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10858336-DS-23
| 10,858,336 | 27,752,267 |
DS
| 23 |
2183-12-14 00:00:00
|
2183-12-14 20:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
simvastatin / naproxen / Lipitor / lisinopril / potassium /
oxybutynin / Ambien / Bactroban / losartan
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ presenting with 24 hours of vague, diffuse abdominal pain
that became severe ___, associated with nausea and vomiting at
home x1 (but none since here). She had a small bowel movement
today. She cant tell when was the last time she passed flatus.
Denies similar episodes of pain in the past. No fevers, no chest
pain.
ROS: negative for 14 systems except as above
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:
DISCHARGE PHYSICAL EXAM
Gen: [x] NAD, [X] AAOx3
CV: [x] RRR, [] murmur
Resp: [x] breaths unlabored, [] CTAB, [] wheezing, [] rales
Abdomen: [x] soft, [x]non distended, [-] tender, [-]
rebound/guarding
Ext: [x] warm, [] tender, [] edema
Pertinent Results:
LABS
___ 06:48AM BLOOD WBC-9.1 RBC-3.96 Hgb-12.4 Hct-37.3 MCV-94
MCH-31.3 MCHC-33.2 RDW-12.8 RDWSD-44.0 Plt ___
___ 06:48AM BLOOD Glucose-156* UreaN-10 Creat-0.7 Na-143
K-4.2 Cl-102 HCO3-28 AnGap-13
___ 06:48AM BLOOD Calcium-9.6 Phos-3.4 Mg-2.___BDOMEN/PELVIS ___
IMPRESSION:
1. Partial or resolving small bowel obstruction with gradual
transition from
dilated to decompressed small bowel in the left mid abdomen.
2. Stable infrarenal abdominal aortic aneurysm measuring up to
3.2 cm,
previously 3.3 cm.
3. Diverticulosis without diverticulitis.
KUB ___
IMPRESSION:
Oral contrast has passed into the colon.
Brief Hospital Course:
Ms ___ was admitted to the Acute Care Surgery service on
___ with a small bowel obstruction which was demonstrated
on CT abdomen/pelvis. She was hemodynamically normal with a
normal white count on admission.
She was managed conservatively with a nasogastric tube for
decompression. She was kept nothing by mouth with IV fluids for
hydration. On hospital day 2, she reported flatus. Gastrografin
was administered via NGT and a KUB was obtained which
demonstrated contrast passing into the colon. The NGT was
removed and she was started on a clear liquid diet which she
tolerated.
Her diet was advanced to regular on hospital day 3. She
continued to pass gas and began to have bowel movements. She was
ambulating with rolling walker, voiding spontaneously, and
hemodynamically stable. She was therefore discharged home on
___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO BID
2. amLODIPine 5 mg PO DAILY
3. amLODIPine 2.5 mg PO DAILY PRN when BP >140/90 after taking
5mg
4. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
5. Ezetimibe 10 mg PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO BID
9. Montelukast 10 mg PO DAILY
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
11. Omeprazole 20 mg PO DAILY
12. Rosuvastatin Calcium 40 mg PO QPM
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
14. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO BID
2. amLODIPine 5 mg PO DAILY
3. amLODIPine 2.5 mg PO DAILY PRN when BP >140/90 after taking
5mg
4. Aspirin 81 mg PO DAILY
5. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 Duration: 1 Dose
6. Ezetimibe 10 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO DAILY
8. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
9. Metoprolol Tartrate 25 mg PO BID
10. Montelukast 10 mg PO DAILY
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. Omeprazole 20 mg PO DAILY
13. Rosuvastatin Calcium 40 mg PO QPM
14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
Discharge Disposition:
Home
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with a small bowel obstruction. You
were managed with decompression with a nasogastric tube, and
your obstruction resolved on its own. You are now ready to
return home to continue your recovery.
Please see below for detailed instructions.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Followup Instructions:
___
|
10858495-DS-15
| 10,858,495 | 23,599,047 |
DS
| 15 |
2164-11-14 00:00:00
|
2164-11-14 10:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
L hip pain
Major Surgical or Invasive Procedure:
L hip hemi ___
History of Present Illness:
HPI: ___ w/ hx of A fib p/w L hip pain s/p mechanical fall. The
pt states she was walking in her house and tripped over a ground
level fan onto her left side w/ no HS/LOC. On imaging she was
found to have a left intertroch femur fx. She is on Coumadin
daily for Afib. She denies any other complaints.
Past Medical History:
1) HTN
2) HLP
3) Hemifacial spasm treated with botox for ___ years
4) Fractured humerus on left
5) Gout
Social History:
___
Family History:
non contributory
Physical Exam:
Left lower extremity:
- incision c/d/I;
- Full ROM at hip, knee, and ankle
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Pertinent Results:
___ 01:45AM GLUCOSE-125* UREA N-14 CREAT-0.9 SODIUM-133
POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-23 ANION GAP-18
___ 01:45AM WBC-12.1*# RBC-4.27 HGB-13.8 HCT-41.3 MCV-97
MCH-32.3* MCHC-33.4 RDW-13.1 RDWSD-46.1
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 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 skilled
nursing facility 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
weight bearing as tolerated in the left lower extremity, and
will be discharged on home Coumadin 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.
Anticipated stay at ___ <30 days
Medications on Admission:
see medication list
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*100 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
This is a new medication to treat your constipation. please hold
for loose stools
RX *docusate sodium 100 mg 2 capsule(s) by mouth twice per day
Disp #*80 Capsule Refills:*0
3. OxyCODONE (Immediate Release) 2.5 mg PO Q4H
This is a new medication to treat your pain. please wean this as
your pain improves.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed for pain Disp #*80 Tablet Refills:*0
4. Senna 8.6 mg PO DAILY
This is a new medication to treat your constipation. Please hold
for loose stools
RX *sennosides [senna] 8.6 mg 2 tablet by mouth at bedtime Disp
#*40 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L displaced femoral neck fx
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:
- Left Lower extremity: weight bearing as tolerated
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 resume your warfarin as directed
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.
Followup Instructions:
___
|
10859189-DS-10
| 10,859,189 | 25,512,158 |
DS
| 10 |
2153-07-25 00:00:00
|
2153-07-25 17:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
griseofulvin / strawberry / macadamia nut oil / Penicillins
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
___ 07:18AM BLOOD WBC-9.7 RBC-4.48 Hgb-12.1 Hct-38.9 MCV-87
MCH-27.0 MCHC-31.1* RDW-13.5 RDWSD-42.5 Plt ___
___ 07:18AM BLOOD Glucose-106* UreaN-12 Creat-0.8 Na-142
K-4.1 Cl-105 HCO3-27 AnGap-10
___ 07:00AM BLOOD LD(LDH)-186
___ 07:18AM BLOOD Mg-1.8
CXR:
FINDINGS:
Cardiac silhouette and hilar contours are unremarkable. No
focal
consolidation or pulmonary edema. No pleural effusions or
pneumothorax.
Visualized osseous structures are unremarkable.
IMPRESSION:
No evidence of pneumonia.
Brief Hospital Course:
___ h/o asthma, DM2 (diet controlled), HIV (not on HAART - last
CD4 count 232, VL ___ admitted with asthma exacerbation
# Acute Asthma exacerbation:
Patient with recurrent exacerbations over the last several days.
She initially presented with poor peak flow and mild
respiratory distress. CXR neg for PNA. Her trigger is unclear
though may be environmental. She clinically improved with
steroids and nebulizers. The goal will be to better control her
symptoms to avoid repeat hospitalization. Pulm was consulted.
PFTs were surprisingly normal. She was discharged to complete a
short course of PO steroids. IN addition, we increased her
advair to 2 puffs BID, and added flovent 220mcg BID, and
Combivent respimat. IgE levels were PENDING on DC.
# HIV (not on HAART - last CD4 count 232, VL ___
At risk of OI with CD4 count of 232. Denied any other
significant symptoms. LDH was initially elevated but normalized
on recheck. O2 sats normal and CXR unremarkable.
- outpatient follow up
# DM2 - diet controlled
- likely to have elevated blood sugar while on steroids
- given short course of steroids, held on ISS
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Montelukast 10 mg PO QPM
2. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
3. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ONCE:PRN
anaphylaxis
4. Advair HFA (fluticasone propion-salmeterol) 230-21
mcg/actuation inhalation BID
Discharge Medications:
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
RX *fluticasone propionate [Flovent HFA] 110 mcg/actuation 2
puffs INH twice a day Disp #*1 Inhaler Refills:*0
2. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN sob
RX *ipratropium-albuterol [Combivent Respimat] 20 mcg-100
mcg/actuation 1 puff INH twice a day Disp #*1 Inhaler Refills:*0
3. PredniSONE 40 mg PO DAILY
through ___
RX *prednisone 5 mg/5 mL 40 ml by mouth once a day Refills:*0
4. Advair HFA (fluticasone propion-salmeterol) 230-21
mcg/actuation inhalation BID
take 2 PUFFS TWICE A DAY FOR NOW
5. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
6. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ONCE:PRN
anaphylaxis
7. Montelukast 10 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma exacerbation
HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a flare of your asthma. You improved
with steroids and frequent inhalers. You also underwent
Pulmonary Function Tests. It is very important that you take
the regimen as prescribed and follow up closely with your PCP
and new lung doctor as scheduled.
For your steroids, do not take both oral and IV steroids at the
same time.
Please note we recommend increasing your advair to 2 puffs twice
daily.
Please rinse your mouth out vigorously after
Followup Instructions:
___
|
10859189-DS-11
| 10,859,189 | 27,784,793 |
DS
| 11 |
2153-08-02 00:00:00
|
2153-08-05 16:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
griseofulvin / strawberry / macadamia nut oil / Penicillins
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
LP ___
History of Present Illness:
Ms. ___ is a ___ woman with a history
notable
for asthma diabetes controlled on diet and exercise and
congenital HIV infection with CD4 count of 232 and viral load of
4.17 not on HAART who presents with an episode of witnessed
seizure. The patient says she was on a boat with family and
friends when all of a sudden she started to fall sideways she
was
caught by family member. She experienced whole body shaking,
she
lost consciousness for short period of time likely a few seconds
to a minute or 2 afterwards she was groggy and confused. She
also reports urinary incontinence and when she awoke a
frontotemporal headache with photophobia. She has no memory of
the events and these details she says were told to her by family
and friends who witnessed the event. When asked about triggers
she said that she has not been sleeping well the last few days
that she was admitted to the ___ for 2 days this week due to
an
asthma exacerbation. She said she consumed 4 puffs of a
marijuana vaporizer pen on the boat and drank 1 beer. She
denies
other drug use.
Of note she has one prior similar episode about 3 to ___ years ago
where she was showering and then felt an overwhelming sense of
dread that she described as an aura and then she says the next
thing she knew she woke up on the floor covered in urine. She
believes she had an EEG at that time but is not sure and does
not
remember what the study revealed. She also has a history of
migraines that she says occur less than once per month and are
well controlled with rest and occasional ibuprofen she did not
feel that this episode was similar to her typical migraines.
In the ED she was found to be afebrile and normotensive with a
white count of 8.0, UA was negative. She underwent an LP which
revealed normal protein of 22 elevated glucose to 75 and a
pleocytosis out of proportion to the red blood cells in the
sample. She underwent a CT head which was grossly unremarkable.
She was given acyclovir cefepime Bactrim and vancomycin for
broader coverage given concern for her immunosuppressed state,
seizure and headache as well as photophobia. She says the last
few days she has had temperatures running from 99-100.0 but
never
100.4. She says now she feels close to her baseline but still
slightly foggy. Denies history of tics, but says she does hike
often and is not diligent about checking for tics. She cannot
remember any recent mosquito bites, but thinks she could have
been exposed to mosquitos regularly.
OF NOTE DO NOT DISCLOSE HIV STATUS WITH FAMILY AS PER ___ REQUEST
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
asthma
HIV not on HAART
diabetes - well controlled w diet and exercise
Social History:
___
Family History:
Father side of the family has a history which is significant for
epilepsy in the father and one paternal cousin
moms side of the family has significant heart disease
blood clots on moms side of the family
Physical Exam:
Physical Exam:
Vitals:
T97.7
HR70
BP135/83
RR18
O2 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation. Able to relate history without difficulty. Attentive,
able to name ___ backward without difficulty. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were no paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. Pt was able to register 3 objects and recall ___ at 5
minutes. The pt had good knowledge of current events. There was
no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Fundoscopic
exam performed, revealed crisp disc margins with no papilledema,
exudates, or hemorrhages. does endorse subjective photophobia.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation
throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF or HKS
bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent.
Discharge EXAM
===================
24 HR Data (last updated ___ @ 825)
Temp: 98 (Tm 98.4), BP: 109/72 (95-141/57-84), HR: 54
(54-73), RR: 15 (___), O2 sat: 99% (96-100), O2 delivery: RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: +neck stiffness
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation. Able to relate history without difficulty. Attentive,
able to name ___ backward without difficulty. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were no paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. Pt was able to register 3 objects and recall ___ at 5
minutes. The pt had good knowledge of current events. There was
no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. does
endorse
subjective photophobia.
III, IV, VI: EOMI without nystagmus. some saccadic breakdown
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted. No drift
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation
throughout. No extinction to DSS.
-DTRs: +B/l UE hoffmans. overall 2+ in UE, and ankles. 3+
patellars R>L. w/ markedly upgoing right toe. Left is mute.
-Coordination: No intention tremor. slight dysmetria on FNF R>L
and w/ fine finger movements
Pertinent Results:
Admission Labs
=================
___ 04:37PM BLOOD WBC-8.0 RBC-4.78 Hgb-13.1 Hct-42.3 MCV-89
MCH-27.4 MCHC-31.0* RDW-13.4 RDWSD-43.8 Plt ___
___ 04:37PM BLOOD Neuts-54.7 ___ Monos-7.9 Eos-0.9*
Baso-0.4 Im ___ AbsNeut-4.40 AbsLymp-2.78 AbsMono-0.63
AbsEos-0.07 AbsBaso-0.03
___ 04:37PM BLOOD Plt ___
___ 06:00AM BLOOD WBC-PND Lymph-PND Abs ___ CD3%-PND
Abs CD3-PND CD4%-PND Abs CD4-PND CD8%-PND Abs CD8-PND
CD4/CD8-PND
___ 05:11PM BLOOD Glucose-104* UreaN-13 Creat-0.8 Na-143
K-3.9 Cl-103 HCO3-29 AnGap-11
___ 06:00AM BLOOD %HbA1c-6.0 eAG-126
___ 09:41PM CEREBROSPINAL FLUID (CSF) TNC-40* RBC-8823*
Polys-42 ___ ___ 09:41PM CEREBROSPINAL FLUID (CSF) TNC-15* RBC-2281*
Polys-29 ___ Monos-6 ___ Macroph-3
___ 09:41PM CEREBROSPINAL FLUID (CSF) TotProt-22 Glucose-75
LD(LDH)-21
___ 05:45AM BLOOD ARBOVIRUS ANTIBODY IGM AND IGG-PND
___ 05:30PM BLOOD ANTI-STREPTOLYSIN O ANTIBODY (ASO)-Test
___ 06:00AM BLOOD WBC-6.6 Lymph-38 Abs ___ CD3%-82
Abs CD3-2057* CD4%-15 Abs CD4-367 CD8%-65 Abs CD8-1639*
CD4/CD8-0.22*
___ 05:46AM BLOOD Glucose-106* UreaN-10 Creat-0.9 Na-139
K-4.4 Cl-107 HCO3-25 AnGap-7*
___ 08:49AM URINE Blood-MOD* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD*
___ 03:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 08:49AM URINE RBC-29* WBC-10* Bacteri-FEW* Yeast-OCC*
Epi-7
___ 05:17PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-3
___ 08:49AM URINE Mucous-OCC*
___ 05:17PM URINE Mucous-RARE*
___ 05:17PM URINE UCG-NEGATIVE
___ 09:41PM CEREBROSPINAL FLUID (CSF) TNC-15* RBC-2281*
Polys-29 ___ Monos-6 ___ Macroph-3
___ 09:41PM CEREBROSPINAL FLUID (CSF) TNC-40* RBC-___*
Polys-42 ___ ___ 09:41PM CEREBROSPINAL FLUID (CSF) TotProt-22 Glucose-75
LD(LDH)-21
___ 02:19PM CEREBROSPINAL FLUID (CSF) ARBOVIRUS ANTIBODY
IGM AND IGG-CANCELLED
___ 09:41PM CEREBROSPINAL FLUID (CSF) HIV-1 RNA, PCR-Test
___ 09:41PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Test Name
___ 01:28PM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG
___ URINE NOT PROCESSED INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ URINE NOT PROCESSED INPATIENT
___ CSF;SPINAL FLUID Enterovirus
Culture-PRELIMINARY EMERGENCY WARD
___ CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY; ACID FAST
CULTURE-PRELIMINARY EMERGENCY WARD
___ CSF;SPINAL FLUID CRYPTOCOCCAL ANTIGEN-FINAL
EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
=====================
EEG FINDINGS:
BACKGROUND: The background activity shows a well-organized and
well-sustained,
symmetric, moderate voltage posterior dominant rhythm reaching
___ Hz, and
attenuating with eye opening. There is a small amount of
superimposed low
voltage frontally predominant beta fast activity. There are
frequent bursts
of generalized polymorphic theta and delta slowing throughout
the recording,
suggestive of drowsiness.
HYPERVENTILATION: Hyperventilation could not be performed.
INTERMITTENT PHOTIC STIMULATION: Stepped photic stimulation from
___ flashes
per second (fps) produces no abnormal activation of the record.
SLEEP: During drowsiness, the posterior dominant rhythm slows
and becomes more
intermittent, and theta range slowing appears diffusely. N1
sleep is
characterized by vertex waves, and N2 sleep is characterized by
symmetric
sleep spindles and K complexes.
CARDIAC MONITOR: Shows a generally regular rhythm with an
average rate of
60-80 bpm.
IMPRESSION: This is a normal routine EEG in the awake and asleep
states. Much
of the recording was spent in drowsiness. No focal abnormalities
or
epileptiform discharges are seen.
===========
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD.
INDICATION: ___ year old woman with HIV and seizures//
structural cause of
seizures.
TECHNIQUE: Sagittal and axial T1 weighted imaging were
performed. After
administration of 8 mL of Gadavist intravenous contrast, axial
imaging was
performed with gradient echo, FLAIR, diffusion, and T1
technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and
coronal
orientations.
COMPARISON: MRI brain with contrast dated ___.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema,
masses, mass
effect, midline shift or infarction. The ventricles and sulci
are normal in
caliber and configuration. There is no abnormal enhancement
after contrast
administration.
A faint, subtle area of wisp like enhancement with corresponding
FLAIR
hyperintensity and signal void at T2* susceptibility weighted
images seen
within the right frontal lobe white matter (series 100, image
74), likely
represents a developmental venous anomaly or capillary
telangiectasia;
unchanged since ___. No other parenchymal
abnormalities. The dural
venous sinuses appear patent.
Normal volume, orientation and signal intensity of both
hippocampi
bilaterally. The ventricles and sulci are normal, without
evidence of
hydrocephalus.
There is small mucous retention cyst at the base of the right
maxillary sinus.
Otherwise; the visualized paranasal sinuses, middle ear
cavities, and mastoid
air cells are well aerated and clear. The orbits are within
normal limits
bilaterally.
Prominent posterior nasopharyngeal palatine tonsil lymphoid
tissue.
IMPRESSION:
1. No acute intracranial abnormality or abnormal enhancement.
2. Both hippocampi show normal signal intensity and volume.
3. No intracranial mass lesion or mass effect.
EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE
INDICATION: ___ year old woman with HIV and infectious seizure
without clear
source and focal spinal related signs on exam. perispinal
abscess? Local
Spine lesion? infectious vs inflammatory?// perispinal abscess?
Local Spine
lesion? infectious vs inflammatory? perispinal abscess?
Local Spine
lesion? infectious vs inflammatory? ___ year old
woman with HIV and
infectious seizure without clear source and focal spinal related
signs on
exam. perispinal abscess? Local Spine lesion? infectious vs
inflammatory? ___
year old woman with HIV and infectio
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR
technique.
Axial T2 imaging was performed. Axial GRE images of the cervical
spine were
performed. After the uneventful administration of Gadavist
contrast agent,
additional axial and sagittal T1 images were obtained.
COMPARISON: MRI cervical spine ___ with without
contrast, MRI head
with without contrast of ___
FINDINGS:
CERVICAL:
Alignment is anatomic. Vertebral body heights are preserved.
There is no
suspicious marrow signal; the marrow is isointense to the disc,
which may
represent marrow reconversion in the setting of patient's HIV
status. Disc
heights are maintained. The visualized posterior fossa is
unremarkable.
There is no abnormal signal enhancement of the cord. There is
no significant
spinal canal or neural foraminal narrowing.
The thyroid is unremarkable. There are prominent lymph right
level 2 and 3
lymph nodes, similar to prior exam as well as prominent
adenoids, within
expected limits for the patient's age.
THORACIC:
Alignment is anatomic.Vertebral body heights are preserved.
There is no
suspicious marrow signal; the marrow is isointense to the disc,
which may
represent marrow reconversion in the setting of patient's HIV
status.disc
spaces are maintained.The spinal cord appears normal in caliber
and
configuration. There is no evidence of spinal canal or neural
foraminal
narrowing. There is no evidence of infection or neoplasm. There
is no
abnormal enhancement after contrast administration.
LUMBAR:
There is transitional anatomy of S1 with a well-formed S1-S2
disc counting
from C2. Lumbar alignment is anatomic. Vertebral body heights
are preserved.
There is no suspicious marrow signal; the marrow is isointense
to the disc,
which may represent marrow reconversion in the setting of
patient's HIV
status. Disc heights are maintained. The conus medullaris
terminates at the
L2 level, top limits of normal. There is no abnormal signal or
enhancement of
the terminal cord, conus medullaris or cauda equina.
Prominent epidural fat is identified in the lower lumbar spine.
Otherwise,
there is no evidence of significant spinal canal narrowing.
There is no
significant neural foraminal narrowing.
There is STIR hyperintense signal involving the left greater
than right
paraspinal muscles associated with the L4-L5 through L5-S1
facets, which may
be very to degenerative facetitis. There is no marrow signal
abnormality.
Small joint effusions are identified at these levels, with small
posteriorly
projecting synovial cysts.
IMPRESSION:
1. There is no evidence of spinal abscess.
2. There is no significant spinal canal or neural foraminal
narrowing.
3. There is no abnormal signal or enhancement of the cord, conus
medullaris or cauda equina.
4. There is left-greater-than-right STIR hyperintense signal of
the paraspinal muscles associated with the L4-L5 through L5-S1
facets, which is felt to be inflammatory secondary to
degenerative facet changes. Small facet joint effusions are
identified. No marrow edema pattern to suggest infectious
synovitis. However, if there is clinical suspicion and the
patient's symptoms progress, repeat examination should be
performed.
5. Additional findings described above.
Brief Hospital Course:
___ year old female with a pmhx of HIV not on ART due to pill
swallowing phobia (CD4 232 and viral load of 4.17), asthma,
diabetes presents one day after discharge from hospitalization
for asthma exacerbation with a witnessed GTC. She had some signs
of meningeal irritation with photophobia, headache, neck pain
and LP showed lymphocytic pleocytosis. Patient was started on
broad spectrum antibiotics and antiviral medications. Serologic
and CSF studies ultimately were inconclusive. Despite an obvious
upward going toe on the right foot, MRI to evaluate for
structural cause of the patient's seizure was normal. Spinal
imaging was also performed given concern for possible aspectic
meningitis iso paraspinal abscess and was also negative.
Antibiotics and antivirals were stopped on ___ and ___ given
lower suspicion for bacterial meningitis and negative HSV
respectively. ID was consulted to guide workup and will
follow-up as an outpatient.
She developed significant severe postural headache consistent
with a low pressure / post-LP headache that was refractory to
IVF, medications and caffeine. Anesthesiology was consulted for
consideration of a blood patch which was not performed given
concern for elevated risk for infection by the anesthesiologists
but she did undergo an occipital nerve block on ___. Overall
her headache were improving prior to discharge and she was
tolerating some PO intake and sitting for longer periods of time
which was a vast improvement.
For her seizures she was started on Keppra 750mg BID, which she
should continue as an outpatient. We discussed the importance of
this, which she acknowledges will be difficult. She was given a
liquid formulation and informed of ___ driving laws.
Of note, she has history of previous episodes that may be
consistent w/ seizures and a family history of epilepsy, which
both confer elevated risk
To Do
======
[] continue to discuss starting patient on ART for her untreated
HIV
[] Keppra dose 750mg BID, gave liquid form given difficulties
with pills
[] Arbovirus still pending, please follow-up
[] follow up with ID, repeat CD4 367 , VL 4.8 this admission
[] Neurology follow up is being arranged, please see above
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Montelukast 10 mg PO QPM
2. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ONCE:PRN
anaphylaxis
3. Advair HFA (fluticasone propion-salmeterol) 230-21
mcg/actuation inhalation BID
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN sob
6. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Cyclobenzaprine 5 mg PO TID:PRN Pain
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth TID PRN Disp #*10
Tablet Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
4. LevETIRAcetam 750 mg PO Q12H
5. Advair HFA (fluticasone propion-salmeterol) 230-21
mcg/actuation inhalation BID
6. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
7. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ONCE:PRN
anaphylaxis
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN sob
10. Montelukast 10 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Viral Meningitis
Post-LP headache
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 ___.
You were admitted because you had a seizure.
In our workup to figure out why you had a seizure, we found that
you had inflammation in your cerebrospinal fluid (meningitis).
You were started on antibiotic medication to treat possible
infectious causes of your meningitis, you had an MRI to look for
evidence of meningitis or why you were seizing. This was normal.
We think the inflammation of your spinal fluid may have been
from a virus, though we haven't been able to confirm this.
You suffered from a severe headache due to the lumbar puncture.
You pain doctors performed ___ nerve block to help with
this pain. Overall your headache was improving a lot before you
left.
You will need to follow up in neurology clinic. You will need to
continue to take Keppra.
Given that you had a seizure, you will not be able to drive for
6 months, per ___ law.
Best,
Your ___ Care Team
Followup Instructions:
___
|
10859189-DS-8
| 10,859,189 | 23,034,119 |
DS
| 8 |
2151-12-06 00:00:00
|
2151-12-06 14:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
griseofulvin / strawberry / macadamia nut oil
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Patient is a ___ pediatric nurse with history of congenital HIV
(not currently on anti-retrovirals, last CD4 count 400, HIV VL
54
___, MDD with prior suicidality, anxiety, possible
factitious disorder, and asthma who presents as a transfer from
outpatient ___ iso tachycardia and
hypophosphatemia.
Patient was admitted to ___ ___
after reporting that she had passed out while sitting on the
toilet tow days prior. Patient thinks that there was ~1min LOC
and she struck her anterior head/face on a towel rack. The fall
was unwitnessed. Upon presentation, patient was noted to have
tachycardia and hypertension. Neuro exam was reassuring. No
head imaging was obtained. Patient was recommended to increase
PO intake given concern for dehydration and she was discharged
home. Given low phosphorus on her labs, patient was instructed
to have repeat labs drawn ___ prior to a follow-up
appointment. Given marked hypophosphatemia (1.0) and persistent
tachycardia/HTN, patient was referred to the ___ ED for
further
evaluation/management.
Upon arrival, patient recounts the recent history as above. She
says that prior to the syncopal episode, she recorded her
temperature as 102 at home. Additionally, she describes
worsening proximal muscle aches over the past several days,
notably in her thighs and triceps. There were ___ episodes of
diarrhea yesterday AM, non-bloody. Patient also endorses a new
cough (non productive) over the past 24h, associated with mild
acute on chronic SOB iso asthma. No CP or irregular heart beat.
Patient does endorse some positional lightheadedness upon
sitting-up/standing. Patient works closely with children. She
had her flu shot earlier this year. No recent travel, no new
sexual partners (last sexual activity ___.
Of note, patient was also recently admitted to ___ iso
'accidental' diphenhydramine overdose. She has had multiple
admissions over the past year or so for myriad complaints
including syncope, chest pain, abdominal pain, focal weakness,
and shortness of breath. Her work-up has been reassuringly
normal and there has been some concern for factitious disorder.
Exam notable for:
Tachycardic (100 on exam), normotensive
Mild TTP RUQ, no additional findings on exam. Normal reflexes.
EKG: Sinus tachycardia (105bpm), normal axis, normal PR/QRS
intervals, QTc 467, TWIs II/III/avF/V3-V5, no significant
STDs/STEs.
Labs showed:
CBC 7.9>11.0/37.6<327 (MCV 76)
BMP ___
Ca ___
Mg 2.0
Phos 1.4
UA: 1.016 SG, pH 7.0, urobilinogen NEG, bilirubin NEG, leuk NEG,
blood NEG, nitrite NEG, protein NEG, glucose NEG, ketones 10
Imaging showed:
CXR ___
FINDINGS:
The lungs are clear without focal consolidation. No pleural
effusion or pneumothorax is seen. The cardiac and mediastinal
silhouettes are
unremarkable.
IMPRESSION:
No acute cardiopulmonary process. No focal consolidation to
suggest
pneumonia.
Consults: NONE
Patient received:
___ 17:57 IVF NS ( 1000 mL ordered)
___ 17:59 PO/NG Neutra-Phos 1 PKT
___ 22:02 IVF NS ( 1000 mL ordered)
Transfer VS were: 98.7 109 130/74 18 99% RA
On arrival to the floor, patient recounts the history as
outlined
above. Her main complaint is muscle/bony pain in her arms and
legs. She endorses some dizziness upon sitting up in bed.
Still
having a dry cough and mild SOB. No ongoing abdominal pain, but
she did have the multiple episodes of diarrhea yesterday and
some
mild nausea (no emesis). No chills/subjective fevers at the
moment.
Past Medical History:
HIV (congenital, previously on antiretrovirals, last ___ and
had self-discontinued ___ prior to that; she was most recently
on Emtricitabine-Tenofovir-Rilpivirine, though this was d/c'd
after developing lactic acidosis and long QTc)
Prediabetes
Asthma
Migraines
MDD with prior suicidality
Anxiety
Factitious disorder
Prior syncopal episodes (___)
Fatty liver disease
Social History:
___
Family History:
Mom (___) HIV, pancreatic cancer
Dad (___) HIV
Brother (___) asthma
MGF (deceased in ___ PE, T2DM
MGM (deceased in ___ sudden cardiac death
PGF (deceased) diabetes
PGM (deceased) diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.7 143/86 114 18 99 RA
GENERAL: NAD, pleasant in conversation, often clicking her
tongue
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, no posterior OP erythema or exudates.
NECK: Supple, no LAD, no JVD.
HEART: Tachycardic, regular rhythm,, S1/S2, ___ systolic
ejection
murmur heard throughout the precordium, no gallops or rubs.
LUNGS: CTABL, no wheezes.
ABDOMEN: Normoactive BS throughout, nondistended, nontender in
all quadrants, no rebound/guarding, no hepatosplenomegaly.
MUSCULOSKELETAL: Tenderness to palpation over thighs and
proximal
arms, no swelling or erythema.
EXTREMITIES: No cyanosis, clubbing, or edema.
PULSES: 2+ radial pulses bilaterally.
NEURO: A&Ox3, CN2-12 intact, sensation to light touch intact
throughout, strength ___ throughout limited by pain, no
dysmetria.
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes.
DISCHARGE PHYSICAL EXAM:
VITALS: ___ 0759 Temp: 97.7 PO BP: 135/86 HR: 65 RR: 18 O2
sat: 99% O2 delivery: Ra
GENERAL: Lying in bed, NAD
EYES: pink conjunctiva, PERRL
ENT: OP clear, MMM
CV: RRR, no m/r/g
RESP: CTAB
GI: obese abd, nontender, nondistended
GU: deferred
MSK: no pitting edema.
SKIN: no rashes noted
NEURO: A&Ox3, Strength: L hip flexor ___, R hip flexor ___.
Hamstrings ___ bilaterally. R dorsiflexion ___, plantarflexion
___. L Dorsi/plantarflexion ___.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:29PM BLOOD WBC-7.9 RBC-4.97 Hgb-11.0* Hct-37.6
MCV-76* MCH-22.1* MCHC-29.3* RDW-14.8 RDWSD-40.6 Plt ___
___ 04:29PM BLOOD Neuts-69.6 ___ Monos-6.1 Eos-0.8*
Baso-0.3 Im ___ AbsNeut-5.47 AbsLymp-1.79 AbsMono-0.48
AbsEos-0.06 AbsBaso-0.02
___ 04:29PM BLOOD Glucose-100 UreaN-9 Creat-0.8 Na-143
K-4.1 Cl-103 HCO3-25 AnGap-15
___ 06:40AM BLOOD ALT-21 AST-32 AlkPhos-78 TotBili-0.3
___ 11:17PM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:40AM BLOOD CK-MB-1 cTropnT-<0.01
___ 04:29PM BLOOD Calcium-10.1 Phos-1.4* Mg-2.0
___ 02:45PM BLOOD D-Dimer-265
PERTINENT/DISCHARGE LABS:
=========================
___ 06:15AM BLOOD WBC-6.4 RBC-4.43 Hgb-10.1* Hct-33.5*
MCV-76* MCH-22.8* MCHC-30.1* RDW-14.9 RDWSD-41.2 Plt ___
___ 06:40AM BLOOD WBC-7.0 Lymph-38 Abs ___ CD3%-86
Abs CD3-2297* CD4%-18 Abs CD4-475 CD8%-66 Abs CD8-1755*
CD4/CD8-0.27*
___ 06:03AM BLOOD Glucose-115* UreaN-7 Creat-0.8 Na-144
K-4.3 Cl-106 HCO3-25 AnGap-13
___ 06:03AM BLOOD VitB12-377
___ 02:45PM BLOOD D-Dimer-265
___ 06:40AM BLOOD %HbA1c-6.2* eAG-131*
___ 06:40AM BLOOD TSH-2.1
___ 03:00AM BLOOD PTH-171*
___ 11:17PM BLOOD 25VitD-11*
___ 11:17PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:40AM BLOOD HIV1 VL-PND
IMAGING REPORTS:
================
___ CXR PA AND LAT:
FINDINGS:
The lungs are clear without focal consolidation. No pleural
effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes
are
unremarkable.
IMPRESSION:
No acute cardiopulmonary process. No focal consolidation to
suggest
pneumonia.
___ MRI AND MRA BRAIN:
IMPRESSION:
1. Moderate motion degraded examination.
2. No evidence for acute infarction or intracranial hemorrhage.
3. No evidence for abnormal white matter signal to suggest
demyelinating
disease.
4. Subtle, wisp like enhancement in the right frontal lobe white
matter likely represents a DVA.
5. Patent intracranial and cervical vasculature without
high-grade stenosis, occlusion, or aneurysm.
___ MR ___ SPINE W/WO CONTRAST:
Normal cervical spine MRI. Specifically, there is no evidence
for
demyelinating disease, spinal cord injury, or other spinal cord
abnormality.
Brief Hospital Course:
This is a ___ year old female with past medical history of HIV
not on anti-retroviral therapy (last CD4 400), admitted with
dehydration, electrolyte disturbances in setting of diarrheal
illness, workup negative for infectious causes, symptoms
resolving with supportive therapy, thought to have been viral
enteritis, discharged home.
# Viral enteritis
# Dehydration and sinus tachycardia
Initially presented with myalgias, weakness, nausea and
diarrhea for several days. In the ED had tachycardia,
hypertention, and a low phos. Overall her symptoms appeared
most consistent with a viral gastroenteritis given the ongoing
nausea, diarrhea, myalgias, and self-reported fever. She was
flu negative. Other work up thus including CBC, CXR not
concerning for infection. Stool cultures negative for CDiff and
other bacterial etiologies. She was treated symptomatically
with IVF and Zofran PRN for nausea with improvement in her
symptoms over subsequent 72 hours. Her symptoms improved and
she was able to tolerate a regular diet.
# Paresthesias
Patient reported weakness and lower extremity paresthesias.
She was seen by neurology service with exam notable for
weakness in ___ lower ext, worse on R than L, parasthesias
bilaterally, also worse on R than L. Her hypophosphatemia was
repleted, but symptoms persisted. B12 and CK did not suggest
relevant contribution to her symptoms. Workup notable for A1c
6.2%, diagnostic of prediabetes. MRI brain and MRI cspine
without signs of acute neurologic process (e.g. demyelinating
disease). Although her symptoms improved, they did not
resolve. She was able to ambulate safely. Neurology
recommended outpatient neurology follow-up for consideration of
EMG and/or additional testing;
# HIV
Per patient, she was maintained on ARVs until she was ___
old, at which point she became 'rebellious' and stopped them
altogether. She was restarted on
emtricitabine-tenofovir-rilpivirine this past ___, though it
was stopped after ___ in the setting of lactic acidosis and
long QTc. In setting of above infection, repeat HIV labs were
checked: Her CD4 count was 475; her VL was 4.1.
# Hypophosphatemia
# Vitamin D deficiency
Patient has reported chronic issues with hypophosphatemia over
the past year. She presented with a phosphorus of 1.4 which
improved to 2.5 after neutra-phos. Her vitamin D was 11 and PTH
171, consistent with secondary hyperparathyroidism. We also
considered the possibility of antiretroviral related selective
phosphorus wasting syndrome (most recently
emtricitabine-tenofovir-rilpivirine ___. However, she had
been off the medication for several months and this seemed much
less likely given vitamin D deficiency. She was started on
vitamin D supplementation. Would consider recheck phos and
vitamin D levels at follow-up. Discharge PHOSPHORUS was 4.9
# Concern for factitious disorder
Previous OSH records report concern for factitious disorder.
Patient symptoms were worked up as above.
# Asthma
Continued home inhalers
TRANSITIONAL ISSUES:
- Discharged home with neurology follow-up
- Consider repeat phosphorus level at follow-up
- Consider repeat 25-OH Vit D level in 8 weeks
- Incidentally found to have new diagnosis of pre-diabetes
based on A1c 6.2%; consider additional dietary and lifestyle
counseling
CODE STATUS: FULL PRESUMED
CONTACT: ___ (MOM) ___
> 30 minutes spent on this discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
5. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Vitamin D ___ UNIT PO 1X/WEEK (SA)
RX *ergocalciferol (vitamin D2) [Vitamin D2] 50,000 unit 1
capsule(s) by mouth weekly Disp #*10 Capsule Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
# Viral enteritis
# Hypophosphatemia
# Sinus tachycardia secondary to dehydration
# HIV
# VITAMIN D DEFICIENCY
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you during this admission.
Why was I admitted to the hospital?
- You were having muscle aches, diarrhea, a fast heart rate, and
other worrisome symptoms, including tingling in your legs
What happened while I was admitted?
- You had a chest x ray which did not show a pneumonia
- You had lab tests which did not show infection, but did show
you had LOW levels of vitamin D. This is probably why your
phosphorus level is low.
- We gave you fluids through your IV and vitamin D supplements.
- We had our neurology doctors ___, and they recommended an
MRI of your brain and cervical spine which looked normal.
What should I do when I leave the hospital?
- Please take your medications, including your new vitamin D
supplement, as listed below
- Please make an appointment with your primary care provider for
lab tests and consider restarting treatment for your HIV.
- Please follow up with neurology to monitor your symptoms and
possible additional testing.
We wish you all the best,
Your ___ Care Team
Followup Instructions:
___
|
10859189-DS-9
| 10,859,189 | 27,945,335 |
DS
| 9 |
2153-03-27 00:00:00
|
2153-04-02 16:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
griseofulvin / strawberry / macadamia nut oil / Penicillins
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with congenital HIV (CD4 210 per pt), NIDDM2, asthma
presenting with recurrent/persistent dyspnea.
Pt reports that she went to ___ - ___ and ___ - with
friends from nursing school, ___ for vacation. She
developed fevers, cough, and sore throat while traveling. She
returned to work on ___. On ___, she noted
worsening dyspnea. She was admitted to ___
___ where she was treated with antibiotics, nebs, and
steroids. At the time of discharge from ___ she felt
well at rest, and notes that symptoms progressed/recurred with
exertion. Reports that getting up the bathroom caused "increased
work of breathing." She was discharged on prednisone but she did
not fill the prescription; she states "I'm not a pill taker;
that's ___ the issue." She believes that she gets better with
treatment but has trouble determining whether improvement is
related to rest, as opposed to getting better from treatment.
She
returned to work on ___, and notes that her symptoms
recurred, including dyspnea, tight breathing. She used albuterol
inhaler x3 puffs without improvement. She endorses fever on
___ to 101.3, took tylenol with improvement. She denies
headache, rhinorrhea. She does intermittently have sore throat
since her travel to ___, without odynophagia. Cough is
productive of rust and green yellow sputum. Denies chest pain,
abdominal pain. She endorses ___ soft, liquid BMs per day, which
is new over the past 3 weeks; without hematochezia or melena.
Denies ___ edema, dysuria, endorses gross hematuria on the day of
presentation with associated frequency.
In the ___ ED:
VS 98.6, 140, 131/73, 28, 100% RA
Exam notable for:
"Moderate respiratory distress, speaking in ___ word sentences,
actively coughing
Tachycardic, no murmur
Diminished breath sounds bilaterally, no appreciable wheezing
Abdomen soft and nontender
Skin warm and dry
No peripheral edema"
Labs notable for: WBC 12.8, Hb 14.8, Plt 263, BUN 7, Cr 0.9
Ca ___, Mg 1.9, Phos 0.7
LDH 241
HCO3 20
UA with small blood
UHCG negative
VBG 7.46/32
ABG ___
Influenza negative
Repeat VBG prior to transfer to floor: 7.42/33, with improved
respiratory status
Imaging:
CXR with low lung volumes, no focal consolidation
Consults: None
Received:
Nebs
Benzonatate
Magnesium sulfate IV
Cefepime 2 gm
IVF
Azithromycin
Zofran
Vancomycin
On arrival to the floor, she feels that her breathing is short,
but improved compared to arrival in ED. Endorses chest pressure
with deep breaths and coughing.
ROS: 10 point review of system reviewed and negative except as
otherwise described in HPI
Past Medical History:
HIV - perinatal - last CD4 in Atrius records 329 on ___, with
HIV-1 4.14 log copies/mL, per pt more recent CD4 was 210
PFO
Vitamin D deficiency
Anxiety
NIDDM2
Asthma
Depression/SI
Social History:
___
Family History:
Mom (___) HIV, pancreatic cancer
Dad (___) HIV
Brother (___) asthma
MGF (deceased in ___ PE, T2DM
MGM (deceased in ___ sudden cardiac death
PGF (deceased) diabetes
PGM (deceased) diabetes
Physical Exam:
ADMISSION EXAM:
VS: ___ 2347 Temp: 98.1 PO BP: 148/84 HR: 108 RR: 30
measured by admitting MD O2 sat: 100% O2 delivery: RA
GEN: pleasant, alert and interactive, comfortable, no acute
distress, intermittently tachypneic, speaking in full and
extended sentences without interruption
HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without
lesion or exudate, moist mucus membranes, ears without lesions
or
apparent trauma
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
appreciated
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs,
or
gallops
LUNGS: Diminished air movement at bilateral bases at L upper
lung
field, no wheeze or rhonchi
GI: soft, nontender, without rebounding or guarding,
nondistended
with normal active bowel sounds, no hepatomegaly
EXTREMITIES: no clubbing, cyanosis, or edema
GU: no foley
SKIN: no rashes, petechia, lesions, or echymoses; warm to
palpation
NEURO: A&Ox3, cranial nerves II-XII grossly intact, strength and
sensation grossly intact
PSYCH: normal mood and affect
DISCHARGE EXAM:
VITALS: ___ 1337 Temp: 98.6 PO BP: 124/76 HR: 74 RR: 18 O2
sat: 98% O2 delivery: RA
GENERAL: Alert, NAD, not dyspneic, speaking in full sentences
EYES: Anicteric, PERRL
ENT: mmm, OP clear
CV: NR/RR, no m/r/g
RESP: CTAB, no wheezes, crackles, or rhonchi
ABD/GI: Soft, ND, NTTP, normoactive bowel sounds
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
VASC/EXT: No ___ edema, 2+ DP pulses
SKIN: No rashes or lesions noted on visible skin
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
LABS:
___ 04:00PM BLOOD WBC-12.8* RBC-5.26* Hgb-14.8 Hct-44.6
MCV-85 MCH-28.1 MCHC-33.2 RDW-12.4 RDWSD-37.9 Plt ___
___ 04:00PM BLOOD Neuts-70.6 ___ Monos-2.5* Eos-1.4
Baso-0.5 Im ___ AbsNeut-9.00* AbsLymp-2.57 AbsMono-0.32
AbsEos-0.18 AbsBaso-0.07
___ 06:30AM BLOOD WBC-14.7* RBC-4.50 Hgb-12.7 Hct-38.1
MCV-85 MCH-28.2 MCHC-33.3 RDW-12.4 RDWSD-37.3 Plt ___
___ 06:30AM BLOOD WBC-15.1* RBC-4.46 Hgb-12.6 Hct-39.0
MCV-87 MCH-28.3 MCHC-32.3 RDW-12.8 RDWSD-40.6 Plt ___
___ 04:00PM BLOOD Glucose-160* UreaN-7 Creat-0.9 Na-140
K-3.9 Cl-102 HCO3-20* AnGap-18
___ 04:00PM BLOOD Calcium-10.1 Phos-0.7* Mg-1.9
___ 06:30AM BLOOD Glucose-187* UreaN-7 Creat-0.7 Na-142
K-4.1 Cl-103 HCO3-22 AnGap-17
___ 06:30AM BLOOD Glucose-133* UreaN-12 Creat-0.7 Na-143
K-4.1 Cl-106 HCO3-25 AnGap-12
___ 06:30AM BLOOD Calcium-9.5 Phos-3.2 Mg-2.0
___ 04:00PM BLOOD LD(LDH)-241
___ 06:30AM BLOOD ALT-31 AST-29 AlkPhos-68 TotBili-0.2
___ 04:18PM BLOOD ___ pO2-44* pCO2-32* pH-7.46*
calTCO2-23 Base XS-0
___ 04:27PM BLOOD Type-ART pO2-105 pCO2-22* pH-7.55*
calTCO2-20* Base XS-0
___ 09:27PM BLOOD ___ Temp-36.9 pO2-61* pCO2-33*
pH-7.42 calTCO2-22 Base XS--1
MICRO:
BCx (___): no growth x2
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
CXR: IMPRESSION:
Low lung volumes without focal consolidation.
Brief Hospital Course:
SUMMARY:
___ with perinatally-acquired HIV (CD4 210 per pt), NIDDM2,
asthma presenting with recurrent/persistent dyspnea ___ asthma
exacerbation.
HOSPITAL COURSE BY PROBLEM:
# Acute asthma exacerbation:
# Infectious bronchitis:
Pt describes symptoms x approx. 2 weeks, with possible transient
improvement in the setting of
hospitalization at ___ for acute asthma exacerbation.
She reports fever to 101.3 at home, with cough productive of
colorful sputum, concerning for infectious process as trigger
for
acute asthma exacerbation. Her symptoms are dramatically
improved after receiving steroids and nebs, which supports the
diagnosis of asthma exacerbation.
After admission her productive sputum ceased and was not able to
provide a sample for PJP (even with induction) so this is less
likely bacterial pneumonia (especially with negative CXR) and
more likely viral bronchitis.
She was treated with methylprednisolone IV rather than
prednisone because of her severe pill anxiety and because liquid
glucocorticoids are not on formulary. She was prescribed liquid
prednisone on discharge to complete the steroid taper.
# HIV: Perinatal acquisition, barriers to care include strong
aversion to pills. Pt is followed by ___,
and transitioning care to Dr. ___ (known to pt from
___ as well). Pt reports most recent CD4 ___ weeks prior to
presentation.
# Hypophosphatemia: Chronically low, currently well below LLN
likely ___ shifts related to hyperventilation. This was
aggressively repleted.
# NIDDM: Last HbA1c 5.0% on ___.
>30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Advair HFA (fluticasone propion-salmeterol) 230-21
mcg/actuation inhalation BID
3. Montelukast 10 mg PO DAILY
Discharge Medications:
1. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*12 Tablet Refills:*0
2. predniSONE 5 mg/5 mL oral DAILY
RX *prednisone 5 mg/5 mL AS DIR ml by mouth once a day
Refills:*0
3. Advair HFA (fluticasone propion-salmeterol) 230-21
mcg/actuation inhalation BID
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs inhaled every
six (6) hours Disp #*1 Inhaler Refills:*0
5. Montelukast 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the hospital with an asthma exacerbation.
You were treated with steroids and nebulizer treatments and your
breathing improved. You should continue to take the prednisone
solution and home and use your albuterol.
You should follow up with your primary care doctor as detailed
below to follow up on your symptoms.
Best wishes for your continued healing.
Take care,
Your ___ Care Team
Followup Instructions:
___
|
10859307-DS-2
| 10,859,307 | 28,368,518 |
DS
| 2 |
2121-04-13 00:00:00
|
2121-04-13 21:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dysuria / pelvic pain
Major Surgical or Invasive Procedure:
___ line placement ___
History of Present Illness:
___ h/o prostate cancer (on active surveillance) presents with
dysuria, pelvic pain, and fevers. His symptoms started ___ days
ago. He has dysuria w/o hematuria or obvious purulent drainage.
He has also developed significant pain in the pelvis and scrotum
over the past day. He has not noticed any scrotal swelling or
erythema. He does not have abdominal pain or flank pain. He has
had fevers/chills at home and worsening headache. He was seen by
his PCP 1 day PTA for these symptoms and was started on cipro
for presumed UTI. His symptoms worsened over the next ___,
prompting him to come to the ED.
He was diagnosed w/ prostate CA ___ years ago and has been
undergoing active surveillance since then. He denies any h/o
UTIs or other GU infections. He is sexually active only with his
wife in a mutually monogomaous relationship.
Initial vitals in ED: 102.2 ___ 18 98%
Labs notable for: WBC 12.8, Cr 1.3, UA+
Patient given: ketorolac, Tylenol, and ceftriaxone
Vitals on transfer: 99.7 108 113/76 18 96% RA
Past Medical History:
Prostate cancer: diagnosed in ___, undergoing active
surveillance w/ Dr. ___ urology
DM2
HTN
Social History:
___
Family History:
Multiple family members w/ CAD. Father had lung cancer;
otherwise, no other cancers in the family.
Physical Exam:
ADMISSION:
Vitals- 98.3 140/78 94 18 97%RA
General: NAD. Ill-appearing. Rigoring. A&Ox3. Very pleasant.
HEENT: Dry MMs. EOMI. PERRL.
Neck: JVP not elevated
CV: RRR. no m/r/g
Lungs: CTAB
Abdomen: Non-tender/Non-distended. Normal bowel sounds.
GU: No penile discharge. No genital rashes or other lesions.
Mild TTP over b/l epididymis. No scrotal edema. Per ED note,
mild TTP of prostate. I did not repeat rectal exam.
Neuro: No focal deficits
DISCHARGE:
Vitals- Tc 98.3 Tm 98.6 134/66 p93 18 100% RA
General: NAD. A&Ox3.
HEENT: EOMI. PERRL.
Neck: JVP not elevated
CV: RRR. no m/r/g
Lungs: CTAB
Abdomen: Non-tender/Non-distended. Normal bowel sounds.
Extremities: no edema or cyanosis
Pertinent Results:
___ 05:02PM BLOOD WBC-12.8*# RBC-4.43* Hgb-14.3 Hct-40.7
MCV-92 MCH-32.2* MCHC-35.1* RDW-12.3 Plt ___
___ 05:02PM BLOOD Neuts-91.0* Lymphs-5.4* Monos-3.4 Eos-0.1
Baso-0.1
___ 07:30AM BLOOD WBC-6.0 RBC-4.58* Hgb-14.3 Hct-41.4
MCV-91 MCH-31.2 MCHC-34.4 RDW-12.4 Plt ___
___ 05:02PM BLOOD Glucose-178* UreaN-18 Creat-1.3* Na-138
K-3.5 Cl-98 HCO3-28 AnGap-16
___ 07:30AM BLOOD Glucose-133* UreaN-14 Creat-1.0 Na-141
K-4.3 Cl-102 HCO3-28 AnGap-15
___ 05:02PM BLOOD Calcium-9.8 Phos-1.3* Mg-2.0
___ 08:05AM BLOOD Calcium-9.3 Phos-3.7# Mg-2.2
___ 05:02PM BLOOD Lactate-2.3*
___ 04:54PM BLOOD Lactate-1.4
___ 2:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- 32 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
SCROTAL U.S.; DUPLEX DOP ABD/PEL LIMITED ___
FINDINGS: The right testicle measures 2.6 x 2.8 x 4.4 cm. The
left testicle measures 2.7 x 2.5 x 4.4 cm. Testicular
echogenicity and morphology are normal. There is no fluid
collection. The epididymides are normal. There are small
bilateral hydroceles. There is no varicocele.
IMPRESSION: No evidence of abscess or other infectious process.
CT ABDOMEN/PELVIS ___
IMPRESSION:
1. Thickened bladder wall consistent with known cystitis,
without evidence of
ascending infection common/pyelonephritis.
2. Very enlarged prostate, consistent with known BPH
PORTABLE CHEST XRAY PRELIM ___
IMPRESSION:
Left PICC ends in approximately the proximal right atrium and
can be pulled back approximately 1.5 to 2 cm, alternatively, a
lateral view can be obtained to confirm position. No
pneumothorax.
Brief Hospital Course:
___ h/o prostate cancer (on active surveillance) presents with
dysuria, pelvic pain, and fevers, overall consistent with
urosepsis
# Urosepsis: Patient came in with scrotal pain and prostate
tenderness on initial exam concerning for
prostatitis/epididymitis. Scrotal U/S showed no evidence of
abscess or infection. Urine Cx grew E. coli and CT abd/pelvis
which was obtained out of concern of ascending infcetion was
consistent with acute cystitis and no evidence of abscess or
pyelonephritis.He was treated with Ceftriaxone initially but
final sensitivities on culture showed resistance so, he was
switched to Cefepime.
Fevers subsided, and pain resolved. Blood Cx were without
growth.
A PICC line was placed to continue IV antibiotics till ___.
# ___: Cr 1.3 from normal baseline on admission. Likely
pre-renal. Resolved with fluids.
#Thrombocytopenia: Mildly decreased to 131k w/u evidence of
bleeding. Likely related to recent antibiotics vs. sepsis. 133
at discharge
#Prostate cancer: Patient undergoing active surveillance
currently.
#DM2: Was treated with humalog SSI
#HTN: Lisinopril held initially due to ___. Resumed upon
discharge.
TRANSITIONAL ISSUES:
Follow up platelet counts to ensure resolution of
thrombocytopenia post infection
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. MetFORMIN (Glucophage) 500 mg PO DAILY
3. Tamsulosin 0.4 mg PO HS
4. Aspirin 81 mg PO DAILY
Discharge Medications:
1. CefePIME 1 g IV Q12H
RX *cefepime [Maxipime] 1 gram 1 gram IV Q12 Disp #*20 Vial
Refills:*0
2. Aspirin 81 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO DAILY
5. Saline flushes
Please provide saline flushes x 20
6. TraMADOL (Ultram) ___ mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth q6h prn Disp #*20 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cystitis
secondary
BPH
prostate CA
Diabetes Mellitus
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 privilege caring for you here at ___. You came in
with fevers and pain in the scrotum. We found you had a bladder
infection and treated you with antibiotics through the veins.
Your fevers have subsided and your pain resolved. You did not
have any bacteria in your blood. You will need 10 more days of
antibiotics through the vein and so we placed a long term
intravenous line(PICC line), through which you will be getting
antibiotics at home. There will be a nurse to come out to help
you with the antibiotics at home.
Please keep all your follow up appointments
Followup Instructions:
___
|
10859320-DS-11
| 10,859,320 | 26,652,072 |
DS
| 11 |
2138-12-29 00:00:00
|
2138-12-29 21:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
colchicine / Quinolones
Attending: ___.
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Cardiac Cath (___) stent of LAD using bare metal stent
History of Present Illness:
___ with history of severe AS ___ 0.7-0.8 in ___, ___
class II, who was referred from ___ clinic ___ SOB when she was
found to have 94%RA and 87% w/ ambulation. Pt notes that she has
had progressive SOB since ___, w/ decreased exercise
tolerance ___ yards -> 4 steps), worsening orthopnea (3
pillows), and PND, in the setting of increased chronic swelling
of her legs. Pt notes that she takes lasix ___ days per week and
does not weigh herself. She also missed one week of her lasix
about one week ago when she ran out of medication. Pt denies any
infectious sx (no sore throat, sneezing, n/v/d, rash, sick
contacts) but says that she has a dry chronic cough. Son also
notes she has had wheezing for the past ___ months. She endorses
occasional lightheadedness with exertion over the past few
months.
Pt was last seen by Dr. ___ in ___, who was going to w/u pt
for ___. Saw Dr. ___ ___ for AVR. At that time, pending
the results of a cardiac catheterization and CT chest without
contrast to identify aortic calcification, her surgical risk for
aortic valve
replacement is "intermediate". She wanted to wait for cardiac
cath until she was more symptomatic.
In the ED, initial vitals were 98.4 57 149/63 20 99% 4L. Pt was
given home dose lasix (20mg PO) and had CBC/CHEM drawn. Pt will
be admitted to ___ for diuresis and emergent w/u for ___ which
pt indicated that she wants. Pt indicated that she is FULL CODE
but does not want blood products ___ religion. Spoke w/ Atrius
Dr ___ who ___ be attg on CMED. Received 20mg IV Lasix in
the ED.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
- HTN
- HLD
- s/p bilateral TKAs
Social History:
___
Family History:
- There is no history of hypertension, diabetes mellitus, heart
disease, or strokes.
- Her mother died in her ___ of colon cancer and her father died
in his ___ of natural causes
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=97.9 BP=173/68 HR=72 RR=22 O2 sat= 95%RA
Wt=88.8 kg (dry weight ~90.9 kg reportedly)
General: NAD, A&Ox3
HEENT: NCAT, EOMi
Neck: Supple, JVD 15cm
CV: III/VI holosystolic murmur RUSB, LUSB. Normal S1, diminished
S2.
Lungs: Bibasilar crackles
Abdomen: Soft, nondistended, nontender
Ext: Bilateral lower extremity edema, 2+ pitting to knees.
Neuro: CN grossly intact, moves all extremities
DISCHARGE PHYSICAL EXAM:
VS: T=97.8 BP=112-141/43-46 HR=56-59 ___ O2sat= 97-100%RA
Wt= 88.3 kg ___ (88.3kg ___, dry weight ~90.9 kg reportedly)
I/O 24 hr: +1260/-925
General: Sitting up in chair, in NAD, A&Ox3
HEENT: NCAT, EOMI
Neck: Supple, JVD 5cm
CV: III/VI holosystolic murmur RUSB, LUSB. Normal S1, diminished
S2.
Lungs: CTAB
Abdomen: Soft, nondistended, nontender
Ext: Trace pedal edema, 1+ DP pulse
Neuro: CN grossly intact, moves all extremities
Pertinent Results:
ADMISSION LABS:
___ 11:07AM BLOOD WBC-7.0 RBC-3.37* Hgb-10.5* Hct-34.4*
MCV-102* MCH-31.0 MCHC-30.4* RDW-13.8 Plt ___
___ 11:07AM BLOOD Neuts-76.8* Lymphs-16.1* Monos-5.6
Eos-1.1 Baso-0.3
___ 12:20PM BLOOD Hypochr-3+ Anisocy-OCCASIONAL
Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
Target-OCCASIONAL
___ 05:20AM BLOOD ___ PTT-41.4* ___
___ 11:07AM BLOOD Glucose-70 UreaN-17 Creat-0.9 Na-134
K-4.4 Cl-101 HCO3-20* AnGap-17
___ 04:14PM BLOOD cTropnT-<0.01
___ 06:49AM BLOOD Calcium-9.0 Phos-4.8* Mg-2.0 Iron-49
___ 06:49AM BLOOD calTIBC-256* VitB12-398 Folate-16.8
Ferritn-134 TRF-197*
___ 11:10AM URINE Color-Straw Appear-Clear Sp ___
___ 11:10AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-4.9 RBC-3.10* Hgb-9.4* Hct-31.2*
MCV-101* MCH-30.5 MCHC-30.2* RDW-13.7 Plt ___
___ 06:25AM BLOOD Glucose-84 UreaN-44* Creat-1.1 Na-134
K-5.2* Cl-100 HCO3-28 AnGap-11
___ 06:25AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.4
MICRO:
___ 11:10 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING/STUDIES:
ECG (___): Sinus bradycardia. Left atrial abnormality.
Leftward axis. Consider left anterior fascicular block.
Prominent voltage in lead aVL and the precordial leads with ST-T
wave abnormalities consistent with left ventricular hypertrophy
and strain and/or ischemia. The QTc interval is short and there
are inferolateral T wave abnormalities. Clinical correlation is
suggested. No previous tracing available for comparison.
ECHO (___): The left atrial volume is severely increased.
The estimated right atrial pressure is ___ mmHg. Mild symmetric
left ventricular hypertrophy with normal wall thickness, cavity
size, and global systolic function (biplane LVEF = 62 %). There
is mild symmetric left ventricular hypertrophy. Overall left
ventricular systolic function is low normal (LVEF 50-55%). The
estimated cardiac index is normal (>=2.5L/min/m2). Transmitral
and tissue Doppler imaging suggests normal diastolic function,
and a normal left ventricular filling pressure (PCWP<12mmHg).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The descending thoracic aorta is mildly dilated. There
are three aortic valve leaflets. The aortic valve leaflets are
severely thickened/deformed. The aortic valve VTI = 133 cm.
There is severe aortic valve stenosis (valve area <1.0cm2).
Trace aortic regurgitation is seen. The mitral valve leaflets
are moderately thickened. Moderate to severe (3+) mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. The pulmonic valve is abnormal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Severe aortic stenosis. Mild left ventricular
hypertrophy with diastolic dysfunction and elevated left
ventricular filling pressures. Severely enlarged left atrium.
Severe pulmonary hypertension. Moderate to severe mitral
regurgitation.
CAROTID U/S (___):
Impression: Right ICA <40% stenosis.
Left ICA <40% stenosis.
CARDIAC CATH (___):
Findings
ESTIMATED blood loss: minimal
Hemodynamics (see above):
Coronary angiography: right dominant. Heavily calcified vessels
LMCA: normal
LAD: 80% tubular stenosis in mid segment
LCX: mild luminal irregularity
RCA: 60% stenosis in proximal segment, eccentric and heavily
calcified. 50% stenosis in mid segment
Other: widely patent infra-renal abdominal aorta and left and
right iliac arteries and CFA's.
Interventional details
Discussion with patient and referring cardiologist. Since
patient
is not a candidate for AVR, felt best to proceed with PCI.
Change
for ___ XB-LAD 3.5 guiding catheter. Mid LAD stenosis pre-dilated
using a 2.5mm balloon. 3.5mm x 15mm Integrity (bare metal) stent
then deployed at 16 atm. Excellent final result with 0% residual
stenosis, no dissection, and brisk flow.
Consideration made to pressure wire of RCA. Attempted to engage
RCA using ___ AL-1 and then JR4 catheters, but unable to torque
well in aorta, and catheters kinked easily in iliac segment. In
addition, patient getting restless on the table. Therefore felt
not worth further pursuing what appears to be moderate severity
stenoses in the RCA.
Assessment & Recommendations
1. 2 vessel CAD
2. Successful PTCA/stent of LAD using bare metal stent.
3. Patient being evaluated for ___.
4. ASA 81mg QD indefinitely. Plavix 75mg QD for 1 month.
5. Hydrate cautiously for prevention of contrast nephropathy,
and will need close monitoring for CHF.
6. Close monitoring for bleeding following manual removal of
femoral sheath since patient is a ___.
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ with history of severe AS ___ 0.7-0.8
in ___, ___ class II, who presents with DOE and
diastolic CHF exacerbation.
# Acute on chronic diastolic CHF: ___ class II. Pt
presents with DOE, orthopnea, PND, leg edema, all consistent
with CHF exacerbation. This is in the setting of eating more
prepared foods with higher salt load as she no longer cooks for
herself, and also missing one week of lasix several days ago.
Dry weight ~90.9 kg reportedly, but patient is actually below
this weight, may have a new dry weight. Admission weight 88.8
kg. She responded well to lasix 20mg PO in the ED (this is her
home dose). TTE this admission with diastolic dysfunction, LVEF
50-55%, elevated LV filling pressures, moderate-to-severe MR ___
TR. ___ CHF likely ___ severe AS (see below #Aortic
stenosis). Discharge weight was 88.3 kg. Carvedilol added to
regimen in setting of CHF. Was continued on home lasix,
losartan and amlodipine initially. Losartan and lasix were held
due to development of contrast induced nephropathy. restarted
lasix on ___ with improvement in renal function. Losartan was
not restarted given good control of BPs off of it. Patient
improved clinically, seen by ___ on ___ - satted well on
ambulation, but per ___ note: primarily limited by endurance,
functioning below her baseline and will require STR given
impairments and living at home alone. Patient discharged to
rehab facility.
# Aortic stenosis, severe: ___ 0.7-0.8 in ___. More
symptomatic with lightheadedness and CHF exacerbation. Had
previously seen Dr. ___ possible ___ in ___, and
decision to defer consideration of ___ at that point. Now she
is more symptomatic and would likely benefit from an
intervention. Of note, she is a ___'s witness member and
would refuse transfusion of another's blood products. Echo
during this admission showed severe aortic valve stenosis (valve
area <1.0cm2). Seen by cardiac surgery: reported she was an
extreme risk for surgical AVR given herfrailty, age, and refusal
to accept blood transfusions if needed, so not a candidate for
surgical intervention, recommended eval for ___. As part of
___ workup patient underwent cardiac cath: had 2 vessel CAD on
cardiac cath, now s/p BMS to mid LAD lesion. Also underwent
carotid u/s as part of workup showing 40% stenosis in L and R
ICA. Rest of ___ workup deferred to outpatient setting. Has
follow up with Dr. ___ on ___ for continued ___ follow
up.
# CAD: 2 vessel CAD on cardiac cath, now s/p BMS to mid LAD
lesion. Patient should continue plavix for one month and ASA 81
indefinitely. Also started on beta blocker (carvedilol 3.125mg
BID) given CHF - should continue as outpatient.
# CIN - patient with decreased UOP, elevated creatinine after
receiving dye load for cardiac cath. Losartan and lasix
initially held. UOP improved, creatinine trended down.
Restarted lasix on day of discharge (___). Losartan was
discontinued, can be reassessed by her outpatient cardiologist.
# Hematuria: Resolved. Had tea colored urine initially on ___.
Then cleared. patient's foley came out with balloon inflated
over weekend of ___. ___ have had some trauma. No clots
noted in foley, and foley flushed well.
# HTN: continued on home amlodipine. Carvedilol added to
regimen. Losartan was discontinued in the setting of kidney
injury, did not restart as BPs were well-controlled off of it.
# HLD: Continued on home simvastatin.
# Anemia: was initially slightly macrocytic, now normocytic.
Iron, B12, folate were normal. Stool guaiac negative. No signs
of active bleeding. Would continue to monitor on outpatient
setting.
TRANSITIONAL ISSUES:
# AORTIC STENOSIS: Undergoing ___ workup - Has follow up with
Dr. ___ for ___. Also has CT scan scheduled
as part of this workup (___).
# CHF: Has follow up with her primary cardiologist Dr. ___ on
___. Of note, her lasix was held for a period due to
development of contrast induced nephropathy. Her lasix home
dose (20 mg daily) was restarted on ___ with
normalization of her creatinine. She should have her
electrolytes monitored daily to ensure continued normal renal
function in the setting of restarting her diuretic. Also
started on beta blocker (carvedilol 3.125mg BID) given CHF -
should continue as outpatient.
# CAD: 2 vessel CAD on cardiac cath, now s/p BMS to mid LAD
lesion. Patient should continue plavix for one month and ASA 81
indefinitely. Also started on beta blocker (carvedilol 3.125mg
BID) given CHF - should continue as outpatient.
# CIN: patient developed contrast induced nephropathy after
receiving dye load during cardiac catheterization. Losartan and
furosemide were subsequently held. Kidney function improved and
lasix was restarted on ___. Discontinued Losartan. Recommend
monitoring of electrolytes daily given restarting of diuretic.
# CODE: Full, no blood products (Je___'s Witness)
# CONTACT: Son ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO DAILY
2. guaiFENesin AC (codeine-guaifenesin) ___ mg/5 mL oral ___
mL q6hr prn cough
3. Amlodipine 10 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Simvastatin 20 mg PO DAILY
3. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
4. Aspirin 81 mg PO DAILY
5. Carvedilol 3.125 mg PO BID
6. Clopidogrel 75 mg PO DAILY
Should continue for 1 month
7. Ferrous Sulfate 325 mg PO DAILY
8. Guaifenesin ___ mL PO Q6H:PRN cough
9. Furosemide 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Severe Aortic Stenosis
CAD s/p Bare Metal Stent to LAD
CHF
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 caring for you during your admission to ___
___. You were admitted for
evaluation of shortness of breath. You underwent testing which
showed one of your heart valves is not functioning properly
which is the likely etiology of your symptoms. You underwent
testing as part of the work up for an aortic valve replacement
procedure. During that work up you had a cardiac
catheterization and a stent was placed. You were started on
medications indicated for patients with cardiac disease. You
should continue taking these medications as prescribed. You
have follow-up scheduled with your cardiologist as well as the
team evaluating you for aortic valve replacement. You should
monitor your weight daily, if you should gain more than 3 lbs or
have increasing swelling in your legs, you should call your
cardiologist's office (Dr. ___ at ___ to
address possible changes in your medications. In addition your
Losartan was discontinued. You should not restart the Losartan
unless advised to do so by your physician. Should you develop
progressive shortness of breath, or chest pain, please seek
evaluation by at a medical facility or at your nearest emergency
department.
Followup Instructions:
___
|
10859320-DS-12
| 10,859,320 | 21,198,754 |
DS
| 12 |
2139-01-11 00:00:00
|
2139-01-13 20:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
colchicine / Quinolones
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with severe AS being evaluated for TAVR, CAD s/p BMS to LAD
(___), CKD recently discharged from ___ ___ seen in Dr.
___ today. Noted to be 10 lbs up since arrival at
rehab 193 ->203 lbs. She was noted to be clinically overloaded,
and unable to lay flat. She states SOB has worsened over the
past few days but has been gaining weight since she left the
hospital. Increased orthopnea, increased SOB. She reports
remaining on a low sodium diet while at rehab and recieving
lasix daily. At rehab her lasix dose was increased from 20mg to
40mg daily. She denies any viral prodrome - no
fever/chills/night sweats, sore throat, nasal congestion.
Denied any episodes of chest pain, light-headedness/dizziness,
diaphoresis, abd pain, diarrhea, or dysuria.
Of note, the patient was recently admitted to ___ from
___. She was admitted from ___ clinic at that time due to
progressive decrease in exercise tolerance, orthopnea and
hypoxia on ambulation to 87%. Echo during that admission on
___ noted severe aortic valve stenosis (valve area <1.0cm2).
During that admission she underwent diuresis for CHF
exacerbation thought ___ to poor diet compliance (increased salt
intake) and missing 1 week of home dose lasix. Admit weight was
88.8 kg, discharge weight on ___ was 88.3 kg. She was also seen
by cardiac surgery who determined she was not a surgical
candidate for AVR. She had cardiac catheterization showing 2
vessel CAD with BMS to mid LAD lesion. She was started on
carvedilol for her CHF, and discharged on her home dose of lasix
20mg per day to rehab (was increased at rehab to 40mg per day).
Also started on aspirin, plavix.
In the ED, initial vitals were 97.4 64 160/60 18 98%. Given
tylenol ___ mg, 40mg IV lasix. Per report put out 2L to IV
lasix. CXR without frank pulmonary edema. Initial labs notable
for: Na/K 133/4.6, ___, BUN/Cr ___, Glu 99, Mg 2.1.
UA was unremarkable. VS prior to transfer Today 15:26 97.6 50
174/55 16 98% RA.
Initial vitals on arrival to the floor were wt 88.9 kg (standing
weight), T 97.8, BP 176/65, HR 60, RR 18, SaO2 94% RA. She was
laying down in bed and comfortable. Denied any SOB, cp,
light-headedness/dizziness, abd pain, myalgias/arthralgias,
dysuria. Reported cough which has been ongoing, but not
productive of sputum.
ROS: + as per HPI. 10 point ROS otherwise negative unless noted
above.
Past Medical History:
- HTN
- HLD
- s/p bilateral TKAs
- Severe AS
- dCHF
Social History:
___
Family History:
- There is no history of hypertension, diabetes mellitus, heart
disease, or strokes.
- Her mother died in her ___ of colon cancer and her father died
in his ___ of natural causes
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: wt 88.9 kg (standing weight), T 97.8, BP 176/65, HR 60, RR
18, SaO2 94% RA (dry weight ~90.9 kg reportedly), discharge
weight was 88.3 kg
General: Sitting up in bed, in NAD, conversant/pleasant
HEENT: NC/AT, EOMI, sclera anicteric, MMM
Neck: Trachea midline, + hepatojugular reflex
CV: RRR, ___ systolic murmur loudest at RUSB
Lungs: mild bibasilar crackles, no wheezes/rhonchi
Abdomen: Soft, non-distended, non-tender to palpation, +BS
GU: Foley in place with clear yellow urine
Ext: 1+ DP pulses, 1+ bilateral ___ edema
Neuro: Moving all extremities, speech fluent
Skin: No rashes noted
DISCHARGE PHYSICAL EXAM:
VS: T97.8 BP 143-150/61-64 HR 56-58 RR ___ SaO2 97-100% RA
I/O: 8hr: +240/-600; +1740/-1550
Wt: 88.0 kg (stand); 88.9 admission weight
(dry weight ~90.9 kg reportedly), previous dc weight was 88.3 kg
General: Sitting up in chair, in NAD, conversant/pleasant
HEENT: NC/AT, EOMI, sclera anicteric, MMM
Neck: Trachea midline, No JVD
CV: RRR, ___ systolic murmur, late peaking CD, loudest at RUSB
Lungs: trace bibasilar crackles, no wheezes/rhonchi
Abdomen: Soft, non-distended, non-tender to palpation, +BS
GU: Foley in place with clear yellow urine
Ext: 1+ DP pulses, trace bilateral ___ edema
Pertinent Results:
LABS:
___ 07:50AM BLOOD WBC-3.9* RBC-2.98* Hgb-9.3* Hct-30.6*
MCV-103* MCH-31.4 MCHC-30.5* RDW-14.1 Plt ___
___ 09:10AM BLOOD WBC-5.0 RBC-3.31* Hgb-10.1* Hct-32.7*
MCV-99* MCH-30.6 MCHC-31.0 RDW-13.9 Plt ___
___ 07:30AM BLOOD WBC-4.8 RBC-3.21* Hgb-10.1* Hct-31.9*
MCV-99* MCH-31.6 MCHC-31.8 RDW-13.6 Plt ___
___ 07:20AM BLOOD WBC-4.6 RBC-3.03* Hgb-9.4* Hct-30.3*
MCV-100* MCH-31.1 MCHC-31.1 RDW-13.9 Plt ___
___ 12:49PM BLOOD Glucose-99 UreaN-26* Creat-1.0 Na-133
K-4.6 Cl-96 HCO3-25 AnGap-17
___ 07:25PM BLOOD Glucose-154* UreaN-25* Creat-1.0 Na-136
K-3.8 Cl-98 HCO3-28 AnGap-14
___ 07:50AM BLOOD Glucose-79 UreaN-28* Creat-1.0 Na-131*
K-4.4 Cl-95* HCO3-25 AnGap-15
___ 09:10AM BLOOD Glucose-90 UreaN-28* Creat-1.0 Na-135
K-4.6 Cl-96 HCO3-27 AnGap-17
___ 07:30AM BLOOD Glucose-80 UreaN-27* Creat-1.0 Na-134
K-4.6 Cl-95* HCO3-27 AnGap-17
___ 03:15PM BLOOD Glucose-106* UreaN-26* Creat-1.2* Na-133
K-5.0 Cl-95* HCO3-29 AnGap-14
___ 07:20AM BLOOD Glucose-85 UreaN-32* Creat-1.2* Na-137
K-4.7 Cl-99 HCO3-28 AnGap-15
___ 12:49PM BLOOD Calcium-9.2 Phos-3.7 Mg-2.1
___ 07:25PM BLOOD Calcium-9.6 Phos-3.5 Mg-1.9
___ 07:50AM BLOOD Calcium-9.4 Phos-4.3 Mg-2.3
___ 09:10AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.1
___ 07:30AM BLOOD Calcium-9.3 Phos-4.8* Mg-2.1
___ 03:15PM BLOOD Calcium-9.4 Phos-4.7* Mg-2.0
___:20AM BLOOD Calcium-9.4 Phos-5.5* Mg-2.1
___ 12:25PM URINE Color-Straw Appear-Clear Sp ___
___ 12:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
IMAGING/STUDIES:
CT CHEST PENDING
CXR (___): FINDINGS: Thoracic scoliosis is noted. There
may be some medial right upper lobe scarring. The cardiac
silhouette is moderately enlarged. The aorta is calcified and
tortuous. No large pleural effusion is seen. The lungs are
hyperinflated with flattening of the diaphragms, suggesting
chronic obstructive pulmonary disease. There is no overt
pulmonary edema or definite focal consolidation seen.
Degenerative changes are seen along the spine. Right
paratracheal opacity without indentation on the trachea most
likely relates to underlying vascular structures,
IMPRESSION: Enlarged cardiac silhouette without frank pulmonary
edema.
Thoracic scoliosis.
ECG ___: Artifact is present. Sinus bradycardia. The P-R
interval is prolonged. Left ventricular hypertrophy with
associated ST-T wave changes, although ischemia or infarction
cannot be excluded. Compared to the previous tracing of the
same date, there is no significant change
Brief Hospital Course:
___ with history of severe AS (Aortic Valve - Valve Area:*0.6
cm2 on ___ echo), ___ class II, who presents with
DOE and diastolic CHF exacerbation.
# Dyspnea: ___ class II. Pt presents with worsening DOE,
orthopnea, and reported 10 lb weight gain from rehab all
consistent with CHF exacerbation. However, standing weight on
floor on admission was 88.9 which is virtually unchanged from
previous discharge weight (88.3 kg), CXR is relatively clear and
lung exam with mild bibasilar crackles. Patient's dyspnea
likely related more to deconditioning and severe AS versus CHF
exacerbation. Patient was diuresed with IV lasix initially, then
lasix PO 40 mg BID. Patient improved clinically and was
discharged on 60 mg Lasix PO QD (increase from 40mg home dose).
Seen by ___ who determined patient was safe for d/c home with
home ___.
# ___: ___ class II. Unclear whether patient has truly gained
much weight since discharge. Standing weight on floor on
admission was 88.9 kg (previous discharge weight was 88.3 kg).
CXR negative for frank pulmonary edema. Received 40 IV lasix in
ED with 2L output. Patient was diuresed with PO lasix 40 BID
and discharged on 60 mg daily of lasix (increase from home dose
of 40 mg daily). Patient was continued on carvedilol 3.25 mg
BID.
Home losartan was held - was dc'd at previous hospitalization
d/t development of CIN, not restarted at rehab. Was held here
as patient underwent CT and would be receiving dye load, there
slight bump in creatinine to 1.2. Was discharged off of
losartan, recommend re-initiating as outpatient pending
normalization of creatinine.
# Anemia: She is a Jehova's witness and would not accept blood
transfusions. Stools during previous admission were guaiac
negative, iron/b12/folate were normal. Daily CBCs were
monitored.
# Aortic stenosis, severe: Aortic Valve - Valve Area: *0.6 cm2
in ___. Not surgical candidate per cardiac surgery during
previous admission. Was seen at Dr. ___ office on date of
admission and there was concern for significant weight gain (10
lb weight gain per rehab records, however this conflicts with
admission weight of 88.9 kg and previous discharge weight of
88.3 kg). CT chest done as part of TAVR work up, final read
was pending as of discharge date. Patient has follow up with
Dr. ___ on ___ for continued TAVR workup.
# CAD: 2 vessel CAD on cardiac cath during previous admission,
now s/p BMS to mid LAD lesion. Patient was continued on plavix
(will need it for one month from date of PCI with BMS, was done
on ___, ASA 81 daily and simvastatin 20 mg daily.
# HTN:
As noted above, held home losartan during this admission.
Losartan was discontinued during previous admission due to
development of ___ held during this admission due to
receiving dye load for CT chest/ c/f CIN. Slight bump in
creatinine during this hospitalization. recommend re-initiating
as outpatient pending normalization of creatine. Paitent was
continued on home amlodipine and carvedilol.
# HLD:
- Was continued on home simvastatin 20 mg daily.
TRANSITIONAL ISSUES:
# Aortic stenosis: patient had CT torso done as part of workup
for aortic stenosis while inpatient. Final read pending as of
discharge. Has follow up with Dr. ___ on ___ regarding
further TAVR workup.
# CHF: patient admitted for CHF exacerbation. Diuresed with IV
and PO lasix. Discharged on 60 mg PO lasix daily (increased from
40 mg prior to admission). Recommend electrolyte check at next
outpatient appointment.
# HTN: patient's Losartan was discontinued during previous
admission due to the development of CIN. It was not restarted
during her stay at rehab. During this admission was also held
given risk of CIN as received dye load during CT scan. There was
a slight creatinine bump to 1.2 (from 1.0 on admission) after CT
scan. Patient's BPs largely in the 130s-140s during
hospitalization on home amlodipine and carvedilol. Losartan not
restarted given above conditions. Recommend consideration of
re-initiating losartan as outpatient given severe AS and risk of
flash with elevated BPs. Has follow up with Dr. ___
(cardiologist on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Simvastatin 20 mg PO QPM
3. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
4. Aspirin 81 mg PO DAILY
5. Carvedilol 3.125 mg PO BID
6. Clopidogrel 75 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Guaifenesin ___ mL PO Q6H:PRN cough
9. Furosemide 40 mg PO DAILY
10. TraZODone 25 mg PO HS:PRN insomnia
11. Milk of Magnesia 30 mL PO DAILY:PRN constipation
12. Bisacodyl ___AILY:PRN constipation
13. Fleet Enema ___AILY:PRN constipation
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Carvedilol 3.125 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Furosemide 60 mg PO DAILY
RX *furosemide 20 mg 3 tablet(s) by mouth Daily Disp #*90 Tablet
Refills:*0
8. Guaifenesin ___ mL PO Q6H:PRN cough
9. TraZODone 25 mg PO HS:PRN insomnia
10. Bisacodyl ___AILY:PRN constipation
11. Fleet Enema ___AILY:PRN constipation
12. Milk of Magnesia 30 mL PO DAILY:PRN constipation
13. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Aortic Stenosis
CHF exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
It was pleasure caring for you during your admission to ___
___. You were admitted for
evaluation due to increased shortness of breath. You were given
medications to help remove excess fluid from your body. You
improved clnically and it was determined you could be discharged
to home with home physical therapy. You also had a CT scan done
as part of the work up for your aortic valve procedure. The
final read of that is still pending. Your Lasix dose was
increased from 40mg per day to 60 mg per day. Also your
Losartan was held during your admission. You should not restart
this medication until you speak with your cardiologist Dr.
___ at your follow up appointment on ___. Should
you develop increasing swelling in your legs, or notice a 3 lb
weight gain, please call Dr. ___ office at ___ as
you may need to adjust your Lasix dose. Should you develop
progressive chest pain or worsening shortness of breath, please
seek evaluation at a medical facility or at your nearest
emergency department.
Followup Instructions:
___
|
10859320-DS-14
| 10,859,320 | 24,892,867 |
DS
| 14 |
2142-03-07 00:00:00
|
2142-03-08 11:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
colchicine / Quinolones
Attending: ___
Chief Complaint:
Dyspnea and lower extremity swelling
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ y/o woman with PMH notable for dCHF, severe AS
s/p TAVR in ___, CAD s/p BMS to LAD in ___, and HTN presenting
with progressive dyspnea x1 week and increased leg swelling.
The patient states that over the past week, she has noticed
increased swelling first in her feet bilaterally (unable to put
her shoes on), progressive shortness of breath, initially with
activity but then subsequently at rest, as well as increase in
weight from dry weight of 185 lbs up to 200 lbs at time of
presentation. She usually sleeps in a bed, using ___ pillows but
over the past couple days was sleeping in her recliner. She has
noticed some more audible wheezing as well as a clear cough. No
PND and denies any chest pressure or pain. She denies any
associated N/V, abdominal pain, dysuria, f/c, diarrhea. She has
been taking her medications as instructed and actually had her
Lasix increased from 60 to 80mg PO daily several days ago when
she first began to notice her increased ___ swelling. She does
admit to eating out several times prior to start of her recent
sx. Functionally, she is able to walk around with her walker at
baseline, although she states that she hardly leaves the ___.
On the day of presentation, her symptoms had become so sever
that she could barely leave her seat/bed. As such, she called
her son, who brought her to the ED for further management.
In the ED, initial vitals were:
-97.0 62 155/66 26 100% Nasal Cannula (3L)
-ED weight: 198.8 lbs
Exam notable for:
-"JVP difficult to appreciate ___ redundant neck tissue, 3+
tense edema in lower extremities b/l, lungs b/l crackles.
AAOx3."
Labs notable for:
-Chem10 with BUN/Cr ___ (baseline Cr ~1), Na 131, Cl 95
(improved to 134 and 97, respectively on recheck after diuresis)
-trop initially 0.01 rising to 0.02
-Negative CK-MB
-Normal LFTs
-CBC at baseline
Imaging was notable for:
-CXR without any acute cardiopulmonary processes
Patient was given:
-Lasix 60mg IV x1
-lidocaine patch
-losartan 25mg PO x1
-atorvastatin 40mg PO x1
Upon arrival to the floor, patient reports feeling ok. Endorses
the above history and is comfortable right now.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
-Hypertension
-Hyperlipidemia
-Diastolic CHF
-Severe AS s/p TAVR in ___
-CAD s/p PCI/BMS to LAD for an 80% stenosis in ___
-s/p bilateral TKR
Social History:
___
Family History:
No FH of HTN, DM, heart disease, or strokes. Mother with colon
cancer.
- Her mother died in her ___ of colon cancer and her father died
in his ___ of natural causes
Physical Exam:
===============================
ADMISSION PHYSICAL EXAM
===============================
Vitals: 98.4 149/47 69 18 100 3L
General: alert, lying in bed at 30 degrees, comfortable, in NAD
HEENT: NC/AT, EOMI, PERRL, MMM, tongue midline on protrusion,
symmetric palatal elevation, smile, and eyebrow raise
Neck: supple, symmetric, JVP appears to be at mandible with
patient at 30 degrees
Lungs: audible wheezing; no increased use of accessory muscles;
good air movement throughout with bibasilar crackles and
+expiratory wheezing
CV: RRR, S1, S2, soft ___ systolic murmur, poorly appreciated
with loud upper airway sounds; no r/g heard
Abdomen: soft, mildly tender in RUQ, non-distended, no r/g, BS+
GU: foley in place
Ext: warm, well perfused, 2+ pulses, 2+ pitting edema up to
hips bilaterally
Neuro: alert, appropriately interactive on exam; strength ___
in b/l UE, able to lift both legs up against gravity, sensation
to light touch grossly intact and symmetric throughout UE,
torso, and ___
===============================
DISCHARGE PHYSICAL EXAM
===============================
Vitals: 98.1 PO 146 / 65 60 18 97 RA
I/O= ___
Weight: pending
Weight on admission: 90.22 kg
General: NAD
HEENT: NCAT, MMM, JVD decreased from yesterday
Lungs: Crackles at b/l bases, slightly increased WOB, no wheeze
appreciated
CV: RRR, ___ systolic murmur
Abdomen: soft, NT, ND
Ext: trace edema b/l; tenderness to first left MTP joint without
any effusion, erythema, warmth
Skin: WWP
Pertinent Results:
===============================
ADMISSION LABS
===============================
___ 12:37PM BLOOD WBC-8.3 RBC-3.41* Hgb-10.8* Hct-33.9*
MCV-99* MCH-31.7 MCHC-31.9* RDW-15.0 RDWSD-54.6* Plt ___
___ 12:37PM BLOOD Neuts-77.2* Lymphs-10.9* Monos-10.6
Eos-0.5* Baso-0.4 Im ___ AbsNeut-6.40* AbsLymp-0.90*
AbsMono-0.88* AbsEos-0.04 AbsBaso-0.03
___ 12:37PM BLOOD Plt ___
___ 07:50AM BLOOD ___ PTT-23.0* ___
___ 12:37PM BLOOD Glucose-99 UreaN-22* Creat-1.0 Na-131*
K-4.8 Cl-95* HCO3-22 AnGap-19
___ 12:37PM BLOOD ALT-20 AST-28 AlkPhos-82 TotBili-0.8
___ 12:37PM BLOOD cTropnT-0.01 proBNP-7920*
___ 08:06PM BLOOD Calcium-9.4 Phos-4.1 Mg-1.8
===============================
IMAGING
===============================
___ cxr: No acute cardiopulmonary abnormality.
Last TTE ___:
1. There is mild concentric left ventricular hypertrophy.
2. Overall left ventricular ejection fraction is normal, with
an estimated LVEF of 55-60%.
3. The left atrium linear dimension is mildly enlarged.
4. The right atrium is mildly dilated.
5. The mitral valve leaflets are mildly thickened.
6. Mild mitral annular calcification present.
7. Mild-to-moderate mitral regurgitation is present.
8. The aortic root is borderline dilated measuring 3.8 cm.
9. The interatrial septum is aneurysmal.
10. There is no evidence of a shunt by color Doppler from views
imaged.
11. Compared with the findings of the prior ___ report of
___, TAVR has been performed.
===============================
DISCHARGE LABS
===============================
___ 05:20AM BLOOD WBC-8.3 RBC-3.40* Hgb-10.8* Hct-32.7*
MCV-96 MCH-31.8 MCHC-33.0 RDW-14.4 RDWSD-51.4* Plt ___
___ 05:20AM BLOOD Plt ___
___ 05:20AM BLOOD Glucose-101* UreaN-43* Creat-1.3* Na-128*
K-4.6 Cl-89* HCO3-27 AnGap-17
___ 05:20AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.5
Brief Hospital Course:
Ms. ___ is a ___ y/o woman with PMH notable for dCHF, severe AS
s/p TAVR in ___, CAD s/p BMS to LAD in ___, and HTN presenting
with dCHF exacerbation, likely triggered by dietary
indiscretion.
ACTIVE ISSUES:
---------------
# Severe AS s/p TAVR in ___
# Hypoxia ___
# Acute on Chronic dCHF exacerbation: Patient with known
diastolic CHF with sx consistent with acute, progressive
exacerbation. Trigger for her exacerbation likely from dietary
indiscretion. Patient is adherent on medications with no signs
of infection. She was diuresed on a Lasix gtt at 15 mg/hour and
then transitioned to Lasix 40 mg po BID. Her home amlodipine was
continued and losartan was increased to 50 mg BID and
spironolactone was added. DISCHARGE WEIGHT: 87.2 kg
#Gout: Patient had severe left MTP joint pain likely gout in
the setting of diuresis. She was given colchicine 1.2 mg once
with immediate relief in her symptoms.
# CAD s/p PCI/BMS to LAD for an 80% stenosis in ___: Low
suspicion for active ischemia as noted below.
# Troponinemia: Patient with minimally elevated troponins,
which mildly rose, but likely I/s/o CKD. Low suspicion for ACS,
most likely demand, especially I/s/o negative CK-MB. No acute
ischemic changes on EKG noted. She was continued on home
aspirin, statin, bb.
CHRONIC ISSUES:
-----------------
# Hypertension:
- continued on home amlodipine with increase in losartan to 50
mg BID and spironolactone was added
# Hyperlipidemia: continued home statin
# Anemia: at baseline, chronic. Likely multifactorial I/s/o
advanced age, renal disease, and perhaps some nutritional
deficiencies.
# CKD, Stage 3: at baseline Cr
# Chronic back pain: continued home lidocaine patch
# Insominia: continued home trazodone
CORE MEASURES:
-------------
# CODE: full (confirmed with patient)
# CONTACT: ___ (___)
TRANSITIONAL ISSUES
===================
[] DISCHARGE WEIGHT: 87.2 kg or 192 pounds
[] trend wt, I/o, adjust medications as indicated
[] monitor for signs of recurrence of gout and consider
prophylaxis if indicated
[] repeat cr as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
2. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
3. Atorvastatin 40 mg PO QPM
4. Furosemide 60 mg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
6. amLODIPine 10 mg PO DAILY
7. Losartan Potassium 25 mg PO BID
8. TraZODone 25 mg PO QHS:PRN insomnia
9. Aspirin 81 mg PO DAILY
10. calcium carbonate-vit D3-min 600 mg (1,500 mg)-200 unit oral
DAILY
11. Docusate Sodium 100 mg PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Spironolactone 12.5 mg PO DAILY
RX *spironolactone [Aldactone] 25 mg Half a tablet by mouth
daily Disp #*15 Tablet Refills:*0
3. Furosemide 40 mg PO BID
RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Losartan Potassium 50 mg PO BID
RX *losartan [Cozaar] 50 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
5. amLODIPine 10 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. calcium carbonate-vit D3-min 600 mg (1,500 mg)-200 unit oral
DAILY
9. Docusate Sodium 100 mg PO DAILY
10. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
12. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIAMRY DIAGNOSIS
=================
Acute on Chronic Diastolic Heart Failure
Hypoxia
Type II NSTEMI
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
You came to the hospital because you had a heart failure
exacerbation which caused you to have increased swelling in your
legs and feel short of breath. We gave you IV Lasix, which is a
diuretic to help you urinate all the fluid and you felt better.
Please follow up with your doctors below and continue to take
your medications as directed.
Your "dry" weight is 192 pounds.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs in 24 hours.
We wish you the best,
Your care team at ___
Followup Instructions:
___
|
10859759-DS-11
| 10,859,759 | 22,447,838 |
DS
| 11 |
2171-11-17 00:00:00
|
2171-11-18 15:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Shellfish Derived / morphine
Attending: ___.
Chief Complaint:
dream like state
legs giving out
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms ___ is a ___ year-old right-handed woman with chronic HA,
right shoulder pain s/p injury, HTN, DM, obesity who presents
with left shoulder injury and c/o of a dream-like state after
the
injury.
Yesterday afternoon, she was carrying a heavy bag of trash on
her
left shoulder. The bag was very heavy and she thinks she might
have injured the left shoulder because it became very painful at
the shoulder joint. She went back to her house. She also noted
pain in her left temple.
As she was trying to walk up the stairs, her bilateral legs gave
out. States that there were episodes of her legs giving out in
the past but they are usually preceded by pain. Says that she
didnt fall but was able to lower herself and sat on the stairs.
Then, she was in a "dream-like state". She was not confused.
She knew what she was doing and needed to do but just did not go
ahead and do what she is supposed to do. She cannot say for
sure
if her legs were weak when she was sitting on the stairs because
she did not try to move them. She did not have any convulsions,
abnormal sensation, numbness, visual changes/distortion,
drooling. Denies out of body experience, ___, rising
sensation in the abdomen. She thinks that she sat on the stairs
for an hour.
After that, she got up and walked up the stairs to the bathroom
without difficulty. She took of her dentures (no clumsiness).
She thought she should call her daughter but did not do so. She
does not know why she did not call her daughter but she "just
didn't". She sat down on her couch and fell asleep. She woke
up
and realized the TV was still on, went ahead and switched it off
and headed to bed.
This mornign, she woke up with peristent L shoulder pain. States
that she had a tension HA at the top of her head (usual HA)
without photophobia/phonophobia/nausea. She called her daughter
and her daughter took her to the ED.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies numbness, parasthesiae. No bowel
or
bladder incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies diarrhea or abdominal pain.
Past Medical History:
DIABETES TYPE II
HYPERTENSION
CORONARY ARTERY DISEASE
CHRONIC KIDNEY DISEASE
OBESITY
OSTEOARTHRITIS
RADICULOPATHY
SHOULDER PAIN
VENTRAL HERNIA
CYSTOCELE
DEPRESSION, ? BIPOLAR DISORDER
HEADACHE
EOSINOPHILIA
SLEEP APNEA
Social History:
___
Family History:
sister died of MI at ___
oldest brother died at ___ years old from dementia
Physical Exam:
Physical Exam on Admission:
Vitals: 98.6, 73, 155/98, 18, 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, cervical paraspinal muscle spasms
Neck: Supple, No nuchal rigidity
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt was able to name both high and low
frequency objects. Speech was not dysarthric. Able to follow
both
midline and appendicular commands. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
Strength exam in the UE (esp the left) is limited by pain with
giveaway but at least 5- throughout. Bilateral ___ ___
throughout.
-Sensory: No deficits to light touch, cold sensation, vibratory
sense throughout.
-DTRs:
1's throughout
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Walked in tandem but with difficulty. Romberg absent.
Physical Exam on Discharge:
unchanged from admission; notable for restricted range of motion
with neck rotation
Pertinent Results:
Labs on Admission:
___ 05:00PM WBC-7.9 RBC-4.74 HGB-12.8 HCT-40.0 MCV-84
MCH-27.0 MCHC-32.0 RDW-14.3
___ 05:00PM PLT COUNT-235
___ 05:00PM NEUTS-45.2* LYMPHS-43.3* MONOS-3.7 EOS-7.3*
BASOS-0.6
___ 05:00PM GLUCOSE-137* UREA N-22* CREAT-1.3* SODIUM-139
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-25 ANION GAP-17
___ 05:00PM CALCIUM-10.0 PHOSPHATE-3.9 MAGNESIUM-2.0
___ 07:06PM ___ PTT-28.2 ___
___ 06:00AM BLOOD ALT-16 AST-18 CK(CPK)-112 AlkPhos-45
TotBili-0.3
___ 06:00AM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:00AM BLOOD Triglyc-155* HDL-45 CHOL/HD-3.8
LDLcalc-97
___ 06:00AM BLOOD TSH-2.0
___ 06:00AM BLOOD %HbA1c-PND
Imaging:
MRI brain w/o contrast
No acute or subacute intracranial process.
Scattered foci of T2/FLAIR signal hyperintensity in the
periventricular and subcortical white matter most likely the
sequela of chronic small vessel ischemic disease.
Brief Hospital Course:
Ms ___ is a ___ year-old right-handed woman with chronic HA,
right shoulder pain s/p injury, HTN, DM, obesity who presents
with left shoulder injury and c/o of a "dream-like state" with
bilateral leg weakness after the injury. Exam is currently
non-focal. The episode of "dream-like state" sounds like a
potential amotivational/abulic state which, in the setting of
leg weakness
and multiple stroke risk factors raises the concern for
potential
TIA in bilateral ACA territory. Given her anxiety over losing
strength/function in the left arm, it was thought to be possible
that her
"dream-like state" may represent a state of severe anxiety/panic
though this is a diagnosis of exclusion. She was admitted for
stroke w/u. MRI brain was unremarkable, did not show stroke,
just some small vessel disease. LDL was 97. Pt has know
cervical and lumbar stenosis and has had episodes of legs giving
out; likely, symptoms were due to known spine disease. Provided
patient with soft cervical collar to be worn at night.
She will follow up with Dr. ___ outpatient
neurologist.
TRANSITIONAL ISSUES:
- HbA1c pending at time of discharge
Medications on Admission:
AMLODIPINE - amlodipine 5 mg tablet. 1 tablet(s) by mouth once a
day
CARVEDILOL - carvedilol 12.5 mg tablet. 1 tablet(s) by mouth
twice a day
CHLORTHALIDONE - chlorthalidone 25 mg tablet. 0.5 (One half)
tablet(s) by mouth once a day
CLONAZEPAM - clonazepam 0.5 mg tablet. 1 Tablet(s) by mouth at
night & 1 QD prn 45 minutes before bed. - (Prescribed by Other
Provider: ___
EPINEPHRINE [EPIPEN 2-PAK] - EpiPen 2-Pak 0.3 mg/0.3 mL
(1:1,000)
injection,auto-injector. 1 injection IM once as needed for
allergic reaction Inject in leg through colothes for allergic
reaction (hives, unable to breathe)
INSULIN GLARGINE [LANTUS] - Lantus 100 unit/mL subcutaneous
solution. 38 units SC twice a day - (Prescribed by Other
Provider; Dose adjustment - no new Rx)
INSULIN LISPRO [HUMALOG KWIKPEN] - Humalog KwikPen 100 unit/mL
subcutaneous. 4 units SC QAC - (Prescribed by Other Provider)
LISINOPRIL - lisinopril 20 mg tablet. 1 tablet(s) by mouth twice
a day Please schedule and keep appointment with Dr. ___.
PILL CUTTER - pill cutter . Use as needed to cut pills in half
PRAVASTATIN - pravastatin 40 mg tablet. one tablet(s) by mouth
daily
TRAMADOL - Dosage uncertain - (Prescribed by Other Provider:
___
Medications - OTC
ASPIRIN [ENTERIC COATED ASPIRIN] - Enteric Coated Aspirin 81 mg
tablet,delayed release. 1 Tablet(s) by mouth daily
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - FreeStyle Lite
Strips. To use for blood glucose monitoring three times a day
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Vitamin D3 400 unit
tablet. 2 Tablet(s) by mouth daily
CYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vit B-12) 500
mcg
tablet. 1 Tablet(s) by mouth once a day
INSULIN NEEDLES (DISPOSABLE) [BD INSULIN PEN NEEDLE UF SHORT] -
BD Insulin Pen Needle UF Short 31 X ___. Use five times daily
as directed with insulin pens
LANCETS [FREESTYLE LANCETS] - FreeStyle Lancets 28 gauge. Use up
to three times daily as directed to test blood sugar.
PSYLLIUM HUSK (WITH SUGAR) [METAMUCIL] - Metamucil 3.4 gram/7
gram oral powder. - (___)
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
3. ClonazePAM 0.5 mg PO QHS
4. Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner<br> Glargine 38 Units Q12H
5. Pravastatin 40 mg PO DAILY
6. TraMADOL (Ultram) 0 mg PO Q6H:PRN pain
7. Amlodipine 5 mg PO DAILY
8. Chlorthalidone 12.5 mg PO BID
9. Cyanocobalamin 500 mcg PO DAILY
10. Vitamin D 800 UNIT PO DAILY
11. Psyllium 1 PKT PO DAILY
12. Lisinopril 20 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
cervical spondylosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital after an episode of feeling
some weakness in your legs. We did an MRI of your brain which
did NOT show a stroke. Most likely, your symptoms were due to
the narrowing of the bones in your neck. You should wear a soft
cervical collar at night.
We have made no changes to your medications.
Please call Dr. ___, your neurologist, to schedule a
follow up appointment at ___.
Followup Instructions:
___
|
10859759-DS-12
| 10,859,759 | 23,010,195 |
DS
| 12 |
2176-02-22 00:00:00
|
2176-02-23 18:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Shellfish Derived / morphine
Attending: ___
Chief Complaint:
Leg swelling, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with a significant history
of T3N1 gastroesophageal adenocarcinoma on chemotherapy, type 2
diabetes complicated by retinopathy, hypertension, and
depression, chronic anemia, who presents for to the ED for
fatigue and leg swelling, found to be hypertensive to 190's and
anemic to 6.5.
She receives her oncologic care at ___ and is s/p partial
gastrectomy, NGT placement, chemo and radiation until that she
completed in ___. She reports that she followed with her
oncologist 2 months ago and on repeat scan was found to have no
evidence of recurrent disease.
She endorses fatigue, chronic reflux from her partial
gastrectomy and is constipated most of the time, loss of
appetite with 80 lb weight loss since cancer diagnosis;
intermittent black stools; depression with cancer diagnosis.
She denies fevers, chills abdominal pain, vomiting, nausea or
diarrhea.
In terms of her chronic anemia, she was being worked up for
anemia with C scope and EGD when she was diagnosed with gastric
cancer.
Of note, she is not taking her home medications. She is on
amlodipine 10mg for HTN, cavedilol 12.5mg BID for CAD.
In the ED, initial vitals:
Pain 0 Temp 99.3 HR 90 BP 186/98 RR 17 pO2 100% RA
- Exam notable for:
General: NAD, cachectic, marked temporal wasting
Heart: RRR, no murmer
Lungs: CTAB
Abdomen: Soft, mild tenderness on left lower guardant, no
rebound
or guarding
Rectal: NO blood in rectal vault
Leg swelling: bilateral leg swelling, R>L
- Labs notable for:
WBC 2.9, H/H 6.5/20.5
Abs-Ret: 0.02
proBNP 4144
BUN/Cr ___
- Imaging notable for:
___ CXR
Transverse cardiomegaly and interstitial pulmonary edema
suggesting cardiac decompensation.
No pneumonia.
___ CT abdomen and pelvis w/o contrast, read pending
- Pt given:
1 unit pRBC
- Vitals prior to transfer:
Pain 5 Temp 99.0 HR 70 BP 189/89 RR 16 pO2 100% RA
Upon arrival to the floor, the patient reports the history per
above. She says that her last chemotherapy was around ___ and
her surgery was ___. She underwent an EGD 3 weeks ago at
___ to evaluate upper GI bleed for anemia, which was negative.
She says that she stopped taking her medications because she
felt
overwhelmed by everything that was going on.
Past Medical History:
DIABETES TYPE II
HYPERTENSION
CORONARY ARTERY DISEASE
CHRONIC KIDNEY DISEASE
OBESITY
OSTEOARTHRITIS
RADICULOPATHY
SHOULDER PAIN
VENTRAL HERNIA
CYSTOCELE
DEPRESSION,? BIPOLAR DISORDER
HEADACHE
EOSINOPHILIA
SLEEP APNEA
Social History:
___
Family History:
Sister died of MI at ___
Oldest brother died at ___ years old from dementia
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VITALS: T 98.6 PO BP 203/92 L Lying HR 67 RR 18 pO2 100% ra
General: Chronically ill-appearing thin older woman, alert,
oriented, no acute distress, low affect
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP at 10 cm, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, tender to light in RUQ and epigastric area,
non-distended, bowel sounds present, no rebound or guarding
Ext: Warm, well perfused, 2+ DP pulse in RLE, 1+ DP pulse in
LLE, no clubbing, cyanosis or edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact grossly, moving all four extremities
appropriately.
DISCHARGE PHYSICAL EXAM:
======================
VS: Temp: 98.6 PO BP: 161/81 HR: 67 RR: 18 O2 sat: 100% O2 RA
General: Thin older woman lying comfortably in bed. Alert,
oriented, NAD.
HEENT: Sclerae anicteric, MMM
NECK: Supple, JVP flat.
CV: Regular rate and rhythm with normal S1 + S2, no murmurs,
rubs, or gallops.
Lungs: Normal respiratory effort. CTAB without wheezes, rales,
or rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no guarding.
Ext: Warm, well perfused, no ___ edema or erythema.
Skin: Warm, dry, no rashes
Neuro: Alert and interactive. CNII-XII intact grossly, ___
strength throughout.
Pertinent Results:
ADMISSION LABS:
==============
___ 12:12AM BLOOD WBC-2.9* RBC-2.31* Hgb-6.5* Hct-20.5*
MCV-89 MCH-28.1 MCHC-31.7* RDW-15.0 RDWSD-48.8* Plt ___
___ 12:12AM BLOOD Neuts-47.6 ___ Monos-9.7 Eos-5.5
Baso-1.0 Im ___ AbsNeut-1.38* AbsLymp-1.04* AbsMono-0.28
AbsEos-0.16 AbsBaso-0.03
___ 12:12AM BLOOD Glucose-104* UreaN-26* Creat-1.8* Na-140
K-4.7 Cl-108 HCO3-22 AnGap-10
___ 12:12AM BLOOD cTropnT-0.03* proBNP-4144*
___ 12:12AM BLOOD calTIBC-200* VitB12-311 Folate-11
___ Ferritn-49 TRF-154*
PERTINENT LABS/MICRO:
===================
___ 12:12AM BLOOD WBC-2.9* RBC-2.31* Hgb-6.5* Hct-20.5*
MCV-89 MCH-28.1 MCHC-31.7* RDW-15.0 RDWSD-48.8* Plt ___
___ 12:40PM BLOOD WBC-3.1* RBC-2.88* Hgb-8.0* Hct-24.9*
MCV-87 MCH-27.8 MCHC-32.1 RDW-15.7* RDWSD-49.9* Plt ___
___ 01:08AM BLOOD ___ PTT-26.9 ___
___ 12:12AM BLOOD Glucose-104* UreaN-26* Creat-1.8* Na-140
K-4.7 Cl-108 HCO3-22 AnGap-10
___ 05:30AM BLOOD Glucose-90 UreaN-27* Creat-2.0* Na-142
K-4.3 Cl-106 HCO3-24 AnGap-12
___ 04:13PM BLOOD Glucose-169* UreaN-28* Creat-1.7* Na-139
K-4.5 Cl-107 HCO3-20* AnGap-12
___ 12:12AM BLOOD cTropnT-0.03* proBNP-4144*
___ 12:40PM BLOOD CK-MB-3 cTropnT-0.02*
___ 12:12AM BLOOD calTIBC-200* VitB12-311 Folate-11
___ Ferritn-49 TRF-154*
___ 05:20AM BLOOD Hapto-77
___ 06:13AM BLOOD %HbA1c-5.4 eAG-108
___ Urine culture: No growth
DISCHARGE LABS:
==============
___ 05:25AM BLOOD WBC-3.1* RBC-2.76* Hgb-7.9* Hct-24.3*
MCV-88 MCH-28.6 MCHC-32.5 RDW-14.6 RDWSD-46.5* Plt ___
___ 04:13PM BLOOD Glucose-169* UreaN-28* Creat-1.7* Na-139
K-4.5 Cl-107 HCO3-20* AnGap-12
___ 05:25AM BLOOD Phos-3.7 Mg-2.0
PERTINENT IMAGING:
==================
___ CXR:
Mild pulmonary vascular congestion could be related to volume
overload.
Normal heart size.
No pneumonia.
This examination neither suggests nor excludes the diagnosis of
pulmonary
embolism.
___ CT Abd/plevis w/o Contrast:
1. Within limitation of a non-contrast CT, there is no
intra-abdominal or
retroperitoneal collection or free fluid to suggest hemorrhage.
No acute
intra-abdominal pathology.
2. Stable appearance of dropped gallstones about the liver.
3. Expected appearance post gastrectomy with
esophagojejunostomy.
4. Distended urinary bladder without definite abnormality.
___ BLE Ultrasound:
No evidence of deep venous thrombosis in the right lower
extremity veins.
Right popliteal cyst measuring 4.9 x 0.9 cm.
___ TTE:
The left atrial volume index is SEVERELY increased. There is no
evidence for an atrial septal defect by 2D/color Doppler. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size. There is normal regional and global left ventricular
systolic function. Quantitative 3D volumetric left ventricular
ejection fraction is 60 %. There is no resting left ventricular
outflow tract gradient. Normal right ventricular cavity size
with normal free wall motion. Tricuspid annular plane systolic
excursion (TAPSE) is normal. The aortic sinus diameter is normal
for gender with normal ascending aorta diameter for gender.
There is a normal descending aorta diameter. There is no
evidence for an aortic arch coarctation. The aortic valve
leaflets (3) appear structurally normal. There is no aortic
valve stenosis. There is trace aortic regurgitation. The mitral
valve leaflets appear structurally normal with no mitral valve
prolapse. There is trivial mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. There is mild-moderate pulmonary artery
systolic hypetension. There is a trivial pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/ global biventricular systolic
function. Mild-moderate pulmonary artery systolic hypertension.
Brief Hospital Course:
Ms. ___ is a ___ y/o female with a significant history of
T3N1 gastroesophageal adenocarcinoma on chemotherapy, type 2
diabetes complicated by retinopathy, hypertension, and
depression, who presented to the ED for fatigue and leg
swelling, found to be hypertensive and anemic. Her home BP
medications were re-initiated with improvement in BP.
Additionally, she was given 1u pRBC without further drop in
blood counts and was monitored for persistent ___.
ACUTE/ACTIVE PROBLEMS:
======================
#Hypertensive Emergency
#Hypertension
Patient presented with fatigue and leg swelling, found to be
hypertensive to the 190s. She reported not taking all her
medications at home for the last several weeks after finding out
that she not longer had diabetes mellitus. Initial assessment
notable for pulm edema and ___ concerning for a component of
hypertensive emergency. Additionally, her BNP was 4144. She was
restarted on her home amlodipine and carvedilol (increased to
25mg BID) as well as prn hydralazine with improvement in BPs.
Blood pressures at time of discharge were 150-160s. Recommended
outpatient follow up with initiation of ACE-I and uptitration as
needed, once ___ resolves.
___
Cr 1.8 on admission, baseline 1.1. Urine studies c/w intrinsic
disease, but microscopy without casts. Trialed diuresis with
minimal improvement. Further diuresis held given euvolemic exam.
Her hospital course was complicated by intermittent diarrhea iso
bowel regimen leading to a dehydrated state. She was given IV
fluids trials with slight improvement. Overall etiology felt to
be intrinsic (possibly ATN) with a small component of pre-renal.
She was discharged with plan to increase oral intake and follow
up with PCP for repeat labs and further management if not
improving with time.
#Acute on chronic anemia
Hgb 6.5 on admission, down from baseline ___. She was given
1u pRBC in the ED with an appropriate bump. Hemolysis labs
negative. Low retic count more concerning for marrow suppression
iso chemotherapy or nutritional deficiency/acute illness.
Additionally, Tsat 18% pointing towards a potential component of
iron deficiency anemia. There was concern for GI bleed iso
malignancy though no recent melena and stool guaiac was
negative. Last colonoscopy in ___ was unremarkable. Last EGD
in ___ showed the known gastric cancer. After receiving 1u
pRBC, her Hgb remained stable around 8 for the remainder of the
hospitalization. She should follow up with her PCP and possibly
GI as an outpatient to discuss repeat EGD/colonoscopy.
#Leg swelling
Initial exam notable for bilateral leg swelling iso acute
hypertension. BNP elevated to 4144 and Cr elevated all
concerning for acute heart failure exacerbation. TTE showed mild
LVH with normal regional/global biventricular systolic function.
DVT felt to be unlikely given bilateral nature. She was given
Lasix 10 mg IV initially and maintained on a low salt diet. She
quickly became euvolemic and then hypovolemic iso diarrhea.
Given persistent ___ as above, she was trialed with IV fluids as
above. At discharge, she was euvolemic on exam.
#CAD
A stress MIBI in ___ showed EF 66% with mild fixed defect
inferior wall. When this was discovered, the plan was for
medical management per Dr. ___ on asa, statin, beta
blocker. The patient, however on admission was not taking her
home meds. TTE w/ preserved overall function but did have some
evidence suggestive of mild diastolic dysfunction. Aspirin was
held in the setting of possible bleed and ACE-I iso ___.
Continued on carvedilol and statin.
#T3N1 gastroesophageal adenocarcinoma
Receives her oncologic care at ___ and is s/p partial
gastrectomy, NGT placement, chemo and radiation until that she
completed in ___. No recurrence per appt 1 month prior to
admission.
#GERD
Described significant reflux symptoms, particularly burning
within her chest. She was started on pantoprazole BID with
improvement in symptoms. She should follow up with her PCP/GI
for further management.
CHRONIC/STABLE PROBLEMS:
========================
#DM2
History of DM c/b retinopathy. A1c on ___ was 5.1%, showing
her DM had resolved.
TRANSITIONAL ISSUES:
====================
[]Repeat BP at follow up appointment, titrate anti-hypertensives
as necessary, considering adding back ACE-I when able
[]Repeat CBC at follow up. Discharge H/H 7.___.3
[]Repeat BMP at follow up. Discharge Cr 1.7
[]Follow up with GI for anemia. Consider repeat EGD/colonoscopy
[]Significant reflux while inpatient. Consider further work up
with EGD, ongoing management with pantoprazole
[]Aspirin held at discharge given new anemia
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Pravastatin 40 mg PO QPM
2. CARVedilol 12.5 mg PO BID
3. amLODIPine 10 mg PO DAILY
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. CARVedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Pravastatin 40 mg PO QPM
RX *pravastatin 40 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
#Primary:
Hypertensive emergency
Normocytic anemia
#Secondary:
Acute kidney injury
Coronary artery disease
T3N1 gastroesophageal adenocarcinoma
Leg swelling
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___!
Why you presented to the hospital:
- You were having fatigue and leg swelling
What happened while you were here:
- We found that your blood pressure was significantly high
without your blood pressure medications
- You were started back on blood pressure medications
- Your blood counts were also low, for which you were given a
unit of blood
- You had worsening kidney function, which remained stable while
here
What you should do once you return home:
- You should continue taking your mediations as prescribed. They
were called into your pharmacy (___) and should be ready
for pick up
- You should follow up with your primary care provider as
outlined below
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10860120-DS-16
| 10,860,120 | 22,482,619 |
DS
| 16 |
2175-10-01 00:00:00
|
2175-10-01 11:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right knee pain
Major Surgical or Invasive Procedure:
Open reduction internal fixation of right tibial plateau
History of Present Illness:
___ female presents with the above fracture s/p MVC.
Patient is a ___ female with a past medical history of
hypertension who presents to the emergency department as a
transfer from ___ with concerns of tibial plateau fracture.
History is limited as patient does not recall events leading up
to her motor vehicle accident. Per medical reports, patient was
a restrained driver of a MVC versus a wall inside her work
parking garage with moderate damage to the front of her vehicle.
It is unclear whether or not patient had any head strike or any
airbag deployment. Unclear if the patient had LOC as patient
does not recall events. It appears as patient might have fallen
asleep while driving. Patient presented to outside hospital
having CT head and C-spine done with no acute traumatic
findings. Patient had x-rays done which were concerning for a
comminuted tibial plateau fracture so she was transferred here
for orthopedic evaluation.
Orthopedic consulted for further evaluation. Patient currently
complaining of right knee pain without any numbness or
paresthesias. She otherwise denies any headache or neck
stiffness. No back pain. No vision changes. No chest pain or
shortness of breath. No abdominal pain. No nausea or vomiting.
Past Medical History:
Hypertension
Social History:
___
Family History:
Noncontributory
Physical Exam:
GEN: well appearing, NAD
CV: regular rate
PULM: non-labored breathing on room air
Right lower extremity:
___ in place, clean and dry
Compartments soft and compressible, no pain with passive stretch
SILT sural/saphenous/tibial/deep peroneal/superficial peroneal
distributions
___
Warm and well perfused, +dorsalis pedis/posterior tibial pulse
Pertinent Results:
___ 06:24AM BLOOD WBC-11.0* RBC-3.05* Hgb-10.1* Hct-31.2*
MCV-102* MCH-33.1* MCHC-32.4 RDW-13.5 RDWSD-51.1* Plt ___
___ 06:24AM BLOOD Glucose-131* UreaN-8 Creat-0.6 Na-139
K-3.6 Cl-101 HCO3-26 AnGap-12
Brief Hospital Course:
The patient presented as a same day admission for surgery. The
patient was taken to the operating room on ___ for open
reduction internal fixation of right tibial plateau fracture,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home with home ___ was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touchdown weightbearing in the right lower extremity in an
unlocked ___ brace, 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:
1. Lisinopril
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QHS
4. Multivitamins 1 TAB PO DAILY
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
6. Senna 8.6 mg PO BID
7. Vitamin D 1000 UNIT PO DAILY
8. Lisinopril
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right tibial plateau fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Touchdown weightbearing on the right lower extremity in an
unlocked ___ brace
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.
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.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
Physical Therapy:
Physical therapy, touchdown weightbearing on the right lower
extremity in unlocked ___ brace.
Treatments Frequency:
Follow-up in 2 weeks for wound check and postop evaluation, and
for suture removal.
Followup Instructions:
___
|
10860143-DS-15
| 10,860,143 | 20,766,332 |
DS
| 15 |
2187-02-23 00:00:00
|
2187-02-25 19:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lorazepam
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with PMH of HTN, HLD, and
alcohol use disorder who presents with sudden onset AMS and
confusion. Patient was in his usual state of health until circa
1 ___ when while getting up out of the chair he was noted to be
confused. Son states that his father speech did not make sense.
This lasted less than 1 hour self resolved by the time he got to
the ED. There was no associated focal weakness,
paresthesias/numbness, difficulty with his gait.
Patient is a daily drinker and his last drink was 2 beers at
lunch. He has no history of alcohol withdrawal seizures and has
been given ativan in the past and became delirious requiring 3
days of hospitalization. ___ stroke scale of 1 for confusion.
Endorses drinking 2 beers at lunch and per son, drinks ___
drinks a day. On Tamsulosin and amlodipine and recently
discontinued metoprolol in ___ due to concern for
hypotension.
Of note, patient was admitted in ___ for a similar presentation
where he had garbled speech. Cause for the AMS was not found.
Work up revealed an EEG with slowing in the left temporal lobe,
but no epileptiform discharges. MRI was normal. Echocardiogram
was normal. The patient was discharged to home on daily aspirin.
In the ED, initial vital signs were: 97.9 120 182/91 20 97% RA
Exam notable for:
NEURO: able to recall the month, unable to recall president and
is oriented to self, tremulous on exam.
Labs were notable for:
-Urine tox screen negative for Benzos, Barbs, Opiates, Cocaine,
Amphet, Mthdne, Oxycodone
-Serum tox screen negative for ASA, Acetmnphn, ___,
Tricyc Neg
-Serum ETOH 13
-UA negative
-Na 134
-K 5.9
-Bicarb 21
-Trop neg
-AST 61
Micro notable for: Urine cx pending
Studies performed include:
___ Noncontrast head CT: Study is mildly limited secondary to
streak artifact emanating from dental amalgam. No evidence of
acute intracranial pathology.
___ CTA NECK: On source images the carotid arteries and the
vertebral arteries are patent from their origin without evidence
of stenosis, occlusion or dissection. There is no internal
carotid artery stenosis by NASCET criteria. The left vertebral
artery is dominant, a normal anatomical variant.
___ CTA HEAD: Vessels of the circle ___ and the major
branches are patent without definite evidence of occlusion or
aneurysm formation. However, on the perfusion study there is an
area of increased mean transit time in the medial right frontal
lobe without evidence of a matching decrease in cerebral blood
flow of less than 30%. No areas of abnormality within this
region are seen on the noncontrast head CT. This finding can be
consistent with an area of hypoperfusion. Further evaluation
with MR is recommended to evaluate for an underlying infarction.
___ CXR: The lungs are clear. There is no focal
consolidation, effusion, or edema. The cardiomediastinal
silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Patient was given:
-Diazepam 10 mg x2
-IVF NS
Consults: Code stroke called given ___ stroke scale of 1 for
confusion. Neuro cleared from code stroke perspective.
Vitals on transfer: 98.2 110 137/72 18 95% RA
Upon arrival to the floor, the patient and his son recount the
above history. Son is very concerned and thinks this is related
to alcohol + blood pressure medications, as he sometimes notices
strange symptoms after his father takes his amlodipine in the
morning and tamsulosin at night. Says he is very sensitive to
medications. Patient denies any headache, dizziness, N/V, CP,
SOB, palpitations, changes in bowel movement or urination. He
feels completely back to normal. Patient says that he is
Past Medical History:
HTN
HLD
ETOH Abuse
White coat HTN and tachycardia
BPH
BCC of upper lip s/p Mohs
S/p L shoulder surgery
Social History:
___
Family History:
Non contributory
Physical Exam:
Admission Physical Exam:
Vitals 97.8 164 / 93 116 18 97 Ra
GENERAL: AOx3, NAD, well appearing
HEENT: EOMI, PEERLA. No conjunctival pallor or injection, sclera
anicteric and without injection. Dry mucous membranes.
CARDIAC: Regular rhythm, tachycardic. No MRG
LUNGS: Clear to auscultation bilaterally with no wheezes
crackles or ronchi.
ABDOMEN: Normal bowels sounds, slightly distended but soft,
slight tenderness to palpation diffusely.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally. Has small
wound on bottom of R foot from stepping on glass, 1cm erythema
surrounding, slight tenderness to palpation, no purulent
drainage.
NEUROLOGIC: CN2-12 intact. Able to say months of the year
backwards. Normal sensation.
