BID
7. RisperiDONE 0.5 mg PO DAILY:PRN anxiety/agitation
8. BuPROPion 150 mg PO DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. Warfarin 7.5 mg PO DAILY16
RX *warfarin 7.5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. BuPROPion 150 mg PO DAILY
4. Gabapentin 800 mg PO QID
5. Methadone 70 mg PO DAILY
6. nalOXone 4 mg/actuation nasal 1 spray overdose
7. RisperiDONE 0.5 mg PO BID
8. RisperiDONE 0.5 mg PO DAILY:PRN anxiety/agitation
9. Sertraline 200 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: DVT; Cellulitis; ___ syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear. Mr. ___,
It was a pleasure taking care of you during your recent
hospitalization at the ___. As
you know, you came to the hospital because your left leg was
swollen and painful. We found that you had worsening of the DVT
in your leg. You also had an ulcer on your left ankle that was
infected. You got antibiotics for this and your ulcer improved.
Please continue to take your warfarin every day. It is very
important that you go to your INR check appointments to keep
track of how well the warfarin is working. You should have your
INR checked 3 times per week. If you do not go to these
appointments, it is very likely that your warfarin levels will
not be in the right range, and you can develop more clots or
have dangerous bleeding.
With Best Wishes,
Your ___ Team
Followup Instructions:
___
|
10824195-DS-15
| 10,824,195 | 26,532,908 |
DS
| 15 |
2131-04-17 00:00:00
|
2131-04-19 09:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
LLE pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: Mr. ___ is a ___ year old man
with ___ syndrome with multiple DVTs on warfarin,
chronic history of opiate abuse due to prescription narcotics
given for DVT-related pain now on methadone and followed by both
Pain Clinic who presents with left leg pain and arm pain.
The patient reported that he stopped taking his warfarin ___
days ago. It was left at his homeless shelter, and he states he
has been staying with his brother in the interim time. He tried
to pick it up but arrived too early at the shelter, and had to
return his brothers car, thus was unable to pick up
prescription. Normally take 7.5mg warfarin daily and checks INR
at ___.
Patient states that he has baseline LLE pain ___, gradually
worsening over past two months acutely worsening over past two
days to ___. Pain is dull, in calf, worse with movement.
Notably, patient with cough and per his report was ruled out for
TB about 3 wks ago at ___. Hospitalized for 5
days tx antibiotics (unclear what one) for pneumonia. At that
time he developed left arm pain at IC site, which resolved after
discharged but reappeared day prior to this admission and was
acutely worsened today with application or tourniquet for IV.
Dull pain, worse with movement of arm or palpation, no radiation
above or below. He also experienced right arm pain of similar
nature but less intensity
In the ED, initial vital signs were: 97.2 85 148/85 14 100%
RA
- Exam notable for:
-- Lungs: ronchi, end exp wheezing bilaterally worse at bases
-- Arms: left upper extremity with bruises ___ blood draws,
swollen; redness/tenderness around previous IV site
-- Legs: left lower calf circumfrance > right. Palpable cords.
Medial malleolar ulceration well cicrcumcribed, no erytemea, no
tenderness
- Labs were notable for lactate:2.9, INR: 1.2
- Studies performed include:
-- Bilat Up Ext Veins Us
1. Nonocclusive thrombus in the bilateral basilic veins
-- Bilat Lower Ext Veins
1. Residual nonocclusive thrombus in the left popliteal vein,
with new
nonocclusive thrombus in the left superficial femoral vein.
2. Interval resolution of thrombus in the left greater saphenous
vein.
3. The left peroneal veins were not well visualized.
4. No evidence of deep vein thrombosis in the right leg.
- Patient was given: 5mg oxycodone, 2L NS
- Vitals on transfer:
Upon arrival to the floor, the patient continues to have left
upper and lower extremity pain exactly as described above; he is
more perturbed by the LUE pain. Denies chest pain or dyspnea.
Does report that he has been feeling off for past few days,
eating less and taking less PO fluid.
Past Medical History:
Complete VTE history difficult to corroborate
-___ Syndrome in ___
-DVTs, more than 10 per patient report
-PEs x ___ per patient report
-Review of clotting history per discharge summary ___ and
Heme-Onc note ___: First DVT ___ after knee surgery -> 6
months Coumadin -> off anticoagulation until ___ with no VTE ->
___ gets another DVT -> ___ LLE DVT -> 6 months Coumadin -> On
pradaxa and aspirin subsequently but still got a PE -> receives
CIV/EIV stent ___ -> on Coumadin which he self-discontinued in
___ -> ___ develops extensive DVT extending throughout L
internal iliac, femoral, popliteal, and gastroc veins ->
thrombolysis, IVC filter in ___ and back on Coumadin ->
___ L femoral vein clot as well as IVC clot -> discharged
on Coumadin-> LLE pain and admission in ___ with INR of
1.1, ___ showed decreased clot burden -> lovenox and aspirin
bridge to Coumadin -> admitted ___ with distal
extension of his LLE DVT and near complete occlusion of LLE
veins by ___ (sparing common femoral vein)-> discharged on
Coumadin with goal INR of 2.5 - 3.5 per previous Heme-Onc
consult in ___
-Left knee injury at age ___ s/p multiple surgeries (most recent
___
-PTA of left iliac veins. Stented with 18x90 mm Wallstent with
proximal stent into distal IVC and overlapped with 14x 3 Smart
stent into left distal EIV ___.
-ORIF L tib/fib fracture, left meniscus tear
-Evacuation of abdominal hematoma after football injury at age
___
-Gout, symptoms occur in his ___ toes typically
Social History:
___
Family History:
No family h/o clotting disorder or DVT
Physical Exam:
ADMISSION EXAM
==============
Vitals- Tm 98.2 BP 132/78 HR 51 RR 18 O2 98% on RA
GENERAL: AOx3, slight distress due to LUE pain
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival pallor or injection, sclera anicteric and without
injection.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
-LLE: Slightly swollen compared to right but not pitting,
multiple varicose veins in lower leg painful to palpation.
Healing 3x3cm ulcer on medial malleolus with some erythema and
crusting, does not appear infected. Palpable cords.
-LUE: Slight swelling in medial aspect of left upper extremity,
very painful to palpation. 3 1x1cm erythematous lesions on
should patients states are from IVs/blood draws. Limb is very
painful with active ROM.
-RUE: No swelling or erythema, slight tenderness to palpation of
medial upper arm.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy except as described above
NEUROLOGIC: CN2-12 grossly intact.
DISCHARGE EXAM
==============
Vitals- Tmax 98.3 BP 100-120/70-80s HR 60-80s RR ___
on RA
GENERAL: AOx3, no acute distress
HEENT: Normocephalic, atraumatic.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, no sign of
atrophy/hypertrophy.
-LLE: Slightly swollen compared to right but not pitting,
multiple varicose veins in lower leg painful to palpation.
Healing 3x3cm ulcer on medial malleolus with some erythema and
crusting, does not appear infected. Palpable cords.
-LUE: Resolved swelling in medial aspect of left upper
extremity, no longer painful to palpation. 3 1x1cm erythematous
lesions on shoulder patients states are from IVs/blood draws.
Limb is painful with active ROM.
NEUROLOGIC: CN2-12 grossly intact.
Pertinent Results:
ADMISSION LABS
==============
___ 10:25AM BLOOD WBC-5.8 RBC-4.34* Hgb-12.3* Hct-36.2*
MCV-83 MCH-28.3 MCHC-34.0 RDW-15.0 RDWSD-45.2 Plt ___
___ 10:25AM BLOOD Neuts-72.0* Lymphs-18.7* Monos-5.8
Eos-2.7 Baso-0.3 Im ___ AbsNeut-4.19# AbsLymp-1.09*
AbsMono-0.34 AbsEos-0.16 AbsBaso-0.02
___ 10:25AM BLOOD ___ PTT-25.6 ___
___ 10:25AM BLOOD Plt ___
___ 10:25AM BLOOD Glucose-120* UreaN-16 Creat-1.1 Na-135
K-3.5 Cl-96 HCO3-24 AnGap-19
___ 10:35AM BLOOD Lactate-2.9*
MICRO
=====
___ BLOOD CULTURE Blood Culture, Routine-FINAL
___ URINE URINE CULTURE-FINAL
IMAGING
=======
___ BILAT UPPER EXT US
IMPRESSION:
1. No evidence of DVT.
2. Nonocclusive thrombus in the bilateral basilic veins.
___ BILAT LOWER EXT US
IMPRESSION:
1. Residual nonocclusive thrombus in the left popliteal vein,
with new
nonocclusive thrombus in the left superficial femoral vein.
2. Interval resolution of thrombus in the left greater saphenous
vein.
3. The left peroneal veins were not well visualized.
4. No evidence of deep vein thrombosis in the right leg.
___ CXR
IMPRESSION:
1. No acute cardiopulmonary process.
2. Previously seen mediastinal lymphadenopathy is not well
evaluated on
radiograph, for which tissue sampling is recommended.
DISCHARGE LABS
==============
___ 04:55AM BLOOD WBC-3.7* RBC-3.99* Hgb-12.1* Hct-35.1*
MCV-88 MCH-30.3 MCHC-34.5 RDW-15.2 RDWSD-47.2* Plt ___
___ 06:20AM BLOOD ___ PTT-43.7* ___
Brief Hospital Course:
BRIEF HOSPITAL COURSE
=====================
Mr. ___ is a ___ man with ___ syndrome with
multiple DVTs on warfarin, chronic history of opiate abuse due
to prescription narcotics given for DVT-related pain now on
methadone and followed by Pain Clinic, who presented with left
leg pain. He was found to have DVT of the left lower extremity
as well as non-occlusive thrombi in the bilateral basilic veins.
His INR was subtherapeutic on admission in setting of missing
several doses of warfarin due to social issues. The patient
received a Lovenox bridge to warfarin, and INR was 2.7 on day of
discharge. The patient also reported pain in his arms, left
greater than right, likely related to the clots. His pain was
treated with Tylenol, ibuprofen, oxycodone, and tramadol, but
all opioids (aside from methadone) were discontinued at time of
discharge. The patient met with Social Work, and declined
further assistance or services. The patient's warfarin was
delivered to the bedside on the day of discharge.
ACTIVE ISSUES
=============
# ___ Syndrome
# LLE DVT
# Non-occlusive thrombi in the bilateral basilic veins.
Patient presented after not taking warfarin in ___ days and
sub-therapeutic INR of 1.2. New nonocclusive thrombus in the
left superficial femoral vein and non-occlusive thrombi in the
bilateral basilic veins, likely iatrogenic from tourniquet use.
No signs/symptoms of PE. Started on heparin gtt in ED,
transitioned to therapeutic Lovenox on ___ because PTT lab
draws were too painful. Pain somewhat more proximal on ___.
Paradoxically decreased INR on ___ then slowly rising. INR 2.7
on discharge, discontinued Lovenox and sent out with 7.5mg
warfarin QD.
# Chronic knee pain
# Pain/Chronic substance use disorder: History of opioid abuse
in setting of treatment for his prior DVTs, currently maintained
on Methadone 75 mg PO/NG DAILY administered through ___.
Increased pain now in setting of DVT and superficial UE thrombi.
Pain control as below, was on oxycodone and tramadol inpatient
but these were weaned off by time of discharge.
- Home methadone 75mg QD
- Tylenol ___ q6hrs
- Ibuprofen 800 mg PO Q8H
- Gabapentin 800 mg PO/NG TID
- Lidocaine patch
- Heat packs
# Depression
- BuPROPion (Sustained Release) 150 mg PO QAM
- Sertraline 200 mg PO/NG DAILY
# Periphal vascular disease s/p LLE stent
- Aspirin 81 mg PO/NG DAILY held in setting of warfarin, to be
discussed at next PCP ___.
# Health care / housing resources: Patient with unstable housing
and decreased access to medications. Social work consulted,
patient states that he has case managers outpatient who help him
with paperwork and he has no need for other services; he feels
he has places to stay (shelters and with family) and will start
carrying warfarin with him in case he moves between different
places.
TRANSITIONAL ISSUES
===================
[] Patient was discharged on his home warfarin dose 7.5 mg
daily, with goal INR of 2.5-3.5. Next INR should be drawn on
___ and follow up by ___.
[] ___ CXR: "Previously seen mediastinal lymphadenopathy is not
well evaluated on radiograph, for which tissue sampling is
recommended." Was previously delineated on ___ CT.
[] Aspirin 81 mg daily held during this admission and upon
discharge. Please re-evaluate the need for this medication at
next PCP ___.
[] Patient reported sore throat on day of discharge.
Oropharyngeal exam was without erythema or exudate. Please
follow up on resolution of this discomfort at next PCP
___.
[] Follow up with PCP on ___ at 2:30 ___
[] Follow up with vascular on ___ at 11:15 AM
[] CODE STATUS: Full, confirmed
[] CONTACT: Father, ___, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Methadone 75 mg PO DAILY
2. Acetaminophen 500 mg PO Q6H
3. Gabapentin 800 mg PO QID
4. BuPROPion (Sustained Release) 150 mg PO QAM
5. Warfarin 7.5 mg PO DAILY16
6. Aspirin 81 mg PO DAILY
7. Sertraline 200 mg PO DAILY
8. capsaicin 0.075 % topical DAILY
9. diclofenac sodium 1 % topical Q12H
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. diclofenac sodium 1 % topical Q12H
4. Gabapentin 800 mg PO QID
5. Methadone 75 mg PO DAILY
6. Sertraline 200 mg PO DAILY
7. Warfarin 7.5 mg PO DAILY16
RX *warfarin [Coumadin] 7.5 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
8. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until you discuss with your PCP.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- Deep vein thrombosis
- Non-occlusive basilic vein thrombi
SECONDARY:
- ___ syndrome
- Chronic pain
- Depression
- Peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you. You came to the hospital
because you had leg pain, and we found that you had blood clots
in your arms and legs. We restarted your home blood thinner and
treated the pain that you had because of the clots.
Please continue to take your blood thinner (warfarin) every day
and follow up with your regular doctor.
We wish you the best of health.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10824195-DS-19
| 10,824,195 | 25,112,305 |
DS
| 19 |
2133-10-08 00:00:00
|
2133-10-08 22:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left Leg Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo man with ___ syndrome c/b multiple DVTs and PEs on
rivaroxaban who presents with L calf pain and swelling x 3 days.
Pt was most recently admitted in ___ at which point he
had a LLE DVT. Per that DC summary, since ___ ___
recommended no more DOAC and that warfarin is best agent for
him.
He had severe pain on that admission which required a lower dose
of suboxone to allow for short acting opiates (was requiring
20mg
PO Q4h). Addiction psych was consulted at that time and assisted
in uptitrating back to home suboxone dose. He was discharged on
warfarin with a therapeutic INR. Unfortunately, he is frequently
lost to follow up and has a hard time maintaining a therapeutic
INR. Since that admission in ___, he has had multiple
admissions at various hospitals with chronic DVT and resultant
LLE pain. Most recently, he was admitted to ___ and discharged
___ with pain secondary to progression of his
DVT. He was discharged from that ___ admission back on
Rivaroxaban.
He followed up with Dr. ___ at ___ who referred him
back to Dr. ___ to discuss anticoagulation strategy in the
future. Unfortunately, that appointment was ___ on the day
that he presented to the ___ ED.
Prior to this presentation, he developed worsening redness and
pain on ___ over lateral L calf consistent with prior episodes
of cellulitis. He was given a course of cephalexin and TMP-SMX.
However, the pain increased and he developed swelling in the L
posterior calf. He reports that it was similar to his prior DVTs
but with worse swelling and with pain radiating up to inner L
thigh.
- In the ED, initial vitals were: T 98.2 HR 94 BP 117/75 RR 16
O2
97% RA
- Exam was notable for: inflamed left calf, motion intact
throughout
- Labs were notable for: WBC 8.0, Hgb 11.2
- Studies were notable for:
___ Doppler
1. Overall similar partial, chronic DVT involving the left
common
femoral and
femoral veins with increased acute on chronic, partially
occlusive DVT
involving the popliteal vein.
2. New, likely acute occlusive thrombus involving the
gastrocnemius veins and
varices about the calf.
- The patient was given: IV heparin
On arrival to the floor, the patient notes continued LLE pain,
swelling, similar to prior DVTs and cellulitis, but with some
worsening pain.
Past Medical History:
IVC filter placement and thrombectomy in ___ and LCIV/EIV stent
placement in ___
Complete VTE history difficult to corroborate
-___ Syndrome in ___ on chronic warfarin
-DVTs, more than 10 per patient report
-PEs x ___ per patient report
-Review of clotting history per discharge summary ___ and
Heme-Onc note ___: First DVT ___ after knee surgery -> 6
months Coumadin -> off anticoagulation until ___ with no VTE ->
___ gets another DVT -> ___ LLE DVT -> 6 months Coumadin -> On
pradaxa and aspirin subsequently but still got a PE -> receives
CIV/EIV stent ___ -> on Coumadin which he self-discontinued in
___ -> ___ develops extensive DVT extending throughout L
internal iliac, femoral, popliteal, and gastroc veins ->
thrombolysis, IVC filter in ___ and back on Coumadin ->
___ L femoral vein clot as well as IVC clot -> discharged
on Coumadin-> LLE pain and admission in ___ with INR of
1.1, ___ showed decreased clot burden -> lovenox and aspirin
bridge to Coumadin -> admitted ___ with distal
extension of his LLE DVT and near complete occlusion of LLE
veins by ___ (sparing common femoral vein)-> discharged on
Coumadin with goal INR of 2.5 - 3.5 per previous Heme-Onc
consult in ___
-Left knee injury at age ___ s/p multiple surgeries (most recent
___
-PTA of left iliac veins. Stented with 18x90 mm Wallstent with
proximal stent into distal IVC and overlapped with 14x 3 Smart
stent into left distal EIV ___.
-ORIF L tib/fib fracture, left meniscus tear
-Evacuation of abdominal hematoma after football injury at age
___
-Gout, symptoms occur in his ___ toes typically
Social History:
___
Family History:
Mother with scleroderma, father with HTN.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
GENERAL: Alert and interactive. In no acute distress. Lying
comfortably in bed.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: LLE with significant tense edema extending up calf.
Open wound at medial malleolus with no exudate, some surrounding
erythema. Intact pulses bilaterally.
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: NAD, comfortable-appearing
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
CARDIAC: RR, no m/r/g
LUNGS: CTAB, normal WOB
ABDOMEN: S, NT, BS+
EXTREMITIES: LLE resolved erythema. Chronic xeroderma changes.
Palpable venous courds. Improved tenderness to palpation. Open
wound at medial malleolus with no exudate, some surrounding
erythema. Intact pulses bilaterally.
NEURO: AOx3, conversant w/ clear speech, stable, slightly
antalgic gait observed
Pertinent Results:
ADMISSION LABS
==============
___ 06:26PM BLOOD WBC-8.0 RBC-4.10* Hgb-11.2* Hct-35.5*
MCV-87 MCH-27.3 MCHC-31.5* RDW-14.4 RDWSD-45.5 Plt ___
___ 06:29PM BLOOD ___ PTT-24.6* ___
___ 06:26PM BLOOD Glucose-88 UreaN-21* Creat-1.0 Na-137
K-3.8 Cl-99 HCO3-25 AnGap-13
DISCHARGE LABS
==============
___ 01:06AM BLOOD ___
RELEVANT IMAGING
================
IMPRESSION:
1. Overall similar partial, chronic DVT involving the left
common femoral and
femoral veins with increased, acute on chronic, partially
occlusive DVT
involving the popliteal vein.
2. New, likely acute occlusive thrombus involving the
gastrocnemius veins and
varices about the calf.
Brief Hospital Course:
___ yo man with ___ syndrome c/b multiple DVTs and PEs on
rivaroxaban, with questionable compliance, who presented with L
calf pain and swelling found to have progression of known
chronic DVT.
TRANSITIONAL ISSUES
===================
[] Patient is being discharged on Warfarin. His INR at discharge
was 2.5, and he received 5mg on day of discharge. His goal is
___.
[] There is significant concern patient's recurrent blood clots
are secondary to poor medication adherence. He was counseled
extensively on the importance of continuing to take his
medications.
[] Patient had expressed interest in transitioning to methadone
from suboxone. Please continue to discuss this transition with
him.
[] Consider repeat iron studies outpatient for further
evaluation of his anemia.
ACUTE/ACTIVE ISSUES:
====================
#. ___ syndrome:
#. Recurrent LLE DVT:
Doppler showed new acute thrombus in gastrocnemius veins and
increased DVT in popliteal vein. Exam reassuring for intact
sensation, strength, and pulses. The patient has a long history
of multiple anticoagulation regimens, complicated by
non-compliance, with most recent suggestions by Dr. ___ to
transition to Warfarin. Though patient was initially treated
with Vanc/Zosyn, there was low suspicion for cellulitis given
rapid improvement and lack of systemic signs of infection, and
thus these were discontinued. After discussion with Dr. ___
___ his outpatient providers, it seems unlikely patient will be
compliant with warfarin, though after a long discussion with
him, he states that he knows this is the correct decision and he
needs to start warfarin as opposed to trying a higher dose of
rivaroxabn. He was bridged with Lovenox to Warfarin. Wound care
was consulted for management of his lower extremity wound.
# Opioid use disorder:
Addiction Psychiatry met with patient to discuss transition to
methadone. Patient is undecided if he would like to pursue this
option, and will follow-up further outpatient. Though patient
appeared uncomfortable, concerning for withdrawal, he repeatedly
declined his suboxone dose.
CHRONIC ISSUES
==============
# ___ pain
Continued home gabapentin
# Depression
Continued home sertraline
# Chronic normocytic anemia
Consistent with baseline, previous iron studies indicate
borderline iron deficiency. He declined labs for further
evaluation.
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 800 mg PO QID
2. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL TID
3. Sertraline 150 mg PO DAILY
4. Rivaroxaban 15 mg PO DAILY
Discharge Medications:
1. ___ MD to order daily dose PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL TID
3. Gabapentin 800 mg PO QID
4. Sertraline 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=======
DVT
SECONDARY
=========
Opiate Use Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital after being found to have a
blood clot.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- While here, we talked to you about your blood thinner choices.
You decided to start therapy with Warfarin. We monitored your
blood levels closely to ensure you were in a therapeutic range.
- Our Social Workers also met with you to help discuss
transitioning to Methadone. This will need to be an ongoing
conversation outpatient.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- It is very important you have your INR checked to ensure your
Warfarin dose is appropriate. YOU NEED TO HAVE THIS CHECKED AT
LEAST EVERY WEEK, AND FOR THE FIRST COUPLE OF WEEKS AT LEAST
EVERY FEW DAYS. YOUR ___ WILL COORDINATE THIS. YOU CANNOT MISS
HAVING THIS CHECKED BECAUSE IF YOU INR IS TOO LOW YOU ARE AT
VERY HIGH RISK TO HAVING ANOTHER CLOT.
- Continue to take all your medicines as prescribed below.
- Show up to your appointments as listed below: YOU HAVE AN
APPOINTMENT WITH ___. ___ ___ AT 2:05 ___ IN THE
___ BUILDING ON THE ___ FLOOR.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with history of ___
syndrome with multiple prior VTE currently prescribed warfarin
therapy who presents with left leg pain.
Per review of the chart, the patient was recently admitted from
___ for left leg pain and was found to have recurrent left
lower extremity DVT. The patient has a history of multiple VTE
on multiple anticoagulation regimens with history of medication
nonadherence; his anticoagulation plan was discussed with his
outpatient hematologist and ultimately he was bridged from
enoxaparin with warfarin despite his debilitating fear of
needles.
The patient reports that he initially took the warfarin
following discharge but that he "tapered off." he states that
the main barrier to him taking the medication is that he
forgets, and that he fears getting the blood draws for INR
monitoring. He estimates that he has taken fewer than 50% of the
doses in the last month, and believes his last dose of warfarin
was over a week ago.
He reports that a few days prior to admission he noted that his
left leg was more red, swollen, and painful. He denies any
trauma to the leg. No fevers or chills. He denies any chest
pain, palpitations, shortness of breath.
In the ED, vitals: 97.6 74 127/75 18 100% RA Exam notable for:
Ext: Left calf with tense erythema, extremely tender to
palpation, distal pulse intact, distal sensation of left
extremity diminished compared to right, acute on chronic Labs
notable for: WBC 4.8, Hb 9.8, INR 1.2, lactate 1.6 Imaging: Left
___, left leg CT Patient given: cefepime 2 g, vancomycin 1 g,
oxycodone 10 mg
On arrival to the floor, the patient reports ongoing severe left
leg pain. He denies any other complaints at this time. ROS:
Pertinent positives and negatives as noted in the HPI. All other
systems were reviewed and are negative.
Past Medical History:
- ___ Syndrome in ___
- DVTs x 7
- PEs x 3
- IVC filter ___ put on pradaxa (Dabigatran)
- Left knee injury at age ___ s/p multiple surgeries (most recent
___
- PTA of left iliac veins. Stented with 18x90 mm Wallstent with
proximal stent into distal IVC and overlapped with 14x 3 Smart
stent into left distal EIV ___.
- ORIF L tib/fib fracture, left meniscus tear
- Evacuation of abdominal hematoma after football injury at age
___
- Gout
Social History:
___
Family History:
Mother with scleroderma, father with HTN.
Physical Exam:
ADMISSION:
=========
VITALS: 98.4 117/69 64 18 98 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.
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs; left leg swollen
compared
to right with calf erythema demarcated, ulcer over left medial
malleolus without purulence, left calf warm and tender to
palpation; right leg within normal limits
SKIN: As above, left leg erythema and medial malleolus ulcer
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, restricted affect
the patient was examined on the day of discharge.
Pertinent Results:
ADMISSION/SIGNIFCANT LABS:
=========================
___ 04:03PM BLOOD WBC-4.8 RBC-3.53* Hgb-9.8* Hct-30.1*
MCV-85 MCH-27.8 MCHC-32.6 RDW-15.1 RDWSD-46.1 Plt ___
___ 04:03PM BLOOD Glucose-83 UreaN-14 Creat-0.9 Na-139
K-4.3 Cl-104 HCO3-24 AnGap-11
___ 04:03PM BLOOD ALT-10 AST-15 AlkPhos-57 TotBili-0.5
IMAGING/OTHER STUDIES:
=====================
CT leg
1. No soft tissue gas.
2. Soft tissue thickening over the left medial malleolus within
an area of previously demonstrated ulceration. No definite
collection however evaluation limited in the absence of IV
contrast. If needed, ultrasound or MRI may be performed to
further assess.
LABS ON DISCHARGE:
=================
Patient refused all lab draws on admission.
Brief Hospital Course:
# Left leg pain
# ___ syndrome complicated by recurrent VTE:
Patient with history of multiple VTE, previously trialed on
multiple different DOACs with alleged "treatment failure" and
recently transitioned to warfarin, who presented with worsening
leg pain in setting of warfarin nonadherence. Patient also with
ulcer on left medial malleolus and nonpurulent erythema
initially concerning for overlying skin and soft tissue
infection and was given Vancomycin/Zosyn/clindamycin in ED.
However, on arrival to the floor, these changes appeared more
consistent with chronic venous stasis. Further antibiotics were
held and the patient was observed > 24h. In regards to his lower
extremity VTE in the setting of ___, he was initially on
lovenox but repeatedly refused this injection as well as all lab
draws due to his severe phobia of needles. The case was
discussed with many of his outside providers and the overall
conclusion was that any anticoagulant that required injection
(ie lovenox) or frequent lab draws (ie warfarin) would not be a
realistic option due to compliance. He was ultimately resumed on
Xarelto despite the patient's concern that he had failed this
agent in the past. Review of his record indicates he was only
taking 15mg daily instead of the standard 20mg maintenance dose.
Additionally, given that there is high suspicion from multiple
providers that he was not compliant with this medication, it is
not accurate to say that he truly failed therapy. PCP and
hematology follow up arranged at discharge.
# Depression: Continued sertraline
# Opioid use disorder: Held Suboxone in setting of acute per
patient preference. Patient with plan to resume on discharge as
he has done multiple times previously.
TRANSITIONAL ISSUES:
==================
[] Xarelto load of 15mg BID to end ___, afterwards ensure
patient takes 20mg daily.
[] continue to emphasize importance of anticoagulation
adherence.
[] consider CBT or other psychotherapy to address severe phobia
of needles.
> 30 mins spent coordinating discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL TID
2. Gabapentin 800 mg PO QID
3. Sertraline 150 mg PO DAILY
___ MD to order daily dose PO DAILY16
Discharge Medications:
1. Rivaroxaban 15 mg PO BID
with food
RX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice a day
Disp #*40 Tablet Refills:*0
2. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL TID
3. Gabapentin 800 mg PO QID
4. Sertraline 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# leg pain in setting of anticoagulation non-compliance:
# Chronic VTE; ___ syndrome:
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege to care for you at the ___
___. You were admitted with worsening leg pain due to
non-compliance with warfarin. After discussion with your
outpatient providers and our blood clot experts, the decision
has been made to resume Xarelto. You will need to complete a
loading period of taking this medication twice a day until the
___, after which time you will need to transition to 20mg daily
(note that this dose is higher than what you were previously
taking).
Please resume your home suboxone as previously directed by Dr.
___. It is EXTREMELY important that you continue taking
your blood thinner as prescribed and follow up with all
appointments as detailed below.
We wish you the best!
Sincerely,
Your ___ team
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Lower leg swelling, redness, pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with history of ___
syndrome with multiple prior VTE currently on rivaroxaban
presenting with left leg swelling and erythema.
Per review of the chart, the patient was recently admitted from
___ for left leg pain. The patient with history of multiple
VTE, previously trialed on multiple different DOACs. At that
time, patient also with ulcer on left medial malleolus and
nonpurulent erythema initially concerning for overlying skin and
soft tissue infection and was initially treated with
antibiotics,
however, ultimately he was thought not to have an superimposed
infection. Regarding his VTE, he was initially placed on
enoxaparin but he declined this due to phobia of
injection/needles. The case was discussed with his outside
providers, and he was transitioned back to rivaroxaban 15 mg BID
with plan to follow up with hematology after discharge.
Per PCP notes, the patient was subsequently seen at ___ on ___
for left leg swelling and redness. He reportedly had an
ultrasound that showed stable clot burden. He was discharged
with
7 days of cephalexin but he did not fill the prescription.
Instead he took some Bactrim that he had at home for 3 days. He
was seen in his PCP's office on ___ for this issue. He was
recommended to present to the ED for IV antibiotics but he
declined. Instead, he was prescribed a 5-day course of
cephalexin; the patient reports that he took this but his leg
got
progressively worse. Per review of chart, multiple voicemails
were attempted to instruct the patient to extend his antibiotic
course. Regarding his anticoagulation, it appears that he was
prescribed rivaroxaban 15 mg daily on ___. The patient reports
that he has been taking 20 mg BID; it is unclear for how long.
He
reports that he does not take it with food.
He tells me that his leg has progressively worsened beginning on
___, with more redness and swelling. He feels like his leg is
more firm now. No fevers or chills. No other complaints.
In the ED, initial vitals: 96.3 89 136/83 17 100% RA
Exam notable for: Left leg with erythema extending from 4 x 1 cm
left medial malleolar wound encompassing the entire calf and
extending to the medial left proximal thigh. There is no pain
out
of proportion, no crepitus. Patient has intact sensation and
pulses distally.
Labs notable for: WBC 4.5, Hb 9.8, plt 281, PTT 39.6, ___ 28.5,
INR 2.6; BMP, LFTs wnl
Imaging: RLE ultrasound
Patient given: Clindamycin 600 mg IV, ibuprofen 800 mg
On arrival to the floor, the patient reports left leg tightness
and swelling. He has some leg discomfort primarily related to
the
swelling. He states that the wound looks stable to him.
Otherwise, denies any complaints.
Past Medical History:
- ___ Syndrome in ___
- DVTs x 7
- PEs x 3
- IVC filter ___ put on pradaxa (Dabigatran)
- Left knee injury at age ___ s/p multiple surgeries (most recent
___
- PTA of left iliac veins. Stented with 18x90 mm Wallstent with
proximal stent into distal IVC and overlapped with 14x 3 Smart
stent into left distal EIV ___.
- ORIF L tib/fib fracture, left meniscus tear
- Evacuation of abdominal hematoma after football injury at age
___
- Gout
Social History:
___
Family History:
Mother with scleroderma, father with HTN. No known family
history of blood clots.
Physical Exam:
ON ADMISSION:
VITALS: 98.1 120/72 86 20 93 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; left leg firm and
swollen
compared to right leg
SKIN: Ulceration over left medial malleolus without purulence,
erythema extending up calf
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, flat affect
====================
ON DISCHARGE:
GENERAL: Alert and in no apparent distress, appears comfortable,
conversant
EYES: Anicteric
ENT: Ears and nose without visible erythema, masses, or trauma.
CV: RRR, no murmurs/rubs, 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, non-tender to palpation. Bowel
sounds present.
GU: No GU catheter present
MSK: Moves all extremities. Left lower leg slightly more warm
than right
leg, tender to palpation (not exquisitely tender to light
touch), with 1+
edema of foot to knee, focal spots of erythema on
medial/posterior
aspect. RLE without swelling, erythema, warmth or tenderness.
SKIN: Left medial malleolus ulcer
NEURO: Alert, oriented x3, face symmetric, speech fluent, moves
all limbs
PSYCH: Not answering questions except with one or several word
answers, not cooperative, flat affect
Pertinent Results:
LABS ON ADMISSION: (Patient refused any further labs, so no
repeat labs were able to be obtained prior to discharge)
___ 01:29PM BLOOD WBC-4.5 RBC-3.65* Hgb-9.8* Hct-31.9*
MCV-87 MCH-26.8 MCHC-30.7* RDW-15.7* RDWSD-50.4* Plt ___
___ 01:29PM BLOOD Neuts-53.3 ___ Monos-10.7 Eos-6.9
Baso-0.7 Im ___ AbsNeut-2.38 AbsLymp-1.23 AbsMono-0.48
AbsEos-0.31 AbsBaso-0.03
___ 01:29PM BLOOD ___ PTT-39.6* ___
___ 01:29PM BLOOD ___
___ 01:29PM BLOOD Ret Aut-1.7 Abs Ret-0.06
___ 01:29PM BLOOD Glucose-93 UreaN-5* Creat-0.7 Na-138
K-4.1 Cl-99 HCO3-27 AnGap-12
___ 01:29PM BLOOD ALT-13 AST-17 AlkPhos-54 TotBili-0.3
___ 01:29PM BLOOD Lipase-14
___ 01:29PM BLOOD Albumin-3.5 Iron-28*
___ 01:29PM BLOOD calTIBC-250* VitB12-407 Folate-11
Hapto-277* Ferritn-303 TRF-192*
==================
Blood cultures x2 ___: No growth to date
==================
Left lower leg venous ultrasound ___:
Partially occlusive thrombus within the left common femoral
vein, superficial femoral vein and popliteal veins as well as
the posterior tibial veins, not significantly changed from the
most recent prior exam.
Brief Hospital Course:
Mr. ___ is a ___ yo man with ___ Syndrome, multiple
prior DVTs and PEs with IVC filter, opioid use disorder on
Suboxone, anemia, hospitalization in ___ for left lower
leg pain (with left medial malleolus ulcer and LLE DVT) and was
discharged on Xarelto. He saw his PCP ___ ___ for increased
lower leg pain, swelling, erythema and was prescribed Keflex,
but came to the ED with worsening symptoms. LLE ultrasound on
admission showed no significant change in partially occlusive
thrombus of left common and superficial femoral veins and
popliteal veins. He does have a chronic left ankle ulcer, so
there is possibility of superimposed cellulitis, though he has
no signs of systemic infection and was not
improving on oral antibiotics prior to admission.
ACUTE/ACTIVE PROBLEMS:
# Left deep and superficial common femoral and popliteal vein
thrombosis:
# ___ syndrome complicated by recurrent VTE: The patient
has long history of recurrent VTE and non-adherence with
multiple anticoagulation regimens. From my chart review, he has
had mention of left common and superficial femoral vein and
popliteal vein thrombosis dating back as far as ___. On
discharge in ___, he was supposed to finish 15mg BID on
___, then start 20mg daily. The patient is currently on
rivaroxaban and reports taking 20mg BID; he was prescribed 20mg
daily by his PCP ___ ___. His ultrasound shows stable clot
burden, though the patient is more symptomatic. It seems
unlikely that this represents "treatment failure," since it's
unclear whether the patient has been completely compliant and
has not
shown worsening. Of note, patient has a needle phobia and is not
a good candidate for warfarin or enoxaparin per prior
discussions; he frequently declines lab draws due to needle
phobia and in the past coagulation parameters have been
difficult
to monitor. Hematology was consulted, primarily due to concern
that he would not follow through with outpatient appt. He was
supposed to see Dr. ___ on ___ but did not show for
appointment and was last seen in ___ clinic in ___.
Hematology recommended Rivaroxaban 20mg daily, which he was
discharged on.
# Possible left lower leg cellulitis: He was seen at ___ on
___ with stable clot burden and discharged with 7 days of
Keflex, but did not fill and took Bactrim for 3 days that he had
at home, but then saw PCP ___ ___ due to worsening symptoms.
Given that he was supposedly on 10 days of Keflex (starting
___ as prescribed by his PCP, which he says he took, with
worsening symptoms, I was less convinced this was a true
infection. He definitely has notable differences between his
left and right
lower legs in terms of erythema, warmth, swelling and
tenderness, but these could be venous stasis changes related to
his chronic DVT. He had no fever or leukocytosis on admission,
but refused further labs, so could not trend his WBC. He got
Clindamycin 600mg in ED and 1 dose of IV Ceftriaxone on ___.
Due to low suspicion for infection, held further antibiotics
after ___ and his left leg did not show significant changes on
exam after holding and prior to discharge. A photo of his left
leg was taken and uploaded to OMR on ___ for future
comparison. He was treated with PRN Tylenol for pain. Blood
cultures from ___ had no growth at time of discharge.
# Chronic left medial malleolus ulcer: The patient reports this
has been present for ___ years but draining more as his leg
swelling increased. Wound care was consulted and recommended:
- Pressure relief per pressure injury guidelines
Support surface: NP24
Turn and reposition every ___ hours and prn off affected area
- Topical Therapy:
Commercial wound cleanser or normal saline to cleanse wounds.
Pat the tissue dry with dry gauze.
Apply Adaptic
Cover with stacked gauze
Wrap with kerlix
Secure with medipore tape.
Change dressing daily
CHRONIC/STABLE PROBLEMS:
# Depression: He was continued on home Gabapentin 800mg QID,
though was refusing doses intermittently.
# Opioid use disorder: He is followed by ___ clinic at ___,
most recently seen on ___ at which time Suboxone dose was
20mg daily and was given 2 week prescription. Urine tox was
actually negative for buprenorphine when should have been
positive; remainder of tox screen was negative except positive
fentanyl. The patient had said he relapsed prior to that visit.
Continued Suboxone 20mg total daily (8mg-2mg tab: 1 tab in AM,
0.5 tab at noon, 1 tab in ___. Of note, the patient has refused
several doses and was educated on the need to take this
medication consistently. He was prescribed 32 films of Suboxone
by addicition psychiatry on discharge, which is a 12 day supply
and will follow up as outpatient.
# Anemia: Chronic, stable from recent admission. The patient
refused further labs.
==============
TRANSITIONAL ISSUES:
[] Will need rescheduling of missed hematology appointment with
Dr. ___.
[] Monitor for signs of cellulitis of left leg
[] Follow up blood cultures from ___ - no growth to date
==============
Mr. ___ 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. Rivaroxaban 20 mg PO BID
2. Gabapentin 800 mg PO QID
3. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL QAM
4. Buprenorphine-Naloxone Tablet (8mg-2mg) 0.5 TAB SL NOON
5. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL QPM
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Rivaroxaban 20 mg PO DAILY
3. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL QAM
4. Buprenorphine-Naloxone Tablet (8mg-2mg) 0.5 TAB SL NOON
Consider prescribing naloxone at discharge
5. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL QPM
Consider prescribing naloxone at discharge
6. Gabapentin 800 mg PO QID
Discharge Disposition:
Home
Discharge Diagnosis:
Left leg DVT
___ Syndrome
Chronic left ankle ulcer
Opioid use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were hospitalized with left lower leg swelling, redness,
pain, and ultrasound showed that you still have blood clot in
your left leg, without significant change since ___. You
were seen by the hematologists (blood specialists) who recommend
20mg daily of the Rivaroxaban. As we discussed, it is important
to take this dose everyday to help your blood clot and prevent
future blood clots.
You were initially given antibiotic therapy in case of possible
skin infection of your left leg. However, it is less likely
that the pain, swelling, redness is due to infection since you
were not improving on antibiotics before hospitalization and you
have not had a fever and had normal white blood cell count.
However, if you develop fevers or chills or worsening symptoms,
you should see your primary care doctor in case antibiotics are
needed.
You can use Tylenol as needed for pain, but would avoid
ibuprofen, Aleve, aspirin since these can increase risk for
bleeding and you are already on a blood thinner.
As we discussed, it is very important to take your blood thinner
everyday and take your Suboxone as scheduled, without missing
doses. These medications work if they are taken consistently.
Please follow up with your primary care doctor - a sooner
appointment has been requested, but as of now, you have an
appointment on ___.
Followup Instructions:
___
|
10824195-DS-7
| 10,824,195 | 21,741,825 |
DS
| 7 |
2130-03-19 00:00:00
|
2130-03-20 10:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left Leg Pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mr. ___ is a ___ male with past medical history of
___ syndrome, status post both common iliac vein and
external iliac vein stent placement, history of at least five
DVTs and two PEs who, of note, in ___, was seen by Dr. ___
___ had an IVC filter placed and iliac stent and lysis done in
___. He is now presenting with LLE pain and subtherapetuic INR.
Patient went for a long walk yesterday and afterwards he noticed
significant swelling and diffulty bearing weight on LLE. THe
pain is in the L foot and radiates to calf. This pain is lower
than the pain he usually has from his clots. Denies any
abrasions or injury to the foot. He has excrutiating pain when
walking, but better when at rest. The swelling has improved
today, which he attributes to leg elevation.
Patient also states that he has had lateral mallelous ulcer
x6-8 months. He states that it has been waxing and waning in its
severity but since his swelling has worsened, the ulcer has
worsened as well. The ulcer drains clear fluid intermittently.
Patient has had diffuculty with anticaogulation for ___
syndrome due to fear of lab draws. He goes to ___ for
anticoagulation management. He has been lost to follow up
several times. Patient has been on pradaxa in the past, but was
transitioned to ___ due to question of treatment failure.
This switch was made during recent hospitaliation at ___
___, admitted for LLRE pain and swelling). His goal INR
2.5-3.5. He states that his last INR check was on ___,
at which time his INR was 3.0. Patient states that he has been
compliant with his warfarin. He took 5mg daily for the last
three days and has been dosing his coumadin based on recs from
___.
His recent INRs and warfarin doses are as follows:
___ 5 mg (INR 2.4)
___ 5 mg
___ 7.5 mg (INR 1.8)
___ 7.5 mg
___ 5 mg (INR 2.4)
___ INR 3.0
___ INR 3.0
___ INR 3.0, 5mg
In the ED, initial vitals were: 98.7 90 128/72 16 99% RA
- Labs were significant for INR 1.2
- Imaging revealed
U/S - 1. Right: No evidence of right lower extremity deep vein
thrombosis.
2. Left: Nonocclusive thrombus of the paired superficial
femoral veins (deep
veins) extending to the popliteal veins.
- The patient was given
___ 17:07 PO/NG Lorazepam 1 mg
___ 19:21 PO/NG HYDROmorphone (Dilaudid) 4 mg
___ 19:23 SC Enoxaparin Sodium 90 mg
He was seen by vascular in the ED who recommended ACE wrap and
no necessity for vascular intervention at this time.
Upon arrival to the floor, patient stated that he had ongoing
LLE pain, though somewhat improved from prior. He is concerned
that he will no longer be able to get INR checks at ___
since he moved farther away.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
PMH: ___ syndrome, multiple DVT's, PE x2
PSH: L CIV/EIV stent placement, ORIF L tib-fib fracture
Social History:
___
Family History:
No h/o clotting disorder or DVT.
Physical Exam:
ADMISSION
Vitals: 98.1, 126/70, 78, 20, 98/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. ___ scar
present from prior cholecystectomy.
GU: No foley
Ext: Warm, well perfused, 2+ distal pulses,. Mild non-pitting
swelling of LLE. L calf 16cm, R calf 15cm in circumference. No
erythema. Mild tenderness to palpation distally, half way up L
calf. Full ankle and knee ROM. L lateral malleolus superficial
ulceration without surrounding erythema or drainage.
Neuro: AOx3, grossly normal sensation, 2+ reflexes bilaterally,
gait deferred.
DISCHARGE
Vitals: T 98.2 BP 120/82 HR 65 R 20 SpO2 98ra
GEN: NAD
___: RRR, no MRG
RESP: CTAB, no increased WOB
ABD: NTND
EXT: ___: warm, pulses 2+ b/l. Sensation intact b/l. trace
pitting edema LLE up to knee. Encouraged superficial veins LLE
Pertinent Results:
ADMISSION
___ 06:00PM BLOOD WBC-3.9* RBC-4.34* Hgb-12.5* Hct-37.7*
MCV-87 MCH-28.8 MCHC-33.2 RDW-14.3 RDWSD-45.1 Plt ___
___ 06:00PM BLOOD Neuts-43.9 ___ Monos-12.5 Eos-4.1
Baso-0.8 Im ___ AbsNeut-1.73# AbsLymp-1.51 AbsMono-0.49
AbsEos-0.16 AbsBaso-0.03
___ 06:00PM BLOOD ___ PTT-26.1 ___
___ 06:00PM BLOOD Glucose-93 UreaN-11 Creat-1.1 Na-139
K-5.3* Cl-102 HCO3-27 AnGap-15
PERTINENT
___ 05:40AM BLOOD Calcium-9.4 Phos-8.8*# Mg-2.2 Iron-57
___ 05:40AM BLOOD calTIBC-311 Ferritn-50 TRF-239
___ 05:40AM BLOOD LD(LDH)-139 CK(CPK)-76
DISCHARGE
___ 05:30AM BLOOD WBC-4.2 RBC-4.45* Hgb-12.8* Hct-38.2*
MCV-86 MCH-28.8 MCHC-33.5 RDW-14.0 RDWSD-42.9 Plt ___
___ 05:30AM BLOOD Glucose-86 UreaN-12 Creat-1.0 Na-139
K-3.8 Cl-101 HCO3-24 AnGap-18
___ 05:30AM BLOOD Calcium-9.8 Phos-4.8* Mg-2.0
STUDIES
Radiology Report BILAT LOWER EXT VEINS Study Date of ___
IMPRESSION:
1. Left: Nonocclusive thrombus of paired proximal superficial
femoral veins to the paired popliteal veins. The left common
femoral vein is without clot and has normal compressibility and
wall to wall color flow. Overall, there is decreased clot
burden.
2. Right: No right lower extremity deep vein thrombosis.
Radiology Report KNEE (AP, LAT & OBLIQUE) LEFT Study Date of
___
IMPRESSION:
THERE IS TRICOMPARTMENTAL HYPERTROPHIC SPURRING WITHOUT JOINT
EFFUSION. IN THE ABSENCE OF A LATERAL VIEW, IT IS DIFFICULT TO
ASSESS FOR COMPARTMENTAL NARROWING. NO EVIDENCE OF FRACTURE OR
STRESS FRACTURE.
Radiology Report FOOT AP,LAT & OBL LEFT Study Date of ___
IMPRESSION:
There is no evidence of fracture or dislocation or appreciable
calcaneal
spurs.
Brief Hospital Course:
Patient is a ___ with a PMHx of ___ syndrome complicated
by multiple DVTs and PE, currently on warfarin who presents with
LLE pain and subtherapeutic INR.
#LLE pain: Pain persistent, given the encouraged superficial
veins and being subtherapeutic INR on admission, this is likely
from another DVT. Vascular surgery has evaluated the patient and
does not feel that there is another surgical intervention to be
done at this time. Exam reassuring for compartment syndrome,
seen by vascular in the ED. Ortho rec's plain film of foot,
ankle and knee to r/o stress Fx which were all negative. On
___ patient was switched to oxycontin 30mg q12H and oxycodone
___ q3H PRN pain which significantly improved his pain.
Patient was able to ambulate with walker with success.
- ACE wrap and elevation
-work on weaning pain medication as outpatient
- anticoagulation as below
#Subtherapeutic INR: patient has had therapeutic INRs recently
per patient at ___ at ___. Goal INR 2.5-3.5. He expressed
concern that he can no longer get his INR checked at ___
since he recently moved. He is afraid of needles, however, and
doesn't want to go somewhere where he will need blood draws for
INR check. Warfarin was increased to 7.5 given subtherapeutic
INR while being bridged with lovenox
- continue warfarin
- bridge with lovenox (goal INR 2.5-3.5)
- trend INR
___ ulcer: patient has had ulceration in the past, now with
worsening of chronic ulcer. likely worsening in the setting of
swelling. no signs of infection at this point on exam.
#Pancytopenia: patient p/w anemia and leukopenia. Has had
similar anemia in the past, but leukopenia is new, though now
imroved. No localizing signs of infection to explain leukopenia.
LDH wnl. Fe studies wnl.
#Depression
- continue home sertraline, gabapentin, and buproprion
TRANSITIONAL ISSUES
[ ] PLEASE ATTEMPT TO WEAN PAIN MEDICATION
[ ] D/C LOVENOX WHEN INR AT GOAL X2 (2.5-3.5)
[ ] PLEASE FOLLOW UP CBC TO ENSURE ANEMIA AND LEUKOPENIA HAVE
RESOLVED
[ ] WARFARIN INCREASED TO 7.5MG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 5 mg PO DAILY16
2. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain
3. Gabapentin 300 mg PO BID
4. Sertraline 50 mg PO DAILY
5. Gabapentin 600 mg PO QHS
6. BuPROPion (Sustained Release) 100 mg PO QAM
Discharge Medications:
1. BuPROPion (Sustained Release) 100 mg PO QAM
2. Gabapentin 300 mg PO BID
3. Gabapentin 600 mg PO QHS
4. Sertraline 50 mg PO DAILY
5. Warfarin 7.5 mg PO DAILY16
6. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
7. Enoxaparin Sodium 90 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 100 mg/mL 90 mg every twelve (12) hours Disp #*60
Syringe Refills:*0
8. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q3h Disp #*56 Tablet
Refills:*0
9. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
RX *oxycodone [OxyContin] 30 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*60 Tablet Refills:*0
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*1
11. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tb by mouth twice a day Disp
#*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Deep Vein thrombosis
___ Syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(CRUTCHES)
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you in the hospital. You came
to the hospital because of pain in your leg. We think that this
is most likely from your blood clots. We gave you medication for
your pain and increased your warfarin dose. We also needed to
start you on another blood thinner until the new warfarin dose
takes affect.
Your medications and follow up appointments are detailed bellow.
We wish you the best!
Your ___ care team
Followup Instructions:
___
|
10824215-DS-11
| 10,824,215 | 20,464,761 |
DS
| 11 |
2154-05-21 00:00:00
|
2154-05-23 12:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Dilaudid / azithromycin / vancomycin / Rocephin / morphine
Attending: ___.
Chief Complaint:
bilateral leg and knee pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ 17 weeks pregnant female PMHx sickle cell
anemia and h/o peripartum UE DVT on ___ who presents for
ongoing management of sickle cell crisis after being discharged
from ___ on ___ for her sickle cell crisis.
She has been having bilateral leg pain (mostly extending from
her knees up) consistent with prior pain crises. She has not
had any rash, joint swelling, no vaginal bleeding/discharge,
dysuria, abdominal pain. She also denies any infectious
symptoms of fever/chills.
Per ED report, she was initially admitted to ___ where she had a
complex admission for pain crisis with difficulty weaning her
off morphine PCA and IV Benadryl 50 mg q3h with concern for
addictive potential related to the IV Benadryl (she has morphine
allergy but tolerates the morphine with Benadryl). During this
hospitalization, both Psychiatry and MFM were closely involved.
The patient ultimately decided to transfer her OB and Hem/Onc
care (previously followed by hematologist Dr. ___ at ___
___ to ___.
In the ED, initial VS 98.3, 98, 103/79, 18, 100% on RA. Exam
showed TTP of her knees and quadriceps without any appreciable
effusion or deformity. Fetal heart tones were intact with HR
140. Initial labs showed wnl chemistries, LDH 175, WBC 15.7,
Hgb 9.1, Plt 483. Retic-Aut 7.2, Abs-Ret 0.28. Lactate 1.0.
UA notable for moderate leuks, negative nitrites, 1 WBC, few
bacteria, 1 Epi. The patient was given 1L NS and morphine x 2
with Benadryl prior to transfer to the floor.
Upon arrival to the floor, the patient reports ongoing pain of
her BLE which prohibit her from walking. She states that during
her pregnancies, she experiences frequent pain crises because
she cannot take her hydroxyurea. She is not sure what
precipitated her pain crisis but states that her typical
triggers are cold weather, dehydration, and stress. She does
not significant social stressors recently (having to move
recently, etc.).
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:
Prenatal Care:
-___ ___ by U/S on ___
-Prenatal labs: Rh positive; remainder of labs not available
-U/S ___: NT 2.3mm, normally shaped gestational sac, CRL
12.3wks 55mm --> pt denies any subsequent ultrasounds
-Issues:
#sickle cell disease: FOB sickle trait. Multiple hospital
admissions in pregnancy for pain crises.
#chronic pain, chronic opioid use
#hx peripartum UE DVT: on lovenox 40mg QD
#transfer of care: Was seeing ___ MD at ___.
#NIPT with XXX: s/p ___ genetics c/s ___. per records, was
considering amnio, but pt declined further w/u as of today.
maternal karyotype 46XX.
#Hx 35w PPROM: Was offered IM vs PV by ___ provider. Started on
PV progesterone during ___ admission ___.
#Admission to ___ ___ with acute pain crisis (back pain,
chest pain, but no acute chest syndrome). Hct nadir 24. No e/o
significant hemolysis. Per discharge summary, pt was on home
regimen of MS ___ ___ and oxycodone 20mg q3h at
admission. Treated with morophine PCA + home regimen, IVF.
Uptitrated to MS ___ 45mg TID, Oxycodone 30mg q6h. Discharged
without narcotic rx.
#Admission to ___ ___: for bilateral leg/knee pain, pain
crisis. See HPI. Left AMA.
ObHx:
-___
-G1: ___, SAB
-G2: ___, SVD, 35w PPROM, multiple hospital admissions for
sickle cell pain crises; neonate hospitalized for ___ weeks due
to neonatal abstinence syndrome, pt on high doses of narcotics
throughout pregnancy
-G3: ___, SAB
-G4: current
PMH:
-Sickle cell disease: Hemoglobin S/beta-thalassemia null (HbS/0)
disease. Recurrent admissions for pain crises. Flares are
sometimes intense and sudden onset. Other times more indolent.
Difficult IV access. Off hydroxyurea since ___ due to
pregnancy.
-History of acute chest syndrome
-History of bilateral avascular necrosis of femoral heads and
shoulder
-Opioid dependence: Per ___ records, has signed narcotic
contract
in ___ and "she agreed to not receive pain medicines from any
other office aside from the ___ Primary Care
Associates."
Review of records shows MS-Contin use dating back to ___.
Records confirm pt receives IV/PO Benadryl with morphine because
of hives vs rash.
-Chronic pain
-Peripartum BUE DVT, dx ___ ___, 3 months postpartum, on
Depo-Provera. Anticoagulated x 6 months. Per records, DVT in UE
recurred in ___ ___enies.
-Hx retropharyngeal abscess ___ at ___, treated w
clindamycin
-Dental abscess
-Hx retinopathy in R eye ___
-Hx MRSA positivity ___: Rpt swab ___ negative.
PSH:
- Splenectomy
- Cholecystectomy
- Port cath placement in right subclavian given difficult
peripheral access
- R hip repair for avascular necrosis
- shoulder exploration for avascular necrosis
Social History:
___
Family History:
Both parents with sickle cell trait. Her daughter is a carrier.
Physical Exam:
On day of discharge:
VS: afebrile, wnl
Gen: well-appearing, NAD, ambulating with minimal assistance
around room
Resp: nl resp effort
Abd: soft, non-tender, gravid
Ext: mild tenderness to palpation in bilateral knees and
anterior thighs, no edema
Pertinent Results:
___ 07:00PM BLOOD WBC-15.7* RBC-3.84* Hgb-9.1* Hct-28.4*
MCV-74* MCH-23.7* MCHC-32.0 RDW-14.8 RDWSD-37.3 Plt ___
___ 07:00PM BLOOD Neuts-71.3* Lymphs-17.0* Monos-4.5*
Eos-6.2 Baso-0.4 NRBC-1.7* Im ___ AbsNeut-11.20*
AbsLymp-2.68 AbsMono-0.71 AbsEos-0.97* AbsBaso-0.06
___ 03:54PM BLOOD WBC-15.6* RBC-3.81* Hgb-9.1* Hct-27.5*
MCV-72* MCH-23.9* MCHC-33.1 RDW-14.6 RDWSD-35.7 Plt ___
___ 07:15AM BLOOD WBC-13.9* RBC-3.29* Hgb-7.9* Hct-24.0*
MCV-73* MCH-24.0* MCHC-32.9 RDW-14.3 RDWSD-35.9 Plt ___
___ 05:52AM BLOOD WBC-13.1* RBC-3.40* Hgb-8.1* Hct-24.8*
MCV-73* MCH-23.8* MCHC-32.7 RDW-14.1 RDWSD-35.5 Plt ___
___ 07:00PM BLOOD ___ PTT-29.1 ___
___ 07:00PM BLOOD Ret Aut-7.2* Abs Ret-0.28*
___ 07:00PM BLOOD Glucose-78 UreaN-5* Creat-0.5 Na-135
K-4.2 Cl-102 HCO3-21* AnGap-16
___ 03:54PM BLOOD Glucose-91 UreaN-4* Creat-0.5 Na-132*
K-4.1 Cl-99 HCO3-20* AnGap-17
___ 07:15AM BLOOD Glucose-89 UreaN-4* Creat-0.5 Na-137
K-3.7 Cl-105 HCO3-20* AnGap-16
___ 05:52AM BLOOD Glucose-96 UreaN-3* Creat-0.5 Na-135
K-3.8 Cl-104 HCO3-22 AnGap-13
___ 07:00PM BLOOD LD(LDH)-175
___ 03:54PM BLOOD ALT-28 AST-27 LD(LDH)-180 AlkPhos-160*
TotBili-0.4
___ 07:15AM BLOOD LD(LDH)-139
___ 07:00PM BLOOD Calcium-10.2 Phos-4.3 Mg-1.7
___ 03:54PM BLOOD Calcium-9.6 Phos-3.5 Mg-1.7
___ 07:15AM BLOOD Calcium-8.8 Phos-4.2 Mg-1.7
___ 05:52AM BLOOD Calcium-9.3 Phos-3.8 Mg-1.8
___ 07:00PM BLOOD Hapto-51
___ 07:09PM BLOOD Lactate-1.0
___ 08:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-MOD
___ 08:15PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-1
___ 04:20PM URINE Color-Straw Appear-Clear Sp ___
___ 04:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 04:50PM URINE bnzodzp-NEG barbitr-NEG opiates-POS*
cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG marijua-NEG
___ 8:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ CXR:
IMPRESSION:
No previous images. There is a right IJ Port-A-Cath that
extends to the level of the cavoatrial junction or upper right
atrium. The cardiac silhouette is within normal limits and
there is no vascular congestion, pleural effusion, or acute
focal pneumonia. There may be mild atelectatic changes above the
elevated right hemidiaphragm
Brief Hospital Course:
Ms. ___ is a ___+ weeks pregnant female PMHx sickle cell
anemia, h/o peripartum UE DVT on Lovenox, chronic pain and
chronic opioid use, hx PPROM who presents for ongoing management
of sickle cell crisis after being discharged from ___ on ___
for her sickle cell crisis.
# Sickle cell crisis:
Patient p/w ongoing pain crisis after being discharged from ___
on day of admission for the same presentation. Here, her labs
were consistent with likely chronic compensated hemolysis (___
is reassuringly wnl, haptoglobin is normal) given her
reticulocytosis. There was not evidence of acute chest syndrome.
Unclear what the precipitant of her pain crisis was, though
patient has been admitted for same presentation for most of past
6 weeks so suspect significant element of chronic pain, with
exacerbation of pains symptoms in pregnancy while off
hydroxyurea. No infectious symptoms. Patient was continued on
home dose of MSContin, and initially treated with a Morphine PCA
(as she has been on at ___. She was seen by Hematology/Oncology
who recommended pain control and O2. She was seen by chronic
pain service. She reported mild improvement in symptoms on
hospital day 3 and was transitioned off of PCA and started on
home dose of oxycodone (30mg q6h). She also reported needing IV
Benadryl while using morphine PCA due to history of allergy
(?hives versus rash). There was concern at ___ per records re
addictive behavior regarding benadryl; this was continued only
while she was using the PCA. She was recommended to remain
inpatient for further monitoring off her symptoms on home
regimen, but she declined and left the hospital against medical
advice. She had reported significant immobility due to her
symptoms upon arrival to the hospital. A ___ consult was
requested but they were unable to see the patient prior to her
discharge. She was able to ambulate with minimal assistance on
the day of discharge.
#Chronic pain, chronic opioid use:
Patient has a significant narcotic regimen that predates the
pregnancy by many years. She has seen her PCP for approximately
the last year, Dr. ___ at ___, who prescribes the narcotics
and has a narcotics contract with her. He was contacted upon her
admission and her history was reviewed. She has seen multiple
chronic pain specialists but without regular follow-up care
anywhere and has remained on chronic short and long acting
opioids for many years. She was not provided with any
prescriptions for opioids upon discharge.
*) Hx BUE DVT:
The patient reports being on prophylactic lovenox 40mg QD for at
least last month of pregnancy. This was continued during her
admission. It is unclear if she has ever had a thrombophilia
work-up in past and this will be re-addressed as an outpatient.
*) Hx PPROM:
Per report, the patient had PPROM at 35 weeks in her prior
pregnancy. She was counseled re progesterone supplementation in
this pregnancy to decrease the risk of recurrent PPROM/PTL, and
offered IM vs PV progesterone. She was started on PV
progesterone during her inpatient stay at ___. She was continued
on this regimen while here. The decision to continue PV vs IM
progesterone will be re-addressed at her outpatient visit, but
she was recommended to continue PV for now at the time of
discharge.
*) NIPT with XXX:
Patient did not report any problems with the fetus at the time
of admission but review of records noted NIPT results notable
for XXX. Per summative discharge notes, patient was seen by
genetic counseling at ___. Per patient's report, she was told
that results were "not a big deal" and she did not need any
further testing. Patient was briefly counseled re NIPT results,
including potential for placental mosaicism, and neonatal
implications of XXX aneuploidy, and option for amniocentesis for
diagnostic testing. Patient underwent a bedside ultrasound that
showed normal appearing fetus with appropriate fluid levels.
Patient was recommended to see genetic counselors for further
counseling and advised to continue inpatient admission to
expedite formal ultrasound and genetic counselor appointment.
Patient declined and decided to leave hospital against medical
advice.
*) Routine prenatal care:
Patient has received all of her prenatal care at ___ but reports
she would like to trasnfer her care to ___. This was
reaffirmed on the day of discharge. A request to ___ schedulers
will be sent to set up outpatient appointments. Once
established, patient will need:
-Medical records release to obtain prenatal labs and outpatient
prenatal records from
current pregnancy and prior pregnancy
-Anesthesia consult
-SW consult
-NICU consult given hx NAS, opioid use
#Dispo:
Patient was discharged home on hospital day 3, against medical
advice. Precautions were reviewed. Prescriptions were provided
for vaginal progesterone alone. An outpatient appointment with
___ will be set up for prenatal care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Morphine SR (MS ___ 30 mg PO Q12H
2. OxyCODONE (Immediate Release) 30 mg PO Q6H:PRN Pain -
Moderate
3. Morphine SR (MS ___ 15 mg PO NOON
4. FoLIC Acid 1 mg PO DAILY
5. Prenatal Vitamins 1 TAB PO DAILY
6. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
Discharge Medications:
1. proGESTerone micronized 200 mg vaginal QHS prevention of
recurrent preterm delivery
RX *progesterone micronized [Endometrin] 100 mg Insert two
tablets iinto vagina nightly. Disp #*60 Insert Refills:*3
2. Enoxaparin Sodium 70 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
3. FoLIC Acid 1 mg PO DAILY
4. Morphine SR (MS ___ 30 mg PO Q12H
5. Morphine SR (MS ___ 15 mg PO NOON
6. OxyCODONE (Immediate Release) 30 mg PO Q6H:PRN Pain -
Moderate
7. Prenatal Vitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
sickle cell pain crisis
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 in the setting of leg pain
consistent with a sickle cell crisis. We attempted to control
your pain in the hospital and had the Hematology Oncology team
consulted in your care. We recommended that you remain in the
hospital for further titration of your pain medications, however
you have decided to leave the hospital against medical advice.
Dr. ___ has spoken with you extensively about your
options and our recommendation for you to remain in the
hospital, however you have clearly expressed your desire to go
home. Please call you primary physician ___ to make an
appointment this week to discuss your pain medications. Given
your history of short cervix, you were given a prescription for
vaginal progesterone, which you should continue every night.
Followup Instructions:
___
|
10824358-DS-15
| 10,824,358 | 23,560,463 |
DS
| 15 |
2163-03-17 00:00:00
|
2163-03-17 15:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Hypertension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ y/o male with no significant PMH who presents
from ___ clinic with BP to 213/128 in left arm and
183/123 in the right arm. The patient denies a personal history
of hypertension but does note that his mother had hypertension.
The patient denies chest pain, SOB, headaches, vision changes.
He reports he has no symptoms at all, and exercises daily.
In the ED, initial vitals were: T 98.9, HR 96, BP 203/125, RR
18, O2 99% RA. Labs were notable for normal chem-7 including Cr
of 1.1 and a normal CBC and U/A with trace protein, otherwise
bland. EKG per report was unremarkable. CXR was negative. BP
peaked at 224/133. He was given 6.25mg of PO captopril and then
10mg IV hydralazine with reduction of his BP to 175/94. VS prior
to transfer: 82 166/83 35 99% RA.
On the floor, patient currently feels very well. He remains
asymptomatic and denies headache, chest pain, SOB. His BP is
160/88 on the floor.
Past Medical History:
-Basal Cell Carcinoma
Social History:
___
Family History:
Father passed away from MI. Mother has hypertension and is ___.
Older sibling with no medical issues.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: 97.6; 160/88; 84; 20; 100/RA
General: Pleasant male in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
murmur best heard at the apex. no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, moving all extremities
Skin: Face, torso, and back erythematous from sunburn,
blanching.
PHYSICAL EXAM ON DISCHARGE:
Vitals: 97.7; 151/92(current) - 162/78; 70-88; 20; 96/RA
General: Pleasant male in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
murmur best heard at the apex. no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, moving all extremities
Skin: Face, torso, and back erythematous from sunburn,
blanching.
Pertinent Results:
LABS ON ADMISSION:
===========================
___ 07:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 07:00PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 03:25PM GLUCOSE-91 UREA N-15 CREAT-1.1 SODIUM-138
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14
___ 03:25PM WBC-9.9 RBC-5.04 HGB-15.4 HCT-42.3 MCV-84
MCH-30.6 MCHC-36.4* RDW-13.8
___ 03:25PM NEUTS-64.7 ___ MONOS-6.4 EOS-1.8
BASOS-0.8
IMAGING:
===========================
Echocardiogram ___
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The ascending
aorta is mildly dilated. The aortic arch is mildly dilated. The
number of aortic valve leaflets cannot be determined. There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. The presence/absence
of mitral valve prolapse cannot be determined. An eccentric,
anteriorly directed jet of Mild to moderate (___) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Preserved regional/global
left ventricular systolic function. Eccentric jet of
mild-moderate mitral regurgitation (possibly underestimated).
LABS ON DISCHARGE:
============================
___ 06:42AM BLOOD Glucose-105* UreaN-17 Creat-1.0 Na-140
K-3.9 Cl-104 HCO3-26 AnGap-14
___ 03:25PM BLOOD %HbA1c-5.6 eAG-114
Brief Hospital Course:
Mr. ___ is a ___ y/o male with no significant PMH, who has not
seen a physician ___ ___ years, who presented from ___
clinic with hypertensive urgency.
ACUTE ISSUES:
=======================
# Hypertensive Urgency: Patient remained asymptomatic
throughout hospitalization. There were no signs of end organ
damage as patient mentated well, Creatinine was 1.1. U/A showed
trace protein but was otherwise bland. There were no signs of
ischemia on EKG. Patient received 6.25 mg PO captopril and 10mg
IV hydralazine in ED with SBP drop from 224 to 175. Because
patient's baseline BP was unknown, attempted to not drop BP too
fast overnight (kept within ___ of peak BP) in order to avoid
possible ischemia. His blood pressure remained in the 150-160s
on the floor. Patient was started on lisinopril 20mg and
amlodipine 5mg the next day and was discharged with close PCP
___. He also underwent an echocardiogram which showed mild
symmetric LVH with preserved EF >55% and mitral regurgitation.
# Health maintenance: Because he has hypertension, checked A1c,
which was 5.6
TRANSITIONAL ISSUES:
===============================
- Patient has new PCP appointment scheduled for ___. Please
___ electrolytes and blood pressure. ___ need to adjust
lisinopril or amlodipine dose.
- Suggested that patient get Omron BP cuff and check BP BID
until PCP ___.
- Consider evaluation for secondary causes of hypertension if
suboptimal response to current regimen initiated
Medications on Admission:
none
Discharge Medications:
1. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Hypertensive urgency
Stage II hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to participate in your care at ___. You were
admitted to the hospital because your blood pressure was found
to be extremely elevated when you were seeing the dermatologist.
We gave you some medication to drop your blood pressure and
switched you over to lisinopril 20mg and amlodipine 5mg for long
term blood pressure control. It is very important that you see
your new PCP, ___, to ___ on your blood pressure
and electrolytes. You may need to have your blood pressure
medication doses adjusted. You also had an echocardiogram to
evaluate your heart and can ___ on the results with Dr.
___.
It is recommended that you check your blood pressure at home. A
good blood pressure cuff to buy is called Omron. Should you be
able to get this prior to your upcoming new primary care
appointment please bring a log of your blood pressure readings
with you.
We wish you the best!
Your ___ team
Followup Instructions:
___
|
10824694-DS-28
| 10,824,694 | 21,593,594 |
DS
| 28 |
2156-05-10 00:00:00
|
2156-05-12 17:39:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nitroimidazole Derivatives / Levofloxacin / Meperidine / Bactrim
/ Flagyl / morphine / Zofran / steri strips / atenolol
Attending: ___.
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
___: ___ guided subcapsular abscess drainage and drain
placement
___: PTBD upsize and replacement
History of Present Illness:
Ms. ___ is a ___ w/ complicated PMH including multiple
abdominal surgeries including s/p fundoplication, pyloroplasty,
gastrojejunostomy, sphincteroplasty, CBD stent, intestinal
dysmotility s/p sigmoid stricture dilation, numerous ERCPs and
billiary stents placed due to recurrent stones and sludge who
presents with intractable RUQ pain.
She most recently underwent a cholangiogram on ___ per ___
which showed a moderate stenosis of the ampulla. She underwent
ampullary balloon plasty and a right internal/external biliary
catheter was placed. Since that time the pt has continued to
have RUQ pain requiring multiple hospitalizations and clinic
visits. She reports that over the past 4 days she has
experienced subjective fevers/chills as well as acute worsening
of her RUQ pain associated with nausea. Today, she developed
shaking chills with abdominal pain radiating to her right
shoulder. She has had minimal output from her biliary catheter,
but she says over the weekend, her drain appeared to be
"clogged". She has been able to take POs and denies any vomiting
or diarrhea.
___ the ED, initial vitals: 100.2 95 116/73 18 98% RA
Labs were significant for WBC 15.6 (85.6% PMNs) H/H 13.2/40.6
Plt 272
Na 133 K 4.5 Cl 92 HCO3 24 BUN 15 Cr 0.7
ALT 57 AST 55 AP 227 T bili 0.3 Alb 4.0
Lactate 1.6
CT abdomen w/contrast showed 4.3 cm rim enhancing subcapsular
collection adjacent to biliary drain with several punctate foci
of gas, concerning for hepatic abscess.
Patient was given 650 mg PO Tylenol and 4.5 g pip/tazo. ___ was
consulted and felt that her severe RUQ pain was ___ the
subcapsular liver abscess seen on CT abdomen and they will plan
to drain the abscess and upsize her current PTBD on ___.
Upon arrival to the floor, initial VS 98.4, 122/73, 72, 16, 98%
on RA.
Past Medical History:
Dilated ___ portion-structural vs functional.
GERD/gastroparesis-fundoplication ___
Anxiety
Intestinal dysmotility
Pelvic floor prolapse
Levator spasm
HTN
Uterine cancer s/p hysterctomy
Sphincteroplasty/pyloroplasty ___ ___, ___
SB enteroscopy, ___, no evidence for obstruction seen.
Social History:
___
Family History:
Father just passed away. Mother died of lung cancer; one brother
died of CAD; another brother died from a brain tumor. Her
husband is ill and is undergoing evaluation at this time as
well.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.4, 122/73, 72, 16, 98% on RA
GEN: Alert, thin elderly female lying ___ bed, intermittently ___
moderate discomfort with episodic abdominal pain
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor,
anicteric sclera
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi, no labored
respirations
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, significant TTP of R flank, R PTBD with clean/intact
dressing, not output from PTBD (clamped)
EXTREM: Warm, well-perfused, no edema
NEURO: AOx3, grossly nonfocal
DISCHARGE PHYSICAL EXAM:
Vitals: T98.2 107/70 61 18 99% RA
GENERAL - Alert, interactive, thin
HEENT - sclerae anicteric, MMM, OP clear
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB
ABDOMEN - Biliary drain ___ RUQ with clean bandages draining
bilious fluid; ___ abscess drain ___ place draining minimal clear
fluid. scaphoid abdomen
EXTREMITIES - WWP, no c/c, no edema
Pertinent Results:
ADMISSION LABS:
___ 03:05PM BLOOD WBC-15.6*# RBC-4.32 Hgb-13.2 Hct-40.6
MCV-94 MCH-30.6 MCHC-32.5 RDW-12.2 RDWSD-42.2 Plt ___
___ 03:05PM BLOOD Neuts-85.6* Lymphs-6.5* Monos-6.4
Eos-0.4* Baso-0.3 Im ___ AbsNeut-13.31* AbsLymp-1.01*
AbsMono-1.00* AbsEos-0.06 AbsBaso-0.04
___ 03:05PM BLOOD Glucose-99 UreaN-15 Creat-0.7 Na-133
K-4.5 Cl-92* HCO3-24 AnGap-22*
___ 03:05PM BLOOD ALT-57* AST-55* AlkPhos-227* TotBili-0.3
CT AB/PELVIS
1. The status post placement of an internal-external biliary
drain with a 4.3 cm rim enhancing subcapsular collection
adjacent to the drain, concerning for abscess. Several punctate
foci of gas are seen beneath the right
hemidiaphragm. Inflammatory changes and fat stranding are seen
within the
soft tissues of the right abdomen along the drain tract.
2. Mild persistent intra hepatic biliary ductal dilatation.
3. Interval development of subcentimeter hypodensity within
segment 8 raises concern for developing hepatic abscess.
4. Splenomegaly.
ABSCESS DRAINAGE/PTBD REPLACEMENT
1. Successful exchange of existing percutaneous transhepatic
biliary drainage catheters with new 12 ___ right posterior
PTBD.
2. Successful placement of an 8 ___ pigtail drainage
catheter and
pericapsular liver abscess. Purulent material from the abscess
was sent to microbiology for analysis.
CXR
New right PICC line terminates ___ the low SVC. There is no
pneumothorax.
___ 3:00 pm ABSCESS Source: Liver.
**FINAL REPORT ___
GRAM STAIN (Final ___:
Reported to and read back by ___ @ ___ ON ___
- ___.
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Final ___:
MIXED BACTERIAL FLORA.
Due to mixed bacterial types [>=3] an abbreviated
workup is
performed; all organisms will be identified and
reported but only
select isolates will have sensitivities performed.
ESCHERICHIA COLI. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ENTEROCOCCUS SP.. SPARSE GROWTH.
CIPROFLOXACIN Sensitivity testing per ___ STACK
(___).
VIRIDANS STREPTOCOCCI. RARE GROWTH.
___ ALBICANS. RARE GROWTH. Yeast Susceptibility:.
Fluconazole MIC=0.25 MCG/ML = SUSCEPTIBLE.
Antifungal agents reported without interpretation lack
established
CLSI guidelines. Results were read after 24 hours of
incubation.
Sensitivity testing performed by Sensititre.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ 4 S <=2 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R <=0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PENICILLIN G---------- 4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
DISCHARGE LABS:
___ 05:27AM BLOOD WBC-5.4 RBC-3.51* Hgb-10.8* Hct-33.8*
MCV-96 MCH-30.8 MCHC-32.0 RDW-12.2 RDWSD-42.5 Plt ___
___ 05:27AM BLOOD Glucose-87 UreaN-13 Creat-0.6 Na-140
K-3.8 Cl-105 HCO3-27 AnGap-12
___ 06:51AM BLOOD ALT-31 AST-22 AlkPhos-163* TotBili-0.2
Brief Hospital Course:
Ms. ___ is a ___ female with a complex past surgical history
who underwent Right PTBD placement and ampullary balloon plasty
on ___ for ampullary stenosis who presents with severe right
upper quadrant pain and found to have a subcapsular liver
abscess.
# Subscapular liver abscess:
# Sepsis:
Thought to be due to leakage of bile around PTBD that was
recently placed. Patient underwent ___ guided aspiration and
drainage with JP drain placed. Patient placed on Zoysn on
admission. Leukocytosis, fevers improved with therapy. ID
consulted for antibiotic course and recommended Zosyn 4.5g Q8h
for 2 weeks with follow up to determine further course. PICC
line placed on this admission and home infusion set up. On
discharge, there was minimal output from JP drain. She will
follow up with ___ ___ 1 week for evaluation and possible removal
of JP drain.
#Ampullary Stenosis: Recent admission for PTBD placement with
ampullary dilatation. Followed by ___ of ___ and Dr.
___ ___. PTBD was uncapped on discharge per ___ instructions.
# Malnutrition: Current weight 95lbs. Patient is under ideal
body weight likely due to recurrent illness and RnY surgery.
Does not want TPN or TF which she has had ___ the past. Continued
vitamin supplements and ensure with meals.
# GERD/esophageal dysmotility. Last EGD and mannometry on ___
with evidence of ineffective esophageal contractions and
positive impedence acid reflux study correlating 100% with
symptoms. Symptoms at home have been stable on home Protonix and
Reglan. Has not required use of NTG for esophageal spasms.
# Hx of Hashimoto thyroiditis. Continued home levothyroxine.
#Recurrent UTI's: On suppressive macrobid therapy chronically.
This was held while on Zosyn and NOT restarted.
Transitional Issues:
-Zosyn 4.5g Q8H for 2 weeks or until determined by ID
-Will need to follow up with ___ for removal of JP drain within 1
week
-CBC w/diff, BUN, Cr drawn weekly and faxed to ___
Attn: ___ CLINIC
-Suppressive Macrobid stopped while on Zosyn
-You stated you have a yeast infection and provided prescription
for diflucan at discharge.
-Labetalol was held during admission and at discharge as BP was
___ during her hospital course. Please recheck BP as
outpatient and resume as indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 50 mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Nitrofurantoin Monohyd (MacroBID) 50 mg PO DAILY
4. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN pain
5. NexIUM (esomeprazole magnesium) 40 mg oral BID
6. HYDROmorphone (Dilaudid) 2 mg PO Q8H:PRN abdominal pain
7. Metoclopramide 5 mg PO TID n/v
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN esophageal spasm
9. Zolpidem Tartrate 2.5 mg PO QHS insomnia
10. Vitamin D 5000 UNIT PO DAILY
11. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) unknown oral
Other
Discharge Medications:
1. HYDROmorphone (Dilaudid) 2 mg PO Q8H:PRN abdominal pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*10 Tablet Refills:*0
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Metoclopramide 5 mg PO TID n/v
RX *metoclopramide HCl 5 mg 1 tab by mouth three times a day
Disp #*20 Tablet Refills:*0
4. Zolpidem Tartrate 2.5 mg PO QHS insomnia
5. Piperacillin-Tazobactam 4.5 g IV Q8H
RX *piperacillin-tazobactam 4.5 gram 4.5 gram IV every eight (8)
hours Disp #*42 Vial Refills:*0
6. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN pain
7. NexIUM (esomeprazole magnesium) 40 mg oral BID
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN esophageal spasm
9. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) unknown ORAL
DAILY
10. Vitamin D 5000 UNIT PO DAILY
11. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
RX *sodium chloride 0.9 % 0.9 % 10 ml IV daily Disp #*40 Syringe
Refills:*0
12. Outpatient Lab Work
CBC w/diff, BUN, Cr drawn weekly and faxed to ___ Attn:
___ CLINIC. ICD10: K75.0 Liver abscess.
13. Fluconazole 150 mg PO Q24H
___ repeat ___ 2 days if not better
RX *fluconazole 150 mg 1 tablet(s) by mouth once Disp #*2 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Subcapsular Liver 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 hospital for an abscess ___ your liver.
You had the abscess drained and your biliary drain was replaced
with a bigger one so that it would no longer leak. You will also
need to continue to take the IV antibiotics for the next 2
weeks, as determined by the ID doctors.
___,
Your ___ ___
Followup Instructions:
___
|
10824694-DS-29
| 10,824,694 | 27,657,231 |
DS
| 29 |
2156-06-28 00:00:00
|
2156-06-29 10:22:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nitroimidazole Derivatives / Levofloxacin / Meperidine / Bactrim
/ Flagyl / morphine / Zofran / steri strips / atenolol / Zosyn
Attending: ___.
Chief Complaint:
Postprandial epigastric pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a complicated GI history, who presents
with subacute intermittent post-prandial epigastric pain.
The patient's GI history is complex, with multiple abdominal
surgeries including gastric fundoplication (___), pyloroplasty
with sphincteroplasty (___), gastrojejuneostomy, s/p Roux en Y
(___), bowel obstruction s/p partial sigmoidectomy, s/p
appendectomy, s/p cholecystectomy, mesenteric ischemia s/p
celiac bypass, CBD stenosis with repeated ERCPs and
cholangiogram with ampulla balloon plasty and ___ R
internal/external biliary catheter placement ___ c/b
subcapscular hepatic polymicrobial abscess s/p drainage ___
and upsized PTDB drain on ___. The patient had a tentative plan
of ___ w IV abx, but she stopped taking the zosyn after 3 weeks
due to abdominal pain and diarrhea. Repeat CT scan done at that
time showed resolution of the abscess but evidence of colitis,
with negative infectious workup (negative C.diff, Salmonella,
Shigella, Campylobacter). She had a subsequent colonoscopy had
negative biopsies. On ___ she had a second balloon dilatation
of ampullary stenosis with replacement of internal external PTDB
catheter. Perihepatic abscess drain was removed at that time.
Since then, patient reports that she has chronic intermittent
epigastric pain that radiates to her chest, but her symptoms
have become worse in the past 2 weeks. The pain is triggered by
eating or exertion, which feels different than her prior history
of esophageal spasm. Her pain has come to the point where she is
unable to tolerate any activity or PO intake secondary to pain,
which she describes as "stabbing". Her symptoms are associated
with nausea and rarely nonbilious vomiting. With exertion she
occasionally has pressure around her esophagus. She had balloon
dilation of her lower esophageal sphincter at OSH (___) last
week. She has had no fevers. She was seen in urgent care
yesterday and was referred to the ED due to concern for
mesenteric ischemia.
In the ED, initial vital signs were: 98.7 87 123/77 18 99% RA.
Labs were notable for normal CBC and chemistry panel (WBC 5.2,
H/H 13.3/41.9, Plt 185; Na 139 K 4.4 Cl 103 HCO3 21 BUN 12 Cr
0.9, Ca ___ Mg 2 P 4.3)
ALT 34 AST 47 AP 147 LDH 265 T bili 0.5 Lipase 35
Trop-T <0.01
Lactate 0.7
Urinalysis with 11 WBC, moderate leuks, few bacteria trace
protein, trace ketones (although UA from several hours prior
negative).
CTA abd/pelvis with no evidence of mesenteric ischemia or bowel
obstruction, unchanged position of internal external PTBD with
mild intrahepatic biliary ductal dilatation, small sliver of
perihepatic fluid near abscess cavity without evidence of
abscess formation. Of note, patient's R PIV infiltrated in the
ED and developed soft tissue swelling, elbow xray showed large
amount of contrast material extravasating into soft tissue of
antecubital fossa.
The patient was given 1L NS, 1 mg IV dilaudid, 10 mg IV
prochlorperazine, 40 mg IV pantoprazole and 400 mg IV cipro.
GI was consulted in the ED and recommended admission to medicine
for workup of worsening chronic post-prandial abdominal pain and
PO intolerance.
Upon arrival to the floor, the patient states she has zero pain.
She is "starving" and is asking to eat. She denies
nausea/vomiting, diarrhea (has about 1 soft BM/day, improved
since her ampulla balloon dilatation). She does report some
dysuria but mostly related to known hx of vaginal dryness, no
increased urinary frequency. She is requesting a third pillow
and her home zolpidem.
REVIEW OF SYSTEMS: Full 10-point ROS reviewed and negative,
except as noted in HPI.
Past Medical History:
-Esophageal strictures s/p multiple balloon dilatations
(___)
-Cholecystectomy and appendectomy (___)
-Hysterectomy (___)
-Leiomyosarcoma, bilateral oophorectomy (___)
-Sigmoid volvulus decompressed via colonoscopy (___)
-Bowel obstruction and partial sigmoid colectomy (___)
-Nephrolithasis s/p ureteral stenting and lithotripsy (___)
-Parathyroid adenoma s/p parathyroid surgery (___)
-Choledocolithiasis s/p pacement of CBD stent ___
-Inguinal hernia repair (___)
-Severe celiac artery stenosis s/p Celiac artery bypass and
graft placement (___)
-Multiple spinal surgeries and placement of a spinal cord
stimulator (___)
-Gastric fundoplication (___)
-Numerous ERCPs and biliary stents placed due to recurrent
stones and sludge Pyloroplasty and sphincteroplasty (___)
-Mesenteric artery syndrome s/p gastrojegunostomy placement
-Roux en Y
-H/o of Hashimoto's thyroiditis
-Recurrent UTIs intermittently on augmentin, cipro, macrobid
Social History:
___
Family History:
Mother died of lung cancer; one brother died of CAD; another
brother died from a brain tumor.
Physical Exam:
Admission Physical Exam:
========================
VITALS - T 97.6 BP 99/70 HR 94 98%RA
GENERAL - Strikingly well-appearing middle aged female sitting
upright in bed in NAD, pleasant
HEENT - NC/AT, anicteric sclerae, MMM
NECK - Supple
CARDIAC - RRR S1+S2 no m/r/g
PULMONARY - CTAB, no wheezes, rales or rhonchi
ABDOMEN - Vertical surgical scar in midline. External-internal
biliary port (right flank), capped, no erythema or discharge.
Scaphoid abdomen, soft, minimally tender in epigastrium and RLQ,
no rebound or guarding, no organomegaly or appreciable masses
EXTREMITIES - Right antecubital fossa with mild soft tissue
swelling extending to forearm, no erythema or ecchymosis,
fingers without parasthesias or numbness, 2+ R radial pulse.
Legs warm, well-perfused, no edema
NEUROLOGIC - AAOx3, CN grossly normal, ambulating without
difficulty
PSYCHIATRIC - Mood and affect appropriate
Discharge Physical Exam:
========================
VITALS - T 97.5 BP 111/88 HR 87 94%RA
GENERAL - Strikingly well-appearing middle aged female sitting
upright in bed in NAD, pleasant
HEENT - NC/AT, anicteric sclerae, MMM
NECK - Supple
CARDIAC - RRR, S1+S2, no m/r/g
PULMONARY - CTAB, no wheezes, rales or rhonchi
ABDOMEN - Vertical surgical scar in midline. External-internal
biliary port (right flank), capped, no erythema or discharge.
Scaphoid abdomen, soft, minimally tender in epigastrium and RLQ,
no rebound or guarding, no organomegaly or appreciable masses
EXTREMITIES - Right antecubital fossa with mild soft tissue
swelling extending to forearm, no erythema or ecchymosis,
fingers without parasthesias or numbness, 2+ R radial pulse.
Legs warm, well-perfused, no edema
NEUROLOGIC - AAOx3, CN grossly normal, ambulating without
difficulty
PSYCHIATRIC - Mood and affect appropriate
Pertinent Results:
Admission Labs:
===============
___ 03:45PM BLOOD WBC-5.2 RBC-4.36 Hgb-13.3 Hct-41.9 MCV-96
MCH-30.5 MCHC-31.7* RDW-13.7 RDWSD-48.8* Plt ___
___ 03:45PM BLOOD Neuts-62.2 ___ Monos-6.0 Eos-2.3
Baso-0.8 Im ___ AbsNeut-3.20 AbsLymp-1.46 AbsMono-0.31
AbsEos-0.12 AbsBaso-0.04
___ 03:45PM BLOOD Glucose-88 UreaN-12 Creat-0.9 Na-139
K-4.4 Cl-103 HCO3-21* AnGap-19
___ 03:45PM BLOOD ALT-34 AST-47* LD(LDH)-265* AlkPhos-147*
TotBili-0.5
___ 03:45PM BLOOD Lipase-35
___ 03:45PM BLOOD cTropnT-<0.01
___ 03:45PM BLOOD Calcium-10.1 Phos-4.3 Mg-2.0
___ 09:15PM BLOOD Lactate-0.7
Discharge Labs:
===============
___ 09:15AM BLOOD WBC-3.1* RBC-3.87* Hgb-11.9 Hct-37.1
MCV-96 MCH-30.7 MCHC-32.1 RDW-13.5 RDWSD-47.5* Plt ___
___ 09:15AM BLOOD Glucose-101* UreaN-10 Creat-0.8 Na-137
K-3.6 Cl-103 HCO3-22 AnGap-16
___ 09:15AM BLOOD ALT-26 AST-35 LD(LDH)-174 AlkPhos-141*
TotBili-0.7
___:15AM BLOOD Lipase-35
___ 09:15AM BLOOD cTropnT-<0.01
___ 09:15AM BLOOD Calcium-9.4 Phos-4.0 Mg-1.8
Micro:
======
Urine culture ___: No growth (final)
Imaging:
========
CTA ABD & PELVIS ___:
1. No evidence of mesenteric ischemia.
2. No evidence of bowel obstruction.
3. Unchanged position of right approach internal external PTBD
with mild intrahepatic biliary ductal dilatation.
4. Small sliver of perihepatic fluid near the prior abscess
cavity without evidence of residual or recurrent abscess
formation.
ELBOW (AP, LAT & OBLIQUE) ___:
Large amount of contrast material extravasated into the soft
tissues within the antecubital fossa. Exact amount is difficult
to quantify.
Brief Hospital Course:
Ms. ___ is a ___ female with a complicated GI history
including multiple abdominal surgeries and balloon dilatations
for ampullary stenosis who presented with subacute intermittent
post-prandial and exertional epigastric pain. CTA negative for
mesenteric ischemia or bowel obstruction. Labs unchanged from
prior. Symptoms improved. Seen by GI consultants. She felt well
and desired discharge. No further inpatient workup needed.
TRANSITIONAL ISSUES:
-Discharge home with followup SBFT as already scheduled this
week and then followup with GI.
-No medication changes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 50 mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___)
3. Metoclopramide 5 mg PO TID:PRN nausea
4. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY
5. Nitroglycerin SL 0.3 mg SL Q6H:PRN chest discomfort
6. Pantoprazole 40 mg PO Q12H
7. Prochlorperazine 10 mg PO Q8H:PRN nausea
8. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
9. Vitamin D 5000 UNIT PO DAILY
10. Probiotic Colon Support (L. gasseri-B. bifidum-B
l
o
n
g
u
m
;
<
b
r
>
L
.
___
unknown unknown oral unknown
11. Lidocaine 5% Patch 1 PTCH TD BID
12. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___)
2. Lidocaine 5% Patch 1 PTCH TD BID
3. Multivitamins 1 TAB PO DAILY
4. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY
5. Prochlorperazine 10 mg PO Q8H:PRN nausea
6. Vitamin D 5000 UNIT PO DAILY
7. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
8. Labetalol 50 mg PO DAILY
9. Metoclopramide 5 mg PO TID:PRN nausea
10. Nitroglycerin SL 0.3 mg SL Q6H:PRN chest discomfort
11. Pantoprazole 40 mg PO Q12H
12. Probiotic Colon Support (L. gasseri-B. bifidum-B
l
o
n
g
u
m
;
<
b
r
>
L
.
___
unknown ORAL Frequency is Unknown
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Abdominal pain
SECONDARY:
History of multiple abdominal surgeries and balloon dilatations
for ampullary stenosis
___'s thyroiditis
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came into the hospital with abdominal pain after eating
concerning for mesenteric ischemia. A CTA abdomen showed widely
patent vessels without mesenteric ischemia or bowel obstruction.
Your blood work was reassuring. Your symptoms resolved. You
were seen by our GI doctors and should continue with your
planned testing at ___ as originally
scheduled and follow up with your outpatient GI doctors.
Followup Instructions:
___
|
10825180-DS-14
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|
2111-05-25 23:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Gallstone pancreatitis
Major Surgical or Invasive Procedure:
___: ERCP, sphincterotomy, plastic stent
___: Laparoscopic cholecystectomy
History of Present Illness:
___ with a history of CAD, MI, S/P CABG in ___ who
presents with a 1 day history of RUQ and epigastric pain. The
pain initially began last night at around midnight. Per patient,
he developed constant, nonradiating, "pulling" pain associated
with nausea and nonbloody, nonbilious vomiting. Not associated
fever or chills, but he did have one episode of diarrhea. Not
changed by food. Currently on aspirin and Plavix after his
CABG.
He was seen at ___ in ___, where he had a CT
scan showing acute early cholecystitis with an elevated lipase
at
1049, as well as elevated LFTs. Surgery there recommended
transfer here for ERCP evaluation.
In the ___ ED, Mr ___ did not endorse nausea but did say he
has vomited twice today. He has dull epigastric pain that is
getting better but is still present. He denies RUQ pain or
further diarrhea. He also does not complain of fevers, chills,
chest pain, or SOB.
Past Medical History:
PMH:
CAD (MI ___, CABG ___
HTN
HLD
Gout
PSH:
CABG (___)
R hip replacement ___
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission exam
=======================
97.6 86 113/69 16 95% RA
Gen: no acute distress, alert, responsive
Pulm: unlabored breathing
CV: regular rate and rhythm
Abd: soft, nondistended, tender to deep palpation in epigastric
region, nontender RUQ, no ___ sign
Ext: warm and well perfused
Discharge exam
=======================
General: AOx3 no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: RRR, S1/S2, no m/r/g
Lungs: CTAB, no wheezes, rales, or rhonchi
GI: soft, NT/ND, BS+, no rebound tenderness or guarding, no
organomegaly
Extremities: warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
Skin: No rash or lesion
Pertinent Results:
Admission labs:
___ 08:29AM BLOOD WBC-11.6* RBC-5.09 Hgb-15.9 Hct-44.9
MCV-88 MCH-31.2 MCHC-35.4 RDW-13.2 RDWSD-42.5 Plt ___
___ 08:29AM BLOOD Neuts-82.2* Lymphs-7.8* Monos-9.3
Eos-0.1* Baso-0.2 Im ___ AbsNeut-9.52* AbsLymp-0.90*
AbsMono-1.08* AbsEos-0.01* AbsBaso-0.02
___ 08:29AM BLOOD Plt ___
___ 08:29AM BLOOD Glucose-201* UreaN-38* Creat-1.5* Na-141
K-4.0 Cl-99 HCO3-27 AnGap-15
___ 08:29AM BLOOD ALT-730* AST-690* AlkPhos-111
TotBili-1.7*
___ 08:29AM BLOOD ___
___ 08:35AM BLOOD Lactate-2.0
Discharge labs:
___ 08:03AM BLOOD WBC-19.2* RBC-4.19* Hgb-12.9* Hct-36.6*
MCV-87 MCH-30.8 MCHC-35.2 RDW-14.2 RDWSD-45.2 Plt ___
___ 08:03AM BLOOD Plt ___
___ 08:03AM BLOOD Glucose-135* UreaN-18 Creat-0.9 Na-134*
K-3.6 Cl-93* HCO3-26 AnGap-15
___ 08:03AM BLOOD ALT-343* AST-290* AlkPhos-244*
TotBili-1.2
Imaging:
___ ERCP: Small periampullary fistula noted. No stones or
sludge retrieved.
___ MRCP: 1. Acute pancreatitis involving the entire gland,
with mild hypoenhancement in
the pancreatic body/tail concerning for early or developing
necrosis.
Peripancreatic hemorrhage is seen involving the uncinate process
and
body/tail.
2. No peripancreatic fluid collection, pseudoaneurysm, or portal
venous system
thrombosis.
3. No focal pancreatic mass identified, with evaluation limited
by extensive
background inflammation.
4. A periampullary fistula seen on recent ERCP is not visualized
on MRI.
___ CT Abd/Pelvis
1. No significant interval change in acute pancreatitis
involving the entire
gland, with area of possible mild/early necrosis involving the
pancreatic head
and body/tail. No peripancreatic fluid collection.
Inflammatory changes
involve the duodenal wall.
2. Postsurgical changes after interval laparoscopic
cholecystectomy, with
expected small volume pneumoperitoneum and right lateral
subcutaneous
emphysema.
Brief Hospital Course:
Mr. ___ was admitted to ___ on ___ for presumed
gallstone pancreatitis. He was managed conservatively with bowel
rest, IV fluid resuscitation, and pain control. Over the next
few days, his pain improved gradually and his lipase trended
down, from ___ on admission to 295 on ___. On ___, he went for
an ERCP which found a small periampullary fistula without stones
or sludge in the ducts. A sphincterotomy was performed and a
plastic stent was placed. Due to a desire to better characterize
his biliary system and pancreas due to the lack of observed
stones on ERCP, he received an MRCP on ___ which demonstrated
cholelithiasis as well as expected pancreatitis, with a section
of early necrosis of the pancreatic body/tail and peripancreatic
hemorrhage. On ___ he underwent an uneventful laparoscopic
cholecystectomy. Following the surgery, his pain was well
controlled, he tolerated a diet without nausea and vomiting, and
he ambulated without difficulty. Due to a mild increase in WBC
count (14.4 -> 19.2) and in LFTs, he underwent a CT
Abdomen/Pelvis on ___ which showed no evidence of bile leak or
fluid collection. He was discharged home on ___ and instructed
to follow up in the surgery clinic on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Colchicine 0.6 mg PO ASDIR
4. hydroCHLOROthiazide 25 mg oral DAILY
5. Atorvastatin 80 mg PO QPM
6. Clopidogrel 75 mg PO DAILY
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. Polyethylene Glycol 17 g PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Clopidogrel 75 mg PO DAILY
7. Colchicine 0.6 mg PO ASDIR
8. hydroCHLOROthiazide 25 mg oral DAILY
9. Lisinopril 40 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Gallstone pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with gallstone pancreatitis.
You underwent an ERCP to evaluate for gallstones. A
sphincterotomy was done and a stent placed. You will need to
return in 4 weeks for a repeat ERCP for stent removal. You were
then taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10825323-DS-26
| 10,825,323 | 20,976,214 |
DS
| 26 |
2193-08-24 00:00:00
|
2193-08-24 13:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Band-Aid Clear Spots / Betadine Viscous Gauze / sertraline /
fentanyl / Potassium / iodine
Attending: ___.
Chief Complaint:
Hypoxia, hypercarbia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ year-old woman with history of MAC and
bronchiectasis presenting with cough prouductive of sputum,
fatigue, increased oxygen requirement. Over the past three weeks
patient has noted increased cough and over the past three days
the cough has been productive of yellow sputum. ___ addition, her
family reports she has been more fatigued, sleeping much of the
time. She was also noted to have oxygen desaturation at home
(one time to high ___ on 2L), so her family uptitrated her
oxygen to three liters. Patient also feels short of breath and
reports she cannot get out of bed, whereaas she is normally up
and out of bed much of the time. She denies fever, chills, chest
pain, abdominal pain, nausea, vomiting.
___ the ED, initial VS were: 98.8 76 90/45 24 91% 3L Nasal
Cannula. Patient had an EKG showing NSR without any acute ST
changes. She had a chest x-ray showing opacification of the left
lung base (atelectasis vs. pulmonary edema). She had an ABG
showing a pH of 7.29 and pCO2 of 91. She had a BNP of 3000 and
troponin of 0.04. She had a CTA given the elevated troponin,
which did not show a PE. Patient's pulmonologist was called and
recommended starting zosyn. Patient received cefepime, flaygl.
Respiratory therapy was called to initiate BIPAP, but deferred
as patient had recently eaten lunch.
On arrival to the MICU, patient continues to complain of
productive cough and fatigue. She does not currenly have
dyspnea, but feels that she would when she is ambulatory. On the
floor, patient fell asleep and desaturated to 79% on 4L. She
improved to mid-90s when awakened.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies wheezing. Denies chest pain, chest pressure,
palpitations. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes ___ bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
1) Bronchiectasis with Mycobacterium avium - Treated ___ for 2
weeks with imipenem for pseudomonas infection; pulmonary MAC -
Again ___ treated with Cipro and Flagyl
2) C. diff infection ___ Treated with Flagyl 1000 mg/day
X 10 days
3) s/p Pseudomonas bronchitis with prolonged treatment with
intravenous meropenem
4) s/p Pneumonia ___ GI bleed ___, with duodenal adenoma on endoscopy
6) GERD
7) Hypertension
8) Supraventricular arrythmia s/p ablation ___ ___
9) Depression
10) s/p hip replacement
11) s/p vertebroplasty ___
12) Back pain, gets lumbar epidural injectons at ___
13) Fractured bone ___ the wrist
14) Osteoporosis
15) Arthritis
16) Pelvic fracture, ___
Social History:
___
Family History:
Mother died age ___ from colon cancer. Father died at age ___
from unknown cause. No other known history of GI disease, heart
disease, lung disease.
Physical Exam:
General: Alert, oriented, no acute distress, hard of hearing
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Bibasilar crackles, no wheezes
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities
Pertinent Results:
Admission Labs:
___ 12:40PM BLOOD WBC-7.5 RBC-4.00* Hgb-12.4 Hct-40.7
MCV-102* MCH-31.1 MCHC-30.5* RDW-13.4 Plt ___
___ 12:40PM BLOOD Neuts-90.2* Lymphs-5.9* Monos-3.5 Eos-0.1
Baso-0.3
___ 12:40PM BLOOD Glucose-145* UreaN-24* Creat-0.9 Na-138
K-4.7 Cl-95* HCO3-38* AnGap-10
___ 12:40PM BLOOD proBNP-3868*
___ 12:40PM BLOOD cTropnT-0.04*
___ 12:11AM BLOOD CK-MB-3 cTropnT-0.03*
___ 06:06AM BLOOD CK-MB-2 cTropnT-0.03*
ABG (___): ART Temp-36.9 pO2-72* pCO2-91* pH-7.29* calTCO2-46*
Base XS-13
.
Discharge Labs:
___ 08:22AM BLOOD WBC-6.5 RBC-3.59* Hgb-11.3* Hct-36.6
MCV-102* MCH-31.4 MCHC-30.8* RDW-13.2 Plt ___
___ 08:22AM BLOOD Glucose-93 UreaN-16 Creat-0.6 Na-140
K-4.8 Cl-95* HCO3-39* AnGap-11
___ 08:22AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8
.
Microbiology:
Blood cx ___: no growth
Urine cx ___: mixed flora
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
MODERATE GROWTH Commensal Respiratory Flora.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
ESCHERICHIA COLI. MODERATE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SECOND TYPE.
Piperacillin/Tazobactam , sensitivity testing performed
by ___
___.
GENTAMICIN , sensitivity testing confirmed by ___
___.
GRAM NEGATIVE ROD(S). RARE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| PSEUDOMONAS AERUGINOSA
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S 4 S
CEFTAZIDIME----------- <=1 S 4 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R <=0.25 S
GENTAMICIN------------ <=1 S 4 I
MEROPENEM-------------<=0.25 S 0.5 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
Imaging:
-CXR - Opacification of the left lung base may represent
atelectasis,
however, pneumonia cannot be excluded ___ the right clinical
setting.
-CTA Chest - 1. No evidence of pulmonary embolism.
2. Thrombosis of the left inferior pulmonary vein is of
uncertain clinical significance.
3. Extensive bibasilar bronchial mucoid impaction on the left
greater than the right increased from ___ with stable
extensive chronic bronchiectasis and emphysematous changes.
4. Age-indeterminate compression fracture of L1 vertebral body,
new from
___, with unchanged compression fracture of T8 and
vertebroplasty of T12
-Chest MRI - 1. No evidence of persistent thrombus within the
left inferior pulmonary vein.
2. The left inferior pulmonary vein has a somewhat flattened
appearance, but demonstrates patency both on flow based
techniques, as well as on anatomic and contrast enhanced images.
3. Small bilateral pleural effusions. Left basilar
consolidation and
bronchiectasis demonstrated on the prior examination is less
evident here
(this examination tailored for assessment of the central
pulmonary veins).
Brief Hospital Course:
ID: Ms. ___ is an ___ year-old woman with history of MAC and
bronchiectasis presenting with productive cough, fatigue, and
increased oxygen requirement consistent with bronchiectasis
flare.
# Bronchiectasis Flare:
Patient with known bronchiectasis, symptoms are likley secondary
to flare of known condition. Patient was admitted to the MICU
for hypoxia and hypercarbia but was transferred to the floor the
next day. Patient was initially covered empirically cefepime and
metronidazole which was narrowed to bactrim, ciprofloxacin, and
flagyl once cultures returned. CTA was done ___ the ER which
showed extensive bibasilar bronchial mucoid impaction on the
left greater than the right increased from ___ with stable
extensive chronic bronchiectasis and emphysematous changes.
There was a questions of thrombosis of the left inferior
pulmonary vein but Chest MRI did not support this finding so
this was likely artifact. Patient's symptoms improved with
antibiotics, chest ___, and nebulizer treatments. She was
discharged on oral antibiotics for her bronchiectasis flare for
a two-week total course. Flagyl was continued as well as C.diff
prophylaxis. Lasix was held as patient appeared dry on exam and
it was felt this was impairing secretion clearance. Patient was
started on probiotics at discharge to improve antibiotic
associated loose stools. She will also be receiving 24-hour care
at home on discharge.
# Hypercarbia:
Patient with partially compensated respiratory acidosis.
Etiology of hypercarbia unclear, patient with severely reduced
FEV1 and severe obstructive ventilatory defect on ___
PFTs. Patient also with likely OSA given desat when sleeping.
Treatment for bronchiectasis given, continued on albuterol and
budesonide. She was given a trial of BIPAP as was observed to
have brief episodes of apnea the first night. Communicated with
her outpatient pulmonologist who agreed with continuing BIPAP
trial. Patient did not tolerate further BiPap on the floor so
this was discontinued due to patient discomfort.
# Pulmonary Vein Clot:
As above, CTA showed clot ___ left inferior pulmonary vein
however this was not seen on subsequent Chest MRI.
# Elevated troponin:
Patient with troponin leak of 0.04, no chest pain or ischemic
EKG changes. Possibly ___ the setting of demand given hypoxia,
recent illness. Cardiac markers were cycled and and were stable
at 0.03 on two repeats.
# Acute renal failure:
Creatinine 0.9 from baseline of 0.5 - 0.7. Unclear etiology.
Possibly pre-renal as patient was instructed to take extra dose
of lasix by PCP. Trended down to 0.6 byt the time of discharge.
Lasix held for this and desire not to increase thickness of
secretions.
# Code Status: code status confirmed DNR/DNI with patient
STABLE ISSUES
# GERD: Continue omeprazole 40 mg daily
# SVT: s/p ablation ___ ___, continued on metoprolol 12.5mg
daily.
# Osteoporosis: Multiple compression fractures, chronicity
unclear. Continue on Calcium/Vit D
.
TRANSITIONAL ISSUES
- Patient will require continued pulmonary follow-up with Dr.
___
___ on Admission:
ALBUTEROL SULFATE - 2.5 mg/0.5 mL Solution for Nebulization - 1
vial nebulized twice daily
BUDESONIDE - 0.5 mg/2 mL Suspension for Nebulization - 1 vial
inhaled via nebulization twice a day
FUROSEMIDE - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
___ times per week as needed for to control swelling ___ feet
METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by
mouth once a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 2 (Two)
Capsule(s) by mouth once a day ___ the morning
CALCIUM CITRATE-VITAMIN D3 [CITRACAL + D] - 250 mg-200 unit
Tablet - 1 (One) Tablet(s) by mouth once a day
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - 1,000 unit Tablet -
1
(One) Tablet(s) by mouth once a day
SENNOSIDES [SENOKOT] - 8.6 mg Tablet - 1 (One) Tablet(s) by
mouth
twice a day as needed for constipation
Discharge Medications:
1. budesonide 0.5 mg/2 mL Suspension for Nebulization Sig: One
(1) neb Inhalation BID (2 times a day).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation twice a day as needed
for shortness of breath or wheezing.
3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Citracal + D 250 mg calcium- 250 unit Tablet, Chewable Sig:
One (1) Tablet, Chewable PO once a day.
6. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for Constipation.
8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 16 days.
Disp:*48 Tablet(s)* Refills:*0*
9. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 9 days.
Disp:*18 Tablet(s)* Refills:*0*
10. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 9 days.
Disp:*18 Tablet(s)* Refills:*0*
11. Florastor 250 mg Capsule Sig: One (1) Capsule PO twice a
day.
Disp:*60 Capsule(s)* Refills:*2*
12. guaifenesin 100 mg/5 mL Syrup Sig: ___ MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*120 ML(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Bronchiectasis flare
Secondary:
Osteoporosis
GERD
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 during this admission. You
were admitted given worsening cough and shortness of breath. You
were briefly ___ the ICU given needing closer monitoring. You
were placed on antibiotics for bronchiectasis flare and
improved. You had a CT of your chest that was concerning for a
clot ___ the pulmonary vein but MRI of the chest did not show
this finding.
The following medications were changed during this
hospitalization:
- START ciprofloxacin 250mg by mouth twice a day for 9 days
- START bactrim by mouth twice a day for 9 days
- START Metronidazole 500mg every 8 hours for 16 more days
- START Florastor twice daily to help with your loose stools
- START Mucinex ___ every six hours as needed for cough
- HOLD the Furosemide until you see your doctor for follow-up.
Please continue all other medications you were taking prior to
this admission.
Followup Instructions:
___
|
10825323-DS-27
| 10,825,323 | 20,780,521 |
DS
| 27 |
2193-11-15 00:00:00
|
2193-11-25 09:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Band-Aid Clear Spots / Betadine Viscous Gauze / sertraline /
fentanyl / Potassium / iodine
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
T6 vertebroplasty
History of Present Illness:
___ with h/o falls, bronchiectasis, htn, depression,
osteoporosis who presents with back pain s/p fall one week ago.
She was in her USOH until she slipped one week ago. SHe denies
immediate pain. about a day later, she started experiencing pain
behind her right shoulder, and 2 days PTA, she began
experiencing pain on the left of her middle back. She describes
the pain as ___, sharp, worse with movement, and no radiation.
