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10837246-DS-4
| 10,837,246 | 20,606,244 |
DS
| 4 |
2119-01-09 00:00:00
|
2119-01-09 21:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ YO M w/ PMH IDDM, COPD, HTN, BPH, HepC, alcohol abuse in AA<
reported CHF presents with abdominal pain.
Per ED records:
Patient ED for evaluation of abdominal pain. Patient reports he
has been having abdominal pain for the past 2 days. It is
associated with decreased appetite and chills. He denies any
diarrhea or constipation. No nausea or vomiting as he has not
had poor appetite. He denies any associated chest pain or
shortness of breath. He is not anticoagulated. He reports that
the abdominal pain radiates to the flank bilaterally. He does
have a history of bladder infection. He typically gets his care
at ___.
Of note, the triage and EMS report says that the patient was
seen at ___ today. However patient reports that he was not seen
at ___ today and is not on antibiotics. He was previously on
antibiotics for his bladder infection. Per pt, he has a "whole
in his bladder and is scheduled for surgery in a month"
In the ED, initial VS were 4 97.4 100 112/62 19 95% RA .
Exam notable for abd soft, non tender, no emphysema so
reassuring
Labs showed WBC 10.5, Hgb 11.5, lipase 75.
Imaging showed Mildly enlarged bilateral kidneys with striated
enhancement and perinephric stranding, most consistent with
bilateral pyelonephritis, left worse than right. No
hydronephrosis. 2. Asymmetric thickening of the bladder dome
with moderate amount of non dependent air. The finding is
nonspecific. Possible represent colovesicular fistula secondary
to prior diverticulitis. If clinically indicated, MRI or direct
visualization would be helpful. Please correlate with history of
instrumentation or surgical history.
Received Insulin, CTX, IVF
Transfer VS were 98 99 114/60 18 95% RA
On arrival to the floor, patient reports that he has been
having chills and pain since discharge from ___ ___.
Patient had been admitted for hydration, originally presented
there for refill of lantus. Since discharge, he has been having
waxing and waning abdomen and back pain, worsening. He has
weight loss and anorexia as well as nausea. He endorses dysuria
and pink urine. He can eat melon.
His COPD SOB is at baseline. He denies CP/dizziness. Denies
Constipation/diarrhea.
Patient only remembers some of his medications and health
problems. Unfortunately, ___ records were unavailable overnight.
Past Medical History:
- IDDM x ___ years, reports neuropathy in his feet
- COPD
- HTN
- Hep C - never been treated
- reports h/o decompensated CHF in ___
- Depression
- BPH
- h/o incarceration
- s/p MVA in ___ w/ large abd surgery, reports perforating his
bladder during that accident
- s/p abd hernia repair w/ mesh
Social History:
___
Family History:
Mother - lung ca, DM
Dad - died of EtOH cirrhosis
brother and sister died of EtOH cirrhosis; 1 brother still
living (___)
1 son died of heroin overdose, 3 living children
Physical Exam:
Admission Physical Exam:
=======================
VS: 98.9PO 100 / 61 93 94
GENERAL: lying in bed, mild distress
HEENT: AT/NC, EOMI, mild anisocoria L>R, anicteric sclera, pink
conjunctiva, dry mucous membranes
NECK: supple, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, tender in LLQ, RUQ, suprapubically.
Soft, voluntary guarding
BACK: CVA tenderness bilaterally.
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes. Multiple tattoos
Discharge Physical Exam:
=======================
Vitals: 98.7 103/61 82 16 93% RA Tmax 100.7
GENERAL: Alert, oriented, comfortable
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: Supple, JVP not elevated, no LAD
RESP: dry crackles consistent with known COPD, no wheeze
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABD: moderately tender to palpation without rebound
GU: no foley
EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: tattoos all over
EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: tattoos all over
Pertinent Results:
Admission Labs:
===============
___ 11:51PM BLOOD WBC-10.5*# RBC-3.73* Hgb-11.5* Hct-33.7*
MCV-90 MCH-30.8 MCHC-34.1 RDW-16.1* RDWSD-53.5* Plt ___
___ 11:51PM BLOOD Neuts-73.1* Lymphs-15.5* Monos-10.4
Eos-0.1* Baso-0.2 Im ___ AbsNeut-7.71* AbsLymp-1.63
AbsMono-1.10* AbsEos-0.01* AbsBaso-0.02
___ 11:51PM BLOOD Glucose-456* UreaN-30* Creat-1.0 Na-127*
K-4.5 Cl-93* HCO3-22 AnGap-17
___ 11:51PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:10AM BLOOD Lactate-1.6
Discharge Labs:
==============
___ 10:42AM BLOOD WBC-7.9 RBC-3.30* Hgb-10.1* Hct-30.6*
MCV-93 MCH-30.6 MCHC-33.0 RDW-16.4* RDWSD-55.7* Plt ___
___ 10:42AM BLOOD Glucose-298* UreaN-26* Creat-1.0 Na-130*
K-3.3 Cl-96 HCO3-23 AnGap-14
___ 11:51PM BLOOD ALT-31 AST-37 AlkPhos-132* TotBili-1.2
___ 10:42AM BLOOD Mg-1.9
Micro:
=====
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Imaging:
=======
CT abdomen and pelvis:
1. Pyelonephritis, left worse than right. No hydronephrosis or
fluid
collection.
2. Asymmetric thickening of the bladder dome with moderate
amount of non
dependent air and chronic inflammatory changes at the dome,
against extensive
sigmoid diverticulosis. The findings could represent recent
catheterization;
however, chronic inflammatory changes at the bladder dome
against sigmoid
diverticulosis is seen, along with a focal bladder wall defect
(___), and therefore a fistula could be considered. Please
correlate with history of recent instrumentation or
diverticulitis.
3. Cholelithiasis.
___ 04:44AM URINE Blood-SM Nitrite-NEG Protein-30*
Glucose-300* Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-LG
Brief Hospital Course:
___ yo man with DM2 on insulin, COPD, HTN, BPH, HepC, and remote
history for alcohol abuse presenting with abdominal pain imaging
findings suggestive of pyelonephritis in setting on known
colovesicular fistula. Transferred to ___ for continuity of
care.
# Abdominal pain: Give suprapubic tenderness and pyuria as well
as known colovesicular fistula suspected his symptoms were from
pyelonephritis. Transaminases overall unremarkable. CT also
demonstrated pyelonephritis. He was not frankly septic but had
soft blood pressures so he received continuous IVF and a fluid
bolus. He was initially on ceftriaxone and then metronidazole
was added because of known history of colovesicular fistula. Day
1= ___. Urine culture preliminary demonstrated e. coli. Given
prior culture data demonstrating ESBL, his abx were changed to
meropenem prior to discharge.
# Colovesicular fistula: Concern for fistula on CT, patient with
known fistula and plan for outpatient repair. Urology was not
consulted given plan to transfer to ___, where he is well known
to urology and colorectal surgery.
# DM2, insulin dependent: Hyperglycemic to >400 on presentation.
He was started on lantus 44 units QHS and 13 units of lispro
with meals. Patient was not certain of home insulin regimen.
Sugars reasonably well controlled on this regimen but will need
continued titration.
CHRONIC:
#COPD: Complained of wheezing but no increase sputum production
so ipratropium/albuterol nebulizers were made standing every 6
hours.
#HTN: His metoprolol and lisinopril were held give his soft
blood pressures.
#BPH:
- Continued on tamsulosin.
#?CHF: Hx of CHF exacerbation in ___. TTE in ___ showed normal
LVEF of 55%.
- no intervention
#Hep C: Hx of untreated Hep C in ___. Unclear if tx since
- transitional issue
Transitional Issues:
===================
- urine culture with E. coli but no sensis at time of transfer
- please follow blood glucose and adjust insulin regimen as
needed
- meropenem started ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Glargine 44 Units Breakfast
Humalog 13 Units Breakfast
Humalog 13 Units Lunch
Humalog 13 Units Dinner
3. Lunesta (eszopiclone) unknown oral QHS
4. Pregabalin 100 mg PO TID
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Cialis (tadalafil) 20 mg oral daily
8. eszopiclone 1 mg oral QHS
9. Lisinopril 10 mg PO DAILY
10. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
11. Omeprazole 20 mg PO DAILY
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
13. Simvastatin 40 mg PO QPM
14. Tiotropium Bromide 1 CAP IH DAILY
15. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H sob, wheeze
3. Meropenem 500 mg IV Q6H
Started ___ when noted urine culture to be growing E. coli
sensis pending.
4. MetroNIDAZOLE 500 mg PO Q8H
day 1= ___. Senna 8.6 mg PO BID:PRN constipation
6. Glargine 44 Units Breakfast
Humalog 13 Units Breakfast
Humalog 13 Units Lunch
Humalog 13 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
7. Aspirin 81 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Pregabalin 100 mg PO TID
10. Simvastatin 40 mg PO QPM
11. Tamsulosin 0.4 mg PO QHS
12. Tiotropium Bromide 1 CAP IH DAILY
13. HELD- Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB This
medication was held. Do not restart Albuterol Inhaler until
discharged from hospital
14. HELD- Cialis (tadalafil) 20 mg oral daily This medication
was held. Do not restart Cialis until you leave the hospital
15. HELD- eszopiclone 1 mg oral QHS This medication was held.
Do not restart eszopiclone until you leave the hospital
16. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until you leave the hospital
17. HELD- Lunesta (eszopiclone) unknown oral QHS This
medication was held. Do not restart Lunesta until you leave the
hospital
18. HELD- MetFORMIN (Glucophage) 1000 mg PO BID This medication
was held. Do not restart MetFORMIN (Glucophage) until you leave
the hospital
19. HELD- Metoprolol Succinate XL 25 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until you leave the hospital
20. HELD- Naproxen 500 mg PO Q12H:PRN Pain - Moderate This
medication was held. Do not restart Naproxen until you leave the
hospital
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnosis:
pyelonephritis
Colovesicular fistula
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 are being transferred to ___.
Why was I here?
- You had belly pain.
What was done while I was here?
- We think you have a urine infection.
- You got antibiotics for your urine infection.
The doctors ___ will direct your care moving
forward.
Followup Instructions:
___
|
10837602-DS-20
| 10,837,602 | 21,241,133 |
DS
| 20 |
2124-03-03 00:00:00
|
2124-03-03 15:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Bactrim / lisinopril / Penicillins / Keflex
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old woman with metastatic breast cancer
who is admitted with fever in setting of recent liver biopsy
complicated by intrahepatic hematoma.
She underwent elective ___ guided liver biopsy on ___. Case was
complicated by sudden onset nausea, vomiting, nad ___ RUQ
abdmonal pain. She was found to have intrahepatic hematoma nnd
was admitted to the medicine service. There, her HGB remained
stable and he pain was controlled with oral dialudid. She was
discharged on ___. Shortly after discharge home she developed
fever of 101.2 with generalized malaise. She called her
oncologist and was directed back into the ED. She reports her
abdominal pain is currently well controlled. She denies any
nausea and is tolerating po. No recent diarrhea, last BM on
___. She denies URTI symptoms. No dysphagia or odynophagia.
No
CP, SOB or cough. No new rashes, joint pain, or swelling.
In the ED, initial VS were pain 2, T 99.2, HR 98, BP 136/75, RR
16, O2 94%RA. Labs notable for Na 139, K 4.0, HCO3 27, Cr 1.1,
Ca
8.3, Mg 1.9, P 3.5, Ca 8.3, Mg 1.9, P 3.5, ALT 218, AST 211, ALP
77, TBili 0.4, WBC 10.4, HCT 28.9, PLT 170, UA 2 WBC no bacteria
nitrate negative. She was given IV vancomycin and cefepime along
with IV dilaudid and Benadryl. VS prior to transfer were T 98.7,
HR 76, BP 123/69, RR 18, O2 94%RA.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST MEDICAL HISTORY:
- Breast Cancer, metastatic to bone and liver
- Hypertension
- Depression/Anxiety
- Asthma
- Osteopenia
- Osteonecrosis
Social History:
___
Family History:
FAMILY HISTORY:
- Mother deceased, Lung Cancer (smoker)
- Father deceased, Lung Cancer (smoker)
- Sister deceased, ___
- Maternal Grandmother deceased, ___ Cancer, CAD, Stroke
- Paternal Grandmother deceased, ___ Cancer
- Paternal Grandfather deceased, Lung Cancer
Physical Exam:
Admission
=========
VS: T 98.2 HR 82 BP 153/78 RR 18 SAT 93% O2 on RA
GENERAL: Pleasant, sleeping comfortably in bed, awakens easily
to
voice
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses
RESPIRATORY: Appears in no respiratory distress, soft
end-expiratory wheeze diffusely with good air movement
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
mildly
TTP in RUQ without rebound or guarding
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented, CN III-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
DISCHARGE
=========
24 HR Data (last updated ___ @ 858)
Temp: 98.1 (Tm 100.2), BP: 133/80 (133-162/77-102), HR: 73
(73-89), RR: 18 (___), O2 sat: 93% (92-95), O2 delivery: Ra
GENERAL: Pleasant, lying comfortably in bed, sweat on forehead
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses
RESPIRATORY: Appears in no respiratory distress, good air
movement
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
mildly
TTP in RUQ without rebound or guarding
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented, CN III-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes. No significant ecchymoses
Pertinent Results:
Admission
=========
___ 10:31PM BLOOD WBC-10.4* RBC-3.45* Hgb-9.3* Hct-28.9*
MCV-84 MCH-27.0 MCHC-32.2 RDW-14.9 RDWSD-45.1 Plt ___
___ 10:31PM BLOOD Neuts-70.9 Lymphs-14.1* Monos-12.5
Eos-1.9 Baso-0.2 Im ___ AbsNeut-7.41* AbsLymp-1.47
AbsMono-1.30* AbsEos-0.20 AbsBaso-0.02
___ 10:31PM BLOOD Glucose-120* UreaN-11 Creat-1.1 Na-139
K-4.0 Cl-101 HCO3-27 AnGap-11
___ 10:31PM BLOOD ALT-218* AST-211* AlkPhos-77 TotBili-0.4
___ 10:41PM BLOOD Lactate-1.0
Discharge
=========
___ 06:22AM BLOOD WBC-10.4* RBC-3.58* Hgb-9.6* Hct-29.6*
MCV-83 MCH-26.8 MCHC-32.4 RDW-14.7 RDWSD-44.0 Plt ___
___ 06:22AM BLOOD ___ PTT-34.7 ___
___ 06:22AM BLOOD Glucose-107* UreaN-9 Creat-1.0 Na-142
K-4.1 Cl-101 HCO3-28 AnGap-13
___ 06:22AM BLOOD ALT-138* AST-88* LD(LDH)-543* AlkPhos-93
TotBili-0.6
___ 06:22AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.1
Micro
======
Blood Cx: Pending
___ 10:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Imaging
========
CXR: no focal pneumonia
RUQUS
1. Again seen is heterogeneous collection in the right hepatic
lobe, measuring 4.2 x 3.2 x 3.7 cm (previously 4.5 x 3.2 x 6.3
cm on recent CT abdomen pelvis from ___ and 4.5 x 4.3
x 2.3 cm on recent ultrasound from ___ compatible
with the known liquefied hematoma. No biliary dilatation.
2. Heterogeneity of the liver, consistent with multiple known
liver
metastases, better evaluated on recent CTA from ___.
3. Unchanged prominence of the bilateral renal collecting
systems, unchanged from prior.
Brief Hospital Course:
___ is a ___ year old woman with metastatic breast cancer
who is admitted with fever in setting of recent liver biopsy
complicated by intrahepatic hematoma.
# Fever
# Intrahepatic hematoma
Patient with fever at home day of discharge after ___ biopsy c/b
hematoma. Patient started on broad spectrum abx with
vanc/cefepime/flagyl. Remained afebrile and HD stable, with
negative infectious work-up to date (work up for UTI, pneumonia,
blood cultures negative to date). Abx stopped on admission (only
received 1 dose). Fever did not recur after 36 hours off abx,
and patient felt well with improvement in abdominal pain. CBC
remained stable. Repaet RUQUS with stable hematoma. ___ was made
aware of the readmission, likely sampling fluid would be of low
diagnostic yield given that patient received abx, recommended
repeat imaging in ___ weeks, abx plan per primary team. Given
lack of clear infectious etiology, and that the hematoma itself
can cause a low-grade fever, and lack of subsequent fevers,
patient was discharged without antibiotics but with plan for
close followup.
# Metastatic breast cancer
Con't home exemestane
# HTN
Con't home losartan
# Hyperlipidemia
Con't home simvastatin 40mg qpm
# Depression/Anxiety
Con't home citalopram, Ativen 0.5mg qhs prn
Tranitional Issues
[]Patient should have repeat imaging of hematoma with RUQ u/s in
___ weeks to reassess hematoma and monitor for development of
abscess
[]Please follow up blood culture results
[]Patient discharged off antibiotics, no fevers throughout
admission, 36 hours off antibiotics. Please monitor for
recurrent fevers or any new infectious symptoms
CODE: Full (confirmed)
EMERGENCY CONTACT HCP:
Health care proxy chosen: Yes
Name of health care proxy: ___
Relationship: Husband
Cell phone: ___
Proxy form in chart: No
Verified on date: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO QPM
2. Exemestane 25 mg PO DAILY
3. LORazepam 0.5 mg PO Q4H:PRN nausea or anxiety
4. Losartan Potassium 50 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. Senna 17.2 mg PO QHS
8. Simvastatin 40 mg PO QPM
9. Polyethylene Glycol 17 g PO DAILY
10. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
11. Cyanocobalamin 100 mcg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Pyridoxine 50 mg PO DAILY
14. sod phos di, mono-K phos mono ___ mg oral DAILY
15. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Moderate
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
3. Citalopram 20 mg PO QPM
4. Cyanocobalamin 100 mcg PO DAILY
5. Exemestane 25 mg PO DAILY
6. LORazepam 0.5 mg PO Q4H:PRN nausea or anxiety
7. Losartan Potassium 50 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. Polyethylene Glycol 17 g PO DAILY
12. Pyridoxine 50 mg PO DAILY
13. Senna 17.2 mg PO QHS
14. Simvastatin 40 mg PO QPM
15. sod phos di, mono-K phos mono ___ mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Liver hematoma
Metastatic breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
WHY DID YOU COME TO THE HOSPITAL?
-You had a fever after you recently had a biopsy of your liver.
The biopsy itself was complicated by a small bleed in the liver.
WHAT HAPPENED WHILE YOU WERE HERE?
-You were initially started on antibiotics, but these were then
stopped because we did not think you had an infection
-You had repeat imaging of your liver which showed that the
bleeding from your procedure was stable
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Please continue to take all of your medications as directed,
and follow up with all of your doctors.
- If you notice a fever, increasing pain, or any of the symptoms
listed below, please seek immediate medical care.
Again, it was a pleasure taking care of you!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10837716-DS-18
| 10,837,716 | 20,770,327 |
DS
| 18 |
2165-04-28 00:00:00
|
2165-04-29 22:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Demerol / Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
n.a.
History of Present Illness:
Neurology Resident Stroke Admission Note
Time/Date the patient was last known well: ___ at 10:00
Pre-stroke mRS ___ social history for description): 1
t-PA Administration
[] Yes - Time given:
[x] No - Reason t-PA was not administered: outside window
Endovascular intervention:
[]Yes - Time:
[x]No - Reason EVT was not performed: NIHSS < 6, outside window
___ Stroke Scale - Total [3]
1a. Level of Consciousness - 0
1b. LOC Questions - 0
1c. LOC Commands - 0
2. Best Gaze - 0
3. Visual Fields - 2 (chronic)
4. Facial Palsy - 1
5a. Motor arm, left - 0
5b. Motor arm, right - 0
6a. Motor leg, left - 0
6b. Motor leg, right - 0
7. Limb Ataxia - 0
8. Sensory - 0
9. Language - 0
10. Dysarthria - 0
11. Extinction and Neglect - 0
NIHSS was performed within 6 hours of patient presentation or
neurology consult at 02:40.
HPI:
Ms. ___ is a ___ right-handed woman with history
notable for right occipital ischemic stroke (ca. ___, HTN,
HLD,
mild AS, hypothyroidism, and ___ transferred from
___ after presenting with confusion.
Ms. ___ reports first noticing symptoms the day prior to
presentation at approximately 10:00 AM, at which time she felt
that her speech was "garbled," describing this more as using
nonsensical words rather than having difficulty with
pronunciation. She happened to have an appointment with her PCP
shortly thereafter, who recommended evaluation with further
imaging. She felt that she remained symptomatic through the
evening, noting that her symptoms resolved the following
morning.
This morning, Ms. ___ reports returning to her baseline at
breakfast. However, by approximately ___, she noticed
recurrence of her speech disturbance as well as confusion. With
respect to the latter, she elaborates that she planned to go to
her bank to withdraw funds for car repairs, but had significant
difficulty finding her way around her local mall (which she
knows
well). She attempted to ask several bystanders for directions,
but would find herself lost in the mall despite their
suggestions. She did also find that she tended to list to her
left side while ambulating. Eventually, she asked ___ staff for
assistance, who referred her to ___ for further
evaluation. There, she reported resolution of her symptoms, and
underwent non-contrast head CT that did not demonstrate new
findings. Following discussion with the hospitalist, MRI was
recommended, which demonstrated a right frontal infarct; note
was
made of T1 hyperintensity along the margin of the infarct
raising
concerns for possible hemorrhagic transformation (without
dedicated susceptibility-weighted imaging), prompting transfer
to
___ for further evaluation.
On review of systems, aside from the above, Ms. ___ denies
recent headache, lightheadedness, vertigo, vision change,
hearing
change, dysarthria, dysphagia, focal weakness, paresthesiae,
bowel or bladder incontinence, fevers, chills, unintended weight
change, nausea, vomiting, cough, chest discomfort, or changes in
bowel or bladder habits. She does report mild epigastric pain,
for which she is planning to undergo EGD.
Past Medical History:
PMH:
Hypothyroid
Asthma
Gout
GERD
HTN
Colonic polyps
PSH: none
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: T: 97.9 HR: 66 BP: 143/91 RR: 18 SpO2: 96% RA
General: NAD
HEENT: NCAT, neck supple
___: RRR
Pulmonary: no tachypnea or increased WOB
Abdomen: soft, ND
Extremities: warm, mild edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to hospital ___ on
MC)
but not city; reported date as ___ Some
difficulty
in relating history. Inattentive, unable to name days of week
backwards, with backward digit span of 2. Speech otherwise
fluent
with intact comprehension and naming. No evidence of hemineglect
within field of view. Able to follow both midline and
appendicular commands.
- Cranial Nerves: PERRL (3 to 2 mm ___. Left homonymous
hemianopia, somewhat more dense inferiorly. EOMI, no nystagmus.
V1-V3 without deficits to light touch bilaterally. Subtle L
NLFF.
Hearing intact to conversation. Palate elevation symmetric.
Trapezius strength ___ bilaterally. Tongue midline.
- Motor: No drift. Some motor impersistence on left, but on best
effort:
[Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA]
L 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [___]
L 2+ 2+ 2+ 0 0
R 2+ 2+ 2+ 0 0
- Sensory: No deficits to light touch or pinprick throughout,
difficulty with graphesthesia bilaterally (though with some
component of inattention). No extinction to DSS.
- Coordination: No dysmetria with finger-to-nose or HKS testing
bilaterally.
- Gait: Narrow-based and steady.
++++++++++++++++++++++++++++++++++++++++++++++++++++++++
DISCHARGE PHYSICAL EXAM
Physical Exam:
24 HR Data (last updated ___ @ 749)
Temp: 97.6 (Tm 98.0), BP: 132/65 (120-136/57-74), HR: 64
(64-76), RR: 18 (___), O2 sat: 96% (93-96), O2 delivery: Ra
General: Awake, cooperative, color better today
HEENT: NGT, NC/AT, no scleral icterus noted, poor dental
status,
MMM
Pulmonary: Breathing comfortably, no tachypnea nor increased
WOB
Cardiac: skin warm, well-perfused.
Abdomen: soft, normal bowel sounds, non-distended
Extremities: Symmetric, no edema.
Neurologic:
-Mental Status: Alert, oriented to person, place, year.
Attentive, able to provide history. Language is fluent with
intact repetition and comprehension. Able to read a book. Speech
is intermittently slurred but without clear dysarthria. No
paraphasic errors. Able to follow both midline and appendicular
commands.
-Cranial Nerves: PERRL. No clear visual field today. EOMI with a
few beats of R endgaze nystagmus. Facial sensation intact to
light touch. Face symmetric at rest and with activation. Hearing
intact to conversation. ___ strength in trapezii bilaterally.
Tongue protrudes in midline and moves briskly to each side.
-Motor: Normal bulk, tone throughout. Mild left pronator drift.
No adventitious movements
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: Proprioception intact BUE. Intact to LT throughout.
-DTRs: 2+ symmetric
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
- Gait: deferred
Pertinent Results:
___ 01:45AM BLOOD WBC-5.5 RBC-4.52 Hgb-13.7 Hct-40.6 MCV-90
MCH-30.3 MCHC-33.7 RDW-13.7 RDWSD-44.6 Plt ___
___ 07:17AM BLOOD WBC-4.8 RBC-4.55 Hgb-13.4 Hct-40.9 MCV-90
MCH-29.5 MCHC-32.8 RDW-13.6 RDWSD-44.6 Plt ___
___ 01:45AM BLOOD Neuts-52.9 ___ Monos-8.0 Eos-1.1
Baso-0.5 Im ___ AbsNeut-2.92 AbsLymp-2.06 AbsMono-0.44
AbsEos-0.06 AbsBaso-0.03
___ 01:45AM BLOOD ___ PTT-27.6 ___
___ 07:17AM BLOOD Plt ___
___ 01:45AM BLOOD Glucose-88 UreaN-18 Creat-0.9 Na-141
K-7.7* Cl-102 HCO3-27 AnGap-12
___ 07:17AM BLOOD Glucose-90 UreaN-19 Creat-1.1 Na-144
K-4.2 Cl-104 HCO3-25 AnGap-15
___ 01:45AM BLOOD ALT-15 AST-48* CK(CPK)-168 AlkPhos-79
TotBili-0.8
___ 10:54AM BLOOD ALT-11 AST-17
___ 10:54AM BLOOD Lipase-24
___ 01:45AM BLOOD cTropnT-<0.01
___ 01:45AM BLOOD Albumin-3.7 Calcium-8.4 Phos-4.6* Mg-2.2
Cholest-232*
___ 07:17AM BLOOD Calcium-8.9 Phos-5.1* Mg-2.2
___ 01:45AM BLOOD %HbA1c-5.7 eAG-117
___ 01:45AM BLOOD Triglyc-286* HDL-52 CHOL/HD-4.5
LDLcalc-123
___ 07:47AM BLOOD Triglyc-300* HDL-50 CHOL/HD-4.3
LDLcalc-105
___ 01:45AM BLOOD TSH-82*
___ 07:47AM BLOOD TSH-95*
___ 01:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
CTA HEAD AND CTA NECK ___
IMPRESSION:
1. Subacute infract involving the anterior right middle cerebral
artery
territory, with internal hemorrhagic foci.
2. Abrupt focal cutoff of the M2 segment of the right middle
cerebral artery
with patent collateral seen distally.
3. Severe multifocal narrowing of the M2 segment of the left
middle cerebral
artery with patent distal segments.
4. Moderate focal narrowing of the supraclinoid segments of the
internal
carotid arteries, secondary to atherosclerotic disease.
5. Moderate narrowing of the right PCA and moderate to severe
focal narrowing
of the left P2 segment.
6. Focal encephalomalacia of the right PCA territory.
7. Hazy ground-glass opacities are seen in the lung apices,
which may be
secondary to small airway or small vessel disease.
8. For incidentally detected single solid pulmonary nodule
smaller than 6 mm,
no CT follow-up is recommended in a low-risk patient, and an
optional CT in 12
months is recommended in a high-risk patient. See the ___
___
___ Guidelines for the Management of Pulmonary Nodules
Incidentally
Detected on CT" for comments and reference:
___
TTE ___:
CONCLUSION:
The left atrial volume index is normal. The right atrial
pressure could not be estimated. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size. There is suboptimal image quality to
assess regional left ventricular function. A left ventricular
thrombus/mass cannot be excluded. Overall
left ventricular systolic function is hyperdynamic. The visually
estimated left ventricular ejection
fraction is >=75%. There is no resting left ventricular outflow
tract gradient. The right ventricle was not
well seen with normal free wall motion. The aortic sinus
diameter is normal for gender with normal
ascending aorta diameter for gender. There is no evidence for an
aortic arch coarctation. The aortic valve
leaflets (3) are moderately thickened. No masses or vegetations
are seen on the aortic valve. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets are mildly thickened with
no mitral valve prolapse. No masses or vegetations are seen on
the mitral valve. There is trivial mitral
regurgitation. The tricuspid valve is not well seen. There is
physiologic tricuspid regurgitation. The
pulmonary artery systolic pressure could not be estimated. There
is a trivial pericardial effusion.
IMPRESSION: Poor image quality. Due to suboptimal image quality,
a cardiac source of embolism
cannot be fully excluded. Mild symmetric left ventricular
hypertrophy with normal cavity size and
hyperdynamic global systolic function. A focal wall motion
abnormality cannot be fully excluded. No
valvular pathology identified in the views obtained.
TEE ___:
CONCLUSION:
There is no spontaneous echo contrast or thrombus in the body of
the left atrium/left atrial appendage.
The left atrial appendage ejection velocity is mildly depressed.
No spontaneous echo contrast or
thrombus is seen in the body of the right atrium/right atrial
appendage. The right atrial appendage
ejection velocity is normal. There is no evidence for an atrial
septal defect by 2D/color Doppler. Overall
left ventricular systolic function is normal. The right
ventricle has normal free wall motion. There are
simple atheroma in the aortic arch with simple atheroma in the
descending aorta. The aortic valve
leaflets (3) are moderately thickened. No masses or vegetations
are seen on the aortic valve. No abscess
is seen. There is mild to moderate [___] aortic regurgitation.
The mitral valve leaflets are mildly
thickened with no mitral valve prolapse. No masses or
vegetations are seen on the mitral valve. No
abscess is seen. There is physiologic mitral regurgitation. The
tricuspid valve leaflets appear structurally
normal. No mass/vegetation are seen on the tricuspid valve. No
abscess is seen. There is physiologic
tricuspid regurgitation. The pulmonary artery systolic pressure
could not be estimated.
IMPRESSION: Preserved biventricular systolic funciton. Mild to
moderate aortic regurgitation. Simple
atheroma descending thoracic aorta and aortic arch.
Brief Hospital Course:
Ms ___ is a ___ right-handed woman with history
notable for right occipital ischemic stroke (ca. ___, HTN,
HLD, mild AS, hypothyroidism, and fibromyalgia was admitted to
the Stroke Service with confusion secondary to an acute ischemic
stroke in the right MCA. The etiology of Ms ___ stroke
remains unclear although her current stroke in addition to her
prior right-sided infarct in the posterior circulation
potentially suggests a cardioembolic cause rather than an
atheroembolism. A TTE and TEE however failed to detect a
cardioembolic source. She continued on dual antiplatelet therapy
of ASA 81 and Plavix.
Her deficits improved greatly prior to discharge. She will
continue rehab at a rehab center.
Her stroke risk factors include the following:
1) DM: A1c 5.7%
2) Intracranial atherosclerosis - atherosclerotic
calcifications of the internal carotid arteries
3) Hyperlipidemia: LDL 105
# Neuro: Ms ___ was started on dual antiplatelet therapy with
ASA and Plavix with plans to discontinue Plavix after 3 months.
For neuropathic pain of the right ___, particularly at night,
gabapentin was started (200mg QHS) with good effect. Her blood
pressure was monitored and adjusted carefully.
#Cardio: Underwent TTE and TEE with no evidence of cardiac
thrombus. No atrial fibrillation was detected on monitoring. A
Holter monitor was provided (monitoring for 4 weeks at home) on
the day of discharge.
#FEN/GI: Was cleared for purees and thin liquids. NGT was
removed. Good PO intake.
# Psych: For anxiety escitalopram was started.
#Rehab: Ms ___ will be transferred to an inpatient
rehabilitation hospital. The anticipated duration of her rehab
stay is less than 30 days.
=======================================================
Transitional issues:
[] Discount Plavix after 3 months
[] Consider further titration of escitalopram therapy
[] Consider further titration of gabapentin
[] Consider further work up for potential restless leg syndrome
[] Holter monitor for 4 weeks
++++++++++++++++++++++++++++++++++++++++++++++++++++++++
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (X) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (X) Yes (LDL = ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (X) No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - () No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (X) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (X) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Levothyroxine Sodium 125 mcg PO DAILY
3. Omeprazole 20 mg PO BID
4. rOPINIRole 0.5 mg PO QPM
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
3. Escitalopram Oxalate 10 mg PO DAILY
RX *escitalopram oxalate 10 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*3
4. Gabapentin 200 mg PO QHS
RX *gabapentin 400 mg 0.5 (One half) capsule(s) by mouth at
bedtime Disp #*30 Capsule Refills:*3
5. Allopurinol ___ mg PO DAILY
6. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
7. Levothyroxine Sodium 125 mcg PO DAILY
8. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*30
Capsule Refills:*3
9. rOPINIRole 0.5 mg PO QPM
RX *ropinirole 0.5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*3
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute cerebral infarct
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were hospitalized due to symptoms of confusion resulting
from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel
providing oxygen and nutrients to the brain is blocked by a
clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the
brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those
risk
factors. Your risk factors are:
- history of ischemic stroke
- high blood pressure
- high cholesterol
We are changing your medications as follows:
- continue aspirin and plavix
- continue atorvastatin
- continue gabapentin
- continue escitalopram
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10838031-DS-16
| 10,838,031 | 26,432,545 |
DS
| 16 |
2136-08-16 00:00:00
|
2136-08-16 21:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chronic Diarrhea
Major Surgical or Invasive Procedure:
Colonoscopy ___
History of Present Illness:
___ yo M PMH HIV, DM, CKD c/b nephrotic proteinuria (membranous
glomerulonephritis) p/w chronic, persistent diarrhea.
Patient was referred for admission for further workup. He was
seen in ___ clinic ___ who considered
immunosuppressants for treatment of membranous
glomerulonephritis, but this was deferred PND GI clearance in
setting of diarrhea.
In the ED,
- Initial vitals: 96.5 72 186/88 16 100% RA
- Labs showed:
Cr 1.5
- Patient received:
Clonidine 0.1 mg x 2
Losartan 100 mg
Atenolol 100 mg
Nifedipine ER 90 mg
- Transfer VS were: 98.6 59 159/93 16 100% RA
On arrival to the floor, pt reports he currently feels well
other
than the diarrhea. Diarrhea has persisted x ___ year, associated
with 40 lbs weight loss. He denies travel history of infectious
symptoms. He has tried changes in his diet including removal of
lactulose which has not improved symptoms. Also tried
loperamide
as much as tid without change in symptoms. Colonoscopy
performed
___ was suboptimal prep but unremarkable.
Past Medical History:
HIV
hypertension
diabetes mellitus
Social History:
___
Family History:
mother ___ d CAD s/p MI, DM2, htn, ESRD on HD
father ___ d DM2, htn
14 siblings, many with DM2; eldest brother CAD s/p CABG at ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.5 152/87 58 18 98 Ra
General: Alert, oriented, no acute distress
___: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, or rhonchi
CV: RRR, S1/S2, no m/r/g
GI: soft, NT/ND, BS+, no rebound tenderness or guarding, no
organomegaly
MSK: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN2-12 intact, no focal deficits
Skin: No rash or lesion
DISCHARGE PHYSICAL EXAM:
Vital Signs: Temp: 98.1 PO BP: 146/78 HR: 71 RR: 18 O2 sat: 100%
O2 delivery: ra
General: Alert, oriented, no acute distress, wife at bedside
___: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales or
rhonchi
CV: RRR, S1/S2, no m/r/g
GI: soft, NT/ND, BS+, no rebound tenderness or guarding, no
organomegaly
MSK: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN2-12 intact, no focal deficits
Skin: No rash or lesion
Pertinent Results:
Admission Labs:
===============
___ 04:15PM BLOOD WBC-8.5 RBC-4.14* Hgb-11.3* Hct-34.1*
MCV-82 MCH-27.3 MCHC-33.1 RDW-13.4 RDWSD-40.0 Plt ___
___ 04:15PM BLOOD Glucose-120* UreaN-25* Creat-1.5* Na-138
K-4.6 Cl-103 HCO3-24 AnGap-11
___ 04:57PM BLOOD ___ PTT-29.3 ___
___ 04:15PM BLOOD ALT-13 AST-16 LD(LDH)-132 AlkPhos-130
TotBili-<0.2
___ 01:00PM BLOOD Calcium-8.6 Phos-2.9 Mg-1.8
___ 04:15PM BLOOD Albumin-2.7*
GASTRIN 61 [<=100 pg/mL]
MICROBIOLOGY
==============
STRONGYLOIDES AB IGG NEGATIVE
MICROSPORIDIA STAIN (Final ___: NO MICROSPORIDIUM SEEN.
CYCLOSPORA STAIN (Pending):
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.
Cryptosporidium/Giardia (DFA) (Final ___: NO
CRYPTOSPORIDIUM OR GIARDIA SEEN.
RPR Negative
IMAGING:
===========
Chest XRay:
IMPRESSION: In comparison with the study of ___, there
is little change and no evidence of acute cardiopulmonary
disease. No pneumonia, vascular congestion, or pleural
effusion.
Discharge Labs:
=================
___ 07:40AM BLOOD WBC-7.0 RBC-3.89* Hgb-10.7* Hct-31.7*
MCV-82 MCH-27.5 MCHC-33.8 RDW-13.8 RDWSD-40.6 Plt ___
___ 07:40AM BLOOD Glucose-145* UreaN-20 Creat-1.3* Na-141
K-3.9 Cl-105 HCO3-18* AnGap-18
___ 07:40AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.7
Brief Hospital Course:
SUMMARY:
----------
Mr. ___ is a ___ year-old male with a history of HIV, Diabetes
Mellitus, hypertension and recently diagnosed membranous
glomerulonephritis who was admitted for work up of chronic
diarrhea.
ACTIVE ISSUES:
--------------
#Diarrhea: The patient was admitted for chronic diarrhea,
present for ___ year. Upon admission, the patient had an
unremarkable history of travel or food history. The patient
paradoxically was constipated during his admission, to the
extent where he was not able to provide stool samples for 2
days. Gastroenterology was consulted for recommendations. Due to
waxing and waning diarrhea and constipation, it is possible that
the patient's symptoms represent irritable bowel syndrome,
diarrhea predominant. Given his history of HIV, an extensive
infectious work up was done, but was all negative (RPR, stool C
diff, stool microsporidia, stool salmonella and shigella, stool
campylobacter, no ova and parasites in the stool, negative
cryptosporidium/giardia, negative strongyloides). Gastrin was
normal. He underwent EGD colonoscopy on ___. Colonoscopy
demonstrated stool in the colon but otherwise normal mucosa. An
EGD was performed and this showed some blunting of the villi in
the duodenum, which can be seen in celiac disease. The following
labs were pending upon discharge: TTG IGA, Vasoactive intestinal
polypeptide, trypsin, stool elastase, cyclospora stain. Biopsies
were also taken during the EGD and colonoscopy and are pending
upon discharge.
CHRONIC ISSUES:
----------------
#Membranous glomerulonephritis: The patient had significant
proteinuria, and kidney biopsy performed on ___ confirmed
membranous glomerulonephritis. Current nephrology thinking is
this is primary membranous glomerulonephritis;
immunosuppressants has
been considered by nephrology, but they would like GI +/- ID
input regarding diarrhea before doing so. During the admission,
his kidney function remained stable.
#HIV: continued home ARV's
#HTN: continued atenolol QHS, losartan, nifedipine, clonidine
#DM: He received SSI while in house.
TRANSITIONAL ISSUES:
# Follow up with nephrology regarding immunosuppression, as
infectious etiology unlikely.
# Follow up with gastroenterology. Please test Anti-enterocyte
antibodies (not able to be added-on at time of discharge)
Appointment is pending at discharge.
# Please follow up pending labs and pending biopsy results taken
during EGD/colonoscopy. Pending labs at discharge: TTG IGA,
Vasoactive intestinal polypeptide, trypsin, stool elastase,
cyclospora stain.
#CODE:FULL (limited trial of life sustaining treatments,
confirmed)
#COMMUNICATION: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. NIFEdipine (Extended Release) 90 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. CloNIDine 0.1 mg PO BID
6. Atorvastatin 40 mg PO DAILY
7. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
8. Efavirenz 600 mg PO DAILY
9. Omeprazole 20 mg PO BID
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. CloNIDine 0.1 mg PO BID
5. Efavirenz 600 mg PO DAILY
6. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
7. Losartan Potassium 100 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. NIFEdipine (Extended Release) 90 mg PO DAILY
10. Omeprazole 20 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Chronic Diarrhea
Secondary Diagnosis:
Membranous glomerulonephritis
HIV
Hypertension
Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___!
WHY WERE YOU HERE?
You were admitted to the hospital because you were having
chronic diarrhea
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
- While you were in the hospital you had a colonoscopy
- We did not find an infectious cause for your diarrhea
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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2141-03-15 00:00:00
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2141-03-15 14:57:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Levaquin
Attending: ___.
Chief Complaint:
Status post falls; right subdural hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with h/o hypertension, hyperlipidemia,
hypothyroidism, and temporal arteritis on prednisone referred to
the ED for right subdural hematoma and hyponatremia in the
setting of recent falls. Collateral information is obtained from
the ___ OMR. He describes confusion and poor memory distinct
from his baseline, which is reportedly "sharp," since initiation
of prednisone taper by his rheumatologist at ___
___ (initially 60mg daily, down to 35mg daily at present)
in the setting of newly diagnosed temporal arteritis 6 weeks
prior to admission; he lives independently with his wife,
performing ___ without assistance, noting recent
difficulty "keeping facts straight" and maintaining his website,
seemingly coinciding with initiation of prednisone.
Approximately 2 weeks prior to admission, he recalls falling,
with review of the ___ OMR suggesting mechanical fall over a
cement block, causing him to strike his face and chest. He was
seen in the ___ on ___, at which time he was
found to have a left forehead hematoma and multiple
lacerations/abrasions, but neurologic exam was unremarkable, and
noncontrast head CT, cervical spine CT, and CXR were without
evidence of hemorrhage or fracture, prompting discharge home. He
returned to the ___ on ___ for transient
bilateral (left greater than right) blurry vision and
visualization of "colorful images," which he characterizes as
"hallucinations," following a second fall, with repeat
noncontrast head CT negative and subsequent transfer to the
___ for further evaluation. In the ___ ED, he was seen by
the neurology service, with low suspicion for transient ischemic
attack and no clear explanation for "colorful images." Opthalmic
exam was unremarkable and reassuring against ocular abnormality,
either primary or secondary to temporal arteritis, particularly
in the setting of ESR of 2. He was discharged home, opting
against physical/occupational therapy evaluation.
On the day prior to admission, he was referred by his primary
care physician for outpatient MRI in the setting of ongoing
confusion, hallucinations, and unsteadiness. At ___,
labs on the day prior to admission were notable for Na of 125,
BUN/Cr of ___ (consistent with baseline), Hct of 34
(consistent with baseline in ___, and platelets of 115
(consistent with baseline in ___. When review of MRI on the
day of admission revealed subdural hemorrhage, felt to be 1 week
old, he was directed by his primary care physician to ___ for
further evaluation.
In the ED, initial vital signs were: 97.3, 57, 133/49, 18, 98%
RA. Neurologic exam was reportedly nonfocal, with the exception
of chronic amblyopia. Admission labs were notable for Na of 119,
BUN/Cr of ___, serum osm of 260, Hct of 32.1, platelets of
106, normal coagulation panel, urine Na of 61, urine osm of 410,
and negative UA. TSH was drawn and is pending. Repeat serum Na
obtained approximately 75 minutes after admission Na had
improved to 122 without fluid challenge, with hyponatremia felt
to reflect SIADH in the setting of known subdural hemorrhage
with suggestive urine electrolytes. He was evaluated by the
neurosurgery NP, including review of outside hospital MRI with
attending neurosurgeon Dr. ___ ___ radiology; presence of
a 7-mm right subdural hemorrhage with minimal midline shift was
confirmed, with no neurosurgical intervention or follow-up
indicated in the absence of new focal neurologic deficits and
given collection <1cm. Vital signs were not obtained at
transfer.
On the floor, he is feeling well without complaint. He believes
that he is thinking clearly, with only intermittent confusion
and visual hallucinations, denying blurry vision, reduced
acuity, diplopia, headaches, jaw claudication, or focal weakness
or sensory loss. He notes that after prednisone was initiated
weeks prior to admission, he "swelled up," prompting him to
reduce his sodium intake in favor of potassium-based sodium
alternatives. He also describes deliberate increase in fluid
intake over the past several days to counter unsteadiness
attributed by his primary care physician ___ "dehydration." He
denies nausea, vomiting, abdominal pain, or loose stools.
Past Medical History:
Hypertension
Hyperlipidemia
Hypothyroidism
GERD
Chronic kidney injury
Carotid stenosis s/p left carotid endarterectomy and right ICA
stenosis
Temporal arteritis
OSA on CPAP
Amblyopia
Melanoma s/p wide local excision in ___
Left humoral fracture s/p fixation
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission physical:
Vitals: 98.4, 152/60, 73, 18, 96% RA, weight 78.7
General: Alert, oriented x3, no acute distress
HEENT: Multiple healing facial ecchymosis, left periorbital
edema, amblyopia (chronic)
Neck: Supple
Lungs: Breathing comfortably without accessory muscle use,
intermittent nonproductive cough, left-sided crackles to
mid-lung
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, trace pitting edema to
shins bilaterally
Neuro: Alert, oriented x3, CNs ___ intact
Discharge physical:
Vitals: Tm/Tc 97.9, BP 122/69, 72, 18, 98% cpap,
General: Alert, oriented x3, no acute distress
HEENT: Multiple facial ecchymosis, amblyopia (chronic). No oral
lesions visible but patient complained of mouth pain on the L
tongue.
Neck: Supple
Lungs: Improved productive cough with mild wheezes and rales
bilaterally
CV: Regular rate and rhythm, ___ holosystolic murmur loudest at
apex and radiating to axilla,
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, trace pitting edema to
shins bilaterally
Neuro: Alert, oriented x3, CNs ___ intact, no
cogwheeling/tremor/frontal release signs. Conversing well and no
recent hallucinations.
Pertinent Results:
Admission labs:
___ 01:36PM BLOOD WBC-10.9# RBC-3.56* Hgb-11.6* Hct-32.1*
MCV-90 MCH-32.5* MCHC-36.0* RDW-14.8 Plt ___
___ 01:36PM BLOOD ___ PTT-27.4 ___
___ 01:36PM BLOOD Glucose-154* UreaN-30* Creat-1.7* Na-119*
K-4.7 Cl-89* HCO3-25 AnGap-10
___ 01:36PM BLOOD Calcium-8.7 Phos-2.3* Mg-2.0
Pertinent labs:
___ 01:36PM BLOOD Osmolal-260*
___ 01:36PM BLOOD TSH-14*
___ 06:50AM BLOOD Free T4-0.22*
___ 06:30AM BLOOD T4-1.2*
Micro: none
Imaging:
Heart size is top normal, unchanged. Tortuous aorta is seen in
descending
portion. Upper lungs are clear. Right basal opacity most
likely representing
linear atelectasis and appears to be unchanged as compared to
prior study.
Left lower lung is essentially clear. Minimal amount of pleural
effusion
appears to be similar to the prior study and alternatively might
represent
area of pleural thickening. Slight leftward deviation of the
trachea and mild
narrowing at its superior portion is redemonstrated due to
slight enlargement
of the right thyroid gland as demonstrated on the CT neck from
___.
Noncontrast head CT (___):
NO EVIDENCE OF ACUTE INTRACRANIAL ABNORMALITY.
Old imaging:
Cervical spine CT (___):
1. NO EVIDENCE OF ACUTE FRACTURE OR MALALIGNMENT.
2. MULTILEVEL DEGENERATIVE CHANGES OF THE CERVICAL SPINE.
3. 6 MM LEFT UPPER LOBE PULMONARY NODULE, INCOMPLETELY
CHARACTERIZED
ON THIS NON-DEDICATED EXAMINATION. FURTHER EVALUATION WITH
DEDICATED CHEST CT CAN BE OBTAINED, IF DESIRED.
Noncontrast head CT (___):
NO EVIDENCE OF ACUTE INTRACRANIAL HEMORRHAGE OR LARGE
TERRITORIAL
INFARCTION.
CXR PA/lateral (___):
Three views. Comparison with the previous study of ___.
There is now streaky density at the lung bases consistent with
subsegmental atelectasis or scarring. Lung volumes are somewhat
low. There is no focal consolidation. The heart is at the upper
limit of normal in size as before. The aorta is mildly tortuous
and calcified. Mediastinal structures are otherwise
unremarkable. The bony thorax is grossly intact. There is no
significant change.
Carotid Duplex ultrasound (___):
SLIGHT INCREASE IN VELOCITY IN THE PROXIMAL RIGHT INTERNAL
CAROTID
ARTERY WHERE THE MARKED SHADOWING FROM THE PLAQUE FORMATION MAY
HIDE A MORE SEVERE STENOSIS. ITS MEASUREMENTS CANNOT BE OBTAINED
IN THE
SHADOWED SEGMENT. THE STENOSIS NOW IS CALCULATED TO 60-70%.
ON THE LEFT SIDE, THE PROXIMAL INTERNAL CAROTID ARTERY HAS A
CALCULATED STENOSIS IN THE REGION OF 40-60%.
Discharge labs:
___ 06:50AM BLOOD WBC-6.9 RBC-3.78* Hgb-12.3* Hct-34.6*
MCV-92 MCH-32.5* MCHC-35.6* RDW-14.8 Plt ___
___ 04:17AM BLOOD Glucose-115* UreaN-25* Creat-1.6* Na-129*
K-4.4 Cl-94* HCO3-33* AnGap-6*
___ 04:17AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.1
Brief Hospital Course:
Mr. ___ is a ___ with h/o hypertension, hyperlipidemia,
hypothyroidism, and temporal arteritis referred to the ED for
right subdural hematoma and hyponatremia in the setting of
recent falls.
#Productive cough: patient had a productive cough during his
hospital stay. Received guifenesin, cough improved. CXR from
___ with no acute abnormalities.
# Subdural hematoma: He was found to have a 7-mm right subdural
hematoma with minimal midline shift in the setting of multiple
recent falls and no focal neurologic deficits. He was evaluated
by the neurosurgical service in the ED, with no intervention or
dedicated neurosurgical follow-up advised, given <1-cm hematoma
and absence of neurologic compromise. Restarted ASA on ___. He
was placed on neuro precautions.
# Hyponatremia: He was found to be hyponatremic to 125 at
___ on the day prior to admission, down from most
recent baseline of 132 on ___ and 141 in ___. Na was 119
on the afternoon of admission, approximately 20 hours later,
back up to 125 approximately 24 hours after initial Na was
obtained, without dedicated intervention. In the setting of
suggestive urine Na, acute-on-subacute hyponatremia likely
represents SIADH in the setting of subdural hematoma, with
improvement following effective fluid restriction. TSH 14,
suggesting that hypothyroidism may also play a role in his
hyponatremia. In addition, cerebral salt wasting is also a
possibility and losartan can potentially cause hyponatremia as
well. Urine uric acid is normal. Trended Na bid for now pending
return to baseline, with aim to correct conservatively by ___
mEq daily, given relative chronicity. TSH/FT4 also noted to be
low and he was changed from 5 days per week to 7 days per week
rather than 5 as TSH 14. Will need further titration as an
outpatient. Losartan held given possible connection to
hyponatremia.
# Confusion/visual hallucinations: Confusion and visual
hallucination may reflect steroid-induced psychosis, given onset
coinciding with initiation of prednisone, though it is not clear
that symptoms have improved with taper. Profound hyponatremia is
likely too acute to account for ongoing symptoms. A progressive
neurological disorder such as ___ body dementia is also
possible, although no clear neurological deficits noted. Will
have timely f/u with rheum to see if current steroid dose is
appropriate.
# Falls: He has experienced multiple recent falls, the first
clearly mechanical by report, the second of less clear etiology
by report, though he denies preceding chest pain, palpitations,
or other prodromal symptoms. Given his age and multiple
antihypertensive agents, orthostasis is possible. Monitored on
telemetry, ___ assessed and patient will need rehab.
# Temporal arteritis: Temporal arteritis was diagnosed
approximately 6 weeks ago and is managed by Dr. ___
___. Prednisone has been tapered from
60mg daily to 35mg daily per his report. Continued prednisone
35mg daily for now; clarify taper with outpatient rheumatologist
# Hypertension: He is mildly hypertensive to 150s systolic on
arrival. Continued home amlodipine and terazosin held home
losartan for now, given possible hyponatremia as above, with low
threshold to resume if blood pressure persistently greater than
150s-160s systolic
# Hyperlipidemia: Continued home rosuvastatin.
# Chronic kidney injury: Creatinine is consistent with recent
baseline at 1.7 on admission. Trended creatinine daily, avoided
nephrotoxins; renally dosed medications
# Chronic normocytic anemia: Hematocrit is consistent with
recent baseline of ___ on admission, perhaps reflecting anemia
of chronic inflammation in the setting of underlying
rheumatologic condition. Myelodysplastic syndrome also is
possible, given concurrent thrombocytopenia. There is no
suggestion of blood loss, except intracranial, by history,
though no recent colonoscopy is available. Trended hematocrit
daily.
# Thrombocytopenia: Platelet count is consistent with recent
baseline of 100s on admission and of uncertain etiology, though
myelodysplastic syndrome is considered as above. Trended
platelets daily
# Possible diabetes mellitus: On confirmation of medication list
at ___ pharmacy, there was mention of lancets and needles in
past records, though no insulin prescribed. Glucose was not
particularly elevated (150s) on admission.
# GERD: Held home lansoprazole (nonformulary) in favor of
pantoprazole (formulary).
# OSA: Consulted respiratory for CPAP.
# CODE: DNR/DNI (confirmed)
# CONTACT: Wife/HCP ___ ___
___ issues:
-Patient will need a BMP performed on ___ to ensure
stability of Na and K. He should continue a 1.5 L fluid
restriction until Na is stable. His losartan was held at
discharge given high-normal K; may be restarted if K not
elevated upon recheck.
-Further discussion needed about the speed of the patient's
prednisone taper as he is having side effects from this
medication, including hallucinations.
-The patient's levothyroxine was made daily rather than 5 days
weekly given his high TSH and low T4. Will likely need further
titration as an outpatient.
-Of note, CT C-spine from ___ (prior to current
hospitalization) showed a pulmonary nodule; follow-up
recommended.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 35 mg PO DAILY
2. Alendronate Sodium 70 mg PO QMON
3. Losartan Potassium 50 mg PO BID
4. Rosuvastatin Calcium 5 mg PO DAILY
5. Terazosin 5 mg PO HS
6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
7. Levothyroxine Sodium 150 mcg PO 5X/WEEK (___)
8. Amlodipine 10 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Calcium Carbonate Dose is Unknown PO Frequency is Unknown
11. Vitamin D Dose is Unknown PO Frequency is Unknown
12. Multivitamins 1 TAB PO DAILY
13. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. PredniSONE 35 mg PO DAILY
Tapered dose - DOWN
5. Terazosin 5 mg PO HS
6. Rosuvastatin Calcium 5 mg PO DAILY
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Guaifenesin ___ mL PO Q6H:PRN cough
9. Lidocaine Viscous 2% 15 mL PO TID:PRN mouth pain
10. Senna 8.6 mg PO BID:PRN constipation
11. Vitamin D 800 UNIT PO DAILY
12. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
13. Calcium Carbonate 500 mg PO BID
14. Alendronate Sodium 70 mg PO QMON
15. Levothyroxine Sodium 150 mcg PO DAILY
16. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
# Subdural hematoma
# Hyponatremia
# Confusion/visual hallucinationns
# Falls
# Temporal arteritis
Secondary diagnoses:
# Hypertension
# Hyperlipidemia
# Chronic kidney injury
# Chronic normocytic anemia
# Thrombocytopenia
# Possible diabetes mellitus
# GERD
# OSA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted
with low salt in your blood and we limited how much water you
drank. This was probably a result of the fall you had where you
hit your head. Your symptoms improved during your
hospitalization and we also adjusted your thyroid medication. We
have scheduled you for close follow-up with Dr. ___ to
discuss your prednisone dose further. You will be going to rehab
after discharge to regain some of your strength.
If you notice increasing confusion, nausea/vomiting, or
unsteadiness on your feet, these may be signs that your symptoms
are returning and you should call your physician's office or go
to the Emergency Department.
Take care, and we wish you the best.
Sincerely,
Your ___ medicine team
Followup Instructions:
___
|
10838161-DS-3
| 10,838,161 | 22,368,009 |
DS
| 3 |
2153-05-12 00:00:00
|
2153-05-14 15:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered Mental Status / Seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old woman with past history remarkable
for an alcohol related fall in ___ with bilateral subdural
hemorrhages status post right sided hemicraniotomy with
evacuation of hematoma and duraplasty who presented to ___ for sudden onset of altered mental status as well as
aphasia. Per the patient's daughters who were present at
bedside, she was noted to be in her usual state of health
despite
having a number of UTIs over the course of the past months (most
recently a MDRO was cultured per the daughter, but she was
unable
to remark its speciation of management with antibiotic). She
was
having normal cognition with the exception of some mild issues
with word finding, which has been persistent since her admission
in ___.
At 1815hrs on ___, she was noted by her rehabilitation
facility to have sudden onset of confusion and aphasia for which
EMS was contacted. In the emergency department at ___, the patient was seen to have generalized convulsive
episodes which were each less than 1 minute in duration and had
interictal periods with decreased responsiveness. She was given
a dose of 1mg Ativan for ablation and loaded at the OSH with
fosphenytoin. At ___, a ___ was performed which
demonstrated what was noted by their radiologist's concerning
for
hydrocephalus of unclear cause, at which time transfer was
initiated to ___ ED for further evaluation here by
neurosurgery.
ROS was unable to be obtained, however, per the daughters who
visited with the patient prior to the onset of her symptoms, she
was noted to have no complaints. She has a history of multiple
UTI, however, no recent dysuria was noted (although the patient
at baseline has been incontinent of urine since her presentation
in ___. At baseline, the patient uses a walker for unsteady
gait.
Past Medical History:
- Bilateral Subdural Hematomas in ___ EtOH related fall
status post right-sided craniotomy for decompression with
evacuation of hematoma and allographic duraplasty
- SDH complicated by non-convulsive status on EEG and convulsive
episodes, also complicated by Ventilator Associated Pneumonia
- Previous EtOH abuse ___ pint of vodka a day
- Atrial Fibrillation
- Hypertension
- Diabetes
- Traumatic head injury
- Hyponatremia
- Altered mental status
Social History:
___
Family History:
- Father - DM
- Mother - ___ CA
Physical Exam:
T=97.6F, HR=73, BP=127/51-145/58, ___, SaO2=99% RA
General: Awake, confused, aphasic
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, inattentive, aphasic. Regarded the
evaluator on the left quickly, but required multiple commands to
cross midline. There was some evidence of right sided neglect;
however, this could be overcome with repeat calls on right side
or repeat threat to right fields of vision. Patient was
globally
aphasic with only minimal response to voice.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm, both directly and consentually; brisk
bilaterally. VFF to threat moreso in left. Funduscopic exam
revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus with poor gaze to right but
was able to cross midline. Saccadic intrusions.
V: Facial sensation ___ strength in masseter
VII: No facial droop evident, facial musculature symmetric but
unable to assess ___ cooperation
VIII: Hearing intact to voice but unable to assess any
lateralizing deficit ___ cooperation.
IX, X, XI, & XII: Did not cooperation with testing of either
- Motor: Normal bulk, tone throughout. Unable to assess pronator
drift ___ compliance. No adventitious movements, such as tremor,
noted. No asterixis noted. Moves all antigravity but did not
cooperate with strength testing
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 4 ___ beat clonus)
R 3 3 3 3 4 ___ beat clonus)
- Plantar response was extensor bilaterally.
- Pectoralis Jerk and Crossed Adductors are present bilaterally.
- Sensory: Unable to fully assess ___ cooperation/AMS, w/d to
pain in all extremities
- Coordination and Gait: Did not evaluate ___ cooperation
Discharge exam:
General: Awake, improved attention, aphasic
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, improved attention, aphasic. -Cranial
Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. VFF to threat moreso in left. Funduscopic exam
revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus with poor gaze to right but
was able to cross midline. Saccadic intrusions.
V: Facial sensation ___ strength in masseter
VII: No facial droop evident, facial musculature symmetric but
unable to assess ___ cooperation
VIII: Hearing intact to voice
IX, X, XI, & XII: Did not cooperation with testing of either
- Motor: Normal bulk, tone throughout. Unable to assess pronator
drift ___ compliance. No adventitious movements, such as tremor,
noted. No asterixis noted. Moves all antigravity but did not
cooperate with strength testing
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 4 ___ beat clonus)
R 3 3 3 3 4 ___ beat clonus)
- Plantar response was extensor bilaterally.
- Pectoralis Jerk and Crossed Adductors are present bilaterally.
- Sensory: intact to LT.
Pertinent Results:
MRI BRAIN:
FINDINGS:
There is a new small area of increased diffusion signal within
the medial left occipital lobe without a definite corresponding
low signal on the ADC map. This is compatible with a subacute
infarct. An older infarct is present within the left temporal
lobe with associated FLAIR signal abnormality as seen on the
prior examination.
Periventricular white matter T2 and FLAIR prolongation is likely
related to small vessel ischemic disease. There is no mass,
mass effect or midline shift. No intracranial hemorrhage is
present. The patient is status post right frontal craniotomy.
The degree of brain atrophy is commensurate with the size of the
ventricles. The ventricles are unchanged in size and
configuration. The major intracranial flow voids are present.
Again noted is fluid signal within both mastoids.
IMPRESSION:
New small region of diffusion signal abnormality within the
medial left
occipital lobe compatible with subacute infarct. There is an
older infarct within the left temporal lobe as seen on the
prior. No intracranial hemorrhage.
CT/CTA HEAD and NECK:
FINDINGS:
And ECT: No intracranial hemorrhage is identified. There is no
mass, mass effect or midline shift. A subacute infarction is
present in the medial left occipital lobe, and there is an older
infarct in the left temporal lobe as seen on the prior MRI
examinations. Hypoattenuation in the periventricular white
matter is most consistent with small vessel ischemic disease.
There is diffuse brain atrophy with compensatory dilatation of
the ventricles. The ventricular system is unchanged in size.
The patient is status post right parietal craniotomy.
CTA head: Atherosclerotic calcifications at the cavernous
portions of both internal carotid arteries do not cause
hemodynamically significant stenosis. There is no evidence for
dissection or occlusion. No aneurysm or arteriovenous
malformation is present.
CTA neck: There is a beaded appearance of both cervical internal
carotid
arteries consistent with fibromuscular dysplasia. No evidence
for
fibromuscular dysplasia is seen in the vertebral arteries.
Calcified plaque is present at both carotid bifurcations without
hemodynamically significant stenosis. The bilateral common
carotid arteries, internal carotid arteries and vertebral
arteries are patent. The origins of the external carotid
arteries are patent. There is no evidence for dissection.
Scattered small lymph nodes are present within the lower neck.
IMPRESSION:
The appearance of the cervical internal carotid arteries is
consistent with fibromuscular dysplasia. No evidence for
fibromuscular dysplasia is seen in
the vertebral arteries.
No evidence for occlusion or stenosis.
Evolving infarct in the left occipital lobe. No intracranial
hemorrhage.
EEG #1:
FINDINGS:
BACKGROUND: Demonstrates a low amplitude delta and theta
frequency slowing over the left hemispheric leads. A higher
amplitude disorganized mixed frequency alpha can be appreciated
over the rightsided leads.
AUTOMATED SPIKE DETECTION: There were approximately 37 entries
in this file. They capture the interictal spike and sharp
discharges most prominently seen over the left temporal leads.
AUTOMATED SEIZURE DETECTION: There were no entries in this file.
PUSHBUTTON ACTIVATION: There were no entries in this file. There
was one
sitter annotation at 19:24:55 stating that the patient is
agitated. There is no electrographic seizure. On video, the
patient is lying in bed and is moving her arms which are in
restraints.
SLEEP: The patient appeared to transition through the various
stages of
sleep.
CARDIAC MONITOR: Showed a generally normal sinus rhythm at 70-80
bpm on
single EKG strip.
IMPRESSION: This 24 hour video EEG telemetry captured no
pushbutton
activations and no electrographic seizures. Automated and
routine sampling
demonstrated interictal discharges over the left temporal leads
and slowing
over the left hemisphere.
EEG #2:
FINDINGS:
BACKGROUND: Demonstrates a relative suppression of the left
hemispheric leads
relative to the right. A low amplitude delta and theta frequency
slowing can
be appreciated over the left hemispheric leads. At times, brief
one to two
second periods of higher amplitude delta with sharp discharges
can be seen
over this region. A disorganized mixed frequency alpha can be
appreciated
over the rightsided leads.
AUTOMATED SPIKE DETECTION: There were 19 entries in this file.
They capture
the interictal spike and sharp discharges most prominently seen
over the left
temporal leads.
AUTOMATED SEIZURE DETECTION: There was one entry in this file.
The event was
triggered by muscle artifact.
PUSHBUTTON ACTIVATION: There were no entries in this file.
SLEEP: The patient appeared to transition through the various
stages of
sleep.
CARDIAC MONITOR: Showed a generally normal sinus rhythm at 70-80
bpm on
single EKG strip.
IMPRESSION: This five hour video EEG telemetry captured no
pushbutton
activations and no electrographic seizures. Automated and
routine sampling
demonstrated interictal discharges over the left temporal leads
and slowing
over the left hemisphere. EEG is unchanged from the prior day.
Brief Hospital Course:
___ RHF with history of b/l SDH related to TBI/EtOH which was
c/b seizures (convulsive and non-convulsive) who presents from
her care facility to ___ ED via OSH for AMS.
# Neuro - subdural hemorrhage, altered mental status and acute
stroke.
Patient was admitted to the general neurology service for
altered mental status and seizures. The patient was placed on
continuous video EEG to assess seizure activity. Upon admission
patient was found to be globally aphasic. The patient was found
to have PLEDs on EEG of uncertain significance. No overt ictal
activity was seen on EEG, however AMS and aphasia was felt to
likely be due to some form of subcortical nonconvulsive status
epilepticus. Thus her AEDs were gradually up titrated. She was
also found to have a retro cardiac opacity on chest xray
concerning for pneumonia and was treated with a 7 day course of
vancomycin and zosyn for health care associated pneumonia. With
treatment of her pneumonia and increased doses of AEDs the
patient's mental status slowly improved, but continued to
fluctuate somewhat. She began to follow some command and was
oriented to self and hospital at times. However, aphasia
continued. As a result repeat MRI was performed which showed a
new evolving left occipital lobe ischemic stroke, which likely
occur just prior to or within the first few days of admission.
The patient was started on aspirin and Hbg A1C, lipids and TSH
were checked. An ECHO was attempted but the patient was unable
to cooperated with the exam. The patient's stroke likely
accounts for her continued aphasia, but mental status is
otherwise improved.
# Pneumonia: s/p 7 day course of vancomycin and zosyn for health
care associated pneumonia as described above. At the time of
discharge, patient was afebrile with no leukocytosis.
# Nutritional status:
The patient's nutritional status has been poor throughout the
admission. Additionally, an attempt was made to change
medications from IV to PO, but the patient could not tolerate
this reliably. As a result a PEG tube was place. Nutrition was
consulted to assist with tubefeed recoomendations.
The patient was discharged to rehab with planned neurology
follow up.
Medications on Admission:
- ASA 81mg Daily
- Levemir 100 unit/mL Sub-Q Subcutaneous 14 units at bedtime
- Zonisamide 300 mg Daily
- Divalproex ___ mg sprinkle BID
- Levetiracetam 500 mg BID
- Trazodone 50 mg bedtime
- Ativan 0.25 mg bedtime
- Citalopram 10 mg Daily
- Bumetanide 1 mg Daily
- Digoxin 125 mcg Daily
- Docusate sodium 100 mg BID
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Citalopram 10 mg PO DAILY
3. Digoxin 0.125 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Zonisamide 300 mg PO DAILY
6. Levemir *NF* (insulin detemir) 100 unit/mL Subcutaneous qhs
7. LACOSamide 150 mg PO BID
8. Phenytoin Infatab 150 mg PO TID
9. LeVETiracetam 750 mg PO BID
10. Lorazepam 0.25 mg PO HS:PRN agitation
11. TraZODone 50 mg PO HS:PRN insomnia
12. Divalproex (DELayed Release) 1000 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ischemic stroke, seizures, pneumonia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for confusion and a seizure.
These likely resulted from both a pneumonia and a new stroke.
Your pneumonia was treated with a week of antibiotics. You were
started on aspirin for stroke prevention. Your seizure medicines
were increased and your mental status improved. However you are
still having some trouble understanding and making speech, which
is most likely resulting from your stroke. A feeding tube was
placed because your nutrition was poor and you were unable to
take pills by mouth.
We made the following changes to your medications:
1) We INCREASED you ASPIRIN to 325mg once a day.
2) We INCREASED your KEPPRA to 750mg twice a day.
3) We INCREASED your DEPAKOTE to 1,000mg twice a day.
4) We STOPPED your BUMETANIDE.
You will need to get your depakote and dilantin level checked
weekly while you are at your nursing facility. These results
should be phoned in to Drs. ___ at ___.
Please follow up in neurology clinic as below.
It was a pleasure taking care of you during this hospital stay.
If you experience any of the below warning signs please call ___
or go to your nearest emergency room immediately.
Followup Instructions:
___
|
10838202-DS-12
| 10,838,202 | 24,373,680 |
DS
| 12 |
2141-02-23 00:00:00
|
2141-02-23 18:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
laparoscopic cholecystectomy
History of Present Illness:
Ms. ___ is a ___ otherwise healthy who p/w acute epigastric
pain found to have gallstone pancreatitis. Briefly, patient
developed new onset epigastric abdominal pain on ___
accompanied
by N/V. She presented to the ED where she was found to have
significantly elevated lipase to ___ and MRCP c/f acute
pancreatitis and cholelithiasis w/o
cholecystitis/choledocolithiasis. ACS is now consulted regarding
timing of interval CCY. Patient currently reports improved
abdominal pain and denies fevers/chills, diarrhea/constipation,
CP/SOB, jaundice/pruritis, dysuria.
Past Medical History:
-headaches
-G1P1 spontaneous vaginal delivery ___ w/ gestational HTN
complication by post-partum hemorrhage. She is not breast
feeding.
Social History:
___
Family History:
-Mother: HTN
-___ h/o gallbladder disease.
Physical Exam:
-VS: reviewed, afebrile
-General Appearance: pleasant, comfortable, no acute distress
-Eyes: PERLL, EOMI, no conjuctival injection, anicteric
-HENT: moist mucus membranes, atraumatic, normocephalic
-Respiratory: clear b/l, no wheeze
-Cardiovascular: RRR, no murmur
-Gastrointestinal: s/p lap chole, surgical sites c/d/I,
appropriate tenderness, non-distended, no guarding, no rebound
-GU: no foley, no CVA/suprapubic tenderness
-Musculoskeletal: no pedal edema, no joint swelling
-Skin: no rash, ulceration, or jaundice noted
-Neuro: no focal neurological deficits, CN ___ grossly intact
-Psychiatric: appropriate mood and affect
Pertinent Results:
ADMISSION LABS
___ 08:00AM BLOOD WBC-8.2# RBC-4.76 Hgb-14.2 Hct-42.3
MCV-89 MCH-29.8 MCHC-33.6 RDW-12.4 RDWSD-40.8 Plt ___
___ 08:00AM BLOOD Neuts-79.2* Lymphs-9.9* Monos-9.8
Eos-0.4* Baso-0.2 Im ___ AbsNeut-6.48* AbsLymp-0.81*
AbsMono-0.80 AbsEos-0.03* AbsBaso-0.02
___ 08:00AM BLOOD Glucose-110* UreaN-9 Creat-0.7 Na-145
K-3.9 Cl-104 HCO3-26 AnGap-15
___ 08:00AM BLOOD ALT-349* AST-534* AlkPhos-118*
TotBili-1.8* DirBili-0.9* IndBili-0.9
___ 08:00AM BLOOD ___
___ 04:00AM BLOOD WBC-6.7 RBC-3.58* Hgb-11.0*# Hct-32.3*
MCV-90 MCH-30.7 MCHC-34.1 RDW-12.6 RDWSD-41.4 Plt ___
___ 06:30AM BLOOD WBC-7.8 RBC-3.63* Hgb-11.1* Hct-32.9*
MCV-91 MCH-30.6 MCHC-33.7 RDW-12.5 RDWSD-41.0 Plt ___
___ 08:00AM BLOOD Neuts-79.2* Lymphs-9.9* Monos-9.8
Eos-0.4* Baso-0.2 Im ___ AbsNeut-6.48* AbsLymp-0.81*
AbsMono-0.80 AbsEos-0.03* AbsBaso-0.02
___ 04:00AM BLOOD ___ PTT-29.8 ___
___ 04:00AM BLOOD Plt ___
___ 06:30AM BLOOD Plt ___
___ 04:00AM BLOOD Glucose-100 UreaN-6 Creat-0.6 Na-141
K-3.7 Cl-104 HCO3-24 AnGap-13
___ 06:30AM BLOOD Glucose-117* UreaN-3* Creat-0.7 Na-141
K-3.4 Cl-101 HCO3-28 AnGap-12
___ 04:00AM BLOOD ALT-175* AST-97* AlkPhos-87 TotBili-0.7
___ 06:30AM BLOOD ALT-131* AST-75* AlkPhos-88 TotBili-0.6
___ 04:00AM BLOOD Lipase-1037*
___ 06:30AM BLOOD Lipase-78*
___ 04:00AM BLOOD Calcium-8.0*
___ 06:30AM BLOOD Calcium-7.9* Phos-3.0 Mg-1.9
Brief Hospital Course:
Ms. ___ is a ___ otherwise healthy who p/w acute epigastric
pain found to have gallstone pancreatitis. Briefly, patient
developed new onset epigastric abdominal pain on ___
accompanied by N/V. She presented to the ED where she was found
to have significantly elevated lipase to ___ and MRCP c/f
acute pancreatitis and cholelithiasis w/o
cholecystitis/choledocolithiasis. ACS was consulted on ___
regarding timing of interval CCY. Patient reported improved
abdominal pain and denies fevers/chills, diarrhea/constipation,
CP/SOB, jaundice/pruritis, dysuria. The patient was consented
for a laparoscopic cholecystectomy once her lipase was
appropriately lowered. On ___, the patient underwent a
laparoscopic cholecystectomy of which she tolerated very well.
The patient recovered well from the procedure. On ___ her labs
continued to trend in the right direction. She was tolerating a
regular diet on ___ and discharged with the appropriate
medication.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with oral medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Ambulation
was
encouraged throughout hospitalization.
GI/GU/FEN: The patient was placed on a regular diet of which
she
tolerated well. She had appropriate tenderness s/p lap
cholecystectomy.
Her dressings were c/d/i. Abdomen was non-distended, w/o rebound
or guarding.
ID: The patient's fever curves were closely watched for signs
of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without
assistance, and pain was adequately controlled. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sprintec (28) (norgestimate-ethinyl estradiol) 0.25-35 mg-mcg
oral ___
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID constipation
Please hold for loose stool.
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO ___ constipation
Please hold if ___ are stooling appropriately or if ___ have
loose stools.
5. Senna 8.6 mg PO BID:PRN constipation
please hold for loose stool.
6. Sprintec (28) (norgestimate-ethinyl estradiol) 0.25-35
mg-mcg oral ___
Discharge Disposition:
Home
Discharge Diagnosis:
Acute pancreatitis, cholelithiasis, now s/p lap cholecystectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ were admitted with abdominal pain found to have acute
pancreatitis. Initially, ___ were treated with IV fluids, pain
medications, and bowel rest with improvement in your symptoms.
As your pancreatitis was caused by a gallstone from your
gallbladder, the decision was made to remove your gallbladder to
avoid any additional episodes of pancreatitis and any other
potential complications. ___ were taken to the operating room
and had your gallbladder removed laparoscopically. ___ 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 ___ have stopped taking pain medicine and
feel ___ could respond in an emergency.
o ___ may climb stairs.
o ___ may go outside, but avoid traveling long distances until
___ 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 ___ may start some light exercise when ___ feel comfortable.
o ___ will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when ___
can resume tub baths or swimming.
HOW ___ MAY FEEL:
o ___ may feel weak or "washed out" for a couple of weeks. ___
might want to nap often. Simple tasks may exhaust ___.
o ___ may have a sore throat because of a tube that was in your
throat during surgery.
o ___ might have trouble concentrating or difficulty sleeping.
___ might feel somewhat depressed.
o ___ 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 ___ may shower and remove the gauzes over your
incisions. Under these dressing ___ 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 ___ 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 ___ were told
otherwise.
o ___ 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 ___ may shower. As noted above, ask your doctor when ___ may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, ___ may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. ___ can get both of these
medicines without a prescription.
o If ___ 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 ___ find the pain
is getting worse instead of better, please contact your surgeon.
o ___ 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 ___ take it before your
pain gets too severe.
o Talk with your surgeon about how long ___ 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 ___ are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when ___
cough or when ___ are doing your deep breathing exercises.
If ___ 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 ___ were on before the operation just as
___ did before, unless ___ have been told differently.
If ___ have any questions about what medicine to take or not to
take, please call your surgeon.
It was a pleasure taking care of ___.
-Your ___ team
Followup Instructions:
___
|
10838334-DS-23
| 10,838,334 | 24,307,114 |
DS
| 23 |
2182-06-19 00:00:00
|
2182-06-19 20:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Keflex / Bactrim / milk
Attending: ___.
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy ___
History of Present Illness:
___ male with past medical history of BPH, hypertension,
hyperlipidemia, who presents with bright red blood per rectum.
The patient reports that around 7:20 this evening he had one
episode of bright red blood associated with tenesmus. He
reports
the blood in the toilet was dark red but was bright red when he
wiped. He then had a second similar BM 20 mins later. He
presented to the emergency department and had another large
bloody bowel movement and syncopized immediately afterwards.
In terms of his GI history he had an episode of hematochezia and
___ and had a subsequent colonoscopy that showed a 4 mm polyp
as
well as internal hemorrhoids. By pathology the polyp was a
tubular adenoma.
In the ED,
Initial Vitals: T 97.4 HR 104 BP 148/102 RR 18 O2 SAt 97% RA
Exam: .
Constitutional: In no acute distress
HEENT: Normocephalic, atraumatic, Extraocular muscles intact
Resp: Clear to auscultation bilaterally, normal work of
breathing
Cardiovascular: Regular rate and rhythm, normal ___ and ___
heart
sounds
Abd: Soft, Nontender, Nondistended
GU: No costovertebral angle tenderness
MSK: No deformity or edema
Skin: No rash, Warm and dry
Neuro: Alert and oriented to person, place, and time. Moving all
extremities.
Psych: Appropriate mood/mentation
Rectal: No external hemorrhoids. Bright red blood per rectum.
Guaiac positive.
Labs: Hgb 11.6
Imaging: none
Consults: GI:
Interventions: 1u PRBCs, 1L NS
On arrival to the floor the patient feels well. He does believe
that if he has another bowel movement he may have more blood.
Past Medical History:
Hypertension
Hyperlipidemia
Atrial flutter status post ablation
Diverticulitis
BPH s/p TURP
CPPD
Social History:
___
Family History:
Mother - stroke, Father MI
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
VS: Reviewed in metavision
GEN: well appearing, in NAD
HEENT: NCAT, MMM, anisocoria L>R
NECK: JVP not elevated
CV: RRR no MRG
RESP: CTAB
GI: soft, mild ttp in LLQ, no rebound or guarding, normoactive
BS
SKIN: warm and well perfused
NEURO: moving 4 extremities with purpose
PSYCH: AOx3, appropriate mood and affect
DISCHARGE PHYSICAL EXAM:
=========================
24 HR Data (last updated ___ @ 811)
Temp: 97.2 (Tm 98.3), BP: 150/73 (139-158/71-83), HR: 60
(56-63), RR: 18 (___), O2 sat: 95% (95-99), O2 delivery: RA
GENERAL: Alert and interactive. In no acute distress.
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: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Hyperactive bowels sounds, non distended, non-tender to
deep palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: AOx3.
Pertinent Results:
ADMISSION LABS:
==================
___ 09:15PM BLOOD WBC-8.4 RBC-4.82 Hgb-11.6* Hct-38.1*
MCV-79* MCH-24.1* MCHC-30.4* RDW-18.9* RDWSD-53.8* Plt ___
___ 09:15PM BLOOD Neuts-57.6 ___ Monos-7.3 Eos-0.6*
Baso-0.2 Im ___ AbsNeut-4.83 AbsLymp-2.86 AbsMono-0.61
AbsEos-0.05 AbsBaso-0.02
___ 09:15PM BLOOD ___ PTT-28.0 ___
___ 09:15PM BLOOD Glucose-195* UreaN-15 Creat-0.9 Na-140
K-4.9 Cl-104 HCO3-22 AnGap-14
___ 09:15PM BLOOD ALT-14 AST-21 AlkPhos-77 TotBili-0.5
___ 09:15PM BLOOD Albumin-4.0 Calcium-9.2 Phos-3.3 Mg-1.9
___ 09:17PM BLOOD Lactate-2.1*
DISCHARGE LABS:
================
___ 03:45PM BLOOD WBC-6.2 RBC-3.30* Hgb-8.5* Hct-26.8*
MCV-81* MCH-25.8* MCHC-31.7* RDW-18.6* RDWSD-54.1* Plt ___
___ 06:08AM BLOOD Glucose-104* UreaN-11 Creat-0.7 Na-145
K-4.3 Cl-116* HCO3-21* AnGap-8*
___ 02:53AM BLOOD ALT-11 AST-17 AlkPhos-55 TotBili-1.2
___ 06:08AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.0
IMAGING:
========
CTA ___ A/P:
IMPRESSION:
1. No evidence of active arterial contrast extravasation, or
contrast pooling
on the portal venous phase to identify a bleeding source in the
bowel.
2. Extensive pancolonic diverticulosis.
MICROBIOLOGY:
==============
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
======================
Mr. ___ is a ___ male with past medical history of
diverticulitis, internal hemorrhoids, CAD, HTN, BPH s/p TURP,
and hyperlipidemia who presented with bright red blood
per rectum and transient hypotension. He was briefly monitored
in the MICU and received 2u pRBCs during hospital stay. CTA
showed no active extravasation and extensive pancolonic
diverticulosis. Colonoscopy was normal. The bleeding was
suspected to be from resolved diverticular bleed. He was
discharged in stable condition with close outpatient follow-up.
TRANSITIONAL ISSUES
===================
[] Outpt cardiac monitoring for burden of flutter/fib
[] Continue risk/benefit discussions re: anticoagulation for
AFib
[] Repeat CBC as outpatient at PCP follow up in 1 week
(___). Discharge Hgb was 8.5.
ACUTE ISSUES
============
#Acute blood loss anemia
#Syncope
#Lower GI bleed
Presented with large volume BRBPR and presyncope, although he
remained hemodynamically stable. CTA was without active
extravasation. He received 2U PRBCs, and was monitored in the
MICU after bleeding stopped where his vitals remained stable.
Colonoscopy showed moderate non-bleeding diverticula, which were
thought to be the source of bleeding. Discharge Hgb was 8.5.
#pAF
#?CAD
Intermittent A fib/flutter while on tele in the ED. He does have
a documented history of CAD but has not followed with cardiology
recently. CHADSVASc2 = ___, would benefit from anticoagulation
but likely needs outpt monitoring to determine burden or whether
this was just triggered in the setting of acute illness. ASA
81mg was stopped given increased bleeding risk and minimal
effect on stroke reduction with AFib.
#Asymptomatic pyuria
s/p cipro in the ED, urine culture was contaminated. He was
asymptomatic and did not receive antibiotics.
#HTN - Held home lisinopril in setting of active bleed.
#HLD - Continued atorvastatin
# CODE: Full confirmed
# CONTACT: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Lisinopril 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Cyanocobalamin 100 mcg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. CoQ-10 (coenzyme Q10) 0 mg oral DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. CoQ-10 (coenzyme Q10) 0 mg oral DAILY
3. Cyanocobalamin 100 mcg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Diverticular bleed
SECONDARY DIAGNOSIS:
====================
Coronary artery disease
Hypertension
Atrial flutter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital because you had bloody bowel
movements.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While in the hospital, you had more bloody bowel movements.
- You were briefly in the ICU and received blood transfusions.
- A colonoscopy was performed, which was normal.
- You most likely bled because of diverticulosis (outpouches in
your intestine), which has now resolved.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
-We recommend you continue eating a high fiber diet and staying
hydrated.
-If you develop bloody bowel movements again, please come back
to the emergency room.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10838580-DS-5
| 10,838,580 | 22,749,412 |
DS
| 5 |
2174-02-12 00:00:00
|
2174-02-13 07:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Indocin / Minocycline /
clarithromycin
Attending: ___.
Chief Complaint:
Dyspnea and hypoxia
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
R subclavian CVL
History of Present Illness:
Mr. ___ is a ___ year old man with advanced COPD,
CAD with prior stenting, and heart failure with preserved
ejection fraction who presents with dyspnea and hypoxia.
According to his wife, he was hospitalized ___ ___ for a
heart failure exacerbation and went to rehab until the end of
___. He's been home since that time working with a ___, ___
and OT, all of which have ended. They intermittently check a
pulse ox on him and noticed on ___ that his oxygen
saturations were ___ the 80's. This improved with nebulizer
treatments. That evening he had a difficult time sleeping due to
dyspnea. Over the course of the next 3 days he continued to have
dyspnea and oxygen saturations below 90's, whereas he is
typically ___ the mid to high 90's on room air. He called his PCP
on ___ and was told to take an extra 20mg Lasix (from 60 to
80mg), but continued worsening and eventually had oxygen
saturations ___ the 70's. His wife also found he had a
temperature of 101 at home.
ED Course
Found to be hypoxic to the high 60's, placed on non-rebreather.
Found to have atrial fibrillation with rapid rates and intubated
before he was cardioverted with subsequent sinus rhythm and
improvement ___ blood pressure from systolics ___ the 80's to the
110's.
- Midaz + fent
- Vancomycin
- Levofloxacin
- Zosyn
- 500cc crystalloid
Past Medical History:
CAD with multiple stents
HTN
COPD
OA
BPH
Hyponatremia
Social History:
___
Family History:
-Father: passed away from stroke at age ___
-Mother: HTN, colon ca
-Brother: HTN
Physical ___:
==============================
ADMISSION PHYSICAL EXAMINATION
==============================
VS: T99.8, HR 80, BP 90/61, O2 95%
GEN: Intubated, sedated, not responsive to loud voice or
physicial stimulus initially, though later waking up when
sedation was lighter
EYES: Pupils 2mm and equal, no scleral icterus or injection
HENNT: ETT ___ place. No JVD.
CV: S1/S2 irregular with no obvious murmurs, rubs or S3/S4
RESP: Ventilated. Rhonchi ___ anterior and lateral lung fields.
Some basilar crackles as well.
GI: Soft, somewhat distended, reducible umbilical hernia.
MSK: Warm extremities. 1+ pitting edema ___ bilateral ankles.
==============================
DISCHARGE PHYSICAL EXAMINATION
==============================
VITALS: Reviewed ___ OMR.
GEN: Alert, oriented, appears comfortable.
HEENT: NCAT, anicteric sclera, clear oropharynx, no JVD.
CV: S1, S2, RRR, II/VI systolic ejection murmur.
RESP: Mild inspiratory rhonchi, no increased WOB on RA.
GI: Soft, NT/ND, BS+
EXT: No ___ edema.
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 05:11PM BLOOD WBC-21.9* RBC-4.56* Hgb-13.7 Hct-43.3
MCV-95 MCH-30.0 MCHC-31.6* RDW-14.0 RDWSD-49.2* Plt ___
___ 05:11PM BLOOD Neuts-80.8* Lymphs-10.5* Monos-7.7
Eos-0.0* Baso-0.2 Im ___ AbsNeut-17.68* AbsLymp-2.31
AbsMono-1.68* AbsEos-0.01* AbsBaso-0.05
___ 05:11PM BLOOD ___ PTT-24.8* ___
___ 05:11PM BLOOD Glucose-208* UreaN-51* Creat-0.9 Na-139
K-3.2* Cl-92* HCO3-31 AnGap-16
___ 03:55AM BLOOD ALT-28 AST-27 LD(LDH)-251* AlkPhos-84
TotBili-1.1
___ 05:11PM BLOOD Calcium-10.1 Phos-2.8 Mg-1.6
___ 05:17PM BLOOD ___ pO2-65* pCO2-55* pH-7.40
calTCO2-35* Base XS-6
============================
PERTINENT LABORATORY STUDIES
============================
___ 05:11PM BLOOD proBNP-3891*
___ 05:11PM BLOOD cTropnT-0.03*
___ 04:05AM BLOOD WBC-9.7 RBC-3.38* Hgb-10.1* Hct-32.8*
MCV-97 MCH-29.9 MCHC-30.8* RDW-14.1 RDWSD-49.7* Plt ___
___ 03:02AM BLOOD ALT-70* AST-59* LD(LDH)-253* AlkPhos-58
TotBili-0.4
___ 05:11PM BLOOD proBNP-3891*
============================
DISCHARGE LABORATORY STUDIES
============================
___ 07:20AM BLOOD WBC-7.6 RBC-3.10* Hgb-9.3* Hct-30.4*
MCV-98 MCH-30.0 MCHC-30.6* RDW-15.1 RDWSD-53.2* Plt ___
___ 07:20AM BLOOD Glucose-133* UreaN-17 Creat-0.6 Na-139
K-3.9 Cl-99 HCO3-29 AnGap-11
===========================
REPORTS AND IMAGING STUDIES
===========================
CXR ___: FINDINGS: AP portable upright view of the chest
provided. There has been interval placement of an orogastric
tube with tip projecting over the left upper quadrant ___ the
expected location of the stomach. An endotracheal tube tip
projects approximately 1.7 cm above the level of the carina. A
right IJ central venous catheter tip projects over the mid SVC.
There is unchanged mild pulmonary vascular congestion as well as
small bilateral, left greater than right, pleural effusions.
Bibasilar atelectasis is also unchanged. There is no focal
consolidation or pneumothorax. The cardiomediastinal silhouette
is moderately enlarged, similar to prior. No acute osseous
abnormalities are identified.
CXR ___: IMPRESSION: ___ comparison with the study of ___,
the monitoring and support devices are unchanged. The tip of the
nasogastric tube again terminates ___ the region of the distal
esophagus. There are improved lung volumes. Continued
enlargement of the cardiac silhouette with decreasing vascular
congestion. Bibasilar opacifications are consistent with
layering pleural effusions and compressive atelectasis.
CXR ___: IMPRESSION: Compared to chest radiographs since
___ most recently ___ through to re-25. Continued
clearing of previous moderate pulmonary edema and any concurrent
pneumonia. Aeration is worst at the left lung base which could
be either infection, or combination of atelectasis and edema.
Small to moderate bilateral pleural effusions persist.
Borderline cardiomegaly stable. No pneumothorax. ET tube and
transesophageal drainage tube are ___ standard placements. Right
subclavian line ends ___ the mid SVC.
___ CXR
FINDINGS:
Low lung volumes limits assessment. The patient's chin obscures
the superior mediastinum. Scattered lung opacities concerning
for multifocal pneumonia appear new from prior. No large
effusion or pneumothorax. No gross signs for edema. The
cardiomediastinal silhouette is unchanged with unfolded thoracic
aorta again noted likely accounting for widened mediastinum. No
pneumothorax is seen. Bony structures appear grossly intact.
Bilateral high-riding humeral heads with associated degeneration
reflect chronic rotator cuff disease. IMPRESSION: Subtle
ill-defined lung opacities concerning for pneumonia.
============
MICROBIOLOGY
============
___ 2:26 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
RARE GROWTH Commensal Respiratory Flora.
C. difficile PCR (Final ___: NEGATIVE.
___ 11:46 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
RESPIRATORY CULTURE (Final ___:
STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.
STREPTOCOCCUS PNEUMONIAE
CEFTRIAXONE-----------<=0.06 S
ERYTHROMYCIN----------<=0.25 S
LEVOFLOXACIN---------- 1 S
PENICILLIN G----------<=0.06 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
___ 5:30 am URINE
Legionella Urinary Antigen (Final ___: NEGATIVE FOR
LEGIONELLA SEROGROUP 1 ANTIGEN.
___ 9:39 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Brief Hospital Course:
Mr. ___ is a ___ year old man with advanced COPD,
CAD with prior stenting, and heart failure with preserved
ejection fraction who presented with hypoxic hypercarbic
respiratory failure from pneumonia who required re-intubation.
He was found to have strep pneumonia which was treated with
antibiotics and found ___ Afib with RVR s/p amiodarone loading
now on metoprolol for rate control and apixaban for
anticoagulation.
ACUTE ISSUES
============
# Acute hypoxic and hypercarbic respiratory Failure
# Multifocal pneumonia/HAP
Previously complicated by septic shock though shock subsequently
resolved with antibiotic therapy. CXR consistent with multifocal
pneumonia and sputum growing strep pneumonia treated with IV
antibiotics. Patient was extubated on ___, however overnight
___ he became tachypneic to the ___, hypoxemic with PaO2 65,
and hypotensive requiring increased pressors. He was reintubated
___ this setting and antibiotics were rebroadened to
cefepime/vancomycin. CXR showed new RLL consolidation concerning
for aspiration pneumonia. He was treated with a final course of
7 days of cefepime (last day ___ for HAP and sucessfully
re-extubated on ___, satting well on room air. Code status
discussion was held between patient and his wife/HCP and he has
chosen to be DNR/DNI moving forward.
# Shock
# Hypotension
Febrile at home and ___ the hospital arguing ___ favor of septic
etiology to shock.
Weaned off norepinephrine on ___ but intermittently
requiring pressor support on ___. He then required pressors
again while intubated. These were weaned. However, his BPs
remained ___ the ___ systolic while he was asymptomatic,
mentating well, and making good urine. He had some episodes of
orthostatic hypotension ___ the setting of reduced PO intake and
restarting of home Lasix dose, so his home Lasix dose was
reduced to 20 mg daily with resolution of his orthostatic
hypotension, although he did remain intermittently "dizzy" while
lying ___ bed or standing.
#Heart failure with preserved ejection fraction
Recently had increasing doses of home diuretics, 60mg lasix
daily most recently prior to admission. BNP very elevated but
may be ___ setting of strain from sepsis. He does have extremity
edema, though it is difficult to tell to what extent his CXR
findings could be consistent with pneumonia. He was initially
diuresed aggressively, then subsequently became more hypotensive
so some IVF was given back. After stabilization from an
infectious standpoint he was restarted a reduced dose of Lasix
20MG daily.
#Atrial Fibrillation with rapid rates
Per his wife, is not known to have AFib ___ the past. Previous
ischemic history but troponin mildly elevated and likely from
demand. More likely precipitated by sepsis. Does have a history
of significant GI bleed ___ the setting of plavix, approximately
___ years ago, though exact details remain unknown despite
multiple attempts to obtain OSH records. S/p amio load for rate
control, converted to NSR. Further amiodarone deferred as it was
felt that atrial fibrillation was ___ the setting of acute
illness and less likely to recur given treatment of septic
shock. Subsequently flipping ___ and out of afib on ___. Heparin
started although briefly held due to hematuria and bloody sputum
that resolved. Metoprolol tartate started with good HR control
and he was transitioned to apixaban without further signs or
symptoms of bleeding.
# Acute transaminitis - Resolved
AST and ALT uptrended during hospitalization with Tbili, alk
phos normal. Low suspicion for viral hepatitis. No recent
periods of hypotension to suspect shock liver. Most likely
etiology is drug induced live injury ___ the setting of multiple
new medications including antibiotics and a load of amiodarone.
CHRONIC ISSUES
==============
# Hematuria
Patient with hematuria ___ ED, follows with Dr. ___ ___ urology
intermittently for BPH and has been known to have gross
hematuria iso UTIs ___ the past. No significant pyuria on UAs
here. Acute component likely iso traumatic foley placement ___
ED.
#COPD
On Anoro Ellipta, fluticasone and albuterol inhaler at home. He
received standing ipratropium nebulizers and his flovent was
continued.
TRANSITIONAL ISSUES
===================
[] Given high CHADS2VASC score, he was started on apixaban this
admission for atrial fibrillation ___ the setting of sepsis.
Continue to monitor for signs/symptoms of bleeding and ongoing
discussion of risk/benefits of anticoagulation.
[] Continue to monitor for signs or symptoms of GI bleeding and
recheck CBC ___ ___ weeks or at PCP follow up.
[] Due to concern orthostatic hypotension his home dose of
furosemide was reduced to 20MG PO daily. Please continue to
monitor for symptoms of orthostasis or volume overload and
adjust direutic dosing accordingly, will likely need a higher
dose of diuretic as his PO intake improves.
[] Concerns for dysphagia after intubation/extubation ___ the
MICU, although improving on discharge and tolerating soft solids
and thin liquids well. Please have patient continue to work with
speech and swallowing therapy and advance diet as tolerated.
[] Patient has been on long-standing PPI, without symptoms this
admission, would consider tapering this down as outpatient given
concern for increased risk of CAP with long term PPI use.
ADVANCED CARE PLANNING
======================
# Code status: DNR/DNI
# Name of health care proxy: ___: wife
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q24H
2. GuaiFENesin ER 600 mg PO Q12H
3. Magnesium Oxide 400 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Potassium Chloride 20 mEq PO BID
6. Chlorthalidone 25 mg PO DAILY
7. Ascorbic Acid ___ mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Vitamin D 1000 UNIT PO BID
10. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
11. Centrum ___
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
12. Aspirin 81 mg PO DAILY
13. Fluticasone Propionate 110mcg 2 PUFF IH BID
14. Furosemide 60 mg PO DAILY
15. Atorvastatin 80 mg PO QPM
16. Senna 17.2 mg PO EVERY OTHER DAY
17. Finasteride 5 mg PO DAILY
18. Tamsulosin 0.4 mg PO QHS
19. LORazepam 0.5 mg PO Frequency is Unknown
20. melatonin 3 mg oral QHS
21. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Lidocaine 5% Patch 1 PTCH TD QAM
3. Furosemide 20 mg PO DAILY
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
5. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
6. Ascorbic Acid ___ mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Centrum ___
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Finasteride 5 mg PO DAILY
12. Fluticasone Propionate 110mcg 2 PUFF IH BID
13. GuaiFENesin ER 600 mg PO Q12H
14. Magnesium Oxide 400 mg PO DAILY
15. melatonin 3 mg oral QHS
16. Metoprolol Succinate XL 50 mg PO DAILY
17. Pantoprazole 40 mg PO Q24H
18. Senna 17.2 mg PO EVERY OTHER DAY
19. Tamsulosin 0.4 mg PO QHS
20. Vitamin D 1000 UNIT PO BID
21. HELD- LORazepam 0.5 mg PO Frequency is Unknown This
medication was held. Do not restart LORazepam until you see your
PCP
22. HELD- Potassium Chloride 20 mEq PO BID This medication was
held. Do not restart Potassium Chloride until you see your PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
=======
Pneumonia
Atrial Fibrillation
Secondary
=========
Acute on Chronic Diastolic Heart Failure
Coronary Artery Disease
Chronic Obstructive Pulmonary Disease
Hyperlipidemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I ___ THE HOSPITAL?
- You had shortness of breath and were found to have pneumonia.
WHAT HAPPENED TO ME ___ THE HOSPITAL?
- You were treated with antibiotics with improvement ___ your
breathing
- You were found to have an abnormal heart rhythm thought to be
due to an infection which was treated with medications. You were
also placed on a blood thinner which you should continue until
told to stop by your PCP.
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:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
latex / chicken derived
Attending: ___.
Chief Complaint:
acute cholecystitis
Major Surgical or Invasive Procedure:
___- laparoscopic cholecystectomy
History of Present Illness:
Ms. ___ is a ___ with PMHx significant for obesity, CKD III
___ Cr 1.5, HLD, left planum sphenoidale meningioma, DM, and
chronic back pain who presents to the ___ ED with stabbing
epigastric/back pain x 1 day. Patient reports that this morning
___ she woke up she started experiencing stabbing back pain that
radiates to her epigastrium. She reports nausea, vomiting, and
inability to tolerate oral intake and therefore did not take her
daily medications today.
Upon arrival, she was afebrile and hemodynamically stable except
hypertensive 168/75. She is also hyperglycemic with BS of 258.
Her lab was notable for normal WBC although an elevated PMN of
74% was noted. Her LFTs and lipase were normal including TBili
of
0.3. Chem panel is notable for Bicarb of 19 and Cr of 1.5. UA
and
troponin were unremarkable. CT abdominal and pelvis was
concerning for cholelithiasis with acute cholecystitis and a
RUQUS demonstrates gallbladder distension with cholelithiasis
and
gallbladder wall thickening with + ___ sign, without biliary
dilation, concerning or acute cholecystitis. Surgery thus was
consulted for acute cholecystitis.
She received multiple doses of morphine and zofran. She was
started on an insulin drip. She was started on LR. Unasyn was
given.
She denies any fever, chills, shortness of breath, chest pain,
chest palpitation, diarrhea, constipation, unintentional weight
loss, cough, dysuria, or any recent illnesses.
Past Medical History:
Past Medical History:
Obesity, CKD III, HLD, left planum sphenoidale meningioma, DM,
non-proliferative retinopathy, anemia, adjustment disorder, and
chronic back pain
Past Surgical History:
___: Laparotomy with supracervical hysterectomy and left
salpingo-oophorectomy
Cataract surgery ___
Social History:
___
Family History:
Stroke: brother, mother
T2DM: maternal grandmother, mother
HTN: maternal grandmother, mother
___ cancer: mother
Kidney disease: sister
Physical ___ physical exam
Physical exam:
Vitals: Temp 98.3 BP115/62 HR 82 RR16 PO296 Ra
Gen: NAD, AxOx3
Card: RRR, no m/r/g
Pulm: CTAB, no respiratory distress
Abd: Soft, appropriately tedner, non-distended, incisions c/d/I
with dermabond in place. JP site with clean dry dressing
Ext: No edema, warm well-perfused
Pertinent Results:
CT A/P ___
IMPRESSION:
1. Distended gallbladder containing layering sludge and stones.
There is mild
pericholecystic fat stranding, and findings could reflect acute
cholecystitis
in the correct clinical setting. Consider further assessment
with ultrasound.
2. Colonic diverticulosis.
3. Hepatic steatosis. Please see recommendations below.
4. No urolithiasis or pancreatitis.
Abdominal U/S ___
IMPRESSION:
1. Gallbladder distension with cholelithiasis and gallbladder
wall thickening
and edema, along with a positive sonographic ___ sign,
findings which are
highly concerning for acute cholecystitis. No biliary
dilatation.
2. 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:
Ms. ___ is a ___ year old female with obesity, CKD III ___ Cr
1.5), hyperlipidemia, meningioma, and diabetes, who was found
to have acute gangrenous cholecysitis, and admitted to the
surgery service for surgical management. On ___, she
underwent a laparoscopic cholecystectomy. The tolerated the
procedure well, please see operative report for additional
details. After a brief PACU stay, she was transferred to the
surgical floor in stable condition.
Throughout her hospitalization, she remained afebrile and
hemodynamically stable. On POD 1, she was advanced to a clear
liquid diet, her pain was controlled on oral pain medication. On
POD 2 her diet was advanced to a regular diet, which was well
tolerated. Her urinary output was originally monitored with a
foley catheter, which was removed on ___, and she voided
adequately and spontaneously after its removal. Her JP drain was
consistent with serosangenous minimal output, and was removed
prior to discharge. She was out of bed and ambulating without
assistance.
She has a baseline history of chronic kidney disease (
creatinine 1.5) and her lisinopril was held during this
admission, and she was told to restart the medication in 1 week
after she improved her PO intake. At the time of discharge her
creatinine was 1.5.
At the time of discharge, she was afebrile, hemodnyamically
normal, she was tolerating a regular diet, voiding adequate and
spontaneously, her pain was well controlled on oral medication
alone, she was ambulating without assistance. She was deemed
stable for discharge home and was discharged with appropriate
outpatient follow up and instructions. She verbalized
understanding and is in agreement with the plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Artificial Tears ___ DROP BOTH EYES Q4H:PRN dry eyes
2. Ketorolac 0.5% Ophth Soln 1 DROP BOTH EYES QID
3. Rosuvastatin Calcium 20 mg PO QPM
4. glimepiride 1 mg oral DAILY
5. amLODIPine 2.5 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. amLODIPine 2.5 mg PO DAILY
3. Artificial Tears ___ DROP BOTH EYES Q4H:PRN dry eyes
4. Artificial Tears ___ DROP BOTH EYES Q4H:PRN dry eyes
5. Hydrochlorothiazide 25 mg PO DAILY
6. Ketorolac 0.5% Ophth Soln 1 DROP BOTH EYES QID
7. Rosuvastatin Calcium 20 mg PO QPM
8. Rosuvastatin Calcium 20 mg PO QPM
9. HELD- glimepiride 1 mg oral DAILY This medication was held.
Do not restart glimepiride until you are taking in good food
intake
10. HELD- Lisinopril 40 mg PO DAILY This medication was held.
Do not restart Lisinopril until your food intake improves to
normal
Discharge Disposition:
Home
Discharge Diagnosis:
acute gangrenous cholecystitis
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 acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o 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 Today you may shower. The guaze and dressing over your prior
drain site can be removed in 2 days ( on ___. The glue on
your incisions will fall off on its own
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 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 If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Best Wishes,
Your ___ Surgery Team
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Lisinopril / Metformin
Attending: ___.
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
___ ex lap, extended right colectomy, end ileostomy
___ redo ex lap, subtotal colectomy, mucous fistula
History of Present Illness:
___ well known to the ___ service, transferred from ___, 12 days s/p ex-lap, right colectomy, and end ileostomy
for
lower GI bleeding localized to the cecum. By report from the
facility, Ms. ___ developed increasing abdominal pain
associated with minimal ileostomy output, one episode of
vomiting, and fever to 100.8 earlier today. She had been NPO
secondary to nausea, but had a stable hematocrit and normal WBC
during her 5 day rehab stay.
Past Medical History:
Diabetes
Dyslipidemia
Hypertension
Atrial fibrillation
Hypothyroidism
Osteoarthritis, s/p bilateral knee replacements ___ ___
Depression
Asthma, diagnosed ___ ___
C-sections ___ past
Social History:
___
Family History:
Family history of CVA/CAD.
Physical Exam:
Vitals: 99.6 127 118/76 26 100%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Irregular, mildly tachycardic 110-120
PULM: Diminished bilaterally
ABD: Soft, mildly distended, +peristomal TTP ___ the RLQ, no
rebound or guarding, no palpable masses. RLQ end ileostomy
flush
with abdominal skin, pink, small amount of watery brown
effluent, no flatus ___ bag. Tender with digitalization.
Midline laparotomy incision with VAC ___ place, no erythema,
induration, drainage, or hernia. Left sided mucous fistula with
scant mucous output.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
Admission
8.0 > 29.5 < 486
N:65 Band:15 ___ M:8 E:0 Bas:0
133 97 34 < 161 AGap=13
------------
4.3 27 1.5
Ca: 6.9 Mg: 1.8 P: 3.2
ALT: 23 AP: 125 Tbili: 0.5 Alb: 3.2
AST: 26
Lip: 26
Lactate:1.___/P:
1. SBO w/ transition pt at ileostomy exit site; cause appears to
be mass effect from herniated mesenteric fat adjacent to the
ileostomy.
2. s/p R colectomy w/ tiny locules of gas adjacent to colonic
staple line - may be post-operative although leak cannot be
excluded.
3. small amt of complex free fluid ___ abdomen/pelvis - ddx
includes blood or bowel leak contents - correlate w/ exam and
hct.
Discharge:
___ 6:33 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
RARE GROWTH Commensal Respiratory Flora.
CULTURE WORKUP REQUESTED BY ___. ___ ___.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. MODERATE
GROWTH.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- <=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- <=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
___ 02:08AM BLOOD WBC-11.5* RBC-2.76* Hgb-8.2* Hct-25.6*
MCV-93 MCH-29.8 MCHC-32.0 RDW-16.3* Plt ___
___ 02:08AM BLOOD ___ PTT-28.2 ___
___ 02:08AM BLOOD Glucose-131* UreaN-19 Creat-1.0 Na-131*
K-4.6 Cl-93* HCO3-29 AnGap-14
___ 02:08AM BLOOD Calcium-8.0* Phos-4.2 Mg-2.0
Brief Hospital Course:
Neuro: On arrival, the patient was awake, but minimally alert
and seemed to be unaware of her surroundings. Over the course of
her stay, she was maintained on the minimum amount of pain
medication necessary to adequately control her pain. As a stay
progress, she became more alert and interactive, and after
extubation, was alert, oriented, and very interactive. At the
time of discharge, the patient was alert, oriented times three,
and had a nonfocal neurologic exam. She was moving all four
extremities, and complained only of tenderness of the abdomen.
Still sluggish with decreased interactiveness but appropriate.
CV: Initially, the patient was tachycardic ranging up to 140.
She initially required a diltiazem drip to control her
tachycardia, but as her stay progressed, the diltiazem drip was
weaned, and she was restarted on her home rate control
medications. She also initially required some low doses of
Neo-Synephrine. This was weaned to fully off finally on hospital
day seven, and she did not require any more
pressors. She is now controlled well on an oral diltiazema and
metoprolol regimen. She has not yet restarted her isosorbide,
diovan, or pradaxa. Those are currently on hold. The patient has
atrial fibrillation at baseline and fluctuates from sinus
tachycardia into afib with rate control 90-115 and stable blood
pressures.
R: After her surgery, the patient was vent dependent for several
days. On post operative day two, she was weaned to pressure
support. She remained on these settings until postoperative day
nine, after which she was extubated. From that point on, she
tolerated minimal oxygen, and Room air. After extubation, the
decision was made by the family, after a long family meeting, to
make the patient DNR/DNI. She is getting albuterol and
ipratropium inhalers as needed.
GI: On postoperative day two, she began to have stool from her
ostomy. Her tube feeds restarted on postoperative day four and
she continued to tolerate these throughout her stay. On
postoperative day 11, she failed a speech and swallow test,
after extubation, and had a dobhoff feeding tube placed, as she
had initially had an OGT while intubated. On postoperative day
one, the patient had a wound VAC placed over the midline
laparotomy incision. Last change ___. End ileostomy with stool
output, scant mucous output from mucous fistula. Two Jp drains
from OR removed prior to discharge. Famotidine prophylaxis
ongoing.
GU: The patient made adequate urine throughout her stay, which
was monitored with the catheter. On postoperative day six, she
began to have signs consistent with pulmonary edema. She was
started on a Lasix drip , But was only slightly negative for the
first several days. On postoperative day ___, she began to
diurese quite effectively, with no compromise of her hemodynamic
stability. On postoperative day 11, Lasix drip as stopped and
she was continued on intermittent Lasix. She continued to have
excellent output after this. She should continue to have close
monitoring of I's and O's and urine output.
Heme: ___ total, the patient received two units of packed red
blood cells. Her hematocrit was monitored frequently. After her
surgery, her hematocrit remained stable throughout her stay.
Pradaxa is being held at this time because it cannot be crushed
via the dophoff tube. The patient's PCP should determine the
patient's risk for stroke ___ setting of afib. For now no
anticoagulation. Heparin prophylaxis should continue 5000 units
sc TID.
ID: During the perioperative period, the patient was initially
placed on vancomycin and Zosyn. The vancomycin was stopped
shortly after surgery. A culture from the wound on ___
grew back pan sensitive E. coli, and the patient antibiotics
were changed to Bactrim. She had two sputum, and two urine
cultures which grew back
only bacteria sensitive to Bactrim. She was discharged on a
two-week course of Bactrim. Her white blood cell count was
monitored throughout her stay.
Medications on Admission:
albuterol HFA 90 q4-6h PRN, cardiazem LA 240', diovan 160',
loratadine 10 PRN, pradaxa 150'', allopurinol ___, Vit D3
1000', lasix 40', glyburide 2.5', isosorbide mononitrate ER 30',
levothyroxine 112', metoprolol ER 100', oxybutynin 5',
pravastatin 40'
Discharge Medications:
1. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
2. Diltiazem 60 mg PO QID
3. Famotidine 20 mg PO Q12H
4. Furosemide 20 mg PO BID
5. Heparin 5000 UNIT SC TID
6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
7. Metoprolol Tartrate 25 mg PO BID
Hold for HR< 60
8. Ondansetron 4 mg IV Q8H:PRN nausea
9. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
10. Sulfameth/Trimethoprim DS 3 TAB PO TID
___ trimethoprim component for tx Stenotrophomonas,
per pharmacy recs
11. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
12. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q2H:PRN pain
13. Levothyroxine Sodium 112 mcg PO/NG DAILY
14. Glargine 10 Units Q24H
Insulin SC Sliding Scale using REG Insulin
15. Ipratropium Bromide MDI 2 PUFF IH Q8H:PRN wheeze / dyspnea
16. Valsartan 160 mg PO/NG DAILY (not yet restarted)
17. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
18. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
(not yet restarted)
19. Oxybutynin 5 mg PO DAILY (not yet restarted)
20. Vitamin D 800 UNIT PO DAILY (not yet restarted)
21. Pravastatin 40 mg PO DAILY (not yet restarted)
22. Allopurinol ___ mg PO DAILY (not yet restarted)
23. GlyBURIDE 2.5 mg PO DAILY (not yet restarted)
24. Medication Alert
PLEASE NOTE MED REC -> MEDICATIONS THAT HAD NOT BEEN RESTARTED
AS OF DISCHARGE FROM ___ ON ___ WERE NOTED.
RESTART THESE MEDICATIONS AS APPROPRIATE ___ CONVERSATION WITH
___. ___ AND REHAB PHYSICIAN.
THE MEDICATIONS THAT THE PATIENT WAS GETTING DURING HER STAY
INCLUDE PO DILTIAZEM, PO METOPROLOL, PO LASIX, PO BACTRIM,
SYNTHROID, INSULIN SLIDING SCALE AND GLARGINE AS WRITTEN,
ELECTROLYTE REPLETION, HEPARIN PROPHYLAXIS. DILAUDID AND TYLENOL
AS NEEDED FOR PAIN AND ZOFRAN FOR NAUSEA.
THE OTHER LISTED MEDICATIONS THAT THE PATIENT WAS TAKING AT HOME
PRIOR TO ADMISSION WERE NOT RESTARTED.
THANK YOU.
25. Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
26. Dabigatran Etexilate 150 mg PO BID (not yet restarted)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
anastamotic leak, colon necrosis
Discharge Condition:
good
Discharge Instructions:
Continue VAC dressing changes every 3 days and close wound
monitoring. Call the Acute Care Surgery Clinic if there are any
concerns about the wound appearance. Last VAC change was ___ at
___.
The patient did have two JP drains which were removed during her
stay at ___. Monitor those skin sites and use dry dressings as
needed.
Please continue ostomy teaching and management. The patient has
an end ileostomy and mucous fistula ___ place. Please call Acute
Care Clinic if concern with appearance or amount of ostomy
output, monitor for dehydration, bloody or melenic output.
Patient is on an antibiotic course with bactrim to cover for
klebsiella and stenotrophomonas ___ her sputum cultures. She
will complete a two week total course of antibiotics. Her last
positive culture was on ___. She will continue the bactrim
through ___.
The patient is taking diltiazem and metoprolol via the dophoff
tube to rate control her atrial fibrillation. Her pradaxa is
currently on hold. She should get prophylactic heparin 5000
units three times daily. Discussion should be had with Dr.
___, Ms. ___ primary care provider ___: anticoagulation.
Patient had been on coumadin ___ the past and one year ago was
transitioned to pradaxa. She is not on aspirin. Her initial
presentation ___ early ___ was with GI bleeding while on
pradaxa. Please discuss risks and benefits of anticoagulating
again once the patient passes speech and swallow. For now she
will remain with her dophoff tube, tube feeds, and oral
medications as possible. Pradaxa will be held. No coumadin or
aspirin to be started at this point. Discuss this issue with Dr.
___ ___ determining how to move forward with anticoagulating.
The patient did not pass her speech and swallow on ___ so a
dophoff tube was placed and tube feeds and medications have been
given through there. The dophoff should be flushed with 30cc q6
as well as additional flush as needed with crushed pills to
prevent clogging.
The patient is also being diruesed. Had been on a lasix drip for
over a week and was transitioned to lasix via the dophoff tube
on ___. She is being discharged on 20mg lasix BID via dophoff,
please closely monitor electrolytes and BUN/Cr and back off on
diuresis as needed.
Continue other home medications as able to give via dophoff.
Continue reassessing speech and swallow ability to transition to
oral feeding and medications.
Call ___ clinic with concerns about ostomy output, inability to
tolerate tube feeds, increasing abdominal pain, or other
concerns.