DISCHARGE PHYSICAL EXAM:
Vitals: 97.6 134/86 97 20 98 RA
GENERAL: AOx3, NAD, well appearing
HEENT: EOMI, PEERLA. No conjunctival pallor or injection, sclera
anicteric and without injection. Dry mucous membranes.
CARDIAC: Regular rhythm, tachycardic. No MRG
LUNGS: Clear to auscultation bilaterally with no wheezes
crackles or ronchi.
ABDOMEN: Normal bowels sounds, slightly distended but soft,
slight tenderness to palpation diffusely.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally. Has small
wound on bottom of R foot from stepping on glass, 1cm erythema
surrounding, slight tenderness to palpation, no purulent
drainage.
NEUROLOGIC: CN2-12 intact. Able to say months of the year
backwards. Normal sensation.
Pertinent Results:
Admission labs
___ 01:15PM BLOOD WBC-8.3 RBC-4.56* Hgb-15.9 Hct-44.1
MCV-97 MCH-34.9* MCHC-36.1 RDW-12.1 RDWSD-43.0 Plt ___
___ 01:15PM BLOOD Neuts-68.1 ___ Monos-11.1
Eos-0.8* Baso-0.5 Im ___ AbsNeut-5.33 AbsLymp-1.50
AbsMono-0.87* AbsEos-0.06 AbsBaso-0.04
___ 01:15PM BLOOD ___ PTT-29.8 ___
___ 01:15PM BLOOD Glucose-101* UreaN-12 Creat-0.9 Na-134*
K-5.9* Cl-96 HCO3-21* AnGap-17
___ 01:15PM BLOOD ALT-15 AST-61* AlkPhos-51 TotBili-0.8
___ 01:15PM BLOOD Lipase-46
___ 01:15PM BLOOD cTropnT-<0.01
___ 01:15PM BLOOD Albumin-4.2 Calcium-9.1 Phos-3.8 Mg-2.1
___ 01:15PM BLOOD ASA-NEG Ethanol-13* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGES:
___ Noncontrast head CT: Study is mildly limited secondary to
streak artifact emanating from dental amalgam. No evidence of
acute intracranial pathology.
___ CTA NECK: On source images the carotid arteries and the
vertebral arteries are patent from their origin without evidence
of stenosis, occlusion or dissection. There is no internal
carotid artery stenosis by NASCET criteria. The left vertebral
artery is dominant, a normal anatomical variant.
___ CTA HEAD: Vessels of the circle ___ and the major
branches are patent without definite evidence of occlusion or
aneurysm formation. However, on the perfusion study there is an
area of increased mean transit time in the medial right frontal
lobe without evidence of a matching decrease in cerebral blood
flow of less than 30%. No areas of abnormality within this
region are seen on the noncontrast head CT. This finding can be
consistent with an area of hypoperfusion. Further evaluation
with MR is recommended to evaluate for an underlying infarction.
___ CXR: The lungs are clear. There is no focal
consolidation, effusion, or edema. The cardiomediastinal
silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
___ MRI
1. Tiny focus of high signal on diffusion within the pons on the
left
suggesting a subacute infarct.
2. Scattered periventricular and subcortical white matter T2
FLAIR
hyperintensities, likely sequela of chronic small vessel
disease. Global volume loss.
3. Questionable asymmetry of the medial temporal lobes which
appears slightly small on the right of unclear clinical
significance, can be correlated with EEG if desired.
___ TTE
The left atrium is normal in size. Normal left ventricular wall
thickness, cavity size, and regional/global systolic function
(3D LVEF = 72 %). Transmitral and tissue Doppler imaging
suggests normal diastolic function, and a normal left
ventricular filling pressure (PCWP<12mmHg). Doppler parameters
are most consistent with normal left ventricular diastolic
function. Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION:
1) No cardiac echocardiographic anatomic/physiologic abnormality
noted to explain stroke/TIA.
2) The aortic sinutubular junction has an small echodensity that
most like represents mobile complex atherosclerotic plaque.
Discharge labs
___ 07:00AM BLOOD WBC-6.9 RBC-4.28* Hgb-14.6 Hct-42.0
MCV-98 MCH-34.1* MCHC-34.8 RDW-12.1 RDWSD-43.7 Plt ___
___ 07:00AM BLOOD Glucose-86 UreaN-8 Creat-0.7 Na-142 K-3.6
Cl-102 HCO3-22 AnGap-18
___ 07:00AM BLOOD ALT-10 AST-19 AlkPhos-65 TotBili-0.8
___ 07:00AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.0 Cholest-167
Brief Hospital Course:
Summary
___ with PMH of HTN, HLD, and alcohol use disorder who presents
with sudden onset AMS and confusion. Patient was at his work
when had garbled speech noted by son and 30 minutes of altered
mental status where he was only oriented to self. He returned
back to baseline within ___ hours and had no neurologic
symptoms. This was felt to be consistent with a TIA in the
setting of alcohol use, combined with likely early dementia. He
was discharged home with services.
# Garbled speech, likely ___ TIA
Patient with acute onset altered mental status with confusion
lasting for less than 1 hour. Has had similar episode to this in
the past (___). Story was most consistent with a TIA. Toxic
metabolic unlikely given negative tox screen, low ETOH level, no
electrolyte abnormalities, and no evidence of infection. MRI
brain done without acute stroke. TTE was without
echocardiographic anatomic/physiologic abnormality noted to
explain TIA. RPR, TSH, lipids and A1C was wnl. EEG and RPR were
pending at discharge. Per neurology he was switched from aspirin
to Plavix, and started on atorvastatin. He will follow with
neurology in clinic.
# Etoh withdrawal
# Tachycardia
Patient reports only ___ drinks per day, however positive
alcohol level on admission so suspect more significant. Some
orthostasis likely d/t volume depletion iso withdrawal. Now
improved with IVF. SW was consulted and patient encouraged to
stop drinking.
CHRONIC ISSUES:
===============
# HTN
Held home amlodipine for orthostasis and TIA as above.
# BPH
Continued home Tamsulosin.
Transitional issues
- Switched aspirin to Plavix and started atorvastatin for TIA,
will follow with neurology.
- EEG pending at discharge, results should be followed by
neurology at followup.
- Discharged home with evaluation for home services.
- Amlodipine held iso orthostasis and TIA, family also thought
it could be causing some side effects.
#CODE: Full
#CONTACT:
Name of health care proxy: ___
___: wife
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Tamsulosin 0.4 mg PO QHS
3. Vitamin D 1000 UNIT PO DAILY
4. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*0
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Tamsulosin 0.4 mg PO QHS
4. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
TIA
Early dementia
Etoh withdrawal
Secondary
HTN
BPH
Sinus tachycardia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital with confusion, which was likely due to
a small stroke which resolved on its own. Please take the
medications we have prescribed and avoid consuming alcohol.
It was a pleasure taking care of you, best of luck.
Your ___ medical team
Followup Instructions:
___
|
10860165-DS-24
| 10,860,165 | 22,746,294 |
DS
| 24 |
2178-08-06 00:00:00
|
2178-08-15 01:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
trauma evaluation s/p fall from ladder
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year old male who complains of S/P FALL
from ___ FT. He was transferred from outside hospital and
presents to ___ ED. His fall was approximately 20 feet off of
a ladder. He Landed on his left side. Seen in outside hospital
and diagnosed with multiple rib fractures on the left with a
pneumothorax and splenic laceration. CT head and neck were
negative. Transferred here for pain control and trauma surgery
evaluation.
Past Medical History:
PMH:
Hepatitis C cirrhosis, grade 2 esophageal varices
PSH:
ankle surgery
Hepatitis C, genotype 3 with resultant cirrhosis
-- last VL: HCV VIRAL LOAD (Final ___: 1,270,000 IU/mL.
-- S/P interferon & ribavirin; d/c'd for thrombocytopenia,
relapsed
-- RUQ ultrasound ___, no lesions stable mild splenomegaly
and tiny gallstones.
-- EGD ___ cords superficial grade 2 varices not bleeding,
ulcers, biopsies of which were negative; on Prilosec and
Nadalol.
Social History:
___
Family History:
Mother deceased from breast cancer, father has diabetes.
Siblings and children are healthy.
Physical Exam:
On admission:
Resp: 18 O(2)Sat: 94 Normal
Constitutional: Uncomfortable
HEENT: Normocephalic, atraumatic
No C-spine tenderness
Chest: No crepitus, left chest wall tenderness to palpation,
bilateral breath sounds
Cardiovascular: Regular Rate and Rhythm
Abdominal: Tender in the left abdomen
GU/Flank: No costovertebral angle tenderness
Extr/Back: No long bone deformities
Skin: No rash
Neuro: GCS 15, moving all extremities well
Psych: Normal mood
On Discharge:
VS: 98.4F HR 62 99/50 RR 16 97%
HEENT: Normocephalic, atraumatic, no C-spine tenderness
Chest: No crepitus, left chest wall tenderness to palpation,
bilateral breath sounds, CTAB, decreased air movement R base
Cardiovascular: RRR no MRG
Abdominal: LUQ tenderness along costal margin
GU/Flank: No costovertebral angle tenderness
Neuro: GCS 15, no focal neuro deficits
Psych: Normal mood, happy about going home
Pertinent Results:
___ 09:55PM ___ 09:55PM PLT COUNT-56*
___ 09:55PM ___ PTT-30.1 ___
___ 09:55PM WBC-10.4 RBC-4.02* HGB-15.2 HCT-40.4 MCV-101*
MCH-37.9* MCHC-37.7* RDW-14.1
___ 09:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:55PM LIPASE-63*
___ 09:55PM estGFR-Using this
___ 09:55PM UREA N-15 CREAT-0.6
___ 09:59PM freeCa-1.12
___ 09:59PM HGB-14.9 calcHCT-45 O2 SAT-76 CARBOXYHB-4 MET
HGB-0
___ 09:59PM ___ PO2-48* PCO2-47* PH-7.35 TOTAL
CO2-27 BASE XS-0 INTUBATED-NOT INTUBA
___ 11:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 11:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:00PM URINE UHOLD-HOLD
___ 11:00PM URINE HOURS-RANDOM
CT Abdomen ___:
1. No suspicious arterially-enhancing liver lesions are
identified.
2. Unchanged sequela of liver cirrhosis and portal hypertension,
including splenomegaly, paraesophageal, and splenic varices.
3. Cholelithiasis without cholecystitis.
CXR ___:
1. Multiple left rib fractures and small to moderate left
pneumothorax.
2. Layering left hemothorax as seen on outside CT.
CXR: ___: Left hemopneumothorax is increased compared to ___, causing increase in tension and contralateral mediastinal
shift.
CXR: ___:
1.Left chest tube has been placed since 8 hr prior. Left
hemopneumothorax is decreased.
2. Left hemidiaphragm is elevated, which could be due to left
lung base
atelectasis or diaphragm injury.
3. Right lung base opacity could be due to atelectasis or
aspiration.
XR Shoulder ___:
Unremarkable appearance of the right shoulder on these limited
views.
CXR: ___: Cardiomediastinal silhouette is unchanged. Left chest
tube is in place. No pneumothorax is seen. Overall no
substantial change since the previous study demonstrated.
CXR: ___ In comparison with the earlier study of this date,
with the chest tube on water seal there is possibly a tiny left
apical pneumothorax. Otherwise, little change in the appearance
of the heart and lungs.
CXR ___:
1. Interval increase in size of a small left apical
pneumothorax.
2. Increased left basilar opacification, likely representing a
layering
pleural effusion.
CXR ___:
Left chest tube is in place. Left pneumothorax appears to be
similar to
previous examination, small. Right lung is well-aerated.
Cardiomediastinal silhouette is stable
CXR ___: Left chest tube is in place. Small left apical
pneumothorax is unchanged. Lung volumes are lower than on the
previous study. Elevated right hemidiaphragm is re-
demonstrated. Cardiomediastinal silhouette is stable. Left rib
fractures are partially imaged
CXR ___: Left chest tube is in unchanged position. Small left
pneumothorax is unchanged. There is mild bibasilar atelectasis.
Elevation of left hemidiaphragm is similar to prior. There is no
pleural effusion. Cardiomediastinal silhouette is mildly
enlarged. Again seen are multiple left rib fractures
posteriorly. Small left pneumothorax is unchanged since 5 hr
prior.
CXR ___: Small residual left pneumothorax unchanged over 24 hr.
Large left juxtahilar
pneumatocele that grew between ___ and ___,
subsequently stable. Bibasilar atelectasis is mild. There is no
appreciable left pleural effusion despite multiple left rib
fractures. Basal pleural drainage catheter place. Essentially
normal cardiomediastinal silhouette.
CXR PA/LAT ___: Left small pneumothorax is unchanged. There
is left lung volume loss and
elevation of left hemidiaphragm, similar to prior. There is
small left pleural effusion/ hemothorax, similar to prior.
Multiple left posterior rib fractures are again noted. No
notable interval change since ___. Stable small left
hemopneumothorax and left lung volume loss.
Brief Hospital Course:
The patient was transferred to ___ Emergency Department on
___ from an outside hospital. Mr. ___ was evaluated by
the acure care surgery team. Initial imaging (CT Abdomen ___
identified multiple rib fractures and small to moderate left
pneumothorax and a grade 2 splenic laceration. ( 1. No
suspicious arterially-enhancing liver lesions are identified.
2. Unchanged sequela of liver cirrhosis and portal hypertension,
including splenomegaly, paraesophageal, and splenic varices. 3.
Cholelithiasis without cholecystitis.) A same day CXR ___
showed again, multiple left rib fractures and small to moderate
left pneumothorax. and layering left hemothorax. CT head and
C-spine were negative.
Given concern for continued hemopneumothorax, a left sided chest
tube was placed on ___ and 200cc drained immediately, with an
additional 800cc afterwards. Platelets were transfused prior to
chest tube placement. The patient was restarted on his home
rifaximin and lactulose. Home spironolactone held for
hyperkalemia. The Acute Pain Service (APS) was consulted for an
epidural, however the patient was deemed to not be a good
candidate given the thromboyctopenia. Serial hematocrits
stabilized: 40->35->36.8->35.6->33.1->33.1. Adjuncts were added
for pain control: APAP ATC (cleared with hematology service
given the history of liver disease) and additional pain control
was achieved with a dilaudid PCA and lidocaine patch. The diet
was advanced to clears and then ADAT regular. The patient was
placed in the trauma surgical intensive care unit and a tertiary
trauma survery was remarkable for shoulder pain. Plain films of
shoulder were negative. The next day the patient was
transitioned to po oxycodone, the dPCA was discontinued.
However, the pain was poorly controlled and other adjuncts were
adjusted: gabapentin increased, clonidine started, dilaudid
PRNs. The chest tubes were placed to water seal and home BP
medications were restarted. On ___, additional pain control
was required and oxycodone was increased per APS. The ___ CXR
looked worse and CT was put back to suction. The patient was
stable and transfered to the surgical care floor. The ___ CXR
showed a persistence of PTX and thus the chest tube was kept on
suction. Patient was demonstrating good respiratory excursion
and using IS well. Physical therapy was consulted and
recommended discharge to home when medically ready.
On ___, repeat CXR continued to show a PTX and CT was kept on
suction. Over the course of the next few days CXR imaging
continued to show a persistent left sided apical PTX with small
left costophrenic angle blunting. However the patient continued
to remain afebrile, with increasingly better pain control, and
continued to not experience any respiratory distress. On ___
CT output decreased to approximately less than 200cc/day and the
CT was placed on water seal. On ___ CXR showed an unchanged
apical PTX and the CT was pulled with stable post-pull CXR. On
___ CXR again showed a stable PTX and Mr. ___ was
prepared for discharge to home with close follow up with CXR
imaging arranged.
The patient received subcutaneous heparin and ___ dyne boots
were used during this stay and was encouraged to get up and
ambulate as early as possible. At the time of discharge, the
patient was doing well, afebrile and hemodynamically stable.
The patient was tolerating a diet, ambulating, voiding without
assistance, and pain was well controlled. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
Famotidine 20', furosemide 60', lactulose 30 cc BID prn
onstipation, nadolol 20', oxycodone 5 mg q6h prn, rifaximin 550
mg BID, sofosbuvir and 5816 one tablet once daily, Aldactone
200', and ursodeoxycholic acid ___ BID
Discharge Medications:
1. Famotidine 20 mg PO DAILY
2. Furosemide 60 mg PO DAILY
3. Lactulose 30 mL PO BID
4. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) apply to affected
chest wall QAM for 12 hours Disp #*14 Patch Refills:*0
5. Nadolol 20 mg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q3hrs Disp #*70 Tablet
Refills:*0
7. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth q day Refills:*0
8. Rifaximin 550 mg PO BID
9. Senna 8.6 mg PO BID constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*50 Capsule Refills:*0
10. Sofosbuvir/___ Study Med 1 tablet ORALLY ONCE A DAY
11. Ursodiol 300 mg PO BID
12. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day
Disp #*100 Tablet Refills:*0
13. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*50 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Rib fractures
Left Pneumothorax/Hemopneumothorax
Splenic laceration (grade 2)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were brought to the ___ ED after sustaining a fall from a
ladder. You were found to have rib fractures, a collapses lung
and a laceration of your spleen. You have recovered and are now
ready to be discharged from the hospital.
Please read the following instructions:
*AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having internal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA.
* Your injury caused multiple 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:
___
|
10860211-DS-21
| 10,860,211 | 29,446,146 |
DS
| 21 |
2140-09-30 00:00:00
|
2140-09-30 17:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a pleasant ___ w/ ___ cell lung cancer, s/p
___ C1D1 ___ who is transferred from ___
for neutropenic fevers.
Pt states he feels very weak and that is why he is here, and
notes he has been feeling weak for months. He denied any fevers
but admitted to chills, and denied any new complaints. He states
he has had a nonproductive cough and low back pain which are
chronic. He denied any CP or sob. He also denied abd pain/n/v/d.
He denied any dysuria or increased urinary frequency. He has a
foley that is in place and yesterday it was removed and had a
voiding trial which he reports did not pass and had the foley
replaced yesterday at the ___. He admitted to ER that his urine
seems to be darker than usual. He denied any mouth pain but
notes
feeling very dry.
In ED, Tmax 102.5, SBP 100-130s, HR 110-120s, RR low 20, 98% Ra.
He received Vanc/Cef and 2L NS with 1 gm apap. CTA torso
revealed
no PE, persistent obstructive consolidation of RML and no other
acute process.
Past Medical History:
Chronic low back pain
GERD
Lung nodule
L5 injection 2 months ago
MVA ___ c/b LLE paresthesias
Oral candidiasis
Social History:
___
Family History:
Mother with ___ Disease
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
VITAL SIGNS: ___ 106/70 105 18 99% 2.5L
General: NAD, Resting in bed comfortably
HEENT: very dry mucous membranes, + thrush on palate
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, diminished, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no palpable masses or HSM
LIMBS: WWP, no ___, no tremors
GU: foley in place draining yellow urine
SKIN: No rashes on the extremities
NEURO: appears generally fatigued
=======================
DISCHARGE PHYSICAL EXAM
========================
VS: 98.7PO 110 / 70 106 18 94% 2 L NC
GEN: NAD
HEENT: PERRLA. MMM.
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: BS+, soft, NT, no rebound/guarding, no HSM
Extremities: wwp, no edema.
Neuro: AOx3, moving all extremities spontaneously
Pertinent Results:
============================
ADMISSION LABS
============================
___ 02:43PM BLOOD WBC-1.4*# RBC-3.94* Hgb-11.1* Hct-33.5*
MCV-85 MCH-28.2 MCHC-33.1 RDW-12.8 RDWSD-38.9 Plt Ct-87*
___ 02:43PM BLOOD Neuts-5* Bands-1 Lymphs-66* Monos-23*
Eos-1 Baso-1 ___ Myelos-0 Blasts-3* Other-0
AbsNeut-0.08* AbsLymp-0.92* AbsMono-0.32 AbsEos-0.01*
AbsBaso-0.01
___ 02:43PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-OCCASIONAL
Stipple-OCCASIONAL
___ 02:43PM BLOOD Plt Smr-LOW Plt Ct-87*
___ 02:43PM BLOOD Plt Smr-LOW Plt Ct-87*
___ 02:43PM BLOOD Glucose-127* UreaN-13 Creat-0.8 Na-132*
K-3.9 Cl-95* HCO3-27 AnGap-14
___ 02:53PM BLOOD Lactate-1.5
=============
MICRO
=============
___ 2:23 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 7:38 am BLOOD CULTURE Source: Venipuncture X 1.
Blood Culture, Routine (Pending):
___ 7:38 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Venipuncture.
BLOOD/FUNGAL CULTURE (Pending):
BLOOD/AFB CULTURE (Pending):
___ 2:52 pm URINE ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). >100,000
CFU/mL.
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 8 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
=======================
IMAGING
========================
___ CXR
1. Right middle lobe opacity, likely combination of atelectasis
and and known lung cancer, better assessed on prior CT on ___.
2. No new consolidation.
___ CTA CHEST AND ABDOMEN
1. No evidence of acute pulmonary embolism to the segmental
levels. No
evidence of acute aortic syndrome. Limited exam due to
respiratory motion for fine details.
2. Right hilar malignancy, mildly decreased compared to ___.
Persistent postobstructive consolidation with near complete
collapse of the right middle lobe, grossly unchanged compared to
___.
3. No acute intra abdominal or intrapelvic abnormalities.
4. Hypodensity in segment 4B of the liver measures up to 1.5 cm,
unchanged
since ___.
5. Multiple sclerotic lesions in the vertebral bodies, new since
___, which are compatible with metastatic osseous
disease. No acute fractures.
============================
DISCHARGE LABS
============================
___ 06:30AM BLOOD WBC-16.5* RBC-3.72* Hgb-10.3* Hct-32.8*
MCV-88 MCH-27.7 MCHC-31.4* RDW-14.1 RDWSD-43.5 Plt ___
___ 06:30AM BLOOD Plt ___
___ 05:45AM BLOOD Neuts-51 Bands-14* ___ Monos-11
Eos-0 Baso-0 ___ Myelos-0 Blasts-3* AbsNeut-12.48*
AbsLymp-4.03* AbsMono-2.11* AbsEos-0.00* AbsBaso-0.00*
___ 06:30AM BLOOD Glucose-102* UreaN-12 Creat-0.8 Na-137
K-3.9 Cl-96 HCO3-30 AnGap-15
___ 06:30AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.1
Brief Hospital Course:
Mr. ___ is a ___ PMH ___ cell lung cancer, s/p
___ C1D1 ___ who was transferred from ___
___ for neutropenic fevers and was found to have a UTI. For his
neutropenia he was put on precautions and given neupogen until
his ANC was greater than 500. He was started empirically on
vanc/cefepime, but the vanc was d/c'ed after 1 dose because he
did not have any signs of skin/soft tissue infection. Blood
cultures showed no growth but urine culture grew pseudomonas and
corynebacterium. ID was consulted and felt that the
corynebacterium was likely a contaminant and that he can be
switched to PO cipro to complete a 10d course of abx (D10 -
___. He has chronic urinary retention so he requires a foley
but his foley was changed on ___.
================
ACUTE ISSUES
================
# Neutropenic Fever/Severe Sepsis/Complicated UTI: On admission
the patient had a fever to 102.5 and tachycardia. He was
cultured and initially treated with broad-spectrum antibiotics.
Ultimately, urinary cultures grew pseudomonas, and his
antibiotics were narrowed to ciprofloxacin for a planned 10 day
course. His foley catheter was exchanged. His last day of
antibiotics will be ___.
He was also treated with neupogen given his neutropenia in the
setting of severe sepsis. His counts recovered, and WBC on
discharge was 16.5 (the elevation was likely due to a response
to the neupogen). He may benefit from growth factor support with
future chemo cycles, or lengthening the chemo cycle to 28 days.
# Urinary Retention: He has urinary retention of uncertain
etiology. MRI of the spine x 2 did not demonstrate cord
compression. He was seen by urology in clinic prior to admission
with plan to consider repeating voiding trial in ___ weeks. He
was continued on tamsulosin and will follow-up with urology in
clinic.
================
CHRONIC ISSUES
================
# Thrush: He has completed a course of nystatin for thrush.
# Extensive stage ___ cell lung cancer: C1D1 of
carboplatin/etoposide was ___. He was initially seen by Dr.
___ at ___. He then saw Drs. ___ in clinic at
___, but prefers to transition care back to Dr. ___. He has
an appointment at ___ for ___. He was continued on oxycodone
for pain related to his spinal metastases.
# Malnutrition: he was continued on nutritional supplements.
# ___ weakness: He has numerous spinal lesions but no cord
compression (evaluated by MRI during prior admission). This was
felt to be most likely due to deconditioning. He will continue
with physical therapy.
================
TRANSITIONAL ISSUES
================
[ ] last day of ciprofloxacin therapy for UTI is ___
[ ] ___ require growth factor support or transitioning to a 28
day cycle with future chemo treatments to avoid cytopenias
[ ] 2L fluid restriction due to SIADH
[ ] consider starting Zomeda as an outpatient for spinal mets
#CODE: Full
#HCP: ___ (brother) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prochlorperazine 5 mg PO Q6H:PRN nausea
2. Tamsulosin 0.4 mg PO QHS urinary retention
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
6. FoLIC Acid 1 mg PO DAILY
7. Ketoconazole 2% 1 Appl TP BID
8. Mirtazapine 15 mg PO QHS
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Nystatin Oral Suspension 5 mL PO QID oral candidiasis
11. Omeprazole 20 mg PO DAILY acid reflux
12. Ondansetron 4 mg PO TID W/MEALS
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
4. FoLIC Acid 1 mg PO DAILY
5. Ketoconazole 2% 1 Appl TP BID
6. Mirtazapine 15 mg PO QHS
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY acid reflux
9. Ondansetron 4 mg PO TID W/MEALS
10. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
11. Prochlorperazine 5 mg PO Q6H:PRN nausea
12. Tamsulosin 0.4 mg PO QHS urinary retention
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Neutropenic fever due to complicated urinary tract infection
Severe sepsis
Secondary:
___ cell lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for a condition called
neutropenic fever. This means that a certain type of white blood
cells, called neutrophils, were low and that you were having
fevers, making us concerned about infection. To help increase
your white blood cell count you were given a medication called
neupogen.
You were found to have a urinary tract infection. Initially this
was treated with IV antibiotics, but when we knew what type of
bacteria you had we switched you to an oral antibiotic called
ciprofloxacin. You will take the ciprofloxacin for 10 days, the
last day will be ___.
Please attend your follow-up appointments as listed below.
Thank you for choosing ___ for your healthcare needs. It was a
pleasure taking care of you.
Sincerely,
Your ___ Team
Followup Instructions:
___
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2162-12-09 00:00:00
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2162-12-09 16:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
diarrea, fever
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
___ year old woman with celiac disese and small intestinal bowel
overgrowth who was recently admitted ___ for fevers,
profuse watery diarrhea, and diffuse abdominal pain worst in LLQ
as well as mild transaminitis (AST/ALT both <200). Pt had
extensive workup of the stool and her transaminitis. Stool viral
and bacterial cultures as well as c-dif testing were negative.
She had testing for HAV/HBV/HCV, CMV and EBV to workup her
transaminitis that was negative as well. Markers of her celiac
disease were similarly unremarkable (pt is strictly adherent to
gluten free/FODMAP diet). Pt also had an endoscopy to the
jejunum which showed normal mucosa except some erythema in the
stomach, biopsies are still pending. Colonoscopy was deferred to
the outpatient setting pending improvement. Pt was initially
covered with cipro/flagyl which were later discontinued. She
showed improvement in her diarrhea, her fevers resolved and she
was able to tolerate a diet, so she was discharged home with
close follow up. Working diagnosis was viral gastroenteritis. Of
note, her LFT's had continued to uptrend slightly throughout her
stay.
Pt went home on ___ and had an unremarkable day. On
___, she says she had a fever in the evening to ___. This
morning she had the return of profuse, watery, brown (nonbloody)
stool after eating. She reports about 8 bowel movements today.
In addition, her abdominal pain also worsened, which she says is
diffuse but most pronounced in the LLQ. She denies nausea or
vomiting. Pt came to the ER after discussing her recurrent
symptoms with her gastroenterologist. In the ED, she had
documented low grade temps ___ F and a marked rise in her LFT's
to ALT 744/AST 1122.
Of note, pt had marked weight loss (120lb -> 100 lb) 6 weeks
ago, which she attributes to a trial of an elemental diet in
order to manage her CIBO. She has not been able to recover her
weight despite increased caloric intake and nutritionist
intervention.
ROS: dry cough for the past 2 weeks, otherwise negative
Past Medical History:
- Celiac Disease on strict gluten-free diet
- Small Intestinal Bacterial Overgrowth on multiple courses of
rifaximin and neomycin, on FODMAP and lactose free diet
- Depression
- Fibromyalgia with Back Pain
- Vitamin D Insufficiency
Social History:
___
Family History:
Mother: ___ disease
Sister: Type I DM, Lupus, Celiac disease
Brother: MS
Physical ___:
Admission Exam:
Vitals: 98.2 ___ 18 96%RA
Gen: gaunt and pale appearing, NAD
HEENT: moist mm, no icterus
CV: rrr, no r/m/g
Pulm: clear b/l
Abd: soft, tenderness in LLQ, nondistended, hyperactive bowel
sounds
Ext: no edema or clubbing; no joint swelling
Neuro: alert and oriented x 3, no focal deficits
Discharge exam
General: thin female, no apparent distress
Vitals: 98.1, 118/80, HR: 70, R: 16, O2: 100% RA
Pain: ___- diffuse abd pain
HEENT: anicteric, dry MM
Card: RRR S1S2 present
Lungs: Coarse breath sounds, that clear with cough
Abd: slim, tender in LLQ, Non distended. No rebound or
guarding.
Ext: wwp
Pertinent Results:
___ 03:35PM GLUCOSE-89 UREA N-10 CREAT-0.6 SODIUM-137
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-23 ANION GAP-19
___ 03:35PM ALT(SGPT)-744* AST(SGOT)-1122* ALK PHOS-320*
TOT BILI-0.2
___ 03:35PM LIPASE-82*
___ 03:35PM ALBUMIN-4.3
___ 03:49PM LACTATE-2.1*
___ 03:35PM WBC-6.2 RBC-4.31 HGB-13.0 HCT-38.7 MCV-90
MCH-30.2 MCHC-33.6 RDW-13.4
___ 03:35PM PLT COUNT-292
___ 03:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
EGD with Enteroscopy ___ (last admission)
Normal mucosa in the esophagus. Liquid food contents were noted
in stomach. Mild erythema appreciated in stomach body mucosa.
(biopsy). Normal mucosa in the duodenum (biopsy). Normal mucosa
in the jejunum. Otherwise normal small bowel enteroscopy to
proximal jejunum
CT Abdomen/Pelvis ___ (at ___, last admission).
Fluid-filled loops of small and large bowel with scattered
air-fluid levels without a definite site of obstruction can be
seen in the setting of gastroenteritis.
MRE:
IMPRESSION:
Normal small bowel fold pattern. No evidence of active small
bowel
inflammation. Incidental transient left upper quadrant small
bowel
intussusception, sometimes seen in the setting of underlying
Celiac disease.
CT Abdomen/Pelvis: ___
IMPRESSION:
No clear intussusception is seen, and there is no bowel
obstruction.
Colonoscopy: ___
Erosions in the whole colon (biopsy)
Normal mucosa in the terminal ileum (biopsy)
Stool in the colon
Otherwise normal colonoscopy to cecum and terminal ileum
Recommendations: Due to fair prep this colonoscopy should not be
used for screening purposes.
Follow up pathology results.
Brief Hospital Course:
___ year old woman with celiac disease, CIBO, fibromyalgia here
with fevers, worsening transaminitis as well as diffuse
abdominal pain and watery diarrhea with PO intake following
recent admission for similar symptoms without clear cause found.
# Transaminitis - The patient has no history of alcohol or
Tylenol use; viral studies negative at last admission. Was
taking supplements but not between previous admission and
readmission. Seen by hepatology during this admission with work
up for autoimmune hepatitis. ___ was positive (thought to be due
to celiac disease) but anti smooth muscle, anti liver kidney
negative and immunoglobulins with only IgG slightly low.
Transaminitis improved without intervention. LFTs remain
elevated (AST 51, ALT 144, Alk Phos 277 T Bili 0.2) but trended
down overall. LFT elevation may have been due to viral illness
vs. drug induced from supplements. Patient instructed to avoid
all supplements. Should have repeat LFTs checked at follow up
appointment.
# Fever/Diarrhea/Abdominal pain - Ongoing symptoms of unclear
etiology; potentially slowly resolving gastroenteritis. C diff
was re-sent and was negative. CMV viral load was also negative.
Diarrhea resolved once the patient was admitted which she
attributed to narcotic pain medication. The patient underwent
MRE which showed intermittent intussusception but no other
findings to explain symptoms. She also underwent coloscopy which
had stool in colon despite 4L moviprep. There were erosions in
the whole colon but the remainder of mucosa appeared normal. The
patient was afebrile throughout her hospitalization. She had
nausea which was well controlled with Zofran. She required
morphine for pain which was able to be discontinued prior to
discharge and she was tolerating a regular diet. She was started
on Prednisone 40 mg daily per GI. She will continue on 40 mg
daily for 2 weeks and will call her gastroenterologist Dr.
___ instructions on taper. Her Linzess was increased to
290 mg daily and she was resumed on her home bowel regimen prior
to discharge.
# Fibromyalgia
Continued on home medications of cyclobenzaprine, lyrica,
cymbalta
# Anemia of chronic inflammation
No signs of bleeding. HCT stable.
Transitional issues:
- LFTs are trending down but have not normalized, please recheck
at follow up
- Started on Prednisone 40mg daily. Advised to continue for two
weeks per GI, then call Dr. ___ taper instructions
- Given small amount of Trazodone for sleep with instructions to
discuss with PCP
___ on ___:
The Preadmission Medication list is accurate and complete.
1. Cyclobenzaprine 10 mg PO HS
2. Duloxetine 60 mg PO BID
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. MethylPHENIDATE (Ritalin) 10 mg PO DAILY
5. Pregabalin 100 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. peppermint oil miscellaneous bid
8. Lorazepam 0.25 mg PO Q4H:PRN nausea/anxiety
9. Polyethylene Glycol 17 g PO BID:PRN constipation
10. Docusate Sodium 100 mg PO BID:PRN contipation
11. Ondansetron 4 mg PO TID W/MEALS
12. Ranitidine 150 mg PO BID
13. Linzess (linaclotide) 145 mcg oral daily
14. Simethicone 40-80 mg PO QID:PRN bloating
Discharge Disposition:
Home
Discharge Diagnosis:
Transaminitis
Diarrhea
Fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with fever, diarrhea,
abdominal pain and elevated liver function tests. You were
followed closely by the gastroenterology service and you were
also seen by the hepatologists. You had a number of lab tests to
figure out the cause of your abdominal pain. Your MRI showed
intussuception, which is likely intermittent and not the cause
of your abdominal pain. You also had a colonoscopy while here.
Your liver tests began to normalize and your diarrhea and fever
resolved prior to discharge. You were started on oral steriods.
Please continue the current dose, 40mg for the next two weeks.
Then call Dr. ___ give you instructions on how
to taper based on your symptoms. You should stop taking all
supplements as it is not clear if these affected your liver.
Followup Instructions:
___
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2162-11-29 19:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Fever
Dehydration
Diarrhea
Weight Loss
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy with Small Bowel Enteroscopy on
___ by Dr. ___ and Dr. ___
History of Present Illness:
___, a ___ yo F PMHx Celiac Disease, SIBO (for years,
multiple course of antibiotics), and fibromyalgia was referred
to inpatient by GI for concern of dehydration. She has been on
strict gluten free diet, FODMPAP, and lactose-free diet. 5
weeks ago, she was placed on elemental diet, lost 20 pounds and
has profuse watery diarrhea (usually constipated). She
discontinued this diet 2 weeks ago but did not gain the weight
back and has had brownish watery stool then (food going through
me). For the past 4 days she has had fevers to 102 and
worsening pain in her abdomen (LLQ, firey burning).
She was seen at ___ on ___, was diagnosed with
pneumonia, and was started on azithromycin. CT-Abd showed
gastroenteritis and patient had elevated transaminases. On CC6
she endorses fever, diarrhea, decreased appetite, generalized
weakness, cough, and abdominal pain. She denies sweats, chills,
new nausea, vomiting, and GI bleeding.
Past Medical History:
- Celiac Disease on strict gluten-free diet
- Small Intestinal Bacterial Overgrowth on multiple courses of
rifaximin and neomycin
- Depression
- Fibromyalgia with Back Pain
- Vitamin D Insufficiency
- FODMAP + Gluten Free + Lactose Free Diet
Social History:
___
Family History:
Mother: ___ disease
Sister: Type I DM, Lupus, Celiac disease
Brother: MS
Physical ___:
ADMISSION PHYSICAL EXAM:
VITALS = Tm/c 101.1, ___, 18, 99% on RA,
___ Pain, Ins ___ PO + 2700 IVF, Outs 260++
GENERAL: NAD, anxious
HEENNT: MMM, Clear oropharnyx, sclera anicteric, no LAD
CARDIAC: Tachycardic, no MRG
LUNG: CTAB
ABDOMEN: Soft, diffusely tender to soft touch, worse in LLQ, no
guarding/rebound
EXTREMITIES: No edema, able to move all extremities
NEURO: alert and oriented, normal gait
SKIN: Warm, capillary refill <2 seconds, no rash
DISCHARGE PHYSICAL EXAM:
VITALS = 98.9, 105-117/51-68, 81-109, 18, 97-99% on RA, Ins
1140, Outs 1560
GENERAL: NAD, tired
HEENNT: MMM, Clear oropharnyx, sclera anicteric, no LAD
CARDIAC: RRR, no MRG
LUNG: CTAB
ABDOMEN: Soft, minimal abdominal tenderness, no guarding/rebound
EXTREMITIES: No edema, able to move all extremities
NEURO: alert and oriented, normal gait
SKIN: Warm, capillary refill <2 seconds
Pertinent Results:
ADMISSION LABS:
___ 06:25PM BLOOD WBC-7.7 RBC-3.84* Hgb-12.1 Hct-34.1*
MCV-89 MCH-31.6 MCHC-35.6* RDW-13.3 Plt ___
___ 06:25PM BLOOD Neuts-71.6* Lymphs-17.5* Monos-9.9
Eos-0.4 Baso-0.6
___ 06:10AM BLOOD ___ PTT-27.3 ___
___ 06:25PM BLOOD Glucose-90 UreaN-6 Creat-0.6 Na-138 K-3.4
Cl-105 HCO3-22 AnGap-14
___ 06:10AM BLOOD Glucose-81 UreaN-4* Creat-0.5 Na-132*
K-3.2* Cl-105 HCO3-18* AnGap-12
___ 06:25PM BLOOD ALT-121* AST-147* AlkPhos-89 TotBili-0.2
___ 06:10AM BLOOD ALT-83* AST-82* LD(LDH)-155 AlkPhos-72
TotBili-0.2
___ 06:25PM BLOOD Lipase-32
___ 06:25PM BLOOD Albumin-3.7 Calcium-8.0* Phos-2.3* Mg-1.7
___ 06:10AM BLOOD Calcium-7.3* Phos-1.5* Mg-1.3*
___ 06:06PM BLOOD Lactate-1.2
CT abd/pelvis ___:
1. The appendix is not visualized.
2. Fluid-filled loops of small and large bowel with 2air-fluid
levels without a definite site of obstruction can be seen in the
setting of gastroenteritis.
3. Peribronchiolar opacities in the right lower lobe which are
likely secondary to aspiration.
KUB ___
Portable supine frontal and left lateral decubitus abdominal
radiographs demonstrate few mildly prominent loops of small
bowel with air-fluid levels.
Air is seen within nondilated colon. Air-fluid levels within the
colon identified. No pneumatosis or free intraperitoneal air. No
air in the rectum.
Limited assessment of the lung bases are clear and osseous
structures are unremarkable.
KUB ___dema and mild localized distension, small bowel
left upper
quadrant and localized in the splenic distension and loss of
haustra aeration
flexure, both probably due to local inflammation. There is no
evidence of
small bowel obstruction or free intraperitoneal gas.
STOOL CONSISTENCY: NOT APPLICABLE 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 ENTERIC GRAM NEGATIVE RODS FOUND.
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.
.
MANY POLYMORPHONUCLEAR LEUKOCYTES.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
CMV IgG ANTIBODY (Final ___:
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
19 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
A positive IgG result generally indicates past exposure.
Infection with CMV once contracted remains latent and may
reactivate
when immunity is compromised.
Greatly elevated serum protein with IgG levels ___ mg/dl
may cause
interference with CMV IgM results.
If current infection is suspected, submit follow-up serum
in ___
weeks.
___ VIRUS VCA-IgG AB (Final ___: POSITIVE BY
EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop ___ weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
Negative UA and urine culture
DISCHARGE LABS:
___ 06:20AM BLOOD WBC-7.6 RBC-4.32 Hgb-12.7 Hct-38.9 MCV-90
MCH-29.4 MCHC-32.7 RDW-13.2 Plt ___
___ 06:20AM BLOOD Glucose-89 UreaN-10 Creat-0.6 Na-138
K-4.7 Cl-101 HCO3-31 AnGap-11
___ 06:20AM BLOOD ALT-151* AST-165*
___ 09:45AM BLOOD calTIBC-176* Ferritn-112 TRF-135*
___ 03:02PM BLOOD VitB12-GREATER TH Folate-16.3
___ 05:15AM BLOOD 25VitD-49
___ 09:45AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HAV-NEGATIVE
___ 05:15AM BLOOD IgA-205
___ 05:15AM BLOOD tTG-IgA-12
___ 09:45AM BLOOD HCV Ab-NEGATIVE
___ 06:30AM BLOOD ZINC-PND
Brief Hospital Course:
SUMMARY:
Ms. ___ presented with new onset of fevers, LLQ abdominal
pain and worsening diarrhea (>15/day) in setting of semi-acute
increase in diarrhea (5/day) over past weeks with 20 pound
weight loss. She received aggressive volume resuscitation (IV
NS) with return to clinical euvolemia, course of
cipro/metronidazole, IV iron supplementation for Fe of 9,
electrolyte repletion, and symptomatic management for nausea,
vomiting and pain. She also received chest and KUB x-rays and CT
abdomen which showed nonspecific inflammation consistent with
gastoenteritis. Fevers resolved and diarrhea became much less
frequent in first 2 days of admission, consistent with
self-limited course of a suspected infectious gastroenteritis.
After resolution of infectious symptoms attention returned to
stabilizing her chronic disease and nutritional status. She
will followup with gastroenterology and nutrition as an
outpatient.
ACUTE ISSUES:
#Acute febrile diarrhea c/b LLQ pain, dehydration: Pt had a
comprehensive infectious workup for bacterial/viral
gastroenteritis (including stool culture, viral culture,
CMV/EBV/Hep A-C tests, campylobacter, C. diff) and for urinary
tract and respiratory infections, all of which returned
negative, and was treated empirically for GI infection with
cipro/flagyl. Abscence of blood in stool and negative culture
ultimately suggested an unusually severe presentation of viral
gastroenteritis in setting of chronic inflammation from known
celiac/IBS/SIBO. Her diarrhea resolved and abdominal pain back
to chronic baseline. She was discharged with ondansetron,
lorazepam, simethicone, and ranitidine for ongoing symptomatic
relief.
# Malnutrition in setting of IBS/SIBO/celiac disease: Ms.
___ is presently malnourished (BMI 16.1, low TIBC and
transferrin despite low iron) secondary to malabsorption,
maldigestion, diarrhea, and anorexia in setting of
SIBO/IBS/celiac. Over past 6 weeks, even prior to
gastroenteritis, she had significant diarrhea (roughly 5x/day)
with weight loss of ___ pounds and dehydration raising concern
among pt and family that her baseline disease was too
decompensated to keep stable at home. Efforts were made to
improve baseline control through consults with GI and nutrition
including her long-time outpatient providers. As noted,
electrolytes and iron were repleted. Nutrition recommended
continued FODMAP/lactose free/gluten free diet with Ensure
Plus/Ensure Clear supplementation as needed if not tolerating
solids. GI recommended EGD with biopsy and colonoscopy to assess
histopathological disease state with results now pending.
TTG-IgA was within normal limits, indicated good compliance with
gluten-free diet. Calorie count confirmed pt taking >1500
calories per day.
CHRONIC ISSUES:
# Depression: Continued home doses of methylphenidate (10 mg PO
daily) and duloxetine (60 mg PO BID).
# Fibromyalgia: Continued cyclobenzaprine 10 mg PO HS,
tapentadol (Nucynta) 50 mg PO PRN pain, and pregabalin 100 mg PO
BID.
TRANSITIONAL ISSUES:
# Follow up pathology results from EGD (___)
# Counsel patient on strategies to maintain adequate PO
hydration when having diarrhea or emesis, support with nausea
control regimen.
# Close outpatient follow-up with Gastroenterology and Nutrition
for IBS/SIBO/celiac.
# Revisit need for anti-emetic medication at next office visit
if patient has symptomatically improved
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rifaximin 200 mg PO BID
2. Neomycin Sulfate 1000 mg PO Q8H
3. MethylPHENIDATE (Ritalin) 10 mg PO DAILY
4. Cyclobenzaprine 10 mg PO HS
5. Nucynta (tapentadol) 50 mg oral BID:PRN pain
6. Linzess (linaclotide) 145 mcg oral daily
7. Pregabalin 100 mg PO BID
8. Duloxetine 60 mg PO BID
9. peppermint oil Other miscellaneous BID
10. Lidocaine 5% Patch 1 PTCH TD QAM
Discharge Medications:
1. Cyclobenzaprine 10 mg PO HS
2. Duloxetine 60 mg PO BID
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. MethylPHENIDATE (Ritalin) 10 mg PO DAILY
5. Pregabalin 100 mg PO BID
6. Multivitamins W/minerals 1 TAB PO DAILY
Talk to your pharmacist to avoid gluten-containing formulations
if possible.
RX *multivitamin,tx-minerals 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
7. Peppermint Oil 0 mL MISCELLANEOUS BID
8. Lorazepam 0.25 mg PO Q4H:PRN Nausea / Anxiety
RX *lorazepam 0.5 mg 0.5 (One half) tablet(s) by mouth Every
four hours Disp #*40 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO BID:PRN Constipation
Avoid if having diarrhea
10. Docusate Sodium 100 mg PO BID:PRN Constipation
Avoid if having diarrhea
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice a Day
Disp #*30 Capsule Refills:*0
11. Ondansetron 4 mg PO TID W/MEALS
RX *ondansetron 4 mg 1 tablet(s) by mouth three times a day with
meals Disp #*40 Tablet Refills:*0
12. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth Twice a Day Disp
#*30 Tablet Refills:*0
13. Linzess (linaclotide) 145 mcg oral daily
Avoid if having diarrhea
14. Simethicone 40-80 mg PO QID:PRN Abdominal Bloating
RX *simethicone 80 mg 0.5-1 tablets by mouth four times a day
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Viral Gastroenteritis
Dehydration with Tachycardia and Orthostatic Hypotension
Malnutrition with Weight Loss
Iron-Deficiency Anemia
SECONDARY:
Celiac Disease
Recurrent Small Intestinal Bacterial Overgrowth Episodes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital from
gastroenterology clinic because you were having severe diarrhea,
fever, abdominal pain, weight loss, and dehydration. You were
given intravenous fluid replacement, pain medications, and
antibiotics. Lab testing showed that fortunately you did not
have C. difficile, Salmonella/Campylobacter diarrhea, parasites,
worsening Celiac Disease, or Hepatitis A, B or C. You had an
upper endoscopy that showed some stomach irritation (biopsy
results still pending at time of discharge). Eventually, your
fevers stopped, you were rehydrated, your diarrhea resolved,
your vomiting improved, and your pain improved. You likely had
viral gastroenteritis (self-resolving viral infection of the
stomach and intestines often requiring supportive care) made
worse in the setting of your Celiac disease and SIBO.
Gastroenterology and Nutrition recommended close followup as an
outpatient (last in-hospital day you took in ___ calories).
Best of luck to you in your future health.
Do not drive or operate heavy machinery if sedated from
medication. Please walk around but avoid stressful or heavy
labor for the next 7 days. Follow a gluten/lactose-free and
FODMAP diet and allow for caloric intake of ___ calories (took
in ___ calories on ___ as tolerated or per your
nutritionist's recommendations. Drink plenty of water to avoid
dehydration as tolerated.
Please take all medications as prescribed, attend all doctors
___ as ___, and call a doctor if you have any
questions or concerns.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
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2165-03-18 00:00:00
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2165-03-30 08:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Mr. ___ is a ___ gentleman with an unknown past
medical history who presented to the ED after a witnessed
seizure was admitted to the MICU with concern for status
epilepticus.
History was obtained primarily from the chart. The patient is
intubated and sedated and there is no one accompanying the
patient.
The patient reportedly walked into a "business under
construction" and asked to use the bathroom. He began to vomit
and was helped down to the floor. He was then witnessed to have
generalized rhythmic jerking motions of his body that lasted
___ seconds. On EMS evaluation, he was found to be afebrile,
hypertensive to 170/108, SpO2 98% RA, and blood glucose 170. He
was also noted to have a minor abrasion above his L eye, was
unable to answer questions but appeared to be in no distress
"resting with his legs crossed and hands behind head throughout
transport."
In ED initial VS: 97.2 96 158/102 98%RA
While in the ED waiting room, the patient developed generalized
rhythmic jerking and was triggered out of concern for GTC
seizure. He was brought directly into the ED while actively
seizing. When he arrived in the room his rhythmic jerking had
terminated but he was diaphoretic and unresponsive with
intermittent episodes of agitation. He was given 1mg IV Ativan
and subsequently began to vomit green bilious fluid. There was
concern he was not protecting his airway so he was intubated
without difficulty.
He was given versed and fentanyl for sedation. Out of concern
for ongoing seizure activity he was loaded with fosphenytoin
1200mg and converted from versed to propofol gtt.
Labs were significant for:
- WBC 4.9, Hgb 9.7, MCV 92, Plt 103
- Normal Na and K, HCO3 19 with AGap 27
- BUN 15, Cr 1.0
- ALT 73, AST 164.
- Normal AP, Tbili, and Alb
- Serum tox EtOH 15
- Utox negative
- U/A benign
- VBG 7.___/41
- Lactate 13.7
Imaging notable for:
- CT Head w/o: No definite acute intracranial abnormality
- CT C-spine: Motion artifact makes study limited but there was
some soft tissue pre-vertbral prominence whicih may be
artifactual, though ligamentous injury is possible. Height loss
of C7 and T1, acuity unable to assess, recommend MR if
concerned.
- CXR: No acute cardiopulmonary abnormality
Consults:
- Neurology: Recommended calcium, mag, phos, trop, CK, CK-MB,
and EEG with MRI compatible leads.
VS prior to transfer: ___ 100% Intubated
Given the new-onset fever, the patient was started on CTX,
vancomycin, and acyclovir for empiric meningitis/encephalitis,
and an LP was performed.
On arrival to the MICU, the patient is sedated and intubated.
Past Medical History:
Alcoholism c/prior hx of alcohol withdrawal seizures
h/o posterior reversible encephalopathy syndrome
Transaminitis (AST and ALT elevated 2:1, consistent with
alcoholic liver disease)
Pancytopenia (though to be ___ alcoholism according to prior OMR
notes)
Social History:
___
Family History:
Unable to obtain
Physical Exam:
ON ADMISSION:
===============
GENERAL: Sedated and intubated
HEENT: Sclera anicteric, pupils pinpoint, MMM
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachycardic, regular rhythm, normal S1 S2, no murmurs,
rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, callous over knees b/l
with some underlying effusion
SKIN: No rashes, abrasions
NEURO: Sedated and intubated. Moves arms with purpose. Not
responsive to voice or noxious stimuli
ON DISCHARGE:
===============
VS: 99.1PO 136/83 54 18 98 RA
Constitutional: thin male, NAD
EYES: Sclera anicteric, EOMI, PERRL
ENMT: MMM, oropharynx clear, normal hearing, normal nares
Neck: c collar in place
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
GI: Soft, non-tender, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding
GU: No foley
EXT: Warm, well perfused, no CCE
NEURO: moving all four extremities purposefully, no gross
abnormalities
MSK: no TTP to scapula on right side and paraspinal musculature
Pertinent Results:
ADMISSION LABS
--------------
___ 10:33PM BLOOD WBC-4.9 RBC-3.04* Hgb-9.7* Hct-27.9*
MCV-92 MCH-31.9 MCHC-34.8 RDW-14.6 RDWSD-48.7* Plt ___
___ 10:33PM BLOOD Plt ___
___ 06:44AM BLOOD ___ PTT-23.1* ___
___ 10:33PM BLOOD Glucose-105* UreaN-15 Creat-1.0 Na-143
K-3.7 Cl-97 HCO3-19* AnGap-27*
___ 10:33PM BLOOD ALT-73* AST-164* CK(CPK)-403* AlkPhos-128
TotBili-0.7
___ 10:33PM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:44AM BLOOD CK-MB-2 cTropnT-<0.01
___ 10:33PM BLOOD Albumin-4.9
___ 10:33PM BLOOD T4-5.8
___ 10:33PM BLOOD TSH-1.5
___ 10:33PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS* IgM
HAV-NEG
___ 06:44AM BLOOD HIV Ab-NEG
___ 06:44AM BLOOD Phenyto-24.4*
___ 10:33PM BLOOD ASA-NEG Ethanol-15* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:33PM BLOOD HCV Ab-NEG
___ 12:59AM BLOOD ___ Temp-36.8 pO2-47* pCO2-41
pH-7.21* calTCO2-17* Base XS--11
___ 12:59AM BLOOD Lactate-13.7*
___ 06:22AM BLOOD Lactate-2.0
IMAGING
-------
CHEST X RAY ___
While no definite focal consolidation is identified, minimal
retrocardiac
opacity may represent aspiration in the appropriate clinical
context.
Endotracheal tube terminates 2 cm above the carina.
NCHCT ___:
1. No acute intracranial abnormality.
C-SPINE ___:
1. Multilevel Schmorl's nodes, no definite acute fracture.
2. Mild degenerative changes.
CHEST X RAY ___:
In comparison with the study of ___, the monitoring and
support devices are stable. The retrocardiac region is steadily
clearing. No evidence of vascular congestion or acute focal
pneumonia at this time.
MRI Brain ___. Study is moderately degraded by motion.
2. No evidence of acute infarct.
3. Within limits of study, no definite evidence of mass or
hemorrhage.
4. Paranasal sinus disease , as described.
MRI C spine
1. Study is at least moderately degraded by motion as described.
2. With doses study, no definite evidence of acute cervical
spine fracture.
3. Multiple chronic concave vertebral endplate fractures without
marked
vertebral body height loss as seen on prior CT C spine.
4. Mild cervical spondylosis with mild vertebral canal and
neural foraminal
narrowing as described.
Relevant labs
___ 01:10PM BLOOD calTIBC-168* VitB___-___ Fe
Ferritin-435* TRF-129*
___ 10:33PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS* IgM
HAV-NEG
MICROBIOLOGY
------------
Blood cultures NGTD
Urine culture NGTD
MRSA screen negative
CSF Gram stain and culture negative
HSV PCR, VZV PCR from CSF negative
Brief Hospital Course:
___ gentleman with past medical history of ETOH abuse,
pancytopenia, no known history of cirrhosis who presented to the
ED after a witnessed seizure is admitted to the MICU with c/f
status epilepticus of unknown etiology.
# Seizures - ? alcohol withdrawal seizures
# Alcohol abuse
The patient presented with vomiting followed by witnessed
seizure activity. His medical history or medications at this
point are also unknown. CT head did not show evidence of ICH or
a mass lesion. He had been loaded with fosphenytoin, and was
continued on propofol for sedation through ___. He was started
on IV Keppra 500 mg BID and then transitioned to oral
levatiracetam. Neurology was consulted and followed him during
his MICU course. Serum ETOH was 15 on arrival, so withdrawal was
a consideration. He was also empirically treated with 48 hours
of vanc/acyclovir/ceftriaxone for meningitis coverage, HSV and
VZV PCR were negative. CSF studies had 0 nucleated cells, and
CSF culture was negative so all antibiotics stopped. We believe
that he may have a history of alcohol withdrawal seizures, and
his records were requested from ___ but never obtained.
Patient was very defensive when discussing his alcohol use, and
possible relation to seizures. He was advised not to drive for
six months given his seizures. Patient was started on a
multivitamin, thiamine and folate. Patient finally admitted to
heavy alcohol use, and was convinced to cut back further on
alcohol and ideally quit completely. He will follow up with a
new PCP one week after discharge. He should also follow up with
Neurology, but we were unable to schedule this given patient is
currently without insurance.
# Respiratory Failure. Intubated for airway protection in the
setting of somnolence. On ___ he self-extubated to nasal
cannula and was weaned to room air.
# Transamnitis. Hepatocellular pattern with ALT:AST ratio 1:2
c/w alcohol or other hepatotoxic ingestion. Given an albumin of
> 4 and normal INR, it is unlikely that he has chronic liver
failure. Hepatitis serologies showed an isolated core Hepatitis
B Ab, negative hepatitis B surface antigen and positive
hepatitis B surface antibody, consistent with resolved
infection.
# Weight loss: patient reports 50 lb weight loss which should be
further explored upon PCP ___.
# Anemia. Normochromic, normocytic. Not iron deficient by labs
and Vitamin B12 wnl. Most likely due to myelosuppression from
alcohol use.
# Thrombocytopenia. Likely etiologies in this patient include
chronic alcohol use or marrow suppression from nutritional
deficiency vs infection.
# Hypertension: patient was restarted on lisinopril, which he
claims he was on in the past, but not taking for several months.
He should have his creatinine and potassium checked upon PCP
___.
# Possible compression fracture of C7 and T1 seen on CT neck.
Patient in C-collar. MRI neck showed no fracture so collar
removed.
# Encephalopathy: EEG showed diffuse slowing, presumably due to
alcohol use, intubation, recent seizure activity. He had
cognitive deficits on exam, such as inability to tell me his
phone number, or last four digits of SSN, and became very
irritable during cognitive testing. He would likely benefit
from more formal cognitive testing going forward.
# Self neglect, lack of medical care: Patient tells me that he
is insured through his job, but that he has no need to see a
physician, that in his home country of ___ people use
natural healers to manage medical problems. I counseled him
at length on need for f/u with neurology and PCP (especially
given his 50 lb reported weight loss). A new PCP appointment
was scheduled for the patient, which he agrees to follow up
with.
TRANSITIONS OF CARE
-------------------
# ___: He will follow up with a new PCP one week after
discharge. He should also follow up with Neurology, but we were
unable to schedule this given patient is currently without
insurance. He will need added support to assist in his quitting
alcohol use. He should have his creatinine and potassium
checked upon PCP ___. Patient reports 50 lb weight loss
which should be further explored upon PCP ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. LevETIRAcetam 500 mg PO Q12H
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule
Refills:*0
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Seizures
Anemia
Encephalopathy
Alcohol abuse with withdrawal
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___.
You were admitted to the hospital after having a seizure in a
pizza shop and then after being brought to our ED, you had
another seizure. You were intubated with a breathing tube, and
were in the ICU. You had a lumbar puncture that did not show
any infection and your MRI does not show any masses in your
brain, so we are concerned that your seizures are related to
drinking alcohol. We advise that you completely stop drinking
alcohol. Your liver is showing signs of injury from alcohol as
well.
You mentioned that you have lost 50 lbs; it is very important to
have regular medical care with a primary care doctor so that we
can determine why you have lost so much weight.
After experiencing a seizure, it is against the law to drive for
the next six months. Please do not drive.
Without medicines, your blood pressures are very high. Please
be sure to take the medicine lisinopril for your blood pressure.
You have been scheduled to see a new primary care doctor here at
___. ___ is important that you follow up with
this appointment and continue to take your medications as
prescribed.
Good luck!
Followup Instructions:
___
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10860467-DS-8
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DS
| 8 |
2153-01-22 00:00:00
|
2153-01-25 15:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness for 2 months
Major Surgical or Invasive Procedure:
___: mediastinoscopy with lymph node biopsy
History of Present Illness:
Patient is a ___ female with PMH of hypothyroidism,
pancytopenia and question SLL who presents from home with
complaint of 2 mos of weakness. Patient was last in her usual
state of health until 2 mos prior to presentation when she
experienced a strange incident. She was in her car after grocery
shopping with the engine on waiting for the car to warm up and
she passed out. She reports waking up 11 hours later and rapidly
coming to her senses. She managed to take a cab home, but later
went to ___ for evaluation. She reports having had
an EEG and an MRI brain done there. The EEG by her report showed
no seizure activity, and she is not sure what the results of the
MRI were. She was discharge home with scheduled followups. Since
that time, patient has been very fatigued she feels chills all
of the time. Her legs feel as though they are pressured
bilaterally. She has a cough but no sputum production. She feels
a sense of stomach uneasiness but no vomiting. On the day of
presentation, patient felt particularly fatigued and at her
daughter's urging presented to the ED at ___
requesting a referral to ___. That ED discharged her and she
then presented to ___ ED.
In the ED, initial VS were:98.4 95 154/73 18 100% ra. Labs were
significant for a positive UA, and she received nitrofurantoin
100mg PO once. CT chest was done for history of cough and
fatigue with abnormal CXR and showed LUL lung mass grown since
___, massive mediastinal LAD, and an enlarged left lobe of the
thyroid. She was admitted to medicine for evaluation. VS on
transfer: 97.8 92 144/72 18 99%.
On arrival to the floor, VS T97.8, BP161/78, HR85, RR18, O2sat
99%RA. Patient was comfortable and the findings of the CT scan
were reviewed regarding the chest pathology.
Past Medical History:
HTN
hypothyroidism
T2DM
ITP
pancytopenia
CLL/SLL
Neuroendocrine tumor- diagnosed ___
Social History:
___
Family History:
father has ___ disease and low platelets
mother is alive and healthy
cancers of unknown types in grandparents
Physical Exam:
Admission exam:
VS: T97.8, BP161/78, HR85, RR18, O2sat 99%RA
GENERAL: well appearing
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, palpable spleen
EXTREMITIES: 2+ non-pitting edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, no
hyperreflexia
Pertinent Results:
Admission labs:
___ 08:40PM BLOOD WBC-2.0* RBC-3.99* Hgb-10.4* Hct-33.2*
MCV-83 MCH-26.1*# MCHC-31.5# RDW-18.2* Plt Ct-74*#
___ 08:40PM BLOOD Neuts-67.5 ___ Monos-8.1 Eos-1.5
Baso-0.5
___ 07:07AM BLOOD ___ PTT-38.2* ___
___ 08:40PM BLOOD Glucose-159* UreaN-13 Creat-0.5 Na-144
K-3.5 Cl-112* HCO3-25 AnGap-11
___ 07:07AM BLOOD ALT-35 AST-60* LD(LDH)-206 AlkPhos-88
TotBili-0.8
___ 07:07AM BLOOD Albumin-3.1* Calcium-8.5 Phos-3.3 Mg-1.7
Imaging:
CXR ___: No focal consolidation. Subtle nodular opacity
projecting over left mid lung likely corresponds to previously
seen pulmonary nodule. Right paratracheal soft tissue density
which may represent prominent vascular structures and may be
similar in appearance to PET-CT scout radiograph from
___, although difficult to compare different modalities,
findings raise concern for underlying lymphadenopathy.
CT Chest ___:
1. Massive mediastinal and left hilar adenopthy.
2. 1.7 x 1.9 cm left upper lobe nodule has slowly grown since
___ when it measured 1 cm in diameter. Given the fairly
slow growth rate, this lesion is not likely the source of
metastasis.
3. 1.8 x 1.7cm hypoenhancing nodule adjacent to the left
thyroid lobe is
likely a node rather than primary thyroid lesion.
4. Splenomegally is stable since ___
The constellation of findings is concerning for lymphoma or
other malignancy. The large mediastinal nodes may be a good
target for tissue sampling.
CT Abd/Pelvis ___:
No acute pathology identified. No evidence of new
lymphadenopathy.
Persistent splenomegaly consistent with history of lymphoma.
Other chronic findings as above.
ECHO ___:
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF 65%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
Thyroid Ultrasound ___:
1. Enlarged heterogenous thyroid with several small nodules or
areas of
regional parenchymal heterogeneity, most consistent with chronic
thyroiditis. Follow up ultrasound could be obtained in one year
to assess stability.
2. Hypoechoic mass inferior and posterior to the left lobe of
the thyroid
likely represents an enlarged lymph node and is likely part of
the same
process affecting the mediastinal nodes.
Radiology Report MR HEAD W & W/O CONTRAST Study Date of ___
7:46 ___
FINDINGS: In the post-contrast axial spin-echo images (image
10:9), there are rounded enhancing foci in the temporal lobes
bilaterally, without correlates in other sequences, likely
representing pulsation artifacts from adjacent ICAs. There is
otherwise no abnormal focal enhancement to suggest intracranial
metastasis.
There is mild asymmetric left lateral ventricle prominence, but
within physiologic limits. There is no shift of normally
midline structures. The gray-white matter differentiation is
preserved. There are predominately subcortical T2/FLAIR white
matter hyperintense foci, somewhat atypical for age-related
chronic microvascular ischemic disease. There is no acute
infarct
or hemorrhage. Major vascular flow voids are present.
There is a 2-cm mucus retention cyst in the left maxillary
sinus. There is a trace amount of fluid retained in the mastoid
air cells bilaterally. The globes are symmetric and
unremarkable.
IMPRESSION:
1. No evidence of intracranial metastasis. No acute infarct or
hemorrhage.
2. Somewhat atypical distribution of predominately subcortical
white matter hyperintense foci, could represent risk-factor
related small vessel disease or sequela of vasculitis.
___ 08:50
SEROTONIN
Test Result Reference
Range/Units
SEROTONIN, BLOOD 125 56-244 ng/mL
___ 08:50
GASTRIN
Test Result Reference
Range/Units
GASTRIN 1436 H <101 pg/mL
___ 08:50
CHROMOGRANIN A
Test Result Reference
Range/Units
CHROMOGRANIN A, ECL 66.0 H 1.9-15.0 ng/mL
PATHOLOGY:
___ Pathology Tissue: Paratracheal Mass,
DIAGNOSIS:
1. PARATRACHEAL MASS, RIGHT (A-B): Involvement by a
neuroendocrine carcinoma, see Note.
2. PARATRACHEAL MASS, RIGHT, ADDITIONAL TISSUE (C):
Involvement by a neuroendocrine carcinoma, see Note.
NOTE: Histologic sections show multiple fragments of soft
tissue with a dense diffuse infiltrate of atypical mononuclear
cells. The cells are mostly large in size, with clear cytoplasm
including some with retraction artifact, irregular nuclear
outlines, fine chromatin, and variably prominent nucleoli.
There is background prominent vascularity and fine fibrosis,
dividing the cellular infiltrates into small nests. Mitoses are
present, and number up to 8:10 high power fields. Individual
apoptotic cells are seen, but confluent necrosis is absent.
There are admixed smaller mature-appearing lymphocytes as well
as normal appearing germinal centers.
Initial concern for a hematologic malignancy prompted a
hematopathology work-up (as evaluated by Dr. ___ in
___. The tumor cells were found to have negative
immunostaining for CD20, CD79a, and PAX5 (which stain only
B-cells of residual germinal centers), BCL6, CD30 (stains rare
background immunoblasts), MUM1 (stains scattered cells), CD23
(stains residual dendritic cell meshwork), and BLC6 and CD10
(which additionally highlight residual germinal centers, which
are appropriately negative for BCL2). CD3 and CD5 highlight
T-cells, which are present most abundantly in the areas with
residual follicles. CD43 highlights a subset of lymphocytes
corresponding to T-cells. In addition, the corresponding flow
cytometric analysis (___) was a non-diagnostic study:
clonality could not be assessed in that case due to insufficient
numbers of B cells. In sum, there is no evidence for involvement
by a B-cell lymphoproliferative disorder.
Further work-up showed the lesional cells to stain positively
with neuroendocrine cell markers CD56, synaptophysin, and
chromogranin, as well as TTF-1 and cytokeratin cocktail. There
was also focal staining for CK7, BCL2, and CD10. Other
immunostains performed that were negative includes melanoma
markers (S100, HMB45, MiTF), markers of germ cell tumors (PLAP
and ___, with c-kit showing only focal positivity), and
breast tissue marker (mammoglobin). The MIB-1/___
proliferation marker was found to have variable staining ranging
___, and is overall ~20%. Residual germinal centers
appropriately show much higher MIB-1 activity.
In summary, the findings are most consistent with a
neuroendocrine carcinoma of likely lung origin. The elevated
mitotic count, MIB-1/___ proliferation index, and focal
necrotic tumor cells would classify this tumor as at least an
ATYPICAL CARCINOID TUMOR; however, a higher grade tumor (such as
large cell neuroendocrine carcinoma) cannot be ruled out on the
basis of this limited small biopsy specimen. Radiologic and
clinical correlation is advised.
___ Pathology Tissue: IMMUNOPHENOTYPING-BM
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: ___, FMC-7,
Kappa, Lambda, and CD antigens 3, 5, 10, 19, 20, 23.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield. CD45 bright B cells comprise 29% of
lymphoid-gated events and exhibit monoclonal kappa light chain
restriction. They co-express pan-B cell markers CD19, CD20,
along with CD5. A CD45 dim, CD19 positive B cell population is
identified that co-expresses CD10 with variable CD20 expression
and absent surface immunoglobulin, immunophenotypically
consistent with hematogone.
INTERPRETATION
Immunophenotypic findings consistent with a minimal population
of Chronic Lymphocytic Lymphoma cells, as well as a small
population of hematogones.
___ Cytogenetics BONE MARROW - CYTOGENETICS
Cytogenetics Report BONE MARROW - CYTOGENETICS Procedure Date of
___
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: ___, ___-7,
Kappa, Lambda, and CD antigens 3, 5, 10, 19, 20, 23.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield. CD45 bright B cells comprise 29% of
lymphoid-gated events and exhibit monoclonal kappa light chain
restriction. They co-express pan-B cell markers CD19, CD20,
along with CD5. A CD45 dim, CD19 positive B cell population is
identified that co-expresses CD10 with variable CD20 expression
and absent surface immunoglobulin, immunophenotypically
consistent with hematogone.
INTERPRETATION
Immunophenotypic findings consistent with a minimal population
of Chronic Lymphocytic Lymphoma cells, as well as a small
population of hematogones.
Specimen Type: BONE MARROW - CYTOGENETICS
INDICATION: Lmphoma
CLINICAL DATA: ___ yo with history of SLL,ITP, COOMBS neg
hemolytic anemia with new medistinal LAD, c/w larbe B cell
lymphoma
___ Pathology Tissue: BONE MARROW ( 1 JAR)
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY.
DIAGNOSIS:
CELLULAR BONE MARROW WITH MATURING TRILINEAGE HEMATOPOIESIS.
Note: By immunohistochemistry, performed on the core biopsy,
CD138 stains plasma cells which occupy less than 5% of the
marrow cellularity. By kappa and lambda staining, clonality
could not be assessed due to high background staining. A
cytokeratin stain is negative.
___ Pathology Tissue: IMMUNOPHENOTYPING-PARATRACHEAL
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: ___, ___-7,
Kappa, Lambda, and CD antigens 3, 5, 10, 19, 20, 23.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield. CD45 bright B cells comprise 29% of
lymphoid-gated events and exhibit monoclonal kappa light chain
restriction. They co-express pan-B cell markers CD19, CD20,
along with CD5. A CD45 dim, CD19 positive B cell population is
identified that co-expresses CD10 with variable CD20 expression
and absent surface immunoglobulin, immunophenotypically
consistent with hematogone.
INTERPRETATION
Immunophenotypic findings consistent with a minimal population
of Chronic Lymphocytic Lymphoma cells, as well as a small
population of hematogones.
Brief Hospital Course:
Patient is a ___ female with PMH of hypothyroisism, ITP,
pancytopenia, and probable SLL who presented with 2 months
progressive fatigue and weakness found to have massive
lymphadenopathy on CT chest, pathology consistent with
neuroendocrine tumor at least atypical carcinoid.
#Neuroendocrine Tumor: On presentation to ___ this time, found
to have massive mediastinal and left hilar lymphadenopathy, as
well as new nodule adjacent to the thyroid consistent with a
lymph node on CT, raising concern for progression or
transformation of lymphoma. CT abdomen/pelvis for staging showed
splenomegaly, but no new areas of lymphadenopathy. LDH, uric
acid, calcium all within normal limits. Heme-onc team consulted
and the decision was made to pursue lymph node biopsy.
Mediastinoscopy and excisional biopsy performed by thoracic
surgery ___. Preliminary path suggested diffuse large B cell
lymphoma. However, after further staining, the tumor shows many
neuroendocrine features. A neuroendocrine tumor work-up was
initiated and the patient was transferred to the OMED service.
Patient also reported increased forgetfullness such forgetting
to turn water off all night. An MRI head was done to rule out
metastatic disease and was negative for metasttic disease.
Further work-up showed the lesional cells to stain positively
with neuroendocrine cell markers CD56, synaptophysin, and
chromogranin, as well as TTF-1 and cytokeratin cocktail. The
findings are most consistent with a neuroendocrine carcinoma of
likely lung origin, classified as at least atypical carcinoid
tumor. A higher grade tumor such as large cell neuroendocrine
tumor could not be ruled out. Patient will follow up with Dr.
___.
#. CLL/SLL: Diagnosed with SLL in ___ when CT torso showed
splenomegaly and lung nodules and peripheral blood had lambda
restricted population of B cells co-expressing CD19, CD20, CD5,
CD23 and FMC7, but were negative for CD10, consistent with
CLL/SLL. She was followed by Dr. ___ ___, when she
transferred care to an oncologist at ___. She has
never had cytotoxic therapy. On presentation to ___ this time,
found to have massive mediastinal and left hilar
lymphadenopathy, initially concerning for transformation of
lymphoma, however ultimately found to be neuroendocrine in
origin. A bone marrow biopsy was performed on ___ pathology
showed cellular bone marrowi with maturing trilineage
hematopoiesis. Flow cytometry showed immunophenotypic findings
consistent with a minimal population of Chronic Lymphocytic
Lymphoma cells, as well as a small population of hematogones.
Patient will follow up with Dr. ___.
#Fatigue: Most likely secondary to malignancy. TSH/free T4 WNL.
Acute worsening likely secondary to UTI, as UA grew pansensitive
E. coli and patient felt significantly stronger with treatment.
She was treated with nitrofurantoin from ___ with end date ___.
#ITP-platelets stable from baseline. This could be an autoimmune
consequence of an underlying malignancy.
#Anemia: Patient is anemic worse from baseline in ___. Marrow
suppression vs hemolysis. Coombs negative, normal LDH; however,
haptoglobin <5. B12 normal.
#Hypothyroidism: continued levothyroxine, TSH, free T4 normal.
#T2DM: hold oral hypoglycemics, HISS in house
Transitional issues
- Patient to follow up with hematology and oncology for
treatment planning
- Prolactin level elevated to 31, this is an intermediate level
and should be rechecked as an outpatient
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Levothyroxine Sodium 112 mcg PO DAILY
2. Lisinopril 20 mg PO DAILY
hold for SBP<100
3. Actoplus MET *NF* (pioglitazone-metformin) ___ mg Oral
daily
4. Ferrous Sulfate Dose is Unknown PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 112 mcg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Actoplus MET *NF* (pioglitazone-metformin) ___ mg Oral
daily
4. Ferrous Sulfate 325 mg PO DAILY
5. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Atypical carcinoid
Lymphoma
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to the hospital with weakness and fatigue.
Your blood counts were low. A CT scan showed large lymph nodes
that were concerning for lymphoma. A biopsy was performed, which
showed that ___ have both lymphoma and another cancer, which is
called atypical carcinoid, which is a kind of neuroendocrine
tumor. ___ need continued work-up and consultation with
specialists before ___ can receive treatment for this disease.
___ were also found to have a urinary tract infection and
treated with antibiotics.
It was a pleasure taking care of ___ during your hospitalization
and we wish ___ all the best going forward. ___ will have
follow-up with a cancer specialist and with Dr. ___.
___ have two new prescriptions:
START allopurinol.
START oxycodone as needed.
Followup Instructions:
___
|
10860467-DS-9
| 10,860,467 | 22,379,588 |
DS
| 9 |
2154-04-28 00:00:00
|
2154-05-01 14:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
word finding difficulties
Major Surgical or Invasive Procedure:
open brain biopsy:
PRINCIPLE PROCEDURE:
1. Exploratory craniotomy for resection of signal
abnormality, right superior frontal gyrus.
2. Intraoperative image guidance.
3. Microscopic dissection.
4. Duraplasty.
History of Present Illness:
___ yo F with a h/o neuroendocrine carcinoma of the lung p/w
word-finding difficulty and dysequilibrium. . She had an episode
of feeling suddenly off balance and generally weak. She had
associated R facial numbness and her husband noted word-finding
difficulties and hesitation on speech. Initially she reported
that her symptoms were fairly acute in onset, but on further
history it appears she has had intermittent symptoms for a few
weeks. Some complaints of clumsiness in her hands L >R and
difficulty with word-finding for 2 weeks. She denies HA/f/c.
She denies cp/dyspnea/n/v/d/abd pain.
In the ED: 98.7 96 138/67 20 97% ra. lytes ok. wbc 2.2, plt 39.
u/a neg. CT head negative.
.
ROS: as above; o/w complete ROS negative
Past Medical History:
HTN
hypothyroidism
T2DM
ITP
pancytopenia of unclear etiology
CLL/SLL
Neuroendocrine tumor of lung with mediastinal LAD- diagnosed
___
Social History:
___
Family History:
father has ___ disease and low platelets
mother is alive and healthy
cancers of unknown types in grandparents
Physical Exam:
t 97.9 132/69 90 18 96%ra
ox3, in NAD
perrl, eomi
neck supple
no ___
chest clear
rrr
abd benign
ext w/wp
neuro: cn ___ intact; strength/sensation grossly intact; DTRs
intact; gait deferred; cerebellar: dysmetria on the L,
over-shooting on finger-to nose on the L; +expressive aphasia
skin: no rash
Exam on day of discharge:
Afeb, VSS
Cons: NAD, sitting up in bed
Eyes: EOMI, no scleral icterus
ENT: MMM
sutures on the top of scalp, no drainage, healing well
Cardiovasc: rrr, no murmur, no edema
Resp: CTA B
MSK: no significant kyphosis
Skin: no rashes
Neuro: speech--unchanged from yesterday
Psych: pleasant, blunted affect
Pertinent Results:
___ 07:00PM GLUCOSE-147* UREA N-11 CREAT-0.5 SODIUM-141
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-25 ANION GAP-10
___ 07:00PM CALCIUM-8.6 PHOSPHATE-2.7 MAGNESIUM-1.8
___ 07:00PM WBC-2.2* RBC-4.06* HGB-12.7 HCT-38.2 MCV-94
MCH-31.3 MCHC-33.2 RDW-15.5
___ 07:00PM PLT COUNT-39*
___ 07:00PM ___ PTT-40.5* ___
___ 07:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 07:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN->12 PH-6.5
LEUK-TR
___ 07:00PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-10 TRANS EPI-<1
___ 07:00PM URINE MUCOUS-OCC
MRI head with and without contrast
IMPRESSION:
1. Progression of bihemispheric predominantly subcortical white
matter
hyperintense foci without associated enhancement or slow
diffusion. Findings
may be sequela of progressing microangiopathy or vasculitis.
Other diagnostic
considerations could include PRES or PML.
2. No evidence of intracranial metastases, acute infarct, or
hemorrhage.
MRI spine
IMPRESSION:
1. No evidence of osseous or epidural malignancy in the
cervical, thoracic,
or lumbar spine. Evaluation for leptomeningeal malignancy is
not possible in
the absence of intravenous contrast.
2. Mild degenerative changes in the cervical, thoracic, and
lumbar spine
without impingement of the spinal cord or nerve roots. The
spinal cord
appears normal in morphology and signal intensity.
3. Patchy fatty infiltration of T3 through T7 vertebral bodies
is likely
related to the history of radiation therapy.
4. Heterogeneous nodule caudal to the left thyroid lobe, which
slightly
displaces the trachea to the right, as well as right
paramediastinal and left
infrahilar pulmonary opacities, are grossly similar in
appearance to the
___ torso CT, on which they were better visualized.
CT chest
IMPRESSION:
Slight increase in size of a left supraclavicular lymph node;
otherwise
unchanged mediastinal lymphadenopathy, post-radiation fibrotic
changes, and
known small pulmonary nodules. No new nodules identified.
CT abdomen
IMPRESSION:
1. Heterogeneous enhancement of the liver, not optimally
evaluated on this
single-phase exam. A MRI may be able to provide further
characterization as
indicated.
2. Unchanged splenomegaly.
Brief Hospital Course:
___ yo woman with hx CLL/SLL, pancytopenia, ITP, neuroendocrine
carcinoma of lung, HTN, Type 2 DM, hypothyroidism who presents
with episodic word-finding difficulty, facial numbness,
dysequilibrium, weakness.
Pt underwent extensive evaluation for these new symptoms with
the neurology and oncology teams. She was ruled out for stroke,
she was found to have abnormal findinsg on her MRI that were of
unclear etiology. She had an LP that was unrevealing. She
eventually underwent an open brain biopsy to have a definitive
diagnosis on ___. Post-biopsy the pt did well and did not
have complications. She completed a course of keppra for
post-biopsy ppx. She was discharged to home with home ___, RN,
health aids as the result from the biopsy will not be available
for quite some time. she will be seen in ___ clinic
for suture removal and post-op wound check.
# Neurologic deficits: MRI demonstrated subcortical white matter
hyperintense changes: In coordination with hematology/oncology
and neurology - the differential included PML, lymphoma,
vasculitis. It would be unusual, however, to see PML in a
patient who has not received chemotherapy in the past. She was
thoroughly evaluated as follows. Spine MRI without any acute
changes. LP done ___ by ___, CSF with multiple serologies
unrevealing, flow cytometry negative for lymphoma, cytology
negative. ___ virus ab positive but DNA PCR negative - not
consistent with PML. Head CTA unremarkable. EEG done ___
without epileptic foci, 24hr EEG ___ limited by artifact
but no evidence seizures. Ddx at this point included vasculitis,
atypical infection, malignancy. This complex case was discussed
in ___ conference on ___. Neurosurgery took the patient for
open brain biopsy on ___.
# SLL/CLL/ITP with pancytopenia: Heme/Onc followed closely. She
does show some evidence of hemolysis on labs, but discussed with
heme fellow and she has had some low grade hemolysis in past.
Currently no schistocytes on their smear review. In preparation
for possible brain bx, as per Hematology, pt received filgastrim
to increase WBC and minimize risk of infection.
# Low back pain: Spine MRI without any acute changes
#Neuroendocrine carcinoma of lung with mediastinal LAD: stable
on most recent imaging ___. s/p XRT ___ chemo held
given cytopenias. She received CT torso as part of followup
care, notable for heterogenous enhancement of the liver of
unclear significance. She will likely need MRI as outpt (heme
fellow aware). Otherwise no acute issues.
# DMII: monitored closely, glucophage held, covered with ISS.
# HTN: stable, continued lisinopril
# hypothyroidism: stable, continued levothyroxine
# dysphagia: attributed to radiation esophagitis, now mostly
with liquids and confirmed with swallowing evaluation. She was
given thickened liquids with regular consistency solids and did
well.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation. (Per OMR: will need confirmation with
family this AM)
1. Omeprazole 20 mg PO DAILY
2. Levothyroxine Sodium 112 mcg PO DAILY
3. Lisinopril Dose is Unknown PO Frequency is Unknown
4. pioglitazone-metformin unknown oral unknown
Discharge Medications:
1. Levothyroxine Sodium 112 mcg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. MetFORMIN XR (Glucophage XR) 750 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
unclear reason for neurologic changes
Discharge Condition:
alert, interactive, ambulatory with walker
Discharge Instructions:
It was a pleasure to participate in your care. You were admitted
with word-finding difficulties, dysequilibrium, hand clumsiness,
and facial numbness. You had an MRI brain that was abnormal.
You had a spinal tap that did not reveal a clear cause of your
symptoms. You underwent a brain biopsy for the purpose of
diagnosis and the results are still pending at this time.
You can showed and wash the hair, but be gentle with the area of
the incision. If you notice pain or swelling there, please call
___. You do NOT need to continue the keppra
(anti-seizre medication) at home-- it was just for the time
after the biopsy.
Followup Instructions:
___
|
10860507-DS-20
| 10,860,507 | 29,798,445 |
DS
| 20 |
2148-07-21 00:00:00
|
2148-07-24 14:46:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Doxycycline / Zithromax
Attending: ___
Chief Complaint:
confusion and lethargy
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ year old female with PMH significant for HTN,
HLD, and multiple prior UTIs who presents to ED with confusion.
Patient was recently started on ciprofloxacin for a possible
urinary tract infection. She reports that five days prior to
presentation she noted increased urinary frequency with some
dysuria. She called her PCP and was prescribed a course of
ciprofloxacin. She initially noted improvement in her dysuria
but had ongoing urinary frequency. For the past two days she has
noted generalized fatigue. Today she was noted to be somewhat
confused by her son. She reported generalized fatigue, ongoing
urinary frequency, and some nausea but no emesis. She denies any
CVA tenderness or pain. She has completed 6 days of abx for her
UTI.
In the ED, initial vs were: 8 97.8 53 132/82 18 97% Labs were
remarkable for Na 119, K3.8. UA with moderate leuk, Nitrite neg,
2 WBC. Patient was given 1L NS. Vitals on Transfer: 98.4 47
104/48 16 96% RA
On the floor patient reports that she still feels confused. She
reports that she has been drinking a lot of water in the setting
of taking the antibiotic and to flush out the bacteria in her
bladder. She reports drinking at least 4 glasses of water per
day (unknown size) for the past 6 days. She also reports having
heartburn currently.
Past Medical History:
ALLERGIC RHINITIS
ESOPHAGITIS
H/O URINARY TRACT INFECTION
HYPERTENSION
BLADDER PROLAPSE
GLAUCOMA
HYPERLIPIDEMIA
ROSACEA
Social History:
___
Family History:
Mother died at age ___ of a stroke. Father died at age
___ of colon cancer.
Physical Exam:
ADMISSION:
Vitals- 97.6 120/63 45 18 97%RA
General- Alert, orientedx3, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally
CV- bradycardic, S1, S2, no murmurs
Abdomen- obese soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE:
Vitals- 97.4 102/60 46 20 100%RA
General- Alert, oriented x 3, NAD
HEENT: NCAT
Neck- supple
Lungs- Clear to auscultation bilaterally.
CV- Regular rate and rhythm.
Abdomen- soft, non-tender, non-distended.
Ext- warm, well perfused, 2+ pulses
Pertinent Results:
___ 08:23PM BLOOD WBC-6.9 RBC-3.77* Hgb-12.4 Hct-35.0*
MCV-93 MCH-32.9* MCHC-35.5* RDW-11.9 Plt ___
___ 07:20AM BLOOD WBC-4.9 RBC-3.77* Hgb-12.3 Hct-34.8*
MCV-92 MCH-32.6* MCHC-35.3* RDW-12.0 Plt ___
___ 08:23PM BLOOD Glucose-144* UreaN-16 Creat-0.8 Na-119*
K-3.8 Cl-84* HCO3-27 AnGap-12
___ 02:21AM BLOOD Glucose-95 UreaN-13 Creat-0.7 Na-121*
K-3.4 Cl-88* HCO3-26 AnGap-10
___ 07:20AM BLOOD Glucose-92 UreaN-11 Creat-0.7 Na-123*
K-4.1 Cl-88* HCO3-27 AnGap-12
___ 01:40PM BLOOD Na-126* K-4.1 Cl-93*
___ 06:40PM BLOOD Na-133 K-4.1 Cl-101
___ 02:03AM BLOOD Na-136 K-4.3 Cl-105
___ 06:45AM BLOOD Glucose-86 UreaN-12 Creat-0.8 Na-138
K-4.0 Cl-106 HCO3-25 AnGap-11
___ 02:21AM BLOOD Mg-1.3*
___ 07:20AM BLOOD Mg-2.1
___ 06:45AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.8
___ 07:20AM BLOOD Cortsol-21.8*
___ 02:21AM BLOOD TSH-2.6
___ 02:21AM BLOOD Osmolal-256*
___ 07:20AM BLOOD Osmolal-257*
SINGLE FRONTAL VIEW XRAY OF THE CHEST ___
There is moderate cardiomegaly. The aorta is elongated. There
is a
questionable hiatal hernia. The lungs are clear. There is no
evidence of pneumonia, CHF, pneumothorax or pleural effusion.
SINGLE FRONTAL VIEW XRAY OF THE CHEST ___
IMPRESSION: No evidence of acute cardiopulmonary abnormalities.
***
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML..
CORYNEBACTERIUM UREALYTICUM SP. ___ ORGANISMS/ML.. PRESUMPTIVE
IDENTIFICATION.
Sensitivity testing performed by Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CORYNEBACTERIUM UREALYTICUM SP.
NOV.
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 2 S
PENICILLIN G---------- 0.25 S
VANCOMYCIN------------ 1 S
Brief Hospital Course:
# Hyponatremia: Pt with severe hyponatremia and confusion as a
result. ___ presents with a mixed picture of hypovolemic vs
eunatremic hyponatremia with a clear pathogenesis: tea and toast
solute depletion as a function of nausea compounded by HCTZ use.
Her condition improved swiftly with Fluid repletion
Na 138 upon discharge. valsartan-hydrochlorothiazide
discontinued temporarily
# Confusion: Likely secondary to profound hyponatremia. Improved
at discharge. Pt now A & Ox3
# h/o UTI: UA now negative. Appears patient received ___ days of
Ciprofloxacin which is adequate treatment for uncomplicated UTI.
Urine culture was done.
**Results, which were pending at discharge, showed
corynebacterium urealyticum 10,000-100,000CFU
# GERD: Continued Omeprazole.
# HLD: Continued simvastatin
# Gluacoma: Stable. continued Travatan Z (travoprost) 0.004 %
___ and Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES QAM
****TRANSITIONAL ISSUES:
Corynebacterium urealyticum associated with kidnety stones.
consider renal u/s to evaluate especially with hx of recurrent
UTI'S.
Can restart HCTZ when instructed to do so with teaching to hold
when ill
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Omeprazole 20 mg PO DAILY
2. Simvastatin 40 mg PO DAILY
3. Travatan Z (travoprost) 0.004 % ___
4. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES QAM
5. valsartan-hydrochlorothiazide 160-12.5 mg Oral daily
Discharge Medications:
1. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES QAM
2. Omeprazole 20 mg PO DAILY
3. Simvastatin 40 mg PO DAILY
4. Travatan Z (travoprost) 0.004 % ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hypovolemic hyponatremia
secondary diagnosis:
HTN
Hyperlipidemia
Discharge Condition:
ALERT AND ORIENTED X 3
NAD
AMBULATORY
Discharge Instructions:
Dear Ms. ___,
You came into the hospital because of weakness and some
confusion and we found that your salt (sodium) levels were low.
This was likely because of your blood pressure medicine
hydrochlorothiazide and poor food intake. We gave you fluids
through IV and stopped the hydrochlorothiazide medication and
your levels are improved back to normal. You are now ready to go
home.
Please do not drive or operate heavy machinery for the next 1
week.
Please follow up with your primary care provider in the next ___
weeks.
Followup Instructions:
___
|
10860566-DS-7
| 10,860,566 | 25,725,672 |
DS
| 7 |
2191-11-27 00:00:00
|
2191-12-06 01:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Keflex
Attending: ___.
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with h/o stroke and Afib on coumadin was seen by PCP 4
days ago with chief complaint of painless jaundice and pruritus.
Painless jaundice was found at annual physical, and pt was
admitted for endoscopic evaluation with heparin bridging given
his high stroke risk. He underwent a CT scan which did show
gallstones and a pancreatic hypodensity, but without evidence of
biliary or pancreatic obstruction. He then underwent evaluation
by endoscopic
ultrasound, and was found to have a 1cm mass in the head and a
sub-centimeter cyst, both in the head of the pancreas, and the
mass was biopsied. However, no evidence of extra-hepatic ductal
obstruction to explain his jaundice/hyperbilirubinemia was
found. He was then seen by the Liver Consult service, and they
felt that the most likely culprit for his jaundice and
hyperbilirubinemia were was medication-related cholestasis,
likely due to his recent Keflex and Bactrim use.
They recommended starting ursodiol, listing Bactrim and Keflex
as allergies, and trending his bilirubin. Other causes of
intrahepatic obstruction were also considered, and are currently
pending, including an alpha-1 anti-trypsin level and IgG/IgG
subclass levels. ___, AMA, anti-Smooth Ab, Hep serologies were
all negative. Although ferritin is elevated, his transferrin
saturation is low-normal. His bilirubin peaked at 26, and was
24 on day of discharge.
Patient returned to ___ on the ___ today with worsening
jaundice and was sent into ED. Pt complains of pruritis, gray
stools, and 12 pound weight loss over the last week, 30 pounds
in the last month. No abdominal pain, chest pain, SOB, headache,
vision changes, difficulty concentrating, fever, chills, nausea,
vomiting, or change in urine.
ROS: Denies any recent pain, diarrhea, hematochezia, vision
changes, sore throat, cough, chest pain, shortness of breath,
nausea, vomiting, urinary changes, fevers, chills, rigors.
Past Medical History:
afib, since age ___
htn
CVA ___ while off coumadin
PVD- carotid stenosis, L<60%
? TIA in ___
Diverticular bleed in ___ -2 transfusions
gout
DM II
BPH
Dyspepsia-chronic PPI
L hip fx, s/p THR ___
T12 khyphoplasty ___
Social History:
___
Family History:
No FH of liver disease
Physical Exam:
Admission exam:
Vitals- 98.4 126/63 61 22 99%RA
General- Alert, oriented, no acute distress
Skin- dramatically jaundiced
HEENT- Sclera dramatically icteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- A&Ox3, alert, fluent, linear & prompt, no tremor or
asterixis
Discharge Physical Exam
Vitals: 138/66 - 97.5 - 56 - 18 - 98 RA - BG 130
General- Alert, oriented, no acute distress
Skin- Jaundiced
HEENT- Sclera icteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- A&Ox3, alert, fluent, linear & prompt, no tremor or
asterixis
Pertinent Results:
___ 10:19AM GLUCOSE-179* UREA N-27* CREAT-1.3* SODIUM-141
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-22 ANION GAP-17
___ 10:19AM ALT(SGPT)-55* AST(SGOT)-60* ALK PHOS-405* TOT
BILI-20.2* DIR BILI-16.5* INDIR BIL-3.7
___ 11:35PM URINE COLOR-DkAmb APPEAR-Hazy SP ___
___ 11:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-2* PH-5.5 LEUK-NEG
___ 11:35PM URINE RBC-2 WBC-9* BACTERIA-FEW YEAST-NONE
EPI-<1 TRANS EPI-<1
___ 11:35PM URINE HYALINE-1*
___ 11:35PM URINE MUCOUS-OCC
___ 10:00PM ALT(SGPT)-54* AST(SGOT)-64* ALK PHOS-402* TOT
BILI-20.0* DIR BILI-15.3* INDIR BIL-4.7
___ 06:35AM BLOOD Glucose-116* UreaN-28* Creat-1.2 Na-139
K-4.1 Cl-104 HCO3-21* AnGap-18
___ 06:35AM BLOOD ALT-51* AST-56* AlkPhos-410*
TotBili-21.7* DirBili-16.4* IndBili-5.3
Brief Hospital Course:
HOSPITAL COURSE:
This is an ___ year old gentleman with a recent h/o cephalexin
and Bactrim-induced indirect hyperbilirubinemia with preserved
hepatic function (assessed by normalization of INR off coumadin)
who presented to the hospital for concern for worsening
hyperbilirubinemia. His total bilirubin was infact improving. He
was evaluated by Physical therapy and discharged to rehab.
.
ACTIVE ISSUES:
1. Hyperbilirubinemia: The patient's total bilirubin peaked at
26.2 on ___ and now is 21.7, with a shift to direct
hyperbilirubinemia, compatible with drug-induced etiology. This
is all in the setting of elevated transaminases and alkaline
phosphatase. A RUQ ultrasound demonstrated undilated intra- and
extra-hepatic ducts. Hep B&C serologies, AMA, ___ all
negative. IgG was 772. Hepatology was again consulted and again
strongly suspected drug-induced causes but also considered IgG4
disease, hepatic infiltration, PBC and PSC. The patient was
continued on ursodiol 300mg tid and pruritis was managed with
hydroxyzine, allegra and saran lotion. The patient should expect
resolution of his hyperbilirubinemia over the time course of
months. Pancreatic bx results from the prior admission were
still pending on discharge.
.
INACTIVE ISSUES:
1. Atrial Fibrillation: The patient was continued on warfarin,
metoprolol and digoxin.
.
2. Hypertension: He was continued on hydralazine, amlodipine,
and furosemide.
.
3. Dyspepsia-chronic PPI: The patient was continued on
omeprazole.
.
TRANSITIONAL ISSUES:
1. Will need to have EUS bisopy results (path and cytology)
followed-up by ERCP
2. Will need to have LFT's checked at next PCP ___ (___)
to monitor for improvement.
3. The patient will need to contact his pharmacy and other
medical providers to inform them of his new allergies to Bactrim
and Keflex
4. Discharge planned for rehab and then home
5. Code Status: Home
Medications on Admission:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
2. hydralazine 10 mg Tablet Sig: Two (2) Tablet PO BID
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. benazepril 10 mg Tablet Sig: Four (4) Tablet PO daily ().
6. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching.
9. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
11. ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID
12. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO once a day for
4 days: please take 3mg daily until your next INR check on
___ and adjust your Coumadin dose per your
___. .
Discharge Medications:
1. Metoprolol Tartrate 50 mg PO BID
hold for HR < 60, SBP < 100
2. HydrALAzine 20 mg PO BID
hold for SBP < 100
3. Amlodipine 10 mg PO DAILY
hold for SBP < 100
4. Omeprazole 20 mg PO DAILY
5. benazepril *NF* 40 mg Oral daily
6. Digoxin 0.125 mg PO DAILY
hold for high or low potassium, arrhythmia, yellow vision, HR <
60
7. Furosemide 20 mg PO DAILY
hold for SBP < 100
8. HydrOXYzine 25 mg PO DAILY
9. camphor-menthol *NF* 0.5-0.5 % Topical wid pruritis
10. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
11. Ursodiol 300 mg PO TID
12. Warfarin 3 mg PO DAILY16
13. Sarna Lotion 1 Appl TP QID:PRN itch
14. Fexofenadine 60 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Drug-induced hyperbilirubinemia
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 ___ while ___ were hospitalized at
the ___ were hospitalized because of your
increasing yellow skin tone. On admission, we consulted with the
liver doctors who had ___ during your recent admission.
They agreed that no further work-up or intervention was
necessary.
The following changes were made to your medication list:
1. DECREASE hydroxyzine to once daily dosing
2. START fexofenadine 60 mg twice daily for pruritis
3. START sarna lotion as needed for pruritis
Followup Instructions:
___
|
10860878-DS-16
| 10,860,878 | 26,304,326 |
DS
| 16 |
2170-11-25 00:00:00
|
2170-11-26 12:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
ACE Inhibitors
Attending: ___
Chief Complaint:
Tubo-ovarian abscess
Major Surgical or Invasive Procedure:
CT-guided drainage of intra-abdominal abscess
History of Present Illness:
___ G0 with several months of abdominal discomfort and fullness
which has worsened over the past ___. She was seen by her
primary care doctor twice in the past week and also by gyn and
underwent a CT scan at ___ that revealed a large
cystic mass in the pelvis that appears to be related to the
uterus as well as lymphadenopathy. She reports night sweats and
chills at home as well as a temperature as high as 100.2, but
never a true fever. She has experienced decreased appetite but
no nausea or vomiting. Has been having constipation
intermittently and loose stool over the past week with last BM
today. No bloody stool. Denies vaginal sxs, bleeding, discharge.
Abdominal pain exacerbated with urination, but no dysuria. No
hematuria. No SOB, dizziness or chest pain. Controlling pain at
home with acetaminophen.
She was transferred to ___ for
further work-up.
Past Medical History:
Reports being told in the past that she had a cyst/fibroids that
potentially required surgery (?at ___. She had a Pap test
yesterday but has not had regular gyn care. No intercourse in ___
years. Menses are monthly. Denies hx STIs.
Ob/Gyn Hx: G0, last intercourse ___ ago. Underwent initial Pap
___ (result pending). Previous pelvic exam attempted
___ ago. No Hx STIs. Menarche ___. Monthly menses. No
intermenstrual bleeding.
PMedHx: Pulm HTN (since ___. Hx of rheumatic heart disease s/p
mitral valve replacement x 3 (most recently ___.
PSurgHx: Cardiac valve replacement x3 - mechanical valve on
coumadin.
Social History:
___
Family History:
FamHx: No hx of colon, breast or gyn cancer.
Physical Exam:
Initial Physical Exam:
O: T 99.5 HR 100 BP 110/70 RR 16 O2 96%RA
NAD, well-appearing
RRR
Abd distented/tympanic, diffusely tender to palpation, no
rebound or guarding
Ext without edema, no calf tenderness
SSE: white discharge in vault, narrow vaginal introitus, cervix
not well visualized
Bimanual exam: limited by pt discomfort, anterior compression of
vagina, no discrete mass appreciated but abdomen tensely
distended, no CMT, no cervical masses palpated on exam
On day of discharge:
Afebrile, vitals stable
No acute distress
CV: regular rate and rhythm
pulm: clear to auscultation bilaterally
abd: soft, nontender, nondistended, drain incisions
clean/dry/intact
___: nontender, nonedematous
Pertinent Results:
___ 09:00AM GLUCOSE-173* UREA N-6 CREAT-0.6 SODIUM-133
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-21* ANION GAP-13
___ 09:00AM estGFR-Using this
___ 09:00AM CALCIUM-8.3* PHOSPHATE-3.9 MAGNESIUM-1.6
___ 09:00AM ___ PTT-80.5* ___
___ 05:00AM WBC-17.6* RBC-3.37* HGB-7.3* HCT-24.7*
MCV-73* MCH-21.6* MCHC-29.6* RDW-17.9*
___ 05:00AM NEUTS-88.3* LYMPHS-6.4* MONOS-4.5 EOS-0.5
BASOS-0.2
___ 05:00AM PLT COUNT-404
___ 12:25AM LACTATE-1.5
___ 12:00AM URINE HOURS-RANDOM
___ 12:00AM URINE UCG-NEGATIVE
___ 12:00AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 12:00AM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-5
___ 11:50PM WBC-16.5* RBC-3.68* HGB-8.1* HCT-26.9*
MCV-73* MCH-22.2* MCHC-30.3* RDW-17.9*
___ 11:50PM NEUTS-87.8* LYMPHS-6.8* MONOS-4.4 EOS-0.7
BASOS-0.3
___ 11:50PM PLT COUNT-399
___ 11:50PM ___
Final Report
EXAMINATION: MR PELVIS WANDW/O CONTRAST
INDICATION: ___ year old woman with e-coli tubo-ovarian
abscesses s/p
CT-guided drainage with interval increased distention; drain
with less than 10cc output for the past 24 hs. Evaluate for
resolution of TOAs
TECHNIQUE: Multiplanar T1 and T2 weighted MR images of the
pelvis were
obtained prior to, during, and after the administration of 7 mL
Gadavist
gadolinium based contrast.
COMPARISON: MRI pelvis from ___. Pelvis ultrasound
from ___
FINDINGS:
The uterus is normal in size. Again seen are multiple fibroids,
the largest measuring 4.2 x 6.2 cm. The uterus measures 5.9 x
8.1 x 10.7 cm. The junctional zone is not well visualized. The
endometrial stripe is not well visualized as well, which may be
due to mass effect from the multiple fibroids. The cervix and
vaginal canal are also normal in appearance with several
subcentimeter nabothian cysts.
Several T1 bright masses are noted within the pelvis, largest
measuring 3.9 cm, compatible with known endometriomas. Again
seen are bilateral
multiloculated T2 bright fluid collections with enhancing
peripheries. The drained collections are markedly smaller than
prior examination. A left lower quadrant drain is seen in place
with no significant surrounding fluid collection. The right
lower quadrant drain sits in a small collection measuring 2.9
cm, previously measuring 5 cm and now contains some blood
product. There are several residual large pockets of fluid, the
largest measuring 3.7 x 4.1 cm (series 7, image 8) and in the
lower midline of the pelvis measuring 3.6 x 4.5 cm (series 7,
image 18), larger than on prior exam. There is a moderate amount
of free fluid in the pelvis. There is edema throughout the
pelvic soft tissues and to a lesser extent the subcutaneous soft
tissues of the pelvis.
Left hemorrhagic cyst, although normal ovarian parenchyma is not
well seen. Right ovary likely essentially replaced by
endometrioma. The urinary bladder is relatively decompressed.
The visualized bowel loops are within normal limits. There are
prior bilateral inguinal lymph nodes, likely reactive. The
osseous structures are unremarkable. The sigmoid colon remains
thickened and collapsed.
No evidence of vascular thrombosis.
Incompletely visualized kidneys, but both ureters appear dilated
to the pelvic brim, unchanged.
IMPRESSION:
1. Marked interval improvement of bilateral drained
tubo-ovarian abscesses. Drainage catheters are in appropriate
position with no significant residual fluid collection seen
surrounding the left catheter and small collection about the
right.
2. Multiloculated fluid collections in the left pelvis, mostly
anteriorly, measuring up to 4.5 cm in greatest dimension, have
enlarged from prior MRI. This is compatible with residual
tubo-ovarian abscess, the largest of which are likely ammenable
to drainage if clinically indicated.
3. Decreased size of right drained collection with residual
collection
remaining with tube in appropriate place. Recommend more
aggressive flushing of this tube to ensure continued appropriate
drainage.
4. Moderate free fluid in the pelvis with marked edema
throughout the pelvis. The colon remains decompressed running
through this region, but not hyperenhancing. Not definite
evidence of active primary infectious colonic disease at this
time.
Findings discussed with Dr. ___ at 9am and again at 9:40am on
___.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
___ ___ 12:54 AM
Final Report
EXAMINATION: MRI OF THE PELVIS.
INDICATION: ___ year old woman with hx significant for CHF,
aflutter,
mechanical heart valve with complex pelvic mass of unclear
etiology on
ultrasound // pls further characterize complex pelvic mass
TECHNIQUE: T1 and T2 weighted multiplanar images of the pelvis
were acquired within a 1.5 Tesla magnet, including 3D dynamic
sequences performed prior to,during, and following the
administration of 7.5 cc of Gadavist intravenous contrast.
COMPARISON: Reference CT from ___.
FINDINGS:
MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST:
The uterus measures 12.1 x 9.1 x 7.2 cm, within normal limits
(series 6, image16, series 3, image 12). Multiple intramural
fibroids are present, denoted by low signal intensity on T2
weighted sequences, with moderate post-contrast enhancement, the
largest arising from the left uterine fundus measuring 5.3 x 4.0
cm (series 6, image 17). A right anterior fibroid measuring 1.9
by 1.7 cm demonstrates a central area of high signal intensity
on T2 weighted sequences, possibly representing mild
degeneration (series 6, image 18). Arising from the uterine
fundus is a well-circumscribed 11 mm submucosal fibroid (series
6, image 16). The endometrium appears normal, distorted
rightward by the dominant fibroid.
A tiny nabothian cyst is present (series 6, image 28). The
cervix and vagina are otherwise normal.
A moderate amount of intraperitoneal free fluid is present
(series 4, image 21). Arising within the cul-de-sac is a 4.1 x
2.3 cm lesion demonstrating high signal intensity on T1 weighted
precontrast images (series 8, image 60), no appreciable internal
contrast enhancement, with areas of low signal intensity on T2
weighted sequences, with a markedly T2-hypointense rim (series
4, image 18), most compatible with endometriosis. Adjacent
posteriorly is a 3.5 x 3.2 cm cystic lesion with predominantly
high internal signal intensity on T2 weighted sequences, with
varying low signal intensity likely reflecting debris or small
amount of hemorrhage (series 4, image 17). Along the right
posterior uterus is an area of spiculated low signal intensity
on T2 weighted sequences, with mild tethering against the rectum
(series 4, image 22), likely reflecting chronic endometriosis.
Arising from the right adnexa is a well-circumscribed 2.5 x 1.5
cm lesion demonstrating a rim of high signal intensity on T1
weighted precontrast images (series 8, image 62, series 4, image
19), likely a hemorrhagic cyst. The remainder of the right
ovary is difficult to visualize. The left ovary appears
displaced anteriorly and leftwards (series 4, image 16),
demonstrating multiple enlarged follicles.
Abutting the uterus superiorly is a 11.7 x 7.0 cm tubular
structure with
mucosal folds, likely a dilated fallopian tube arising from the
right (series 6, image 9, series 4, image 15), demonstrating
irregular wall thickening and avid contrast enhancement (series
1101, image 52, 40). Adjacent cystic lesions demonstrating
predominantly high signal intensity on T2 weighted sequences
also demonstrate irregular thickened walls with avid
hyperenhancement, the largest collection measuring 5.9 x 3.6 cm,
arising from the right lower quadrant (series 1101, image 34),
difficult to distinguish from the ovaries. There is extensive
adjacent fat stranding which extends superiorly (series 1101,
image 20). Multiple enlarged para-aortic and paracaval lymph
nodes measure up to 1.6 x 1.4 cm (series 1101, image 16).
The bladder appears normal. There are no bony lesions concerning
for
malignancy or infection. Moderate subcutaneous edema is denoted
by increased signal intensity on T2 weighted sequences.
IMPRESSION:
1. Multicystic pelvic lesion with a dilated right fallopian
tube,
demonstrating MR signal characteristics and enhancement pattern
most
compatible with a tubo-ovarian abscess. Extensive adjacent fat
stranding and enlarged para-aortic and paracaval lymph nodes,
likely reactive. Given the relatively benign clinical course of
this patient per OMR, atypical infections should also be
considered. The largest collection within the right lower
quadrant may be amenable to percutaneous aspiration.
2. Cul-de-sac endometriosis with a moderate amount of
intraperitoneal fluid. Likely right adnexal hemorrhagic cyst.
3. Fibroid uterus, including an 11 mm fundal submucosal
leiomyoma.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
___: WED ___ 5:41 ___
Imaging Lab
Final Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: ___ year old woman with tubo-ovarian abscesses s/p
CT-guided
drainage with new abdominal distention // ___ persisting? new
collection?
previous collections after drain placement?
TECHNIQUE: Grayscale ultrasound images of the pelvis were
obtained utilizing a transabdominal approach .
COMPARISON: CT ___ and MR ___.
FINDINGS:
Bilateral adnexal drains are noted. The left catheter is
positioned within a phlegmonous mass in the midline/left adnexal
region. This measures approximately 6.4 x 4.0 cm, with a minor
thinly septated fluid component seen anteriorly measuring 2.7 x
4.8 cm.
There is internal flow on color Doppler imaging. The right
adnexal drain is also seen within a region of phlegmon.
The major fluid components seen on prior imaging have been
drained. Fibroid uterus is demonstrated with dystrophic
calcification.
IMPRESSION:
1. Bilateral pelvic drains surrounded by solid-appearing
phlegmonous material. The major fluid components have been
drained bilaterally.
2. Fibroid uterus as seen on the prior imaging.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
___: FRI ___ 9:40 ___
Brief Hospital Course:
Ms. ___ was admitted to the gynecology oncology service after
presenting to the ED for abdominal pain and having an pelvic US
which showed a multilocular cystic mass with septations. She was
started on Zosyn for possible abscess. On admission, her INR was
supratherapeutic so her coumadin was held. Her pain was
controlled with percocet and IV dilaudid for breakthrough. Her
other home medications were continued.
On hospital day #2, Ms. ___ was seen by cardiology and
medicine for recommendations regarding her supratherapeutic INR.
Per their recommendations, Coumadin was held and INR trended
down without intervention.
On hospital day #3, Ms. ___ had a pelvic MRI. She was
continued on Zosyn, and her INR remained supratherapeutic.
On hospital day #4, the MRI results indicated that she had an
11cm dilated right fallopian tube with 6cm pelvic abscess and
endometrial implants in the cul-de-sac. Her antibiotics were
switched to oral levofloxacin and flagyl.
On hospital day #5, her INR was 2.3. She was started on heparin
bridging given anticipated procedural intervention, after we
confirmed that she has been able to tolerate heparin in the past
despite testing positive for HIT type 2. Ms. ___ underwent
CT-guided drainage of the pelvic abscess. 250cc of pus were
drained from the left and 15cc of pus were drained from the
right. 2 JP drains were placed. Please see the operative report
for full details. Following her procedure, Coumadin 3mg was
started per Pharmacy recommendations.
On hospital day #6, INR was 2.1. Ms. ___ was continued on her
Coumadin.
On hospital day #7, her INR was therapeutic at 2.8 so her
heparin was discontinued. The patient had abdominal distention
and KUB was consistent with ileus. She was made NPO/IVF for
bowel rest, and she was transitioned to IV cefipime and flagyl
per Infectious disease recommendations. She also had a TVUS
which showed interval decompression of bilateral abscesses where
the drains were.
On hospital day ___, the patient had bowel movements and was
passing flatus. Her diet was advanced to regular. Her coumadin
was held for 3 days while it was infratherapeutic. On Day 10, we
also obtained a MRI that showed multiloculated fluid collection
up to 4.5cm consistent with residual tubo-ovarian abscess. The
two drains were contained in phlegmons with the right side with
roughly 2.9cm residual pocket. Her left drain was removed. We
discussed with the patient that there is an abscess that is
amenable to drainage in her pelvis; however, given her
co-morbidities, it may be difficult to proceed with another
abscess drainage. The patient was thoroughly counselled and she
chose to pursue conservative management with IV antibiotics and
follow-up with MRI imaging in 2 weeks.
During her whole stay, the wound care team and nursing changed
her dressing as instructed by the wound care team. The final
infectious disease team recommend 14 days of IV ceftriaxone 2g
and po flagyl 500mg TID.
We continued to manage her INR with coumadin. ___ services were
obtained for the patient to manage her sternal wound care, IV
antibiotic administration and INR management. A midline was
placed on the day of discharge, and the patient received her
first dose of ceftriaxone without issues.
Ms. ___ was tolerating a regular diet, voiding spontaneously,
and ambulating independently. She was then discharged home in
stable condition with a MRI scheduled in 2 weeks, ID appointment
in 2 week and follow-up appointment with Dr. ___ in 3 weeks.
Medications on Admission:
Warfarin (3mg on T/Th/F, 5mg on ___
Metoprolol XL 25mg daily
Vitamin C/B
FeSO4
Lasix 80mg daily
spironolactone 25mg daily
Potassium/chloride.
Discharge Medications:
1. Furosemide 80 mg PO DAILY
2. Spironolactone 25 mg PO DAILY
3. Metoprolol Succinate XL 75 mg PO BID
4. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram 1 unit IV daily Disp #*13 Vial Refills:*0
5. Ferrous GLUCONATE 324 mg PO BID
RX *ferrous gluconate 236 mg (27 mg iron) 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
6. MetRONIDAZOLE (FLagyl) 500 mg PO TID
do not take with alcohol
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8
hrs Disp #*42 Tablet Refills:*0
7. Warfarin 1.5 mg PO DAILY16
please take daily and work with ___ to manage your coumadin
level
RX *warfarin 1 mg ___ tablet(s) by mouth every day Disp #*45
Tablet Refills:*0
8. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
don't combine with alcohol or driving. no more than 4g in 24 hrs
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every ___ hrs Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
tubo-ovarian abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the gynecologic oncology service after
undergoing the procedures listed below. You have recovered well
after your operation, and the team feels that you are safe to be
discharged home. Home health will come to your house to help you
with daily IV antibiotic administration, coumadin management as
well as your sternal wound infection. Please follow-up with your
primary care doctor as you had anemia and elevated blood sugars
during our hospital stay. Please follow-up with your PCP for ___
colonoscopy since there were some inflammatory changes in your
abdomen. Please call us with any fevers, increased pain or
anything that concerns you at ___ or go to the nearest
Emergency Room. Please follow these instructions:
.
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* No heavy lifting of objects >10lbs for 4 weeks.
* You may eat a regular diet.
* It is safe to walk up stairs.
.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
* You should remove your drain site dressings ___ days after
your surgery. If you have steri-strips, leave them on. If they
are still on after ___ days from your procedure, you may remove
them.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
.
Call your doctor at ___ for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
* chest pain or difficulty breathing
* onset of any concerning symptoms
Followup Instructions:
___
|
10860892-DS-7
| 10,860,892 | 22,181,260 |
DS
| 7 |
2139-12-04 00:00:00
|
2139-12-05 21:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with minimal contact with medical system who
presents as transfer from ___ for bilateral pulmonary
emboli.
Patient reports that he has been experiencing progressive
dyspnea on exertion for 4 days. He denies CP, hemoptysis,
history DVT/PE, hx malignancy, or recent immobilization. Has
chronic cough from smoking but this has not changes recently.
No family history of PE. Pt has not seen doctor in many years.
He does not that he has experienced some increased ankle
swelling over past week as well.
At ___, BNP was noted to be 716, for which he received IV
Lasix. CTA was then obtained, which showed bilateral PE, with
right heart strain noted per referral note. Patient was started
on heparin gtt and transferred for further evaluation/care.
VS prior to transfer: BP 155/89, HR 86, SpO2 98% on 2L
In the ED, initial VS were: T 99.1 HR 85 BP 148/88 RR 18 SpO2
94%2L NC
Exam notable for:
Head: Normocephalic and atraumatic
Eyes: PERRL, EOMI
Lungs: CTAB
Cardiac: RRR, no murmur
Abdomen: Soft, nontender, nondistended
Extremities: 1+ ankle edema b/l
Neurologic: Awake, alert, moves all extremities. Speech fluent.
Dermatologic: Skin is warm and dry
ECG: T wave inversions V3, V4
Labs showed:
- WBC 13.7
- Hg 12.8
- Cr 0.8
- Trop < 0.01
- INR 1.1, PTT 35
Imaging showed:
POC ECHO: no evidence RH strain.
Consults: none
Patient received:
- IV heparin gtt
Transfer VS were: T 98.5 HR 87 BP 122/81 RR 14 SpO2 95% 3L NC
On arrival to the floor, patient reports that he feels well,
denies dyspnea at rest, denies chest pain, denies palpitations.
Past Medical History:
Opioid use disorder
Tobacco use disorder
Social History:
___
Family History:
No history PE, clotting disorders, or malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS: T 98.0 BP 146 / 100 HR 82 RR 22 SpO2 89% Ra (91% on 2L)
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, obese, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing. 1+ pitting edema to the
mid-shins bilaterally
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
======================
Vitals: Temp: 98.0 PO BP: 145/95 HR: 66 RR: 18 O2 sat: 92% O2
delivery: Ra FSBG: 186
GENERAL: Obese male in NAD. Sitting comfortably in bed.
HEENT: AT/NC, anicteric sclera, MMM.
CV: RRR with normal S1 and S2. No murmur or gallops.
PULM: Normal respiratory effort. CTAB without wheezes, rales or
rhonchi.
GI: Soft, NT/ND. No guarding or masses.
EXTREMITIES: Warm, well perfused. No ___ edema or erythema.
DERM: Warm, well perfused. No rashes.
Pertinent Results:
ADMISSION LABS:
==============
___ 07:30PM BLOOD WBC-13.7* RBC-4.35* Hgb-12.8* Hct-38.2*
MCV-88 MCH-29.4 MCHC-33.5 RDW-14.2 RDWSD-43.6 Plt ___
___ 07:30PM BLOOD Neuts-56.6 ___ Monos-6.1 Eos-2.6
Baso-0.4 Im ___ AbsNeut-7.68* AbsLymp-4.61* AbsMono-0.83*
AbsEos-0.36 AbsBaso-0.06
___ 07:30PM BLOOD Glucose-214* UreaN-11 Creat-0.8 Na-140
K-4.7 Cl-99 HCO3-26 AnGap-15
___ 07:30PM BLOOD Calcium-9.1 Phos-3.1 Mg-1.7
PERTINENT LABS:
==============
___ 07:30PM BLOOD cTropnT-<0.01
___ 09:30AM BLOOD %HbA1c-10.9* eAG-266*
___ 04:25AM BLOOD Triglyc-264* HDL-27* CHOL/HD-5.0
LDLcalc-56
DISCHARGE LABS:
==============
___ 04:11AM BLOOD WBC-10.0 RBC-3.89* Hgb-11.6* Hct-36.3*
MCV-93 MCH-29.8 MCHC-32.0 RDW-14.5 RDWSD-48.5* Plt ___
___ 04:11AM BLOOD Glucose-116* UreaN-12 Creat-0.8 Na-142
K-4.3 Cl-100 HCO3-30 AnGap-12
PERTINENT IMAGING:
================
___ CXR:
Resolution of previously seen pulmonary edema. No
consolidation.
___ BLE Ultrasound:
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
___ TTE:
The left atrium is mildly dilated. There is normal left
ventricular wall thickness with a normal cavity size. There is
suboptimal image quality to assess regional left ventricular
function. Overall left ventricular systolic function is normal.
The visually estimated left ventricular ejection fraction is
60%. There is no resting left ventricular outflow tract
gradient. Dilated right ventricular cavity with SEVERE global
free wall hypokinesis. The aortic sinus is mildly dilated with
mildly dilated ascending aorta. The aortic arch diameter is
normal with a mildly dilated descending aorta. The aortic valve
leaflets (3) appear structurally normal. There is no aortic
valve stenosis. There is no aortic regurgitation. The mitral
valve leaflets appear structurally normal with no mitral valve
prolapse. There is trivial mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is moderate
[2+] tricuspid regurgitation. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Brief Hospital Course:
Mr. ___ is a ___ y/o male with minimal medical care who
presented as a transfer from ___ for bilateral
pulmonary emboli, treated with anticoagulation. He was also
diagnosed with diabetes mellitus and treated per ___
recommendations. He remained HD stable and was discharged home
with plan to establish care with a PCP.
ACUTE ISSUES:
===============
#Submassive PE
Presented with five days of increasing dyspnea on exertion,
found to have new hypoxia. CTA at ___ showed
bilateral pulmonary emboli. BNP elevated to ~700, troponin
negative. He was started on a heparin drip and transferred to
___ for further management. Further work up included negative
LENIs. Additionally, TTE showed severe RV global free wall
hypokinesis with dilated ventricle. Overall picture was
consistent with a submissive pulmonary embolism. ___ was
consulted and recommended continuing conservative measures with
anticoagulation and supportive treatments. Etiology of the clot
remained unknown without obvious triggers. He will need
outpatient cancer screening and hematology evaluation.
#Acute hypoxic respiratory failure
Found to have a new 3L O2 requirement, felt to be ___ the
pulmonary embolism. CXR was without pulmonary edema or
infection. His oxygenation improved with time though he did
require O2 at discharge based on desaturation to 85% with
ambulation and nocturnal desaturations.
#Diabetes mellitus
Admission labs notable for hyperglycemia, prompting a Hgb A1c
that was elevated to 10.9. ___ was consulted and he was
initially started on basal/bolus insulin. His BG improved and he
was transitioned to glipizide 5 mg BID and metformin 500mg
daily, with plan to continue this regimen without insulin as an
outpatient. He will need PCP follow up for further management
and will call ___ to follow with them as well. He was
given a glucometer on discharge with instructions to check BG
twice daily.
#Normocytic anemia
Hgb 12.8 on admission. Unknown baseline. He had no signs of
bleeding and stool guaiac was negative. Etiology possibly ___
consumption in the setting of his PE. Blood counts remained
stable.
CHRONIC:
=========
#Tobacco use disorder
Reported smoking ~1ppd for the last ___ years. He was interested
in nicotine supplementation while inpatient, treated with the
nicotine patch and oral lozenges. He would benefit from ongoing
counseling as an outpatient.
#Hx opioid use disorder
Had been stable on methadone 82 mg daily, dose confirmed with
___. He was continued on his home
methadone without issues.
#Obesity
#Concern for OSA
Exam notable for morbid obesity and symptoms of paroxysmal
nocturnal dyspnea concerning for a component of OSA. He should
have an outpatient sleep study done.