Pt denies loss of consciousness, dizziness, or fatigue leading
to the fall. Her PCP prescribed tramadol and oxycodone have not
provided relief. OSH XR showed an acute compression fracture at
T6 so she presented to the ED. Pt reports constipation that was
present before the fall. She also reports decreased frequency in
urination and says she does not drink a lot of fluids. She
currently denies fever, chills, headache, vision changes, sore
throat, cough, shortness of breath, chest pain, abdominal pain,
n/v, diarrhea, dysuria.
In the ED, initial vs were T 98.8 HR 72 BP 151/79 RR 16 O2Sat 94
Low. She was given 3x 0.5mg morphine which brought her pain from
a 9 to a 7.
On arrival to the floor, patient reports the pain has reached an
8.
REVIEW OF SYSTEMS:
Benign unless described as aboved.
Past Medical History:
1) Bronchiectasis with Mycobacterium avium - Treated ___ for 2
weeks with imipenem for pseudomonas infection; pulmonary MAC -
Again ___ treated with Cipro and Flagyl
2) C. diff infection ___ Treated with Flagyl 1000 mg/day
X 10 days
3) s/p Pseudomonas bronchitis with prolonged treatment with
intravenous meropenem
4) s/p Pneumonia ___ GI bleed ___, with duodenal adenoma on endoscopy
6) GERD
7) Hypertension
8) Supraventricular arrythmia s/p ablation in ___
9) Depression
10) s/p hip replacement
11) s/p vertebroplasty ___
12) Back pain, gets lumbar epidural injectons at Pain Clinic
13) Fractured bone in the wrist
14) Osteoporosis
15) Arthritis
16) Pelvic fracture, ___
Social History:
___
Family History:
Mother died age ___ from colon cancer. Father died at age ___
from unknown cause. No other known history of GI disease, heart
disease, lung disease.
Physical Exam:
VS: T 97.9 Tm 98.2 BP 152/88 HR 81 RR 20 O2 96% RA
Gen: Frail, elderly, cachectic, NAD, pleasant, chatty, hard of
hearing (right hearing aide irritates ear canal)
HEENT: NCAT, moist mucus membranes, normal oro/nasopharynx
Neck: Soft, supple
Respiratory: Shallow breaths, good air movement, some accessory
muscle use, diffuse ronchi throughout
Cardiac: RRR, no murmurs/gallops/rubs
GI: Non-tender, distended and mildly firm, +BS
MSK: TTP mid thoracic, along inferior left scapula.
EXT: ___ strength in all extremeties. Able to flex hip b/l. 2+
pulses palpable bilaterally in upper and lower extremeties
NEURO: CNs2-12 intact, motor function grossly normal, tremor in
R hand
SKIN: PIV in R arm, previous IV sites seen on R hand and L arm
Neuro: AAOx3, able to recount events from overnight, attentive
and organized thought process
Discharge Exam:
VS T 97.9 Tm 98.2 BP 158/82 HR 81 RR 20 O2 91% 3LNC
MSK: Dressing in place, clean, dry, intact at midthoracic
region, no surrounding erythema/swelling, ttp in mid thoracic
and inferior left scapula
Exam is otherwise unchanged from admission
Pertinent Results:
___ 01:35PM BLOOD WBC-9.3 RBC-3.70* Hgb-12.0 Hct-36.3
MCV-98 MCH-32.5* MCHC-33.1 RDW-13.1 Plt ___
___ 01:35PM BLOOD Neuts-88.8* Lymphs-5.9* Monos-3.9 Eos-0.9
Baso-0.5
___ 01:35PM BLOOD ___ PTT-27.3 ___
___ 01:35PM BLOOD Glucose-94 UreaN-19 Creat-0.5 Na-132*
K-5.1 Cl-90* HCO3-37* AnGap-10
___ 08:05AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.9
___ 06:56PM BLOOD Lactate-1.2
Studies:
T-spine X-ray
IMPRESSION: T6 and T8 vertebral body compression fractures
again noted with
possible subtle interval increase in height loss at T6 compared
to the most
recent prior examination.
CXR
IMPRESSION: No acute cardiopulmonary process. Unchanged
appearance of lungs
compared to ___.
MR ___
IMPRESSION:
1. Interval progression of compression fractures of T5, T6, and
L1. Minimal
retropulsion of T6 into the canal, without significant canal
narrowing or cord
compression.
2. Unchanged moderate anterior wedge compression of T8 without
water signal
abnormalities to suggest progression. Also, unchanged
appearance of T12
compression fracture with kyphoplasty.
Verterbroplasty
FINDINGS: Successful implantation of vertebroplasty cement into
the T6
vertebral body, which remains localized to that vertebral body.
There is
redemonstration of multiple wedge deformities including T6, T8,
and T12, the
latter of which was previously vertebroplastied. The patient is
quite
osteoporotic.
IMPRESSION: Successful vertebroplasty of the T6 body level.
Additional Labs:
___ 09:30PM BLOOD D-Dimer-831*
___ 07:44AM BLOOD VitB12-873
___ 07:44AM BLOOD TSH-2.1
___ 06:56PM BLOOD Type-ART Rates-/30 pO2-79* pCO2-55*
pH-7.44 calTCO2-39* Base XS-10 Intubat-NOT INTUBA Comment-O2
DELIVER
Discharge Labs:
___ 06:50AM BLOOD WBC-7.2 RBC-3.57* Hgb-11.4* Hct-35.6*
MCV-100* MCH-32.0 MCHC-32.1 RDW-13.4 Plt ___
___ 07:15AM BLOOD Glucose-103* UreaN-13 Creat-0.4 Na-137
K-4.7 Cl-98 HCO3-35* AnGap-9
___ Blood and urine cultures no growth
___ RPR not reactive
Brief Hospital Course:
___ year old woman with history of bronchiectasis, hypertension,
GERD, depression, osteoporosis, osteoarthritis, chronic back
pain with known fractures who presents 5 days s/p mechanical
fall with severe, persistent back pain not responsive to
analgesics at home, now s/p vertebroplasty.
ACTIVE ISSUES
# Back pain: Most likely new compression fracture from
mechanical fall at home 5 days prior to admission. A TLSO brace
and then a soft brace were both trialed with no relief. She was
given tylenol, dilaudid, and tizanidine for pain management. She
was given intranasal calcitonin, calcium, and Vit D for
compression fractures. Vertebroplasty procedure done on ___
with no complications, bleeding, or neurological sequelae. No
immediate relief of pain. Pt refused back brace. Was seen by ___
to assess baseline and rehab therapy. Will be discharged to
rehab facility.
# HTN: High readings during hospital course most likely due to
back pain. Has a history of long-standing HTN. During admission,
systolic readings ranged from 130's to 180's. PCP was
withholding metoprolol due to hypotension. We continued with the
PCP recs and withheld meds. Pt was never in a hypertensive
crisis.
# PNA: On ___, RR in the 40's. CXR impression was ?PNA. ABG
showed pH 7.44, PaCO2 55, PaO2 79. D-Dimer was 831. Pt started
on broad-spectrum IV abx. Cultures negative, afebrile. Converted
to IV ctx. Most likely from a mucus plug due to a bronchiectasis
flare. Nebulizer improved symptoms and moved secretions. No
signs of PE on physical exam, pt was afebrile. No CTA ordered
although equivical D-dimer. Pt remained afebrile and continued
to receive scheduled nebulizers. No recurring episodes.
INACTIVE ISSUES
# Suicidal ideation: Pt has expressed throughout the admission
that she would rather die than be in her current state. Has been
followed by psychologist for ___ years for depression and
anxiety. She continuously reports that her family does not care
as much as they should and that they are far away. Family knows
about her wishes to die. Does not refuse medications and care.
Psych consulted, does not think patient is a risk of suicide.
Venlafaxine dose was increased during stay, and will remain
increased on discharge.
# Hypercarbia: Chronic. Most likely due to the bronchiectasis,
as previous labs suggest this is baseline.
# GERD: Chronic. Home antacid pills have been helping pt. Have
explained to her she can take more than 2 every morning.
# Hyponatremia: Admitted with Na of 132 most likely due to
hypovolemia or SIADH ___ pain. No signs of hypervolemic
hyponatremia. Received maintenance fluids, and Na has been
stable since throughout hospital course.
Medications on Admission:
ALBUTEROL SULFATE - 2.5 mg/0.5 mL Solution for Nebulization - 1
vial nebulized twice daily
BUDESONIDE - 0.5 mg/2 mL Suspension for Nebulization - 1 vial
inhaled via nebulization twice a day
FLUOCINONIDE - 0.05 % Cream - twice a day as needed for itchy
FUROSEMIDE - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a
day ___ times per week as needed for to control swelling in feet
METOPROLOL TARTRATE - (On Hold from ___ to unknown for
Low BP) - 25 mg Tablet - 0.5 (One half) Tablet(s) by mouth once
a day
MUCUS CLEARING DEVICE [ACAPELLA] - Misc - Follow directions in
package insert daily
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 2 (Two)
Capsule(s) by mouth once a day in the morning
OVERNIGHT OXIMETRY ON ROOM AIR - - please perform overnight
oximetry on room air to assess patient's need for nocturnal 02
OXYGEN - - 2L/min at night and with exertion over 150 ft
THE "VEST" - - Use up to twice daily for 20min at a setting of
"2"
TRIAMCINOLONE ACETONIDE - (Prescribed by Other Provider: Dr.
___ - Dosage uncertain
TRAMADOL - 50 mg Tablet - 1 (One) Tablet(s) by mouth once a day
in the morning
VENLAFAXINE - 25 mg Tablet - 1 (One) Tablet(s) by mouth once a
day in the morning
Medications - OTC
ACETAMINOPHEN [TYLENOL ARTHRITIS PAIN] - 650 mg Tablet Extended
Release - 1 (One) Tablet(s) by mouth three times a day as needed
for pain
CALCIUM CITRATE-VITAMIN D3 [CITRACAL + D] - 250 mg-200 unit
Tablet - 1 (One) Tablet(s) by mouth once a day
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - 1,000 unit Tablet -
1 (One) Tablet(s) by mouth once a day
DEXTRAN 70-HYPROMELLOSE (PF) [NATURAL TEARS (PF)] - 0.1 %-0.3 %
Dropperette - 2 (Two) drops topically every hour as needed for
eye irritation
DEXTROMETHORPHAN POLY COMPLEX [DELSYM 12 HOUR] - 30 mg/5 mL
Suspension, Extended Rel 12 hr - 1 by mouth at bedtime
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 (One) Capsule(s)
by mouth twice a day as needed for constipation
GUAIFENESIN [MUCINEX] - 600 mg Tablet Extended Release - 1 (One)
Tablet(s) by mouth twice a day
MAGNESIUM HYDROXIDE [MILK OF MAGNESIA] - (OTC) - 400 mg/5 mL
Suspension - 1 (One) tsp by mouth at bedtime as needed for
constipation
SENNOSIDES [SENOKOT] - 8.6 mg Tablet - 1 (One) Tablet(s) by
mouth twice a day as needed for constipation
Discharge Medications:
1. Omeprazole 40 mg PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
3. Bisacodyl 10 mg PR HS:PRN constipation
4. Calcitonin Salmon 200 UNIT NAS DAILY Duration: 4 Days
5. Calcium Carbonate 1500 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Albuterol 0.083% Neb Soln 1 NEB IH BID
8. Vitamin D ___ UNIT PO DAILY
9. Acetaminophen 1000 mg PO TID
10. Artificial Tears ___ DROP BOTH EYES PRN dryness
11. CeftriaXONE 1 gm IV Q24H
12. budesonide *NF* 0.5 mg/2 mL Inhalation BID Reason for
Ordering: Wish to maintain preadmission medication while
hospitalized, as there is no acceptable substitute drug product
available on formulary.
13. Gelusil *NF* (alum-mag hydroxide-simeth) 200-200-25 mg Oral
PRN QID indigestion * Patient Taking Own Meds *
14. Metoprolol Tartrate 12.5 mg PO BID
hold for HR < 60 or SBP < 100
15. HYDROmorphone (Dilaudid) 0.5 mg PO TID:PRN pain
16. HYDROmorphone (Dilaudid) 0.5 mg PO Q4H
17. Tizanidine 2 mg PO Q6H
18. Venlafaxine XR 37.5 mg PO DAILY Please give in the morning
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
T6 Compression fracture secondary to osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ was a pleasure taking part in your care during your stay at
the ___.
You came in because you were having increasing back pain after
sustaining a fall at home a week ago. Imaging of your back
showed a compression fracture of the vertebra level T6, as well
as some old compression fractures. These are very likely a
complication of your osteoporosis.
In the hospital, a vertebroplasty, which is an injection of a
type of cement, was performed to alleviate the pain caused by
this compression.
We focused on controlling your pain while you were here, as well
as addressing your underlying osteoporosis medically by
addressing your bone healing and bone deposition with
calcitonin, calcium, and vitamin D. Finally, we arranged for
physical therapists to assess and support your mobility.
While you were here, you developed some difficulty breathing and
a chest X-ray indicated a possible infection in your lungs. You
have been covered with antibiotics to treat this, and you have
not had significant difficulty breathing since.
On discharge, please keep to the physical therapist's
recommendations. You are going to a rehabilitation facility to
further coordinate your care and pain management.
Once again, it was a pleasure to meet you, and I wish you the
best going forward.
Sincerely,
___, MD
Followup Instructions:
___
|
10825782-DS-15
| 10,825,782 | 26,893,229 |
DS
| 15 |
2171-07-27 00:00:00
|
2171-07-27 16:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
monosodium glutamate / glycine urologic solution
Attending: ___.
Chief Complaint:
L eye pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female PMH glaucoma, hypothyroidism presenting with
left orbital cellulitis.
-___: first developed sinusitis after swimming in pool
w/
significant sinus congestion, anterior and posterior nasal drip,
and headaches. Improved after a course of Augmentin.
-___: recurrence with worsening headaches, thick nasal
drainage, and facial pain, repeat Augmentin course w/o
improvement
-2 wks ago: severe worsening of her left knee pain and left
periorbital/eye pain and swelling that has progressed with
associated mild blurry vision in her eye as well as mild left
eye
redness and tearing but no mucus discharge.
-___: went to ___ where CT showed significant left-sided
sinusitis with associated left retroantral fat-pad stranding as
well as soft tissue thickening and inflammatory stranding in the
left cheek and left preseptal soft tissues (see report below).
Prescribed oral clindamycin and Ceftinir, with minimal
improvement in her symptoms, presented to ___ for further
management iso ongoing symptoms.
Past Medical History:
1. Anxiety.
2. Hypothyroidism as above - started on LT4 by psychiatrist.
3. Shingles.
4. PTSD abuse as child.
5. Positional vertigo.
6. Glaucoma.
Social History:
___
Family History:
Multiple women on mother's side including cousins and daughter
have hypothyroidism
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: reviewed in chart
GENERAL: Alert and interactive. In no acute distress.
EYES: left eye proptosis and chemosis, erythema, warmth,
tenderness. surrounding cheek edema, tenderness and erythema.
pain elicited with L ocular mvts
ENT: MMM. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. .
MSK: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+
bilaterally.
SKIN: Warm. Cap refill <2s.
NEUROLOGIC: AOx3. grossly intact
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 737)
Temp: 98.3 (Tm 99.1), BP: 146/84 (117-146/66-84), HR: 84
(71-84), RR: 18 (___), O2 sat: 95% (94-100)
GENERAL: Alert and interactive. In no acute distress.
EYES: Left eye proptosis and chemosis, erythema, warmth,
tenderness continues to decrease. Left cheek swelling,
tenderness
and erythema but improved from prior
ENT: MMM. No JVD. No gingival swelling, no visible sinus
tract/drainage into the oral cavity.
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.
MSK: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+
bilaterally.
SKIN: Warm. Cap refill <2s. Erythematous lesion in R axilla and
inguinal region with cottage-cheese like discharge
NEUROLOGIC: AOx3. grossly intact
PSYCH: appropriate mood and affect
Pertinent Results:
ADMISSION LABS:
===============
___ 04:45PM LACTATE-1.4
___ 03:10PM GLUCOSE-93 UREA N-15 CREAT-0.8 SODIUM-139
POTASSIUM-3.4* CHLORIDE-95* TOTAL CO2-25 ANION GAP-19*
___ 03:10PM estGFR-Using this
___ 03:10PM WBC-13.7* RBC-3.99 HGB-12.1 HCT-37.2 MCV-93
MCH-30.3 MCHC-32.5 RDW-13.2 RDWSD-45.5
___ 03:10PM NEUTS-82.1* LYMPHS-11.1* MONOS-6.1 EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-11.27* AbsLymp-1.52 AbsMono-0.83*
AbsEos-0.01* AbsBaso-0.03
___ 03:10PM PLT COUNT-385
DISCHARGE LABS:
===============
___ 06:17AM BLOOD WBC-8.2 RBC-3.49* Hgb-10.5* Hct-32.7*
MCV-94 MCH-30.1 MCHC-32.1 RDW-13.2 RDWSD-44.8 Plt ___
___ 06:17AM BLOOD Plt ___
___ 06:17AM BLOOD Glucose-85 UreaN-5* Creat-0.5 Na-139
K-3.5 Cl-101 HCO3-25 AnGap-13
___ 06:17AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.0
IMAGING:
=========
CT ORBITS, SELLA & IAC W/ CONTRAST ___
IMPRESSION:
1. Findings concerning for left orbital cellulitis with fat
stranding at the floor of the left orbit left globe proptosis,
and asymmetric prominence of the left inferior rectus muscle.
2. Significant left-sided paranasal sinus disease
MICRO:
======
Maxillary sinus culture: Pansensitive proteus mirabilis from
___ outside records
Brief Hospital Course:
BRIEF SUMMARY
==============
Ms. ___ is a ___ female with a history of glaucoma,
hypothyroidism and chronic L rhinosinusitis presenting with left
orbital cellulitis likely from sinusitis refractory to PO
antibiotics (cefdinir and clindamycin). Sinus cultures showed
proteus mirabilis and she was treated with cefepime and
vancomycin and then transitioned to levofloxacin prior to
discharge.
TRANSITIONAL ISSUES:
====================
[]continue levofloxacin 500 mg q24h (___
[]QT noted to be prolonged at 490. Please obtain repeat EKG one
week following discharge for QT monitoring
[]Patient will need ongoing treatment for fungal rash,
discharged on clotrimazole and should avoid PO antifungals for
now given QT but would consider fluconazole following antibiotic
course
[]consider HIV testing given extensive candidiasis
[]patient should follow up within ___ days in the ___
___ at ___ and in the ___.
ACUTE ISSUES:
=============
#Left orbital cellulitis
#Recurrent Sinusitis
Most likely etiology of cellulitis is the patient's preceding
sinusitis. Sinus cultures returned with pan-sensitive Proteus
Mirabilis. There may be involvement of organisms including staph
or strep, possibly GNR or pseudmonas due to proximity of symptom
onset to swimming, unlikely anaerobic. She was treated with
cefepime and vancomycin, as well as afrin, Flonase, and nasal
saline irrigation. Her vision has been patent throughout her
course, and she had significant improvement in eye pain and
swelling. She was discharged on levofloxacin to complete a 14
day course (___) per ID, ophtho and ENT
recommendations (no surgery needed or planned).
___ intertrigo
#Vulvovaginal candidiasis
Likely in the setting of broad-spectrum antibiotic use. Patient
was
offered vaginal miconazole but declined. We avoided PO
antifungals given QT of 490. She was discharged with topical
clotrimazole. She should follow up with her PCP for further
management of candidiasis.
CHRONIC ISSUES:
===============
#Sinusitis:
Patient had chronic L rhinosinusitis, actively bothering her
since ___. Outpatient treatment with augmentin did not help.
Patient should follow up with ENT outpatient, with consideration
for outpatient sinus surgery.
#Glaucoma
Continue timolol maleate 0.5 % bid.
#Hypothyrodism
Continue home levothyroxine 50mg.
#Anxiety
Continue klonopin qHS and ramelteon for sleep as needed.
Benzodiazepine held in setting of serious infection; restart
when appropriate.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. ClonazePAM 1 mg PO QHS:PRN insomnia
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
Discharge Medications:
1. Clotrimazole Cream 1 Appl TP BID
RX *clotrimazole 1 % apply to rash twice a day Refills:*1
2. LevoFLOXacin 500 mg PO DAILY Duration: 12 Doses
RX *levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp
#*12 Tablet Refills:*0
3. ClonazePAM 1 mg PO QHS:PRN insomnia
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Orbital cellulitis
SECONDARY DIAGNOSIS
===================
Sinusitis
Candidiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You had an infection of the skin around your left eye
WHAT HAPPENED IN THE HOSPITAL?
==============================
- We did imaging of your eye and sinuses
- We gave you antibiotics to treat your infection
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take all of your medications as directed
- Please follow up with all the appointments scheduled with your
doctor
___ you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10826482-DS-3
| 10,826,482 | 20,486,823 |
DS
| 3 |
2144-05-30 00:00:00
|
2144-05-30 11:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
cervical mass biopsy
History of Present Illness:
Ms ___ is a pleasant ___ with no
PMH however without medical care in years, who presents as
transfer from ___ after fall today due to ___
weakness, 1 month of generalized weakness as well as bilateral
hip pain and abd pain. In regards to the fall, pt denies
syncope/LOC, she states that her legs suddenly felt week and she
fell to the floor without headstrike. She subsequently called
her brother and was brought to ___. She denies any CP, SOB,
palps prior to the fall. She does endorse new dysuria and has a
hx of chronic incontinence. She also endorses intermittent
diarrhea without dark or bloody stools. Additionally, she notes
worsening ___ and blistering for about a month, did not seek
medical treatment for this. At ___ she was found to have a
large
intrabd/pelvic mass and was therefore transferred to ___ for
further w/u.
In the ___ ED, initial vitals were: 97.6 101 109/65 18 99% RA.
Exam was notable for a firm RLQ mass, distended abdomen, full
ROM
in bilat ___ without pain, bilateral ___ pitting edema with
scattered bullae. While in the ED, labs were notable for mild
hyponatremia, creatinine of 2.2, Ca125 of 142, WBC 35.3, hct
23.8, grossly positive UA, anion gap of 19. A head CT was
obtained which showed no acute intracranial process. CT
abd/pelvis showed large sidewall to sidewall mass within the
pelvis extending into the lower abdomen. There is probably a
combination of neoplasm in addition to opacified loops of bowel
that are matted together. Bilateral ureteral obstruction
secondary to mass. While in the ED, she was seen by OB/GYN, who
recommended medicine admission for further w/u, will xfer to GYN
onc if diagnosed as onc malignancy. She was also seen by
surgery, who recommended no immediate intervention, and urology
who signed off after recommending bilat PCN tubes. While in the
ED, she received Zosyn, cefepime, and flagyl. She was taken
from
the ED to ___ for bilateral PCN tubes.
On the floor, she has no new complaints but states that she has
ongoing abd pain and dysuria which has been present for only "a
short amt of time" She also endorses a small amt of wt loss
which she is unable to quantify further.
Past Medical History:
no known
Social History:
___
Family History:
mother with uterine cancer, died at ___ from it.
Dad died of stroke.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
Vitals: 97.7 PO125 / 75 93 ___
Constitutional: Alert, oriented, no acute distress, fatigued
appearing and falling asleep during interview
EYES: Sclera anicteric, EOMI, PERRL
ENMT: MMM, oropharynx clear, normal hearing, normal nares
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
GI: distended and firm, diffusely tender, bowel sounds present,
no rebound or guarding
GU: foley in place draining clear urine, bilateral nephrostomy
tubes in place draining pink urine
EXT: Warm, well perfused, bilateral ___, multiple erythematous
lesions on ___: aaox3, CNII-XII and strength intact
SKIN: as above
Discharge exam
RR: 24
GENERAL: sleeping in bed, ill appearing
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: tachycardic, no murmur, no S3, no S4. No JVD. 1+ ___ edema
b/l
RESP: Lungs clear to auscultation. Breathing is fast and mildly
labored
GI: Abdomen slightly firm, distended, mildly tender in all
quadrants.
EXT: Warm and well perfused. fluid filled blisters at lower legs
bilaterally, at various stages of healing
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: flat affect
Pertinent Results:
ADMISSION LABS:
==============
___ 11:46PM BLOOD WBC-35.4* RBC-3.90 Hgb-7.5* Hct-26.8*
MCV-69* MCH-19.2* MCHC-28.0* RDW-22.4* RDWSD-53.2* Plt ___
___ 12:08AM BLOOD ___ PTT-24.1* ___
___ 12:08AM BLOOD Glucose-68* UreaN-66* Creat-1.8* Na-138
K-5.6* Cl-99 HCO3-14* AnGap-25*
___ 10:23AM BLOOD ALT-12 AST-16 LD(LDH)-311* AlkPhos-98
TotBili-0.4
___ 10:23AM BLOOD Albumin-2.6* Calcium-8.7 Phos-5.0* Mg-2.4
Iron-24*
___ 06:08AM BLOOD Hapto-411*
___ 10:23AM BLOOD calTIBC-204* Ferritn-149 TRF-157*
___ 10:23AM BLOOD CEA-2.5 CA125-142*
___ 11:51PM BLOOD Lactate-2.0 K-5.0
IMAGING/STUDIES:
===============
___ B/L ___:
Limited evaluation of the calves, however, no evidence of deep
venous thrombosis in the right or left lower extremity veins.
___ CT A/P:
1. 18.9 x 19.2 x 14.4 cm large pelvic mass containing a 8.7 x
7.3 x 9.8 cm complex fluid collection with locules of gas and
coarse calcifications, as described above.
2. Pelvic, inguinal, mesenteric and left para-aortic
lymphadenopathy.
3. No evidence of bowel obstruction.
4. No aggressive osseous lesions.
5. Large hiatal hernia, as described above.
6. Moderate right and mild left hydronephrosis, likely secondary
to large
pelvic mass.
7. Nonobstructing subcentimeter left renal calculi.
___ KUB:
Nonspecific, nonobstructive bowel gas pattern. Enteric contrast
material is
seen within the colon.
___ CXR:
No acute intrathoracic process. Please note that evaluation for
metastatic
disease is limited by chest radiograph.
pathology:
PATHOLOGIC DIAGNOSIS:
Cervical polyp, biopsy:
- High grade adenocarcinoma with squmaous differentiation most
suggestive of high grade
endometrioid carcinoma with focal area concerning for
sarcomatous differentiation. See note.
Note: Tumor cells show positive staining for Pax8 and estrogen
and progesterone receptors
(diffuse). The p53 stain shows a wild-type pattern of staining.
Morphological features with
immunoprofile are are consistent with adenocarcinoma of
mullerian origin, endometrioid type.
Clinical correlation is recommended to ascertain the exact site
of origin.
___ MRI pelvis:
1. Findings concerning for cervical carcinoma with infiltration
into the
endometrial canal, upper vagina and parametria.
2. Gas within the endometrial cavity may reflect a necrotic
fibroid. However, part of the anterior myometrium is not
enhancing and a fistulous connection with overlying small bowel
cannot be excluded
3. Large confluent masses in the lower abdomen and omentum
extending to the pelvic sidewall and encasing the sigmoid colon.
These most likely represent peritoneal carcinomatosis. Omental
biopsy could be performed for confirmation.
4. Metastatic pelvic lymphadenopathy.
___ CTA chest:
1. Small areas of nonocclusive/subtotal occlusive pulmonary
emboli in the
right lower lobe and lingula, as described. No pulmonary
infarct or imaging evidence of right heart strain.
2. No evidence of thoracic metastasis.
3. Massive hiatal hernia with complete intrathoracic stomach
with small amount of adjacent free fluid, likely inflammatory,
also containing a small portion of the pancreas.
Discharge labs (prior to CMO status)
___ 01:15PM BLOOD WBC-35.6* RBC-3.96 Hgb-8.0* Hct-29.7*
MCV-75* MCH-20.2* MCHC-26.9* RDW-26.9* RDWSD-69.0* Plt ___
___ 01:15PM BLOOD Glucose-90 UreaN-41* Creat-1.6* Na-139
K-3.9 Cl-102 HCO3-13* AnGap-24*
___ 06:23AM BLOOD ALT-6 AST-13 LD(LDH)-454* AlkPhos-85
TotBili-0.2
___ 01:15PM BLOOD Calcium-8.1* Phos-3.2 Mg-1.9
Brief Hospital Course:
Pt is a ___ year old previously healthy female who was admitted
___ with ___ secondary to large pelvic mass with bilateral
hydronephrosis, status post bilateral perc nephrostomy tubes,
pathology revealing high grade endometrioid carcinoma, course
otherwise notable for diagnosis of acute pulmonary embolism,
started on IV heparin, recently transferred to ICU for tachypnea
and elevated lactate, thought to be related to advanced
malignancy and cell turnover, with possible superinfection of
tumor, now transitioned to comfort measures only.
FICU Course ___
While on the floor she was noted to be tachycardic, tachypnic
with a rising lactate and was transferred the ICU. In the ICU
she was treated with fluid resuscitation and medical oncology,
radiation oncology and gynecologic oncology were consulted. It
was determined there were no surgical or chemotherapy options.
She was treated with fluids and antibiotics for her rising
lactate and acidosis, however suspect this was related to
necrosis from her large malignant pelvic mass. She remained
hemodynamically stable and was transferred back to the floor
with plans for palliative care consult and involvement.
MEDICINE FLOOR COURSE:
# High grade endometrioid carcinoma
# Generalized abdominal pain
Pt underwent vertical mass biopsy and was diagnosed with stage 4
advanced endometrial cancer based on pathology and imaging. She
was seen by gyn-onc, med-onc and rad-onc. Unfortunately she is
not a candidate for surgery, chemotherapy or radiation therapy
(unless needed for palliation). This was discussed with pt and
family in depth on ___, and pt opted for transition to CMO. At
that time, antibiotics and IV heparin were discontinued and
patient was treated symptomatically with liquid morphine prn
pain and dyspnea as patient lost IV access and did not want it
replaced.
# Sepsis
Pt was being treating with broad antibiotics for possible
abscess or superinfection was tumor. She was transferred to ICU
in setting of elevated lactate and tachypnea; suspected by ICU
to relate to response to metabolic acidosis and possible
superinfection of tumor (appears to invade into bowel, which
could be source of infection); patient was placed on empiric
antibiotics and improved over 24 hours. However, prognosis
remained poor given advanced cancer, and as above, antibiotics
were discontinued when goals of care were transitioned to CMO.
# ___
# Ureteral obstruction secondary to tumor: pt presented with ___
secondary to ureteral obstruction secondary to tumor. She
underwent bilateral PCN placement with initial improvement in
Cr. However renal function later worsened due to poor PO intake
and sepsis physiology. She was initially treated with IVFs, but
the were discontinued when patients goals of care transitioned
to CMO.
# Acute pulmonary embolism: diagnosed during admission; IV
heparin was initially started and later discontinued given GOC.
She was given nebs for symptomatic treatment for shortness of
breath.
# Acute severe protein calorie malnutrition
Likely secondary to acute illness
-regular diet as tolerated given GOC
# Lower extremity edema
Suspect secondary to venous/lymph compression from malignancy;
Doppler early in admission without DVT
Patient was discharged to ___ on ___.
Greater than 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. This patient is not taking any preadmission medications
Discharge Medications:
1. Docusate Sodium 100 mg PO BID hold for loose stools
2. Ipratropium-Albuterol Neb 1 NEB NEB Q8H
3. Miconazole Powder 2% 1 Appl TP TID:PRN irritation
4. Morphine Sulfate (Oral Solution) 2 mg/mL 2.5 mg PO Q6H:PRN
dyspnea, pain
RX *morphine 10 mg/5 mL 2.5 mg by mouth every 6 hours as needed
Refills:*0
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Endometrial cancer
acute kidney injury
hydronephrosis
pulmonary embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with weakness. Unfortunately, you
were found to have endometrial cancer. After discussions with
you and your family, we decided to focus your care on being as
comfortable as possible. You will be able to continue receiving
this care at a hospice house.
It has been a pleasure and honor taking care of you and we wish
you all the best.
Your ___ Care Team
Followup Instructions:
___
|
10827000-DS-16
| 10,827,000 | 29,339,344 |
DS
| 16 |
2112-08-07 00:00:00
|
2112-08-09 00:47:00
|
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:
None
attach
Pertinent Results:
ADMISSION LABS
==============
___ 12:40PM BLOOD WBC-7.4 RBC-3.55* Hgb-12.8 Hct-35.9
MCV-101* MCH-36.1* MCHC-35.7 RDW-13.5 RDWSD-50.1* Plt ___
___ 12:40PM BLOOD Neuts-74.7* Lymphs-17.2* Monos-5.7
Eos-0.8* Baso-1.2* Im ___ AbsNeut-5.55 AbsLymp-1.28
AbsMono-0.42 AbsEos-0.06 AbsBaso-0.09*
___ 12:40PM BLOOD ___ PTT-32.6 ___
___ 12:40PM BLOOD Glucose-107* UreaN-4* Creat-0.8 Na-136
K-4.4 Cl-98 HCO3-18* AnGap-20*
___ 12:40PM BLOOD ALT-33 AST-62* AlkPhos-138* TotBili-3.1*
DirBili-1.0* IndBili-2.1
___ 12:40PM BLOOD Albumin-4.3 Calcium-9.4 Phos-3.9 Mg-1.4*
___ 05:50AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 06:10AM BLOOD HAV Ab-POS*
___ 12:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 05:50AM BLOOD HCV Ab-NEG
IMAGING:
RUQ US ___. Gallbladder sludge without evidence of acute cholecystitis.
2. Echogenic liver which likely represents steatosis however
other forms of
liver disease cannot be excluded. See recommendations below.
RECOMMENDATION(S): Radiological evidence of fatty liver does
not exclude
cirrhosis or significant liver fibrosis which could be further
evaluated by
___. This can be requested via the ___
(FibroScan), or the
Radiology Department with MR ___, in conjunction with a
GI/Hepatology
consultation" *
CXR: ___
IMPRESSION:
No acute cardiopulmonary abnormality.
Brief Hospital Course:
SUMMARY
___ year old woman with PMH EtOH use disorder presents with
transaminitis and RUQ abdominal pain consistent with mild
alcoholic hepatitis.
She was seen by ___ this admission and expressed to them that she
has a good
support network and is followed by ___ as outpt. She expressed
that she would be
contacting her outpatient center to re-enroll there on
discharge.
TRANSITION ISSUES
=================
[] Consider starting Naltrexone as outpatient
[] Continue to encourage alcohol abstinence and IOP admission
ACUTE ISSUES:
=============
# RUQ abdominal pain
# Mild alcoholic hepatitis
# Steatosis
Patient presented with acute RUQ abdominal pain. Given
significant EtOH use history and transminitis (approx 2:1
AST:ALT), her presentation was most c/w alcoholic hepatitis. MDF
of 17.4 on admission that improved along with improvement of
LFTs. RUQUS was obtain with noted Cholelithiasis but reassuring
against cholecystitis, choledocolithiasis; lipase was normal for
rule out possible pancreatitis. Negative Hepatitis serologies.
Will follow up in ___ clinic for steatosis seen on
RUQUS this admission.
# Coagulopathy
INR of 1.4 was noted on admission. Felt secondary to nutritional
deficiency vs. liver disease. She was started on 3 day course of
PO vitamin K with improvement in there INR. INR at discharge
1.1.
# Alcohol use disorder
No history of complicated withdrawal. Per patient, last known
drink ___, though may have had alcohol containing drink
last night prior to admission. Patient noted she was motivated
to restart an an outpatient program and has an IOP that she
would like to access in the community where she already has a
connection; she contacted them prior to discharge to arrange
re-enrollment. Patient had no signs of withdraw during this
admission. She was given thiamine, folate and MVI to help manage
her nutritional deficiencies and counseled on the importance of
high-protein diet.
CHRONIC ISSUES:
===============
# Anxiety
# Depression
- Continued home clonazepam PRN
- Continued home fluoxetine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
2. TraZODone 50 mg PO QHS:PRN insomnia
3. FLUoxetine 40 mg PO DAILY
4. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
5. Tri-Previfem (28) (norgestimate-ethinyl estradiol)
0.18/0.215/0.25 mg-35 mcg (28) oral DAILY
6. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ONCE:PRN
allergic reaction
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidocaine Pain Relief] 4 % apply 1 patch once a
day Disp #*10 Patch Refills:*0
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Chewable-Vite] 1 tablet by mouth once a day
Disp #*30 Tablet Refills:*0
4. Ranitidine 75 mg PO DAILY
RX *ranitidine HCl [Acid Reducer (ranitidine)] 75 mg 1 tablet(s)
by mouth once a day Disp #*30 Tablet Refills:*0
5. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
6. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
7. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ONCE:PRN
allergic reaction
8. FLUoxetine 40 mg PO DAILY
9. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
10. TraZODone 50 mg PO QHS:PRN insomnia
11. Tri-Previfem (28) (norgestimate-ethinyl estradiol)
0.18/0.215/0.25 mg-35 mcg (28) oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
=================
Alchohic hepatitis
Secondary diagnosis
==================
Alcohol Use Disorder
Anxiety
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___
___ were admitted to the hospital because abdominal pain, nausea
and vomiting
WHAT HAPPENED WHILE ___ WERE IN THE HOSPITAL?
- ___ had blood work that showed that your liver was damaged
from alcohol use.
- ___ also had an US of your liver that showed that ___ had
gallstone in your gallbladder. But your gallbadder was not
infected or obstructing anything.
- ___ were given medication for your abdominal pain and nausea
- ___ improved and were ready to leave the hospital.
WHAT DO ___ NEED TO DO WHEN ___ LEAVE THE HOSPITAL?
- ___ must never drink alcohol again or ___ will die
- Please enroll in AA and work with your primary care doctor to
determine the best strategy to help ___ stay sober
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- If ___ experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish ___ the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10827464-DS-12
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| 12 |
2151-03-18 00:00:00
|
2151-03-19 10:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
CHIEF COMPLAINT: Blood In Stool
REASON FOR MICU TRANSFER: concern for brisk bleed
Major Surgical or Invasive Procedure:
___ colonoscopy
History of Present Illness:
Ms. ___ is a ___ ___ lady with EtOH cirrhosis s/p OLT
in
___, portal vein thrombosis on anticoagulation, HCC, and
known 1cm sigmoid polyp who presents with BRBPR.
She has been holding her Warfarin and has been taking Enoxaparin
shots for the past 4 days in anticipation of outpatient
colonoscopy tomorrow (___). No Enoxaparin today. No ASA or
NSAID use. She was doing fine until 4AM on ___ (the day
prior to presentation) when she had an episode of passing red
stool with red toilet water. She has had 3 more episodes since
then. The stool is red; no dark/tarry stool. Mild upper
abdominal discomfort. Denies any SOB, chest pain,
lightheadedness. She has felt weakness for the entire day, and
pain in her abdomen at the site of her injections. Her BP at
home was 130/90. She called in and was referred to the ED.
In the ED, initial VS were: T 97.8, HR 50, BP 138/64, RR 16, POx
100% RA. Exam revealed lower abdominal tenderness, rectal exam
with no hemorrhoids, watery bloody stool on rectal exam. Labs
were notable for Hct 35 (baseline 37), BUN 17/Cr 1. ALT 52, AST
52, TBili 1, INR 1.1. EKG showed sinus bradycardia with no
ischemic changes. He had 2 18G PIV placed and was admitted to
the MICU. He received 2L NS. Repeat Hct was 32. Due to having
blood on rectal exam, she was admitted to the MICU. VS prior to
transfer were: T 98.1, HR 54, BP 109/58, RR 16, POx 100%RA.
On arrival to the MICU, she feels OK. Does not want to do the
bowel prep. Just had one more episode of bright blood mixed with
urine and brown stool in her commode.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, constipation. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
- Orthotopic liver transplant on ___ for cirrhosis ___ HCC
and EtOH
- Asthma
- Anxiety/depression
Social History:
___
Family History:
Nobody with liver disease.
Physical Exam:
ADMISSION EXAM
Vitals: T 98.5 °F, HR 54, BP 102/60, RR 15, SpO2 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: well-healed surgical scars; soft, non-distended, bowel
sounds present, no organomegaly; mild TTP of RUQ and LUQ but no
rebound or guarding
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, finger-to-nose intact
DISCHARGE EXAM
Pertinent Results:
LABS:
___ 08:30PM BLOOD WBC-6.1 RBC-4.13* Hgb-11.9* Hct-35.0*
MCV-85 MCH-28.7 MCHC-33.9 RDW-14.0 Plt ___
___ 08:30PM BLOOD Neuts-42.5* Lymphs-45.0* Monos-5.3
Eos-6.6* Baso-0.6
___ 08:51PM BLOOD ___ PTT-45.9* ___
___ 08:30PM BLOOD Glucose-91 UreaN-17 Creat-1.0 Na-141
K-4.0 Cl-108 HCO3-23 AnGap-14
___ 08:30PM BLOOD ALT-52* AST-52* AlkPhos-89 TotBili-1.0
___ 08:30PM BLOOD Albumin-3.8
___ 11:34PM BLOOD Hgb-10.8* calcHCT-32
PATHOLOGY:
Colonic biopsies ___
I. Colon (descending, mass), biopsy:
1. Fragment of unremarkable colon.
2. Blood with bacteria.
Note: Correlation with endoscopic findings is needed.
II. Colon (sigmoid), polypectomy:
Adenoma.
STUDIES:
.
EKG ___: Sinus bradycardia. Non-diagnostic Q waves in
leads II, III and aVF. Mild Q-T interval prolongation.
Non-diagnostic inferior Q waves. Since the previous tracing of
___ no significant change.
.
COLONOSCOPY ___:
Impression:
Descending colon mass, submucosal hematoma highly suspicious for
underlying pathology (GIST, carcinoid).1 cm semi-pedunculated
___ appearing sigmoid colon polyp completely removed with
cold snare polypectomy s/p 2 hemoclips with good hemostasis.
(biopsy, biopsy, endoclip)
Otherwise normal colonoscopy to cecum and terminal ileum
Recommendations:
CT Abdomen/Pelvis
Hold on anticoagulation
Monitor CBC
Will need repeat colonoscopy/+_ EUS in 2 weeks to rule out
underlying pathology (Carcinoid, GIST)
CT Abd/Pelvis with contrast ___
1. 4.0 cm (AP) x 3.1 cm (TV) x 5.0 cm (CC) mass within the
descending colon at the splenic flexure which significantly
narrows the lumen. There is however no obstruction.
2. Post-transplant liver is again seen with a similar
appearance of main, right, and left portal vein thrmbosis.
Multiple previously visualized indeterminate foci of arterial
enhancement on MRI are not clearly identified on today's study;
however, MRI is more sensitive for evaluation of these foci.
3. Mild intrahepatic biliary dilatation is again seen.
4. 1.0 x 1.0 left adenxal cystic focus is again noted and
indeterminate.
5. A fat-containing incisional hernia is again noted in the
right upper
quadrant.
Lower EUS ___:
Clips of previous polypectomy were noted in the sigmoid colon.
A ulcerated 3 cm mass was found in the descending colon. The
mass caused a partial obstruction. The scope traversed the
lesion. A large blood clot was noted in the surface of the
lesion.
EUS was performed using a mini EUS probe at ___ MHz frequency.
The mass measured at least 2.9 cm X 2.8 cm. Shape of the mass
was round and irregular. Echotecture of the mass was hypoechoic
and heterogeneous. The walls of the mass were well demarcated
and irregular. The mass appeared to compromise all the mucosal
layers invading the muscularis propia and the serosa.
No adjacent lymphadenopathy were noted.
Brief Hospital Course:
___ with h/o EtOH cirrhosis, HCC s/p OLT in ___, portal vein
thrombosis on anticoagulation admitted for BRBPR which was found
to be due to mass with submucosal hematoma in the descending
colon.
#) Colonic mass: Pt was admitted with several days of BRBPR and
was found on colonoscopy ___ to have large mass in descending
colon with submucosal hemorrhage. Did not cause symptoms of
bowel obstruction. Biopsies of the mass were nondiagnostic.
Transplant surgery and colorectal surgery were consulted. Lower
EUS was performed ___ characterized mass as an ulcerated
hypoechoic and heterogeneous 3 cm mass with large blood clot in
its surface. It appeared to compromise all the mucosal layers
invading the muscularis propia and the serosa. It was decided to
repeat colonoscopy in the outpatient setting after holding
anticoagulation for an additional 2 weeks so that repeat
biopsies could be taken. She will also need MRI enterography and
will follow up with transplant hepatology and colorectal surgery
in 3 weeks to determine need for potential surgical resection
after tissue diagnosis achieved.
#) Anemia: Pt reported several episodes of BRBPR related to
colonic mass as above. She had been chronically on warfarin for
portal vein thrombosis with recent switch to lovenox 4 days
prior to presentation in anticipation of colonoscopy.
Anticoagulation was held during admission. Pt continued to
experience small amounts of bright red blood with bowel
movements and HCT decreased gradually from 35->26.7 over course
of admission. She was transfused 2 units PRBCs ___ in
anticipation of continued bleeding. She was noted to have low
grade fever 100.8 in the last 30min of the second transfusion
but ______did/did not have further fever or complication
concerning for transfusion reaction overnight. She was
discharged with plan to have labs drawn twice weekly to include
CBC, transfusion goal HCT>26.
#) Hypotension: Pt noted to have SBP ___ in the MICU,
asymptomatic. Received 1L NS prior to transfer to floor. SBP
remained ___. Home nadolol was discontinued due to
continued low-normal blood pressure and unclear indication post
liver transplant (no evidence of esophageal varices on most
recent EGD ___. Home amlodipine was also held.
#) H/o EtOH cirrhosis and HCC s/p OLT: On tacrolimus 1mg BID at
home which was increased to 2mg BID for tacrolimus trough of 4.6
on ___. Goal tacro level ___ as patient is ___ years post
transplant.
#) Transaminitis: ALT/AST elevated this admission (50s-80s).
Concerning as sign of potential graft rejection in the setting
of recent low tacro level. CMV viral load and EBV panel pending
at time of discharge. LFTs will be monitored twice weekly and
faxed to the ___.
#) Portal vein thrombus: Pt had been on anticoagulation with
warfarin which had been transitioned to ___ prior to
admission in anticipation of outpatient colonoscopy. Given
continued lower GI bleed from ulcerated colonic mass and
upcoming repeat colonoscopy with biopsies.
#) Transitional Issues
- Pt previously anticoagulated with warfarin which had been
transitioned to ___ prior to admission in anticipation of
outpatient colonoscopy; ___ held this admission and should
continue to be held pending repeat colonoscopy with biopsies in
2 weeks.
- Will need MRI enterography in 2 weeks
- AST/ALT mildly elevated this admission; will need to be
monitored twice weekly as outpatient. CMV viral load and EBV
panel pending at time of discharge.
- CBC to be monitored twice weekly pending repeat colonoscopy;
will need transfusion for HCT<26
- please follow the Tacro level given recent dose adjustment
from 1 mg q12 to 2 mg q12
- Discontinued nadolol given unclear indication post transplant
- Home amlodipine held this admission in the setting of ongoing
GI bleed and low-normal blood pressures; consider restarting as
necessary once bleeding stabilized
-EMERGENCY CONTACT: ___ (Son) ___
-CODE STATUS: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 11 mg PO DAILY16
(on hold while taking Enoxaparin in preparation for colonoscopy)
2. Enoxaparin Sodium 100 mg SC Q12H
3. Tacrolimus 1 mg PO Q12H
4. Nadolol 20 mg PO DAILY
5. Amlodipine 5 mg PO DAILY
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
7. Lactulose 1 tablespoon PO BID OR TID
as needed for to achieve ___ bowel movements per day
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
10. Omeprazole 40 mg PO DAILY
11. Fluticasone Propionate NASAL 1 SPRY NU DAILY
12. Docusate Sodium 100 mg PO BID
13. calcium carbonate-vitamin D3 *NF* 600 mg(1,500mg) -400 unit
Oral twice a day
14. Ferrous Sulfate 325 mg PO TID
15. FoLIC Acid 1 mg PO DAILY
16. hydroquinone *NF* 4 % Topical twice a day
17. Loratadine *NF* 10 mg Oral daily
18. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Omeprazole 40 mg PO DAILY
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
6. Tacrolimus 2 mg PO Q12H
RX *tacrolimus 1 mg 2 capsule(s) by mouth Twice a day Disp #*120
Capsule Refills:*0
7. calcium carbonate-vitamin D3 *NF* 600 mg(1,500mg) -400 unit
Oral twice a day
8. Docusate Sodium 100 mg PO BID
9. Ferrous Sulfate 325 mg PO TID
10. FoLIC Acid 1 mg PO DAILY
11. hydroquinone *NF* 4 % Topical twice a day
12. Loratadine *NF* 10 mg Oral daily
13. Senna 1 TAB PO BID:PRN constipation
14. Outpatient Lab Work
Please check the following twice per week and fax to liver
clinic at ___:
CBC, tacrolimus, AST, ALT, Alk Phos, Total bilirubin
Diagnosis code: Diagnosis Code V42.7 Liver replaced by
transplant
15. Lactulose 1 tablespoon PO BID OR TID
as needed for to achieve ___ bowel movements per day
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Lower gastrointestinal bleed
Colonic mass
Secondary diagnoses:
Portal vein thrombosis
End stage liver disease status post transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
to the hospital for rectal bleeding and were found to have a
large mass in your colon which was the source of the bleeding. A
small sample of the mass showed blood but provided little other
information. You were given several blood transfusions to
maintain your blood count and the blood thinner that you had
been on, lovenox, was stopped.
You were seen by our surgeons who recommended holding your blood
thinner and repeating a repeat colonoscopy with biopsies in 2
weeks to obtain more information about the mass. You will need
to follow up with both our liver transplant and surgery doctors
after the ___ in order to determine if you will need
surgery to remove the mass.
You will need to have your blood count checked twice per week to
determine if you need more blood transfusions and to monitor
your liver and tacrolimus levels.
Please follow up at the appointments which will be arranged by
the ___ and continue to take your medications with the
following changes:
- STOP lovenox
- STOP nadolol
- STOP amlodipine
- CHANGE tacrolimus to 2 mg twice daily
Followup Instructions:
___
|
10827464-DS-13
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| 13 |
2151-08-10 00:00:00
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2151-08-13 20:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p OLT 2/t EtOH (also w/ HCC) in ___ c/b portal vein
thrombosis and resulting hepatic encephalopathy controlled with
lactulose w/ coumadin being held in the setting of a colonic
hemotoma and with recently enlarging hepatic lesions from ___
s/p US guided biopsy x2 (last on ___ who was transferred
from ___ with diffuse abdominal pain x 2 days. Pt
describes intermittent and crampy b/l UQ abdominal pain (R>L)
that started yesterday after having a coffee drink. Pain
relieved by Tiger Balm. She had 1 episode of nausea/vomiting
(undigested food, no blood, ___ this morning. Denies coffee
ground emesis, hematemesis, BRBPR, melena. Denies fevers/chills.
Has been having BMs but endorses constipation, denies diarhea.
No URI like symptoms, no travel or sick contacts. Denies cough,
dysuria, hematuria, sore throat, nasal congestion.
At OSH, had a CT that showed biliary dilatation. No antibiotics
given.
In the ED, initial VS were: 98 67 108/63 20 98% RA. No ascites
on bedside ultrasound. Labs were remarkable for elevation in
liver enzymes and bili. Liver US showed known decreased hepatic
vein blood flow. Vitals on Transfer: 98 66 104/71 18 100%.
On the floor, pt feeling much better, no abdominal pain, but has
not eaten recently.
Review of sytems:
Per HPI
Past Medical History:
- Orthotopic liver transplant on ___ for cirrhosis ___ HCC
and EtOH c/b portal vein thrombosis (h/o anticoagulatioN) now
with multiple hepatic lesions s/p biopsy
- LGIB from suspected colonic hemotoma ___
- PUD (healed ulcer in ___
- Asthma
- Anxiety/depression
- Thyroid nodule
- Adnexal cyst
Social History:
___
Family History:
Denies fam h/o liver disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.3 125/80 64 20 100%RA
General: NAD, obese
HEENT: Dry MM, icteric sclera, pink conj
Neck: Supple, no JVD/LAD
CV: S1S2 RRR no m/g/c/r
Lungs: CTAB
Abdomen: Decrease BS, diffuse RUQ/LUQ pain, no rebound or
guarding, soft, hepatomegaly on exam
Ext: No c/c/e, 2+ pulses
Neuro: No asterexis, CN2-12 intact, motor/sensation in tact
Skin: No rash, large surgical abdominal scars
DISCHARGE PHYSICAL EXAM:
VS: 98.7 97-125/61-70 ___ 18 99-100%RA
Gen: NAD, laying in bed, obese
HEENT: MMM, improving white sclera, pink conj
CV: S1S2 RRR no m/g/c/r
Lungs: CTAB
Abdomen: BS+ soft nd, hepatomegaly on exam and mild pain with
palpation of organ, no ascites detectable
Ext: No c/c/e, 2+ pulses
Neuro: No asterexis, CN2-12 intact, motor/sensation in tact
Skin: No rash, large surgical abdominal scars
Pertinent Results:
ADMISSION LABS
___ 03:00PM BLOOD WBC-7.4 RBC-4.41 Hgb-12.3 Hct-37.2 MCV-84
MCH-27.9 MCHC-33.1 RDW-15.0 Plt ___
___ 03:00PM BLOOD Neuts-73.1* ___ Monos-4.5 Eos-1.3
Baso-0.6
___ 06:30AM BLOOD ___ PTT-40.3* ___
___ 03:00PM BLOOD Glucose-94 UreaN-21* Creat-1.0 Na-137
K-4.4 Cl-105 HCO3-24 AnGap-12
___ 03:00PM BLOOD ALT-196* AST-167* AlkPhos-292*
TotBili-5.4* DirBili-4.3* IndBili-1.1
___ 03:00PM BLOOD Lipase-127*
___ 06:30AM BLOOD Albumin-3.5 Calcium-8.7 Phos-3.1 Mg-1.9
___ 03:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-2* pH-7.0 Leuks-NEG
___ 03:00PM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-2
STUDIES
Liver US
1. Occlusion of the portal venous system, unchanged. Patent
hepatic arteries and left and right hepatic veins; middle
hepatic vein was not specifically evaluated.
2. Heterogeneous liver echotexture without focal lesions. No
perihepatic fluid.
MRCP
Mild increased caliber of the central intrahepatic bile ducts
with a beaded appearance, peribiliary enhancement and mosaic
perfusion in the early arterial phase. In the right clinical
setting this may represent cholangitis.
Stable appearance of mild narrowing at the level of the surgical
anastomosis within the common bile duct.
Numerous hepatic masses which demonstrate variable enhancement
pattern, not typical for ___. However, in the setting of portal
vein occlusion and already altered hepatic supply, the imaging
appearance is not specific. The size and morphology has not
changes from the prior study of ___.
Chronically thrombosed extra- and intra-hepatic portal vein.
MICRO:
Blood Cx Pending
___ 6:30 am Immunology (CMV)
**FINAL REPORT ___
CMV Viral Load (Final ___:
CMV DNA detected, less than 137 IU/mL.
Performed by Cobas Ampliprep / Cobas Taqman CMV Test.
Linear range of quantification: 137 IU/mL - 9,100,000
IU/mL.
Limit of detection 91 IU/mL.
This test has been verified for use in the ___ patient
population.
Reported to and read back by ___ ___ 4:43PM
___.
DISCHARGE LABS:
___ 05:50AM BLOOD WBC-6.1 RBC-4.30 Hgb-12.3 Hct-36.9 MCV-86
MCH-28.7 MCHC-33.5 RDW-15.4 Plt ___
___ 05:50AM BLOOD ALT-172* AST-136* AlkPhos-257*
TotBili-1.8*
Brief Hospital Course:
___ s/p OLT 2/t HCC in ___ c/b portal vein thrombosis and
resulting hepatic encephalopathy controlled with lactulose w/
coumadin being held in the setting of a recent colonic hemotoma
and with recently enlarging hepatic lesions from ___ s/p US
guided biopsy x2 (last on ___ who was transferred from
___ with diffuse abdominal pain x 2 days.
# Hemobilia: S/p recent liver biopsy aboue a wek ago for hepatic
lesions. CT at OSH is c/f an obstrutive pathology given biliary
dilatation, no masses. Associated transaminitis and
hyperbilirubinemia. Most likely cause in the setting of a recent
liver biopsy is hemobilia as a complication from the biopsy.
Given h/o hepatic lesions, constellation of finding c/f
enlarging lesions or new lesions protruding on duct, however,
was not visaulized on OSH CT, in addition to RUQ US and MRCPO
done during this admission. Other considerations were infection,
however, afebrile and without leukocytosis in the setting of
immunosuppresion; worsening poral vein thrombosis in the setting
of no anti-coagulation. Lasty, rejection is also a
consideration. MRCP suggests beading which can be seen with
hemobilia, but also ascending cholangitis (no fever,
leukocytosis, and neg culture work-up). LFTs were trended during
admission and improved without antibiotics or any other
intervention. AFP 2.1 (from 1.9). Tacro trough was slightly
below goal 4.4 (goal ___, however, it was determined that pt
was taking a different formulation as an outpt on which the
patient was having stable troughs at goal. Initial pathology
reports from recent biopsy last week did not show clear
eveidence of malignancy, but was still pending at time of
discharge. Pt was discharged with the diagnosis of hemobilia and
close follow-up.
# Transaminitis: Hemobilia 2/t liver biopsy versus mass
obstruction versus rejection versus infecion versus worsening
portal vein thrombosis as detailed above. Denies EtOH. +Hep A
previously. No RF for acute Hep C at this time. Trending down
and improving icterus on exam during admission. Given no
interventions, transaminitis likely 2/t hemobilia.
# S/p Liver Tx: 2/t EtOH/HCC. C/b portal vein thrombosis.
Bactrim was continued in addition to stool softener. No
anticoagulation was required for portal vein thrombosis given
chronicity. Continued immunosuppression with Tacrolimus.
Transitional Issues:
-Hemobilia s/p liver biopsy.
-Continued Tacrolimus at current dose given trough levels at
goal as an outpt (was taking different formulation as outpt
compared to the one taken as inpt).
-Recheck LFTs at next PCP visit to confirm downtrending LFTs
-F/u CMV viral load -> + mild elevation, outpt Hepatologist
notified
-F/u blood cx
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO BID
2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
3. Tacrolimus 1 mg PO Q12H
4. calcium carbonate-vitamin D3 *NF* 600 mg(1,500mg) -400 unit
Oral twice a day
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO TID
7. FoLIC Acid 1 mg PO DAILY
8. Senna 1 TAB PO BID:PRN constipation
9. Lactulose 1 tablespoon PO BID OR TID
as needed for to achieve ___ bowel movements per day
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Ferrous Sulfate 325 mg PO TID
3. FoLIC Acid 1 mg PO DAILY
4. Lactulose 1 tablespoon PO BID OR TID
5. Omeprazole 40 mg PO BID
6. Senna 1 TAB PO BID:PRN constipation
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. calcium carbonate-vitamin D3 *NF* 600 mg(1,500mg) -400 unit
Oral twice a day
9. Tacrolimus 1 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hemobilia
Secondary: Portal vein thrombosis, End stage liver disease
status post transplant
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 during your stay at ___.
You were admitted for abdominal pain. You had an imaging study
done which showed that you had blood in your liver ducts that
was causing pain. This blood is likely from bleeding after the
biopsy.
The initial reports of the pathology from you liver biopsy do
not show clear evidence of cancer but the final report is
pending.
Please keep the follow-up appointments made for you.
___ MDs
Followup Instructions:
___
|
10827567-DS-14
| 10,827,567 | 28,397,885 |
DS
| 14 |
2156-08-02 00:00:00
|
2156-08-05 17:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Peanut / ibuprofen
Attending: ___.
Chief Complaint:
Abdominal distension
Major Surgical or Invasive Procedure:
Lymph node biopsy ___
Lumbar puncture ___
CVVH line placement on R ___
PICC placement ___
PiCC removal prior to discharge
History of Present Illness:
___ PMH liver transplant (EtOH cirrhosis c/b HCC), HTN, gout,
presenting to the ED for abd distention, GERD symptoms and
decreased UOP.
Patient was largely in USOH (some fluctuating weight gain and
loss, baseline weight 192lb, over past few months) until 2 weeks
ago, when he developed significantly worsening abdominal
distension with associated worsening indigestion/reflux. Reports
decreased appetite and PO intake since ___, hasn't been
eating much at all since ___. Had constipation about 1 week
ago, but has had nl BMs subsequently although decreasing ISO
decreased PO intake. Reports still able to drink plenty of
fluid,
but feels very dehydrated and not peeing much over past several
days; some associated leg cramps and back spasms. Reports night
sweats over the past 2 weeks as well; no fever, chills, and has
had weight gain rather than loss. Generally feels crummy and
weak
all over. Has some L sided upper abdominal/chest discomfort, not
associated with exertion.
Past Medical History:
liver transplant (ISO EtOH cirrhosis c/b HCC)
HTN
gout
OA
Social History:
___
Family History:
Brother with melanoma. Father with prostate CA. Mother with
breast CA, died of ___. Afib in 3 brothers.
Physical Exam:
ADMISSION EXAM
========================
VS: 137/66 125 28 92/RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
NECK: supple, 5cm L supraclavicular LN, no other LAD
HEART: Tachycardic, RR, nl S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
but mildly tachypneic
ABDOMEN: Substantially distended but not taut, discomfort to
palpation without frank tenderness
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, CN ___ intact, strength and sensation intact
throughout
DISCHARGE EXAM
========================
___ 0719 Temp: 97.8 PO BP: 101/58 HR: 99 RR: 16 O2 sat: 96%
O2 delivery: RA
GEN: Well appearing sitting in chair, NAD
HEENT: MMM. OP clear.
CV: RRR, no m/r/g
PULM: CTAB, no wheezes or crackles
ABD: Soft, non tender, non-distended BS+
EXT: WWP, no edema in ___
SKIN: erythematous pruritic pustular-papules back and neck and
forearm have improved
NEURO: AOx3, grossly non-focal
ACCESS: PICC without tenderness, erythema or swelling
Pertinent Results:
ADMISSION LABS
===================================
___ 10:20PM POTASSIUM-5.8*
___ 10:20PM LIPASE-35
___ 10:20PM ALBUMIN-4.0
___ 07:15PM URINE HOURS-RANDOM
___ 07:15PM URINE UHOLD-HOLD
___ 07:15PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-10* BILIRUBIN-SM* UROBILNGN-2* PH-5.5
LEUK-NEG
___ 07:15PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-<1 TRANS EPI-<1
___ 07:15PM URINE GRANULAR-1* HYALINE-10*
___ 07:15PM URINE MUCOUS-RARE*
___ 06:24PM ___ COMMENTS-GREEN TOP
___ 06:24PM LACTATE-2.9* K+-5.9*
___ 06:15PM GLUCOSE-89 UREA N-43* CREAT-2.1* SODIUM-135
POTASSIUM-7.3* CHLORIDE-97 TOTAL CO2-11* ANION GAP-27*
___ 06:15PM LIPASE-39
___ 06:15PM cTropnT-<0.01
___ 09:10AM GLUCOSE-64*
___ 09:10AM UREA N-41* CREAT-1.9* SODIUM-140
POTASSIUM-5.5* CHLORIDE-97 TOTAL CO2-15* ANION GAP-28*
___ 09:10AM estGFR-Using this
___ 09:10AM ALT(SGPT)-32 AST(SGOT)-53* ALK PHOS-79 TOT
BILI-0.4 DIR BILI-<0.2 INDIR BIL-0.4
___ 09:10AM TOT PROT-6.6 ALBUMIN-4.1 GLOBULIN-2.5
MAGNESIUM-1.7 URIC ACID-9.1* CHOLEST-153
___ 09:10AM ___ FERRITIN-324
___ 09:10AM %HbA1c-5.6 eAG-114
___ 09:10AM TRIGLYCER-348* HDL CHOL-26* CHOL/HDL-5.9
LDL(CALC)-57
___ 09:10AM tacroFK-6.9
___ 09:10AM WBC-9.0 RBC-3.93* HGB-12.4* HCT-38.4* MCV-98
MCH-31.6 MCHC-32.3 RDW-13.8 RDWSD-50.2*
___ 09:10AM NEUTS-65.9 ___ MONOS-8.5 EOS-0.6*
BASOS-0.8 IM ___ AbsNeut-5.94 AbsLymp-2.09 AbsMono-0.77
AbsEos-0.05 AbsBaso-0.07
___ 09:10AM PLT COUNT-303
___ 09:10AM ___
PERTINENT LABS
===================================
DISCHARGE LABS
===================================
reviewed in OMR
PERTINENT IMAGING
===================================
RUQUS (___)
1. Status post right hepatic lobe liver transplant. Diffuse
echogenicity of
the transplanted liver, suggestive of steatosis. More severe
forms of liver
disease including hepatic fibrosis or steatohepatitis are not
excluded on the
basis of this exam.
2. Hepatic vasculature is patent.
3. Persistent sequela of portal hypertension including
splenomegaly and new
small volume ascites.
CT ABD/PELVIS (___)
1. Extensive posterior mediastinal, epicardial, retroperitoneal,
and
mesenteric lymphadenopathy, new from ___,
circumferential thickening
and mild dilation of a short segment of the proximal jejunum in
the left upper
abdomen and adjacent soft tissue mass/lymphadenopathy, and
extensive omental
caking, also new from ___. While a nonspecific
collection of
findings, these findings are concerning for PTLD, lymphoma,
other malignancy,
or less likely infection. Correlate with clinical assessment.
The region of
jejunal abnormality likely would be accessible by upper
enteroscopy.
2. No abdominal aortic aneurysm or evidence of dissection on
this limited
noncontrast exam.
3. Status post right liver transplant with moderate volume
ascites and mild
splenomegaly. Hepatosteatosis as on prior MRI.
4. Nonspecific soft tissue nodules cutaneous fat of the
anterior left chest
wall measuring up to 1.2 cm.
5. Normal appearing colon with mild diverticulosis,
decompressed.
6. Moderate nonhemorrhagic left pleural effusion.
7. Probable anemia.
CXR (___)
Moderate left pleural effusion and atelectasis.
CT CHEST (___)
New adenopathy involving the left supraclavicular region,
mediastinal,
bilateral internal mammary, retrocrural bilateral hilar and
upper abdominal
regions, could represent lymphoma or metastasis from an
intra-abdominal
primary.
Small new bilateral effusions left greater than right with
bibasilar
atelectasis in both lung bases.
Small pericardial effusion.
Ascites.
Upper abdominal adenopathy.
CXR (___)
Left-sided PICC line terminates within the cavoatrial junction.
No evidence
of pneumothorax.
TTE ___:
The left atrium is mildly dilated. The right atrium is mildly
enlarged. There is normal left ventricular
wall thickness with a normal cavity size. There is suboptimal
image quality to assess regional left
ventricular function. Global left ventricular systolic function
is hyperdynamic. The visually estimated
left ventricular ejection fraction is >=75%. No ventricular
septal defect is seen. There is no resting left
ventricular outflow tract gradient. Tissue Doppler suggests a
normal left ventricular filling pressure
(PCWP less than12mmHg). Normal right ventricular cavity size
with normal free wall motion. The
aortic sinus is mildly dilated. The aortic arch is mildly
dilated. There is no evidence for an aortic arch
coarctation. The aortic valve leaflets (?#) are mildly
thickened. There is no aortic valve stenosis. There
is no aortic regurgitation. The mitral leaflets appear
structurally normal with no mitral valve prolapse.
There is trivial mitral regurgitation. The tricuspid valve
leaflets appear structurally normal. There is
physiologic tricuspid regurgitation. The pulmonary artery
systolic pressure could not be estimated.
There is no pericardial effusion. A left pleural effusion is
present.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with normal
cavity sizes and hyperdynamic global biventricular systolic
function.
___ Imaging BILAT LOWER EXT VEINS
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ Imaging DX CHEST PORT LINE/TUBE
Comparison to ___. The patient has received the new
right-sided
hemodialysis line. The course of the line is unremarkable, the
tip of the
line projects over the right atrium. Stable moderate left
pleural effusion
with subsequent left lower lobe atelectasis. No evidence of
pneumonia. No
pneumothorax.
PERTINENT MICRO
===================================
URINE CX ___ NGTD
BLOOD CX ___ NGTD
___ VIRUS VCA-IgG AB (Final ___: POSITIVE BY
EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop ___ weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
CSF ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH
PATHOLOGY
===================================
___ Tissue: immophenotyping lymph node
INTERPRETATION
Immunophenotypic findings consistent with involvement by a CD10
positive B-cell lymphoma. Correlation with clinical, morphologic
(see separate pathology report ___ and other ancillary
findings is recommended. Flow cytometry immunophenotyping may
not detect all abnormal populations due to topography, sampling
or artifacts of sample preparation.
Brief Hospital Course:
___ man with PMHx notable for EtOH & heterozygous
hemochromatosis cirrhosis and hepatocellular carcinoma s/p
living-donor liver transplant admitted for new diagnosis
post-transplant lymphoproliferative disorder of Burkitt's
subtype. Transferred to ___ for initiation of EPOCH with
hospital course notable for tumor lysis syndrome requiring
transfer to ___ for CVVH. Following stabilization of TLS labs,
patient was transferred back to ___ service and EPOCH was
resumed without any further concerns of tumor lysis.
ACUTE PROBLEMS
=================
# PTLD - BURKITT'S SUBTYPE
Initially presented for abdominal distension and fatigue with CT
torso demonstrating extensive adenopathy. Aleft supraclavicular
node biopsy was done with pathology concerning for PTLD of
Burkitt's or Burkitt's-like subtype. The patient was initated on
EPOCH therapy (___) with intrathecal methotrexate for CNS
prophylaxis. Hospital course complicated by tumor lysis
syndrome, discussed below, requiring transfer to the ICU for
further management. On resolution ___ and tumor lysis
syndrome, the patient returned back to the floor and resumed
chemotherapy. He received rituximab and then re-started EPOCH on
___. He tolerated this without issues and labs were
reassuringly stable.
# TUMOR LYSIS SYNDROME
# HYPERPHOSPHATEMIA
# ___ course initially notable for hyperuricemia which
resolved with rasburicase. Following initiation of EPOCH therapy
subsequently developed severe hyperphosphatemia. Transferred to
the ICU where CRRT was initiated with stabilization of serum
phosphate levels.
# HYPOXIA
# PLEURAL EFFUSION
# PULMONARY EDEMA
Hypoxia primarily due to left sided, large effusion as well as
pulmonary edema from large volume resuscitation. Effusion most
likely malignant in setting of high grade lymphoma. Pulmonary
edema improved with diuresis, later transitioned to CRRT in
setting of tumor lysis syndrome with hyperphosphatemia.
# ACUTE KIDNEY INJURY
On initial presentation with Cr >2 consistent with acute renal
failure, most likely due to decreased PO intake and possible
urate crystal deposition from hyperuricemia. Initially improved
with fluid resuscitation. Subsequently transitioned to CRRT for
treatment of tumor lysis syndrome. CRRT was discontinued and his
renal function recovered back to baseline.Discharge Cr 1.0.
CHRONIC CONDITIONS
====================
# S/P LIVER TRANSPLANT
Underwent transplantation at ___. MELD-Na 17 on
admission. Per hepatology recommendations tacrolimus was
under-dosed in setting of post-transplant lymphoproliferative
disorder. He was dosed for a goal of tacro trough ___.
# HYPERTENSION
The patient's lisinopril was held due to ___. He was continued
on amlodipine.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Tacrolimus 2 mg PO QAM
5. Tacrolimus 1 mg PO QPM
6. Ursodiol 300 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
heartburn
RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL 3
tablespoons by mouth four times a day Disp #*1 Bottle Refills:*3
3. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 10 mL by mouth daily Refills:*6
4. Docusate Sodium 100 mg PO BID
5. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*10 Tablet Refills:*0
7. Ranitidine (Liquid) 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*6
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
RX *triamcinolone acetonide 0.1 % Apply to affected area twice a
day Refills:*2
10. Tacrolimus 1.5 mg PO Q12H
Until you can fill the new prescription, take 2 mg in the
morning and 1 mg in the evening.
RX *tacrolimus 0.5 mg 3 capsule(s) by mouth twice a day Disp
#*180 Capsule Refills:*6
11. Allopurinol ___ mg PO DAILY
12. amLODIPine 5 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. Lisinopril 40 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Ursodiol 300 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=============
#BURKITTS LYMPHOMA
SECONDARY DIAGNOSIS:
===============
___
#LIVER TRANSPLANT
#HTN
#LARGE LEFT PLEURAL EFFUSION
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 you were in the hospital:
- You were having abdominal distension and fatigue.
What was done for you in the hospital:
- You had a biopsy of a lymph node which showed a new diagnosis
of lymphoma.
- You were started on chemotherapy to treat your lymphoma. The
first time it was started, your kidneys were injured because of
the release of chemicals into your body from the tumor cells.
- Because of this, you went to the ICU and had to have a
catheter placed to temporarily filter your blood.
- Your kidneys recovered and you restarted chemotherapy without
any troubles.
What you should do after you leave the hospital:
- Please take your medications as detailed in the discharge
papers.
- SPECIFIC MEDICATION ISSUES:
1) We would like you to take 1.5 mg (three 0.5 mg tablets) of
tacrolimus in the morning, and the same at night. Because you
cannot get the new pills for a few days, please continue taking
2 mg in the morning at 1 mg at night until you can fill the new
prescription
2) We are discharging you with a prescription for a medication
called atovaquone to prevent a specific type of pneumonia.
Please start taking this medication as soon as you can fill it
3) Please take the senna and Colace regularly to avoid
constipation
- Please go to your follow up appointments as scheduled in the
discharge papers. We will have you come for labs ___ morning
___ (First thing in the morning, do not take your tacrolimus
until after, at ___, ___, ___ floor) and
then see Dr. ___ ___. We will work on
setting up a ___ appointment with the liver doctors ___.
- Please monitor for worsening symptoms. 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.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10827892-DS-21
| 10,827,892 | 25,178,286 |
DS
| 21 |
2128-04-26 00:00:00
|
2128-04-26 21:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea/vomiting
Tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with history of cardiac congential anomaly and
coarctation of the aorta s/p surgery many years ago who presents
with abdominal pain and nausea. She reports that she was in her
usualy state of health until this morning when she awoke with
abdominal cramps and nausea. She attributed her symptoms to
menses however also noted that she had drank excessively the
night prior. She reports having ___ beers and one shot of
whiskey after not eating dinner. Also reports THC use however
denies any other drug use. She states that she then began
feeling shaky and diaphoretic. She was took Midol and NyQuil at
home however when she felt worse she called EMS for help, who
reportedly found her lethargic. She was then brought to the ED
for evaluation.
In the ED, initial VS were: 97.2 104 131/87 16 100% RA
Evaluation was significant for sinus tachycardia on EKG, Mg 1.5
and HCO3 19 (AG 12). Her LFTs where also abnormal with ALT 176
and AST 53. Urine and serum tox were negative. Patient received
4LNS, zofran 4mg x1, ativan 2mg x 1, ketorolac 15mg IV x1,
reglan 5mg IV x 1, and magnesium oxide 400mg PO x 1. Patietn
received tachycardic and so she was admitted for further
management. VS prior to transfer were 98.6 ___ 20 100%
RA.
Currently, she reports ongoing nausea however denies any
abdominal pain. She states that she is lightheaded when she
stands but denies palpitations and chest pain. Denies SOB,
hematemesis, melena or hematochezia.
Past Medical History:
- Cardiac congential anomaly
- Coarctation of aorta s/p repair
Social History:
___
Family History:
history of heart disease on fathers side however no history of
sudden cardiac death
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.7 118/74 106 20 98%RA
GENERAL: well appearing
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM
NECK: supple, no LAD,
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
DISCHARGE PHYSICAL EXAM
VS: 98.6 113/61 120 19 100%RA
GENERAL: well appearing
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM
NECK: supple, no LAD,
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact, sensation
grossly intact throughout
Pertinent Results:
ADMISSION LABS
___ 04:00PM BLOOD WBC-11.9* RBC-4.65 Hgb-14.3 Hct-43.7
MCV-94 MCH-30.8 MCHC-32.8 RDW-12.2 Plt ___
___ 04:00PM BLOOD Neuts-88.4* Lymphs-8.2* Monos-2.2 Eos-0.6
Baso-0.5
___ 04:00PM BLOOD Glucose-127* UreaN-11 Creat-0.6 Na-134
K-3.9 Cl-103 HCO3-19* AnGap-16
___ 04:00PM BLOOD ALT-176* AST-53* CK(CPK)-109 AlkPhos-87
TotBili-0.6
___ 04:00PM BLOOD cTropnT-<0.01
___ 04:00PM BLOOD Lipase-13
___ 04:00PM BLOOD Albumin-4.4 Calcium-8.3* Phos-3.1 Mg-1.5*
___ 04:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:51AM BLOOD HCV Ab-PND
___ 04:11PM BLOOD Lactate-1.9
___ 10:35PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:35PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-1
___ 11:25AM URINE UCG-NEGATIVE
___ 10:35PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
DISCHARGE LABS
___ 04:51AM BLOOD WBC-10.4 RBC-4.01* Hgb-12.6 Hct-36.4
MCV-91 MCH-31.4 MCHC-34.6 RDW-12.7 Plt ___
___ 04:51AM BLOOD Glucose-144* UreaN-10 Creat-0.6 Na-138
K-3.9 Cl-110* HCO3-23 AnGap-9
___ 04:51AM BLOOD Calcium-7.1* Phos-3.7 Mg-2.8*
STUDIES:
FINDINGS:
The heart size is borderline enlarged. Mediastinal and hilar
contours are
within normal limits. Lungs are clear and the pulmonary
vascularity is within
normal limits. There is no pleural effusion or pneumothorax.
There are no
acute osseous abnormalities.
Brief Hospital Course:
___ with history of cardiac congential anomaly and coarctation
of the aorta s/p surgery many years ago who presents with
abdominal pain and nausea found to have persisent sinus
tachycardia.
# Sinus tachycardia: EKG with frequent VPCs and borderline QTc.
Thought likely related to dehydration; however, was not fluid
responsive, remained tachy s/p several liters of fluids in ED
and the floor. Magnesium and calcium repleted. Not orthostatic.
As pt remained tachycardic into afternoon on HD1, concern rose
for PE despite no hypoxia and very low risk. Also spoke w/
pediatric cardiologist in ___ (Dr. ___, who said
pt had a satisfactory repair with a low gradient, but was
concerned for progression of stenotic outlet and subsequent
early diastolic failure; recommended echocardiogram. D-dimer and
echo recommended to pt, who was very anxious to leave, refused
these interventions. Suggested getting d-dimer and arranging
close cardiology follow up as pt had no cardiologist in
___, but pt continued to refuse, left AMA. Did manage
to arrange an appointment with a new PCP in ___ clinic, who
should be able to set her up with a cardiologist.
# Nausea: Likely ___ alcohol intoxication and menstruation.
Urine Hcg negative. Pt given reglan and zofran in ED despite
borderline QTc, nausea resolved.
# Transaminitis: Patient at risk for viral hepatitis given
tattoos. Other causes include ETOH; however, ALT > AST so less
likely. Viral serologies pending at discharge.
TRANSITIONAL ISSUES:
- Viral hepatitis serologies pending
- Pt needs outpt cardiologist, echocardiogram
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Nausea/vomiting
Tachycardia w/ borderline QTc
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted for nausea
accompanied by a rapid heart rate with some premature beats.
With your history of coarctation repair we kept you overnight
for observation and gave you IV fluids. We spoke with your
cardiologist, Dr. ___ in ___, who thought you
would benefit from an echocardiogram. We also recommended a
d-dimer to screen for a pulmonary embolism, since your heart
rate continues to be quite high with frequent premature beats,
not responsive to fluids. We also offered to arrange cardiology,
but it could not be arranged before you wanted to leave. You are
leaving against medical advice.
Followup Instructions:
___
|
10827899-DS-10
| 10,827,899 | 27,281,485 |
DS
| 10 |
2145-03-23 00:00:00
|
2145-03-24 11:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
ibuprofen / verapamil
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___. Exploratory laparotomy.
2. Omental flap creation with right gastroepiploic arcade.
3. ___ patch repair of duodenal perforation.
History of Present Illness:
___ with history of a duodenal ulcer on omeprazol presenting
with a one week history of abdominal pain and poor appetite that
significantly worsened yesterday afternoon. The pain is sharp,
constant and located in epigatrium. She denies nausea, emesis,
hematemesis, fevers, worsening dyspnea, chest pain.
The patient reports that her bowel movements are usually dark
because she is on iron for anemia secondary to a bleeding
hemorrhoid.
Past Medical History:
PMH:
- DM
- HTN
- Pulmonary HTN, being evaluated for home oxygen.
- Heart failure with preserved ejection fraction. Echo
___
EF>75%, increased left ventricular filling pressure
(PCWP>18mmHg).
PSH: None
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
VS: 97.4 83 159/65 20 95% 4 L NC
NAD
RRR
CTA bil
Abdomen soft, distended, tender to palpation diffusely but worse
in epigastrium, no peritonitis
No surgical scars
No edema
Discharge Physical Exam:
98.1, 130/68, 87, 28, 100 5L
Gen: Sitting up in chair. States " I feel good"
CV: HRR
Pulm: wheezing improved. Slight crackles at base
Abd: Soft, NT/ND. Midline incision with staples. Incisional
erythema is traced, redness fading / clearing up. Inferiorly,
there is an opened portion of the incision, lightly packed with
gauze, serosanguinous drainage.
Pertinent Results:
___ 07:40AM BLOOD WBC-6.4 RBC-3.77* Hgb-8.0* Hct-29.5*
MCV-78* MCH-21.2* MCHC-27.1* RDW-27.4* RDWSD-75.3* Plt ___
___ 06:37AM BLOOD WBC-6.7 RBC-3.69* Hgb-7.8* Hct-29.0*
MCV-79* MCH-21.1* MCHC-26.9* RDW-28.0* RDWSD-77.0* Plt ___
___ 06:52AM BLOOD WBC-7.8 RBC-3.76* Hgb-7.9* Hct-29.6*
MCV-79* MCH-21.0* MCHC-26.7* RDW-27.9* RDWSD-76.6* Plt ___
___ 07:40AM BLOOD ___ PTT-29.3 ___
___ 06:37AM BLOOD ___ PTT-27.5 ___
___ 12:45PM BLOOD ___ PTT-30.0 ___
___ 07:40AM BLOOD Glucose-136* UreaN-13 Creat-0.9 Na-144
K-4.8 Cl-98 HCO3-35* AnGap-11
___ 06:37AM BLOOD Glucose-238* UreaN-12 Creat-0.9 Na-142
K-4.8 Cl-95* HCO3-32 AnGap-15
___ 06:52AM BLOOD Glucose-144* UreaN-12 Creat-0.8 Na-146
K-4.4 Cl-98 HCO3-35* AnGap-13
___ 07:40AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.7
___ 06:37AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.9
___ 06:52AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.4
Imaging:
___ CT Abd/pelvis
1. Intraperitoneal free air and small volume free fluid likely
due to perforation at the level of the first segment of the
duodenum.
2. Hyperdense and hypodense renal cortical lesions can be
further
assessed on a nonemergent renal ultrasound in the absence of
prior work-up.
UGI ___:
No definite evidence of leak or obstruction.
CXR ___:
Slightly increased bilateral pleural effusions and bibasilar
atelectasis.
CXR ___:
IMPRESSION:
Mild improvement of left retrocardiac airspace disease either
representing
pneumonia or atelectasis.
No significant change in increased interstitial markings
suggestive of
moderate pulmonary edema.
CTA ___:
1. Scattered areas of mainly nonocclusive segmental and
subsegmental pulmonary
emboli in the right upper, right lower, and left lower lobes.
Flattening of
the interventricular septum suggests some degree of right heart
strain.
2. Ill-defined areas of consolidation in the lingula and
left-greater-than-right lung bases concerning for a multifocal
pneumonia.
3. No acute aortic abnormality.
4. Enlarged pulmonary artery suggestive of pulmonary arterial
hypertension.
5. Unchanged mediastinal and bilateral hilar lymphadenopathy, of
unclear
cause.
6. Suggestion of mild pulmonary edema.
7. Mild emphysema.
8. Thyroid goiter, not well evaluated due to streak artifact.
Consider
thyroid ultrasound for further evaluation, if clinically
indicated.
LENIs ___:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins
___ 01:17
HELICOBACTER ANTIGEN DETECTION, STOOL
Test Result Reference
Range/Units
HELICOBACTER PYLORI AG, EIA, SEE NOTE
STOOL
HELICOBACTER PYLORI AG, EIA, STOOL
MICRO NUMBER: ___
TEST STATUS: FINAL
SPECIMEN SOURCE: STOOL
SPECIMEN QUALITY: ADEQUATE
RESULT: Not Detected
Pathology:
SURGICAL PATHOLOGY REPORT - Final
PATHOLOGIC DIAGNOSIS:
Duodenum, ulcerated tissue, biopsy:
- Duodenal mucosa with chronic active duodenitis.
- No dysplasia identified.
Brief Hospital Course:
Ms. ___ was emergently taken to the operating room on ___.
Exploratory laparotomy revealed a perforated duodenal ulcer. She
underwent omental flap creation with right gastroepiploic arcade
and ___ patch repair of duodenal perforation. The patient
was transferred intubated and on pressors to the Surgical ICU.
Her ventilator parameters and pressor requirements were slowly
weaned. She was kept on Cefepime/Flagyl for 4 days and her JP
drain was checked routinely. On POD1,
she had a 10 point hematocrit drop and received one unit of
RBCs. She was agitated and Seroquel was started with adequate
response. She developed LUE edema and erythema, and US ruled out
DVT. She was started on a Lasix drip given positive fluid
balance, which she tolerated well. She was extubated on POD4,
but remained on HFNC. On POD5, she underwent UGI which ruled out
leak. Bedside swallow showed no aspiration and her diet was
advanced. She was started on her home medications. Her Foley was
removed and she voided without difficulty. ___ diabetes team
was consulted to help manage blood glucose and adjust insulin
regimen as needed.
Once transferred out to the floor, the patient continued to have
a persistent
oxygen requirement up to 50% ___ mask since surgery, despite
diuresis. On ___, the patient's symptoms of shortness of breath
and hypoxia increased. A CTA was obtained which showed
nonocclusive segmental and subsegmental pulmonary emboli in the
right upper, right lower, and left lower lobes. Also seen on CTA
was signs of heart strain, pulmonary arterial hypertension, mild
pulmonary edema, mild emphysema. The patient was started on
lovenox with a warfarin bridge. Pulmonology was consulted. They
felt the combination of lungs with emphysema, baseline pHTN,
home oxygen requirement places the patient at high risk for
higher oxygen needs when factors such as PEs and pneumonia are
added into the clinical situation. They recommended
anticoagulation for pulmonary embolism, standing nebulisers.
On ___, the midline abdominal incision was noted to be
erythematous. Staples were removed and purulent drainage was
expressed. The opening was packed with gauze and the erythema
was traced for monitoring. The wound erythema was improving over
the next few days.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. She continued to have non-sustained
bursts of hypoxia with activity but was able to quickly settle
out and return to an oxygen saturation above 90% on 5L nasal
canula. On discharge the patient denied SOB and states her
breathing feels good. The patient was tolerating a regular
diet, ambulating with assist, voiding without assistance, and
pain was well controlled on tylenol. The patient was discharged
to rehab to continue her recovery. 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. Aspirin 81 mg PO DAILY
2. Januvia (SITagliptin) 50 mg oral Daily
3. Glargine 15 Units Bedtime
4. glimepiride 4 mg oral Daily
5. Losartan Potassium 100 mg PO DAILY
6. MetFORMIN XR (Glucophage XR) 1500 mg PO QAM
7. MetFORMIN XR (Glucophage XR) 750 mg PO QPM
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO 3X/WEEK (___)
11. Simvastatin 40 mg PO QPM
12. Calcium Carbonate 500 mg PO BID
13. Furosemide 40 mg PO DAILY
14. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Enoxaparin Sodium 70 mg SC Q12H Duration: 6 Months
Start: Today - ___, First Dose: First Routine
Administration Time
RX *enoxaparin 60 mg/0.6 mL 60 mg SC every twelve (12) hours
Disp #*14 Syringe Refills:*0
3. Ipratropium Bromide Neb 1 NEB IH Q6H
4. Pantoprazole 40 mg PO Q12H
5. ___ MD to order daily dose PO DAILY16
To be followed by PCP
___ *warfarin 5 mg 1 tablet(s) by mouth once a day Disp #*10
Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
7. Calcium Carbonate 500 mg PO BID
8. Ferrous Sulfate 325 mg PO DAILY
9. Furosemide 40 mg PO DAILY
10. glimepiride 4 mg oral DAILY
11. Januvia (SITagliptin) 50 mg oral Daily
12. Losartan Potassium 100 mg PO DAILY
13. MetFORMIN XR (Glucophage XR) 750 mg PO QPM
Do Not Crush
14. MetFORMIN XR (Glucophage XR) 1500 mg PO QAM
15. Metoprolol Succinate XL 25 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Simvastatin 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Perforated duodenal ulcer
Nonocclusive segmental and subsegmental pulmonary emboli
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ were admitted to ___ and
underwent abdominal surgery to care for your Perforated duodenal
ulcer. Post-operatively, your oxygen levels were low and ___
were requiring extra supplemental oxygen. A CT scan showed ___
had pulmonary embolisms. ___ were started on an anticoagulant
(lovenox and warfarin) to treat this. ___ are recovering well
and are now ready for discharge to rehab. Please follow the
instructions below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
___ experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If ___ are vomiting and cannot keep down fluids or your
medications.
___ are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
___ see blood or dark/black material when ___ vomit or have a
bowel movement.
___ experience burning when ___ urinate, have blood in your
urine, or experience 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.
___ 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
___.
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 ___ 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 ___ have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
___ may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If ___ have staples, they will be removed at your follow-up
appointment.
Followup Instructions:
___
|
10827900-DS-10
| 10,827,900 | 21,285,540 |
DS
| 10 |
2123-07-24 00:00:00
|
2123-07-24 18:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Anorexia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ female with history of anorexia nervosa
and self-harm, referred to the ___ by her PCP and
psychiatrist,
found to have hypokalemia to 3.0.
She states that she was first diagnosed with anorexia nervosa
over ___ years ago. Shortly after her diagnosis, she spent several
months at ___ Eating Disorder ___, requiring NGT for 3
months. She subsequently spent ___ at ___.
Additionally, she has multiple prior admissions for low weight,
bradycardia, and dehydration. She reportedly was seen most
recently at ___ with hyponatremia.
Per patient report, she typically eats 1 meal per day after noon
(often a bagel or vegetables or garbanzo beans). She has purged
in the past but not recently. She was previously diagnosed with
gastroparesis and routinely takes mirilax and Colace for this as
well as for chronic constipation. She has a h/o suicidal
gestures
and self harm (cutting, burning her abdomen with heating pads),
but she currently denies SI/HI or thoughts of self harm.
Of note, the patient underwent a right BKA at age ___ due to a
congenital lower leg/foot deformity. Her father reports that due
to ongoing weight loss, her prosthetic leg no longer fits well.
The patient adds that she previously walked ___ miles per day,
but is now on exercise restrictions.
At request of the patient's PCP and psychiatrist, her father
brought her to the ___ ED.
In the ED, initial vital signs were: 97.6 89 ___ 100% RA
Exam notable for: Underweight. No c/c/e. No new arm lacerations,
evidence of old scarring. Superficial erythema from heating pad
on abdomen.
Labs were notable for:
Hgb 14.3, K 3.0, Na 139, Mg 2.1, Phos 4.4, LFTs WNL
Patient was given:
___ 14:32 IVF NS ( 1000 mL ordered) ___
Started
___ 15:32 IVF NS ___ Not Stopped
___ 15:34 PO Potassium Chloride 40 mEq ___
Partial Administration
Consults: Psychiatry, who recommended admission.
Upon arrival to the floor, the patient endorsed lightheadedness
(especially with standing), occasional blurry vision, headaches,
nausea, dyspnea on exertion (especially with stairs), abdominal
pain, constipation, ___ edema, occasional tingling in both arms.
Denies chest pain, dyspnea at rest, diarrhea, dysuria.
Past Medical History:
- anorexia nervosa (diagnosed ___ yrs ago)
- h/o self harm (cutting, burning abdomen with heating pad)
- h/o suicidal gestures (tying sweater around her neck at
inpatient psych facility)
- gastroparesis
Social History:
___
Family History:
patient is adopted.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 97.5 96/70 70 16 100% Ra
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Moist mucous membranes, good
dentition. Oropharynx is clear.
NECK: Supple
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
ABDOMEN: Normal bowels sounds, scaphoid abdomen, non-tender to
deep palpation in all four quadrants. Old burn marks (from
heating pad) visible diffusely across abdomen. No new burn
marks/other lesions.
EXTREMITIES: BKA of ___ with prosthesis in place. L lower leg
WWP without edema but with compression stocking in place.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation.
DISCHARGE PHYSICAL EXAM
========================
Vitals: 97.5, 95/59, 62, 18, 97% RA
Wt: 46.6 (minus prosthetic) +0.25kg since yesterday, +8kg since
admission
GENERAL: AOx3, NAD, sitting up in bed
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Moist mucous membranes, good
dentition.
NECK: Supple
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
ABDOMEN: Heating pad in place. Normal bowels sounds, soft, non
distended, mildly tender to palpation in LLQ and RLQ. No
guarding
or rebound.
EXTREMITIES: BKA of R ___. L lower leg with compression stocking
in place, dry skin, no pitting edema on bilateral legs, fingers
do not appear swollen, no pitting edema in upper extremities
SKIN: warm and well perfused, no rashes
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation.
Pertinent Results:
ADMISSION LABS
==============
___ 02:00PM BLOOD WBC-4.5 RBC-5.39* Hgb-14.3 Hct-43.1
MCV-80* MCH-26.5 MCHC-33.2 RDW-16.5* RDWSD-46.3 Plt ___
___ 02:00PM BLOOD Neuts-36.1 Lymphs-54.2* Monos-8.1
Eos-0.7* Baso-0.7 Im ___ AbsNeut-1.64 AbsLymp-2.46
AbsMono-0.37 AbsEos-0.03* AbsBaso-0.03
___ 02:00PM BLOOD Glucose-81 UreaN-14 Creat-0.9 Na-139
K-3.0* Cl-97 HCO3-25 AnGap-17
___ 02:00PM BLOOD ALT-12 AST-23 AlkPhos-73 TotBili-0.5
___ 02:00PM BLOOD Albumin-5.1 Calcium-9.7 Phos-4.4 Mg-2.1
___ 08:20AM BLOOD TSH-3.4
___ 08:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:45PM URINE UCG-NEGATIVE
___ 09:31PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 09:31PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:31PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-40* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 09:31PM URINE RBC-1 WBC-6* Bacteri-FEW* Yeast-NONE
Epi-1
DISCHARGE LABS
==============
___ 08:00AM BLOOD WBC-4.0 RBC-3.47* Hgb-9.5* Hct-29.5*
MCV-85 MCH-27.4 MCHC-32.2 RDW-17.5* RDWSD-55.0* Plt ___
___ 08:00AM BLOOD Glucose-92 UreaN-12 Creat-0.4 Na-142
K-4.4 Cl-105 HCO3-29 AnGap-8*
___ 08:00AM BLOOD Calcium-8.6 Phos-4.2 Mg-2.0
MICRO
====
___ Urine culture: No growth
IMAGING
========
___ CXR: FINDINGS:
Both lungs are fully expanded and clear. Cardiac size is
normal. There is no pneumonia, pleural effusion pulmonary edema
or pneumothorax. Scratch current
IMPRESSION:
There is no acute cardiopulmonary pathology.
Brief Hospital Course:
___ with history of anorexia nervosa and self-harm, referred to
the ED by her psychiatrist and PCP, presenting with hypokalemia,
subjective orthostasis, and low body weight (80 lbs, 5'2" -
though assessment of her body weight relative to "ideal"
complicated by her R BKA), consistent with unstable anorexia.
ACUTE ISSUES:
=============
#Unstable anorexia nervosa
#Refeeding syndrome: ___ has a ___ year h/o anorexia nervosa and
multiple extended hospitalizations in the past. Most recent
admission was 6 weeks prior to current admission. Patient was
admitted to ___ when patient signed herself out AMA. She
endorsed restrictive eating (~1 meal a day) and occasional
purging (non recently), and prior over exercising. She has been
unable to exercise much d/t very low energy. Upon admission
weight was 82 lbs (16 lbs down from ___ discharge weight, 6
weeks ago). She was objectively and subjectively orthostatic and
had hypokalemia on admission. EKG on admission showed U waves,
this resolved with electrolyte repletion. She was placed on ED
protocol with Nutrition. In addition she was followed by
psychiatry during admission. She had 30 minutes to consume
entire meal under direct observation during meal and for 1 hr
after to prevent vomiting. During admission, ___ father was
granted temporary guardianship by the courts. At time of
discharge her weight was 105.49 lb, BP was 108/70 and
electrolytes were stable.
CHRONIC ISSUES:
===============
#Gastroparesis
#Chronic diarrhea
- Patient was placed on once daily miralax for the duration of
her admission but may benefit from twice daily miralax if needed
to ensure BMs every few days.
Transitional Issues
====================
[] Follow up with Psychiatry
[] Consider transition from inpatient treatment to possible day
program
[] Father granted guardianship during this admission
[] Please check lytes within ___ days of admission. Stable at
the time of discharge but required some potassium and phosphate
repletion during this admission.
[] Please check orthostatics. At time of discharge pt was still
mildly orthostatic, HR increases with standing and BP also
increases.
#Code Status: Full
#Contact: ___ (Father/guardian) - ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. OLANZapine 5 mg PO QHS
2. TraZODone 150 mg PO QHS Sleep
3. melatonin 10 mg oral QHS
4. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) Dose is Unknown
oral Daily
5. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
1. Calcium Carbonate 500 mg PO BID
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Simethicone 40-80 mg PO QID:PRN abdominal discomfort
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Vitamin D 1000 UNIT PO DAILY
6. melatonin 10 mg oral QHS
7. OLANZapine 5 mg PO QHS
8. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) Dose is Unknown
oral DAILY
9. TraZODone 150 mg PO QHS Sleep
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
Unstable Anorexia Nervosa
Refeeding syndrome
Secondary Diagnosis
===================
Constipation
Gastroparesis
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 rapid decrease
in your weight and your family and psychiatrist were worried you
weren't eating enough.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
- While you were in the hospital your electrolytes were
monitored
- You ate a regular diet and your weight was monitored
- You were dizzy when you stood up and you were given fluids
WHAT SHOULD I DO WHEN I GET HOME?
1) Follow up with your Primary Care Doctor.
2) Follow up with your Psychiatrist
3) Take your time when standing up, make sure you go slowly when
going from sitting to standing
Your ___ Care Team
Followup Instructions:
___
|
10828164-DS-17
| 10,828,164 | 22,032,258 |
DS
| 17 |
2187-01-24 00:00:00
|
2187-01-24 17:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest and back pain, xfer for ERCP
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Mr ___ is a pleasant ___ with hx DM, anxiety presenting
with 1 day history of nonexertional chest and back pain,
radiating to the shoulder and associated with nausea and
vomiting. He was initially seen at ___ where he had
negative trop/nl ekg but elevated LFTS and CT scan of the
abdomen was concerning for bilary dilation. He was given one
dose of Zosyn and transferred to ___ for ERCP eval. Of
note he was found to have bradycardia to the ___ at ___
however this was not present on arrival to ___.
In the ED, initial vitals were: 97.4 64 144/94 14 95% RA.
Zosyn was continued and he was also started on fluids and given
Zofran and morphine. Labs were notable for ALT/AST in 200s,
tbili 3.0, lipase 159, WBC 12.4. Repeat US in our ED showed
cholelithiasis and a well distended gallbladder, but no
gallbladder wall edema to specifically suggest cholecystitis.
Echogenic liver consistent with steatosis.
Pt went for ERCP on arrival to ___, where he was found to have
duodenal ulcers. Biliary cannulation did not show stones or
sludge, however given high suspicion for cholangitis, a stent
was placed.
On the floor, pt states that he feels fine except has worsening
RUQ pain and nausea. He states he feels a little SOB/sweaty and
anxious from the pain. Had vomiting while at ___ but none
since arrival. No dysuria. He states that the pain he had at
___ was not true CP, states it started in RUQ and radiated
to the epigastrium.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough. Denies palpitations. Denies
diarrhea, constipation. No recent change in bowel or bladder
habits. No dysuria. Denies arthralgias or myalgias. 10 pt ros
otherwise negative.
Past Medical History:
(per chart, confirmed with pt):
DM-not medicationss
Anxiety
Nephrolithiasis
Social History:
___
Family History:
(per chart, confirmed with pt): No known
Physical Exam:
Admission PE
Vitals: 97.9 PO___ / 95 58 1896 RA
Constitutional: Alert, oriented, no acute distress, later
becoming sleepy but arousable
EYES: Sclera anicteric, EOMI, PERRL
ENT: MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
GI: Soft, TTP in RUQ, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding
GU: No foley
EXT: Warm, well perfused, no CCE
NEURO: aaox3 CNII-XII and strength grossly intact
SKIN: no rashes or lesions
Discharge PE
97.9 158 / 92 84 18 96 RA
Gen: NAD, resting comfortably in bed
HEENT: EOMI, PERRLA, MMM, OP clear
CV: RRR nl s1s2 no m/r/g
Resp: CTAB no w/r/r
Abd: Soft, NT, ND +BS
Ext: no c/c/e
Pertinent Results:
___ 03:30AM BLOOD WBC-12.4*# RBC-5.00 Hgb-15.1 Hct-43.5
MCV-87 MCH-30.2 MCHC-34.7 RDW-12.2 RDWSD-38.8 Plt ___
___ 03:30AM BLOOD Neuts-83.2* Lymphs-10.1* Monos-5.5
Eos-0.2* Baso-0.6 Im ___ AbsNeut-10.35* AbsLymp-1.26
AbsMono-0.69 AbsEos-0.02* AbsBaso-0.07
___ 03:30AM BLOOD Glucose-306* UreaN-14 Creat-0.8 Na-133
K-4.1 Cl-95* HCO3-21* AnGap-21*
___ 03:30AM BLOOD ALT-289* AST-262* AlkPhos-104
TotBili-3.0* DirBili-2.3* IndBili-0.7
___ 03:30AM BLOOD Lipase-159*
___ 03:30AM BLOOD cTropnT-<0.01
___ 03:30AM BLOOD Albumin-4.3
___ 03:43AM BLOOD Lactate-1.9
See below, prior labs, imaging and records reviewed in ___
OSH labs, imaging and records reviewed by me
MICRO: blood cxs pending
STUDIES:
CT abdomen:
1. In the distal common bile duct, in the region of the ampulla,
there
is an obstructing stone which causes mild intra and extra
hepatic
biliary dilatation. Tiny gallstones are present in the
gallbladder
which is mildly distended. There is no pericholecystic stranding
or
gallbladder wall thickening.
CTA:
1. No CT evidence of pulmonary embolism.
2. Elevated right hemidiaphragm.
RUQ US
1. Cholelithiasis and a well distended gallbladder, but no
gallbladder wall edema to specifically suggest cholecystitis.
If further evaluation for possible cholecystitis is desired,
HIDA scan could be considered.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease including steatohepatitis, hepatic fibrosis, or
cirrhosis cannot be excluded on the basis of this examination.
RECOMMENDATION(S): Cholelithiasis and a well distended
gallbladder, but no gallbladder wall edema to specifically
suggest cholecystitis. If further evaluation for possible
cholecystitis is desired, HIDA scan could be considered.
CXR:
No acute abnormality.
ERCP
Impression:
Multiple duodenal erosions and ulcerations were noted
thorughout the duodenum.
The scout film was normal.
The bile duct was deeply cannulated with the sphincterotome.
Contrast extended to the entire biliary tree.
The left and right hepatic ducts and all intrahepatic branches
were normal.
No evidence of sludge or stones was noted.
Given high suspicion for cholangitis a ___ FR X 9 cm plastic
biliary stent was placed successfully using a OASIS stent
introducer kit.
Sphincterotomy was not done given cirrhotic changes of the
liver.
Excellent bile and contrast drainage was seen endoscopically
and fluoroscopically.
Recommendations:
Clear fluids when awake then advance diet as tolerated.
Follow-up with Dr. ___ as previously scheduled.
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call ERCP
fellow on call ___
Trend labs (LFTs) if markedly improved post procedure would
recommend follow-up ERCP for sphincterotomy.
PPI BID for duodenal erosions and H. pylori testing.
EKG: sinus bradycardia
RUQ US ___:
IMPRESSION:
1. Limited examination. The gallbladder is decompressed, and
there is no
evidence of acute cholecystitis. There may be a small pocket of
perihepatic
fluid.
2. Echogenic liver, likely representing steatosis. Other forms
of liver
disease and more advanced liver disease including
steatohepatitis or
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
CT A/P ___:
IMPRESSION:
1. Acute Pancreatitis. New from ___. No areas of
hypoperfusion
in the pancreas.
2. Resolution of the intrahepatic biliary dilation following
biliary stent
placement. Pneumobilia noted.
3. No focal liver lesions. No abscess identified.
Brief Hospital Course:
___ y.o male with h.o DM and anxiety who presented with chest and
back pain and was found to have concern for cholangitis,
duodenal ulcers.
#abdominal pain
#cholangitis/biliary obstruction
#transaminitis
#Post-ERCP pancreatitis
Imaging suggestive of biliary obstruction. No stones seen on
ERCP but may have passed a stone. Given concern for cholangitis
biliary stent placed and continued on antibiotics for possible
cholangitis. His pain resolved post-ERCP but he had worsening
leukocytosis and persistent low grade fevers. Cultures
negative. He underwent repeat CT A/P which was consistent with
acute pancreatitis, likely cause of his leukocytosis and fevers.
-Repeat ERCP in 2 months for stent pull and re-evaluation
-Continue cipro and flagyl for total 14 day course
-outpt f/u for ?liver cirrhosis
#duodenal ulcers-
Found on ERCP, no signs of bleeding.
-Continue BID PPI
-f/u h. pylori serology
#AGMA-lactate WNL, sugars well controlled, no evidence of renal
failure, unclear etiology, resolved.
#DM- pt states not on meds at home.
-Outpatient f/u
#steatosis-likely NASH, outpt f/u
#elevated L.hemidiaphragm-noted on OSH CT, prior provider ___
radiology who reviewed and noted that this is unchanged from
imaging ___ and not lung pathology to explain pain.
#FEN-regular
#ppx SC Heparin
#access -PIV
#code-full
#dispo- home without services
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H Duration: 7 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*21 Tablet Refills:*0
3. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
cholangitis, biliary obstruction
duodenal ulcers
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for abdominal pain. You had an ERCP which
found some ulcers in your duodenum for which you were started on
an acid suppressing medication. In addition, you had a stent
placed in your bile duct to help with drainage. You will need
another ERCP in the future which will be arranged by the ERCP
team. In addition, it will be important for you to establish
care with a primary care doctor to discuss work up for possible
cirrhosis and to recheck your liver function tests.
Followup Instructions:
___
|
10828230-DS-16
| 10,828,230 | 29,506,558 |
DS
| 16 |
2177-12-06 00:00:00
|
2177-12-07 16:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea, dizziness, cough
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ yoF with PMH of hashimotos thyroiditis, exercise induced
asthma and chronic migraines presents with dizziness, nausea and
cough. The patient woke up in the middle of the night on
___, with shortness of breath. She treated her sypmtoms
with water. Has noticed intermittent dry cough that has gotten
progressively worse since then. Reports dizziness, denies fever
but reports chills. Reports chest pain which is worse with deep
inspiration and worse with cough. Patient denies abdominal pain,
vomitting, diarrhea dysuria, hematuria, lower extremity edema.
In the ED, initial vitals were: 99.0 HR: 87 BP: 107/62 Resp: 16
O(2)Sat: 100 Normal, patient was evaluated with CXR found to
have pnuwas given NS 1L IV, zofran, acetaminophen
EKG NSR 72, NA/NI, TWI V3
She was treated with levofloxacin 750mg PO qday
The patient was found to desat to 88% with ambulation
On the floor, patient reports persistent chest pain, worse with
inspiration as well as persistent cough. Denies frank SOB.
Past Medical History:
chronic migraine
hashimoto's thyroiditis
exercise induced asthma
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
Vital Signs: T98.0, BP 120/70, HR 96, RR 18, O298% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, no
lymphadenopathy
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: limited ___ to frequent coughing, no wheeze appreciated
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
DISCHARGE PHYSICAL EXAM
Vitals: T: 98.4 BP:113/91 P:72 R:18 O2:99RA
General: Alert, oriented, no acute distress
HEENT: MMM
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: crackles in right lung base, no wheeze
Abdomen: Soft, mild tenderness to deep palpation in RLQ/LLQ,
non-distended, bowel sounds present, no organomegaly, no rebound
or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Pertinent Results:
ADMISSION LABS
___ 01:15PM BLOOD WBC-6.6# RBC-4.33 Hgb-11.2 Hct-35.4
MCV-82 MCH-25.9* MCHC-31.6* RDW-14.1 RDWSD-41.5 Plt ___
___ 01:15PM BLOOD Neuts-74.3* Lymphs-17.8* Monos-7.1
Eos-0.2* Baso-0.3 Im ___ AbsNeut-4.90 AbsLymp-1.17*
AbsMono-0.47 AbsEos-0.01* AbsBaso-0.02
___ 01:15PM BLOOD Glucose-92 UreaN-8 Creat-0.9 Na-136 K-3.5
Cl-102 HCO3-22 AnGap-16
___ 01:15PM BLOOD Calcium-9.1 Phos-3.0 Mg-1.8
___ 01:15PM BLOOD TSH-1.7
___ 01:15PM BLOOD T4-8.5
DISCHARGE LABS N/A
MICROBIOLOGY
___ 01:15PM URINE Color-Straw Appear-Clear Sp ___
___ 01:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
___ 01:15PM URINE UCG-NEGATIVE
IMAGING
CXR ___
There is dense consolidation at the right lung base.
Elsewhere, the lungs
are grossly clear. The cardiomediastinal silhouette is within
normal limits.
No acute osseous abnormalities.
IMPRESSION:
Right lower lobe pneumonia.
Brief Hospital Course:
Ms. ___ is a ___ year old female with a past medical history
of hashimotos thyroiditis, exercise induced asthma and chronic
migraines presents with dizziness, nausea and cough found to
have right lower lobe pneumonia
# Community acquired pneumonia: Patient presented with nausea,
dizziness, cough and decreased oxygen saturation on ambulation,
found to have right lower lobe consolidation on CXR. The patient
was initially treated in the ED with levofloxacin, will
transition to cefpodoxime and azithromycin given the patient's
hx of playing soccer given risk for tendon injury on medication.
The patient's ambulatory oxygen saturation improved on this
regimen. She will continue this course of cefpodoxime 200mg PO
q12hrs through ___ and azithromycin 250mg PO qday through
___. She was treated symptomatically with benzonatate 100mg
TID PRN cough and acetaminophen 650mg PO q6hrs PRN pain and
ibuprofen 400mg PO q8hrs PRN pain. The patient was instructed to
refrain from sports for 2 weeks (until completion of her
antibiotic regimen).