Followup Instructions:
___
|
10839217-DS-21
| 10,839,217 | 23,110,547 |
DS
| 21 |
2160-12-23 00:00:00
|
2160-12-23 16:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Increased work of breathing, bilateral ptosis (right>left),
generalized weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is an ___ year-old R-handed F w/ PMH of HTN who presents
with unilateral ptosis, dysarthria, and generalized weakness. Hx
obtained from pt and OSH records.
Pt reports that over last ___ days she has experienced
increasing
fatigue/generalized weakness as well as difficulty breathing. In
terms of latter issue, pt feels that it is more difficult to get
breaths in and out appropriately but denies associated CP or
cough. Reports she took puff of family member's nebulizer with
some improvement. She also was seen by family around same time
to
develop new R sided ptosis, w/ pt denying associated eye pain,
diplopia, or blurry vision. Denies clear dysphagia/aspiration
although feels that her throat is tight and at baseline she does
not eat well. No apparent fatigability of her reported sx except
that respiratory distress increased at nighttime.
In the last day, pt noticed acute onset of slurred speech and
presented to Urgent Care for evaluation. While there, pt was
seen
to have new onset Afib. Out of concern for acute stroke, she was
sent to ___ where she was deemed not to be tPA candidate
after consultation through telestroke with BI Stroke Fellow.
CT/CTA performed with various vessel stenoses as noted below but
no acute ischemic process apparent. While there, due to
complaint
of difficulty breathing, underwent NIF which was -18 (unclear
contribtion from non-participation) and was therefore placed on
nonrebreather on oxygen therapy. While at OSH, pt was also found
to be hypertensive to 200s requiring Labetalol and Cardene gtt
per report. Out of concern for her clinical state, pt was
transferred to ___ for further evaluation. At time of
interview, pt continues to endorse difficulty breathing
effectively and dysarthria (at bedside her son reports "she
sounds normal to me") and fatigue. However, she denies any
weakness or sensory symptoms in extremities and no other focal
neurologic deficit. Denies personal or family hx of strokes or
neuromuscular conditions. Denies recent f/c, n/v, or other
infectious sx.
Past Medical History:
HTN
Melanoma on L thigh, s/p resection w/ clear margins
Squamous cell carcinoma of the lip
Heard-of-hearing
Hysterectomy
Social History:
___
Family History:
Scleroderma - daughter
___ histiocytosis - niece
Physical ___:
ADMISSION EXAMINATION
=====================
-VS reviewed in Metavision, AF, episodic HTN w/ SBP up to 202,
respiratory status stable, remains on 2L of O2 w/ SpO2 > 96%
-Mental Status: Awake and alert, oriented to person, place,
date,
and year. Appropriate affect, language fluent, can follow 2
step
commands across midline.
-CN: R pupil>left, both reactive to light (R ___ and L ___,
right ptosis with pupil almost completely covered, left pupil
mostly covered, EOMi, significant bulbar weakness (especially
eye
closure), tongue strength good, guttural dysarthria and mild
palate weakness with symmetric elevation.
-Motor:
Del Bic Tri FF FE IP Quad Ham Gas TA
R 5 5 5- 5 5 5 5 5 5 5
L 5 5- 5 5 5 5 5 5 5 5
Notable for fatigue post 30 repetitions of movement in deltoids.
Mild ___ spasticity bilaterally.
-Reflexes: 3 throughout, but patient not relaxed, R toe down, L
toe equivocal, no ___ sign.
-Sensory: Intact to light touch throughout.
-Coordination: FNF and HKS normal bilaterally, normal finger
tapping.
-Gait: Not assessed at this time due to oxygen requirements at
this time.
DISCHARGE EXAMINATION
=====================
Vitals: Temp: 98.6 (Tm 98.7), BP: 131/77 (131-161/51-98), HR:
104 (91-104), RR: 18 (___), O2 sat: 96% (96-98), O2 delivery:
RA
HEENT: NC/AT
Pulmonary: breathing comfortably on RA, able to count to
10 (rapidly and quietly) four and a half times in one breath
Cardiac: skin warm, well-perfused
Abdomen: soft, ND
Extremities: symmetric, no edema
Neurologic:
-Mental Status: Alert, cooperative. Language is fluent with
intact comprehension. Able to follow both midline and
appendicular commands.
-Cranial Nerves: EOMI without nystagmus or diplopia. Face
symmetric at rest and with activation. Hearing intact to
conversation.
-Motor: No pronator drift bilaterally. Neck flexion 4+/5, neck
extension full. Moves all four extremities purposefully.
-Sensory: Intact to LT throughout.
-DTRs: ___.
-Coordination: No dysmetria.
Pertinent Results:
HEMATOLOGY AND CHEMISTRIES
==========================
___ 09:20AM BLOOD WBC-7.9 RBC-3.13* Hgb-9.7* Hct-30.5*
MCV-97 MCH-31.0 MCHC-31.8* RDW-20.8* RDWSD-71.3* Plt ___
___ 09:20AM BLOOD Glucose-77 UreaN-26* Creat-0.8 Na-139
K-3.9 Cl-100 HCO3-26 AnGap-13
___ 09:20AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.0
___ 06:15AM BLOOD %HbA1c-5.5 eAG-111
___ 06:15AM BLOOD Triglyc-79 HDL-85 CHOL/HD-3.1
LDLcalc-159*
___ 06:15AM BLOOD TSH-4.1
___ 07:35PM BLOOD CRP-7.8*
___ 10:22PM BLOOD IgA-182
THIOPURINE METHYLTRANSFERASE (TPMT), ERYTHROCYTES
Test Result Reference
Range/Units
TPMT ACTIVITY 23 nmol/hr/mL RBC
Reference Range for TPMT Activity:
>12 Normal
___ Heterozygote or low metabolizer
<4 Homozygote Deficient Range
VOLTAGE GATED CALCIUM CHANNEL (VGCC) ANTIBODY ASSAY
Test Result Reference
Range/Units
VOLTAGE GATED CALCIUM <30 <30 pmol/L
CHANNEL (VGCC) AB ASSAY
ACETYLCHOLINE RECEPTOR MODULATING ANTIBODY
Test Result Reference
Range/Units
ACETYLCHOLINE RECEPTOR 85 H % binding
inhib
MODULATING ANTIBODY
Reference Range:
< 32%
BINDING INHIBITION
ACETYLCHOLINE RECEPTOR ANTIBODY
Test Result Reference
Range/Units
ACETYLCHOLINE RECEPTOR 43.00 H <=0.30 nmol/L
BINDING ANTIBODY
Reference Range:
----------------
Negative: <=0.30 nmol/L
Equivocal: 0.31-0.49 nmol/L
Positive: >=0.50 nmol/L
SED RATE
Test Result Reference
Range/Units
SED RATE BY MODIFIED 17 < OR = 30 mm/h
___
MICROBIOLOGY
============
___ 7:07 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefepime MINIMAL INHIBITORY CONCENTRATION: >32 MCG/ML.
Cefepime test result performed by Microscan.
___ 12:10 pm BRONCHOALVEOLAR LAVAGE
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final ___:
~5000 CFU/mL Commensal Respiratory Flora.
IMAGING
=======
MR ___ w/wo contrast ___:
IMPRESSION:
1. Study is moderately degraded by motion.
2. No acute intracranial abnormality, with no definite evidence
of acute infarct.
3. Mild white matter chronic small vessel ischemic disease.
4. Generalized parenchymal volume loss, likely age related.
5. Paranasal sinus disease , as described.
Echo ___:
Conclusions:
The left atrial volume index is moderately increased. Mild
symmetric left ventricular hypertrophy with normal cavity size,
and regional/global systolic function (biplane LVEF = 68 %). The
estimated cardiac index is normal (>=2.5L/min/m2). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. 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.
EMG ___:
IMPRESSION:
The electrophysiolgic findings demonstrate an abnormal decrement
with slow repetitive nerve stimulation, as can be seen in
disorders of neuromuscular transmission such as myasthenia
___.
CT Chest w/ contrast ___:
1. No evidence of thymoma.
2. Lytic lesion in the T9 vertebral body demonstrates an
appearance most suggestive of a hemangioma, although there is
cortical breakthrough of the right anterior vertebral body,
correlation with prior imaging if available is recommended.
3. Bibasilar airspace opacities with trace bilateral pleural
effusions,
findings probably represent atelectasis, although given that
there is
hypoenhancement, if there is concern for infection, pneumonia
would be
included on the differential.
4. Dilated main pulmonary trunk suggestive of pulmonary
hypertension.
5. 3 mm pulmonary nodule, please see below regarding incidental
pulmonary nodules.
RECOMMENDATION(S): For incidentally detected single solid
pulmonary nodule smaller than 6 mm, no CT follow-up is
recommended in a low-risk patient, and an optional CT in 12
months is recommend in a high-risk patient.
___ 5:55 ___ BILAT LOWER EXT VEINS
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Brief Hospital Course:
Ms. ___ is an ___ woman with history notable for
hypertension admitted with ptosis, dysarthria, and generalized
weakness. Examination at time of admission was notable for
fatigability concerning for myasthenia ___, which was
subsequently confirmed on EMG as well as with AChR antibody
testing. Chest CT was negative for thymoma, and brain MRI was
unremarkable. Treatment was initiated with IVIG, but initial
treatment course was complicated by disease progression
resulting in hypercarbic respiratory failure requiring
intubation and ventilation (___). Respiratory
improvement was noted upon completion of IVIG, prompting a trial
of extubation that was ultimately unsuccessful, requiring
elective reintubation on ___. During this time, therapy
with prednisone was initiated in consultation with the
Neuromuscular service, and a second trial of extubation was
attempted following clinical improvement on ___. This
course was complicated by pulmonary edema (felt to be related to
oncotic load from IVIG as well as IV fluids) requiring a third
elective intubation from ___, during which time
Ms. ___ respiratory status improved with aggressive diuresis.
As respiratory support with ventilation was available, a second
course of IVIG was completed in consultation with the
Neuromuscular service. Ms. ___ was then started on
azathioprine (with TMP-SMX for PJP prophylaxis) and continued on
prednisone with plan for outpatient taper.
Of note, Ms. ___ had recently been noted to have new atrial
fibrillation just prior to admission, also confirmed during her
hospital stay. Echocardiogram obtained during the admission was
notable for mild pulmonary hypertension. Ms. ___ was started
on apixaban for anticoagulation as well as diltiazem (selected
over beta blockers in setting of myasthenia) and amiodarone for
her heart rate.
Incidental note was made of pseudothrombocytopenia during the
admission (for which future hematology studies should be
obtained in a citrated tube) as well as mild asymptomatic true
thrombocytopenia. An E. coli urinary tract infection was also
treated during the admission.
TRANSITIONAL ISSUES
1. Continue prednisone 60 mg daily until follow up with Dr.
___.
2. Outpatient speech and swallow follow-up.
3. Follow up platelets as outpatient.
4. Please monitor serum potassium periodically while on TMP-SMX
and lisinopril.
5. Avoid medications known to worsen myasthenia ___, such as
aminoglycosides, fluoroquinolones, and beta blockers, when
feasible.
6. Avoid EDTA tubes for future hematology laboratory draws.
7. ___ consider follow-up CT for incidentally detected 3 mm
pulmonary nodule 12 months.
Medications on Admission:
1. lisinopril-hydrochlorothiazide ___ mg oral DAILY
2. ALPRAZolam 0.25 mg PO QHS
3. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
Discharge Medications:
1. Amiodarone 400 mg PO BID
2. Apixaban 5 mg PO BID
3. AzaTHIOprine 100 mg PO DAILY
4. Calcium Carbonate 500 mg PO BID
5. Diltiazem 90 mg PO Q6H
6. FLUoxetine 20 mg PO DAILY
7. Pantoprazole 40 mg PO DAILY
8. PredniSONE 60 mg PO DAILY
9. Pyridostigmine Bromide 30 mg PO TID
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. ALPRAZolam 0.25 mg PO QHS
13. lisinopril-hydrochlorothiazide ___ mg oral DAILY
14. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Myasthenia ___, antibody-positive
2. Atrial fibrillation
3. Thrombocytopenia
4. Cystitis
5. Hypercarbic respiratory failure
6. Pulmonary edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Requires assistance with ADLs and walking.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for
evaluation of weakness, difficulty breathing, right eyelid
droop, and difficulty speaking. Testing of your nerves and
muscles (EMG) as well as blood tests showed that your weakness
was due to myasthenia ___, a condition where your immune
system attacks the connection between your nerves and muscles.
Despite starting treatment for your myasthenia, your weakness
continued to worsen, so you required intubation to help support
your breathing. You were briefly weaned off the ventilator twice
before being able to breathe comfortably without the assistance
of the ventilator. Your swallowing function also improved prior
to discharge and you did not need the assistance of tube
feeding. You were started on medications to treat your
myasthenia (azathioprine, prednisone, and pyridostigmine). You
were also started on an antibiotic (Bactrim) to prevent
infections while on prednisone and azathioprine.
During your stay, you were also found to have atrial
fibrillation, an abnormal heart rhythm that increases your risk
of stroke. You were started on a medication to prevent blood
clots and strokes (apixaban), as well as medications to control
your heart rate (amiodarone and diltiazem).
You also developed a urinary tract infection during your stay
that was treated. You were also found to have slightly low
platelet levels that can be followed up by your primary care
provider.
Please attend your follow up appointments listed below.
It was a pleasure taking care of you at ___.
Sincerely,
Neurology at ___
Followup Instructions:
___
|
10839265-DS-23
| 10,839,265 | 27,735,816 |
DS
| 23 |
2114-09-07 00:00:00
|
2114-09-07 17:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea and lower extremity edema
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ year old female with a history of systolic
CHF (EF ___ from ___ s/p AICD who presents with bilateral
lower extremity edema and dyspnea. She usually walks with a
walker but her ankles have swollen and she was not able to walk
for the last 24 hours as a result of this. Her daughter noticed
a three pound weight gain in the last 48 hours. Her daughter has
noticed that the patient is sleepy but not confused. The patient
denies fevers, chills, vomiting, diarrhea, and endorses feeling
constipated. Her last bowel movement was yesterday morning after
a Fleet enema. It was watery and brown, no blood/melena.
.
In the ED, initial VS: 97.6 72 115/60 18 100% 2L Nasal Cannula
.
Vitals upon transfer to the floor: 98.1-65-18-110/60-18-1002l
.
Currently, she complains of mild abdominal bloating and
discomfort.
Past Medical History:
- HLD
- HTN
- CAD s/p MI with CABG in ___ (in ___
- DES X2 in OM/Cx placed in ___. DES in LM in ___. ___
___
- PPM/ICD in ___ (Guidant ICD placed on ___
- Ischemic CMP (TTE: ___ EF: ___ Severe regional left
ventricular dysfunction with an aneurysm of the
anterior/anteroapical wall. Mild to moderate mitral
regurgitation)
- Atrial Fibrillation on Coumadin and Amiodarone
- CKD. Baseline creatinine 1.6-2.0. Multifactorial origin
thought to be secondary to atrophic right kidney, longstanding
hypertension, and prior cardiac events.
- Solitary Kidney (due to nephrolithiasis/pyelonephritis)
- Pituitary Adenoma
- Thyroid Nodule
.
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ON ADMISSION:
VS - Temp 97.4 F, BP 118/74 , HR 72, R 22, O2-sat 100 % 4LNC
GENERAL - Alert, interactive, sleepy, mildly uncomfortable,
speaks full sentences
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, JVD to the angle of the jaw, no
carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - crackles ___ up bilateral bases, no wheezes, good air
movement, resp unlabored, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c, 2+ pitting in the left ankle and 1+
in the right ankle 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout when encouraged to make good effort, sensation
grossly intact throughout
.
AT DISCHARGE:
97.5 ___ 59 18 99%RA
improvement in lower extremity edema, only trace pitting.
Overall affect and energy much improved. Crackles remain at left
base but otherwise improved. Exam otherwise unchanged.
Pertinent Results:
.
ADMISSION LABS:
___ 02:15AM BLOOD WBC-6.3 RBC-3.34* Hgb-8.9* Hct-28.5*
MCV-85 MCH-26.7* MCHC-31.3 RDW-14.9 Plt ___
___ 02:15AM BLOOD ___ PTT-35.9 ___
___ 02:15AM BLOOD Glucose-144* UreaN-96* Creat-2.8* Na-132*
K-4.4 Cl-92* HCO3-25 AnGap-19
___ 02:15AM BLOOD Calcium-8.7 Phos-5.8*# Mg-2.8*
.
CARDIAC ENZYMES:
___ 02:15AM BLOOD CK(CPK)-27*
___ 10:00AM BLOOD CK(CPK)-53
___ 02:15AM BLOOD CK-MB-2 cTropnT-0.02* ___
___ 10:00AM BLOOD CK-MB-2 cTropnT-0.01
.
___
___ 02:15AM BLOOD ___ PTT-35.9 ___
___ 07:05AM BLOOD ___ PTT-34.9 ___
___ 07:15AM BLOOD ___ PTT-34.7 ___
.
OTHER LABS OF HOSPITAL COURSE:
___ 02:15AM BLOOD TSH-1.0
___ 02:25AM BLOOD Lactate-1.7
.
creatinine down to 1.9 on day of discharge.
.
CXR ___
IMPRESSION:
1. Moderate congestive heart failure, improved from prior
examination.
2. Persistent bibasilar opacities may represent atelectasis,
aspiration,
and/or pneumonia.
.
noncon head CT ___
IMPRESSION: Slight progression of chronic volume loss and
microvascular
disease. No hemorrhage or vascular territorial infarcts. Please
note that MR would be more sensitive for detection of
acute/subacute microinfarcts if not CI.
Brief Hospital Course:
REASON FOR HOSPITAL ADMISSION:
Ms. ___ is an ___ year old woman with a PMH of CAD, sCHF (ef
___, AF, HTN, HC, s/p ICD, and CKD who presents with dyspnea
and lower extremity edema.
.
HOSPITAL COURSE:
# Acute on chronic systolic heart failure: pt presented with
increased lower extremity edema and 3lb weight gain in last ___
days. Also complaining of generalized fatigue and overall
discomfort and shortness of breath. Iciting factors were
considered; TSH wnl, no report of dietary indiscretion, no
fever/leukocytosis, and daughter diligently ensuring med
adherence. Cardiac enzymes negative x2. Pt was found to have UTI
which was felt to be a likely precipitator, see UTI below. BNP
on presentation was over 60,000 up from 40K on last admission in
___. Home torsemide was held. Diuresis attempted with
lasix, however she put out minimal urine to first bolus, which
was then doubled but still without effect. Pt received morphine
occasionally prn for air hunger and agitation. Digoxin was also
started with plan to go home at very low dose given renal
function see below.
.
#goals of care - as it became increasingly evident that renal
and cardiac function were not improving and pt with extremely
poor quality of life, pt and daughter made the decision to
transition to hospice. DNR/DNI order was signed. Pt was
discharged to ___ facility.
.
#UTI - pt noted to have positive UA on admission. Urine grew
E.Coli sensitive to CTX. pt recieved a 4 day course of IV CTX.
.
#atrial fibrillation - pt is on warfarin at home. INR was
supratherapeutic on admission so this was held. Warfarin was
held on discharge due to supratherapeutic INR (likely secondary
to amiodarone use). Rehab facility will draw INR day after
discharge and adjust warfarin dosing as needed. Carvedilol was
continued for rate control, and amiodarone also continued.
Digoxin was also started during this hospitalization.
.
# Acute on Chronic renal failure: Pt admitted with acute
increase in creartinine on top of chronic renal failure. Felt to
be secondary to decompensated heart failure/poor forward flow.
___ likely also compounded by UTI, see above. Lasix was
attempted with fair effect. Creatinine was down to 1.9 on the
day of discharge from 2.9 on admission. Pt was sent home on
previous home regimen of 20mg daily torsemide.
.
#CAD: continued baby ASA, carvedilol
.
# Hypertension: continued carvedilol
.
#Constipation and dyspepsia: Pt requires frequent enemas for
bowel movements. Pt is fixated on bowel movements, per daughter,
and per history. Abdominal exam continued to be benign.
Agressive bowel regimen including enemas was utilized during
hospitalization with successful achievement of bowel movements.
.
Pt was maintained as DNR/DNI during this hospitalization.
Medications on Admission:
amiodarone 200mg daily
carvedilol 3.25mg bid
torsemide 20mg daily
aspirin 81mg daily
rosuvastatin 20mg daily
coumadin .5mg daily
b12 250mcg daily
docusate 100mg bid
senna bid prn
omeprazole 20mg daily
miralax prn
simethicone tid prn
acetaminophen prn
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for dyspepsia.
12. glycerin (adult) Suppository Sig: One (1) Suppository
Rectal PRN (as needed) as needed for constipation.
13. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for fever/pain.
14. digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
acute systolic congestive heart failure
.
SECONDARY
urinary tract infection
acute on chronic renal failure
atrial fibrillation
constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure taking care of you during your recent
hospitalization. You came in with leg swelling and weight gain.
We felt you had a congestive heart failure exacerbation. It was
challenging to remove fluid from you because of your kidney
injury, but we were successful in removing fluid with IV
medications and your kidney function improved. We felt it was
safe for you to leave on your home diuretic medication. We found
that you had a urinary tract infection, which we felt was likely
responsible for the CHF exacerbation. We treated you with IV
antibiotics for the urinary tract infection.
.
We made the following CHANGES to your medications:
STARTED glycerin suppositories as needed for constipation
STARTED digoxin for heart failure
STOPPED warfarin for now. Your INR was too high. You will need
to have blood drawn ___ for further monitoring of this with
dose adjustment as needed.
.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10839265-DS-24
| 10,839,265 | 26,544,432 |
DS
| 24 |
2114-09-17 00:00:00
|
2114-09-17 17:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain and Nausea
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ year old ___ Female with severe chronic
systolic CHF (EF ___ from ___ s/p AICD, recently
discharged, who presents with RLQ abdominal pain for 24 hours,
along with nausea and anorexia. She denies any fevers, chills,
or diarrhea. She states that she has had similar pain in the
past due to her cholelithiasis. According the patient's
daughter, an ___ was performed at rehab and showed a possible
SBO. Per the daughter, the patient's health has been declining
recently, and she doesn't sleep well during the nights and was
recently started on an anti-depressant. At baseline she normally
ambulates with a walker at home.
In the ED, VS were T 98.7 HR 60 BP 123/49 RR 16 100% 4L. EKG
showed sinus 59, atrial paced. Labs were significant for lipase
which was slightly elevated (111), INR 1.4, lactate 0.5, Cr 1.6
(1.9 at discharge on ___. Her rectal guiaic was negative
for occult blood. A non-contrast abdominal/pelvic CT (only has
one kidney) prelim read showed "no definite acute process. Small
pleural effusions. Slight gastric thickening, probably
underdistension but hard to exclude inflammation.
Cholelithiasis. Appendix not identified but no evidence of
appendicitis. Recommended ultrasound of right adnexal lesion -
malignancy not excluded". Portable CXR was 'neg acute, no free
air'. In ED her pain was relieved with a total of 10mg Morphine.
Overnight, she complained of mild abdominal bloating and
discomfort. Furthermore she is very sleepy but oriented x3, able
to follow commands. She appeared anxious and expressed a concern
about being left alone in her room.
Past Medical History:
- Hyperlipidemia
- Benign Hypertension
- CAD s/p MI with CABG in ___ (in ___
- Drug Eluting Stent X2 in OM/Cx placed in ___. DES in LM in
___. ___ in ___
- PPM/ICD in ___ (Guidant ICD placed on ___
- Ischemic Cardiomyopathy (TTE: ___ EF: ___ Severe
regional left ventricular dysfunction with an aneurysm of the
anterior/anteroapical wall. Mild to moderate mitral
regurgitation)
- Atrial Fibrillation on Coumadin, digoxin and Amiodarone
- CKD stage 4. Baseline creatinine 1.6-2.0. Multifactorial
origin thought to be secondary to atrophic right kidney,
longstanding hypertension, and prior cardiac events.
- Solitary Kidney (due to nephrolithiasis/pyelonephritis)
- Pituitary Adenoma
- Thyroid Nodule
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: + Nausea, - Vomitting, - Diarhea, + 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
PHYSICAL EXAM:
VSS: 98, 105/49, 60, 18, 99%
GEN: frail, elderly woman with moderate confusion
Pain: ___
HEENT: EOMI, Dry MM, - OP Lesions
PUL: B/L Crackles to midlung field
COR: RRR, S1/S2, II/VI HSM
ABD: moderate tenderness to palpation b/l LQ, ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Motor: ___ ___ Spread flex/ext
EXAM ON D/C:
VS T 98.1 BP 117/53 HR 61 RR 18 O2 98% ON RA
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD visualised
HEART - PMI non-displaced, RRR, nl S1-S2, ___ systolic murmur
loudest in LUSB
LUNGS - CTAB
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c
NEURO - awake, A&Ox3
Pertinent Results:
ADMISSION LABS:
___ 08:05PM BLOOD WBC-5.1 RBC-3.67* Hgb-9.5* Hct-31.7*
MCV-86 MCH-25.8* MCHC-29.8* RDW-15.5 Plt ___
___ 08:05PM BLOOD Neuts-65.3 ___ Monos-5.8 Eos-0.7
Baso-0.7
___ 08:05PM BLOOD ___ PTT-21.3* ___
___ 08:05PM BLOOD Glucose-104* UreaN-26* Creat-1.6* Na-135
K-4.0 Cl-97 HCO3-31 AnGap-11
___ 08:05PM BLOOD ALT-19 AST-32 AlkPhos-67 TotBili-0.5
___ 08:05PM BLOOD Lipase-111*
___ 08:05PM BLOOD Albumin-3.4*
___ 12:17AM BLOOD Lactate-0.5
___ 07:10AM BLOOD Digoxin-1.7
___ 04:40PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
DISCHARGE LABS:
___ 06:35AM BLOOD WBC-3.7* RBC-3.44* Hgb-9.0* Hct-30.4*
MCV-89 MCH-26.1* MCHC-29.5* RDW-15.8* Plt ___
___ 06:35AM BLOOD ___
___ 06:35AM BLOOD Glucose-82 UreaN-23* Creat-1.7* Na-138
K-3.7 Cl-101 HCO3-28 AnGap-13
___ 06:35AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.4
Time Taken Not Noted Log-In Date/Time: ___ 12:17 am
BLOOD CULTURE
Blood Culture, Routine: no growth
___ 12:59 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
CHEST (PORTABLE AP) Study Date of ___ 8:32 ___
IMPRESSION:
1. Significant interval improvement of recent pulmonary edema
with trace
residual right effusion.
2. Stable cardiomegaly.
3. No definite acute cardiopulmonary process.
CT ABD & PELVIS W/O CONTRAST Study Date of ___ 10:53 ___
1. No definite evidence of acute disease.
2. Cholelithiasis.
3. Similar large stone in the central right renal collecting
system with
marked asymmetric renal atrophy.
4. Mild apparent thickening of the gastric antrum, commonly due
to
underdistension, but sequelae of fluid overload or potentially
an inflammatory
process could be considered.
5. Right adnexal mass versus fibroid for which ultrasound
evaluation is
recommended when clinically appropriate. Malignancy cannot be
excluded by
this study, but in addition to a fibroid or ovarian mass, a
uterine anomaly
could be considered.
6. High liver density which can be seen with iron overload
states or
amiodarone administration.
Pelvic US ___:
IMPRESSION: Extremely limited visualization of the pelvis. A
complex region
of the uterus may represent a fibroid but cannot be definitively
characterized. If it is important to get further
characterization an MRI
could be performed.
Pelvic US ___:
1. Complex mass within the uterus measuring about 4.1 cm in
diameter. The
differential is wide and could include a degenerating fibroid;
however,
ultrasound cannot characterize this mass. An endovaginal exam
was not deemed to be necessary as the mass is well depicted
since the bladder is well distended.
2. Normal-sized ovaries with no suspicious ovarian or adnexal
mass
identified. Tiny simple cyst seen in the right ovary.
Brief Hospital Course:
HOSPITAL COURSE: MS ___ presented from rehab with abdominal
pain and nausea. She had a CT scan which shoed a fibroid which
was unlikely to be the cause of her symptoms. Her urine grew out
enterococcus so she was started on ampicillin and dc/ed back to
rehab.
1. Urinary Tract Infection - Bacterial, Pelvic Mass:
Pt presented with a chief complaint of nausea, abdominal pain
and urinary retention. Her initial UA was clean. CT scan with
uterine mass. Pelvic ultrasound for further evaluation thought
that the mass was likely a degenerate fibroid though could not
rule out malignancy without tissue biopsy. Given patient's goals
of care patient and HCP didnt want further intervention.
Furthermore she is not a surgical candidate given comorbidities.
Pain controlled with standing tylenol and low dose oxycodone
without delirium. Nausea controlled with compazine and zofran.
Patient tolerating clears and banana prior to discharge back to
rehab. Eventually however, her urine culture grew out
Enterococcus so she was started on intially IV and then PO
ampicillin (continue until ___ for 7 day course). Per
patient's goals of care she hoped to enroll in outpatient
hospice program.
2. Atrial Fibrillation:
Patient was subtherapeutic on her INR. Patient was started on 1
mg of warfarin and her INR started to climb up. We continued
Amiodarone, Carvedilol and Digoxin. Dig levels were normal. At
discharge INR was 2.9 so we went back to her home dose of 0.5mg
warfarin. She will need to have her INR rechecked at rehab.
3. Severe Chronic Systolic CHF:
Patient has an extremely low EF (15%) and has had multiple
previous admissions for CHF. However, she remained stable from
this perspective during this admission. We continued Carvedilol,
digoxin and Torsemide.
4. CKD Stage III:
We renally dosed medications and avoided nephrotoxic
medications. Cr was stable at 1.7, close to her baseline, at dc.
5. CAD Bypass Vessle:
Pt has a sig past CAD hx. We continued Aspirin, Carvedilol and
Crestor.
6. Benign Hypertesion:
Pt remained normotensive. We continued Carvedilol
7. Constipation:
Pt remained fixated on attemptimg to move her bowels. We
continued Colace, Mirilax and Senna and added lactulose and
bisacodyl enemas. Pt continued to move her bowels and pass gas
throughout the admission.
Goals Of Care: Dr. ___ ___ again saw her on this
admission, and she had a long discussion around the goals of
this admission and the patient's ultimate goals. She definitely
is trending towards hospice.
Transitinal Issues: Patient is DNR/DNI (recently seen by
Palliative care) and needs to be advanced to hospice care. Pt
needs an INR check on ___. Ampicillin needs to be continued
until the ___ for 7 day course. Pt needs soft diet/BRAT
diet initially and then advance as tolerated.
Medications on Admission:
1. amiodarone 200 mg Tablet
2. aspirin 81 mg Tablet
3. rosuvastatin 20 mg
4. torsemide 20 mg Tablet
5. carvedilol 3.125 mg TablBID
6. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: DAILY
(Daily).
7. docusate sodium 100 mg BID
8. senna 8.6 mg Tablet BID
9. polyethylene glycol 3350 17 gram Powder
10. omeprazole 20 mg Capsule
11. simethicone 80 mg Tablet, Chewable PO QID (4 times a day) as
needed for dyspepsia.
12. glycerin (adult)) Suppository Rectal PRN (as needed) as
needed for constipation.
13. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for fever/pain.
14. digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
15. Coumadin 0.5mg (likely not given in rehab)
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
10. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for DYSPEPSIA.
12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
13. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
15. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours).
16. glycerin (laxative) 2.8 gram/2.7 mL Solution Sig: One (1)
Rectal once a day as needed for constipation.
17. Outpatient Lab Work
Please draw INR on ___, and titrate warfarin dose
based on that. Goal INR is ___.
18. ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 6 days: last day ___.
19. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for nausea.
20. warfarin 1 mg Tablet Sig: ___ Tablet PO once a day: Based
on INR. Hold if INR > 3.0.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- ABDOMINAL PAIN
- PROBABALE UTERINE FIBROID
SECONDARY DIAGNOSES:
- SEVERE CHRONIC SYSTOLIC HEART FAILURE
- GATRO-ESOPHAGEAL REFLUX DISEASE
- DEPRESSION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care of you here at the ___. You
were admitted with abdominal pain and it was suspected that you
may have had an obstruction in your intestines. However, we did
a very detailed workup which revealed that there was no
obstruction. However, your urine showed that you had a urinary
tract infection which was the most likely cause of your
symptoms.
We discussed your goals of care with you and your daughter and
it seems that you do not desire any furhter invasive workup for
the fibroid which was found on CT scan. Your priorities
currently are pain and nausea control. Please continue
discussion about hospice care at your rehab facility.
We discharged you back to rehab on antibiotics as well as
additional medications for pain and nausea control.
MEDICATION changes:
1. STARTED OXYCODONE: take 2.5mg tablet 4 times daily for pain
2. STARTED PROCHLORPERAZINE: take thrice a day 30 minutes before
meals for nausea
3. INCREASED OMEPRAZOLE: increased from 20 once daily to 40 once
daily.
4. INCREASED ACETAMINOPHEN: increased to 1000 mg, three times a
day.
5. START AMPICILLIN 500mg four times daily for urinary tract
infection, last day ___.
6. START zofran 4 mg, 1 tab, every 8 hours as needed for
nausea/vomiting.
Followup Instructions:
___
|
10839295-DS-15
| 10,839,295 | 29,902,771 |
DS
| 15 |
2195-01-27 00:00:00
|
2195-01-29 12:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Perforated duodenal ulcer
Major Surgical or Invasive Procedure:
Laparoscopic washout and primary repair with ___ patch
History of Present Illness:
___, recently discharged from the hospital (___) for
afib with RVR, also with CAD s/p PCI (___), with a diagnosis of
HFpEF although last echo on ___ shows an EF of 39%, paroxysmal
afib (on apixaban), fatigued since her discharge, now with one
day of sudden onset severe abdominal pain in the epigastric area
with an OSH CT scan c/f perforated viscous. Per her and her
family, she has been weak since her discharge with a decreased
appetite and energy. This afternoon, she began complaining of
severe abdominal pain in the epigastric region. She was
nauseated
and dry heaving but no episodes of emesis. No change in BMs
except possibly one bloody bowel movement 3 days ago. Denies any
fevers.
Has never had an EGD before. No diagnosis of ulcers, not taking
NSAIDs.
Past Medical History:
- CAD status post PCI (___)
- Diastolic dysfunction with possible HFpEF
- Paroxysmal atrial fibrillation (on apixaban)
- LBBB
- Hypertension
- Bronchiectasis
- Depression
- Breast mass (declined further evaluation)
Social History:
___
Family History:
No family history of premature coronary disease or sudden death.
Physical Exam:
VS: Temp: 98.0 (Tm 98.9), BP: 161/75 (152-185/62-76), HR: 81
(79-92), RR: 18 (___), O2 sat: 97% (95-97), O2 delivery: Ra
GEN: A&Ox3, NAD, resting comfortably
HEENT: EOMI, sclera anicteric
CV: RRR
PULM: no respiratory distress
ABD: soft, appropriately tender, ND, no rebound or guarding
EXT: warm, well-perfused
PSYCH: normal insight, memory, and mood
WOUND(S): Incision c/d/i
DRAIN(S): JP with serous output
Pertinent Results:
___ 04:30AM BLOOD WBC-10.2* RBC-2.70* Hgb-7.8* Hct-25.0*
MCV-93 MCH-28.9 MCHC-31.2* RDW-15.2 RDWSD-49.3* Plt ___
___ 04:30AM BLOOD Plt ___
___ 02:00AM BLOOD ___
___ 04:30AM BLOOD Glucose-81 UreaN-10 Creat-0.6 Na-140
K-3.8 Cl-101 HCO3-25 AnGap-14
___ 05:49PM BLOOD CK(CPK)-18*
___ 04:30AM BLOOD Calcium-7.5* Phos-2.3* Mg-1.8
Brief Hospital Course:
The patient was transferred from an outside hospital and
admitted to the General Surgical Service on ___ for
evaluation and treatment of severe epigastric abdominal pain.
OSH CT revealed perforated viscous. The patient was taken to the
operating room emergently for laparoscopic repair of perforated
duodenal ulcer and abdominal washout. There were no adverse
events in the operating room; please see the operative note for
details. Post-operatively the patient was taken to the PACU
until stable and then transferred to the ICU until stable to be
transferred to the floor.
#NEURO: The patient was alert and oriented throughout
hospitalization; pain was initially managed with fentanyl and
transitioned to Tylenol and oxycodone. Pain was very well
controlled.
#CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
#PULMONARY: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
#GI/GU/FEN: The patient had a foley placed intra-operatively,
which was removed post-surgery on POD 1 with autonomous return
of voiding. The patient was tolerating a regular diet prior to
discharge.
#ID: The patient's fever curves were closely watched for signs
of infection, of which there were none. For her perforated
viscus the patient was placed on a 5 day antibiotic/antifungal
course.
#HEME: Patient received BID SQH for DVT prophylaxis, in
addition to encouraging early ambulation and Venodyne
compression devices.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating diet as
above per oral, ambulating, voiding without assistance, and pain
was well controlled. The patient was discharged home without
services. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Apixaban 2.5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Furosemide 20 mg PO DAILY
5. Losartan Potassium 50 mg PO BID
6. Metoprolol Succinate XL 50 mg PO BID
7. Amiodarone 200 mg PO BID
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain
9. olopatadine 0.2 % ophthalmic (eye) BID:PRN Itchy eyes
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Amiodarone 200 mg PO BID
Continue to take this medication twice a day for one month. Then
continue on it once a day.
3. Apixaban 2.5 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Furosemide 20 mg PO DAILY
7. Losartan Potassium 50 mg PO BID
8. Metoprolol Succinate XL 50 mg PO BID
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain
10. olopatadine 0.2 % ophthalmic (eye) BID:PRN Itchy eyes
Discharge Disposition:
Home
Discharge Diagnosis:
Perforated duodenal ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital for
a perforated duodenal ulcer on ___. You tolerated the
procedure well and are ambulating, stooling, tolerating a
regular diet, and your pain is controlled by pain medications by
mouth. You are now ready to be discharged to home. Please follow
the recommendations below to ensure a speedy and uneventful
recovery.
ACTIVITY:
- Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
- You may climb stairs. You should continue to walk several
times a day.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- You may start some light exercise when you feel comfortable.
Slowly increase your activity back to your baseline as
tolerated.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- No heavy lifting (10 pounds or more) until cleared by your
surgeon, usually about 6 weeks.
- You may resume sexual activity unless your doctor has told
you otherwise.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your
throat during the surgery.
YOUR BOWELS:
- If needed, you may take a stool softener (such as Colace, one
capsule) or gentle laxative (such as milk of magnesia, 1 tbs)
twice a day. You can get both of these medicines without a
prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluids and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
PAIN MANAGEMENT:
-You may take Tylenol as directed, not to exceed 3000mg in 24
hours. Take regularly for a few days after surgery but you may
skip a dose or increase time between doses if you are not having
pain until you no longer need it.
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- chest pain, pressure, squeezing, or tightness
- cough, shortness of breath, wheezing
- pain that is getting worse over time or pain with fever
- shaking chills, fever of more than 101
- a drastic change in nature or quality of your pain
- nausea and vomiting, inability to tolerate fluids, food, or
your medications
- if you are getting dehydrated (dry mouth, rapid heart beat,
feeling dizzy or faint especially while standing)
-any change in your symptoms or any symptoms that concern you
Additional:
- pain that is getting worse over time, or going to your chest
or back
- urinary: burning or blood in your urine or the inability to
urinate
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.
WOUND CARE:
-Dressing Removal: You may take off your drain dressing in 2
days. If the wound is still open at that time, you may continue
to wear a dressing on the wound.
-You may shower with any bandage strips that may be covering
your wound. Do not scrub and do not soak or swim, and pat the
incision dry. If you have steri strips, they will fall off by
themselves in ___ weeks. If any are still on in two weeks and
the edges are curling up, you may carefully peel them off.
-Do not take baths, soak, or swim for 6 weeks after surgery
unless told otherwise by your surgical team.
-Notify your surgeon if you notice abnormal (foul smelling,
bloody, pus, etc) or increased drainage from your incision site,
opening of your incision, or increased pain or bruising. Watch
for signs of infection such as redness, streaking of your skin,
swelling, increased pain, or increased drainage.
Please call with any questions or concerns. Thank you for
allowing us to participate in your care. We hope you have a
quick return to your usual life and activities.
-- Your ___ Care Team
Followup Instructions:
___
|
10839643-DS-11
| 10,839,643 | 25,055,559 |
DS
| 11 |
2166-02-28 00:00:00
|
2166-03-05 21:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Rib Fractures post- Motor Vehicle Crash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female who was transferred from
___ s/p MVC, where she was an unrestrained
intoxicated passenger (+airbag, no known LOC). She presented
with the following injuries: Right rib ___ right displaced
fractures, Right rib 10
non-displaced fracture, and L4-L5 non-traumatic disc herniation.
Past Medical History:
H/o Ectopic pregnancy ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM
------------------
Vitals: Afebrile, HR 83, BP 131/73, RR 20, SPO2 98%RA
GSC 15
Eyes: WNL
Face: 2 cm laceration on chin
Neck: C-collar in place
Respiratory: CTAB
Chest: TTP at right chest
GI: Soft, NT, ND, +BS
Ext: Decreased ROM on right and left leg ___ pain
Neuro: CN II-XII intact
Psych: anxious
GU: no foley
Skin: Tatoos
DISCHARGE EXAM:
VS: 98.1 PO125 / 82 L ___
HEENT: 2 cm laceration on chin with removed sutures, well
healed, no erythema
Chest: CTAB, TTP on right chest/ribs
Cardiac: RRR, normal s1/s2, no murmurs
GI: soft, non-tender, non-distended, +BS
Ext: full ROM on all extremities. Ambulating with cane.
Neuro: Grossly intact
Psych: anxious
GU: Foley
Skin: +Tatoos
Pertinent Results:
ADMISSION LABS
------------------
___ 04:00AM BLOOD WBC-23.2*# RBC-4.36 Hgb-13.7 Hct-41.3
MCV-95 MCH-31.4 MCHC-33.2 RDW-12.4 RDWSD-43.5 Plt ___
___ 04:00AM BLOOD Neuts-91.2* Lymphs-4.6* Monos-3.3*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-21.16* AbsLymp-1.06*
AbsMono-0.77 AbsEos-0.00* AbsBaso-0.04
___ 04:00AM BLOOD ___ PTT-24.7* ___
___ 04:00AM BLOOD Glucose-91 UreaN-9 Creat-0.9 Na-142 K-4.5
Cl-104 HCO3-25 AnGap-18
___ 03:03PM BLOOD Calcium-8.8 Phos-3.5 Mg-1.9
___ 04:00AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:22AM URINE Color-Yellow Appear-Clear Sp ___
___ 10:22AM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:22AM URINE RBC-7* WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
___ 10:22AM URINE Mucous-RARE
___ 10:22AM URINE Hours-RANDOM
___ 10:22AM URINE UCG-NEG
___ 10:22 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
RECENT LABS PRIOR TO DC
___ 11:30AM BLOOD WBC-11.1* RBC-3.76* Hgb-12.0 Hct-35.8
MCV-95 MCH-31.9 MCHC-33.5 RDW-12.1 RDWSD-42.4 Plt ___
___ 11:30AM BLOOD Glucose-91 UreaN-11 Creat-0.9 Na-136
K-3.9 Cl-103 HCO3-26 AnGap-11
___ 11:30AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.1
IMAGING
---------
___ PORTABLE ABDOMEN ___
___ DX SHOULDER & HUMERUS ___
___ CT C-SPINE W/O CONTRAST ___
___ CT HEAD W/O CONTRAST ___
___ TRAUMA #3 (PORT CHEST O ___
___
___ CT L-SPINE Outside FacilityREF ONLY
___ TORSO (CHEST, ABD & PELVIS) Outside
FacilityREF ONLY
___ T-SPINE Outside FacilityREF ONLY
___ CT HEAD: OSH study
Brief Hospital Course:
Ms ___ is a ___ who presented s/p MVC intoxicated with EtOH
(BAL 164) s/p MVC w right4-10 rib fracture with BAL of
#TRAUMA COURSE: Trauma imaging was notable for Right ribs ___
displaced fractures, a right rib 10 non-displaced fracture, and
an L4-L5 non-traumatic disc herniation. C-spine was cleared.
Tertiary exam was notable for right-shoulder pain but right
shoulder x-ray was negative for fracture. Patient also
experienced a small < 1 inch chin laceration that was sutured on
HD2 and removed prior to discharge. Was discharged with
bacitracin ointment and close medical followup with PCP and
trauma surgery.
#NEURO: The patient was alert and oriented throughout
hospitalization; pain was initially managed with an epidural and
then as pain improved, patient was switched to a variety of PO
pain medications for optimal control and a lidocaine patch. By
discharge, pain was very well controlled and patient was
ambulating and taking care of ADLs without difficulty. While
patient had elevated BAL, she did not score on the CIWA scale
and had no signs of ETOH withdrawals.
#CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
#PULMONARY: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
#GI/GU/FEN: The ___ hospital course was complicated by
nausea and vomiting, likely in the setting of narcotic pain
medications. KUB on ___ only showed a non-obstructive bowel gas
pattern. Her nausea improved with ativan and titration of her PO
pain medications. The patient was tolerating a regular diet
prior to discharge.
#ID: The patient's fever curves were closely watched for signs
of infection, of which there were none.
#HEME: Patient received BID SQH for DVT prophylaxis, in addition
to encouraging early ambulation and Venodyne compression
devices.
#TRANSITIONAL ISSUES
--------------------
- Patient needs close monitoring on new pain regimen.
- ___ require referral to pain management if pain is not well
controlled.
- Injuries:
-Right ribs ___ displaced fractures
-Right rib 10 non-displaced fracture
-L4-L5 non-traumatic disc herniation
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
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*1
2. Bacitracin Ointment 1 Appl TP BID
RX *bacitracin zinc 500 unit/gram Apply to Chin Wound twice a
day Refills:*0
3. cane 1 cane miscellaneous With ambulation Duration: 13
Months
DX:807.06 Closed fracture of 6 ribs PX: Good ___: 13 months
RX *cane Use with walking Daily Disp #*1 Each Refills:*0
4. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth three times a day
Disp #*60 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
Please take with food
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*60 Tablet Refills:*0
7. Lidocaine 5% Patch 1 PTCH TD QAM rib pain
RX *lidocaine 5 % Apply 1 patch to rib pain area Q24H Disp #*20
Patch Refills:*0
8. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
9. Ramelteon 8 mg PO QHS insomnia
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
10. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [Natural Senna Laxative] 8.6 mg 1 tablet by mouth
twice a day Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma from Motor Vehicle Crash
Right ribs ___ displaced fractures
Right rib 10 non-displaced fracture
L4-L5 non-traumatic disc herniation
Small Chin Laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You presented to the hospital with trauma injuries after a motor
vehicle crash.
In the hospital:
-You were found to have Right Rib ___ rib fractures, which did
not require surgery.
-You also had a chin laceration that was sutured. The sutures
were removed on ___.
- Imaging from an outside hospital indicated you had a lumbar
___ non-traumatic disc herniation. Please follow this up with
your primary care doctor.
- Your pain was controlled and your were evaluated by physical
therapy and occupational therapy who determined you did not need
physical/occupational therapy rehab. You were ambulating
independently by the time you left the hospital.
When you leave the hospital
- Take all your medications as prescribed and follow up with
your health care providers
- ___ from heavy lifting (>10 lbs) as your injuries heal
- if your IV sites get redder or more painful, please call your
doctor or seek medical attention.
- Also watch out for the danger signs below.
It was a pleasure taking care of you,
--Your ___ Care Team
Followup Instructions:
___
|
10840596-DS-16
| 10,840,596 | 23,385,392 |
DS
| 16 |
2116-12-20 00:00:00
|
2116-12-20 15:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
bee stings / tomatoes / aspirin / acetaminophen / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
left arm erythema
Major Surgical or Invasive Procedure:
___
ultrasound guided fine needle aspiration left arm fluid
collection
History of Present Illness:
HPI: ___ year old female s/p left axillary to brachial artery
bypass with PTFE now transferred from ___ with cellulitis of the
left upper extremity. She reports that for the past 3 days she
has noticed redness at the incision site. She was given bactrim
on discharge and notes that she was taking this until it ran out
yesterday. She reports pruritis in the area starting ___ but
denies any itching of the area.
Endorses one fever to 100.7F yesterday. No chills or malaise.
There has been a scant amount of purulent drainage from the
site.
There has been moderate pain at the site of the left upper arm
incision.
She denies any picking at the incision or injection into the
graft.
Past Medical History:
PMH: hep C untreated, bronhcitis, COPD, HLD, migranes, DM2,
obesity, pancreatitis, GERD, bipolar disorder, left brachial
artery occlusion
PSH:ventral hernia repair with mesh, left arm vascular steting,
left knee arthroscopy, left axillary to brachial bypass with
PTFE
(___)
Social History:
___
Family History:
noncontributory
Physical Exam:
admission exam
GEN: alert, orientedx3
CV: borderline elevated rate, regular rhythm
Pulm: nonlabored respirations, clear
Abd: soft, no distention
Ext: warm, well perfused. 2+ left radial pulse. normal capillary
refill left upper extremity.
Incisions: left upper extremity incision intact. significant
erythema and induration surronding the incision. overlying the
incision there is an area of fluctuance. only able to express
minimal sanginopurulent fluid from the incision. no injection
site marks appreciable over the incision. chest incision clean,
dry, intact, no surrounding erythema with steri strips intact.
discharge exam
GEN: alert, orientedx3
CV: RRR
Pulm: nonlabored respirations, clear
Abd: soft, no distention
Ext: warm, well perfused. 2+ left radial pulse. normal capillary
refill left upper extremity.
Incisions: left upper extremity incision intact. minimal
induration under left arm incision. minimal serous drainage.
erythema almost entirely resolved. chest incision
clean,dry,intact. no erythema surrounding. no palpable hematoma
Pertinent Results:
Radiology ReportUS INTERVENTIONAL PROCEDUREStudy Date of
___ 9:21 AM
___ 9:21 AM
US INTERVENTIONAL PROCEDURE Clip # ___
Reason: ? ultrasound guided fluid aspiration, please send for
gram s
UNDERLYING MEDICAL CONDITION:
___ year old woman s/p left axillary-brachial artery bypass
grafting. Now with
___ fluid collection along brachial anastamosis in
left arm. concern for
abscess
REASON FOR THIS EXAMINATION:
? ultrasound guided fluid aspiration, please send for gram
stain,
aerobic/anaerobic and fungal culture
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: ___ year old woman s/p left axillary-brachial artery
bypass
grafting. Now with ___ fluid collection along brachial
anastamosis in
left arm. concern for abscess // ? ultrasound guided fluid
aspiration, please
send for gram stain, aerobic/anaerobic and fungal culture
COMPARISON: Ultrasound dated ___ performed at an
outside hospital.
PROCEDURE: Ultrasound-guided aspiration of the collection
adjacent to the
left axillary-brachial bypass graft
OPERATORS: Dr. ___, abdominal radiology fellow and Dr. ___.
___,
attending radiologist, who was present and supervising
throughout the total
procedure time.
TECHNIQUE: The risks, benefits, and alternatives of the
procedure were
explained to the patient. After a detailed discussion, informed
written
consent was obtained. A pre-procedure timeout using three
patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US table.
Limited
preprocedure ultrasound was performed to localize the
subcutaneous collection
adjacent to the left axillary-brachial bypass graft. The site
was marked.
Local anesthesia was administered with 1% Lidocaine solution.
Using continuous sonographic guidance, an 18 gauge spinal needle
was advanced
into the collection on 2 separate passes. 7 cc of bloody fluid
was aspirated
and sent to microbiology for analysis. The needle was then
removed and a
sterile dressing was applied.
The procedure was tolerated well, and there were no immediate
post-procedural
complications.
FINDINGS:
Similar to the previous ultrasound, there is a heterogeneous
collection
superficial to the left axillary-brachial bypass graft in the
left upper arm.
This was targeted for aspiration.
IMPRESSION:
Technically successful ultrasound-guided aspiration of
subcutaneous collection
adjacent to the left axillary-brachial bypass graft. The
findings likely
represent an infected hematoma. A sample was sent to
microbiology for
analysis.
The study and the report were reviewed by the staff radiologist.
___ 06:15AM BLOOD WBC-4.0 RBC-2.99* Hgb-9.4* Hct-29.0*
MCV-97 MCH-31.5 MCHC-32.5 RDW-14.0 Plt ___
___ 06:45AM BLOOD WBC-4.5 RBC-2.96* Hgb-9.9* Hct-28.5*
MCV-96 MCH-33.3* MCHC-34.6 RDW-13.6 Plt ___
___ 05:40AM BLOOD WBC-6.5# RBC-3.20* Hgb-10.7* Hct-31.0*
MCV-97 MCH-33.5* MCHC-34.6 RDW-13.7 Plt ___
___ 06:30AM BLOOD WBC-4.3 RBC-2.99* Hgb-9.2* Hct-28.7*
MCV-96 MCH-30.9 MCHC-32.2 RDW-13.7 Plt ___
___ 08:18AM BLOOD WBC-4.2# RBC-2.91* Hgb-9.5* Hct-27.9*
MCV-96 MCH-32.5* MCHC-34.0 RDW-13.5 Plt ___
___ 03:00AM BLOOD WBC-8.5 RBC-3.23* Hgb-10.5* Hct-30.9*
MCV-96 MCH-32.5* MCHC-33.9 RDW-13.6 Plt ___
___ 06:30AM BLOOD ___ PTT-34.6 ___
___ 06:15AM BLOOD Glucose-135* UreaN-8 Creat-0.6 Na-137
K-4.0 Cl-102 HCO3-27 AnGap-12
___ 05:40AM BLOOD Creat-0.6
___ 08:18AM BLOOD Glucose-123* UreaN-11 Creat-0.7 Na-137
K-4.0 Cl-105 HCO3-25 AnGap-11
___ 03:00AM BLOOD Glucose-93 UreaN-8 Creat-0.7 Na-135 K-4.2
Cl-99 HCO3-26 AnGap-14
___ 08:00PM BLOOD ALT-38 AST-111* AlkPhos-121* TotBili-0.4
___ 06:15AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.7
___ 08:00PM BLOOD Albumin-3.4*
___ 08:18AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.9
___ 08:18AM BLOOD CRP-26.3*
___ 02:05PM BLOOD Vanco-7.6*
___ 05:38AM BLOOD Vanco-6.1*
___ 08:00PM BLOOD Vanco-10.1
___ 03:06AM BLOOD Lactate-1.2
___ 6:42 pm SWAB Site: ARM Source: left arm.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 3:10 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
The patient was admitted to the Vascular Surgery Service for
evaluation and treatment. Hospital course by system as below:
Neuro/psych: The patient received oxycodone with good effect and
adequate pain control. The patient appearing somnolent as during
previous hospitalization on her prescribed home regimen of
seroquel, neurontin and amitriptyline. These medications were
confirmed using the electronic medical record as being
prescribed to the patient. Toxicology was sent that returned
positive for cocaine metabolites, which the patient stated she
used 3 days prior to admission. The psychiatry service was
consulted who recommended stopping neurontin, reducing the dose
of seroquel and making it only a PRN medication. Social work and
the addiction psychiatry nursing services were also consulted
who offered resources to the patient and established psychiatric
care followup with her post discharge. The patient was
instructed to discuss her antipsychotic medications with her new
psychiatrist in followup this week. Her mental status remained
clear during this hospitalization.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Statin was
continued. Left arm remained with adequate perfusion during
hospitalization.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored.
GI/GU/FEN: Regular diet was given which was well tolerated.
Patient's intake and output were closely monitored, and IV fluid
was adjusted when necessary. Electrolytes were routinely
followed, and repleted when necessary. Home omeprazole was
continued.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Broad spectrum IV
antibiotics were started on admission. Superficial wound
cultures were negative. Infectious disease service was consulted
who recommended initial broad spectrum IV antibiotics and
aspiration of the fluid collection seen on ultrasound alongside
the graft in the left arm. This was performed ___ by
radiology without immediate complication. Aspiration grossly
appeared to represent a possibly infected hematoma. Cultures
from this aspiration were negative. The infectious disease
service recommended oral antibiotics on discharge and this was
implemented with a 2 week course of bactrim and cipro. The
patient was advised regarding concerning signs of infection that
should prompty return, as well as to avoid attempting to express
discharge or manipulate the incision.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly. Oral glycemic
agents were restarted on discharge.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin during
this stay; was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Amitriptyline 50 mg PO HS
Atorvastatin 40 mg PO DAILY
Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg po bid
Gabapentin 600 mg PO TID
Omeprazole 20 mg PO DAILY
QUEtiapine Fumarate 200 mg PO TID
Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
do not drink alcohol, take other substances or drive while
taking oxycodone
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
albuterol prn
metformin 250 mg po qd
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze,shortness of
breath
2. Atorvastatin 40 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Omeprazole 20 mg PO DAILY
5. QUEtiapine Fumarate 50 mg PO TID prn anxiety,agitation
6. Amitriptyline 25 mg PO HS
7. MetFORMIN (Glucophage) 250 mg PO DAILY
8. Nicotine Patch 14 mg TD DAILY
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*12 Tablet Refills:*0
10. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
11. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
left upper arm infected hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
WHAT TO EXPECT:
1. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the arm you were operated
on:
Elevate your arm above the level of your heart (use ___
pillows) every ___ hours throughout the day and at night
3. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
Follow your discharge medication instructions
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
You should get up every day, get dressed and walk
You should gradually increase your activity
You may up and down stairs, go outside and/or ride in a car
Increase your activities as you can tolerate- do not do too
much right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower - no direct spray on incision, let the soapy
water run over incision, rinse and pat dry
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed. DO NOT MASSAGE, ITCH
OR ATTEMPT TO EXPRESS DRAINAGE FROM THE WOUND.
CALL THE OFFICE FOR: ___
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your arm or the
ability to feel your arm
Temperature greater than 100.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
___
|
10840912-DS-4
| 10,840,912 | 25,267,407 |
DS
| 4 |
2116-06-29 00:00:00
|
2116-06-29 14:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cellulitis/VP shunt infection
Major Surgical or Invasive Procedure:
___: VP shunt removal and EVD placement
___: EVD removal
___: right pigtail placed for hepatic fluid collection by
___
___: pigtail removed by ___
History of Present Illness:
___ yo Male with PMH right cerebellar hemangioblastoma s/p
suboccipital craniotomy resection (___) complicated by
pseudomeningocele s/p right frontal VP shunt placement on
___omplicated by submassive pulmonary
embolism s/p IVC filter placement ___ who presents with 1
day of redness and swelling on the abdomen concerning for
cellulits.
Patient states that he woke up on ___ and noted redness and
mild pain on his abdomen without discharge. No fevers/chills,
abdominal pain, nausea, vomitting, diarrhea. He has had a
"pulling" sensation at the surgical site for the past 2 weeks
that has remained stable. An abdominal ultrasound was
concerning
for a fluid collection which was found to be related to likely
CSF collection from the VP shunt. Surgery was consulted in the
ED and did not suspect a drainable collection with
recommendation for admission to medicine to treat cellulitis.
Neurosurgery was also consulted given VP shunt and question of
infection related to abdominal CSF collection near the
termination of the shunt catheter.
- In the ED, initial vitals were:
T 97.2 HR 73 BP 125/58 RR 16 Sat 100% RA
- Exam was notable for:
Skin: well demarcated area of erythema on abdomen at area of
prior incision, palpable mass in area of erythema (outlined in
marker), warm to touch, mildly tender. Incision well healed
- Labs were notable for:
WBC 8.4
H/H 10.1/34.7
Pt ___
-----------
___
- Studies were notable for:
CT abdomen/Pelvis w/ contrast
1. Partial visualization of VP shunt catheter which terminates
within a focal fluid collection within the periphery of the
liver
in segments ___ and measures 4.4 x 5.4 x 3.4 cm. This fluid
collection likely represents CSF from the VP shunt catheter,
although infection cannot be excluded. Pericatheter
fat stranding is nonspecific but possibly reactive. No definite
focal fluid collection about the extraperitoneal course of the
visualized catheter. Neurosurgical consultation recommended.
2. Ill-defined hyperdensity within the left rectus musculature
with mild stranding of the overlying subcutaneous fat is
nonspecific. Correlate for recent surgery.
3. Right lower lobe consolidation likely represents atelectasis,
although in the proper clinical setting pneumonia cannot be
excluded.
4. Suprarenal positioning of the IVC filter. Correlate for
intended positioning.
Abdominal soft tissue u/s:
Approximately 4.0 x 4.0 x 0.8 cm irregular fluid collection in
the superficial tissues of the right paramidline upper ventral
abdomen contains part of the VP shunt catheter which is not
visualized distally traveling beneath the peritoneal lining and
could represent fluid collection associated with fractured VP
shunt catheter. Infection cannot be excluded.
Shunt series AP/Lat skull:
1. Post-surgical changes from right frontal ventriculoperitoneal
drain.
2. The shunt tubing appears patent, however, there is a kink in
the abdominal portion of the tubing.
CT head:
1. No significant change in positioning of the tip of the right
frontal approach VP shunt catheter with stable prominence of the
supratentorial ventricular system.
2. Foci of air within the right lateral ventricle and basal
cisterns is likely related to shunt catheter.
3. Air within the cavernous sinus is likely iatrogenic.
4. Interval decrease in size of large extra-axial fluid
collection within the surgical bed about the suboccipital
craniotomy, possibly a pseudomeningocele.
5. Continued interval decrease in size of posterior right
cerebellar cavity which could represent air or fat packing.
- The patient was given:
IV Vancomycin 1g
On arrival to the floor, patient has no complaints and feels
well overall. Confirms history above.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
==============================
-Pseudomeningocele s/p right parietal VP shunt (___)
-Right cerebellar lesion Hemangioblastoma s/p resection
(___)
-Pulmonary embolism ___ s/p IVC placement (on Apixiban)
- H/o prolonged QTC
- HTN
- HLD
-Osteoarthritis (left knee, bilat hands and feet)
-Lumbar stenosis
-Headaches
-Hx hepatitis
Surgical History:
==================
___ Suboccipital craniotomy and resection of cerebellar
Hemangioblastoma
___ right parietal laparoscopic VP shunt
___ IVC filter placement
___ Right knee replacement
Social History:
___
Family History:
His father did have heart issues, but were not specified.
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
___
T 99.7 BP 106/62 HR 92 RR 18 Sat 96% RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
well healed surgical scar on neckk and right side of scalp, no
TTP of the shunt
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: Mild TTP in RUQ at the area of cellulitis as below,
otherwise non-tender, non distended
EXTREMITIES: No ___ edema. Pulses DP/Radial 2+ bilaterally.
SKIN: RUQ with fluctulant area and overlying erythema, warmth
around a well healed surgical site, no discharge or extension
beyond demarcated area
NEUROLOGIC: AOx3. CN2-12 intact. ___ strength throughout. Normal
sensation. intact finger to nose testing and alternating
repetitive hand movement
DISCHARGE PHYSICAL EXAM
=======================
General:
T 98.7 BP ___ HR 68 RR 24 O2 95%RA
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: Right 3-2mm, brisk Left 3-2mm, brisk
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No
Comprehension Intact: [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
Right 5 5 5 5 5
Left 5 5 5 5 5
IPQuadHamATEHLGast
Right5 5 5 5 5 5
Left5 5 5 5 5 5
[x]Sensation intact to light touch in all four extremities.
Cranial Wound:
[x]Clean, dry, EVD site left open to air
[x]P Fossa Incision - no evidence of pseudomeningocele,
well-healed.
Abdominal Wound: dressing present at the RUQ, c/d/i
Pertinent Results:
See OMR for pertinent imaging & labs
Brief Hospital Course:
Mr. ___ is a ___ y/o male with PMH right cerebellar
hemangioblastoma s/p suboccipital craniotomy resection
(___) complicated by pseudomeningocele s/p right frontal
VP shunt placement on ___omplicated
by submassive pulmonary embolism s/p IVC filter placement
___ who presents with 1 day of redness and swelling on the
abdomen concerning for cellulitis now with GPC on gram stain
from VP shunt tap concerning for VP shunt infection.
#VP Shunt Infection
The was initial concern for cellulitis given redness on the
abdomen. VP shunt found to be penetrating liver capsule on
radiology review. Surgery and Neurosurgery were consulted.
Antibiotics were started with vancomycin (st ___ and broadened
to include ceftriaxone at 2gQ12 hours and flagyl on ___ given
the concern for VP shunt infection. VP shunt was tapped on ___
by neurosurgery which found GPC and 29 WBC. He remained
hemodynamically stable. Apixaban was on hold as of ___.
He was transferred to the neurosurgery service on ___, taken to
the operating room for VP shunt explantation and placement of an
EVD. He was extubated in the OR and transferred to PACU for
post-anesthesia monitoring. He remained neurologically and
hemodynamically stable and was transferred to the neuro ICU for
ongoing neurologic monitoring. Postoperatively, the patient
remained neurologically stable. He was continued on empiric
vancomycin, ceftriaxone and flagyl pending culture results. EVD
remained open at 10cm. EVD was clamped on ___. Antibiotics were
narrowed to vancomycin only on ___ per ID recommendations. OR
cultures grew STAPHYLOCOCCUS, COAGULASE NEGATIVE. Patient
tolerated clamp trial for >24 hours without true ICP elevations
or symptoms. Patient underwent a NCHCT in the AM of ___ was
stable. His EVD was subsequently removed. CSF was sent on ___.
Patient underwent an abdominal ultrasound on ___ per ACS
recommendations which revealed mild decrease in the size of the
fluid collection adjacent to the dome of the right hepatic lobe.
He went to Interventional Radiology for drainage of this fluid
on ___. Fluid was sent for testing and final cultures came back
as coag negative staphylococcus and pigtail was placed. The
patient remained in the NIMU, neurologically stable from
___. Final ID recommendations are to continue Vancomycin
1250mg IV q12h to a minimum end date ___ with weekly labs. A
head CT was obtained on ___ which showed stable ventricle size
and post-op changes, no intracranial hemorrhage. Social work was
consulted for patient and family coping given his intermittent
confusion. Patient was given tramadol for headaches with
improvement. ___ removed his right sided pigtail on ___. Patient
was medically cleared for discharge. ___ and OT recommended
rehab.
#PE s/p IVC
#C/f IVC malposition
Submassive PE with IVC filter placement by vascular medicine
(___). CT imaging with placement of IVC in the
suprarenal position. Per cath report on ___ the IVC was placed
just below the renal veins. No evidence of renal dysfunction.
Per last vascular note, the IVC filter could have been removed
during prior admission. The vascular medicine team has been
contacted and will provide recommendations regarding the IVC
filter. The vascular team evaluated patient on ___ and stated
that the IVC filter was in fact in the correct place. He was
recommended to follow up with Dr. ___ for discussion
of outpatient removal of the IVC filter.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Polyethylene Glycol 17 g PO DAILY
3. Propranolol LA 120 mg PO DAILY
4. Ramelteon 8 mg PO QHS:PRN sleep
5. Senna 8.6 mg PO QHS:PRN Constipation - First Line
6. Simvastatin 40 mg PO QPM
7. Tamsulosin 0.4 mg PO QHS
8. QUEtiapine Fumarate 50 mg PO QHS
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID
3. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line
flush
4. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
5. Vancomycin 1250 mg IV Q 12H
6. Apixaban 5 mg PO BID
7. Polyethylene Glycol 17 g PO DAILY
8. Propranolol LA 120 mg PO DAILY
9. QUEtiapine Fumarate 50 mg PO QHS
10. Ramelteon 8 mg PO QHS:PRN sleep
11. Senna 8.6 mg PO QHS:PRN Constipation - First Line
12. Simvastatin 40 mg PO QPM
13. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
VP shunt infection
Hepatic fluid collection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Surgery
You presented for a VP shunt infection. Your VP shunt was
removed on ___ and an EVD was placed. EVD was removed on ___.
Your incisions should be kept clean and dry. Do not apply
lotions or creams to the surgical site.
You had a drain placed in your hepatic fluid collection on
___ and removed on ___.
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:
Headache or pain along your incision.
Some neck tenderness along the shunt tubing.
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:
___
|
10841353-DS-20
| 10,841,353 | 27,764,986 |
DS
| 20 |
2121-11-06 00:00:00
|
2121-11-06 15:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ___
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
CC: food impaction
Major Surgical or Invasive Procedure:
___ upper endoscopy with removal of impacted food
History of Present Illness:
HPI: The patient is a ___ male w/no significant PMHx who
presented with food impaction. He was in his usual state of
health until around 5 ___ while eating steak he felt food become
stuck in his throat. He had difficulty tolerating his
secretions, although he denied chest pain or shortness of
breath.
He initially had some difficulty speaking which have been
improved by the time he arrived to the emergency department on
___. He was seen at twice daily ___, lateral and neck x-ray
and chest x-ray were performed and were unremarkable. A trial
of
glucagon did not result in any improvement, and he was unable to
tolerate sips of water. As a result he was transferred to the
___ emergency department. Nothing like this has happened to
him before.
In the ED: Vitals were unremarkable, he was seen and found to be
"drooling, spitting up secretions." Gastroenterology was
consulted, and he was transferred to the endoscopy suite where a
disimpaction via upper endoscopy was performed. Postprocedure
he
had a significant oxygen requirement, and so is admitted for
monitoring, and weaning of oxygen.
Seen on the floor, he is doing well, and feels well. He denies
shortness of breath or cough, fevers or chills. He confirms he
is not on oxygen at home. He does endorse a significant smoking
history, he quit ___ years ago, however prior to that he smoked
for at least ___ years 1 pack per day. He has had chest x-rays
prior to this one, although has never been told without any
abnormalities. He understands the situation, and the plan of
care. He has no questions for me.
ROS: [x] As per above HPI, otherwise reviewed and negative in
all
systems
Primary Care Provider: ___, MD
Past Medical History:
PMHx:
BPH
No hospitalizations other than for the procedures noted below
PSHx:
Partial colectomy with ostomy creation, and then takedown,
approximately ___ years ago, performed at ___ for
perforated diverticulitis
Recent colonoscopy unremarkable
Left hip fracture due to a motorcycle accident in his ___,
repaired with screws at that time
Social History:
___
Family History:
FHx:
No family history of esophageal swallowing problems, however his
father did die of esophageal cancer at age ___
No other family history of cancers, other than skin cancers
Physical Exam:
Admission Physical Exam:
VS: T 98.4, BP 135/79, HR 101, RR 18, O2 sat 94% on 2 L nasal
cannula
Lines/tubes: PIV
Older man lying in bed, alert, cooperative, NAD. Anicteric,
PERRL, MMM. Equal chest rise, good air movement bilaterally
posteriorly, no work of breathing, or cough. He does have
inspiratory crackles bilaterally at the bases, no rhonchi or
wheezes. Heart regular. No murmurs. Abdomen soft, NT ND.
Extremities warm, no pitting edema. Speaking easily, no obvious
focal neurological deficits. Oriented ×3.
Discharge Physical Exam
Same as above except now off oxygen
T 98.4, BP 129/68, HR 73, RR 18, O2 sat 94% on RA
Pertinent Results:
Admission Labs
___ 09:39PM URINE MUCOUS-RARE
___ 09:39PM URINE RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 09:39PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 09:39PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:39PM URINE UHOLD-HOLD
___ 09:39PM URINE HOURS-RANDOM
___ 10:30PM ___ PTT-32.8 ___
___ 10:30PM PLT COUNT-343
___ 10:30PM NEUTS-75.5* LYMPHS-14.9* MONOS-6.2 EOS-2.6
BASOS-0.5 IM ___ AbsNeut-8.74* AbsLymp-1.73 AbsMono-0.72
AbsEos-0.30 AbsBaso-0.06
___ 10:30PM WBC-11.6* RBC-4.89 HGB-14.7 HCT-42.6 MCV-87
MCH-30.1 MCHC-34.5 RDW-12.8 RDWSD-39.9
___ 10:30PM estGFR-Using this
___ 10:30PM GLUCOSE-92 UREA N-13 CREAT-0.8 SODIUM-138
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-22 ANION GAP-18
Imaging
___ CXR
IMPRESSION: There are no prior chest radiographs available for
review. Heart size normal. Lungs clear. No pleural
abnormality. Normal hilar and mediastinal contours.
Procedures
___ EGD
Impression: A large amount of solid food consistent with steak
was found in esophageal lumen. This was removed using ___ net
and rat tooth forceps. A large bolus of food could ultimately be
pushed down into the stomach. (foreign body removal)
Esophageal ring
Otherwise normal EGD to third part of the duodenum
Recommendations: - Wean oxygen as able
- Omeprazole 20 mg BID (30 minutes breakfast) till next
endoscopy
- Repeat EGD for possible dilation in 14 days in ___
- Liquid diet for 24 hours and soft solid after that
Discharge Labs
Same as admission -- no others were checked
Brief Hospital Course:
___ man with no significant past medical history now
presenting with esophageal food impaction, likely related to
esophageal ring, status post upper endoscopy with disimpaction,
with ongoing oxygen requirement suspected due to atelectasis.
The day of discharge, he ate tuna fish and other soft foods
without difficulty. He was seen by Nutrition who instructed him
on a soft diet and gave him handouts. He has their clinic phone
number for any questions.
#Persistent O2 requirement after upper endoscopy
-Suspected due to atelectasis based on chest imaging, although
given his significant smoking history it is possible that there
is a component of obstructive lung disease
-Given the lack of wheezing on exam, we treated this with
incentive spirometry, and ambulation, and were able to wean his
oxygen easily
#Esophageal food impaction, associated with esophageal ring
-Per gastroenterology recommendations, we will have him on
omeprazole 20 mg p.o. twice daily, and a soft diet as noted
above, and he will ___ with them in 2 weeks for a dilation
#Benign prostatic hypertrophy
-Continue home finasteride and tamsulosin
#Advance care planning
- Health Care Proxy: as per ___, he identifies his wife
- Care ___: He has thought about the kind of care he
would want if he were to get very sick some day. He does say "I
do not want to be dead, but I do not want to be in any pain or
discomfort. I would rather go ___ years early if that is what it
meant." He states he has talked with his wife about his wishes.
The patient was safe to discharge and on the day of discharge I
spent >30min in discharge day services and coordination of care.
________________________________________
___, MD
___
Pager ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO QHS
2. Finasteride 5 mg PO DAILY
3. Grape Seed (grape seed extract) unk unk oral DAILY
4. Glucosamine-Chondroitin Max St (glucosamine-chondroit-vit
C-Mn) unk unk oral DAILY
Discharge Medications:
1. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
2. Finasteride 5 mg PO DAILY
3. Glucosamine-Chondroitin Max St (glucosamine-chondroit-vit
C-Mn) unk unk oral DAILY
4. Grape Seed (grape seed extract) unk unk oral DAILY
5. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
#Esophageal food impaction
#Esophageal web
#Benign prostatic hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after suffering a food impaction in your
esophagus. This was likely due to an "esophageal ring" which is
a narrowing in the esophagus. You had an endoscopy and the food
was removed. After the procedure you tolerated a soft diet
without difficulty. You should continue this diet, and the acid
reducing pill (omeprazole) at least until you are seen by
Gastroenterology in two weeks as noted below.
Followup Instructions:
___
|
10841368-DS-6
| 10,841,368 | 27,711,991 |
DS
| 6 |
2143-06-06 00:00:00
|
2143-06-06 13:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Demerol
Attending: ___.
Chief Complaint:
B/l lower extremity swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old female h/o LLE swelling x ___
months with recent diagnosis of extensive retroperitoneal
retrocrual b/l common iliac lyphadenoapathy probably secondary
to malignancy in the uterus. She then developed RLE edema ___
days ago. Pt also with extra-hepatic and intraphepatic
dilatation. Pt L iliac common femoral vein is completely
occluded, pt also has a gallstone. Given the sudden nature of
the RLE swelling she presented to the ED.
In the ED
She otherwise ___ sob, cp, nausea, post prandial pain or any
abdominal pain, fevers, chills, malaise, dysuria. No diarrhea.
She does report a decreased in her appetite. No neuro sx. All
other ROS negative.
Past Medical History:
Uterine cancer
Glaucoma
HTN
HLD
Social History:
___
Family History:
Father died of an MI at age ___
Mother died of an MI at age ___
Brother died of an MI at age ___ had ___ MIs before he was ___
Physical Exam:
97.5 165/44 83 18 92% on RA
GEN: NAD, comfortable appearing
She is a good historian
HEENT: Pupils sluggish
CV: s1s2 rr SEM at LUSB
RESP: b/l crackles at the bases to ___ up
ABD: +bs, soft, NT, ND, no guarding or rebound
back:
EXTR: b/l lower 3++ -4++ edema b/l
Metastasis on upper L arm.
Pulses are dopplable b/l but cannot be appreciated
DERM: no rash
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
Discharge PE:
VS: T: 97.3 HR: 77 BP: 145/53 RR: 16 99% RA
Gen: NAD, resting comfortably in bed
HEENT: EOMI, PERRLA, MMM
CV: RRR nl s1s2 no m/r/g
Resp: CTAB no w/r/r
Abd: Soft, NT, mild distention +BS
Ext: 4+ pitting edema bilaterally, hard nodule in left upper arm
Neuro: CN II-XII intact, ___ strength throughout
Psych: normal affect
Skin: warm, dry no rashes
Pertinent Results:
___ 01:13AM GLUCOSE-85 UREA N-26* CREAT-1.2* SODIUM-137
POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-18* ANION GAP-17
___ 01:13AM estGFR-Using this
___ 01:13AM WBC-9.0 RBC-3.88* HGB-7.8* HCT-26.4* MCV-68*
MCH-20.1* MCHC-29.5* RDW-18.9* RDWSD-45.1
___ 01:13AM NEUTS-79.8* LYMPHS-12.4* MONOS-6.7 EOS-0.4*
BASOS-0.4 IM ___ AbsNeut-7.18* AbsLymp-1.12* AbsMono-0.60
AbsEos-0.04 AbsBaso-0.04
___ 01:13AM PLT COUNT-504*
=================
CT scan of abdomen ___
Extensive retrocrural, retroperitoneal b/l common iliac and L
pelvic LAD
2.3 x 2.2 hypodense mass along the R uterus which may the source
of the patient's primary malignancy
3. Moderate intrahepatic and extra-hepatic biliary dilatation
Occlusion of the L iliac nad common femoral vein due to
patient's extensive LAD
Gallstone
Non-obstructing kidney stones
====================
___
7.8/28.5\593
=======================
141|104|25 /
4.7| ___
===============
AST = 54
=============
OSH LEUS:
No visualized evidence of RLE DVT
Incomplete exam of the LLE without occlusive thrombus
CT A/P ___:
IMPRESSION:
1. Extensive, confluent and heterogeneous retroperitoneal, left
pelvic
sidewall and bilateral inguinal lymphadenopathy as described
above consistent with extensive metastatic disease. Enhancing
heterogeneous mass along the right side of the uterus may
represent a primary focus of disease. 1.9 cm left adrenal
lesion may represent an additional metastatic focus.
2. Moderate to severe intrahepatic biliary ductal dilatation and
common bile
duct dilatation up to 1.6 cm. Recommend correlation with LFTs.
3. Small bilateral pleural effusions. Diffuse body wall edema.
Brief Hospital Course:
___ year old female with h/o metastatic cancer with mullerian
primary c/b retroperitoneal LAD with venous occlusion with left
sided edema with new onset of severe RLE edema.
.
METASTATIC mullerian cell cancer
VENOUS OCCLUSION
Severe lower extremity edema
Recently diagnosed in ___ when she presented with left
leg swelling s/p biopsy of inguinal lymph node on ___
showing metastatic poorly differentiated carcinoma with
neuroendocrine features and consistent with mullerian primary.
CT
on ___ showed diffuse retroperitoneal, retrocrural, common
iliac and left pelvic lymphadenopathy with 2.3x2.2 cm right
uterine mass. She has not seen on oncologist yet or started
treatment and presented due to new onset severe right lower
extremity edema. Lower extremity dopplers negative for DVT.
Currently stable without any acute need for radiation or
chemotherapy. She was seen by the oncology consult service.
Her records including her pathology slides had previously been
sent to ___. It was determined that following up at ___ as
scheduled would be the fastest way to determine appropriate
treatment.
- Plan for discharge with close outpatient follow-up at ___ on
___.
- pain control with Percocet
- bowel regimen
- continue Lasix for leg swelling. She is declining compression
stockings due to pain.
- ___ recommending rehab, plan for d/c to STR on ___
.
BILIARY DILATATION: CT showing biliary dilation similar to
prior, her LFTs are
essentially normal (aside from trivially elevated AST to 41)
without current significant abdominal symptoms
-Trend LFTs
.
HTN: Discontinued Cardizem in case it was contributing to leg
swelling. Started HCTZ.
ANEMIA, iron deficiency. Severe iron deficiency that has been
progressive, hemoglobin on ___ was 8.8. She has never had
a colonscopy before and is not interested in one. She denies any
recent vaginal bleeding, she reports having a hemorrhoid but
denies any recent GI bleeding. Anemia worsening likely
multifactorial from chronic disease, possible occult blood loss
and dilution. Received 1 unit pRBC on ___ with more than
appropriate increase in hemoglobin. No signs of active
bleeding.
- Continue ferrous sulfate
FEN/PPX: regular diet, heparin SC
Full code
Dispo: D/c to STR
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 120 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q6H:PRN pain
5. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
3. Simvastatin 40 mg PO QPM
4. ClonazePAM 1 mg PO BID:PRN anxiety
RX *clonazepam 1 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 2 tablet(s) by mouth
every four (4) hours Disp #*180 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Ferrous Sulfate 325 mg PO DAILY
8. Hydrochlorothiazide 25 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
metastatic uterine cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for worsening swelling in your legs due to
your uterine cancer. You were seen by the oncology team and
they recommended following up with your doctor at the ___
___. You were also given 1 unit of blood
for worsening anemia (low red blood cell count). Please
follow-up with your oncologist at ___ as scheduled.
Followup Instructions:
___
|
10841600-DS-16
| 10,841,600 | 24,851,723 |
DS
| 16 |
2185-07-11 00:00:00
|
2185-07-11 15:43:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Necrotic left leg wound
Major Surgical or Invasive Procedure:
Debridment of left leg wound
History of Present Illness:
___ year old female sent from her nursing
home for evaluation of a left lower extremity wound. The
patient is a poor historian and unable to recount the timing
of her left c wound. From the nursing home documentation she
has had a small skin tear and hematoma in that region over
the past few weeks however it has opened and began draining
over the last day. The patient is without any complaints.
From the notes there is no fever or other symptoms.
Past Medical History:
- Hypertension
- Hyperlipidemia
- Psoriasis
- Rib Fracture
- Pelvic fracture
- Peptic ulcer disease, UGIB
- Diastolic congestive heart failure
- Aortic regurgitation (newly diagnosed)
Family History:
Non-contributory
Physical Exam:
Upon presentation to ___:
Temp: 98.7 HR: 87 BP: 121/82 Resp: 18 O(2)Sat: 100 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender
Extr/Back: Left lower extremity with 2+ swelling, a 12 cm
laceration of the lateral aspect of the lower extremity with
hematoma and extensive ecchymosis. 1+ DP ___ is felt in the
left foot, and sensation is intact to light touch.
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mentation, Normal mood
Pertinent Results:
___ 06:30PM GLUCOSE-111* UREA N-22* CREAT-0.7 SODIUM-136
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-33* ANION GAP-10
___ 06:30PM CALCIUM-9.0 PHOSPHATE-4.0 MAGNESIUM-2.0
___ 06:30PM WBC-9.2 RBC-3.38* HGB-11.3* HCT-32.2* MCV-95
MCH-33.4* MCHC-35.1* RDW-13.6
___ 06:30PM PLT COUNT-257
___ 06:30PM ___ PTT-31.4 ___
Left tibia/fibula, AP and lateral views.
FINDINGS: AP and lateral views of left tibia/fibula were
obtained. Per the radiology technologist, these are the best
images possible. Patient unable to move lower leg.
There is osteopenia. No acute fracture or dislocation is seen.
Soft tissue disruption/ulceration is seen along the lateral
aspect of the calf without definite underlying osseous
destruction; however if clinical concern for acute osteomyelitis
persists, consider MRI or nuclear medicine bone scan, which are
more sensitive. Vascular calcifications are seen.
IMPRESSION: Soft tissue disruption/ulceration along the lateral
aspect of the calf without radiographic evidence of underlying
osseous destruction; however if clinical concern for acute
osteomyelitis persists, consider MRI or nuclear medicine bone
scan, which are more sensitive.
Brief Hospital Course:
She was admitted to the Acute Care Surgery team for management
of her left leg wound. The wound was irrigated and debrided;
twice a day normal saline wet to dry dressing changes were then
implemented. She was given Tylenol and prn Oxycodone 2.5 mg for
pain which was effective.
Her pre-hospital medications were restarted and she was
tolerating a regular diet at time of discharge.
She was discharged back to her extended nursing facility with
instructions for her wound care and an appointment for follow up
in the Acute Care Surgery clinic.
Medications on Admission:
Citalopram, Simvastatin, Mapap (acetaminophen), Tums,
furosemide, latanoprost, metoprolol succinate, omeprazole,
Klor-Con 10, bisacodyl, Vitamin D3, senna,
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN wheezing
3. Calcium Carbonate 500 mg PO BID
4. Citalopram 20 mg PO DAILY
5. Furosemide 60 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Milk of Magnesia 30 mL PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Simvastatin 20 mg PO DAILY
11. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 4
hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Necrotic left leg wound
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with a wound on your left leg
that required a procedure to clean up (debride) the wound. You
are being discharged on twice a day dressing changes.
You should keep your right leg elevated when at rest.
Your home medications may be resumed.
Followup Instructions:
___
|
10841633-DS-13
| 10,841,633 | 26,237,340 |
DS
| 13 |
2125-09-11 00:00:00
|
2125-09-11 15:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex
Attending: ___.
Chief Complaint:
shortness of breath, chest discomfort, lightheadedness
Major Surgical or Invasive Procedure:
TEE/DCCV: ___
___ Chamber PPM: ___
History of Present Illness:
This is a ___ yo F with PMHx of CHF and SVT presenting with
shortness of breath, chest discomfort/palpitations, and
lightheadedness. Patient reports that she has baseline
intermittent shortness of breath but for the past two days it
has come on more frequently at rest and worsens with minimal
activity. It has become associated with palpitations, chest
discomfort, lightheadedness. She also endorses lightheadedness
and feels like she is going to faint. Denies headache, weakness,
numbness, vision changes, abdominal pain, nausea, vomiting,
diaphoresis, urinary symptoms, cough, lower extremity pain or
swelling. She reports that she was diagnosed with CHF ___ years
ago and has been on Lasix in the past, but this medication was
stopped due to no clinical improvement. Her last ECHO was ___
years ago.
In the ED
- Initial vitals: 97.2 100 154/89 18 100%
- EKG - atrial fibrillation with rapid ventricular response
- CXR - No acute cardiopulmonary process.
- Labs significant for: Trop < 0.1, lactate 1.8, proBNP 1516,
D-Dimer 459
- Transfer vitals: 98.9 106 132/66 20 100% RA
Past Medical History:
Meniere's disease
SVT
CHF
Herniated Discs
Thyroid nodules
Social History:
___
Family History:
Both of patient's parents died of MIs at age ___. Mother had
stroke.
Physical Exam:
ADMISSION EXAM
================
VS: 97.9 138/95 100 22 99% RA
General: NAD, sitting comfortably
HEENT: Atraumatic, normocephalic, EOMI
Neck: soft, no JVP
CV: Normal S1S2, tachycardic and irregular rate, no m/r/g
Lungs: CTAB, Right upper lung crackles
Abdomen: Soft, NTND, +BS
Ext: warm, well perfused, no edema
Neuro: AAOx3, neuro grossly in tact
Skin: no rashes, no lesions
PULSES: 2+ distal pulses bilaterally
DISCHARGE EXAM
================
VS: 98.6 138/71 18 97% RA
GENERAL: well appearing woman, NAD.
HEENT: NCAT.
NECK: unable to appreciate JVP
CHEST: pacemaker in place, bandage clean and dry
CARDIAC: sinus, no M/R/G
ABDOMEN: Soft, NTND.
EXTREMITIES: No edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS:
===============
___ 11:00AM BLOOD WBC-6.7 RBC-5.00 Hgb-15.5 Hct-46.3 MCV-93
MCH-31.0 MCHC-33.5 RDW-13.5 Plt ___
___ 11:00AM BLOOD Neuts-73.9* Lymphs-17.5* Monos-6.6
Eos-1.2 Baso-0.7
___ 11:00AM BLOOD ___ PTT-26.4 ___
___ 11:00AM BLOOD Glucose-91 UreaN-19 Creat-1.1 Na-143
K-4.4 Cl-107 HCO3-25 AnGap-15
___ 11:00AM BLOOD ALT-23 AST-23 AlkPhos-105 TotBili-0.4
___ 11:00AM BLOOD proBNP-1516*
___ 11:00AM BLOOD cTropnT-<0.01
___ 05:00PM BLOOD cTropnT-<0.01
___ 11:00AM BLOOD Albumin-4.2 Calcium-9.4 Phos-2.9 Mg-2.3
___ 05:15AM BLOOD TSH-2.9
___ 11:46AM BLOOD D-Dimer-459
___ 11:25AM BLOOD Lactate-1.8
PERTINENT LABS:
===============
___ 05:15AM BLOOD TSH-2.9
DISCHARGE LABS:
===============
___ 05:30AM BLOOD WBC-6.7 RBC-4.19* Hgb-13.2 Hct-38.2
MCV-91 MCH-31.6 MCHC-34.7 RDW-13.0 Plt ___
___ 05:30AM BLOOD Glucose-88 UreaN-21* Creat-1.0 Na-136
K-4.2 Cl-104 HCO3-23 AnGap-13
___ 05:30AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.3
IMAGING:
===============
-CXR ___: No acute cardiopulmonary process.
-EKG ___: Atrial fibrillation with rapid ventricular
response. Diffuse ST-T wave changes. Compared to the previous
tracing no change.
-TTE ___:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Doppler parameters are indeterminate for left
ventricular diastolic function. There is no ventricular septal
defect. The right ventricular free wall is hypertrophied. Right
ventricular chamber size is normal. with borderline normal free
wall function. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion. There is
an anterior space which most likely represents a prominent fat
pad.
IMPRESSION: Suboptimal image quality due to body habitus. Left
and right ventricular systolic function are probably normal, a
focal wall motion abnormality cannot be excluded. No significant
valvular abnormality. Normal pulmonary artery systolic
pressures.
-TTE ___:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Overall left ventricular
systolic function is normal (LVEF>55%). The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque to 28 cm from the incisors.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion.
IMPRESSION: No left atrial or left atrial appendage thrombus.
Normal gross LV systolic structure and function.
MICROBIOLOGY:
===================
___ 11:00 am BLOOD CULTURE: NO GROWTH
Brief Hospital Course:
This is a ___ yo F with PMHx of CHF and SVT presenting with
shortness of breath, chest discomfort, and lightheadedness
likely ___ new atrial fibrillation with RVR and heart failure
exacerbation s/p TEE/DCCV c/b bradycardia s/p PPM.
ACUTE ISSUES
===============
# SOB/CP/Lightheadedness: Patient presenting with SOB, chest
pain and lightheadedness in the setting of new atrial
fibrillation on EKG and likely some elements of heart failure
exacerbation. Unlikely ACS, as trop x 2 negative, EKG without
signs of ischemia/infarct. Patient's atrial fibrilliation and
heart failure were treated as below and patient's symptoms
resolved.
# Atrial Fibrillation with RVR s/p TEE/DCCV c/b bradycardia:
Patient symptomatic with EKG showing Afib with RVR.
Precipitating factor of Afib unlikely ACS (trops neg, no signs
of inschemia/infarct on EKG), no signs of infection, TSH normal.
Patient was started on Metop Succ 100 mg PO with good rate
control and rivaroxaban 20 mg QHS for anticoagulation. and
aspirin discontinued. Patient underwent TEE/cardioversion that
was complicated by long pause for which she was started on
dopamine. She was then transferred to the CCU where she was
maintained on dopamine with HRs in 50-60 and MAPs ___. Patient
ultimately received a ___ dual chamber PPM on ___ with
adminstration of prophylactic antibiotics (vancomycin =>
Clindamycin). She was discharged on Rivaroxaban for
anticoagulation.
# HFpEF: Patient presenting with subacute cough, acute SOB and
chest discomfort. Appears euvolemic on exam, however, TTE with
enlarged right atrium suggests that heart failure may be
contributing to these symptoms. Patient was started on Torsemide
5 mg daily and tolerated it well with no further symptoms of
dyspnea.
TRANSITIONAL ISSUES
=====================
-code: full
-contact: ___ (husband) H: ___ W:
___ ___ (SON) C: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO QPM
2. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Simvastatin 20 mg PO QPM
2. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. Rivaroxaban 20 mg PO DINNER
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth Q ___ Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
-new onset atrial fibrillation
-sick sinus syndrome
-diastolic heart failure
Seoncdary Diagnosis:
-hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital for
shortness of breath, lightheadedness, and chest discomfort. You
were found to be in atrial fibrillation with a fast heart rate,
which was a major cause of these symptoms. You were started on a
medication (Metoprolol) to slow down your heart rate and a
medication (Rivaroxaban) to keep your blood thin and prevent
blood clots. You also underwent an echocardiogram and
cardioversion, which converted your heart rate back to a normal
rhythm, however this was complicated by your heart beating very
slow. You were then given medication to increase your heart rate
(dopamine) and your metoprolol was stopped. Given that your
heart rate continued to be slow, you received a pacemaker to
help control your heart rates.
Your shortness of breath was also thought to be from mild
congestive heart failure for which you were given diuretics to
remove fluid from your lungs. Your breathing improved after
these interventions.
Please follow-up with the appointments listed below and continue
taking your medications as instructed below.
Wishing you the best,
Your ___ team
Followup Instructions:
___
|
10841701-DS-5
| 10,841,701 | 21,558,137 |
DS
| 5 |
2170-07-28 00:00:00
|
2170-07-28 16:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
gabapentin-diet. supp 11 / modafinil
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
LABS:
=====
___ 11:58AM BLOOD WBC-5.7 RBC-3.80* Hgb-12.0 Hct-35.6
MCV-94 MCH-31.6 MCHC-33.7 RDW-11.6 RDWSD-40.0 Plt ___
___ 06:48AM BLOOD WBC-4.7 RBC-3.83* Hgb-12.3 Hct-35.4
MCV-92 MCH-32.1* MCHC-34.7 RDW-11.8 RDWSD-39.8 Plt ___
___ 11:58AM BLOOD Neuts-60.2 ___ Monos-7.6 Eos-0.9*
Baso-0.7 Im ___ AbsNeut-3.42 AbsLymp-1.71 AbsMono-0.43
AbsEos-0.05 AbsBaso-0.04
___ 11:58AM BLOOD Glucose-86 UreaN-17 Creat-0.7 Na-132*
K-4.6 Cl-98 HCO3-23 AnGap-11
___ 06:48AM BLOOD Glucose-84 UreaN-14 Creat-0.6 Na-134*
K-4.4 Cl-100 HCO3-21* AnGap-13
___ 11:58AM BLOOD ___ PTT-32.8 ___
___ 11:58AM BLOOD ALT-25 AST-30 CK(CPK)-88 AlkPhos-109*
TotBili-0.3
___ 06:48AM BLOOD ALT-21 AST-24 LD(LDH)-206 AlkPhos-105
TotBili-0.2
___ 11:58AM BLOOD cTropnT-<0.01
___ 02:50PM BLOOD cTropnT-<0.01
___ 11:58AM BLOOD Albumin-4.1 Calcium-8.9 Phos-4.0 Mg-2.1
___ 06:48AM BLOOD Albumin-3.9 Calcium-8.6 Phos-4.0 Mg-1.9
___ 12:08PM BLOOD Lactate-1.5
MICROBIOLOGY:
=============
___ 12:17 pm URINE
URINE CULTURE (Pending):
IMAGING:
========
___
CXR:
IMPRESSION:
No acute intrathoracic process.
CT HEAD W/O CONTRAST:
IMPRESSION:
1. No acute intracranial process. Specifically, no evidence of
intracranial
hemorrhage.
2. Unchanged subcortical periventricular hypodensities, which
are nonspecific
likely consistent with a combination of chronic small vessel
disease, and
underlying demyelinating changes.
MRI ORBITS AND BRAIN:
IMPRESSION:
1. Unremarkable MRI of the orbits with no evidence of mass
lesions, or
abnormal enhancement after contrast administration.
2. Partial visualization of numerous T2 hyperintense foci in the
subcortical
white matter, likely consistent with demyelinating changes in
this patient
with history of multiple sclerosis.
Brief Hospital Course:
Ms. ___ is a ___ year old woman w/PMH HCM (mild LVOT
gradient), NSVT, MS, osteoporosis, and depression presenting
with blurry vision and lightheadedness.
ACUTE ISSUES:
=============
# Visual changes
# Lightheadedness
No clear etiology of her presenting symptoms which resolved
quickly. Evaluated by neurology who found her neurological exam
and rapid improvement of her symptoms reassuring and recommended
MRI brain to assess for vascular or demyelinating lesion. MRI
Brain showed no evidence of mass lesions, or abnormal
enhancement but with partial visualization of numerous T2
hyperintense foci in the subcortical white matter, likely
consistent with demyelinating changes ___ to MS. ___
evaluated by cardiology who did not think her symptoms were
likely to be related to LVOT obstruction as they occurred at
rest and her symptoms would be an unusual
presentation of arrhythmia (also has had recent negative holter
monitoring). She has no new EKG changes and troponin was
negative. She should have follow up with an ophthalmologist for
eye examination as an outpatient. She should follow up with her
cardiologist and neurologist.
# HCM
TTE in ___ showing mild LVH with mild resting LVOT gradient.
Has been experiencing progressive DOE. Should consider stress
TTE as an outpatient to assess gradient with activity as above.
Continued metoprolol succinate 25mg daily
CHRONIC ISSUES:
===============
# Benign MS
___ flares as sensory disturbances. No current evidence
of MS flare though MRI as above with possible foci of
demyelination consistent with history of MS. ___ continued on
oxcarbazepine 450mg BID
TRANSITIONAL ISSUES:
[] She should have follow up with an ophthalmologist for eye
examination as an outpatient.
[] She should follow up with her cardiologist as scheduled
___
[] Ensure outpatient follow up with her neurologist.
[] consider stress TTE as an outpatient to assess gradient with
activity
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. armodafinil 150 mg oral DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. OXcarbazepine 450 mg PO BID
4. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. armodafinil 150 mg oral DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. OXcarbazepine 450 mg PO BID
4. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Vision changes
Lightheadedness
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 did you come to the hospital?
- You were experiencing visual changes and lightheadedness.
What did you receive in the hospital?
- You were seen by neurologists and had a brain MRI which did
not show a stroke but did show changes consistent with your
known MS.
- You had an EKG and cardiac biomarker testing which did not
show a heart attack.
- Your symptoms resolved and you felt ready to go home.
What should you do once you leave the hospital?
- Please take your medications as prescribed and go to your
future appointments which are listed below.
-You will need to see your primary care doctor within the week.
- Please schedule and appointment with an eye doctor to have
your vision checked.
- You should follow up closely with your neurologist. You have
an MRI scheduled for ___, please confirm with your neurologist
if this MRI is still needed at this time.
- You should follow up closely with your cardiologist
- You should return to the emergency room if you experience any
of the warning signs listed below.
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10841707-DS-10
| 10,841,707 | 21,249,432 |
DS
| 10 |
2178-08-10 00:00:00
|
2178-08-10 13:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abd Pain, Abnormal Labs
Major Surgical or Invasive Procedure:
TIPS on ___
Therapeutic paracentesis on ___
US guided right liver biopsy ___
History of Present Illness:
This is a ___ male with history of prostate cancer, HIV
with (CD4 count 762, viral load 22) on Genvoya and recent
admission for fluid overload secondary to portal hypertension
and
new diagnosis of ___ syndrome (started on apixaban),
discharged on ___.
Patient presented for f/u in GI clinic on ___ where he
presented
with massive ascites and had therapeutic para with 4.5L removed.
He had labs checked and was called today on ___ to present to ED
for abnormal labs (WBC 19, K 5.5, Na 130) and 2 days of
increasing fatigue, mild abdominal discomfort/bloating.
Regarding his most recent admission: he was admitted after
having
worsening abdominal distension and lower extremities swelling.
He
was also complaining from cough and was diagnosed with
bronchiolitis. On abdominal imaging he was found to have
extensive PVT with extension to splenic vein and right /left
intra-hepatic veins. He was initiated on heparin which was then
transitioned to Apixiban. He underwent diagnostic/therapeutic
paracentesis twice which was negative for SBP. Patient received
Lasix/spironolactone while in the hospital, however he was not
discharged on any diuretic given his hyponatremia (Na 128 at
discharge). EGD was performed on ___ and showed evidence of
portal hypertension with some grade I varices.
In terms of malignancy/ hypecoagulable state workup patient had
negative Torso CT scan with no evidence of solid mass or any
obvious lymphadenopathy or mass. AFP was normal. Factor V Leiden
mutation negative. Protein C/S nl. JAK2 pending.
He was found to have abnormal liver chemistry with
hepatocellular
and
cholestatic pattern. His iron levels were unremarkable, ___
normal, AMA and ___ negative. Negative RF. HCV neg, HIV neg.
EBV
and CMV neg. Beta 2 glycoprotein and cardiolipin Ab neg.
Currently, patient denies fevers, chills, vomiting, diarrhea,
blood in the stool, dysuria, hematuria, cough, back or flank
pain, rashes, lower extremity edema. He denies tobacco or
alcohol
use, +crystal meth use several months ago. He started feeling
more tired and sluggish in the last few days, requiring naps
during the day. Thinks breathing has improved
Initial vital signs in the ED were notable for: 98.4 117 140/91
20 98% RA
Labs were notable for:
21.8>16.7/51.4<247
N 86.9, L 6.2, M 4.2
130 95 27
---------<123
5.5 20 1.1
Repeat K 5.1, Na 129, Lactate 2.9
ALT 186, AST 229, AP 298, TBili 2.8, Alb 3.1
Peritoneal Fluids: WBC 501, Poly 49, Lymph 28, RBC ___
Studies performed include:
CXR: Lung volumes are low. There is bibasilar atelectasis. No
significant pleural effusion cardiomediastinal silhouette is
within normal limits. No acute osseous abnormalities.
IMPRESSION:
Low lung volumes with bibasilar atelectasis.
Patient was given:
2g CTX
Vitals on transfer: 97.8 102 124/79 17 96% RA
Past Medical History:
Prostate cancer- s/p brachytherapy in ___
HIV on Genvoya
Chronic pain
Amphetamine abuse now sober for 2 months
Avoidant personality disorder
Dysthymia
H/o primary VZV, h/o reactivation in around ___
Social History:
___
Family History:
Mother died at ___ from "natural causes". She did not go to the
doctor very often. Father ___ alive and well. One of his 8
siblings died but he is not sure of the cause.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITALS: 98.2PO 121 / 81 94 18 95 Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: Pupils equal, round, and reactive bilaterally,
extraocular
muscles intact. Sclera anicteric and without injection. Moist
mucous membranes.
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
ABDOMEN: Normal bowels sounds, distended, mild tenderness to
deep
palpation in all four quadrants. Has pain on right side of lower
ribs.
EXTREMITIES: 1+ edema bilaterally in ___
___: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. AOx3. No Asterixis
DISCHARGE PHYSICAL EXAM:
==========================
___ 0502 Temp: 97.8 PO BP: 110/65 HR: 96 RR: 18 O2 sat: 92%
O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress. Oriented
x3. Able to perform days of week forward and backward without
difficulty.
HEENT: Pupils equal, round, and reactive bilaterally,
extraocular
muscles intact. Sclera anicteric and without injection. Moist
mucous membranes.
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. Decreased breath
sounds
throughout but no adventitious sounds discernible.
ABDOMEN: Normal bowels sounds, distention improved, nontender to
palpation. Ecchymosis on right side of abdomen around liver
biopsy site.
EXTREMITIES: trace edema bilaterally in ___
___: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. AOx3. No Asterixis.
Pertinent Results:
ADMISSION LABS:
==================
___ 01:35PM BLOOD WBC-21.8* RBC-5.86 Hgb-16.7 Hct-51.4*
MCV-88 MCH-28.5 MCHC-32.5 RDW-21.2* RDWSD-62.9* Plt ___
___ 01:35PM BLOOD Neuts-86.9* Lymphs-6.2* Monos-4.2*
Eos-0.3* Baso-0.7 NRBC-0.1* Im ___ AbsNeut-18.90*
AbsLymp-1.35 AbsMono-0.91* AbsEos-0.06 AbsBaso-0.15*
___ 01:35PM BLOOD ___ PTT-34.0 ___
___ 01:35PM BLOOD Glucose-123* UreaN-27* Creat-1.1 Na-130*
K-5.5* Cl-95* HCO3-20* AnGap-15
___ 01:35PM BLOOD ALT-186* AST-229* AlkPhos-298*
TotBili-2.8*
___ 01:35PM BLOOD Albumin-3.1*
PERTINENT/DISCHARGE LABS:
============================
___ 07:25AM BLOOD WBC-17.7* RBC-5.12 Hgb-14.7 Hct-44.2
MCV-86 MCH-28.7 MCHC-33.3 RDW-21.2* RDWSD-62.3* Plt ___
___ 07:45AM BLOOD ___ PTT-34.8 ___
___ 07:25AM BLOOD ___ PTT-78.0* ___
___ 07:25AM BLOOD Glucose-113* UreaN-14 Creat-0.8 Na-133*
K-5.2 Cl-97 HCO3-19* AnGap-17
___ 07:45AM BLOOD ALT-138* AST-172* LD(___)-410*
AlkPhos-201* TotBili-3.5*
___ 07:53AM BLOOD ALT-120* AST-130* LD(LDH)-380*
AlkPhos-203* TotBili-2.8*
___ 08:03AM BLOOD ALT-325* AST-436* LD(LDH)-652*
AlkPhos-193* TotBili-3.5*
___ 07:25AM BLOOD ALT-288* AST-311* LD(LDH)-498*
AlkPhos-228* TotBili-4.1*
___ 07:45AM BLOOD TotProt-5.8* Albumin-4.2 Globuln-1.6*
Calcium-8.6 Phos-2.7 Mg-2.2
___ 07:53AM BLOOD Albumin-3.2* Calcium-8.2* Phos-3.0 Mg-2.2
___ 08:03AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.3
___ 07:25AM BLOOD Calcium-8.1* Phos-2.2* Mg-2.1
___ 07:45AM BLOOD Osmolal-275
___ 07:45AM BLOOD Cortsol-14.9
___ 07:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
IMAGING/RESULTS:
==================
CXR ___:
IMPRESSION:
Low lung volumes with bibasilar atelectasis.
TIPS ___:
FINDINGS:
1. Completely thrombosed right hepatic vein
2. Post angioplasty, successful restoration of flow into the
right hepatic vein.
3. Thrombosis of the right portal vein.
4. Contrast enhanced portal venogram showing widely patent left
portal vein. Thrombosis of the right portal vein..
4. Post-TIPS portal venogram showing good wall-to-wall flow
through the TIPS stent.
5. Post-TIPS right atrial pressure of 18 and portal pressure of
28 resulting in portosystemic gradient of 10 mmHg.
6. 4 liters of bloody fluid removed through right paracentesis
drain.
IMPRESSION:
Successful right hepatic vein recannulization and transjugular
intrahepatic portosystemic shunt placement from right hepatic
vein to right portal vein.
US GUIDED RIGHT LIVER BIOPSY ___:
FINDINGS: Small amount of perihepatic ascites
IMPRESSION: Successful non targeted liver biopsy
Brief Hospital Course:
Mr. ___ is a ___ male with history of prostate
cancer, HIV with (CD4 count 762, viral load 22) on Genvoya and
recent Budd-Chiari syndrome (on apixaban), extensive PVT, who
was admitted with increasing fatigue, abdominal
discomfort/bloating, and abnormal labs.
# Budd Chiari syndrome with extensive PVT and SVT
# Ascites
Patient was recently diagnosed with Budd Chiari syndrome with
extensive PVT and SVT during recent hospitalization at ___.
Hypercoagulability work up was notable for JAK2 mutation
(resulted during current admission). He was discharged on
apixaban. Since discharge, he underwent therapeutic paracenteses
as outpatient but had worsening fatigue and abdominal
discomfort/bloating. ___ was consulted during admission and
performed TIPS procedure and therapeutic paracentesis with 4L
removed on ___. Given his LFT abnormalities and liver synthetic
dysfunction, he underwent US guided right liver biopsy on ___.
He was intermittently on heparin gtt given procedures and was
restarted on home apixaban 5mg BID at time of discharge. His
LFTs transiently increased due to procedure and were
downtrending at time of discharge - discharge LFTs were ALT 288
and ALT 311. No diuretics were started during hospitalization;
plan for patient to weigh himself daily and call hepatologist if
weight increasing to initiate diuresis.
# Leukocytosis
Admitted due to worsening leukocytosis as outpatient. Initial
concerns for SBP and was started on CTX and albumin. However,
after correction for RBCs on diagnostic paracentesis, patient
only had 190 PMNs and CTX/albumin were discontinued. Blood and
peritoneal fluid cultures were NGTD at time of discharge. His
leukocytosis increased briefly post-procedure after TIPS and
downtrended at time of discharge - discharge WBC 17.7.
# Hypercoagulable state:
As noted above, patient was found to have Budd-Chiari syndrome
during recent hospitalization. He was screened from malignancy
with CT Torso during hospitalization without evidence of
lymphadenopathy or mass. He underwent hypercoagulability work-up
and was found to have JAK2 mutation. He was intermittently on
heparin gtt and was discharged on apixaban. He is scheduled to
follow up with hematology on ___.
# Hyponatremia
Given overall volume overload status with ascites and peripheral
edema, suspect hyponatremia related to low effective arterial
blood volume in setting of ongoing liver dysfunction. Sodium
remained stable during hospitalization - discharge Na 133.
# Hyperkalemia
Potassium elevated to 5.5 as outpatient, with repeat check
stable. Etiology unclear but improved during hospitalization
without intervention. There was concern for adrenal
insufficiency but ACTH and AM cortisol were normal. Discharge K
of 5.2.
CHRONIC ISSUES:
===============
# HIV infection:
His CD4 is ___ on ___. He remained on home
Genvoya daily.
# Bronchiolitis
He remained on home albuterol nebs PRN.
TRANSITIONAL ISSUES:
======================
[] Repeat CBC, Chem-10, LFTs on ___
[] Follow up liver biopsy
[] Consider initiation of diuresis if patient's weight is
increasing - patient informed to weigh himself daily and call
hepatologist if weight is increasing
[] Follow up with hematology about new JAK2 mutation diagnosis
[] Uncertain if patient will require further therapeutic
paracentesis in future now s/p TIPS - monitor for increasing
abdominal distention
#CODE: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
BID:PRN
3. Genvoya (elviteg-cob-emtri-tenof ALAFEN) ___ mg
oral DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Genvoya (elviteg-cob-emtri-tenof ALAFEN) ___ mg
oral DAILY
3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
BID:PRN
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Budd-Chiari Syndrome
JAK2 Mutation
Ascites
Hyponatremia
Secondary diagnoses:
HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you.
WHY WERE YOU ADMITTED?
- You had worsening fatigue and abdominal discomfort and were
found to have abnormal labs
WHAT HAPPENED DURING YOUR HOSPITALIZATION?
- You had a procedure (called TIPS) to help improve blood flow
to your liver.
- You had a biopsy of your liver to better determine the cause
of your liver dysfunction.
- You had a paracentesis to remove the fluid from your abdomen.
- Your labs were monitored and improved.
WHAT SHOULD YOU DO ONCE YOU ARE HOME?
- Continue to take all of your medications as prescribed.
- Follow up with all of your providers as outlined below.
- Weigh yourself everyday. If your weight is increasing, call
your liver doctor to discuss starting a medication to help
remove excess fluid.
Again, it was a pleasure taking care of you during your
hospitalization!
All the best,
Your ___ Team
Followup Instructions:
___
|
10842401-DS-22
| 10,842,401 | 29,919,477 |
DS
| 22 |
2148-09-13 00:00:00
|
2148-09-13 12:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Meperidine / Sulfa (Sulfonamide Antibiotics) / trazodone /
Macrolide Antibiotics
Attending: ___.
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of OSA on
CPAP, migraines, insomnia, depression/anxiety followed by Dr.
___ presents with leg swelling and pain.
THe patient underwent meniscal knee surgery (same day surgery)
one week prior to presentation. She had no leg swelling or pain
prior to this procedure. 1 to 2 days afterward, she developed
new
onset swelling of the foot spreading up to back of the knee and
left leg pain in the region. No erythema or warmth. No fever.
She
reports no trauma to the area. She has been active since the
procedure, using a crutch and mobilizing as recommended to her.
She denies past history of blood clots or bleeding problems.
The patient reports chest discomfort at rest at this time.
Nonradiating and left sided. Nonpleuritic. No back pain. She
denies dyspnea. No nausea, vomiting, diarrhea.
ED: Found to have left lower extremity DVT and bilateral
segmenta/subsegmental PE on CTA chest. Given lovenox therapeutic
dosing.
A complete 10 point review of systems was obtained and otherwise
negative.
Past Medical History:
PMH: chronic headaches, mild sleep apnea not requiring oxygen or
CPAP
PSH: Multiple surgeries including Cesarean section,
hysterectomy, stomach surgery for a benign mass, brain surgery
for a benign tumor resection in ___, rotator cuff surgery in
___, as well as a lipoma excision of the right upper extremity
in ___.
ALL: demerol (pruritis), sulfa (N/V, pruritis)
Social History:
___
Family History:
Mother STROKE
Father CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
STROKE
Sister BREAST CANCER
THYROID DISEASE
Physical Exam:
98.2
PO 117 / 83 81 18 96 Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs. LLE with edema.
PSYCH: pleasant, appropriate affect
NEUROLOGIC:
MENTATION: alert and cooperative. Oriented to person and place
and time.
Pertinent Results:
___ 08:10AM BLOOD WBC-6.5 RBC-4.06 Hgb-10.8* Hct-34.3
MCV-85 MCH-26.6 MCHC-31.5* RDW-14.3 RDWSD-44.1 Plt ___
___ 12:50AM BLOOD WBC-11.2* RBC-4.67 Hgb-12.2 Hct-39.6
MCV-85 MCH-26.1 MCHC-30.8* RDW-14.3 RDWSD-44.0 Plt ___
___ 08:10AM BLOOD Glucose-105* UreaN-15 Creat-0.8 Na-144
K-4.0 Cl-109* HCO3-25 AnGap-10
___ 12:50AM BLOOD Glucose-99 UreaN-16 Creat-0.8 Na-145
K-4.4 Cl-108 HCO3-24 AnGap-13
___ 08:10AM BLOOD cTropnT-<0.01
___ 01:25PM BLOOD cTropnT-<0.01
___ 12:50AM BLOOD cTropnT-<0.01
___ 12:50AM BLOOD proBNP-29
___ 12:50AM BLOOD HCG-<5
___ TTE
Findings
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV
systolic function.
AORTA: Normal aortic diameter at the sinus level. Normal aortic
arch diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.
___ VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion. There is an anterior space
which most likely represents a fat pad, though a loculated
anterior pericardial effusion cannot be excluded.
Conclusions
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size is normal with borderline normal free wall
function. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Normal sized right ventricle with borderline normal
function and no evidence of pulmonary hypertension
=====
___ CTA Chest
EXAMINATION: CTA chest
INDICATION: ___ with palpitations, dyspnea, HR90, new DVT// PE
TECHNIQUE: Axial multidetector CT images were obtained through
the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and
oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy
(Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 2.0 s, 1.0 cm; CTDIvol = 4.6 mGy
(Body) DLP = 4.6
mGy-cm.
3) Spiral Acquisition 6.5 s, 25.1 cm; CTDIvol = 8.8 mGy
(Body) DLP = 206.1
mGy-cm.
Total DLP (Body) = 223 mGy-cm.
COMPARISON: None
FINDINGS:
The aorta and its major branch vessels are patent, with no
evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There
is no
evidence of penetrating atherosclerotic ulcer or aortic arch
atheroma present.
There are pulmonary emboli in the segmental pulmonary artery to
the right
upper lobe, right middle lobe with extension into the medial
subsegmental
pulmonary artery as well as in the segmental right lower lobe
with extensive
extension into the lateral basal, anterior basal, and posterior
basal
subsegmental pulmonary arteries on the right. There are also
pulmonary emboli
in the segmental left upper lobe and within the lateral basal
subsegmental
pulmonary artery in the left lower lobe. There is no suggestion
of right
heart strain. The main and right pulmonary arteries are normal
in caliber,
and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar
lymphadenopathy.
The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. There is no
pleural effusion.
There is bibasilar atelectasis without focal consolidation or
suggestion of
pulmonary infarction. The airways are patent to the
subsegmental level.
Limited images of the upper abdomen show a small hiatal hernia
and are
otherwise unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is
identified.
IMPRESSION:
1. Segmental pulmonary emboli to the right upper, middle, and
lower lobes with
extension into the subsegmental pulmonary arteries in these
areas. Segmental
pulmonary emboli in the left upper lobe with subsegmental
pulmonary emboli in
the left lower lobe. No suggestion of right heart strain.