TRANSITIONAL ISSUES:
==================
[ ] Needs outpatient cancer screening, including colonoscopy
[ ] Repeat CBC at follow up appointment to rule out worsening
anemia
[ ] Consider referral to hematology for further work up
[ ] Follow up with cardiology with plan for repeat TTE in 6
weeks given new RV dysfunction
[ ] Diagnosed with diabetes mellitus. Needs further management
with possible referral to endocrinology at ___ (patient was
interested in following at ___. he was discharged with
metformin with plan for uptitration from 500mg daily to 1000mg
BID over 2 weeks.
[ ] Needs outpatient sleep study to evaluate for OSA as patient
had nocturnal desaturations
[ ] Reevaluate patient in clinic setting for O2 needs as expect
him to return to room air as PE resolves.
[ ] Continue ongoing discussions regarding smoking cessation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Methadone 82 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. FreeStyle Lancets (lancets) 28 gauge miscellaneous BID
RX *lancets [FreeStyle Lancets] 28 gauge use lancet to check
blood sugar BID as directed Disp #*60 Each Refills:*0
3. FreeStyle Lite Meter (blood-glucose meter) 1 meter
miscellaneous ONCE
RX *blood-glucose meter [FreeStyle Lite Meter] use to check
___ sugar PRN Disp #*1 Kit Refills:*0
4. FreeStyle Lite Strips (blood sugar diagnostic) 1 strip
miscellaneous BID
RX *blood sugar diagnostic [FreeStyle Lite Strips] use to
check blood sugar BID as directed Disp #*60 Strip Refills:*0
5. GlipiZIDE 5 mg PO BID
RX *glipizide 5 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. MetFORMIN (Glucophage) 500 mg PO DAILY
RX *metformin 500 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
7. Methadone 82 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Primary
Submassive pulmonary embolism
#Secondary
Acute hypoxic respiratory failure
Diabetes mellitus, new diagnosis
Normocytic anemia
Tobacco use disorder
Opioid use disorder
Obesity
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 you were admitted to the hospital:
- You were having shortness of breath, particularly with walking
What happened while you were here:
- You were diagnosed with a blood clot in your lungs
- Imaging showed that the right side of your heart was having a
hard time pumping against the blockage
- You were diagnosed with diabetes mellitus and started on
several new medications
What you should do once you return home:
- IT IS VERY IMPORTANT THAT YOU TAKE YOUR APIXABAN AS PRESCRIBED
WITHOUT MISSING ANY DOSES!
- Continue taking your medications as prescribed
- Please follow up at the appointments outlined below. It will
be very important for you to continue receiving regular health
care moving forward
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10860986-DS-15
| 10,860,986 | 29,144,583 |
DS
| 15 |
2116-12-14 00:00:00
|
2116-12-16 15:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Erythromycin Base / Gentamicin / Streptomycin
Attending: ___.
Chief Complaint:
Dysarthria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with remote history of clival
chondroma, status post craniotomy with resection in ___. She
has had multiple long term complications including seizure
disorder, chronic vertigo and tinnitus leading to R temporal
lobectomy for control of seizures. She has also had CSF leak
requiring VP shunt, see full neuro details below.
She was last seen by Dr. ___ ___ at which time she
reported ongoing facial spasms. She had previously tried
multiple antiepiletics as summarized in his note, many stopped
due to side effects. Currently, she is on single-agent
oxcarbezepine. Last month she had an episode of choking due to
facial spasm that ocurred while eating forced her to swallow
suddenly, required Heimlich by bystander in the restaurant. She
tries to use the left side of mouth to avoid this but cannot
always control. She denies any dysphagia, able to swallow pills
and solids without difficulty. She states that over the past 3
days R facial spasms are increasing in frequency. Yesterday,
they were nearly constant, today they have subsided a bit.
Yesterday her mother reported she had slurred speech and she
states that
she was very fatigued. She also has some imbalance with
walking, she is not sure if it is worse than baseline. Denies
HA, neck pain, new numbness, has chronic numbness over R side of
face thus spasms are not painful. No other areas of spasm, does
not lose consciousness when they occur. She called in to report
symptoms and was referred for admission by Dr ___ MRI and
EEG.
She states that she was recenty treated for C. difficile; Flagyl
ended about one week ago, stool snow formed and regular.
Past Medical History:
Her oncological problem began in ___ with right frontal
headaches and double vision. A head CT showed a mass in the
clivus. It was resected by Dr. ___ in ___ at ___, followed by proton beam irradiation to the
resection site in ___ at ___ to ___
cGy. In ___ she developed strabismus in the right eye. She
developed defness and chronic otitis, which was thought to be a
complication of her prior radiation therapy, requiring a
tympanoplasty in ___. She later developed seizures in ___ and
she later underwent a temporal lobectomy, which controlled her
seizures. In ___, developed facial spasms on the
right side of her face. She attributed to the episodes of
crying from losing her husband. These facial spasms initially
will last about 5 minutes. Since then the spasms have increased
in frequency and are now triggered by stress, facial touch, and
lasting about ___ seconds. She denies any pain, tongue biting
or incontinence. She has sensation loss on the right side of
her face.
Timeline of Neuro problems:
(1) ___ Developed right frontal headaches and double vision,
(2) ___ Diagnosed with clivus chordoma,
(3) ___ She underwent a craniotomy and partial removal of
chordoma by Dr ___ in ___,
(4) ___ She received proton beam radiation therapy at ___ (___
cGy),
(5) ___ She developed strabismus in her right eye which was
attributed to a abducens nerve palsy,
(6) ___ She underwent a tympanoplasty and she developed
consistent lightheartedness and complete deafness in her right
ear,
(7) ___ She developed a seizure disorder and failed to respond
to anticonvulsants and was referred to Dr ___ at the
___,
(8) ___ She had a right temporal lobectomy and later she had no
futher seizures,
(9) ___ Right facial spasms started,
(10) repair of CSF leak on ___ by Drs. ___ and
___ at the ___ Ear ___,
(11) lumbar puncture on ___ that showed 3 WBC, 38 protein,
64 glucose, and negative infection work up,
(12) recurrence with increased frequency and severity of
right-sided hemifacial spasms in ___,
(13) removal on ___ at ___ of
ventriculoperitoneal shunt due to meningitis,
(14) neuropsychological evaluation by Dr. ___ on
___, and
(15) repair of CSF leak with programmable ventriculoperitoneal
shunt by Drs. ___ and ___ on ___ at the
___.
Other Past Medical History:
- History of hypertension
- Allergies/Chronic rhinitis
- History of HSV
Social History:
___
Family History:
No known history of cancer.
Physical Exam:
EXAMINATION ON ADMISSION:
===========================
___: NAD
VITAL SIGNS: afeb, VSS, on RA
HEENT: MMM, no OP lesions, frequent intermittent spams of
entire right side of face
Neck: supple, no JVD
Lymph: no cervical, supraclavicular, axillary or inguinal
adenopathy
CARDIOVASCULAR: RR, NL S1S2 no S3S4 or MRG
PULMONARY: CTAB
ABDOMEN: BS+, soft, NTND, no masses or hepatosplenomegaly
EXTREMITIES: warm well perfused, no edema
SKIN: no rashes or skin breakdown
NEUROLOGICAL EXAMINATION: She is alert and oriented to person
place and date. Language fluent and appropriate with slight
dysarthria during facial spasms ___, has known R ___ nerve
palsy with lack of full rigth lateral gaze peripheral vision
intact bilateral when spasms subside has mild right facial droop
no sensation over the right cheek or forehead
She has right tongue deviation. Motor strength is ___ at all 4
extremities. Sensation is intact to light touch in all
extremities. There is no dysmetria with FTN or HTS testing, did
not assess gait. She has no clonus, babinski down going.
EXAMINATION ON DISCHARGE:
===========================
VITAL SIGNS: Temperature 98.4 F, blood pressure 118/83, pulse
89, respiration 18 and oxygen saturation 97% in room air
___: NAD, very pleasant woman
HEENT: moist mucous membranes, OP claer, sustained contractions
of R face every ___ minutes (did not impair ability speak)
CARDIOVASCULAR: RRR, normal S1/S2, no m/r/g
PULMONARY: CTAB
ABDOMEN: BS+, soft, nontender, nondistended
EXTREMITIES: warm well perfused, no edema
SKIN: No rashes or skin breakdown
NEUROLOGICAL EXAMINATION: She is alert and oriented x 3,
language fluent and appropriate, ___, lack of sensation on
right side of face, inability to move right eye laterally
(otherwise other EOMI), right-sided facial droop (both in smile
and eyelids), loss of hearing on right side, uvula midline,
tongue deviates to right; strength ___ symmetric in all 4
extremities, sensation intact bilaterally, no dysarthri.
Pertinent Results:
PERTINENT RESULTS ON ADMISSION:
==================================
___ 01:30PM BLOOD WBC-6.5 RBC-4.23 Hgb-12.5 Hct-39.8 MCV-94
MCH-29.4 MCHC-31.3 RDW-13.9 Plt ___
___ 01:30PM BLOOD Neuts-66.8 ___ Monos-3.8 Eos-1.7
Baso-0.7
___ 01:30PM BLOOD Glucose-76 UreaN-17 Creat-0.7 Na-136
K-6.0* Cl-98 HCO3-26 AnGap-18
___ 01:30PM BLOOD Calcium-9.2 Phos-4.5 Mg-2.1
___ 01:50PM BLOOD Lactate-1.4 K-4.4
PERTINENT RESULTS ON DISCHARGE:
==================================
___ 06:41AM BLOOD WBC-6.0 RBC-4.20 Hgb-12.5 Hct-39.0 MCV-93
MCH-29.7 MCHC-32.0 RDW-13.9 Plt ___
___ 06:41AM BLOOD Glucose-95 UreaN-17 Creat-0.7 Na-141
K-4.3 Cl-103 HCO3-28 AnGap-14
___ 06:41AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.0
MICROBIOLOGY:
==================================
___ blood culture (ED) pending
IMAGING:
==================================
___ shunt series:
Intact VP shunt catheter without evidence of kinking.
___ CT head w/o contrast:
1. Right posterior approach VP shunt terminates in the frontal
horn of the right lateral ventricle. No evidence of
hydrocephalus.
2. No intracranial hemorrhage.
3. No evidence of large vascular territory infarction.
4. Stable postsurgical and postradiation changes dating back to
___.
___ EEG:
This is an abnormal routine EEG, mostly in the drowsy state, due
to the presence of intermittent focal slowing in the right
hemisphere maximal in the right temporal region and, at times,
bursts of generalized slowing.
These findings are indicative of focal subcortical dysfunction
in the right hemisphere and deep midline brain dysfunction.
Activity over the right temporal region was consistent with a
breach rhythm, as might be seen in the setting of a skull
defect. The disorganized mixed frequency background was
indicative of a mild diffuse encephalopathy which implies
widespread cerebral dysfunction but is non-specific as to
etiology. No epileptiform features were seen at any time.
___ MR HEAD/MRA/MR PITUITARY:
1. Acute infarct of the right upper pons.
2. Absence of flow signal within the right intracranial
internal carotid artery with reconstitution in the supraclinoid
region, otherwise: No major vessel occlusion or hemodynamically
significant stenosis on MRA of the head.
3. Inhomogeneous signal and enhancement of the clivus
consistent with history of chordoma with new sphenoid paranasal
sinus disease.
4. Ventricular shunt catheter in place. Decompressed
ventricles.
Brief Hospital Course:
___ is a ___ woman with history of clival
chordoma treated in ___, previous seizure history, and now
difficult to control hemifacial spasm who presents with ___ days
of worsened facial spasms, imbalance, and fatigue.
1. Pontine Stroke: Acute infarct noted on MRI to be on right
upper pons, manifested as worsened imbalance, fatigue,
dysarthria in days prior to presentation. MRI/MRA also revealed
no intracranial flow in intracranial ICA. EEG revealed no
epileptiform features at any time. The patient's symptoms,
specifically dysarthria, were improved day after admission, and
she was started on baby aspirin for secondary stroke
prophylaxis. She may be transitioned to Aggrenox in the
outpatient setting. It was confirmed with ___ Neurosurgery
(where the patient originally had her shunt placed on ___
that it did not need to be re-programmed after MRI. She will
follow-up with Dr. ___ in the near future. While
inpatient she was continued on her outpatient regimen of
Trileptal with no changes. Upon discharge, the patient is to
eat meals with a witness at home, in case of choking.
2. History of C. Difficile: She completed therapy with Flagyl,
and had no diarrhea while inpatient.
3. Chronic Rhinitis: She is on pseuodephedrine.
4. GERD: She is on omeprazole
5. Hypertension: She is on HCTZ 25mg daily.
TRANSITIONAL ISSUE:
=============================
- consider Aggrenox for secondary prevention of stroke
- f/u with Dr. ___ in the near future
- have a witness present while eating due to risk of choking
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO BID
2. Baclofen 20 mg PO BID
3. Omeprazole 20 mg PO BID
4. Oxcarbazepine 150 mg PO TID
5. Docusate Sodium 50 mg PO BID
6. Senna 8.6 mg PO BID
7. Senna 8.6 mg PO HS
8. Multivitamins 1 TAB PO DAILY
9. Polytrim (polymyxin B sulf-trimethoprim) 10,000 unit- 1 mg/mL
ophthalmic qhs
10. Pseudoephedrine 120 mg PO BID
11. Acetaminophen 500 mg PO Q6H:PRN mild pain ,fever
12. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, SOB
13. Cetirizine 10 mg oral daily
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN mild pain ,fever
2. Acyclovir 400 mg PO BID
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, SOB
4. Baclofen 20 mg PO BID
5. Docusate Sodium 50 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO BID
8. Oxcarbazepine 150 mg PO BID
9. Oxcarbazepine 300 mg PO QPM
10. Pseudoephedrine 120 mg PO BID
11. Senna 8.6 mg PO BID
12. Senna 8.6 mg PO HS
13. Aspirin 81 mg PO DAILY
14. Polytrim (polymyxin B sulf-trimethoprim) 10,000 unit- 1
mg/mL ophthalmic qhs
15. Cetirizine 10 mg oral daily
16. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID
17. Artificial Tears ___ DROP RIGHT EYE HS
Discharge Disposition:
Home
Discharge Diagnosis:
Stroke to right side of pons
Hemifacial spasm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure participating in your care while you were
inpatient at ___. You came in with worsened facial spasms,
fatigue, and intermittent difficulty with words. You were found
to have had a stroke in an area of your brain called the pons.
To prevent further strokes, you were re-started on aspirin. In
follow-up with Dr. ___ may start you on a medication called
aggrenox. After your admission, your symptoms improved somewhat
(specifically difficulty with words) and you were therefore
discharged.
As Dr. ___, because of your risk for choking, please
eat your meals with someone else.
We wish you the best!
Your ___ team
Followup Instructions:
___
|
10860986-DS-16
| 10,860,986 | 21,707,369 |
DS
| 16 |
2117-02-05 00:00:00
|
2117-02-06 03:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Erythromycin Base / Gentamicin / Streptomycin
Attending: ___
Chief Complaint:
Fatigue, Gait Instability
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ year-old right-handed woman with remote history
of
clival chondroma, status post craniotomy with resection in ___
c/b seizure s/p R temporal lobectomy for control of seizure
disorder, chronic vertigo and tinnitus, recent pontine stroke in
___ thought to be ___ a vasculopathy as a result of prior
proton beam therapy p/w gait instability since yesterday.
She is followed by Dr. ___ and ___ saw him in clinic a
few
days ago. She remained in her normal state of health until
yestersday when she started developing extreme fatigue and gait
instability. She states that this reminds her of the prodrome
of
the stroke in ___ which ultimately evolved to involve
dysarthria. For further details related to that admission,
please see d/c summary dated ___.
States that the gait instability "comes and goes". Thinks that
the longer she walks the more unsteady she becomes. Her
fatigue,
however, is "constant". When asked, thinks she may be falling
towards the right when she walks. Denies focal weakness,
numbness or other new neurologic deficits.
ED resident called Dr. ___ Dr. ___ an MRI to
r/o stroke. As per his clinic note a few days ago, if there is
recurrent stroke, would consider starting aggrenox.
ROS - positive for diarrhea x ___ yesterday. Denies headache, loss
of vision, blurred vision, dysarthria, dysphagia. She has
baseline right-sided hearing difficulty. Denies difficulties
producing or comprehending speech. Denies new focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention.
On ___ review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain
or
tightness, palpitations. Denies nausea, vomiting, constipation
or abdominal pain.
Past Medical History:
Her oncological problem began in ___ with right frontal
headaches and double vision. A head CT showed a mass in the
clivus. It was resected by Dr. ___ in ___ at ___, followed by proton beam irradiation to the
resection site in ___ at ___ to 6750
cGy. In ___ she developed strabismus in the right eye. She
developed defness and chronic otitis, which was thought to be a
complication of her prior radiation therapy, requiring a
tympanoplasty in ___. She later developed seizures in ___ and
she later underwent a temporal lobectomy, which controlled her
seizures. In ___, developed facial spasms on the
right side of her face. She attributed to the episodes of
crying from losing her husband. These facial spasms initially
will last about 5 minutes. Since then the spasms have increased
in frequency and are now triggered by stress, facial touch, and
lasting about ___ seconds. She denies any pain, tongue biting
or incontinence. She has sensation loss on the right side of
her face.
Timeline of Neuro problems:
(1) ___ Developed right frontal headaches and double vision,
(2) ___ Diagnosed with clivus chordoma,
(3) ___ She underwent a craniotomy and partial removal of
chordoma by Dr ___ in ___,
(4) ___ She received proton beam radiation therapy at ___ (___
cGy),
(5) ___ She developed strabismus in her right eye which was
attributed to a abducens nerve palsy,
(6) ___ She underwent a tympanoplasty and she developed
consistent lightheartedness and complete deafness in her right
ear,
(7) ___ She developed a seizure disorder and failed to respond
to anticonvulsants and was referred to Dr ___ at the
___,
(8) ___ She had a right temporal lobectomy and later she had no
futher seizures,
(9) ___ Right facial spasms started,
(10) repair of CSF leak on ___ by Drs. ___ and
___ at the ___,
(11) lumbar puncture on ___ that showed 3 WBC, 38 protein,
64 glucose, and negative infection work up,
(12) recurrence with increased frequency and severity of
right-sided hemifacial spasms in ___,
(13) removal on ___ at ___ of
ventriculoperitoneal shunt due to meningitis,
(14) neuropsychological evaluation by Dr. ___ on
___, and
(15) repair of CSF leak with programmable ventriculoperitoneal
shunt by Drs. ___ and ___ on ___ at the
___.
Other Past Medical History:
- History of hypertension
- Allergies/Chronic rhinitis
- History of HSV
Social History:
___
Family History:
No known history of cancer.
Physical Exam:
___: Awake, cooperative, NAD.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Speech
was not dysarthric. Able to follow both midline and appendicular
commands. The pt had good knowledge of current events. There was
no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: left pupil 2--> 1.5, right 1.5--> 1.25 (chronic). Left lens
is opacified. VFF to confrontation except for decreased
peripheral vision in the nasal half of the right eye. (chronic)
III, IV, VI: Right ___ nerve palsy (chronic)
V: Facial sensation decreased to light touch on the right.
(chronic)
VII: Right upper and lower face weakness with intermittent right
facial spasms. (chronic)
VIII: Hearing intact to finger-rub on the left but decreased on
the right. (chronic)
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes to the right. (chronic)
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, cold sensation, vibratory
sense, proprioception throughout.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Slightly wide-based, cautious gait and
leans towards either side. (she uses her hands to catch herself
when that happens and did not fall.) Interestingly, when she
stands, she is more wide base than when she walks. Unable to
walk in tandem. Romberg positive (chronic).
=================================================
Discharge Examination:
More stable gait, occational instability initially, but this
improved ___ of seconds after coming to a stand to approach
baseline gait stability per patient
Pertinent Results:
WBC 7.2, Hgb 12.7, Hct 38.2, Plt 252
Na 141, K 3.7, Cl 99, HCO3 31, BUN 17, Cr 0.7, Glc 80
Ca 9.2, Mg 1.9, Phos 4.5
HgbA1c 5.4% LDL 155
TSH 2.8
t-bili 0.3, AST 20, ALT 14, AlkPhos 98, CPK 253, Lipase 31
CK-MB 3, Trop <0.01
MRI Brain/MRA Neck (___) IMPRESSION:
1. No evidence of acute infarction or hemorrhage. The previously
demonstrated infarcted tissue within the right pons has evolved
and is not seen in this current study.
2. Absence of flow signal within the right internal carotid
artery just beyond the carotid bulb, with reconstitution of
signal in the supraclinoid region, unchanged from prior exam.
Otherwise, no other major vessel occlusion or stenosis.
3. Ventricular shunt catheter in appropriate position within the
right lateral ventricle. No hydrocephalus.
Brief Hospital Course:
Patient was admitted with complaint of fatigue and worsened
gait. MRI showed no acute stroke. HgbA1c was 5.4%, LDL was 155.
At patient's request she was discharged on an increased dose of
Aspirin (i.e. 81mg BID) after discussion that there are no data
indicating the ideal dose of Aspirin and that while this may
theoretically lower her risk of stroke, it will also increase
her risk of bleeding. No changes were made to her Atorvastatin
as she has recently begun this medication. She was also provided
with a prescription for outpatient Physical Therapy at
discharge.
Medications on Admission:
ACYCLOVIR - acyclovir 400 mg tablet. 1 tablet(s) by mouth twice
daily - (Prescribed by Other Provider)
ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation
aerosol inhaler. 2 puffs(s) oral morning and evening as needed -
(Prescribed by Other Provider)
BACLOFEN - baclofen 20 mg tablet. 1 tablet(s) by mouth twice a
day - (Prescribed by Other Provider)
CONJUGATED ESTROGENS [PREMARIN] - Premarin 0.625 mg/gram vaginal
cream. apply to vagina 3 times weekly - (Prescribed by Other
Provider)
FLUTICASONE - fluticasone 50 mcg/actuation nasal
spray,suspension. 1 sprays each nostril daily - (Prescribed by
Other Provider)
HYDROCHLOROTHIAZIDE - hydrochlorothiazide 12.5 mg tablet. 1
tablet(s) by mouth daily - (Prescribed by Other Provider)
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1
capsule(s) by mouth twice daily - (Prescribed by Other
Provider)
OXCARBAZEPINE - oxcarbazepine 150 mg tablet. 1 tablet(s) by
mouth
a.m., 1 tab p.m. and 2 tabs bedtime - (Prescribed by Other
Provider)
POLYMYXIN B SULF-TRIMETHOPRIM - polymyxin B sulfate 10,000
unit-trimethoprim 1 mg/mL eye drops. 1 drop(s) OD once daily -
(Prescribed by Other Provider)
PREDNISOLONE ACETATE [OMNIPRED] - Omnipred 1 % eye
drops,suspension. - (Prescribed by Other Provider)
Medications - OTC
ACETAMINOPHEN - acetaminophen 500 mg tablet. 2 tablet(s) by
mouth
2 to 3 times daily - (Prescribed by Other Provider)
ASCORBIC ACID - ascorbic acid ___ mg tablet. 1 tablet(s) by
mouth
twice daily - (Prescribed by Other Provider)
ASPIRIN [ADULT LOW DOSE ASPIRIN] - Adult Low Dose Aspirin 81 mg
tablet,delayed release. 1 tablet(s) by mouth daily -
(Prescribed
by Other Provider)
CALCIUM CARBONATE-VIT D3-MIN - calcium carb-vit D3-minerals 600
mg calcium-400 unit tablet. 1 tablet(s) by mouth twice daily -
(Prescribed by Other Provider)
CETIRIZINE - cetirizine 10 mg tablet. 1 Tablet(s) by mouth daily
- (Prescribed by Other Provider)
MULTIVITAMIN - multivitamin tablet. 1 Tablet(s) by mouth daily -
(Prescribed by Other Provider)
PSEUDOEPHEDRINE HCL - pseudoephedrine ER 120 mg tablet,extended
release. 1 Tablet(s) by mouth twice daily - (Prescribed by
Other
Provider)
SENNOSIDES-DOCUSATE SODIUM - sennosides-docusate sodium 8.6
mg-50
mg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other
Provider)
SODIUM CHLORIDE - sodium chloride 0.65 % nasal spray aerosol. 2
puffs(s) nasal both nostrils 2 to 3 times daily - (Prescribed
by
Other Provider)
VITAMIN E - vitamin E 400 unit capsule. 1 Capsule(s) by mouth
daily - (Prescribed by Other Provider)
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
3. Aspirin 81 mg PO BID
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*5
4. Baclofen 20 mg PO BID
5. Cetirizine 10 mg PO DAILY
6. Estrogens Conjugated 1 gm VG QMWF Duration: 3 Weeks
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Omeprazole 20 mg PO BID
9. Oxcarbazepine 150 mg PO BID
10. Oxcarbazepine 300 mg PO HS
11. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
12. polymyxin B sulf-trimethoprim 10,000 unit- 1 mg/mL
ophthalmic Bedtime
13. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QAM
14. Hydrochlorothiazide 12.5 mg PO DAILY
15. Ascorbic Acid ___ mg PO BID
16. calcium carbonate-vit D3-min 600 mg calcium- 400 unit oral
twice daily
17. Multivitamins 1 TAB PO DAILY
18. pseudoephedrine HCl 120 mg oral daily
Pseudoephedrine ER
19. Senna 8.6 mg PO BID:PRN constipation
20. Sodium Chloride Nasal 2 SPRY NU TID
21. Vitamin E 400 UNIT PO DAILY
22. Outpatient Physical Therapy
Physical Therapy
23. Atorvastatin - dose unknown
Discharge Disposition:
Home
Discharge Diagnosis:
Gait Instability
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid at
times
Discharge Instructions:
Dear ___,
___ were admitted for workup of symptoms fatigue and
unsteadiness concerning for a stroke. Our evaluation shows that
___ did not have a stroke. The cause of your complaints is not
clear at this time. However, we are reassured that ___ have
improved so rapidly. At your request ___ will be discharged on a
higher dose of Aspirin. As we discussed, there are no strong
data that clearly demonstrate the ideal dose of Apirin. While
this increase may decrease the risk of future stroke, it also
increases the likelihood of bleeding. Please continue outpatient
Physical Therapy as prescribed.
Changed Medications
Aspirin 81mg twice daiy
Followup Instructions:
___
|
10861047-DS-19
| 10,861,047 | 20,295,498 |
DS
| 19 |
2143-10-25 00:00:00
|
2143-10-25 08:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L knee pain
Major Surgical or Invasive Procedure:
L tibial plateau ORIF
History of Present Illness:
___ y/o M w/history left tibial plateau fracture presenting after
slipping on wet grass this morning. He reports feeling acute
pain in his left leg and noted swelling. He was unable to weight
bear. He presented to the ___ where plain films found a
left minimally displaced tib-fib fracture. He was transferred to
___ for orthopedics evaluation given his previous surgeries
were here.
Patient currently reports pain with movement and palpation but
otherwise denies parathesias, numbess, or weakness.
Past Medical History:
ORIF left bicondylar tibial plateau fracture (___) with
removal of hardware on ___
Right ___ hip arthroplasty ___
laminectomy of L4 and ___
Osteoarthritis
Chronic low back pain
Spinal stenosis
lumbar radiculopathy
Hypertension
borderline Diabetes
Crohn's disease s/p ileocolectomy in ___
Obesity
Social History:
___
Family History:
Non-contributory
Physical Exam:
Discharge Exam:
VS: 98.6 77 108/50 18 94%RA
Gen: NAD, AAOx3
Wound: dressing C/D/I, ___ brace
LLE: In locked ___, fires ___, SILT ___
Pertinent Results:
___ 05:46AM BLOOD WBC-7.2 RBC-3.59* Hgb-11.3* Hct-31.9*
MCV-89 MCH-31.4 MCHC-35.3* RDW-13.4 Plt ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left tibial plateau fracture as well as non-operative
left fibula fractures and was admitted to the orthopedic surgery
service. The patient was taken to the operating room on ___
for ORIF left tibial plateau fracture, which the patient
tolerated well (for full details please see the separately
dictated operative report). The patient was taken from the OR to
the PACU in stable condition and after recovery from anesthesia
was transferred to the floor. The patient was initially given
IV fluids and IV pain medications, and progressed to a regular
diet and oral medications by POD#1. The patient was given
perioperative antibiotics and anticoagulation per routine. The
patients home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home with ___ 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 touchdown weightbearing in a
locked ___ brace in the left lower extremity, and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up in two weeks per routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet extended release(s) by mouth
every 6 hours Disp #*60 Tablet Refills:*1
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*30 Capsule Refills:*2
3. Doxazosin 2 mg PO HS
4. Enoxaparin Sodium 40 mg SC DAILY Duration: 2 Weeks
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*14 Syringe
Refills:*0
5. Hydrocortisone Cream 1% 1 Appl TP DAILY:PRN itch Duration: 5
Days
RX *hydrocortisone [___] 1 % Apply to poison ___ rash once
daily. Do not apply to facial or genital areas. daily Disp #*1
Tube Refills:*0
6. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp
#*30 Tablet Refills:*2
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
L tibial plateau fracture
L proximal and distal fibula fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Touchdown weightbearing in ___ brace locked in extension
Physical Therapy:
Touchdown weightbearing in left lower extremity
Remain in ___ brace locked in extension
Treatments Frequency:
Dressing changes daily until dry, then may leave open to air
Remain in ___ brace locked in extension
Sutures/staples will be removed at follow-up appointment
Followup Instructions:
___
|
10861152-DS-7
| 10,861,152 | 24,828,260 |
DS
| 7 |
2133-10-27 00:00:00
|
2133-10-28 07:26:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Yeast
Attending: ___
Chief Complaint:
Groin pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo male with a h/o HIV who p/w scrotal pain x 2 days.
Pt reports waking with non-radiating scrotal pain two days
PTA, similar to prior epididymitis. Received azithromycin @
clinic in ___ without relief (prior epididymitis resolved with
abx). Reports some relief with advil and dose of vicodin. Denies
dysuria or hematuria. Pt reports no relief with ejaculation.
Reports unprotected oral sex ___ days ago with a mild episode of
meatal tenderness (prior meatus surgery/meatotomy). Pt also
reports prior prostatitis, reports that this does not feel like
those episodes.
Also of note, pt reports that he recently discontinued his
HIV meds per his PCP due to the development of a resistance.
He denies any fever, chills, chest pain, shortness of breath
or headache.
Initial vitals in the ED were 98.2 123 134/76 18 100%. Labs
were notabel for a WBC of 21.7.
On admission to the medicine floor his vitals were: 98.2 °F
(36.8 °C). Pulse 104. Respiratory Rate 16. Blood Pressure
122/76. O2 Saturation 100.
Pt reports that his most recent CD4 count three weeks ago was
in the 700's.
Currently on the floor he is in significant pain, but otherwise
without compliant.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
HIV
Meatal stenosis
Epididymitis/prostatitis
Social History:
___
Family History:
Mother and father are healthy.
Physical Exam:
Physical Exam on admission:
VS - Temp 98.8 F, BP 127/65, HR 104, R 18, O2-sat 98 % RA
GENERAL - uncomfortable but appropriate ansd able to conduct
interview
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
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 - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
GU: Diffusely swollen, erythematous scrotum with bilateral
tender testes and bilateral painful epididymus. No crepitus
appreciated.
DRE- nontender prostate
Physical Exam on discharge:
VS - Tmax 99.8 Tc 98.3; BP 109-123/69-81; 89-114; 18; 99% RA
GENERAL - NAD, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact
GU: Diffusely swollen, erythematous scrotum with bilateral
tenderness, warm to touch. No crepitus appreciated. No obvious
skin necrosis
Pertinent Results:
Labs on admission:
___ 02:45PM BLOOD WBC-21.7* RBC-4.45* Hgb-13.5* Hct-41.4
MCV-93 MCH-30.4 MCHC-32.7 RDW-12.8 Plt ___
___ 02:45PM BLOOD Neuts-81* Bands-1 Lymphs-13* Monos-3
Eos-1 Baso-0 ___ Metas-1* Myelos-0
___ 02:45PM BLOOD Glucose-104* UreaN-11 Creat-1.0 Na-135
K-4.1 Cl-98 HCO3-31 AnGap-10
___ 06:45AM BLOOD Calcium-9.4 Phos-3.7 Mg-1.8
Labs on discharge:
___ 07:30AM BLOOD WBC-7.1 RBC-4.17* Hgb-12.3* Hct-38.7*
MCV-93 MCH-29.5 MCHC-31.8 RDW-12.4 Plt ___
___ 07:30AM BLOOD Glucose-92 UreaN-7 Creat-0.8 Na-139 K-4.4
Cl-103 HCO3-27 AnGap-13
Microbiology:
___ 10:15 am URINE Source: ___.
**FINAL REPORT ___
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final
___: Negative for Chlamydia trachomatis by PCR.
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Final ___: Negative for Neisseria Gonorrhoeae by
PCR.
___ 10:15 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Blood cx ___ and ___: pending
Imaging:
Scrotal US ___:
IMPRESSION:
1. Bilateral epididymal enlargement and hyperemia is consistent
with
bilateral epididymitis. Hypoechoic complex fluid in the tail of
the left
epididymis may represent an early phlegmon. No drainable fluid
collection is present.
2. Bilateral hydroceles, complex on the left.
3. Normal testicles.
Brief Hospital Course:
___ yo male with pmh of HIV (off medications currently) who
presents with two days of scrotal pain and swelling, ultrasound
consistent with bilateral epididymitis, who was admitted for IV
antibiotics and serial scrotal exams.
Active Issues:
# Epididymtis: Based on clinical history of scrotal pain, exam
and ultrasound, the pt was diagnosed with epididymitis. Given
that he practices insertive anal intercourse, he was treated
initially with ceftrixone and levofloxacin to cover for enteric
organisms and neisseria. He was followed with serial scrotal
exams as ___ gangrene would be the most feared
complication. Per urology there was no role for surgical
intervention and scrotal exam remained benign. He was
transitioned to doxycylcine and levofloxacin on ___ in
anticipation for discharge. He remained afebrile with falling
WBC with an improvement in scrotal pain, edema and erythema. He
was d/c'd on ___ on a 10-day course of levo, doxycycline, with
ibuprofen and tramadol for pain control.
# Thrush: Pt was treated with Nystatin S&S x7 days for oral
thrush.
# HIV: Currently off HAART. Pt will follow up as an outpt for
consideration of re-starting HAART
Medications on Admission:
Vitamin D and herbal supplements prn
Discharge Medications:
1. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 10 days.
Disp:*20 Capsule(s)* Refills:*0*
2. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) for 7 days.
Disp:*42 Tablet(s)* Refills:*0*
3. Vitamin D3 Oral
4. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
5. tramadol 50 mg Tablet Sig: One (1) Tablet PO three times a
day for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
6. nystatin 100,000 unit/mL Suspension Sig: Five (5) ml PO four
times a day for 7 days.
Disp:*qs * Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Epididymitis
Secondary:
HIV infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization at ___. You
were admitted with swelling and pain in your testicles. We
diagnosed you with epididymitis and treated you with
antibiotics. The swelling, redness and pain in your testicles
slowly improved.
You are now safe for discharge home.
PLEASE NOTE THE FOLLOWING MEDICATIONS CHANGES:
STARTED DOXYXCYCLINE 100 MG TWICE A DAY FOR THE NEXT ___ DAYS
STARTED LEVOFLOXACIN 500 MG ONCE A DAY FOR THE NEXT ___ DAYS
STARTED IBUPROFEN 800 MG THREE TIMES A DAY TO DECREASE SWELLING
FOR THE NEXT WEEK
STARTED TRAMADOL 50 MG THREE TIMES A DAY FOR THE NEXT WEEK FOR
PAIN
STARTED NYSTATIN 5 ML FOUR TIMES A DAY FOR THE NEXT WEEK
Followup Instructions:
___
|
10861654-DS-4
| 10,861,654 | 29,045,680 |
DS
| 4 |
2123-02-20 00:00:00
|
2123-02-20 16:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute leukemia, leukostasis
Major Surgical or Invasive Procedure:
___ and ___ CVL placement
___, and ___ bone marrow biopsies
___ and ___ lymph node biopsies
___ bronchoscopy
History of Present Illness:
Mr. ___ is a ___ gentleman with PMH of HTN, with one week
progressive dyspnea and cough, started on CAP coverage, and then
found to have >200 WBCs with 40% blasts and 30% monos/"monos",
___, liver injury, troponin leak, who presented to ___,
found to have acute leukemia with concern for leukostasis and is
transfered to the ___ ICU for urgent pheresis.
His present illness started ___ when he had a sore throat and
was seen by PCP. He was prescribed 10 days of Augmentin for
pharyngitis. Then on ___ he was feeling worse, and PCP
prescribed inhaler and flu swab was negative for influenza. He
has also noted swollen lymph nodes in his neck. He was started
on prednisone 50mg from his PCP. He underwent outpatient chest
xray ___, which he reports showed pneumonia, and he was started
on doxycycline. He had one episode of vomiting overnight. ___
having considerable dyspnea with only a few steps, very unusual
for him.
At ___
- Initial Vitals: T 97.7 HR 83 BP 139/77 95% on RA
- Exam: notable for diminished lung sounds right base, all else
wnl
- Labs: WBC 199.4- 6% neuts ANC "not reportable", 2% bands, 14%
lymph, 37% monos, 41% blasts, Hgb 8.1, Hct 24.5, plt 118
Na 135, K 3.4, Cl 103, CO2 21, AG 11, BUN 38, Cr 1.35, Glu 148,
ca 8.6, phos 4.3, Mg 2.1. Uric Acid 14.8. Tbili 1.5, AST 125,
ALT
151, Alk Phos 304, tot prot 6.3, alb 3.0
Flu A and B negative
- Imaging: CXR with right perihilar infiltrate
- EKG read: Sinus rhythm with a rate of 82. Incomplete right
bundle branch block. No acute ischemic changes.
- Consults: ___ heme/onc consulted and recommended transfer
to
___
- Interventions: supportive IVF started, received rasburicase 6
mg 119 @ 1500, ceftriaxone, azithromycin
At ___ ED
- Initial Vitals: T 98.4, HR 110, BP 146/78 94% on 4L
- Exam: none recorded
- Labs: WBC 222, hgb 7.4, hct 22.1, plt 130. Na 141, K 2.9, Cl
104, CO2 21, BUN 35, Cr 1.2, glu 149, AG 16. Ca 8.6, Mg 2.0, P
4.5.
INR 1.7. fibrinogen 230. d-dimer ___. uric acid 10.2. ALT
142.
AST 132. AP 325. LDH 3222. Tbili 1.1. Peripheral smear with
numerous blasts, adherent in clumps.
- Imaging: CXR RIJ CV cath terminating in upper SVC. Patchy
perihilar and parenchymal opacities, which most likely represent
mild to moderate pulmonary edema. There is no focal
consolidation, pleural effusion or pneumothorax. The
cardiomediastinal silhouette is within
normal limits. No acute osseous abnormalities are identified
- EKG- no acute ischemic changes
- Consults: Dx and interventions per Heme/Onc. Ddx
AML>>ALL>APML>
myelodysplastic syndrome>CML or myeloproliferative neoplasm.
Some
evidence of DIC. Performed bmbx.
- Interventions- continued IVF, NS @ 150 ml/hr. Bone marrow bx
performed, looks likely AML. R IJ temp dialysis line placed.
Planning for pheresis. 3g hydroxyurea, 40 mEq KCl, 1 mg Ativan
On arrival to the ___, patient confirms the above history.
Several family members not limited to wife, son, daughter, and
son-in-law at bedside. He reports feeling well at the moment and
that he has had a nonproductive cough for several weeks. Felt
worse the past couple of days including nausea/vomiting
yesterday, accompanied by headache and intermittent abdominal
pain. Reports fevers to 100-101 at home. Seen by pheresis team
and initiated pheresis on arrival to ___.
Past Medical History:
Hypertension, Rotator cuff tear s/p arthroscopy ___,
bilateral Dupuytren's contractures, BPH
Social History:
___
Family History:
father died of blood cancer (uncertain which) at ___; mother
died of colon cancer at ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 98.3 HR 91 BP 132/66 RR 23 SpO2 95% 5L O2
GEN: awake alert pleasant gentleman upright in bed in no acute
distress on pheresis
EYES: no scleral icterus, PERRLA
HENNT: nc/at, L cervical lymphadnopathy, pharynx clear, mmm
CV: regular rate and rhythm, no murmurs/rubs/gallops
RESP: faint bibasilar inspiratory crackles otherwise ctab
GI: soft, nontender, nondistended, normoactive bowel sounds
MSK: no peripheral edema, warm, well perfused
SKIN: no rash
NEURO: grossly normal
PSYCH: AOx3
DISCHARGE PHYSICAL EXAM:
========================
GENERAL: Alert and interactive, standing up, in NAD
HEENT: Improving submandibular LAD on the L, resolved LAD on the
R; anicteric sclera, clear oropharynx without oral lesions, no
tonsillar erythema, MMM
CV: S1, S2, RRR, no m/r/g
PULM: Expiratory wheeze in RUL and upper airway wheeze,
otherwise clear, no increased WOB on room air
EXT: 3+ pitting edema of the ___ bilaterally
SKIN: Areas of non-bullous erythema on R toes and R forefoot,
non-TTP, non-pruritic, improved from prior
LINES: RUE PICC c/d/i without surrounding erythema/TTP
Pertinent Results:
ADMISSION LABS:
===============
___ 05:00PM BLOOD WBC-222.9* RBC-2.25* Hgb-7.4* Hct-22.1*
MCV-98 MCH-32.9* MCHC-33.5 RDW-16.1* RDWSD-57.5* Plt ___
___ 05:00PM BLOOD Neuts-2* Lymphs-3* Monos-0* Eos-0* Baso-0
Metas-4* Myelos-1* Blasts-90* Other-0 AbsNeut-4.46 AbsLymp-6.69*
AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 05:00PM BLOOD Schisto-1+* RBC Mor-SLIDE REVI
___ 05:00PM BLOOD ___ PTT-24.9* ___
___ 05:00PM BLOOD ___
___ 05:00PM BLOOD G6PD-NORMAL
___ 05:00PM BLOOD Ret Aut-0.2* Abs Ret-0.00*
___ 05:00PM BLOOD Glucose-149* UreaN-35* Creat-1.2 Na-141
K-2.9* Cl-104 HCO3-21* AnGap-16
___ 05:00PM BLOOD ALT-142* AST-132* LD(LDH)-3222*
AlkPhos-325* TotBili-1.1
___ 03:00AM BLOOD CK-MB-2 cTropnT-0.04*
___ 09:00AM BLOOD CK-MB-2 cTropnT-0.05*
___ 03:39PM BLOOD CK-MB-2 cTropnT-0.04*
___ 04:15AM BLOOD ___
___ 05:00PM BLOOD Albumin-3.5 Calcium-8.6 Phos-4.5 Mg-2.0
UricAcd-10.2*
___ 05:00PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 05:00PM BLOOD HCV Ab-NEG
___ 08:20PM BLOOD ___ pO2-32* pCO2-38 pH-7.38
calTCO2-23 Base XS--2
___ 05:08PM BLOOD Lactate-1.6
___ 05:08PM BLOOD freeCa-1.15
___ 05:00PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 05:00PM BLOOD HIV Ab-NEG
___ 05:00PM BLOOD HCV Ab-NEG
DISCHARGE LABS:
===============
___ 12:00AM BLOOD WBC-1.6* RBC-2.69* Hgb-7.9* Hct-24.5*
MCV-91 MCH-29.4 MCHC-32.2 RDW-15.8* RDWSD-51.5* Plt ___
___ 12:00AM BLOOD Neuts-80* Lymphs-10* Monos-1* Eos-0*
___ Metas-2* Myelos-7* AbsNeut-1.28* AbsLymp-0.16*
AbsMono-0.02* AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD Plt Smr-NORMAL Plt ___
___ 12:00AM BLOOD Glucose-105* UreaN-29* Creat-1.1 Na-142
K-4.8 Cl-102 HCO3-25 AnGap-15
___ 12:00AM BLOOD ALT-141* AST-46* LD(LDH)-329*
AlkPhos-190* TotBili-0.5
___ 12:00AM BLOOD Calcium-8.4 Phos-4.3 Mg-1.7
MICROBIOLOGY:
=============
___ respiratory viral PCR
Human coronavirus (NP swab) POSITIVE
Influenza A - H1N1-09 (NP swab) POSITIVE
___ 3:58 pm TISSUE Source: left lymph node,
superficial.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
__________________________________________________________
___ 12:00 am Blood (Toxo) Source: Line-picc.
**FINAL REPORT ___
TOXOPLASMA IgG ANTIBODY (Final ___:
NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA.
If acute infection is suspected request IgM antibody
testing and/or
submit convalescent serum in ___ weeks.
__________________________________________________________
___ 12:00 am Blood (EBV) Source: Line-picc.
**FINAL REPORT ___
___ VIRUS VCA-IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE BY EIA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop ___ weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
__________________________________________________________
___ 12:00 am SEROLOGY/BLOOD Source: Line-picc.
**FINAL REPORT ___
VARICELLA-ZOSTER IgG SEROLOGY (Final ___:
POSITIVE BY EIA.
A positive IgG result generally indicates past exposure
and/or
immunity.
__________________________________________________________
___ 12:00 am SEROLOGY/BLOOD Source: Line-picc.
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
__________________________________________________________
___ 12:00 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-picc.
BLOOD/FUNGAL CULTURE (Pending): No growth to date.
BLOOD/AFB CULTURE (Pending): No growth to date.
__________________________________________________________
___ 10:25 am ABSCESS NECK LYMPH NODE.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Reported to and read back by ___ (___) AT
11:29 AM
___.
BUDDING YEAST WITH PSEUDOHYPHAE.
___ 1:40 pm BRONCHOALVEOLAR LAVAGE
BRONCHIAL LAVAGE,RML BAL NEUTROPENIC,DAH.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
Immunofluorescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 1:40 pm BRONCHOALVEOLAR LAVAGE
BRONCHIAL LAVAGE,RML BAL NEUTROPENIC,DAH.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
___:
Negative for Cytomegalovirus early antigen by
immunofluorescence.
Refer to culture results for further information.
___ 01:40PM OTHER BODY FLUID ASPERGILLUS GALACTOMANNAN
ANTIGEN-5.65 H
PATHOLOGY:
==========
___ Bone marrow immunophenotyping
Immunophenotypic findings consistent with involvement by acute
myeloid leukemia with normal karyotype. Molecular studies are
pending and will be reported separate. Correlation with
clinical, morphologic (see separate pathology report ___-___)
and other ancillary findings is recommended. Flow cytometry
immunophenotyping may not detect all abnormal populations due to
topography, sampling or artifacts of sample preparation.
___ Lymph node biopsy (L cervical)
LYMPH NODE WITH MORPHOLOGIC AND IMMUNOPHENOTYPIC FEATURES IN
KEEPING WITH INVOLVEMENT BY MYELOID SARCOMA.
___ Bone marrow aspirate and core biopsy
The peripheral blood and aspirate smears show numerous abnormal
blasts with immature chromatin, folded nuclei and moderate
amounts of cytoplasm which represent 79% of the aspirate
differential count. The core biopsy shows a cellularity of >90%
with the vast majority of the cellular
elements present representing blasts. Corresponding flow
cytometry detected a large population of CD34 negative/CD117
positive (subset) myeloblasts showing evidence of monocytic
differentiation (see separate report ___ for full final
results). Cytogenetics work-up revealed a normal male karyotype
(see separate report ___ for full results). The findings
are in keeping with involvement by acute myeloid leukemia.
Correlation with clinical, laboratory and molecular testing
results is recommended for further characterization.
___ Bone marrow biopsy
MARKELDY HYPOCELLULAR BONE MARROW WITH BACKGROUND EOSINOPHILIC
DEBRIS
CONSISTENT WITH CHEMOTHERAPY-INDUCED MARROW ABLATION. NO
EVIDENCE OF
INVOLVEMENT BY ACUTE MYELOID LEUKEMIA SEEN.
___ Lymph node biopsy
NEUTROPHIL-RICH INFILTRATE WITH A SUBSET OF MONONUCLEAR CELLS.
THE
DIFFERENTIAL DIAGNOSIS INCLUDES MYELOID SARCOMA VERSUS SWEET
SYNDROME OR
LESS LIKELY INFECTIOUS PROCESS. SEE NOTE.
___ Lymph node biopsy
Non-diagnostic study. Cell marker analysis was attempted, but
was non-diagnostic in this case due to a low number of evaluable
events and non-specific staining. Correlation with clinical,
morphologic (see separate pathology report ___ and
___) and other ancillary findings is recommended. Flow
cytometry immunophenotyping may not detect all abnormal
populations due to topography, sampling or artifacts of sample
preparation.
___ Skin biopsy (RLE)
Sparse superficial perivascular lymphocytic inflammation with
red cell extravasation and mild upper dermal edema.
___ Lymph node biopsy
LYMPH NODE WITH NEUTROPHIL COLLECTIONS, FOCI OF NECROSIS,
NUMEROUS
HISTIOCYTES AND NO DIAGNOSTIC FEATURES OF MYELOID SARCOMA.
IMAGING:
========
___ CT neck without contrast
Bilateral cervical lymphadenopathy, with the largest lymph node
measuring up to 2.5 cm.
___ CT chest without contrast
1. Diffuse, bilateral, ground-glass opacities with interlobular
septal
thickening. Differential diagnosis includes pulmonary edema,
pulmonary
lymphocytic infiltration or bronchopneumonia.
2. Mediastinal, axillary, and probable hilar lymphadenopathy.
3. Please refer to the separate report of the CT abdomen and
pelvis performed on the same day for subdiaphragmatic
characterization.
___ CT A/P without contrast
1. Enlarged periportal, left external iliac, and bilateral
common femoral
lymph nodes. Multiple prominent but nonenlarged mesenteric lymph
nodes.
2. Moderate splenomegaly.
3. Mild perinephric fat stranding, which is nonspecific but may
represent
acute kidney injury.
4. Please refer to the separate report of the chest CT performed
on the same day for intrathoracic characterization.
___ ___
Occlusive deep vein thrombosis in the left peroneal veins.
___ TTE
The left atrial volume index is normal. The right atrium is
mildly enlarged. There is no evidence for an atrial septal
defect by 2D/color Doppler. The estimated right atrial pressure
is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size. There is normal regional and global left ventricular
systolic function. The visually estimated left ventricular
ejection fraction is 55-60%. Left
ventricular cardiac index is normal (>2.5 L/min/m2). 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) appear structurally normal. There
is no aortic valve stenosis. There is no aortic regurgitation.
The mitral valve leaflets appear structurally normal with no
mitral valve prolapse. There is trivial mitral regurgitation.
The tricuspid valve leaflets appear structurally normal. There
is physiologic tricuspid regurgitation. The pulmonary artery
systolic pressure could not be estimated. There is no
pericardial effusion.
___ CT chest
1. Progression of extensive bilateral ground-glass opacities in
keeping with acute respiratory distress syndrome.
2. Limited evaluation of the previously seen bibasilar pulmonary
nodules due to respiratory motion. However, the appearance of
the nodules and nodular septal thickening is most likely due to
lymphangitis spread of hematological disease.
3. New small amount of ascites and left pleural effusion.
___ ___
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ RUQUS
1. Mild central intrahepatic biliary ductal dilatation, which
appears new
compared to prior ultrasound from ___. Normal
caliber common
hepatic duct.
2. Sludge in the gallbladder. Mural edema of the gallbladder,
likely third
spacing of fluids in the setting of underlying systemic process.
3. Right pleural effusion.
___ FDG-PET
1. Multiple FDG avid bilateral deep cervical lymph nodes.
2. Single 1.4 cm FDG avid mesenteric lymph node with an SUV max
of 5.8.
3. Additional 8 mm FDG avid right inguinal node with an SUV max
of 3.6.
4. Diffuse bilateral peribronchovascular opacities, in keeping
with known acute respiratory distress syndrome.
___ MRCP
1. Hemosiderosis of liver and spleen.
2. Findings suggestive of third spacing with periportal edema
and mild edema in the upper abdomen including between the liver
and the gallbladder.
3. Gallstones.
4. Left renal cyst.
___ Renal ultrasound
Unremarkable renal ultrasound. No hydronephrosis.
___. Bilateral level ___ neck lymphadenopathy, worsened.
2. Interval improvement in bilateral pulmonary opacities.
___ TTE
The left atrium is dilated. The right atrium is mildly enlarged.
The estimated right atrial pressure is >15mmHg. There is normal
left ventricular wall thickness with a normal cavity size.
Overall left ventricular systolic function is low normal. The
visually estimated left ventricular ejection fraction is 50%.
There is no resting left ventricular outflow tract gradient.
Normal right normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter is normal with a
mildly dilated descending aorta. The aortic valve leaflets (3)
appear structurally normal. There is no aortic valve stenosis.
There is no aortic regurgitation. The mitral valve leaflets
appear structurally normal with no mitral valve prolapse. There
is mild [1+] mitral regurgitation. The pulmonic valve leaflets
are normal. The tricuspid valve leaflets appear structurally
normal. There is mild [1+] tricuspid regurgitation. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
___ LLE ultrasound
No evidence of deep venous thrombosis of the left lower
extremity veins.
___ CT chest without contrast
Interval improvement of the extensive bilateral parenchymal
opacities as
compared to ___.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
======================
Mr. ___ is a ___ man with history of hypertension who
presented with several weeks of dyspnea and cough and was found
to have hyperleukocytosis, for which he was admitted to the ICU
for leukapheresis. He was diagnosed with FLT3+ acute myeloid
leukemia with extensive infiltration of the lymph nodes and
spleen. He underwent a cycle of 7+3 (completed on ___, as
well as a cycle of consolidation chemotherapy with
decitabine/venetoclax (completed on ___. His hospital
course was c/b febrile neutropenia, Aspergillus PNA, and acute
hypoxic respiratory failure requiring intubation ___ diffuse
alveolar hemorrhage. His course was further c/b acute renal
failure, thought ___ nephrotoxic medications,
cervical/submandibular lymphadenopathy thought ___ Sweet
syndrome vs infection, for which he was treated with a high-dose
steroid taper, broad-spectrum abx, and anti-fungals, and
hospital-acquired influenza A, for which he received a course of
Tamiflu. Throughout his course, he was closely monitored for
tumor lysis syndrome and disseminated intravascular
coagulopathy, and he was given transfusion support as needed.
Bone marrow biopsy was performed once his counts recovered;
results are currently pending. He was ultimately discharged home
with plan for outpatient ID and dental evaluation prior to allo
SCT.
TRANSITIONAL ISSUES:
====================
[] Patient should complete his steroid taper as prescribed:
-- ___: Prednisone 40mg daily
-- ___: Prednisone 30mg daily
-- ___: Prednisone 20mg daily
-- ___: Prednisone 10mg daily
-- ___: Prednisone 5mg daily
[] Oncology: Please trend LFT's given noted uptrending
transaminitis on this admission. Additional work-up was deferred
due to lack of localizing signs/symptoms but may be warranted
prior to transplant if transaminitis does not resolve.
[] Oncology: Please stop omeprazole once steroid taper is
complete.
[] Oncology: Please ensure patient has outpatient pre-transplant
evaluation by ID (scheduled for ___ ___ and by his
own dentist.
[] Oncology: Patient was found to have reduced LVEF s/p 7+3 on
this admission. Per Cardiology, please repeat TTE prior to SCT.
If low-normal, recommend trying to avoid cardiotoxic
medications; if not possible, please obtain weekly TTE's during
___ admission. If patient's LVEF is worse than current baseline
when he is re-admitted, please re-consult ___ Cardiology.
[] Oncology: Please follow up on pending studies: ___ lymph node
biopsy universal PCR and AFB culture.
[] Oncology/PCP: ___ continue to monitor patient's anxiety
and pain and encourage non-pharmacologic/non-opioid
interventions. Patient was discharged with a small supply of
lorazepam and oxycodone.
Medication changes:
STARTED oseltamivir 75mg BID (to be completed on ___
STARTED prednisone taper as above (to be completed on ___
STARTED acyclovir 400mg q12h
STARTED atovaquone 1500mg qd
STARTED voriconazole 300mg q12h
STARTED betamethasone ointment BID for RLE rash (to be completed
by ___
STARTED amlodipine 10mg qd
STARTED hydralazine 10mg TID
STARTED omeprazole 20mg qd
STARTED lorazepam 0.5mg q6h:PRN
STARTED oxycodone 5mg q6h:PRN
STARTED zolpidem 10mg qHS
Full Code
Contact: ___ (wife), ___
PROBLEM-BASED SUMMARY:
======================
#Acute myeloid leukemia
#Tumor lysis syndrome
#Disseminated intravascular coagulation
Patient presented with WBC >200 with 90% blasts. He was admitted
to the ICU and received one round of leukapheresis with
hydroxyurea. Bone marrow biopsy showed FLT3+ acute myelogenous
leukemia, and L cervical LN biopsy showed involvement with
myeloid sarcoma. He was initiated on induction chemotherapy with
7+3 ___, completed on ___. He was closely monitored for
TLS and DIC and received rasburicase, IVF, and blood product
transfusions as needed. Patient was briefly treated with
midostaurin (___), which was discontinued due to ___ and
transfusion-refractory thrombocytopenia. Bone marrow biopsies on
___ and ___ demonstrated ablation. Course was c/b increasing
LAD as below with c/f refractory disease of the neck; however,
work-up was negative for leukemia involvement. He underwent
consolidation chemotherapy with one cycle of
venetoclax/decitabine ___, completed on ___. Once his
counts recovered, he underwent bone marrow biopsy on ___ to
confirm remission; results were pending at discharge. During his
admission, he was started on prophylactic acyclovir and
voriconazole.
#Febrile neutropenia
#Community-acquired pneumonia
On admission, given patient's functional neutropenia and c/f
radiographic evidence of PNA, he was started on antibiotics.
Course was further c/b febrile neutropenia and c/f sepsis, and
he was continued on an extended course of broad-spectrum
antibiotics.
#Acute hypoxemic respiratory failure
#Diffuse alveolar hemorrhage
#Aspergillus pneumonia
___ hospital course was c/b acute hypoxemic respiratory
failure requiring intubation. Bronchoscopy showed diffuse
alveolar hemorrhage likely ___ thrombocytopenia and fluid
overload from IVF and transfusion products. He was given
platelet transfusions and treated with pulse-dose steroids,
Amicar gtt, and IV diuresis. He was also found to have positive
galactomannan on BAL c/f pulmonary Aspergillosis, so his
anti-fungal coverage was broadened to voriconazole.
#Reduced LVEF
Patient was noted to have newly-reduced LVEF from 70% (___) to
50% (___) s/p
one cycle of 7+3. His cardiac output may have been artificially
elevated on admission. Cardiology was consulted and recommended
repeat TTE prior to transplant; if still low-normal at that
time, they suggested avoiding further cardiotoxic agents if
possible, and if not possible, recommend weekly TTE.
#Acute renal failure
Baseline Cr 1.2. Patient developed acute renal failure in the
setting of hyperuricemia ___ TLS, volume overload, and exposure
to nephrotoxic medications. He was seen by Nephrology, who
thought the renal failure was caused by ATN from vancomycin
toxicity. UPEP did not demonstrate AML-induced lysozymuria. He
was actively diuresed, and Cr improved to baseline prior to
discharge.
#Leukoclastic vasculitis
Patient developed bilateral lower extremity palpable purpura.
Dermatology was consulted; skin biopsy showed leukoclastic
vasculitis. He was treated with two weeks of topical
betamethasone with resolution. Later in his course, he developed
new areas of purpura on his RLE and was again treated with
betamethasone with improvement.
#Cervical/submandibular LAD c/f ___ syndrome
Patient was noted to develop new and progressively enlarging
cervical LAD on ___. Lymph node biopsy showed focal collections
of neutrophils and necrosis without microorganisms or evidence
of myeloid sarcoma, potentially more consistent with Sweet
syndrome. Universal PCR showed ___ (unclear
whether contaminant or true pathogen), covered with voriconazole
as above. He was also treated with broad-spectrum antibiotics,
though work-up has been negative for a bacterial infection. He
was started on high-dose IV steroids with improvement in LAD.
Initial attempt to decrease these steroids was c/b
re-enlargement of the LAD, so he was placed on a slower taper.
He will be discharged on the remainder of this oral prednisone
taper.
#Influenza A
Patient was diagnosed with hospital-acquired influenza A and
found on respiratory viral PCR to also have coronavirus. ___ CT
chest showed interval improvement of bilateral opacities from
___ (prior diffuse alveolar hemorrhage). He was treated with
a 10-day course of Tamiflu 75mg BID ___ end ___.
#L peroneal distal DVT
Found to have peroneal DVT during his admission. Anticoagulation
was deferred due to thrombocytopenia. Interval ultrasound showed
resolution of the clot.
#Transaminitis
Patient was noted to have uptrending AST/ALT without localizing
signs/symptoms. Transaminitis may be medication-induced. Please
continue to monitor as an outpatient.
#Insomnia/anxiety
Treated with Ativan prn and zolpidem 10mg qHS while inpatient.
He was discharged with a small supply of Ativan.
#Back pain
Treated with low-dose oxycodone while inpatient. He was
discharged with a small supply of oxycodone.
CHRONIC ISSUES:
===============
#HTN
Patient was continued on home metoprolol succinate and started
on amlodipine 10mg qd and hydralazine 10mg TID for improved
control of blood pressures.
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. Doxycycline Hyclate 100 mg PO Q12H
2. PredniSONE 50 mg PO DAILY
3. guaiFENesin 100 mg/5 mL oral unknown
4. Benzonatate 100 mg PO TID
5. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
unknown
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Finasteride 0.25 mg PO DAILY
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
2. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 10 ml by mouth once a day Refills:*0
4. Betamethasone Dipro 0.05% Oint 1 Appl TP BID Duration: 5
Days
RX *betamethasone dipropionate 0.05 % Apply to rash on right
foot twice a day Refills:*0
5. Calcium Carbonate 1500 mg PO DAILY dyspepsia
RX *calcium carbonate 500 mg calcium (1,250 mg) 3 tablet(s) by
mouth once a day Disp #*90 Tablet Refills:*0
6. HydrALAZINE 10 mg PO TID
RX *hydralazine 10 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
7. LORazepam 0.5 mg PO Q6H:PRN anxiety/nausea/vomiting
RX *lorazepam [Ativan] 0.5 mg 1 tablet(s) by mouth every six (6)
hours Disp #*20 Tablet Refills:*0
8. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
9. OSELTAMivir 75 mg PO BID Duration: 6 Days
RX *oseltamivir 75 mg 1 capsule(s) by mouth twice a day Disp #*5
Capsule Refills:*0
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
11. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
once a day Disp #*60 Tablet Refills:*0
12. Voriconazole 300 mg PO Q12H
RX *voriconazole 200 mg 1.5 tablet(s) by mouth every twelve (12)
hours Disp #*90 Tablet Refills:*0
13. Zolpidem Tartrate 10 mg PO QHS
RX *zolpidem [Ambien] 10 mg 1 tablet(s) by mouth at bedtime Disp
#*30 Tablet Refills:*0
14. PredniSONE 40 mg PO DAILY Duration: 2 Doses
This is dose # 1 of 5 tapered doses
RX *prednisone 10 mg 4 tablet(s) by mouth once a day Disp #*8
Tablet Refills:*0
15. PredniSONE 30 mg PO DAILY Duration: 3 Doses
This is dose # 2 of 5 tapered doses
Tapered dose - DOWN
RX *prednisone 10 mg 3 tablet(s) by mouth once a day Disp #*9
Tablet Refills:*0
16. PredniSONE 20 mg PO DAILY Duration: 3 Doses
This is dose # 3 of 5 tapered doses
Tapered dose - DOWN
RX *prednisone 10 mg 2 tablet(s) by mouth once a day Disp #*6
Tablet Refills:*0
17. PredniSONE 10 mg PO DAILY Duration: 3 Doses
This is dose # 4 of 5 tapered doses
Tapered dose - DOWN
RX *prednisone 10 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
18. PredniSONE 5 mg PO DAILY Duration: 3 Doses
This is dose # 5 of 5 tapered doses
Tapered dose - DOWN
RX *prednisone 5 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
19. Benzonatate 100 mg PO TID
20. guaiFENesin 100 mg/5 mL oral unknown
21. Metoprolol Succinate XL 50 mg PO DAILY
22. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
unknown
23.Outpatient Lab Work
Please draw CBC with differential, BMP, Ca, Mg, phos, and LFT's
by ___.
Please fax results to Dr. ___ (___).
ICD-9: 205.01
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
Acute myeloid leukemia
Pancytopenia
Leukostasis
Acute hypoxemic respiratory failure
Diffuse alveolar hemorrhage
Tumor lysis syndrome
Disseminated intravascular coagulation
Acute renal failure
Acute tubular necrosis
Aspergillus pneumonia
Febrile neutropenia
Cardiomyopathy, likely non-ischemic
HTN
Cervical and submandibular lymphadenopathy thought to be ___
Sweet syndrome
SECONDARY DIAGNOSES:
====================
Hyperbilirubinemia
Transaminitis
Distal DVT
Insomnia
Splenomegaly
Hyperglycemia
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 came to the hospital because you were having difficulty
breathing.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- You were found to have an extremely high white blood cell
count.
- You had a procedure called a bone marrow biopsy, which
diagnosed you with acute myeloid leukemia, a type of cancer
where the bone marrow makes abnormal white blood cells.
- Because of the risks associated with very high levels of white
blood cells in your blood, you had a procedure called
leukapheresis to remove these extra cells.
- You also were started on chemotherapy regimens to treat the
leukemia. You were closely monitored for any complications. The
regimens were daunorubicin/cytarabine and decitabine/venetoclax.
- Both the cancer and the chemotherapy cause your blood counts
to go down, so you were given transfusions of red blood cells
and platelets.
- You developed a fever, and we were worried that you had an
infection. Your lungs showed signs of a fungal infection called
Aspergillus. You were treated with antibiotics and anti-fungal
medications.
- You developed a condition called diffuse alveolar hemorrhage,
where your lungs filled with blood. You had to have a breathing
tube placed (be intubated) and stayed in the intensive care unit
for several days.
- Your kidney function declined due to the cancer and
medications you received. Your kidneys improved over the course
of your hospital stay.
- You developed a rash on your legs (leukoclastic vasculitis)
due to inflammation of your blood vessels. This resolved with
steroid ointment.
- Your blood pressures were high, so you were started on
medications (amlodipine and hydralazine) to lower your blood
pressure.
- You developed swelling of the lymph nodes in your neck.
Several samples were taken of these lymph nodes, and the
swelling was thought to be due to a condition called Sweet
syndrome, which can develop in association with blood cancers.
You were treated with high-dose steroids, as well as antibiotics
and anti-fungals in case the swelling was due to an infection.
Our evaluation did not show signs that the swelling is related
to leukemia.
- You caught the flu while you were in the hospital and were
treated with Tamiflu.
- We helped you schedule outpatient transplant evaluations with
Infectious Disease and with your dentist.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue your steroids as prescribed:
-- ___: Prednisone 40mg daily
-- ___: Prednisone 30mg daily
-- ___: Prednisone 20mg daily
-- ___: Prednisone 10mg daily
-- ___: Prednisone 5mg daily
- Please monitor the swelling of your neck and let your doctors
know if the swelling increases.
- Please complete the medication for the flu (Tamiflu).
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments, including with
the Infectious Disease physicians and with your dentist.
We wish you all the best (with phase 2 and beyond)!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10861654-DS-5
| 10,861,654 | 24,070,422 |
DS
| 5 |
2123-02-28 00:00:00
|
2123-02-28 19:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
new RML PNA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with history of AML diagnosed
during recent admission, treated with 7+3 and one cycle
dacogen/venetoclax with complicated hospital course including
respiratory failure, DAH, influenza and aspergillus PNA who is
admitted with fever.
Please see discharge summary from ___ for details of
diagnosis and treatment including complications. Briefly, he was
admitted on ___ after a week of progressive dyspnea. He was
initially admitted to the ICU and underwent cytoreduction with
leukopheresis and hydroxyurea. Hew as then diagnosed with FLT+
AML with extensive infiltration of the liver and spleen. He
underwent induction with 7+3 (D1 ___. He was also briefly
treated with midostaurin (___), which was discontinued due
to ___ and transfusion-refractory thrombocytopenia. Bone marrow
biopsies on ___ and ___ demonstrated ablation. Course was c/b
increasing LAD as below with c/f refractory disease of the
neck;
however, work-up was negative for leukemia involvement. He
underwent consolidation chemotherapy with one cycle of
venetoclax/decitabine ___, completed on ___. Once his
counts recovered, he underwent bone marrow biopsy on ___ to
confirm remission.
His hospital course was c/b febrile neutropenia, aspergillus
PNA, and acute hypoxic respiratory failure requiring intubation
___ diffuse alveolar hemorrhage. His course was further c/b
acute renal failure, thought ___ nephrotoxic medications,
cervical/submandibular lymphadenopathy thought ___ Sweet
syndrome vs infection, for which he was treated with a high dose
steroid taper, broad-spectrum abx, and anti-fungals, and
hospital-acquired influenza A, for which he received a course of
Tamiflu.
Since discharge he continued to have ongoing chest congestion
and intermittent productive cough, but he generally has felt
well. He completed Tamiflu on ___. CXR was done in ___
clinic on ___ which did not show evidence of PNA. However, at
about 4am on ___ he awoke feeling warm and noted a
temperature of 102. He had associated chills and felt light
headed with a mild headache. He otherwise had no visual changes.
No sore throat or dysphagia.
His neck lymphadenopathy is much improved. No CP or SOB. His
cough is persistent but not too bothersome. Appetite is good. No
N/V/D. He has had some constipation but had a large formed BM
this am. No dysuria. He has a rash on his right foot improving
with steroid cream. His peripheral edema is also improving. No
other complaints.
In the ED, initial VS were pain 2, T 99.6, HR 106, BP 142/59, RR
18, O2 98%RA. Initial labs were notable for Na 134, K 4.3, HCO3
22, Cr 1.4, ALT 72, 33, ALP 422, LDH 330, TBili 0.8, Alb 3.7,
Hapto 458, WBC 4.7 (82%N), PLT 189, INR 1.1, lactate 0.8. UA was
negative. UA negative. CXR showed RML consolidation compatible
with PNA. Patient was given LR, IV vancomycin and cefepime, and
home hydralazine. VS prior to transfer were T 98.6, HR 84, BP
121/72, RR 18, O2 98%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:
- AML, as above
- Aspergillus PNA
- Diffuse alveolar hemorrhage
- Hypertension
- Rotator cuff tear s/p arthroscopy ___,
- Bilateral Dupuytren's contractures
- BPH
Social History:
___
Family History:
father died of blood cancer (uncertain which) at ___; mother
died of colon cancer at ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
=================================
VS: T 97.8 HR 80 BP 127/64 RR 18 SAT 99% O2 on RA
GENERAL: Pleasant and generally well appearing man standing up
comfortably at bedside
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops
RESPIRATORY: Appears in no respiratory distress, soft
end-expiratory wheeze in right mid lung fields but good air
movement. Otherwise no adventitial sounds.
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities with ___
pitting edema ___ up lower extremities bilaterally; Normal bulk
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: Nonblanching erythematous macular rash over right dorsal
foot
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
DISCHARGE PHYSICAL EXAM
==========================================
24 HR Data (last updated ___ @ 1315)
Temp: 98.1 (Tm 99.1), BP: 136/60 (132-140/60-82), HR: 81
(78-88), RR: 18, O2 sat: 99% (97-99), O2 delivery: Ra, Wt: 183.4
lb/83.19 kg
GENERAL: Well-appearing, sitting up at side of bed, in no acute
distress
HEENT: NC/AT, anicteric sclera, clear oropharynx without oral
lesions, MMM, mild L-sided cervical LAD
CARDIAC: S1, S2, RRR, no m/r/g
PULM: faint expiratory wheezes throughout R lung but otherwise
clear, no crackles, rhonchi.
ABDOMEN: Soft, NTND, normoactive BS throughout.
EXT: 2+ pitting edema to the shins bilaterally
SKIN: Two areas of nonblanching erythematous macular rash over
right dorsal foot
NEURO: AOx3, cooperative with exam
Pertinent Results:
LABORATORY STUDIES
===============================
___ 09:20AM BLOOD Neuts-80* Bands-11* Lymphs-0* Monos-5
Eos-0* ___ Metas-3* Myelos-1* AbsNeut-5.19 AbsLymp-0.00*
AbsMono-0.29 AbsEos-0.00* AbsBaso-0.00*
___ 09:30AM BLOOD WBC-5.1 RBC-3.15* Hgb-9.3* Hct-28.1*
MCV-89 MCH-29.5 MCHC-33.1 RDW-16.0* RDWSD-51.5* Plt ___
___ 09:30AM BLOOD Neuts-85* Bands-1 Lymphs-6* Monos-3*
Eos-0* ___ Metas-3* Myelos-2* AbsNeut-4.39 AbsLymp-0.31*
AbsMono-0.15* AbsEos-0.00* AbsBaso-0.00*
___ 09:20AM BLOOD Ovalocy-1+* Tear Dr-1+* RBC Mor-SLIDE
REVI
___ 09:30AM BLOOD Poiklo-1+* Ovalocy-1+* Schisto-1+* RBC
Mor-SLIDE REVI
___ 09:20AM BLOOD Plt Smr-NORMAL Plt ___
___ 09:30AM BLOOD Plt Smr-NORMAL Plt ___
___ 12:46PM BLOOD ___
___ 09:20AM BLOOD Glucose-104* UreaN-23* Creat-1.2 Na-139
K-5.3 Cl-102 HCO3-25 AnGap-12
___ 09:30AM BLOOD UreaN-32* Creat-1.3* Na-135 K-5.0 Cl-99
HCO3-24 AnGap-12
___ 09:20AM BLOOD ALT-78* AST-43* LD(LDH)-356* AlkPhos-483*
TotBili-0.5
___ 09:30AM BLOOD ALT-81* AST-26 LD(___)-334* AlkPhos-306*
TotBili-0.6
___ 06:05AM BLOOD GGT-1150*
___ 06:05AM BLOOD proBNP-1835*
___ 09:20AM BLOOD Albumin-3.7 Calcium-8.7 Phos-3.6 Mg-1.7
___ 09:30AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.3* UricAcd-5.3
___ 12:47PM BLOOD Hapto-458*
___ 09:20AM BLOOD IgG-803 IgA-72 IgM-21*
IMAGING STUDIES
==========================
CXR ___
FINDINGS: Since prior, there has been interval development of an
opacity at the right lung base which localizes to the right
middle lobe on the lateral view. Elsewhere, the lungs are clear.
Cardiomediastinal silhouette is within normal limits. No acute
osseous abnormalities.
IMPRESSION: Right middle lobe consolidation compatible with
pneumonia in the proper clinical setting.
Brief Hospital Course:
ASSESSMENT AND PLAN: A ___ year-old male with history of
recently-diagnosed AML c/b prolonged hospital course including
acute hypoxic respiratory failure, Aspergillus PNA, diffuse
alveolar hemorrhage, and hospital-acquired influenza
A/coronoviral PNA, s/p 7+3 and one cycle of
decitabine/venetoclax, who now presents with RML PNA.
ACUTE ISSUES:
#RML PNA: Presented with fevers at home on ___. has been
afebrile throughout hospital stay. CXR revealed right middle
lobe consolidation compatible with pneumonia in the proper
clinical setting. Suspect secondary bacterial pneumonia
precipitated by recent influenza A/coronavirus infection, though
viral PNA is
also possible. Has been on broad anti-fungal coverage as an
outpatient. Patient remained afebrile and hemodynamically
stable. Therefore, was de-escalated from IV vancomycin & IV
cefepime (___) to Levofloxacin (D1:
___ then switched to Augmentin to avoid QTC
prolongation (___) with plan to complete a 7D course.
-Urine Legionella Ag negative ___
-Completed azithromycin 500mg qd x 3 days (___)
-Continue home atovaquone and voriconazole
-Continue with guaifenesin, tessalon pearles, duonebs q6h, and
PRN albuterol
-Consider CT chest if fevers reoccur or respiratory status
decompensates
#AML/Anemia of Malignancy: Status post 7+3 (D1 ___ and most
recently underwent consolidation chemotherapy with one cycle
dacogen/venetoclax (C1D1: ___ dose of venetoclax on
___. BM Bx on ___ showed no evidence of disease; however,
he remains FLT3-ITD+. Most recent BM bx obtained ___,
revealed normal karyotype. Trialed on midostaurin but stopped
due to c/f nephrotoxicity. Anemia most
likely in the setting of disease and recent marrow suppressive
therapy.
-Regimen day: C1D35 venetoclax/decitabine
-Repeat voriconazole trough 2.7 on ___
-Continue prophylaxis with ACV & Voriconazole
-Transfuse for Hgb < 7, platelets < 10
-Pre-transplant ID appointment with Dr. ___ reschedule dental evaluation for allogeneic SCT
work-up
#Transaminitis: Stable ALT/AST, with up trended in the AP in the
400 range. Bilirubin is normal. Also, noted on prior admission,
thought to be secondary to viral infection or drug effect.
Patient has no localizing s/s. Continue to trend LFT outpatient.
CHRONIC/RESOLVED ISSUES:
==========================================
___ (resolved): Creatinine stable, 0.8 on ___. Likely
prerenal azotemia in the setting of acute infection. Resolved
with IVF resuscitation.
#Sweet Syndrome: Cervical/submandibular LAD consistent with
Sweet Syndrome. Continues with prednisone taper as below. Given
prolonged high-dose steroid use, will continue daily omeprazole
for GI PPX as well as vitamin D 800 units qd + calcium carbonate
1g qd.
-Prednisone 20mg daily from ___ - ___
-Prednisone 10mg daily from ___ - ___
-Prednisone 5mg daily from ___ - ___
-Continue atovaquone 1500mg qd for PJP ppx
#Recent Aspergillus PNA: Diagnosed during prolonged admission
with AML diagnosis in ___. Fungal markers negative on
___. Continue voriconazole as above
#REDUCED EJECTION FRACTION: Noted on serial echos (70% on ___
-> 50% on ___.
-Needs repeat TTE prior to SCT
#HTN: Normotensive throughout hospital course. Continue home
regimen as below.
-Continue amlodipine 10mg qd
-Continue metoprolol succinate 50mg qd
-Continue hydralazine 10mg TID
#Insomnia and Anxiety:
-Continue ativan 0.5-1mg q8h:PRN
-Continue zolpidem 10mg qhs
#L PERONEAL DISTAL DVT, HISTORY OF: Found to have peroneal DVT
during initial admission ___. Anticoagulation was deferred
at the time due to thrombocytopenia. Interval ultrasound
obtained ___ showed resolution of the clot.
CORE MEASURES
=============
#HCP: ___ (wife), ___
#CODE STATUS: Full confirmed
d/c planning > 30 min
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Voriconazole 300 mg PO Q12H
2. Acyclovir 400 mg PO Q12H
3. Benzonatate 100 mg PO TID:PRN cough
4. Metoprolol Succinate XL 50 mg PO DAILY
5. amLODIPine 10 mg PO DAILY
6. Atovaquone Suspension 1500 mg PO DAILY
7. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
8. Calcium Carbonate 1500 mg PO DAILY dyspepsia
9. HydrALAZINE 10 mg PO TID
10. Omeprazole 20 mg PO DAILY
11. Vitamin D 800 UNIT PO DAILY
12. Zolpidem Tartrate 10 mg PO QHS
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN Shorntess of breath
14. PredniSONE 40 mg PO DAILY
This is dose # 1 of 5 tapered doses
15. PredniSONE 30 mg PO DAILY
This is dose # 2 of 5 tapered doses
Tapered dose - DOWN
16. PredniSONE 20 mg PO DAILY
This is dose # 3 of 5 tapered doses
Tapered dose - DOWN
17. PredniSONE 10 mg PO DAILY
This is dose # 4 of 5 tapered doses
Tapered dose - DOWN
18. PredniSONE 5 mg PO DAILY
This is dose # 5 of 5 tapered doses
Tapered dose - DOWN
19. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
20. LORazepam 0.5 mg PO Q6H:PRN anxiety/nausea/vomiting
21. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
22. guaiFENesin 200 mg oral Q6H:PRN cough
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 3 Days
start medication on ___ and continue until ___ then stop.
2. GuaiFENesin ER 1200 mg PO Q12H:PRN cough
3. Betamethasone Dipro 0.05% Oint 1 Appl TP BID:PRN apply to
top of right foot
4. Acyclovir 400 mg PO Q12H
5. amLODIPine 10 mg PO DAILY
6. Atovaquone Suspension 1500 mg PO DAILY
7. Benzonatate 100 mg PO TID:PRN cough
8. Calcium Carbonate 1500 mg PO DAILY dyspepsia
9. HydrALAZINE 10 mg PO TID
10. LORazepam 0.5 mg PO Q6H:PRN anxiety/nausea/vomiting
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
14. PredniSONE 10 mg PO DAILY
take from ___ - ___ then stop.
This is dose # 4 of 5 tapered doses
Tapered dose - DOWN
15. PredniSONE 5 mg PO DAILY
take from ___ - ___ then stop.
This is dose # 5 of 5 tapered doses
Tapered dose - DOWN
16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN cough, shortness of breath, wheezing
17. Vitamin D 800 UNIT PO DAILY
18. Voriconazole 300 mg PO Q12H
19. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
RIGHT MIDDLE LOBE PNEUMONIA
SECONDARY DIAGNOSES
AML
ANEMIA
TRANSAMINITIS
ASPERGILLUS PNEUMONIA
HYPERTENSION
REDUCED EJECTION FRACTION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted on ___ after a chest x-ray revealed a new
pneumonia. You received IV antibiotics and were ultimately
transitioned to oral antibiotics which you are to continue at
home. Your last dose will be ___. While you were admitted you
had no fevers and clinically improved. You will be discharged
home with an albuterol inhaler to use as needed for cough,
shortness of breath or wheezing. You will return to clinic for
an appointment with Dr. ___ on ___. It was a pleasure
taking care of you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10861801-DS-4
| 10,861,801 | 29,959,287 |
DS
| 4 |
2131-12-28 00:00:00
|
2131-12-28 16:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Optiray 160 / Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ woman with h/o breast cancer, anxiety with perumbilical
cramping, nausea starting ___ with worsening cramping
___. Pt had no vomiting, diarrhea, constipation at this time.
On ___, Pt presented to an outside physician, not her PCP, and
had notable abdominal pain and chills on day of admission. She
did not eat breakfast given her pain and had no appetitite. Pt
has never had melena or hemetochezia. No vomiting/fevers/vaginal
discharge/bleeding/dysuria/pyuria. Her exam in the clinic was
notable for rebound in the RLQ, suprapubic/periumbilical
tenderness of palpation. Pain was also elicited in the RLQ with
palpating the left lower quadrant. At the time her vitals were
150/90, HR ___, Temp 98.4, negative UA. For concerns of possible
appendicitis of abdominal pathology requiring admission, she was
transferred to the ED from clinic.
Her last colonoscopy was back in ___ with diverticulosis/grade
I internal hemorrhoids. Pt also had an EGF in ___ which showed
a hiatal hernia and sessile hyperplastic polyp.
In the ED, labs notable for WBC 10.5, with 72.6% polys, normal
H/H/plts. Alk phos was 110, LFTs nl, chem 7 nl. Lactate 0.9, UA
with large leuks, tr blood, few bacteria.
Imaging notable for CT abd & pelvis w/o contrast showing acute
diverticulitis. Given her colonic thickening, colonoscopy is
recommended after the acute presentation resolved. The appendix
was deemed normal. Pt was given 2L NS IVF, po alprazolam, and
transferred.
Vitals prior to transfer: 98.4, 68, 131/78, 16, 100% r.a.
Since transfer to wards, pt was been stable. Improved nausea/no
fevers, no vomiting. She has notable anxiety from medications,
asserting that she is sensitive to high doses of medications.
She has not yet had a bowel movement. She has imrpvoved but
persistnet abdominal pain and has attempted clears without
issues.
Past Medical History:
-stage IIIA left breast cancer (Dx in ___, off all therapy
since ___ with no clinical recurrence)
-hyperlipidemia
-anxiety
-tachycardia
-migraines
Social History:
___
Family History:
no significant cardiac history, mother died of appendicitis at
age ___, father died of "heart problem" in his ___
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
PHYSICAL EXAM:
Vital Signs: 98.6 153 / 89 77 18 100 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation.
DISCHARGE PHYSICAL EXAM
=======================
PHYSICAL EXAM:
VS - 98.6m, 153/89, 77, 18, 100/r.a.
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, wincing upon deep palpation of RLQ
and LLQ, no tenderness upon mild palpation
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS
===============
___ 04:42PM WBC-10.5* RBC-4.06 HGB-12.6 HCT-38.6 MCV-95
MCH-31.0 MCHC-32.6 RDW-13.2 RDWSD-46.4*
___ 04:42PM GLUCOSE-102* UREA N-9 CREAT-0.6 SODIUM-136
POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-27 ANION GAP-15
___ 04:45PM LACTATE-0.9
___ 08:25PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:25PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:25PM URINE RBC-1 WBC-13* BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-<1
IMAGING
===============
___BD & PELVIS W/O CON
Lung Bases: Minimal subsegmental basal atelectasis is noted. A
subpleural nodule in the left lower lobe measuring less than 4
mm is unchanged when compared with CT from ___. The
imaged portion of the heart is unremarkable.
Abdomen: The unenhanced appearance of the liver and spleen is
normal. Gallbladder not seen. Pancreas and adrenals are
unremarkable. Kidneys contain no stones and there is no
hydronephrosis. A retro aortic left renal vein is noted. The
abdominal aorta is normal in course and caliber with minimal
atherosclerosis. No free air or free fluid. The stomach and
duodenum appear normal.
Pelvis: Small bowel loops demonstrate no signs of ileus or
obstruction. The appendix is normal. Enteric contrast is seen
through the level of the rectum. Colonic diverticulosis is
present. Inflammatory fat stranding is seen adjacent to the
proximal sigmoid colon as well as mural thickening of this short
segment of colon. There is loss of fat plane with the adjacent
left ovary and overall findings are concerning for acute
diverticulitis. No drainable fluid collection or definite signs
of extraluminal gas. No free fluid. The uterus is small possibly
reflective of a supracervical
hysterectomy. Right ovary contains calcifications. The urinary
bladder is mostly decompressed. No pelvic sidewall or inguinal
adenopathy.
Bones: No worrisome lytic or blastic osseous lesion is seen.
Degenerative disc disease at L4-5 and L5-S1 is mild to moderate.
IMPRESSION: Acute sigmoid diverticulitis. Given associated
colonic thickening at this level, recommend colonoscopy to
exclude underlying lesion once the acute symptoms resolve.
Normal appendix visualized.
___ 10:00:00 AM - EGD report
Esophagus: Normal esophagus.
Stomach:
Lumen: A small size hiatal hernia was seen.
Protruding Lesions A single sessile 4 mm polyp was found in the
fundus. A cold forceps biopsy was performed for histology at the
labeled "gastric polyp".
Duodenum: Other Normal appearing duodenum. Biopsies taken to
assess for celiac disease. Cold forceps biopsies were performed
for histology.
Impression: Polyp in the fundus (biopsy)
Normal appearing duodenum. Biopsies taken to assess for celiac
disease. (biopsy), Small hiatal hernia. Otherwise normal EGD to
third part of the duodenum
___ 8:00:00 AM - colonoscopy report
Protruding Lesions Grade 1 internal hemorrhoids were noted.
Excavated Lesions Several diverticula with medium openings were
seen in the descending colon and sigmoid colon.
Impression: Grade 1 internal hemorrhoids Diverticulosis of the
descending colon and sigmoid colon Otherwise normal colonoscopy
to cecum
Recommendations: Colonoscopy in ___ years, High Fiber Diet
Brief Hospital Course:
Pt is a ___ year old woman w/ hx of breast cancer, anxiety
presenting with periumbilical cramping associated with nausea
and anorexia of 4 days found to have acute sigmoid
diverticulitis on CT Scan with no evidence of complication.
#Acute Sigmoid Diverticulitis- Confirmed with CT, patient with
slight leukocytosis and abdominal tenderness, but no fevers. No
known hx of diverticulitis on prior colonoscopy. Likely cause of
abdominal pain. No other pathology noted on imaging or lab
abnormalities. Patient appears to be doing well no evidence of
complications. She improved from overnight given desire to
attempt drinking, improved pain - minimal at time of discharge.
Pt was started on IV cipro/flagyl later transitioned to oral
cipro 400mg BID /flagyl 500mg q8H(d1= ___. Pt tolerated
without issues. Pt was put in for Zofran prn but did not require
any during hospitalization. Pt is to continue cipro/flagyl for a
10-day course until ___. Pt also was given prescription for
Zofran as needed for 10 days. Pt was informed of warning signs
(fever, sharp abdominal pain, melena/hematochezia) for returning
to the hospital.
#Depression
Pt was continue Citalopram 5 mg PO.
#Hypertension
Pt was continued Propranolol 10 mg PO QAM AND QNOON , 20 mg PO
QHS
and Lisinopril 2.5 mg PO daily.
# Insomnia
Pt was continued on home alprazolam.
#HLD
Pt was continued on home simvastatin.
TRANSITIONAL
========================
-Pt is to continue oral cipro 400mg BID /flagyl 500mg q8H(d1=
___. Pt is to continue meds for a 10-day course until ___.
-Pending blood cultures x 2 (___) and urine culture
(___).
-Pt is to follow-up with outpatient colonoscopy (already
scheduled for ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q8H:PRN nausea
2. Lisinopril 2.5 mg PO DAILY
3. Acyclovir Ointment 5% 5% Other 1X:ASDIR
4. ALPRAZolam 0.25 mg PO QHS:PRN insomnia
5. Propranolol 20 mg PO QHS
6. Propranolol 10 mg PO QAM AND QNOON
7. Simvastatin 10 mg PO QPM
8. Multivitamins 1 TAB PO DAILY
9. Acyclovir 200 mg PO TID
10. melatonin 3 mg oral QHS:PRN insomnia
11. valerian root unknown oral unknown
12. Omeprazole 40 mg PO DAILY
13. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
14. Citalopram 5 mg PO DAILY
15. biotin 1 mg oral BID
16. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. ALPRAZolam 0.25 mg PO QHS:PRN insomnia
2. Citalopram 5 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*3
7. Propranolol 20 mg PO QHS
8. Propranolol 10 mg PO QAM AND QNOON
9. Simvastatin 10 mg PO QPM
10. Vitamin D 1000 UNIT PO DAILY
11. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*18 Tablet Refills:*0
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*20 Tablet Refills:*0
12. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*27 Tablet Refills:*0
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
13. Acyclovir 200 mg PO TID
prn herpes outbreaks, per the ___ medical records
14. Acyclovir Ointment 5% 1 application OTHER 1X:ASDIR
15. biotin 1 mg oral BID
16. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
17. melatonin 3 mg oral QHS:PRN insomnia
18. valerian root unknown ORAL Frequency is Unknown
continue home medication
Discharge Disposition:
Home
Discharge Diagnosis:
acute sigmoid diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It has been a pleasure taking care of you at ___. You were
admitted for your abdominal pain which was diagnosed as
diverticulitis by CT imaging. You were started on two
antibiotics and will continue both of them for a 10-day course
(end date ___. Please refrain from drinking alcohol while
taking these antibiotics. You will also follow-up with a
colonoscopy which is already scheduled for you in ___.
Please continue a high-fiber diet to help prevent future
episodes.
We expect that you will continue to have some pain and nausea
with eating. If you need to, can try soup and return to regular
diet more slowly. If you develop fever, abdominal pain or nausea
that is getting worse, or are unable to take in any food or
water by mouth, please call your PCP office and discuss whether
coming to the ED is necessary. If you feel very sick, please
come back to the ED for evaluation.
We wish you the best in your recovery.
Your ___ team
Followup Instructions:
___
|
10862025-DS-3
| 10,862,025 | 23,180,260 |
DS
| 3 |
2139-01-24 00:00:00
|
2139-01-24 18:11:00
|
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 on exertion, chest pressure
Major Surgical or Invasive Procedure:
___: TEE
___: single chamber pacemaker placement
History of Present Illness:
___ w/ hx of CAD, CHF, afib on coumadin, DM, aortic stenosis who
presents with dyspnea on exertion and chest pressure. She was
recently hospitalized at ___ from ___ for a CHF
exacerbation and was discharged on 20mg daily furosemide, and
was home for one day before she started experiencing increasing
SOB with minimal exertion and epigastric chest pressure
associated with exertion as well. She denies dietary
indiscretions and endorses medication compliance. She presented
initially to ___ where there was initially concern
for ST elevations on EKG but troponins were negative and on
re-examination of the EKG she appears to be in a-flutter wtih
4:1 block, with LBBB, no signs of ischemia. In ___ BNP was
elevated and CXR showed pulmonary congestion, patient initially
required CPAP and was transferred to ___ for further work up
and treatment.
In the ___ ___, initial vitals were: 99.2 66 152/69 18 100%
cpap. Started on a nitro gtt and given lasix 40mg IV x1. K was
noted to be high without EKG changes and she was given
kayexalate x1 per patient (cannot locate on med rec) At time of
transfer she was BP 145/69, HR 66, RR 16, 100% on 2L NC.
On arrival to the floor patient reports that she is comfortable
and not short of breath at rest. No chest pressures, nausea,
diaphoresis, palpitations, syncopee, dizziness. She reports that
at home she had increasing leg edema, DOE and orthopnea as soon
as she went home from ___ and ___ daughter insisted she go to
___ 2 days prior to this admission where she was told to
increase lasix dose to 20mg BID PO instead of just daily. when
symtpoms worsened the next day the patient's daughter, who is a
nurse, brought her back in.
Past Medical History:
Afib
Coronary artery disease
Chronic left bundle branch block
Peripheral vascular disease, followed by Dr. ___
___ mellitus
Hypertension
Hyperlipidemia
Prior GI bleed, occult, panendoscopy and capsule study otherwise
unremarkable
Anemia
Glaucoma, ___
Cataract surgery
Fibrocystic breast changes
Tonsillectomy
Left ankle surgery
CKD baseline creatinine 1.2-1.4
Social History:
___
Family History:
Father deceased ___, DM; Mother deceased ___
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T=97.4 BP=142/81 HR=67 RR=20 O2 sat=992L
GENERAL: Ill appearing woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 10 cm.
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.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c, 2+ bilateral lower extremity edeam, trace
sacral
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ Radial 2+
Left: Carotid 2+ DP 2+ Radial 2+
NEURO: CN II-XII, strength ___, LT intact and symetric in BLE
and BUE
DISCHARGE PHYSICAL EXAMINATION:
VS: Tc= 98.1 BP= 137/69 (98-137/53-70) HR=70 (69-78) 18 96% RA
I/O: ___(24h); wght 51.71->...->49.4-> 49.3
tele: aflutter mostly 4:1, no episodes of brady or tachy
___: 243->200->359->312
GENERAL: awake, alert, pleasant individual in NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple, JVP not elevated.
CHEST: pacer pocket site with overlying dressing c/d/i, no
swelling or erythema
CARDIAC: regular, normal S1, S2. No m/r/g. No thrills, lifts. No
S3 or S4.
LUNGS: good air movement, slight crackles RLB otherwise clear
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c, no edema in ___ bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS:
___ 02:10PM BLOOD WBC-10.7# RBC-3.74* Hgb-11.1* Hct-34.6*
MCV-93 MCH-29.6 MCHC-32.0 RDW-15.5 Plt ___
___ 02:10PM BLOOD Neuts-88.1* Lymphs-6.9* Monos-4.0 Eos-0.4
Baso-0.6
___ 02:10PM BLOOD ___ PTT-32.0 ___
___ 02:10PM BLOOD Glucose-222* UreaN-31* Creat-1.3* Na-135
K-8.8* Cl-101 HCO3-25 AnGap-18
___ 02:17PM BLOOD Lactate-2.1* K-5.8___ 02:10PM BLOOD ___
___ 02:10PM BLOOD cTropnT-0.03*
___ 04:15PM URINE Color-Straw Appear-Clear Sp ___
___ 04:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 02:30PM URINE RBC-66* WBC-2 Bacteri-MOD Yeast-NONE
Epi-<1
___ 06:45AM BLOOD %HbA1c-7.3* eAG-163*
DISCHARGE LABS
___ 07:20AM BLOOD WBC-8.6 RBC-3.67* Hgb-10.5* Hct-33.1*
MCV-90 MCH-28.6 MCHC-31.7 RDW-15.4 Plt ___
___ 07:20AM BLOOD Glucose-144* UreaN-30* Creat-1.3* Na-137
K-4.5 Cl-101 HCO3-29 AnGap-12
___ 07:20AM BLOOD Calcium-8.8 Phos-4.8* Mg-2.2
MICRO
___ BLOOD CULTURE Blood Culture,
Routine-FINAL
___ 4:28 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION. PREDOMINATING ORGANISM.
INTERPRET RESULTS WITH CAUTION.
AMPICILLIN SENSITIVITIES PERFORMED ON REQUEST..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
REPORTS
Cardiovascular ReportECGStudy Date of ___ 10:52:56 AM
Atrial flutter with controlled ventricular response.
Intraventricular
conduction delay. Left ventricular hypertrophy. Left anterior
fascicular
block. Delayed R wave transition. Compared to the previous
tracing of ___
no diagnostic interim change.
TTE (Complete) Done ___ at 3:39:24 ___ FINAL
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). No
atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. There is mild global left ventricular hypokinesis (LVEF =
40 %). The estimated cardiac index is depressed (<2.0L/min/m2).
Right ventricular chamber size is normal with mild global free
wall hypokinesis. There is abnormal septal motion/position. 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. Mild (1+)
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 severe
pulmonary artery systolic hypertension. The end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery diastolic hypertension. There is no pericardial
effusion.
IMPRESSION: Severe pulmonary artery hypertension. Mild symmetric
left ventricular hypertrophy with normal cavity size and
biventricular global hypokinesis. Mild-moderate mitral
regurgitation.
TEE (Congenital) Done ___
The left atrium is dilated. Moderate to severe spontaneous echo
contrast is present in the left atrial appendage. A thrombus is
seen in the left atrial appendage. A patent foramen ovale is
present. There is mild to moderate global left ventricular
hypokinesis (LVEF = 35-40 %) while in 2:1 atrial flutter. Right
ventricular chamber size is normal. with depressed free wall
contractility. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Mild (1+) 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 no pericardial effusion.
IMPRESSION: ___ thrombus. Global biventricular systolic
dysfunction
Brief Hospital Course:
___ w/ hx of CAD, CHF, afib on coumadin, DM, aortic stenosis who
presents with DOE and chest pressure, found to have recurrent
CHF exacerbation.
# Acute on chronic diastolic congestive heart failure: LVEF
"53-77%" per echo week prior to admission at ___. Most
likely reason for presentation so close to recent discharge from
OSH was inadequate diures is with oral lasix related to
decreased absorption in patient with gut edema. She initially
required CPAP at time of transfer but dyspnea and hypoxia
improved with diuresis and nitroglycerine drip, and she was
eventually able to be weaned of nitroglycerin and supplemental
oxygen. She was diuresed from admission weight of 51.7 kg to a
discharge weight of 49.4. Repeat ECHO on ___ revealed EF 40%
with mild global LV hypokenisis. She was noted to have
persistent aflutter on tele and underwent TEE (as below). Her
metoprolol tartrate was changed to 200 mg XL daily. Lisinopril
20 mg was initiated and she tolerated it well. She was
discharged on a diuretic regimen of torsemide 20 mg daily. ___
evaluated the patient and felt she would benefit from rehab.
# Afib/aflutter: As per chart review, patient with hx. of afib
since ___. She had a recent development of aflutter within
the last few weeks. She was in persistent aflutter this
admission with predominately 4:1 block and heart rates in the
___ but rate was noted to drop as slow as the ___ and go as fast
as the 130s occasionally (8:1 or 2:1 variable conduction).
Given these findings and concern for tachy-brady syndrome, EP
was consulted re: possible cardioversion and pacemaker. Patient
underwent TEE on ___ which revealed a clot in her left atrium
and cardioversion was deferred. The patient notably had
subtherapeutic INR several times over the last few months,
making ___ thrombus unlikely to represent a coumadin failure.
Patient did undergo single chamber pacemaker placement on ___
with good results. Diltiazem was discontinued for concern for
bradycardia. Her antiarrhythmic regimen included metoprolol XL
200 mg upon discharge. Her INR fluctuated this admission but she
was bridged with heparin while subtherapetuic. She restarted
her home coumadin regimen upon discharge but with subtherapeutic
INR, will need lovenox bridge. Goal INR continues to be ___.
INR followed by Dr. ___.
# Left atrial appendage clot: noted on TEE ___, was
subtherapeutic on a few occasions as listed above. After TEE,
had strict bridging with heparin or lovenox when INR was
subtherapeutic. Should be bridged in the future when INR <2.
# Chest pain: Chest pressure on admission most likely consistent
with CHF exacerbation but given risk factors and history of CAD,
ruled out for MI with unchanged EKG (known LBBB) and negative
troponins (0.05 highest this admission, in setting of impaired
renal function). Continued metoprolol, clopidogrel (for
peripheral vascular disease) and warfarin. Not on aspirin
because of bleeding risk, per patient. Chest discomfort
dissipated after adequate diuresis and was no longer of concern.
# UTI: patient developed slight white count during hospital
stay, as foley was placed for close urine output monitoring u/a
was sent which was suspicious for infection. Patient was
started on IV ceftriaxone. Culture grew pansensitive E. coli.
Completed 7d course of ceftriaxone for catheter associated UTI.
# Loose stools: after beginning abx above for UTI, ruled out for
cdiff with PCR, likely non-cdiff abx associated diarrhea.
CHRONIC ISSUES:
# Hypertension: continued metoprolol, diltiazem was discontinued
due to bradycardia and lisinopril started. Might require
further titration although BPs were ~110-120 throughout the
admission.
# Hyperlipidemia: continued simvastatin
# Peripheral vascular disease: continued clopidogrel 75 daily
# Diabetes mellitus: Continued 12U glargine, had elevated BS in
setting of UTI and required escalating sliding scale. Will
require further titration of her insulin after discharge from
rehab.
# Nutrition: Continued vitamin D, restarted calcium supplement
on discharge
# Glaucoma: Continued brimonidine, dorzolamide/timolol, and
latanoprost eye drops
TRANSITIONAL ISSUES:
- Code status: DNR/DNI confirmed with patient and HCP
- HCP is daughter ___ ___
- Will need electrolytes checked one week from discharge
- Will need daily INRs and lovenox bridge until coumadin is
therapeutic given left atrial thrombus
- Weight at discharge was 49.3.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 2.5 mg PO 5X/WEEK (___)
2. Furosemide 20 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Glargine 12 Units Bedtime
Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
9. Latanoprost 0.005% Ophth. Soln. 4 DROP BOTH EYES HS
10. Diltiazem Extended-Release 120 mg PO DAILY
11. Rosuvastatin Calcium 20 mg PO DAILY
12. Famotidine 20 mg PO BID
13. Warfarin 5 mg PO 2X/WEEK (___)
14. Metoprolol Tartrate 100 mg PO BID
15. Tradjenta *NF* (linagliptin) 5 mg Oral daily
Discharge Medications:
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
2. Clopidogrel 75 mg PO DAILY
3. Diltiazem Extended-Release 120 mg PO DAILY
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
5. Famotidine 20 mg PO BID
6. Glargine 12 Units Bedtime + ISS
7. Latanoprost 0.005% Ophth. Soln. 4 DROP BOTH EYES HS
8. Metoprolol Tartrate 100 mg PO BID
9. Rosuvastatin Calcium 20 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Warfarin 4 mg PO DAILY16
12. Enoxaparin Sodium 50 mg SC Q24H
13. Lisinopril 20 mg PO DAILY
14. Metoprolol Succinate XL 200 mg PO DAILY
15. Torsemide 20 mg PO DAILY
16. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
acute on chronic diastolic heart failure
atrial flutter
sick sinus syndrome s/p pacemaker placement
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for shortness of breath and chest disfort and
were found to be having an exacerbation of your congestive heart
failure, causing fluid to build up in your lungs and legs. We
gave you medicines to help you urinate out the extra fluid and
your symptoms improved and you were able to be discharged home
on an oral form of these medicines.
Followup Instructions:
___
|
10862177-DS-19
| 10,862,177 | 25,725,244 |
DS
| 19 |
2147-04-21 00:00:00
|
2147-04-22 11:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p assault
Major Surgical or Invasive Procedure:
Open reduction and internal fixation with closed reduction and
maxillomandibular fixation of bilateral mandibular parasymphysis
fractures.
History of Present Illness:
___ otherwise healthy presented after being assaulted last
night, + LOC for unclear period of time, amnestic to the event,
was taken to OSH where he had head CT and c spine - both
negative
for traumatic injuries but found to have isolated mandibular
fracture. He was transferred to ___ for further care.
In ED his pain is controlled, alert and oriented, GSC of 15,
denies chest pain, difficulty breathing, pain anywhere else
besides the jaw, no nausea or vomiting, denies double vision and
or visual field changes
Past Medical History:
GERD
PSH:
Esophagoscopy
Colonoscopy
Social History:
___
Family History:
N/C
Physical Exam:
Admit PE:
Vitals: T97.8, HR 72,BP 138/89, RR 16, sat 98%/RA
GEN: A&Ox3, appears comfortable
HEENT: EOMI, PERRL, C collar in place, no cervical spine
tenderness, trachea is midline, no hematomas or penetrating
injuries to the neck, there is an apparent mandibular asymmetry,
otherwise CNII-XII intact,
CV: RRR,
PULM: Clear to auscultation b/l, No labored breathing, no chest
tenderness or sigs of traumatic injury
ABD: Soft, nondistended, nontender, no rebound or guarding, no
signs of traumatic injury, negative FAST,
Ext: No ___ edema, ___ warm and well perfused, no tenderness or a
abrasions
Discharge PE:
VS: Temp 98.0, HR 60, BP 130/80, RR 18, SaO2 99% RA
General: NAD, A&Ox3
HEENT: NCAT except for lower facial edema. EOMI, PERRLA. V3
paresthesias. Speech muffled but fluent.
CV: RRR, well perfused
Resp: Clear, normal WOB
GI/Abd: soft, NT/ND
Extremities: atraumatic, no CCE
Pertinent Results:
___ 09:26AM BLOOD ASA-NEG Ethanol-56* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:26AM BLOOD Glucose-83 UreaN-8 Creat-0.8 Na-141 K-4.2
Cl-104 HCO3-20* AnGap-21*
___ 09:26AM BLOOD Neuts-81.0* Lymphs-11.4* Monos-6.9
Eos-0.1* Baso-0.2 Im ___ AbsNeut-9.20* AbsLymp-1.29
AbsMono-0.78 AbsEos-0.01* AbsBaso-0.02
___ 09:26AM BLOOD WBC-11.4* RBC-4.77 Hgb-13.5* Hct-41.6
MCV-87 MCH-28.3 MCHC-32.5 RDW-14.2 RDWSD-45.2 Plt ___
___ 09:26AM BLOOD ___ PTT-31.2 ___
Brief Hospital Course:
___ is a ___ year old otherwise healthy male who presents
as a transfer from OSH with isolated mandibular fracture, s/p
assault, +ETOH abuse. He was seen and evaluated by ___ who
requested an admission to ___ for surgical repair or mandibular
fracture. HD 1 he underwent open reduction and internal fixation
with closed reduction and maxillomandibular fixation of
bilateral mandibular parasymphysis fractures by ___. He
remained stable post-op and was discharged home to follow-up in
one week as per the recommendations of ___.
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 and early ambulation were encouraged throughout
hospitalization.
GI/GU/FEN: The patient was initially kept NPO. On POD 1the diet
was advanced sequentially to a Full Liquid Diet, which was well
tolerated. Patient's intake and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. The patient was given IV
ancef while inpatient which was transitioned to PO keflex x7
days as per the recommendations of OMFS. He will also continue
peridex mouth rinse.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. He will receive a followup
panorex outpatient which was ordered.
Medications on Admission:
omeprazole 40 mg '
Discharge Medications:
1. Cephalexin 500 mg PO Q6H Duration: 1 Week
RX *cephalexin 250 mg/5 mL 10 ml by mouth every six (6) hours
Refills:*0
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL QID
RX *chlorhexidine gluconate 0.12 % oral rinse with 15 ml four
times a day Refills:*0
3. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
do not drive or drink alcohol while taking this medication
RX *oxycodone 5 mg/5 mL ___ ml by mouth every four (4) hours
Refills:*0
4. Acetaminophen (Liquid) 650 mg PO Q6H
RX *acetaminophen 650 mg/20.3 mL 20 ml by mouth every six (6)
hours Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
-Comminuted mandibular fractures involving the right mandibular
ramus, body and parasymphyseal/mental region and the left
parasymphyseal/mental region
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 repair of your mandibular fractures. You are
recovering well and are now ready for discharge. Please follow
the instructions below to continue your recovery:
Take 1 week of PO Keflex ___ 4 times a day as prescribed
Peridex mouth rinse swish and spit twice daily
Apply Ice to face to help reduce swelling and pain
Full liquid diet, no solid food until cleared by ___ at
follow-up
Pain control:
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10862544-DS-14
| 10,862,544 | 21,987,637 |
DS
| 14 |
2159-06-06 00:00:00
|
2159-06-09 16:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
enoxaparin
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mr. ___ is a ___ man with
long-standing history of metastatic RCC recently initiated on
everolimus due to progression on PD-1 therapy. The patient was
seen in the clinic today for follow up when he was noted to have
severe dyspnea on exertion and sent to ER for further
evaluation.
Recently, in ___, when admitted for intractable back pain,
he was noted to have lumbar spine mets, in addition to extensive
b/l lower extremity DVT. He was initiated on treatment-dose
enoxaparin, but unfortunately, he suffered a large thigh
hematoma
in ___. He was transitioned to Arixtra.
In the ED, VS 97.6 HR 98 BP 129/72 RR 18 97% on RA. CTA of the
chest was not done due to the fact that he has 1 kidney and
already received a contrast CT of the chest today. No massive PE
seen on second look of today's CT by radiology.
On arrival to the oncology floor, the patient did not complain
of
any SOB. He states that over the past few months, he has had DOE
with ___ feet, dressing, stairs, but this is actually
improving
if not stable. When SOB, he does not have any
CP/sweating/nausea/elbow pain. He rests and w/in minutes feels
back to baseline. He uses 1 pillow at night, denied
PND/Orthopnea. Admits to ___ that is stable/improving. He saw
his
cardiologist who did not feel this was cardiac and rather due to
the burden of tumor.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
- ___: presented with hematuria, malaise, left flank pain,
N/V and ultrasound showed left kidney mass which was 6-7 cm on
CT
scan
- ___: Left nephrectomy/renal vein thrombectomy as had
involvement of left renal vein down to IVC and lumbar vein.
Pathology with ___ grade III/IV RCC with hemorrhage and
necrosis, 7.5cm in diameter with extension through capsule into
perinpehric soft tissue classified as T3BN0Mo
- Approx ___: Radiation therapy to the lumbar spine for
metastatic disease presenting as spinal cord compression (in
NH).
- ___: Radiofrequency ablation to a local recurrence in the
renal bed
- ___: Excision of a re-recurrence in the renal bed. The
surgery was followed by CyberKnife therapy because of a positive
surgical margin.
- ___: VATs/RUL wedge shows RCC
- ___: C1D1 sutent + PD1, he was only intermittently on
Sutent due to HTN ___ (days 9,___) and then
lowered to 37.5mg ___. PD1 was held on ___ and then C2D22
held on ___ due to LFT abnormalities.
- ___: Sutent discontinued due to DOE, continued on PD-1
- ___: CT scan new right lower lobe lung nodule (3 total,
4mm
or smaller), stable aortocaval lymph node, stable right renal
inferior pole hypodensity has grown since ___
- ___: CT torso showed resolution of right lower lung
nodule, and stability of other nodules, stable retroperitoneal
tissue.
- ___: Disease progression on PD-1, stopped trial
- ___: Disease progression (pulmonary nodules,
periaortic intermediate lumbar LN mass, retroperitoneal LN, soft
tissue mass at aortic bifurcation), no treatment initiated given
asymptomatic, low-volume disease and previous poor tolerance of
TKIs
- ___: Hospitalization with back pain, found to have
osseous metastases in lumbar spine. No Neurosurgery or
radiation
therapy possible. Plan initiation of everolimus. Found to have
bilateral DVT, started Lovenox.
- ___: Admission for large thigh hematoma. Clot found
to
extend up IVC, no filter possible. Switched Lovenox to
fondaparinux.
- ___: start everolimus
PAST MEDICAL HISTORY:
1. PE during postsurgical course in ___, bilateral DVT with
clot extending up IVC (___).
2. Hypertension.
3. Hyperlipidemia.
4. Coronary artery disease. Two weeks prior to this admission
cardiac catheterization at ___ showed
occluded coronary arteries. He plans to have a follow-up cardiac
catheterization at ___ to address this.
5. BPH
Social History:
___
Family History:
Mother: lt kidney removed for unknown cause, died of aneurysm
at
___
Father: died of lymphoma or lung cancer at ___
One brother deceased from ___ syndrome. One sister
was born with one kidney. One son and one daughter, both are
healthy.
Physical Exam:
ADMISSION:
VITAL SIGNS: 98 138/82 91 16 95% RA
HEENT: MMM, no OP lesions, no cervical or supraclavicular
adenopathy
CV: RR, NL S1S2 no S3S4 No MRG, JVP 5 cm H2O
PULM: CTAB, No C/W/R
ABD: BS+, soft, NTND, no palpable masses or HSM
LIMBS: WWP, +2 ___, no tremors, + palpable hematoma
SKIN: No rashes on the extremities
NEURO: Grossly normal, AOx3
DISCHARGE:
VS: Tc:98.7 Tm:98.7 P:74(72-77) BP:115/70(110/50-140/68) RR:20
O2:86%RA
HEENT: MMM, no OP lesions, no cervical or supraclavicular
adenopathy
CV: RR, NL S1S2 no S3S4 No MRG, JVP 10 cm
PULM: CTAB, No wheezes, rales, rhonchi
ABD: BS+, soft, NTND, no palpable masses or HSM
LIMBS: WWP, +2 ___, no tremors, + palpable hematoma
SKIN: No rashes on the extremities
NEURO: Grossly normal, AOx3
Pertinent Results:
ADMISSION:
___ 03:00PM BLOOD WBC-5.4 RBC-3.72* Hgb-10.7* Hct-31.1*
MCV-84 MCH-28.6 MCHC-34.2 RDW-14.4 Plt ___
___ 07:10PM BLOOD Neuts-76.3* Lymphs-13.5* Monos-7.1
Eos-2.7 Baso-0.4
___ 03:00PM BLOOD Plt ___
___ 03:00PM BLOOD UreaN-12 Creat-1.1 Na-136 K-4.3 Cl-103
HCO3-22 AnGap-15
___ 03:00PM BLOOD ALT-20 AST-26 AlkPhos-105 TotBili-0.4
___ 07:10PM BLOOD proBNP-300*
___ 07:10PM BLOOD cTropnT-<0.01
___ 05:13AM BLOOD cTropnT-<0.01
___ 03:00PM BLOOD Calcium-9.1 Phos-2.0*# Mg-2.2
DISCHARGE:
___ 06:07AM BLOOD WBC-4.2 RBC-3.37* Hgb-9.6* Hct-28.4*
MCV-84 MCH-28.5 MCHC-33.8 RDW-14.3 Plt ___
___ 06:07AM BLOOD Plt ___
___ 06:07AM BLOOD ___ PTT-150* ___
___ 06:07AM BLOOD Glucose-99 UreaN-10 Creat-1.0 Na-136
K-4.0 Cl-103 HCO3-24 AnGap-13
___ 06:07AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.2
IMAGING:
___ ECHO Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. The estimated
cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Doppler parameters are most consistent with Grade
I (mild) left ventricular diastolic dysfunction. The isovolumic
relaxation time is prolonged at ~120 - 130 ms ___ < 100 ms).
The myocardial performance index is elevated due to the
prolonged isovolumic relaxation time at 0.9 (normal < 0.6).
Right ventricular chamber size is normal. Tricuspid annular
plane systolic excursion is normal (2.5 cm; nl>1.6cm) consistent
with normal right ventricular systolic function. The aortic root
is mildly dilated at the sinus level. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. There is an anterior space which
most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Normal biventricular
regional/global systolic function. However, due to image quality
a regional wall motion abnormality cannot fully be excluded. The
isolvolumic relaxation time is prolonged suggesting impaired
early diastolic left ventricular filling consistent with type I
diastolic dysfunction. No echocardiographic evidence of acute
right heart strain noted.
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, if not previously known or
a change, a follow-up echocardiogram is suggested in ___ year; if
previously known and stable, a follow-up echocardiogram is
suggested in ___ years.
___ ECG
Sinus rhythm. Early R wave transition. Left ventricular
hypertrophy.
Low voltage in the precordial leads. Compared to the previous
tracing
of ___ the ventericular rate is slower.
Brief Hospital Course:
Mr. ___ is a ___ w/ long-standing history of metastatic RCC
recently initiated on everolimus due to progression on PD-1
therapy, who also has h/o extensive b/l DVT with recent staging
CT scan who presented from clinic with concern for dyspnea on
exertion. Primary oncologist concern for PE given extensive clot
burden. Initial labwork including cardiac enzymes, as well as,
EKG were reassuring. Pt non-tachycardic and without signs of
rightheart straing on EKG as well as follow-up echocardiogram.
Given recent heavy contrast load, single kidney as well as,
patient recieving theraputic dosing of fondaparenox, CTA
deferred given low liklihood of PE causing signficant acute
dyspnea. Pt evaluated by physical therapy and cleared for home
without ___ from a mobility standpoint. The patient maintained
ambulatory saturation.
#DOE
Unclear etiology. Stable to improved in setting of chronic DOE
per pt report on arrival to floor. He has been evaluated by his
cardiologist who does not think this is cardiac and rather tumor
burden. Pt is laying flat in bed and not SOB w/ his legs
elevated. PE is possibility but he has already been on
therapeutic Arixtra. Primary onc team is concerned about emboli
from the b/l extensive DVTs. AM troponin flat, EKG RR w/o
evidence of RHS. Repeat ECHO on ___ showed no evidence of
right heart strain. Pt currently denies SOB and has had success
walking the wards. Cleared physical therapy for discharge home
with home ___. Pt will follow-up sx with outpatient oncologist
who will direct further evaluation as appropriate.
#RCC
Followed by Dr. ___ Dr. ___. Recent staging CT scan
shows "Progression of large known retroperitoneal metastasis,
with new unstable erosion of the right L1 pedicle and transverse
process, along with invasion and 6 mm of encroachment on the
central spinal canal at the T12 on L1 levels, as above."
Previously evaluated by Dr. ___ Neurosurgery. Neurosurgery
consulted, recommended bracing with TLSO but patient threw out
previous brace given due to issues with mobility with use.
Provided ___ Overlay Brace to use as outpatient. Patient
advised to follow-up with Dr. ___ will help determine if
further follow-up with Dr. ___ is needed.
-- cont fentanyl patch
-- cont Afinitor
#DVT, B/L
Not IVC candidate due to exenstive IVC clot burden.
-- cont fondaparinux
#CAD/HTN/DL
Stable.
-- cont isosorbide monotirtate, toprol xl
-- note: not on asa
#BPH
-- cont tamsulosin
TRANSITIONAL ISSUES
-Patient recommended to wear TLSO brace but refused, having
disposed prior brace. As second option, patient offered ___
brace to enable flexibility and encouraged to use for some
support. This was obtained prior to discharge. Further
management of spinal stability in context of goals of care to be
discussed with patient by his primary oncologist.
- Seen to have mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, a follow-up echocardiogram
is suggested in ___ year if new (if known and stable, can repeat
in ___ years)
- ___ benefit from further pulmonary testing to identify sources
of dyspnea
- Neurosurgery does not feel routine follow up is necessary
unless requested by outpatient providers
- ___ code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Tamsulosin 0.4 mg PO QHS
4. Docusate Sodium 100 mg PO BID
5. Polyethylene Glycol 17 g PO DAILY:PRN constip
6. Nitroglycerin SL 0.4 mg SL ASDIR chest pain
7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
8. Everolimus 10 mg PO Q24H
9. Fondaparinux 10 mg SC DAILY
10. Fentanyl Patch 50 mcg/h TD Q72H
11. Gabapentin 300 mg PO QHS
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
3. Fentanyl Patch 50 mcg/h TD Q72H
4. Fondaparinux 10 mg SC DAILY
5. Gabapentin 300 mg PO QHS
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Nitroglycerin SL 0.4 mg SL ASDIR chest pain
9. Polyethylene Glycol 17 g PO DAILY:PRN constip
10. Tamsulosin 0.4 mg PO QHS
11. Everolimus 10 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY: Metastatic renal cell carcinoma, dyspnea
SECONDARY: Deep venous thrombosis, 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 treating you at ___
___. You were admitted with concern for your shortness of
breath and recent CT scan findings. While admitted you underwent
labwork and imaging which were reassuring. You were found to be
walking well without desaturations and were cleared for home
from a mobility standpoint by our physical therapists.
Neurosurgery was consulted and recommended no acute surgical
intervention. You were recommended to wear a TLSO brace as
prescribed during your last admission but were not interested in
wearing this support. Another brace was ordered that may enable
you to have more flexibility while maintaining some stability.
Please use it as described. You will follow-up with Dr. ___,
___ will help determine the next steps in your evaluation.
Wishing you the best of health,
Your ___ team
Followup Instructions:
___
|
10862640-DS-10
| 10,862,640 | 29,865,442 |
DS
| 10 |
2175-03-01 00:00:00
|
2175-03-01 17:55:00
|
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:
Laparascopic Appendectomy
History of Present Illness:
___ with PMHx of alcohol abuse and liver surgery presenting with
abdominal pain and bloating. Three days ago, the patient began
to have bloating. Two days ago, he palpated his own abdomen and
found himself to be tender in the RLQ. Yesterday, his tenderness
increased, and today he began to have intermittent RLQ >
umbilical pain. He denies N/V or F/C. C/o anorexia today; last
meal was last night. Passing flatus and had ___ loose stools
today, which is his baseline. In the ED his physical exam
revealed RLQ tenderness to palpation and the CT scan shows
dilated appendix with appendecolith and adjacent stranding so he
was taken to the OR for laparascopic appendectomy. The patient's
LFTs and coags are within normal limits.
Past Medical History:
PMH - GERD, ?lactose intolerance, alcohol abuse
PSH - exploratory laparotomy in ___ at ___ for stabbing in the
liver with repair of liver damage
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM ON ADMISSION
VS: 97.6, 72, 166/93, 16, 100%
Gen - NAD
Heart - RRR
Lungs - CTAB
Abdomen - soft, non-distended, TTP in the RLQ, no rebound, no
guarding, negative Rovsing's, well healed mid-line laparotomy
scar and 2 JP drain scars on the right
Extrem - warm, no edema
PHYSICAL EXAM ON DISCHARGE
VS: 97.7, 59, 141/79, 18, 95%
Gen - NAD
Heart - RRR
Lungs - CTAB
Abdomen - soft, non-distended, non-tender, no rebound, no
guarding, well healed mid-line laparotomy scar and 2 JP drain
scars on the right
Extrem - warm, no edema
Pertinent Results:
___ 06:35PM BLOOD WBC-7.2 RBC-4.44* Hgb-15.1 Hct-46.3
MCV-104* MCH-33.9* MCHC-32.5 RDW-13.8 Plt ___
___ 06:35PM BLOOD Neuts-66.9 ___ Monos-6.1 Eos-2.8
Baso-1.0
___ 06:35PM BLOOD Glucose-82 UreaN-16 Creat-1.0 Na-140
K-4.2 Cl-100 HCO3-26 AnGap-18
___ 06:35PM BLOOD ALT-43* AST-45* AlkPhos-69 TotBili-0.5
___ 06:35PM BLOOD Albumin-4.7
Brief Hospital Course:
The patient presented as mentioned above and was admitted under
the acute care surgery service on ___ for management of his
acute appendicitis. He was taken to the operating room and
underwent a laparoscopic appendectomy. Please see operative
report for details of this procedure. He tolerated the procedure
well and was extubated upon completion. He was subsequently
taken to the PACU for recovery.