# Hashimotos Thyroiditis: The patient's TSH and T4 were found to
be within normal limits. She was continued on her home
levothyroxine 68mcg PO qday
# Exercise induced asthma: continued proair
# Chronic Migraine: continued tompiramate 50mg PO BID
Transitional Issues:
- Continue cefpodoxime 200mg PO q12hrs through ___
- Continue azithromycin 250mg PO qday through ___
- f/u with PCP regarding further management of chronic medical
conditions including hypothyroidism and chronic migraines
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Topiramate (Topamax) 50 mg PO BID
2. Levothyroxine Sodium 68.5 mcg PO DAILY
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
4. Minastrin ___ Fe (norethindrone-e.estradiol-iron) 1 mg-20
mcg(24) /75 mg (4) oral DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Levothyroxine Sodium 68.5 mcg PO DAILY
3. Topiramate (Topamax) 50 mg PO BID
4. Azithromycin 250 mg PO Q24H
RX *azithromycin 250 mg 1 tablet(s) by mouth every day Disp #*4
Tablet Refills:*0
5. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth every 12 hours Disp
#*12 Tablet Refills:*0
6. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times per day
as needed Disp #*15 Capsule Refills:*0
7. Minastrin ___ Fe (norethindrone-e.estradiol-iron) 1 mg-20
mcg(24) /75 mg (4) oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: community acquired pneumonia, hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for allowing us to participate in your care at ___.
You were admitted to the hospital with dizziness, nauease and
cough. You were found to have a pneumonia. You were treated with
antibiotics, cefpodoxime and azithromycin. You should continue
your azithromycin through ___. You should continue your
cefpodoxime through ___. These antibiotics may interact with
your birth control medication. They may make your birth control
medication less effective. You should use alternative forms of
contraception, if needed, while you are on these antibiotics and
for 1 week after you finish your antibiotics.
After discharge, please continue to follow up with your primary
care provider for further management of your hypothyroidism,
migraines, and exercise induced asthma.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10828296-DS-20
| 10,828,296 | 26,388,589 |
DS
| 20 |
2146-11-09 00:00:00
|
2146-11-09 16:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / contrast dye
Attending: ___.
Chief Complaint:
Dyspnea, Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with a history of CAD, HLD, HTN, CKD, who
presents with 2 weeks of worsening shortness of breath and two
episodes of chest pain in the last week.
She reports her chest pain began while she was sleeping last
night. She points to the pain it as below the nipple line a
bilateral, epigastric pattern. It did not radiate to the neck,
arm, or back. It lasted approximately 30 minutes and was
resolved
after taking sublingual nitroglycerin spray. She endorses a
similar chest pain ___ while also at rest - also resolved with
nitroglycerin. It did not radiate to the neck, arm, or back.
Regarding shortness of breath, she has experienced
exertional
dyspnea for the past ___ years. However, for the last two weeks,
she has been awakening complaining of breathing issues and not
being able to return to sleep; this dyspnea at rest has been the
most striking change. She has been using 3 pillows for ___ years
to elevate her head at night for her breathing. Her weight is
134
lbs (up from reported bl 130 lbs).
Last week, while in ___, her daughter reports that she
passed out while on the toilet and was found slumped over - no
headstrike. Her other daughter in ___ was able to wake her
and provided sublingual nitroglycerin, although ___ denies
chest pain at the time. ___ reports the episode as "feeling
out
of this world" and denies it being related to straining on the
toilet. She is unable to provide any more detail and is a poor
historian at baseline. Her last episode of syncope was ___
related to climbing stairs with the assistance of her family
members. She passed out while standing and required vigorous
sternal rub to be roused. She had a three day stay at ___
after this. Daughter attributes the fall to "low sodium" per the
hospital.
Denies fevers, chills, recent cough or illness. Did recently
travel on a flight home from ___, where she has been for the
past 3 months, however her shortness of breath began prior to
her
return plane flight. No history of blood clots. No history of
asthma or COPD.
Due to the increase in chest pain and dyspnea at night, she saw
her PCP this AM where her O2 sat was 90-92% and she had
diminished breath sounds bilaterally. She was then referred to
the ED.
In the ED:
- Initial vital signs were notable for:
T:97.8 BP: 157/80 HR RR:18 PO2:96%
- Exam notable for:
Well-appearing woman, no acute distress. Regular rate and
rhythm.
Lungs with diminished breath sounds in the bilateral bases. No
obvious rales or crackles. No tachypnea or respiratory distress.
No lower extremity edema.
Labs were notable for:
- CR: 1.5
- proBNP:712
- WBC:8.4
- HGB: 8.4
- PLT:414
- Trop-T: <0.01
Studies performed include:
-ECG: Sinus rhythm, LBBB.
-CXR PA LAT:
- Crowding of the pulmonary vasculature with no overt pulmonary
edema. Widened vascular pedicle and cardiac silhouette may
represent mild volume overload. Possible small pleural effusions
bilaterally with likely concomitant basilar atelectasis.
- Patient was given:
Aspirin 324 mg PO
CefTRIAXone 2g IV
Furosemide 40 mg IV
- Consults: N/A
Past Medical History:
CORONARY ARTERY DISEASE
pos ett mibi ___
GASTROESOPHAGEAL REFLUX
HYPERLIPIDEMIA
HYPERTENSION
LEFT CARPAL TUNNEL REPAIR
___
OSTEOARTHRITIS
TAHBSO
HEADACHE
ALLERGIC RHINITIS
LENTEGINES
SEBORRHEIC KERATOSIS
CONSTIPATION
FALL RISK
CHRONIC KIDNEY DISEASE
Social History:
___
Family History:
N/A
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VITALS: ___ Temp: 97.7 PO BP: 187/71 R Lying HR: 63
RR:
18 O2 sat: 95% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score:
___
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
ENT: MMM. Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD noted.
CARDIAC: Decreased heart sounds. Regular rhythm, normal rate.
Audible S1 and S2. No murmurs/rubs/gallops.
RESP: Increased expiratory phase with wheezes with increased
work
of breathing. No rhonchi or rales.
ABDOMEN: hypoactive bowels sounds, non distended, minimally
tender to deep palpation in RUQ and RLQ. No organomegaly.
MSK: No spinous process tenderness. No CVA tenderness.
Extremities: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash. Back wet with urine.
NEUROLOGIC: Oriented to person and place. Oriented to day of
week, year, and not month.
PSYCH: appropriate mood and affect
DISCHARGE PHYSICAL EXAM
=========================
VITALS: Reviewed in OMR
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT, has a solid, mobile growth above right eyelid. EOMI.
Sclera anicteric and without injection.
ENT: No JVD noted.
CARDIAC: Regular rhythm, normal rate. Normal S1 and S2. No
murmurs/rubs/gallops.
RESP: Mildly diminished breath sounds bilaterally at bases, no
crackles, expiratory noises.
ABDOMEN: Soft, nontender, nondistended
Extremities: Lower extremities warm and well perfused without
edema. Pulses ___ 2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: Awake and conversant, moving all four extremities,
no
noted asymmetries
Pertinent Results:
ADMISSION LABS
=================
___ 03:02PM BLOOD WBC-8.4 RBC-3.83* Hgb-8.4* Hct-28.5*
MCV-74* MCH-21.9* MCHC-29.5* RDW-19.0* RDWSD-49.9* Plt ___
___ 03:02PM BLOOD ___ PTT-27.0 ___
___ 03:02PM BLOOD Glucose-94 UreaN-20 Creat-1.5* Na-136
K-5.2 Cl-100 HCO3-22 AnGap-14
___ 03:02PM BLOOD proBNP-712*
___ 03:02PM BLOOD cTropnT-<0.01
PERTINENT INTERVAL LABS
=========================
___ 07:25PM BLOOD Glucose-139* UreaN-24* Creat-1.8* Na-131*
K-5.0 Cl-95* HCO3-21* AnGap-15
___ 12:55AM BLOOD cTropnT-<0.01
___ 06:35AM BLOOD calTIBC-330 Ferritn-19 TRF-254
___ 01:08AM URINE Color-Straw Appear-Clear Sp ___
___ 01:08AM URINE Blood-NEG Nitrite-POS* Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 01:08AM URINE RBC-1 WBC-25* Bacteri-FEW* Yeast-NONE
Epi-<1 TransE-<1
___ 01:08AM URINE CastHy-3*
DISCHARGE LABS
===================
___ 06:42AM BLOOD WBC-8.4 RBC-3.47* Hgb-7.6* Hct-25.3*
MCV-73* MCH-21.9* MCHC-30.0* RDW-18.8* RDWSD-49.1* Plt ___
___ 06:42AM BLOOD Glucose-87 UreaN-16 Creat-1.4* Na-131*
K-4.3 Cl-97 HCO3-24 AnGap-10
___ 06:42AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.9
IMAGING
==========
CXR ___
Crowding of the pulmonary vasculature with no overt pulmonary
edema. Widened vascular pedicle and cardiac silhouette may
represent mild volume overload. Possible small pleural effusions
bilaterally with likely concomitant basilar atelectasis.
TTE ___
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
a small cavity with hyperdynamic regional/global systolic
function. Normal right ventricular cavity size and systolic
function. Mild mitral regurgitation. Mild tricuspid
regurgitation. Mild pulmonary artery systolic hypertension.
MICROBIOLOGY
===============
___ 1:08 am URINE Source: ___.
**FINAL REPORT ___
REFLEX URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
___ with a history of CAD, HLD, HTN, CKD (bl Cr 1.1-1.3), with a
recent 3 month stay in ___ who presents with acute on
chronic
SOB and two episodes of central chest pain, initially responsive
to diuresis, eventually with worsening pre-renal ___.
TRANSITIONAL ISSUES
[] Increased isosorbide mononitrate to 15 TID in setting of
increased angina symptoms and worsened hypertension. Consider
further escalation of nitrates for stable angina as needed.
Unable to further increase beta blockade due to heart rates.
[] Assess volume status, weight at follow-up, adjust Lasix
dosing as needed
[] Re-check renal function, sodium at follow-up
[] Re-check orthostatics
[] Assess for dysuria, consider treating for uncomplicated UTI
if present; asymptomatic while inpatient but UA showing pyuria
and positive leuk esterase, nitrites
[] Patient not on statin despite known CAD. Did not start while
inpatient based on age, life-expectancy
New Medications:
None
Changed Medications:
Isosorbide mononitrate increased to 15 TID
Stopped/Held Medications:
Amitriptyline
Lorazepam
ACUTE ISSUES:
=============
#Chest Pain
History of chest pain likely angina in setting of known CAD.
Sometimes occurs at rest, but is worsened by exertion and
relieved by nitroglycerin. ACS ruled out given troponins
negative x2 and no EKG changes. No regional WMA or reduced EF on
TTE. Increased home isosorbide mononitrate to 15 TID, can
continue to uptitrate as needed for anginal symptoms. Continued
home metoprolol, but unable to uptitrate in setting of
intermittent bradycardia and orthostasis. Suspect recent chest
pain is in setting of recent increased physical activity rather
than progression of underlying CAD. Can continue to maximize
medical therapy rather than pursuing angiography and possible
revascularization given age and co-morbidities. Continued home
aspirin.
#Dyspnea
Patient presented with history of worsening dyspnea. Overall
suspect dyspnea is ___ deconditioning and stable angina, more
prominent in setting of increased activity prior to
hospitalization rather than progression of underlying disease.
Activity is greatly limited at baseline. Mildly elevated proBNP,
increased weight, and worsening orthopnea initially concerning
for decompensated heart failure, although did not appear
overloaded on exam. Trialed diuresis with IV Lasix without
significant improvement in symptoms, and with creatinine
uptrending to 1.8. TTE showed normal EF and systolic function
without any regional WMA or significantly elevated PASP; notable
only for LVH. Subsequently received IV fluids for resuscitation
without worsening symptoms or evidence of volume overload. PE
unlikely given absence of hypoxia or tachycardia. No evidence of
pneumonia or other infectious etiology. As noted above,
isosorbide was uptitrated for angina, and chest pain resolved
prior to discharge. Continued to have mild nocturnal dyspnea
prior to discharge, but resolving spontaneously and without
associated O2 desaturation. Differential includes GERD, reactive
airway disease, OSA. Encouraged patient and daughter to elevate
head, trial nebs if having nocturnal dyspnea at home.
___ on CKD
Pt presented with Cr of 1.5, which is increased from recent ___
of
1.2-1.4. Uptrended with diuresis to peak 1.8. Subsequently
downtrended to 1.4 with IV fluids.
#Acute on chronic anemia
Hgb 8.3 with MCV of 73 potentially suggestive of iron-deficiency
anemia. Transferrin saturation of 6.3%. Received 2 doses of IV
ferric fluconate for repletion while inpatient.
#Possible syncope
History of possible syncopal event, although history unclear and
not strongly suggestive of syncope. Positive orthostatics while
inpatient, although also having severe supine hypertension at
times. Given questionable history of syncope, significant
anginal symptoms, and markedly elevated systolic blood
pressures, did not decrease isosorbide. No symptomatic
orthostasis while inpatient. No evidence on telemetry of
malignant arrhythmias (monitored >48 hours). TTE showed no
significant valvular disease, normal EF, no regional WMA.
#HTN
Pt BPs have ranged from 130s-160s over ___ in past year in
outpatient clinic. She presented within this range, but BP has
been increasing on floor to SBP 180s. Family reports
fractionating home medications: amlodipine 5mg (to 2.5 BID) and
metoprolol succinate 50mg (to 25mg BID). Only took half doses on
day of admission (___). Continued home amlodipine, increased
isosorbide as above.
#Constipation
Senna, miralax for constipation.
#Pyuria
24 WBCs with ___ and nitrites on UA. However, patient
asymptomatic while inpatient, thus did not treat for UTI.
CHRONIC ISSUES:
===============
#Osteoarthritis
#MSK Pain
- Acetaminophen 500mg q6hrs PRN
#GERD
Takes esomeprazole 20mg daily at home. Continued on discharge.
#Headaches
- Held home amitriptyline. No significant headaches while
inpatient.
#Anxiety
- Held home Lorazepam .5mg PRN given patient age
#HLD
Pt has history of HLD, not on a statin. No records of
lipid panel since ___. Deferred initiation based on age and
life expectancy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 15 mL PO Q8H:PRN constipation
2. LORazepam 0.5 mg PO Q8H:PRN anxiety
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. amLODIPine 5 mg PO DAILY
7. Furosemide 20 mg PO DAILY:PRN CHF
8. Isosorbide Mononitrate 10 mg PO TID W/MEALS
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. Amitriptyline 10 mg PO QHS:PRN headache
11. albuterol sulfate 90 mcg/actuation inhalation 2 puffs Q4-6
hours
12. Aspirin 81 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Isosorbide Mononitrate 15 mg PO TID W/MEALS
RX *isosorbide mononitrate 10 mg 1.5 tablet(s) by mouth three
times a day with meals Disp #*45 Tablet Refills:*0
2. albuterol sulfate 90 mcg/actuation inhalation 2 puffs Q4-6
hours
3. amLODIPine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Furosemide 20 mg PO DAILY:PRN CHF
7. Lactulose 15 mL PO Q8H:PRN constipation
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. Omeprazole 20 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Dyspnea
SECONDARY DIAGNOSES:
====================
Stable angina
HTN
___
Dysuria
HLD
Anemia
CKD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were having chest pain and shortness of breath.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had cardiac testing that confirmed that you were not
having a heart attack. Your chest pain is likely due to a
combination of stable heart disease and heartburn. Your heart
medications were adjusted, and your chest pain resolved. An
ultrasound of your heart showed no worsening of your heart
function.
- Your labs showed signs of dehydration, which improved with
fluids.
- You had cardiac monitoring, which showed no evidence of
dangerous heart rhythms.
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:
___
|
10828820-DS-4
| 10,828,820 | 24,958,374 |
DS
| 4 |
2177-08-10 00:00:00
|
2177-08-19 12:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
nasuea, vomiting, gait disturbance
Major Surgical or Invasive Procedure:
___ R EVD placement
___ Resection of R cerebellar lesion
History of Present Illness:
Ms. ___ is a ___ yo F otherwise healthy who presented to
OSH today. She complains of 1 month of headaches progressively
worsening. She describes the headaches as occipital. She also
reports progressive nausea and vomiting over the last 2 weeks.
She has not been able to keep anything down since last night.
She
reports having no appetite. She also reports about a week of
gait
instability. She states she "feels like she's drunk" when she's
ambulating. She denies double vision or blurry vision, fever,
chest pain, abdominal pain.
Past Medical History:
Fracture of R arm s/p fixation as a child
Social History:
___
Family History:
Non-contributory
Physical Exam:
EXAM ON ADMISSION
O: T:98.3 HR 128 BP 118/75 RR 18 O2 Sat 97%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 5-4mm bilaterally
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 5 to 4
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally with
vertical nystagmus on upward gaze.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch and proprioception bilaterally.
Toes downgoing bilaterally
Coordination: positive dysmetric on finger-nose-finger R>L,
rapid
alternating movements and heel to shin are intact
Pertinent Results:
___ CTA head
1. Large heterogeneous, predominantly hyperdense right posterior
fossa mass, which appears extra-axial, with compression of the
basal cisterns, medulla, and cervicomedullary junction, downward
herniation of the cerebellar tonsils, compression of the fourth
ventricle, and supratentorial hydrocephalus. These findings are
unchanged compared to the CT from approximately 5 hr earlier.
2. No evidence for intracranial arterial supply to the right
posterior fossa mass. No evidence for arterial phase
enhancement within the mass.
3. Of the posterior fossa arteries, bilateral vertebral
arteries, bilateral PICAs, and the basilar artery are patent.
Superior cerebellar arteries are patent proximally, but their
distal courses are not well seen.
4. Please refer to the same day brain MRI report for discussion
of the
differential diagnosis of the mass.
___ ___
1. Interval placement of a right frontal ventriculostomy
catheter ending in the left side of the third ventricle.
2. Mass effect in the posterior fossa with complete displacement
of the fourth ventricle of the left of midline andfullness of
this cisterna magna consistent with mild downward herniation are
relatively unchanged.
3. Non-communicating hydrocephalus with dilation of the third
and lateral
ventricles also appears relatively unchanged.
___ MRI brain with and without contrast
1. Large right posterior fossa mass along the right tentorium,
which appears extra-axial. Signal characteristics consistent
with hypercellularity are suggestive of a meningioma, but
heterogeneous contrast enhancement and the patient's young age
are not typical for a meningioma. Heterogeneity of enhancement
is also not typical for lymphoma. Diagnostic considerations
include an atypical meningioma, a metastasis, or lymphoma if the
patient is immunocompromised.
2. The right cerebellar hemisphere is compressed and edematous,
with edema extending into the vermis and medial left cerebellar
hemisphere. Basal cisterns are compressed with 6 mm herniation
of the right cerebellar tonsil and mass effect on the medulla
and cervicomedullary junction.
3. The fourth ventricle is compressed and shifted to the left,
and the lateral and third ventricles are dilated with
transependymal CSF flow, unchanged in appearance to earlier head
CTs both before and after right frontal ventriculostomy
placement.
4. Acute infarction in the right cerebellar vermis immediately
above the mass, which is likely secondary to arterial
compression.
___ MRI WAND:
1. Unchanged heterogeneously enhancing mass lesion centered in
the right
posterior fossa as described above, apparently extra-axial,
associated with
vasogenic edema and mass effect, causing narrowing of the fourth
ventricle and
persistent enlargement of the supratentorial lateral ventricles
and third
ventricle as described above. .
2. Given the pattern of enhancement and age of the patient, the
differential
diagnosis is broad, most likely suggestive of meningioma,
however as described
in the prior report, other entities cannot be completely rule
out, including
metastasis.
3. Right frontal ventricular shunt via right frontal burr hole
with the tip
terminating at the level of the third ventricle, the ventricles
and third
ventricle remain slightly prominent.
___ CT Head:
1. Postoperative changes following removal of a right posterior
fossa mass,
detailed above.
2. Slight interval improvement in local mass effect and
obstructive
hydrocephalus.
___ MRI Brain:
1. Study is mildly degraded by motion.
2. Postoperative changes status post resection of a right
posterior fossa
extra-axial tumor without MRI evidence of residual enhancing
disease.
3. Blood products within the resection cavity and stable mass
effect and edema
within the cerebellum causing compression of the fourth
ventricle and mild
hydrocephalus. Right frontal ventriculostomy drainage catheter
in place
without complication.
4. Unchanged subacute infarction within the cerebellum, as
described.
5. Small filling defect at the origin of the right transverse
sinus, not
visualized on prior study, concerning for new small venous
thrombosis.
Recommend clinical correlation and attention on followup
imaging.
6. Stable right frontal approach ventriculostomy catheter as
described.
___ NCHCT
1. Status post right occipital craniotomy with metallic plate
cranioplasty for
resection of a right posterior fossa mass with associated
postsurgical changes including pneumocephalus and blood products
within resection cavity, unchanged from ___ MR.
2. Stable vasogenic edema with partial effacement of fourth
ventricle and
ambient cisterns.
3. Right frontal approach ventriculostomy catheter which
terminates in third ventricle, unchanged.
4. Stable size and appearance of enlarged ventricles since ___.
___ LENIS
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
___ NCHCT
1. Status post right occipital craniotomy with postsurgical
changes re-
demonstrated.
2. Moderate interval improvement in ventricular size from prior
imaging.
3. Decrease posterior fossa mass effect and decreased effacement
of the fourth
ventricle compared to prior imaging.
4. Right frontal-approach ventriculostomy catheter terminating
in the third ventricle, unchanged from prior imaging.
___ MRI C/T/L spine
1. Stable post surgical changes from right suboccipital
craniotomy without evidence of residual cerebellar tumor.
2. No evidence of abnormal enhancement or masses within the
cervical, thoracic and lumbar spine to suggest metastatic
disease.
Brief Hospital Course:
Ms. ___ was admitted to the surgical intensive care unit on
___ after presenting the emergency department with a month of
nausea and vomiting. Another NCHCT was obtained which showed
continued hydrocephalus was obtained. The patient was intubated
and an EVD was placed at the bedside on her arrival to the unit.
___: She was extubated and her neurologic exam was intact. She
was awaitingOR for ___ and was cionsented and pre-opped.
On ___ her neuro exam was stable and she underwent craniotomy
for tumor resection. Post-operatively, she returned to the ICU
for close monitoring.
On ___, the patient remained neurologically stable on
examination. The ICPs were ___ and it was determined it would
be raised to 20. The Aline was discontinued and the foley
catheter removed. A CSF gram stain and culture were sent.
On ___, the patient remained neurologically stable on
examination. A clamp trial was attempted, but was terminated
after 45 minutes secondary to elevated ICPs. She underwent a MRI
of the brain, but the MRI of the cervical, thoracic and lumbar
spine could not be completed given the EVD catheter was not long
enough to enter the scanner.
___, the patient remained stable and her ICPs were within
normal limits. Neuro exam stable. In the morning, the patient
complained of visual field deficits and eye spots. A NCHCT was
ordered for these complaints and was unremarkable.
___, her exam was stable and her EVD was clamped at noon.
___ repeat NCHCT demonstrated stable ventricle size and her
EVD was removed. The patient and her and family were made aware
of the initial pathology and were very upset. Social work was
consulted to cope with the new diagnosis.
___, the patient remained neurologically stable. an MRI of the
spine was negative for metastic disease.
___, the patient was stable. Follow up for chemo-radiation was
discussed and she was discharged to home.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Senna 8.6 mg PO BID:PRN constipation
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drive or operative machinery while taking.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
5. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID:PRN constipation
Take while using narcotic information.
7. Dexamethasone 4 mg PO Q8H Duration: 6 Doses
This is dose # 1 of 3 tapered doses
RX *dexamethasone 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*2 Tablet Refills:*0
8. Dexamethasone 3 mg PO Q8H Duration: 6 Doses
This is dose # 2 of 3 tapered doses
RX *dexamethasone 1 mg 3 tablet(s) by mouth every eight (8)
hours Disp #*18 Tablet Refills:*0
9. Dexamethasone 2 mg PO Q8H Duration: 6 Doses
This is dose # 3 of 3 tapered doses
Tapered dose - DOWN
RX *dexamethasone 2 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*6 Tablet Refills:*0
10. Dexamethasone 2 mg PO Q12H
This is the maintenance dose to follow the last tapered dose
Tapered dose - DOWN
RX *dexamethasone 2 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cerebellar mass
hydrocephalus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You underwent surgery to remove a brain lesion from your
brain.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10828900-DS-11
| 10,828,900 | 21,210,316 |
DS
| 11 |
2114-01-05 00:00:00
|
2114-01-05 14:31:00
|
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:
Pt transferred here from ___ for 3.2cm AAA with
penetrating ulcer on CT scan for vague abdominal pain. She had a
bypass ___ ago at ___ and had complications from
bypass requiring them to revise due to PO intolerance. She has
been having pain and inability to eat since ___. She has been
vomiting with some hematemsis and dark stools. She admits to
smoking several packs of cigarettes every day and drinking every
day. She takes NSAIDS occasionally for abdominal pain. She takes
her vitamins occasionally as well. Has been followed up by her
PCP for nutrition labs and bypass follow up. She has an
endoscopy scheduled this week, she had an endoscopy in the past
that showed ulcers as well. She is not being treated for her
Hepatitis C that she has as well. She also says that she has
lost weight in the past few weeks from PO intolerance, her CT
scan showed pulmonary nodules that are also being evaluated by
specialist. She has lost 180lbs since bypass.
Past Medical History:
Past Medical History:
Morbid Obesity
Fibromyalgia
HTN
Reflux
Ulcers
Hepatitis C
Alcohol Dependence
Past Surgical History:
Open Bypass
Lap Cholecystectomy
Social History:
___
Family History:
NC
Physical Exam:
Vitals: 71 128/84 24 98% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, moderate tenderness in epigastric
region, no rebound or guarding, normoactive bowel sounds, no
palpable masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 12:45PM URINE HOURS-RANDOM
___ 12:45PM URINE HOURS-RANDOM
___ 12:45PM URINE UHOLD-HOLD
___ 12:45PM URINE GR HOLD-HOLD
___ 12:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 12:45PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-1
___ 12:45PM URINE HYALINE-3*
___ 12:45PM URINE MUCOUS-RARE
___ 12:00PM GLUCOSE-81 UREA N-18 CREAT-0.5 SODIUM-138
POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
___ 12:00PM estGFR-Using this
___ 12:00PM WBC-9.2 RBC-4.12* HGB-13.8 HCT-40.8 MCV-99*
MCH-33.5* MCHC-33.8 RDW-12.0
___ 12:00PM NEUTS-65.8 ___ MONOS-6.3 EOS-3.4
BASOS-0.7
___ 12:00PM PLT COUNT-233
___ 12:00PM ___ PTT-31.0 ___
Brief Hospital Course:
Ms. ___ was admitted to the hospital on ___ with
epigastric pain and nausea. Upon arrival, she was placed on
bowel rest, given intravenous fluids, antacids and a banana bag.
She underwent an abdominal x-ray without acute findings. She
was then admitted to the ___ surgical service for further
work-up and observation.
The patient remained afebrile with stable vital signs and blood
count. On HD7, she underwent an upper endoscopy, which revealed
ulcers throughout her jejunum. She continued to receive
pantoprazole with improved epigastric pain and she was able to
tolerate a stage 5 diet. Of note, just prior to discharge, the
patient was found to be hypertensive with SBP 170-180s. It was
advised that she remain in the hospital for additional
treatment, however, she elected to leave against medical advice.
We reviewed danger signs and she agreed to schedule a follow-up
appointment as soon as possible. She was then discharged to
home with skilled nursing and medical social work follow-up for
ongoing treatment of alcohol and tobacco additiction. She will
continued to take oral PPI BID and carafate and follow-up with
Dr. ___ PCP in clinic. Her PCP's office was notified
of admission and acute issues. They will also reach out to her
as well.
Medications on Admission:
Cymbalata
Tramadol
Omeprazole
Lisinopril
MVI
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Duloxetine 20 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour 1 patch Q24s Disp #*30 Patch
Refills:*0
6. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
7. Sucralfate 1 gm PO QID
RX *sucralfate [Carafate] 1 gram 1 tablet(s) by mouth four times
a day Disp #*120 Tablet Refills:*0
8. TraZODone 50-100 mg PO HS:PRN insomnia
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Epigastric pain
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.
Followup Instructions:
___
|
10829329-DS-15
| 10,829,329 | 29,747,328 |
DS
| 15 |
2143-08-07 00:00:00
|
2143-08-07 18:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
cephalexin / codeine / donepezil
Attending: ___.
Chief Complaint:
Hypothermia, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male, with prior history of fronttemporal dementia,
hypothermia, now presenting with recurrent hypothermia. He is
now admitted to the MICU for management of hypothermia.
History is obtained from his wife given that he is confused. His
wife reports that for the past 24 hours, he has become
increasingly confused. He usually is able to go to ___
___, and take care of himself. However for the past 24
hours, he has become increasingly confused. Patient was having
difficulty going to bed, pressing buttons on the phone, and
accidentally called ___. The police then arrived, and patient
was then taken to ___ for further evaluation. She states
that his hypothermia has been a problem for now he past year or
so, and has been hospitalized several times over the past year
or so at ___ and ___. He was just
hospitalized last week at ___ for this issue, and
his wife is requesting transfer there as well given multiple
episodse. Furthermore, he was just evaluated by his
endocrinologist Dr. ___ week and Dr. ___.
She does take his temperature at home, and usually is around 91
degrees orally on most days, but has never had a normal core
temperature in the past year or so.
Of note, patient was recently hospitalized at ___ for
bradycardia, altered mental status and hypothermia. This was
thought to be ___ to higher doses of Aricept and some autonomic
dysfunction from this. Furthermore, when patient was seen in the
office on ___, patient's temperature was recorded in OMR as
being 92 degrees F. Patient was seen in the office on ___ for
hypoglycemia and hypothermia which his PCP. His history is
recounted that patient was seen for altered mental status in
___, for hypothermia. At that time his
hypothermia presents as shivering, sweating, and hypoglycemia.
Patient was then discharged with autonomic neuropathy. Patient
was screened for heavy metal intoxication in ___ with
negative lead, arsenic, arsenic, cadmnium and mercury. Patient
was then evaluated by Dr. ___ at ___ for pituitary
dysfunction which was negative. Dr. ___ is his neurologist at
___ has been following.
Of note, patient was
In the ED, initial vitals: 96.8 55 98/57 22 98% RA
- Exam notable for hypothermia.
- Labs were notable for: WBC 3.6, Hgb 10.7, Hct 32.2, Plt 208.
INR 1.
- Imaging showed: CT Head negative, CXR reportedly negative.
- Patient was given:
___ 07:37 IV Meropenem 1000 mg
- Consults: None
On arrival to the MICU, 96.8 71 ___ 14 98% RA
Past Medical History:
1. Frontotemporal Dementia
2. Autonomic Dysfunction of unclear etiology
3. History of Recurrent UTI
4. Neurogenic Bladder
5. Hypothermia - recurrent
6. Inguinal Hernia.
7. Cognitive Impariment with intermittent memory relapases.
8. Left Quadriceps Rupture s/p attempted surgical repair.
Social History:
___
Family History:
No family medical history of hypothermia, thyroid disease or
diabetes. Mother: ___ on her lower back. Father: Died of a
gastric ulcer.
Physical Exam:
ADMISSION:
Temperature 96.5 Rectally, HR 64, BP 112/58 O2 98 RA.
General: Oriented x 1, self. No acute distress, soft spoken,
confused.
HEENT: Plethoric face, no cervical LAD, oropharynx is clear,
mucous membranes dry.
Neck: Supple, no JVD.
Lungs: Clear to auscultation bilaterally, no adventitial sounds
heard.
Abdomen: Soft, NT/ND. +BS. They are hypoactive.
Extremities: No ___ edema, cold extremities.
NEURO: CN II-XII grossly intact. No focal deficits. AOx1.
Access: 2 peripheral IVs
DISCHARGE:
Tm 98.2 Tc 97.4 BP 146/78 HR ___ RR 16 95% on RA
Gen - elderly man who is in no acute distress, resting
comfortably, he awakens to voice and is fully communicative and
remains awake during our discussion
Eyes - anicteric, EOMI
ENT - moist mucous membranes, no nasal discharge, oropharynx
clear
Neck - No LAD, JVP normal
Cardiovascular - RR, s1s2 nl, no m/r/g, no edema
Respiratory - breathing comfortably, no accessory muscle use,
CTAB
GI - soft, non-tender, not distended, bowel sounds present
Skin - warm, dry, with no rash
MSK - normal strength and ROM throughout
Neuro - awake, alert, oriented to person, place, date and reason
for hospitalization ("hypothermia, among other things"); moving
all 4 extremities; speech is fluent; memory is poor; had some
pronounced word-finding difficulties
Psych - alert, calm
Pertinent Results:
ADMISSION LABS:
___ 05:00AM WBC-3.6* RBC-3.19* HGB-10.7* HCT-32.2*
MCV-101* MCH-33.5* MCHC-33.2 RDW-14.9 RDWSD-54.4*
___ 05:00AM NEUTS-53.0 ___ MONOS-12.0 EOS-2.0
BASOS-0.3 IM ___ AbsNeut-1.90 AbsLymp-1.16* AbsMono-0.43
AbsEos-0.07 AbsBaso-0.01
___ 05:00AM ___ PTT-35.7 ___
___ 05:00AM ALBUMIN-3.4* CALCIUM-9.0 PHOSPHATE-2.8
MAGNESIUM-1.8
___ 05:00AM GLUCOSE-85 UREA N-17 CREAT-0.5 SODIUM-140
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-28 ANION GAP-9
PERTINENT:
___ 05:00AM FREE T4-1.1
___ 05:00AM TSH-3.8
___ 05:00AM CORTISOL-4.3 TESTOSTER-132* SHBG-52*
calcFT-20*
___ 05:09AM LACTATE-0.7
___ 11:00AM CORTISOL-9.4
___ 05:00AM ___ AM Cortisol - ___ Cortisol s/p cosyntropin - 23.5
IMAGING:
-___ CXR: There is chest hyperinflation. The cardiac,
mediastinal, hilar, and pleural outlines are otherwise normal.
Lungs are clear of air space opacity or congestive change. There
is no pneumothorax or adenopathy. The skeletal chest wall
structures visualized appear unremarkable. Conclusion: Chest
hyperinflation, compatible with COPD, with no evidence of active
chest disease.
-___ NCHCT: Ventricles are not dilated. No midline shift.
No acute intraventricular or intracerebral bleed. No extra-axial
collection. No effacement of sulci or gyri. Minimal white matter
changes consistent with small vessel disease unchanged from the
prior exam.
1. No acute intracranial process. No change from the prior exam
MICRO:
___ Flu PCR negative
___ BCx - NGTD
___ BCx - NGTD
___ Blood fungal/AFB Cx - NGTD
___ UCx - no growth (final)
Brief Hospital Course:
___ year old male, with past history of hypothermic episodes,
fronto-temporal dementia, now presenting with recurrent
hypothermia.
FICU COURSE:
===================================
# Hypothermia: Patient has now had several episodes of
hypothermia, and it is unclear what the trigger is but most
likely appears to be neurologic in etiology. He has been
evaluated by endocrine in the outpatient setting, with negative
thyroid, adrenal axis abnormalities, and reportedly pituitary
MRI imaging which was negative. This could represent a
hypothalamic dysfunction. Given his history of dementia,
neurogenic bladder, an etiology could be autonomic dysfunction
without endocrine abnormalities. It was difficult to assess his
axis in the setting of him being hypothermic currently
(decreased responsiveness when patients hypothermic) and
therefore if adrenally suppressed may be factitious. However, in
the ICU a cortisol level was checked which was normal,
testosterone was low. He was started on a bair hugger initially.
Blood and fungal cultures were checked. This was then removed
and his temperature was trended; he uptrended on his own to
normothermic temperature, more consistent with autonomic
dysfunction
- warm up slowly to normothermia with bear hugger
- repeat endocrinology testing with TSH, cortisol
- cortisol stimulation testing
- testosterone, FSH testing
- t/b with outpatient neurologist and endocrinologist ___,
___
- obtain prior records from ___ last week.
- hold antibiotics at this time given no signs of acute
infection and covered
- f/u cultures blood and urine.
- trend mental status with warming.
# Leukopenia: Unclear baseline, however could be related to his
hypothermia. Does not appear to have infectious source at this
time.
- trend WBC with diff.
# Bradycardia: Patient is now bradycardic likely ___ to
hypothermia. No J-waves seen on EKG now.
- trend HRs.
# Macrocytic Anemia: Likely anemia of chronic disease and likely
some degree of nutritional.
- trend Hgb
- add on folate, b12.
# Frontemporal Dementia: Per his wife, patient has been able to
take care of hismelf with memory difficulties, but not currently
on treatment as likely ___ to autonomics. When he becomes
increasingly hypothermic, he gets increasingly confused.
- trend mental status with warming
- t/b with outpatient neurologist.
# History of recurrent UTI: Prior history, has foley cathter in,
no signs of acute infection given clean U/A.
- remove foley cathter.
- add on urine culture.
# Hypoglycemia: likely ___ to hypothermia and autonomic
dysfunction.
- QID fingersticks
HMED (floor) COURSE:
===================================
# Hypothermia - recurrent, requiring multiple hospitalization,
resolved s/p FICU tx. Unclear etiology at this time. DDx
thought to include autonomic dysfunction, hypopituitarism,
hypoadrenalism, hypoglycemia, medication-induced hypothermia,
sepsis, among others. Leading dx is autonomic dysfunction. No
signs/symptoms of infection; BCx NGTD; UA clean and UCx
negative. AM cortisol was borderline, seems low in setting of
an acute stress such as this, but ___ test showed good
adrenal response. Endocrinology evaluated the patient and felt
that his recurrent hypothermia is unlikely to be due to an
underlying endocrine cause. No evidence of hypoglycemia
following ICU stay. Clinically much improved and asymptomatic
despite temperatures as low as 94.1 (on ___ without
evidence of worsening mental status. Discussed his case with
Dr. ___ by phone, e-mailed Dr. ___ reviewed Dr. ___
___ recent clinic note. Given the extensive work-up he has
already undergone and dramatic clinical improvement since
admission, after discussion with his family, we felt it was
reasonable to discharge him with plans to continue outpatient
evaluation (e.g. autonomic testing).
# Encephalopathy - initially severe, now much improved, though
not quite back to baseline based on discussion of his baseline
with his wife. On the day of discharge he is awake, alert,
oriented to person, place, time, and reason for hospitalization.
Evaluated by ___: would benefit from ___ rehab with
continued ___ prior to returning home with services.
# Constipation - mild. Started docusate and senna as new
standing meds for constipation treatment and prophylaxis, can be
held for diarrhea.
# Bradycardia - mild, likely due to or exacerbated by
hypothermia, now improved
# Leukopenia - likely due to hypothermia, now resolved
# Macrocytic anemia - stable, no evidence of B12 or folate
deficiency or thyroid dysfunction on lab testing
# Dementia - FTD vs. ___ syndrome; previously
followed by Dr. ___ Neurology, now reportedly
followed by Dr. ___ ___ ___.
# Time spent: 50 minutes spent in patient care and
discharge-related activities on the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 325 mg PO DAILY
2. trospium 20 mg oral DAILY
3. Melatin (melatonin) 3 mg oral QHS
4. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Senna 17.2 mg PO DAILY
3. Aspirin EC 325 mg PO DAILY
4. Melatin (melatonin) 3 mg oral QHS
5. trospium 20 mg oral DAILY
6. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Hypothermia
Metabolic encephalopathy
Autonomic dysfunction 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).
Gen - elderly man who is in no acute distress, resting
comfortably, he awakens to voice and is fully communicative and
remains awake during our discussion
Eyes - anicteric, EOMI
ENT - moist mucous membranes, no nasal discharge, oropharynx
clear
Neck - No LAD, JVP normal
Cardiovascular - RR, s1s2 nl, no m/r/g, no edema
Respiratory - breathing comfortably, no accessory muscle use,
CTAB
GI - soft, non-tender, not distended, bowel sounds present
Skin - warm, dry, with no rash
MSK - normal strength and ROM throughout
Neuro - awake, alert, oriented to person, place, date and reason
for hospitalization ('hypothermia, among other things'); moving
all 4 extremities; speech is fluent; memory is poor; had some
pronounced word-finding difficulties
Psych - alert, calm
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you on the ___ Medicine
service. You were initially admitted to the ___ ICU with
hypothermia and altered mental status. You were warmed up in
the ICU and your temperature normalized. Your mental status
gradually improved. You were evaluated by the Endocrinology
specialists, who felt that you recurrent episodes of hypothermia
are not due to underlying endocrine dysfunction. Your primary
neurologist, Dr. ___, was notified of your admission and will
have access to all of the records from this stay. We recommend
you follow up with him for continued evaluation of your
autonomic dysfunction. You were evaluated by the physical and
occupational therapy doctors who recommended ___ be discharged
to rehab for a brief stay prior to returning home. We wish you
an expeditious recovery.
Sincerely,
The ___ Medicine Team
Followup Instructions:
___
|
10829468-DS-9
| 10,829,468 | 21,136,729 |
DS
| 9 |
2144-06-15 00:00:00
|
2144-06-16 19:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Anterior abdominal wall pain and swelling and well as
fatigue/lightheadedness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with h/o AVR on Coumadin with recently
aborted TEP LIH repair ___ bradycardia (___) who is
transferred from OSH for abdominal pain and CT imaging showing
large extraperitoneal hematoma. Briefly, pt underwent attempted
TEP LIH repair at ___ on ___ that was c/b severe
intra-operative bradycaria to the ___ prompting abortion of the
surgery. Pt underwent negative cardiac work up and was
discharged on ___ with instructions to continue holding home
metoprolol (last taken ___ by his outpt cardiologist.
Since discharge, pt had noted gradually worsening anterior
abdominal wall pain and swelling and well as
fatigue/lightheadedness, though denied back pain, fevers/chills,
N/V, decreased PO intake, dysuria. Given worsening pain, he
presented to ___ on ___ where he was found to have
Hct drop from 43 (pre-op) to 33 and thus received 2U pRBCs. CT
imaging showed large extra-peritoneal hematoma c/f active
postopertive bleed as well as ?R calyceal rupture of unknown
etiology. He was thus transferred to ___ for surgical
evaluation.
On arrival, pt was afebrile and hemodynamically stable. On
further review, pt states he had stopped Coumadin 5d
preoperative (___) and was placed lovenox bridge - INR on
arrival to ___ is 1.2. ___ was placed in ED for urinary
retention thought ___ pain, and it was noted that pt developed
new hematuria. He
otherwise denies back pain, N/V/D, fevers/chills, CP/SOB.
Past Medical History:
___:
- Aortic valve replacement (___, on lifelong Coumadin)
- HTN
- seizure d/o
PSH:
- s/p attempted L inguinal hernia repair (aborted ___
bradycardia, negative cardiac work up)
- s/p AVR ___ (St. ___ valve, on lifelong Coumadin)
- s/p b/l orchiopexy for undescended testicles in childhood
Social History:
___
Family History:
Non contributory
Physical Exam:
Physical Exam on admission:
Vitals: 98.7 66 156/89 99% RA
Gen: A&Ox3, pale and uncomfortable-appearing male, in NAD
HEENT: No scleral icterus, no palpable LAD
Pulm: CTAB, no w/r/r
CV: NRRR, no m/r/g
Abd: soft, distended, exquisitely TTP along anterior abdominal
wall in region of known hematoma w/ overlying ecchymoses; no
rebound/guarding, no palpable masses
GU: Foley in place with light hematuria, no CVA tenderness
Ext: WWP bilaterally, no c/c/e, no ulcerations
Neuro: moves all limbs spontaneously, no focal deficits
Physical Exam on discharge:
Vitals: 98.3, PO114 / 75, 92, 18, 96%Ra
Gen: A&Ox3, comfortable in no acute distress
HEENT: No scleral icterus, no palpable lymphadenopathy
Pulm: Clear to ascultation bilaterally, no wheezes present
CV: regular rate and rhythm, loud grade IV systolic ejection
murmur
Abd: soft, slightly distended, non tender wall, palpable mass w/
resolving/mild ecchymoses consistent with known hematoma, no
rebound/guarding
Ext: warm well perfused bilaterally
Neuro: moves all limbs spontaneously, no focal deficits
Pertinent Results:
___: ABDOMEN (SUPINE ONLY)
IMPRESSION:
Residual contrast in the renal parenchyma, suggestive of renal
insufficiency. Few mildly distended bowel loops, most prominent
at the cecum, consider adynamic ileus.
___: CT PELVIS W&W/O C
IMPRESSION:
1. Stable right rectus hematoma with extraperitoneal pelvic
hematoma and posterior displacement of the bladder, unchanged.
Stable amount of hemoperitoneum.
2. Persistent bilateral delayed nephrograms, concerning for
acute renal failure.
3. Sequelae of previous right forniceal rupture.
___: CT ABD & PELVIS W/O CONTRAST
IMPRESSION:
1. Large extraperitoneal anterior pelvic hematoma posteriorly
displacing the
urinary bladder is not appreciably changed compared to the
outside hospital
CT.
2. Small volume intermediate density ascites, not changed from
prior.
3. Bilateral delayed nephrograms with vicarious excretion of
contrast in the
gallbladder concerning for acute renal failure, either as a
sequela of
hypotension/shock related to the large hematoma, or possibly
acute tubular
necrosis.
4. Findings suspicious for right-sided forniceal rupture with
extravasation of
excreted contrast material into the right retroperitoneum,
possibly due to
papillary necrosis as result of hypotension/shock. No
hydroureteronephrosis.
5. Mild L1 vertebral body height loss, indeterminate age, but
possibly
chronic.
___ 11:57AM BLOOD Glucose-170* UreaN-22* Creat-1.0 Na-132*
K-5.8* Cl-97 HCO3-20* AnGap-21*
___ 07:20AM BLOOD Glucose-135* UreaN-47* Creat-3.6*#
Na-131* K-5.8* Cl-95* HCO3-16* AnGap-26*
___ 01:10PM BLOOD Glucose-124* UreaN-49* Creat-3.7* Na-132*
K-4.9 Cl-94* HCO3-18* AnGap-25*
___ 06:31AM BLOOD Glucose-93 UreaN-43* Creat-2.0*# Na-132*
K-4.5 Cl-99 HCO3-20* AnGap-13
___ 07:05AM BLOOD Glucose-90 UreaN-23* Creat-1.0 Na-138
K-4.5 Cl-99 HCO3-21* AnGap-18*
___ 01:30AM BLOOD Glucose-101* UreaN-17 Creat-0.8 Na-139
K-4.5 Cl-102 HCO3-25 AnGap-12
___ 09:00AM BLOOD Glucose-95 UreaN-17 Creat-0.9 Na-143
K-4.5 Cl-102 HCO3-24 AnGap-17*
___ 06:50AM BLOOD Glucose-89 UreaN-16 Creat-0.8 Na-139
Cl-103 HCO3-16* AnGap-20*
___ 07:00AM BLOOD Glucose-91 UreaN-17 Creat-0.8 Na-140
K-5.1 Cl-102 HCO3-25 AnGap-13
___ 11:57AM BLOOD ___ PTT-24.8* ___
___ 09:19PM BLOOD PTT-67.0*
___ 03:04AM BLOOD PTT-67.8*
___ 07:00AM BLOOD ___ PTT-69.2* ___
___ 07:00AM BLOOD WBC-11.6* RBC-3.02* Hgb-9.0* Hct-28.1*
MCV-93 MCH-29.8 MCHC-32.0 RDW-13.7 RDWSD-46.3 Plt ___
___ 11:51AM URINE Color-Yellow Appear-Clear Sp ___
Brief Hospital Course:
Mr. ___ is a ___ with history of AVR on Coumadin with
recently aborted TEP Left inguinal hernia repair ___ bradycardia
(___) who is transferred from OSH for abdominal pain and CT
imaging showing large extraperitoneal hematoma with a hematocrit
drop from 43 (pre-op) to 33. At ___ he was
noted to have urinary retention and new hematuria. He was
transferred to the floor and was hemodynamically stable on the
floor. He was monitored on telemetry and followed with serial
abdominal exams and hemoglobin/hematocrit. On hospital day 2
his hematocrit dropped further to 19.9 and he received 2 units
of packed red blood cells (total 4 including outside hospital).
His foley stayed in place secondary to hematuria with associated
acute kidney injury believed to be secondary to a pre-renal
disease; hypotension in the setting of acute bleed at outside
hospital. On hospital day 3 his creatinine returned to base
line. His foley stayed in place until hospital day ___ when it was
deemed safe to remove with 1 dose of antibiotics per urology. At
the time of discharge he was hemodynamically stable, moving his
bowels well, tolerating a regular diet and with good pain
control.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Captopril 12.5 mg PO DAILY
3. Warfarin 5mg-10mg mg PO DAILY
4. LevETIRAcetam 750 mg PO BID
5. OxyCODONE (Immediate Release) Dose is Unknown PO UNKNOWN:PRN
Pain - Moderate
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
Please do not take more than 4000mg/day. Try to 2000mg per day
due to interactions with Coumadin.
2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
3. Polyethylene Glycol 17 g PO DAILY
You can get this medication over the counter to treat moderate
constipation.
4. Simethicone 40-80 mg PO QID:PRN gas pain
You can buy this medication over the counter.
5. OxyCODONE (Immediate Release) unknown PO UNKNOWN:PRN Pain -
Moderate
This medication was prescribed by a prior doctor. Please follow
his recs.
6. Captopril 12.5 mg PO DAILY
7. LevETIRAcetam 750 mg PO BID
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Warfarin 5mg-10mg mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Exraperitoneal hematoma
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for
management of your post-operative extraperitoneal heamtoma and
acute kidney injury. You are recovering well and are now ready
for discharge. Please follow the instructions below to continue
your recovery:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
BLADDER:
o You had a foley in place while in the hospital. This can cause
discomfort and lead to an increased chance of developing a
urinary tract infection.
o Please call your Acute Care Trauma Surgery team if you develop
symptoms of increase frequency, burning or bloody or dark urine.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Please don't take any other pain medicine, including
non-prescription pain medicine, unless your surgeon has said its
okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10829688-DS-5
| 10,829,688 | 23,519,128 |
DS
| 5 |
2202-03-23 00:00:00
|
2202-03-23 16:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfa (Sulfonamide Antibiotics) / morphine
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
HPI:
___ female history of biliary stricture status post ___
and ___, peptic ulcer disease. She has presented to ED today
with severe abdominal pain, nausea, vomiting.
She reports abdominal pain sudden in onset, mostly in the right
upper quadrant, feels like contractions. She is at ___ episodes
of this today, every episode lasting about 30 minutes. It is
associated with vomiting, 4 episodes, initially bilious, now
clear. No hematemesis.
In the ED, he was treated with IV fluids, Zofran, IV Dilaudid
with temporary relief of symptoms. She feels like the episode
is
similar to her last episode of biliary colic ___ years ago.
Of note, over the last week she has been taking more ibuprofen,
___ tablets a day for cervical disc herniation. She has been
needing more Pepcid due to more acid reflux.
Currently she is in distress due to abdominal pain and nausea
but
is able to provide a good history.
Review of system otherwise negative across 12 systems. No chest
pain or dyspnea or fever or chills.
Past Medical History:
s/p CCY ___ for choledocholithiasis
prior ERCP with sphincterotomy at ___,
sphincteroplasty in ___ for sphincter restenosis, ERCP ___
at ___ with balloon sweep and sphincteroplasty
HLD - improved with dietary changes
Mitral valve prolapse (per records)
GERD
Social History:
___
Family History:
Mother died from brain aneurysm at age ___. Father had CABG 3v at
age ___, developed DM2, died from kidney failure at age ___.
Physical Exam:
VITALS: ___ 0745 Temp: 98.6 PO BP: 128/74 HR: 50 RR: 18 O2
sat: 95% O2 delivery: RA FSBG: 87
GEN: NAD
HEENT: EOMI, sclerae anicteric, MMM, OP clear
NECK: No LAD, no JVD
CARDIAC: RRR, no M/R/G
PULM: normal effort, no accessory muscle use, LCAB
GI: soft, ND, NABS. nontender to palpation
MSK: No visible joint effusions or deformities.
DERM: No visible rash. No jaundice.
NEURO: AAOx3. No facial droop, moving all extremities.
PSYCH: Full range of affect
EXTREMITIES: WWP, no edema
Pertinent Results:
___ 08:20PM BLOOD WBC-13.0* RBC-4.56 Hgb-14.1 Hct-42.1
MCV-92 MCH-30.9 MCHC-33.5 RDW-13.3 RDWSD-45.2 Plt ___
___ 05:14AM BLOOD WBC-9.4 RBC-3.97 Hgb-12.1 Hct-36.6 MCV-92
MCH-30.5 MCHC-33.1 RDW-13.1 RDWSD-44.6 Plt ___
___ 06:20AM BLOOD WBC-7.5 RBC-3.75* Hgb-11.5 Hct-35.1
MCV-94 MCH-30.7 MCHC-32.8 RDW-13.5 RDWSD-46.2 Plt ___
___ 08:20PM BLOOD Neuts-83.0* Lymphs-12.5* Monos-3.6*
Eos-0.1* Baso-0.3 Im ___ AbsNeut-10.75* AbsLymp-1.62
AbsMono-0.47 AbsEos-0.01* AbsBaso-0.04
___ 05:14AM BLOOD Neuts-79.9* Lymphs-15.0* Monos-4.4*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-7.51* AbsLymp-1.41
AbsMono-0.41 AbsEos-0.00* AbsBaso-0.02
___ 08:20PM BLOOD Glucose-119* UreaN-14 Creat-0.8 Na-137
K-5.0 Cl-99 HCO3-22 AnGap-16
___ 05:14AM BLOOD Glucose-163* UreaN-11 Creat-0.7 Na-138
K-4.4 Cl-102 HCO3-25 AnGap-11
___ 06:20AM BLOOD Glucose-90 UreaN-8 Creat-0.8 Na-145 K-4.5
Cl-106 HCO3-27 AnGap-12
___ 06:20AM BLOOD ALT-87* AST-38 AlkPhos-79 TotBili-0.3
___ 05:14AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.8
___ 08:20PM BLOOD Albumin-4.2
___ 05:14AM BLOOD Albumin-3.4*
___ 08:26PM BLOOD Lactate-2.5*
IMPRESSION:
1. The common hepatic duct measures up to 12 mm, unchanged
since ___. Status post cholecystectomy.
2. Persistent unchanged small amount of pneumobilia.
3. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis cannot
be excluded on this study.
Brief Hospital Course:
___ w/ history of gallstone disease (s/p ERCP with stone
extraction/sphincterotomy and CCY), ampullary restenosis s/p
balloon dilation in ___, and prior duodenal ulcers, who
presented with RUQ pain now s/p ERCP with sludge removal feeling
improving.
#Abdominal pain, vomiting:
Possibly related to a partial obstruction of the distal CBD by
biliary sludge, now removed by ERCP ___. Significance of this
sludge
is unclear, given normal LFTs and lack of CBD dilatation on
imaging. Pain has now completely resolved and she is tolerating
a
regular diet. She is to closely follow up with GI.
#Steatosis
Seen on RUQUS. She had mildly elevated ALT. Should have LFTs
repeated in one week. She should have repeat RUQUS and
discussion of steatosis with GI on follow up. Synthetic function
intact.
> 30 minutes spent on complicated discharge
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Famotidine 20 mg PO BID:PRN reflux
2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
Discharge Medications:
1. Famotidine 20 mg PO BID:PRN reflux
2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
#Abdominal pain, vomiting
#Biliary Sludge
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
you were admitted after you began to have abdominal pain. You
underwent an ultrasound which did not show the source of your
pain. Gastroenterologists were consulted and you underwent an
ERCP.
During ERCP sludge was removed from your biliary ducts. After
ERCP you felt much better and no longer were having pain or
nausea. You were able to eat normally. You will need to follow
with your primary care doctor and gastroenterology.
It was a pleasure caring for you,
Your ___ Team
Followup Instructions:
___
|
10829710-DS-11
| 10,829,710 | 22,233,867 |
DS
| 11 |
2132-11-05 00:00:00
|
2132-11-05 15:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Breast Cancer metastatic to Brain
Major Surgical or Invasive Procedure:
Lumbar Puncture ___
History of Present Illness:
___ year old Female transferred for urgent neurosurgical
evaluation for an occipital brain mass. The patient has a
history of breast cancer, status post lumpectomy and mastectomy,
chemotherapy and radiation on maintenance tamoxifen. She
experienced a headache one month prior to admission, which
lasted several days, but resolved. She states the headache
recurred one week prior to admission in ___ where she
works. She states the hospital gave her something that worked.
She came to the ___ to visit a friend and noted a
worsening of the headache on the flight. She went to ___
___ which noted the mass on CT. She underwent a ___ at
___, and was noted to have a right cerebellar brain mass.
She was started on dexamethasone and a PPI. She notes the
development of left ptosis, visual blurring of her left eye and
right hip parathesias. and she was transferred for neurosurgical
and neuro-oncologic evaluation.
Initial vitals in the ___ ED, 97.6, 78, 133/91, 7, 100%. She
was seen by neurosurgery in the ED, who felt there was no need
for neurosurgical intervention.
Past Medical History:
Breast Cancer
Chemotherapy: finished ___
XRT: finished ___
Right mastectomy: ___
Social History:
___
Family History:
Mother: ___ Cancer, DM
Aunt: ___ Cancer
Cousin: ___ ___
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, + Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomiting, - Diarrhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, + Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, + Headache
Admission PHYSICAL EXAM:
VSS: 98.1, 121/87, 75, 99%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions, Note swollen right cheek
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: Mild RLQ TTP, ND, +BS, - CVAT
EXT: - CCE
NEURO: Left Ptosis, Anisicoria L>R, flattened right nasolabial
fold, possible Left Tongue Deviation, Motor ___ ___: Flex/Ext,
Motor ___: Finger spread
Discharge physical exam:
Gen: Lying in bed in no apparent distress
HEENT: Anicteric, eyes conjugate, MMM, no JVD
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Lung fields clear to auscultation throughout
Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present, no HSM
MSK: No edema
Skin: No rashes or ulcerations evident
Neurological: CN ___ intact, full strength in UE and ___
bilaterally, no dysmetria apparent on finger to nose testing
bilaterally.
Psychiatric: pleasant, appropriate affect
Pertinent Results:
___ 01:40AM BLOOD WBC-10.8* RBC-4.22 Hgb-12.1 Hct-36.0
MCV-85 MCH-28.7 MCHC-33.6 RDW-14.3 RDWSD-44.0 Plt ___
___ 01:40AM BLOOD Neuts-92* Bands-3 Lymphs-2* Monos-2*
Eos-0 Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-10.26*
AbsLymp-0.32* AbsMono-0.22 AbsEos-0.00* AbsBaso-0.00*
___ 01:40AM BLOOD Glucose-177* UreaN-17 Creat-0.6 Na-139
K-3.7 Cl-103 HCO3-25 AnGap-15
___ 01:40AM BLOOD ALT-23 AST-12 AlkPhos-64 TotBili-0.4
___ 01:40AM BLOOD Albumin-3.3*
___ 10:35PM URINE Color-Straw Appear-Clear Sp ___
___ 10:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 10:35PM URINE UCG-NEGATIVE
CSF Cytology: + for adenocarcinoma
OSH ___ CT (uploaded to ___, ___ Read): Right 2.3cm low
density lesion worrisome for metastatic disease. Recommend MRI
brain with contrast
OSH Hip X-Ray: Unremarkable right hip
MR ___ ___: 1. 41 x 32 x 31 mm heterogeneously enhancing
likely extra-axial posterior
fossa mass, consistent with metastatic disease, with surrounding
vasogenic
edema, associated mass effect with complete effacement of the
distal fourth
ventricle and downward displacement of the cerebellar tonsils
with crowding of
the foramen magnum, with associated moderate hydrocephalus, as
seen on the CT
examination from 1 day prior.
2. No other enhancing lesion is seen.
3. No evidence of hemorrhage.
CT Chest ___: No suspicious pulmonary nodules or masses. No
lymphadenopathy. No pleural
abnormalities. Status post right breast surgery.
CT Abdomen/Pelvis ___:
1. Large soft tissue mass in the pelvis. Although this could
represent a
pedunculated uterine fibroid, it is indeterminate. Further
evaluation with
ultrasound is recommended.
2. No pathologic lymphadenopathy or evidence of metastatic
disease in the
abdomen and pelvis.
Pelvic Ultrasound ___:
Transabdominal ultrasound only was performed. An anteverted
uterus is present that measures 9.9 x 5.6 x 5.4 cm. The
endometrium is normal measuring 4 mm. Multiple fibroids are
present, the largest extends from the fundus. Ultrasonically it
measures 9 x 9 x 8.5 cm. This corresponds with the masses seen
on the CT.
Neither ovary was identified.
IMPRESSION:
Pelvic masses seen on CT is a fibroid
Brief Hospital Course:
1. Breast Cancer, Metastatic to Brain: CSF cytology returned
positive for adenocarcinoma, confirming this is likely
metastatic breast cancer, as opposed to meningioma, which was
another diagnostic consideration. CT Chest demonstrated no signs
of malignancy. CT A/P was notable for multiple pelvic masses
with the appearance of fibroids; transabdominal ultrasound
confirmed that these were fibroids. She was followed closely by
___ (Dr. ___ and ___ Oncology (Dr. ___
___ during her stay. On ___ she went for radiation simulation
and underwent her first of 10 planned treatments with whole
brain radiation. She was also seen by Neurosurgery, who
recommended against operative intervention. She was continued on
Dexamethasone 4mg q6h on discharge.
It should be noted that, at the time of this writing, it is
still unclear whether or not her current health insurance will
cover any of the medical costs resulting from this current stay.
She has been cleared to return to ___ upon completion of
her 10 radiation treatments, where she will follow-up with her
local Oncologist, Dr. ___ (___), to discuss
further treatment options.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Dexamethasone 4 mg PO Q6H
2. DimenhyDRINATE 50 mg PO TID
3. Omeprazole 20 mg PO DAILY
4. Tamoxifen Citrate 20 mg PO DAILY
5. TraMADol 50 mg PO TID
Discharge Medications:
1. Dexamethasone 4 mg PO Q6H
2. DimenhyDRINATE 50 mg PO TID
3. Omeprazole 20 mg PO DAILY
4. Tamoxifen Citrate 20 mg PO DAILY
5. TraMADol 50 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Breast cancer with metastasis to the brain (posterior fossa)
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 here at ___ in
___. As you know, you were admitted to our hospital to be
evaluated for a concerning brain mass seen on CAT scan. You were
evaluated by multiple specialists including Dr. ___ from
___, Dr. ___ from ___ Oncology, and Dr.
___ with ___. You had a lumbar puncture
performed, and the results from this study confirmed that the
brain mass is likely due to spread (metastasis) of your previous
breast cancer to your brain. On ___ you underwent your
first of 10 planned radiation treatment to the brain, with the
goal of shrinking the tumor. Upon completion of the radiation
treatments, you are free to return to ___. ___. When you
return, we encourage you to speak with your oncologist, Dr.
___, to discuss further treatment options for your brain
tumor.
Followup Instructions:
___
|
10829799-DS-15
| 10,829,799 | 25,293,444 |
DS
| 15 |
2157-03-16 00:00:00
|
2157-03-16 17:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
ORIF of left distal radius fracture ___, Dr. ___
History of Present Illness:
___ year old healthy and active female with left wrist injury s/p
fall. She states that she was walking to meet up with her
personal trainer when she stepped into a pothole, lost her
balance and fell. She tried to catch her fall and she had
immediate pain and deformity with swelling to the left wrist.
Past Medical History:
-Dyslipidemia
-Osteoporosis
-Rheumatoid arthritis
Social History:
___
Family History:
Notable for rheumatoid arthritis in her daughter. Her mother is
alive at age ___ with some hypertension.
Physical Exam:
Left upper extremity:
- splint intact
- fingers warm and well perfused
- no motor/sensory exam at discharge ___ peripheral nerve block
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left distal radius fracture and right Weber A fibula
fracture and was admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ for ORIF L
distal radius 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'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
NWB in the left upper extremity in the splint and weight bearing
as tolerated in an Aircast stirrup for the right lower
extremity, and will be discharged on aspirin for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Zolpidem Tartrate 5 mg PO QHS
2. Rosuvastatin Calcium 10 mg PO QPM
Discharge Medications:
1. Aspirin 325 mg PO DAILY Duration: 14 Days
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 -6 hours as
needed for pain Disp #*72 Tablet Refills:*0
4. Rosuvastatin Calcium 10 mg PO QPM
5. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Left distal radius fracture and right Weber A stable ankle
fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
- ___ were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Nonweightbearing in the left upper extremity in the splint; ok
to do light activities of daily living.
- Weightbearing as tolerated in the right lower extremity in the
Aircast boot or Aircast stirrup.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so ___ should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take 325mg Aspirin daily for 2 weeks
WOUND CARE:
- ___ may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if ___ experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Followup Instructions:
___
|
10830192-DS-11
| 10,830,192 | 25,950,859 |
DS
| 11 |
2118-06-06 00:00:00
|
2118-06-06 16:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
RLQ pain
Major Surgical or Invasive Procedure:
1. laparoscopic appendectomy
History of Present Illness:
Mr. ___ is a ___ p/w 48 hours of RLQ pain with imaging and
leukocytosis consistent with acute unperforated appendicitis. He
describes the pain as ___ now progressing to ___, initially in
the RLQ now becoming diffuse, without any clear provoking or
palliating factors. It is associated with nausea, NBNB emesis,
anorexia and diaphoresis. He denies fevers or rigors. On exam he
is afebrile but tachycardic with a taut, non-distended,
diffusely tender abdomen particularly in the RLQ and LLQ. Psoas
sign and Rovsings sign negative. McBurney's point tender. He has
a WBC to 14.7 and a CT was performed that showed a fecolith and
periappendiceal inflammation.
Past Medical History:
none
Social History:
___
Family History:
Non-contributory. No bleeding or clotting disorders. No cancers.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.7 98 136/76 22 98% RA
GEN: NAD, well-nourished, appropriately groomed.
NEURO: AOx3, CN II-XII grossly intact
HEENT: Sclerae anicteric, trachea midline, no JVD
CV: RRR no MRG, 2+ peripheral pulses bilaterally
RESP: CTAB no WRC, no respiratory distress
GI: Abdomen firm, mildly distended and tender to the RLQ and
LLQ, Psoas sign and Rovsing's sign negative. No rebound
tenderness, +voluntary guarding. Dull to percussion. Rectal exam
deferred
EXT: WWP no CCE
DISCHARGE PHYSICAL EXAM:
GEN: NAD, well-nourished, appropriately groomed.
NEURO: AOx3, CN II-XII grossly intact
HEENT: Sclerae anicteric, trachea midline, no JVD
CV: RRR no MRG, 2+ peripheral pulses bilaterally
RESP: CTAB no WRC, no respiratory distress
GI: Abdomen mildly distended, appropriately tender near
incisions, port sites c/d/i. No rebound or guarding.
EXT: WWP no CCE
Pertinent Results:
CT Abdomen/Pelvis w/ contrast (___):
Dilated appendix with appendicolith and adjacent fat stranding
reflective of acute appendicitis. No focal fluid collection.
___ 03:15AM BLOOD WBC-14.7* RBC-5.37 Hgb-15.0 Hct-48.0
MCV-89 MCH-27.9 MCHC-31.3* RDW-12.0 RDWSD-39.2 Plt ___
___ 03:15AM BLOOD Neuts-88.9* Lymphs-5.8* Monos-4.1*
Eos-0.1* Baso-0.4 Im ___ AbsNeut-13.03* AbsLymp-0.85*
AbsMono-0.60 AbsEos-0.02* AbsBaso-0.06
___ 03:15AM BLOOD Glucose-140* UreaN-11 Creat-0.9 Na-138
K-4.2 Cl-102 HCO3-22 AnGap-18
___ 03:15AM BLOOD ALT-23 AST-35 AlkPhos-82 TotBili-0.6
___ 03:54AM BLOOD Lactate-2.2*
___ 05:30AM BLOOD WBC-8.7 RBC-4.29* Hgb-12.1* Hct-37.4*
MCV-87 MCH-28.2 MCHC-32.4 RDW-12.4 RDWSD-39.5 Plt ___
___ 01:30PM BLOOD Glucose-138* UreaN-8 Creat-0.8 Na-135
K-3.6 Cl-102 HCO3-22 AnGap-15
___ 01:30PM BLOOD Calcium-8.5 Phos-1.9* Mg-2.2
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed appendicits. WBC was
elevated at 14.7. The patient underwent laparoscopic
appendectomy and was found to have perforated appendicits. The
procedure went well without complication (reader referred to the
Operative Note for details). He was placed on 4days of
antibiotics post-operatively to cover for a source-controlled
infection. While in the PACU, the patient was tachycardic to 115
(as he had been pre-operatively), and he received a 500cc bolus.
He voided appropriately subsequently. After a brief stay in the
PACU, the patient arrived on the floor tolerating clears, on IV
fluids, and adequately pain control. The patient was
hemodynamically stable.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home on post-operative
day 5 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 325-650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
Use to treat constipation caused by your pain medication. Hold
for loose stools.
3. Ondansetron 4 mg PO Q8H:PRN nausea
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
5. Senna 8.6 mg PO BID
Use to treat constipation caused by your pain medication. Hold
for loose stools.
Discharge Disposition:
Home
Discharge Diagnosis:
perforated appendicits
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for management of perforated appendicitis and
underwent laparoscopic appendectomy (removal of your appendix).
You did well post-operatively and are being discharged home in
stable condition to complete a total 4 day course of antibiotics
(to end ___. Please follow the following directions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
10830214-DS-21
| 10,830,214 | 23,898,699 |
DS
| 21 |
2148-10-19 00:00:00
|
2148-10-20 06:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right upper quadrant abdominal pain
Major Surgical or Invasive Procedure:
___ CHOLECYSTECTOMY LAPAROSCOPIC
History of Present Illness:
Mr. ___ is ___ who is ___ with no significant PMH who
presents to the ED with eight hours of severe RUQ and epigastric
pain. ___ was working at home when the pain started. ___ described
this as a 'squeezing' feeling, and it has been constant and
unremitting since that time. ___ says that the pain does not
radiate anywhere. Mr. ___ has not felt anything like this before.
___ has not felt any CP or SOB. ___ denied any n/v/d, fevers or
chills and dysuria.
Past Medical History:
none known
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam upon presentation:
VS: T97.4 HR 46 BP 134/74 RR 19 O2 100%
General: well appearing in NAD, no jaundice noted
HEENT: PEERLA, OP clear, sclera non-icteric
NECK: no JVD
CARD: RRR, clear s1/s2
PULM: clear to auscultation bilaterally
___: +BS, non-distended thin abdomen that is soft, tympanic to
percussion with tenderness and involuntary guarding to light
palpation in the RUQ. Also tender in R epigastrium. No shifting
dullness, negative ___ exam. No masses appreciated.
EXT: warm, well perfused with +DP pulses, no c/c/e
NEURO: AxO3, displeased with plan, desires to go home
Physical Exam upon discharge:
Pertinent Results:
___ 06:15AM BLOOD WBC-6.3 RBC-3.81* Hgb-12.6* Hct-38.6*
MCV-101* MCH-33.1* MCHC-32.7 RDW-12.1 Plt ___
PTT-37.6* ___ ALT-7 AST-21 AlkPhos-41 TotBili-0.5
___:
WBC-6.4 RBC-3.91* Hgb-13.2* Hct-39.9* MCV-102* MCH-33.7*
MCHC-33.0 RDW-12.5 Plt ___ Neuts-56 Bands-0 ___ Monos-7
Eos-3 Baso-0 ___ Myelos-0 ___ PTT-39.7*
___ Plt Smr-NORMAL Plt ___
Glucose-100 UreaN-15 Creat-0.9 Na-141 K-3.9 Cl-109* HCO3-23
AnGap-13 ALT-8 AST-21 AlkPhos-41 TotBili-0.4 ALT-7 AST-18
AlkPhos-38* TotBili-0.3 Albumin-3.9
___ MRCP (MR ABD ___
IMPRESSION:
1. CBD 5 mm in diameter, panc duct 2 mm. No evidence of
ampullary mass. No intrahepatic duct dilatation.
2. Gallbladder mildly thick-walled with a small amount of fluid
adjacent to the fundus of the gallbladder. No filling defects
identified within the gallbladder or biliary tree.
3. 1.4 cm complex cyst within lower pole of right kidney
demonstrating
peripheral nodular enhancement post-contrast (se 15 im 56).
4. Bilateral simple renal cysts.
5. Pancreas, liver, adrenals and spleen within normal limits.
___ LIVER OR GALLBLADDER US
1. cholelithiasis; distended GB w/ thickened nom-edematous wall;
no
sonographic ___ sign and no pericholecystic fluid make
cholecystitis less likely.
2. prominent CBD (6 mm) and panc duct (3 mm) - if concern for a
more subtle ampullary obstruction, MRCP may be considered.
Brief Hospital Course:
Mr. ___ is ___ year old male who is ___ with no significant
past medical history who presents to the ED with eight hours of
severe RUQ and epigastric pain. ___ was working at home when the
pain started. ___ described this as a 'squeezing' feeling, and it
has been constant and unremitting since that time. ___ says that
the pain does not radiate anywhere. ___ was admitted to the Acute
Care Surgery Service, where ___ underwent a gallbladder
ultrasound; imaging demonstrated cholelithiasis. The patient
remained NPO and IV Antibiotics were initiated. Due to suspicion
of am ampullary mass, patient also underwent an MRCP to rule out
any abnormalities before being taken to the OR. The MRCP showed
"No intra- or extra-hepatic biliary dilatation. No intraductal
filling defects or overt ampullary mass, within the limitations
of the scan. Thick-walled but only partially distended
gallbladder with a small amount of high T2 signal adjacent to it
either representing fluid adjacent to the gallbladder or
asymmetric edema. Differential is ___ include acute or
chronic inflammation, sequellae from hepatitis or pancreatitis,
or
third-spacing. On ___, patient had an uncomplicated
laparoscopic cholecystectomy. Post-operatively, his pain was
well controlled and ___ was advanced to a regular diet. ___ denies
Nausea/vomiting/diarrhea. Lap incision sites are
clean/dry/intact.
Medications on Admission:
None
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
CHOLECYSTITIS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___, you were admitted to the hospital for abdominal pain and
found to have acute cholecystitis. You were taken to the OR on
___ for a laprascopic cholesytectomy. You tolerated the
procedure well.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
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| 16 |
2121-10-08 00:00:00
|
2121-10-08 10:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
vancomycin / IV Dye, Iodine Containing Contrast Media
Attending: ___
Chief Complaint:
RUQ Pain
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy.
History of Present Illness:
___ with hx of "gallbladder issues" ___ years ago that was in her
usual state of health until 2 days ago when she experienced
sudden onset of epigastric pain, severe ___, wave-like,
+bloating, no radiation, with associated 4 bowel movements but
denied diarrhea. Pt states her symptoms began 30 minutes after
eating pizza dough. She had associated nausea, dry heaves but
without emesis. At home she confirmed a fever to ___ and
associated shaking chills. She subsequently went to an OSH. At
the OSH imaging revealed a cystic duct stone, noted to have
transaminitis (200-300s), was given a dose of Zosyn 3.375mg and
the pt was subsequently referred to ___ ED. Following transfer
it was noted her blood cultures were positive for GNRs.
.
-In the ED, initial VS: 101.2 132/55 114 18 98%RA.
-Exam notable for: +epigastic pain without rebound.
-Labs notable for: improving LFTs
-The pt received: morphine sulfate and tylenol.
-The pt was seen by: ERCP and general surgery.
-Vitals prior to transfer were stable.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria. All other ROS negative.
Past Medical History:
PMH: gallstones, asthma, ___ MRSA infection
PSH: TAH w/ appendectomy, c-section x2
Social History:
___
Family History:
No significant family history for gallstones.
Physical Exam:
Admission Exam:
VS: 96.6 130/97 96 18 100RA
GENERAL: NAD, comfortable, appropriate.
HEENT: No scleral icterus. PERRLA, EOMI, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Tenderness on deep palpation to RUQ. Otherwise soft.
ND. +BS.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact.
Pertinent Results:
Admission Labs:
___ 08:42AM WBC-10.9 RBC-4.72 HGB-13.3 HCT-36.9 MCV-78*
MCH-28.1 MCHC-36.0* RDW-13.5
___ 08:42AM NEUTS-89.3* LYMPHS-6.4* MONOS-3.7 EOS-0.4
BASOS-0.3
___ 08:42AM ___ PTT-30.6 ___
___ 08:42AM PLT COUNT-152
___ 08:42AM ALT(SGPT)-288* AST(SGOT)-164* ALK PHOS-107*
TOT BILI-1.3 DIR BILI-0.4* INDIR BIL-0.9
___ 08:42AM LIPASE-23
___ 08:42AM GLUCOSE-114* UREA N-11 CREAT-1.1 SODIUM-140
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15
___ 09:04AM LACTATE-1.2
.
HIDA:
IMPRESSION: Non-visualization of the gallbladder including post
morphine.
Findings compatible with acute cholecystitis.
.
U/S:
FINDINGS: The liver appears mildly coarsened without focal
lesion. There is no biliary dilatation. The gallbladder contains
multiple shadowing stones, but does not appear distended. There
are areas of ring-down artifacts along the anterior wall,
raising question of adenomyomatosis. There is no pericholecystic
fluid. There is no biliary dilatation. The common duct measures
4 mm. There is normal hepatopetal flow in the portal vein. The
spleen measures 12 cm. Partially visualized pancreas, aorta, and
IVC are within normal limits.
IMPRESSION:
1. Cholelithiasis without definite evidence of cholecystitis.
2. Findings suggestive of gallbladder adenomyomatosis.
3. Mildly coarsened liver.
Brief Hospital Course:
Medical Admission:
___ with hx of "gallbladder issues" presenting with
cholelithiasis and cholecystitis on HIDA.
.
ACTIVE ISSUES:
# GNR Septicemia: Pt presented to OSH with fever + tachycardia
which meet criteria for sepsis. Pt then noted to have GNR
bacteremia. Given aggressive IVF and IV abx. Source likely acute
cholecysitis. Surgery and ERCP consulted.
Pt was continued on Cipro/Flagyl
- Aggressive IVF overnight
- Appreciate - f/u OSH Blood Cx, will do surveillance x48hrs
here.
- Pt will need a total of 14d of antibiotics given GNR
bactermia.
.
# Acute Cholecystitis/Cholelithiasis/Choledocolithiasis: Pt
found to have acute cholecystitis on HIDA.
INACTIVE ISSUES:
# Dyslipidmiea: Holding statin given LFTs up.
.
TRANSITIONAL ISSUES:
Full Code
Transfer to surgery:
The Acute Care Surgery service was consulted on ___ due to concerns for cholangitis versus cholecystis. A HIDA
scan was recommended and revealed acute cholecystitis prompting
surgical intervention via laparascopic cholecystectomy which
occured on ___ please see operative notes for
details. The patient was extubated and transferred to the PACU
for recovery. Once deemed stable, she was admitted to the
general surgical ward for further observation.
Post-operatively, the patient was afebrile with stable vital
signs and without leukocytosis (WBC 6.8). Pain was well
controlled with oral Vicodin and then transitioned to oral
oxycodone prn. The patient's diet was gradually advanced to
regular, which was well tolerated; electrolytes were repleted
prn and LFTs began normalizing. Additionally, the patient was
voiding adequately and ambulating independently.
Following an uncomplicated post-operative course, the patient
was discharged to home on ___. She will follow-up
with the Acute Care Service on ___ and her PCP on
___.
Medications on Admission:
simvastatin 20', ___ ketones', CONJUGATED LINOLEIC ACID
___, CaVitD, Omega3 FA
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
3. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Calcium-Vitamin D Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis with obstruction of the cystic duct by a
stone
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to an outside hospital with abdominal pain and
fevers and subsequently transferred to ___ due to elevated
laboratory results in conjuction with concern for impacted
gallstones seen on an Abdominal CT scan. Upon arrival to ___,
you underwent further imaging which was suggestive of acute
cholecystitis, therefore, you underwent a laparascopic
cholecytectomy. You recovered in the hospital and are now
preparing for discharge to home with the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
****Please resume all regular home medications, unless
specifically advised not to take a particular medication
including:
*****Please note, a new prescription for a lower dosage of
simvastatin has been provided for you due to elevation of your
liver function tests upon presentation to ___. Your liver
function tests have begun normalizing following your surgery,
therefore, please discuss with your Primary Care Provider when
it is appropriate for you to resume your full dosage of this
medication******.
Also, please take any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
10830614-DS-11
| 10,830,614 | 26,847,833 |
DS
| 11 |
2151-01-06 00:00:00
|
2151-01-06 19:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Lower left quadrant pain with large pelvic mass
Major Surgical or Invasive Procedure:
Exploratory laparotomy and bilateral salpingo-oophorectomy
History of Present Illness:
This is a ___ yo G2P2 who presents as a transfer from ___
___ for GYN Oncology consult re: large pelvic mass. Patient
states she has had intermittent abdominal pain for the past 2
months but yesterday morning around 630am her pain became more
severe ___ in the left lower quadrant associated with nasuea
and vomiting, which prompted her to go to urgent care. They
identified a large pelvic mass and sent her to ___
___. At ___, they then decided that given the
concern for torsion vs. malignancy, that she be transferred to
___ for Oncology care.
She states that her pain has persisted. Without medication it is
___, with the medication it improves to ___. No further
nausea, but endorses decreased appetite. No weight changes, no
early satiety.
ROS otherwise negative.
Past Medical History:
Past OB History: G2P2, SVD x 1, LTCS x 1
Past Gyn History: Regular menses, denies history of sexually
transmitted infections. Denies history of abnormal Papsmears.
Last Pap was approximately ___ years ago and negative. Last
mammogram also approximately ___ years ago and negative.
Past medical history: reports history of provoked lower
extremity deep vein thrombosis in setting of knee surgery (did
not take anticoagulation)
Social History:
___
Family History:
Mother had a deep vein thrombosis in the setting of long plane
flight. Denies family history of ovarian, endometrial, cervical,
breast, or colon cancer.
Physical Exam:
Afebrile, vitals stable
No acute distress, comfortable, and conversing actively
CV: regular rate and rhythm
Pulm: clear to auscultation bilaterally
Abd: soft, appropriately tender, nondistended, vertical midline
incision clean/dry/intact with sutures, no rebound/guarding
___: nontender, nonedematous
Pertinent Results:
___ 04:36AM BLOOD WBC-11.8* RBC-2.86* Hgb-8.4* Hct-24.9*
MCV-87 MCH-29.4 MCHC-33.7 RDW-13.1 RDWSD-41.5 Plt ___
___ 07:05AM BLOOD WBC-12.1* RBC-3.69* Hgb-10.8* Hct-31.4*
MCV-85 MCH-29.3 MCHC-34.4 RDW-13.1 RDWSD-40.4 Plt ___
___ 09:11PM BLOOD WBC-11.6* RBC-4.11 Hgb-11.9 Hct-34.7
MCV-84 MCH-29.0 MCHC-34.3 RDW-13.0 RDWSD-39.6 Plt ___
___ 04:36AM BLOOD Neuts-78.5* Lymphs-13.9* Monos-7.0
Eos-0.1* Baso-0.1 Im ___ AbsNeut-9.26* AbsLymp-1.64
AbsMono-0.82* AbsEos-0.01* AbsBaso-0.01
___ 09:11PM BLOOD Neuts-78.1* Lymphs-16.1* Monos-5.0
Eos-0.2* Baso-0.3 Im ___ AbsNeut-9.03* AbsLymp-1.87
AbsMono-0.58 AbsEos-0.02* AbsBaso-0.04
___ 04:36AM BLOOD Glucose-130* UreaN-11 Creat-0.6 Na-139
K-3.8 Cl-106 HCO3-23 AnGap-14
___ 07:05AM BLOOD Glucose-91 UreaN-10 Creat-0.6 Na-138
K-3.7 Cl-107 HCO3-22 AnGap-13
___ 09:11PM BLOOD Glucose-99 UreaN-13 Creat-0.6 Na-138
K-3.8 Cl-106 HCO3-20* AnGap-16
___ 04:36AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.6
___ 07:05AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9
___ 09:11PM BLOOD CEA-<1.0 CA125-20
___ 12:12AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:12AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 12:12AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Blood Culture, Routine (Pending):
Brief Hospital Course:
Ms. ___ is a ___ yo G2P2 who initialy presented from outside
hospital for left lower quadrant pain and large pelvic mass who
was admitted to the gynecologic oncology service for further
evaluation. A pelvic US showed: large, left adnexal solid and
cystic mass, worrisome for malignancy. Nonvisualized left ovary,
precluding the exclusion of left ovary torsion, particularly in
the setting of large volume, complex free pelvic fluid which may
represent hemorrhage.
Due to the findings on ultrasound, the decision was made to
proceed with an exploratory laparotomy. Intraoperatively, a
torsed necrotic left ovary was noted, so the patient underwent a
left salpingo-oophorectomy. Please see the operative report for
full details.
Immediately postoperatively, her pain was controlled immediately
with an epidural, and advanced post operative day #1 to
Acetaminophen and Ibuprofen after epidural was removed. She
never required narcotics. Her diet was advanced without
difficulty to a regular diet immediately after her procedure. On
post-operative day #1, her urine output was adequate so her
Foley catheter was removed and she voided spontaneously. She was
ambulating independently during her hospital stay. She was
discharged home on post-operative day #2 in stable condition
with outpatient follow-up scheduled.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*50 Tablet Refills:*1
2. Ibuprofen 600 mg PO Q6H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*50 Tablet Refills:*1
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp
#*50 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*50 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
left adnexal mass
ovarian torsion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the gynecologic oncology service after
undergoing an exploratory laparotomy with left
salpingo-oophorectomy (removal of your left ovary and tube). You
have recovered well after your operation, and the team feels
that you are safe to be discharged home. Please follow these
instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* 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.
* Nothing in the vagina (no tampons, no douching, no sex) for 12
weeks.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* It is safe to walk up stairs.
.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
* If you have steri-strips, leave them on. If they are still on
after ___ days from surgery, you may remove them.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
10830961-DS-16
| 10,830,961 | 25,012,078 |
DS
| 16 |
2165-04-03 00:00:00
|
2165-04-03 18:36:00
|
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Demerol / Lipitor / Cipro / fentanyl
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/CAD, anxiety/depression, ___ disease presents
with cough. Pt unable to give details of his symptoms, but
according to the ED he reported that he had a common cold
approximately 10 days ago with residual cough that seemed to
worsen on ___. Cough has continued since ___ and is
productive of green mucus, all other cold symptoms have
resolved. His wife notes that he began wheezing yesterday which
has persisted through today. Patient denies any SOB, however he
is uncomfortable with labored breathing at times related to back
pain. Pt presented to his PCP for evaluation of the cough. CXR
was performed which showed ___ definite abnormality, and pt was
sent to ED.
___ recent travel or sick contacts, his only recent illness was
the cold which started approximately 10 days ago.
In ED pt desatting to low ___ on RA and pt with significant
wheezing on exam. Started duonebs, IVF, solumedrol and empiric
azithromycin for presumed CAP. also given 1L bolus.
On arrival to floor pt reports back pain. States breathing is
"as good as its been". ___ other complaints. Unable to confirm
above history.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
- CAD s/p cardiac catheterization in ___ showed RCA was
diffusely diseased with a 30% proximal lesion, a 50% mid lesion,
and a 90% distal lesion. Distal RCA stented w/ Taxus DES. LVEF
55%
- Type 2 diabetes mellitus
- Hypertension
- Hyperlipidemia - LDL 125 in ___
- ___ Disease
- Chronic Nasal Obstruction
- Obtructive Sleep Apnea
- Sacroiliitis, L4 to S1 fusion with L34 anterolisthesis
- Status post left rotator cuff surgery ___
Social History:
___
Family History:
- Mother: Died at ___ from CAD
- Father: Died at ___ from lymphoma
Physical Exam:
Vitals: T:97.4 BP:176/97 P:77 R:22 O2:93%ra
PAIN: 8
General: nad
Lungs: faint scattered wheezes
CV: rrr ___ m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: ___ e/c/c
Skin: healing abrasions on knees/shins
Neuro: alert, follows commands, resting tremor
PE at discharge
Afeb, VSS
Cons: NAD, sitting in chair, ___ sob with speaking
Eyes: EOMI, ___ scleral icterus
ENT: MMM
Cardiovasc: rrr, ___ edema
Resp: exp wheezes still present, but greatly diminished today
GI: +bs,soft, nt, nd
MSK: ___ significant kyphosis
mild ttp lower back, not a focal ttp point
Skin: ___ rashes
right shin area of erythema greatly improved from admit
Neuro: ___ facial droop
+masked facies +tremors, +ridigity in B arms
Psych: blunted affect
Pertinent Results:
___ 05:40PM GLUCOSE-105* UREA N-39* CREAT-1.7* SODIUM-137
POTASSIUM-5.2* CHLORIDE-102 TOTAL CO2-27 ANION GAP-13
___ 05:57PM LACTATE-0.8
___ 05:40PM WBC-8.9 RBC-4.30* HGB-12.4* HCT-41.2 MCV-96
MCH-28.8 MCHC-30.0* RDW-13.5
___ 05:40PM NEUTS-66.4 ___ MONOS-6.1 EOS-4.4*
BASOS-0.8
___ 05:40PM PLT COUNT-255
___ 07:30PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 07:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
___ 07:30PM URINE RBC-3* WBC-3 BACTERIA-FEW YEAST-NONE
EPI-<1
CXR IMPRESSION:
Limited study due to low lung volumes. Patchy opacities in the
lung bases likely reflect atelectasis, though the left lung base
is not completely imaged. Consider repeat PA and lateral views
with improved inspiratory effort when the patient is able to
better assess the lung bases.
CXR ___
FINDINGS: As compared to the previous radiograph, pre-existing
signs of mild
fluid overload have completely resolved. There currently is ___
evidence for
pulmonary edema. Low lung volumes. Normal size of the cardiac
silhouette.
___ pleural effusions. ___ pneumonia
echocardiogram ___:
LEFT ATRIUM: Moderate ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. ___ ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. ___ resting LVOT gradient. ___ VSD.
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Mildy dilated aortic root.
AORTIC VALVE: Mildly thickened aortic valve leaflets. ___ masses
or vegetations on aortic valve, but cannot be fully excluded due
to suboptimal image quality. ___ AS. ___ AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. ___ masses
or vegetations on mitral valve, but cannot be fully excluded due
to suboptimal image quality. ___ MS. ___ MR.
___ VALVE: Tricuspid valve not well visualized.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: ___ pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - poor parasternal views. Suboptimal
image quality - poor apical views. Suboptimal image quality -
body habitus. Suboptimal image quality - patient unable to
cooperate.
Conclusions
Suboptimal image quality. The left atrium is moderately dilated.
___ atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. There is ___ ventricular septal defect. The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets are mildly thickened (?#). ___
masses or vegetations are seen on the aortic valve, but cannot
be fully excluded due to suboptimal image quality. There is ___
aortic valve stenosis. ___ aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. ___ masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. ___ mitral
regurgitation is seen. There is ___ pericardial effusion.
Compared with the prior study (images reviewed) of ___, ___
clear change
Brief Hospital Course:
___ w/CAD, anxiety/depression, ___ disease presents
with cough, audible wheezing.
The pt underwent eval with CXR which did not show PNA. He was
placed on azithro and nebs as needed and did well clinically.
He had slow improvement of his scattered wheezes. Further, the
pt was noted to have mild confusion (worse than usual) upon
admit. This improved in the first 48 hours of the ___ hospital
stay and he returned to his baseline state. The patient was
found to have +blood culture. Eventually found to be strep
viridans. Echo was negative for vegetation and repeat blood cx
were negative. Vanc that was started was stopped due to ID
input.
Pt underwent ___ eval and recommended home ___. He returned to
home with his wife and will have ___, a home health aid to help
with bathing, and ___ home RN to check on vitals.
Cough:
bronchitis, treated with azithro. Occasional albuterol nebs did
not help pt's dyspne per the pt.
Back Pain: ___ recent mechanical fall
- cont home dilaudid
___ - attempted to keep at baseline with appropriate
timing of medications. will have home ___ to help with improving
mobility.
DM type 2
due to hypoglycemia in the AM, decreased the pt's ___ NPH
CAD/HTN/HLD: s/p Distal RCA DES. LVEF 55%
- continued home meds
Chronic Nasal Obstruction: cont home meds
Obtructive Sleep Apnea: not on CPAP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 25 Units Breakfast
NPH 60 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
2. Parcopa (carbidopa-levodopa) ___ mg oral QID
3. Selegiline HCl 5 mg PO DAILY
4. Donepezil 10 mg PO DAILY
5. Ropinirole 6 mg PO QAM
6. Ropinirole 4 mg PO DINNER
7. ClonazePAM 0.5 mg PO QHS
8. QUEtiapine Fumarate 12.5 mg PO DAILY
9. QUEtiapine Fumarate 50 mg PO HS
10. Sertraline 100 mg PO DAILY
11. Lorazepam 1 mg PO TID
12. Lorazepam 0.5 mg PO QAM
13. BuPROPion 150 mg PO BID
14. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q4H:PRN
pain
15. Furosemide 20 mg PO DAILY
16. Allopurinol ___ mg PO DAILY
17. Gabapentin 400 mg PO TID
18. Methocarbamol 750 mg PO QID
19. Metoprolol Succinate XL 25 mg PO DAILY
20. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
21. Losartan Potassium 25 mg PO DAILY
22. Nitroglycerin SL 0.3 mg SL PRN chest pain
23. Pravastatin 20 mg PO HS
24. Aspirin 81 mg PO DAILY
25. Restasis (cycloSPORINE) 0.05 % ophthalmic daily
26. Ditropan XL (oxybutynin chloride) 5 mg oral daily
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. BuPROPion 150 mg PO BID
4. ClonazePAM 0.5 mg PO QHS
5. Donepezil 10 mg PO DAILY
6. Gabapentin 400 mg PO TID
7. Glargine 25 Units Breakfast
NPH 40 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Lorazepam 1 mg PO TID
10. Lorazepam 0.5 mg PO QAM
11. Losartan Potassium 25 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Parcopa (carbidopa-levodopa) ___ mg oral QID
14. Pravastatin 20 mg PO HS
15. QUEtiapine Fumarate 12.5 mg PO DAILY
16. QUEtiapine Fumarate 50 mg PO HS
17. Ropinirole 6 mg PO QAM
18. Ropinirole 4 mg PO DINNER
19. Selegiline HCl 5 mg PO DAILY
20. Sertraline 100 mg PO DAILY
21. Methocarbamol 750 mg PO QID
22. Oxybutynin 5 mg PO TID
23. Artificial Tears Preserv. Free ___ DROP BOTH EYES TID
24. carboxymethylcellulose sodium 0.5 % ophthalmic 1 gtt ___ TID
25. Ditropan XL (oxybutynin chloride) 5 mg oral daily
26. Fluocinonide 0.05% Cream 1 Appl TP BID PRN itchy back
27. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q4H:PRN
pain
28. Hydrocortisone Cream 2.5% 1 Appl TP RECTALLY BID
29. moxifloxacin 400 mg ORAL DAILY X14 DAYS PRN cellulitis
30. Mupirocin Cream 2% 1 Appl TP TID:PRN skin
31. Nitroglycerin SL 0.4 mg SL PRN chest pain
32. Restasis (cycloSPORINE) 0.05 % ophthalmic TID
33. diclofenac sodium 1 % TOPICAL QID ON AFFECTED JOINTS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
bronchitis
___ disease
Discharge Condition:
alert, ambulatory
Discharge Instructions:
you were admitted with shortness of breath and wheezing in the
chest. you were found to have a bronchitis and given
azithromycin for an antibiotic and occasionally used albuterol
nebulizer to help the breathing. the initial confusion that you
had improved. there was found a bacteria in the blood called
strep viridans. We checked your heart valve to be sure that
there was not a collection of bacteria there. the infectious
disease specialist did not think that any further treatment was
needed for this. You were set up with a physical therapist, home
health aid, and RN to visit your home and be sure that you
continue to do well.
Followup Instructions:
___
|
10830961-DS-18
| 10,830,961 | 25,278,067 |
DS
| 18 |
2165-05-23 00:00:00
|
2165-05-24 08:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Demerol / Lipitor / Cipro / fentanyl
Attending: ___.
Chief Complaint:
___: fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo male with ___ disease, CAD, HTN, HL, and recent
admission for polypharmacy with subsequent down titration of his
sedating medications (narcotics were discontinued, and
___ medication doses were decreased) who now presents
status post 2 mechanical falls. The patient was recently
discharged from rehab after a 2 week stay. He was doing well at
home until the evening prior to admission when at approximately
8
pm he fell hitting his right side attempting to transfer to his
wheel chair. He did not have any pre-syncopal symptoms, head
strike or loss of consciousness. Pain was manageable so they
did
not bring him into the emergency department. Then at 3 am he was
getting up from bed to use the restroom when he again fell. Once
again there was no preceding dizziness, palpitations or chest
pain. There was no headstrike or loss of consciousness. Given
worsened right side pain his wife took home to ___ where
CT torso demonstrated a right rib fracture and a pulmonary
contusion. He required 2 doses of ativan in addition to
fentanyl
to tolerate the CT. He was subsequently noted to be very sleepy.
Per report this improved with a single dose of narcan. Vital
signs remained stable. He was transferred to ___ for trauma
eval.
Of note the patient is being followed by Dr. ___ ___
regarding a L1 compression fracture he was scheduled for an MRI
today. This was seem on CT torso from ___ and was unchanged
from prior. ___ discussed this with ___ did not feel he
needed further evaluation of the fracture at this time.
Past Medical History:
- CAD s/p cardiac catheterization in ___ showed RCA was
diffusely diseased with a 30% proximal lesion, a 50% mid lesion,
and a 90% distal lesion. Distal RCA stented w/ Taxus DES. LVEF
55%
- Type 2 diabetes mellitus
- Hypertension
- Hyperlipidemia - LDL 125 in ___
- ___ Disease
- Chronic Nasal Obstruction
- Obtructive Sleep Apnea
- Sacroiliitis, L4 to S1 fusion with L34 anterolisthesis
- Status post left rotator cuff surgery ___
Social History:
___
Family History:
- Mother: Died at ___ from CAD
- Father: Died at ___ from lymphoma
Physical Exam:
PHYSICAL EXAMINATION: ___ upon admission:
HR: 78 BP: 136/65 O(2)Sat: 95
Constitutional: Somnolent but arousable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
Normal
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft
GU/Flank: Normal
Extr/Back: Normal
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood
Physical examination upon dicharge: ___
vital signs: t 976, hr=83, bp=137/65, rr=18, oxygen sat= 98%
General: sitting comfortably in chair, NAD
CV: ns1,s2, -s3 -s4
LUNGS: clear
ABDOMEN: soft, non-tender
EXT: hyper-pigmentation ant. aspect of lower ext. bil., no
pedal edema bil, no calf tenderness bil
NEURO: alert and oriented x 3, speech clear, tremors of upper
ext. bil.
Pertinent Results:
___ 05:50AM BLOOD WBC-6.4 RBC-4.65 Hgb-13.9* Hct-44.7
MCV-96 MCH-29.8 MCHC-31.0 RDW-13.6 Plt ___
___ 09:50AM BLOOD Neuts-69.8 ___ Monos-7.3 Eos-2.0
Baso-1.0
___ 05:50AM BLOOD Plt ___
___ 05:50AM BLOOD ___ PTT-29.6 ___
___ 05:50AM BLOOD Glucose-196* UreaN-46* Creat-1.3* Na-135
K-4.4 Cl-101 HCO3-24 AnGap-14
___ 09:50AM BLOOD Glucose-155* UreaN-55* Creat-1.6* Na-136
K-4.6 Cl-105 HCO3-21* AnGap-15
___ 09:50AM BLOOD ALT-8 AST-19 AlkPhos-109 TotBili-0.6
___ 05:50AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.3
___ 10:16AM BLOOD Lactate-1.5
___ 10:16AM BLOOD O2 Sat-80
___: EKG:
Marked baseline artifact. Indeterminate rhythm. Right
bundle-branch block.
Overall poorly interpretable tracing. Compared to the previous
tracing is
difficult.
TRACING #1
___: chest x-ray:
IMPRESSION: Patient is rotated to the left. Low lung volumes.
Patchy right upper lobe opacity again seen. Difficult to
exclude small bilateral pleural effusions, although none seen on
preceding chest CT.
___: chest x-ray:
Resolution of right upper lobe opacity may have been due to
contusion or aspiration.
Brief Hospital Course:
The patient was admitted to the hospital after a mechanical
fall. There was no head-strike or loss of consciousness. He was
evaluated at an outside facility and underwent imaging. Prior to
imaging, he received ativan and fentanyl for sedation and became
very sleepy requiring narcan. On imaging, he was reported to
have a lung contusion as well as a lumbar vertebral fracture.
In the emergency room, no neurologic deficits were identified.
He was evaluated by the Spine service for his lumbar fracture,
and no surgical intervention was indicated. He was transferred
here for pain management and pulmonary toilet.
The ___ hospital course was stable. On chest x-ray, he
was noted to have a right upper lobe opacity, which on repeat
scan had resolved. His pulmonary status was closely monitored
and he demonstarted no signs of oxygen desaturation. His
medication list was reviewed and revisions made in his
___ medications and his narcotic regimen. His mental
status improved after discontinuation of the narcotic pain
medication and recommendations made to avoid narcotics. The
patient was evaluated by physical therapy and recommendations
made for discharge to a rehabilitation center where he could
further regain his strength and progress to his baseline status.
The patient's vital signs were stable and he was afebrile. He
was tolerating a regular diet. His white blood cell count
remained within normal limits. THe patient was discharged on HD
#6 in stable condition. An outpatient appointment was made for
follow-up with the acute care service, and with the spine
service.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO QHS
3. BuPROPion 150 mg PO BID
4. ClonazePAM 0.5 mg PO QHS
5. Donepezil 10 mg PO Q11AM
6. Gabapentin 400 mg PO TID
7. Glargine 25 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Lorazepam 0.5 mg PO QAM
10. Lorazepam 1 mg PO TID
11. Losartan Potassium 25 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Parcopa (carbidopa-levodopa) 50-200 mg oral TID
14. Parcopa (carbidopa-levodopa) ___ mg ORAL Q11PM
15. QUEtiapine Fumarate 12.5 mg PO 11AM
16. QUEtiapine Fumarate 50 mg PO QHS
17. Sertraline 100 mg PO DAILY
18. Lidocaine 5% Patch 1 PTCH TD QPM
19. Mupirocin Ointment 2% 1 Appl TP TID:PRN as directed
20. Nitroglycerin SL 0.4 mg SL PRN chest pain
21. Pravastatin 20 mg PO HS
22. Restasis (cycloSPORINE) 0.05 % ophthalmic TID
23. Ropinirole 4 mg PO QAM
24. Ropinirole 2 mg PO QPM
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO QHS
3. BuPROPion 150 mg PO BID
4. ClonazePAM 0.5 mg PO QHS
5. Donepezil 10 mg PO Q11AM
6. Gabapentin 400 mg PO TID
7. Glargine 25 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Lidocaine 5% Patch 1 PTCH TD QPM
10. Lorazepam 0.5 mg PO QAM
11. Lorazepam 1 mg PO TID
12. Losartan Potassium 25 mg PO DAILY
13. Metoprolol Succinate XL 25 mg PO DAILY
14. Mupirocin Ointment 2% 1 Appl TP TID:PRN as directed
15. Parcopa (carbidopa-levodopa) 50-200 mg oral TID
16. Parcopa (carbidopa-levodopa) ___ mg ORAL Q11PM
17. Pravastatin 20 mg PO HS
18. QUEtiapine Fumarate 12.5 mg PO 11AM
19. QUEtiapine Fumarate 50 mg PO QHS
20. Restasis (cycloSPORINE) 0.05 % ophthalmic TID
21. Sertraline 100 mg PO DAILY
22. Acetaminophen 1000 mg PO Q8H
23. Heparin 5000 UNIT SC TID
24. Levothyroxine Sodium 50 mcg PO DAILY
25. Nitroglycerin SL 0.4 mg SL PRN chest pain
26. Requip XL (rOPINIRole) 6 mg oral QAM
27. Requip XL (rOPINIRole) 2 mg oral DAILY
please give at 4pm
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Trauma: fall:
Right pulmonary contusion
Right 7th rib fracture
L1 fracture (OLD - from ___
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:
___ were admitted to the hospital after falling from your
wheel-chair and while attempting to get out of bed landing on
your right side. ___ sustained a bruise to your lung and a
right rib fracture. ___ were also noted to have an L1 compresson
fracture. No further treatment indicated by this fracture. ___
were seen by physical therapy and recommendations made for
discharge to an extended care facility.
Followup Instructions:
___
|
10831845-DS-14
| 10,831,845 | 26,846,576 |
DS
| 14 |
2122-05-07 00:00:00
|
2122-05-07 12:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Intraabdominal fluid collections, ___ drain fell out
Major Surgical or Invasive Procedure:
___:
PROCEDURE: CT-guided abdominal abscess aspiration.
History of Present Illness:
Mr ___ is a very pleasant ___ year old gentleman, well-known
the ___ surgery service from his recent operation and
hospitalization. Please refer to the discharge summary from
___ for full details of his hospital course. He has been
doing well at rehab and returned to clinic for a follow-up visit
last
week. At that time, one of his drains had inadvertantly fallen
out. Plan was to follow up with interventional radiology today
to assess drains and existing fluid collections. Mr ___ is
transferred to the ___ ED today after concern for an episode
of confusion at his rehab facility as well as a low grade
temperature. He does not recall this episode now, but does feel
that he is back at his baseline. His pain is controlled and he
is tolerating a regular diet. He is working on gaining his
strength back at rehab.
Past Medical History:
1. Pancreatic Adenocarcinoma
2. Hypertension
3. Hyperlipidemia
4. Chronic Back Pain
5. Occasional tremors
6. Pancreatic insufficiency
Social History:
___
Family History:
Father: lung cancer, died at the age ___ from lung cancer
Sister: thyroid cancer
Brother: "abdominal" cancer, from which he died.
Physical Exam:
Prior to discharge:
VS: 98.1, 62, 135/65, 18, 98% RA
GEN: Pleasant with NAD
CV: RRR
PULM: CTAB
ABD: Midline incision healing well, inferior part with
moist-to-dry dressing. Right flank PTBD catheter capped. RLQ old
___ site with small urostomy bag and minimal purulent drainage.
JP to bulb suction and site with mild erythema.
EXTR: 2+ pitting edema bilateral ___.
Pertinent Results:
___ 03:55AM BLOOD WBC-19.8* RBC-2.68* Hgb-8.1* Hct-24.8*
MCV-93 MCH-30.2 MCHC-32.7 RDW-15.6* RDWSD-52.9* Plt ___
___ 04:32AM BLOOD WBC-18.0* RBC-2.53* Hgb-7.6* Hct-23.5*
MCV-93 MCH-30.0 MCHC-32.3 RDW-15.4 RDWSD-52.5* Plt ___
___ 05:50AM BLOOD WBC-19.4* RBC-2.98* Hgb-9.1* Hct-27.6*
MCV-93 MCH-30.5 MCHC-33.0 RDW-15.6* RDWSD-52.8* Plt ___
___ 03:55AM BLOOD Glucose-92 UreaN-28* Creat-0.8 Na-139
K-4.6 Cl-109* HCO3-22 AnGap-13
___ 04:32AM BLOOD Glucose-110* UreaN-21* Creat-0.7 Na-139
K-4.5 Cl-110* HCO3-22 AnGap-12
___ 05:50AM BLOOD Glucose-118* UreaN-24* Creat-0.7 Na-134
K-3.9 Cl-103 HCO3-20* AnGap-15
___ 05:45AM BLOOD Glucose-159* UreaN-26* Creat-0.7 Na-139
K-4.5 Cl-105 HCO3-26 AnGap-13
___ 04:32AM BLOOD ALT-14 AST-20 AlkPhos-92 TotBili-0.4
___ 05:50AM BLOOD ALT-15 AST-15 AlkPhos-83 TotBili-0.5
___ 04:32AM BLOOD Albumin-2.0* Calcium-8.0* Phos-3.7 Mg-1.9
___ 05:50AM BLOOD Albumin-2.0* Calcium-8.0* Phos-3.5 Mg-1.7
___ 05:45AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.9
___ 05:50AM BLOOD Vanco-14.9
___ 4:30 pm ABSCESS INTRAABDOMINAL ABSCESS RLR.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ SHORT CHAINS.
2+ ___ per 1000X FIELD): BUDDING YEAST.
WOUND CULTURE (Preliminary):
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
___ CT ABD:
FINDINGS:
1. Interval decrease ___ size of the collection adjacent the
duodenum,
containing small locules of air.
2. Sinus tract from the skin, leading to it a tiny abdominal
sidewall
collection.
3. Interval decrease ___ the size of the right lower quadrant
collection post aspiration.
IMPRESSION: Uneventful CT guided aspiration of a right lower
quadrant collection.
___ ___ US:
IMPRESSION: Preliminary Report:
Limited visualization of the bilateral peroneal veins. Otherwise
no
evidence of deep venous thrombosis ___ the visualized bilateral
lower extremity veins. Bilateral subcutaneous edema.
Brief Hospital Course:
The patient well know for ___ service was admitted from
rehabilitation after his ___ drain fell out. On ___, the
patient underwent CT-guided aspiration of the right lower
quadrant collection. The fluid was sent for microbiology
evaluation. Patient was restarted on Vancomycin, Meropenem, TPN
and diet was advanced to regular. Fluid gram stain was positive
for budding yeast and patient was started on Fluconazole. On HD
2, patient was transfused with 2 units of pRBc for HCT 23.5,
post transfusion HCT was 29.9. On HD 3, patient was noticed to
have small purulent drainage from his old ___ site and ostomy bag
was applied to the site. Radiology was consulted for possible
new drain placement, and after discussion drain placement was
differed. Patient's dose of Lasix was reduced to 40 mg BID as
his weight still coming down to goal (89 kg). On PO 4, patient
was discharged back ___ rehabilitation facility.
During this hospitalization, the patient ambulated early and
frequently with assist, was adherent with respiratory toilet and
incentive spirrometry, and actively participated ___ the plan of
care. The patient received subcutaneous heparin and venodyne
boots were used during this stay. The patient's blood sugar was
monitored regularly throughout the stay; sliding scale insulin
was administered when indicated. Labwork was routinely followed;
electrolytes were repleted when indicated.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with RW and assist 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. Calcium Carbonate 500 mg PO QID:PRN heartburn
2. Citalopram 10 mg PO DAILY
3. Creon 12 2 CAP PO TID W/MEALS
4. Docusate Sodium 100 mg PO BID
5. Ertapenem Sodium 1 g IV ONCE Duration: 1 Dose
6. Furosemide 80 mg PO BID
8. Insulin SC
Sliding Scale
9. Megestrol Acetate 400 mg PO BID
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Octreotide Acetate 100 mcg SC Q8H
12. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting
13. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*100 Tablet Refills:*0
14. Pantoprazole 40 mg PO Q24H
15. PrimiDONE 50 mg PO DAILY
16. Senna 8.6 mg PO BID
17. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
18. Sodium Chloride 0.9% Flush 20 mL IV X1 PRN For PICC
insertion
19. Spironolactone 50 mg PO BID
20. Tamsulosin 0.4 mg PO QHS
21. Vancomycin 750 mg IV Q 12H
22. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
23. amlodipine-benazepril ___ mg oral DAILY
Discharge Medications:
1. Citalopram 10 mg PO DAILY
2. Creon 12 2 CAP PO TID W/MEALS
3. Ferrous Sulfate 325 mg PO DAILY
4. Fluconazole 200 mg PO Q24H
5. Ertapenem Sodium 1 g IV DAILY
6. Furosemide 40 mg PO BID
Please stop Lasix if patient's weight will reach 89 kg.