2. Bibasilar atelectasis without focal consolidation or
suggestion of
pulmonary infarction.
Brief Hospital Course:
Ms. ___ is a ___ female with
history of OSA on CPAP, migraines, insomnia, depression/anxiety
followed by Dr. ___ presents with leg swelling and pain
found to have LLE DVT and bilateral segmental/subsegmental PE.
#Acute LLE DVT
#Acute bilateral pulmonary emboli
-On room air. Patient had normal 96-100% room air ambulatory
saturation with HR 90-100s and not dyspneic. She was also seen
by ___ and recommended to continue using crutches at home prn
(from her recent meniscal surgery) while going to her existing
outpatient ___.
-Troponin negative x 3 checks, proBNP normal. No evidence right
heart
strain on the CTA chest itself or on echocardiogram (but it did
show borderline normal RV function).
-Telemetry had no events.
-EKG with nonspecific V1-V3 TWI, and patient had chest pressure.
Patient was seen by cardiology and thought the chest pressure
was non-cardiac related, as it was chronic in the past and
unchanged atypical features here. She had EKGs done reviewed by
the cardiologist which showed TWI in V4-V6 that would also
normalize; thought to be due to her acute PE.
-Unclear if truly unprovoked versus provoked in context of minor
meniscal knee surgery. SHe is not taking OCPs and her hCG
testing was negative. Regardless,
recommend indefinite anticoagulation if possible, needs
outpatient follow up to determine duration and also to consider
hypercoagulable testing.
-PESI score 52, low risk ___ 30-day mortality in this group.
#OSA on CPAP
-CPAP qhs
#depression/anxiety
#Insomnia
-COnitnued home cyproheptadine, clonazepam, gabapentin
#Migraines
-Continued home propranolol
Greater than 30 minutes was spent on discharge planning and
coordination.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 2 mg PO QHS
2. Cyproheptadine 4 mg PO QHS
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN congestion
4. Gabapentin 1800 mg PO BID
5. Ipratropium-Albuterol Inhalation Spray 1 INH IH DAILY:PRN
congestion
6. Methocarbamol 750 mg PO DAILY:PRN pain
7. Propranolol LA 120 mg PO DAILY
8. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia
9. eszopiclone 3 mg oral QHS
Discharge Medications:
1. Acetaminophen 500 mg PO 5X/DAY
RX *acetaminophen 500 mg 1 tablet(s) by mouth 5 times daily Disp
#*60 Tablet Refills:*0
2. Apixaban 10 mg PO BID
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day
Disp #*74 Tablet Refills:*0
3. ClonazePAM 2 mg PO QHS
4. Cyproheptadine 4 mg PO QHS
5. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia
6. eszopiclone 3 mg oral QHS
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN congestion
8. Gabapentin 1800 mg PO BID
9. Ipratropium-Albuterol Inhalation Spray 1 INH IH DAILY:PRN
congestion
10. Methocarbamol 750 mg PO DAILY:PRN pain
11. Propranolol LA 120 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute bilateral pulmonary emboli
Acute left lower extremity DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Instructions: Dear Ms. ___,
It was a pleasure to be a part of your care team at ___
___.
====================================
Why did you come to the hospital?
====================================
-You had acute leg pain on your left leg.
====================================
What happened at the hospital?
====================================
-You were found to have a deep venous thrombosis in the left
leg.
-You complained of chest pressure, so you also had a CT scan of
your chest, which showed thrombosis (clot) in your lung blood
vessels.
-You underwent extra testing in the hospital to make sure your
chest pain is not from a heart problem. Blood work, ultrasound,
electrical heart tracing and monitoring did not show any acute
heart problem. You also were seen by the cardiologist while
hospitalized.
==================================================
What needs to happen when you leave the hospital?
==================================================
-Please take your APIXABAN (Eliquis) medication as prescribed.
DO NOT MISS ANY DOSES. YOU MUST TAKE 10 MG (TWO TABLETS) TWICE
DAILY FOR SEVEN DAYS, THEN CHANGE TO TAKING 5 MG (ONE TABLET)
TWICE DAILY, and do not stop until instructed otherwise by your
office doctors.
-___ up with your PCP as scheduled below. He will need to
refer you back to your cardiologist for further workup of why
you had these blood clots.
-Follow up with your surgeon as scheduled. Continue using
crutches as needed, and outpatient physical therapist as you
were already doing.
It was a pleasure taking care of you during your stay!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10842735-DS-8
| 10,842,735 | 29,052,731 |
DS
| 8 |
2145-03-05 00:00:00
|
2145-03-05 13:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Latex / vancomycin / Penicillins
Attending: ___
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
___ Pericardial window
History of Present Illness:
___ year old female with known metastatic melanoma, undergoing
experimental chemotherapy with vemurafenib. She presented with a
three-day history of chest discomfort that worsens with lying
down and improves with leaning forward. She states the symptoms
had started this past ___ and it gradually worsened. She
has undergone an echocardiogram at ___ and this
suggested a small circumferential pericardial effusion without
any signs of tamponade. Given that this is a recurrent
pericardial effusion, when practice initially noticed after
initiating this chemotherapeutic agent and was admitted from
___ through ___ and an EKGs at that time
shows clear-cut signs of pericarditis. She was treated with
steroids as mentioned before and the pericardial effusion
reportedly resolved. She was now transferred to ___ from ___
___ for recurrent pericardial effusion and is now being
referred to cardiac surgery for evaluation of a pericardial
window.
Past Medical History:
Recurrent pericardial effusion s/p pericardial window
Past medical history:
Metastatic melanoma, initially appeared in her left hip,
biopsied on ___ and underwent wide local excision,
later had recurrence and required chemotherapy with a new agent
called vemurafenib
Abnormal transaminase of unclear etiology: ___
Irritable bowel syndrome in childhood
Unclear history of bipolar ___
Pericarditis ___
Past Surgical History:
s/p wide local excision of left hip
s/p left ovariectomy ___ (hemorrhagic cyst)
s/p hysterectomy and right ovariectomy ___ ("abnormal cells")
s/p appendectomy ___
s/p cholecystectomy ___
Social History:
___
Family History:
Paternal aunt with breast cancer. Mother with "heart problems".
Physical Exam:
Pulse:77 Resp:16 O2 sat:97/RA
B/P 94/52
Height:62.2" Weight:76.3 kgs
General: awake, alert, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade _____
Abdomen: Soft [x] non-distended [x] non-tender [] bowel sounds
+
[x] bilateral lower abdominal tenderness c/w chronic cancer pain
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
___ Right: palp Left: palp
Radial Right: palp Left: palp
Carotid Bruit Right: none Left: none
Pertinent Results:
___ EKG: 70 NSR, Q III, TWI V2-3 - unchanged from ___
except TWI was V1-2
.
___ Echo: The left atrium is mildly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is a very small pericardial effusion. There are no
echocardiographic signs of tamponade. Compared with the prior
study (images reviewed) of ___, the pericardial effusion
is now slightly larger.
.
Brief Hospital Course:
As mentioned in the HPI, Ms. ___ is a ___ year old female
with metastatic melanoma complicated by recurrent pericardial
effusion/pericarditis from Vemurafenib admitted with pleuric
chest pain, dyspnea and recurrence of pericardial effusion.
Upon admission she was work-up and initially medically managed.
Vemurafenib was stopped due to causing her
pericarditis/effusion. Echo performed on ___ revealed a small
pericardial effusion. Cardiac surgery was consulted to perform a
pericardial window due to her need to be restarted back on her
chemotherapy medication Vemurafenib. On ___ she was brought to
the operating room where she underwent a pericardial window.
Following surgery she was transferred to the PACU and ultimately
to the step-down unit. On post-op day one her chest tube was
removed. She made good progress and was discharged home with the
appropriate medications and follow-up appointments on post-op
day two.
Medications on Admission:
Colchicine 0.6 bid
lamotrigine 200 qhs
venlafaxine 225 daily
gabapentin 800 qhs
tizanidine 2 qhs
nortriptyline 25 qpm
ibuprofen 600 qid
oxycodone sr 60 bid
valium 10 qhs prn
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
Disp:*15 Tablet(s)* Refills:*2*
2. tizanidine 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
6. lamotrigine 200 mg Tablet Sig: One (1) Tablet PO once a day.
7. gabapentin 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
8. gabapentin 100 mg Capsule Sig: One (1) Capsule PO at bedtime:
at bedtime take with 800mg for total of 900mg
at bed time.
9. venlafaxine 75 mg Tablet Extended Rel 24 hr Sig: Four (4)
Tablet Extended Rel 24 hr PO once a day.
10. prochlorperazine maleate 5 mg Tablet Sig: ___ Tablets PO
every eight (8) hours as needed for nausea.
11. prednisone 20 mg Tablet Sig: One (1) Tablet PO twice a day.
12. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for anxiety.
13. vemurafenib 240 mg Tablet Sig: Two (2) Tablet PO twice a
day.
14. oxycodone 20 mg Tablet Extended Release 12 hr Sig: Three (3)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
Disp:*120 Tablet Extended Release 12 hr(s)* Refills:*0*
15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Recurrent pericardial effusion s/p pericardial window
Past medical history:
Metastatic melanoma, initially appeared in her left hip,
biopsied on ___ and underwent wide local excision,
later had recurrence and required chemotherapy with a new agent
called vemurafenib
Abnormal transaminase of unclear etiology: ___
Irritable bowel syndrome in childhood
Unclear history of bipolar ___
Pericarditis ___
Past Surgical History:
s/p wide local excision of left hip
s/p left ovariectomy ___ (hemorrhagic cyst)
s/p hysterectomy and right ovariectomy ___ ("abnormal cells")
s/p appendectomy ___
s/p cholecystectomy ___
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Oxycodone
Incisions:
Inra-mamm - healing well, no erythema or drainage
Edema: none
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 while taking narcotics
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10843324-DS-5
| 10,843,324 | 23,421,342 |
DS
| 5 |
2124-04-18 00:00:00
|
2124-04-23 20:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Erythromycin Base
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ presents with 1 day of periumbilical and right lower
quadrant
pain presents for evaluation following a CT scan that revealed a
thickened 9mm appendix that was not inflammed but concerning for
evolving appendicitis. She denies fevers, chills, nausea,
vomiting and diarrhea. She reports that she had a bowel movement
while in the ED following contrast administration. She reports
that her current symptoms are very similar to the symptoms she
had in ___ when she also presented with RLQ abdominal pain and
was found not to have appendicitis.
Past Medical History:
Seizure disorder, likely primary generalized based on EEG
Eating disorder
Left sided breast/rib lump
Lipoma on left shoulder
Achilles tendonitis
Amenorrhea
Irritable bowel syndrome
Osteopenia
Mild anemia
Social History:
___
Family History:
Her maternal great-aunt had seizures. DM runs in
her family, including her paternal grandfather, maternal
grandmother, maternal cousin, and maternal aunt.
Physical Exam:
Physical Exam: upon admission: ___
Vitals: 98.2 90 121/72 16 100% 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, mild tenderness to deep palpation over
RLQ, no rebound or guarding, normoactive bowel sounds, no
palpable masses
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
___ 08:55 4.2 4.06* 12.3 36.4 90 30.2 33.7 12.7 157
___ 11:50AM BLOOD WBC-8.6# RBC-3.89* Hgb-11.8* Hct-34.3*
MCV-88 MCH-30.4 MCHC-34.5 RDW-12.9 Plt ___
___ 03:40PM BLOOD ___ PTT-34.0 ___
___ 11:50AM BLOOD UreaN-17 Creat-0.8 Na-136 K-3.9 Cl-100
HCO3-29 AnGap-11
___: cat scan abdomen:
IMPRESSION: Stable appearance of the appendix compared to ___
with mild
thickening but no adjacent inflammation. Chronicity of these
findings argues against early acute appendicitis, but in view of
caliber of appendix and current symptoms, surgical consultation
is recommended.
Brief Hospital Course:
___ year old female admitted to the hospital with right sided
abdominal pain. Upon admission, she was made NPO, given
intravenous fluids, and underwent imaging of the abdomen. A cat
scan of the abdomen was done which showed a stable appearance of
the appendix with mild thickening but no adjacent inflammation.
There was no adjacent fat stranding. A 2 cm cyst was seen in the
right kidney. The patient's vital signs remained stable and her
abdominal pain decreased in severity. The patient resumed a
regular diet on HD #2. Her white blood cell count on discharge
was 4.2.
The patient was discharged home on HD #2 in stable condition.
An appointment for follow-up was made with the primary care
provider.
Medications on Admission:
folic acid 1mg', lamictal 75 BID
Discharge Medications:
1. LaMOTrigine 75 mg PO BID
2. FoLIC Acid 1 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
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 and you were found to have a thickened
appendix which was not inflammed, but concerning for
appendicitis. Your white blood cell count was closely monitored
as well as your abdominal examination. Your abdominal pain
began to resolve and you were discharged home with the following
instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* Recurrence of abdominal pain
* 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:
___
|
10843492-DS-2
| 10,843,492 | 24,587,417 |
DS
| 2 |
2118-04-28 00:00:00
|
2118-04-29 11:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea and angina with exertion
Major Surgical or Invasive Procedure:
Balloon aortic valvuloplasty
History of Present Illness:
Mr. ___ is an ___ year old man with severe aortic stenosis and
end stage renal disease (s/p renal transplant, now with graft
rejection since ___ and nephrotic syndrome), CAD S/P two CABGs
___, again in ___, who presents with worsening dyspnea on
exertion (DOE). He has been having worsening DOE and lower
extremity edema for the last few months. The lower extremity
edema extends up to his hips and seems to correspond with his
worsening renal failure and nephrotic syndrome. Patient has been
followed by Dr. ___ evaluation of candidacy for the
___ for management of his severe aortic stenosis. He
initially evaluated by the ___ cardiologist for the
percutaneous ___ Valve, but was deemed not appropriate given
the diameter of his iliac arteries as well as his comorbidities.
By his account, he is s/p CABG at age of ? ___ and again in ___.
He did well after his renal transplantation in ___ for the last
several years until he noticed bilateral ankle edema several
months ago. This was associated with an increase in his
creatinine suggestive of transplant rejection. His dyspnea has
continued and progressed to the point that he has difficulty
walking across the room. He had been swimming regularly but has
stopped swimming in ___ due to dyspnea. He currently has ___
Class III-IV symptoms of CHF. He has chest
pain on occassion. He has not had syncope.
Patient has ESRD, S/P transplant in ___, initially did well but
this past year has had graft rejection. He had allograft biopsy
in ___ which showed extensive injury of epithelial cells and
epithelial foot processes. He is awaiting venous imaging and AV
fistula formation. He reports being hospitalized at the ___ for ten days this Fall for fluid overload. His kidney
was biopsied at that time, after which no medication changes
were made.
In the ED, initial vitals were: T 97.5 HR 68 BP 150/96 RR 22
SaO2 99% on 4 L/min Nasal Cannula. Labs were significant for Hct
31.1, BUN 84 and Cr 4.8. Trop-T 0.13. EKG showed accelerated
junctional rhythm with occasional episodes of bradycardia,
u-waves present, left anterior hemiblock. He was given an ASA 81
mg. Vitals on transfer were: afebrile, HR 77, BP 138/67, RR 22,
SaO2 97% on RA.
On arrival to the floor, patient reports feeling well, denies
any dyspnea. He is lying flat and has no shortness of breath. He
does, however, report that his DOE has been getting
progressively worse over time. His dry weight is 185 lb (but
prior dry weight from ___ was 193 lb) and he is ___ lb today. He
takes Lasix 160 mg BID at home. While being interviewed, his HR
briefly dropped to 39; he was asymptomatic. The HR then quickly
recovered to the ___.
REVIEW OF SYSTEMS
On review of systems, 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. He denies recent fevers, chills or rigors.
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, palpitations, syncope or
presyncope.
Past Medical History:
1. CAD RISK FACTORS: +kidney disease
2. CARDIAC HISTORY:
- Severe Aortic Stenosis - unclear valve area
- CAD: s/p CABG x2 in ___ s/p CABG x3 in ~ ___
3. OTHER PAST MEDICAL HISTORY:
Horseshoe kidney
Nephrotic syndrome - age ___
- Nephrectomy in ___
- started dialysis in ___
- s/p Renal Transplant ___ - deceased donor transplant
- transplant worked well until just a few months ago
Blindness secondary to series of retinal detachments which
started at age ___, has had multiple surgeries
Social History:
___
Family History:
There is a family history of heart disease but not of
hypertension, diabetes, or strokes. His mother died in her late
___ due to a ruptured aortic aneurysm. his father died in his
___ due to heart and kidney disease.
Physical Exam:
On admission
T=97.2 BP=138/75 HR=75 R=22 O2 sat=99% on 2 L/min
Constitutional: comfortable, no acute distress
HEENT: PERRL. JVP 9
Neck: The mucous membranes were moist.
Lungs: Few minimal crackles at bases.
Cardiovascular: S1 was normal. There was a III/VI late peaking
systolic murmur consistent with aortic stenosis. No tardus, no
parvus.
Abdomen: Soft without hepatosplenomegaly
Neurologic Examination: Alert and Oriented x 3. Blind, deaf
Skin: No CCE. Pedal edema up to hips bilaterally
On discharge
VS: T=97.8 BP=126/76 (103/68-126/76) HR=72 (60-72) RR=20 SaO2
96% on RA
Wt 88.1 kg (89.6 kg yesterday, admission weight 93.7 kg)
I/O: 1108/1460+ yesterday (260/600 overnight)
Gen: Alert, interactive, NAD
HEENT: Sclera anicteric, MMM
NECK: JVP elevated to clavicle at 45 degrees
CV: Irregular, grade III late peaking systolic murmur at ___
with radiation, grade II holosystolic murmer at ___ and apex.
RESP: CTAB, no wheezes or crackles
ABD: Soft, NT/ND, +BS. No tenderness over graft.
EXT: 1+ pitting edema bilaterally but improved from admission.
No groin hematoma or femoral bruits
Pertinent Results:
Admission labs:
___ 04:45PM BLOOD WBC-5.9 RBC-3.24* Hgb-10.0* Hct-31.1*
MCV-96 MCH-30.8 MCHC-32.1 RDW-14.1 Plt ___
___ 04:45PM BLOOD Neuts-76.6* Lymphs-15.0* Monos-5.2
Eos-2.6 Baso-0.5
___ 04:45PM BLOOD Glucose-112* UreaN-84* Creat-4.8* Na-141
K-5.0 Cl-107 HCO3-24 AnGap-15
___ 04:45PM BLOOD CK(CPK)-48 BLOOD CK-MB-3 cTropnT-0.13*
___ 06:45AM BLOOD CK-MB-3 cTropnT-0.14*
___ 05:00PM BLOOD CK-MB-3 cTropnT-0.14*
Discharge labs:
___ 12:40PM BLOOD Hct-28.6*
___ 06:25AM BLOOD WBC-5.7 RBC-3.00* Hgb-9.1* Hct-27.8*
MCV-93 MCH-30.3 MCHC-32.8 RDW-13.9 Plt ___
___ 06:25AM BLOOD Glucose-104* UreaN-100* Creat-5.3* Na-138
K-3.9 Cl-96 HCO3-31 AnGap-15
___ 06:25AM BLOOD Calcium-8.7 Phos-6.0* Mg-2.2
EKG (___): Sinus rate of 77, PR prolongation, LAD, IVCD.
CXR (___):
1. Top normal heart size, without acute chest pathology.
2. Calcified structure seen posterior to the heart on the
lateral view might represent a calcified lymph node.
ECHO (___):
The left atrium is moderately dilated. The right 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 ascending aorta is mildly dilated.
The aortic arch is mildly dilated. The aortic valve leaflets are
severely thickened/deformed. The mean LVOT gradient is 1.3 mmHg.
The aortic valve VTI = 100 cm. There is critical aortic valve
stenosis (valve area <0.8cm2). 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 no pericardial effusion.
IMPRESSION: Critical calcific aortic stenosis ___ 0.6 cm2).
Mild symmetric LVH with normal global and regional biventricular
systolic function. Dilated thoracic aorta.
CT chest without contrast (___):
1. Heavily calcified aortic valve. Top normal size ascending
aorta, mildly calcified, including the anterior wall
calcification except for a segment, 2.5 x 2 cm, just superior to
the origin of right coronary artery, which includes the
anastomosis of a severely calcified venous graft.
2. Small bilateral pleural effusions and bi-basal atelectasis.
3. Mild pulmonary artery hypertension.
4. Severely calcified left renal artery with atrophic left
kidney. Right kidney is not imaged.
5. Small volume of fluid in the right upper abdomen should be
evaluated by ultrasound.
RUQ ultrasound (___):
1. Trace ascites.
2. Small right pleural effusion.
3. The gallbladder wall is mildly edematous - a non specific
sign in the setting of ascites that might be attributable to
third spacing.
Cardiac cath report ___, preliminary report):
Baseline RA 18, RV 54/18, PA 54/21/28, PCW 25 mm Hg, LV 215/29,
FA 141/68/91, AoV mean gradient 58 mmHg, ___ 0.8 cm2, CO 6.5
L/Min, CI 3.1 L/min/m2. After balloon aortic valvuloplasty using
a 28 mm balloon, LV 206/27, FA 150/74/99, AoV mean gradient 45
mmHg, ___ 1.0 cm2.
ECHO (___)
s/p several balloon inflations across the aortic valve. There is
symmetric left ventricular hypertrophy. Overall left ventricular
systolic function is normal (LVEF>55%). There is no ventricular
septal defect. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. Mild
to moderate (___) mitral regurgitation is seen. Tricuspid
regurgitation is present but cannot be quantified. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the gradients across the aortic valve are slightly lower and the
calculated ___ is slightly larger (0.8 cm2). The degree of AR is
probably slightly more but still fairly negligable.
Brief Hospital Course:
___ yo M with H/O aortic stenosis, CAD s/p CABG twice, s/p renal
transplant now with graft rejection who presents with worsening
shortness of breath, exertional angina, and lower extremity
swelling. This is concerning for progression of aortic stenosis
vs. worsening ESRD/nephrotic syndrome.
# Dyspnea on Exertion/Volume overload: Patient with critical AS
___ 0.6 cm2) with LVEF of 55%. Symptoms likely secondary to
symptomatic aortic stenosis (acute on chronic diastolic heart
failure) and volume overload in patient with ESRD/nephrotic
syndrome. Per patient,his dry weight is 185; admission weight
was 206 lbs. Patient was initially started on a Lasix gtt which
was titrated up to 20 mg/hr. He was also started on metolazone
BID. Patient diuresed well, however, creatinine continued to
climb at which point the Lasix gtt was stopped. He was switched
to po diuretic regimen including torsemide and metolazone prior
to discharge. Discharge weight was 88.1 kg. Patient was
continued on aspirin. Beta blockers were held in the setting of
bradycardia.
# Aortic stenosis - Echo on admission showed critical AS with
valve area of 0.6 cm. Patient was evaluated by cardiac surgery
and it was felt that he was not a surgical candidate. He was
also seen by the ___ team and given his renal failure, he
did not qualify for that percutaneous aortic valve at this time.
Patient subsequently underwent a balloon valvuloplasty with
improvement in aortic valve area from 0.6 to 0.8-1.0. He
tolerated the procedure well without any apparent complications.
There was no evidence of groin hematoma or bruit.
# RUQ Abdominal Fluid: Incidental finding on Chest CT. Patient
asymptomatic. We obtained an US as recommended by radiology for
further evaluation which showed trace ascites. This was likely
due to fluid overload from his ESRD and diastolic CHF.
# Bradycardia: On telemetry, patient at times had junction
rhythm with HR dipping into the ___ and ___. Patient remained
asymptomatic. All nodal agents were held and heart rate remained
mostly in ___.
# ESRD: s/p renal transplant in ___, now with worsening renal
function/proteinuria (13 g/day) since ___. Cr 4.8 on
admission, up from 3.9 in ___. Patient had recent renal
biopsy at the ___ with no subsequent change in his medications.
On admission, patient appeared volume overloaded. He was
evaluated by the transplant nephrology team here during this
admission. They felt that the patient did not need dialysis at
this time as he continued to make adequate urine output. He was
started on a Lasix gtt and metolazone. He diuresed well, however
Cr increased to 5.5. He was then transitioned to a po regimen.
He was also started on Sevelamer for elevated phosphate. He was
continued on his home dose of CellCept. His tacrolimus dose was
changed to 2 mg BID prior to discharge as his levels were
slightly elevated.
# CAD: Patient s/p CABG twice. Troponin T elevated to 0.13 on
admission and stable at 0.13-0.14, likely due to impaired
clearance due to significant end stage renal disease and not
acute coronary syndrome. CKMB normal. He was continued on ASA
and Simvastatin.
# Glaucoma: Continued home eye drops.
Transitional Issues
- patient will need close follow up with nephrology to monitor
kidney function and need for dialysis
- diuretic regimen may need further adjustment after discharge
- patient was full code on this admission
- Contact: ___ (daughter, HCP) ___
___ on Admission:
BRIMONIDINE - (Prescribed by Other Provider) - Dosage uncertain
ECHOTHIOPHATE IODIDE [PHOSPHOLINE IODIDE] - (Prescribed by Other
Provider) - Dosage uncertain
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - one
Tablet(s) by mouth daily at bedtime
FUROSEMIDE - (Prescribed by Other Provider) - 80 mg Tablet - 2
Tablet(s) by mouth twice daily
MYCOPHENOLATE MOFETIL - (Prescribed by Other Provider) - 500mg
BID
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth daily
TACROLIMUS - (Prescribed by Other Provider) - 1 mg Capsule - 2
tabs in AM and 3 tabs in ___
ZOLPIDEM - (Prescribed by Other Provider) - 10 mg Tablet - one
Tablet(s) by mouth daily at bedtime
ASCORBIC ACID - (Prescribed by Other Provider) - 500 mg Tablet -
one Tablet(s) by mouth twice daily
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet - one
Tablet(s) by mouth daily
Discharge Medications:
1. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
2. Phospholine Iodide Ophthalmic
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for Insomnia.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day.
10. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet(s)*
Refills:*0*
11. metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please take 30 minutes prior to torsemide . Disp:*30 Tablet(s)*
Refills:*1*
12. torsemide 100 mg Tablet Sig: Two (2) Tablet PO once a day:
please take 30 minutes after metolazone. Disp:*60 Tablet(s)*
Refills:*1*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Aortic stenosis
End stage renal disease with prior renal transplant
Coronary artery disease with prior bypass graft surgery
Acute on chronic left ventricular diastolic heart failure
Acute on chronic renal failure
Hyperphosphatemia
Bradycardia, junctional
Glaucoma
Ascites
Blindness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you while you were admitted to
___. You were admitted because you were having shortness of
breath and chest pain with exertion. You were started on a
medication to help remove fluid from your body. The nephrology
team also helped manage your volume overload given your
compromised kidney function. They did not feel the need to start
dialysis on this admission as you were responding well to the
fluids.
You were evaluated by the cardiac surgery team who did not feel
that you were a candidate for heart surgery. You also were
evaluated for the ___ and deemed not a candidate given
your poor kidney function and your vascular anatomy. You
underwent a balloon valvuloplasty with some improvement in your
valve diameter. Your medication regimen was optimized during
your admission.
The following changes have been made to your medication regimen:
Please START
- torsemide 200mg daily
- metolazone 5mg daily, please take 30 minutes prior to your
torsemide
- sevelamer 2400mg three times daily with meals
Please STOP
- lasix
Please CHANGE your tacrolimus dose to be 2mg twice daily
Please take the rest of your medications as prescribed and
follow up with your doctors as ___.
Followup Instructions:
___
|
10843578-DS-16
| 10,843,578 | 20,975,926 |
DS
| 16 |
2183-02-05 00:00:00
|
2183-02-08 21:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
atenolol / hydrochlorothiazide
Attending: ___.
Chief Complaint:
falls, hyponatremia
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ w/pmh HTN and CKD III presents from home with falls,
hyponatremia and leukocytosis.
Patient presented to PCP ___ ___ after 2 days diarrhea, with
presumptive gastroenteritis. He also reported a fall with
ecchymoses R hip noted then, but was ambulating and without
signs of fracture.
He then continued to fall over the past week and was seen at
___ Ctr ER ___. There were reportedly no labs drawn
and he had a left elbow lac sutured. A head Ct, spine CT and
plain films were also reportedly negative, elbow xray showed
fracture of olecranon spur on right elbow. Since then he was
weaker and unable to walk last few days with more R hip pain
(s/p R THR in ___. Denies fever/chills but does have
intermittant diarrhea. He has not stopped his hctz. Denies any
asa/nsaid use in years. Taking ___ Tylenol. Per his daughter
at bedside, pt has been more confused of late, decreased memory
and confabulation. Patient lives independently and ambulates
with a walker. Initial labs were concerning for leukocytosis and
hyponatremia. He was started on NS at 100cc/hr and admitted to
the MICU for further treatment.
In the ED, initial vitals: 97.8 76 134/67 16 96% RA.
On transfer, vitals were: 98.2 86 129/64 18 100% RA.
On arrival to the MICU, patient is AAOx3. He easily confirmed
the above history. Currently does not feel confused. Only has
minimal pain in his right elbow. No abdominal pain and only had
1 formed BM today. Otherwise has no acute complaints.
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:
Positive PPD
Hypertension, essential
Peptic ulcer
Spinal stenosis
Diverticulosis
Osteoarthrosis, localized, primary, knee
Urinary retention
HX: anticoagulation
History of total hip replacement
Advanced care planning/counseling discussion
Bilateral pseudophakia
Constipation, chronic
CKD (chronic kidney disease), stage III
ARMD (age-related macular degeneration), bilateral
Anemia
Social History:
___
Family History:
No history of kidney disease.
Physical Exam:
ADMIT EXAM
==========
Vitals: T: 97.4 BP: 139/57 P: 82 R: 14 O2: 98% RA
GENERAL: Adult male alert, oriented x3, 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, ___ systolic murmur
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly, bruising on
flanks
EXT: Warm, well perfused, 2+ pulses, right hip with bruising
and hematoma
NEURO: AAOx3, CN II-XII intact, moving all extremities
DISCHARGE EXAM
==============
Vitals: 97.3 150/80 74 19 100 RA
General: pleasant elderly man, well appearing, NAD
HEENT: MMM
Neck: supple, JVP not elevated
Lungs: CTAB, no w/c/r appreciated
CV: RRR, distant heart sounds but no murmurs appreciated
Abdomen: soft, nontender throughout, nondistended, NABS
GU: no foley
Ext: WWP, no ___ edema
Neuro: AOx3, moving all ext equally
Pertinent Results:
ADMIT LABS
==========
___ 06:30PM BLOOD WBC-19.6* RBC-3.11* Hgb-9.3* Hct-27.3*
MCV-88 MCH-29.9 MCHC-34.1 RDW-16.4* RDWSD-51.7* Plt ___
___ 06:30PM BLOOD Neuts-86* Bands-0 Lymphs-9* Monos-4*
Eos-1 Baso-0 ___ Myelos-0 AbsNeut-16.86*
AbsLymp-1.76 AbsMono-0.78 AbsEos-0.20 AbsBaso-0.00*
___ 06:30PM BLOOD Hypochr-OCCASIONAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-1+
Polychr-OCCASIONAL Schisto-OCCASIONAL Stipple-OCCASIONAL
Pappenh-OCCASIONAL
___ 06:30PM BLOOD ___ PTT-26.9 ___
___ 06:30PM BLOOD Glucose-87 UreaN-18 Creat-1.0 Na-110*
K-6.1* Cl-75* HCO3-23 AnGap-18
___ 11:11PM BLOOD ALT-20 AST-30 LD(LDH)-258* CK(CPK)-329*
AlkPhos-70 TotBili-1.1
___ 11:11PM BLOOD Lipase-26
___ 06:30PM BLOOD proBNP-2202*
___ 11:11PM BLOOD Albumin-4.1 Calcium-8.7 Phos-2.4* Mg-1.8
UricAcd-5.6 Iron-39*
___ 11:11PM BLOOD calTIBC-261 VitB12-1366* Ferritn-707*
TRF-201
___ 06:30PM BLOOD Osmolal-246*
___ 11:11PM BLOOD TSH-1.2
___ 04:08AM BLOOD Cortsol-22.1*
___ 07:26PM BLOOD Lactate-2.2* Na-112* K-4.6 Cl-80*
___ 06:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:15PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 06:15PM URINE RBC-<1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
___ 06:15PM URINE Hours-RANDOM Na-96
___ 12:59PM URINE Hours-RANDOM UreaN-548 Creat-93 Na-61
___ 06:15PM URINE Osmolal-___
IMAGING/MICRO
=============
EKG ___: Baseline artifact. Sinus rhythm. Frequent premature
ventricular contractions. Borderline left ventricular
hypertrophy by voltage criteria. No previous tracing available
for comparison.
Rt hip xray ___: No fracture.
CXR ___: Low lung volumes without definite acute cardiopulmonary
process.
CT C-spine ___: No acute fracture. Anterolisthesis of C7 on T1
and T1 on T2 which is likely degenerative but to be correlated
clinically as no priors available to evaluate for chronicity.
NCCTH ___: No acute intracranial process.
NCCTC ___:
1. No acute intrathoracic process identified.
2. Multiple bilateral solid pulmonary nodules measuring up to 2
mm. Recommend correlation with patient risk factors in
consideration of dedicated follow-up CT chest imaging.
3. Cholelithiasis.
RECOMMENDATION(S): The ___ pulmonary nodule
recommendations are intended as guidelines for follow-up and
management of newly incidentally detected pulmonary nodules
smaller than 8 mm, in patients ___ years of age or older. Low
risk patients have minimal or absent history of smoking or other
known risk factors for primary lung neoplasm. High risk patients
have a history of smoking or other known risk factors for
primary lung neoplasm.
In the case of nodule size <= 4 mm: No follow-up needed in
low-risk patients. For high risk patients, recommend follow-up
at 12 months and if no change, no further imaging needed.
___ 11:35 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
__________________________________________________________
___ 9:17 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 6:30 pm BLOOD CULTURE #1 SOURCE: VENIPUNCTURE.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
DISCHARGE LABS
==============
___ 06:10AM BLOOD WBC-13.4* RBC-2.75* Hgb-8.4* Hct-26.2*
MCV-95 MCH-30.5 MCHC-32.1 RDW-18.0* RDWSD-62.3* Plt ___
___ 06:25AM BLOOD Neuts-69 Bands-1 Lymphs-15* Monos-7 Eos-5
Baso-0 ___ Metas-1* Myelos-2* AbsNeut-10.15* AbsLymp-2.18
AbsMono-1.02* AbsEos-0.73* AbsBaso-0.00*
___ 06:25AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Burr-1+
___ 06:10AM BLOOD Glucose-91 UreaN-31* Creat-1.2 Na-130*
K-4.7 Cl-93* HCO3-26 AnGap-16
___ 09:40AM BLOOD Hapto-45
___ 12:50AM URINE Hours-RANDOM Na-52
___ 03:43PM URINE Hours-RANDOM UreaN-816 Creat-83 Na-50
___ 09:40AM URINE Osmolal-332
___ 03:43PM URINE Osmolal-529
Brief Hospital Course:
Mr. ___ is a ___ yo man with h/o hypertension, CKD, urinary
retention, who initially presented to PCP with falls and was
transferred to ED with hyponatremia. Admission sodium was 110.
This was thought to be secondary to chronic HCTZ use. He was
admitted to MICU and HCTZ held. Sodium gradually improved with
administration of fluids, though it eventually mildly
improved/plateaued, even with fluid restriction. He was
transitioned to 1500cc fluid restriction, with ensures TID and
encouraged to restrict free water intake, as pt also thought to
have a component of SIADH. His sodium was 130 at discharge, felt
to be related to SIADH, as still had high UOsm at discharge.
#Hyponatremia: Likely chronic as patient reportedly mentating
well despite Na 110 on admission. ___ be from chronic HCTZ use
though may be multifactorial with hypovolemia (diarrhea prior to
admission) and/or low solute intake contributing. Now
significantly improved. During initial 3 days in MICU got 75cc/h
of NS with frequent Na checks. UOsm have not appropriately
responded, therefore also likely SIADH is contributing as well,
UOsm of 529 at last check. Na improving with fluid restriction
of 1.5L, up to 130 on dischage. Encouraged Ensure for solute
intake as well, no salt tabs per renal, which followed the pt
over his admission. CT chest without e/o lung malignancy; small
pulm nodules will not require f/u as patient low risk with
minimal distant smoking history. Patient would benefit from
outpatient renal follow-up after discharge.
#Leukocytosis: Patient with persistent leukocytosis with left
shift (bands, metas, myelos) of unclear etiology. Infectious
workup in MICU was unremarkable, stool/BCx neg. Strong suspicion
for underlying hematologic disorder. Can consider hem/onc
consult as outpatient if within pt's goals of care.
#BPH: C/b inability to place foley (for I/Os, no retention) by
urology in MICU. Patient voiding so further management deferred,
continued tamsulosin, scheduled outpt urology f/u.
#Falls: Likely in setting of hyponatremia vs orthostasis (given
not requiring any BP meds here). Patient previously living
independently. ___ consulted, recommended DC to ___ nursing
facility.
#CKD stage III: Cr on admission 1.0, below most recent baseline
1.5, had some mild elevation on DC to 1.2. Will f/u with
Nephrology as above for ongoing management and evaluation of his
hyponatremia.
#Normocytic anemia: ___ be in setting of CKD, ACD, concern for
hematologic disorder as above. Stable. No transfusions required
#HTN: BPs stable. Held home HCTZ, amlodipine, metop; should
consider restarting amlodipine if sBP>150
TRANSITIONAL ISSUES
===================
-Please check sodium/lytes on ___ and ___ to ensure Na levels
are stable, DC Na 130; scheduled f/u with outpt Nephrology
-Home BP meds held as patient remained normotensive in house,
consider restarting amlodipine if develops sustained SBPs>180
-Please avoid all diuretics given risk of hyponatremia, HCTZ
listed as allergy
-Pt with leukocytosis with left shift (bands, metas, myelos) and
anemia of unclear etiology but large concern for marrow process.
Consider outpatient hem/onc referral if within goals of care
-Patient was unable to have foley placed here by urology.
Started tamsulosin. No urinary retention in house, scheduled
outpatient urology referral
#Code: Full confirmed
#Communication: ___, daughter ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Metoprolol Succinate XL 12.5-25 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit po DAILY
Discharge Medications:
1. Tamsulosin 0.4 mg PO QHS
2. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit po DAILY
3. Multivitamins 1 TAB PO DAILY
4. HELD- amLODIPine 10 mg PO DAILY This medication was held. Do
not restart amLODIPine until sBP>150 sustained
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
Hyponatremia/SIADH
Falls
Secondary
Leukocytosis
Hypertension
urinary retention
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after some falls and your
sodium level was found to be extremely low. This probably
occurred because of your long-term use of hydrochlorothiazide.
This was stopped and should never be taken again. Your other
blood pressure medications were also stopped as your blood
pressure remained normal. Your sodium level improved. It is
important that you continue to eat and drink well as an
outpatient in order to keep this in a good range. You were seen
by physical therapy who recommended you go to rehab to regain
your strength. You will follow up with your PCP and our kidney
doctors to ensure your sodium level remains stable.
It was a pleasure taking care of you during your stay in the
hospital.
- Your ___ Team
Followup Instructions:
___
|
10843779-DS-15
| 10,843,779 | 21,340,871 |
DS
| 15 |
2126-10-06 00:00:00
|
2126-10-06 15:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Rectal bleeding, abdominal pain.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with known diverticulosis who presents to the ED with 4 days
of loose stools and BRBPR. He traveled to ___ last
week
and had some flu-like URI symptoms late in the week. He ate some
fried pork there on ___ and had multiple episodes of diarrhea
that night and into ___. He flew back to ___ on ___ and
in the evening began to see blood mixed in with his diarrhea and
at times blood only passing per rectum. He was having ___
bowel
movements per day. This continued into ___ and ___. On
___ he began having lower abdominal pain with the bowel
movements that would improve after passing stool. No fevers or
chills, no nausea, no vomiting, no weight loss, eating and
drinking well last few days, no change in symptoms with diet.
Prior episode of minor rectal bleeding last year, diagnosed with
internal hemorrhoids which he said improved on their own. Last
colonoscopy in Atrius system was incomplete but did identify
sigmoid diverticulosis. He had a barium enema which confirmed
this and found diverticular disease in the descending and
ascending colon as well. No overt masses or other abnormal
findings. Patient denies prior episodes of GI bleeding requiring
hospitalization and also denies episodes of diverticulitis
requiring antibiotics or hospitalization. Denies episodes like
this one in the past.
Patient feeling much improved after receiving IVF, pain
medication, and antibiotics in the ED. He was initially seen in
his PCP office earlier today and sent to the ED for evaluation
when he described his symptoms and admitted to lightheadedness
and weakness.
Past Medical History:
___: hypothyroidism, dyspepsia, arthritis
PS: open appendectomy, R rotator cuff
Social History:
___
Family History:
Mother passed away a few years ago related to colonic
disease, unknown if cancer or inflammatory but did require
surgery, no other family history of cancer or colonic disease
Physical Exam:
PHYSICAL EXAMINATION upon admission: ___
Temp: 99.9 HR: 74 BP: 134/83 Resp: 18 O(2)Sat: 98 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, diffuse tenderness to palp, no guarding
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
On discharge:
98.8, 59, 138/66, 14, 96% on room air
Pertinent Results:
___ 06:08AM BLOOD WBC-11.3* RBC-4.59* Hgb-14.6 Hct-42.4
MCV-93 MCH-31.8 MCHC-34.4 RDW-12.9 Plt ___
___ 01:41AM BLOOD Hct-40.0
___ 09:50PM BLOOD Hct-41.4
___ 06:07PM BLOOD Hct-41.5
___ 11:40AM BLOOD Hct-39.5*
___ 06:30AM BLOOD WBC-12.4* RBC-4.48* Hgb-14.4 Hct-42.1
MCV-94 MCH-32.2* MCHC-34.3 RDW-13.0 Plt ___
___ 12:00AM BLOOD Hct-40.7
___ 09:00PM BLOOD Hct-41.5
___ 12:55PM BLOOD WBC-16.6* RBC-5.14 Hgb-16.2 Hct-47.3
MCV-92 MCH-31.6 MCHC-34.4 RDW-13.0 Plt ___
___ 12:55PM BLOOD Neuts-80.5* Lymphs-11.4* Monos-7.5
Eos-0.2 Baso-0.5
___ 12:55PM BLOOD ___ PTT-33.0 ___
___ 06:08AM BLOOD Glucose-85 UreaN-7 Creat-0.9 Na-142 K-3.8
Cl-105 HCO3-26 AnGap-15
___ 06:30AM BLOOD Glucose-91 UreaN-8 Creat-1.1 Na-141 K-4.0
Cl-107 HCO3-27 AnGap-11
___ 12:55PM BLOOD Glucose-107* UreaN-11 Creat-0.9 Na-142
K-3.4 Cl-104 HCO3-27 AnGap-14
___ 06:08AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.2
___ 06:30AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.2
___ 03:42PM BLOOD Lactate-1.3
___ 11:47 pm STOOL CONSISTENCY: WATERY PRESENCE OF
BLOOD.
Source: Stool.
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 (Pending):
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.
.
MODERATE RBC'S.
FEW POLYMORPHONUCLEAR LEUKOCYTES.
FECAL CULTURE - R/O VIBRIO (Pending):
FECAL CULTURE - R/O YERSINIA (Pending):
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
___: CTA abdomen and pelvis:
1. Progressive increase in size of focal hyperdensity in the
distal sigmoid colon compatible with a small diverticular bleed.
2. Extensive diverticulosis involving predominantly the
descending and
sigmoid colon. Mural thickening of the sigmoid colon with mild
surrounding hazy fat and fascial thickening may represent mild
colitis, but findings are potentially chronic (no prior study
available).
3. Small hiatal hernia.
Brief Hospital Course:
Mr. ___ was admitted to the inpatient ward under the Acute
Care Surgery service for further management of his abdominal
pain and BRBPR. He was given IV fluids, antibiotics and pain
medication in the Emergency Department, where he felt better
thereafter. He was pan-cultured, of which most results are
negative at the time of this writing. He was kept NPO and
observed closely. His electrolytes were checked daily and
repleted as necessary while NPO. His hematocrit remained stable
during his stay with an average baseline level of 40. He had a
few episodes of bloody diarrhea, but those slowly subsided.
Bedside anoscopy showed no active bleeding from the rectum. A
CTA of the abdomen and pelvis was completed showing a likely
small diverticular bleed in the distal sigmoid colon. The
primary source of this patient's BRBPR and abdominal pain was
attributed to infectious colitis.
By HD 2, Mr. ___ stopped having bloody bowel movements. His
diet was progressed to full liquids only. His hematocrit levels
stable during this time. On HD 3, the patient's diet was
advanced to regular, which he tolerated well, without nausea or
vomiting. His Foley catheter was discontinued and he had no
issues voiding thereafter.
At the time of discharge, Mr. ___ was hemodynamically
stable, afebrile and in no acute distress. He was given
prescriptions for Cipro and Flagyl to finish a 10-day course. A
follow-up appointment was made for him to see his PCP in one
week. At the time of this writing, stool cultures were pending
for yersinia, vibrio and Campylobacter.
Medications on Admission:
Synthroid ___, vitamin D 1000', omeprazole prn
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*16 Tablet Refills:*0
2. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
3. Levothyroxine Sodium 112 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Infectious colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ on
___ with complaints of loose stools and bright red blood in
your bowel movements. On further evaluation using CT scanning,
you were found to have diverticulosis with a possible bleeding
in your sigmoid colon. You were started on antiobiotics and
kept inpatient for further observation. Stool cultures, thus
far, have been negative for any organisms. You will be called
if any of the pending exams are positive.
You are now tolerating a diet well and have had no further
issues of bleeding when moving your bowels.
Please continue to take all home medications as you were prior
to this admission.
A follow-up appointment has been made with your PCP (see below).
In the meantime, if you have any of the below warning signs or
have any other concerns, contact your PCP ___.
Followup Instructions:
___
|
10844073-DS-8
| 10,844,073 | 25,180,210 |
DS
| 8 |
2118-02-04 00:00:00
|
2118-02-04 22:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
atrial fibrillation with RVR asymptomatic
Major Surgical or Invasive Procedure:
Attempted TEE w/cardioversion
History of Present Illness:
___ M with a history of cataracts undering ___ for cataract
surgery found to be in atrial fibrillation with RVR. He was
asymptomatic without any hemodynamic instability. On no cardiac
meds or anticoagulation. He denies any prior cardiac issues. He
denies any palpitations or shortness of breath. He endorses some
mild chest pressure if he notices it, but generally denies any
chest pressure.
He denies any infectious symptoms including fevers, chills,
cough, dysuria, or rash.
In the ED, initial vitals were 98.2 ___ 16 97% RA
EKG: atrial fibrillation without ST changes.
Labs/studies notable for:
Normal CBC, slightly low platelets to 139, normal chem 7 (Cr.
0.9), Lactate 1.6. TSH wnl. Coags, wnl. Trop neg x 1 @ 0900.
UA: trace leuks, otherwise no indication of infection.
___ CXR (AP):
FINDINGS:
The lungs are clear. There is no consolidation, effusion, or
edema. Cardiac silhouette is top-normal for technique. Slight
tortuosity of the thoracic aorta is noted. No visualized acute
osseous abnormality.
IMPRESSION:
No acute cardiopulmonary process.
Patient was given:
___ 13:47 IVF 1000 mL NS 1000 mL
___ 13:47 IV Metoprolol Tartrate 5 mg
___ 14:26 PO Metoprolol Tartrate 25 mg
___ 14:50 IV Metoprolol Tartrate 5 mg
___ 22:15 PO/NG Metoprolol Tartrate 25 mg
___ 23:45 PO Terazosin 2 mg
___ 23:45 PO/NG Apixaban 2.5 mg
___ 07:42 PO Metoprolol Succinate XL 25 mg
___ 09:25 PO/NG Apixaban 2.5 mg
___ 09:25 IV Metoprolol Tartrate 5 mg
___ 10:45 PO Metoprolol Tartrate 12.5 mg
___ 12:52 IV Metoprolol Tartrate 5 mg
Vitals on transfer:
T: 98.2 HR: 116 BP: 119/74 RR: 16 Sp02:99% RA
On the floor he is asymptomatic. He relates that he once failed
a military physical for a heart murmur many years ago, but he
has not heard anything about it since. He also endorses being
constipated from time to time.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, or cough. 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 chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
HTN
BPH
Cataracts
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: T: 97.7 BP: 145/91 HR: 130 RR: 20 Sp02: 99% RA
General: Elderly man, conversant in no acute distress.
HEENT: MMM
Neck: No JVD, loose neck skin
CV: Irregularly irregular rhythm, tachycardic, murmur difficult
to appreciate given rate.
Lungs: On RA, no increased work of breathing, no wheezes, rales
or ronchi.
Abdomen: Soft, non-tender, non-distended, bowel sounds present
GU: Report of need for circumsion, exam deferred but plan to
examine soon, asymptomatic.
Neuro: AAO x3, Strength ___ in upper and lower extremities,
distal sensation intact, CN II-XII intact.
DISCHARGE PHYSICAL EXAM:
=======================
Vitals: Tm: 98.5 BP: 126/79 (97-126/57-79) HR: 67 (68-78) RR: 18
Sp02: 98% RA
Wt: 79.2kg (80.7) (79.7) (79.8)
I/O: +460/-BR//50/-250
General: Elderly man, conversant in no acute distress.
HEENT: NCAT
Neck: No JVD, loose neck skin
CV: Irregularly irregular, tachycardic, murmur difficult to
appreciate given rate.
Lungs: CTABL, no wheezes, rales or ronchi.
Abdomen: Soft, non-tender, non-distended, bowel sounds present
Neuro: AAOx3, grossly non-focal
Pertinent Results:
ADMISSION LABS:
===============
___ 01:45PM BLOOD WBC-6.0 RBC-5.01 Hgb-14.9 Hct-45.1 MCV-90
MCH-29.7 MCHC-33.0 RDW-13.6 RDWSD-44.2 Plt ___
___ 01:45PM BLOOD Neuts-67.2 ___ Monos-8.3 Eos-3.5
Baso-1.2* Im ___ AbsNeut-4.03 AbsLymp-1.17* AbsMono-0.50
AbsEos-0.21 AbsBaso-0.07
___ 01:45PM BLOOD Plt ___
___ 01:45PM BLOOD ___ PTT-30.5 ___
___ 01:45PM BLOOD Glucose-99 UreaN-14 Creat-0.9 Na-140
K-4.3 Cl-107 HCO3-22 AnGap-15
___ 09:00AM BLOOD cTropnT-<0.01
___ 01:45PM BLOOD TSH-1.4
___ 01:55PM BLOOD Lactate-1.6
CARDIAC LABS:
=============
___ 07:20PM BLOOD CK-MB-3 cTropnT-<0.01
___ 09:00AM BLOOD cTropnT-<0.01
PERTINENT IMAGING/STUDIES:
===========================
___ CXR (AP):
The lungs are clear. There is no consolidation, effusion, or
edema. Cardiac silhouette is top-normal for technique. Slight
tortuosity of the thoracic aorta is noted. No visualized acute
osseous abnormality.
___ Failed TEE
The TEE probe could not be passed into the esophagus. If needed,
deeper sedation with anesthesia would be required.
___ TTE
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). There is no
ventricular septal defect. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
MICRO:
======
___ BLOOD CULTURE: pending
DISCHARGE LABS:
===========
___ 06:50AM BLOOD WBC-5.6 RBC-4.88 Hgb-14.4 Hct-44.3 MCV-91
MCH-29.5 MCHC-32.5 RDW-13.7 RDWSD-45.6 Plt ___
___ 08:19AM BLOOD ___ PTT-30.2 ___
___ 06:50AM BLOOD Glucose-100 UreaN-28* Creat-0.9 Na-142
K-4.1 Cl-108 HCO3-26 AnGap-12
___ 06:50AM BLOOD Calcium-9.5 Phos-2.9 Mg-2.0
Brief Hospital Course:
Mr. ___ is an ___ year old man with no significant cardiac
history who was found to be in atrial fibrillation with rapid
ventricular rate incidentally w/o Sx at ___ clearance. No
clear inciting factor was discovered, unknown duration of Afib.
Troponins were negative. He was started on increasing doses of
Dilt up to 120mg TID, tolerated well, though still with rates to
140s with exertion. Also started on Apixaban for
anticoagulation. His echocardiogram showed left atrial
elongation, wnl LVEF, had an attempted TEE w/cardioversion on
___, but was unable to pass endoscope down esophagus ___
anatomical issues. Was DC'd with Dilt XL 360 qd and ___ with
Cardiology f/u
# Atrial Fibrillation with RVR: CHADSVASC-2 (age, hypertension).
No prior cardiac history. TSH wnl. No infectious signs or
symptoms. Troponins negative x 2. Attempted prior control with
metoprolol. Was ultimately controlled with Dilt, increased to
Dilt 120mg TID, though still with rates >100 occasionally with
exertion. Was started on Apixaban 5mg BID. Had an attempted TEE
w/cardioversion though this was unsuccessful as was unable to
advance endoscope so could not cardiovert. A TTE showed left
atrial enlargement and wnl LVEF. Was continued on apixaban and
transitioned to Dilt XL 360mg qd.
CHRONIC ISSUES
==============
# Benign Prostatic Hyperplasia: Was continued on home terazosin
2mg, finasteride 5mg
# Cataracts: Continued home eye drops. Will need to reschedule
cataract surgery and get ___ clearance again before surgery.
Transitional Issues
===========
[ ] Follow-up with cardiology after finishing ___ monitor. Will
need to decide whether to cardiovert with TEE w/anesthesia vs no
TEE if on apixaban for necessary duration
[ ] Follow up with PCP for repeat ___ clearance as s/p
hospitalization before surgery
[ ] Started on Apixaban 5mg BID (Apixaban started on ___, will
need to continue until told to DC by Outpatient Cards
[ ] Started on Dilt XL 360mg for rate control of Afib
# DC WEIGHT: 79.2kg
# CODE: Full, confirmed with patient
# CONTACT: Patient, ___ (Nephew) c: ___
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Terazosin 2 mg PO QHS
3. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
4. Ketorolac 0.5% Ophth Soln 1 DROP LEFT EYE QID
5. Docusate Sodium 100 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Ketorolac 0.5% Ophth Soln 1 DROP LEFT EYE QID
4. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
5. Terazosin 2 mg PO QHS
6. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth Every 12 hours
(2 times a day) Disp #*60 Tablet Refills:*0
7. Diltiazem Extended-Release 360 mg PO DAILY
RX *diltiazem HCl 360 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Atrial Fibrillation with RVR
Secondary:
Benign Prostatic Hyperplasia
Cataracts
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted after you found to have a fast heart rate and
a rhythm called atrial fibrillation. We gave you some
medication to help control your heart rates. We did an
echocardiogram of your heart in order to do a cardioversion to
make your rhythm back to normal.
Please follow-up with your primary care physician and with ___
cardiologist. Please take all of your medications as listed
below.
It was a pleasure taking care of you,
-Your ___ Team
***You were given a 1 month prescription of Apixiban 5mg one
tablet twice a day. The ___ is working to set you up with their
___ clinic to get you this medication, please ensure
that this is done so that you can make sure you take this
medication for as long as prescribed***
Followup Instructions:
___
|
10844079-DS-19
| 10,844,079 | 25,269,079 |
DS
| 19 |
2155-03-12 00:00:00
|
2155-03-12 16:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left subcapital displaced femur fracture
Major Surgical or Invasive Procedure:
L hip hemiarthroplasty (___)
History of Present Illness:
She slept last night and fell, but she is not sure why. She
thinks it was mechanical. She does not know if she hit her
head. She reports pain only in her left hip and has only felt
pain in her left hip. She presented to the twice daily MC
___, where she was evaluated, found to have a left hip
fracture, and transferred for further evaluation. At baseline,
she uses a wheelchair sometimes, and sometimes uses a crutch to
ambulate. She lives with her daughter.
She otherwise feels well, denying fever chills sweats nausea
vomiting diarrhea chest pain shortness of breath dizziness
lightheadedness headache.
Past Medical History:
hypertension, hyperlipidemia, history of CVA (___) with
residual left-sided weakness
Social History:
___
Family History:
N/C
Physical Exam:
Pulm: Non labored respirations
LLE:
- Skin intact, dressings c/d/i
- Able to extend her ankle, has limited ability to fire other
muscles of left lower extremity, per patient this is baseline
- Sensory intact in S/S/SP/DP/T distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 06:00AM BLOOD WBC-8.2 RBC-2.98* Hgb-8.8* Hct-27.3*
MCV-92 MCH-29.5 MCHC-32.2 RDW-12.7 RDWSD-41.8 Plt ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left subcapital displaced femur fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for L hip
hemiarthroplasty, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT in the LLE, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up with Dr. <<<>>> per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
Colace 100 mg capsule oral
1 capsule(s) Twice Daily
___ ___ 08:25)
atorvastatin 20 mg tablet oral
1 tablet(s) Once Daily
___ ___ 08:26)
oxybutynin chloride 5 mg tablet oral
1 tablet(s) Twice Daily
___ ___ 08:26)
amlodipine 10 mg tablet oral
1 tablet(s) Once Daily
___ ___ 08:26)
lisinopril 20 mg tablet oral
1 tablet(s) Once Daily
___ ___ 08:26)
Senna Laxative 8.6 mg tablet oral
2 tablet(s) Once Daily
___ ___ 08:27)
___ of Magnesia 400 mg/5 mL oral suspension oral
1 suspension(s) Once Daily
___ ___ 08:27)
___ Aspirin 325 mg tablet oral
1 tablet(s) Once Daily
___ ___ 08:27)
baclofen 10 mg tablet oral
1 tablet(s) Once Daily, at bedtime
___ ___ 08:28)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL 40 mg Nightly Disp #*30 Syringe
Refills:*0
3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*20 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
5. amLODIPine 10 mg PO DAILY
6. Aspirin 325 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left subcapital displaced femur fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weight bearing as tolerated of the left lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone 2.5 mg every four hours as needed for
increased pain. Aim to wean off this medication in 1 week or
sooner. This is an example on how to wean down:
Take 1 tablet every 4 fours needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
WBAT LLE
Treatments Frequency:
Gauze/tegaderm dressing changes as needed.
Followup Instructions:
___
|
10844468-DS-20
| 10,844,468 | 29,064,085 |
DS
| 20 |
2175-11-25 00:00:00
|
2175-11-28 08:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
___ pericardiocentesis
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of diabetes
mellitus type I, subarachnoid hemorrhage s/p VP shunt in ___
___, no bleeding since), and GERD. She presented in ___ with
left sided abdominal pain, and subsequently
chest pain, found to be in DKA (anion gap 28, now 12) with
NSTEMI and lateral ST depressions on ECG. She underwent coronary
artery bypass grafting x 4. Her postoperative course was
relatively routine, however ___ was consulted for assistance
with Diabetes management. It was felt that she is not a good
candidate for her Insulin pump. She was discharged to home on
postoperative day 5. She reports feel well with good appetite.
She was walking twice daily following discharge. Two days prior
to admission she became increasingly fatigued with decreased
appetite/PO intake, orthopnea, bilateral lower extremity edema,
and intermittent nausea/vomiting without fever/chills. She
complained of left upper quadrant pain that radiates to left
flank, but says this has been the same since OR. She has
continued all medications prescribed on discharge although her
lantus has been decreased from 27->17units qHS with AC/HS
Humalog SSI only due to hypoglycemia episodes. She reports
hyperglycemia to 200s for past 2 days despite decreased eating.
Today, while going to MD visit, she became ___ and was
helped to ground by her daughter w/o head trauma/full LOC. In
ER, labs are stable compared to ___ discharge. She was admitted
for further work up and evaluation.
Past Medical History:
Coronary Artery Disease
Diabetes Mellitus Type I, insulin Pump
Gastroesophageal Reflux Disease
Non-ST Elevation Myocardial Infarction
Sub-arachnoid Hemorrhage s/p VP shunt
Surgical History:
C-Section
Inguinal Hernia Repair
Sinus Surgery
Tendon Surgery, finger
Social History:
___
Family History:
No family history of early cardiac disease
Physical Exam:
Pulse: 60 BP: 118/62 RR: 20 O2 sat: 98% on RA Temp: 97.3 F
Height: 67 in Weight: 72.3 kg at prior admit
General: NAD but easily fatigues [x]
Skin: Dry [x] intact [x]
HEENT: PERRL [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Sternotomy healing well w/very small amount erythema at
distal pole, no drainage/warmth/tenderness. CT incisions
healing well [x] Lungs clear with decreased bases bilaterally
[x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] mildly distended [x] non-tender [x] bowel
sounds hypoactive +[x]
Extremities: Warm [x], well-perfused [x] Edema [x]1+ BLE
R groin IABP site healing well [x]
Left radial harvest site: healing well no
erythema/drainage/warmth [x]
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:p Left:p
DP Right:p Left:p
___ Right:p Left:p
Radial Right:p Left:harvested
Carotid Bruit: Right: - Left: -
.
Discharge Exam:
98.0
PO 132 / 72
L Sitting 64 16 97 Ra
.
General: NAD [x]
Neurological: A/O x3 [x] non-focal []
HEENT: PEERL []
Cardiovascular: RRR [x] Irregular [] Murmur [] Rub []
Respiratory: CTA [x] No resp distress []
GI/Abdomen: Bowel sounds present [x] Soft [] ND [] NT []
Extremities:
Right Upper extremity Warm [x] Edema
Left Upper extremity Warm [x] Edema
Right Lower extremity Warm [x] Edema --
Left Lower extremity Warm [x] Edema --
Pulses:
DP Right: 2+ Left:2+
___ Right: Left:
Radial Right: Left:
Skin/Wounds: Dry [x] intact []
Sternal: CDI [x] no erythema or drainage []
Sternum stable [x] Prevena []
Lower extremity: Right [] Left [] CDI []
Upper extremity: Right [x] Left [] CDI []
Pertinent Results:
Transthoracic Echocardiogram ___
The left atrial volume index is mildly increased. A prominent
Chiari network is seen in the right atrium (normal variant). The
interatrial septum is aneurysmal. There is no evidence for an
atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is >15mmHg. There is normal left ventricular
wall thickness with a normal cavity size. There is mild regional
left ventricular systolic dysfunction with basal inferior wall
hypokinesis (see schematic) and preserved/normal contractility
of the remaining segments. Overall left ventricular systolic
function is normal. The visually estimated left ventricular
ejection fraction is >=60%. Left ventricular cardiac index is
low normal (2.0-2.5 L/min/m2). There is no resting left
ventricular outflow tract gradient. The right ventricle was not
well seen with normal free wall motion. The aortic sinus
diameter is normal 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 trivial mitral
regurgitation. The pulmonic valve leaflets are not well seen.
The tricuspid valve leaflets appear structurally normal. There
is physiologic tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is normal. There is a moderate
circumferential pericardial effusion measuring up to 2cm along
RV free wall and posteriorly. The subcostal images are very
limited and taken off axis. The right ventricle appears to be
underexpanded but the tricuspid valve is not seen on these views
which means the right ventricle is not fully imaged which could
be giving this appearance. The right atrium has only brief end
diastolic collapse (right atrial systole) which along with
absence of exaggerated respiratory inflow
across the mitral valve despite a moderate posterior pocket
argues against frank tamponade. A left pleural effusion is
present.
IMPRESSION: Moderate circumferential pericardial effusion (see
above). Left pleural effusion. TEE could be considered for
better visualization of the right ventricle if exam suggests
tamponade. Compared with the prior TTE (images reviewed) of
___, the pericardial effusion is new, pleural effusion
new, basal inferior hypokinesis was present on prior.
Transthoracic Echocardiogram ___
There is normal left ventricular wall thickness with a normal
cavity size. Overall left ventricular systolic function is
normal. The visually estimated left ventricular ejection
fraction is >=55%. The mitral valve
leaflets are mildly thickened with no mitral valve prolapse.
There is trivial mitral regurgitation. There is a moderate
circumferential pericardial effusion. Diastolic expansion of the
right ventricle is blunted/delayed but frank tamponade is not
seen. A left pleural effusion is present.
IMPRESSION: Moderate pericardial effusion with mixed evidence of
increased pericardial pressure (absence of augmented inflow
variation across mitral valve suggests pericardial pressure not
elevated, but delayed/blunted expansion of right ventricle in
diastole (see attached image) does
suggest some increased pericardial pressure). However, frank
tamponade not seen. Compared with the prior TTE (images
reviewed) of ___ , images are better on current study but
overall not significantly changed.
.
___ Echo
CONCLUSION:
The estimated right atrial pressure is ___ mmHg. Overall left
ventricular systolic function is normal.
There is a small to moderate circumferential pericardial
effusion located predominantly adjacent to the
right ventricle. There is normal respiratory variation in
transmitral or transtricuspid inflow, suggesting
absence of tamponade physiology.
Compared with the prior TTE ___, the percardial effusion
is now smaller.
.
___ 06:00AM BLOOD WBC-7.5 RBC-3.16* Hgb-8.7* Hct-28.4*
MCV-90 MCH-27.5 MCHC-30.6* RDW-13.8 RDWSD-45.1 Plt ___
___ 02:34AM BLOOD ___ PTT-26.0 ___
___ 06:00AM BLOOD Glucose-132* UreaN-12 Creat-1.0 Na-137
K-4.3 Cl-100 HCO3-25 AnGap-12
___ 02:34AM BLOOD ALT-19 AST-18 AlkPhos-135* Amylase-40
TotBili-0.2
___ 02:34AM BLOOD Lipase-23
___ 06:00AM BLOOD Mg-1.7
Brief Hospital Course:
She was admitted on ___ for further work up. A
transthoracic echocardiogram on ___ demonstrated a
moderate pericardial effusion without tamponade physiology. A
repeat echocardiogram the next day revealed a moderate
pericardial effusion with mixed evidence of increased
pericardial pressure (absence of augmented inflow variation
across mitral valve suggests pericardial pressure not elevated,
but delayed/blunted expansion of right ventricle in diastole.)
She was taken to the cath lab for pericardial drain placement on
___.
She tolerated this procedure well and transferred to CVICU in
stable condition. She developed AFib/flutter with rates into
the 130s/140s. Beta blocker titrated, amio given and lytes
repleted. She converted to SR. Drain discontinued on POD 2 and
colchicine initiated. ___ continued to follow for glucose
management. Statin discontinued for intolerance. She reports a
history of muscle cramping and fatigue as well as nausea. The
patient will discuss alternatives with Dr. ___. The patient
is discharged home with ___ services on hospital day 10. She
will follow-up with Dr. ___ week with a repeat echo. She
will be discharged with detailed Insulin instructions and is to
follow-up with ___ in one week.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. B-100 Complex (vit B complex ___ combo no.2) 100 mg oral
DAILY
2. Cyclobenzaprine 5 mg PO TID:PRN musculoskeletal pain
3. Ferrex ___ (polysaccharide iron complex) 150 mg iron oral
DAILY
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. biotin 2,500 mcg oral DAILY
8. TraMADol ___ mg PO Q4H:PRN Pain - Moderate
9. Aspirin EC 81 mg PO DAILY
10. Atorvastatin 80 mg PO QPM
11. Isosorbide Dinitrate 10 mg PO TID
12. Metoprolol Tartrate 25 mg PO BID
13. Ranitidine 150 mg PO DAILY
14. Potassium Chloride 20 mEq PO DAILY
15. Furosemide 40 mg PO DAILY
16. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Colchicine 0.6 mg PO DAILY
RX *colchicine 0.6 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
2. Glargine 20 Units Bedtime
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
4. Metoprolol Tartrate 25 mg PO TID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*1
5. 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
6. Aspirin EC 81 mg PO DAILY
7. B-100 Complex (vit B complex ___ combo no.2) 100 mg oral
DAILY
8. biotin 2,500 mcg oral DAILY
9. Cyclobenzaprine 5 mg PO TID:PRN musculoskeletal pain
10. Ferrex ___ (polysaccharide iron complex) 150 mg iron oral
DAILY
11. Isosorbide Dinitrate 10 mg PO TID
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 40 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
pericardial effusion, cardiac tamponade
s/p pericardiocentesis
.
Coronary artery disease s/p Coronary artery bypass graft x ___
Myocardial infarction
Past medical history:
DM1 on insulin pump (A1c 7.3%, no DKA exacerbations since age
___
GERD
Sub-arachnoid hemorrhage s/p VP shunt in ___, performed at ___
C-section
Inguinal hernia repair
Sinus surgery
Finger tendon 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
Edema- none
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**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
___
|
10844869-DS-4
| 10,844,869 | 25,409,260 |
DS
| 4 |
2148-11-17 00:00:00
|
2148-11-18 14:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Heparin Agents / Coumadin / aspirin
Attending: ___.
Chief Complaint:
Chief Complaint: SOB
Reason for MICU transfer: hypoxia, hypercarbia, AMS
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ year old gentleman history of Child ___
Class A EtOH/NASH cirrhosis, Gold class 3 (severe) COPD (not on
home O2), CKD (stage ___ who presented with cough productive of
white sputum and wheezing and chest tightness similar to his
typical COPD exacerbations.
He has had ___ weeks of gradually worsening symptoms of
shortness of breath, worst today and the last few days, plus a
productive cough. His girlfriend has been asking for him to to
go to the hospital but he refuses. He feels it is worse because
of the weather change and his seasonal allergies are setting
things off. Per charts sats mid ___ on room air.
In the ED, initial vitals: 12:40 7 99.2 88 145/74 20 88%.
ED exam/imaging significant for poor air movement, minimal leg
swelling symmetric bilaterally, CXR w/chronic changes, no acute
changes, some vascular congestion/effusion.
In the ED, labs showed last ABG 7.30, 73, 56, lactate 1.5, COHb
7. K 6.4, lactate 1.8. Na 130, Cl 93, BUn 28, cre 2.3, ca 8.1,
BNP 1383, WBC 6, HCT 53.4, MCV 100 platelets 116.
In the ED, he received oxycodone 5x2, albuterol neb x5, ipratrop
x4, methylpred 125 iv x1, and azithromycin PO 500x1.
Plan had been to go to the floor but he was persistently hypoxic
on 2 or 6L, 87%. Unfortunately he was started on bipap for
hypercarbia, which was complicated by his large beard and air
leak. Noted to have muscular twitching in ED, as well as
anxiety. Reported chronic back pain, dry mouth, discomfort on
stretcher, claustrophobia.
Per respiratory, placed on BIPAP machine at ___ and 10L for
sats 90%.
On transfer, vitals were: Today ___ 126/79 27 91% bipap
He also had a mechanical fall last night in a puddle of water in
the bathroom where he hit the side of the tub on his left arm.
No head strike or LOC.
On arrival to the MICU, he reports his dyspnea has improved.
Reports he doesn't take fluticasone because it is bad for his
kidneys. No recent chest pain, weight gain, leg swelling. Notes
him arm hurts but is not weak. Has never had these twitches
before. He can go up 3 flights of stairs without stopping.
Review of systems:
(+) Per HPI
He denies fevers, chills, or nausea/vomiting. No abdominal
pain, diarrhea, constipation. He denies chest pain or leg
swelling. +Cough productive white sputum, yearly. No
palpitations. Denies dysuria. Denies rashes or skin changes.
Past Medical History:
BACK PAIN on narcotics agreement
CHRONIC KIDNEY DISEASE off HD since ___. Unknown etiology. He
was on dialysis for an episode of ARF at ___ Dialysis
___, two times a week ___ and ___ for a few months, then
stopped.
EMPHYSEMA/COPD, FEV1 46, GOLD 3 in ___
SEASONAL ALLERGIES
HYPERTENSION
ALCOHOLIC/NASH CIRRHOSIS, Child ___ Class A- Grade 4 last bx
___, grade 2 varices. Previously on transplant list.
SQUAMOUS CELL CARCINOMA
LUNG MASS - stable on imaging, thought to be benign
___ ESOPHAGUS
HEPARIN-INDUCED THROMBOCYTOPENIA
Tobacco abuse
Anxiety/claustrophobia
Questionable chronic aspiration
Left clavicular fracture
Wrist fracture
Social History:
___
Family History:
Per OMR, His mother had lung cancer and died from it. His father
had coronary artery disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.2 -137/___ -100% on bipap
GENERAL: Alert, oriented, on bipap, looks anxious
HEENT: Sclera anicteric, MM dry, large beard
NECK: supple, difficult to assess given habitus
LUNGS: expiratory wheezes throughout, decrease sounds at bases,
poor air movement
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
EXT: no pedal edema, mild clubbing toenails/fingernails
SKIN: no spider angioma
NEURO: oriented x3 however, however has myoclonic jerks, as well
as asterixis
DISCHARGE EXAM:
VS Tmax 98.7 Tc 97.1 HR ___ BP 125/75-143/69 RR ___ SpO2 91%
2.5 L to 91% 1L NC
Wt 113.1 kg, I/O 24h 1760/3955 (-2.2L), 8h NR/1450(-1.45L)
GENERAL: Alert, orientedx3 but appears anxious
HEENT: Sclera anicteric, MM dry, large beard
NECK: Supple, difficult to assess given habitus
LUNGS: Diminished breath sounds at bases bilaterally, minimal
wheezing at bases.
CV: RRR, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
EXT: No pedal edema, mild clubbing toenails/fingernails
SKIN: No spider angioma, jaundice, or palmar erythema
NEURO: oriented x3 however, no asterixis
Pertinent Results:
ADMISSION LABS
================
___ 01:00PM BLOOD WBC-6.0 RBC-5.31 Hgb-17.4 Hct-53.4*
MCV-100* MCH-32.7* MCHC-32.5 RDW-17.1* Plt ___
___ 01:00PM BLOOD Neuts-76.3* Lymphs-9.7* Monos-12.3*
Eos-1.2 Baso-0.4
___ 01:00PM BLOOD Plt ___
___ 01:00PM BLOOD Glucose-100 UreaN-28* Creat-2.3* Na-130*
K-4.9 Cl-93* HCO3-32 AnGap-10
___ 01:00PM BLOOD proBNP-1383*
___ 01:00PM BLOOD Calcium-8.1* Phos-4.1 Mg-2.5
___ 01:00PM BLOOD TSH-0.52
___ 01:12PM BLOOD Lactate-1.8 K-6.4*
BLOOD GAS
============
___ 05:32PM BLOOD Type-ART O2 Flow-4 pO2-56* pCO2-73*
pH-7.30* calTCO2-37* Base XS-6 Intubat-NOT INTUBA
___ 01:02AM BLOOD Type-ART Temp-36.7 O2 Flow-10 pO2-97
pCO2-92* pH-7.22* calTCO2-40* Base XS-6 Intubat-NOT INTUBA
___ 04:49AM BLOOD Type-ART Temp-36.1 O2 Flow-15 pO2-64*
pCO2-84* pH-7.26* calTCO2-39* Base XS-7 Intubat-NOT INTUBA
___ 02:22PM BLOOD ___ Temp-36.8 pO2-46* pCO2-67*
pH-7.31* calTCO2-35* Base XS-4 Intubat-NOT INTUBA
___ 05:32PM BLOOD O2 Sat-81 COHgb-7* MetHgb-0
MICROBIOLOGY
=============
___ MRSA SCREEN MRSA SCREEN-PENDING
EKG
Sinus rhythm. Poor R wave progression, likely normal variant.
Compared to the previous tracing of ___ findings are similar.
Rate PR QRS QT/QTc P QRS T
74 ___ 51 38 44
CXR FINDINGS:
Pulmonary vascular markings are diffusely increased with
prominent septal
markings, suggestive of mild edema. No new focal consolidation
is identified.
Chronic opacity at the left costophrenic angle is similar to
prior and
consistent with a combination of loculated effusion and
atelectasis. Rounded opacity projecting posteriorly over the
thoracic spine is also similar to prior and consistent with
round atelectasis. No pneumothorax. The heart is mildly
enlarged. Cardiomediastinal contours are otherwise unremarkable.
Chronic left clavicular and left rib fractures.
IMPRESSION: Mild cardiomegaly with probable mild pulmonary
edema. No new focal lung consolidation. Chronic loculated left
pleural effusion and rounded atelectasis.
DISCHARGE LABS:
===============
___ 06:45AM BLOOD WBC-5.0 RBC-5.40 Hgb-17.3 Hct-55.3*
MCV-102* MCH-32.1* MCHC-31.3 RDW-17.0* Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-64* UreaN-36* Creat-2.0* Na-142
K-3.9 Cl-97 HCO3-36* AnGap-13
___ 06:45AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.4
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman history of Child ___
Class A EtOH/NASH cirrhosis, Gold class 3 (severe) COPD (not on
home O2), CKD stage ___ who presented with cough and wheezing
and chest tightness similar to his typical COPD exacerbations.
MICU COURSE:
# Acute on chronic hypercarbic respiratory failure. Patient
required increasing supplemental O2 and subsequently required
MICU stay for Bipap. He was continued on COPD management with
nebs, received IV methylprednisone, and IV Lasix. He did not
require intubation and mechanical ventilation in the ICU. He was
weaned to 4L NC when called out to the medical floor.
MEDICAL FLOOR COURSE:
# COPD Exacerbation: Evidenced by increased wheezing and sputum
production. Exacerbation may be d/t non-compliance as he failed
to take his fluticasone d/t concerns that it would affect his
liver and kidney function. The patient was managed with standing
Albuterol/Ipratropium nebulizers, Prednisone 40 mg PO QDaily x 5
days and Azithromycin (500 mg PO day 1, followed by 250 mg PO
QDaily x 4 days).
The patient's dyspnea and wheezing improved with these
treatments. The patient was satting low ___ on RA, but had
desats to mid ___ with ambulation. Thus, the patient was
discharged on home O2. He was also discharged on Spiriva,
Fluticasone, and close pulmonary followup.
# Pulmonary Edema: TTE with preserved LVEF. Presentation from
possible diastolic CHF vs fluid retention from CKD with patient
not on HD. The patient received IV Lasix in the MICU and
subsequently transitioned to his home Lasix 40 mg PO QDaily at
discharge.
# Child ___ Class A ETOH/NASH cirrhosis, not decompensated.
With 2 cords of grade I varices seen ___, no history of
bleeding. followed by Dr. ___. Remains abstinent from alcohol
and without clinical evidence of decompensation. No clinical
signs or symptoms of decompensated cirrhosis or acute liver
failure during this hospitalization.
-Continued Thiamine 100 mg PO/NG DAILY
# Chronic Kidney Disease: Patient with known CKD stage ___,
previously on HD. Continued to be elevated during this
hospitalization but near baseline.
# Metabolic Alkalosis: HCO3 34, rose from 32 on admission.
Patient has known COPD and likely CO2 retainer, hence likely
represents compensatory metabolic alkalosis from chronic
respiratory acidosis. No intervention done.
CHRONIC ISSUES:
# Hypertension:
-Continued home Amlodipine 10 mg PO QDaily
# Back pain: On narcotics contract, though notes he takes 10mg
BID of oxycodone.
-Continued Oxycodone (Immediate Release) 5 mg PO/NG BID:PRN
pain
TRANSITIONAL ISSUES:
[]CODE STATUS: Full
[]Patient discharged on Spiriva 2 INH Daily
[]Patient discharged on supplemental O2 1 L NC with activity
[]Patient resumed on home Lasix 40 mg PO QDaily at discharge
[]Patient will have close followup with primary care physician
and pulmonary
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Ranitidine 150 mg PO BID
4. Furosemide 40 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. OxycoDONE (Immediate Release) 5 mg PO BID:PRN Additional 8
pills are to be used 1 PO qhs prn
7. Fluticasone Propionate 110mcg 1 PUFF IH BID
8. Calcium Acetate 667 mg PO TID W/MEALS
9. Magnesium Oxide 400 mg PO DAILY
10. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN SOB
11. FoLIC Acid 1 mg PO DAILY
12. Thiamine 100 mg PO DAILY
13. Vitamin B Complex 1 CAP PO DAILY
14. Ascorbic Acid ___ mg PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
16. coenzyme Q10 unknown mg oral DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Calcium Acetate 667 mg PO TID W/MEALS
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 40 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO BID:PRN Additional 8
pills are to be used 1 PO qhs prn
8. Ranitidine 150 mg PO BID
9. Thiamine 100 mg PO DAILY
10. Vitamin B Complex 1 CAP PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN SOB
13. coenzyme Q10 0 mg ORAL DAILY
14. Fluticasone Propionate 110mcg 1 PUFF IH BID
RX *fluticasone [Flovent HFA] 110 mcg/actuation 1 PUFF INH twice
a day Disp #*60 Inhaler Refills:*1
15. Lisinopril 10 mg PO DAILY
16. Magnesium Oxide 400 mg PO DAILY
17. Tiotropium Bromide 1 CAP IH DAILY
Please take two inhalations daily
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 dose
INH once a day Disp #*30 Capsule Refills:*1
18. Nebulizer Prescription
Diagnosis COPD, ICD-9 code 496. Prescription for nebulizer
machine.
19. Home Oxygen Prescription
Diagnosis COPD, ICD-9 Code 496. Prescription for home
supplemental oxygen 1 L NC with activity due to desats to 83%
with ambulation
20. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
RX *albuterol sulfate 90 mcg 1 every six (6) hours Disp #*60
Inhaler Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Chronic Obstructive Pulmonary Disorder (COPD)
Hypoxia
Pulmonary Edema
Metabolic Alkalosis
Secondary:
Cirrhosis (well-compensated)
Chronic Kidney Disease
Hypertension
Chronic Back Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
the ___. As you know, you were
admitted with wheezing, chest discomfort, and shortness of
breath thought to be due to a flare of your lung disease called
chronic obstructive pulmonary disorder (COPD). Your oxygen level
was low and you needed respiratory support in the intensive care
unit (ICU). You were treated with nebulizers, steroids,
antibiotics, and supplemental oxygen. We also removed some fluid
in your lungs with intravenous lasix and continued your home
lasix medication. You did well with these treatments. At
discharge, your shortness of breath and wheezing significantly
improved. You were discharged with a medication called Spiriva.
Please continue to take this medication as well as your
Fluticasone regularly. You will also need supplemental oxygen
with acitivy (while walking and going up stairs). Please take
your medications as instructed. Please followup with your
primary care physician and lung doctor. If you develop any chest
pain, difficulty breathing, severe breathing, or find that you
need to take your inhlaers more frequently without relief,
please seek medical attention urgently.
Please talk to the oxygen company to inquire about a nebulizer
machine. You can also ask your PCP.
Nobody can smoke around your oxygen tank. The combination of the
two can cause combustion and fires.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10845142-DS-15
| 10,845,142 | 29,099,547 |
DS
| 15 |
2138-11-27 00:00:00
|
2138-11-27 16:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dysuria
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ hx of remote prostate cancer, HIV (well controlled, VL last
month
undetectable) coming in w dysuria, flank pain and fevers.
Per History obtained in the ED: Few days of dysuria and urinary
frequency. Has noticed b/l flank pain radiating to the front.
Notes two bouts of vomiting this morning. Pain is aching in
nature, constant and progressively worsening. Denies black tarry
stools or BRBPR. No ab surgeries. Missed two days of HIV
medication. No IVDU. Fever to 100.4. Denies chest pain or SOB.
- Initial Vitals: T: 100.4, HR: 86, BP: 123/72, R: 18, O2 Sat:
97% on RA
- Exam: b/l CVA tenderness. Ab is soft and nondistended.
- Labs: WBC: 12.9 with neutrophilic predominance, Hgb: 11.7,
INR:
1.4, Glucose: 327, Cr: 1.6, Phos: 1.3, Lactate: 2.0 (was 5.1),
UA: Moderate blood, 30 protein, 1000 glucose, Large leukocytes,
negative nitrites, 118 WBC's, few bacteria, blood/urine cx
pending
- Imaging: CXR: Negative, CT Abdomen/Pelvis: Bilateral
pyelonephritis, bilateral ureteritis and cystitis. No renal
abscess
or hydroureteronephrosis.
- Consults: None
- Interventions: Ceftriaxone, Fluids
Upon arrival to the FICU, patient noted that he has experienced
the symptoms above, and has also had some pain in his left
testicle. No groin rashes or lesions. In the FICU, he states
that
he is not currently having any symptoms. Specifically denies
shortness of breath, chest pain, flank pain, dysuria, or other
pain.
ROS: Positives as per HPI; otherwise negative.
====
Past Medical History:
Prostate CA (Treated with radiation in ___
HIV (Dx in ___
HLD
IDDM
CKD
HTN
Restless Leg Syndrome
Social History:
___
Family History:
Not pertinent to admission
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Patient was seen and examined on day of discharge ___ at 10AM.
>30 minutes was spent of coordination of care.
GENERAL: Alert and interactive. In no acute distress.
HEENT: Sclera anicteric and without injection.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: no CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
GU: no scrotal swelling.
bilateral testes non-tender.
EXTREMITIES: No ___ edema.
SKIN: Warm. No rashes.
NEUROLOGIC: Alert and oriented, moving all 4 extremities
spontaneously.
PSYCH: Normal mood and affect.
Pertinent Results:
ADMISSION LABS
===============
___ 02:02PM BLOOD WBC-12.9* RBC-3.96* Hgb-11.7* Hct-35.9*
MCV-91 MCH-29.5 MCHC-32.6 RDW-13.5 RDWSD-45.1 Plt ___
___ 09:23PM BLOOD ___ PTT-26.4 ___
___ 02:02PM BLOOD Glucose-327* UreaN-15 Creat-1.6* Na-135
K-4.1 Cl-99 HCO3-21* AnGap-15
___ 02:02PM BLOOD ALT-23 AST-28 AlkPhos-79 TotBili-0.6
___ 02:02PM BLOOD Lipase-23
___ 02:02PM BLOOD Albumin-4.3 Calcium-9.8 Phos-1.3* Mg-2.1
___ 02:09PM BLOOD Lactate-3.3*
___ 07:16PM BLOOD Lactate-5.1*
DISCHARGE LABS
===============
OTHER RELEVANT LABS
===================
IMAGING/STUDIES
================
CT A/P ___
IMPRESSION:
Bilateral pyelonephritis, bilateral ureteritis and cystitis. No
renal abscess or hydroureteronephrosis. Correlation with
urinalysis is recommended.
CXR ___
IMPRESSION:
No acute cardiopulmonary abnormality.
___ 05:45AM BLOOD WBC-7.6 RBC-3.89* Hgb-11.2* Hct-34.2*
MCV-88 MCH-28.8 MCHC-32.7 RDW-13.8 RDWSD-44.3 Plt ___
___ 05:40AM BLOOD WBC-15.8* RBC-4.20* Hgb-12.0* Hct-37.2*
MCV-89 MCH-28.6 MCHC-32.3 RDW-13.8 RDWSD-44.5 Plt ___
___ 05:35AM BLOOD WBC-6.0 Lymph-37 Abs ___ CD3%-76
Abs CD3-1685 CD4%-21 Abs CD4-472 CD8%-54 Abs CD8-1208*
CD4/CD8-0.39*
___ 05:45AM BLOOD Glucose-123* UreaN-9 Creat-1.0 Na-145
K-4.1 Cl-108 HCO3-24 AnGap-13
Brief Hospital Course:
SUMMARY/ASSESSMENT: Mr ___ is a ___ with h/o HIV on ART (VL
undetectable ___, CKD (baseline Cr ~1.5), distant h/o
prostate cancer s/p XRT/hormonal therapy, and IDDM2 (A1c 7.0
___ who presented on ___ with 2d of dysuria, fevers, flank
pain, and L testicular pain ___ sepsis iso bilateral
pyelonephritis, epididymitis, orchitis, and ___ bacteremia
admitted to the FICU on ___ for hypotension that improved with
abx and fluid resuscitation.
# Sepsis- RESOLVED.
# Hypotension
# ___ bacteremia
# Pyelonephritis ___ ___
# Epidydimitis
# Orchitis
Pt presented with 2 d dysuria, fevers/chills to his PCP and
subsequently to ED. CT in ED with c/f bl pyelonephritis and
hydroureteritis without any e/o perinephric abscess or
nephrolithiasis. UCx at PCP with ___ and ___ BCx from our ED
with
___, rest pending. Had hypotension and elev lactic acid to 5.1
that resolved with fluid resuscitation and initiation of
antibiotics. Exam also notable for L testicular pain and mild
prostate tenderness on exam. US showed evidence of epididymitis
and orchitis.
___ + E coli blood culture
___ urine culture also E coli
___ negative blood culture
- ceftazidime to CTX 2gram q24hr on ___, and transition to
ciprofloxacin 500mg BID on ___ to complete 2 week course since
negative blood culture last day ___.
# h/o HTN:
On lisinopril 5, amlodipine 7.5 mg, torsemide 60 mg daily at
home
- BP meds continued while here with exception of torsemide which
was held. He did not retain fluid. torsemide was started by
nephrologist for CKD (reported Cr baseline 1.5). discharge Cr
1.0. I let him know to resume torsemide but if feeling
lightheaded or dehydrated to stop and contact his PCP.
# IDDM: A1c 6.7 on ___.
On sitagliptin and pioglitazone at home as well as glargine 30 u
and ___ per SS
# Chronic problems
- HIV on HAART: dx 1980s, no prior opportunistic infections. VL
last ___ undetectable. c/h ART. CD4 472 when checked here.
- HLDL: c/h atorva 20
- CKD: bl Cr reported ~ 1.6. Cr 1.0 on discharge.
- RLS: c/h carbidopa-levodopa
- Prostate CA: Diagnosed and treated with radiation in ___.
Patient follows with urologist. last PSA in ___ 1.2. can
consider repeat given presentation of bl pyelonephritis
E coli sensitivities ___ blood culture
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
TRANSITIONAL ISSUES
[ ] E coli bacteremia/pyelo/orchitis/epididymis: clinically
improving. continue 2 week course of Ciprofloxacin. follow up
with PCP.
[ ] Torsemide: indication CKD. restarted home med torsemide
60mg on discharge but patient did not require here and was
euvolemic with no peripheral edema. volume status with PCP and
consider dose adjustment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Potassium Chloride 10 mEq PO BID
3. Atorvastatin 20 mg PO QPM
4. Dolutegravir 50 mg PO DAILY
5. darunavir-cobicistat 800-150 mg-mg oral DAILY
6. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using Aspart Insulin
7. amLODIPine 7.5 mg PO DAILY
8. Carbidopa-Levodopa (___) 1 TAB PO QHS
9. Pioglitazone 15 mg PO DAILY
10. Torsemide 60 mg PO QAM
11. Fenofibrate 67 mg PO DAILY
12. SITagliptin 50 mg oral DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H e coli bacteremia, pyelo,
orchitis, epidydimitis.
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*21 Tablet Refills:*0
2. Glargine 30 Units Bedtime
3. amLODIPine 7.5 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Carbidopa-Levodopa (___) 1 TAB PO QHS
6. darunavir-cobicistat 800-150 mg-mg oral DAILY
7. Dolutegravir 50 mg PO DAILY
8. Fenofibrate 67 mg PO DAILY
9. Lisinopril 5 mg PO DAILY
10. Pioglitazone 15 mg PO DAILY
11. Potassium Chloride 10 mEq PO BID
Hold for K > 4.4
12. SITagliptin 50 mg oral DAILY
13. Torsemide 60 mg PO QAM
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis due to E. Coli
bacteremia/pyelonephritis/orchitis/epididymitis
Discharge Condition:
good.
Discharge Instructions:
You were admitted to the hospital for sepsis, caused by an E.
coli infection that was in your blood, both kidneys, testicles,
epididymis. Your symptoms improved with antibiotics in the
hospital. It is important that you continue to take
antibiotics. Please take ciprofloxacin 500mg twice a day
through ___. If you are having fevers, chills, painful
urination, or symptoms that concern you, seek medical attention.
Followup Instructions:
___
|
10845745-DS-8
| 10,845,745 | 20,992,710 |
DS
| 8 |
2168-03-04 00:00:00
|
2168-03-04 16:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ___
Allergies:
Biaxin / Sulfa (Sulfonamide Antibiotics) / morphine / peanuts /
clarithromycin / milk
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ woman with a history of chronic asthma not
on maintenance therapy, though with a prior recent exacerbation
the last 2 months who presents to the ED for evaluation of
dyspnea.
The patient indicates that she has been in her usual state of
health until about 6 weeks ago when she started having
increasing dyspnea cough and wheezing. She saw her primary care
physician at that time who prescribed her albuterol nebulizers,
albuterol inhaler and prednisone and diagnosed her with
pneumonia and treated her with levofloxacin. She improved
fairly quickly upon completion of therapy and has been doing
well until this past ___. She indicates that on ___ her
symptoms started all over again identical to previous. She
indicates she started having back pain first followed by
shortness of breath, increased cough as well as wheezing
sensation. This progressed over the next couple days she saw
her primary care doctor who diagnosed her with an asthma
exacerbation, prescribed albuterol nebulizers again and sent her
home. However she continued to get worse so presented again to
her primary care physician the following day who referred to the
ED for ongoing worsening of her symptoms.
In the ED, initial vitals were: 98.1 98 136/84 24 100% Nasal
Cannula. And was notable for loud expiratory wheezing in
posterior lung fields as well as mild crackles at bilateral
bases. Chest x-ray revealed patchy opacifications concerning
for possible infectious process. She was treated with
Vancomycin and Pip-Tazobactam, Prednisone 60mg, albuterol and
ipratropium nebs, Tessalon Pearls for cough, admitted to
___.
On the floor, ___ indicates she feels improved from prior still
with mild shortness of breath, wheezing sensation and overall
does not feel well. We discussed the possibility of her being
discharged tomorrow she indicated that she is unlikely to feel
better by then, and she is not to go home until she does feel
better because she is worried about coming back. At this point
time she is not anywhere near her baseline which is very
functional, gardening outside and she is very independent.
Currently she is shortness of breath with minimal exertion such
as walking to the bathroom. However during her conversation she
does not exhibit any coughing, sputum production or audible
wheezing. She denies any recent fevers or chills. Denies any
sputum production or chest pain. She denies any orthopnea or
PND.
Review of systems:
(+) Per HPI also reports constipation
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. 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. Otherwise ROS is negative.
Past Medical History:
-Breast cancer status post treatment
-Chronic asthma previously on maintenance therapy though
discontinued in ___
-Pulmonary embolism, on chronic warfarin, provoked in the
setting of breast cancer therapy ___ years ago
-History of supraventricular tachycardia status post ablation on
verapamil
Social History:
___
Family History:
-Mother with colon cancer
-Aunt with breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
PHYSICAL EXAM:
Vitals: 98.0 ___ 30 97 2lNC
Pain Scale: ___
General: Patient appears overall well. She is seated upright in
bed, calm, communicative, in good humor and asking lots of
questions. Alert, oriented and in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, but suspect
clear secretions into tissues but does not demonstrate clear
sputum production,
Neck: supple, JVP low, no LAD appreciated
Lungs: Reduced air movement bilaterally however lungs are clear
to auscultation bilaterally, moving air symmetrically, no
wheezes, rales or rhonchi appreciated
CV: Regular rate and rhythm, S1 and S2 clear and of good
quality, no murmurs, rubs or gallops appreciated
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds throughout, no rebound or guarding
Ext: Warm, well perfused, full distal pulses, no clubbing,
cyanosis or edema
Neuro: CN2-12 grossly in tact, motor and sensory function
grossly intact in bilateral UE and ___, symmetric
DISCHARGE PHYSICAL EXAM
VS: T 97.7, BP 147/81, HR 58, RR 16, O2 sat 95% on RA
Gen: seated in a chair next to the bed, well appearing, NAD
Eyes: anicteric, non-injected
CV: RRR, no m/r/g
Chest: decreased BS throughout, more so at bases. no wheezing.
no r/r.
Abs: soft, NT/ND, NABS
Ext: WWP, no c/c/e
Neuro: alert and oriented motor and sensory function grossly
intact in bilateral UE and ___, symmetric
Pertinent Results:
ADMISSION LABS:
___ 12:08PM BLOOD WBC-5.6 RBC-4.14 Hgb-13.0 Hct-39.5 MCV-95
MCH-31.4 MCHC-32.9 RDW-15.1 RDWSD-53.1* Plt ___
___ 12:08PM BLOOD Neuts-33.4* ___ Monos-8.0
Eos-7.8* Baso-0.4 Im ___ AbsNeut-1.89 AbsLymp-2.82
AbsMono-0.45 AbsEos-0.44 AbsBaso-0.02
___ 12:08PM BLOOD ___ PTT-47.3* ___
___ 12:08PM BLOOD Plt ___
___ 12:08PM BLOOD Glucose-96 UreaN-12 Creat-0.8 Na-138
K-6.6* Cl-98 HCO3-26 AnGap-14
___ 12:08PM BLOOD CK(CPK)-448*
___ 12:08PM BLOOD CK-MB-9
___ 05:09AM BLOOD Calcium-9.0 Phos-4.2 Mg-1.9
___ 12:12PM BLOOD K-3.9
IMAGING
- CXR (___): Patchy opacities in lung bases, potentially
atelectasis, though infection or aspiration is not excluded in
the correct clinical setting.
DISCHARGE LABS:
___ 06:20AM BLOOD ___
___ 05:09AM BLOOD WBC-5.6 RBC-3.87* Hgb-11.6 Hct-36.7
MCV-95 MCH-30.0 MCHC-31.6* RDW-15.3 RDWSD-52.9* Plt ___
___ 05:09AM BLOOD Glucose-116* UreaN-15 Creat-0.7 Na-140
K-4.8 Cl-100 HCO3-26 AnGap-14
Brief Hospital Course:
Ms ___ is a ___ year old woman with a history of asthma
and pulmonary embolism and with worsening shortness of breath
and cough consistent with acute on chronic asthma exacerbation.
On the day of discharge, the patient felt well and wanted to go
home. We discussed her history, current situation, medications,
and ___ plan, her nurse was present for this conversation.
We worked through all of the patient's questions. She is
looking forward to going home.
# Acute on chronic asthma exacerbation
# Acute community-acquired pneumonia
# Acute Hypoxemic Respiratory Failure: Admitted with new O2
requirement. Patient with cough and CXR with basilar infiltrates
possibly suggestive of pneumonia. She was treated with steroids,
and broad spectrum antibiotics in the ED. On the floor, she was
given prednisone, levofloxacin, standing nebs and her condition
improved. She was weaned from oxygen with improvement in her
subjective dyspnea, and peak flows. She ambulated without
difficult or desaturation. Her peak flow was still suboptimal
on discharge (150), however she overall had clinically improved,
and we felt comfortable with her going home.
With further discussion on discharge, we elicited that this was
her third or fourth admission for asthma exacerbation this year.
One at ___, and then a couple associated with
viral infections. She was under the impression that inhaled
steroids would lead to significant adverse effects such as
weight gain and other complications. I explained how oral
steroids can lead to these complications but that the amount of
inhaled steroid that makes it into the body is much less, and
that I would recommend she use an inhaled steroid to prevent
future asthma exacerbations. After working through her
concerns, I learned that she had been previously prescribed
fluticasone inhaled by her primary care's office, and I reviewed
the records and see that on ___ she was given fluticasone
220 mcg twice daily. However she states that she has not been
using this medication, for fear of the side effects. She
indicated that she would now start taking this, and did not need
a prescription for it. I encouraged her to ___ closely
with her PCP, which she is already planning, and suggested that
a referral to a pulmonologist may be useful at some point, she
agrees and will explore this with her PCP.
# Pulmonary embolism:
# Supratherapeutic INR: Prior PE was provoked in the setting of
active malignancy and cancer treatment, currently on warfarin.
Admitted at 4.3 and warfarin was held until back in normal
range. It was 2.4 on discharge. Given that she had not received
warfarin at all for several days (so the ___ INR is likely to be
lower), and is only receiving 2 more days of steroids and
antibiotics, I encouraged her to use just 10mg daily of warfarin
until reassessed by her ___ clinic, which she says
she will contact tomorrow, ___.
TRANSITIONAL ISSUES
- Warfarin management
- PCP ___, consideration of referral to Pulmonary
[x] The patient is safe to discharge today, and I spent [ ]
<30min; [x] >30min in discharge day management services.
___, MD
___
Pager ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lidocaine 5% Patch 1 PTCH TD QAM
2. Verapamil SR 360 mg PO Q24H
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Warfarin 12.5 mg PO 3X/WEEK (___)
5. Vitamin D 1000 UNIT PO DAILY
6. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
7. Furosemide 20 mg PO DAILY
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
9. Warfarin 10 mg PO 4X/WEEK (___)
10. Loratadine 10 mg PO DAILY
11. fluticasone 220 mcg/actuation inhalation BID -- patient was
not taking this
Discharge Medications:
1. Levofloxacin 500 mg PO Q24H Duration: 2 Days
Take on ___ and ___, then stop.
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth DAILY
Disp #*2 Tablet Refills:*0
2. PredniSONE 40 mg PO DAILY Duration: 2 Days
Take on ___ and ___, then stop.
RX *prednisone 10 mg 4 tablet(s) by mouth DAILY Disp #*8 Tablet
Refills:*0
3. Warfarin 10 mg PO DAILY16
Use this dose daily (rather than alt. w/12.5mg) while on
steroids/antibiotics.
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
5. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. fluticasone 220 mcg/actuation inhalation BID
8. Furosemide 20 mg PO DAILY
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Loratadine 10 mg PO DAILY
11. Verapamil SR 360 mg PO Q24H
12. Vitamin D 1000 UNIT PO DAILY
13. HELD- Warfarin 12.5 mg PO 3X/WEEK (___) This
medication was held. Do not restart Warfarin until seen in
___ (use lower dose, 10mg daily, while on steroids and
antibiotics)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Asthma Exacerbation
Community Acquired Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were admitted to the hospital because you were short of
breath. You were found to have an asthma exacerbation, possibly
triggered by a pneumonia. You were treated with nebulizers,
steroids, and antibiotics and your condition improved.
After you leave the hospital, you will need to take several
additional days of steroids and antibiotics to fully treat your
condition.
Additionally, after you leave the hospital you will be started
on a new medication to help prevent recurrent attacks in the
future.
Please speak to your primary care doctor about having a
pulmonary function test after you leave the hospital.
Please take all medications as prescribed and keep all scheduled
doctor's appointments. Seek medical attention if you develop a
worsening or recurrence of the same symptoms that originally
brought you to the hospital, experience any of the warning signs
listed below, or have any other symptoms that concern you.
Followup Instructions:
___
|
10845916-DS-16
| 10,845,916 | 29,472,477 |
DS
| 16 |
2177-10-28 00:00:00
|
2177-10-29 20:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
bacitracin / ___ / adhesive
Attending: ___.
Chief Complaint:
Bloody stools
Major Surgical or Invasive Procedure:
Colonoscopy with biopsy of transverse colon mass
History of Present Illness:
Ms. ___ is a ___ with history of diverticulosis, colonic
polyps, idiopathic cecal rupture status post cecectomy, and
breast cancer with multiple recurrences who presents with
bright red blood per rectum. She was in her usual state of
health until the morning prior to admission, when she developed
nausea, followed by nonbloody, bilious emesis soon after
drinking coffee and tomato juice. She experienced diffuse dull
abdominal pain throughout the day. At approximately 10pm on the
night prior to admission, she noted that her stool was
intermixed with bright red blood, with 2 subsequently similar
bowel movements.
In the ED, initial vital signs were as follows: 97.6 70 130/74
16 100% RA. Rectal exam was unremarkable, with the exception of
guaiac positive brown stool. Admission labs were notable for
hematocrit of 46.6 and lactate of 2.7. CTA abdomen revealed an
apple core lesion in the transverse colon concerning for
malignancy. She experienced a recurrent bloody bowel movement,
followed by a second characterized by cloudy fluid. She received
no medications. Vital signs prior to transfer were as follows:
98.2 96 138/69 16 98% RA.
On the floor, she reports mild abdominal pain most prominent in
the left lower quadrant.
Past Medical History:
Diverticulosis
Colonic polyps
Idiopathic cecal rupture status post cecectomy
Breast cancer with multiple recurrences status post lumpectomy
x2, chemoradiation therapy, and bilateral mastectomy with
reconstruction
Pneumococcal meningitis in ___
Unexplained tachycardia
Hypertension
Hyperlipidemia
Graves disease
Gastroesophageal reflux/peptic ulcer disease
Osteoarthritis
Actinic keratosis
Endometrial polyps
Social History:
___
Family History:
Father, deceased, with prostate cancer and hypertension. Mother,
deceased, with arthritis, diabetes mellitus, and stroke.
Paternal aunt, deceased, with breast cancer. Paternal
grandmother, deceased, with colon cancer.
Physical Exam:
On admission:
Vitals- 97.8 149/85 93 20 100%RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, unable to assess heart sounds for MRG due to
distant heart sounds
Abdomen- soft, bowel sounds present, mild tenderness in all fall
quadrents, most sensitive in LLQ. no rebound tenderness or
guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
At discharge:
Vitals- 98.5 115/70 70 19 97 RA
Otherwise unchanged.
Pertinent Results:
On admission:
___ 11:30PM BLOOD WBC-9.7 RBC-4.85# Hgb-15.1# Hct-46.6#
MCV-96 MCH-31.0 MCHC-32.3 RDW-12.9 Plt ___
___ 11:30PM BLOOD Neuts-30* Bands-0 Lymphs-61* Monos-3
Eos-2 Baso-0 Atyps-4* ___ Myelos-0
___ 11:30PM BLOOD ___ PTT-28.5 ___
___ 11:30PM BLOOD Glucose-128* UreaN-17 Creat-0.8 Na-136
K-3.8 Cl-102 HCO3-20* AnGap-18
___ 11:30PM BLOOD ALT-29 AST-35 AlkPhos-85 TotBili-0.6
___ 11:30PM BLOOD Lipase-98*
___ 11:30PM BLOOD Albumin-4.7
___ 11:43PM BLOOD Lactate-2.7*
In the interim:
___ 06:35AM BLOOD CEA-2.6
At discharge:
___ 06:45AM BLOOD WBC-5.8 RBC-3.83* Hgb-12.1 Hct-37.1
MCV-97 MCH-31.6 MCHC-32.7 RDW-13.3 Plt ___
___ 06:45AM BLOOD Glucose-108* UreaN-7 Creat-0.6 Na-139
K-3.4 Cl-105 HCO3-23 AnGap-14
Imaging:
EKG (___):
Artifact is present. Left axis deviation. There is an early
transition which is non-specific. Probable non-specific ST-T
wave changes. If clincally indicated, a repeat tracing may
provide better diagnostic quality. No previous tracing available
for comparison.
IntervalsAxes
___
___
CTA abdomen/pelvis (___):
1. An apple core mass in the distal transverse colon spanning 3
cm is
concerning for malignancy. Colonoscopy is recommended.
2. Several focally enlarged mesenteric lymph nodes with
increased enhancement are suspicious.
3. The superior mesenteric artery is patent but demonstrates
significant
narrowing along the short segment just beyond the ostium
measuring
approximately 1 cm in length. Remaining major branches of the
abdominal aorta are widely patent.
4. There is no evidence of bowel ischemia.
5. 2.2 x 1.6 cm uterine fibroid.
Colonoscopy (___):
Polyp in the descending colon (polypectomy)
Mass in the distal transverse colon (biopsy, injection)
Polyp in the transverse colon (polypectomy)
Anatomy consistent with an ileocolonic anastomosis
Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to ileum
CT chest without contrast (___):
1. No pulmonary opacities concerning for metastasis. Evidence
of prior
radiation therapy.
2. Mild atherosclerotic disease in the aorta and coronary
arteries.
3. Degenerative changes within the thoracic spine.
4. A low left axillary lymph node with no fatty hilus adjacent
to the
intercostal muscles measures 8 mm in the short axis. Left
axillary ultrasound should be considered for further evaluation.
Brief Hospital Course:
Ms. ___ is a ___ with history of diverticulosis, colonic
polyps, idiopathic cecal rupture status post cecectomy, and
breast cancer with multiple recurrences who presented with
bright red blood per rectum and was found to have a transverse
colonic mass on colonoscopy highly concerning for malignancy.
Active Issues:
# Bright red blood per rectum/transverse colonic mass: On
presentation to the ED, she was found to be hemodynamically
stable with hematocrit of 46.6, up from recent baseline of 41 to
42, perhaps reflecting mild hemoconcentration. Rectal exam was
notable for guaiac positive brown stool in the rectal vault. CTA
abdomen/pelvis with contrast revealed an apple core mass in the
distal transverse colon spanning 3cm concerning for malignancy
along with enlarged mesenteric lymph nodes. She underwent
colonoscopy the following day, revealing a bleeding transverse
colonic mass that was biopsied, as well as multiple polyps that
were resected. She was evaluated by the colorectal surgery
service, with close follow up for further discussion of surgical
options advised. Chest CT for staging purposes was negative for
metastatic lesions, and CEA was 2.6. She remained
hemodynamically stable with hematocrit of 37.1 at discharge, and
home omeprazole was continued. Her primary care provider and
oncologist were notified of her admission by email, and close
follow up with both is anticipated. She likely will require
repeat colonoscopy postoperatively in the setting of inadequate
preparation.
Inactive Issues:
# Hypertension: Home metoprolol was held throughout admission
and at discharge, given bleeding colonic mass.
# Hyperlipidemia: Home pravastatin was continued.
# Neuropathic pain: Home gabapentin was continued.
Transitional Issues:
* Close oncology, colorectal surgery, and primary care follow up
is advised.
* She likely will require repeat colonoscopy postoperatively in
the setting of inadequate preparation.
* A left axillary lymph node adjacent to the intercostal muscles
measuring 8 mm in the short axis was found incidentally on chest
CT for staging purposes, with left axillary ultrasound advised
for further evaluation.
* Home metoprolol succinate was held at discharge in the setting
of stable vital signs, given concern for recurrent
gastrointestinal bleed, and may be resumed in the outpatient
setting at the discretion of her primary care provider.
* Pending studies: Transverse colonic mass and polyp pathology
(___).
* Code status: DNR/DNI (willing to be intubated for procedure).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO QHS:PRN pain
2. Gabapentin 100 mg PO HS
3. Omeprazole 20 mg PO DAILY
4. Pravastatin 40 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. hydrocorTISone Valerate 0.2 % topical prn flares
7. Caltrate 600+D Plus Minerals
(
C
a
-___
600 mg - 400 unit tab oral daily
Discharge Medications:
1. Acetaminophen 1000 mg PO QHS:PRN pain
2. Gabapentin 100 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Caltrate 600+D Plus Minerals
(
C
a
-___
600 mg - 400 unit tab oral daily
5. hydrocorTISone Valerate 0.2 % topical prn flares
6. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Transverse colon mass
Colonic polyps status post polypectomy
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 part in your care during your admission
to ___. As you know, you were
admitted after you experienced bloody stools. Unfortunately, CT
scan of your abdomen and colonoscopy revealed a mass in your
colon that is likely to be cancer; however, formal evaluation of
tissue samples obtained during colonoscopy remains in progress
at discharge. You were evaluated by the gastroenterologists and
the colorectal surgeons while in the hospital and were advised
to follow up closely with the surgeons for further discussion of
a surgical plan. It is also important that you follow up closely
with your primary care doctor and oncologist, both of whom were
notified of your admission to the hospital and findings on
colonoscopy, to review additional treatment.
It is important that you undergo surgery in the shortterm for
treatment of likely cancer and to prevent further bloody stools.
In the event that you experience blood stools prior to surgery,
it is important that you seek immediate medical attention to
ensure stable red blood cell count.
It was a pleasure caring for you.
Your ___ Care Team
Followup Instructions:
___
|
10845916-DS-18
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DS
| 18 |
2183-01-16 00:00:00
|
2183-01-16 14:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
bacitracin / nickel / adhesive
Attending: ___.
Chief Complaint:
Nausea and Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ F with history of laparoscopic transverse
colectomy ___, Dr. ___ and multiple other abdominal
surgeries who presents with nausea and vomiting.
She reports that since last night she has had 7 episodes of
vomiting, initially they were NBNB but have become progressively
bilious. This was associated with progressively severe abdominal
pain. She also reports not passing gas or have any BM for the
past 2 days. She denies any episodes like this in the past. She
went to her PCP and was sent to our emergency department for
further evaluation. She denies fevers, chills, shortness of
breath, chest pain, or leg swelling.
In the ED she was tachycardic to the 110s but normotensive. She
received fluids with some response. She got morphine and Zofran
which helped with her nausea and pain. She has not vomited for
the past 4 hours. Her labs were notable for WBC of 5.9, Cr 0.9
and Plt of 256. LFTs were within normal limits and lipase was
53.
CT scan revealed findings consistent with an SBO and transition
point in the left lower quadrant.
Past Medical History:
Diverticulosis
Colonic polyps
Idiopathic cecal rupture status post cecectomy
Breast cancer with multiple recurrences status post lumpectomy
x2, chemoradiation therapy, and bilateral mastectomy with
reconstruction
Pneumococcal meningitis in ___
Unexplained tachycardia
Hypertension
Hyperlipidemia
Graves disease
Gastroesophageal reflux/peptic ulcer disease
Osteoarthritis
Actinic keratosis
Endometrial polyps
Social History:
___
Family History:
Father, deceased, with prostate cancer and hypertension. Mother,
deceased, with arthritis, diabetes mellitus, and stroke.
Paternal aunt, deceased, with breast cancer. Paternal
grandmother, deceased, with colon cancer.
Physical Exam:
DISCHARGE PHYSICAL EXAM:
Gen: NAD, AxOx3,
Card: RRR
Pulm: no respiratory distress
Abd: Soft, non-tender, non-distended, no rebound, no guarding,
Wounds: c/d/i
Ext: No edema, warm well-perfused
Pertinent Results:
___ 12:30PM BLOOD WBC-5.9 RBC-4.80 Hgb-15.1 Hct-46.6*
MCV-97 MCH-31.5 MCHC-32.4 RDW-13.9 RDWSD-49.4* Plt ___
___ 07:13AM BLOOD WBC-7.0 RBC-4.06 Hgb-12.8 Hct-40.1
MCV-99* MCH-31.5 MCHC-31.9* RDW-14.4 RDWSD-52.3* Plt ___
___ 12:30PM BLOOD Glucose-141* UreaN-19 Creat-0.9 Na-143
K-4.2 Cl-103 HCO3-22 AnGap-18
___ 07:13AM BLOOD Glucose-126* UreaN-16 Creat-0.8 Na-144
K-4.0 Cl-105 HCO3-25 AnGap-14
___ 12:30PM BLOOD Albumin-4.3 Calcium-9.6 Phos-3.0 Mg-1.7
___ 12:30PM BLOOD ALT-22 AST-30 AlkPhos-91 TotBili-0.5
RADIOLOGY:
___, CTAP:
IMPRESSION:
Small-bowel obstruction with narrow zone of transition in the
left lower
pelvis. At the level of obstruction, the wall of the small
bowel is thickened
which is consistent with a component of enteritis. Recommend
clinical
correlation.
Brief Hospital Course:
Ms. ___ was admitted on ___ with abdominal pain, nausea and
vomiting and was found to have a small bowel obstruction on CTAP
with a transition point in the LLQ. Due to persistent emesis and
NGT was placed and she was made NPO with IVF fluid
rescucitation. On ___ her exam was improving and she started
passing gas. On ___ her NGT output had decreased, her exam
improved and she had a bowel movement. Her NGT was discontinued
at that time and her diet was advanced which she tolerated well.
On ___ she continued to tolerate a regular diet and her home
medications were restarted. Given improving exam she was
discharged home on a regular diet, voiding spontaneously and
ambulating independently. All questions were answered to her
satisfaction.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Pravastatin 40 mg PO QPM
2. Hydroxychloroquine Sulfate 200 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation
inhalation DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
3. Hydroxychloroquine Sulfate 200 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Pravastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
1. Small bowel obstruction
2. Asthma
3. Dermatitis, unspecified type
4. History of colorectal cancer
5. Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the ___
with nausea and vomiting. You were found to have a small bowel
obstruction. This was managed conservatively and appears to have
since resolved. You are tolerating a normal diet and are now
considered ready for discharge. Bowel obstructions may recur
and are associated with your history of abdominal surgeries. Be
on the look out for similar symptoms in the future which include
worsening abdominal pain, distension , nausea, vomiting, failure
to pass gas or have bowel movements. Feel free to call your
primary care provider or visit the Emergency Department if any
of these symptoms happen again. It was a pleasure taking care of
you!
Followup Instructions:
___
|
10846062-DS-7
| 10,846,062 | 26,981,322 |
DS
| 7 |
2141-01-03 00:00:00
|
2141-01-03 16:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hiccups
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH IDDM, PAD s/p R BKA, HTN, afib on Xarelto, CKD stage
III,
HLD, h/o DVTs/PE, aortic stenosis p/w intractable hiccups a/w
nausea, NBNB vomiting, loose stools. Pt has been admitted for
similar intractable hiccups twice since ___, though at those
times the sx were also associated with coffee ground emesis and
melena. EGD at the time showed esophagitis with no evidence of
active bleeding; colonoscopy showed polyps which were removed.
Pt
reports that since his last workup in ___, he has not had
sx.
However 4 days PTA hiccups resumed initially after eating
dinner.
He states that typically he would then feel nausea and have NBNB
emesis through the night. Pt has also been having loose green
stools. On day of admission, pt began having hiccups and emesis
without provoking food, so he came to the ED after calling his
PCP. Pt now afraid of re-initiating PO intake for fear of
provoking further emesis. No onset noted, no
palliating/provoking
factors. Denies hematemesis, hematochezia, melena, fatigue,
weight loss, fevers, chills, night sweats, chest pain, SOB. No
recent travel.