He was transferred to the surgical floor hemodynamically stable.
His vital signs were routinely monitored and he remained
afebrile and hemodynamically stable. He was initially given IV
fluids postoperatively, which were discontinued when he was
tolerating PO's. His diet was advanced to regular, which he
tolerated without abdominal pain, nausea, or vomiting.
At the time of discharge on ___, the patient was doing
well, afebrile with stable vital signs. The patient was
tolerating a regular diet, ambulating and pain was well
controlled. The patient received discharge teaching and
follow-up instructions and verbalized understanding of and
agreement with the discharge plan.
Medications on Admission:
1. Omeprazole 20 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Ascorbic Acid ___ mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Antabuse (disulfiram) 250 mg oral ___ times a week
6. Finasteride 5 mg PO DAILY
7. Calcium Carbonate 500 mg PO TID
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Omeprazole 20 mg PO DAILY
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
4. Senna 1 TAB PO BID
5. Aspirin 81 mg PO DAILY
6. Ascorbic Acid ___ mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Antabuse (disulfiram) 250 mg oral ___ times a week
9. Finasteride 5 mg PO DAILY
10. Calcium Carbonate 500 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. 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.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. 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:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the 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.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
10862644-DS-5
| 10,862,644 | 25,177,809 |
DS
| 5 |
2130-12-04 00:00:00
|
2130-12-07 11:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bloody diarrhea
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy ___
History of Present Illness:
___ with no significant PMH presenting with bloody diarrhea x 5
days. States that about 1 month prior to admission he started to
lose his appetite and was eating poorly. He has since lost 12
lbs unintentionally. At the same time he developed a sour taste
in his mouth that he notice every morning as well as epigastric
discomfort, both of which tended to resolve throughout the day
and then recurr the next AM. Then 5 days ago he developed
diarrhea, watery ___ x per day which then turned bloody the next
day and persisted. He does endorse some associated LLQ
discomfort with the diarrhea. Denies Nausea or vomiting or
fevers or chills. Denies any recent travel, sick contacts. He
works as a ___, but does not think he has had any accidental
oral contact to raw meat products. He has not eaten any
suspicious foods lately. He does not have any family history of
IBD. He is sexually active only with his wife. He has a sister
who had some type of intraabdominal cancer but he does not know
what type.
Of note he also states that over the last month he has had felt
some swelling near his right clavicle.
In the ED, initial vitals were: 97.8 78 ___ 99% RA
- CT Abdomen showed near pan colitis with preservation of only a
small segment large bowel at the splenic flexure.
- The patient was given 1LNS, cipro 400mg IV, Flagyl 500mg IV
and Morphine IV 5mg
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, constipation.
No dysuria. Denies arthralgias or myalgias.
Past Medical History:
HYPERLIPIDEMIA
GASTROESOPHAGEAL REFLUX
PREDIABETES
OSTEOARTHRITIS
Social History:
___
Family History:
Sister with unknown type of intestinal cancer.
Physical Exam:
EXAM ON ADMISSION:
Vitals: 98.4 83 124/70 18 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Fluctuance just inferior to right clavicle. Nontender.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, with minimal tenderness in the LLQ,
bowel sounds present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation.
EXAM ON DISCHARGE:
Vitals: Tm 98.1 BP 102-133/57-80 HR ___ RR 18 O2 99%RA
HEENT- Sclerae anicteric, PERRL, no hypopyon in anterior
chamber, moist MM, oropharynx clear
Chest- thickened tendon of proximal end of R clavicle with mild
surrounding swelling, no TTP, no crepitus
Abdomen- soft, non-distended, nontender, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Skin- no rashes, no lesions over shins
Remainder of the exam unchanged.
Pertinent Results:
====================LABS ON ADMISSION===================
___ 03:41PM BLOOD WBC-5.0 RBC-4.79 Hgb-14.3 Hct-42.6 MCV-89
MCH-29.9 MCHC-33.6 RDW-12.9 RDWSD-42.5 Plt ___
___ 03:41PM BLOOD Neuts-57 Bands-14* Lymphs-16* Monos-8
Eos-2 Baso-0 Atyps-1* ___ Myelos-2* AbsNeut-3.55
AbsLymp-0.85* AbsMono-0.40 AbsEos-0.10 AbsBaso-0.00*
___ 03:41PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 02:12PM BLOOD ___ PTT-27.6 ___
___ 02:12PM BLOOD Glucose-105* UreaN-22* Creat-1.1 Na-136
K-4.2 Cl-96 HCO3-30 AnGap-14
___ 02:12PM BLOOD ALT-54* AST-34 AlkPhos-61 TotBili-0.5
___ 02:12PM BLOOD Lipase-21
___ 02:12PM BLOOD Albumin-4.2
___ 03:41PM BLOOD CRP-196.5*
___ 06:32PM BLOOD Lactate-1.2
___ 02:12PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:12PM URINE Blood-SM Nitrite-NEG Protein-600
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 02:12PM URINE RBC-11* WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
======================LABS ON DISCHARGE=================
___ 07:40AM BLOOD WBC-4.2 RBC-4.60 Hgb-13.6* Hct-40.6
MCV-88 MCH-29.6 MCHC-33.5 RDW-12.7 RDWSD-41.3 Plt ___
___ 07:40AM BLOOD Glucose-99 UreaN-10 Creat-0.8 Na-138
K-4.1 Cl-103 HCO3-26 AnGap-13
___ 07:40AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.0
=========================IMAGING=====================
___ CT ABD and PELVIS with CONTRAST
Mild near pancolitis with preservation of only a small segment
large bowel at
the splenic flexure.
___ CXR
In comparison with study of ___, there is little
change and no
evidence of acute cardiopulmonary disease. No pneumonia,
vascular congestion,
or pleural effusion.
Again, there is an impression on the right side of the lower
cervical trachea,
raising the possibility of a thyroid mass.
======================OTHER RESULTS===================
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.
FEW POLYMORPHONUCLEAR LEUKOCYTES.
FEW RBC'S.
___ 11:25 pm STOOL CONSISTENCY: WATERY PRESENCE OF
BLOOD.
Source: Stool.
MICROSPORIDIA STAIN (Pending):
CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Preliminary):
Reported to and read back by ___ ___ ___ ___
330PM.
SHIGELLA FLEXNERI.
Presumptive identification pending confirmation by
___
Laboratory.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SHIGELLA FLEXNERI
|
AMPICILLIN------------ =>32 R
CEFTRIAXONE----------- <=1 S
LEVOFLOXACIN----------<=0.12 S
TRIMETHOPRIM/SULFA---- =>16 R
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
MANY POLYMORPHONUCLEAR LEUKOCYTES.
MANY RBC'S.
.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
Brief Hospital Course:
___ with no significant PMH p/w with bloody diarrhea x 5 days in
the setting of 1 month of fatigue, sweats/chills, and wt loss
found to have shigella on stool studies.
# Shigella enterocolitis
# Inflammatory diarrhea
The patient presented with bloody diarrhea for 4 days in the
setting of 1 month of fatigue, sweats/chills, and weight loss.
CT abdomen showed pancolitis, and CRP was 200. Flexible
sigmoidoscopy on ___ showed acute colitis in the sigmoid colon
but not rectum; biopsy results pending on discharge. Lab results
include C. diff neg, no cyclospora, no ova/parasites, no giardia
seen. Stool culture grew Shigella on ___. He received 3 days of
ciprofloxacin and metronidazole while inpatient, completing the
appropriate antibiotic course for Shigellosis. He did not have
another episode of blood in his stools after admission. Given
that he works in the ___ industry, he was advised to
stay out of work until he had three negative stool samples for
Shigella. His PCP was informed of the results. It was also
confirmed with hospital epidemiology that they will inform ___
department of health of results.
# GERD
In addition, the patient had epigastric discomfort, sour taste
in mouth, and loss of appetite, consistent with esophageal
reflux (GERD). He was started on omeprazole 20mg once a day. He
will follow up with endoscopy in ___ weeks to evaluate this
further.
# Thyroid nodule
CXR on ___ showed a thyroid nodule that is unchanged from a
prior CXR in ___. Given he had no symptoms and TSH was normal
in ___, we recommend follow up outpatient with a thyroid
ultrasound.
# Right chest swelling
On presentation, the patient was complaining of right chest
swelling on admission. On exam, he has thickened tendon of
proximal end of right clavicle with mild surrounding swelling,
nontender. Given his history of regular weight lifting and
swelling has spontaneously improved already, we think this is
likely tendonopathy from overuse. CXR also ruled out underlying
mass.
Transitional issues:
- Please take omeprazole 20mg once a day for your upper
abdominal discomfort.
- Please follow up with your primary care doctor on ___ for the
results of Yersinia serology and colon biopsy.
- Patient should follow up with a gastroenterologist to get a
full colonoscopy and endoscopy in ___ weeks.
- Consider a thyroid ultrasound to further evaluate likely
thyroid nodule.
- FULL CODE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Shigella enterocolitis
Gastroesophageal reflux disease (GERD)
Thyroid nodule
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for bloody diarrhea for 5 days. We performed a
sigmoidoscopy, which gave us a look at only part of your colon.
From this, we took samples from your colon, and the results are
still pending. A stool culture returned positive for Shigella,
which causes infectious colitis. You received 3 full days of
antibiotics, which is the treatment for Shigella. You should not
work until cleared by your primary care physician.
In addition, you were having some upper abdominal discomfort and
loss of appetite, and we think this may be due to esophageal
reflux (GERD). Please take omeprazole 20mg once a day.
Lastly, we noticed a thyroid nodule on your chest x-ray, please
follow up with your primary care doctor to get a thyroid
ultrasound.
It was a pleasure taking care of you! We wish you all the best.
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10862731-DS-17
| 10,862,731 | 23,633,050 |
DS
| 17 |
2160-12-02 00:00:00
|
2160-12-02 19:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ w/ hx gall bladder adenocarcinoma, diagnosed
in ___, s/p chemoradiation (last cycle completed ___ p/w 2
wks abdominal pain. The pain was initially intermittent. The
patient was seen by Dr. ___ on ___ and diagnosed with
possible UTI, prescribed omeprazole and cipro. Over time, the
pain did not improve, and the pt went to ___
___ on ___. She was admitted for a stay of one day and a
CT abdomen did not show pathology that would explain pt sxs (see
impression below). She continued to be treated for a UTI. Pain
has gotten worse, particularly in the past 48 hours. She states
that the pain has been ___ in the past two days, and it
essentially wraps around both flanks, and then creeps up toward
the epigastrium. It is unrelated to eating. The pain is not
relieved or worsened with defecation. No urinary symptoms. Some
pleuritic component to pain. Some nausea over the past day, and
vomited x1 a few days ago. The patient has had no diarrhea. No
fever, chills, SOB, CP, urinary sxs. Last BM was ~3 days ago,
but pt continues to pass gas.
Reviewed outside hospital records from ___
___ on ___:
-CT scan from ___ demonstrated contracted gallbladder.
Bilateral renal cysts. Small umbilical hernia.
-CXR on ___ demonstrated no radiographic e/o acute
cardiopulmonary process.
UA and culture was negative.
In ED initial vitals were: pain 10 98.3 77 174/61 100% RA.
Exam was significant for some crackles RLL, otherwise CTAB, RRR
Abd soft ND, TTP epigastrum and LUQ, no rebound or guarding.
Labs were significant for Na 126, Mg 1.4, Cr 0.8, Hct 32 and
unremarkable LFTs. Lactate nl. UA only remarkable for sm blood
in urine.
Patient was given 1L NS, 5mg IV morphine
Patient underwent CTA of chest, and demonstrated no large PE on
preliminary read. The patient was given zofran for nausea.
Final vitals prior to transfer were Vital Signs: Temp: 98.8 °F
(37.1 °C), Pulse: 75, RR: 16, BP: 146/68, O2Sat: 98.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies cough, shortness of breath, or wheezes.
Denies diarrhea, constipation, abdominal pain, melena,
hematemesis, hematochezia. Denies dysuria, stool or urine
incontinence. Denies arthralgias or myalgias. Denies rashes or
skin breakdown. No numbness/tingling in extremities. All other
systems negative.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR): Stage III (T4,N1,M0)
gallbladder adenocarcinoma
ONCOLOGIC HISTORY:
-Presented with epigastric pain in ___.
-MRI ___ showed a 4.9 x 3.2 gallbladder mass with adjacent
liver enhancement measuring approximately 3.3 x 3.2 cm.
-On ___, she underwent EUS-guided biopsy of a periportal
lymph node, which was positive for adenocarcinoma. She was
treated with 8 cycles gemcitabine/cisplatin as well as radiation
with concurrent capecitabine, which completed ___.
-Her course was complicated by newly diagnosed rheumatoid
arthritis.
PAST MEDICAL HISTORY:
-Hypertension
-umbilical hernia
-RA
Social History:
___
Family History:
negative for any known cancers.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals -
98.2 145/60 71 26 97%RA
GENERAL: NAD, lying comfortably in bed with daughter at side
___: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
MM mildly dry, thrush on tongue
CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, tender to deep palpation in
eqigastrium, no other locales, no rebound/guarding, no
hepatosplenomegaly appreciated
BACK: mild CVA tenderness b/l, no spinal tenderness
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities, negative straight leg raise
b/l
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes appreciated
Pertinent Results:
ADMISSION LABS:
___ 10:00AM BLOOD WBC-4.9 RBC-3.23* Hgb-10.9* Hct-31.8*
MCV-99* MCH-33.8* MCHC-34.4 RDW-14.9 Plt ___
___ 10:00AM BLOOD Neuts-77.6* Lymphs-14.1* Monos-7.2
Eos-0.9 Baso-0.2
___ 07:40AM BLOOD ___ PTT-27.8 ___
___ 10:00AM BLOOD Glucose-131* UreaN-18 Creat-0.8 Na-126*
K-4.9 Cl-87* HCO3-27 AnGap-17
___ 10:00AM BLOOD ALT-20 AST-55* AlkPhos-90 Amylase-45
TotBili-0.5
___ 10:00AM BLOOD Albumin-3.7 Calcium-9.4 Phos-3.2 Mg-1.4*
___ 10:00AM BLOOD Osmolal-262*
___ 10:00AM URINE Color-Straw Appear-Clear Sp ___
___ 10:00AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 10:00AM URINE RBC-12* WBC-3 Bacteri-NONE Yeast-NONE
Epi-3
PERTINENT LABS:
___ 06:55AM BLOOD WBC-3.0* RBC-3.16* Hgb-10.4* Hct-31.8*
MCV-101* MCH-32.9* MCHC-32.7 RDW-14.7 Plt ___
___ 09:40AM BLOOD WBC-3.2* RBC-3.06* Hgb-10.0* Hct-30.4*
MCV-99* MCH-32.7* MCHC-33.0 RDW-14.7 Plt ___
___ 07:40AM BLOOD WBC-3.2* RBC-2.87* Hgb-9.4* Hct-28.2*
MCV-98 MCH-32.7* MCHC-33.3 RDW-14.8 Plt ___
___ 10:00AM BLOOD WBC-4.9 RBC-3.23* Hgb-10.9* Hct-31.8*
MCV-99* MCH-33.8* MCHC-34.4 RDW-14.9 Plt ___
___ 06:55AM BLOOD Plt ___
___ 09:40AM BLOOD Plt ___
___ 09:40AM BLOOD ___ PTT-28.5 ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD ___ PTT-27.8 ___
___:55AM BLOOD Glucose-101* UreaN-18 Creat-1.0 Na-133
K-4.3 Cl-96 HCO3-27 AnGap-14
___ 09:40AM BLOOD Glucose-110* UreaN-19 Creat-1.0 Na-131*
K-3.4 Cl-93* HCO3-29 AnGap-12
___ 07:40AM BLOOD Glucose-93 UreaN-17 Creat-0.9 Na-128*
K-3.5 Cl-92* HCO3-28 AnGap-12
___ 07:40AM BLOOD ALT-15 AST-25 LD(LDH)-175 AlkPhos-83
TotBili-0.6
___ 06:55AM BLOOD Calcium-9.5 Phos-2.9 Mg-1.7
___ 07:40AM BLOOD Albumin-3.2* Calcium-8.9 Phos-3.8 Mg-2.
MICRO:
Urine culture (___): no growth
___ 10:45 am BLOOD CULTURE
Blood Culture, Routine (Pending
STUDIES:
CTA ___:
IMPRESSION:
1. No pulmonary embolism to the proximal segmental level of the
lower lobes. The distal segmental and subsegmental lower lobe
pulmonary arteries cannot be evaluated due to patient motion.
2. Pulmonary arterial hypertension.
3. 3-mm right apical pulmonary nodule, similar to ___.
L-spine and T-spine radiograph (___):
THORACIC SPINE: There are no compression deformities of the
thoracic spine. Intervertebral disc spaces are relatively
preserved. There is mild spurring anteriorly of several mid
thoracic vertebral bodies consistent with early degenerative
changes. There is no abnormal ___- or retrolisthesis. The
heart size is enlarged. No focal consolidation or
pneumothoraces are seen.
LUMBAR SPINE: There are five non-rib-bearing lumbar-type
vertebral bodies. Evaluation is somewhat limited due to the
contrast material within the bowel. There are no compression
deformities. There is generalized demineralization. There is
mild grade 1 anterolisthesis of L4 over L5 and posterior facet
joint arthropathy of the lower lumbar spine at L4-L5.
Sacroiliac joints are grossly preserved.
Brief Hospital Course:
BRIEF CLINICAL SUMMARY:
Ms. ___ is a ___ w/ hx gall bladder adenocarcinoma, diagnosed
in ___, s/p chemoradiation (last cycle completed ___ p/w 2
wks abdominal pain, worse in the past 48 hours. Work-up this
far, including CT abd/pelvis and CTA of chest has been
unrevealing.
ISSUES:
#. Abdominal Pain: Much improved with morphine, ___ today.
Still no clear diagnosis. DDx remains broad. Most likely
clinically would be nephrolithiasis vs. neuropathic pain. Would
have expected nephrolithiasis to have shown up on outside CT.
pain regimen was changed to morphine immediate release as
needed.
# Hyponatremia: Improved, Na 131 at discharge, improved with
hydration.
#. Gallbladder adenocarcinoma, diagnosed in ___, s/p
chemoradiation (last cycle completed ___, followed by Dr.
___.
#. Thrush: pt w/ thrush on tongue. Pt states has had since last
chemo, on nystatin at home. improved with clotrimazole troche.
d/c w/ 5d of clotrimazole troche.
# RA: pt diagnosed relatively recently w/ rheumatoid arthritis.
continued prednisone 9mg qd. asymptomatic. follow-up w/ rheum
per schedule.
#. HTN: normotensive. continued home antihypertensive regimen,
including HCTZ, amlodipine, atenolol, w/ holding parameters.
TRANSITIONAL ISSUES:
[]please follow up on back/flank pain. Neuropathic vs. renal
stone.
Medications on Admission:
Medications - Prescription
AMLODIPINE - (Prescribed by Other Provider) - 5 mg Tablet - 2
Tablet(s) by mouth DAILY (Daily)
ATENOLOL - (Prescribed by Other Provider) - 50 mg Tablet - 2
Tablet(s) by mouth DAILY (Daily)
CIPROFLOXACIN [CIPRO] - 250 mg Tablet - 1 Tablet(s) by mouth Q12
hour for 5 days
HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 12.5 mg
Capsule - 2 Capsule(s) by mouth DAILY (Daily)
NYSTATIN - 100,000 unit/mL Suspension - 5 ml(s) by mouth four
times a day for 14 days - No Substitution
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth daily
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth every 12 hours
as
needed for pain
POLYETHYLENE GLYCOL 3350 - (Prescribed by Other Provider) - 17
gram Powder in Packet - 1 pkt by mouth twice a day
PREDNISONE - 10 mg Tablet - 1 Tablet(s) by mouth AS DIRECTED
take
1 tablet daily - No Substitution
PREDNISONE - 5 mg Tablet - 1 Tab by mouth AS DIRECTED take 1 x
5mg tablet daily (with additional 1mg tabs as prescribed (total
9mg daily x 1mo, then 8mg daily dose)
PREDNISONE - 1 mg Tablet - 1 Tab by mouth as prescribed: 4 x 1mg
tabs with 5mg tablet x1 (total 9mg) daily prednisone x 1month,
then decrease to total 8mg daily dose
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
q6hour
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider) - 325 mg Tablet
-
2 Tablet(s) by mouth every six (6) hours as needed for Pain no
more than 2000mg per day
CALCIUM CARBONATE-VITAMIN D3 - 500 mg calcium (1,250 mg)-400
unit
Tablet - 1 Tablet(s) by mouth daily
DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 1 Capsule(s) by mouth three a day
SENNOSIDES [SENNA] - 8.6 mg Tablet - 2 Tablet(s) by mouth once a
day
Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
3. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
4. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day) for 5 days.
Disp:*20 Troche(s)* Refills:*0*
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
4 x 1mg
tabs with 5mg tablet x1 (total 9mg) daily prednisone x 1month,
then decrease to total 8mg daily dose (as prescribed by your
rheumatologist).
7. prednisone 1 mg Tablet Sig: Four (4) Tablet PO once a day: 4
x 1mg
tabs with 5mg tablet x1 (total 9mg) daily prednisone x 1month,
then decrease to total 8mg daily dose (as prescribed by your
rheumatologist).
8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea, abdominal pain.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit
Tablet Sig: One (1) Tablet PO once a day.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): hold for loose stools.
12. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day)
as needed for constipation: hold for loose stools.
13. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation: continue to take while taking pain medications,
hold for loose stools.
Disp:*15 Powder in Packet(s)* Refills:*0*
14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation: continue to take while taking pain medications,
hold for loose stools.
Disp:*45 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
15. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for abdominal
discomfort.
Disp:*45 Tablet, Chewable(s)* Refills:*0*
16. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO twice a
day.
Disp:*120 Capsule(s)* Refills:*0*
17. morphine 15 mg Tablet Sig: ___ Tablet PO every ___ hours
as needed for pain for 3 weeks.
Disp:*84 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
abdominal pain
Secondary Diagnosis:
gallbladder carcinoma
rheumatoid arthritis
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.
You were admitted to the ___ for abdominal pain that had
become more severe.
Although we did a thorough work-up, we were not able to identify
a definitive cause of your abdominal pain. We think the most
likely etiology of your pain is from kidney stones. With
medications, your pain improved.
You should continue taking your medications as you had prior to
your hospitalization, EXCEPT:
STOP taking CIPROFLOXACIN
STOP taking OXYCODONE
STOP taking nystatin
CHANGE tylenol to 650mg every 6 hours as needed for pain
START polyethylene glycol and bisacodyl as needed for
constipation
START gabapentin 200mg twice per day
START taking morphine immediate release (___) 7.5-15mg every ___
hours as needed for abdominal pain
START simethicone, as needed, for bloating or cramping
Followup Instructions:
___
|
10862731-DS-19
| 10,862,731 | 25,113,092 |
DS
| 19 |
2161-03-12 00:00:00
|
2161-03-12 18:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Delirium
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old female with a history of gallbladder
cancer s/p CTX and RTX presents with confusion - per the
daughter, she was confused at the time of discharge from her
last hospitalization however she feels ___ is more confused
than usual. The patient was also complaining of abdominal pain
which is intermittent and consistent with prior abdominal pain
history. She also has a history of hyponatremia and was
discharged home on salt tablets at last hospitalization; on the
day prior to admission, she was seen by her PCP in the clinic
and was found to have a sodium of 128. Given the worsening
confusion, PCP recommended ___ evaluation. In the ___, abdominal
CT was performed - no new lesions or infectious focus was noted.
No leukocytosis or fevers. She is recently placed on
prednisone for rheumatoid arthritis flare. Review of systems
otherwise negative for chills, CP, SOB, cough, diaphoresis,
nausea/vomiting, diarrhea, melena/hematochezia, dysuria,
hematuria.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR): Stage III (T4,N1,M0)
gallbladder adenocarcinoma
ONCOLOGIC HISTORY:
-Presented with epigastric pain in ___.
-MRI ___ showed a 4.9 x 3.2 gallbladder mass with adjacent
liver enhancement measuring approximately 3.3 x 3.2 cm.
-On ___, she underwent EUS-guided biopsy of a periportal
lymph node, which was positive for adenocarcinoma. She was
treated with 8 cycles gemcitabine/cisplatin as well as radiation
with concurrent capecitabine, which completed ___.
-Her course was complicated by newly diagnosed rheumatoid
arthritis.
PAST MEDICAL HISTORY:
-Hypertension
-umbilical hernia
-RA
Social History:
___
Family History:
negative for any known cancers.
Physical Exam:
VS: 98, 156/73, 78, 16, 98% RA
Gen: Pleasant Hispanic female in no apparent distress
Neuro: alert, oriented X 3
Cardiac: Nl s1/s2, RRR, no appreciable murmurs
Pulm: clear bilaterally
Abd: reducible hernia, soft, nontender, normoactive bowel sounds
Ext: no edema noted
DISCHARGE EXAM UNCHANGED FROM ABOVE.
Pertinent Results:
___ 05:35PM URINE HOURS-RANDOM CREAT-56 SODIUM-84
POTASSIUM-37 CHLORIDE-75
___ 05:35PM URINE OSMOLAL-438
___ 06:55AM GLUCOSE-88 UREA N-10 CREAT-0.6 SODIUM-128*
POTASSIUM-3.3 CHLORIDE-90* TOTAL CO2-25 ANION GAP-16
___ 06:55AM CALCIUM-9.4 PHOSPHATE-3.4 MAGNESIUM-1.5*
___ 06:55AM WBC-5.6 RBC-3.70* HGB-10.9* HCT-31.6* MCV-85
MCH-29.4 MCHC-34.4 RDW-13.8
___ 06:55AM PLT COUNT-309
___ 06:55AM ___ PTT-35.7 ___
___ 08:25PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG
Discharge labs:
___ 06:50AM BLOOD WBC-4.8 RBC-3.66* Hgb-10.8* Hct-31.8*
MCV-87 MCH-29.5 MCHC-34.1 RDW-14.8 Plt ___
___ 07:10AM BLOOD Glucose-95 UreaN-15 Creat-0.8 Na-124*
K-4.0 Cl-87* HCO3-26 AnGap-15
CT abd ___:
IMPRESSION: 1. Local recurrence of gallbladder adenocarcinoma,
locally invading the liver and the gallbladder fossa. A large
necrotic centered lymph node encases the celiac and SMA axes. 2.
Mild wedge deformity of T12 is new from ___.
Brief Hospital Course:
Ms. ___ was admitted to ___ on ___ for worsening mental
status at home in setting of gallbladder adenocarcinoma. Her
hospital course is detailed as below:
1) Delirium/altered mental status: Ms. ___ was determined to
have a hypoactive delirium on admission. Discussion with her
daughter identified the patient's baseline to be somewhat
independent at home - she was able to clean and dress herself,
but the cooking and shopping were performed by the daughter or
other family members. Ms. ___ daughter reported a chronic
decline in independence and functional ability, which was more
acutely exacerbated. On the day prior to admission, she was
acutely confused and unsure of where she was. On exam, she
believed herself to be in ___ (rather than ___, and
was disoriented to time. The etiology of this decline remains
unclear. Her sodium levels were consistently near her normal
range, she denied pain, and an infectious work-up was negative.
She did receive a CT abdomen. As indicated above, this
unfortunately showed a recurrence of her gallbladder
adenocarcinoma. Attempt was made to perform MRI to rule out
leptomeningeal neoplastic involvement, but this was
unfortunately of poor quality due to patient non-compliance and
therefore unable to be interpreted. It was surmised her
recurrent disease and ongoing malnutrition played a role in her
more recent cognitive decline. By end of discharge, her mental
status had improved somewhat. She remained disoriented to time
or place, but her daughter stated she was acting much closer to
her usual state of health/mentation.
2) Recurrent gallbladder carcinoma - Unfortunately, Ms. ___
gallbladder adenocarcinoma was demonstrated to be recurrent, as
seen in above CT abdomen result. This finding was communicated
to her and her family; her primary oncologist was involved in
this discussion. It was felt her advancing age and poor overall
state of health would be detrimental to outcomes from further
chemotherapy or invasive surgical options. After much emotional
support and discussion, Ms. ___ family elected to pursue
palliative management and hopsice care for future health needs.
3) Hyponatremia - Ms. ___ presented with a sodium level in
the high 120's, approximately near her baseline. This was
suspected to be secondary to SIADH based on her underlying
malignancy, euvolemic appearance, and previous notes in the
medical record. She did receive a fluid challenge, given her
poor PO intake and clinician concern for dehydration - this
unfortunately temporarily exacerbated her hyponatremia. Fluid
restrictions were then re-enforced, and she received doses of
oral furosemide on sequential days. She demonstrated good
response to this therapy, and was discharged with a sodium level
near her baseline.
4) Thrush - Ms. ___ was noted to have oral candidiasis on
physical exam. She was receiving oral nystatin as an outpatient.
Given the severity of her thrush, she was placed on a 14 day
course of oral fluconazole. This regimen was to be discontinued
on ___.
================================================
TRANSITIONAL ISSUES:
- Ms. ___ was made DNR/DNI on ___ prior to discharge at
the wishes of her daughter and health-care proxy, ___. The
patient elected to defer to her daughter for this decision.
- Ms. ___ was discharged with home hospice services.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Amlodipine 10 mg PO DAILY
hold for SBP<100 and inform H.O.
2. Atenolol 100 mg PO DAILY
hold for SBP<100 or HR<60 and inform H.O.
3. Docusate Sodium 100 mg PO BID
4. Morphine SR (MS ___ 30 mg PO Q8H
hold for over-sedation or RR<12
5. Morphine Sulfate ___ 15 mg PO Q4H:PRN pain
6. Nystatin Oral Suspension 5 mL PO QID
7. Polyethylene Glycol 17 g PO DAILY
8. PredniSONE 7 mg PO DAILY
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Senna 2 TAB PO DAILY
11. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Pantoprazole 40 mg PO Q12H
3. Prochlorperazine 10 mg PO Q6H:PRN nausea
4. Senna 2 TAB PO DAILY
5. hospice
Screen and admit to hospice care
6. Acetaminophen 975 mg PO TID:PRN pain
7. PredniSONE 7 mg PO DAILY
8. Fluconazole 200 mg PO Q24H
9. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
- recurrent gallbladder adenocarcinoma
- delirium
SECONDARY:
- SIADH
- rheumatoid arthritis
- ___ esophagitis
Discharge Condition:
Mental Status: Confused - most of the time.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
Thank you for choosing ___ for your medical care. You came to
the hospital because of increasing confusion at home. While you
were here, you had a CT scan which showed your gallbladder
cancer has returned. We are very sorry to learn of your cancer
recurrence. You and your family have decided to treat the
symptoms of your disease and ensure your comfort. You are going
home with hospice care support. It was a pleasure participating
in your care.
Followup Instructions:
___
|
10862893-DS-9
| 10,862,893 | 29,403,530 |
DS
| 9 |
2155-01-19 00:00:00
|
2155-01-20 18:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amitriptyline / tenofovir / Penicillins / dapsone / ritonavir /
Mepron
Attending: ___
Chief Complaint:
acute liver injury, respiratory failure
Major Surgical or Invasive Procedure:
endotracheal intubation at ___
transesophageal echocardiogram
incision and drainage of right hand abscess
History of Present Illness:
Ms. ___ is a ___ year old female with a history of HIV who was
found down in the lobby of her apartment buidling by neighbors
earlier this evening. By report she was brought into an
apartment where she was unresponsive and EMS was called, on
arrival EMS gave her 0.4mg of narcan with no effect. She was
then taken to ___ where she was given another 0.4mg
of narcan, she then woke up and became very aggressive. She was
given a total of 20mg of IV ativan, then became lethargic and
was intubated for airway protection. Labs at the OSH were
notable for: AST of 3506, ALT of 1361, T-bili of 6.0, D-bili of
3.1, Cr of 2.69, lipase of 440, myoglobin>1000, INR of 2.85 and
troponin I of 2.98. U/A was concerning for infection 25 leuks,
+nitrites, and moderate bacteria. A CT of her head was limited
by motion but grossly negative, She had a right IJ placed for
access, was given empiric vancomycin and ceftriaxone, there was
concern for acute liver failure so she was transferred to ___
for further evaluation.
.
In the ED, initial VS were: 37.6C, 95, 106/56, 100% on AC
16x500, PEEP of 5, FiO2 of 100. Labs were notable for Na of
147, HCO3 of 36, Cr of 2.9, AST of 2467, ALT of 999, T-bili of
6.0, serum acetaminophen level of 7, CK of 4028, MB of 22,
troponin of 0.17, INR of 2.9, U/A showed moderate blood but only
2 RBC's. Urine tox screen was positive for methadone. Toxicology
was consulted in the ER and recommended starting a NAC infusion.
Hepatology was consulted who recommended continuing NAC, serial
tylenol levels, LFT's and renal function, broad spectrum abx,
PPI and blood work for transplant work up. ABG on AC 16x500,
100% FiO2 was 7.47/52/352. Imaging was significant for bibasilar
atelectasis, no evidence of any infectious process. VS on
transfer: 112/63, 96, 100% on 500x17, PEEP 5, FiO2 100%, she has
not woken up in the ER, but did grimace with OGT replacement,
has been on propofol in th ER.
.
On arrival to the MICU initial VS were: 95, 113/70, 99% on AC
16x500, PEEP of 5 and FiO2 of 60%. Off sedation she is moving
all extremities but not responding to any commands, appears
comfortable.
Past Medical History:
HIV: most recent CD4 422 in ___
h/o Mac PNA ___, MAC PNA with hemolytic anemia and hepatitis in
___
Hepatitis C
IVDU, attends ___ clinic is Habit Opco in ___,
___
Social History:
___
Family History:
non-contributory
Physical Exam:
General Appearance: Well nourished
Eyes / Conjunctiva: PERRL, conjunctval injection L>R
Head, Ears, Nose, Throat: Endotracheal tube, OG tube, no teeth
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, bilateraly
inguinal ecchymoses with evidence of needle sticks and some
blood oozng
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, bilateral anterior shin
hyperpigmentation, consistent with chronic venous stasis
changes, area of erythema along the lateral edge of right foot
Skin: Warm, scattered areas of petechie and small ecchymoses
with minimal trauma along clothing lines
Neurologic: Responds to: Noxious stimuli, Movement: Purposeful,
Sedated, Tone: Normal, brisk, symmetric reflexes in b/l lower
extremities
Pertinent Results:
Admission labs:
___ 11:30PM BLOOD WBC-10.4 RBC-4.13* Hgb-11.4* Hct-39.0
MCV-95 MCH-27.7 MCHC-29.3* RDW-18.6* Plt Ct-90*
___ 11:30PM BLOOD ___ PTT-29.8 ___
___ 11:30PM BLOOD Glucose-115* UreaN-60* Creat-2.9* Na-147*
K-4.5 Cl-104 HCO3-36* AnGap-12
___ 11:30PM BLOOD ALT-999* AST-2467* CK(CPK)-4028*
AlkPhos-48 TotBili-6.0*
___ 11:30PM BLOOD cTropnT-0.17*
___ 11:30PM BLOOD CK-MB-22* MB Indx-0.5
___ 11:30PM BLOOD Albumin-2.8* Calcium-7.0* Phos-1.9*
Mg-2.1
___ 11:30PM BLOOD Lipase-292*
___ 11:30PM URINE UCG-NEGATIVE
.
Other pertinent results:
___ 06:34AM BLOOD WBC-8.3 Lymph-15* Abs ___ CD3%-40
Abs CD3-504* CD4%-16 Abs CD4-205* CD8%-22 Abs CD8-270
CD4/CD8-0.8*
___ 03:31AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
___ 04:33AM BLOOD IgM HBc-NEGATIVE IgM HAV-NEGATIVE
___ 04:23AM BLOOD HEPATITIS C VIRAL RNA, GENOTYPE: 1a
___ 04:33AM BLOOD CERULOPLASMIN: 43
___ 11:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-POS
.
Microbiology:
Blood cultures ___) ___: Positive for Staph
epidermidis in ___ bottles (from separate sets of cultures),
resistent only to penicillin. Positive for diphtheroids in ___
bottles after 5 days.
Blood culture ___: no growth
Urine culture ___: no growth
Sputum ___: BETA STREPTOCOCCUS GROUP A. SPARSE GROWTH.
HIV viral load ___: HIV-1 RNA is not detected.
HCV viral laod ___: 13,267,294 IU/mL.
Blood culture ___: pending
Skin scrapings ___ (preliminary): HERPES SIMPLEX LIKE
CYTOPATHIC EFFECT CULTURE CONFIRMATION PENDING.
Swab (right hand) ___: GRAM STAIN: NO POLYMORPHONUCLEAR
LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE: NO
GROWTH
.
CT C-epine without contrast ___:
1. Orogastric tube is coiled within the oro- and hypopharynx and
does not
reach the stomach (based on the CT of the torso).
2. No acute fracture or subluxation.
3. Left supraclavicular lymphadenopathy of unknown clinical
significance.
NOTE ADDED AT ATTENDING REVIEW: There is a hypodense lesion in
the right side of the C6 vertebral body. This may represent a
hemangioma or focal fat deposition. However, comparison with
prior studies is recommended to exclude a more aggressive
etiology, such as a neoplasm. If prior studies are not
available, then an MR of the cervical spine may be helpful.
.
CT torso ___:
1. Appropriately placed endotracheal tube. Orogastric tube ends
in the
distal esophagus.
2. Left supraclavicular lymphadenopathy.
3. Cardiomegaly and prominent pulmonary artery. Enlarged
pulmonary artery
may relate to pulmonary artery hypertension; correlate
clinically.
4. Mildly fatty liver. Steatohepatitis cannot be excluded based
on imaging.
5. No acute process of the abdomen orpelvis.
.
TTE ___:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). The right ventricular cavity is mildly dilated with mild
global free wall hypokinesis. 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. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Dilated right ventricle with mild global systolic
dysfunction. Normal global and regional left ventricular
systolic function. Mild pulmonary hypertension.
.
RUQ U/S ___:
1. Patent hepatic vasculature.
2. Sludge in the gallbladder with no sonographic evidence of
cholecystitis.
.
MR ___ contrast ___: Diffuse marrow signal
abnormality involving the cervical spine, which may be seen with
reactive marrow changes in patients with anemia, diffuse
neoplastic marrow infiltration such as with lymphoma is also a
consideration. The focal lesion seen in C6 vertebral body likely
represents an atypical hemangioma. Attention on followup imaging
is recommended.
.
TEE ___: No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). The right
ventricular cavity is dilated with borderline normal free wall
function. The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic plaque
to 32 cm from the incisors. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. No aortic valve
abscess is seen. No aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. No mass or vegetation is
seen on the mitral valve. Mild to moderate (___) mitral
regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
IMPRESSION: No valvular vegetation seen. Mild to moderate mitral
regurgitation.
.
Right hand ___: There is soft tissue swelling along the
hypothenar aspect of the hand and wrist. Underlying infection is
suspicious. There is no cortical destruction to indicate acute
radiographic/osteomyelitis. No retained radiopaque foreign
bodies are seen.
.
CTA chest ___:
1. No acute aortic pathology or pulmonary embolism.
2. Small bilateral pleural effusions, right larger than left,
with adjacent compressive atelectasis and bilateral lower lobe
subsegmental atelectasis, worse since ___. Lingular
collpase similar to prior study. 3. Diffuse ground-glass opacity
throughout the lungs is nonspecific but may be related to fluid
overload in the appropriate clinical setting.
4. Circumferential esophageal wall thickening may be due to
esophagitis.
5. Prominant hilar lymph nodes of uncertain significance.
.
Right lower extremity ultrasound ___: No evidence of deep
vein thrombosis in the right leg.
Brief Hospital Course:
___ y/o female with HIV, hepatitis C, h/o IVDU, on methadone
maintenance, who was found down in her apartment building. Her
mental status improved with naloxone, but then she became
agitated, was given lorazepam, and required intubation for
airway protection. She was found to have acute kidney and liver
injury, which presumable caused accumulation of methadone,
explaining her mental status on presentation. She was admitted
to the intensive care unit, where her liver and kidney function
recovered. Following extubation, she was transferred to the
medical floor for further management. As the ___ mental
status improved, she began to withdraw, and methadone was
titrated until her withdrawal symptoms were relieved. ___ blood
culture bottles from ___ grew Staph epidermidis, so
the patient was started on vancomycin. She underwent TEE, which
was negative for valvular vegetation. She was discharged to
rehab with a PICC to complete a 2-week course of vancomycin.
.
#Found down/Non-responsiveness: The patient was found down in
her apartment. She received naloxone in the field without
improvement of her mental status. A second dose of naloxone was
given in the emergency department at ___, with
improvement in the ___ somnolence. However, the patient
became agitated, was given IV ativan, and required intubation
for airway protection. As her condition improved, she was
extubated, and returned to a normal mental status.
.
#Acute Liver Injury: The patient presented with ALT 999, AST
2486, AlkPhos 48, Tbili 6.0, INR 2.9. Precipitating source not
completely clear, mildly elevated acetaminophen level of 7
(given at OSH) but has subsequently trended to 0. Once the
patient woke up, she denied any unusual ingestions, and her son
was not aware of any toxic ingestions, though notes she has had
fatigue and poor appetite for ~5 days. There was no documented
hypotension to suggest possible shock liver. Hepatitis
serologies showed evidence of prior hep B vaccination and hep A
exposure or vaccination. Hepatitis C viral load was 13 million,
genotype 1a. Right upper quadrant ultrasound showed patent
hepatic vasculature. Ceruloplasmin was normal. The patient was
treated empirically with an N-acetyl cysteine drip, although
there was no clear history of acetaminophen overdose. The
___ liver function tests gradually improved, and at the
time of discharge, were notable only for mildly elevated
transaminases ALT 102, AST 43, with normal Alk phos, Tbili, and
INR.
.
#Acute kidney injury: The patient presented with creatinine 2.9.
Her creatinine rapidly normalized with IV fluids and was thought
to be pre-renal in etiology. There was a second mild increase in
creatinine on ___ that was thought to be related to
mild contrast nephropathy. At the time of discharge, the
___ creatinine was 1.1.
.
#Rhabdomyolysis: CK was 4000 on admission, and was likely higher
than this prior to admission. This was thought to be due to the
___ being down for an extended period of time. The patient
was treated with IV flids, with normalization of her CK.
.
#Respiratory failure: The patient was intubated for airway
protection in the emergency department at ___. She
was extubated on ___.
.
#Hypoxia: The patient had persistent hypoxemia, requiring 4L of
oxygen through most of her hospital course, but requiring only
2L/min at the time of discharge. The patient informed the
medical team that she is on home oxygen at a rate of 2L/min.
According to the ___ primary care physician, the ___
hypoxia is presumed to be related to COPD. Her lasts PFTs
reported showed severe obstructive pulmonary disease, with
severely reduced diffusion capacity. The patient has a
pulmonologist, Dr. ___ ___. The patient was treated
with her home regimen of Spiriva. She uses Symbicort at home,
but was given Advair while in the hospital. She was discharged
on her home regimen of Spiriva and Symbicort.
.
#Pulmonary hypertension/RV dysfunction: Echocardiogram showed
dilated right ventricle with mild global systolic dysfunction,
along with evidence of pulmonary hypertension. Per PCP, echo
from ___ showed normal RV function. CTA chest showed
no pulmonary embolism. The ___ pulmonary hypertension was
thought to be related to her underlying lung disease, although
the differential diagnosis would include pulmonary arterial
hypertension related to HIV. She will follow up with her primary
care doctor and pulmonologist for further evaluation.
.
#Staph epidermidis bacteremia: ___ blood cultures from ___
___ grew Staph epidermidis. There were no positive blood
cultures from ___. TEE was negative for valvular vegetation.
The patient was treated with vancomycin, with a plan for a
2-week course (day 1 = ___ per Infectious Diseases
recommendations. The patient will complete her course of
vancomycin on ___. Her PICC should be removed once the
course of vancomycin is complete.
.
#Positive blood culture with diphtheroids: ___ blood cultures at
___ grew diphtheroids. This was felt to be a
contaminant by the Infectious Diseases service.
.
#Supraclavicular/hilar lymphadenopathy/ground glass opacity: CT
of the chest on ___ showed left supraclavicular
lymphadenopathy measuring up to 18 x 17 mm. CTA of the chest on
___ showed prominent hilar lymph nodes, along with diffuse
ground-glass opacity throughout the lungs which per radiology
may be related to fluid overload. This finding was communicated
to Dr. ___ PCP, who will arrange for appropriate
follow-up.
.
#C6 lesion: On CT ___ ___, incidental note was made of a
hypodense lesion in the right side of the C6 vertebral body.
This was further characterized by MR ___ ___, showing
the C6 lesion to likely be an atypical hemangioma.
.
#Increased marrow signal on MR neck: On MR ___ ___, note
was made of Diffuse marrow signal abnormality involving the
cervical spine. Per radiology, this can be seen with reactive
marrow changes in patients with anemia, but
diffuse neoplastic marrow infiltration such as with lymphoma is
also a
consideration. This finding was communicated to Dr. ___
___ PCP, who will arrange for appropriate follow-up.
.
#History of IV drug abuse: The patient has a history of IV drug
use and is enrolled in a methadone maintenance program, Habit
Opco in ___. Methadone was initially held due
to the patience somnolence. As the ___ liver and kidney
function improved, and she became mort alert, she began to
complain of symptoms of methadone withdrawal. Methadone was
restarted, and gradually uptitrated until the ___
withdrawal symptoms resolved at a dose of 30 mg TID. The dose
was then consolidated to twice daily dosing with 45 mg, and then
90 mg daily. The patient was discharged on a dose of methadone
90 mg daily.
.
#Hepatitis C: HCV viral load was 13 million, genotype 1b.
.
#HIV: The ___ HIV medications were initially held in the
setting of severe liver and kidney dysfunction. As the ___
liver and kidney function improved, her HIV medications were
restarted.
.
#Grouped vesicles on lower back, just above buttocks: These were
thought to be caused by HSV. A viral culture was sent and
confirmed HSV-2. The patient was treated with acyclovir while
inpatient and was discharged on her pre-admission suppressive
regimen of valacyclovir.
.
#Pustular lesion on ulnar aspect of right hand: The patient was
treated with I+D by plastic surgery. The culture was negative.
.
#Anxiety/Depression: Clonazepam was initially held due to
somnolence. As the patient liver and kidney function improved,
and she became more alert, clonazepam was gradually restarted,
eventually reaching the ___ preadmission dose of 2 mg BID.
The patient informed the inpatient team that she had stopped
taking paroxetine 1 month prior to admssion. The psychiatry team
was consulted for assistance with titration of the ___
methadone, and due to concern on the part of the liver team that
the ___ presenting liver failure could have been related
to acetaminophen toxicity. The patient denied any ingestions or
suicidal ideation.
.
#Transitional issues:
-Complete vancomycin course for Strep epidermidis bacteremia on
___.
-Primary care and pulmonology follow-up for pulmonary
hypertension, RV hypokinesis, chronic lung disease with
persistent 2L oxygen requirement.
-Follow-up of hilar and supraclavicular lymphadenopathy noted on
MRI.
-Follow-up of increased marrow signal noted on MR neck.
-Monitoring of liver and kidney function.
Medications on Admission:
Valacyclovir 1000mg daily
Etravirine 200mg BID
Raltegravir 400mg BID
Truvada 200mg-300mg 1 tablet daily
Methadone 128mg daily
Albuterol 2puffs BID
Clonazepam 2mg BID
Oxycodone 5mg BID
Clotrimazole 10mg 5 times per day
HCTZ 25mg daily
Aspirin 81mg daily
Discharge Medications:
1. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO once a day.
2. etravirine 200 mg Tablet Sig: One (1) Tablet PO twice a day.
3. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ puffs Inhalation twice a day as needed for shortness of
breath or wheezing.
6. clonazepam 2 mg Tablet Sig: One (1) Tablet PO twice a day.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. Symbicort 160-4.5 mcg/actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
11. methadone 10 mg Tablet Sig: Nine (9) Tablet PO DAILY
(Daily).
12. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 5 days: Last dose
___.
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
16. 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.
17. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day as needed for
heartburn, reflux.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
1. Altered mental status
2. Acute liver injury
3. Acute kidney injury
4. Rhabdomyolysis
5. Respiratory failrue
6. Hypoxia
7. Pulmonary hypertension
8. Staph epidermidis bacteremia
9. Lymphadenopathy
10. Herpes genitalis
11. HIV
12. h/o IV drug abuse
13. Hepatitis C
14. Pustule on right hand s/p I+D
15. Anxiety/Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were found in your apartment in an unresponsive state. You
were brought to the hospital, where you had a breathing tube put
in to protect your airway and were admitted to the ICU. As your
condition improved, you were able to breath on your own, and you
were tranferred out of the intensive care unit.
.
You were found to have severe liver and kidney failure. It was
thought that your methadone built up in the setting of liver and
kidney failure, and was responsible for the sleepiness. The
cause of the liver failure was unclear. There was some concern
about acetaminophen (Tylenol) toxicity, so you were treated with
a medication called N-acetylcysteine. However, you said you did
not take any Tylenol. No other causes of liver damage were found
other than your chronic hepatitis C. Never take more than 2
grams of Tylenol (acetaminophen) in 1 day.
.
You had some laboratory evidence of muscle damage when you
arrived. We believe that this is because you were found down.
This resolved, as did your kidney and liver function.
.
You had blood cultures at ___ that grew some
bacteria. All of your blood cultures drawn at ___
___ have been negative. You had a transesophageal
echocardiogram, which did not show any evidence of a heart valve
infection. You were started on an antibiotic called vancomycin,
which you need to take for a total of 2 weeks, including the
doses you received here in the hospital. You will complete your
course of vancomycin on ___. You PICC line should be removed
once your course of vancomycin is complete.
.
Your echocardiogram showed evidence of pulmonary hypertension
(high blood pressure in the lungs). You had a CT angiogram of
your chest to make sure that this was not related to blood clots
in the lungs. There was no evidence of blood clots in your
lungs. You should follow up with your primary care doctor and
lung doctor for further management of your pulmonary
hypertension. The echocardiogram also showed some dilatation of
the right side of your heart. You should discuss this further
with your primary care doctor.
.
Your CT scans showed some enlarged lymph nodes in your chest and
under your clavicle on your right side. This could be related to
infection, but it will be important for you to have close
follow-up with your primary care physician, and possible
reimaging, to make sure that this is not evidence of a cancer.
There was also some increeased signal in the bone marrow on the
MRI of your neck which you should discuss with your primary care
doctor.
.
You had an abscess on your right hand which was drained by
plastic surgery. You also had some herpes lesions on your lower
back that were treated with acyclovir. You will be back on
Valtrex after discharge.
.
You methadone was initially held because you were so sleepy. It
was restarted at a lower dose when you woke up and started to
demonstrate some symptoms of withdrawal. When you reached a
certain dose, the withdrawal symptoms stopped. You new dose of
methadone will be 90 mg daily, which is lower than the dose that
you used to take.
.
There are some changes to your medications:
START vancomycin 1 gram twice daily. Continue this until
___.
START omeprazole 20 mg daily as needed for reflux or heartburn.
START docusate and senna for constipation
DECREASE methadone to 90 mg daily.
STOP oxycodone, clotrimazole, HCTZ, compazine, Paxil, and
ibuprofen
Followup Instructions:
___
|
10863119-DS-6
| 10,863,119 | 29,678,799 |
DS
| 6 |
2129-11-14 00:00:00
|
2129-11-14 21:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
clindamycin / Keflex
Attending: ___.
Chief Complaint:
Fall: left leg laceration
Major Surgical or Invasive Procedure:
___ Washout left leg wound
___ Washout, partial closure left leg wound
History of Present Illness:
This is an ___ female who presented to the emergency
room after her being found down by her son for an unknown
duration at the bottom of her stairs. She had a large left
lower extremity laceration. She had undergone primary and
secondary survey evaluation by the trauma team in the ED and was
found to only have this injury. She was on Coumadin for
anticoagulation for her atrial fibrillation and there was a
large soft tissue defect that needed debridement and partial
closure in the OR
Past Medical History:
PMH: Afib on coumadin, HTN, HLD, dementia, gastric ulcer s/p
endoscopy
PSH: b/l TKR , Moh's for BCC on nose
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
- VS - please see OMR
- General: c collar in place, delirious
- HEENT: PERRL, no acute traumatic injuries, no facial trauma
- Neck: no c spine tenderness to palpation
- CV: irregular rhythm, reg rate
- Lungs: bilateral breath sounds equal bilaterally
- Abdomen: soft, obese, non tender, non distended
- GU: foley in place
- Ext: LLE with large 15cm laceration, +dopplerable pulses on
b/l ___, +venous stasis skin changes, pt reports decreased
sensation surrounding the large LLE laceration, hemostatic,
gaping.
- Neuro: alert to person and birthday, cannot recall place, no
focal deficits, following commands.
- Skin: see above
Physical examination upon discharge: ___:
vital signs: 98.4, ___, hr=76, 18 98% room air
GENERAL: NAD
CV: Irregular rate
LUNGS: clear
ABDOMEN: hypoactive BS, soft, non-tender
EXT: Hands warm, ecchymotic antecubital areas bil., and post
aspect of arms, + radial pulses bil., VAC dressing lat. aspect
of left leg removed, wound tunnels to upper aspect of knee,
laceration left lower ext. pink with fibrous tissue, moist to
dry dressing applied, + DP bil.
NEURO: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___ 05:05AM BLOOD WBC-4.7 RBC-2.74* Hgb-8.2* Hct-26.6*
MCV-97 MCH-29.9 MCHC-30.8* RDW-18.0* RDWSD-62.1* Plt ___
___ 05:20AM BLOOD WBC-5.9 RBC-2.85* Hgb-8.5* Hct-27.5*
MCV-97 MCH-29.8 MCHC-30.9* RDW-17.9* RDWSD-62.6* Plt ___
___ 06:10PM BLOOD WBC-13.6* RBC-1.85* Hgb-5.7* Hct-20.0*
MCV-108* MCH-30.8 MCHC-28.5* RDW-16.7* RDWSD-66.9* Plt ___
___ 04:29AM BLOOD Neuts-83.8* Lymphs-6.4* Monos-9.3
Eos-0.0* Baso-0.1 Im ___ AbsNeut-8.52* AbsLymp-0.65*
AbsMono-0.94* AbsEos-0.00* AbsBaso-0.01
___ 10:05AM BLOOD ___
___ 05:05AM BLOOD Glucose-80 UreaN-11 Creat-0.8 Na-139
K-4.0 Cl-110* HCO3-21* AnGap-12
___ 04:29AM BLOOD LD(LDH)-316* TotBili-0.9 DirBili-0.3
IndBili-0.6
___ 06:10PM BLOOD Lipase-33
___ 06:10PM BLOOD CK-MB-5 cTropnT-<0.01
___ 05:05AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.9
___ 04:29AM BLOOD Hapto-55
___ 04:40AM BLOOD ___ pO2-106* pCO2-23* pH-7.56*
calTCO2-21 Base XS-0
___ 12:47AM BLOOD Lactate-1.0
___: EKG:
Atrial fibrillation with rapid ventricular response. Compared to
tracing #1 ventricular response has slightly increased.
TRACING #2
___: CT of abdomen and chest:
1. Large left thigh laceration is partially imaged. No fracture
or traumatic
malalignment.
2. Bilateral moderate pleural effusions are nonhemorrhagic.
3. 3 mm left upper lobe pulmonary nodule.
4. Diverticulosis without evidence of diverticulitis.
5. Nonspecific trace free fluid in the pelvis.
6. Aneurysmal dilatation and a small dissection flap in the
right common iliac artery.
7. Bilateral severe glenohumeral degenerative change.
8. Enlargement of the main pulmonary artery is suggestive of
pulmonary
hypertension.
___: CT c-spine:
1. No acute fracture seen. Multilevel degenerative changes.
Mild
anterolisthesis of C7 over T1 is of indeterminate age, but may
be
degenerative.
2. 4 mm left upper lobe pulmonary nodule.
___: chest x-ray:
New left PICC at the cavo-atrial junction.
___: PICC x-ray:
1. The accessed vein was patent and compressible.
2. Basilic vein approach double lumen left PICC with tip in the
lower SVC.
___: US upper ext.:
1. Occluded left basilic vein containing the PICC line.
2. Occluded left cephalic vein around the antecubital fossa.
Brief Hospital Course:
___ year old female with a history of dementia, Afib on Coumadin,
s/p bilateral TKRs presenting on ___ after an unwitnessed fall
at home down a flight of stairs. Upon arrival to ___, she was
found to have sustained a large laceration extending down the
muscle over her left knee from distal femur to proximal tibia.
Initially admitted to the intensive care unit where she received
a unit of PRBC for a hematocrit of 20. She did not have an
appropriate increase in her blood-work after the transfusion and
received an additional unit. She underwent serial hematocrit
checks in addition to her vital signs. Her INR upon admission
was 4.3 and she received vitamin K for correction. On ___ she
was taken to the operating room for wash-out and partial closure
of the left leg wound. A VAC dressing was placed at this time.
She returned to the operating room on ___ for wound washout.
The patient transferred to the surgical floor on ___.
Post operatively she was noted to have increasing amounts of
clear/yellow drainage from her incision site. Culture from the
drainage grew MSSA and Pasturella canus. The Infectious disease
service was consulted and made recommendations regarding her
care. She was originally placed on
Vancomycin/Aztreonam/Metronidazole (vague Keflex
allergy) transitioned to TMP-SMX after receipt of culture data.
Ultrasound of the extremity was negative for seroma. She had a
PICC line placed for access and antibiotic infusion. During her
hospitalization, she was noted to have swelling of her left
upper extremity. The patient was taken to US for imaging of her
left arm which showed an occluded left basilic vein containing
the PICC line and
an occluded left cephalic vein around the left ante-cubital
fossa. The PICC line was removed and peripheral access was
obtained. The patient's antibiotics were discontinued on ___.
A bedside VAC dressing change was done on ___. She also
experienced difficulty voiding and required replacement of the
foley catheter. She was started on a course of tamulosin. The
foley catheter has since been removed and she has been voiding
without difficulty.
In preparation for discharge, the patient was evaluated by
physical therapy and recommendations were made for discharge to
a rehabilitation facility in order for the patient to regain her
strength and mobility. During the remainder of her
hospitalization, her vital signs were stable and she was
afebrile. She has been tolerating a regular diet and voiding
witout difficulty. She has required assistance to transfer to
the chair. Her hematocrit has stabilized at 26.6 and her renal
function has been normal. Her current INR is 1.3. She was
started on Coumadin on ___ at 5mg and received another 5 mg on
___.
VAC dressing removed prior to discharge and a wet to dry
dressing applied. Please re-apply VAC dressing, black sponge
with 125mm hg.
Appointments for follow-up were made with her primary care
provider: need for follow-up for pulmonary nodules. The acute
care clinic will call the facility with an appointment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q12H
2. Atenolol 25 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. Calcium 600 (calcium carbonate) 600 mg (1,500 mg) oral DAILY
5. Ferrous Sulfate 325 mg PO BID
6. Docusate Sodium 100 mg PO DAILY
7. Simvastatin 20 mg PO QPM
8. Warfarin 2.5 mg PO 2X/WEEK (___)
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Docusate Sodium 100 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. Simvastatin 20 mg PO QPM
6. Warfarin 2.5 mg PO 2X/WEEK (___)
7. Warfarin 5 mg PO 5X/WEEK (MO,WE,TH,FR,SA)
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Senna 8.6 mg PO BID:PRN constipation
10. Tamsulosin 0.4 mg PO QHS
11. Calcium 600 (calcium carbonate) 600 mg (1,500 mg) oral DAILY
12. Ferrous Sulfate 325 mg PO BID
13. Heparin 5000 UNIT SC BID
until INR at goal 2.0-3.0, then may d/c
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Traumatic wound to the left lower extremity
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 after a fall down stairs. You
sustained a laceration to your left leg. You were taken to the
operating room for a washout of your wound and partial closure.
You had a VAC dressing place to help facilitate healing. You
have resumed your Coumadin. You were seen by physical therapy
and recommendations were made for discharge to a rehabilitation
facility to help you regain your strength and mobiiity. You are
being discharged with the following instructions:
You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*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.
Followup Instructions:
___
|
10863164-DS-11
| 10,863,164 | 20,725,424 |
DS
| 11 |
2153-11-17 00:00:00
|
2153-11-17 22:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headaches and seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ year old right handed woman with no PMH,
takes no medications, reports years of early morning headaches
resolving after a few hours of being awake for the past year,
who
presented to ___ following a 10 minute seizure. She woke
up with a bad frontal, nonthrobbing, frontal headache, that is
worse when she lays Flat, which she has been having almost daily
for the past year. She often takes one advil and it resolves
after a few hours ~ 11 am. However, this morning she went to
church and the cemetery and the headache persisted. It was
frontal in location, severe in intensity but similar to prior
headaches. Persisted throughout the morning. Patient decided to
take a nap around noon on the couch, her next memory is being
the
hospital. Her brother was with her and states that she was
unresponsive and with generalized rhythmic shaking that lasted
~10 minutes. There was no reported focality. EMS was called
and
___ in the field was normal. EMS found patient post-ictal with
small anterior tongue lacerations. It took about 30 minutes for
her to become oriented and conversent. Per report she arrived
in
OHS with multiple episodes of NBNB emesis, complaining of severe
headache, worse with laying flat. While at the OSH, got
reportedly 1 gram of keppra at 2:45 pm a CT head was performed
and negative for ICH, but a CTA of the head and neck performed
demonstrated a 5 mm sacular aneurysm of the A1 segment. With
concern for ___, an LP was performed showing 0 RBC and 1 WBC (no
diff in record). She was later transferred to ___ for
neurology evaluation.
No seizures in the past, has no history of strokes, has been
sleeping well although with lots of early wakening and restroom
breaks at night. no illness that she can relate.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies diarrhea, constipation or abdominal pain.
No recent change in bowel or bladder habits. No dysuria.
Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
Hearing loss from "scarlet fever" as a child
Social History:
___
Family History:
mother with heart disease but otherwise no pertinent history
Physical Exam:
Physical Exam:
Vitals: T:97.6 P: 84 R: 16 BP:125/76 SaO2:96% on 2L
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
.
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Mildly inattentive but was able to name ___
backward without difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high but had
difficulty with low frequency objects. Able to read without
difficulty. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Pt. was able to register 3
objects and recall ___ at 5 minutes, but got the last 2 with
semantic cues. The pt. had good knowledge of current events.
There was no evidence of apraxia or neglect. Calculation was
intact (answers seven quarters in $1.75)
.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was extensor bilaterally.
.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
.
-Gait: defferred as patient was vomiting
Pertinent Results:
ADMISSION LABS:
___ 07:57PM BLOOD WBC-11.1* RBC-4.43 Hgb-12.9 Hct-39.6
MCV-89 MCH-29.0 MCHC-32.5 RDW-13.0 Plt ___
___ 07:57PM BLOOD Neuts-88.3* Lymphs-9.6* Monos-1.9* Eos-0
Baso-0.1
___ 07:57PM BLOOD ___ PTT-26.9 ___
___ 07:57PM BLOOD Glucose-122* UreaN-11 Creat-0.6 Na-138
K-3.8 Cl-103 HCO3-25 AnGap-14
___ 07:57PM BLOOD Calcium-8.6 Phos-3.7 Mg-2.2
DISCHARGE LABS:
___ 05:15AM BLOOD WBC-8.3 RBC-4.21 Hgb-12.1 Hct-38.0 MCV-90
MCH-28.7 MCHC-31.8 RDW-13.2 Plt ___
___ 05:15AM BLOOD Glucose-91 UreaN-10 Creat-0.6 Na-138
K-3.5 Cl-106 HCO3-25 AnGap-11
___ 05:15AM BLOOD ALT-15 AST-25 LD(LDH)-219 CK(CPK)-489*
AlkPhos-65 TotBili-0.4
___ 05:15AM BLOOD CK-MB-7 cTropnT-<0.01
___ 05:15AM BLOOD TSH-0.37
REPORTS:
CXR ___: IMPRESSION: No evidence of acute disease.
MRI/MRV ___: IMPRESSION:
1. Bilateral cortical small vessel ischemic disease. A tiny
focus of slow
diffusion in the right cerebellar hemisphere with a punctate
area of
hemorrhage, likely represents an acute lacunar infarct with
hemorrhage. No
cause identified to explain the patient's generalized seizure.
2. No evidence of venous sinus thrombosis.
Brief Hospital Course:
Ms ___ is a ___ year old right handed woman with PMHx of
hearing loss from "scarlet fever" as a child who reports at
least one year of early morning headaches resolving after a few
hours of being awake, who presented to ___ following a 10
minute seizure. Her neurological exam has remained relatively
normal, with the exception of some mild inattention and mild
sway on her Romberg.
.
# NEURO: On repeat history taking, pt's H/A's were much less
concerning, given that they did not wake the pt up in the middle
of the night, and even when she woke up to use the restroom in
the middle of the night, she didn't have a headache. However,
almost every day when she wakes up she has a H/A, not a/w
vomiting, phono or photophobia. There is no worsening with
coughing or position changes. Therefore, we became less
concerned about a space occupying mass. Pt's MRI/MRV did not
show any source of pt's possible seizure. We decided to hold
any further AED's. We obtained an EEG whose final read is still
pending. Pt will be called at home with the results.
.
# CARDS: pt was placed on telemetry throughout this
hospitalization. No irregular heart rhythms were noted.
.
# CODE: Full Code
PENDING RESULTS:
EEG ___ - pt will be called at home with these results.
TRANSTIONAL CARE ISSUES:
Pt instructed not to drive for 6 months and given a long list of
seizure safety tips.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
First time seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___ have been admitted to ___ after ___ had a first time
seizure.
We do not know the exact cause of your seizure. Your brain
imaging did not reveal an acute stroke or a lesion that could
cause your seizure. ___ had an EEG that has not yet been read.
___ will be able to have this followed up by your doctors as ___
outpatient.
Seizures can be provoked by infections or any metabolic
disturbances such as with dehydration or illness.
Given that this is your first seizure, we won't be starting ___
on anit-seizure medications.
Your headaches can be related to your poor sleep quality, and we
would like to check whether ___ have obstructive sleep apnea
after your discharge from ___. Therefore we have made ___ an
appointment in our sleep clinic with Dr. ___.
If ___ experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of ___ on this hospitalization.
Please observe the following safety measures:
SEIZURE SAFETY
________________________________________________________________
The following tips will help ___ to make your home and
surroundings as safe as possible during or following a seizure.
Some people with epilepsy will not need to make any of these
changes. Use this list to balance your safety with the way ___
want to live your life.
Make sure that everyone in your family and in your home knows:
- what to expect when ___ have a seizure
- correct seizure first aid
- first aid for choking
- when it is (and isn't) necessary to call for emergency help
Avoid things that are known to increase the risk of a seizure:
- forgetting to take medications
- not getting enough sleep
- drinking a lot of alcohol
- using illegal drugs
In the kitchen:
- As much as possible, cook and use electrical appliances only
when someone else is in the house.
- Use a microwave if possible.
- Use the back burners of the stove. Turn handles of pans toward
the back of the stove.
- Avoid carrying hot pans; serve hot food and liquids directly
from the stove onto plates.
- Use pre-cut foods or use a blender or food processor to limit
the need for sharp knives.
- Wear rubber gloves when handling knives or washing dishes or
glasses in the sink.
- Use plastic cups, dishes, and containers rather than breakable
glass.
In the living room:
- Avoid open fires.
- Avoid trailing wires and clutter on the floor.
- Lay a soft, easy-to-clean carpet.
- Put safety glass in windows and doors.
- Pad sharp corners of tables and other furniture, and buy
furniture with rounded corners.
- Avoid smoking or lighting fires when ___ by yourself.
- Try to avoid climbing up on chairs or ladders, especially when
alone.
- If ___ wander during seizures, make sure that outside doors
are
securely locked and put safety gates at the top of steep stairs.
In the bedroom:
- Choose a wide, low bed.
- Avoid top bunks.
- Place a soft carpet on the floor.
In the bathroom:
- Unless ___ live on your own, tell a family member ___
before ___ take a bath or shower.
- Hang the bathroom door so it opens outward, so it can be
opened
if ___ have a seizure and fall against it.
- Don't lock the bathroom door. Hang an "Occupied" sign on the
outside handle instead.
- Set the water temperature low so ___ won't be hurt if ___ have
a seizure while the water is running.
- Showers are generally safer than baths. Consider using a
hand-
held shower nozzle.
- If taking a bath, keep the water shallow and make sure ___
turn
off the tap before getting in.
- Put non-skid strips in the tub.
- Avoid using electrical appliances in the bathroom or near
water.
- Use shatterproof glass for mirrors.
At work:
___
Out and about:
- Carry only as many medications with ___ as ___ will need, and
2
spare doses.
- Wear a medical alert bracelet to let emergency workers and
others know that ___ have epilepsy.
- Stand well back from the road when waiting for the bus and
away
from the platform edge when taking the subway.
- If ___ wander during a seizure, take a friend along.
- Don't let fear of a seizure keep ___ at home.
Sports:
- Use common sense to decide which sports are reasonable.
- Exercise on soft surfaces.
- Wear a life vest when ___ are close to water.
- Avoid swimming alone. Make sure someone with ___ can swim
well
enough to help ___ if ___ need it.
- Wear head protection when playing contact sports or when there
is a risk of falling.
- When riding a bicycle or rollerblading, wear a helmet, knee
pads, and elbow pads. Avoid high traffic areas; ride or skate
on
side roads or bike paths.
Driving:
- ___ may not drive in ___ unless ___ have been
seizure- free for at least 6 months.
- Always wear a seatbelt.
Parenting:
- Childproof your home as much as possible.
- If ___ are nursing a baby, sit on the floor or bed with your
back supported so the baby will not fall far if ___ should lose
consciousness.
- Feed the baby while he or she is seated in an infant seat.
- Dress, change, and sponge bathe the baby on the floor.
- Move the baby around in a stroller or small crib.
- Keep a young baby in a playpen when ___ are alone, and a
toddler in an indoor play yard, or childproof one room and use
safety gates at the doors.
- When out of the house, use a bungee-type cord or restraint
harness so your child cannot wander away if ___ have a seizure
that affects your awareness.
- Explain your seizures to your child when he or she is old
enough to understand.
Followup Instructions:
___
|
10863438-DS-17
| 10,863,438 | 27,238,881 |
DS
| 17 |
2118-11-04 00:00:00
|
2118-11-04 14:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Liver abscess
Major Surgical or Invasive Procedure:
___:
PROCEDURE: Ultrasound-guided drainage of right hepatic
collection.
History of Present Illness:
The patient is a ___ with prior gastric bypass for obesity who
had type 4A
choledochocyst s/p resection. She underwent robot assisted
resection of extrahepatic bile duct from hilar confluence to
intrapancreatic segment, revision of Roux-en-Y
gastrojejunostomy, CBD exploration with stone retrieval, CCY,
Roux-en-Y hepaticojejunostomy on ___ with Dr ___.
She
initially had diarrhea and weight loss postoperatively but on
her last postop visit on ___ was recovering well. Her
weight then was 115 lbs. She reports that over the past few
weeks to months she has lost ___ lbs" though has not weighed
herself. She feels weak and has had a poor appetite. She says
she fell out of bed today so went to ___, where she
underwent a
CT scan and was transferred to ___ for further mgmt. She has
no abd pain, no N/V, has normal BMs (nonbloody, not lighter in
color). Subjective fevers and weight loss at home.
Past Medical History:
Past Medical History (per PCP ___:
1. Arthritis of the knees
2. Hypothyroidism
3. Postmenopausal bleeding
4. Osteopenia
5. Fecal Incontinence
6. Anemia
7. Hypertension
8. Hypercholesterolemia
Past Surgical History:
1. Roux-en-Y Gastric Bypass ___ Dr. ___
2. Cesarean section x 4
3. Breast biopsy (benign)
Social History:
___
Family History:
Her mother had ___ disease. She has no family history of
cancer, including pancreatic, colorectal, skin, and breast
cancer.
Physical Exam:
On Admission:
VS: 99.1, 85, 102/54, 16, 96%
later febrile to 103.0
Gen: nontoxic, NAD
CV: RRR
Pulm: CTA b/l
Abd: old scars. soft, nondistended, nontender.
Prior to discharge:
VS: 99.6, 83, 116/59, 18, 95% RA
GEN: Pleasant with NAD
CV: RRR, no m/r/g
PULM: Diminished BS on bases
ABD: Soft, NT/ND, right flank drain site open to air and healed
well.
EXTR: Warm, RUE with PICC line dressing c/d/i
Pertinent Results:
___ 09:36AM BLOOD WBC-16.0*# RBC-3.02* Hgb-8.7* Hct-27.6*
MCV-91 MCH-28.7 MCHC-31.5 RDW-12.9 Plt ___
___ 09:36AM BLOOD ___ PTT-25.3 ___
___ 09:36AM BLOOD Glucose-129* UreaN-27* Creat-1.3* Na-135
K-4.1 Cl-95* HCO3-30 AnGap-14
___ 09:36AM BLOOD ALT-31 AST-29 AlkPhos-212* TotBili-0.4
___ 03:45AM BLOOD Calcium-7.6* Phos-2.4* Mg-1.7
___ 04:20AM BLOOD WBC-10.6 RBC-3.01* Hgb-9.1* Hct-26.8*
MCV-89 MCH-30.2 MCHC-33.9 RDW-14.4 Plt ___
___ 04:20AM BLOOD Glucose-85 UreaN-7 Creat-0.7 Na-135 K-4.0
Cl-98 HCO3-31 AnGap-10
___ 08:06AM BLOOD ALT-15 AST-21 LD(LDH)-183 AlkPhos-123*
TotBili-0.3
___ 04:20AM BLOOD Calcium-7.9* Phos-2.7 Mg-1.5*
___ 4:32 pm ABSCESS LIVER ABSCESS.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Final ___:
ESCHERICHIA COLI. HEAVY GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ESCHERICHIA COLI. HEAVY GROWTH. SECOND MORPHOLOGY.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- =>32 R 16 I
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ANAEROBIC CULTURE (Final ___:
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES. BETA LACTAMASE POSITIVE.
___ LIVER US:
IMPRESSION:
1. Findings concerning for large abscess (9x10 cm) within the
right hepatic lobe corresponding to abnormality seen on CT from
outside hospital.
2. Dilated remnant intrapancreatic CBD measuring 1.1 cm which
contains
layering stones, unchanged from the ___ CT.
___ CXR:
IMPRESSION:
1. Right internal jugular central line terminates in the right
atrium.
Recommend retracting by 3 cm to be at the cavoatrial junction.
2. Mediastinal widening, new from prior, may reflect portable
technique.
Recommend repeat with more optimal technique to resolve this
finding.
Alternatively, if there is concern for mediastinal hematoma CT
is recommended.
___ CXR:
IMPRESSION:
Resolved pulmonary edema.
New bibasilar subsegmental atelectasis.
Low lying right IJ central venous catheter enters the right
atrium.
Retraction by 2 cm would position its tip in the lower SVC.
___ LIVER US:
IMPRESSION:
1. Interval decrease in size of right hepatic lobe complex fluid
collection status post placement of pigtail catheter. Additional
2.7 and 4.5 cm complex collections within right level liver are
similar in appearance to ___ and appear solid. These
collections are not drainable at this time.
2. Patent hepatic vasculature.
3. Status post cholecystectomy with expected pneumobilia.
4. Small left pleural effusion noted.
___ MRI:
IMPRESSION:
1. Dominant abscess in the right hepatic lobe containing a
percutaneous drain is decreased in size compared to pre drainage
CT exam. Several small satellite abscesses in the right lobe,
without significant internal liquefied contents to suggest
amenability to drainage.
2. Infrahepatic hematoma, probably related to the placement of
percutaneous drainage catheter.
3. Hepatic steatosis.
4. Mild biliary dilatation with pneumobilia.
5. Bilateral small pleural effusions and anasarca.
___ CXR:
IMPRESSION:
There is a new right-sided PICC line with tip at the cavoatrial
junction. Lung volumes are low and there increased interstitial
markings and small bilateral effusions. There is no
pneumothorax.
Brief Hospital Course:
The patient well known to ___ service was transferred from
OSH and admitted to the ___ Surgical Service for treatment of
the newly diagnosed liver abscess. Liver US on admission
confirmed large right lobe hepatic abscess and ___ was consulted
for possible drainage. Patient received 1 unit of FFP for INR
1.8, and was started on Vanc/Zosyn. Patient underwent successful
US-guided placement of ___ pigtail catheter into the
collection, sample was sent for microbiology evaluation (please
see Radiology report for details). The patient was transferred
in ICU for observation. The patient was febrile, hypotensive
with elevated WBC concerning for SIRS. On HD 2, patient's HCT
dropped from 27 to 21, thought to secondary to aggressive fluid
resuscitation. She received 5 mg of vitamin K for INR 2.0.
Abscess fluid was positive for GNRs and ID was called for
consult and Vanc was discontinued. Patient's HCT remained stable
and she was transferred to the floor on clear liquid diet, with
IVF, IV antibiotics, with Foley catheter, and PO Oxycodone for
pain control. The patient was hemodynamically stable.
Neuro: The patient received PO with good effect and adequate
pain control. When tolerating oral intake, the patient was
transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Home dose
antihypertensives were discontinued secondary to low blood
pressure.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI: On admission patient was made NPO with IV fluids. Diet was
advanced when appropriate, which was well tolerated. Patient's
intake and output were closely monitored, and IV fluid was
adjusted when necessary. Electrolytes were routinely followed,
and repleted when necessary. Repeat liver US on HD 3
demonstrated decrease in size of right hepatic lobe complex
fluid collection status post placement of pigtail catheter, and
additional solid right liver lobe collections (see Radiology
report for details). On HD 5, patient underwent MRI, which
demonstrated decreased size of the dominant abscess and multiple
undrainabe right liver lobe abscesses. On HD 9, pigtail drain
was removed as output was low and patient remained afebrile with
WBC within normal limits.
GU: The foley catheter was discontinued at midnight of HD # 4.
The patient subsequently voided without problem.
ID: Patient's WBC was 16.0 on admission and she had low grade
fevers. Patient was started on Vanc and Zosyn. She underwent
right hepatic abscess drainage on HD 1. Gram stain was positive
for GNRs and Vanc was discontinued. Patient continued to spike
fever and fever work up was done. Patient's urine and blood
cultures were negative, stool was negative for C.diff, E.
Histolytica antibody negative. The patient abscess fluid
cultures was positive for E. coli and Bacteroides Fragilis
group, Zosyn was switched to Ceftriaxone and Flagyl on HD 3. The
patient's WBC started to downward and returned to normal on HD
9, her fever subsided as well. PICC line was placed on HD 5 for
long-term antibiotics treatment. Patient will have an outpatient
liver US and she has a f/u with ID as outpatient.
Endocrine: No issues.
Hematology: On admission, patient's HCT was 27.6, it dropped
down to 21.8 on HD 2, thought to be secondary for aggressive
fluid resuscitation and possible post procedural hematoma. HCT
was followed Q6H an demeaned stable low. On HD 3, patient
received 2 units of pRBC for HCT 20.7, persistent hypotension.
Post transfusion HCT ws 28.4.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
1. Levothyroxine Sodium 88 mcg PO DAILY
2. Metoprolol Tartrate 50 mg PO DAILY
3. Acetaminophen ___ mg PO Q6H:PRN pain/fever
4. Cholestyramine 4 gm PO TID
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
6. Pantoprazole 40 mg PO Q12H
7. Senna 8.6 mg PO BID
8. Alendronate Sodium 70 mg PO 1X/WEEK (___)
9. Atorvastatin 10 mg PO DAILY
10. Diltiazem 120 mg PO DAILY
11. Hydrochlorothiazide 25 mg PO DAILY
12. Ascorbic Acid ___ mg PO DAILY
13. B Complete (B complex vitamins) 1 oral QD
14. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral QD
15. cyanocobalamin (vitamin B-12) 1000 oral QD
16. Ferrous Sulfate 325 mg PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. Vitamin E 400 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain, fever
do not exceed more then ___ mg/day
2. Atorvastatin 10 mg PO QPM
3. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram 2 g PICC once a day Disp #*21 Vial
Refills:*0
4. Cyanocobalamin 50 mcg PO DAILY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*52 Tablet Refills:*0
7. Multivitamins 1 TAB PO DAILY
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
9. Pantoprazole 40 mg PO Q12H
10. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
11. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
12. Vitamin E 400 UNIT PO DAILY
13. Ferrous Sulfate 325 mg PO DAILY
14. Ascorbic Acid (Liquid) 500 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Liver abscess
2. SIRS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the surgery service at ___ for evaluation
of weakness and weight loss. You were found to have infected
liver abscess. You were started on IV antibiotics and your
abscess was drained by ___. Your liver drain was removed before
discharge and you were sent home to continue treatment with
antibiotics. You were found to have hypotension and your
antihypertensive medications were discontinued.
.
Please ___ Dr. ___ office at ___ if you have any
questions or concerns.
.
Please do not take your antihypertensive medications:
Metoprolol, Diltiazem, and HCTZ until you see your PCP.
Please take any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
PICC Line:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your ___ Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
___
|
10863998-DS-20
| 10,863,998 | 23,983,593 |
DS
| 20 |
2151-07-26 00:00:00
|
2151-07-26 20:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lidocaine
Attending: ___.
Chief Complaint:
Nausea and vomiting, s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ female who presents to ___ on
___ with a cerebellar IPH. Patient is prescribed Aspirin
81mg daily, which was last taken one week ago. History obtained
primarily through her husband, who has an unclear memory of
events. Per her husband, the patient had multiple procedures
yesterday with Urology as part of a work-up for bladder cancer.
She went home, but in the middle of the night she developed
left-sided abdominal pain and vomited multiple times. Per her
husband, when he woke up she was on the floor. Unclear if she
had
a mechanical fall or if she syncopized. After the fall she was
awake, but was complaining of abdominal pain and a headache, so
her husband called ___. In the ED, she was found to be in acute
afib and had an elevated lactate. After she was stabilized,
___
was obtained that revealed an acute right-sided cerebellar IPH
as
well as occiput fracture. Neurosurgery called for evaluation.
Past Medical History:
Work-up for possible high grade bladder cancer ___ (left
ureteroscopy, bilateral retrograde pyelogram, biopsy)
HTN
Prior TIA Hyponatremia
Social History:
___
Family History:
Non-contributory
Physical Exam:
ON ADMISSION:
============
Physical Exam:
O: T 97.8; HR 80; 160/88; RR 18; SpO2 97% RA
GCS at the scene: Unknown
GCS upon Neurosurgery Evaluation: 14
Time of evaluation: 0700 on ___
Airway: [ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[x]3 Opens eyes to voice
[ ]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
ICH Score:
GCS
[ ]2 GCS ___
[ ]1 GCS ___
[x]0 GCS ___
ICH Volume
[x]1 30 mL or Greater
[ ]0 Less than 30 mL
Intraventricular Hemorrhage
[x]1 Present
[ ]0 Absent
Infratentorial ICH
___ Yes
[ ]0 No
Age
[x]1 ___ years old or greater
[ ]0 Less than ___ years old
Total Score: __4__
Exam:
Gen: Ill-appearing elderly woman, eyes closed, nauseous.
Extremities: Warm and well-perfused.
Neuro:
Mental Status: Lethargic, EO voice, follows all commands,
although slow to respond to questions/commands.
Orientation: Oriented to person, place, and date.
Language: Slow speech, minimal verbal output.
Cranial Nerves:
I: Not tested
II: PERRL 3-2.5mm. No visual field deficits noted.
III, IV, VI: EOMI bilaterally without nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation appears symmetrical.
XI: Trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
+Left-sided dysmetria on finger-to-nose
Normal heel-to-shin bilaterally
=
=
=
=
=
=
=
================================================================
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 619)
Temp: 98.3 (Tm 98.4), BP: 152/85 (95-152/65-85), HR: 70
(59-85), RR: 18, O2 sat: 93% (93-99), O2 delivery: Ra, Wt: 117.5
lb/53.3 kg
GENERAL: NAD, alert and oriented. Appropriately conversational
HEENT: AT/NC, anicteric sclera, MMM
CV: regular rate, S1/S2, slight systolic murmur, no gallops, or
rubs
PULM: CTAB, with RLL crackles that resolve after continued deep
breaths, no wheezes, breathing comfortably on RA without use of
accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
suprapubic tenderness to palpation
GU: Foley in place, draining
EXTREMITIES: no cyanosis, clubbing, no pitting edema in lower
extremities.
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric==
Pertinent Results:
Please refer to OMR for pertinent imaging and lab results.
ADMISSION LABS:
___ 05:30PM ___ PO2-52* PCO2-39 PH-7.43 TOTAL CO2-27
BASE XS-1
___ 05:30PM LACTATE-1.5
___ 05:30PM freeCa-1.11*
___ 03:09PM GLUCOSE-143* UREA N-13 CREAT-0.5 SODIUM-134*
POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-22 ANION GAP-16
___ 03:09PM CALCIUM-8.1* PHOSPHATE-2.3* MAGNESIUM-2.5
CHOLEST-189
___ 03:09PM %HbA1c-5.8 eAG-120
___ 03:09PM TRIGLYCER-58 HDL CHOL-80 CHOL/HDL-2.4
LDL(CALC)-97
___ 03:09PM TSH-0.50
___ 10:41AM GLUCOSE-152* UREA N-13 CREAT-0.6 SODIUM-134*
POTASSIUM-3.4* CHLORIDE-96 TOTAL CO2-23 ANION GAP-15
___ 10:41AM CALCIUM-8.8 PHOSPHATE-2.7 MAGNESIUM-1.7
___ 10:41AM WBC-14.7* RBC-4.15 HGB-12.6 HCT-37.7 MCV-91
MCH-30.4 MCHC-33.4 RDW-13.2 RDWSD-44.4
___ 06:08AM LACTATE-4.1* K+-3.3*
___ 04:20AM URINE COLOR-RED* APPEAR-Cloudy* SP ___
___ 04:20AM URINE BLOOD-LG* NITRITE-NEG PROTEIN-100*
GLUCOSE-300* KETONE-40* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD*
___ 04:20AM URINE RBC->182* WBC-175* BACTERIA-NONE
YEAST-NONE EPI-0
___ 03:06AM LACTATE-4.3*
___ 03:00AM GLUCOSE-217* UREA N-17 CREAT-0.7 SODIUM-132*
POTASSIUM-2.8* CHLORIDE-89* TOTAL CO2-21* ANION GAP-22*
___ 03:00AM ALT(SGPT)-16 AST(SGOT)-25 ALK PHOS-74 TOT
BILI-0.5
___ 03:00AM LIPASE-17
___ 03:00AM ALBUMIN-4.4 CALCIUM-9.1 PHOSPHATE-3.5
MAGNESIUM-1.7
___ 03:00AM WBC-16.1* RBC-4.29 HGB-13.1 HCT-38.7 MCV-90
MCH-30.5 MCHC-33.9 RDW-13.2 RDWSD-43.2
___ 03:00AM NEUTS-84.0* LYMPHS-9.7* MONOS-5.5 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-13.54* AbsLymp-1.57 AbsMono-0.88*
AbsEos-0.00* AbsBaso-0.02
___ 03:00AM ___ PTT-30.1 ___
OTHER PERTINENT LABS/MICRO/IMAGING:
___ Imaging CHEST (PORTABLE AP)
Ill-defined opacities in the right apex, with increased air
bronchograms
compared to the left. Findings could represent a right upper
lobe pneumonia or aspiration.
___ Imaging RENAL U.S.
1. Mild fullness of the left collecting system with a stent in
the proximal ureter. While the distal tip of the urethral
stent was not appreciated on this study, a concomitantly
acquired abdominal radiograph demonstrated its appropriate
position within the bladder.
2. Normal right kidney.
3. Exophytic bladder mass consistent with blood clot
___ Imaging PORTABLE ABDOMEN
Left ureteral stent in expected appropriate position.
___ Imaging CT HEAD W/O CONTRAST
1. Acute fracture of the occipital bone extending into the
skullbase on the right, with a 4.1 cm acute intraparenchymal
hematoma within the right
cerebellum.
2. Additional probable contusions as described.
3. Intraventricular hemorrhage as described.
4. Right tentorial subdural hematoma, small left tentorial
subdural hematoma.
5. A small focus of high density along the left frontal cortex
concerning for subarachnoid and/or subdural hemorrhage (.
6. Posterior fossa mass effect with cerebellar tonsils at
approximate level of the foramen magnum as described.
___ Imaging CTA HEAD & CTA NECK
1. Nondisplaced fracture through the right occipital bone with
intraparenchymal hematoma centered within the right cerebellar
hemisphere,
suboptimally assessed in setting of extensive streak artifact in
the posterior
fossa but likely not significantly changed compared to the prior
CT Head
performed 2 hours prior.
2. Additional areas of intracranial hemorrhage including right
tentorial
subdural hematoma, intraventricular hemorrhage, and left frontal
likely
subdural and possibly subarachnoid hemorrhage are not
appreciably changed. No new areas of intracranial hemorrhage.
Similar mild effacement of the right basal cisterns. No midline
shift.
3. Multiple areas of focal narrowing in the bilateral P2
segments without
evidence of focal occlusion.
4. No evidence of a dural AV fistula.
5. Short segment of the right transverse sinus is not well
visualized,
possibly related to contrast bolus timing. Thrombus is not
entirely excluded however, this is not well assessed on this
nondedicated exam. Evaluation with CTV or MRV may be performed
if clinically indicated.
6. Mild-to-moderate focal narrowing just proximal to the origin
of the left vertebral artery. Otherwise patent bilateral
cervical carotid and vertebral arteries without definite
evidence of stenosis, occlusion, or dissection.
7. Peripheral consolidated opacity in the right lung apex and
anterior right upper lobe may be related to radiation treatment
versus scarring/fibrosis.
___-SPINE W/O CONTRAST
1. No acute fractures or traumatic dislocation within the
cervical spine.
2. Partial redemonstration of the known right occipital bone
fracture and
intracranial hemorrhage.
___ Imaging MR HEAD W & W/O CONTRAS
1. Moderately motion degraded study.
2. Stable right cerebellar hematoma, with no identifiable
etiology.
3. Mild diffuse pachymeningeal enhancement
4. No evidence of new acute intracranial process.
5. Known left occipital bone fracture better assessed on prior
CT of the head.
6. Moderate to severe small vessel ischemic changes.
___ Cardiovascular ECG
Atrial fibrillation
Probable LVH with secondary repol abnrm
ST depression, consider ischemia, diffuse lds
When compared with ECG of ___ at 02:57
Atrial fibrillation A fib has replaced sinus rhythm
Electronically signed by MD ___ (81)
___ Imaging RENAL U.S.
1. Decompressed bladder cannot be evaluated on the current
study.
2. No masses or hydronephrosis in bilateral kidneys.
___ Imaging CHEST (PORTABLE AP)
Interval development of pulmonary vascular congestion and
bilateral pleural effusions possibly part of the spectrum of
noncardiogenic pulmonary edema. Underlying pneumonia is not
excluded.
___ Cardiovascular ECG
Normal sinus rhythm
Left ventricular hypertrophy with repolarization abnormality
Abnormal ECG
___ Cardiovascular Transthoracic Echo Report
The visually estimated left ventricular ejection fraction is
65%.
___ Imaging CT HEAD W/O CONTRAST (therapeutic on
warfarin)
1. Expected interval evolution of high moderate-sized
intraparenchymal
hematoma within the right cerebellum. There is underlying
vasogenic edema
which appears similar extent to the prior MRI, however it is
difficult to
exclude superimposed ischemia.
2. Trace right parietal subarachnoid hemorrhage as well as
parafalcine and
tentorial subdural hematomas are mildly improved from the prior
study.
3. Mild effacement of the basal cisterns more prominent on the
right,
otherwise no substantial mass effect.
___ Cardiovascular Unconfirmed ECG
Sinus rhythm with premature supraventricular complexes
Minimal voltage criteria for LVH, may be normal variant
Borderline ECG
___ EKG
Sinus tachycardia
Left ventricular hypertrophy with repolarization abnormality
Abnormal ECG
When compared with ECG of ___ 04:44, (Unconfirmed)
Sinus rhythm has replaced Atrial fibrillation
ST more depressed in Inferior leads
ST more depressed in Lateral leads
T wave inversion more evident in Lateral leads
___ EKG
Sinus rhythm with marked sinus arrhythmia
Otherwise normal ECG
When compared with ECG of ___ 05:36, (Unconfirmed)
Vent. rate has decreased BY ___ no longer depressed in Inferior leads
ST no longer depressed in Anterolateral leads
T wave inversion no longer evident in Inferior leads
T wave inversion no longer evident in Lateral leads
DISCHARGE LABS:
___ 06:45AM BLOOD ___
___ 6:45 GLUCOSE-100* UREA N-27 CREAT-0.5 SODIUM-135
POTASSIUM-4.0 CHLORIDE-95 TOTAL CO2-28 ANION GAP-12
Brief Hospital Course:
====================
PATIENT SUMMARY:
====================
Ms. ___ is an ___ with hx of HTN, prior TIA, recently
diagnosed high-grade bladder cancer, who was initially admitted
to neurosurgery on ___ after a fall, found to have a cerebellar
IPH and new-onset Afib, for which she was started on warfarin
and metoprolol. She also developed a O2 requirement, in the
setting of IVF; with active diuresis, she was breathing
comfortably on room air, and euvolemic on exam at time of
discharge. Notably, she was orthostatic towards the end of her
stay; with neurology input, her blood pressure medications were
stopped, and her blood pressure improved and remained within the
goal of SBP <180.
====================
TRANSITIONAL ISSUES:
====================
#discharge INR: 1.9
#stopped medications: nifedipine, losartan, tamsulosin
#changed medications: none
#new medications: warfarin 2.5 mg, metoprolol succinate 12.5
daily
[ ] Of note, patient was subtherapeutic on warfarin at
discharge (goal 2.0-3.0). She has not yet received a dose of
warfarin on day of discharge, would recommend giving 2.5 mg upon
arrival to rehab facility and continuing on 2.5 mg daily. Please
check ___ on ___ and adjust dose accordingly.
[ ] Needs follow-up with Atrius neurologist. Please help
arrange.
[ ] Needs interval MRI brain w/wo cont in ___ weeks to rule
out underlying mass.
[ ] Follow-up with Dr. ___ of urology 1 month after
discharge to assess urinary retention and complete urologic
malignancy workup.
[ ] Requires weekly void trials, as long as Foley catheter is
in place.
[ ] Consider ziopatch as outpatient to assess afib burden
#code status: full
#contact: ___ ___
====================
ACUTE ISSUES:
====================
#TBI
#Right Cerebellum IPH
#Right occipital bone fracture
Patient presented to ED after being found down at home with head
CT findings demonstrated right occipital bone fracture and right
cerebellum IPH. Patient was admitted to neurosurgery to the
___ for close neurologic monitoring and EVD watch. Patient was
GCS 14 on presentation and her exam remained neuro intact with
exception of slight L dysmetria. Due to the characteristics of
the IPH, there was concern for possible underlying lesion. CTA
was done and negative for vascular lesions. MRI was done and
showed stable right cerebellar hematoma, with no identifiable
etiology. Patient had occasional episodes of vomiting typically
occurring after oral medication administration. Patient was
started on salt tabs for hyponatremia. Her neuro checks were
liberalized to q2hours. She remained in the ICU and NPO for
ongoing EVD watch. Her neurologic exam remained stable, and she
was transferred out to the ___ on ___. While on the floor,
neurosurgery continue to follow peripherally with goal SBPs
maintained with blood pressure medications. By the end of her
stay, her blood pressure medications were down titrated and she
was discharged only with metoprolol for her atrial fibrillation.
Goal SBP < 180.
#Atrial fibrillation
#Supraventricular tachycardia
Patient noted to be in Afib on admission EKG ___ and ___
OVN. She denied known prior history of Afib, though endorses
history of frequent PACs. She was monitored on telemetry.
CHADS2Vasc 6. Started warfarin ___, goal INR ___, therapeutic
on warfarin 2 mg daily. Per neurosurgery recommendation, head
CT was obtained when she became therapeutic on warfarin, without
acute findings. For atrial fibrillation, we also began
Metoprolol succinate 12.5 qd.
# Hypertension
# Orthostatic vitals
Her blood pressure was controlled per goals outlined by
neurosurgery team, with appropriate medications. As more time
progressed from the initial fall, we noted that she had
orthostatic vitals. Given this, we down titrated her blood
pressure medications, with input from neurology and
neurosurgery, and she is discharged only on metoprolol
succinate, primarily for her atrial fibrillation.
# Acute hypoxemic respiratory failure, resolved
# Iatrogenic volume overload
She developed a O2 requirement during her admission, most likely
iatrogenic volume overload given IVF. Chest x-ray taken ___
showed interval development of pulmonary vascular congestion and
bilateral pleural effusions. TTE taken ___ showed visually
estimated left ventricular ejection fraction of 65%. She was
diuresed as needed to good effect. She was stable on room air
at time of discharge.
#Electrolyte abnormalities
Over the course of her admission, she was hyponatremic for which
she was started on salt tabs. She was additionally found to be
hypokalemic, hypocalcemic, hypomagnesemic, and hypophosphatemic
over the course of her hospitalization, all of which were
followed and repleted as necessary.
#Workup for Urologic Cancer
#Urinary retention
Patient was worked up by urology for concern of urologic cancer
and is s/p cystoscopy, selective cytology, bilateral, left
ureteroscopy, bladder biopsies, left ureteral biopsy and left
kidney biopsy, left ureteral stent placement on ___ for concern
for upper tract urothelial carcinoma. On presentation to ED
after being found down, urology was consulted. Urology
recommendations were followed closely during ___ hospital
course. Her initial urine culture was negative. She was
discharged with Foley in place, with recommendation for weekly
void trials and outpatient urology follow-up.
#CAUTI
UA culture notable for E coli; with symptom of suprapubic
tenderness, was treated for CAUTI, given recent Foley catheter,
for 7 days. She denied symptoms at time of discharge.
Medications on Admission:
Medications:
Anticoagulants [ ]No [x]Yes
Name: ___ 81mg daily
Last Taken: One week prior Indication: Cardioprotection
--------------- --------------- --------------- ---------------
The Preadmission Medication list is accurate and complete.
1. NIFEdipine (Extended Release) 30 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Timolol Maleate 0.5% 1 DROP LEFT EYE DAILY
4. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
2. Metoprolol Succinate XL 12.5 mg PO DAILY
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
4. Warfarin 2 mg PO DAILY16
5. Timolol Maleate 0.5% 1 DROP LEFT EYE DAILY
6. HELD- Losartan Potassium 50 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until you speak with
your physician about your blood pressures.
7. HELD- NIFEdipine (Extended Release) 30 mg PO DAILY This
medication was held. Do not restart NIFEdipine (Extended
Release) until you speak with your physician about your blood
pressures.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Traumatic brain injury
Cerebellar intraparenchymal hemorrhage
Right occipital bone fracture
Atrial fibrillation
Urinary retention
Catheter associated urinary tract infection
Acute hypoxemic respiratory failure
Secondary diagnosis:
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because of a fall and were found to have a
bleed in your brain
- You were also found to have an abnormal heart rhythm called
atrial fibrillation
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were started on medications to control your heart rate
(metoprolol) and to prevent blood clots (warfarin) because of
your abnormal heart rhythm
- You had a Foley catheter placed because you were having
difficulty urinating
- You were treated for a urinary tract infection
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications as prescribed
- You will need to follow-up with your primary care doctor. The
rehab facility will arrange this appointment.
- You will need to follow-up with a neurologist at Atrius. Your
PCP can help arrange this appointment.
- You will go to rehab with a Foley catheter in place. You
should try removing this once a week to see if you can pee on
your own. You should follow-up with urology to discuss your
urination issues.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
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2127-03-14 13:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
ranitidine / pantoprazole / venlafaxine / pseudoephedrine
Attending: ___
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
NA
History of Present Illness:
The pt is a ___ year-old right-handed woman with Alzheimer's
disease (___) and h/o generalized seizure on Depakote
who p/w seizure x2 today.
She was first diagnosed with seizures ___ at ___ during an admission for evaluation for agitation and
delusions. She had an EEG on ___ that showed ___
to be "prone" to possible seizures. On ___ she had an episode
of lightheadedness and fell. 5 hours later a nurse witnessed ___
GTC with resultant tongue bite. At that point she was started on
Depakote. She has had subsequent seizures witnessed by husband
and described as tonic stiffening, eyes open but not deviated
with heavy breathing, clenched teeth and foaming of the mouth
that lasted less than 5 minutes with post-ictal phase lasting
___ minutes.
She reportedly had a 10 minute seizure today at ___ ALF. VS at
___ were: 99.4 temporal, 103, 141/91, 13, 97RA. She was also
found to have UTI ___ wbc, ___ 100, neg nitrite) and given
ceftriaxone. Found to be dehydrated and given 2 liters IVFs.
CXR
reportedly negative for pna. Depakote dose was found to be
subtherapeutic at 16.9. She was given depakote 500mg. She had
another generalized seizure ___ minutes long) with tongue
biting
several hours into ___ ED stay at ___ for which she was
given ativan 0.5mg x 1. She was transferred to ___ for neuro
eval.
She is followed by a neurologist in ___, Dr. ___. She has
been on keppra for over ___ years per ___ husband. ___ depakote
was decreased months ago (?___) to ___ current dose
due
to sleepiness. Husband does not know ___ usual therapeutic
level.
As baseline, she is only oriented to self and family members.
She is wheelchair bound and lives in ___. She has poor short
term
memory and makes paraphasic errors.
Of note, she had a h/o behavioral outburst, agitation,
fluctuations in consciousness which has been worked up in the
past and thought to be behavioral and non-epileptic in nature.
(She was on cvEEG ___ to ___. Push button somnolence
events had no electrographic correlation. Background was slow
without epileptiform features.)
Past Medical History:
-Alzheimer's disease - dx ___ (symptoms since ___ Followed
at
___ by psychiatrist Dr. ___. She was in an Alzheimer's
drug
trial with the last drug infusion ___. Initially tried on
Aricept but stopped due to GI issues. She was admitted to ___
for agitation and worsening delusions ___. She
had good response to Clozaril, which per records will be
followed
by Dr. ___ with weekly CBC and ANC.
-depression - since ___ ___. Received ECT in ___ that was
stopped to participate in ___ drug trial.
-HTN
-HL
-seizures - see hx in HPI
-bladder prolapse with surgical repair
-hx interstitial cystitis and recurrent UTIs
-anemia
Social History:
___
Family History:
negative for seizure
Physical Exam:
Physical Exam:
Vitals: 97.6 100 153/84 16 97% ra
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple. Resists examination of the neck.
Pulmonary: Lungs CTA
Cardiac: RRR
Abdomen: soft, NT/ND
Neurologic:
-Mental Status: Sleepy but easily arousable to calling of ___
name and rubbing of ___ hand. She is very inattentive (keeps
falling back to sleep) but able to tell me ___ name. Does not
know where she is or the year/month (baseline). Follows some
simple one-step commands such as opening ___ eyes and lifting of
hands but unable to follow more complex commands. No spontanous
speech. Speaks 1 word answers ___ name, and "yes" or "no") in
response to simple questions.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm. Blinks to threat in all quadrants
III, IV, VI: EOMF grossly.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact grossly
IX, X: Palate elevates symmetrically.
XII: Does not protrude tongue to command.
-Motor: Paratonic throughout with grasp reflex in bilateral
hand.
Able to raise and hold arms antigravity. Moves arms against
resistance and legs antigravity symmetrically. Unable to
cooperate with confrontational exam.
-Sensory: Withdraws to tickle in all fours.
-DTRs:
___ throughout.
Plantar response was flexor bilaterally.
-Coordination: No evidence of dysmetria though unable to
cooperative with confrontational exam.
-Gait: Deferred
Discharge exam is largely unchanged. CN exam is notable for very
minimal vertical eye movements. She also has minimal movement of
the ___ bl.
Pertinent Results:
___ 01:58AM BLOOD WBC-11.6*# RBC-4.35 Hgb-13.2 Hct-40.2
MCV-93# MCH-30.4# MCHC-32.9 RDW-13.5 Plt ___
___ 01:58AM BLOOD Neuts-83.8* Lymphs-10.2* Monos-4.8
Eos-1.1 Baso-0.2
___ 01:58AM BLOOD ___ PTT-31.2 ___
___ 10:50AM BLOOD Glucose-93 UreaN-10 Creat-0.8 Na-142
K-4.1 Cl-106 HCO3-24 AnGap-16
___ 10:50AM BLOOD ALT-18 AST-24 CK(CPK)-245* AlkPhos-69
TotBili-0.4
___ 10:50AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.1
___ 01:58AM BLOOD Valproa-41*
Brief Hospital Course:
___ year-old right-handed woman with Alzheimer's disease (Dx in
___ and a history of generalized seizure on Depakote and
keppra who presented with 2 seizures in the setting of a UTI.
The patient had been seizure free since ___ and was undergoing
some medication adjustments by ___ out patient doctors. ___
___ level was found to be subtherapeutic at 16 and she
recieved a depakote load of 500mg. Post load level was 41. CT
head in the ED was without acute pathology. The patient was
somnulent during ___ stay so ___ Depakote was eventually held
with increased Keppra dose of 750BID from 500 BID. ___ clozaril
was also held due to day time somnolence which improved off of
this medication. ___ UTI was treated with 3 days of CTX. The
patient returned to ___ usual state of health without recurrence
of seizure.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clozapine 25 mg PO HS
2. Venlafaxine XR 225 mg PO DAILY
3. Losartan Potassium 25 mg PO DAILY
4. Aripiprazole 15 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Memantine 10 mg PO BID
7. LeVETiracetam 500 mg PO BID
8. Divalproex (EXTended Release) 250 mg PO DAILY
9. Simvastatin 20 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Vitamin D ___ UNIT PO DAILY
12. Arthritis Pain Reliever (acetaminophen) 325 mg oral Q6H pain
13. Ferrous Sulfate 325 mg PO BID
14. Docusate Sodium 100 mg PO HS
15. Fluticasone Propionate NASAL 1 SPRY NU DAILY
16. Exelon (rivastigmine;<br>rivastigmine tartrate) 9.5 mg/24 hr
transdermal daily
Discharge Medications:
1. Aripiprazole 15 mg PO DAILY
2. Docusate Sodium 100 mg PO HS
3. Exelon (rivastigmine;<br>rivastigmine tartrate) 9.5 mg/24 hr
transdermal daily
4. Ferrous Sulfate 325 mg PO BID
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. LeVETiracetam 750 mg PO BID
RX *levetiracetam 750 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
7. Losartan Potassium 25 mg PO DAILY
8. Memantine 10 mg PO BID
9. Omeprazole 20 mg PO DAILY
10. Simvastatin 20 mg PO QPM
11. Venlafaxine XR 225 mg PO DAILY
12. Arthritis Pain Reliever (acetaminophen) 325 mg oral Q6H pain
13. Multivitamins 1 TAB PO DAILY
14. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Seizure
Alzheimer's dementia
urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were admitted to the neurology service for seizures. You
were found to have a urinary tract infection which was treated
with antibiotics. We increased the dose of your seizure medicine
keppra from 500mg to 750mg twice per day. While you were here we
also discontinued your depakote as we believed that this was
making you too sleepy. The remainder of your medications were
unchanged.
Please follow up with your out patient neurologist for further
medication adjustments as needed.
It was a pleasure caring for you,
___ neurology team
Followup Instructions:
___
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2113-12-13 19:59:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Valium / Demerol / Percocet / Novocain
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP pending
History of Present Illness:
___ with h/o CCY w/retained stones requiring ERCP retrieval c/b
bowel perforation approximately ___ years ago p/w RUQ/epigastric
pain x 5 days. She reports that they were unable to remove the
stones and that she has had intermittent abdominal pain x ___
years. She started feeling ill approximately 5 days ago and
developed nausea, vomiting, and diarrhea x 2 days. Emesis and
diarrhea were non bloody and resolved. She still feels
nauseated and has had fevers up to 101. She is pain free at
present but the pain fluctuate from 0 to ___ in severity and is
sharp. The duration is completely variable.
.
She has also noted darker urine and in the past few days her
daughter noted that she was more jaundiced.
.
ROS: +fevers, poor ___, nausea; no further vomiting. + very
slight chest pressure like angina tonight, mild SOB, no cough,
no palpitations, dysuria, urinary frequency, urgency, myalgias,
arthralgias, numbness, tingling, rashes. 10 point ROS otherwise
unremarkable
In the ER, ERCP team rec ERCP tomorrow. Surgery also evaluated
and will follow.
Past Medical History:
Afib not on coumadin
HTN
Hypercholesterolemia
Angina
CCY
hypothyroidism
ERCP complicated by bowel perforation.
ED records indicate CAD as hx but pt denies it.
Social History:
___
Family History:
CAD
Physical Exam:
PE: 96 HR 89 BP 144/75 RR 18 O2 sat 98% on RA
GEN: NAD, appears fatigued
HEENT: oropharynx clear, dry mucous membranes
Neck: supple
CV: RRR, no m/r/g
PULM: CTAB
ABD: +BS, soft, NTND
Neuro: CN2-12 grossly intact, moves all extremities, reports no
difficulty ambulating; normal strength, sensation
MS: normal tone
Psych: normal affect
DERM; no rashes, lesions
Pertinent Results:
Gallbladder US: 1.3 cm CBD stone w upstream CBD of 15mm and mild
intrahep biliary dilatation.
s/p CCY
Admission Labs:
___ 10:05PM ___ PTT-26.9 ___
___ 08:58PM ___ PO2-61* PCO2-24* PH-7.50* TOTAL
CO2-19* BASE XS--2 COMMENTS-GREEN TOP
___ 08:58PM LACTATE-1.4
___ 08:52PM GLUCOSE-97 UREA N-20 CREAT-0.5 SODIUM-134
POTASSIUM-2.9* CHLORIDE-94* TOTAL CO2-25 ANION GAP-18
___ 08:52PM estGFR-Using this
___ 08:52PM ALT(SGPT)-174* AST(SGOT)-113* ALK PHOS-170*
TOT BILI-9.9*
___ 08:52PM LIPASE-24
___ 08:52PM ALBUMIN-3.4*
___ 08:52PM WBC-14.0* RBC-4.62 HGB-14.1 HCT-40.5 MCV-88
MCH-30.5 MCHC-34.8 RDW-13.3
___ 08:52PM NEUTS-90.0* LYMPHS-4.9* MONOS-3.8 EOS-0.6
BASOS-0.7
___ 08:52PM PLT COUNT-225
Discharge Labs:
___ 07:30AM BLOOD WBC-9.1 RBC-4.23 Hgb-12.5 Hct-37.0 MCV-87
MCH-29.6 MCHC-33.8 RDW-13.9 Plt ___
___ 07:16AM BLOOD Glucose-107* UreaN-7 Creat-0.5 Na-139
K-3.9 Cl-102 HCO3-30 AnGap-11
___ 06:00AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:30AM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:09PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:36AM BLOOD CK-MB-3 cTropnT-0.02*
ERCP Report:
S/P sphincterotomy. Bile duct was successfully cannulated using
a sphincterotome. Cholangiogram revealed large stones in the
common bile duct with diffuse dilation to 15mm. Given
presentation with cholangitis and present of pus in the bile
duct, stone extraction was not attempted.
A biliary stent was placed. Normal limited exam of pancreatic
duct in head of pancreas. Otherwise normal ercp to third part of
the duodenum.
Brief Hospital Course:
___ y/o woman with afib on ASA only, ? CAD, hx. retained CBD
stones requiring ERCP c/b bowel perf ___ years ago (unable to
remove stones) has had intermittant abd pain for ___ yy. 5 d PTA
she developed n/v/abd pain and fever to 101 and presented to the
ED, where she was found to have a 15 mm CBD and labs c/w
obstruction. She was started on Unasyn and admitted with plan
for ERCP.
The patient complained of some chest pressure on night of
admission. ECG with TWF AVF, TWI in III. Trop 0.02. No prior
ECG for comparison. Repeated Cardiac enzymes and ECG in ERCP
suite - no new changes or progression on ECG, Troponin still
0.02 on repeat. Pt. was without complaints of pain or pressure
or sob. ERCP proceded, she was stented, and stones were not
removed, but pus seen at ampulla. A pigtail stent was placed
and the plan is for pt. to have repeat ERCP in two weeks for
stone and stent removal. She tolerated the procedure well. Post
procedurally we advanced her diet and changed to oral abx
without difficulty. She had one further episode of chest
pressure radiating to her right shoulder c/w prior pains in the
abdomen per pt (likey from retained stones stent that are still
in position). EKG was without changes, CEs were repeated and
normal. Her pain resolved without intervention.
Pt. was discharged with a plan to follow up for repeat ercp for
stone and stent extraction (scheduled for ___ - see below.
Medications on Admission:
atenolol 50 mg ___
amlodipine 2.5 mg ___
levothyroxine 25 mcg ___
cozaar 50 mg ___
tricor 145 mg ___
zetia 10 mg ___
folic acid/vit b vitamin
apirin 81 mg x 4 ___
prevacid 15 mg ___
klorcon 20 meq ___
advair 250/50 ___
nitro stat prn
Discharge Medications:
1. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest
pressure.
2. atenolol 50 mg Tablet Sig: One (1) Tablet ___.
3. amlodipine 2.5 mg Tablet Sig: One (1) Tablet ___
(___).
4. losartan 50 mg Tablet Sig: One (1) Tablet ___.
5. ezetimibe 10 mg Tablet Sig: One (1) Tablet ___.
6. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet ___
___ ().
7. folic acid 1 mg Tablet Sig: One (1) Tablet ___.
8. B complex vitamins Capsule Sig: One (1) Cap ___
(___).
9. aspirin 325 mg Tablet Sig: One (1) Tablet ___.
10. lansoprazole 30 mg Tablet,Rapid Dissolve, ___ Sig: 0.5
Tablet,Rapid Dissolve, ___ ___.
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet ___ Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
12. metronidazole 500 mg Tablet Sig: One (1) Tablet ___ Q8H
(every 8 hours) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
13. levothyroxine 25 mcg Tablet Sig: One (1) Tablet ___ once a
day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Choledocholithiasis with obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with nausea, vomiting, and abdominal
pain and underwent an ERCP. A stent was placed and you were
started on antibiotics, which you will continue to take for a
total of seven days. You can re-start your home aspirin
___.
Followup Instructions:
___
|
10864544-DS-13
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DS
| 13 |
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2114-07-12 14:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pedestrian Struck by car while intoxicated
Major Surgical or Invasive Procedure:
___:
1. Irrigation and debridement, open left tibia fracture.
2. Intramedullary rod fixation of left tibia fracture.
3. Closed reduction left fibular fracture with manipulation.
History of Present Illness:
___ presenting as transfer from ___ after being
struck by a car in a parking lot while intoxicated. Injury
occured at approximately 6:55pm. Pt does not remember accident,
daughters note that he has history of depression, express
concern that this could have been suicide attempt. R shoulder
dislocation s/p reduction at OSH. Closed R fib fracture. Open L
tib/fib fracture. R orbital floor and maxillary fracture. Pt was
noted to have SAH and SDH, transferred to ___ for possible
operative management. Repeat ___ in ED shows small SAH, no
SDH. Admitted to ___ initially for neurological monitoring.
Past Medical History:
HTN, Lyme disease, disc herniation, cataract surgery,
partial deafness, vastectomy, LBP. Multiple attempts at alcohol
detoxification and rehabilitation
Social History:
___
Family History:
Non-contributory
Physical Exam:
On Admission:
Vitals: AVSS in trauma bay, GCS 15.
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Some dried blood in the oropharynx, but otherwise within
normal limits, dentition intact. Alcoholic halitosis.
Chest: No crepitus, no subcutaneous air, no tenderness to
palpation, no visible deformities. Lungs clear to
auscultation, airway clear.
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds, 2+ DP and radial pulses B/L.
Abdominal: Soft, Nontender, Nondistended
Extr/Back: No cyanosis, clubbing or edema. Superficial
abrasion on the L foot. 2cm distal anterior L leg abrasion
with exposed muscle. Superficial R elbow laceration. Pelvis
is stable.
Skin: No rash, Warm and dry
Neuro: Speech fluent.
On Discharge:
Pertinent Results:
___ 09:54PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 09:54PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
___ 09:05PM BLOOD WBC-13.8* RBC-4.00* Hgb-13.2* Hct-39.1*
MCV-98 MCH-33.0* MCHC-33.8 RDW-14.4 Plt ___
___ 11:33PM BLOOD WBC-11.5* RBC-3.91* Hgb-12.3* Hct-38.4*
MCV-98 MCH-31.6 MCHC-32.1 RDW-13.9 Plt ___
___ 06:20AM BLOOD WBC-7.9 RBC-2.47*# Hgb-8.0*# Hct-24.5*#
MCV-99* MCH-32.4* MCHC-32.8 RDW-14.0 Plt ___
___ 04:54AM BLOOD WBC-6.2 RBC-2.17* Hgb-7.0* Hct-21.5*
MCV-99* MCH-32.2* MCHC-32.5 RDW-14.5 Plt ___
___ 10:40AM BLOOD Hct-24.8*
___ 06:05PM BLOOD Hct-25.4*
___ 06:25AM BLOOD WBC-5.9 RBC-2.60* Hgb-8.2* Hct-25.4*
MCV-98 MCH-31.5 MCHC-32.2 RDW-15.2 Plt ___
___ 09:05PM BLOOD ___ PTT-25.5 ___
___ 11:31PM BLOOD ___ PTT-26.5 ___
___ 06:20AM BLOOD ___ PTT-25.3 ___
___ 11:33PM BLOOD Glucose-127* UreaN-15 Creat-1.2 Na-140
K-4.3 Cl-106 HCO3-19* AnGap-19
___ 04:54AM BLOOD Glucose-100 UreaN-14 Creat-0.9 Na-140
K-3.9 Cl-107 HCO3-26 AnGap-11
___ 06:25AM BLOOD Glucose-117* UreaN-16 Creat-1.0 Na-141
K-4.1 Cl-106 HCO3-28 AnGap-11
___ 06:25AM BLOOD ALT-37 AST-55* AlkPhos-48 TotBili-0.7
___ 11:33PM BLOOD Calcium-8.5 Phos-3.1 Mg-1.5*
___ 06:20AM BLOOD Calcium-7.9* Phos-2.9 Mg-2.2
___ 04:54AM BLOOD Calcium-8.0* Phos-2.4* Mg-2.1
___ 07:40AM BLOOD Albumin-3.2* Calcium-9.2 Phos-4.3 Mg-1.9
Iron-39*
___ 06:25AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.1
___ 07:40AM BLOOD calTIBC-265 ___ Ferritn-96
TRF-204
___ 06:25AM BLOOD TSH-2.7
___:01PM BLOOD Phenoba-9.7*
___ 09:05PM BLOOD ASA-NEG Ethanol-12* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:19PM BLOOD Glucose-121* Lactate-2.5* Na-140 K-4.1
Cl-108 calHCO3-18*
___ 04:36AM BLOOD Lactate-1.7
Imaging ___:
PORTABLE CXR: IMPRESSION: Interval reduction of the right
glenohumeral joint. Otherwise, no injury seen
CT Left Lower Extremity:
IMPRESSION:
1. Comminuted distal diaphyseal tibia fracture with displacement
and overlap. Segmental fibula fracture with comminuted proximal
fibula and comminuted mid fibula fractures. The mid fibular
fracture has dorsal angulation and approximately 2 cm overlap.
2. Hematoma and foci of air seen throughout the lower leg.
CT C-Spine:
IMPRESSION: No fracture or malalignment of the cervical spine.
CT-Head:
IMPRESSION:
1. Moderate amount of right parietotemporal subarachnoid
hemorrhage. No mass effect.
2. Tiny hyperdensity in the posterior falx may represent a tiny
subdural hematoma can be assessed at the time of followup.
3. Fractures of the right orbital floor and maxillary sinus as
described above.
4. 5-mm foreign body in subcutaneous tissues of the right
periorbital frontal subcutaneous tissues.
Bilateral Tib/Fib:
FINDINGS: LEFT TIBIA/FIBULA: AP and lateral views of the left
tibia and
fibula were provided. Please note the lateral view only
includes the lower two-thirds of the tibia and fibula. There is
an acute segmental fracture involving the fibula at the level of
the fibular neck and mid shaft. The fracture fragment lies
displaced laterally by approximately one-half to one full bone
with overlap of the intervening fracture fragment with the
distal shaft. There is also an acute open fracture through the
distal shaft of the tibia with lateral displacement by one full
bone of the distal fracture fragment. There is also posterior
displacement of the distal fracture fragment.
RIGHT TIBIA/FIBULA: There is a nondisplaced fracture through
the head/neck of the right fibula as well as the proximal shaft.
No definite acute fractures are seen involving the right tibia.
Overlying fiberglass splint is noted. The medial malleolar
fracture has undergone prior ORIF with two threaded screws in
place. The fracture lucency remains conspicuous suggesting this
with a recent injury. Please correlate clinically.
Bilateral Femurs:
FINDINGS: Six views of the bilateral femur were provided. On
the left, the left femoral head aligns normally with the lower
pelvis. A Foley catheter is situated within the lower pelvis
likely residing within the bladder. The left femur appears
intact. A fracture through the neck of the left fibula is
noted. No joint effusion at the left knee. The right hip
articulates normally and the right femoral head and neck appear
intact. The mid and distal right femur are also intact in
appearance. A subtle deformity of the right fibular neck is
compatible with an acute fracture. No joint effusion at the
right knee.
___
Non-Contrast Head CT:
FINDINGS: Subarachnoid hemorrhage along the right parietal and
temporal
convexities is relatively unchanged. Punctate hyperdensity
along the
posterior falx is also unchanged and may represent a subdural
hematoma. There is no shift of normally midline structures.
There is no evidence of herniation. The ventricles and sulci
are unchanged in configuration. The basal cisterns are patent
and there is preservation of gray-white matter differentiation.
Fractures of the right orbital floor along with anterior and
lateral walls of the maxillary sinus are again noted. The sinus
remains filled with blood which extends into the frontal ethmoid
recess. Opacification in the anterior ethmoid air cells is also
unchanged. The mastoid air cells and middle ear cavities remain
clear. A metal foreign body in the right frontal subcutaneous
tissues is unchanged. The globes remain intact.
IMPRESSION: Relatively unchanged right parietotemporal
subarachnoid
hemorrhage and tiny subdural along the falx. Fractures of the
right orbital floor and maxillary sinuses are again noted
Lower Extremity Fluoroscopy:
COMPARISON: ___.
FINDINGS:
21 films from the OR demonstrate interval placement of a tibial
rod with proximal and distal screws. The images at the end of
the procedure show improved alignment of the tibial fracture.
Fibular fracture is incompletely evaluated but the spiral
fracture of the proximal fibula is again visualized only
minimally displaced
___
Repeat CXR:
FINDINGS:
The lungs are clear without infiltrate or effusion. The cardiac
and
mediastinal silhouettes are unchanged. There is no
pneumothorax.
___
Gleno-Humeral Shoulder (w/ Y-View):
RIGHT SHOULDER, THREE VIEWS:
There is widening of the glenohumeral joint. No gross anterior
or posterior humeral head dislocation is identified. However,
the humeral head is high riding and probably slightly anteriorly
subluxed. No obvious fracture is identified. Mild degenerative
change is seen at the acromioclavicular joint.
No soft tissue calcification. The visualized right lung is
grossly clear.
Brief Hospital Course:
___ presenting as transfer from ___ on ___
after being struck by a car in a parking lot while intoxicated.
Injury occured at approximately 6:55pm. Pt does not remember
accident, daughters note that he has history of depression,
express concern that this could have been suicide attempt. R
shoulder dislocation s/p reduction at OSH. Closed R fib
fracture. Open L tib/fib fracture. R orbital floor and maxillary
fracture. Pt was noted to have SAH and SDH, transferred to ___
for possible operative management. Repeat ___ in ED shows
small SAH, no SDH. Admitted to ___ initially for neurological
monitoring. In the emergency department, multiple services were
consulted to assist in his care including the ___ (trauma)
surgery service, orthopedics, neurosurgery, plastic surgery, and
ophthalmology.