7. Gabapentin 600 mg PO QHS
8. Heparin 5000 UNIT SC TID
9. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
10. Megestrol Acetate 400 mg PO BID
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Octreotide Acetate 100 mcg SC Q8H
13. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
14. Pantoprazole 40 mg PO Q12H
15. PrimiDONE 50 mg PO DAILY:PRN tremors
16. Spironolactone 50 mg PO BID
17. Tamsulosin 0.4 mg PO QHS
18. Vancomycin 750 mg IV Q 12H
please follow up Vanc trough weekly
19. Insulin SC
Sliding Scale
Fingerstick q6h
Insulin SC Sliding Scale using REG Insulin
20. amlodipine-benazepril ___ mg oral DAILY
21. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Pancreatic ductal adenocarcinoma
2. Intraabdominal abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
+ assist).
Discharge Instructions:
You were admitted to the surgery service at ___ after your ___
drain fell out ___ Rehabilitation. You underwent ___ aspiration of
your intraabdominal fluid collection. You have done well ___ the
post procedure period and are now safe to return back ___
rehabilitation facility to complete your recovery with the
following instructions:
.
Please ___ Dr. ___ office at ___ if you have any
questions or concerns.
.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
Incision Care:
*Please change dressing on inferior part of the wound with
moist-to-dry gauze daily.
*Please ___ your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
.
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 ___ the drain. ___
the doctor, ___, or ___ nurse if the amount
increases significantly or changes ___ 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 ___
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
PICC Line:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE ___ THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your ___ Nurse if the dressing comes undone or is
significantly soiled for further instructions.
.
PTBD catheter care: Keep capped. Make sure to keep the drain
attached securely to your body to prevent pulling or
dislocation.
Change drain sponge daily.
.
Ols ___ drain site: Covered with small ostomy bag. Please empty
bag frequently.
Followup Instructions:
___
|
10831845-DS-15
| 10,831,845 | 21,427,435 |
DS
| 15 |
2122-07-03 00:00:00
|
2122-07-03 17:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
___:
1. Ultrasound-guided access of the left common femoral vein.
2. Venogram of the inferior vena cava.
3. Placement of a ___ Denali inferior vena cava filter.
History of Present Illness:
The patient is a ___ with pancreatic cancer s/p attempted
Whipple,
complicated by an anastomotic leak from the hepaticojej, abscess
formation which required ___ guided drainage, and development of
jejunal fistulae, was transferred from OSH ED with concern for
sepsis. Patient was most recently discharged from ___ on
___ to rehab, returned home 2 days prior to current
presentation. He reports two days of fatigue, poor PO intake,
and near-syncopal episode 1 day prior to presentation at home.
He felt dizzy while
trying to get out of bed with his wife, was tachycardic to 150s,
with systolic blood pressure in the ___ per visiting nurse. He
presented to ___ ED with Temp 98.8, HR 144, BP
103/64, RR ___ O2 98% RA
His labs were notable for leukocytosis of 22, elevated BUN and
creatinine, and UA positive for leukocyte esterase (no urine
culture was sent). CT A/P with oral contrast was done and he was
transferred to ___ with concern for ? jejunal fistula.
Past Medical History:
1. Pancreatic Adenocarcinoma
2. Hypertension
3. Hyperlipidemia
4. Chronic Back Pain
5. Occasional tremors
6. Pancreatic insufficiency
Social History:
___
Family History:
Father: lung cancer, died at the age ___ from lung cancer
Sister: thyroid cancer
Brother: "abdominal" cancer, from which he died.
Physical Exam:
Prior to Discharge:
VS: ___.6, 65, 156/74, 18, 96% RA
GEN: Pleasant with NAD
CV: RRR, no m/r/g
PULM: CTAB
ABD: Incision well healed, RUQ and right flank fistulas covered
by pediatric urostomy bags with monimal purulent drainage.
EXTR: RLE swollen, + PP.
Pertinent Results:
___ 01:24AM BLOOD WBC-33.3*# RBC-2.66* Hgb-8.2* Hct-24.0*
MCV-90 MCH-30.8 MCHC-34.2 RDW-14.6 RDWSD-47.4* Plt ___
___ 04:30AM BLOOD WBC-15.3* RBC-2.52* Hgb-7.6* Hct-23.5*
MCV-93 MCH-30.2 MCHC-32.3 RDW-13.9 RDWSD-47.2* Plt ___
___ 04:30AM BLOOD Glucose-87 UreaN-13 Creat-0.7 Na-137
K-4.2 Cl-102 HCO3-26 AnGap-13
___ 04:53AM BLOOD ALT-28 AST-20 AlkPhos-97 TotBili-0.4
___ ___ US:
IMPRESSION:
1. Extensive deep venous thrombosis involving the right lower
extremity
extending from the common femoral vein into the superficial and
deep femoral veins, popliteal vein, and the calf veins. The
proximal extent of the thrombus cannot be adequately assessed on
this study.
2. No deep venous thrombosis in the left lower extremity.
___ CT ABD:
IMPRESSION:
1. Right lower extremity venous thrombosis extends to the common
femoral/external iliac vein junction, and its nonocclusive at
this level. The remainder of the external iliac vein is patent.
2. Abdominal postoperative changes as described above.
3. No significant change of the pancreatic head mass.
___ ECG:
Sinus tachycardia. Prior inferior wall myocardial infarction. No
major change from the previous tracing.
___ CTA CHEST:
IMPRESSION:
1. Pulmonary embolus within the posterior basal branch of the
right lower lobe pulmonary artery. No evidence of right heart
strain or pulmonary infarction.
2. Known pancreatic head mass is better demonstrated on prior
studies.
3. Partially imaged postoperative changes in the upper abdomen.
Unchanged intrahepatic biliary dilation.
4. Probable 1.2 cm left thyroid nodule, which could be further
evaluated with ultrasound non urgently.
Brief Hospital Course:
The patient with history of unresectable cancer was admitted to
the Surgical Oncology Service for treatment of dehydration and
___. The OSH CT scan revealed intraabdominal fluid collections
seen on previous CT scan, no new fistulas. Patient has a long
history of infected intraabdominal fluid collection with known
EC fistula (hepaticojejunostomy to old ___ tract), and
continued to follow by ID as outpatient for this. ID was
contacted, and per ID patient was started on
___. Patient was rehydrated with IV fluid and
his Cre returned back to normal limits. Patient diet was
advanced to regular diet and calories count was started.
Vancomycin was changed to Daptomycin on HD 3 per ID. Patient
remained afebrile with leukocytosis. Wound care consult was
called for fistula care and small urostomy pouch were applied on
two small EC fistulas with minimal daily output. Patient was
noticed to have orthostatic hypotension, thought to be secondary
to chronic anemia and general decondition. On HD 4, patient was
ordered to receive 2 units of pRBC for HCT 23.1. During
transfusion patient developed low grade fever and transfusion
was aborted per hospital policy. He received one unit of pRBC,
his orthostatic hypotension improved after blood transfusion. On
HD 5, during work up with ___ patient was noticed to have swollen
right lower extremity with positive ___ sign. Doppler
evaluation demonstrated extensive RLE DVT. Patient was started
on therapeutic Lovenox and vascular surgery was consulted.
Vascular surgery recommended to continue Lovenox, surgery was
deferred at this time. On HD 6, patient developed tachycardia,
which did not responded to fluid bolus. Tachycardia continued on
HD 7, ECG revealed sinus tachycardia. On HD 8, patient continued
to be tachycardic and CTA chest was obtained. CTA was positive
for right lower lobe PE. Vascular surgery was reconsulted for
possible IVC filter placement. On HD 9, patient underwent
placement of IVC filter. On HD 10, patient was evaluated by ___,
and ___ recommended discharge in rehabilitation. Prior discharge
in rehabilitation, patient received one unit of pRBC for HCT
23.5. He was noticed to have tachycardia with exertion and
Cardiology was consulted. Patient home dose Lopressor was
increased, and he was recommended to follow up with his
outpatient cardiologist, and continue on Lovenox.
By the systems:
Neuro: Pain well controlled with PO medications.
CV: Tachycardia with physical activity, thought to be secondary
to PE and decondition. Toprol increased to 37.5 qd per
cardiology.
Pulmonary: Diagnosed with right PE, O2 Sats within normal limits
on room air.
GI: Tolerates regular diet.
ID: Patient has chronic hepatico-jejunostomy fistula. Currently
on ___, ID continue to follow as outpatient. Prior to
discharge remained afebrile with mild leukocytosis.
Endocrine: Continue on sliding scale insulin.
Hematology: Patient received 2 units of pRBC during admission
for anemia of chronic disease. HCT stable low. Started on
Lovenox for PE, RLE DVT, and IVC filter was placed. Not
transitioned to Warfarin secondary for possible chemotherapy in
the future.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, able to transfer from bed to chair with assist, 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:
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Citalopram 10 mg PO DAILY
3. Creon 12 2 CAP PO TID W/MEALS
4. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 0.8 mL SQ twice daily Disp #*60
Syringe Refills:*0
5. Fluconazole 400 mg PO Q24H
stop after ___
RX *fluconazole [Diflucan] 200 mg 2 tablet(s) by mouth daily
Disp #*64 Tablet Refills:*0
6. Gabapentin 600 mg PO QHS
7. Ertapenem Sodium 1 g IV DAILY
stop after ___
RX *ertapenem [Invanz] 1 gram 1 g IV daily Disp #*32 Vial
Refills:*0
8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*40
Tablet Refills:*0
9. Pantoprazole 40 mg PO Q24H
10. Pravastatin 40 mg PO QPM
11. PrimiDONE 50 mg PO DAILY:PRN tremors
12. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
13. Tamsulosin 0.4 mg PO QHS
14. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
15. Vancomycin 750 mg IV Q 12H
please check trough before 4 th dose ___ AM. stop after
___
RX *vancomycin 750 mg 750 mg IV every 12 hours Disp #*64 Vial
Refills:*0
16. Zolpidem Tartrate 5 mg PO QHS
17. Metoprolol Succinate XL 37.5 mg PO DAILY
18. Insulin SC
Sliding Scale
Fingerstick Q6H
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Unresectable pancreatic ductal carcinoma.
2. Failure to thrive.
3. Enterocutaneous fistula.
4. Right lower extremity DVT.
5. Dehydration
6. Pulmonary emboli
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the surgery service at ___ for evaluation
of your leukocytosis and near syncopal episode. You were started
on IV antibiotics to treat your known enterocutaneous fistula.
During hospitalization, you were found to have right leg DVT and
were started on anticoagulation therapy with Lovenox. You are
now safe to return HOME or REHABILITATION to complete your
recovery with the following instructions:
.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
.
Please ___ your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. ___ 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.
.
PICC Line:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your ___ Nurse if the dressing comes undone or is
significantly soiled for further instructions.
.
Fistula care: Continue to drain fistulas into small urostomy
bags. Empty bags and record an output. Make sure to keep the
drain attached securely to your body to prevent pulling or
dislocation.
Followup Instructions:
___
|
10831915-DS-14
| 10,831,915 | 23,789,573 |
DS
| 14 |
2130-05-10 00:00:00
|
2130-05-10 18:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Leg weakness
Major Surgical or Invasive Procedure:
Bone marrow biopsy ___
Muscle biopsy ___
History of Present Illness:
___ is an otherwise healthy ___ presenting to the ED
with c/o bilateral leg weakness and fever.
She states that she first began to get sick with URI symptoms
around ___. She was ultimately seen at urgent care, diagnosed
with Influenza A, and started on Tamiflu. She reports feeling
back to baseline after completing her course of Tamiflu. Soon
after this, she began developing lower extremity soreness,
swelling and subsequently weakness. She feels these symptoms
came
on gradually over the ___ weeks after completing tamiflu. She
describes "dark," concentrated-looking urine but no foamy urine.
On the night of ___, she had vivid nightmares, prompting her to
return to urgent care. Given her weakness, she was sent to the
ED
at ___ on ___ where she was found to have CK ___
and transaminitis concerning for rhabdomyolysis. She was given
IVF discharged about 8 hours afterwards with instructions to
drink a lot of fluids.
Since being discharged she followed with her PCP ___ ___ days
to ensure resolution of her rhabdo, however her lower-extremity
weakness has persisted over this time, and she subsequently
developed upper extremity weakness. She has fallen 4 times over
this time. She has had some slurred speech, but no change in
vision or sensation. She has not had any chest pain, shortness
of
breath, abdominal pain, vomiting, dysuria, melena, hematochezia.
She endorses 2 episodes of diarrhea ~1 week ago which have since
resolved. She has not taken any OTC medications. No recent
travel. No sick contacts other than her nephew who has an ear
infection for which he is currently being treated. She denies
any
tick or spider bites.
At ___, she was febrile to 103. Labs were notable
for hematocrit 28.4, CK 13,781, AST 1181, ALT 295, creatinine
1.6, troponin I 0.08, without ischemic changes on her EKG.
Echocardiogram revealed a small pericardial effusion. NIF was
-40. She underwent lumbar puncture with glucose 64, protein 23,
cell count (tube 1): 342 RBC, 3 WBC, (tube 4): 1 RBC, 1 WBC.
She
was started on broad-spectrum antibiotics, including vancomycin,
ceftriaxone, and ampicillin. She received 3 L IV fluids and was
transferred to ___ for further evaluation.
In the ED,
Initial Vitals: T98, HR 94, BP 85/41, RR 15, 99% RA
Exam:
Bilateral ___ quadriceps strength ___, diminished patellar
reflexes, no appreciable clonus, down-going Babinski
bilaterally,
mild/moderate bilateral ___ edema, sensation to light touch
intact
Bilateral UE biceps strength ___, sensation to light touch
intact
No spinal midline tenderness
Skin warm and dry, no appreciable rash
NIF -40
Labs:
WBC 3.3, H/H 7.7/243., Plt 157
Na 130, K 4.0, Cl 103, HCO3 17, BUN 28, Cr 1.2, Ca 6.5, Mg 2.1
ALT 170, AST 817, AP 123, Tbili 0.7, Albumin 1.8, Lipase 583, LD
1278
PTT 44.3, INR 1.5
Serum tox: acetaminophen 10, otherwise negative
CK ___
Trop 0.78, MB 25
CRP 7.8
VBG ___
lactate 0.8
Flu A/B negative
OSH labs:
LP results:
-- Glucose 64
-- Protein 23
-- Cell count (tube 1): 342 RBC, 3 WBC
-- Cell count (tube 4): 1 RBC, 1 WBC
-- CSF culture / gram stain pending
CRP/ESR were not elevated
HIV screen (done as outpatient ___ negative
Hep A IgG was reactive (___), no IgM ordered
Hep B surface Ab positive (___)
Hep C non-reactive (___)
Imaging:
Bedside ultrasound with trace pericardial effusion, good EF
Consults:
Neurology
Interventions:
-Started on peripheral levophed for SBP ___
-bicarb gtt started for rhabdo
VS Prior to Transfer:
HR 75, BP 103/60, RR 19, 99% RA
On arrival to the ICU, the patient has no new acute complaints.
Past Medical History:
- Influenza A diagnosed ___
- Sickle cell trait
Social History:
___
Family History:
Grandmother has ___ disease, CKD, HTN, and
gout. Mother has hyperlipidemia and ___ thyroiditis. No
family history of neurological illness.
Physical Exam:
ADMISSION EXAM:
===============
VS: reviewed in metavision
GEN: Tired-appearing, lying in bed, NAD
EYES: No scleral icterus, EOMI, PERRLA
HENNT: NCAT, no JVD
CV: RRR, ?S4 gallop, no r/m
RESP: Bibasilar crackles, respiratory effort normal
GI: Soft, NTND
EXT: 2+ ___ edema, 1+ UE edema
SKIN: WWP
NEURO: AO x 3. CN II-XII intact. Decreased tone throughout.
Sensation intact throughout. Distal LEs with ___ strength
bilaterally. ___ strength LLE, 1+/5 RLE. ___ grip strength
bilaterally, L>R, 4+/5 L biceps/triceps, ___ R biceps/triceps.
1+
Achilles reflexes bilaterally, ?1+ bilateral patellar reflexes,
although previously described as absent, and exam performed
while
patient lying in bed. UE reflexes 2+, equal. Toes mute
bilaterally.
DISCHARGE EXAM:
================
VS: 24 HR Data (last updated ___ @ 747)
Temp: 98.8 (Tm 99.9), BP: 120/80 (110-122/62-82), HR: 122
(114-122), RR: 16 (___), O2 sat: 100% (99-100), O2 delivery:
RA
GEN: sitting up in bed, NAD.
HEENT: No scleral icterus, MMM. Tongue with some yellowing. Some
small white patches on inside cheeks, improved.
CV: tachycardic, regular rhythm, no murmurs/rubs/gallops.
PULM: CTAB, no crackles/wheezing/rhonchi.
GI: Soft, NTND.
EXT: Warm, pitting bipedal edema, improved.
NEURO: ___ strength in ___
Pertinent Results:
ADMISSION LABS:
================
___ 03:45AM BLOOD WBC-3.3* RBC-3.18* Hgb-7.7* Hct-24.3*
MCV-76* MCH-24.2* MCHC-31.7* RDW-18.7* RDWSD-43.0 Plt ___
___ 03:45AM BLOOD Neuts-59.8 ___ Monos-7.1 Eos-0.0*
Baso-0.3 NRBC-0.6* Im ___ AbsNeut-1.95 AbsLymp-0.93*
AbsMono-0.23 AbsEos-0.00* AbsBaso-0.01
___ 07:53AM BLOOD Hypochr-1+* Anisocy-2+* Poiklo-3+*
Microcy-1+* Ovalocy-1+* Target-1+* Schisto-1+* Echino-2+* RBC
Mor-SLIDE REVI
___ 03:45AM BLOOD ___ PTT-44.3* ___
___ 07:53AM BLOOD Fibrino-80*
___ 07:53AM BLOOD Ret Aut-1.2 Abs Ret-0.04
___ 03:45AM BLOOD Glucose-129* UreaN-28* Creat-1.2* Na-130*
K-4.0 Cl-103 HCO3-17* AnGap-10
___ 03:45AM BLOOD ALT-170* AST-817* LD(LDH)-1278*
___ AlkPhos-123* TotBili-0.7
___ 03:45AM BLOOD Lipase-583*
___ 03:45AM BLOOD CK-MB-25* MB Indx-0.2 cTropnT-0.78*
___ 01:48PM BLOOD CK-MB-38* cTropnT-0.70*
___ 04:25PM BLOOD cTropnT-0.67*
___ 03:45AM BLOOD TotProt-4.9* Albumin-1.8* Globuln-3.1
Calcium-6.5* Mg-2.1
___ 07:53AM BLOOD calTIBC-130* Hapto-<10* Ferritn-3408*
TRF-100*
___ 03:45AM BLOOD TSH-4.4*
___ 03:45AM BLOOD CRP-7.8*
___ 03:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-10
Tricycl-NEG
___ 04:15AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 06:57AM URINE Color-Straw Appear-Hazy* Sp ___
___ 06:57AM URINE Blood-MOD* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:57AM URINE RBC-1 WBC-0 Bacteri-MOD* Yeast-NONE
Epi-<1
___ 06:57AM URINE Hours-RANDOM Creat-29 Na-<20 TotProt-28
Prot/Cr-1.0*
PERTINENT LABS:
===============
___ 07:25AM BLOOD Hb A-59.2 Hb S-35.0* Hb C-0 Hb A2-3.3 Hb
F-2.5*
___ 07:25AM BLOOD Sickle-POS*
___ 08:15AM BLOOD Parst S-NEGATIVE
___ 08:15AM BLOOD proBNP-6316*
___ 03:45AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-POS*
___ 03:31AM BLOOD IgM HAV-NEG
___ 07:25AM BLOOD ANCA-NEGATIVE B
___ 07:53AM BLOOD ___
___ 07:25AM BLOOD ___ CRP-6.5*
___ 10:25AM BLOOD dsDNA-NEGATIVE
___ 08:35AM BLOOD RheuFac-23*
___ 08:35AM BLOOD PEP-MILD POLYC IgG-1747* IgA-163 IgM-85
___ 03:31AM BLOOD C3-27* C4-6*
___ 07:25AM BLOOD C3-28* C4-6*
___ 06:45AM BLOOD C3-37* C4-8*
___ 07:27AM BLOOD C3-33* C4-7*
___ 03:45AM BLOOD CMV IgG-NEG CMV IgM-NEG CMVI-There is n
EBV IgG-POS* EBNA-POS* EBV IgM-NEG EBVI-Results in
___ 05:11PM BLOOD Trep Ab-NEG
___ 08:15AM BLOOD Lyme Ab-NEG
___ 05:11PM BLOOD HIV Ab-NEG
___ 03:45AM BLOOD HCV Ab-NEG
___ 08:15AM BLOOD HIV1 VL-Not Detect
___ 12:54PM BLOOD CMV VL-NOT DETECT
___ 07:53
SED RATE
___ Result Reference
Range/Units
SED RATE BY MODIFIED 6 < OR = 20 mm/h
___
___ 07:53
HEPATITIS E ANTIBODY (IGG)
___ Result Reference
Range/Units
HEPATITIS E ANTIBODY (IGG) NOT DETECTED
___ 07:53
ALDOLASE
___ Result Reference
Range/Units
ALDOLASE 11.4 H <=8.1 U/L
___ 07:53
ANTI-JO1 ANTIBODY
___ Result Reference
Range/Units
___ ANTIBODY <1.0 NEG <1.0 NEG AI
___ 07:53
MYOSITIS ANTIBODY PROFILE
___ Result Reference
Range/Units
___ AB <11 < 11 SI
PL-7 AB <11 < 11 SI
PL-12 AB <11 < 11 SI
EJ AB <11 < 11 SI
OJ AB <11 < 11 SI
SRP AB <11 < 11 SI
MI-2 ALPHA AB <11 < 11 SI
MI-2 BETA AB <11 < 11 SI
MDA-5 AB <11 < 11 SI
___ AB <11 < 11 SI
NXP-2 AB <11 < 11 SI
___ 17:11
RNP ANTIBODY
___ Result Reference
Range/Units
RNP ANTIBODY <1.0 NEG <1.0 NEG AI
___ 17:11
RO & ___
___ Result Reference
Range/Units
SJOGREN'S ANTIBODY (SS-A) <1.0 NEG <1.0 NEG AI
SJOGREN'S ANTIBODY (SS-B) <1.0 NEG <1.0 NEG AI
___ 17:11
SM ANTIBODY
___ Result Reference
Range/Units
SM ANTIBODY 1.0 POS A <1.0 NEG AI
___ 17:11
CARDIOLIPIN ANTIBODIES (IGG, IGM)
___ Result Reference
Range/Units
CARDIOLIPIN AB (IGG) <14 GPL
Value Interpretation
----- --------------
< or = 14 Negative
15 - 20 Indeterminate
21 - 80 Low to Medium Positive
>80 High Positive
___ Result Reference
Range/Units
CARDIOLIPIN AB (IGM) <12 MPL
Value Interpretation
----- --------------
< or = 12 Negative
13 - 20 Indeterminate
21 - 80 Low to Medium Positive
>80 High Positive
___ 17:11
BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)
___ Result Reference
Range/Units
B2 GLYCOPROTEIN I (IGG)AB <9 <=20 SGU
B2 GLYCOPROTEIN I (IGM)AB <9 <=20 SMU
B2 GLYCOPROTEIN I (IGA)AB <9 <=20 ___
IL 2 Receptor (CD25), Soluble
Received: ___ 10:24 Reported: ___ 15:50
Value: 4090
Reference Value ___
___ 08:10
PARVOVIRUS B19 ANTIBODIES (IGG & IGM)
___ Result Reference
Range/Units
PARVOVIRUS B19 ANTIBODY <0.9
(IGG)
Reference Range
<0.9 Negative
0.9-1.1 Equivocal
>1.1 Positive
IgG persists for years and provides life-long immunity.
To diagnose current infection, consider Parvovirus
B19 DNA, PCR.
___ Result Reference
Range/Units
PARVOVIRUS B19 ANTIBODY <0.9
(IGM)
Reference Range
<0.9 Negative
0.9-1.1 Equivocal
>1.1 Positive
___ 08:15
PARVOVIRUS B19 DNA
___ Result Reference
Range/Units
SOURCE Serum
PARVOVIRUS B19 DNA, QL REAL Not Detected Not Detected
TIME PCR
___ 08:15
ANAPLASMA PHAGOCYTOPHILUM (HUMAN GRANULOCYTIC EHRLICHIA AGENT)
IGG/IGM
___ Result Reference
Range/Units
A. PHAGOCYTOPHILUM IGG <1:64 <1:64
A. PHAGOCYTOPHILUM IGM <1:20 <1:20
INTERPRETATION see note
Antibody Not Detected
___ 08:15
MYCOPLASMA PNEUMONIAE ANTIBODIES (IGG, IGM)
___ Result Reference
Range/Units
MYCOPLASMA PNEUMONIAE <=0.90 <=0.90
ANTIBODY (IGG)
Reference Range:
<=0.90 Negative
0.91-1.09 Equivocal
>=1.10 Positive
A positive IgG result indicates that the patient has
antibody to Mycoplasma. It does not differentiate
between an active or past infection. The clinical
diagnosis must be interpreted in conjunction with
the clinical signs and symptoms of the patient.
___ Result Reference
Range/Units
MYCOPLASMA PNEUMONIAE 385 <770 U/mL
ANTIBODY (IGM)
___ 08:15
___ VIRUS B ANTIBODIES
___ Result Reference
Range/Units
___ B1 AB <1:8 <1:8
___ B2 AB <1:8 <1:8
___ B3 AB <1:8 <1:8
___ B4 AB <1:8 <1:8
___ B5 AB <1:8 <1:8
___ B6 AB <1:8 <1:8
INTERPRETIVE CRITERIA:
<1:8 Antibody Not Detected
> or = 1:8 Antibody Detected
___ 08:15
ADENOVIRUS PCR
___ Result Reference
Range/Units
SOURCE Whole Blood
ADENOVIRUS DNA, QN PCR <500 <500 copies/mL
___ 08:15
HERPES VIRUS 6 DNA, PCR
___ Result Reference
Range/Units
SOURCE Whole Blood
HERPESVIRUS 6 DNA, QN PCR <500 <500 copies/mL
___ 08:30
EBV PCR, QUANTITATIVE, WHOLE BLOOD
___ Result Reference
Range/Units
SOURCE Whole Blood
EBV DNA, QN PCR <200 <200 copies/mL
___ 08:30
DENGUE FEVER ANTIBODIES (IGG, IGM)
___ Result Reference
Range/Units
DENGUE FEVER ANTIBODY (IGG) 0.15
REFERENCE RANGE: <0.80
INTERPRETIVE CRITERIA:
<0.80 NEGATIVE
0.80-1.09 EQUIVOCAL
>=1.10 POSITIVE
___ 21:15
HERPES SIMPLEX VIRUS 1 AND 2 (IGG)
___ Result Reference
Range/Units
HSV 1 IGG, TYPE SPECIFIC AB 1.09 H index
HSV 2 IGG, TYPE SPECIFIC AB <0.90 index
Index Interpretation
----- --------------
<0.90 Negative
0.90-1.09 Equivocal
>1.09 Positive
___ 08:35
HERPES SIMPLEX VIRUS, TYPE 1 & 2 DNA, QUANTITATIVE REAL TIME PCR
___ Result Reference
Range/Units
SOURCE Serum
HSV 1 DNA, QN PCR <100 <100 copies/mL
HSV 2 DNA, QN PCR <100 <100 copies/mL
___ 06:55
CRYOGLOBULIN
___ Result Reference
Range/Units
% CRYOCRIT SEE NOTE NONE DETECTED
%
A LOW cryoprecipitate was detected (Cryocrit = 0.5 %).
___ Result Reference
Range/Units
CRYOCRIT IMMUNOFIXATION SEE NOTE
No monoclonal proteins detected by immunofixation studies.
___ Result Reference
Range/Units
CRYOCRIT IMMUNODIFFUSION SEE NOTE
Immunodiffusion studies of the patient's cryoprecipitate
detected IGA, IGM, KAPPA, LAMBDA and ALBUMIN.
___ Result Reference
Range/Units
RHEUMATOID FACTOR 26 H <14 IU/mL
CRYOGLOBULIN, QL POSITIVE A
___ 06:45PM URINE Color-Straw Appear-Clear Sp ___
___ 06:45PM URINE Blood-MOD* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 06:45PM URINE RBC-5* WBC-2 Bacteri-NONE Yeast-NONE
Epi-1
___ 06:45PM URINE Hours-RANDOM Creat-34 TotProt-44
Prot/Cr-1.3*
___ 07:04AM URINE U-PEP-NO MONOCLO IFE-NO MONOCLO
___ 11:55AM URINE 24Creat-729 24Prot-774
PERTINENT MICRO:
================
___ BLOOD CULTURE: negative x2.
___ URINE CULTURE: negative.
___ BLOOD CULTURE: negative x2.
___ 2:15 pm URINE Source: ___.
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
___ 1:02 am STOOL CONSISTENCY: FORMED Source:
Stool.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
___ 1:02 am STOOL CONSISTENCY: FORMED Source:
Stool.
VIRAL CULTURE (Final ___: NO VIRUS ISOLATED.
___ 3:47 pm URINE Source: ___.
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. 10,000-100,000 CFU/mL.
Susceptibility testing performed on culture # ___
___.
PERTINENT IMAGING:
===================
___ EMG:
Clinical interpretation: Abnormal study. The
electrophysiological data are
most consistent with a subacute myopathy with denervating
features. It is
likely that the low response amplitudes of the peroneal and
sural nerves were
technical, due to limb edema. However the absence of F waves
raises the
possibility of an underlying, proximal neurogenic process. The
data do not
meet electrophysiologic criteria for an acute inflammatory
demyelinating
polyneuropathy, however. The reduced activation may be
volitional, due to
pain or due to a central process.
___ MRI Thigh:
Diffuse and symmetric muscle edema compatible with myositis,
most prominent in
the quadriceps musculature, particularly the rectus femoris,
vastus lateralis
and vastus intermedius.
___ TTE:
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color Doppler. There is normal
left ventricular wall thickness with a normal cavity size. There
is normal regional and global left ventricular systolic
function. Quantitative biplane left ventricular ejection
fraction is 65 %. Left ventricular cardiac index is normal (>2.5
L/min/m2). There is no resting left ventricular outflow tract
gradient. Normal right ventricular cavity size with normal free
wall motion. Tricuspid annular plane systolic excursion (TAPSE)
is normal. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch
diameter is normal with a normal descending aorta diameter.
There is no evidence for an aortic arch coarctation. The aortic
valve leaflets (3) appear structurally normal. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets appear structurally normal with no mitral
valve prolapse. There is trivial mitral regurgitation. The
pulmonic valve leaflets are normal. The tricuspid valve leaflets
appear structurally normal. There is physiologic tricuspid
regurgitation. The pulmonary artery systolic pressure could not
be estimated. There is no pericardial effusion.
IMPRESSION: Normal left ventricular wall thickness and
biventricular cavity sizes and regional/global systolic
function. No significant valvular pathology or pericardial
effusion identified.
___ CXR:
In comparison with the study of ___ there is no interval
change or
evidence of acute cardiopulmonary disease. No pneumonia,
vascular congestion,
or pleural effusion.
___ CXR:
Small left pleural effusion. No focal consolidation.
___ LENIs:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ EEG:
IMPRESSION: This routine EEG showed a normal background during
wakefulness
and sleep. There were no focal findings, epileptiform
discharges, or
electrographic seizures.
___ Left UE Doppler:
1. No evidence of deep vein thrombosis.
2. Edema of the subcutaneous fat of the left antecubital fossa
with no
drainable collection noted.
___ NCHCT:
No acute intracranial abnormality.
___ MR Head:
1. There is no evidence of acute intracranial process or
hemorrhage, there is
no evidence of abnormal enhancement after contrast
administration.
2. Prominent ventricles and sulci for the patient's age,
although this
finding is nonspecific suggest brain volume loss.
3. Diffuse low signal in the bone marrow throughout the
calvarium is
consistent with history of sickle cell trait and anemia.
4. Patchy opacification of the mastoid air cells and paranasal
sinuses
suggest an ongoing inflammatory process.
___ MR Spine:
1. Diffusely low vertebral body bone marrow signal, compatible
with known
history of sickle cell trait anemia.
2. No evidence of acute abnormalities involving the cervical,
thoracic, and
lumbar spine spinal canal, there is no evidence of neural
foraminal narrowing
or spinal cord compression.
3. Bilateral pleural effusions and left lung base consolidation,
better
detected in the concurrent CT of the chest, please refer to this
report for
details.
___ Bone marrow biopsy:
HYPOCELLULAR BONE MARROW WITH MATURING TRILINEAGE HEMATOPOIESIS,
STROMAL DAMAGE, FOCAL CELL DROP OUT, AND EVIDENCE OF
HEMOPHAGOCYTOSIS ON
A CD68-STAINED MARROW SECTION, SEE NOTE.
Note: By immunohistochemistry, CD3 and CD5 highlight scattered
background T-cells. CD20
highlights rare background B-cells. CD34 highlights blasts
comprising <1% of the marrow.
CD68, in addition to highlighting granulocytic precursors, also
highlights numerous
macrophages, that stain strongly with CD68, few of which exhibit
phagocytosed erythroblasts
and other cell remnants. By CD138 staining, plasma cells occur
singly and in clusters and
approximately represent 10% of the total cells. By kappa and
lambda staining, the plasma
cells are polytypic. Parvovirus staining is negative.
Taken together these findings are highly suggestive for
hemophagocytic
lymphohistiocytosis/macrophage activation syndrome. Lack of a
bone marrow aspirate
precludes a more complete assessment. According to clinical
note, the patient fulfils clinical
criteria for HLH. Nevertheless, rhabdomyolysis is not a typical
finding of HLH/MAS. It has,
however, been reported in cases of viral associated
hemophagocytic syndromes, particularly
viral infections, including influenza.
___ CT A/P w/ contrast:
1. Multiple prominent retroperitoneal and pelvic lymph nodes
bilaterally
measuring up to 1.7 x 1.3 cm in the left common iliac region are
nonspecific.
2. Moderate bilateral, nonhemorrhagic pleural effusions with
adjacent
compressive atelectasis.
3. Small volume intra-abdominal ascites.
4. Diffuse anasarca.
___ CT chest w/ contrast:
1. No focal consolidations. No lymphadenopathy.
2. Mild diffuse smooth septal thickening, moderate bilateral
pleural
effusions, and diffuse body wall edema, compatible with
anasarca.
3. Please refer to the CT abdomen pelvis with the same date for
evaluation of
subdiaphragmatic structures.
DISCHARGE LABS:
================
___ 07:29AM BLOOD WBC-6.7 RBC-3.04* Hgb-8.8* Hct-28.3*
MCV-93 MCH-28.9 MCHC-31.1* RDW-26.3* RDWSD-86.6* Plt ___
___ 07:29AM BLOOD Neuts-56.2 ___ Monos-11.0
Eos-0.1* Baso-0.3 NRBC-1.3* Im ___ AbsNeut-3.77
AbsLymp-1.89 AbsMono-0.74 AbsEos-0.01* AbsBaso-0.02
___ 07:29AM BLOOD ___ PTT-25.2 ___
___ 07:29AM BLOOD ___
___ 07:29AM BLOOD Ret Aut-3.8* Abs Ret-0.12*
___ 07:29AM BLOOD Glucose-119* UreaN-17 Creat-0.5 Na-139
K-3.9 Cl-105 HCO3-22 AnGap-12
___ 05:41AM BLOOD ALT-114* AST-162* LD(LDH)-690*
CK(CPK)-962* AlkPhos-213* TotBili-0.6
___ 07:29AM BLOOD Calcium-9.5 Phos-4.3 Mg-1.4*
___ 07:29AM BLOOD Hapto-<10* Ferritn-829*
Brief Hospital Course:
___ w/ PMH of sickle cell trait who presented with 2 weeks of
progressive proximal muscle weakness initially thought to be
post-viral myolysis in the setting of recent influenza A, found
to have HLH. Course c/b hypotension, rhabdomyolysis, ATN, DIC,
initially requiring ICU admission. Currently on PO dexamethasone
taper and s/p 2 doses of IVIG (___). Continues to have
laboratory abnormalities which are stable to improving. Weakness
has greatly improved.
ACUTE ISSUES:
==============
#HLH:
#Fevers, resolved:
#Transaminitis:
#Pancytopenia:
#DIC, resolved:
Patient presented with recurrent fevers, found to be
pancytopenic with low fibrinogen and labs c/w DIC. Infectious
workup largely negative, had LP done at ___ which was
unremarkable. Had been briefly on vanc/CTX/ampicillin at ___
but stopped upon arrival at ___ given low suspicion for
bacterial process. Also no obvious bleeding/clotting given labs
c/w DIC. Specifically, had low fibrinogen, mild
thrombocytopenia, and coagulopathy, schistocytes on peripheral
smear. She received a partial unit of cryo in the ICU which was
stopped due to possible transfusion reaction. She also had
transaminitis, with hepatitis serologies and viral etiologies
negative. After infectious workup and autoimmune workup largely
negative (see list below), concern was raised for HLH. Fulfills
___ criteria for HLH (1)fever >38.5°C, 2)cytopenia, 3)
fibrinogen <150 mg/dL 4)Ferritin >500 (in 3000s), 5) elevated
sIL2R). Other diagnostic criteria include splenomegaly,
hemophagocytosis on biopsy, and low/absent NK activity but Heme
advises not needed for diagnosis. The question remains what is
the trigger for this reaction. Most likely trigger is post-viral
given known influenza A, EBV (prior exposure by serology) and a
case report of post-influenza rhabdo with HLH has been described
___: ___. MAS from primary rheum less
likely given rheum w/u negative to date but RF mildly elevated
as is cryoglobulin and may increase suspicion for something like
___ (though can be nonspecific). Malignancy as a trigger is more
likely the older the person with HLH is at presentation, and
Heme has a low concern for lymphoma as CT only showed peritoneal
lymphadenopathy with smaller nodes. She had a bone marrow biopsy
___ that confirmed the diagnosis of HLH. Started dexamethasone
IV dosed at 10mg/m2 (18mg daily) on ___, which was tapered to
5mg/m2 (9mg daily) and switched to PO on ___ with plan for
further taper. Concurrently started Bactrim for PCP ppx, PPI
switched to H2 blocker given hypomagnesemia, vitamin D, calcium.
She also received IVIG on ___ and ___. Decision was made to hold
off on etoposide for now unless clinically deteriorates. She has
been followed by rheumatology, hematology, and infectious
disease for the above.
IL2-receptor: HIGH 4090
EBV: IgG high, IgM negative (prior infection)
aldolase: high 11.4
C3/C4: LOW
___: POSITIVE (borderline)
RF: slightly high 23
Cryoglobulins: positive
HSV: HSV1 IgG equivocal
SPEP: MILD POLYCLONAL HYPERGAMMAGLOBULINEMIA HYPOALBUMINEMIA
PATTERN ALSO SUGGESTS MILD HYPOCOMPLEMENTEMIA (C3)
Hep A IgM, autoimmune serology: negative
HIV: negative
HCV: negative
Hep serologies: Hep B immune
urine legionella: negative
urine strep: negative
RPR: negative
treponema Ab: negative
Blood Smear For Parasites: negative
CMV: negative
HIV-1 Viral Load: ND
Parvovirus B19 DNA, PCR: negative
Mycoplasma Pneumoniae Antibodies (Igg, Igm): neg
Anaplasma phagocytophilum (human granulocytic Ehrlichia agent)
IgG/IgM: neg
Adenovirus PCR: neg
Herpes Virus 6 DNA, PCR: neg
___ Virus B Antibodies: neg
Lyme IgG/IgM Ab: neg
CMV VL: ND
EBV VL: neg
dengue: neg
Anti-dsDNA: negative
anti-rnp: negative
anti-beta2 glycoprotein: wnl
___: neg x2
SSA/SSB: neg
___: neg
ANCA: negative
myositis panel: negative
anti-cardiolipin: negative
UPEP: neg
Igs: IgG 1747, IgA 163, IgM 85
# Anemia:
H/o sickle cell trait, with Hgb ___ range upon admission. Also
with dx of HLH, on dexamethasone, s/p IVIG x2. Hgb had been
slowly downtrending, low of 6.9 on ___ w/ over-appropriate
response to 1U pRBC on ___. Retic count uptrending with LDH
downtrending iso treating HLH. No overt e/o blood loss, has
remained HD stable.
#Progressive proximal muscle weakness:
#Rhabdomyolysis:
Patient presented with progressive proximal muscle weakness and
rhabdomyolysis since recovered from influenza. Initially
concerned whether this was a primary neurologic issue vs.
muscular injury. Neuro consulted in ED (given concern for GBS)
and recommend EMG which was more consistent with a myositis
picture. In addition, CSF from LP at OSH WNL, although this does
not r/o GBS. Rheum consulted and thought picture was more
consistent with inflammatory myopathy (possibly polymyositis) as
well given the EMG findings, persistently elevated CK, and
primarily proximal muscle weakness. There was also concern for
possible underlying lupus or possible overlap syndrome given
pancytopenia, ___ with proteinuria, and now with low complement.
However rheumatologic workup largely negative. At this point,
believe more likely post-viral inflammatory myopathy, possibly
related to recent influenza vs. prior EBV infection. Picture is
also muddled by diagnosis of HLH. HLH could be the result of
viral or autoimmune disease, and it is likely that the insult
that led to HLH is also causing the myolysis. CK has downtrended
with IVF and time, and weakness is getting better slowly.
Decision was made to move forward with muscle biopsy in the
event that weakness does not get significantly better with
steroids. Muscle biopsy showed myonecrosis consistent with
rhabdomyolysis and did not show much inflammation making
inflammatory myopathy less likely. She is being discharged to
rehab, though has shown significant improvement.
#Thrush:
Patient noted to have thrush on ___, likely in the setting of
prolonged steroids and immunocompromised iso HLH. Started on
nystatin swishes for 2-week course.
# Hyperglycemia:
FSBG have been into 300s while on steroids. On insulin sliding
scale for now.
#Hypomagnesemia:
Has been consistently low, s/p repletion with IV Magnesium PRN.
Also started on standing PO magnesium repletion. Could
potentially be from PPI, so switched to H2 blocker. ___ also be
the result of fluid shifts given recent increase in mobilization
and had been volume overloaded on exam. Otherwise, not having
diarrhea. Can consider renal loss as well. Urine studies showed
possible renal wasting; will be set up with outpatient
nephrology appointment.
#Altered mental status:
Patient with brief period of unresponsiveness evening ___ where
eyes fluttered and ?rolled up a little bit. Prior to this had
been feeling tongue tingling/swelling. After episode continued
to feel confused, with some word finding difficulties and head
shaking. However, when asked to stop, she could. Morning ___
felt back to her normal self. Initial concern for bleed given
DIC, however NCHCT negative. MRI with some likely chronic volume
loss, no acute abnormalities. EEG negative for seizure. She had
additional episodes on ___ and ___ where she had non-specific
symptoms like numbness and head-shaking or eye-fluttering, at
which time neurology evaluated her and believe these are
stress-related reactions with low concern for primary neurologic
etiology.
#Pseudomonas bacteriuria:
Urine cx from ___ with pseudomonas >100,000 cfu with repeat cx
also positive (had negative culture ___. Benign UA and patient
asymptomatic without frequency/dysuria, suprapubic tenderness.
Ddx includes benign carrier vs. altered presentation of UTI in
context of HLH. ID did not feel it necessary to treat, so
holding abx.
RESOLVED ISSUES:
=================
___:
#Proteinuria:
#Hypoalbuminemia:
Cr 1.6 at OSH, at ___ 1.1 to 1.4. Possibly due to
rhabdomyolysis. Proteinuria (P/Cr 1.0, 24 urine protein 774,
total protein 4.8, albumin 1.5) seems out of proportion to her
___, this could be more explained by autoimmune processes,
possibly lupus nephritis, however autoimmune workup negative per
above. Patient also with very low albumin which could be
combination of proteinuria and inflammation. She was evaluated
by Nephrology on the floor who felt the ___ was from ATN based
on muddy brown casts, however the underlying proteinuria wasn't
fully explained. There were no baseline Cr in her outpatient
records prior to her illness. Cr improved, thought maybe protein
was from myoglobin in the setting of rhabdo, and no further
workup warranted inpatient.
#Elevated lipase:
No symptoms of pancreatitis. ___ have some degree of edema in
pancreas due to hypoalbuminemia vs ?auto-immune process.
#Elevated troponin:
Troponin elevated to 0.78. No ischemic changes on EKG. Bedside
TTE showed no pericardial effusion and normal EF. No symptoms
c/w ACS or myopericarditis. With elevated CKMB but normal MB-I,
likely all elevated in setting of rhabdo.
#Hyponatremia:
Na 130 on admission, now improved to normal limits. Volume up on
exam, s/p ~multiple L of IVF since admission at OSH. Likely
hypervolemic.
#Hypotension:
Possibly lower currently due to hypoalbuminemia and likely has
low BP at baseline. Mentating well with normal lactate with SBP
in ___. On lephoved for short time in ICU, but weaned
quickly.
TRANSITIONAL ISSUES
====================
HLH:
[ ] Bloodwork every other day starting ___ to be faxed to
Dr. ___ (___): CBC with diff, Chem10, LFTs,
fibrinogen, haptoglobin, ferritin, CK.
[ ] On PO dexamethasone taper: 5 mg/m2 (9 mg) daily thru ___
2.5 mg/m2 starting ___ for 2-weeks with continued taper to be
determined by HemOnc. Please be sure to calculate BSA when
starting new dose.
[ ] On ranitidine, Bactrim, calcium, and vitamin D for
prophylaxis while on steroids.
[ ] Consider genetic testing given HLH.
Renal:
[] Will need outpatient renal follow up for proteinuria. ___
need non-urgent renal biopsy if proteinuria is persistent.
Neurology:
[ ] ___ benefit from outpatient neurology follow up re: volume
loss seen on MRI.
[ ] Neuromuscular follow up with Dr. ___.
Other:
[ ] Follow up final muscle biopsy results.
[ ] On nystatin swishes for thrush thru ___ continue if
thrush has not resolved or recurs.
[ ] On insulin sliding scale while on steroids. Continue to
monitor FSBG and discontinue when appropriate.
[ ] Has been persistently hypomagnesemic, likely in the setting
of volume shifts. Started on PO magnesium repletion. Can
titrate/discontinue as appropriate.
[ ] TSH mildly elevated at 4.4. Repeat TSH ___ weeks.
[ ] Has been growing pseudomonas in her urine without symptoms
of urinary tract infection. Did not treat given asymptomatic.
======================================
#CODE STATUS: Full
#EMERGENCY CONTACT: ___: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Calcium Carbonate 500 mg PO DAILY
4. Dexamethasone 9 mg PO DAILY Duration: 8 Days
Please take daily from ___.
5. Dexamethasone 4.5 mg PO DAILY
Start taking daily on ___. PLEASE RE-CALCULATE BSA TO ENSURE
THIS IS CORRECT DOSING (2.5 mg/m2).
6. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
7. Magnesium Oxide 800 mg PO BID
8. Nystatin Oral Suspension 5 mL PO QID
Please take thru ___, or until your thrush resolves.
9. Polyethylene Glycol 17 g PO DAILY
10. Ranitidine 150 mg PO BID
11. Senna 8.6 mg PO BID
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14.Outpatient Lab Work
ICD-10: D76.1
Every other day starting ___. Fax to Dr. ___
___: CBC with diff, Chem10, LFTs, fibrinogen,
haptoglobin, ferritin, CK.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
-Hemophagocytic lymphohistiocytosis
-Pancytopenia
-Transaminitis
-Disseminated intravascular coagulopathy
-Progressive muscle weakness
-Rhabodymyolysis
SECONDARY:
-Altered mental status
-Acute kidney injury
-Thrush
-Hypomagnesemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. Occasionally requires
assistive device.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because you were having fevers
and worsening weakness.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-___, your labs showed evidence of muscle
breakdown. You were started on antibiotics given your persistent
fevers, and you were then transferred to ___.
-You were initially in the ICU because your blood pressures were
a little low, and once this improved, you were transferred to
the floors.
-You had a lot of bloodwork done, and the findings overall were
consistent with something called HLH (Hemophagocytic
lymphohistiocytosis), which is when certain cells that are part
of your immune system get overactivated. This could happen in
the setting of infection, like influenza, or an autoimmune
disease. Other than your history of influenza, other infectious
workup and autoimmune workup has been largely negative. You had
a bone marrow biopsy, which confirmed the diagnosis of HLH. You
were started on steroids to treat your HLH. You also got two
doses of IVIG.
-Your muscle weakness and breakdown is likely the result of your
influenza as well. You had a muscle biopsy, which showed
evidence of muscle breakdown and not much inflammation. Over the
course of your hospitalization, your weakness improved greatly.
-You had a few episodes of confusion and numbness of your
extremities. You had scans of your head and an EEG which did not
show anything concerning. Neurology came to evaluate you, and
they feel like these episodes were most likely related to
stress, as you have had a very prolonged and stressful hospital
course.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
-Continue to take all medications as prescribed.
-Please attend all follow up clinic appointments.
-You will be getting lab tests a few times a week at rehab, and
these will be sent to the hematology/oncology department at
___.
We wish you all the best,
Your ___ Care Team
Followup Instructions:
___
|
10831915-DS-15
| 10,831,915 | 22,842,000 |
DS
| 15 |
2130-09-11 00:00:00
|
2130-09-11 17:33:00
|
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:
None
attach
Pertinent Results:
Admission Labs:
___ 11:31AM BLOOD WBC-3.6* RBC-5.38* Hgb-12.9 Hct-40.9
MCV-76* MCH-24.0* MCHC-31.5* RDW-19.3* RDWSD-50.7* Plt ___
___ 11:31AM BLOOD Neuts-73.2* Lymphs-18.7* Monos-6.1
Eos-1.4 Baso-0.3 Im ___ AbsNeut-2.62 AbsLymp-0.67*
AbsMono-0.22 AbsEos-0.05 AbsBaso-0.01
___ 11:31AM BLOOD Plt ___
___ 11:39AM BLOOD ___ D-Dimer-1207*
___ 11:31AM BLOOD Glucose-113* UreaN-4* Creat-0.7 Na-135
K-4.6 Cl-101 HCO3-23 AnGap-11
___ 11:31AM BLOOD ALT-15 AST-45* LD(LDH)-349* CK(CPK)-673*
AlkPhos-49 TotBili-0.4
___ 11:31AM BLOOD Albumin-3.8 Calcium-9.6 Phos-3.1 Mg-1.6
Cholest-159
___ 11:31AM BLOOD Ferritn-119
___ 05:25AM BLOOD Hapto-270*
___ 11:31AM BLOOD Triglyc-86 HDL-29* CHOL/HD-5.5
LDLcalc-113
___ 05:15AM BLOOD IgG-1705* IgA-144 IgM-85
___ 05:15AM BLOOD C4-16
___ 05:25AM BLOOD C3-68*
___ 05:25AM BLOOD ALDOLASE-PND
___ 05:25AM BLOOD C2-PND
___ 05:25AM BLOOD MYOSITIS ANTIBODY PROFILE-PND
___ 05:25AM BLOOD INTERLEUKIN 2 RECEPTOR (CD25),
SOLUBLE-PND
___ 05:25AM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM-PND
___ 05:00AM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODIES (IGG,
IGM)-PND
___ 05:00AM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG & IGM)-PND
CXR:
IMPRESSION:
No pneumonia or acute cardiopulmonary process.
Pertinent Interval labs:
=========================
Mycoplasma pending
anaplasma pending
IL2, soluble normal
myositis antibody panel negative
C2 complement component pending
Aldolase mildly elevated
ESR normal
Parvovirus ab negative
WBC Count trend:
================
___ 05:00AM BLOOD WBC-2.8* RBC-4.89 Hgb-11.6 Hct-36.1
MCV-74* MCH-23.7* MCHC-32.1 RDW-18.9* RDWSD-49.2* Plt ___
___ 05:00AM BLOOD Neuts-62.2 ___ Monos-7.2 Eos-2.5
Baso-0.7 AbsNeut-1.72 AbsLymp-0.76* AbsMono-0.20 AbsEos-0.07
AbsBaso-0.02
___ 05:15AM BLOOD WBC-1.8* RBC-4.89 Hgb-11.6 Hct-36.9
MCV-76* MCH-23.7* MCHC-31.4* RDW-19.1* RDWSD-50.7* Plt ___
___ 05:15AM BLOOD Neuts-52.7 ___ Monos-7.2 Eos-2.2
Baso-0.6 Im ___ AbsNeut-0.95* AbsLymp-0.66* AbsMono-0.13*
AbsEos-0.04 AbsBaso-0.01
___ 04:55AM BLOOD WBC-2.7* RBC-4.61 Hgb-11.0* Hct-33.8*
MCV-73* MCH-23.9* MCHC-32.5 RDW-19.1* RDWSD-50.0* Plt ___
___ 04:55AM BLOOD Neuts-65 Bands-2 ___ Monos-7 Eos-0*
Baso-1 AbsNeut-1.81 AbsLymp-0.68* AbsMono-0.19* AbsEos-0.00*
AbsBaso-0.03
CK trend:
===========
___ 05:25AM BLOOD ALT-13 AST-37 CK(CPK)-588* AlkPhos-44
TotBili-0.3
___ 05:00AM BLOOD ALT-13 AST-38 LD(___)-279* CK(CPK)-772*
AlkPhos-38 TotBili-0.3
___ 05:15AM BLOOD ALT-13 AST-38 LD(___)-275* CK(CPK)-774*
AlkPhos-39 TotBili-0.2
___ 04:55AM BLOOD ALT-15 AST-41* LD(___)-306* CK(CPK)-852*
AlkPhos-39 TotBili-0.2
___ 06:45AM BLOOD ALT-17 AST-46* LD(___)-326* CK(CPK)-991*
AlkPhos-42 TotBili-0.2
___ 08:49AM BLOOD ALT-21 AST-54* CK(CPK)-1093* AlkPhos-47
TotBili-0.3
Discharge labs:
================
___ 08:49AM BLOOD WBC-2.2* RBC-5.01 Hgb-11.7 Hct-37.5
MCV-75* MCH-23.4* MCHC-31.2* RDW-20.0* RDWSD-52.1* Plt ___
___ 08:49AM BLOOD Neuts-56.2 ___ Monos-6.8 Eos-3.8
Baso-0.9 AbsNeut-1.32* AbsLymp-0.75* AbsMono-0.16* AbsEos-0.09
AbsBaso-0.02
___ 08:49AM BLOOD UreaN-4* Creat-0.6
___ 08:49AM BLOOD ALT-21 AST-54* CK(CPK)-1093* AlkPhos-47
TotBili-0.3
Discharge exam:
================
98.6 PO 118 / 72 69 19 100 RA (afebrile x24 hours)
Comfortable, well appearing
MMM, OP clear, no scleral icterus
RRR, no murmurs
lungs CTAB
Abdomen soft, nontender, nondistended
___ strength in bilateral upper and lower extremities
No muscle tenderness
Moving all extremities
Brief Hospital Course:
___ y/o F with PMHx of sickle cell trait, as well as influenza A
infection in ___ c/b
rhabdomyolysis and HLH on ___ with lengthy admission
(___) at that time, who is presented with several
days of fever, mild sore throat, and proximal muscle weakness
felt likely to be due to viral illness complicated by mild
neutropenia and CK elevation.
#Fever
#Neutropenia
Patient had no localizing symptoms on presentation other than
some weakness and pain in her girdle muscles and sensation of
difficulty swallowing. UA with 8 WBCs and +nitrites so she
receied a dose of ctx, though this was discontinued when she was
found to be asymptomatic. She was seen by ID with broad
infectious w/u including RRV panel, blood and urine cultures,
parasite smear and parvovirus ab negative. Mycoplasma and
anaplasma ab pending at time of discharge. LDH mildly elevated
but ferritin largely unremarkable making recurrent HLH unlikely.
She defervesced without intervention (last fever to 100.7 on
___ at 3pm) making viral illness most likely. She was noted to
have mild neutropenia this admission with nadir of ANC at 950
that recovered to 1320 at time of discharge. Will need repeat
CBC within one week of discharge though suspect this was
reactive to her viral illness.
#Muscle weakness
#Axillary muscle pain
#CK elevation (673 on admission, now ___
Mild lower extremity weakness with mild CK elevation (300s) was
noted in ___ and thought to be due to high intensity
exercise regimen in the setting of recent myonecrosis, with
possible contribution of steroid myopathy. Her CK normalized in
___ (CK 95) but she presented to the ED this visit with CK in
700s despite IVF. She has recurrence of mild symptoms (weakness
of girdle muscles, pain with wrist flexion/extension,
dysphagia), but etiology unclear. Possibilities include
infectious/post-infectious (though no clear localizing
symptoms), autoimmune (aldolase mildly elevated, myositis panel
negative) vs metabolic/genetic (awaiting appt in ___ for
possible genetic testing). Given that CK rising in setting of
likely infectious process (as it has previously), most
concerning for possible metabolic predisposition. CK only mildly
increased following discontinuation of aggressive fluids (1090
from 950) and given lack of symptoms of rhabdo, decision made
for outpatient ___ with rheumatology for consideration of
additional w/u (MRI, biopsy) in conjunction with inpatient rheum
team. She will need repeat CK within one week of d/c to ensure
stability and was counseled on s/s of rhabdo to monitor for at
home.
#History of ?HLH
There is some controversy over whether this is a real diagnosis
or whether flu caused similar lab abnormalities. However she had
characteristic findings of HLH on BMBx last admission. Pt should
follow up with ___ specialist at ___ once she is discharged.
Transitional Issues:
======================
[ ]Please repeat CK and WBC count with diff within one week of
discharge to ensure pt is not neutropenic and that CK is stable
(discharge CK 1093, discharge WBC 2.2 with ANC 1320)
[ ]Please ensure patient follows up with ___ specialist at ___
[ ___ pending mycoplasma ab, C2 and anaplasma serology
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Medications:
1. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Disposition:
Home
Discharge Diagnosis:
Fevers
Muscle weakness
CK elevation
Neutropenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with fevers and muscle pain.
You were found to have a low WBC count and elevated CK (muscle
enzyme). You had a broad infectious work-up which was negative.
Your symptoms were felt to most likely be due to a viral
infection. Your fevers decreased and your blood counts improved.
Your CK remains elevated which is likely due to your body's
reaction to this infection. You will need close follow-up with
your rheumatologist for ongoing work-up of your CK elevation and
muscle symptoms. You are scheduled for follow-up with your
rheumatologist, Dr. ___, ___ at 10:30am.
You are also scheduled to see your primary care doctor tomorrow.
We recommend that you have your WBC count checked within the
next week (CBC with diff) to ensure that your white blood cell
count normalizes after this admission.
Please call your PCP or return to the ED if you develop
recurrent high fevers (>101), have persistent fevers ongoing
beyond ___, have severe muscle or joint pains, develop
dark urine or have any other symptoms that concern you.
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
10832365-DS-6
| 10,832,365 | 26,578,709 |
DS
| 6 |
2110-04-03 00:00:00
|
2110-04-06 15:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pressure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with COPD who presented with chest pain and was found to be
in new Afib. Pt states that this morning he had the onset of
substernal chest pressure and generally did not feel well. He
cannot elaborate further other than by saying he felt weak all
over. He denies any new SOB at this time, although has some
baseline dyspnea ___ COPD. Denies orthopnea, PND, exertional
angina or palpitations recently.
Of note, the pt was recently admitted to ___ 1 month ago with
a reported TIA. He awoke and his right arm/leg were weak, his
speech was also slurred. It is unclear what work-up was done at
the time as ___ records are not available for this pt at this
time. Does not sound as if he received tPA although pt wasn't
sure.
In the ED, initial vitals were 100.6 114 129/66 18 98% 3L Nasal
Cannula. Labs and imaging significant for initial trop <0.01,
normal electrolytes. Patient was found to be in Afib with RVR
to the 130s at arrival and was given metoprolol 5mg IV. He
subsequently became hypotensive to the ___ systolic afterwards
and was given 3L IVF. Rate subsequently improved and SBP was in
the 80-90s prior to arrival. He denies any changes in his
symptoms when he was hypotensive. Bedside echo was performed by
the ED, which while of limited utility, showed no WMAs or
effusion.
Vitals on transfer were 97.7 ___ 22 94%. On arrival to
the floor, patient has no specific complaints aside from still
feeling weak.
REVIEW OF SYSTEMS
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of , paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. COPD
2. TIA ___
3. BPH
4. MSSA staph aureus osteomyelitis of the right ___ toe (at
___.
5. Multiple infections of the toe from World War-II injury where
he got frostbite and now has neuropathy of the foot.
Charcot foot c/b ulceration secondary to war injury (No h/o
diabetes)
6. B/L Hernia repairs.
Social History:
___
Family History:
-Mother had CAD and MI at unknown age
Physical Exam:
Discharge weight 78.4kg
ADMISSION PHYSICAL EXAMINATION:
VS- T 98.4 BP 88/63 HR 101 RR 18 SpO2 96/RA
GENERAL- WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI.
NECK- Supple with JVP of 5-6 cm H2O
CARDIAC- irregularly irregular rate, distant S1/S2, no m/r/g
LUNGS- Distant breath sounds, no wheezes, rales or ronchi
ABDOMEN- Soft, NTND.
EXTREMITIES- No c/c/e. No femoral bruits.
SKIN- Ulcer on medial aspect of right food is without induration
or erythema.
PULSES-
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
Neuro: CN II-XII intact, strength ___ in all extremities,
sensation intact except for diminished feeling in feet
bilaterally. Gait deferred.
Discharge Exam:
98.0 Tm 98.5, 79 (79-103), 118/74-122/78, ___, 92-97%RA
78.4kg, I/O: 240/45, 400/600
GENERAL- Pleasant male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI.
NECK- Supple with JVP of 8cm
CARDIAC- irregularly irregular rate, distant S1/S2, no m/r/g
LUNGS- Distant breath sounds, no wheezes, rales or ronchi
ABDOMEN- Soft, NTND.
EXTREMITIES- No c/c/e. No femoral bruits.
R Foot: valgus position with 2x1cm ulceration on the medial
longitudinal arch. Surrounding erythema.
PULSES-
Right: DP 1+ ___ 1+
Left: DP 1+ ___ 1+
Pertinent Results:
Admission Labs:
___ 06:25PM BLOOD WBC-8.1 RBC-4.37* Hgb-14.4 Hct-41.3
MCV-95 MCH-33.0* MCHC-34.9 RDW-13.5 Plt ___
___ 06:25PM BLOOD Neuts-80.9* Lymphs-9.0* Monos-9.3 Eos-0.5
Baso-0.3
___ 06:25PM BLOOD ___ PTT-38.2* ___
___ 06:25PM BLOOD Glucose-102* UreaN-22* Creat-0.9 Na-136
K-4.3 Cl-103 HCO3-19* AnGap-18
___ 06:25PM BLOOD Calcium-8.4 Phos-2.3* Mg-2.0
Interim Labs:
___ 06:25PM BLOOD TSH-1.3
___ 12:12AM BLOOD %HbA1c-5.2 eAG-103
___ 04:31AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 04:31AM URINE RBC-4* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
Cardiac Labs:
___ 06:25PM BLOOD cTropnT-<0.01
___ 06:25PM BLOOD CK(CPK)-66
___ 06:19AM BLOOD CK-MB-17* MB Indx-11.5* cTropnT-0.17*
___ 06:19AM BLOOD CK(CPK)-148
Discharge Labs:
___ 06:15AM BLOOD WBC-5.8 RBC-3.84* Hgb-12.2* Hct-36.9*
MCV-96 MCH-31.9 MCHC-33.1 RDW-13.9 Plt ___
___ 06:15AM BLOOD Glucose-94 UreaN-22* Creat-0.9 Na-140
K-4.4 Cl-106 HCO3-27 AnGap-11
___ 06:15AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.1
___ 12:12AM BLOOD %HbA1c-5.2 eAG-103
Microbiology:
___ Urine culture pending
Imaging:
CXR ___:
FINDINGS: AP portable upright chest radiograph obtained.
Several calcified pleural plaques project over the lungs. There
is no definite sign of pneumonia or CHF. No large effusion is
seen, though the left CP angle is excluded. There is no
pneumothorax. The heart is within normal limits of size. A
retrocardiac density containing gas lucency is compatible with a
hiatal hernia. The aorta is somewhat unfolded with partially
calcified aortic knob. Bony structures appear intact with an
old left mid clavicular shaft deformity.
IMPRESSION: No signs of CHF or pneumonia. Hiatal hernia noted.
TTE ___
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and preserved biventricular systolic
function. Mildly dilated aortic root and ascending aorta. Mild
mitral regurgitation. Mild-moderate tricuspid regurgitation.
Moderate pulmonary artery systolic hypertension.
Brief Hospital Course:
___ with COPD and recent TIA who presented with new onset atrial
fibrillation and community acquired pneumonia
# Paroxysmal Atrial Fibrillation: In setting of recent TIA,
unlikely this is truly new. Also contribution from underlying
infection(s). He was rate controlled with metoprolol which was
uptitrated and transitioned to 100mg XL qd. He was
anticoagulated with heparin bridged to coumadin. He was gently
diuresed with IV lasix 10mg daily for 2 days. Discharge weight
was 78.4kg.
# CAP: - levofloxacin for total 7 days as he has been afebrile
and doing well symptomatically without elevated WBC count.
# R Charcot Foot w/ ulcer - Secondary to frostbite during WW2.
Previous history of MSSA osteomyelitis
- appreciate podiatry recs - they placed a dressing that will be
changed in ___ days, in addition he will need daily or every
other day betadine and gauze dressings to the exposed portion of
the ulcer
- Continue wound care as per podiatry
- f/u podiatry as an outpatient, their office will call with an
appointment on ___ or he can contact ___ for a
follow up in ___ days
# COPD: O2 sats are normal at admission, no dyspnea.
- Continue fluticasone
- duonebs PRN
Transitional Issues:
- New initiation of warfarin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Albuterol-Ipratropium ___ PUFF IH BID
4. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Levofloxacin 750 mg PO DAILY Duration: 2 Days
7 days of antibiotics
___ - ___
last dose ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
6. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. Warfarin 3 mg PO DAILY16
dose to be adjusted by INR with Dr ___
___ *warfarin 3 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
RX *warfarin 1 mg ___ tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
8. Albuterol-Ipratropium ___ PUFF ___ BID
Discharge Disposition:
Home With Service
Facility:
___
___:
atrial fibrillation
pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure caring for you at ___
___. You came to the hospital with chest pain and
some difficulty breathing. You were found to be in an irregular
heart rhythm (atrial fibrillation). We also found signs of a
pneumonia, which we treated with antibiotics. The pneumonia may
have stressed your heart and caused the irregular rhythm. It
may have also caused some difficulty breathing.
We started an anti-clotting medication, coumadin (warfarin), to
prevent blood clots forming in your heart. These can lead to
stroke or pulmonary embolism (clot in the lung). Given your
recent history of a TIA, we were concerned you were high risk
for a stroke and should remain on anti-clotting medication.
Your primary care physician's office will help you manage the
anti-clotting medication, coumadin (warfarin). This will
require regular bloodwork and dose adjustment to ensure it stays
in the therapeutic range. You will see a PA in his office on
___ to learn more about the medication and to schedule
your blood work.
Please follow-up with your physicians as listed below. We made
several changes to your medications, so please review the list
carefully.
Followup Instructions:
___
|
10832535-DS-10
| 10,832,535 | 26,982,115 |
DS
| 10 |
2174-06-08 00:00:00
|
2174-06-08 14:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
sulfanilamide
Attending: ___
Chief Complaint:
Right upper quadrant pain
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
___ is a ___ year old man with pancreatic cancer
metastatic to the liver on chemotherapy (gem/abraxane), who
presented with fever and worsening R-sided abdominal pain. He
was
diagnosed about 8 months ago. He underwent pancreatic duct and
CBD stent placements at that time, which were subsequently
removed and a metal stent placed across a biliary stricture. He
also underwent EUS with celiac plexus block at that time, which
helped quite a bit with his pain, and he was started on
gem/abraxane chemotherapy. He is followed by Dr. ___ in ___ but has also seen Dr. ___ at ___ for his oncologic care.
At the time of his last visit with Dr. ___ in ___ he had
completed 6 cycles of chemotherapy and was taking a break due to
fatigue. He underwent a He restarted chemotherapy 3 weeks ago
and has received 2 cycles since that time, the last having been
one week ago. He also had a repeat celiac plexus block performed
one month ago, which he states has not been as effective as the
first one.
His current symptoms began about 3 days ago, initially with R
sided abdominal pain. He states that this pain was different
from
his celiac pain, which has also been bothersome. He describes
the
new pain as at "stomach level" and more on the R than left, and
with a different quality than his celiac pain. It is worse on an
empty stomach or after a large meal and better with a light
meal.
The onset of this pain 3 days ago was dramatic. He has had
associated nausea and vomiting for which he takes Compazine. He
has been able to keep some food down, but less than normal. He
also manages chronic constipation with lactulose and miralax and
notes that his last bowel movement was 2 days ago. In addition
to
the pain he had a fever at home to 103, which was 2 days ago. No
fevers that high since then. He initially went to ___, where imaging was concerning for occlusion of his CBD
stent in that there was an appearance of soft tissue within the
stent but no significant dilation of the biliary system. He was
transferred to ___ for further advanced endoscopy management.
OSH labs:
Tbili 2.2
Direct bili 1.3
Cr 1.2
ALT 182, AST 133 Alk phos 301
WBC 2, Hgb 9.1, plt 161
In the ED the patient had stable VS with Tmax 99.9, HR 70-82, BP
110s-120s/60s-70s, RR 16 and satting 87-98% on room air. His
labs
were notable for pancytopenia with mild neutropenia, mild
transaminase and alk phos elevation, and mild direct
hyperbilirubinemia. He received zosyn and IV dilaudid, as well
as
Tylenol and omeprazole. Urine and blood cultures were sent.
After his arrival to the floor he underwent ERCP, which showed
large amounts of stones, sludge and debris in the bile duct,
which were balloon swept, and his stent was replaced. He did not
endorse any significant pain after the procedure.
Past Medical History:
stage IV pancreatic adenocarcinoma metastatic to the liver
diagnosed ___ s/p 6 cycles of gem/abraxane
h/o of acute bacterial prostatitis at age ___
Osteoarthritis, chronic back pain
OSA on CPAP
GERD
h/o colonic polyps "large one of concern in ___ and repeat
colonoscopy was recommended in one year
h/o actinic keratosis on his scalp treated with topical ___
h/o appendectomy
Social History:
___
Family History:
Brother - Lung cancer (___)
Mother - COPD, CAD
Paternal Uncles - CAD
Physical ___:
VITAL SIGNS:
___ 0842 Temp: 98.5 PO BP: 104/53 HR: 61 RR: 18 O2 sat: 98%
O2 delivery: RA
EXAMINATION
GENERAL: Alert and in no apparent distress
EYES: Pupils equally round and reactive to light
ENT: Ears and nose without visible erythema, masses, or trauma.
Moist oral mucosa with ecchymosis on the left/medial hard
___.
CV: Heart regular, no murmur. Radial and DP pulses present.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen more soft, scattered areas of tenderness with focus
in right upper quadrant extending to mid-abdomen. Bowel sounds
present.
GU: No suprapubic tenderness
MSK: No clear swollen or erythematous joints
SKIN: No rashes or ulcerations noted
EXTR: No lower extremity edema
NEURO: Alert, interactive, face symmetric, gaze conjugate with
EOMI, speech fluent
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 07:05AM BLOOD WBC-5.3 RBC-2.91* Hgb-8.9* Hct-27.6*
MCV-95 MCH-30.6 MCHC-32.2 RDW-14.2 RDWSD-49.6* Plt ___
___ 02:20AM BLOOD WBC-1.6* RBC-2.61* Hgb-7.9* Hct-24.6*
MCV-94 MCH-30.3 MCHC-32.1 RDW-14.5 RDWSD-49.5* Plt ___
___ 02:20AM BLOOD Neuts-76* Lymphs-16* Monos-8 Eos-0*
Baso-0 AbsNeut-1.22* AbsLymp-0.26* AbsMono-0.13* AbsEos-0.00*
AbsBaso-0.00*
___ 07:15AM BLOOD Neuts-80* Bands-6* Lymphs-5* Monos-9
Eos-0* Baso-0 AbsNeut-2.32 AbsLymp-0.14* AbsMono-0.24
AbsEos-0.00* AbsBaso-0.00*
___ 06:58AM BLOOD ___ PTT-27.5 ___
___ 07:15AM BLOOD ___ PTT-25.5 ___
___ 07:05AM BLOOD Creat-1.2 Na-146 K-3.3* HCO3-25 AnGap-12
___ 02:20AM BLOOD Glucose-121* UreaN-22* Creat-1.1 Na-135
K-4.5 Cl-103 HCO3-21* AnGap-11
___ 07:05AM BLOOD ALT-49* AST-16 AlkPhos-273* TotBili-0.6
___ 02:20AM BLOOD ALT-122* AST-86* AlkPhos-240*
TotBili-1.7* DirBili-1.0* IndBili-0.7
___ 02:20AM BLOOD Lipase-5
___ 07:05AM BLOOD Phos-2.9 Mg-2.3
___ 02:24AM BLOOD Lactate-0.6
ERCP: stones, sludge, debris, cleared with balloon sweeps; metal
stent replaced
Brief Hospital Course:
___ year old man with pancreatic cancer metastatic to the liver
on chemotherapy (gem/abraxane), who presented with fever and
worsening right sided abdominal pain due
to stent obstruction and cholangitis, now s/p ERCP with removal
of sludge/stones and stent replacement.
#Acute cholangitis, Choledocholithiasis, malignant biliary
stricture, biliary
obstruction of stent and common bile duct. Patient's
presentation complicated by sepsis, present on admission
(characterized by fever and leukopenia). SIRS
resolved through discharge. History in brief: Patient presented
with 3 days of a new pain and fevers, most likely due to
obstruction of his stent by stones and sludge. There was no
other source of infection. Patient underwent ERCP with balloon
sweeping of sludge and stones as well as replacement of stent
(which migrated during balloon sweeps). Patient was given
supplemental IV fluids and diet was advanced. Patient's pain
improved through discharge. Patient was treated with empiric IV
Zosyn that is transitioned to ciprofloxacin and metronidazole on
discharge to complete total 10 day
course of antibiotics from time of ERCP (per ERCP) - stop date
___.
# GPC bacteremia likely represented contamination as cultures
showed coagulase negative staphylococcus. Patient was treated
with empiric IV vancomycin until culture data resulted and
repeat blood cultures remain no growth through discharge.
Vancomycin was discontinued without clinical decline/worsening
and no new fevers.
# Diarrhea. Likely multifactorial caused by a combination of
medication side effect, resuming diet after constipation/ERCP,
and pancreatic insufficiency. Patient instructed to take creon
and maintain adequate oral intake to prevent electrolytes
deficiencies or volume depletion. Patient should have labs by
outpatient provider in about 4 days. CDIFF was negative and
patient can trial Imodium.
# Metastatic pancreatic cancer on chemotherapy complicated by
pancytopenia and mild neutropenia. Patient has received total 8
cycles of gem/abraxane (although with break between 6 and 7) and
currently has stable disease per report. He has liver
metastasis. Pancytopenia is presumed to be from recent
chemotherapy and exacerbated by further bone marrow suppression
from infection. Pancytopenia improved with time and treatment of
infection. Counts to be monitored as outpatient on schedule.
Outpatient oncologist should continue scheduled follow-up to
determine timing of next chemotherapy based on the clinical
course. Given held diet, patient is given thiamine replacement
as recommended by nutrition, despite low risk for refeeding
syndrome. Continue to follow electrolytes as above.
# Chronic pain and nausea related to malignancy. Recent celiac
block less successful than prior. At home he takes oxymorphone
and Tylenol. This will be continued on discharge. Patient was
given scheduled Tylenol and PO dilaudid with IV dilaudid for
breakthrough pain during the acute illness. Home Compazine PRN
can be continued.
#Constipation transitioned to diarrhea as above. KUB obtained to
make sure this didn't represent overflow diarrhea. There was
notable amount of gas in intestines, but not significant stool
burden. Patient to continue home regimen when diarrhea resolves.
#GERD
- continue AM omeprazole and ___ ranitidine
#OSA
- no longer needs CPAP after weight loss
Hospital course, assessments, and discharge plans discussed with
patient and family who express understanding and agree with
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Creon ___ CAP PO TID W/MEALS
3. oxyMORphone 15 mg oral Q12H
4. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
5. Cetirizine 10 mg PO DAILY:PRN allergies
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergies
7. Ranitidine 150 mg PO QHS
8. Omeprazole 20 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
10. Lactulose 15 mL PO Q8H:PRN constipation
11. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
heartburn
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*15 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*23 Tablet Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) [Vitamin B-1] 100 mg 1 tablet(s)
by mouth once a day Disp #*5 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
5. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
heartburn
6. Cetirizine 10 mg PO DAILY:PRN allergies
7. Creon ___ CAP PO TID W/MEALS
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergies
9. Lactulose 15 mL PO Q8H:PRN constipation
10. Omeprazole 20 mg PO DAILY
11. oxyMORphone 15 mg oral Q12H
12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
13. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
14. Ranitidine 150 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholangitis
Choledocholithiasis
Malignant biliary stricture, biliary obstruction of stent and
common bile duct
Sepsis, resolved.
Coagulase negative blood culture contamination
Metastatic pancreatic cancer on chemotherapy
Pancytopenia with mild neutropenia, resolved
Chronic pain and nausea
Constipation and diarrhea
GERD
Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for ERCP in the setting of
cholangitis/choledocholithiasis (obstruction and infection of
the biliary duct) due to stone and sludge. The ERCP was
performed and was uncomplicated. They removed the debris and
placed a new fully covered metal stent. Your pain continues to
improve and your liver tests are improving as well. You will
complete a 10 day course of antibiotics. Please have your
outpatient provider check labs in about ___ days confirm
stability of your values (CBC, BMP, magnesium, LFTs). Your
course was complicated by diarrhea that is likely caused by a
combination of medication side effect, resuming diet after
constipation/ERCP, and pancreatic insufficiency. Continue your
creon and continue to maintain adequate oral intake. If you
continue to have diarrhea contact your outpatient provider as
you may become deficient in electrolytes or become dehydrated.
It was a pleasure meeting you.
Your ___ care team
Followup Instructions:
___
|
10832658-DS-10
| 10,832,658 | 23,929,938 |
DS
| 10 |
2188-10-26 00:00:00
|
2188-10-26 16:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
low H/H
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
History of Present Illness: Mr. ___ is a ___ yo M with PMH of
poorly controlled HTN resulting in recent ICH as well as DM and
CKD who presents from rehab because the rehab noted his H/H was
low. Pt reports increased fatigue today, but otherwise is at
baseline since discharge ___. Denies HA, CP, SOB, N/V,
diarrhea, melena, or hematochezia. He has R calf pain x 1d.
In the ED, he was found to be hyperkalemic to 5.8 and EKG was
concerning for peaked T waves. He was given calcium gluconate,
insulin, D50, and kayexelate. His hematocrit was actually
higher than it was 3 days prior when he was discharged, however,
he did have one episode of coffee ground emesis. The ED
consulted GI who wanted 1 unit pRBCs and admission to ICU, with
plan to perform EGD in the am. Because of his history of
hypertension, they were thinking hemight need full sedation and
intubation for the EGD. Vitals prior to transfer were: 98.7 73
163/80 16 100%.
On arrival to the MICU, he is feeling well. He reports that he
would not want to be intubated, even for a short time for a
procedure. He reports his calf pain is a burning type
sensation, not worse with movement of his legs.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
-Diabetes controlled by diet/exercise (last HgA1C: 7 on ___
-Glaucoma
-HTN, poorly controlled with baseline of 150-180s/70s-90s
-CKD
Social History:
___
Family History:
Mother had diabetes
Physical Exam:
Vitals: BP: 185/86, P: 68, R: 10, O2: 100% RA
General: Alert, oriented x 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, left pupil
fixed at 3 mm, right pupil not visible due to milky anterior
chamber
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
sensation intact in dermatomes C5-T1 and L3-S1, gait deferred
Pertinent Results:
___ 07:00PM ___ PTT-32.2 ___
___ 07:00PM PLT COUNT-286
___ 07:00PM NEUTS-85.1* LYMPHS-10.0* MONOS-4.0 EOS-0.8
BASOS-0.1
___ 07:00PM WBC-7.5# RBC-2.75* HGB-8.4* HCT-25.7* MCV-93
MCH-30.7 MCHC-32.8 RDW-13.6
___ 07:00PM GLUCOSE-143* UREA N-34* CREAT-3.4* SODIUM-133
POTASSIUM-5.8* CHLORIDE-104 TOTAL CO2-21* ANION GAP-14
___ 08:59PM URINE MUCOUS-RARE
___ 08:59PM URINE RBC-32* WBC-10* BACTERIA-FEW YEAST-NONE
EPI-0
___ 08:59PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
___ 08:59PM URINE COLOR-Straw APPEAR-Clear SP ___
Date: ___ Endoscopist(s): ___, MD
___, MD (___)
Patient: ___
___, MD
___ Date: ___ ___ years) Instrument: ___ (___)
ID#: ___
Medications: MAC Anesthesia
Indications: Hematemesis
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, patient's daughter,
and wife (HCP), who indicated their understanding and gave
consent for the procedure. A physical exam was performed. The
patient was administered MAC anesthesia. Supplemental oxygen was
used. The patient was placed in the left lateral decubitus
position and an endoscope was introduced through the mouth and
advanced under direct visualization until the third part of the
duodenum was reached. Careful visualization of the upper GI
tract was performed. The vocal cords were visualized. The
procedure was not difficult. The patient tolerated the procedure
well. There were no complications.
Findings: Esophagus:
Mucosa: Erythema of the mucosa with exudate with stigmata of
recent bleeding, but no active bleeding or visible vessels was
noted in the lower third of the esophagus compatible with
esophagitis.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Impression: Erythema with exudate in the lower third of the
esophagus compatible with esophagitis, likely the cause of this
patient's hematemesis
Otherwise normal EGD to third part of the duodenum
Recommendations: High dose PO PPI BID (equivalent of omeprazole
40mg po BID) for the next 8 weeks and then daily thereafter
Follow up with outpatient GI
Additional notes: The attending was present for the entire
procedure. The patient's home medication list is appended to
this report. FINAL DIAGNOSES are listed in the impression
section above. Estimated blood loss = zero. No specimens were
taken for pathology
Brief Hospital Course:
___ yo M with h/o poorly controlled HTN c/b ICH, DM, CKD who
presented with low hematocrit and coffee ground emesis in the
ED.
# Coffee ground emesis: underwent EGD on ___ which showed
esophagitis. PPI therapy prescribed and outpatient GI followup
recommended. Got 1 unti pRBC and Hct remained stable as well as
hemodynamics were stable. Was also on IV PPI gtt during the
admission.
# Hyperkalemia: ___ be due to blood absorption from gut,
although BUN is not equally elevated. He is not taking
medications which would cause hyperkalemia since last admission.
Already recieved treatment in the ED with kayexelate and
insulin and calcium gluconate and potassium levels resolved to
normal range.
# HTN: poorly controlled with baseline of 150-180s/70s-90s. Has
had end organ damage in the past (see below) so we kept a tight
control over the BP even though he is having a GI bleed.
Continued carvediolol 25 mg BID amlodipine 5 mg daily
and doxazosin 2 mg QHS
# intracranial hemorrhage ___ HTN ___: currently neuro exam
is at baseline recorded in prior d/c summary and per patient
report. patient is blind at baseline
# Diabetes: moderately compliant with meds, last HgA1C: 7 on
___. continued glargine 8 units and sliding scale
# CKD: admission Cr at baseline 3.4. continued epo
# UTI: during last admission he had a urine culture + for staph
and enterococcus. was treated with augmentin, planned for 14
day course to treat for complicated UTI. To continue augmentin,
until ___.
# Glaucoma: continued home meds
.
Transitions of care:
-needs GI followup as outpatient
-needs LOW potassium diet
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from ___ rehab records.
1. Epoetin Alfa 4000 units SC MOWEFR Start: HS
2. travoprost *NF* 0.004 % ___ daily
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
6. Carvedilol 25 mg PO BID
please hold for SBP < 100, HR < 50
7. Docusate Sodium 100 mg PO BID
8. Doxazosin 2 mg PO HS
please hold for SBP < 100
9. Amlodipine 5 mg PO DAILY
please hold for SBP < 100
10. Glargine 8 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
11. Senna 1 TAB PO BID:PRN constipation
12. Simvastatin 10 mg PO DAILY
13. Sodium Bicarbonate 650 mg PO TID with meals
14. Vitamin D 50,000 UNIT PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
please hold for SBP < 100
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
please continue until ___
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES DAILY
4. Carvedilol 25 mg PO BID
please hold for SBP < 100, HR < 50
5. Docusate Sodium 100 mg PO BID
6. Doxazosin 2 mg PO HS
please hold for SBP < 100
7. Glargine 8 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
9. Senna 1 TAB PO BID:PRN constipation
10. Simvastatin 10 mg PO DAILY
11. Sodium Bicarbonate 650 mg PO TID with meals
12. Vitamin D 50,000 UNIT PO DAILY
13. Epoetin Alfa 4000 units SC MOWEFR
14. travoprost *NF* 0.004 % ___ daily
15. Omeprazole 40 mg PO BID
For the next 8 weeks and then once daily thereafter. Follow up
with outpatient GI.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
esophagitis
hyperkalemia
Secondary:
chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure participating in your care at ___. You were
admitted to the hospital for high potassium and concern for a
gastrointestinal bleed. Your high potassium levels were treated
and an upper endoscopy was done and found irritation of your
esophagus. Otherwise, this was a normal study. Please continue
low potassium diet.
It is very important that you take all of your usual home
medications as directed in your discharge paperwork.
Please followup with your primary care physician regarding the
course of this hospitalization after you are discharged from
rehab.
Please followup with your outpatient gastroenterologist in the
next ___ weeks as well given the esophagitis.
Followup Instructions:
___
|
10832658-DS-11
| 10,832,658 | 22,420,943 |
DS
| 11 |
2188-11-11 00:00:00
|
2188-11-11 15:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of poorly controlled HTN resulting in recent ICH as
well as DM and CKD from rehab facility with lethargy but AOx3
and fever of 104 (axillary temperature). Recieved 650mg po
tylenol at ___ home.
In the ED, initial VS were: 103.2, 95, 150/66, 20, 97% RA. Labs
notable for lactate 1.8, troponin 0.28, Creatinine 4, BUN 34, K
5.2, WBC 14. UA with >182 WBC and positive leuk esterase. He was
started on vanc/zosyn. EKG shows improvement from prior. Given
toradol, ice packs, and aspirin. Denies abd
pain/n/v/cough/cp/SOB. Pt with indwelling foley and has a
history of ESRD and about to start dialysis. Pt is responsive
only to verbal stimuli and unable to provide much of a history.
Also received 1.5L of IVF.
On arrival to the MICU, patient's VS were 98.2, 85, 142/72, 15,
98% RA. Reports chills, but denies any chest pain, headache,
congestion, cough, diarrhea, abdominal pain, bloody stools,
dysuria, myalgias, or skin rashes.
Patient was previously hospitalized ___ for UGIB. His EGD
showed esophagitis. Also hospitalized for DKA and intracranial
hemorrhage ___ HTN on ___.
Past Medical History:
-Diabetes controlled by diet/exercise (last HgA1C: 7 on ___
-Glaucoma
-HTN, poorly controlled with baseline of 150-180s/70s-90s
-CKD
-Legally blind
Social History:
___
Family History:
Mother had diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 98.2, 85, 142/72, 15, 98% RA
General: Alert and oriented x3, no acute distress
HEENT: Sclera anicteric, slightly dried mucous membranes,
oropharynx clear, EOMI, R eye with cloudy anterior chamber (pt.
reports this is chronic), left pupil fixed at 3 mm
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: ___ strength in R lower extremities otherwise ___,
grossly normal sensation, no clonus, negative babinski,
intention tremor in bilateral upper extremities
DISCHARGE PHYSICAL EXAM
Pertinent Results:
ADMISSION LABS
___ 09:16PM LACTATE-1.8
___ 09:00PM GLUCOSE-136* UREA N-34* CREAT-4.0* SODIUM-139
POTASSIUM-5.2* CHLORIDE-107 TOTAL CO2-24 ANION GAP-13
___ 09:00PM ALT(SGPT)-16 AST(SGOT)-21 ALK PHOS-61 TOT
BILI-0.3
___ 09:00PM cTropnT-0.28*
___ 09:00PM ALBUMIN-3.6
___ 09:00PM WBC-14.0*# RBC-3.04* HGB-9.6* HCT-28.6*
MCV-94 MCH-31.7 MCHC-33.7 RDW-13.6
___ 09:00PM NEUTS-93.8* LYMPHS-3.1* MONOS-2.0 EOS-1.1
BASOS-0
___ 09:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 09:00PM URINE BLOOD-LG NITRITE-POS PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
___ 09:00PM URINE RBC-170* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-0 RENAL ___ blood culture: pending
___ urine culture: pending
Imaging:
___ CXR (preliminary):
FINDINGS: Portable AP chest radiograph demonstrates clear lungs.
There is no pleural effusion or pneumothorax. The
cardiomediastinal silhouette is normal.
Impression: No acute cardiopulmonary process.
EKG: sinus rhythm, mild ST elevations in precordial leads and
non-specific ST depressions that are also present in previous
EKGs.
DISCHARGE LABS
___ 07:00AM BLOOD WBC-10.0 RBC-2.91* Hgb-8.8* Hct-26.7*
MCV-92 MCH-30.1 MCHC-32.9 RDW-14.5 Plt ___
___ 07:00AM BLOOD Glucose-125* UreaN-36* Creat-3.6* Na-135
K-3.4 Cl-102 HCO3-24 AnGap-12
___ 03:37AM BLOOD CK-MB-2 cTropnT-0.22*
___ 07:00AM BLOOD calTIBC-135* VitB12-496 Ferritn-186
TRF-104*
MICRO:
___ 9:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
Piperacillin/Tazobactam.
sensitivity testing performed by ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
Brief Hospital Course:
___ yo M with h/o poorly controlled HTN c/b ICH, DM, CKD who
presents with fever, leukocytosis, and positive UA.
# Sepsis: He presented with grossly dirty urine and positive UA
with culture eventually growing pseudomonas (sensitive to
quinolones). His emperic antibiotics initially included zosyn
and vancomycin. Blood cultures grew out coag negative staph
felt to be a contaminant. His antibiotics were narrowed to PO
cipro on ___ and he will continue therapy for an additional 7
days. His foley was removed without urinary retention during
this admission (initially replaced in the MICU). He required IV
hydration in the ED.
# Hyperkalemia: Likely a result of his worsening chronic kidney
injury due to DM and poorly controlled HTN. EKG with no
hyperkalemia changes. Patient is also asymptomatic and likely
able to tolerate higher levels of K+ given chronic kidney
injury. Hyperkelemia resolved on ___. Repeat EKG also with no
acute changes.
# elevated troponins: in setting of CKD. However, patient has
had normal troponins with elevated creatinine in the past. He
remained asymptomatic throughout his FICU course with no acute
changes in EKG. Repeat troponin showed downtrending troponins
(peak at 0.28 down to 0.22) He was not felt to have ACS.
# CKD: secondary to uncontrolled HTN. Planning starting HD as
outpatient. Currently Cr. 4 (baseline ___. GFR is 20 (stage
IV). No need for emergent HD at this point as no sign of uremia,
acidosis, ingestion, volume overload. Creat on discharge 3.6.
He was seen by his transplant surgeon re: access and potential
fistula surgery, but he was still undecided about scheduling
surgey.
**PLEASE DO NOT USE LEFT ARM AT ALL FOR ANY IVS OR LAB DRAWS AS
HE SHOULD PRESERVE VASCULATURE FOR FUTURE L BRACHIOCEPHALIC AVF.
# HTN: poorly controlled with baseline of 150-180s/70s-90s
resulting in end organ damage. Initially BP meds were held due
to pressures in the 100s, but restarted on ___.
# Diabetes: moderately compliant with meds, last HgA1C: 7 on
___. HIS LANTUS DOSE WAS increased to 14 units.
#Anemia: Normocytic, most likely due to CKD. Iron studies done
on ___ to rule out iron deficiency showed normal iron level and
low TIBC most consistent with anemia of chronic disease. His
anemia remained at baseline and he was continued on epo.
-fyi: UGIB on last admission with EGD showing esophagitis,
currently on prilosec
# Glaucoma: continue on home meds
# TRANSITIONAL:
**PLEASE DO NOT USE LEFT ARM AT ALL FOR ANY IVS OR LAB DRAWS AS
HE SHOULD PRESERVE VASCULATURE FOR FUTURE L BRACHIOCEPHALIC AVF.
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES DAILY
3. Carvedilol 25 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Epoetin Alfa 4000 units SC 3X/WEEKLY: PRN Hbg<10
MWF when Hbg<10
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Omeprazole 20 mg PO DAILY
8. Senna 1 TAB PO BID:PRN constipation
9. Simvastatin 10 mg PO DAILY
10. Sodium Bicarbonate 650 mg PO TID
with meals
11. Acetaminophen 650 mg PO Q6H:PRN fever/pain
12. Ciprofloxacin HCl 250 mg PO Q24H
RX *ciprofloxacin 250 mg 1 tablet(s) by mouth once a day Disp
#*7 Tablet Refills:*0
13. Glargine 14 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
14. Doxazosin 2 mg PO HS
15. travoprost *NF* 0.004 % ___ daily
16. Vitamin D 50,000 UNIT PO DAILY
PLEASE MAKE SURE THIS IS A SHORT COURSE, AND ONLY TAKE THIS FOR
TWO WEEKS UNLESS INSTRUCTED BY PHYSCIIAN TO TAKE FOR LONGER
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
SEPSIS
CATHETER RELATED UTI
PSEUDOMONAL UTI
BENIGN HYPERTENSION
DIABETES TYPE TWO, CONTROLLED WITH COMPLICATIONS
ckd stage 4
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 to
the hospital because of an infection in your urinary tract. You
were given antibiotics to treat the infection. Your foley
catheter was removed.
TRANSITIONAL ISSUES
[]IT IS IMPORTANT THAT YOU DISCUSS HEMODIALYSIS ACCESS WITH YOUR
SURGEON, Dr. ___ YOUR NEPHROLOGIST, ___. ___
[]MONITOR RENAL FUNCTION WITH CHEM7
[]MONITOR FOR SIDE EFFECTS OF ANTIBIOTIC
[]MONITOR BP, AS AMLODIPINE DOSE INCREASED
Followup Instructions:
___
|
10833257-DS-31
| 10,833,257 | 23,330,807 |
DS
| 31 |
2193-05-13 00:00:00
|
2193-05-13 15:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
cough, fevers
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
___ yo ___ speaking M dCHF, AF on warfarin, SSS s/p PPM, HLD,
HTN, history of colon cancer and other medical issues presents
with cough and fever. His grandson was in the room with him
during this interview
Patient reports having productive cough with yellow sputum for
several days days. This morning, he reported subjective fever.
He was diagnosed with URI at the end of ___. Grandson stated
that the patient completed a course of antibiotics about ___
weeks ago, but neither him or the patient know the name of the
antibiotics. It is not listed on OMR. He denies chest pain,
abdominal pain, N/V, or SOB.
In the ED, initial VS were: 97.2 ___ 16 96% RA. Labs
were notable for WBC 12.4, H/H 14.3/42.8, Plt 124, PMN 85.2%, Na
137, K 3.6, Cl 100, Bicarb 27, BUN 15, Crt 0.9, Glucose 106, Ca
8.9, Mg 1.9, Phos 2.0, proBNP ___, trop <0.01, Lactate 1.7, INR
2.1, ___ 23, PTT 37.5. Blood culture x 2 pending. EKG showed AF
with RBBB and LAFB and LVH. CXR showed new patchy consolidation
at the left base with left linear atelectasis. Patient received
lasix 40 mg IV x1, ASA 325 mg po x 1, CTX 1 g, Vanc 1g, and
nitroglycerin SL 0.4 mg x1, and azithromycin 500 mg IV x1. VS on
transfer: 97.6 108 159/85 20 98%
Patient reports having pinkish/blood tinged phlagm down in the
ED. He also states that he has been taking Mucinex without much
improvement. He has some shortness of breath with activities. He
is normally not on any oxygen.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies headache, sinus
tenderness. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
PAST MEDICAL HISTORY: per OMR
- ___, EF 60% ___
- Atrial fibrillation s/p cardioversion x 2, on warfarin
- SSS, s/p ___ single chamber pacemaker
- known RBBB/LAFG
- Hypertension
- Dyslipidemia
- Mitral regurgitation
- Glucose intolerance
- h/o B12 deficiency anemia
- PNA ___
- Colon CA (colonoscopy ___ Status post hemicolectomy ___
- BPH
- osteoarthritis
- seronegative RA
- Lung nodules (left) noted on CT.
- Hx of recurrent epididymitis rx'd with cipro, recurrent on L
w/ pseudomonas UTI's, followed by urology
- h/o Indirect right inguinal hernia, pt declined surgery
- h/o pelvic fracture after MVA ___ years ago
- s/p inguinal hernia repair
Social History:
___
Family History:
FAMILY HISTORY:
- denies family history of heart or pulmonary disease
Physical Exam:
ADMISSION LABS:
.
VS: 98.2, 148/85 (right) and 148/104 (left), 95, 18, 99% 2L
GENERAL: NAD, breathing comfortably
HEENT: PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, JVD: 7 cm
LUNGS: coarse breath sound bilaerally, bibasilar wheeze worse on
the left, rhonchi L>R, no accessory muscle use
HEART: difficult to appreciate heart sound due to the coarse
breath sound and bibasilar rhonchi/wheeze
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: trace edema in the legs bilaterally, + chronic
venous statsis discoloration, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact, gait is slightly
wide based
.
DISCHARGE LABS:
.
VITALS: 98.8 98.5 131/73 80 18 98% 2L NC
WEIGHT: 86.2 kg
GENERAL: Appears in no acute distress. Alert and interactive.
Well nourished appearing. Mildly diaphoretic.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Mucous membranes
moist with plaques or exudates.
NECK: supple without lymphadenopathy. JVP not elevated.
___: Paced. Irregularly irregular rhythm, without murmurs, rubs
or gallops.
RESP: Stable inspiratory effort without labored breathing.
Decreased breath sounds and rhonchi noted at left lung base to
mid-zones. Sparse inspiratory crackles at left upper lobe. Right
lung clear.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. EXTR: no cyanosis, clubbing or edema, 2+ peripheral
pulses; venous stasis changes noted throughout.
Pertinent Results:
ADMISSION LABS:
.
___ 08:40PM BLOOD WBC-12.4*# RBC-4.05* Hgb-14.3 Hct-42.8
MCV-106* MCH-35.4* MCHC-33.5 RDW-13.3 Plt ___
___ 08:40PM BLOOD Neuts-85.2* Lymphs-9.8* Monos-4.5 Eos-0.3
Baso-0.3
___ 08:40PM BLOOD ___ PTT-37.5* ___
___ 08:40PM BLOOD Glucose-106* UreaN-15 Creat-0.9 Na-137
K-3.6 Cl-100 HCO3-27 AnGap-14
___:40PM BLOOD Calcium-8.9 Phos-2.0* Mg-1.9
___ 08:40PM BLOOD cTropnT-<0.01
___ 07:15AM BLOOD cTropnT-<0.01
___ 08:40PM BLOOD proBNP-___*
___ 09:01PM BLOOD Lactate-1.7
.
DISCHARGE LABS:
.
___ 07:15AM BLOOD WBC-4.7 RBC-3.83* Hgb-13.5* Hct-40.8
MCV-106* MCH-35.1* MCHC-33.0 RDW-13.3 Plt ___
___ 10:40AM BLOOD ___ PTT-38.9* ___
___ 07:15AM BLOOD Glucose-97 UreaN-16 Creat-1.0 Na-137
K-4.1 Cl-101 HCO3-28 AnGap-12
.
MICROBIOLOGY DATA:
___ Blood cultures (x 2) - pending
___ Urine culture - pan-sensitive Pseudomonas
___ Urine legionella - negative
___ Sputum culture - poor sample, cancelled
IMAGING:
___ CHEST (PA & LAT) - Minimal increase in the left lower
lobe patchy opacification, which could be due to mild worsening
chronic changes or a superimposed new infiltrate.
ECG (___) - Atrial fibrillation with rapid ventricular
response to 122 bpm. RBBB and LAFB noted and similar compared to
prior. LVH. Anterior TWIs in leads V1-2, non-specific laateral
ST-changes. Similar compared to prior with superimposed
rate-related changes likely.
Brief Hospital Course:
IMPRESSION: ___ ___ with PMH significant for dCHF,
AF on warfarin, SSS s/p PPM, HLD, HTN, history of colon cancer
and other medical issues presenting with cough and fever.
# Community acquired bacterial pnuemonia (LLL) - CXR suggestive
of LLL consolidation in the setting of recent fever and cough
for ___ days. Patient has had no recent hospitalization, nursing
home stays, HD, etc. suggesting CAP. He has received CTX, Vanc,
and azithromycin in the ED. He had no respiratory distress
although had frequent cough and phlegm production that was
slightly blood tinged (most likely result of being on
anticoagulation and airway irritation from cough). He quickly
improved with Azithromycin and was continued on Cefepime given
concern for superimposed UTI. Prior to discharge, we changed him
to oral Levofloxacin. He was discharged feeling improved, with
minimal cough and no residual oxygen requirement. Ambulatory
saturation was normal.
# Atrial fibrillation - Chronically anticoagulated, with
therapeutic INR on admission. We continued his beta-blocker and
coumadin at home dosing. He did require one additional dose of
Coumadin for a sub-therapeutic INR on admission, but his INR was
2.3 on discharge. Electrolytes repleted.
# Acute on chronic diastolic congestive heart failure - Mildly
volume overloaded on admission exam. BNP was mildly elevated
(2000s from 800s). Already received IV lasix in the ED with good
effect. Source of decompensation likely respiratory infection.
Cardiac enzymes negative and EKG reassuring. We returned to his
home diuretic regimen, ACEI, beta-blocker and nitrate prior to
discharge. He had no evidence of volume overload on discharge.
# Pseudomonal UTI - History of complicated UTI with recurrent
Pseudomonal infections (some with fluoroquinolone resistance).
Currently asymptomatic. Speciated Pseudomonas, that was
pan-sensitive. Initially was on Cefepime and transitioned to
Levofloxacin on discharge.
# Hypertension, benign - Continued ACEI, diuretic, beta-blocker
and nitrate with adequate response.
# HLD - Continued simvastatin.
# BPH - Continued doxazosin and finasteride.
TRANSITIONAL CARE ISSUES:
1. To complete oral levofloxacin course given community acquired
pneumonia and complicated UTI.
2. Will continue chronic anticoagulation with Coumadin. Last INR
2.3 with 2.5 mg PO dose given prior to discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4-6H PRN SOB, wheeze
2. Doxazosin 4 mg PO HS
hold if SBP < 100
3. Finasteride 5 mg PO DAILY
4. Furosemide 20 mg PO DAILY
hold if SBP < 100 or HR < 60
5. Gabapentin 300 mg PO DAILY
6. Hydroxychloroquine Sulfate 400 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
hold if SBP < 100
8. Lisinopril 10 mg PO DAILY
hold if SBP < 100
9. Metoprolol Succinate XL 50 mg PO DAILY
hold if SBP < 100 or HR < 60
10. Nitroglycerin SL 0.4 mg SL PRN CP
please obtain VS, EKG, and call house officer prior to giving
11. olopatadine *NF* 0.1 % ___ BID
12. Simvastatin 10 mg PO DAILY
13. Warfarin 5 mg PO 3X/WEEK (___)
14. Warfarin 2.5 mg PO 4X/WEEK (___)
15. Acetaminophen 1300 mg PO Q8H:PRN pain or fever
16. Aspirin 81 mg PO DAILY
17. Carbamide Peroxide 6.5% 5 DROP AD QHS
18. Cyanocobalamin 1000 mcg PO DAILY
19. Guaifenesin ER 600 mg PO Q12H
20. Fluorometholone 0.1% Ophth Susp. 1 DROP BOTH EYES DAILY
Discharge Medications:
1. Acetaminophen 1300 mg PO Q8H:PRN pain or fever
2. Aspirin 81 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Doxazosin 4 mg PO HS
5. Finasteride 5 mg PO DAILY
6. Fluorometholone 0.1% Ophth Susp. 1 DROP BOTH EYES DAILY
7. Furosemide 20 mg PO DAILY
8. Gabapentin 300 mg PO DAILY
9. Hydroxychloroquine Sulfate 400 mg PO DAILY
10. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
11. Lisinopril 10 mg PO DAILY
12. Nitroglycerin SL 0.4 mg SL PRN CP
13. olopatadine *NF* 0.1 % ___ BID
14. Simvastatin 10 mg PO DAILY
15. Warfarin 5 mg PO 3X/WEEK (___)
16. Warfarin 2.5 mg PO 4X/WEEK (___)
17. Albuterol Inhaler 2 PUFF IH Q4-6H PRN SOB, wheeze
18. Carbamide Peroxide 6.5% 5 DROP AD QHS
19. Guaifenesin ER 600 mg PO Q12H
20. Metoprolol Succinate XL 50 mg PO DAILY
21. Levofloxacin 750 mg PO DAILY
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth DAILY
Disp #*9 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. Community acquired bacterial pneumonia
2. Urinary tract infection, Pseudomonas
3. Mild, acute on chronic diastolic congestive heart failure
exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent (occasionally with
cane)
Discharge Instructions:
Dear Mr. ___,
You were admitted to the Internal Medicine service at ___
___ on ___ regarding management
of your pnuemonia (lung infection). You were treated with IV
antibiotics and transitioned to oral antibiotics. You were also
found to have bacteria in the urine. We suspect this did not
reflect a true infection.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
Followup Instructions:
___
|
10833257-DS-32
| 10,833,257 | 27,060,123 |
DS
| 32 |
2195-02-17 00:00:00
|
2195-02-20 17:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
cough, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with history of heart failure, hypertension,
afib on coumadin, complete heart block s/p pacemaker who
presents with productive cough and fever to 102-103. Pt. and
daughter report that symptoms have been present for about 5
days. He has had associated myalgias, chills, rhinorrhea, and
decreased PO. He has mild chest pain associated with coughing
and occasional wheezing, but denies any increased pedal edema,
nause, vomiting, or diarrhea. He did receive his flu shot this
year. No sick contacts.
Vitals in the ED: 99.1, 88, 144/67, 18, 96% on RA
Labs notable for: FluA POSITIVE.
WBC 6.6, H/H 12.___/38.7, Plt 115. INR 2.7. Cr 1.1. ProBNP 951.
TropT 0.01. Lactate 1.
CXR with question of chronic ateclactasis vs. infiltrate in the
left lung base.
Patient given: oseltamivir, azithromycin, ceftriaxone, and
ipra/albuterol nebs.
Vitals prior to transfer: 99.5, 84, 122/62, 18, 93% on RA.
On the floor, pt. reported feeling significantly better, though
he continued to report productive cough and wheezing. He was
afebrile and hemodynamically stable.
Past Medical History:
Suspected CAD
Afib on coumadin
BPH with recurrent UTIs
Complete heart block s/p PPM
HFpEF
HTN
OA in back and knees
Obstructive lung disease - asthma vs COPD; on home inhalers
B/l ingional hernias
Colon cancer - s/p right hemocolectomy in ___
Social History:
___
Family History:
FAMILY HISTORY:
- denies family history of heart or pulmonary disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 98.5, HR 66, BP 119/59, RR 20, SpO2 98% on 2L
GENERAL: NAD, speaking in full sentences
HEENT: AT/NC, MMM
NECK: supple
CARDIAC: RRR, no murmurs appreciated
LUNG: breathing comfortably without use of accessory muscles;
audible wheezing without stethescope; wheezing throughout with
intermittent rhonchi; some crackles in LLL field
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no edema, moving all 4 extremities with purpose
SKIN: warm and well perfused
DISCHARGE PHYSICAL EXAM:
Vitals: T 97.8 BP 159/78 HR 84 RR 18 O2 96RA
GENERAL: NAD, speaking in full sentences
HEENT: AT/NC, MMM
NECK: supple
CARDIAC: distant heart sounds, RRR, no murmurs appreciated
LUNG: breathing comfortably without use of accessory muscles;
scattered wheezing; rhonchi and crackles in LLL field
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no edema, moving all 4 extremities with purpose
SKIN: warm and well perfused
Pertinent Results:
ADMISSION LABS:
___ 04:30PM BLOOD WBC-6.6# RBC-3.67* Hgb-12.9* Hct-38.7*
MCV-105*# MCH-35.2* MCHC-33.5 RDW-13.2 Plt ___
___ 04:30PM BLOOD Neuts-71.8* ___ Monos-7.9 Eos-0.7
Baso-0.1
___ 04:30PM BLOOD ___ PTT-42.6* ___
___ 04:30PM BLOOD Glucose-102* UreaN-22* Creat-1.1 Na-134
K-4.1 Cl-99 HCO3-28 AnGap-11
___ 07:15AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.0
___ 04:30PM BLOOD cTropnT-0.01 proBNP-951*
___ 04:44PM BLOOD Lactate-1.0
DISCHARGE LABS:
___ 07:15AM BLOOD WBC-4.5 RBC-3.59* Hgb-12.6* Hct-38.4*
MCV-107* MCH-35.1* MCHC-32.8 RDW-13.1 Plt ___
___ 07:15AM BLOOD ___ PTT-44.1* ___
___ 07:15AM BLOOD Glucose-103* UreaN-15 Creat-1.0 Na-135
K-4.2 Cl-100 HCO3-29 AnGap-10
___ 07:20AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.1
MICRO:
___ 04:20PM OTHER BODY FLUID FluAPCR-POSITIVE *
FluBPCR-NEGATIVE
___ BLOOD CULTURE Blood Culture, Routine-FINAL
IMAGING:
CXR: Patchy opacity in the left lower lobe could reflect an area
of chronic atelectasis but infection cannot be completely
excluded. Unchanged moderate cardiomegaly with mild chronic
pulmonary vascular congestion.
Brief Hospital Course:
Mr. ___ is a ___ gentleman with history of HFpEF, HTN,
afib on warfarin, CHB s/p PPM, obstructive lung disease who
presents with fevers and respiratory symptoms found to be flu
positive.
# Pneumonia: Influenza A pneumonia with suspician for secondary
bacterial pnuemonia given prolonged nature of illness with
worsening sputum production several days into illness, physical
exam findings, and CXR features. However, no leukocytosis or
fever while inpatient. Given multiple comorbidities will treat
for possible superimposed bacterial PNA. Differential includes
strictly influenza pneumonia, influenza with superimposed
bacterial pneumonia, or influenza with COPD flare. Patient is
documented as having asthma/COPD with mild obstructive
physiology on PFTs in the past. He does not use inhalers at home
and has not been treated for frequent COPD exacerbations in the
past. Will treat with albuterol/ipratropium and fluticasone
inhaled for obstructive component. Patient received oseltamivir
for 5 day course (start ___, end ___, azithromycin x 5 days
(start ___, end ___, and ceftriaxone x 7 days transitioned to
PO amoxicillin (starte ___, end ___.
Received alb/ipratropium nebs Q6hrs and discharged with nebs as
well. Will having ___ and follow up with PCP ___ ___.