In the ED:
- VS: T97.0 BP 132/75 HR 71 RR 18 O2 Sat 100% RA FSG 65
- Exam: still hiccuping, exam otherwise stable
- Labs: K 3.4, lipase 123, first trop @ 2pm negative, guiaic
negative
- Studies: CXR prominent soft tissue density in the subcarinal
region, possibly normal but Radiology rec for repeat CXR PA/L or
chest CT. EKG with afib but otherwise unchanged from previous
- Interventions: ___ amp D50 given for FSG 65, repeat FSG 147.
FSG later again dropped to 42, additional ___ amp D50 given with
juice and crackers. Started on D51/2NS with 20mEq KCl for
repletion. Got Reglan PO x1.
VS on transfer: T97.4 BP 144/77 HR 67 RR 18 O2 Sat 99% RA
Upon arrival to the floor, pt was stable and in NAD.
REVIEW OF SYSTEMS:
Complete ROS obtained and is otherwise negative.
Past Medical History:
- IDDM
- PAD s/p R BKA ___
- HTN
- Afib on Xarelto
- CKD stage III
- HLD
- Aortic stenosis
- L common carotid stenosis 40-59%
- h/o DVTs/PE post-surgery ___
- h/o GI bleeds ___ with EGD with esophagitis, colonoscopy with
polyps (removed), no sign of active bleeding
Social History:
___
Family History:
- Mother died of cancer in late ___/early ___.
- Father died in ___, unknown cause.
- 5 brothers. Oldest brother passed away of CAD. Younger brother
passed away from unspecified infectious disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: T97.0 BP 132/75 HR 71 RR 18 O2 Sat 100% RA FSG 65
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
CARDIAC: Irregularly irregular 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: R BKA
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. Strength grossly intact. AOx3.
DISCHARGE PHYSICAL EXAM:
========================
___ ___ Temp: 98.0 PO BP: 143/73 HR: 76 RR: 18 O2 sat:
99% O2 delivery: Ra FSBG: 70 GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
Pertinent Results:
ADMISSION LABS:
==============
___ 02:32PM BLOOD WBC-5.8 RBC-4.66 Hgb-11.2* Hct-35.3*
MCV-76* MCH-24.0* MCHC-31.7* RDW-18.9* RDWSD-51.6* Plt ___
___ 02:32PM BLOOD Neuts-58.8 ___ Monos-9.5 Eos-0.7*
Baso-0.7 Im ___ AbsNeut-3.40 AbsLymp-1.74 AbsMono-0.55
AbsEos-0.04 AbsBaso-0.04
___ 02:32PM BLOOD ___ PTT-28.8 ___
___ 02:32PM BLOOD Glucose-115* UreaN-25* Creat-1.6* Na-140
K-3.4* Cl-102 HCO3-23 AnGap-15
___ 02:32PM BLOOD ALT-12 AST-17 AlkPhos-115 TotBili-0.5
___ 02:32PM BLOOD Lipase-123*
___ 02:32PM BLOOD cTropnT-<0.01
___ 02:32PM BLOOD Albumin-3.8
___ 02:30PM BLOOD Lactate-1.6
DISCHARGE LABS:
=-=============
___ 07:45AM BLOOD WBC-6.1 RBC-4.89 Hgb-11.6* Hct-37.2*
MCV-76* MCH-23.7* MCHC-31.2* RDW-18.9* RDWSD-51.8* Plt ___
___ 07:45AM BLOOD Plt ___
___ 07:45AM BLOOD Glucose-72 UreaN-17 Creat-1.3* Na-143
K-3.6 Cl-103 HCO3-26 AnGap-14
___ 02:32PM BLOOD ALT-12 AST-17 AlkPhos-115 TotBili-0.5
STUDIES/REPORTS:
===============
___
EKG r 77 PR 219 QRS 102 QT 434 P ___
CXR IMPRESSION:
Prominence soft tissue density in the subcarinal region,
potentially normal
structures accentuated by low lung volumes however, repeat with
PA technique
and better inspiration versus chest CT is suggested to further
clarify.
___
REPEAT CXR IMPRESSION:
No evidence of acute cardiopulmonary disease.
Brief Hospital Course:
Mr. ___ is a ___ with PMHx notable for IDDM, PAD s/p R BKA,
HTN, afib on Xarelto, CKD stage III, HLD, h/o DVTs/PE, aortic
stenosis who was admitted with persistent hiccups and associated
vomiting and loose stool, also found to have hypoglycemia in the
setting of poor PO intake and taking his insulin regimen.
He was previously admitted for similar persistent hiccups
lasting days twice since ___, though at those times his
hiccups were associated with coffee ground emesis and melena.
EGD at the time showed esophagitis with no evidence of active
bleeding; colonoscopy showed polyps which were removed.
Regarding his current symptoms, hiccups started 4 days PTA with
associated vomiting. He was given reglan with resolution of
hiccups by hospital day one and was then tolerating PO. His
hypoglycemia resolved once patient was maintaining adequate PO.
Etiology of hiccups currently unclear but did not find clear
provoking factors. Patient discharged with short course of PO
reglan and was instructed to follow up with his primary care
physician and gastroenterology if symptoms recur.
TRANSITIONAL ISSUES:
====================
- CXR initially showed subcarinal prominent soft tissue density,
potentially normal structures accentuated by low lung volumes.
Repeat with PA technique
and better inspiration was normal. Would consider CT torso to
eval for potential anatomic etiologies of hiccups if hiccups
persist.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Metoprolol Tartrate 25 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO BID
4. amLODIPine 10 mg PO DAILY
5. Rivaroxaban 20 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Pantoprazole 40 mg PO Q12H
8. Tamsulosin 0.4 mg PO QHS
9. Tresiba 22 Units Breakfast
Discharge Medications:
1. Glucose Gel 15 g PO PRN hypoglycemia protocol
RX *dextrose 15 gram/33 gram 1 gel(s) by mouth as needed for
blood sugar <50 Disp #*10 Packet Refills:*0
2. Metoclopramide 10 mg PO ONCE MR1 Duration: 1 Dose
RX *metoclopramide HCl 10 mg 1 tablet on tongue every 6 hours as
needed for hiccups or nausea Disp #*10 Tablet Refills:*0
3. amLODIPine 10 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Tresiba 22 Units Breakfast
6. Lisinopril 40 mg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Metoprolol Tartrate 25 mg PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Rivaroxaban 20 mg PO DAILY
11. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
#Hiccups
#Hypoglycemia in setting of diabetes mellitus
#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 caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had bad hiccups and your blood sugar was low.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given medication called reglan and your hiccups
stopped. Your blood sugar improved once you were able to eat.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please call your primary care doctor's office on ___ to
make a follow up appointment after your hospitalization.
- If you feel hiccups coming on, you can try a dose of the
reglan. We sent you home with a short course of this
medication. You can dissolve this on your tongue.
- If you feel your blood sugar is too low (~50-60) and you are
unable to eat or drink, please use the glucose gel under your
tongue to make sure your glucose isn't too low.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10846520-DS-21
| 10,846,520 | 26,936,492 |
DS
| 21 |
2138-08-24 00:00:00
|
2138-08-26 07:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Botox / Dilaudid / doxycycline / iodine / Lyrica / morphine /
Penicillins / shellfish derived / Sulfa (Sulfonamide
Antibiotics)
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female presenting with worsening of chronic back
pain that started after her RIDE car went over a bump 2 days
ago. She had a rhizotomy earlier that day. Reports multiple
falls recently and was told by her orthopedist that she would
need to have "one big fall where you break your femur" before
anyone could do anything for her.
Also with one week of constipation. Usually improves with
lactulose, but lactulose gives her horrible cramps.
In ED, initial Vitals: pain:9 97.6 76 139/84 18 96%. She had a
CT lumbar spine that showed No evidence of fracture. Mild
anterolisthesis of L4 on L5, likely degenerative causing
moderate canal stenosis at L4-5. X-ray Hip showed Severe right
hip osteoarthritis. No acute fracture or dislocation and Xray
Pelvis showed right hip osteoarthritis. No acute fracture or
dislocation.
They attempted to discharge her to rehab but she declined
several rehabs.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. No recent change in bowel or bladder
habits. No dysuria. Denies arthralgias or myalgias. Ten point
review of systems is otherwise negative.
Past Medical History:
Chronic regional pain syndrome (LUE)/ RSD
Chronic back pain
Chronic constipation
Social History:
___
Family History:
Father died on hospice in the past year.
Physical Exam:
Admission:
Vitals: 98.6, 151/98, 94, 20, 96%RA
Gen: Appears comfortable, seated in bed with legs crossed
HEENT: poor dentition, mmm
CV:RRR no mgr
Pulm: CTAB
Abd: soft, NT/ND, BS+
Extrem: warm, no edema
GU: no foley
Skin: no rash
Neuro: A+Ox3, speech fluent, ___ strength in bilat ___,
contractures in L hand, full ROM in R
Discharge (exam from prior date, she refused discharge
examination):
AVSS
Appears comfortable. Sitting in bed.
Warm well perfused.
Able to stand and pivot from bed to commode. ___ strength in
left leg. Sensation exam intact (although patient with
subjective complaints of sensation change). Right leg with 4+/5
weakness throughout. Chronic.
Pertinent Results:
___ 02:25PM BLOOD WBC-9.1 RBC-4.10* Hgb-12.4 Hct-39.1
MCV-95 MCH-30.2 MCHC-31.7 RDW-13.3 Plt ___
___ 02:25PM BLOOD Neuts-69.4 ___ Monos-3.3 Eos-0.9
Baso-0.8
___ 02:25PM BLOOD Glucose-94 UreaN-21* Creat-0.8 Na-144
K-4.0 Cl-106 HCO3-27 AnGap-15
CT L SPINE
1. No evidence of acute fracture.
2. Mild grade 1 anterolisthesis of L4 on L5, likely
degenerative, causing
moderate central canal stenosis.
R HIP XRAY
Severe right hip osteoarthritis. No acute fracture or
dislocation.
Brief Hospital Course:
___ with RSD, chronic pain, wheelchair bound who presents with
low back pain.
# Low back pain:
The history regarding her traumatic events has changed multiple
occassions so the inciting event is not clear. She is consistent
that she states the RIDE got into an accident. She initially
stated this was due to a bump, then a pothole, then an open
manhole cover with the vehicle going onto two wheels and
violently slamming to the ground. She states that she did not
have pain initially, but only a few days later. The pain was in
her lower back and involved her left leg. She has been getting
physical therapy and seeing a pain specialist for her back and
legs and made some progress (although she states the last time
she could use a supportive walker is >5 months ago and she has
been restricted to a wheelchair since that time; she reports
this decompensation is secondary to multiple "the RIDE"
accidents for which she is actively suing the ___).
She had paraspinal muscle tenderness and subjective weakness and
sensation deficit. However, stength examination and sensory
examination were preserved in the locations she noted weakness.
She had x-ray and CT imaging in the ED and they were comfortable
sending her to rehab from the ED. However, the patient, per
report, refused. Thus they admitted her to medicine.
On medicine, physical exam was stable and consistent throughout
her stay. She always appeared comfortable in lying, sitting or
standing positions despite stating she was in significant pain.
She was evaluated by physical therapy and chronic pain service.
In addition, her outpatient providers were contacted, and it
appears that she is at her functional baseline. ___ recommended
___ rehabilitation vs outpatient rehabilitation with
supervision given she was sometimes unsteady during transfers.
Of note, she was observed by staff transferring to the commode
by herself. It was felt that no change in her outpatient pain
regimen was reasonable at this time and that she should work to
wean herself off of narcotics in the future. The reasonable next
step in her symptoms, was to undergo a course of rehabilitation
and defer further imaging unless if her symptoms were worsening
or did not resolve with rehabilitation (for which the patient
and outpatient providers and inpatient providers agreed with).
She was admitted under observation custodial care. Given this,
under medicare, she did not qualify for ___ rehab. She was
screened by acute rehab but did not qualify. She refused
___ screening. She was also screened under an
auto insurance claim but was declined by multiple rehab groups.
Given this, ___ rehabilitation was not an option. We were
concerned that her home living situation was not optimal (of
note, this has been not optimal for a long time, her outpatient
case manager noted that it was since at least ___ that she
has recommended a new apartment due to her mobility
limitations). The patient refuses to find a new apartment. She
refuses to let ___, physical therapy into her home and recently
fired an aide. Given this, we recommended alternative options
such as a respite home, living with her significant other,
staying at a shelter, having her children help. She refused all
of these options. The only option left was to discharge to her
apartment with maximizing services ___, social work, physical
therapy -- were being arranged at time of discharge) and
recommend 24 hour supervision. In addition, ___
___ saw the patient to provide support to her
home situation.
Multiple team meetings were held and legal was consulted. There
were no other available options that the patient would accept.
Thus she was discharged home with recommendation of 24 hour
supervision and maximization of resources. She was, per her
report, met at home by her significant other. She refused chair
car home and preferred taxi voucher instead.
# Psychiatric:
She has a number of psychiatric issues which may be barriers to
her receiving optimal care. She has PTSD, anxiety and other
issues that are being treated by an outpatient psychiatrist. She
has poor coping mechanisms. However, she eventually would think
issues through and was deemed by providers to have capacity. She
did threaten on 1 occasion to throw herself down the stairs. She
was evaluated by psychiatry and stated her goal was to
manipulate the system so she could get into rehab. They felt, as
do I, that she had no active SI, HI or other acute psychiatric
condition that would necessitate involuntary admission. That
being said, I do think she needs very close psychiatric follow
up for her chronic psychiatric conditions.
Of note, she asked to be transferred to ___. We
contacted both ___ group as well as her
orthopedic surgeon who did not accept transfer (given no
___ hospital need).
Also of note, she refused to leave the hospital Medicare appeal
process was completed and she was denied. After this, she was
notified that there were no further options and that we would
have to discharge her home with home services and she further
refused to leave the hospital but refused any further nursing or
doctor care. The following day she accepted discharge home. She
refused to accept any paperwork or listen to discharge
instructions (including warning symptoms for which to seek
immediate medical care). She was aware that if her symptoms
worsen or do not resolve with physical therapy further
evaluation will be necessary.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. celecoxib 200 mg oral bid
2. CloniDINE 0.2 mg PO 5X/DAY
3. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
4. Citalopram 20 mg PO DAILY
5. esomeprazole magnesium 40 mg oral daily
6. FoLIC Acid 1 mg PO DAILY
7. Lactulose 30 mL PO TID
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Loratadine 10 mg PO DAILY
10. Lorazepam 0.5 mg PO BID
11. Mupirocin Ointment 2% 1 Appl TP TID:PRN rash
12. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
13. Potassium Chloride 10 mEq PO BID
14. Prazosin 2 mg PO DAILY
15. rizatriptan 10 mg oral daily
Discharge Medications:
1. celecoxib 200 mg ORAL BID:PRN pain
2. CloniDINE 0.2 mg PO 5X/DAY
3. Escitalopram Oxalate 40 mg PO DAILY
4. esomeprazole magnesium 40 mg oral daily
5. FoLIC Acid 1 mg PO DAILY
6. Lactulose 30 mL PO TID
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Loratadine 10 mg PO DAILY
9. Lorazepam 0.5 mg PO BID
10. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
11. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
12. Prazosin 2 mg PO DAILY
13. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
14. Mupirocin Ointment 2% 1 Appl TP TID:PRN rash
15. Potassium Chloride 10 mEq PO BID
16. rizatriptan 10 mg oral daily
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Low back pain
Leg pain
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted with back and leg pain. You were evaluated and
had multiple imaging studies which did not show any acute
process (such as fracture). We recommended physical therapy as
the next step in treatment prior to any further interventions or
imaging. The evaluation and findings indicated you were not
qualified for ___ rehabilitation. Given this, we recommend
24 hour supervision with outpatient rehabilitation and visiting
nurses. ___ cannot provide you with 24 hour care; however, we are
arranging for visiting nurses, physical therapy, and social work
to come to your home (awaiting insurance verification). You will
need to be followed closely by your outpatient providers to make
sure you symptoms improve with rehabilitation. If they do not
improve you may need further evaluation or management (which
should be decided by your outpatient physicians that know you
well).
No changes were made to you home regimen.
It is reasonable to get a "life alert" bracelet. This can be
arranged by your visiting nurse.
Followup Instructions:
___
|
10846692-DS-18
| 10,846,692 | 22,916,492 |
DS
| 18 |
2168-08-16 00:00:00
|
2168-08-16 19:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Concern for Acute Leukemia
Major Surgical or Invasive Procedure:
___ Biopsy ___
History of Present Illness:
Mr. ___ is a ___ male with no significant past
medical history who presents with concern for acute leukemia.
Patient reports multiple symptoms over the past 7 days including
fatigue, fever with chills, night sweats, headaches, chest pain
with palpitations, abdominal pain, sneezing with associated
shortness of breath, and poor appetite. He has been taking
Aleve.
He went to urgent care and was noted to have multiple lab
abnormalities concerning for acute leukemia so was referred to
the ___ ED.
On arrival to the ED, initial vitals were 98.7 87 146/87 17 100%
RA. No exam documented. Labs were notable for WBC 143.2, H/H
9.1/28.0, Plt 104, INR 1.4, fibrinogen 488, Na 144, K 4.3,
BUN/Cr
___, Tbili 5.3, Dbili 4.7, uric acid 9.0, LDH 1333, hapto
119,
trop 0.08, and UA with mod leuks, neg nitrite, 29 WBCs, and few
bacteria. CT head negative for acute process. RUQ ultrasound
with
cholelithiasis, splenomegaly, and prominent periportal lymph
nodes. Patient was given unasyn 3g IV, allopurinol ___ PO,
hydrea 1500mg PO, and 1L NS. ___ was consulted and recommended
admission. Prior to transfer vitals were 97.8 67 146/77 16 99%
RA.
On arrival to the floor, patient reports feeling better. He
denies current chest or abdominal pain. His breathing is better.
He denies vision changes, dizziness/lightheadedness,
weakness/numbness, cough, hemoptysis, nausea/vomiting, diarrhea,
hematemesis, hematochezia/melena, dysuria, hematuria, and new
rashes.
Past Medical History:
- Bladder Outlet Obstruction s/p TURP
- Glaucoma
Social History:
___
Family History:
No family history of malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 98.1, BP 129/77, HR 77, RR 20, O2 sat 100% RA.
GENERAL: Pleasant man, in no distress, lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, RUQ tenderness to palpation without rebound or
guarding, non-distended, positive bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
DISCHARGE PHYSICAL EXAM:
VS: Temp 98.3 BP 156//84 HR 75 RR 19 100 O2 Sat on RA
Gen: Pleasant, NAD lying in bed
Head/Eyes: Anicteric, EOMI.
ENT: Supple, nontender.
CV: NR, RR. Nl S1, S2, no m/r/g, no pain to palpation of chest
wall
Resp: Bibasilar crackles, no wheezes, rhonchi.
GI: Soft without tenderness, nondistended, no rebound/guarding.
Liver enlarged.
Msk: trace ___ edema.
Skin: No rash, lesions.
EXT: Right arm with no tenderness to palpation. PIC line sight
appears well healing without erythema or tenderness.
Neuro: AOx3. CN II-XII intact. No focal neurologic signs.
Strength and sensation equal and intact bilaterally.
Pertinent Results:
ADMISSION LABS
==============
___ 07:45PM BLOOD WBC-143.2* RBC-3.55* Hgb-9.1* Hct-28.0*
MCV-79* MCH-25.6* MCHC-32.5 RDW-15.4 RDWSD-42.2 Plt ___
___ 07:45PM BLOOD Neuts-8* Bands-1 Lymphs-89* Monos-0 Eos-0
Baso-0 ___ Metas-1* Myelos-1* NRBC-5* Other-0 AbsNeut-12.89*
AbsLymp-127.45* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 07:45PM BLOOD Hypochr-1+* Anisocy-1+* Poiklo-1+*
Macrocy-NORMAL Microcy-2+* Polychr-OCCASIONAL Ovalocy-1+*
Target-1+* Pencil-1+* Tear Dr-1+* Ellipto-1+*
___ 11:00PM BLOOD ___ PTT-26.5 ___
___ 07:45PM BLOOD ___
___ 07:45PM BLOOD Ret Aut-2.9* Abs Ret-0.11*
___ 07:45PM BLOOD Glucose-86 UreaN-29* Creat-1.3* Na-144
K-4.3 Cl-105 HCO3-23 AnGap-16
___ 07:45PM BLOOD ALT-26 AST-63* LD(LDH)-1333* AlkPhos-352*
TotBili-5.3* DirBili-4.7* IndBili-0.6
___ 07:45PM BLOOD cTropnT-0.08*
___ 07:45PM BLOOD Albumin-3.2* Calcium-9.1 Phos-3.4 Mg-2.1
UricAcd-9.0*
___ 07:45PM BLOOD Hapto-119
___ 07:45PM BLOOD HBsAg-POS* HBsAb-NEG HBcAb-POS*
___ 07:45PM BLOOD HCV VL-NOT DETECT
___ 07:45PM BLOOD HCV Ab-NEG
___ 03:45AM BLOOD HBV VL-1.9*
___ 04:09AM BLOOD ___ Temp-39.2 pO2-67* pCO2-48*
pH-7.29* calTCO2-24 Base XS--3 Intubat-NOT INTUBA Comment-GREEN
TOP
___ 04:09AM BLOOD Lactate-4.3*
DISCHARGE LABS
==============
___ 06:15AM BLOOD WBC-3.2* RBC-3.10* Hgb-8.2* Hct-26.2*
MCV-85 MCH-26.5 MCHC-31.3* RDW-22.3* RDWSD-66.4* Plt ___
___ 06:15AM BLOOD Neuts-40 Bands-1 ___ Monos-7 Eos-2
Baso-0 ___ Myelos-0 AbsNeut-1.31* AbsLymp-1.60
AbsMono-0.22 AbsEos-0.06 AbsBaso-0.00*
___ 06:15AM BLOOD Glucose-91 UreaN-13 Creat-0.6 Na-144
K-4.5 Cl-106 HCO3-25 AnGap-13
___ 06:15AM BLOOD ALT-26 AST-18 LD(LDH)-348* AlkPhos-80
TotBili-0.6
___ 01:40PM BLOOD CMV VL-2.9*
___ 03:05PM BLOOD HBV VL-2.0*
___ 12:00AM BLOOD CMV VL-2.6*
___ 12:30PM BLOOD CMV VL-2.4*
___ 12:56 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool. FEC,CCU,ROE ADDED ON ___ AT 1850.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___ 21:00
___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay. (Reference
Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
STUDIES
=======
RUQUS ___
1. Cholelithiasis without evidence of acute cholecystitis.
2. Multiple prominent periportal lymph nodes are nonspecific,
however could be related to patient's acute presentation.
3. Splenomegaly, with spleen measuring 17.7 cm.
CT HEAD NONCON ___
No acute intracranial process. Please note that MRI is more
sensitive in
detecting small intracranial lesions.
CT TORSO W CONTRAST ___
No evidence of intrathoracic malignancy.
Evidence of previous granulomatous exposure
Cardiomegaly
Small bilateral pleural effusion.
1. Hepatosplenomegaly, with multiple splenic infarcts. Enlarged
portocaval lymph node measures 2.3 cm. No additional enlarged
abdominal or pelvic lymph nodes identified.
2. Mild haziness of the mesentery, subcutaneous edema, and
pleural effusions, all of which likely relate to generalized
edema/third-spacing of fluid.
3. Small stone in the cystic duct without gallbladder distention
or findings of acute cholecystitis.
___ Imaging CHEST PORT. LINE PLACEM
Interval placement of a right PICC which ends in the mid to low
SVC.
TTE ___
The left atrial volume index is normal. There is normal left
ventricular wall thickness with a normal cavity size.
There is normal regional left ventricular systolic function. The
visually estimated left ventricular ejection
fraction is 65%. There is no resting left ventricular outflow
tract gradient. Mildly dilated right ventricular cavity
with normal free wall motion. 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 to moderate [___]
mitral regurgitation. The tricuspid valve
leaflets appear structurally normal. There is mild [1+]
tricuspid regurgitation. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
___ Imaging CTA CHEST
1. No evidence of pulmonary embolism or aortic abnormality.
2. Worsening bilateral moderate pleural effusions with
overlying atelectasis.
No focal consolidation identified.
___ Imaging LIVER OR GALLBLADDER US
1. Cholelithiasis. No sonographic evidence to suggest acute
cholecystitis.
No extrahepatic biliary dilation.
2. Persistent marked splenomegaly with known splenic infarcts.
3. Small volume ascites and small right pleural effusion.
Patent portal vein
with hepatopetal flow.
5. 2.3-cm portocaval node as seen on CT.
6. 1.1-cm right hepatic hemangioma, unchanged from prior US.
___ Cardiovascular Transthoracic Echo Report
Preserved biventricular systolic function. Mild aortic, mitral,
and tricuspid regurgitation. Mild
pulmonary hypertension. Trivial pericardial effusion.
Compared with the prior TTE
___
, the severity of mitral regurgitation is now lower. The
pulmonary
pressure has mildly decreased. A trivial pericardial effusion is
now seen.
___ Imaging CT SINUS/MANDIBLE/MAXIL
1. Mild mucosal thickening of the right frontal ethmoidal recess
and of the
ethmoid air cells. There is mild mucosal thickening of the
maxillary sinuses
with small left greater than right mucous retention cysts in the
alveolar
recesses.
2. Partially opacified small Haller cells. Mild mucosal
thickening along the
ostium of the bilateral ostiomeatal infundibulum, which are
otherwise patent.
3. Right concha bullosa. Leftward deviation of the nasal septum
without
perforation.
4. Additional findings as described above.
___BD & PELVIS WITH CO
1. Multiple wedge-shaped splenic hypodensities without
associated peripheral
hyperemia or internal locules of air, unchanged from prior.
2. No findings identified to suggest colitis. No enhancing
abdominal or
pelvic collections identified to suggest abscess formation.
3. Mild interval increase in small bilateral pleural effusions.
___ Imaging UNILAT UP EXT VEINS US
Nonocclusive venous thrombus in the right axillary and proximal
brachial
veins, as well as the distal basilic vein. Mid and proximal
portions of the
right basilic vein were not visualized secondary to overlying
bandaging.
___ 10:30 am MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Pending):
__________________________________________________________
___ 10:42 am URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
__________________________________________________________
___ 12:37 am BLOOD CULTURE Source: Line-picc.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 2:40 pm STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
__________________________________________________________
___ 2:35 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 12:30 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-PICC.
BLOOD/FUNGAL CULTURE (Pending):
BLOOD/AFB CULTURE (Pending):
__________________________________________________________
___ 5:27 am BLOOD CULTURE Source: Line-PICC.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 6:30 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 1:20 am BLOOD CULTURE Source: Line-picc.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 1:39 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Preliminary): No growth to date.
__________________________________________________________
___ 1:39 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 2:50 pm SPUTUM Site: INDUCED Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
MTB Direct Amplification (Final ___:
M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: A negative NAAT
cannot rule
out TB or other mycobacterial infection.
.
NAAT results will be followed by confirmatory testing with
conventional culture and DST methods. This TB NAAT method
has not
been approved by FDA for clinical diagnostic purposes.
However, this
laboratory has established assay performance by in-house
validation
in accordance with ___ standards.
.
Test done at ___ Mycobacteriology
Laboratory..
__________________________________________________________
___ 6:40 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:10 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
Mr. ___ is a ___ year-old male with no significant PMH,
presenting with atypical CLL vs splenic marginal zone lymphoma
s/p bendamustine therapy with hospital course complicated by
fevers.
ACUTE ISSUES
============
# Atypical CLL
Admitted due to leukocytosis with hematologic abnormalities most
concerning for acute leukemia. Bone marrow biopsy performed, and
after further review of peripheral smear and BM diagnosis most
consistent with Atypical CLL v. Leukemic Splenic Marginal Zone
Lymphoma. In preparation for chemo, parasite smear negative x3.
TTE nl. Anaplasma negative, Lyme negative. Treated with prophase
dexamethasone x5 days (___). Started on Bendamustine
___, without Rituxan due to high white count. His counts were
stable at time of discharge.
# Cdiff Infection
# Fever of Unknown Origin:
Patient with persistent fevers since ___. Urinalysis
unremarkable x2. CXR without any focal consolidation x2. RUQ US
with cholelithiasis but no cause for infection or clot. TTE
without vegetations. CTA ___ without clot or pneumonia. CT
Abdomen/pelvis without focus for infection and CT sinuses
negative. No diarrhea. Workup notable for negative legionella,
parasite smear negative. CMV VL of 2.4, then 2.6, and then 2.9
on repeat testing. EBV negative, HIV negative, MRSA swab
negative, urine strep negative.
Patient was started on cefepime (___), vancmocyin
(___), and micafungin ___. On ___, a line
associated clot was found, and managed as below. However, he
continued to fever after this, without any clear source
identified. On ___ patient developed diarrhea, with Cdiff
testing positive. CT abd/pelvis was unremarkable. PO Vanc was
started, and at time of discharge patient's diarrhea was
improved and his fevers had resolved.
#. Line Associated Clot: Found by US on ___ near patients right
sided PICC line. PICC removed on ___ and started on Lovenox. A
repeat U/S on ___ indicated resolution of the clot and thus
anticoagulation was discontinued.
# volume overload:
The patient received 10mg IV Lasix PRN with adequate output.
Likely iatrogenic
and from increased third spacing. He had no further problems
with fluids.
# Abdominal Pain
# Direct Hyperbilirubinemia
# Hepatitis B
Patient with epigastric burning which seemed most likely related
to reflux. Lipase within normal limits so pancreatitis less
likely. The patient had right upper quadrant ultrasounds on
___ and ___ which showed cholelithiasis. Had evidence of
ongoing chronic Hep B infection. Reported history of needlestick
and being treated for Hep B in the past and he was under the
impression he had been cured. Bilirubin drastically improved
with steroids, therefore likely a component of
hyperbilirubinemia due to involvement by malignancy. Hepatology
consulted. Hepatitis Be Antibody reactive but hep B E Ab IgG and
IgM non reactive. Started Entecavir with plan for patient to
follow up in outpatient clinic with twice weekly LFTs and once a
week HBV VL.
# Indirect Hyperbilirubinemia
# Hemolytic Anemia
Large indirect component of hyperbilirubinemia with haptoglobin
< 10. No evidence of coagulation abnormalities or falling
platelets to suggest TTP or DIC. DAT negative. Indirect
bilirubin downtrended over admission.
# Prior Granulomatous Disease
CT torso noted calcified lymph nodes. He patient is from
high-risk area in ___ but no recent travel outside of the
country. No previous known history of TB. 3x sputum & NAT
negative. Quant gold was indeterminant so will need further
evaluation for latent TB. Per ID, started Isoniazid + Pyridoxine
treatment on ___ as his LFTs had improved with plan to continue
for 9 months.
# Sinus Bradycardia/ AVNRT
Noted to be bradycardic AM of ___ with unclear etiology but
thought to be due to dexamethasone as it has been shown to be
associated with bradycardia. No other new medications. No
chronotropic incompetence as heart rate increased with walking
around
unit. However, over admission, with increased HRs to 130s-150s,
up to 190s with evidence of AVNRT. Most tachycardia occurring in
the setting of fevers. Electrophysiology saw the patient and
initially recommended verapamil which was chaned to metoprolol
given potential interaction of rifampin and verapamil below. He
had no further episodes.
#Hypertension:
Patient with persistently elevated blood pressures likely due to
steroids. The patient was given diuresis and placed on
metoprolol as above.
# Chest pain, resolved:
Early in admission patient with elevated troponn to 0.21 but EKG
without ischemic changes. Likely troponin elevation secondary to
kidney dysfunction. Patient with chest pressure ___ and new O2
requirement. EKG unchanged and CK-MB and troponin are flat (trop
as high as .21 on ___. CTA ___ negative for PE but with
bilateral pleural effusions and no aortic abnormality. Most
likely combination of symptomatic AVNRT and GI symptoms.
CHRONIC ISSUES
==============
# Prerenal ___
Cr 1.3 on admission, unknown baseline. Improved after fluids.
# Anemia/Thrombocytopenia:
Likely due to chemotherapy and phlebotomy as well as infection
above. CBC was trended and patient was transfused as needed.
# Glaucoma
- Continued home eye drops
TRANSITIONAL ISSUES
===================
- Patient will require continued treatment for HBV with
entecavir
- Patient requires twice weekly LFTs and once a week HBV
- Patient needs to follow up with ID for CMV VL
- Patient will need to continue treatment with Isoniazid for 9
months
- Would benefit from Fibroscan as outpatient to quantify
cirrhosis.
- Consider EP study given bradycardia/AVNRT
# Code Status: Full
# Emergency Contact: Wife ___ (___)
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Timolol Maleate 0.5% 1 DROP BOTH EYES QAM
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
3. Naproxen 500 mg PO Q8H:PRN Pain - Moderate
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Entecavir 1 mg PO DAILY
RX *entecavir 1 mg 1 tablet(s) by mouth qday Disp #*30 Tablet
Refills:*0
3. Isoniazid ___ mg PO DAILY
RX *isoniazid ___ mg 1 tablet(s) by mouth qday Disp #*30 Tablet
Refills:*1
4. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Pyridoxine 50 mg PO DAILY
RX *pyridoxine (vitamin B6) 50 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*1
6. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day
Disp #*28 Capsule Refills:*0
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Timolol Maleate 0.5% 1 DROP BOTH EYES QAM
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Atypical CLL
Sinus Bradycardia
Hepatitis B, Chronic
Volume Overload
Fever
Sinus Bradycardia/ Atrioventricular nodal reentry tachycardia
Clostridium Difficile Infection
SECONDARY DIAGNOSES
===================
Prior Granulomatous Disease Exposure
Direct Hyperbilirubinemia
Hepatitis B
Acute Kidney Injury
Hypertension
Anemia/Thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had fevers and chills and had a very high white blood cell
count.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We did a bone marrow biopsy to look at your blood cells and
saw that you had a type of chronic leukemia.
- We gave you steroids and then started you on chemotherapy.
- We did a CT scan which showed evidence of an infection in the
past. You tested negative for acute TB.
- You had a low heart rate and a fast heart rate so we started
you on medications after having the cardiologists come see you
- You had fevers so we had the Infectious Disease doctors ___
___ and we placed you on antibiotics
- After you developed diarrhea, we found the source of your
infection and fevers, and placed you on the correct antibiotic
to treat the infection
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please follow up in bone marrow clinic as instructed
- Please follow up in the liver as instructed
- Please follow up in the infectious disease clinic as
instructed
- Please take your new medications as prescribed: Entecavir,
Metoprolol, Pyridoxine, Isoniazid, Vancomycin
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10846829-DS-14
| 10,846,829 | 21,447,426 |
DS
| 14 |
2161-10-21 00:00:00
|
2161-10-24 07:28:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
increased secretions
Major Surgical or Invasive Procedure:
Bedside PICC placement with adjustment by ___ ___
History of Present Illness:
___ yo M, with history of intraventricular hemorrhage in ___,
s/p tracheostomy and PEG placement, tCAD s/p MI ___, c/b CHB
s/p PPM, who presents from ___ with concern for PNA and
UTI. Patient is nonverbal at baseline, but has been noted to
have had increased secretions, cough, and increased work of
breathing for six days at ___. Of
note, patient had fever 101 which improved with Tylenol at
nursing home. Patient was started on Levaquin day prior but
symptoms worsened. No v/d. At ___-N had CXR with likely RUL
infiltrate and UA with negative nitrite, ___, 500 leukocyte
esterase, 2+ bacteria. He was therefore started on vancomycin
and Bactrim and given a 500cc bolus of fluids.
Of note, patient was treated in ___ for Influenza A infection
with associated bronchopneumonia and asthmatic bronchitis due to
MRSA infection at ___. Sputum culture was positive for
MRSA.
In the ED, initial vitals:
97.7, 101, 153/85, 22, 97% RA
Initial labs were concerning for wbc 18.7 (N86.9%), h/h 10.4/29,
and creatinine 1.4.
In the ED, patient was given 4.5g Piperacillin-Tazobactam.
On transfer, vitals were: 97.9, 104, 152/96, 24, 97% RA
On arrival to the MICU, patient was in mild respiratory
distress. He met criteria for severe sepsis and due to
secretions, cough, respiratory distress, infiltrate, treated
with HCAP antibiotics. Bactrim and Zosyn discontinued and
started on vancomycin/cefepime for HCAP, while also covering for
UTI. Received IVF bolus prn for UOP goal 0.5cc/kg/hr. Echo
showed EF 50-55% with some e/o overload (elevated PCWP). He has
a history of BPH, and once Foley catheter placed, autodiuresed
1L. Also restarted his prazosin.
Upon transfer to ___ 2, he appears comfortable, on humidified
trach mask, intermittently coughing, still non-verbal, not
responding to commands, does not withdraw to noxious stimuli.
ROS: unable to obtain due to non-verbal status
Past Medical History:
Stroke in ___ with intraventricular hemorrhage
multiple TIAs
status post G-tube
status post upper lung tracheostomy requirement, now breathing
through his normal airway - decannulated ___ years ago
history of seizure?
multiple UTIs
CAD s/p MI in ___ with multiple PCIs and c/b CHB, s/p PPM
amyloidosis
hypertension
question chronic kidney disease
benign prostatic hypertrophy with TURP in ___
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission PHYSICAL EXAM:
Vitals: T97, HR 102, BP 146/68, RR 21, 99% on 35% FiO2 10L NC
trach mask
GENERAL: nonverbal, emaciated
HEENT: Sclera anicteric, dry MM, oropharynx clear
NECK: stoma with white secretions
LUNGS: coarse breath sounds bilaterally
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present,
G-tube in place, no rebound tenderness or guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: unable to do a full neuro exam
Discharge physical exam:
Vitals: T 97.8, 110-120/50-60, 60-70, 20, 98% on humidified TM
GENERAL: nonverbal, well nourished, occasional gurgling, cough
HEENT: Sclera anicteric, dry MM, oropharynx clear
NECK: stoma with minimal white secretions
LUNGS: coarse breath sounds bilaterally
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, G
tube in place, no rebound tenderness or guarding
EXT: left arm with contracture, right arm with decerebrate
posturing, warm, well perfused, 2+ pulses, no clubbing, cyanosis
or edema
NEURO: unable to do a full neuro exam. does not withdraw to
sternal rub, does not blink to threat, PERRL
Pertinent Results:
Admission labs:
___ 11:40PM BLOOD WBC-18.7*# RBC-3.14* Hgb-10.4* Hct-29.0*
MCV-92 MCH-33.1* MCHC-35.9* RDW-14.9 Plt ___
___ 11:40PM BLOOD Neuts-86.9* Lymphs-6.7* Monos-5.8 Eos-0.4
Baso-0.1
___ 11:40PM BLOOD Plt ___
___ 11:40PM BLOOD Glucose-125* UreaN-38* Creat-1.4* Na-140
K-4.4 Cl-103 HCO3-24 AnGap-17
___ 11:40PM BLOOD Calcium-9.5 Phos-2.8 Mg-2.1
___ 06:27AM BLOOD calTIBC-281 TRF-216
___ 11:53PM BLOOD Lactate-2.3*
___ 06:48AM BLOOD Lactate-3.0*
___ 01:07PM BLOOD Lactate-1.9
___ ___
-BLOOD CULTURE Preliminary ___ No Growth to Date.
-RAPID INFLUENZA A & B Final ___
INFLUENZA A NEGATIVE
INFLUENZA B NEGATIVE
-URINE CULTURE Final ___
>100,000 org/ml ESCHERICHIA COLI
S to cephalosporins, R to levofloxacin, Cipro, Bactrim
___ Sputum cx: gram stain >25 PMN, >25 epi, sputum culture with
rare growth MRSA - Sensitive only to gent, linezolid,
tetracycline, trim/sulfa, vancomycin
Prior urine culture with proteus mirabilis (50-100,000,
resistant only to Macrobid)
Images:
___ PCXR
IMPRESSION:
Low lung volumes. Retrocardiac opacity could represent either
atelectasis or pneumonia.
.
___ Echocardiogram
Conclusion:
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Left ventricular dysnchrony is present. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size is
normal. with normal free wall contractility. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
.
___ PCXR
IMPRESSION:
Malpositioned right-sided PICC line.
.
___ PCXR
IMPRESSION:
Successful flushing of a right arm PICC with its tip currently
in the distal SVC.
Discharge labs:
___ 09:45AM BLOOD WBC-5.4 RBC-2.82* Hgb-9.3* Hct-26.3*
MCV-93 MCH-33.0* MCHC-35.4* RDW-14.3 Plt ___
___ 09:45AM BLOOD Glucose-116* UreaN-38* Creat-1.5* Na-144
K-4.2 Cl-110* HCO3-26 AnGap-12
MICROBIOLOGY ___
___ Blood Cultures x 2 sets: No Growth (FINAL)
___ Urine Culture: No Growth
___ MRSA Screen: POSITIVE for MRSA
___ Sputum Culture: Cancelled due to poor quality sample
Brief Hospital Course:
Brief Hospital Course:
___ gentleman, with history of intraventricular
hemorrhage in ___ that required tracheostomy and prolonged
hospitalization and rehab as well as G-tube placement, coronary
artery disease status post MI in ___ complicated by heart block
requiring pacemaker, who presented as an ICU to ICU transfer
from ___ with findings of sepsis likely secondary to
pneumonia and possible UTI.
Upon arrival to ___ 2, he appears comfortable, on humidified
trach mask, intermittently coughing, still non-verbal, not
responding to commands, does not withdraw to noxious stimuli.
# Severe sepsis: On arrival to the MICU, patient was in mild
respiratory distress. He met criteria for severe sepsis and due
to secretions, cough, respiratory distress, infiltrate, was
treated for HCAP. Outside hospital antibiotics of Bactrim and
Zosyn discontinued and started on vancomycin/cefepime for HCAP,
while also covering for UTI. Received IVF bolus prn for UOP goal
0.5cc/kg/hr. Echo showed EF 50-55% with some e/o overload (high
PCWP). He has a history of BPH, and once foley catheter placed,
autodiuresed 1L, secondary to urinary retention. Also restarted
his prazosin.
# HCAP: SIRS with radiographic evidence of pneumonia on CXR with
associated cough, increased sputum production, and rising
lactate and worsening creatinine. Narrowed initial ICU empiric
coverage of vancomycin/cefepime x 7days for HCAP, ___ to
vancomycin/ceftriaxone. ___ culture without growth
however he has a history of MRSA pneumonia, and as such, we
continued vancomycin.
# Urinary tract infection and urinary retention: U/A mildly
positive with urine culture showing >100,000 E. coli.
Antibiotics coverage per above for HCAP, with E. coli also
sensitive to cephalosporins, so narrowed cefepime to
ceftriaxone. He had urinary retention in the setting of this
UTI, and had 1L urine output in the ICU after placement of
foley. Given his BPH, placement may have been traumatic,
resulting in few small clots and pink-tinged urine. Plan for 7
days with Foley and trial of void and subsequent removal at
nursing facility.
# ___ on CKD: unclear baseline but as high as 1.81 at prior
admission. Fluid resuscitated and trended creatinine. Trended
down to 1.5 on discharge.
# History of stroke, nonverbal at baseline: Aspiration
precautions
# Coronary artery disease, status post myocardial infarction in
___: continued home metoprolol.
# Hypertension: amlodipine and lisinopril initially held in ICU
in setting of sepsis. Amlodipine restarted, but lisinopril held
for normotension.
# Anemia: iron studies consistent with anemia of chronic
disease. H/H up from prior baseline. Noted to have drop in hgb
to 8.7 in prior admission with plan to f/u with outpatient
colonoscopy, if in line with goals of care (per children,
avoiding invasive or painful procedures).
# Recent thrush: now resolved, completed 5 days nystatin.
TRANSITIONAL ISSUES:
[] For pneumonia and UTI, continue antibiotic coverage with
vancomycin/ceftriaxone x 8days, ___.
[] Restart home lisinopril dose (40mg daily) as needed for
hypertension. Normotensive during hospitalization so did not
restart.
[] Trial of void and discontinuation of Foley catheter 7 days
after discharge (___). Had urinary retention in setting of
UTI, and pink-tinged urine from likely traumatic Foley
placement, and Foley was not removed in first 3 days of
hospitalization.
[] Can discontinue PICC line after completion of antibiotics.
# Communication: HCP: ___ ___
# Code: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO BID
3. Oxcarbazepine 300 mg PO BID
4. Prazosin 2 mg PO BID
5. Cholestyramine 4 gm PO DAILY
6. Ipratropium-Albuterol Neb 1 NEB NEB Q2H:PRN shortness of
breath/wheezing
7. Artificial Tears ___ DROP BOTH EYES TID
8. Amlodipine 10 mg PO DAILY
9. Fleet Enema ___AILY:PRN constipation
10. Bisacodyl 10 mg PO DAILY:PRN constipation
11. Acetaminophen 650 mg PO Q6H:PRN pain
12. Multivitamins 1 TAB PO DAILY
13. Guaifenesin ___ mL PO Q6H:PRN cough
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Artificial Tears ___ DROP BOTH EYES TID
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Cholestyramine 4 gm PO DAILY
5. Ipratropium-Albuterol Neb 1 NEB NEB Q2H:PRN shortness of
breath/wheezing
6. Metoprolol Tartrate 50 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Oxcarbazepine 300 mg PO BID
9. Prazosin 2 mg PO BID
10. CeftriaXONE 1 gm IV Q24H
Continue until ___.
11. Vancomycin 1000 mg IV Q 24H
Continue until ___.
12. Acetaminophen 650 mg PO Q6H:PRN pain
13. Fleet Enema ___AILY:PRN constipation
14. Guaifenesin ___ mL PO Q6H:PRN cough
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
primary diagnosis:
healthcare-associated pneumonia
urinary tract infection
secondary diagnosis:
history of stroke with intraventricular hemorrhage
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr ___,
It was a pleasure to care for you at ___. You were admitted to
the hospital because you were having fever and a likely
infection. You were found to have a pneumonia (lung infection)
and urinary tract infection. We treated you with antibiotics and
discharged you with a picc line to continue 7 days of
antibiotics at your nursing facility.
We wish you all the best.
- Your ___ care team
Followup Instructions:
___
|
10846829-DS-15
| 10,846,829 | 23,797,432 |
DS
| 15 |
2162-05-15 00:00:00
|
2162-05-16 06:38:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
urosepsis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ gentleman, with history of intraventricular
hemorrhage ___ ___ that required tracheostomy and prolonged
hospitalization and rehab as well as G-tube placement, coronary
artery disease status post MI ___ ___ complicated by heart
block
requiring pacemaker, who had recent ICU stay ___ for sepsis
admitted to MICU green ___ following with concern with AMS and
altered breathing from nursing home, found to have urosepsis and
HCAP vs tracheobronchitis.
At initial admission ___ ___ the ED, initial vitals:
T 99.8 HR 88 BP 75/44 RR 28 98 RA%
labs were notable for lactate 3.3, na 129, dirty U/A with > 182
WBCs,
Patient was started on vancomycin and cefepime and given 3 L
NS.
During ED stay patient acutely decompensated, and had thick
vicous secretions coming up. He was agitated and was unable to
keep secretions down.
#MICU Green Course significant for:
-vitals were: soft BP ___ systolic, continued to spike
fevers
-Respiratory status improved. He was given 2 mg morphine with
good effect. Family reiterated wishes for DNR/DNI, but wishes
for antibiotics/fluid support.
-Episodes of possible Vtach versus paced tachycardic rhythm, and
amiodarone gtt was started. He was persistently hypotensive and
required 2 L NS.
-EP investigated pacer: No VT
#Patient transferred to ___ as pressures improving on abx.
course c/b production of thick secretions requiring close 1:1
monitoring and suctioning. Patient w/then became mildly hypoxic
w/O2 76 on ABG and producing excessive secretions. It was felt
at this time that for patient safety he required more consistent
observation and was transferred to ICU
Past Medical History:
Urosepsis
Stroke ___ ___ with intraventricular hemorrhage
multiple TIAs
status post G-tube
status post upper lung tracheostomy requirement, now breathing
through his normal airway - decannulated ___ years ago
history of seizure?
multiple UTIs
CAD s/p MI ___ ___ with multiple PCIs and c/b CHB, s/p PPM
amyloidosis
hypertension
question chronic kidney disease
benign prostatic hypertrophy with TURP ___ ___
Social History:
___
Family History:
noncontributory
Physical Exam:
ON ADMISSION:
Vitals: T: 90.7 BP: 151/71 P: 83 R: 35 O2: 92 %
GENERAL: no acute distress; asleep. No signs of secretions. No
significant secretions coming out of prior trach site.
HEENT: dry mucous membranes
NECK: no jvp elevation
LUNGS: significant B/L coarse breath crackles at bases and
rhonchi.
CV: tachycardic, no m/r/g
ABD: soft, non-tender,
EXT: warm, 2+ radial, DP pulses
GU: foley to gravity w/cloudy dilute urine
Pertinent Results:
==ADMISSION LABS==
___ 07:20PM BLOOD WBC-19.7*# RBC-2.84* Hgb-8.9* Hct-27.1*
MCV-95 MCH-31.3 MCHC-32.8 RDW-14.9 RDWSD-52.5* Plt ___
___ 07:20PM BLOOD Neuts-88.4* Lymphs-2.7* Monos-7.7
Eos-0.0* Baso-0.2 Im ___ AbsNeut-17.38* AbsLymp-0.54*
AbsMono-1.52* AbsEos-0.00* AbsBaso-0.03
___ 07:20PM BLOOD ___ PTT-24.6* ___
___ 07:20PM BLOOD Plt ___
___ 07:20PM BLOOD Glucose-229* UreaN-54* Creat-2.4* Na-129*
K-3.7 Cl-94* HCO3-21* AnGap-18
___ 07:20PM BLOOD ALT-16 AST-20 AlkPhos-113 TotBili-0.4
___ 07:20PM BLOOD cTropnT-0.06*
___ 07:20PM BLOOD Albumin-3.6 Calcium-9.1 Phos-2.7 Mg-2.2
___ 07:32PM BLOOD Lactate-3.3*
== DISCHARGE LABS ==
== IMAGING ==
CXR ___
IMPRESSION:
There is no interval change. There is a dual lead left-sided
pacemaker,
unchanged. There is unchanged cardiomegaly. Bilateral pleural
effusions and a left retrocardiac opacity remain. There is mild
pulmonary edema, stable. There are no pneumothoraces.
GTUBE STUDY ___
IMPRESSION:
A G-tube is correctly positioned ___ the stomach. Injected
contrast passes
easily into the duodenum.
CXR ___
IMPRESSION:
Improved vascular congestion
Bibasilar opacities a combination of effusions and adjacent
consolidations, this consolidation could represent atelectasis
or pneumonia ___ the appropriate clinical setting
CXR ___
IMPRESSION:
Large right, a small moderate left pleural effusions with
adjacent atelectasis and mild to moderate pulmonary edema are
new. Cardiomegaly cannot be evaluated. Pacer leads are ___
standard position. There is no pneumothorax
KUB ___
IMPRESSION:
1. Location of G-J tube not well visualized ___ the absence of
injected
contrast.
2. Bilateral pleural effusions
CXR ___
IMPRESSION:
Low lung volumes with patchy bibasilar opacities; given relative
improvement from same-day radiograph, findings likely represent
atelectasis or uncomplicated aspiration.
== MICROBIOLOGY ==
___ 7:20 pm BLOOD CULTURE #1.
Blood Culture, Routine (Preliminary):
ENTEROBACTER CLOACAE COMPLEX. FINAL SENSITIVITIES.
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 ___
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___ ON ___ -
___.
GRAM NEGATIVE ROD(S).
___ 7:33 pm URINE SOURCE: CATHETER.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROBACTER CLOACAE COMPLEX. ___
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.
CIPROFLOXACIN sensitivity testing confirmed by ___
___.
ENTEROBACTER CLOACAE COMPLEX. ___
ORGANISMS/ML..
SECOND MORPHOLOGY.
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.
CIPROFLOXACIN sensitivity testing performed by ___
___.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
| ENTEROBACTER CLOACAE
COMPLEX
| |
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- 1 I S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I 64 I
PIPERACILLIN/TAZO----- 8 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
___ 12:29 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
___ 7:33 pm BLOOD CULTURE #2.
Blood Culture, Routine (Pending):
___ 12:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 3:05 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending
___ 12:28 pm URINE Source: Catheter.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
== URINE ==
___ 07:33PM URINE Color-Yellow Appear-Hazy Sp ___
___ 07:33PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 07:33PM URINE RBC-3* WBC-68* Bacteri-MANY Yeast-NONE
Epi-0
___ 07:33PM URINE CastHy-3*
== FLU ==
___ 08:25PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
Brief Hospital Course:
___ gentleman, with history of intraventricular
hemorrhage ___ ___ that required tracheostomy and prolonged
hospitalization and rehab as well as G-tube placement, coronary
artery disease status post MI ___ ___ complicated by heart block
requiring pacemaker w/recent admission for urosepsis and HCAP,
who presented to ICU ___ with urosepsis and significant
secretions transferred back from floor for respiratory distress
___ continuous production of thick secretions.
# Hypoxic Respiratory distress: During ED stay patient acutely
decompensated, and had thick viscous secretions coming up. He
was agitated and was unable to keep secretions down. He was
admitted to the ICU and continued to spike fevers; he was
treated empirically with vancomycin and cefepime. His
respiratory status improved, and he was transferred to the
medical floor. On the floor he developed increasing thick
secretions requiring close 1:1 monitoring and suctioning.
Patient became hypoxic w/paO2 76 on ABG. He was again
transferred to ICU. He had blood gases significant for resp
alkalosis and hypoxia. His sputum cx grew GNR and commensal GPC,
and antibiotics were narrowed to cefepime. He also received
expectorants, humidifiers, and chest ___ and was improved prior
to discharge.
#Severe sepsis: Pt presented with a low-grade temp of 99.8 with
SBPs ___ the ___ and a lactate of 3.3 with a positive UA. He was
started on vancomycin and cefepime and given 3 L NS. His
presentation was thought to be ___ to UTI and bacteremia with Cx
growing ENTEROBACTER CLOACAE COMPLEX, and possible HCAP vs
tracheobronchitis with thick purulent secretions also w/Cx
pending w/SN. His antibiotics were narrowed to cefepime, which
will be continued for a two week course (day 1: ___.
___ on CKD: unclear baseline but his Cr was as high as 1.9 on
prior admissions. 2.4 now trending down to 1.9, thought to be
prerenal ___ the setting of sepsis that improved with management
of the above.
#PEG tube, h/o stroke: the pt was put on aspiration precautions
and remained NPO. Initially there was concern that his PEG was
misplaced, but after further investigation, there was no
evidence that the pt was having high residuals at his SNF and ___
had not seen evidence of obstruction/misplacement. However, a
tube study was done to determine if there was any distal
obstruction; results were normal and tube feeds were restarted.
#Stage 3 Coccygeal Pressure Ulcer: present prior to admission.
Wound care was consulted.
#Wide complex tachycardia: During his stay the pt was noticed
to have episodes of possible Vtach versus paced tachycardic
rhythm, and amiodarone gtt was started. He was persistently
hypotensive and required 2 L NS. EP interrogated the pacer and
reported no VT.
TRANSITIONAL ISSUES:
- Cefepime to be continued for 2 week course (day 1: ___, last
day: ___. Midline may be removed after antibiotics are
completed.
- Discharge Cr: 1.7. Please recheck ___ one week to confirm
stable
- Blood cultures pending at time of discharge
- DNR/DNI
- Please use limiting medications for secretions given concern
for tracheobronchitis, and please re-evaluate with increased
suctioning as needed.
- HCPXy: ___ ___: daughter Phone:
___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
2. Aquaphor Ointment 1 Appl TP HS right nare mass
3. Bisacodyl ___AILY:PRN constipation
4. Fleet Enema ___AILY:PRN constipation
5. Milk of Magnesia 30 mL PO PRN constipation
6. Prazosin 2 mg PO BID
7. Oxcarbazepine 300 mg PO BID
8. Metoprolol Tartrate 50 mg PO BID
9. Ranitidine 150 mg PO DAILY
10. Cholestyramine 4 gm PO DAILY
11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
2. Aquaphor Ointment 1 Appl TP HS right nare mass
3. Bisacodyl ___AILY:PRN constipation
4. Cholestyramine 4 gm PO DAILY
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
6. Metoprolol Tartrate 50 mg PO BID
7. Milk of Magnesia 30 mL PO PRN constipation
8. Oxcarbazepine 300 mg PO BID
9. Prazosin 2 mg PO BID
10. Ranitidine 150 mg PO DAILY
11. CefePIME 2 g IV Q24H
12. Fleet Enema ___AILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- ENTEROBACTER CLOACAE COMPLEX bacteremia
- urinary tract infection
- acute on chronic kidney injury
- dysphagia with PEG tube placement
- hypoxemic respiratory failure
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure participating ___ your care here at ___.
You were admitted on ___ with a change ___ breathing. You
were found to have an infection ___ your urine and blood. You
were given IV antibiotics and you were feeling better by time of
discharge. You will need to continue taking the antibiotics for
a total of 2 weeks.
If you have any worsening breathing, fevers, chills, or any
other concerning symptom, please let your doctor know.
Again, it was our pleasure participating ___ your care.
We wish you the best,
- Your ___ Medicine Team -
Followup Instructions:
___
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2162-06-02 00:00:00
|
2162-06-02 13:47:00
|
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:
___ gentleman, with history of intraventricular
hemorrhage in ___ that required tracheostomy and prolonged
hospitalization and rehab as well as G-tube placement, coronary
artery disease status post MI in ___ complicated by heart block
requiring pacemaker, with recent ICU stays ___ for sepsis,
___ with urosepsis and HCAP) presenting for fever.
Last discharge 2 weeks ago following pan sensitive enterobacter
urosepsis. Also known to have stage 3 sacral decub on prior
admission. Finished course of cefepime on ___. DNR/DNI on last
admission. Presenting from ___
___. The ___ called his daughters yesterday
reporting that patient was febrile to 100.4 and hypotensive to
90/57. They reported his breathing also appeared labored, and
that his known sacral decubitus ulcer appeared to have
progressed (unclear if they meant progressed in extent or in
appearance, i.e. looking infected). Patient was incontinent of
stool x1 in ___ that was soft but formed (not diarrhea per ___
RN). Family also note that his MS is at baseline and that he is
much improved from his previous admission.
#In the ___, initial vital signs were: T 98.1 P 84 BP 116/70 R 18
O2 sat. 98%RA
- Exam notable for: sacral wound with erythema
- Labs were notable for WBC 14.5, H/H 8.8/27.6 (baseline Hgb
___, bicarb 21, SCr 1.4 (baseline 1.4-1.7), Alk phos 138,
lactate 2.1, rapid flu negative
- Studies performed include CXR with markedly improved
bibasilar opacities compared to ___ with appearance
favoring atelectasis. Coexisting aspiration or infection is not
fully excluded.
- Patient was given x2 1L NS, 1gm vanc, 2gm cefepime, 650 APAP
- Vitals on transfer: 100.4 97 135/88 25 99%RA
Of note recent surveillance labs on ___ with WBC 5.6, H/H
9.0/27.8, SCr 1.3. On ___, the patient was started on
loperamide for diarrhea.
Past Medical History:
Urosepsis
Stroke in ___ with intraventricular hemorrhage
multiple TIAs
status post G-tube
status post upper lung tracheostomy requirement, now breathing
through his normal airway - decannulated ___ years ago
history of seizure?
multiple UTIs
CAD s/p MI in ___ with multiple PCIs and c/b CHB, s/p PPM
amyloidosis
hypertension
question chronic kidney disease
benign prostatic hypertrophy with TURP in ___
Social History:
___
Family History:
noncontributory
Physical Exam:
On admission:
Vitals- T 98.3 HR 89 BP 135/84 RR 18 SaO2 100% RA
General: non-verbal, flushes, diaphoretic male, sitting up in
bed
HEENT: PERRL, EOMI, black papule with surrounding scaling on R
nasal ala, MMM, PO clear
Neck: supple, 2+ carotid pulses, persistent stoma at
tracheostomy site
CV: RRR, nl s1 and s2, holosystolic murmur heard best at LLSB
Lungs: rhonchorous throughout in anterior fields without
wheezing
Abdomen: soft, mildly distended, nt, no rebound/guarding, no
HSM
GU: no foley, scrotum with minimal ulceration on posterior
aspect
Rectal: passing liquid green stool
Ext: BLE hairless with 1+ pulses, all extremities wwp, no
cyanosis or edema
Neuro: non-verbal, opens eyes to verbal and touch, does not
follow commands, moves all fours
Skin: stage 3 4x5 sacral decubitus ulcer with blacked area at
4 o'clock, no surrounding erythema, x2 full-thickness
___ ulcers and scrotal ulcers
On discharge:
Vitals: 100.3 now 99.6 140/83 90-100 20 96% RA
General: non-verbal, sitting up in bed
HEENT: PERRL, EOMI, black papule with surrounding scaling on R
nasal ala, MMM, PO clear
Neck: supple, 2+ carotid pulses, persistent stoma at
tracheostomy site
CV: RRR, nl s1 and s2, holosystolic murmur heard best at LLSB
Lungs: rhonchorous throughout in anterior fields without
wheezing, transmitted upper airway sounds
Abdomen: soft, nd, nt, no rebound/guarding, no HSM
GU: no foley, scrotum with ulcerations on posterior aspect
Ext: BLE hairless with 1+ pulses, all extremities wwp, no
cyanosis or edema
Neuro: non-verbal, opens eyes to verbal and touch, does not
follow commands, moves all fours
Pertinent Results:
On admission:
___ 12:35AM BLOOD WBC-14.5*# RBC-2.83* Hgb-8.8* Hct-27.6*
MCV-98 MCH-31.1 MCHC-31.9* RDW-15.6* RDWSD-55.0* Plt ___
___ 12:35AM BLOOD Neuts-82.1* Lymphs-7.7* Monos-7.8 Eos-1.3
Baso-0.3 Im ___ AbsNeut-11.89*# AbsLymp-1.12* AbsMono-1.13*
AbsEos-0.19 AbsBaso-0.05
___ 12:35AM BLOOD Glucose-138* UreaN-43* Creat-1.4* Na-138
K-4.3 Cl-105 HCO3-21* AnGap-16
___ 12:35AM BLOOD ALT-18 AST-18 AlkPhos-138* TotBili-0.4
___ 12:35AM BLOOD Lipase-58
___ 12:35AM BLOOD Albumin-3.9
___ 12:35AM BLOOD CRP-51.1*
___ 12:43AM BLOOD Lactate-2.1*
On discharge:
___ 07:25AM BLOOD WBC-5.7 RBC-2.59* Hgb-7.8* Hct-25.1*
MCV-97 MCH-30.1 MCHC-31.1* RDW-15.5 RDWSD-54.8* Plt ___
___ 07:25AM BLOOD Glucose-89 UreaN-24* Creat-1.4* Na-145
K-3.8 Cl-110* HCO3-24 AnGap-15
___ 07:23AM BLOOD Lactate-1.3
Imaging:
CHEST (PA & LAT) Study Date of ___ 2:09 AM
IMPRESSION:
Markedly improved bibasilar opacities compared to ___ with
appearance favoring atelectasis. Coexisting aspiration or
infection is not fully excluded. Short-term followup
radiographs may be helpful if there remains clinical suspicion
for pneumonia.
Microbiology:
___ 4:20 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___ ___ AT
12:27.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
___ 1:15 am BLOOD CULTURE Site: ARM
Blood Culture, Routine (Pending):
___ 1:15 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 8:30 pm SPUTUM Source: Induced.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Brief Hospital Course:
___ gentleman, with history of intraventricular
hemorrhage in ___ that required tracheostomy and prolonged
hospitalization and rehab as well as G-tube placement, coronary
artery disease status post MI in ___ complicated by heart block
requiring pacemaker, with recent ICU stays ___ for sepsis,
___ with urosepsis and HCAP) who presented for fever of
unclear origin.
#Severe C diff colitis: Pt with multiple recent admission for
sepsis, meeting SIRS criteria at presentation. Initially,
possible sources included GI (c. diff given recent abx, smell,
appearance of stool, started on loperamide at ___ 2d PTA),
respiratory (bacterial PNA, aspiration PNA, viral bronchitis),
urinary (though less likely given UA), and soft tissue given
sacral ulcer. Originally on broad spectrum abx, (vanc 1gm q12,
zosyn 4.5gm q8, PO vanco 125mg q6) given multiple infectious
sources. Though, CXR was negative, UA negative, ulcers did not
appear to be source based on exam. On HD2, the patient's WBC
trended to normal, and his c diff testing returned positive,
thus his IV abx were discontinued. He was continued on PO
vancomycin, and given stability, was deemed safe for discharge.
He will continue QID vancomycin until ___.
#Multiple pressure ulcer: multiple sacral, scrotal and
___ ulcers. Per wound care, the ___ and scrotal
ulcers likely occurred in the setting of frequent stooling. Thus
wound care recommended the following:
Topical Therapy:
Commercial wound cleanser or normal saline to cleanse wounds.
Pat the tissue dry with dry gauze.
To Sacrum:
Apply Mepilex Sacral Border - apply upside down to keep away
from anus. Change Q3d and PRN
To wounds around anus and scrotum:
Apply Criticaid Clear, Lay Xeroform on top of wound, Change
daily and prn.
He will follow-up in wound care clinic at ___ in the
future.
#CKD stage III: pt with baseline creatinine elevation. Stage III
CKD based on creatinine clearance. His creatinine was stable
during this admission.
#Anemia: Baseline hgb ___, this was monitored during his
hospitalization and he did not require blood transfusions during
his stay.
#CAD- home metoprolol was initially held and can be re-started
on discharge
#HTN- home lisinopril and amlodipine were initially held and can
be re-started on discharge
Transitional issues:
#Pt will cont vancomycin PO QID until ___
#DO NOT GIVE PATIENT ANTI-DIARRHEAL MEDICATIONS AS HE HAS AN
ACTIVE INFECTION OF HIS COLON
#Pt will need to f/u with ___ wound care
#Regarding wound care:
Wound care-
Topical Therapy:
Commercial wound cleanser or normal saline to cleanse wounds.
Pat the tissue dry with dry gauze.
To Sacrum:
Apply Mepilex Sacral Border - apply upside down to keep away
from anus. Change Q3d and PRN
To wounds around anus and scrotum:
Apply Criticaid Clear, Lay Xeroform on top of wound, Change
daily and prn.
#Pt was DNR/DNI during this admission
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Artificial Tears ___ DROP BOTH EYES QID:PRN dry eyes
2. Questran (cholestyramine (with sugar)) 4 gram oral DAILY
3. Amlodipine 10 mg PO DAILY
4. Hydrocortisone Cream 2.5% 1 Appl TP BID PRN dry ears, scaling
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H: PRN SOB, dyspnea
6. Ketoconazole Shampoo 1 Appl TP ASDIR
7. Lisinopril 20 mg PO DAILY
8. Metoprolol Tartrate 50 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Mupirocin Ointment 2% 1 Appl TP BID
11. Oxcarbazepine 300 mg PO BID
12. Ranitidine 150 mg PO DAILY
13. Prazosin 2 mg PO BID
14. Collagenase Ointment 1 Appl TP DAILY
15. Silver Sulfadiazine 1% Cream 1 Appl TP DAILY
16. Glycopyrrolate 1 mg NG DAILY
17. LOPERamide 2 mg NG BID
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES QID:PRN dry eyes
2. Glycopyrrolate 1 mg NG DAILY
3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H: PRN SOB, dyspnea
4. Multivitamins 1 TAB PO DAILY
5. Oxcarbazepine 300 mg PO BID
6. Ranitidine 150 mg PO DAILY
7. Vancomycin Oral Liquid ___ mg PO Q6H
8. Amlodipine 10 mg PO DAILY
9. Hydrocortisone Cream 2.5% 1 Appl TP BID PRN dry ears, scaling
10. Ketoconazole Shampoo 1 Appl TP ASDIR
11. Lisinopril 20 mg PO DAILY
12. Metoprolol Tartrate 50 mg PO BID
13. Mupirocin Ointment 2% 1 Appl TP BID
14. Prazosin 2 mg PO BID
15. Questran (cholestyramine (with sugar)) 4 gram oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
severe c. diff colitis
decubitus and pressure ulceration of the sacrum, anus, and
scrotum
___ on CKD
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Mr ___-
You were admitted to the hospital for fevers. You were noted to
be having diarrhea, and studies were sent which confirmed that
you are suffering from an infection from c. diff, a bacteria.
This infection affects the colon and causes diarrhea. You were
treated with a medicine called vancomycin through your G-tube,
you stopped having fevers, and your white blood count, a sign of
infection, trended down to normal. You will continue to get
vancomycin four times a day until ___. We wish you the best in
the future-
-Your ___ Care Team
Followup Instructions:
___
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2121-07-09 16:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
orthostatic hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: ___ with a hx of anorexia nervosa referred from PCP for
orthostatic hypotension and UA positive for ketones in PCP
___. Patient reports that she has only been picking at her
food recently and not drinking much, feeling nauseous with food,
but denies vomiting, purging or laxative use. Denies feeling
depressed and any suicidal intent. She has good insight and
acknowledges that is an exacerbation of her anorexia, likely
provoked by increased stress recently in the context of selling
her house. She reports feeling lightheaded, dizzy and having
blurry vision with right-sided chest pressure on standing. No
LOC. +sore throat and nasal discharge x1 wk. Dec. No dysuria,
last moved her bowels 2 days ago, which is normal for her. No
abdominal pain, diarrhea, constipation.
.
Patient reports that she has a strong support network outside
the hospital with her PCP, nutritionist and therapist all
following her very closely.
.
In the ED, initial VS: 98.9 61 106/49 16 100% ra. Weight 135.2
pounds Labs revealed electrolytes within normal limits. Blood
counts with normocytic anemia and thrombocytopenia. EKG shows
sinus bradycardia with HR 51.
.
Currently, patient is AAOx3, cooperative, conversant, good
insight. Acknowledges recent stress in life cuasing her not to
eat well. Denies purging. Denies fevers, chills, dysphagia,
vomiting, diarrhea.
.
ROS: Denies fever, chills, night sweats, headache, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Anorexia Nervosa
Anxiety/Depression
palpitations
Postural orthostatic tachycardia syndrome
Right hip bursitis
Osteoporosis per patient report
PTSD
Past Medical History:
Anorexia Nervosa
Anxiety/Depression
palpitations
Postural orthostatic tachycardia syndrome
Right hip bursitis
Osteoporosis per patient report
PTSD
Social History:
___
Family History:
Mother: coronary artery disease, type II diabetes
Father: bipolar disorder
Daughter: depression/anxiety
Paternal uncle and aunt with completed suicides
Per patient she has a cousin with an eating disorder
Physical Exam:
On admission:
Vitals: 98.6, 100/52, 52, 18, 100% RA
General: Alert, oriented, no acute distress, thin
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, II/VI SEM at URSB.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Eczematous eruption right thumb.
Neuro: A&O x 3. Pleasant. CNII-XII grossly intact. Normal
affect. No active SI, HI, or plans to do harm to herself.
.
At discharge:
Objective: Vitals: 97.5, 74/32, 53, 18, 93% RA.
General: Alert, oriented, no acute distress, thin
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, II/VI SEM at URSB.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Eczematous eruption right thumb.
Neuro: A&O x 3. Pleasant. CNII-XII grossly intact. Normal
affect. No active SI, HI, or plans to do harm to herself.
Pertinent Results:
___ 04:50PM BLOOD WBC-7.1# RBC-3.77* Hgb-10.5* Hct-31.7*
MCV-84# MCH-27.9# MCHC-33.2 RDW-16.1* Plt ___
___ 09:00AM BLOOD WBC-4.6 RBC-3.48* Hgb-9.7* Hct-29.6*
MCV-85 MCH-27.9 MCHC-32.8 RDW-16.2* Plt ___
___ 04:50PM BLOOD Neuts-77.9* Lymphs-13.4* Monos-6.0
Eos-1.4 Baso-1.2
___ 06:19AM BLOOD Neuts-67.5 ___ Monos-8.7 Eos-3.8
Baso-1.1
___ 04:50PM BLOOD Plt ___
___ 06:19AM BLOOD ___ PTT-32.9 ___
___ 06:19AM BLOOD Plt ___
___ 09:00AM BLOOD Plt ___
___ 06:19AM BLOOD Ret Aut-0.9*
___ 04:50PM BLOOD Glucose-81 UreaN-12 Creat-0.5 Na-135
K-3.7 Cl-101 HCO3-24 AnGap-14
___ 09:00AM BLOOD Glucose-80 UreaN-11 Creat-0.5 Na-142
K-4.0 Cl-111* HCO3-26 AnGap-9
___ 06:19AM BLOOD ALT-8 AST-12 LD(LDH)-149 AlkPhos-44
TotBili-0.4
___ 04:50PM BLOOD Calcium-9.1 Phos-3.6 Mg-2.0
___ 06:19AM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.5 Mg-2.0
Iron-36
___ 09:00AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.0
___ 06:19AM BLOOD calTIBC-348 VitB12-560 Folate-19.9
___ Ferritn-6.5* TRF-268
___ 06:19AM BLOOD TSH-1.0
.
___ CXR
Heart size is normal. Mediastinum is normal. Lungs are clear. No
pleural
effusion or pneumothorax demonstrated.
.
___ ECG
Sinus bradycardia. Early R wave transition. Compared to the
previous tracing of ___ the findings are similar.
Brief Hospital Course:
___ y/o F with orthostatic hypotension, anorexia nervosa, with
recent decline in PO intake secondary to psychological
stressors, presenting from PCP's office with orthostasis and
ketonuria.
.
# Orthostatic Hypotension: Patient has history of POTS,
previously presented to hospital with orthostasis. Likely
secondary to poor fluid intake. Albumin 3.8, unlikely that low
serum protein is contributing to fluid shifts and orthostasis.
Per PCP: patient had previously been prescribed florinef but had
not been taking florinef recently. Pt was treated with
intravenous fluids and she was started back on florinef, with
some improvement in orthostatic blood pressures and resolution
of her subjective dizziness, lightheadedness, chest pressure and
visual blurring on standing. There were no episodes of
tachycardia while the patient was admitted. By the time of
discharge, she was asymptomatic ambulating without assistance.
.
# Anorexia Nervosa: Getting worse recently, patient reports
stressors due to selling house, splitting up with husband, has
not been eating well. Receives close outpatient followup with
PCP, ___, therapist. Currently at close to 100% ideal body
weight, no electroylte abnormalities, EKG shows sinus
bradycardia but HR>50, however has anemia and orthostatic
hypotension. PCP who knows her very well was concerned and
ketones were positive on the office UA. She did not meet
criteria for the hospital eating disorder protocol. She was
seen by nutrition, social work and physical therapy and cleared
for discharge with close outpatient followup with her PCP,
therapist and dietitian.
.
# Thrombocytopenia: At baseline. Likely secondary to nutritional
deficiencies per hem/onc note. LFTs at baseline. No evidence of
active bleeding.
.
# Anemia: Normocytic anemia, however has been hypochromic
microcytic in the past. However, increased RDW, likely mixed
picture with microcytosis and macrocytosis secondary to
nutritional deficiencies. Ferritin was very low at 6.5 and she
was reporting restless leg symptoms. Pt received a single dose
of IV iron and was continued on iron supplementation.
.
TRANSITIONAL ISSUES:
Patient will followup closely with her PCP for ___
management of her anorexia nervosa and orthostatic hypotension.
We started florinef, which we suggest she continue taking as an
outpatient to help with management of her orthostatic
hypotension.
Medications on Admission:
-Zoloft
-Iron supplements
Discharge Medications:
1. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
2. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Orthostatic Hypotension
Secondary: Anorexia Nervosa
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted with low blood
pressures and dizziness while standing up. We gave you fluids
and started you on a medication called fludrocortisone, and your
symptoms improved. We also gave you intravenous iron for
restless leg syndrome.
We made the following changes to your medications:
-STARTED Fludrocortisone
Please continue taking your other medications as usual.
Please followup with your doctors, see below.
Followup Instructions:
___
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2122-03-20 23:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o female history of restrictive eating disorder, anxiety,
depression, and PTSD seen at PCP today where she endorsed not
eating/drinking for a few days, foudn to have BP low, HR high,
CP on standing, some radiation into the back + nausea so sent
into ED.
Patient reports she hasn't really eaten or drank anything since
___ (4d PTA). She says she had a recent traumatic experience
(didn't press for details) which flared her anxiety/panic and
made her not want to eat at all. For the last 2 days she's felt
weak, dizzy, and like she is having muscle cramps. Chest feels
tight (she says painful). Denies syncope or falls. Denies HA. No
SOB. Feels like dehydration may be worse than usual. No diarrhea
or constipation. She's been taking ativan the last couple days
due to worsened anxiety. She denies any binging episodes.
Has history of orthostatic hypotension related admissions (last
in ___ - all in the setting of poor intake. No other
recent illness. Also came to the ER on ___ for anorexia and
hypotension - also sent in by PCP at that time due to positive
orthostatics. Was given 2L IVF at that time and discharge for
PCP ___. In ER today, she reported thinking inpatient treatment
may be beneficial, but is somewhat scared of the prospect and
the eating involved.
In the ED, initial VS were: 97.8 97 102/42 16 100% ra. EKG: SR
96, no ischemic changes, no ST changes, no peaked tw. Labs
normal. Given IVF. Admitted to medicine for hydration and
potential food introduction. VS at transfer: 97.8 72 105/58 16
100%.
On arrival to the floor, patient is anxious. Doesn't feel like
eating. Feels lightheaded.
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:
Anorexia Nervosa
Anxiety/Depression
palpitations
Postural orthostatic tachycardia syndrome
Right hip bursitis
Osteoporosis per patient report
PTSD
Social History:
___
Family History:
Mother: coronary artery disease, type II diabetes
Father: bipolar disorder
Daughter: depression/anxiety
Paternal uncle and aunt with completed suicides
Per patient she has a cousin with an eating disorder
Physical Exam:
ADMISSION EXAM
VS - Temp 97.7F, BP 105/44, HR 66, R 16, O2-sat 100% RA
GENERAL - thin female, anxious appearing, minimally interractive
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical LAD, no parotid enlargement
NEURO - awake, A&Ox3, weak but not focally, sensation intact
DISCHARGE EXAM
VS Tc 98 90/52 64 18 100% RA
GEN awake, alert, thin appearing woman in NAD
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
ADMISSION LABS
___ 03:38PM WBC-6.1 RBC-4.57 HGB-14.0 HCT-42.0 MCV-92
MCH-30.7 MCHC-33.4 RDW-14.1
___ 03:38PM NEUTS-69.9 ___ MONOS-4.9 EOS-0.9
BASOS-1.4
___ 03:38PM PLT COUNT-214
___ 03:38PM ALT(SGPT)-15 AST(SGOT)-22 ALK PHOS-51 TOT
BILI-0.4
___ 03:38PM LIPASE-28
___ 03:38PM cTropnT-<0.01
___ 03:38PM GLUCOSE-86 UREA N-20 CREAT-0.8 SODIUM-136
POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-29 ANION GAP-15
___ 05:20PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-2
___ 05:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 05:20PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 05:20PM URINE UCG-NEGATIVE
DISCHARGE LABS
___ 07:30AM BLOOD WBC-4.4 RBC-3.76* Hgb-11.6* Hct-34.6*
MCV-92 MCH-31.0 MCHC-33.7 RDW-14.0 Plt ___
___ 07:30AM BLOOD Glucose-84 UreaN-15 Creat-0.6 Na-140
K-3.9 Cl-101 HCO3-30 AnGap-13
___:30AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.8
MICRO
___ URINE CULTURE-NEGATIVE, FINAL
IMAGING
CHEST (PA & LAT)Study Date of ___ 7:42 ___
FINDINGS: Frontal and lateral views of the chest are compared
to previous
exam from ___ and ___. The lungs are
hyperinflated, but remain clear. Cardiomediastinal silhouette
is within normal limits.
Osseous and soft tissue structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
___ year old female with history of anorexia, depression/anxiety,
PTSD presenting with ___ days of no PO intake found to be
hypotensive in her PCP's office.
# Eating disorder: patient has a long history of an eating
disorder and is currently seeing her primary care physician, ___
therapist, and nutritionist to address this issue. She admitted
to increased stress in her life this past week and had recently
discontinued Zoloft because she thought it wasn't effective.
Nutrition was consulted and deemed patient not a candidate for
eating disorder protocol. Patient was encouraged to eat and was
eating small amounts of food on hospital day 1. She was given
intravenous fluids until she was taking subtantial POs. She was
started on citalopram (as below) and also given ativan PRN
anxiety. Patient is being discharged with instructions to call
her PCP for ___ close follow-up appointment to continue to address
this issue.
# Hypotension: Patient has history of admissions for orthostatic
hypotension usually in the setting of decreased PO intake.
Patient was bolused 2L NS on admission and given additional
fluids until she was taken substantial PO intake. By hospital
day 2, she was taking in good POs. Her blood pressures were
running in the ___ systolic, which are per her baseline.
# Depression/anxiety: patient endorsed increased depression and
anxiety recently but no SI during this admission. She had
recently discontinued zoloft because she thought it wasn't
effective. Patient agreed to try citalopram and this was
started on day of discharge. Patient was instructed to follow
up with her primary care doctor and therapist to assess her
progress on this new medication.
TRANSITIONAL ISSUES
Patient will need continued evaluation and treatment of her
depression/anxiety and eating disorder. She has started a new
SSRI and her response to this will need monitoring. She was
encouraged to make an appointment with her PCP to discuss these
issues.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam Dose is Unknown PO Frequency is Unknown
5 day course for panic attacks/anxiety
Discharge Medications:
1. Lorazepam 0.5 mg PO HS:PRN anxiety
5 day course for panic attacks/anxiety
2. Citalopram 20 mg PO DAILY
RX *citalopram [Celexa] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Dehydration, malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure to take care of you at ___. You were
admitted for low blood pressure. This was likely because you
were not eating. We gave you intrevenous fluids and you were
feeling better and able to eat. We also started you on a new
medication. It is important that you continue to be careful
when you stand up as you regain your strength.
Please make the following changes to your medications:
Please START citalopram 20 mg daily
Please continue to take your other medications as prescribed.
Followup Instructions:
___
|
10846923-DS-27
| 10,846,923 | 26,726,683 |
DS
| 27 |
2122-10-31 00:00:00
|
2122-11-02 01:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Dizziness after restricting diet
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of annorexia presenting with syncope. Pt has
not been eating the last week and today awoke and was unable to
stand due to syncope. Says she ate from nothing to 200 calories
per day with no liquid intake. She states she blacked out at
least 5 times with no head strike. Fell back onto her bed. Had
one episode with loss of control of bladder when she passed out.
No neck pain. Is complaining of calf pain/cramping. In the ED
has chest pain in ___ chest traveling to back exactly like
prior pain pt gets with anxiety. Has been worked up and no
etiology found. Now chest pain has resolved. Feels nauseated
with no vomiting today. Decreased urine output the last several
days. Was intentionally vomiting last week. No exercise, no
laxatives, no diuretics. Currently after 2L bolus IVF in ED less
dizzy, still dizzy when gets up to go to bathroom but much
improved from earlier.
In the ED was evaluated by psychiatry who noted she does not
need sitter and not at risk for self-harm.
Past Medical History:
Anorexia Nervosa
Anxiety/Depression
palpitations
Postural orthostatic tachycardia syndrome
Right hip bursitis
Osteoporosis per patient report
PTSD
Iron Deficiency Anemia
Social History:
___
Family History:
Mother: coronary artery disease, type II diabetes
Father: bipolar disorder
Daughter: depression/anxiety
Paternal uncle and aunt with completed suicides
Per patient she has a cousin with an eating disorder
Physical Exam:
Admission Physical Exam
=======================
Vitals- 97.5 106/34 64 18 98% on RA
General: NAD well appearing woman
HEENT: PERRLA, EOMI, no enamel erosion
Neck: no thyromegaly
CV: RRR no m/g/r
Lungs: CTAB/L no w/r/r
Abdomen: soft/nontender/nondistended +BS, no organomegaly, no
rebounding, no guarding
Ext: no edema, WWP
Neuro: CN ___ intact
Skin: no excoriations or lesions on hands
Discharge Physical Exam
Vitals- 98.2 103/57 ___ 16 100% on RA
General: NAD well appearing woman
HEENT: PERRLA, EOMI,
Neck: no thyromegaly
CV: RRR no m/g/r
Lungs: CTAB/L no w/r/r
Abdomen: soft/nontender/nondistended +BS, no organomegaly, no
rebounding, no guarding
Ext: no edema, WWP
Neuro: CN ___ intact
Skin: no excoriations or lesions on hands
Pertinent Results:
ADMISSSION LABS
=================
___ 12:15PM BLOOD WBC-6.9# RBC-4.08* Hgb-10.9* Hct-34.3*
MCV-84# MCH-26.7*# MCHC-31.7 RDW-15.5 Plt ___
___ 12:15PM BLOOD Neuts-81.7* Lymphs-13.3* Monos-3.8
Eos-0.5 Baso-0.7
___ 12:15PM BLOOD Glucose-103* UreaN-16 Creat-0.7 Na-139
K-3.4 Cl-94* HCO3-27 AnGap-21*
___ 12:15PM BLOOD ALT-14 AST-22 CK(CPK)-64 AlkPhos-37
TotBili-0.5
___ 12:15PM BLOOD Albumin-4.7 Calcium-8.9 Phos-3.3 Mg-1.9
Iron-29*
___ 12:15PM BLOOD calTIBC-549* Ferritn-8.6* TRF-422*
___ 12:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS
=================
___ 05:50AM BLOOD WBC-4.7 RBC-3.16* Hgb-8.5* Hct-27.1*
MCV-86 MCH-26.9* MCHC-31.3 RDW-15.5 Plt ___
___ 05:50AM BLOOD Glucose-79 UreaN-6 Creat-0.4 Na-140 K-4.0
Cl-108 HCO3-28 AnGap-8
___ 05:50AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.9
CHEST XRAY ___
===================
FINDINGS: Frontal upright and lateral chest radiographs
demonstrate
hyperinflated lungs. Heart is normal in size, and
cardiomediastinal contouris within normal limits. Lungs are
clear. There is no pleural effusion and no pneumothorax.
IMPRESSION: No significant changes compared to the prior study
and no
evidence of pneumonia. The study and the report were reviewed by
the staff radiologist.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with multiple admissions in the
past for anorexia who presented with presyncope and dehydration
after restricting her diet.
#Presyncope - The dizziness was thought to be due to her
limiting her PO intake. She was given multiple fluid boluses in
the ED. On the floor she continued to receive boluses. She
triggered for an episode of hypotension in the systolic of ___.
She was asymptomatic. With fluid resuscitation and increased PO
intake her dizziness resolved.
#Anorexia - Psych evaluated her in the emergency department and
determined she was not actively harming to herself. Nutrition
was consulted who recommended starting her on a regular diet.
She was encouraged to take greater PO intake and by discharge
was drinking water and eating small amounts of soup. She has
previously stopped her Tamoxifen and Lexapro because they had
caused her to gain weight. She agreed to restart her Lexapro by
the end of admission. Psych recommended she be discharge to a
partial program in order to be more appropriately counseled and
monitored and she was to follow up with her PCP in ___ week. She
was sent home on multivitamins and Vitamin D and Calcium
supplementation.
#Hypotension - Thought to be secondary to her decreased PO
intake. As noted above throughout her stay she received IV
fluids. She originally presented with systolic blood pressures
in the ___ and discharged with them in the 100s.
#Depression, Anxiety - Psych evaluated her and determined she
was not SI. She was very agreeable to restarting her Lexapro.
She also agreed to a partial program as mentioned above. She was
in a good mood throughout her stay in the hospital.
#Iron Deficiency Anemia - Labs were found to be consistent with
iron deficiency anemia which could be secondary menorrhagia and
poor intake. One dose of IV iron therapy was tolerated well and
she was sent home on oral iron therapy. Recommended continue to
monitor as an outpatient for response to PO iron. Would also
consider GI evaluation to rule out occult GI source of blood
loss as well.
Medications on Admission:
None
Discharge Medications:
1. Escitalopram Oxalate 10 mg PO DAILY depression
RX *escitalopram 10 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
2. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*90 Tablet Refills:*0
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Vitamin D 800 UNIT PO DAILY
5. Calcium Carbonate 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Anorexia, Dehydration
Secondary Diagnosis: Depression, Iron deficiency anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted for anorexia leading to dizziness
and dehydration. Your blood pressure was low. You were given
fluids in order to keep you well hydrated. You were also started
on Zoloft for depression. Your iron levels are low which causes
blood levels to be low which can add to dizziness. You were
given one dose of IV iron and started on iron pills. You were
also started on vitamins and calcium supplements to maintain
your bone health.
You have an intake appointment at ___ Behavioral Health on
___ at 10:30am at ___ in ___
Mass. The phone number there is ___.
Followup Instructions:
___
|
10847023-DS-14
| 10,847,023 | 20,050,136 |
DS
| 14 |
2175-07-09 00:00:00
|
2175-07-09 15:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Reglan / vancomycin / Demerol / Fioricet
Attending: ___.
Chief Complaint:
Neck pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with PMH of ETOH use disorder, chronic low back pain s/p
fusion in ___ on chronic dilaudid, seizure disorder, recent SDH
after fall s/p evacuation with burr holes in ___ and recent
hospitalization (___) for hypercarbic respiratory failure
presents with neck pain.
Regarding last admission was found down by friend and taken to
___ by EMS. Tox screen at that time was positive for
benzos and methadone. She reports that her methadone dose had
been increased to 30 mg recently prior to being found down. She
was initially admitted to the MICU treated with BiPAP. She was
transferred to the floor and did well however she reports that
her hospital team tried to discharge her earlier than she wanted
and she felt like she had no choice but to tell them she would
commit suicide if discharged. She was then discharged to ___ on a involuntary inpatient admission. Upon discharge
she
called her PCP and was complaining of inability to walk, chest
pain, neck pain and head pain. She was instructed to come to the
___ ED for evaluation.
She also had a recent admission from ___ this year after
presenting to the ___ clinic near her house and complaining
of some throat swelling. She is found to be hypertensive
advised
to go to the ED. At ___ she had an MRI/MRA done in the
that showed a stable right subdural hygroma with no significant
mass-effect or midline shift. There was also a subarachnoid
hemorrhage extending into the left frontal and parietal lobes.
She continued to have massive headaches and was taken to the OR
for left burr holes ×2 and subdural hematoma evacuation. Upon
further investigation it appeared that she had been drinking
prior to admission and may have suffered several falls.
She again presented to the ED on ___ was admitted until ___ ___. At this time she suffered a mechanical fall and
was complaining of pain on her right side as well as headache.
She had a head CT that was negative for hemorrhage or infarct.
She was discharged on Dilaudid 2 mg as needed.
In the ED, initial vitals were:
- Exam notable for: large palm-sized skin abrasion over
posterior
neck that the patient reports has been there for several weeks.
- Labs notable for: Hemoglobin 12.6 potassium 4.1
- Imaging was notable for:
CT head showed no fracture or traumatic malalignment. There was
soft tissue edema and stranding posteriorly extending from the
base of the occiput to the T2 vertebral body.
- Patient was given: Morphine, IV clindamycin and amlodipine.
An
occipital nerve block was attempted but failed to control pain.
Upon arrival to the floor, patient reports she continues to have
pain in the left side of her head and throughout her neck. She
has no fevers, chills, nausea, vomiting, diarrhea, chest pain or
shortness of breath.
Past Medical History:
Hypothyroidism
Chronic low back pain
Alcohol use disorder
Hypertension
Osteo-arthritis
Opioid use disorder
Seizure disorder
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITAL SIGNS: 98.0 126/75 53 18 97 Ra
GENERAL: Chronically ill-appearing female, in no acute distress
HEENT: NCAT, sclera anicteric, MMM, PERRLA, EOMI, well healed
craniotomy scar left frontal temporal region
NECK: Supple, JVP not elevated, no LAD
CARDIAC: 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
EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
NEUROLOGIC: AOx3 CN ___ intact, ___ strength upper/lower
extremities
MSK: intense tenderness to palpation in the left aspect of her
scalp and throughout cervical vertebrae and bilateral trapezius
SKIN: rectangular erythematous lesion on the posterior neck
DISCHARGE PHYSICAL EXAM:
==========================
PHYSICAL EXAM:
VITAL SIGNS: 98.2 113/74 68 18 92% RA
GENERAL: Chronically ill-appearing female, in no acute distress,
sleeping in bed, in pain with movement of head
HEENT: NCAT, sclera anicteric, MMM, well healed craniotomy scar
left frontal temporal region
CARDIAC: 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
EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
NEUROLOGIC: AOx3 CN ___ intact, ___ strength upper/lower
extremities with preserved sensation and proprioception in the
lower extremities bilaterally
MSK: intense tenderness to palpation in the left aspect of her
scalp and throughout cervical vertebrae and bilateral trapezius
SKIN: rectangular 5x6cm erythematous lesion on the posterior
neck
which is stable
Pertinent Results:
ADMISSION LABS:
================
___ 03:15PM BLOOD WBC-7.3 RBC-3.73* Hgb-12.6 Hct-38.5
MCV-103* MCH-33.8* MCHC-32.7 RDW-14.4 RDWSD-54.7* Plt ___
___ 03:15PM BLOOD ___ PTT-29.1 ___
___ 03:15PM BLOOD Glucose-67* UreaN-10 Creat-0.9 Na-139
K-6.4* Cl-99 HCO3-22 AnGap-18
___ 03:15PM BLOOD Albumin-4.1 Calcium-9.4 Phos-4.1 Mg-2.0
IMAGING:
================
CT HEAD:
--
There is no evidence of acute infarction,hemorrhage,edema, or
mass. There is prominence of the ventricles and sulci suggestive
of involutional changes.
Evidence prior left parietal burr holes are noted. No acute
fracture. The visualized portion of the paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable.
Carotid siphon calcifications are noted bilaterally. Suggestion
of soft
tissue swelling centered low just below the occiput (for example
see series 3, image 1).
1. No acute intracranial process. No acute intracranial
hemorrhage.
2. Mild focal soft tissue swelling/edema just inferior to the
occiput in the midline. No acute fracture.
3. Chronic findings include global involutional change and
vascular
calcifications.
CT C SPINE
--
Alignment is normal. No fractures are identified. Subtle lucency
across the anterior aspect of the transverse process of C1 is
likely secondary to a vascular channel. There is no evidence of
severe spinal canal or neural foraminal stenosis. There is no
prevertebral soft tissue swelling
As seen on prior head CT, there is soft tissue edema and
stranding posteriorly extending from the base of the occiput to
approximately the level of the T2 vertebral body superior and
just deep to the slightly edematous posterior spinal muscles.
No drainable fluid collection is seen. No subcutaneous
emphysema.
5-mm ground glass lesion is incidentally noted at the right lung
apex.
IMPRESSION:
1. No fracture or traumatic malalignment.
2. Soft tissue edema and stranding posteriorly extending from
the base of the occiput to the T2 vertebral body maybe secondary
to cellulitis/infectious process.
3. No drainable fluid collection or subcutaneous emphysema.
4. Incidental 5-mm ground glass lesion is noted at the right
lung apex.
MR ___
---
___ is mildly degraded by motion.
There is a 2 mm anterolisthesis of C7 on T1. Vertebral body
heights are
preserved. There is no marrow signal abnormality. Schmorl's
nodes are seen at Ne C6 and C7 superior endplates.
The visualized portion of the spinal cord is preserved in signal
and caliber.
There is loss of intervertebral disc height and signal
throughout the cervical spine.
There is no prevertebral soft tissue swelling..
The visualized portion of the posterior fossa, cervicomedullary
junction and lung apicesare preserved.
At C2-3 there is no vertebral canal or neural foraminal
narrowing.
At C3-4 there is mild disc bulging and uncovertebral osteophytes
without
vertebral canal narrowing and mild bilateral neural foraminal
narrowing (left greater than right).
At C4-5 there is disc bulging and uncovertebral osteophytes with
mild
vertebral canal narrowing and moderate bilateral neural
foraminal narrowing.
At C5-6 there is disc bulging and uncovertebral osteophytes
resulting in mild vertebral canal narrowing and mild left neural
foraminal narrowing.
At C6-7 there is disc bulging and uncovertebral osteophytes
without vertebral canal narrowing and moderate left neural
foraminal narrowing.
At C7-T1 there is no vertebral canal or neural foraminal
narrowing.
There is extensive abnormal T2/STIR signal of the posterior neck
with sprain versus partial tearing of the nuchal ligament as
well as strain versus partial tearing of the trapezius muscles.
There is also involvement of the capitis muscles. There is
extensive edema extending into the subcutaneous fat of the
posterior neck and upper back. There is no definite evidence of
peripherally enhancing fluid collection.
IMPRESSION:
1. ___ is mildly degraded by motion.
2. Extensive enhancing edema involving suboccipital soft tissues
with
extension into dorsal cervical subcutaneous soft tissues and
involving
bilateral superior trapezius muscles. Question partial tearing
of nuchal
ligament as well as strain and high-grade partial tearing of the
trapezius and capitis muscles. Findings suggestive of
posttraumatic etiology with
differential considerations of infectious and inflammatory
etiologies such as cellulitis and/or myositis.
3. No definite evidence of abscess.
4. No evidence of discitis-osteomyelitis or epidural abscess.
5. Mild spondylotic changes of the cervical spine most
significant at C4-C5 where there is mild vertebral canal
narrowing and moderate bilateral neural foraminal narrowing.
MICRO
============
None
DISCHARGE LABS
============
___ 04:45AM BLOOD WBC: 3.4* RBC: 3.29* Hgb: 11.2 Hct: 34.1
MCV: 104* MCH: 34.0* MCHC: 32.8 RDW: 14.2 RDWSD: 54.6* Plt Ct:
185
___ 04:45AM BLOOD Glucose: 78 UreaN: 7 Creat: 0.8 Na: 142
K: 4.3 Cl: 107 HCO3: 25 AnGap: 10
___ 04:45AM BLOOD Calcium: 9.0 Phos: 4.4 Mg: 1.8
Brief Hospital Course:
PATIENT SUMMARY:
================
___ yo F with PMH of ETOH use disorder, chronic low back pain s/p
fusion in ___ on chronic dilaudid, seizure disorder, recent SDH
after fall s/p evacuation with burr holes in ___ and recent
hospitalization (___) for hypercarbic respiratory failure
presenting with neck pain found to have partial tearing of
nuchal ligament as well as strain and high-grade partial tearing
of the trapezius and capitis muscles.
=============
ACUTE ISSUES:
=============
#Head and neck pain
The patient presented with ___ weeks of severe neck and head
pain. Per review of outside electronic medical records and
discussion with the patient's primary care doctor, it appears as
though she has had chronic head and neck pain for several months
to a year. Prior imaging has been unremarkable. She had a repeat
CT scan of the head during this admission which showed no acute
intracranial process and no evidence of intracranial hemorrhage.
There was mild focal soft tissue swelling and edema just
inferior to the occiput in the midline without any evidence of
fracture. There were chronic findings including global
involutional change and vascular calcifications. She also had an
MRI of the cervical spine which showed extensive enhancing edema
involving suboccipital soft tissues with extension into the
dorsal cervical subcutaneous soft tissues and involving
bilateral superior trapezius muscles there was also questionable
partial tearing of nuchal ligament as well as strain and
high-grade partial tearing of the trapezius and capitis muscles.
She was seen by the neurology consult service who thought a
focal neurological abnormality was unlikely. They recommended a
neck brace to help support her neck. The patient's pain was
controlled initially with Dilaudid which had been started at the
outside hospital. She was subsequently transitioned to morphine
15 mg every 4 hours for acute pain, with further opiate
management to be handled by the patient's primary care team.
Upon discharge the patient continued to experience significant
posterior head and superficial neck pain. She adamantly
requested an MRI of the brain with contrast. However, this was
not indicated according to neurology for the primary team.
#Urinary retention
Patient developed urinary retention during this hospitalization.
This was likely secondary to use of opioids as pain medications.
She underwent intermittent straight catheterizations. She will
be sent home with a Foley catheter. She will have urology
follow-up on ___ as above.
===============
CHRONIC ISSUES:
===============
#HTN
The patient's hypertension was controlled with home metoprolol
and amlodipine.
#Seizure disorder
The patient has a history of primary seizure disorder. She
states however that she had not taken her Lamictal and has not
had a seizure in over ___ years. It is unclear to her whether or
not she should be taking her antiepileptic. This should be
followed up in the outpatient setting.
#Hypothyroidism
According to the patient's primary care doctor, she is no longer
taking levothyroxine. This was not restarted during this
hospitalization.
#Alcohol use disorder/opioid use disorder
The patient has a documented history of both opioid use disorder
and alcohol use disorder. She however denies this history. She
is set to follow-up with a new primary care doctor at ___
___ in order to help manage
her long-term opioid needs. She was seen by the addiction social
work team during this hospitalization.
=======================================
TRANSITIONAL ISSUES:
1) The patient should have a TSH checked in the outpatient
setting. She should resume levothyroxine depending on this
result.
2) It is unclear whether or not the patient should be on
Lamictal for seizure prophylaxis. Should also be followed up
with in the outpatient setting.
3) Discharged with Foley Catheter: to be managed by urology on
___ Discharged with 12 tablets of morphine for acute pain.
Please wean as per primary team.
5) Started amitriptyline for neuropathic pain
6) Holding home zolpidem to avoid over-sedation in setting of
opiates.
# CODE: FULL CODE (PRESUMED)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. ClonazePAM 0.5 mg PO TID
4. Zolpidem Tartrate 10 mg PO QHS
5. Omeprazole 20 mg PO DAILY
6. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
7. Atorvastatin 40 mg PO QPM
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Multivitamins 1 TAB PO DAILY
10. LamoTRIgine 75 mg PO BID
11. Pregabalin 75 mg PO BID
12. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Moderate
RX *acetaminophen [Acetaminophen Pain Relief] 500 mg 1 tablet(s)
by mouth every six (6) hours Disp #*30 Tablet Refills:*0
2. Amitriptyline 10 mg PO QHS
RX *amitriptyline 10 mg 1 tablet(s) by mouth at bedtime Disp
#*30 Tablet Refills:*1
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*14 Capsule Refills:*0
4. Lidocaine 5% Ointment 1 Appl TP BID
RX *lidocaine [LC-5] 5 % Apply to burn on neck and back of head
twice a day Refills:*0
5. Morphine Sulfate ___ 15 mg PO Q4H:PRN Pain - Severe Duration:
12 Doses
Reason for PRN duplicate override: Alternating agents for
similar severity
Do NOT take with clonazepam as this can be unsafe.
RX *morphine 15 mg 1 tablet(s) by mouth every six (6) hours Disp
#*12 Tablet Refills:*0
6. ClonazePAM 0.5 mg PO TID:PRN Anxiety
7. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
8. amLODIPine 5 mg PO DAILY
9. Atorvastatin 40 mg PO QPM
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Pregabalin 75 mg PO BID
15. Thiamine 100 mg PO DAILY
16.Pediatric Rolling Walker
Pediatric Rolling Walker
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: traumatic neck injury
Secondary diagnoses: recent subdural hematoma status post
evacuation with burr holes, opioid use disorder, alcohol use
disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
-You were admitted to the hospital due to bad you had head and
neck pain.
WHAT HAPPENED IN THE HOSPITAL?
-You had CT imaging of the head which was reassuring and showed
no evidence of bleeding.
-You were given pain medications to control your pain.
-You were started on low-dose amitriptyline for better head pain
control.
-You had an MRI of your upper spine which showed significant
swelling as well as strained ligaments and muscles.
-You were evaluated by the neurology team who believed to her
head pain was caused by the injuries above.
-Your also evaluated by the physical therapy team. They
recommended getting out of bed as many as 3 times per day in
order to help you get better.
-You were given a soft collar to wear around her neck. This
should help support her neck muscles.
- You were unable to urinate so we had to place a Foley
Catheter, which a urologist will remove at the appointment on
___ if you are able to urinate on your own at that point(see
below)
WHAT SHOULD YOU DO AT HOME?
-You should follow-up with Dr. ___ at 3:15 ___ on ___,
___. Her office is located at ___. The office phone is ___.
-You should continue to take all of your medications at home.
-You should watch out for any worsening weakness in your legs or
arms.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
10847303-DS-18
| 10,847,303 | 29,872,108 |
DS
| 18 |
2186-05-05 00:00:00
|
2186-05-05 17:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Toe Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with a history of AFib
(recently started on apixaban from warfarin 2 weeks ago), COPD,
DM2 (previously on insulin), ESRD (on ___ HD), and PAD s/p LLE
angioplasty and stenting who was referred from ___ clinic
for left leg and toe pain.
He developed left big toe discoloration and pain after dropping
furniture on it. His pain is severe and constant, limiting his
movement. He had an angioplasty a couple weeks ago at ___, since then causing intermittent pain in his thigh
and calf.
He denies fevers, chills, chest pain, or discoloration / nodules
in the hands.
In the ED,
Initial vital signs: T 97.5 HR 75 BP 140/70 RR 20 O2 Sat 96% RA
Exam notable for:
His L great toe is slightly cooler than the rest of his foot but
the foot overall is warm.
EKG:
HR 72, Atrial fibrillation
Labs were notable for:
Lactate 1.3
Chem panel: Na 140, K 5.4, Cl 95, CO2 29, BUN 48, Cr 6.6, Glc
154
CBC: WBC 6.1, Hgb 8.7 with MCV 97, Hct 27.7, Plt 164
Coags: ___ 14.8, PTT 32.2, INR 1.4
Studies performed include:
CTA Lower extremity w/ and w/out contrast-
Extensive atherosclerotic calcifications throughout the
abdominal
aorta is main branches and lower extremity vessels. Vessels in
the calves are densely calcified therefore limiting evaluation
for patency to the foot. The left anterior tibial and posterior
tibial arteries are patent to the foot.
Multiple cystic lesions in the pancreas measuring up to 1.2 cm,
potentially side-branch IPMNs. Consider one year follow-up MRI.
Left XR foot- No radiopaque foreign body.
Patient was given:
- IV Morphine 2mg
- Gabapentin 300mg
- Apixaban 2.5mg
- IV heparin drip
Consults:
Vascular - "His L great toe is slightly cooler than the rest of
his foot but the foot overall is warm and has signals present.
He
could potentially have an element of blue toe syndrome from
atheroemboli from his recent angio." Recommendations - Obtain
records and imaging from St. E's angiogram, place on heparin gtt
in case of potential procedures, admit to medicine for pain
control and further workup.
Upon arrival to the floor, patient is resting. He requests CPAP
for his sleep. His pain is overall well controlled and as long
as
he is not moving his leg, he does not have significant pain. Of
note, his insulin regimen is a little unclear. It is not
provided
on his wife's list although patient reports he takes "20U once
every 3 days."
Past Medical History:
Morbid obesity
Obstructive sleep apnea on CPAP (setting of 16)
Diabetes Type II
Hypertension
Hypercholesterolemia
Persistent atrial fibrillation
___ Right sided pneumonia
Nephritis
URI 09
Preserved LV systolic function with mild to moderate MR
S/p TURP
COPD with an FEV1 of 1.62, 56% of predicted
Proteinuria, previously followed by Dr. ___, was on
prednisone.
Social History:
___
Family History:
father is ___ and had stents placed at ___. Mother died from
complications of diabetes at ___
Physical Exam:
Admission
VITALS: T 98.0 BP 166 / 74 HR 72 RR 18 O2 Sat 93 RA
GEN: In NAD. Resting in bed, drowsy. BMI ~35 corresponding with
Obese
HEENT: PERRL, moist mucous membranes, oropharynx clear without
exudates.
PSYCH: Normal affect.
NECK: No JVD, no cervical lymphadenopathy.
CV: Irregular rate and rhythm, normal HR ___. no
murmurs/gallops/rubs.
PULM: CTAB, no wheezing/crackles/rhonchi.
ABD: Soft, non tender, non distended.
EXTREM: Dopplerable pulses bilaterally- DP and ___. 1+ lower
extremity edema in left lower extremity with purpuric
discoloration of the left great toe with no evidence of
ulceration of the foot or toe. Tender to palpation.
was tender to palpation.
SKIN: Dystrophi nail changes, most prominent on left great toe.
No rashes.
NEURO: A&Ox3, CN II-XII intact, motor and sensation grossly
intact.
Discharge Exam:
===========================
GEN: Well appearing, in no acute distress
LUNGS: CTAB
HEART: RRR, nl S1, S2. II/VI SEM.
ABD: NT/ND, normal bowel sounds.
EXTREMITIES: Trace edema. WWP. Left ___ toe dusky/blue, mild TTP
Pertinent Results:
Admission Labs
___ 04:10PM BLOOD WBC-6.1 RBC-2.85* Hgb-8.7* Hct-27.7*
MCV-97 MCH-30.5 MCHC-31.4* RDW-14.0 RDWSD-49.9* Plt ___
___ 04:10PM BLOOD ___ PTT-32.2 ___
___ 04:10PM BLOOD Glucose-154* UreaN-48* Creat-6.6*# Na-140
K-5.4 Cl-95* HCO3-29 AnGap-16
Studies:
___ Foot XR
There is no fracture. No focal erosions. Joint spaces are
preserved.
Moderate plantar calcaneal spur is identified. Extensive
vascular
calcifications identified. No radiopaque foreign body.
IMPRESSION:
No radiopaque foreign body.
___ CTA
Extensive atherosclerotic calcifications throughout the
abdominal aorta is main branches and lower extremity vessels.
Vessels in the calves are densely calcified therefore limiting
evaluation for patency to the foot. The left anterior tibial
and posterior tibial arteries are patent to the foot. Multiple
cystic lesions in the pancreas measuring up to 1.2 cm,
potentially side-branch IPMNs. Consider one year follow-up MRI.
Discharge Labs:
___ 07:10AM BLOOD WBC-6.1 RBC-2.93* Hgb-8.7* Hct-27.8*
MCV-95 MCH-29.7 MCHC-31.3* RDW-14.3 RDWSD-50.2* Plt ___
___ 08:41AM BLOOD ___
___ 07:10AM BLOOD Glucose-130* UreaN-68* Creat-9.5*# Na-138
K-5.6* Cl-92* HCO3-27 AnGap-19*
___ 07:10AM BLOOD Calcium-10.2 Phos-7.8* Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ year old man with PMH significant for
HTN, HLD, ESRD (on ___ HD), CAD, AF, hx CVA (___), DM2, OSA,
who presented with ongoing pain in left ___ large toe, s/p LLE
angioplasty/stenting at ___ 1 week prior to admission.
He had not been taking plavix at home and recently transitioned
to apixiban for afib. He was started on heparin gtt and Plavix
for suspicion of arterial embolism to the toe. Vascular surgery
was consulted who recommended medical managment with transition
to coumadin given limited data on apixiban in ESRD.
ACUTE ISSUES
=============
# Left leg pain
# Concern for lower limb ischemia
Patient has recent history of peripheral arterial disease and
has extensive atherosclerosis involving the popliteal and tibial
vessels without an obvious focal stenosis. He recently underwent
LLE angioplasty and stenting at ___ but concern is
for possible small plaque embolization to toe or ongoing
ischemia
after stent placement. He was started on a heparin gtt and
brdiged to warfarin. He was restarted on home Plavix which he
was not previously taking over the last week. Vascular surgery
was consulted, and recommended ongoing medical managment. His
pain was managed with acetaminophen 1g q8h PRN, gabapentin 300mg
BID, tramadol 50mg TID PRN. Discharged on coumading 7.5mg daily
once INR therapeutic.
# ESRD on dialysis:
Gets dialysis on MWF at ___. Nephrology had previously been
trying to challenge his dry weight to about ___ kg due to
hypotension. He was continued on calcium acetate and calcitriol.
He continued midodrine 10mg TID (and additional 5mg PRN at
dialysis) due to hypotension.
# Atrial fibrillation: S/p ablation. CHADSVasc 5.
Per recent cardiology note, Dr. ___
discontinuation of apixaban (2.5mg daily) given its uncertain
safety profile in ESRD hemodialysisand recommended returning to
warfarin therapy, but appears patient has not been taking
warfarin at home and failed to go to ___ clinic. Now, given
the need for anticoagulation for the PAD above, he was bridged
to warfarin with goal INR of ___. He continued digoxin 0.125mg
MWF. He was counseled on the importance of close INR monitoring
and will have his INR checked next week on ___
CHRONIC ISSUES
===============
# Type 2 diabetes:
Not on insulin currently. Per the patient, he is now on
Tradjenta which his non-formulary. He was continued on ISS while
in hospital, but will be transitioned back to tradjenta at
discharge
# CAD
Continued atorvastatin 80mg daily, Plavix as above
# OSA
On CPAP at night
# GERD
Continued on pantoprazole 40mg daily
Transitional Issues
====================
[] Patient will need careful INR monitoring while in ___.
Goal INR ___
[] Continue Plavix for 3 months given drug-coated balloon
angioplasty procedure.
[] Vascular follow up with Dr. ___ upon return
from ___
[] Patient has the name of ___ vascular surgeon in ___ that he
will see if new or worsening symptoms
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Pantoprazole 40 mg PO Q24H
2. Calcitriol 0.25 mcg PO DAILY
3. Midodrine 10 mg PO TID
4. TraMADol 50 mg PO TID:PRN Pain - Moderate
5. FoLIC Acid 1 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Tradjenta (linaGLIPtin) 5 mg oral DAILY
8. Calcium Acetate 667 mg PO TID W/MEALS
9. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
10. brimonidine 0.2 % ophthalmic (eye) BID
11. Midodrine 5 mg PO PRN At HD for hypotension
12. Digoxin 0.125 mg PO EVERY OTHER DAY MWF
13. Apixaban 2.5 mg PO DAILY
14. Gabapentin 300 mg PO BID
15. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Warfarin 7.5 mg PO DAILY16
RX *warfarin [Coumadin] 7.5 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
2. Calcium Acetate 1334 mg PO TID W/MEALS
3. Gabapentin 300 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. brimonidine 0.2 % ophthalmic (eye) BID
6. Calcitriol 0.25 mcg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Digoxin 0.125 mg PO EVERY OTHER DAY MWF
9. FoLIC Acid 1 mg PO DAILY
10. Midodrine 10 mg PO TID
11. Midodrine 5 mg PO PRN At HD for hypotension
12. Pantoprazole 40 mg PO Q24H
13. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
14. Tradjenta (linaGLIPtin) 5 mg oral DAILY
15. TraMADol 50 mg PO TID:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Peripheral arterial embolization
Acute toe ischemia
Secondary:
Hypertension
Peripheral arterial disease
Hyperlipidemia
End stage renal disease
Diabetes
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure caring of you at ___.
WHY WAS I IN THE HOSPITAL?
- You were hospitalized for worsening pain in your toe
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were found to likely have a blood clot in the blood vessel
going to your toe
- You received blood thinning medications to dissolve the clot
- You were restarted on coumadin
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- You will need to continue taking Plavix (Clopidogrel) for at
least 3 months. Please make sure to continue taking this
medication until you are seen by your vascular doctors
- You should follow up with ___ clinic in ___ within
the next ___ days. Your INR goal is ___.
- Please make sure to see a vascular surgeon in ___ if you
have any new or worse symptoms
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10847398-DS-17
| 10,847,398 | 29,455,859 |
DS
| 17 |
2167-12-09 00:00:00
|
2167-12-09 16:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / lactose / ceftriaxone / adhesive / Tegaderm
/ ultrasound gel
Attending: ___
Chief Complaint:
Cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx EtOh Cirrhosis (MELD 40, Child ___ Class C)
previously c/b ascites and HE being referred from liver clinic
for management of cellulitis and need for IV abx.
Patient began developing area of erythema on posterior R thigh
approximately two weeks ago which was mildly painful. He denied
any local trauma or inciting event. Patient was evaluated in
___ clinic approximately one week ago and had U/S done
which was negative for DVT. He was seen in clinic again on
___ for routine 8L therapeutic paracentesis and had noted
worsening erythema/pain in thigh area. He was subsequently
referred to ED due to concern for cellulitis and recommended
admission for IV abx.
- In the ED, initial vitals were: 97.5 | 57 | 114/56 | 16, 99%RA
- Exam was notable for: Palm sized area of erythema without
fluctuance or crepitus on posterior left thigh. No scrotal
involvement.
- Labs were notable for: No leukocytosis. HgB 9.4. Na: 132. Cr
1.3 which is baseline. INR: 2.5. Tb 6.5.
- Studies were notable for: Dx Para negative for SBP
- The patient was given:
___ 16:11 IV Clindamycin 600 mg
___ 20:18 PO OxyCODONE 5 mg
- Hepatology was consulted who recommended clindamycin and
admission to ET under Dr ___.
On arrival to the floor, the pt endorsed the above history. He
endorsed low grade temp of 99 x 4 days, but otherwise denied
chills, cp, sob, abd pain, change in urinary or bowel habits.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
Alcoholic cirrhosis
Hepatic encephalopathy
Ascites
Obesity
Chronic pain
Anxiety
History of alcohol misuse disorder
Tobacco dependence
Social History:
Prior to 5 weeks ago at his hospitalization at ___, he had
been using alcohol almost on daily basis consuming 1 pint of
vodka daily. Since his hospitalization at ___ in ___, he
quit drinking. No recent drug use. Not currently employed. Lives
at home with his wife. ___ ___ cigarettes per day.