Patient was admitted to the ACS service on ___ with
additional services providing recs. Plastics recommended: head
of bed elevation, sinus precautions, augmentin x 5 days, an
optho consult, likely non operative management of facial
fractures and close follow up in clinic. Orthopedics
recommended ORIF of his left tib/fib fracture once stable and
closed management of his R fibular fracture. Also recommended
placing RUE in NWB sling and follow up in clinic. Neurosurgery
was consulted for the patient's SAH and SDH and recommended
Strict SBP less than 140, Q4 neurochecks, Repeat head CT in AM
or sooner if there is any change in exam.
- Ortho to take to OR for fixation of open ankle fracture, and
OK for postoperative DVT prophylaxis with SC heparin or Lovenox.
Ophtho evaluated the patient and found no retinal detachment
and no optic neuropathy in either eye along with no globe injury
in either eye. Ophtho recommended f/u in 4 weeks with his
ophthalmologist or at the ___ EYE unit or sooner if patient
reports double vision, decreased vision, pain on eye movements,
floaters, flashes of light or VF cut.
On ___ after a repeat CT scan demonstrated stable
intracranial changes, the patient was taken to the OR with ortho
for management of his bilateral lower extremity fractures. For
a detailed report of this case, please see the operative note
from that date. In short, procedure performed:
1. Irrigation and debridement, open left tibia fracture.
2. Intramedullary rod fixation of left tibia fracture.
3. Closed reduction left fibular fracture with manipulation.
IMPLANTS: Synthes tibial nail (EX) 10 x ___, with 3 locking
screws.
Postoperatively he was transferred to the PACU where he
underwent an uneventful recovery period. The patient was then
transferred to the floor remaining in a C-spine collar and
remaining NPO on IV fluids and dilaudid for pain control. The
patient was also initiated on a phenobarbital taper protocol at
this time to protect him in the event he began to experience
withdrawal from ETOH.
On ___ while on the floor Mr. ___ was found to be more
agitated, unaware of the reason for hospitalization or injuries,
and was pulling at his lines and putting himself at risk by
attempting to rise out of bed while still unsteady. He was
evaluated and found to be at risk to himself and given 5 mg of
zyprexa and placed in soft restraints for the minimum amount of
time necessary to ensure his safety.
On ___ he was advanced to a soft diet. He remained unable
to consistently indicate the reason for his hospitalization, and
was frequently reoriented to his location and the date. Pt also
frequently was found to be making inappropriate remarks or
recalling events that were years past. He was evaluated for
c-spine tenderness but was unable to give consistent answers on
exam and perhaps indicated that he was tender in T1, though
giving inconsistent answers stating that the same location was
both painful and non painful, tender and non-tender. Beause of
this, his c-collar was kept for his own protection.
On ___, he was found be in atrial fibrillation following an
episode of tachycardia. The pt was experiencing no new sx at
the time including no palpitations, SOB or CP. He was found to
have a hct of 21.5 and transfused 1 u PRBCs. A post transfusion
hct was 24.8, and he was started on metoprolol 5 mg IV q6 hours.
He was also placed on telemetry.
Early in the morning ___ the patient's foley was dc'd and he
voided without difficulty, his rhythm converted back to NSR, and
he was started on PO meds which he tolerated well. His fluids
were stopped and he was also given supplemental thiamine at 500
mg IV TID x 6 doses
On ___ Mr. ___ was evaluated by psychiatry. His
Alcohol dependence and concern of withdrawal being treated with
phenobarb protocol, was found to be demonstrating no signs of
w/d. His Delirium was resolving - his persistent confusion may
be due to brain injury, or could be assigned to iatrogenic
effects of narcotics, barbiturate. He was found to demonstrate
a basic but limited understanding of his injuries and care
needs; unclear if patient has any baseline
deficits, but his judgment currently is certainly impaired by
delirium. Nevertheless, he has been overall cooperative with
care and in this interview indicates a willingness to go to
rehab as is recommended.
Psychiatry recommended to proceed with plan to refer to rehab as
he appears to accept this - if patient again refuses necessary
care we would need to evaluate at that time to assess his
capacity to refuse. His overall mental status was anticipated
to improve as he recovers from injury, also with phenobarb taper
and also reduction in narcotic requirement.
On ___ with the patient more able to consistently describe
his location, time and date, and orientation questions, an
attempt was made to clear his cervical spine. Following a
thorough exam and review of radiology records, his c-spine
collar was cleared. He was also found to be holding up his RUE
to move it. A series of shoulder x-rays found no dislocation,
but orthopedics found his R shoulder to be anteriorly subluxed
and plans to re-evaluate it at his clinic appt ___, for now
plan to continue RUE NWB sling. His mental status continued to
improve and he was through the majority of the day A&O ___, and
requiring minimal redirection and a posey belt restraint to keep
him safe in bed. He completed his phenobarbital taper and was
initiated on a zyprexa regimen per psychiatric recommendations.
CV: The patient was found to be in A-fib with RVR on ___,
following an evaluation, initiation of metoprolol 5 g q6hrs, and
transfusion of 1 u PRBCs, the patient converted back to NSR on
___ otherwise vital signs were routinely monitored and
found to be WNL.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. The wound dressings
were changed daily.
Hematology: The patient's complete blood count was examined
routinely; following his ORIF on ___, the patient's
hematocrit dropped
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible given the limitations
presented by his surgery and bilateral lower extremity
fractures.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
soft diet, ambulating with assistance, voiding without
assistance, and pain was well controlled. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. Acetaminophen 650 mg PO Q4H:PRN Pain
Do not take more than 4000 mg of tylenol in one day.
3. Nicotine Patch 14 mg TD DAILY
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Please do not drink or drive while taking this medication. ___
cause drowsiness
5. Bisacodyl 10 mg PO DAILY:PRN constipation
6. OLANZapine 2.5 mg PO BID
7. Thiamine 100 mg PO DAILY
8. OLANZapine 5 mg PO HS
9. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
10. Metoprolol Tartrate 25 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Polytrauma
Right anterior shoulder dislocation
Right Orbital Floor Fracture
Right Lateral and anterior maxilla fractures
Closed right fibular fracture
Right parietotemporal subarachnoid hemorrhage
Subdural hemorrhage
Alcohol Dependence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You will be discharged to a rehab facility and will also have
multiple follow up appointments with various different
specialties. To maximize your recovery from your injuries, it
is important to work as best as possible with the rehabilitation
facility and to keep your follow up appointments with the
various specialists listed below. In particular, you have a
postoperative appointment with orthopedics on ___ and an
appointment with neurosurgery on ___. You should present
to the ___ before 9:45 AM on ___ in the
radiology department to have a CT scan of your head prior to
your appointment to evaluate whether the bleeding in your brain
has resolved. Please refer to the follow up instructions as
provided below and call the appropriate phone numbers with any
questions.
You were hospitalized after being struck by a car and breaking
multiple bones in both legs, your face, dislocating your right
shoulder, and some bleeding in your brain (subarachnoid
hemorrhage and subdural hemorrhages). After a period of
observation in the ICU, you underwent a surgical open reduction
and internal fixation of your left lower leg to fix your
tibia/fibular fracture there. At ___ your right
shoulder
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Followup Instructions:
___
|
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|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
pravastatin
Attending: ___
Chief Complaint:
abd pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History of Present Illness:
___ is an ___ F with a PMHx of paroxysmal a fib,
recent L MCA stroke, HTN and HLD presents with 1 week of
worsening abd pain. The patient's daughter notes that she
developed abd pain approximately one week ago and was diagnosed
with a urinary tract infection on ___. The patient was started
on cipro, but immediately developed nausea, emesis, and diarrhea
with this. She was thus switched to macrobid on the second day
of therapy. She reports one additional BM 2d PTA, but denies any
continued symptoms of diarrhea or emesis, just notes nausea and
L sided abd pain at this time. The patient dates her abd and
back pain to beginning approximately one week ago, however
started requiring a lidocaine patch to L back during her last
week in rehab (discharged home on ___ following her
hospitalization for her stroke in ___. At this time she notes it
is extremely painful to move around in bed and prefers lying
still. Pt denies gross hematuia, hx of nephrolithiasis, dysuria
or vaginal discharge.
Pt also reports that she has also had a headache for
approximately 2 days time and reports this is the worst pain she
has ever felt. Pt denies photophobia or worsening with loud
sounds, denies blurred vision. She is unable to move her neck
and declined LP in the emergency department. She denies any
recent trauma, denies HA with her previous stroke. She notes
her pain "feels like someone is pushing on her face". She notes
some black spots in her vision and pain over her temples. Also
reports some rhinorrhea and congestion.
Regarding her home coumadin and propafenone her PCP discontinued
these medications once she was started on ciprofloxacin and
instructed to restart these medications once her antibiotic
course had concluded.
Of note patient was recently hospitalized ___ for embolic
stroke to the L anterior choroidal artery thought to be most
likely cardiac in origin restarted on coumadin at that point.
ASA discontinued at recent neurology followup.
In the ED, initial vital signs were: T 98.3 P84 BP 118/70 R 16O2
sat. 94%RA
- Exam notable for: previous RUE/RLE motor deficits and R facial
droop
- Labs were notable for WBC 11.7 H/H 9.7/30.1 2% bands, K 3.0,
INR 1.3, alb 2.7, AST 76 ALT 55, Alk Phos 648, UA with Lg leuks,
trace blood, neg nitrites, 17 RBC's 142 WBC's few bact, lactate
0.8
- Studies performed include CT head, c-spine, abd/pelvis
- Patient was given IV 4mg ondansetron, tramadol 25mg PO x2,
40meq K Cl x5 1g APAP IV, 1g CTX
- Vitals on transfer: 97.3 63 148/67 16 97%RA
Upon arrival to the floor, the patient notes exquisite pain in
the L flank and LLQ and also HA. On interview pt also reports
recent night sweats and some pleuritic chest pain with deep
inspiration.
Review of Systems:
(+) per HPI
(-) chills, sore throat, cough, shortness of breath, chest pain,
Past Medical History:
Past Medical History:
ATRIAL FIBRILLATION
AFib, AFlutter, s/p ablation. ___. Saw Dr. ___, ? GI
bleed on anticoagulation, stopped, not needed anymore
HYPERTENSION
HYPOTHYROIDISM
DIVERTICULOSIS
ARTHRITIS
GASTROESOPHAGEAL REFLUX
HYPERLIPIDEMIA
OSTEOPOROSIS
VITAMIN B12 DEFICIENCY
TAH+BSO IN HER ___, BLEEDING
PARTIAL COLECTOMY AT ___
CHOLECYSTECTOMY
ECHO ___: MILD PULM REGURG, EF 50%, POF
INTERNAL HEMORRHOIDS
Social History:
___
Family History:
Mother and father with strokes in their ___.
Physical Exam:
On admission:
Vitals- 97.9 156/73 52 16 97%RA
General: elderly female, ill appearing, lying without moving in
bed
HEENT: Temporal wasting, ttp over temporal artieries
bilaterally, AT, sclera anicteric, PERRL, EOMI, MM tacky,
oropharynx clear
Neck: stiff, tenderness to palpation along paraspinal muscles,
no LAD, no JVD
Back: no ttp over spinous processes, tenderness along L lumbar
paraspinal muscles out towards L flank
CV: irregular rhythm, normal rate, nl S1 and S2 no MRG
Lungs: CTAB with dullness at bilateral bases
Abdomen: soft, ttp in L sided quadrants ___, with mild ttp
over R sided abd, no rebound or guarding, no HSM
GU: no foley
Ext: Thin, 2+ radial pulses, 1+ DP pulses, warm, without
cyanosis or edema
Neuro: AOx3, CN 7 deficits with asymteric smile and R facial
droop, unable to move RUE, RLE ___ throughout, LUE/LLE ___
throughout
Skin: multiple scattered ecchymoses, no rash noted
Upon discharge:
Vitals: 98.0 155/75 56 18 100%RA
General: elderly female, resting in bed comfortably
HEENT: Temporal wasting, no ttp over temporal artieries
bilaterally, AT, sclera anicteric, PERRL, EOMI, MMM, oropharynx
clear
Neck: improved ROM from prior, no LAD, no JVD
Back: no ttp over spinous processes, minimal tenderness over L
flank
CV: regular rhythm, normal rate, nl S1 and S2 no MRG
Lungs: CTAB with dullness at bilateral bases
Abdomen: soft, nt, nd, no rebound or guarding, no HSM
GU: no foley
Ext: Thin, 2+ radial pulses, 1+ DP pulses, warm, without
cyanosis or edema
Neuro: AOx3, CN 7 deficits with asymteric smile and R facial
droop, unable to move RUE, RLE ___ throughout, LUE/LLE ___
throughout
Skin: multiple scattered ecchymoses, no rash noted
Pertinent Results:
Pertinent labs on admission:
___ 02:45AM BLOOD WBC-11.7* RBC-3.47* Hgb-9.7* Hct-30.1*
MCV-87 MCH-28.0 MCHC-32.2 RDW-16.3* RDWSD-51.1* Plt ___
___ 02:45AM BLOOD Neuts-78* Bands-2 Lymphs-12* Monos-4*
Eos-3 Baso-0 ___ Myelos-1* AbsNeut-9.36*
AbsLymp-1.40 AbsMono-0.47 AbsEos-0.35 AbsBaso-0.00*
___ 02:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Tear ___
___ 02:45AM BLOOD ___ PTT-29.5 ___
___ 04:22AM BLOOD Ret Aut-1.9 Abs Ret-0.06
___ 02:45AM BLOOD Glucose-106* UreaN-13 Creat-0.5 Na-133
K-3.0* Cl-97 HCO3-23 AnGap-16
___ 04:22AM BLOOD ALT-51* AST-75* LD(LDH)-205 AlkPhos-632*
TotBili-0.5
___ 04:22AM BLOOD GGT-278*
___ 02:45AM BLOOD Lipase-22
___ 02:45AM BLOOD Albumin-2.7*
___ 04:35PM BLOOD Calcium-8.6 Phos-2.8 Mg-1.9
___ 04:22AM BLOOD Hapto-390*
___ 07:20AM BLOOD AMA-NEGATIVE
___ 04:22AM BLOOD CRP-110.7*
Pertient results on discharge:
___ 07:20AM BLOOD WBC-6.0 RBC-3.55* Hgb-9.6* Hct-31.6*
MCV-89 MCH-27.0 MCHC-30.4* RDW-16.8* RDWSD-54.8* Plt ___
___ 07:10AM BLOOD ___ PTT-79.2* ___
___ 07:10AM BLOOD Glucose-67* UreaN-11 Creat-0.6 Na-144
K-3.8 Cl-108 HCO3-25 AnGap-15
___ 07:10AM BLOOD ALT-112* AST-178* AlkPhos-837*
TotBili-0.6
___ 07:10AM BLOOD Calcium-9.3 Phos-3.6 Mg-2.1
Microbiology:
Time Taken Not Noted Log-In Date/Time: ___ 3:26 pm
URINE TAKEN FROM ___ ON ___ @1104.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 7:33 am URINE ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
Blood cultures from ___: pending
Reports:
Urine cytology ___
1 of 2
CYTOLOGY REPORT - Final
SPECIMEN(S) SUBMITTED: URINE
DIAGNOSIS:
Urine:
NEGATIVE FOR MALIGNANT CELLS.
Urothelial cells, macrophages, neutrophils and ___.
___ EKG
Sinus rhythm. Left ventricular hypertrophy. No major change from
the previous tracing.
___ CT Head without contrast
IMPRESSION:
1. No acute intracranial hemorrhage or acute large vascular
territorial
infarction.
2. Encephalomalacia within the left basal ganglia, caudate
nucleus, and
posterior limb of the internal capsule is consistent with
sequela of chronic infarct.
3. Fluid in scattered right-sided mastoid air cells. Recommend
correlation with patient's symptoms.
___ CT C-spine without contrast
IMPRESSION:
1. No acute fracture or subluxation.
2. Multilevel, multifactorial degenerative changes are present.
Widening of the anterior disc space at C4-5, C5-6, and C6-7 is
presumed to be degenerative in nature. Prominent degenerative
atlantodental pannus.
3. Bilateral pulmonary nodules, measuring up to 5 mm. Consider
nonemergent CT of the chest for further evaluation, if
clinically indicated.
___ CT abd/pelvis with contrast
IMPRESSION:
1. Moderate to severe left-sided hydroureteronephrosis, without
obvious
obstructing etiology. Possible focus of enhancing soft tissue
at the left ureter vesicular junction, although this is
difficult to assess completely secondary to metallic streak
artifact from a right hip prosthesis. Recommend direct
visualization with cystoscopy for further evaluation.
2. Urothelial enhancement is seen throughout the left ureter.
3. A 6 mm hypodensity in the body of pancreas is most consistent
with an ___.
4. Mild focal ectasia of the infrarenal abdominal aorta.
RECOMMENDATION(S):
Moderate to severe left-sided hydroureteronephrosis, the cause
of obstruction is not identified. Possible focus of enhancing
soft tissue at the left ureter vesicular junction, although this
is difficult to assess completely secondary to metallic streak
artifact from a right hip prosthesis. Differential diagnosis
includes TCC or inflammatory change from recent stone passage.
Recommend direct visualization with cystoscopy for further
evaluation.
___ Abd US complete
IMPRESSION:
Status post cholecystectomy with no findings to explain elevated
liver
function tests. Moderate left hydronephrosis (please see CT
report for full evaluation).
Brief Hospital Course:
___ is an ___ F with a PMHx of paroxysmal a fib,
recent L MCA stroke, HTN and HLD who presented with 1 wk of L
sided abd pain and severe HA x2d found to have severe
hydroureteronephrosis.
#Pyelonephritis: Pt with L sided abd pain, nausea and vomiting
with severe L sided hydroureteronephrosis on CT scan w/o obvious
obstructing etiology but c/f enhancing lesion at UVJ with
evidence of UTI consistent with a complicated pyelonephritis. At
this time ddx for possible obtruction at UVJ include impacted
stone vs malignant mass vs less likely polyp. Pt with remote hx
of smoking and no personal hx of kidney stones, also with
pulmonary nodules on CT c-spine concerning for mets. Pt also
requiring lido patches to L lumbar area possibly MSK in origin
though this is a dx of exclusion at this time given more
worrisome GU pathology. Urology was consulted who noted that
both kidneys were draining contrast appropriately on CT. They
were initially concerned for neurogenic bladder as the cause,
however the patient had very low post-void residuals. She was
treated with ceftriaxone in the interim given her clinical signs
of pyelonephritis. Her creatinine remained at 0.5 during her
admission, without evidence of kidney disfunction. The patient's
pain was controlled with tylenol. Cx results from patient's
initial diagnosis of urinary tract infection revealed e.coli
sensitive to bactrim, fluoroquinolones, and cephalosporins.
Given that the patient was also on propafenone, it was decided
to complete her course with bactrim as an outpatient, and to
have the patient follow-up with urology as an outpatient for
possible future cystoscopy vs ultrasound.
#HA/neck pain: pt with x2 days of severe HA and neck pain, noted
visual changes but no photosensitivity. DDx included meningitis
vs SAH vs GCA vs malignancy vs mastoid sinusitis. Pt initially
tender over temporal arteries with limited flexion of her neck,
however this quickly improved on HD2 with transdermal lidocaine
patches and was believed to be secondary to MSK stiffness and
strain rather than an underlying rheumatologic or infectious
process.
#Afib/flutter- pt s/p ablation procedure EKG in NSR with PAC's
and recent ischemic stroke, with strong suspicion for cardiac
origin. Pt was recently d/c'd off ASA but kept on coumadin.
Coumadin was stopped in the setting of cipro tx per her PCP. INR
1.3 on admission. The patient continued to be in NSR on
telemetry during her admission, and a heparin drip was started
while she bridged to an appropriate INR. The patient was
transitioned to lovenox subcutaneous shots to continue bridging
therapy as an outpatient. Her propafenone was continued while in
house for rhythm control.
#Elevated alk phos, transaminitis- Pt with elevated liver
function tests, most prominently alkaline phosphatase and GGT
which are markedly elevated, concerning for possible primary
biliary cirrhosis. However, AMA was negative. Imaging including
RUQ US and CT scan showed no evidence of disease. She should
have her LFT's re-checked to evaluate for resolution and further
work-up at PCP discretion including ___.
#Anemia: baseline hemoglobin ___, hgb 9.7 on admission,
without evidence of active bleeding from GI source or otherwise.
Recent iron studies with elevated ferritin, concerning for AoCD.
Likely decreased production, reticulocyte studies showed
hypoproliferation in the setting of anemia. Concerning for
possible myeloproliferative process given occasional tear drop
cells on red cells. Her hemoglobin remained stable throughout
her admission.
#Pulmonary nodules: noted on CT c-spine, pt with h/o BOOP, CXR
on ___ poor film quality and nodules not noted at that
time. Concerning for scar from previous BOOP vs malignant
process. Pt should have dedicated chest imaging in AM CXR vs CT
#Pancreatic mass- As seen on CT abd/pelvis, appears c/w ___,
___ need f/u imaging as outpatient. Low suspicion for cause of
elevated Alk phos.
#HTN: pt mildly HTN during admission without need for
pharmacologic intervention.
#HLD/ history of stroke: pt was re-started on coumadin and
bridged with heparin as above. The patient's aspirin was
discontinued and her home gabapentin was continued for
post-stroke nerve pain.
TRANSITIONAL:
-Last day of bactrim ___, dose adjusted because of coumadin per
pharmacy
-Will need dedicated Chest CT to further evaluate her pulmonary
nodules noted on C-Spine CT
-Pt with elevated liver function tests, alkaline phosphatase and
GGT, concerning for possible primary biliary cirrhosis. She
should have her LFT's re-checked to evaluate for resolution.
Her imaging here was negative. Consider ___ as outpt.
-Pt will be discharged on lovenox to contiue bridging to
coumadin until she is at therapeutic goal of ___, will continue
taking 2mg coumadin QPM during this bridge. Will need INR
checked ___ and faxed to ___ Attn: Dr
___, patient with hypoproliferative anemia with normal MCV
concerning for anemia of chronic disease, with recent elevated
ferritin so unlikely d/t iron deficiency.
-Pancreatic mass- As seen on CT, appears c/w ___
# Code Status: DNR/DNI
# Emergency Contact/HCP: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
2. Atorvastatin 40 mg PO QPM
3. Ferrous Sulfate 325 mg PO DAILY
4. Gabapentin 400 mg PO TID
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Tums Freshers (calcium carbonate) 200 mg calcium (500 mg)
oral as needed at bedtime
7. TraZODone 50 mg PO QHS:PRN insomnia
8. Sorbitol 1 solution PO QD PRN constipation
9. Bisacodyl 10 mg PR QOD PRN constipation
10. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
11. Senna 8.6 mg PO BID:PRN constipation
12. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___)
13. Acetaminophen 325 mg PO Q6H:PRN pain
14. Mylanta unknown oral as needed
15. Propafenone HCl 150 mg PO BID
16. Warfarin 2 mg PO DAILY16
17. Ciprofloxacin HCl 500 mg PO Q12H
18. Vitamin D 800 UNIT PO DAILY
19. Levothyroxine Sodium 200 mcg PO 1X/WEEK (___)
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Atorvastatin 40 mg PO QPM
3. Bisacodyl 10 mg PR QOD PRN constipation
4. Ferrous Sulfate 325 mg PO DAILY
5. Gabapentin 400 mg PO TID
6. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___)
7. Levothyroxine Sodium 200 mcg PO 1X/WEEK (___)
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Propafenone HCl 150 mg PO BID
10. Senna 8.6 mg PO BID:PRN constipation
11. TraZODone 50 mg PO QHS:PRN insomnia
12. Vitamin D 800 UNIT PO DAILY
13. Enoxaparin Sodium 70 mg SC QD
Dont stop until instructed by health care professional.
RX *enoxaparin 150 mg/mL 0.5 (One half) mL SC once a day Disp
#*10 Syringe Refills:*0
14. Sulfameth/Trimethoprim DS 1 TAB PO DAILY Duration: 11 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth once a day Disp #*10 Tablet Refills:*0
15. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
16. Sorbitol 1 solution PO QD PRN constipation
17. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
18. Tums Freshers (calcium carbonate) 200 mg calcium (500 mg)
oral as needed at bedtime
19. Warfarin 2 mg PO DAILY16
20. Outpatient Lab Work
427.31 Atrial fibrillation
INR Check on ___
Please fax results to ___ Attn: Dr ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Pyelonephritis
Hydroureteronephrosis
Transaminitis
Secondary Diagnosis:
Atrial fibrillation
Pulmonary nodules
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:
Ms. ___,
You were recently hospitalized at ___ for an infection of
your kidney, called pyelonephritis. Your pain was treated with
medications, and you were given antibiotics through an IV. We
additionally gave you medicine to help with your neck pain. We
continued your coumadin and gave you heparin to help with your
anticoagulation, as your INR was low. Please take all your
medications as described below and attend all follow-up
appointments as scheduled. You will see the urologist as an
outpatient for further workup.
You should have your INR checked on ___ and have it
faxed to your primary doctor. Do not stop Lovenox until you are
told to do so. Again, it was a pleasure taking part in your
care.
-Your ___ Care Team
Followup Instructions:
___
|
10865085-DS-8
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DS
| 8 |
2140-12-17 00:00:00
|
2140-12-17 17:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Vancomycin / Gluten / xanthan gum / Benefiber (guar gum)
Attending: ___
Chief Complaint:
Diplopia ___ headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ YO M with PMH of Type 1 DM, HTN, Celiac
disease, Alopecia, mood disorder presented to the ED with
complaints of double vision.
Patient reports that he was in ___ normal state of health until
3
days ago. He woke up on ___ with a headache located on the
left temporal bone, behind the left eye with associated blurry
vision ___ dizziness which lasted a few minutes. He went to take
a shower ___ symptoms resolved during that time ___ reports
that it may have lasted a total of 15 to 30 minutes. ___
headache
was on off that morning but resolved with in the hour. He felt
fine until last night when he noticed double vision. He was
looking into ___ phone ___ when he suddenly looked up he saw
distant objects being double. He tried to adjust ___ gaze but
___ symptoms persisted. ___ blood sugars during this episode
were okay ___ he went to bed late in the night. He woke up this
morning with persistent double vision ___ also felt left
temporal
headache similar to the one he had on ___. ___ headache
remained stable throughout, rates it as ___ in severity ___
sharp in nature. He notes that double vision is present only
when he looks to the left ___ is worse with farther compared to
near. he did not have any associated blurry vision or dizziness
today. Denies any focal weakness or sensory problems or trouble
breathing or chest pain. He did have difficulty walking but he
attributes it to double vision. He did not have any similar
complaints in the past.
Of note, he was taken off of ___ Lasix(he was taking for
hypertension) by ___ nephrologist about a month ago ___
cardiologist asked him to monitor ___ blood pressure at home.
He
has been checking ___ blood pressure daily for the past week ___
noticed it to be high(systolic around 180 ___ diastolic in ___.
He is supposed to review these readings with ___ cardiologist to
changing ___ antihypertensives. Wife also adds that ___ insulin
pump sensor has been going off more frequently in the past month
due to high or low readings ___ they have been adjusting ___
bolus doses. He decided to wear a glucometer after ___
episode ___ blood sugars yesterday were fluctuating. ___
blood glucose was 50 around 6 ___ yesterday but he did not have
any associated symptoms, he ate ___ dinner ___ the episode of
diplopia occurred late in the night. ___ blood sugar in the ED
today was 53 ___ he received oral supplement with improvement
but
diplopia persisted.
On neurologic review of systems, the patient denies difficulty
with producing or comprehending speech. Denies loss of vision,
vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia.
Denies focal muscle weakness, numbness, parasthesia. Denies loss
of sensation. Denies bowel or bladder incontinence or retention.
He did have difficulty with gait associated with double vision.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
BACK PAIN
CELIAC SPRUE
DEPRESSION
DIABETES TYPE I
GASTROESOPHAGEAL REFLUX
OTITIS EXTERNA
PNEUMONIA
STRESS TEST
TRANSAMINITIS
URINARY FREQUENCY
Discharge Summary Past Medical History form MON ___:
Type 1 diabetes
HTN
Celiac sprue - recently diagnosed with serology but having
biopsy ___
Depression
Hyperlipidemia
Elevated LFTs (?NAFLD)
Partial factor V Leiden deficiency (although patient says
actually it's factor VII partial deficiency . . . no h/o clots
or bleeding though)
GERD
Social History:
___
Family History:
Relative Status Age Problem Comments
Other FAMILY HISTORY FAMILY HISTORY:
___ mother is ___
___ healthy.
___ died of a
___ ___ ___ also
___ MI in ___
___. Sister had a
___, age ___, ___
___ passed away at
___. ___ also has
diabetes type 1 ___
___
grandmother died of
___
maternal side 64.
___ gmother had
stomach cancer.
___ had liver
___ with
melanoma.
Physical Exam:
PHYSICAL EXAMINATION admission:
Vitals: reviewed in omr:
General: Awake, alert cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds.
Extremities: No ___ edema.
Skin: no rashes or lesions noted. Noted minimal scalp
tenderness palpation over the left temporal, no prominent
vessels
to palpation.
Neurologic:
-Mental Status: Alert, awake, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
___
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high ___ low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline ___ appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm ___ brisk. EOMI without
nystagmus except trace visible sclera on lateral side in the
left
eye on the left abduction(left gaze). Diplopia elicited on left
gaze(slightly past midline) in the horizontal plane ___ noted
some worsening in the left upper quadrant ___ similar diplopia
in
the left lower quadrant. Noted worsening diplopia(objects
apart)
when looking at farther objects compared to closer.
L eye appears isodeviated. With binocular diploplia. Goes away
with eye covering. Worsening double vision the left. Resolves
with looking right.
Normal saccades. VFF to confrontation. Visual acuity ___
bilaterally with corrective lenses. Fundoscopic exam revealed no
papilledema (except left optic disc not completely visualized),
exudates, or hemorrhages. evidence of diabetic retinopathy L>R.
Left retinal drusen
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 ___ SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout. Decreased vibratory sense -6 seconds
in the toes bilaterally. no extinction to DSS.
-DTRs:
Bi Tri ___ ___ Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Good initiation. Narrow-based, normal stride ___ arm
swing.
Physical exam at discharge:
Vitals: 24 HR Data (last updated ___ @ 445)
Temp: 97.6 (Tm 98.4), BP: 164/96 (164-186/74-96), HR: 71
(67-71), RR: 16 (___), O2 sat: 96% (96-98), O2 delivery: Ra
General: Awake, alert cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds.
Extremities: No ___ edema.
Skin: no rashes or lesions noted. Noted minimal scalp
tenderness palpation over the left temporal, no prominent
vessels
to palpation.
Neurologic:
-Mental Status: Alert, awake, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
___ comprehension. Normal prosody. There were no paraphasic
errors.
Pt was able to name both high ___ low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline ___ appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm ___ brisk. EOMI without
nystagmus except trace visible sclera on lateral side in the
left
eye on the left abduction(left gaze). Diplopia elicited on left
gaze(slightly past midline) in the horizontal plane with
appearance of 2 objects next to each other, resolved with
looking to the right, ___ worsened with looking to the left,
also resolved with covering one eye. Visual field grossly
intact ___ acuity intact with with glasses on. Normal saccades.
VFF to confrontation. Unable to differentiate if I positioning
was abnormal, with the right eye appearing more medial.
V: Facial sensation intact to light touch, ___ cold sensation.
VII: No facial droop, facial musculature symmetric, ___
strength full.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii ___ SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
throughout bilaterally in both upper ___ lower extremities. No
adventitious movements, such as tremor, noted. No asterixis
noted.
-Sensory: No deficits to light touch, or cold sensation,
-Coordination: no dysdiadochokinesia noted. No dysmetria on
FNF bilaterally. rapid alternating movement symetric
bilaterally, finger tap within normal limits.
-Gait: Differed as above.
Pertinent Results:
___ 06:40AM BLOOD WBC-8.2 RBC-5.28 Hgb-15.3 Hct-45.1 MCV-85
MCH-29.0 MCHC-33.9 RDW-13.1 RDWSD-40.7 Plt ___
___ 12:07PM BLOOD WBC-8.7 RBC-5.39 Hgb-15.5 Hct-45.5 MCV-84
MCH-28.8 MCHC-34.1 RDW-13.0 RDWSD-40.2 Plt ___
___ 12:07PM BLOOD Neuts-57.9 ___ Monos-9.0 Eos-3.4
Baso-0.6 Im ___ AbsNeut-5.05 AbsLymp-2.52 AbsMono-0.79
AbsEos-0.30 AbsBaso-0.05
___ 12:07PM BLOOD ___ PTT-28.0 ___
___ 12:07PM BLOOD Glucose-53* UreaN-15 Creat-0.9 Na-142
K-4.4 Cl-105 HCO3-26 AnGap-11
___ 06:40AM BLOOD Glucose-66* UreaN-12 Creat-1.0 Na-141
K-4.0 Cl-105 HCO3-26 AnGap-10
___ 06:40AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.0 Cholest-125
___ 12:07PM BLOOD Calcium-9.4 Phos-3.3 Mg-1.9
___ 06:40AM BLOOD %HbA1c-7.3* eAG-163*
___ 06:40AM BLOOD Triglyc-57 HDL-42 CHOL/HD-3.0 LDLcalc-72
___ 12:07PM BLOOD TSH-2.7
___ 12:07PM BLOOD CRP-9.5*
ECG: Sinus rhythm Probable left atrial enlargement When compared
with ECG of ___, No significant change was found
Electronically signed by MD ___ (20) on ___
9:57:11 ___
=============
___ HEAD W & W/O CONTRAS
TECHNIQUE: Sagittal ___ axial T1 weighted imaging were
performed. After
administration of intravenous contrast, axial imaging was
performed with
gradient echo, FLAIR, diffusion, ___ T1 technique. Sagittal
MPRAGE imaging was
performed ___ re-formatted in axial ___ coronal orientations.
COMPARISON: CT dated ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift
or infarction. The ventricles ___ sulci are normal in caliber
___
configuration. There are few scattered T2/FLAIR hyperintensity
in the
periventricular subcortical white matter compatible with chronic
microangiopathy. There is no abnormal enhancement after
contrast
administration. The visualized vascular flow voids are grossly
unremarkable.
No evidence of dural venous sinus thrombosis. There is mild
mucosal
thickening of the ethmoid air cells, otherwise the paranasal
sinuses are
clear. Mild effusion in the bilateral mastoid air cells. There
is no
abnormal marrow signal.
IMPRESSION:
1. No acute intracranial abnormality. No evidence of acute
stroke,
intracranial mass, or hemorrhage.
___ HEAD ___ CTA NECK
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of infarction,hemorrhage,edema,ormass. The
ventricles
___ sulci are mildly prominent suggesting involutional changes.
There is mild mucosal thickening in the inferior aspect of the
left maxillary
sinus. Otherwise, the visualized paranasal sinuses, mastoid air
___
middle ear cavities are clear. The visualized portion of the
orbits are
normal.
CTA HEAD:
The vessels of the circle of ___ ___ their principal
intracranial branches
appear patent without stenosis, occlusion, or aneurysm.
Atherosclerotic
calcification of the cavernous ___ supraclinoid internal carotid
arteries is
noted as well as the petrous internal carotid arteries, left
greater than
right. However, there is no significant stenosis. Posterior
communicating
artery not definitely seen on the left. There is a small patent
posterior
communicating artery on the right. There is a patent anterior
communicating
artery. Early branching of the left middle cerebral artery.
The dural venous
sinuses are patent.
CTA NECK:
Conventional three-vessel aortic arch. Proximal great vessels
___ subclavian
arteries are widely patent. Minimal calcification noted in the
proximal right
subclavian artery without stenosis
Bilateral carotid ___ vertebral artery origins are patent.
There is calcified ___ noncalcified atherosclerotic plaque at
the bilateral
carotid bifurcations, right greater than left, but this causes
no measurable
stenosis of the internal carotid arteries by NASCET criteria.
The carotidandvertebral arteries ___ their major branches
otherwise appear
normal with no evidence of stenosis or occlusion. The left
vertebral artery
is slightly dominant.
OTHER:
The visualized portion of the lungs are clear. The visualized
portion of the
thyroid gland is within normal limits. There is no
lymphadenopathy by CT size
criteria. Multilevel degenerative changes of the cervical spine
noted.
IMPRESSION:
1. No acute intracranial abnormality.
2. Patent circle of ___ without evidence of
stenosis,occlusion,or aneurysm.
3. Patent bilateral cervical carotid ___ vertebral arteries
without evidence
of hemodynamically significant stenosis, occlusion,or dissection
Brief Hospital Course:
Mr. ___ is a ___ year old right handed man with past medical
history most pertinent for DMI, hypertension, celiac sprue, ___
autoimmune blistering skin disorder who presented with
horizontal double vision ___ found on examination to have left
___ nerve palsy.
Mr. ___ was admitted for workup of central vs peripheral
etiology of left ___ nerve palsy. Exam supported a peripheral L
___ Nerve Palsy. Workup included labs, which found hypoglycemia,
but otherwise no signs of infection or metabolic source. HbA1C
7.3%, CRP 9.5, TSH 2.7. LDL 72. EKG was normal sinus. MRI brain
without evidence of acute stroke. CTA without any concerning
abnormalities.
Mr. ___ has an ischemic left sixth nerve palsy. He does not
have an examination consistent with a central sixth nerve palsy
___ MRI brain was without pontine stroke. Mr. ___ has been
told that ___ double vision will improve, but that he needs to
work to improve management of DMI ___ hypertension. I have
recommended that while he has double vision that he wear an eye
patch ___ alternate it between eyes. I have told him that ___
headache is likely because of the double vision ___ that the
headache will improve also with the eye patch. I will have Mr.
___ follow up in ___ clinic in ___ weeks to
consider prism lenses if he continues to have double vision.
Medications on Admission:
The Preadmission Medication list is accurate ___ complete.
1. Lisinopril 30 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Simvastatin 40 mg PO QPM
4. tadalafil 20 mg oral as directed
5. Venlafaxine XR 150 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Ranitidine 150 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Target glucose: 80-180
Discharge Medications:
1. eye patch 1 Patch miscellaneous DAILY
Alternate eyes that are wearing the patch daily
RX *eye patch [Opticlude Eye Patch] 1 Patch Daily, alternating
eyes once a day Disp #*60 Each Refills:*0
2. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Target glucose: ___
Fingersticks: QAC ___ HS
3. Aspirin 81 mg PO DAILY
4. Lisinopril 30 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Ranitidine 150 mg PO DAILY
7. Simvastatin 40 mg PO QPM
8. tadalafil 20 mg oral as directed
9. Venlafaxine XR 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left Peripheral ___ Nerve Palsy.
Discharge Condition:
Mental Status: Clear ___ coherent.
Level of Consciousness: Alert ___ interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ neurology due to symptoms of double
vision ___ headache. You were also found to have low blood
sugar ___ high blood pressure. Youre lab workup showed
inflammation consistent with your chronic inflammatory disease,
___ MRI of your brain showed no stroke. Your exam is consistent
in this setting with a peripheral ___ nerve palsy that is likely
secondary to having long standing diabetes ___ hypertension.
We are not changing any of your existing medications at this
time ___ recommend that you wear an eye patch ___ alternate eyes
each day to help with your recovery. We are also recommending
that you follow up with a neuropthamologist in ___ weeks. We
placed a referral ___ you should be hearing about when your
appointment is within a week.
You should also follow up with your primary care provider, your
cardiologist ___ your endocrinologist within a week to follow up
on this admission.
Than you for the opportinity to partake in your care,
The ___ Neurology Team.
Followup Instructions:
___
|
10865237-DS-16
| 10,865,237 | 22,929,344 |
DS
| 16 |
2138-02-01 00:00:00
|
2138-02-01 09:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
amlodipine
Attending: ___.
Chief Complaint:
vertigo
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: The patient is a ___ year old woman with history of atrial
fibrillation on Coumadin, HTN, R posterior fossa meningioma, and
hypothyroidism who presents with acute onset of room spinning
vertigo, nausea and right leg parasthesias. History obtained
from
patient.
Ms. ___ reports she was in her usual state of health
until 0100 this morning. She was last well at approximately
midnight. She had taken all of her evening medications on ___
and felt well. She went to sleep at midnight, and woke up one
hour later with dizziness.
She describes the dizziness as both a room spinning vertigo
sensation and sensation of unsteadiness/disequilibrium. It is
associated with nausea and frequent dry heaving. She also
complains of right leg parasthesias which she also noticed after
waking up. Denies any weakness, denies hearing loss, denies
tinnitus. Reports the vertigo has been persistent since waking
up
at 0100, without stopping. It is always present, regardless of
head position changes. She was brought to ___ for further
evaluation.
She denies any recent illness, denies any recent fevers/chills.
Reports she has been taking her medications consistently
including Coumadin, and says her INR has been therapeutic
recently as far as she is aware. Reports she has been having
adequate PO intake recently.
Of note, per chart review the patient has a history of recurrent
falls and an unsteady gait. Patient denies this, saying she can
ambulate independently without assistive devices. She lives at
home independently but does have home health aid.
Past Medical History:
.
PMHx
1) Paroxysmal Atrial fibrillation
- followed by Dr. ___
- ___ TTE: LVEF >55%, nl regional LV wall motion, 1+ AR, 1+ MR
- ___ ETT MIBI: ___ protocol X 7.25 min, 103% PMHR, no
angina, no sig EKG changes. No fixed or reversible myocardial
perfusion defects. LVEF 74%.
2) Right posterior fossa meningioma 1 cm
- followed annually by Dr. ___
3) s/p resection of benign spindle cell tumor of stomach ___
- yearly endoscopy
4) PUD
5) s/p TAH/BSO
6) Bronchiectasis: h/o hemoptysis
- Bronch x ___ neg
- ___ PFTs wnl
7) PPD (+); neg AFB cultures for M. TB
8) MAC infection: central nodular densities on Chest CT
9) Hepatitis B
10) Osteoporosis
11) Hypercholesterolemia: ___ chol 159, HDL 81, LDL 63
12) Basal cell carcinoma: on legs bilaterally, s/p resection
___ s/p left ORIF
14) Depression
15) Hypertension
.
Social History:
___
Family History:
FHx: Father with CVA in ___, mother with ___ disease. No
family history of early cardiac disease
.
Physical Exam:
On admission:
PHYSICAL EXAMINATION
Vitals: 97.6F, HR 88-116, BP 134-171/84-95, RR ___, O2 98% RA
General: Awake, alert, in no acute distress
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: warm, well perfused; regular on telemetry
Pulmonary: breathing non labored on room air
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name days of the
week backward without difficulty. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No paraphasias. No dysarthria. Normal prosody.
No apraxia. No evidence of hemineglect. No left-right confusion.
Able to follow both midline and appendicular commands, but
struggles with complex commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. No skew deviation. Negative head impulse
test. V1-V3 without deficits to light touch bilaterally. No
facial movement asymmetry. Hearing intact to finger rub
bilaterally. Palate elevation symmetric. SCM/Trapezius strength
___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 5 5 5 5 ___ 5 5 5 5 5
R 5 5 5 5 ___ 5 5 4 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: Reports parasthesias throughout the entire right leg,
but on sensory testing, no deficits to pinprick, light touch or
proprioception bilaterally. No extinction to DSS.
- Coordination: Difficult to assess as patient has difficulty
following instructions for testing. Notable for overshoot on
right hand mirroring and mild ataxia on right heel to shin. No
dysmetria with finger to nose testing bilaterally. Good speed
and
intact cadence with rapid alternating movements.
- Gait: Patient declined due to persistent vertigo
On discharge: nonfocal exam, questionable overshoot on mirror
testing in the RUE but no dysmetria
Pertinent Results:
___ 03:55AM %HbA1c-6.1* eAG-128*
___ 03:55AM TRIGLYCER-106 HDL CHOL-78 CHOL/HDL-2.8
LDL(CALC)-118
___ 03:55AM TSH-5.2*
___ 03:55AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:55AM CK-MB-2 cTropnT-<0.01
___ 03:55AM LIPASE-81*
___ 03:55AM ALT(SGPT)-11 AST(SGOT)-35 CK(CPK)-77 ALK
PHOS-83 TOT BILI-0.5
___ INR 2.0
MRI brain:
1. No evidence of slowed diffusion, particularly within the
cerebellum, to
suggest acute infarction.
2. 1.6 cm right posterior fossa meningioma, compatible with
provided history.
3. Sequela of chronic small vessel ischemic disease.
CTA head/neck:
CTA: Patent circle ___ and its major tributaries. No evidence
of
flow-limiting stenosis or aneurysm larger than 3 mm. Patent neck
vessels
without focal stenosis or evidence of dissection.
CXR:
-Moderate pulmonary edema. No pleural effusion.
-Bibasilar focal opacities may represent subsegmental
atelectasis versus
pneumonia.
-Worsening cardiomegaly, likely related to volume overload.
Brief Hospital Course:
___ is a pleasant ___ year old woman with history
of atrial fibrillation
on Coumadin, HTN, R posterior fossa meningioma, and
hypothyroidism who presents with acute onset of room spinning
vertigo, nausea and right leg parasthesias. Clinical history
notable for persistent vertigo that is not episodic and not
positional. Exam notable for possible right sided ataxia
(overshoot on R mirror testing). She was found to be
subtherapeutic on Coumadin with INR 1.6. It was unclear if this
was due to a posterior circulation cardio-embolism vs.
peripheral vertigo. MRI brain did not show a stroke. However,
given high suspicion for a TIA, we touched base with PCP and
bridged her to therapeutic INR with heparin drip. She was
discharged with home ___ and INR 2.0. Her LDL was elevated, she
was switched from simvastatin 10 mg to atorvastatin 20 mg.
Transitional Issues:
# Vertigo: Likely due to a transient ischemic attack
- home ___
# Afib on Coumadin
- INR to be checked ___ with ___ clinic
aware
# Abnormal CXR: fluid overload, atelectasis vs PNA: on physical
exam, pt had no crackles. Never spiked a fever, no white count.
Did not start treatment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 50 mg PO DAILY
2. Diltiazem Extended-Release 120 mg PO DAILY
3. Simvastatin 10 mg PO QPM
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
7. Warfarin 2 mg PO DAILY16
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet
Refills:*3
2. Warfarin 3 mg PO DAILY16
3mg ___ and ___, 2mg M-F per prior schedule
3. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
4. Diltiazem Extended-Release 120 mg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
vertigo
TIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro: nonfocal
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Neurology service due to vertigo. You
had a brain MRI that did not show a stroke. You were continued
on your home warfarin. Because your INR was less than 2.0, you
were started on a heparin drip to bridge you to a therapeutic
INR. Today, your INR is 2.0, which is therapeutic.
We checked your stroke risk factors, and your cholesterol was
high. Because of this, we switched your simvastatin to
atorvastatin 20mg. If you get muscle aches, please call your
primary care physician.
It was a pleasure taking care of you, and we wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10865237-DS-18
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DS
| 18 |
2139-04-09 00:00:00
|
2139-04-12 20:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amlodipine / cefpodoxime / adhesive tape
Attending: ___.
Chief Complaint:
lightheadedness and tachycardia
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ with AF and SSS c/b syncope s/p PPM (VVI 60 ppm) ___ on
warfarin, presenting to ED for lightheadedness found to have
tachycardia.
Last 2 days has been lightheaded and SOB. She has been having
ongoing urinary symptoms including dysuria for which she was
seen
by her PCP's office ___ and found to be have urine growing
Enterobacter cloacae resistant to Bactrim. She was started on a
5 days course of macrobid, but had no improvement after the
course had been completed. She denies cought, fever, vomiting,
or diarrhea. She endorises nausea and anorexia. No HA, visual
changes, numbness, tingling, chills.
In the ED:
Patient was tachycardic, in AF with RVR to the 150-170's. Her
UA
was significant for > 182 WBC, 13 RBC, moderate bacteria, and
positive nitirites. She was started on piperacillin-tazobactam
iso cephalosporin allergy and 2L IVF for ongoing UTI and given
diltiazem for her heart rates. IV and PO diltiazem were given
with total doses of 65 and 30 mg respectively and her rates
improved to < 100.
Of note, patient was last admitted to ___ ___ for
pre-syncope found to have SSS requiring PPM placement ___. She
was started on diltiazem for rate control for ongoing AF and
continued on home warfarin. She had dysuria empirically treated
with bactrim from ___, UCx from that admission positive
for
polymicrobial growth consistent with normal flora. She had her
pacemaker interrogated on routine follow up ___ with normal
study.
Initial vital signs were notable for:
___ 13:21
0, 99.8F, 94, 127/73, 18, 99% RA
Exam notable for:
No significant findings in the ED.
Labs were notable for:
WBC 12.9, Hgb 12.7, PLT 193
Na 137, K 4.2, Cl 96, HCO3 25, BUN 24, Cr 1.0
TnT < 0.01
Lactate 1.9
INR 3.8
UA: 13 RBC, >182 WBC, Moderate Bacteria, Large Leukocytes,
Moderate blood, positive nitrites
Studies performed include:
___ CXR
Mild congestion and probable mild interstitial pulmonary edema
Patient was given:
___ 16:41 IVF NS ___ Started
___ 18:15 IVF NS 1000 mL ___ Stopped (1h ___
___ 19:29 IVF NS ___ Started
___ 19:45 IV Piperacillin-Tazobactam ___
Started
___ 19:45 IV Diltiazem 15 mg ___
___ 19:45 PO Acetaminophen 1000 mg ___
___ 20:45 PO Diltiazem 30 mg ___
___ 20:45 IV Diltiazem 20 mg ___
___ 20:45 IV Ketorolac 30 mg ___
___ 20:53 IV Piperacillin-Tazobactam 4.5 g ___
Stopped (1h ___
___ 20:53 IVF NS 1000 mL ___ Stopped (1h ___
Consults:
None
Vitals on transfer:
Today 20:54
0, 89-98, 116/56, 23, 98% 2L NC
Upon arrival to the floor, patient is feeling much better
overall. She states that she is no longer having
lightheadedness. Per her daughter on the phone, she had the
history as above, is a difficult historian.
Past Medical History:
.
PMHx
1) Paroxysmal Atrial fibrillation
- followed by Dr. ___
- ___ TTE: LVEF >55%, nl regional LV wall motion, 1+ AR, 1+ MR
- ___ ETT MIBI: ___ protocol X 7.25 min, 103% PMHR, no
angina, no sig EKG changes. No fixed or reversible myocardial
perfusion defects. LVEF 74%.
2) Right posterior fossa meningioma 1 cm
- followed annually by Dr. ___
3) s/p resection of benign spindle cell tumor of stomach ___
- yearly endoscopy
4) PUD
5) s/p TAH/BSO
6) Bronchiectasis: h/o hemoptysis
- Bronch x ___ neg
- ___ PFTs wnl
7) PPD (+); neg AFB cultures for M. TB
8) MAC infection: central nodular densities on Chest CT
9) Hepatitis B
10) Osteoporosis
11) Hypercholesterolemia: ___ chol 159, HDL 81, LDL 63
12) Basal cell carcinoma: on legs bilaterally, s/p resection
___ s/p left ORIF
14) Depression
15) Hypertension
Social History:
___
Family History:
___: Father with CVA in ___, mother with ___ disease. No
family history of early cardiac disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VITALS: 97.9F, 91, 100/68, 18, 95% on 2L
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, one irregular beat, normal rate.
Audible
S1 and S2. No murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
DISCHARGE PHYSICAL EXAM:
======================
24 HR Data (last updated ___ @ 007)
Temp: 98.9 (Tm 98.9), BP: 130/83 (101-132/68-90), HR: 100
(83-100), RR: 18, O2 sat: 95% (95-97), O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: irregularly irregular, 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. No CVAT.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. AOx3.
Pertinent Results:
ADMISSION LABS:
=============
___ 04:18PM WBC-12.9* RBC-4.06 HGB-12.7 HCT-37.8 MCV-93
MCH-31.3 MCHC-33.6 RDW-13.2 RDWSD-45.0
___ 04:18PM NEUTS-83.6* LYMPHS-7.0* MONOS-8.4 EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-10.82* AbsLymp-0.90*
AbsMono-1.08* AbsEos-0.00* AbsBaso-0.02
___ 04:18PM GLUCOSE-138* UREA N-24* CREAT-1.0 SODIUM-137
POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-25 ANION GAP-16
___ 04:18PM cTropnT-<0.01
___ 04:18PM ___ PTT-38.0* ___
___ 06:26PM URINE BLOOD-MOD* NITRITE-POS* PROTEIN-100*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG*
___ 07:52PM LACTATE-1.9
DISCHARGE LABS:
=============
___ 07:23AM BLOOD WBC-10.7* RBC-3.73* Hgb-11.5 Hct-34.8
MCV-93 MCH-30.8 MCHC-33.0 RDW-13.0 RDWSD-44.7 Plt ___
___ 07:23AM BLOOD ___
___ 07:23AM BLOOD Glucose-120* UreaN-15 Creat-1.1 Na-142
K-4.4 Cl-104 HCO3-24 AnGap-14
MICROBIO:
========
___ 4:18 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 6:26 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 2:19 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI.
Identification and susceptibility testing performed on
culture #
___ ___.
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
___ 7:33 am BLOOD CULTURE #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 17:20
HELICOBACTER ANTIGEN DETECTION, STOOL
Test Result Reference
Range/Units
HELICOBACTER PYLORI AG, EIA, SEE NOTE
STOOL
HELICOBACTER PYLORI AG, EIA, STOOL
MICRO NUMBER: ___
TEST STATUS: FINAL
SPECIMEN SOURCE: STOOL
SPECIMEN QUALITY: ADEQUATE
RESULT: Not Detected
Antimicrobials, proton pump inhibitors, and
bismuth preparations inhibit H. pylori and
ingestion up to two weeks prior to testing
may
cause false negative results. If clinically
indicated the test should be repeated on a
new
specimen obtained two weeks after
discontinuing
treatment.
IMAGING:
=======
CHEST (PA & LAT)Study Date of ___ 12:11 ___
Left-sided pacemaker is unchanged. Cardiomediastinal silhouette
is stable.
There is no pleural effusion. No pneumothorax is seen.There is
mild
bronchiectasis.
OTHER SELECTED RESULTS:
=====================
EGD ___
A large size hiatal hernia was seen. Normal mucosa was noted in
the whole esophagus. Endoscopic findings were consistent with
normal post-operative anatomy with gastrogastric anastomosis
visualized. Diffuse edema and friability of the mucosa with
contact bleeding was noted in the stomach. A non-bleeding 1.5cm
lesion was found in the body of the stomach. Normal mucosa was
noted in the whole examined duodenum.
Recommendations: continue PPI, repeat EUS to evaluate gastric
mass, H pylori stool antigen.
Brief Hospital Course:
Ms. ___ is an ___ year-old lady with AF s/p PPM who
presented with AF in RVR and Pyelonephritis with E. coli Sepsis,
with course complicated by UGIB due to possible gastritis.
ACUTE ISSUES
============
# Pyelonephritis
# E Coli Bacteremia
While hospitalized in ___, Ms. ___ complained of
dysuria and was treated empirically with Bactrim. She presented
to her PCP with continued urinary symptoms and a culture showed
E. cloacae. She was given macrobid which did not improve her
symptoms. On this admission she presented to the ED for
lightheadedness and tachycardia and was found to have Afib with
RVR and a UA suggestive of UTI. The urine grew out pan-sensitive
E coli and blood cultures were positive for the same bacteria.
She was given Zosyn IV because of a cephalosporin allergy,
narrowed to ciprofloxacin PO to complete a 2 week course.
# UGIB
During the admission, the patient had a concern for "black
stools". While it was not dark black, but more green, it did
smell like melena and stool Guaiac was positive. Hgb was 12.7 on
admission ___ and dropped to 11.5 about a week later. Of note,
the patient has a history of spindle cell lyomyoma of the
stomach ___ years ago which was stable on serial EGDs. Out of
concern for upper GIB and possible recurrence of tumor, H.
pylori stool antigen was obtained (negative), PO omeprazole BID
was started, and GI was consulted for an EGD which showed
friable tissue throughout the stomach and a 1.5cm mass in the
stomach for which they suggest pursuing EUS to further
characterize. Hb remained stable throughout admission.
# Atrial Fibrillation with RVR
The patient presented with Afib with RVR likely ___ sepsis from
urinary source. Improved with antibiotics, resuscitation, and
IV+PO diltiazem. Restarted on equivalent dosing of home
diltiazem fractionated and HRs remained around the 110s.
Restarted home dilt ER before discharge. The patient arrived
with an INR of 3.8, so warfarin was held while watching INR, for
goal ___. Because of the patient's upper GI bleed and
supratherapeutic INR on presentation we discussed switching to
___ with her. After asking us to discuss with her
cardiologist and determining that the drug would be affordable,
she agreed to switch. We held her warfarin until INR<2 and then
initiated ___ before discharge. She will follow up with her
outpatient cardiologist.
CHRONIC ISSUES
==============
# HLD
Continued home atorvastatin 20mg.
# HTN
Continued diltiazem as above.
# Hypothyroidism
Continued home levothyroxine 88mcg.
# MDD
Continued home sertraline 50mg daily.
TRANSITIONAL ISSUES
===================
[ ] Patient had slow upper GI bleed while in hospital after
coming in supratherapeutic on Warfarin. She was transitioned to
___ given higher risk of bleeding with Warfarin. Black
stools stopped prior to discharge. F/u UGIB signs and symptoms.
[ ] Omeprazole was initiated for UGIB, consider a stop date in a
few months
[ ] 1.5cm mass noted on EGD along with friable mucosa. GI
recommends outpatient EUS to further characterize.
# CODE: Full
# CONTACT: Daughter, ___ (c: ___, p:
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Docusate Sodium 100-200 mg PO DAILY:PRN Constipation - First
Line
3. Levothyroxine Sodium 88 mcg PO DAILY
4. Sertraline 50 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Warfarin 4 mg PO TUES
7. Warfarin 3 mg PO 6X/WEEK (___)
8. Diltiazem Extended-Release 120 mg PO DAILY
9. PreserVision AREDS 2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral BID
10. Calcitrate (calcium citrate) 600 mg oral DAILY
Discharge Medications:
1. ___ 5 mg PO BID
RX ___ [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*11 Tablet Refills:*0
3. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
4. Atorvastatin 20 mg PO QPM
5. Calcitrate (calcium citrate) 600 mg oral DAILY
6. Diltiazem Extended-Release 120 mg PO DAILY
7. Docusate Sodium 100-200 mg PO DAILY:PRN Constipation - First
Line
8. Levothyroxine Sodium 88 mcg PO DAILY
9. PreserVision AREDS 2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral BID
10. Sertraline 50 mg PO DAILY
11. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
- UTI
- Pyelonephritis
- Upper GI Bleed
SECONDARY:
- A fib
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 privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you had a urinary
tract and kidney infection. Bacteria were also found in your
blood.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We gave you intravenous antibiotics for several days. We then
transitioned the antibiotics to an oral option which will treat
the bacteria in your blood and the urinary tract infection.
- During this admission, you began to have dark stools which
tested positive for blood. We gave you stomach acid blocking
medications and scheduled an endoscopy to look for a source of
bleeding.
-The endoscopy showed that your stomach tissue was fragile and
bled easily when scraped. The acid blockers will help improve
this. It also showed a 1.5cm polyp in the stomach. You will
need to see a Gastroenterologist to have a sample of these cells
obtained and examined by a Pathologist.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Follow up with your cardiologist and gastroenterologist.
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10865237-DS-19
| 10,865,237 | 25,229,179 |
DS
| 19 |
2139-07-17 00:00:00
|
2139-07-18 12:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amlodipine / cefpodoxime / adhesive tape
Attending: ___.
Chief Complaint:
Flank pain
Major Surgical or Invasive Procedure:
___: placement of percutaneous nephrostomy tube
History of Present Illness:
Ms. ___ is a ___ yo F with a sig PMHx of recurrent UTIs
and nephrolithiasis s/p gentamicin instillation of the bladder
X4, A fib on Apixaban, SSS s/p PPM (___), spindle cell tumor of
the stomach s/p resection, who presents with acute onset L flank
pain.
The patient was in her usual state of health until 2 days PTA,
when she felt lethargic, and developed acute onset sharp L flank
pain radiating to her groin. She was unable to get comfortable.
This pain was similar to her prior kidney stones. Over the next
day, the pain progressed and she also developed subjective
fevers, chills, and weakness. She also described dysuria, and
urinary frequency, but denied any hematuria, abdominal pain,
n/v,
changes in bowel function. She otherwise felt lethargic and
weak.
She denied any presyncope or syncope. Given her worsening
symptoms, she presented to ___ ED for further evaluation.
Of note, the patient was recently hospitalized in ___ for A fib
with RVR iso pyelonephritis and E. coli sepsis c/b UGIB iso
gastritis. She was treated with empiric Bactrim and when she
developed urinary symptoms, she was broadened to IV zosyn and
narrowed to ciptrofloxacin to complete a 2 week course of
antibiotics.
In the ED, her abdominal pain has since resolved.
- Initial vitals were:
T99.7 HR146 BP142/70 RR20 SPO298% RA
- Exam notable for:
CV:Irregularly irregular in the 140s
- Labs notable for:
CBC: WBC 15.1 Hb 12.4 Plt 241
BMP: Na 135 BUN/Cr ___
Lactate: 2.5
INR: 1.5
UA: few bact, 36 WBC, nit pos, large leuk
- Imaging was notable for:
+CT Abd/Pelvis
IMPRESSION:
1. An obstructing 7 mm stone in the left ureter resulting in
mild
left
hydroureteronephrosis with moderate perinephric stranding. There
are no large
perinephric fluid collections.
2. A nonobstructing 5 mm left kidney stone is demonstrated.
3. Stable postsurgical changes following partial gastrectomy
without evidence
of local disease recurrence in the surgical bed.
- Patient was given:
IV Zofran 4mg X1
IV NS 1000mL
IV Meropenem 500mg
IV Acetaminophen 1000mg
The patient was otherwise **
Upon arrival to the ICU, the patient reports that her flank pain
has now resolved. She otherwise denies any urinary symptoms,
fevers, chills, dyspnea, chest pain, n/v. She has no other acute
concerns.
Review of systems was negative except as detailed above.
Past Medical History:
.
PMHx
1) Paroxysmal Atrial fibrillation
- followed by Dr. ___
- ___ TTE: LVEF >55%, nl regional LV wall motion, 1+ AR, 1+ MR
- ___ ETT MIBI: ___ protocol X 7.25 min, 103% PMHR, no
angina, no sig EKG changes. No fixed or reversible myocardial
perfusion defects. LVEF 74%.
2) Right posterior fossa meningioma 1 cm
- followed annually by Dr. ___
3) s/p resection of benign spindle cell tumor of stomach ___
- yearly endoscopy
4) PUD
5) s/p TAH/BSO
6) Bronchiectasis: h/o hemoptysis
- Bronch x ___ neg
- ___ PFTs wnl
7) PPD (+); neg AFB cultures for M. TB
8) MAC infection: central nodular densities on Chest CT
9) Hepatitis B
10) Osteoporosis
11) Hypercholesterolemia: ___ chol 159, HDL 81, LDL 63
12) Basal cell carcinoma: on legs bilaterally, s/p resection
___ s/p left ORIF
14) Depression
15) Hypertension
Social History:
___
Family History:
FHx: Father with CVA in ___, mother with ___ disease. No
family history of early cardiac disease
Physical Exam:
ADMISSION EXAM:
===============
GENERAL: Pleasant elderly female. lying in bed comfortably. In
no
acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: irregularly irregular. 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: +L percutaneous nephrostomy tube draining ~50cc
serosanguinous fluid. Normal bowels sounds, non distended,
non-tender to deep palpation in all four quadrants. No
organomegaly.
EXTREMITIES: No peripheral edema. WWP. Pulses DP/Radial 2+
bilaterally.
SKIN: No rash.
DISCHARGE PHYSICAL EXAM:
Vitals: 24 HR Data (last updated ___ @ 807)
Temp: 98.9 (Tm 99.1), BP: 136/85 (99-143/65-85), HR: 110
(87-110), RR: 18 (___), O2 sat: 91% (91-98), O2 delivery: Ra
General: alert, oriented, no acute distress
Eyes: Sclera anicteric
HEENT: MMM, oropharynx clear
Neck: no JVD
Resp: scattered and diffuse fine crackles throughout both lung
fields
CV: irregularly irregular rate, borderline tachycardic, could
not appreciate murmurs
GI: soft, non-tender, non-distended, bowel sounds present
MSK: warm, well perfused, no edema
Back: bandage along left lower back. No CVA tenderness
Neuro: AOx3, facial symmetry, moving extremities with purpose
GU: foley in place, draining yellow urine
Pertinent Results:
ADMISSION LABS:
======================
___ 04:58PM BLOOD WBC-15.1* RBC-4.06 Hgb-12.4 Hct-37.5
MCV-92 MCH-30.5 MCHC-33.1 RDW-13.2 RDWSD-45.0 Plt ___
___ 04:58PM BLOOD Plt ___
___ 05:09PM BLOOD ___ PTT-25.9 ___
___ 11:11AM BLOOD UreaN-22* Creat-1.1 Na-137 K-4.3 Cl-97
HCO3-24 AnGap-16
___ 04:28AM BLOOD ALT-7 AST-13 AlkPhos-64 TotBili-0.9
___ 11:11AM BLOOD Albumin-4.3 Calcium-9.2 Phos-2.9
___ 11:11AM BLOOD TSH-0.53
___ 11:11AM BLOOD PTH-45
___ 11:11AM BLOOD 25VitD-62*
___ 05:16PM BLOOD Lactate-2.5*
DISCHARGE LABS:
======================
___ 06:50AM BLOOD WBC-9.5 RBC-3.60* Hgb-10.9* Hct-34.0
MCV-94 MCH-30.3 MCHC-32.1 RDW-12.9 RDWSD-44.5 Plt ___
___ 06:50AM BLOOD Glucose-117* UreaN-12 Creat-0.9 Na-140
K-3.6 Cl-101 HCO3-26 AnGap-13
___ 06:50AM BLOOD Glucose-117* UreaN-12 Creat-0.9 Na-140
K-3.6 Cl-101 HCO3-26 AnGap-13
___ 06:50AM BLOOD Calcium-7.9* Phos-2.3* Mg-1.9
IMAGING:
======================
___ CT Abd/Pelvis w/o contrast
1. An obstructing 7 mm stone in the left ureter resulting in
mild
left hydroureteronephrosis with moderate perinephric stranding.
There
are no large perinephric fluid collections.
2. A nonobstructing 5 mm left kidney stone is demonstrated.
3. Stable postsurgical changes following partial gastrectomy
without evidence of local disease recurrence in the surgical
bed.
___ CXR:
Compared to chest radiographs since ___, most recently
___.
Patient had transient pulmonary edema in ___ and ___. Lungs were clear in ___, and hyperinflation was
demonstrated, but interstitial abnormality developed again in
late ___ and has not resolved or has recurred. The
relatively even distribution of the interstitial abnormality
would argue for a diagnosis other than edema, but given the
previous episodes of edema, cardiogenic edema, on a background
of emphysema, should be considered before the possibility of a
rapidly progressive infiltrative interstitial lung disease. No
pneumothorax or pleural effusion. No focal consolidation to
suggest
pneumonia. Transvenous right ventricular pacer lead in place.
MICROBIOLOGY:
======================
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 5:00 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
PROTEUS MIRABILIS.
Identification and susceptibility testing performed on
culture #
___ (___).
STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL
MORPHOLOGIES.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ (___) @11:21
(___).
Brief Hospital Course:
SUMMARY:
=======================
___ female presented with infected 7mm left obstructing
ureteral calculus, now s/p left percutaneous nephrostomy tube
placement.
ACTIVE ISSUES:
=======================
#Left obstructing ureteral calculus:
#Urosepsis with proteus bacteremia:
Presented with sudden onset left sided flank pain and
generalized malaise. Found to have GNR bacteremia and an
obstructing stone. She is s/p percutaneous nephrostomy tube
placement on ___ for decompression with marked improvement in
symptoms. She was continued on zosyn until sensitivities
returned; transitioned to Cipro 500 mg q12 for a total of 14
days post last positive culture (final day ___. At follow up
with GU, plan will be to discuss definitive stone treatment for
her 7mm L ureteral calculus and 5mm left renal calculus once she
has recovered from this admission.
# Atrial fibrillation: switched her diltiazem to bedtime given
that she experiences orthostatic hypotension, often in the
mornings. Restarted her apixaban 24 hours post procedure per ___.
Will need to touch base with GU prior to next procedure to
determine if/when to hold her apixaban.
# Abnormal lung exam: pt with diffusely fine crackles. CXR
report suggested non-contrast chest CT to evaluate for an
underlying pulmonary process (e.g. amiodarone induced fibrosis).
Given lack of symptoms, this was deferred to outpatient setting.
Note that this is not new and had been worked up in the past,
though per radiology read the findings have progressed.
CHRONIC ISSUES:
=======================
# Recurrent urinary retention and UTIs:
Reportedly has had multiple UTIs in the setting of retention.
Followed by urology as an outpatient. She is s/p gentamicin
bladder stimulatation, round 5 on ___. During this
hospitalization, she had a foley placed for almost 48 hours post
operatively; removed without e/o retention which was
reassuring.
# History of duodenal ulcer: patient reports not taking her
omeprazole at home. She occasionally has a tiny bit of blood in
her stool. Recommended restarting it, especially while on
apixaban.
# Depression: continued home sertraline
# Hypothyroidism: continued home levothyroxine
# Hyperlipidemia: continued home Atorvastatin
# Osteoporosis: vitamin D level 62. Continued home vitamin D
2,000 U.
TRANSITIONAL ISSUES:
=======================
Code status: full, confirmed
HCP: ___, Daughter - ___
Left obstructing ureteral calculus:
- ___ services for management of tube, wound care
- Plan for ___ follow up, appointment not yet made
- For eventual pre-operative planning, would be helpful to know
if can stop her Apixaban ___ for a ureteroscopy
procedure.
Atrial fibrillation:
- Changed home Diltiazem from qAM to qPM to help minimize
symptoms of orthostasis
Abnormal lung exam:
- Recommend outpatient non contrast chest CT
Urosepsis with proteus bacteremia:
- Ciprofloxacin 500 mg q12h, final dose evening of ___
Recurrent UTIs (in the setting of urinary retention)
- If continues to recur despite bladder stimulation, consider
prophylactic fosfomycin once weekly
Greater than ___ hour spent on care on day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 180 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
3. Apixaban 5 mg PO BID
4. Estradiol 7.5 mcg mg PO Q 12 WEEKS
5. Atorvastatin 20 mg PO QPM
6. Omeprazole 40 mg PO BID
7. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 600-750 mg
oral DAILY
8. Sertraline 50 mg PO DAILY
9. Levothyroxine Sodium 88 mcg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 12 Days
Final dose ___ ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*23 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
4. Diltiazem Extended-Release 180 mg PO QHS
5. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth in the morning, 30
minutes before breakfast. Disp #*30 Capsule Refills:*3
6. Apixaban 5 mg PO BID
7. Atorvastatin 20 mg PO QPM
8. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 600-750 mg
oral DAILY
9. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
10. Estradiol 7.5 mcg mg PO Q 12 WEEKS
11. Levothyroxine Sodium 88 mcg PO DAILY
12. Sertraline 50 mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
==================
Left obstructing ureteral calculus
Urosepsis with proteus bacteremia
SECONDARY:
==================
Atrial fibrillation
Abnormal lung exam
Recurrent urinary retention and UTIs (chronic problem, followed
by urology)
History of duodenal ulcer
Depression
Hypothyroidism
Hyperlipidemia
Osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___
because you had a bad infection caused from a kidney stone.
What happened in the hospital?
- You had a procedure to relieve the infection in your kidney.
- You were given antibiotics
- You felt much better after the procedure and the antibiotics
What should I do when I go home?
- Please take your medications as prescribed.
- Please take your antibiotic twice daily with meals (breakfast,
dinner) so that it does not make you nauseated. Your last dose
will be the evening of ___ (Christmas!)
- We changed your diltiazem (afib medication) to night time to
help avoid your light headedness
- Please go to your follow up appointments. You should receive a
call from the urology team to schedule your appointment.
- Please call your primary care doctor (___) to
schedule a follow up appointment in the next week.
Followup Instructions:
___
|
10865278-DS-21
| 10,865,278 | 28,186,950 |
DS
| 21 |
2154-02-28 00:00:00
|
2154-02-28 12:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Keflex / Latex / Lipitor / Zosyn
Attending: ___.
Chief Complaint:
febrile x 2 days, acute onset of SOB and mental
status changes
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mrs ___ is well known to the cardiac surgery service. She
originally underwent CABG x3 on ___. She was readmitted on
___ for sternal wound dehisence and on ___ underwent
bilaterl pectoral flaps and plating with
Dr. ___. She was discharged to rehab on ___ on a 6 week
course of Vanco and Cipro despite negative OR cultures. Sternal
drains placed by plastics remained in place. She was due to f/u
with Dr. ___ week to have them removed. Over the past
48hrs she spiked fever and zosyn was added. Today she became
acutely SOB and lethargic. She was brought to the ER and was
intubated. Head CT was negative (recent hx of stroke after
CABG),
CTA of chest suggestive OF PE. ALabs, EKG and bedside Echo was
unremarkable. During her ER stay she became mildly hypotensive.
Central line was placed and she was started on levo. She was
admitted cardiac surgery service for further evaluation
Past Medical History:
Coronary Artery Disease
s/p Coronary artery bypass grafting x 3 ___
Hypertension
insulin dependent Diabetes
peripheral vascular disease
Hypercholesterolemia
Right Breast CA in ___ s/p lumpectomy and radiation therapy
with recurrence in ___ s/p right breast mastectomy and
reconstruction
Left great toe to left shin cellulitis s
Depression
Restless leg syndrome
Hypothyroidism
h/o deep vein thrombophlebitis
s/p appendectomy
Social History:
___
Family History:
non-contributory
Physical Exam:
Pulse: 80 SR Resp: 24 O2 sat:100 vented
B/P Right:120/89 Left:
Height: Weight:
Five Meter Walk Test #1_______ #2 _________ #3_________
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [] hyperactive
bowel sounds + []
Extremities: Warm [x], well-perfused [x] Edema [x] _+1____
Varicosities: None [x]
Neuro: Intubated and sedated
Pulses:
Femoral Right:+2 Left:+2
DP Right:+1 Left:+1
___ Right:+1 Left:+1
Radial Right: +2 Left:+2
Carotid Bruit Right: None Left:None
Pertinent Results:
ECHO: ___ The left atrium and right atrium are normal in
cavity size. The estimated right atrial pressure is at least 15
mmHg. 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 low normal (LVEF 50%) with
abnormal septal motion and septal hypokinesis. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal study. Low-normal global left ventricular
systolic function and hypokinesis of the septum. Mildly dilated
right ventricle with mild free wall hypokinesis.
___ 05:45AM BLOOD WBC-11.0 RBC-3.41* Hgb-9.3* Hct-28.8*
MCV-85 MCH-27.2 MCHC-32.1 RDW-15.4 Plt ___
___ 06:01AM BLOOD WBC-10.0 RBC-3.24* Hgb-9.0* Hct-27.8*
MCV-86 MCH-27.7 MCHC-32.2 RDW-15.2 Plt ___
___ 07:20PM BLOOD WBC-13.5* RBC-3.94* Hgb-10.9* Hct-32.9*
MCV-84 MCH-27.6 MCHC-33.0 RDW-15.2 Plt ___
___ 05:45AM BLOOD Glucose-76 UreaN-22* Creat-1.0 Na-145
K-4.2 Cl-111* HCO3-29 AnGap-9
___ 06:01AM BLOOD Glucose-99 UreaN-29* Creat-1.1 Na-146*
K-3.9 Cl-112* HCO3-27 AnGap-11
Brief Hospital Course:
Mrs ___ arrived in the ER from rehab after becoming acutely
short of breath, lethargic and developing a rash after receiving
a one time dose of zosyn for fever. She was also mildly
hypotensive and neo was started. She was intubated and sent for
a CTA and head CT to r/o PE. Both were negative for acute
processes. ECHO was unremarkable.
She was admitted to the CVICU, weaned from the vent and
extubated on HD#2. She was pan cultured and continued on Vanco,
Zosyn, and Cipro. ID was consulted and recommended all
antibiotics be discontinued since previous OR cultures were
negative and event was thought to be related to a Zosyn
reaction. She was seen by Plastic Surgery - Dr. ___- and one
of two JP drains was removed. The remaining JP will be removed
at subsequent follow up visit to Dr. ___.
On HD #3 she was transferred to the stepdown unit. Her foley was
removed but was re-inserted after failing to void. She continued
to progress, remained afebrile with normal WBC. She did have
large volumes of loose stool which was negative for c-diff and
O+P. It was noted that due to her very poor appetite she was
only consuming Glucerna whicih caused diarrhea. She was started
on banana flakes with significant improvement. She was noted to
have a Stage II pressure ulcer on coccyx and was seen by the
wound care specialist and regimen of Criticaide and DXeroform
gauze was recommended.
She was discharged on ___ to ___ Rehab with appropriate
follow up appointments.
Medications on Admission:
ciprofloxacin 500 mg q 12hrs, vancomycin 750mg q 24hrs, 81 mg
daily, pravastatin 20 mmg DAILY, pantoprazole 40 mg daily,
ergocalciferol weekly, levothyroxine 50 mcg daily, heparin sc
tid,clopidogrel 75 mg daily, citalopram 20 mg daily, metoprolol
25mg TID, tramadol 50 mg prn,Imdur 60 mg q 24hrs, hydralazine 50
mg q 6hrs, Norvasc 5 mg daily,lomotil prn, lantus 80 units q am
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
12. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for loose stools.
13. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
14. glargine
___very morning at breakfast
15. novolin -R
dose based on sliding scale fingerstick before meals and at
bedtime
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
mental status changes
s/p sternal dehiscence, debridement, sternal plating
Coronary artery disease
s/p coronary artery bypass grafts
hypertension
insulin dependent Diabetes
peripheral vascular disease
hyperlipidemia
Breast CA in ___
s/p lumpectomy (radiation therapy with recurrence in ___ s/p
right breast mastectomy and reconstruction
Left great toe to left shin cellulitis problem
Depression
Hypothyroidism
s/p appendectomy
Obesity
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait and assist of onw
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Edema 1+ bilateral lower extremities
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10865538-DS-31
| 10,865,538 | 24,732,876 |
DS
| 31 |
2182-03-15 00:00:00
|
2182-03-15 22:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
OxyContin / Oxycodone
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history ___ gastric bypass and Aflutter (s/p
cavotricuspid isthmus ablation ___ and no history of CAD who
presented with <24 hrs of chest pressure.
The patient woke up the morning of admission, went to pick up a
friend, and upon returning home felt tired, weak, and chest
pressure with radiation to L arm. Symptoms not relieved by rest.
Wife took vitals and he had normal HR. He has been in USOH prior
characterized by chronic lumbago due to DJD s/p lumbar fusion
___ and was doing moderate activity with ___ 1d PTA with no
anginal sx. He was BIBA for evaluation. In ED, CP improved with
morphine but not nitroglycerin. Troponins normal x2, d-dimer
elevated, CTA neg for PE, and no arrhythmias or ECG changes
concerning for MI.
He had a stress test on ___ with Dr. ___ had very poor
exercise tolerance but did not have CP or ischemic changes
during the study.
Historical symptoms of Aflutter prior to ablation last month
were fatigue, sweating, chest pressure.
In the ED, initial vitals were 10 98.2 74 125/57 16 98% RA
Given the following medications:
___ 13:16 IV Morphine Sulfate 5 mg ___
___ 13:16 PO Aspirin 243 mg ___
___ 13:45 IV Morphine Sulfate 2 mg ___
___ 18:20 IV Morphine Sulfate 5 mg ___
___ 19:40 SL Nitroglycerin SL .4 mg ___
___ 19:44 SL Nitroglycerin SL .4 mg ___
Vitals prior to transfer: 9 76 113/73 20 RA
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.
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:
1. Morbid obesity s/p open gastric bypass (02)
2. Sinusitis
3. Osteoarthritis
4. Anxiety
5. Sleep apnea
6. Atrial flutter s/p Ablation ___. First occurance in
setting of spinal surgery.
Social History:
___
Family History:
Obesity
Physical Exam:
Admission Physical Exam:
VS: Tmax 98.3, 104-113/52-61, 51-56, ___, 98-99% RA
Wt: 134.9kg <- 134.6kg
I/O: NR
General: Obese but well appearing middle aged man sitting at
edge of bed
HEENT: No oral or ocular lesions, no LAD
Neck: JVP flat
CV: Distant heart sounds, RRR, no m/r/g
Lungs: CTAB
Abdomen: Obese. Mild TTP in epigastrium. No masses, guarding,
rebound
Extr: Warm, 2+ DP and radial. No edema
Neuro: A&Ox3. PERRL. EOMI. Face symmetric. Mild ___ anterior
weakness ___ bilaterally. Normal sensation throughout
Skin: No lesions
Discharge Physical Exam:
VS: Tmax 98.2, 115-145/58-74, 55-69, 18, 96-100% RA
Weight: NR <- 134.9kg <- 134.6kg
I/O: 1.1L/2.1L, since MN ___
General: Obese but well appearing middle aged man sitting at
edge of bed
HEENT: No oral or ocular lesions, no LAD
Neck: JVP flat
CV: Distant heart sounds, RRR, no m/r/g
Lungs: CTAB
Abdomen: Obese. Mild TTP in epigastrium. No masses, guarding,
rebound
Extr: Warm, 2+ DP and radial. No edema
Neuro: A&Ox3. PERRL. EOMI. Face symmetric. Mild ___ anterior
weakness ___ bilaterally. Normal sensation throughout
Skin: No lesions
Pertinent Results:
Admission Labs:
----------------
___ 12:45PM BLOOD WBC-7.6 RBC-4.50* Hgb-13.2* Hct-39.9*
MCV-89 MCH-29.3 MCHC-33.1 RDW-14.7 RDWSD-47.5* Plt ___
___ 12:45PM BLOOD Neuts-62.8 ___ Monos-6.7 Eos-0.5*
Baso-0.7 Im ___ AbsNeut-4.80 AbsLymp-2.21 AbsMono-0.51
AbsEos-0.04 AbsBaso-0.05
___ 12:45PM BLOOD ___ PTT-26.1 ___
___ 12:45PM BLOOD Glucose-127* UreaN-14 Creat-0.7 Na-141
K-4.0 Cl-103 HCO3-24 AnGap-18
___ 12:45PM BLOOD ALT-34 AST-32 AlkPhos-63 TotBili-0.5
___ 07:45PM BLOOD cTropnT-<0.01
___ 12:45PM BLOOD cTropnT-<0.01
___ 12:45PM BLOOD Albumin-4.8
___ 01:08PM BLOOD D-Dimer-643*
___ 08:54PM BLOOD Lactate-1.5
Discharge Labs:
----------------
___ 06:50AM BLOOD WBC-5.4 RBC-4.36* Hgb-12.7* Hct-39.2*
MCV-90 MCH-29.1 MCHC-32.4 RDW-14.7 RDWSD-48.3* Plt ___
___ 06:50AM BLOOD Glucose-84 UreaN-13 Creat-0.8 Na-142
K-4.2 Cl-106 HCO3-28 AnGap-12
___ 06:50AM BLOOD Calcium-9.7 Phos-3.9 Mg-2.4
Pertinent Imaging:
------------------
Persantine Nuclear Perfusion Stress Test ___:
Sub-optimal stress test (57% max HR achieved). Persantine
induced chest discomfort reported in the absence of ischemic ECG
changes. Appropriate hemodynamic responses to Persantine. The
image quality is adequate. Left ventricular cavity size is
dilated with an estimated end-diastolic volume of 152 cc. Rest
and stress perfusion images reveal a mild-to-moderate partially
reversible perfusion defect in the septum and anterior wall,
unchanged from the prior study. Gated images reveal normal wall
motion. The calculated left ventricular ejection fraction is
49%, although visual estimation suggests it is more in the range
of 40-45%.
IMPRESSION: 1. Unchanged mild to moderate partially reversible
perfusion defect in the septum and anterior wall. 2. Dilated
left ventricular cavity with estimated LVEF of 40-45%.
Brief Hospital Course:
___ M with PMH significant for smoking, obesity, and Aflutter
s/p catheter ablation (___) who presents with atypical chest
pain.
The patient was in the car running errands when the pain,
described as "pressure", began. It was associated with
diapheresis. Patient reported feeling similar pressure in the
past when his heart had been in Aflutter, but he was in NSR in
the ED. He reported that the pressure during this episode was
more severe and lasted longer than the episodes he had
experienced in the past. He had exercise stress test ___ w/
poor exercise tolerance but no ST changes on ECG; ~ ___ METS and
64% of maximum HR achieved mostly limited by orthopedic issues.
Troponin neg in ED x2 and pain not improved with SLNG. SLNG PRN
and ASA were continued during his hospital stay. A PMIBI was
performed ___ and showed EF 40-45% and mild to moderate
partially reversible perfusion defect in the septum and anterior
wall that was unchanged compared to a stress test in ___.
Patient given Omeprazole daily and Tums and Maalox PRN for
presumptive peptic ulcer disease, given tenderness to palpation
on exam and history of gastric bypass and ASA use.
Transitional Issues:
--------------------
- Consider checking a lipid panel and starting the patient on a
statin if indicated.
- EF low (45%) on PMIBI. Needs a TTE at his outpatient
cardiologist follow-up appointment to better assess LV function.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diazepam 5 mg PO Q8H:PRN back spasm
2. Fluticasone Propionate NASAL 2 SPRY NU BID
3. Gabapentin 800 mg PO TID
4. LaMOTrigine 275 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Tizanidine 4 mg PO TID
7. HYDROcodone-acetaminophen ___ mg ORAL QID:PRN pain
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Diazepam 5 mg PO Q8H:PRN back spasm
3. Fluticasone Propionate NASAL 2 SPRY NU BID
4. Gabapentin 800 mg PO TID
5. HYDROcodone-acetaminophen ___ mg ORAL QID:PRN pain
6. LaMOTrigine 275 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Tizanidine 4 mg PO TID
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
---------
Atypical chest pain
Heart failure with reduced EF
Peptic ulcer disease
Secondary:
-----------
Depression
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 hospital stay.
Due to your chest pressure, a stress test was performed, which
showed no change compared to a stress test you had in ___. This
test indicated that the chest pressure you experienced was not
due to a heart attack. We started you on a new medication called
nitroglycerin to take as needed if you develop chest pain. We
also started you on a pill called omeprazole to control your
stomach acid, since your chest pain/pressure symptoms may have
been due to acid reflux. Please continue to take all of your
medications as prescribed and follow-up with your PCP and
___. Please ask your Cardiologist about performing an
echocardiogram (ultrasound) to look at your heart and better
assess how well it is pumping.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10865811-DS-19
| 10,865,811 | 20,804,621 |
DS
| 19 |
2131-10-19 00:00:00
|
2131-10-19 19:20:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R ankle pain
Major Surgical or Invasive Procedure:
R ankle ORIF
History of Present Illness:
___ female presents with the above fracture s/p mechanical fall.
History obtained via phone translator as patient is ___
speaking. 1 week ago, patient says she tripped and fell onto
stairs while at work. She works in the home of elderly people
assisting them. She says she tripped on the wet floor. She had
immediate pain in her right ankle but was able to bear weight
and has been walking with a limp. Due to persistent pain and
swelling of the right ankle, she went to her PCP yesterday where
___ showed "bimalleolar fracture of R ankle with oblique
fracture of the distal fibula and small mildly displaced
avulsion fracture of medial malleolus". She was told to present
to the emergency department where orthopedics was consulted.
She denies any numbness or tingling of the lower extremity.
Pt states that right ankle injury occurred at work on ___.
Place of work:
___
___
Attn: ___: ___
Past Medical History:
none
Social History:
___
Family History:
NC
Physical Exam:
Right lower extremity exam
-splint c/d/I
-fires ___
-silt exposed toes
-exposed toes 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 right bimalleolar equivalent ankle fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for a right ankle ORIF which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in the right lower extremity, and will be discharged on
lovenox for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
do not exceed 4g of acetaminophen in 24 hours
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL ___t bedtime Disp #*28
Syringe Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
do not drink or drive while taking
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right bimalleolar equivalent ankle fx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires crutches/walker
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing right lower extremity in splint
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.
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.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___. You
will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Followup Instructions:
___
|
10866343-DS-12
| 10,866,343 | 26,792,752 |
DS
| 12 |
2166-08-04 00:00:00
|
2166-08-16 21:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
EtOH intoxication
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ hx of ETOH abuse who was found at ___
unable to ambulate and clearly intoxicated. He states he had a
___ pint of vodka this morning (last drink was at 10am). He
complained or abdominal pain that was initially right and sharp,
but then became more diffuse and dull. Denies radiation to the
back. Denies n/v/brbpr/melena/diarrhea. Denies tactile
stimulus/AH/VH/SI/HI
In the ED, initial vital signs were 98.4 86 73/41 10 96%. Pt
arousable, conversant, MAE. Labs notable for black CBC with MCV
of 105, lipase 2823, AST/ALT 84/85, T bili 0.2, Na 149, Cl 112,
BUN/Cr ___, lactate 1.6. Pt given thiamine and folic acid, 3L
NS. CXR done. Pt admitted for EtOH intox, pancreatitis. Vitals
on transfer: 92 104/64 18 96% RA.
Of note patient states he drinks ___ pint of vodka a day. He has
a history of alcohol withdrawal, most recently 1 week ago.
Typical withdrawals include shaking, anxiousness, vomiting.
Patient denies history of seizures, DTs.
On the floor, vitals were T 98 HR 85 BP 120/84 RR 18 95% RA
Review of Systems:
No Back pain, Black stool, Bloody stool, Chest pain, Cough,
Dysuria/freq, Fever/chills, Headache or Rash
Past Medical History:
- Alcohol abuse: ___ pint/day, no seizures/DTS in past
- Tobacco abuse: ___ PPD
- Bilateral foot fungal cellulitis
- Appendectomy as teen
- Left shoulder fracture with persistent left shoulder pain ___
trauma ___ years ago
Social History:
___
Family History:
adopted, unknown
Physical Exam:
ADMISSION:
Physical Exam:
Vitals- T 98 BP 120/84 HR 85 RR 18 95% RA
General: NAD, thin male resting in bed,
HEENT: poor dentition, clear oropharynx, sclera nonicteric, no
conjuctival pallor
CV: RRR, no m/r/g
Lungs: CTA b/l, no w/r/r
Abdomen: Soft, mild diffuse tenderness R>L, nondistended, no
hepatomegaly.
Ext: WWP, no edema
Neuro: CNII-XII intact, slight tongue fasciculations, no tremor,
___ strength in b/l UE and ___.
Skin: macular rash on lower abdomen.
DISCHARGE:
General: NAD, thin male resting in bed,
HEENT: poor dentition, clear oropharynx, sclera nonicteric, no
conjuctival pallor
CV: RRR, no m/r/g
Lungs: CTA b/l, no w/r/r
Abdomen: Soft, nontender, nondistended, no hepatomegaly.
Ext: WWP, no edema
Neuro: slight tongue fasciculations, minimal hand tremor, ___
strength in b/l UE and ___.
Skin: macular rash on lower abdomen.
Pertinent Results:
ADMISSION:
___ 12:30PM ___ PTT-27.5 ___
___ 12:30PM NEUTS-54.4 ___ MONOS-5.5 EOS-1.5
BASOS-1.1
___ 12:30PM WBC-6.5 RBC-3.89* HGB-14.0 HCT-40.9 MCV-105*
MCH-35.9* MCHC-34.1 RDW-14.1
___ 12:30PM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 12:30PM ALBUMIN-4.4
___ 12:30PM LIPASE-2823*
___ 12:30PM ALT(SGPT)-85* AST(SGOT)-84* ALK PHOS-99 TOT
BILI-0.2
___ 12:30PM GLUCOSE-88 UREA N-8 CREAT-0.5 SODIUM-149*
POTASSIUM-4.2 CHLORIDE-112* TOTAL CO2-24 ANION GAP-17
___ 02:28PM LACTATE-1.6
___ 07:45PM WBC-5.0 RBC-3.86* HGB-13.5* HCT-40.7 MCV-105*
MCH-34.9* MCHC-33.2 RDW-14.3
___ 07:45PM GLUCOSE-79 UREA N-4* CREAT-0.5 SODIUM-146*
POTASSIUM-4.2 CHLORIDE-112* TOTAL CO2-25 ANION GAP-13
___ 07:45PM GLUCOSE-79 UREA N-4* CREAT-0.5 SODIUM-146*
POTASSIUM-4.2 CHLORIDE-112* TOTAL CO2-25 ANION GAP-13
DISCHARGE:
___ 06:15AM BLOOD WBC-6.3 RBC-3.55* Hgb-12.4* Hct-37.2*
MCV-105* MCH-34.9* MCHC-33.4 RDW-13.4 Plt ___
___ 06:15AM BLOOD Glucose-60* UreaN-4* Creat-0.4* Na-138
K-3.5 Cl-106 HCO3-24 AnGap-12
___ 06:15AM BLOOD Lipase-109*
___ 06:15AM BLOOD Calcium-8.3* Phos-2.0* Mg-1.7
___ 12:30PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
___
Chest Xray
Clear lungs. No pulmonary edema. Possible prior fracture of
the posterior
lateral left 9th rib. Expansion of the distal right clavicle,
not well
evaluated, correlate for history of prior trauma at this site.
Brief Hospital Course:
___ w/ hx of ETOH abuse who was found at ___
unable to ambulate and clearly intoxicated found to have
pancreatitis.
ACTIVE ISSUES:
#Pancreatitis: Pt is alcoholic with no known previous history of
pancreatitis who presented with abdominal pain and was found to
have a lipase of 2823. He was given 3L of fluids in the ED and
was transferred to the floor stable with improvement of pain. He
was continued on 150 ml/hr of LR and was made NPO except
ice/meds. The next day he was transitioned to clears and then
regulars prior to discharge. He clinically improved with
resolution of abdominal pain and his lipase trended down to 109.
#hypernatremia: Patient was found to have sodium of 149 in the
ED attributed to free water deficit from chronic alcohol use. He
was given 3L NS in ED then transitioned to LR on the floor for
maintenance. His sodium on discharge was 138.
#Alcohol Abuse: Pt is alcoholic who consumes ___ pint of vodka a
day and has a history of uncomplicated withdrawals. On
presentation he had small tongue fasciculations but otherwise no
signs of withdrawal. Overnight he was placed on CIWA but did not
score high enough to receive valium. He was also given thiamine,
folate, and a multivitamin. We strongly encouraged the patient
to quit drinking alcohol and offered him the option of talking
to a social worker. He declined detox or rehab services but
expressed some interest in quitting. He was discharged with a
small prescription of valium to help with withdrawal symptoms
and instructed to follow up with his primary care physician. He
was told to go to an emergency room if he had symptoms of
withdrawal that did not improve with valium.
#Rash: Patient had macular rash on lower abdomen, likely ___ to
contact dermatitis vs heat rash. Did not appear to be scabies.
He was treated symptomatically with Sarna lotion.
Chronic issues:
#Tobacco use: nicotine patch
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 1 SPRY NU BID
2. DiphenhydrAMINE 25 mg PO HS
3. Thiamine 100 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Fluticasone Propionate NASAL 1 SPRY NU BID
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Thiamine 100 mg PO DAILY
5. Diazepam 5 mg PO Q8H:PRN alcohol withdrawal symptoms (tremor,
sweating)
RX *diazepam 5 mg 1 tablet by mouth every 8 hours Disp #*10
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis, alcohol abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You presented to the hospital due to being intoxicated and
complaining of abdominal pain. You were found to have
pancreatitis (inflammation of your pancreas). The pancreatitis
was due to your alcohol use. You were given fluids and monitored
overnight. You were also watched for alcohol withdrawal.
We strongly encourage you to consider quitting alcohol. You
expressed interest in quitting but declined a ___ facility. If
you are interested in counseling or rehabilitation for your
alcohol use please let your primary care provider ___. On
discharge, you will have a prescription for a few tabs of
valium. Please take 1 tab as needed for symptoms of withdrawal.
You can take up to 3 tabs in 1 day spread out throughout the
day, but do not take more than 3 tabs in 1 day. It is very
important that you follow-up in the ___ clinic (appointment
listed below). If you have symptoms of withdrawal that are
concerning and not improved by valium, call the ___ clinic
for help.
Please follow up with your primary care doctor in 1 week. You
should also talk to your doctor about getting a CT of your
abdomen as an outpatient.
Followup Instructions:
___
|
10866343-DS-14
| 10,866,343 | 28,981,708 |
DS
| 14 |
2167-11-29 00:00:00
|
2167-11-29 13:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Intoxication, s/p assault, hypoxia
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
___ w/ hx of ETOH abuse, pancreatitis brought in by EMS for
intoxication and complaining of assault on ___. States
that he has had "too much to drink" today, and that he states he
was jumped last night in ___. Complains of
intermittent headache.
Of note, patient has had multiple recent ED visits for
intoxication, but has not expressed interest in alcohol
cessation.
In the ED, initial vitals were: 96.8 72 119/72 17 97% 2L Nasal
Cannula. Labs significant for WBC 4.9, unremarkable
electrolytes, mild transaminitis, normal lactate. CT head
unremarkable. CT ___ without evidence of fracture. CXR with
RLL infiltrate concerning for pneumonia. given poor social
support and chronic homelessness, patient admitted for eval and
treatment. Patient given IV levofloxacin in ED.
On the floor, patient reports that he has had increased dyspnea
and productive cough for the past month following an upper
respiratory infection. He reports progressive shortness of
breath to the point where he can no longer climb a flight of
stairs without stopping. He denies fevers, although he does
report periodic chills. Denies chest pain, chest pressure,
orthopnea, leg swelling. Feels that he is starting to withdraw
from alcohol, and reports nausea and tremulousness. He does
report that he has had withdrawal seizures, which have been new
over the past year. He drinks about a pint of vodka per day, and
his last drink was this morning. He reports that he previously
quit drinking for about a year when he had a job; he does not
think that it would be possible for him to quit now because "I'm
homeless, what else would I do?".
Past Medical History:
1. Alcohol abuse: 1 pint/day. reports hx of 2 withdrawal
seizures.
2. Tobacco abuse: ___ PPD
3. Bilateral foot fungal cellulitis
4. Appendectomy as teen
5. Pancreatitis
6. Rash
7. Left shoulder fracture with persistent left shoulder pain
___ trauma ___ years ago
Social History:
___
Family History:
Adopted, unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: T: 98.1 BP: 120/80 P: 100 R: 18 O2: 98%/3L
General: Disheveled but pleasant, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. poor dentition.
healed scrapes on head.
Neck: supple
Lungs: breathing comfortably. poor inspiratory effort on exam
but faint crackles in RLL. no wheezes appreciated
CV: mildly tachycardic but regular, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, ___. tender to palpation in RUQ and
epigastrium, no rebound or guarding, mild hepatomegaly
Ext: no edema
Skin: flaking of skin on feet
Neuro: A and O x3. PERRL, EOMI, face symmetric, strength
grossly symmetric.
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: 97.9, 100/63, pulse 90, rr18, 97% on RA
General: Pleasant, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. poor dentition.
Healed scrapes on head.
Neck: supple
Lungs: CTAB, good respiratory effort.
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, ___. tender to palpation in RUQ and
epigastrium, no rebound or guarding, mild hepatomegaly
Ext: Trace lower extremity edema
Neuro: AAOx3. PERRL, EOMI, face symmetric, strength grossly
symmetric.
Pertinent Results:
ADMISSION LABS:
===============
___ 05:50PM BLOOD ___
___ Plt ___
___ 05:50PM BLOOD ___
___
___ 05:50PM BLOOD ___
___ 05:50PM BLOOD ___
___ 05:57PM BLOOD ___
OTHER PERTINENT LABS:
=====================
___ 07:25AM BLOOD ___
___
___ 03:10PM BLOOD ___
___
___ 07:25AM BLOOD ___
___ Plt ___
___ 03:10PM BLOOD ___
___ 03:10PM BLOOD ___
___ 07:25AM BLOOD ___
___ 07:25AM BLOOD ___
___ 06:00AM BLOOD ___
___ Plt ___
___ 06:00AM BLOOD ___
___
___ 06:00AM BLOOD ___.
IMAGING:
============
CXR ___
Vague opacity in the right lower lung adjacent to the cardiac
silhouette is new since ___. No pulmonary edema, pleural
effusion or pneumothorax. The cardiac and mediastinal contours
are normal. There are old left rib fractures.
IMPRESSION:
Right lower lung opacity is concerning for pneumonia in the
correct clinical setting.
CT head ___
No acute intracranial hemorrhage or mass effect.
CT Chest ___:
Small airway infection at the right lung base with focal area of
consolidation within right middle lobe compatible with pneumonia
in the right clinical setting.
Renal Ultrasound ___:
A cyst with a single thin septation is located in the upper pole
of the right kidney. Otherwise, normal renal ultrasound. No
___ is required.
MICROBIOLOGY:
==============
___: Blood cx x 2 NGTD
DISCHARGE LABS:
================
No labwork day of discharge.
Brief Hospital Course:
___ y/o homeless male with history of ETOH abuse brought in with
intoxication and history of assault, with 1 month of productive
cough and worsening dyspnea on exertion, RLL opacity on CXR and
CT scan found to be a likely bacterial pneumonia.
# RLL pneumonia:
Patient with progressively worsening cough and dyspnea. CXR and
CT scan indicative of a RLL pneumonia. Given risk factors for
community acquired pneumonia, he was started on Levofloxacin
750mg daily for a total of a 5 day course that was started on
___. He responded well to the antibiotics, with
improvement of his oxygen saturation. Prior to discharge, his
ambulatory oxygen saturation was 95%, greatly improved from
admission. Patient also noted subjective decrease in his cough.
# ETOH abuse:
Patient has self reported history of 2 withdrawal seizures from
alcohol. He is dependent on alcohol, and drinks daily with no
breaks in his drinking. He takes a MVI at home, but in the
hospital was provided thiamine, folate, and multivitamin along
with adequate nutrition and electrolyte repletion. The patient
was offered social work assistance and refused it. He was
counseled extensively on the importance of both alcohol and
tobacco cessation, but was ___ for both of these
conversations. He was maintained on CIWA precautions and
provided with Diazepam for CIWA>10. At the time of discharge he
was taking less than 10mg of Diazepam daily for withdrawal sx
and so was provided a 2 day course of 10mg Diazepam after
discharge.
# Transaminitis:
Likely related to ETOH abuse. Hepatitis serologies last checked
in ___, negative at that time. CT abdomen showed likely hepatic
steatosis ___. Patient's LFTs were trended as an inpatient,
and should be ___ at his next PCP ___.
# Anemia:
Mild, macrocytic. His anemia is likely related to folate
deficiency ___ alcohol abuse. Supplemental folate was provided
as noted above.
# Thrombocytopenia
Not present in ___. Currently stable, and likely ___ alcohol
and/or splenic sequestration. Was stable during hospitalization,
and should also be followed up as an outpatient. If no
improvement after discharge would consider further workup such
as repeat HIV/Hepatitis serologies.
# Right upper pole renal cortical hypodensity:
Seen on CT abdomen on prior hospitalization in ___. Was
better characterized with a renal ultrasound and found to be a
benign cyst. No further imaging indicated as per radiology.
TRANSITIONAL ISSUES:
====================
- Follow up with PCP
- ___ ultrasound shows benign cyst, no further imaging needed
- ___ LFTs at next PCP ___
- 2 day course of Diazepam provided for alcohol withdrawal
FULL CODE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins W/minerals 1 TAB PO DAILY
2. Ibuprofen 400 mg PO Q8H:PRN left shoulder pain
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
RX ___ 1 capsule(s) by mouth once a day
Disp #*30 Capsule Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
4. Ibuprofen 400 mg PO Q8H:PRN left shoulder pain
5. Levofloxacin 750 mg PO DAILY Duration: 2 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*1
Tablet Refills:*0
6. Diazepam 10 mg PO QD Duration: 2 Days
RX *diazepam 10 mg 1 tablet by mouth once a day Disp #*2 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Bacterial Pneumonia
Alcohol Abuse
Transaminitis
Anemia
Thrombocytopenia
SECONDARY:
Tobacco Abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You came to ___ due to a severe
cough. You were found to have pneumonia, and treated with
antibiotics. Your cough improved prior to discharge, and during
your stay you had no fevers or chills. After leaving the
hospital it is important that you complete your entire course of
medication.
During your hospitalization a social worker offered to speak
with you, but you were not interested in meeting with them. In
addition, you were counseled extensively on the importance of
alcohol cessation. After leaving the hospital if you would like
to seek assistance with your alcoholism, then please call
___, a free assistance line run by the state of
___.
It has been a pleasure caring for you, and we wish you all the
best.
Kind regards,
Your ___ Team
Followup Instructions:
___
|
10866343-DS-15
| 10,866,343 | 27,098,496 |
DS
| 15 |
2168-02-15 00:00:00
|
2168-02-16 07:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with hx of alcoholism presented to the ED with hypoxia
and tachycardia, found to have pneumonia.
The patient reports he had an episode of PNA one month ago and
was treated for about a week of PO abx. He states he was treated
here, however, last treatment documented in our records was in
___. Then, he was treated with levofloxacin for a total of a
5 day course that was started on ___. No hospitalizations
since then. He claims his breathing initially got better,
however, over the past week he notes increased shortness of
breath, both at rest and with exertion. No fevers/chills, no
sick contacts. Denies aspiration events. Is coughing with sputum
production.
The patient has also been drinking about 1 pint of vodka
nightly. His last drink was the evening of ___. Reports one
withdrawal seizure in the past, none recently. Has quit
previously for about one year many years ago, but is not
interested in sobriety at this time. Denies other drugs. Denies
recent falls or trauma.
In the ED, initial vitals: 99.1 100 108/61 18 93%. In the ED he
desatted to the mid ___ with HRs in the 120s and required O2
supplementation briefly, however, was weaned to RA prior to
transfer. Labs were significant for alcohol level of 514,
negative tox screen, ALT 56, AST 69, lipase 108, hct 35, plts
138, no leukocytosis, ddimer 693. CXR negative; CTA chest
negative for PE but showed possible PNA. The patient was given
1L IVF, IV thiamine, albuterol and ipratropium nebs, 1mg folic
acid, multivitamin, IV ceftriaxone and IV azithromycin. Vitals
prior to transfer: 90 102/60 22 95% RA
Currently, the patient feels tremulous. Reports some shortness
of breath. No pain, no other complaints.
Past Medical History:
1. Alcohol abuse: 1 pint/day. reports hx of 2 withdrawal
seizures.
2. Tobacco abuse: ___ PPD
3. Bilateral foot fungal cellulitis
4. Appendectomy as teen
5. Pancreatitis
6. Rash
7. Left shoulder fracture with persistent left shoulder pain
___ trauma ___ years ago
Social History:
___
Family History:
Adopted, unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.6 119/68 92 18 91% RA
GEN: Alert, lying in bed, no acute distress
HEENT: Tacky MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Crackles at bases bilaterally
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: Mild tremor of hands b/l
DISCHARGE PHYSICAL EXAM:
VITALS: 98.5 ___ 18 97 RA
GEN: Alert, lying in bed, no acute distress
HEENT: MMM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: CTAB
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: Mild tremor of hands b/l
Pertinent Results:
ADMISSION LABS:
___ 02:20AM BLOOD WBC-4.9 RBC-3.36* Hgb-11.9* Hct-35.4*
MCV-106* MCH-35.3* MCHC-33.5 RDW-15.3 Plt ___
___ 02:20AM BLOOD Glucose-108* UreaN-9 Creat-0.6 Na-142
K-3.7 Cl-104 HCO3-23 AnGap-19
___ 02:20AM BLOOD Albumin-4.0 Calcium-8.8 Phos-4.3 Mg-1.7
___ 02:20AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:43AM BLOOD ___ pO2-70* pCO2-41 pH-7.37
calTCO2-25 Base XS--1
DISCHARGE LABS: None
STUDIES:
CXR ___:
No acute cardiopulmonary process.
CTA chest ___:
1. No evidence of acute pulmonary embolism.
2. Ground-glass opacities in the right upper lobe are likely
infectious or inflammatory in etiology.
3. Bilateral lower lobe bronchial wall thickening with scattered
mucous plugging, also likely related to a chronic small airways
infectious process.
MICRO: Blood cx ___ pending
Brief Hospital Course:
___ yo M with hx of alcoholism, tobacco use, and homelessness
presented to the ED with hypoxia and tachycardia, found to have
pneumonia.
# Pneumonia: patient with hypoxia in the ED to the ___ on RA,
with new consolidation on CT chest. Also reports shortness of
breath and productive sputum. No fevers. Patient with pneumonia
___ that was treated with levofloxacin. Pt given IV
ceftriaxone and azithro in the ED. He was treated for a
community-acquired pneumonia for 5 days of azithromycin and
cefpodoxime with improvement of his respiratory status. By
discharge, his ambulatory sat was 96%.
# Alcohol use: Patient with alcoholism without significant
periods of absinence. He was placed on CIWA protocol for mild
alcohol withdrawal. By discharge the patient was not requiring
benzodiazepines. He was also given folate, multivitamins and
thiamine, and his electrolytes were repleted. Social work saw
the patient, but he did not want to quit drinking at this time.
TRANSITIONAL ISSUES:
- One more dose of the cefpodoxime the evening of discharge;
___ delivered the medication to the patient in the
hospital
- Encouarged alcohol and smoking cessation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
Not taking these medications as prescribed.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin one tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg one capsule(s) by mouth TID prn Disp #*30
Capsule Refills:*0
5. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL ___ mL by mouth q6h prn Refills:*0
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg two tablet(s) by mouth once Disp #*2
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Community-acquired pneumonia
Alcohol withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ due to pneumonia and alcohol
withdrawal. You were started on antibiotics for the pneumonia,
and you should take one more dose of the cefpodoxime this
evening around 8pm. In addition, you were treated for alcohol
withdrawal with valium. You improved and by discharge did not
need the valium. We encourage you to stop drinking, as this may
avoid health difficulties in the future. We wish you the best!
Your ___ care team
Followup Instructions:
___
|
10866343-DS-19
| 10,866,343 | 28,081,620 |
DS
| 19 |
2168-10-16 00:00:00
|
2168-10-16 16:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
EtOH Withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of EtOH dependence and multiple presentations for
intoxication and withdrawal who presents with abdominal pain. He
was most recently discharged from ___ on ___ after being
admitted for EtOH withdrawal after he had a seizure in the
setting of tapering his EtOH use. He was loaded with phenobarb
uneventfully and otherwise was noted to have abnormal LFTs with
ascites seen on RUQ U/S. He declined shelter placement as he
preferred to live on the street. He had a 9th rib fracture and
was discharged with a small amount of tramadol.
Following discharge the patient resumed drinking ___ pint of
vodka daily. On the day of admission, the patient was picked up
by EMS from the ___ T-station. He had alerted the T
inspector that he was having difficulty breathing due to his rib
injury, having pain over the rib associated with deep breathing.
His vitals per the EMS report were all WNL. He was brought to
the ___ emergency room.
On arival to ED, vitals notable for: 96.9 96 116/79 20 97% RA
- Labs notable for: WBC 7.4, H/H ___ Plt 496, Na 146, Cr 0.5.
- Imaging notable for: CXR with left lateral 9th rib fracture
and left humeral head deformity.
- Events: patient hypoxic to 91% at ___ so patient was given
Ceftriaxone given concern for PNA.
- Patient given: Diazepam 10mg x2, Ceftriaxone 1gm, 1L NS
REVIEW OF SYSTEMS: (+) Per HPI
Past Medical History:
1. Alcohol abuse: 1 pint/day. reports hx of 3 withdrawal
seizures.
2. Tobacco abuse: ___ PPD
3. Bilateral foot fungal cellulitis
4. Appendectomy as teen
5. Pancreatitis
6. Rash
7. Left shoulder fracture with persistent left shoulder pain ___
trauma ___ years ago
Social History:
___
Family History:
non contributory
Physical Exam:
ADMISSION EXAM:
Vitals: 98.2 140/93 66 16 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds throughout with slight crackles
at both bases
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. Pain in the LLQ which
is most severe with point tenderness over a posterior rib.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAOx3, + tremor in bilateral upper extremities, no
asterixis
DISCHARGE EXAM:
Vitals: 97.9 max 136/89 92 18 99% on RA
General: Alert, oriented, comfortable appearing, no acute
distress, tremulous, shaved beard
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB, no crackles, wheezes, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. Pain in the LLQ which
is most severe with point tenderness with palpation over
posterior ribs
GU: No foley , no CVA tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAOx3, + improved tremor in bilateral upper extremities
Pertinent Results:
ADMISSION:
___ 04:23PM BLOOD WBC-7.4# RBC-3.17* Hgb-11.4* Hct-34.3*
MCV-108* MCH-36.0* MCHC-33.2 RDW-14.6 RDWSD-58.6* Plt ___
___ 04:23PM BLOOD Neuts-61.4 ___ Monos-6.6 Eos-1.1
Baso-1.5* Im ___ AbsNeut-4.55# AbsLymp-2.16 AbsMono-0.49
AbsEos-0.08 AbsBaso-0.11*
___ 05:45AM BLOOD ___ PTT-27.7 ___
___ 04:23PM BLOOD Glucose-92 UreaN-7 Creat-0.5 Na-146*
K-4.0 Cl-105 HCO3-27 AnGap-18
___ 04:23PM BLOOD ALT-67* AST-64* LD(LDH)-254* AlkPhos-143*
TotBili-0.1
___ 04:23PM BLOOD Lipase-100*
___ 05:45AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.5*
___ 12:28AM BLOOD Ethanol-85*
___ 04:23PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 12:32AM BLOOD ___ pO2-129* pCO2-35 pH-7.43
calTCO2-24 Base XS-0 Comment-GREEN TOP
DISCHARGE:
___ 04:30AM BLOOD WBC-5.4 RBC-3.30* Hgb-12.0* Hct-36.4*
MCV-110* MCH-36.4* MCHC-33.0 RDW-14.4 RDWSD-59.0* Plt ___
___ 06:22AM BLOOD Glucose-80 UreaN-12 Creat-0.6 Na-138
K-4.3 Cl-101 HCO3-25 AnGap-16
___ 04:30AM BLOOD ALT-53* AST-56* LD(LDH)-210 AlkPhos-153*
TotBili-0.2
___ 06:22AM BLOOD Calcium-10.4* Phos-5.0* Mg-2.0
___ 06:22AM BLOOD Calcium-10.4* Phos-5.0* Mg-2.0
EKG:
Sinus rhythm. Baseline artifact. Mildly delayed R wave
progression across the precordium which could be a variant based
on variations in precordial lead positioning. Compared to the
previous tracing of ___ there is likely variation in
precordial lead positioning. The other findings are similar.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
96 174 94 362 425 65 86 82
CXR:
___
No acute cardiopulmonary process. Unchanged appearance of left
humeral head and lateral left ninth rib osseous deformities.
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with history of EtOH
dependence and multiple presentations for intoxication and
withdrawel who presents with alcohol withdrawal and hypoxia
secondary to old rib fracture pain and splinting. Patient was
monitored with CIWA scale and treated with benzodiazepenes as
needed for symptoms of withdrawal. Once patient no longer at
risk for alcohol withdrawal he was discharged with plan for
close PCP follow up.
# EtOH withdrawal:
Patient with history of alcohol abuse and withdrawal complicated
by seizures. He stopped drinking 2 days prior to admission and
demonstrated signs of withdrawal with tremulousness,
tachycardia, diaphoresis, anxiety, headache. He was monitored
q2h on CIWA scale, receiving diazepam for score greater than 10.
He was spaced to q4h monitoring and subsequently did not show
significant signs of withdrawal and did not require
benzodiazepines 24 hours prior to discharge. Patient continued
on PO thiamine, folate, multivitamin. Patient met with social
work several times during this admission and refused to enroll
in alcohol treatment program. He is currently at the
contemplative stage.
# Subacute Rib fracture:
Patient with ___ rib fracture from previous fall. No evidence
of pneumothorax or respiratory compromise on exam or chest xray.
Complicated by splinting and hypoxia which resolved with
adequate pain control. Patient initially treated with standing
acetaminophen and prn tramadol, transitioned to lidocaine gel
for long term pain management. Patient did not have fevers,
leukocytosis, or chest xray findings consistent with pneumonia
and did not receive antibiotic therapy during admission. Patient
was discharged with acetaminophen, lidocaine gel, and incentive
spirometer to be used daily.
CHRONIC MEDICAL ISSUES:
# Anemia:
At baseline. No signs of bleeding during this admission.
Macrocytic anemia consistent with chronic alcohol abuse.
# Tobacco Abuse:
Patient counseled on tobacco cessation. Given nicotine patch and
nicotine lozenges while inpatient.
TRANSITIONAL ISSUES:
======================
[ ] Continue to encourage patient to seek treatment for his
alcohol abuse
[ ] Patient discharged on acetaminophen and lidocaine for pain
control for rib fracture
# CODE STATUS: Full (confirmed)
# CONTACT: ___ (sister) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob/wheeze
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. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Vitamins & Minerals] 1 tablet(s)
by mouth daily Disp #*30 Tablet Refills:*0
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Albuterol Inhaler 2 PUFF ___ Q6H:PRN sob/wheeze
6. Lidocaine Jelly 2% 1 Appl TP TID:PRN rib pain
RX *lidocaine 5 % apply small amount to rib/chest wall three
times a day Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol Withdrawal, uncomplicated
Alcohol Abuse
Subacute rib fracture
Hypoxia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your admission to
___. You came to the hospital
because you stopped drinking and were feeling like you were
withdrawing from alcohol. You were also feeling short of breath
because of your previous rib fracture. We found that you did not
have a pneumonia or other infection. Your breathing improved
with pain medicine (acetaminophen and lidocaine) and incentive
spirometry. Please continue to use your incentive spirometer
when you leave to prevent pneumonia.
For your alcohol withdrawal you were monitored closely and
received benzodiazepenes to help you to safely withdraw. We
strongly recommend that you attend rehab to help you to stop
drinking safely but you refused at this time. Please continue to
think about quitting alcohol use as this is detrimental to your
health.
We wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10866397-DS-11
| 10,866,397 | 21,955,609 |
DS
| 11 |
2125-01-10 00:00:00
|
2125-01-22 23:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
EGD on ___.
History of Present Illness:
___ with a PMH of nephrotic syndrome undergoing workup with
renal biopsy on ___ presenting with acute onset shortness of
breath and dyspnea on exertion. She noticed these symptoms upon
awakening on the morning of ___. She felt lightheaded whenever
changing positions from sitting to standing or when bending
over. Additionally, she noticed that she became significantly
short of breath when walking up stairs. She denies having any
chest pain or pressure. She flew to ___ around 2 months
prior, but otherwise does not have recent travel or
immobilization. She had chronic bilateral ___ edema related to
her nephrotic syndrome which has only been improving recently in
the setting of starting diuretics. She denies any person or
family history of VTE or bleeding disorders.
She called Dr. ___ with her symptoms who was concerned that
they may be either related to PE or anemia in the setting of her
recent biopsy and referred her to the ED.
In the ED, initial vitals were: 98.8 ___ 18 100% RA
- Labs were significant for improved anemia (Hgb 9.9), Cr 1.4
(baseline ___, lactate 2.6, and D-dimer ___.
- ___ showed no evidence of DVT
- V/Q scan showed moderate-high probability of PE
- The patient was started on a heparin gtt and given ativan
REVIEW OF SYSTEMS:
(+) Per HPI
She does endorse joint swelling in ___ after returning from
___, with ankle swelling and hand myalgias. She was
concerned that she may have caught Chikungunya but her swelling
quickly resolved.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias.
Past Medical History:
Nephrotic Syndome ___ Lupus Nephritis
SLE
Uterine Fibroids
Social History:
___
Family History:
No family history of kidney disease. No known bleeding or
clotting disorders.
Physical Exam:
ADMISSION PHYSICAL:
Vitals: 98 133/82 78 18 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, holosystolic murmur
at ___
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Back: L sided renal biopsy site covered by DSD. No CVA
tenderness.
Ext: Warm, well perfused, 2+ pulses, 2+ lower extremity edema in
the ankles.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL:
VS: 97.6 126/74 80 16 O2 98% on RA (stable)
General: Alert, oriented, no acute distress.
HEENT: MMM.
CV: RRR NMRG
Lungs: CTAB
Abdomen: soft, nontender.
Ext: Compression stockings b/L, trace ___ edema.
Pertinent Results:
ADMISSION LABS:
___ 06:57PM BLOOD WBC-6.4 RBC-4.26 Hgb-9.9* Hct-29.7*
MCV-70* MCH-23.1* MCHC-33.1 RDW-20.4* Plt ___
___ 06:05AM BLOOD WBC-8.5 RBC-4.21 Hgb-9.4* Hct-29.5*
MCV-70* MCH-22.4* MCHC-32.0 RDW-20.7* Plt ___
___ 06:57PM BLOOD Neuts-79.6* Lymphs-16.8* Monos-3.2
Eos-0.3 Baso-0.2
___ 06:57PM BLOOD ___ PTT-24.5* ___
___ 06:57PM BLOOD Plt ___
___ 06:57PM BLOOD Glucose-134* UreaN-33* Creat-1.4* Na-135
K-4.6 Cl-97 HCO3-30 AnGap-13
___ 06:05AM BLOOD Glucose-139* UreaN-34* Creat-1.3* Na-138
K-4.1 Cl-100 HCO3-28 AnGap-14
___ 06:57PM BLOOD cTropnT-<0.01 proBNP-245*
___ 06:57PM BLOOD Calcium-8.4 Phos-5.2* Mg-1.8
___ 06:57PM BLOOD D-Dimer-GREATER TH
___ 07:08PM BLOOD Lactate-2.6*
___ 07:41AM BLOOD Lactate-1.9
KEY LABS:
___ 06:05AM BLOOD Thrombn-150*
___ 07:32AM BLOOD Ret Aut-1.0*
___ 07:33AM BLOOD Ret Aut-1.1
___ 07:33AM BLOOD CD5-DONE CD23-DONE CD45-DONE ___
___ Kappa-DONE CD2-DONE CD7-DONE CD10-DONE CD19-DONE
CD20-DONE Lambda-DONE
___ 07:33AM BLOOD CD3%-DONE
___ 07:33AM BLOOD IPT-DONE
___ 06:05AM BLOOD ___ ca
___ 10:48AM BLOOD Lipase-81*
___ 07:33AM BLOOD Albumin-1.2* Calcium-8.7 Phos-4.9* Mg-1.7
Cholest-385*
___ 10:48AM BLOOD Hapto-200
___ 07:32AM BLOOD Hapto-233*
___ 07:32AM BLOOD IgG-871 IgA-466* IgM-117
___ 06:24AM BLOOD tacroFK-5.4
___ 07:33AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 07:33AM BLOOD HCV Ab-NEGATIVE
___ 07:33AM BLOOD Triglyc-301* HDL-84 CHOL/HD-4.6
LDLcalc-241* LDLmeas-256*
___ 07:32AM BLOOD IgG-871 IgA-466* IgM-117
DISCHARGE LABS:
___ 06:24AM BLOOD WBC-10.2* RBC-3.41* Hgb-7.8* Hct-24.7*
MCV-72* MCH-22.9* MCHC-31.6* RDW-25.0* RDWSD-63.3* Plt ___
___ 06:24AM BLOOD Plt ___
___ 06:24AM BLOOD ___
___ 06:24AM BLOOD Glucose-98 UreaN-58* Creat-1.8* Na-139
K-4.2 Cl-99 HCO3-32 AnGap-12
___ 06:48AM BLOOD Calcium-8.1* Phos-5.4* Mg-2.1
KEY IMAGING:
CXR ___: The lungs are clear without consolidation,
effusion, or pneumothorax. The cardiomediastinal silhouette is
within normal limits. No acute osseous abnormalities identified
noting an minimal lower thoracic dextroscoliosis. No acute
cardiopulmonary process.
V/Q Scan ___: Moderate to high likelihood ratio for acute
pulmonary
thromboembolism.
Renal US ___: 1. Normal renal ultrasound.
2. Patent renal veins bilaterally.
CT Abd+Pelvis w/o contrast: 1. Small subcapsular hematoma at the
left kidney lower pole.
2. Mild mesenteric and subcutaneous edema may be due to third
spacing or IV
hydration.