# Afib: Currently paced. Continued warfarin at lower dose given
concurrent antibiotics and patient knows that his INR has
increased in the past with administration of antibiotics. INR
stayed stable so resumed home dose on discharge. Continued ASA
81mg
# Chronic HFpEF/HTN: BP currently under good control. No e/o CHF
exacerbation on exam, though BNP is elevated. Continued imdur,
lisinopril, furosemide 20mg daily, and metoprolol succ XL
# BPH: continued home finasteride and doxazosin
# HL: continued simvastatin
# Seronegative rheumatoid arthritis/CPPD disease: Continued
voltaren gel, acetaminophen prn, gabapentin, and
Hydroxychloroquine Sulfate
**Transitional Issues**
- Treated with course of tamiflu, amoxicillin, and azithromycin
to end on ___
- Prescribed ipratropium-albuterol nebulizers for shortness of
breath
- Prescribed benzonatate and guaifenesin/dextramethorphan as
needed for cough relief
- Should have INR checked on ___ at PCP ___
# Code: full
# Emergency Contact: ___ (daughter) ___ (h), ___ (c); ___ (granddaughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Doxazosin 4 mg PO HS
4. Finasteride 5 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Gabapentin 300 mg PO DAILY
7. Hydroxychloroquine Sulfate 200 mg PO BID
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. Lisinopril 20 mg PO DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. Omeprazole 20 mg PO DAILY
13. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea, wheeze
14. Simvastatin 10 mg PO QPM
15. Cyanocobalamin 1000 mcg PO DAILY
16. Voltaren (diclofenac sodium) 1 % topical QID:PRN pain
17. Warfarin 2.5 mg PO 3X/WEEK (___)
18. Warfarin 5 mg PO 4X/WEEK (___)
19. olopatadine 0.1 % ophthalmic BID:PRN eye itching
20. Lidocaine 5% Patch 1 PTCH TD QAM pain
21. Carbamide Peroxide 6.5% ___ DROP AD BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Doxazosin 4 mg PO HS
5. Finasteride 5 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Gabapentin 300 mg PO DAILY
8. Hydroxychloroquine Sulfate 200 mg PO BID
9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
10. Lisinopril 20 mg PO DAILY
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Simvastatin 10 mg PO QPM
14. Warfarin 2.5 mg PO 3X/WEEK (___)
15. Warfarin 5 mg PO 4X/WEEK (___)
16. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea, wheeze
17. Carbamide Peroxide 6.5% ___ DROP AD BID
18. Lidocaine 5% Patch 1 PTCH TD QAM pain
19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
20. olopatadine 0.1 % ophthalmic BID:PRN eye itching
21. Voltaren (diclofenac sodium) 1 % topical QID:PRN pain
22. OSELTAMivir 75 mg PO Q24H Duration: 1 Dose
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth daily Disp
#*1 Capsule Refills:*0
23. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 5 mL by mouth
Q6hr:prn cough Refills:*0
24. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth TID prn: cough Disp
#*21 Capsule Refills:*0
25. Azithromycin 250 mg PO Q24H Duration: 1 Dose
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
26. Amoxicillin 500 mg PO Q8H Duration: 4 Doses
RX *amoxicillin 500 mg 1 tablet(s) by mouth three times a day
Disp #*4 Tablet Refills:*0
27. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath, wheezing
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1
nebulizer inhaled QID: prn shortness of breath, wheezing Disp
#*100 Each Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Influenza, Pneumonia
Secondary: Chronic diastolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___ ___. You were admitted with cough and
fever. You were diagnosed with influenza and a pneumonia. You
were treated with oseltamivir (Tamiflu) for the flu as well as
azithromycin and amoxicillin for the pneumonia. Please continue
your last couple of doses on these antibiotics. You were also
given benzonatate and guaifenisin/dextromethorphan for cough
relief. Only use these if needed for coughing. You were sent
home with nebulizer treatments which you should use for
shortness of breath and wheezing as needed. As always, weigh
yourself every morning, call MD if weight goes up more than 3
lbs. Please follow up with your primary care provider on
___.
We wish you the best!
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
10833257-DS-35
| 10,833,257 | 20,187,305 |
DS
| 35 |
2197-01-10 00:00:00
|
2197-01-10 17:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Productive cough and fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ speaking w/ HFpEF, HTN, AF (on warfarin), SSS (s/p
PPM), HLD, colon CA (s/p hemicolectomy), recently diagnosed
hepatitis C who presented with cough and shortness of breath.
Patient reported a recent URI with a productive cough of whitish
sputum and fevers over the past 5 days. Seen by his PCP on the
day of presentation. At PCP, vitals were notable for afebrile,
BP 92/48, 82/44 standing, HR 88, sating 96%RA. The PCP was
concerned for possible pneumonia and hypotension, so the patient
was referred to the ED.
On arrival to the ED, he endorsed productive cough, and
decreased oral intake. He denied N/V/D, dysuria, hematuria or
blood in the stool. No CP, SOB or increased extremity swelling.
In the ED initial vitals were: 98.1 92/46 (improved to 120/70)
60 16 98% RA
EKG: rate 66, Afib, vpaced left axis, RBBB, LAFB.
Labs/studies notable for: no leukocytosis, Hgb 11.4 (at
baseline), platelets 104 (at baseline), Cr 1.3 (b/l 1.1), proBNP
1401 (950 on ___, lactate 1.4. Blood cultures drawn. Flu
negative.
CXR w/ cardiomegaly, congestion and mild interstitial pulmonary
edema. No signs of pneumonia.
Patient was given: prednisone 60mg, Ceftriaxone/azithro (stopped
after CXR returned negative for PNA), NEBS
On the floor, VS: 97.6 160/64 68 20 95% RA
Patient reported that he felt much better. He stated that he
does not feel short of breath and his cough has improved.
Reported stable 2 pillow orthopnea, no PND, no weight gain, no
lower extremity edema. No chest pain. No abdominal pain, nausea
or emesis. No diarrhea. No dysuria.
Past Medical History:
Atrial fibrillation on Coumadin
CAD
S/P PPM
CHF
Seronegative rheumatoid arthritis vs chronic CPPD disease
BPH
Colon cancer s/p right hemicolectomy
Hypertension
Osteoarthritis
Social History:
___
Family History:
FAMILY HISTORY:
- denies family history of heart or pulmonary disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 98.2, 138-160/64-77, 62-70, ___, 95-96% RA
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, JVP at mid neck at 30 degrees
CARDIAC: irregular rhythm, normal S1, S2. No
murmurs/rubs/gallops
LUNGS: Diffuse wheezing and rhonchorous breath sounds
bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 98.2, 127-148/60-77, 60s-80s, ___, 94-97% RA
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, no JVP elevation at 90 degree angle
CARDIAC: irregular rhythm, normal S1, S2. No
murmurs/rubs/gallops
LUNGS: Mild expiratory wheezing in bilateral upper lung bases
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:20AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.0
___ 07:59PM BLOOD proBNP-1401*
___ 04:20AM BLOOD Glucose-180* UreaN-31* Creat-1.2 Na-135
K-3.7 Cl-97 HCO3-24 AnGap-18
___ 04:20AM BLOOD ___ PTT-32.7 ___
___ 04:20AM BLOOD WBC-2.9* RBC-3.14* Hgb-10.9* Hct-33.6*
MCV-107* MCH-34.7* MCHC-32.4 RDW-13.2 RDWSD-52.2* Plt ___
IMAGING:
========
CXR (___):
IMPRESSION:
Cardiomegaly, congestion and mild interstitial pulmonary edema.
No signs of pneumonia.
MICROBIOLOGY:
=============
Blood/Urine cultures (___): pending
DISCHARGE LABS:
===============
___ 05:07AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.2
___ 05:07AM BLOOD Glucose-147* UreaN-33* Creat-1.2 Na-135
K-4.0 Cl-98 HCO3-25 AnGap-16
___ 05:07AM BLOOD ___ PTT-31.0 ___
___ 05:07AM BLOOD WBC-7.9# RBC-3.10* Hgb-11.2* Hct-32.7*
MCV-106* MCH-36.1* MCHC-34.3 RDW-13.2 RDWSD-51.4* Plt ___
Brief Hospital Course:
___ ___ speaking w/ HFpEF, HTN, AF (on warfarin), SSS (s/p
PPM), HLD, colon CA (s/p hemicolectomy), recently diagnosed
hepatitis C who presents with cough, found to have a HFpEF
exacerbation and COPD exacerbation.
#)HFpEF exacerbation: Patient appeared warm and mildly
overloaded on exam with mildly elevated JVP and signs of
pulmonary congestion on CXR. Laboratory studies were notable for
elevated proBNP (1401, previously 951), and normal lactate and
CXR with pulmonary edema. Patient was diuresed with 40 mg IV
Lasix x 2. He was continued on his home dose of metoprolol,
Imdur, and lisinopril. Admission weight:85.7 kg Discharge
Weight: 85.7kg. Repeat TTE on ___ demonstrated normal LVEF
55% but diastolic parameters suggested some elevation of left
heart filling pressure and IVC size/collapse was consistent with
elevated right heart filling pressures. His home Lasix was
increased from 40mg Daily to 40mg BID x 1 week until follow up
with ___ NP at which time it can be adjusted as needed.
He will have a repeat basic metabolic profile in ___ days drawn
by ___ and faxed to the Heart Failure office.
#)Mild COPD exacerbation: Patient with history of mild
obstructive ventilatory defect on prior PFTs (although no PFTs
recently). On admission, patient with diffuse wheezing in
setting of recent URI and mild CHF exacerbation. No evidence of
pneumonia given afebrile, no leukocytosis and no infiltrate seen
on CXR. Received 60 mg prednisone in the ED. On the floor,
patient was started on standing duonebs, azithromycin x 5 days,
and an additional dose of 40 mg prednisone x 4 days.
#)Asymptomatic bacteriuria: Urinalysis sent in ED and + for
leuks/nitrites. No fever, dysuria, or abdominal pain so was not
treated.
CHRONIC ISSUES:
===============
#)Afib: patient was continued on home metoprolol and Coumadin.
#)HLD: patient continued on home simvastatin
#)GERD: patient continued on home omeprazole
#)CAD: patient continued on home metoprolol, ASA
#)Inflammatory arthritis: patient was continued on home
hydroxychloroquine. Home MTX was continued on discharge.
#)BPH: patient was continued on home finasteride, doxazosin.
#)Chronic hepatitis C: newly diagnosed, does not want follow up
with GI.
#)B12 Deficiency: patient continued on vitamin B12.
Transitional Issues:
-Discharge Weight: 85.7kg
-Increased home Lasix from 40mg daily to 40mg BID x 1 week until
follow up with ___ NP.
-Will need BMP drawn on ___ and faxed to ___ attn: Dr.
___ 500mg x1 + 250mg x 4 days (last day ___
-Prednisone 40mg x 4 days (last day ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 10 mg PO QPM
2. Senna 8.6 mg PO BID:PRN constipation
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. Gabapentin 300 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Furosemide 40 mg PO DAILY
11. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
12. Cyanocobalamin 1000 mcg PO DAILY
13. Doxazosin 4 mg PO HS
14. diclofenac sodium 1 % TOPICAL FOUR TIMES DAILY PRN to knees
/ hands for pain
15. Warfarin 5 mg PO 2X/WEEK (MO,FR)
16. Warfarin 2.5 mg PO 5X/WEEK (___)
17. Methotrexate 12.5 mg PO QWED
18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 4 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
2. PredniSONE 40 mg PO DAILY Duration: 4 Doses
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*4 Tablet
Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Aspirin 81 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. diclofenac sodium 1 % TOPICAL FOUR TIMES DAILY PRN to knees
/ hands for pain
7. Doxazosin 4 mg PO HS
8. Finasteride 5 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Furosemide 40 mg PO DAILY
11. Gabapentin 300 mg PO DAILY
12. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
13. Lisinopril 20 mg PO DAILY
14. Methotrexate 12.5 mg PO QWED
15. Metoprolol Succinate XL 50 mg PO DAILY
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
17. Senna 8.6 mg PO BID:PRN constipation
18. Simvastatin 10 mg PO QPM
19. Warfarin 5 mg PO 2X/WEEK (MO,FR)
20. Warfarin 2.5 mg PO 5X/WEEK (___)
21.Walker
Rolling Walker
Duration: 12 months
Prognosis: Good
ICD-10: I50.30
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
CHF Exacerbation
COPD Exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for a viral illness (cold)
causing your lungs to clamp down (COPD exacerbation) as well as
excess fluid in your lungs. We gave you steroids, antibiotics,
and some extra fluid pills to help with these problems.
You will be taking the same medications as you were before you
came to the hospital. You will also take prednisone for 2 more
days and azithromycin for 3 more days.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10833257-DS-37
| 10,833,257 | 29,720,421 |
DS
| 37 |
2197-12-31 00:00:00
|
2197-12-31 18:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Dyspnea, chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o ___ man with a PMH of
HFpEF, HTN, AFib (on warfarin), SSS s/p PPM, colon CA (s/p
hemicolectomy), seronegative RA (on MTX/HCQ/prednisone), CPPD
disease, and chronic HCV, who presented with dyspnea and chest
pain. He has been experiencing progressive shortness of breath
and lower extremity edema over the past week and this morning
developed chest pain. An ambulance was called, and he received
aspirin and nitroglycerin, with improvement in his chest pain.
He
denied fevers, chills, nausea, vomiting, abdominal pain.
On arrival to the ___ ED, his initial vital signs were T 97.1F
P ___ BP 170/92 RR 18 O2 96% RA. ECG demonstrated atrial
fibrillation, ventricular rate 103, RBBB, LAFB, 2mm downsloping
ST depression in V2/V3, TWI in I/aVL. Examination notable for
regular rate and rhythm, crackles scattered in the mid and lower
lung bases bilaterally, soft, non-tender, and non-distended
abdomen. 2+ pulses bilaterally with 2+ edema in bilateral lower
extremities. Labs were notable for troponin-T of 0.03 x2, CKMB 5
proBNP of 1772, BUN/Cr ___, Na 144, K 4.9, INR 3.2, ALT 20,
AST 46, WBC 8.0k, H/H 9.7/___.1, MCV 102, PLT 204,000. Lactate
1.8. CXR demonstrated mild pulmonary edema with small bilateral
pleural effusions. Bibasilar air space opacities, possibly
atelectasis, with aspiration or pneumonia not excluded. He
received IV furosemide 40 mg x1, gabapentin 300 mg PO,
isosorbide
mononitrate 60 mg, lisinopril 10 mg, and metoprolol succinate 50
mg. He was admitted to cardiology.
Upon arrival to the floor, interview was conducted with the
assistance of telephone ___ interpreter. He reports that he
is feeling better now than when he arrived. He had been
experiencing shortness of breath for several days, and
occasionally has had orthopnea and paroxysmal nocturnal dyspnea,
although not currently. He was also experiencing left-sided,
non-radiating chest pain, which he says is now gone. He reports
that he has been taking his Lasix every other day, and that he
has been adding extra salt to his soup (with a shot of vodka).
He
endorses headache, which he believes is from lying in a gurney
all day. He denies fevers, chills, cough, abdominal pain,
nausea,
vomiting, diarrhea, hematuria, dysuria, lightheadedness, or
dizziness.
Past Medical History:
Atrial fibrillation on Coumadin
CAD
S/P PPM
CHF
Seronegative rheumatoid arthritis vs chronic CPPD disease
BPH
Colon cancer s/p right hemicolectomy
Hypertension
Osteoarthritis
Social History:
___
Family History:
FAMILY HISTORY:
- denies family history of heart or pulmonary disease
Physical Exam:
==================
ADMISSION PHYSICAL EXAM:
==================
VS: Afebrile, BP 159/94 mmHg P ___ RR 16 O2 95% RA
General: Comfortable, NAD.
HEENT: Anicteric sclerae, EOMs intact, MMM.
Neck: Supple, JVD elevated above clavicle while seated upright.
CV: Tachycardic, irregular, no MRGs; normal S1/S2.
Pulm: Scant crackles at bases bilaterally; no wheezes. No
accessory muscle usage.
Abd: Soft, non-tender, non-distended, NABS.
Ext: Bilateral venous stasis changes. Warm and well-perfused. 1+
pitting edema bilaterally.
Neuro: A&Ox3. CNs II-XII grossly intact.
==================
DISCHARGE PHYSICAL EXAM:
==================
VS: T: 98.3, BP: 103 / 54, HR: 64, RR: 18, SpO2: 94% RA
WT: 77.07 from ___ yesterday (83.5kg on admission)
General: Comfortable, NAD.
HEENT: Anicteric sclerae, EOMs intact, MMM.
Neck: Supple, No JVD
CV: Distant heart sounds, irregular, normal S1/S2, ___ early
systolic murmur best appreciated at ___.
Pulm: Clear to auscultation bilaterally; no wheezes. No
accessory muscle usage.
Abd: Soft, non-tender, non-distended, NABS.
Ext: Bilateral venous stasis changes. Warm and well-perfused.
Trace pitting edema bilaterally.
Neuro: A&Ox3. CNs II-XII grossly intact.
Pertinent Results:
===============
ADMISSION LABS:
___
___ 09:20AM BLOOD WBC-8.0 RBC-3.06* Hgb-9.7* Hct-31.1*
MCV-102* MCH-31.7 MCHC-31.2* RDW-19.6* RDWSD-72.5* Plt ___
___ 09:20AM BLOOD Neuts-70.1 Lymphs-18.5* Monos-9.6 Eos-1.0
Baso-0.1 Im ___ AbsNeut-5.62 AbsLymp-1.48 AbsMono-0.77
AbsEos-0.08 AbsBaso-0.01
___ 03:29PM BLOOD ___ PTT-37.3* ___
___ 09:20AM BLOOD Glucose-97 UreaN-26* Creat-1.1 Na-144
K-4.9 Cl-103 HCO3-26 AnGap-15
___ 09:20AM BLOOD ALT-20 AST-46* AlkPhos-110 TotBili-0.8
___ 09:20AM BLOOD Albumin-3.8
___ 09:20AM BLOOD CK-MB-5 proBNP-1772*
___ 09:20AM BLOOD cTropnT-0.03*
___ 03:29PM BLOOD cTropnT-0.03*
========================
PERTINENT INTERVAL LABS:
========================
___ 07:35AM BLOOD Calcium-7.9* Phos-3.5 Mg-2.1 Iron-35*
Cholest-121
___ 03:43PM BLOOD Ferritn-97
___ 07:35AM BLOOD calTIBC-322 VitB12-899 Folate-17
Ferritn-96 TRF-248
___ 07:35AM BLOOD %HbA1c-5.4 eAG-108
___ 03:43PM BLOOD Triglyc-62 HDL-60 CHOL/HD-1.9 LDLcalc-44
___ 03:43PM BLOOD TSH-1.3
===============
DISCHARGE LABS:
===============
___ 07:45AM BLOOD WBC-6.1 RBC-3.11* Hgb-9.7* Hct-30.9*
MCV-99* MCH-31.2 MCHC-31.4* RDW-19.4* RDWSD-70.2* Plt ___
___ 07:45AM BLOOD ___
___ 07:45AM BLOOD Glucose-83 UreaN-48* Creat-1.6* Na-142
K-4.1 Cl-93* HCO3-36* AnGap-13
___ 07:45AM BLOOD Calcium-8.9 Phos-4.8* Mg-2.4
================
IMAGING STUDIES:
================
CXR (___): Mild pulmonary edema with small bilateral
pleural effusions. Bibasilar airspace opacities, possibly
atelectasis, with aspiration or pneumonia not
excluded.
TTE (___)
The left atrial volume index is severely increased. The right
atrium is markedly dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF = 60%).
However, the posterior wall is hypokinetic. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular free wall is hypertrophied.
The right ventricular cavity is moderately dilated with
depressed free wall contractility. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. There are three aortic valve leaflets.
The aortic valve leaflets are moderately thickened. There is
mild aortic valve stenosis (valve area 1.2-1.9cm2). The mitral
valve leaflets are mildly thickened. Mild to moderate (___)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. Severe [4+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. [In the setting
of at least moderate to severe tricuspid regurgitation, the
estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] There
is no pericardial effusion. IMPRESSION: Compared with the prior
study (images reviewed) of ___, the posterior wall now
appears hypokinetic.
DEVICE INTERROGATION (___)
Interrogation:
Battery voltage/time to ERI: 2.73/26 months ___ months)
Presenting rhythm: AFib, VS
Underlying rhythm: AF in ___
Mode,base and upper track rate: VVI 50 bpm
Lead Testing
R waves: 2.8-4.0 RV thresh: 0.75V @0.4ms RV imp: 378 ohms
Diagnostics:
VP:9.8%
Events: None
HR histograms show 50-120 bpm
Summary:
1. Pacer function normal with acceptable lead measurements and
battery status nearing ERI in the next ___ years. No significant
events nor elevated heart rate episodes. See full report.
2. Programming changes: none
3. Follow-up: 6 month device clinic or per Dr ___.
=============
MICROBIOLOGY:
=============
__________________________________________________________
___ 1:19 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ 4 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
Brief Hospital Course:
Mr. ___ is a ___ year old ___ man with a PMH
of HFpEF, HTN, AFib (on warfarin), SSS s/p PPM, colon CA (s/p
hemicolectomy), seronegative RA (on MTX/HCQ/prednisone), CPPD
disease, and chronic HCV, who presents with dyspnea and chest
pain.
# ACUTE ON CHRONIC HFpEF
Patient presented with dyspnea, chest pain, elevated proBNP
1772, orthopnea, and PND concerning for decompensated heart
failure. Additionally, he had evidence of volume overload on
examination, including bibasilar crackles, lower extremity
edema, and JVD. Suspect the etiology most likely multifactorial
from medication non adherence (taking Lasix every other day),
dietary indiscretion, and/or UTI with urinary retention. Repeat
TTE with stable, preserved (>55%). He was treated with IV
diuresis with significant improvement in respiratory status.
Will continue torsemide 20mg daily at discharge, as well as home
metoprolol. Holding home Lisinopril in the setting of ___.
# DEMAND ISCHEMIA
# CORONARY ARTERY DISEASE
Patient did have chest pain on admission, with non-specific EKG
changes. Troponin only minimally elevated (0.03), with normal
CKMB. Most likely that this is anginal chest pain related to
demand ischemia in the setting of heart failure exacerbation,
rather than a driving ischemic event. TTE did show new posterior
wall hypokinesis when compared to prior, however unclear if this
is contributing to current heart failure exacerbation. Continue
home aspirin, metoprolol, imdur. Increased home simvastatin to
atorvastatin 40mg. Plan for continued workup of underlying CAD
per outpatient cardiologist.
# ATRIAL FIBRILLATION
Upon review of records, INR goal appears to be 1.5-2.5 given
frequent falls with hemarthrosis in the past and, most recently,
traumatic C1 spinal fracture (which was managed conservatively).
INR during admission supratheraputic to 3.7, and warfarin dosing
was titrated to 3mg daily from 5mg daily at home. INR
downtrended to 1.8 on discharge. Will continue warfarin at
reduced dose (3mg daily). Follow up with primary care provider
for further anticoagulation management. Continue home Metoprolol
as above for rate control.
___
Patient had creatinine elevation ___ to 1.9 from 1.3, likely
secondary to overdiuresis and concurrent ACE inhibitor therapy.
Cr on discharge is down trending (1.6). Hold home lisinopril on
discharge. Will repeat chemistry panel early next week, with
cardiology follow up.
#COMPLICATED UTI
Urine culture growing Pseudomonas. Does report increased urinary
retention, although otherwise asymptomatic. Treated with IV
Cefepime 1g q24h (___) with transition to PO
Ciprofloxacin to complete 7 day course of antibiotics
(___).
CHRONIC ISSUES:
===============
# SSS S/P PPM: Device interrogated during admission with no
events.
# Seronegative Rheumatoid Arthritis: Continue home methotrexate
15 mg QWED, prednisone 5 mg daily, and hydroxychloroquine 200 mg
PO daily.
# B12 Deficiency Anemia: Continue cyanocobalamin 1000 mcg daily.
# BPH/urinary retention: Continue home doxazosin 2 mg qhs and
finasteride 5 mg qPM.
# Chronic neuropathy: Continue gabapentin 300 mg daily.
TRANSITIONAL ISSUES:
====================
ADMISSION WEIGHT: 83.5kg, 184.08lbs
DISCHARGE WEIGHT: 75.4kg, 166.23lbs
DISCHARGE CR: 1.6
DISCAHRGE INR: 1.8
[ ] Continue torsemide 20mg daily, which was changed from home
furosemide 40mg
[ ] Holding home Lisinopril in the setting of ___. Patient given
prescription to repeat chemistry panel on ___. Would likely
benefit from restarting home Lisinopril at cardiology follow up,
if ___ improves.
[ ] New posterior wall hypokinesis on TTE when compared to
imaging one year prior. Will defer further evaluation of
underlying CAD to outpatient cardiologist, Dr. ___.
[ ] Simvastatin stopped and switched to high dose atorvastatin
40mg daily (he was previously not on this secondary to insurance
issues, no known adverse reaction to Lipitor).
[ ] INR during admission supratheraputic to 3.7, with goal per
outpatient notes 1.5 - 2 due to high bleeding risk. Warfarin
dosing was titrated during admission to 3mg daily from 5mg daily
at home. INR down-trended to 1.8 on discharge. Will continue
warfarin at reduced dose (3mg daily) on discharge. Patient given
prescription for repeat INR early next week. Please follow INR
and titrate warfarin accordingly.
[ ] Continue PO Ciprofloxacin for Pseudomonal UTI (last dose
___
[ ] Patient discharged with H&H 9.7 & 30.9 at baseline, iron
studies consistent with mild macrocytic anemia please continue
routine monitoring.
[ ] Discharge Cr 1.6 from baseline of 1.1-1.3, mild elevation in
phosphorous at 4.8 from ___, and mild contraction alkalosis with
bicarb at 36. Please check routine labs at first outpatient
visit to ensure stability and return to baseline.
# CODE: Full (presumed)
# CONTACT: HCP: ___, DAUGHTER, ___
# DISPO: ___, pending above
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Doxazosin 2 mg PO HS
5. Finasteride 5 mg PO QPM
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 300 mg PO DAILY
8. Simvastatin 10 mg PO QPM
9. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB/wheezing
10. Furosemide 40 mg PO QAM
11. Hydroxychloroquine Sulfate 200 mg PO DAILY
12. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
13. Lisinopril 10 mg PO DAILY
14. Methotrexate 15 mg PO 1X/WEEK (WE)
15. Metoprolol Succinate XL 50 mg PO DAILY
16. Warfarin 5 mg PO 1X/WEEK (MO)
17. PredniSONE 5 mg PO DAILY
18. Warfarin 2.5 mg PO 6X/WEEK (___)
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*7 Tablet Refills:*0
3. PredniSONE 5 mg PO DAILY
4. Warfarin 3 mg PO DAILY16
RX *warfarin 3 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB/wheezing
7. Aspirin 81 mg PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Doxazosin 2 mg PO HS
10. Finasteride 5 mg PO QPM
11. FoLIC Acid 1 mg PO DAILY
12. Gabapentin 300 mg PO DAILY
13. Hydroxychloroquine Sulfate 200 mg PO DAILY
14. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
15. Methotrexate 15 mg PO 1X/WEEK (WE)
16. Metoprolol Succinate XL 50 mg PO DAILY
17. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until speaking with your cardiologist
18.Outpatient Lab Work
Date: ___
Labs: Chem (BUN, Cr, Na+, K+, Cl-. HCO3-), INR
Diagnosis: Atrial fibrillation (I48.0), ___ (N17.9)
Please fax results to ___ f. ___ and
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
==================
Congestive Heart Failure
Secondary Diagnosis:
====================
Coronary Artery Disease
Atrial Fibrillation
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had shortness of breath and chest
pain.
What happened while I was in the hospital?
- We did an chest X-ray that showed fluid in your lungs which
was making you short of breath. This extra fluid builds up
because of your heart failure.
- We gave you medications through your veins to help you urinate
out this extra fluid. You will need to continue to take a new
medication called torsemide every day to prevent this fluid from
coming back.
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10833257-DS-41
| 10,833,257 | 22,551,541 |
DS
| 41 |
2199-08-19 00:00:00
|
2199-08-19 16:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amiodarone
Attending: ___
___ Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF THE PRESENTING ILLNESS:
This ___ male (___) with past medical
history of HFpEF (Ef 58%), severe tricuspid regurgitation, CKD 3
(baseline 1.4-1.5), active basal cell cancer (abdomen, declined
treatment ___, HTN, Afib on apixaban, and SSS s/p PPM who
presents with fever.
He reported possible onset of R-sided abdominal pain last night
(but denied later on repeat questioning) without nausea, emesis,
CP, SOB, melena, hematochezia or dysuria. In the ED, he reported
that he had an episode of diarrhea the day before (although on
the floor, he also denied this).
In the ED, initial vitals were:
T 102.2 HR 110 BP 135/75 RR 16 O2 Sat 96% RA
Exam notable for:
General: Ill-appearing
Pulmonary: Bibasilar crackles
Abdominal/GI: Right upper quadrant and right lower quadrant
tenderness
Labs notable for:
UA positive for large leukocytes, positive for nitrites, 30
protein, few bacteria, previously grew pan-sensitive
pseudomonas.
Cr 2.1
Lactate 2.2 -> 1.6 -> 2.7
CBC: WBC 10.1, Hgb ___, Plt 122
BNP 2249
Imaging was notable for:
CT A/P with Contrast ___
1. Moderate right and small left nonhemorrhagic pleural
effusions. Cannot exclude overlying infectious process.
2. No acute findings within the abdomen or pelvis to correlate
with the patient's symptoms.
3. Resolution of previously demonstrated colonic wall
thickening.
There is persistent trace subhepatic nonhemorrhagic fluid with
some haziness of the right-sided mesentery which overall appears
improved from the prior study. No organized fluid collections.
4. Interval mild increase in size of a 3.0 cm left pelvic
sidewall soft tissue density lesion.
5. Extensive diverticulosis of the bladder, unchanged from the
prior study and likely related to chronic outlet obstruction.
CXR ___
1. Increased pulmonary vascular congestion with findings
concerning for central pulmonary edema, however superimposed
pneumonia is difficult to exclude.
2. Interval increase in moderate cardiomegaly.
Patient was given:
- IV ceftriaxone 1g at 3AM
- Apixaban 2.5mg PO
- Hydroxychloroquine 200mg PO
- APAP 1g
- IV ciprofloxacin 400mg
- PO azithromycin 500mg
Consults: None
VS Prior to Transfer:
HR 85 BP 111/58 RR 18 O2 Sat 96% RA
Upon arrival to the floor, patient reports overall feeling well.
He endorses that fever started the night before (T=102)
associated with chills and shivering, but he otherwise had no
symptoms. Specifically he reported increased urinary frequency
without dysuria or hematuria. He also reported that he has had
dyspnea with turning to the side while laying in bed over the
last day, but he denies cough. He has had no sick contacts. He
does intermittently cough when he eats.
He reports that about ___ weeks ago, he had a stent placed in
his
left lower extremity vein at the ___
wound healing. (___). He was prescribed tramadol for
pain, which he still uses intermittently. He received no
antibiotics. He has been seen weekly and was last seen this past
___. He was told that his wound was healing well.
On the floor, he also reports new onset of left back pain. He
has
had some itching on his back recently without rash. He denies
any
headache, blurred vision, or other complaints.
On reviewing his chart, it appears that he has had issues with
left lower extremity arterial insufficiency and underwent
angiography and PCI on ___ ___. He was
to get another procedure in several weeks due to non-healing
ulcers and pain at rest.
He also has a history of severe C. diff diarrhea requiring PO
vancomycin and flagyl. He was most recently treated for C.diff
in
___ when he was admitted for lightheadedness and
diarrhea.
He had a prolonged taper of vancomycin then.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
-heart failure with preserved EF
-severe TR on last ECHO
-CKD
-HTN
-atrial fibrillation
-SSS s/p PPM
-colon CA s/p hemicolectomy
-seronegative RA/CPPD disease
-macrocytic anemia
-active hepatitis C
-iron deficiency
-basal cell carcinoma on abdomen (declined treatment ___
-chronic sialoadenitis
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITAL SIGNS: T 97.6 BP 114 / 66 HR 77 RR 20 O2 Sat 95 2L
GENERAL: Appears comfortable, in no distress. Sitting up in bed
HEENT: EOMI. Oral mucosa moist.
NECK: No adenopathy. No JVD appreciated but with significant
regurg from TR.
CARDIAC: Regular rate and rhythm, no murmurs.
LUNGS: Lungs with crackles at the bases. No wheezes.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: 2+ lower extremity edema. Venous insufficiency.
Left leg wrapped. Poor pulses appreciated given bandages.
NEUROLOGIC: Mood and affect appropriate
SKIN: Venous stasis and insufficiency as above.
DISCHARGE PHYSICAL EXAM:
========================
VITAL SIGNS:
___ 0859 Temp: 98.3 PO BP: 128/64 HR: 77 RR: 20 O2 sat: 96%
O2 delivery: RA
Weight: 157.8lbs/71.6kg
GENERAL: Appears comfortable, in no distress. Sitting up in
bed.
HEENT: EOMI. Oral mucosa moist.
NECK: No adenopathy. No JVD appreciated but with significant
regurg from TR.
CARDIAC: Regular rate and rhythm, no murmurs.
LUNGS: Lungs with soft crackles at the bases. No wheezes.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: 2+ lower extremity edema extending up to his mid
shins. Venous insufficiency.
SKIN: Venous stasis and insufficiency as above. Multiple
ecchymosis over extremities in upper and lower extremities and
on
chest. Open skin on bilateral upper extremities.
Pertinent Results:
ADMISSION LABS:
===============
___ 01:30AM WBC-10.1* RBC-3.06* HGB-8.2* HCT-28.1* MCV-92
MCH-26.8 MCHC-29.2* RDW-22.4* RDWSD-75.6*
___ 01:30AM NEUTS-82.5* LYMPHS-11.1* MONOS-5.9 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-8.30* AbsLymp-1.12* AbsMono-0.59
AbsEos-0.00* AbsBaso-0.01
___ 01:30AM GLUCOSE-83 UREA N-45* CREAT-2.1* SODIUM-137
POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-25 ANION GAP-15
___ 01:35AM LACTATE-2.2*
___ 01:30AM LIPASE-29
___ 01:30AM proBNP-___*
___ 06:33PM PO2-47* PCO2-54* PH-7.32* TOTAL CO2-29 BASE
XS-0
MICROBIOLOGY:
==============
___ BLOOD CULTUREBlood Culture, Routine-PRELIMINARY
{STREPTOCOCCUS GALLOLYTICUS SSP. PASTEURIANUS (STREPTOCOCCUS
BOVIS)}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle Gram
Stain-FINAL
___ CULTURE-FINAL {PSEUDOMONAS AERUGINOSA}
**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.
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ 4 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
S. PNEUMONIAE ANTIGENS, Not Detected Not Detected
URINE
PERTINENT LABS:
===============
CBC Trend
___ 01:30AM BLOOD WBC-10.1* RBC-3.06* Hgb-8.2* Hct-28.1*
MCV-92 MCH-26.8 MCHC-29.2* RDW-22.4* RDWSD-75.6* Plt ___
___ 06:40AM BLOOD WBC-10.2* RBC-2.87* Hgb-7.8* Hct-27.1*
MCV-94 MCH-27.2 MCHC-28.8* RDW-22.6* RDWSD-78.0* Plt ___
___ 01:10PM BLOOD WBC-7.7 RBC-2.68* Hgb-7.2* Hct-24.4*
MCV-91 MCH-26.9 MCHC-29.5* RDW-22.5* RDWSD-75.2* Plt ___
___ 05:51AM BLOOD WBC-8.4 RBC-2.55* Hgb-6.9* Hct-23.1*
MCV-91 MCH-27.1 MCHC-29.9* RDW-22.6* RDWSD-74.9* Plt ___
___ 05:52AM BLOOD WBC-8.0 RBC-2.81* Hgb-7.7* Hct-25.9*
MCV-92 MCH-27.4 MCHC-29.7* RDW-21.7* RDWSD-73.6* Plt ___
___ 06:30AM BLOOD WBC-6.9 RBC-2.59* Hgb-7.1* Hct-24.0*
MCV-93 MCH-27.4 MCHC-29.6* RDW-21.6* RDWSD-72.8* Plt ___
Creatinine Trend
___ 01:30AM BLOOD Glucose-83 UreaN-45* Creat-2.1* Na-137
K-4.6 Cl-97 HCO3-25 AnGap-15
___ 06:40AM BLOOD Glucose-94 UreaN-53* Creat-2.3* Na-139
K-5.0 Cl-99 HCO3-22 AnGap-18
___ 10:00PM BLOOD Glucose-123* UreaN-74* Creat-3.0* Na-134*
K-4.8 Cl-95* HCO3-22 AnGap-17
___ 06:52AM BLOOD Glucose-98 UreaN-78* Creat-3.2* Na-136
K-4.3 Cl-98 HCO3-25 AnGap-13
___ 05:47AM BLOOD Glucose-107* UreaN-82* Creat-2.7* Na-140
K-4.6 Cl-102 HCO3-25 AnGap-13
___ 06:30AM BLOOD Glucose-119* UreaN-86* Creat-2.6* Na-138
K-4.3 Cl-100 HCO3-24 AnGap-14
Lactate Trend
___ 01:35AM BLOOD Lactate-2.2*
___ 08:00AM BLOOD Lactate-1.6
___ 01:23PM BLOOD Lactate-2.7*
___ 06:33PM BLOOD Lactate-1.6
___ 06:50AM BLOOD Lactate-1.5
CRP Trend
___ 06:52AM BLOOD CRP-28.3*
___ 05:52AM BLOOD CRP-14.4*
DISCHARGE LABS:
===============
___ 06:30AM BLOOD WBC-6.9 RBC-2.59* Hgb-7.1* Hct-24.0*
MCV-93 MCH-27.4 MCHC-29.6* RDW-21.6* RDWSD-72.8* Plt ___
___ 06:30AM BLOOD Glucose-119* UreaN-86* Creat-2.6* Na-138
K-4.3 Cl-100 HCO3-24 AnGap-14
___ 06:30AM BLOOD Calcium-8.4 Phos-5.3* Mg-2.5
Imaging/Studies:
================
CXR ___
1. Increased pulmonary vascular congestion with findings
concerning for
central pulmonary edema, however superimposed pneumonia is
difficult to
exclude.
2. Interval increase in moderate cardiomegaly.
___ CT A/P with Contrast
1. No finding in the abdomen/pelvis to explain the patient's
symptoms.
Bilateral pleural effusions, right greater than left,
potentially masking
underlying pulmonary process as possible cause for the patient's
symptoms.
2. Interval resolution of colitis and decrease in ascites, now
minimal.
3. Slight interval increase in size of left pelvic sidewall
lymph node, now
measuring 2.8 x 3 cm.
4. Stable extensive bladder diverticulosis.
___ TTE
IMPRESSION: Possible vegetation on the tricuspid valve (see clip
42). Differential diagnosis
includes fibrin strand on RV pacer lead. Moderately dilated mild
to moderately hypokinetic right
EMR 2853-P-IP-OP (___) Name: ___ MRN: ___
Study Date: ___ 7:30:00 p. ___
ventricle. Severe tricuspid regurgitation. Low normal global
right ventricular systolic function. At
least moderate mitral regurgitation. Moderate pulmonary
hypertension. Small pericardial
effusion without evidence for tamponade.
Compared with the prior TTE (images reviewed) of ___ ,
possible vegetation seen on the
tricuspid valve, there is more tricuspid regurgitation, the
right ventricle is more dilated and hypokinetic,
the left ventricle is less vigorous.
___
1. Interval improvement of mild pulmonary edema.
2. Unchanged bilateral pleural effusions.
3. No focal consolidation concerning for pneumonia.
___
Normal renal ultrasound. No evidence of hydronephrosis.
Brief Hospital Course:
SUMMARY: ___ ___ with PMH HfPEF 58%, TR, CKD III (Cr 1.5),
Afib on apixaban, SSS s/p PPM, HTN who presents with fever. +/-
abdominal pain, left flank pain. Found to have blood cx growing
S. bovis concerning for colon cancer. He was management
conservatively given his goals of care, and was discharged to a
skilled nursing facility with IV antibiotics.
ACUTE ISSUES
===================
#Bacteremia
#Sepsis
#Endocarditis
He presented with fever and was found to have positive blood
cultures growing GPCs (no GNRs). Initially thought to be d/t
recent instrumentation for ___ stent placement but now with
echo showing vegetation and BCx speciated to s. Bovis. This
association is well known to be correlated with colon cancer.
Additionally it is possible and highly likely that the lead of
the pacemaker is also infected per the echo. Of note, the
patient has a history of basal cell cancer which he and his
family chose not to pursue treatment for. Additionally, CT scan
did not show any colonic pathology, though this was a CTA and
not a barium contrast study. urine legionella negative. He
received vancomycin and ceftriaxone, but eventually transitioned
to IV Ceftriaxone 2g q24hr for a total 4 week course ___ -
___. A PICC was placed on ___. Cardiology was consulted and
suggested TEE. However, this was not within patient's goals of
care, per his daughter. Removal of pacemaker is also not within
goals of care.
- Pt needs weekly CBC with diff, BUN, Cr, AST, ALT, Tbili, Alk
phos and CRP
# Hypoxia- 2L NC
# Elevated BNP- at baseline
# Chronic HFpEF
# Acute decompensated heart failure
His normal regimen is Torsemide 40mg daily and, PRN metolazone
2.5mg. His BNP on admission was 2200s, at baseline (last BNP
also ___ in early ___ but with CXR showed congestion at
admission. His weight is 160lb which is similar to his discharge
weight of 159lb in ___, during which he was clinically
euvolemic. He required O2 intermittently at 2L and was found to
have crackles in lung bases, with JVD, and edema extending
higher than on admission. CXR with interval improvement of mild
pulmonary edema and stable as of ___. His metoprolol was
continued for his tachycardia ___ A. fib found on EKG. His
Lisinopril and isosorbide mononitrate were held given concern
for infection as well as ___.
# ___ on CKD:
He has baseline CKD III with Cr 1.2-1.6. Most recent Cr was 1.5
in ___, now presenting with Cr 2.3 and increased to 3.2,
was 2.6 on day of discharge. This could be secondary to ATN in
setting of sepsis (although should be improved by now given
normotension while in house) vs. contrast-induced nephropathy
(received contrast on ___ vs. obstruction (has required
frequent straight caths) vs. cardiorenal syndrome (but not
overtly volume overloaded on exam, CXR stable, did not respond
well to IV diuresis). A renal U/S showed no hydronephrosis.
Intermittent hemodialysis was discussed but the patient
determined that was not within his goals of care. Foley catheter
was placed on day of discharge for continued urinary retention.
He should get a foley trial as an outpatient in about one week
with Urology.
Stable issues:
==============
#Acute coronary syndrome (Stable, resolved)
Patient complained of CP radiating to L arm with a pressure like
feeling, SOB, and had emesis x1 on day 3 of hospitalization. His
sx also improved with NG. Trop elevated to 0.13, then 0.11. CKMB
10. EKG with no changes appreciated. Cardiology informed and
followed; no heparin drip was indicated given downtrending
troponins. He received nitroglycerin sublingual x 3 with some
resolution of pain, Aspirin 325mg, and Atorvastatin 80mg for
this episode.
#Pyuria- Stable
His pyuria, leukocystosis, flank pain, and frequent urination
were initially concerning for pyelonephritis. Of note, he was
previously pan-sensitive pseudomonas but also note suspicion for
chronic colonization. At last admission, pt had urinary
frequency but UTI was not treated since he improved with C.diff
treatment. His current left back pain seems secondary to MSK
strain. CT scan did not show any abdominal pathology and given
his relatively normal LFTs, will not continue to trend or
evaluate with ultrasound. On exam he has no CVA tenderness and
his pain is reproducible by palpation of the upper hip, thus it
is most likely to be musculoskeletal. A urine culture did show
pseudomonas colonization but without urinary symptoms,
antibiotic treatment was deferred.
# Lactic acidosis (Resolved)
It peaked to 2.7, improved to 1.6 on recheck without fluids.
# Thrombocytopenia:
He has multiple ecchymosis over extremities and even truncal
area, likely due to triple therapy with aspirin, clopidogrel and
Apixaban. Aspirin was discontinued in consultation with his
vascular surgeon given his recent lower extremity stent
placement. His platelet count on discharge was 118, and multiple
ecchymoses with skin tearing and bleeding on the extremities
were persistent.
# Anemia:
His Hgb is 8.2, baseline around 8. It could be related to CKD
with poor EPO production vs anemia of chronic disease. No active
bleeding identified. On vitamin B12 although notably his recent
Vit B12 level was > ___ in ___ and his anemia is not
macrocytic. He has also since been d/c-ed off methotrexate. His
home vitamin B12 and folate were continued. He received 1U blood
on ___. His discharge Hgb was 7.1, and he may require frequent
transfusions.
CHRONIC ISSUES:
===============
# Goals of care:
DNR/DNI was confirmed ___. He wishes to "go in peace". MOLST
form was signed.
# Lower extremity insufficiency- s/p recent stent placement.
He noted some mild pain related to procedure, His Plavix and
apixaban were continued, aspirin d/c'd given above conversation
with vascular surgeon.
# SSS s/p Pacemaker
It was last interrogated by Dr. ___ on ___ and was noted
to be functioning well without arrhythmias
# Benign prostatic hypertrophy
Finasteride was continued. Tamsulosin was added.
# Hx of HCV infection:
This was documented on prior discharge summary with plan for
Hepatology follow-up. Later, on ___, patient reported to Dr.
___ that he wanted to minimize MD appointments
and did not want to see Hepatology. "does not want to be treated
for his abdominal BCC or hepatitis C, even though he is aware
that without treatments, these conditions will likely worsen and
negatively impact his death, namely risk of liver failure,
invasive cancer, mets, death."
# Health maintenance
Multivitamin with folate, vitamin D, vitamin B12, atorvastatin
were continued
# Rheumatoid arthritis
His hydroxychloroquine and prednisone 5mg daily were continued.
Transitional Issues:
====================
NEW MEDICATIONS:
- IV ceftriaxone 2g every 24 hours
Start Date: ___
Projected End Date: ___
- Tamsulosin
HELD MEDICATIONS:
- Blood pressure medications: Lisinopril, isosorbide mononitrate
--- Do not restart Lisinopril until ___ improves
- Diuresis: Torsemide, metolazone (Restart if weight goes up
greater than ___ lbs)
- Potassium tablets
STOPPED MEDICATIONS:
- Aspirin (due to increased risk of bleed)
ACCESS: ___
[] Patient is discharged with Foley. Recommend voiding trial in
one week with ___ clinic
[] Antibiotic recommendations-
NEEDS WEEKLY: CBC with differential, BUN, Cr, AST, ALT, Total
Bili, ALK PHOS, and CRP
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
[] Patient will follow with ID for final recommendations
regarding antibiotic course. The ___ will schedule further
follow up (the next follow up is ___ and contact the patient
or discharge facility. All questions regarding outpatient
parenteral antibiotics after discharge should be directed to the
___ R.N.s at ___ or to the on-call ID
fellow when the clinic is closed.
[] Patient declined dialysis in house. If confusion worsens,
consider worsening uremia and palliative care referral or
hospice
Code: DNR/DNI
Proxy name: ___
Relationship: Daughter Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Cyanocobalamin 1000 mcg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Hydroxychloroquine Sulfate 200 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Potassium Chloride 20 mEq PO DAILY
8. PredniSONE 5 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Torsemide 40 mg PO DAILY
11. Lisinopril 2.5 mg PO DAILY
12. Apixaban 2.5 mg PO BID
13. MetOLazone 2.5 mg PO PRN volume overload
14. Aspirin 81 mg PO DAILY
15. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
16. Clopidogrel 75 mg PO DAILY
17. FoLIC Acid 1 mg PO DAILY
18. TraMADol 50 mg PO QHS:PRN Pain - Severe
Discharge Medications:
1. CefTRIAXone 2 gm IV Q 24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g once a day
Disp #*22 Intravenous Bag Refills:*0
2. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth Every night Disp
#*30 Capsule Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Apixaban 2.5 mg PO BID
5. Atorvastatin 10 mg PO QPM
6. Clopidogrel 75 mg PO DAILY
7. Cyanocobalamin 1000 mcg PO DAILY
8. Finasteride 5 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Hydroxychloroquine Sulfate 200 mg PO DAILY
11. Metoprolol Succinate XL 50 mg PO DAILY
12. PredniSONE 5 mg PO DAILY
13. TraMADol 50 mg PO QHS:PRN Pain - Severe
14. Vitamin D 1000 UNIT PO DAILY
15. HELD- Isosorbide Mononitrate (Extended Release) 60 mg PO
DAILY This medication was held. Do not restart Isosorbide
Mononitrate (Extended Release) until your doctor tells ___ to.
___ may not need this anymore.
16. HELD- Lisinopril 2.5 mg PO DAILY This medication was held.
Do not restart Lisinopril until your doctor tells ___ to. ___
may not need this anymore.
17. HELD- MetOLazone 2.5 mg PO PRN volume overload This
medication was held. Do not restart MetOLazone until ___ gain
weight >3lbs or feel short of breath.
18. HELD- Potassium Chloride 20 mEq PO DAILY This medication
was held. Do not restart Potassium Chloride until ___ take
metolazone or torsemide.
19. HELD- Torsemide 40 mg PO DAILY This medication was held. Do
not restart Torsemide until ___ gain >3lbs or ___ feel short of
breath.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
===================
S. ___ bacteremia
Acute on chronic heart failure with preserved ejection fraction
Acute Kidney injury on chronic kidney disease
Secondary Diagnoses:
====================
Urinary retention
Acute coronary syndrome
Thrombocytopenia
Anemia
Pyuria
Lower extremity vascular insufficiency
Atrial fibrillation
Sick sinus syndrome s/p pacemaker
Benign Prostatic Hypertrophy
Hx of HCV infection
Rheumatoid Arthritis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair with walker use intermittently.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of ___ at the ___
___!
Why was I admitted to the hospital?
- ___ were admitted for a fever
- ___ were found to be growing bacteria (Strep bovis) in your
blood
What happened while I was in the hospital?
- ___ received IV antibiotics to treat your blood infection. We
placed a PICC line so that ___ can get IV antibiotics when ___
leave the hospital
- We offered to look at your pacemaker to see if it was
infected, but ___ declined
- We offered a colonoscopy to look for colon cancer (which is
often associated with your bacteria) but ___ declined
- ___ also received diuretic medicines to help remove the fluid
in your body.
- Your kidney function got worse in the hospital. ___ declined
dialysis. It was improving slightly on discharge, but we placed
a Foley catheter (since ___ cannot urinate on your own). ___
will need to have this catheter in for about a week.
What should I do after leaving the hospital?
- ___ will be going to ___
- ___ should see urology in about one week to see if we can
remove your Foley
- Please take your medications as listed in discharge summary
- We stopped your diuretics, but if your weight starts to go up
(over ___ lbs within ___ days), it is important to restart your
diuresis. Discharge weight is 157 lbs.
Thank ___ for allowing us to be involved in your care, we wish
___ all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10833257-DS-42
| 10,833,257 | 22,333,679 |
DS
| 42 |
2199-09-01 00:00:00
|
2199-09-07 20:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male (___) with past
medical history of HFpEF (Ef 58%), severe tricuspid
regurgitation, CKD 3 (baseline 1.4-1.5), active basal cell
cancer
(abdomen, declined treatment ___, HTN, Afib on apixaban, SSS
s/p PPM, and recent hospitalization from ___ for Strep
bovis
bacteremia and endocarditis (discharged to rehab on IV
ceftriaxone) who presents from ___ with bilat arm
swelling and skin tears and bleeding.
On arrival to the ED, he was noted to have Hgb 6.4 (Hgb 6.8 at
rehab, decreased from 7.1 on discharge from hospital on ___.
His
blood pressure was difficult to take given his skin tears on his
arms, but initial measurement was notable for BP 75/59. Of note,
he had reported two melanotic stools on ___ but had not
had any bowel movements since then.
Vitals
T 96.1 HR 63 BP 75/59 RR 17 O2 Sat 93% RA
His BP improved to 121/90 with 1U RBC. He was noted to have
blood-tinged urine in his Foley although no clots were
identified. Wounds to his bilateral upper extremities were
redressed. His FOBT was positive. INR 2.2.
He was given IV ceftriaxone 2g and IV pantoprazole 40mg.
CXR showed moderate bilateral pleural effusions with
atelectasis.
Right PICC tip in the mid SVC.
GI was consulted but felt that the anemia should just be
addressed with transfusions. Since the patient did not want
colonoscopy and EGD during the prior admission, they did not
recommend further intervention unless the patient's goals of
care
should change. They recommended changing the patient's PPI from
IV to PO twice daily.
Vitals prior to transfer
HR 70 BP 127/62 RR 20 O2 Sat 95% RA
On arrival to the floor, he appears well. He denies any pain,
dizziness or lightheadedness. He is not having any active
bleeding at this time. His arms are wrapped.
Past Medical History:
-heart failure with preserved EF
-severe TR on last ECHO
-CKD
-HTN
-atrial fibrillation
-SSS s/p PPM
-colon CA s/p hemicolectomy
-seronegative RA/CPPD disease
-macrocytic anemia
-active hepatitis C
-iron deficiency
-basal cell carcinoma on abdomen (declined treatment ___
-chronic sialoadenitis
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
GENERAL: Appears comfortable, in no distress. Sitting up in
bed.
HEENT: EOMI. Oral mucosa moist.
NECK: No adenopathy. No JVD appreciated but with significant
regurg from TR.
CARDIAC: Regular rate and rhythm, no murmurs.
LUNGS: Lungs with soft crackles at the bases. No wheezes.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: 2+ lower extremity edema extending up to his mid
shins. Venous insufficiency. PICC in R arm.
SKIN: Venous stasis and insufficiency as above. Multiple
ecchymosis over extremities in upper and lower extremities and
on
chest. Open skin on bilateral upper extremities.
DISCHARGE PHYSICAL EXAM
==========================
VITALS: 24 HR Data (last updated ___
Temp: 97.4 (Tm 97.7), BP: 167/76 (108-167/60-76), HR: 77
(77-91), RR: 10 (___), O2 sat: 93% (90-100)
General: chronically ill elderly man lying in bed, in no acute
distress
HEENT: NC/AT, sclera anicteric and without injection
CV: Regular rate, irregularly irregular rhythm, normal S1 + S2,
no murmurs, rubs, gallops
Abdomen: NTND
Neuro: Opens eyes to touch, not voice.
Skin: multiple large bruises and ecchymoses over upper
extremities and chest as well as lower extremities
Pertinent Results:
SEE OMR
Brief Hospital Course:
SUMMARY: Mr. ___ is a ___ male (___)
with past
medical history of HFpEF (Ef 58%), severe tricuspid
regurgitation, CKD 3 (baseline 1.4-1.5), active basal cell
cancer
(abdomen, declined treatment ___, HTN, Afib on apixaban, SSS
s/p PPM, and recent hospitalization from ___ for Strep
bovis
bacteremia and endocarditis (discharged to rehab on IV
ceftriaxone) who initially presented from ___
with
bilat arm swelling and skin tears and bleeding. On arrival to
our ED he was
noted to be anemic to Hgb 6.4 thought to be due to bleeding from
the GI tract i/s/o melanotic FOBT positive stools. GI was
consulted but endoscopy was not within goals of care so they
signed off. His anemia was treated with transfusions prn. His
course has been complicated by altered mental status,
precipitating CODE STROKE with negative NCHCT as well as sepsis
secondary to VRE UTI requiring transfer to the ICU for fluid
resuscitation (never on pressors, no central line placed). On
the floor his UTI was treated with linezolid. However he was
noted to be thrombocytopenic so linezolid was stopped and
transitioned to daptomycin. Despite appropriate antibiotic
regimen with daptomycin for his UTI and endocarditis he
continued to deteriorate with worsening thrombocytopenia, and
worsening renal function. He was intermittently somnolent,
refusing and unable to take p.o. medications. Continued to have
bleeding from his multiple ecchymoses. Noted to have dark and
tarry stools. Family opted to have him eat and drink normally
for comfort despite aspiration risk. After multiple goals of
care discussions with family, decision was made to make him
comfort measures only on ___. His medications such as
antibiotics, multivitamins, steroids, PPI, etc. were stopped. He
was provided pain medications as needed, and medications to help
with his secretions.
===================
Transitional Issues
===================
[] Please continue to ensure patient comfort.
====================
Acute Medical Issues
====================
#GOC
#CMO
He is DNR/DNI. On ___ after further ___ discussions with family
decided that they do not want him to return to the ICU. They did
not want invasive procedures but okay for antibiotics, fluids.
Ok to take
food and drink by mouth despite aspiration risk per family
wishes. On the floor he continued to become more somnolent,
refused PO medications frequently. Blood counts continuing to
decline and renal function worsening despite antibiotics. Per
discussion with family on ___, patient is now CMO.
#Bilateral UE Skin Tears/Ecchymoses
Noted to have bilateral upper extremity skin tears on admission
with Bleeding. His wounds were dressed with gauze during his
admission.
#Acute on chronic thrombocytopenia, worsening
On presentation had multiple ecchymoses over extremities and
trunk. Appears to
have chronic thrombocytopenia. ___ labs ___ reassuring against
DIC. Likely exacerbated by linezolid. Transitioned from
linezolid to daptomycin ___. Platelets continued to downtrend
to 29. When he transition to CMO labs were no longer followed.
#Dry cough
First noted on ___ by family. Likely ___ aspiration given he
Was at high aspiration risk but family has opted for regular
diet
for comfort. Hyoscyamine for secretions.
#Sepsis, resolved
#Strep bovis Endocarditis
#VRE UTI
Patient with recent admission for S. Bovis bacteremia and with
TTE showing vegetation. TEE deferred by family as not within
___.
Discharged on IV Ceftriaxone 2g q24hr for a total 4 week course
(___). PICC placed on ___. Patient readmitted 2 days after
discharge for acute anemia and anasarca. Triggered ___ for
hypotension with SBPs in ___ and altered mentation. Of note, had
been having rising leukocytosis up to 15 and rising lactate that
peaked at delivery prior to transfer. He was started on
Linezolid. He received 750cc
IVF with improvement in pressures. However, given tenuous state
and concern for septic shock was transferred to the unit. Per
___
discussion prior to transfer, no further invasive lines, HD, or
procedures. Family wanted to try medications and antibiotics
to see if patient has improvement. Confirmed DNR/DNI. S/p
increased prednisone to 15mg x 3 days (___). Linezolid
transitioned to daptomycin for VRE UTI (ends ___ due to
thrombocytopenia. On ___ antibiotics stopped after ___
discussions and decision to have patient CMO.
#TME
Patient noted to be confused with unequal pupils ___.
Code stroke called but non-contrast head CT (no bleed) performed
as family did not want to risk contrast given CKD. Mental status
improved morning ___ per family but was still waxing and
waning.
Reportedly also had hallucinations per patient
himself. Likely multifactorial in the setting of language
barrier, change in surroundings, advanced age, disruption of
sleep-wake cycle, uremia, critical illness. Delirium precautions
were maintained on the floor. His ramelteon and Seroquel stopped
for CMO.
#Acute on Chronic HFpEF
EF 50% ___. Home torsemide was held on admission. On transfer
to the floor he was mildly volume overloaded on exam after 80 mg
IV Lasix on ___. Resumed home Torsemide 40mg daily ___ but
patient did not take PO so given Lasix 80mg IV. Diuretics
stopped on ___
for CMO.
#Acute on Chronic Normocytic Anemia
He presented with hemoglobin 6.6. Likely multifactorial in the
setting of CKD IV-V (poor EPO production), presumed colon cancer
(patient has history of polyps
and declined colon cancer screening or colonoscopy on prior
admission), medications (patient was on aspirin, apixaban, and
plavix on recent hospitalization and only recently discontinued
apixaban), skin tears/hematuria. Family and patient declined
EGD/colonoscopy previously. Has received multiple transfusions
this admission. PPI stopped for CMO on ___. GI scopes not
within ___.
___ on CKD
#Hematuria (from prior traumatic foley placements and triple
therapy)
Previously had baseline CKD III with Cr 1.2-1.6. Most recent Cr
1.5 in ___, recent hospitalization revealed peak Cr 3.2.
This insult was attributed to contrast-induced nephropathy vs
obstruction (discharged with ___ given failure to void). Foley
discontinued ___. FeUr 33.72% suggesting pre-renal etiology. Cr
uptrended to 3.8 while on the floor but was no longer trended
when patient became CMO.
#NSTEMI, Type II
Patient complained of CP radiating to L arm with a pressure like
feeling, SOB, and had emesis x1 during last admission.
Cardiology
was informed and recommended no heparin drip at that time.
Troponin 0 0.14×2 with a mildly elevated MB likely representing
demand, decreased clearance in the setting ___ on CKD.
Patient asymptomatic this admission. Statin stopped on ___ for
CMO.
=====================
Chronic Medical Issues
======================
# Afib: Patient was monitored on telemetry. Apixaban was held
given acute anemia. Metoprolol was temporarily held due to
hypotension and bleeding.
# SSS s/p Pacemaker
Last interrogated by Dr. ___ on ___ and was noted to be
functioning well without arrhythmias.
# Benign prostatic hypertrophy: Stopped finasteride, tamsulosin
___ for CMO.
# Hx of HCV infection:
Per prior discharge summary and documentation - on ___,
patient reported to Dr. ___ that he wanted to
minimize MD appointments and did not want to see Hepatology.
"does not want to be treated for his abdominal BCC or hepatitis
C, even though he is aware that without treatments, these
conditions will likely worsen and negatively impact his health,
namely risk of liver failure, invasive cancer, mets, death."
# Vitamin Deficiency
Was on multivitamin with folate, vitaminD, vitamin B12
- Vitamins stopped ___ for CMO. Patient refusing PO meds.
# Rheumatoid Arthritis
Has had methotrexate held since ___ not currently taking,
declined to follow up with rheumatology. Received his home pred
5
this admission and methylpred when unable to take PO. Steroids
stopped ___ for CMO.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CefTRIAXone 2 gm IV Q 24H
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. Apixaban 2.5 mg PO BID
4. Clopidogrel 75 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Finasteride 5 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Hydroxychloroquine Sulfate 200 mg PO DAILY
10. PredniSONE 5 mg PO DAILY
11. TraMADol 50 mg PO QHS:PRN Pain - Severe
12. Tamsulosin 0.4 mg PO QHS
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Pravastatin 40 mg PO QPM
Discharge Medications:
1. Glycopyrrolate 0.1-0.2 mg IV Q4H:PRN excess secretions
2. Haloperidol 0.5-2 mg IV Q4H:PRN nausea/vomiting
3. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q15MIN:PRN
moderate-severe pain or respiratory distress
4. LORazepam 0.5-2 mg IV Q2H:PRN anxiety
5. Morphine Sulfate ___ mg IV Q6H:PRN Pain - Moderate
6. OLANZapine (Disintegrating Tablet) 5 mg PO Q4H:PRN delirium
Discharge Disposition:
Expired
Facility:
___
Discharge Diagnosis:
Primary diagnoses
==================
Acute anemia
VRE UTI
Thrombocytopenia
Endocarditis
Lower GI bleed
Secondary diagnoses
====================
- HFpEF
- Labile hypertension
- Chronic AF
- Moderate/severe TR, moderate MR
- CKD, stage 3
- Colon cancer, s.p. right hemicolectomy.
- Rheumatoid arthritis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
- You were admitted because you had low blood counts.
What happened while I was in the hospital?
-We transfused red blood cells into your blood to stabilize your
blood counts.
-You were found to have low blood pressure and had to be
transferred.
-You were started on antibiotics for urinary tract infection.
-You continued to have bleeding from your skin and your
intestines.
-Your kidneys were damaged and your kidney function worsened
during your stay.
-You were not able to take medications by mouth.
-Your family decided that it was in your best interest to stop
___ medical procedures and pursue comfort measures only.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10833304-DS-11
| 10,833,304 | 21,689,216 |
DS
| 11 |
2193-06-10 00:00:00
|
2193-06-11 10:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine / lisinopril
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ Laparoscopic Cholecystectomy
___ ERCP with sphincterotomy and placement of a ___ X 5cm
Advanix double pigtail biliary stent.
History of Present Illness:
Patient is a ___ year old female with a history of chronic
abdominal pain who presents for evaluation of worsening
abdominal pain. Patient has been seen in the ED three times for
the same pain over the last week. She had CT abd/pelvis
and a RUQ u/s that were without explanation of her pain. Patient
states she has not been able to tolerate PO for the last week.
No black or bloody stool. No fevers, chest pain, or difficulty
breathing. No syncope or dizziness. Patient
states she has previously had an extensive workup including an
upper GI series as well as endoscopy and colonoscopy.
Past Medical History:
- B12 deficiency/Pernicious anemia.
- Fibroids.
- Hypertension.
- Hypothyroidism.
- Insomnia.
- Anemia.
- Depression.
- Posttraumatic stress disorder.
- Vitamin D deficiency.
- Pubic rami fracture.
- Rectal bleeding.
- Ovarian cyst.
Social History:
___
Family History:
Estranged from family. The patient is of ___ ethnic
descent.
Physical Exam:
Admission Physical Exam:
Temp: 98.3 HR: 94 BP: 123/59 Resp: 18 O(2)Sat: 99 Normal
Constitutional: Comfortable, awake and alert
HEENT: Normocephalic, atraumatic
Chest: Clear to auscultation, normal effort
Cardiovascular: Regular Rate and Rhythm, Normal first and second
heart sounds
Abdominal: Soft, Nondistended, focal RUQ TTP, no rebound or
gurarding
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent, moving all extremities
Discharge Physical Exam
VS:98.6, 73, 113/59, 18, 98% RA
Gen: Awake, sitting up in chair, pleasant and interactive.
HEENT: No deformity. PERRL, EOMI. Neck supple, trachea midline.
Mucus membranes pink/moist.
CV: RRR
Pulm: Clear to auscultation bilaterally.
Abd: Soft, non-tender, non-distended. Laparoscopic incisions
well healed with small amount of dermabond on skin.
Ext: Warm and dry. 2+ ___ pulse. no edema.
Neuro: A&Ox3, follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 07:20AM BLOOD WBC-10.2* RBC-3.70* Hgb-10.8* Hct-30.6*
MCV-83 MCH-29.2 MCHC-35.3 RDW-13.7 RDWSD-40.4 Plt ___
___ 08:45AM BLOOD WBC-12.8* RBC-3.88* Hgb-11.2 Hct-32.2*
MCV-83 MCH-28.9 MCHC-34.8 RDW-13.4 RDWSD-40.0 Plt ___
___ 08:18AM BLOOD WBC-9.7 RBC-3.47* Hgb-10.1* Hct-29.1*
MCV-84 MCH-29.1 MCHC-34.7 RDW-13.4 RDWSD-41.0 Plt ___
___ 09:45AM BLOOD WBC-10.2* RBC-3.68* Hgb-10.8* Hct-30.3*
MCV-82 MCH-29.3 MCHC-35.6 RDW-13.2 RDWSD-39.6 Plt ___
___ 07:20AM BLOOD WBC-7.5 RBC-3.77* Hgb-11.0* Hct-31.2*
MCV-83 MCH-29.2 MCHC-35.3 RDW-13.0 RDWSD-39.6 Plt ___
___ 07:40AM BLOOD WBC-8.8 RBC-3.36* Hgb-9.8* Hct-27.8*
MCV-83 MCH-29.2 MCHC-35.3 RDW-13.0 RDWSD-39.3 Plt ___
___ 02:58PM BLOOD WBC-10.5* RBC-3.55* Hgb-10.4* Hct-29.5*
MCV-83 MCH-29.3 MCHC-35.3 RDW-13.0 RDWSD-39.5 Plt ___
___ 08:10AM BLOOD WBC-12.2* RBC-3.97 Hgb-11.7 Hct-33.2*
MCV-84 MCH-29.5 MCHC-35.2 RDW-13.1 RDWSD-40.2 Plt ___
___ 09:45AM BLOOD ___ PTT-34.7 ___
___ 08:10AM BLOOD ___ PTT-26.8 ___
___ 07:20AM BLOOD Glucose-101* UreaN-10 Creat-1.0 Na-134
K-3.2* Cl-92* HCO3-29 AnGap-16
___ 08:45AM BLOOD Glucose-120* UreaN-11 Creat-1.1 Na-138
K-3.6 Cl-98 HCO3-25 AnGap-19
___ 08:18AM BLOOD Glucose-99 UreaN-13 Creat-0.9 Na-137
K-3.7 Cl-99 HCO3-29 AnGap-13
___ 09:45AM BLOOD Glucose-128* UreaN-8 Creat-0.9 Na-135
K-3.2* Cl-93* HCO3-30 AnGap-15
___ 07:20AM BLOOD Glucose-120* UreaN-6 Creat-1.0 Na-140
K-3.0* Cl-97 HCO3-29 AnGap-17
___ 07:40AM BLOOD Glucose-118* UreaN-8 Creat-0.9 Na-138
K-3.5 Cl-103 HCO3-27 AnGap-12
___ 02:58PM BLOOD Glucose-125* UreaN-9 Creat-0.9 Na-136
K-3.2* Cl-100 HCO3-28 AnGap-11
___ 06:38AM BLOOD Glucose-134* UreaN-16 Creat-0.9 Na-138
K-3.6 Cl-101 HCO3-25 AnGap-16
___ 08:10AM BLOOD Glucose-94 UreaN-26* Creat-1.3* Na-138
K-4.6 Cl-95* HCO3-28 AnGap-20
___ 07:20AM BLOOD ALT-101* AST-76* AlkPhos-197* TotBili-0.9
___ 08:45AM BLOOD ALT-100* AST-76* AlkPhos-220* TotBili-1.0
___ 08:18AM BLOOD ALT-85* AST-70* AlkPhos-195* TotBili-1.1
___ 09:45AM BLOOD ALT-93* AST-93* AlkPhos-219* TotBili-1.6*
___ 07:20AM BLOOD ALT-76* AST-63* AlkPhos-201* TotBili-2.4*
___ 08:10AM BLOOD ALT-24 AST-35 AlkPhos-56 TotBili-0.4
___ 08:45AM BLOOD Lipase-153*
___ 08:18AM BLOOD Lipase-74*
___ 09:45AM BLOOD Lipase-25
___ 07:20AM BLOOD Lipase-33
___ 08:10AM BLOOD Lipase-28
___ 09:50AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 07:20AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.1
___ 08:45AM BLOOD Calcium-9.3 Phos-2.8 Mg-2.0
___ 08:18AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.1
___ 09:45AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.1
___ 07:20AM BLOOD Calcium-8.8 Phos-2.3* Mg-1.7
___ 07:40AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.8
___ 02:58PM BLOOD Calcium-8.6 Phos-2.5* Mg-1.8
___ 06:38AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.1
___ 08:34AM BLOOD Lactate-1.5
Brief Hospital Course:
Ms. ___ is a ___ yo F admitted to the Acute Care Surgery
Service on ___ with abdominal pain. She had a CT scan that
showed cholelithiasis and acute cholecystitis. Informed consent
was obtained and she was taken to the operating room on ___
for a laparoscopic cholecystectomy. Please see operative report
for details. She was extubated post operatively and taken to the
PACU in stable condition. She was then transferred to the
surgical floor for further management.
Post operatively she had unremitting nausea, vomiting, and
increased abdominal pain and distention despite Zofran and
minimizing and trying different narcotic agents. On POD4 her
total bilirubin was noted to be elevated at 2.4 with a
transaminitis of ALT 76, AST 63, Alk Phos 201. She had a HIDA
scan that did not show evidence of a leak and cholestasis. On
POD6 she underwent ERCP that showed a common bile duct filling
defect consistent with a stone. A sphincterotomy was preformed.
Occlusion cholangiogram was performed that showed contrast
extravasation consistent with a cystic stump leak. A double
pigtail bliary stent was successfully placed across the ampulla.
Her liver function tests were monitored and continued to trend
down. Her total bilirubin trended down to normal. On POD7 her
diet was advanced as tolerated to regular without abdominal pain
or emesis.
Throughout this hospitalization the patient remained alert and
oriented. Pain was initially managed with IV dilauid and
transitioned to oral acetaminophen at time of discharge. She
remained stable from a cardiopulmonary standpoint; vital signs
were routinely monitored. Good pulmonary toilet, early
ambulation and incentive spirometry were encouraged throughout
hospitalization. The patient's fever curves were closely
watched for signs of infection, of which there were none. The
patient's blood counts were closely watched for signs of
bleeding, of which there were none. The patient received
subcutaneous heparin and ___ dyne boots were used during this
stay and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. Follow up appointments were
scheduled.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation
aerosol inhaler. 1 puff inh every four (4) hours as needed for
shortness of breath
BENZONATATE - benzonatate 100 mg capsule. 1 capsule(s) by mouth
TID:prn as needed for cough
BUDESONIDE [PULMICORT FLEXHALER] - Pulmicort Flexhaler 180
mcg/actuation breath activated. 2 puffs INH twice a day
LEVOTHYROXINE - levothyroxine 75 mcg tablet. 1 tablet(s) by
mouth once a day
LOSARTAN - losartan 25 mg tablet. 1 tablet(s) by mouth daily
OMEPRAZOLE - omeprazole 40 mg capsule,delayed release. 1
capsule(s) by mouth twice a day
POTASSIUM CHLORIDE - potassium chloride ER 20 mEq
tablet,extended release(part/cryst). 1 tablet(s) by mouth daily
SUCRALFATE - sucralfate 1 gram tablet. 1 tablet(s) by mouth
every six (6) hours as needed for abdominal pain
TAMOXIFEN - tamoxifen 20 mg tablet. 1 tablet(s) by mouth once a
day
TORSEMIDE - torsemide 10 mg tablet. 4 tablet(s) by mouth daily
Goal weight 206 lb -- call your doctor if changes
TORSEMIDE - torsemide 20 mg tablet. 2 tablet(s) by mouth daily
Medications - OTC
ALUM-MAG HYDROXIDE-SIMETH [ANTACID] - Antacid ___ mg-200 mg-20
mg/5 mL oral suspension. ___ ml by mouth four times a day as
needed for abdominal pain
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
1,000 unit capsule. 1 capsule(s) by mouth daily please allow 4
hours in between orlistat dose
CYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vit B-12) ER
1,000 mcg tablet,extended release. 1 tablet(s) by mouth daily
GUAIFENESIN - guaifenesin 200 mg tablet. 1 tablet(s) by mouth
BID:prn as needed for cough
MISCELLANEOUS MEDICAL SUPPLY [BLOOD PRESSURE CUFF] - Blood
Pressure Cuff. Use s directed
MISCELLANEOUS MEDICAL SUPPLY [COMPRESSION STOCKINGS] -
Compression Stockings. wear to prevent swelling daily
NAPHAZOLINE-PHENIRAMINE [NAPHCON-A] - Naphcon-A 0.025 %-0.3 %
eye drops. 1 drop both eyes four times a day - (Not Taking as
Prescribed)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Antibiotic course to be completed on ___.
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*6 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
Hold for diarrhea.
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Losartan Potassium 25 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Potassium Chloride 20 mEq PO DAILY
9. Pulmicort Flexhaler (budesonide) 180 mcg/actuation
inhalation BID
10. Sucralfate 1 gm PO Q6H:PRN pain
11. Tamoxifen Citrate 20 mg PO DAILY
12. Torsemide 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
Common bile duct stone status post laparoscopic cholecystectomy
Cystic stump leak status post laparoscopic cholecystectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
abdominal pain. You were found to have cholecystitis, an
infection in your gallbladder. You were taken to the operating
room and had your gallbladder removed laparoscopially.
Post operatively, you continued to have abdominal pain and
vomiting. You had an endoscopy that showed a stone in your
common bile duct and a leak from the cystic duct stump. You had
a sphincterotomy to clear the stone and a stent placed to
reapair the leak. You tolerated the procedure well, you liver
enzymes are trending down, and you are tolerating a regular diet
without abdominal pain or nausea. You are now ready to be
discharged to home to continue your recovery.
Please note the following discharge instructions:
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10833307-DS-20
| 10,833,307 | 24,607,336 |
DS
| 20 |
2149-10-10 00:00:00
|
2149-10-10 15:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
indomethacin
Attending: ___.
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is ___ with history of non-small cell
lung cancer with brain metastasis, s/p cyberknife, c/b seizures,
who was brought in by EMS for seizure. The patient reports that
at 6am she noted that her right hand started shaking suddenly.
The patient reports that this right hand shaking lasted for
about ___ minutes, and then she noticed that her left leg was
twitching. Once she saw that her hand was shaking, she tried to
stand up and get to the bathroom using her walking when she said
she fell. The patient is not the best historian, but denies any
LOC; she also denies hitting her head. She says that she was
down on the ground for about 15 minutes; she was yelling out and
someone from her assisted living came to help her. She denies
any urinary or stool incontinence. She denies any tongue
biting. She does reports having some confusion after the
episode.
Of note, the patient reports being in her usual state of health
prior to this episode this morning. At her baseline, she
ambulates with a walker. She is generally steady on her feet,
but reports that the fell trying to get out of bed this past
___. She also reports having some baseline left-sided
weakness since her initial diagnosis with her brain metastasis.
She normally takes her anti-seizure medications at 8 am and did
not take any this morning. Of note, on ___, the patient's
dexamethasone dosing was changing from 3 mg daily to 4 mg four
times weekly.
On ROS, the patient reports feeling well. She denies any
headaches, no chest pain, no trouble breathing, no shortness of
breath. She denies any abdominal pain, no recent fevers, no
changes in her bowel movements, no pain or burning with
urination.
In the emergency department, the patient was having intermittent
shaking of her left leg. Examination notable for left sided
weakness ___ in both arms and legs) with continued left leg
seizing and a pill-rolling tremor of her left hand. Good
strength on right side. Cranial nerves II-XII was intact. Her
examination otherwise normal. While in the emergency
department, Neuro-Oncology was contacted and she was given 10 mg
dexamethasone, IV levetiracetam, and lorazepam.
On arrival to the floor, the patient reports feeling well. No
acute complaints; reports feeling hungry.
Past Medical History:
Past Oncologic History:
(1) ___ CT of the chest at ___
showed an upper lobe lung nodule,
(2) ___ PET SCAN showing left upper lobe 1.6 cm nodule,
(3) ___ CT guided biopsy of lung mass,
(4) ___ fine-needle aspiration demonstrates malignant cells
consistent with non-small cell lung carcinoma,
(5) ___ brain MRI showing a right parafalcine frontal mass,
measuring 18 mm x 17 mm x 12 mm, with associated cerebral edema,
(6) ___ received CyberKnife radiosurgery for her
parafalcine metastasis to 1800 cGy, and
(7) hospitalized at ___ in ___ from
___ to ___ after a seizure.
Past Medical History:
Diabetes mellitus type 2 for over ___ years
Hypertension for over ___ years
Hyperlipidemia for over ___ years
Gout for over ___ years and not currently active
Peripheral neuropathy for over ___ years (since ___ of unclear
etiology
s/p hysterectomy more than ___ years ago
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.3 F, blood pressure 110/73, pulse
81, respiration 18, and oxygen saturation 96% on 2 liters via
nasal cannula
GENERAL: Pleasant, elderly woman, NAD, laying comfortably in
bed, alert and appropriate, AAOx3
HEENT: EOMI, PERRL
CARDIOVASCULAR: RRR, S1 S2, no murmurs/rubs/gallops
LUNGS: Clear to auscultation b/l, no wheezes, rhonchi, crackles
ABDOMEN: Soft, non-tender, non-distended, +BS
EXTREMITIES: Warm, well perfused, ___ pitting edema halfway up
anterior shin b/l, 2+ DP pulses, +onchomycosis, overgrown toe
nails bilaterally
NEUROLOGICAL EXAMINATION: Her Karnofsky Performance Score is
50. She is awake, alert, and able to follow commands. Her
language is fluent with good comprehension. Her recent recall
is poor. Cranial Nerve Examination: Her pupils are equal and
reactive to light, 4 mm to 2 mm bilaterally. Extraocular
movements are full; there is no nystagmus. Visual fields are
full to confrontation. Her face is symmetric. Facial sensation
is intact bilaterally. Her hearing is intact bilaterally. Her
tongue is midline. Palate goes up in the midline.
Sternocleidomastoids and upper trapezius are strong. Motor
Examination: She does not have a drift. Her muscle strengths
are ___ at all muscle groups, except for ___ strength in the
left upper and lower extremities. Her muscle tone is normal.
Her reflexes are absent throughout. Her ankle jerks are also
absent. Her right toe is down going while the left is up.
Sensory examination is intact to pinch. Coordination
examination does not reveal gross appendicular dysmetria. She
has truncal instability.
DISCHARGE PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.3 F, blood pressure 110/73, pulse
81, respiration 18, and oxygen saturation 96% on 2 liters via
nasal cannula
GENERAL: Pleasant, elderly woman, NAD, laying comfortably in
bed, alert and appropriate, AAOx3
HEENT: EOMI, PERRL
CARDIOVASCULAR: RRR, S1 S2, no murmurs/rubs/gallops
LUNGS: Clear to auscultation b/l, no wheezes, rhonchi, crackles
ABDOMEN: Soft, non-tender, non-distended, +bowel sound
EXTREMITIES: Warm, well perfused, ___ pitting edema halfway up
anterior shin b/l, 2+ DP pulses, +onchomycosis, overgrown toe
nails bilaterally
NEUROLOGICAL EXAMINATION: KPS 50. She is awake, alert, and
able to follow commands. Her language is fluent with good
comprehension. Her recent recall is poor. Her pupils are equal
and reactive to light, 4 mm to 2 mm bilaterally. Extraocular
movements are full; there is no nystagmus. Visual fields are
full to confrontation. Her face is symmetric. Facial sensation
is intact bilaterally. Her hearing is intact bilaterally. Her
tongue is midline. She does not have a pronator drift. Her
muscle strength is ___ at all muscle groups, except for ___
strength in the left upper and lower extremities. Left foot
dorsiflexion is improved today with strength at 4+/5.
Her muscle tone is normal. Her reflexes are absent throughout.
Her ankle jerks are also absent. Her right toe is down going
while the left is up. Sensory examination is intact to pinch.
No appendicular dysmetria. No truncal ataxia. She walks with a
walker.
Pertinent Results:
Admission labs:
___ 08:58AM BLOOD WBC-13.0* RBC-3.81* Hgb-11.3* Hct-35.5*
MCV-93 MCH-29.7 MCHC-31.9 RDW-15.0 Plt ___
___ 08:58AM BLOOD Glucose-110* UreaN-20 Creat-1.1 Na-145
K-4.3 Cl-108 HCO3-22 AnGap-19
___ 08:58AM BLOOD ALT-20 AST-28 AlkPhos-91 TotBili-0.2
___ 08:58AM BLOOD Albumin-3.9 Calcium-9.0 Phos-3.0 Mg-1.6
Discharge labs:
CT head ___:
IMPRESSION:
1. No acute intracranial abnormality.
2. Allowing for differences in imaging modality, there has been
an apparent significant decrease in the overall enhancement of
the known right frontal metastasis, with no change in the extent
of the surrounding vasogenic edema.
3. No evidence of new hemorrhage or second metastasis.
CXR ___:
IMPRESSION: Streaky left basilar opacities, most suggestive of
atelectasis. Findings similar to a recent prior CT with regard
to findings suggesting primary pulmonary malignancy and
mediastinal lymphadenopathy.
Brief Hospital Course:
Mrs. ___ is ___ woman with history of
non-small cell lung cancer with brain metastasis, s/p
cyberknife, c/b seizures, who was brought in by EMS for seizure
in the setting of decreasing Decadron dose about one month ago,
who was found to have dirty urinalysis.
(1) Seizures: The patient presented from her assisted living
facility with a seizure in the context of starting to taper her
decadron about one month ago. New metastasis or bleeding
precipitating her seizure was ruled out in the setting of a CT
head that was unchanged from prior head imaging. While in
patient, her dexxamethasone was increased to 4 mg BID and her
levetiracetam was also uptitrated to 750 mg TID. Because she
was having intermittent tremor of her left lower extremity, the
patient had bedside EEG done, which was negative. She continued
to have left upper extremity and left lower extremity twitching,
and a 24 hour EEG was performed which did not show any seizure
activity or epileptiform waves. It was determined that her left
upper extremity and left lower extremity twitching observed in
the hospital were not due to seizure activity.
(2) Lung Cancer with Brain Metastasis: The patient has stage IV
nonsmall cell lung cancer and is s/p Cyberknife to brain
metastasis. She has seen Dr. ___ in clinic, where
palliative chemotherapy options have been discussed.
(3) Urinary Tract Infection: The patient was found to have
dirty urinalysis. Although she was asymptomatic, given her
presentation, it was decided to treat her infection. Because of
her seizures, Cipro was avoided, and the patient as treated with
3 days of Bactrim DS. After three days of Bactrim DS, the
patient was transitioned back to Bactrim SS which she has been
taking for PCP ppx while on chronic steroid use.
(4) Diabetes Mellitus: The patient has history of diabetes
mellitus. She was continued on her home Actos and glipizide.
Her metformin was initially held in the setting of possibly
needing futher brain imaging with contrast. Her metformin was
soon restarted. The patient was also placed on humalog insulin
sliding scale. Of note, we did go up on the patient's
dexamethasone dose. Her sugars will have to be followed as an
outpatient in the setting of increasing her steroids; she might
need to have her oral hypoglycemics uptitrated.
(5) Hypertension: The patient was continued on her home
atenolol 50 mg daily and irbesartan 300 mg daily.
(6) Hyperlipidemia: The patient was continued on her home
simvastatin 40 mg daily.
Transitional Issues:
- The patient's dexamethasone was increased during this
hospitalization. She will need to have her sugars followed as
an outpatient.
Medications on Admission:
Keppra 1000 mg BID
Atenolol 50 mg daily
Allopurinol ___ mg daily
Actos 45 mg daily
glipizide 5 mg BID
Vitamin B12 500 mcg daily
Avapro (Irbesartan) 300 mg daily
Simvastatin 40 mg qhs
Metformin 500 mg daily
Prilosec 20 mg BID
Bactrim SS daily
ASA 81 daily
Decadron 4 mg S, M, W, F
Discharge Medications:
1. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Keppra 750 mg Tablet Sig: One (1) Tablet PO three times a
day.
3. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO twice a day.
4. allopurinol ___ mg Tablet Sig: One (1) Tablet PO once a day.
5. Actos 45 mg Tablet Sig: One (1) Tablet PO once a day.
6. glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Vitamin B-12 500 mcg Tablet Sig: One (1) Tablet PO once a
day.
8. Avapro 300 mg Tablet Sig: One (1) Tablet PO once a day.
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
12. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
13. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Lung cancer with brain metastasis
Seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you while you were hospitalized
at ___. You were admitted to the hospital because you had a
seizure at home. We scanned your brain and did not see any new
changes. We increased your anti-seizure medications and your
steroids.
We also found that you had a urinary tract infection; we treated
you with antibiotics for this.
We had the physical therapist see you and we think that you
would do be better at a rehab facility instead of an assisted
living.
We made the following changes to your medications:
CHANGE levetiracetam to 750 mg by mouth three times daily
INCREASE dexamethasone to 4 mg by mouth twice daily
Followup Instructions:
___
|
10833322-DS-19
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DS
| 19 |
2110-07-07 00:00:00
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2110-07-07 14:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Influenza, Pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ history of COPD and prior CVA presents from ___ facility with agitation.
History obtained from chart review as patient was unable to
provide history.
He had a recent admission at ___ from ___ to ___ for
generalized weakness and altered mental status after he
presented
from home for generalized body weakness. During that
hospitalization, a NCHCT was performed and was negative. B12 and
TSH were stable and his infectious and metabolic work ups were
negative. He was discharged to rehab. Of note, during his last
hospitalization, his digoxin which he takes for atrial
tachycardia was discontinued. Per cardiology notes from ___, this was because he has marked LVH without a history
of
hypertension which was concerning to that cardiologist for
amyloid. In the setting of amyloid, digoxin can concentrate in
the protein fibrils and cause localized myocardial toxicity.
He presented on ___ from rehab due to progression of his
baseline
confusion and new agitation, including throwing a cup at the
nurses and refusing to eat.
He denied any fevers/chills, chest pain, dyspnea or cough. He
has
no abdominal pain, n/v/d or dysuria.
Past Medical History:
COPD
Atrial tachycardia in the form of paroxysmal atrial
fibrillation
and paroxysmal atrial tachycardia, not an anticoagulation due to
high risk for falls
Osteo-arthritis
Gait instability, frequent falls
History of Alcohol use
Syncope
CVA with no deficit
L index finger amp d/t infection ___
L ___ toe amp
TURP
L inguinal hernia repair
Partial amputation left index finger ___ for infection
Left fifth toe amputation remotely
TURP
Left inguinal hernia repair
Social History:
___
Family History:
Unable to obtain
Physical Exam:
Admission exam:
VS: T 98.4 BP 117/76 HR 81 R 18 SpO2 99 Ra
GEN: NAD
HEENT: Dry mucous membranes. +arcus senilis bilaterally
___: Distant heart sounds RRR II/VI SEM
RESP: No increased WOB, no wheezing, rhonchi or crackles
ABD: NTND No HSM
EXT: Warm, no edema. Deformity of R hand
NEURO: CN II-XII intact. Moving all 4 extremities with purpose.
Able to sit up in bed without help
Discharge exam:
___ 0754 Temp: 97.8 PO BP: 122/76 L Lying HR: 63 RR: 18 O2
sat: 96% O2 delivery: RA
GEN: NAD, lying in bed under blankets.
HEENT: Moist mucous membranes. +arcus senilis bilaterally
___: Distant heart sounds RRR II/VI SEM
RESP: No increased WOB, no wheezing, rhonchi or crackles
ABD: NTND No HSM
EXT: Warm, no edema.
NEURO: CN II-XII intact. Moving all 4 extremities with purpose.
Able to sit up in bed without help. AAOx3 though tangential in
speech and repeats stories.
Pertinent Results:
Admission labs:
___ 08:27PM BLOOD WBC-6.9 RBC-4.91 Hgb-13.8 Hct-40.7 MCV-83
MCH-28.1 MCHC-33.9 RDW-15.2 RDWSD-46.1 Plt ___
___ 08:27PM BLOOD Glucose-107* UreaN-24* Creat-1.0 Na-144
K-4.9 Cl-103 HCO3-23 AnGap-18
___ 08:27PM BLOOD Calcium-9.3 Phos-2.9 Mg-2.1
Discharge labs:
___ 07:35AM BLOOD WBC-5.9 RBC-4.33* Hgb-12.2* Hct-37.0*
MCV-86 MCH-28.2 MCHC-33.0 RDW-15.5 RDWSD-48.1* Plt ___
___ 07:35AM BLOOD Glucose-71 UreaN-13 Creat-0.8 Na-143
K-4.7 Cl-109* HCO3-19* AnGap-15
___ 07:35AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.0
C. difficile DNA amplification assay (Final ___:
THIS IS A CORRECTED REPORT (___) @ 15:48.
Reported to and read back by ___ ___ (___) @
3:45PM
___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay. (Reference
Range-Negative).
Brief Hospital Course:
___ presents from rehab with agitation, found to have influenza,
community acquired pneumonia. He recovered with Tamiflu and
antibiotics but developed c dificile in house. On discharge he
was recommended to go to rehab, but patient adamantly refused.
After substantial discussion of risks and benefits from the
patient's healthcare proxy ___ and ___, the
plan was made to discharge home with ___, homemaker, as well as
some home visits through friends, meals on wheels and ___
services.
#Toxic metabolic encephalopathy/ Possible underlying dementia
#Refusal of rehab
#Discharge planning
#Change of healthcare proxy
His prior HCP and niece ___ reported that he was
previously living at home, had an admission to ___
___ with discharge to rehab at that time. Per Ms.
___ while in rehab he was angry, agitated and combative
with staff. The patient reports that he was trying to get out of
rehab. He was brought back to the hospital for agitation. While
in house he was initially agitated but rapidly cleared with
administration of IVF, and abx for infection as below. ___
evaluated him and recommended discharge to rehab, however the
patient repeatedly and adamantly declined. He remained calm and
did not become agitated unless we discussed possible rehab
placement with him. At baseline he was AAOx3, but did
demonstrate tangential speech. Per family he has difficulty with
dressing and feeding himself due to hand arthritis, and
consistently demonstrated unsteady gate. His understanding of
his strength and ability to care for himself at home were felt
to be poor. This was discussed with his initial healthcare
proxy, his niece ___. The patient changed his
healthcare proxy halfway through the admission to ___ and
___, close family friends. After extensive discussion
regarding the risks and benefits, ultimately the decision was
made to discharge the patient home. We recommended 24 hour care
at home, but unfortunately for financial reasons this was not
feasible. Mr. ___ worked with our case manager and social
worker to increase care for Mr. ___ to include ___,
homemaker several times per week with companion service for
appointments, visits through the ___, meals on wheels, and family
to check in on him. While Ms. ___ Mr. ___ demonstrated an
understanding of the risks of discharging Mr. ___ home, his
consistent and adamant refusal to participate in rehab, and
demonstration of acute agitation on discussion of the topic, he
was ultimately discharged home with services.
#Influenza:
#Community Acquired Pneumonia:
Infiltrate on XR, and productive cough. Treated for CAP with
CTX/azithromycin x5d ___ well as for influenza with
Tamiflu (started on ___. He was afebrile throughout his
admission and his cough resolved with treatment.
#C Diff Colitis
Started having multipel watery stools on ___. C dif positive.
Started on vancomycin ___ to continue through ___ for 10d
course. He did have 2 episodes of hypotension thought related to
dehydration from his stool output. He was given IVF with
improvement with stable blood pressure at discharge. Oral intake
should be emphasized. His metoprolol was held but should be
restarted at discharge.
#COPD: No hypoxia or wheezing on exam. Home medications
monteleukast, advair, and fluticasone were continued.
#Atrial Tachycardia: Rates mildly tachycardic in sinus. BP
stable. Digoxin recently discontinued in the setting of concern
for amyloidosis. Home metoprolol and ASA were continued at
discharge.
#Positive blood culture
Blood cultures positive on ___. Speciated to micrococcus on ___
suggesting contaminant. Started empirically on Vanc on ___,
discontinued on ___ after speciation results.
Transitional Issues:
[ ] Continue PO Vancomycin for C Diff Collitis. Last day of
treatment is ___
[ ] Going home because of his wishes and wishes of his family,
and due to patient's adamant refused to participate in rehab. If
patient declines at home, strongly recommend placement at rehab.
[ ] Close monitoring of PO intake at home, with encouragement of
PO intake, as patient had hypotension in setting of dehydration
from his diarrhea.
[ ] If patient continues to have multiple watery stools per day
he should be reevaluated in clinic, as he should have
improvement on PO vancomycin.
[ ] Ongoing assessments of home safety
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
3. QUEtiapine Fumarate 25 mg PO Q4H:PRN agitation
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Montelukast 10 mg PO DAILY
6. QUEtiapine Fumarate 25 mg PO QHS
7. Vitamin D 1000 UNIT PO DAILY
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Aspirin 325 mg PO DAILY
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day
Disp #*24 Capsule Refills:*0
2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
3. Aspirin 325 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Montelukast 10 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Influenza
Community acquired pneumonia
Toxic metabolic encephalopathy
C dificile infection
Failure to thrive
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 Mr. ___,
It was a pleasure to take care of you at ___.
WHY WERE YOU HERE?
You were admitted to the hospital because you were not yourself
at the nursing home you were in, and were found to have the flu
and pneumonia.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
- You were started on anti-viral medication and antibiotics to
treat your infections. Y
- While you were in the hospital, you developed some loose
stools caused by an infection called C. Dificile. We gave you an
antibiotic for this.
- You had some episodes of low blood pressure which were related
to dehydration from your diarrhea. We gave you fluids for this.
- Our physical therapists worked with you and did not feel that
you would be safe at home without people to help you ___. We
discussed this with you and with ___ and ___. You
declined to go to rehab, so we worked to have as many extra
supports as possible at home.
WHAT SHOULD YOU DO WHEN YOU GET HOME?
1) Please follow up at your outpatient appointments.
2) Please take your medications as prescribed.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
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2122-09-16 16:04:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
laparoscopic appendectomy
History of Present Illness:
HPI: ___ year old male presenting with abdominal pain for the
past
24 hours, initially periumbilical, then radiated to the RLQ.
Progressively worse during the past several hours. He has been
having anorexia during the day. He denies any nausea or
vomiting,
no fevers or chills.
Past Medical History:
Seasonal Allergies
Perforated eardrum in childhood
Social History:
___
Family History:
Mother and father w/o medical issues. He has two younger sisters
who have no medical problems.
Physical Exam:
Physical Exam: upon admission: ___:
Vitals: T 98.6 HR 102 BP 144/77 RR 16 SO2 100%
GEN: A&Ox3 , NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, moderately tender in RLQ, no rebound or
guarding, normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 12:30AM BLOOD WBC-8.3# RBC-4.62 Hgb-14.8 Hct-47.2
MCV-102* MCH-32.0 MCHC-31.3 RDW-12.3 Plt ___
___ 12:30AM BLOOD Neuts-72.1* ___ Monos-3.9 Eos-1.4
Baso-0.3
___ 04:41AM BLOOD ___ PTT-31.2 ___
___ 12:30AM BLOOD Plt ___
___ 12:30AM BLOOD Glucose-93 UreaN-13 Creat-1.0 Na-141
K-3.6 Cl-102 HCO3-27 AnGap-16
___: cat scan of abdomen and pelvis:
IMPRESSION: Acute uncomplicated appendicitis with an
appendicolith noted at the base of the appendix.
Brief Hospital Course:
Admitted to the acute care service with abdominal pain. Upon
admission, he was made NPO, given intravenous fluids and
underwent an abdomial cat scan which showed a 14 mm dilated
tubular structure in the right lower quadrant in the
expected region of the appendix with a hyperdensity within it
suggestive of
appendicolith. On HD #1, he was taken to the operating room for
a laparoscopic appendectomy. His operative course was stable.
He was extubated in the recovery room.
His post-operative course was stable. His incisional pain was
controlled with intravenous anaglgesia with conversion to oral
agents. He was started on clear liquids with advancement to a
regular diet on HD #3. His vital signs were stable and he was
afebrile. He is preparing for discharge home with instructions
to follow up in the acute care clinic in ___ weeks.
Medications on Admission:
none
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain: may cause incresed sedation, avoid driving
while on this medication.
Disp:*25 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for loose stools.
3. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You
underwent a cat scan of your abdomen which showed appendicitis.
You were taken to the operating room where you had your appendix
removed. You are slowly recovering from your surgery and you
are preparing for discharge home with the following
instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips ___ days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
___
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2161-09-12 14:47:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lidocaine / nifedipine / Penicillins / prochlorperazine
Attending: ___.
Chief Complaint:
Throat/Mouth swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo male with T2DM, asthma, trach for
type III hereditary angioedema presents with sudden onset
angioedema from an outside hospital. He has a recurrent hx of
angioedema requiring hospital admissions sometimes intubation,
last to ___ in ___. Now s/p trach but with recurrence of
angioedema. He is followed at ___ for angioedema and usually
gets kalbitor and ffp for angioedema. Today this began at 22:30
with worsening tongue swelling. Sent here for evaluation and
potential need for critical care. received kalbitor and 1 unit
ffp en route. On presentation. On presentation he has received
3u
FFP, one dose kalbitor, and one dose Icatibant thus far with
some
improvement in tongue edema. Airway secured with trach. Allergy
was consulted to provide recs and they said just observe on the
floor. He was given one more dose of Kabitor while on the floor.
Patient follows with Dr. ___ at ___ ___.
On arrival to the floor, the patient was communicating via
typing
on his cellphone. No complain except for pain in the tongue.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
-hereditary angioedema, type 3
-T2DM
-asthma
-Ramsay Hunt syndrome type II c/b distal esophageal spasm and
rapid gastric empyting requiring J-tube placement s/p Roux-en-Y
jejunostomy ___
-colostomy
-J-tube ___ (Dr. ___ c/b cellulitis tx with
abx in ___
-open jejunostomy for dislodgement (___)
-clogged J-tube ___, attempted exchange at bedside
unsuccessfully
-attempted removal of J-tube by ___ but unable to tolerate ___
pain ___
-surgical J-tube exchange ___
-Roux-en-Y jejunostomy ___
Social History:
___
Family History:
NC as it relates to patients current presentation
Physical Exam:
Vitals:
24 HR Data (last updated ___ @ 1000)
Temp: 98.8 (Tm 98.9), BP: 110/72 (110-130/63-76), HR: 67
(63-69),
RR: 18, O2 sat: 100% (97-100), O2 delivery: 35%TM
GENERAL: Alert and in no apparent distress
EYES: Anicteric, non-injected
HEENT: Ears and nose without visible erythema, masses, or
trauma.
Tongue back to normal and not protruding. No facial edema.
CV: RRR nl S1/S2 no g/r/m No JVD.
RESP: CTAB no w/r/r. trach in place, well appearing
Chest: Right Hickman well appearing, no e/e, non-tender
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. Ostomy in place with liquid stool. No HSM
GU: interval improvement in penile and scrotal edema, mild at
best today
MSK: Neck supple, moves all extremities.
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. Decreased sensation along lat R thigh,
lat/ant
lower leg, plantar foot.
PSYCH: Pleasant, appropriate affect.
Pertinent Results:
RECENT LABS:
WBC 11.3, Hgb 12.3, Chem10 wnl. Triglycerides 53. CRP 2.7. Free
Ca 1.26.
MICRO: None
IMAGING:
___ MRI:
Lumbar spine MRI demonstrates demonstrate a herniation of the
L5-S1 lumbar disc with impingement of the descending S1 nerve
root as well as L5-S1 neuroforaminal narrowing.
___ CXR:
Tracheostomy tube midline. Lungs clear. Heart size normal. No
pleural abnormality. No mediastinal widening. Dual channel
right
supraclavicular central venous catheter ends in the low SVC.
Brief Hospital Course:
Mr. ___ is ___ gentleman with a PMH including NIDDM2,
asthma, type III hereditary angioedema with home chronic trach
and TPN who was admitted ___ with sudden onset angioedema.
Angioedema was treated with FFP, 3 doses of Kalbitor and 1 dose
of Icatibant. Treatment was coordinated with outpatient and
inpatient allergists. Angioedema gradually resolved. At time of
discharge he was taking orals normally. He was set up with home
TPN (given inconsistent ability to take orals) and plans to
start Lanadalumab prophylaxis once he gets home.
His hospital course was complicated by development of lower back
pain and radiating numbness down his right leg. MRI and
consulting spine surgeon confirmed herniated L5/S1 disc with
associated radiculopathy. Initially on a PCA, he was weaned to
occasional oxycodone 5mg and started on a Medrol pack. He was
discharged with prescriptions for a 21-dose Medrol pack (4mg
daily). He already has a prescription for liquid oxycodone at
his home (last filled ___, confirmed via the PMP on
___.
He was set up with follow-up appointments with his PCP,
___, and at the spine clinic.
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Kalbitor (ecallantide) 30 mg subcutaneous DAILY:PRN
2. LORazepam 0.5 mg PO BID:PRN anixety
3. Metoclopramide 5 mg PO TID
4. Nortriptyline 50 mg PO QHS
5. OxycoDONE Liquid 5 mg PO Q8H:PRN Pain - Moderate
6. Omeprazole 40 mg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Ranitidine 150 mg PO BID
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Gabapentin 300 mg PO TID
11. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection DAILY:PRN
12. Ondansetron 8 mg PO Q6H:PRN Nausea/Vomiting - First Line
Discharge Medications:
1. Methylprednisolone 4 mg PO DAILY
RX *methylprednisolone 4 mg 1 tablet(s) by mouth daily Disp #*21
Tablet Refills:*0
2. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection DAILY:PRN
3. Gabapentin 300 mg PO TID
4. Kalbitor (ecallantide) 30 mg subcutaneous DAILY:PRN
5. LORazepam 0.5 mg PO BID:PRN anixety
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Metoclopramide 5 mg PO TID
8. Nortriptyline 50 mg PO QHS
9. Omeprazole 40 mg PO DAILY
10. Ondansetron 8 mg PO Q6H:PRN Nausea/Vomiting - First Line
11. OxycoDONE Liquid 5 mg PO Q8H:PRN Pain - Moderate
12. Ranitidine 150 mg PO BID
13. Vitamin D ___ UNIT PO DAILY
14.Rolling Walker
Rolling Walker
Dx: ___.16 Prognosis: good
Length of need: 13 months.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Angioedema
Discharge Condition:
Stable
Discharge Instructions:
Dear ___,
You came to the hospital for evaluation of swelling of your
mouth and throat. You were given specialized medicines to help
with your swelling and you improved. Please start Lanadelumab
when you get home.
You also developed a herniated disk at the beginning of the
hospitalization. The spine orthopedic surgery service saw you in
the hospital and recommended physical therapy and meds for pain
control including a trial of steroids. You are being discharged
with a roller walker, prescriptions for a few weeks of steroids
and you already have a prescription for liquid oxycodone from
your outpatient doctor.
We have set up follow up appointments with your primary care
doctor, ___, and at the spine clinic.
It was a pleasure taking care of you!
Sincerely,
Your ___ Team
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Demerol / lactose
Attending: ___.
Chief Complaint:
Abdominal distention and cramping
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMHx myeloid metaplasia s/p bone marrow transplant in ___
(considered cured), HLD who presents with acute on chronic
abdominal distension and cramping.
Per report from outpatient PCP, patient has had "sx of
distention, bloating, and discomfort over the past month and
these have progressively worsened so that she is symptomatic at
all times. Intermittently, she will have what she describes as
severe "cramping" which has awakened her from sleep most nights
and also causes her to bend in pain during the day, but the
cramping lasts minutes only and then returns to baseline. Denies
fevers, chills, sweats, but has been generally feeling unwell,
fatigued and not herself. She had had abnormal LFTs for years
within Atrius system, most recent LFTs wnl in ___, but has
not
had other synthetic function checked.
She was referred for outpatient CT scan, which resulted with
loculated pelvic fluid collections, new ascites, ?cirrhosis, and
soft tissue mesenteric nodularity all concerning for possible
malignancy v. infection. In this context she was referred to
___ for admission, medical and surgical consultations. She was
to travel to ___ tomorrow for a week.
PMHx is notable for hx of myeloid metaplasia and underwent BMT
at
___ in ___. In ___, had 6 week hospitalization for
pseudomonas infection (details not entirely clear, but ?
Multiple
sites of abscesses/sepsis).
In the ED, initial VS were: 96.7, 94, 168/106, 18, 100% RA
Exam notable for: Abd minimally tender diffusely, No asterixis,
caput, clonus, jaundice or icterus
Labs showed: ___
Imaging showed: RUQ US no cirrhosis, small amount of ascites and
cholelithiasis
Consults: Surgery was consulted, recommended admission to
medicine for further w/u. No acute surgical needs.
Patient received: Nothing
Transfer VS were: 98, 90, 136/79, 16, 99% RA
On arrival to the floor, patient reports the above symptoms.
Reports minimal abdominal pain currently but usually feels
discomfort around ___, waking her up from sleep. She usually
walks around the house at night which helps the pain. Endorses
constipation with small infrequent bowel movements, usually
every
other day. Is UTD with pelvic exams (at PCP), mammograms (once
every year, normal) and colonsoscopy ___ years ago with PCP
without
abnormality. She reports weight loss, weighing approximately 133
at ___ office last month and now ___ on admission here.
Eating less given poor appetite. Trying to focus on high protein
diet to ensure she is getting nutrients. She follows with
oncologist at ___ once yearly. She has mild skin GVH but is no
longer on prednisone for this.
Past Medical History:
Myeloid metaplasia s/p Bone marrow transplant
Mitral valve prolapse
Vaginal enterocele
Hypercholesteremia
Traumatic closed displaced fracture of tibial plafond with
fibula
HPV in female
Osteopenia
Fracture of left olecranon process
Left hip pain
Social History:
___
Family History:
Maternal Grandfather Cancer
Mother Cancer - Breast; Cancer - Uterine
Other Diabetes; Hypertension
Paternal Grandfather Cancer - ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.7, 142/89, 93 18 95 RA
GENERAL: NAD, sitting comfortably in chair
HEENT: AT/NC, EOMI, PERRL, left mild conjunctival hemorrhage,
MMM
NECK: supple, no submandibular or supraclavicular LAD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, tender to light palpation LLQ and
RLQ. no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions
DISCHARGE PHYSICAL EXAM:
VS: 98.1 121/78 87 16 96 Ra
GENERAL: NAD, sitting comfortably in chair
HEENT: AT/NC, EOMI, PERRL, MMM
NECK: supple, no submandibular or supraclavicular LAD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, tender to light palpation LLQ and
RLQ. no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions
Pertinent Results:
Admission labs
___ 06:54PM BLOOD WBC-6.1 RBC-4.61 Hgb-13.4 Hct-41.0 MCV-89
MCH-29.1 MCHC-32.7 RDW-12.4 RDWSD-40.3 Plt ___
___ 06:54PM BLOOD Neuts-60.0 ___ Monos-11.1
Eos-0.5* Baso-0.3 Im ___ AbsNeut-3.64 AbsLymp-1.69
AbsMono-0.67 AbsEos-0.03* AbsBaso-0.02
___ 06:54PM BLOOD ___ PTT-29.4 ___
___ 06:54PM BLOOD Glucose-83 UreaN-12 Creat-0.7 Na-141
K-4.6 Cl-99 HCO3-24 AnGap-18
___ 06:54PM BLOOD ALT-20 AST-28 LD(LDH)-386* AlkPhos-88
TotBili-0.4
___ 06:54PM BLOOD Lipase-39
___ 06:54PM BLOOD Albumin-4.1 Calcium-9.0 Phos-3.0 Mg-2.1
___ 06:54PM BLOOD %HbA1c-5.5 eAG-111
___ 06:54PM BLOOD TSH-3.3
___ 06:54PM BLOOD HCG-<5
___ 06:54PM BLOOD CRP-82.4* CEA-1.5 AFP-2.0 CA125-46*
___ 06:54PM BLOOD HCV Ab-NEG
___ 07:00PM BLOOD Lactate-1.1
Imaging
RUQ US ___
1. No sonographic hepatic parenchymal abnormality to suggest
cirrhosis. Small intra-abdominal ascites.
2. Cholelithiasis
CT Chest ___
1. No evidence of intrathoracic malignancy. No acute
intrathoracic process.
2. Limited evaluation of the upper abdomen demonstrate findings
suggestive of cirrhosis with portal hypertension including
perisplenic varices, possible splenorenal shunt and small volume
ascites
Discharge labs
___ 07:25AM BLOOD WBC-4.9 RBC-4.23 Hgb-12.2 Hct-37.9 MCV-90
MCH-28.8 MCHC-32.2 RDW-12.6 RDWSD-40.7 Plt ___
___ 07:25AM BLOOD Neuts-59.5 ___ Monos-10.2
Eos-0.8* Baso-0.4 Im ___ AbsNeut-2.93 AbsLymp-1.41
AbsMono-0.50 AbsEos-0.04 AbsBaso-0.02
___ 07:25AM BLOOD Glucose-75 UreaN-13 Creat-0.5 Na-142
K-4.0 Cl-102 HCO3-26 AnGap-14
___ 07:25AM BLOOD ALT-16 AST-19 LD(LDH)-244 AlkPhos-78
TotBili-0.4
___ 07:25AM BLOOD Albumin-3.7 Calcium-8.5 Phos-3.2 Mg-2.1
Brief Hospital Course:
Summary
___ PMHx myeloid metaplasia s/p bone marrow transplant in ___
(considered cured), HLD who presents with acute on chronic
abdominal distension and cramping, found to have loculated
pelvic fluid collections, new ascites and soft tissue mesenteric
nodularity concerning for malignancy v. infection. She was
clinically stable and will follow with gynecology as outpatient
for further workup.