Per ___ Psychiatric consult note: "Patient is the youngest
out of 3 children in the family. He has an older brother and an
older sister. Patient's parents got divorced. Patient was raised
by his mother. He graduated from high school and worked at a
___. Patient is currently disabled and supports himself
by receiving SSDI. Patient lives at home with his wife of ___
years. He does not have any children. Patient denied any prior
history of inpatient psychiatric care. He denied history of
mania or psychotic features. Patient denied any history of
suicidal or homicidal attempts or ideations Patient started
abusing alcohol as a teenager."
Family History:
T2DM
No history of liver disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 98.5, BP 101/60, HR 74, RR 18, O2 99% on RA
GENERAL: Alert and interactive, NAD
CARDIAC: RRR, no m/r/g
LUNGS: CTAB, no wheezes or crackles
ABDOMEN: Soft, slightly distended, non tender, no
rebound/guarding, BS+
EXTREMITIES: Posterior L thigh w/ large poorly demarcated
reticular erythematous rash, warm to touch, no open areas or
drainage, no induration
SKIN: Rash as noted above
NEUROLOGIC: AOx3, CNII-XII intact, no asterixis
DISCHARGE PHYSICAL EXAM:
========================
___ 0739 Temp: 98.0 PO BP: 104/58 HR: 70 RR: 18 O2 sat: 99%
O2 delivery: Ra
GENERAL: NAD, appears comfortable
CARDIAC: RRR, no m/r/g
LUNGS: normal WOB, CTAB, no wheezes or crackles
ABDOMEN: Soft, slightly distended, non tender, no
rebound/guarding, BS+
EXTREMITIES: Posterior L thigh w/ large poorly demarcated raised
erythematous rash, warm to touch, no open areas or drainage, no
induration or fluctuance
SKIN: Rash as noted above
NEUROLOGIC: AOx3, CNII-XII intact, no asterixis
Pertinent Results:
ADMISSION LABS:
===============
___ 07:25AM BLOOD WBC-5.3 RBC-2.99* Hgb-10.2* Hct-31.4*
MCV-105* MCH-34.1* MCHC-32.5 RDW-14.6 RDWSD-56.7* Plt Ct-82*
___ 12:53PM BLOOD Neuts-65.1 Lymphs-15.8* Monos-10.8
Eos-6.4 Baso-1.4* Im ___ AbsNeut-2.76 AbsLymp-0.67*
AbsMono-0.46 AbsEos-0.27 AbsBaso-0.06
___ 07:25AM BLOOD ___
___ 07:25AM BLOOD Creat-1.5* Na-140 K-4.4
___ 07:25AM BLOOD ALT-22 AST-67* AlkPhos-208* TotBili-6.5*
___ 07:25AM BLOOD Albumin-3.6
___ 10:59AM BLOOD Albumin-3.3* Calcium-8.6 Phos-3.1 Mg-1.7
___ 07:25AM BLOOD Ethanol-NEG
___ 03:15PM BLOOD K-8.9*
___ 05:35PM BLOOD K-4.2
___ 09:37AM ASCITES TNC-89* RBC-876* Polys-2* Lymphs-21*
Monos-7* Mesothe-3* Macroph-67*
___ 09:37AM ASCITES TotPro-1.4 Albumin-0.7
DISCHARGE LABS:
===============
___ 06:02AM BLOOD WBC-4.6 RBC-2.69* Hgb-9.2* Hct-27.9*
MCV-104* MCH-34.2* MCHC-33.0 RDW-14.6 RDWSD-55.8* Plt Ct-79*
___ 06:02AM BLOOD Plt Ct-79*
___ 10:59AM BLOOD Plt Ct-77*
___ 10:59AM BLOOD ___ PTT-63.5* ___
___ 06:02AM BLOOD Glucose-100 UreaN-21* Creat-1.3* Na-140
K-4.3 Cl-107 HCO3-23 AnGap-10
___ 06:02AM BLOOD ALT-17 AST-49* AlkPhos-134* TotBili-6.5*
___ 06:02AM BLOOD Albumin-3.2* Calcium-8.8 Phos-3.4 Mg-1.8
PERTINENT STUDIES:
==================
Radiology Report CT LOW EXT W/O C LEFT Study Date of ___
10:18 ___
COMPARISON: CT ___
FINDINGS:
There is mild skin thickening and subcutaneous edema diffusely
throughout the
lower thigh. No deep fluid collection.
Mild degenerative spurring superior acetabulum. Lobulated, soft
tissue
density within the medullary cavity of the proximal left femur,
likely
represents marrow reconversion, but is indeterminate.
No fracture, no fracture or dislocation. No knee joint effusion.
Muscle is
normal in bulk.
There is a large amount of fluid, likely ascites within the
visualized pelvis.
Left fat containing inguinal hernia is moderate. Otherwise,
limited
assessment of the intrapelvic structures is unremarkable.
IMPRESSION:
1. Mild skin thickening and subcutaneous edema throughout the
left thigh. No
deep fluid collection or evidence of deep infection.
2. Lobulated, soft tissue density within the medullary cavity of
the proximal
left femur, likely represents marrow reconversion, but is
indeterminate.
Recommend non-urgent MRI when the patient's acute symptoms have
resolved.
3. Large volume intra-abdominal ascites.
MICROBIOLOGY:
=============
__________________________________________________________
___ 10:59 am BLOOD CULTURE #2.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 6:46 am BLOOD CULTURE #1.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 9:37 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Brief Hospital Course:
___ with PMHx EtOh Cirrhosis (Child ___ Class C) previously d/b
ascites, HE, referred from liver clinic d/t c/f cellulitis and
need for IV abx.
ACUTE/ACTIVE ISSUES:
====================
# Localized cellulitis
Patient referred from ___ clinic d/t worsening region of
erythema and pain in R posterior thigh. Recent US negative for
DVT. Afebrile, HDS, no leukocytosis, no fluctuance, minimally
tender. CT of thigh showed did not show any evidence of a deep
infection. Rapidly improved on IV vancomycin. Transition to PO
Bactrim and will complete 7 day total course of antibiotics as
outpatient.
# Hyponatremia
Patient admitted with Na of 132 iso of his cirrhosis as below.
Stable.
CHRONIC/STABLE ISSUES:
======================
# Etoh Cirrhosis (MELD 28)
- Volume: Continued home 20mg lasix
- Infection: s/p 8L LVP ___, w/o SBP
- Bleeding: No h/o varices
- Encephalopathy: Has h/o HE, continued home lactulose/rifaximin
- Continued home midodrine
# CKD
Patient admitted with Cr of 1.3 which is his baseline. Stable.
# Depression
# Sleep
Continued home SSRI and trazodone.
# Chronic pain
Continued home oxycodone.
CORE MEASURES:
==============
# CODE: Full (confirmed)
# CONTACT: ___ (HCP) ___
TRANSITIONAL ISSUES:
====================
[] Continue PO Bactrim for cellulitis for 7 day course (last day
___.
[] Follow up with Dr. ___ liver clinic) on
___. Obtain labwork and paracentesis on that day.
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. Midodrine 15 mg PO TID
2. Lactulose 15 mL PO DAILY
3. Simethicone 40-80 mg PO QID
4. Nicotine Patch 21 mg/day TD DAILY
5. LORazepam 1 mg PO BID:PRN Anxiety
6. Furosemide 20 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. OxyCODONE (Immediate Release) 2.5 mg PO Q8H:PRN Pain -
Moderate
9. Pantoprazole 40 mg PO Q24H
10. rifAXIMin 550 mg PO BID
11. Sertraline 25 mg PO DAILY
12. TraZODone 50 mg PO QHS:PRN Insomnia
13. FoLIC Acid 1 mg PO DAILY
14. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Sulfameth/Trimethoprim DS 2 TAB PO BID
2. FoLIC Acid 1 mg PO DAILY
3. Lactulose 15 mL PO DAILY
4. LORazepam 1 mg PO BID:PRN Anxiety
5. Midodrine 15 mg PO TID
6. Multivitamins 1 TAB PO DAILY
7. Nicotine Patch 21 mg/day TD DAILY
8. OxyCODONE (Immediate Release) 2.5 mg PO Q8H:PRN Pain -
Moderate
9. Pantoprazole 40 mg PO Q24H
10. rifAXIMin 550 mg PO BID
11. Sertraline 25 mg PO DAILY
12. Simethicone 40-80 mg PO QID
13. Thiamine 100 mg PO DAILY
14. TraZODone 50 mg PO QHS:PRN Insomnia
15. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until told by your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Localized cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at ___.
Why you were in the hospital:
-You had a skin infection on your left leg.
What was done for you in the hospital:
-You were treated with antibiotics.
What you should do after you leave the hospital:
- Please ensure you get your regular labs drawn next week.
- Please take the antibiotic, Bactrim, to finish treating your
skin infection. Your last day of antibiotics will be on ___.
- Please monitor your rash. If it worsens, call your doctor.
- Please take your medications as detailed in the discharge
papers. If you have questions about which medications to take,
please contact your regular doctor to discuss.
- Please go to your follow up appointments as scheduled in the
discharge papers. Most of them already have a specific date &
time set. If there is no specific time specified, and you do not
hear from their office in ___ business days, please contact the
office to schedule an appointment.
- Please monitor for 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:
___
|
10848070-DS-10
| 10,848,070 | 25,258,928 |
DS
| 10 |
2160-12-12 00:00:00
|
2160-12-18 15:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
vertigo, unsteadiness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old right handed woman with history of
HTN, HLD, diabetes on insulin, Hep C and tobacco abuse who
presents with persisent vertigo since yesterday morning. When
patient woke up yesterday and stood up, the room started
spinning
to the right and she felt nauseated but did not vomit. She sat
back down on the bed and noted that closing her eyes helped.
She
endorses blurred vision, but no diplopia. She tried to eat
something to see if that would help, but it did not. Patient
took a nap, but vertigo persisted upon waking up. She states it
is more severe with position changes, especially with walking,
but also present at rest. Ms. ___ reports that her left arm
has been weak "on and off" since yesterday. For example, she
had
difficulty bringing a glass to her mouth. She has been quite
unsteady with walking, no falls, not sure if she is veering to
the left or the right more. She did not have a headache
initially but now she does after being examined in the ED and
"the doctors ___ back and forth." Currently, the
room spinning sensation persists and has not improved since
yesterday. She continues to be nauseated and zofran did not
help. She denies weakness in her legs, numbness, speech
difficulty, recent infectious symptoms, ear pain, changes in
hearing. Does endorse tinnitus lasting seconds in both ears
occasionally for the last 6 months or so.
Ms. ___ had a similar episode of dizziness 6 months or a
year
ago which lasted ___ days. She did not present for evaluation
at
that time. She told her PCP only after the fact and was
prescribed meclezine as needed. She did not have any work up.
On neuro ROS, the pt endorses occasional twitches in her arms
and
legs for months. denies loss of vision, diplopia, dysarthria,
dysphagia, lightheadedness. Denies difficulties producing or
comprehending speech. Denies focal numbness, parasthesiae. No
bowel or bladder incontinence or retention.
On general review of systems, the pt endorses chronic dry cough
and constipation. denies recent fever or chills. No night
sweats
or recent weight loss or gain. Denies shortness of breath.
Denies chest pain or tightness, palpitations. Denies nausea,
vomiting, diarrhea, abdominal pain. No recent change in bowel
or bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
DM type 2 on insulin
Hypertension
Hyperlipidemia
Hepatitis C, diagnosed ___, never treated
Alcohol abuse in remission since ___
Anxiety
Depression
??(per records) CKD per patient from ___ (?MPGN) though Cr is
0.9
GERD
Tobacco abuse
Past surgical history: 2 c-sections
Social History:
___
Family History:
Mother - alive DM2, DM in others. Brother died of colon cancer
at age ___.
No strokes, seizures
Physical Exam:
ADMISSION EXAM:
Vitals: T 99.1 HR 92 BP 139/72 RR 18 O2 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self, date, place. Able to
relate history without difficulty. Attentive, able to name ___
backward with mild difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Speech was not dysarthric. Able to follow
both midline and appendicular commands. Pt. was able to register
3 objects and recall ___ at 5 minutes, ___ when given options.
There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI, left beating sustained nystagmus on left gaze
and right beating sustained nystagmus on right gaze. On upgaze,
there is left beating rotatory 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.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, proprioception
throughout. No extinction to DSS. Decreased sensation to pin
prick distally in lower extremities to just above the ankles.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 3+ 2
R 2+ 2+ 2+ 3+ 2
Plantar response was flexor bilaterally.
-Coordination: Mild dysmetria on FNF on left. Ataxia with
finger tapping on crease and overshoot with mirroring on left.
No dysmetria on HKS bilaterally.
-Gait: Good initiation. Mildly wide based and unsteady, tends to
fall towards the left perhaps. Romberg absent.
___ SLEEPINESS SCALE: 15
- sitting and reading: 1
- watching tv: 3
- sitting inactive in a public place: 1
- as a passenger in a car for an hour without a break: 3
- lying down to rest in the afternoon when circumstances permit:
3
- sitting and talking to someone: 2
- sitting quietly after lunch without alcohol: 2
- in a car, while stopped for a few minutes in traffic: 0
+ Endorsed snoring hx
+ Patient described having no difficulty falling asleep with her
current sleep medications, but wakes up 3x per night coughing
and choking for breath. She takes cough syrup each evening
before bed for the cough.
DISCHARGE EXAM:
EOMI with non-extinguishing leftward-beating nystagmus on
leftward gaze as well as rightward-beating nystagmus on
rightward gaze which extiguishes after five beats. There is no
upward-beating nystagmus.
Pertinent Results:
ADMISSION EXAM: ___
WBC-11.4*# RBC-3.88* Hgb-12.4# Hct-34.0* MCV-88# MCH-32.0
MCHC-36.5*# RDW-12.7 Plt ___
Neuts-63.8 ___ Monos-3.2 Eos-0.8 Baso-0.3
Glucose-177* UreaN-13 Creat-0.9 Na-138 K-3.6 Cl-103 HCO3-25
AnGap-14
Calcium-9.5 Phos-2.7 Mg-1.5*
ALT-28 AST-26 AlkPhos-101 TotBili-0.1
Calcium-8.9 Phos-3.0 Mg-1.9
UA bland
UTox negative
STROKE WORKUP:
Cholest-130 Triglyc-334* HDL-18 CHOL/HD-7.2 LDLcalc-45
%HbA1c-13.6* eAG-344*
IMAGING:
CTA Neck ___
IMPRESSION:
1. Chronic left lamina lacune without evidence of acute
intracranial hemorrhage. - Common origin of LCCA and innominate
2. Mildly narrowed right cavernous and supraclinoid ICA from
calcified &
non-callc plaque, w/out stenosis.
3. 1.5mm Infundibulum at origin of L ophthalmic artery. No
aneurysm greater than 3 mm in size.
4. Patchy airspace disease in the left upper lung with enlarged
mediastinal lymph node. Dedicated chest CT is recommended for
further evaluation. This report is provided without 3D and
curved reformats. When these images are available, and if
additional information is obtained, then an addendum may be
given to this report.
RECOMMENDATION(S):
1. Patchy airspace disease in the left upper lung with enlarged
mediastinal lymph node. Dedicated chest CT is recommended for
further evaluation.
MRI ___
IMPRESSION:
No evidence of acute ischemia.
No evidence of other acute intracranial process.
Multiple scattered foci of high signal intensity identified in
the subcortical and periventricular white matter, are
nonspecific and may reflect changes due to small vessel disease.
ECHO ___
Conclusions
The left atrium and right atrium are normal in cavity size. No
left atrial mass/thrombus seen (best excluded by transesophageal
echocardiography). No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The 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. Moderate (2+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: No cardiac source of embolism seen. Normal global
and regional biventricular systolic function. Moderate mitral
regurgitation. Negative bubble study.
CT Chest ___
IMPRESSION:
Multifocal mediastinal lymphadenopathy accompanied by diffuse
lung disease with predominantly ground-glass features.
Differential diagnosis includes acute processes such as atypical
infection, subacute processes such as hypersensitivity
pneumonitis, and more chronic abnormalities including
sarcoidosis. A neoplastic abnormality such as lymphoma or
multicentric lung adenocarcinoma is considered less likely.
RECOMMENDATION:
___ MONTH FOLLOWUP CT WITH INTERVAL ANTIBIOTIC THERAPY IF
PULMONARY INFECTIOUS SYMPTOMS ARE PRESENT.
Brief Hospital Course:
___ is a ___ old right-handed woman with a history
of uncontrolled diabetes, hypertension, hepatitis C and tobacco
abuse who presented with persistent vertigo and unsteadiness. On
examination she had direction changing nystagmus and subtle
left-sided dysmetria. Her MRI was negative for acute stroke
although there was evidence of small vessel disease. Her
presenting symptoms were felt to be secondary to peripheral
vertigo. However, she was noted to have multiple poorly
controlled stroke risk factors, most notably her uncontrolled
diabetes and smoking.
# Neurologic:
Her vertigo was attributed to peripheral vertigo; her presenting
symptoms of direction-changing nystagmus was thought to be
related to her multiple psychoactive medications and there was
no evidence of stroke on MRI. CTA showed mild plaque in the
right ICA, LDL was 45 and HDL was 15. A1c was elevated at 13.6%.
Echocardiogram showed no intracardiac thrombus. She worked with
physical therapy; rehab was recommended but she elected to go
home with home physical therapy.
# Cardiovascular:
She was hypertensive to the 150s and she was started on
lisinopril 5 mg which she has taken in the past.
# Endocrine:
Her A1c was markedly elevated and her blood sugars were in the
200-300s at the onset of her hospitalization. At home she is
only partially compliant with her lantus regimen and she has
frequent overnight snacking which is exacerbated by increaed
appetite secondary to seroquel. ___ was consulted and
recommended restarting her metformin (which had been stopped
last year in the context of an ___ and changing to a 70/30
regimen for improved control. This was discussed with the
patient and her primary care physician and both were in
approval. She should follow up with an endocrinologist if
possible. She was discharged with a ___ to help with blood sugar
monitoring and medication compliance.
# Psychiatric:
Ms. ___ has significant depression and anxiety with
additional psychosocial stressors. This has resulted in
significant polypharmacy with large doses of seroquel and
trazodone at bedtime which are contributing to her metabolic
abnormalities as well as morning somnolence. Her depression is
exacerbating medication non-compliance. We spoke with her
outpatient psychiatric nurse practitioner about management of
her psychatric and medical comorbidities. No changes were made
to her psychoactive medications.
# Respiratory:
She had had diffuse airway thickening on her chest X-ray and
lung parenchyma abnormalities on her CT neck which prompted a CT
chest. THis showed diffuse parenchymal abnormalities and
lymphadenopathy, broad differential, recommend follow up imaging
in ___ months.
# Sleep:
She was quite somnolent in the mornings. Her trazodone and
seroquel was decreased from her home dose. Given her habitus we
were concerned for sleep apnea. An ___ Sleepiness Scale was
15 (as documented above) and was concering for sleep apnea. She
should follow up in sleep clinic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. CloniDINE 0.1 mg PO BID
3. Cyclobenzaprine 10 mg PO HS:PRN back pain
4. Fluoxetine 40 mg PO DAILY
5. Lorazepam 0.5 mg PO DAILY:PRN anxiety
6. Omeprazole 20 mg PO BID
7. QUEtiapine Fumarate 50 mg PO QAM
8. QUEtiapine Fumarate 800 mg PO QHS
9. TraZODone 300 mg PO QHS:PRN insomnia
10. Venlafaxine 100 mg PO DAILY
11. DiCYCLOmine 10 mg PO QID:PRN abd pain
12. Glargine 80 Units Breakfast
Discharge Medications:
1. Lorazepam 0.5 mg PO DAILY:PRN anxiety
2. Omeprazole 20 mg PO BID
3. Aspirin 81 mg PO DAILY
4. CloniDINE 0.1 mg PO BID
5. Cyclobenzaprine 10 mg PO HS:PRN back pain
6. DiCYCLOmine 10 mg PO QID:PRN abd pain
7. Fluoxetine 40 mg PO DAILY
8. QUEtiapine Fumarate 50 mg PO QAM
9. QUEtiapine Fumarate 800 mg PO QHS
10. TraZODone 300 mg PO QHS:PRN insomnia
11. Venlafaxine 100 mg PO DAILY
12. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
13. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin [Glucophage] 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*3
14. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour one patch daily Disp #*14 Patch
Refills:*0
RX *nicotine 7 mg/24 hour one patch daily Disp #*14 Patch
Refills:*0
15. NovoLOG Mix 70-30 (insulin asp prt-insulin aspart) 100
unit/mL (70-30) subcutaneous 60 Units before BKFT; 40 Units
before DINR;
RX *insulin asp prt-insulin aspart [Novolog Mix ___ FlexPen]
100 unit/mL (70-30) AS INSTRUCTED AS INSTRUCTED Disp #*10
Syringe Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
peripheral vertigo
diabetes mellitus (A1c 13.4%)
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 the hospital with symptoms of spinning
(vertigo) and unsteadiness. We believe that these symptoms were
probably caused by peripheral vertigo which comes from your
inner ear and is frequently caused by vestibular neuronitis.
This is usually because of a virus. This condition heals over
days to a week. While you were here you worked with physical
therapy until you were safe to go home. We do not expect any
lasting consequences of this condition.
However, we see that your blood sugar has been very high. Your
A1c, a measure of your blood sugar over the past three months,
is 13.4%. The goal is less than 7.0%! It is very important to
have good blood sugar control because elevated blood sugar can
lead to problems with your eyes, your kidneys, your stomach and
your nerves. It can lead to infections which result in
amputations! It increases your risk of heart attack and stroke.
The ___ Diabetes doctors saw ___ and ___ your insulin
regimen. We would like for you to restart metformin and we would
also like for you to change your insulin from Lantus (long
acting) to a combination of short- and long- acting insulin. We
spoke with your primary care, Dr. ___ she is in
agreement. Along with this change in your medication it will be
important for you to limit snacking, especially foods high in
sugars. This is a difficult change to make and our diabetes
educator spoke with you about this.
We saw that you had trouble sleeping and staying asleep. We
believe that you may have a condition called sleep apnea. This
is where your airway becomes loose when you are sleeping, and
intermittently blocks your ability to breathe. THis causes you
to wake up and therefore your sleep is not restful. When you
have sleep apnea, it worsens your mood, makes you feel tired and
not well-rested, and can also affect your breathing and increase
your risk for stroke. For tihs reason we would like for you to
have a sleep study. You should speak to your PCP about
scheduling this test. We believe that it is very important for
your health in the future!
We also saw that your blood pressure was high (SBP 140-160s)
during your admission. We are starting a medication, lisinopril,
to treat your blood pressure.
You have had trouble with your mood and energy for a long time.
Your problems with your mood and your diabetes work together to
worsen the other. This is a common problem and it sounds like
you ahve good care providers who have been working with you to
help with these problems. It is important that you continue to
work on this as it will help your overall health. We have not
made any changes to your medications for your mood and your
sleep. However, they do have some side effects of worsening
diabetes and increasing the likelihood of sleep apnea, so please
continue to work with ___ on decreasing the doses of these
medications, particularly the seroquel.
During your imaging for your vertigo, we saw incidentally that
you had an enlarged lymph node in your chest. This can happen
for a number of reasons. We got a CT scan of your chest which
showed that there were some areas in your lungs that we need to
monitor. The cause is still unclear but we recommend another CT
scan in ___ months to monitor it. If you are having worsening
shortness of breath, coughing up phlegm or blood, please follow
up with your primary care doctor sooner than that.
You smoke cigarettes. This is bad for your lungs but also bad
for your blood vessels and increases your risk of heart attack
or stroke. We have been giving you a nicotine patch while you
are here in the hospital. We encourage you to quit smoking. We
have given you a prescription for nicotine patches to help you
quit. If you decide that now is the time to quit please talk to
your primary care doctor so that we can help you.
You should follow up with your primary care provider within the
week to check how you are doing with your blood sugars and your
blood pressure. We are also arranging for a visiting nurse to
help you with checking your vitals and managing your insulin and
blood sugar.
We wish you all the best. It has been a pleasure taking care of
you.
Followup Instructions:
___
|
10848309-DS-19
| 10,848,309 | 26,967,624 |
DS
| 19 |
2169-04-18 00:00:00
|
2169-04-18 18:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Tibia Fracture
Major Surgical or Invasive Procedure:
Tibia ORIF
History of Present Illness:
___ otherwise healthy who p/w a left distal third tibia fx w/
intra-articular extension s/p fall out of the tree (~10 ft).
Denies HS/LOC. Denies paresthesias.
Past Medical History:
None
Social History:
___
Family History:
NC
Physical Exam:
MSK:
- left lower extremity is soft.
- dressing is intact. Some sanguineous drainage at distal tibia.
- Fires ___, AT, FHL, gastrocnemius
- SILT in exposed toes.
- WWP extremity.
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 distal third tibia fracture with intra-articular
extension and was admitted to the orthopedic surgery service.
The patient was taken to the operating room on ___ for ORIF,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient worked with ___ who determined that discharge to home
without services 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
neurovascularly intact and WBAT in the operative extremity, and
will be discharged on ___ 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:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth q8hr Disp #*100
Tablet Refills:*0
2. Aspirin 325 mg PO DAILY Duration: 4 Weeks
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
Use while taking narcotics
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4hr prn Disp #*30
Tablet Refills:*0
5.crutches
Tall crutches
Dx: tibia fracture, closed
Px: good
___: 13mo
Discharge Disposition:
Home
Discharge Diagnosis:
Tibia fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please
follow your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated in air-cast boot
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This
is an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter andmay be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take ASA325 daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Followup Instructions:
___
|
10849254-DS-52
| 10,849,254 | 28,176,840 |
DS
| 52 |
2136-02-13 00:00:00
|
2136-02-13 20:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Acyclovir / Bactrim / Minocycline
Attending: ___
Chief Complaint:
Leg Swelling, SOB
Major Surgical or Invasive Procedure:
EP VT ablation
History of Present Illness:
Patient is a ___ year old male with a history of CAD s/p CABG in
___, ICM EF 35%, history of VT with ICD and chronic ICD
infection, COPD, and delusions of parasitosis who presented to
the ED today with several weeks worth of worsening leg swelling.
Also of note, he has been having steady increase in weight from
158 to 164lbs over the past two months. According to the
patient, he has noted L>R leg swelling for the past 6 months
(vein grafts were taken out of his left leg for CABG). He has
alos noticed multiple punctate lesions on his legs and arms,
which scab over, when he subsequently picks off the scabs. He
notes that they form from an "anatenae-like organism" in his
skin. Going back in the record, he seems to be having delusions
of parasitosis. There was report from the ED that he was
experiencing increasing SOB; however, on further questioning, he
actually reports a dry cough and sore throat for the last
several weeks, associated with some mild nasal congestion. No
orthopnea, palpitations or syncope. He did not have ICD shocks.
In the ED, initial VS were: 97.5 67 117/57 18 100% RA. CXR
clear, BNP elevated at 3481. U/A positive. ___ u/s negative for
DVT. Patient was given dose of cipro and tylenol for leg pain.
Roughly 4 hours elapsed beofre patient was givena dose of 10 mg
IV lasix. ECG showed RBBB, NSR, c/w prior. Vitals on transfer
were 97.9 68 150/80 16 98% RA.
REVIEW OF SYSTEMS:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Diabetes mellitus
Dyslipidemia
Hypertension
Coronary artery disease, s/p CABG in ___ (LIMA to the LAD, SVG
to the diag, SVG to the RPL, SVG to the OM1 and the OM2) and PCI
in ___
H/o VT s/p ICD placement, chronically infected
Chronic systolic CHF (last EF 35%)
COPD
Depression/Anxiety
OSA on CPAP
Osteoarthritis
Cervical and lumbar spinal stenosis
s/p carpal tunnel release
h/o hydradenitis surgery
s/p hernia ___
Social History:
___
Family History:
Siblings with various stages of heart disease, all alive.
Physical Exam:
Admission Exam:
VS - 98.6 169/99 71 18 98% RA
GENERAL - elderly male, anxious, moving around
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear, large
2x2 cm hematoma on right forehead from prior fall
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - Numerous punctate, raised, scab lesion on right
leg and right arm, some with surrounding erythema. Patient
constants is picking at the lesions during the exam. 1+ pitting
edema L>R.
NEURO - awake, A&Ox3
.
Discharge Exam:
VS: 98.6 141/79 70 18 97%RA
GENERAL: NAD. Conversive. Laying upright in bed. Some word
finding difficulty at baseline
HEENT: MMM. NCAT. EOMI. Injury over R. orbit healing well.
NECK: Supple with JVP ~7 cm
CARDIAC: RRR. NS1&S2. NMRG. PMI at ___ left intercostal space
LUNGS: Bibasilar inspiratory crackles still present. Expiratory
wheeze at apices. Good air flow. No wheeze/rhonchi.
ABDOMEN: BS+4. S/NT/ND
EXTREMITIES: 1+ b/l pitting edema on L>R. Worsened today in
setting of erythema and fresh excoriations over R medial
malleoli
SKIN: Multiple excoriations over all extremities.
Pertinent Results:
Admission Labs:
___ 05:30PM BLOOD WBC-6.2 RBC-3.80* Hgb-11.7* Hct-33.9*
MCV-89 MCH-30.7 MCHC-34.5 RDW-14.5 Plt ___
___ 05:30PM BLOOD Glucose-85 UreaN-13 Creat-0.8 Na-138
K-4.0 Cl-96 HCO3-32 AnGap-14
___ 06:26AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.0
.
Discharge Labs:
___ 07:43AM BLOOD WBC-6.1 RBC-3.62* Hgb-10.6* Hct-32.8*
MCV-91 MCH-29.3 MCHC-32.3 RDW-14.6 Plt ___
___ 07:43AM BLOOD Plt ___
___ 07:43AM BLOOD Glucose-97 UreaN-23* Creat-0.9 Na-143
K-3.8 Cl-103 HCO3-33* AnGap-11
___ 07:43AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.1
.
Pertinent Labs:
___ 05:30PM BLOOD proBNP-3481*
___ 05:30PM BLOOD cTropnT-<0.01
___ 04:42AM BLOOD CK-MB-6 cTropnT-<0.01
.
Studies:
___ CXR:
Frontal and lateral views of the chest are compared to previous
exam from ___. Left chest wall pacing device is
again noted. The lungs are clear of consolidation or pulmonary
vascular congestion. Cardiac silhouette is slightly enlarged but
unchanged. Postoperative changes of median sternotomy wires
again noted with fracture of the top and third from the top
sternal wires. Osseous structures are unchanged noting possible
compression deformity at the lower thoracic level with an acute
kyphosis which is unchanged from prior.
.
___ BLE ___:
IMPRESSION:
1. No bilateral lower extremity DVT.
2. Diffuse subcutaneous edema
.
___ TTE:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with
inferior/inferolateral hypokinesis. There is very mild
hypokinesis of the remaining segments (LVEF = 40%). 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. Mild
(1+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild mitral regurgitation. Moderate ICD lead-related
tricuspid regurgitation.
Compared with the prior study (images reviewed) of ___,
mitral regurgitation is slightly more prominent. The other
findings are similar.
Brief Hospital Course:
___ yo M with PMH signifcant for CAD s/p CABG and PCI, ICM s/p
ICD implantation and COPD. Presents with several week-month h/o
worsening DOE, and BLE swelling, L>R. Elevated BNP on admission
and volume overloaded. Actively diuresed and transitioned to
oral medications with good UOP. Recommendation for ___ rehab
per ___.
.
# Acute on chronic sCHF exacerbation: Pt came in with worsening
dyspnea on exertion and lower extremity swelling. His JVP was
elevated to ~10mmhg and he had bibasilar fine inspriratory
crackles. He was on 20mg PO lasix at home, and reports good
compliance and no dietary indiscretions. His SBP was elevated,
and he was started on hydralazine for after-load reduciton in
order to improve forward flow. His topro XL was also d/c'ed, and
he was started on carvedilol 6.25BID with reduction to 3.75 BID.
A TTE was performed to look for new wall motion abnormalities
that would be suggestive of subacute ischemia. EF remained
preserved, and no new abnormalities were notd, so no further
intervention was pursued. He was actively diursed with 80mg
lasix BID with good UOP, and switched to 20mg torsemide prior to
discharge. At discharge he c/o mild DOE, but much improved from
admission. Edema had resolved and BP was stable.
.
#Hypotension: Patient was started on hydralazine and carvedilol
as an inpatient forafterload reduction given high SBP in
admission. He developed several episodes of isolated
asymptomatic hypotension following diuresis to euvolemia. This
was likely ___ med effect. Hydralazine was d/c'ed after
successful diuresis and carvedilol was decreased (see above).
.
#UTI: Pt with cipro sensitive pseudomonas asymptomatic UTI on
admission. Treating as complicated UTI with ciprofloxacin x 7
days (day ___
.
# Excoriations: Multiple excoriations on all extremities. Pt has
h/o delusional parasitosis, and scratches repeatedly at skin. On
day of discharge he had a fresh excoriation over r. medial
malleoli that needed to be dressed. Treated with mupirocin cream
and collagenase ointments
.
# Depression/Anxiety/Delusions: H/o delusional parasitosis and
depression at baseline. Pt had some word finding difficulties
during stay, but remained oriented x3, and conversive with
appropriate affect. Continued risperidone, wellbutrin,
venlafaxine.
.
#CAD: H/o CAD s/p LIMA to LAD and SVG to OM with failed PCI to
RCA in ___. No h/o chest pain, palpitations, dizziness, or
pre-syncope. Recent TTE negative for new wall motion
abnormalities, so presentation not likey ___ ischemia.
.
HTN: Continued on imdur and lisinopril. His metoprolol was
exchanged for carvedilol, as both meds are indicated in ___,
but carvedilol has better afterload reduction.
.
#H/o VT: On amiodarone, and no recent shocks from ICD. No
arrhythmias on telemetry, and he remained ventricularly paced
.
#H/o ICD lead infection: Continued on lifelong augmentin 500mg
TID
.
# Chronic pain: Continue home regimen.
.
# Diabetes: Held metformin, but may restart as outpt
.
Transitional Issues:
#Will need 1 dose of ciprofloxacin on ___ to complete 7 day
course
#Will need electrolytes checked within 48 hours
#Check daily weights. If >3lb weight gain, then please call
cardiologist
#Please monitor excoriations, and continue to dress with
mupirocin and collagenase
#Expected LOS <30 days at rehab facility
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Amoxicillin-Clavulanic Acid ___ mg PO Q24H
3. BuPROPion (Sustained Release) 200 mg PO QAM
4. Collagenase Ointment 1 Appl TP DAILY
5. Diazepam 5 mg PO QD:PRN anxiety
6. Epinephrine 1:1000 0.3 mg IM ONCE Allergic reaction Duration:
1 Doses
7. Furosemide 20 mg PO DAILY
8. Gabapentin 300 mg PO TID
9. ipratropium-albuterol *NF* 0.5 mg-3 mg(2.5 mg base)/3 mL
Inhalation Q6:PRN SOB
10. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
11. Lisinopril 40 mg PO DAILY
12. MetFORMIN (Glucophage) 500 mg PO BID
13. Metoprolol Succinate XL 50 mg PO BID
14. Mupirocin Cream 2% 1 Appl TP BID
15. Nitroglycerin SL 0.4 mg SL PRN chest pain
16. Nystatin Oral Suspension 5 mL PO QID:PRN symptoms
17. Omeprazole 20 mg PO DAILY
18. oxybutynin chloride *NF* 10 mg Oral Daily
19. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
20. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
21. Pravastatin 80 mg PO DAILY
22. Risperidone (Disintegrating Tablet) 0.5 mg PO DAILY
23. Tamsulosin 0.4 mg PO HS
24. Venlafaxine XR 150 mg PO DAILY
25. ascorbic acid *NF* 1,000 mg Oral Daily
26. Aspirin 81 mg PO DAILY
27. Docusate Sodium 100 mg PO BID
28. Nicotine Patch 21 mg TD DAILY
29. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. BuPROPion (Sustained Release) 200 mg PO QAM
4. Collagenase Ointment 1 Appl TP BID
5. Diazepam 5 mg PO QD:PRN anxiety
6. Docusate Sodium 100 mg PO BID
7. Gabapentin 300 mg PO TID
8. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
9. Lisinopril 40 mg PO DAILY
10. Mupirocin Cream 2% 1 Appl TP BID
11. Nicotine Patch 21 mg TD DAILY
12. Nitroglycerin SL 0.4 mg SL PRN chest pain
13. Nystatin Oral Suspension 5 mL PO QID:PRN symptoms
14. Omeprazole 20 mg PO DAILY
15. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
16. Pravastatin 80 mg PO DAILY
17. Risperidone (Disintegrating Tablet) 0.5 mg PO DAILY
18. Senna 1 TAB PO BID:PRN constipation
19. Tamsulosin 0.4 mg PO HS
20. Venlafaxine XR 150 mg PO DAILY
21. Ciprofloxacin HCl 500 mg PO Q12H
22. ascorbic acid *NF* 1,000 mg Oral Daily
23. Epinephrine 1:1000 0.3 mg IM ONCE Allergic reaction
Duration: 1 Doses
24. MetFORMIN (Glucophage) 500 mg PO BID
25. oxybutynin chloride *NF* 10 mg Oral Daily
26. ipratropium-albuterol *NF* 0.5 mg-3 mg(2.5 mg base)/3 mL
Inhalation Q6:PRN SOB
27. Carvedilol 3.125 mg PO BID
28. Torsemide 20 mg PO DAILY
29. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
30. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary diagnosis:
Acute on chronic systolic congestive heart failure exacerbation
Secondary diagnosis:
hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at ___. You were admitted
because you had increasing fluid in your legs and shortness of
breath. We believe this is due to your underlying congestive
heart failure. You were given medication through your veins to
make you urinate more frequently, and get rid of the fluid. We
believe this occurred because you were not taking enough
diuretic. Several medications were changed to help prevent this
from happening in the future. Please continue the new
medications and discard any of the old ones that you may have
left in your house.
You also had a urinary tract infection. We treated you with
antibiotics to get rid of this for seven days. Please take your
last dose of antibiotic when you get to your rehab facility.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
The following medication changes were made:
START torsemide 20mg daily
START ciprofloxacin 500mg twice daily x1 dose
START carvedilol 3.125mg twice daily
STOP metoprolol xL 50mg daily
STOP lasix 20mg daily
Followup Instructions:
___
|
10850048-DS-23
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| 23 |
2125-12-21 00:00:00
|
2125-12-22 21:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Fentanyl / Oxycodone
Attending: ___.
Chief Complaint:
Nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
Upper endoscopy ___
History of Present Illness:
___ year-old man with history of tracheoesophageal stent
placement ___ s/p removal 3 months later with long history of
congenital abnormalities (esophageal atresia, pyloric stenosis,
absence of right wrist and thumb) presents with nausea,
vomiting, diarrhea from ___ where he left AMA to return to
___ to be seen by Dr. ___. He had surgery for a
tracheoesophageal fistula around age ___, with recurrent in ___
and had a stent placed but has not had any fistulas since then.
He does periodically have esophageal strictures dilated and
esophageal polypectomies. Last EGD was > ___ years ago (last ___
in our system.)
He was vacationing in ___, feeling well, when he developed
severe abdominal pain, and vomiting of coffee ground emesis. He
reports eating tuna at a restaurant prior to the onset of
symptoms. He was admitted to an OSH and was per his report
treated with Phenergan, protonix, and pain meds. He had a CT
scan that was unremarkable. He then had a barium swallow which
showed a fistula and then an EGD. He has pictures with him but
no report. He left ___ at 6AM this morning to fly back. He has
not had any pain meds since 4AM and is in ___ pain in his
bilateral lower quadrants. No constipation. Last BM was earlier
this afternoon. The patient reports that his pain has always
been in the lower abdomen regardless of the location of the
fistula.
ROS otherwise unremarkable.
Drug allergies: penicillin --> hives. Fentanyl & oxycodone -->
itchiness. Patient tolerates codeine well.
Past Medical History:
- Multiple congenital abnormalities including esophageal
atresia, status post tracheoesophageal fistula repair,
pyloric stenosis,
- Status post appendectomy,
- Congenital absence of right thumb and wrist
- Congenital 13 ribs.
- History of Esophagitis, gastritis, esophageal polypectomy,
___ esophagus, esophageal stricture dilatation.
- History of small bowel obstruction in his ___.
- Multiple right upper extremity surgeries.
- Recent bronchitis; denies asthma. (Treated with nebs and
z-pack.)
Social History:
___
Family History:
Peptic ulcer disease, gastric cancer, DM
Physical Exam:
ADMISSION EXAM:
VS: 98.6 129/97 102 14 97% on RA
GEN: Uncomfortable
HEENT: EOMI, oropharynx clear
NECK: Supple, no LAD
CV: Tachycardic, no m/r/g
PULM: CTAB
ABD: +BS, soft, tender to palpation in bilateral lower
quandrants. surgical scars well Healed.
EXT: No edema
MSK: Normal tone
NEURO: A&O x 3, no focal deficits
PSYCH: normal affect
DISCHARGE EXAM:
VS: Afebrile, normal vitals, normal oxygen sat
GEN: NAD
CHEST: Minimal rhonchi
ABD: Soft, minimally tender around epigastric and umbilical
area, nondistended, normal bowel sounds
Pertinent Results:
___ 07:00PM BLOOD WBC-8.3 Hgb-11.8* Hct-36.0* MCV-75* Plt
___
___ 06:52AM BLOOD WBC-12.4 Hgb-12.7* Hct-39.5* MCV-75* Plt
___
___ 07:30AM BLOOD WBC-20.3* Hgb-11.9* Hct-37.7* MCV-77* Plt
___
___ 07:00PM BLOOD ___ PTT-29.8 ___
___ 07:00PM BLOOD Glu-80 UreaN-11 Creat-0.9 Na-138 K-3.5
Cl-98 HCO3-26
___ 07:30AM BLOOD Glu-111* UreaN-10 Creat-0.8 Na-137 K-3.7
Cl-99 HCO3-28
___ 07:00PM BLOOD ALT-13 AST-16 AlkPhos-76 TotBili-0.5
___ 07:00PM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0
___ 07:30AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.7
___ 06:52AM BLOOD Triglyc-139
CXR ___:
COMPARISON: ___.
FINDINGS: There has been interval placement of a right upper
extremity PICC,
the tip of which projects over the expected region of the
cavoatrial junction. The lungs are clear without pleural
effusion or pneumothorax. The cardiac silhouette and
mediastinal contours are normal. Incidental note is made of
fusion of the posterior fourth and fifth ribs. The pulmonary
vasculature is normal.
RUE ULTRASOUND ___: No DVT in right upper extremity. No
cause of pain identified at the site of maximal pain.
EGD ___:
Findings:
Esophagus:
Lumen: 2 benign appearing, intrinsic strictures noted at the
middle third of the esophagus
Excavated Lesions A small, single ulcer was found in the
distal esophagus. No fistula noted
Stomach:
Mucosa: Normal mucosa was noted.
Duodenum:
Mucosa: Normal mucosa was noted.
Fluoroscopic interpretation:
Esophagogram was obtained after inflating a balloon catheter.
Complete filling of the esophageal lumen was obtained. No leak
or communication with the bronchi noted
CXR PA/LATERAL ___:
1. Diffuse pneumonia, possibly from aspiration.
2. Stable appearance of known pericardial cyst.
BARIUM SWALLOW ___:
Small sinus tract off of the esophagus which is blind ending and
does not communicate with the trachea. This is likely a
residual portion of the previous fistula.
Brief Hospital Course:
___ year-old man with a history of tracheoesophageal fistula,
multiple congenital abnormalities, with esophageal stricutres,
polyps who presents from an hospital in ___ with the
diagnosis of a new trahcheoesophageal fistula. Evaluation with
upper endoscopy could not locate the fistula, but did see
stricturing of the esophagus and an esophageal ulcer. Barium
swallow did reveal a blind stump from his prior
tracheoesophageal fistula from ___.
The patient did have a cough, though, and CXR revealed diffuse
PNA. He was started on Levofloxacin for PNA and he was
discharged in fair condition.
# PNA: Treat for community acquired PNA with 5-day course of
Levofloxacin
# Esophageal stricture
# Esophageal ulcer: PPI
# Esophagitis and gastritis: Continue PPI
# Tracheoesophageal fistula: None seen on studies.
# Abdominal pain, NOS: Dispense 12 tabs of morphine ___
# Code status: Full code
TRANSITIONAL ISSUES:
- Patient is going to obtain a copy of the barium study
performed in ___ the week prior to his admission to see if
what they saw is the blind stump seen on our study here.
- F/u HCA to ensure resolution of PNA
Medications on Admission:
ESOMEPRAZOLE MAGNESIUM [NEXIUM] - 40 mg Capsule by mouth twice a
day
Discharge Medications:
1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days: Complete 5 days ___ - ___.
Disp:*4 Tablet(s)* Refills:*0*
2. morphine 15 mg Tablet Sig: 0.5 to 1 Tablet PO q6-8 hours as
needed for severe pain for 1 weeks.
Disp:*12 Tablet(s)* Refills:*0*
3. promethazine 12.5 mg Tablet Sig: One (1) Tablet PO every ___
hours as needed for nausea for 2 weeks.
Disp:*15 Tablet(s)* Refills:*0*
4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
- Esophageal ulcer
- Esophageal stricture
- Remnant of old tracheoesophageal fistula
- Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for re-evaluation of tracheoesophageal fistula
that was seen on studies performed in a ___ hospital.
An endoscopy revealed strictures in the middle of your esophagus
and a small ulcer at the bottom of your esophagus. You should
continue taking Nexium (esomeprazole) for the ulcer. It is also
very helpful to continue to stop smoking.
A barium swallow study revealed the remnant stump of your prior
tracheoesophageal fistula from ___. Nothing further needs to be
done regarding that finding. Chest x-ray revealed a pneumonia
for which you should complete a 5-day course of antibiotics.
MEDICATION INSTRUCTIONS:
- Levofloxacin 750 mg daily for 5 total days ___ - ___.
- Morphine 7.5 - 15 mg every 6 to 8 hours as needed for severe
pain. Taper this medication as your pain improves. This
medication can cause constipation and sedation. Do not operate
heavy machinery or drive a car after taking a dose of this
medication.
- Promethazine (Phenergan) 12.5 mg every 6 to 8 hours as needed
for nausea.
Followup Instructions:
___
|
10850048-DS-24
| 10,850,048 | 26,581,886 |
DS
| 24 |
2126-04-26 00:00:00
|
2126-04-29 10:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Fentanyl / Oxycodone
Attending: ___.
Chief Complaint:
Motor vehicle accident with vertebral fractures.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a ___ with h/o esophageal fistula and h/o right arm
deformity who presents 1 day after MVA with neck pain. MVA
occurred after car went over pothole and tired ruptured. Car
flipped onto sidewalk and he swerved to miss phone pole and
flipped car. He was restrained, going about 20mph. He was alone.
Airbags did not deploy. Denies ETOH use. Patient initially
presented to an OSH where per patient he was told that he had a
C6-C7 fracture. He left AMA from OSH because he had a business
trip however because of pain cancelled his trip and instead
sought help with his PCP.
At his PCP's office, he was noted to be in distress from pain
and was then sent to ED for further evaluation.
In ED, initial VS were: 98.3 111 145/96 18 94%RA. Evaluation
revealed leukocytosis to 19 and CT revealed fractures of C2 and
C7. CXR showed e/o pneumonia. Spine was consulted who felt there
was no neurosurgical intervention needed. Patient received
levofloxacin, morphine and dilaudid for pain. Pt was then
admitted for pain management. VS prior to transfer were: 7 98.4
98 161/105 16 97%
On arrival to the floor, patient reported ___nd stated that he felt tired. Currently reports tingling in
thumb, ___ and ___ digits on left arm
Past Medical History:
- Multiple congenital abnormalities including esophageal
atresia, status post tracheoesophageal fistula repair,
pyloric stenosis,
- Status post appendectomy,
- Congenital absence of right thumb and wrist
- Congenital 13 ribs.
- History of Esophagitis, gastritis, esophageal polypectomy,
___ esophagus, esophageal stricture dilatation.
- History of small bowel obstruction in his ___.
- Multiple right upper extremity surgeries.
- Recent bronchitis; denies asthma. (Treated with nebs and
z-pack.)
Social History:
___
Family History:
Peptic ulcer disease, gastric cancer, DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.5 102 28 122/88 94% RA
GENERAL - well-appearing man in NAD, in mild distress
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - in hard collar, pt tenderness in ___
LUNGS - b/l rhonchorous BS with faint wheezing
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), right hand deformity noted
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, diminished sensation over thumb, ___ and ___
digits at tips on left hand
DISCHARGE PHYSICAL EXAM:
VS - 97.8 102 22 149/108 95% RA
GENERAL - well-appearing man, comfortable appearing
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - in hard collar, pt tenderness in ___
LUNGS - b/l rhonchorous BS
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), right hand deformity noted
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, mild diminished sensation over thumb, ___ and
___ digits at tips on left hand no change from admission
Pertinent Results:
___ 06:00PM BLOOD WBC-19.9* RBC-4.89 Hgb-11.5* Hct-36.0*
MCV-74* MCH-23.6* MCHC-32.1 RDW-16.8* Plt ___
___ 05:25AM BLOOD WBC-10.9 RBC-4.60 Hgb-10.8* Hct-34.4*
MCV-75* MCH-23.5* MCHC-31.4 RDW-16.7* Plt ___
___ 05:45AM BLOOD WBC-13.2* RBC-4.87 Hgb-11.6* Hct-36.0*
MCV-74* MCH-23.8* MCHC-32.2 RDW-16.8* Plt ___
___ 06:00PM BLOOD Glucose-101* UreaN-12 Creat-0.9 Na-138
K-3.8 Cl-101 HCO3-25 AnGap-16
___ 05:25AM BLOOD Glucose-124* UreaN-11 Creat-0.9 Na-136
K-3.9 Cl-102 HCO3-25 AnGap-13
MR ___ ___:
1. Interspinous STIR signal abnormality, raising concern for
non-displaced interspinous ligamentous injury.
2. Prevertebral soft tissue STIR signal abnormality at C7-T1,
could also represent anterior longitudinal ligamentous injury.
3. Multilevel degenerative changes as above. No significant
spinal canal stenosis. Normal cervical cord signal, without
evidence of cord contusion.
CTA NECK ___:
1. No evidence of vascular injury, including no aneurysm,
dissection or hematoma.
2. Known minimally displaced left C7 lateral mass fracture,
better evaluated in the CT ___ earlier.
3. Multifocal ground-glass opacities and ___ appearance
in the visualized lung apices, concerning for
infectious/inflammatory process.
4. Patulous esophagus, incompletely assessed. Please correlate
with patient's history of congenital esophageal atresia and
stenting.
CHEST X-RAY ___:
New right lower lobe opacity worrisome for pneumonia in the
proper clinical setting. Bilateral perihilar opacities as on
prior, potentially due to aspiration or chronic lung changes.
Please correlate clinically. Repeat exam after treatment to
document resolution of the right lower lobe finding.
CT HEAD ___:
No acute intracranial process. Left scalp hematoma without
underlying fracture.
CT ___ ___:
1. Minimally displaced fracture through the left lateral mass
of C7 with
extension to the pedicle.
2. Minimally displaced fracture of the spinous process of C2.
3. Probable small fracture of the inferior facet of C6 on the
left.
4. Patulous appearance of the esophagus - findings present on
prior
examination from ___, though now more severe.
Brief Hospital Course:
REASON FOR ADMISSION: ___ with history of TE fistula and
multiple congential abnormalities who presented s/p MVA and was
found to have C2 and C7 fractures and pneumonia.
#C2 and C7 fractures: The patient was admitted with posterior
cervical neck pain and known ___ fractures after a motor
vehicle accident. On CT, he was found to have a minimally
displaced fracture through the left lateral mass of C7 with
extension to the pedicle, a minimally displaced fracture of the
spinous process of C2, and a probable small fracture of the
inferior facet of C6 on the left. Neurosurgery requested an MRI
___ which showed interspinous STIR signal abnormality,
raising concern for non-displaced interspinous ligamentous
injury, prevertebral soft tissue STIR signal abnormality at
C7-T1 representing likely anterior longitudinal ligamentous
injury. MRI was without significant spinal canal stenosis and
demonstrated normal cervical cord signal, without evidence of
cord contusion.
After extensive review of imaging, in context of patient exam,
neurosurgery decided there was no indication for surgerical
intervention. Per neurosurgery, he will remain ___
for one month and will follow-up with neurosurgery as an
outpatient. A ___ will come to his home to help with collar
care. He was given instructions to limit lifting to no more
than 15lbs. He was written for a short course of dilaudid
(HYDROmorphone ___ mg PO Q6H:PRN pain; 30 tablets) for pain
management with instruction that medication causes sedation.
Prescription should be sufficient until first outpatient visit.
At visit, pain can be reassessed and additional pain medications
can be dispensed if needed.
#Pneumonia/aspiration pneumonitis: In the ED, the patient
underwent a chest x-ray which showed evidence of b/l pneumonia.
His white count was initially elevated to 19.9, and he had a
mild productive cough and was therefore started on levofloxacin
(start date ___. In house, he remained afebrile and his
white cell count trended down. His oxygenation remained in the
upper 90%s on room air. His last day of levofloxacin will be
___.
TRANSITIONAL ISSUES:
#Hypertension: On the last day of admission, the patient's blood
pressure on multiple checks was around ___. He was
asymptomatic. He should follow-up with his primary care
physician for management and potential initiation of
anti-hypertensives
#PNA, Continue levofloxacin through ___.
#Cervical Fracture. Continue in ___ J collar for 1month with
___ care and plan for neurosurgery follow-up
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral daily
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY Duration: 2 Doses
day 1 = ___
day 5 = ___
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily
Disp #*2 Tablet Refills:*0
2. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain Duration: 30
Doses
Please avoid alcohol while taking this medication
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
six hours Disp #*30 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY:PRN narcotic use Duration:
15 Doses
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 pack by mouth
daily Disp #*15 Packet Refills:*0
4. NexIUM *NF* (esomeprazole magnesium) 40 mg ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cervical Fracture
Cervical muscle sprain
cervical ligamentous injury
Pneumonia
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 in the
hospital.
While hospitalized you were diagnosed with cervical fractures
and soft tissue injury. You were seen by our team of
neurosurgeons who did not feel surgery was indictated. The
recommened you need to wear your a collar at all times for one
month. You should not drive while in the cervical collar. You
should not lift >15 lbs until follow up in one month.
Additionally during this hospitalization you were found to have
a pneumonia. You will be taking an antibiotic (levofloxacin)
ending on ___.
Of note your blood pressure was found to be high. You are not on
medications for this. When you follow-up with your primary care,
you should discuss ways to lower your blood pressure.
Medications that were started:
Levofloxacin 750mg daily by mouth for your pneumonia ending
___.
Dilaudid ___ every ___ hours as needed for pain.
** This medication causes sedation so avoid consumption of
alcohol when using **
Miralax 17g by mouth daily as needed for constipation.
Medications that were stopped or changed: None.
Followup Instructions:
___
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2133-06-09 19:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Fentanyl / Oxycodone
Attending: ___.
Major Surgical or Invasive Procedure:
EGD - ___
attach
Pertinent Results:
ADMISSION
___ 12:00PM BLOOD WBC-11.8* RBC-5.53 Hgb-13.1* Hct-42.7
MCV-77* MCH-23.7* MCHC-30.7* RDW-14.6 RDWSD-39.8 Plt ___
___ 12:00PM BLOOD Glucose-154* UreaN-20 Creat-1.2 Na-138
K-3.6 Cl-92* HCO3-24 AnGap-22*
___ 12:00PM BLOOD ALT-14 AST-17 AlkPhos-276* TotBili-0.4
DISCHARGE
___ 06:19AM BLOOD WBC-8.9 RBC-4.45* Hgb-10.7* Hct-34.6*
MCV-78* MCH-24.0* MCHC-30.9* RDW-14.6 RDWSD-39.2 Plt ___
___ 06:19AM BLOOD Glucose-112* UreaN-9 Creat-0.8 Na-141
K-3.7 Cl-99 HCO3-25 AnGap-17
___ 05:18AM BLOOD ALT-7 AST-11 AlkPhos-136* TotBili-0.3
CT thorax:
1. No evidence of tracheoesophageal fistula.
2. Postsurgical change of partial esophagectomy with dilated
upper esophagus.
3. Interval decrease in size of the right loculated complex
pleural effusion
and interval removal of the chest tube.
4. Other chronic/incidental findings described as in above.
EGD - see full report in OMR
stricture in the esophagus at 25 cm with associated esophagitis
in this area. Balloon dilation was performed. Just proximal to
the stricture the previously noted fistula was seen.
Brief Hospital Course:
___ year old with a history of congenital tracheal-esophageal
fistula status post repair, esophageal atresia and stricture s/p
dilation, ___ esophagus, recent prolonged hospital stay
for tracheal-esophageal fistula leak and pneumonia admitted
___ with emesis followed by hematemesis thought to be
related to ___ tear, with subsequent hospital course
notable for dysphagia and abdominal pain, status post esophageal
stricture dilation and initiation of reglan, subsequently with
improving symptoms, tolerating soft solids diet, able to be
discharged home
# Esophageal Stricture
# Hematemesis
Patient presented with one day of multiple episodes of
persistent vomiting, followed by hematemesis and coffee ground
emesis. Unclear what triggered initial vomiting--concern for
possible viral gastritis with contribution from known esophageal
stricture. Given his history of tracheoesophageal fistula (TEF)
requiring prior
interventions, he underwent CT, which showed no evidence of
persistent TEF--thoracic surgery consult felt this was not the
etiology. He underwent endoscopy and dilation of an esophageal
stricture by advanced endoscopy team on ___, with subsequent
reported persistence of nausea and symptoms of food getting
stuck. He was started on trial of reglan, with slow resolution
of above symptoms--unclear if this was secondary to reglan
effect, or resolution of localized inflammation or other process
that was impacting esophagus. Was able to advance diet without
issue. At time of discharge was eating pureed diet without
issue. Scheduled for repeat advanced endoscopy evaluation for
consideration of additional dilations. Given possible
improvement with reglan, he might benefit from outpatient
motility study to rule out gastroparesis contribution.
Discharged with planned 2 week course of reglan--can assess at
outpatient follow-up whether this trial should be continued vs
stopped. Continued home PPI.
# Generalized Abdominal Pain
Course notable for generalized abdominal pain, without obvious
source on CT abdomen. In setting of extensive vomiting, there
was concern for esophageal tear, complicated by his abnormal
baseline anatomy. Patient treated conservatively as above, with
slow improvement in symptoms. Was able to be weaned from prn
pain medications and tolerated a diet as above.
# Dehydration
# SIRS criteria without infection
Presented with tachycardia, leukocytosis and elevated lactate to
2.8. Infectious workup without notable findings. Rapidly
improved with treatment as above and IV fluids.
#Loculated Pleural Effusion
Patient with history of loculated pleural effusion in setting of
prior TEF. This admission had CT showing interval improvement.
Lung exam unremarkable, patient denied respiratory symptoms, and
no focal respiratory issues developed over course of admission.
# Chronic Severe Protein Calorie Malnutrition
Patient with chronic weight loss in setting of recent TEF
admission, with weight nadir 110lbs. Weight this admission
118lbs. Patient knows to weigh self and to seek care if losing
weight.
# Mild intermittent asthma
Continued flovent, prn albuterol
# Peripheral neuropathy
Continued Gabapentin
Transitional Issues:
- Discharged home with PCP and advanced endoscopy follow-up
- Could consider evaluation for dysmotility disorder, as above
> 30 minutes spent on discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO TID:PRN pain
2. Esomeprazole 40 mg PO BID
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
4. Fluticasone Propionate 110mcg 1 PUFF IH BID
Discharge Medications:
1. Metoclopramide 5 mg PO TID
RX *metoclopramide HCl 5 mg 5 mg by mouth three times a day Disp
#*42 Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
3. Esomeprazole 40 mg PO BID
4. Fluticasone Propionate 110mcg 1 PUFF IH BID
5. Gabapentin 300 mg PO TID:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
# Dysphagia secondary to
# Esophageal stricture
# Generalized Abdominal Pain
# Chronic moderate protein calorie malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___:
It was a pleasure caring for you at ___. You were admitted
with vomiting.
You underwent an endoscopy that showed a narrowing in your
esophagus ("stricture"). This was treated with a procedure to
try to open this narrowing ("dilation").
To help with your symptoms you were started on a new anti-nausea
medication.
Your symptoms improved and you are now ready for discharge. It
will be important for you to follow-up with your GI team to
discuss additional testing and treatment, and whether or not you
will need to continue this new anti-nausea medication.
It will be important for you to continue your soft diet.
Followup Instructions:
___
|
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2133-07-15 00:00:00
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2133-07-16 20:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Fentanyl / Oxycodone
Attending: ___.
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
Admission Labs:
=================
___ 04:45PM BLOOD WBC-24.1* RBC-5.37 Hgb-13.1* Hct-40.9
MCV-76* MCH-24.4* MCHC-32.0 RDW-17.3* RDWSD-46.5* Plt ___
___ 04:45PM BLOOD Neuts-87.2* Lymphs-5.8* Monos-5.9
Eos-0.0* Baso-0.2 Im ___ AbsNeut-21.01* AbsLymp-1.40
AbsMono-1.42* AbsEos-0.01* AbsBaso-0.06
___ 04:45PM BLOOD Plt ___
___ 04:45PM BLOOD Glucose-188* UreaN-21* Creat-1.1 Na-142
K-4.0 Cl-90* HCO3-28 AnGap-24*
___ 04:45PM BLOOD ALT-17 AST-18 AlkPhos-196* TotBili-0.4
___ 04:45PM BLOOD Albumin-4.9 Calcium-11.4* Phos-1.5*
Mg-2.1
___ 04:51PM BLOOD Lactate-3.4*
___ 08:56PM BLOOD Lactate-1.0
Pertinent Labs:
=================
___ 05:55AM BLOOD WBC-13.6* RBC-4.34* Hgb-10.6* Hct-34.0*
MCV-78* MCH-24.4* MCHC-31.2* RDW-16.9* RDWSD-48.2* Plt ___
___ 04:14PM BLOOD WBC-11.0* RBC-4.08* Hgb-9.7* Hct-32.2*
MCV-79* MCH-23.8* MCHC-30.1* RDW-16.9* RDWSD-48.9* Plt ___
___ 06:00AM BLOOD WBC-7.3 RBC-4.01* Hgb-9.8* Hct-31.1*
MCV-78* MCH-24.4* MCHC-31.5* RDW-15.9* RDWSD-45.0 Plt ___
___ 06:00AM BLOOD WBC-8.4 RBC-4.07* Hgb-9.9* Hct-31.7*
MCV-78* MCH-24.3* MCHC-31.2* RDW-15.9* RDWSD-44.1 Plt ___
___ 05:30AM BLOOD Glucose-103* UreaN-10 Creat-0.7 Na-136
K-3.9 Cl-95* HCO3-26 AnGap-15
___ 06:00AM BLOOD Glucose-107* UreaN-7 Creat-0.8 Na-134*
K-3.5 Cl-94* HCO3-28 AnGap-12
___ 06:00AM BLOOD Glucose-102* UreaN-4* Creat-0.7 Na-137
K-3.2* Cl-98 HCO3-27 AnGap-12
___ 05:55AM BLOOD ALT-11 AST-13 LD(LDH)-165 AlkPhos-147*
TotBili-0.3
___ 04:45PM BLOOD Lipase-17
___ 06:00AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.2
___ 06:00AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.8
___ 05:07AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-40* Bilirub-NEG Urobiln-NORMAL pH-8.0
Leuks-NEG
___ 05:07AM URINE RBC-0 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
Pertinent Micro:
=================
___ 5:55 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Pertinent Imaging:
====================
___ Imaging CHEST (PA & LAT)
IMPRESSION:
Similar basilar opacification consistent with chronic pleural
effusion and
atelectasis. No evidence of superimposed acute abnormality.
___ Imaging ABDOMEN (SUPINE & ERECT
IMPRESSION:
Nonobstructive bowel gas pattern.
___ Imaging CHEST (PA & LAT)
IMPRESSION:
Opacification at the right lower lung base is slightly increased
in size, best appreciated on lateral radiograph, consistent with
the chronic pleural
effusion and atelectasis.
___ Imaging PORTABLE ABDOMEN
IMPRESSION:
Nonobstructive bowel gas pattern.
Discharge Labs:
==================
___ 05:09AM BLOOD WBC-7.1 RBC-4.05* Hgb-9.9* Hct-31.0*
MCV-77* MCH-24.4* MCHC-31.9* RDW-15.9* RDWSD-43.9 Plt ___
___ 05:09AM BLOOD ___ PTT-30.4 ___
___ 05:09AM BLOOD Plt ___
___ 05:09AM BLOOD Glucose-446* UreaN-3* Creat-0.7 Na-134*
K-3.8 Cl-98 HCO3-23 AnGap-13
___ 05:09AM BLOOD Calcium-9.1 Phos-3.2 Mg-1.9
Brief Hospital Course:
Patient summary statement for admission:
===================================================
___ hx esophageal atresia, tracheoesophageal fistula s/p
repair, esophageal stricture s/p dilation, ___ esophagus,
hx of SBO, vocal cord surgery on ___, presented with
persistent coffee ground emesis and abdominal pain similar to
previous presentations that resolved with conservative
management.
ACUTE/ACTIVE PROBLEMS:
==========================
# Intractable nausea/vomiting
# Coffee ground emesis
# Abdominal Pain
Pt presented with coffee-ground emesis and inability to tolerate
PO
following recent vocal cord surgery. Of note, patient has had
multiple recent
hospitalizations in which he experienced dysphagia and inability
to tolerate PO in the setting of TEF fistula requiring multiple
procedural interventions. Patient hematemesis was believed to be
secondary to ___ tears in the setting of high volume
emesis and endoscopic intervention was deferred given patient
clinical stability as well as high procedural risk. Patient
bleeding self resolved with conservative management. The
etiology of patient vomiting and dysphagia was believed to be
secondary to underlying esophageal strictures, however,
endoscopic intervention was similarly deferred given inability
to intubate patient in setting of recent vocal cord surgery.
Patient was managed with clear diet and symptomatically until
nausea improved and by time of discharge, he was tolerating PO
without any difficulty. Of note, patient ENT provider (Dr.
___ recommended patient refrain from intubation for up to
six months post-procedurally, which would potentially impede any
additional endoscopic interventions.
# S/p vocal cord surgery
Pt underwent L medialization laryngoplasty on ___. Was
prescribed prednisone taper (50mg starting on ___, decrease by
10mg daily) and continued post-operative clindamycin for a total
of 10 days.
# Tachycardia
Pt with persistent tachyardia to 120s-130s since presentation,
improved with fluids. Most likely hypovolemic shock with mildly
elevated lactate that resolved with IVF as well as
component of pain/anxiety. Pt had no sign of infection during
hospitalization. basic infectious work-up was done to rule out
sepsis. CXR: chronic pleural effusion. BC and UC unrevealing.
# Leukocytosis
Most likely reactive following surgery as well as steroids.
Infectious work up negative as above.
# ___
Cr mildly elevated above baseline of 0.7-0.8 on presentation.
Most likely hypovolemic. improved with IVF.
# Hypercalcemia
improved with IVF.
# ___ esophagus
continude esomeprazole 40mg BID
# Chronic pain
At home only takes cannabis edibles. During hospitalization pain
controlled with pain meds.
# HTN
Continue home amlodipine 5mg QD. BP controlled with Enalaprit.
Core Measures:
=========================
# Code status: Full, confirmed
# Health care proxy/emergency contact:
Name of health care proxy: ___
___: wife
Phone number: ___
___ Issues:
[ ] Consider additional esophageal dilation at discretion of
outpatient GI provider
[ ] Refrain from intubation at request of patient ENT team for
six months from vocal cord surgery. The risk-benefit of
intubation for endoscopic procedure above will require
multidisciplinary discussion with ENT and GI
[ ] Consider need for longer-term nutritional plan if patient
continues to experience intermittent inability to tolerate PO
[ ] Please check CBC at next primary care appointment to ensure
hemoglobin remains stable
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Esomeprazole 40 mg Other DAILY
2. amLODIPine 5 mg PO DAILY
3. Clindamycin 300 mg PO Q6H
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Clindamycin 300 mg PO Q6H
Antibiotic Course (___)
3. Esomeprazole 40 mg Other DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
ACUTE:
==========================
# Intractable nausea/vomiting
# Coffee ground emesis
# Abdominal Pain s/ to intractable vomiting
# Tachycardia
# S/p vocal cord surgery
# Leukocytosis
# ___
# Hypercalcemia
CHRONIC:
==========================
# ___ esophagus
# Chronic pain
# HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
===================================
- You were admitted because you had persistent vomiting and
abdominal pain.
What happened while I was in the hospital?
==========================================
- It was noted you were vomiting content with blood in it.
- We monitored your blood count until we made sure you
stabilized.
- We gave you medication to control your vomiting and your pain.
- Your symptoms improved so we slowly advanced your diet
- We spoke to different specialty and coordinated with them to
best care for you.
What should I do after leaving the hospital?
============================================
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
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2117-09-29 16:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left quad tendon superficial infection
Major Surgical or Invasive Procedure:
None during this admission
History of Present Illness:
___ h/o pre-diabetes, quad tendon rupture (___) s/p
multiple revisions, last ___ with allograft, s/p knee
manipulation this week presenting with 2 day history of
knee/thigh pain, erythema, and fevers to 103.
Patient reports that he had some new knee pain this week, and
followed up with his orthopedic surgeon at ___. He had a knee manipulation, is currently developed
increasing pain, erythema, swelling over the last 2 days. He
noted subjective fevers at home. He was seen at an outside
hospital emergency department, where a CT scan obtained that
demonstrated no free air in the soft tissues, with some
nonspecific fat stranding extending into the quadricep with a
small fluid collection. The patient had a funeral to attend,
and
left AGAINST MEDICAL ADVICE, now re-presenting to ___
definitive care.
In the emergency department, patient febrile to 103 and
tachycardic to 110s-120s. Noted to have a white blood cell
count
of 10, and increased CRP from 12.7 at outside hospital to 183
now
in house. Patient denies numbness/tingling distally, no other
sites of pain.
Past Medical History:
Multiple quad tendon revisions (last ___ at ___
Pre-diabetes
Social History:
___
Family History:
noncontributory
Physical Exam:
Vitals: ___ 0638 Temp: 100.3 PO BP: 148/91 L Lying HR: 126
RR: 18 O2 sat: 95% O2 delivery: Ra
General-alert and oriented x3, resting comfortably
Left Lower Extremity Exam:
Erythema improving as evidenced by decreased from previously
outlined area. Minimal edema.
SILT sp/dp/s/s/t
Firing ___
WWP
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left quad tendon superficial infection and was
admitted to the orthopedic surgery service. The patient was
observed and determined that he did not need surgery acutely. He
was on IV antibiotics per infectious disease and was discharged
on oral antibiotics until follow up with his primary surgeon at
___. Vitals were stable. Wound was improving at
the time of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. glimepiride 2 mg oral DAILY
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Simvastatin 10 mg PO QPM
4. amLODIPine Dose is Unknown PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*15 Tablet Refills:*0
5. Senna 17.2 mg PO QHS
RX *sennosides [senna] 8.6 mg 17.6 mg by mouth at bedtime Disp
#*60 Tablet Refills:*0
6. glimepiride 2 mg oral DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Simvastatin 10 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
soft tissue infection overlying left knee
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions:
- Resume your regular activities as tolerated, but please
follow your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weight bearing as tolerated left lower extremity
ANTIBIOTICS
- please take augmentin by mouth twice daily for 7 days or
until follow up with your primary surgeon for further
conversation regarding your antibiotic course
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is an
over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean off
this medication in 1 week or sooner. This is an example on how
to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and continue following
the bowel regimen as stated on your medication prescription
list. These meds (senna, colace, miralax) are over the counter
and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your physicians
at discharge.
8) Continue all home medications unless specifically instructed
to stop by your surgeon.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever >101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please go to your scheduled MRI appointment on ___ and
follow up with your Orthopaedic Surgeon, Dr. ___ at New
___ ___ as scheduled for ___.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Followup Instructions:
___
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2140-07-08 16:51:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left lower leg swelling and redness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ with paranoid schizophrenia, hypertension,
and CAD, h/o bladder cancer s/p resection with ileostomy who
presents from nursing home due to increased weakness, decreased
appetite and swelling of left lower extremity. Per patient he
has felt unwell and was diagnosed as pneumonia which required
PICC placement and IV antibiotics. NP call in states that he had
a PNA which was treated with doxycline. Patient was also found
to have an ESBL UTI recently and is currently receiving
ertapenem. Per NP email he has had a 20 lb weight loss in the
past month. Also per NP admission email the patient has also had
dehydration with acute renal failure with baseline bun 21, creat
1.8, as high as 50-60s and creat 2.7-3.0, now down to 28 and
___ s/p at least 4L IVF. His renal u/s neg for hydronephrosis.
Patient has noticed increased left lower leg redness and
swelling for couple days. Patient denies any fevers, chills,
nausea, vomiting or chest pain.
In ER: (Triage Vitals: 98.4 101 ___ 98%. Labs significant
for Cr 2.0, lactate 0.9, Hct 36, plts 130, bicarb 19, Cl 117.
Coags WNL. Radiology Studies: LLE US showed left popliteal clot
and CXR my read is largely unremarkable. Meds Given: Vancomycin
and heparin gtt. He was started on a heparin gtt given his CKD
he was not a candidate for lovenox.
On the floor, patient is pleasant, comfortable, speaking full
sentences.
Past Medical History:
Paranoid schizophrenia
HLD
HTN
UTI, ESBL ecoli
CAD
Bladder ca s/p ileostomy, dx about ___ ago per pt
Pneumonia
CKD-III
hyperparathyroidism
ventral hernia
Social History:
___
Family History:
not obtained
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals - 97.4 130/59 88 20 98%RA
GENERAL: NAD, pleasant elderly man
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, oral thrush
CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs
LUNG: some exp wheezing on the right, otherwise clear, breathing
comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, + ventral hernia with
suprapubic ostomy draining clear yellow urine
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, left lower leg with marked
erythema and warmth
DISCHARGE PHYSICAL EXAM
========================
Vitals - 98.2 119/90 82 18 92% on RA
GENERAL: NAD, lying in bed
HEENT: NCAT
CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs
LUNG: clear to ascultation bilaterally
ABDOMEN: normoactive bowel sounds, soft, nontender,
nondistended, suprapubic ostomy c/d/i, pink and patent
EXTREMITIES: left lower leg with erythema and 1+ edema as
compared to the right
stable. RUE with PICC, c/d/i
Pertinent Results:
ADMISSION LABS
===============
___ 03:20PM BLOOD WBC-7.6 RBC-4.17* Hgb-11.3*# Hct-36.1*
MCV-87 MCH-27.0 MCHC-31.2# RDW-15.4 Plt ___
___ 03:20PM BLOOD Neuts-73.0* Lymphs-13.7* Monos-5.6
Eos-7.4* Baso-0.4
___ 03:20PM BLOOD Plt ___
___ 06:32PM BLOOD ___ PTT-29.9 ___
___ 03:20PM BLOOD Glucose-96 UreaN-30* Creat-2.0* Na-144
K-4.2 Cl-117* HCO3-19* AnGap-12
___ 05:40AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.0
___ 03:27PM BLOOD Lactate-0.9
DISCHARGE LABS
===============
___ 06:10AM BLOOD WBC-7.7 RBC-4.05* Hgb-10.9* Hct-34.6*
MCV-85 MCH-27.0 MCHC-31.6 RDW-15.2 Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD ___ PTT-43.2* ___
___ 06:10AM BLOOD Glucose-85 UreaN-28* Creat-1.7* Na-140
K-4.4 Cl-112* HCO3-23 AnGap-9
___ 06:10AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.2
RADIOLOGY
=========
___ ___
1. Occlusive thrombus in the left popliteal vein extending into
the deep
peroneal and posterior tibial veins.
2. No deep vein thrombosis in the right lower extremity.
CXR ___
Biapical thickening. Upper lobe scarring with possible
bronchiectasis, best seen on the lateral view, correlate with
history of
chronic lung disease.
Brief Hospital Course:
The patient is ___ year old male with multiple medical problems
including bladder cancer s/p bladder cancer resection with
ileostomy, CKD, paranoid schizophrenia who presents s/p
treatment for PNA and currently receiving IV therapy for ESBL
UTI now with LLE swelling and redness found to have a DVT.
ACTIVE ISSUES
==============
# Acute DVT:
Found on ___. Patient was given a dose of vancomycin in the ED
out of concern for cellulitis however was subsequently found to
have a DVT. Given CKD he is not a candidate for lovenox and so
requires an IV heparin to coumadin bridging with goal INR of
2.0-3.0. Trigger for DVT is likely due to his recent acute
illness recent PNA and UTI which lead to a rehab stay him being
weak and less mobile, but cannot rule out bladder cancer
recurrence at this time. He was maintained on a heparin gtt
until INR had been therapeutic for 24 hours at which point
heparin gtt was discontinued (AM of ___. Will require
outpatient followup for consideration of malignancy causing a
hypercoagulable state.
# ESBL UTI
Was on ertapenem with PICC at rehab (day ___ for 14 day
course). While hospitalized at ___, he was given Meropenem IV
q8hrs, as Erapenem was not on formulary. Urine culture obtained
in the ED was negative. He should resume ertapenem at discharge
to his SNF.
# Hyperchloremic metabolic acidosis
Resolved at time of discharge.
# Hypernatremia
Had resolved at time of discharge.
# Oral Thrush
Swish and swallow nystatin QID
CHRONIC ISSUES
==============
# Schizophrenia: Continued his home medications of olanzapine
17.5mg qHS and Lorazepam 0.5mg PO TID.
# Bladder cancer s/p resection with ileostomy: outpatient
followup to look for reoccurance
# CKD: Cr 2.1 on admission, baseline near 1.8
# recent PNA: He is s/p a course of doxycycline. Not seen on
CXR upon admission. Blood cultures taken upon admission showed
no growth.
# HLD: Continued home simvastatin 20mg Qhs
TRANSITIONAL ISSUES
====================
- was started on coumadin for treatment of his DVT, will require
ongoing INR monitoring, will need daily INR and dosing of
coumadin based on level until stable coumadin regimen. He can
not be bridged with lovenox given CKD, if subtherapeutic will
need to be on heparin gtt.
- he will require outpatient followup to investigate whether
this DVT could represent recurrence of his malignancy (bladder
cancer- hypercoagulable state) versus whether it was due to
immobility
- he was continued on treatment for his ESBL UTI (Meropenem
while hospitalized at ___ as Ertapenem is not on formulary)-
for a total 14 day treatment course (day 1- ___, last day
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 50,000 UNIT PO QMON
2. Cyanocobalamin 1000 mcg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Lorazepam 0.5 mg PO TID
5. Ascorbic Acid ___ mg PO BID
6. Docusate Sodium 100 mg PO BID
7. ___ (cranberry extract) 500 mg oral BID
8. Senna 17.2 mg PO HS
9. Simvastatin 20 mg PO QPM
10. OLANZapine 17.5 mg PO HS
11. Bisacodyl 5 mg PO DAILY:PRN constipation
12. Bisacodyl 10 mg PR HS:PRN constipation
13. Acetaminophen 650 mg PO Q6H:PRN pain
14. Milk of Magnesia 30 mL PO DAILY:PRN constipation
15. Guaifenesin 10 mL PO Q6H:PRN cough
16. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
17. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze
18. ertapenem 1 gram injection Q24h
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
3. Bisacodyl 5 mg PO DAILY:PRN constipation
4. Bisacodyl 10 mg PR HS:PRN constipation
5. Cyanocobalamin 1000 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Guaifenesin 10 mL PO Q6H:PRN cough
9. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze
10. Lorazepam 0.5 mg PO TID
11. Milk of Magnesia 30 mL PO DAILY:PRN constipation
12. OLANZapine 17.5 mg PO HS
13. Senna 17.2 mg PO HS
14. Simvastatin 20 mg PO QPM
15. Nystatin Oral Suspension 5 mL PO QID oral thrush
16. Ascorbic Acid ___ mg PO BID
17. ___ (cranberry extract) 500 mg oral BID
18. ertapenem 1 gram injection Q24h
19. Vitamin D 50,000 UNIT PO QMON
20. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
21. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
22. ___ MD to order daily dose PO DAILY16
dose coumadin based on daily INR, until on stable coumadin dose
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY
Deep Vein Thrombosis
Urinary Tract Infection
SECONDARY
Paranoid Schizophrenia
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
came in with left leg swelling and redness and an ultrasound
showed that there is a blood clot. You were started on
treatment with a medication called heparin as well as warfarin,
which are both blood thinners. Once the warfarin reached
therapeutic levels in your blood, the heparin drip was stopped.
You were also continued on treatment for your urinary tract
infection.
Followup Instructions:
___
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2136-01-08 20:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hyperglycemia/altered mental status/cough
Major Surgical or Invasive Procedure:
There were no major surgical or invasive procedures during
hospitalization.
History of Present Illness:
___ with history of dementia, hypertention, diabetes presenting
with lethargy, cough for one week, noted to have a pneumonia on
a chest x-ray at ___ yesterday. Patient was started on
azithromycin for this by basilar pneumonia. Patient is in a
memory unit. At this unit, they do have access to
rehabilitation. Patient normally uses a walker. Because of the
weakness for the past one week, the patient has been using a
wheelchair. Patient's thought his medical care in ___,
and never establish primary care in ___, the doctor at
his facility has been continuing medications from his doctor in
___. Daughter concerned that the patient is not
receiving adequate attention at facility. Doctor at facility
concerned that glucose 367 today. Low 200s here. Patient denies
complete ROS. A&Ox1. Patient sent to ___ for further
evaluation.
-In the ED, initial vitals were: T 98.7 HR 80 BP 136/91 RR 18
SpO2 97% RA
-Exam notable for: bibasilar crackles, otherwise normal exam
-Labs notable for WBC 9.0, Cr 0.8, lactate 2.7
-CXR was notable LLL opacity concerning for PNA
-Received: 1 L IV NS, Levofloxacin 750 mg IV, Olanzapine 10 mg
PO total, and his home medications (Metformin, Memantine,
Aspirin, Glipizide, Lisinopril
-Transfer VS were: T 102.4 HR 102 BP 128/75 RR 23 SpO2 95% RA
-On arrival to the floor, the patient unable to engage in ROS
evaluation. Patient appeared to be sleeping comfortably. He was
continued on IV abx, his home medications, and started on
insulin sliding scale.
On arrival to the floor, patient was sleeping comfortably, not
responsive to voice and unable to participate in ROS. Family
members were in the room who reports the patient has been
complaining of cough and more lethargic compared to baseline
mental status. The patient was given 1 L IV fluids, continued on
IV abx, started on insulin sliding scale, but otherwise
continued on his home medications.
Past Medical History:
-Hypertension
-Hyperlipidemia
-Dementia
-Type II Diabetes Mellitus
-___: hospitalized at ___ due to hyperglycemia secondary to
underlying pneumonia.
Social History:
___
Family History:
Father had CAD and died of MI. Mother had stomach cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
=====================
VS T 98.3 BP 153/84 HR 95 RR 20 SpO2 98 RA
General: Sleeping comfortably, snoring, does not respond to
voice
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: L basilar inspiratory crackles, no wheezing or rhonci
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM
======================
Vitals: 98.4 122/75 82 18 94RA
General: Awake, alert and oriented x 1 (to person)
HEENT: Sclerae anicteric, MMM, neck supple, JVP not elevated.
CV: RRR, normal S1 + S2, no murmurs.
Lungs: Clear to auscultation
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding.
Ext: Warm, well perfused, no lower extremity edema.
Pertinent Results:
ADMISSION LABS
=============
___ 08:02PM BLOOD WBC-7.3 RBC-3.87* Hgb-12.8* Hct-37.4*
MCV-97 MCH-33.1* MCHC-34.2 RDW-13.2 RDWSD-46.6* Plt ___
___ 08:02PM BLOOD Neuts-63.4 Lymphs-16.3* Monos-15.0*
Eos-4.1 Baso-0.7 Im ___ AbsNeut-4.64 AbsLymp-1.19*
AbsMono-1.10* AbsEos-0.30 AbsBaso-0.05
___ 08:02PM BLOOD Glucose-203* UreaN-17 Creat-0.8 Na-134
K-4.2 Cl-94* HCO3-28 AnGap-16
___ 09:00PM BLOOD Calcium-9.3 Phos-3.7 Mg-1.6
DISCHARGE LABS
=============
___ 06:45AM BLOOD WBC-5.6 RBC-3.99* Hgb-12.7* Hct-38.5*
MCV-97 MCH-31.8 MCHC-33.0 RDW-13.1 RDWSD-46.5* Plt ___
___ 06:45AM BLOOD Glucose-288* UreaN-15 Creat-0.8 Na-142
K-4.5 Cl-101 HCO3-22 AnGap-24*
___ 06:45AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.8
HEMOGLOBIN A1C
==============
___ 09:15AM BLOOD %HbA1c-8.0* eAG-183*
URINE STUDIES
============
___ 11:03PM URINE Color-Straw Appear-Clear Sp ___
___ 11:03PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 11:03PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
MICROBIOLOGY
============
___: BLOOD CULTURE X 2: PENDING.
___: BLOOD CULTURE X 1: PENDING.
___ 4:40 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING
=======
IMPRESSION:
Left lower lobe opacity may reflect pneumonia. Comparing with
prior
radiograph would be helpful to determine progression or
improvement.
Brief Hospital Course:
___ year old gentleman with history of dementia, hypertension,
and diabetes presenting with lethargy found to have LLL PNA
complicated by hyperglycemia.
# Community Acquired Left Lower Lobe Pneumonia: Patient was
initially treated as an outpatient with azithromycin for
suspected pneumonia, however, hyperglycemia ensued in the
setting of pneumonia leading to admission to ___ (patient
lives in a memory unit at ___ on ___ and they were
concerned regarding his hyperglycemia). CXR at ___ confirmed
left lower lobe pneumonia. He initially was started on
levofloxacin and was subsequently transitioned to ceftriaxone
and azithromycin. On admission, required supplemental O2 (up to
3L) but was quickly weaned back to room air. He was asymptomatic
with normal saturation on room air for 3 days at the time of
discharge, at which point he had taken 6 days of antibiotics and
the decision was made to end his course.
# Type II Diabetes Mellitus Complicated by Hyperglycemia: At
Memory unit at ___ on the ___ patient had blood sugars
in the high 300s. Given concern for the hyperglycemia, was
transferred to ___ for evaluation. As noted above, etiology of
the hyperglycemia was in the setting of pneumonia. At his
facility he is on metformin 1000 mg PO BID and glipizide 2.5 mg
PO daily. Initially, these were held and he was continued
insulin sliding scale. He resumed his home glipizide and
metformin. He remained hyperglycemia, so sitagliptin was added
and metformin and glipizide were increased. He continued to
require sliding scale insulin at discharge.
During hospitalization, his hemoglobin A1C was noted to be 8.0%.
As insulin administration in the Memory Unit at his facility is
somewhat complicated, an attempt was made to develop an oral
diabetes regimen. ___ Diabetes was consulted for further
recommendations. They recommended the above regimen with a plan
to increase his oral agents and try to wean off the sliding
scale. If he is unable, the ___ clinic can change him to a
basal bolus insulin regimen and rehab providers and family can
determine how this will impact his living situation.
# Hypertension: Continued lisinopril 30 mg PO daily.
# Dementia: Alert and oriented x 1 at baseline. Continued
meantime 5 mg PO BID. His home ___ was not on formulary at
the hospital. He was discharged on memantine 5 mg PO BID and
galantine 16 mg PO daily.
TRANSITIOANL ISSUES
=================
Transitional Issues:
- needs vitamin D checked as an outpatient
- ___ follow up
- Patient was persistently hyperglycemic on metformin,
glipizide, Januvia. Insulin sliding scale was added to the
regimen. We recommend gradually increasing his glipizide and
tapering down his sliding scale to get him off insulin and
hopefully transition back to the memory unit. If he is unable to
come off the insulin, the ___ clinic can transition him to a
basal/bolus insulin regimen at his follow up appointment and if
this is a barrier to returning to the memory unit, his long term
residential situation will need to be re-addressed with family.
- Code Status: DNR/DNI (confirmed, has MOLST)
- Contact Information: ___ (___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. galantamine 16 mg oral QDaily
4. GlipiZIDE 2.5 mg PO DAILY
5. Lisinopril 30 mg PO DAILY
6. Memantine 5 mg PO BID
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Vitamin D ___ UNIT PO Q21DAYS
Discharge Medications:
1. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
2. Januvia (SITagliptin) 100 mg oral DAILY
3. GlipiZIDE 5 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. galantamine 16 mg oral QDaily
7. Lisinopril 30 mg PO DAILY
8. Memantine 5 mg PO BID
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Vitamin D ___ UNIT PO Q21DAYS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
================
-Community Acquired Pneumonia
-Type II Diabetes Mellitus
-Dementia
-Hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ after
you were noted to have elevated blood sugars. You were also
noted to have a pneumonia. The reason for the elevated blood
sugars was likely secondary to the underlying pneumonia.
You initially required oxygen but after receiving intravenous
antibiotics, you were able to breath comfortably on room air.
in order to better control your blood sugars and optimize you on
an oral medication regimen to control your blood sugars, you
were seen by the Diabetes specialists at ___. They
recommended continuing with metformin, glipizide and
sitagliptin. You will remain on sliding scale insulin for now.
This will be stopped if recovery from your illness or increased
doses of your oral medications will allow.
Best Wishes,
Your ___ Care Team
Followup Instructions:
___
|
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2136-01-26 18:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abd Pain, ABD Distention
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx dementia, hypertention, diabetes, recent admission
___ with hyperglycemia from underlying LLL PNA completed
tx with CTX/azithromycin, returns for abdominal distension,
altered mental status, admitted for same and fever, tachycardia.
Per ED notes, after discharge he was evaluated at his memory
facility for tachycardia on ___ but no interventions were
performed. Today, daughters were called and told pt was
complaining of abdominal pain, that he was more distended, and
more agitated. Daughters felt mental status different from
baseline, he was more somnolent. His last BM was ___ per
facility.
In the ED, initial VS were: 98.3 99 160/99 20 99% RA. He did
spike a fever to 101.8 at 1345 and was tachy to the low 100s.
ED physical exam was recorded as:
Hypertensive 160/99mmHg, Tachycardic 101x'
Somnolent but easily arousable and responds to verbal commands.
Not oriented in person, time, or place but seems to recognize
his daughters. This is a change from baseline, he is usually
more alert and can state his full name.
___ equal and reactive
JVP at 6cm at 30 degrees
Nl s1, s2, no m/r/g
Lungs with bilateral rhonchi and crackles in bases
Abdomen is distended, tenderness to palpation in lower abdomen,
particularly suprapubic. No peritoneal signs, bowel sounds
present
No peripheral edema
Peripheral pulses preserved
ED labs were notable for: WBC 11.9. Cl 93, Glucose 286.
Otherwise normal Chem10, CBC, LFTs. UA with neg Leuk, neg Nitr,
38 WBC and few bacteria. 66 RBCs (with protein, glucose, and 80
ketones).
CT A/P was unremarkable. CXR was unremarkable.
EKG showed: NSR, no ischemic change.
Patient was given:
___ 12:36 IVF NS 500 mL
___ 13:30 IV CeftriaXONE
___ 14:17 IV Acetaminophen IV 1000 mg
Transfer VS were: 93 124/74 16 95% RA.
When seen on the floor, patient is pleasant and oriented to
self, unable to provide further subjective history. His
daughters essentially confirm the story as above.
Past Medical History:
-Hypertension
-Hyperlipidemia
-Dementia
-Type II Diabetes Mellitus
-___: hospitalized at ___ due to hyperglycemia secondary to
underlying pneumonia.
Social History:
___
Family History:
Father had CAD and died of MI. Mother had stomach cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.1 125 / 86 88 18 96 room air
Gen: Older male, supine in bed, NAD
HEENT: NCAT, EOMI, PERRLA, anicteric sclera, clear OP, MMM
CV: RRR, no r/g/m
Chest: CTAB, no w/r/r
GI: soft, NT, not distended here, BS+. No suprapubic tenderness.
MSK: No kyphosis. No synovitis.
Skin: No jaundice.
Neuro: AAOx1. No facial droop. Moving all extremities
spontaneously
Psych: Full range of affect
DISCHARGE PHYSICAL EXAM:
Vitals: 98.3 129/84 90 18 96 RA
Gen: NAD, sitting up in the chair with an empty ___ of food in
front of him.
Eyes: EOMI, sclerae anicteric
ENT: MMM
Cardiovasc: RRR, no murmur.
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
Skin: No visible rash. No jaundice.
Neuro: No facial droop.
Pertinent Results:
ADMISSION LABS:
___ 09:51AM BLOOD WBC-11.9*# RBC-4.43* Hgb-13.9 Hct-42.7
MCV-96 MCH-31.4 MCHC-32.6 RDW-13.0 RDWSD-46.5* Plt ___
___ 09:51AM BLOOD Glucose-286* UreaN-19 Creat-0.9 Na-136
K-5.1 Cl-93* HCO3-24 AnGap-24*
___ 09:51AM BLOOD Lipase-26
___ 09:51AM BLOOD cTropnT-<0.01
___ 09:51AM BLOOD Albumin-4.3 Calcium-9.6 Mg-1.9
___ 10:02AM BLOOD Lactate-1.7
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-5.2 RBC-4.13* Hgb-13.0* Hct-39.7*
MCV-96 MCH-31.5 MCHC-32.7 RDW-13.0 RDWSD-46.3 Plt ___
___ 06:50AM BLOOD Glucose-202* UreaN-15 Creat-0.8 Na-134
K-4.5 Cl-97 HCO3-28 AnGap-14
___ 06:50AM BLOOD WBC-5.2 RBC-4.13* Hgb-13.0* Hct-39.7*
MCV-96 MCH-31.5 MCHC-32.7 RDW-13.0 RDWSD-46.3 Plt ___
___ 06:50AM BLOOD Glucose-202* UreaN-15 Creat-0.8 Na-134
K-4.5 Cl-97 HCO3-28 AnGap-14
___ 06:50AM BLOOD Mg-2.1
Imaging:
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with abdominal pain
distention NO_PO
contrast // eval for acute process
FINDINGS:
LOWER CHEST: There is mild bibasilar bronchiectasis and
ground-glass opacity, incompletely evaluated on this
examination. A calcified granuloma is noted. A subpleural, 3 mm
nodule is seen at the right lung base (2:3).
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
Scattered hepatic hypodensities are noted, measuring less than 1
cm, likely representing small cysts or hamartomas (02:13, 24,
17). There is no evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas is nearly entirely fatty replaced. There
is no
peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram. Subcentimeter hypodensities are seen in the
bilateral kidneys, and are too small to characterize, but likely
represent small cysts or hamartomas. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable aside from a small
hiatal
hernia. The duodenal bulb and sweep are distended with fluid,
which may be
related to peristalsis. The remainder of the small bowel is
normal in
caliber. The colon and rectum are within normal limits. The
appendix is
normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is heterogeneous and enlarged
and contains multiple coarse calcifications.
LYMPH NODES: There are numerous, nonenlarged retroperitoneal and
pelvic
sidewall lymph nodes. There is no mesenteric or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease is noted.
BONES: Minimal degenerative changes are seen in the lower
thoracic and lumbar spine. There is grade 1 retrolisthesis of
L5 on S1.
SOFT TISSUES: A small fat containing umbilical hernia is
present.
IMPRESSION:
1. No definite findings to explain patient's symptoms.
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hx PNA, returns with +SIRS, ?
source, eval for interval development PNA after hydration //
eval for PNA eval for PNA
IMPRESSION:
In comparison with study of ___, there is little overall
change. Again there is mild asymmetry of opacification at the
left base without silhouetting of the hemidiaphragm. Although
most likely representing atelectatic changes, in the appropriate
clinical setting superimposed pneumonia could be considered,
especially in the absence of a lateral view.
Brief Hospital Course:
___ hx dementia, hypertention, diabetes, recent admission
___ with hyperglycemia from underlying LLL PNA completed
tx with CTX/azithromycin, returns for abdominal distension,
altered mental status, admitted for same and fever, tachycardia,
c/f infection. Treated for presumed PNA then developed c. diff
colitis.
# C. Diff Colitis: Developed in the setting of antibiotic
exposure. Stable volume status and no leukocytosis. Will
complete a 14 day course of PO vancomycin (D1 ___.
# Sepsis due to possible PNA:
qSOFA = 1, SIRS = 2. Source of infection is unclear but
supra-pubic tenderness but negative urine culture. On CXR
possible small infiltrate in same loacation as prior. Question
of meningitis was raised on admission but he has full ROM of his
neck, no meningeal signs, is alert and appropriate with dementia
and inattention on exam. s/p 5 day CTX to PO cefpedoxime cto
complete 5 day course of antibiotics for presumed PNA with
return of baseline mental status.
# Toxic Metobolic Encephalopathy: In the setting of above
sepsis. Improved to baseline mental status on ___.
# DM2 w/Hyperglycemia
Previously had hyperglycemia in response to an infection when
last admitted. A1c was 8.0% then. Given difficulty with insulin
administration at his Memory Unit, he was discharged on a
predominantly oral regimen of antiglycemics, with plan to
eventually transition to a basal/bolus regimen.
- Continued home glipizde, ISS here
- Held home metformin and Januvia that were resumed on
discharge.
# CV, HTN, HLD:
- Continued home ASA, statin, lisinopril
# Dementia:
- Continue homed memantine, held home galantamine
- Aspiration, delirium, fall precautions
# Code status: DNR/DNI (confirmed)
# Contact: ___ (daughter ___
Greater than 30 minutes was spent in care coordination and
counseling on the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Lisinopril 30 mg PO DAILY
3. Memantine 5 mg PO BID
4. galantamine 16 mg oral QDaily
5. Vitamin D ___ UNIT PO Q21DAYS
6. GlipiZIDE 5 mg PO BID
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Januvia (SITagliptin) 100 mg oral DAILY
9. Pravastatin 40 mg PO QPM
10. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
11. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 14 Days
RX *vancomycin 125 mg 1 capsule(s) by mouth 4 times per day Disp
#*52 Capsule Refills:*0
2. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
3. Aspirin 81 mg PO DAILY
4. galantamine 16 mg oral QDaily
5. GlipiZIDE 5 mg PO BID
6. Januvia (SITagliptin) 100 mg oral DAILY
7. Lisinopril 30 mg PO DAILY
8. Memantine 5 mg PO BID
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Pravastatin 40 mg PO QPM
11. Senna 8.6 mg PO BID:PRN constipation
12. Vitamin D ___ UNIT PO Q21DAYS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Sepsis due to possible PNA
C. Diff colitis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr ___,
It was a pleasure taking care of you while you were in the
hospital. You were admitted with altered mental status thought
to be due to an infection. You were treated with antibiotics and
you improved. You were found to have an infection in your stool
(c. diff colitis) and that will require 2 weeks of antibiotics.
Please take your medications as directed and follow up as noted
below.
Followup Instructions:
___
|
10850433-DS-21
| 10,850,433 | 22,333,431 |
DS
| 21 |
2166-05-31 00:00:00
|
2166-06-01 10:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
doxycycline
Attending: ___.
Chief Complaint:
Shortness of Breath and Worsening Abdominal Distension
Major Surgical or Invasive Procedure:
Thoracentesis x2 with placement of pigtail catheter
Large Volume Paracentesis
Transjugular intrahepatic portosystemic shunt
History of Present Illness:
Ms. ___ is a ___ y/o male with PMH significant for EtOH
cirrhosis (Child ___ Class B, MELD as of ___ 16) with known
grade 1 varices s/p banding, portal hypertension, diuretic
refractory ascites, and recurrent pleural effusions who presents
with SOB. Pt. was in his usual state of ealth until this past
___ when he was diagnosed with cirrhosis. Since this time,
pt. has required intermittent paracentesis and thoracentesis.
Most recent thoracenteses were on ___ and ___. At the ___
drainage, 1.8 L removed which grew gram positive cocci on
culture, repeat ___ on ___ revealed no growth on culture,
2.2L of fluid was removed.
Since his last ___, pt. had ___ days symptom free. Over the
last ___ days, pt. reports worsening SOB now at rest. He
presented to the ED, initial vitals were 97.8 110 114/84 34 96%
ra. Labs were notable for PLT 117, INR 1.5 unchanged, Tbili 2.7
up from 1.9, Na 126. CXR showed whiteout left hemithorax. Diag
and therapeutic ___ with 2L drained, paracentesis with 450 WBC
and 90 polys. RUQ u/s patent portal flow.
Past Medical History:
ETOH Cirrhosis complicated by grade 1 varices s/p banding,
portal hypertension, diuretic refractory ascites, and recurrent
left-sided hepatohydrothorax
Arthritis (knees, back, wrists)
Alcohol dependence
GERD
s/p hemorrhoidectomy ___
s/p R knee replacement
Social History:
___
Family History:
-Father-deceased, emphysema, ?cancer
-Mother-deceased, healthy
-Brother-died of a blood clot
-No known family hx of liver disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VS: T 97.9 BP 117/89 HR 72 RR 18 O2 99%RA
General: Well appearing, no jaundice
CV: RRR, no murmurs
Lungs: ___ site c/d/i left subscap, breath sounds bilaterally
R>L, no crackles
Abdomen: Tense ascites, nontender, +bs
Ext: Pitting edema bilateral lower extremities to knee
DISCHARGE PHYSICAL EXAM:
==========================
VS: Tm 98.3, 118/61, 87, 18, 96%RA
GEN: resting comfortably in bed, NAD, AAOx3, pleasant,
conversational
HEENT: NCAT, MMM
NECK: No JVD
CV: RR, S1+S2, NMRG
RESP: CTA, diminished BS lower left. Bandage at chest tube site
C/D/I
ABD: soft, non-tender, non-distended, BS present. L flank with
erythema, pitting edema and mild induration of skin. No area of
fluctuance. Warm to touch. 5mm shallow ulcerated lesion,
previous para site with 1 stitch in place and intact. ___ site
at edge of erythema with clean and dry bandage in place.
EXT: WWP, no edema
NEURO: CN II-XII grossly intact, MAE No asterixis
Pertinent Results:
ADMISSION LABS
================
___ 09:48PM BLOOD WBC-8.1 RBC-4.25* Hgb-14.0 Hct-42.2
MCV-99* MCH-32.9* MCHC-33.1 RDW-14.0 Plt ___
___ 09:48PM BLOOD Neuts-69.2 Lymphs-12.8* Monos-14.1*
Eos-3.6 Baso-0.4
___ 09:48PM BLOOD ___
___ 09:48PM BLOOD Glucose-153* UreaN-14 Creat-1.1 Na-126*
K-5.0 Cl-91* HCO3-25 AnGap-15
___ 09:48PM BLOOD ALT-25 AST-71* AlkPhos-74 TotBili-2.7*
___ 09:48PM BLOOD Albumin-3.4*
DISCHARGE LABS
================
___ 05:15AM BLOOD WBC-4.4 RBC-3.13* Hgb-10.9* Hct-30.9*
MCV-99* MCH-34.9* MCHC-35.4* RDW-14.0 Plt Ct-44*
___ 06:25AM BLOOD Neuts-67.4 Lymphs-14.0* Monos-13.5*
Eos-4.5* Baso-0.5
___ 05:15AM BLOOD ___ PTT-42.6* ___
___ 05:15AM BLOOD Glucose-111* UreaN-12 Creat-0.8 Na-127*
K-3.8 Cl-93* HCO3-27 AnGap-11
___ 05:15AM BLOOD ALT-57* AST-94* AlkPhos-69 TotBili-3.7*
___ 05:15AM BLOOD Albumin-3.6 Calcium-8.9 Phos-2.1* Mg-1.9
STUDIES
=========
CXR (___): IMPRESSION: Nearly complete opacification of
the left lung with rightward mass effect suggesting marked
increase in a pleural effusion. The possibility of malignancy
should be considered in addition to sequelae of cirrhosis.
TTE (___): The left atrium and right atrium are normal in
cavity size. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is a small pericardial effusion. The effusion appears
loculated and confined anteriorly (clip 2).
IMPRESSION: Small loculated anteriorly located pericardial
effusion. Due to image quality I cannot exclude tamponade
physiology. There are large bilateral fibrinous pleural
effusions and ascites. Normal biventricular regional/global
systolic function.
RIGHT UPPER QUADRANT ULTRASOUND W/ ___: 1.
Patent portal vein. 2. Large amount of ascites within the
abdomen and a large left pleural effusion. 3. Nodular
echogenic liver consistent with cirrhosis.
TIPS:
Successful right IJ access with transjugular intrahepatic
portosystemic shunt placement with decrease in porto-systemic
pressure gradient from 20mmHg to 7mmhg.
Of note the stent may be further dilated to 10mm if required.
Uncomplicated right-sided paracentesis and drainage of the large
left pleural effusion.
MICRO
=========
___ 12:00 am PERITONEAL FLUID
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Brief Hospital Course:
BRIEF SUMMARY STATEMENT: Ms. ___ is a ___ y/o male with PMH
significant for EtOH cirrhosis (Child ___ Class B, MELD 16 as
of ___ with known grade 1 varices s/p banding, portal
hypertension, diuretic refractory ascites, and recurrent
hepatohydrothorax who presented with SOB and worsening abdominal
distension. Pt. was found to have recurrent left-sided
hepatohydrothorax. Thoracentesis was done in the ED with
improvement in symptoms. Large Volume Paracentesis and
additional thoracentesis with placement of a temporary pigtail
chest catheter was performed by interventional radiology. Pt.
tolerated these procedures well and had subsequent transjugular
intrahepatic portosystemic shunt placed. He was discharge with
close follow-up.
ACTIVE ISSUES
=============
# Recurrent Left-Sided Hepatohydrothorax: Pt. presented with
SOB. Pt. had left sided thoracentesis done in the ED with
removal of approximately 2L. Pt. was sent to interventional
radiology for TIPS procedure. For concern of reduced
respiratory reserve in setting of recurrent hepatohydrothorax,
pt. had a repeat thoracentesis with placement of left-sided
pigtail pleural catheter. Pt's respiratory status remained
stable throughout hospitalization. Pig tail catheter was
removed prior to discharge. He will need a repeat CXR in 6 days
to eval for reaccumulation
# Diuretic Refractory Ascites: Pt. presented with worsening
abdominal distension, most likely ___ chronic portal
hypertension and ongoing non-compliance with 2G Na diet. To
evaluate for cardiac contribution, pt. had a TTE which revealed
small loculated anteriorly located pericardial effusion with
normal regional and global ventricular function. Pt. on maximum
dose diuretics at home with spironolactone and furosemide
without improvement in his ascites. As such, pt. had a large
volume paracentesis on ___ with 4.7L removed. He then
underwent TIPS procedure with improvment noted in hepatic portal
system pressures. He will need a repeat RUQ US to eval patency
in 6 days. GIven placement of TIPS, he was started on lactulose
BID to prevent encephalopathy.
# Hyponatremia: Pt. with intermittent hyponatremia in the
setting of EtOH Cirrhosis. Pt's diuretics were held. His
hyponatremia responded well to albumin on admission. Diuretics
were restarted after on discharge at lower dose.
# EtOH Cirrhosis: Pt. with known EtOH cirrhosis since ___. On
admission pt. with ___ Class B Cirrhosis with MELD near
16. Pt. has not yet been involved in substance abuse recovery
program, and as such has not yet been initiated on transplant
work-up. He did report that he has been sober since time of
diagnosis. Pt. had not had an episode of known SBP or
encephalopathy at this time. He has known portal hypertension,
diuretic refractory ascites, and recurrent left
hepatohydrathorax as noted above. Grade 1 esophageal varices
s/p banding, no episodes of GI bleeding in the past.
CHRONIC ISSUES
===============
# GERD: Stable. Continued on omeprazole.
# Anxiety: Stable. Continued on home dose alprazolam.
TRANSITIONAL ISSUES
======================
# Transplant work-up: Pt. is likely a good candidate for
transplant. He should be enrolled in a substance abuse recovery
program and should have tranplant work-up.
# Grade 1 varices s/p banding: Pt. may benefit from nadolol.
# Obtain labs, CXR, and RUQ US on ___ prior to f/u with Dr.
___ on ___
# CODE: Full (confirmed)
# CONTACT: Patient, girlfriend ___ ___ work
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO BID
2. Omeprazole 20 mg PO BID
3. Spironolactone 50 mg PO TID
4. Potassium Chloride 20 mEq PO DAILY
5. ALPRAZolam 0.5 mg PO TID:PRN anxiety
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Cough
7. BuPROPion (Sustained Release) 150 mg PO BID
8. Ascorbic Acid Dose is Unknown PO Frequency is Unknown
9. Vitamin E Dose is Unknown PO Frequency is Unknown
10. HYDROcodone Compound (hydrocodone-homatropine) ___ mg/5 mL
oral Q6H:PRN Cough
Discharge Medications:
1. ALPRAZolam 0.5 mg PO TID:PRN anxiety
2. Omeprazole 20 mg PO BID
3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Cough
4. Ascorbic Acid ___ mg PO DAILY
5. BuPROPion (Sustained Release) 150 mg PO BID
6. Furosemide 40 mg PO DAILY
7. HYDROcodone Compound (hydrocodone-homatropine) ___ mg/5 mL
oral Q6H:PRN Cough
8. Potassium Chloride 20 mEq PO DAILY
9. Spironolactone 50 mg PO DAILY
10. Vitamin E 400 UNIT PO DAILY
11. Lactulose 15 mL PO BID
RX *lactulose 10 gram/15 mL 15 ml by mouth twice a day
Refills:*0
12. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0
13. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth q6hrs Disp #*40
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
# Alcohol Related Cirrhosis
# Hepatohydrothorax
# Diuretic Refractory Ascites
# Hyponatremia
# Abdominal Wall Cellulitis
SECONDARY DIAGNOSES
===================
# GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure meeting and caring for you during your
hospitalization at ___. You
were admitted for worsening distension of your abdomen and also
some shortness of breath. You were found to have a recurrent
fluid collection in your chest and also worsening ascites in
your belly. You had a chest tube placed by the interventional
radiologists to help remove the fluid there. You also had a
"TIPS" procedure which should help reduce the amount of fluid
that collects in your belly. You tolerated both procedures well
and were discharged. We started you on a higher dose of
lactulose as well as antibiotics for a skin infection. We also
reduced your dose of diuretics. You also need to come to ___
on ___, the day before your appointment with Dr. ___ have
a liver ultrasound, chest x ray, and labs drawn.
Followup Instructions:
___
|
10850680-DS-10
| 10,850,680 | 26,004,480 |
DS
| 10 |
2182-07-16 00:00:00
|
2182-07-16 18:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ACE Inhibitors / amlodipine / ___ Receptor
Antagonist / citalopram / Benzodiazepines / Lunesta / Remeron
Attending: ___.
Chief Complaint:
SOB and anasarca
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with with history of CAD s/p CABG x 3 and
stenting, AF on warfarin, PVD with AAA repair, CKD stage IV-V
c/b cardiorenal syndrome, and a recent admission to OSH with
acute on chronic kidney disease secondary to UTI, now presenting
with increasing fluid retention over the past 5 weeks. Since
discharge from the OSH to rehab and subsquently to home, he has
been experiencing increasing fluid retention with worsening
pitting edema in his lower extremities, increasing shortness of
breath as well as abdominal distension. He noted increasing
dyspnea on exertion as well as orthopnea. His edema has worsened
to the point of significant penile and scrotal edema at times,
with subsequent improving and worsening. At his PCP's office
yesterday, these symptoms prompted the NP seeing him to
recommend evaluation at the ___ ED. He was opposed to this,
but decided to follow the recommendation to hear what the
doctors had to say. He is opposed to hemodialysis, stating that
he believes his quality of life will suffer greatly and that the
improvement of his symptoms would not be a reasonable trade-off
for having to get dialysis 3 times a week.
She notes that his baseline creatinine is 2.3 - 2.8, with an
acute elevation to 4. His edema extends now to his hips, with
evidence of ascites, pulmonary edema with wheezing throughout.
He had been tried on metolazone, but this worsening his renal
function and caused hypokalemia. Increasing his furosemide dose
to 80mg daily did help with the edema. He notes that his
appetite is poor and he has been struggling with frequent bowel
movements (formed, not diarrheal), which has improved with
Lomotil. He also reports difficulty swallowing, feels like he is
regurgitating food (last EGD showed only hemorrhagic gastritis,
done for iron deficiency anemia work-up). He also complains of
fatigue, insomnia, though denies orthopnea.
Weights from his last 5 encounters are as follows (per Atrius
notes)
ADMISSION: 165 lbs
___ : 160 lb (72.576 kg)
___ : 165 lb 4 oz (74.957 kg)
___ : 170 lb 3.2 oz (77.202 kg)
___ : 151 lb 2 oz (68.55 kg)
___ : 151 lb 12.8 oz (68.856 kg)
In the ED, initial VS were: 97.6 79 123/58 24 100% RA. CXR
showed mild pulmonary vascular engorgement, a small right
pleural effusion, and mild bibasilar atelectasis. Labs notable
for creatinine of 4.1, K+ 3.8, BNP of 33006, INR of 4.5, and PTT
of 51.5. Vital on transfer: 97.4 92 133/85 22 100% 2L NC.
On arrival to the floor, he is comfortably sitting up in the
chair at the bedside, requesting crackers and soda. His
breathing appears labored but he is not in any distress. He is
mostly concerned about how long he has to stay in the hospital.
Overnight, he was given 80 mg IV lasix x 1 at roughly 3 AM, put
out 375 cc by eval this morning.
Past Medical History:
- CAD s/p CABG x 3 ___ - ___), stent placed to OMB branch of a
bypass graft, c/b by stent narrowing s/p angioplasty
- Systolic heart failure - declining EF with pulmonary
hypertension
- Atrial fibrillation, on coumadin
- COPD
- CKD stage IV-V - not on HD yet
- AAA repair (___ ___
- Carotid endarterectomy (___ ___
- Cerebrovascular disease with a history of TIAs and retinal
vein occlusion
- partial colectomy at ___
- fem-pop bypass in (___ ___
- hyperlipidemia
- hypertension
- sciatica
- diverticulitis
Social History:
___
Family History:
Brother CAD/PVD - Early; Cancer; Diabetes - Type II
Father CAD/PVD - Early; Cancer
Paternal Grandfather ___ - Type II
Sister CAD/PVD - Early; Diabetes - Type II
Physical Exam:
ADMISSION PE:
VS - 97.8 120/69 85 20 98% 3L Wt 74.4 kg (163.6 lbs)
GENERAL - elderly male with mild respiratory distress, temporal
wasting with anasarca, appropriate
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, JVP to earlobe sitting up straight in chair,
LUNGS - profound expiratory wheezes with reasonable air
movement, resp mildly labored, decreased BS to bases R>L
HEART - irregularly irregular, no MRG, nl S2, S1 very quiet
ABDOMEN - distended without evidence of ascites/fluid wave, no
masses or HSM, no rebound/guarding; significant bruising in
___ area
EXTREMITIES - profound ___ edema throughout legs continuing to
scrotum and penis
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, + asterixis
DISCHARGE PE:
98 ___ 18 97% RA 64.9 kg yesterday
GENERAL - elderly male NAD
HEENT - sclerae anicteric, MMM
NECK - supple, JVP below mandible
LUNGS - no significant wheezes with reasonable air movement
HEART - irregularly irregular, no MRG, nl S2, S1
ABDOMEN - NT
EXTREMITIES - 1+ pitting edema ___ ___, improved, weak pedal
pulses bilaterally
NEURO - awake, A&O x person, ___- hospital, not time), minimal
asterixis
Pertinent Results:
ADMISSION LABS:
___ 08:35PM BLOOD WBC-5.7 RBC-3.41* Hgb-10.4* Hct-35.1*
MCV-103* MCH-30.6 MCHC-29.7* RDW-19.2* Plt Ct-65*
___ 08:35PM BLOOD ___ PTT-51.5* ___
___ 08:35PM BLOOD Glucose-104* UreaN-92* Creat-4.1* Na-143
K-3.8 Cl-101 HCO3-30 AnGap-16
___ 06:05AM BLOOD Albumin-3.5 Calcium-9.6 Phos-6.0* Mg-2.2
TTE ___:
The left atrium is moderately dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
There is an extensive inferoposterobasal left ventricular
aneurysm. Overall left ventricular systolic function is severely
depressed (LVEF = 20%) secondary to akinesis of the inferior
septum, inferior free wall, and posterior wall. All other
segments of the left ventricle are hypokinetic to one degree or
another. [Intrinsic left ventricular systolic function is likely
even more depressed than indicated by the ejection fraction
given the severity of valvular regurgitation.] Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular free wall thickness is
normal. Right ventricular chamber size is normal. with severe
global free wall hypokinesis. [Intrinsic right ventricular
systolic function is likely more depressed given the severity of
tricuspid regurgitation.] The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Moderate
(2+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The mitral valve leaflets do not fully coapt.
An eccentric, posteriorly directed jet of severe (4+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The tricuspid valve leaflets fail to fully coapt.
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.] Significant pulmonic
regurgitation is seen. There is no pericardial effusion.