3. Prominent retroperitoneal and iliac chain lymph nodes,
slightly decreased since ___.
4. Calcified uterine fibroid.
Renal US+DOPPLER ___: 1. Normal renal ultrasound. No
hematoma seen.
2. Patent renal veins bilaterally. No renal vein thrombosis.
Unilateral UE Venous US ___: No evidence of deep vein
thrombosis in the left upper extremity. Slow flow with Rouleaux
is noted in one of the two left brachial veins.
MICRO:
___ HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
POSITIVE BY EIA.
(Reference Range-Negative).
___ 10:00 pm URINE:
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final
___:
Negative for Chlamydia trachomatis by ___ System,
APTIMA COMBO 2
Assay.
Validated for use on Urine Samples by the ___
Microbiology
Laboratory. Performance characteristics on urine samples
were found
to be equivalent to those of FDA- approved TIGRIS APTIMA
COMBO 2
and/or COBAS Amplicor methods.
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Final ___:
Negative for Neisseria gonorrhoeae by PANTHER System,
APTIMA COMBO 2
Assay.
Validated for use on Urine Samples by the ___
Microbiology
Laboratory. Performance characteristics on urine samples
were found
to be equivalent to those of FDA- approved TIGRIS APTIMA
COMBO 2
and/or COBAS Amplicor methods.
Brief Hospital Course:
___ with recent new diagnosis of nephrotic syndrome presented to
the ED with dyspnea and was found to have a PE. While inpatient,
her nephrotic syndrome was diagnosed as lupus nephritis and she
was started on immunosuppression for SLE.
ACTIVE ISSUES:
Retroperitoneal bleeding, possible Had fluctuating H/H yesterday
concerning for RP bleed, but CTAP does not demonstrate this
finding.
Abdominal discomfort
H.pylori infection
# SLE with lupus nephritis: During her inpatient stay, Ms.
___ was diagnosed with SLE, complicated by Lupus
nephritis, Class III + V that was the cause of her nephrotic
syndrome. In consultation with Nephrology and rheumatology, the
patient was started on immunosuppressive therapy with
Mycophenolate Mofetil 1000mg QD and Tacrolimus 3mg BID in
addition to the Prednisone 100mg q.o.d. she had been taking
before admission. The patient was discharged with Bactrim SS 1
tab qd for prophylaxis while on immunosuppression. She was also
treated with Lisinopril 10 mg PO daily and Torsemide 20 mg BID,
both of which she will continue after discharge. She will be
followed by rheumatology and nephrology after discharge.
# Pulmonary embolism: PE likely secondary to hypercoagulable
state associated with nephrotic syndrome. However, new clot in
this ___ woman with few overt risk factors warranted workup
for occult malignancy, especially given the finding of new
diffuse lymphadenopathy on imaging. This workup showed no
evidence of malignancy. Full workup for other causes of a
hypercoagulable state were deferred and can be pursued as an
outpatient. Ms. ___ was admitted to the medical floor
on telemetry and continuous pulse oximetry. A heparin drip was
started and continued to bridge the patient to warfarin with a
goal ___. She was ultimately therapeutic on Warfarin 5mg PO
qd. She will need to followed for labs and medication management
as an outpatient.
# Occult malignancy workup: The patient was noted on imaging to
have diffuse adenopathy and a breast mass with
microcalcifications. Particularly in the setting of new
thromboembolism, workup for occult malignancy was initiated.
This workup included lymph node biopsy and biopsy of a breast
mass in consultation with hematology/oncology and surgery. The
lymph node biopsy showed no evidence of malignancy. However, the
consulting oncologist noted that the sample was minimally
sufficient and recommended further workup in the future if the
lymphadenopathy were to recur and persist. Management of the
breast mass can occur as an outpatient, patient can follow up
with breast surgery for excision.
# Anemia: Patient found to be anemic at admission and through
hospital course, with Hgb = ___ compared to prehospital Hgb =
___ in early ___. No evidence of bleeding was found.
Hematology and iron studies suggested iron-deficiency. Also
likely contribution from anemia of chronic disease. Patient was
started on oral iron supplementation but this was discontinued
due to stomach upset. Iron supplementation with ferrous
gluconate IV was administered for two doses (a complete course)
while in the hospital. H&H should be followed routinely as
outpatient.
# H. pylori: Patient was diagnosed with H. pylori in the course
of investigating abdominal pain that the patient has had
intermittently for the past month. Treatment with PPI,
Amoxicillin, and azithromycin was initiated. Of note,
azithromycin was chosen over clarithromycin because it minimized
risk of interaction with immunosuppressive meds. She finished
the course of azithromycin in the hospital and will finish the a
10-day course of amoxicillin after discharge. She was discharged
on Pantoprazole 40mg BID and will continue that medication for
symptoms of gastritis detailed below.
# Abdominal pain, likely gastritis: Patient complained of
abdominal pain bloating and cramping which has been intermittent
for at least 1 month. In the setting of H. pylori, this pain is
most likely related to gastritis. However, the abdominal pain
may also be related to SLE. An EGD on ___ demonstrated
gastritis near the pylorus and antrum. GI recommended PPI
therapy and patient will be discharged on Pantoprazole 40mg BID.
Of note, pantoprazole was prescribed in favor of omeprazole to
minimize risk of interaction with her immunosuppressive agents.
Patient has an appointment to follow up with GI and recommend a
repeat EGD in 10 weeks.
CHRONIC ISSUES:
# Uterine Fibroids: Patient still having pelvic pain both during
and between menses, with a history of uterine leiomyomata. A
pelvic ultrasound suggested adenomyosis. A follow up appointment
with Ob/Gyn was made for after discharge.
TRANSITIONAL ISSUES:
# Anticoagulation: Patient discharged on Warfarin for PE and
will need at least 3 months of AC therapy, potentially longer.
Recommended follow-up with Heme/Onc to determine appropriate
duration of therapy in the setting of provoked PE due to
nephrotic syndrome.
# Abdominal Pain: Has been a longstanding issue, recalcitrant to
multiple therapies. Patient should follow up with GI and
providers should consider possible contribution of SLE to her
abdominal pain.
# CODE STATUS: FULL (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 100 mg PO EVERY OTHER DAY
2. Omeprazole 20 mg PO DAILY
3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
4. Torsemide 60 mg PO QAM
Discharge Medications:
1. PredniSONE 100 mg PO EVERY OTHER DAY
2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
3. Torsemide 20 mg PO BID
4. Amoxicillin 1000 mg PO Q12H Duration: 10 Days
RX *amoxicillin 500 mg 2 tablet(s) by mouth twice a day Disp #*9
Tablet Refills:*0
5. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Hydrocortisone Acetate 10% Foam 1 Appl PR TID
7. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Mycophenolate Mofetil 500 mg PO BID
RX *mycophenolate mofetil 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
9. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
10. Tacrolimus 3 mg PO Q12H
RX *tacrolimus 1 mg 3 capsule(s) by mouth q. 12 hrs Disp #*90
Capsule Refills:*0
11. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
12. Outpatient Lab Work
CBC, ___, BMP, Tacrolimus level
On ___, please fax result to PCP:
___
___: ___
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1) Pulmonary Embolism
2) Lupus Nephritis
3) Anemia
4) H. pylori
5) Abdominal pain, likely gastritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the hospital with shortness of breath and
found to have a pulmonary embolism. You were treated with blood
thinners and have recovered well. You are being discharged on a
blood thinner called Warfarin, which will need to be monitored
by your doctor using weekly blood tests. The doses may have to
be adjusted over time.
You were also diagnosed with lupus nephritis causing a condition
called nephrotic syndrome. This condition is being treated with
water pills and immunosupressant medicines. Because these may
affect your kidney, you will have to be followed by a
nephrologist (kidney doctor) and your primary care provider
should do some lab tests as soon as you are seen.
You were also diagnosed with H. pylori, an infection of the
stomach that can cause irritation and ulcers. You have been
prescribed antibiotics to treat this infection.
Because you have had recurrent stomach pain, you got an
endoscopy to look at your stomach and small intestine. This
procedure showed gastritis, an inflammation of the stomach
lining which can cause pain and stomach upset. It is treated
with a drug called a proton-pump inhibitor, which you have taken
in the hospital and will continue after discharge. You have an
appointment to follow up with the gastroenterology doctors.
___ you for letting us participate in your care,
Your ___ care team
Followup Instructions:
___
|
10866613-DS-9
| 10,866,613 | 27,034,155 |
DS
| 9 |
2180-10-10 00:00:00
|
2180-10-10 14:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
Aspirin / Naprosyn / Ibuprofen / Tylenol-Codeine #3 / Percocet /
Roxicet / Ultram / Neurontin / Vicodin / Influenza Virus
Tri-Split / Tramadol / Aspirin / Adhesive / Valium / peppers
(green and red) / Dilaudid
Attending: ___.
Chief Complaint:
left upper arm incision with malodorous drainage, + fevers
Major Surgical or Invasive Procedure:
___
Ultrasound-guided drainage of left axillary abscess
History of Present Illness:
___ yo female with PMH significant for HTN, morbid obesity and
prior DVT on prophylactic lovenox s/p panniculectomy, primary
repair of multiple small ventral hernias, bilateral
brachioplasty ___ ___ with prolonged
postoperative course due to difficulty mobilizing and pain
management p/w fever to ___ yesterday and malodorous drainage
from LUE. She was seen in clinic on ___nd
abdominal drain removed. Then, had fevers up to 101.7, chills
and malaise so she presented to outside hospital who transferred
patient to ___. She also complains of a "knot" in left thigh
and burning sensation in right thigh in region of her lovenox
injection sites.
Past Medical History:
___: stress test ___ atypical anginal type sx in absence of
ischemic egg changes, ECHO in ___ LVEF 65%, heart murmur,
HTN, asthma (mod- severe, well controlled), bronchitis, OSA
(BiPAP), occasional headaches, left ankle ligamentous injury, DM
(borderline), ulcers/gastritis, reflux, idiopathic urticaria,
h/o DVT ___ s/p surgery (treated w/ Coumadin x ? ___ months),
anxiety/anger/ depression, obesity (BMI 44.6)
.
PSH: trigger finger release ___, left shoulder RTV repair, c/s
x 2, right knee scope
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical exam per Plastic Surgery Consult Note ___:
99.9, 110, 95/50, 26, 99% RA
Gen: NAD, A&Ox3, lying on stretcher.
HEENT: Normocephalic.
CV: RRR
R: Breathing comfortably on room air. No wheezing.
Ext: WWP.
RUE: incision cdi, well approximated, no dehiscence of incision,
no obvious fluid collections.
LUE: Incision well approximated with small dehiscence in axilla
with malodorous seropurulent drainage, no frank pus. No obvious
pocked but axilla/chest wall portion of incision is tender and
firm.
Bilateral thigh ecchymosis from lovenox. No calf tenderness.
Palpable radial, DP bilaterally. No significant ___ edema but
bilaterally obese LEs.
Pertinent Results:
ADMISSION LABS:
___ 02:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-NEG
___ 02:45PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 02:45PM URINE GRANULAR-2*
___ 02:45PM URINE MUCOUS-RARE*
___ 03:29AM LACTATE-1.3
___ 03:26AM GLUCOSE-121* UREA N-17 CREAT-1.3* SODIUM-135
POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-19* ANION GAP-16
___ 03:26AM estGFR-Using this
___ 03:26AM WBC-18.9* RBC-3.25* HGB-8.7* HCT-27.9* MCV-86
MCH-26.8 MCHC-31.2* RDW-13.5 RDWSD-42.2
___ 03:26AM NEUTS-84.4* LYMPHS-7.7* MONOS-6.0 EOS-1.1
BASOS-0.2 IM ___ AbsNeut-15.96* AbsLymp-1.45 AbsMono-1.13*
AbsEos-0.20 AbsBaso-0.04
___ 03:26AM PLT COUNT-529*
.
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-8.6 RBC-2.69* Hgb-7.0* Hct-23.1*
MCV-86 MCH-26.0 MCHC-30.3* RDW-14.1 RDWSD-44.1 Plt ___
.
IMAGING:
Radiology Report UNILAT LOWER EXT VEINS LEFT Study Date of
___ 3:25 AM
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
.
Radiology Report UNILAT LOWER EXT VEINS RIGHT Study Date of
___ 5:34 AM
IMPRESSION:
1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. Nonspecific fluid in the subcutaneous tissues in the area of
panniculectomy could be postsurgical. No drainable fluid
collection.
.
Radiology Report US EXTREMITY LIMITED SOFT TISSUE LEFT Study
Date of ___ 5:35 AM
IMPRESSION:
Complex fluid collections measuring 2.4 x 1.3 x 2.0 cm in the
medial left
upper extremity and 9.4 x 6.6 x 4.6 cm in the lateral left upper
torso could represent postsurgical fluid collections such as
hematomas. However, in the proper clinical setting, abscess or
superimposed infection cannot be excluded.
.
Radiology Report US ABD LIMIT, SINGLE ORGAN Study Date of
___ 8:28 AM
IMPRESSION:
No definite drainable fluid collection.
.
Radiology Report PERC IMAGE GUID FLUID COLLECT DRAIN W CATH
(ABSC,HEMA/SEROMA,LYMPHOCELE,CYST),SOFT TISSUE (EXTREM,ABD
WALL,NECK) Study Date of ___ 2:11 ___
IMPRESSION:
Successful US-guided drainage and placement of ___ pigtail
catheter into the left axillary collection. Samples sent for
microbiology evaluation.
.
Radiology Report CT ABD & PELVIS WITH CONTRAST Study Date of
___ 2:29 ___
IMPRESSION:
1. Post ventral hernia repair and panniculectomy with anterior
lower abdominal subcutaneous drain in situ. There is extensive
surrounding subcutaneous edema, with areas of more confluent
edema/fluid noted along the course of the drain. No organized
fluid collections.
2. No intraperitoneal free fluid, fluid collections or
pneumoperitoneum.
.
MICROBIOLOGY:
___ 3:15 pm FLUID,OTHER Site: HEMATOMA LEFT UPPER.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
___ with complaints of foul smelling drainage from left
brachioplasty incision and fevers over 101. Patient was sent to
ultrasound where a fluid collection was seen beneath left
brachioplasty incision. A needle was inserted and 100 cc of dark
brown fluid was drained with a sample sent for microbiology
evaluation and a pigtail drain left in place. The patient
tolerated the procedure well.
.
Neuro: The patient received oral pain medications with good
pain control noted.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: The patient was given IV fluids for support while NPO
and then diet was advanced when appropriate, which was tolerated
well. She was also started on a bowel regimen to encourage bowel
movement. Intake and output were closely monitored.
.
ID: The patient was initially started on IV cefazolin and
vancomycin, then switched to vancomycin, cefepime and flagyl on
hospital day #2. For discharge home, patient was given a 10 day
course of bactrim and cipro. In addition, patient complained of
symptoms of vaginal yeast infection on day of discharge. She
was given a 3 day course of Terconazole suppositories. The
patient's temperature was closely watched for signs of
infection.
.
Prophylaxis: The patient received subcutaneous lovenox 60mg,
and was encouraged to get up and ambulate as early as possible.
She was given a 10 day course of lovenox on discharge.
.
At the time of discharge on hospital day #5, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. Left axillary ___ pigtail drain with dark
brown fluid draining. Left axillary wound clean and dressed
with clean dressing daily. Abdominal JP with creamy to serous
fluid draining.
Medications on Admission:
1. Acetaminophen 1000 mg PO Q8H
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation Q8H:PRN
3. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
4. Celecoxib 100 mg oral BID
5. Cetirizine 10 mg PO BID
6. Vitamin D ___ UNIT PO 1X/WEEK (MO)
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Hydrocortisone Cream 2.5% 1 Appl TP BID
9. Lidocaine 5% Ointment 1 Appl TP BID
10. Lisinopril 10 mg PO DAILY
11. Miconazole Powder 2% 1 Appl TP BID
12. Montelukast 10 mg PO DAILY
13. Xolair (omalizumab) 150 mg subcutaneous EVERY 2 WEEKS
14. Omeprazole 20 mg PO DAILY
15. Tizanidine 8 mg PO QHS
16. Topiramate (Topamax) 100 mg PO BID
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*20 Tablet Refills:*0
3. Enoxaparin Sodium 60 mg SC Q24H
RX *enoxaparin 60 mg/0.6 mL 60 Mg subcutaneous once a day Disp
#*10 Syringe Refills:*0
4. Morphine Sulfate ___ 15 mg PO Q4H:PRN Pain - Moderate
RX *morphine 15 mg 1 tablet(s) by mouth every ___ hours Disp
#*14 Tablet Refills:*0
5. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth every twelve (12) hours Disp #*40 Tablet Refills:*0
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
7. Cetirizine 10 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Montelukast 10 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Tizanidine 8 mg PO QHS
12. Topiramate (Topamax) 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
LUE incisional hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Personal Care:
1. You may remove your dressings after 48 hours post surgery.
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
Dr. ___.
.
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 Dr. ___.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
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 antibiotics 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 drains 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:
___
|
10866696-DS-5
| 10,866,696 | 29,593,717 |
DS
| 5 |
2177-11-24 00:00:00
|
2177-11-24 14:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cephalexin
Attending: ___.
Chief Complaint:
1. Hypomagnesemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male history of A. fib on Coumadin, pacemaker,
chronic diarrhea with history of low magnesium sent in by his
PCP for electrolyte derangement and elevation of his creatinine.
Patient discontinued his magnesium a week ago and now developed
worsening diarrhea in the last few days. On ___, he began
having loose brown stools with accompaning lower left and right
quadrant abdominal pain. Stools were non-bloody and gradually
became watery bowel movements. He notes that he was going around
six times a day. He endorses accompanying increased malaise and
decreased appetite. He denies f/c/n/v, chest pain, shortness of
breath, dysuria, hematuria, joint/muscle pain. He took two
Immodium yesterday and feels like the diarrhea has gotten better
- his last bowel movement last night resulted in formed stool.
Of note, his INR at a check on ___ was 6. He stopped his
coumadin for 3 days and resumed it on ___. Yesterday, he saw
his PCP who evaluated him for his low magnesium.
In the ED, initial vitals: 97.4 84 130/69 20 97% RA
Vitals prior to transfer: 74 121/68 23 100% RA
On admission he felt well.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No cough, no
shortness of breath, no dyspnea on exertion. No chest pain or
palpitations. No nausea or vomiting. No diarrhea or
constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits.
Past Medical History:
DVT on coumadin, afib/flutter
pacemaker
HTN
Hx of chronic DVT and PE on coumadin
Hyperlipidemia
Chronic Diarrhea
Hypernatremia, currently seeing Dr. ___, ?Central DI
?MVP
Social History:
___
Family History:
Family history of cardiac problems in mother, died her ___, 1
sister who died in her ___, and other siblings. No hx of
arrythmias, sudden cardiac death, early coronary disease.
Physical Exam:
ADMISSION PHYSICAL:
Vitals- 97.9 124/60 74 18 99%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, Systolic murmur present
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL:
Vitals: 98.2 143/55 53 18 98%RA
Weight 79.7 kg
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
HEART - RRR, nl S1-S2, systolic murmur
LUNGS - CTAB
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no CVA tenderness
EXTREMITIES - WWP, no c/c, no edema, 2+ peripheral pulses
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
ADMISSION LABS AND IMAGING:
___ 07:20AM NEUTS-77.2* LYMPHS-12.9* MONOS-5.8 EOS-3.8
BASOS-0.3
___ 07:20AM WBC-10.9 RBC-3.66* HGB-11.7* HCT-36.5*
MCV-100* MCH-31.9 MCHC-32.0 RDW-13.4
___ 07:20AM ALBUMIN-3.8 CALCIUM-6.9* PHOSPHATE-3.7
MAGNESIUM-0.9*
___ 07:20AM ALT(SGPT)-13 AST(SGOT)-42* ALK PHOS-90 TOT
BILI-0.4
___ 07:20AM GLUCOSE-90 UREA N-38* CREAT-3.0* SODIUM-138
POTASSIUM-6.0* CHLORIDE-104 TOTAL CO2-20* ANION GAP-20
___ 07:52AM ___ PTT-32.4 ___
___ 08:36AM K+-4.0
___ 09:35AM URINE RBC-5* WBC-37* BACTERIA-FEW YEAST-NONE
EPI-0
___ 09:35AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 09:35AM URINE OSMOLAL-241
___ 09:35AM URINE HOURS-RANDOM CREAT-51 SODIUM-44
POTASSIUM-18 CHLORIDE-45
___ RENAL ULTRASOUND: Dilated left renal pelvis with
caliectasis and mild prominence of the right renal pelvis,
unchanged from the CT of ___ and progressed from ___. Bilateral simple renal cysts.
DISCHARGE LABS:
___ 08:19AM BLOOD WBC-8.0 RBC-3.28* Hgb-10.6* Hct-32.7*
MCV-100* MCH-32.2* MCHC-32.3 RDW-13.1 Plt ___
___ 08:19AM BLOOD ___ PTT-32.0 ___
___ 08:19AM BLOOD Plt ___
___ 08:19AM BLOOD Glucose-91 UreaN-20 Creat-2.1* Na-144
K-4.8 Cl-110* HCO3-23 AnGap-16
___ 01:17PM BLOOD ALT-9 AST-19 AlkPhos-81
___ 08:19AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.9
___ 08:17AM BLOOD Folate-11.3
___ 11:18AM BLOOD Vit___-___*
Brief Hospital Course:
Mr. ___ is an ___ male with history of afib on
Coumadin, pacemaker, chronic diarrhea with history of low
magnesium sent in by his PCP for electrolyte derangement and
elevation of his creatinine. On admission, he was found to have
low magnesium, low calcium, and an elevated creatinine of 3.0
above his baseline of around 1.2. He additionally had had
diarrhea of several days that was an acute change in his normal
diarrhea.
ACTIVE ISSUES:
# Diarrhea - Self-limited acute diarrhea on chronic diarrhea.
Patient has loose stools at baseline given magnesium
supplementation. Acute episode of 2 days - watery stools with
abdominal pain but no other associated systemic symptoms such as
fevers/nausea/vomiting. This is most likely a viral
gastroenteritis. Low suspicion for bacterial gastroenteritis or
chronic GI issue. Diarrhea might have caused dehydration thus
explaining the rise in creatinine. Over the course of his
admission, he was given IV fluids and was able to take a normal
diet. Did not have any more episodes of watery diarrhea.
# Acute kidney injury - Rise in creatinine likely due to
prerenal cause / dehydration in the setting of his diarrhea.
Urine sediment was examined with a renal fellow, which showed
WBCs and rare WBC casts. The differential diagnosis for
sediment findings includes pyelonephritis vs acute interstitial
nephritis, with the most likely medication culprit being
omeprazole. Urine cultures were pending at the time of
discharge. He had no signs / symptoms of urinary tract
infection, so he was not treated with antibiotics. He was IV
fluids and creatinine improved to 2.1 upon discharge. Renal U/S
unconcerning for acute obstructive process but shows evidence of
uteropelvic junction obstruction, stable from ___.
# Electrolyte Abnormalities (Hypomagnesemia, Hypocalcemia) - Mr.
___ presented with an Mg of 0.9. This is a chronic issue for
Mr. ___ although his use of a PPI and daily alcohol intake
might contribute. This acute decrease in Mg is potentially due
to the exacerbation of his diarrhea. He was repleted with Mg and
Ca. His Mg and Ca normalized. The remainder of his stay with
respect of electrolyte abnormalities was unremarkable.
#Supratherapeutic INR - Supratherapeutic INR possible in the
setting of diarrhea and thus quick gut motility and impaired
absorption of vitamin K (coag factor). His warfarin was held due
to his admission INR of 3.3. The team obtained daily coags and
he was eventually placed back on warfarin 2.5 mg daily after
discussion with ___ anticoagulation team.
CHRONIC ISSUES
#Afib - On coumadin 2.5 mg daily. See above for plan on
supratherapuetic INR
#HTN - Held lisinopril for concern of kidney injury. Continue
with home metoprolol
#HLD - Continue Lipitor 20 mg tablet
#Macrocytic anemia, chronic - Given folic acid and vitamin B12.
TRANSITIONAL ISSUES
- Please review causes of chronic diarrhea with Mr. ___. His
use of Sweet and Low (sucralose) can perpetuate diarrhea as well
as some chewing gum that he frequently uses.
- Ensure follow up at ___ clinic to ensure therapeutic INR
(___)
- Follow-up Mg and Ca levels
- Omeprazole was discontinued because of hypomagnesemia and
possible acute interstitial nephritis
- Urine cultures pending upon discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 30 mg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Warfarin 2.5 mg PO DAILY16
5. Citracal + D (calcium phosphate-vitamin D3) 250 mg calcium-
250 unit oral daily
6. Vitamin D 1000 UNIT PO DAILY
7. magnesium gluconate 27 mg (500 mg) oral BID
8. Omeprazole 40 mg PO DAILY
9. B-12 DOTS (cyanocobalamin (vitamin B-12)) 1000 mcg oral BID
Discharge Medications:
1. Atorvastatin 30 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Citracal + D (calcium phosphate-vitamin D3) 250 mg calcium-
250 unit oral daily
5. B-12 DOTS (cyanocobalamin (vitamin B-12)) 1000 mcg oral BID
6. magnesium gluconate 27 mg (500 mg) oral BID
7. Loratadine 10 mg PO DAILY
8. Warfarin 2.5 mg PO DAILY16
9. Outpatient Lab Work
Diagnosis: Atrial fibrillation 427.31, Acute kidney injury
584.9
Labs: ___ - Check INR, Chem10
Fax to PCP: ___, Dr. ___
Discharge Disposition:
Home
Discharge Diagnosis:
1.) Hypomagnesemia
2.) Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for choosing ___ for your care. You were admitted
for concern of low magnesium and a rising creatinine (indicative
of kidney injury).
You have a history of low magnesium for which you take daily
supplementation. It is possible that your recent diarrhea has
exacerbated your low Mg as well as your Prilosec and alcohol
use. During your stay we repleted your with more Magnesium to
reach the appropriate levels. Additionally, your calcium was low
which we also corrected.
We also explored causes for your rising creatinine. Certainly,
your recent diarrhea and thus dehydration can cause an increase
in this number. For this you were given IV fluids. We did,
however, explore other causes of kidney injury such as infection
or an obstruction. Your kidney ultrasound demonstrated that
there was no obstruction and you did not have signs on an
infection.
It was a pleasure to take care of you. We wish you the very
best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10866777-DS-18
| 10,866,777 | 27,487,266 |
DS
| 18 |
2137-09-04 00:00:00
|
2137-09-07 01:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
IV Dye, Iodine Containing Contrast Media / shrimp, lobster /
peanuts / Skelaxin / morphine
Attending: ___
Chief Complaint:
back ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old right-handed man with history of lumbar stenosis s/p
multiple surgeries who present with worsening back ___ and
inability to ambulate.
His last surgery was ___ years ago and he had been doing ok until
this ___. His issues had been mainly with the left side, and
he felt left foot is starting to improve. ___ had wanted to
fuse his back due to "instability." At baseline has muscle
spasms
in hip and cramping in leg.
___, back felt tight, so went to the ___ and did his usual
exercises and hot tub. Thought it might be due to carrying the
commode up and down. It got worse over the weekend, radiating to
thighs and left foot feels like there is rubber band on it with
pins and needles in the toes.
This morning, he got up and could not walk due to spasms and
losing balance. He grabbed onto something and cruised to the
bathroom and back. Had slept in back brace overnight.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest ___ or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal ___. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- Lumbar radiculopathy s/p 2 surgeries at ___ with Dr. ___
in ___
- Ruptured ___ s/p anterior decompression/fusion in ___
- L gastroc rupture
- L Antecubital tunnel syndrome s/p ulnar nerve transposition
- Shingles - history of rashes on different distributions per
patient, on chronic suppressive therapy
Social History:
___
Family History:
Mother with DM, blind ?macular degeneration vs. retinal tear,
CAD
and lymphoma; passed away on ___
Father with bladder cancer and strokes; passed away ___
Twin sister - hypoglycemic, ?heart condition
Niece - cystic fibrosis, insulin dependent diabetes
Physical Exam:
Admission Physical Exam
Vitals: 97.5 75 127/78 20 100% RA
General: Awake, cooperative, NAD at rest; ___ with movement.
HEENT: NC/AT
Neck: Decreased range of motion in all directions
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to person, place and off by one
on date. Able to relate history without difficulty. Attentive,
able to name ___ backward without difficulty. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were no paraphasic errors. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of left-right confusion as the patient was able to
accurately follow the instruction to touch left ear with right
hand.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk; left palpebral fissure slightly
smaller than right. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal tone throughout. Decreased bulk in hands/feet. No
pronator drift bilaterally. No adventitious movements, such as
tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO |IP*Quad Ham TA Gastroc** ___
L 5 5 4+ 5 4+ 4+ 4 |4 5 4 4 5- 3 4
R 5 ___ ___ |4 5 4+ 5 5 4 4
Bilateral FDI/APB atrophy and weakness.
*IP somewhat ___ limited with some give away; Hip ADduction
4+/5, Hip ABduction 4+/5; toe flexor 4+/5
**history of left gastroc tear
-Sensory: No deficits to light touch, pinprick, cold sensation
throughout. Decreased vibration at the big toes bilaterally,
normal at the ankles. Proprioception dimished at left big toe
only. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 0 2 1+ 0
R 2 2 2 1+ 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Deferred given ___.
DISCHARGE EXAM: On exam today, strength is ___, but
appears full
throughout except for chronic ___ weakness. He is able to
walk,
antalgic gait but otherwise without overt weakness or imbalance.
Pertinent Results:
Studies:
140 107 18
-------------< 114
3.9 25 0.8
estGFR: >75 (click for details)
6.5 > 13.1/38.0 < 132
N:82 Band:2 ___ M:4 E:3 Bas:0
Anisocy: OCCASIONAL
Plt-Est: Low
Lumbar x-ray:
AP and lateral views of the lumbar spine were obtained. There
is
very minimal retrolisthesis of L3 over L4 and L4 over L5. There
is also minimal arthrosis of L2 over L3. Disc space narrowing is
seen at L2-L3. Vertebral body heights are maintained without
evidence acute fracture. Multi-level anterior osteophytes are
seen, including at L3 and L4. The sacroiliac joints are intact.
Aortic calcifications are seen. There also pelvic phleboliths.
MRI LUMBAR SPINE
FINDINGS:
Lumbar spine alignment is unchanged with minimal retrolisthesis
of L3 with
respect to L4 and L4 with respect L5. Bone marrow signal is
diffusely
heterogeneous without focal suspicious abnormality. Vertebral
body heights are
preserved. There is loss of disc space height and signal
diffusely throughout
the lumbar spine.
The conus medullaris is normal in morphology and signal
intensity and
terminates at the level of L1-L2. The cauda equina demonstrates
normal
morphology is well. There is no abnormal enhancement of the
nerve roots.
T12-L1 and L1-L2: No significant spinal canal or neural
foraminal narrowing is
present.
L2-L3: There is minimal disk bulging and facet degenerative
changes without
significant spinal canal or neural foraminal narrowing.
L3-L4: There is mild disc bulging, facet hypertrophy and
thickening of the
ligamentum flavum causing mild narrowing of the subarticular
zones. The disc
bulge contacts the traversing left L4 nerve root. The neural
foramina are
patent.
L4-L5: There is a mild diffuse disc bulge and facet degenerative
changes
causing mild narrowing of the subarticular zones. The disc bulge
contacts the
bilateral traversing L5 nerve roots. A small enhancing disc
fragment or scar
tissue is present in the left subarticular recess as seen
previously. There is
mild bilateral neural foraminal narrowing.
L5-S1: There is no significant spinal canal or neural foraminal
narrowing.
Mild facet degenerative changes are present.
IMPRESSION:
Multilevel degenerative changes above, not significantly changed
from the
previous examination. There is no high-grade spinal canal or
neural foraminal
narrowing.
Brief Hospital Course:
Mr. ___ is a ___ year old right-handed man with history of
lumbar radiculopathy s/p multiple lumbar surgeries who presented
with worsening back with anterior leg and groin ___. He was
ordered for an x-ray of the lumbar spine and an MRI L-spine that
demonstrated widespread degenerative changes without severe
foraminal narrowing or stenosis. His ___ improved with the
combination of NSAIDs, tramadol, snd cyclobenzaprine. He worked
with physcial therapy and has been able to walk, although he
develops spasms of the paraspinal muscles after walking.
His ___ is most likely related to lumbar strain without
evidence of frank radiculopathy and he appears to have an
element of meralgia paresthetica as well. We decided to
dicharge on a brief standing course of naproxen and tramadol,
with prn
cyclobenzaprine for spasms. He has an appointment in the ___
clinic on the afternoon of discharge to discuss injection
therapy. Follow-up will also be arranged in clinic with Dr.
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ValACYclovir 1000 mg PO Q24H
2. Allegra-D 12 Hour (fexofenadine-pseudoephedrine) 60-120 mg
oral daily
3. fluticasone 50 mcg/actuation nasal daily
Discharge Medications:
1. ValACYclovir 1000 mg PO Q24H
2. fluticasone 50 mcg/actuation nasal daily
3. Allegra-D 12 Hour (fexofenadine-pseudoephedrine) 60-120 mg
oral daily
4. Cyclobenzaprine 10 mg PO TID:PRN spasms
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*1
5. TraMADOL (Ultram) 50 mg PO BID
RX *tramadol 50 mg 1 tablet(s) by mouth twice daily Disp #*15
Tablet Refills:*0
6. Naproxen 500 mg PO Q12H
RX *naproxen 500 mg 1 tablet(s) by mouth twice per day Disp #*15
Tablet Refills:*0
7. Outpatient Physical Therapy
Please evluate and treat low back ___ and gait instability
Discharge Disposition:
Home
Discharge Diagnosis:
meralgia parasthetica
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 ___ on ___ with
worsening back ___ and gait instability. We did an MRI of
your spine that showed old degenerative changes but no acute
pathology. While you were admitted we controlled your ___ with
IV toradal, and added a muscle relaxant called flexeril. Dr.
___ you in the hospital and felt that your symptoms were
most consistent with a diagnosis of meralgia paresthetica, which
is syndrome caused by impingement of the nerves along your upper
legs. Prior to discharge, we converted you to oral tramadol
and naproxen that we will have you taper over the course of 10
days. The combination of these medications improved your ___
to a manageable level and you were able to work with physical
therapy, who felt that you were safe for discharge home with
home ___. We arranged a clinic appointment at the ___
___ this afternoon, at which time you can discuss the
possibility of local injections for ___ relief.
Your dishcarge medication plan:
1) NAPROXEN 500mg BID for be take twice daily for 5 days, then
once daily for 5 days, then STOP
2) TRAMADOL 50 BID for be take twice daily for 5 days, then
once daily for 5 days, then STOP
3) FLEXERIL 10mg TID prn
4) We will give you a prescription for further outpatient
physical therapy
It was a pleasure to take care of you during this
hospitalization.
Followup Instructions:
___
|
10867055-DS-14
| 10,867,055 | 23,516,382 |
DS
| 14 |
2169-10-23 00:00:00
|
2169-10-23 13:52:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Tylenol / Penicillins
Attending: ___.
Chief Complaint:
Leukocytosis
Major Surgical or Invasive Procedure:
___: Successful placement of 8 ___ catheter
into organized splenectomy bed 8.9 cm collection.
History of Present Illness:
___ with ITP & autoimmune hemolysis s/p lap splenectomy ___,
discharged home on ___, presenting with leukocytosis. He was
seen by Dr. ___ for his first postop visit. At that
time, his L abdominal ___ drain was noted to have migrated; it
was replaced with a red rubber catheter. Lab results drawn ___
were then called into Dr. ___. These revealed a WBC
of 23; pt was then contacted and asked to return to the ED. Of
note, WBC was 24.9 on discharge ___. Pt reports persistent
abdominal pain since his operation. It has worsened since his
drain was exchanged yesterday; however, prior to that, he had
not thought it to be worse than upon discharge.
No fevers,chills,nausea, or vomiting.
Past Medical History:
1. History of alcoholism.
2. History of IV drug use.
3. Hepatitis C virus.
4. History of alcoholic pancreatitis.
5. COPD with a 35-pack-year history of smoking.
6. GERD.
7. DVT.
Social History:
___
Family History:
His father died of lymphoma.
Mother had hypertension.
Physical Exam:
Vitals: 98.9, 65, 136/78, 16, 95% RA
Gen: NAD, A&O, nontoxic appearance
___: RRR
Pulm: CTA b/l
Abd: soft, non-distended, non-tympanitic, drain intact in left
flank: small amount of brownish fluid in bag
Ext: no c/c/e
Pertinent Results:
___ 06:20AM BLOOD WBC-24.8* RBC-4.30* Hgb-12.6* Hct-37.6*
MCV-87 MCH-29.2 MCHC-33.4 RDW-14.3 Plt ___
___ 07:00AM BLOOD WBC-27.5* RBC-4.01* Hgb-11.5* Hct-35.5*
MCV-89 MCH-28.7 MCHC-32.5 RDW-14.3 Plt ___
___ 06:30AM BLOOD WBC-33.7* RBC-4.11* Hgb-12.1* Hct-36.5*
MCV-89 MCH-29.3 MCHC-33.0 RDW-14.4 Plt ___
___ 07:00AM BLOOD WBC-37.6* RBC-4.70 Hgb-14.0 Hct-41.6
MCV-89 MCH-29.7 MCHC-33.6 RDW-14.7 Plt ___
___ 12:08PM BLOOD WBC-28.4* RBC-5.06 Hgb-14.8 Hct-45.1
MCV-89 MCH-29.3 MCHC-32.9 RDW-14.6 Plt ___
___ 07:00AM BLOOD Glucose-60* UreaN-8 Creat-0.7 Na-140
K-4.4 Cl-95* HCO3-29 AnGap-20
___ 01:45PM BLOOD ALT-54* AST-56* AlkPhos-143* Amylase-49
TotBili-0.9
___ 06:20AM BLOOD Vanco-17.7
___ 11:37AM ASCITES Amylase-2048
___ 12:00 pm FLUID,OTHER PERISPLENIC FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
Reported to and read back by ___ ON ___ @ 415
___.
FLUID CULTURE (Preliminary):
ENTEROBACTER CLOACAE COMPLEX. HEAVY GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
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
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
___ 06:40AM BLOOD WBC-17.8* RBC-4.84 Hgb-13.8* Hct-42.7
MCV-88 MCH-28.6 MCHC-32.4 RDW-14.3 Plt ___
___ 07:00AM BLOOD Glucose-60* UreaN-8 Creat-0.7 Na-140
K-4.4 Cl-95* HCO3-29 AnGap-20
___ ABD CT:
IMPRESSION:
Rim-enhancing fluid collection at the left splenectomy bed with
adjacent clips and surrounding fat stranding measuring up to 8.7
cm. There is stranding surrounding the course of the drain
which appears to terminate at the lateral edge of the
collection.
Brief Hospital Course:
Mr ___ is a ___ year old male with medical history of
ITP & autoimmune hemolysis s/p lap splenectomy ___,
discharged home on ___, presenting to ___ with leukocytosis
and admitted on ___. On arrival to the ED, he was afebrile
with stable vital signs. His labs were notable for WBC 28.4 and
his existing drain was putting out clear yellow-orange fluid.
He was mildly tender near the drain site. A CT-abdomen on
___ showed rim-enhancing fluid collection (8.7 cm x 4.7 cm x
3.6 cm) at the left splenectomy bed with adjacent clips and
surrounding fat stranding. On ___ he underwent ___ drainage
of this fluid collection. A ___ ___ ___ catheter was
placed near the fluid collection. He had a transient fever to
101.2 on ___ which responded to ibuprofen. He was started on
vancomycin/ciprofloxacin/flagyl post-procedure on ___. The
fluid was sent for culture and grew Gram Negative Rods,
speciated to Enterobacter cloacae that was pan-sensitive. He
remained afebrile and his WBC trended down throughout his
admission (37.6->33.7->27.5->24.8 -> 17.5). He had mildly
increased pain post-procedure near the ___ drain site so was
given a lidocaine patch. On hospital day 4, he was started on
octreotide and his prior abdominal drain was removed. The fluid
from ___ drain was sent for amylase level which was ___. Based
on his fluid cultures, his antibiotics were switched to PO
cipro, PO flagyl on hospital day 5 and he remained afebrile with
well-controlled pain. On POD # 6 WBC continued to downtrend and
drain output decreased. Octreotide was stopped and patient was
sent home with ___ in stable condition. During hospitalization
patient's Prednisone was dicreased to 5 mg qd, he was instructed
to discontinue taking Prednisone on ___.
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:
Norvasc 10', Dulcolax prn, clindamycin 300"", Colace 100",
Ativan 1 qhs, oxycodone 20 q8h prn pain, Protonix 40', Spiriva 1
cap', prednisone 10'
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*28 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Lidocaine 5% Patch 1 PTCH TD DAILY
RX *lidocaine 5 % (700 mg/patch) 1 once a day Disp #*10
Transdermal Patch Refills:*0
5. Lorazepam 1 mg PO HS:PRN insomnia
6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*42 Tablet Refills:*0
7. OxycoDONE (Immediate Release) 20 mg PO Q4H:PRN pain
RX *oxycodone 20 mg 1 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
8. Pantoprazole 40 mg PO Q24H
9. PredniSONE 5 mg PO DAILY
Last day for this medication is ___, do not take Prednisone
after that day.
10. Tiotropium Bromide 1 CAP IH DAILY
11. Ondansetron 4 mg PO Q12H:PRN nausea
RX *ondansetron HCl [Zofran] 4 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*30 Tablet Refills:*0
12. Lidocaine 5% Patch 1 PTCH TD DAILY
13. Sodium Chloride 0.9% Flush 10 mL IV DAILY
___ drain, please flush and aspirate back.
RX *sodium chloride 0.9 % [Normal Saline Flush] 0.9 % 10 mL ___
drain once a day Disp #*30 Syringe Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Infected intraadominal fluid collection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for an elevated white blood
cell count, which can indicate inflammation or infection. You
had a CT-scan which showed a fluid collection near your recent
splenectomy site. This fluid collection was drained by
interventional radiology and sent for fluid culture. We started
you on antibiotics to treat the bacteria growing in that fluid.
Your white cell count decreased throughout your stay. You will
be discharged with your drain and continue your antibiotics.
You have a follow-up appointment with Dr. ___ on ___ with
CT scan prior.
.
Call Dr. ___ office at ___ if you have any
questions or concerns.
.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
You last day of taking Prednisone is ___. Please
stop taking Prednisone after ___.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
___ Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Flush drain daily with 10 cc of NS and aspirate back.
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water or ___ strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
10867088-DS-10
| 10,867,088 | 29,464,038 |
DS
| 10 |
2114-11-25 00:00:00
|
2114-11-25 11:45:00
|
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 elbow pain
Major Surgical or Invasive Procedure:
Left distal humerus ORIF (___)
History of Present Illness:
___ s/p fall from ladder w/ L supracondylar fracture. He was
standing approx 10 fe off ground on ladder when it slipped out
from beneath him and he fell to groud. He believes that his
elbow was flexed when it struck the ground. He had immediate
severe pain, but did not have weakness or numbness. No LOC. Only
current pain is in L elbow. Orthopedics due to suspicion for L
elbow fracture.
Past Medical History:
None
Social History:
___
Family History:
NC
Physical Exam:
In general, the patient is awake, alert, in NAD.
Vitals: HR 80 BP 120/70 RR 18 O2 94% RA
Right upper extremity:
Skin intact
Soft, non-tender arm and forearm
Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Left upper extremity:
Significant swelling over L elbow w/ diffuse TTP & pain w/ any
ROM. 5mm wound w/ oozing over extensor surface. Deformed.
Full, painless AROM/PROM of shoulder wrist, and digits
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Pertinent Results:
___ 01:00PM ___ PTT-28.6 ___
___ 11:15AM LACTATE-1.4
___ 11:00AM GLUCOSE-108* UREA N-16 CREAT-0.8 SODIUM-136
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-23 ANION GAP-14
___ 11:00AM WBC-13.3*# RBC-4.92# HGB-15.6# HCT-46.8#
MCV-95 MCH-31.8 MCHC-33.4 RDW-13.0
___ 11:00AM NEUTS-86.5* LYMPHS-7.3* MONOS-5.1 EOS-0.6
BASOS-0.4
___ 11:00AM PLT COUNT-259
___ 11:00AM ___ TO PTT-UNABLE TO ___
TO
___ 09:30AM GLUCOSE-77 UREA N-11 CREAT-0.4* SODIUM-148*
POTASSIUM-2.4* CHLORIDE-126* TOTAL CO2-18* ANION GAP-6*
___ 09:30AM estGFR-Using this
___ 09:30AM WBC-6.0 RBC-3.32* HGB-10.6* HCT-31.7* MCV-95
MCH-31.9 MCHC-33.4 RDW-12.7
___ 09:30AM NEUTS-70.0 ___ MONOS-5.7 EOS-1.5
BASOS-0.2
___ 09:30AM PLT COUNT-190
___ 09:30AM ___ PTT-29.7 ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an open left supracondylar distal humerus fracture and
was admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for L distal humerus ORIF
(___), which the patient tolerated well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
Musculoskeletal: Prior to operation, patient was NWB LUE.
After procedure, patient's weight-bearing status remained NWB
LUE with range of motion as toelrated. Throughout the
hospitalization, patient worked with occupational therapy. The
patient was transitioned to a removable posterior orthoplast
splint for comfort while sleeping with instructions to come out
of the splint often to range at the elbow.
Neuro: Post-operatively, patient's pain was controlled by
dilaudid PCA and was subsequently transitioned to dilaudid PO/
tizanidine/ tylenol with good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient was not transfused blood products.
Hematocrits remained stable.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received Ancef for open fracture and
perioperative prophylaxis. The patient's temperature was closely
watched for signs of infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and 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, voiding without assistance, and pain
was well controlled. The incision was clean, dry, and intact
without evidence of erythema or drainage; the extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QPM Duration: 2 Weeks
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe SC QPM Disp #*14 Syringe
Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *Dilaudid 2 mg ___ tablet(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
5. Tizanidine 4 mg PO TID Pain, spasm
RX *tizanidine 4 mg 1 capsule(s) by mouth three times a day Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left open distal humerus 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.
- Posterior orthoplast splint for comfort. Please remove splint
often and range at elbow.
ACTIVITY AND WEIGHT BEARING:
- NWB LUE, range of motion as tolerated
Followup Instructions:
___
|
10867180-DS-19
| 10,867,180 | 21,186,327 |
DS
| 19 |
2177-04-05 00:00:00
|
2177-04-05 18:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Reglan / Compazine
Attending: ___
Chief Complaint:
abdominal pain, Nausea Vomiting
Major Surgical or Invasive Procedure:
___ ___ abscess drain placement
History of Present Illness:
___ PMH longstanding Crohns s/p total proctocolectomy w/ end
ileostomy, urostomy, presenting with 24 hours of nausea,
vomiting, and abdominal pain. She states that she was first
diagnosed with Crohns decades ago ___ years), and that she
underwent a 2-stage total proctocolectomy for Crohns many
decades
ago with Dr. ___ at ___. She subsequently developed
necrosis of her bladder and underwent a urostomy. She then went
many years without any medication for her Crohns disease. More
recently she developed mild small bowel obstructions, which she
was mostly able to manage at home with bowel rest. Occasionally
she would seek care at ___. These episodes have been
worsening in frequency and intensity over the past year. Her
gastroenterologist, Dr. ___ at ___, started her on
Remicade in ___ (last dose 2 weeks ago). She was also started
on
steroids. She is currently tapering down from 40 to 30mg of
prednisone.
Her acute complaints began yesterday afternoon, when she noticed
decreased output of stool and gas from her ileostomy in the late
afternoon. She quickly developed severe nausea and vomiting, and
sought care at ___. Soon after arrival her ileostomy
produced a large volume of stool, with some dark material she
thought might be blood. There a CT A/P w/ PO contrast was
performed, which showed a collection of fluid and stool in
continuity with the small bowel in the lower abdomen. She was
transferred to ___ for further care. Colorectal surgery was
consulted for further management.
On initial assessment, Ms. ___ denies fevers, chills,
shortness of breath, chest pain, or dysuria. She does endorse
nausea, recent vomiting as above, abdominal pain mostly in her
epigastrium, and L flank pain.
Past Medical History:
-Crohns s/p total proctocolectomy w/ end ileostomy
-AFib
-Iatrogenic ___
-Asthma
Social History:
___
Family History:
Noncontributory
Physical Exam:
GEN: NAD
HEENT: anicteric, ___ hump
CV: RRR
PULM: normal excursion, no respiratory distress
ABD: soft, NT, ND, no mass
EXT: WWP, no CCE, 2+ B/L radial
NEURO: A&Ox3, no focal neurologic deficits
PSYCH: normal mood/affect
WOUND:
[X] urostomy with vascular lesion on mucosa
[X] ileostomy with minimal output
[X] abdominal drain in epigastric region with bilious output
Pertinent Results:
___ 05:56AM BLOOD WBC-6.3 RBC-3.70* Hgb-10.8* Hct-34.8
MCV-94 MCH-29.2 MCHC-31.0* RDW-14.6 RDWSD-50.3* Plt ___
___ 05:31AM BLOOD WBC-8.8 RBC-3.65* Hgb-10.7* Hct-33.8*
MCV-93 MCH-29.3 MCHC-31.7* RDW-14.4 RDWSD-48.4* Plt ___
___ 05:51AM BLOOD WBC-8.8 RBC-3.53* Hgb-10.3* Hct-33.0*
MCV-94 MCH-29.2 MCHC-31.2* RDW-14.3 RDWSD-48.7* Plt ___
___ 05:33AM BLOOD WBC-9.0 RBC-3.33* Hgb-9.7* Hct-30.6*
MCV-92 MCH-29.1 MCHC-31.7* RDW-14.1 RDWSD-47.6* Plt ___
___ 05:27AM BLOOD WBC-7.2 RBC-3.36* Hgb-9.7* Hct-31.3*
MCV-93 MCH-28.9 MCHC-31.0* RDW-13.9 RDWSD-47.6* Plt ___
___ 05:43AM BLOOD WBC-7.4 RBC-3.31* Hgb-9.5* Hct-30.9*
MCV-93 MCH-28.7 MCHC-30.7* RDW-14.1 RDWSD-47.8* Plt ___
___ 07:28AM BLOOD WBC-8.6 RBC-3.43* Hgb-9.9* Hct-32.3*
MCV-94 MCH-28.9 MCHC-30.7* RDW-13.8 RDWSD-47.7* Plt ___
___ 08:40AM BLOOD WBC-7.6 RBC-3.62* Hgb-10.5* Hct-33.2*
MCV-92 MCH-29.0 MCHC-31.6* RDW-13.8 RDWSD-46.9* Plt ___
___ 08:40AM BLOOD WBC-11.4* RBC-3.71* Hgb-10.9* Hct-34.5
MCV-93 MCH-29.4 MCHC-31.6* RDW-14.6 RDWSD-49.7* Plt ___
___ 08:40AM BLOOD Neuts-70.1 ___ Monos-7.3 Eos-1.0
Baso-0.4 Im ___ AbsNeut-7.97* AbsLymp-2.32 AbsMono-0.83*
AbsEos-0.11 AbsBaso-0.04
___ 10:20AM BLOOD ___ PTT-19.0* ___
___ 05:56AM BLOOD Glucose-97 UreaN-19 Creat-0.7 Na-142
K-4.7 Cl-105 HCO3-22 AnGap-15
___ 05:31AM BLOOD Glucose-95 UreaN-13 Creat-0.7 Na-142
K-4.4 Cl-109* HCO3-20* AnGap-13
___ 05:51AM BLOOD Glucose-125* UreaN-15 Creat-0.7 Na-140
K-4.0 Cl-107 HCO3-22 AnGap-11
___ 05:33AM BLOOD Glucose-127* UreaN-15 Creat-0.7 Na-142
K-3.3* Cl-106 HCO3-25 AnGap-11
___ 05:27AM BLOOD Glucose-112* UreaN-12 Creat-0.8 Na-141
K-3.9 Cl-107 HCO3-26 AnGap-8*
___ 05:43AM BLOOD Glucose-99 UreaN-9 Creat-0.8 Na-141 K-4.0
Cl-107 HCO3-23 AnGap-11
___ 07:28AM BLOOD Glucose-112* UreaN-11 Creat-0.8 Na-141
K-4.2 Cl-104 HCO3-29 AnGap-8*
___ 08:40AM BLOOD Glucose-151* UreaN-15 Creat-0.8 Na-139
K-4.6 Cl-103 HCO3-27 AnGap-9*
___ 08:40AM BLOOD Glucose-88 UreaN-18 Creat-1.0 Na-139
K-4.4 Cl-104 HCO3-22 AnGap-13
___ 05:43AM BLOOD ALT-20 AST-12 AlkPhos-49 TotBili-0.2
___ 05:56AM BLOOD Calcium-9.1 Phos-4.6* Mg-2.1
___ 05:31AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.1
___ 05:51AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.1
___ 05:33AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.1
___ 05:27AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.3
___ 05:43AM BLOOD Albumin-3.2* Calcium-8.3* Phos-3.2 Mg-2.0
Iron-40
___ 07:28AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.2
___ 08:40AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.1
___ 05:43AM BLOOD calTIBC-252* TRF-194*
___ 08:40AM BLOOD calTIBC-306 TRF-235
Brief Hospital Course:
Ms. ___ presented to ___ due to nausea, vomiting and
abdominal pain on ___. She was found to have an abdominal
abscess demonstrated on CT scan. On ___ She had an
abdominal drain placed by Interventional Radiology. He/She
tolerated the procedure well without complications. The patient
was consented and PICC was placed for long term TPN in order to
correct her nutrition for a future operation.
Neuro: Pain was well controlled on Tylenol and oxycodone,
morphine for breakthrough pain.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulm: The patient remained stable from a pulmonary standpoint;
oxygen saturation was routinely monitored. He/She had good
pulmonary toileting, as early ambulation and incentive
spirometry were encouraged throughout hospitalization.
GI: The patient was initially started on a clear liquid diet
which she tolerated reasonably, but had some nausea and
abdominal pain. The patient was discharged as NPO and sips for
comfort, with nutrition supplementation via TPN. Patient's
intake and output were closely monitored.
GU: At time of discharge, voiding reasonably well through her
urostomy. Urine output was monitored as indicated.
ID: The patient was closely monitored for signs and symptoms of
infection and fever, of which there was none. She was initially
given IV ceftriaxone and flagyl from ___.
Heme: The patient received subcutaneous heparin and ___ dyne
boots during this stay. He/She was encouraged to get up and
ambulate as early as possible. The patient is being discharged
on prophylactic Lovenox.
ENDO: The patient was maintained on her prednisone taper. She
was tapered to 20mg QD from 30mg QD on ___. She was
instructed to continue to taper her prednisone by 5mg after
week.
On ___, the patient was discharged to home with ___
services. At discharge, he/she was tolerating TPN, passing
flatus, voiding, and ambulating independently. He/She will
follow-up in the clinic in ___ weeks. This information was
communicated to the patient directly prior to discharge.
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehab hospital disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
dispo
[x] No social factors contributing in delay of discharge.
Medications on Admission:
-ASA 325 QD
-Citalopram 20 QD
-Albuterol inhaler
-Budesonide inhaler
-Metop 50 XR QD
-Prednisone taper
-Ambien 10 QD
-Lasix 20 QD
Discharge Medications:
1. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*10 Tablet Refills:*0
2. OxyCODONE Liquid ___ mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet by mouth every four (4) hours Disp
#*10 Tablet Refills:*0
3. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
RX *sodium chloride 0.9 % 0.9 % ___ ml IV once a day
Refills:*1
4. PredniSONE 20 mg PO DAILY
Decrease by 5mg every week
Tapered dose - DOWN
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
6. Aspirin 325 mg PO DAILY
7. Citalopram 20 mg PO DAILY
8. Fluticasone Propionate NASAL 2 SPRY NU BID
9. Furosemide 20 mg PO DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Abdominal abscess
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 due to an abdominal
collection. You were given bowel rest, intravenous fluids, and
TPN. An abdominal drain was placed by Interventional Radiology.
You have been able to tolerate TPN and your pain is controlled
with pain medications by mouth.
If you have any of the following symptoms, please call the
office or go to the emergency room (if severe): increasing
abdominal distension, increasing abdominal pain, nausea,
vomiting, inability to tolerate food or liquids, prolonged loose
stool, or extended constipation.
You will be going home with your abdominal drain. Please look at
the site every day for signs of infection (increased redness or
pain, swelling, odor, yellow or bloody discharge, warm to touch,
fever). Note color, consistency, and amount of fluid in the
drain. Call the doctor, ___, or ___ nurse if the
amount increases significantly or changes in character. Be sure
to empty the drain as needed and record output. You may shower;
wash the area gently with warm, soapy water. Keep the insertion
site clean and dry otherwise. Avoid swimming, baths, hot tubs;
do not submerge yourself in water. Make sure to keep the drain
attached securely to your body to prevent pulling or
dislocation.
Your currently taking predisione 20mg daily. You will be
tapering down on the amount by 5mg every week. Staring
___ please take 15mg daily.
Thank you for allowing us to participate in your care, we wish
you all the best!
Followup Instructions:
___
|
10867180-DS-21
| 10,867,180 | 28,247,560 |
DS
| 21 |
2177-05-30 00:00:00
|
2177-05-30 17:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Reglan / Compazine / Cipro
Attending: ___.
Major Surgical or Invasive Procedure:
n/a
attach
Pertinent Results:
ADMISSION LABS
================
___ 03:00AM BLOOD WBC-4.8 RBC-3.40* Hgb-9.5* Hct-29.7*
MCV-87 MCH-27.9 MCHC-32.0 RDW-13.2 RDWSD-41.9 Plt ___
___ 03:00AM BLOOD Neuts-73* Bands-3 Lymphs-10* Monos-11
Eos-2 Baso-1 AbsNeut-3.65 AbsLymp-0.48* AbsMono-0.53 AbsEos-0.10
AbsBaso-0.05
___ 03:00AM BLOOD ___ PTT-27.2 ___
___ 03:00AM BLOOD Plt Smr-HIGH* Plt ___
___ 03:00AM BLOOD Glucose-103* UreaN-18 Creat-0.9 Na-140
K-2.8* Cl-94* HCO3-31 AnGap-15
___ 03:00AM BLOOD ALT-23 AST-29 AlkPhos-87 TotBili-0.6
___ 03:00AM BLOOD Albumin-3.4* Calcium-8.7 Phos-3.4 Mg-1.9
INTERIM:
___ 07:30 Copper103
___ 06:10 Vitamin B1 202 H
___ 07:45 Zinc 48 L
___ 11:15 Sed Rate 29
___ 07:06 Aldosterone39
___ 04:47 Aldosterone42
___ 04:47 ACTH 12
PERTINENT IMAGING
===================
___ CT ABD AND PELVIS W & W/O CONTRAST
1. There is a stable appearance status-post colectomy and end
ileostomy ___ the right lower quadrant and urostomy ___ the left
lower quadrant.
2. The anterior abdominal fluid collection is decompressed,
containing scant fluid and gas locules with a pigtail catheter
___ situ. With instillation of contrast into the pigtail drain,
there is intraluminal opacification of small bowel loops,
suggestive either fistula from the fluid collection into
small-bowel or migration of the tube into a small bowel loop.
3. Unchanged thickening and coarse trabeculations of the left
iliac bone,
consistent with Paget's disease.
4. There is a stable appearing 0.9 cm nodular opacity ___ the
right lower lobe.
___ CT ABD AND PELVIS WITH CONTRAST
-The superior pigtail drainage catheter appears to have its
pigtail within the small bowel.
-The more inferior pigtail drainage catheter appears to be
within the gas and feces containing collection ___ the anterior
abdomen which is similar ___ size when compared to the prior
study.
-Unchanged 11 mm soft tissue density lesion ___ the left kidney
for which
ultrasound is previously been recommended.
___ CXR
There is a new consolidative opacity ___ the right middle lobe
concerning for pneumonia. Heart size is normal. There is no
pleural effusion. No
pneumothorax is seen. Left-sided PICC line projects to the
cavoatrial
junction. Cardiomediastinal silhouette is stable.
MICROBIOLOGY:
==========
___ CULTURE-FINAL {PSEUDOMONAS
AERUGINOSA}
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
___ SCREEN NEGATIVE
___ URINE CULTURE-FINAL
{ESCHERICHIA COLI}INPATIENT
___ CULTURE x2: NO GROWTH
___
**FINAL REPORT ___
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 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed ___
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
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
DISCHARGE LABS
===============
___ 05:54AM BLOOD WBC-10.1* RBC-3.08* Hgb-8.5* Hct-28.1*
MCV-91 MCH-27.6 MCHC-30.2* RDW-15.1 RDWSD-50.2* Plt ___
___ 05:54AM BLOOD Glucose-164* UreaN-29* Creat-0.9 Na-137
K-4.9 Cl-102 HCO3-28 AnGap-7*
___ 05:54AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.4
Brief Hospital Course:
SUMMARY:
=================
Ms. ___ is a ___ Y/o F w/ Crohn's disease s/p total
proctocolectomy w/ end ileostomy, urostomy, and multiple
intraabdominal abscesses, on TPN, Afib, asthma and ___
Disease, who presented for hypokalemia ___ setting of GI losses
from increased diuretics. Lasix was discontinued and she
received aggressive repletion. Without diuretics, she became
fluid overloaded and was very uncomfortable, so initially was
started on potassium sparing diuretic, then also required
Torsemide, which she was discharged on. Her TPN potassium was
also increased and she did not require daily repletion of
potassium at time of discharge. Her course was further
complicated by sinus tachycardia, acute on chronic heart failure
with preserved ejection fraction, acute blood loss anemia
requiring transfusion, and hospital-acquired pneumonia.
**Of note, she had a prolonged hospitalization and was initially
hesitant to be discharged home, then left the hospital without
the discharge paperwork stating she was ___ a rush to leave with
her family. She was called shortly after this was discovered to
review her medication reconciliation over the phone.**
TRANSITIONAL ISSUES:
=====================
[ ] recheck electrolytes on ___, replete magnesium to
2 and potassium to 4
[ ] recheck CBC at followup
[ ] please ensure followup with her endocrinologist
[ ] if increasing volume status/leg edema, consider uptitrating
spironolactone and/or Torsemide
[ ] titrate metoprolol for sinus tachycardia, discharged on ___
dosing, concern that she was not absorbing succinate as HR
better controlled with tartrate, though she did not tolerate q6H
dosing
[ ] will complete 1 more dose of 5-day treatment with levaquin
for hospital-acquired pneumonia
[ ] repeat EKG to check QTC, which was 500 on admission ___
setting of patient taking home Zofran
[ ] hold Zofran until finished course of Levaquin, then start
twice daily
[ ] incidental soft tissue density lesion ___ the left kidney was
stable, renal ultrasound recommended previously
[ ] incidental pulmonary nodule seen
[ ] discharged on flexeril for hand cramping, please stop as
soon as symptoms improve
[ ] Consider iron supplementation for iron deficiency anemia
after treatment of infection
[ ] alk phos found to be elevated, would recheck
[ ] mildly elevated INR, thought nutritionally mediated
[ ] Please review medications with her. She left the hospital
without the paperwork. We called her to tell her the medications
over the phone but she would benefit from further clarification
of her new/changed medications at discharge.
ACUTE ISSUES:
=============
#Hypokalemia:
Hypokalemia to 2.8. She received potassium repletion and
potassium normalized. Her acute drop ___ potassium attributed to
increased doses of Lasix. Her home Lasix was stopped and she was
started on spironolactone and torsemide. She was continued on
TPN with potassium supplementation. She did not require
supplement on discharge but if she does ___ future, please ensure
it is powder, not pills, as these were seen exiting her ostomy
whole.
#Chronic abdominal pain/nausea:
#Crohn's disease s/p total proctocolectomy w/ end ileostomy,
urostomy, and multiple intraabdominal abscesses, on TPN
Patient with chronic abdominal pain that remained at baseline,
but she complained of high output from abscess drains. Abdominal
pain initially thought due to secondary adrenal insufficiency,
but this was disproved as she appropriately increased with ___
stim test. She continued to have persistent abdominal pain
throughout the admission, attributed to her Crohns disease.
Colorectal surgery was consulted for this, and for high output
from drains, but serial imaging was stable and there was no
surgical intervention to offer. Inflammatory markers mildly
elevated. GI team contacted regarding this and said nothing
actively to do for her known fistulizing disease right now. Her
RUQ drain was removed prior to discharge due to poor output. She
continued home dilaudid. For nausea, she was taking TID Zofran
at home but QTc was prolonged on admission. She had IV Ativan
available initially which she was taking prior to any intake,
but over her hospital course her nausea improved and she was
able to resume Zofran with use ___ x per day. This was held
briefly on discharge due to pneumonia treatment with
fluoroquinolone.
#Acute on chronic heart failure with preserved ejection fraction
#Hand cramping
She was ___ sinus tachycardia with associated dyspnea despite
diuresis and pain control (below). TTE showed preserved systolic
function, EF 70%. Given tachycardia, dyspnea, and peripheral
edema ___ setting of malnutrition, there was concern for
high-output heart function on TTE due to wet beriberi disease.
She was initiated on thiamine supplementation through her TPN.
Her thiamine level subsequently was normal. She diuresed well to
40 mg Torsemide daily however complained that she did not feel
well when taking it, so dosing was decreased to 20 mg for
maintenance. Also started and uptitrated spironolactone, but
this was decreased on discharge due to feeling weak after taking
diuretics and too much output from her urostomy for patients
comfort. She developed hand cramping ___ this setting, which
improved with diuretics and flexeril, which should be
discontinued as soon as feasible.
#Hx Atrial fibrillation:
#Sinus tachycardia:
#Exertional dyspnea and chest discomfort
She was not ___ Afib during this hospitalization, rather sinus
tachycardia on telemetry, had intermittent palpitations with
exertional dyspnea and chest pain. She was initially on tartrate
Q6H and heart rates were ___ to low 100s, however later ___
hospitalization noted up to the 130s periodically and often
sustained ___ 110s-120s. Initially this was thought possibly
related to dehydration from high GI output from drains, acute on
chronic anemia, and inadequate absorption of metoprolol
succinate as her heart rates seemed to climb after consolidation
from tartrate and there was concern for residue ___ her ostomy
after taking metop succinate. She received IVF resuscitation, 1u
pRBC, and replaced back on metoprolol tartrate which was
uptitrated and dosed Q8H for ease of use and better tolerated
than Q6H dosing. PE was also considered but felt less likely
with negative DVT studies, troponin, BNP, and no EKG changes.
Avoided CTA given 2 recent contrast loads. Also possible her
tachycardia was ___ response to pneumonia as below, and
deconditioning, though she was independent and did not require
___ evaluation.
#Hospital-acquired pneumonia:
She developed productive cough during admission with new
leukocytosis (neutrophilic predominance), found with RML
consolidation on CXR concerning for HAP. Given risk of MDRO due
to abx within 30 days (Augmentin ___, she was covered
with cefepime. Sputum culture grew pan-sensitive pseudomonas and
she was narrowed on discharge to levofloxacin to complete a
7-day course (___). Cough treated symptomatically.
#Acute on chronic Anemia ___ acute blood loss: baseline ___.
Iron labs consistent with iron deficiency anemia. Also concern
for GI bleed as her hemoglobin dropped to 7.0 requiring 1 unit
red blood cell. This was thought due to known bloody output from
her abscess drain and possibly some bone marrow suppression iso
acute illness. No other signs of bleeding.
#+ UA with E coli pansensitive
Thought likely to be colonization, not treated.
CHRONIC ISSUES:
===============
#Depression: continued home citalopram. Noted to have anxiety
about repeated hospitalizations.
#Hyperglycemia: Noted on chemistry panels, HbA1c 5.6%.
CORE MEASURES
=============
#CODE: full code (confirmed)
#CONTACT: ___ ___ ___
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. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
2. Citalopram 20 mg PO DAILY
3. Furosemide 60 mg PO DAILY
4. Zolpidem Tartrate 7.5 mg PO QHS
5. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
7. Aspirin 325 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Fluticasone Propionate NASAL 2 SPRY NU BID
10. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation DAILY:PRN
Discharge Medications:
1. Benzonatate 100 mg PO TID
2. Cyclobenzaprine 5 mg PO BID:PRN hand spasm
3. GuaiFENesin ___ mL PO Q6H:PRN cough
4. LevoFLOXacin 750 mg PO DAILY Duration: 1 Day
5. Metoprolol Tartrate 25 mg PO Q8H
6. Spironolactone 50 mg PO DAILY
7. Torsemide 20 mg PO DAILY
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
9. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
10. Aspirin 325 mg PO DAILY
11. Citalopram 20 mg PO DAILY
12. Fluticasone Propionate NASAL 2 SPRY NU BID
13. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
14. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation DAILY:PRN
15. Zolpidem Tartrate 7.5 mg PO QHS
16. HELD- Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First
Line This medication was held. Do not restart Ondansetron until
you finish levaquin. When you restart ondansetron, please do not
take more than two times a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
==================
hypokalemia
Crohns ___
Hospital acquired pneumonia
sinus tachycardia
acute on chronic anemia
Secondary diagnosis:
==================
Pyuria
Hypertension
Anemia
Depression
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- Your potassium level was low
WHAT HAPPENED WHILE I WAS ___ THE HOSPITAL?
==========================================
- You were given potassium to correct your low levels.
- You had abdominal imaging tests to ensure that the location of
her drains are ___ the right place. One of your drains was
removed by colorectal surgeons.
- You received diuretic medications to remove fluid from your
body
- You were also diagnosed with pneumonia and started taking
antibiotics to treat the infection.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
- Please continue to weigh yourself daily. If your weight
increases by more than 3 pounds, please call your doctor.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10867202-DS-10
| 10,867,202 | 28,656,675 |
DS
| 10 |
2145-04-16 00:00:00
|
2145-04-17 21:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ old ___ speaking only woman, history of CHF,
end-stage interstitial lung disease (at home on ___ O2 at
baseline, IPF/UIP by imaging), severe pHTN (PA 69/23, mPAP 43),
on sildenafil 20 TID, dCHF (LVEF 50-55%, RV dysfunction with
mod/severe TR), and GERD with progressive shortness of breath.
Patient had last been discharged in ___ and states
she was discharged from rehab 20 days ago. Since then she
reports she has been eating salty foods and drinking more water
due to dry throat. She checked her weight 5 days ago at home and
it was 107-lbs (48-kg). Dry weight per prior DC summary is 49-50
kg. She reports progressive ___ edema for past 6-days and SOB for
x 2days. ___ helps with her medications, last visited 3 days
ago. Patient does not recall any of her medications, including
what dose of torsemide she is taking at this time. She does not
have her pill box with her. She denies CP, did have some nausea
two days ago. Due to progressive SOB, she called EMS today.
Per EMS Report - SaO2 on RA was 79% with RR to 48. She was
coughing, and dyspneic. BP was 120/60 and EKG was without
concerning findings and she was A&Ox3.
In the ED,
-Initial vitals were 98 ___ 100% 10L NRB, with crackles to
mid lung fields.
-BNP of 7481 (was 7936 during last admit) and CXR showed incr
opacification of RLL mild edema on background of chronic
interstitial lung dz.
-She was on BIPAP for approximately 1 hour, and given lasix IV
40 mg and weaned off BIPAP to RA.
-On transfer VS: T97.2 93 ___ 95% 5L.
On the floor, initial VS: 96.1 97/68 92 18 90% 4L. Weight was
elevated at 52-kg from prior d/c summary dry weight 49-50kg.
It was noted that on previous admission, patient had been sent
home with plan for hospice and expressed she did not wish to be
readmitted. Per prior notes, in an effort to avoid readmission
for fluid overload/RHF, patient had been counseled to increase
her home torsemide dose to 40 mg daily for weight gain > 3-lbs.
However, on discussion with patient, she had poor understanding
of what hospice meant and stated she wanted to be admitted to be
treated for her breathing. She stated that her breathing was
much improved after IV lasix and brief 20 minutes of BIPAP. She
has 650 cc in foley bag at this time.
Past Medical History:
Interstitial lung disease
Chondrocalcinosis
Chronic rhinitis
Erosive osteoarthritis
Gastroesophageal reflux
Hypertension
Seasonal allergies
Bilateral septic arthritis with streptococcus viridans
S/p I&D bilateral knees
Social History:
___
Family History:
- Father: Died from PNA
- Mother: Died from MI
- Brother: OA
- Three children: One daughter died from CVA
Physical Exam:
EXAM ON ADMISSION:
VS: Wt: 116-lb (52-kg) 96.1 97/68 92 18 90% 4L
General: NAD, comfortable, pleasant ___ speaking, A&O x 2.5
(slow and initially said ___, but then corrected to ___,
___, knew ___
HEENT: NCAT, PERRL, EOMI
Neck: supple, JVD to ear
CV: regular rhythm, no m/r/g
Lungs: Coarse crackles throughout bilateral ___nd
fine crackles at apex
Abdomen: soft, NT/ND, BS+
Ext: Extremities cool, 3+ pitting edema to below knees,
difficult to palpate DP pulses with edema, upper extremities
well perfused with 2+ pulses
Neuro: moving all extremities grossly
.
VS: 98.6 ___ 95-100% 4L
Wt ___: 47.8kg
24HR I/O: 720/200+
General: frail pleasant female, A&O x3, comfortable, NAD
HEENT: NCAT, PERRL, EOMI
Neck: supple, JVP ~8cm
CV: RRR no M/R/G
Lungs: Coarse crackles greater than mid-lung field b/l
Abdomen: soft, NT/ND, BS+, no masses, guarding or rebound
tenderness. Foley catheter in place draining clear-yellow
urine.
Ext: Extremities cool, trace pedal edema, no posterior calf or
sacral edema. ___ 2+ B/L.
Neuro: Motor strength and sensation grossly intact.
Pertinent Results:
LABS ON ADMISSION:
___ 02:23PM BLOOD WBC-8.2 RBC-4.29 Hgb-12.9 Hct-37.5 MCV-88
MCH-30.0 MCHC-34.3 RDW-17.4* Plt ___
___ 02:23PM BLOOD Neuts-73.3* Lymphs-17.3* Monos-5.1
Eos-4.0 Baso-0.3
___ 02:23PM BLOOD ___ PTT-30.9 ___
___ 02:23PM BLOOD Glucose-123* UreaN-21* Creat-0.9 Na-125*
K-4.4 Cl-85* HCO3-27 AnGap-17
___ 02:23PM BLOOD proBNP-7481*
___ 11:45PM BLOOD Mg-1.7
.
PERTINENT RESULTS:
___ 07:40AM BLOOD ALT-41* AST-43* AlkPhos-134* TotBili-1.1
___ 11:45PM BLOOD cTropnT-<0.01 proBNP-9376*
.
LABS ON DISCHARGE:
___ 07:00AM BLOOD Glucose-78 UreaN-16 Creat-1.1 Na-134
K-4.1 Cl-90* HCO3-37* AnGap-11
___ 07:00AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.1
.
MICRO:
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
.
IMAGING/STUDIES:
CXR (___): Minimally increased opacification of the right
lower lung may reflect mild edema superimposed on chronic severe
interstitial lung disease.
.
CXR (___): There are low lung volumes. Cardiomegaly and
widened mediastinum are stable. Extensive interstitial reticular
abnormalities larger in the left perihilar and left lower lobe
region are grossly unchanged allowing the difference in
inspiratory effort of the patient without evidence of new
abnormalities pneumothorax or effusion.
Brief Hospital Course:
___ old woman w/dCHF (LVEF 50-55%, RV dysfunction with
mod/severe TR), end-stage interstitial lung disease (on home
___ O2), severe pHTN (PA 69/23, mPAP 43), who presented with
SOB and swelling of lower extremities consistent with acute
diastolic heart failure exacerbation.
# Acute diastolic heart failure exacerbation (EF 50-55%, RV
dysfunction): Patient presented grossly volume overloaded, 2-kg
up from dry weight w/elevated JVP and BNP similar to BNP level
on prior heart failure admission. Most likely precipitant was
not taking torsemide at home since discharge (per Hospice ___
records) along with diet and fluid indiscretion. She initially
required BIPAP in the ED, improved to 5L with initial dose of IV
lasix then was quickly weaned back to her baseline home O2. She
continued to diurese well with IV lasix over the next several
days and then was transitioned back to home dose of 20mg
torsemide when she reached her dry weight. On the day of
discharge her weight was 47.8kg (previous dry weight 49-50kg).
Sildenafil was continued at the recommendation of her
Pulmonologist, Dr. ___ treatment of her pulmonary
hypertension. Her metoprolol was initially held to allow BP room
while diuresing, restarted prior to discharge. Pt instructed to
weigh herself daily and follow up with her primary care doctor
and Cardiologist for further adjustment of diuretic regimen.
# Hypervolemic hyponatremia: Patient with Na of 125 on
admission, likely due to hypervolemia. No change in mental
status or neuro deficits on exam. Improved with diuresis and
fluid restriction. Sodium stable at 134 on the day of discharge.
# UTI: Pt reported dysuria during hospitalization in the setting
of foley catheter. UA with 33 WBCs, 6 RBCs, few bacteria. UCx
growing >100,000 alpha strep vs lactobacillus. No elevation in
WBC count or fever. Foley catheter was removed. She completed 3
day course of Bactrim while inpatient (___).
# ILD: End-stage ILD, requires ___ O2 by NC at home. Returned
to baseline home O2 requirement following initial diuresis.
Chronic symptoms of dyspnea treated with home liquid oxycodone,
continued during admission along with albuterol/ipratropium nebs
as needed for comfort. She will continue to work with home
hospice for symptom management following discharge.
# Pulmonary HTN: Per ___ records had been off sildenafil at home
prior to admission, restarted while inpatient. Also diuresed
with IV lasix and torsemide as above. Discussed dual therapy
with Pulmonary (Dr. ___, who felt that it would be
beneficial to continue.
# Goals of care: During initial discussions pt seemed to have
poor understanding of hospice. Per report she had previously
discussed not wanting to come back into the hospital, however
she had called EMS today. Per daughter-in-law, she states that
culturally, the concept is hospice is difficult to understand
for the patient and the family. Patient and daughter-in-law in
agreement DNR/DNI (could not reach son). According to ___, pt
was on home hospice since prior to last admission in ___. It
was unclear when or why several of her previous medications
including torsemide and sildenafil had been discontinued since
last hospital discharge. While inpatient pt met with ___
from Palliative Care as well as social work, plan for home with
hospice to best meet GOC that patient expressed. Working on
setting up system at home that pt can activate if having more
symptoms to bring care to her at home, potentially avoiding
unnecessary hospitalizations in the future.
# Chronic rhinitis: Continued home guaifenesin. Azelastine
unavailable while inpatient.
# GERD: Continued home pantoprazole.
TRANSITIONAL ISSUES:
# Discharged on torsemide 20mg daily
# Dry weight on discharge: 47.8kg (previous dry weight 49-50kg)
# Continue dual therapy with torsemide and sildenafil for
pulmonary hypertension, discussed with ___ (Dr. ___
# Treated for UTI with Bactrim x 3 days (complete ___
# Home hospice to be resumed on discharge, plan in place to have
emergency notification system in place so patient can have
treatments at home to prevent unnecessary rehospitalization
# CODE: DNR/DNI (confirmed)
# EMERGENCY CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB, wheezing
2. Atorvastatin 40 mg PO DAILY
3. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB, wheezing
4. Aspirin 81 mg PO DAILY
5. Loratadine 10 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Senna 8.6 mg PO BID
8. azelastine 137 mcg nasal BID
9. ketotifen fumarate 0.025 % ophthalmic BID
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Guaifenesin ___ mL PO Q6H:PRN congestion
13. OxycoDONE Liquid 2.5-5.0 mg PO Q4H:PRN dyspnea
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB, wheezing
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Guaifenesin ___ mL PO Q6H:PRN congestion
5. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB, wheezing
6. Loratadine 10 mg PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. Senna 8.6 mg PO BID
9. Sildenafil 20 mg PO TID
RX *sildenafil 20 mg 1 tablet(s) by mouth three times a day Disp
#*84 Tablet Refills:*0
10. azelastine 137 mcg nasal BID
11. ketotifen fumarate 0.025 % ophthalmic BID
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. Metoprolol Succinate XL 25 mg PO DAILY
14. OxycoDONE Liquid 2.5-5.0 mg PO Q4H:PRN dyspnea
15. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Acute diastolic heart failure exacerbation
Secondary:
End-stage interstitial lung disease
Pulmonary hypertension
Hypervolemic hyponatremia
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___
because of your shortness of breath and swelling in your legs.
We think this was caused by fluid overload from not taking your
diuretic (torsemide) after you left rehab. While you were here
you were treated with IV lasix (diuretic) which helped take off
extra fluid. You were then transitioned back to your previous
home dose of torsemide, which you should continue taking after
you leave. You also met with the Palliative care team and made a
plan to go home with hospice after you leave the hospital. We
will be arranging for an emergency button that you can use at
home to call for assistance if you become short of breath and
staff from the hospice service will come to your house to give
you treatment to avoid unnecessary trips back to the hospital.
You will also have follow-up appointments with your primary care
doctor and Cardiology. Please weigh yourself every morning, call
MD if weight goes up more than 3 lbs so that we can adjust your
medication. It was a pleasure taking care of you - we wish you
all the best.
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10867202-DS-4
| 10,867,202 | 21,418,702 |
DS
| 4 |
2142-11-12 00:00:00
|
2142-11-12 18:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old ___ female with history of idiopathic
pulmonary fibrosis, recent bilateral septic arthritis, chronic
UTI with VRE, presenting from ___ with shortness of
breath and reported low hematocrit. Today, she reports
shortness of breath at rest, slightly worse than her baseline,
associated with productive cough with yellow sputum. Patient is
not on supplemental O2 at home. She reports having some dyspnea
over the last 1.5 weeks since her previous discharge, although
the productive cough is new. Patient also reports continued
bilateral R>L knee pain, though no change from recent discharge.
Patient reports no recent fevers or chills. Notes from
___ report HCT drop to 23 and requested transfusion.
In the ED, initial vitals T 98.8, P ___, BP 122/72, Sat 85% RA,
for which she triggered on arrival. Patient was placed on
non-rebreather with improvement to 100% O2 saturation, then
weaned to 6 liters. Chest X-ray showed bilateral pneumonia,
and patient was administered vancomycin and levofloxacin.
Hematocrit was 26 which is her baseline. White blood cell count
was 11.1K, notable for 10% eosinophils. Platelet count was 711.
Lactate was 1.2. Chem7 was unremarkable. INR was 1.2. ECG
showed SR 108, NANI, with no ST elevations. Notes from ___
report HCT drop to 23 and requested transfusion. Patient then
dropped to 87% on nasal cannula, started back on non-rebreather
transiently and is now back to 100% on 6 liters O2. Current
vitals are HR 94, RR 22, BP 103/59 Sat 100% on 6 liters face
mask.
Past Medical History:
Pseudogout
Hyperlipidemia
Idiopathic pulmonary fibrosis
Recurrent urinary tract infection
Bilateral septic arthritis (Strep viridans)
Recent dental infection s/p removal
Social History:
___
Family History:
Father died from ___. Mother died from ___. Brother with
OA. Three children, one daughter who died of a CVA.
Physical Exam:
ADMISSION EXAM
Vitals: T 98.3 P ___ BP 126/61 R 23 Sat 100% 4 liters O2
General: pleasant elderly woman, NAD
EENT: PERRL, EOMI, neck supple, MMM, OP clear
CV: RRR, normal S1/S2, no murmurs to auscultation
Pul: rales present bilaterally throughout lung fields, no
wheezes or rhonchi
GI: normoactive bowel sounds, soft, non-tender, non-distended
MSK: left knee with small palpable effusion, TTP, well-healing
stapled surgical scar, moderate warmth; right knee with small
palpable effusion, TTP, well-healing stapled surgical scar,
moderate warmth
EXT: palpable distal pulses, <2s cap refill, sensation intact,
trace edema
SKIN: no rashes, no jaundice
NEURO: AAOx3
Discharge exam:
VS: Tm AF Tc 98.4 BP 116/66 HR 82 RR 20 pOx 98
I/O NR, bowel movement x 3
General: pleasant elderly woman, NAD
EENT: PERRL, EOMI, neck supple, MMM, OP clear
CV: RRR, normal S1/S2, no murmurs to auscultation
Pul: coarse breath sounds present bilaterally throughout lung
fields
GI: normoactive bowel sounds, soft, non-tender, non-distended
MSK: bilateral knee with well healing surgical scars, right knee
with pain on ROM with obvious arthritis
EXT: palpable distal pulses, <2s cap refill, sensation intact,
trace edema
SKIN: old sacral ulcer with no open area - appears chronic
NEURO: AAOx3
Pertinent Results:
I. Labs
A. ADMISSION LABS
___ 06:00PM BLOOD WBC-11.1* RBC-3.06* Hgb-8.4* Hct-26.6*
MCV-87 MCH-27.6 MCHC-31.7 RDW-13.0 Plt ___
___ 06:00PM BLOOD Neuts-58.7 ___ Monos-6.0
Eos-10.2* Baso-0.3
___ 06:00PM BLOOD ___ PTT-32.8 ___
___ 06:00PM BLOOD Glucose-109* UreaN-16 Creat-0.6 Na-133
K-4.6 Cl-93* HCO3-29 AnGap-16
___ 04:34AM BLOOD Calcium-9.4 Phos-4.3 Mg-2.0
B. Discharge labs
___ 03:14AM BLOOD WBC-8.7 RBC-2.88* Hgb-8.2* Hct-25.4*
MCV-88 MCH-28.3 MCHC-32.1 RDW-13.6 Plt ___
___ 03:14AM BLOOD Glucose-96 UreaN-14 Creat-0.7 Na-136
K-4.2 Cl-97 HCO3-34* AnGap-9
___ 03:14AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.1
___ 06:28PM BLOOD Vanco-23.2*
C. PERTINENT LABS
___ 08:15AM BLOOD Ret Aut-4.0*
___ 08:15AM BLOOD Hapto-476* Ferritn-702*
II. Radiology
___ CXR
Relatively unchanged appearance of the chest compared to prior
exam.
Persistent opacities within the right upper lobe, left lung base
and left
perihilar region are redemonstrated on a background of chronic
interstitial lung disease which on the prior chest CT was
thought to reflect UIP or fibrosing NSIP. As before, these more
focal opacities may reflect progression of chronic interstitial
lung disease, acute exacerbation of interstitial lung disease,
or possibly infection.
___ CXR\
INDICATION: Evaluate right PICC positioning.
COMPARISONS: Most recent chest radiograph from ___.
FINDINGS: AP, lateral, and oblique radiographs of the chest are
somewhat
limited in the determination of the exact termination point of
the right PICC,
which is difficult to visualize amongst the mediastinal
structures. However,
it appears to terminate in the lower portion of the SVC. There
has been
marked improvement in the bilateral effusions and heterogeneous
opacities when
compared to the prior study. Prominent interstitial lung
markings reflect the
patient's baseline pulmonary fibrosis. There is no
pneumothorax. The aorta
is stably tortuous with atherosclerotic calcifications in the
arch.
IMPRESSION:
1. New right PICC is difficult to visualize but likely ends
within the lower
SVC.
2. Marked interval improvement in what was likely multifocal
pneumonia as
well as near complete clearance of the bilateral pleural
effusions compared to
___.
3. Stable interstitial lung markings consistent with chronic
pulmonary
fibrosis.
III. Microbiology
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
Brief Hospital Course:
___ history of pseudogout and recent bilateral septic arthritis
complicated by high-grade S. viridans bacteremia with no
evidence of endocarditis by TEE and recently switched from
ceftriaxone to vancomycin in setting of eosinophilia, non-oxygen
depedent idopathic pulmonary fibrosis and recurrent UTI
presented with shortness of breath and cough likely secondary to
transient mucous plug. She was treated briefly for pneumonia
with discontinuation of antibiotics.
# Transient dyspnea/hypoxemia
Patient initially presented to the ___ ER in respiratory
distress with new oxygen requirement. CXR was consistent with
patient's previous interstitial lung disease with no significant
change. She was admitted to the ___ given respiratory distress
that improved rapidly with conservative measures. She was
briefly treated with levofloxacin in addition to her vancomycin
for her recent bacteremia. A serial CXR (PA and LAT) on ___
to confirm her PICC line showed stable parenchymal changes. At
night, she did have desaturations to 88 % at times, which may be
consistent with ? sleep apnea. She does have low saturations in
the low-mid ___ on room air likely secondary to her underlying
interstitial lung disease.
She was continued on her home nebulizers without further event.
#. Bilateral septic arthritis:
The patient was hospitalized last month at ___ for bilateral
septic arthritis with high grade S. viridans bacteremia likely
from a tooth infection. She was recently switched from
ceftriaxone to vancomycin (end date: ___ after the
development of eosinophilia. Her right knee was exquisitely
painful. Orthopedics evaluated her in the hospital on ___
and thought that this was more consistent with chronic
arthropathy rather than acute infection or other deranagement.
She will continue IV vancomycin 1000 mg IV q 12 hr until
___ at which point she will follow-up with her infectious
disease provider. A level was checked in the hospital on
___ that was 23, which her evening dose held. She needs no
further vancomycin levels or monitoring labs as these can be
performed at her above appointment. Her eosinophilia has also
decreased as well. Inflammatory markers were performed, and CRP
has decreased from ~ 120 to ~ 60.
Pain control has also been an issue. She remains on oxycontin
and oxycodone for pain. Her oxycontin could be titrated up if
she has uncontrolled pain. She would also benefit from a
venodyne compression stocking on her right knee given
aforementioned arthropathy.
# Normocytic anemia, subacute:
Patient had a recent baseline Hct of ___. She likely developed
anemia secondary to marrow suppresion from antibiotics and
underlying inflammation. Her Hct was stable during
hospitalization with discharge Hct ~ 25. Reticulocyte count was
obtained with adequate reticulocyte index suggestive of marrow
response. Recent nutritional studies were within normal limits.
#. Urinary incontinence:
Patient was incontinent of urine. Urine culture ___ with
VRE. Treatment was not started at rehab or in the FICU. She
does have a history of chronic UTIs so this might represent
colonization. Upon further clarification, she states that
trouble with urination if supine and not endorsing UTI symptoms.
She will continue to monitor her symptoms.
#.Pseudogout: stable
-continue home colchicine
#.Hypertension: She was continued on valsartan.
# Hyperlipidemia: She was continued on simvastatin
# GERD: She was continued on her home PPI
# Impaired skin integrity
Patient noted to have old sacral ulcer on exam with no evidence
of breakdown. Continue wound care as directed with Critic Aid
clear moisture barrier ointment cleansing.
# Pending studies: Blood cultures dated ___
#PPX: enoxaparin s/p knee washout (proposed end date: ___.
#Access: Left PICC (placement confirmed on CXR dated ___
#Code: Full Code
#Communication: Discharge was discussed with both patient and
daughter and agree with rehab.
Medications on Admission:
Vancomycin 1 gm IV q12h
Colchicine 0.6 mg PO DAILY
Albuterol nebs IH BID
OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Oxycodone SR (OxyconTIN) 20 mg PO Q12H
Astelin 137 mcg Nasal Spray Aerosol, 2 sprays per nostril daily
Valsartan 40 mg Tab daily
Pantoprazole 40 mg Tab BID
Acetaminophen ER 650 mg Tab q4h prn (taking 2 at night)
Simvastatin 40 mg Tab daily
Docusate 100 mg PO BID
Senna 1 tab PO QHS
Polyethylene glycol PO daily
Lactulose 30 mg PO daily
Calcium carbonate 500 mg PO daily
Ferrous sulfate 325 mg PO BID
Lidoderm patch TP daily to bilateral knees
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH TID:PRN dyspnea/wheezing
2. Calcium Carbonate 500 mg PO DAILY
3. Lactulose 30 mL PO DAILY
hold for loose stools
4. Lidocaine 5% Patch 1 PTCH TD DAILY
to knees
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
6. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Simvastatin 40 mg PO DAILY
9. Vitamin D 400 UNIT PO DAILY
10. Pantoprazole 40 mg PO Q12H
11. Enoxaparin Sodium 30 mg SC Q12H
Indication: s/p bilateral knee washout
End date: ___
12. Colchicine 0.6 mg PO DAILY
13. Docusate Sodium 100 mg PO BID
14. Senna 1 TAB PO HS:PRN constipation
15. Acetaminophen 1000 mg PO TID
do not exceed > 3 grams/day
16. Vancomycin 1000 mg IV Q 12H
changed from Ceftriaxone on ___ due to eosinophilia; proposed
end day is ___.
17. Valsartan 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis
- mucus plugging
- drug induced anemia
Secondary diagnosis
- idiopathic pulmonary fibrosis
- pseudogout
- recurrent UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You came to our hospital for shortness of breath and low blood
count. Your symptoms were most likely related to a transient
mucous plug that caused difficulty breathing and also
possibility to the antibiotics you were receiving. We changed
your antibiotics to vancomycin. You were seen by orthopedics
and the staples over your right knee were removed during this
admission. We also had the orthopedic doctors ___ at your right
knee. You have bad arthritis in this joint and should use
venodynes or compression stockings to help with mobility. You
recovered well, and may return to rehab.
You will finish your antibiotic course on ___. You will
visit the infectious disease doctor at this time.
You also have the following followup appointment (see below).
It has been a pleasure taking care of you here at ___. We
wish you a speedy recovery.
Followup Instructions:
___
|
10867202-DS-6
| 10,867,202 | 22,343,469 |
DS
| 6 |
2144-07-06 00:00:00
|
2144-07-08 11:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female, with h/o CHF, pulmonary fibrosis, HTN, who
presents with worsening dyspnea. Patient reports she has had
increased dyspnea for the past three days, particularly last
night. Also reports nausea, cough, palpitations and fever.
Denies chest pain. Denies medication ___ or dietary
indiscretion. She uses oxygen at home, but does not know how
much.
In the ED, initial vitals were 99.4 104 122/68 28 96% 4L. Labs
significant for mildly elevated Creatinine from baseline 1.2
from 0.9, elevated BNP of 4588, and CXR with no pulmonary edema.
She recieved 40mg IV lasix. Prior to transfer VS were 105 129/76
17 92% nc.
On the floor, Pt endorses dyspnea and cough. Denies chest pain.
Review of sytems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No dysuria. Denies arthralgias
or myalgias. Ten point review of systems is otherwise negative.
Past Medical History:
Interstitial lung disease
Chondrocalcinosis
Chronic rhinitis
Erosive osteoarthritis
Gastroesophageal reflux
Hypertension
Seasonal allergies
Bilateral septic arthritis with streptococcus viridans
S/p I&D bilateral knees
Social History:
___
Family History:
Father died from pneumonia. Mother died from MI. Brother with
OA. Three children, one daughter who died of a CVA.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.5 130/81 104 18 91 4L, 98 4L
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: tachycardic, no m/r/g
Lungs: crackles throughout, particularly middle/lower lobes, R>L
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c, 2+ distal pulses bilaterally, 1+ edema LLE>RLE
Neuro: moving all extremities grossly
DISCHARGE PHYSICAL EXAM:
VS: 97.4 95/65 ___ 74 ___ 17 98 on 3.5L 53kg -1.9 L
GENERAL: NAD, alert, interactive
HEENT: NC/AT, sclerae anicteric
LUNGS: diffuse velcro crackles
HEART: RRR, loud TR murmur
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: WWP, no edema
NEURO: awake, A&Ox3
Pertinent Results:
ADMISSION LABS:
___ 09:00PM CK(CPK)-87
___ 09:00PM ___ cTropnT-<0.01
___ 01:08PM ___ ___
___ 12:01PM ___ UREA ___
___ TOTAL ___ ANION ___
___ 12:01PM ___ this
___ 12:01PM cTropnT-<0.01
___ 12:01PM ___
___ 12:01PM ___
___
___ 12:01PM ___
___
___ 12:01PM PLT ___
CARDIAC ENZYMES
___ 09:00PM BLOOD CK(CPK)-87
___ 05:50AM BLOOD ___ cTropnT-<0.01
___ 09:00PM BLOOD ___ cTropnT-<0.01
___ 12:01PM BLOOD cTropnT-<0.01
___ 12:01PM BLOOD ___
DISCHARGE LABS:
___ 06:20AM BLOOD ___
___ Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD ___
___
___ 06:20AM BLOOD ___
STUDIES/IMAGING
___ CXR
FINDINGS:
Lung volumes are reduced. Diffuse interstitial opacities most
pronounced
within the periphery and lung bases with architectural
distortion are
unchanged compared to the previous chest CT and compatible with
chronic
interstitial lung disease, previously characterized as UIP or
fibrosing NSIP. Previously noted hazy opacities in both lungs
has resolved. No new areas of focal consolidation are
demonstrated. There is no pulmonary vascular congestion,
pleural effusion or pneumothorax. Mild degenerative changes are
noted in the thoracic spine. The cardiac and mediastinal
contours are unchanged.
IMPRESSION:
Findings compatible chronic interstitial lung disease,
previously
characterized on chest CT as UIP or fibrosing NSIP. No new
areas of focal consolidation or pulmonary edema.
ECHO ___
Conclusions
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is unusually
small. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is low normal (LVEF ___.
There is no ventricular septal defect. The right ventricular
cavity is markedly dilated with mild global free wall
hypokinesis. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The ascending
aorta is mildly dilated. 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. The tricuspid valve
leaflets fail to fully coapt. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe 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.] The ___ pulmonic regurgitation velocity is
increased suggesting pulmonary artery diastolic hypertension.
There is no pericardial effusion.
IMPRESSION: Marked right ventricular cavity dilation with global
free wall hypokinesis. There is ___ overload of the
left ventricle which is therefore small/underfilled. Severe
pulmonary artery systolic hypertension. Moderate to severe
tricuspid regurgitation.
Compared with the prior study (images reviewed) of ___,
the results are similar.
Brief Hospital Course:
Ms. ___ is an ___ year old with a history of pulmonary
fibrosis, pulmonary hypertension and mild LV dysfunction who
presents with worsening dyspnea, likely a flare of her ILD.
# ILD leading to worsening right heart failure: Patient had a
lack of pleural fluid or pulmonary edema, so the presentation
was likely secondary to worsening IPF with elevation of BNP
secondary to ___ failure. An echo showed EF ___. She
was diuresed with IV lasix and appeared euvolemic. Her
furosimide was changed to torsemide. Weight at discharge was 53
kg. She was started on prednisone, and discharged home on
prednisone 50mg. She was treated with levaquin for possible
pneumonia. As she continued to be dyspneic, she was started on
prednisone, with improvement in her symptoms, and discharged on
50 mg qdaily. She was continued on ASA and metoprolol.
# GERD: Continued on omeprazole.
# HLD: Continued on atorvastatin.
TRANSITIONAL ISSUES:
- Follow up PCP
- ___ up Pulmonology - Patient discharged home on Prednisone
50 mg (8 day supply).
- Follow up Heart Failure Clinic
Weight at discharge 53kg
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO DAILY
2. azelastine 137 mcg nasal BID
3. Furosemide 40 mg PO DAILY
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Pantoprazole 40 mg PO Q12H
6. Calcium 500 + D (calcium ___ D3) 500
mg(1,250mg) -200 unit oral daily
7. ketotifen fumarate 0.025 % ophthalmic BID
8. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. azelastine 137 mcg nasal BID
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Pantoprazole 40 mg PO Q12H
6. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,chewable(s) by mouth qdaily Disp #*30
Tablet Refills:*0
7. Calcium 500 + D (calcium ___ D3) 500
mg(1,250mg) -200 unit oral daily
8. ketotifen fumarate 0.025 % ophthalmic BID
9. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth qdaily Disp #*30 Tablet
Refills:*0
10. PredniSONE 50 mg PO DAILY
RX *prednisone 50 mg 1 tablet(s) by mouth qdaily Disp #*8 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
Pulmonary fibrosis
CHF
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 shortness of breath. You
were started on steroids to help your lung disease. You were
given antibiotics to treat pneumonia and medication to reduce
the excess fluid in your blood. Your shortness of breath
improved. Please take your medication as prescribed and follow
up at your medical appointments listed below.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10867202-DS-8
| 10,867,202 | 21,515,801 |
DS
| 8 |
2144-08-20 00:00:00
|
2144-08-20 20:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with a history of interstitial pulmonary
fibrosis and severe pulmonary hypertension, recently discharged
___ for IV diuresis presents today with dyspnea.
The patient on ___ L of home O2, but ___ today reported
saturations in the 80's. Per report, the patient felt acutely
short of breath, but with an interpreter, patient reports no
subjective change in her dyspnea since discharge. She is always
SOB, especially with lying down. She takes her medications,
including torsemide, daily. She reports no dietary
indescretions, no chest pain, no new swelling of her legs.
In the ED intial vitals were: 97.3 93 ___ 100% nrb. Labs
were notable for WBC 11.1, BNP 8696, BUN/Cr ___, trop <0.01,
lactate 2.4. VBG 7.42/47/72, UA negative. CXR unchanged from
prior, EKG
Patient was given: MethylPREDNISolone 125mg, Albuterol 0.083%
Neb, Ipratropium Bromide Neb, Furosemide 40mg IV and
Levofloxacin 750mg IV.
On the floor, the patient reports feeling better. She made 900cc
urine. No chest pain, still feels short of breath.
Past Medical History:
Interstitial lung disease
Chondrocalcinosis
Chronic rhinitis
Erosive osteoarthritis
Gastroesophageal reflux
Hypertension
Seasonal allergies
Bilateral septic arthritis with streptococcus viridans
S/p I&D bilateral knees
Social History:
___
Family History:
- Father: Died from PNA
- Mother: Died from MI
- Brother: OA
- Three children: One daughter died from CVA
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 97.5 BP 102/68 HR 88 RR 18 O2 93-98%4LO2
GENERAL: breathing comfortably, no acute distress, speaking full
sentences
HEENT: NCAT. Sclera anicteric.
NECK: No JVD
CARDIAC: RRR, normal S1, S2. systolic murmur best heard along
left sternal border, no S3 or S4.
LUNGS: Diffuse dry crackles throughout all fields, resp
unlabored, no accessory muscle use.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 1+ bilateral DP
DISCHARGE PHYSICAL EXAM:
========================
VS: 98.5 100-110s/70s (103/72) 80-110s (84) 88/4L (on AM
re-check 4L 100%)
Weight: 52.1 kg (___) 52.5 (___)
I&Os: 820/500 (24h) ___ (MN)
GENERAL: Appears mildly dyspneic but in NAD, speaking full
sentences though worse while walking even from the bed to comode
HEENT: NC/AT, sclera anicteric, blue lips
NECK: No e/o JVD
CARDIAC: RRR, normal S1, S2. Grade II/VI SEM LLSB.
LUNGS: Diffusely dry, velcro crackles throughout all lung
fields, no accessory lung muscle use
ABDOMEN: Soft, NT/ND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 1+ bilateral DP
Pertinent Results:
DISCHARGE LABS:
===============
___ 06:45AM BLOOD WBC-10.9 RBC-3.91* Hgb-11.9* Hct-38.0
MCV-97 MCH-30.4 MCHC-31.3 RDW-14.7 Plt ___
___ 06:45AM BLOOD Glucose-92 UreaN-28* Creat-1.2* Na-144
K-4.1 Cl-97 HCO3-35* AnGap-16
___ 06:45AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.1
___ 06:45AM BLOOD WBC-10.9 RBC-3.91* Hgb-11.9* Hct-38.0
MCV-97 MCH-30.4 MCHC-31.3 RDW-14.7 Plt ___
___ 06:40AM BLOOD WBC-11.2*# RBC-3.78* Hgb-11.6* Hct-36.3
MCV-96 MCH-30.7 MCHC-32.0 RDW-14.4 Plt ___
___ 06:50AM BLOOD WBC-6.0 RBC-4.01* Hgb-12.5 Hct-37.8
MCV-94 MCH-31.2 MCHC-33.0 RDW-14.1 Plt ___
___ 02:25PM BLOOD WBC-11.1* RBC-4.02* Hgb-12.7 Hct-37.8
MCV-94 MCH-31.7 MCHC-33.6 RDW-14.2 Plt ___
___ 06:45AM BLOOD Glucose-92 UreaN-28* Creat-1.2* Na-144
K-4.1 Cl-97 HCO3-35* AnGap-16
___ 06:40AM BLOOD Glucose-90 UreaN-28* Creat-1.2* Na-142
K-3.4 Cl-97 HCO3-34* AnGap-14
___ 06:50AM BLOOD Glucose-119* UreaN-29* Creat-1.3* Na-146*
K-4.1 Cl-100 HCO3-32 AnGap-18
___ 02:25PM BLOOD Glucose-135* UreaN-27* Creat-1.2* Na-136
K-4.8 Cl-95* HCO3-27 AnGap-19
___ 02:25PM BLOOD cTropnT-<0.01
___ 02:25PM BLOOD proBNP-86___*
___ 06:45AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.1
___ 06:40AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.9
___ 06:50AM BLOOD Calcium-9.2 Phos-4.6* Mg-1.8
___ 02:36PM BLOOD ___ pO2-72* pCO2-47* pH-7.42
calTCO2-32* Base XS-4
___ 02:27PM BLOOD Lactate-2.4*
IMAGING:
========
CXR (___):
IMPRESSION: Findings again compatible with patient's known
pulmonary fibrosis without definite superimposed acute process,
noting that subtle change would be difficult to detect based on
a portable film.
Brief Hospital Course:
___ year old female with severe pulm hypertension, recently
discharged s/p IV diuresis with evidence of signigificant
worsening lung disease, who presents again with dyspnea and
hypoxia.
ACTIVE ISSUES:
==============
# IPF and Pulm HTN:
Worsening underlying IPF (thought to be driving her pulm HTN) is
the likely etiology for her presentation of dyspnea and hypoxia.
Desatted to 80's on regular 4L home O2, improved to mid 90's on
4L in ED and on the floor. Limited improvement despite
combination of lasix 40mg IV, methylprednisone, and
levofloxacin. Did not appear to be volume overloaded, being at
prior discharge dry weight. Prior VQ scan with intermediate
probability of PE though CT scan prior appears to be most akin
to IPF. No e/o infection. Plan had been to use sildenafil for
mild sx relief given mild response to NO as an outpt but had not
been able to setup after last discharge yet. As a result,
pulmonary was consulted who agreed that sx largely driven by her
IPF w/ no significant options available. Recommended palliative
care discussion moving forawrd. Her outpatient pulmonologists,
___ and ___, were also notified with Dr. ___
she would follow-up with the pt to initiate sildenafil treatment
for symptomatic relief since previously NO responsive on RHC.
Paperwork was sent to ___ compassionate care to help obtain
medication for patient due to lack of insurance coverage.
Palliative care assisted in goals of care discussions with pt
deciding to become DNR/DNI with decision to try rehab to help
her improve functionally. Also recommended liquid oxycodone for
treatment of dyspnea related discomfort. Continued discussion
with palliative warranted moving forward. Pt evaluated pt with
recommendation for rehab, continue to adjust O2 needs as needed,
and recommended ways to minimize overly exerting herself.
Continued follow-up as an outpatient with cardiology,
pulmonology and palliative care arranged.
Weight on discharge 52.5 kg.
TRANSITIONAL ISSUES:
====================
- Paperwork to ___ faxed to assist pt in obtaining sildenafil
for palliative treatment of sx related to her pulm HTN
- Continue to titrate O2 as needed, consider nasal pendant for
additional O2
- Continue palliative care follow-up to assist w/ pt discomfort
with dyspnea, breathing
- Continue goals of care discussion with patient
- Continue assess for services after discharge from rehab since
more assistance will be needed
- Consider hospice care as an option once patient ready
- Made DNR/DNI during this hospitalization
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. Loratadine 10 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Torsemide 20 mg PO DAILY
8. azelastine 137 mcg nasal BID
9. ketotifen fumarate 0.025 % ophthalmic BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. Loratadine 10 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Torsemide 20 mg PO DAILY
8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB, wheezing
9. Docusate Sodium 100 mg PO BID
10. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB, wheezing
11. OxycoDONE (Concentrated Oral Soln) ___ mg PO Q2H:PRN
dyspnea, pain
12. Senna 8.6 mg PO BID
13. azelastine 137 mcg nasal BID
14. ketotifen fumarate 0.025 % ophthalmic BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
End-Stage Pulmonary Fibrosis
Pulmonary Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you were short of
breath. This is due to your lung disease that is getting worse
and is not expected to improve.
You will go to rehab to help you get a little stronger. You
should also follow-up with your pulmonologist Dr. ___ who is
helping to get you a medication called sildenafil that may help
you feel better. However, these treatments will not stop your
disease from getting worse.
As a result, you should continue to follow-up with the
palliative care doctors who ___ help treat any discomfort you
may feel and with end of life issues.
You should also continue to follow-up with your cardiologist
after leaving the hospital. Weigh yourself every morning, call
MD if weight goes up more than 3 lbs.
Take care.
- Your ___ Team
Followup Instructions:
___
|
10867202-DS-9
| 10,867,202 | 21,380,035 |
DS
| 9 |
2145-02-04 00:00:00
|
2145-02-04 16:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ w/PMH notable for end-stage ILD (strongly
suspected IPF / UIP by imaging), severe pHTN (PA 69/23, mPAP
43), on sildenafil 20 TID, ___ (LVEF 50-55%, RV dysfunction
with mod/severe TR), and GERD who presented with 3 days of
worsening dyspnea, reduced exercise tolerance, lower extremity
edema, and 5 lb weight gain.
Patient is on 2L - 4L O2 at home for her ILD and PHTN. She has
had multiple recent admissions for dyspnea, most recently
___, in which she presented with fluid overload, an
elevated lactate, and was diuresed w/partial response. She was
started on sildenafil 20 TID after admission (RHC in ___
documenting mild NO responsiveness) as an outpatient with
reported symptomatic improvement per PCP. She has also been seen
by palliative care as an outpatient.
Patient was in her USOH at home until 3 days PTA when she began
to note worsening dyspnea on exertion. She notes that she has
been consuming more fluids lately due to a worsening of her
allergies and endorses a recent 5 lb weight gain. She has been
compliant on her home medications. Otherwise denies fevers,
chills, new cough, chest pain, nausea, vomiting, medication
non-adherence. Her dyspnea worsened over the 24 hours prior to
admission, and this morning she called EMS today with worsening
dyspnea and was brought to the ED.
In the ED, initial vitals: 97.9 114 ___ 76% NRB
Labs/Studies notable for: Negative troponin, Normal WBC, ALT 41,
AST 47. proBNP 7936. She was noted to have increased work of
breathing on NC. She was seen by pulmonary team who felt that
she was in acute decompensated RHF, and diuresed with lasix 40
mg IV x1.
Vitals prior to transfer: T 97.9, HR 99-114,
BP ___, RR ___, SpO2 97% 4L NC (brought in on NRB).
On arrival to the floor, she was afebrile with 97.4, BP 121/79,
HR 103, RR 24, ___ NC. Her weight was 55kg up from a
baseline of 52.5Kg.
Currently, she states that her breathing has improved since she
arrived. She otherwise feels well. Review of systems as above,
otherwise negative in detail as below.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No chest pain or
palpitations. No nausea or vomiting. No diarrhea or
constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits.
Past Medical History:
Interstitial lung disease
Chondrocalcinosis
Chronic rhinitis
Erosive osteoarthritis
Gastroesophageal reflux
Hypertension
Seasonal allergies
Bilateral septic arthritis with streptococcus viridans
S/p I&D bilateral knees
Social History:
___
Family History:
- Father: Died from PNA
- Mother: Died from MI
- Brother: OA
- Three children: One daughter died from CVA
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T97.4 BP 121/79, HR 103, RR 24, SpO2 97% 4L
Weight: 55Kg (prior hosp: Weight on discharge ___ 52.5 kg.)
General: Mild increased work of breathing. NAD. Sitting up in
bed eating dinner.
HEENT: MMM. No thyromegaly or faces.
Neck: JVP to angle of jaw.
Lungs: crackles throughout, courser crackles in lung bases b/l.
No rhonchi or wheezing.
CV: RRR, ___ HSM RUSB, LUSB
Abdomen: soft, NT, ND, BS+, no rebound or guarding.
GU: No foley
Ext: cool, 2+ edema to mid-tibia.
Skin: mottling of lower extremities to mid-tibia.
Neuro: Aox3, strength ___ throughout, sensation diffusely in
tact.
DISCHARGE PHYSICAL EXAM:
VITALS: Tm 98.3 , Tc 98.0 , BP 97/60, P 96, SpO2 97% on 4L
8h I/O -/-
24h I/O 840/inc
Overnight oximetry: no desats, O2 > 92% o/n on 4L.
Weight (51.0 ___ on bed scale, 51.2 ___ admission weight 55kg
on standing scale).
PHYSICAL EXAM:
General: Slight increased WOB. NAD.
HEENT: MMM. No thyromegaly.
Neck: JVP to angle of jaw.
Lungs: crackles throughout, courser crackles in lung bases b/l.
No rhonchi or wheezing.
CV: RRR, ___ HSM RUSB, LUSB
Abdomen: soft, NT, ND, BS+, no rebound or guarding.
GU: No foley
Ext: cool, tr edema
Skin: mottling of lower extremities to mid-tibia.
Neuro: Aox3, strength ___ throughout, sensation diffusely
intact.
Pertinent Results:
ADMISSION:
___ 12:35PM BLOOD WBC-8.8 RBC-4.69 Hgb-13.5 Hct-42.2
MCV-90# MCH-28.8 MCHC-32.1 RDW-16.9* Plt ___
___ 12:35PM BLOOD ___ PTT-28.6 ___
___ 12:35PM BLOOD Neuts-73.6* Lymphs-17.0* Monos-5.7
Eos-3.3 Baso-0.3
___ 12:35PM BLOOD Glucose-132* UreaN-17 Creat-1.1 Na-136
K-4.6 Cl-100 HCO3-24 AnGap-17
___ 12:35PM BLOOD ALT-41* AST-47* AlkPhos-149* TotBili-1.0
___ 12:35PM BLOOD proBNP-7936*
___ 12:35PM BLOOD cTropnT-<0.01
___ 12:35PM BLOOD Albumin-4.0
___ 08:25AM BLOOD Calcium-8.8 Phos-4.6* Mg-2.0
___ 01:10PM BLOOD Type-ART pO2-60* pCO2-40 pH-7.42
calTCO2-27 Base XS-0
___ 12:48PM BLOOD Lactate-3.0*
DISCHARGE:
___ 07:37AM BLOOD WBC-8.2 RBC-4.48 Hgb-12.7 Hct-39.9 MCV-89
MCH-28.3 MCHC-31.8 RDW-16.4* Plt ___
___ 07:37AM BLOOD Glucose-91 UreaN-16 Creat-1.1 Na-139
K-3.2* Cl-87* HCO3-40* AnGap-15
___ 07:37AM BLOOD Calcium-8.8 Phos-4.3 Mg-1.8
___ 04:45PM BLOOD Na-132* K-4.1 Cl-84*
PERTINENT:
___ 03:56PM BLOOD Lactate-2.5*
___ 01:26PM BLOOD Lactate-3.0*
IMAGING:
CXR ___
IMPRESSION:
In comparison with the study of ___, there are somewhat
better lung volumes. Continued enlargement of the cardiac
silhouette with extensive parenchymal opacities bilaterally
consistent with known fibrotic lung disease.
CXR ___
Lung volumes remain low. Heart size is mildly enlarged but
unchanged. The
aortic knob is calcified. Diffuse parenchymal opacities with
architectural distortion and bronchiectasis is re- demonstrate
compatible with known chronic fibrotic lung disease, overall
similar compared to the prior exam. No new areas of focal
consolidation, pleural effusion or pneumothorax is seen. No
pulmonary edema is demonstrated.
IMPRESSION:
Relatively similar appearance of diffuse chronic chronic lung
disease. No new gross focal consolidation identified.
MICROBIOLOGY:
BCx ___: NG (final) x2
Brief Hospital Course:
Ms. ___ is an ___ w/PMH notable for end-stage ILD (strongly
suspected IPF / UIP by imaging), severe pHTN (PA 69/23, mPAP
43), on sildenafil 20 TID, dCHF (LVEF 50-55%, RV dysfunction
with mod/severe TR), and GERD who was admitted with dyspnea
secondary to decompensated R heart failure.
Acute Medical Issues:
#Acute Decompensated RHF: Patient was admitted with dyspnea and
increased O2 saturation requiring ___ O2 by NC in the ED. Her
weight was 55kg on admission (up from previous discharge weight
of 52 kg), ___ edema, elevated JVP and proBNP of 7900. She was
noted to have transaminitis and a lactate of 3.0 on admission.
She was felt to be in decompensated right heart failure
w/congestive hepatopathy from fluid overload and diursed with IV
lasix x3 for a total of 3L over the next three days. With
diuresis, her dyspnea symptoms returned to baseline, and her O2
requirement decreased to 4L O2 NC. Her home metoprolol was held
in order to maintain her pressures during diuresis. She had
several episodes of desats to ___ in setting of ambulation or
excess movement, which spontaneously corrected and were
attributed to poor pulmonary reserve. She was restarted on her
home metoprolol on HD5 which she tolerated well. As below, in an
effort to avoid readmission for fluid overload/RHF, patient was
counseled to increase her home torsemide dose to 40 mg daily for
weight gain > 3lbs. Her DRY WEIGHT IS 49-50 kg
# ILD, pHTN: Patient has end-stage ILD which is progressive and
felt to be IPF by HRCCT. She is on ___ O2 by NC at home. She
previously had home hospice, however her hospice services felt
that she required more services than they were able to provide
in the homes, especially since she lives alone, without other
clsoe support. She understands the progressive nature of her
condition, voicing her wish to be DNR/DNI on admission. Her new
baseline of 4L O2 requirement was felt to represent progression
of her underlying ILD.
# Dyspnea: Patient had symptomatic dyspnea which improved with
diuresis as above. Given her end-stage ILD, a symptom management
plan with liquid oxycodone ___ q4hrs was put into place to
manage her dyspnea symptomatically should it recur and become
bothersome to the patient, but as her dyspnea improved with
diuresis, she did not require oxycodone for symptomatic rx
during this hospitalization.
# Chronic rhinitis: Patient has a long standing history of
mucous project and nasopharyngeal irritation secondary to
chronic rhinitis. She was maintained on loratidine as an
inpatient. Guiafenesin was added to her regimen with improvement
in her symptoms of mucous production.
# Chronic Medical Issues:
# GERD: The patient was continued on her home pantoprazole.
# Asthma: The patient uses albuterol prn for asthma which she
did not require during this admission.
# Transitional Issues:
1) Patient would like to avoid readmission for RHF / fluid
overload in the future. She should be weighed daily if > 3lBs
___ gain increase her torsemide to 40 mg daily. Her dry weight
is 49-50KG. Her pulmonolgoist Dr. ___ is also
available to help manage her heart failure; if further titration
of her diuretics in needed.
2)Goals of care: pt spoke with hospice respresentative and
discussed not wanting to keep coming in and out of the hospital.
She was made DNR/DNI this admission, but would recommend hospice
services initating MOSLT form in discussion with the patient.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. Loratadine 10 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Torsemide 20 mg PO DAILY
8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB, wheezing
9. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB, wheezing
10. OxycoDONE (Concentrated Oral Soln) ___ mg PO Q2H:PRN
dyspnea, pain
11. Senna 8.6 mg PO BID
12. azelastine 137 mcg nasal BID
13. ketotifen fumarate 0.025 % ophthalmic BID
14. Sildenafil 20 mg PO TID
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB, wheezing
2. Atorvastatin 40 mg PO DAILY
3. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB, wheezing
4. Aspirin 81 mg PO DAILY
5. Loratadine 10 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Senna 8.6 mg PO BID
8. Sildenafil 20 mg PO TID
9. Torsemide 20 mg PO DAILY
10. azelastine 137 mcg nasal BID
11. ketotifen fumarate 0.025 % ophthalmic BID
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. Metoprolol Succinate XL 25 mg PO DAILY
HOLD FOR SBP < 100 AND hr < 60
14. Guaifenesin ___ mL PO Q6H:PRN congestion
15. OxycoDONE Liquid 2.5-5.0 mg PO Q4H:PRN dyspnea
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Acute Decompensated Right Heart Failure
Secondary Diagnosis
end-stage interstitial lung disease
pulmonary hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your hospitalization at
___. You were treated for an exacerbation of your breathing
problems because of too much fluid. We gave you medicines to
remove the fluid. Your symtoms improved. Your dry weight is 108
lbs. If you gain more than 3lbs you should increase your
torsemide to 40 mg daily. When you are back at your dry weight
please resume to torsemide 20 mg daily.
You are being discharge to a ___ facility where you will
continue to receive your hospice services.
Please take all medications as prescribed and keep all follow up
appointments.
Your rehab will arrange a follow up with your primary care
doctor when you are discharged.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10867682-DS-8
| 10,867,682 | 23,771,873 |
DS
| 8 |
2115-05-12 00:00:00
|
2115-05-13 18:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ceclor
Attending: ___.
Chief Complaint:
Fever, positive HIV viral load
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ homosexual male who is presenting for expedited
workup of acute HIV infection. 4 days prior to this admission,
pt developed fever to 104, HA, chills, sore throat,
myalgias/arthralgias. 1d prior to admisison, he was seen at
___ for above complaints. At that visit, HIV VL was
sent, and returned positive >20,000 copies; patient was called
back to office today to discuss test results. At that visit, he
remained with above symptoms as well as increasing fatigue, sore
throat, poor PO intake. He reported feeling very weak and dizzy,
was found to be orthostatic on exam (115/50 to 90/40). Patient
was referred to ___ for expedited workup and management.
Of note, patient was seen in clinic 1 wk prior w/o significant
complaint, and had an STD screen positive for chlamydia and
gonorrhea, but negative for HIV Ab.
In ED, initial vital signs were 104.4 110 106/71 16 98%RA. Exam
noted erythematous pharynx, with supple neck, unremarkable neuro
exam, negative kernig/brudzinski. Labs were remarkable for WBC
1.4 (N35, L47, 4atyps, 2metas, 1myelo), ANC 490, ALT 41, AST 88,
Cr 1.2, lactate 1.2. CXR and NCHCT was unremrakable. LP
performed to ruleout acute CNS involvement, opening pressure
14cmH20. Patient was given tylenol and morphine for throat pain,
fluid resuscitated with 2L NS, and given vanco/cefepime for
febrile neutropenia. Admitted to medicine for further
management, including rule out of additional infections,
following up of labs (CD4 count, viral hep serologies, RPR,
toxo, lipids, EBV, HIV VL, HSV PCR all pending at time of
admission). Vital signs prior to transfer were 99.4 83 108/62 19
96%RA. Access was 18g x1.
On arrival to the floor, vital signs were 102.6 121/68 80 18
100%RA. Patient reported some throat discomfort, otherwise
comfortable.