# Abdominal bloating, distention
# Weight loss
# Loculated pelvic fluid collections
# Mesenteric soft tissue nodularity
Patient presents with months of worsening abdominal distention,
bloating, cramping sensation, referred for outpatient CT scan
with results as detailed above, notably multiple pelvic
loculated fluid collections concerning for abscesses, new
ascites, portal HTN, ?cirrhosis and mesenteric soft tissues
nodularity. In total, most concerning for new malignancy
(especially given concurrent weight loss), GYN, ovarian highest
on the differential given location of soft tissue mesenteric
nodules. No bowel obstruction to explain symptoms. Consider
infectious etiology for loculated pelvic fluid collections. Exam
notable for abdominal TTP,
otherwise benign, evaluated by surgery in the ED without acute
surgical intervention. Reassuringly, afebrile without
leukocytosis. Was stable off antibiotics and suspect this is not
infectious. A CT chest was done without any lesions identified.
After discussion with interventional radiology, gynecology and
gyn-onc, decision was made to discharge patient home and follow
for additional workup as an outpatient. She remained stable and
clinically well throughout admission.
# Nephrolithiasis
Incidentally noted on CT, asymptomatic.
# Intra-abdominal ascites
# Portal HTN
# ?Cirrhosis
Patient presents with radiographic e/o of portal HTN (enlarged
portal vein, enlarged splenic vein, gastric varices) on CT scan
with small intra-abdominal ascites. OSH CT and ___ RUQ US are
discordant with regards to e/o cirrhosis (CT suggest cirrhosis,
RUQUS without e/o cirrhosis). LFTs normal, no stigmata of
cirrhosis on exam. Suspect this is more likely related to her
pelvic process. Would recommend ascites sampling as above, with
SAAG. Could also non-urgently be evaluated by hepatology.
CHRONIC ISSUES:
===============
# HDL. Continued simvastatin
# Anxiety. Continued Ativan prn
# Menopause. Held Vagifem inpatient pending malignancy w/u as
above
# S/p BMT for myeloid metaplasia (___), c/b skin GVHD previous
on prednisone now off. Considered cured. Followed yearly by
oncologist at ___.
# Transitional issues
- Held vagifem on discharge.
- ___ pending at discharge.
- Will follow with ___ gynecology for coordination of
additional workup, will involve ___ GYN-ONC if appropriate and
they are aware of patient.
- As above, CT findings concerning for portal hypertension and
cirrhosis, but this was not evident on RUQUS at ___. Consider
repeat evaluation as outpatient and non-urgent hepatology
referral.
- On CT scan, nodular thickening of the left adrenal gland is
incompletely characterized. Comparison can be made if prior
imaging becomes available. Otherwise, non urgent dedicated
adrenal CT can provide further assessment.
#CODE: Full (presumed)
#CONTACT: Husband ___ ___ (cell)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO QPM
2. LORazepam 0.5-1 mg PO QHS:PRN insomnia, anxiety
3. Vagifem (estradiol) 10 mcg vaginal 2X/WEEK
4. Psyllium Powder 1 PKT PO TID:PRN constipation
Discharge Medications:
1. LORazepam 0.5-1 mg PO QHS:PRN insomnia, anxiety
2. Psyllium Powder 1 PKT PO TID:PRN constipation
3. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pelvic collections, infection vs malignancy
Secondary:
HLD
Anxiety
Menopause
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 your upset stomach
and abnormal CT scan.
WHAT HAPPENED WHILE YOU WERE HERE:
- Our radiology and gynecology experts evaluated you.
- They would like to see you in clinic and get some more
information
It was a pleasure taking care of you, best of luck. Your ___
medical team
Followup Instructions:
___
|
10833980-DS-8
| 10,833,980 | 28,182,613 |
DS
| 8 |
2112-02-15 00:00:00
|
2112-02-15 14:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Central line
Cardiac catheterization
Pacemaker placement
History of Present Illness:
Mr. ___ is a ___ y/o man with known CAD s/p DES to OM in
___, HTN, DM, dyslipidemia, who initially presented to
___ with 3 days of progressive substernal chest pain.
States that he initially had acute onset right sided crushing
chest pain that woke him from sleep. Associated with significant
diaphoresis and shortness of breath. Also endorsing fevers
(unmeasured) and chills over last several days. At baseline has
a
productive cough he attributes to his smoker's cough that is
unchaged from baseline.
At ___, found to have NSTEMI with troponin 0.9, EKG there
with RBBB no obvious ischemic changes per report, was aspirin
loaded there and given SLNG with only temporary relief. Had CTA
there which showed no evidence of PE, was transferred here for
cardiac evaluation.
In the ED here,
Initial VS: T 98.3 HR 87 BP 100/67 RR 20 O2 95%RA
Exam: Not documented
Labs notable for:
- WBC 25.1, Hb 15.8, PLT 193
- Na 137, K 4.5, Cl 94, BUN 24, Cr 1.3, glucose 262
- Troponin 0.87
- ProBNP 2230
- UA: Sml leuks, negative nitrite, 9 WBC, few bactereia
Consults: Was evaluated by cardiology. Given up-trending
troponin
to 1.10 with MB 18 and ongoing chest pain, patient underwent
cardiac cath showing no new coronary disease,
with known right CTO. Got 100cc contrast. LVEDP normal
suggesting
euovlemia. Following cath, had worsening hypotension to ___/
50s.
Initially fluid responsive (got 1L in cath lab) up to 100s.
However subsequently dropped his MAPs again and was started on
peripheral levophed.
Subjective: On arrival to the MICU, patient confirms the above
history. States that he had acute onset crushing right sided
chest pain that started ___ that awoke him from sleep. The
chest pain feels worse than the chest pain he had in ___.
States
that the chest pain has been persistent since then, currently
endorsing some chest discomfort. Cough is at his baseline with
intermittent productive sputum. Denies any abdominal pain,
nausea, vomiting. Had 1 episode of diarrhea several days ago
however none since then. Denies any dysuria or burning on
urination. At baseline able to walk "miles" without chest pain.
Past Medical History:
HTN
HL
STEMI s/p RCA stenting ___
Status post back surgery disk, L4, L5, S1.
Social History:
___
Family History:
Father died at ___ from cancer, but also had
coronary artery disease. Mother passed away from an MI at
___. Strong family history of hypertension, coronary artery
disease, CVA, and cancer. His brother has diabetes ___
type 2. No siblings have been diagnosed with coronary artery
disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
GEN: Comfortable, in NAD
HENNT: HEENT, NC/AT, PERRL, EOMI
Neck: Supple, no lymphadenopathy, no elevated JVD
CV: Regular rate and rhythm, no murmurs, rubs, or gallops
RESP: Tachypneic, coarse breath sounds throughout, no wheezes or
rhonchi
GI: Soft, NT/ND. Normoactive bowel sounds, no evidence of
organomegaly
MSK: 2+ peripheral pulses, no c/c/e
NEURO: CN II-XII grossly intact. No focal neurological deficits.
DISCHARGE PHYSICAL EXAM
=======================
VS: ___ 0454 Temp: 98.2 PO BP: 117/69 L Lying HR: 77 RR: 18
O2 sat: 95% O2 delivery: RA
Fluid Balance (last updated ___ @ 454)
Last 8 hours Total cumulative -750ml
IN: Total 0ml
OUT: Total 750ml, Urine Amt 750ml
Last 24 hours Total cumulative -330ml
IN: Total 1220ml, PO Amt 1220ml
OUT: Total 1550ml, Urine Amt 1550ml
GENERAL: well-appearing, sitting up in chair
NECK: JVP 6 cm
CARDIAC: RRR, no MRG
CHEST: Dressing where pacemaker implanted c/d/i.
LUNGS: normal WOB, CTAB. +rhonchi b/l. No rales or wheezes.
EXTREMITIES: wwp, no edema
Pertinent Results:
ADMISSION LABS
==============
___ 03:20PM BLOOD WBC-25.1* RBC-5.26 Hgb-15.8 Hct-46.7
MCV-89 MCH-30.0 MCHC-33.8 RDW-13.1 RDWSD-42.7 Plt ___
___ 03:20PM BLOOD Neuts-86.1* Lymphs-5.5* Monos-7.4
Eos-0.0* Baso-0.2 Im ___ AbsNeut-21.64* AbsLymp-1.37
AbsMono-1.85* AbsEos-0.00* AbsBaso-0.05
___ 09:35PM BLOOD ___ PTT-40.2* ___
___ 03:20PM BLOOD Glucose-262* UreaN-24* Creat-1.3* Na-137
K-4.5 Cl-94* HCO3-26 AnGap-17
___ 03:20PM BLOOD cTropnT-0.87*
___ 03:04AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.6
PERTINENT LABS
==============
___ 12:28PM BLOOD ALT-17 AST-50* LD(LDH)-450* AlkPhos-74
TotBili-1.2
___ 03:20PM BLOOD cTropnT-0.87*
___ 09:35PM BLOOD CK-MB-23* cTropnT-0.91*
___ 03:04AM BLOOD CK-MB-18* cTropnT-1.10* proBNP-___*
___ 12:28PM BLOOD CK-MB-12* cTropnT-1.07*
___ 12:46PM BLOOD Lactate-2.7*
___ 04:59PM BLOOD Lactate-2.1*
IMAGING & STUDIES
==================
Cardiac Catheterization ___
LM
The left main coronary artery is with 20% focal.
LAD
The left anterior descending coronary artery is with 40-50%
eccnetric mid (appears improved compared to prior ___
angiography, images reviewed).
Circ
The circumflex coronary artery is with widely patent OM stents.
RCA
The right coronary artery is with 100% chronic mid occlusion at
the proximal edge of the prior stent.
There are faint left-to-right collaterals present.
Findings
Single vessel coronary artery disease with CTO of the RCA
No coronary culprit lesion identified
Normal left ventricular filling pressure
Hypotension requiring IV levophed
TTE ___
Suboptimal image quality. Mild left ventricular cavity dilation
with regional systolic dysfunction most c/w CAD (PDA
distribution). No valvular pathology or pathologic flow
identified.
TEE ___
Mild mitral regurgitation with normal leaflet morphology. No
discrete vegetations or abscess seen. Small pericardial
effusion.
DISCHARGE LABS
==============
___ 04:56AM BLOOD Glucose-173* UreaN-43* Creat-1.2 Na-137
K-4.0 Cl-98 HCO3-26 AnGap-13
___ 04:56AM BLOOD Calcium-7.7* Phos-3.1 Mg-2.8*
Brief Hospital Course:
Mr. ___ is a ___ y/o man with known CAD s/p DES to mid RCA
___ (inferior STEMI), ___ 2 to proximal LCx (___), HTN, DM,
dyslipidemia, initially presenting to ___ with 3 days of
progressive chest pain, found to have NSTEMI with troponin
elevation to 1.1, s/p cardiac cath here showing chronic R CTO
otherwise no other intervenable lesion. Admitted to MICU with
pneumococcal sepsis post cath requiring pressors, found to have
new pAF and complete heart block of unclear etiology, now s/p
PPM implantation.
TRANSITIONAL ISSUES:
==================
[ ] Should receive pneumococcal vaccines if not already received
[ ] Follow up as scheduled in device clinic for PPM
[ ] Follow up as scheduled in cardiology clinic Dr. ___
[ ] Held HCTZ on discharge
[ ] Restarted on Lisinopril 5mg daily on discharge, can
uptitrate as allowed outpatient
[ ] Started on Apixiban 5mg BID for anticoagulation for pAF
[ ] Discharge antibiotic course: Ceftriaxone 2g Q24 x 14 day
course ___, last day ___. Midline placed right arm.
[ ] Please have home ___ or infusion services pull midline after
last dose of CTX.
[ ] Follow up SPEP/UPEP
ACUTE ISSUES:
============
#Complete heart block
Noted to have new AV dissociation on this admission. This was
initially concerning for valvular abscess I/s/o bacteremia,
however TEE negative. Lyme serologies were negative. EP was
consulted and PPM was placed on ___. His home metoprolol was
initially held and subsequently restarted after PPM placement.
[ ] will require follow-up with Dr. ___ and with device
clinic as scheduled
#Septic shock
Presented with septic shock secondary to strep pneumo
bacteremia. Most likely source is pneumonia despite negative
chest x-ray given respiratory symptoms and crackles on chest
x-ray. He was started initially on IV vancomycin, then
transitioned to ceftriaxone 2g on ___. He was continued on Abx
and was discharged home with a midline to complete a 14 day
course ___ - ___. HIV was checked given invasive strep
pneumo and was negative; SPEP/UPEP was pending at the time of
discharge. Cultures were negative starting ___.
#Atrial fibrillation
Intermittent atrial fibrillation on telemetry. CHADS-VASc 3. He
was started on lovenox initially then transitioned to apixaban.
His home metoprolol was restarted as above.
#NSTEMI
Presenting with 3 day history of chest pain. Initially concern
for type I NSTEMI given degree of troponin elevation (peaked at
1.1) managed on heparin gtt however s/p cath showing stable RCA
CTO no culprit lesion intervenable upon. TTE EF 40% mild LV
dilation regional systolic dysfunction c/w CAD. He presented on
ASA and clopidogrel due to prior stent. However, given plan to
start on anti-coagulation discontinued plavix after discussion
with cardiology given no indication for triple therapy. He was
continued on atorvastatin.
___
Cr peaked at 1.9 with improvement after fluids. Baseline 1.0. Cr
at time of discharge was 1.2.
#Anemia
Stable and no evidence of bleeding. Most likely from phlebotomy.
Hemoglobin at time of discharge was stable.
CHRONIC ISSUES:
==============
#HTN
- Home HCTZ was held; home Lisinopril was restarted at 5mg daily
at discharge. To be uptitrated as outpatient.
#GERD
- He was initially switched to pantoprazole while receving
plavix. Omeprazole was subsequently restarted once plavix was
discontinued.
#DM
- Home metformin, Januvia were held. He received sliding scale
insulin.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
2. Niaspan Extended-Release (niacin) 500 mg oral BID
3. Metoprolol Tartrate 50 mg PO BID
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Lisinopril 40 mg PO DAILY
6. Januvia (SITagliptin) 100 mg oral DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*3
2. CefTRIAXone 2 gm IV Q 24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g IV every 24
hours Disp #*8 Intravenous Bag Refills:*0
3. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Januvia (SITagliptin) 100 mg oral DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Metoprolol Tartrate 50 mg PO BID
9. Niaspan Extended-Release (niacin) 500 mg oral BID
10. Omeprazole 40 mg PO DAILY
11. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until you are told
to by a doctor.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
=================
NSTEMI
Complete heart block
Atrial fibrillation
Sepsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___.
Why was I here?
- You came to the hospital because you were having chest pain.
What was done while I was here?
- You were found to have an infection in your blood stream which
was treated with antibiotics.
- You underwent a cardiac cath to evaluate the blood vessels
that supply the heart. This showed that your heart disease
(coronary artery disease) was stable.
- You were also found to have an abnormal heart rhythm called
heart block. You had a pacemaker placed.
- You also developed another abnormal heart rhythm called atrial
fibrillation. You were started on a blood thinner for this.
What should I do when I get home?
- Please take all of your medications as prescribed and go to
all of your follow up appointments as listed below.
We wish you the best!
- Your ___ team
Followup Instructions:
___
|
10834132-DS-2
| 10,834,132 | 26,434,508 |
DS
| 2 |
2174-08-26 00:00:00
|
2174-08-27 14:45:00
|
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending: ___.
Chief Complaint:
Shortness of Breath and Distended Abdomen
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient has had SOB for about one week and culminated today
while he was walking with increased sob, substernal chest
tightness and feeling weak. + cough, LLE swelling, ___ sputum
production or abdominal pain. Feels he is "wheezing" when he is
sitting watching TV and has difficulty taking a deep breath due
to his increased abdominal girth. ___ N/V, had diarrhea ___
after taking mag citrate but BM otherwise
In the ED initial vitals were: 97.4 60 158/72 18 99%
- Labs were significant for WCC of 12, BNP of 2873, creatinine
of 1.7 and transaminits.
- Patient was given Lasix 20mg IV and aspirin
On the floor, patient was comfortable but felt slightly air
hungry
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:
DIABETES MELLITUS - moderate control
CHRONIC KIDNEY DISEASE
HYPERTENSION
MULTIPLE RENAL CYSTS
DIVERTICULOSIS
GASTROESOPHAGEAL REFLUX
HERPES SIMPLEX II
MIGRAINE HEADACHES
MITRAL VALVE PROLAPSE
POSITIVE PPD
CERVICAL OSTEOARTHRITIS
ATYPICAL CHEST PAIN
BENIGN PROSTATIC HYPERTROPHY
BORDERLINE GLAUCOMA
Social History:
___
Family History:
Unknown
Physical Exam:
On ADMISSION:
VITALS: 98.6 60 133/62 16 96RA 73.3kg <-- 73.5
I/O: ___ NET: -515
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, ___ LAD, ___ JVD
CARDIAC: Bradycardic, S1/S2, regularly irregular rate, ___
systolic murmur best heard at apex, S4, ___ gallops, or rubs
LUNG: Occasional crackle bilaterally limited to lower lung
bases, ___ wheezes or rhonchi.
ABDOMEN: Distended (further deflated) with small umbilical
hernia, +BS, nontender in all quadrants, ___ rebound/guarding,
unable to palpate liver or spleen due to distention.
EXTREMITIES: +1 pedal edema, ___ cyanosis, clubbing, moving all 4
extremities with purpose
PULSES: 1+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, ___ excoriations or lesions, ___
rashes
On DISCHARGE ___:
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, ___ LAD, JVD flat, still at 10cm
CARDIAC: Bradycardic, S1/S2, S4 present, regularly irregular
rate, ___ systolic murmur best heard at apex, ___ gallops, or
rubs
LUNG: Occasional crackle bilaterally limited to lower lung bases
, ___ wheezes or rhonchi.
ABDOMEN: Less tensely distended (further deflated) with small
umbilical hernia, +BS, nontender in all quadrants, ___
rebound/guarding, unable to palpate liver or spleen due to
distention.
EXTREMITIES: +1 pedal edema, ___ cyanosis, clubbing, moving all 4
extremities with purpose
PULSES: 1+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, ___ excoriations or lesions, ___
rashes
Pertinent Results:
On ADMISSION:
___ 08:45PM BLOOD WBC-12.1* RBC-4.46* Hgb-12.3* Hct-39.4*
MCV-88 MCH-27.6 MCHC-31.3 RDW-17.1* Plt ___
___ 08:45PM BLOOD Neuts-68.6 ___ Monos-4.1 Eos-2.5
Baso-0.4
___ 08:45PM BLOOD Plt ___
___ 08:45PM BLOOD Glucose-187* UreaN-26* Creat-1.7* Na-141
K-4.2 Cl-106 HCO3-26 AnGap-13
___ 08:45PM BLOOD ALT-125* AST-61* AlkPhos-142* TotBili-0.5
___ 08:45PM BLOOD proBNP-2873*
___ 08:45PM BLOOD cTropnT-<0.01
___ 05:40AM BLOOD CK-MB-6 cTropnT-<0.01
___ 08:45PM BLOOD Albumin-3.3* Calcium-8.3* Phos-3.2 Mg-2.4
___ 06:00PM BLOOD Ferritn-80
___ 05:40AM BLOOD TSH-2.9
___ 05:40AM BLOOD HBsAb-POSITIVE
___ 04:10PM BLOOD ___ SPECIFI FreeKap-PND FreeLam-24.7
___ 05:40AM BLOOD HCV Ab-NEGATIVE
On DISCHARGE:
___ 06:32AM BLOOD WBC-10.5 RBC-4.44* Hgb-12.5* Hct-39.1*
MCV-88 MCH-28.1 MCHC-31.9 RDW-16.9* Plt ___
___ 06:15AM BLOOD Glucose-51* UreaN-36* Creat-2.2* Na-143
K-3.9 Cl-101 HCO3-34* AnGap-12
___ 06:15AM BLOOD ALT-40 AST-25
___ 06:15AM BLOOD Calcium-8.7 Phos-4.5 Mg-2.0
Brief Hospital Course:
Mr ___ came to the ED with 1 week of increasing shortness of
breath and abdominal distention. He was found to be in acute
heart failure. He was diuresed, responded best to 40mg IV lasix,
and was transitioned to 20mg PO Torsemide, remaining euvolemic
for 24+hrs on a 2g sodium diet. During this his electrolytes
remained grossly stable. His Cr peaked at 2.2. His dry weight
was established to be 73.2 kg.
Etiologies for the HF were assessed. TSH was normal, Ferritin
was normal, HIV negative. A cardiac echo showed a preserved EF
of >55% and beat-to-beat variability consistent with ventricular
bigeminy which were seen on EKG. He was also noted to have
pulmonary artery hypertension (moderate), 2+ TR and 1+ MR. ___
signs of sarcoid or amyloidosis. TTE and clinical picture were
most consistent with HFpEF secondary to hyeprtension. Stress
MIBI showed possible small reversible perfusion defect in base
of inferolateral wall that was difficult to distinguish from
motion artifact. The decision was made to focus on medical
optimization for CAD without cath this admission.
The pt was also noted to be hypertensive during his stay, his BP
improved after changing BB to carvedilol.
ACTIVE ISSUES
# HF - see above
# CVD - Statin was changed to 80mg atorvastatin on discharge
given findings of stress MIBI and hx DM putting pt at increased
CV risk
# HTN - managed ok on Carvedilol BID, ___ and diuretics as for
HF as above
# Leukocytosis - unclear etiolgoy, improved thorughout stay, pt
without isgns of infection
# Transaminitis - improved as CHF exacerbation improved
# DM - pt hypoglycemic in AM, QHS lantus reduced to 20u, with
improvement in AM Fasting sugars; ISS used with good effect
CHRONIC ISSUES - see above
TRANSITIONAL ISSUES
# Renal function - Cr was elevated due to diuresis. Home
diuretic dose adjusted. Please follow-up on volume status and
Creatinine (Cr). Cr on d/c was 2.2 and torsemide reduced to 20mg
daily.
# Blood Glucose - pt had hypoglycemic episode ___ AM of
hospitalization after eating normally and recieving home qhs
insulin. ___ glargine was reduced to 20u QHS and pt remained
without hypoglycemia
# outpatient cardiac MR may be needed to assess etiology of HF
# Dry Wt = 73.3kg (161 lbs)
# Statin was changed to 40mg atorvastatin (given increased CV
risk factors and DM)
# Code: Full
# Emergency Contact: ___, wife, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO BID
2. Metoprolol Succinate XL 100 mg PO DAILY
3. NIFEdipine CR 90 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
7. Glargine 32 Units Bedtime
8. Duloxetine 40 mg PO DAILY
9. Hydrochlorothiazide 25 mg PO DAILY
10. Calcitriol 0.25 mcg PO EVERY OTHER DAY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcitriol 0.25 mcg PO EVERY OTHER DAY
3. Duloxetine 40 mg PO DAILY
4. Losartan Potassium 100 mg PO BID
5. NIFEdipine CR 90 mg PO DAILY
6. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*0
7. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*0
8. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Outpatient Lab Work
Labwork to be done: Chem 10
ICD9 code = 428.0
Please fax results to ___, NP at ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- New onset heart failure with preserved ejection fracture (EF
of 55%, ___
Secondary Diagnosis
- Congestive hepatopathy
- Hypertension
- DM2
- CKD (Cr baseline 1.7-2)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
You were admitted to the hospital because you had difficulty
breathing and your belly was enlarged. We think this was
because your heart was not working properly. The name for this
is heart failure. People get heart failure for a number of
reasons. In your case, it is likely because you have had high
blood pressure for many years.
From now on, it is very important that you see a cardiologist
regularly for this. It is also important that you take the new
medication we are prescribing you, and that you watch your salt
intake. Generally we recommend that you limit salt intake to 2g
(2000mg) per day. Also, if you find your belly getting big, if
you develop shortness of breath, or if you gain more than 3lbs
in one day, you should call your doctor.
It is important that you have your kidney function tested at
your endocrinologist and cardiologist appointments as the level
was mildly elevated.
It has been a pleasure taking care of you. Be well and best of
luck.
- Your ___ Care Team
Followup Instructions:
___
|
10834132-DS-3
| 10,834,132 | 24,726,815 |
DS
| 3 |
2178-05-01 00:00:00
|
2178-05-02 10:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending: ___.
Chief Complaint:
shortness of breath, orthopnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of HFpEF, IDDM2, HTN, CKD IV, who presents for
acute shortness of breath and orthopnea.
Yesterday morning he developed new shortness of breath while
resting at home, worse when lying flat, and better when he sat
up
in the chair. Denies any chest pain or cough. He likes to add
salt to his meals and has been doing this more frequently of
late. Prior to yesterday, he had been in usual state of health.
He doesn't do much physical activity, but is able to walk up and
down the stairs in his house without any new DOE. He's had
issues
with peripheral edema and on ___ heart failure clinic visit,
torsemide dose was increased by cardiologist from 40mg BID to
60mg qAM and 40mg qPM. His dry weight is thought to be less than
160lbs.
I regards to his heart failure history, he has had 1
hospitalization in ___ for exacerbation. At that time,
pharmacologic nuclear stress test showed possible small
partially
reversible perfusion defect in basal inferolateral wall, versus
artifact. It was recommended he get a cardiac MRI to assess for
amyloidosis or other infiltrative disease, but he has not
scheduled this. He has had a history of symptomatic junctional
bradycardia for which it was recommended he hold beta blocker,
but he's been taking carvedilol without any subsequent issues.
In the ED initial vitals were:
- 97.8 64 171/65 20 100% RA
- Exam: b/l crackles, b/l ___ edema
- Labs: Trop-T 0.04->0.02, MB 4, ProBNP 558, BUN 4, Cr 3.5
- CXR: Mild pulmonary vascular congestion, without interstitial
edema.
- EKG: sinus rhythm. New TWI V5-6.
- He received 80mg IV Lasix to which he diuresed 750cc. He then
received Torsemide 60mg PO. ALso received home
antihypertensives:
Imdur 30, Losartan 100, Nifedipine 90, Carvedilol 6.25)
- Discussed with primary cardiologist who recommended admission
to heart failure service for IV diuresis
On arrival to the floor, he reports shortness of breath is much
improved after Lasix. He continues to deny chest pain. He has no
other complaints currently.
Past Medical History:
PAST ___ MEDICAL HISTORY:
Diastolic congestive heart failure
Type 2 Diabetes Mellitus
Hypertension
OTHER PAST MEDICAL HISTORY:
Chronic Kidney Disease IV c/b diabetic nephropathy
GERD
Osteoarthritis
BPH
Diverticulosis
Bilateral complex renal cysts
Social History:
___
Family History:
Father had coronary artery disease, cerebrovascular disease,
hypertension and diabetes. Mother had a stroke.
No reported history of premature coronary artery disease,
cardiomyopathies, arrhythmias, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
___ 1115 Temp: 97.5 PO BP: 186/77 HR: 60 RR: 18 O2 sat:
100%
O2 delivery: r/a Dyspnea: 0 RASS: 0 Pain Score: ___
Admission weight; 158.5lb
GENERAL: Well developed, well nourished, lying in shallow angle
in no acute distress
HEENT: MMM, EOMI
NECK: JVP 12cm
CARDIAC: RRR, S1, S2, soft systolic murmur
LUNGS: bibasilar rales
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. 1+ edema to knees
SKIN: No significant skin lesions or rashes.
PULSES: 2+ radials
NEURO: moves all extremities with full and symmetric strength;
no
focal deficits
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 1144)
Temp: 98.5 (Tm 99.1), BP: 152/75 (131-194/53-78), HR: 62
(58-68), RR: 18 (___), O2 sat: 98% (97-99), O2 delivery: RA
Fluid Balance (last updated ___ @ 1015)
Last 8 hours Total cumulative 245ml
IN: Total 620ml, PO Amt 620ml
OUT: Total 375ml, Urine Amt 375ml
Last 24 hours Total cumulative -200ml
IN: Total 800ml, PO Amt 800ml
OUT: Total 1000ml, Urine Amt 1000ml
GENERAL: Well appearing, sitting in a chair, pleasant, in NAD
NECK: JVD at 7-8 cm, +HJR
CARDIAC: RRR, ___ systolic murmur at ___, nl s1/s2, no rubs,
gallops, or thrills
LUNGS: CTAB, no wheezes, crackles, or rhonchi
ABDOMEN: Soft, non tender, non distended, BS+
EXTREMITIES: Warm, well perfused, no lower extremity edema
SKIN: No significant skin lesions or rashes
Pertinent Results:
ADMISSION LABS
___ 11:22PM BLOOD WBC-9.5 RBC-4.35* Hgb-11.4* Hct-35.6*
MCV-82 MCH-26.2 MCHC-32.0 RDW-16.1* RDWSD-48.1* Plt ___
___ 11:22PM BLOOD Neuts-63.8 ___ Monos-5.1 Eos-3.1
Baso-0.5 NRBC-0.3* Im ___ AbsNeut-6.06 AbsLymp-2.42
AbsMono-0.48 AbsEos-0.29 AbsBaso-0.05
___ 11:22PM BLOOD Glucose-159* UreaN-44* Creat-3.5* Na-143
K-3.8 Cl-102 HCO3-29 AnGap-12
___ 11:22PM BLOOD ALT-11 AST-15 AlkPhos-97 TotBili-0.4
___ 11:22PM BLOOD cTropnT-0.04* proBNP-558
___ 11:22PM BLOOD Albumin-3.4*
PERTINENT/DISCHARGE LABS
___ 07:15AM BLOOD WBC-11.8* RBC-4.26* Hgb-11.3* Hct-35.1*
MCV-82 MCH-26.5 MCHC-32.2 RDW-17.0* RDWSD-50.4* Plt ___
___ 07:15AM BLOOD Glucose-66* UreaN-50* Creat-4.1* Na-143
K-4.3 Cl-103 HCO3-26 AnGap-14
___ 07:15AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.4
IMAGING/STUDIES
CXR ___- Mild pulmonary vascular congestion, without
interstitial edema.
Brief Hospital Course:
___ with HFpEF (EF 65%) HTN, IDDM2, CKD IV who presented with
dyspnea, orthopnea and lower extremity edema due to acute on
chronic heart failure exacerbation likely ___ uncontrolled blood
pressures.
ACTIVE ISSUES:
==============
# Hypertensive emergency
Presented w/SBPs in the 170s and had difficult to control blood
pressures on the floor with persistent hypertension. Hydralazine
held due to concern for poor renal perfusion. Isosorbide
mononitrite was increased from 30 mg daily to 120 mg daily.
Nifedipine 90 mg was continued. Hydralazine was restarted and
increased to 100 mg TID daily. Losartan was briefly held due to
rise in renal function, but then restarted at 100 mg daily.
Carvedilol was continued at 6.25 mg PO BID and not increased due
to history of symptomatic bradycardia.
Presented w/elevated BPs with acute HF exacerbation. Torsemide
was increased to 100 mg qd.
# Acute diastolic heart failure:
Volume overloaded on admission with JVP elevation, rales,
and leg edema to knees. Weight (after diuresis) 158lb, from last
clinic weight 165lb 5 weeks ago. Trigger likely multifactorial
given self-endorsed dietary indiscretion and liberal fluid
intake as well as poor blood pressure control and concern for
poor compliance. Pt initially treated with IV diuretic and then
transitioned to PO torsemide at 100 mg qd. Her
anti-hypertensives were changed as above.
# CKD IV:
Creatinine slightly elevated compared to last check, but
essentially within his recent range. Presumed secondary to
longstanding HTN and DM2. Given persistently elevated Cr and
hypertension, nephrology consulted who recommended BP management
and follow-up with them.
# IDDM2: Continued on home insulin
**TRANSITIONAL ISSUES**
Discharge weight: 70.1 kg
Discharge Cr: 4.1
Discharge diuretic: Torsemide 100 mg qd
NEW medications:
Hydralazine 100 mg TID
CHANGED medications:
Torsemide 60 mg qd to 100 mg qd
Imdur 30 mg qd to 120 mg qd
HELD medications:
None
[] F/u chem 10 within one week of discharge
[] Ensure follow up with heart failure team as well as
nephrology
[] Needs strict monitoring of blood pressures
[] Discharged with ___ for medication management
-Full code
-Contact: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Gabapentin 600 mg PO QHS
3. Carvedilol 6.25 mg PO BID
4. NIFEdipine (Extended Release) 90 mg PO DAILY
5. linaGLIPtin 5 mg oral DAILY
6. Atorvastatin 80 mg PO QPM
7. Glargine 30 Units Bedtime
8. Torsemide 60 mg PO QAM
9. Torsemide 40 mg PO QPM
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Latanoprost 0.005% Ophth. Soln. Dose is Unknown BOTH EYES
QHS
12. Aspirin 81 mg PO DAILY
13. Calcitriol 0.25 mcg PO EVERY OTHER DAY
14. Calcitriol 0.5 mcg PO EVERY OTHER DAY
15. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Medications:
1. HydrALAZINE 100 mg PO Q8H
RX *hydralazine 100 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
2. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
RX *isosorbide mononitrate 120 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
3. Torsemide 100 mg PO DAILY
RX *torsemide 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Calcitriol 0.25 mcg PO EVERY OTHER DAY
7. Calcitriol 0.5 mcg PO EVERY OTHER DAY
8. Carvedilol 6.25 mg PO BID
9. Gabapentin 600 mg PO QHS
10. Glargine 30 Units Bedtime
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. linaGLIPtin 5 mg oral DAILY
13. Losartan Potassium 100 mg PO DAILY
14. NIFEdipine (Extended Release) 90 mg PO DAILY
15. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Heart failure, preserved EF, exacerbation
Hypertensive emergency
Chronic kidney disease
Secondary diagnoses:
Type II Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
What brought you to the hospital?
- You came to the hospital with fatigue, worsening breathing and
leg swelling
What happened while you were in the hospital?
- You were given IV diuretics (medications to help get rid of
extra fluid in your body)
- We also changed your blood pressure medications since we
believe your high blood pressure is the cause of your difficulty
breathing and fluid build up
What should you do when you leave the hospital?
- Continue to take your medications as prescribed. See below for
a complete list of your new medications.
- Please make sure that you follow up with your primary care
doctor, cardiologist and nephrologist
- Please weigh yourself every morning and call your cardiologist
if you gain more than 3 lbs.
It was a pleasure taking care of you.
-Your ___ Team
Followup Instructions:
___
|
10834132-DS-4
| 10,834,132 | 23,607,054 |
DS
| 4 |
2178-07-11 00:00:00
|
2178-07-12 17:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
Intubated on ___, extubated ___
EGD on ___
History of Present Illness:
Mr. ___ is a ___ man who is a ___'s witness, with
history of CKD V, DM, HTN, GERD, and diverticulosis, who
presented with 2 days of melena and abdominal pain. Yesterday
afternoon, patient developed nausea and abdominal pain after
lunch. Started having BMs at 4pm, continued with frequent BMs
through the night. +Diaphoresis, lightheadedness, and weakness.
However, at 1500 today patient was noted to have an unwitnessed
fall en route to bathroom. Per pt report, no LOC. Wife could not
get him, up so she called an ambulance.
Vitals: Tachy to 110, BP 115/49 (relative hypotension from
baseline 150s).
Exam: drowsy but interactive. systolic murmur, lungs clear. abd
distended but very soft. Rectal with visible melena (obviously
guaiac +).
Hgb 5.0, lactate 7.2. Pt is Je___'s witness and after
extensive discussion of the risks of refusing blood and blood
products, they confirm that they will not accept blood. Ok with
plasma.
A/P: hemorrhagic shock iso presumed UGIB. Given CKD V, would be
c/f uremic bleed.
-Imaging notable for: No acute process in CT C-spine, CT head,
CXR
-GI Consult: recommended Pantoprazole 80mg x1, followed by 40mg
BID. Resuscitate aggressively and strongly recommended pRBC
transfusion. Intubate if develops hematemesis. Likely ___ uremic
bleed, consider DDAVP.
-Medications given: 80mg IV protonix, 28 mcg desmopressin
-Vitals prior to transfer:
On arrival to the MICU, the patient had a central line placed
and was intubated for an EGD.
Past Medical History:
PAST ___ MEDICAL HISTORY:
Diastolic congestive heart failure
Type 2 Diabetes Mellitus
Hypertension
OTHER PAST MEDICAL HISTORY:
Chronic Kidney Disease IV c/b diabetic nephropathy
GERD
Osteoarthritis
BPH
Diverticulosis
Bilateral complex renal cysts
Social History:
___
Family History:
Father had coronary artery disease, cerebrovascular disease,
hypertension and diabetes. Mother had a stroke.
No reported history of premature coronary artery disease,
cardiomyopathies, arrhythmias, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, tender, distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM:
========================
GENERAL: Alert, oriented to self and place but not to time
(___).
HEENT: NC/AT, sclera anicteric. Mucous membranes dry. Dobhoff in
place.
CV: RRR, S1, S2 with +SEM.
PULM: Clear to auscultation bilaterally, no wheezes or rhonchi.
No increased work of breathing.
ABD: Soft, (+) distention but non-tender to deep palpation in
all
quadrants. Normal bowel sounds.
EXT: Trace pitting edema of the ___ bilaterally.
GU: Condom catheter in place.
Pertinent Results:
ADMISSION LABS:
===============
___ 06:16PM GLUCOSE-293* UREA N-137* CREAT-5.9*
SODIUM-150* POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-20* ANION
GAP-24*
___ 06:16PM WBC-24.4* RBC-1.86* HGB-5.0* HCT-16.3* MCV-88
MCH-26.9 MCHC-30.7* RDW-16.6* RDWSD-51.8*
___ 06:16PM ___ PTT-24.8* ___
___ 06:16PM PLT COUNT-257
___ 06:39PM LACTATE-7.2*
DISCHARGE LABS: (no labs drawn in the final ___dmission)
===============
___ 05:45AM BLOOD Na-157* K-3.5 Cl-126*
___ 05:45AM BLOOD Hgb-4.5* calcHCT-14
STUDIES:
========
___ EGD
-Old blood in whole esophagus, stomach, and duodenum.
Particularly in fundus--limiting visualization.
-Scarred-appearing pylorus with juxt-pyloric diverticulum.
-angioectasias in the mid body of stomach. (Possible source of
bleeding.) 3 small AVMs were intervened with BiCAP.
___ EGD
-Two vascular blebs were noted in the esophagus suspicious for
OGT trauma. These were washed and appeared unchanged.
- Ulcer in the GEJ.
- Linear erosions with two areas of ulceration from the prior
BiCAP in the stomach body.
- A prepyloric diverticulum was noted.
Brief Hospital Course:
___ who is a ___s Witness with history of chronic kidney
disease stage 5 not on hemodialysis, T2DM, HTN, GERD, and
diverticulosis, who presented with melena and abdominal pain,
found to be in pressor-dependent hemorrhagic shock with initial
Hgb 5.0 and requiring intubation. EGD demonstrated a
non-bleeding gastroesophageal junction ulcer and AVM's s/p
ablation, thought to be the source of GI bleed. Patient was
extubated, transferred to floor, and made DNR/DNI in
consultation with the patient's family. Non-transfusion
interventions were optimized, including IV iron, ddAVP, and EPO.
The patient's family ultimately decided to discontinue IV
therapies and to bring him home with home hospice in order to
maximize comfort.
ACTIVE ISSUES
=============
#ANEMIA
#UPPER GI BLEED
Patient presented with abdominal pain and melena for 2 days and
was admitted to the ICU for pressor-dependent hemorrhagic shock.
He was intubated for EGD, which showed extensive clot in the GI
tract and some AVMs that were treated with BiCAP ablation.
Repeat EGD showed no lesions requiring intervention and no
ongoing bleeding. Patient is a Jehovah's Witness, so no blood
was administered throughout his hospital course. He was
supplemented with transfusion-sparing therapies, including iron,
folate, and vitamin K. He was also given EPO and ddAVP given his
uremia from CKD stage V, which was thought to be contributing to
platelet dysfunction and coagulopathy. His Hgb was as low as
3.2. He was extubated and transferred to the medicine service on
___. On the wards, he was noted to have a change in his mental
status, likely secondary to hypoxia from anemia, hypernatremia,
uremia, and overlying delirium. A family meeting was held, and
his code status was changed to DNR/DNI with no escalation of
care to the ICU. On subsequent discussion with the patient's
wife and son and following a family meeting with a ___
___ minister/___ liaison and Palliative Care, the
decision was made to take the patient home with home hospice
from ___.
#DYSPHAGIA
#NUTRITION
Given the patient's fluctuating mental status, he was initially
made nothing by mouth and started on tube feeds with Nutrition
recommendations. Given the family's decision to maximize comfort
and the patient's requests to eat and drink, his diet was
liberalized. The family voiced understanding of his risk of
aspiration and will ensure he is awake and alert when eating and
that someone stays with him throughout. Tube feeds were
continued per family request to optimize nutrition.
#HYPERNATREMIA
Likely due to poor oral free water intake while intubated and on
tube feeds. He was given free water to try to correct the
hypernatremia.
#ESRD STAGE V
#UREMIA
Hemodialysis was held given the very high risk of bleeding and
fluid shifts in the setting of profound anemia. Unfortunately,
the patient's uremia likely contributed to his coagulopathy. He
was given FFP and ddAVP to try to correct his platelet
dysfunction.
#COAGULOPATHY
Patient had elevated INR with no known anticoagulation. Possibly
due to nutritional deficiency and therefore given Vitamin K.
#LEUKOCYTOSIS
Patient presented with a leukocytosis of unclear etiology that
downtrended over the course of the hospitalization. He was
treated empirically with ceftriaxone and Flagyl for 5 days for
possible diverticulitis. His infectious work-up returned
negative. Given the family's decision to discontinue blood
draws, repeat CBC's were not performed.
#DIABETES TYPE II
Patient was continued on basal/bolus dosing of insulin.
Fingerstick blood glucoses were thought to be inaccurate given
low hematocrit. His sugars were maintained between 200-350. Per
family decision, continued insulin on discharge.
#HYPERTENSION
He was continued on losartan and carvedilol with systolic blood
pressures from 150-180, thought to be secondary to severe anemia
and autoregulation to allow for sufficient cerebral perfusion.
CHRONIC ISSUES
==============
#GERD
Patient was initiated on an IV PPI in the setting of ongoing GI
bleed. Given the decision to go home on hospice, PPI was
discontinued on discharge.
TRANSITIONAL ISSUES
===================
- Patient will be receiving hospice services from ___
___.
- Please monitor the patient for any pain. He will receive a PO
morphine script on discharge, and the family will receive
additional comfort medications from hospice care
- Consider further de-escalation of care at home- family wished
to continue with feeds via dohboff and insulin therapy
Contact: ___ (wife), ___
DNR/DNI
>30 minutes were spent in coordinating care and discharge
planning.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Calcitriol 0.25 mcg PO EVERY OTHER DAY
4. Calcitriol 0.5 mcg PO EVERY OTHER DAY
5. Carvedilol 12.5 mg PO BID
6. Gabapentin 600 mg PO QHS
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. linaGLIPtin 5 mg oral DAILY
9. Vitamin D ___ UNIT PO 1X/WEEK (MO)
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Losartan Potassium 100 mg PO DAILY
12. NIFEdipine (Extended Release) 90 mg PO DAILY
13. Torsemide 100 mg PO DAILY
14. HydrALAZINE 50 mg PO BID
15. Glargine 30 Units Bedtime
Discharge Medications:
1. Cyanocobalamin 500 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) [B-12 DOTS] 500 mcg 1
tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Morphine Sulfate (Oral Solution) 2 mg/mL ___ mg PO Q6H:PRN
Pain - Mild
RX *morphine 10 mg/5 mL 5 mL by mouth every six (6) hours
Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth once a day Refills:*0
RX *polyethylene glycol 3350 [Miralax] 17 gram 17 g by mouth
once a day Disp #*30 Packet Refills:*0
5. Sarna Lotion 1 Appl TP TID:PRN itching
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % apply when
itching three times a day Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [Senna Laxative] 8.6 mg 8.6 mg by mouth once a
day Disp #*30 Tablet Refills:*0
7. Glargine 30 Units Bedtime
8. Carvedilol 12.5 mg PO BID
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Losartan Potassium 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
==================
#ANEMIA
#UPPER GI BLEED
#HEMORRHAGIC SHOCK
#ABDOMINAL DISTENSION
#HYPERNATREMIA
#COAGULOPATHY
#ESRD STAGE V
#LEUKOCYTOSIS
#DIABETES TYPE II
#HYPERTENSION
#ENCEPHALOPATHY
#UREMIA
SECONDARY DIAGNOSES
===================
#GERD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure to care for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
You had dark stools and belly pain.
WHAT HAPPENED IN THE HOSPITAL?
- You were found to have a very low red blood cell count due to
bleeding.
- We performed an endoscopy, a procedure where we use a camera
to look down your throat, in order to evaluate for any sources
of bleeding from the gut. We found an ulcer that was not
actively bleeding but which was thought to be the cause of your
low red blood cell count.
- We gave you medications to help your body produce more of your
own blood.
- You received antibiotics to treat an infection in your belly.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Please continue drinking and eating when you are alert.
- Please monitor for any pain and take pain medications as
needed.
- Please do all of the things that make you comfortable and
bring you happiness.
We wish you all the best.
Sincerely,
Your care team at ___
Followup Instructions:
___
|
10834494-DS-21
| 10,834,494 | 20,171,180 |
DS
| 21 |
2135-12-09 00:00:00
|
2135-12-09 22:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Moexipril / Naltrexone
Attending: ___
Chief Complaint:
Abdominal discomfort
Major Surgical or Invasive Procedure:
Paracentesis (___)
History of Present Illness:
___ year old male with recent cirrhosis evaluation, alcohol
abuse, diabetes mellitus, hypertension, dyslipidemia, and GERD
who presents with two weeks or worsening abdominal distention
and GERD symptoms. His reflux symptoms are worse with eating and
associated with early satiety. He has also been having nausea
and vomiting several times each week. He has been feeling
fatigued and has decreased appetite.
He reports increased urinary frequency, occasionally red urine.
He has a history of significant alcohol abuse, but reports that
he has decreased his intake recently. He currently reports
drinking about one pint of rum each week. He has recently been
undergoing evaluation for cirrhosis with Hepatology here, but
has not yet had a liver biopsy.
Initial vitals in ED triage were T 98.0, HR 110, BP 133/75, RR
20, and SpO2 97% on RA. Labs were notable for ALT 28, AST 102,
TBili 1.6, INR 1.2, Albumin 3.3, and Lactate 2.1. Urinalysis was
positive with WBC 8 and hyaline casts. Diagnostic paracentesis
was performed with WBC 235, but only 7% neutrophils. RUQ
ultrasound showed an echogenic liver, small ascites, and patent
portal vein. Stool guaiac was negative.
He was given Ceftriaxone 1000 mg IV for UTI as well as normal
saline 1000 ml for volume depletion. He was admitted to medicine
for further management of UTI and his abdominal symptoms. Vitals
prior to floor transfer were T 98.9, HR 97, BP 116/77, RR 16,
and SpO2 97% on RA. On reaching the floor, he reported feeling
somewhat better overall, but with similar symptoms as those
noted above.
Past Medical History:
# Possible Cirrhosis
# Diabetes Mellitus Type 2
# Hypertension
# Dyslipidemia
# Obesity
# Alcohol abuse
# Tobacco abuse
# Gout
# GERD
Social History:
___
Family History:
# Mother: died from MI at age ___
# Father: died from MI at age ___
# Maternal Uncle: cirrhosis and alcohol abuse
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 98.4 BP 118/80 HR 78 RR 18 SaO2 98% on RA
GEN: Well appearing ___ gentleman is ambulating in
his room without difficulty and appears in no apparent distress.
HEENT: Moist mucous membranes. OP clear.
NECK: No JVD. No lymphadenopathy.
CV: RRR, no m/r/g.
CHEST: Clear to auscultation bilaterally. No accessory muscle
use.
ABDOMEN: Distended abdomen, tympanic. Normoactive bowel sounds.
Minimally tender to deep palpation in midabdomen. No
tenderness in other areas. No rebound tenderness. Unable to
palpate liver edge.
EXT: Warm and well perfused. Nonedematous.
NEURO: Alert & oriented x 3. No asterixis. Moving all four
limbs spontaneously. Follows commands. Normal gait.
Pertinent Results:
___ 06:20PM BLOOD WBC-7.9# RBC-3.52* Hgb-11.7* Hct-36.8*
MCV-105* MCH-33.3* MCHC-31.9 RDW-15.0 Plt ___
___ 05:17AM BLOOD WBC-5.8 RBC-3.12* Hgb-10.5* Hct-32.7*
MCV-105* MCH-33.5* MCHC-32.0 RDW-14.8 Plt ___
___ 05:17AM BLOOD ___ PTT-32.4 ___
___ 06:20PM BLOOD Glucose-145* UreaN-7 Creat-0.9 Na-143
K-4.1 Cl-109* HCO3-24 AnGap-14
___ 05:17AM BLOOD Glucose-149* UreaN-5* Creat-0.7 Na-138
K-3.6 Cl-108 HCO3-23 AnGap-11
___ 06:20PM BLOOD ALT-28 AST-102* LD(LDH)-312* AlkPhos-275*
TotBili-1.6* DirBili-0.7* IndBili-0.9
___ 05:17AM BLOOD ALT-22 AST-77* LD(___)-245 AlkPhos-200*
TotBili-1.2
___ 05:17AM BLOOD TotProt-5.0* Calcium-7.8* Phos-3.3
Mg-1.3*
___ 06:20PM URINE RBC-3* WBC-10* Bacteri-FEW Yeast-NONE
Epi-2
___ 06:20PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-TR Ketone-10 Bilirub-SM Urobiln-4* pH-5.5 Leuks-TR
___ 10:35PM ASCITES WBC-235* RBC-40* Polys-7* Lymphs-70*
Monos-0 Eos-2* Mesothe-4* Macroph-17*
___ 10:35PM ASCITES TotPro-2.1 Glucose-140
MICROBIOLOGY
============
___ 10:35 pm PERITONEAL FLUID
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 (Preliminary):
ANAEROBIC CULTURE (Preliminary):
___ 9:14 pm URINE
URINE CULTURE (Pending):
___ 10:35 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
Fluid Culture in Bottles (Preliminary): NO GROWTH.
IMAGING
=======
ABDOMINAL X-RAY (___)
FINDINGS: Supine and upright views of the abdomen and pelvis
demonstrate
non-obstructive bowel gas pattern. No dilated bowel loops or
air-fluid
levels. No pneumoperitoneum or pneumatosis. No overt colonic
fecal loading.
IMPRESSION: No obstruction or free air
LIVER ULTRASOUND (___)
1. Echogenic liver, most consistent with hepatic steatosis,
although more
advanced disease such as cirrhosis and/or fibrosis cannot be
excluded.
2. Small volume ascites, as seen on prior ultrasound from
___.
3. Patent main portal vein.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION
==================================
#) ABDOMINAL DISCOMFORT: Paracentesis was performed on small
volume ascites and was negative for spontaneous bacterial
peritonitis by cell counts. Fluid culture is pending at the
time of discharge, and will require follow-up. Mr. ___
continued to have lower epigastric discomfort which was worse
postprandially, although slightly relieved after successful
laxative therapy. KUB was negative for obstruction or other
acute intrabdominal process. Ultrasound revealed echogenic
liver. Mr. ___ was clinically very stable and in only very
mild discomfort. His epigastric pain had no exertional
relationship to suggest cardiac ischemia. He relates a fairly
clear history of GERD with postprandial discomfort as well as a
brash taste in his throat. However, EGD done on ___
demonstrated absence of esophagitis or gastritis, but notably,
Mr. ___ symptoms of postprandial fullness developed after his
EGD. The leading differential was gastroparesis, due to
diabetic enteric neuropathy or another cause and we organized a
gastric emptying study as an outpatient. We also communicated
directly with his PCP throughout his admission.
#) POSSIBLE UTI: Mr. ___ denied any symptoms of dysuria,
urgency, hesitancy, incomplete voiding but did endorse some
recent increased frequency prior to admission. His urine
analysis was borderline with 10 WBCs, 2 EPIs, few bacteria, and
trace leukocyte esterase, so we decided against antibiotic
therapy. Of note, the final culture of his urine sample needs
follow up as noted below.
TRANSITIONAL ISSUES
===================
1. Follow-up on final blood culture results.
2. Follow-up on final urine culture results.
3. Follow-up on final peritoneal fluid results.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Valsartan 320 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Acamprosate 666 mg PO TID
4. Amlodipine 10 mg PO DAILY
5. Ranitidine 150 mg PO QHS:PRN reflux
6. Rosuvastatin Calcium 20 mg PO DAILY
7. Spironolactone 12.5 mg PO DAILY
8. Omeprazole 40 mg PO BID
9. Potassium Chloride 40 mEq PO DAILY
10. Aspirin 81 mg PO DAILY
11. traZODONE 50 mg PO HS:PRN insomnia
Discharge Medications:
1. Acamprosate 666 mg PO TID
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Omeprazole 40 mg PO BID
6. Rosuvastatin Calcium 20 mg PO DAILY
7. Spironolactone 12.5 mg PO DAILY
8. traZODONE 50 mg PO HS:PRN insomnia
9. Valsartan 320 mg PO DAILY
10. Ranitidine 150 mg PO QHS:PRN reflux
11. Potassium Chloride 40 mEq PO DAILY
Hold for K > 4
12. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp
#*14 Tablet Refills:*0
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 Packet by mouth Daily
Disp #*7 Packet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal discomfort
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted for abdominal discomfort. We
performed a paracentesis and tested the fluid in your abdomen
and found that it was not infected. We gave you stool softeners
and you improved. Given your symptoms after eating, we want to
perform a test called a Gastric Emptying Study which will
evaluate your ability to move food through your gastrointestinal
tract. This test can be done as an outpatient as we have
arranged.
Followup Instructions:
___
|
10834554-DS-5
| 10,834,554 | 24,875,226 |
DS
| 5 |
2187-10-17 00:00:00
|
2187-10-17 13:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Shortness of Breath and Fatigue
Major Surgical or Invasive Procedure:
Diagnostic Cardiac Catheterization ___ CABG X5(LIMA->LAD,SVG->Diag,SVG->RAMUS->OM2,SVG->PLV)
History of Present Illness:
The patient is a ___ M with PMHx obesity, HLD, HTN who
presented to PMD today (___) with ___ days of malaise, SOB, and
epigastric bloating. Over the past 2 weeks he could not lie flat
and occasionally had PND. He also noted intermittant fever and
chills with myalgias with an intermittent dry cough while lying
flat. No recent travel or sick contacts. The patient denies
having any chest pain, including no CP on exertion. No dizziness
or palpitations.
On entrance into Urgent Care today, initial oxygen saturation
was 86%. With 6 L nasal cannula, increased to 90% with some
improvement in
symptoms.
The patient reports that he had recently been lost to follow up
because he lost his job and also his health insurance. During
this time (___) he was very depressed and began
drinking heavily. The patient would finish a full bottle of
Vodka every ___ days. He stopped after convincing from his
daughter and subsequently found a new job last month.
He reports that while he had no health insurance, he was not
able to take some of his BP medications.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, hemoptysis, black stools or red stools. He
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
ankle edema, palpitations, syncope or presyncope. He does have
SOB on exertion and orthopnea.
Past Medical History:
-Obesity
-DM Type II
-HLD
-HTN
-Depression
-Dyspepsia
-Gout
*No known hx of CAD or CHF
Social History:
___
Family History:
Father had an MI at age ___. Brother with DM
Physical Exam:
On Admission
VS: T= 98.3 BP= 102/65 HR= 99 RR= 30 O2 sat= 95% on BiPAP 50%O2,
PEEP-7
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple- JVP difficult to assess ___ Central line and BiPAP
mask
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, S1, S2, S3 gallop appreciated. No thrills, lifts. No
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
tachypnic, no accessory muscle use, dec breath sounds with
rales up to mid lung fields, in particular RLL.
ABDOMEN: Obese, Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Pertinent Results:
Admission Labs
___ 12:20PM WBC-18.9* RBC-4.99 HGB-15.4 HCT-45.3 MCV-91
MCH-30.8 MCHC-33.9 RDW-13.7
___ 12:20PM NEUTS-86.6* LYMPHS-9.4* MONOS-2.7 EOS-0.8
BASOS-0.5
___ 12:27AM BLOOD Glucose-182* UreaN-25* Creat-0.9 Na-140
K-3.8 Cl-100 HCO3-25 AnGap-19
___ 12:20PM BLOOD cTropnT-0.63*
___ 12:27AM BLOOD CK-MB-6 cTropnT-0.90* proBNP-282___*
Notable Labs
___ 12:27AM BLOOD %HbA1c-7.9* eAG-180*
___ 12:27AM BLOOD Triglyc-205* HDL-36 CHOL/HD-6.6
LDLcalc-160* LDLmeas-160*
___ 12:27AM BLOOD TSH-0.94
ECG ___
Possible atrial ectopic rhythm given unusual axis of P wave.
Possible old
anteroseptal myocardial infarction. Possible old inferior
myocardial
infarction. Diffuse non-specific ST-T wave abnormalities.
TTE ___
Left ventricular wall thicknesses and cavity size are normal.
There is moderate regional left ventricular systolic dysfunction
with near akinesis of the distal half of the anterior septum and
anterior walls. The apex is mildly aneurysmal and akinetic. The
remaining segments contract normally (LVEF = 30 %). No masses or
thrombi are seen in the left ventricle. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Regional left ventricular systolic dysfunction c/w
CAD (mid LAD distribution; cannot exclude Takosubo
cardiomyopathy if clinically cuggested).
Compared with the prior study (images reviewed) of ___, the
findings are similar.
Caridac Cath- ___. Selective coronary angiography of this right dominant system
demonstrated severe three vessel coronary artery disease. The
LMCA was
free of any angiographically-apparent flow-limiting stenoses.
The LAD
had a large 90% lesion proximally. There was a 100% occlusion
in the
large D1. The LCx also had a 90% stenosis proximally in the
large ramus
intermedius branch. The large OM2 had an 80% stenosis. The RCA
had a
100% occlusion in the mid-vessel. The distal vessel filled via
well-established left-to-right collaterals.
2. Limited resting hemodynamics revealed normal systemic
systolic
arterial pressures, with a central aortic pressure of 124/84,
mean 98
mmHg.
Brief Hospital Course:
___ year old male presented to ___ ___ from urgent care with 3
days worsening shortness of breath and fatigue. He was found to
be in systolic heart failure. Cardiac cath revelaed severe 3
vessel disease and patient is scheduled for CABG procedure ___.
Systolic CHF
Patient presented with decompensated CHF and severe pulmonary
edema, requiring intermittent BiPAP on admission. After several
days of aggressive IV diuresis, the patient no longer needed any
O2 therapy to maintain normal sats. His medication regimen for
heart failure was optimized: now on 40mg Lisinopril daily, 12.5
Carvedilol BID, and Furosemide 40mg Daily. Spirionolactone may
be started as an
outpatient.
3 Vessel Coronary Artery Disease
Cardiac Cath ___ revealed:
The LAD had a large 90% lesion proximally. There was a 100%
occlusion in the
large D1. The LCx also had a 90% stenosis proximally in the
large ramus
intermedius branch. The large OM2 had an 80% stenosis. The RCA
had a
100% occlusion in the mid-vessel. The distal vessel filled via
well-established left-to-right collaterals.
The patient was maintained on ASA 81mg.
The patient is scheduled for CABG ___.
Based on ECG findings and patient's history, he likely had a
silent, large anterior MI approximately ___ weeks prior to
presenting to urgent care center.
The patient's CAD was medically managed before CABG procedure
with Aspirin and Atorvastatin. He was chest pain free and did
not experience shortness of breath leading up to his surgery.
The patient was brought to the operating room on ___ where
the patient underwent Urgent coronary artery bypass graft x5;
left internal mammary artery to left anterior descending artery,
and saphenous vein graft to diagonal, and saphenous vein
sequential graft to ramus and obtuse marginal, and saphenous
vein graft to posterior left ventricular branch and Endoscopy
harvesting of the long saphenous vein.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found
the patient extubated, alert and oriented and breathing
comfortably. The patient was neurologically intact. He required
milrinone for hemodynamic support until POD#2. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery on POD#3. Chest tubes and
pacing wires were discontinued without complication. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD #5 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged to home in good condition with
appropriate follow up instructions including the need to obtain
a cardiologist for follow up.
?Pnemonia-
On admission, patient had SOB, and elevated WBC count (18) with
likely RLL infiltrate. He completed a 5 day course of PO
azithromycin and 7 day course of ceftriaxone IV in house. His
WBC normalized during hospitalization of RLL infiltrate
resolved.
#HTN
The patient's blood pressures were well controlled on the
carvedilol and lisinopril mentioned above.
#HLD
Patient unreliably took is statin at home. This dose was
continued in house. Measured LDL was 160.
#DM
Measured HgA1c was 7.9. The patient was kept on an insulin
sliding scale while in house.
#Depression
The patient was maintained on his home fluoxetine dose. He
required benzodiazepines intermittently to help him sleep.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientAtrius.
1. Felodipine 5 mg PO DAILY
2. Enalapril Maleate 40 mg PO DAILY
3. Atenolol 75 mg PO DAILY
4. Fluoxetine 60 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Simvastatin 40 mg PO DAILY
7. Omeprazole 20 mg PO BID
Discharge Medications:
1. Fluoxetine 60 mg PO DAILY
2. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
3. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
4. Simvastatin 40 mg PO DAILY
5. Acetaminophen 650 mg PO Q4H:PRN pain, fever
6. Aspirin EC 81 mg PO DAILY
RX *Adult Low Dose Aspirin 81 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
7. Metoprolol Tartrate 75 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
RX *metoprolol tartrate 25 mg 3 tablet(s) by mouth three times a
day Disp #*270 Tablet Refills:*1
8. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every four (4) hours Disp #*65 Tablet Refills:*0
9. Enalapril Maleate 20 mg PO DAILY
RX *enalapril maleate 20 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*1
10. Furosemide 20 mg PO BID Duration: 7 Days
RX *furosemide 20 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
11. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
RX *potassium chloride 20 mEq 20 mEq by mouth once a day Disp
#*7 Tablet Refills:*0
12. Felodipine 2.5 mg PO DAILY
RX *felodipine 2.5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
___:
Coronary Artery Disease
Systoilc CHF
Diabetis Mellutis, Hyperlipidemia, Hypertension, Gout,
Depression, Dyspepsia, Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10834756-DS-9
| 10,834,756 | 29,376,797 |
DS
| 9 |
2145-06-30 00:00:00
|
2145-07-01 21:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Inability to tolerate POs. Progressive cognitive decline.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ with history of Alzheimer's dementia,
recent diagnosis of DVT on Eliquis, MI s/p quadruple bypass on
digoxin, and CVA who presents with progressive cognitive decline
and failure to tolerate POs.
He has been at ___ Care ___ in the ___
unit, where he has his own space but receives nursing assistance
for medications and is also supervised while eating (although he
eats by himself). He was brought to ___ by his son
(previously living alone at home) because he was no longer able
to perform ADLs as he would forget to eat/shower etc. At
___, staff say that he eats food by himself; particularly,
he eats finger foods because he has difficulty manipulating
utensils given his severe rheumatoid arthritis. He was also
tolerating all PO meds well. He also is a "wanderer" and walks
around a lot by himself (supervised). At baseline, he is
minimally communicative, although he does respond to simple 1
word commands. Overnight on ___, he was noted to be yelling,
which his nurse (___) says is his normal way of expressing
pain. The next morning he refused to get out of bed which was
unusual for him. He was also groaning in pain which she thinks
was in his right leg and chronic arthritic pain. He refused to
eat food or medications on ___ and simply stared at it. Even
with assistance from staff, he refused. They did not note any
secretions or evidence of pain when swallowing. His nurse also
states that their staff thought he had R sided facial droop
around 6pm yesterday.
He has not had any recent fevers. Other than his increased
moaning, he has not complained of other symptoms over this time
period. He is incontinent to stool and urine at baseline.
Past Medical History:
Rheumatoid arthritis
History of MI ___ years ago), s/p quadruple bypass
H/o CVA
Testicular cancer s/p surgery
H/o several nerve blocks for back pain
H/o GI ulcers
HTN
Social History:
___
Family History:
history of Cancer, diabetes
Physical Exam:
ON ADMISSION:
VITALS: T 98.1, afebrile HR 73 (64-73), BP 145/68
(145-163)/(65-72) RR 16 O2 sat 97-100% on RA
GENERAL: A&O x0. Says "hi" when greeted. Otherwise nonverbal.
Responds to command to squeeze fingers.
Neuro: CN- Pupils round, equal and reactive. Other CN difficult
to assess due to poor participation.
HEENT: Sclerae anicteric, poor dentition
NECK: Supple, no tender lymphadenopathy
RESP: Anterior exam. No respiratory distress. Poor air movement
but clear to auscultation bilaterally.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABD: Normoactive bowel sounds. Nondistended, nontender to deep
palpation.
GU: no foley
EXT: warm, well perfused. RLE > LLE. RLE nontender to palpation.
Ulnar deviation on b/l hands. Arms flexed at elbows, and
resisting extension.
ON DISCHARGE:
Vitals: T 97.7 HR 71 (59-71) BP 130/64 (130-183)/(59-76) RR
___ O2 sat 100% on RA
Exam:
GENERAL: A&O x0. Sleeping comfortably in bed
Neuro: Difficulty following verbal commands, but able to follow
visual commands to mimic actions (close eyes, open mouth, turn
head to different sides). Pupils round, equal and reactive.
Other CN difficult to assess due to poor participation. Eyes
track past midline. Reflexes not assessed.
HEENT: Sclerae anicteric, poor dentition
NECK: Supple, no tender lymphadenopathy
RESP: Anterior exam. No respiratory distress. CTAB
CV: Regular rate and rhythm w/ frequent extra beats, normal S1 +
S2, ___ systolic murmur unchanged.
ABD: Hypoactive bowel sounds. Nondistended. Groans on deep
palpation.
GU: no foley
EXT: warm, well perfused. Atrophied.
Pertinent Results:
On Admission:
___ 03:00PM BLOOD WBC-7.4 RBC-3.20* Hgb-9.2* Hct-27.8*
MCV-87 MCH-28.8 MCHC-33.1 RDW-14.2 RDWSD-45.0 Plt ___
___ 03:00PM BLOOD Neuts-81.2* Lymphs-7.9* Monos-8.8 Eos-1.2
Baso-0.4 Im ___ AbsNeut-5.96# AbsLymp-0.58* AbsMono-0.65
AbsEos-0.09 AbsBaso-0.03
___ 03:00PM BLOOD Plt ___
___ 03:00PM BLOOD ___ PTT-35.9 ___
___ 03:00PM BLOOD Glucose-95 UreaN-28* Creat-1.4* Na-138
K-4.2 Cl-104 HCO3-26 AnGap-12
___ 03:00PM BLOOD ALT-10 AST-29 AlkPhos-72 TotBili-0.3
___ 03:00PM BLOOD Albumin-3.5 Calcium-8.9 Phos-3.9 Mg-2.4
___ 07:10AM BLOOD VitB12-499
___ 07:10AM BLOOD TSH-3.6
___ 03:00PM BLOOD Digoxin-0.4*
___ 03:18PM BLOOD Lactate-2.1*
On Discharge: Not checked on discharge
on ___ 07:27AM BLOOD WBC-4.7 RBC-3.42* Hgb-9.5* Hct-29.6*
MCV-87 MCH-27.8 MCHC-32.1 RDW-14.3 RDWSD-44.8 Plt ___
___ 07:27AM BLOOD Glucose-69* UreaN-17 Creat-1.2 Na-135
K-4.2 Cl-97 HCO3-21* AnGap-21*
___ 07:27AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.0
Pertinent results:
___ 07:10AM BLOOD VitB___-___
___ 07:10AM BLOOD TSH-3.6
Imaging:
___ Chest X ___:
Persistent mild prominence of the ascending aorta. Mild left
base
atelectasis. No focal consolidation to suggest pneumonia.
___ CT head w/o contrast:
There is no evidence of acute intracranial hemorrhage, midline
shift, mass
effect, or acute large vascular territorial infarct. The
ventricles and sulci are enlarged suggesting age related
atrophy. Periventricular white matter hypodensities are
nonspecific but likely sequela of chronic small vessel disease.
Bilateral basal ganglia lacune or infarcts are seen.
There is no evidence of acute fracture. There is mild mucosal
thickening in the maxillary and ethmoid air cells. The
remainder of the paranasal sinuses are clear. There have been
lens replacement bilaterally.
___ ___:
1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. Near occlusive thrombus of the right greater saphenous vein,
a superficial vessel, also seen on ___. Compared to
prior there may be mild increase in flow within this vessel.
___ MRI head:
1. No evidence of infarct or hemorrhage.
2. Prominent global atrophy.
3. Nonspecific white matter changes in a configuration
suggestive of chronic small vessel ischemic disease.
Brief Hospital Course:
Mr. ___ is a ___ with history of Alzheimer's dementia,
recent diagnosis of superficial RLE thrombosis on Eliquis, MI
s/p quadruple bypass, afib on digoxin due to h/o massive GI
bleed, and CVA who presented with progressive cognitive decline
and failure to tolerate POs.
Initially, reversible causes for dementia were ruled out. An
infectious workup was conducted, and urine culture was positive
for E. coli and therefore treated with IV Ceftriaxone for 5
days. The overall presentation was thought to be most concerning
for progressive end stage dementia. A goals of care conversation
with his son and healthcare proxy guided decision-making to not
pursue placement of a G-tube. He was discharged to ___
rehabilitation, per recommendations from physical therapy. Dr.
___ primary care doctor, has agreed to continue the
goals of care discussion, specifically around his code status,
after discharge.
#Inability to tolerate POs: This was thought to be either due to
transient delirium, progression of dementia and resulting
disinterest in eating, or more mechanical causes such as
dysphagia or odynophagia. Given appropriate management of
secretions, obstruction was felt to be unlikely. Speech and
swallow evaluated Mr. ___, and felt that there was no
concern for a mechanical process. Transient delirium in the
setting of a UTI was possible, although unlikely given no
resolution of symptoms after antibiotic treatment. This was felt
to therefore be most likely disinterest in eating due to
progression of end stage dementia. His willingness to take small
amounts of POs with his son feeding him suggested that
reorientation and familiar people/environments were helping.
#Progressive cognitive decline, Goals of care: Acute causes of
cognitive decline, including MI or PE, were rule out (no EKG
changes, no tachycardia, evidence of RH strain, or respiratory
distress). LENIs showed interval improvement in superficial RLE
thrombosis. A stroke or vascular dementia were ruled out given
negative NCHCT, and then negative head MRI. Reversible dementia
was ruled out with normal B12, RPR, and TSH levels. Transient
delirium in the setting of infection was postulated, but CXR was
negative. UA was negative, but a urine culture showed >100,000
colonies of E. coli. Although he is incontinent to urine and
stool, this was treated as a complicated UTI due to his
worsening mental status with IV Ceftriaxone x5 days with some
improvement in his mental status. Electrolytes were consistently
within normal limits. Digoxin level was 0.4. This was held on
admission, and stopped at discharge in consultation with his
PCP, as he was in sinus rhythm and the risks were felt to
outweigh the benefits. Geriatrics was consulted, and agreed with
the workup and recommendations. A goals of care discussion with
his son and healthcare proxy resulted in no G-tube consideration
and understanding about the prognosis. He expressed considerable
insight and understanding into his father's condition, and felt
that he may soon end up at hospice. He also felt that
intubation, chest compressions, and shock would be very
traumatic, and likely not in line with his father's current
goals of care. However, he strongly felt that his father would
have wanted to be "given a chance," and felt that he needed more
time to think about changing his father from Full code to
DNR/DNI. So, he was discharged to ___ rehab, Full code,
with plans for Dr. ___ to continue the discussion about his
code status (per conversation with Dr. ___. He was continued
on his home dose of Namenda at discharge.
#RLE superficial thrombosis: he was on home Eliquis (last dose
___. However, he was not tolerating POs while admitted, and
was unable to take this medication although it was continued.
This was discontinued at discharge, in consultation with his
PCP, as the risks of bleeding given high fall risk were felt to
outweigh the benefits of anticoagulation for low-risk
superficial thrombus.
#Hypertension: Blood pressures were within SBP 130-160, with
occasional episodes to 180. Toprol was switched to Metoprolol to
allow for crushing pills in puree, but he rarely was able to
take these. This was continued at discharge.
#CHF, afib: Digoxin was held on admission given the uncertain
indication (outpatient records not available). Ultimately, it
was learned that he has a history of afib, and major bleeding on
anticoagulation, thus on digoxin. He was in sinus rhythm, so
this was held and discontinued on discharge.
He was discharged to an ___ rehab facility.
TRANSITIONAL ISSUES:
1) Hospice: Please consider consulting palliative care/hospice
during ___ rehab, given his son's suggestion that this may
be the appropriate next step.
2) After discussion with the patient's primary care doctor, his
digoxin and apixaban were discontinued as the risks of these
medications were thought to outweight the benefits. As goals of
care conversations continue, may consider discontinuation of
metoprolol and/or memantine as well.
-CODE: full
-CONTACT: son, (HCP) ___ ___, ___
___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Memantine 5 mg PO BID
3. Digoxin 0.125 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Metoprolol Tartrate 12.5 mg PO BID
2. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
3. Memantine 5 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY: E. coli urinary tract infection; Alzheimer's Dementia;
end stage dementia.
SECONDARY: Hypertension; atrial fibrillation; congestive heart
failure.
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 taking care of you during your recent
hospitalization at the ___. You
came to the hospital from the ___ facility because you were
having a difficult time eating food and became less responsive
to people around you. You were evaluated from causes that might
explain this. You were found to have a mild urinary tract
infection which was treated with antibiotics. Imaging of your
head was not concerning for a stroke. However, it was thought
that your Alzheimer's dementia may be progressively worsening,
making your appetite less than normal. Geriatrics became
involved in your care during your hospitalization. Along with
your son, we discussed whether you needed a feeding tube placed.
However, the decision was made that this would be a high risk
procedure, and the benefits would not outweigh the risks.
Physical therapy recommended that you go to an ___
rehabilitation facility to become stronger and to receive the
care that you would need to hopefully be able to return to a
nursing home or other assisted living facility in the future.
Please follow up with Dr. ___ primary care physician,
after completing ___ rehabilitation. He is aware of your
hospitalization and updated about your condition.
With best wishes,
Your ___ team
Followup Instructions:
___
|
10834821-DS-11
| 10,834,821 | 21,906,355 |
DS
| 11 |
2156-08-15 00:00:00
|
2156-08-19 11:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
monostat
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo G0 woman s/p egg retrieval ___ who is transferred
from ___ for ___. She is an egg donor and s/p egg
retrieval ___ with Lupron trigger + 1,000 HCG, peak E2 >7400,
51
eggs retrieved.
Since the retrieval she has noted nausea vomiting and inability
to tolerate p.o.'s. She has not able to keep anything down
since
her procedure. She also noted increasing abdominal distention
and diffuse tenderness. Yesterday she had episode of syncope
and
overall weakness and presented to ___ for
evaluation. She denies hitting her head or trauma.
Findings at ___ was significant for ___ count 21,
Hct
45, normal kidney and liver function tests, moderate ascites on
exam. She was also noted to have some pleural effusion and
ascites on imaging. She was transferred to twice daily MC for
further management.
In the ED here, she reports that her nausea vomiting has
resolved. She continues to note abdominal distention. She had
diffuse tenderness that worsened on her ambulance ride here that
is now controlled after IV morphine. She denies any chest pain.
She has no shortness of breath but does feel that her abdominal
pressure is making it harder to take deep breaths. Denies any
cough, fevers, vaginal bleeding, abnl vaginal discharge,
dysuria, hematuria.
Past Medical History:
OBHx:
-TAB x 1 , D&C
GynHx:
- denies h/o abnl Pap, fibroids, STIs
PMH:
-Asthma
PSH:
-Open umbilical hernia repair
Social History:
___
Family History:
denies bleeding/clotting disorders
Physical Exam:
Physical exam Upon prsentationL
VS:
98.4 92 115/75 16 97% RA
98.3 89 110/71 18 98% RA
Gen: A&Ox3, NAD
CV: RRR
Pulm: no respiratory distress, decreased breath sounds in the
lower bases
Abd: soft, moderately distended, no rebound/guarding. Diffusely
mildly tender. No peritoneal signs
Ext: no TTP, no edema
Pelvic:
Deferred
Physical Exam on Discharge:
Pertinent Results:
___ 06:20AM BLOOD WBC-11.1* RBC-3.80* Hgb-10.7* Hct-31.3*
MCV-82 MCH-28.2 MCHC-34.2 RDW-13.2 RDWSD-39.3 Plt ___
___ 03:10AM BLOOD WBC-17.9* RBC-4.50 Hgb-12.5 Hct-37.5
MCV-83 MCH-27.8 MCHC-33.3 RDW-13.2 RDWSD-40.1 Plt ___
___ 03:10AM BLOOD Neuts-74.0* Lymphs-16.1* Monos-8.6
Eos-0.0* Baso-0.3 Im ___ AbsNeut-13.27* AbsLymp-2.88
AbsMono-1.55* AbsEos-0.00* AbsBaso-0.05
___ 06:20AM BLOOD Glucose-81 UreaN-7 Creat-0.6 Na-143 K-4.3
Cl-107 HCO3-21* AnGap-15
___ 03:10AM BLOOD Glucose-70 UreaN-13 Creat-0.8 Na-137
K-4.1 Cl-102 HCO3-20* AnGap-15
___ 03:10AM BLOOD ALT-12 AST-16 AlkPhos-45 TotBili-1.1
___ 03:10AM BLOOD Lipase-10
___ 03:10AM BLOOD Albumin-3.1* Calcium-8.3* Phos-3.0 Mg-1.8
Chest PA/Lateral: Small right and trace left pleural effusions.
Subsegmental atelectasis at the
lung bases, versus very small infiltrates.
Pelvic Ultrasound:
FINDINGS:
The uterus is anteverted and measures 7.7 x 3.5 x 4.7 cm. The
endometrium is
homogenous and measures 5 mm.
The ovaries are markedly enlarged, and contain multiple cysts
with a open
"spoke-wheel appearance." Right ovary measures 10.6 x 8.1 x
8.4 cm. The
left ovary measures 10.9 x 7.2 x 11.7 cm. Small to moderate
ascites is noted.
IMPRESSION:
Markedly enlarged ovaries with multiple cysts, associated with
mild to
moderate ascites, suspicious for ovarian hyperstimulation
syndrome.
Brief Hospital Course:
Ms. ___ was admitted to the GYN service due to concern for
ovarian hyperstimulation syndrome.
*)Moderate ovarian hyperstimulation syndrome
She was status post egg retrieval on ___ and was transferred
from ___ for ___. She is an egg donor and status
post egg retrieval on ___ with Lupron trigger + 1,000 HCG, peak
E2 >7400, 51 eggs retrieved. She presented with abdominal pain
and inability to tolerate PO and syncopal episode. She was
hemodynamically stable but hemoconcentrated. She also had
abdominal ascites on ultrasound and a small pleural effusion
however so she was admitted to the GYN service for further
management.
She had her weight monitored daily and was started on lovenox
prophylaxis. Her pain was controlled with PO pain meds. She was
made NPO for a possible parcentesis for symptomatic relief and
given IV fluids. She had an interventional radiology consult for
possible drainage of fluid however, there was no large enough
pocket to drain via paracentesis. Her symptoms improved the next
morning as well, so paracentesis was deferred.
On hospital day 2, her pain had significantly improved and she
was able to tolerate PO. Her hemoconcentration resolved with
judicious IV and PO fluids. Given her improved clinical picture
and normalized labs, she was discharged home with instructions
to follow up closely with Dr. ___.
Medications on Admission:
Cabergoline
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Do not exceed 4000 mg in a day
RX *acetaminophen 500 mg ___ tablet(s) by mouth Q6HR Disp #*50
Tablet Refills:*1
2. cabergoline 0.5 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Ovarian hyperstimulation syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the GYN service for care of ovarian
hyperstimulation syndrome. The team feels you have recovered
well.
Please follow the instructions below:
* Please call Dr. ___ for a follow up appointment in
the 1 week
* Please call your doctor if you notice the below:
- rapid weight gain
- abdominal pain
- vomiting
- shortness of breath
Followup Instructions:
___
|
10834978-DS-22
| 10,834,978 | 25,817,712 |
DS
| 22 |
2198-12-07 00:00:00
|
2198-12-07 17:39:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Unresponsiveness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with a PMH notable for
dementia, T2DM, and hypertension who presents from home after an
episode of unresponsiveness. The patient lives with his wife,
who
provided the history due to the patient's inability to provide
history secondary to his dementia and somnolence at the time of
interview.
Per his wife, the patient had been doing well up until the
morning of presentation. He got up and had breakfast, although
he
appeared a bit off, complaining of a runny nose. In the
afternoon, he suddenly had an episode of unresponsiveness,
staring off into the distance. He appeared pale and was very
diaphoretic. He then lost bowel function, soiling himself with
loose stool. His wife managed to get him into the bathroom, but
he was not able to help clean himself and just sat slumped over
in the bathroom. His wife checked his ___, which was 177. An
ambulance was called and brought him to the ED.
Prior to today, his wife reports that he was doing well without
any specific symptoms. He did not have any fevers, chills,
dyspnea, nausea, vomiting, abdominal pain, diarrhea. He does
have
a chronic cough. His wife is fairly certain that he never loss
consciousness, as he never slumped to the ground.
In the ED, he had a fever to 102.4F. He was quite agitated and
required haloperidol to calm down. He received 2L IVF and
Tylenol
PR for fever.
ROS: Unable to be obtained from patient due to mental status.
Past Medical History:
- Dementia, Alzheimer's disease
- Type 2 diabetes mellitus
- Hypertension
- Hyperlipidemia
- Lower extremity edema
- Anemia
- Gout
- Obesity
- Previous paroxysmal atrial fibrillation
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VITALS: T 97.5, BP 157/82, HR 67, RR 18, O2 SAT 100% on RA
GENERAL: Somnolent, rousable but doesn't answer questions and
promptly goes back asleep, 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.
MSK: 1+ edema in the left leg, none in the right leg.
SKIN: No rashes or ulcerations noted.
NEURO: Unable to comply with full exam.
Pertinent Results:
===================================
Initial admission data (per H&P)
WBC 9.0, H/H 13.2/40.9, PLT 217
Cr 1.3, otherwise normal BMP
Normal LFTs, negative troponin-T, negative flu swab, normal UA,
lactate 3.3 -> 1.1
VBG: pH 7.38, pCO2 46
CHEST (SINGLE VIEW) Study Date of ___ 8:18 ___
IMPRESSION:
No acute cardiopulmonary process.
CT ABD & PELVIS W/O CONTRAST Study Date of ___ 12:01 AM
IMPRESSION:
1. No acute intra-abdominal pathology to explain patient's
abdominal pain. Sigmoid diverticulosis without evidence of
diverticulitis.
2. 0.4 cm gallstone is noted in the gallbladder neck without
evidence of cholecystitis.
3. Thickened bilateral adrenal glands may represent adrenal
hyperplasia.
4. 2.3 cm right renal angiomyolipoma.
ECG : normal sinus rhythm, 73 BPM, normal axis, normal
intervals, normal
tracing
===================================
Subsequent data:
CBC wnl except mild anemia (hgb 12.0-13.2)
Cre: 1.3 -> 1.0 -> 0.9
LFT wnl
trop neg x2
===================================
Brief Hospital Course:
Mr. ___ is a ___ male with dementia, T2DM, and
hypertension who presented after an unresponsive episode, had an
isolated fever in the ED, but otherwise had an unremarkable
work-up and hospital course and was discharged back home.
# Episode of unresponsiveness
# Encephalopathy
# Fever
# Dementia
# Mild hypovolemia (mild lactic acidosis and mild ___ improved
with fluids)
Initial episode at home on ___ associated with diaphoresis,
feeling cool to touch, and appearing pale. Associated with an
episode of fecal incontinence, although he reportedly has some
incontinence at baseline. Glucose was normal. No shaking. No
full LOC per his wife. He was febrile to 102.4 per ED
flowsheets, which occurred after an episode of agitation for
which he was given Haldol. Otherwise all temps were in 96-98
range throughout the admission. There was no other history to
suggest an infection. Cardiac work-up was unrevealing, and
suspicion for a cardiac cause was low. Suspicion for CNS
infection or seizure was very low. The case was preliminarily
discussed with neurology, who had been planning to consult, but
given the benign course the patient was discharged prior to
their formally seeing him. Head CT was initially ordered but was
ultimately cancelled as it was not felt to be a high yield study
in this clinical context. By hospital day 2 the family reported
the patient's mental status was at his recent baseline, which
continued through the remainder of the hospital course.
Ultimately it was felt that his initial presentation may have
been the result of dehydration +/- a situational presyncopal
event related to his large bowel movement. It is also possible
he had a mild transient viral illness that resolved. His family
was counseled to return to care and/or call his doctor with any
further concerning symptoms. His creatinine continued to improve
between hospital day 2 and 3 with PO intake alone, suggesting
that he would be able to maintain his volume status at home.
He was discharged on an unchanged home medication regimen.
==========================================
Transitional issues:
- consider further work-up if any recurrence of symptoms
- consider rechecking BMP in follow-up
==========================================
>30 minutes in patient care and coordination of discharge on
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Memantine 10 mg PO BID
3. Lisinopril 40 mg PO DAILY
4. amLODIPine 10 mg PO DAILY
5. Allopurinol ___ mg PO DAILY
6. Donepezil 10 mg PO QHS
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Donepezil 10 mg PO QHS
5. Lisinopril 40 mg PO DAILY
6. Memantine 10 mg PO BID
7. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Episode of unresponsiveness
Dementia
Fever
Acute kidney injury
Discharge Condition:
Mental Status: Confused - always.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted after an episode of unresponsiveness,
associated with a bowel movement. After 48 hours of monitoring
we did not determine any concerning causes of this episode. It
is possible that your blood pressure dropped for a very short
period of time due to your bowel movement. If you have any
further symptoms you should contact one of your doctors ___
away ___ seek further evaluation.
Followup Instructions:
___
|
10835043-DS-13
| 10,835,043 | 23,091,323 |
DS
| 13 |
2151-02-07 00:00:00
|
2151-02-28 14:09:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
stabbing
Major Surgical or Invasive Procedure:
___ Right thumb FPL laceration, Right thumb ulnar digital
nerve laceration
___ Bilateral hand laceration washout, L hand nerve block
with finger tendon repair, and skin closure.
History of Present Illness:
___ year-old RHD female presents in transfer with multiple stab
wounds following an altercation at a hotel around midnight on
___. She was initially taken to ___ where she
was noted to have stab wounds to the anterior chest associated
with hemopneumothroax, right shoulder and bilateral hands. She
was stabilized, given tetanus/ancedf and her wounds were sutured
at ___ prior to transfer. She complains of numbness
over the right ulnar thumb.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory.
Physical Exam:
Admission physical Exam:
Vitals: ___ Temp: 98.5 PO BP: 130/82 R Sitting HR: 92
RR: 18 O2 sat: 96% O2 delivery: RA
___: NAD, A&Ox4
Left Hand:
1.5cm laceration over dorsal index finger PIP joint. Unable to
extend index PIP or DIP joint. Able to flex index finger. Motor
intact in all other digits. Sensation intact to light touch in
radial, median, and ulnar distributions. 2+ radial pulse. Skin
warm and well-perfused.
Left Hand:
1.5cm lac repair clean and dry. She has full extension of
fingers ___. Flexion limited in index secondary to pain, though
intact. Sensation intact to light touch in radial, median, and
ulnar distributions. 2+ radial pulse. Skin warm and
well-perfused.
Right Hand:
Obscured by surgical brace. She is sensory intact at the tips of
fingers ___. Finger tips appear well perfused with appropriate
cap refill.
Pertinent Results:
___ 04:45AM BLOOD WBC-5.2 RBC-2.69* Hgb-7.6* Hct-23.0*
MCV-86 MCH-28.3 MCHC-33.0 RDW-12.6 RDWSD-39.0 Plt ___
___ 04:45AM BLOOD Plt ___
___ 04:45AM BLOOD ___ PTT-24.0* ___
___ 04:45AM BLOOD Glucose-99 UreaN-3* Creat-0.5 Na-142
K-3.9 Cl-108 HCO3-23 AnGap-11
___ 04:45AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.0
___ bil hand XR: No acute fracture or dislocation of either
hand. No radiopaque foreign body.
___ chest XR: Minimal left basilar atelectasis without focal
consolidation. No pneumothorax.
Left Shoulder: No previous images. The AC and glenohumeral
joints are essentially within normal limits. No radiopaque
foreign body is identified
Brief Hospital Course:
Pt is a ___ y/o F presenting to ___ on ___ from OSH status
post assault with knife sustaining stab wounds to anterior
chest, right shoulder, and bilateral hands. Wounds were closed
and patient given tetanus/ancef prior to transfer to ___. ACS
consulted and following. Left index extensor tendon with
complete laceration explored and repaired at bedside by
orthopedic surgery. On ___ the patient was taken to the
operating room with hand surgery for repair of right thumb FPL
laceration and right thumb ulnar digital nerve laceration.
Bilateral hands were splinted.
Pain was treated during hospitalization with oxycodone,
morphine, gabapentin, ibuprofen, and tylenol. Once tolerating a
regular diet, her pain management was transitioned to oral
agents. The patient remained afebrile and hemodynamically stable
throughout stay. Local wound care was given to other
lacerations. The patient was seen and evaluated by social work
and feels safe with discharge plan.
The patient was seen and evaluated by occupational therapy who
recommended discharge to home to continue recovery.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with visiting
nursing services. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth every six (6) hours Disp #*50 Tablet
Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*28 Capsule Refills:*0
3. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*42 Capsule Refills:*0
4. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Right first finger flexor pollicis longus laceration
Right thumb ulnar digital nerve laceration
L index finger tendon laceration
Multiple deep stab wounds: L anterior chest, L scapula, R upper
arm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
On ___ you were admitted to ___ as a transfer from ___
after you were stabbed. You had injuries to both your hands with
damage to the tendons, as well as injuries to the chest, left
shoulder, and upper arms. Upon arriving to the emergency
department at ___ your stitches were removed, and your hands
were explored for injuries and cleaned. You were found to have
an injury to the tendon in your left finger. The finger was
numbed, and the tendon was repaired. Your right thumb needed
surgery to fix the tendon. Splints were applied.
=
=
=
================================================================
Right hand care instructions:
Do not lift or put any weight on.
Elevate on several pillows to decrease swelling.
You may continue to wear a sling on the right arm for comfort.
Apply ice as needed.
Keep splint in place until follow up.
Change gauze daily and as needed.
Apply bacitracin over stitches daily.
=
=
=
=
================================================================
Left hand care instructions:
Do not lift or put any weight on.
Elevate on several pillows to decrease swelling.
Apply ice as needed.
Keep splint in place until follow up.
Change gauze daily and as needed.
Apply bacitracin over stitches daily.
=
=
=
=
================================================================
All other stab wounds:
Cleanse all wounds with saline daily.
Cover all wounds with dry sterile dressings.
Monitor for signs of infection: Increased redness, increased
pain, drainage that is white or foul smelling.
=
=
=
=
================================================================
You will be discharged home with additional occupational therapy
and visiting nursing to help with wound care.
=
=
=
=
================================================================
___ 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.
Followup Instructions:
___
|
10835125-DS-17
| 10,835,125 | 21,436,531 |
DS
| 17 |
2140-06-05 00:00:00
|
2140-06-05 22:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chief Complaint: SOB
Reason for MICU transfer: Hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with h/o depression, prior opiate abuse, and tobacco abuse
with questionable COPD history who is here with progressive SOB.
On review of her admission history and phsyical, she reported
started feeling unwell about 1 week prior. She was reported
experiencing URI symptoms, subjective fevers, and progressive
SOB. She was evaluated in the outpatient setting and was given
a prescription for an albuterol inhaler which some, but minimal
improvement. She also began to report a cough that was
primarily dry, but occasionally productive of green colored
sputum.
She presented to the ___ and was started on thearpy for a
possible COPD flare. She was started on nebulizer therapy and
steroids. She was also given levofloxacin to cover for possible
PNA. On the floor, she was transitioned to CTX/azithro for CAP
treatment. She continued to have an oxygen requirement with
sats in the upper ___ on ___.
Overnight prior to transfer, the patient triggered for hypoxemia
(88-90% on a high flow face mask). She was noted to have
increased work on breathing, chest pressure, and endorsed
increased anxiety. Per report, she had audible wheezes and was
using accessory muscles to breath. She was given furosemide 10
mg IV followed by 20 mg IV and put out an approximate 800 mL of
UOP with a report of dysuria. A CTPA was negative for acute PE
on the wet read, but revealed diffuse ground glass opacities.
On arrival to the unit, the patient appears quite anxious. She
is coughing and reporting on going SOB. She was started on
NIPPV with subjective improvement.
Review of systems:
(+) Per HPI
Past Medical History:
Per chart
1. Pancreatitis - diagnosed ___ yrs ago, hospitalized ___ at
___, ___ for pain, last in ___, etiology unclear
2. Anxiety/depression - also on a mood stabilizer
3. Narcotic addiction - Pt reports that after starting on
high-dose narcotics from a Dr ___ was later indicted for
overprescribing pain meds). When this was identified she was
placed in a methadone treatment program to wean her from the
narcotics. Denies any illicit drug use.
Social History:
___
Family History:
Per chart, her sons have asthma.
Physical Exam:
ADMISSION PHYSICAL EXAM
General: Alert, oriented, in moderate distress. All 4
extremities are twitching
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, but difficult to assess given
body habitus, no LAD
Lungs: Moderate air entry, low pitched wheezes and crackles
appreciated throughout. Tachypenic, using accessory muscles to
breath
CV: Tachycardic rate and regular rhythm, normal S1 + S2, no
murmurs, rubs, gallops appreciated
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: Foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM
afebrile, normal VS. 92-94% on RA with ambulation
pulm: rare wheezes in left base, otherwise clear to
auscultation, good air movement
CV: RRR, normal S1, S2, no murmurs
Abdomen: benign
GU: Foley cath removed
Neuro: CNs intact
Ext: as above
Psych: appropriate affect, denies depression, slightly anxious
Pertinent Results:
ADMISSION LABS
--------------
___ 08:25AM PLT COUNT-183
___ 08:25AM NEUTS-75.8* LYMPHS-17.7* MONOS-5.4 EOS-0.9
BASOS-0.3
___ 08:25AM WBC-9.8 RBC-4.24 HGB-13.1 HCT-38.6 MCV-91
MCH-31.0 MCHC-34.0 RDW-13.7
___ 08:25AM GLUCOSE-98 UREA N-11 CREAT-1.0 SODIUM-141
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-27 ANION GAP-14
___ 08:51AM LACTATE-1.8
___ 04:00PM HCG-<5
___ 04:00PM cTropnT-<0.01
___ 04:00PM LIPASE-22
___ 04:00PM ALT(SGPT)-17 AST(SGOT)-20 ALK PHOS-104 TOT
BILI-0.5
___ 11:05AM URINE UCG-NEGATIVE
___ 11:05AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 11:05AM URINE ___ WBC-0 BACTERIA-NONE YEAST-NONE
___
PERTINENT INTERIM LABS
___ 09:00AM BLOOD cTropnT-<0.01
___ 12:32AM BLOOD proBNP-649*
DISCHARGE LABS
WBCRBCHgbHctMCVMCHMCHCRDWPlt Ct
___
GlucoseUreaNCreatNaKClHCO3AnGap
___
TSH 0.22, free T4 1.3
HIV negative
MICROBIOLOGY
------------
Blood cultures ___: no growth
Blood culture ___: no growth
Urine culture ___: Negative
Sputum culture ___: Gram stain >25 PMNs and >10 epithelial
cells/100X field. Culture contaminated with upper respiratory
secretions.
RPR ___: non-reactive
IMAGING
-------
CXR AP ___
Frontal view of the chest provided. Lung volumes are somewhat
low,
though there are diffuse ground-glass pulmonary airspace
opacities with
scattered more irregular consolidative opacities, most notable
in the right lower lung. Overall appearance raises potential
concern for pulmonary edema with superimposed pneumonia.
Correlate clinically. The cardiomediastinal silhouette appears
normal. No large effusion is seen. No pneumothorax. Bony
structures are intact.
IMPRESSION: Findings concerning for pulmonary edema with
superimposed
pneumonia. Please correlate clinically.
CXR PA/lateral ___
PA and lateral views of the chest were provided. There are
scattered airspace opacities concerning for pneumonia. No large
effusion or pneumothorax seen. Cardiomediastinal silhouette is
normal. Bony structures are intact. No free air below the
right hemidiaphragm.
IMPRESSION: Persistent pulmonary airspace opacities throughout
both lungs
remain concerning for pneumonia.
CXR AP ___
Heart size is top normal. Mediastinum is unremarkable. There
is substantial interval progression of widespread parenchymal
opacities as compared to the prior examination including upper
lobes as well as lower lobes. The distribution is concerning
for pulmonary edema. Alternatively multifocal infection is a
possibility, less likely. For precise details, previous review
CTA of the chest obtained on ___ under corresponding
report.
CTA chest with and without contrast ___. No clear pulmonary
embolism identified. Diffuse bilateral multifocal
airspacedisease concerning for multifocal pneumonia. Associated
mediastinal and bilateral hilar adenopathy felt to be reactive
in nature. Followup chest CT after appropriate therapy is
recommended to assess for resolution of both the
lung findings and the lymphadenopathy.
TTE ___
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality (poor apical views), a focal wall
motion abnormality cannot be fully excluded. Doppler parameters
are indeterminate for left ventricular diastolic function. Right
ventricular chamber size and free wall motion are normal. There
is abnormal septal motion/position. The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
Brief Hospital Course:
___ year old female with history of tobacco abuse and
questionable COPD history who is here with progressive dyspnea
and hypoxia.
ACTIVE ISSUES
-------------
# Multifocal pneumonia and bronchospasm: patient with acute on
subacute respiratory decline. She reported one week of symptoms
with worsening SOB. She has been told she has COPD based on
exam and tobacco history, but has not been given this formal
diagnosis. On initial exam, the patient had both crackles and
diffuse wheezing. She had been requiring oxygen support on the
floor, and this began to worsen overnight. Her presentation was
worsened by a heightened sense of anxiety. She was also febrile
on transfer. She had wheezing on exam, but as noted, her COPD
history is not fully clear. She received IV steroids in the ED
and had been transitioned to PO prednisone on the floor. As
noted below, she was quite delirious concerning for possible
steroid psychosis. Leukocytosis on transfer was difficult to
interpret given steroid administration as well. She was started
on a NIPPV trial and received anxiety to help with SOB upon
arrival. Antibiotics were broadened to
vancomycin/cefepime/azithromycin given persistent fever despite
antibiotics (ceftriaxone/azithromycin) and ultimately
de-escalated back to cefpodoxime/azithro. CTA chest showed no
clear PE but diffuse bilateral multifocal airspace disease
concerning for multifocal pneumonia. She underwent TTE which
showed normal LV systolic function, unable to assess diastolic
function, normal RV chamber size and free wall motion and
abnormal septal motion/position. On the floor, her oxygenation
improved, and she continued her steroid course with taper as
well as antibiotic regimen that was narrowed to cefpodoxime and
azithromyxin. She will complete 14 day course of antibiotics
after discharge along with short prednisone taper.
# Delirium: patient appeared delirious during her stay. She was
occasionally speaking sensical, but non-relevent sentences. She
was having difficulties sitting still and occasionally appeared
to be responding to external stimuli. Concerning for alcohol
vs. benzodiazepine withdrawal, but patient denied history of
alcohol or benzodiazepine use. Steroids were another possible
etiology. She was evaluated by Psychiatry ___ who recommended
checking a valproate trough, TSH, RPR, thiamine, B12, folate,
and consideration of HIV. They recommended avoiding
benzodiazepines in particular, in addition to other deliriogenic
meds, advising quetiapine ___ mg up to QID PRN if she was not
redirectable. They recommended holding or decreasing methadone
dose if highly delirious or sedated. Her delirium resolved
after transfer to the floor, likely duet to a combo of hypoxia
and steroids.
INACTIVE ISSUES
---------------
# Polysubstance abuse: Pt has a history opiate and tobacco
abuse. She vehemently denies alcohol or benzodiazepine abuse.
Home methadone was continued and she was given a nicotine patch.
# Depression/anxiety: patient carries a diagnosis of depression
and anxiety. Her medicines were reported as confirmed in the
PAML, but the patient reports being on different medications
however she was delirious. She was treated with divalproex and
sertraline. Her home hydroxyzine, Benadryl were discontinued,
prazosin started upon discharge, and sertraline was uptitrated.
TRANSITIONAL ISSUES
-------------------
# Follow-up: patient will follow up with new PCP at ___ (her
listed PCP is not practicing medicine)
# Followup chest CT after appropriate therapy is recommended to
assess for resolution of both the lung findings and the
lymphadenopathy, likely can repeat in ___ weeks
# Mother brought up a potential pancreatic mass seen on prior
imaging at ___. Recommended f/u with outpatient PCP
# ___ try to discontinue Depakote and methadone in the coming
months if patient is able to establish care and follow up with
her appointments
# Please see SW note for details on homelessness
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. DiphenhydrAMINE 25 mg PO HS:PRN insomnia
3. Gabapentin 300 mg PO TID
4. HydrOXYzine 100 mg PO Q8H:PRN anxiety
5. Sertraline 100 mg PO DAILY
6. Divalproex (EXTended Release) 1000 mg PO QHS
7. Prazosin 1 mg PO QHS
8. Methadone 140 mg PO DAILY
Discharge Medications:
1. Divalproex (EXTended Release) 1000 mg PO QHS
2. Docusate Sodium 100 mg PO BID
3. Methadone 140 mg PO DAILY
4. Nicotine Patch 7 mg TD DAILY
RX *nicotine 7 mg/24 hour apply to shoulder daily Disp #*14
Patch Refills:*0
5. PredniSONE 30 mg PO DAILY Duration: 3 Days
RX *prednisone 10 mg 3 tablet(s) by mouth daily Disp #*20 Tablet
Refills:*0
6. Prazosin 1 mg PO QHS
7. Azithromycin 250 mg PO Q24H
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
8. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
9. Sertraline 150 mg PO DAILY
RX *sertraline 50 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
multifocal pneumonia
Secondary diagnoses:
COPD/RAD
opiate dependence
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 the ___. You came for
further evaluation of shortness of breath. You were found to
have pneumonia, and are being treated with antibiotics and
antiviral therapy, as well as steroids. You have now improved.
It is very important that you take all medications as prescribed
and follow up with the appointments listed below. It is also
very important that you continue to abstain from smoking
cigarettes.
Please see below for you follow up appointments and medications.
Followup Instructions:
___
|
10835125-DS-18
| 10,835,125 | 25,952,372 |
DS
| 18 |
2140-07-22 00:00:00
|
2140-07-22 21:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a PMHx of ?COPD, depression,
narcotic addiction, who presents with bilateral ___ swelling and
pain, fever, and cough.
She has had worsening ___ edema which results ___ severe pain. She
says that the pain started 1 week after her last hospitalization
___ for multifocal PNA) and that ___ weeks ago, she
started noticing leg swelling, with L>R. Additionally, she c/o
intermittent numbness and tingling down the back of her legs.
Two days ago, she got up to walk but fell backwards and hit the
back of her head. She said she lost consciousness and woke up on
the floor. She did not appear to have confusion after the
incident and did not seek care. Denied palpitations or flushing
prior to the fall. This morning, the pt says she had trouble
getting out of bed due to pain from swelling and was unable to
make it to the bathroom to urinate.
This AM, pt developed subjective fevers/chills. Notably, she has
had a cough since her last hospitalization for multifocal PNA.
She has continued to produce gray and yellowish sputum since
then with no change ___ volume or quality. She does feel more
short of breath. Denies orthopnea, paroxysmal nocturnal dypsnea,
denies worsening SOB with exertion. Does not require oxygen at
baseline. Said she had some chest pressure and nausea ___ the
ambulance on the way to ED but it resolved after several minutes
with no intervention. Endorses anxiety, which has kept her up
for the past 3 nights. Admitted to taking 1 mg Valium belonging
to a friend to relieve anxiety yesterday evening (___). Also has
been on hydroxyzine for anxiety and receiving a trial of Lasix
10 mg PO x 3 days at ___. Complains of
headache.
On arrival to the ED, she developed HA and severe anxiety re
fevers.
Woke up with fever this AM. ___ the ED, initial VS: 100.8 125
120/43 24 97%. Labs showed lactate 2.7, PLT 131. CXR showed
decrease ___ bl pulm opacities (improvement of pulmonary edema
vs. multifocal infection). She received 1L IVF, albuterol,
tylenol, ipratropium, cefepime and levofloxacin.
Of note, pt was admitted ___ for dyspnea and went to ICU
for hypoxia. She was diagnosed with multifocal PNA. ___ addition,
there was concern for possible component of COPD and dCHF
(crackles, TTE unable to assess diastolic function). Repeat
chest CT was recommended ___ ___ weeks.
Past Medical History:
- Possible COPD
- Pancreatitis - sp multiple hospitalizations at ___,
___ for pain, last ___ ___, etiology unclear
- Anxiety/depression
- Narcotic addiction - Pt reports that after starting on
high-dose narcotics from a Dr ___ by ___ report was
later indicted for overprescribing pain meds). When this was
identified pt says she was placed ___ a methadone treatment
program to wean her from the narcotics. Denies any illicit drug
use.
- Cholecystectomy
- Kidney stones (seen on CT abd pelvis w/o contrast ___
right mid pole renal calculus per records from ___
Social History:
___
Family History:
Per chart, her sons have asthma.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: T: 97.8 BP: 116/65 P: 92 R: 20 O2: 98% 3L
General: Obese tired-appearing female, oriented but speech slow
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP at mid-neck w/ bed at 45 degrees, no LAD
Lungs: Diffuse crackles greater ___ lung bases bilaterally than
upper lung, no wheezes, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
heard loudest at right sternal border, no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, striae
present
Ext: Warm, well perfused, 2+ DP pulses ___, 2+ pitting edema ___
to knees, with swelling ___ L>R, sensation preserved
Skin: petechial rash on anterior R anterior shin
Neuro: ___ strength ___ upper and lower extremities bilaterally
DISCHARGE PHYSICAL EXAM
=======================
Vitals: T max 98.2 BP 98/49-128/70, P ___ SAO2 95% RA
General: Obese tired-appearing female, oriented but speech slow
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP nl , no LAD
Lungs: Diffuse crackles at bases, some wheezing diffusely,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
heard loudest at right sternal border, no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, striae
present
Ext: Warm, well perfused, 2+ DP pulses ___, 2+ pitting edema ___
to knees, with swelling ___ L>R, sensation preserved
Skin: petechial rash on anterior R anterior shin
Pertinent Results:
ADMISSION LABS
==============
___ 08:00AM BLOOD WBC-8.5 RBC-4.22 Hgb-12.9 Hct-39.0 MCV-92
MCH-30.7 MCHC-33.2 RDW-14.6 Plt ___
___ 08:00AM BLOOD Neuts-79.2* Lymphs-14.0* Monos-5.5
Eos-1.0 Baso-0.3
___ 08:00AM BLOOD Glucose-143* UreaN-12 Creat-1.0 Na-143
K-4.1 Cl-104 HCO3-28 AnGap-15
___ 08:00AM BLOOD ALT-32 AST-34 AlkPhos-82 TotBili-0.3
___ 08:00AM BLOOD Lipase-22
___ 08:06AM BLOOD Lactate-2.7*
___ 05:10PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-POS
___ 05:10PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:10PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-1
PERTINENT LABS
==============
___ 03:09PM BLOOD CK-MB-5 cTropnT-<0.01
___ 08:00AM BLOOD cTropnT-<0.01
___ 08:00AM BLOOD CK-MB-5 proBNP-8
___ 08:00AM BLOOD TSH-0.69
___ 08:00AM BLOOD HCG-<5
___ 03:09PM BLOOD ___ PTT-32.0 ___
___ 03:09PM BLOOD Ethanol-NEG
___ 08:00AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 02:32PM BLOOD Type-ART pO2-74* pCO2-48* pH-7.37
calTCO2-29 Base XS-1
___ 02:32PM BLOOD Lactate-1.1
DISCHARGE LABS
==============
___ 07:30AM BLOOD WBC-5.3 RBC-3.58* Hgb-11.2* Hct-33.5*
MCV-94 MCH-31.2 MCHC-33.3 RDW-15.0 Plt ___
___ 07:30AM BLOOD ___ PTT-30.9 ___
___ 07:30AM BLOOD Glucose-97 UreaN-13 Creat-0.8 Na-138
K-4.4 Cl-103 HCO3-28 AnGap-11
___ 07:30AM BLOOD Calcium-9.1 Phos-4.1 Mg-1.8
RELEVANT MICRO/PATH
===================
BCX ___ - pending
___ 5:10 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
Urine legionella Ag - negative
RELEVANT IMAGING
================
CT C-spine ___:
1. No evidence of acute fracture or malalignment.
2. Severe maxillary sinus disease, left greater than right.
noncon CT head ___:
1. No evidence of acute intracranial process.
2. Extensive left maxillary sinus disease, as above.
___ US ___:
No evidence of deep venous thrombosis ___ the bilateral lower
extremity veins. Right peroneal veins were not visualized.
Brief Hospital Course:
BRIEF SUMMARY
=============
Ms. ___ is a ___ with a PMHx of depression, prior opiate
and tobacco abuse, ?COPD, who presented with bilateral ___
swelling and pain, fever, and cough.
# Bronchitis/asthma exacerbation:
Patient presented to ED with Tmax 100.8 and HR to 125,
widespread ___ pulmonary opacities on CXR (improving from
prior). Lactate of 3.3 but has downtrended to 1.1 after IVF. Of
note, pt had recent hospitalization for multifocal PNA
___. She continueed to have cough and grey-yellow sputum
(unchanged ___ volume and quality) since discharge ___ ___. She
briefly required 3L supplemental O2. She initially received
vanc/cefepime/azithro (___) but de-escalated to Levo (___)
since afebrile, improvement ___ breathing. Neg urine legionella.
Pt also c/o chest pain on ambulance ride but has been r/o for
MI. Breathing also improved with nebs, so will treat for
bronchitis/asthma exacerbation. Given wheeze noted on ___, she
was started on prednisone burst for likely exacerbation of
chronic bronchitis/COPD. She was also given Advair.
# ? Somnolence - Patient initially appeared sleepy on exam
though she was alert and oriented. Given her recent fall on ___,
concern for acute intracranial process but noncon head CT neg.
Pt denies any recent alcohol or drug usage, though she did take
1 mg Valium belonging to her friend. ___ and urine screen
approriately positive for benzos and methadone. No evidence of
fx on C-spine films. Called ___ clinic and verified 120 mg
of methadone dose for pt. Pt says that she has daytime
sleepiness, has been told she snores loudly and stops breathing
___ the middle of the night, and that her mother has sleep apnea.
Patient was placed on trial of CPAP but did not tolerate it
throughout the night.
# Lower extremity edema/?CHF:
2+ pitting edema bilaterally along with numbness and tingling
down the back of her leg. During her last hospitalization, there
was concern of a component of dHF contributing to her dyspnea
and TTE was performed (though unable to assess diastolic
function). BNP and TSH was nl during this admission. Given
somewhat asymmetrical swelling and pain, concern for DVT but ___
___ U/s ___ was neg. Likely ___ venous stasis. Pt advised to
increase physical activity, continue weight loss and elevate
lower extremities.