CXR ___:
IMPRESSION:
Mild pulmonary vascular engorgement and small right pleural
effusion. Mild bibasilar atelectasis.
Brief Hospital Course:
___ year old male with with history of CAD s/p CABG x 3 and
stenting, ICM with EF 20%, AF on warfarin, PVD with AAA repair,
and CKD stage IV-V, presenting with acute decompensated systolic
heart failure.
# Acute Decompensated Systeolic HF: Weight gain, worsening SOB,
and worsening renal failure all suggest acute decompensation.
Has ICM with EF 20%. Was started on a lasix gtt + 2.5 mg
metolazone daily with both cardiology and renal consulting. The
lasix gtt was titrated up to 20cc/hr and he diuresed roughly ___
L for 3 consecutive days with an associated weight loss of
roughly 7 kg. His energy level increased and he felt better. On
day 4 of the lasix gtt, BUN And HCO3 began to rise, so the gtt
was dc'ed and patient transitioned to 100 BID IV lasix bolus
dosing, then to 60 PO torsemide BID. Metolazone was
discontinued. He will be discharged on torsemide 60 BID and his
weight on discharge was 64.9 kg. Spironolactone was added to
his regimen and he was continued on hydral/imdur, metoprolol. He
also required daily potassium supplementation of ___ mEq of
potassium, and will be discharged on 10 mEq daily as he is on
spironolactone as well as loop diuretics. He will follow up
with Dr. ___ as an outpatient.
# Acute on chronic renal failure: Likely decompensated heart
failure as above. Diuresis management as above. Patient made
it very clear that he would not want ultrafiltration or HD. His
renal failure improved with diuresis as above.
# GIB: Pt with BRBPR on ___ and reported black stools. INR was
2.3 at the time as patient was on coumadin. He was given DDAVP,
Vitamin K, and coumadin held. His Hct decreased from 28 to 25
and he was transfused 1 unit PRBCs. He was started on IV PPI
and seen by the GI consult service. The bleeding resolved
spontaneously and his Hct remained stable at 30 after the
transfusion. He still had small amounts of melena, which was
thought to be old blood. He will be continued on PO PPI.
# Atrial fibrillation and anticoagulation: In afib chronically,
but rate controlled. INR supratherapeutic initially so warfarin
held, then restarted, then stopped again and INR reversed with
Vitamin K as above in the setting of GIB. INR remained stable at
1.5. After conversation with both patient and family once
patient's delerium resolved (see below), patient stated
adamently that he would want to be on coumadin, accepting the
risk of further GI bleeding, stating he definitely would not
want a stroke. His coumadin was restarted at a dose of 1 mg on
discharge. He will need to have his INR checked on ___ and
likely daily, as he is on flagyl, which can increase the INR.
# Catheter Associated UTI and Delerium: Patient had foley
catheter in place on admission for urine output monitoring while
on a lasix drip. On HD 5, he started to get agitated and
delerious. Foley catheter was removed. Urine culture grew
proteus, sensitive to ciprofloxacin, and enterococcus sensitive
to vancomycin. He was started on ceftriaxone, then cipro for a
total 7 day course. He was started on 7 days of vancimycin,
renally dosed, to treat the enterococcus. His delerium
gradually cleared by discharge as the UTI was treated and GIB
resolved.
# C diff: Patient had increased stool output on HD 10. C diff
test returned positive and patient was started on PO flagyl.
Stool output began to slow graudally by discharge. He will need
to be on PO flagyl for a total 2 week course following his last
day of antibiotics, which is ___, stopping ___.
# Goals of Care and Hospice: On admission, patient was very
adament that he does not want any heroic or aggressive measures,
including resuscitation, intubation, and dialysis. Palliative
care was consulted and a family meeting was held, more to
discuss patient's goals of care and what to do if he becomes
severely ill again. Both him and his son (the health care
proxy) agreed that once the patient is discharged from rehab, he
will go home with hospice.
Per palliative care note dated ___:
"Patient wishes to focus on comfort and maximizing functional
status, with life prolongation a goal provided it does not
interfere with comfort and function.
Accordingly, he wishes to go to rehab short term and then home
with hospice." Case management at ___ aware of patient's
wishes.
TRANSITIONAL ISSUES:
- Hospice care on discharge from ___
- DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN frequent BMs
2. HydrALAzine 10 mg PO Q8H
3. Aspirin 81 mg PO DAILY
4. Omeprazole 40 mg PO BID
5. Furosemide 80 mg PO DAILY
recently increased from 60mg per most recent progress note
6. Metoprolol Tartrate 50 mg PO BID
7. Calcitriol 0.25 mcg PO DAILY
8. ___ *NF* (ferrous sulfate) 325 mg (65 mg iron) Oral
BID
9. Warfarin 1 mg PO DAILY16
10. Simvastatin 80 mg PO DAILY
11. Fluticasone Propionate 110mcg 2 PUFF IH PRN SOB
12. Albuterol-Ipratropium ___ PUFF IH Q4H:PRN SOB
13. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH PRN SOB
4. HydrALAzine 10 mg PO Q8H
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Metoprolol Tartrate 50 mg PO BID
7. Omeprazole 40 mg PO BID
8. Simvastatin 80 mg PO DAILY
9. Warfarin 1 mg PO DAILY16
10. Spironolactone 25 mg PO DAILY
RX *spironolactone [Aldactone] 25 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
11. Albuterol-Ipratropium ___ PUFF IH Q4H:PRN SOB
12. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN frequent BMs
13. ___ *NF* (ferrous sulfate) 325 mg (65 mg iron) Oral
BID
14. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
LAST DAY = ___. Torsemide 60 mg PO BID
16. Potassium Chloride 10 mEq PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute Decompensated Systolic Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were seen in the hospital because of an acute exacerbation
of heart failure. We gave you high doses of IV lasix, which
helped to remove a large amount of extra fluid, which improved
your breathing and your energy level. We transitioned you to a
new diuretic called torsemide. While in the hospital, you also
had a urinary tract infection, which we treated you with a week
of antibiotics. You also had profuse diarrhea caused by a
bacteria called C diff. We will be giving you an oral antibiotic
to treat this bacteria which you will need to take for another
two weeks.
Because of your heart failure, you should weigh yourself every
morning, call MD if weight goes up more than 3 lbs.
Followup Instructions:
___
|
10850692-DS-20
| 10,850,692 | 22,583,896 |
DS
| 20 |
2155-04-21 00:00:00
|
2155-04-22 18:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Left heart catheterization with placement of drug eluting stent
___
History of Present Illness:
Patient is a ___ M with history of CAD s/p MI ___ yrs ago with
NSTEMI ___, s/p recent hospitalization at ___ with PCI
(drug-eluting stent of the proximal LAD) who presents to the ED
w/ syncope.
Patient reports that on the AM of admission, patient was going
from the bathroom to the kitchen when he suddenly fell. Patient
describes that his 'body let loose.' He describes his legs and
arms caving in. He reports hitting his head. The next thing he
remember is being in the ambulance. He denies any symptoms of
nausea, dizziness/lightheadedness or flushing. He is unsure of
whether of not he had chest pain. The patient denies
fevers/chills as well as sick contacts. He reports a poor
appetite the past couple of days, but has been drinking bottled
water. The patient reports that on the AM of presentation, he
woke up in a drenching sweat, but he denies chest pain being the
cause of waking him up from sleep. The patient denies chest
pains or discomfort in the days leading up to the patient's
admission tonight. He reports that he has been compliant with
his medications including his Plavix, but he has not taken it
today given today's events. He denies loss of bowel or bladder
function as well as tongue biting.
Patient's wife called on the AM of admission stating that her
husband
passed out. Patient states that he suddenly became extremely
weak and dizzy and found himself on the floor. Denied chest
pain. Was able to get himself off the floor and into a chair. No
further
symptoms per the triage RN's note that took the call. Patient
was referred to the ED for evaluation.
In the ED, initial vitals were: 97.2 144/68 84 18 98% on RA.Labs
were notable for sCr 1.8, troponin 0.07 and 0.06 ___K-MB. CXR The patient's EKG showed no acute cardiopulmonary
process. Head CT showed no acute process. Shoulder and knee
films were negative. The patient received NTG times 2 and APAP
1000mg ONCE. Vital signs prior to transfer: 98.3 97 18 116/81
96% on RA.
Upon arrival to the floor, the patient has chest pain rating
___ in the same location as where he experienced his NSTEMI
pain. He is also having diaphoresis. Pain does not radiate.
Improves with SL NTG.
On review of systems, 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. He denies recent fevers, chills or rigors.
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 dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: DES to LAD ___
-PACING/ICD: None
-CAD s/p MI ___ yrs ago, old RBBB
3. OTHER PAST MEDICAL HISTORY:
-Severe osteoarthritis,
-Glaucoma
-Gastritis
-Venous insufficiency of his legs
-chronic renal failure
-s/p prostate biopsy
-herniated disc
Social History:
___
Family History:
Mother had ___ at old age. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
Admission physical exam:
VS: T= Afebrile BP=138/95 HR=100 RR= 18 O2 sat= 98% on RA
GENERAL: WDWN mildly in distress. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with no JVD
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi, anteriorly.
ABDOMEN: Soft, Distended. TTP in the LLQ. No HSM. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
Discharge physical exam:
Vitals: T 97.4 BP 124/62 HR 68 RR 18 O2 Sat 98% on RA Weigh
102kg
General: Patient sitting up in chair eating breakfast in NAD
HEENT: EOMI. PERRL. MMM.
Neck: No JVD appreciated with patient at 75 degrees. Supple.
CV: RRR. No M/R/G
Lungs: CTAB posteriorly without crackles or wheezes. No
increased work of breathing or accessory muscle use.
Abd: Soft. No rebound or guarding. BS+
Ext: No clubbing, cyanosis, or edema. Mild bruising over the
left radial access site.
Pertinent Results:
Admission labs:
___ 10:30AM BLOOD WBC-9.0 RBC-4.90 Hgb-14.8 Hct-45.5 MCV-93
MCH-30.3 MCHC-32.6 RDW-13.5 Plt ___
___ 08:00AM BLOOD ___ PTT-32.0 ___
___ 10:30AM BLOOD Glucose-89 UreaN-22* Creat-1.8* Na-140
K-4.3 Cl-105 HCO3-27 AnGap-12
___ 10:30AM BLOOD ALT-14 AST-18 CK(CPK)-29* AlkPhos-42
TotBili-1.0
___ 10:30AM BLOOD Albumin-4.1
Discharge labs:
___ 10:46AM BLOOD WBC-7.9 RBC-4.49* Hgb-13.8* Hct-42.2
MCV-94 MCH-30.8 MCHC-32.8 RDW-14.1 Plt ___
___ 10:46AM BLOOD Glucose-146* UreaN-27* Creat-1.6* Na-144
K-4.0 Cl-108 HCO3-28 AnGap-12
___ 10:46AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.1
Cardiac catheterization ___:
ASSESSMENT
1. One vessel coronary artery disease involving the LCX/OMB
2. Successful PCI with drug-eluting stent of the ___ OMB
EKG:
Sinus rhythm with increase in rate as compared to the previous
tracing
of ___. A-V conduction delay. Right bundle-branch block. Left
anterior
fascicular block. Prior inferior wall myocardial infarction. Low
precordial lead voltage. No diagnostic interim change.
CXR (PA and Lateral):
Lungs are oligemic. There is neither vascular congestion nor
edema nor pleural effusion. No consolidation is present. Heart
size is normal.
Brief Hospital Course:
Patient is a ___ M with history of CAD s/p MI ___ yrs ago with
NSTEMI ___, s/p recent hospitalization at ___ with PCI
(drug-eluting stent of the proximal LAD) who presents to the ED
w/ syncope and developed CP now s/p DES to the OMB ___.
# Shortness of breath: Patient acutely complained of shortness
of breath after receiving IV fluids. Patient received IV lasix,
with resultant bump in serum creatinine. CXR was done that did
not show evidence of pulmonary edema, effusion or PNA. Patient
did have a leukocytosis that was attributed to receiving
pre-medication in light of IV contrast allergy. Patient's oxygen
saturation remained stable. On day of discharge, patient's
symptoms resolved.
# Coronary artery disease: Patient with recent NSTEMI during
prior hospitalization at ___ with placement of DES to LAD
___. The patient acuetly presented with chest pain with
no EKG changes and flat CK-MB, CK despite elevated troponin. The
patient underwent repear cardiac catheterization with placement
of DES to the OMB. Patient was symptoms free for the duration of
her hospitalization. The patient was continued as aspirin 325mg
daily, Plavix 75mg daily. Metoprolol was uptirated with the goal
of heart rates in the 60-70s. Statin was continued during this
hospitalization. Physical therapy saw the patient and cleared
the patient to go home without physical therapy. On day of
discharge, patient was symptom free.
# Syncope: Etiology: Vasovagal versus orthostatics versus
arrhythmia in light of myocardial ischemia. TTE as last
hospitalization with preserved EF. No events on telemetry
through hospitalization. Patient was without events during this
hospitalization, and he was cleared to go home without physical
therapy, but physical therapy.
# Chronic kidney disease: Creatinine initially stabe at 1.6,
then acutely rose to 2.0 in the setting of receiving 40mg IV
lasix. Serum creatinine improved to 1.6 with IV fluids.
# Gastritis: Replaced esomeprazole with omeprazole while in
house.
# Glaucoma: Continued home medications.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
2. Gabapentin 300 mg PO TID
3. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral Daily
4. Rosuvastatin Calcium 10 mg PO DAILY
5. Tricor *NF* (fenofibrate nanocrystallized) 145 mg Oral DAILY
6. aspirin *NF* 325 mg Oral DAILY
7. Clopidogrel 75 mg PO DAILY
8. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
9. Metoprolol Tartrate 25 mg PO BID
10. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Aspirin *NF* 325 mg PO DAILY
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
3. Clopidogrel 75 mg PO DAILY
4. Gabapentin 300 mg PO Q12H
5. Rosuvastatin Calcium 10 mg PO DAILY
6. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
7. Tricor *NF* (fenofibrate nanocrystallized) 145 mg ORAL DAILY
8. Nitroglycerin SL 0.4 mg SL PRN Chest pain
RX *nitroglycerin 0.4 mg 1 tablet sublingually every 5 minutes
Disp #*60 Tablet Refills:*0
9. NexIUM *NF* (esomeprazole magnesium) 40 mg ORAL DAILY
10. Metoprolol Succinate XL 75 mg PO DAILY
RX *metoprolol succinate 50 mg 1.5 tablet(s) by mouth daily Disp
#*42 Tablet Refills:*0
11. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary artery disease
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of during this admission at ___
___.
You were hospitalized after an episode of syncope (losing
consciousness), and you developed chest pain while in the
hospital. You underwent a cardiac catheterization with placement
of a stent to another one of your vessels. Your previous stent
was patent by the cardiac catheterization. There were no events
on telemetry to explain your fall.
TAKE YOUR ASPIRIN AND PLAVIX DAILY. DO NOT MISS ANY DOSES. ONLY
stop this medication if instructed to by Dr. ___.
During this admission, we increased your dose of metoprolol to
75mg ONCE daily (one and a half tablets). You are being provided
with a new prescription.
Keep your appointment with Dr. ___ on ___.
To find a new primary care doctor associated with ___
___ call the following number:
___. It is important for you to establish care with a
primary care doctor.
Followup Instructions:
___
|
10851337-DS-18
| 10,851,337 | 23,664,336 |
DS
| 18 |
2187-03-26 00:00:00
|
2187-03-28 11:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old male who complains of N/V/D. Pt
with hx of ___ s/p colectomy for colon CA ___ last
year). No need for chemo radiation because it was a successful
resection. Pt presents with poor oral intake since post-sugery,
stating that "everything tastes like cardboard." He enjoys still
drinking water, ice cream, yogurt drink, but all solids are
unpalatable to him. He complained of nausea and vomiting ___
yesterday with one episode of bilious vomiting as well as loose
watery stools. He states that these symptoms have improved
today.
In the ED, initial vs were: 96.8 100 127/83 20 100%. Labs were
notable for ___ (Cr 1.4 from 0.9), hypokalemia (K+ 3.1),
leucocytosis (15.2) and transaminitis (ALT 64, AST 63, normal
AP, Tbili and Lipase). CXR clear. Patient was given IV fluids
with potassium.
On the floor, pt states he does not feel sick. Denies sick
contacts, unusual food or travel. He denies dysphagia,
odonyphagia, GERD-like symptoms, heartburn, chest discomfort,
abdominal pain. He does not think he has lost weight. He states
that his mood has been a little worse, endorsing feeling more
fatigued, sad, and looking less forward to activities.
Past Medical History:
-Colectomy for Adenocarcinoma ___
- Diabetes
- Hypertension
- cervical radiculopathy
- spinal stenosis
- Cholecystectomy
Social History:
___
Family History:
Pt states he has no idea about medical family history. Both his
parents passed away but he is unclear what this is from. He has
2 brothers and 1 sister who are older than he. He has 3 sons and
daughters who he sees irregularly. He is divorced.
Physical Exam:
On admission:
Vitals: T: 100.1 BP: 148/99 P: 95 RR: 18 O2: 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, Seborrheic keratosis
appearing lesion on posterior left neck.
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, two scars:
one from
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
On discharge:
Afebrile. VSS
Unchanged from admission and benign.
Pertinent Results:
On Admission:
___ 10:42AM GLUCOSE-143* NA+-135 K+-3.1* CL--88* TCO2-26
___ 10:35AM UREA N-21* CREAT-1.4*
___ 10:35AM ALT(SGPT)-64* AST(SGOT)-63* ALK PHOS-99 TOT
BILI-0.5
___ 10:35AM LIPASE-46
___ 10:35AM ALBUMIN-4.7
___ 10:35AM WBC-15.2* RBC-5.13# HGB-13.9*# HCT-38.9*#
MCV-76* MCH-27.1 MCHC-35.7* RDW-14.3
___ 10:35AM NEUTS-83.1* LYMPHS-13.4* MONOS-2.7 EOS-0.1
BASOS-0.7
___ 10:35AM PLT COUNT-382#
___ 10:35AM ___ PTT-28.8 ___
Urine:
___ 04:01PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:01PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-80 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 04:01PM URINE RBC-0 WBC-5 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 04:01PM URINE HYALINE-33*
Discharge:
___ 06:30AM BLOOD WBC-10.8 RBC-4.20* Hgb-11.6* Hct-32.5*
MCV-77* MCH-27.7 MCHC-35.8* RDW-14.4 Plt ___
___ 03:00PM BLOOD Na-140 K-3.7 Cl-99
Studies:
Cxray: No acute process
Brief Hospital Course:
___ yo male with htn, DMII s/p colectomy for adenocarcinoma
presents with poor intake for past month, diarrhea, vomiting for
past day.
# Viral gastroenteritis: Patient presented with diarrhea and
vomiting for one day. Pt also had mildly elevated temperature
to low 100s and an elevated white blood count. This most likely
was a viral gastroenteritis. Predominant neutrophilia can occur
early on in viral processes. There was no pain by report or per
physical exam. Pt was treated with IV fluids and complained of
no further symptoms.
# Acute Kidney injury: Creatinine on admission was 1.4, most
likely from poor PO intake as well as fluid loss from viral
gastroenteritis. This improved with IV fluids and his
creatinine and urea returned to ___.
.
# Ageusia: Pt complained that after his colectomy for
adenocarcinoma, everything tasted like cardboard. He reported
no issues swallowing, but an inability to tolerate solid foods
due to their bland and cardboard like nature. I am unclear of
the cause of this, but differential includes nutritional defects
such as zinc deficiency and niacin, neurological defects which
the patient had no other signs of, dysgeusia such as from GERD,
and depression. The patient was started on zinc sulfate 220 mg
TID and remeron 15 mg QHS. After the first night of taking
these medications, he reported his ageusia disappeared. The pt
enjoyed eating food for the first time in weeks, and his family
stated that this was the first time they saw him tolerating
solid foods since the surgery.
# DM II: ISS while in the hospital. Discharge on metformin.
# HTN: Pt restarted on home meds prior to discharge Losartan,
HCTZ, amlodipine, atenolol.
# Depression: Pt endorsing symptoms of depression with decreased
appetite. Per pt's brother, ever since the surgery, pt seemed
fatigued, unkempt, and not enjoying activities. The patient was
started on Remeron 15mg. Pt denied suicidal thoughts or
thoughts of hurting himself. The day after starting Remeron he
reported feeling much better and his family noted how much more
energy he seemed to have.
Code: Full (discussed with patient)
Communication: Patient
Emergency Contact: ___, Brother ___
TRANSITIONAL: Follow up with PCP. Started new medications of
Remeron and zinc supplement.
Medications on Admission:
losartan 100mg daily
- amlodipine 10mg daily
- atenolol 50mg BID
- HCTZ 25mg daily
- metformin 500mg BID
- metoclopramide 10mg PRN
Discharge Medications:
1. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
5. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
6. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
7. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Acute kidney injury
Viral gastroenteritis
Secondary diagnoses
Colon cancer s/p resection
Diabetes
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at the ___ Mr. ___. You
came in because of months of poor appetite and one day of
diarrhea with an episode of vomiting. Your diarrhea and vomiting
were probably from a viral infection that has now resolved. Your
poor appetite is probably from a mixture of mild depression and
vitamin deficiency. We started you on mirtazapine (Remeron) and
Zinc supplements to help your appetite.
Because you weren't taking in enough fluids you had injury to
your kidneys that has improved. When you go home, please be sure
to drink adequate fluids.
The following changes were made to your medications:
START mirtazapine (Remeron) 15mg before bed. This medication can
make you sleepy, so do not take it before driving or operating
heavy machinery.
START Zinc 1 tablet three times a day
Followup Instructions:
___
|
10852109-DS-20
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DS
| 20 |
2163-01-07 00:00:00
|
2163-01-07 19:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abnormal Labs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old ___ M w/ EtOH
cirrhosis complicated by varices, ascites, and HE with recent
admission for alcoholic hepatitis presenting as a transfer from
___ in ___ for abnormal labs.
He is interviewed with a telephone ___ interpreter, and
notes he was seen at ___ today for his scheduled
paracentesis after having worsening abdominal distention, where
his labs were abnormal including elevated bilirubin and a
transaminitis, so he was transferred for further evaluation.
Paracentesis showed 111 TNC, 733 RBCS, LDH 34, protein 1.1, and
glucose 145. It is not recorded in the records accompanying him
how much fluid was removed or if he got albumin after.
He only endorses vomiting and abdominal/back pain at home, but
otherwise had no symptoms including fevers, cough, shortness of
breath, rash, dysuria, increased urinary frequency, or altered
mental status. He was recently admitted for leukocytosis thought
to be secondary to alcoholic hepatitis, which was not responsive
to steroids. He was sent home with the goal of sobriety for 3
months and eventually being listed for transplant. He has not
relapsed and has no cravings for EtOH currently.
In the ED, his Tmax was 100.0 and otherwise vitals were
unremarkable. He was noted to be jaundiced, have a fluid wave on
his abdominal exam, and mild asterixis. He was evaluated by the
Hepatology fellow who recommended infectious workup which
revealed UA with 13 WBCs but no leukocyte esterase or nitrites,
blood cultures sent, flu swab negative, and CXR without definite
focal consolidation; and a RUQUS with Doppler which showed no
PVT. He was started on empiric ceftriaxone for concern for
non-specific infection.
Subjectively, he continues to have abdominal pain and
distention,
although feels better after his paracentesis.
Past Medical History:
EtOH cirrhosis complicated by esophageal varices, HE, and
ascites
Alcoholic hepatitis
Social History:
___
Family History:
No known family history of liver disease
Physical Exam:
Admission Exam:
==================
VS: 98.3 PO 111 / 66 106 18 98 RA
GENERAL: Chronically-ill and jaundiced appearing male laying in
bed in no acute distress
HEENT: PER. EOMI. Scleral icterus present. Dried blood in nares.
NJ tube in R nares. No oropharyngeal exudates.
NECK: supple, JVP @ 7 cm
HEART: Tachycardic, regular rhythm, normal S1/S2, grade ___
systolic ejection murmur heard throughout precordium. No rubs or
gallops
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Soft. Non-tender. Distended with fluid wave.
Normoactive
bowel sounds. No hepatosplenomegaly.
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: A&Ox3, ___ backwards successfully, CN grossly intact,
moving all 4 extremities with purpose
SKIN: jaundiced, warm and well perfused, no excoriations or
lesions, no rashes
MSK: Decreased muscle mass throughout
Discharge Exam:
====================
T 98.3 PO 125 / 65 97 18 95 Ra
Gen: overall jaundice and cachectic, lying in bed comfortably
HEART: regular rhythm, normal S1/S2, grade ___
systolic ejection murmur heard throughout precordium. No rubs or
gallops
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Soft. Non-tender. Distended with fluid wave.
Normoactive
bowel sounds. No hepatosplenomegaly.
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, ___ backwards successfully, CN grossly intact,
moving all 4 extremities with purpose
SKIN: jaundiced, warm and well perfused, no excoriations or
lesions, no rashes
Pertinent Results:
Admission labs:
======================
___ 08:45PM BLOOD WBC-28.5* RBC-2.87* Hgb-9.3* Hct-25.8*
MCV-90 MCH-32.4* MCHC-36.0 RDW-25.4* RDWSD-81.3* Plt ___
___ 08:45PM BLOOD Neuts-77* Bands-7* Lymphs-6* Monos-6
Eos-3 Baso-1 AbsNeut-23.94* AbsLymp-1.71 AbsMono-1.71*
AbsEos-0.86* AbsBaso-0.29*
___ 08:45PM BLOOD ___ PTT-38.6* ___
___ 08:45PM BLOOD Glucose-85 UreaN-39* Creat-1.3* Na-131*
K-4.4 Cl-94* HCO3-21* AnGap-16
___ 08:45PM BLOOD ALT-68* AST-142* AlkPhos-286*
TotBili-37.6* DirBili-27.9* IndBili-9.7
___ 08:45PM BLOOD Albumin-3.0* Calcium-8.3* Phos-3.4 Mg-2.4
___ 06:25AM BLOOD Triglyc-150* HDL-10* CHOL/HD-7.2
LDLcalc-32
___ 08:52PM BLOOD Lactate-1.5
___ 08:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
Discharge labs:
========================
___ 06:25AM BLOOD WBC-29.6* RBC-2.77* Hgb-8.9* Hct-25.1*
MCV-91 MCH-32.1* MCHC-35.5 RDW-25.3* RDWSD-81.1* Plt ___
___ 06:25AM BLOOD Neuts-81.9* Lymphs-5.5* Monos-6.6 Eos-2.6
Baso-0.5 Im ___ AbsNeut-24.15* AbsLymp-1.64 AbsMono-1.96*
AbsEos-0.77* AbsBaso-0.16*
___ 06:25AM BLOOD ___ PTT-37.5* ___
___ 06:25AM BLOOD Glucose-141* UreaN-41* Creat-1.6* Na-131*
K-3.6 Cl-94* HCO3-22 AnGap-15
___ 06:25AM BLOOD ALT-67* AST-122* AlkPhos-300*
TotBili-36.4*
___ 06:25AM BLOOD Albumin-2.9* Calcium-8.8 Phos-3.6 Mg-2.5
Cholest-72
Studies:
====================
Urine and blood cultures- NGTD
CXR- Small left pleural effusion and bibasilar atelectasis,
unchanged.
___ RUQ US
1. Cirrhotic liver, without evidence of focal lesion.
2. Patent main portal vein.
3. Sequela of portal hypertension, splenomegaly, small to
moderate volume
ascites and patent paraumbilical vein.
Brief Hospital Course:
Mr. ___ is a ___ year old ___ M w/ EtOH
cirrhosis complicated by varices and recent admission for
alcoholic hepatitis presenting as a transfer from ___
___
for abnormal labs. Stable leukocytosis with negative tap for SBP
at ___. Has had a new cough though CXR without
evidence of pneumonia. Given bandemia resolved with abx and
cough treated conservatively with Augmentin for CAP and
discharged home as patient's labs are otherwise stable and
clinical status is unchanged from recent discharge. Extensive
___ discussion at last hospitalization with priority to remain
home as much as possible. In the future, patient will plan to
take lab-work with him to ___ for paracentesis given
stably elevated leukocytosis and hyperbilirubinemia in the
setting of alcoholic hepatitis.
ACUTE PROBLEMS:
===============
# Leukocytosis
# Concern for infection
Patient presenting with ongoing leukocytosis, unchanged from
discharge. His diff is notable for new bandemia on discharge
suggestive of possible infection with T 100 in the ED.
Infectious workup negative though with new dry cough over the
past day. Started on CTX with resolution of bandemia. Diagnostic
paracentesis at OSH without evidence of SBP and gram stain and
culture negative to date. Plan to treat empirically for
pneumonia outpatient. Given bandemia resolved with abx and cough
treated conservatively with Augmentin for CAP and discharged
home as patient's labs are otherwise stable and clinical status
is unchanged from recent discharge. Extensive ___ discussion at
last hospitalization with priority to remain home as much as
possible.
# Alcoholic hepatitis
# EtOH cirrhosis, decompensated
MELDNa: 33, MDF: 84, Childs: C.
Cirrhosis decompensated by ascites and esophageal varices with
alcoholic hepatitis over last hospitalization. No improvement
with steroids and complicated by GI bleed. Lab work has remained
stable since discharge. Patient and family aware of poor
prognosis but remain hopeful for liver transplant if he is able
to remain sober for 3 months. Continues with tube feeds at home.
# ___
Last hospitalization given albumin challenge and octreotide gtt
for possible HRS with some improvement. Cr 1.6 from recent
baseline of 1.3. Treated with 50g albumin prior to discharge
given paracentesis on ___ with unclear amount of fluid removed.
# EtOH use disorder
Has remained sober while outpatient since discharge.
# QTc prolongation
QTc 501. Avoiding QTc prolonging medications. Received one dose
of azithromycin inpatient.
# Ascites
Para on ___. Unknown how many L removed or if he received
albumin. Continues on home furosemide with plan for scheduled
paracentesis outpatient.
# Hepatic encephalopathy
Continue home lactulose TID
# Elevated lipase
Not evidence of clinical pancreatitis. ___ be secondary to
generalized gut inflammation.
# UGIB ___ esophageal varices
Hgb stable from time of discharge. s/p banding of grade III
esophageal varices on ___. Not on nadolol given kidney
function. Continues on sucralfate 1 gm QID. Pantoprazole changed
to omeprazole due to insurance coverage.
CHRONIC PROBLEMS:
=================
# Malnutrition
- Continue home tube feeds
- Nutrition consult to evaluate if any changes need to be made
Transitional Issues:
==============================
[] Please ensure that patient has a copy of most recent lab
results from office visits at ___ to present to ___
___ during admissions
[] Augmentin course for 5 days (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Lactulose 30 mL PO TID
4. Multivitamins 1 TAB PO DAILY
5. Pantoprazole 40 mg PO Q12H
6. Sucralfate 1 gm PO QID
7. Thiamine 100 mg PO DAILY
8. Lidocaine 5% Patch 1 PTCH TD QPM
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*6 Tablet Refills:*0
2. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
3. FoLIC Acid 1 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Lactulose 30 mL PO TID
6. Lidocaine 5% Patch 1 PTCH TD QPM
7. Multivitamins 1 TAB PO DAILY
8. Sucralfate 1 gm PO QID
9. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
=====================
Community acquired pneumonia
Secondary diagnosis:
====================
Alcoholic hepatitis
severe malnutrition
alcoholic cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were found to
have abnormal labs
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had repeat lab work done that was the same as when you
were discharged from the hospital on ___
- You had a new cough and got treatment for a possible pneumonia
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please take all of your medications as prescribed and go to
your follow up appointments with your doctors ___ below)
- You will need to finish a 5 day course of antibiotics for a
possible pneumonia
- Please maintain a low salt diet and monitor your fluid intake
- Please take your lab results with you to your next
paracentesis session to show how your blood counts have been
previously for comparison
- Seek medical attention if you have new or concerning symptoms
or you develop
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10852329-DS-8
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2130-06-21 00:00:00
|
2130-06-21 14:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Demerol / lisinopril
Attending: ___.
Chief Complaint:
Left Femoral Neck Fracture
Major Surgical or Invasive Procedure:
Left hip hemiarthroplasty (___)
History of Present Illness:
___ medically complex pmhx including metastatic lung Ca, PD,
multiple stents/PAD, T2DM presents with L hip pain s/p
mechanical fall. Patient states she was walking in her home when
she slid on the floor and sustained a fall directly onto her L
hip. Noted immediate pain and unable to bear weight. Presented
to ___ shortly after fall this evening. Denies numbness,
tingling, weakness distally LLE. States despite her medical
comorbidities has been relatively healthy with no recent fevers
or chills.
Of note, states has significant PAD of RLE but was denied
recommended fem-pop bypass by vascular ___ medical
comorbidities.
Past Medical History:
Coronary artery disease
___ disease
Esophageal strictures with dilation x 2
Diabetes
Allergic rhinitis
Hypertension
Hyperlipidemia
Previous ventricular tachycardia
R shoulder injury last summer after a fall
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: ___ 2253 Temp: 98.2 PO BP: 147/78 HR: 94 RR: 18 O2
sat: 96% O2 delivery: Ra
General: Well-appearing older female reclined in bed, alert and
oriented, answering questions appropriately, pleasant affect.
Resp: Normal respiratory effort on room air.
CV: Regular rate and rhythm by peripheral palpation.
Left Lower Extremity:
Gauze dressing over hip clean and dry.
No erythema or fluctuance.
Motor intact to APF/ADF, ___.
Sensation intact to light touch in S/S/SP/DP/T distributions.
Foot warm and well perfused.
Pertinent Results:
___ 11:04AM WBC-6.9 RBC-4.01 HGB-11.5 HCT-35.9 MCV-90
MCH-28.7 MCHC-32.0 RDW-13.2 RDWSD-42.7
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 femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for L hip hemiarthroplasty, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The patient also developed diarrhea during
admission and was diagnosed with C Diff Colitis. She was started
on PO Vancomycin and was markedly improved during her
hospitalization. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT in the LLE, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Rosuvastatin Calcium 5 mg PO QPM
3. LOPERamide 2 mg PO TID:PRN GI Sx
4. Carbidopa-Levodopa (___) 1 TAB PO QID
5. Cilostazol 50 mg PO BID
6. Metoprolol Succinate XL 75 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Sulfameth/Trimethoprim DS 1 TAB PO BID
9. Vitamin D 1000 UNIT PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
3. Enoxaparin Sodium 40 mg SC QHS
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
6. Vancomycin Oral Liquid ___ mg PO QID
7. Aspirin 81 mg PO DAILY
8. Carbidopa-Levodopa (___) 1 TAB PO QID
9. Cilostazol 50 mg PO BID
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. LOPERamide 2 mg PO TID:PRN GI Sx
12. Metoprolol Succinate XL 75 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Rosuvastatin Calcium 5 mg PO QPM
15. Sulfameth/Trimethoprim DS 1 TAB PO BID
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated of the left lower extremity.
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone 2.5 5 mg every four hours as needed for
increased pain. Aim to wean off this medication in 1 week or
sooner. This is an example on how to wean down:
Take 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox 40 mg nightly for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Please remain in the splint until follow-up appointment. Please
keep your splint dry. If you have concerns regarding your
splint, please call the clinic at the number provided.
Pin Site Care Instructions for Patient and ___:
For patients discharged with external fixators in place, the
initial dressing may have Xeroform wrapped at the pin site with
surrounding gauze.
Often, the Xeroform is used in the immediate post-op phase to
allow for control of the bleeding. The Xeroform can be removed
___ days after surgery.
If the pin sites are clean and dry, keep them open to air. If
they are still draining slightly, cover with clean dry gauze
until draining stops.
If they need to be cleaned, use ___ strength Hydrogen Peroxide
with a Q-tip to the site.
Call your surgeon's office with any questions.
Followup Instructions:
___
|
10852633-DS-10
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DS
| 10 |
2132-02-09 00:00:00
|
2132-02-09 17:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / pioglitazone
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
___ 10:49AM BLOOD WBC-5.3 RBC-4.65 Hgb-13.0* Hct-38.7*
MCV-83 MCH-28.0 MCHC-33.6 RDW-14.4 RDWSD-43.3 Plt ___
___ 10:49AM BLOOD Neuts-71.2* Lymphs-16.3* Monos-8.3
Eos-3.2 Baso-0.4 Im ___ AbsNeut-3.80 AbsLymp-0.87*
AbsMono-0.44 AbsEos-0.17 AbsBaso-0.02
___ 10:49AM BLOOD Glucose-248* UreaN-19 Creat-1.1 Na-138
K-4.4 Cl-100 HCO3-21* AnGap-17
___ 10:49AM BLOOD cTropnT-<0.01
___ 04:56PM BLOOD cTropnT-0.02*
___ 06:30AM BLOOD cTropnT-0.01 proBNP-79
___ 06:30AM BLOOD %HbA1c-8.6* eAG-200*
___ 06:30AM BLOOD Triglyc-152* HDL-58 CHOL/HD-2.2
LDLcalc-38
DISCHARGE LABS:
==================
___ 06:30AM BLOOD WBC-4.5 RBC-5.01 Hgb-14.0 Hct-42.2 MCV-84
MCH-27.9 MCHC-33.2 RDW-14.3 RDWSD-43.7 Plt ___
___ 06:30AM BLOOD Neuts-55.0 ___ Monos-10.3 Eos-3.8
Baso-0.4 Im ___ AbsNeut-2.45 AbsLymp-1.35 AbsMono-0.46
AbsEos-0.17 AbsBaso-0.02
___ 06:30AM BLOOD Glucose-138* UreaN-25* Creat-1.2 Na-143
K-4.2 Cl-98 HCO3-31 AnGap-14
ECHO
=========
Quantitative biplane left ventricular ejection fraction is 61 %
(normal 54-73%). There is no resting left ventricular outflow
tract gradient. Diastolic parameters are
indeterminate. Normal right ventricular cavity size with normal
free wall motion. The aortic sinus
diameter is normal for gender with a normal ascending aorta
diameter for gender. The aortic arch
diameter is normal. There is no evidence for an aortic arch
coarctation. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. There is no
aortic regurgitation. The mitral valve
leaflets 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 a trivial pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global biventricular systolic
function. No valvular pathology or pathologic flow identified.
Unable
to quantify pulmonary artery systolic pressure.
STRESS TEST:
CONCLUSION: No ischemic ECG changes with no symptoms to
dobutamine stress. No 2D echocardiographic evidence of inducible
ischemia to dobutamine stress. Normal resting blood pressure
with a normal blood pressure and a normal heart rate response to
dobutamine stress.
Brief Hospital Course:
TRANSITIONAL ISSUES:
==========================
[] Most recent A1C at ___ 8.6%, would benefit from
tighter blood glucose control.
[] Started on carvedilol 6.25 BID for hypertension, titrate as
needed outpatient.
[] Underwent dobutamine stress test with normal result, will not
need to follow up with a cardiologist unless he has more chest
pain.
PATIENT SUMMARY:
==================
Pt is a ___ year-old man with history of HTN, HLD and T2DM who
presents with atypical CP, with questionable response to NG,
slight
tropnin leak and stable EKG admitted with dizziness and chest
pain.
Troponin leak possibly related to hypotensive episode, however
pt has
q waves inferiorly suggestive of old IMI. Echocardiogram showed
normal wall motion. He underwent a dobutamine echo stress test
that was normal.
# CORONARIES: Unknown
# PUMP: LVEF 61%
# RHYTHM: sinus
# DOBUTAMINE STRESS: no ischemic changes with exercise, normal
heart rate and BP result
ACUTE ISSUES
=============
#chest pain
#dizziness
Pt p/w chest pain that began this morning with associated
dizziness. SBP reportedly in ___ at home which resolved by the
time he arrived at the hospital and he remained normotensive
here. Blood glucose normal with EKG showing NSR with old
inferior infarct, no acute STTW changes, mild troponin leak 0.01
-> 0.02. He received high dose ASA in ambulance and SL NG in ED
at which point chest pain went away. He remained CP free for
remainder of admission without further intervention. His CP
could have been caused by hypotension however the hypotension
appeared to be an isolated episode without clear etiology - no
infectious signs/symptoms. PE was considered however Ddimer
negative and was never hypoxic or tachycardic. NTproBNP normal
as well. TTE showed mild symmetric hypertrophy and LVEF 61% and.
Stress Echo showed No ischemic ECG changes with no symptoms to
dobutamine stress. No 2D echocardiographic evidence of inducible
ischemia to dobutamine stress. Normal resting blood pressure
with a normal blood pressure and a normal heart rate response to
dobutamine stress. Given normal stress test, he was felt to be
low-risk despite indeterminate troponin and was discharged home
with secondary prevention medication.
#CAD
He was continued on ASA, Statin, and started on low dose
carvedilol for CAD and blood pressure control.
#T2DM
Pt on metformin and insulin at home, reports from ___
with
record of uncontrolled DM; last A1c 8.6 in ___. Is on
1000mg Metformin BID and Humulin 70/30 of 25u qam and 15u qpm
per
chart review, resumed at discharge.
#HTN
Pt with h/o uncontrolled HTN, on losartan (allergic to
lisinopril
per ___ notes) Continued home losartan, HCTZ. Started
carvedilol 6.25 BID.
#Low grade fever (resolved)
Low grade fever to 100.2 on admission, however no specific
infectious
complaint and no leukocytosis or documented fevers. CXR WNL.
Afebrile
this admission.
CHRONIC ISSUES
==============
#HLD: continued home atorvastatin
#BPH: continued home finasteride, tamsulosin
#Gastritis: continued home omeprazole
#Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Losartan Potassium 100 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. 70/30 20 Units Breakfast
70/30 10 Units Dinner
Insulin SC Sliding Scale using 70/30 Insulin
7. Aspirin 81 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. CARVedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Aspercreme (lidocaine)] 4 % apply 1 patch to back
QAM PRN Disp #*15 Patch Refills:*1
3. 70/30 20 Units Breakfast
70/30 10 Units Dinner
Insulin SC Sliding Scale using 70/30 Insulin
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Finasteride 5 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Omeprazole 20 mg PO DAILY
11. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
==============
chest pain concerning for acute coronary symptom
dizziness
coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had an episode of low blood
pressure and chest pain that was concerning for a heart attack
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You had blood work that showed a small leak in enzymes from
your heart muscle. Because of this, you had an ultrasound and a
pharmacological stress test done of your heart.
- The imaging studies of your heart were normal. No ischemic ECG
changes with no symptoms to dobutamine stress. No 2D
echocardiographic evidence of inducible ischemia to dobutamine
stress. Normal resting blood pressure with a normal blood
pressure and a normal heart rate response to dobutamine stress.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Team
Followup Instructions:
___
|
10852883-DS-5
| 10,852,883 | 29,163,893 |
DS
| 5 |
2150-06-02 00:00:00
|
2150-06-03 17:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Presyncope, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo woman w/ CAD s/p 3 stents, last ___ yr ago, carotid
stenosis, TIA, Afib new onset ___ (not on anticoagulation),
HTN and AAA presenting to BI-M after pre-syncopal episode,
transferred to ___ for evaluation of AAA seen on imaging and
further w/u.
She reports that at 8:30PM on ___, while walking from her
living
room to her dining room she experienced acute onset of
generalized weakness, lightheadedness, and N/V. During the
episode she experienced abdominal pain and a sharp pain along
her
mid back. Her daughter found her mother and noted her to be
unresponsive with eyes close, eventually when she responed her
speech was slowed, she experienced urinary incontinence, and
loss
of postural tone (she slumped to the side). She sat down and
drank soda, which alleviated her symptoms. She then walked to
the
bathroom and had a normal BM. Afterward, she reported feeling
hot
and diaphoretic. Of note, the entire episode lasted only a few
minutes. She denied any CP, SOB, palpitations. Mrs. ___
reported that this episode occurred ISO intermittent abdominal
pain over the past few months, and that other than vomiting and
incontinence, the episode was similar to TIAs in the past.
___:
She vomited several times while being imaged in the ED.
Troponins
negative x2. CTA chest showed 2 large aortic aneurysms (one
lower thoracic, one abdominal with extension to iliac
bifurcation) with hypodense material consistent with clot, but
no
evidence of rupture or leakage.
In the ED, initial VS were: 98.2 67 113/57 16 96% RA
Exam notable for:
PERRLA, EOMI
b/l carotid bruits, L>R
RRR
CTAB
abd soft, mild mid-abdominal TTP, soft bruit
No ___ edema
2+ radial pulses, 1+ DP pulses b/l, ext WWP
Labs showed: Hgb 12.8, WBC 12.7 platelet 183 Cr 1.0
Imaging showed:
CT A&P-
1. Large aneurysm of the descending thoracic aorta measuring up
to 5.4 cm and large aneurysm of the infrarenal abdominal aorta
measuring up to 4.8 cm without findings to suggest rupture on
this noncontrast examination.
2. There are small dilation of the left common iliac artery
measuring up to 1.7 cm.
3. 2.5 cm fatty mediastinal mass may represent a lipoma or fatty
replacement of a mediastinal lymph node. Recommend correlation
with prior exams if available to assess for stability.
4. Mild emphysema.
Consults:
Vascular- No evidence of AAA rupture on workup. Recommend
admission to ___ for workup of
syncope/pre-syncope. Vascular to follow to discuss possible
elective endovascular repair of AAA.
Patient received: nothing
Transfer VS were: 98 |69| 141/76 |18 |95% RA
On arrival to the floor, patient reports feeling well. She
denies
any weakness, dizziness, lightheadedness, nausea, vomiting,
abdominal pain. She has no SOB or cough. She has no dysuria.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
Myocardial infarctions x3 (last in ___ s/p three stents ___
x1, ___ x2)
Peripheral vascular disease c/b bilateral carotid stenosis (90%
R, 75% L, inoperable on 1990s workup per patient)
Recurrent TIA (since ___ grade, most recent episode in ___,
previously worked up)
Thoracic aortic aneurysm
Abdominal aortic aneurysm
R common iliac aneurysm
Atrial fibrillation (last episode at ___ in ___ not on
Warfarin)
Hypercholesterolemia
Hypertension
GERD
Basal cell carcinoma
COPD
Hysterectomy for unspecified cancer in ___
Social History:
___
Family History:
Father: hypertension, kidney disease, death from cerebral
hemorrhage at age ___
Mother: hypertension, death from cerebral hemorrhage at age
___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 24 HR Data (last updated ___ @ 1458)
Temp: 98.0 (Tm 98.2), BP: 118/64 (88-147/52-64), HR: 77
(71-77), RR: 18, O2 sat: 91% (91-94), O2 delivery: Ra
General: Elderly woman, alert and cooperative, and appears to be
in no acute distress.
HEENT: Normocephalic, atraumatic. Pupils are equal, round, and
reactive to light and accommodation constricting from 2.5mm to
2mm bilaterally. EOMI in all cardinal directions of gaze without
nystagmus. Vision is grossly intact and full to confrontation in
all quadrants. Hearing grossly intact. Nares patent with no
nasal
discharge. Oral cavity and pharynx are without inflammation,
swelling, exudate, or lesions. Teeth and gingiva in good general
condition.
Neck: Neck supple, non-tender without lymphadenopathy, masses or
thyromegaly.
Cardiac: Normal S1 and S2. II/VI systolic murmur at LUSB with
radiation to carotids. Rhythm is regular. Carotid bruits present
bilaterally. There trace peripheral edema in b/l ___, cyanosis or
pallor. Extremities are warm and well perfused. Capillary refill
is <2 seconds.
Pulmonary: Clear to auscultation without rales, rhonchi,
wheezing
or diminished breath sounds.
Abdomen: Normoactive bowel sounds. Soft, nondistended,
nontender. No guarding or rebound. Pulsatile mass in
epigastrium.
Musculoskeletal: No joint erythema or tenderness. Muscle bulk
and
tone appropriate for age and habitus.
Skin: Skin type II. Scattered telangiectasias. There is a
dome-shaped nodule with a central keratin-filled punctum on R
lateral brow line.
NEURO:
Mental Status: Alert and oriented x3.
Cranial Nerves:
Visual Fields: Full to confrontation in all quadrants
bilaterally
Visual Acuity: Vision grossly intact
Fundi: Normal, red reflex intact
Eye Movements: Intact to all cardinal directions of gaze without
nystagmus
V: Sensation to soft touch intact in all distributions. Muscles
of mastication intact.
VII: Facial expression is full and symmetric
VIII: Hearing intact to soft finger rub bilaterally
IX, X: Uvula is midline
XI: Shoulder shrug and strength in sternocleidomastoid intact
XII: Tongue protrudes to midline
Motor:
Bulk, tone: Appropriate for age, sex and body habitus. Without
rigidity.
RUE: 5+
LUE: 5+
RLE: 5+
LLE: 5+
Abnormal movements: Absent
Pronator drift: Absent
Sensory:
Light touch: Intact
Coordination:
RAM: Brisk, without dysdiodokinesia
Finger-Nose: Without dysmetria or overshoot
Gait:
Gait and station: not assessed
Reflexes:
Babinski: Downgoing b/l
DISCHARGE PHYSICAL EXAM:
=======================
24 HR Data (last updated ___ @ 1016)
Temp: 98.0 (Tm 98.6), BP: 109/69 (94-137/56-72), HR: 74
(63-87), RR: 20 (___), O2 sat: 97% (95-98), O2 delivery: Ra,
Wt: 106.2 lb/48.17 kg
General: Elderly woman, alert and cooperative, in no acute
distress.
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive to light with adequate accommodation. EOMI in all
cardinal directions of gaze without nystagmus. Hearing grossly
intact. No nasal discharge. Oral cavity and pharynx without
inflammation, swelling, exudate, or lesions. Teeth and gingiva
in
good general condition.
CV: Regular rate and rhythm. Normal S1 and S2. II/VI systolic
murmur at RUSB with radiation to carotids. Carotid bruits
present
bilaterally L>R. Trace peripheral edema in b/l ___, no cyanosis
or
pallor. Extremities warm and well perfused.
Pulmo: Clear to auscultation without rales, rhonchi, wheezing or
diminished breath sounds.
Abdomen: Normoactive bowel sounds. Soft, nondistended,
nontender.
No guarding or rebound. Pulsatile mass in epigastrium. Renal
bruits present bilaterally.
Skin: Scattered telangiectasias. There is a
dome-shaped nodule with a central keratin-filled punctum on R
lateral face near eye.
NEURO:
Mental Status: Alert and oriented x3.
Cranial Nerves:
III, IV, VI: Intact to all cardinal directions of gaze without
nystagmus.
V: Sensation to soft touch intact in all distributions. Muscles
of mastication intact.
VII: Facial expression full and symmetric.
VIII: Hearing intact to soft finger rub and finger nail click
bilaterally.
IX, X: Uvula midline.
XI: Shoulder shrug and sternocleidomastoid strength intact
bilaterally.
XII: Tongue protrudes to midline.
Pertinent Results:
ADMISSION LABS:
=================
___ 12:45AM BLOOD WBC-12.7* RBC-4.22 Hgb-12.8 Hct-38.2
MCV-91 MCH-30.3 MCHC-33.5 RDW-13.8 RDWSD-45.5 Plt ___
___ 12:45AM BLOOD Neuts-82.5* Lymphs-10.1* Monos-5.0
Eos-1.5 Baso-0.6 Im ___ AbsNeut-10.49* AbsLymp-1.28
AbsMono-0.64 AbsEos-0.19 AbsBaso-0.07
___ 12:45AM BLOOD ___ PTT-27.6 ___
___ 12:45AM BLOOD Plt ___
___ 12:45AM BLOOD Glucose-110* UreaN-17 Creat-1.0 Na-143
K-3.8 Cl-104 HCO3-22 AnGap-17
___ 10:40AM BLOOD ALT-8 AST-16 LD(LDH)-177 CK(CPK)-39
AlkPhos-84 TotBili-0.9
___ 10:40AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.7
IMAGING:
TTE ___ :
CONCLUSION:
The left atrial volume index is mildly increased. There is no
evidence for an atrial septal defect by 2D/ color Doppler. The
estimated right atrial pressure is ___ mmHg. There is normal
left ventricular wall thickness with a normal cavity size. There
is mild-moderate left ventricular regional systolic dysfunction
with akinesis of the inferior and inferolateral walls (see
schematic) and preserved/normal contractility of the remaining
segments. The visually estimated left ventricular ejection
fraction is 40-45%. There is no resting left ventricular outflow
tract gradient. No ventricular septal defect is seen. Tissue
Doppler suggests an increased left ventricular filling pressure
(PCWP greater than 18mmHg). Normal right
ventricular cavity size with normal free wall motion. The aortic
sinus diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter is normal with a
moderately dilated descending aorta. The abdominal aorta is
moderately dilated. There is no evidence for an aortic arch
coarctation. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis.
There is no aortic regurgitation. The mitral leaflets are mildly
thickened with no mitral valve prolapse.
There is mild [1+] mitral regurgitation. The tricuspid valve
leaflets appear structurally normal. There is mild [1+]
tricuspid regurgitation. There is mild pulmonary artery systolic
hypertension. There is a trivial
pericardial effusion.
MRA BRAIN AND NECK:
IMPRESSION:
1. Small subcortical left parietal lesion which likely
represents an acute to subacute infarct.
2. Complete occlusion of the right internal carotid artery at
the bifurcation,
which appears present on prior angiography from ___.
3. Tight stenosis of the left subclavian origin, with likely
slow flow within
a patent left vertebral artery. This is chronic in nature and
appears
worsened since ___.
4. Patent intracranial vasculature without stenosis, occlusion
or aneurysm.
CT CHEST WITHOUT CONTRAST:
IMPRESSION:
1. Large aneurysm of the descending thoracic aorta measuring up
to 5.4 cm and large aneurysm of the infrarenal abdominal aorta
measuring up to 4.8 cm without findings to suggest rupture on
this noncontrast examination.
2. Aneurysmal dilation of the left common iliac artery measuring
up to 1.7 cm. 3. 2.5 cm fat containing mass in the right middle
lobe which abuts the mediastinum likely represents a pulmonary
hamartoma. Recommend correlation with prior exams if available
to assess for stability.
4. Mild emphysema.
DISCHARGE LABS:
===============
___ 05:10AM BLOOD WBC-8.0 RBC-4.08 Hgb-12.6 Hct-36.9 MCV-90
MCH-30.9 MCHC-34.1 RDW-13.6 RDWSD-44.9 Plt ___
___ 05:10AM BLOOD ___ PTT-76.2* ___
___ 05:10AM BLOOD Glucose-107* UreaN-14 Creat-0.9 Na-142
K-3.8 Cl-101 HCO3-27 AnGap-14
___ 05:10AM BLOOD Calcium-9.5 Phos-3.0 Mg-1.6 Cholest-148
___ 05:10AM BLOOD Triglyc-101 HDL-60 CHOL/HD-2.5 LDLcalc-68
___ 12:45AM BLOOD TSH-1.9
Brief Hospital Course:
Ms. ___ is a ___ YOF w/ PMH of CAD c/b three previous episodes
of MI s/p placement of three stents (last two in ___, PVD c/b
bilateral carotid stenosis (deemed "inoperable" in ___, and
recurrent TIA (last in ___ presenting with an episode of a
few minutes duration of presyncope, generalized weakness,
N/V, and lightheadedness.
=============
ACUTE ISSUES:
=============
# Pre-syncope
# concern for TIA
Patient presented with episode of slowed speech,
lightheadedness/dizziness, presyncope. This was simlar to
episodes she's had since ___ grade. Highest suspicion for
hypoperfusion in setting of known carotid stenosis and
subclavian stenosis, differential includes vertebrobasilar TIA
(but less likely without significant vertigo per neurology),
atypical migraine. No orthostasis here. Antihypertensives aside
from metoprolol were held (metop was restarted for asymptomatic
PVCs). No obvous precipitant for a vasovagal episode. She was
monitored on tele w/o afib. ECHO without valvulvar disease and
EF 40-45%. She will follow up as an outpatient w/neuro and with
vascular surgery. Continued home metoprolol, aspirin, and
statin.
#Symptomatic AAA
CT imaging showing descending thoracic aortic aneurysm, 5.4 cm;
infrarenal abdominal aortic aneurysm, 4.8 cm, L common iliac
aneurysm, 1.7 cm. She was seen by vascular surgery while
inpatient who recommend OPEN repair - she will not be a
candidate for endovascular repair given complex anatomy. BP <
140s without intervention. She was counseled regarding smoking
cessation. After initial discussion about risks/benefits of
surgery or waiting, she prefers to f/u as outpatient with
vascular surgery for further discussion of surgical options.
#Sbuclavian stenosis: she was noted to have much higher BP in L
arm compared to R. MRI brain showed Tight stenosis of the left
subclavian origin, with likely slow flow within a patent left
vertebral artery. This is chronic in nature and appears worsened
since ___. This explains her BP differential.
===============
CHRONIC ISSUES
================
# HTN- continued metoprolol; held amlodipine and losartan, and
BPs were still at goal.
# GERD -Continued home pantoprazole
# Anxiety
-Continued home alprazolam PRN
# Osteoporosis
- Continued vitamin D and calcium.
====================
TRANSITIONAL ISSUES:
====================
1. Aortic and iliac aneurysms: As above, she will need very
close follow up with vascular surgery for her aneurysms and
further discussion about open repair.
2. Presyncopal episodes: She will follow up as outpatient with
neurology. While the current episode was not thought to be
related to a TIA, she may benefit from an outpatient holter
monitor.
3. Med changes: BPs were mostly in low 100s while inpatient so
amlodipine and losartan were stopped. Metoprolol was restarted
on the day of discharge because she had frequent PVCs. Atrial
fibrillation was NOT observed while inpatient. Would restart
anti hypertensives if BPs >140 given AAA. Pt to check at home
and call if any SBPs>140.
4. Her famiy mentioned ongoing weight loss. We were unable to
obtain a copy of her outpatient EGD but please continue prior
evaluation of ongoing weight loss and abdominal pain. Ate well
while inpatient and had only very mild abdominal pain with
normal exam.
# Code status: DNAR/DNI (DO NOT attempt resuscitation, DO NOT
intubate)
# Incidental 2.3 x 2.7 cm RUL mass
# 8 mm R pretracheal lymph node ___ CT suggests pulmonary
hamartoma. Can be correlated with prior studies if available.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Pantoprazole 40 mg PO Q24H
6. Aspirin 81 mg PO DAILY
7. ALPRAZolam 0.5 mg PO TID:PRN anxiety
Discharge Medications:
1. ALPRAZolam 0.5 mg PO TID:PRN anxiety
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
presyncope
aortic aneuryms
subclavian steal syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___:
It was a pleasure to care for ___ at the ___
___.
Why did ___ come to the hospital?
- ___ had an episode where ___ felt like ___ were going to pass
out.
What did ___ receive in the hospital?
- ___ were seen by neurology. They did not think this episode
was from a TIA. ___ might have been dehydrated, or this could
have been from a type of migraine. They felt ___ could be
further evaluated as an outpatient. ___ had an MRI of your brain
that showed an tiny stroke that probably happened a week or so
ago and does not explain your symptoms.
- ___ were seen by vascular surgery for your aneurysms. They
recommended ___ have an open repair of your aneurysms. ___ will
follow up with them as an outpatient for this.
What should ___ do once ___ leave the hospital?
- As we discussed, your blood pressure was low in the hospital.
Please keep taking your blood pressure daily. If ___ see numbers
higher than 140 for the top number, please call your PCP's
office. ___ will need to restart blood pressure meds if it's
high. We are continuing your medicine metoprolol but stopping
amlodipine and losartan.
We wish ___ the best!
Your ___ Care Team
Followup Instructions:
___
|
10852977-DS-20
| 10,852,977 | 20,873,278 |
DS
| 20 |
2164-11-22 00:00:00
|
2164-11-22 18:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Bactrim / latex
Attending: ___.
Chief Complaint:
Right arm and face numbness, left arm tremor.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ left-handed woman presenting
with Right arm and face numbness, left arm tremor in the context
of a migraine and in the presence of a history of complex
migraine with aura and overweight.
She was in her usual state of health until 10 AM today. At that
time she noted that her vision became glary. She thought this
was her typical migraine aura, but that instead of a large
moving
black dot it was glary. She could not make out words and small
things (but said that she could not appreciate shape, not that
words looked odd or that she could not read). Numbness then
started in her hand about 20 minutes later and moved to her
lower
face and chest over about 5 minutes. She went to the bathroom
several minutes later and became shaky in her legs and in the
left, but not right arm. Her headache did come after the visual
symptoms, but was very mild. Typically she has severe headache
and sometimes nausea. This time there was nausea. but headache
was only ___ at best. She then decided to come to the ED given
these unusual symptoms.
While in the ED, her exam and numbness changed somewhat. She
initially noted numbness of the right cheek down to her midchest
and including the arm. Later, she noted numbness over her whole
right head, then later still this resolved. She was at no time
weak, but claimed that she was unable to do certain parts of the
exam owing to 'tremor' or 'shakes' - this consisted of not being
able to lift her legs off the bed very high or for long.
Review of systems negative except as above. No recent neck
manipuation, no medication changes (continues Topamax and no
recent Zomig).
Past Medical History:
- Migraine on Topamax and Zomig PRN, followed by Dr. ___.
Presently ___ migraine with aura per month, one prior complex
migraine with right arm numbness.
- Overweight
- G1P1A0
Social History:
___
Family History:
Mother with likely provoked clots after accident. No seizures,
migraine, stroke, other neurologic family history.
Physical Exam:
ADMISSION LABS:
Afebrile; 83 BPM; 14 breaths; 100% RA; 125/79 mmHg
General Appearance: Comfortable, no apparent distress.
HEENT: NC, OP clear, MMM.
Neck: Supple. No bruits.
Lungs: CTA bilaterally.
Cardiac: RRR. Normal S1/S2. No M/R/G.
Abdominal: Soft, NT, BS+
Extremities: Warm and well-perfused. Peripheral pulses 2+.
Neurologic:
Mental status:
Awake and alert, cooperative with exam, normal affect.
Orientation: Oriented to person, place, date and context.
Language: Normal fluency, comprehension, repetition, naming. No
paraphasic errors.
Registration of three words at one trial and recall of all at
five minutes without hints.
Fund of knowledge for recent events within normal limits.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light bilaterally.
Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength intact and symmetric. Decreased pin and
light tough in the lower part of V2 and V3 initially, then V1-3
and posterior of head also.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetric.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
There is a loose resting tremor on the left that is
distractable.
Tone normal throughout.
Power
Full throughout later, but symmetric give-way throughout
initially.
D B T WE WF FF FAb | IP Q H AT G/S ___ TF
R ___ ___ 5 | ___ ___ 5
L ___ ___ 5 | ___ ___ 5
Reflexes: B T Br Pa Ac
Right ___ 2 2
Left ___ 2 2
Toes downgoing bilaterally
Sensation decreased to pin, vibration (splits midline on
forehead and sternum), and light touch as above and on right
arm, then later right leg, then later still the left leg.
Otherwise intact to light touch, vibration, joint position,
pinprick bilaterally.
Normal finger nose, great toe finger, RAM's bilaterally. Tremor
on left at rest, distractable, but no dysmetria nor intention
tremor.
Gait: Bobs up and down as with slow orthostatic tremor but also
while walking. Seems steady.
********************
DISCHARGE EXAMINATION:
AF VSS
CN and motor examination unremarkable. No tremors today.
Still reports decreased sensation on right hemibody.
Pertinent Results:
ADMISSION LABS:
___ 12:37PM BLOOD WBC-6.2 RBC-5.17 Hgb-14.8 Hct-44.0 MCV-85
MCH-28.6 MCHC-33.6 RDW-12.9 Plt ___
___ 12:37PM BLOOD ___ PTT-37.9* ___
___ 12:37PM BLOOD Glucose-85 UreaN-15 Creat-0.6 Na-141
K-4.3 Cl-109* HCO3-17* AnGap-19
___ 12:37PM BLOOD Calcium-9.5 Phos-2.6* Mg-2.1
___ 05:00PM URINE Color-Straw Appear-Clear Sp ___
___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
SERUM/URINE TOX:
___ 05:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
___ 12:37PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
IMAGING:
CT HEAD ___: Focal hypodensity involving gray and white
matter in the left temporal lobe is concerning for edema.
Recommend urgent MRI for further evaluation as ischemic stroke
is a concern.
CTA HEAD/NECK ___: 1. A prominent vessel within the left
parietal lobe likely represents a prominent vein; however, it
could be the single manifestation of a congenital or
arteriovenous anomaly.
2. The questionable region of hypodensity within the left
temporal lobe is no longer seen on this study; however, this
study is not optimized for detection of subtle changes in that
region and MRI should still be considered rule out any
underlying abnormalities within this region. MRI would also be
helpful in further characterizing the prominent vascular anomaly
described above.
MRI HEAD ___: IMPRESSION:
1. Normal MRI head.
2. No MR correlates to the equivocal left temporal hypodensity
seen in the prior CT head, making the CT findings more likely an
artifact.
Brief Hospital Course:
Mrs. ___ is a ___ yo LH woman with history of migraine
with visual aura in the past who presented with right arm/leg
numbness, left hand tremor and speaking backwards. She was
evaluated in the ED and her CT showed questaionable area of
hypodensity in the left temporal lobe versus artifact, so she
was admitted for MRI of her head. Her symptoms were thought to
be due to a complex migraine given the history of spreading
numbness in the right arms/legs. Unclear etiology of her left
hand tremor and speaking in backwards order, though that may
have occurred in the past under stress as well. Her MRI was
normal and the CT finding was thought to be artifactual.
Patient preferred to go see her outpatient neurologist to
further discuss her migraines and migraine management so she was
discharged to keep her existing appointment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Topiramate (Topamax) 25 mg PO BID
2. Zomig *NF* (ZOLMitriptan) 5 mg NU prn migraine
3. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Topiramate (Topamax) 25 mg PO BID
2. Omeprazole 20 mg PO DAILY
3. Zomig *NF* (ZOLMitriptan) 5 mg NU prn migraine
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: complex migraine
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 neurology service with right sided numbness
and left arm tremor after glaring visual change. You had a head
CT done yesterday which showed a possible area of hypodensity in
the left temporal region and you were admitted for an MRI. MRI
was normal. The cause of your symptoms likely was a complex
migraine.
Followup Instructions:
___
|
10853018-DS-13
| 10,853,018 | 29,680,046 |
DS
| 13 |
2165-09-03 00:00:00
|
2165-09-03 18:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ F with history of Stage IV non small cell lung
cancer, diagnosed in ___ after prior admission in ___ with
episode of hospitalization with productive cough. She was
subsequently found to have Stage IV nonsmall cell lung cancer
(adenocarcinoma with ALK rearrangement [FISH positive]),
diagnosed via thoracentesis ___. Her tumor burden has been
notable for l arge heterogeneous FDG-avid right hilar mass
invading into adjacent bronchovascular structures resulting in
post-obstructive partial right upper lobe and complete right
middle lobe collapse
Since then she has had pleurex placed for recurrent likely
malignant pleural effusions from ___ on right and
left thoracentesis on ___.
She presented to the ED with worsening lower left pleuritic
chest pain which she feels is similar to pain she had prior when
she required thoracentesis.
In the ED, initial VS were:
98.0 62 104/56 23 96% RA
Labs were notable for: WNL CBC, plt 406, chem-7 unremarkable
Imaging included:
CTA which showed: 1. No acute pulmonary embolism or aortic
abnormality. Stable, residual
thrombus in a left lingular segmental branch.
2. Stable right hilar mass with extension into the subcarinal
mediastinum and
encasement of the right middle lobe bronchus. Stable, associated
postobstructive atelectasis involving the right middle and lower
lobes.
Superimposed infection cannot be excluded.
3. New, lytic lesion involving the anterior aspect of the second
left rib.
4. Stable, multiple lytic and sclerotic spinal metastases.
Consults called:
none
Recommendations:
none
Treatments received:
none
On arrival to the floor, patient denies any chest pain save for
left sided lower pleuritic chest pain. She reports that she has
not had any fevers, chills, abdominal pain or other symptoms.
She reports her functional capacity has lessened in the context
of this pain.
Past Medical History:
HYPOTHYROIDISM
HYPERLIPIDEMIA
Stage IV lung cancer diagnosed ___
Recurrent malignant pleural effusions, s/p right sided pluerex
___, left sided thoracentesis ___
Social History:
___
Family History:
Mother with glaucoma, breast CA and hypothyroidism; brother with
glaucoma and DM2; nephew with glaucoma
Physical Exam:
ADMISSION PHYSICAL EXAM
BP 118/60 HR 64 RR 22 96 % RA tc 98
GEN: NAD, NC in place
HEENT: Dry mucous membranes
___: RRR, S1 and S2 ausculted over aortic and pulmonic valves.
PULM: CTAB over anterior chest, diminished breath sounds on left
posterior chest, bibasilar crackles B/L noted.
ABD soft nt
EXT: warm and well perfused
NEURO: no gross deficits
PSYCH: mood and affect stable
SKIN: no rashes
DISCHARGE PHYSICAL EXAM:
VS 97.9 102-124/50-62 52-63 20 95RA
GEN: NAD, NC in place
HEENT: MMM
___: RRR, S1 and S2 ausculted over aortic and pulmonic valves.
PULM: CTAB over anterior chest, diminished breath sounds on left
posterior chest, bibasilar crackles B/L noted.
ABD soft nt
EXT: warm and well perfused
NEURO: no gross deficits
PSYCH: mood and affect stable
SKIN: no rashes
Pertinent Results:
ON ADMISSION
___ 09:26AM ___ PTT-32.1 ___
___ 09:26AM PLT COUNT-406*
___ 09:26AM NEUTS-74.8* LYMPHS-10.3* MONOS-11.8 EOS-2.3
BASOS-0.4 IM ___ AbsNeut-5.53 AbsLymp-0.76* AbsMono-0.87*
AbsEos-0.17 AbsBaso-0.03
___ 09:26AM WBC-7.4 RBC-4.26 HGB-11.2 HCT-35.8 MCV-84
MCH-26.3 MCHC-31.3* RDW-17.1* RDWSD-52.6*
___ 09:26AM TSH-7.0*
___ 09:26AM proBNP-89
___ 09:26AM estGFR-Using this
___ 09:26AM ALT(SGPT)-23 AST(SGOT)-24 ALK PHOS-119* TOT
BILI-0.2
___ 09:26AM GLUCOSE-128* UREA N-11 CREAT-0.7 SODIUM-136
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-29 ANION GAP-13
___ 07:30PM URINE MUCOUS-RARE
___ 07:30PM URINE RBC-2 WBC-5 BACTERIA-NONE YEAST-NONE
EPI-4
___ 07:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
DISCHARGE LABS
___ 06:30AM BLOOD WBC-6.1 RBC-4.06 Hgb-10.3* Hct-34.4
MCV-85 MCH-25.4* MCHC-29.9* RDW-17.0* RDWSD-52.1* Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-74 UreaN-9 Creat-0.6 Na-137 K-4.6
Cl-102 HCO3-32 AnGap-8
___ 06:30AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.2
MICROBIOLOGY
__________________________________________________________
___ 7:30 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
__________________________________________________________
___ 7:30 pm URINE Source: ___.
URINE CULTURE (Pending):
__________________________________________________________
___ 4:53 pm BLOOD CULTURE #2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 4:53 pm BLOOD CULTURE #1.
Blood Culture, Routine (Pending):
CTA CHEST
IMAGING
1. No acute pulmonary embolism or aortic abnormality. Stable,
residual
thrombus in a left lingular segmental branch.
2. Stable right hilar mass with extension into the subcarinal
mediastinum and
encasement of the right middle lobe bronchus. Stable, associated
postobstructive atelectasis involving the right middle and lower
lobes.
Superimposed infection cannot be excluded.
3. New, lytic lesion involving the anterior aspect of the second
left rib.
4. Stable, multiple lytic and sclerotic spinal metastases.
EKG SR 65, TWF over precordial leads
BONE SCAN Study Date of ___
1. Diffuse osseous metastasis.
2. Irregular uptake in the proximal femurs raises concern for
lytic lesions at
risk of pathologic fracture. Radiographs of the bilateral
proximal femurs are recommended for further evaluation.
BILAT HIPS (AP,LAT & AP PELVIS) Study Date of ___
Sclerotic lesions in the proximal femurs bilaterally measuring
up to 12 mm,
without disruption of the cortical bone. Lesions in the sacrum
and pelvic
bones are not well seen on radiographs, better seen on prior CT.
CT ABD & PELVIS WITH CONTRAST Study Date of ___
1. Progression of metastatic disease with growth of multiple
hepatic lesions.
2. Numerous mixed sclerotic lytic osseous metastatic lesions
appear overall similar to prior.
3. Please see chest CTA report from previous day for complete
evaluation of thoracic findings.
Brief Hospital Course:
Patient is a ___ F with history of Stage IV non small cell lung
cancer, diagnosed in ___ after prior admission in ___ with
episode of hospitalization with productive cough. She was
subsequently found to have Stage IV nonsmall cell lung cancer
(adenocarcinoma with ALK rearrangement [FISH positive]),
diagnosed via thoracentesis ___ and malignancy related PE.
Her oncologic course has been notable for right sided pleurex
for malignant effusion ___ and left sided
thoracentesis, as well as being treated with crizotinib 250 mg
bid and lovenox.
She presented to hospital on ___ with pleuritic chest pain
concerning for new PE or pleural effusion. CTA showed no new
effusion and no new PE (save residual clot from known PE in
___ for which she is on chronic lovenox). However, bone scan
showed lytic lesions on ___ and ___ left rib explaining
patient's symptoms, and concern for lytic lesions in femurs
which might suggest fracture. Patient had CT abd/pelvis in house
to complete routine planned outpatient staging scan, and plain
films of hips which showed NO fractures. She will follow up with
Dr. ___ week as an outpatient. She will resume her prior
___ services. Her pain was well controlled with acetaminophen
and low dose (2.5 mg) oxycodone.
TRANSITIONAL ISSUES
======================================
-patient to continue lovenox and crizotinib for known Stage IV
lung cancer and PE above
-defer consideration for possible outpatient bisphosphonate
therapy or radiation oncology treatment to primary oncologist;
currently patient has no fractures in load bearing areas and
pain well controlled on Tylenol
-Patient discharged with acetaminophen and very low dose
oxycodone (short course) for ___ and 6th rib left side pain
above
-outpatient staging CT scan that was previously scheduled
___ was performed in house.
-Blood culture data and urine legionella/strep pending at
discharge (was initially ordered for concern pleuritic pain
could be infectious process)
#CODE: Full confirmed
#EMERGENCY CONTACT HCP: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. crizotinib 250 mg oral BID
3. Enoxaparin Sodium 60 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
4. LOPERamide ___ mg PO TID:PRN diarrhea
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Vitamin D 5000 UNIT PO Q48H
7. Dextromethorphan Polistirex ___ mg PO Q12H:PRN cough
8. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___)
9. Levothyroxine Sodium 150 mcg PO 1X/WEEK (___)
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. crizotinib 250 mg oral BID
3. Dextromethorphan Polistirex ___ mg PO Q12H:PRN cough
4. Enoxaparin Sodium 60 mg SC Q12H
Start: ___, First Dose: Next Routine Administration
Time
5. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___)
6. Levothyroxine Sodium 150 mcg PO 1X/WEEK (___)
7. LOPERamide ___ mg PO TID:PRN diarrhea
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Vitamin D 5000 UNIT PO Q48H
10. Acetaminophen ___ mg PO Q6H:PRN pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hrs Disp
#*30 Tablet Refills:*0
11. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
12. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) capsule(s) by mouth every 6
hrs Disp #*12 Capsule Refills:*0
13. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*28 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
New left rib lytic lesion
Known stage IV lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital because you had left sided chest pain.
At the hospital, you had a CT scan of your chest and it was
found that you had no clot in your lung and no new pleural
effusion, however it was noted that you had a new lesion on your
second and sixth rib that was concerning for the case of your
pain.
We started you on Tylenol and oxycodone for your pain. We talked
to our interventional pulmonologists and radiologists who felt
that your pleural effusions had not changed much and therefor no
thoracentesis was necessary. Lastly, we did a bone scan and scan
of your torso to restage your cancer (you were ordered for this
as an outpatient by Dr. ___ and ensure you had no fractures.
The imaging showed no new fractures.
We wish you all the best!
-Your ___ Care Team
Followup Instructions:
___
|
10853891-DS-9
| 10,853,891 | 27,385,351 |
DS
| 9 |
2186-11-11 00:00:00
|
2186-11-14 21:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / IV Dye, Iodine Containing Contrast Media
Attending: ___.
Chief Complaint:
Urosepsis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient presented to the ED with fever and altered mental
status, was initially seen at ___, has received
levo/vanc/zosyn at this point, had recent urine culture
sensitive to fluoroquinolones. Fever at OSH, but afebrile once
at ___. No n/v/d. Denies any shortness of breath. No
headache. Denies any urinary complaints.
Was transferred due to presence of VP shunt, need for possible
neurosurgical evaluation, sepsis with likely urinary source.
Had recently been treated for PCP, is still on steroids and
atorvaquone. Patient was seen by NSGY with no indication for
shunt tap at this time.
Prior to transfer, VS were 137/72 ___ 20 100% RA, urine is
cloudy. New foley. He got 1.5 L NS.
In the ED, initial VS were: 97.8 HR: 78 BP: 124/62 Resp: 20
O(2)Sat: 96
On arrival to the MICU, the patient was in no apparent distress,
alert and oriented, and normal hemodynamics.
Review of systems:
(+) Per HPI
(-) Denies 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:
- left temporal lobe AVM s/p bleeding in ___ and ___. He had a
VP shunt after the last episode, and received two cyberknife
treatments at the end of ___ and in ___. He received short
courses of steroids after both treatments. Both episodes left
him
with subtle language deficits and mild right hemiparesis.
- seizures post-stroke, on keppra
- hypertension
- hyperlipidemia
- BPH
Social History:
___
Family History:
Father with early MI, o/w negative.
Physical Exam:
ADMISSION
General: Alert, oriented to person, place, self, no acute
distress, mumbles intermittently
HEENT: Sclera anicteric, MMM, oropharynx clear, 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: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley present, clear yellow urine
Ext: cool, well perfused, 2+ pulses, no c/c/e
Neuro: strength slightly diminished on R, but moves all
extremities spontaneously
Pertinent Results:
ADMISSION LABS:
___ 02:42AM BLOOD WBC-19.1*# RBC-3.78* Hgb-12.1* Hct-34.8*
MCV-92 MCH-31.9 MCHC-34.7 RDW-19.1* Plt ___
___ 02:42AM BLOOD Neuts-84* Bands-4 Lymphs-10* Monos-2
Eos-0 Baso-0 ___ Myelos-0 NRBC-1*
___ 02:42AM BLOOD Glucose-143* UreaN-20 Creat-0.7 Na-131*
K-3.7 Cl-94* HCO3-22 AnGap-19
___ 02:42AM BLOOD Albumin-3.4* Calcium-9.1 Phos-3.8 Mg-1.9
___ 02:30AM URINE Color-Yellow Appear-Hazy Sp ___
___ 02:30AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 02:30AM URINE RBC-14* WBC->182* Bacteri-MOD Yeast-NONE
Epi-0
___ 02:30AM URINE Mucous-MOD
___ 2:30 am URINE
.
DISCHARGE LABS:
___ 06:05AM BLOOD WBC-13.1* RBC-3.53* Hgb-11.1* Hct-32.7*
MCV-93 MCH-31.3 MCHC-33.9 RDW-18.6* Plt ___
___ 06:05AM BLOOD Neuts-84* Bands-1 Lymphs-8* Monos-4 Eos-1
Baso-0 ___ Metas-2* Myelos-0
___ 06:05AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Tear Dr-OCCASIONAL
___ 06:05AM BLOOD Glucose-74 UreaN-24* Creat-0.6 Na-135
K-3.9 Cl-99 HCO3-25 AnGap-15
___ 06:05AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.9
.
MICRO:
.
___ 2:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
CIPROFLOXACIN Sensitivity testing per ___ ___ ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S =>8 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- 0.5 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
VANCOMYCIN------------ 1 S
.
IMAGING:
.
CT OF THE HEAD: ___
A right frontal approach ventriculostomy catheter (VP shunt)
ends in the third
ventricle, unchanged from prior studies. Compared to the MRI
from ___ and the CT from ___, the bilateral extra-axial
subdural fluid
collections have increased and the ventricular size has
decreased, suggesting
mild overshunting. Hypodense vasogenic edema at the left
peritrigonal and
temporoparietal region is unchanged from prior studies based on
the previous
MRI likely due to radiation necrosis. There is no acute
intracranial
hemorrhage, or herniation.
The paranasal sinuses and mastoids are clear. There are no
suspicious lytic
or sclerotic bony lesions.
IMPRESSION:
1. Slight interval increase of extra-axial, bilateral fluid
subdural
collections and decrease of the ventricular size, suggesting
mild
overshunting.
2. Otherwise, no change from the most recent prior studies in
___.
.
CXR ___
IMPRESSION:
1. Moderate to severe centrilobular emphysema.
2. No acute cardiothoracic process.
3. Predominantly upper lobe interstitial disease, previously
exaggerated by edema.
.
___ Scrotal US:IMPRESSION:
1. Right epididymitis.
2. Heterogeneous right testicle with evidence of vascular
compromise,
suggesting ischemia, which may be due to swelling. Given the
patient's age, torsion is unlikely.
3. Mild septations in a right hydrocele may represent
developing pyocele.
Brief Hospital Course:
The patient is a ___ y/o male h/o VP shunt, AVM, SIADH and
thrombocytopenia, presenting with fever and AMS, ___ SIRS,
admitted for urosepsis with stable hemodynamics. In the ICU, the
pt was hemodynamically stable and was treated for urosepsis; he
improved clinically and was called out to the floor the morning
of hospital day 2 hemodynamically stable and at baseline mental
status. On the medical floor, he was found to have orchitis of
the R testicle, which was treated with cipro and doxycycline
given U-Cx sensitivities.
.
ACTIVE ISSUES:
.
# Epididymitis, orchitis, hydrocele: ___, at 0445 pt was being
cleaned and nurses noted TTP in scrotal area despite pt denying
pain in area. Pt was denying any type of pain, but would move
hands towards groin when being examined. This may have been
present previously and may be cause for pt's fevers upon initial
presentation. Scrotal US showed e/o florid epidiymitis that is
vascular; hydrocele with minimal septations suggestive of
possible pyocele; testis with decreased vascularity with no flow
in diastole suggestive of decreased venous outflow; heterogenous
testis likely ___ ischemia. Urology c/s deemed no surgical
intervention necessary and was not concerned for torsion, and
recommended abx for 2 weeks (see below). He was initially
covered with vanc given enterococcus in blood that was resistant
to cipro, but transitioned to doxycycline on ___ and has been
afebrile thus far.
.
# UTI/Urosepsis: Pt was initially admitted to the ICU. In the
setting of gross pyuria, patient had received CTX, vanc, levo.
He did not require pressors. Patient had a previous urine
culture with pseudomonas sensitive to quinolones, but had been
treated with nitrofurantoin to which it was resistant; he was
covered during his MICU stay with cipro for sensitive
pseudomonas; his U-Cx also grew out Enterococcus which was cipro
resistant; doxycycline was added on ___.
.
# Hyponatremia: Currently stable and improving. He had SIADH
treated with fluid restriction in previous admission. We cont
fluid restrict to ___ and his Na remained stable at about
130 most of his stay, but increased to 135 on the day of
discharge.
.
# AMS: Likely due to urosepsis. Per his wife, the pt appears to
be at his baseline mentation, but has been more sleepy and
confused since early ___. DDx included long-term effects of L
temporal radiation necrosis, or possible "overshunting" observed
on head CT compared with CT from ___. The CT head
"overshunting" finding was not likely significant at this time,
per neurosurgery evaluation.
.
# Left temporal Brain Lesion: During previous admission, he had
extensive w/u which believed the lesion to be radiation
necrosis. He did have a positive beta-glucan and concerning lung
imaging, and thus is being treated for PCP on atovaquone being
tapered down and prednisone. We continued his current steroid
regiment (40mg daily until ___, then 30mg daily starting ___
per neuro-onc. We continued atovaquone 750mg bid until ___, then
1500mg daily starting ___. He was maintained on seizure PPx with
home Keppra of 1500 bid.
.
# PCP ___: thought to be cause of pt's hypoxia, CXR findings,
and elevated beta-glucan during previous admission. Pt's regimen
is below:
-Pred taper: START prednisione 30mg (3 x 10mg tabs) daily on
___, then 20mg (2 x 10mg tabs) daily on ___, and finally
10mg daily on ___ and stay on 10mg po daily. f/u with
neuro-oncologist, Dr. ___.
-START atovaquone 750mg by mouth twice daily until ___, then
switch to atovaquone 1500mg by mouth once daily. stop taking
atovaquone when you are only taking 10mg of prednisone daily.
.
# chronic constipation: has been a longstanding problem for the
pt in previous admissions. We cont standing docusate bid, senna
bid, and polyethylene glycol (Miralax) daily.
.
TRANSITIONS OF CARE:
-- Prednisone taper as above. Please contact his
neuro-oncologist Dr ___ prior to any changes in treatment
related to this.
-- Complete antibiotic courses with Ciprofloxacin and
Doxycycline for Pseudomonas and Enterococcus
UTI/epididymitis/orchitis.
-- Check electrolytes in ___ days to trend hyponatremia
Medications on Admission:
Medications (per ___ discharge summary):
1. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day: (5 x 10mg tabs) daily. Switch to 40mg (4 x 10mg tabs) daily
on ___, then 30mg (3 x 10mg tabs) daily on ___, then 20mg
(2 x 10mg tabs) daily on ___, and finally 10mg daily on
___ and stay on 10mg po daily .
6. atovaquone 750 mg/5 mL Suspension Sig: One (1) PO BID (2
times a day) for 3 weeks: atovaquone 750mg by mouth twice daily
until ___, then switch to atovaquone 1500mg by mouth once
daily until prednisone tapered to 10mg daily.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
9. nitrofurantoin macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO Q6H (every 6 hours) for 7 days.
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
11. Vitamin D3 1,000 unit Capsule Sig: One (1) Capsule PO once a
day. Capsule(s)
12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Pt may refuse if ambulating tid.
Discharge Medications:
1. levetiracetam 100 mg/mL Solution Sig: Fifteen (15) mL PO BID
(2 times a day).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day:
TAPER COURSE: decrease to 20mg
(2 x 10mg tabs) daily on ___, and then 10mg daily on ___,
and stay on 10mg po daily.
5. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
8. Vitamin D3 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Pt may refuse if ambulating tid.
10. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) mL PO once a
day: Continue atovaquone 1500mg PO Q24 while remaining on
prednisone.
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 12 days.
Disp:*24 Tablet(s)* Refills:*0*
12. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 12 days.
Disp:*24 Capsule(s)* Refills:*0*
13. insulin lispro 100 unit/mL Solution Sig: One (1) injection
Subcutaneous three times a day: before meals according to
attached sliding scale.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Sepsis secondary to Urinary tract infection
Epididymitis
Orchitis
Secondary diagnoses:
Left arteriovenous malformation
History of seizures
Hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a privilege to provide care for you here at the ___
___. You were admitted because you had a
fever, and you were found to have a urinary tract infection,
epididymitis, and orchitis (an infection of the testicles). You
were treated with antibiotics and were closely monitored. Your
condition has improved and you can be discharged to your rehab.
The following changes were made to your medications:
NEW:
Ciprofloxacin 500 mg twice daily for 12 more days
Doxycycline 100 mg twice daily for 12 more days
Please keep your follow-up appointments as scheduled below.
Followup Instructions:
___
|
10853893-DS-18
| 10,853,893 | 23,633,319 |
DS
| 18 |
2197-08-12 00:00:00
|
2197-08-13 07:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
epigastric pain
Major Surgical or Invasive Procedure:
suture removal
History of Present Illness:
___ with a hx of HCV, IVDA (last use ___ on methadone, PTSD,
recurrent pancreatitis (?gallstone), recent hospitalization
___ for sepsis in the setting of cholangitis, s/p ERCP
with sphincterotomy ___ presenting with acute onset
epigastric pain x1 day. She reports that, on ___
she felt generally, nonspecifically unwell. Decided to go home
and watch TV. Went to sleep pain-free, woke up at 2 am to use BR
and still pain-free. At 6 am, she woke up, and noted severe pain
upon standing. Pain was epigastric, ___, stabbing, radiated
through to back. Felt like repeated stabbing in the stomach,
similar to prior episodes of pancreatitis. Did have nonbloody,
bilious emesis in ED, not at home. Denies diarrhea or
constipation. Denies F/C. She reports last EtOH ___ years ago.
She reports that her problems have always been with IVDU, has
not been difficult to abstain from EtOH. Denies recent weight
loss.
She has noted some fecal leakage as well, small volume. She
reports that this did happen when she had pancreatitis in the
past, although unclear if this has occurred at other times as
well.
She went to liver clinic on ___ (no OMR note yet, but can
see from ___ that she did keep that appointment). She also had
removal of basal cell carcinoma over L temporal region in the
week prior to presentation.
In the ___ ED:
___ 91 139/87 16 96% RA
TTP at ___ and epigast___ notable for:
ALT/AST ___
Alk phos 285
Tbili 0.6
Lipase 117
WBC 9.8
Hb 13.3
LA 3.2
UA negative for infection
CT abd/pelvis with contrast: stranding and ill-defined fluid
around the head and uncinate process of the pancreas suggesting
pancreatitis. No e/o peripancreatic fluid or pancreatic
necrosis.
Seen by GI - recommended supportive care for pancreatitis
Ordered for morphine sulfate 5 mg x3 and 2 mg x2
1L NS
Diphenhydramine 25 mg x1
Zofran 4 mg IV x1
Past Medical History:
Hep C - Genotype 3A (___), VL 24,500 IU/mL (___), liver
fibrosis panel pending
HSV I
HTN
arthritis
pernicious anemia
Hypercalcemia
Prior IVDA
PTSD
Anxiety
vaginal hysterectomy at age ___
tubal ligation age ___
right eye cornea transplant ___
Social History:
___
Family History:
no pancreatic problems. Father with HCV cirrhosis.
Physical Exam:
VS 98.5, 104/63, 65, 16, 96% RA
Gen: Intermittently tearful when discussing SHx, very pleasant,
discomfort with movement in bed, NAD
HEENT: PERRL, EOMI, clear oropharynx, no cervical or
supraclavicular adenopathy. Sutures in place over L temporal
area, clean, dry and intact, no surrounding erythema or TTP.
CV: RRR, no m/r/g
Lungs: CTAB, no wheeze, rhonchi, good breath sounds throughout
Abd: soft, nondistended, occasional voluntary guarding, no
rebound. Marked TTP at RUQ and epigastrium, nondistractible.
Hypoactive bowel sounds.
Ext: WWP, no clubbing, cyanosis or edema
Neuro: Grossly intact
DISCHARGE
Vitals: T:98.3 BP:133/90 P:78 R:16 O2:97%ra
PAIN: 0
General: nad
EYES: anicteric
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Pertinent Results:
___ 11:00AM URINE HOURS-RANDOM
___ 11:00AM URINE UCG-NEGATIVE
___ 11:00AM URINE UHOLD-HOLD
___ 11:00AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
___ 11:00AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-5
___ 11:00AM URINE MUCOUS-MANY
___ 10:03AM LACTATE-3.2*
___ 09:45AM GLUCOSE-97 UREA N-5* CREAT-0.6 SODIUM-139
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-19* ANION GAP-21*
___ 09:45AM ALT(SGPT)-68* AST(SGOT)-88* ALK PHOS-285* TOT
BILI-0.6
___ 09:45AM LIPASE-117*
___ 09:45AM ALBUMIN-4.0
___ 09:45AM HCG-LESS THAN
___ 09:45AM WBC-9.8 RBC-4.49 HGB-13.3 HCT-40.8 MCV-91
MCH-29.6 MCHC-32.6 RDW-14.3 RDWSD-47.2*
___ 09:45AM NEUTS-61.4 ___ MONOS-5.0 EOS-2.1
BASOS-0.8 IM ___ AbsNeut-6.03 AbsLymp-2.98 AbsMono-0.49
AbsEos-0.21 AbsBaso-0.08
___ 09:45AM PLT COUNT-251
___ 09:45AM ___ PTT-ERROR ___
___ CT Abd/pelvis with contrast IMPRESSION:
1. Stranding and ill-defined fluid around the head and uncinate
process of the pancreas suggesting pancreatitis. No evidence of
peripancreatic fluid collection or pancreatic necrosis.
Secondary inflammation of the second and third portions of the
duodenum.
2. Fat in the apex of the left ventricle and septum suggests
prior myocardial infarct. Consider Echocardiogram as clinically
appropriate.
3. Coronary artery atherosclerosis.
4. Mild fatty liver.
RECOMMENDATION(S): Consider Echocardiogram as clinically
appropriate.
___ ECHO IMPRESSION: The left atrium is normal in size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). 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. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
Brief Hospital Course:
___ with a hx of HCV, IVDA (last use ___ on methadone, PTSD,
recurrent pancreatitis (?gallstone), recent hospitalization
___ for sepsis in the setting of cholangitis, s/p ERCP
with sphincterotomy ___ presenting with acute onset
epigastric pain x1 day likely due to a flare of her pancreatitis
triggered by eating fatty take out food. No evidence of ongoing
obstructive process. Clearly states no EtOH for ___ years.
Triglycerides elevated but not enough to enduce pancreatitis. Pt
kept npo with IVF at 200 cc/hr. Judicious use of dilaudid IV,
minibagged - discussed with patient concerns about jeopardizing
her recovery, she is aware of these concerns and agrees with
cautious use. Her pain improved and she was able to transition
to oral dilaudid and general low fat diet. She required minimal
doses of dilaudid and at the time of discharge had no abdominal
pain. She was seen by nutrition and given guidelines on a low
fat diet. Seen by GI who recommended ACS referral for eval for
CCY in future.
Cardiac changes seen on CT abd/pelvis: EKG and TTE wnl
Hx of IVDA: Continued home methadone 30 mg daily. Pt without med
seeking behavior. However, her husband was demanding that she be
discharged with opioid prescription. This was not done. Please
see telephone conversation note from ___ for more details.
Anxiety/Depression: Pt does endorsed passive SI on admission.
She notes that her friend died of OD the night prior to
presentation, feels like every day she looks online "someone
else died." She clearly denies any active SI. Continued home
meds. Would benefit from referral for ongoing mental health
support as outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 1 mg PO TID
2. Gabapentin 600 mg PO TID
3. Methadone 30 mg PO DAILY
Discharge Medications:
1. ALPRAZolam 1 mg PO TID
2. Gabapentin 600 mg PO TID
3. Methadone 30 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___, you were admitted due to a flare of your
pancreatitis. This may have been caused by eating fatty foods.
It will be important to stick to a low fat diet to prevent pain
and future admissions. You should also follow up with surgeons
to determine if removing your gallbladder will also be helpful
in preventing future episodes of pancreatitis.
Followup Instructions:
___
|
10853893-DS-20
| 10,853,893 | 27,795,352 |
DS
| 20 |
2199-02-11 00:00:00
|
2199-02-11 14:37:00
|
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:
This is a ___ woman with a PMH of anxiety/PTSD, opioid
use disorder on methadone (last IVDU ___ year ago), Hepatitis C,
cholangitis s/p CCY (___), and chronic pancreatitis, who is
presenting with abdominal pain. She reports that she has had
nausea for the past two weeks. On the morning of admission, she
awoke with acute onset dull epigastric pain radiating to her
back, which she reports feels exactly like prior episodes of
pancreatitis. Her pain is worse when she lies down and with PO
intake. She also endorses diarrhea. She denies any alcohol
intake.
Denies any fevers, chills, vomiting, melena, hematochezia,
shortness of breath, chest pain, palpitations.
In the ED
- initial VS: 97.4 74 112/63 20 95% RA
- labs: cbc with wbc 10.3, otherwise wnl; chem10 normal; LFTs
with ALT 166, AST 138, AP 492, lip 233. lactate 1.7. coags with
ptt 39, otherwise normal. UA with neg ___, neg nitr, few bact, 3
epi.
- RUQUS: as below
- ECG: none
- interventions: morphine, crystalloid x2L, ondansetron
- consults: none
Admitted to Medicine for further evaluation.
Past Medical History:
-HSV1: Herpes Simplex Cornea - right eye cornea transplant ___
-HTN
-Hep C: Genotype 3A (___)
-Pernicious Anemia
-Unspecified Skin Cancer
-MVA in ___ with brain hemorrhage - memory loss as a result
-Depression
-PTSD
-Anxiety
-Arthritis
-Hypercalcemia
-Prior IVDA (most recent use ___ year ago)
-cholangitis s/p CCY (___)
-recurrent pancreatitis
-tubal ligation age ___
-vaginal hysterectomy at age ___
Social History:
___
Family History:
-Father with HCV cirrhosis
-Daughter: has similar symptoms to mother of pancreatitis
-___ Grandfather: ___ cancer
-___ Grandmother: ___
-Mother: ___ of eye
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.9 123/63 97.9 18 96% RA
General: No acute distress, sitting upright in bed
HEENT: atraumatic, normocephalic, MMM
Neck: no LAD
CV: Normal S1 and S2, no murmurs/rubs/gallops
Pulm: CTAB, no w/r/r
Abd: +BS, tenderness to palpation in epigastrium, + voluntary
guarding, no rebound
Neuro: no focal deficits
MSK: 2+ pulses in bilateral DPs and radials, no edema in
bilateral lower extremities
DISCHARGE PHYSICAL EXAM:
Vitals: 98.2 PO 125 / 84 79 18 93 RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, mildly tender to palpation at the epigastrium w/o
rebound or guarding. NABS. No organomegally.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
___ 11:30AM BLOOD WBC-10.3* RBC-4.05 Hgb-12.5 Hct-36.9
MCV-91 MCH-30.9 MCHC-33.9 RDW-15.3 RDWSD-50.5* Plt ___
___ 11:30AM BLOOD Neuts-50.2 ___ Monos-4.1* Eos-5.0
Baso-1.2* Im ___ AbsNeut-5.18 AbsLymp-3.97* AbsMono-0.42
AbsEos-0.51 AbsBaso-0.12*
___ 11:30AM BLOOD Glucose-105* UreaN-14 Creat-0.7 Na-135
K-4.7 Cl-99 HCO3-23 AnGap-18
___ 11:30AM BLOOD ALT-166* AST-138* AlkPhos-492*
TotBili-1.4
Pertinent labs:
___ 06:30AM BLOOD HBsAg-NEGATIVE HBsAb-Positive
HBcAb-Positive*
___ 06:30AM BLOOD HIV Ab-Negative
___ 11:30AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 11:30AM BLOOD Triglyc-600*
___ 11:30AM BLOOD ALT-166* AST-138* AlkPhos-492*
TotBili-1.4
___ 06:30AM BLOOD ALT-115* AST-85* AlkPhos-425* TotBili-1.1
___ 05:40AM BLOOD ALT-83* AST-59* AlkPhos-409* TotBili-0.8
Discharge labs:
___ 05:40AM BLOOD WBC-6.9 RBC-3.45* Hgb-11.0* Hct-31.7*
MCV-92 MCH-31.9 MCHC-34.7 RDW-14.8 RDWSD-49.6* Plt ___
___ 05:40AM BLOOD Glucose-108* UreaN-10 Creat-0.7 Na-141
K-3.8 Cl-107 HCO3-25 AnGap-13
___ 05:40AM BLOOD ALT-83* AST-59* AlkPhos-409* TotBili-0.8
STUDIES
----------------
___ RUQ US
IMPRESSION:
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.
The pancreas is not well visualized secondary to overlying bowel
gas. No duct
dilation in visualized pancreas.
Brief Hospital Course:
___ yof with a history of cholangitis s/p cholecystectomy,
chronic recurrent pancreatitis, and IVDU maintained in remission
with methadone, who presents with acute on chronic pancreatitis.
#Acute on chronic pancreatitis: Patient with chronic recurrent
pancreatitis with multiple previous admission. Her BISAP score
was 0 on admission and she rapidly improved and was able to take
PO. Patient's care is fragmented among multiple hospitals, but
per review of our records she was presumed to have gallstone
pancreatitis. However, no confirmed stones in our system and
pathology from gallbladder was without stones. Patient has
continued to have episodes since her cholecystectomy. On
presentation her triglycerides were 600 and per review of our
records and per discussion with PCP office she has chronically
elevated triglycerides. She was therefore started on gemfibrozil
with follow up with GI and in the cardiology ___ clinic.
Chronic issues:
----------------
# Dysphagia: Patient reports ongoing dysphagia for months. PCP
aware and plan was for outpatient GI follow up. No weight loss.
Will follow up with GI
# Opiate use disorder:
- confirmed methadone dose with clinic, sent last dose letter
with patient
- Not discharged with narcotics
# Anxiety/PTSD
- continue alprazolam
# Chronic pain:
- Continue gabapentin
Transitional issues:
[] suspect that hyperlipidemia is driving recurrent
pancreatitis. She was started on gemfibrozil. Patient should
follow in ___ clinic
[] patient reports dysphagia to solids which is chronic for
months, please follow up with gastroenterology for pancreatitis
and dysphagia
Contact: ___) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 600 mg PO TID
2. ALPRAZolam 1 mg PO TID
3. Methadone 20 mg PO DAILY
4. ClonazePAM 2 mg PO QHS:PRN anxiety
Discharge Medications:
1. Gemfibrozil 600 mg PO BID
RX *gemfibrozil 600 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. ALPRAZolam 1 mg PO TID
3. ClonazePAM 2 mg PO QHS:PRN anxiety
4. Gabapentin 600 mg PO TID
5. Methadone 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for another episode of pancreatitis.
We believe that too much fat (triglycerides) in your blood may
be contributing to these episodes. We therefore started you on a
new medication. It is important that you continue taking this
medication and follow up with cardiology and gastroenterology.
Thank you for allowing us to be a part of your care.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10854133-DS-19
| 10,854,133 | 24,212,608 |
DS
| 19 |
2159-06-17 00:00:00
|
2159-06-17 20:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
n brief this is a ___ with uncontrolled HTN admitted with
syncopal episode. Per husband over the last year the patient
has had several episodes of unwitnessed falls at home. Once
while on a ladder at home, but other episodes were in unclear
circumstances. However, he does report that he found her with
vomit on herself after 2 falls. He has also noticed over the
last ___ months that she has had significant changes in her
memory with problems remembering dates and times. He thinks
that she tries to rationalize her memory deficits by talking
around the issue but he thinks that she knows something is going
wrong because she has told him on occasion that she might die
soon. She also has a bit a paranoia when dealing with medical
system. She has avoided coming to her PCP because she lost
contact with Dr. ___ feels ashamed. She has a great
relationship with her Opthalmologist and trusts her judgement.
In the ED, she was found to have significantly elevated SBP >200
and was given labetalol 10mg IV x 2 and Hydral 10mg and BP
decreased to <200. Afterwards while on tele in the ED, she
bradied down to the ___ and was nauseous and had one episode of
NBNB emesis. On arrival to the floor, she was started on
Captopril with better control of her BP. On tele overnight, she
had several episodes of bradycardia to the ___, pt was sleeping
and asymptomatic. She also had several ___ second pauses,
during which time she was in bed and asymptomatic.
This morning, the patient is unable to recant the events
surrounding the episode where she passed out and does not recall
passing out in the past. When asked if she has been having
problems with her memory she reports that it is because she has
been taking care of sick family members and has been stressed
about it. She cannot recall the name of any of her physicians
except her Ophthalmologist.
For complete medication, past medical, social and family
histories please see the admission note.
Past Medical History:
Hypertension
Hypercholesterolemia
Glaucoma
ETT MIBI ___ no myocardial perfusion defect
Social History:
___
Family History:
No heart disease, no DM2, no HTN. Mother with glaucoma.
Physical Exam:
ADMISSION EXAM:
VS: T=98.4 BP=163-184/81-89 HR=65-70 RR=18 O2 sat=98%RA
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Left eye with diffuse ecchymosis and scleral hemorrhage.
PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa. No xanthelasma.
NECK: Supple with flat JVP.
CARDIAC: RRR, II/VI SEM heard best over RSB. No rubs, gallops.
LUNGS: No chest wall deformities, scoliosis or kyphosis. CTAB,
no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominal bruits.
EXTREMITIES: Trace pedal edema. No c/c. 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+
Neuro exam (as assessed by Dr. ___:
Neuro and MMS Exam: Alert and oriented to person place and time.
Patient able to spell "WORLD" backwards. Able to identify pen,
and "tip of pen", can identify watch but cannot describe second
hand ("the hand that tells the time that is not the minute
hand"). Unable to recall any of three objects at 5 minutes
(watch, table, car). Can repeat "No ifs, ands, or buts" without
aphasia. Unable to recall examiner's name (___) after 5
minutes (initially stated easy to remember as her cat's name is
___ Able to draw a clockface and document 10 minutes to 2
using drawn in clock hands. Can copy image of intersecting
pentagons.
Cranial nerves: Visual fields in tact. EOMI are intact in all
directions. Sensation to gross touch in tact bilaterally on
face with ___ masseter/temporalis strength. Slight asymmetric
smile with flattening on right side. Gross hearing intact with
no visualized nystagmus. Uvula and tongue midline. SCM and
trapezius strength ___.
Strength: ___ UE strength in deltoid, ___, triceptal, and
interosseous muscles on Left. Right with ___ deltoid, bicpetal,
triceptal strength. ___ interosseus strength on left. Lower
extremities with ___ leg/thigh flexion and extension. Right
with 4+/5 leg/thigh flexion and extension.
Sensation grossly intact in face, upper extremities, and lower
extremities.
Cerebellar: Past pointing on finger to nose test when patient
used right hand index finger. No past pointing with left hand
index finger.
No pronator drift.
No Asterixis.
DTR's: 2+ ___ reflexes bilaterally. Tricepetal difficult
to evoke. 2+ BR reflexes. Patellar 1+ bilaterally. Achilles
difficult to evoke. No ankle clonus. Downgoing Babinski reflex
on left. Flat toes on right with Babinski reflex.
Gait: Deferred at pt. request.
DISCHARGE EXAM:
VS: T=98.2 BP=130/58 ___ RR=18 O2 sat=100%RA
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Left eye with diffuse ecchymosis and scleral hemorrhage.
PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa. No xanthelasma.
NECK: Supple with flat JVP.
CARDIAC: RRR, II/VI SEM heard best over RSB. No rubs, gallops.
LUNGS: No chest wall deformities, scoliosis or kyphosis. CTAB,
no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominal bruits.
EXTREMITIES: Trace pedal edema. No c/c. 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+
Neuro exam: Pt AOx2, strength 4+/5 RUE, ___ LUE, ___ ___.
Sensation normal, Toes down going bilaterally
Pertinent Results:
ADMISSION LABS:
___ 10:00PM BLOOD WBC-7.4 RBC-5.14 Hgb-14.6 Hct-43.0 MCV-84
MCH-28.4 MCHC-33.9 RDW-13.1 Plt ___
___ 10:00PM BLOOD Neuts-71.2* ___ Monos-4.5 Eos-0.8
Baso-0.8
___ 10:00PM BLOOD ___ PTT-31.5 ___
___ 10:00PM BLOOD Glucose-106* UreaN-8 Creat-0.7 Na-142
K-3.9 Cl-103 HCO3-26 AnGap-17
___ 06:50AM BLOOD ALT-17 AST-19 AlkPhos-66 TotBili-0.5
___ 10:00PM BLOOD cTropnT-<0.01
___ 02:00AM BLOOD cTropnT-<0.01
___ 06:50AM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:50AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.9 Cholest-253*
___ 06:50AM BLOOD VitB12-261
___ 06:50AM BLOOD %HbA1c-5.6 eAG-114
___:50AM BLOOD Triglyc-134 HDL-55 CHOL/HD-4.6
LDLcalc-171*
___ 06:50AM BLOOD TSH-1.6
___ 12:25AM URINE RBC-<1 WBC-24* Bacteri-NONE Yeast-NONE
Epi-<1
___ 12:25AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 12:25 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
CT HEAD ___:
IMPRESSION: No evidence of an acute intracranial process or
calvarial fracture.
Carotid Ultrasound ___:
Impression: Right ICA with <40% stenosis. Left ICA with <40%
stenosis.
MRI BRAIN ___:
IMPRESSION:
1. No acute intracranial abnormalities. No gross abnormal
enhancement, allowing for the motion-graded images.
2. Mild chronic microangiopathy. Mild global atrophy
TTE ___:
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Physiologic mitral regurgitation is seen
(within normal limits). The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: No cardiac etiology of syncope identified. Preserved
biventricular regional and global systolic function. Aortic
sclerosis with mild aortic regurgitation and no stenosis. Mild
dilatation of the ascending aorta.
DISCHARGE LABS:
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ with PMH of uncontrolled HTN presenting
with syncope found to have short term memory deficits,
bradycardia to ___.
# Syncope - Pt has hx of likely vasovagal syncope in the past
with reports of nausea and vomiting. The episode she experienced
prior to ophtho visit is certainly concerning for cardiogenic
syncope given sudden onset and facial trauma. She did have
episode of bradycardia in ED, but was after she was given 2
doses of labetolol which could have slowed her HR down. Given
her sensitivity to BB without any appreciable PR longation
suspect she may have SSS and benefit from PPM. She was r/o for
MI as etiology for her sxs. Clearly the labetalol may have
contributed to this episode, but her hx of prior syncopal
episodes while not beta-blocking agents is suspicious for
cardiac origin given documented abnormalities on tele overnight.
It is likely that she also has chronic small vessel
disease/lacunar infarcts from uncontrolled HTN so a larger CVA
is also in the ddx although she has no focal neurologic
deficits. Per EP not clear that bradycardia is contributing to
syncope and rec that pt be discharged with ___ of Hearts
monitor. She will follow-up with Cardiology as an outpatient
after a period of monitoring as an outpatient.
# Hypertensive urgency - pt without any evidence of end organ
ischemia, but she does have relatively new memory deficits
likely from vascular dementia in the setting of prolonged
uncontrolled HTN. Her blood pressure is persistently elevated as
she admits to not taking home BP meds in years. She has not
seen her listed PCP ___ ___. MRI and CT showed chronic small
vessel disease likely ___ uncontrolled HTN. A1c 5.6, LDL 171.
AV nodal agents were avoided given documented bradycardia. Her
HTN was treated with captopril which was transitioned to
Lisinopril, cholorthalidone and amlodipine. She also received
hydralazine for BP control while amlodipine reached a steady
state. She was also started on a statin for her hyperlipidemia.
# New Memory deficits - likely ___ chronic small vessel
disease/lacunar infarcts from uncontrolled hypertension which is
very unfortunate. She could also have carotid vessel disease
although, no appreciable bruits were heard on exam. Pt has
pyuria as well which may be contributing although she has no
complaints of dysuria. Carotid u/s wnl. MRI brain notes
chronic small vessel changes, B12 and TSH wnl. Urine cx was
negative. OT was consulted who also documented significant
memory deficits and recommended that patient be discharged home
with 24hr supervision or to assisted living facility. Patient
will also have follow-up with Neurology for formal evaluation
and referral to Cognitive neurology. Geriatrics was consulted
who agreed with the above, but no behavioral agents were added
given her bradycardia the risk of prolongation of her QTc.
# Glaucoma - continue home meds
TRANSITIONAL ISSUES:
- when treating her BP, please AVOID all atrioventricular node
blocking agents!
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
Discharge Medications:
1. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
2. Chlorthalidone 25 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Lorazepam 0.5 mg PO UNDEFINED agitation
6. Amlodipine 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Hypertensive Urgency
Vascular Dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___, you were admitted to the ___ with complaints of
syncope. You were found to have severe high blood pressure and
confusion. Your heart was monitored and there were several
instances when your heart rate slowed down which may be the
reason you are passing out.
You were given an "EVENT MONITOR" to wear at home. You were
instructed on its use in case you feel light headed or that you
may black out so your cardiologists can compare your heart
rhythm to your symptoms
It was also noted that you have memory impairments. This is
likely due to uncontrolled high blood pressure. You have been
started on several new blood pressure medications, and will need
to followup with neurology
Please see below for your follow-up appointments. Please have
your labs checked sometime the week of ___
Followup Instructions:
___
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2181-05-11 14:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
symptomatic carotid stenosis
Major Surgical or Invasive Procedure:
Left carotid endarterectomy
History of Present Illness:
Mr. ___ is an ___ man with a history of diabetes,
hypertension, hyperlipidemia, peripheral vascular
disease and a prior pontine infarct who developed confusion,
difficulty with speech and right-sided weakness, which
prompted cerebral imaging. He was found to have a borderline
zone infarct in an MRI of his brain as well as critical left
internal carotid artery stenosis and CT angiography. The patient
was transferred to ___ for further evaluation. Here,
he was found on cerebral perfusion imaging to have a large
territory of threatened parenchyma. The patient was therefore
urgently scheduled for a left carotid endarterectomy.
Past Medical History:
PMH:
-Diabetes
-Pontine CVA ___?
-HTN
-BPH
-carotid artery stenosis
-HLD
-PVD
-CKD
PSH:
-AAA repair (___)
-Bilateral cataract extraction (___)
-Colon surgery (___)
-R fem-pop bypass (___)
-Rotator cuff repair
Social History:
___
Family History:
FAMILY HISTORY: Unknown
Physical Exam:
Objective
GENERAL: [x]NAD [x]A/O x 3 []intubated/sedated []abnormal
CV: [x]RRR [] irregularly irregular []no MRG []Nl S1S2
[]abnormal
PULM: []CTA b/l x[]no respiratory distress []abnormal
ABD: []soft []Nontender []appropriately tender
[]nondistended []no rebound/guarding []abnormal
WOUND: [x]CD&I [x]no erythema/induration. Closed with staples.
EXTREMITIES: [x]no CCE []abnormal
NEURO: Strength ___ through out; CN ___ intact.
Pertinent Results:
___ 04:20AM BLOOD WBC-8.9 RBC-3.00* Hgb-9.8* Hct-29.6*
MCV-99* MCH-32.7* MCHC-33.1 RDW-12.7 RDWSD-45.5 Plt Ct-84*
___ 09:40PM BLOOD Neuts-50.2 ___ Monos-7.9 Eos-3.9
Baso-0.8 Im ___ AbsNeut-3.83 AbsLymp-2.81 AbsMono-0.60
AbsEos-0.30 AbsBaso-0.06
___ 04:20AM BLOOD Plt Ct-84*
___ 04:20AM BLOOD ___ PTT-26.2 ___
___ 04:20AM BLOOD Glucose-137* UreaN-14 Creat-1.5* Na-138
K-4.3 Cl-105 HCO3-19* AnGap-14
___ 09:40PM BLOOD ALT-11 AST-19 AlkPhos-93 TotBili-0.5
___ 04:20AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.4*
___ 09:40PM BLOOD Albumin-3.7
Brief Hospital Course:
Mr. ___ is an ___ man with a history of diabetes,
hypertension, hyperlipidemia, peripheral vascular disease and a
prior pontine infarct who developed confusion, difficulty with
speech and right-sided weakness, which
prompted cerebral imaging. He was found to have a borderline
zone infarct in an MRI of his brain as well as critical left
internal carotid artery stenosis and CT angiography. The patient
was transferred to ___ for further evaluation. Here,
he was found on cerebral perfusion imaging to have a large
territory of threatened parenchyma. The patient was therefore
urgently scheduled for a left carotid endarterectomy.
Patient underwent a left carotid endarterectomy with Dr. ___
on ___ without complication. For full details of the
surgical procedure please see the dicated operative note. After
a brief stay in PACU, he was transferred to the vascular surgery
floor where he remained for the remainder of his
hospitalization. His diet was advanced to a house diet which he
tolerated well. He was able to void on his own QS. His
postoperative pain was minimal and controlled with acetaminophen
and low dose oxycodone. He had no postoperative swelling and
was able to eat and drink without issue. His neck incision was
covered with steri-strips prior to discharge.
He was followed by neurology throughout admission and found to
have mild pronator drift and mild left facial droop. He will be
followed by stroke service as an outpatient.
Patient has a PMH of DM which was stable throughout his
admission. Patient will be re-started on his baseline lantus
10units qhs and metformin 500mg BID with meals.
Patient has PMH of HTN which was stable. His home meds were
continued at discharge.
Patient will require follow up with vascular surgery and the
neurology stroke service in the next 4 weeks. These appointments
have been scheduled prior to his discharge.
He will be discharged to a short term rehab facility in an
improved and stable condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. TraMADol 50 mg PO BID
3. Lantus Solostar U-100 Insulin (insulin glargine) 10 units
subcutaneous QHS
4. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Reason for PRN duplicate override: different context
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain -
Severe
Reason for PRN duplicate override: different context
decrease frequency and dose as pain level improves
6. Senna 17.2 mg PO QHS
7. Atorvastatin 80 mg PO QPM
8. Lantus Solostar U-100 Insulin (insulin glargine) 10 units
subcutaneous QHS
9. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Symptomatic carotid artery stenosis, stroke
Secondary: DM2, HTN, CKD III
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital after a
carotid endarterectomy. This surgery was done to restore proper
blood flow to your brain. To perform this procedure, an
incision was made in your neck.
You tolerated the procedure well and are now ready to be
discharged from the hospital. Please follow the
recommendations below to ensure a speedy and uneventful
recovery.