REVIEW OF SYSTEMS:
+ as above
- as follows: denies vision changes, rhinorrhea, cough,
shortness of breath, chest pain, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- Recent chlamydia/gonorrhea infection treated with azithromycin
- wisdom tooth extraction in ___
Social History:
___
Family History:
From ___ student, studying flute performance. Denies
tobacco, illicits, ___ sexually active w men, 7
partners in last 6 months, consistently uses condoms
Physical Exam:
Admission Exam:
VS - 102.6/101.2; 121/68; 80; 18; 100RA
GENERAL - Alert, well-appearing, NAD
HEENT - bilateral OP erythema and lymphadenpathy L>R without
exudate, airway clear, PERRLA, sclerae anicteric, small
ulceration in L. buccal mucosa
NECK - Supple, + L anterior cervical LAD
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh
ABDOMEN - NABS, mild left upper quadrant tenderness w/o
rebound/guarding, no HSM
EXTREMITIES - WWP, no c/c/e, 2+ radial pulses
SKIN - no rashes or lesions
NEURO - A&Ox3, moving all extremities
Discharge Exam:
VS - Temp 99.0, HR 86, BP 110/72, RR 18, 100% on RA
GENERAL - Alert, well-appearing, NAD
HEENT - bilateral OP erythema and lymphadenpathy L>R without
exudate, airway clear, PERRLA, sclerae anicteric, small
ulceration in L. buccal mucosa
NECK - Supple, + L anterior cervical LAD
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh
ABDOMEN - NABS, soft, NT, ND
EXTREMITIES - WWP, no c/c/e, 2+ radial pulses
SKIN - no rashes or lesions
NEURO - A&Ox3, moving all extremities
Pertinent Results:
Pending Studies:
Bcx (___) - pending
EBV IgG/IgM (___) - pending
CSF (___) - Gram stain negative / culture NGTD
Throat CX to r/o HSV: NGTD
CMV VL (___) - pending
HSC PCR on CSF - pending
QG6PD-PND
BLOOD HIV GENOTYPING-PND
BLOOD HIV Ab-PND
CBCs:
___ 04:55PM BLOOD WBC-1.4* RBC-4.68 Hgb-13.5* Hct-42.1
MCV-90 MCH-28.8 MCHC-32.0 RDW-12.2 Plt ___
___ 06:45AM BLOOD WBC-0.9* RBC-4.58* Hgb-13.5* Hct-42.3
MCV-92 MCH-29.4 MCHC-31.9 RDW-12.4 Plt Ct-97*
___ 09:20AM BLOOD WBC-1.4*# RBC-4.89 Hgb-14.1 Hct-43.6
MCV-89 MCH-28.8 MCHC-32.4 RDW-12.2 Plt Ct-85*
___ 04:55PM BLOOD Neuts-35* Bands-4 Lymphs-47* Monos-7
Eos-0 Baso-0 Atyps-4* Metas-2* Myelos-1*
___ 06:45AM BLOOD Neuts-33* Bands-2 Lymphs-56* Monos-8
Eos-0 Baso-0 ___ Metas-1* Myelos-0 NRBC-1*
___ 09:20AM BLOOD Neuts-45* Bands-0 ___ Monos-12*
Eos-0 Baso-0 Atyps-5* ___ Myelos-0
CD4:
___ 04:55PM BLOOD WBC-1.4* Lymph-47* Abs ___ CD3%-75
Abs CD3-494* CD4%-34 Abs CD4-226* CD8%-35 Abs CD8-233
CD4/CD8-1.0
___ 06:45AM BLOOD Ret Aut-0.3*
___ 06:45AM BLOOD ___ ___
Chemistry:
___ 04:55PM BLOOD Glucose-92 UreaN-12 Creat-1.2 Na-135
K-4.5 Cl-100 HCO3-27 AnGap-13
___ 06:45AM BLOOD Glucose-112* UreaN-8 Creat-1.0 Na-134
K-3.9 Cl-103 HCO3-26 AnGap-9
___ 09:20AM BLOOD Glucose-120* UreaN-9 Creat-0.8 Na-134
K-4.2 Cl-100 HCO3-26 AnGap-12
___ 04:55PM BLOOD ALT-41* AST-88* AlkPhos-33* TotBili-0.2
___ 06:45AM BLOOD ALT-43* AST-90* AlkPhos-27* TotBili-0.2
___ 09:20AM BLOOD ALT-88* AST-162* LD(LDH)-455* AlkPhos-34*
TotBili-0.2
Other:
___ 04:55PM BLOOD Triglyc-138 HDL-18 CHOL/HD-4.0 LDLcalc-26
___ 04:55PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HAV
Ab-NEGATIVE
___ 04:55PM BLOOD HCV Ab-NEGATIVE
___ 05:09PM BLOOD Lactate-1.2
Micro:
CSF Cell Counts - WBC 3, RBC 1, Tprot 27, Gluc 62
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final
___: Negative for Chlamydia trachomatis by PCR.
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Final ___: Negative for Neisseria Gonorrhoeae by
PCR.
___ 7:51 pm CSF;SPINAL FLUID Source: LP.
HIV-1 Viral Load/Ultrasensitive (Final ___: 485
copies/ml.
___ Blood: VL
HIV-1 Viral Load/Ultrasensitive (Final ___: 5,900,254
copies/ml
CRYPTOCOCCAL ANTIGEN (Final ___: CRYPTOCOCCAL ANTIGEN NOT
DETECTED
TOXOPLASMA IgG ANTIBODY (Final ___:
NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA.
0.0 IU/ML. Reference Range: Negative < 4 IU/ml, Positive >= 8
IU/ml.
TOXOPLASMA IgM ANTIBODY (Final ___:
NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
Radiology:
CXR (___): IMPRESSION: No acute cardiopulmonary process.
Please note that entities such as PCP may be radiographically
occult.
Head CT (___): IMPRESSION: No acute intracranial pathology.
Brief Hospital Course:
___ y/o homosexual M presenting w fever, pharyngitis, malaise,
anorexia, recently positive HIV VL, symptoms all consistent with
acute HIV syndrome, also with Group C Strep pharyngitis.
# Acute HIV - Patient found to have newly positive HIV VL
(___), repeat 6million. Small amount of HIV VL copies in CSF
This is acute as patient reportedly had neg Ab 1wk ago. All of
his symptoms including high fevers, malaise, mylagias, can be
contributed to acute retroviral syndrome. Plan to hold off on
starting anti-retrovirals pending genotype studies, and
potentially enrolling in ___ trial. Studies for concurrent
infections pending (see below). CD4 count 226, but may be due
to total WBC being low. Bactrim was not initiated during
hospitalization but CD4 should be rechecked at outpatient visit
to decide if this is necessary. Pt will follow-up in ___
___ clinic 5 days after discharge.
# Neutropenic Fever - Likely secondary to acute HIV, but
important to rule out additional causes in setting of
neutropenia. Patient did also have Group C strep from swab
taken on ___ at ___. CXR unremarkable, CSF cell
count unremarkable, skin without obvious source. Patient was
started on vanc/cefepime initially, but does not have risk
factors, exam findings for MDR organisms such as MRSA or
Pseudomonas so these were discontinued when result of Group C
Strep was discovered. We started treationg Group C Strep
Pharyngitis with 5-day course of Penicillin V (last day
___. Tylenol for fever. Still febrile on day of discharge,
but fever curve was trending down.
# Transaminitis - likely ___ acute HIV, no e/o cholestatic
process on labs or exam. Viral hepatitis panel negative. EBV,
CMV studies pending. Will need to be checked in follow up to
make sure resolving.
# Transitional issues:
- Psychosocial: Patient's family very distressed by new
diagnosis and overwhelmed by all that it might means. They are
concerned he will not have enough support and would like him to
get plugged into as many supporting resources as possible.
- Code status: full code
- Follow up with Dr. ___ at ___ on ___
- Studies pending:
Bcx (___) - pending
EBV IgG/IgM (___) - pending
CSF (___) - Gram stain negative / culture NGTD
Throat CX to r/o HSV: NGTD
CMV VL (___) - pending
HSC PCR on CSF - pending
QG6PD-PND
BLOOD HIV GENOTYPING-PND
BLOOD HIV Ab-PND
Medications on Admission:
None
Discharge Medications:
1. lidocaine HCl 2 % Solution Sig: Twenty (20) ml Mucous
membrane TID (3 times a day) as needed for throat pain.
Disp:*200 ml* Refills:*0*
2. penicillin V potassium 500 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours) for 4 days: last day ___.
Disp:*12 Tablet(s)* Refills:*0*
3. ibuprofen 200 mg Tablet Sig: Three (3) Tablet PO three times
a day.
4. Tylenol ___ mg Tablet Sig: Two (2) Tablet PO four times a day
as needed for fever or pain: Do not take more than 3 grams/day.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Acute Human Immunodeficiency Virus infection
Group C Streptococcal pharyngitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted because you had high fevers, fatigue and sore throat
and your HIV VL was positive. Your symptoms are likely all due
to acute HIV infection, and Group C Strep. We treated the Group
C Strep with Penicillin V (which you will continue till
___. You will follow up at ___ in one week
(___) to get plugged into the services there.
Once your HIV genotype results come back in ___ weeks your
primary care doctor at ___ discuss with you plan
regarding starting HIV medications.
We made the following changes to your medications:
STARTED Penicillin V 500mg three times/day (last day ___
STARTED Tylenol ___ four times each days as needed for fever
(do not exceed 2,500mg in 24 hours)
STARTED Viscous lidocaine as needed for throat pain
STARTED Ibuprofen along with your tylenol to help with fevers
and pain. The dose should be 600mg three times a day, and should
be taken with meals and plenty of liquids.
Followup Instructions:
___
|
10867818-DS-2
| 10,867,818 | 21,716,308 |
DS
| 2 |
2187-04-14 00:00:00
|
2187-04-16 15:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
codeine / Vicodin
Attending: ___.
Chief Complaint:
?stroke
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ year-old L-handed woman who presents with right
facial numbness/heaviness, mild dysarthria and now resolved R
arm
weakness transferred for neurologic evaluation.
Pt was in normal state of health when she was at the grocery
store at around 7pm this evening when she tried to pick up some
meat with her right hand and dropped it twice. She then felt
onset of numbness/tingling in both of her hands (involving all
fingers) that rose up to involve both arms. She then started to
feel that her body felt "funny"/"internal heaviness"/"internal
trembling" and she walked to the front of the store. As she
spoke
to a store employee she started slurring her words and felt the
right side of her face/mouth was heavy and numb. She asked for
EMS to be called because she thought she was having a stroke and
then reports feeling lightheaded, falling/bending over the
checkout conveyer belt with possible brief loss of
consciousness.
The she remembers being on the ground with the ___ employee
holding her.
She specifically denies any numbness/tingling or weakness in her
legs throughout all of this.
Her symptoms started improving only several hours later at
___. She currently only has right facial
heaviness/numbness and intermittent dysarthria. Head CT and CTA
H
and N done at ___ were unremarkable.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysphagia, lightheadedness, vertigo, hearing
difficulty. Denies difficulties comprehending speech. No bowel
or
bladder incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. Denies history of palpitations, chest pain.
Past Medical History:
Migraine Headaches with visual aura
s/p Neck surgery (?fusion)
Low back pain - ?DJD
Asthma
Depression
Insomnia - ever since the death of her son
s/p Hysterecotmy
Social History:
___
Family History:
DM - Brother and Uncle
Heart disease - Brother (MI at ___) and Aunt
Father had lung cancer
Unsure about history of strokes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Physical Exam:
Vitals: 98.3F, HR 73, BP 111/64, RR 18, 100% on NC
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, No nuchal rigidity
Cardiac: RRR
Abdomen: soft, NT/ND
Extremities: No ___ Edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history with
difficulty with details. Mildly Inattentive, able to name ___
backward until ___ then stops. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. Pt was able to register 3 objects and recall ___ at 10
minutes. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: Pupils 1.5mm b/l and minimally reactive to
light. EOMI with several beats of fine end gaze nystagmus. VFF
to
confrontation.
V: Decreased LT and pinprick over V2 and V3 of right face.
VII: Initially her left mouth appeared drooped compared to the
right. Then throughout our conversation she had R NLFF compared
to L with symmetric activation.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
Mild fluctuating dysarthria - with lingual and guttural sounds
but palate elevates symmetrically and tongue is midline.
-Motor: Normal bulk, tone throughout. On testing of pronator
drift, her right fingers curl.
No adventitious movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 4+ ___ 5 5 5 4+ 4+
R 5 ___ 5 4+ ___ 5 5 5 4+ 4+
-Sensory: No deficits to light touch, pinprick throughout.
Initially said that left arm was decreased to light touch
compared to right, then said that it was equal. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 2
R 2 2 2 3 2
Plantar response was flexor bilaterally. No Hoffmans, b/l
pectoral jerks, b/l crossed adductor. One beat ankle clonus
bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing.
===================================================
DISCHARGE PHYSICAL EXAM:
AAO x 3. R NLFF with symmetric activation, no dysarthria. Fex
weakness on the left. SILT. Coordination intact.
Pertinent Results:
ADMISSION LABS:
___ 12:08AM BLOOD WBC-11.7* RBC-4.26 Hgb-13.0 Hct-39.3
MCV-92 MCH-30.5 MCHC-33.1 RDW-12.7 RDWSD-42.4 Plt ___
___ 12:08AM BLOOD Neuts-57.2 ___ Monos-6.5 Eos-0.9*
Baso-0.4 Im ___ AbsNeut-6.71* AbsLymp-4.06* AbsMono-0.76
AbsEos-0.10 AbsBaso-0.05
___ 12:08AM BLOOD ___ PTT-34.7 ___
___ 12:08AM BLOOD Glucose-95 UreaN-9 Creat-0.6 Na-137 K-3.6
Cl-105 HCO3-21* AnGap-15
___ 04:45AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.2 Cholest-179
___ 04:45AM BLOOD %HbA1c-5.0 eAG-97
___ 04:45AM BLOOD Triglyc-67 HDL-44 CHOL/HD-4.1 LDLcalc-122
___ 04:45AM BLOOD TSH-2.5
___ 12:08AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
CXR ___:
No acute process
MRI BRAIN ___:
Small acute infarct in the left frontal cortical region. No
signs of
hemorrhage. No mass effect or hydrocephalus.
TTE ___:
The left atrial volume index is normal. The interatrial septum
is aneurysmal. No atrial septal defect is seen on color flow
Doppler, but there is early appearance of agitated
saline/microbubbles in the left atrium/ventricle at rest most
consistent with an atrial septal defect or stretched patent
foramen ovale (though a very proximal intrapulmonary shunt
cannot be fully excluded). The estimated right atrial pressure
is ___ mmHg. Normal left ventricular wall thickness, cavity
size, and regional/global systolic function (biplane LVEF = 61
%). Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). Doppler parameters are most
consistent with normal left ventricular diastolic function.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Aneurysmal and dynamic interatrial septum with
evidence of stretched PFO/ASD.
LOWER EXT ULTRASOUND ___:
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
MRV PELVIS ___:
1. No evidence of pelvic venous thrombosis or thrombosis in the
inferior vena cava.
2. 2 peripherally enhancing structures in the left adnexa,
containing high signal intensity on precontrast T1 weighted
images with peripheral rim enhancement on post-contrast images,
not fully assessed on this examination which was performed to
assess for venous thrombosis, might represent endometrioma or
hemorrhagic cyst with hematosalpinx, but can be further
evaluated with pelvic ultrasound and/or dedicated pelvic MRI as
clinically indicated.
3. Simple cyst, hepatic segment 6.
Brief Hospital Course:
___ woman with no vascular risk factors who presented
with sudden onset R hand weakness, b/l arm numbness/tingling,
right facial heaviness and slurred speech, which resolved, found
to have a left corona radiata stroke. Her exam was initially
significant for R NLFF with symmetric activation, intermittent
mild dysarthria with lingual and guttural sounds, R fingers curl
when testing for drift and mild finger ext weakness on the left.
Etiology of stoke is likely PFO in the setting of valsalva. MRV
negative for clot, though did show an incidental finding of two
peripherally enhancing structures in the left adnexa. LENIs
negative. Stroke risk factors: LDL 122 and HBA1c 5.0. Patient
was sent home with with aspirin and atorvastatin. She was given
a prescription for outpatient hypercoaguble work-up. She will
follow-up with stroke neurology.
Transitional issues:
-continue aspirin, atorvastatin
-f/u neurology
-f/u hypercoagulable labs
-Consider pelvic ultrasound to further eval incidental finding
on mrv pelvis
==========================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - hsq () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - aspirin () No
4. LDL documented? (x) Yes (LDL =122 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - atorva 80 ()
No [if LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - atorva 80 () No [if
LDL >100, reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - aspirin() Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Asmanex Twisthaler (mometasone) 220 mcg (60 doses) inhalation
BID
2. Cyclobenzaprine 10 mg PO BID:PRN spasm
3. Prochlorperazine 10 mg PO Q6H:PRN nausea
4. Venlafaxine 37.5 mg PO DAILY
5. TraZODone 50 mg PO QHS
6. Nortriptyline 25 mg PO QHS
Discharge Medications:
1. Cyclobenzaprine 10 mg PO BID:PRN spasm
2. Nortriptyline 25 mg PO QHS
3. Prochlorperazine 10 mg PO Q6H:PRN nausea
4. TraZODone 50 mg PO QHS
5. Venlafaxine 37.5 mg PO DAILY
6. Asmanex Twisthaler (mometasone) 220 mcg (60 doses) inhalation
BID
7. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*5
8. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*5
9. Outpatient Lab Work
Protein C, Protein S, Anti-thrombin III, B2 glycoprotein,
anti-cardiolipin, lupus anti-coagulant, factor V Leiden,
homocysteine, Prothrombin gene mutation
Discharge Disposition:
Home
Discharge Diagnosis:
Acute ischemic stroke
___ foramen ovale
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of right arm weakness and
trouble speaking 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:
-high cholesterol
We are changing your medications as follows:
-Start Aspirin 81
-Start Atorvastatin 80
Please take your other medications as prescribed.
Please get outpatient lab work at a ___ facility ___
would be closer to your home) so we can see the results.
Please follow-up 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:
___
|
10867893-DS-7
| 10,867,893 | 23,852,776 |
DS
| 7 |
2157-11-04 00:00:00
|
2157-11-04 15:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Fruits (unknown)
Attending: ___.
Chief Complaint:
Trauma: fall vs jump
fracture right distal radius
L2 compression fracture
Major Surgical or Invasive Procedure:
cast to right distal radius fracture
History of Present Illness:
This patient is a ___ year old male with history of DM
arrives via ES transferred from ___ for
tertiary evaluation of acute L2 fracture and right distal
fracture s/p fall today. Story is unclear in the setting of
ETOH intoxication however it was reported that patient fell
out of a 2 story window, about 13 feet high. It is unclear
if this was intentional or secondary to ETOH intoxication.
Pt unable to recall if he did this intentionally. He was
transported to ___ where he was found to have acute
L2 fracture and right distal fracture. CT abdomen
demonstrated no kidney on the right and hydrourter
nephrosis. He was neurologically intact and CT head and
c-spine was negative. He was administered 8mg morphine and
zofran prior to arrival. He has had stable vital signs, good
blood pressure throughout.
Past Medical History:
Diabetes insipidous
Depression
congenital abscence of right kidney
Social History:
Patient reported ETOH use has only become a problem in the
past ___ year. Patient reported he started drinking when he was
___ or
___, but pt didn't start drinking heavily until over a year ago
when pt's ex-girlfriend broke up with him. Pt reported he would
drink 16 beers and then would drink some Jägermeister. Pt
reported recently pt quit "cold ___ for 2 weeks, but then pt
relapsed. Pt's motivation to quit was to move back into pt's
parents house and to prove that pt could be sober. Pt reported
that the lowest amount of ETOH pt drinks is 3 beers a day
Pt has awareness to pt's ETOH use and pt's mental ___. Pt
reported that pt self medicates with ETOH. Pt reports it helps
control his mind from racing. Pt is aware that pt will drink
heavily when pt experiences a social stressor. In the most
recent incident, pt's friend (dating relationship) is currently
in the hospital due to seizures. Also, pt reported that when pt
was drinking his friends told him not to go home and pt wanted
to
go home and this increased pt's stress level. Pt reported these
social/emotional stressors contributed to pt increase in his
drinking.
Family History:
none
Physical Exam:
PHYSICAL EXAMINATION upon admission ___
Temp: 98.9 HR: 122 BP: 130/66 Resp: 16 O(2)Sat: 98 Normal
Constitutional: moderate distress
HEENT: pupils 2mm and reactive., Normocephalic, atraumatic,
Extraocular muscles intact
c-spine cleared
Chest: airway intact, good bilat breath sounds
Cardiovascular: tachycardic, Normal first and second heart
sounds
Abdominal: suprapubic tenderness. linear abrasions lower
abdomen and chest wall.
Rectal: prostate normal, no gross blood and good rectal
tone.
Extr/Back: good pulses,good radial pulses, L2 tenderness to
palpation. L3-L4 and sacral tenderness.
Skin: Warm and dry, abrasions to chest wall and lower
abdomen
Neuro: awake and alert
PHYSICAL EXAMINATION upon discharge ___
Temp: 97.9 HR: 70 BP: 118/70 Resp: 16 O(2)Sat: 99% RA
Constitutional: moderate distress
HEENT: Normocephalic, atraumatic,
Extraocular muscles intact
Chest: clear bilaterally
Cardiovascular: RRR
Abdominal: nondistended, nontender
Extr: cast applied right distal radius for fracture; intact
sensation distally, no discloration
Skin: Warm and dry, abrasions to chest wall and lower
abdomen
Neuro: awake and alert
Pertinent Results:
___ 06:50AM BLOOD WBC-6.7 RBC-4.24* Hgb-13.1* Hct-41.5
MCV-98# MCH-31.0 MCHC-31.7# RDW-11.9 Plt ___
___ 06:00AM BLOOD WBC-10.2 RBC-4.46* Hgb-14.2 Hct-40.2
MCV-90 MCH-31.9 MCHC-35.4* RDW-12.1 Plt ___
___ 08:35AM BLOOD WBC-18.9* RBC-5.28 Hgb-16.2 Hct-47.2
MCV-89 MCH-30.6 MCHC-34.3 RDW-12.5 Plt ___
___ 06:50AM BLOOD Plt ___
___ 08:35AM BLOOD ___ PTT-29.9 ___
___ 08:35AM BLOOD ___
___ 06:40AM BLOOD Glucose-113* UreaN-12 Creat-0.9 Na-140
K-4.3 Cl-97 HCO3-25 AnGap-22*
___ 11:41AM BLOOD Glucose-120* UreaN-10 Creat-0.9 Na-135
K-4.8 Cl-96 HCO3-28 AnGap-16
___ 01:06AM BLOOD Glucose-103* UreaN-8 Creat-0.9 Na-150*
K-3.5 Cl-110* HCO3-30 AnGap-14
___ 08:35AM BLOOD Lipase-20
___ 06:40AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.3
___ 08:35AM BLOOD ASA-NEG Ethanol-94* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:00AM BLOOD TSH-2.4
___ 06:00AM BLOOD VitB12-388
___ 08:35AM BLOOD Glucose-132* Lactate-3.0* Na-154* K-4.3
Cl-118* calHCO3-18*
___: chest x-ray:
No acute cardiopulmonary process.
___: ct of abdomen and pelvis:
1. Solitary left kidney with moderate hydroureteronephrosis.
No visualized cause of obstruction. Distended bladder.
2. Acute compression deformity of the L2 vertebral body and a
possible right L1 transverse process fracture.
3. No free air or free fluid in the abdomen or pelvis. No
evidence of solid organ injury.
___: left wrist x-ray:
Three views of the right wrist. Fine bony detail is obscured
by
overlying cast. There has, however, been interval reduction of
the dorsal angulation seen at the distal right radius fracture.
Ulnar styloid fracture was better seen on prior exam. There is
no new displaced fracture visualized.
___: left knee:
No fracture
___: MRI lumbar spine:
Acute L2 compression fracture with less than 25% anterior height
loss. There is no bony retropulsion or cauda equina compression.
___: X-ray of abdomen:
Nondilated loops of large bowel with a relative paucity of
small bowel air which is nonspecific
Brief Hospital Course:
The patient was admitted to the hospital after a fall vs jump
from a 2 story window. The patient reported to EMS on the scene
that it was intentional but later denied suicide ideation.
Becuse of this, the patient was placed under a 1:1 watch. He
was also reported to have an elevated alcohol level to 93. Upon
admission, the patient was made NPO, given intravenous fluids
and underwent imaging of his head, neck and back. He was placed
in a cervical collar for neck stabilzation, pending imaging
results. Imaging at an outside hospital showed no cervical
injury and the cervical collar was removed after clinical
examination. Chest imaging showed a L2 compression fracture. To
provide further recommendations, Neurosurgery was consulted.
After examination, they determined that the patient was
neurologically stable, and recommended a TLSO brace. No
surgical intervention was indicated. During his inital
assessment, the patient was found to have a right distal radius
fracture. The right wrist was casted, and follow-up in the
___ clinic was recommended. Physical and occupational
therapy evaluated the patient and provided recommendations for
discharge.
Because of the circumstances leading to the patient's
hospitalization, the Psychiatry service was consulted to
evaluate the patient. The patient continued with 1:1 sitters.
He resumed his pre-hospital home medications and placed on a
CIWA scale for alcohol withdrawal. The patient has had no signs
of alcohol withdrawal, but because he reported anxiety, he was
admininstered valium as per CIWA protocol.
The patient's vital signs have been stable and he has been
afebrile. He did require additional valium for a CIWA scale
score of 19 on ___, scoring in heart rate and anxiety. He has
not had any further evidence of requiring valium. His CIWA
scale has been decreased to every 4 hours. He has reported
that he always feels anxious. He has been tolerating a regular
diet and voiding without difficulty. He has been ambulating
with the lumbar brace for back support. On HD # 6, the patient
was reported to have a marked area of erythema on his left wrist
related to a prior intravenous site so the catheter was removed
and warm packs were applied. The site of erythema resolved by
the time of discharge.
The patient has been medically cleared for discharge to an
inpatient psychiatric facility for further monitoring. He has
multiple follow up appointments scheduled as seen in follow up
instructions.
Medications on Admission:
DDAVP
Celexa
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Desmopressin Acetate 0.1 mg PO DAILY
please give at 1500 hours
3. Desmopressin Acetate 0.2 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
9. Senna 8.6 mg PO BID:PRN constipation
10. Tamsulosin 0.4 mg PO HS
11. Thiamine 100 mg PO DAILY
12. Acetaminophen 650 mg PO Q6H:PRN pain
13. Diazepam 5 mg PO Q4H:PRN CIWA >10
14. TraZODone 25 mg PO HS:PRN insomnia
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Trauma: fall from ___ story window
right distal radius fracture
L2 compression fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane) ( requires lumbar brace when OOB and when HOB >30
degrees)
Discharge Instructions:
You were admitted to the hospital after a fall/jump from a 2
story window. You sustained a fracture to your right arm, and a
fracture to your lower back. You were seen by the orthopedic
and neurosurgery services who determined that no intervention
was indicated. Becauses of the circumstances of the fall, you
were evaulated by the Psychiatry service and recommendations
made for inpatient psych admission.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
continue to keep the splint on the right arm, please report:
*increased pain fingers right hand
*numbness fingers right hand
*inability to move fingers right hand
Please wear the brace when you are ambulating and when the head
of bed is greater than 30 degrees. Please report any decrease
sensation lower extremities, difficulty walking, weakness legs,
inabilty to control your bowels and bladder
Followup Instructions:
___
|
10868254-DS-18
| 10,868,254 | 22,063,465 |
DS
| 18 |
2166-05-25 00:00:00
|
2166-05-26 11:52:00
|
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___ consolidation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ Down syndrome, alzehimer's, h/o mild disphyagia (per ___
swallow study), hypothyroidism, chronic anemia, sent by PCP for
___ consolidation.
Per report, group home coordinator by bedside, reports new cough
this week. +coarse cough, though inability to cough up sputum.
He also noted elevated temp, though did not have exact number.
He notes that his diet was recently liberalized from pureed to
"chopped" based on another recent swallow eval, and he is
concerned for aspiration. The coordinator cannot think of
additional sick contact, though pt does attending a daily adult
rehab program. Group home aids has not noted emesis. Had
___ diarrhea x 1 this week, ___ recent abx,
usually happens ___ per month. Does chronically lie in
bed, but well's 1.5. Additional subjective symptoms were unable
to be obtained as patient was not cooperating with
history/physical.
In the ED intial vitals were: 98.1 88 109/54 20 94%
- Exam: afebrile RR low ___, Pox 94 -96%. lung - weak effort, +
corase upper airway transmitted sound. heart RRR, soft SEM, abd-
NTND. Lower extremities - ___ sig. swelling.
- Labs were significant for: WBC 15 (84%N), Hct 34, lactate 1.1,
normal chem
- Patient was given: Vanc/zosyn
- Pt is being admitted for elevated RR in the setting of ___
consolidaiton with concerns for asp.
- Vitals prior to transfer were: 97.9 84 113/73 18 94% RA
On the floor, pt mostly nonverbal. Brother accompanies patient
and reports all that he knows is that pt had a cold at the group
home for a couple of days with low grade temp and cough. He is
not sure if others were sick at the group home. Pt went to see
PCP today and PNA was found. He does not know much more. ___
recent admissions to hospital in last 3mo. Pt's brother mentions
that advancing from pureed to ground diet recently has
contributing to improved weight and QOL for patient.
Review of Systems:
(+) per HPI, limited by MS
Past Medical History:
___: Prostate Nodule: Referred to Urology
Alzheimers dementia: followup: Dr. ___: ___
History of urinary and fecal incontinence x >/= ___ years
History of GI evaluation ___
History of evaluation by Urology: Dr ___ at ___
Downs syndrome
Mental Retardation
___ Disorder
History of grade II systolic murmur: Reported evaluated with
echocardiogram (cardiology reported as diagnosed as physiologic
murmur only)
dx in ___ with " classic narcolepsy" - trial of
ritalin for this brought about decreased socialization
hx of hyperlipidemia started on lipitor 10 mg daily 2001Psych
started Vit E on ___ with stated improvement on EPS from
risperdal ( had significant cogwheeling sympotms before)
full dentures
wears glasses
colonosocpy done at ___ ___ - per group home staff
hypothyroidism
history immune to Hep B - labs ___: HepB surface, and total
core,
AB's positive, AG negative; Hep A and C AB's negative
Brother: ___: Medical Guardian ___
? asthma in childhood
swallowing study ___ ___: ___ aspiration - mild
dysphagia - recommended minced food, aspiration precuations/1:1,
GERD
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission:
___, 128/60, 88, 18, 92% RA
General- ___ male with downs syndrome who appears older
than stated age, in NAD
HEENT- repetitive movements of face and mouth, tongue out often
CV- RRR, ___ murmurs
Lungs- noncompliant with exam, ___ deep breathing able to be
prompted so unable to appreciate abnormal lung sounds
Abdomen- soft, NT, ND
Ext- ___ edema
Neuro- mostly nonverbal, makes occasional sounds, moves all
extremities
Discharge:
Vitals: 97.6 103/57 81 18 100% RA
General: Alert, oriented, ___ acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, tardive
dyskinesia
Neck: supple, JVP not elevated, ___ LAD
Lungs: Exam limited by inability of pt to cooperate with exam
but notable for decreased breath sounds and dullness to
percuhssion at left base
CV: Prominent holosystolic murmur heard on the back and
throughout the precordium
Abdomen: soft, ___, bowel sounds present,
___ rebound tenderness or guarding, ___ organomegaly
Ext: Warm, well perfused, 2+ pulses, ___ clubbing, cyanosis or
edema
Skin: ___ rashes on visualized skin
Neuro: Unable to assess fully but CN ___ grossly intact, pt
ambulated without difficulty
Pertinent Results:
Admission labs:
___ 06:30PM PLT ___
___ 06:30PM ___
___
___ 06:30PM ___
___
___ 06:30PM ___
___ 06:30PM ___
___ 06:30PM ___ this
___ 06:30PM ___ UREA ___
___ TOTAL ___ ANION ___
___ 06:42PM ___
___ 06:42PM ___ TOP
Discharge labs:
___ 06:50AM BLOOD ___
___ Plt ___
___ 06:50AM BLOOD ___
___
___ 06:50AM BLOOD ___
Micro:
___ 6:30 pm BLOOD CULTURE #1 SOURCE: VENIPUNCTURE.
Blood Culture, Routine (Pending):
___ 10:55 pm Influenza A/B by ___
Source: Nasopharyngeal swab.
**FINAL REPORT ___
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
Imaging:
CXR ___: Multifocal pulmonary consolidation is most pronounced
in the lingula and left
lower lobe, with probable tertiary component in the right middle
lobe.
Moderate left pleural effusion and small right pleural effusion
are present.
Cardiac silhouette is obscured but probably not enlarged and the
pulmonary
vasculature is not engorged.
CT chest w/ contrast ___:
Preliminary report:
IMPRESSION:
1. Multifocal pneumonia lower lobe prominent with large
area of ground glass
and peribronchial consolidation, more severe to the left
involving mainly the
left lower lobe and lingula and lesser extent the right
lower lobe and
posterior segment of the right upper lobe.
2. Bilateral pleural effusion is moderate to the left
and minimal to the
right. More dense at the left lung base probably for
fluid organization.
3. Mediastinal lymphadenopathy is severe especially in
the AP window with
largest lymph node of 21 x 24 mm, likely reactive to
pneumonia.
4. Aortic arch has point of narrowing with mild
___ dilatation and
compatible with aortic coarctation and also with
anatomical variants of
arteria lusoria and common origin of the left subclavian
and right and left
common carotid arteries.
Brief Hospital Course:
___ Down syndrome, alzehimer's, h/o mild disphyagia (per ___
swallow study), hypothyroidism, sent by PCP for PNA.
# Multifocal PNA: Most prominent infiltrate in ___. CAP vs
aspiration PNA given diet change from pureed to chopped. Pt
lives in group home (not nursing home) and has not otherwise
been admitted to the hospital so does not require HCAP coverage.
There is a question of a preceding viral illness per reports
from pt's brother with URI symptoms, though flu was neg. WBC
trended down. Clinically improved, afebrile/normoxic. CT chest
with reactive LAD, apparently uncomplicated pleural effusion w/o
e/o empyema. He was started on a 7 day course of
levofloxacin/flagyl. His diet was changed to pureed solids and
thin liquids pending s/s reevaluation. He should be monitored
for signs of aspiration. He needs close chest imaging followup
within ___ weeks to monitor for improvement in the effusion
(volume was less than half of the left hemithorax). If not
improving or is worsening then he should be referred to ___ or IP
for thoracentesis.
# Anemia: Hct of 34 on admission, new from previous baseline in
___. Normocytic. Improved to 38 at discharge. Iron studies c/w
chronic dx.
# Murmur: Likely ___ coarct seen on CT. Could also consider MR.
___ signs of obvious CHF, though. Reportedly has a h/o systolic
murmur, reportedly benign on TTE. If this particular murmur has
not been characterized previously then consider outpt TTE to
characterize.
# Alzheimers, Downs syndrome: Continued donepezil, risperidone.
# OCD/Depression: Continued sertraline.
# HLD: Continued ___ 81
# GERD: Continued PPI
# Hypothyroidism: Continued levothyroxine
Transition issues:
- Discharged on 7 day course of levaquin/flagyl (completes ___
- Outpt PCP followup
- ___ have repeat CXR in ___ weeks. If effusion is unchanged
or enlarging then should referred for paracentesis by
interventional radiology or pulmonology
- Noted to have a systolic murmur on exam. Could be ___ aortic
coarctation seen on CT or previously known systolic murmur but
consider TTE to exclude valvular pathology if felt by outpt
providers to be new
- Discharged on pureed solids/thin liquids diet.
- Speech and swallow evaluation should be repeated as an
outpatient
- Final read of CT chest should be followed up
- Monitor for signs of aspiration
Medications on Admission:
1. Donepezil 10 mg PO QAM
2. Aspirin 81 mg PO DAILY
3. Loratadine 10 mg PO DAILY
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Psyllium 1 PKT PO BID
7. Sodium Chloride Nasal ___ SPRY NU BID:PRN nasal congestion
8. HydrOXYzine 25 mg PO QHS
9. Docusate Sodium 100 mg PO HS
10. Atorvastatin 10 mg PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Ketoconazole 2% 1 Appl TP PRN rash
13. Acetaminophen 650 mg PO Q4H:PRN HA, pain, fever
14. RISperidone 0.5 mg PO QAM
15. Sertraline 100 mg PO BID
16. RISperidone 4 mg PO HS
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN HA, pain, fever
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Docusate Sodium 100 mg PO HS
Hold for loose stools
6. Donepezil 10 mg PO QAM
7. Levothyroxine Sodium 150 mcg PO DAILY
8. Loratadine 10 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Psyllium 1 PKT PO BID
11. RISperidone 0.5 mg PO QAM
12. RISperidone 4 mg PO HS
13. Sertraline 100 mg PO BID
14. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
15. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*15 Tablet Refills:*0
16. HydrOXYzine 25 mg PO HS:PRN insomnia
17. Ketoconazole 2% 1 Appl TP PRN rash
18. Sodium Chloride Nasal ___ SPRY NU BID:PRN nasal congestion
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Community acquired pneumonia
Parapneumonic effusion
Secondary diagnoses:
Down's syndrome
Alzheimer's disease
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted after your PCP found that you had pneumonia.
The chest ___ found that you have a fluid collection in your
lung near the pneumonia. Many times this clears up on its own
with some time. We will discharge you with close ___ with
Dr. ___. You will need some outpatient chest ___ in the
next two weeks to ensure that the fluid collection is improving.
If it doesn't improve, you may require a small procedure to
drain the fluid. This can be discussed further with your PCP.
Antibiotics have been added to your medication regimen. Please
complete the entire course of antiobiotics.
It was a pleasure participating in your care, thank you for
choosing ___!
Followup Instructions:
___
|
10868254-DS-19
| 10,868,254 | 26,241,576 |
DS
| 19 |
2166-06-06 00:00:00
|
2166-06-06 13:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
failed swallow eval
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History from ___ the ___ and from ___ notes as patient is
non-verbal.
.
___ year old M with history of Down Syndrome and recent admission
for aspiration PNA who failed a video swallow evaluation today
admitted for discussion of PEG placement.
.
Patient failed video swallow with fluids of all consistence
today. PCP was unable to contact the ___ and the group home
was unable to accept him back without clarification of his
dietary status.
.
In the ED VS 96.8 66 120/73 16 99%. Labs with normal WBC, Hct,
and Chem 7.
.
Upon arrival the floor, patient is accompanied by both ___ his
bother and ___ and ___, a representative from the group
home. They deny any recent fevers, dyspnea, cough, c/o of pain.
the patient has been eating regularly at the group home and does
seem to choke intermittently.
.
REVIEW OF SYSTEM:
please see HPI. Patient is non-verbal and only some review of
symptoms was obtained from ___ and caretaker.
Past Medical History:
Prostate Nodule
Alzheimers dementia: followup: Dr. ___: BWH
History of urinary and fecal incontinence for more than ___ years
Downs syndrome
Mental Retardation
Obsessive-Compulsive Disorder
HLD
Hypothyroidism
GERD
Dysphagia
Social History:
___
Family History:
unknown
Physical Exam:
ADMISSION AND DISCHARGE PHYSICAL EXAM:
VS: 98.0, 76, 118/63, 20, 100% RA
General: Alert, no acute distress, non-verbal
HEENT: MMM
Lungs: Exam limited by inability of pt to cooperate with exam
but clear on limited exam
CV: holosystolic murmur heard on the precordium
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: no c/c/e
Skin: No rashes on visualized skin
Neuro: patient moving all extremities and gait is normal
Pertinent Results:
ADMISSION LABS:
___ 07:00PM BLOOD WBC-6.5 RBC-4.47* Hgb-13.4* Hct-43.4
MCV-97 MCH-29.9 MCHC-30.8* RDW-17.0* Plt ___
___ 07:00PM BLOOD Neuts-62.3 ___ Monos-6.7 Eos-1.2
Baso-1.0
___ 07:00PM BLOOD Plt ___
___ 07:00PM BLOOD Glucose-89 UreaN-15 Creat-0.9 Na-135
K-5.0 Cl-99 HCO3-28 AnGap-13
.
Video Swallow Eval ___
IMPRESSION: Aspiration with thin liquid, nectars and honey
thickened barium consistency. Please see the complete speech
and swallow division note in the ___ medical record for full
details.
Brief Hospital Course:
___ Down syndrome, alzehimer's, h/o mild disphyagia (per ___
swallow study), hypothyroidism, sent by PCP after failing
swallow eval.
.
# Aspiration. Patient failed video swallow evaluation on
___ with liquids of all consistence. After discussing goals
of care and patient's wants with both the group home
representative ___ and HCP ___, it was decided the patient
should continue to eat and accept the risk fo aspiration. Risk
and complications were discuss with understanding from all
parties. We discussed code status, and the HCP overall agrees
with plan for DNR/DNI but wanted more family discussion, so code
status changes were NOT made. Please see the speech and swallow
note for full recommendations, in short PO diet consist of
nectar-thick liquids and moist ground/chopped solids. Speech and
swallow will call the patient regarding outpatient follow up.
- consider weaning down medications to minimize the risk of pill
aspiration
# Alzheimers, Downs syndrome. Continued donepezil, risperidone.
# OCD/Depression. Continued sertraline.
# HLD. Held atorvastation and ASA during admission
# GERD. Held PPI during admission.
# Hypothyroidism. Continued levothyroxine
# CODE STATUS: Full. Family will discuss code status and likely
change to DNR/DNI.
# CONTACT: ___ (Brother) Medical ___ ___
___ issues
# consider reducing the number of medications to reduce risk of
aspiration
# rediscuss code status
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO BID
2. Donepezil 10 mg PO QAM
3. Aspirin EC 81 mg PO DAILY
4. Loratadine 10 mg PO QAM
5. Levothyroxine Sodium 150 mcg PO QAM
6. Cyanocobalamin 1000 mcg PO QAM
7. Hydrocerin 1 Appl TP DAILY
8. Psyllium 1 PKT PO BID
9. Sodium Chloride Nasal 2 SPRY NU BID
10. HydrOXYzine 25 mg PO QHS
11. Docusate Sodium 100 mg PO HS
12. Atorvastatin 10 mg PO HS
13. Ketoconazole 2% 1 Appl TP DAILY
14. Acetaminophen 650 mg PO Q6H:PRN pain
15. Betamethasone Dipro 0.05% Cream 1 Appl TP QHS:PRN itch
16. RISperidone 0.5 mg PO QAM
17. Sertraline 100 mg PO BID
18. RISperidone 4 mg PO HS
Discharge Medications:
1. Betamethasone Dipro 0.05% Cream 1 Appl TP QHS:PRN itch
2. Donepezil 10 mg PO QAM
3. Hydrocerin 1 Appl TP DAILY
4. Ketoconazole 2% 1 Appl TP DAILY
5. Levothyroxine Sodium 150 mcg PO QAM
6. RISperidone 0.5 mg PO QAM
7. RISperidone 4 mg PO HS
8. Sertraline 100 mg PO BID
9. Sodium Chloride Nasal 2 SPRY NU BID
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. Aspirin EC 81 mg PO DAILY
12. Atorvastatin 10 mg PO HS
13. Cyanocobalamin 1000 mcg PO QAM
14. Docusate Sodium 100 mg PO HS
15. HydrOXYzine 25 mg PO QHS
16. Loratadine 10 mg PO QAM
17. Omeprazole 40 mg PO BID
18. Psyllium 1 PKT PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Dysphagia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert, unable to assess orientation
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to participate in your care at the ___
___. You were admitted after failing a
video swallow evaluation. This test is different than the
clinical exam that was done in ___ and you have not had a
video swallow evaluation in ___ years. You aspirated liquids of
all consistence.
We discussed with you in detail the risks of aspiration
including frequent and possible severe infections. Your ___
___ and ___ providers understand the risks involved. Since
eating is so important to you, we all agree you should continue
to eat and accept the risks of aspiration. We highly recommended
considering Do Not Resuscitate/Do Not Intubate (DNR/DNI) in the
future.
The recommendations from the speech and swallow team is as
follows:
1. With HCP accepting risk of aspiration, suggest PO diet of:
nectar-thick liquids and moist ground/chopped solids.
2. When not with meals, Pt may have thin liquids after oral
care,
for comfort/QOL accepting increased risk of aspiration.
3. Direct supervision with all meals (suggest anywhere from 1:1
to 1:4) to assist Pt in following safe swallow strategies.
4. Aspiration precautions/safe swallow strategies:
A. Only offer the Pt one small bite/sip at a time. Try to
avoid Pt taking sequential sips/chugging liquids.
B. Have Pt eat/drink at a slow rate.
C. Food should be cut/chopped into very small pieces
approximately ___ inch x ___ inch in size or less.
D. Food should be kept moist with extra soft butter or
gravy.
E. Encourage Pt to swallow 2x per bite/sips
F. Have the Pt alternate between bites/sips (one bite then
one small sip)
G. After every few bites/sips, have Pt cough and re-
swallow saliva
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
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2166-06-22 00:00:00
|
2166-06-22 20:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Jaw pain following a fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with Down syndrome, presented to ED via EMS s/p witnessed
fall onto his face. Per group home staff, Mr. ___ was walking
from one room to another when he fell forward, striking his chin
first, and without putting his hands down. Though there is a
raised threshold in the doorway, staff are unsure whether this
was a mechanical fall or a syncopal event. Per the group home,
he lifted his head up soon after landing on the ground and
looked around and subsequently stood up. Staff denied LOC or
seizure activity, and report Mr. ___ seemed at his baseline
immediately after getting up. The patient's brother reports the
patient has suffered several falls in the past year, but denies
any prior head or neck injury. He does recall a longstanding
issue with aggressive rocking behavior with snapping of the neck
back and forth which concerned family and caregivers, but no
known injury was associated.
CT head and C-spine were obtained in the ED, given the mechanism
of injury and obvious resulting mandible injury, and revealed
comminuted mandibular fracture as well as atlanto-occipital
subluxation.
Past Medical History:
Prostate Nodule
Alzheimers dementia: followup: Dr. ___: ___
History of urinary and fecal incontinence for more than ___ years
Downs syndrome
Mental Retardation
Obsessive-Compulsive Disorder
HLD
Hypothyroidism
GERD
Dysphagia
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: 97.8 72 112/65 18 100%
GEN: Alert, inconsistently follows directions from brother only.
Pulling at cervical collar and grunting.
NEURO: Though patient is uncooperative, he MAE with full
strength
x4. Cranial nerves II-XII grossly intact.
HEENT: Syndromic, PERRLA. 4x3cm ecchymosis with superficial
abrasion over the left chin, superficial abrasion to the left
cheek and two small superficial lacerations to the upper lip and
philtrum. Obvious mandible deformity. Hard cervical collar on.
+blood-tinged drainage from R ear.
CV: Regular, +murmur
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused. Strength ___ b/l
upper and lower extremities.
Discharge Physical Exam:
97.8 / 97.2 / 71 / 102/61 / ___ RA
GEN: Alert, inconsistently follows directions from and
caretaker. NAD.
NEURO: Though patient is uncooperative, he MAE with full
strength
x4. Cranial nerves II-XII grossly intact.
HEENT: Syndromic, PERRLA. 4x3cm ecchymosis with superficial
abrasion over the left chin, superficial abrasion to the left
cheek and two small superficial lacerations to the upper lip and
philtrum. No drainage from ear. Appropriately TTP onver
mandible
CV: Regular, +murmur
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused. Strength ___ b/l
upper and lower extremities.
Pertinent Results:
___ 08:35PM BLOOD WBC-5.1 RBC-4.24* Hgb-13.3* Hct-41.3
MCV-97 MCH-31.4 MCHC-32.3 RDW-16.5* Plt ___
___ 08:35PM BLOOD Neuts-55.4 ___ Monos-9.1 Eos-3.5
Baso-1.1
___ 08:35PM BLOOD Plt ___
___ 08:35PM BLOOD Glucose-99 UreaN-18 Creat-0.9 Na-137
K-4.0 Cl-102 HCO3-29 AnGap-10
___ 08:35PM BLOOD estGFR-Using this
___ 06:00AM BLOOD WBC-9.3# RBC-4.17* Hgb-12.7* Hct-40.2
MCV-97 MCH-30.5 MCHC-31.6 RDW-16.5* Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-99 UreaN-14 Creat-0.8 Na-138
K-4.5 Cl-101 HCO3-28 AnGap-14
___ 01:00PM BLOOD CK(CPK)-70
___ 06:00AM BLOOD CK(CPK)-72
___ 01:00PM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:00AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.2
IMAGING:
___: CT C-SPINE W/O CONTRAST
IMPRESSION (wet read):
1. Fracture through the left angle of the mandible as detailed
above.
2. Subluxation of the right atlanto-occipital articulation
concerning for
craniocervical dissociation. MRI is recommended for evaluation
of possible ligamentous injury
___: CT HEAD W/O CONTRAST
IMPRESSION (wet read):
1. Comminuted and displaced fracture of the right mandibular
condyle as detailed above. This is an open fracture as there is
gas about the fracture and blood in the external auditory canal.
2. Chronic paranasal sinus disease
___: CHEST (PA+LAT)
awaiting read
___: CT SINUS/MANDIBLE/MAXIL
Wet Read:
1. Right mandibular condyle fracture is better evaluated on this
study. There is communition. The dominant fracture component
involves the articular surface and is displaced medially and
inferiorly. The non-fracture portion of the condyle is subluxed
posteriorly. There is gas about the fracture and blood in the
external auditory canal representing OPEN FRACTURE.
2. There is non-displaced fracture through the left angle of the
mandible.
3. Again there is subluxation of the right atlanto-occipital
articulation
concerning for craniocervical dissociation for which MRI is
recommended for evaluation of possible ligamentous injury
4. Chronic paranasal sinus disease with mucosal thickening and
atrophy of the sinuses.
___: MANDIBLE (Panorex only):
FINDINGS: Three radiographs of the mandible are provided.
Non-displaced
fracture through the angle of the left mandible is
redemonstrated. Again
there is fracture of the right mandibular condyle with some
comminution. The patient is edentulous.
___: HAND (PA, LAT, & OBLIQUE), RIGHT:
FINDINGS: There are severe post traumatic or degenerative
changes at the
first carpometacarpal joint. No acute fracture or dislocation
is detected. There is no concerning lytic or sclerotic lesion
and no radiopaque foreign body.
Brief Hospital Course:
The patient was evaluated in the ED s/p fall. Found to have an
open R mandibular condyle fracture on CT. Evaluated by ___,
Neurosurgery and ENT.
CT head and C-spine were obtained in the ED, given the mechanism
of injury and obvious resulting mandible injury, and revealed
comminuted mandibular fracture as well as atlanto-occipital
subluxation. He was then placed in a hard cervical collar and
neurosurgery was consulted. The CT was reviewed with Dr. ___,
___ neurosurgeon on call, and determined not to have any
features suggestive of acute traumatic component. In light of
the patient having gotten up post-injury and self-mobilized his
head and neck with a fully intact exam on arrival, it is safe
to clear the cervical spine without the need for MRI, per
discussion with Dr. ___. No further imaging or neurosurgical
intervention necessary for the finding of subluxation at this
time. Management of the remaining mandibular injuries per
ED/trauma surgery. Of note, Mr. ___ brother reports that he
has had several falls in the past year, and that he has a long
history of heart murmur, primarily followed at the ___.
Appropriate recs were provided by the consulting services. Per
___ Surgery was not indicated, and the patient was scheduled
for outpatient followup. Pt was trialed on a full liquid diet
after a Speech and Swallow evaluation demonstrated no
aspiration. He tolerated the diet well without pain or
aspiration and was then transitioned to a pureed diet. After
discussion with the patient's care provider and brother, it was
determined he would be safe at home, on a pureed diet, with
appropriate follow up.
Throughout the patient's hospitalization his vital signs and
I/Os were closely monitored. He reported no pain and was not in
any apparent distress. He was discharged ambulatory, voiding
without difficulty, and tolerating a pureed diet. His caretaker
was given instructions for post hospitalization care and follow
up along with contact information, and agreed to provide for his
further care needs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Betamethasone Dipro 0.05% Cream 1 Appl TP QHS Itch
2. Donepezil 10 mg PO HS
3. Hydrocerin 1 Appl TP DAILY
4. Ketoconazole 2% 1 Appl TP DAILY
5. Levothyroxine Sodium 150 mcg PO DAILY
6. RISperidone 0.5 mg PO QAM
7. RISperidone 4 mg PO HS
8. Sertraline 100 mg PO BID
9. Sodium Chloride Nasal 2 SPRY NU BID:PRN Congestion
10. Acetaminophen 650 mg PO Q6H:PRN Pain
11. Aspirin 81 mg PO DAILY
12. Atorvastatin 10 mg PO HS
13. Cyanocobalamin 1000 mcg PO DAILY
14. Docusate Sodium 100 mg PO HS
15. HydrOXYzine 25 mg PO QHS
16. Loratadine 10 mg PO QAM
17. Omeprazole 40 mg PO BID
18. Psyllium 1 PKT PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO HS
3. Cyanocobalamin 1000 mcg PO DAILY
4. Docusate Sodium 100 mg PO HS
5. Donepezil 10 mg PO HS
6. HydrOXYzine 25 mg PO QHS
7. Levothyroxine Sodium 150 mcg PO DAILY
8. Omeprazole 40 mg PO BID
9. Psyllium 1 PKT PO BID
10. RISperidone 0.5 mg PO QAM
11. Sertraline 100 mg PO BID
12. RISperidone 4 mg PO HS
13. Acetaminophen 650 mg PO Q6H:PRN Pain
14. Betamethasone Dipro 0.05% Cream 1 Appl TP QHS Itch
15. Hydrocerin 1 Appl TP DAILY
16. Ketoconazole 2% 1 Appl TP DAILY
17. Loratadine 10 mg PO QAM
18. Sodium Chloride Nasal 2 SPRY NU BID:PRN Congestion
19. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth Every 6
hours Disp #*25 Tablet Refills:*0
20. CIPRODEX (ciprofloxacin-dexamethasone) 0.3-0.1 % otic BID
Duration: 10 Days
4 drops in right ear each dose
RX *ciprofloxacin-dexamethasone [CIPRODEX] 0.3 %-0.1 % 4 drops
Right Ear Twice daily Disp #*1 Bottle Refills:*0
21. Ensure Plus (food supplement, lactose-free) 0.05-1.5
gram-kcal/mL oral With each Meal
RX *food supplement, lactose-free [Ensure Plus] 0.05 gram-1.5
kcal/mL 1 Bottle by mouth Each Meal Disp #*60 Bottle Refills:*2
22. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Vitamin] 1 tablet(s) by mouth Daily
Disp #*60 Capsule Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Fall
Right Mandibular Condyle fracture involving articular surface,
displaced medially and inferiorly. Represents open fracture due
to air and blood in external auditory canal.
Nondisplaced fracture through left angle of mandible.
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Confused - sometimes.
Discharge Instructions:
You will have multiple follow up appointments to keep. Please
call ___ if you have any questions.
You were seen at ___ for falling and injuring your jaw. After
being evaluated by the Trauma surgery team, the ENT surgeons,
and the Oral Maxillo Facial surgeons, it was determined that you
were safe to go home without surgery and to have a follow up
appointment with your primary care provider to evaluate the
cause of your fainting episodes. You should schedule this
appointment as soon as possible.
You should take all of your medications before as prescribed,
and take your new medications as directed. In addition, it is
important to follow the following recommendations:
- Please use the Ciprodex ear drops as prescribed 4 drops in
right ear BID x10 days
- Do the best you can to keep your ear dry other than the ear
drops
- Follow-up with Dr. ___ in clinic in 5 days for wick
removal and re-evaluation.
- It is okay if the ear wick falls out on its own prior to
follow-up. This is a good sign that suggests that the swelling
in
the patient's EAC has improved. Continue using ear drops even if
the wick falls out.
Using Ear Drops
1. Lie down with the affected ear up. You cannot do this
when sitting
2. Place the prescribed number of drops in the ear.
3. Stay in this position for 5 minutes.
4. While you are lying there:
Pull on the earlobe a few times;
Push in front of the ear a few times;
Open and close the mouth a few times.
5. When you sit up, the excess drops will come out. Blot this
excess with a tissue.&
-If the ear drops make you dizzy, try warming them up by holding
them in your hand or against your body.
-If you taste the drops, this is okay, as long as they do not
hurt.
-You can use a cotton ball in the ear to catch the excess
drops, or the discharge from the infection or blood if the ear
is
bleeding. However, do not leave the cotton ball in the ear
longer than necessary.
You should also begin taking a multivitamin daily and ensure
plus with each meal as you can tolerate it to help with your
nutrition.
If you notice any fevers, chills, swelling, new drainage or
swelling in your jaw, difficulty breathing, or anything else
that concerns you, please don't hesitate to call or return to
___.
Followup Instructions:
___
|
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2167-05-02 00:00:00
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2167-05-02 16:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
atorvastatin
Attending: ___.
Chief Complaint:
Cough, malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with a history of Down syndrome, dementia,
GERD, oropharygneal dysphagia with recurrent aspiration, who
presents with a cough x1 week.
Patient lives in a group home, but has been at home with his
mother the past few days. His mother in the ___ reported that he
has had a productive cough, which is worsening. She reports that
he feels warm and had a temperature 99.9 at home. She denied any
history of vomiting, diarrhea, complaints of chest pain or
shortness of breath or decreased p.o. intake. However, states he
has been more lethargic than usual.
In the ___, initial vitals were: 98.7 72 92/37 20 92% ra. Labs
were significant for white count of 10.4 with 82% PMNs. CXR with
left lower lobe consolidation. He was given 1g IV vanc. He was
admitted to medicine for treatment of possible aspiration PNA.
The patient has had recurrent aspiration pneumonias, most
recently in ___. He has failed swallow studies, but
documented discussions with the HCP/family state they want to
feed him despite the risks with aspiration. His documents from
his group home indicate that he eats a ground dysphagia diet,
with whole pills swallowed with applesauce. S/S note from ___
indicate he should drink thickened liquids, or thin liquids for
comfort knowing the risks of aspiration. Note from PCP in
___ notes that brother/HCP has decided to allow Mr. ___
to continue eating solid foods.
On the floor, the patient is sitting poolside, unable to
communicate meaningfully. Has a rhonchorous cough. Requests a
bottle of coke. Appears well.
Past Medical History:
Past Medical History:
1. Down syndrome.
2. Alzheimer's dementia.
3. Obsessive-compulsive disorder.
4. Hypothyroidism.
5. Oropharyngeal dysphagia.
6. GERD.
7. Hyperlipidemia.
8. Recent fractured mandible.
9. Recurrent aspiration
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 98.5 124/70 72 16 95% RA
General: Alert, oriented, no acute distress, speaking
comfortably
HEENT: Sclera anicteric, MM dry, poor oral care. Oropharynx
clear. No LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased air movement at bases bilaterally, upper airway
expiratory rhonchi, junky cough
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no edema
DISCHARGE PHYSICAL EXAM:
Vitals: 97.6 102/55 71 20 98% RA
General: Alert, oriented, no acute distress, speaking
comfortably
HEENT: Sclera anicteric, MMM, Oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB, improved cough
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no edema
Pertinent Results:
ADMISSION LABS:
___ 12:20PM BLOOD WBC-10.4 RBC-3.59* Hgb-12.2* Hct-35.1*
MCV-98 MCH-34.1* MCHC-34.8 RDW-15.9* Plt ___
___ 12:20PM BLOOD Neuts-82.4* Lymphs-14.4* Monos-2.9
Eos-0.1 Baso-0.2
___ 12:20PM BLOOD Glucose-102* UreaN-18 Creat-0.9 Na-138
K-3.7 Cl-103 HCO3-26 AnGap-13
___ 12:20PM BLOOD Calcium-8.1* Phos-2.4* Mg-2.4
___ 12:57PM BLOOD Lactate-1.2
DISCHARGE LABS:
___ 10:10AM BLOOD WBC-8.6 RBC-3.79* Hgb-13.0* Hct-37.6*
MCV-99* MCH-34.2* MCHC-34.5 RDW-15.8* Plt ___
___ 10:10AM BLOOD Glucose-142* UreaN-11 Creat-0.8 Na-138
K-3.6 Cl-103 HCO3-26 AnGap-13
___ 10:10AM BLOOD Calcium-8.4 Phos-2.4* Mg-2.4
STUDIES:
CXR ___:
Findings compatible with left lower lobe pneumonia and
associated pleural effusion, worsened from ___. Coarse
interstitial markings may be a combination of chronic
interstitial disease and mild interstitial edema.
MICRO: Blood cx ___ pending, no growth to date
Brief Hospital Course:
___ male with a history of Down syndrome, dementia,
GERD, oropharygneal dysphagia with recurrent aspiration, who
presents with a cough and CXR concerning for pneumonia.
ACTIVE ISSUES:
# Pneumonia: The patient was admitted for productive cough,
subjective fevers, and maliase. CXR showed LLL consolidation,
consistent with pneumonia. Patient at risk for community
acquired pneumonia and aspiration pneumonia, given chronic
oropharyngeal dysphagia. Patient has had repeated episodes of
aspiration pneumonia, most recently in ___. Patient has
historically gotten his aspiration pneumonias in LLL. He has not
been hospitalized for 6 months, thus he is not at risk for
healthcare-acquired pneumonia. The patient was initially given
IV vancomycin in the ___. On the floor, he was placed on oral
levofloxacin and flagyl. He remained afebrile without an oxygen
requirement during his hospital stay. By discharge he was
feeling well and had symptomatically improved. He will take
antibiotics for a total of 7 days, until ___.
CHRONIC ISSUES:
# Oropharyngeal dysphagia c/b multiple episodes of aspiration:
Patient with hx of recurrent aspirations, with decision to let
patient eat for comfort. Confirmed this with the patient's
brother/HCP during admission. Gave the patient ground solids and
thin liquids. Patient did well with this diet, with no evidence
of aspiration during admission. Code status is ok to intubate,
do not resuscitate.
# GERD: continued omeprazole
# Dementia/OCD: continued donepezil, risperidone, sertraline
# HLD: continued atorvastatin
# Hypothyroidism: continued levothyroxine
TRANSITIONAL ISSUES:
- Continue antibiotics until ___
- CODE: DNR, ok to intubate
- CONTACT: ___ (___) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 175 mcg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Donepezil 10 mg PO QAM
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Multivitamins 1 TAB PO DAILY
7. Aspirin 81 mg PO DAILY
8. Loratadine 10 mg PO DAILY
9. Omeprazole 40 mg PO BID
10. Acetaminophen 650 mg PO Q6H:PRN pain, fever
11. RISperidone 0.5 mg PO QAM
12. RISperidone 4 mg PO QHS
13. Sertraline 100 mg PO BID
14. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. Aspirin 81 mg PO DAILY
3. Donepezil 10 mg PO QAM
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Levothyroxine Sodium 175 mcg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 40 mg PO BID
8. RISperidone 0.5 mg PO QAM
9. RISperidone 4 mg PO QHS
10. Sertraline 100 mg PO BID
11. Vitamin D 1000 UNIT PO DAILY
12. Levofloxacin 750 mg PO DAILY
Please take through ___
RX *levofloxacin 750 mg one tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
13. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
Please take through ___
RX *metronidazole 500 mg one tablet(s) by mouth three times a
day Disp #*18 Tablet Refills:*0
14. Atorvastatin 10 mg PO QPM
15. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
daily
16. Loratadine 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Mental Status: Clear.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for pneumonia. You were put on
antibiotics to help treat your infection. You did well during
your stay--you did not have any fevers or require oxygen. We
are discharging you home with a total of 7 days of antibiotics.
Please continue your usual home medications. Please follow up
with your primary care physician after discharge.
We wish you the best!
Your ___ care team
Followup Instructions:
___
|
10868656-DS-8
| 10,868,656 | 26,836,505 |
DS
| 8 |
2135-08-12 00:00:00
|
2135-08-12 21:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath, wheezing, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h/o asthma and OSA presents with the acute onset of
shortness of breath occurred earlier this week after exerting
himself doing lawn work. He was originally controlling his
breathing with his albuterol inhaller which progressively was
not working as the week went on. He feels the high level of
pollen in the air is contributing. The patient denies chest
pain. Patient does state he has increased dyspnea on exertion.
Patient has been using his inhaler at home. He has a history of
asthma, never intubated, never in ICU. Patient's asthma is
otherwise pretty well-controlled besides this current
exacerbation. He had multiple nebulizer treatments without
relief last one was proximately 10 minutes prior to arrival to
the emergency department today. Patient complains of increased
dyspnea on exertion, cough productive of whitish sputum.
Afebrile, no chills. Patient c/o orthopnea. Denies lower
extremity edema.
.
In the ED, initial vs were: T97 ___ BP158/115 R48 O2 sat94% RA.
Labs were remarkable for WBC 10.8 w/ 9.2%eos, BUN of 11 and Cr
0.9, H/H of 13.6/43.4. Patient was given duonebs, 125mg of
methylpred and azithromycin. He required CPAP for approx 30mins
for increased WOB and tachypnea. His breathing then improved and
micu admission was averted. Vitals on Transfer: T 98.1, 109,
139/98, 18 96% 3L.
.
Review of sytems:
(+) Per HPI
(-) 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.
Past Medical History:
Asthma
OSA on CPAP
Hypertension
Obesity
Psoriasis
Diabetes mellitus, type II
Dyslipidemia
Erectile dysfunction
Colonic adenoma (___)
Social History:
___
Family History:
Father with COPD and diabetes, died at age ___. Mother alive and
well without medical condition. Brother died at age ___ of
pneumonia.
Physical Exam:
PHYSICAL EXAM:
Vitals: T: 98.1 BP:150/120 P:106 R: 20 O2:96% 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, Mallampati 3
Neck: supple, difficult to assess JVP due to habbitus, no LAD
Lungs: decreased air movement throughout, wheeze present
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: diffuse psoiatic patches present on UE and torso
Neuro: CN II-XII intact
DISCHARGE EXAM:
HR 100-120, O2 95-100% on RA
Lungs: faint, end expiratory wheezes, good breath sounds
bilaterally, no crackles, consolidations
Pertinent Results:
ADMISSION LABS:
___ 01:08PM BLOOD WBC-10.8 RBC-4.86 Hgb-13.6* Hct-43.4
MCV-89 MCH-28.0 MCHC-31.3 RDW-13.7 Plt ___
___ 01:08PM BLOOD Neuts-67.8 ___ Monos-3.3 Eos-9.2*
Baso-0.5
___ 01:08PM BLOOD ___ PTT-32.0 ___
___ 01:08PM BLOOD Glucose-136* UreaN-11 Creat-0.9 Na-140
K-4.3 Cl-101 HCO3-27 AnGap-16
___ 01:08PM BLOOD proBNP-17
___ 01:08PM BLOOD cTropnT-<0.01
___ 06:25AM BLOOD cTropnT-<0.01
___ 01:19PM BLOOD Lactate-2.2*
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-14.3* RBC-4.85 Hgb-13.9* Hct-43.3
MCV-89 MCH-28.7 MCHC-32.2 RDW-13.9 Plt ___
___ 06:25AM BLOOD Glucose-135* UreaN-21* Creat-1.1 Na-140
K-3.9 Cl-99 HCO3-30 AnGap-15
___ 06:25AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.2
EKG:
Sinus tachycardia, rate 103. Left anterior fascicular block.
Tracing is largely unchanged except for rate compared to the
previous tracing of ___.
CXR:
Previous vascular congestion has improved, although the hilar
pulmonary arteries are slightly larger today than on the
baseline examination ___. Heart is normal size
and the lungs are grossly clear. There is no pleural
abnormality.
BCx: NGTD
Brief Hospital Course:
Mr. ___ is a ___ with a PMH significant for asthma who
presented with shortness of breath, tachypnea, and cough who was
diagnosed and treated for an asthma exacerbation.
1. Asthma: The patient has a history of asthma based on history
and physical, however, he has no documented PFTs. He gets
exacerbations about once per year, during which time he has been
hospitalized, but never intubated. The patient had been
prescribed Albuterol and Flovent, however, the patient was not
using his Flovent. The patient was outside trimming bushes and
feels as though that, as well as pollen and an upper respiratory
infection triggered this episode. Before presentation, the
patient was using his Albuterol very frequently, but was still
short of breath. In the ED, he was tachypnic and hypoxic, and
required transient BiPap. He was started on prednisone,
azithromycin, and standing albuterol and ipratropium. He was
weaned from Bipap as well as nasal cannula after his ___
hospital day. His wheezing improved and he did not have any
desaturation with ambulation. He was discharge on flovent 220mcg
BID, albuterol PRN, and a prescription to finish a 5day course
of both prednisone and azithromycin. The patient has follow-up
with his PCP, at which time he can be further started on
leukotriene antagonists or other supplementary asthma
medications. The patient should have PFTs as an outpatient, as
it is unclear whether he has asthma along with a restrictive
lung disease from his obesity. He should know what his peak flow
is when he is feeling well, so that he can prevent further
exacerbations.
2. OSA: The patient was maintained on his nasal CPAP at night
for his OSA. During the night, he still had intermittent
desaturations to 70%. On mask CPAP, he did not desat, however.
He should follow up with sleep medicine to determine whether he
needs uptitration of his CPAP.
3. Tachycardia: The patient had persistent sinus tachycardia to
110-120. EKG showed sinus rhythm with LAFB. He did not have
palpitations or symptoms from his tachycardia. His tachycardia
may be secondary to deconditioning, obesity, and albuterol use.
If he remains tacycardic, he may benefit from adding a beta
blocker to his regimen, although this may flare his asthma.
4. HTN: Patient continued on triamterene-hydrochlorothiazide
37.5mg-25mg. SBP elevated from goal of 130 given his DM2.
Consider adding ACEI as an outpatient.
5. DM II: Continued metformin.
6. Psoriasis: He was undergoing UV light treatment. He is
awaiting for re-approval from his insurance company to restart
treatment.
Transitional:
- PFTs, peak flows, escalation of asthma treatment
- Workup of tachycardia
- Possible ACEI
- Uptitration of CPAP
Medications on Admission:
Metformin 1000mg BID
HCTZ-Triamterene 37.5mg-25mg
Albuterol prn
Discharge Medications:
1. fluticasone 220 mcg/actuation Aerosol Sig: Two (2) puff
Inhalation twice a day.
Disp:*3 inhalers* Refills:*2*
2. Spacer
Please provide patient with spacer for inhaler use
3. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 3 days: Last Day is ___.
Disp:*6 Tablet(s)* Refills:*0*
4. azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: Last Day ___.
Disp:*3 Tablet(s)* Refills:*0*
5. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
6. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation Q4H (every 4 hours) as needed for SOB.
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at ___
___. You were admitted to the hospital with an asthma
exacerbation most likely triggered by seasonal allergies and
viral bronchitis. You were treated with a course of steroids and
antibiotics and your breathing improved. Please follow up with
Dr. ___ as scheduled below.
The following changes have been made to your medications:
TAKE Fluticasone 2 puffs twice a day everyday even if you are
not having any asthma symptoms at all. This will prevent future
exacerbations.
TAKE Prednisone 40mg once a day until ___
TAKE Azithromycin 250mg once a day until ___
Please discuss with Dr. ___ your fast heart rate. Also,
discuss whether you should be on an ACEI for blood pressure
control as well as kidney protection.
Followup Instructions:
___
|
10868733-DS-5
| 10,868,733 | 21,576,889 |
DS
| 5 |
2147-08-06 00:00:00
|
2147-08-07 17:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
Mr. ___ is an ___ with a history of HLP, CAD, BPH, COPD and
dementia, who presented to ___ with worsening dyspnea for
___ ___. Per his wife he did have congestion and increasing
cough in the ___ leading up to his presentation. He denied
fevers, chills or chest pain. He was hypoxic to the ___ with
wheeze and accessory muscle use. He was given 325mg aspirin,
steroids and Combivent with modest improvement. EKG there was
concern for possible ST depressions in the lateral lead and
troponin was positive to 0.4. CTA chest was negative for PE
however limited exam due to timing of contrast. He was started
on a heparin drip for NSETMI and transferred to ___ in case he
needed cardiac catheterization.
In the ED, initial vs were: 98.7 93 154/76 20 97% 3L NC. He
endorsed shortness of breath and was noted to be breathing in
the ___, which improved with nebulizers and BiPAP. Cardiology
evaluated the patient and thought the elevated troponin was due
to demand ischemia. He did not have chest pain in the ED. A
foley was placed with 475cc output and he was bolused 500cc for
an elevated lactate.
On admission to the ICU, he was placed on BiPAP with mild
increased work of breathing using accessory muscles. He noted at
that time to be feeling much better and denied dyspnea or chest
pain.
Past Medical History:
Dementia
COPD
CAD
HLP
BPH
Social History:
___
Family History:
COPD in father who was a smoker
Physical Exam:
ON ADMISSION:
Vitals: 97.5 84 109/59 27 99% NIV
General: Alert, oriented to person only
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: rhonchorous breath sounds bilaterally, no wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
ON DISCHARGE:
Vitals: 99.2 144/66 73 18 90% RA
General: Sleeping, easily aroused, not agitated, in NAD
HEENT: Sclera anicteric
Neck: supple
Lungs: Poor air movement throughout, no expiratory wheezes heard
CV: Distant heart sounds, RRR, no clear murmur.
Abdomen: Soft, non-tender
Ext: Warm, well perfused, + clubbing, trace edema BLE
Skin: Warm, non-diaphoretic
Neuro: Oriented to self, ___, and ___ though not to year.
Fell asleep during exam. Decreased attention: unable to name
___ of week backward
Pertinent Results:
Admission:
------------------
___ 02:12AM BLOOD WBC-9.9 RBC-4.15* Hgb-13.4* Hct-40.0
MCV-96 MCH-32.2* MCHC-33.4 RDW-13.8 Plt ___
___ 02:12AM BLOOD Neuts-96.8* Lymphs-1.7* Monos-1.1*
Eos-0.2 Baso-0.2
___ 02:12AM BLOOD ___ PTT-83.6* ___
___ 02:12AM BLOOD Glucose-217* UreaN-26* Creat-1.8* Na-141
K-4.3 Cl-101 HCO3-31 AnGap-13
___ 02:12AM BLOOD CK(CPK)-128
___ 02:12AM BLOOD cTropnT-0.16*
___ 02:12AM BLOOD CK-MB-7
___ 02:12AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.5*
___ 02:19AM BLOOD ___ pO2-76* pCO2-46* pH-7.38
calTCO2-28 Base XS-0
___ 02:19AM BLOOD Lactate-3.6*
Pertinent Interval:
-------------------
___ 02:19AM BLOOD Lactate-3.6*
___ 08:17AM BLOOD Lactate-2.1*
___ 08:31AM BLOOD Lactate-1.7
Discharge:
------------
___ 06:50AM BLOOD WBC-6.4 RBC-4.25* Hgb-13.5* Hct-40.2
MCV-95 MCH-31.7 MCHC-33.5 RDW-13.7 Plt ___
___ 06:00AM BLOOD Glucose-109* UreaN-40* Creat-1.6* Na-142
K-3.9 Cl-106 HCO3-28 AnGap-12
___ 07:20AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.7
Imaging:
-------------------
EKG: ___
Artifact is present. Sinus rhythm. The P-R interval is
prolonged. Left axis deviation. There is a late transition that
is probably normal. Non-specific ST-T wave changes. No previous
tracing available for comparison.
CXR ___
IMPRESSION: Normal heart, lungs, hila, mediastinum and pleural
surfaces.
ECHO ___
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (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 are mildly thickened
(?#). The study is inadequate to exclude significant aortic
valve stenosis. No aortic regurgitation is seen. No mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Moderate symmetric left
ventricular hypertrophy with preserved global systolic function.
Unable to exclude regional wall motion abnormality with
certaintly. Normal right ventricular cavity size and systolic
function. Cannot exclude aortic stenosis.
Brief Hospital Course:
Mr. ___ is an ___ year old gentleman with a history of HLP,
CAD, BPH, COPD, and dementia who presents with respiratory
distress and elevated troponins from an outside hospital.
# COPD exacerbation: Mr. ___ has a history of COPD and
presented in respiratory distress, initially requiring ICU
admission and BiPAP. BNP was 200, CXR was not consistent with
volume overload. CTA at OSH was negative for PE with limited
scan. Further corroboration with his wife reveals that he did
have symptoms of an upper respiratory tract infection in the
___ leading up to his admission, the likely the precipitant of
his acute exacerbation. He received iptratropium nebulizer
treatments, albuterol inhalers, was started on prednisone. His
symptoms improved and he was transferred to the medicine floor
where he was also started on azithromycin for added
anti-inflammatory effect. His symptoms resolved and he is
discharged to rehab on tiotropium as well as albuterol and
ipratropium nebs as needed.
# Elevated troponin: Mr. ___ presented with elevated
troponin to 0.4 and was started on a heparin drip for presumed
NSTEMI at the outside hospital prior to transfer to ___.
Troponins downtrended at ___. MB remained flat. The patient
remained chest pain free. EKG was notable for ST depressions in
the lateral leads. Cardiology was consulted and determined that
the etiology was most likely secondary to demand ischemia. His
heparin drip was discontinued. He was continued on aspirin and
was switched to atorvastatin. He was not started on metoprolol
due to a note in ___ noting he was unable to tolerate secondary
to his COPD.
# ___: Creatinine was elevated to 1.8. Per PCP, his baseline is
around 1.5. His FeNa was consistent with pre-renal etiology,
though contrast induced nephropathy from outside hospital CTA
could not be excluded. He received IVF at ___. Foley placed to
rule out obstruction with good urine output. His creatinine was
trended and was 1.6 at discharge.
# Dementia and Delirium: Mr. ___ has a history of
Alzheimer's Dementia per his family, though is not on any
medications currently. He had waxing and waning mental status
consistent with superimposed delirium. He was managed
conservatively with frequent reorientation, scheduled trazodone,
and olanzapine as needed for agitation. On day of discharge,
the patient's mental status was improved.
# Hyperglycemia: Patient noted to be hyperglycemic in-house,
though no history of diabetes. Likely precipitated by prednisone
for COPD exacerbation. He was maintained on an insulin sliding
scale in-house.
# Hypertension: Patient noted to be hypertensive in-house,
likely again secondary to steroids. He was started amlodipine 5
mg.
TRANSITIONAL:
- Follow up with PCP after discharge from rehab
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO DAILY
2. Simvastatin 80 mg PO DAILY
3. TraZODone 50 mg PO HS:PRN insomnia
4. Allopurinol ___ mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. Omeprazole 20 mg PO BID
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
Discharge Medications:
1. TraZODone 50 mg PO HS insomnia
2. Allopurinol ___ mg PO DAILY
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Omeprazole 20 mg PO BID
5. Tiotropium Bromide 1 CAP IH DAILY
6. Aspirin 81 mg PO DAILY
7. Tamsulosin 0.8 mg PO HS
8. Atorvastatin 40 mg PO DAILY
9. Amlodipine 5 mg PO DAILY
10. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary:
COPD exacerbation
Secondary:
Dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you were having
difficulty breathing. This was due to an exacerbation of your
COPD. We treated you with medications to help you through this
exacerbation, including antibiotics. Your symptoms resolved and
we feel that you are safe for discharge from the hospital. You
will go to a rehabilitation facility, where you will work to get
stronger before going home.
It was a pleasure to be a part of your care!
Your ___ treatment team.
Followup Instructions:
___
|
10869067-DS-11
| 10,869,067 | 22,412,691 |
DS
| 11 |
2140-09-23 00:00:00
|
2140-09-25 18:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Azithromycin / metoprolol
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH significant for chronic back/hip pain and obesity
who presents with worsening back pain, referral from Dr. ___.
She has had back pain for years, which increased particularly in
the region of her right iliac crest after a fall ___ years ago.
She has undergone ___ in the past with some success. Pain has
become progressively worse over the last 3 weeks, and she was
started on Ultram with some relief. This morning she woke up and
was unable to walk secondary to pain. The pain is worst in her R
hip, but is present across her lower back and L hip as well. She
denies bladder/bowel symptoms, radiation of pain down her
leg(s), no saddle anesthesia. She has not had any injuries or
falls recently.
In the ED, initial VS were ___ 162/81 16 97%
Exam notable for tenderness to palpation over R hip. Pain with
passive R leg raise, as well as internal/external rotation. No
tenderness to palpation over spine or paraspinal muscles.
Strength intact. No saddle anesthesia.
No imaging done in ED, labs WNL, except for glucose of 192.
Received 5mg oxycodone PO
Transfer VS were 5 98.0 75 139/79 18 96% RA
Decision was made to admit to medicine for further management.
Past Medical History:
1. Obesity.
2. Hypertension.
3. History of hyperlipidemia.
4. Asthma.
5. CAD: ___ MIBI scan which revealed essentially unchanged
clinical finding of septal akinesis consistent with existing
LBBB
and normal LVEF without reversible ischemia
Social History:
___
Family History:
Sister with lung cancer, maternal aunt with breast cancer.
Physical Exam:
Admission:
VS - 98.3 149/89 82 97/RA
GENERAL: patient lying still, in pain
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: no JVD
CARDIAC: faint heart sounds, RRR, S1/S2, no murmurs, gallops, or
rubs
LUNG: some expiratory wheezes throughout, no rales, rhonchi,
breathing comfortably without use of accessory muscles
ABDOMEN: nontender in all quadrants, no rebound/guarding
BACK: No paraspinal or spinal tenderness on palpation. Focal
tenderness only in region of right iliac crest, extending into
surrounding musculature.
EXTREMITIES: 2+ tibial edema, no cyanosis, clubbing
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, downgoing babinski, no inner thigh
sensation changes, ___ strength upper and lower extremities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
VS - 98.2 126/66 65 96/RA
GENERAL: patient lying still, in pain
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: no JVD
CARDIAC: faint heart sounds, RRR, S1/S2, no murmurs, gallops, or
rubs
LUNG: some expiratory wheezes throughout, no rales, rhonchi,
breathing comfortably without use of accessory muscles
ABDOMEN: nontender in all quadrants, no rebound/guarding
BACK: No paraspinal or spinal tenderness on palpation. Focal
tenderness only in region of right iliac crest, extending into
surrounding musculature.
EXTREMITIES: 2+ tibial edema, no cyanosis, clubbing
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, downgoing babinski, no inner thigh
sensation changes, ___ strength upper and lower extremities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
LABS: Reviewed in OMR, See attached
Pertinent Results:
Admission:
___ 07:05AM BLOOD WBC-5.1 RBC-4.34 Hgb-11.9 Hct-38.5 MCV-89
MCH-27.4 MCHC-30.9* RDW-14.6 RDWSD-47.1* Plt ___
___ 07:05AM BLOOD Neuts-63.4 ___ Monos-9.0 Eos-1.2
Baso-0.6 Im ___ AbsNeut-3.25 AbsLymp-1.31 AbsMono-0.46
AbsEos-0.06 AbsBaso-0.03
___ 07:05AM BLOOD Glucose-192* UreaN-12 Creat-0.7 Na-139
K-4.4 Cl-97 HCO3-28 AnGap-18
Discharge:
___ 07:55AM BLOOD WBC-4.8 RBC-4.70 Hgb-12.7 Hct-43.0 MCV-92
MCH-27.0 MCHC-29.5* RDW-14.6 RDWSD-49.1* Plt ___
___ 07:55AM BLOOD Glucose-157* UreaN-11 Creat-0.8 Na-136
K-4.2 Cl-94* HCO3-31 AnGap-15
___ 07:55AM BLOOD Calcium-9.7 Phos-4.0 Mg-2.0
Imaging:
MRI Lumbar spine ___:
1. Mild, multilevel spondylitic changes of the lumbar spine,
worst at L4-5, mild spinal canal stenosis.
2. Incomplete characterization of a left upper renal cyst,
containing a septation for which a nonemergent renal ultrasound
is recommended for further evaluation
Brief Hospital Course:
___ with PMH significant for chronic back/hip pain and obesity
who presents with acute on chronic right lower back pain. MRI
showed no acute spinal pathologies and she was discharged with
tramadol and diazepam for spondylolysis and muscle spasm.
#Acute on chronic back pain: Well controlled on valium and
tramadol. Focal tenderness over right iliac crest (site of
previous fall injury) is most consistent with muscle spasm.
Considered osteoarthritis given patient's age and obesity, but
pain is not at a joint site. Also considered radiculopathy but
patient has negative straight leg raise and no symptoms of pain
radiation; considered kidney stones but patient has no CVA
tenderness and reports no hematuria or dysuria. MRI revealed
mild multilevel spondylitic changes of the lumbar spine, worst
at L4-5 and mild spinal canal stensosis. Pt will be discharged
on a home regimen of tramadol Q6H PRN and diazepam Q8H for
muscle spasm. Pt was cleared to go home with physical therapy.
All other chronic conditions have been managed with home
medications, with no acute changes in their clinical status.
=====================
TRANSITIONAL ISSUES:
- MRI preliminary report revealed incomplete characterization of
a left upper renal cyst, containing a septation, for which a
nonemergent renal ultrasound is recommended for further
evaluation
- CODE: Full (confirmed)
- EMERGENCY CONTACT HCP: Daughter, ___: ___, Daughter,
___: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN SOB
7. Hydrochlorothiazide 25 mg PO DAILY
8. Lisinopril 20 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL Q1HR:PRN chest pain
10. Omeprazole 40 mg PO DAILY
11. TraMADOL (Ultram) 50 mg PO BID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN SOB
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Lisinopril 20 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL Q1HR:PRN chest pain
10. Omeprazole 40 mg PO DAILY
11. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth BID PRN Disp
#*30 Capsule Refills:*0
12. Diazepam 5 mg PO Q8H muscle spasm
RX *diazepam 5 mg 5 mg by mouth every eight (8) hours Disp #*24
Tablet Refills:*0
13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth Q6H PRN Disp #*32 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic lower back pain
Spondylosis of lumbar spine
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 for sudden worsening
of your lower back/right hip pain. We performed an MRI, which
showed no dangerous condition, however, just chronic changes of
your spine. We gave you a new medication called diazepam, or
valium, which helped you greatly. Our physical therapists
recommended that you are safe to go home. Please follow-up with
your PCP at the appointment listed below.
On behalf of your ___ team,
We wish you all the best
Followup Instructions:
___
|
10869309-DS-8
| 10,869,309 | 25,249,358 |
DS
| 8 |
2157-08-06 00:00:00
|
2157-08-07 16:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lethargy, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old gentleman with a history of
depression, anxiety, htn, carinoid tumor s/p gastrectomy with
R-en-Y (___), diverticular rupture s/p colonic resection p/w
subacute lethargy and chronic LUQ pain.
___ was in his usual state of health until this past month
wherein ___ began feeling lethargic during the day despite
sleeping ___ hours per day. Progressively, his lethargy has
worsened. These symptoms are associated with anhedonia and
thoughts of hurting himself, but would not further clarify out
of fear of "being locked up again."
In addition, ___ complains of a constant "burning" LUQ pain that
is post-prandial, associated with nausea, dry heaves, and nbnb
emesis. ___ endorses chronic abdominal pain at baseline that ___
has had since childhood, but has worsened in the setting of
multiple abdominal surgeries. Denies diarrhea, fever, chills,
steatorrhea, dysuria.
In the ED, initial vitals: T 98 P 55 BP 125/63 RR 16 O2 96% RA
-Course notable for sinus rhythm to mid-30s; patient somnolent
but arousable. Hypoglycemic x2 (60 mg/dl, 58 mg/dl) - now s/p 2
amps dextrose.
-CT Ab showed distended gallbladder with mild edema, multiple
hyper enhancing foci within liver as well as 1.3 cm hypodense
lension, short segment intussusception without obstruction.
-RUQUS c/f cholecystitis
-Surgery consulted, no identifiable source of pain. No
cholecystitis or R-en-Y abnormalities on CT.
Tx:
-2L NS, 1L D10W, Dextrose 50% 25 gm
On arrival to the MICU, T 97.5 P 38 BP 134/58 RR 20 O2 >97%. ___
endorsed ___ abdominal pain, lethargy, and thoughts of hurting
himself, but would not elaborate. Multiple aspects of his
history were not clear and ___ had difficulty providing specific
details on his medical history, medications, and why ___ was
here.
Past Medical History:
Carcinoid tumor resected in ___ with a partial
Gastrectomy via Roux-en-Y gastrojejunostomy, hypertension,
Depression, anxiety, and a diverticular rupture requiring
partial
Colonic resection
Social History:
___
Family History:
Father- DM, heart attack, bladder cancer
Mother: gastric adenocarcinoma
Brother- DM
Physical ___:
ADMISSON PHYSICAL EXAM:
Vitals: T 97.5 P 38 BP 134/58 RR 20 O2 >97%
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, 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
DISCHARGE PHYSICAL EXAM:
Vitals: T 98.4, HR 70, BP 119/59, RR 16, SaO2 96% RA
GENERAL: Alert, oriented, no acute distress, agitated at times
but directable and able to calm self down
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally
CV: RRR, normal S1 S2, no murmurs, rubs, gallops
ABD: Thin, soft, mild LUQ tenderness, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
=========================
___ 06:30PM BLOOD WBC-7.0 RBC-3.98* Hgb-11.8* Hct-36.3*
MCV-91 MCH-29.6 MCHC-32.5 RDW-16.6* RDWSD-55.8* Plt ___
___ 06:30PM BLOOD Neuts-64.3 ___ Monos-6.6 Eos-4.3
Baso-0.6 Im ___ AbsNeut-4.47 AbsLymp-1.68 AbsMono-0.46
AbsEos-0.30 AbsBaso-0.04
___ 06:30PM BLOOD Plt ___
___ 06:30PM BLOOD Glucose-186* UreaN-8 Creat-0.9 Na-137
K-4.1 Cl-100 HCO3-29 AnGap-12
___ 06:30PM BLOOD estGFR-Using this
___ 06:30PM BLOOD ALT-12 AST-16 CK(CPK)-164 AlkPhos-85
TotBili-0.3
___ 06:30PM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:30PM BLOOD Albumin-4.2 Calcium-9.1 Phos-3.2 Mg-1.9
___ 06:30PM BLOOD TSH-0.34
___ 06:30PM BLOOD Free T4-1.1
___ 06:30PM BLOOD Cortsol-5.6
___ 06:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
=========================
___ 06:25AM BLOOD WBC-7.1 RBC-4.25* Hgb-12.8* Hct-39.6*
MCV-93 MCH-30.1 MCHC-32.3 RDW-16.3* RDWSD-55.5* Plt ___
___ 06:25AM BLOOD Neuts-52.1 ___ Monos-7.4 Eos-9.5*
Baso-1.0 Im ___ AbsNeut-3.68 AbsLymp-2.10 AbsMono-0.52
AbsEos-0.67* AbsBaso-0.07
___ 06:25AM BLOOD Glucose-73 UreaN-13 Creat-0.9 Na-141
K-3.8 Cl-102 HCO3-31 AnGap-12
___ 06:25AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.0
IMAGING:
===============
___ CT abd/pelvis:
1. A status post Roux-en-Y gastric bypass. Short segment
intussusception is seen at the anastomosis of the enteric loop
without evidence of obstruction or vascular compromise.
2. Distended gallbladder with mild gallbladder wall edema. If
there is
clinical concern for cholecystitis, this could be further
evaluated with right upper quadrant ultrasound.
3. Multiple hyperenhancing foci within the liver as well as a
1.3 cm hypodense lesion which are incompletely characterized on
this single phase CT and concerning for metastases in the
setting of history of metastatic carcinoid tumor.
4. Severe stenosis of the celiac axis with poststenotic
dilatation and
surrounding soft tissue. While this could be related to prior
surgery or
atherosclerosis, tumoral involvement is not excluded and can be
further
evaluated at time of MRI.
5. Prominent retroperitoneal lymph nodes which could reflect
metastatic
disease.
___ Echo
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. 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
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
___ Liver/Gallbaldder US
IMPRESSION:
1. Distended gallbladder with stones and wall edema is equivocal
but could
represent acute cholecystitis in the correct clinical setting.
2. Liver lesions seen on CT were not visualized on this focused
gallbladder exam however a specific searched for them was not
made.
RECOMMENDATION(S): Recommend non emergent liver MRI for further
evaluation of liver lesions seen on CT.
___ MRI Abdomen with and without contrast
IMPRESSION:
1. There is presumed non-specific inflammation with progressive
enhancement and restricted diffusion around the celiac axis
which narrows the origin and results and post-stenotic
dilatation. Given the remote history of tumor and surgery,
tumor recurrence and post-surgical change is thought to be less
likely. Inflammation around the celiac trunk could also
represent focal vasculitis.
2. Multiple enhancing lesions in the liver are most in keeping
with
hemangiomas and transient hepatic intensity differences as
described above.
Upper GI Study (___):
IMPRESSION:
1. Esophageal dysmotility with aspiration of retained
esophageal barium while transitioning from a standing to supine
position.
2. Widely patent GJ anastomosis.
3. No evidence of intussusception or focal narrowing at the JJ
anastomosis or elsewhere within the small bowel.
Celiac artery Duplex ultrasound (___):
Focal narrowing of the celiac origin on grayscale images due to
abnormal
surrounding soft tissue, consistent with findings on MRI and CT.
However, the celiac arterial velocity is within normal limits
without spectral Doppler evidence to suggest hemodynamically
significant stenosis. Background atherosclerotic calcifications
of the aorta.
Brief Hospital Course:
Mr. ___ is a ___ gentleman with a history of
depression, anxiety, hypertension, carinoid tumor s/p
gastrectomy with R-en-Y (___), diverticular rupture s/p colonic
resection who presented with subacute lethargy, LUQ pain,
hypoglycemia, and bradycardia.
___ Course:
# Bradycardia: Sinus. HDS no signs MI. Ddx: medications
(ondansetron, quetiapine), anorexia, MI,, infection, tertiary
lyme, , hypothyroidism, adrenal insufficiency. Given inability
to recall extensive medication list and recent SI, there is
possibility for drug overdose either accidental or purposeful.
Elevated AG suggests possible toxic ingestion. Toxicology feels
this may be related to beta blocker toxicity. Improved to
___ with being NPO. s/p Cards consult: there was appropriate
augmentation of heart rate with exertion while seen today,
rising to ~70 bpm from baseline of 50 bpm prior to exertion. ___
did not complain of any symptoms during the walk test. An
evaluation with TTE demonstrated normal Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). ___ was ambulatory with HR in the ___, BP
stable and remained asymptomatic. Per cardiology, no outpatient
workup, EKG was borderline first degree AV block, ___ is
asymptomatic, baseline in ___, down to ___ in the setting of
receiving opiate medications, which they felt was the reason for
his bradycardia.
# Abdominal pain/decreased PO intake: chronic LUQ pain
,relatively unchanged. Due to MRI demonstrating celiac axis
narrowing in the setting of patient feeling post-prandial
abdominal pain, there is a concern for celiac artery compression
syndrome. Also syncope history? with eating, perhaps vagal tone
superimposed on a baseline bradycardia due to underlying
esophageal dysfunction. Vascular surgery was consulted to obtain
a celiac artery duplex to r/o celiac artery compression
syndrome. Vascular surgery recommended no surgical intervention
for chronic abdominal pain. Additionally, the UGI barium showed
esophageal dysmotility. As a result, we obtained a GI
consultation to evaluate for this. They recommended outpatient
follow-up with GI for EGD and manometry to further evaluate his
esophageal dysmotility noted on barium swallow. Final read of
celiac artery Duplex study pending at discharge. Patient noted
to be iron deficient and was also started on iron
supplementation. We also scheduled him an appointment with
chronic pain service.
# Hypoglycemia: Questionable hypoglycemia due to serum BG always
normal, but s/p endocrine eval: Lowest was BG 49. Fingerstick
can be falsely low. venous blood glucose is gold standard, which
have always been normal. Fingerstick may be due to equipment
variability. Capillary vs. venous can be different by 10.
Reports of low fingerstick glucose in the psychiatry note
however this was never confirmed in the serum. Extensive workup
by endocrine only yielded a low baseline cortisol level
concerning for adrenal insufficiency, but had robust adrenal
response to ACTH stimulation test and his response is
appropriate. Has not established criteria for hypoglycemia, does
not meet criteria for ___'s triad. Could not document
symptoms during episodes of low glycemic times. Symptoms may not
be caused by hypoglycemia and may be due to medication overdose,
as ___ has not had the tremulousness since hospitalization. Per
endocrine consultation, all workup has been negative. Prolactin,
LH, FSH, insulin, pro-insulin, IC-peptide, are all normal. Am
Cortisol was 12.2 after a ACTH stim test, which was normal
appropriate endocrinologic response. ___, IGF are also normal. ___
tolerated PO well, and never had an episode of hypoglycemia
during this hospitalization. After a thorough endocrine workup,
they did not feel patient met ___'s triad to have an
establishment of hypoglycemia. All workup was negative.
Endocrine does not recommend any outpatient workup.
# Severe Agitation: Severely agitated over the evening, wanted
to leave AMA. Psych was consulted and evaluated the patient
together with house officers. ___ was deemed to have capacity,
and also agreed to stay for the evening. ___ remained calm and
stable for the remainder of the hospitalization until ultimately
leaving AMA before above w/u was completed.
# History of carcinoid tumor: Obtained history from the ___
___ including recent note from primary oncologist (Dr.
___, as well as review of path and imaging with
fellow on call. Patients assertion of widely metastatic disease
is not supported by oncologic assessment from his Oncologist or
by his recent CT at ___. Review of CT and MRI at ___
with radiology showed some contrast irregularities called ___
or ___ and 2 hemangiomas but no evidence of metastatic disease.
TTE showed no evidence of carcinoid effect on his valves or
regurgitant lesions. Moreover, his most recent MRI of abdomen
does not support this. At this point, the data available does
not strongly point to recurrent disease.
# Anemia: normocytic and downtrending (Hgb 14.1 --> 13). Iron
studies with low ferritin concerning for iron deficiency anemia,
would recommend outpt colonoscopy. B12 normal. H/H stable and
near baseline.
# SI: not actively suicidal, now passive and endorses
occasionally thinks about his plans but does not think ___ can
actually go through with it. Psych states SI likely a coping
mechanism and pt without active SI now. For the remainder of his
hospitalization, ___ did not endorse any active SI.
# Depression and insomnia: Spoke with psychiatrist Dr. ___
___, who reocmmended to discontinue sertraline 100mg PO qday.
We also continued him on Cymbalta 90mg, and Seroquel 50mg Qhs.
# HTN: We held his amlodipine during this hospitalization due to
him being normotensive.
#Medical management issues: inability to understand which meds
___ needs to take, and came in with a large bag of redundant
medications for his medical problems. We confirmed his
medications with the PCP and psychiatrist, and all of his
medication regimens are now adequately sorted out.
MICU Course:
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
2. Sucralfate 1 gm PO BID
3. Cyanocobalamin 3000 mcg PO DAILY
4. Amlodipine 5 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. ClonazePAM 1 mg PO BID:PRN anxiety
7. Gabapentin 400 mg PO TID
8. Duloxetine 90 mg PO DAILY
9. QUEtiapine Fumarate 50 mg PO QHS PRN sedation, agitation,
anxiety
10. FoLIC Acid 1 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. ClonazePAM 1 mg PO BID:PRN anxiety
2. Cyanocobalamin 3000 mcg PO DAILY
3. Duloxetine 90 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 400 mg PO TID
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
8. QUEtiapine Fumarate 50 mg PO QHS PRN sedation, agitation,
anxiety
9. Sucralfate 1 gm PO BID
10. Vitamin D ___ UNIT PO DAILY
11. Amlodipine 5 mg PO DAILY
12. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
13. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses: Bradycardia, hypoglycemia, chronic abdominal
pain, chronic depression.
Secondary Diagnoses: Hypertension, Gastrectomy via Roux-en-Y
gastrojejunostomy, anxiety, and a diverticular rupture requiring
partial colonic resection.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after presenting with low
blood sugars, slow heart rate, and abdominal pain. You were
admitted to the ICU after they found your fingerstick blood
sugars to be low, and was started on a sugar drip to increase
your blood sugar levels. In the ICU, you were followed by
endocrinology and cardiology doctors, who recommended that you
don't need any treatment for your slow heart rate given that you
were asymptomatic the entire time. The endocrine doctors
recommended ___ workup for your low blood sugar, but all
of that was negative. Your fingersticks improved to normal after
eating.
Afterward, you were transferred to the medicine floor, where we
worked up the cause of your abdominal pain. We obtained an Xray
of your swallowing which showed some poor motility. You should
see the gastroenterologists as an outpatient for further testing
(including an endoscopy). Furthermore, on an MRI, we saw some
narrowing of one of the arteries in your belly, which may cause
abdominal pain when you eat.
Unfortunately, you decided to leave the hospital against medical
advice. As we discussed, the risks of leaving the hospital
include worsening pain, dizziness/confusion from low blood
sugar, and possibly death if you do not need medical attention.
If you feel unwell (worsening pain, nausea/vomiting, dizziness,
passing out, confusion), please call your primary care doctor at
___ or go to the nearest Emergency Department.
For follow-up, we would like you to see your primary care
doctor, the GI clinic, nutrition clinic, and chronic pain
clinic. Unfortunately, you left the hospital before these
appointments could be scheduled.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10869691-DS-16
| 10,869,691 | 23,061,706 |
DS
| 16 |
2154-06-01 00:00:00
|
2154-06-01 14:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
R hip hemiarthroplasty ___
History of Present Illness:
___ year-old male with a history significant for dementia who
presents after a fall down a flight of approximately 12 stairs.
Per the patient's family, the fall was unwitnessed. The patient
presently reports pain in his right knee, left hand, and left
hip. He is able to answer basic yes/no ROS questions but
incapable of answering more substantive questions.
Past Medical History:
PMH: Afib, colorectal Ca, alzheimers, CHF, HTN
PSH: Colorectal Ca s/p resection with colostomy
Social History:
___
Family History:
NC
Physical Exam:
On discharge, Mr. ___ was a pleasantly demented man. He was
AVSS. He was alert but not oriented. He had significant
secretions and his lungs had crackles throughout. His heart was
irregular. His abdomen was soft and nontender.
Pertinent Results:
___ 04:00AM BLOOD WBC-15.5* RBC-4.45* Hgb-12.7* Hct-38.5*
MCV-87 MCH-28.5 MCHC-32.9 RDW-14.6 Plt ___
___ 05:49AM BLOOD WBC-17.9* RBC-3.23*# Hgb-9.4*# Hct-28.7*#
MCV-89 MCH-29.1 MCHC-32.7 RDW-14.8 Plt ___
___ 02:03AM BLOOD WBC-11.9* RBC-2.75* Hgb-7.9* Hct-24.8*
MCV-90 MCH-28.7 MCHC-31.8 RDW-15.3 Plt ___
___ 12:19AM BLOOD WBC-15.7* RBC-3.10* Hgb-9.0* Hct-28.6*
MCV-92 MCH-29.1 MCHC-31.5 RDW-16.1* Plt ___
___ 12:19AM BLOOD Glucose-117* UreaN-33* Creat-0.9 Na-152*
K-4.8 Cl-117* HCO3-28 AnGap-12
___ 04:00AM BLOOD Glucose-173* UreaN-17 Creat-1.5* Na-137
K-4.5 Cl-101 HCO3-24 AnGap-17
Brief Hospital Course:
Mr. ___ was transferred to the ICU on POD 2 after he was
noted to have dyspnea with O2 saturation of 70% while on the
floor. An ABG was obtained revealin a Po2 of 47. The patient was
intubated for hypoxic respiratory failure. A CXR was obtained
revealing left upper lobe collapse in addition to pre-exisiting
left lower lobe atelectasis seen on prior xray. A bronchoscopy
was performed revaling extensive mucous plugging in the left
mainstem and lower lobes. Post-procedure he was noted to become
hypotensive to the 60's. He was given IV fluid boluses and was
started on a Levophed drip with adequate response. Later on he
spiked a fever to 102 with pan-cultures sent and he was started
on Vancomycin and Cefepime. An ECHO was obtained revealing mild
RV dilation with depressed EF of 45-50%. Subsequent chest xrays
show improved lung expansion but with persistent left lower lobe
opacity concerning for infiltrate. On POD 3 a BAL was sent with
gram stain showing GNR and eventually grew pan sensitive E.
Coli, so his antibiotic coverage was changed to ceftriaxone. He
was able to wean off pressors and tube feeds were initiated. He
was able to wean down his ventilatory requirements and was
tolerating pressure support. He was extubated on POD5, however
he required continue nasotracheal suctioning for pulmonary
toilet. On POD7 a family meeting was held and the patient the
decision was made to transfer the patient to hospice.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Digoxin 0.25 mg PO DAILY
3. Diltiazem 60 mg PO QID
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Fall
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You are being discharged on hospice care after your fall. You
are unable to swallow and all of your home medications have been
discontinued.
Followup Instructions:
___
|
10869829-DS-10
| 10,869,829 | 21,593,731 |
DS
| 10 |
2141-09-11 00:00:00
|
2141-09-11 17:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
___ removed ___
PICC placed ___ Left arm
History of Present Illness:
___ yr male s/p Aortic valve replacement (25mm ___
bioprosthetic ___. Initially admitted for
endocarditis,
no positive culture data but vegetation noted intra-op.
Underwent
successful surgical AVR. He was treated with vanco and
ceftiaxone. Followed closely by the ID department. PICC was
placed the day prior to discharge and he was discharged to home
on POD #5. Post-op course was on note unremarkable. Today he was
seen on ___ clinic and was found to be neutropenic with low grade
fevers and rigors. According to the patient he has been doing
well spiked fever 100.5 a few days ago, but overall was doing
well. On his way to his ID f/u appointment while walking from
the
___ parking lot he began to shake and feel cold/tired.He was
seen at the ___ clinic and was found to be neutropenic with low
grade fevers and rigors. He sent to the ER for
admission/work-up.
Past Medical History:
Has not seen a physician ___ ~ ___ years
fractured left ankle
new thrombocytopneia
hepatosplenomegally
T12 compression
Social History:
___
Family History:
+ CAD - both parents died in their ___ (Mother- CHF)
Physical Exam:
Temp: 98.4 HR: 122 BP: 136/84 Resp: 20 O(2)Sat: 98
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Abdominal: Soft, Nontender, Nondistended
Extr/Back: No cyanosis, clubbing or edema/ PICC line - no
redness or tenderness
Skin: No rash
Pertinent Results:
___ 03:30PM BLOOD WBC-2.8* RBC-3.26* Hgb-8.7* Hct-27.7*
MCV-85 MCH-26.7 MCHC-31.4* RDW-14.9 RDWSD-46.1 Plt ___
___ 06:50AM BLOOD WBC-3.2* RBC-2.73* Hgb-7.3* Hct-23.4*
MCV-86 MCH-26.7 MCHC-31.2* RDW-15.0 RDWSD-46.8* Plt ___
___ 03:30PM BLOOD Neuts-70.1 Lymphs-15.5* Monos-12.2
Eos-0.7* Baso-1.1* Im ___ AbsNeut-1.95# AbsLymp-0.43*
AbsMono-0.34 AbsEos-0.02* AbsBaso-0.03
___ 06:55AM BLOOD Neuts-45.0 ___ Monos-12.6 Eos-2.9
Baso-1.3* Im ___ AbsNeut-1.07* AbsLymp-0.90* AbsMono-0.30
AbsEos-0.07 AbsBaso-0.03
___ 03:30PM BLOOD ___ PTT-33.9 ___
___ 06:55AM BLOOD ___
___ 03:30PM BLOOD Glucose-112* UreaN-10 Creat-0.7 Na-133
K-4.3 Cl-97 HCO3-24 AnGap-16
___ 06:50AM BLOOD Glucose-105* UreaN-7 Creat-0.6 Na-136
K-3.8 Cl-102 HCO3-24 AnGap-14
___ 06:50AM BLOOD CK(CPK)-13*
___ 06:50AM BLOOD Mg-1.8
___ 07:35AM BLOOD Mg-1.8
___ 07:35AM BLOOD Vanco-11.0
___ 04:03PM BLOOD Lactate-2.0
CXR ___
Left PICC tip is in thecavoatrial junction. Study
cardiomediastinal silhouette is unchanged with large hiatal
hernia. There is increasing atelectasis in the left lower lobe
and in the right lower lobe. There is no pneumothorax. Sternal
wires are aligned
Echocardiogram ___
LEFT ATRIUM: Mild ___.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Suboptimal technical quality, a focal LV wall motion abnormality
cannot be fully excluded. Overall normal LVEF (>55%). Doppler
parameters are indeterminate for LV diastolic function. No
resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated, normal leaflet/disc motion and transvalvular
gradients. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild to moderate (___) MR.
___ VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). Doppler
parameters are indeterminate for left ventricular diastolic
function. Right ventricular chamber size and free wall motion
are normal. A bioprosthetic aortic valve prosthesis is present.
The aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
(___) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: No evidence of valvular vegetations or abscesses
(better excluded by TEE). Well seated bioprosthetic aortic valve
with normal gradients and no aortic regurgitation. Moderate
symmetric left ventricular hypertrophy with preserved overall
systolic function. Mild-moderate mitral regurgitation.
Brief Hospital Course:
Presented to clinic follow up and found neutropenic with low
grade fevers and rigors. He sent to the emergency room and
admitted for fever workup. Blood cultures were obtained, PICC
line removed, echocardiogram with no vegetations. His
antibiotics were changed per infectious disease to meropenum
then daptomycin and placed on neutropenic precautions. His
white blood cell count improved and fever resolved, blood
cultures remain no growth to date. It was felt that it was all
related to ceftriaxone and he is discharged on daptomycin thru
___ with follow up in infectious disease clinic ___. He is
clinically stable and ready for discharge home with service with
new PICC line in place.
Medications on Admission:
1. Acetaminophen 650 mg PO Q4H:PRN pain, fever
2. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 1 once a day
Disp #*37 Intravenous Bag Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
5. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL
1 four times a day Disp #*150 Syringe Refills:*0
6. Metoprolol Tartrate 50 mg PO Q8H
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ capsule(s) by mouth every six (6) hours
Disp #*60 Capsule Refills:*0
8. Vancomycin 1250 mg IV Q 8H
RX *vancomycin 750 mg 2 three times a day Disp #*101 Vial
Refills:*0
9. Potassium Chloride 20 mEq PO Q12H Duration: 7 Days
RX *potassium chloride 20 mEq 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
10. Furosemide 20 mg PO BID Duration: 7 Days
RX *furosemide 20 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
Discharge Medications:
1. Daptomycin 500 mg IV Q24H
planned thru ___ to see ID in clinic ___
RX *daptomycin [Cubicin] 500 mg 500 mg IV once a day Disp #*20
Vial Refills:*0
2. Acetaminophen 325-650 mg PO Q6H:PRN pain
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Metoprolol Tartrate 50 mg PO TID
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours
Disp #*15 Capsule Refills:*0
7. Ranitidine 150 mg PO DAILY
8. statin
Due to daptomycin not recommended for statin use during
antibiotic course, due to CAD non obstructive on cardiac
catheterization recommend when daptomycin complete that statin
should be initiated which you can discuss with your PCP
9. Outpatient Lab Work
ATTN: ___ CLINIC - FAX: ___
DAPTOMYCIN WEEKLY: CBC with differential, BUN, Cr, CPK
ESR/CRP
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Leukopenia secondary to medications
Secondary Diagnosis
Aortic valve endocarditis culture negative with aortic
insufficiency s/p Aortic Valve Replacement
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10870329-DS-16
| 10,870,329 | 20,927,679 |
DS
| 16 |
2186-06-06 00:00:00
|
2186-06-06 16:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Heart catheterization ___
History of Present Illness:
Mr. ___ is a ___ male with no significant PMH who
presents with chest pain and exertional dyspnea. The patient
states that he has been feeling more fatigued with chest
discomfort, especially with exertion for about one week. While
at work, he has noticed difficulty getting around with minimal
exertion. Starting on ___ night, 3 days prior to admission,
he developed burning and intense central chest pain with
radiation to his right arm at rest. He had spent the entire day
in his bed due to the symptoms with exertion. The pain lasted
all evening, and he was unable to sleep well. Since that night,
the symptoms have improved, but he still has pain, dyspnea, and
fatigue with exertion. He went to see his PCP today and was
referred to the ___ ED.
In the ED initial vitals were: 97.6 84 117/87 16 98% RA
EKG: read ED staff, thought to have no evidence of STEMI.
Labs/studies notable for: trop 0.43.
Chest x-ray showed no acute cardiopulmonary process.
Patient was given: full dose aspirin and heparin drip.
Cardiology was consulted and recommended cardiac cath, but
because the patient had eaten lunch, the procedure was deferred
to the following day.
On the floor, the patient reports feeling ok with no chest pain
or shortness of breath, unless he tries to exert himself.
Of note, patient reports that he got an insect bite on his right
shoulder about 10 days ago, when he was at his house in the
___. It may have been a tick. The area around it got red and
tender, and he was started by his PCP on ___ for a 7 day
course, which he started taking on ___. He had negative blood
test for Lyme, Anaplasma, and Erlichia on ___.
REVIEW OF SYSTEMS:
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations,
syncope, or presyncope.
On further review of systems, denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. Denies exertional
buttock or calf pain. Denies recent fevers, chills or rigors.
All of the other review of systems were negative.
Past Medical History:
- Cellulitis of back
Social History:
___
Family History:
Family history significant for father and 2 brothers with heart
disease in ___ (not cause of death).
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.0 BP 111/71 HR 71 RR 16 O2 SAT 100% on RA; Wt: 170 lbs
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with no JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No lower extremity edema.
SKIN: Has a large >10cm circular erythematous lesion at the
right scapula region with a scaling central lesion that is more
prominent
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
VS: Tm98.1 ___ ___ 16 99RA
Tele - No events
Wt: Not recorded
Yesterday I/Os: 120/139 // not recorded
GENERAL: well appearing man in NAD. Oriented x3.
NECK: Supple, no evidence of JVD
CARDIAC: regular rhythm. Normal S1, S2. No murmur appreciated
LUNGS: Resp unlabored, no accessory muscle use. No crackles or
wheezes
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No ___ edema, 1" lesion on R shoulder with
surrounding erythema ~8in in diameter with outer ring,
non-tender
Pertinent Results:
ADMISSION LABS:
___ 12:49PM BLOOD WBC-8.4 RBC-4.91 Hgb-16.0 Hct-45.2 MCV-92
MCH-32.6* MCHC-35.4 RDW-11.7 RDWSD-39.1 Plt ___
___ 12:49PM BLOOD Neuts-71.3* Lymphs-18.0* Monos-8.8
Eos-1.0 Baso-0.5 Im ___ AbsNeut-6.01 AbsLymp-1.51
AbsMono-0.74 AbsEos-0.08 AbsBaso-0.04
___ 07:30PM BLOOD ___ PTT-46.9* ___
___ 12:49PM BLOOD Glucose-103* UreaN-14 Creat-0.9 Na-139
K-4.3 Cl-102 HCO3-24 AnGap-17
PERTINENT LABS:
___ 12:49PM BLOOD Calcium-9.9 Phos-3.8 Mg-2.3
___ 12:49PM BLOOD cTropnT-0.43*
___ 07:30PM BLOOD cTropnT-0.48*
___ 06:15AM BLOOD CK-MB-3 cTropnT-0.43*
___ 06:00AM BLOOD cTropnT-0.38*
___ 12:49PM BLOOD CK(CPK)-161
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-5.7 RBC-4.60 Hgb-14.6 Hct-41.8 MCV-91
MCH-31.7 MCHC-34.9 RDW-11.8 RDWSD-38.9 Plt ___
___ 06:00AM BLOOD ___ PTT-30.4 ___
___ 06:00AM BLOOD Glucose-93 UreaN-11 Creat-0.8 Na-138
K-4.3 Cl-105 HCO3-23 AnGap-14
___ 06:00AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.1
CARDIAC STUDIES:
___ CXR
No acute cardiopulmonary process.
___ TTE
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with borderline
left ventricular systolic function. No significant valvular
disease.
___ Heart Cath
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery
The LMCA is normal.
* Left Anterior Descending
The LAD has mild luminal irregularities.
The ___ Diagonal is a small caliber vessel (<2.0 mm diamter)
with 60% ___ stenosis.
* Circumflex
The Circumflex has 100% thrombotic occlusion of the mid
segment..Fills distally via collaterals from both
left and right coronaries.
The ___ Marginal is a large vessel with 30% stenosis.
* Right Coronary Artery
The RCA has 30% mid stenosis.
Intra-procedural Complications: None
Impressions:
1 vessel CAD.
Successful PTCA/stent of occluded mid LCX.
Recommendations
ASA 81mg QD indefinitely. Ticagrelor 90mg bid for 12 months.
Further management as per primary cardiology team, but needs
aggressive risk factor modification given
significant atherosclerotic disease.
Brief Hospital Course:
Mr. ___ is a ___ male with no significant PMH who
presents with chest pain and exertional dyspnea for 1 week and
elevated troponin, concerning for NSTEMI vs. resolving MI.
# NSTEMI
Patient presenting with chest burning and decreased exercise
tolerance x1 week. Symptoms seem to have increased to occur
while at rest 3 days prior to admission. Since then, symptoms
have appeared to improve but not resolve. His EKG with evidence
of posterior MI, but his troponin on presentation were
uptrending. Appeared euvolemic currently with no ongoing
symptoms. TTE w/ EF 50-55% w/o wall motion abnormality. Patient
was taken for heart cath and found to have 100% stenosis of LCx
and had BMS placed. He was started on ASA, Brilinta, and
atorvastatin. He was ambulating on his own at discharge, and
given appropriate cardiology and PCP ___.
# Back Cellulitis | Insect Bite
Rash has a circular appearance with a central lesion, that
raises the possibility of erythema migrans given reported
history of tick exposure and bite. Lyme assay negative at PCP
___. Redrawn here for concern of false negative due to early
disease. Alternatively, could still be cellulitis from an insect
bite. Patient continued on Keflex per PCP regimen and scheduled
for ___. Will contact patient and/or PCP regarding in house Lyme
test.
====================
TRANSITIONAL ISSUES:
====================
- Started on Aspirin 81mg daily, Ticagrelor 90mg BID, and
Atorvastatin 80mg.
- Give SL Nitro prescription and counseled about returning to ED
if chest pain does not improve or recurs with medication.
- Will need PCP ___ for insect bite and cellulitis on R
shoulder. Second Lyme panel was sent during admission and
pending at ___.
- Will need close cardiac ___ for new dx of CAD and strong family
hx.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cephalexin 500 mg PO Q24H
2. Fluocinolone Acetonide 0.01% Cream 1 Appl TP BID
Discharge Medications:
1. Cephalexin 500 mg PO Q24H
2. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*1
3. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*1
4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually Q15min Disp
#*100 Tablet Refills:*0
5. TiCAGRELOR 90 mg PO BID
RX *ticagrelor [BRILINTA] 90 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
6. Fluocinolone Acetonide 0.01% Cream 1 Appl TP BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
NSTEMI
Cellulitis surrounding insect bite
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted because you had a
heart attack. You had a angiogram of your heart that showed an
occlusion of one of the blood vessels around your heart. A stent
was placed in this vessel to help open it and improve blood flow
to your heart.
It is very important to take all of your heart healthy
medications. Very importantly, you are now taking aspirin and
Ticagrelor (also known as Brilinta). These two medications keep
the stent in the vessel of the heart open and help reduce your
risk of having a future heart attack. If you stop these
medications or miss ___ dose, you risk causing a blood clot
forming in your heart stents, which could result in another,
larger heart attack. Please do not stop taking either medication
without talking to your heart doctor, even if another doctor
tells you to stop the medications.
Please weigh yourself every day in the 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 more than 5 lbs in 3 days, please
call your heart doctor or your primary care doctor and alert
them to this change.
Additionally, you had a rash on your shoulder during your
admission. You should continue to take the antibiotic that your
PCP prescribed you until the redness resolves. Please ___
with your PCP regarding your new diagnosis of coronary artery
disease and this rash.
We wish you the best of health,
Your ___ Care Team
Followup Instructions:
___
|
10870329-DS-17
| 10,870,329 | 22,924,651 |
DS
| 17 |
2188-05-05 00:00:00
|
2188-05-05 16:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Left heart catheterization
History of Present Illness:
Mr. ___ is a ___ gentleman with PMH of CAD s/p BMS to
mid LCx ___ requiring ballooning and re-stenting, HTN who
presents after undergoing exercise stress test with positive
ischemic findings.
The patient has a history of NSTEMI in ___ s/p BMS to mid
LCx. However, the patient developed stent thrombosis requiring
ballooning and re-stenting with BMS in ___. However, it was
noted the patient required high pressure ballooning to expand
the
stent, with comment that "if the vessel re-occludes again, would
recommend to treat medically given these issues".
Since undergoing PCI, the patient has had intermittent
exertional
angina which improved with rest. He has been very active
otherwise and has had no issues performing aerobic exercise.
However, most recently, the patient reports experiencing several
episodes of mild transient substernal chest pressure even with
mild exertion. The patient had another episode of substernal
pressure this morning while walking to his car which resolved
with rest. However, he was concerned that he experienced anginal
symptoms with comparatively little exertion. As a result, he
called his cardiologist's office and was scheduled for an
exercise stress test.
During his stress test, the patient was able to exercise for 7
minutes and 43 seconds. He developed worsening chest pressure
while exercising, resulting in termination of the test. During
the test, his EKG was noted to have >1mm ST depressions in leads
II, III, aVF, V4-6 during exercise at a HR of 111 BPM, which
persisted five minutes after stopping. The patient's chest
pressure also persisted for approximately one minute following
cessation of exercise. Given his stress test findings, the
patient was referred to ___ ER for further evaluation.
In the ED, initial vitals were T 98.6F, HR 86, BP 111/73, RR 18,
O2 sat 99% RA. EKG demonstrated NSR at 79 BPM with normal axis.
ST elevations in V1, V2 concave upwards, consistent with benign
early repolarization. Labs included normal CBC, chem-7 with
bicarb 20 but otherwise normal, normal coags troponin <0.01. CXR
was unremarkable. The patient was given ASA 243mg to complete a
full dose aspirin for the day, and was admitted to Cardiology
for
further management.
On arrival to the floor, the patient's vitals were T 98.1F, HR
74, BO 132/76, RR 16, O2 sat 98% RA. He confirmed the history
above. He denies current chest, jaw, or shoulder pain/pressure,
or shortness of breath.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
2. CARDIAC HISTORY
- Coronary artery disease: s/p BMS to mid LCx ___ requiring
ballooning and re-stenting
3. OTHER PAST MEDICAL HISTORY
None
Social History:
___
Family History:
- Father: MI in ___
- Brother: MI age ___
- Brother: MI in ___
Physical Exam:
ADMISSION EXAM:
===============
VS: T 98.1F, HR 74, BO 132/76, RR 16, O2 sat 98% RA
GENERAL: Appears to be in no apparent distress
HEENT: PERRL, EOMI
NECK: Unable to visualize JVP above the clavicle with patient
standing in upright position
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops. No thrills or lifts.
LUNGS: Clear to auscultation bilaterally
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: 3cm region of redness and swelling on the right upper
back
with central puncture.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM:
===============
VS:
___ 1506 Temp: 98.2 PO BP: 121/78 HR: 81 RR: 18 O2 sat: 98%
O2 delivery: ra
GENERAL: Appears to be in no apparent distress
HEENT: PERRL, EOMI
NECK: Unable to visualize JVP above the clavicle with patient
standing in upright position
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops. No thrills or lifts.
LUNGS: Clear to auscultation bilaterally
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: 3cm region of redness and swelling on the right upper back
with central puncture.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:15PM BLOOD WBC-5.6 RBC-4.81 Hgb-14.9 Hct-43.3 MCV-90
MCH-31.0 MCHC-34.4 RDW-11.9 RDWSD-38.6 Plt ___
___ 04:15PM BLOOD Neuts-67.3 ___ Monos-7.9 Eos-3.8
Baso-0.9 Im ___ AbsNeut-3.75 AbsLymp-1.10* AbsMono-0.44
AbsEos-0.21 AbsBaso-0.05
___ 04:15PM BLOOD ___ PTT-27.8 ___
___ 04:15PM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-140
K-4.1 Cl-102 HCO3-20* AnGap-18
___ 04:15PM BLOOD CK(CPK)-136
___ 04:15PM BLOOD CK-MB-3
___ 04:15PM BLOOD cTropnT-<0.01
TRANSTHORACIC ECHO (___):
=========================
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. There is normal left ventricular
wall thickness with a normal cavity size. There is normal
regional left ventricular systolic function. Quantitative
biplane left ventricular ejection fraction is 58%. Left
ventricular cardiac index is normal (>2.5 L/min/m2) There is no
resting left ventricular outflow tract gradient. No ventricular
septal defect is seen. Transmitral and tissue Doppler suggests
normal diastolic function, and a normal left ventricular filling
pressure (PCWP less than 12mmHg). Normal right ventricular
cavity size with normal free wall motion. The aortic sinus
diameter is normal with normal ascending aorta diameter. The
aortic arch is mildly dilated. There is no evidence for an
aortic arch coarctation. The aortic valve leaflets (3) appear
structurally normal. There is no aortic valve stenosis. There is
no aortic regurgitation. The mitral leaflets appear
structurally normal with no mitral valve prolapse. There is mild
[1+] mitral regurgitation. The tricuspid valve leaflets appear
structurally normal. There is physiologic tricuspid
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: Good image quality. Normal biventricular wall
thicknesses, cavity sizes, and regional/global systolic
function. Mild mitral regurgitation with normal valve
morphology. Mildly dilated thoracic aorta.
LEFT HEART CATHETERIZATION (___):
=================================
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery
The LMCA is normal.
* Left Anterior Descending
The LAD has hazy 80% stenosis in the mid segment.