# Thrombocytopenia:
Pt had decrease ___ Plt count from 143 ___ to ___. Per ___.
___ records, she did have 133 ___ ___. Noted to have
petechial rash on R anterior shins. Coags were generally normal
(INR 1.2). Likely ___ viral infection. Could be component of
hemodilution. Plt increased to 159 ___ pm and 147 on AM of
discharge.
# Anemia:
Pt had downtrending Hgb to 11.0 from baseline of ~13. No
evidence of GIB and hemolysis labs negative.
# Depression/Anxiety:
According to medication administration record from ___
___, pt was on hydroxyzine 100 mg PO Q8H:PRN and sertraline
100 mg daily for anxiety. Pt also reported having been on
divalproex ER 1000 mg PO BID for several months but stated that
she self-d/c'd the medication because it made her "jumpy" and
she did not like how it felt.
# Polysubstance abuse:
Pt reported that she had opiate abuse after being prescribed
high-dose narcotics from Dr. ___ was later indicted for
overprescribing pain meds). When this was identified she was
placed ___ a methadone treatment program to wean her from the
narcotics. Her ___ clinic is Habit Opco at ___. She
has a history of positive drug tests (though pt adamantly denies
history of illicits). Tox screen appropriately pos for methadone
and benzo (pt reported taking unprescribed valium x 1). Pt also
found to have baclofen ___ a colace bottle ___ her purse.
# ?Pancreatic mass:
On previous d/c summary, it was documented that ___ mother
mentioned a pancreatic mass that was noted at ___. However, pt
says she has received all of her care re. pancreatitis at ___.
___. ___ does report record of pancreatic 10mm cystic
lesion (CT ___. 6 mo follow up with Gadolinium was
recommended.
# Homelessness:
Patient lives at ___ ___. She expressed anxiety
and stress ___ regards to her six children. SW consult was
offered.
TRANSITIONAL ISSUES
====================
# CODE: Full code, confirmed
# CONTACT: mother, ___
- Chest CT on follow-up as previously recommended to assess for
resolution of LAD
- Please arrange for follow-up imaging (w gadolinium) of likely
IPMN asap
- ___ iron studies ___ outpatient setting
- Recheck CBC on follow-up
- Follow up urine albumin
- Consider outpatient PFTs
- Consider sleep study as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO TID
2. Prazosin 1 mg PO QHS
3. Docusate Sodium 100 mg PO BID
4. Sertraline 100 mg PO DAILY
5. Furosemide 10 mg PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
7. HydrOXYzine 100 mg PO Q8H:PRN anxiety
8. Ibuprofen 600 mg PO Q6H:PRN fever
9. methadone 120 mg oral daily
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. HydrOXYzine 100 mg PO Q8H:PRN anxiety
3. methadone 120 mg oral daily
4. Levofloxacin 500 mg PO DAILY Duration: 4 Days
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
6. Gabapentin 300 mg PO TID
7. Prazosin 1 mg PO QHS
8. Sertraline 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Pneumonia
SECONDARY DIAGNOSES
===================
Lower extremity edema
Depression/anxiety
Narcotic dependence
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 meeting and caring for you during your most
recent hospitalization at ___.
You presented with a fever, shortness of breath, and swelling ___
your legs. While you were ___ the hospital, we started you on
antibiotics and gave you nebulizers to help with your breathing
to treat bronchitis and asthma. You were no longer short of
breath and we have given you 3 days of antibiotics (last dose
___, 4 days of a steroid medication (last dose ___, and
inhalers.
Additionally, we have ruled you out for blood clots ___ your
legs. Please follow-up with your PCP within one week.
All the best,
Your ___ Care Team
Followup Instructions:
___
|
10835235-DS-10
| 10,835,235 | 28,395,391 |
DS
| 10 |
2174-06-05 00:00:00
|
2174-06-05 16:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
adhesive tape
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ hx asthma, DM, and HTN who presents to the
ED with 3 months of reported cough and dyspnea, with acute
decline day prior to arrival, transferred to MICU for
respiratory distress requiring BIPAP.
The patient reports that for the past three months she has felt
that she has had a cough. Over the past day, her cough became
acutely worse, and every time she coughed she experienced right
shoulder and back pain. She has had asthma exacerbations in the
past (with a 5 day ICU stay in ___ where she required
intubation) and feels that her symptoms this time are consistent
with prior exacerbations. She denies any fevers/chills, sputum
production, abdominal pain, N/V/D, dysuria. She has no sick
contacts.
In the ED, initial vitals: T 98.8 HR 150 BP 171/107 RR 32 100%
2L NC
Exam notable for a tachypneic female, unable to form complete
sentences, with lung exam with poor air movement without
appreciable wheeze.
Labs were significant for: Lactate 3.5 -> 8. Initial VBG
7.35/46/47. Following VBG 7.28/36/81.
8.6 > 13.5/41.6 < 565
138 98 5
-----------< 297
3.7 24 0.9
proBNP 159
Flu swab negative.
CXR showed no acute cardiopulmonary process.
Patient received 3L NS, 500 mg azithromycin, 60 mg prednisone,
ASA 325 mg, albuterol nebs x3, ipratropium nebs x3, 100 mg
benzonatate, 20 mg lisinopril, 500 mg metformin, cepacol
lozenges, and 2mg IV Mg.
On transfer, vitals were: 108 153/81 22 99% BIPAP ___ O2
On arrival to the MICU, the patient is breathing much more
comfortably on BIPAP.
Past Medical History:
DM2
Hypertriglyceridemia
History alcohol overuse
HTN
Iron deficiency anemia
Asthma
Social History:
___
Family History:
Mother, multiple siblings with DM, HTN. Sister with thyroid
disease. Denies family history of heart disease or cancer.
Physical Exam:
Admission Physical Exam:
=======================
Vitals: T 98.0 BP 165/98 HR 129 (improved to 103) R 27 SpO2 97%
BIPAP ___ NC
GENERAL: Tachypneic, coughing, but able now to speak in full
sentences, no tripoding.
HEENT: Sclera anicteric, bipap mask in place
NECK: supple
LUNGS: Very diminished breath sounds bilaterally, trace wheezes
CV: Tachycardic, S1+S2 no m/r/g
GU: No foley
EXT: Warm, well perfused, no cyanosis, no edema
SKIN: No lesions.
NEURO: A&O x3
ACCESS: PIVs
DISCHARGE PHYSICAL EXAM:
=================================
Vitals: 97.9 PO 132 / 82 88 18 99 RA
GENERAL: Well appearing, frustrated, NAD.
HEENT: MMM, PERRL. EOMI
LUNGS: No wheezing, rales or rhonchi appreciated.
CV: RRR, normal S1/S2. No m/r/g
GU: No foley
EXT: WWP, no ___ edema, intact sensation to light touch.
SKIN: No rash
NEUROLOGY CONSULT NEUROLOGIC EXAM:
+ MS: Awake, alert, oriented x 3. Able to relate history without
difficulty. Mildly inattentive, able to repeat ___ backwards but
with some difficulty. Some trouble with complex commands. Fluent
speech. Could not repeat "No ifs, ands, or buts about it"
accurately but could repeat another long sentence without issue.
Naming intact. No paraphasias. No dysarthria. Normal prosody.
Able to register 3 objects and recall ___ at 5 minutes
spontaneously, ___ with some prompting. Able to follow both
midline and appendicular commands.
+ Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2 mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Mild
strabismus evident with cover-uncover test
V: Facial sensation intact to light touch. Reported slightly
decreased sensation on R forehead along V1 distribution.
VII: No facial droop, facial musculature symmetric.
VIII: hearing intact to finger rub bilaterally.
IX, X: palate elevation symmetric
XI: ___ strength in trapezii and SCM bilaterally.
XII: tongue protrusion midline
+ Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
[Delt] [Bic] [Tri] [ECR] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [L2] [L3] [L5] [L4] [S1]
L ___
R ___
+ Sensory - Decreased sensation to pinprick bilaterally from
toes to ankles. Mild decreased vibratory sense at toes at 9
seconds. No deficits to light touch or proprioception
bilaterally.
+ DTRs:
[Bic] [Tri] [___] [Pat] [Ach]
L 2+ 2+ 2+ 0 0
R 2+ 2+ 2+ 0 0
*She says that in the past, years ago, her patellar reflexes
were present on physical exam. Plantar response flexor
bilaterally.
+ Coordination - No dysmetria with finger to nose testing
bilaterally. No overshoot with finger following. Good speed and
intact cadence with finger tapping.
+ Gait - Able to stand independently. Walks with narrow base
with slow tentative steps but otherwise normal stride length.
She appears nervous/unsteady but will take several steps without
apparent difficulty, than suddenly tremble. She will lurch
forward to grab but does not fall. With testing of Romberg, she
was initially steady after closing her eyes, then after a period
of seconds, swayed and reached out to steady herself. `
Pertinent Results:
Admission Labs:
===============
___ 11:38PM ___ PO2-87 PCO2-34* PH-7.41 TOTAL CO2-22
BASE XS--1 COMMENTS-GREEN TOP
___ 11:38PM LACTATE-3.5*
___ 11:30PM GLUCOSE-127* UREA N-11 CREAT-0.8 SODIUM-140
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16
___ 11:30PM D-DIMER-175
___ 11:30PM WBC-11.6* RBC-3.82* HGB-10.8* HCT-33.7*
MCV-88 MCH-28.3 MCHC-32.0 RDW-13.7 RDWSD-44.2
___ 05:14PM LACTATE-6.4*
___ 02:31PM LACTATE-8.3*
___ 03:44AM WBC-8.6 RBC-4.87# HGB-13.5# HCT-41.6# MCV-85
MCH-27.7 MCHC-32.5 RDW-13.2 RDWSD-40.8
MICROBIOLOGY:
======================
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
Imaging:
======================
+ CXR ___- Cardiomediastinal silhouette is within normal limits.
There are no focal consolidations, pleural effusion, or
pulmonary edema. There are no pneumothoraces.
+ CXR ___ - There is no focal consolidation, effusion, or
pneumothorax. The cardiomediastinal silhouette is normal. Imaged
osseous structures are intact. No free air below the right
hemidiaphragm is seen.
+ MRI (___):
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift or infarction. There is mild generalized
parenchymal atrophy. There is no hydrocephalus. There are mild
chronic small vessel ischemic changes. There is submucosal
retention cyst in the right maxillary sinus. Otherwise,
paranasal sinuses, bilateral mastoid air cells, middle ear
cavities are patent. There is bulbous prominence of left M1
segment of MCA, aneurysm cannot be excluded. MRA brain without
contrast recommended in further evaluation. The intracranial
vascular flow voids are otherwise within normal limits.
+ TTE (___): The left atrium and right atrium are normal
in cavity size. Normal left ventricular wall thickness, cavity
size, and regional/global systolic function (biplane LVEF = 58
%). The estimated cardiac index is normal (>=2.5L/min/m2). There
is no left ventricular outflow obstruction at rest or with
Valsalva. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion. IMPRESSION: Normal study. No structural heart disease
or pathologic flow identified.
+ MRA HEAD AND NECK (___):
1. Patent intracranial arterial vasculature without significant
stenosis,
occlusion, or aneurysm formation.
2. Patent cervical arterial vasculature without significant
stenosis, or
occlusion.
DISCHARGE LABS:
======================================
___ 06:44AM BLOOD WBC-8.3 RBC-4.48 Hgb-12.4 Hct-39.9 MCV-89
MCH-27.7 MCHC-31.1* RDW-12.9 RDWSD-42.1 Plt ___
___ 06:44AM BLOOD ___ PTT-28.6 ___
___ 06:38AM BLOOD Glucose-317* UreaN-24* Creat-1.2* Na-134
K-4.8 Cl-96 HCO3-27 AnGap-16
___ 06:44AM BLOOD Calcium-9.7 Phos-4.3 Mg-2.1
___ 06:38AM BLOOD VitB12-282 Folate-10
___ 07:03AM BLOOD %HbA1c-8.7* eAG-203*
___ 06:06AM BLOOD Triglyc-1370* HDL-33 CHOL/HD-7.4
LDLmeas-93
___ 06:38AM BLOOD TSH-0.95
Brief Hospital Course:
Ms. ___ is a ___ with history of asthma, poorly controlled
IDMM, and HTN who presented to the ED with 3 months of reported
cough and dyspnea, with acute decline day prior to arrival. She
required admission to MICU for respiratory distress requiring
BIPAP. Workup revealed no infiltrate on CXR, no leukocytosis or
sputum production. D-dimer was negative and Flu swab was
negative. Etiology thought to be secondary to cough predominant
asthma exacerbation. She received steroids and bronchodilators
with improvement. Hypoxia resolved but dyspnea and cough
persisted. Thought to be partially ___ GERD symptoms, so was
started on high dose PPI and lisinopril was also discontinued.
During hospital course, developed symptoms of dysuria, urgency
and frequency c/w UTI so was treated with CTX, and ultimately
transitioned to cefpodoxime, completing a ___espite resolution of cough with discontinuation of lisinopril
and treatment of reflux, she developed gait instability /
astasia abasia gait. She complained of intermittent diplopia and
dyspnea on exertion. Orthostatics were negative, MRI/MRA were
negative for acute pathology. TTE was normal. She was seen by
neurology who felt that gait instability was not from primary
neurologic condition but likely related to deconditioning and
diabetic neuropathy. It was felt that given prolonged duration
of symptoms leading to significant deconditioning, patient
discharged to rehab for further recovery.
ACTIVE ISSUES:
==============================
# Diplopia:
# Gait Instability:
# Deconditioning:
During hospitalization patient developed difficulty with
ambulation, reporting
She had no falls but had marked gait instability / astasia
abasia gait. She also complained of intermittent diplopia and
dyspnea on exertion. Orthostatics were negative, MRI/MRA were
negative for acute pathology. TTE was normal. She was seen by
neurology who felt that gait instability and diplopia was not
from primary neurologic condition but likely related to
deconditioning and diabetic neuropathy. It was felt that given
prolonged duration of symptoms leading to significant
deconditioning, patient discharged to rehab for further recovery
with expected ability to improve with further rehabilitation.
RESOLVED:
================================
# Asthma Exacerbation:
# Cough:
# Respiratory Failure:
Patient presented with severe cough and respiratory distress
without infiltrate on CXR, no leukocytosis or sputum production.
Thought to be secondary to asthma exacerbation given prior
history and improvement with steroids and nebs. D-dimer was
negative and Flu swab was negative. Etiology thought to be
secondary to cough predominant asthma exacerbation.
Additionally, given significant acid reflux symptoms and
prolonged duration of symptoms it was thought that GERD and
lisinopril were contributing to cough. She was given high dose
PPI and lisinopril was discontinued with resolution of cough and
shortness of breath.
# Complicated UTI: uptrending WBC. Could be ___ prednisone
effect, although noted uptrending at day 6 of treatment while
only mildly elevated previously. Given new dysuria, dirty UA,
c/f cystitis. repeat urine cx showing >100,000 E. coli. S/p
cefpodoxime for 7 day course (D1= ___
# GERD: Patient presented with several weeks of waterbrash
sensation and acid reflux. Given cough worse in AM, likely
contributing to chronic cough. Cough and acid reflux improved on
high dose pantoprazole. Given severity of symptoms recommend
outpatient EGD with her screening colonoscopy.
# Paresthesias: new onset paresthesias in stocking and glove
distribution. In setting of long term diabetes, most likely ___
diabetic neuropathy. She was started on gabapentin for
neuropathic pain.
CHRONIC ISSUES:
============================
# Triglyceridemia: Trigylceride level 1000 during admission.
Patient with history of elevated triglycerides in past c/b
pancreatitis. No symptoms of pancreatitis currently and negative
Lipase. No evidence of proteinuria on dip to suggest nephrotic
syndrome as etiology. TSH normal, ruling out hypothyroidism as
etiology. She was started on fish oil and fenofibrate. Please
recheck fasting lipid panel at next visit.
# Sciatica: chronic lower back pain, now w/ symptoms of
paresthesias in the right lower extremity c/w lumbar
radiculopathy.
# IDDM: Hyperglycemic initially without ketones in her urine.
Continued home glargine qHS and HISS. Of note patient had not
been taking insulin regularly.
# HTN: well controlled on HCTZ 25 mg daily, and verapamil 120 mg
daily.
# Iron deficiency anemia: Patient has hx ___, supposed to take
iron supplements at home, but is not compliant. Continued
Ferrous sulfate 325 mg daily
TRANSITIONAL ISSUES:
====================
# Communication/HCP: Fiance (___) ___ daughter
___ (primary HCP): ___
# Code: Full, confirmed
[ ] started on pantoprazole 40mg q24hr for GERD symptoms
[ ] recommend outpatient EGD for persistent severe GERD symptoms
if not responding to PPI therapy
[ ] discontinued lisinopril due to concern for ACE-I cough. If
cough continues to improve, consider switching to ___ as
diabetic
[ ] discharged with benzonatate and guaifenesin w/ codeine for
cough suppression
[ ] recommended outpatient workup for constipation as patient
reports having bowel movements only once a month
[ ] patient noted to have continued hypertriglyceridemia
previously complicated by pancreatitis, though no evidence at
this time. She was started on fish oil and fenofibrate, please
recheck fasting lipid panel at next visit.
[ ] patient with intermittent diplopia/blurry vision with
negative neurologic workup, recommend outpatient opthamology
eval given uncontrolled diabetes
[ ] recommend followup with endocrinologist for diabetic
management
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Verapamil SR 120 mg PO Q24H
3. MetFORMIN (Glucophage) 850 mg PO TID
4. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
6. Hydrochlorothiazide 25 mg PO DAILY
7. Calcium Carbonate 500 mg PO QID:PRN acid reflux
Discharge Medications:
1. Benzonatate 200 mg PO TID:PRN cough
RX *benzonatate 200 mg 1 capsule(s) by mouth twice daily Disp
#*42 Capsule Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Fenofibrate 48 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO BID
7. Gabapentin 300 mg PO TID
8. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL ___ ml by mouth at
bedtime Refills:*0
9. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN coughing, sob,
wheezing
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 2.5 ml inhaled via
nebulizaiton every 6 hours Disp #*30 Vial Refills:*0
10. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*14
Tablet Refills:*0
11. Polyethylene Glycol 17 g PO DAILY
12. Senna 8.6 mg PO BID constipation
13. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
14. Calcium Carbonate 500 mg PO QID:PRN acid reflux
15. Hydrochlorothiazide 25 mg PO DAILY
16. MetFORMIN (Glucophage) 850 mg PO TID
17. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
18. Verapamil SR 120 mg PO Q24H
19.Home nebulizer
Home nebulizer machine, 1 unit
Diagnosis: cough variant asthma ___.___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
======================
hypoxic respiratory failure
SECONDARY DIAGNOSIS:
=====================
asthma exacerbation
complicated urinary tract infection
GERD
gait instability
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory with assistance
Discharge Instructions:
Dear Ms. ___,
It was a pleasure meeting you and taking care of you. You were
admitted to ___ with cough and shortness of breath. You had to
briefly stay in the intensive care unit to support your
breathing. You were treated with steroids and nebulizers for an
asthma flare and your shortness of breath improved. You were
also given a medication for acid reflux. Your blood pressure
medication lisinopril was stopped because there was concern it
may have contributed to your cough. You were also found to have
a urinary tract infection and were started on antibiotics.
While in the hospital you had difficulty walking and visual
complaints. We did brain imaging which was normal and had you
see our neurologists who felt that this was likely because of
your diabetes and should get better with physical therapy.
It was a pleasure being involved in your care.
Your ___ Care Team
Followup Instructions:
___
|
10835235-DS-9
| 10,835,235 | 25,154,998 |
DS
| 9 |
2169-11-13 00:00:00
|
2169-11-13 16:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
adhesive tape
Attending: ___.
Chief Complaint:
Abdominal pain
Nausea and vomiting
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ yo female with history of HTN, DM2, and asthma who presented
with 4 day history of epigastric pain and vomiting. Went out
"to the club" drank liquor for the first time in a while and
abdominal pain became severe over 2 days prior to admission.
Intermittant NBNB emesis and was unable to tolerate PO. Also
had black emesis x 1 the day prior to admission.
Past Medical History:
DM2
Hypertriglyceridemia
History alcohol overuse
HTN
Iron deficiency anemia
Asthma
Social History:
___
Family History:
Mother, multiple siblings with DM, HTN. Sister with thyroid
disease. Denies family history of heart disease or cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 100.4 130/70 90 20 98% RA,
GENERAL: well-appearing female, comfortable, appropriate, NAD
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK: supple, no cervical LAD, no JVD
HEART: RRR, no r/m/g, nl S1-S2
LUNGS: CTAB, no wheezes/rales/rhonchi, good air movement
bilaterally, respirations unlabored
CHEST: TTP over sternum
ABDOMEN: bowel sounds present, soft, non-distended, moderate
tenderness to palpation in epigastric area with guarding but no
rebound tenderness, no organomegaly
EXTREMITIES: warm, well-perfused, no edema, DP/PTs 2+
bilaterally
SKIN: no rashes or lesions
NEURO: A&Ox3, CNs II-XII grossly intact, muscle strength ___
throughout, sensation grossly intact throughout, steady gait
DISCHARGE PHYSICAL EXAM:
VS - T97.8 BP 131/89 HR 65 SpO2 97% on RA
GENERAL - Well-appearing female who appears comfortable resting
in bed.
LUNGS - CTAB. Moving air well and symmetrically, no accessory
muscle use
HEART - rrr, no m/r/g
ABDOMEN - Bowel sounds normoactive. Pain on deep palpation of
epigastric area
Pertinent Results:
Admission:
___ 06:35PM BLOOD WBC-10.7 RBC-3.85*# Hgb-9.0* Hct-29.6*#
MCV-77* MCH-23.4*# MCHC-30.4* RDW-16.1* Plt ___
___ 06:25AM BLOOD Lipase-1050*
___ 06:20AM BLOOD Lipase-127*
___ 06:35PM BLOOD ALT-19 AST-48* AlkPhos-109* TotBili-0.4
___ 06:05AM BLOOD ALT-28 AST-27 AlkPhos-245* TotBili-0.2
___ 06:35PM BLOOD cTropnT-<0.01
___ 06:25AM BLOOD Triglyc-236*
Discharge:
___ 06:10AM BLOOD WBC-8.6 RBC-3.37* Hgb-8.4* Hct-27.1*
MCV-80* MCH-25.0* MCHC-31.1 RDW-17.7* Plt ___
___ 06:10AM BLOOD Glucose-95 UreaN-2* Creat-0.9 Na-138
K-3.5 Cl-105 HCO3-22 AnGap-15
___ 06:10AM BLOOD AlkPhos-186*
___ 06:05AM BLOOD GGT-118*
___ 06:10AM BLOOD Calcium-8.9
CT ABDOMEN (___):
1. Findings suggestive of acute pancreatitis at the pancreatic
tail. No
drainable collection.
2. Multiple subserosal fibroids. Low density structure also
seen within the endometrial canal potentially representing a
submucosal fibroid or polyp; however, this is less well
evaluated by CT than it would be by ultrasound which can be done
on a non-urgent basis if not already performed.
RUQ Ultrasound (___):
FINDINGS: The liver is unremarkable in appearance with no focal
liver lesion identified. No biliary dilatation is seen and the
common duct measures 4 mm. The patient is status post
cholecystectomy. The portal vein is patent with hepatopetal
flow. The pancreas is unremarkable, but is only minimally
visualized due to overlying bowel gas. The spleen is at the
upper limits of normal measuring 12.4 cm. No hydronephrosis is
seen on limited views of the kidneys. The aorta is obscured
from view by overlying bowel gas. The intrahepatic portion of
the IVC is unremarkable. There is a right pleural effusion. No
ascites is seen in the upper abdomen.
IMPRESSION:
1. No hepatobiliary pathology identified.
2. Right pleural effusion.
Microbiology:
___ 6:35 pm BLOOD CULTURE: Pending, no growth to date
(___)
URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION
==================================
Ms. ___ came in with severe abdominal pain, nausea and
nonbloody nonbilious vomiting, black stool x 1. Her elevated
lipase and CT abdomen were consistent with acute pancreatitis.
She felt that her pain was more severe during this admission
than during her admission in ___ for pancreatitis.
==================================
ACTIVE PROBLEMS
#) ACUTE PANCREATITIS: Ms. ___ was treated with supportive
care (IVF, pain control) and she improved. Her lipase peaked in
the 1000s but since came down to normal levels along with the
remainder of her liver function tests with the exception of her
alkaline phosphatase. Her alkaline phosphatase remained
elevated, so she received a RUQ ultrasound which did not show
any evidence of hepatobiliary pathology. It did, however show a
small right pleural effusion which was thought to be secondary
to regional inflammation from her pancreatitis. Alk phos
trending downward to 186 on day of discharge.
#) IRON DEFICIENCY ANEMIA: Likely due to blood loss due to
fibroids. Received 2U pRBCs while here due to symptomatic anemia
(lightheadedness, fatigue) with hematocrits around 21.
Hematocrit responded appropriately to transfusion and remained
stable at 31.6 on day of discharge. She complained of black
stool x1 prior to admission but was guaiac negative while here.
#) CHEST PAIN: Had negative troponin and pain was nonexertional
and reproducible on palpation, so it was thought to be
noncardiac in origin. Pancreatitis can sometimes cause pain at
distant sites due to significant cytokine release, and this was
thought to be the likely culprit. Further, she complained of
similar pain during her last admission for pancreatitis. It
resolved and she reported being pain free upon discharge.
#) UTI: Urine culture + E. Coli. Dysuria resolved with 3 days
ciprofloxacin.
#) Acute renal failure: Cr 1.3 on admission, up from baseline of
0.6-0.7. Likely secondary to pre-renal azotemia in setting of
volume depletion from ongoing emesis/diarrhea and poor PO
intake. With volume repletion, Cr. down to 0.9 on discharge.
#)Diabetes Mellitus Type 2: metformin was held while in
hospital. Continued home dose of Lantus 30 units QHS (half-dose
while she was NPO). Blood glucose was well controlled throughout
hospitalization.
#) ASTHMA: Treated with nebulizer PRN.
#) HTN: well controlled on home regimen of atenolol, lisinopril,
and verapamil.
========================================
TRANSITIONS OF CARE
#) Pending studies: Blood cultures from ___, no growth to
date (___).
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Atrius.
1. Verapamil SR 240 mg PO QAM
2. Verapamil SR 120 mg PO QPM
3. Atenolol 25 mg PO DAILY
4. Glargine 30 Units Dinner
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Ferrous Sulfate 325 mg PO TID
7. Lisinopril 40 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob/wheezing
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Ferrous Sulfate 325 mg PO TID
3. Lisinopril 40 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Verapamil SR 240 mg PO QAM
6. Verapamil SR 120 mg PO QPM
7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID Asthma
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob/wheezing
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Glargine 30 Units Bedtime
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses-
-Acute pancreatitis
-Iron deficiency anemia
-Urinary tract infection
Secondary diagnoses-
-History of alcohol abuse
-Diabetes mellitus, type 2
-Hypertension
-Hypertriglyceridemia
-Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You came in with severe abdominal pain and were
found to have acute pancreatitis which is an inflammation of the
pancreas. You were previously admitted here for pancreatitis in
___. Your pancreatitis is likely from drinking
alcohol. While here we treated you with fluids and pain
medications and you improved.
In addition, during your stay at ___, we found that you had
low blood levels (anemia.) This could be the reason for your
lightheadedness and increased fatigue recently It is likely due
to a lack of iron in your body. We gave you iron by mouth and
gave you a blood transfusion, and you improved.
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You came in with severe abdominal pain and were
found to have acute pancreatitis which is an inflammation of the
pancreas. You were previously admitted here for pancreatitis in
___. Your pancreatitis is likely from drinking
alcohol. While here we treated you with fluids and pain
medications and you improved.
In addition, during your stay at ___, we found that you had
low blood levels (anemia.) This could be the reason for your
lightheadedness and increased fatigue recently. It is likely
due to a lack of iron in your body. We gave you iron by mouth
and gave you a blood transfusion, and you improved.
You also had an bladder infection (urinary tract infection or
UTI) You were treated with an antibiotic called ciprofloxacin
and your infection resolved.
Please continue to take your regular medications as you have
been at home. In addition, you were prescribed 2 new
medications. Advair is to treat your asthma. Zofran is to treat
your nausea. These symptoms should resolve within the next week
or so.
Followup Instructions:
___
|
10835634-DS-23
| 10,835,634 | 27,586,874 |
DS
| 23 |
2179-09-20 00:00:00
|
2179-09-20 19:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Abdominal Swelling
Major Surgical or Invasive Procedure:
Diagnostic paracentesis on ___: neg for SBP
Therapeutic paracentesis on ___: 5L removed
History of Present Illness:
___ year old male with CAD s/p CABG , HTN, HIV who presents with
numerous complaints including lower extremity swelling, ascites,
diarrhea x 2 wks (resolving), scrotal / penile swelling, and
burn wounds sustained 5 days prior. History limited by
tangential speech. He endorses having a "stomach virus" for two
weeks characterized by non-bloody diarrhea. He denies fevers,
chills, nausea, vomiting, or other GI symptoms, besides
abdominal distension. He apparently sustained a mechanical fall
5 days prior at home, and landed on his left arm, without
residual deficits, headstrike, or loss of consciousness. As a
result, he was not mobile enough to shut off the hot water when
taking a bath, and has burn injuries to his lower extremities
and genital area. He has been using vaseline and hydrogen
peroxide for his wounds.
He states he has had progressive lower extremity edema and
abdominal distension for the past ___ weeks. His weight in ___
was 172 lbs, and his current weight is 196. He does not take any
diuretics. He voids twice daily, however has had some difficulty
given his penile swelling after his burn injury. He states that
he has had elevated LFTs, and was scheduled to get a liver
ultrasound to evaluate for NASH.
In the ED, triage vitals were 97.8 67 136/67 16 98% RA. Initial
labs notable for a Na 120 Cr 1.7, ALT 228, AST 271, LDH 1246,
Tbili 2.3, Albumin 2.9, White count 15.3, INR 1.5. CXR showed
small bilateral pleural effusions. RUQ ultrasound showed mildly
heterogeneous and possibly nodular liver suggesting underlying
liver disease with massive ascites. Exam in the ED notable for
tense ascites and massive swelling and erythema of his penis and
some swelling of his scrotum. He was given vancomycin and 20 mg
IV lasix. Vitals on transfer 98.4 70 140/68 16 99%.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, nausea, vomiting, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Coronary artery disease s/p stents x 2 to left anterior
descending, 4 vessel CABG in ___
hypertension
HIV
s/p right carotid endarterectomy
peripheral vascular disease
h/o deep vein thrombophlebitis
Social History:
___
Family History:
No family history of liver disease. Twin sister with back
problems.
Physical Exam:
ADMISSION:
T98.1| BP 138/87| HR77| RR18| Satting 98% on RA
GENERAL: Well appearing, NAD. Extremely tangential/pressured
speech. Requires frequent reorientation.
HEENT: Sclera icteric. MMM.
CARDIAC: RRR with no excess sounds appreciated. CABG scar well
healed.
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: Extremely distended but soft, non-tender to palpation.
Dullness to percussion over dependent areas but tympanic
anteriorly. No HSM or tenderness appreciated. LLQ with dx
paracentesis site CDI.
GU: Extremely swollen erythematous penis and scrotum. Difficulty
exposing glans secondary to pain.
EXTREMITIES: 4+ edema b/l to thigh. Warm and well perfused, no
clubbing or cyanosis. Shins with appearance of chronic venous
stasis. B/L UE with erythema and scratches.
NEUROLOGY: No asterixis. Difficulty complying with full neuro
exam as tangential. MAE. No focal cranial nerve deficits.
DISCHARGE:
VS: afebrile 98.4 83/44 HR 64 sat 92% on RA
GENERAL: NAD
HEENT: Sclera icteric. MMM.
CARDIAC: NR, RR, sternotomy scar well healed.
LUNGS: CTAB
ABDOMEN: tense abdominal swelling, NT
GU: Extremely swollen erythematous penis and scrotum. Difficulty
exposing glans secondary to pain.
EXT: gross ___ to knees
NEUROLOGY: A&O, no gross deficits
PSYCH: pressured speech, tangential
Pertinent Results:
ADMISSION LABS:
___ 02:45PM BLOOD WBC-15.3*# RBC-3.43* Hgb-13.1* Hct-38.6*
MCV-112*# MCH-38.1* MCHC-33.9 RDW-18.4* Plt ___
___ 02:45PM BLOOD ___ PTT-29.2 ___
___ 02:45PM BLOOD Glucose-136* UreaN-47* Creat-1.7* Na-120*
K-5.1 Cl-90* HCO3-20* AnGap-15
___ 02:45PM BLOOD ALT-228* AST-271* LD(LDH)-1246*
AlkPhos-121 TotBili-2.3* DirBili-1.3* IndBili-1.0
___ 02:45PM BLOOD Albumin-2.9* Calcium-8.2* Phos-3.4 Mg-2.1
___ 08:50PM BLOOD Osmolal-267*
___ 03:11AM BLOOD TSH-6.7*
___ 03:11AM BLOOD T3-66*
___ 02:45PM BLOOD HBsAb-NEGATIVE IgM HBc-POSITIVE*
___ 05:45AM BLOOD HBsAg-PND HBcAb-PND HAV Ab-PND
___ 09:46PM BLOOD Lactate-1.8
___ 02:45PM BLOOD HEPATITIS B VIRUS GENOTYPE-PND
___ 02:45PM BLOOD HEPATITIS Be ANTIGEN-PND
___ 02:45PM BLOOD HEPATITIS Be ANTIBODY-PND
DISCHARGE LABS:
___ 06:23AM BLOOD WBC-7.3 RBC-3.21* Hgb-12.3* Hct-36.0*
MCV-112* MCH-38.4* MCHC-34.2 RDW-19.8* Plt Ct-99*
___ 06:23AM BLOOD ___
___ 06:23AM BLOOD Glucose-122* UreaN-38* Creat-1.3* Na-130*
K-5.0 Cl-100 HCO3-24 AnGap-11
___ 06:23AM BLOOD ALT-97* AST-115* AlkPhos-104 TotBili-1.8*
___ 06:23AM BLOOD Albumin-2.6* Calcium-7.1* Phos-2.8 Mg-2.0
-Transthoracic ECHO ___: The left atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses and cavity size are normal.
There is mild to moderate regional left ventricular systolic
dysfunction with severe hypokinesis/akinesis of the distal half
of the anterior septum and anterior wall. The apex is aneurysm
and mildly dyskinetic. The remaining segments contract normally
(LVEF = 35-40 %). The estimated cardiac index is normal
(>=2.5L/min/m2). A large 2.4x1.2cm pedunculated/partially mobile
THROMBUS is seen in the left ventricular apex. 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 structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction c/w CAD (mid-LAD) and partially mobile
apical THROMBUS. Mild mitral regurgitation with normal valve
morphology.
Compared with the prior study (images reviewed) of ___,
the left ventricular dysfunction is more extensive and an apical
thrombus is now seen
-Renal Ultrasound ___ IMPRESSION: **Preliminary Report
1. Normal appearance of the kidneys without evidence of
hydronephrosis.
2. Large amount of ascites.
-Abdominal Ultrasound ___: Mildly heterogeneous and
possibly nodular liver suggesting underlying liver disease with
massive ascites. Patent main portal vein. Gallbladder mural
edema is likely secondary to hypoproteinemia with a 4 mm
gallbladder polyp for which no further imaging follow up is
required.
-CXR ___: Small Bilateral pleural effusions.
MICRO:
-HCV VIRAL LOAD-PENDING
-HBV Viral Load-PENDING
-___ Urine cx: growing 100,000+ MSSA (PCP notified on
___ at 18:30 via email)
Brief Hospital Course:
Mr. ___ is a ___ M w/ CAD s/p CABG & stenting, HIV w/ last CD4
565 with cirrhosis of unknown etiology c/b ascites who presents
with worsening abdominal distention and lower extremity edema
and found to have chronic HBV and acute renal faiure with
hyponatremia.
# Cirrhosis: Unclear that patient has cirrhosis though with the
combination of ascites, elevated INR, thrombocytopenia and
hyponatremia, this is likely cirrhosis. Likely due to Hep B,
possible reactivation which could be complicated by hx of being
on Truvada which could lead to resistance. Patient admitted with
large volume ascites and transaminitis in the 200's. Diagnostic
para ___ neg for SBP. HepBc IgM positive. Therapeutic
paracentesis on ___: 5L removed with albumin given. HBV and HCV
viral loads pending at time of discharge.
will need to change lamivudine to truvada if HBV viral load
positive. Will need EGD to assess for varices. Does not require
lactulose at this time as not encephalpathic. Started Lasix 20mg
po and Spironolactone 50mg daily on ___, will have lytes
checked ___ ___. Patient opted to make own follow
up with a Hepatologist.
# Left ventricular thrombus: Patient found to have incidental LV
thrombus on ECHO ___. The mass is 2x2cm and mobile, it is
unclear whether this needs to be removed endovascularly. Started
heparin bridge to warfarin, PTT 150 and INR is now 2.0 after
only 5mg warfarin yesterday. Will hold heparin gtt and check in
the ___, may not need further bridging though INR may be
influenced by elevated PTT. Warfarin 2mg daily (started ___
Cardiology consuled and recommended goal INR ___ for 3 months
then repeat TTE. Patient discharged with bridge with lovenox to
therapeutic INR x 2 days. Patient will follow up with OSH
cardiologist; cardiologist ___ emailed with info
about admission and need for ___ on ___.
# Hyponatremia: Na 120 on admission, likely hypervolemic
hyponatremia from cirrhosis. Now downtrending to 118 despite
fluid restriction. Will give another 24 hours of fluid
restriction and start tolvaptan if not improving. Discharged
with Na 130. Fluid restricted to 1.5L. Discharge weight 75 kg
(88 kg on ___.
# ___ on CKD: Cr 1.7 on admission. Per PCP ___ 1.5 in ___
and 1.3 in ___. Etiologies include pre-renal from total volume
overload, or hepatorenal syndrome. He recived 20 mg IV lasix in
the emergency department. Renal U/S ___ shows no
hydronephrosis.
# Recent Hypotension: On ___ was hypotensive to 80's though
mentating well. Unclear baseline. He may have peripheral
vasodilitation due to cirrhosis, sepsis unlikely. ___ also have
contribution of systolic heart failure with impaired
contractility due to hypervolemia. SBP now up to 110's following
para ___.
# Scrotal/Penile Edema: Scrotum and penis are very enlarged,
likely secondary to gross anasarca in addition to reportedly
accidental burns sustained in bathtub. Only minor skin break
down on the posterior portion of distal penis. U/A with few
bacteria and pyuria. Foley pulled ___ AM and patient able to
produce good UOP. Oxycodone for pain control. Urology consult:
defer abx pending ___ cx, elevate genitalia, bacitracin ointment.
MSSA 100,000+ grew from U/A add-on, his PCP was notified of this
via email on ___. No dysuria.
# CAD: s/p stents x 2 to left anterior descending, 4 vessel CABG
___. TTE ___ shows LV thrombus, regional systolic dysfunction,
and EF 35-40%. Continued ASA 81 qday, Atorvastatin and
Metoprolol. Lisinopril 40 was initially held due to hypotension
& ___, and should be restarted at lower dose pending Cardiology
given risk of hyperkalemia with spironolactone.
# HIV: Last CD4 was 565 in ___. Last viral load
non-detectable in ___. Continued home HIV medications.
___ need to change regimen if HBV viral load elevated as above.
# Psych: patient had pressured and tangential speech on
admission, now more appropriate though very tangential.
Continued home Alprazolam qhs prn.
# Diarrhea: Less likely unusual organisms given CD4 over 500 at
last check and recent undetectable HIV viral load. Resolved.
#CODE: Full
#DISPO: ET service to home ___
### TRANSITIONAL ISSUES ###
-HBV and HCV viral loads pending at time of discharge
-will need to change lamivudine to truvada if HBV viral load
positive
-will need EGD to assess for varices
-Started Lasix 20mg po and Spironolactone 50mg daily on ___,
will have lytes checked ___ ___.
-Patient opted to make own follow up with a Hepatologist.
-Warfarin 2mg daily (started ___, will have INR checked as
outpatient on ___ ___ LV thrombus, will follow up with Dr. ___ with Cardiology
at ___
-Urine culture MSSA 100,000+ grew from U/A add-on, his PCP was
notified of this via email on ___.
-Lisinopril 40 was initially held due to hypotension & ___, and
should be restarted at lower dose pending Cardiology given risk
of hyperkalemia with spironolactone.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Raltegravir 400 mg PO BID
2. Atorvastatin 40 mg PO DAILY
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. ALPRAZolam 0.25 mg PO QHS:PRN insomnia
7. Nevirapine 200 mg PO BID
8. LaMIVudine 300 mg PO DAILY
Discharge Medications:
1. ALPRAZolam 0.25 mg PO QHS:PRN insomnia
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. LaMIVudine 300 mg PO DAILY
5. Raltegravir 400 mg PO BID
6. Bacitracin Ointment 1 Appl TP BID
RX *bacitracin zinc 500 unit/gram apply to any breaks in skin of
testes and penis twice daily Disp #*1 Tube Refills:*0
7. Furosemide 20 mg PO DAILY
to prevent belly and leg swelling
RX *furosemide 20 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
8. Metoprolol Succinate XL 12.5 mg PO DAILY
9. Warfarin 2 mg PO DAILY16
blood thinner for heart clot
RX *warfarin 2 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
10. Spironolactone 50 mg PO DAILY
to prevent swelling in belly and legs
RX *spironolactone 50 mg 1 tablet(s) by mouth once daily Disp
#*30 Tablet Refills:*0
11. Nevirapine 200 mg PO BID
12. Enoxaparin Sodium 80 mg SC Q12H
blood thinner in addition to warfarin until your INR is stable
RX *enoxaparin 80 mg/0.8 mL 80 mg sc every 12 hours Disp #*3
Syringe Refills:*0
13. Outpatient Lab Work
INR, chem-7
Dx: Left ventricle Thrombus
Please fax results to Dr. ___ Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Hepatitis
Chronic Liver disease
Left Ventricle Thrombus
Secondary diagnoses:
HIV
Coronary artery disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___, you were admitted to ___ for worsening abdominal
swelling found to be due to your liver. Your liver labs are
pending, but we are concerned for Hepatitis B as the cause of
your liver disease. It is very important you follow up with a
Hepatologist to follow your liver disease, since you would
prefer not to come here for care. Also, you were found to have a
clot in the left ventricle of your heart. You were started on
blood thinners, and it is important you continue to have your
INR checked to make sure your warfarin is at the right dose.
Followup Instructions:
___
|
10835660-DS-14
| 10,835,660 | 27,075,775 |
DS
| 14 |
2192-09-04 00:00:00
|
2192-09-08 16:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Latex
Attending: ___.
Chief Complaint:
acute kidney injury
Major Surgical or Invasive Procedure:
-Upper endoscopy with biopsies
History of Present Illness:
___ woman w/ multiple medical comorbidites including
HTN, hyperlipidemia, GERD, carotid stenosis, afib, who had a
ventral hernia repair on ___ in ___ that was
subsequently complicated by a long postop course including bowel
perforation, septic shock, ATN, multiple abdominal surgeries and
revisions which included ileostomy and abdominal wall
debridement, now presenting from clinic due to concern for acute
renal failure. She had been in rehab for an extended period, and
was recently discharged home, and now has 24-hour care at home.
She saw her PCP ___ for f/u of her medical issues, who found
that her Cr was 4.0, up from 0.8 in ___. At her PCP's
office, she was very weak and was vomiting.
She had been vomiting for months on a regular basis, not
controlled on Zofran and Compazine, now on dronabinol. She
states that the vomiting is NBNB and is more like retching, and
that she usually only brings up small amounts of mucus. It is
not related to meals and she has been eating a regular diet (had
a hamburger and cottage cheese earlier today). No associated
abdominal pain. Of note, she has not had an EGD to evaluate and
H. pylori antibody was positive. She is now able to take food by
mouth. For several months she has also had profuse loose liquid
brown/greenish output from the ostomy and has to change the bag
5x/day. Per OMR sheet her weight has decreased from 138 on
___ to 117 on ___ (21 lbs over 1.5 months). Her urine
output is decreased and she has occasional dysuria. Has had
intermittent fevers up to 100.6 approx 1 week ago. Also for the
past 10 days has been having a cough productive of yellow
phlegm.
In ___, she was admitted for klebsiella UTI with a
positive UA, dysuria, and low-grade temp, treated with a 7-day
course of IV ciprofloxacin. During this admission, she had
persistent nausea/vomiting throughout, thought to have been due
to her extensive abdominal surgical history. She had tube feeds
during this time which she tolerated well. At discharge on
___, she was tolerating small amounts of PO intake of full
liquids.
She is followed by Dr. ___ ___ who has evaluated her
recently for ileostomy reversal. He feels that she needs to wait
at least until ___ (6 mos after last large operation) for
considering this.
In the ED, initial VS were 97.8, 97/71, 104, 18, 96%RA. Labs
were notable for a lactate 3.8, Na 127, Cl 82, bicarb 26, BUN
132, Cr 4.3, AG 19. CXR showed new mild elevation of the right
hemidiaphram but no pneumonia or other acute process. She was
given 1L NS. VS prior to transfer were 98.2, 105, 120/76, 24,
95%RA.
On the floor, she continues to feel nauseous and tired but has
had no further retching/vomiting since coming in to the ED.
Past Medical History:
PAST MEDICAL HISTORY:
HTN
Hyperlipidemia
GERD
Diverticulosis
L carotid stenosis
Obesity
Hx DVT without anticoagulation
Mitral valve prolapse
Anxiety
Paroxysmal atrial fibrillation
PAST SURGICAL HISTORY:
Total abdominal hysterectomy
Ventral hernia repair (___)
Cholecystectomy
___ Ventral hernia repair w Composix LP mesh
___ Ex lap/SBR/J-tube placement/Ventral hernia repair w
Allomax mesh for SB perforation/abdominal sepsis
___ Ex lap/SBR/end ileostomy for anastomotic leak
___ Excisional debridement necrotic abdominal wall
___ Debridement skin/soft tissue w complex closure of skin
and vac placement over bowel
___ebridement, vac change
___ Ileostomy revision
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.2, 116/63, 96, 18, 98%RA
General: elderly F in no acute distress, A&Ox3
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD, no carotid bruits
Lungs: Coarse BS throughout with faint bibasilar rales, no
wheezing
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, mildly TTP around ostomy and lower abdomen, no
guarding or rebound, non-distended, bowel sounds present
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII intact, ___ strength in UE, ___ strength in ___
but symmetric, sensation grossly intact, gait not assessed
DISCHARGE PHYSICAL EXAM:
Vitals: 98.0/98.9 131/92 [110-131/64-92] 60-71 20 98% RA
I/O: 1210/UOP 150+/ostomy 250+
General: Thin woman sitting upright in chair, NAD, A&Ox3
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: Supple, JVP not elevated
Lungs: Coarse BS throughout with faint rhonchi in LLL, no
wheezing or crackles
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: Soft, mildly TTP around ostomy and lower abdomen, no
guarding or rebound, non-distended, bowel sounds present, ostomy
bag in place draining liquid green-brown output
Ext: Warm, well perfused, 2+ pulses, trace ___ nonpitting edema
Skin: contact dermatitis underneath ostomy bag
Neuro: CN II-XII intact, ___ strength in UE, ___ strength in
proximal ___, ___ in distal ___ but symmetric, sensation
symmetrically decreased over anterolateral thighs, gait not
assessed
Pertinent Results:
ADMISSION LABS:
WBC-8.0 RBC-5.02 Hgb-14.5 Hct-43.6 MCV-87 MCH-28.8 MCHC-33.2
RDW-13.2 Plt ___
Neuts-72.9* ___ Monos-4.3 Eos-1.3 Baso-0.8
Glucose-142* UreaN-132* Creat-4.3* Na-127* K-4.9 Cl-82* HCO3-26
AnGap-24*
ALT-44* AST-22 LD(LDH)-126 AlkPhos-195* TotBili-0.2 Lipase-79*
TotProt-8.1 Albumin-4.2 Globuln-3.9 Calcium-10.5* Phos-6.0*#
Mg-2.3
Osmolal-321*
Lactate-3.8*
Urine studies: Color-Straw Appear-Hazy Sp ___ Blood-TR
Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-5.5 Leuks-LG
RBC-6* WBC-99* Bacteri-MANY Yeast-MOD Epi-9 AmorphX-RARE
Mucous-RARE
Eos-POSITIVE RANDOM Creat-93 Na-<10 K-52 Cl-<10 Osmolal-459
LABS ON DISCHARGE:
___ 09:00AM BLOOD Glucose-112* UreaN-8 Creat-0.8 Na-139
K-3.6 Cl-108 HCO3-21* AnGap-14
OTHER PERTINENT LABS:
VitB12-657
Folate-GREATER TH
25VitD-29*
Cortsol-28.1*
ESR-43*
CRP-3.6
IgA-274
tTG-IgA-8
SPEP-NO SPECIFIC ABNORMALITIES SEEN
MICROBIOLOGY:
Blood cultures (___): NEGATIVE
C diff toxins A/B (___): NEGATIVE
Urine culture (___): mixed flora c/w contamination
Urine culture (___): mixed flora c/w contamination
CHEST X-RAY (___):
1. No evidence of pneumonia.
2. New mild relative elevation of the right hemidiaphragm since
___.
CT ___ WITHOUT CONTRAST ___, pt refused contrast):
1. Heterogenous appearance of the liver parenchyma on
non-contrast study is nonspecific and may represent
inhomogeneous fatty deposition. Correlation with prior imaging
and liver ultrasound or MR is advised to further evaluate.
2. Area of fat necrosis inferior to the left hepatic lobe is
more pronounced than on prior study.
3. Unusual tubular structure lying lateral to the ascending
colon likely
represents post-surgical phlegmon and is slightly decreased in
size since the prior study. No evidence of large or small-bowel
obstruction. Satisfactory appearance of the right iliac fossa
stoma (ileostomy). There is grade 1 anterolisthesis of L4 on L5.
EGD REPORT (___): Normal mucosa in the esophagus. Erythema,
friability and congestion in the antrum compatible with
gastritis (biopsy). Erythema in the duodenal bulb compatible
with mild duodenitis (biopsy). Otherwise normal EGD to third
part of the duodenum.
Recommendations: Prilosec 20mg BID. Follow-up biopsy results.
Additional recs per inpatient GI team.
GI MUCOSAL BIOPSIES ___, final):
A) Gastric body: Corpus mucosa, within normal limits.
B) Antrum: Antral mucosa with focal reactive (chemical-type)
gastropathy and very focal intestinal metaplasia, no dysplasia
identified.
C) Duodenum: Duodenal mucosa, within normal limits.
LIVER/GALLBLADDER ULTRASOUND (___):
1. Echogenic liver consistent with fatty deposition. Other forms
of liver
disease such as hepatic fibrosis/cirrhosis cannot be excluded.
2. Gallbladder surgically absent.
Brief Hospital Course:
# ACUTE KIDNEY INJURY: Patient's admission creatinine was 4.3.
It was 4.0 3 days prior to admission, and 0.8 on ___. Given
her history of nausea/vomiting, decreased PO intake, and
possible high ostomy output, pre-renal etiology was thought to
be the most likely etiology. Her BUN/Cr ratio >30, FENa=0.36%,
urine osmolality of 459 all supported pre-renal azotemia,
further supported by rapid improvement of her creatinine with IV
fluids. Obstruction was thought unlikely as she was passing
urine. With IV fluids, her creatinine improved over 4 days to
1.0. She was producing adequate urine during this time. Based on
rare urine eosinophils and sterile pyuria, omeprazole was
changed to ranitidine for the concern for unlikely interstitial
nephritis, despite urine sediment analysis which only revealed
clumps of white cells but no WBC casts. On the day of discharge,
her creatinine was 0.8.
# LABORATORY ABNORMALITIES: Patient had a number of laboratory
abnormalities on admission, including anion-gap metabolic
acidosis with metabolic alkalosis, hyponatremia, hypercalcemia
and elevated LFTs. These were all thought to have been due to
dehydration and ___, as there was resolution with IV fluids and
normalization of her creatinine. On admission, she had an anion
gap of 19, likely due to lactic acidosis (lactate 3.8).
Delta-Delta was 4.25, suggesting that there was also a metabolic
alkalosis component, likely from vomiting and loss of H+.
Patient was not on metformin or other meds known to cause lactic
acidosis. This had resolved by the time of discharge. Na on
admission was 127. Based on her whole clinical picture it was
thought that her hyponatremia was likely due to hypovolemia.
However, given her initial high-normal K, hypotension, symptoms
of weakness, anorexia, and nausea/vomiting, adrenal
insufficiency was considered, but AM cortisol ruled this out.
Hypovolemic hyponatremia was confirmed when her Na normalized
with IV fluids. Her calcium on admission was 10.5, with a normal
albumin level. With hypercalcemia, ___, and weight loss,
SPEP/UPEP were performed to r/o multiple myeloma and these were
negative. Calcium also normalized with IV fluids. ALT and
alkaline phosphatase were elevated on ___, without elevation in
bilirubin. A RUQ ultrasound was performed because of her nausea
and abdominal pain, which showed an echogenic liver consistent
with fatty deposition. Repeat LFTs demonstrated normalization of
transaminases and a downtrendding alkaline phosphatase.
# NAUSEA/VOMITING: This was thought to have been the major
precipitating factor in causing the patient's ___, along with
decreased PO intake. The patient has a lifelong history of
nausea with rare vomiting at times of anxiety. She was reporting
increased nausea and vomiting since ___ after her
abdominal surgeries. Still not entirely clear why she is having
persistent nausea/vomiting. She is currently on a regimen of
Zofran, Compazine, and dronabinol. The recent addition of
dronabinol has improved control as well as stimulated her
appetite, but she still has intermittent periods of nausea. She
did not produce any emesis in the hospital. She did have
intermittent epigastric abdominal pain not associated with food
intake. Based on a lactose hydrogen breath test performed in
___, she is lactose-intolerant. She was therefore kept on a
lactose-free diet for a period of time, but this did not seem to
have any relation to her nausea. She also gave a history of high
ostomy output, and input/output monitoring in the hospital did
not show an excessively high output (1525cc on first day, less
on subsequent days). C. diff was negative. Labs for celiac
disease were unremarkable. Short bowel syndrome and bile salt
diarrhea were thought to be unlikely as she had only 13cm of
ileum removed. EGD was performed which showed normal esophageal
mucosa, gastritis, and mild duodenitis. She was discharged on a
H2 blocker. For her nausea, her regimen of Zofran, Compazine,
and dronabinol was continued. To prevent increased liquid ostomy
output, her loperamide was increased to 4x/day standing, and
Metamucil wafers were added to her regimen.
# CONTACT DERMATITIS AT OSTOMY SITE: Patient complained of a
moderate amount of pain around her ostomy site. It was noted
that the patient had contact dermatitis at her ostomy site,
which is likely contributing to this pain. She was provided
ostomy care teaching and new supplies, including miconazole
powder.
# COUGH: Her admission was preceded by over a week of
intermittent fever to 100.6 and cough productive of yellowish
phlegm. During her hospitalization she was afebrile but
continued to have intermittent cough productive of yellow
phlegm. CT demonstrated bibasilar tree in ___ opacities,
suggesting aspiration. Given her history of vomiting, this was
thought to be most likely. Suspicion for pneumonia was low given
no fever or leukocytosis.
# CRITICAL-ILLNESS MYOPATHY: She complained of significant lower
extremity weakness which was symmetric and bilateral. She also
reported numbness/tingling, decreased sensation to light touch,
and shooting pain bilaterally over her anterolateral thighs. Her
motor weakness was thought to be due to critical-illness
myopathy and deconditioning. Her sensory complaints could be due
to neuropathy but also lateral cutaneous femoral nerve damage or
entrapment. Lidocaine patches applied over her thighs were
somewhat beneficial in alleviating her pain.
# PAROXYSMAL ATRIAL FIBRILLATION: Developed in setting of acute
illness and was initially managed with amiodorone on a prior
admission. Not on warfarin (CHADS2 score is 1). Rate control
with metoprolol was continued. ECG on ___ showed sinus
rhythm and she appeared to remain in sinus rhythm throughout her
hospital course.
# ANXIETY/DEPRESSION: Citalopram and lorazepam were continued.
Medications on Admission:
citalopram 20mg daily
odansetron 4mg/2mL solution, 8 solutions Q8H:PRN
prochlorperazine 5mg Q6H:PRN
dronabinol 2.5mg BID
omeprazole 20mg daily
simethicone 80mg QID
metoprolol tartrate 12.5mg TID
lorazepam 0.25mg Q6h:PRN
lidocaine 5% patch daily to upper legs
fluticasone 50mcg 1 spray daily
Tylenol ___ Q8H:PRN
folic acid 1mg daily
ferrous gluconate 324 mg (38 mg iron) daily
vitamin B12 500mcg daily
calcium carbonate 1300mg calcium BID
sodium chloride nasal spray
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for bloating, gas.
Disp:*120 Tablet, Chewable(s)* Refills:*0*
4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*0*
5. lorazepam 0.5 mg Tablet Sig: ___ Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
6. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Please
apply one patch to each leg daily.
Disp:*60 Adhesive Patch, Medicated(s)* Refills:*0*
7. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*120 Tablet(s)* Refills:*0*
8. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) as needed for nausea.
Disp:*90 Tablet(s)* Refills:*0*
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. ferrous gluconate 325 mg (37.5 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
Disp:*1 bottle* Refills:*0*
12. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. sodium chloride 0.65 % Aerosol, Spray Sig: One (1) Spray
Nasal QID (4 times a day) as needed for nasal dryness.
Disp:*1 bottle* Refills:*0*
14. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
15. calcium carbonate 500 mg calcium (1,250 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day.
Disp:*60 Tablet, Chewable(s)* Refills:*0*
16. loperamide 2 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*0*
17. psyllium 1.7 g Wafer Sig: One (1) wafer PO BID (2 times a
day).
Disp:*60 wafer* Refills:*0*
18. Tylenol ___ mg Tablet Sig: Two (2) Tablet PO every eight (8)
hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Acute renal failure (prerenal, due to dehydration)
-Chronic nausea and nausea/vomiting (reassuring workup, GI
biopsies pending from EGD)
SECONDARY:
-S/P ileostomy
-GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with kidney failure that
resolved with IV fluids. This was likely due to dehydration. You
also underwent work-up for your nausea and vomiting and were
followed by our gastroenterology team. You had labs and a CT
abdomen that were all reassuring. You also underwent endoscopy,
which showed mild gastritis (stomach irritation). Biopsies from
the endoscopy are pending; your doctor should follow up these
results. We made some changes to your medications to help
prevent increased ostomy output in the future. You were also
seen by our ostomy care team who recommended drinking 10 glasses
of fluid per day going forward.
.
Please attend the follow-up appointments listed below with your
primary care doctor and surgery. You should also call our
gastroenterology doctors ___ # listed below) on ___ to set
up outpatient follow-up for your nausea and vomiting issues.
.
We made the following changes to your medications:
1. STARTED loperamide (Immodium) 2mg with breakfast, lunch,
dinner and before bedtime (to treat increased ostomy output)
2. STARTED psyllium (Metamucil) 1.7g wafers twice daily (to
treat increased ostomy output)
3. STARTED ranitidine 150mg by mouth twice daily (to treat your
GERD/stomach irritation)
4. STOPPED omeprazole 20mg by mouth daily (replaced with
ranitidine)
5. STOPPED aspirin 81mg by mouth daily (can cause stomach
irritation)
Followup Instructions:
___
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10835660-DS-17
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2192-12-07 00:00:00
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2192-12-07 08:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Latex / Lactose / bee sting /
Percocet
Attending: ___.
Chief Complaint:
Postoperative nausea/emesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female who has a prior history of ex
lap, ileostomy reversal, and VHR w/ ___ on ___ and
discharged to ___ yesterday. On the day of readmission
she developed nausea, vomiting, and fevers. She is not sure if
her abdominal pain is worse. At rehab, reportedly febrile to
101. Continues to have flatus and small bowel movements, last
just
prior to presentation. No drainage from incisional wound.
Denies large fluctuation in JP output, quality since discharge.
On arrival to the ED, she was afebrile, sinus tachycardia,
otherwise hemodynamically appropriate with soft abdomen,
___ tenderness without peritoneal signs. WBC 7.3
(N85.7).
Past Medical History:
HTN
Hyperlipidemia
GERD
Diverticulosis
L carotid stenosis
Obesity
Hx DVT without anticoagulation
Mitral valve prolapse
Anxiety
Paroxysmal atrial fibrillation
PAST SURGICAL HISTORY:
Total abdominal hysterectomy
Ventral hernia repair (___)
Cholecystectomy
___ Ventral hernia repair w Composix LP mesh
___ Ex lap/SBR/J-tube placement/Ventral hernia repair w
Allomax mesh for SB perforation/abdominal sepsis
___ Ex lap/SBR/end ileostomy for anastomotic leak
___ Excisional debridement necrotic abdominal wall
___ Debridement skin/soft tissue w complex closure of skin
.
Social History:
___
Family History:
Positive for ulcer disease, coronary artery
disease, pancreatitis, father had cancer, but she did not recall
the site of origin of the tumor.
Physical Exam:
Vitals:T: 98.4 Bp: 138/79 P:80 RR: 16
General: Patient is in NAD.
Resp:CTAB, good air movement
CV:RRR. No murmurs, rubs, or gallops
Abdominal:soft, nontender,nondistended. Incision site is c/d/i
Extremities:no c/c/e
Pertinent Results:
___ 05:50AM BLOOD WBC-7.4 RBC-2.72* Hgb-7.7* Hct-25.0*
MCV-92 MCH-28.5 MCHC-31.0 RDW-14.1 Plt ___
___ 05:50AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-86 UreaN-6 Creat-0.7 Na-141 K-4.1
Cl-105 HCO3-25 AnGap-15
___ 06:45AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.8
___ 02:52AM BLOOD Lactate-1.1
Brief Hospital Course:
Ms. ___ was readmitted from ___ rehab on ___ for
poor PO intake, nausea, and vomiting. She was readmitted to the
___ surgical service and initially managed comfortably.
Her hospital course was as such:
Neuro: She was neurologically stable throughout her entire
hospital course. Initially her pain was managed with PO
oxycodone, but this was associated with nausea. She was
transitioned to PO dilaudid which she tolerated well.
Cardiovascular: She was started on her home metoprolol dose when
admitted.
Respiratory: She had no respiratory issues. She was
saturating in high 90 percent on room air.
Gastrointestinal: initially she was made NPO. No NGT was used.
She was advanced from sips to clears on Hospital day 2. With
tolerance she was advanced to a regular diet, which she began to
tolerate well on ___.
Genitourinary: Ms. ___ had a foley placed on admission to
monitor her urine output. It was discontinued in the am of
___. She voided appropriately thereafter.
Prophylaxis: She was on DVT prophylaxis via subcutatneous
heparin and SCD boots while in house.
Consults: She was seen by physical therapy and plastics while in
house. Plastics removed the Jp drains. She will follow-up with
Plastic Surgery in clinic. Physical Therapy recommended for the
patient to ambulate at home with a walker.
Discharge Medications:
1. Cholestyramine 4 gm PO BID
2. Citalopram 20 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO TID
Hold for SBP<90 or HR <50
6. Zolpidem Tartrate 5 mg PO HS:PRN prn insomnia
7. Ranitidine (Liquid) 150 mg PO BID
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Cyanocobalamin 500 mcg PO DAILY
10. Lorazepam 0.5 mg PO BID prn anxiety
11. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide 10 mg 10 mg by mouth four times a day Disp
#*120 Tablet Refills:*0
12. Psyllium Wafer 1 WAF PO X3 PRN diarrhea
Take with meals.Stop taking this medication if you experience
constipation.
RX *Metamucil 1 wafer by mouth three times a day Disp #*30
Packet Refills:*0
13. Acetaminophen (Liquid) 650 mg PO Q6H Duration: 1 Weeks
Do not exceed 4 grams of acetaminophen per day.
RX *8 HOUR PAIN RELIEVER 650 mg 650 mg by mouth every six (6)
hours Disp #*28 Tablet Refills:*0
14. Omeprazole 40 mg PO DAILY
15. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain Duration: 5
Days
This narcotic medication can be used for breakthrough pain you
may experience. Do not mix with alcohol or sedatives. Do not
drive or operate heavy machinery while on this medication.
RX *Dilaudid 2 mg 2 mg Tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Failure to thrive
Diarrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___,
you were admitted for nausea, poor oral intake, and diarrhea.
You were observed in the hospital and improved after
conservative management and bowel rest. You are now ready to
return to rehab and finish your recovery.
Followup Instructions:
___
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2193-04-04 17:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Latex / Lactose / bee sting /
Percocet
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ yo right handed woman who presented to the
ED from home for confusion this morning noticed by her friend.
Her friend states that when she arrived at her house this
morning
she stated that she was feeling "off". When her friend started
talking to her she was unable to remember details from earlier
in
the week about a meeting she had with her daughter. She was also
unable to recall what she had eaten for breakfast. She asked her
friend ___ multiple questions which she then repeated several
minutes later as if she did not remember asking them. Her friend
decided to bring her into the hospital for evaluation after the
symptoms did not resolve. As far as the patient can remember
there was nothing out of the ordinary over the past few days.
She
is currently at her home in ___, although she also lives
some of the time in ___. She has had no illnesses that she
can remember and no recent change in her medications. She noted
no visual complaints and no weakness or sensory loss.
She has a history of atrial fibrillation, but is not
anticoagulated. She had been on aspirin therapy until 4 months
ago when she had a reversal of a colectomy. This was secondary
to
a bowel perforation during surgery for an SBO. After the
reversal
she was not restarted on aspirin.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Atrial Fibrillation - not on coumadin or aspirin
SBO with colon injury s/p partial colectomy and reversal
Hypertension - controlled on meds
Hyperlipidemia - not on medication
Anxiety - on clonazepam
Social History:
___
Family History:
M - died in ___ - suicide
F - lymphoma
brother - cancer
Physical ___:
Physical Exam on Admission:
Vitals: 99 66 175/81 18 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: irregular rhythm, normal rate, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 5 4+ 4+ 5 4+ ___ 4+ 5- 5 5 5
R 5 5 4+ 4+ 5 4+ ___ 4+ 5- 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 2
R 3 3 3 3 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Physical Exam on Discharge:
Vitals: T 97.9, BP 114-150/59-75 HR ___ O2 97 RA
Mental status: awake, alert, speech fluent, able to spell
"world" backwards, no paraphasic errors, recalls 7 digits
forward and 6 backwards, registers 5 words and recalls all 5 in
5 minutes, names 23 animals in 1 minute
Exam unchanged from admission
Pertinent Results:
Labs on Admission:
___ 01:00PM WBC-9.1 RBC-5.13# HGB-14.6# HCT-44.7# MCV-87
MCH-28.5 MCHC-32.7 RDW-14.0
___ 01:00PM NEUTS-80.5* LYMPHS-15.1* MONOS-3.6 EOS-0.6
BASOS-0.3
___ 01:00PM ___ PTT-28.7 ___
___ 01:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:00PM GLUCOSE-114* UREA N-27* CREAT-1.0 SODIUM-144
POTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-26 ANION GAP-15
___ 01:10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 01:10PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:10PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 01:10PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 01:23PM LACTATE-1.5
___ 08:50PM ALT(SGPT)-12 AST(SGOT)-13 LD(LDH)-135 ALK
PHOS-47 TOT BILI-0.3
___ 08:50PM %HbA1c-5.6 eAG-114
___ 08:50PM TRIGLYCER-57 HDL CHOL-94 CHOL/HDL-2.0
LDL(CALC)-85
___ 08:50PM TSH-2.6
Imaging:
CT head w/o contrast
FINDINGS: There is no hemorrhage, major vascular territorial
infarction,
edema, mass, or shift of normally midline structures.
Periventricular
hypodensities, compatible with small vessel ischemic changes,
are mild.
Ventricles and sulci are mildly enlarged, compatible with a mild
degree of
cortical atrophy. Basal cisterns are patent. Gray-white
differentiation is preserved. There is no osseous or soft
tissue lesion. There is partial
opacification of the right ethmoidal air cells. Otherwise, the
remainder of the paranasal sinuses and mastoid air cells are
well aerated.
IMPRESSION: No acute intracranial process.
MRI brain and MRA head/neck
1. No acute infarction.
2. Apparent diminished flow in the proximal superior divisions
of the right and left middle cerebral arteries, more severe on
the left, which is most likely related to motion artifacts.
However, CTA could provide better
assessment, if clinically indicated.
3. No evidence of hemodynamically significant stenosis or
dissection in the cervical carotid or vertebral arteries.
4. 2-mm focus of high signal on fat-suppressed T1-weighted
images in the
right anterior epidural space at the level of the C3 pedicles.
This could
represent atypical disc material or a nerve sheath tumor.
Suggest cervical
spine MRI with and without contrast for further evaluation.
EEG
IMPRESSION: This is a normal EEG during the waking and drowsy
states. There
were no focal abnormalities or epileptiform discharges.
Brief Hospital Course:
Ms. ___ is a ___ yo RHW with PMH of HTN, HLD, afib (not on
coumadin or aspirin)who presented to the ED from home after she
was found by her friend/assistant to be confused this morning
with repeated questions and difficulty remembering recent
events.
# Neuro: She could not remember any specific triggering events
but felt "off" since waking up. Her friend reports that she
continued to ask questions multiple times and did not then
remember the answers. She has Afib, but is not anticoagulated
and was taken off of aspirin after a colectomy reversal 4 months
ago and not restarted. On examination in ED, there was no
evidence of visual field deficit, but she is unable to recall
any of the 3 words given during the examination. She has b/l
upper and lower extremity weakness and brisk reflexes likely due
to myelopathy. Given her Afib there is a possibility of an
embolic stroke in the PCA territory. Other etiology is transient
global amnesia or a partial seizure. She was admitted for
further work up. MRI brain was obtained which ruled out
ischemic infarct. Stroke risk factors were checked, HbA1c 5.6.
and LDL 85. Did increase aspirin from 81mg to 325mg given afib
and risk for stroke. EEG did not show any epileptiform
activity. Morning after admission, Ms. ___ was unable to
recall events leading up to hospitalization. She does report
she has been under a lot of stress recently. Ms. ___
recently married and her husband is ___ as is his
family. Patient was in charge of cooking intricate meals for
the recent many Jewish holidays. This was very stressful for
her as though she is Jewish, she was not brought up extremely
religious and felt pressures to meet high expectations for her
new family. Given recent stressors and ruled out stroke and
seizure, most likely diagnosis is transient global amnesia. Less
likely is TIA.
# CV: Will have TTE as outpatient to complete stroke w/u as she
is at risk given afib, not on anticoagulation.
TRANSITIONS OF CARE:
- will obtain TTE
- will f/u in neurology clinic
Medications on Admission:
Citalopram 20 mg daily
Clonazepam 1 mg at bedtime
Lunesta 3 mg PRN insomnia
Fluticasone
Folic Acid
Metoprolol 12.5 TID
Ranitidine 150 mg BID
Vit B12
Vitamin D
Discharge Medications:
1. Aspirin 325 mg PO DAILY
RX *aspirin [E.C. Prin] 325 mg 1 tablet(s) by mouth daily Disp
#*120 Tablet Refills:*1
2. Citalopram 20 mg PO DAILY
3. Clonazepam 1 mg PO QHS:PRN insomnia
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Ranitidine 150 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Transient Global Amnesia (TGA)
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 neurology service for a complaint of
confusion. It seems as though you had what we call transient
global amnesia or TGA. You had an MRI of the brain which did not
show a stroke. You also had an EEG which showed that you did not
have a seizure. You were placed back on an aspirin 325 mg daily
for primary stroke prevention since you have Atrial
fibrillation. We would also like you to have an ultrasound of
your heart.
We have made the following changes to your medications:
INCREASE Aspirin to 325mg daily
You should follow up with neurology in the next ___ months to
ensure everything is going well.
It was a pleasure taking care of you, we wish you all the best!
Followup Instructions:
___
|
10835819-DS-16
| 10,835,819 | 27,759,377 |
DS
| 16 |
2115-03-09 00:00:00
|
2115-03-09 19:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
clindamycin / pemoline / epinephrine / hydrochlorothiazide /
lincomycin / Penicillins / Tetracyclines / bee venom protein
(honey bee) / chocolate flavor / erythromycin base / peanut /
peanut oil / theophylline / amiodarone
Attending: ___.
Chief Complaint:
Tachypnea, dyspnea
Major Surgical or Invasive Procedure:
- CVL placed ___
- CVL replaced/re-sited ___
- CT placed ___ for PTX
- Extubated ___
- Bronch ___
History of Present Illness:
___ yo F with history of asthma, CAS, T2DM schizo-affective
disorder, bipolar disorder, attention deficit hyperactivity
disorder, who presented to ___ from her nursing home
with palpitations, shortness of breath, and chest discomfort.
Per ED records: At ___, she was found to be tachycardic and
febrile to 102.3. She was also noted to be hypotensive requiring
levophed. She was given nebulizers, which helped with her
shortness of breath, and was started on vancomycin and cefepime.
CTA was negative for PE. ECG showed sinus tachycardia with new
ECG changes and trop of 0.08, so she was started on aspirin and
heparin drip. She was transferred to ___ for further workup.
At ___, she reported chronic sweating and insomnia that have
been significantly getting worse. She reported chest discomfort,
palpitations, shortness of breath over the last couple of
months, also progressively getting worse. She has pain all over,
and reports worsening confusion. She tells was recently admitted
to ___ for up-titration of Namenda (Memantine) for
early Alzheimer and dementia.
There was an initial concern for ACS given trop leak and ECG
changes. Seen by cards fellow, no concern for type 1 ACS, likely
demand from tachycardia and possibly pre-existing CAD.
Per OSH records: Patient presented from nursing home with fever,
chest pain, and hypotension. She has had a recent psych
admission. EKG there showed lateral STDs. Fever to 102.8. She
was given heparin and aspirin. CTA there negative for PE,
bedside echo with good systolic fxn and no effusion. She
received Lasix for pulm edema. She also received levophed for
hypotension to 62/33. She was given cefepime and vanc. Her
Bilirubin there was 1 with an alk phos of 187, AST 31, ALT 42.
BNP 1624
Per nursing home referral form: patient was anxious and
agitated, stating "I want to go to the hospital". She yelled and
screamed in hallway, then complained of stomach pain.
In the ED, initial VS were: 98.0 120 163/68 20 93% 2L NC
Exam notable for: Her volume status shows crackles in the lungs
and JVP ~9.
ECG: sinus tach with likely LVH and strain
Labs showed:
WBC 10.7 H/H 11.0/34.0 Platelets 185
N:81.6 L:6.6
Na 134 K 4.7 Cr 0.7
Ca: 8.8 Mg: 1.8 P: 2.7
___: 13.9 PTT: 37.3 INR: 1.3
Hapto: 103
TSH:0.02 T4: 11.0 T3: 165
ALT: 30 AP: 158 Tbili: 1.6 Alb: 4.0
AST: 35 LDH: 309 Dbili: 0.5
GGT:371
proBNP: 2664
CK: 64 MB: 6
Lactate: 2.6 -> ___
FluAPCR: Negative
FluBPCR: Negative
Imaging showed: No PE per OSH CTA read, some edema
Patient received: IV heparin gtt
Transfer VS were: 0 124 ___ 25 95% RA
On arrival to the floor, patient reports that she restarted
smoking and then caught a cold, which made her asthma worse. She
has had increased cough with sputum x ___ days. She has had a
mild sore throat but no runny nose. She complains it's dry. She
endorses fevers. She currently has no chest pain or dizziness.
She endorses lower abdominal pain that is improved on arrival to
the floor. It's not worse with eating.
She states she's been on a diet and has lost 30lbs in 1 month by
eating 1 meal per day. She endorses constipation and chronic
neuropathy. She endorses being raped by staff members at her
nursing home and would like to be discharged to a safer
location. She denies SI/HI but does say she's struggling
mentally.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
Anemia
B12 deficiency
Borderline personality
CAD
Chronic laryngitis
Depression
T2DM
GERD
Fibromyalgia
Female stress incontinence
HTN
Iron deficiency
PTSD
Schizophremia
Venous insufficiency
Aortoiliac occlusive disease
Tobacco use
Dizziness
Social History:
___
Family History:
- Two sisters ___ and ___, brother ___
___:
ADMISSION PHYSICAL EXAM:
VS: 98.2 PO 116 / 62 120 24 95 RA
GENERAL: Tachypneic and profoundly diaphoretic. Conversant,
A&Ox3
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, nonpalpable thyroid
HEART: Rapid rate, + murmur
LUNGS: CTAB
ABDOMEN: nondistended, mildly tender in lower abdomen,
significantly tender in RUQ neg ___ (limited by obesity) no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
DISCHARGE PHYSCIAL EXAM:
VS: Temp: 98.2 PO BP: 117/69 Lying HR: 65 RR: 18 O2
sat: 95% O2 delivery: Ra
GENERAL: Alert to person and place. No acute distress. Resting
comfortably in bed.
CARDIAC: RRR, no g/r. 2+ holosytolic murmur.
LUNGS: CTAB, decreased anterior rales, soft expiratory ronchi.
ABDOMEN: Bowel sounds present, non-tender, distended, no rebound
or guarding.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally. No petechial, clear nail beds. Extremities warm and
dry.
SKIN: Warm. No rash. Multiple scares from cuts on both arms b/l,
legs b/l.
NEURO: A&O to person, place and date. Pt is aware brother ___
and Sister ___ are coming today. CNII-XII grossly intact. ___
___ strength.
PSYCH: Pt is now perseverating on her prior psych medications.
She says she took them to help her "think clearer."
Pertinent Results:
ADMISSION:
___ 05:35PM BLOOD WBC-10.7* RBC-3.62* Hgb-11.0* Hct-34.0
MCV-94 MCH-30.4 MCHC-32.4 RDW-15.2 RDWSD-52.4* Plt ___
___ 05:35PM BLOOD Neuts-81.6* Lymphs-6.6* Monos-10.6
Eos-0.1* Baso-0.2 Im ___ AbsNeut-8.70* AbsLymp-0.70*
AbsMono-1.13* AbsEos-0.01* AbsBaso-0.02
___ 05:35PM BLOOD ___ PTT-37.3* ___
___ 05:35PM BLOOD Glucose-294* UreaN-11 Creat-0.7 Na-134*
K-4.7 Cl-96 HCO3-23 AnGap-15
___ 05:35PM BLOOD ALT-30 AST-35 LD(LDH)-309* CK(CPK)-64
AlkPhos-158* TotBili-1.6* DirBili-0.5* IndBili-1.1
___ 05:35PM BLOOD Lipase-9 GGT-371*
___ 05:35PM BLOOD CK-MB-6 proBNP-2664*
___ 05:35PM BLOOD Albumin-4.0 Calcium-8.8 Phos-2.7 Mg-1.8
___:35PM BLOOD TSH-0.02*
___ 05:35PM BLOOD T4-11.0 T3-165
___ 05:43PM BLOOD ___ pO2-32* pCO2-38 pH-7.42
calTCO2-25 Base XS--1 Intubat-NOT INTUBA
___ 05:43PM BLOOD Lactate-2.6*
___ 04:31PM BLOOD O2 Sat-91
NOTABLE:
___ 12:44AM BLOOD %HbA1c-6.3* eAG-134*
___ 04:40AM BLOOD RheuFac-54*
___ 01:57AM BLOOD ___
___ 05:55AM BLOOD PEP-NO SPECIFI IgG-696* IgA-169 IgM-191
IFE-NO MONOCLO
___ 04:04PM BLOOD HIV Ab-NEG
___ 04:45PM BLOOD CMV VL-NOT DETECT
___ FUNGITELL(R) ___ 102 H Positive A
___ Galactomannan Not Detected
___ ___ BCR ABL1 Not Detected
___ BCR ABL1 Not Detected
___ RPR negative
___ A. PHAGOCYTOPHILUM IGG <1:64
A. PHAGOCYTOPHILUM IGM <1:20
___ anti-CCP negative
MICRO:
___ 8:29 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
**FINAL REPORT ___
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final ___:
CYTOMEGALOVIRUS . PRESUMPTIVE IDENTIFICATION.
Reported to and read back by ___ AT 15:12 ON
___.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
___:
Negative for Cytomegalovirus early antigen by
immunofluorescence.
Refer to culture results for further information.
___ 8:29 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
ADD ON REQUEST PER ___. ___ (___) ON ___.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
TEST CANCELLED, PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
Immunofluorescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final ___:
QUANTITY NOT SUFFICIENT.
TEST NOT PERFORMED.
Reported to and read back by ___. ___ (___ 1600
___.
ACID FAST CULTURE (Final ___:
QUANTITY NOT SUFFICIENT.
TEST NOT PERFORMED.
Reported to and read back by ___. ___ (___ 1600
___.
___ 4:25 am BLOOD CULTURE Source: Line-aline.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ ON ___ @
10:40AM.
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PENDING
INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
___ URINE Legionella Urinary Antigen -FINAL
INPATIENT
___ URINE URINE CULTURE-FINAL
___ 10:10 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM POSITIVE RODS.
Anaerobic Bottle Gram Stain (Final ___: GRAM
POSITIVE ROD(S).
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. Normal
gallbladder.
___ CXR:
In comparison with study of ___, there is
enlargement of cardiac silhouette with pulmonary vascular
congestion, especially in the central regions. More focal
opacification in the right mid and upper zone would be worrisome
for superimposed aspiration/pneumonia in the appropriate
clinical setting.
___ CT A/P without contrast:
1. Atelectatic/consolidative changes at both lung bases, with
bilateral small pleural effusions. Clinical correlation for
underlying pneumonia is
recommended.
2. No acute intra-abdominal pathology.
3. Hepatic steatosis, with mild splenomegaly
___ TTE:
hyperdynamic left ventricle with marked systolic anterior motion
of the mitral valve resulting in severe mitral regurgitation and
at least moderate resting left ventricular outflow tract
obstruction.
___ Bilateral ___:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ RUQ 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. 1.5 x 0.8 x 1.4 cm isoechoic lesion in segment 4B is
incompletely
characterized, but may represent atypical hemangioma. Follow-up
of this
lesion should be performed via ultrasound in approximately 3
months. If
definitive characterization is desired, MRI of the liver should
be pursued.
RECOMMENDATION(S): Ultrasound of the liver is required in
approximately 3
months. If definitive characterization is desired, MRI of the
liver should be
pursued.
___ Bilateral UENI:
1. No evidence of deep vein thrombosis in the bilateral upper
extremity veins. Nonvisualization of the left internal jugular
vein due to patient positioning.
2. Occlusive thrombus in the right distal cephalic vein is
consistent with
superficial thrombophlebitis.
___ MRI head
1. No imaging evidence for encephalitis or other acute
intracranial
abnormalities. 2. Intermediate/low T1 signal of within portions
of the clivus as well as with the visualized cervical vertebrae.
This most often represents red marrow reconversion in the
setting of anemia, smoking, or chronic systemic illness. An
infiltrative process is less likely. Recommend correlation with
clinical history and laboratory data, in the first instance.
___ CT A/P with contrast:
1. No evidence of enteritis or colitis. No abscess.
2. Hepatosplenomegaly.
___ CT chest with contrast:
Diffuse patchy areas of ground-glass and parenchymal
opacification scattered throughout both lungs can be seen in the
setting of ARDS. Superimposed multifocal pneumonia is also
suspected given bilateral hilar and mediastinal lymphadenopathy.
Follow-up chest CT is recommended after treatment to ensure
resolution of lymphadenopathy.
Bilateral pleural effusions and associated atelectasis.
Suspected pulmonary hypertension.
Please see concurrent abdomen and pelvis CT report for
additional findings.
___ TTE:
1) There is a mild LVOT gradient at rest due to basal septal
hypertrophy. There is chordal systolic anterior motion in
setting of inferolaterally directed moderate mitral
regurgitation which raises the
possibility that the mechanism of mitral regurgitation is
valvular systolic anterior motion. However, this has not been
visualized. 2) Normal biventricular regional/global systolic
function.
___ RUQ U/S
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. Gallbladder sludge without cholelithiasis or evidence of
acute
cholecystitis.
___ CTA chest
1. Study is limited for the evaluation of the distal segmental
and
subsegmental branches due to motion artifact. No evidence of
pulmonary
embolism to the level of the proximal segmental arteries or
aortic
abnormality.
2. Diffuse, contiguous ground-glass opacification encompassing
nearly the
entire right and left lungs are noted with areas of ill-defined
nodularity
predominantly noted in the upper lobes bilaterally. There is
interval
resolution of diffuse depend consolidation. Findings are
suspicious for ARDS and/or infection.
3. Interval mildly decreased size of mediastinal and hilar
adenopathy.
4. Interval resolution of bilateral pleural effusions.
5. More focal pulmonary nodule/consolidation in the left lower
lobe measuring 1.2 cm (301:158) may represent a more focal area
of pneumonia, however an underlying malignancy cannot be
excluded. Continued imaging to resolution is recommended.
___ TTE:
The left atrial volume index is moderately increased. There is
mild symmetric left ventricular hypertrophy with a normal cavity
size. There is normal regional left ventricular systolic
function. Quantitative 3D volumetric left ventricular ejection
fraction is 66 %. There is a SEVERE (peak 70 mmHg) resting left
ventricular outflow tract gradient. Moderate pulmonary
hypertension. Normal right ventricular cavity size with normal
free wall motion. The aortic sinus diameter is normal for gender
with normal ascending aorta diameter for gender. The aortic arch
diameter is normal. The aortic valve leaflets (3) appear
structurally normal. There is no aortic valve stenosis. The
increased velocity is due to high stroke volume. There is no
aortic regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse. There is valvular
systolic anterior motion (___). There is moderate to severe [3+]
mitral regurgitation. The tricuspid valve leaflets appear
structurally normal. There is physiologic tricuspid
regurgitation. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
___ CT Abdomen w/ IV and PO contrast
1. No evidence of infection or hemorrhage.
2. Area of hypoenhancement in the lower pole of the left kidney
is likely
evolving focal ischemia.
3. Enteric tube is seen with tip in the stomach but side-port
just a few cm
beyond the GE junction. Would advance the tube at least 5 cm.
4. Please see the separate report for the same day CT chest for
intrathoracic
findings.
___ CT Chest w/ contrast
Increasing mediastinal lymphadenopathy. Stable diffuse
ground-glass opacities
with a subtle reticular component. New bilateral anterior upper
lobe
consolidations without evidence of fibrotic changes. New
bilateral pleural
effusions, small on the right and minimal on the left.
___ TTE
There is normal regional left ventricular systolic function. No
thrombus or mass is seen in the left ventricle. Overall left
ventricular systolic function is normal. The right ventricle has
normal free wall motion. There is abnormal septal motion c/w
conduction abnormality/paced rhythm. The aortic valve leaflets
(?#) appear structurally normal. No masses or vegetations are
seen on the aortic valve. The
mitral valve leaflets appear structurally normal with no mitral
valve prolapse. No masses or vegetations are seen on the mitral
valve. No masses/vegetations are seen on the pulmonic valve. The
tricuspid valve leaflets appear structurally normal. No
mass/vegetation are seen on the tricuspid valve. There is no
pericardial effusion. Color doppler was not performed for
assessment of valvular regurgitation. Color doppler was not
performed for assessment of valvular regurgitation.
DISCHARGE LABS:
==============
___ 10:08AM BLOOD WBC-12.2* RBC-2.83* Hgb-7.6* Hct-26.7*
MCV-94 MCH-26.9 MCHC-28.5* RDW-17.8* RDWSD-59.7* Plt ___
___ 10:08AM BLOOD ___ PTT-28.5 ___
___ 10:08AM BLOOD Glucose-236* UreaN-9 Creat-0.7 Na-134*
K-4.4 Cl-95* HCO3-27 AnGap-12
___ 07:25AM BLOOD Calcium-9.1 Phos-4.5 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ yo F with history of asthma, schizo-affective
disorder, bipolar disorder, PTSD, CAD, T2DM, attention deficit
hyperactivity disorder who presented from her nursing home with
palpitations, shortness of breath, and chest discomfort and was
initially admitted to the medicine floor due to concern for
pneumonia and sepsis on ___. The patient was transferred to the
MICU on ___ due to concern for acute hypoxic respiratory
failure in the setting of sepsis and shock.
HOSPITAL COURSE BY PROBLEM:
===============================
# ACUTE HYPOXEMIC RESPIRATORY FAILURE, resolved
# SEPTIC SHOCK, resolved
# ARDS, resolved
Patient presented with dyspnea and chest discomfort with
subsequent worsening of her respiratory status and development
of bilateral opacities consistent with ARDS. Upon transfer to
ICU, she had shock requiring levophed. Initial imaging
suggestive of PNA so this was presumed trigger. She was
intubated and treated for HCAP (vanc/cefepime/azithro narrowed
to ceftaz/azithro. Viral respiratory panel was negative. CMV
culture from an initial bronchioalveolar lavage was positive
although unclear if contaminant as no evidence of CMV inclusion
bodies and CMV IgM was negative. Sputum cultures were negative.
She was extubated ___.
# Hospital Acquired Pneumonia
After transfer from MICU to floor on ___, ___ developed
fevers and rising leukocytosis with tachypnea. A repeat CT
torso was performed on ___ showing new bilateral anterior upper
lobe consolidations. The patient had increasing O2 requirement,
saturating in the low ___ on room air w/ physical exam
significant for rales in the anterior lung fields and a
leukocytosis that peaked at 19. Given pt's persistent fever and
leukocytosis, her presentation was initially unclear whether
this represented volume overload vs a new infection. She was
gently diuresed. She was also started on a 7 day course of
Cefepime on ___, with end of therapy ___. Her rales, o2
requirement, and fever resolved with antibiotic treatment.
# RECURRENT FEVERS, resolved
As above, patient initially admitted with fevers, attributed to
pneumonia. However given persistence of fevers throughout MICU
stay, she underwent a thorough infectious work up. Her
infectious work up was notable for only one blood culture
growing coag negative staph, thought to be a contaminant. She
had negative sputum cultures, urine cultures, C diff testing,
and mycolytic blood cultures. EBV DNA was elevated likely
represents reactivation in critical illness. A bronchealveolar
lavage on admission grew CMV in culture, but ID felt this did
not represent an active infection. Beta Glucan elevated, though
unclear significance. Lyme, anaplasma, babesia negative.
Rheumatologic work-up including ___, ANCA negative. RF mildly
elevated, likely nonspecific. In terms of malignancy workup,
pleural fluid cytology from bronch was negative, peripheral
smear negative. Heme/onc consulted, recommend flow cytometry for
BCR-ABL which was negative. In addition, two peripheral blood
smears were not suggestive of malignancy. There was also concern
for drug fever so all new medications (antibiotics, sedatives,
etc) were discontinued or changed and most home medications were
held as well. Her last fever was on ___ at which time a new
nosocomial HAP was diagnosed as above, but resolved with
treatment of HAP with Cefepime.
# MITRAL REGURGITATION
# HYPOTENSION
# HYPERTROPHIC CARDIOMYOPATHY ___
Patient with evidence of new LVOT obstruction on transthoracic
echo. Patient must maintain in a narrow therapeutic volume
window to avoid pulmonary edema and adequate preload for cardiac
output. Metoprolol was uptitrated on the floor to maintain a
target HR in the ___. She remained hemodynamically stable and
non-hypotensive/non-bradycardic during her stay on the general
medicine floor. Cardiology was consulted: they recommended
outpatient follow up and potentially ICD placement as
outpatient.
# PARANOID SCHIZOPHRENIA
# TOXIC METABOLIC ENCEPHALOPATHY
# SUNDOWNING
# HYPOACTIVE DELIRIUM, SCHIZOAFFECTIVE DISORDER:
Patient with significant psychiatric history at baseline. Her
extensive home regimen was held due to concern for contribution
to encephalopathy and possible drug fever. Medications were
introduced with the assistance of psychiatry. Encephalopathy
likely multifactorial given infections, prolonged ICU stay and
underlying psychiatric disorder. While in the ICU, she was
valuated by psychiatry on ___, suspected flat affect at the
time represented a hypoactive delirium. They did not recommend
restarting her home medications given risk of polypharmacy and
given that these medications usually treat positive symptoms of
schizophrenia. Previously evaluated with EEG and MRI, without
seizure or acute pathology. Pt was continued on depakote. Psych
was reconsulted while on the floor and olanzapine 7.5mg qHS,
olanzapine 2.5 qAM were added for agitation. All other home
psych medications (includes memantine, atemoxetine, fluoxetine,
lamotrigine, Haldol decanoate) were held. Ramelteon was given
for sleep/wake cycle optimization.
# Left Renal Hypoenhancement
# Ischemia/infarct of the left kidney
# Paroxysmal afib
CT Abd findings from ___ were significant for a focal area of
hypoenhancement in the lower pole of the L kidney. Given her
hypoenhancement is wedgeshaped, this likely indicated an embolic
source. TTE from ___ was negative for vegetations or thrombi.
The patient was previously in AFib with RVR while in the MICU.
It was unclear whether this renal finding could have represented
a cardiogenic emboli from her afib. Her afib was through to be
secondary to her sepsis and this was transient only lasting some
days. Se was in normal sinus rhythm on the floor.
Anticoagulation was discussed with her family but they declined
this given concern for bleeding given patient's past self
harm/cutting behavior. They would like to continue to think
about anticoagulation but defer this to the outpatient setting.
# MALNUTRITION
# DYSPHAGIA:
Patient's dentures were lost during floor to MICU transfer. She
was hesitant to uptitrate her diet with SLP given she lacked her
dentures. SLP recommended ground solids and thin liquids with
aspiration precautions, with strict 1:1 supervision.
TRANSITIONAL ISSUES
==================
- Antibiotic course: Cefepime 2g IV Q12H, end of 7 day course
for HAP on ___. Patient discharged with peripheral IV to
complete course. Please remove IV after course completes on
___.
- Please ensure patient follows with cardiology as scheduled for
her LVOT and HCM. She was discharged on metoprolol for rate
control, goal HR ~60s. She also has mitral regurgitation on TTE
and had paroxysmal afib in ICU. She was initially treated with
amiodarone load but this was stopped in ICU given c/f possible
adverse effect of transaminitis. Family deferred anticoagulation
for her pAF given history of self harm behavior but should
continue discussion with family re anticoagulation as an
outpatient.
- SLP recommendations:
1. Diet: GROUND SOLIDS and THIN LIQUIDS
2. Medications: whole with liquids
3. Aspiration Precautions
-1:1 supervision during meals
-upright positioning
4. Frequent oral care (Q4)
- Please ensure patient has follow up with outpatient
psychiatrist. Discharged on Valproic Acid ___ mg PO Q12H,
OLANZapine 2.5 mg PO QD and 7.5 mg PO QHS, and ClonazePAM 0.5 mg
PO/NG BID:PRN Agitation.
- Patient had frequent platelet clumping on lab draws but no
thrombocytopenia on discharge. Has hepatosplenomegaly.
- CT chest on ___ notable for increasing mediastinal
lymphadenopathy, likely reactive.
- CT chest on ___ notalbe for focal pulmonary nodule in the
left lower lobe measuring 1.2 cm may represent a more focal area
of pneumonia, however an underlying malignancy cannot be
excluded. Would recommend repeat CT chest in 4 weeks.
- BCx drawn on ___ (anaerobic bottle only) grew GP Rods 6 days
later, reported on ___ suspected to likely be a contaminant but
will need to follow final speciation.
- Discharged on glargine for diabetes; previously only on
metformin. Metformin restarted on discharge, would monitor for
hypoglycemia.
- Would repeat CBC ___. Discharge Hbg 7.4 felt to be
secondary to chronic disease and phlebotomy from prolonged
hospital course.
- Patient below her baseline functioning but was hestitant to
participate in ___. Would benefit from additional ___ as
tolerated by her.
>30 minutes in patient care and coordination of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. FLUoxetine 80 mg PO DAILY
3. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
4. Lisinopril 5 mg PO DAILY
5. montelukast 10 mg oral QAM
6. Vitamin D 1000 UNIT PO DAILY
7. atomoxetine 120 mg oral DAILY
8. ClonazePAM 0.5 mg PO BID
9. Memantine 5 mg PO BID
10. Haloperidol Decanoate (long acting) 100 mg IM EVERY 4 WEEKS
(___)
11. Haloperidol Decanoate (long acting) 75 mg IM EVERY 4 WEEKS
(FR)
12. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
13. Metoprolol Tartrate 25 mg PO BID
14. Gabapentin 300 mg PO BID
15. OxyCODONE (Immediate Release) 10 mg PO Q8H
16. LamoTRIgine 175 mg PO QHS
17. OLANZapine 20 mg PO QHS
18. Simvastatin 20 mg PO QPM
19. Ferrous Sulfate 325 mg PO BID
20. Lactulose 30 mL PO BID
21. Docusate Sodium 100 mg PO DAILY
22. MetFORMIN (Glucophage) 500 mg PO BID
23. Bisacodyl ___AILY:PRN constipation
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. CefePIME 2 g IV Q12H HCAP
3. Glargine 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. OLANZapine (Disintegrating Tablet) 2.5 mg PO DAILY
5. Ramelteon 8 mg PO QHS insomnia
6. Valproic Acid ___ mg PO Q12H
7. ClonazePAM 0.5 mg PO BID:PRN Agitation
RX *clonazepam 0.5 mg 1 tablet(s) by mouth twice a day as needed
for anxiety Disp #*6 Tablet Refills:*0
8. Metoprolol Tartrate 25 mg PO Q6H Hypertrophic
Cardiomyopathy/ Left Ventricular Outflow Tract Obstruction
9. OLANZapine 7.5 mg PO QHS
10. Bisacodyl ___AILY:PRN constipation
11. Docusate Sodium 100 mg PO DAILY
12. MetFORMIN (Glucophage) 500 mg PO BID
13. Simvastatin 20 mg PO QPM
14. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
15. Vitamin D 1000 UNIT PO DAILY
16. HELD- atomoxetine 120 mg oral DAILY This medication was
held. Do not restart atomoxetine until you are told to by a
doctor.
17. HELD- Ferrous Sulfate 325 mg PO BID This medication was
held. Do not restart Ferrous Sulfate until you are told to by a
doctor.
18. HELD- FLUoxetine 80 mg PO DAILY This medication was held.
Do not restart FLUoxetine until you are told to by a doctor.
19. HELD- Gabapentin 300 mg PO BID This medication was held. Do
not restart Gabapentin until you are told to by a doctor.
20. HELD- Incruse Ellipta (umeclidinium) 62.5 mcg/actuation
inhalation DAILY This medication was held. Do not restart
Incruse Ellipta until you are told to by a doctor.
21. HELD- Lactulose 30 mL PO BID This medication was held. Do
not restart Lactulose until you are told to by a doctor.
22. HELD- LamoTRIgine 175 mg PO QHS This medication was held.
Do not restart LamoTRIgine until you are told to by a doctor.
23. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until you are told to by a doctor.
24. HELD- Memantine 5 mg PO BID This medication was held. Do
not restart Memantine until you are told to by a doctor.
25. HELD- montelukast 10 mg oral QAM This medication was held.
Do not restart montelukast until you are told to by a doctor.
26. HELD- Omeprazole 20 mg PO DAILY This medication was held.
Do not restart Omeprazole until you are told to by a doctor.
27. HELD- OxyCODONE (Immediate Release) 10 mg PO Q8H This
medication was held. Do not restart OxyCODONE (Immediate
Release) until you are told to by a doctor.
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
#Acute hypoxic respiratory failure
#Sepsis
#Hypertrophic Cardiomyopathy with Left Ventricular Outflow Track
Obstruction
#Schizoaffective disorder
#Acute on Chronic Anemia
___ acquired pneumonia
#Hospital acquired pneumonia
#Malnutrition
#Ischemia and infarction of the kidney
#Atrial fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
WHY WAS I IN THE HOSPITAL?
You were in the hospital because you had fevers, were
confused, and were having difficulty breathing.
WHAT HAPPENED TO ME IN THE HOSPITAL?
You were treated on the general medicine floor and a special
critical care unit for very sick patients.
You were treated for pneumonia.
You were very weak and briefly needed a feeding tube for
nutrition but this was removed
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
Continue to take all your medications as prescribed.
Follow up with your psychiatrist.
You will need to see a cardiologist after discharge. Please
see below.
We wish you the best!
Your ___ Team
Followup Instructions:
___
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2160-11-20 00:00:00
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2160-11-20 13:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
barium sulfate
Attending: ___.
Chief Complaint:
Lightheadedness, chest pain, blurry vision
Major Surgical or Invasive Procedure:
___ Left craniotomy for tumor resection
History of Present Illness:
___ is a ___ year old female with hx of drop attacks
who presents with complaints of lightheadedness and chest pain.
She is an inconsistent historian. History is obtained from
patient and medical records. She began having unprovoked
episodes of falling ___. She underwent further workup by ___
Neurology in ___ with MRI/MRA, EEG, and cardiac workup. Per
records, MRI/MRA were negative for abnormality. EEG showed
slowing but no epileptiform discharges. Holter monitor showed
some abnormal rhythm but she was asymptomatic during those
times. It was determined these episodes were consistent with
drop attacks of unknown etiology. Due to poor cognition and
unclear baseline upon presentation to ___, she underwent NCHCT
that was significant for brain lesion, edema and MLS. She was
started on Dexamethasone and Keppra and Neurosurgery was
consulted for further recommendations. At time of examination,
she endorses right-sided upper chest pain. When questioned she
endorses vision loss for the past ___ months and intermittent
numbness in the right hand. She denies headache, nausea,
vomiting, and weakness. Of note, CXR completed in the ED was
significant for a right apical lung lesion 8.3 x 7.1cm with
chest wall invasion and bony destruction.
Past Medical History:
COPD
Drop Attacks
Social History:
___
Family History:
Unknown, unable to obtain
Physical Exam:
On admission
============
O: T: 97.8 BP: 135/79 HR: 88 R: 20 O2Sats: 99% RA
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic, atraumatic
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm-3mm
bilaterally. Visual fields are difficult to asses but indicate a
possible right homonymous hemianopia.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: decreased bulk and normal tone bilaterally. No abnormal
movements, tremors. Strength full power ___ throughout with the
exception of the right tricep which is 4+/5.
+ right pronation on drift testing
Sensation: Intact to light touch bilaterally.
Coordination: + dysmetria on right finger-nose-finger
============
On Discharge
============
She is A&Ox3 - answering questions appropriately. PERRL with
EOM's intact. ___. No drift. RUE with delt/tris 4+/5 with
remaining groups ___ in strength and equal. She is ambulating
around room independently with steady gait. She uses a walker
with wheels for ambulating long distances.
Her sutures are intact with no s/s of infection, no redness,
swelling or discharge noted.
Pertinent Results:
Please see OMR for all labs and imaging.
Brief Hospital Course:
___ year old female with history of drop attacks, presents with
lightheadedness, chest pain and vision changes. CT scan revealed
Left parieto-occipital brain lesion with MLS and a large right
apical lung mass.
#Left parieto-occipital brain lesion
Patient was admitted to ___ from Emergency Room for further
management. She was started on keppra, dexamethasone. She went
to the OR on ___ for L craniotomy for tumor resection, which
was uncomplicated; please see full operative note in OMR for
further detail. Her neurological exam improved postoperatively,
and remained stable while in the ___. She was transferred to
the floor. She continued to stay neurologically stable while
hospitalized and was deemed stable for discharge home with
outpatient follow up. She will follow up in office and brain
tumor conference for further oncologic follow up. She will
remain on Keppra and Dexamethasone until follow up.
Neuro-oncology and radiation oncology were consulted for
treatment planning. She was seen and examined by Physical
therapy and occupational therapy and was cleared for discharge
home. Case management was able to facilitate visiting nurses for
home care and social work helped to set up medical
transportation for patient's follow up appointments.
#Agitation
On ___ patient became increasingly agitated and upset that
she could not smoke. She was offered a nicotine patch and
attempted to deescalate patient. Patient threated to leave
against medical advice however, psychiatry was consulted to
assess if she had capacity to make her own decisions. It was
deemed by psychiatry that she is unable to demonstrate adequate
decision making capacity regarding testing and
interventions/treatment. She was restrained with bilateral wrist
restraints and given Haldol and ativan. EKG was obtained to
monitor QTC interval. Social work was consulted. Her agitation
cleared over the next few hours. Social work helped to
facilitate the naming and authorization of a Health Care Proxy.
On ___, psychiatry re-evaluated the patient and recommended
Remelteon for her insomnia with good effect.
#Right apical lung mass
A CT Scan of Chest was obtained to further investigate lung mass
viewed on Chest-xray. Results showed Large right upper lobe mass
penetrates the chest wall toward the axilla and destroys the
first and second ribs and is concerning for lung primary rather
than secondary neoplasia. Thoracic surgery was consulted and
recommended no intervention as long as tissue would be obtained
from the brain mass.
#Hypertension
She was noted to be hypertensive while hospitalized. She was
started on amlodipine and up titrated to maintain a SBP<160.
Upon discharge she was maintained on 7.5mg amlodipine po daily.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. amLODIPine 7.5 mg PO DAILY
RX *amlodipine 5 mg 1.5 tablet(s) by mouth once a day Disp #*45
Tablet Refills:*0
3. Codeine Sulfate ___ mg PO Q6H:PRN pain
RX *codeine sulfate 15 mg ___ tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
4. Dexamethasone 2 mg PO Q12H
This is the maintenance dose to follow the last tapered dose
RX *dexamethasone 2 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
6. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
7. LevETIRAcetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
8. Nicotine Patch 14 mg TD DAILY
9. Senna 17.2 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Multiple Metastatic brain lesions
Right Lung mass
Cerebral Edema
Insomnia
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:
Discharge Instructions
Brain Tumor
Surgery
- You underwent surgery to remove a brain lesion from your
brain.
- You underwent a biopsy. A sample of tissue from the lesion in
your brain was sent to pathology for testing.
- Please keep your incision dry until your sutures are removed.
- You may shower at this time but keep your incision dry.
- It is best to keep your incision open to air but it is ok to
cover it when outside.
- Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
- We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
- You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
- No driving while taking any narcotic or sedating medication.
- No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
***You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
- You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
- You may experience headaches and incisional pain.
- You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
- You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
- Feeling more tired or restlessness is also common.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
- Severe pain, swelling, redness or drainage from the incision
site.
- Fever greater than 101.5 degrees Fahrenheit
- Nausea and/or vomiting
- Extreme sleepiness and not being able to stay awake
- Severe headaches not relieved by pain relievers
- Seizures
- Any new problems with your vision or ability to speak
- Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
- Sudden numbness or weakness in the face, arm, or leg
- Sudden confusion or trouble speaking or understanding
- Sudden trouble walking, dizziness, or loss of balance or
coordination
- Sudden severe headaches with no known reason
Followup Instructions:
___
|
10835840-DS-17
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| 17 |
2160-12-19 00:00:00
|
2160-12-19 14:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
barium sulfate / iodine / Bactrim
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of
idiopathic drop attacks, HTN, COPD not O2 dependent, and ___
diagnosis of metastatic adenocarcinoma of unknown primary to the
brain s/p craniotomy and currently on cyberknife treatment who
presents with chest pain.
THe patient states she has been having chest pain off and on for
past several months. But in the last 24 hours it has become
progressively worse and severe. The pain is currently, and has
always been, in the right upper chest radiating into the axilla,
sharp, stabbing, comes in waves. Not worse with palpation. No
dyspnea associated with it. She denies any cough or fever. No
headache, N/V, diarrhea, abd pain otherwise.
She reportedly has history of iodine ?contrast allergy in past.
However she cannot recall this. She says she has allergy to
barium contrast before, which causes constipation.
Of note on ___ she was sent to ED from ___ for dyspnea,
but this resolved on arrival, so she was sent home.
Patient was seen by new PCP ___ on ___. The patient
is now still waiting for her initial medical oncology and
palliative care appointment (for pain mgmt).
ED: received 40 mg IV solumedrol at 1:30 AM for CTA study
premedication
Past Medical History:
ONCOLOGIC HISTORY:
-She began having unprovoked episodes of falling ___. She
underwent further workup by ___ Neurology in ___ with
MRI/MRA,
EEG, and cardiac workup. On ___ she presented with
lightheadedness and underwent NCHCT that was significant for
left
parieto-occipital brain lesion, edema and midline shift. She
underwent craniotomy with neurosurgery on ___.
-During admission, CT Scan of Chest was obtained to further
investigate lung mass viewed on Chest-xray. Results showed Large
right upper lobe mass penetrates the chest wall toward the
axilla and destroys the first and second ribs and is concerning
for lung primary rather than secondary neoplasia. Thoracic
surgery was consulted and recommended no intervention as long as
tissue would be obtained from the brain mass.
-Brain biopsy reveals metastatic adenocarcinoma, although stains
nondiagnostic for primary site.
-___ The brain MRI from shows a total of 6 lesions in
addition
to the cavity. She begins cyberknife treatment.
OTHER PAST MEDICAL HISTORY:
COPD
Drop Attacks, idiopathic
HTN
Social History:
___
Family History:
Relative Status Age Problem Onset Comments
Mother Living ___
Father ___
Sister Living
Brother Living
Physical ___:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
CV: Heart regular, no murmur. No reproducible tenderness to
palpation on chest.
RESP: Lungs clear to auscultation
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
PSYCH: pleasant, appropriate affect
NEUROLOGIC:
MENTATION: alert and cooperative. Oriented to person and place
and time.
Examined on day of discharge -- AVSS, though her SBP dropped
from ~145 to 120 while standing. Otherwise, no notable changes.
Pertinent Results:
LABORATORY RESULTS:
___ 07:20AM BLOOD WBC-7.7 RBC-3.39* Hgb-11.0* Hct-32.9*
MCV-97 MCH-32.4* MCHC-33.4 RDW-15.2 RDWSD-54.2* Plt ___
___ 10:51PM BLOOD WBC-7.4 RBC-3.58* Hgb-11.7 Hct-34.2
MCV-96# MCH-32.7* MCHC-34.2 RDW-14.8 RDWSD-52.2* Plt ___
___ 07:20AM BLOOD Glucose-161* UreaN-13 Creat-0.5 Na-135
K-4.0 Cl-94* HCO3-27 AnGap-14
___ 10:51PM BLOOD Glucose-91 UreaN-12 Creat-0.6 Na-132*
K-3.5 Cl-90* HCO3-25 AnGap-17
CTA CHEST
1. No evidence of pulmonary embolism or aortic abnormality.
2. Re-demonstration of 9.0 cm right upper lobe mass with
invasion of the chest
wall destruction of the right second and third ribs similar to
prior.
CT head
1. Status post left parietal craniotomy and resection with
interval
development of encephalomalacia in the resection cavity.
Evaluation for
recurrence in this region is limited on the current modality and
better
assessed with contrast enhanced MRI.
2. Subtle hyperdensity in the left frontal lobe, likely
corresponding with the
known metastatic lesion seen on prior MRI from ___.
Brief Hospital Course:
Ms. ___ was initially admitted with chest pain; a CTA chest
showed no PE, but demonstrated right rib infiltration from her
CA. Her EKG and troponin were likewise not suggestive of
ischemia. Her pain was very pleuritic, and localized over the
rib lesions -- therefore, this was most consistent with cancer
pain. Her symptoms were also dramatically improved after having
a large bowel movement. Her pain was well controlled with her
home dose of oxycodone. She received a single dose of radiation
for her brain metastases while she was an inpatient, and was
placed on a dexamethasone taper as described below. Overall, she
had not been doing well at home -- falling, having difficulty
taking medications. She was evaluated by ___ and OT, and
discharged to a ___.