Carotid Endarterectomy
Patient Discharge Instructions
WHAT TO EXPECT:
Bruising, tenderness, mild swelling, numbness and/or a firm
ridge at the incision site is normal. This will improve
gradually in the next 2 weeks.
You may have a sore throat and or mild hoarseness. Warm tea,
throat lozenges, or cool drinks usually help.
It is normal to feel tired for ___ weeks after your surgery.
MEDICATION INSTRUCTIONS:
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
It is very important that you take Aspirin every day! You
should never stop this medication before checking with your
surgeon
You should take Tylenol ___ every 6 hours, as needed for neck
pain. If this is not enough, take your prescription pain
medication. You should require less pain medication each day.
Do not take more than a daily total of 3000mg of Tylenol.
Tylenol is used as an ingredient in some other over-the-counter
and prescription medications. Be aware of how much Tylenol you
are taking in a day.
Narcotic pain medication can be very constipating. If you take
narcotics, please also take a stool softener such as Colace.
If constipation becomes a problem, your pharmacist can suggest
an additional over the counter laxative.
CARE OF YOUR NECK INCISION:
You may shower 48 hours after your procedure. Avoid direct
shower spray to the incision. Let soapy water run over the
incision, then rinse and gently pat the area dry. Do not scrub
the incision.
You will need to return to the office in 5 days for removal of
your staples from your neck. This appointment will be set up
for you.
Your neck incision may be left open to air and uncovered unless
you have a small amount of drainage at the site. If drainage is
present, place a small sterile gauze over the incision and
change the gauze daily.
Do not take a bath or go swimming for 2 weeks.
ACTIVITY:
Do not drive for one week after your procedure. Do not ever
drive after taking narcotic pain medication.
You should not push, pull, lift or carry anything heavier than 5
pounds for the next 2 weeks.
After 2 weeks, you may return to your regular activities
including exercise, sexual activitiy and work.
DIET:
It is normal to have a decreased appetite. Your appetite will
return over time. Follow a well-balanced, heart healthy diet,
with moderate restriction of salt and fat.
SMOKING:
If you smoke, it is very important for you to stop. Research
has shown that smoking makes vascular disease worse. Talk to
your primary care physician about ways to quit smoking.
The ___ Smokers' Helpline is a FREE and confidential
way to get support and information to help you quit smoking.
Call ___
CALLING FOR HELP
If you need help, please call us at ___. Remember your
doctor, or someone covering for your doctor is available 24
hours a day, 7 days a week. If you call during non-business
hours, you will reach someone who can help you reach the
vascular surgeon on call.
To get help right away, call ___.
Call the surgeon right away for:
headache that is not controlled with pain medication or
headache that is getting worse
fever of 101 degrees or more
bleeding from the incision, or drainage the is new or
increased, or drainage that is white yellow or green
pain that is not relieved with medication, or pain that is
getting worse instead of better
If you notice any of the following signs of stroke, call ___ to
get help right away.
sudden numbness or weakness of the face, arm or leg
(especially on one side of the body)
sudden confusion, trouble speaking or trouble understanding
speech
trouble seeing in one or both eyes
sudden trouble walking, dizziness, loss of balance or
coordination
sudden severe headache with no known cause
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Jaw fracture
Major Surgical or Invasive Procedure:
Transoral open reduction and internal fixation of left angle and
symphysis mandible fractures.
History of Present Illness:
___ no significant PMHx s/p punch in face during altercation at
party last night. LOC 30 seconds and fell to ground, awoke lucid
and followed by left jaw pain and blood oozing out of mouth.
Patient came to ED w/ left jaw swelling, looseness of left lower
medial and lateral teeth. Patient denies other injuries, denies
fevers/chills, headaches/dizziness, nausea/vomiting, chest
pain/SOB, abdominal pain, changes in bowel or urinary habits.
Upon evaluation in ED, patient appears comfortable and NAD.
Obvious swelling of left jaw but no other injuries apparent on
exam. Head CT negative, patient has been seen by OMFS.
Past Medical History:
PMH:
- Non-contributory
PSH:
- Tonsillectomy as child, wisdom teeth out ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
DISCHARGE PHYSICAL EXAM:
General: NAD, AOx3
HEENT:
Head: atraumatic and normocephalic except for left lower and
middle third facial edema.
Eyes: EOM Intact, PERRL, vision grossly normal
Ears: right ear normal, left ear normal, no external
deformities and gross hearing intact
Nose: straight nose, non-tender, no epistaxis
EOE: left sided soft tissue swelling, chin dressing in place.
TMJ: normal TMJ bilaterally though has jaw pain while opening
Neurology: cranial nerves II-XII grossly intact except for
bilateral V3 parasthesia
Neck: normal range of motion, supple, no JVD, and no
lymphadenopathy
IOE: vestibular incisions closed with sutures and hemostatic
oropharynx clear, no dysphagia, , FOM soft non-elevated,
dentition grossly intact, uvula midline, occlusion stable and
repeatable.
Skin: warm, dry, normal turgor, brisk capillary refill
CV: RRR, no murmurs, no gallops
Resp: No respiratory distress, no accessory muscle use, clear
to auscultation
Abd: soft, nontender, nondistended
Pertinent Results:
___ 06:03AM BLOOD WBC-12.6* RBC-4.79 Hgb-14.8 Hct-41.8
MCV-87 MCH-30.9 MCHC-35.4 RDW-12.2 RDWSD-39.2 Plt ___
___ 06:03AM BLOOD Neuts-86.3* Lymphs-8.1* Monos-4.9*
Eos-0.0* Baso-0.4 Im ___ AbsNeut-10.91* AbsLymp-1.02*
AbsMono-0.62 AbsEos-0.00* AbsBaso-0.05
___ 06:03AM BLOOD Plt ___
___ 06:03AM BLOOD ___ PTT-26.6 ___
___ 06:03AM BLOOD Glucose-98 UreaN-13 Creat-1.1 Na-142
K-4.2 Cl-101 HCO3-23 AnGap-18
Imaging:
CT MANDIBLE:
IMPRESSION:
1. Minimally comminuted fracture of the left mandibular ramus
with 1 bone
width posterior and medial displacement. Associated
subcutaneous swelling and emphysema. No evidence of hematoma.
The left mandibular foramen appears to be disrupted.
2. Second nondisplaced fractures through the symphysis,
extending to the right mandibular body and midline. No evidence
of dental fracture.
CT HEAD
IMPRESSION:
No acute intracranial abnormalities. No acute fracture of the
calvarium.
MANDIBLE X-RAY
FINDINGS:
There is a plate and screws transfixing the left mandibular rami
fracture.
There are also 2 plates and interlocking screws transfixing the
right
symphyseal fracture. No evidence of early hardware failure is
noted.
Brief Hospital Course:
Mr. ___ is a ___ years old man with no significant PMHx s/p
punch in face during altercation at party last night. LOC 30
seconds and fell to ground, awoke lucid and followed by left jaw
pain and blood oozing out of mouth. Patient came to ED w/ left
jaw swelling, looseness of left lower medial and lateral teeth.
Patient denies other injuries, denies fevers/chills,
headaches/dizziness, nausea/vomiting, chest pain/SOB, abdominal
pain, changes in bowel or urinary habits.
Upon evaluation in ED, patient appears comfortable and NAD.
Obvious swelling of left jaw but no other injuries apparent on
exam. Head CT negative but CT mandible showed 2 mandibular
fractures so ___ was consulted. Patient was seen by ___ who
after evaluating the patient recommended surgery.
Patient was taken to the OR on ___ for ORIF of left symphysis
and left angle of mandible fractures through intraoral approach.
Patient tolerated the procedure well (for operative details
please refer to Op. note). Patient was transferred to the floor
after a short PACU stay. On POD 1 the patient was doing well,
tolerating a full liquid diet and pain was well controlled. ___
evaluated the patient and deemed him appropriate to being
discharged home.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a full
liquid diet, ambulating, voiding without assistance, and pain
was well controlled. The patient was discharged home without
services. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: will dc IV administration
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
Duration: 2 Weeks
RX *chlorhexidine gluconate [Peridex] 0.12 % Mouth rinse twice
daily twice a day Refills:*0
3. Clindamycin 300 mg PO Q6H Duration: 7 Days
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6)
hours Disp #*28 Capsule Refills:*0
4. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left angle and symphysis mandible fracture.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ and
underwent surgery on your mandible. You are recovering well and
are now ready for discharge. Please follow the instructions
below to continue your recovery:
Wound care: Do not disturb or probe the surgical area with any
objects. The sutures placed in your mouth are usually the type
that self dissolve. If you have any sutures on the skin of your
face or neck, your surgeon will remove them on the day of your
first follow up appointment. SMOKING is detrimental to healing
and will cause complications.
Bleeding: Intermittent bleeding or oozing overnight is normal.
Placing fresh gauze over the area and biting on the gauze for
___ minutes at a time may control the bleeding. Bleeding
should never be severe. If bleeding persists or is severe or
uncontrollable, please call our office immediately. If it is
after normal business hours, please come to the emergency room
and request that the oral surgery resident on call be paged.
Healing: Normal healing after oral surgery should be as
follows: the first ___ days after surgery, are generally the
most uncomfortable and there is usually significant swelling.
After the first week, you should be more comfortable. The
remainder of your postoperative course should be gradual, steady
improvement. If you do not see continued improvement, please
call our office.
Physical activity: It is recommended that you not perform any
strenuous physical activity for a few weeks after surgery. Do
not lift any heavy loads and avoid physical sports unless you
obtain permission from your surgeon.
Swelling & Ice applications: Swelling is often associated with
surgery. Swelling can be minimized by using a cold pack, ice bag
or a bag of frozen peas wrapped in a towel, with firm
application to face and neck areas. This should be applied 20
minutes on and 20 minutes off during the first ___ days after
surgery.
Hot applications: Starting on the ___ or ___ day after surgery,
you may apply warm compresses to the skin over the areas of
swelling (hot water bottle wrapped in a towel, etc), for 20
minutes on and 20 min off to help soothe tender areas and help
to decrease swelling and stiffness. Please use caution when
applying ice or heat to your face as certain areas may feel numb
after surgery and extremes of temperature may cause serious
damage.
Tooth brushing: Begin your normal oral hygiene the day after
surgery. Soreness and swelling may not permit vigorous brushing,
but please make every effort to clean your teeth with the bounds
of comfort. Any toothpaste is acceptable. Please remember that
your gums may be numb after surgery. To avoid injury to the gums
during brushing, use a child size toothbrush and brush in front
of a mirror staying only on teeth.
Mouth rinses: Keeping your mouth clean after surgery is
essential. Use 1 teaspoon of salt dissolved in an 8 ounce glass
of warm water and gently rinse with portions of the solution,
taking 5 min to use the entire glassful. Repeat as often as you
like, but you should do this at least 4 times each day. If your
surgeon has prescribed a specific rinse, use as directed.
Sleeping: Please keep your head elevated while sleeping. This
will minimize swelling and discomfort and reduce pain while
allowing you to breathe more easily.
Pain: Most facial and jaw reconstructive surgery is accompanied
by some degree of discomfort. You will usually have a
prescription for pain medication. Some patients find that
stronger pain medications cause nausea, but if you precede each
pain pill with a small amount of food, chances of nausea will be
reduced. The effects of pain medications vary widely among
individuals. If you do not achieve adequate pain relief at first
you may supplement each pain pill with an analgesic such as
Tylenol or Motrin. If you find that you are taking large amounts
of pain medications at frequent intervals, please call our
office.
Diet: Unless otherwise instructed, only a cool, clear liquid
diet is allowed for the first 24 hours after surgery. After 48
hours, you can increase to a full liquid diet, but please check
with your doctor before doing this. Avoid extreme hot and cold.
After one week, you may be able to gradually progress to a soft
diet, but ONLY if your surgeon instructs you to do so. It is
important not to skip any meals. If you take nourishment
regularly you will feel better, gain strength, have less
discomfort and heal faster. Over the counter meal supplements
are helpful to support nutritional needs in the first few days
after surgery.
Medications: You will be given prescriptions, some of which may
include antibiotics, oral rinses, decongestants, nasal sprays
and pain medications. Use them as directed. If you have any
questions about your progress, please call ___ at
___ or ___ or call the page operator at ___
___ and have them page the on call Oral &
Maxillofacial Surgery resident.
Followup Instructions:
___
|
10854695-DS-11
| 10,854,695 | 21,560,117 |
DS
| 11 |
2191-01-20 00:00:00
|
2191-01-21 21:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUQ abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
Date: ___
Time: ___
_______________________________________________________________
PCP: ___ Affil Phys -- ___
___ ___
Primary oncologist:
___ MD
________________________________________________________________
HPI: > or equal to 4 ( location, quality, severity, duration,
timing, context, modifying factors, associated signs and sx)
___ hx synovial sarcoma locally recurrent and w/ mets to lungs
s/p lung resection x 2 also s/p chemo and XRT who presents with
constant ___ RUQ abd pain x 2 weeks, saw PCP today, sent to ER
for evaluation. Pain is constant but getting progressively
worse. Pain improves with oxycontin and laying down. It is
worsened by eating. No vomiting. Had temp to ___ yesterday. +
subjective temps today for which she took tylenol but did not
check her temperature. No change in bowel habits, last BM
___. Denies CP, SOB, cough/cold sx. Decreased PO's with 3 lb
weight loss. She has mild rhinorhea which she thinks might be
allergies.
Had CT a/p on ___: 1. Overall significant progression of
metastatic disease in the chest with multiple new lesions and
increased size of existing lesions, with increased left effusion
and decreased aeration of the left lung. She is s/p lung
resection of previous lesions. Abdominal CT also demonstrated
new large intra-abdominal mass with mass effect on the SMV and
gallbladder, apparently new from ___. No discrete fat
plane is seen between the mass and the liver. Small
intra-abdominal and pelvic ascites.
In ER: (Triage Vitals: 17:41 5 97 98 170/79 16 100%)
Meds Given: morphine 5 mg IV x 2
Fluids given: 1 LNS
Radiology Studies:
RUQ US
consults called: oncology who recommended admission for pain
control and monitoring of fever day prior to presentation
PAIN SCALE: ___ location: RUQ
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[ +] Fever [ ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [+ ] sweats
[ + ] ___3__ lbs. weight loss
Eyes
[] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat
[] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [+ ] Other: rhinorrhea
RESPIRATORY: [X] All Normal
[ ] Shortness of breath [ ] Dyspnea on exertion [ ] Can't
walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum
[ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [x] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ]
Chest Pain [ ] Dyspnea on exertion [ ] Other:
GI: [] All Normal
[ ] Nausea [] Vomiting [+] Abd pain [] Abdominal swelling [
] Diarrhea [ ] Constipation [ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ +] Anorexia [ ] Reflux
[ ] Other:
GU: [X] All Normal
[ ] Dysuria [ ] Incontinence or retention [ ] Frequency
[ ] Hematuria []Discharge []Menorrhagia
SKIN: [x] All Normal
[ ] Rash [ ] Pruritus
MS: [] All Normal
[ ] Joint pain [ ] Jt swelling [ +] Back pain - improved
with IV morphine in ED- chronic, no new changes [ ] Bony pain
NEURO: [x] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [x] All Normal
[ ] Skin changes [ ] Hair changes [ ] Heat or cold
intolerance [ ] loss of energy
HEME/LYMPH: [] All Normal
[ +] Easy bruising - secondary to Coumadin [ ] Easy bleeding
[ ] Adenopathy
PSYCH: [x] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
ALLERGY:
[ x]Medication allergies- NKDA [ ] Seasonal allergies
[]all other systems negative except as noted above
Past Medical History:
ONC HISTORY:
Metastatic synovial sarcoma, left thigh, s/p resection ___
and XRT, local recurrence and bilateral lung mets (2) ___,
s/p resection of local recurrence and left upper lobectomy
___ she underwent wedge resection of RUL nodule, path (+)
for 0.5cm synovial sarcoma, margins (-).
- ___: Cycle #1 ifosfamide complicated by pulmonary edema.
- ___: Cycle #2 ifosfamide given.
- s/p ___ cycle of doxorubicin ___
- s/p ___ cycle of adriamycin on ___
Admitted with PNA in ___ and treated with levo
.
OTHER PMHx:
DM.
HTN.
Asthma.
On Coumadin for port cath associated thrombosis - inr not being
monitored as she is on a sub therapeutic dose
Anemia.
Arthritis.
Depression.
.
PAST SURGICAL HISTORY:
1. Posterior spinal fusion at L4-L5 in ___ at ___.
2. Hysterectomy and unilateral oopherectomy at the age of ___ for
fibroids. After the resection, she was told that she had a
small focus of cancer, but that it was all resected and she
required no follow-up treatment.
3. Bladder suspension ___.
4. Tubal ligation.
5. Wide resection left thigh synovial sarcoma ___.
Social History:
___
Family History:
Aunt with breast cancer. Cousin with leukemia.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS 98.2, 130/72, 93, 18, 96% RA
GENERAL: Pleasant female who appears younger than her stated
age
Nourishment: good, obese
Grooming: good
Mentation: good, alerts, appropriately tearful and demonstrates
insight into her condition.
HEENT: Eyes: [X] WNL, PERRL, EOMI without nystagmus,
Conjunctiva: clear/injection/exudates/icteric
Ears/Nose/Mouth/Throat: MM dry, no lesions noted in OP
CV: RRR, S1, S2 normal, BLE edema
ABD: Tender- markedly tender in the right upper quadrant.
Obesely distended abdomen
Musculoskeletal-Extremities - WNL, Upper extremity strength ___
and symmetrical, Lower extremity strength ___ and symmetrical
Neurological - Alert and Oriented x 3
Skin - Warm, Dry
DISCHARGE PHYSICAL EXAM
VS Tc 99.3, Tm 99.3, BP 110/66 (102-132/58-78), HR 94 (87-95) R
18 96% RA
GENERAL: Pleasant female, calm, NAD who appears younger than
her stated age
HEENT: PERRL, EOMI, MMM
CV: RRR, S1, S2 normal, no M/R/G
PULM: CTAB, w/ decreased breath sounds at the bases
ABD: Tender to deep palpation in the RUQ and epigastrum but
softer than previous exam
EXTREM: warm, well perfused, no edema noted
Pertinent Results:
ADMISSION LABS
___ 06:59PM BLOOD WBC-5.4# RBC-3.59* Hgb-9.4* Hct-30.9*
MCV-86 MCH-26.2*# MCHC-30.4*# RDW-14.5 Plt ___
___ 06:59PM BLOOD Neuts-79.4* Lymphs-14.1* Monos-5.2
Eos-0.7 Baso-0.6
___ 07:00PM BLOOD ___ PTT-29.6 ___
___ 06:30PM BLOOD Glucose-185* UreaN-8 Creat-0.9 Na-137
K-3.9 Cl-98 HCO3-26 AnGap-17
___ 06:30PM BLOOD ALT-21 AST-38 AlkPhos-153* TotBili-0.5
___ 06:30PM BLOOD Albumin-3.7
___ 05:35AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.2 Iron-13*
___ 05:35AM BLOOD calTIBC-212* VitB12-1615* Ferritn-155*
TRF-163*
___ 06:36PM BLOOD Lactate-1.2
DISCHARGE LABS
___ 06:00AM BLOOD WBC-3.0* RBC-3.45* Hgb-9.0* Hct-29.4*
MCV-85 MCH-26.0* MCHC-30.5* RDW-14.3 Plt ___
___ 04:30AM BLOOD Neuts-87.0* Lymphs-8.2* Monos-4.6 Eos-0
Baso-0.1
___ 06:00AM BLOOD ___ PTT-28.7 ___
___ 06:00AM BLOOD Glucose-156* UreaN-13 Creat-1.0 Na-138
K-3.7 Cl-98 HCO3-30 AnGap-14
___ 06:00AM BLOOD ALT-40 AST-72* AlkPhos-218* TotBili-0.7
___ 06:00AM BLOOD Calcium-8.3* Phos-4.1 Mg-2.2
MICROBIOLOGY
___ Blood Culture, Routine (Pending):
___ Blood Culture, Routine (Pending):
IMAGING
___ CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS:
Overall significant progression of metastatic disease in the
chest with multiple new lesions and increased size of existing
lesions, with increased left effusion and decreased aeration of
the left lung. Large intra-abdominal mass with mass effect on
the SMV and gallbladder, apparently new from ___. No
discrete fat plane is seen between the mass and the liver. Small
intra-abdominal and pelvic ascites.
___ LIVER OR GALLBLADDER US (SINGLE ORGAN): Large
heterogeneous mass again seen extending inferiorly from the
liver was better evaluated on the CT from ___. No
evidence of cholecystitis. Portal patent vein.
___ CHEST (PA & LAT): Left lung pleural based
masses/effusion account for the left lung opacity. Findings are
better appreciated on the recent CT.
Brief Hospital Course:
___ year old female with major depression, DM II poorly
controlled along with a history of synovial sarcoma dx ___
s/p resection XRT and chemo c/b lung metastatses s/p resection x
2 along with new finding of large intraabdominal mass thought to
be worsening of metastatic disease p/w abdominal pain.
# Abdominal pain - This is probably secondary to large abdominal
mass seen recently on CT. Pt on Oxycodone 30 mg TID at home
(initially thought to be Oxycontin 30mg TID), and was initially
started on morphine IV on admission. She was evaluated by
palliative care for symptom management who recommended Oxycontin
30mg in AM, 60mg in pm, and 60mg at night and she was put on a
morphine PCA. Based on her PCA requirements, it was decided to
increase her Oxycontin to 60mg TID. Pt was w/o somnolence or
sedation with this dosage. However, because of insurance issues,
pt was discharged on MS ___ 60mg in the morning, 60mg in the
afternoon, and 90mg in the evening, along with prn Oxycodone
___ q3hours as needed. She was notably depressed prior to
admission, but denied suicidal ideation upon discharge and
voiced a safety plan. She was continued on her home dose of
neurontin.
# Fever - Pt was initiated on chemotherapy in the hospital per
Dr. ___ had a fever related to gemcitabine. Pt also
with report of fever at home but no localizing sign of
infection. CXR demonstrated a left pleural effusion which was
also seen on her recent CT scan, but given lack of symptoms
antibiotics were not administered. Pt was without fever for the
remainder of the hospitalization.
# Synovial sarcoma - Diagnosed in ___, s/p resection, XRT,
and chemo, course c/b lung metastases s/p resection. New finding
of intrabdominal mass which is likely causing her presenting
symptom. She was initiated on chemotherapy during this
hospitalization with day 1 = gemcitabine and day 8 = gemcitabine
and docitaxel (as outpatient).
# Anxiety/Depression - Despite recent depression, pt denies any
thoughts of suicide/suicidal ideation during this
hospitalization and denied suicidal ideation on the day of
discharge. She was continued on her home Methylphenidate SR 20
mg DAILY and Olanzapine 7.5 mg BID. She has a f/u appointment
with her outpatient psychiatrist on ___.
# Anemia - HCT around baseline and iron studies showed she was
not iron deficient and her B12 was normal.
# Chronic diastolic heart failure - Pt was continued on her home
dose of lasix.
# HTN - Pt was continued on her home Lisinopril.
# DM II - Pt was continued on her home glargine 45 U qam and 42
U qpm along with SSI and diabetic diet.
# Asthma - Pt was continued on her home advair along with
inhalers prn
# GERD - Pt was continued on her home PPI
TRANSITIONAL ISSUES
# Recommend f/u pending blood cultures
# Recommend re-assessment of pain at f/u appointments and
adjusting pain medication as indicated.
Medications on Admission:
Reviewed with patient on admission
Sliding scale insulin and glargine 42 U QAM and 45 U QPM
Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
Ipratropium Bromide MDI 2 PUFF IH QID
Calcium Carbonate 500 mg PO/NG QID
Lisinopril 40 mg PO/NG DAILY
Lorazepam 0.5 mg PO/NG TID:PRN anxiety
Docusate Sodium 100 mg PO/NG BID
Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID - recently
changed by ___ but pt states that she never received the
prescription
Methylphenidate SR 20 mg PO DAILY
Furosemide 40 mg PO/NG BID
Oxycodone prn but pt reports that this is not effective
OLANZapine (Disintegrating Tablet) 7.5 mg PO BID
Gabapentin 300 mg PO/NG QAM
Omeprazole 40 mg PO DAILY Order date: ___ @ ___
Gabapentin 300 mg PO/NG Q 4 ___
Ondansetron 8 mg PO/NG Q8H:PRN nausea Order date: ___ @ 2254
Gabapentin 900 mg PO/NG HS
Oxycodone SR (OxyconTIN) 30 mg PO Q8H
Discharge Medications:
1. insulin glargine 100 unit/mL Solution Sig: ___ (45)
units Subcutaneous qAM.
2. insulin glargine 100 unit/mL Solution Sig: ___ (42)
units Subcutaneous qPM.
3. Insulin sliding scale - please resume the sliding scale you
were on at home
4. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day).
6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*0*
10. methylphenidate 20 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO DAILY (Daily).
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 1.5 Tablet,
Rapid Dissolves PO BID (2 times a day).
13. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day: Once in the morning, once at 4pm.
14. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
15. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
16. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
17. ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for nausea.
18. oxycodone 10 mg Tablet Sig: ___ Tablets PO q3h as needed for
pain.
Disp:*80 Tablet(s)* Refills:*0*
19. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
20. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
Disp:*30 Powder in Packet(s)* Refills:*0*
21. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
22. iron Oral
23. MS ___ 30 mg Tablet Extended Release Sig: ___ Tablet
Extended Releases PO three times a day: Please take 2 tablets in
the morning, 2 tablets in the afternoon, and 3 tablets at
nighttime.
Disp:*96 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Abdominal mass
Secondary Diagnosis
Synovial Sarcoma
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 hospital stay
at ___. You were admitted due to abdominal pain. It is likely
that your abdominal pain was caused by the mass in your abdomen
seen on the cat scan. You were seen by Palliative Care to help
manage your pain. You will see the changes to your pain regimen
listed below.
You were also started on chemotherapy while you were here and
will continue chemotherapy with Dr. ___.
Please note the following changes to your medications.
1. START MS Contin: take 60mg in the morning, 60mg in the
afternoon, and 90mg at night
2. CHANGE Oxycodone to ___ every three hours only as needed
for pain
3. START Senna for constipation
4. START Miralax for constipation
Please continue taking your other medications as prescribed.
Followup Instructions:
___
|
10854780-DS-7
| 10,854,780 | 26,406,524 |
DS
| 7 |
2123-05-23 00:00:00
|
2123-05-24 14:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Keflex / enalapril
Attending: ___
___ Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old gentleman who is s/p anterior and
posterior L3-S1 fusion (Dr. ___ who presents to the ED from
rehabilitation with a fever.
Mr. ___ underwent anterior and posterior fusion in a staged
2-part procedure, with an ALIF of L4-S1 on ___ and a L3-S1
fusion on ___. His hospital course was unremarkable, and he
was discharged on ___ with stable vital signs, afebrile and
with well controlled pain on PO pain medications on POD #3 (from
stage 2, POD #6 from stage 1).
He was transported to a rehabilitation facility, where he was
promptly sent back to the ED on ___ after being found
febrile to ___. He reports that he had been having some
abdominal distention/pain, left leg pain/swelling, and scrotal
swelling since the second stage of the surgery, and that he did
not feel ready to go to rehabilitation. He also reported some
chills as well as some burning on urination for the past 24
hours or so.
At the ED, initial vitals where T 100.2 HR94 BP152/62 RR15 O294%
on Nasal Cannula. He was well appearing, but was found to have
bil crackles at the bases and was found to be hypoxic, with
improvement on ___ NC. He had 2+ ___ edema bil. His abdomen was
distended, and he was minimally tender in the LLQ/RLQ, back and
abdominal incisions, but these were reportedly clean and dry. He
had no meningismus.
Imaging at the ED was notable for CXR with small bil pleural
effusions and volume overload, and CT A/P showed a moderate
amount of no hemorrhagic fluid in the abdomen and in the scrotum
with no evidence of an abscess. Laboratory work was notable for
WBC of 12.8, BNP of 1503, Trop <0.01, flu A/B PCR negative, and
UA with ketones, trace protein and negative leukocytes. He was
also found to have anemia (HgB 9.8), low serum albumin (2.5) and
mild electrolyte inbalances with hyponatremia (131),
hypochloremia (93), hypocalcemia (7.7) and hypophosphatemia
(2.7). Given fluid overload and possible CHF, he was given 40mg
Furosemide with reported improvement. He also received IV
Hydromorphone .5mg, Odansetron 4mg, Acetaminophen 1000mg, and
Morphine 4mg x2.
He was seen by both orthopedic surgery and vascular surgery, and
given stable lower extremity neurological exam, CT without any
abscess, and unremarkable wounds, he was admitted to medicine
for evaluation of possible new onset CHF as well as fever.
On arrival to the floor, vital signs where stable and he was
afebrile, with good O2 saturation on 2L NC. He endorses some
continued pain since his surgery, with some temporary control on
pain medications. He reports that abdominal distention, leg
swelling and scrotal swelling has greatly improved since the
administration of Furosemide, and reports making over 2.5L of
urine since then. He also denies any current or past shortness
of breath or chest pain.
Past Medical History:
Hyperlipidemia
Hypertension
Asthma
AAA
Gout
s/p EVAR ___
s/p EIA to hypogastric bypass in ___
s/p bil Knee replacement in ___
Social History:
___
Family History:
Positive for heart failure, coronary artery disease,
HTN, lung disease, cancer, peripheral arterial disease,
stroke.
Physical Exam:
ADMISSION EXAM
==============
Vital Signs: T 99.3 BP: 134/72 HR: 82 RR:24 O2Sat 94 on NC
General: Alert, oriented, appears uncomfortable and in pain.
HEENT: Sclerae anicteric, MMM, oropharynx clear, PERRL, neck
supple and without lymphadenopathy, JVP not elevated
CV: Distant heart sounds, but regular rate and rhythm, with
normal S1 + S2, no murmurs, rubs, gallops
Lungs: Decreased air movement at the bases, with some bil
crackles.
Abdomen: Soft, non-tender, fairly distended with normoactive
bowel sounds, no organomegaly, no rebound or guarding
GU: No foley. Scrotum distended.
Ext: Warm, well perfused bil, with 2+ pulses, no clubbing. Left
lower extremity with some mild non-pitting edema.
Neuro: Alert and oriented. Left lower extremity strength ___
secondary to pain. Sensation to light touch intact in bil lower
extremities.
DISCHARGE EXAM
==============
Vitals: T: 98.6 BP: 123/73 HR: 72 RR: 20 O2: 98 RA
General: Lying in bed, alert and in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Mild crackles at the bases bil, but otherwise clear to
ausculatation bil
CV: regular rate and rhythm, with normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: mildly distended, soft, non-tender, hyperactive bowel
sounds,
no rebound tenderness or guarding, no organomegaly. Abdominal
incision clean and dry with no discharge or erythema.
Ext: Warm, well perfused, 2+ pulses, no edema, clubbing or
cyanosis.
Skin: Back incision remains clean and dry with no discharge.
Neuro: Alert and oriented per exam with no gross deficits. ___
strength ___.
Pertinent Results:
ADMISSION LABS
==============
___ 12:04AM ___ PTT-25.6 ___
___ 12:04AM PLT COUNT-282#
___ 12:04AM NEUTS-79.5* LYMPHS-10.5* MONOS-7.7 EOS-1.4
BASOS-0.2 NUC RBCS-0.2* IM ___ AbsNeut-10.21*# AbsLymp-1.35
AbsMono-0.99* AbsEos-0.18 AbsBaso-0.02
___ 12:04AM WBC-12.8* RBC-3.28* HGB-9.8* HCT-29.5* MCV-90
MCH-29.9 MCHC-33.2 RDW-13.0 RDWSD-42.7
___ 12:04AM ALBUMIN-2.5* CALCIUM-7.7* PHOSPHATE-2.6*
MAGNESIUM-1.7
___ 12:04AM CK-MB-<1 proBNP-1503*
___ 12:04AM cTropnT-<0.01
___ 12:04AM LIPASE-11
___ 12:04AM ALT(SGPT)-31 AST(SGOT)-34 CK(CPK)-125 ALK
PHOS-78 TOT BILI-0.7
___ 12:04AM GLUCOSE-95 UREA N-15 CREAT-0.7 SODIUM-131*
POTASSIUM-3.4 CHLORIDE-93* TOTAL CO2-24 ANION GAP-17
___ 12:12AM LACTATE-1.1
___ 01:15AM URINE RBC-2 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 01:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:15AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:53AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
MICRO
=====
__________________________________________________________
___ 2:25 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 1:15 am
URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 12:57 am
BLOOD CULTURE
Blood Culture, Routine (Pending):
DISCHARGE LABS
==============
___ 04:55AM BLOOD WBC-8.5 RBC-3.41* Hgb-10.1* Hct-31.3*
MCV-92 MCH-29.6 MCHC-32.3 RDW-13.0 RDWSD-42.8 Plt ___
___ 04:55AM BLOOD Plt ___
___ 04:55AM BLOOD Glucose-104* UreaN-14 Creat-0.7 Na-134
K-3.9 Cl-94* HCO3-29 AnGap-15
___ 04:55AM BLOOD Calcium-8.0* Phos-3.6 Mg-2.0
IMAGING/STUDIES
===============
___ LOWER EXT VEINS
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ ABD & PELVIS WITH CO
1. Status post fusion of L4 through S1 with intervertebral
spacing devices. No evidence of prosthetic or periprosthetic
fracture.
2. There is a moderate amount of nonhemorrhagic fluid extending
along the left pericolic gutter and pelvis. The fluid and small
locules of air tract within a left inguinal hernia. There is
also a large amount of fluid within the scrotum. These findings
may be postoperative in nature given the recent surgery. There
are no focal fluid collections to suggest abscess formation.
3. Distended gallbladder without evidence of wall thickening or
pericholecystic fluid.
4. Air within the bladder lumen should be correlated with any
recent
catheterization.
5. Small bilateral nonhemorrhagic pleural effusions and trace
pericardial effusion.
___ CHEST
1. No evidence of pulmonary embolism.
2. Small bilateral nonhemorrhagic pleural effusions, left
greater than right, with adjacent compressive atelectasis.
3. Small nonhemorrhagic pericardial effusion, with mild
cardiomegaly.
Extensive coronary artery calcifications.
4. Small tracheal secretions.
5. Multiple bridging thoracic osteophytes, compatible with DISH
(diffuse idiopathic skeletal hyperostosis).
___
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic valve leaflets
are mildly thickened (?#). There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is a very small pericardial
effusion. There are no echocardiographic signs of tamponade.
IMPRESSION: Normal biventricular chamber size and systolic
function. No pathologic valvular flow. Very small pericardial
effusion without evidence of tamponade.
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman s/p anterior and posterior
L3-S1 fusion who presents with fever and CHF. He was recently
admitted for an elective spinal surgery. Upon discharge to rehab
on ___, he was found on admission to have a fever to 103 and
refused for admission.
# Hypoxemia
# Acute Diastolic Congestive Heart Failure
The patient was found on exam to have new CHF on arrival to the
ED and on admission with crackles, hypoxemia, elevated JVP,
scrotal swelling, lower extremity swelling, and elevated proBNP
(1503). Received diuresis with low dose IV furosemide with
excellent urine output and improvement in respiratory status.
Echocardiogram did not show any valvular and LV systolic
dysfunction. Troponin was negative on presentation. Most likely
cause of new heart failure was receiving constant maintenance
fluid during his hospitalization for spinal surgery and existing
mild diastolic dysfunction. He was discharged on furosemide 10
mg daily for 7 days to help remove residual abdominal swelling
and scrotal edema.
# Fever
Patient remained afebrile since admission. Basic work up
negative for infection with normal UA and no consolidation on
imaging. Blood cultures had no growth from admission until
discharge. Patient had no localizing symptoms. CTA was performed
for PE, which was negative. Fever was most likely consistent
with benign post-operative fever due to inflammatory state.
# Anemia
Patient was admitted from prior hospitalization with H/H
13.3/40.7. On last discharge, it was 9.5/29.4. That drop was
most likely due to surgical blood loss. It improved to 10.1/31.3
with diuresis, suggesting some component of volume overload as
well.
# Lumbar Spondylosis and Stenosis s/p Spine Surgery
s/p a two stage anterior and posterior fusion on ___ and
___, and was moderately well-controlled on PO pain
medication. Was having LLE pain attributed to nerve irritation
during surgery that continued to improve. No alarm symptoms.
Managed with PO Oxycodone PRN pain, gabapentin 300 mg TID, and
diazepam 5 mg Q6H PRN spasm.
# Hypertension:
Continued amlodipine 10 mg daily
# Hyperlipidemia:
Continued pravastatin 80 mg daily
TRANSITIONAL ISSUES
[ ] Discharged on 10 mg furosemide daily to ensure further
removal of fluid he received during post-op period. Likely will
NOT need to be a chronic med - may be stopped at the discretion
of the PCP
[ ] ACTIVITY: DO NOT lift anything greater than 10 lbs for 2
weeks. ___ times a day you should go for a walk for ___
minutes as part of your recovery. You can walk as much as you
can tolerate. You will be more comfortable if you do not sit or
stand more than ~45 minutes without changing positions.
[ ] BRACE: You have been given a brace. This brace should be
worn for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
[ ] WOUND: Do not soak the incision in a bath or pool until
fully healed. If the incision starts draining at any time after
surgery, cover it with a sterile dressing. Please call the
office.
Greater than 30 minutes was spent on this patient's discharge
day management.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Pravastatin 80 mg PO QPM
3. Tamsulosin 0.4 mg PO QHS
4. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
5. Diazepam 5 mg PO Q6H:PRN spasm
6. Docusate Sodium 100 mg PO BID
7. Gabapentin 300 mg PO TID
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
9. Senna 8.6 mg PO BID:PRN constipation
10. Aspirin 325 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Furosemide 10 mg PO DAILY
RX *furosemide 20 mg One-half tablet(s) by mouth Once a day Disp
#*4 Tablet Refills:*0
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram One packet by
mouth Once a day Disp #*24 Packet Refills:*0
3. Senna 17.2 mg PO QHS
RX *sennosides [senna] 8.6 mg One tablet by mouth Twice a day
Disp #*60 Tablet Refills:*0
4. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
5. amLODIPine 10 mg PO DAILY
6. Aspirin 325 mg PO DAILY
7. Diazepam 5 mg PO Q6H:PRN spasm
RX *diazepam 5 mg One tablet by mouth Every 6 (six) hours Disp
#*10 Tablet Refills:*0
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg One tablet(s) by mouth Twice a day
Disp #*60 Tablet Refills:*0
9. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg One capsule(s) by mouth Three times a day
Disp #*90 Capsule Refills:*0
10. Multivitamins 1 TAB PO DAILY
11. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg One-two tablet(s) by mouth Every 4 (four)
hours Disp #*28 Tablet Refills:*0
12. Pravastatin 80 mg PO QPM
13. Tamsulosin 0.4 mg PO QHS
14.Rolling walker
Dx: post-op sciatic nerve irritation
Px: good
___: 13 months
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Acute Diastolic Congestive Heart Failure, Hypoxemia
SECONDARY: Anemia, Lumbar Spondylosis and Stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr ___,
You were admitted to ___ from
___ to ___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were found to have a fever upon arrival to rehab.
- Your oxygen level was quite low in the emergency room,
requiring supplemental oxygen to improve the level.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had blood work and imaging done to look for any signs of
infection causing your fever - we did not find anything that
looked like an infection.
- You had a scan of your chest to look for a blood clot in your
lungs, which can also cause fever - there was no clot.
- You had an ultrasound of your heart to look for any
dysfunction that may have caused fluid to back-up in your lungs
and legs - it showed normal heart function.
- You were given a water pill/diuretic (called furosemide or
Lasix), which caused you to urinate more and get rid of extra
fluid. Your breathing improved with the medication.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Please continue to follow the instructions given after your
prior admission.
- Please take furosemide for 1 week or until you follow up with
your outpatient doctor. You will likely not need to continue on
furosemide long term.
- If you have a scale at home, please weigh your self every
morning after you go to the bathroom and before you get dressed;
if your weight goes up by more than 3 lbs in 1 day or 5 lbs in 3
days, then please call your primary care doctor and take twice
the number of furosemide pills (20 mg total, instead of 10 mg),
until your weight returns back to normal.
- ACTIVITY: DO NOT lift anything greater than 10 lbs for 2
weeks.
___ times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can tolerate.
You will be more comfortable if you do not sit or stand more
than ~45 minutes without changing positions.
- BRACE: You have been given a brace. This brace should be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
- WOUND: Do not soak the incision in a bath or pool until fully
healed. If the incision starts draining at any time after
surgery, cover it with a sterile dressing. Please call the
office.
We wish you the best with your health going forward.
Your ___ Medicine Team
Followup Instructions:
___
|
10854947-DS-9
| 10,854,947 | 23,616,372 |
DS
| 9 |
2178-01-20 00:00:00
|
2178-01-22 11:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with PMH of COPD, anxiety, and alcohol and
benzodiazepine dependence who presents from home with worsening
shortness of breath.
Patient reports that symptoms initially began in ___. She was
evaluated by her PCP, who treated her for bronchitis with
prednisone and azithromycin. Her symptoms improved, but not
completely. She was then admitted to ___ in ___ for
alcohol detox, during which time she developed recurrent
symptoms of shortness of breath, wheezing, and productive cough.
She was treated again with antibiotics and a prednisone burst,
though her PCP quickly discontinued the prednisone so she only
had a 3 day course. She was discharged to the ___,
where she completed a 2 week alcohol detox program, during which
time her respiratory status remained stable. However, for the
past few weeks and particularly last ___ days she has noticed
worsening shortness of breath again, getting significantly worse
over past 4 days. This prompted her to present to her PCP, who
noted her to be hypoxic to 86% on RA for which so she was
referred to the ED. She reports compliance with her medications
at home, including Allegra, Pulmicort, Atrovent, and albuterol
inhalers TID with albuterol nebs Q4H.
In the ED, intial vital signs were 98.2, 80, 151/97, 24, 100% 6
L. Patient had a CXR which was unremarkable. Labs were
remarkable for hyponatremia to 126 which had previously been
noted at ___. Patient received Duonebs x3, Solumedrol 125 mg
IV x1, and azithromycin 500 mg x1. While in the ED, her blood
pressure dropped to SBP in 90's, for which she received 2 L NS
with improvement in her pressures. She also desatted to 81% on 5
L, briefly requiring a ___ mask before being weaned to 6 L NC.
Because of her desat, patient received a dose of Levaquin as
well. Vitals on transfer were 98.5, 89, 123/79, 18, 94% NC.
This morning, patient reports that breathing has improved
slightly but at times she has significant problems with dyspnea
on exertion, for example getting up to go to the bathroom 45
minutes earlier. Breathing comfortably at rest. Before ___,
COPD well-controlled, requiring only rare use of inhalers. She
cannot identify any specific triggers. She denies fever, chills,
weight loss or gain, chest pain, orthopnea, PND, and SOB. She
endorses cough. She denies abdominal pain, nausea, vomiting,
diarrhea, constipation, and new lower extremity swelling.
Past Medical History:
- Hypertension
- Complete heart block s/p pacer
- COPD
- Depression/anxiety
- Benzodiazepine dependence
- Alcohol dependence
Social History:
___
Family History:
No family history of pulmonary disease.
Physical Exam:
ADMISSION EXAM
Vitals: 98.6, 83, 156/86, 18, 92% 4 L
General: Well-appearing female, no distress, full sentences
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
CV: RRR, nl S1/S2, no MRG
Lungs: Crackles to mid-fields, scattered wheezes and rhonchi
Abdomen: Soft, NTND, normoactive bowel sounds
GU: No foley
Ext: Warm, well-perfused, 1+ edema, 2+ pulses
Neuro: CN II-XII intact, motor function grossly normal
Skin: No concerning lesions
DISCHARGE EXAM
Vitals: 97.8, 80, 111/58, 18, 94% 0.5 L
General: Well-appearing female, no distress, full sentences
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: RRR, nl S1/S2, no MRG
Lungs: End-expiratory wheezes and prolonged expiratory phase.
Abdomen: Soft, NTND, normoactive bowel sounds
Ext: Warm, well-perfused, 1+ edema, 2+ pulses
Neuro: CN II-XII intact, motor function grossly normal
Skin: No concerning lesions
Pertinent Results:
ADMISSION LABS
___ 12:40PM BLOOD WBC-4.7 RBC-4.79 Hgb-15.6 Hct-46.9 MCV-98
MCH-32.6* MCHC-33.3 RDW-12.2 Plt ___
___ 12:40PM BLOOD Neuts-63.0 ___ Monos-7.3 Eos-9.4*
Baso-0.9
___ 12:40PM BLOOD Glucose-97 UreaN-8 Creat-0.5 Na-126*
K-4.5 Cl-91* HCO3-26 AnGap-14
___ 12:40PM BLOOD Calcium-9.3 Phos-2.8 Mg-2.1
___ 12:40PM BLOOD TSH-1.0
___ 12:40PM BLOOD Cortsol-9.6
PERTINENT LABS
___ 07:00AM BLOOD Osmolal-273*
___ 07:00AM BLOOD Cortsol-9.3
___ 06:00PM URINE Hours-RANDOM Creat-52 Na-80 K-28 Cl-75
___ 03:23AM URINE Hours-RANDOM Creat-12 Na-37 K-8 Cl-39
___ 06:00PM URINE Osmolal-501
___ 03:23AM URINE Osmolal-167
DISCHARGE LABS
___ 07:00AM BLOOD WBC-4.9 RBC-4.32 Hgb-13.9 Hct-43.1
MCV-100* MCH-32.2* MCHC-32.3 RDW-12.5 Plt ___
___ 07:00AM BLOOD Glucose-80 UreaN-10 Creat-0.5 Na-129*
K-4.0 Cl-94* HCO3-27 AnGap-12
___ 07:00AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.0
MICROBIOLOGY: Admission blood cultures NEGATIVE
IMAGING
CT chest (___): 1. Extensive bilateral lower lobe bronchial
wall thickening and mucoid impaction, suggestive of an
inflammatory or infectious airways disease. Aspiration is a
potential consideration in the setting of a small hiatal hernia.
In the appropriate clinical setting, ABPA is an additional
possibility, but it typically involves more central airways. 2.
Marked upper lobe predominant emphysema. 3. Right adrenal
adenoma.
CXR (___): In comparison with study of ___, there is little
change and no evidence of acute cardiopulmonary disease. No
pneumonia, vascular congestion, or pleural effusion. Single
channel pacer wire again extends to the region of the apex of
the right ventricle.
CXR (___): No acute cardiopulmonary process.
Brief Hospital Course:
___ yo F with PMH of COPD presenting from ___'s office with acute
on chronic shortness of breath.
ACTIVE ISSUES
# Acute on chronic shortness of breath: Patient's symptoms most
consistent with COPD flare. Unclear what is causing patient's
recurrent flares recently, especially since she had previously
been very well controlled on her COPD regimen. She denies any
changes to her environment and has no new exposures. Patient
does have a history of seasonal allergies, but has been taking
Allegra, which has helped her in the past. She was treated with
5 days prednisone, 5 days azithromycin, nebs, and supplemental
oxygen with improvement in her symptoms. However, she continued
to experience intermittent shortness of breath at rest and
significant dyspnea and hypoxia on ambulation. Because of this
there was concern for ILD vs. malignancy, which was especially
concerning in the setting of hyponatremia. CT chest was obtained
which showed no evidence of either of these diagnoses. Patient
continued to improve but was still requiring oxygen on
discharge. Because of this she was sent home with a prescription
for home oxygen to use with physical activity. Patient should
___ with Pulmonology and have PFT's as outpatient.
# Medication-induced SIADH: Hypotonic hyponatremia was noted on
admission labs. Patient reports being told that she was
hyponatremic during her detox admission in ___, attributed to
alcohol and poor solute intake. However, patient has now been
sober for 55 days with normal appetite, so this explanation is
no longer reasonable. She was euvolemic on exam. She does have
several medications which may contribute to hyponatremia,
specifically sertraline and oxcarbazepine. Serum TSH and
cortisol within normal limits. Urine lytes were consistent with
mild SIADH, likely due to one of both of these medications.
Sodium 130 on discharge. Consider switching regimen as
outpatient.
CHRONIC ISSUES
# Hypertension: Patient hypotensive in ED. Normotensive to
hypertensive on floor. Restarted home lisinopril which patient
tolerated well.
# Alcohol abuse: Patient has now been sober for 55 days. She is
currently maintained on Valium, with plan for taper, although
she does not currently have a psychiatrist. Continue Valium 2.5
mg TID.
# Anxiety and depression: Stable at this time. Continued home
regimen.
TRANSITIONAL ISSUES
- Discharged on home oxygen for use with physical activity
- Needs chemistries checked as outpatient. Discharge Na was
stable at 130.
- Consider PFT's as outpatient
- Consider TTE and/or ETT as outpatient
- Consider stopping sertraline and/or oxcarbazepine given SIADH
- Clarify Valium taper. Consider referral to psychiatrist.
- PCP to arrange ___
- PCP to arrange ___ with pulmonologist
- Right adrenal adenoma noted on CT chest. No ___ imaging
recommended.
- Code: Full (confirmed)
- Contact: ___ (husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Pulmicort (budesonide) 0.25 mg/2 mL inhalation BID
3. Sertraline 200 mg PO DAILY
4. Oxcarbazepine 150 mg PO BID
5. Oxcarbazepine 300 mg PO QHS
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Diazepam 2.5 mg PO Q8H
8. HydrOXYzine 25 mg PO Q4H:PRN anxiety
9. Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN wheezing, shortness
of breath
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, shortness of
breath
11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing,
shortness of breath
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing,
shortness of breath
2. Diazepam 2.5 mg PO Q8H
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. HydrOXYzine 25 mg PO Q4H:PRN anxiety
5. Lisinopril 10 mg PO DAILY
6. Oxcarbazepine 150 mg PO BID
7. Oxcarbazepine 300 mg PO QHS
8. Pulmicort (budesonide) 0.25 mg/2 mL inhalation BID
9. Sertraline 200 mg PO DAILY
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, shortness of
breath
11. Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN wheezing,
shortness of breath
12. Home oxygen
Continuous, 1 L through Nasal cannula. Conservation device for
portable.
Diagnosis: COPD
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: COPD exacerbation
Secondary diagnosis: Medication-induced SIADH
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 while you were a patient at
___. You came to us with
shortness of breath which was due to an exacerbation of your
COPD. We treated you with steroids, antibiotics, and nebulizer
treatments which resulted in improvement in your symptoms. We
are discharging you with a prescription for home oxygen which
you can use if you become short of breath when you walk. Please
___ with Dr. ___ discuss a referral to a lung doctor as
an outpatient.
Followup Instructions:
___
|
10855160-DS-8
| 10,855,160 | 27,176,723 |
DS
| 8 |
2152-05-01 00:00:00
|
2152-05-21 14:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ no significant PMH or PSH presents with abdominal pain.
He states the pain first began 3 weeks ago, was sharp and in the
RLQ, and lasted for ___ days. It resolved on its own. The pain
then recurred 48 hours ago and was associated with periumbilical
discomfort. No nausea or vomiting, but he had an episode of
fever with chills today, which prompted his visit to the ED. Had
WBC of 6 in ED with left shift, and CT revealed perforated
appendicitis without drainable collection.
Past Medical History:
Past Medical History: anxiety
Past Surgical History: none
Social History:
___
Family History:
prostate cancer in father
Physical ___:
PHYSICAL EXAMINATION
Temp: 100.2 HR: 93 BP: 151/63 Resp: 17 O(2)Sat: 100 Normal
Constitutional: Uncomfortable appearing
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
Mucous membranes moist
Chest: Clear to auscultation anteriorly
Cardiovascular: Regular Rate and Rhythm
Abdominal: RLQ tenderness, focal rigidity, bowel sounds
present, negative rovsings.
Extr/Back: No ___ edema
Skin: Warm and dry
Neuro: Speech fluent
Psych: Anxious
DISCHARGE PHYSICAL EXAM:
VS: 98.4 PO 123 / 77 52 100
GEN: awake, alert, pleasant and interactive.
CV: RRR
PULM: Clear to auscultation bilaterally.
ABD: Soft, non-tender, non-distended.
EXT: Warm and dry. No edema.
NEURO: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 05:35AM BLOOD WBC-7.3 RBC-3.67* Hgb-11.9* Hct-35.5*
MCV-97 MCH-32.4* MCHC-33.5 RDW-12.1 RDWSD-43.4 Plt ___
___ 06:02AM BLOOD WBC-11.1* RBC-3.60* Hgb-11.9* Hct-34.6*
MCV-96 MCH-33.1* MCHC-34.4 RDW-12.0 RDWSD-41.9 Plt ___
___ 09:45AM BLOOD WBC-12.6* RBC-3.77* Hgb-12.4* Hct-35.8*
MCV-95 MCH-32.9* MCHC-34.6 RDW-12.0 RDWSD-41.5 Plt ___
___ 04:20AM BLOOD WBC-12.6* RBC-3.83* Hgb-12.6* Hct-36.6*
MCV-96 MCH-32.9* MCHC-34.4 RDW-11.9 RDWSD-41.4 Plt ___
___ 01:40PM BLOOD WBC-6.1 RBC-4.17* Hgb-13.6* Hct-39.4*
MCV-95 MCH-32.6* MCHC-34.5 RDW-11.7 RDWSD-40.5 Plt ___
___ 05:35AM BLOOD ___ PTT-26.7 ___
___ 06:02AM BLOOD ___ PTT-27.9 ___
___ 09:45AM BLOOD ___ PTT-27.6 ___
___ 04:20AM BLOOD ___ PTT-26.1 ___
___ 02:47PM BLOOD ___ PTT-24.1* ___
___ 05:35AM BLOOD Glucose-103* UreaN-9 Creat-0.9 Na-143
K-4.3 Cl-104 HCO3-26 AnGap-13
___ 06:02AM BLOOD Glucose-99 UreaN-18 Creat-1.2 Na-142
K-4.2 Cl-104 HCO3-24 AnGap-14
___ 09:45AM BLOOD Glucose-94 UreaN-18 Creat-1.0 Na-142
K-3.6 Cl-105 HCO3-27 AnGap-10
___ 04:20AM BLOOD Glucose-95 UreaN-17 Creat-1.1 Na-140
K-3.5 Cl-102 HCO3-26 AnGap-12
___ 01:40PM BLOOD Glucose-96 UreaN-27* Creat-1.0 Na-140
K-3.9 Cl-99 HCO3-27 AnGap-14
___ 01:40PM BLOOD ALT-21 AST-26 AlkPhos-54 TotBili-0.8
___ 05:35AM BLOOD Calcium-8.8 Phos-2.7 Mg-2.2
___ 06:02AM BLOOD Calcium-8.7 Phos-2.5* Mg-2.0
___ 09:45AM BLOOD Calcium-8.9 Phos-2.5* Mg-2.1
___ 04:20AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.1
___ 2:35 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 4:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
Mr. ___ is a ___ yo M who was admitted to the Acute Care
Surgery Service on ___ with abdominal pain, fevers, and
chills. He had a WBC of 6 with left shift. CT abdomen/pelvis
revealed perforated appendicitis without drainable collection.
He was made NPO, given IV fluids and admitted to the surgical
floor for serial abdominal exams and IV antibiotics.
On HD2 the patient was febrile to 102.8 and antibiotics were
changed from ciprofloxacin and flagyl to ceftriaxone and flagyl.
On HD3 the patients was afebrile and clinical exam greatly
improved and was therefore given a regular diet which he
tolerated well. On HD4 the patient was transitioned to oral
antibiotics with continued good effect.
On HD4 the patient was afebrile with minimal abdominal pain and
a WBC count of 7.3 tolerating a regular diet. He was discharged
to home to complete a course of oral antibiotics. Follow up was
scheduled with the Acute Care Surgery clinic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HydrOXYzine 25 mg PO DAILY:PRN anxiety
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H
end ___.
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*22 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H
end ___
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*33 Tablet Refills:*0
4. HydrOXYzine 25 mg PO DAILY:PRN anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
Perforated appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___
with abdominal pain and fevers and found to have a perforated
appendicitis on CT scan. You were given bowel rest, IV
antibiotics, and IV fluids and your abdominal pain improved. You
were given a regular diet and oral antibiotics and continued to
do well. You are now ready to be discharged to home with the
following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
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2138-11-11 21:21:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Lipitor / Transderm-Nitro
Attending: ___
Chief Complaint:
Nausea/vomitting
Major Surgical or Invasive Procedure:
Cardiac Catheterization with five bare metal stents
History of Present Illness:
___ y.o woman with past medical history significant for CAD, DM
2, HTN, HL, hx of massive PE, multiple recent back surgeries who
presented with nausea and vomiting since the morning. The
patient was in her usual state of health until this morning when
she awoke with abdominal pain. Shortly afterwards, she felt
nauseous and then vomited multiple times. She felt unwell so she
asked her husband to call EMS to take her to the ED. She reports
her husband and son both have "viral illness" and are also
experiencing nausea and vomiting. She did not report any CP or
SOB.
On arrival to the ED, vital signs were T- 96.4, HR- 60, BP-
103/40, R-- 24, SaO2- 98% on RA. She was found to have a lactate
of 5.1 for which she received 4L NS with good response as repeat
lactate was 1.9. EKG demonstrated new TWI, initial troponins
were negative x 2. CTA chest performed for concern of
PE/dissection vs perf esophagus and revealed "no
central/subsegmental PE, no pneumomediastinum, esoph looks ok
with no perf". She was admitted to the medicine floor for rule
out MI and IV hydration. Vital signs on transfer T- 98.7, HR-
113, RR: 24, BP: 149/70, O2Sat: 98% on RA. On arrival to the
floor, vital signs were T- 99.2, BP- 145/82, HR- 117, RR- 20,
SaO2- 97% on RA. Patient felr better and went to sleep. However,
___ third set of CEs was elevated at 0.22 so she was transferred
to the Cardiology service.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, abdominal pain, chest pain. diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- CAD, s/p MI (remote, prior to ___, has a tight ___ RCA which
was medically managed)
- Type II DM on insulin
- Hypertension
- Hyperlipidemia
- Hypothyroidism
- Hx of PE in ___, IVC filter in place
- hyponatremia
- osteoporosis
- allergies
- spinal stenosis
- s/p laminectomy ___
- s/p appendectomy and cholecystectomy
- s/p TAH and oophorectomy
- s/p multiple hernia operations
- s/p B/L total knee replacements
- s/p tonsillectomy
Social History:
___
Family History:
No family history of abnormal clotting. One brother died of an
MI in his early ___. Father died of MI at ___, mother of leukemia
at ___.
Physical Exam:
PHYSICAL EXAM on admission:
VS: T- 99.4, BP 135/74, HR 96, RR 20, 1L O2
GENERAL: NAD, comfortable, appropriate.
HEENT: NC/AT, EOMI, sclerae anicteric, dry mucous membranes, OP
clear.
NECK: no LAD
HEART: RRR, ___ systolic murmur nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: No tenderness to palpation, positive bowel sounds,
soft, non-distended.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
NEURO: Awake, A&Ox3, non-focal.
PHYSICAL EXAM ON DC:
VS: 98.2 ___ 95% RA
HEENT: NC/AT, EOMI, sclerae anicteric, dry mucous membranes, OP
clear.
NECK: no LAD
HEART: RRR, ___ systolic murmur nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: No tenderness to palpation, positive bowel sounds,
soft, non-distended.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
NEURO: Awake, A&Ox3, non-focal.
Pertinent Results:
LABS ON ADMIT:
___ 11:10AM BLOOD WBC-10.9# RBC-4.41 Hgb-11.8* Hct-34.7*
MCV-79* MCH-26.7* MCHC-33.9# RDW-13.3 Plt ___
___ 11:10AM BLOOD Neuts-81.9* Lymphs-13.1* Monos-3.6
Eos-0.7 Baso-0.6
___ 06:34PM BLOOD ___ PTT-31.7 ___
___ 11:10AM BLOOD Glucose-237* UreaN-24* Creat-1.0 Na-137
K-4.3 Cl-103 HCO3-16* AnGap-22*
___ 11:10AM BLOOD ALT-12 AST-18 CK(CPK)-95 AlkPhos-80
TotBili-0.6
___ 11:10AM BLOOD cTropnT-<0.01
___ 05:35PM BLOOD cTropnT-<0.01
___ 02:11AM BLOOD CK-MB-8 cTropnT-0.22*
___ 06:10AM BLOOD CK-MB-11* MB Indx-6.0 cTropnT-0.31*
___ 06:10AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.9
___ 03:29PM BLOOD ___ pO2-47* pCO2-22* pH-7.55*
calTCO2-20* Base XS-0 Intubat-NOT INTUBA
___ 02:45PM BLOOD Lactate-5.1*
___ 04:27PM BLOOD Lactate-4.6*
___ 08:17PM BLOOD Lactate-1.9
LABS ON DC:
___ 07:45AM BLOOD WBC-11.1* RBC-4.38 Hgb-11.6* Hct-34.4*
MCV-79* MCH-26.5* MCHC-33.7 RDW-13.4 Plt ___
___ 11:59AM BLOOD ___ PTT-26.7 ___
___ 07:45AM BLOOD Glucose-218* UreaN-22* Creat-0.8 Na-137
K-3.7 Cl-103 HCO3-25 AnGap-13
___ 07:45AM BLOOD Calcium-9.2 Phos-1.4* Mg-2.1
CT ABD:
1. Diverticulosis in the descending and sigmoid colon without
signs of acute
diverticulitis.
2. Appendix not visualized, though no secondary signs of acute
appendicitis.
3. Interval removal of thoracolumbar spinal hardware since ___.
Unchanged severe degenerative changes of the spine with
persistent
retropulsion of the T12 vertebral body into the spinal canal. No
acute
fracture or malalignment.
4. IVC filter is in standard unchanged position.
CTA:
1. No central or lobar pulmonary embolus. Evaluation of
subsegmental vessels
is difficult due to the small contrast bolus and motion
artifact.
2. Normal aorta without signs of acute aortic syndrome.
3. No confluent consolidation or large pleural effusion.
4. Mild-to-moderate pulmonary edema
5. 4 mm nodule in the right middle lobe. If the patient is a
nonsmoker or
low risk for malignancy, no further followup is necessary.
However, if high
risk for malignancy or a smoker, followup chest CT in 12 months
is recommended
per ___ guidelines.
ECHO:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with hypokinesis of the basal to mid
inferior, inferolateral, and lateral walls. The remaining
segments contract normally (LVEF = 55 %). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
are mildly thickened with mild aortic valve stenosis (valve area
1.5 cm2). Mild (1+) central aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Hypokinesis of the basal to mid inferior,
inferolateral, and lateral walls with overall normal systolic
function. Mild aortic stenosis. Mild aortic regurgitation. Mild
mitral regurgitation. Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
the inferior wall motion abnormality appears new. The suboptimal
image quality on the prior study precludes definitive
conclusions regarding additional differences in wall motion
abnormalities.
CARDIAC CATH:
Findings
ESTIMATED blood loss: <100 cc
Hemodynamics (see above):
Coronary angiography: right dominant
LMCA: No angiographically-apparent CAD.
LAD: Mild luminal irregularities. 10% stenoses and moderate
calcification.
LCX: Origin 50% calcific stenosis. Ostial OM1 70%. OM2 has
mild disease. OM3 has proximal 50% stenosis.
RCA: Diffuse moderate calcification with moderate tortuosity.
Serial 80-90% stenoses into the mid portion. Mid vessel and
distal 50% stenosis into PL and PDA.
Interventional details
Change for 6 ___ AR-1 after AL-0.75 was too long. Crossed
with a ChoICE ___ XS wire into the PL. Predilated with a 2.0 and
then 2.5 mm balloon. The origin and proximal vessel exhibited
stable linear type A dissection. Could not cross with a 2.5 x
26
mm Integriti stent despite placement of two buddy wires
(Whisper,
___ Grafix Intermediate). Deployed a 2.25 x 8 mm Integriti stent
in the ostium at 26 ATM and then was able to deliver a
nonoverlapping 2.25 x 12 mm Integriti stent to the mid RCA. A
more proximal overlapping 2.5 x 15 mm Integriti stent was
deployed and a more proximal overlapping stent connected the
most
proximal ostial stent. All stents were then post-dilated at
high
pressure to 2.5 mm. Ostial uncovered disease was then treated
with a 2.25 x 8 mm Integriti stent and postdilated with a 2.5 mm
balloon. Final angiography revealed normal flow, no dissection,
0% residual stenosis in the stent.
Assessment & Recommendations
1.ASA 81 mg PO QD
2.Warfarin for goal INR 1.5-2.0
3.Plavix (clopidogrel) 75 mg daily X 1 months.
Brief Hospital Course:
HOSPITAL COURSE: ___ y.o woman with past medical history
significant for CAD, DM 2, HTN, HL, multiple recent back
surgeries who presented with nausea and vomiting since the
morning. Transferred to ___ service after Trop elevation.
Underwent cath which showed tight 70% ___ LAD and chronic
calcified RCA which was stented w/ BMS X 5.
ACTIVE ISSUES:
NSTEMI: Pt's CEs were intially normal but then became elevated
at 0.22 and then 0.31. Pt didnt have any CP but did have n/v. Pt
is diabetic so may not have been able to reproduce typical
cardiac sx. Pt also has peaked T-waves and st depressions in
V2-4. Underwent cath which showed tight 70% ___ LAD and chronic
calcified RCA which was stented w/ BMS X 5. She was started on
asa 81, plavix and we continued diltiazem, metoprolol.
# N/V- Patient's symptoms began suddenly on the morning of
presentation with abdominal pain and nausea/vomiting. She
reported multiple episodes of vomiting this AM and then came to
the ED for further eval. The patient had no history of
gastroparesis. She reported that both her husband and son had a
"viral infections" with similar symptoms these days. She denied
fevers, chills, diarrhea, constipation or dysuria. We provided
the pt zofran, maalox and reglan prn. Likely, the patient had a
viral process (?norovirus- less likely given no diarrhea).
Patient felt better and was tolerating PO diet on d/c.
# Lactic acidosis- patient presented with lactate of 5.6 and
HCO3 of 16 on admission. She received 4L NS in the ED with
improvement of her lactate to 1.6. Likely secondary to poor PO
intake and vomiting.
INACTIVE ISSUES:
# DM- patient on long acting insulin at night and humalog
sliding scale during the day. Restarted on home dose.
# Hypertension: we continued lisinopril, metoprolol.
# Hyperlipidemia: we continued ezetimibe, increased simvastatin
to 80.
# Hypothyroidism: we continued levothyroxine 137mcg daily.
# osteoporosis: continue calcium carbonate.
# GERD: continue omeprazole.
Medications on Admission:
1. Alendronate q weekly
2. Diazepam prn
3. Diltiazem 120 mg a day
4. Lexapro
5. Vytorin ___. Insulin- NPH (unknown dose) and humalog
7. Levothyroxine 137mcg daily
8. Lisinopril 10 mg a day,
9. Metoprolol tartrate 25 mg p.o. b.i.d.
10. Omeprazole 20 mg p.o. b.i.d.
11. Oxycodone prn
12. Warfarin 10mg daily
13. Aspirin 81 mg a day
14. Xanax 0.25 mg p.r.n. which the patient takes about twice a
week
15. Trazodone 12.5 mg at night.
Discharge Medications:
1. alendronate Oral
2. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
3. escitalopram 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Vytorin ___ mg Tablet Sig: One (1) Tablet PO once a
day.
5. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen
Subcutaneous
6. Humalog Subcutaneous
7. levothyroxine 137 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. warfarin 5 mg Recon Soln Sig: One (1) Intravenous Once
Daily at 4 ___.
13. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for anxiety.
14. trazodone Oral
15. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
___ MLs PO QID (4 times a day) as needed for nausea/vomitting.
Disp:*12 ML(s)* Refills:*0*
16. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
17. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
Disp:*20 Tablet, Chewable(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Non-ST elevation MI
Viral Gastroenteritis
TYPE 2 DIABETES
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care of you at the ___. You were
admitted with nausea and vomitting. However, there was some
concern that there was some damage to your heart. You underwent
cardiac cath which revealed that you had a blockage in one of
your vessels to the heart which was opened with five bare metal
stents.
NEW MEDICATIONS:
- Plavix: blood thinning medicine - please take for at least one
month after discharge. Do not stop this medication unless your
cardiologist tells you to because otherwise you could get a clot
in your stent and have another heart attack.
- Maalox for nausea/vomitting
- Simethicone for gas/bloating
Medication changes:
** Decrease Warfarin to 5 mg a day and have your INR rechecked
on ___. Your new INR goal is 1.5 to 2.0 (lower now because
you are also on the Plavix).
Followup Instructions:
___
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2142-01-12 23:35:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Lipitor / Transderm-Nitro / Desmopressin
Attending: ___.
Chief Complaint:
flank pain
Major Surgical or Invasive Procedure:
- Nuclear stress test on ___
History of Present Illness:
___ yo F with a past medical history notable for HTN, HLD, DMII,
CAD s/p s/p NSTEMI ___ with BMS x 5 to RCA, spinal surgery,
recurrent DVTs with placement of an IVC filter on warfarin and
hypothyroidism presenting with abdominal pain. She reports a
"band-like" squeezing sensation across her torso (worse in the
flanks and back) which started ___. She states that these
symptoms are similar to her prior MI, but not entirely identical
(confirmed on OMR, patient presented in ___ with n/v and
negative Tn, which turned positive on third set). She called her
PCP who told her to report to the ED. She denies any fevers,
chills, CP, SOB, vomiting and bowel or bladder changes. She has
some nausea but no vomiting.
In the ED, initial vitals were: 98.0 64 ___ 94% RA
- Exam was notable for crackles over the left lung fields,
systolic murmur, minimal tenderness to palpation over the
epigastric, RUQ and LUQ, patient guaiac negative
- Labs were significant for Na 131, K 5.3, Cl 95, HCO3 26, BUN
35, Cr 1.1, glucose 172, Tn 0.08, lactate 1.3, WBC 8.4, H/H
9.6/28.9, plt 192, INR 7.7, ALT 15, AST 32, AP 52, Tbili 0.2,
alb 3.4 and lipase 14. UA was largely unremarkable.
- Imaging revealed CXR with mild interstitial pulmonary edema,
stable elevation of the left hemidiaphragm
- The patient was given oxycodone
Vitals prior to transfer were: 98.7 67 137/54 16 96% RA
Upon arrival to the floor, the patient reports severe back and
flank pain. She states that she needs her chronic pain
medications. She denies CP, palpitations and current N/V. She
has experienced several episodes of SOB during the last week.
Past Medical History:
- Coronary disease s/p NSTEMI ___ with BMS x 5 to RCA,
pharmacologic stress testing which showed no ischemia on nuclear
imaging on ___
- Type II DM on insulin
- Hypertension
- Hyperlipidemia
- Hypothyroidism
- Hx of PE in ___, IVC filter in place
- hyponatremia
- osteoporosis
- allergies
- spinal stenosis
- s/p laminectomy ___
- s/p appendectomy and cholecystectomy
- s/p TAH and oophorectomy
- s/p multiple hernia operations
- s/p B/L total knee replacements
- s/p tonsillectomy
- s/p anterior and posterior colporrhaphy, cystoscopy
- Hx of MRSA in spinal hardware which was removed
Social History:
___
Family History:
No family history of abnormal clotting. One brother died of an
MI in his early ___. Father died of MI at ___, mother of leukemia
at ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===================
Vitals: 99.3 135/53 71 21 99% on RA
General: obese, moderately kyphotic elderly female in mild
amount of pain
HEENT: PERRL, nose clear, OP w/o lesions
NECK: supple, no JVD or HJR
Heart: RRR, S1/S2 normal, no R/G, ___ systolic murmur with
radiation to the carotids
Lungs: scattered crackles (non-dependent)
Abdomen: +BS, S/NT/ND
Genitourinary: deferred
Extremities: warm, no edema
Neurological: AAOx3
DISCHARGE PHYSICAL EXAM:
====================
Vitals - Tm 98.7, Tc 98.2, HR 65 (62-79), BP 145/61
(101-145/53-75), RR 18, O2 Sat 90-97%RA
Wt 85.7 today, ___ yesterday, standing weights
I/O -
Today PO: 0 mL, UOP: 800 mL - net -800 mL
Yesterday PO: 1540 mL, IV: 160 mL UOP: 1650 mL - net +50 mL
General - appears comfortable, laying in bed
HEENT - PERRL, EOMI, sclerae anicteric, dry MM, JVD 2 cm above
the clavicle at 30 degrees
Cardiac - regular rate, normal S1/S2 with crescendo-decrescendo
murmur (grade III) loudest at the RUSB radiating to the
carotids, holosystolic murmur over mitral area
Pulmonary - clear lungs posteriorly
Abdomen - soft, non-tender, non-distended, normal bowel sounds
Extremities - warm, well perfused, no edema
Pertinent Results:
==== ADMISSION LABS ====
___ 06:54PM ___ PTT-56.9* ___
___ 06:54PM PLT COUNT-192
___ 06:54PM NEUTS-55.4 ___ MONOS-6.9 EOS-5.6*
BASOS-0.5
___ 06:54PM WBC-8.4 RBC-3.51* HGB-9.6* HCT-28.9* MCV-82
MCH-27.3 MCHC-33.3 RDW-13.8
___ 06:54PM calTIBC-309 FERRITIN-66 TRF-238
___ 06:54PM ALBUMIN-3.4* IRON-25*
___ 06:54PM cTropnT-0.08* proBNP-2216*
___ 06:54PM LIPASE-14
___ 06:54PM ALT(SGPT)-15 AST(SGOT)-32 ALK PHOS-52 TOT
BILI-0.2
___ 06:54PM estGFR-Using this
___ 06:54PM GLUCOSE-172* UREA N-35* CREAT-1.1 SODIUM-131*
POTASSIUM-6.0* CHLORIDE-95* TOTAL CO2-26 ANION GAP-16
___ 07:05PM LACTATE-1.3 K+-5.3*
___ 07:05PM LACTATE-1.3 K+-5.3*
___ 07:05PM ___ COMMENTS-GREEN TOP
___ 08:45PM URINE MUCOUS-RARE
___ 08:45PM URINE RBC-1 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-3 TRANS EPI-<1
___ 08:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
___ 08:45PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:45PM URINE GR HOLD-HOLD
___ 08:45PM URINE UHOLD-HOLD
___ 08:45PM URINE HOURS-RANDOM
==== DISCHARGE LABS ====
___ 04:55AM BLOOD WBC-7.9 RBC-3.49* Hgb-9.3* Hct-29.0*
MCV-83 MCH-26.7* MCHC-32.2 RDW-13.4 Plt ___
___ 04:55AM BLOOD ___ PTT-75.3* ___
___ 04:55AM BLOOD Glucose-177* UreaN-36* Creat-1.1 Na-137
K-4.1 Cl-96 HCO3-32 AnGap-13
___ 04:55AM BLOOD Calcium-9.5 Phos-3.5 Mg-1.8
==== INTERIM LABS OF NOTE ====
___ 06:54PM BLOOD cTropnT-0.08* proBNP-2216*
___ 01:07AM BLOOD CK-MB-5 cTropnT-0.07*
___ 06:40AM BLOOD CK-MB-4 cTropnT-0.09*
___ 01:00PM BLOOD cTropnT-0.12*
___ 05:25AM BLOOD CK-MB-2 cTropnT-0.12*
___ 01:00PM BLOOD CK-MB-3 cTropnT-0.11*
==== MICROBIOLOGY ====
___ URINE CULTURE: Negative
==== IMAGING ====
___ ECG:
Sinus rhythm. Right bundle-branch block with left anterior
fascicular block. Left ventricular hypertrophy.
___ CXR (PA AND LAT):
Mild interstitial pulmonary edema. Stable elevation of the left
hemidiaphragm.
___ ECG:
Sinus rhythm. Right bundle-branch block with left anterior
fascicular block. Left ventricular hypertrophy. No major change
from the previous tracing.
___ CARDIAC PERFUSION PHARM:
IMPRESSION: Normal cardiac perfusion and wall motion with an
ejection fraction of 62%.
___ STRESS:
IMPRESSION: Atypical symptoms with ischemic ST segment changes
noted post-infusion (see above). Appropriate hemodynamic
response to the Persantine infusion. Nuclear report sent
separately.
___ CXR (PA AND LAT):
Lung volumes are chronically very low, and subsegmental
atelectasis is a feature of the left lower lung. There is more
vascularity, background interstitial pulmonary abnormality, and
bronchial cuffing on the 3 radiographs in ___,
___, and today, than there was in ___. Heart size is
borderline enlarged, but not recently so. Therefore is
difficult to distinguish between a mild generalized interstitial
lung disease and early recurrent congestive heart failure. There
is no appreciable pleural effusion. Lateral view shows chronic
gibbus deformity in the thoracolumbar spine at the
site of moderate and severe compression fractures, not
appreciably changed since ___.
Brief Hospital Course:
___ yo F with a past medical history notable for HTN, HLD, DMII,
CAD s/p s/p NSTEMI ___ with BMS x 5 to RCA, spinal surgery,
recurrent DVTs with placement of an IVC filter on warfarin and
hypothyroidism presenting with bilateral flank pain/nausea and +
troponin and a 2 pt drop in hemoglobin.
ACTIVE ISSUES:
=============
#FLANK PAIN:
Patient presenting with new intermittent bilateral flank pain,
which appears somewhat exertional, and possibly similar to her
prior anginal equivalent, however normal stress test discussed
below. Of note, her Hb of 9.3, down from 11.2, two weeks prior
to admission, raising initial concern for RP bleed, however hgb
subsequently stable throughout admission and VS remained stable.
Would consider CT for RP bleed if unstable VS in the future or
further dropping hgb. Patient also with chronic pain, possibly
related to pain syndrome as a diagnosis of exclusion.
#NSTEMI/CAD s/p PCI:
Patient's presentation of flank pain and nausea was concerning
for possible anginal equivalent, given similar prior
presentations with NSTEMI and elevated troponins this admission
withpseudonormalization of T waves in the inferior leads. She
was medically managed and underwent a nuclear stress test.
During infusion of the persantine, patient had some nausea which
resolved with reversal agent, and a few minutes later with ST
depression EKG changes, however nuclear images were without
defects. Symptoms felt most likely related to persantine,
however possible ischemia from infusion as well. Given nuclear
images clear, will continue with medical management, with ASA,
BB, CCB, statin, SLN, and follow up as outpatient with
consideration of increasing anti-anginal medication if symptoms
recur or worsen.
#POSSIBLE HEART FAILURE:
On admission, patient noted to have pulmonary edema on CXR,
though exam was not concerning for volume overload. BNP was
elevated at 2216, and noted to desat to low ___ on RA, so was
diuresed with one time dose of 40mg IV lasix with good effect.
#ANEMIA:
Labs with 2 point drop in hgb over 2 weeks prior to admission.
Given her flank pain and drop in hematocrit, initial suspicion
for retroperitoneal bleed. Patient remained stable throughout
admission, but would recommend continued monitoring in case of
occult bleeding given flank pain. Iron studies this admission
were normal.
#H/O DVT: S/p IVC filter.
Patient noted to have supratherapeutic INR to 7, coumadin held
and subsequently started on heparin drip once INR subtherapeutic
for above nuclear stress test. On discharge, patient started on
rivaroxaban for anticoagulation in the setting of recurrent
DVT/PE, as patient's INR noted to be very labile on warfarin.
CHRONIC ISSUES:
==============
#DMII: Glucose on initial labs 172. Patient takes low dose NPH
twice daily and a Humalog SS, continued this admission.
#HYPERLIPIDEMIA: Continued crestor 5 mg daily.
#HYPERTENSION: Continued home metoprolol, lisinopril, and
amlodipine.
#DEPRESSION/ANXIETY: Stable. Continued lexapro and diazepam.
#CHRONIC PAIN: Secondary to prior spinal surgeries. Continued
home fentanyl patch 25 mcg, oxycontin, oxycodone, and
gabapentin.
#GERD: Stable. Continued omeprazole.
#HYPOTHYROIDISM: No signs of hypo/hyperthyroidism. Continued
levothyroxine.
#CONSTIPATION: Stable.
TRANSITIONAL ISSUES:
=========================
# Patient started on rivaroxaban for history of recurrent
DVT/PEs.
# Follow up with Dr. ___ as outpatient to continue monitoring
symptoms.
# CODE STATUS: Full
# CONTACT: husband ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
2. Loratadine 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Rosuvastatin Calcium 5 mg PO QPM
5. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal twice a week
6. Fluticasone Propionate NASAL 1 SPRY NU PRN allergies
7. NPH 4 Units Breakfast
NPH 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Escitalopram Oxalate 20 mg PO DAILY
9. OxyCODONE SR (OxyconTIN) 20 mg PO BID:PRN pain
10. Diazepam 2 mg PO QHS:PRN anxiety
11. Warfarin 10 mg PO DAILY16
12. Ezetimibe 10 mg PO DAILY
13. Amlodipine 5 mg PO DAILY
14. Aspirin 81 mg PO DAILY
15. BuPROPion (Sustained Release) 100 mg PO QAM
16. Vitamin D ___ UNIT PO DAILY
17. Fentanyl Patch 25 mcg/h TD Q72H
18. Ferrous Sulfate 325 mg PO DAILY
19. Gabapentin 300 mg PO BID
20. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
21. Levothyroxine Sodium 175 mcg PO DAILY
22. Lisinopril 20 mg PO DAILY
23. Metoprolol Tartrate 25 mg PO BID
24. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
25. Omeprazole 20 mg PO BID
26. OxycoDONE (Immediate Release) ___ mg PO Q8H:PRN pain
27. Gabapentin 900 mg PO QHS
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. BuPROPion (Sustained Release) 100 mg PO QAM
4. Diazepam 2 mg PO QHS:PRN anxiety
5. Docusate Sodium 100 mg PO BID
6. Escitalopram Oxalate 20 mg PO DAILY
7. Ezetimibe 10 mg PO DAILY
8. Fentanyl Patch 25 mcg/h TD Q72H
9. Ferrous Sulfate 325 mg PO DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU PRN allergies
11. Gabapentin 300 mg PO BID
12. Gabapentin 900 mg PO QHS
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. Levothyroxine Sodium 175 mcg PO DAILY
15. Lisinopril 20 mg PO DAILY
16. Loratadine 10 mg PO DAILY
17. Metoprolol Tartrate 25 mg PO BID
18. Omeprazole 20 mg PO BID
19. OxycoDONE (Immediate Release) ___ mg PO Q8H:PRN pain
20. OxyCODONE SR (OxyconTIN) 20 mg PO BID:PRN pain
21. Rosuvastatin Calcium 5 mg PO QPM
22. Vitamin D ___ UNIT PO DAILY
23. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
24. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal twice a
week
25. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
26. Rivaroxaban 15 mg PO DAILY
This is a new medication to prevent recurrent blood clots.
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
27. NPH 4 Units Breakfast
NPH 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Angina
- Coronary artery disease
Secondary Diagnoses:
- Type II Diabetes Mellitus
- Hypertension
- Hyperlipidemia
- History of pulmonary embolism/deep venous thromboses
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your recent hospital
stay at the ___. You came in
with bilateral back and side pain and nausea. Becuase of your
cardiac history, there was some concern this might be related to
your heart disease, so you had a procedure to evaluate your
heart vessels called a stress test and this was negative for
evidence of worsening disease. We are medically treating your
coronary artery disease, as we were concerned your back/flank
pain is related to your heart disease and your labs showed some
evidence of injury to the heart. There was also some evidence of
heart failure based on your labs, and we gave you a medication
to help remove fluid from the body to help your heart failure.
Your coumadin levels were noted to be high when you arrived, and
this can cause problems with bleeding. Given your history with
difficulty controlling your blood thinner levels on coumadin,
your warfarin was stopped and you were started on a new blood
thinner medication called rivaroxaban to help prevent blood
clots.
Your medication list, including your new medications, is listed
below for you. Your future medical appointments are also listed
below for you. It is important that you take all of your
medications as prescribed and attend your follow up
appointments.
We wish you the best with your health.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
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DS
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2144-02-29 15:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Lipitor / Transderm-Nitro / Desmopressin
Attending: ___.
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
Left femur intramedullary nail ___ ___
Cardiac catheterization (___)
History of Present Illness:
___ female On Xarelto with PMHx CAD, MI, PE, DM2, MGUS
presents to ___ ED after a mechanical fall down stairs. She
was walking down her steps when she tripped on the bottom two
stairs landing on her left hip. Immediate pain, inability to
bear weight. Called ambulance which brought her to ___ ED.
Unknown HS or LOC. Denies numbness or tingling distally in the
LLE. Denies any antecedent pain.
Past Medical History:
- Coronary disease s/p NSTEMI ___ with BMS x 5 to RCA,
pharmacologic stress testing which showed no ischemia on nuclear
imaging on ___
- severe aortic stenosis
- Type II DM on insulin
- Hypertension
- Hyperlipidemia
- Hypothyroidism
- Hx of PE in ___, IVC filter in place
- hyponatremia
- osteoporosis
- allergies
- spinal stenosis
- s/p laminectomy ___
- s/p appendectomy and cholecystectomy
- s/p TAH and oophorectomy
- s/p multiple hernia operations
- s/p B/L total knee replacements
- s/p tonsillectomy
- s/p anterior and posterior colporrhaphy, cystoscopy
- Hx of MRSA in spinal hardware which was removed
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM
==============
Left lower extremity:
Incisional dressing clean, dry, and intact
Sensation intact to light touch
Fires TA, ___, ___, EDL/FDL
DP 2+
DISCHARGE EXAM
==============
- VITALS: T 98.5, BP 135-148/69-78, HR 69-74, RR 18, SpO2 93/RA
- I/Os: (8hrs) -/1000 (-1000), (24hrs) 1260/1750 (-490)
- WEIGHT: not weighed since admission (immobile)
- WEIGHT ON ADMISSION: 86.0 kg
- TELEMETRY: sinus rhythm, rates ___
GENERAL: well-appearing, NAD. Lying propped up in bed.
NECK: Supple, no JVP appreciated.
CARDIAC: RRR, S1+S2, III/VII SEM heard throughout with radiation
to carotids.
LUNGS: cannot move to facilitate posterior auscultation; CTAB
anteriorly and laterally.
ABDOMEN: non-distended, soft, non-tender
EXTREMITIES: WWP, no edema. L proximal femur incision C/D/I; no
surrounding erythema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS
==============
___ 01:44PM RET AUT-1.4 ABS RET-0.06
___ 01:44PM PLT COUNT-157
___ 01:44PM NEUTS-64.5 ___ MONOS-9.1 EOS-1.8
BASOS-1.0 IM ___ AbsNeut-4.66# AbsLymp-1.68 AbsMono-0.66
AbsEos-0.13 AbsBaso-0.07
___ 01:44PM WBC-7.2 RBC-4.30 HGB-11.1* HCT-36.4 MCV-85
MCH-25.8* MCHC-30.5* RDW-13.5 RDWSD-41.7
___ 01:44PM PEP-ABNORMAL B Free K-52.5* Free L-28.3* Fr
K/L-1.9* IgG-1212 IgA-157 IgM-119
___ 01:44PM calTIBC-397 FERRITIN-22 TRF-305
___ 01:44PM TOT PROT-7.1 ALBUMIN-3.9 GLOBULIN-3.2
CALCIUM-9.4 IRON-83
___ 01:44PM ALT(SGPT)-8 AST(SGOT)-10 ALK PHOS-47
___ 01:44PM UREA N-21* CREAT-1.0
___ 01:44PM GLUCOSE-251* UREA N-21* CREAT-0.9 SODIUM-137
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-25 ANION GAP-17
___ 02:43PM URINE U-PEP-NO PROTEIN
___ 02:43PM URINE HOURS-RANDOM CREAT-124 TOT PROT-13
PROT/CREA-0.1
___ 09:22PM ___ PTT-28.3 ___
___ 09:22PM PLT COUNT-137*
___ 09:22PM NEUTS-68.1 ___ MONOS-9.1 EOS-1.4
BASOS-0.7 IM ___ AbsNeut-7.04*# AbsLymp-2.08 AbsMono-0.94*
AbsEos-0.14 AbsBaso-0.07
___ 09:22PM WBC-10.3* RBC-4.08 HGB-10.8* HCT-34.9 MCV-86
MCH-26.5 MCHC-30.9* RDW-13.2 RDWSD-41.1
___ 09:22PM cTropnT-<0.01
___ 03:58PM PLT COUNT-124*
___ 03:58PM WBC-11.9* RBC-3.54* HGB-9.2* HCT-30.3* MCV-86
MCH-26.0 MCHC-30.4* RDW-13.3 RDWSD-42.1
IMAGING/STUDIES
===============
___ Imaging CT HEAD W/O CONTRAST
No acute intracranial process.
___-SPINE W/O CONTRAST
Degenerative changes without fracture or acute malalignment.
___ Imaging FOREARM (AP & LAT) LEFT
No fracture.
___ Imaging CHEST (SINGLE VIEW)
1. No significant interval change.
2. Persistent left lung atelectasis with left diaphragm
eventration.
3. Persistence of prominent pulmonary vasculature with moderate
cardiomegaly but no frank pulmonary edema.
___ Imaging WRIST(3 + VIEWS) RIGHT
No fracture identified.
___ Imaging HIP UNILAT MIN 2 VIEWS
Images obtained for surgical purposes.
___ Cardiovascular ECHO
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild regional left ventricular systolic dysfunction with severe
hypokinesis of the basal halves of the inferior and
inferolateral walls. The remaining segments contract normally
(LVEF = 40 %). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic arch is mildly dilated. The aortic valve leaflets are
moderately thickened. There is severe aortic valve stenosis
(valve area <1.0cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild to moderate (___) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Severe aortic valve stenosis. Mild symmetric left
ventricular hypertrophy with regional systolic dysfunction most
c/w CAD (PDA distribution). Mild-moderate mitral regurgitation
most likely due to papillary muscle dysfunction. Mild pulmonary
artery systolic hypertension. Mildly dilated aortic arch.
Compared with the prior study (images reviewed) of ___,
regional left ventricular systolic dysfunction is now present
and the calculated aortic valve area is now smaller/more severe
stenosis. Mild-moderate mitral regurgitation is also now seen.
CLINICAL IMPLICATIONS:
The patient has severe aortic valve stenosis. Based on ___
ACC/AHA Valvular Heart Disease Guidelines, if the patient is
asymptomatic, it is reasonable to consider an exercise stress
test to confirm symptom status. In addition, a follow-up study
is suggested in ___ months. If they are symptomatic (angina,
syncope, CHF) and a surgical or TAVI candidate, a mechanical
intervention is recommended.
___ Cardiovascular Cath Physician ___
___: Right
* Left Main Coronary Artery
The LMCA is 40% distal stenosis.
* Left Anterior Descending
The LAD is mildly diseased.
* Circumflex
The Circumflex is 60% proximal.
The ___ Marginal is ostial 60%.
* Right Coronary Artery
The RCA is occluded.
Impressions:
2v CAD including occluded RCA.
Recommendations
CABG/AVR versus TAVR/PCI evaluation.
Risk factor modification.
DISCHARGE LABS
==============
___ 05:45AM BLOOD WBC-9.4 RBC-3.57* Hgb-9.7* Hct-30.6*
MCV-86 MCH-27.2 MCHC-31.7* RDW-14.2 RDWSD-43.2 Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD PTT-26.6
___ 05:45AM BLOOD Glucose-196* UreaN-16 Creat-0.6 Na-134
K-4.9 Cl-99 HCO3-26 AnGap-14
___ 05:45AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.8
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 subtrochanteric femur fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for Left femur IMN (___), which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate.
On POD2, patient sustained an NSTEMI and the Cardiology service
was consulted. Patient's Xarelto was discontinued the following
morning and she was started on IV heparin. The Internal Medicine
service was re-consulted and transfer of care was initiated to
the cardiology service.
___ with CAD s/p NSTEMI ___, with BMX x 5 to RCA), HTN, HLD,
DM2 who was admitted to the orthopedic surgery service initially
for a femur fracture, s/p IMN on ___, who was transferred to
the cardiology service for NSTEMI.
#NSTEMI:
#CORONARY ARTERY DISEASE: history of NSTEMI with 5 BMS to RCA in
___ other disease noted at the time. Was previously on triple
therapy; de-escalated to aspirin and rivaroxaban in ___. Last
stress test in ___ was negative. Developed chest pain POD #3
___epressions diffusely. TTE on ___ showing regional
left ventricular systolic dysfunction (new) and mild-moderate
mitral regurgitation, likely due to papillary muscle
dysfunction. She was started on a heparin gtt, rosuvastatin was
increased to 20mg daily before being transferred to the
cardiology service. s/p coronary angiogram on ___, which
showed 3 vessel disease. Recommended PCI/TAVR vs CABG/AVR. Both
cardiac surgery and structural heart team saw the patient, they
will see patient as outpatient to evaluate for TAVR vs SAVR. Pt
is fairly clear that she would not want an open procedure.
Continued aspirin 81mg daily, metoprolol tartrate 25mg BID,
rivaroxaban 15mg daily (though she was briefly transitioned to a
heparin gtt in the setting of ACS). Increased rosuvastatin dose
to 20mg daily.
#ANEMIA: present on admission; had been downtrending since
surgery. No e/o active bleeding, but downtrending H/H was likely
due to equilibration following operative blood loss. s/p 1U pRBC
on ___ and 1U on ___ with stabilization of H/H.
#SEVERE AORTIC STENOSIS: history of aortic stenosis, now noted
to be severe with valve area < 1 cm2. This is worse than prior.
___ be contributing to angina, but there is also a known
coronary source, given new regional WMA and 3 vessel disease
noted on angiogram. Seen by structural heart team and cardiac
surgery team while admitted and being evaluated for TAVR vs.
SAVR. Will follow-up with cardiac surgery and structural heart
team as an outpatient.
#HYPERTENSION: on amlodipine and metoprolol at home. Was
previously on lisinopril. Continued amlodipine 5mg daily,
metoprolol tartrate 25mg BID.
#DIABETES: Continued NPH and Humalog sliding scale.
#h/o PE: on rivaroxaban at home. Stopped rivaroxaban in favor of
heparin gtt during NSTEMI. Transitioned back to rivaroxaban 15mg
daily (and d/c'ed heparin gtt) prior to discharge.
#HYPERLIPIDEMA: Continued increased rosuvastatin dose of 20mg
daily, as above.
#DEPRESSION/ANXIETY: Continued BuPROPion (Sustained Release) 100
mg PO QAM, Escitalopram Oxalate 20 mg PO/NG QPM, Diazepam 2 mg
QHS:PRN insomnia.
TRANSITIONAL ISSUES
===================
[ ] pt will follow-up with structural heart (TAVR) team and
cardiac surgery team on outpatient basis for evaluation of TAVR
vs. SAVR
[ ] Cardiac cath with 3vd but no plans for revascularization.
Plan for AVR and reassessment of symptoms, per discussion with
primary cardiologist.
[ ] anticoagulated/antiplatelet treatment with rivaroxaban and
aspirin, given history of PE and CAD
[ ] should have CBC checked at rehab on ___ to ensure
stability
Code: DNAR/DNI (DO NOT attempt resuscitation, DO NOT intubate)
Contact: ___ (husband) ___
Disposition: ___ Rehab
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 spontaneously. The patient is WBAT in the
Left lower extremity, and will be discharged/continued on home
Rivaroxaban 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. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. BuPROPion (Sustained Release) 100 mg PO QAM
4. Diazepam 2 mg PO QHS:PRN INSOMNIA
5. Docusate Sodium 100 mg PO BID
6. Escitalopram Oxalate 20 mg PO QHS
7. Ezetimibe 10 mg PO DAILY
8. Fentanyl Patch 25 mcg/h TD Q72H
9. Ferrous GLUCONATE 324 mg PO DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN ALLERGIES
11. Gabapentin 300 mg PO BID
12. Gabapentin 600 mg PO QHS
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. Levothyroxine Sodium 175 mcg PO DAILY
15. Loratadine 10 mg PO DAILY
16. Metoprolol Tartrate 25 mg PO BID
17. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN CHEST PAIN
18. Omeprazole 20 mg PO BID
19. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN PAIN
20. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
21. Rivaroxaban 15 mg PO DAILY
22. Rosuvastatin Calcium 5 mg PO QPM
23. Senna 8.6 mg PO HS
24. Clindamycin 300 mg PO BID
25. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
26. econazole 1 % topical BID
27. estradiol 0.01 % (0.1 mg/gram) vaginal 2X/WEEK
28. NPH 5 Units Breakfast
NPH 7 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
29. nystatin 100,000 unit/gram topical BID
30. wheat dextrin 3 gram/3.5 gram oral DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
Take for baseline pain control. Use Oxycodone for pain not
relieved by Acetaminophen.
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours as
needed Disp #*100 Tablet Refills:*1
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
Use daily as needed for constipation not relieved by Senna and
Colace.
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily as needed Disp
#*20 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
This is a new medication to prevent post-operative constipation.
Hold for diarrhea or loose stools.
RX *docusate sodium 100 mg 2 capsule(s) by mouth twice daily
Disp #*80 Capsule Refills:*0
4. Milk of Magnesia 30 mL PO Q6H:PRN constipation
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Don't take before driving, operating machinery, or with alcohol.
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed
Disp #*40 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 8.6 mg PO BID
This is a new medication to prevent post-operative constipation.
Hold for diarrhea or loose stools.
RX *sennosides [senna] 8.6 mg 2 tablets by mouth every evening
Disp #*40 Tablet Refills:*0
8. amLODIPine 5 mg PO DAILY
9. Aspirin EC 81 mg PO DAILY
10. BuPROPion (Sustained Release) 100 mg PO QAM
11. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
12. Diazepam 2 mg PO QHS:PRN INSOMNIA
RX *diazepam 2 mg One tablet by mouth At bedtime Disp #*10
Tablet Refills:*0
13. econazole 1 % topical BID
14. Escitalopram Oxalate 20 mg PO QPM
15. estradiol 0.01 % (0.1 mg/gram) vaginal 2X/WEEK
16. Ezetimibe 10 mg PO DAILY
17. Fentanyl Patch 25 mcg/h TD Q72H
RX *fentanyl 25 mcg/hour Apply to clean skin Once every 72 hours
Disp #*5 Patch Refills:*0
18. Ferrous GLUCONATE 324 mg PO DAILY
19. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN seasonal
allergies
20. Gabapentin 300 mg PO QAM
21. Gabapentin 300 mg PO QPM
22. Gabapentin 600 mg PO QHS
23. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
24. Levothyroxine Sodium 175 mcg PO DAILY
25. Loratadine 10 mg PO DAILY
26. Metoprolol Tartrate 25 mg PO BID
27. Nitroglycerin SL 0.4 mg SL DAILY:PRN angina
28. nystatin 100,000 unit/gram topical BID
29. Omeprazole 20 mg PO BID
30. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone 20 mg One tablet(s) by mouth Once every 12 hours
Disp #*20 Tablet Refills:*0
31. Rivaroxaban 15 mg PO DAILY
32. Rosuvastatin Calcium 20 mg PO QPM
33. wheat dextrin 3 gram/3.5 gram oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left subtrochanteric femur fracture
Non-ST elevation myocardial infarcation
Severe aortic stenosis
Anemia
Hypertension
Diabetes
history of pulmonary embolism, s/p IVC filter
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:
INSTRUCTIONS FROM CARDIOLOGY:
WHY WERE YOU ON THE CARDIOLOGY SERVICE?
You had a heart attack after your leg surgery.
WHAT HAPPENED WHILE YOU WERE ON THE CARDIOLOGY SERVICE?
- You had an ultrasound of your heart (echocardiogram), which
showed a very narrow/tightened heart valve (aortic valve).
- You had a cardiac catheterization, which showed 3 narrowed
blood vessels around your heart.
- We feel that your chest pain was most likely related to the
tightened aortic valve, and not directly because of blockages in
your coronary arteries and therefore we did not do any stenting
procedure.
- You were seen by our cardiac surgery and interventional
cardiology teams. They will continue evaluating you for aortic
valve replacement as an outpatient.
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
- Continue to take all of your medicines as prescribed.
- Go through ___ rehab for your leg.
- You will see the cardiac surgeons in the office after you
complete rehab.
INSTRUCTIONS FROM ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weightbearing as tolerated/full weightbearing
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please continue your home Xarelto (Rivaroxaban) to prevent
blood clots.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Followup Instructions:
___
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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:
s/p assault
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of diabetes and HTN, s/p assault last
night, patient states that he was "punched in face" last night
when he was ___ out of bar, + LOC for unclear period of time,
went home and was brought to ___ friends for
further work up. Reportedly he was alert and oriented,had GCS of
15 on presentation at OSH. His trauma work up including head CT
revealed SAH on R including basal cissterns and 2 mm SDH w/o
mass
effect. No C spine was obtained. He had a small R eye laceration
which was sutures at OSH. He remained neurologically intact and
was transferred to ___ for further workup and management.
In ED he remained alert and oriented with GCS of 15, HDS, with
no
SOB or chest pain. He does complain of mild R orbital pain but
it
does not get worse with eye movements and he denies double
vision. He also denies nausea/ vomiting and photophobia.
Denies pain anywhere else.
Past Medical History:
PMH: HTN,DM, HLD, syncope/cardiac arrhythmia-pt cannot recall
what type
PSH: pacemaker placement
Social History:
___
Family History:
non contributory
Physical Exam:
Physical Exam:
Vitals: T 98.5HR 79, BP 163/87, RR 18, sat 94%/RA
GEN: A&Ox3, appears comfortable
HEENT: ecchymosis of R orbit, EOMI, no active bleeding or
laceration, PERRL, no cervical spine tenderness on palpation,
trachea is midline, no neck hematoma or penetrating injuries
CV: Regular/paced
PULM: Clear to auscultation b/l, No labored breathing, no chest
tenderness or signs of traumatic injuries, no spine tenderness
ABD: Soft, nondistended, nontender, no rebound or guarding, no
traumatic injuries
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 98.2, 69, 120/74, 18, 95%ra
GEN: A&Ox3, appears comfortable
HEENT: ecchymosis of R orbit, EOMI, no active bleeding or
laceration, PERRL, no cervical spine tenderness on palpation,
trachea is midline, no neck hematoma or penetrating injuries
CV: Regular/paced
PULM: Clear to auscultation b/l, No labored breathing, no chest
tenderness or signs of traumatic injuries, no spine tenderness
ABD: Soft, nondistended, nontender, no rebound or guarding, no
traumatic injuries
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 05:10AM BLOOD WBC-9.6 RBC-3.98* Hgb-12.5* Hct-37.0*
MCV-93 MCH-31.4 MCHC-33.8 RDW-13.3 RDWSD-45.1 Plt ___
___ 06:42AM BLOOD WBC-11.8* RBC-3.96* Hgb-12.2* Hct-36.1*
MCV-91 MCH-30.8 MCHC-33.8 RDW-13.1 RDWSD-42.6 Plt ___
___ 05:10AM BLOOD Glucose-121* UreaN-16 Creat-1.1 Na-140
K-4.0 Cl-104 HCO3-25 AnGap-15
___ 06:42AM BLOOD Glucose-81 UreaN-22* Creat-1.1 Na-137
K-4.5 Cl-100 HCO3-20* AnGap-22*
Imaging:
___ CT head w/o contrast from OSH: SAH on R including basal
cissterns,2 mmm R frontal SDH w/o mass effect, left scalp
hematoma
CT max/facefrom OSH: blowout fracture of medial wall of R orbit,
nasal fractures.
CT C spine at ___:
Faint lucent line involving the left lamina of C6, extending to
the articular facet, may represent a tiny questionable
nondisplaced fracture. No traumatic malalignment or critical
spinal canal narrowing.
CXR: No acute sequelae of trauma. No acute cardiopulmonary
process.
R-Shoulder Xray: There is no acute fracture or dislocation.
___ CT Head:
1. No significant interval change in right sided subarachnoid
hemorrhage and subdural hematomas.
2. No new hemorrhage.
3. Known right medial orbital wall fracture.
Brief Hospital Course:
___ s/p assault, +LOC for unclear period of time, GCS of 15,
neurologically intact, found to have small SDH and right SAH, as
well as right orbital blowout medial wall fracture and nasal
fractures, and question of a C6 spinal fracture. The patient was
hemodynamically stable. He was admitted to the ACS/Trauma
service for further management. Neurosurgery was consulted and
recommended SBP less than 140 and keppra x1 week. Plastic
Surgery was consulted and recommended a delayed surgical repair
once edema has resolved in ___ days, sinus precautions, and
Bacitracin to repaired laceration x1 week. Ophthalmology was
consulted and performed an eye exam, which was normal. They
recommended no need for follow-up unless patient has new ocular
symptoms.
On HD2, a repeat head CT showed no interval blossoming of SAH or
SDH. Neurological exam remained stable. Neurosurgery signed off
and requested the patient follow up in 1 month for a repeat head
CT and to continue the keppra for 1 week and hold aspirin x3
days. The patient was seen by Occupational Therapy for a
congnitive evaluation due to +LOC. The patient did well and was
educated about post-concussive symptoms.
At the time of discharge on HD3, 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. He had follow-up scheduled
with Neurosurgery and Plastics.
Medications on Admission:
___: metformin, glipizide, amiodarone, atorvastatin, ASA 81',
bacillus coagulancs,amlodipine
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Amiodarone 200 mg PO DAILY
3. amLODIPine 10 mg PO DAILY
4. Carvedilol 12.5 mg PO TID
5. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*12 Tablet Refills:*0
6. Spironolactone 25 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Status post assault:
Right sided subarachnoid hemorrhage and subdural hematomas
Right medial orbital wall fracture
Small 2cm facial laceration (repaired at outside hospital)
around right eyebrow
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ after being assaulted. Your injuries
were a right orbital wall fracture and a minor intracranial
bleed. A repeat head CT scan showed the bleeding was stable and
not increasing in size. Neurosurgery was consulted and
recommended you take Keppra, an antiseizure medication, for 1
week. You should also hold off on taking your Aspirin 81mg until
tomorrow ___. You will need to follow-up in the ___
clinic in about 4 weeks for a repeat head CT.
Plastic Surgery was consulted for the facial fractures. They did
not recommend any immediate intervention while the swelling is
acute but you should follow-up in a week. They also recommend
sinus precautions x 1 week (e.g. no using straws, sneeze with
mouth open, no sniffing, no smoking, keep head of bed elevated
to 45 degrees). Sutures from face laceration can be removed in
___ days. Please apply bacitracin to laceration twice a day x1
week.
Opthalmology evaluated you due to the orbital wall fracture to
rule out any eye injury. Your exam was negative and they
recommend routine follow up with your Opthalmologist.
Because you lost consciousness and have a head injury,
Occupational Therapy preformed a cognitive evaluation to see if
you were suffering from post concussive syndrome. They did not
note any deficits and you do not need cognitive neurology
follow-up.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Head Injury Instructions:
Return to the Emergency Department or see your own doctor right
away if any problems develop, including the following:
Persistent nausea or vomiting.
Increasing confusion, drowsiness or any change in alertness.
Loss of memory.
Dizziness or fainting.
Trouble walking or staggering.
Worsening of headache or headache feels different.
Trouble speaking or slurred speech.
Convulsions or seizures. These are twitching or jerking
movements of the eyes, arms, legs or body.
A change in the size of one pupil (black part of your eye) as
compared to the other eye.
Weakness or numbness of an arm or leg.
Stiff neck or fever.
Blurry vision, double vision or other problems with your
eyesight.
Bleeding or clear liquid drainage from your ears or nose.
Very sleepy (more than expected) or hard to wake up.
Unusual sounds in the ear.
Any new or increased symptoms
Followup Instructions:
___
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Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
___ line placement ___
History of Present Illness:
___ with T2DM, GCA on prednisone, HLD, HTN who presented to the
ED with fevers and cough. He was recently discharged from ___
on ___ after he presented with N/V from a presumed
gastroenteritis. After he returned home, he felt unwell with
tachypnea, somnolence, poor po intake and was broight back to
___ where he was noted to be febrile to 104.8F. He was
subsequently admitted to the MICU for monitoring and management.
There was initially concern for PNA given that he reported
coughing. He was started on vanco/aztreonam (given PCN allergy)
and levofloxacin. BCx were positive for ___ bottles MSSA. He was
noted to have erythema and tenderness over his left hand at site
of PIV from prior admission. ID was consulted who recommended
continuing vanco for now and continuing levoflox given coughing
but with no e/o PNA on admission CXR. Repeat CXR ___ showed
concern for early infiltrate in the retrocardiac region.
On initial exam in the MICU, patient is intermittently coughing.
He denies any pain.
Past Medical History:
# Hypertension
# Osteopenia ___ steroid use
# Diabetes mellitus Type 2
# Diabetic peripheral neuropathy
# Hypercholesterolemia
# Osteoarthritis
# Hemorrhoids
# Peripheral vascular disease
# Cataracts
# Mitral regurgitation
# Giant cell temporal arteritis
Social History:
___
Family History:
Son with intermittent vertigo which resolves with meclizine.
Physical Exam:
ADMISSION EXAM
Vitals: HR 84, T 100.1, 155/79, HR 84, RR 22
General: Alert, oriented, no acute distress, sleeping, easily
arousable; of note, patient had difficulty tolerating water with
medications (coughing frequently)
HEENT: Sclera anicteric, 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: scattered rales at bases, improve with cough/inspiration
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no organomegaly
GU: foley in place
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 EXAM
VS 98, Tm 98.1, BP 152/83 (130-170/72-80), 81, 18, 96%RA
GENERAL - pleasant elderly man in NAD
HEENT - NC/AT, PERRLA, EOMI
LUNGS - bibasilar soft crackles
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND
EXTREMITIES - WWP, 2+ ___ edema on the left, trace on the RLE
SKIN - left hand dorsal surface with improving erythema and
swelling
NEURO - awake, A&Ox3, CNs II-XII grossly intact, no focal
defitics appreciated
Pertinent Results:
ADMISSION LABS
___ 06:55AM BLOOD WBC-5.4 RBC-3.36* Hgb-9.7* Hct-30.5*
MCV-91 MCH-29.0 MCHC-31.9 RDW-16.6* Plt ___
___ 02:30PM BLOOD Neuts-61.7 ___ Monos-14.4*
Eos-0.2 Baso-0.6
___ 02:30PM BLOOD ___ PTT-38.5* ___
___ 06:55AM BLOOD Glucose-104* UreaN-29* Creat-1.5* Na-137
K-4.2 Cl-107 HCO3-23 AnGap-11
___ 07:19PM BLOOD ALT-23 AST-42* AlkPhos-121 TotBili-0.8
___ 06:55AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.3
___ 02:51PM BLOOD Lactate-1.5
URINALYSIS
___ 03:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:00PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 03:00PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
MICRO DATA
___ 2:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___
AT 0330.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
___ 3:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 2:45 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM POSITIVE COCCUS(COCCI).
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
___ 4:48 am BLOOD CULTURE Site: ARM
Blood Culture, Routine (Pending):
___ 3:59 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
CXR ___
AP semi-upright portable chest radiograph obtained. The lungs
are
clear without focal consolidation, effusion, pneumothorax. The
heart and
mediastinal contours are normal. Bony structures are intact.
CXR ___
The heart size is enlarged. There is increased density at the
left
retrocardiac area which may represent a developing infiltrate
versus
atelectasis. No pneumothoraces are seen. There are no signs
for acute
pulmonary edema.
CXR PA AND LATERAL ___:
The lungs are clear. There is no evidence of pneumonia. Right
innominate artery and the aorta are tortuous. There is no
pleural effusion or pneumothorax.
CONCLUSION: There is no evidence of pneumonia.
TTE ___:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are elongated. There is mild posterior leaflet
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The left ventricular inflow pattern suggests impaired
relaxation. Tricuspid valve prolapse is present. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of ___, the findings are grossly similar but the
technically suboptimal nature of both studies precludes
definitive comparison.
IMPRESSION: Suboptimal image quality. No definite vegetations
Brief Hospital Course:
Mr. ___ is a ___ ___ speaking gentleman who
presented with fever one day after discharge in the setting of
MSSA bacteremia. He was stabilized in the MICu and was
transferred to the Medical floor.....
ACTIVE ISSUES
#. Fever: MSSA bacteremia.
Admission blood cultures grew GPCs in 2 of 2 bottles. Pt was
initially treated with IV vanc. Speciation and sensitivities
revealed MSSA. Pt was changed to IV nafcillin. There was
question of a PCN allergy; however, the pt's son (HCP) confirmed
that this was written in error. there is no documented allergic
reaction to a penicillin in the electronic medical record. The
patient received a TTE which did not show any vegetations.
However, he will be treated empirically for IE with a six week
course of antibiotics. He will follow up with infectious disease
at the ___ clinic on ___. He should have labs checked
weekly while on nafcillin as specified below
#. Bronchitis/URI: Pt presented with fever and tachypnea
initially. He was also noted to have a cough. Portable CXR
showed possible PNA. He was treated empirically with levaquin
for 2 days. Repeat PA and lateral confirmed lack of pneumonia,
so levaquin was stopped. Suspect bronchitis or upper respiratory
tract infection causing cough. Treated with standing duonebs and
cough medications. His symptoms improved.
INACTIVE ISSUES
#. Type 2 DM: stable. Held home Glipizide, covered with Humalog
sliding scale. ___ restart glipizide upon discharge.
#. GCA: stable. He was continued on his home dose of Prednisone
and did not require stress dosing.
#. PAD: stable. He was continued on ASA.
#. HTN: stable. Metoprolol initially held for sepsis. It was
restarted at lower dose and on discharge was 150mg metoprolol
XL. This can be uptitrated to his home dose of 200mg XL daily.
#. Hyperlipidemia: stable. Continued home Atorvastatin.
TRANSITIONAL ISSUES
# IV nafcillin for 6 weeks; follow up with ID on ___
# Uptitrate metoprolol XL to 200mg XL daily as needed to control
BP
RECOMMENDED LABORATORY MONITORING:
CBC with differential (weekly)
BUN/Cr (weekly)
AST/ALT (weekly)
Alk Phos (weekly)
Total bili (weekly)
ESR/CRP (weekly)
All laboratory results should be faxed to the ___
R.N.s at ___. All questions regarding outpatient
parenteral antibiotics should be directed to the ___ R.N.s at ___ or to the on-call ID fellow when
the clinic is closed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Alendronate Sodium 35 mg PO QMON
3. Amlodipine 5 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Atorvastatin 40 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. PredniSONE 2 mg PO DAILY
10. Senna 1 TAB PO DAILY
11. Metoprolol Succinate XL 200 mg PO DAILY
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
13. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral Daily
14. GlipiZIDE 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. PredniSONE 2 mg PO DAILY
9. Senna 1 TAB PO DAILY
10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing, dyspnea
11. Benzonatate 100 mg PO TID
12. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
13. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing, dyspnea
14. Nafcillin 2 g IV Q6H
15. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
16. Alendronate Sodium 35 mg PO QMON
17. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral Daily
18. GlipiZIDE 5 mg PO DAILY
19. Metoprolol Succinate XL 150 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Staph aureus bactermia (Methicillin sensitive)
Bronchitis
Secondary diagnoses:
Chronic kidney disease
Hypertension
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You came to the
hospital with fever and were found to have a blood stream
infection. You were started on antibiotics, and your condition
improved greatly. You will need to continue IV antibiotics for a
total of 6 weeks and follow up with infectious disease clinic.
Also, you had a cough which is likely due to bronchitis. You can
use nebulizers and cough medicines as needed to improve your
symptoms.
We made the following changes to your medications:
DECREASE metoprolol
START nafcillin
START albuterol neb as needed for wheezing
START ipratropium neb as needed for wheezing
START guaifenesin syrup as needed for cough
START benzonatate as needed for cough
Followup Instructions:
___
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Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
fatigue, chest tightness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a pleasant ___ w/hx HTN, DM2, GCA on prednisone
and recent hospital admission for MSSA bacteremia on IV abx who
presents from SNF with fatigue, intermittent chest tightness and
worsening anemia. History obtained from son and pt via son
interpreting given patient is hard of hearing and ___
speaking. Son notes that over the last couple of days, the
patient has not been his normal self, feeling more fatigued and
with less of an appetite. Previously he would get out of bed
for meals but has not done that for the past two days and has
had decreased PO intake over that time frame as well. Also over
the last few days he has complained of intermittent chest
pressure without pain, nausea, vomiting or SOB. This pressure
comes on spontaneously and usually last a couple of hrs before
improving on its own. Because of his complaints, CBC was drawn
at rehab and was found to be 24.1, therefore he was referred to
the ED for further w/u. He was guiac negative at SNF.
In the ED, labs were notable for crit of 25.6. Troponin was
mildly elevated at 0.05 and creatinine elevated at 2.0. EKG
showed NSR with inferior/lateral tw flattening but no acute ST
changes. Pt refused guiac. Vitals prior to transfer were 97.9
79 146/76 18 100%.
On arrival to the floor, the patient denies any complaints
including chest tightness. Last bowel movement earlier today
and noted to be dark brown per family, and he has not had any
bloody or dark stools recently.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
# Hypertension
# Osteopenia ___ steroid use
# Diabetes mellitus Type 2
# Diabetic peripheral neuropathy
# Hypercholesterolemia
# Osteoarthritis
# Hemorrhoids
# Peripheral vascular disease
# Cataracts
# Mitral regurgitation
# Giant cell temporal arteritis
# Hearing loss R>L
Social History:
___
Family History:
Son with intermittent vertigo which resolves with meclizine.