The ___ Diagonal is a moderate sized branch (2.0 mm diameter)
with 70% ostial stenosis.
* Circumflex
The Circumflex has 50% diffuse in-stent restenosis in the mid
segment (small distal territory).
The ___ Marginal has 30% ___ stenosis.
* Right Coronary Artery
The RCA has 30% mid stenosis.
Interventional Details:
___ EBU 3.5 guiding catheter provided adequate support for the
intervention on the mid LAD. Wires were passed into distal LAD
and D2. Mid LAD dilated using a 2.5mm balloon and D2 origin
dilated using a 2.0 mm balloon. 3.0mm x 12mm Promus Premier
(drug eluting) stent deployed in the mid LAD at 16 atm.
Excellent final result with 0% residual stenosis in the LAD, no
dissection, and brisk flow. D2 jailed by the stent but has only
50% ostial stenosis and normal flow.
DISCHARGE LABS:
===============
___ 08:00AM BLOOD WBC-4.5 RBC-5.01 Hgb-15.4 Hct-45.3 MCV-90
MCH-30.7 MCHC-34.0 RDW-11.9 RDWSD-38.8 Plt ___
___ 08:00AM BLOOD Glucose-86 UreaN-12 Creat-0.9 Na-142
K-5.0 Cl-107 HCO3-22 AnGap-13
___ 08:00AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.2 Cholest-114
Brief Hospital Course:
Mr. ___ is a ___ gentleman with PMHx of CAD s/p BMS
to mid LCx ___ requiring re-ballooning and re-stenting for
in-stent thrombosis who presented after undergoing exercise
stress test with positive ischemic findings.
Underwent coronary angiography on ___ which showed 2-vessel
CAD affecting the LAD and the circumflex. A DES was placed in
the LAD with good angiographic results.
===============
ACTIVE ISSUES:
===============
# Increasing angina:
# Positive exercise stress test:
Patient has significant history of CAD requiring several
interventions on the LCx due to stent thrombosis. Prior to
admission, the patient reported increasing chest pain at times
with even minimal exertion. As a result, there was concern that
the patient's coronary artery disease was worsening. He
underwent stress test which was positive for ischemic findings
and was referred to ___ for further evaluation on ___. After
arrival, the patient underwent left heart catheterization which
demonstrated 80% stenosis of mid-LAD (Promus ___ and
50% diffuse in-stent restenosis and RCA with 30% mid-stenosis.
TTE was obtained which showed mild MR, but otherwise normal wall
thickness, cavity size and overall regional and global systolic
function with LVEF=58%. He was started on ezetimibe to maximize
his LDL-lowering pharmacotherapy and otherwise continued on his
other medications including aspirin, atorvastatin 80mg,
ticagrelor BID, and metoprolol. Pre-admission clopidogrel was
discontinued in favor of ticagrelor given history of in-stent
restenosis.
# Tick bite:
Patient was found to have a tick on his right upper back on the
morning of admission. Unclear when the tick initially bit the
patient. He noted the tick to his primary care physician, who
prescribed the patient prophylactic doxycycline 200mg in the
setting of unclear exposure duration. At the time of
presentation, the patient had an approximately 3cm area of
swelling and erythema on his upper right back with central bite
mark. Otherwise, he denied systemic symptoms so he was monitored
during his admission.
===============
CHRONIC ISSUES:
===============
# HTN: continued home metoprolol and Imdur.
====================
TRANSITIONAL ISSUES:
====================
[ ] Started ezetimibe for more intensive lipid lowering given
progressive disease on max dose statin (goal to lower LDL below
70).
[ ] Consider initiation of PCSK-9 inhibitor for further
LDL-lowering.
[ ] Recommend recheck patient's lipid panel to determine whether
he is meeting his LDL goal.
[ ] Please follow-up regarding whether patient continues to
experience anginal symptoms.
CONTACT: ___ (Spouse, ___
CODE: Full (presumed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO BID
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
7. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Ezetimibe 10 mg PO DAILY
RX *ezetimibe 10 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*1
2. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*1
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO BID
7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
8. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Coronary Artery disease
SECONDARY DIAGNOSIS:
====================
Tick exposure
Primary Hypertension
Hyperlipidemia
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.
WHY WERE YOU ADMITTED:
- You had a stress test, the results of which were concerning
for worsening blockages in the arteries supplying your heart.
WHAT HAPPENED IN THE HOSPITAL:
- We did a catheterization to look at your heart arteries which
showed a blockage in an artery (the left anterior descending
artery). This was a new blockage than the one you previously had
a procedure for (left circumflex artery).
WHAT SHOULD YOU DO AFTER LEAVING:
- Please take your medications as prescribed.
- Please follow-up with your doctors as ___.
- If you notice severe chest pain radiating up to your neck or
shoulder, shortness of breath, and any other symptoms that
concern you please return to the hospital.
Thank you for allowing us to participate in your care!
Your ___ team
Followup Instructions:
___
|
10870373-DS-12
| 10,870,373 | 23,689,796 |
DS
| 12 |
2113-12-01 00:00:00
|
2113-12-01 18:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Left thoracentesis ___
Left chest tube placement ___
History of Present Illness:
___ with known lung adenocarcinoma with adrenal metastases with
recurrent left-sided pleural effusion presenting with shortness
of breath. The patient was previously following at ___, but is
transitioning his care to ___ because of insurance
issues and was scheduled to see oncology in ___. At ___, he
was known to have recurrent left pleural effusions, for which he
has undergone two thoracentesis, most recently in late ___. He was told by his oncologist that if he developed
worsening shortness of breath to come to the ED for therapeutic
thoracentesis.
In the ED, VS were 99.3 107 152/75 33 99% RA.
Labs were significant for WBC 7.3, Hb 9.5, Plt 340, BMP WNL,
lactate 1.2. INR 1.3. UA was negative.
CXR significant for a large left-sided pleural effusion.
EKG showed sinus with PACs, 100, normal axis, no ST elevation,
normal intervals.
He was subsequently admitted to the ICU for persistent
tachypnea.
Upon arrival to the floor, the patient states that he has been
feeling progressively short of breath for the last week. His
shortness of breath is exacerbated by any activity but is not
positional. He has mild chest pain with his shortness of breath
but no palpitations. He endorses a dry cough, which is
nonproductive of sputum. He denies fevers, chills, rhinorrhea,
urinary symptoms, or changes in appetite. He does endorse a 8 lb
weight loss that occured in the last few weeks.
Past Medical History:
1. HTN
2. COPD
3. Positive PPD: hx of TB, three negative AFBs recently per
report
4. Lumbar disc disease
5. Left rotator cuff syndrome
6. Benign prostatic hypertrophy
Social History:
___
Family History:
His father had HTN. His mother died from MI. He has five
brothers and two sisters, with two brothers dying from a MI. No
known family history of malignancy.
Physical Exam:
ADMISSION Physical Exam:
Vitals- T 99.7 HR 121 BP 141/88 RR 30 SPO2 94%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: significantly decreased breath sounds in the left lower
lung, no wheezes or rhonchi in other lung fields
CV: tachycardiac, irregular, no murmurs/rubs/gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE Physical Exam:
VS: Tm 97.9 Tc 97.9 BP 120/74 P ___ RR 18 96 RA
GENERAL: NAD, lying in bed
HEENT: NC/AT, EOMI, PERRL, MMM
LYMPH: Palpable, tender enlarged LN 2 cm x 1 cm right posterior
neck. No warmth or erythema. No other cervical or
supraclavicular LAD.
CARDIAC: RRR with multiple irregular beats, nl S1 and S2, no
murmurs
LUNG: Decreased BS left peripheral lung field, left chest tube
in place.
ABD: +BS, soft, NT/ND, no r/g. Pulsatile abdominal mass
EXT: No lower extermity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: CN II-XII intact.
SKIN: Warm and dry, no rashes
Pertinent Results:
ADMISSION LABS:
___ 12:00PM BLOOD WBC-7.3 RBC-3.77* Hgb-9.5* Hct-29.2*
MCV-77* MCH-25.1* MCHC-32.5 RDW-14.6 Plt ___
___ 12:00PM BLOOD Neuts-76.4* Lymphs-16.3* Monos-6.0
Eos-1.1 Baso-0.2
___ 12:00PM BLOOD ___ PTT-31.2 ___
___ 12:00PM BLOOD Glucose-111* UreaN-20 Creat-0.8 Na-138
K-4.4 Cl-101 HCO3-27 AnGap-14
___ 02:30AM BLOOD LD(___)-141
___ 12:00PM BLOOD CK-MB-2
___ 12:00PM BLOOD cTropnT-<0.01
___ 12:00PM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1
___ 06:36PM BLOOD ___ Temp-37.6 pO2-40* pCO2-37
pH-7.46* calTCO2-27 Base XS-2 Intubat-NOT INTUBA
___ 12:22PM BLOOD Glucose-108* Lactate-1.2 K-4.3 calHCO3-28
PERTINENT LABS:
___ 07:27AM BLOOD ALT-15 AST-14 AlkPhos-74 TotBili-0.3
___ 09:29PM PLEURAL WBC-5175* Hct,Fl-5.0* Polys-21*
Lymphs-76* Monos-1* Eos-1* Other-1*
___ 09:29PM PLEURAL TotProt-4.8 LD(LDH)-551
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-7.2 RBC-3.69* Hgb-9.2* Hct-28.0*
MCV-76* MCH-24.8* MCHC-32.8 RDW-15.1 Plt ___
___ 07:30AM BLOOD Glucose-112* UreaN-25* Creat-0.6 Na-137
K-4.3 Cl-101 HCO3-26 AnGap-14
___ 07:30AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0
MICRO:
- Blood Cx ___ x 2: pending
STUDIES:
CXR ___: In comparison with the study of ___, there is
little change in the
degree of left pleural effusion. There is increasing
indistinctness of
engorged pulmonary vessels, consistent with worsening pulmonary
vascular
congestion.
CXR ___: In comparison with the study of ___, there
has been placement of a
PleurX catheter on the left with decrease in the amount of left
pleural
effusion. The right lung remains essentially clear.
LENIS ___
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
CXR ___
IMPRESSION:
Large left pleural effusion. Left lower lobe collapse.
EKG ___: Sinus tachycardia with frequent premature atrial
contractions.
Pleural Fluid Cytology: PENDING
OSH records:
Bronchoscopy ___: 2+ prevotella oris, + ___,
mycobacterial cx were without growth
MRI brain ___: No evidence of metastases, frontal
prominence of extraaxial spaces greater on the right than the
left, and moderate white matter disease consistent with small
vessel ischemic changes
PET/CT scan ___: L pleural effusion, FFDG avid left hilar
lymph node with SUV 4.9, FDG avid subcarinal lymph node with SUV
of 4.4, 1.7 cm soft tissue density in right paraspinal area of
neck with SUV of 3.2 and thickening of left adrenal gland with
SUV of 2.5
Nuclear stress test ___
Possible small area of infarcation in the ___ segment
but normal LV function
PFTS ___: moderate obstruction to airflow
FVC 2.32
FE1 1.34
FEV6 2.16
VC 2.6
DLCO 70% predicted
Upper endoscopy ___: normal esophagus, stomach and
duodenum, and enlarged left adrenal gland without a discrete
mass.
Fine needle aspirate of adrenal gland ___:
immunochemistry stains positive for AEE1:3, CK7 and TTF-1 and
negative for CK20.
Subcarinal lymph node biopsy ___: metastatic
adenocarcinoma
Thoarcentesis ___: Adenocarcinoma, + TTF-1.
Brief Hospital Course:
___ with COPD and known lung adenocarcinoma with adrenal
metastases with recurrent left-sided pleural effusion presenting
with dyspnea. Dyspnea resolved with thoracentesis, chest tube
later placed by interventional pulm for long term palliation to
prevent recurrence of fluid build up. Will be discharged with
home ___ for MWF drainage of fluid and outpatient pulm f/u.
# Metastatic Adenocarcinoma with recurrent LLL pleural effusion:
- pleur-x catheter in place, will go home with ___ and
outpatient IP f/u
- outside hospital with path to run EGFR test, will call to add
on ALK/Ros1/Kras
# TACHYCARDIA: Previous EKG shows sinus tachycardia with
frequent PACs. DDx includes stress response to tachypnea,
however, given his known malignancy and shortness of breath,
cannot exclude PE. LENIs ordered per FICU team and negative
- deferred to outpatient f/u
#DYSPNEA/ TACHYPNEA: RESOLVED s/p thoracentesis. Pleural fluid
studies consistent with lymphocytic hemorrhagic effusion. Low
likelihood that COPD contributing to overall picture. No
systemic signs to suggest PNA, low concern for aspiration.
Concern for PE remains on differential ___ persistent
tachycardia.
- outpatient f/u
TRANSITIONAL ISSUES:
- EGFR, ALK/Ros1/Kras test results on lung biopsy to be complete
by ___ pathology department by ___- will have to call ___
path to obtain (case number ___
- instructions provided to ___ for management of chest tube, IP
to f/u in ___ weeks, pt discharged with PleurX drainage
materials
- needs abdominal ultrasound for AAA screening (?audible
abdominal bruit on exam and patient reports not being screened)
- discuss with patient need for medical management of COPD
- patient tachycardic throughout most of stay, EKG sinus with
PAC's- PE not definitely ruled out but patient otherwise stable
on RA. may require further work-up in the future if symptoms
persist/worsen
Pleur-x catheter instructions per IP:
1. Please drain Pleurx __every mon, wed, fri____________.
Keep a log of amount & color, have the patient bring it with him
to his appointment.
2. Do not drain more than 1000 ml per drainage.
3. Stop draining for pain, chest tightness, or cough.
4. Do not manipulate catheter in any way.
5. Keep a daily log of Drainage amount and color.
6. You may shower with an occlusive dressing
7. If the drainage is less than 50cc for three consecutive
drainages please call the office for further instructions.
8. Please call office with any questions or concerns at
___.
9. Please order PleurX drainage starter kit 1000mL: ___ to
send with patient on discharge
10. PleurX catheter sutures may be removed in ___ days post
PleurX placement.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 600 mg PO BID:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
do not take more than 3 g total/day
RX *acetaminophen 325 mg 2 tablet(s) by mouth Q6H:PRN Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Metastatic Adenocarcinoma
Recurrent left malignant pleural effusion
Secondary Diagnosis:
Tobacco Abuse History
Chronic obstructive pulmonary disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted for shortness of breath and recurrence of
fluid in your lung. This fluid was likely caused by your known
lung cancer. The fluid was drained and your breathing improved.
To prevent this from happening further, the interventional
pulmonology team put a tube in your chest that will be drained
three times a week going forward. You will be contacted by the
lung doctors for ___ of a follow-up appointment in ___
weeks. Their number is ___ if you have any questions or
concerns.
Wishing you well,
Your ___ Medicine Team
Followup Instructions:
___
|
10870373-DS-13
| 10,870,373 | 27,627,052 |
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| 13 |
2114-01-24 00:00:00
|
2114-01-29 20:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Placement of L pigtail catheter (___)
Placement of ___ L chest tube (___)
Discontinuation of chest tube (___)
Minor thoracostomy, washout, and re-placement of L pleurex
catheter (___)
History of Present Illness:
___ gentleman with CAD, stage IV lung adenocarcinoma,
recurrent malignant pleural effusion s/p multiple thoracenteses
and PleurX catheter (now removed) presenting with exertional
shortness of breath x 1 week. Recent admission ___ with
similar complaint. Had thoracentesis and left sided chest tube
placed with resolution of symptoms. He was discharged with
Pleurex ___ place with plan for intermittent drainage. Pleurex
was subsequently removed on ___ as output had decreased.
Reports 1 week of exertional shortness of breath associated with
left sided chest pain. Pain radiates into the left back.
Associated with cough productive of sputum. Denies hemoptysis.
Presented to the ED. Had workup including chest xray (showing
large left pleural effusion), troponin (negative). Received 325
mg ASA. Bedside US ___ the ED revealed loculated pleural
effusion. Patient was admitted to the ICU due to severe
tachypnea and concern for respiratory compromise.
On arrival to the MICU, patient reports improving symptoms.
Complete resolution of chest pain.
Review of systems:
(+) Per HPI
(-) Denies fever, chills.. Denies headache. shortness of
breath, or wheezing. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
- Newly diagnosed stage IV NSCLC/adenocarcinoma
- Cytology confirmed malignant pleural effusion
- EBBx proven LLL endobronchial disease
- Cytology+ adrenal and station 7 disease
- FDG avid right cervical paraspinal soft tissue mass
- COPD
- Latent TB
- BPH
- L-spine DJD/DDD
- Left rotator cuff syndrome
- CAD
Social History:
___
Family History:
His father had HTN. His mother died from MI. He has five
brothers and two sisters, with two brothers dying from a MI. No
known family history of malignancy.
Physical Exam:
On admission:
Tcurrent: 37.1 °C (98.8 °F) HR: 103 BP: 117/72(84) RR: 25 SpO2:
93% 1L
GENERAL: AAOx3, NAD
HEENT: PERRL
NECK: normal ROM
LUNGS: Expiratory wheezes bilaterally. decrease AE on left side.
no crackles
CV: RRR S1 and S2 without MRG
ABD: Soft, NT
EXT: 1+ edema bilateral lower extremities
NEURO: Speech fluent, moving all extremities
On discharge:
VS:Tmax 98.9, Tc 98.8, BP 98-112/50-62, HR 85-107, RR ___,
SpO2 95-99%2LNC
GENERAL: AAOx3, NAD, talking several word sentences, thin
appearing
HEENT: PERRL
NECK: supple, normal ROM
LUNGS: decrease AE on left side. crackles around new pleurex
entry site
CV: irregular, S1 and S2 without MRG, peripheral pulse
ABD: Soft, NT
EXT: 1+ edema bilateral lower extremities
NEURO: ___, EOMI, face symmetric, no nystagmus, Speech fluent,
moving all extremities against resistance, sensation intact to
light touch, no clonus.
Pertinent Results:
On admission:
___ 12:15AM BLOOD WBC-4.3 RBC-3.62* Hgb-8.6* Hct-27.1*
MCV-75* MCH-23.8* MCHC-31.8 RDW-17.2* Plt ___
___:15AM BLOOD Neuts-76.4* Lymphs-15.6* Monos-6.9
Eos-1.0 Baso-0.1
___ 12:15AM BLOOD Glucose-118* UreaN-23* Creat-0.7 Na-137
K-4.5 Cl-97 HCO3-27 AnGap-18
___ 12:15AM BLOOD ALT-36 AST-29 AlkPhos-114 TotBili-0.4
___ 12:15AM BLOOD cTropnT-<0.01
___ 06:05AM BLOOD cTropnT-<0.01
___ 12:15AM BLOOD Albumin-3.0*
___ 06:49AM BLOOD ___ pO2-65* pCO2-39 pH-7.45
calTCO2-28 Base XS-2
___ 12:35AM BLOOD Lactate-1.2
___ the interim:
___ 12:15AM BLOOD cTropnT-<0.01
___ 06:05AM BLOOD cTropnT-<0.01
___ 12:15AM BLOOD Lipase-36
___ 12:15AM BLOOD ALT-36 AST-29 AlkPhos-114 TotBili-0.4
___ 06:49AM BLOOD ___ pO2-65* pCO2-39 pH-7.45
calTCO2-28 Base XS-2
___ 12:35AM BLOOD Lactate-1.2
___ 06:49AM BLOOD Lactate-0.7
On discharge:
___ 07:05AM BLOOD WBC-3.3* RBC-3.37* Hgb-8.5* Hct-26.1*
MCV-78* MCH-25.2* MCHC-32.5 RDW-18.5* Plt ___
___ 07:05AM BLOOD ___ PTT-31.3 ___
___ 07:05AM BLOOD Glucose-99 UreaN-17 Creat-0.7 Na-132*
K-5.1 Cl-95* HCO3-31 AnGap-11
___ 07:05AM BLOOD TotProt-5.3* Calcium-8.5 Phos-3.9 Mg-1.9
Microbiology:
___ 11:06 am PLEURAL FLUID
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
Reported to and read back by ___ ___ @
1544.
FLUID CULTURE (Final ___:
STAPHYLOCOCCUS EPIDERMIDIS. SPARSE GROWTH.
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.
STAPHYLOCOCCUS EPIDERMIDIS. SPARSE GROWTH. SECOND
MORPHOLOGY.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted. SPECIATION PER ___.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
| STAPHYLOCOCCUS
EPIDERMIDIS
| |
CLINDAMYCIN-----------<=0.25 S <=0.25 S
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN----------<=0.12 S <=0.12 S
OXACILLIN-------------<=0.25 S <=0.25 S
TETRACYCLINE---------- 2 S 2 S
VANCOMYCIN------------ 2 S 2 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___: Blood cultures- No growth.
___ Pleural fluid culture:
___ 10:00 am PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): .
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
Imaging and other studies:
CXR (___):
IMPRESSION:
___ comparison with the study of ___, the pigtail
catheter at the left base was inadvertently pulled. There is an
area of lucency the at the left base seen previously suggesting
the possibility of a loculated gas collection. Extensive
opacification is seen ___ the left hemithorax, shown on recent CT
to represent an obstructing mass. Slightly more aeration is seen
___ the upper zone laterally. The right lung is essentially
clear.
CT chest without contrast (___):
IMPRESSION:
1. Significant interval decrease of the dependent aspect of the
left pleural effusion since ___, though several
septations are now visible. The anterior loculation is
unchanged. Moderate basal pneumothorax is stable.
2. Limited assessment of the known left lower lobe mass causing
lobar collapse.
3. Mild interval improvement of left upper lobe consolidation.
CTA chest (___):
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Left lower lobe mass is difficult to discern however appears
visually similar to the prior study. This mass was known to
obstruct the left lower lobe bronchus and there are additionally
obstructing secretions ___ the distal left mainstem bronchus with
associated complete left lower lobe collapse and near complete
left upper lobe collapse, new/worsened.
3. Left pleural drainage catheter ___ place with adjacent
associated small to moderate basal pneumothorax. Overall
loculated pleural effusion component has decreased posteriorly,
with stable anterior component.
4. Diffuse left pleural thickening is re- demonstrated,
representing
irritation from a chronic loculated effusions or tumor implants.
5. Overall stable sclerotic bony metastases, as above, with
minimal increase ___ size of a sclerotic T8 vertebral body
lesion.
6. Stable left adrenal metastasis.
7. Moderate emphysema.
CXR ___, newer):
IMPRESSION:
As compared to the prior radiograph from earlier today, a left
pigtail pleural catheter is been placed. There remains near
complete opacification of the left hemithorax with only a small
amount of residual aerated lung ___ the left suprahilar region.
Known central mass ___ the left hemi thorax has been more fully
evaluated by CT and is known to result ___ bronchial obstruction.
Considering only minimal improvement ___ the degree of left hemi
thorax opacification following pigtail pleural catheter
placement, CT may be helpful
to determine whether the tube is optimally placed and may also
help determine the relative contributions to left hemi thorax
opacification by post obstructive atelectasis and pleural fluid.
CXR (___):
IMPRESSION:
Interval increase ___ the left pleural effusion, with near total
opacification of the left hemithorax. Minimally aerated lung is
seen ___ the left lung apex.
Brief Hospital Course:
___ gentleman with CAD, stage IV lung adenocarcinoma,
recurrent malignant pleural effusion s/p multiple thoracenteses
and PleurX catheter (recently removed) presenting with
exertional shortness of breath x 1 week and recurrent left sided
pleural effusion.
# Pleural effusion/empyema, dyspnea: Likely malignant given
similar to prior presentations. Appeared loculated on ED and
MICU US. S/p thoracentesis and chest tube placement by IP
___. Pleural fluid studies showed Staphylococcus, which
was initially treated with Vancomycin. Multiple imaging studies
were obtained, and patient had a second chest tube placed with
IP. The first tube output significantly decreased and was
discontinued. The patient accidentally self-discontinued the
second tube while adjusting himself ___ the bed. At that point,
his respiratory status was stable, and he was saturating well on
2L NC (he had no previous home O2 requirement). CTA chest had
confirmed LLL and LUL collapse (PE had been ruled out). IP and
Thoracic Surgery, along with the primary Oncology team decided
to pursue medical thoracoscopy for minor washout and
re-placement of Pleurex catheter intra-op. Patient successfully
had a final Pleurex catheter placed on ___, and was discharged
on ___ with Vancomycin switched to Dicloxacillin to continue
for 3 weeks post-discharge. He was also discharged and provided
with services to have home oxygen; ___ will conduct daily
drainage of Pleurex catheter to prevent re-accumulation, and
chest tube was capped at the time of discharge. Morphine ___
q6hr PRN was added for dyspnea, per Palliative Care, ___ addition
to low-dose Oxycodone that was used for tube exit site pain
control.
# Tachycardia/paroxysmal SVT: Patient was intermittently ___ SVT
vs. A-fib this admission. He was eventually rate-controlled with
Metoprolol 25 mg PO q8hr. TSH was checked and was WNL. CHADS 0,
CHADS-VASC 1. Anti-coagulation was held this admission given his
co-morbidities; Aspirin was considered, but was not finally ___
alignment with goals of care. Of note, patient had a TTE on ___
which was grossly normal, with slightly depressed systolic
function (EF 50-55%).
# Pain control: Patient generally reported adequate pain control
this admission. He was provided with a Lidocaine patch for chest
tube exit site pain, and received low-dose Oxycodone 2.5-10 mg
PO q4hr PRN. Morphine was added for dyspnea as above, per
Palliative Care.
CHRONIC ISSUES:
#COPD: Patient with moderate obstructive disease; prescribed
Proair and Spiriva at home but reports not taking. no evidence
of exacerbation. Patient was trialed on Atrovent and Spiriva
___. He was also provided with Ipratropium nebulizers PRN
(no albuterol due to tachycardia, as above).
# Pulsatile abdominal mass: Pt denies hx of AAA screening.
Concern for AAA based on smoking hx. Abdominal ultrasound was
deferred, ___ alignment with goals of care this admission.
# Anemia: Patient remained hemodynamically stable, no acute
concerns for bleed but H/H were slowly downtrending at the
beginning of his admission. Given sero-sanguineous/sanguineous
output from his chest tubes, he was transfused 1u PRBC with
initial inappropriate response; transfusion was repeated x 1,
and he responded appropriately.
#BPH: Patient did not have any symptoms this admission.
ONCOLOGIC PLAN: Patient was on palliative Carboplatin/Pemetrexed
per Dr. ___ at the time of admission. However, his
prognosis was discussed, and with the help of Dr. ___
patient and the family made the decision to not pursue any more
chemotherapy. Radiation Oncology was consulted, but did not have
anything to offer. Patient was discharged home with home
hospice.
# CODE STATUS: Full (confirmed)
# EMERGENCY CONTACT: Wife ___ ___
TRANSITIONAL ISSUES:
- Patient was maintained on Metoprolol 25 mg PO q8hr for HR
control.
- Daily drainage of Pleurex with home nursing; patient being
discharged with drain capped and few supplies to hold over. Will
follow-up with IP within 2 weeks for suture removal.
- Dicloxacillin, Day 1 = ___ total 3 week course ourse to
end at end of the day on ___.
- Patient remains Full Code with home hospice care; will
re-address with Dr. ___ at scheduled appointment
this week.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Lorazepam 0.5 mg PO QHS:PRN insomnia
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
4. Docusate Sodium 100 mg PO DAILY:PRN constipation
5. Senna 8.6 mg PO DAILY
6. Dexamethasone 3 mg PO Q12H
Discharge Medications:
1. Docusate Sodium 100 mg PO DAILY:PRN constipation
2. OxycoDONE (Immediate Release) 2.5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
3. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Morphine Sulfate (Oral Soln.) ___ mg PO Q6H:PRN dyspnea
RX *morphine 10 mg/5 mL ___ mL by mouth every six (6) hours
Refills:*0
5. Polyethylene Glycol 17 g PO DAILY constipation
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*100 Packet Refills:*0
6. Sodium Chloride Nasal ___ SPRY NU BID:PRN dry nose
RX *sodium chloride [Nasal Spray (sodium chloride)] 0.65 % ___
sprays nasal twice a day Disp #*1 Spray Refills:*0
7. Acetaminophen 650 mg PO Q6H:PRN pain
8. Metoprolol Tartrate 25 mg PO Q8H
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth every eight
(8) hours Disp #*90 Tablet Refills:*0
9. Lorazepam 0.5 mg PO QHS:PRN insomnia
RX *lorazepam 0.5 mg 1 tablet by mouth at bedtime Disp #*14
Tablet Refills:*0
10. DiCLOXacillin 500 mg PO Q6H
to end at the end of the day on ___.
RX *dicloxacillin 500 mg 1 capsule(s) by mouth every six (6)
hours Disp #*85 Capsule Refills:*0
11. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) 1 patch once a day
Disp #*30 Patch Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Stage IV lung adenocarcinoma
Loculation effusion, empyema
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 being a part of your care during your
admission to ___. You were
admitted for shortness of breath, and it was found that you had
re-accumulation of fluid within your left lung. You had a chest
tube replaced, which continued to drain fluid. Another fluid
collection was found, and at one point you had 2 tubes ___ place.
One was removed, and one fell out on its own.
___ order to keep the fluid level ___ the lung down, you had a
final tube placed with the Interventional Pulmonologists ___ the
operating room. The nurses who come to visit you at home will
drain this tube daily.
Your high heart rates were controlled with a medication called
Metprolol during this hospital stay. Also, along with Dr.
___ Dr. ___ decided not to pursue any further
chemotherapy.
Once again, it was a pleasure being a part of your care, and we
wish you all the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10870419-DS-4
| 10,870,419 | 22,376,693 |
DS
| 4 |
2112-11-24 00:00:00
|
2112-11-30 13:22:00
|
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 and emesis
Major Surgical or Invasive Procedure:
___: Colonoscopy with colonic stent placement
History of Present Illness:
___ year old previously healthy male who presents with
obstruction. He started having emesis of yellow-green vomitus on
___ (two days ago), then developed lower abdominal pain
___ last night, so he presented to the ED. He hasn't had
flatus or a BM for a day. No recent weight loss, fevers, chills,
night sweats. No symptoms like this ever before. No LLQ pain
previously. Has never had a colonoscopy.
Past Medical History:
PMHx: OSA
PSHx: none
Social History:
___
Family History:
Mother with breast cancer at age ___
Physical Exam:
Admission Physical Exam:
Gen: uncomfortable at times
CV: RRR
Pulm: no respiratory distress on room air
Abd: no scars. soft, nondistended. tender in right abdomen. no
rebound, guarding, or rigidity
Rectal: no hemorrhoids or skin tags. no masses. no gross blood.
hemoccult negative
Ext: no edema
Discharge Physical Exam:
VS: T: 98.5 PO BP: 148/90 HR: 89 RR: 16 O2: 96% RA
GEN: A+Ox3, NAD
HEENT: MMM, atraumatic
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, non-tender to palpation
EXT: wwp, no edema b/l
Pertinent Results:
IMAGING:
___: CT Abdomen/Pelvis:
Large-bowel obstruction with a transition point at a short
segment of colonic narrowing in the descending colon concerning
for malignant stricture. No pneumatosis or free intraperitoneal
air. Colonoscopy is recommended when clinically appropriate.
___: CXR:
Lungs are low volume with stable moderate cardiomegaly. There
is no pleural effusion. There is no pneumothorax. No new
consolidations concerning for pneumonia.
___: CT Chest:
No evidence of intrathoracic metastatic disease. Scattered
nonspecific
pulmonary micronodules.
RECOMMENDATION(S): For incidentally detected multiple solid
pulmonary nodules smaller than 6mm, no CT follow-up is
recommended in a low-risk patient, and an optional CT follow-up
in 12 months is recommended in a high-risk patient.
LABS:
___ 04:43PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:43PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-40* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 02:56PM LACTATE-1.2
___ 02:52PM GLUCOSE-117* UREA N-15 CREAT-0.7 SODIUM-144
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-24 ANION GAP-16
___ 02:52PM ALT(SGPT)-15 AST(SGOT)-18 ALK PHOS-54 TOT
BILI-0.4
___ 02:52PM LIPASE-15
___ 02:52PM ALBUMIN-4.4 CALCIUM-8.9 PHOSPHATE-3.3
MAGNESIUM-2.1
___ 02:52PM WBC-8.3 RBC-5.00 HGB-14.9 HCT-43.9 MCV-88
MCH-29.8 MCHC-33.9 RDW-13.2 RDWSD-42.1
___ 02:52PM NEUTS-93.3* LYMPHS-4.2* MONOS-1.9* EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-7.77* AbsLymp-0.35* AbsMono-0.16*
AbsEos-0.00* AbsBaso-0.01
___ 02:52PM PLT COUNT-200
Brief Hospital Course:
Ms. ___ is a ___ y/o M who presented to ___ with
abdominal pain and emesis and was found on CT to have a large
bowel obstruction from a stricture in the descending colon,
concerning for malignancy. Gastroenterology was consulted
regarding colonoscopy. The patient received tap water enemas
and endoscopy was performed with stent placement and biopsies
were sent. The patient's abdominal pain improved after this
procedure and he began to have bowel movements. The patient was
scheduled to follow-up at ___ next week for scheduled surgical
removal of the affected colon. ___ ostomy RN visited with the
patient and marked the stoma site and engaged in stoma teaching
with the patient. The patient tolerated a regular, pureed diet,
intake and output were monitored. Pain was controlled without
pain medication. The patient remained stable from a
cardiovascular and pulmonary standpoint; vital signs were
routinely monitored. The patient received subcutaneous heparin
for DVT prophylaxis.
At the time of discharge, the patient was hemodynamically
stable, tolerating a regular diet, ambulating independently and
voiding without assist. Plan was made to have patient follow-up
next week for scheduled operation with Dr. ___. Bowel prep
medication was called into the patient's pharmacy and the clinic
e-mailed the patient with pre-op instructions. The patient
verbalized understanding and was in agreement with the discharge
plan.
Medications on Admission:
None
Discharge Medications:
1. GuaiFENesin ___ mL PO Q6H:PRN cough
Discharge Disposition:
Home
Discharge Diagnosis:
Large bowel obstruction due to stricture in the descending colon
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with
abdominal pain and were found to have a large bowel obstruction
due to mass causing a stricture (narrowing of the bowel). You
underwent a colonoscopy by the Gastroenterologists and had a
colonic stent placed to open the stricture. This procedure went
well, you had return of bowel function and are now tolerating a
diet. You are scheduled to have surgery next ___
to undergo surgical removal of the affected colon.
You are now ready to be discharged home to continue your
recovery. Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. 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:
___
|
10870690-DS-8
| 10,870,690 | 26,919,836 |
DS
| 8 |
2133-11-28 00:00:00
|
2133-11-28 18:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Gait Difficulty
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ with hx of anxiety and depression here
with several weeks of progressive gait difficulty.
Pt reports that he has had years of knee pain with going up
stairs for years and over the last several months has felt that
his right leg has been "giving out under him" when going down
steps every once and a while. However, these changes had never
caused him significant functional problems and he was able to
maintain his normal degree of activity.
Over the last two weeks however, he has had progressive
difficulty with walking due to both of his knees giving out,
both
of his legs shaking and "having a mind of their own", and
unsteadiness with walking that has lead to several falls. He has
even needed to purchase a walker and now requires this to walk.
He is unable to walk as far as he usually is also due to
shortness of breath which he attributes to needing to hold and
shift the walker as he walks. He has also noted
numbness/tingling
at the bottoms of his feet also present over the last 2 weeks.
He denies any abrupt onset of his difficulties.
He is able to manage without the walker in his small apartment,
but only when his shoes are off and by holding on to furniture.
On neurologic review of systems, the patient denies headache,
lightheadedness. Denies difficulty with producing or
comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, dysarthria, or dysphagia. Denies focal muscle
weakness, numbness, parasthesia. Denies bowel or bladder
incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies nausea, vomiting, diarrhea,
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias.
Past Medical History:
Anxiety
Depression
L finger surgery from trauma
Social History:
___
Family History:
Father's side - many members with CAD and MI
Mother's side - many members with DM
No neurologic conditions that he knows of.
Physical Exam:
=== ADMISSION EXAM ===
PHYSICAL EXAMINATION
Vitals: 98.2F, HR 90, 153/68, RR 16, 98% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND
Extremities: No ___ edema. Pt notes that he feels that his b/l
quad muscle bulk has decreased compared to prior.
Neurologic:
-Mental Status: Alert, oriented to month, ___, year, but not
actual date - cannot remember since he has been laid off. Able
to
relate history without difficulty. Attentive, able to name ___
backward without difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Had to try twice for three step command. Pt was
able to register 3 objects and recall ___ at 5 minutes, ___ with
category cue. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. ?Breakdown of smooth pursuit. Normal saccades.
Difficulty with visual field exam - had to look at fingers in
periphery in order to count - had lost his prescription glasses
and was using drugstore glasses. Fields intact to finger wiggle.
When tested fields with red tip of reflex hammer, he could not
see the redness until it was quite central in all directions -
?b/l tunnel vision.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing slightly decreased on right compared to left on
finger rub.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal tone in UE at rest. Increased tone in ___ with
spasticity. No pronator drift bilaterally.
+both postural and action tremor. No rest tremor.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch. Pinprick was felt
everywhere but possibly mildly decreased over medial leg.
Vibratory sense was 11sec in R toe and 13 sec in L toe.
Proprioception was affected in b/l UE both with testing of small
joint position in fingers as well as with touching his nose with
eyes closed. He also had difficulty with joint position in b/l
great toes somewhat improved in ankle better with larger
movements than smaller movements. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 1
R 3 3 3 3 1
Plantar response was flexor on left and mute on the right. No
clonus at ankles. +Crossed adductors b/l. +pectoral jerks
bilaterally. +Hoffmans on the L.
-Coordination: Both postural and action tremor in UE that makes
interpreting finger/nose/finger difficult but he does seem to
overshoot several times when testing mirroring. Very dysmetric
b/l with heel/knee/shin - pt has more subjective difficulty with
right compared to left but it appears grossly dysmetric
bilaterally.
-Gait: Has much difficulty getting up out of bed independently
that is out of proportion to strength exam. He does not appear
to
have truncal ataxia on testing. When standing, broad based and
shuffles forward. Looks very unsteady when standing and walking
several steps with walker and I did not feel comfortable testing
romberg.
=== DISCHARGE EXAM ===
***** ENTER TODAY'S EXAM ***
Pertinent Results:
=== LABS ===
___ 10:32AM BLOOD WBC-6.6 RBC-4.61 Hgb-13.6* Hct-41.4
MCV-90 MCH-29.5 MCHC-32.9 RDW-13.0 RDWSD-42.5 Plt ___
___ 03:00PM BLOOD Neuts-72.3* Lymphs-17.6* Monos-9.0
Eos-0.4* Baso-0.4 Im ___ AbsNeut-5.03 AbsLymp-1.23
AbsMono-0.63 AbsEos-0.03* AbsBaso-0.03
___ 03:00PM BLOOD ___ PTT-30.6 ___
___ 03:00PM BLOOD Plt ___
___ 07:03AM BLOOD Glucose-97 UreaN-20 Creat-1.0 Na-137
K-4.0 Cl-103 HCO3-22 AnGap-16
___ 10:32AM BLOOD Glucose-133* UreaN-18 Creat-0.9 Na-135
K-4.0 Cl-100 HCO3-23 AnGap-16
___ 03:00PM BLOOD ALT-22 AST-50* AlkPhos-125 TotBili-0.4
___ 07:03AM BLOOD ALT-22 AST-25
___ 04:45PM BLOOD ALT-23 AST-24
___ 10:32AM BLOOD ALT-24 AST-24 AlkPhos-143* TotBili-0.4
___ 07:03AM BLOOD GGT-20
___ 04:45PM BLOOD GGT-21
___ 03:00PM BLOOD Albumin-3.8 Calcium-8.6 Phos-3.3 Mg-2.1
___ 10:32AM BLOOD Calcium-8.7 Phos-2.5* Mg-2.0
___ 07:03AM BLOOD VitB12-346 Folate-9.9
___ 07:03AM BLOOD TSH-5.4*
___ 10:32AM BLOOD T4-5.8 T3-93
___ 03:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:04PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
Brief Hospital Course:
___ man with history of depression and anxiety admitted for
worsening gait difficulty, in the setting of recently starting
bupropion in addition to previous Doxepin (TCA) and fluoxetine
(SSRI). His exam was significant for upper and lower extremity
ataxia, tremor, saccadic intrusions, and diffuse hyperreflexia
including jaw jerk and ___. His labs have been mostly
normal thus far (normal B12 and folate, T3/T4 wnl, pending B1
and B6) with only mild elevation in AST that resolved on day
two, and mild elevation in AP. His symptoms and history were
consistent with serotonin syndrome, triggered by the recent
addition of bupropion, and his outpatient psychiatrist informed
us that he was no longer supposed to be taking Doxepin. His
symptoms clearly began to improve 1 day after discontinuation of
all psychiatric medications (except clonazepam). The treatment
for serotonin syndrome is continued holding of doxepin,
fluoxetine, and bupropion, with close follow-up (from rehab)
with his psychiatrist within the next week to slowly re-initiate
appropriate medications.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Doxepin HCl 50 mg PO DAILY
2. FLUoxetine 60 mg PO DAILY
3. ClonazePAM 0.5 mg PO DAILY
4. BuPROPion (Sustained Release) 200 mg PO DAILY
Discharge Medications:
1. Clonazepam 0.5 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Serotonin Syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
You were admitted to the hospital for symptoms of difficulty
walking and tremors. These symptoms were found to be the result
of too many anti-depressant medications resulting in something
called "Serotonin Syndrome" caused by an excess of serotonin.
When mild, this causes elevated heart rate, muscle
jerking/tremor, overresponsive reflexes, and other symptoms.
Other symptoms can include confusion, hallucinations, sweating,
nausea, and diarrhea. Not all symptoms may always be present.
The improvement in your symptoms after stopping these
medications indicates this as the likely diagnosis. Treatment is
to stop all offending medications for a period of time before
restarting some slowly. We discussed this with your psychiatrist
who informed us you were not supposed to be taking the Doxepin
any longer. Your psychiatrist agrees with this plan, and would
like to see you very soon in their office.
- STOP Doxepin
- STOP Prozac
- STOP Wellbutrin
Follow-up with your psychiatrist from the rehabilitation
facility.
It was a pleasure taking care of you!
Thank you,
Your ___ Neurology Team
Followup Instructions:
___
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2136-01-24 13:49:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
EGD
Blood transfusion
History of Present Illness:
Mr. ___ is a ___ y/o gentleman without any significant
medical history who presented to the ED from his PCP's office
for a Hgb of 6.
He was in his normal state of health until five months ago when
he started to feel as if his 'stomach was bubbling'. He
attributed the sensation to excessive caffeine use, as he was
drinking several soft and energy drinks every day. As a result,
he stopped drinking caffeine and experienced severe caffeine
withdrawal headaches. To self-treat his withdrawal headaches he
was taking approximately 9 regular aspirin a day for about a
week, and then continued to take numerous aspirin after that
weeks.
In the setting of his excessive aspirin intake, he began to
notice dark tarry stools and increasing fatigue. He appoximates
that he's had about one melanic stool per day, although in the
past few days it has been more frequent. No other symptoms of
diarrhea or bright red blood in his stool. He had a couple
episodes of nonbilious, nonbloody vomiting approximately two
weeks ago.
As the month progressed, he noted increasing fatigue, especially
as his job as the ___ ___ requires a great deal of
energy. He notes increasing muscle weakness, a heart that 'was
working hard' and the sensation of 'seeing bright lights' with
exertion. A few weeks ago, he had a episode of left arm and
chest pain that resolved over the day, was not associated with
exertion, and changed with movement, which the patient
attributed to an uncomfortable sleeping position. He also noted
that his skin appeared more pale.
He initially attributed his symptoms to dehydration and thus,
drank a great deal of gatorade and water to compensate. When
this did not relieve his symptoms, he visited his PCP. Labs
done by his primary care physician ___ ___ were notable for
severe ___ deficiency anemia with Hg 6.0, Hct 19.9, MCV 68.3,
Plt 446, Serum Fe 27, TIBC 479, Tfn ___ 5.6 and Transferrin 342.
Due to his severe anemia and suggestive symptoms, his PCP
suggested he present to the ___ ED. At the advice of his PCP,
he presented to the ___ ED.
He does not report any fevers, chills, dyspnea, pain, chemical
exposures, travel history or trauma.
In the ED, initial vitals: 98.8 98 131/58 16 100% RA. He had
guiaic positive stools and GI was consulted. They suggested an
EGD tomorrow morning, and starting a PPI tonight.
Vitals prior to transfer: 98.1 79 93/61 18 100%RA
Currently, he feels slightly fatigued, but has no other
symptoms, including no pain, no dizziness, no lightheadedness
and no palpitations. He is comfortable laying in bed.
ROS:
No fevers, chills, night sweats. Has gained 3 lbs over the last
month.
No changes in hearing, no changes in balance.
No cough, no shortness of breath.
No chest pain.
No dysuria or hematuria.
No numbness or weakness, no focal deficits.
Past Medical History:
Oral surgery when a teenager.
Social History:
___
Family History:
Maternal grandmother- multiple brain aneurysms
Maternal grandfather- ___ disease
Paternal grandmother- throat cancer
___ grandfather- throat and stomach cancer
Mother- ___ deficiency anemia
Father- hyperlipidemia
Brother- ___ years old in good health
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- 98.3 106/58 78 20 100% RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric/pale, MMM, oropharynx clear
Neck- Supple, JVP at 8cm, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- Soft, normoactive bowel sounds, NT/ND, no rebound
tenderness or guarding, no organomegaly, liver felt 1cm below
the rib cage.
GU- no foley
Ext- Warm, well perfused, 2+ radial and DP pulses, no clubbing,
cyanosis or edema, 2x 18G IVs, one in each arm.
Neuro- CNs2-12 intact, motor function grossly normal
Skin- Extremely pale.
DISCHARGE PHYSICAL EXAM
Vitals: 98.1 99/51(80-100/40-60s) 77(50-80s) 20 100%RA
Exam:
General- Alert, oriented, no acute distress
HEENT- No conjunctiva pallor, MMM, oropharynx clear
Neck- Supple
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- Soft, normoactive bowel sounds, NT/ND, no rebound
tenderness or guarding, no organomegaly.
GU- no foley
Ext- Warm, well perfused, 2+ DP pulses, no clubbing, cyanosis or
edema, 2x 18G IVs, one in each arm.
Neuro- CNs2-12 intact, motor function grossly normal
Skin- pale.
Pertinent Results:
ADMISSION LABS:
___ 02:05PM BLOOD WBC-4.0 RBC-2.65* Hgb-5.1* Hct-20.1*
MCV-76* MCH-19.4* MCHC-25.5* RDW-18.5* Plt ___
___ 02:05PM BLOOD Neuts-68.6 ___ Monos-6.4 Eos-0.9
Baso-0.4
___ 02:05PM BLOOD Plt ___
___ 02:05PM BLOOD ___ PTT-30.0 ___
___ 02:05PM BLOOD Ret Man-5.2*
___ 12:25PM BLOOD Glucose-88 UreaN-16 Creat-1.1 Na-138
K-3.7 Cl-106 HCO3-24 AnGap-12
DISCHARGE LABS:
___ 07:55AM BLOOD WBC-6.5 RBC-3.67* Hgb-8.7* Hct-28.7*
MCV-78* MCH-23.8* MCHC-30.4* RDW-19.2* Plt ___
RELEVANT INTERIM LABS:
H.pylori negative
EGD ___
Irregular z-line (biopsy)
Mild gastritis and erosion of the antrum. This does not
necessarily explain the patients severe anemia. (biopsy)
Normal mucosa in the whole duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
IMAGING:
CT A/P ___
IMPRESSION:
1. No imaging features to suggest small bowel lymphoma.
2. Multiple abnormal appearing segments of small bowel are
identified, some with apparent wall thickening and other with
fecalization as described above which may be related to
processes such as Crohn disease. Assessment is limited given the
static nature of CT enterography, and as the majority of enteric
contrast was in the colon. MR-Enterography is recommended for
further evaluation.
PATHOLOGY
-Upper GI biopsy pending at time of discharge
Brief Hospital Course:
Mr. ___ is a ___ y/o gentleman with approximately one
month of melenic stools, excessive aspirin use and labs
suggestive of ___ deficiency anemia suggestive for upper
gastrointestinal bleeding.
ACTIVE ISSUES:
# Anemia: He presented with lab values consistent with ___
deficiency anemia with Hgb of 5.1, melena history consistent
with upper gastroinstestinal bleed. He received 3U PRBC which
stabilized his Hgb at 8. GI was consulted and preformed a EGD,
which showed no source of bleeding, but did show mild gastritis.
He was started on po pantoprazole. He also received a CT scan
to evaluate for possible source of bleed in small intestine (eg,
small intestinal lymphoma given h/o night sweats), which showed
some changes which might be consistent with inflammatory process
such as Crohn's disease, but no masses. H. Pylori serology and
hemolysis labs were negative. At the time of discharge, he was
hemodynamically stable with a Hgb/Hct of 8.7/28.7. He was
recommended by GI to have an outpatient colonoscopy.
TRANSITIONAL ISSUES
- Will need CBC rechecked at appointment with PCP to ensure
stability
- Will need outpatient colonoscopy, and given evidence of
changes possibly consistent with Crohn's on CT enterography,
will need referral to GI (in Atrius system)
- Pathology from biopsy from EGD pending at time of discharge
Medications on Admission:
None. Some aspirin use, as detailed in the HPI.
Discharge Medications:
1. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate 325 mg (65 mg ___ 1 tablet(s) by mouth
twice daily Disp #*60 Tablet Refills:*0
2. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth daily Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
___ deficiency anemia.
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 part in your care during your stay at
the ___. As you know, you were
admitted to the hospital to receive a blood transfusion and
investigate the cause of your anemia (low blood counts). You
received a Esophagogastroduodenoscopy or EGD in which a camera
took pictures of your esophagus, stomach and the upper part of
your small intestine. There was no site of bleeding identified
during the EGD.
You also received a CT scan to look for changes in your
intestine that might be bleeding and could also result in a low
blood count. The results of this test were pending at the time
of discharge.
We have made you an appointment with your primary doctor who you
should ___ with so that he can help get you scheduled for
an outpatient colonoscopy. You may also need a capsule study
(which looks at your small intestine), but only if the other
tests are negative.
We wish you good health in the future.
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
doxycycline
Attending: ___
Chief Complaint:
Found at home unable to talk or move.
Major Surgical or Invasive Procedure:
___ Left LEG THROMBECTOMY AND 4 compartment fasciotomy
___ Percutaneous gastrostomy tube placement
History of Present Illness:
Mr. ___ is a ___ yo man with poorly controlled type II
diabetes, HLD, HTN, atrial fibrillation , DM, HLD, HTN, and
a-fib (not on anticoagulation) who is transferred from ___
___ in the setting of a large L PCA infarct and ischemic
LLE. History was obtained from chart review and partner. Mr.
___ was last seen well at 12pm on ___. His partner states
that he is functional and independent without any deficits apart
from a diabetic neuropathy. She left the house that day and did
not return until 11pm. At that time, she found him sprawled over
the bed, unable to talk and unable to move enough to get out of
bed. He was brought to ED. There he had a NIHSS of 14. He was
non-verbal, not moving R arm and R leg, not responding to
commands. CT head showed a large left-sided occipito-temporal
infarct and CTA shows proximal cut-off of the L PCA. He was seen
by tele-neuro (not ___ who felt that he was not a TPA
candidate or thrombectomy candidate given the elapsed time since
last normal and overt CT changes suggesting completed infarct.
He was then admitted to the ICU for post-stroke care. He
underwent MRI and was started on aspirin and statin. In the
early hours on ___, he was noted to a cold, dusky LLE. His
pulse was weakly dopplerable. CTA of his leg was obtained and he
was transferred ___ for further management. Vascular surgery
performed left leg thrombectomy and 4
compartment fasciotomy ___. Heparin gtt was started.
Patient admitted to SICU. Patient transferred to NEURO ICU on
___
Past Medical History:
Type 2 Diabetes
HTN
paroxysmal atrial fibrillation, not on anticoagulation
Social History:
___
Family History:
non contributory
Physical Exam:
Admission Physical Exam:
====================
Vitals: T: P: R: 16 BP: SaO2:
General: Awake, confused appearing
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. LLE cold, dusky. No palpable pulse
Skin: seborrheaic dermatitis on all extremities
Neurologic:
-Mental Status: Awake, mute. Does not respond to orientation
question. Unable to answer yes/no questions. Does not follow
commands. There appears to be R sided neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 2 to 1 mm and brisk. EOMI by VOR. BTT
in
all quadrants though less reliably on R. Face appears symmetric
at rest.
-Motor: Decreased tone in RUE/RLE. Slight movement in R delt
otherwise no spontaneous movement. no spontaneous movement noted
in RLE. Moves LUE/LLE antigravity though not to command. Offers
some resistance when attempting to passively move LUE.
-Sensory: Does not localize to pain in RUE/RLE. RLE TF.
Withdraws in LUE/LLE.
-DTRs: Unable to obtain DTRs. ___ response flexor on L,
extensor on R
-Coordination: unable to assess
-Gait: deferred
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Discharge Physical Exam
Temp: 98.3 (Tm 98.3), BP: 121/79 (109-125/72-79), HR: 88
(88-94), RR: 20 (___), O2 sat: 94% (92-96), O2 delivery: RA
Sitting in chair
Neck: Supple
Pulmonary: Breathing comfortably
Cardiac: Warm, well-perfused
Abdomen: Soft, non-distended
Extremities: Groin region with staples, dry and clean dressing,
LLE with dressing in place / VAC on, erythema is stable, no
induration, no fluctuant mass
Skin: Seborrhea
Neurological
MS: Awake. Eyes open. Left gaze preference. Looks at the
examiner
briefly but does not track. Does not follow commands.
CN: Face appears symmetric. Pupils 3-2mm, left gaze preference.
Blinks to threat left eye, does not blink to threat right eye
Motor:
LUE: moving antigravity, purposeful movements
LLE: moves spontaneously, withdraws to noxious
RUE: no purposeful movement to noxious, grimaces to noxious
RLE: no purposeful movement to noxious
Pertinent Results:
LABS
___ 06:00AM BLOOD WBC-6.3 RBC-3.80* Hgb-11.1* Hct-34.4*
MCV-91 MCH-29.2 MCHC-32.3 RDW-15.3 RDWSD-50.2* Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-187* UreaN-21* Creat-0.6 Na-141
K-3.5 Cl-98 HCO3-32 AnGap-11
___ 12:57AM BLOOD CK-MB-45* MB Indx-0.2
___ 06:00AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.9
Imaging
======
Non-Contrast CT of Head:
1. Study is partially limited by patient motion.
2. Acute ischemic changes in the vascular territory of the left
PCA and likely left calcarine artery. Additional infarct
extends
toward the pulvinar of the left thalamus suggestive of
compromise
of the left posterior choroidal artery. No hemorrhagic
transformation.
3. Involutional changes suggestive of global volume loss.
4. Findings consistent with chronic microangiopathy in a
bilateral periventricular and subcortical white matter
distribution.
CTA HEAD
1. Complete occlusion of the left PCA and its origin. No
evidence of hemorrhagic transformation. Other vessels of the
circle of ___ are patent without evidence of occlusion,
stenosis or aneurysm.
2. Severe narrowing of the left carotid siphon.
3. Partially imaged bilateral nodular pulmonary opacities
measuring up to 1.1 cm in the left upper lobe. Recommend
dedicated chest CT for further evaluation.
4. Multilevel, multifactorial degenerative changes throughout
the
cervical spine consistent with anterior and posterior
spondylosis, more significant from C3 through C6 C7 levels.
___ TTE The left atrial volume index is normal. No
thrombus/mass is seen in the body of the left atrium (best
excluded by TEE) The right atrium is mildly enlarged. 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 but
the basal inferior wall appears to be
hypokinetic (clip 75). Overall left ventricular systolic
function is low normal. The visually estimated left
ventricular ejection fraction is 50%. There is no resting left
ventricular outflow tract gradient. Normal
right ventricular cavity size with normal free wall motion.
Tricuspid annular plane systolic excursion
(TAPSE) is normal. The aortic sinus diameter is normal for
gender with mildly dilated ascending aorta.
The aortic arch diameter is normal with a mildly dilated
descending aorta. There is no evidence for an
aortic arch coarctation. The aortic valve leaflets (?#) appear
structurally normal. There is no aortic valve
stenosis. There is no aortic regurgitation. The mitral valve
leaflets are mildly thickened with no mitral
valve prolapse. There is mild to moderate [___] mitral
regurgitation. The tricuspid valve leaflets appear
structurally normal. There is physiologic tricuspid
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Poor image quality. Mild symmetric left ventricular
hypertrophy with mild regional
systolic dysfunction and low normal global ejection fraction.
MIld-moderate mitral regurgitation. Mild
pulmonary artery systolic hypertension. Mildly dilated ascending
aorta.
Brief Hospital Course:
In brief, Mr ___ is a ___ year old M w/ diabetes, HTN, pAF not
on A/C presented to OSH ___ with a large L ___
transferred to ___ for surgical evaluation of left ischemic
limb. Initial NIHSS 23.
NCHCT shows evolving L PCA infarct but no hemorrhage. Patient
was not a tPA or thrombectomy candidate as he presented outside
the window for intervention. The patient has several vascular
risk factors. His stroke is likely cardioembolic given that he
has known atrial fibrillation and is not on A/C.
Summary:
Neurologic:
1) Left PCA stroke ischemic stroke possibly some watershed MCA
territory involvement. TTE negative for intracardiac source of
thrombosis. His atorvastatin was held iso CK elevation from
rhabdomyolysis but eventually restarted at a low dose. Patient
has history of afib and prior refusal of anticoagulation. He was
started on anticoagulation with apixaban.
Cardiovascular:
1) Hx of hypertension: Lisinopril and HCTZ were held in ICU to
allow BP to auto regulate. Metoprolol was restarted.
2) Paroxysmal a-fib: Patient was continued on metoprolol after
period of auto regulation. Metoprolol was uptitrated to 100mg
TID iso increasing tachycardia, though this was in the setting
of aggressive diuresis and likely patient was more tachycardic
from overdiuresis. He was continued on heparin gtt for
anticoagulation and transitioned to apixaban.
Respiratory
Patient intubated for vascular procedure, remained intubated in
the ICU for continued difficulty following commands and
suppressed mental status. He was extubated on ___ and weaned
to RA.
GI/Abdomen: Received stress ulcer PPx: Famotidine 20mg BID
FEN: A PEG was placed and tube feeds were initiated without
difficulties.
Hematology: Anemia due to chronic disease. Improved over the
course of the admission.
MSK: Acute LLE ischemia s/p thrombectomy and fasciotomy for
compartment syndrome. Course was complicated by rhabdomyolysis.
He was on fluid for goal 100cc/hr urine output. His kidney
function was monitored and was stable. CK was coming
downtrending appropriately. Vascular surgery was consulted and
wound vacs were placed. Vascular surgery continued to follow.
Staples, including for the groin access, were left in situ due
to concerns about wound dehiscence. Dry dressings were applied.
Patient will follow up with Dr. ___ in Vascular ___ on
___.
Endocrine: Type II diabetes: Initially BG difficult to control,
and he was briefly on insulin gtt. He was started on NPH and
regular sliding scale. Goal BG <180. Holding his Januvia,
Glyburide, Metformin while in hospital. Evidence of poorly
controlled prior to admission with HgA1C of 11. Hypothyroid:
patient was continued on home synthroid.
Infectious Disease: Possible PNA on admission that resolved
after course of antibiotics. LLE cellulitis was traded with
vancomycin and later Bactrim with completion of a 10d course.
Cellulitis improved appropriately.
Transitional Issues
===================
- Continue apixaban
- Optimization of stroke risk factors (hypertension,
hypercholesterolemia, diabetes, atrial fibrillation)
- Continue applied dry wound dressing. Change frequently.
- Follow-up with vascular surgery. Appointment is scheduled with
Dr. ___ on ___.
- Follow up in our stroke clinic. Please call ___ with
questions.
+++++++++++++++++++++++
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) (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 - () No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - If no, why not (I.e.
bleeding risk, etc.) () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. SITagliptin 100 mg oral DAILY
4. Metoprolol Succinate XL 75 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Atorvastatin 20 mg PO QPM
3. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
4. Docusate Sodium 100 mg PO BID
5. NPH 44 Units Q12H
Insulin SC Sliding Scale using REG Insulin
6. Metoprolol Tartrate 25 mg PO Q8H
7. Multivitamins W/minerals Chewable 1 TAB PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. Levothyroxine Sodium 75 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute Ischemic Stroke
Acute Left Lower Limb Ischemia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of being unable to speak
or move 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:
1) DM: A1c 11.2%
2) Hyperlipidemia: LDL 81
3) Atrial Fibrillation not previously on anticoagulation
An echocardiogram did not show a PFO on bubble study, though
the image quality was poor.
We are changing your medications as follows:
- continue apixaban
- continue atorvastatin
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:
___
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2164-11-16 12:13:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
doxycycline
Attending: ___
Chief Complaint:
G tube dislodgement
Major Surgical or Invasive Procedure:
___ guided G-tube replacement ___
History of Present Illness:
___ yo M with hx of HTN, Afib on AC, T2D living in ___ after
suffering a massive RCA CVA in ___ w/ aphasia, right sided
hemiplegia, oropharyngeal dysphagia w/ PEG tube, dementia,
presents today with CC of G tube having fallen out overnight
Patient completely nonverbal and unable to provide Hx; does
shake
head for answers, but appears to consistently shake head yes for
all questions
___ transfer records reviewed and summarized as follows:
Resides at ___ since ___. Limited details documented;
patient's PEG 'fell out' without any mention of any trauma or
tugging, concerning discharge. VS at ___ all WNL, afebrile.
In ED:
VS: afeb, HR 58, 146/63, RR 18, 96% RA
ED Exam: NAD, nonill appearing; soft abdomen, no TTP
Labs: wbc 9, hb 13, plt 143, BMP WNL, INR 1.2
Imaging: ordered for portable abdomen, has not been obtained
Received: nothing
Consult: ED spoke to ___ who will attempt to replace tomorrow but
could not guarantee schedule; given that pt likely in house
>___,
admit instead of ED obs
Past Medical History:
Type 2 Diabetes
HTN
Paroxysmal atrial fibrillation
L PCA CVA ___ with residual aphasia and R sided hemiplagia
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
VITALS: Afebrile and vital signs significant for normotensive,
oxygenating well
GENERAL: Alert and in no apparent distress; nonverbal; can shake
head yes or no but does not seem reliably able to answer yes/no
questions
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. Difficult to assess
JVD given habitus. No ___ edema
RESP: Lungs clear to auscultation with good air movement on
partial lateral auscultation. Breathing is non-labored
GI: Abdomen soft, obese, mildly tender to palpation around
G-tube
site; no signs of cellulitis; no discharge from G tube site.
Bowel sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves LUE extremity but notably does not move
RUE
SKIN: No rashes or ulcerations noted
NEURO: Alert; cannot assess orientation; face symmetric, gaze
conjugate with EOMI, able to move LUE but no movement of RUE;
not
appreciating commands to attempt grip of LUE though he appears
able; not moving b/l ___
PSYCH: unable to assess
PHYSICAL EXAM ON DISCHARGE:
==========================
PHYSICAL EXAM ON ADMISSION:
===========================
VITALS: Afebrile and vital signs significant for normotensive,
oxygenating well
GENERAL: Alert and in no apparent distress; nonverbal; can shake
head yes or no but does not seem reliably able to answer yes/no
questions
EYES: Anicteric, pupils equally round, appears to have L gaze
preference
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. Difficult to assess
JVD given habitus. No ___ edema
RESP: Lungs clear to auscultation with good air movement on
partial lateral auscultation. Breathing is non-labored
GI: Abdomen soft, obese, G tube site c/d/I. Bowel sounds
present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves LUE extremity but notably does not move
RUE
SKIN: No rashes or ulcerations noted
NEURO: Alert; cannot assess orientation; face symmetric, gaze
conjugate with EOMI, able to move LUE but no movement of RUE;
not
appreciating commands to attempt grip of LUE though he appears
able; not moving b/l ___
PSYCH: unable to assess
Pertinent Results:
LAB RESULTS ON ADMISSION:
==========================
___ 03:26PM BLOOD WBC-9.2 RBC-4.16* Hgb-13.1* Hct-39.3*
MCV-95 MCH-31.5 MCHC-33.3 RDW-14.8 RDWSD-50.8* Plt ___
___ 03:26PM BLOOD ___ PTT-29.2 ___
___ 03:26PM BLOOD Glucose-97 UreaN-15 Creat-0.6 Na-136
K-5.1 Cl-95* HCO3-27 AnGap-14
LAB RESULTS ON DISCHARGE:
=========================
___ 07:00AM BLOOD WBC-8.6 RBC-3.97* Hgb-12.3* Hct-38.6*
MCV-97 MCH-31.0 MCHC-31.9* RDW-14.8 RDWSD-53.2* Plt ___
___ 07:00AM BLOOD ___ PTT-33.4 ___
IMAGING:
========
PROCEDURE: 1. Replacement of a balloon retention gastrostomy
tube through
the existing gastrostomy site.
PROCEDURE DETAILS: Following the discussion of the risks,
benefits and
alternatives to the procedure, written informed consent was
obtained from the
health care proxy. The patient was then brought to the
angiography suite and
placed supine on the exam table. A pre-procedure time-out was
performed per
___ protocol. The upper abdomen and tube site was prepped and
draped in the
usual sterile fashion.
Scout image was obtained which demonstrated no radiopaque
residual foreign
body. No tube was identified. A Glidewire was advanced through
the existing
gastrostomy tracking coiled in the stomach. Over the wire, a
new 16 ___
MIC gastrostomy tube was attempted to be passed however would
not pass. The
tract was dilated with a 16 ___ dilator and the Glidewire was
exchanged for
a stiff Glidewire. Over the stiff Glidewire, a new 16 ___
MIC gastrostomy
tube was advanced into the stomach under fluoroscopy. The
balloon was
inflated and pulled back against the anterior wall of the
stomach. The wire
was removed. Contrast injection confirmed appropriate position
within the
stomach. The tube was then flushed and capped. Sterile
dressings were
applied. There were no immediate complications.
FINDINGS:
1. 16 ___ MIC gastrostomy tube in the stomach.
IMPRESSION:
Successful replacement of a gastrostomy tube for a new 16 ___
MIC
gastrostomy tube through the existing gastrostomy site. The
tube is ready to
use.
Brief Hospital Course:
___ year old gentleman with history of hypertension, atrial
fibrillation on apixaban, insulin dependent diabetes residing in
___ after suffering L PCA ischemic stroke with possible
watershed MCA territory involvement with reported aphasia, R
hemiplegia, oropharyngeal dysphagia with PEG tube, who presents
after G tube dislodgement, now replaced.
# PEG tube dislodgement: No apparent trauma or other
precipitating factor; s/p ___ replacement of a ___ Fr gastrostomy
tube. Tube feeds were advanced to goal which patient tolerated
well.
# Atrial fibrillation: Initially metoprolol was held and patient
was on heparin gtt for anticoagulation. Home apixaban restarted
after ___ tube replacement. Home metoprolol HELD at discharge-
the reason for this is that his HR were in 50-70 even without
beta-blockade. Please titrate as needed.
# T2DM: Home NPH initially dose reduced to 20 mg BID in setting
of NPO from 64U BID; however, even after restarting tube feeds
to goal note that BG were 150s on reduced dose regimen. At
discharge, we uptitrated slightly to 25 mg NPH BID, please
continue to titrate as needed.
CHRONIC/STABLE PROBLEMS:
# HTN: Home metoprolol held as above, SBP 120s off this
medication.
# Hypothryoid: Continued home levothyroxine 75 mcg daily
# Hx CVA: Continue home apixaban as above
# Chronic pain: on standing acetaminophen 1g BID
TRANSITIONAL ISSUES:
=====================
[] Please continue to address GoC with HCP; patient remains full
code. Notably patient appeared to be uncomfortable and pushed us
away when G tube was being replaced
[] Home metoprolol held- when off this medication SBP 120s-130s
and HR 50-70s, please titrate as needed
[] Insulin regimen modified to 25U NPH BID + home SSI (on 20U
NPH BID, even at goal TF of 60/hr, BG were generally in the 150
range, did not require any sliding scale coverage), please
titrate as needed- as he was on significantly higher dose at ___
[] Consider bolus feeds
# Code: Full per MOLST
# HCP: ___
Relationship: Partner
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Apixaban 5 mg PO BID
3. Famotidine 20 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. melatonin 3 mg oral QHS
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Metoprolol Tartrate 25 mg PO Q6H
8. multivitamin oral DAILY
9. NPH 64 Units Breakfast
NPH 64 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. Acetaminophen 1000 mg PO Q12H
11. omeprazole magnesium 20 mg oral DAILY
12. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID
13. Valproic Acid ___ mg PO QAM
14. Valproic Acid ___ mg PO QPM
15. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
16. Milk of Magnesia 30 mL PO Q6H:PRN ___ line
17. Fleet Enema (Saline) ___AILY:PRN step 3
18. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
19. Senna 17.2 mg PO BID:PRN Constipation - First Line
20. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
Discharge Medications:
1. NPH 25 Units Breakfast
NPH 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Acetaminophen 1000 mg PO Q12H
3. Apixaban 5 mg PO BID
4. Atorvastatin 20 mg PO QPM
5. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
6. Docusate Sodium 100 mg PO BID
7. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID
8. Famotidine 20 mg PO DAILY
9. Fleet Enema (Saline) ___AILY:PRN step 3
10. Levothyroxine Sodium 75 mcg PO DAILY
11. melatonin 3 mg oral QHS
12. Milk of Magnesia 30 mL PO Q6H:PRN ___ line
13. multivitamin oral DAILY
14. omeprazole magnesium 20 mg oral DAILY
15. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
17. Senna 17.2 mg PO BID:PRN Constipation - First Line
18. Valproic Acid ___ mg PO QAM
19. Valproic Acid ___ mg PO QPM
20. HELD- Metoprolol Tartrate 25 mg PO Q6H This medication was
held. Do not restart Metoprolol Tartrate until your doctor tells
you to
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
G tube dislodgement
s/p CVA
IDDM
Atrial fibrillation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___!
You first came to us after your G tube fell out and needed to be
replaced. Our interventional radiologists replaced this, and you
were able to tolerate tube feeds and medications through the new
tube without issues.
While you were here, we noticed that your heart rates and blood
pressures were well controlled even off your metoprolol, so this
was held at discharge. We also changed around your insulin
regimen, as your sugars appeared well controlled on a lower
dose. This will require ongoing modification at your nursing
facility.
Please take care, we wish you the very best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10871616-DS-19
| 10,871,616 | 29,229,806 |
DS
| 19 |
2157-12-21 00:00:00
|
2157-12-21 14:45:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
vertigo
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with atrial fibrillation (on
Xarelto) that presented to the ED after being transferred from
urgent care where he presented for evaluation of persistent
vertigo. Patient was in usual state of health until yesterday
morning when he woke up and had an episode of vertigo. Of
note, patient has suffered from vertigo for the past ___ years
after experiencing a mild concussion. Per patient, vertigo
episodes usually lasts from seconds to a minute before self
resolving but this time symptoms have persisted for more than 36
hours. While at home he also noted that he had trouble walking,
as he was stumbling and felt unsteady due to the vertigo. For
this reason he decided to go to an urgent care for evaluation
where he had a head CT done which was unremarkable but on exam
was noted to have some trouble with rapid alternating movements
and an unsteady gait. For this reason he was transferred to our
ED for further evaluation and management. While in the ED
patient continues to feel dizzy/vertiginous but if he keeps his
head still symptoms would improve. Also, he has been
experiencing bilateral ear ringing for the past day.
Past Medical History:
Atrial Fibrillation dx ___ yrs ago after vasovagal syncope.
Hyperlipidemia.
ACL reconstruction
Social History:
___
Family History:
No fam h/o early stroke; father with MI in ___
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: T:98.3 HR:59 BP:130/66 RR:19 SaO2: 100% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RR
Pulmonary: Breathing comfortably on RA
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Naming intact. No
paraphasias. No dysarthria. Normal prosody. Able to register 3
objects and recall ___ at 5 minutes. No apraxia. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
Head impulse test: negative
Skew deviation test: negative
___ test: positive
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating movements.
- Gait: Initially felt unsteady and appeared wide-based but
corrected. Didn't test tandem gait.
DISCHARGE PHYSICAL EXAM
Vitals: Tm 97.4, HR 49-57 (sinus brady), BP 141-172/78-86, RR
___, >95% RA
General: NAD, sitting up in bed
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, well perfused
Pulmonary: Breathing comfortably on RA
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Neuro:
MS: Awake, alert, oriented, able to recount history well,
language fluent, no paraphasic errors, no apraxia or neglect.
CN: Pupils reactive, L 4to2mm, R 3to2mm; EOMI without nystagmus,
VFF, no vertical skew, +head impulse test to right, decreased
hearing in left ear, with Weber test louder in right ear; face
symmetric, facial sensation intact, trapezius/SCM intact, palate
symmetric, tongue midline
Motor: Normal bulk and tone. No drift. No tremor or asterixis.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 1 1 1 1 1
R 1 1 1 1 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch bilaterally. No
extinction to DSS.
- Coordination: FNF and HKS intact. Good speed and intact
cadence with rapid alternating movements.
- Gait: Normal based, Unterberger negative, Romberg negative;
leans slightly to the left with tandem gait
Pertinent Results:
___ 12:45AM BLOOD WBC-7.0 RBC-4.92 Hgb-14.4 Hct-43.5 MCV-88
MCH-29.3 MCHC-33.1 RDW-12.7 RDWSD-41.1 Plt ___
___ 12:45AM BLOOD Neuts-50.4 ___ Monos-11.0 Eos-4.0
Baso-0.9 Im ___ AbsNeut-3.51 AbsLymp-2.33 AbsMono-0.77
AbsEos-0.28 AbsBaso-0.06
___ 12:45AM BLOOD Glucose-94 UreaN-15 Creat-1.0 Na-141
K-4.0 Cl-103 HCO3-27 AnGap-15
IMAGING:
CT/CTA ___:
NECT: No acute intracranial abnormalities.
CTA:
Patent circle ___ and its major tributaries. Mild outpouching
of M1
segment on the right may represent an artifact (___).
Atherosclerotic disease in the left ICA at the level of C2
(3:195). Intense streak artifacts from the dental amalgam limits
evaluation at the level of C2-3 where the left ICA appears
attenuated (3:180). This may be a combination of narrowing
secondary to atherosclerotic disease and artifact. The right ICA
is also attenuated at the same level, though to a lesser degree.
Proximal and distal reconstitution bilaterally.
Right dominant vertebral artery system. No dissection.
1.7 cm left thyroid nodule. Nonemergent ultrasound follow up
recommended.
FINDINGS:
MRI BRAIN ___:
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift or infarction. The ventricles and sulci are mildly
prominent, suggesting age-related volume loss. Incidental note
is made a cavum septum pellucidum et vergae an anatomical
variant. Minimal periventricular FLAIR hyperintensities are
nonspecific, but likely sequela of chronic small vessel ischemic
disease.
There is no abnormal enhancement after contrast administration.
MRA BRAIN:
The intracranial vertebral and internal carotid arteries and
their major
branches appear normal without evidence of stenosis, occlusion,
or aneurysm
formation.
MRA NECK:
The common, internal and external carotid arteries appear
normal. There is no evidence of internal carotid artery stenosis
by NASCET criteria. The origins of the great vessels, subclavian
and vertebral arteries appear normal bilaterally.
The left vertebral artery is hypoplastic, given the dominant
right system. The left vertebral artery itself terminates in
the left ___, and remains patent throughout its course. No
definite evidence of dissection.
IMPRESSION:
1. No evidence of infarction.
2. Hypoplastic left vertebral artery which terminates in the
left ___, but remains patent throughout its course. No definite
evidence of dissection.
Brief Hospital Course:
Mr. ___ is a ___ right-handed man with atrial
fibrillation (on Xarelto) and remote concussion who presented
with vertigo for about 36 hours with nausea and gait
unsteadiness. He was noted to have decreased hearing in the
left ear as well as a sense of fullness in the right ear. Head
CT was unremarkable and MRI showed no evidence of stroke. CTA
showed a hypoplastic left vertebral artery but no evidence of
dissection or stenosis. His symptoms improved by the morning
after admission and he had no further deficits. Most likely
diagnosis is peripheral etiology of vertigo, vestibular neuritis
most likely. No evidence of stroke or mass. He was continued
on his home Xarelto and flecanide for atrial fibrillation. He
will have close follow-up with Audiology for a hearing test and
in Neurology clinic.
Discharge Issues:
1. Audiology appointment to evaluate hearing
2. Non-emergent ultrasound follow up recommended for 1.7 cm left
thyroid nodule.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rivaroxaban 20 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Flecainide Acetate 150 mg PO Q12H
4. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Flecainide Acetate 150 mg PO Q12H
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Rivaroxaban 20 mg PO DAILY
4. Simvastatin 20 mg PO QPM
5.Outpatient Physical Therapy
Vestibular Physical Therapy
Dx: vertigo
Please eval and treat
Discharge Disposition:
Home
Discharge Diagnosis:
vestibular neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with vertigo (sensation of
room-spinning). You had a brain MRI that did not show evidence
of stroke or other explanation for your symptoms. You likely
have a peripheral (inner ear)
Please take your medications as prescribed.
Please follow-up 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:
___
|
10871684-DS-16
| 10,871,684 | 23,627,526 |
DS
| 16 |
2124-12-14 00:00:00
|
2124-12-28 10:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Vomiting, fever, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per admitting Fellow: ___ yo female patient known status post
revision of a laparoscopic band ___ to a VG band ___.
The band was last adjusted on ___ to 11.50 from 10 cc. She
reports being compliant with the stage 3 diet. However, when
questioned, she drank up to 1 hour prior to going to sleep.
Starting on ___ AM, she reports that she felt nauseated with
vomiting, and a fever associated with a cough productive of
green sputum. She thought that she was developing a cold as her
2 children and husband were sick. She says she has restriction.
She was vomiting, non bloody non bilious. Her last BM ___ days
ago. She reports NSAIDs intake, reviewed avoidance of NSAIDs
with the patient.
Past Medical History:
PMHX: Hypertension, seizures, morbid obesity,
hypercholesterolemia, anxiety.
PSHX: laparoscopic band ___, lap VG band ___
Social History:
___
Family History:
Hyperlipidemia, arthritis, diabetes, heart disease, stroke,
obesity and cancer
Physical Exam:
VSS
Constitutional: NAD
Neuro: Alert and oriented x 3
Cardiac: RRR
Lungs: CTA
Abd: Soft, non-tender, non-distended, no rebound
tenderness/guarding, well healed abd incisions
Ext: Warm, well perfused, no edema
Pertinent Results:
___ 06:50AM BLOOD WBC-14.6* RBC-3.81* Hgb-10.5* Hct-32.7*
MCV-86 MCH-27.7 MCHC-32.3 RDW-13.8 Plt ___
___ 08:45AM BLOOD WBC-24.9* RBC-4.04* Hgb-11.3* Hct-34.2*
MCV-85 MCH-27.9 MCHC-33.0 RDW-13.6 Plt ___
___ 01:00AM BLOOD Neuts-93.3* Lymphs-4.4* Monos-1.3*
Eos-0.9 Baso-0.1
___ 08:45AM BLOOD Glucose-107* UreaN-10 Creat-0.7 Na-140
K-3.7 Cl-107 HCO3-22 AnGap-15
___ 01:00AM BLOOD Glucose-114* UreaN-8 Creat-0.7 Na-136
K-3.9 Cl-103 HCO3-22 AnGap-15
___ 01:00AM BLOOD ALT-15 AST-20 AlkPhos-54 TotBili-0.6
___ 08:45AM BLOOD Calcium-8.2* Phos-3.9# Mg-1.3*
___ 01:00AM BLOOD Albumin-4.0
___ 01:08AM BLOOD Lactate-1.2
___ CHEST (PA & LAT):
IMPRESSION:
Multifocal pneumonia involving the left lung and possibly the
right lower
lobe. Follow up CXR needed in 4 weeks to document substantial
clearing in
order to exclude other conditions.
___ UGI AIR W/KUB:
IMPRESSION:
Appropriate lap band position, patent stoma, no evidence of
leak.
Brief Hospital Course:
Ms. ___ presented to the ___ Emergency Department on
___ with complaints of vomiting, fever and
productive cough. A CXR was obtained revealing multilobar
pneumonia with leukocytosis (WBC 19.6); given recent band fill
with vomiting, the band was unfilled and an UGI series confirmed
appropriate lap band position. The patient was subsequently
placed on bowel rest, given intravenous fluids and antibiotics
and transferred to the general surgical floor for further
evaluation.
On HD1, the patient continued to have a productive cough with an
increase in WBC to 24.9. Intravenous Zosyn was continued and a
Pulmonary consult was obtained; Pulmonary recommendations
included continuation of current antibiotic regimen. On HD2,
the patient was ruled out for influenza. Her WBC decreased to
14.6, therefore, at the direction of Pulmonary, antibiotics were
transitioned to oral Augmentin. The patient remained stable
from a pulmonary standpoint without supplemental oxygenation.
Her diet was advanced on HD1 to stage3, which was well tolerated
without nausea, vomiting or abdominal pain.
At the time of discharge on HD2, the patient was afebrile with
stable vitals signs. She will continue oral Augmentin and
follow-up with her Primary Care Provider ___ 1 week.
Additionally, she will have a repeat CXR within 4 weeks.
Medications on Admission:
Atenolol 25 mg BID
Fluoxetine 60 mg Daily
Keppra 250 mg BID
Lorazepam 1 mg PO daily prn
Discharge Medications:
1. Amoxicillin-Clavulanate Susp. 875 mg PO Q12H Duration: 10
Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth
twice a day Disp #*20 Tablet Refills:*0
2. Atenolol 25 mg PO BID
3. Fluoxetine 60 mg PO DAILY
4. LeVETiracetam 250 mg PO BID
5. Lorazepam 1 mg PO DAILY:PRN anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
Multifocal pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to the hospital with a productive cough, fevers,
nausea and vomiting. A chest x-ray was obtained and suggestive
of pneumonia, therefore, you were treated with antibiotics with
subsequent improvement of your symptoms and a decrease of your
white blood cell count. Additionally, your Lap-Band was
completely unfilled and and Upper GI series was performed
showing normal position of your band.
You are now preparing for discharge to home with the following
instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*New or worsening cough, shortness of breath, or wheeze.
*You experience new chest pain, pressure, squeezing or
tightness.
*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 have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Followup Instructions:
___
|
10871819-DS-12
| 10,871,819 | 28,782,888 |
DS
| 12 |
2162-05-03 00:00:00
|
2162-05-04 18:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Animal dander (cats)
Attending: ___.
Chief Complaint:
Lightheadedness, dyspnea
Major Surgical or Invasive Procedure:
DC Cardioversion (___)
History of Present Illness:
Mr. ___ is a ___ year old male with a history of atrial
fibrillation and atrial flutter s/p ablation ___ presenting
with
palpitations.
The patient has had difficult to manage atrial
fibrillation/flutter. He failed trials of metoprolol,
flecainide,
and dronedarone as well as multiple cardioversions. He underwent
his first atrial flutter ablation in ___. However, he began
to develop persistent palpitations in ___ (some episodes
documented as atrial flutter, other as atrial fibrillation) and
underwent catheter ablation for typical atrial flutter on
___. After that procedure, he had 4 episodes of atrial
fibrillation associated with exercise. He was continued on
pradaxa for one month post procedure.
In the past, the patient's arrhythmia has been triggered by
alcohol and exercise. His symptoms include palpitations and
dyspnea on exertion.
Of note, he has had a UTI in the past post foley placement.
The patient flew to ___ on ___ to visit his brother.
His brother has been having family issues so the visit was very
stressful and he was sleep derived. On ___, he began to
have
intermittent lung irritation that felt like something was stuck
in his lungs but he denies cough. His temperature was 99, but
he
felt feverish. He believes that his lung irritation was due to
allergies so he took his albuterol inhaler and Flovent with
minimal effect. He had gone for hikes/walks with his brother
and
developed dyspnea on exertion as well as dehydration. He also
developed stomach upset, but no nausea, vomiting, or diarrhea.
He states that his urine was darker than normal but he denies
dysuria, urgency, or frequency. He tried drinking more water to
help him feel better. The patient had been taking up to 500 mg
of aspirin in order to help his dyspnea on exertion (with little
improvement) as well as his bilateral chronic knee pain with
improvement. On ___, he started to feel his
arrhythmia. He states that his heart rates intermittently were
irregular and went up to 160.
On ___, the patient got on a 6 hour flight from ___
to
___. At around 5:15 ___, he started to develop shortness of
breath and palpitations. This felt identical to his previous
episodes of atrial fibrillation/flutter. While on the flight, he
was attended to by a bystander physician and nurse, who
monitored
his vital signs and gave him supplemental oxygen. He was stable
and completed his flight to ___. Upon arrival to the
ED, he reported feeling short of breath with exertion, but
denied
nausea, chest pain, lightheadedness, dizziness. He denied any
pain in his legs, history of PEs.
In the ED, initial heart rates were in the 160s with SBP 200. He
received 20 mg IV diltiazem with improvement in rates to 150s.
Afterwards, he felt wiped out.
In the ED...
- Initial vitals:
Prehospaial: ___ 16 95
in ED 96.5 142 129/91 18 97% RA
- EKG:
afib with ventricular rates to 150s, STD in V4-V6, no STE or TWI
- Labs/studies notable for:
Na 137, K 3.8, HCO3 20, BUN 19, Cr 0.9
WBC 16.7, hgb 15.3, plt 191
troponin <0.01
UA with mod leuks, negative nitrite, 27 WBC, few bacteria
- Patient was given:
IV Diltiazem 20 mg
IVF NS ( 1000 mL ordered)
PO/NG Metoprolol Tartrate 12.5 mg
PO Dabigatran Etexilate 150 mg
- Vitals on transfer:
99.9 118 104/57 16 95% RA
On the floor, the patient is feeling tired and hungry.
Shortness
of breath is mildly improved. He denies any dysuria, urgency,
or
frequency. Denies any nausea, vomiting abdominal pain. He
still
feels his lung irritation but denies any cough or fevers. He is
still feeling stressed from his visit with his brother. He
denies any blood in his stool or dark stools.
REVIEW OF SYSTEMS:
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema.
All of the other review of systems were negative.
Past Medical History:
PAST MEDICAL HISTORY
====================
1. CARDIAC RISK FACTORS
- Hypertension
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
-Seasonal allergies
HOME MEDICATIONS
================
The Preadmission Medication list is accurate and complete
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
2. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN shortness of
breath
3. Aspirin 325 mg PO DAILY
ALLERGIES
=========
NKDA
Social History:
___
Family History:
FAMILY HISTORY
==============
The patient's mother had a pacemaker, arrhythmia, and sleep
apnea. Patient's father had coronary artery disease/CABG,
arrhythmia with a pacemaker and maze procedure, valvular
disease.
Physical Exam:
ADMISSION EXAM
==============
VS: ___ 0051 Temp: 99.2 PO BP: 129/83 HR: 145 RR: 20 O2
sat:
93% O2 delivery: Ra
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD, JVD not appreciated due to habitus
CV: Irregular rhythm, tachycardic, 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, symmetric lower
extremities
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM
==============
VS: 98.7 112 / 76, 60, 18, 95% 2L
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD, JVD not appreciated due to habitus
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, symmetric lower
extremities
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
==============
___ 09:40PM BLOOD WBC-16.7* RBC-4.97 Hgb-15.3 Hct-43.6
MCV-88 MCH-30.8 MCHC-35.1 RDW-12.1 RDWSD-38.5 Plt ___
___ 09:40PM BLOOD Neuts-79.3* Lymphs-12.1* Monos-7.5
Eos-0.4* Baso-0.2 Im ___ AbsNeut-13.26* AbsLymp-2.02
AbsMono-1.25* AbsEos-0.06 AbsBaso-0.04
___ 09:40PM BLOOD Glucose-108* UreaN-19 Creat-0.9 Na-137
K-3.8 Cl-98 HCO3-20* AnGap-19*
___ 09:40PM BLOOD cTropnT-<0.01
___ 09:40PM BLOOD Mg-2.1
___ 10:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 10:00PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-2* pH-5.5 Leuks-MOD*
___ 10:00PM URINE RBC-3* WBC-27* Bacteri-FEW* Yeast-NONE
Epi-0
___ 10:00PM URINE Mucous-OCC*
DISCHARGE LABS
==============
___ 05:10AM BLOOD WBC-15.6* RBC-4.82 Hgb-14.8 Hct-42.1
MCV-87 MCH-30.7 MCHC-35.2 RDW-11.9 RDWSD-38.3 Plt ___
___ 05:10AM BLOOD Glucose-109* UreaN-13 Creat-0.8 Na-140
K-4.0 Cl-104 HCO3-20* AnGap-16
Urine culture (___) - pending
___ 05:10AM BLOOD ALT-17 AST-15 LD(LDH)-214 CK(CPK)-136
AlkPhos-62 TotBili-0.8
___ 05:10AM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:10AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ year old male with a history of atrial
fibrillation and atrial flutter s/p ablation ___ presenting
with
palpitations and atrial fibrillation with RVR.
# Paroxysmal afib s/p aflutter ablation: The patient presented
with palpitations and with symptomatic atrial fibrillation with
RVR. He received 20 mg IV diltiazem and 12.5 mg PO metoprolol in
the ED. His aspirin was decreased to 81 mg and he was started on
pradaxa 150 mg BID. His troponins and CK-MB were negative. It is
thought that his triggers for the current episode of atrial
fibrillation were family stress and a urinary tract infection.
His CXR was negative. He had a TEE which showed no thrombus in
his left atrium or atrial appendage. He underwent DC
cardioversion, which was unsuccessful. However, when back on the
floor after the failed ___, he spontaneously converted to sinus
rhythm, which was confirmed with EKG.
# UTI: Patient presented with leukocytosis, which is likely due
to his UTI. He had no fevers. His CXR was negative. UA showed
pyuria. He was placed on Bactrim.
CHRONIC ISSUES:
===============
# Asthma: We continued his albuterol inhaler.
TRANSITIONAL ISSUES:
====================
[ ]Please make sure patient is regularly taking his pradaxa and
rate-controlling medications.
[ ]Patient expressed concern that he would not be able to
tolerate exercise with his rate-controlling medications. Please
assess if on correct regimen for his lifestyle.
[ ]Patient expressed concern about his recent bloodwork that
showed hypertriglyceridemia at ___.
CORE MEASURES
=============
# CODE: Full (confirmed)
# CONTACT: wife, ___- ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
2. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN shortness of
breath
3. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Dabigatran Etexilate 150 mg PO BID
2. Metoprolol Tartrate 50 mg PO Q6H
3. Sulfameth/Trimethoprim DS 1 TAB PO BID
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
5. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN shortness of
breath
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Atrial fibrillation with RVR
SECONDARY DIAGNOSIS
===================
Urinary tract infection
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 WAS I ADMITTED TO THE HOSPITAL?
You were brought to the hospital because you were having
lightheadedness and dizziness on your flight from the ___
___.
WHAT WAS DONE WHILE I WAS HERE?
You got an echocardiogram, which is an ultrasound picture of
your heart. You were also cardioverted because of your atrial
fibrillation.
WHAT DO I NEED TO DO WHEN I LEAVE?
Please follow-up with Dr. ___ on ___ at 1 pm. Please
follow-up with Dr. ___ on ___ at 1:20 pm. Dr. ___
___ will call you to schedule an appointment. If you don't
hear from them in 2 business days, please call them. Please
continue to take your medications.
Be well,
Your ___ Care Team
Followup Instructions:
___
|
10872648-DS-8
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2124-04-07 00:00:00
|
2124-04-07 11:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
codeine / Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Sternal dehiscence
Major Surgical or Invasive Procedure:
___ - Sternal wound debridement and repair of dehiscence
with sternal plating system and bilateral pectoralis advancement
flaps.
___ - Sternal wound washout with removal of wires and
plates, repair of RV injury
History of Present Illness:
Mr. ___ is a pleasant ___ year old man with a history of
coronary artery disease status post coronary artery bypass
grafting x 3 and sternal plating on ___. His
postoperative course was uncomplicated and he was discharged to
rehab on POD 6. He stayed at rehab until ___ and was
discharged to home. He reports that he has been recovering well,
able to ambulate significantly more yesterday than he had
previously. He had been seen by his PCP for ___ UTI and he was
following up yesterday after he completed his antibiotics. He
says his PCP felt his sternal incision was healing well. Tonight
she says he was sitting in a chair and thinks he used his hands
to push himself up and felt a 'pop' and noticed a large amount
of blood coming from his sternal incision. His family called ___
and he was transferred to ___, who transferred him here for
surgical evaluation. He denies fever or chills, no recent
respiratory symptoms, no nausea or vomiting, he reports other
than the UTI he has been feeling well.
Past Medical History:
Chronic Kidney Disease
Coronary Artery Disease
Hypertension
Hypothyroidism
Lymphedema, bilateral lower extremities
Nephrolithiasis
Obesity
Obstructive Sleep Apnea
Past Surgical History:
Cholecystectomy
Social History:
___
Family History:
Father's brother had bypass. No history of heart attacks, or
diabetes.
Mother had high pressure.
Father died of pulmonary fibrosis.
Physical Exam:
HR: 87 regular. BP: 157/84. RR: 10. O2 sat: 96% on RA
General: well appearing in no distress
Skin: Dry [x] intact [x] lower extremities not examined as under
lymphedema dressing
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur []
Abdomen: Soft [x] obese, non-distended [x] non-tender [x] bowel
sounds +[x]
Extremities: Warm [x], well-perfused [x] Edema [x] chronic ___
Neuro: Grossly intact [x]
Pulses:
DP Right: 2+ Left: 2+
___ Right: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Sternal incision: 9cm opening, appears freshly opened with clot
at the base and clean edges, suture material visible in wound
and able to see and palpate his sternum at the base of the
wound. There is no erythema, no purulent drainage and no obvious
source of infection.
Temp: 98.6 (Tm 98.6), BP: 90/51 (90-120/51-80), HR: 91
(89-105), RR: 18 (___), O2 sat: 95% (93-100), O2 delivery: Ra,
Wt: 309.96 lb/140.6 kg
Physical Examination:
General: NAD
Neurological: Alert, Moves all extremities but deconditioned
generalized weakness R=L Follows commands
Cardiovascular: RRR, no MGR
Respiratory: Diminished throughout but clear, No resp distress
chest binder in place with Prevena in place, JP drains x2
w/serosang drainage- sites c/d/i
GI/Abdomen: Bowel sounds present Soft, ND, NT, Morbidly obese
Extremities:
Right Upper extremity Warm Edema +1
Left Upper extremity Warm Edema +1
Right Lower extremity Warm Edema +2
Left Lower extremity Warm Edema +2
Pulses:
DP Right: D Left: D
___ Right: D Left: D
Skin/Wounds: Bilateral lower extremities Dry with brown dry skin
and chronic venous stasis changes
Sternal: Sternum stable Prevena in place
Lower extremity: Left CDI, healing well, no
erythema/drainage/warmth
Pertinent Results:
Chest CT ___
1. Status post median sternotomy with plate screw fixation of
the sternum.
The sternum is well approximated. There is up to 2 cm of
dehiscence along the soft tissues overlying the sternum. Mild
stranding and moderate subcutaneous emphysema without definite
fluid collections or evidence of osseous thinning.
2. Postsurgical changes along the anterior mediastinum and the
heart border. Small pericardial effusion which is unchanged from
prior.
3. Incidentally noted 4 mm nonobstructing left renal calculus
with bilateral punctate nonobstructing calculi within the renal
collecting systems.
___ 05:23AM BLOOD WBC-9.1 RBC-3.08* Hgb-9.4* Hct-30.6*
MCV-99* MCH-30.5 MCHC-30.7* RDW-15.0 RDWSD-53.6* Plt ___
___ 05:23AM BLOOD Plt ___
___ 05:23AM BLOOD Glucose-107* UreaN-37* Creat-1.4* Na-141
K-3.9 Cl-94* HCO3-35* AnGap-12
PA and Lateral ___
Lungs are low volume with bibasilar atelectasis. The NG tube
has been
removed. Right-sided PICC line projects to the cavoatrial
junction.
Cardiomediastinal silhouette is stable. No pneumothorax is
seen. There is no
pleural effusion
Brief Hospital Course:
He was admitted to ___ for further management of wound
dehiscence. The plastic and reconstructive surgery service was
consulted. They recommended conservative treatment including
debridement of the wound, removal of the plates, and VAC
dressing with possible pectoralis flaps and closure following
several days without foreign material. He was taken to the
operating room on ___ for sternal wound exploration, washout
and hardware removal. Cultures were obtained intrapoperatively.
On extubation, the sternum dehisced and there was a small tear
to the RV free wall that required reintubation and primary
repair. Please see operative report for full details. He was
transfused 3 units of PRBCs for acute blood loss anemia. He
returned to the CVICU with open chest, paralyzed and sedated.
The wound appeared clean but he was placed on empiric
antibiotics. He remained stable and was taken back to the
operating room on ___ for sternal wound debridement and
repair of dehiscence with sternal plating system and bilateral
pectoralis advancement flaps with Dr. ___.
He remained intubated until ___ due to somnolence. Tube
feeds were initiated for nutritional support. He remained in he
CVICU for several days. He was very weak and deconditioned. He
eventually transferred to the floor. PICC line placed for
antibiotic therapy, vancomycin x 7days per plastics team last
dose ___. He was cleared by speech and swallow to advance
his diet. Tube feedings were discontinued and ___
discontinued ___. He remains on strict sternal precautions,
with sternal binder. He was evaluated by the physical therapy
service for assistance with strength and mobility. He should
wear a sternal binder at all times. By the time of discharge on
hospital day 13 he was ambulating with assist, sternal wound
with prevena in place until plastic surgery follow up. Pain was
controlled with Tylenol, sensitive to narcotics. He was
discharged to ___ Inpt ___ in good
condition with appropriate follow up instructions.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Metoprolol Tartrate 25 mg PO BID
4. Ranitidine 150 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Acidophilus Probiotic (acidophilus-pectin, citrus) 100
million cell-10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
3. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
4. Docusate Sodium (Liquid) 100 mg PO BID
5. Furosemide 40 mg PO BID
6. Heparin 5000 UNIT SC TID
7. Lactulose 30 mL PO Q6H:PRN Constipation - Third Line
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 17.2 mg PO DAILY
11. Metoprolol Tartrate 12.5 mg PO TID
12. Acidophilus Probiotic (acidophilus-pectin, citrus) 100
million cell-10 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. Atorvastatin 80 mg PO QPM
15. Clopidogrel 75 mg PO DAILY
16. Ranitidine 150 mg PO DAILY
17. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until recommended
by cardiologist or PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Sternal dehiscence
Secondary Diagnosis:
Chronic Kidney Disease
Coronary Artery Disease
Hypertension
Hypothyroidism
Lymphedema, bilateral lower extremities
Nephrolithiasis
Obesity
Obstructive Sleep Apnea
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage,
Prevena in place
Edema: ___ lymphedema
Discharge Instructions:
Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10872780-DS-13
| 10,872,780 | 23,377,562 |
DS
| 13 |
2171-06-11 00:00:00
|
2171-06-11 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:
agitation, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old male with history of prostate cancer who
was brought to the ED by EMS. Per EMS report, he was found by
the ___ Police Department to be shouting and walking on the
streets confused. BPD took him to his home and then called EMS.
The patient refused to come to the hospital, was acting agitated
and was not oriented to time, so he was taken to the ___ ED
for evaluation.
In the ED, initial vitals were Temp 98.9, HR 100, BP 155/91, RR
20, sat 100% RA. The patient was noted to be alert but confused,
refusing labs on the basis of him being ___.
He was deemed unsafe for discharge; psychiatry was consulted for
evaluation, and they attributed his behavior to delirium
secondary to urinary tract infection. CT head ruled out acute
intracranial process. ECG showed atrial fibrillation and
evidence of an old anterior infarct. CXR revealed Pt had an
indwelling urinary catheter without a bag on arrival and UA was
noted to be positive for leukocytes, blood, nitrites, protein,
bacteria, RBCs. Labs were also notable for mild anemia (Hgb
10.8) but no leukocytosis, mild AST elevation to 42 and elevated
anion gap to 25 (CO2 17). Patient received the following
medications:
Haloperidol - 12.5 mg IM total
Olanzapine 10 mg IM total
Ceftriaxone 1 g iv
On the floor, Mr ___ remains agitated and
uncooperative. He was switching between refusing treatment and
mimicking the staff and falling asleep. He refused to cooperate
with the interview and would not answer any questions.
Past Medical History:
prostate cancer, untreated.
dementia
atrial fibrillation not on anticoagulation
?anterior MI (based on ECG, no records available)
CHF (EF> 55%)
BPH
Social History:
___
Family History:
unable to obtain.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
============================
Vital Signs: 97.9, 108/66L Lying HR 86 RR22 98%RA
General: Agitated, switching between alert and asleep,
noncooperative, oriented to place ('hospital')
HEENT: Sclerae anicteric, MMM, oropharynx clear, red spots on
chin, unclear if stain or skin lesion
CV: irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: unable to examine; pt refused to cooperate
GU: indwelling catheter with cap in place.
Ext: Warm, trace edema, no clubbing, superficial wound on RLE
below knee anteriorly; superficial wound on R elbow
Neuro: CNII-XII grossly intact, sensation/gait/strength deferred
PHYSICAL EXAM ON DISCHARGE:
===========================
Vital Signs: afebrile 91/50-109/62 ___ 98-100
General: Awake and alert, resting calmly in bed, no distress
HEENT: Sclera nonicteric.
CV: RRR nl s1/s2
Pulm: CTAB without wheezes or crackles, breathing comfortably
on room air
GU: Foley in place, urine appears concentratd.
Ext: Warm, stasis dermatitis, 1+ ___ edema
Pertinent Results:
LABS ON ADMISSION:
==================
___ 03:10AM WBC-8.9 RBC-3.75* HGB-10.8* HCT-34.8* MCV-93
MCH-28.8 MCHC-31.0* RDW-15.1 RDWSD-50.9*
___ 03:10AM NEUTS-59.6 ___ MONOS-9.2 EOS-1.5
BASOS-0.4 IM ___ AbsNeut-5.31 AbsLymp-2.58 AbsMono-0.82*
AbsEos-0.13 AbsBaso-0.04
___ 03:10AM GLUCOSE-84 UREA N-14 CREAT-0.9 SODIUM-138
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-17* ANION GAP-25*
___ 03:10AM ALT(SGPT)-31 AST(SGOT)-46* ALK PHOS-60 TOT
BILI-0.8
___ 03:10AM ALBUMIN-4.1 CALCIUM-9.0 PHOSPHATE-3.7
MAGNESIUM-2.1
___ 05:57PM LACTATE-1.2
___ 05:57PM ___ PO2-56* PCO2-47* PH-7.38 TOTAL
CO2-29 BASE XS-1
___ 12:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 12:30AM URINE RBC-12* WBC-27* BACTERIA-FEW YEAST-NONE
EPI-<1
___ 12:30AM URINE BLOOD-MOD NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG
___ 12:30AM URINE COLOR-Straw APPEAR-Clear SP ___
MICRO:
======
UA ___: same as on admission: few bacteria, 15 RBC, 32 WBC, sm
leuks, nitrite + UCx: contaminated with genital flora
BCx: negative to date
MRSA swab: negative
RPR negative
___ 11:50 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in MCG/ML
________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
STUDIES:
========
___
CT ABD W/WO CONTRAST
IMPRESSION:
1. Bilateral indeterminate adrenal masses demonstrating absolute
washout of 10% on the left and 49% on the right, and relative
washout of 7% on the left and 24% on the right. If the lung
lesions are proven malignant, further evaluation with MRI may be
obtained.
RECOMMENDATION(S): Bilateral indeterminate adrenal masses
demonstrating
absolute washout of 10% on the left and 49% on the right, and
relative washout of 7% on the left and 24% on the right. If the
lung lesions are proven malignant, further evaluation with MRI
may be obtained.
CTA Chest ___
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. A 2.1 cm nodular soft tissue density in the right suprahilar
region likely represents a lymph node or mass. If no outside
prior CT's are available for comparison, consider bronchoscopy
or short term imaging followup in ___ weeks to reevaluate
nodule.
3. There is a 1.0cm lymph node adjacent to inferior pulmonary
vein
4. Tracheomalacia
5. Cardiomegaly
6. Multiple hepatic cysts, and hepatic hemangioma in segment 2
of liver
7. 1.8cm right adrenal mass, recommend further evaluation with
limited
noncontrast CT of adrenals.
RECOMMENDATION(S): Recommend bronchoscopy or short term imaging
f/u in ___ weeks to reevaluate right suprahilar soft tissue
nodule.
TTE ___:
IMPRESSION: Suboptimal image quality. Right ventricular cavity
dilation with preserved free wall motion. Moderate to severe
tricuspid regurgitation. Moderate pulmonary artery systolic
hypertension. Mild symmetric left ventricular hypertrophy with
preserved regional and global systolic function. Mild mitral
regurgitation.
CXR ___:
Comparison to ___. Low lung volumes. Mild pulmonary
edema. No pleural effusions. Mild fluid overload but no overt
pulmonary edema. No pneumonia. Mild elongation of the
descending aorta.
RUE Duplex ___:
IMPRESSION: No evidence of deep venous thrombosis in the right
lower extremity veins.
CXR ___:
Lung volumes are slightly low. Heart size is mildly enlarged.
The aorta is slightly tortuous. There is mild pulmonary edema
with perihilar haziness and vascular indistinctness. No focal
consolidation, large pleural effusion or pneumothorax is
present. Assessment of the right apex is somewhat obscured by
the patient's chin projecting over this area. No acute osseous
abnormality is detected. There are degenerative changes noted
involving both glenohumeral and acromioclavicular joints.
IMPRESSION:
Mild pulmonary edema.
CT head ___:
1. Chronic left parietal and temporal lobe tissue loss, likely
due to infarction.
2. No evidence of hemorrhage or recent infarction.
3. Moderate severe age related atrophy.
ECG: Atrial fibrillation. Old anterior infarct.
QT 420 msec
Other labs
=====================
___ 08:40PM BLOOD proBNP-1351*
___ 07:00AM BLOOD VitB12-288
___ 07:00AM BLOOD TSH-36*
___ 07:00AM BLOOD Free T4-0.5*
LABS ON DISCHARGE:
==================
(most recent labs)
___ 05:50AM BLOOD WBC-6.5 RBC-3.14* Hgb-8.9* Hct-29.8*
MCV-95 MCH-28.3 MCHC-29.9* RDW-15.9* RDWSD-54.7* Plt ___
___ 05:50AM BLOOD Neuts-56.5 ___ Monos-10.0 Eos-5.7
Baso-0.6 Im ___ AbsNeut-3.68 AbsLymp-1.75 AbsMono-0.65
AbsEos-0.37 AbsBaso-0.04
___ 05:50AM BLOOD Glucose-90 UreaN-24* Creat-0.9 Na-143
K-3.8 Cl-103 HCO3-27 AnGap-17
___ 05:50AM BLOOD ALT-31 AST-31 AlkPhos-94 TotBili-0.5
___ 05:50AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.3
___ 07:40AM BLOOD cTropnT-0.03* ___
Brief Hospital Course:
Mr ___ is a ___ M h/o dementia, untreated prostate
cancer, BPH with chronic indwelling foley catheter who was
brought in by EMS for confusion and agitation after being found
wandering the streets of ___. Long hospital course
complicated by UTI x2, agitation and difficulty with placement
resulting in custody hearing and appointment of new guardian.
>> ACTIVE ISSUES:
#Dementia, agitation: unclear on presentation whether
presentation was consistent with dementia or delirium given
chronic indwelling foley and dirty UA. Patient was treated with
a 7d course of ceftriaxone for a CAUTI, and catheter was
exchanged. Given no improvement in mental status, with marked
agitation and confusion, it was determined that this is probably
the patient's baseline. Vitamin B12 was in the low end of normal
(supplementation was started, subsequently discontinued before
discharge to reduce number of meds), and TSH was 36, for which
patient was started on levothyroxine 25 mcg (increased to 50mcg
prior to discharge). During his outbursts, the patient required
doses of haloperidol and olanzapine to calm down. It was,
however, noted that haloperidol accentuated the patient's
underlying tremor, and with Psychiatry's input, pt was placed on
a regimen of scheduled olanzapine, with good effect on mood and
affect. He had altered mental status again on ___ in the
setting of leukocytosis and fever after traumatic foley pull.
UCx grew enterococcus and he was started on vancomycin and then
transitioned to Augmentin with improvement in mental status. In
the setting of AMS his olanzapine dose was reduced from 5mg BID
to 2.5mg BID, which he tolerated well. He was discharged on
2.5mg olanzapine BID.
#H/o prostate cancer
#BPH
#Chronic indwelling catheter: Based on information acquired from
patient's son and patient's friends in ___, it was gathered
that patient has a history of prostate cancer that was not
operated on, as well as BPH, with history of hospitalization in
___ in ___, after which foley was placed
permanently. It was exchanged weekly until ___ when
patient flew back to the ___ and refused to have it
exchanged again. During the hospitalization, a voiding trial was
attempted, which the patient failed. He was started on
tamsulosin. On ___, patient accidentally ripped out his foley
catheter; Foley was replaced by urology to allow the urethra to
heal. Bleeding around the meatus, as well as hematuria, resolved
in 24 hours. He will need continued voiding trials after
discharge or will need to be followed by Urology for chronic
indwelling foley.
#CAUTI x2: On admission the patient had a dirty UA and negative
UCx but was treated empirically for UTI due to presence of
delirium with 1 week of ceftriaxone (notably no leukocytosis or
fevers, negative BCx). Then on ___ and ___ in the setting of
leukocytosis, fever and AMS, UCx were rechecked and grew
___ cfu Enterococcus. Patient was given Vancomycin, with
dramatic improvement of mental status, fever and white count.
Sensitivities showed enterococcus was susceptible to ampicillin,
so patient to be discharged on augmentin 875 BID with total 14
day course for complicated UTI. Last day of Augmentin was
completed ___.
#Diastolic heart failure: Noted based on limited history found
in records from ___ initially. Pt was not taking any medication
on arrival to the hospital but was started on 20 mg po
furosemide after developing tachypnea and tachycardia one
evening with a clear CXR, to good effect. BNP at that time was
1300. TTE at that time showed RV dilation, moderate to severe
tricuspid regurgitation, ___ and mild LVH, with preserved wall
motion and global systolic function. In the setting of ongoing
UTI on ___, Mr. ___ went into respiratory distress.
Patient's BNP was rechecked and noted to be ___. Additional
doses of lasix were given, to good effect. Patient was
eventually resumed on 20 mg orally daily as it seemed to be a
stable dose at baseline.
#Atrial fibrillation: Not treated on arrival. Given history of
medication non-compliance, unclear how long patient was
untreated. Mr. ___ was started on 81 mg po daily aspirin
and low-dose metoprolol for rate control. He is discharged on
100mg metoprolol XL with HRs in the ___.
#Troponinemia: Troponinemia to 0.04 noted in the setting of
acute diastolic heart failure exacerbation. Patient
asymptomatic, without any ECG changes.
#Tremor: Jaw and upper extremity tremor (R>L) noted at baseline
with this patient, absent while asleep but present both at rest
and with purposeful actions. Unclear if intention tremor v
Parkinsonism. Exacerbated by haloperidol, thus medication was
avoided.
#Incidental adrenal and hilar lesions on CT: CTA chest noted
accidental 1.8 cm Right adrenal mass, as well as 2 cm right
hilar soft tissue mass. A limited non-contrast CT was
recommended and ordered for further workup of the adrenal mass,
but was unrevealing. Recommendation was made for close follow-up
with additional CT. Radiology recommended that hilar mass was to
be further characterized by bronchoscopy or close follow-up with
CT in ___ weeks.
#Anemia: Hgb on arrival 10.8. Etiology unclear. In the context
of hematuria from foley trauma patient's Hgb dropped but then
stabilized. The patient did not require transfusion this
admission.
=======================
TRANSITIONAL ISSUES:
=======================
[ ] continue levothyroxine supplementation at 50. Last TSH was
52 on ___. Please recheck TSH in 2 weeks (End of ___ and
adjust dose for target
[ ] Patient failed multiple voiding trials and has indwelling
foley at discharge. Please continue to attempt voiding trials
and if patient requires ongoing foley please arrange follow-up
with urology as needed.
[ ] please continue aspirin and metoprolol for atrial
fibrillation. Recommend discussion with guardian regarding risks
and benefits of anticoagulation. Chads2vasc score is 3.
[ ] continue zyprexa 2.5mg BID scheduled, with additional prn
doses for agitation management. Please continue to monitor his
QTc.
[ ] Incidentally noted 2.5cm suprahilar soft tissue nodule noted
on ___ requires follow-up with bronchoscopy or imaging in
___ weeks (mid ___.
[ ] Incidentally noted bilateral indeterminate adrenal masses
noted on CT abdomen on ___. If the above lung nodules prove
malignant the patient should get an MRI of adrenals to further
evaluate these masses.
[ ] Patient is status post treatment of enterococcus UTI (last
day of augmentin ___.
[ ] ___ ___ is the patient's former
neighbor who was awarded healthcare proxy status on ___,
___ obtained on ___
[ ] Full Code during this admission, please readdress with new
Healthcare Proxy.
[ ] last QTc 407 on ___
[ ] The patient loves sparkling water! He frequently requests it
when agitated and it has successfully calmed him down in the
past.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Furosemide 20 mg PO DAILY
6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. OLANZapine (Disintegrating Tablet) 2.5 mg PO BID
10. OLANZapine (Disintegrating Tablet) 5 mg PO BID:PRN
agitation
11. OLANZapine (Disintegrating Tablet) 2.5 mg PO BID
12. Senna 8.6 mg PO BID:PRN constipation
13. Tamsulosin 0.4 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Dementia
Delirium
Catheter-associated UTI
Diastolic Heart Failure exacerbation
BPH
Prostate Cancer
Urinary Retention
Atrial Fibrillation
Anemia
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. ___,
It was a pleasure taking care of you during your stay at ___
___.
Why you were here:
- You were admitted because people noticed you were more
confused than usual.
What we did while you were here:
- We treated you for an infection of the bladder with
antibiotics. You got 1 course of antibiotics in ___ when you
were admitted and another one at the end of ___. These
infections were related to your foley catheter.
- We tried to remove the foley catheter, but you were not able
to urinate without it.
- We gave you some medications to help with your confusion and
dementia.
- We coordinated a hearing to appoint ___ to be
your legal guardian and make medical decisions on your behalf.
What to do when you go home:
- Please take all your medications as prescribed.
- Please follow up with Urology for the care of your foley
catheter.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10872930-DS-27
| 10,872,930 | 24,406,981 |
DS
| 27 |
2113-10-16 00:00:00
|
2113-10-16 14:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine / Celexa / Dilaudid / Ambien / Methotrexate /
citalopram
Attending: ___.
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
Enteroscopy and colonscopy with thermal therapy for AVMs
History of Present Illness:
Ms. ___ is a ___ F with history of iron deficiency
anemia requiring transfusions and ischemic colitis s/p
hemicolectomy ___ who presents with relative hypotension and
vague abdominal discomfort. She was in her normal state of
health until today when she slid out of bed onto the floor.
Patient denies falling and was able to glide down slowly without
hitting her head, buttocks or any body part. No LOC. She had
some vague abdominal discomfort earlier today that she has
difficulty describing but complained of this to staff and told
them about this "fall" so they were monitoring her closely and
noted hypotension to SBP in the ___ from baseline in the 130s.
.
Of note, her hematocrit was routinely drawn ___ and found to be
24 from previous baseline of 26 on ___ and 25 on ___. Last blood
transfusion was here at ___ in ___, and last hct in our
system was ___ with hct 27. Rehab notes record 3 guaiac
positive brown stools over the past few days. Patient does not
look at her ostomy output and cannot say if things have changed
or what her stools look like.
In the ED, initial vitals were: 98.4 70 94/30 16 96% RA. Her
hematocrit was 23.7, and she was consented for blood. One unit
pRBCs were transfusing, and vitals on transfer were 75, 108/31,
22, 96% RA.
On the floor, she reports feeling well now aside from her
typical arthralgias from arthritis and chronic fatigue. She
can't further describe the abdominal discomfort she had earlier
but it is gone now.
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. The ten point review
of systems is otherwise negative.
Past Medical History:
Papillary thyroid carcinoma with lymph node metastases
Syncope due to recurrent polymorphic ventricular tachycardia
CAD s/p CABG
Diabetes
HTN
PVD
Left CEA for carotid stenosis
Rheumatoid arthritis
Factor V Leiden
Depression
Iron def anemia
Hypothyroidism
Failure to thrive
Cholecystectomy
Urinary incontinence
Interstitial lung disease
Restless leg syndrome
Seizure ___ years ago
Recurrent Anemia requiring multiple tranfusions as per son,
details unknown (possible GI losses w/negative work-up)
Social History:
___
Family History:
Her son had a papillary thyroid cancer that was removed. Her
sister has a rare throat cancer.
Physical Exam:
On Admission:
PHYSICAL EXAM:
VS: 97.5, 104/42, 79, 18, 98% RA
GENERAL: Well-appearing, pale elderly lady in NAD, comfortable,
appropriate.
HEENT: NC/AT, sclerae anicteric, MMM, OP clear.
NECK: Supple, no JVD.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no ronchi/rales/wheezes, good air movement,
resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding,
ostomy with healthy appearing tissue, bag empty.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3.
On Discharge:
O: VS: T 97.8 BP 131/52 P 66 RR 18 98% RA
General: NAD
CV: Paradoxically split S2, ___ systolic murmur best heard at
___ without radiation, nl S1-S2.
LUNGS: Crackles at bases, good air movement otherwise.
ABDOMEN: Soft, mildly tender on deep palpation in RLQ and LLQ,
no masses or HSM, no rebound/guarding, ostomy with healthy
appearing tissue, bag empty.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. Right knee is
swollen with palpable effusion. Big toe with dactitylitis
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3.
Pertinent Results:
___ 08:59PM WBC-7.6 RBC-2.79* HGB-7.1* HCT-23.7* MCV-85
MCH-25.6*# MCHC-30.2* RDW-17.4*
___ 08:59PM NEUTS-57.8 ___ MONOS-10.3 EOS-4.3*
BASOS-0.9
___ 08:59PM PLT COUNT-351
___ 08:59PM calTIBC-291 FERRITIN-41 TRF-224
___ 10:30AM BLOOD Ret Aut-3.6*
___ 08:59PM IRON-22*
___ 08:59PM GLUCOSE-141* UREA N-31* CREAT-1.6* SODIUM-136
POTASSIUM-5.1 CHLORIDE-97 TOTAL CO2-26 ANION GAP-18
___ 09:20PM freeCa-1.07*
___ 09:20PM LACTATE-2.4*
___ 09:20PM ___ PH-7.42 COMMENTS-GREEN TOP
___ 11:00PM ___ PTT-28.8 ___
___ 05:40AM BLOOD WBC-7.4 RBC-3.44* Hgb-8.9* Hct-29.3*
MCV-85 MCH-25.9* MCHC-30.4* RDW-16.5* Plt ___
___ 05:40AM BLOOD UreaN-21* Creat-1.1 Na-139 K-4.3 Cl-101
___ 06:51PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 06:51PM URINE RBC-6* WBC-80* Bacteri-FEW Yeast-NONE
Epi-<1
___ 06:51PM URINE Hours-RANDOM Creat-40 Na-57 K-33 Cl-57
CXR: Minimal congestive changes. No additional acute finding
.
Colonscopy ___:
Impression: Angioectasia in the cecum (thermal therapy)
Otherwise normal colonoscopy to cecum and terminal ileum
.
Enteroscopy ___:
Impression: Angioectasia in the duodenum and jejunum (thermal
therapy)
Angioectasias in the duodenum (thermal therapy)
Otherwise normal small bowel enteroscopy to Jejunum
.
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML..
Brief Hospital Course:
Ms. ___ is a ___ F with history of iron deficiency
anemia requiring transfusions, history of AVMs and pylorus
ulcer, ischemic colitis s/p hemicolectomy ___ who presents with
relative hypotension and vague abdominal discomfort in setting
of guiac positive stools found to have multiple AVMs on scope
which were treated with thermal therapy.
# Gastrointestinal bleeding: Pt found to be anemic at her
extended care facility. She was noted to be guaiac positive
from her ostomy site. Her stools were brown but guaiac positive
in the ED, and upon review of her prior records had AVMs seen on
EGD and ___ in ___ that were treated with cautery. She does
have h/o iron deficiency requiring intermittent transfusions,
last in ___. The pt had one unit of prbc transfusion here
for a HCT of 23.7. The pt underwent colonscopy and enteroscopy
here which demonstrated AVMs. These were treated with thermal
laser therapy. Pt tolerated procedure well and HCT remained
stable thereafter.
# Abdominal discomfort: Initially had mild discomfort but this
resolved; possibly related to bleeding. Pt has known past ulcer
disease but nothing evident on endoscopy. Pt's exam remained
benign. No evidence of ischemic colitis on colonscopy and pt
with no systemic symptoms.
# Anemia: ___ from bleeding with normal ferritin and transferrin
explained by component of anemia of chronic disease likely from
her RA. Pt is hypoproliferative which could be from either
condition. Pt continued on home folic acid and iron.
# Hypotension: Initially pt's blood pressure was low to 104 from
her reported baseline in 130s. Her lisinopril was thus held. On
fluid bolus and 1 unit PRBC pt's blood pressure improved to
normal. She was restarted on lisinopril. Pt most likely
hypovolemic given elevated creatinine and lactate from bleeding
and poor PO intake.
# UTI: Pt without dysuria and has baseline urinary incontinence.
UA however c/w infection and in setting of abdominal discomfort
and fatigue treating w/ 3 day Bactrim course. Urine culture
showed >100,000 GNRs, sensitivities are pending at the time of
discharge.
# Acute renal failure: Creatinine on admission to 1.6 from
baseline of 1.0. Resolved with fluids.
# DM: On sliding scale insulin in ___.
# Arthritis: Continued home pain regimen and prednisone.
# CAD: Continued amiodarone, ASA; restart lisinopril.
# Paradoxically split S2: Unclear cause. No LBBB on ecg, no
aortic stenosis, HOCM
# Hypothyroidism: Continue levothyroxine
# Depression: Continue remeron and effexor
.
TRANSITIONAL:
-Repeat Hct in few days. Hct on last check here was 27.3
-Continue 3 day treatment for UTI
-Follow-up urine culture sensitivity results
-Outpatient follow-up with GI
Medications on Admission:
Lisinopril 10mg daily
Multivitamins 1 TAB PO/NG DAILY
Amiodarone 200 mg PO/NG QOD
Mirtazapine 30 mg PO/NG HS
Aspirin 81 mg PO/NG DAILY
Omeprazole 40 mg PO DAILY
Acetaminophen 650 mg PO/NG TID
OxycoDONE (Immediate Release) 2.5 mg PO/NG Q4H:PRN pain
Cyanocobalamin 1000 mcg PO/NG DAILY
PredniSONE 5 mg PO/NG EVERY OTHER DAY
Calcium Carbonate 500 mg PO/NG DAILY
Simvastatin 10 mg PO/NG DAILY
FoLIC Acid 1 mg PO/NG DAILY
Simethicone 40-80 mg PO/NG BID
Ferrous Sulfate 325 mg PO/NG BID
TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
Vitamin D 400 UNIT PO/NG DAILY
Venlafaxine XR 37.5 mg PO DAILY
Levothyroxine Sodium 112 mcg PO/NG DAILY
traZODONE 50 mg PO/NG HS
Discharge Medications:
1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
4. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three
times a day.
8. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
9. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
10. prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
12. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
15. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
16. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
17. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
18. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
19. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 2 days.
20. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: GI bleed from AVMs, ___, UTI
Secondary: Anemia, rheumatoid arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were
admitted for GI bleeding and were found to have multiple
arteriovenous malformations which were most likely causing your
bleeding. These were treated with a laser and your blood counts
remained stable.
There were no changes made to your medications.
Followup Instructions:
___
|
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