HOSPITAL COURSE
1. Metastatic adenocarcinoma.
-Dexamethasone taper:
- dexamethasone 2 mg BID until ___ THEN
- dexamethasone 2 mg daily x 10 days THEN
- dexamethasone 1 mg daily x 10 then THEN
- STOP
- outpatient oncology and palliative care follow up
- oxycodone ___ mg q4h PRN
- bowel reg as below
2. FTT
- SNF on discharge
3. Opiate induced constipation
- Daily Miralax
4. Headache. Patient complained of intermittent headache while
inpatient. Neurological exam was unchanged. CT head did not show
any change.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. amLODIPine 7.5 mg PO DAILY
3. Dexamethasone 2 mg PO Q12H
This is the maintenance dose to follow the last tapered dose
4. Docusate Sodium 100 mg PO BID
5. Famotidine 20 mg PO DAILY
6. LevETIRAcetam 500 mg PO BID
7. Nicotine Patch 14 mg TD DAILY
8. Senna 17.2 mg PO QHS
9. DULoxetine 30 mg PO DAILY
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. amLODIPine 7.5 mg PO DAILY
3. Dexamethasone 2 mg PO Q12H
2 mg BID until ___ THEN 2 mg daily x 10 days THEN
1 mg daily x 10 THEN STOP
Tapered dose - DOWN
4. Docusate Sodium 100 mg PO BID
5. Famotidine 20 mg PO DAILY
6. LevETIRAcetam 500 mg PO BID
7. Nicotine Patch 14 mg TD DAILY
8. Senna 17.2 mg PO QHS
9. DULoxetine 30 mg PO DAILY
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth EVery four hours as
needed Disp #*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Faiilure to thrive
Chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with severe chest pain, and not feeling safe
at home. Fortunately, a CT scan showed no blood clot in your
lungs (a pulmonary embolus), and an EKG showed no heart attack.
You were given stool softeners and had a large bowel movement
with dramatic improvement in your symptoms. You will be
discharging to a skilled nursing facility and will follow up
with Dr. ___ as an outpatient for your cancer.
Followup Instructions:
___
|
10836135-DS-14
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2176-05-07 00:00:00
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2176-05-08 09:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
morphine
Attending: ___.
Chief Complaint:
Draining of odorous fluid from prior abdominal port site.
Major Surgical or Invasive Procedure:
___
1) Closure of 10x15 cm full-thickness abdominal wall defect with
bilateral fasciocutaneous advancement flaps.
2) Flexible Bronchoscopy, cleansing and aspiration of right
lower
lobe.
History of Present Illness:
Mrs. ___ is a ___ year old female status post robotic TAH for
endometrial carcinoma approximately 1 mo ago w/ peritoneal
metastasis c/b enterocutaneous fistula s/p ex lap/SBR. On day of
admission, she presented with drainage from one port site. The
patient states that she has been feeling well, no
nausea/vomiting, no fevers or chills. She has been breathing
w/o discomfort. She noticed purulent material draining from her
LUQ port site starting this am during her wound vac change, w/
feculent smell. The drainage hascontinued until her presentation
at the ED today.
Past Medical History:
Past Medical History:
Endometrial CA s/p hysterectomy, EC Fistula s/p SBR, HL, Asthma,
GERD.
Past Surgical History:
Robotic TAH, Ex Lap SB___ in ___.
Social History:
___
Family History:
Father had bladder cancer and passed away at ___ yo. Mother had
DM2 and colon cancer and passed away at ___ yo. 2 siblings,
sister
aged ___ and brother aged ___, healthy to patient's knowledge.
Physical Exam:
On admission:
Physical Exam:
Vitals: 98.2 103 122/58 16 98RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
On discharge:
VS 98.4, 92, 140/70, 14, 95% on room air.
Pertinent Results:
___ 06:01AM BLOOD WBC-9.6 RBC-3.05* Hgb-7.8* Hct-24.8*
MCV-81* MCH-25.7* MCHC-31.6 RDW-18.8* Plt ___
___ 06:10AM BLOOD WBC-8.7 RBC-3.02* Hgb-7.6* Hct-24.1*
MCV-80* MCH-25.3* MCHC-31.6 RDW-19.2* Plt ___
___ 02:00PM BLOOD WBC-9.9 RBC-3.55*# Hgb-8.9*# Hct-28.2*#
MCV-80*# MCH-25.1*# MCHC-31.5 RDW-18.8* Plt ___
___ 02:00PM BLOOD Neuts-81.9* Lymphs-11.1* Monos-5.0
Eos-1.2 Baso-0.7
___ 10:28AM BLOOD Glucose-106* UreaN-5* Creat-0.3* Na-136
K-3.8 Cl-103 HCO3-26 AnGap-11
___ 06:01AM BLOOD Glucose-85 UreaN-5* Creat-0.3* Na-135
K-4.0 Cl-103 HCO3-27 AnGap-9
___ 04:08PM BLOOD Glucose-84 UreaN-5* Creat-0.3* Na-136
K-3.5 Cl-102 HCO3-26 AnGap-12
___ 06:10AM BLOOD Glucose-74 UreaN-6 Creat-0.4 Na-138
K-3.0* Cl-102 HCO3-26 AnGap-13
___ 12:15AM BLOOD Glucose-81 UreaN-7 Creat-0.3* Na-136
K-3.0* Cl-100 HCO3-25 AnGap-14
___ 02:00PM BLOOD Glucose-104* UreaN-6 Creat-0.3* Na-137
K-2.8* Cl-99 HCO3-24 AnGap-17
___ 10:28AM BLOOD Calcium-7.4* Phos-2.4* Mg-1.6
___ 06:01AM BLOOD Calcium-7.3* Phos-2.3* Mg-2.1
___ 04:08PM BLOOD Calcium-7.4* Phos-3.0 Mg-1.3*
___ 06:10AM BLOOD Calcium-7.3* Phos-3.1 Mg-1.4*
___ 05:59PM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:59PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-4* pH-6.0 Leuks-LG
___ 05:59PM URINE RBC-0 WBC-57* Bacteri-FEW Yeast-NONE
Epi-1 TransE-1
IMAGING:
___ CT abdomen and pelvis with contrast
1. Acute partial small bowel obstruction with enteric contrast
passing to
colon and no definite transition point.
2. Complex 4.7 x 3.3 cm collection in the left hemipelvis which
may or may not have a connection to large bowel. 1.7 cm
rim-enhancing collection in pelvis may represent small abscess,
which is too small to drain.
3. Stranding and fluid around gallbladder fundus extending into
right
paracolic gutter without rim-enhancement. Correlate with
bilirubin levels.
4. Mildly rim-enhancing subcutaneous fluid collection in the
left anterior abdominal wall with sinus tract extending to the
midline skin surface.
5. Right lower abdominal wall sinus tract extending into
subcutaneous tissues without definite track to skin surface.
6. Large right Bochdalek hernia.
7. Defect in anterior abdominal wall. Scar tissue or fluid in
anterior
abdominal midline near small bowel.
Brief Hospital Course:
Mrs. ___ was admitted to ___ under the Acute Care Surgery
service. In brief, she presented with feculent discharge coming
from one of her prior port sites (s/p small bowel resection).
On CT imaging, she was found to have a 4.7 x 3.3 cm collection
in the left hemipelvis as well as a 1.7 cm rim-enhancing
collection in the pelvis. There was also a soft tissue defect
in the patient's anterior abdominal wall. The patient was
started on vancomycin and cefepime for empiric antibiotic
coverage. A pre-operative chest x-ray showed concerns for RLL
pneumonia and Mrs. ___ was also started on azithromycin
empirically for pneumonia. She was kept NPO in preparation for
an operative procedure.
On HD 2, Mrs. ___ was taken to the operating room where she
underwent closure of a 10cm by 15cm full-thickness abdominal
wall defect with bilateral fasciocutaneous advancement flaps.
Abdominal fluid was sent for culture and sensitivities. Please
see the operative report for further details. During the
procedure, a bronchoscopy was also conducted due to concerns of
right lower lobe pneumonia. The bronchoscopy was negative for
any acute process. Prior chest x-ray images noting a RLL
infiltrate was likely lobar atelectasis instead. Mrs. ___
was recovered in PACU and transferred to the inpatient ward for
further management and observation.
Post-operatively, Mrs. ___ antibiotics were changed to
ciprofloxacin and metronidazole. She was kept NPO and given
maintenance IV fluids until her bowel function returned. Once
she began to pass flatus and bowel movements, the patient's diet
as advanced from clears to regular, which she tolerated well.
At that time, she was transitioned to oral medications. Her
abdominal fluid sensitivities showed sparse growth of
Enterobacter cloacae which was pan-sensitive to ciprofloxacin;
therefore her metronidazole and azithromycin was discontinued.
Lastly, the patient had no issues voiding and was ambulating
independently.
As previously mentioned, Mrs. ___ was recently diagnosed with
endometrial adenocarcinoma and was being followed by physicians
in ___. Based on this new diagnosis and most recent
surgery, the ___ Oncology service was asked to see this
patient. It was their recommendation that the patient be
treated with chemotherapy (carboplatin plus paclitaxel) once she
recovers from her most recent surgery. It was communicated to
the Oncology team that she should be fine to receive
chemotherapy in approximately 4 weeks.
At the time of discharge, Mrs. ___ was afebrile,
hemodynamically stable and in no acute distress. She was given
follow-up appointments for both the ___ clinic as well as
Oncology. From a surgical perspective, the patient was informed
that she may begin chemotherapy in approximately four weeks from
the time of surgery. The patient was discharged home in the
care of her sister and was given prescriptions for pain
medications as well as antibiotics. Mrs. ___ had an
incidental, bilateral fungal groin infection which was treated
with miconazole cream. She was instructed to continue this
treatment for 5 days or when the infection resolves.
Medications on Admission:
Statin (discontinued)
Provera (from OSH note ___, 10 mg)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*10 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Miconazole 2% Cream 1 Appl TP BID Duration: 5 Days *AST
Approval Required*
RX *miconazole nitrate [Antifungal Cream] 2 % Apply to affected
area twice a day Disp #*15 Gram Refills:*1
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
Full thickness abdominal wall defect subsequent to above with
intra-abdominal abscess, abdominal wall abscess and extensive
exposure of unprotected bowel.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ on
___ due to noted odorous drainage coming from a prior port
site in your abdomen. On further evaluation, you were found to
have an abdominal wall abscess and exposed bowel nearing the
skin surface. You were taken to the operating room on ___ to
have the wound repaired. Two drains were placed during the
procedure. Since that time, one drain has been removed. You
will be going home with one drain in place and you will
follow-up with Dr. ___ in one week (appointment below).
Medications:
*Please continue any pre-admission medications that you were
taking prior to this hospitalization.
* Finish all doses of the antibiotic provided (Cipro). This is
found your wound infection.
* Do not drive or operate heavy machinery while taking narcotic
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.
*Do not lift anything greater than ___ pounds over the next 6
- 8 weeks.
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:
___
|
10836215-DS-17
| 10,836,215 | 27,886,125 |
DS
| 17 |
2144-04-17 00:00:00
|
2144-04-18 18:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
sodium carbonate / aspirin
Attending: ___.
Chief Complaint:
worsened neck and left shoulder pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old gentleman with ESRD on HD MWF, PAF on coumadin,
diastolic CHF (last TTE per ___ records in ___ with normal EF
and mild diastolic dysfunction), CAD, hypertension, ___,
macular degeneration (legaly blind), monoclonal gammopathy, left
craniectomy and cranioplasty (___) for evaluation of newly
discovered left parietal skull lesion (per patient benign) who
was admitted at the end of ___ with altered mental status,
back pain, and weakness and found to have MSSA bacteremia
(likely HD line associated) and MRI compataible with c-spine
osteomyelitis (C7-T1). Few weeks ago was admitted to the ___ with
altered mental status in the setting of hypercalcemia along with
dilirium from narcotics and C diff for which he completed 2 week
course of oral vancomycin). He was treated with Cefazolin dosed
at HD for 8 weeks, which was completed on ___ and discharged
from rehab back to home.
He has had this pain for several weeks and was referred to pain
clinic. States dilaudid is not helping. Pain is no different on
admission day but is more intense. It has been constant with
difficulty sleeping and functioning in general. Also has
tingling on ulnar aspect of hand for 1 week. Denies
fevers/chills, limited Range of motion of his shoulder. Denies
chest pain, SOB, N/V, diaphoresis.
He was seen at ___ this morning because of proximity of the
worsening symptoms to a recent access intervention with no
apparent complications or any sign of steal.
He was also seen by Dr. ___ on ___ for follow-up. Her
impression was that infection was less likely given no fever, no
leukocytosis with clear cultures. Repeating MRI was recommended
but not overnight to look for a new drainable collection
including epidural abscess that would require intervention and
to discuss with neuroradiology about the findings. If none, then
his pain would be attributed to mechanical etiology. It is very
common for patients with osteomyelitis to get pain at this point
in their course as they start to become more active.
.
In the ED, initial vital signs were ___ 95 113/66 16
100%. UA was notable for no bacteria, negative leuks and Nit but
hazy in color. Urine culture pending. Blood cultures were drawn
and pending as well. The ER spoke with Dr. ___ ___)
regarding etiology. This could be malignancy and needs further
work-up. The ER also touched base with his PCP (pager
___ as the patient keeps getting sent to BI and ___. He
agrees with admission to ___. Renal was also contacted, and
they will dialyze in the morning following the day of admission.
Patient was given 1 mg dilaudid IV. Vitals on transfer were: T
98, HR 85, BP 116/65, RR 16 Sat 100%RA pain ___. Admitted for
pain control. Patient reports that fentayl caused him to
hallucinate and dilaudid is too strong.
On the floor, patient reported left shoulder and neck pain that
has been going on for several weeks now. He reported that the
pain got worse and he had to come to the ED. His pain currently
is graded as ___. He is sitting in bed.
Review of sytems:
as in HPI.
Denies chest pain, SOB, DOE, orthopnea, PND, hematochezia,
diarrhea, consitpation, melena, BRBPR, dysuria, hematuria, sore
throat, runny nose, headache.
Past Medical History:
Past Medical History:
1) CAD with ___ PTCA/stenting of PDA
2) Diastolic dysfunction
3) Hypertension, severe
4) DM, type ___ c/b retinopathy, nephropathy, and neuropathy, A1c
8.8% ___
6) Chronic infected diabetic ulcer
7) PAF on coumadin (managed by ___
8) Obstructive sleep apnea
9) Peripheral edema
10) Hyperlipidemia
11) Obesity
12) GERD
13) MGUS
14) ESRD ___ to HTN and DMII - Baseline Cr ~3.5
15) History of C diff ___ (completed 2 weeks of oral
vancomycin ___
16) hypercalcemia
17) Recent VRE UTI treated with course of linezolid
18) diverticulosis s/p hemicolectomy
Social History:
___
Family History:
Father with lung cancer, Mother natural causes and DM ___, 2
brothers with DM ___, sister with breast cancer, hypertension
"everyone".
Physical Exam:
Admission physical exam:
Vitals- 98.3, 124/78, 78 regular, 16, 97%RA, pain ___ BG 166
General- Alert, orientedx3, 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
GU- no foley
Ext- warm, dry skin in lower extremities, 1+ pulses, no
clubbing, cyanosis, edema +1 in the lower extremities
Neuro- CNs2-12 intact, motor function grossly normal
Spine-tender neck and upper thoracic in the midline along with
left upper back tenderness.
Shoulder-left shoulder is tender to palpation, but not swollen,
not tender, impengement syndrome signs are all positive. patient
able to raise arm above the head but with significant pain in
his neck and left shoulder, pain is similar when done passively.
power remains ___ but slightly limited secondary to pain. right
shoulder normal. Slightly reduced muscle bulk of left
hypothenar. relatively more numbness at the left little finger
compared to other fingers but overall intact sensation
bilaterally. hand grip normal bilaterally. intact proprioception
bilaterally.
Discharge physical exam:
Vitals- Tc98.9 Tmax 98.9, 120-158/60-88, 94 regular, 16, 100%RA,
pain ___
General- Alert, orientedx3, 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
GU- no foley
Ext- warm, very dry skin in lower extremities, 1+ pulses, no
clubbing, cyanosis, has trace edema in the lower extremities
Neuro- CNs2-12 grossly intact, motor function grossly normal
Back- No CVA tenderness.
Spine- No tenderness on neck and upper thoracic in the midline
along with left upper back
Elbow- No deformity or atrophy. Tender to palpation along joint.
Some pain with movement. Pain does not radiate.
Shoulder- On inspection, no obvious deformity. No atrophy. Left
shoulder is no longer tender to palpation and not swollen. Pt
able to raise arm above the head but with some pain in his neck
and left shoulder, pain is similar when done passively.
Impengement syndrome signs are all positive-Neer and ___.
Power remains ___ but limited secondary to pain. Right shoulder
normal. Slightly reduced muscle bulk of left hypothenar.
Relatively more numbness at the left little finger compared to
other fingers but overall intact sensation bilaterally. Hand
grip normal bilaterally. Interossei strength ___ bilaterally.
Intact proprioception bilaterally. Vibration intact bilaterally.
Pertinent Results:
Admission labs:
===============
___ 10:30AM BLOOD WBC-8.1 RBC-4.28* Hgb-12.1* Hct-40.3
MCV-94 MCH-28.3 MCHC-30.0* RDW-17.8* Plt ___
___ 10:35PM BLOOD ___ PTT-46.4* ___
___ 10:35PM BLOOD Glucose-108* UreaN-31* Creat-4.4*# Na-139
K-4.3 Cl-101 HCO3-25 AnGap-17
___ 10:35PM BLOOD TotProt-6.5 Calcium-9.5 Phos-5.6*# Mg-2.2
Discharge labs:
===============
___ 07:15AM BLOOD WBC-6.7 RBC-4.21* Hgb-12.1* Hct-39.0*
MCV-93 MCH-28.7 MCHC-31.0 RDW-18.2* Plt ___
___ 07:15AM BLOOD ___ PTT-50.3* ___
___ 07:15AM BLOOD Glucose-108* UreaN-19 Creat-3.4* Na-136
K-4.0 Cl-99 HCO3-26 AnGap-15
___ 07:15AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.9
Other labs:
===========
___ 10:35PM BLOOD PEP-NO SPECIFIC ABNORMALITIES SEEN
Urine:
======
___ 09:09PM URINE U-PEP-NEGATIVE
___ 04:00PM URINE RBC-1 WBC-4 Bacteri-NONE Yeast-NONE Epi-0
___ 04:00PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 04:00PM URINE Color-Yellow Appear-Hazy Sp ___
Microbiology:
=============
Urine culture ___: < 10,000 organism
Blood culture ___: pending
Imaging:
========
MRI C & T spine without contrast: ___
IMPRESSION:
Stable to slightly improved signal abnormality from C6 through
T1 including
the intervening disc spaces. No evidence for progression.
Significant degenerative changes in the cervical spine are
stable.
No significant abnormality in the thoracic spine. Stable focal
rounded lesion at T7 without associated edema. Attention on
followup imaging recommended. No epidural disease or cord
compression in the thoracic spine.
Brief Hospital Course:
___ year old gentleman with past medical history of monoclongal
gammopathy and recent hospitalization at the end of ___ with
MSSA bacteremia (likely HD line associated) and MRI compatiable
with c-spine osteomyelitis (C7-T1) who presented with worsening
of left neck and left shoulder pain with radiation to his hand
(has it for several weeks). He was discharged home in stable
condition with higher dose of dilaudid for pain control.
# Neck/Shoulder/Elbow pain: Initially he had tenderness upon
palpating the cervical spine and upper thoracic along with
tenderness upon palpating the shoulder area. On the day of
discharge, these were not present. The cause of his pain is most
likely secondary to disc/spine pathology. The differential
considered on presentation were an abscess, malignancy, or
fracture. There was less concern about infection or progression
of prior infection given lack of swelling, erythema,
fever/chills with improvement in his CRP compared to prior. He
has remained afebrile, without leukocytosis and his blood
cultures are negative. Malignancy is much less of a concern now
given negative S- and U-pep. Given ? osteo and possible
malignancy, patient could have had pathological fracture of
c-spine however physical exam improved and there was no
tenderness. Though the patient had MRI a week prior to
presentation, we repeated the MRI on this admission to clarify
the cause of presentation. Antibiotics were not given during his
hospital stay. It is very common for patients with osteomyelitis
to get pain at this point in their course as they start to
become more active so we will keep this in mind if further
workup is negative. Repeat MRI showed stable to slightly
improved signal abnormality from C6 through T1 including the
intervening disc spaces. No evidence for progression along with
significant degenerative changes in the cervical spine are
stable. There was no significant abnormality in the thoracic
spine. Stable focal rounded lesion at T7 without associated
edema. No epidural disease or cord compression in the thoracic
spine.
# Pain control: Pain was ___ on admission which was ___ on
discharge. Lidocaine ointment was being applied as needed which
resulted in good pain control along with ___ mg of po dilaudid q
4 hr instead of 2mg of po dilaudid q 4 hr as needed at home. He
was discharged home with ___ of dilaudid every 4 hour as
needed with follow up. We avoided fentanyl patch given his prior
hallucinations and delirium while being on low dose of fentanyl.
His pain was much better on discharge.
# DM: Hgb A1c 8.8 in ___ improved from 12 previously.
complicated by retinopathy, nephropathy, and neuropathy. His
home regimen of NPH twice daily was continued as inpatient and
discharged on the same regimen.
# PAF: rate controlled, CHADS-2 score 3 (HTN,dCHF,DM). Stable,
asymptomatic. Home regimen of coumadin and verapamil was
continued.
# ESRD: He is on ___ schedule for dialysis at ___. He
received his appropriate dialysis as inpatient.
# Hypertension: on verapamil 80 mg ___ tab three times daily.
This was continued as inpatient. Please see physical exam for BP
readings.
# CAD: not on aspirin. We continued verapamil as above. We also
continued pravastatin 40 mg daily at bed time for
hyperlipidemia.
# Diastolic CHF: Stable, chronic. Asymptomatic. On verapamil
only. No diuretics. Fluid is managed by HD.
# GERD: Takes omeprazole at home. This was continued as
inpatient and discharged on it. He has 1 episode of heartburn
requiring tums.
------------------
Transitional issues:
- pain control
- f/u ___ blood culture
Medications on Admission:
-nortriptyline 50 mg cap daily
-docusate 1 capsule twice daily
-folic acid 1mg 1 tab daily
-senna two tablet twice daily as needed
-lidocaine 5% ointment to be applied to fistula
-nephrocaps 1 cap every evening
-pravastatin 40 mg daily at bedtime
-insulin NPH novolin 8unit every morning and 6 unit every
evening
-lubricating ophth oint ___ in left eye at bedtime
-atropine sulfate 1% ophth 1 drop in right eye twice a day for
-glaucoma
-tylenol ___ mg 1 tab every 6 hour
-verapamil 80 mg half tab every 8 hour
-dilaudid 2 mg 1 tab every 4 hour as needed for pain
-warfarin 5 mg daily
-vitamin D liquid ___ every day
-Ferrous sulfate 325 mg daily
-Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Wheezing sob
-Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing sob
-omeprazole 20 mg daily
Discharge Medications:
1. Nortriptyline 50 mg PO HS
2. Docusate Sodium 100 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Senna 1 TAB PO BID:PRN constipation
5. Lidocaine 5% Ointment 1 Appl TP TID:PRN pain
6. Nephrocaps 1 CAP PO DAILY
7. Pravastatin 40 mg PO HS
8. NPH 8 Units Breakfast
NPH 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. Artificial Tear Ointment 1 Appl LEFT EYE HS
10. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE BID
11. Acetaminophen 500 mg PO Q6H:PRN pain
max per day 2 gram
12. Verapamil 40 mg PO Q8H
please hold for SBP < 100 or HR < 60
13. Warfarin 5 mg PO DAILY16
14. Vitamin D 800 UNIT PO DAILY
15. Ferrous Sulfate 325 mg PO DAILY
16. Omeprazole 20 mg PO DAILY
17. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze or SOB
18. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB or wheeze
19. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
please hold for sedation or RR < 10
RX *Dilaudid 2 mg every 4 hour Disp #*30 Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Neck and left shoulder pain
History of C7/T1 osteomyelitis
Secondary Diagnoses:
Diabetes
Paroxysmal AFib
Hypertension
End Stage Renal Disease on Dialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a great pleasure taking care of you. As you know you were
admitted to ___ for worsened
neck and left shoulder pain radiating down to your hand.
We provided you your home regimen for pain control but slightly
her dose of your home dilaudid. We also repeated MRI of your
spine and left shoulder which showed no change compared to
prior.
We did the following changes to your medication list.
- Please INCREASE your dilaudid from 2mg every 4 hour as needed
to ___ mg every 4 hour as needed
Please continue the rest of your home medications the way you
were taking them at home prior to admission.
Please follow with your appointments as illustrated below.
Please Weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
Followup Instructions:
___
|
10836215-DS-19
| 10,836,215 | 21,286,165 |
DS
| 19 |
2148-10-22 00:00:00
|
2148-10-23 18:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
sodium carbonate / aspirin
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ yo M pt with multiple medical problems presenting from
nursing home for evaluation of GIB. Pt is non-verbal at baseline
(will say yes, no, ___, etc.) Per report, pt has had BRBPR since
___ and had 2 massive melanotic BMs today. His hct today was
17, down from ___ yesterday. He received 2 ___, 10mg PO
vitamin K prior to transfer to ED; no FFP given. Upon arrival to
___ ED, he received an additional unit of PRBC. He continued
to remain HD stable.
Of note, pt receives dialysis ___. His
HCP is ___, his daughter.
In the ED, initial vitals: T 97.6F, HR 91, BP 115/40, RR 18 98%
RA
On exam pt was: Awake, nonverbal, resting comfortably
Labs were significant for: H/H ___
Imaging was significant for: ___ opacities on CXR
Consults: GI
On transfer, vitals were: HR 89, BP 101/59, RR 14, 99% RA
On arrival to the MICU, pt appears comfortable and in no acute
distress
Past Medical History:
Past Medical History:
Osteo of C7/T1, MSSA bacteremia- ___ treated with Cefazolin
1) CAD with ___ PTCA/stenting of PDA
2) Diastolic dysfunction
3) Hypertension, severe
4) DM, type ___ c/b retinopathy, nephropathy, and neuropathy, A1c
8.8% ___
6) Chronic infected diabetic ulcer
7) PAF on coumadin (managed by ___
8) Obstructive sleep apnea
9) Peripheral edema
10) Hyperlipidemia
11) Obesity
12) GERD
13) MGUS
14) ESRD ___ to HTN and DMII - Baseline Cr ~3.5
15) History of C diff ___ (completed 2 weeks of oral
vancomycin ___
16) hypercalcemia
17) Recent VRE UTI treated with course of linezolid
18) diverticulosis s/p hemicolectomy
Social History:
___
Family History:
Father with lung cancer, Mother natural causes and DM ___, 2
brothers with DM ___, sister with breast cancer, hypertension
"everyone". No history of prostate cancer.
Physical Exam:
======================
ADMISSION EXAM:
======================
Vitals: T: BP: 101/59 P: 88 R: 12 O2: 100% RA
GENERAL: opens eyes but is non verbal
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: R IJ tunnel catheter
LUNGS: Clear to auscultation bilaterally
CV: Regular rate and rhythm
ABD: soft, non-tender, non-distended, G tube in place, multiple
scars
EXT: ___ AKA, L upper arm fistula + bruit, thrill
SKIN: ulcer on coccyx which probes to bone
NEURO: non verbal
==========================
DISCHARGE EXAM
==========================
Vitals: Tm 98.2, BP 129 / 53, HR 76, RR 16, O2 100 Ra
Gen: sleeping, easily awoken, mostly one word answers, A&O to
person and hospital
HEENT: JVP not elevated, left NICC line in place.
CV: Regular rate and rhythm, normal S1 + S2, no m/r/g
Lungs: clear anteriorally
Abdomen: Laparotomy scar noted, soft, NTND, +BS, PEG tube in
place and site is non-inflamed without discharge around the
drain.
GU: No foley
Ext: Left AVF, bilateral AKA with clean stumps, right arm more
swollen than left.
Pertinent Results:
========================
ADMISSION LABS:
========================
___ 09:25PM BLOOD WBC-8.5 RBC-3.17* Hgb-9.0*# Hct-28.9*
MCV-91 MCH-28.4 MCHC-31.1* RDW-16.8* RDWSD-54.8* Plt ___
___ 09:25PM BLOOD Neuts-79* Bands-10* Lymphs-7* Monos-1*
Eos-0 Baso-0 ___ Metas-2* Myelos-1* AbsNeut-7.57*
AbsLymp-0.60* AbsMono-0.09* AbsEos-0.00* AbsBaso-0.00*
___ 09:25PM BLOOD ___ PTT-47.4* ___
___ 09:25PM BLOOD Glucose-216* UreaN-44* Creat-1.7* Na-136
K-3.9 Cl-98 HCO3-22 AnGap-20
___ 09:25PM BLOOD ALT-19 AST-25 LD(LDH)-207 AlkPhos-140*
TotBili-0.4
___ 09:25PM BLOOD Albumin-2.5*
___ 09:25PM BLOOD CRP-173.5*
___ 01:07AM BLOOD HBsAg-Negative HBsAb-Positive
HBcAb-Positive*
___ 01:31AM BLOOD Lactate-2.3*
==========================
DISCHARGE LABS
==========================
___ 06:30AM BLOOD WBC-10.5* RBC-2.93* Hgb-8.6* Hct-28.0*
MCV-96 MCH-29.4 MCHC-30.7* RDW-15.8* RDWSD-54.4* Plt ___
___ 06:30AM BLOOD Glucose-111* UreaN-47* Creat-3.0* Na-138
K-5.6* Cl-98 HCO3-29 AnGap-17
___ 06:30AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.8*
==========================
IMAGING/STUDUES
==========================
___ CXR
Right internal jugular central venous catheter tip terminates in
the mid SVC.
No definite pneumothorax is seen though the right apex is
obscured due to
patient's chin projecting over this area. Lung volumes are low.
Heart size
is mildly enlarged, unchanged. The aorta is mildly tortuous
with
atherosclerotic calcifications again noted at the aortic knob.
Pulmonary
vasculature is not engorged. Patchy opacities in the lung bases
with
peribronchial cuffing could reflect areas of atelectasis, though
infection or
aspiration is not completely excluded. No focal consolidation
or pleural
effusion is present. A vascular stent projects over the left
axillary and
subclavian region. There is marked gaseous distension of the
stomach which
contains a percutaneous catheter. No acute osseous
abnormalities detected.
IMPRESSION:
1. Right internal jugular central venous catheter terminates in
the mid SVC.
2. Patchy opacities within the lung bases may reflect
atelectasis, but
infection or aspiration is not excluded in the correct clinical
setting.
3. Marked gaseous distention of the stomach which contains a
percutaneous
catheter.
___ Pelvis XR
The sacrum is not clearly seen due to patient positioning and
overlying bowel
gas. No fracture or dislocation is identified. Limited
evaluation of
bilateral hip joints demonstrates moderate degenerative changes
with mild
acetabular protrusio. There are dense vascular calcifications.
IMPRESSION:
The sacrum is not well evaluated on this examination due to
patient
positioning and overlying bowel gas. If there is high clinical
concern for
osteomyelitis, an MRI can be performed.
Moderate bilateral hip osteoarthritis.
___ Right VENOUS DUP UPPER EXT UNILATERAL
There is normal flow with respiratory variation in the right
subclavian vein.
Eccentric clot is seen in the right internal jugular vein
surrounding the
central venous line extending to the junction of the right
subclavian vein.
Nonocclusive deep venous thrombosis is seen in the right
axillary vein. The
right brachial, basilic, and cephalic veins are patent,
compressible and show
normal color flow and augmentation.
IMPRESSION:
1. Deep venous thrombosis of the right internal jugular
extending to the
junction of the right subclavian.
2. Nonocclusive deep venous thrombosis of the right axillary
vein.
=========================
MICRO
=========================
___ Blood cultures negative
Brief Hospital Course:
TRANSITIONAL ISSUES
# Needs palliative care doctor and consider transfer to hospice
# HD schedule: ___, Th, ___
# Has right upper extremity DVT, we discussed the risks and
benefits of anticoagulation given recent GI bleed and the
decision was made not to anticoagulate or continue aspirin.
# Consider MRI/bone biopsy to guide treatment of chronic
osteomyelitis if within goals of care
# Contact: HCP ___ (sister) ___
# Code status: Full code (confirmed at family meeting ___
=====================
SUMMARY:
___ year old man with many advanced, accumulating medical
problems including ESRD on HD, bilateral AKA, multiple recent
aspiration pneumonias, hx recurrent CVAs with declining mental
status currently minimally verbal for months, diabetes,
hypertension, and chronic sacral decubitus ulcer complicated by
chronic osteomyelitis who presents with GIB, likely
diverticular, was initially admitted to the ICU for close
monitoring s/p 4 units of blood and 2 units FFP then discharged
to the medical floor where he remained hemodynamically stable
and continued to receive his chronic medical care. Of note, a
family meeting on ___ confirmed that the patient is to remain
full code, but they are considering hospice. It was decided not
to pursue invasive procedures.
#GI bleed:
Evaluated by gastroenterology who thought most likely source was
diverticular bleed. His last colonoscopy was ___ that showed
diverticulosis of the entire colon. Overall, received 4 units of
pRBCS, 2U FFP, and Vitamin K PO. Did not have recurrent bleeding
during his hospital stay and remained hemodynamically stable.
Colonoscopy was deferred in house given clinical stability.
#Stage 4 Ulcer:
Per ID consult, likely chronic osteomyelitis. CRP is 173.5, ESR
70. No need for treatment in the acute setting and can be worked
up further with MRI and bone biopsy to guide treatment as an
outpatient if this is within goals of care
#RUE DVT: RUE swelling noted during admission. Duplex US showed
nonocclusive DVTs of Rt IJ extending to the junction of the Rt
subclavian and of Rt axillary vein. Discussion was held with the
family on the risk and benefits of anticoagulation and the
decision was made not to anticoagulate given GI bleed.
#Paroxysmal AFib:
Remained in sinus rhythm when rate control was held in the
setting of GIB, but prior to discharge his metoprolol was
restarted. From an anticoagulation standpoint, warfarin and
aspirin discontinued during the admission given GI bleed risk
and severity of presenting bleed.
#ESRD on HD (T, Th, ___:
Renal was consulted and continued HD while he was inpatient.
#Diabetes:
Sliding scale was continued in house.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO DAILY
3. Tamsulosin 0.4 mg PO QHS
4. Nephrocaps 1 CAP PO QHS
5. Warfarin 2 mg PO DAILY16
6. Mirtazapine 7.5 mg PO QHS
7. Ascorbic Acid ___ mg PO BID
8. Zinc Sulfate 220 mg PO DAILY
9. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB, wheezing
11. LOPERamide 2 mg PO TID
12. Metoprolol Tartrate 25 mg PO BID
13. nystatin 100,000 unit/gram topical BID
14. Pantoprazole 40 mg PO Q12H
15. Florastor (Saccharomyces boulardii) 250 mg oral BID
16. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Insulin SC
Sliding Scale
Fingerstick q6h
Insulin SC Sliding Scale using HUM Insulin
2. Pantoprazole (Granules for ___ ___ 40 mg PO BID
3. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
4. Ascorbic Acid ___ mg PO BID
5. Calcium Carbonate 500 mg PO DAILY
6. Florastor (Saccharomyces boulardii) 250 mg oral BID
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB, wheezing
8. LOPERamide 2 mg PO TID
9. Metoprolol Tartrate 25 mg PO BID
10. Mirtazapine 7.5 mg PO QHS
11. Nephrocaps 1 CAP PO QHS
12. nystatin 100,000 unit/gram topical BID
13. Tamsulosin 0.4 mg PO QHS
14. Thiamine 100 mg PO DAILY
15. Zinc Sulfate 220 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: diverticular bleed
Secondary diagnosis: chronic kidney disease stage 5, paroxysmal
atrial fibrillation, chronic osteomyelitis, diabetes mellitus,
hypertension, chronic sacral decubitus ulcer
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Mr. ___,
==================================
WHY DID YOU COME TO THE HOSPITAL?
==================================
- You were bleeding excessively from your GI tract.
==================================
WHAT HAPPENED DURING YOUR STAY?
==================================
- The bleeding stopped on its own.
- You received blood transfusions
- Your blood clot was found to be in three vessels in your right
arm
- Your goals of care were discussed by your closest family
members and decision makers and it was decided to not perform
invasive testing such as bone biopsy and colonoscopies and to
follow up with palliative care to continue discussions
========================================
WHAT NEEDS TO HAPPEN OUTSIDE THE HOSPITAL?
========================================
- Continue receiving medical care as you were.
- See a palliative care doctor with your family to plan for the
future as your conditions will continue to progress
Sincerely,
Your ___ team
Followup Instructions:
___
|
10836215-DS-21
| 10,836,215 | 27,244,669 |
DS
| 21 |
2148-12-19 00:00:00
|
2148-12-23 10:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
sodium carbonate / aspirin
Attending: ___.
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Endoscopy procedure on ___
History of Present Illness:
___ male PMH diabetes, end-stage renal disease on
dialysis ___ last HD ___, bilateral AKA, sacral decubitus
ulcer c/b osteomyelitis and sepsis, Afib w/ RVR, presenting from
rehab for GI bleed.
Patient is limited in his ability as a historian. Per his
report, he has had a GI bleed for "a month" Per report from his
referring physician from rehab, he has had BRBPR x3 days with
clots through his rectal tube; over the last day he has put out
1300 cc of melenic stool. He has been reportedly hemodynamically
stable throughout these episodes at rehab. Patient received 2
units of packed red blood ___ and ___ cells along with 100 cc
of normal saline, and transferred to ___ for further
evaluation. Patient states that he has some abdominal pain. Has
had GI bleeds before. Denies any fevers, chills, nausea,
vomiting, diarrhea.
Patient was recently hospitalized ___ - ___ for septic shock
___ osteomyelitis from sacral decub ulcer with CoNS bacteremia
(discharged with PICC for long course zosyn); as well as
paroxysmal afib w/ RVR with hypotensive episodes thought ___
cardiogenic shock; toxic metabolic encephalopathy; hematemesis
for which he was transferred to the ICU and ultimately not
scoped ___ anesthesia concern given his overall poor status,
which subsequently stabilized. Palliative care was also
consulted; patient is DNR/DNI, though would possibly accept
intubation on a case by case basis.
In the ED, initial vitals: 96.7 137/50 63 18 100/RA
On exam pt with mild right-sided abdominal tenderness. Bilateral
AKA. Moist oral mucosa. PICC line right arm. No significant
melenic stool output while he has been in the ED.
Labs were significant for:
(___) 9.6 >8.6/26.8 < 126 -> (___) 7.8/23.8 -> (___) 8.4/26.3
135 | 101 | 28
---------------<172
3.4 | 23 | 1.3
Lactate 0.9
phos 1.4
INR 1.2
Imaging was significant for:
-CTA abdomen pelvis:
1. No evidence of active extravasation at this time.
2. There is mild nonspecific thickening of the distal sigmoid
colon wall.
3. Multiple decubitus ulcers overlying the sacrum and extending
laterally to the left. A fluid collection, concerning for a
phlegmon, with a few punctate foci of gas measures approximately
3.3 x 1.5 cm. Notably gas extends inferiorly to the level of the
greater trochanter.
4. Atrophy of the bilateral kidneys with thinning of the
cortices, consistent with ESRD.
5. Bibasilar consolidation, which may represent atelectasis with
pneumonia not excluded in the proper clinical setting.
-CXR: Right PICC tip in the low SVC. Bibasilar streaky and
linear airspace opacities likely reflect areas of atelectasis.
Consults:
-GI: IV PPI and NPO after midnight in case EGD ___ just be
irritation from long-term rectal tube, but will treat as upper
for now; per last discharge summary, doesn't want invasive
procedures, so want to find out what the deal is prior to
pursuing scope.
Patient received:
___ 18:21 IV Pantoprazole 40 mg ___
___ 20:30 IV Morphine Sulfate 4 mg ___
___ 08:53 IV Dextrose 50% 12.5 gm ___
___ 09:09 PO/NG Amiodarone 400 mg ___
___ 09:09 IV Pantoprazole 40 mg ___
no given transfusions in the ED
On transfer, vitals were: 97.4 95/53 73 16 100/RA
On arrival to the MICU, patient is in no acute distress. He
denies any symptoms at present, although endorses some abdominal
tenderness.
Past Medical History:
Sacral osteomyelitis, currently on OPAT course
Osteo of C7/T1, MSSA bacteremia ___ treated with Cefazolin
CAD with ___ PTCA/stenting of PDA
Diastolic dysfunction
Hypertension, severe
DM, type ___ c/b retinopathy, nephropathy, and neuropathy
Chronic infected diabetic ulcer
PAF on coumadin (managed by ___
Obstructive sleep apnea
Peripheral edema
Hyperlipidemia
Obesity
GERD
MGUS
ESRD ___ to HTN and DMII - Baseline Cr ~3.5
History of C diff
hypercalcemia
VRE UTI treated with course of linezolid
Diverticulosis s/p hemicolectomy
Social History:
___
Family History:
Per review of records, father with lung cancer, Mother natural
causes and DM ___, 2 brothers with DM ___, sister with breast
cancer, hypertension "everyone". No history of prostate cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: 97.7 133/44 72 14 110/RA
GENERAL: Alert but fatigued, oriented, no acute distress
HEENT: Sclera anicteric on L (R eye blind), MM a little dry,
oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi on limited anterior exam
CV: Regular rate and rhythm, normal S1 S2, harsh end-systolic
murmur, no rubs, gallops
ABD: soft, mildly tender in bilateral lower quadrants,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly, feeding tube in place, large midline
scar.
GU: No foley
EXT: AKA bilaterally. Warm, well perfused, no clubbing,
cyanosis. 2+ edema bilaterally in hands. RUE fistula with good
bruit and thrill. R picc in place.
SKIN: Covered on my exam, but large stage IV sacral decub ulcer
present.
NEURO: A&O x3. CN ___ intact, strength ___ LUE ___ RUE,
sensation intact.
ACCESS: PIVs
DISCHARGE PHYSICAL EXAM:
========================
VS - T 97.7, BP 102 / 48, HR 75, RR 18, O2 100% Ra
GENERAL: Alert but fatigued, oriented to person, no acute
distress
HEENT: Sclera anicteric on L (R eye blind)
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi on limited anterior exam
CV: Regular rate and rhythm, normal S1 S2, harsh end-systolic
murmur, no rubs, gallops
ABD: soft, nontender to palpation, non-distended, bowel sounds
present, no rebound tenderness or guarding.
NEURO: Alert to person only. ___ strength in bilateral upper
extremities
Pertinent Results:
ADMISSION LABS
==============
___ 05:10PM BLOOD WBC-9.6 RBC-2.85* Hgb-8.6* Hct-26.8*
MCV-94# MCH-30.2 MCHC-32.1 RDW-17.5* RDWSD-59.0* Plt ___
___ 05:10PM BLOOD Neuts-72.0* Lymphs-15.6* Monos-10.3
Eos-1.1 Baso-0.5 Im ___ AbsNeut-6.92*# AbsLymp-1.50
AbsMono-0.99* AbsEos-0.11 AbsBaso-0.05
___ 05:10PM BLOOD ___ PTT-33.6 ___
___ 05:10PM BLOOD Glucose-172* UreaN-28* Creat-1.3* Na-135
K-3.4 Cl-101 HCO3-23 AnGap-14
___ 05:10PM BLOOD Calcium-8.5 Phos-1.4* Mg-2.2
___ 05:14PM BLOOD Lactate-0.9
PERTINENT LABS
==============
___ 01:18PM BLOOD Hgb-8.7* calcHCT-26
___ 05:14PM BLOOD Lactate-0.9
DISCHARGE LABS
==============
___ 05:53AM BLOOD WBC-11.1* RBC-2.57* Hgb-7.6* Hct-25.4*
MCV-99* MCH-29.6 MCHC-29.9* RDW-15.9* RDWSD-56.5* Plt ___
___ 05:53AM BLOOD Glucose-112* UreaN-22* Creat-1.7* Na-137
K-4.3 Cl-94* HCO3-29 AnGap-18
___ 05:53AM BLOOD Calcium-8.8 Phos-1.7* Mg-2.4
IMAGING
=======
___: CXR
Right PICC tip in the low SVC. Bibasilar streaky and linear
airspace
opacities likely reflect areas of atelectasis.
___: CTA Abd/Pelvis:
1. No evidence of active extravasation.
2. Mild nonspecific thickening of the distal sigmoid colon wall.
3. Multiple decubitus ulcers overlying the sacrum and extending
laterally to the left. A small phlegmon, with a few punctate
foci of gas measures
approximately 3.3 x 1.5 cm. Gas extends laterally from the
midline to the
left greater trochanter.
4. Atrophy of the bilateral kidneys with thinning of the
cortices, consistent with ESRD.
5. Bibasilar consolidation, which may represent atelectasis with
pneumonia not excluded in the proper clinical setting.
___: RUE US:
No evidence of deep vein thrombosis in the left upper extremity.
Left upper extremity graft appears patent. The left basilic
was not visualized.
Brief Hospital Course:
___ male ___ diabetes, end-stage renal disease on
dialysis (___ last HD ___, bilateral AKA, sacral decubitus
ulcer c/b osteomyelitis and sepsis, Afib w/ RVR, and dementia
presenting for GI bleed. Patient had an endoscopy on ___ showed
no active bleed; small ulcer not actively bleeding around PEG
which may have been contributing. He required 1 unit pRBCs on
___, but otherwise H/H have remained stable. Medicine team also
had Goals of Care discussion with patient's family and
determined that his code status was changed to DNR/DNI. Hospice
was introduced as well as do not hospitalize order but family
would like to discuss with other family members prior to
transitioning to hospice.
# UGI bleed
# Anemia
Patient presenting with BRBPR/"melena" out of rectal tube. Has
recent hx of hematemesis, not scoped due to overall poor
clinical status at that time and resolved without intervention.
Required 2u PRBC as an outpatient with dialysis over the 2d
prior to admission, w/ Hb dropping ~1 point/___ since being in
the ED; subsequently stabilized and improved to admission
baseline. No hx cirrhosis or varices. Source may be UGI given
recent hematemesis, vs LGI (possibly from tube irritation given
e/o inflammation in sigmoid on CTA). He has required 2U pRBCs on
___ at dialysis prior to admission and 1U on ___. EGD on ___
showed no active bleed; small ulcer not actively bleeding around
PEG. H/h now stable. Continued on Pantoprazole 40mg PO BID.
# Afib w/ RVR
Patient with history of Afib w/ RVR on Coumadin; had frequent
episodes of hypotension ___ arrhythmia + infection at last
admission. Not on Coumadin. Continued Amiodarone 100mg BID.
# Sacral osteomyelitis
Diagnosed on prior admission. Has risk for contamination, as
below with wound care. On long course of zosyn TID (course ends
___. ID made aware of admission. Plan for outpatient ID follow
up after discharge.
# Thrombocytopenia
Platelets 136 on admission from baseline in high 100s. Possibly
___ acute bleed vs chronic infection, although had been
reasonably normal during prior admission. Of note, patient does
have history of MGUS.
# Wound care:
During prior admission, wound care has been an ongoing issue for
this patient. He is chronically incontinent of stool. Flexiseal
was in place, but leaking and contaminate sacral ulcer.
Evaluated by colorectal surgery and not a candidate for
colostomy surgery. Has been on bulking agents w/ banana flakes
and loperamide. Rectal tube dc'd in ED given sigmoid irritation.
# PEG tube:
Per GI patient's PEG tube may need to be replaced as it is at
risk for becoming occluded. Will determine if this is within
patient's GOC. Can continue tube feeds in interim.
# GOC: On ___ a ___ discussion was held with the patient and
his son, ___. as well as ___ (Palliative Care) and
Dr. ___. Per Palliative Care note from ___ patient and
his family agreed on DNR/DNI code status with plan to treat all
medical problems in an attempt for him to live a longer life.
However, per patient and sister/HCP, had additional discussions
since and he is again full code. Following family meeting on
___ his code status was changed DNR/DNI.
# CAD with ___ PTCA/stenting of PDA
# Diastolic dysfunction
Continue ASA and atorvastatin
# ESRD on HD MFW
Continue HD, continue nephrocaps
# DM, type ___ c/b retinopathy, nephropathy, and neuropathy
On insulin sliding scale, no longer requiring insulin.
# Chronic issue med rec:
Continue mirtazapine, duonebs, tamsulosin
# Communication/HCP: ___ ___
# Code: DNR/DNI
TRANSITIONAL ISSUES:
=====================
- Continue HD TTHS
**** Patient needs HD on ___
- Patient's G tube is at risk of occlusion. If he is no longer
able to receive tube feeds can discuss exchange of PEG if that
is within goals of care.
- Patient has had repeated episodes of GI bleed with melena.
Underwent EGD on this admission. Given risk of procedure, did
not undergo colonoscopy during this admission. Would only
consider this procedure in case of emergency.
- F/u CBC in ___ days following discharge.
- continue ongoing meticulous wound care
- IV Access: R PICC is only site. Cannot augment b/c of L
fistula and R subclav stenosis
- continue IV Zosyn TID for Osteo ongoing with ID OPAT f/u as
described above (current course planned 6 weeks End Date
___
- initiated discussion of hospice, would recommended
readdressing in near future, family wanted to discuss with other
family members
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Mirtazapine 7.5 mg PO QHS
3. Nephrocaps 1 CAP PO QHS
4. Thiamine 100 mg PO DAILY
5. Amiodarone 100 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Piperacillin-Tazobactam 2.25 g IV Q8H
9. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
10. Ascorbic Acid ___ mg PO BID
11. Florastor (Saccharomyces boulardii) 250 mg oral BID
12. nystatin 100,000 unit/gram topical BID
13. Tamsulosin 0.4 mg PO QHS
14. Zinc Sulfate 220 mg PO DAILY
15. Pantoprazole (Granules for ___ ___ 40 mg PO BID
16. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Amiodarone 100 mg PO BID
4. Ascorbic Acid ___ mg PO BID
5. Atorvastatin 40 mg PO QPM
6. Florastor (Saccharomyces boulardii) 250 mg oral BID
7. Mirtazapine 7.5 mg PO QHS
8. Nephrocaps 1 CAP PO QHS
9. nystatin 100,000 unit/gram topical BID
10. Pantoprazole (Granules for ___ ___ 40 mg PO BID
11. Piperacillin-Tazobactam 2.25 g IV Q8H
12. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
13. Tamsulosin 0.4 mg PO QHS
14. Thiamine 100 mg PO DAILY
15. Zinc Sulfate 220 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Upper GI bleed
Secondary diagnoses: Anemia, atrial fibrillation, sacral
osteomyelitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
Why was I here?
- You had dark/bloody stool from your rectal tube
What was done while I was here?
- You got a blood transfusion
- You had an endoscopy that showed a small ulcer by your feeding
tube. It is not clear if this explains the bloody stools.
What should I do when I get home?
- Take all your medicines as prescribed.
- Monitor for dark/bloody stools. You may need additional blood
transfusions with dialysis.
Followup Instructions:
___
|
10836349-DS-21
| 10,836,349 | 27,737,118 |
DS
| 21 |
2193-12-18 00:00:00
|
2193-12-18 20:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
Nasogastric tube - ___
History of Present Illness:
Ms. ___ is a ___ with SLE and hypothyroidism, who was
admitted with abdominal pain, concerning for SBO on initial CT.
She reports waking up early on ___ to urinate, and upon
returning to bed felt epigastric abdominal pain. She tried
resting to allow the pain to resolve, but it did not. That
morning the pain increased and she describes it starting to come
in waves. She presented to her PCP where ___ CT A/P showed
possible SBO. Her last bowel movement had been ___
afternoon. By the time she arrived at the ED she was now having
nausea and vomiting. She was not passing gas. She was admitted
to the ACS Service and had gradual improvement of pain. On the
evening of ___ she began having profuse watery diarrhea. A
repeat CT abdomen and pelvis on ___ showed no evidence of
SBO, and the appearance was more consistent with infection and
inflammation. The frequency of the diarrhea has been decreasing
but the consistency remains completely watery without formed
stool. She denies abdominal pain, nausea or vomiting.
She denies any symptoms of her normal lupus flares, which
include a specific kind of pain that is not consistent with this
presentation, and red blotchy rash on her legs. She has not had
viral URI symptoms or had sick contacts in the recent past. She
does report being hospitalized around ___ for C. diff at which
time her diarrhea was much more profound than this and caused
dehydration.
Past Medical History:
Lupus
Hypertension
Depression
Proliferative glomerulonephritis
Hyperlipidemia
Social History:
___
Family History:
Father PD
Mother T2DM
Physical Exam:
ADMISSION EXAM
==============
Vitals: 98.4 PO 132 / 86 77 18 98 RA
General: Alert and interactive, looks clinically very well, NAD
HEENT: sclera anicteric, no conjunctival pallor
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,
stringy/rubbery texture subcutaneous upon palpation
Ext: warm, well perfused, 2+ pulses, no edema
Neuro: CNs2-12 intact, motor function grossly normal
DISCHARGE EXAM
==============
Vitals: T 98.3, BP 123-142/87-94, HR 83-84, RR 18, SpO2 96/RA
General: Alert and interactive, oriented, moves easily in bed
for exam, NAD
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, normoactive bowel
sounds
Ext: warm, well perfused, 2+ pulses, no edema. ~2-3cm flat
erythematous patch over R anterior shin, warm to touch. No TTP.
No open lesions or drainage.
Neuro: moving all 4 extremities with purpose
Pertinent Results:
ADMISSION LABS
==============
___ 05:20PM URINE RBC-1 WBC-4 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 05:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
___ 05:20PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:30PM ___ PTT-27.8 ___
___ 05:30PM PLT COUNT-280
___ 05:30PM NEUTS-70.0 ___ MONOS-4.6* EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-6.49* AbsLymp-2.30 AbsMono-0.43
AbsEos-0.01* AbsBaso-0.03
___ 05:30PM WBC-9.3# RBC-4.99# HGB-14.0# HCT-42.3#
MCV-85# MCH-28.1 MCHC-33.1 RDW-14.6 RDWSD-44.4
___ 05:30PM ALBUMIN-4.4
___ 05:30PM LIPASE-65*
___ 05:30PM ALT(SGPT)-19 AST(SGOT)-22 ALK PHOS-59 TOT
BILI-0.6
___ 05:30PM GLUCOSE-99 UREA N-6 CREAT-0.7 SODIUM-138
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-22 ANION GAP-20
___ 05:36PM LACTATE-2.8*
___ 12:39AM LACTATE-1.5
___ 08:43AM PLT COUNT-266
___ 08:43AM WBC-8.5 RBC-4.71 HGB-13.5 HCT-41.0 MCV-87
MCH-28.7 MCHC-32.9 RDW-15.2 RDWSD-48.0*
___ 08:43AM CALCIUM-9.0 PHOSPHATE-4.5 MAGNESIUM-2.2
___ 08:43AM GLUCOSE-113* UREA N-8 CREAT-0.7 SODIUM-138
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-24 ANION GAP-17
___ 02:54PM ___ PTT-27.1 ___
___ 02:54PM PLT COUNT-269
___ 02:54PM WBC-9.2 RBC-4.60 HGB-13.0 HCT-40.5 MCV-88
MCH-28.3 MCHC-32.1 RDW-15.1 RDWSD-47.9*
___ 02:54PM CALCIUM-9.2 PHOSPHATE-3.6 MAGNESIUM-2.0
___ 02:54PM GLUCOSE-107* UREA N-8 CREAT-0.7 SODIUM-141
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-27 ANION GAP-16
MICRO
=====
__________________________________________________________
___ 7:15 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
__________________________________________________________
___ 7:15 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
__________________________________________________________
___ 5:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
DISCHARGE LABS
==============
___ 06:40AM BLOOD WBC-5.0 RBC-4.34 Hgb-12.2 Hct-39.1 MCV-90
MCH-28.1 MCHC-31.2* RDW-14.8 RDWSD-49.2* Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-115* UreaN-6 Creat-0.7 Na-141
K-3.8 Cl-105 HCO3-25 AnGap-15
LABS OF NOTE
============
___ 06:40AM BLOOD CRP-0.9
___ 06:40AM BLOOD CRP-0.9
___ 06:25AM BLOOD CRP-4.6 dsDNA-POSITIVE *
___ 06:25AM BLOOD C3-87* C4-20
IMAGING/STUDIES
===============
___ (SINGLE VIEW)
1. Nasogastric tube tip is within the proximal stomach, but side
port is likely proximal to the gastroesophageal junction, but
not well visualized on this exam.
2. No acute cardiopulmonary process.
___ ABD & PELVIS WITH CO
1. Homogeneous, contiguous bowel wall thickening involving the
distal jejunum to the ileocecal valve. Differential includes
lupus or infection. No obstruction.
2. Cholelithiasis.
Brief Hospital Course:
Ms. ___ is a ___ with SLE and hypothyroidism, who was
admitted to the ___ Service with abdominal pain, concerning for
SBO, but on repeat CT, found to have no SBO. CT findings
consistent with inflammation vs. infection in the jejunem and
ileum. Pt developed diarrhea while admitted, eventually
transferred to medicine service for work-up of diarrhea in the
setting of immunosuppression.
#ABDOMINAL PAIN:
#NAUSEA/VOMITING:
#DIARRHEA:
#SMALL BOWEL OBSTRUCTION: Pt presented to PCP ___ ___ with
abdominal pain and constipation, had a CT abd/pelvis which
showed clear transition point, concerning for SBO. On arrival to
___ ED, pt also reporting nausea and vomiting. Not passing
flatus. Had NGT for several hours in the ED, unclear why this
was d/c'ed so quickly. Regardless, abdominal pain, nausea, and
vomiting resolved over ___ days, over which time she was
re-introduced to PO intake and escalated gradually to a full
diet, which she tolerated. Also over this time, the patient
develop significant loose, watery stool. Subsequent CT at ___
showed no evidence of obstruction. CT did show "Small bowel
loops demonstrate diffuse and mildly dilated in caliber. There
is contiguous, homogeneous wall thickening of the distal jejunum
to the ileocecal valve. There is mild diffuse mesenteric
stranding." These findings were concerning for inflammation
versus infection. At this point, she was transferred to the
medicine service for further work-up/management of diarrhea in
the setting of immunosuppression (on MMF for lupus). On transfer
to the medicine service, pt appeared clinically quite well. C
diff and norovirus testing were negative. Diarrhea slowed in
frequency. Discharged patient to home with close PCP ___
and recommendation for GI evaluation if symptoms worsen or do
not resolve (considerations include new Crohn's presentation,
CMV enteritis while on MMF).
Overall, though, we suspected that this was a viral
gastroenteritis - however if recurs or if skin findings (see
below) evolve further, consideration should be made for GI
referral to rule out IBD or other etiologies.
#LUPUS: CRP, ESR, C3, C4 WNL at the time of admission. Denied
symptoms of typical lupus flare, which include arthralgias and
blotchy rashes on the legs. Pt did have ~2-3cm flat erythematous
patch over R anterior shin, warm to touch noted on the day of
discharge. Non-tender. Confirmed that this is not consistent
with typical lupus skin changes for the patient. Unclear
etiology, there was thought that perhaps this could be
blossoming erythema nodosum in the setting of viral illness, or
possible IBD, though the skin changes were not strictly
consistent with erythema nodosum. Continued home
hydroxychloroquine 200 mg p.o. twice daily and mycophenolate
1000 mg p.o. twice daily, as well as prophylactic valacyclovir.
#HYPERTENSION: Continued home amlodipine 10 mg daily
#DEPRESSION: Continued home citalopram 20 mg daily
#HYPERLIPIDEMIA: Continued home atorvastatin 10 mg daily
TRANSITIONAL ISSUES
===================
[ ] Stool culture not yet finalized by the time of discharge.
Primary inpatient team will ___ the results and contact
patient if further treatment/work-up is necessary.
[ ] If diarrhea worsens or does not resolve by the time of PCP
___, consider GI consult for possible colonoscopy
(considerations include new Crohn's presentation, CMV enteritis
while on MMF).
[ ] If flat erythematous patch on R anterior shin becomes more
diffuse, nodular, or pain, consider erythema nodosum in the
setting of viral illness, or possible IBD.
Greater than 30 minutes were spent on this patient's discharge
day management.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ValACYclovir 1000 mg PO Q24H
2. Citalopram 20 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Acetaminophen w/Codeine ___ TAB PO BID:PRN Pain - Moderate
5. amLODIPine 10 mg PO DAILY
6. Saxenda (liraglutide) 3 mg/0.5 mL (18 mg/3 mL) subcutaneous
DAILY
7. Hydroxychloroquine Sulfate 200 mg PO BID
8. Mycophenolate Mofetil 1000 mg PO BID
Discharge Medications:
1. Acetaminophen w/Codeine ___ TAB PO BID:PRN Pain - Moderate
2. amLODIPine 10 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Citalopram 20 mg PO DAILY
5. Hydroxychloroquine Sulfate 200 mg PO BID
6. Mycophenolate Mofetil 1000 mg PO BID
RX *mycophenolate mofetil 500 mg Two tablet(s) by mouth Twice a
day Disp #*28 Tablet Refills:*0
7. Saxenda (liraglutide) 3 mg/0.5 mL (18 mg/3 mL) subcutaneous
DAILY
8. ValACYclovir 1000 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Systemic lupus erythematous
Hypertension
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 ___ from
___ to ___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You had a CT scan of your belly before you came to the
hospital, which showed concern for a small bowel obstruction
(complete blockage of your small intestine). You were admitted
for monitoring and treatment of this condition.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were evaluated by the surgery team, who felt that you did
not require surgery for this issue.
- You had a tube placed into your stomach, through your nose, to
help empty out all of the stomach content that couldn't pass by
the obstruction. This seemed to help quite a bit.
- You had a repeat CT scan of your belly, which showed
resolution of the small bowel obstruction, but some inflammation
of your small intestine.
- You developed significant diarrhea. As you are on medicine
(Cellcept) that inhibits your immune system, we sent off several
tests looking for infection as the cause of your diarrhea. Your
testing for c diff and norovirus was negative (meaning you do
NOT have these things).
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
- You will continue to take all of the medicines that you were
taking prior to coming into the hospital.
- You will ___ with your primary care doctor, as scheduled
below.
- If you continue to have diarrhea, please call your primary
care doctor for further work-up. If you notice blood in your
stool, or start feeling lightheaded/dizzy, please call your
primary care doctor or go to your nearest emergency room.
We wish you the very best with your health going forward.
Your ___ Medicine Team
Followup Instructions:
___
|
10836444-DS-20
| 10,836,444 | 29,879,617 |
DS
| 20 |
2167-01-27 00:00:00
|
2167-01-27 23:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ poorly controlled type I diabetes with recent admission
for the flu and DKA discharged ___ who presents with worsening
cough and hyperglycemia with BG 393.
Pt was recently admitted to ___ for influenza and DKA,
discharged 4 days ago. He received 5 days of Tamiflu (___)
that was completed prior to discharge. Pt states that he was
feeling okay over the last several days at home, although not
back to this baseline. He noticed worsening BG in the
200's-300's over the last several days which made him concerned
for recurrent infection. During hospitalization pt had A1C of
10%, BG ranged 50-280. During hospitalization, ___ adjusted
insulin to lantus 45U qpm with mealtime humalog 10U TID + ISS
humalog. He had a persistent dry cough following discharge that
he reports has become more wet and occasionally productive of
yellowish sputum over the last several days. He denies SOB
except after bouts of coughing. Overall he is not sure that he
feels any worse than he did not discharge but also does not feel
much better. Complained of feeling parched and polyuria, as well
as chest congestion and cough. He presented to his PCP's office
where he was instructed to go to the ED for further evaluation.
In the ED, initial vitals were: 98.6 88 179/74 18 98% ra
Labs notable for wbc of 12.8, chem notable for Na of 131
Imaging: CXR read interstitial prominence, as on prior exam,
compatible with known influenza. No focal lung consolidation
Pt was treated with CefePIME 2 g, Vancomycin 1gm, benzonatate
and 1L NS bolus.
On the floor, he still complains of persistent cough without
SOB, unchanged since the ED. Denies wheeze, chest pain, fevers,
chills, nausea, vomiting or diarrhea. States that he has a
sensation of fullness in his abdomen that has decreased his
appetite.
Past Medical History:
Diabetes Mellitus type I
Hyperlipidemia
Hypertension
Social History:
___
Family History:
Noncontributory
Physical Exam:
EXAM ON ADMISSION:
==================
Vitals: 98.2, 160/72, 81, 18, 97% RA BG 239
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, mildly dry MM, oropharynx clear, EOMI,
PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Faint bibasilar crackles, occasional scattered rhonchi,
otherwise clear without wheeze.
Abdomen: Obese, Soft, non-tender, non-distended, bowel sounds
present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, trace pitting edema b/l
lower extremity, no cyanosis or clubbing.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
EXAM ON DISCHARGE:
==================
Vitals: 98.5, 153-161/67-73, 78-93, 18, 93-98% RA BG 221
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB, no wheezes, rhonchi or rales
Abdomen: Obese, Soft, non-tender, non-distended, bowel sounds
present, no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, trace pitting edema b/l
lower extremity, no cyanosis or clubbing.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
LABS ON ADMISSION:
==================
___ 04:40PM BLOOD WBC-12.8* RBC-3.41* Hgb-10.7* Hct-30.9*
MCV-91 MCH-31.5 MCHC-34.8 RDW-12.7 Plt ___
___ 04:40PM BLOOD Neuts-73.4* ___ Monos-5.6 Eos-1.9
Baso-0.4
___ 04:40PM BLOOD Glucose-241* UreaN-8 Creat-1.0 Na-131*
K-4.7 Cl-97 HCO3-21* AnGap-18
___ 04:42PM BLOOD ___ pO2-80* pCO2-34* pH-7.47*
calTCO2-25 Base XS-1 Comment-PERIPHERAL
___ 04:42PM BLOOD O2 Sat-96
URINANALYSIS: ___ 04:40PM URINE Color-Straw Appear-Clear Sp
___
___ 04:40PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 04:40PM URINE RBC-0 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 04:40PM URINE Hours-RANDOM UreaN-99 Creat-21 Na-44 K-9
Cl-37 Mg-2.1
___ 04:40PM URINE Osmolal-157
LABS ON DISCHARGE:
==================
___ 06:30AM BLOOD WBC-11.6* RBC-3.47* Hgb-10.8* Hct-31.3*
MCV-90 MCH-31.1 MCHC-34.4 RDW-12.7 Plt ___
___ 06:30AM BLOOD Glucose-191* UreaN-7 Creat-1.0 Na-133
K-4.6 Cl-98 HCO3-26 AnGap-14
STUDIES/IMAGING:
================
CXR (___): Diffuse interstitial prominence, as on prior
exam, compatible with known influenza. No focal lung
consolidation.
CXR (___): Essentially normal chest radiograph.
Brief Hospital Course:
___ y/o M with PMHx significant for type I diabetes recently
admitted for DKA found to have the flu discharged on ___ who
presented from PCP's office for evaluation of cough. Initially
concerned for pneumonia given recent flu, however CXR negative
for acute infiltrate and so most likely represents
post-infectious cough.
ACTIVE ISSUES:
==============
# Post-viral cough: History of mostly dry cough, only
occasionally productive of small amount of yellowish sputum, is
consistent with post-viral cough from recent influenza. Pt
denies SOB and did not have an oxygen requirement. Pt remained
afebrile with stable WBC count. His exam was unchanged exam with
clear lung fields throughout his brief admission. CXR was
performed that did not show any evidence of focal infiltrate
that would suggest pneumonia. He was started on broad-spectrum
antibiotics in the ED given initial concern for potential
post-influenza pneumonia, however these were stopped on arrival
to the general medical floor. He was treated with medication to
help with cough. On the day following admission he continued to
state that his symptoms were stable. He was breathing
comfortably and was able to walk around the unit without acute
distress. He was cleared for discharge home without further
antibiotics. He will need to follow up with his PCP.
# Type I diabetes: Pt reported sugars were a little more
difficult to control over the last several days at home. This
was in the setting of recent discharge on lower sliding scale,
although patient interpreted this number as a sign of infection.
Initial work-up revealed no gap on chemistry and no other
sources of infection (UA normal, no diarrhea or rahes). His home
glargine dose was increased to 50U nightly in addition to the
standing mealtime humalog and correctional sliding scale. He
will have a followup appointment with ___ within the next
week.
# Hyponatremia: Sodium was stable from discharge sodium after
accounting for hyperglycemia. Urine lytes consistent with
hypovolemia or could be SIADH from process in the lung. Na
stable following IVF. Encourage PO fluid intake.
CHRONIC ISSUSES:
================
# HTN: Mildly hypertensive during this admission to peak SBP
160's. Home HCTZ losartan and Coreg were continued. Will need to
continue dosing adjustment as an outpatient.
# Anemia: Normocytic to borderline microcytic. He was started on
iron supplementation during last admission based on iron
studies. Hgb stable from recent values at 10.8 on admission. He
will need to have a repeat CBC and further anemia work-up as an
outpatient.
# HLD: Continued home dose statin.
# Depression: Continued home dose buproprion.
TRANSITIONAL ISSUES
===================
# Encourage PO fluid intake, supportive care for cough
# Patient discharged on the following insulin regimen: Lantus 50
units QPM, mealtime 10U humalog TID and humalog sliding scale
QID
# BP elevated during admission, recheck as outpatient and
uptitrate medications as needed
# Trend CBC as an outpatient and pursue further work-up for
anemia as indicated
# F/u with ___ as an outpatient
# CODE: Full
# CONTACT: ___ (friend) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 300 mg PO QAM
2. Doxazosin 8 mg PO HS
3. Carvedilol 40 mg PO DAILY
4. Ranitidine 150 mg PO BID
5. Ferrous Sulfate 325 mg PO BID
6. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9. Glargine 45 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. BuPROPion (Sustained Release) 300 mg PO QAM
2. Carvedilol 40 mg PO DAILY
3. Doxazosin 8 mg PO HS
4. Ferrous Sulfate 325 mg PO BID
5. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Glargine 50 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. Losartan Potassium 100 mg PO DAILY
9. Ranitidine 150 mg PO BID
10. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*50 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Post-infectious cough
Secondary:
Type 1 diabetes mellitus
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
referred to the hospital because you had increased cough and
there was concern that you had a pneumonia. We did a CXR which
did not show evidence of pneumonia. Your cough is likely a
post-viral cough from your recent flu. We gave you some
medication to help with your cough. Your blood sugars were also
high so we increased your glargine (long-acting insulin) to 50
units which you should start taking tonight. Please follow up
with your primary care doctor and ___. It was a pleasure
participating in your care - we wish you all the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10836444-DS-21
| 10,836,444 | 25,551,438 |
DS
| 21 |
2170-12-15 00:00:00
|
2170-12-15 13:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ Coronary angiogram
___:
1. Coronary artery bypass graft x 4, Total arterial
revascularization.
2. Skeletonized left internal mammary artery sequential
grafting to diagonal and left anterior descending artery.
3. Skeletonized in situ right internal mammary artery graft
to distal circumflex artery.
4. Left radial artery graft to posterior descending artery.
5. Endoscopic harvesting of the left radial artery.
History of Present Illness:
___ w/ hx of poorly controlled DMI, HTN/HLD who presents with
abdominal pain and shortness of breath.
The pt states that he has had back and abdominal pain
intermittently for about one month, but has become increasingly
worse in the past 3 days. It has been associated with eating and
is not exertional. The pt describes the pain as starting in his
mid back and radiating towards his epigastric area. Accompanied
with abdominal distention and feeling of fullness, but no change
in bowel movements. Concurrently, he also has had progressive
shortness of breath that is worse with laying down and with
exertion. He has also noticed lower leg swelling. The pt denies
chest pain, palpitations, cough, fevers, nausea, vomiting, or
diarrhea. The pt says that it was his worsening shortness of
breath that prompted him to come to the ED today.
In the ___ ED, the pt's vital signs were notable for
relatively
soft SBPs in the ___, otherwise within normal limits.
An EKG showed NSR, ___, Q waves V1-V3, and lateral T wave
flattening.
Labs were significant for:
- TropT 0.99-> 0.90-> 0.89
- proBNP 1105
- Hbg 10.7
- Na 131, Cr 1.8, glucose >300, AG=13
- VBG w/ pH 7.37
CXR w/ RLL and perihilar opacities most likely representing
atelectasis and developing pneumonia though trace bilateral
pleural effusions could suggest interstitial edema.
CTA Chest and CT A&P showed:
1. No pulmonary embolus or acute aortic abnormality identified.
2. Findings consistent with pulmonary edema and volume overload
status
including bilateral pleural effusions, as well as periportal and
gallbladder wall edema.
3. Non dependent airspace opacities in the right upper lobe
could
represent superimposed developing pneumonia.
4. Diverticulosis of a is diverticulitis.
Patient was given:
- 8u SQ insulin
- 250mL IVF
- 324mg PO ASA
- Heparin gtt
Cardiology was consulted in the ED and recommended diuresis,
TTE,
ASA load, and heparin drip. The pt was admitted to ___ for
further management.
On the floor the pt confirmed the above history, adding that he
has also had severe depressive symptoms that have worsened in
the
past several months. Reports that he was suicidal recently, but
is now seeing a therapist and on an increased dose of
wellbutrin,
which has helped. He complained of continued abdominal fullness,
orthopnea, lower extremity swelling.
Past Medical History:
1. CARDIAC RISK FACTORS
- Type I Diabetes
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- None
3. OTHER PAST MEDICAL HISTORY
- Diabetic retinopathy
- Diabetic polyneuropathy
- CKD (baseline Cr 1.2-1.4)
- Osteoarthritis
- Depression
PAST SURGICAL HISTORY:
-- Surgery on left foot to correct toe contractures, ___
-- Amputation of toes
-- Appendectomy, ___
-- Laser eye surgery ___
Social History:
___
Family History:
Father and brother with DMI
Mother, father, brother with depression
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
==============================
VS: T 97.5, BP 117/81, HR 85, RR 18, O2 SAT 99% on RA
GENERAL: Well appearing, NAD
NECK: Supple, JVP difficult to appreciate
CARDIAC: RRR, no m/r/g
LUNGS: CTAB, but decreased breath sounds in bases bilaterally
ABDOMEN: Distended, non tender, BS+, no rebound/guarding
EXTREMITIES: Warm and well perfused, 2+ peripheral edema to
knees
bilaterally
SKIN: No significant skin lesions or rashes
PULSES: Distal pulses palpable and symmetric
Discharge PE:
Physical Examination:
General: NAD
Neurological: A/O x3 non-focal
Cardiovascular: RRR
Respiratory: Clear decreased left base
GI/Abdomen: Bowel sounds present Soft ND NT BM ___
Extremities:
Right Upper extremity Warm Edema +1
Left Upper extremity Warm Edema +1
Right Lower extremity Warm Edema +2 pitting
Left Lower extremity Warm Edema +2 pitting
Pulses:
DP Right: P Left: P
Sternal: CDI no erythema or drainage Sternum stable
Upper extremity: Left CDI
Pertinent Results:
ADMISSION LABS
===============
___ 08:30AM BLOOD WBC-8.8 RBC-3.46* Hgb-10.7* Hct-32.0*
MCV-93 MCH-30.9 MCHC-33.4 RDW-12.9 RDWSD-43.1 Plt ___
___ 08:30AM BLOOD Neuts-70.6 Lymphs-17.7* Monos-7.5 Eos-2.7
Baso-0.9 Im ___ AbsNeut-6.18* AbsLymp-1.55 AbsMono-0.66
AbsEos-0.24 AbsBaso-0.08
___ 08:30AM BLOOD ___ PTT-30.0 ___
___ 08:30AM BLOOD Glucose-363* UreaN-33* Creat-1.8* Na-131*
K-4.5 Cl-100 HCO3-18* AnGap-13
___ 08:30AM BLOOD ALT-28 AST-32 AlkPhos-171* TotBili-0.5
___ 08:30AM BLOOD Lipase-18
___ 08:30AM BLOOD cTropnT-0.99* proBNP-1105*
___ 08:30AM BLOOD Albumin-3.5 Calcium-9.3 Phos-4.6* Mg-1.9
___ 08:30AM BLOOD %HbA1c-10.2* eAG-246*
___ 04:19AM BLOOD Triglyc-170* HDL-37* CHOL/HD-6.7
LDLcalc-176*
Discharge:
=
=
=
=
=
================================================================
STUDIES/IMAGING
===============
PA/LAT CXR ___:
Compromised the aeration at both lung bases has not resolved.
Pneumonia is a
possibility, particularly on the right. Small bilateral pleural
effusions
remain. Cardiomediastinal silhouette has the expected
postoperative
appearance. No pneumothorax or pulmonary edema.
___ TEE
Conclusions
Pre-bypass:
No spontaneous echo contrast is seen in the left atrial
appendage. No thrombus is seen in the left atrial appendage. A
small patent foramen ovale is present. There is mild symmetric
left ventricular hypertrophy. Right ventricular chamber size is
normal with mild global free wall hypokinesis. The diameters of
aorta at the sinus, ascending and arch levels are normal. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion.
Post-bypass:
The patient is s/p CABG and in sinus rhythm on infusions of
norepinephrine and epinephrine and later only norepinephrine
1) Biventricular function improved in the setting of inotropic
support with LVEF approximately 45-50%
2) All valvular function unchanged.
3) All visualized portions of aorta intact.
.
___ CTA chest and abdomen
1. No pulmonary embolus or acute aortic abnormality identified.
2. Findings consistent with pulmonary edema and volume overload
status
including bilateral pleural effusions, as well as periportal and
gallbladder
wall edema.
3. Non dependent airspace opacities in the right upper lobe
could represent
superimposed developing pneumonia versus asymmetric pulmonary
edema.
4. Diverticulosis without findings of diverticulitis.
___ TTE
The left atrial volume index is normal. There is mild symmetric
left ventricular hypertrophy with a normal cavity size. There is
moderate-severe regional left ventricular systolic dysfunction
with akinesis of the distal half of the inferior wall and apex,
moderate hypokinesis of the other distal ventricular segments
(see schematic) and mild global hypokinesis of the remaining
segments. The apex is aneurysmal. No thrombus or mass is seen in
the left ventricle. Quantitative biplane left ventricular
ejection fraction is 27 %. Left ventricular cardiac index is
depressed (less than 2.0 L/min/m2). There is no resting left
ventricular outflow tract gradient. Tissue Doppler suggests an
increased left ventricular filling pressure (PCWP greater than
18 mmHg). Normal right ventricular cavity size with mild global
free wall hypokinesis. The aortic sinus diameter is normal for
gender with normal ascending aorta diameter for gender. The
aortic arch diameter is normal. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. There
is no aortic regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse. There is mild [1+]
mitral regurgitation. The tricuspid valve leaflets appear
structurally normal. There is physiologic tricuspid
regurgitation. The pulmonary artery systolic pressure could not
be estimated. There is a trivial pericardial effusion.
___ Coronary angiogram
1. Very severe left ventricular diastolic heart failure.
2. Premature three vessel coronary artery disease with
near-total or total occlusion of all 3 major epicardial coronary
arteries and their major branches.
Brief Hospital Course:
PREOPERATIVE MEDICAL HOSPITAL COURSE
===========
Mr. ___ is a ___ year old male with a history of poorly
controlled DMI, HTN, and HLD who presented with back and
abdominal pain, was found to have NSTEMI, significant 3 vessel
coronary artery disease, newly reduced ejection fraction
(EF=27%), and evidence of fluid overload.
CORONARIES: 3vd
PUMP: EF=27 %
RHYTHM: NSR
# 3 vessel CAD/NSTEMI
Troponins were elevated on admission and continued to rise with
concurrent anginal type symptoms. The patient's EKGs showed
evidence of an anterior infarction and a TTE showed regional
wall motion abnormalities primarily in the apical and inferior
walls, consistent with multivessel CAD. He was started on a
heparin drip, aspirin, high intensity statin, and a beta
blocker. The patient underwent a coronary angiogram which showed
significant 3 vessel coronary artery disease, so no stents were
deployed. Cardiac surgery was consulted and the patient
underwent CABG on ___.
# Acute HFrEF
He also presented with elevated BNP, evidence of volume
overload, and his echo was revealing for newly reduced ejection
fraction w/ EF=27%. The regional wall motion dysfunction was
consistent with ischemic cardiomyopathy as underlying cause. He
was diuresed with IV lasix. His home ___ was held initially in
the setting of an ___. He was also continued on a beta blocker
as above.
# ___ on CKD
Likely cardiorenal given new HF and evidence of volume overload.
The patient was diuresed. Renal function was trended daily and
improved with diuresis.
# Apical akinesis/hypokinesis
TTE was notable for apical dysfunction, but no thrombus. The
patient was continued on a heparin drip while awaiting CABG.
# DMI
Poorly controlled, A1c 10.2%. He was continued on home lantus
and an insulin sliding scale.
POSTOPERATVE ___ COURSE:
Mr. ___ was brought to the Operating Room on ___ where
the patient underwent CABGx4 (LIMA>Diag>LAD, RIMA>dLCx,
LRad>PDA). Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight.
___ was consulted for insulin management given preop A1C of
10.2. He developed ___ on CRI (peak 2) but improved to 1.6
prior to discharge. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. Foley was
replaced for elevated post void residuals, he was started on
Flomax and in setting of low EF (___) his Lasix was changed
to torsemide with improved UO. He will continue on Torsemide
until cardiology follow up. *He will not be discharged on an ACE
inhibitor due to an elevated creatinine* He needs to continue
isosorbide for 6 months due to skeletonized and L radial
arterial grafts. He was evaluated by the Physical Therapy
service for assistance with strength and mobility. By the time
of discharge on POD 6 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to ___ & Rehab and
___ in good condition with appropriate follow up
instructions.
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Glargine 30 Units Breakfast
Glargine 40 Units Bedtime
Insulin SC Sliding Scale using Novalog Insulin
3. Losartan Potassium 100 mg PO DAILY
4. Chlorthalidone 25 mg PO DAILY
5. Coreg CR (carvedilol phosphate) 40 mg oral DAILY
6. Atorvastatin 80 mg PO QPM
7. Doxazosin 12 mg PO HS
8. Wellbutrin XL (buPROPion HCl) 450 mg oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. BuPROPion XL (Once Daily) 450 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Duration: 6 Months
5. Metoprolol Succinate XL 25 mg PO Q12H
6. Ranitidine 150 mg PO DAILY Duration: 30 Days
7. Senna 17.2 mg PO BID:PRN Constipation - First Line
8. Tamsulosin 0.4 mg PO QHS
9. Torsemide 20 mg PO DAILY
Continue until cardiology follow up
10. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
11. Glargine 30 Units Breakfast
Glargine 40 Units Dinner
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
12. Aspirin 81 mg PO DAILY
13. Atorvastatin 80 mg PO QPM
14. HELD- Chlorthalidone 25 mg PO DAILY This medication was
held. Do not restart Chlorthalidone until talking with your
cardiologist
15. HELD- Doxazosin 12 mg PO HS This medication was held. Do
not restart Doxazosin until talking with your cardiologist
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
CAD s/p NSTEMI and CABG this admit
___ on CRI
Urinary retention requiring foley
Uncontrolled Diabetes (A1C 10.2)
Secondary:
Diabetic retinopathy s/p laser surgery, Diabetic polyneuropathy
of feet, CKD (baseline Cr 1.2-1.4), Osteoarthritis, Depression,
type I Diabetes followed by PCP, ___, CAD
Past Surgical History: Surgery on left foot to correct toe
contractures, ___, Amputation of R 1,2 and ___ toe,
appendectomy, ___, Laser eye surgery ___
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
trace Edema
Discharge Instructions:
Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10836446-DS-13
| 10,836,446 | 24,750,712 |
DS
| 13 |
2170-02-20 00:00:00
|
2170-02-21 10:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
erythromycin base / red dye
Attending: ___.
Chief Complaint:
right lower quadrant pain
Major Surgical or Invasive Procedure:
laparoscopic appendectomy
History of Present Illness:
___ with hx of recurrent bilateral ovarian cysts presenting with
3 days of abdominal pain. Patient reports she developed
bilateral
lower quadrant pain in similar fashion to her previous episodes
of ovarian cysts and rupture. She however noted increasing pain,
focused in the right lower abdomen last evening without
palliation.
She reports anorexia, nausea and non-bilious emesis. Denies
fevers or chills. She also reports preceding diarrhea with
abrupt
transition to constipation in the past 24 hours. Patient has an
IUD in place and has not had a menstrual cycle for some time,
with intermittent vaginal bleeding.
Denies hematuria, dysuria, or history of IBD.
Past Medical History:
migraines, ovarian cyst
Social History:
___
Family History:
grandmother with diverticulitis, otherwise no history of
IBD
Physical Exam:
On admission:
PE: VS:97.2 82 110/67 16 100% RA
General: in no acute distress, non-toxic appearing
HEENT: mucus membranes moist, nares clear, trachea at midline
CV: regular rate, rhythm. No appreciable murmurs, rubs, gallops
Pulm: clear to auscultation bilaterally
Abd: obese. non-distended, tender in b/l lower quadrants, R>L
without guarding.
MSK: warm, well perfused
Neuro: alert, oriented to person, place, time
Pertinent Results:
___ 11:28AM URINE WBCCLUMP-RARE MUCOUS-RARE
___ 11:28AM URINE RBC-4* WBC-50* BACTERIA-FEW YEAST-NONE
EPI-11
___ 11:28AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 11:28AM PLT COUNT-214
___ 11:28AM NEUTS-78.3* LYMPHS-10.5* MONOS-7.5 EOS-1.8
BASOS-0.3 IM ___ AbsNeut-7.90* AbsLymp-1.06* AbsMono-0.76
AbsEos-0.18 AbsBaso-0.03
___ 11:28AM WBC-10.1* RBC-4.34 HGB-13.8 HCT-40.6 MCV-94
MCH-31.8 MCHC-34.0 RDW-11.9 RDWSD-40.5
___ 11:28AM ALBUMIN-4.5 CALCIUM-9.4 PHOSPHATE-2.9
MAGNESIUM-2.3
___ 11:28AM ALT(SGPT)-48* AST(SGOT)-28 ALK PHOS-66 TOT
BILI-0.6
___ 11:28AM GLUCOSE-88 UREA N-11 CREAT-0.9 SODIUM-137
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-23 ANION GAP-12
CT A/P:
1. Mildly dilated appendix demonstrating wall edema and subtle
mucosal hyperenhancement with surrounding mild fat stranding.
Although there may be some component superimposed
inflammation/fluid tracking along the right gonadal veins from a
likely rupture right adnexal cysts, in the appropriate clinical
setting findings are concerning for acute appendicitis. No
evidence
of periappendiceal abscess or rupture.
2. 2.2 x 1.7 cm right adnexal cyst with adjacent free simple
pelvic fluid,
compatible with a ruptured cyst.
3. Hepatic steatosis.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed mildly dilated appendix
demonstrating wall edema and subtle mucosal hyperenhancement
with surrounding mild fat stranding in the appropriate clinical
setting findings are concerning for acute appendicitis. No
evidence of periappendiceal abscess or rupture. A 2.2 x 1.7 cm
right adnexal cyst with adjacent free simple pelvic fluid,
compatible with a ruptured cyst, and hepatic steatosis.
WBC was elevated at 10.1. The patient underwent laparoscopic
appendectomy, which went well without complication (refer to the
Operative Note for details). Intraoperative consultation with
ob/gyn found normal appearing uterus, normal tubes, bilateral
cystic ovaries with small simple appearing cysts, no active
bleeding, with no surgical intervention indicated at that time.
After a brief, uneventful stay in the PACU, the patient arrived
on the floor on IV fluids, and on medication for pain control.
The patient was hemodynamically stable. She was given
depo-provera on ___ per ob/gyn recommendations.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. Patient to follow up with primary GYN at
___.
Medications on Admission:
zonigram 125', imitrex, zoloft, wellbutrin; IUD in place
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
Do not take more than 3 grams per day
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Bisacodyl 10 mg PR QHS:PRN constipation
Do not take if having diarrhea
RX *bisacodyl 10 mg 1 suppository(s) rectally at bedtime Disp
#*12 Suppository Refills:*0
3. Docusate Sodium 100 mg PO BID
Do not take if having diarrhea
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
4. Naproxen 500 mg PO Q8H:PRN pain
Do not take if bleeding or if you have stomach pain
RX *naproxen 500 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drive or operate machinery when taking
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
6. Senna 8.6 mg PO BID
Do not take if having diarrhea
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendecitis
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear ___,
You were admitted to ___ and
underwent surgery for removal of your appendix. You are
recovering well and are now ready for discharge. Please follow
the instructions below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
10836638-DS-12
| 10,836,638 | 21,573,101 |
DS
| 12 |
2147-12-06 00:00:00
|
2147-12-06 23:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
iodine / clindamycin / Statins-Hmg-Coa Reductase Inhibitors /
Iodinated Contrast Media
Attending: ___.
Chief Complaint:
Abdominal pain, chest pain, concern for malignancy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Dr. ___ is a ___ retired ___ with past
medical history of diabetes, CAD, history of sponataneous
pneumothorax, retroperitoneal lymphadenopathy, and FDG-avid lung
nodules on outpatient PET-CT, who initially presented to ED with
L sided aching chest pain with unremarkable evaluation, admitted
for evaluation of chronic abdominal/chest pain/concern for
malignancy as patient is originally from ___, and
had
concern about speed of outpatient work up.
Please note that patient arrived with several hundred pages of
old medical records as well as dozens of CDs that I was unable
to
completely review. However, here are the relevant highlights
based on very prolonged discussion with patient and review of
records.
Approximately ___ years ago patient was evaluated for RUQ
abdominal
pain/dysphagia including colonoscopy ___ showing normal
colon
to the cecum, EGD ___ showing esophagitis with erosion,
ultimately culminating in RUQ U/S with concern for polyp and a
positive HIDA scan leading to a laparoscopic cholecystectomy.
However, following procedure had worse/excruciating abdominal
pain, nausea and vomiting.
She then she had repair of umbilical hernia, complicated by an
infection, which lead to CTA/P which revealed some
retroperitoneal mesenteric adenopathy. In review of her imaging,
she has had multiple CTA/P throughout the years. In ___ this
demonstrated multiple lymph nodes in the mesentery and left
paraaortic region. In ___, repeat CT noted "multiple small
lymph nodes in the central abdominal mesentery are again noted
and in the left para-aortic region have not changed
significantly
since the previous scan of ___ and the spleen is not enlarged
but does contain calcified granulomata". Also noted were two
subcentimeter nodules at left base, unchanged since ___ and
___. Throughout this time, she continues to have diffuse
cramping abdominal pain, occasionally associated with vomiting.
Also with reports of regurgitation. She has not lost weight
despite this; notes indicate that she has tried antireflux
therapy to no avail. Repeat scans were obtained again ___
and
___ without change in adenopathy.
However, due to her ongoing GI symptoms in setting of this
lymphadenopathy, she saw heme/onc as an outpatient (Dr. ___. She received PET-CT scan which revealed "FDG avid
lung
nodules and abnormal FDG avid soft tissue lesion in the anterior
mediastinum. The soft tissue lesions/nodules are partially
calcified and could simply represent partially active in
completely burned-out sequelae of granulomatous infection,
however neoplasm also in the differential. Percutaneous biopsy
may be performed as clinically indicated. Stable adenopathy in
the abdomen without abnormal FDG activity. Left kidney lesion
with higher than simple fluid attenuation, new compared to
prior,
no abnormal FDG activity, indeterminate. Indeterminate bilateral
thyroid gland lesions. Recommend thyroid ultrasound for further
evaluation." She received thyroid ultrasound with bilateral
nodules reportedly up to 2.6 cm.
She then had multiple specialist visits at multiple different
centers- she reports that she had an abnormal mammogram, and
went
to ___ for 3D mammogram with plan for core needle biopsy but the
radiologist said that he could not see the lesion and the biopsy
was cancelled.
She was again seen by GI for choking/vomiting, with normal
gastric emptying study; she also reports multiple barium swallow
studies; note is also made of "endoscopy showing hiatal hernia
and dysphagia, as well as mild schastzki ring, not stenosed".
One
of her multiple scans revealed substernal thyroid, which she
worried could be compressing her trachea and esophagus. She
reportedly also saw a pulmonologist at ___ (Dr. ___
who felt that the nodules in patient's lung were unchanged for ___
years and suspected that these were related to prior pleurodesis
for spontaneous pneumonothorax at age ___ did not recommend
further work up.
Review of notes also reveals: negative quantiferon gold and 1:8
positive histoplasmosis
Today she presented to our ED complaining of L sided aching
chest
pain. She reports that when she was ___ she had history of
spontaneous pneumothorax requiring open thoracotomy, and since
then she has had intermittent L sided sharp chest pain. Current
chest pain comes and goes x 4 weeks, not worse with exertion.
Not
associated with shortness of breath, lightheadedness,
diaphoresis, nausea, vomiting. She has had 3 cardiac
catheterizations in the past; does not appear required stenting
at any time. Prior TTE were all with normal EF and no WMA.
In the ED, initial vitals: 97.3 163/72 18 99% RA
GENERAL: AxOx4, well-appearing and in NAD
HEENT: NC, AT. PERRL. EOMI, no conjunctival injection,
oropharynx
clear. MMM
CV: RRR, no murmurs, rubs, or gallops.
RESP: CTAB, moving air well. No crackles or wheezes.
ABD: Soft, non-tender, non-distended. No CVAT.
EXT: No cyanosis, clubbing, or edema. Well perfused, cap refill
<2 sec
NEURO: Grossly non-focal. CNs II-XII grossly intact. Sensation
and motor function of extremities grossly intact.
SKIN: Warm and dry without any rash.
Labs: WBC 5.6 Hgb 12.2 Plt 240
142 | 106 | 28
---------------
4.1 | 25| 0.6
Lactate 1.8
Trop < 0.01
D-dimer 534
CXR: No acute intrathoracic process.
EKG: Sinus rhythm rate 85, LAD, LAFB, normal intervals, LVH, no
acute ST/T wave changes
When she arrived on floor, she confirmed history as above. Also
notes that ___ traffic was very overwhelming, and shares that
she had a good experience with medical care in ___ many years
ago for a brain AVM.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Hypertension
Diabetes
Dyslipidemia
Pulmonary nodules
Non-obstructive CAD s/p cath x 2
ADHD
Retroperitoneal lymphadenopathy
? Schatzki ring
Hiatal hernia
S/p open thoracotomy for spontaneous pneumothorax age ___
Appendectomy age ___
Colon polypectomy ___
LHC x 3 (___)
Carpal tunnel release, bilateral
L TKA ___
Lap cholecystectomy ___
Social History:
___
Family History:
Father deceased from ___ lymphoma at age ___
Mother deceased at age ___, aspiration pneumonia
Brother with CAD, deceased from ruptured AAA
Physical Exam:
ADMISSION EXAM:
VITALS: ___ 2324 Temp: 97.4 PO BP: 133/77 L Sitting HR: 69
RR: 16 O2 sat: 97% O2 delivery: RA FSBG: 155
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. No
cervical lymphadenopathy.
CV: Heart regular, ___ SEM, no S3, no S4. +JVD mid-neck noted
while sitting at 90 degrees
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
___. BG 115
GENERAL: Alert and in no apparent distress, ambulating
independently in hallway
EYES: Anicteric, pupils equally round
ENT: MMM
CV: Heart regular
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, speech fluent, moves all
limbs
PSYCH: pleasant, appropriate affect; very tangential in
conversation
Pertinent Results:
ADMISSION LABS
--------------
___ 08:37PM BLOOD WBC-5.6 RBC-3.87* Hgb-12.2 Hct-37.7
MCV-97 MCH-31.5 MCHC-32.4 RDW-12.3 RDWSD-44.3 Plt ___
___ 08:37PM BLOOD Neuts-57.0 ___ Monos-10.8
Eos-7.3* Baso-0.9 Im ___ AbsNeut-3.18 AbsLymp-1.33
AbsMono-0.60 AbsEos-0.41 AbsBaso-0.05
___ 08:37PM BLOOD ___ PTT-29.9 ___
___ 08:37PM BLOOD Glucose-239* UreaN-28* Creat-0.6 Na-142
K-4.1 Cl-106 HCO3-25 AnGap-11
___ 08:37PM BLOOD ALT-17 AST-19 AlkPhos-75 TotBili-0.3
___ 08:37PM BLOOD Lipase-42
___ 08:37PM BLOOD cTropnT-<0.01
___ 06:58AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:05AM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:37PM BLOOD Albumin-4.2 Calcium-9.6 Phos-2.7 Mg-1.9
___ 07:49AM BLOOD TSH-1.9
___ 08:51PM BLOOD Lactate-1.8
IMAGING
-------
CT torso with contrast on ___, compared to previous OSH CT Chest
performed ___
1. No new lymphadenopathy.
2. Re-demonstrated are multiple areas of subpleural
calcification
consistent patient's history of pleurodesis.
3. Bilateral solid pulmonary nodules measuring up to 6 mm are
unchanged. See recommendations below.
4. Re-demonstration of a multinodular thyroid goiter. As
before,
thyroid ultrasound is recommended if clinically indicated.
5. Lucent lesions in the vertebral bodies measuring 7 mm in T2
and 6 mm in T5 are stable.
6. Moderate hiatal hernia, as before.
7. Please refer to dedicated CT abdomen pelvis for description
of
subdiaphragmatic findings.
RECOMMENDATION(S): For incidentally detected multiple solid
pulmonary nodules measuring 6 to 8mm, a CT follow-up in 3 to 6
months is recommended in a low-risk patient, with an optional CT
follow-up in 18 to 24 months. In a high-risk patient, both a CT
follow-up in 3 to 6 months and in 18 to 24 months
is recommended.
CT abd pelv performed on ___ and compared to previous OSH
CT abd/pelv ___
1. No acute intra-abdominal or intrapelvic pathology.
2. Subcentimeter hypoattenuating lesions in the pancreatic body
measuring up to 5 mm are unchanged since ___ and
likely
represent side branch IPMNs. However, these could be further
evaluated with MRCP if clinically indicated.
3. Stable 8 mm hyperdense renal lesion in the right lower pole
is
consistent with a hemorrhagic cyst.
4. Stable retroperitoneal lymphadenopathy. No new or enlarging
lymph nodes are identified.
5. Stable mild bile duct dilation post cholecystectomy.
6. Please refer to dedicated CT chest performed on the same day
for description of intrathoracic findings.
Second read CT chest (OSH CT from ___
1. Multiple areas of subpleural calcification consistent with
the
patient's prior history of pleurodesis.
2. Bilateral solid pulmonary nodules measuring up to 7 mm,
follow-up is recommended per the ___ criteria as detailed
below.
3. Partially visualized and stable retroperitoneal adenopathy.
4. Multinodular thyroid goiter, recommend ultrasound for further
evaluation if not previously performed.
5. Stable 1 cm indeterminate right renal lesion, recommend
ultrasound for further evaluation if not previously performed.
SECOND OPINION of PET scan from ___:
IMPRESSION:
Many FDG avid pleural based nodules in the left lung. Many small
non avid nodes
in the abdomen and pelvis. Possible hydronephrosis of the left
kidney with a
large cyst.
Video swallow ___:
Single episode of penetration with thin liquids. No aspiration.
CXR ___:
No acute intrathoracic process
Brief Hospital Course:
___ retired psychiatrist with past medical history of
diabetes, CAD, history of sponataneous pneumothorax,
retroperitoneal lymphadenopathy, and FDG-avid nodules on
outpatient PET-CT, who initially presented to ED with left-sided
aching chest pain with unremarkable evaluation, admitted for
evaluation of chronic abdominal/chest pain/concern for
malignancy as patient is originally from ___, and
had concern about speed of outpatient work up.
# Lung nodules: Patient with FDG avid lung nodules seen on
recent PET-CT scan (partially calcified in LUL measuring up to
1.0 cm, 1.1 cm in LUL) however based on CT imaging reports these
appear to have been stable (see CT report from ___. Reportedly
these were evaluated by ___ pulmonologist Dr. ___ who
noted
stability for ___ years which argues against malignant etiology.
Heme-Onc was consulted with question of whether anything needed
to be biopsied urgently and reviewed the current CT chest in
comparison the previous CT chest and the prior PET scan with
radiology. The FDG-Avid left pleural based lesions have
remained stable and seem likely related to the history of
pleurodesis. There was NO evidence of any FDG-Avid anterior
mediastinal mass. The chest imaging showed lucent vertebral
lesions in T2 & T5 that were stable as compared to prior and
will require outpatient follow-up with your oncologist.
Non-urgent thryoid ultrasound should be pursued for the
multinodular goiter. However, ___ Oncology did not recommend
any further inpt evaluation but recommended ongoing follow up
for these imaging findings to ensure stability.
# Retroperitoneal lymphadenopathy: Appears to have been stable
for on serial CTs and LN have been non FDG-avid. Pt denied any
weight loss and lab evaluation was reassuring. Pt was
tolerating po well without any constipation, diarrhea or abd
pain during admission. Heme-Onc did not recommend any further
evaluation of the this finding.
# Dysphagia, Intermittent Nausea, vomiting : much improved
during admission
# Pt was seen by GI and Swallow team with a video swallow test
that was largely unremarkable. GI recommended PPI trial and
Speech team recommended specific behavior strategies. With
these interventions, pt was essentially asymptomatic without any
N/V or difficulty swallowing. Recommend continuing PPI for a 4
week trial and prescription was provided.
# Atypical, intermittent Chest pain: Resolved. EKG without
ischemic changes, troponin negative x 4. States more pronounced
when she lies on her right side and seems to correlate with
anxiety.
# Social, hx of remote TBI: Social work consulted on admission
due to some odd decision making. Pt was noted to have very
tangential conversation. Psychiatry was consulted and felt that
pt had capacity but recommended further OT evaluation for
executive functioning. Pt actually did well with all OT
assessments and executive functioning tests. We were able to
speak with Dr. ___ (___), who states that
many physicians have felt patient was possibly reporting new
symptoms out of concern for cancer. He had no specific
concerns for her mental status. Pt was seen by oncology and
ultimately left frustrated with the lack of a diagnosis or
treatment plan. We spent some time discussing that she will
need ongoing follow up over time but it was reassuring that
nothing was found that required urgent inpt evaluation.
CHRONIC ISSUES:
# Hypertension: Continued home irbesartan 150 mg BID, amlodipine
5 mg daily
# Diabetes: resumed Metformin home regimen on discharge
# ADHD: Continue home Amphetamine-Dextroamphetamine XR 20 mg PO
DAILY
- Continue home Amphetamine-Dextroamphetamine XR 10 mg PO NOON
TRANSITIONS OF CARE
-------------------
[ ] f/u thyroid u/s with biopsy if needed for multi nodular
goiter
[ ] work up for lucent lesions seen at T2 & T5 including SPEP
[ ] f/u mammogram as pt reported previous abnormal ___ though
breast exam was reassuring
[ ] repeat chest imaging in ___ to ensure stability of small
<1cm lung nodules
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. MetFORMIN XR (Glucophage XR) 500 mg PO BID
3. Celecoxib 200 mg oral BID
4. Ranitidine 150 mg PO BID
5. Magnesium Oxide 500 mg PO DAILY
6. irbesartan 150 mg oral BID
7. Amphetamine-Dextroamphetamine XR 20 mg PO DAILY
8. Amphetamine-Dextroamphetamine XR 10 mg PO NOON
9. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
10. Simethicone 40-80 mg PO QID:PRN gas
11. Calcium Carbonate 500 mg PO QID:PRN reflux
12. Lactase Enzyme (lactase) 9000 FCCLU oral TID W/MEALS
13. Voltaren (diclofenac sodium) 1 % topical BID:PRN BID:PRN
Discharge Medications:
1. Omeprazole 20 mg PO BID
4 week trial
RX *omeprazole 20 mg one capsule(s) po twice a day Disp #*60
Capsule Refills:*0
2. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg one tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Amphetamine-Dextroamphetamine XR 20 mg PO DAILY
4. Amphetamine-Dextroamphetamine XR 10 mg PO NOON
5. Calcium Carbonate 500 mg PO QID:PRN reflux
6. Celecoxib 200 mg oral BID
7. Diclofenac Sodium ___ ___ sodium) 1 % topical BID:PRN
BID:PRN
8. irbesartan 150 mg oral BID
RX *irbesartan 150 mg one tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
9. Lactase Enzyme (lactase) 9000 FCCLU oral TID W/MEALS
10. Magnesium Oxide 500 mg PO DAILY
11. MetFORMIN XR (Glucophage XR) 500 mg PO BID
12. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
13. Ranitidine 150 mg PO BID
14. Simethicone 40-80 mg PO QID:PRN gas
Discharge Disposition:
Home
Discharge Diagnosis:
Chest pain, improved
Abdominal pain, imroved
Stable retroperitoneal lymphadenopathy (non FDG avid)
Stable left pleural based nodules, may be due to prior
pleurodesis
Chronic dysphagia
Multinodular goiter, recommend outpt follow up with ultrasound
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___,
___ was a pleasure caring for you during your recent
hospitalization. You came to the hospital with generalized
weakness, chest pain and abdominal pain with concern for
expedited work up. You underwent a CT chest that was compared to
your previous chest CT from ___ and did not show any new
lymphadenopathy. The solid pulmonary nodules were measuring up
to 6mm and appeared unchanged as compared to the prior. Your
PET scan from ___ was reviewed with radiology and
oncology. The FDG-Avid left pleural based lesions have remained
stable and seem likely related to the history of pleurodesis.
There was NO evidence of any FDG-Avid anterior mediastinal mass.
The chest imaging showed lucent vertebral lesions in T2 & T5
that were stable as compared to prior and will require
outpatient follow-up with your oncologist. You should consider
non-urgent thryoid ultrasound for the multinodular goiter.
___ Oncology did not recommend any further inpt evaluation but
recommended ongoing follow up for these imaging findings to
ensure stability.
You mentioned an abnormal mammogram which was meant to be
followed up with biopsy but they were unable to find the initial
lesion during attempted biopsy. Our oncology team performed a
complete breast exam which did not reveal any abnormality.
However given pt's report of abnormal mammogram, we would
recommend a repeat diagnostic mammogram as an outpatient and a
biopsy if indicated.
You were seen by GI and our swallow team for the chronic
dysphagia. You were started on a PPI and have been doing well
with some behavioral strategies to mitigate aspiration risk. We
have put together all of your imaging studies and faxed these
results to your outpatient oncologist. Please make sure to
follow up with your providers close to home for ongoing follow
up.
Best wishes with your ongoing care
Followup Instructions:
___
|
10836841-DS-9
| 10,836,841 | 23,673,711 |
DS
| 9 |
2133-01-20 00:00:00
|
2133-01-20 12:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left leg claudication
Major Surgical or Invasive Procedure:
___: mechanical thrombectomy, lysis catheter placement
___: removal of lysis catheter, L EIA stent x2
History of Present Illness:
This is a case of ___ year old male patient with history of CAD,
HTN and dyslipidemia s/p EVAR on ___ presents with left leg
claudication since ___. every time he walk for more than
100
feet he start having pain all over the left leg. He doesn't have
rest pain nor coldness, weakness or numbness. he denies having
nausea/vomiting, fever or chills or any other complaints. He
came
to the ED for further evaluation
ROS:
(+) per HPI
(-) Denies pain, fevers, chills, night sweats, unexplained
weight
loss, fatigue/malaise/lethargy, changes in appetite, trouble
with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
nausea, vomiting, hematemesis, bloating, cramping, melena,
BRBPR,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary
frequency, urgency
Past Medical History:
dyslipidemia, hypertension, remote MI and two coronary stenting
procedures approximately 19 and ___ years ago; history of heart
failure, however, he endorses stability over the recent years;
emphysema; COPD; anxiety; arthritis.
Social History:
___
Family History:
Significant for two uncles and father with AAA. Once succumbed
to ruptured AAA. Father also had hypertension. Maternal
history of malignancy.
Physical Exam:
On Admission ___:
Vitals: 98.3 77 ___ 100% RA
GEN: AOx3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Pulses: L:P/D/-/D R:P/D/D/D
On Discharge ___:
98.7/98.7 82 97/60 18 96RA
GEN: AOx3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: no c/c/e, both ___, no trauma, groins are c/d/I
Pulses: L: P/P/P/P R:P/P/P/P
Pertinent Results:
___ 07:05AM BLOOD WBC-10.7* RBC-2.92* Hgb-9.5* Hct-28.9*
MCV-99* MCH-32.5* MCHC-32.9 RDW-12.6 RDWSD-45.3 Plt ___
___ 07:05AM BLOOD ___ PTT-29.8 ___
___ 07:05AM BLOOD Glucose-116* UreaN-27* Creat-1.0 Na-132*
K-4.5 Cl-96 HCO3-24 AnGap-17
___ 07:05AM BLOOD Calcium-8.5 Phos-2.3* Mg-2.2
Brief Hospital Course:
Mr. ___ was admitted to the vascular surgery service on
___ with complaints of LLE claudication. He was found on
imaging and physical exam to have an occlusion of the left iliac
portion of his prior EVAR stent. He was treated with heparin
drip and taken to the OR urgently on ___ for an aortogram and
mechanical thrombectomy of the L iliac thrombus with placement
of a lysis catheter for continued tPA infusion over the ensuing
24 hours (see operative report from ___ for further details).
He tolerated this procedure well with postoperative labs all
within normal limits. He was taken back to the OR on ___ for
a repeat aortogram, stent x2 of the L CIA, and removal of the
lysis catheter (see operative report dated ___ for further
details). The patient tolerated this procedure well, with normal
postoperative labs. His groin puncture site appeared intact and
he was started on xarelto on ___. There was a minor amount of
bleeding at his groin puncture site on ___ which resolved
after pressure was applied to the area. Ultrasound was
unrevealing for evidence of pseudoaneurysm formation or
hematoma.
By ___ pt continued to appear well, with stable groin
bruising and no pain on exam. He remained hemodynamically
stable, tolerating a regular diet, and voiding normally. He was
deemed safe for discharge home and was in agreement with this
plan. Follow-up appointments were discussed with the patient who
expressed understanding.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. LORazepam 0.5 mg PO BID:PRN anxiety
3. Atenolol 50 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Pravastatin 40 mg PO QPM
6. albuterol sulfate 90 mcg/actuation inhalation 2 puffs
inhalation q 4 hours
7. Aspirin 81 mg PO DAILY
8. Budesonide 160 mcg-4.5 mcg INHALATION 2 PUFFS INHALATION
EVERY MORNING AND EVERY EVENING
Discharge Medications:
Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
lorazepam 0.5 mg PO/NG BID prn anxiety
Tylenol ___ q6-8hr prn fever/pain
Pravastatin 40 mg PO QPM
Aspirin 81 mg PO/NG DAILY
Rivaroxaban 15 mg PO/NG BID For the next 3 weeks only. Then
change to 20 mg daily.
Atenolol 50 mg PO/NG DAILY
lisinopril 5mg daily
Discharge Disposition:
Home
Discharge Diagnosis:
L iliac graft occulsion
Discharge Condition:
good
Discharge Instructions:
You may continue to eat your regular diet/foods.
You may shower and get your groin wet.
You may continue to take your regular home medications as usual.
You will continue to take xarelto 15mg twice a day for 3 weeks
after your surgery (until ___.
You will then take 20mg xarelto daily.
If you develop fevers, chills, chest pain/shortness of breath,
new and worsened pain in your groin, swelling, bleeding,
expanding hematoma, return of pain/numbness in your left leg, or
any symptoms which are concerning to you, please contact us at
___ (Dr. ___: ___ with
questions or concerns or seek evaluation at the emergency
department.
Followup Instructions:
___
|
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