Physical Exam:
Admission examination
VS - 98.1 158/76 74 20 97% RA
GENERAL - well-appearing man appears younger than stated age in
NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
decreased hearing, R>L
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, ___ SEM loudest at apex, nl
S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 1+ bilat pedal edema
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII intact, muscle strength ___
throughout however slightly limited in ___ to pain
RECTAL: refused
Pertinent findings on discharge:
Patient seen with interpreter.
Lungs with faint scattered rhonchi, afebrile, patient alert and
oriented, fluent speech with interpreter and with 1+ bilateral
___ pitting edema.
Pertinent Results:
Admission labs:
___ 06:11PM BLOOD WBC-6.8# RBC-2.82* Hgb-8.1* Hct-25.6*
MCV-91 MCH-28.8 MCHC-31.7 RDW-17.5* Plt ___
___ 06:11PM BLOOD Neuts-63 Bands-0 ___ Monos-11 Eos-0
Baso-0 ___ Myelos-0
___ 06:11PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
___ 04:30PM BLOOD Glucose-66* UreaN-29* Creat-2.0* Na-142
K-4.1 Cl-108 HCO3-20* AnGap-18
___ 04:30PM BLOOD ALT-21 AST-36 AlkPhos-109 TotBili-0.4
___ 04:30PM BLOOD cTropnT-0.05*
___ 04:30PM BLOOD proBNP-3101*
___ 04:30PM BLOOD Albumin-3.4*
___ 04:35PM BLOOD Lactate-1.2
CXR: Trace bilateral pleural effusions.
EKG: NSR with lateral t wave flattening
Blood cultures: No growth to date, pending since ___
Brief Hospital Course:
Pleasant ___ yo M with hx DM, HTN, on IV abx for recent MSSA
bacteremia, now presenting for fatigue and worsening anemia.
ASSESSMENT & PLAN: Pleasant ___ yo M with hx DM, HTN, on IV abx
for recent MSSA bacteremia, presenting for fatigue and worsening
anemia.
# Generalized fatigue: Multifactorial, secondary to anemia of
chronic disease, deconditioning and resolving bacteremia.
-Continue Ferrous Sulfate 325 mg PO/NG DAILY
-trend crit, Transfuse as necessary.
-Continue Abx
-Dc to ___ where he will receive ___ for
deconditioning.
# Anemia: No e/o active bleeding with negative guiac at ___.
labs consistent with AOCD.
-trend crit, Today ___.
-maintain active t&s
-guiac stools
# ___: concern for abx toxicity, however FeNA<1 and no eos on UA
and pt with reported decreased PO intake over the past few days,
therefore more likely pre-renal. Cr improving with IVF. Today
1.4
-Continue IVF
-trend creatinine
# Hx MSSA bacteremia: switched to cefazolin on ___ out of
concern for renal failure due to nafcillin.
-cont cefazolin, renally dosed.
-Dispo would be back to ___ for the remainer of the 6
weeks of abx.
-Check ESR and CRP at next blood work per ID OPAT request, with
results continued to Dr ___.
#. Type 2 DM: stable
-ISS
-restart glipizide upon discharge, but decreased to 2.5 given
relatively low BGs while here. ___ be able to discontinue
depending on oral intake and BGs at rehab.
#. GCA: with osteopenia secondary to steroid use. Stable.
-cont steroids, allendronate, vit d, calcium
#. PAD: stable.
-cont ASA
#. HTN: stable
-cont home metoprolol
#. Hyperlipidemia: stable
-cont atorvastatin.
#. Med rec: On PPI but no hx of GERD, so will discontinue given
risk of renal toxicity.
# CONTACT: Son, ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. PredniSONE 2 mg PO DAILY
9. Senna 1 TAB PO DAILY
10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing, dyspnea
11. Benzonatate 100 mg PO TID
12. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
13. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing, dyspnea
14. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
15. Alendronate Sodium 35 mg PO QMON
16. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral Daily
17. Metoprolol Succinate XL 150 mg PO DAILY
18. CefazoLIN 2 g IV Q12H
19. GlipiZIDE 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing, dyspnea
3. Alendronate Sodium 35 mg PO QMON
4. Amlodipine 10 mg PO DAILY
5. Aspirin 325 mg PO DAILY
6. Atorvastatin 40 mg PO DAILY
7. Benzonatate 100 mg PO TID
8. CefazoLIN 2 g IV Q12H
9. Docusate Sodium 100 mg PO BID
10. Ferrous Sulfate 325 mg PO DAILY
11. Metoprolol Succinate XL 150 mg PO DAILY
12. PredniSONE 2 mg PO DAILY
13. Senna 1 TAB PO DAILY
14. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
17. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
18. GlipiZIDE 2.5 mg PO DAILY
PLEASE HOLD for BG < 140. Or if patient not eating.
19. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral Daily
20. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing, dyspnea
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
- MSSA Septicemia
- Anemia of Chronic Inflammation
- Acute renal failure
- Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with weakness and renal
failure in the setting of your staph infection. You received IV
fluids and your symptoms improved. You were also noted to have
low blood levels, but it is unclear why they were so low. You
were given 2 units of blood during this hospitalization.
You were changed from Nafcillin to cefazolin for treatment of
your bacteria in your blood.
Followup Instructions:
___
|
10855805-DS-5
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| 5 |
2181-12-26 00:00:00
|
2181-12-26 13:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
BACK PAIN
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with pancreatic cancer stage IIA on gemcitabine who
presents with PET/CT findings concerning spinal cord involvement
at T8. Patient had PET/CT today which showed diffuse bony
lesions that were most prominent at T8. Patient reports mild
ache at mid-back but is otherwise asymptomatic. She reports no
neurologic symptoms. She was referred to the ED for MRI T-spine
for Radiation Oncology consult. Dr. ___ is aware of patient.
In the ED, initial vital signs were 98, 86, 153/86, 16, 98% on
RA. Labs were unremarkable and the patient had no complains. MRI
T-spine showed... Decision was made to admit to OMED for
expedited workup. VS prior to transfer were 0 99.3 72 118/86 18
97% RA.
On the floor, the patient was completley stable, hungry,
reproted no soreness in abck, which reports occurs on left side
of mid back on and off, not pain but soreness. No fveres,
chills, n/v/d. No focal neurological signs.
Past Medical History:
asthma, allergic rhinitis, bladder diverticulum with a stone,
contact dermatitis, eczema, dermatitis of her eyelids,
hypercholesterolemia, hypothyroidism, ovarian cysts, renal cyst
Social History:
___
Family History:
Her mother died of pancreatic cancer in her late ___. She has a
strong family history of gallbladder disease as well. Her dad
had colon cancer in his late ___.
Physical Exam:
ADMISSION EXAM
=========================================
VITALS: 98.4 118/82 86 18 97 ra
GENERAL: NAD
HEENT: NC/AT, EOMI, PERRL, MMM
CARDIAC: RRR, nl S1 and S2, no murmurs
LUNG: CTAB no w/r/rh
ABD: +BS, soft, NT/ND, no r/g
EXT: No lower extermity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: CN II-XII intact. Full motor and senory system intact.
AOx3. No vertebral tendereness
SKIN: Warm and dry
DISCHARGE EXAM
=========================================
VITALS: 98.4 118/82 86 18 97 ra
GENERAL: NAD
HEENT: NC/AT, EOMI, PERRL, MMM
CARDIAC: RRR, nl S1 and S2, no murmurs
LUNG: CTAB no w/r/rh
ABD: +BS, soft, NT/ND, no r/g
EXT: No lower extermity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: CN II-XII intact. Full motor and senory system intact.
AOx3. No vertebral tendereness
SKIN: Warm and dry
Pertinent Results:
ADMISSION LABS
=================================
___ 02:00PM BLOOD WBC-6.4 RBC-4.02* Hgb-12.2 Hct-36.3
MCV-90 MCH-30.4 MCHC-33.6 RDW-14.3 Plt ___
___ 02:00PM BLOOD Neuts-65.2 ___ Monos-11.3*
Eos-3.0 Baso-0.6
___ 02:00PM BLOOD Glucose-103* UreaN-18 Creat-0.7 Na-138
K-3.9 Cl-99 HCO3-30 AnGap-13
___ 02:00PM BLOOD Calcium-9.2 Phos-4.5 Mg-2.1
INTERVAL STUDIES
=================================
___ PET/CT SCAN
1. FDG avid disease in the portacaval region, left omentum, and
multiple foci throughout the skeleton, as described above and
representing widespread metastatic disease.
2. Many sites of focal bowel uptake suggestive of metastases to
the bowel wall, although can not be entirely distinguished from
physiological bowel activity.
___ MRI T& L SPINE, WITH & WITHOUT CONTRAST
Thoracic spine: Metastatic lesions seen in the T10 vertebral
body with high signal on recent PET demonstrating dark signal on
T1 and high signal on STIR sequences. There is no definite bony
breakthrough posteriorly in the region of this lesion. There is
no evidence of spinal cord compression. High signal within the
central canal at the T5-T7 levels represents a small synrinx vs.
persistent central canal.
Lumbar spine: No evidence of cord compression or abnormal cord
signal within the lumbar spine. Grade 1 anterolisthesis of L4-5.
Canal narrowing at multiple levels with broad based disc bulges
and ligamentum flavum thickening causing severe spinal canal
narrowing at the L4-5 and moderate to severe spinal canal
narrowing at the L3-4 level.
No abnormal areas of spinal cord enhancement in the thoracic or
lumbar spine.
DISCHARGE LABS
================================
___ 07:05AM BLOOD WBC-7.3 RBC-4.42 Hgb-13.0 Hct-39.3 MCV-89
MCH-29.4 MCHC-33.1 RDW-14.6 Plt ___
___ 07:05AM BLOOD Glucose-93 UreaN-14 Creat-0.6 Na-139
K-4.4 Cl-101 HCO3-29 AnGap-13
Brief Hospital Course:
This is a ___ year old woman with stage II-A pancreatic cancer
s/p resection, on gemcitabine, who presents with PET/CT findings
concerning spinal cord involvement at T8.
ACUTE ISSUES:
# Metastatic pancreatic cancer: the patient has known pancreatic
cancer (stage II-A). She is s/p resection with negative but
narrow margins and then completed six months of adjuvant
gemcitabine as well as adjuvant chemoradiation as of ___.
However, she underwent scan given a recent increase in serum CA
___. PET-CT scan for further evaluation and staging of her
disease demonstrated widespread metastatic disease. MRI of the
T- and L- spine was pending at time of note. Clinically, she had
no neurologic deficits. She reports mid-back ache only. MRI
report as listed above - no cord compression. Radiation oncology
consulted - will have XRT as outpatient. No steroids given,
secondary to stable clinical and neurologic appearance.
CHRONIC ISSUES:
# Asthma: hold home albuterol MDI PRN as hasnt used it in a
year.
# Hypothyroidism: Continue home levothyroxine.
# OA: was using iburpofen but no pain at present. Will hold off.
TRANSITIONAL ISSUES
- Radiation oncology for XRT on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 75 mcg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 75 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Metastatic pancreatic adenocarcinoma
Secondary diagnoses: - Hyperlipidemia
- Asthma
- Pancreatic adenocarcinoma, as above (s/p radical distal
pancreatectomy & splenectomy)
- Hypothyroidism
- Splenic artery aneurysm
- Renal cysts
- Ovarian cysts
- Bladder diverticulum with stone
- Eczema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized at ___ for coordination of care for
radiation therapy to your back. While in house, you had further
imaging of your back, which showed no spinal cord compression.
You will follow up on ___ for radiation.
Followup Instructions:
___
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2182-07-27 00:00:00
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2182-07-27 14:04:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
neck and back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PCP: ___. MD
PRIMARY ONCOLOGIST: currently received care through Cancer
Treatment ___, was receiving care from ___,
___
PRIMARY DIAGNOSIS: pT3N0 stage IIA pancreatic adenocarcinoma,
now
metastatic to bone and peritoneum
TREATMENT REGIMEN: currently not on chemotherapy (last received
chemo ___
TREATMENT HISTORY: completed six
months of adjuvant gemcitabine as well as adjuvant
chemoradiation
as of ___. Cancer recurrence was diagnosed by rising CA
___ and PET-CT findings showing diffuse metastases to the bone,
omentum, bowel, and likely liver in ___. She received
radiation to the T-spine and then began systemic chemotherapy
with FOLFIRINOX ___. Due to toxicity she transitioned to
FOLFOX with cycle 2. Following two cycles, she made a decision
to forego further chemotherapy.
CC: neck and back pain
HISTORY OF PRESENTING ILLNESS:
___ with metastatic pancreatic cancer w/mets to cervical and
thorasic spine presents with five days of increased right neck
and back pain, with radiation down right shoulder and arm.
Denies
numbness or tingling in bilateral upper extremities. Endorses
some decreased strength of the RUE. Denies incontinence. The
patient was evaluated at ___ on ___ of this week
given significant pain, underwent CT C-spine with ?spinal
impingement, was discharged home in C-collar and RUE sling and
told to follow up with Oncologist the next day. She was not
evaluated by a neurosurgeon at that time. She presents today
after following up with her PCP, who received a report of the CT
scan from ___ and recommended immediate presentation to ___
ED.
In the ED, initial VS were:
99.0 112 141/76 18 97%
Labs were notable for: WBC 12.4 Ht 24 plat 352
Imaging included: MRI which showed 1. Diffuse marrow
infiltration
throughout the visualized cervical and thoracic spine, worst in
comparison to prior study with multiple new discrete lesions
suspicious for progressive metastatic osseous disease.
2. New dorsally expansile lesion at C7 which effaces the thecal
sac contacting and mildly deforming the traversing cervical
spinal cord. Motion artifact on axial and sagittal T2 weighted
images limits evaluation for cord edema at this site. No
associated abnormal T1 signal or postcontrast enhancement.
3. New posterior left rib lesions consistent with progressive
metastatic disease.
4. Multilevel degenerative changes, as described.
5. Small right-sided pleural effusion, which is new.
6. New left-sided hydronephrosis.
7. Stable syringohydromyelia extending from T6-T8.
neurosurgery was consulted and recommended admission to Omed for
pain control and they will give more recommendations after MRI
final read.
Treatments received: dilaudid 3mg, dex ___, lidocaine patch,
lorazepam 1 mg
On arrival to the floor, the patient feels her pain has improved
though she is asking for pain medication. She denies fevers
chills, rash, abdominal pain. She reports having pain in her
ribs, pelvis frequently but the neck pain was new.
REVIEW OF SYSTEMS: per HPI, all other ROS negative
Past Medical History:
PAST ONCOLOGIC HISTORY
___ was undergoing routine
surveillance CT for her known splenic artery aneurysm in
___ when a cyst measuring 1.5 x 2.6 x 1.4 cm was
identified in the pancreatic tail. She underwent endoscopic
ultrasound ___, and FNA biopsy showed atypical
cells. On ___ she underwent robotic-assisted
radical distal pancreatectomy and splenectomy. Preoperative CA
___ was 222 U/mL. Pathology showed a pT3N0 stage IIA
pancreatic
adenocarcinoma with 0 of 13 lymph nodes involved. Margins were
negative, although within 0.1 mm. Perineural invasion was seen.
No large vessel or angiolymphatic invasion was seen. Ms. ___
initiated adjuvant gemcitabine on ___. She was
then
treated with radiation with concurrent capecitabine, which was
completed on ___, and resumed gemcitabine on ___. Adjuvant therapy completed as of ___. Ms. ___
presented in ___ with rising CA ___, and PET-CT in ___
confirmed the finding of metastatic pancreatic cancer. She
received radiation to the T-spine completed ___ and began
FOLFIRINOX chemotherapy ___. With cycle 1 she experienced
substantial toxicity, nausea, and anorexia. With cycle 2 she
transitioned to FOLFOX. She made a decision to hold
chemotherapy
as of ___.
-Radiation treamtents: Palliative radiotherapy to whe pancreas,
the T9 to
T11 spine ___, to ___.
left rib last ___ in ___
PAST MEDICAL HISTORY:
-Pancreatic adenocarcinoma (see oncologic history)
-Splenic artery aneurysm
-Asthma
-Allergic rhinitis.
-Bladder diverticulum with a stone.
-Eczema.
-Dyslipidemia
-Hypothyroidism.
-Ovarian cysts.
-Renal cysts.
Social History:
___
Family History:
Mother: ___ cancer at age ___
-Father: ___ cancer at age ___
-Maternal Great Aunt: ___ cancer s/p double mastectomy
Physical Exam:
VS: T 98 BP 120/60 RR 18 HR 86 O2 96% RA
GENERAL: laying in bed with C collar on
HEENT: NC/AT, EOMI, PERRL, MMM
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: clear to auscultation, no wheezes or rhonchi
ABD: Soft, NT/ND, no rebound or guarding
EXT: No lower extremity pitting edema
NEURO: CN II-XII intact, no focal deficits.
SKIN: Warm and dry, without rashes
Pertinent Results:
admission
___ 10:40PM BLOOD WBC-12.4* RBC-2.64* Hgb-8.3* Hct-24.1*
MCV-91 MCH-31.4 MCHC-34.4 RDW-16.7* RDWSD-55.3* Plt ___
___ 10:40PM BLOOD Neuts-68.9 Lymphs-5.9* Monos-18.5*
Eos-5.3 Baso-0.6 Im ___ AbsNeut-8.50* AbsLymp-0.73*
AbsMono-2.29* AbsEos-0.66* AbsBaso-0.08
___ 10:40PM BLOOD Plt Smr-NORMAL Plt ___
___ 10:40PM BLOOD Ret Aut-1.4 Abs Ret-0.04
___ 10:40PM BLOOD Glucose-171* UreaN-16 Creat-0.6 Na-134
K-4.1 Cl-93* HCO3-28 AnGap-17
___ 10:40PM BLOOD Iron-15*
___ 10:40PM BLOOD calTIBC-178* Ferritn-512* TRF-137*
___ to severe left hydronephrosis.
2. 6.1 x 5.1 cm left adnexal cystic lesion with a 1.6 cm solid
mural nodule, also noted on prior CT scan from ___,
concerning for a metastatic focus. It is possible that this
lesion is the cause of hydronephrosis, CT could be considered
for
further evaluation.
MRI T spine ___ IMPRESSION:
1. Diffuse marrow infiltration throughout the visualized
cervical
and thoracic spine, worst in comparison to prior study with
multiple new discrete lesions suspicious for progressive
metastatic osseous disease.
2. New dorsally expansile lesion at C7 which effaces the thecal
sac contacting and mildly deforming the traversing cervical
spinal cord. Motion artifact on axial and sagittal T2 weighted
images limits evaluation for cord edema at this site. No
associated abnormal T1 signal or postcontrast enhancement.
3. New posterior left rib lesions consistent with progressive
metastatic disease.
4. Multilevel degenerative changes, as described.
5. Small right-sided pleural effusion, which is new.
6. New left-sided hydronephrosis.
7. Stable syringohydromyelia extending from T6-T8.
IMPRESSION:
1. Moderate to severe left hydronephrosis.
2. 6.1 x 5.1 cm left adnexal cystic lesion with a 1.6 cm solid
mural nodule,
also noted on prior CT scan from ___, concerning for a
metastatic
focus. It is possible that this lesion is the cause of
hydronephrosis,
although this cannot be directly assessed with ultrasound and CT
could be
considered for further evaluation.
RECOMMENDATION(S): Abdominal and pelvic CT scan can be
considered to further evaluate cause of the left
hydronephrosis.
X-ray Pelvis:
Multiple lucent lesions with calcified rims are seen throughout
the pelvis and proximal femurs. This is consistent with
metastases from pancreatic cancer, though the unusual
calcification raises the possibility of prior treatment.
X-ray Femur:
No previous images. There are multiple lytic lesions within the
femur with several causing endosteal scalloping, consistent with
metastases. Many of these lesions have a somewhat unusual
configuration, with a a rim of sclerosis about the lytic
process. It is possible that this appearance could reflect some
prior treatment.
Brief Hospital Course:
___ h/o metastatic pancreatic cancer to the spine presents with
acute neck and shoulder pain and imaging shows progression of
her
pancreatic cancer and C7 expansile lesion.
#C7 expansile lesion: ___ metastatic disease. No cord edema on
MRI and exam not c/w cord compression but likely impending w/o
treatment. presented w/ neck pain.
- Neurosurgery consulted in ED, no indication for surgical
decompression as pt has diffuse disease
Radiation oncology consulted and radiation started. Patient to
continue as an outpatient.
- Continue dex 2mg PO BID, further titration per rad onc
- C-collar to remain in place throughout XRT and then for 2
weeks
following radiation.
- Continued home fentanyl patch for pain and added PRN PO
dilaudid. Also continued home lidocaine patches.
#hx impending pathologic femur fracture
- X-rays showed multiple lesions. Orthopedic surgery recommended
weight bearing as tolerated with a walker and physical therapy.
#Metastatic Pancreatic cancer: pt does not wish to have chemo
and
would like to focus on comfort but is interested in continuing
her current care and receiving radiation therapy. Focused on
pain control and palliative care was consulted.
#L moderate-severe Hydronephrosis: renal u.s shows left adnexal
cystic lesion with a 1.6 cm solid mural nodule which may
indicate
a met. Pt did not wish to work this up further given her goals
of care.
#Goals of care: She would like to focus on her comfort and would
like to pursue only those medical interventions that will
achieve
that purpose. She is DNR DNI.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Acetaminophen 325-650 mg PO Q6H:PRN pain
3. Prochlorperazine 10 mg PO Q6H:PRN nausea
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Lorazepam 0.5-1 mg PO Q8H:PRN nausea, anxiety, insomnia
6. Creon 12 2 CAP PO TID W/MEALS
7. Fentanyl Patch 62 mcg/h TD Q72H
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
10. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
3. Creon 12 2 CAP PO TID W/MEALS
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Lorazepam 0.5-1 mg PO Q8H:PRN nausea, anxiety, insomnia
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. Dexamethasone 2 mg PO Q12H
RX *dexamethasone 2 mg 1 tablet(s) by mouth every 12 hours Disp
#*8 Tablet Refills:*0
9. Fentanyl Patch 62 mcg/h TD Q72H
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. Pantoprazole 40 mg PO Q24H
12. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
13. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
metastatic pancreatic cancer
Spinal metastases
Neck pain
hydroureter
anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory as tolerated - requires assistance
or aid (walker or cane).
Discharge Instructions:
Dear Ms ___,
It was a pleasure caring for you at ___. You were admitted
because of neck and back pain. You had imaging done which showed
metastatic pancreatic cancer in your spine. You were seen by the
neurosurgeons as well as the radiation oncologists and the
decision was made to treat you with radiation therapy. Other
imaging showed that you have a dilated ureter, possibly related
to the cancer. You did not want further imaging at this time.
Doctors ___ here:
- Oncology Hospitalist: Dr. ___, Dr. ___,
Dr. ___.
- Palliative Care: Dr. ___
- ___ Oncology: Dr. ___
- ___ Surgery: Dr. ___
Followup Instructions:
___
|
10856002-DS-22
| 10,856,002 | 26,346,838 |
DS
| 22 |
2143-10-21 00:00:00
|
2143-10-24 19:04:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Keflex / Catapres / Trazodone / Levaquin in D5W /
Colchicine / Fluoxetine / Lexapro / Lisinopril / metformin /
gabapentin
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ ___ h/o lung CA ___, s/p lobectomy,
chronic sCHF, CAD, depression, who is referred from PCP for
acute on subacute left lower back pain for 2 weeks, worse in the
past day. Pt states that 2 weeks ago she developed left-sided
groin pain, that became progressively worse with "stabbing" pain
in her left buttock, that radiated down her left thigh. Denies
any numbness, tingling or trauma. The pain became ___, not
relieved with tylenol. She has never had this pain before.
Endorses chills, but no fevers. Denies wt changes. Denies
urinary or fecal incontinence. Denies any numbness when she
wipes. Feels that her left leg is weak, but has not had any
falls.
Initial VS in the ED: 10 97.8 69 163/68 18 100% ra
Exam notable for Exam significant for uncomfortable elderly
female, normal cardiopulmonary exam, no abdominal tenderness,
lower extremity exam limited by pain however ___ strength, 2+
reflexes, downgoing toes, normal rectal tone, and otherwise
normal.
Labs notable for chem 10 wnl, LFT's wnl. Dig level 0.5. CT T and
L spine showed no evidence of acute fractures.
Patient was given Tylenol, tramadol, lidocaine patch, oxycodone
and cyclobenzaprine.
VS prior to transfer: 5 98.0 72 127/66 18 98%.
On the floor, her pain is now ___, but none if she doesn't
move.
Review of systems:
(+) Per HPI. Had a cold a couple weeks ago, but otherwise feels
well.
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
1. Coronary ___ disease, status post inferoposterior lateral
MI in ___, status post stent in the left circumflex and two
stents in the right coronary artery with a known chronically
occluded right coronary artery.
2. Carotid stenosis status post left carotid stent placement by
Dr. ___.
3. Hypertension.
4. Hyperlipidemia.
5. Type 2 diabetes.
6. Ischemic cardiomyopathy with EF of 30%.
7. History of ischemic mitral regurgitation.
8. History of ventricular tachycardia, status post ICD placement
in ___.
9. An 80-pack-year history of tobacco, quit ___ years ago.
10. COPD.
11. Lung cancer status post left lobectomy with a new lung
nodule on the right. Per patient, she had recently seen her
oncologist, Dr. ___ confirmed the stability of the
lung nodule and feels that she is okay to follow up within one
year.
Social History:
___
Family History:
Father died of MI at ___ yo. Mother had CVA at ___ yo. 2 sister,
both healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.1 BP: 134/63 P: 72 R: 20 O2: 95%RA
General: pleasant elderly female, appaers stated age, NAD
HEENT: PERRL, EOMI, MMM, OP Clear
Neck: soft, supple, no JVD
CV: RRR, nl S1 S2, soft ___ systolic murmur
Lungs: CTAB
Abdomen: +BS, soft, NTND
Ext: warm, dry, no edema, 2+ ___ pulses
BACK: no spinal process tenderness, slight ttp over left
buttock, neg straight leg test
Neuro: oriented x3, 4+/5 to flexion at hip seems to be limited
by pain, otherwise, ___ throughout, reports slight decreased
sensation of left thigh to light touch compared with right, 2+
patellar reflexes on left, unable to get pt to relax to fully
assess patellar on right, toes downgoing bilaterally
Skin: warm, dry, no rashes
DISCHARGE PHYSICAL EXAM:
Vitals: 99.2, 97.9, 59-72, 110-134/63-82, ___, 98%RA
General: pleasant elderly female, appaers stated age, NAD
HEENT: PERRL, EOMI, MMM, OP Clear
Neck: soft, supple, no JVD
CV: RRR, nl S1 S2, soft ___ systolic murmur
Lungs: CTAB
Abdomen: +BS, soft, slightly tender to palpation in suprapubic
area
Ext: warm, dry, no edema, 2+ ___ pulses
BACK: no spinal process tenderness, slight ttp over left
buttock, neg straight leg test
Neuro: oriented x3, ___ strength in lower extremities
bilaterally. Sensation intact. Downgoing toes bilaterally.
reflexes 2+ patellar bilaterally. Rectal tone is normal, there
is full sensation to pinprick around anus.
Skin: warm, dry, no rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 03:10PM GLUCOSE-116* UREA N-32* CREAT-1.1 SODIUM-144
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-28 ANION GAP-15
___ 03:10PM estGFR-Using this
___ 03:10PM ALT(SGPT)-21 AST(SGOT)-14 ALK PHOS-77 TOT
BILI-0.4
___ 03:10PM LIPASE-48
___ 03:10PM CALCIUM-9.6 PHOSPHATE-4.0 MAGNESIUM-2.0
___ 03:10PM DIGOXIN-0.5*
IMAGING:
========
___ CT L-spine:
IMPRESSION:
1. No acute fracture or malalignment.
2. Mild degenerative changes with slight retrolisthesis of the
L5 vertebral
body and mild disc bulge at the L5-S1 level as described above.
___ CT C-spine
IMPRESSION:
1. No fracture or malalignment. No osseous lesion suspicious
for malignancy
is present.
2. A 7 mm ground-glass nodule in the right lower lobe was likely
present
previously, but due to respiratory motion, this is difficult to
ascertain.
Follow up chest CT could be performed for further evaluation.
MICROBIOLOGY:
============
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Brief Hospital Course:
Ms. ___ is a ___ ___ h/o lung CA ___, s/p lobectomy in
remission, chronic sCHF, CAD, depression, who is referred from
PCP for acute on subacute left lower back pain for 2 weeks,
worse in the past day, consistent with sciatica.
# Sciatica: Most likely sciatica given location of pain with
radiation down her thigh, and benign neuro exam. Spinal stenosis
also possible. No concerning neuro findings. CT of the L spine
and C spine showed retrolisthesis at the level of L5. The
patient was started on gabapentin for pain control and
discharged on 200mg TID.
# Orthostasis: The patient was mildly orthostatic when working
with ___. She states this is chronic and is followed by her
outpatient cardiologist. She was able to work with ___ and
ambulate unassisted. After receiving fluids, her symptoms
improved.
# Urinary retention: The patient was bladder scanned for 600ccs
after not voiding for ___ hours. She did not experience the urge
to void at this volume, was monitored and voided on her own. She
will be discharged to follow up with her PCP for urodynamic
testing if indicated.
# UTI: The patient had a positive UA and was started on
ciprofloxacin as she was complaining of some suprapubic
tenderness. Urine culture grew E. Coli sensitive to
ciprofloxacin. She will complete a ___hronic issues:
# CAD: Stable, no current chest pain. Continued on statin,
plavix, aspirin, metoprolol
# Chronic sCHF: Continued on digoxin, spironolactone,
metoprolol, furosemide, losaratan
# T2DM: Glyburide was held and the patient was started on an
insulin sliding scale.
# Hypothyroidism: Continued on levothyroxine
# Depression: Continued on sertraline
# GERD: Continued on PPI
# Lung Cancer: s/p lobectomy in ___, currently in remission.
TRANSITIONAL ISSUES:
-may need urodynamic testing. Patient retains 600+ cc's of urine
prior to voiding but does void without difficulty
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO DAILY
2. Acetaminophen w/Codeine ___ TAB PO Q8H:PRN pain
just prescribed, not yet filled
3. Clopidogrel 75 mg PO DAILY
4. Digoxin 0.125 mg PO EVERY OTHER DAY
5. Febuxostat 80 mg PO DAILY
6. Furosemide 60 mg PO DAILY
7. GlyBURIDE 1.25 mg PO QAM
8. GlyBURIDE 2.5 mg PO QPM
9. Ipratropium Bromide MDI 2 PUFF IH QID as needed for SOB
10. Levothyroxine Sodium 137 mcg PO DAILY
11. Lorazepam 0.5-1 mg PO HS:PRN insomnia
12. Losartan Potassium 25 mg PO DAILY
13. Metoprolol Tartrate 100 mg PO BID
14. Nitroglycerin SL 0.3 mg SL PRN chest pain
15. Pantoprazole 40 mg PO Q12H
16. Sertraline 100 mg PO DAILY
17. Spironolactone 12.5 mg PO DAILY
18. Tiotropium Bromide 1 CAP IH DAILY
19. Aspirin 325 mg PO DAILY
20. Bisacodyl 10 mg PO DAILY:PRN constipation
21. Senna 3 TAB PO BID:PRN constipation
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Digoxin 0.125 mg PO EVERY OTHER DAY
5. Febuxostat 80 mg PO DAILY
6. Furosemide 60 mg PO DAILY
7. GlyBURIDE 1.25 mg PO QAM
8. GlyBURIDE 2.5 mg PO QPM
9. Levothyroxine Sodium 137 mcg PO DAILY
10. Lorazepam 0.5-1 mg PO HS:PRN insomnia
11. Losartan Potassium 25 mg PO DAILY
12. Metoprolol Tartrate 100 mg PO BID
13. Pantoprazole 40 mg PO Q12H
14. Senna 3 TAB PO BID:PRN constipation
15. Sertraline 100 mg PO DAILY
16. Spironolactone 12.5 mg PO DAILY
17. Tiotropium Bromide 1 CAP IH DAILY
18. Gabapentin 200 mg PO TID
RX *gabapentin 100 mg 2 capsule(s) by mouth three times a day
Disp #*84 Capsule Refills:*0
19. Acetaminophen w/Codeine ___ TAB PO Q8H:PRN pain
20. Bisacodyl 10 mg PO DAILY:PRN constipation
21. Ipratropium Bromide MDI 2 PUFF IH QID as needed for SOB
22. Nitroglycerin SL 0.3 mg SL PRN chest pain
23. Ciprofloxacin HCl 500 mg PO Q12H
___
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*12 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary diagnosis: sciatic pain
Secondary diagnoses: CHF, h/o lung cancer, hypothyroidism,
hypertension, anemia, orthostatic hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted for back pain and there was concern
that your spinal cord was being compressed. Your imaging and
physical exam were reassuring. You worked with physical therapy
and were dizzy. You were given fluids and improved. Gabapentin
was added to your medication to help with your pain. No other
changes were made to your medications. Please continue to take
them as you have been doing and follow up with your PCP.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10856155-DS-10
| 10,856,155 | 22,814,051 |
DS
| 10 |
2111-08-19 00:00:00
|
2111-08-21 17:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/PMHx of heart murmurs presents who presents with one week
of ocular irritation accompanied with developing rash.
Pt reported that on ___ she started having watery eyes,
discharge, and crusts. She then presented to ___, where she
was diagnosed with conjunctivitis. She said that she did not
take the medication for conjunctivitis due to high cost. She
says that her lips were starting to swell. This ___ she
noticed that her lips started to have blisters. She says that
she could not eat today due to the pain in her mouth. Trouble
opening mouth due to mouth pain. Also reports rash spreading
throughout her body. She says her rash is irritating, painful,
and itchy. Took benadryl and aleve with minimal symptom relief.
One episode of mild wheezing at home but no hx of asthma. She
says she has never had this before, and pt does not know
possible culprit. She says her eye blurriness has improved.
Reports no changes in vision.
Denies fever, chills, headache, dizziness, CP, SOB, abdominal
pain, nausea, vomiting, or dysuria.
In the ED, initial VS were: 97.8 74 131/92 16 100% RA
Exam notable for:
HEENT: PERRLA, trace scleral erythema, Lips swollen lower lip >
upper lip, and erythematous, with white blisters on lower lip.
Aphthous ulcers seen in oral cavity. No swelling or erythema or
ulcers seen on tongue.
Skin: Diffuse small nodules in back of neck, face, arms, hands,
chest, abdomen, and lower torso. No erythmea.
Labs showed: Hb: 12.4 BMP: wnl
Patient received: Solumedrol 125mg, Benadryl 50mg, 2L NS
Dermatology was consulted, obtained HSV/VZV DFA and recommended
the following:
1. Would recommend checking mycoplasma serologies and obtaining
chest x-ray to assess for signs of infection
2. Would treat with IV methylprednisolone 1 mg/kg daily
3. Can apply potent topical steroid such as clobetasol 0.05%
ointment to affected areas
4. F/u HSV/VZV DFA; in the meantime, WOULD treat with acyclovir
10 mg/kg q8hr IV or 400 mg five times daily PO for empiric
treatment of herpes labialis
5. Would avoid any unnecessary medications, and would AVOID
NSAIDS
6. Keep an eye out for progression of rash and skin sloughing,
as
these may be signs that transfer to a burn unit may be warranted
7. Avoid strong adhesives. Use Telfa dressings and paper tape if
necessary
8. Good oral care with magic mouthwash or viscous lidocaine
9. Good ocular care- recommend an ophthalmology consult to
assess
for ocular involvement (as this was her first presenting
complaint)
Transfer VS were: 97.2 64 94/56
On arrival to the floor, patient reports her skin itching and
rash is improving quite a bit. Still has some lip and mouth
pain. Also reports some continued brownish vaginal spotting, but
is finishing her period.
Past Medical History:
None
Social History:
___
Family History:
"eye issues" in her mother; otherwise, non-contributory
Physical Exam:
Admission exam
VS: 98.0 100/60 59 17 99 Ra
GENERAL: Adult female in NAD
HEENT: AT/NC, lower lip with multiple vesicles and broken
mucosa, lower tongue and palate with ___ vesicular lesions
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: Scattered few palpable nodules without erythema or pain on
torso, palms with many flat red macules nonpuritic or palpable,
no lesions on feet (all improving per patient)
Discharge exam
Vitals: 98.0 107/70 50 17 99 Ra
GENERAL: Adult female in NAD
HEENT: AT/NC, lower lip with multiple vesicles and broken
mucosa, lower tongue and palate with ___ vesicular lesions
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: Scattered few palpable nodules without erythema or pain on
torso, palms with many flat red macules nonpuritic or palpable,
no lesions on feet (all improving per patient)
Pertinent Results:
Admission labs
___ 01:45AM BLOOD WBC-4.2 RBC-3.99 Hgb-12.4 Hct-37.8 MCV-95
MCH-31.1 MCHC-32.8 RDW-12.1 RDWSD-42.4 Plt ___
___ 01:45AM BLOOD Neuts-35.0 ___ Monos-10.3 Eos-1.7
Baso-0.2 Im ___ AbsNeut-1.46* AbsLymp-2.20 AbsMono-0.43
AbsEos-0.07 AbsBaso-0.01
___ 01:45AM BLOOD Glucose-84 UreaN-9 Creat-0.6 Na-138 K-3.8
Cl-98 HCO3-27 AnGap-13
___ 01:45AM BLOOD ALT-11 AST-20 AlkPhos-74 TotBili-0.2
Imaging
___ CXR
No comparison. The lung volumes are normal. Normal size of the
cardiac silhouette. Normal hilar and mediastinal contours. At
the bases of the right lung, visualized on both the frontal and
the lateral image, is an ill-defined area of increased
radiodensity, with air bronchograms, reflecting pneumonia in the
appropriate clinical setting. No pleural effusions. No
pulmonary edema.
Discharge labs
___ 09:00AM BLOOD WBC-4.7 RBC-3.70* Hgb-11.5 Hct-35.2
MCV-95 MCH-31.1 MCHC-32.7 RDW-12.3 RDWSD-43.1 Plt ___
___ 09:00AM BLOOD Glucose-148* UreaN-9 Creat-0.6 Na-142
K-3.5 Cl-101 HCO3-23 AnGap-18
Brief Hospital Course:
Summary
___ w/PMHx of heart murmurs presented with one week of ocular
irritation accompanied with developing rash. She was recommended
a skin biopsy but declined. Her rash improved over the next ___
hours and she was discharged with outpatient followup.
# Rash
# Conjunctivitis
Patient's rash was initially concerning for SJS vs erythema
multiforme, given oral lesions. She also had significant tearing
and eye discharge with conjunctival injection which mostly
resolved by the time she was admitted. CXR without pneumonia,
RPR, GC and chlamydia were negative. Ophthalmology consulted
with normal exam, will see as outpatient followup. Dermatology
consulted and DFA was attempted twice without adequate cells.
She was started on Acyclovir 400mg po 5x/day for empiric
treatment of herpes and clobetasol with good improvement. She
was discharged home to followup as an outpatient.
Transitional issues
- Patient needs to establish with a new PCP, and will make an
appointment within 1 week. She will also make a dermatology
appointment through the new PCP.
- Ophthalmology f/u appointment was made.
- She was discharged with clobetasol 0.05% ointment to affected
areas and acyclovir 400mg 5x/day to complete 1 week empiric
treatment
- Mycoplasma serology was pending at discharge.
#CODE: Full (presumed)
#CONTACT:
Next of Kin: ___
Relationship: OTHER
Phone: ___
Medications on Admission:
None
Discharge Medications:
1. Acyclovir 400 mg PO 5X/DAY
RX *acyclovir 400 mg 1 tablet(s) by mouth 5 times per day Disp
#*30 Tablet Refills:*0
2. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
RX *clobetasol 0.05 % Apply to affected areas twice a day
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Skin eruption
Secondary
Viral conjunctivitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to ___ with a skin rash. We are not sure what caused
this but it has gotten better. Please followup with your PCP and
dermatology, and take the medication we have prescribed you.
It was a pleasure taking care of you, best of luck.
Your ___ medical team
Followup Instructions:
___
|
10856332-DS-18
| 10,856,332 | 26,382,867 |
DS
| 18 |
2118-01-18 00:00:00
|
2118-01-18 16:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PLASTIC
Allergies:
Penicillins / diltiazem
Attending: ___.
Chief Complaint:
Active bleeding/hematoma s/p abdominoplasty at ___
Major Surgical or Invasive Procedure:
Evacuation of hematoma and closure of abdominoplasty.
History of Present Illness:
___ s/p abdominoplasty on ___ at ___ with Dr. ___
___ post-op bleed and hypotension. Pt notes large amounts of
bloody drainage and experienced dizziness and blurred vision at
home prior to presentation to ED. Pt was discharged from ___
___ on POD1 and started back on his Pradaxa. His last dose
was last night around 11:15pm. Received 1 unit blood at ___
___ ED before he was trasnferred to ___ for further
managment.
Past Medical History:
HTN
afib on pradaxa
Past Surgical History:
Atrial Septal Defect Repair (___)
Hernia Repair "groin area" Right side ___ years ago)
Breast Augmentation (___)
Abdominoplasty (___)
Myotomy h/o achalasia (___) at ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
Pre-procedure physical exam as documented in anesthesia record
___:
General: nad
mental/psych: a/o x 3
Airway: detailed in anesthesia record
Dental: good
Head/neck: free range of motion
Heart: irregular
Lungs: clear to auscultation
Pertinent Results:
___ 11:04PM HCT-24.0*
___ 08:28PM PLT COUNT-115*
___ 03:04PM GLUCOSE-141* UREA N-25* CREAT-1.8* SODIUM-134
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-26 ANION GAP-12
___ 03:04PM CALCIUM-7.5* PHOSPHATE-3.9 MAGNESIUM-1.5*
___ 03:04PM WBC-7.4 RBC-3.40* HGB-10.9* HCT-29.8* MCV-88
MCH-32.1* MCHC-36.6* RDW-14.8
___ 03:04PM PLT SMR-VERY LOW PLT COUNT-79*
___ 03:04PM ___ PTT-39.0* ___
___ 11:32AM ___ COMMENTS-GREEN TOP
___ 11:32AM LACTATE-3.1* K+-4.3
___ 11:32AM HGB-9.4* calcHCT-28
___ 11:00AM GLUCOSE-134* UREA N-31* CREAT-2.3* SODIUM-133
POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-23 ANION GAP-16
___ 11:00AM estGFR-Using this
___ 11:00AM ALT(SGPT)-51* AST(SGOT)-43* ALK PHOS-42 TOT
BILI-1.5
___ 11:00AM LIPASE-14
___ 11:00AM cTropnT-<0.01
___ 11:00AM ALBUMIN-3.1*
___ 11:00AM WBC-8.7 RBC-2.87* HGB-8.9* HCT-25.8* MCV-90
MCH-31.1 MCHC-34.6 RDW-14.7
___ 11:00AM NEUTS-84.2* LYMPHS-8.4* MONOS-6.4 EOS-0.3
BASOS-0.8
___ 11:00AM PLT COUNT-112*
___ 05:05AM BLOOD Hct-27.2*
___ 11:00AM BLOOD WBC-7.4 RBC-3.36* Hgb-10.5* Hct-29.3*
MCV-87 MCH-31.3 MCHC-35.9* RDW-14.2 Plt ___
___ 10:35PM BLOOD WBC-7.8 RBC-3.36* Hgb-10.6* Hct-29.1*
MCV-87 MCH-31.5 MCHC-36.3* RDW-14.3 Plt ___
___ 10:00PM BLOOD Glucose-146* UreaN-10 Creat-0.8 Na-134
K-4.0 Cl-99 HCO3-29 AnGap-10
___ 10:00PM BLOOD ALT-38 AST-32 CK(CPK)-125 AlkPhos-51
TotBili-0.9
___ 10:00PM BLOOD CK-MB-1 cTropnT-<0.01
___ 10:35PM BLOOD proBNP-1039*
___ 10:00PM BLOOD Calcium-7.8* Phos-2.1*# Mg-1.8
___ 05:25AM BLOOD Calcium-7.8* Phos-2.8 Mg-1.8
.
MICROBIOLOGY:
___ 1:09 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
.
Cardiovascular Report ECG Study Date of ___ 11:31:14 AM
Sinus rhythm with premature atrial contractions. RSR' pattern in
leads V1-V2, probably normal variant. Non-specific inferior T
wave flattening. No previous tracing available for comparison.
.
___ ___ M ___ ___
Cardiovascular Report ECG Study Date of ___ 9:13:06 ___
Atrial fibrillation with rapid ventricular rate. Incomplete
right
bundle-branch block. There is one millimeter horizontal
downsloping ST segment depression in lead I. There is slight ST
segment sagging in lead aVL. There is one millimeter horizontal
upsloping ST segment depression in lead II with non-specific
slightly upsloping J point depression in lead aVF. There is one
to one and a half millimeter upsloping to horizontal ST segment
depression in leads V4-V6. Compared to the previous tracing
atrial fibrillation with rapid ventricular rate has replaced
normal sinus rhythm. Incomplete right bundle-branch block is
unchanged. Inferolateral repolarization abnormalities are
concerning for an ongoing ischemic process. Clinical correlation
is suggested.
.
RADIOLOGY
Radiology Report CHEST (PORTABLE AP) Study Date of ___ 9:35
___
FINDINGS: The lung volumes are normal. Normal size of the
cardiac
silhouette. No pulmonary edema. No pleural effusion. Minimal
atelectasis at the left lung bases, and retrocardiac location,
the change could be better evaluated on the lateral radiograph.
No pneumothorax. No pneumonia. No overt pulmonary edema.
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
___ and had an evacuation of hematoma and closure of
abdominoplasty s/p hematoma. He was transfused with 4 units of
PRBCs and 2 platelet transfusions. The patient tolerated the
procedure well. Patient had 2 JP drains placed that initially
put out sanguinous fluid that gradually turned serous during
inpatient stay. On POD#3, the right lower abdominal JP drain
fell out. An abdominal binder was maintained to assist with
compression to abdominal incision post-operatively.
.
Neuro: Post-operatively, the patient received dilaudid PCA with
good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
On POD#3, patient complained of increasing right ankle pain
which he attributed to possible gouty flare. Patient was
restarted on home dose of colchicine with good effect. Patient
reported good relief by POD#4.
.
CV: On the evening of POD#1, patient went into atrial
fibrillation with RVR confirmed by EKG. He was given lopressor
IV x 2 without effect at which point he was transferred to the
ICU for IV administration of amioderone and cardiology consult.
Patient converted to sinus by the morning of POD#2 and was
switched to PO amioderone per cardiology recommendation. He was
then transferred back to the floor and PO amioderone was
discontinued in favor of his home antiarrhythmic, Multaq 400
milligram 2 times a day which was restarted in the evening along
with home Toprol dose. On POD#3, patient restarted home AM
medications including toprol, lisinopril, spironolactone and
multaq. Patient became hypotensive to 70's/40s in the afternoon
and was monitored closely. Lisinopril and spironolactone were
discontinued and toprol and multaq maintained. Patient will
follow up with home cardiologist regarding blood pressure
medications and anticoagulation plan.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. Intake and output were closely
monitored.
.
ID: Post-operatively, the patient was started on IV cefazolin,
then switched to PO cefadroxil for discharge home. The patient's
temperature was closely watched for signs of infection.
.
Prophylaxis: The patient wore pneumoboots while in bed and was
encouraged to get up and get out of bed to chair and to ambulate
as early as possible.
.
At the time of discharge on POD#4, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating with walker, voiding without assistance, and pain was
well controlled. Lower abdominal incision was clean and intact
and left JP was draining serous fluid.
Medications on Admission:
Pradaxa 150 mg PO twice daily
Colcrys 0.6 milligrams PO once daily
Lisinopril 40 milligrams PO once daily
Lovastatin 20 milligram PO once daily
Multaq 400 milligram 2 times a day
Spironolactone 25 mg PO once a day
Toprol XL 100/50 mg PO twice a day (100 mg in AM, 50 mg in ___
Potassium cloride 20 milliequivalents PO 2 times daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
2. cefaDROXil *NF* 500 mg Oral Q12H Duration: 7 Days
RX *cefadroxil 500 mg 1 capsule(s) by mouth every twelve (12)
hours Disp #*14 Capsule Refills:*0
3. Colchicine 0.6 mg PO DAILY
4. Dronedarone 400 mg PO BID
5. Metoprolol Succinate XL 50 mg PO QPM
6. Metoprolol Succinate XL 100 mg PO QAM
7. Pantoprazole 40 mg PO Q24H
8. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*50 Tablet Refills:*0
9. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
11. Senna 1 TAB PO HS
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
1) bleeding s/p abdominoplasty
2) atrial fibrillation
3) right foot pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Requires assistance with walker
Discharge Instructions:
You were admitted on ___ for bleeding/hematoma after an
abdominoplasty at an outside hospital. Your heart also had an
abnormal heart rhythm called atrial fibrillation and you were
seen by Cardiology for this. Please follow these discharge
instructions.
.
Personal Care:
1. You may leave your incisions open to air.
2. Clean around the drain site(s), where the tubing exits the
skin, with soap and water.
3. Strip drain tubing, empty bulb(s), and record output(s) ___
times per day.
4. A written record of the daily output from each drain should
be brought to every follow-up appointment. Your drains will be
removed as soon as possible when the daily output tapers off to
an acceptable amount.
5. You may shower but do not bathe in a tub until cleared by
your plastic surgeon.
6. You should keep your abdominal binder in place until
instructed otherwise by your plastic surgeon.
.
Activity:
1. You may resume your regular diet.
2. DO NOT lift anything heavier than 5 pounds or engage in
strenuous activity until instructed by your plastic surgeon.
.
Medications:
1. Resume your regular medications except for the Pradaxa. This
has been discontinued. You should HOLD your daily Lisinopril,
spironolactone, and potassium. Continue your Toprol and
Dronedarone. You should take your blood pressure prior daily
and record values in a log that you will bring to your follow up
Cardiologist appointment. This will give him an idea of how it
is running on the current medication regimen.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Take your antibiotic as prescribed.
5. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
6. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
7. do not take any medicines such as Motrin, Aspirin, Advil or
Ibuprofen etc
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
DRAIN DISCHARGE INSTRUCTIONS
You are being discharged with drain in place. Drain care is a
clean procedure. Wash your hands thoroughly with soap and warm
water before performing drain care. Perform drainage care twice
a day. Try to empty the drain at the same time each day. Pull
the stopper out of the drainage bottle and empty the drainage
fluid into the measuring cup. Record the amount of drainage
fluid on the record sheet. Reestablish drain suction.
Followup Instructions:
___
|
10856638-DS-14
| 10,856,638 | 28,627,577 |
DS
| 14 |
2148-08-14 00:00:00
|
2148-08-15 13:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
leg swelling and pain
Major Surgical or Invasive Procedure:
Pacemaker placement
History of Present Illness:
Mr. ___ is a ___ y/o male with a PMH of HFrEF (EF ___, CAD
s/p BMS ___, HTN, HLD, Chronic Hep C, polysubstance use
disorder, multiple psychiatric comorbidities who presented with
worsening leg swelling and pain, found to have complete heart
block on ECG.
History obtained primarily from medical record as patient
altered
and somnolent at time of admission. He was hospitalized at ___
___ and left against medical advice on ___. He was
admitted with ___ edema, shortness of breath with weight of
87.6kg, echo with EF of 15%. Recent underwent RHC showing PCWP
19
at 86.6kg ago, precise dry weight unknown. He was initially
diuresed with Lasix drip but there were issues with compliance
and patient would disconnect drip due to report of not working.
Patient then diuresed effectively with 80mg IV Lasix BID.
Exacerbations felt to be driven by atrial tachycardia and
cocaine
use. Felt to be euvolemic on ___ (weight ~85 kg) at
transitioned
to home torsemide 60mg PO daily.
Patient underwent an EP study on ___ which showed focal septal
atrial tachycardia. The His bundle was injured on ablation and
caused intermittent complete heart block with an escape rhythm
of
50-60bpm, and the atrial tachycardia was no successfully
terminated. Plan for AVJ ablation and CRT-D however patient
eloped prior to the procedure on ___.
Patient in ED reported hematemesis vs hemoptysis, but he is
unsure if he coughed up blood or vomited blood two times a few
days ago. He also complained of a sore on his buttock that is
___ pain, but he denies trauma to the area. He denies CP/SOB,
nausea, vomiting, diarrhea. He endorses tobacco, ETOH,
marijuana,
and cocaine use. His last cocaine use was 1 day ago.
In the ED,
- Initial vitals were: T 96.3, HR 66, BP 108/80, RR 20 O2 sat
100% on RA
- Exam notable for: NAD, systolic flow murmur, diminished
breath
sounds over lower lung fields, 2+ pitting edema to knees, 1cm
ulcerations to R and L buttock near gluteal cleft inferior to
sacrum
- Labs notable for: Hgb 10.4, Na 135, K 5.4, Cr 1.5, Trop
0.21,
ProBNP 9042, INR 2.0
- Studies notable for: EKG multiple PVCs, possible CHB vs 2:1
AV conduction delay with narrow ventricular escape, prolonged
QTc
- Patient was given: 40mg PO Lasix, 1mg PO lorazepam,
flumazenil
0.2mg
On arrival to the CCU, patient was bradycardic but HD stable,
asleep, and not cooperating with interview. He would not wake up
to answer questions. Upon reassessment, he is more alert and
answers questions. He reports that he has had leg swelling and
pain for the past two-three days. He denies chest pain. He
denies
shortness of breath. He states that he has not had access to
medications since discharge from ___.
Past Medical History:
Cardiac History:
- CAD s/p stent details unknown at time of admission
- HFrEF (20%)
Other PMH:
- Hep C
- Substance Use Disorder
- PTSD
- Schizophrenia
- Bipolar Disorder
- Atrial Tachycardia
Social History:
___
Family History:
Reports mother died of heart issues last year; denies other
family history of heart attack.
Physical Exam:
VS: HR 56 BP 82/46 -> 104/63 RR 12 O2sat 94% on RA
GENERAL: Well developed, well nourished sleeping in bed.
Refusing
to answer questions. Not participating in questions. Generally
moving around trying to find a comfortable position
HEENT: Normocephalic, atraumatic. Erythematous conjunctiva.
Pupils 2 mm bilaterally, minimally responsive
NECK: Supple. JVP not visualized.
CARDIAC: Bradycardic. Normal S1/S2. Systolic murmur heard.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No adventitious breath
sounds.
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, 2+ edema to shins.
SKIN: No significant lesions or rashes on arms or legs.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
___ 05:33AM ___ PTT-30.4 ___
___ 05:33AM PLT COUNT-244
___ 05:33AM NEUTS-67.5 LYMPHS-16.5* MONOS-14.5* EOS-0.7*
BASOS-0.4 NUC RBCS-0.3* IM ___ AbsNeut-4.78 AbsLymp-1.17*
AbsMono-1.03* AbsEos-0.05 AbsBaso-0.03
___ 05:33AM WBC-7.1 RBC-4.50* HGB-10.4* HCT-35.1* MCV-78*
MCH-23.1* MCHC-29.6* RDW-23.1* RDWSD-62.9*
___ 05:33AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG tricyclic-NEG
___ 05:33AM Trep Ab-NEG
___ 05:33AM CRP-19.0*
___ 05:33AM TSH-1.6
___ 05:33AM calTIBC-430 FERRITIN-90 TRF-331
___ 05:33AM CALCIUM-9.0 PHOSPHATE-4.3 MAGNESIUM-1.9
IRON-57
___ 05:33AM proBNP-9042*
___ 05:33AM cTropnT-0.21*
___ 05:33AM GLUCOSE-103* UREA N-32* CREAT-1.7*
SODIUM-129* POTASSIUM-9.6* CHLORIDE-95* TOTAL CO2-25 ANION
GAP-9*
___ 07:06AM estGFR-Using this
___ 07:06AM GLUCOSE-94 CREAT-1.5* NA+-135 K+-5.4
___ 11:16PM URINE opiates-NEG cocaine-POS* amphetmn-NEG
mthdone-NEG marijuana-POS*
___ 11:16PM URINE HOURS-RANDOM
+ EKG - EKG multiple PVCs, possible CHB vs 2:1 AV conduction
delay with narrow ventricular escape, prolonged QTc (587)
+ TTE ___:
The left atrium is elongated. The right atrium is markedly
enlarged. There is mild symmetric left ventricular
hypertrophy with a moderately increased/dilated cavity. There is
SEVERE global left ventricular hypokinesis.
The visually estimated left ventricular ejection fraction is
20%.
There is no resting left ventricular
outflow tract gradient. Diastolic function could not be
assessed.
Mildly dilated right ventricular cavity with
moderate global free wall hypokinesis. Intrinsic right
ventricular systolic function is likely lower due to the
severity of tricuspid regurgitation. The aortic sinus diameter
is
normal for gender with normal ascending aorta
diameter for gender. There is a normal descending aorta
diameter.
The aortic valve leaflets (3) appear
structurally normal. No masses or vegetations are seen on the
aortic valve. There is no aortic valve stenosis.
There is no aortic regurgitation. The mitral valve leaflets
appear structurally normal with no mitral valve
prolapse. No masses or vegetations are seen on the mitral valve.
There is mild to moderate [___] mitral
regurgitation. The pulmonic valve leaflets are normal. The
tricuspid valve leaflets appear structurally normal.
No mass/vegetation are seen on the tricuspid valve. There is
moderate to severe [3+] tricuspid regurgitation.
There is mild-moderate pulmonary artery systolic hypetension. In
the setting of at least moderate to severe
tricuspid regurgitation, the pulmonary artery systolic pressure
may be UNDERestimated. There is no
pericardial effusion.
IMPRESSION: Dilated left ventricle with severe global
hypokinesis. Mild right ventricular cavity
dilation with moderate global hypokinesis. At least
mild/moderate
mitral regurgitation. Severe
tricuspid regurgitation with at least mild to moderate pulmonary
hypertension.
+ CXR - linear bibasilar atelectasis
Brief Hospital Course:
===========================
TRANSITIONAL ISSUES
===========================
SUMMARY: Mr. ___ is a ___ y/o M with a history of CAD, HFrEF
(20%), COPD,
complete heart block, Polysubstance use, who presents with ___
days of dyspnea, weight gain, and orthopnea in the setting of
not being able to get his medicines after leaving AMA from ___
___ days ago. Pt was found to be in complete heart block with
acute HF exacerbation. He was diuresed with several doses of
40mg IV ___ and CRT-D was placed from subclavian vein (lead in
RA, defib in RV and bundle in LV port).
====================
Acute Medical Issues
====================
#Complete Heart block
Iatrogenic in setting of recent attempt of atrial septal focus
of atrial tachycardia. Has narrow ventricular escape. In setting
of underlying HFrEF, CAD. He is asymptomatic. TTE with no
evidence of valvular disease. CRP elevated raising concern for
occult infection. TSH wnl. EP placed ___ MRI CRT-D on ___.
The device was appropriately positioned and functioning well.
Some mild concern on ___ if device was properly capturing, EP
reassessed in the AM and device was well-functioning. He was
d/c'ed with follow up in Device Clinic for an appointment on
___.
#Heart Failure with Reduced EF 20%:
#Mild volume overload
Given report of only single vessel stenting, appears out of
proportion to coronary disease. Heart failure may be due to ETOH
or cocaine use. Mildly volume overloaded with peripheral edema.
ProBNP 9042 on admission. Diursed with several doses of of 40mg
IV Lasix.
-Preload: Resume maintenance diuretic 60mg torsemide PO
-Afterload: Held off on afterload agents but pt will need to
have appropriate follow-up, and appointment has been set up at
Heart Failure Clinic.
-NHBK: NO beta blockers in setting of active cocaine use
#Elevated INR
Unclear etiology possibly due to congestive hepatopathy,
nutritional deficiency, hep C infection. Initial transaminases
mildly elevated ALT 44, AST 42, AP 154, Tbli 1.9. INR normalized
with several doses of vitamin K.
=====================
Chronic Medical Issues
======================
#Apparent intoxication
Patient initially quite somnolent upon arrival to CCU. Was not
able to consent to procedure due to intoxication. In setting of
cocaine, marijuana use, administration of Ativan. Patient
subsequently more alert. Urine tox screen positive for marijuana
and cocaine
___ Cr 1.7 from baseline ___ per ___ records. Not
necessarily cardiorenal given low suspicion for decompensated
heart failure. Back to baseline 1.1-1.2
#Polysubstance Use
#Homelessness
Patient with history of tobacco, ETOH, marijuana, and cocaine
use. last use of cocaine reported ___. Monitored for acute
withdrawal and social work was consulted.
#Microcytic Anemia: Hgb 10.4 with MCV of 78. Possibly due to
iron deficiency, chronic disease, or kidney disease. Iron
studies ___ Ferritin 90, TIBC 430, Transferrin 331.
#CAD
BMS in ___, unclear vessel. Plavix recently discontinued as
beyond necessary treatment window for DAPT. Continued on ASA
81mg daily and atorvastatin 80mg daily.
#Vasculitis
- Obtain ___ CTA
- recent ___ discharge paperwork notes transitional issue to
obtain non-urgent Brain MRI
#Reactive airways disease
He is breathing comfortably on room air with good O2 saturation.
He received duonebs PRN.
#Chronic Hep C
Not on treatment
#PTSD
#Bipolar Disorder
#Schizophrenia
Not on medications currently.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Torsemide Dose is Unknown PO TID
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
3. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
4. Atorvastatin 80 mg PO QPM
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Torsemide 60 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. HELD- Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
This medication was held. Do not restart Albuterol Inhaler
until you visit the CDAC
5. HELD- Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain This
medication was held. Do not restart Nitroglycerin SL until you
visit the CDAC on ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Heart Failure with reduced Fraction (20%)
Complete Heart block status ___ CRT-D placement
Elevated INR
Cocaine use
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at ___.
Why was I admitted to the hospital?
- You had worsening leg swelling
- You were found to have an abnormal heart rhythm
What happened while I was in the hospital?
- You were given medications to remove fluid
- You underwent a procedure to place a pacemaker and a
defibrillator to protect your heart from the abnormal rhythm
What should I do now that I am leaving the hospital?
- Continue to take your medications. Remember that your water
pill, torsemide, should be taken every day. If you think that
you have more swelling in your legs or difficulty breathing,
please take 1 additional pill every other day.
- Proceed to your appointments with the cardiologists (see
below): The first appointment you have is this upcoming ___
on ___ at 9:00 AM. The rest of your appointments are
listed below.
- Please stop using all cocaine products, which is very
stressful for the heart and will make the heart much worse.
Thank you for allowing us to participate in your care,
Your CCU Team
Followup Instructions:
___
|
10856703-DS-13
| 10,856,703 | 28,443,063 |
DS
| 13 |
2145-04-30 00:00:00
|
2145-08-06 11:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
fall from horse
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Fall from a horse, wearing a helmet, head strike. Patient denied
loss of consciousness but had dizziness post fall with back and
neck ___. She was found to have L1 fracture and L2,L3
nondisplaced fractures, and possible cervical spine process
injury. Hematocrit original drop with CTA of liver finding of
hemangioma vs extravasation.
Past Medical History:
epilepsy
anxiety
asthma with recent exacerbations, bronchitis
depression
mild cognitive impairment, hx of skull fracture
closed head trauma
concussions
toe fractures
Past Surgical History:
Bilateral breast reduction in ___
Social History:
___
Family History:
Father- renal cancer
Mother, brother- schizophrenia
sister- breast cancer
Physical Exam:
Admission physical exam- please see ACS ER trauma History and
physical sheet in scanned documents
Discharge Physical Exam:
VS: 98.2T HR 74 BP 102/60 RR 16 96% SpO2, on room air
General: No acute distress, sitting in a chair with TLSO brace
in place and ___ J collar. Clear and fluid speech
HEENT: NCAT, EOMI, no scleral icterus/injection/hemorrhage
CV: RRR, no murmurs/rubs/gallops, S1 and S2 present
PULM: Clear to auscultation bilaterally, with no adventitious
sounds
Abd: soft, nontender, nondistended.
Ext: moving all 4 extremities, no paresthesia or weakness noted.
No peripheral edema.
Pertinent Results:
___ 04:00AM BLOOD WBC-7.6 RBC-3.96 Hgb-12.3 Hct-38.2 MCV-97
MCH-31.1 MCHC-32.2 RDW-11.9 RDWSD-42.0 Plt ___
___ 02:55PM BLOOD WBC-7.1 RBC-3.75* Hgb-11.5 Hct-35.8
MCV-96 MCH-30.7 MCHC-32.1 RDW-11.9 RDWSD-41.8 Plt ___
___ 02:10PM BLOOD WBC-7.2 RBC-3.63* Hgb-11.4 Hct-33.8*
MCV-93 MCH-31.4 MCHC-33.7 RDW-12.0 RDWSD-41.9 Plt ___
___ 08:15AM BLOOD WBC-6.0# RBC-3.07* Hgb-9.8* Hct-29.8*
MCV-97 MCH-31.9 MCHC-32.9 RDW-12.1 RDWSD-42.8 Plt ___
___ 02:20PM BLOOD WBC-13.9* RBC-3.76* Hgb-11.8 Hct-35.7
MCV-95 MCH-31.4 MCHC-33.1 RDW-12.1 RDWSD-42.2 Plt ___
___ 08:15AM BLOOD Neuts-70.5 Lymphs-18.0* Monos-9.9
Eos-0.8* Baso-0.3 Im ___ AbsNeut-4.19 AbsLymp-1.07*
AbsMono-0.59 AbsEos-0.05 AbsBaso-0.02
___ 04:00AM BLOOD Plt ___
___ 08:15AM BLOOD Plt ___
___ 02:20PM BLOOD ___ PTT-23.8* ___
___ 02:20PM BLOOD Plt ___
___ 02:20PM BLOOD ___
___ 02:20PM BLOOD UreaN-16 Creat-1.0
___ 04:00AM BLOOD ALT-11 AST-19 AlkPhos-92 TotBili-0.2
___:20PM BLOOD Lipase-39
___ 02:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:50PM BLOOD pO2-35* pCO2-35 pH-7.46* calTCO2-26 Base
XS-1
___ 02:50PM BLOOD Lactate-1.9
___ 02:50PM BLOOD Hgb-11.8* calcHCT-35
Imaging:
Brief Hospital Course:
She was admitted. efforts were made to control pain. She was
initially on bed rest. She had a TLSO brace fitted. C-collar was
kept in place.
She was seen by ___ and OT who felt that there was no need for
further tx/consult
discussed findings with ortho spine team and Dr. ___
l2-l3, said ok for dc with tlso; She is to f.u 2 weeks in his
office.
incidental findings , a possible portal arterial shunt was
discussed with ___- she is aware of future imaging needs.
She was discharge with collar and TLSO.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LamoTRIgine 50 mg PO NOON
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. PARoxetine 40 mg PO DAILY
4. LamoTRIgine 200 mg PO BID
5. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
PRN wheezing
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 325 mg 1 to 2 tablet(s) by mouth every six (6)
hours Disp #*35 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 (One) tablet(s) by mouth twice a
day Disp #*45 Tablet Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
RX *oxycodone 5 mg 1 (One) tablet(s) by mouth up to every four
(4) hours Disp #*18 Tablet Refills:*0
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. LamoTRIgine 200 mg PO BID
Take as previously
6. LamoTRIgine 50 mg PO NOON
7. PARoxetine 40 mg PO DAILY
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
PRN wheezing
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma, fall from horse:
-Lumbar 1 vertebrae compression fracture, Lumbar 2 and Lumbar 3
vertebrae nondisplaced fractures
-hyperattenuation in hepatic segment 7, possible hemangioma
- left upper renal pole 1.4centimeter hypodense lesion
- 1.3 centimeter cyst in left adnexa
Trauma, fall from horse:
-L1 vertebrae compression fracture, L2 and L3 vertebrae
nondisplaced fractures
-hyperattenuation in hepatic segment 7, possible hemangioma
- left upper renal pole 1.4cm hypodense lesion
- 1.3cm cyst in left adnexa
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ after suffering a fall from a horse.
You were found to have lumbar spine fractures and were fitted
with a TLSO brace. You should continue to wear this brace when
you are out of bed or moving/walking. Due to a possible cervical
(neck) spine process injury, you also have a collar on at all
times until your follow up visit. Your blood counts initially
had decreased, and you had an additional scan to look for a
source of bleeding, of which none was found. Your blood counts
were watched and were found to be stable and increasing. Once
you had your brace, you worked with the physical and
occupational therapists. You have recovered well, are eating a
regular diet and your pain is well controlled with oral
medications. You are now ready for discharge home to continue
your recovery. Please follow the directions below to ensure a
speedy return to your normal life:
You had incidental findings on your imaging, which were
discussed with you. You will need renal(kidney) and pelvic
ultrasounds. In addition, you will need imaging in 3 months to
re-evaluate the liver finding to make sure it is not changing.
Activity:
- Please continue the exercises and practices advised to you by
the physical and occupational therapists.
- The ___ representative educated you on your TLSO brace. You
are to continue to wear this brace whenever you get out of bed
and when you are moving (walking).
- Avoid bending, twisting, or lifting more than 5 pounds.
- Wear the C-collar (collar on your neck) at all times until
your follow up appointment. The orthopedic surgeon will evaluate
you and determine if you need to continue wearing this collar.
- Do not drive until you have stopped taking pain medicine, you
feel you could respond in an emergency, and once your brace is
cleared (removed) by your surgeon.
- You may climb stairs. You should continue to walk several
times a day.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
YOUR BOWELS:
- Constipation is a common side effect of narcotic pain medicine
such as oxycodone. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
- You are being discharged with a prescription for oxycodone for
pain control. You may take Tylenol as directed, not to exceed
3000mg in 24 hours. Take the Tylenol (acetaminophen) regularly
for a few days after surgery but you may skip a dose or increase
time between doses if you are not having pain until you no
longer need it. You may take the oxycodone for moderate and
severe pain not controlled by the Tylenol. You may take a stool
softener while on narcotics to help prevent the constipation
that they may cause. Slowly wean off these medications as
tolerated.
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- chest pain, pressure, squeezing, or tightness
- cough, shortness of breath, wheezing
- pain that is getting worse over time or pain with fever
- shaking chills, fever of more than 101
- a drastic change in nature or quality of your pain
- nausea and vomiting, inability to tolerate fluids, food, or
your medications
- if you are getting dehydrated (dry mouth, rapid heart beat,
feeling dizzy or faint especially while standing)
-any change in your symptoms or any symptoms that concern you
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.
Please call with any questions or concerns. Thank you for
allowing us to participate in your care. We hope you have a
quick return to your usual life and activities.
Your ___ Surgery Team
Followup Instructions:
___
|
10856915-DS-21
| 10,856,915 | 22,893,151 |
DS
| 21 |
2140-02-29 00:00:00
|
2140-02-29 12:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left hip pain
Major Surgical or Invasive Procedure:
___ Left hip hemiarthroplasty
History of Present Illness:
A ___ year old female with PMH fo osteoporosis, depression had a
mechanical fall on ___, injuring her left hip and was
ampulating with a cane until today when she felt a pop while
walking and was suddenly unable to bear weight. No new fall.
Previously ambulatory without assistance. Hx of Right hip
replacement at ___ ___ year ago for a fall and hip
fracture. Pt denies numbness, weakness, abd pain, cp, sob,
lightheadedness, n/v.
Past Medical History:
Depression, ospeoporosis, right hip replacement in ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision healing well with staples
* Scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 05:50AM BLOOD Hct-32.5*
___ 10:50AM BLOOD Neuts-80.8* Lymphs-11.6* Monos-5.6
Eos-1.5 Baso-0.6
___ 04:55AM BLOOD Plt ___
___ 04:55AM BLOOD Glucose-149* UreaN-15 Creat-0.6 Na-131*
K-3.7 Cl-95* HCO3-28 AnGap-12
___ 04:55AM BLOOD Calcium-8.0* Phos-1.7*# Mg-2.0
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left fem neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for Left hip hemiarthroplasty , which
the patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to a facility was appropriate. The
___ hospital course was otherwise unremarkable. At the
time of discharge the patient was afebrile with stable vital
signs that were within normal limits, pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT LLE wiht posterior precuations, and will be discharged on
lovenox for DVT prophylaxis. The patient will follow up in two
weeks per routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course, and all questions were answered prior to discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion 300 mg PO DAILY
2. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Multivitamins 1 CAP PO DAILY
3. Vitamin D 800 UNIT PO DAILY
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
5. BuPROPion 300 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
7. Calcium Carbonate 1250 mg PO TID
8. Enoxaparin Sodium 40 mg SC DAILY Duration: 28 Doses
Start: Today - ___, First Dose: Next Routine Administration
Time
9. Senna 8.6 mg PO DAILY
10. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
MEDICATIONS:- Please take all medications as prescribed by your
physicians at discharge.- Continue all home medications unless
specifically instructed to stop by your surgeon.- Do not drink
alcohol, drive a motor vehicle, or operate machinery while
taking narcotic pain relievers.- Narcotic pain relievers can
cause constipation, so you should drink eight 8oz glasses of
water daily and take a stool softener (colace) to prevent this
side effect.
ANTICOAGULATION:- Please take lovenox 40mg daily for 2 weeks
WOUND
CARE:- No baths or swimming for at least 4 weeks.- Any stitches
or staples that need to be removed will be taken out at your
2-week follow up appointment.- No dressing is needed if wound
continues to be non-draining.-
ACTIVITY AND WEIGHT BEARING:- WBAT LLE with posterior
precuations
Physical Therapy:
ACTIVITY AND WEIGHT BEARING:- WBAT LLE with posterior
precuations
Treatments Frequency:
CARE:- No baths or swimming for at least 4 weeks.- Any stitches
or staples that need to be removed will be taken out at your
2-week follow up appointment.- No dressing is needed if wound
continues to be non-draining.-
ACTIVITY AND WEIGHT BEARING:- WBAT LLE with posterior
precuations
Followup Instructions:
___
|
10857046-DS-11
| 10,857,046 | 28,458,301 |
DS
| 11 |
2160-12-18 00:00:00
|
2160-12-27 19:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
amoxillin
Attending: ___.
Chief Complaint:
Polytrauma s/p bicycle crash:
1. Left ___ and 5th rib fractures
2. Left pneumothorax
3. Left clavicle fracture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ otherwise healthy who was training for a triathalon who hit
a pothole while riding his bike and flipped over the handlebars.
He had a +HS, no LOC, and landed on his left shoulder. Had pain
in his left shoulder, came to ___ for further evaluation.
Denies paresthesias.
Past Medical History:
none
Social History:
___
Family History:
noncontributory
Physical Exam:
PE: 98.0 78 138/94 18 100%
Alert and oriented x3, in pain, GCS 15
left occipitoparietal scalp lac repaired with staples by ED
midface stable, no malocclusion, PERRL, EOMI, tympanic membranes
clear
Trachea midline, no neck crepitus, c-spine cleared by ED, no
c-spine tenderness
Visible soft tissue swelling over left clavicle, no chest wall
crepitus
Large superficial abrasions over majority of back, predominantly
on left side, some TTP on left chest wall
Minor skin abrasions L hand
Abdomen soft, NT/ND
No pelvic instability
No visible injuries to bilateral ___ other than superficial
abrasions, sensation/motor intact
Pertinent Results:
LABS:
137 101 11
--------------<101
3.8 24 1.1
9.5>43.2<207
N:56.5 L:37.3 M:4.3 E:1.1 Bas:0.7
INR: 1.1
IMAGING:
CXR:
Known small left pneumothorax better seen on CT of the cervical
spine. Left third and fifth rib and left midclavicular fractures
appear acute.
Pelvic film:
There is no fracture or focal osseous abnormality. Pubic
symphysis and SI joints are preserved. Soft tissues are
unremarkable.
Elbow film:
There is no fracture or focal osseous abnormality. There is no
elbow joint effusion. Soft tissues are unremarkable.
CT head:
1. No acute intracranial abnormality.
2. Left parietal subgaleal hematoma.
3. Extensive sinus disease, as above.
CT C-Spine:
1. Small, apical left pneumothorax.
2. Simple, oblique, moderately displaced fracture of the mid
left
clavicle seen only on the scout images.
3. Nondisplaced fracture through the lateral aspect of the left
fifth rib, also seen only on the scout images.
4. No evidence of fracture or malalignment within the cervical
spine.
5. Mild-moderate cervical osteoarthritis.
Brief Hospital Course:
___ bicyclist thrown over handlebars of bicycle, +head strike,
no LOC, presented to ___ for evaluation complaining of left
sided chest pain. Injuries found were several left sided rib
fractures, mid clavicular fracture with moderate displacement,
and small pneumothorax. The patient was hemodynamically stable
and did not require a chest tube. Orthopedic Surgery was
consulted for the clavicle fracture, and they recommended no
immediate surgery, sling for comfort, and outpatient follow up.
He was admitted to the ACS service for pain management,
continuous O2 saturation monitoring, and serial chest xrays. On
HD#2 the tertiary exam was negative for any subsequent injuries.
The chest xray showed no interval increase in size of the
pneumothorax and the patient's respiratory status was stable.
Physical therapy signed off on the patient, as he was ambulatory
and demonstrating good function of the left arm with minimal
pain. The patient was tolerating a regular diet and his pain was
well controlled.
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 on HD#2, the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The patient was discharged home without
services. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
do not exceed 3000mg/day
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Ibuprofen 400-600 mg PO Q6H
take with food
RX *ibuprofen 200 mg ___ tablet(s) by mouth every six (6) hours
Disp #*20 Tablet Refills:*0
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
do not drink alcohol while taking
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Polytrauma:
1. Left ___ and 5th rib fractures
2. Left pneumothorax
3. Left clavicle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ after sustaining injuries from a
bicycle accident. Your injuries included a left rib fracture, a
clavicle fracture, and a small injury to your lung. You were
observed overnight and your chest x-ray this morning shows no
progression of the lung injury. Your vital signs have all been
stable and your pain is under control. The Orthopedic doctors
have examined your clavicle and you may wear a sling for comfort
and follow-up in the ___ clinic. Please note the
following discharge instructions:
* Your injury caused several rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10857236-DS-4
| 10,857,236 | 27,357,814 |
DS
| 4 |
2149-12-07 00:00:00
|
2149-12-06 16:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
pedestrian hit by car
Major Surgical or Invasive Procedure:
No invasive procedures. Non operative treatment of hip
fractures.
History of Present Illness:
This is a ___ year old female on Motrin who stepped off a
median strip today and was struck by a car on her right side.
The accident was witnessed. The patient is reported to have
stood up immediately after being struck however was amnestic to
the event. There was no loss of consciousness. Patient reports
headache, denies nausea or vomiting. She was transferred from
OSH after being and at presentation was +LOC, gcs 15,
hemodynamically stable w/ bilat SAH, R sup to inf pelvic rami
fx, r orbital lat wall & max sinus fracture
Patient was transfered from outside hospital and OSH films: Ct
head, CT face, CT abdomen/pelvis show SAH (small amount on Right
and Left sides), R maxillary fx, pelvic fx, small pelvic
hemorrhage.
List of Injuries:
RIGHT maxillary fx
RIGHT lateral orbital wall fx
displ.fx R sup to inf pubic rami
Small RIGHT & LEFT SAH
R ___ hematoma
Nasal bone fx
Past Medical History:
?schizophrenia/dementia
HTN
hysterectomy
breast Bx
Social History:
___
Family History:
Non contributory
Physical Exam:
Admission:
PE: Vitals: T 97.6 P 58 BP 136/90 R 17 O2sat 95% on RA
Gen: NAD, A+Ox3
Neuro: CN II - XII intact
Scalp: No lacerations on scalp. No step-offs.
Face: Significant R ___ bruising. There is no
flattening of the malar eminences. There is no nasal deviation.
The midface stable to palpation, jaw occlusion normal by exam
and
by direct questioning of the patient, no palpable stepoffs but
these are difficult to assess due to marked swelling.
3cm facial laceration lateral to the R eye with abrasions on the
R cheek.
Eyes: PERRLA, EOMI, moderate periorbital swelling and
ecchymosis,
moderate subconjunctival hemorrhage, no visible corneal injury,
no enophthalmos or exophthalmos on the left or right.
Ears: No hemotympanum, no otorrhea
Nose: Symmetrical without palpable stepoffs with no obvious
nasal
fracture, septum midline, no septal hematoma, no rhinorrhea
Mouth: No intraoral lacerations, fair dentition, no loose teeth,
normal occlusion, maxilla and mandible stable w/o palpable step
offs, TMJ stable
Right lower extremity:
Skin intact
Soft, non-tender thigh and leg. Bruising around knee, with
minor
abrasion and swelling.
Full, moderate painful AROM/PROM of hip, knee, no pain ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
+DP, foot warm and well-perfused
Left lower extremity:
Skin intact
Soft, non-tender thigh and leg
Knee swollen, more than right, with ecchymosis
Full, moderately painful AROM/PROM of hip, knee, no pain ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
+DP pulses, foot warm and well-perfused
At Discharge:
General: Comfortable in chair
Chest: CTAB, tender to palpation on R chest and sternum from
acute on chronic injuries to the ribs
CV: RRR no mrg
Abdomnen: soft, nttp, non distended, no rebound or guarding
Ext: Distal pulses intact, R knee with hematoma and tenderness
to palpation
Pertinent Results:
___ 04:51PM GLUCOSE-134* UREA N-24* CREAT-0.6 SODIUM-137
POTASSIUM-3.2* CHLORIDE-109* TOTAL CO2-20* ANION GAP-11
___ 04:51PM CALCIUM-6.5* PHOSPHATE-2.8 MAGNESIUM-1.1*
___ 04:51PM WBC-14.3* RBC-3.35* HGB-10.4* HCT-29.6*
MCV-89 MCH-31.2 MCHC-35.2* RDW-12.9
___ 12:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Brief Hospital Course:
___ year old female who was struck by a car on the right side
when she stepped off the curb and was hit at about 15mph. The
patient is reported to have stood up immediately after being
struck however was amnestic to the event. Upon further review
there was no loss of consciousness. She was seen at ___
where she was reported to have GSC 15 with +LOC, gcs 15 and
___ transfered from outside hospital to
___.
At transfer to ___ the patient was HDS with GSC 15. T 97.6 P
58 BP 136/90 sO2 95% She had images obtained and she was
started on IV antibiotics. SQH was started and we continued q4
neuro checks for her neurological injuries. Trauma Surgery
admitted the patient to the trauma ICU for management of
traumatic subarachnoid hemorrhage and pelvic fracture. She was
awake, alert/oriented. Bilateral traumatic and started on keppra
500mg bid and with BP control for pain she received Tylenol PRN
and tramadol. Her C spine was cleared. She was recuscitated with
IVF and vasopressor was used PRN. She was placed on 2L NC and
breathed comfortably. She was placed on stress ulcer
prophylaxis. She was started on a regular diet and we trended
her hematocrits which were stable. She was on sub q heparin and
pressure boots for dvt prophylaxis. She had a mild elevation in
Cr after imaging but this resolved with hydration.
The list of consultants included:
Neurosurgery - The neurosurgery service noted that she was noted
on arrival to be neurologically intact. A CT scan done at an
outside hospital showed very small bilateral subarachnoid
hemorrhages. Her cervical spine CT scan did not show any
fracture or malalignment. On exam the day after her admission,
she remained neurologically intact. There is no neurosurgical
intervention indicated. She should remain on keppra 500mg bid
for 7 days. A repeat head CT should be obtained
only if there is a change in her neurologic exam/mental status.
She will be seen as an outpatient and is scheduled for follow
up.
Ophthalmology - The opthamology service was consutled and they
noted multiple facial fractures including lateral orbital wall
fracture of the right eye, pelvic fracture and small
subarachnoid hemorrhage. Small subconjunctival hemorrhage of the
right eye, no other ocular injury on exam. For the small
subconjunctival hemorrhage OD they offered artificial tears as
needed for irritation and recommended time and to avoid
ibuprofen and aspirin if possible. They recommend followup with
BI general ophthalmology clinic on discharge or with own
ophthalmologist
Orthopedics was consulted and they evaluated her to have a a
stable pelvic fracture that is a lateral compression type with
no major widening. If she
continues to have possible pelvic bleeding I would recommend
angiography which was not necessary. They recommended
closed/non-operative treatment. They recommended follow up with
___ in ___ weeks for repeat xrays of her pelvis.
Plastic Surgery was consulted and they repaired the 3cm facial
laceration with sutures.
Trauma surgery transfered the patient to the floor on HD 2 where
she finished her recuperation. She was medically ready for
discharge but required a few days of rehab screening to find a
place for ___ rehabilitation. She was seen by physical
therapy who have been working with her. At discharge she
demonstrates
improved mental status compared with initial evaluation,
currently requires min-mod assist for standing transfers and
stationary marching and was unable to progress to gait training
___ pain with ___ weightbearing, decreased standing balance
and c/o "wooziness" ___ pain meds. They recommended OOB to chair
with RW and assist for all meals, Bed/chair alarm on for safety
at all time, and frequent reorientation and normalization of
sleep/wake cycle to minimize risk of delirium.
At discharge she is alert awake and oriented x3, HDS, afebrile,
eating by herself, and voiding and stooling normally. Her pain
is under control and her follow up appointments have been made.
She is ready for further rehab at a rehab facility.
List of Imaging:
IMAGING:
-Maxillofacial CT ___: Acute fracture of the medial and
lateral maxillary sinus walls posteriorly with hemorrhage
layering within the right maxillary sinus. Right lateral orbital
wall fracture, nondisplaced. No retro-orbital hematoma.
Significant right periorbital swelling and hematoma. Age
indeterminate fractures of the left nasal bone and frontal
process of the maxilla on the right.
-C-spine CT ___: Degenerative changes without fracture or
acute malalignment. A 1.3 cm left thyroid nodule which can be
further assessed by a nonurgent thyroid ultrasound.
-CT Head ___: Subarachnoid hemorrhage in the left sylvian
fissure and right frontal sulcus.
-CT abd/pelvis ___: There is fracture of the right
inferior and superior ramus of the pubis, as well as right
posterior ilium.
Subcutaneous hematoma at the right hip. Incidentally noted is a
cystic structure in the left hemi pelvis measuring 7.2 x 5.7 cm.
Multi nodular thyroid goiter. Small left pleural effusion. Left
renal cyst. Bladder stone.
-XR R femur ___: Known superior and inferior pubic rami
fractures are better seen on prior CT scan. Excreted contrast
seen in the pelvis. Soft tissue swelling seen in the soft
tissues overlying the greater trochanter. Degenerative changes
are noted at the knee with joint space loss and osteophyte
formation. Multiple calcific densities noted in the soft
tissues. Soft tissue swelling seen overlying the patella. There
is no fracture at the knee.
-XR R shoulder ___: There is no acute fracture.
Degenerative changes noted at the glenohumeral joint. There is a
high-riding humerus suggesting underlying chronic rotator cuff
injury. Included portions of the right hemi thorax are
unremarkable.
Of note, patient was found to have a RLL Pulm nodule and a left
adnexal mass which she should follow up with her PCP.
Medications on Admission:
Ibuprofen PO PRN
HCTZ 25mg PO q day
Lisinopril 5mg PO q day
Risperidol 0.5mg PO TID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Heparin 5000 UNIT SC BID
4. Hydrochlorothiazide 25 mg PO DAILY
5. LeVETiracetam 500 mg PO BID
Your dosing will finish with your second dose on ___
6. Lidocaine 5% Patch 1 PTCH TD QAM chest wall pain
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4 Disp #*40 Tablet
Refills:*0
8. RISperidone 0.5 mg PO TID
9. Senna 8.6 mg PO BID:PRN constipation
10. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth q 6hrs Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
bilateral SAH, R sup to inf pelvic rami fracture, right orbital
lateral wall & max sinus fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Your head injuries:
A CT scan done at an outside hospital showed very small
bilateral
subarachnoid hemorrhages. Her cervical spine CT scan did not
show any fracture or malalignment. On exam the day after her
admission, she remained neurologically intact. There is no
neurosurgical intervention indicated. She should remain on
keppra 500mg bid for 7 days. A repeat head CT should be
obtained
only if there is a change in her neurologic exam/mental status.
**You will need to take Keppra for 2 more days after
discharge.**
Your hip injuries:
Did not require surgery. You will need to take sub q heparin
shots at the rehab facility to keep you from forming clots. You
can follow up with ___ in ___ weeks for repeat
xrays of her pelvis.
Your eye injuries:
Small subconjunctival hemorrhage OD
- artificial tears as needed for irritation
- will resolve on it's own
- avoid ibuprofen and aspirin if possible
- followup with ___ general ophthalmology clinic on discharge or
with your own ophthalmologist
Rib Fractures:
* Your injury caused old rib fractures to hurt more which can
cause severe pain and subsequently cause you to take shallow
breaths because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10857996-DS-28
| 10,857,996 | 20,830,453 |
DS
| 28 |
2136-10-20 00:00:00
|
2136-10-20 16:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Rituxan / Omeprazole / levetiracetam
Attending: ___.
Chief Complaint:
dysarthria, facial droop, seizures
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ is a ___ year old woman with history of large R
frontoparietal stroke and R cerebellar infarct ___ Afib
who presents with acute onset left facial droop and dysarthria.
History is obtained from the daughter, as the patient is unable
to provide a history. Essentially, the patient was otherwise in
her usual state of health until 8PM, when she and her daughter
went to bed. The daughter then heard strange sounds coming from
her mother's room, described as a high pitched grunting. She ran
into the room, and found her mother sitting on the side of the
bed appearing confused, with left facial droop and slurring of
her words. She did not notice significant weakness or other
neurologic symptoms. She was immediately concerned, and called
EMS.
The daughter denies recent sick symptoms at home, or other
events
concerning for seizures.
In the ED, the staff noticed several seconds of left facial
twitching, which resolved on its own. During Neurology
evaluation, the patient became less responsive, with left gaze
deviation, left arm tonic clonic jerking, which lasted 2
minutes.
She did receive 1mg of IV Ativan with subsequent return to her
baseline, though she did appear confused afterward. She also
received a 20mg/kg of keppra IV.
Of note, she presented to ___ in ___ for similar concerns
of worsened left sided weakness and seizure activity. She was
started on keppra at this time and discharged. She did see Dr.
___ in Stroke clinic in ___, who noted that the family
had
stopped her keppra after 3 doses due to worsening depression and
unusual thoughts. He recommended another AED, but the family
declined given only one seizure. Her Coumadin was kept at
current
dose, though the idea of a NoAC was broached.
On neurologic review of systems, the family reports that the
patient was not endorsing any headache, difficulty with
producing
or comprehending speech, visual changes, slurred speech, urinary
incontinence.
General review of systems as noted above.
Past Medical History:
Low grade B-cell Lymphoma: She was last treated for her
low-grade
lymphoma in ___, when she received her sixth cycle of RCVP
chemotherapy. This was followed by maintenance Rituxan for ___
years and she has had no therapy for her low-grade lymphoma
since
___.
Ischemic CVA R frontoparietal, temporal, cerebellar ___
Hx MI ___ managed medically
Low-grade NHL s/p R-CVP in ___ now in remission
Hypertension
HLD
Hypothyroidism
GERD
Atrophic Pancreas
Lactose Intolerance
Abdominal Wall Hernias
Arthritis - L knee
Cataracts
Frequent falls
Vitamin D deficiency
Social History:
___
Family History:
No family history of strokes
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals:
P 90 BP 142/99 RR 23 97% RA
General: anxious, chronically ill appearing
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: irregularly irregular
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert tracking examiner. Unable to
relate
history. Lying on bed muttering incomprehensible sounds. Does
not
follow commands.
- Cranial Nerves: Right pupil is opaque, very slightly reactive.
Left pupil 3->2. No BTT bilaterally, though difficult due to
patient's mental status. She has a left facial droop.
- Sensorimotor: decreased bulk. unable to perform
confrontational
testing, but does move right arm and bilateral legs
spontaneously
antigravity. left arm with less spontaneous movement, but does
resist examiner's manipulation against arm flexion/extension.
does appear to withdraw to noxious in all four extremities.
- Reflexes: 1+ throughout. left upgoing toe, right downgoing
- Coordination/Gait: deferred.
DISCHARGE EXAM
Vitals:
Tmax: 37.3 °C (99.2 °F)
Tcurrent: 36.2 °C (97.2 °F)
HR: 82 (47 - 88) bpm
BP: 109/62(75) {88/54(65) - 140/109(116)} mmHg
RR: 15 (9 - 18) insp/min
SpO2: 99%
Heart rhythm: SB (Sinus Bradycardia), LBBB (Left Bundle Branch
Block)
General: awake, alert, chronically ill appearing
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: irregularly irregular
Pulmonary: non labored on room air
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert. Attends to examiner.
Spontaneously speaks in brief ___ phrases, at other times
incomprehensible speech. Unable to relate history via daughter.
Does not follow commands. No evidence of hemineglect.
- Cranial Nerves: Right pupil is opaque, very slightly reactive.
Left pupil 3->2. Left facial droop.
- Sensorimotor: decreased bulk. Moves right arm and bilateral
legs spontaneously in plane of bed. The left arm and leg has
less
spontaneous movement, but does move antigravity, not against
resistance. Unable to assess individual muscle groups due to
motor impersistence.
- Reflexes: 1+ throughout. left upgoing toe, right downgoing
- Coordination: no overt evidence of ataxia, though limited
assessment given mental status
- Gait: able to ambulate with rolling walker, required cues for
steering and maintaining correct direction in tight spaces. Slow
cadence, and short shuffled steps. No significant ataxia or
sway.
Pertinent Results:
LABORATORY STUDIES:
BLOOD WBC-6.2 RBC-4.34 Hgb-12.8 Hct-38.9 MCV-90 MCH-29.5
MCHC-32.9 RDW-15.1 RDWSD-49.3* Plt ___
BLOOD Glucose-98 UreaN-22* Creat-0.8 Na-145 K-4.3 Cl-109*
HCO3-24 AnGap-16
BLOOD Calcium-9.2 Phos-3.7 Mg-1.9
BLOOD %HbA1c-5.5 eAG-111
BLOOD Triglyc-90 HDL-54 CHOL/HD-1.9 LDLcalc-29
BLOOD TSH-0.97
URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-0.2 pH-7.0 Leuks-TR
URINE RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-0
URINE Color-Yellow Appear-Clear Sp ___
URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG
amphetm-NEG oxycodn-NEG mthdone-NEG
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
*****************
IMAGING STUDIES:
CT Head w/o contrast ___. Motion limited exam.
2. No acute hemorrhage seen.
3. Small area of effaced gray/white matter differentiation in
the left
occipital lobe appears new, suggesting an evolving acute
infarction or
subacute infarction.
4. Chronic infarctions are again seen in the right frontal lobe,
right
parietal/occipital lobes, and right posterior inferior
cerebellar hemisphere.
Brief Hospital Course:
___ year old woman with history of large R frontoparietal stroke
and R cerebellar infarction in Feburary ___ atrial
fibrillation who presents with acute onset left facial droop and
dysarthria. She also was noted to have focal motor seizures
characterized by left facial twitching, with or without left
eye/head deviation, tonic contraction of left arm, with no loss
of awareness.
#Left Occipital Stroke: For workup of her symptoms, she was
found to have a new left occipital infarct. The etiology for
this stroke is likely cardioembolic given known history of
atrial fibrillation and prior strokes. It was difficult to
assess if she had any new symptoms from this stroke. In
particular a left occipital stroke would classically cause a
right homonymous hemianopia, but this was difficult to assess
given that she had right eye blindness at baseline and was a
poor historian. She remained in atrial fibrillation on
telemetry. Stroke risk factors included hemoglobin A1c 5.5, LDL
29, and TSH 0.97. MRI brain w/o contrast was deferred given
clear etiology for recurrent seizure, frailty and hyperactive
delirium. She was evaluated by ___ and recommended for discharge
home with 24 hour supervision. This was discussed at length with
family who voiced understanding. She was continued on Warfarin
for goal INR ___.
#Seizures: The most likely etiology for her seizures, on the
other hand, is more likely related to prior right frontoparietal
infarctions given left sided motor activity. Given that her old
infarct is continuing to act as a seizure focus, she was started
on anti epileptic therapy. Unfortunately, Keppra seemed to
worsen her mental status. As a result, she was transitioned to
lacosamide 100mg BID and taken off of the Keppra. She was
monitored for 24 hours on lacosamide without seizures and
tolerated it well, without significant sedation or further
seizures. Her mental status improved as well to her baseline.
#Hyperactive delirium: Her hospital course was otherwise notable
for hyperactive delirium, for which she did require small
amounts of zyprexa as needed. This was likely due to
hospital-acquired delirium in setting of elderly age, multiple
medical comorbidities, with possible contribution from new
stroke and lacosamide. Infectious workup did include a
relatively benign UA (WBC 4, RBC 1, few bacteria) which was not
treated given that she improved in terms of her mental status.
#Bradycardia: Patient was noted to have intermittent bradycardia
to ___ during hospitalization, often with HRs running in
___. Her home metoprolol was held given its AV nodal
effects. This can be re-assessed as an outpatient.
TRANSITIONAL ISSUES:
- Follow up with Stroke Neurology as scheduled, Dr. ___, on
___ at 2:30 ___. Should you wish to follow up with Dr. ___
___, please contact his office. Currently there were no
available appointments within the next ___ months, but you could
be placed on a waiting list.
- Continue Warfarin as directed by ___ clinic for
goal INR ___.
- Continue Lacosamide 100mg BID for seizure prophylaxis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Mirtazapine 7.5 mg PO QHS
6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
7. Nystatin Cream 1 Appl TP DAILY:PRN itching
8. Ranitidine 150 mg PO BID
9. Warfarin 1 mg PO AS DIRECTED
Discharge Medications:
1. LACOSamide 100 mg PO BID
RX *lacosamide [Vimpat] 100 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*3
2. Warfarin 2 mg PO 5X/WEEK (___)
3. Warfarin 3 mg PO 2X/WEEK (WE,SA)
4. Atorvastatin 40 mg PO QPM
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Lisinopril 2.5 mg PO DAILY
7. Mirtazapine 7.5 mg PO QHS
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
9. Nystatin Cream 1 Appl TP DAILY:PRN itching
10. Ranitidine 150 mg PO BID
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Left occipital ischemic stroke
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of seizure, facial droop
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
-atrial fibrillation (irregular heart rhythm)
-prior strokes
We are changing your medications as follows:
-Started lacosamide (vimpat), an anti-seizure medication
-Stopped metoprolol (Lopressor) given low heart rate during your
hospital stay
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10858252-DS-13
| 10,858,252 | 24,338,398 |
DS
| 13 |
2183-12-04 00:00:00
|
2183-12-04 17:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Protonix
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ year old female w/ PMH significant for
resolved HTN and DM who presented with leg weakness and a weak
voice.
She was in USOH until last night, according to her daughter. Her
daughter was with her last night. She noted that coming out of
bathroom the patient had stated her left knee hurt, and her
daughter noted she was having trouble standing, with the L leg
buckling. They helped her into bed. She was able to do leg
kicking exercises while laying in bed without an issue, and she
did not have other symptoms. She then went to sleep. On waking
up, she appeared tired, and her voice was soft, which was new
from the previous night. She seemed globally weak and she
continued to have problems walking, she needed wheelchair
instead of a walker. She was still reporting L knee pain. She
sometimes uses a wheelchair at baseline. She appeared engaged in
the morning news, per family, which had reported on the arrest
___. The nurse are her assisted living thought her
voice seemed slightly slurred. Her daughter did not note any
speech slurring or facial droop. Her speech content and
understanding was normal. Her lower dentures were not in. She
was brought in to ___ for evaluation. There is no known
history of previous stroke. She had not had any recent
infectious symptoms.
At baseline she lives in assisted living, needs help with
showering and dressing. Walks with walker or wheelchair. She has
had progressive difficulties with ambulation over the years as
she has gotten older. She did have b/l hip replacements
previously.
ROS:
On neurological review of systems, the patient denies headache,
confusion, difficulties producing or comprehending speech, loss
of vision, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denies
focal weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the patient denies recent fever,
chills, night sweats, or recent weight changes. Denies cough,
shortness of breath, chest pain or tightness, palpitations.
Denies nausea, vomiting, diarrhea, constipation or abdominal
pain. Denies dysuria, or recent change in bowel or bladder
habits. Denies arthralgias, myalgias, or rash.
Past Medical History:
colon ca s/p colectomy ___
hip replacement Bbl ___ years ago
HTN no longer on meds as resolved
DM no longer on meds as resolved
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
Vitals: T99.2 HR72 BP 150/96RR 20 Spo296% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert. states Age as ___, month as ___.
Attentive, to conversation. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Able to describe where she was born and lived
in the past. Names majority of objects on stroke card correctly,
has difficulty seeing some of them due to vision. Can name pen,
watch dial, watch, watch hands. Able to read without difficulty.
Speech soft, somewhat hard to understand, lower dentures not in
place. Able to follow both midline and appendicular commands.
There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm . EOMI without nystagmus. Normal
saccades. VFF to finger wiggle. Has low vision in L eye
chronically
V: Facial sensation intact to light touch.
VII: mouth appears somewhat asymmetric, nasolabial folds appear
equal
VIII: Hearing intact to conversation
IX, X: Palate elevates symmetrically.
XI:
XII: Tongue protrudes in midline
-Motor:
decreased bulk throughout. No pronator drift.
No adventitious movements, such as tremor or asterixis noted.
[___]
L 5 5 5 5 5 ___ 3 5 5 5
R 5 5 5 5 5 ___ 5 5 5 5
Able to overcome all muscle groups, but appears symmetric except
for where noted.
Able to keep L arm up for 10 seconds without issue
Quad and hamstring testing elicit grimace and ___, appears pain
limited.
-Sensory: No deficits to light touch, pinprick, temperature,
vibration, throughout. No extinction to DSS. Romberg absent.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. Occasional slight dysmetria on FNF seen on L arm
-Gait: deferred
DISCHARGE EXAM:
===============
Pertinent Results:
LABS RESULTS:
============
___ 08:35AM BLOOD WBC-6.6 RBC-4.02 Hgb-11.6 Hct-35.7 MCV-89
MCH-28.9 MCHC-32.5 RDW-14.0 RDWSD-45.4 Plt ___
___ 08:35AM BLOOD Neuts-85.4* Lymphs-7.3* Monos-6.3
Eos-0.3* Baso-0.2 Im ___ AbsNeut-5.66 AbsLymp-0.48*
AbsMono-0.42 AbsEos-0.02* AbsBaso-0.01
___ 08:35AM BLOOD ___ PTT-28.0 ___
___ 08:35AM BLOOD ALT-11 AST-21 AlkPhos-118* TotBili-0.5
___ 08:35AM BLOOD cTropnT-0.01
___ 08:35AM BLOOD Albumin-3.8 Cholest-156
___ 08:35AM BLOOD %HbA1c-5.3 eAG-105
___ 08:35AM BLOOD Triglyc-86 HDL-67 CHOL/HD-2.3 LDLcalc-72
___ 08:35AM BLOOD TSH-1.2
___ 08:43AM BLOOD Glucose-101 Creat-0.6 Na-137 K-3.7 Cl-103
calHCO3-30
___ 06:10AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.2
___ 05:25AM BLOOD ALT-9 AST-17 LD(LDH)-205 AlkPhos-99
TotBili-0.6
___ 06:10AM BLOOD Glucose-88 UreaN-21* Creat-0.6 Na-143
K-3.3* Cl-106 HCO3-22 AnGap-15
___ 06:10AM BLOOD WBC-5.4 RBC-3.56* Hgb-10.3* Hct-31.4*
MCV-88 MCH-28.9 MCHC-32.8 RDW-13.8 RDWSD-45.1 Plt ___
___ 06:10AM BLOOD WBC-5.4 RBC-3.56* Hgb-10.3* Hct-31.4*
MCV-88 MCH-28.9 MCHC-32.8 RDW-13.8 RDWSD-45.1 Plt ___
RADIOLOGY
==========
TTE: Mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global biventricular systolic function.
Mild-moderate mitral regurgitation. Mild aortic regurgitation.
Mild pulmonary artery systolic hypertension.
HCT: No evidence of acute large territorial infarction. A
subacute right pontine infarction is better assessed on recent
MRI. Otherwise severe chronic ischemic changes appear similar.
No evidence of intracranial hemorrhage.
CTA: 1. CT perfusion analysis demonstrates a possible penumbra
involving the right
frontal lobe. No core infarct or intracranial hemorrhage.
2. No stenosis, occlusion or aneurysm of the circle of ___
vessels.
3. No stenosis, occlusion or dissection of the cervical vessels.
4. Left thyroid lobe not visualized and likely surgically
absent.
5. Cervical spondylosis with 2 mm anterior subluxation of C7-T1,
moderate to
severe bilateral foraminal narrowing at C5-6 and C6-7 and mild
spinal canal narrowing at C5-6 and C6-7.
MRI BRAIN
1. Small late acute infarct involving the right pons and left
peritrigonal
occipital lobe. No hemorrhage.
2. Subcentimeter old infarcts in the left pons and left
cerebellum.
3. Extensive chronic microangiopathy changes.
4. Additional findings described above.
TTE: Mild symmetric left ventricular hypertrophy with normal
cavity size and regional/
global biventricular systolic function. Mild-moderate mitral
regurgitation. Mild aortic
regurgitation. Mild pulmonary artery systolic hypertension
Brief Hospital Course:
Mrs. ___ is a ___ year old female with past medical history
significant for hypertension (no longer on medications as
improved) and type II diabetes (no longer on meds) who presented
with dysarthria, left sided weakness, and left knee
pain/effusion. NIHSS was 3 on admission. No tpa was given as she
was out of window. No large vessel occlusion on imaging. MRI
brain showed small R pontine stroke. NCHCT showed old stroke,
likely small vessel disease, as lacunar basal ganglia location.
She was admitted to the stroke service for further workup and
management. Her stroke risk factor evaluation included: TTE with
only mild biventricular dilation, normal EF; TSH 1.4; HbA1c 5.5;
LDL 53.
While admitted Mrs. ___ demonstrated improvement in her motor
function of the left side, however it is still limited. She will
be discharged to a rehab facility to help improve her
functioning even further.
Other medical issues during her hospitalization included a
urinary tract infection with Klebsiella for which she received 3
days for ceftriaxone. She had intermittent periods of confusion
and hallucinations, likely delirium. She had a repeat HCT at one
point during these episodes which did not show new change.
Speech and swallow followed her as well and noted she was having
difficulty with swallowing therefore recommended pureed diet.
She also had difficulty meeting her nutrition goals, nutrition
was consulted. Lisinopril was restarted for hypertension
management and may need to be titrated further.
TRANSITIONAL ISSUES:
[] QTC 520, will need PCP follow up and possibly cardiology
referral
[] Hypertension management per PCP
[] Nutrition and oral intake, advance diet
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL =53 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? () Yes - (x) No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 1000 mcg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Ferrous Sulfate 325 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Ascorbic Acid ___ mg PO DAILY
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 1000 mcg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Ferrous Sulfate 325 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Ascorbic Acid ___ mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
5. Lisinopril 10 mg PO QPM
6. Ramelteon 8 mg PO QHS
7. Ascorbic Acid ___ mg PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Stroke
Discharge Condition:
Stable
Discharge Instructions:
Dear ___,
___ were admitted to ___ because your
caregivers noticed that ___ were having difficulty walking and
your speech sounded different. Imaging of your brain (a CT scan
and MRI) showed that ___ had suffered a small stroke in an area
of the brain called the pons. While in the hospital, ___ were
started on several medications to help prevent another stroke,
including aspirin, plavix, lisinopril, and atorvastatin.
Additionally, ___ were found to have a urinary tract infection,
and were given antibiotics to treat this.
It was our pleasure to care for ___ while admitted to the
hospital. Thank ___ for involving us in your care.
Sincerely,
___ Neurology
Followup Instructions:
___
|
10858336-DS-22
| 10,858,336 | 24,433,114 |
DS
| 22 |
2182-04-08 00:00:00
|
2182-04-08 18:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
simvastatin / naproxen / Lipitor / lisinopril / potassium /
oxybutynin
Attending: ___.
Chief Complaint:
abdominal pain, bloody stools
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ ___ speaking female with a past
medical history of hypertension, hyperlipidemia, diabetes, AAA
(ultrasound ___ cm) who presented to the emergency
department today with abdominal pain. Over the past day, patient
noted periumbilical and suprapubic crampy abdominal pain that
comes and goes. Pain associated nausea and one episode of
nonbloody emesis. Pain does not radiate to the back. Last night,
patient also describes episodes of severe pain with associated
diaphoresis. This morning, her pain did improve after having a
bowel movement. She did note blood on the toilet paper and on
the
stool. No dysuria or hematuria, but increased frequency
recently.
Otherwise, she denies any shortness of breath, any chest pain,
lightheadedness, dizziness, abdominal pain. No headaches or
vision changes.
She has a history of multiple UTIs with E. Coli resistant to
multiple abx.
In the ED, initial VS were: 97.2 64 157/73 19 100% RA
Exam notable for:
DRE- brown stool, guaiac neg, visible external hemorrhoid
Abdomen- pulsatile mass, periumbilical and suprapubic tenderness
without rebound tenderness or guarding.
Labs showed:
Chem7 was 137/6.0 (hemolyzed, 4.2 on blood gas) ___
with
gluc 162. CBC WBC 11.7 H/H 12.4/37.8, Plts 188
UA with >182 WBC, few bacteria, 11 RBC, Neg nitrite, Lg Leuk.
Lactate was 2.0 then 1.7.
UCx, BCx x 2, fecal cultures, O&P and c. dif all sent.
Imaging showed:
CT Abd pelvis with contrast:
1. Descending colitis of infectious, inflammatory, or ischemic
etiology.
2. Stable size and appearance of bilobed infrarenal abdominal
aortic aneurysm measuring up to 3 cm.
3. Dilated left gonadal vein and left-sided pelvic varices which
is
nonspecific but can be seen in the setting of pelvic congestion
syndrome.
Per ED - bedside US - AAA (unchanged from previous)
EKG NSR at 57, 1st degree block, normal axis, QTc 477
Patient received:
IV CefTRIAXone 1 gm
IVF NS 1000 mL
PO Nitrofurantoin Monohyd (MacroBID) 100 mg
Surgery was consulted. Noted no ischemic changes noted, and
recommended admission to medicine. Final recs have not been
determined.
Transfer VS were: 99.1 64 142/80 16 96% RA
On arrival to the floor, patient reports still having watery
stools with blood. She notes no dysuria, CP. Continues to have
abdominal pain. No SOB.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
Hypothyroidism
Sleep apnea
Diabetes mellitus type II
Hypertension
Gout
HLD
Appendectomy
Varicose vein surgery
CAD
h/o stomach ulcer
Social History:
___
Family History:
Both parents died at ___ from old age; no known heart disease.
She has two sisters and two brothers, all living in good health.
There is no family history of premature heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.1 173/91 66 18 97% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink
conjunctiva,MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, very mild tenderness to deep palpation,
no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
T: 97.9 PO BP: 122 / 64 HR: 50 RR: 18 O2: 97 RA
GENERAL: NAD, elderly woman lying in bed
HEENT: AT/NC, anicteric sclera, OP clear, MMM
NECK: supple
HEART: RRR, s1/S2, mild systolic murmur
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender, +BS, no rebound or guarding
SKIN: no rashes or lesions
NEURO: A&Ox3, moving all 4 extremities with purpose
Pertinent Results:
ADMISSION LABS
___ 05:35PM BLOOD WBC-11.7* RBC-4.08 Hgb-12.4 Hct-37.8
MCV-93 MCH-30.4 MCHC-32.8 RDW-12.8 RDWSD-43.6 Plt ___
___ 05:35PM BLOOD Neuts-73.4* Lymphs-16.6* Monos-8.2
Eos-1.0 Baso-0.4 Im ___ AbsNeut-8.56* AbsLymp-1.94
AbsMono-0.96* AbsEos-0.12 AbsBaso-0.05
___ 05:35PM BLOOD Glucose-162* UreaN-26* Creat-0.7 Na-137
K-6.0* Cl-98 HCO3-26 AnGap-13
___ 05:35PM BLOOD ALT-22 AST-50* LD(LDH)-610* AlkPhos-87
TotBili-0.8
___ 05:35PM BLOOD Lipase-29
___ 05:35PM BLOOD Albumin-4.3
___ 05:34PM BLOOD Lactate-2.0 K-4.2
DISCHARGE LABS
___ 06:15AM BLOOD WBC-6.8 RBC-3.83* Hgb-12.0 Hct-35.2
MCV-92 MCH-31.3 MCHC-34.1 RDW-12.9 RDWSD-42.7 Plt ___
___ 06:15AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.0
URINE STUDIES
___ 03:49PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 03:49PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-LG*
___ 03:49PM URINE RBC-11* WBC->182* Bacteri-FEW* Yeast-NONE
Epi-0
MICROBIOLOGY
___ 3:49 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 12:05 am STOOL CONSISTENCY: WATERY 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).
IMAGING:
CT abdomen/pelvis with contrast ___
1. Descending colitis of infectious, inflammatory, or ischemic
etiology.
2. Stable size and appearance of bilobed infrarenal abdominal
aortic aneurysm measuring up to 3 cm.
3. Dilated left gonadal vein and left-sided pelvic varices which
is
nonspecific but can be seen in the setting of pelvic congestion
syndrome.
CTA abdomen/pelvis ___
1. Descending colon colitis, differential includes ischemic,
infectious, or inflammatory etiologies. No significant stenosis
of the celiac axis, SMA, or ___.
2. Infrarenal abdominal aortic aneurysm measuring up to 3.4 cm
with associated penetrating atherosclerotic ulcer.
3. Mild nonspecific thickening of upper vaginal wall for which
clinical
correlation is recommended.
Brief Hospital Course:
Ms. ___ is a ___ ___ speaking female with a PMH
of hypertension, hyperlipidemia, diabetes, AAA (ultrasound
___ cm) who presented to the emergency department with
abdominal pain. CT scan showed colitis and diverticulosis
without diverticulitis. CTA did not show significant lesions in
the major arteries supplying the intestines. Her abdominal pain
and hematochezia resolved.
ACUTE ISSUES:
=============
#Colitis
CT abdomen/pelvis showed colitis and diverticulosis without
diverticulitis. Surgery evaluated her in the ED and recommended
against surgical intervention. Differential includes ischemic vs
infectious vs segmental diverticulosis associated with colitis.
Patient has risk factors for ischemic colitis, but CTA showed no
significant lesions in the major arteries supplying the
intestines. C diff negative; ova/parasites negative. Her diet
was advanced from NPO to liquids to regular, which she tolerated
well. She was started on cipro/flagyl, which she will continue
for a total of 10 days. Her abdominal pain and hematochezia
resolved by the time of discharge.
#Suprapubic pain
Patient with suprapubic pain on presentation, initially
concerning for UTI. She has had multiple past UTIs with cultures
growing E Coli with variable resistance. However, urine cx on
this hospitalization showed <10 000 cfu and we stopped macrobid.
Patient asymptomatic at time of discharge.
#Nonspecific thickening of vaginal wall
Incidental finding on CT scan. Patient will follow up with
ob/gyn on an outpatient basis.
CHRONIC ISSUES:
===============
#Hypothyroidism
We continued her home synthroid.
#Sleep apnea
We continued her CPAP.
#Diabetes mellitus type II
She was treated with sliding scale insulin while in hospital. We
held her home metformin.
#Hypertension
We continued her home amlodipine.
#Gout
We continued her home allopurinol.
#HLD
We continued her home crestor and ezetimibe.
#CAD
We continued her home aspirin and metoprolol.
TRANSITIONAL ISSUES:
[ ] Patient was started on ciprofloxacin 500 mg q12h and
metronidazole 500 mg q8h on ___ and should continue this for
a total of 10 days (end date ___.
[ ] Nonspecific vaginal wall thickening (incidental finding on
CT scan) should be f/u by ob/gyn. Patient has appointment set
up.
[ ] Patient has known abdominal aortic aneurysm measuring 3.4
cm. She will need annual follow up ultrasound.
>30 minutes were spent on discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO BID
2. Ezetimibe 10 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Levothyroxine Sodium 100 mcg PO 1X/WEEK (___)
5. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
6. Metoprolol Tartrate 25 mg PO BID
7. Rosuvastatin Calcium 20 mg PO QD
8. Zolpidem Tartrate 5 mg PO QHS
9. Aspirin 81 mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
11. Fish Oil (Omega 3) 1200 mg PO BID
12. amLODIPine 5 mg PO DAILY
13. Loratadine 10 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*13 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth 3 times a day Disp
#*20 Tablet Refills:*0
3. Allopurinol ___ mg PO BID
4. amLODIPine 5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Ezetimibe 10 mg PO DAILY
7. Fish Oil (Omega 3) 1200 mg PO BID
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Levothyroxine Sodium 100 mcg PO 1X/WEEK (___)
on ___
10. Loratadine 10 mg PO DAILY
11. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
12. Metoprolol Tartrate 25 mg PO BID
13. Rosuvastatin Calcium 20 mg PO QD
14. Vitamin D ___ UNIT PO DAILY
15. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
infectious colitis
Secondary:
hypothyroidism
sleep apnea
diabetes type II
hypertension
gout
hyperlipidemia
coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You presented to ___ with abdominal pain and bloody
stools. You had a CT scan, which showed that you had some
inflammation of your colon. You were treated with antibiotics,
and you began to feel better. You should continue the
antibiotics after you leave the hospital. Please also follow up
with your primary care doctor and gynecologist (see below for
appointments).
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
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