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10872930-DS-28
| 10,872,930 | 27,246,344 |
DS
| 28 |
2113-10-29 00:00:00
|
2113-10-30 11:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine / Celexa / Dilaudid / Ambien / Methotrexate /
citalopram
Attending: ___
Chief Complaint:
Fatigue and guiac positive stool
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ woman with a history of
hemicolectomy in ___ secondary to ischemic colitis and history
of AVMs in the duodenum, jejunum, and cecum who presents with
transient hypotension and guaiac positive stool. Patient has a
history of chronic GI bleeding and iron deficiency anemia ___
her AVMs. She was recently admitted ___ for hypotension from
___ to ___ during which time she underwent enteroscopy and
colonoscopy (under MAC) with thermoplasty of AVMs.
.
Since discharge, patient has been doing well at ___,
playing bingo and otherwise enjoying herself! However, on day
of admission she complained of feeling unwell. Her BP was 60/37
with a HR of 76; repeat was 124/54 and HR of 71. Stool in
colostomy bag was guaiac positive. Ms. ___ was
transferred to ___ ED for further evalauation.
In the ED, initial vital signs were 98.8 81 17 96% RA 120/36.
Hct was 25 and patient was given 1 unit of PRBCs. CT abdomen
showed colonic inflammation without evidence of diverticulitis.
She was given cipro/flagyl in the ED. CT also showed mild antral
wall thickening consistent with gastritis. She was subsequently
transferred to the floor for further evaluation and management.
On the floor, Ms. ___ reported pain in her knees and
elbows. She also said she wanted to back to rehab so that she
could play bingo.
.
ROS: Denies fever, chills, night sweats, headache, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation,
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 mellitus type II
HTN
PVD
carotid stenosis s/p left CEA
Rheumatoid arthritis
Factor V Leiden
Depression
Iron deficiency anemia
Hypothyroidism
s/p cholecystectomy
Interstitial lung disease
Restless leg syndrome
Social History:
___
Family History:
Her son had a papillary thyroid cancer that was removed. Her
sister has a rare throat cancer.
Physical Exam:
Admission Exam:
VS: 98.6, 118/38, 80, 94% on 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, nondistended. No masses. Tenderness to deep
palpatation. no rebound/guarding, ostomy with approximately
teaspoon size dark stool w/o erythema around the ostomy site
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3.
Discharge Exam:
VS: 97.7, 142/54, 72, 18 93% on 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, nondistended. No masses. Tenderness to deep
palpatation. no rebound/guarding, ostomy clear w/o erythema
around the ostomy site
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3.
Pertinent Results:
___ 06:50AM BLOOD WBC-6.2 RBC-3.62* Hgb-9.1* Hct-30.1*
MCV-83 MCH-25.2* MCHC-30.3* RDW-15.5 Plt ___
___ 12:08AM BLOOD Hct-25.9*
___ 03:50PM BLOOD Hct-26.2*
___ 06:35AM BLOOD WBC-10.4 RBC-3.18* Hgb-8.2* Hct-26.6*
MCV-85 MCH-25.7* MCHC-30.4* RDW-15.7* Plt ___
___ 05:50PM BLOOD WBC-9.3 RBC-3.07* Hgb-7.7* Hct-25.8*
MCV-84 MCH-24.9* MCHC-29.8* RDW-15.8* Plt ___
___ 05:50PM BLOOD Neuts-66.3 ___ Monos-7.4 Eos-4.0
Baso-1.0
___ 06:50AM BLOOD Glucose-125* UreaN-16 Creat-1.1 Na-139
K-4.2 Cl-103 HCO3-27 AnGap-13
___ 06:35AM BLOOD Glucose-146* UreaN-22* Creat-1.2* Na-138
K-4.6 Cl-105 HCO3-24 AnGap-14
___ 05:50PM BLOOD Glucose-172* UreaN-32* Creat-1.5* Na-135
K-4.9 Cl-98 HCO3-25 AnGap-17
___ 05:50PM BLOOD ALT-7 AST-15 AlkPhos-86 TotBili-0.1
___ 06:50AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.2
___ 06:35AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.0
___ 05:50PM BLOOD Albumin-3.9
CT Abdomen ___
CT ABDOMEN: Patchy basilar opacities suggest minor atelectasis.
There are no pleural effusions. Surgical clips project about
the right cardiophrenic angle.
There is a geographic focal fatty infiltration along the
falciform ligament on the side of the quadrate lobe. The
patient is status post cholecystectomy, probably accounting for
slight prominence of biliary ducts.
There are few small hypodense foci in the spleen, the largest
measuring 16 mm in diameter which appears cystic and not
significantly changed. The adrenal glands and pancreas appear
within normal limits. Subcentimeter hypodense foci in each
kidney are too small to characterize, but unchanged.
The stomach demonstrates apparent wall thickening along the
antrum. The
patient is status post partial colectomy with a colostomy site
in the left lower quadrant. Upstream of the ostomy site,
although collapsed, the transverse colon demonstrates mild
surrounding fat stranding and prominent mucosal enhancement.
CT PELVIS: The patient is status post hysterectomy. The
bladder appears
within normal limits. Vascular calcifications are widespread.
There is no lymphadenopathy or ascites.
BONE WINDOWS: There are no suspicious lytic or blastic bone
lesions. The bones appear demineralized. Mild-to-moderate
degenerative changes are present along the lower lumbar facets.
Mild superior endplate compression deformities of the T9 and T10
vertebral bodies with degenerative changes appear similar.
IMPRESSION: Findings suggestive of colonic inflammation. There
is also a mild apparent thickening of the gastric antrum with
prominent mucosal
enhancement. The possibility of gastritis could be considered
in the
appropriate clinical setting.
CXR ___
IMPRESSION: Mild similar background interstitial abnormality
suggesting
pulmonary congestion, but similar to before.
Brief Hospital Course:
Ms. ___ is an ___ woman with anemia requiring
multiple tranfusions s/p thermoplasty of duodenum, cecum and
jejunal AVM in ___ who presents from rehab with transient
hypotension and guaiac positive stools.
.
# POSSIBLE GI BLEED: Patient had dark blood in her ostomy bag
without evidence of melena, though she reports dark stool at
baseline because she takes iron. Hct was slightly lower than on
previous admissions. A CT scan showed colitis and signs of
gastritis. Patient was given a dose of cipro/flagyl empirically
and a unit of blood. No fever or white count to suggest
infection. GI was consulted who thought that guaiac positive
stools may have been the result of another episode of "ischemic
colitis" in the setting of hypotension. Did not feel repeat
endoscopy or colonoscopy were indicated. GI did recommend
testing for H.Pylori, which can be done as an outpatient.
Aspirin 81mg QD was restarted. Hct remained stable and patient
was discharged back to rehab. She should have her hct rechecked
in 1 week. Ferrous sulfate was continued.
.
# HYPOTENSION: Patient had one blood pressure reading at rehab
that was low. Unclear whether this was a spurious value or if
patient was truly hypotensive. Ms. ___ is not taking any
anti-hypertensives. She remained normotensive during this
hospitalization and was encouraged to keep up fluid intake.
.
# ___: Patient's creatinine was up to 1.5 from a baseline of
1.0 on admission. Likely due to hypovolemia from poor PO intake.
With 1 unit PRBCs, creatinine trended back to baseline.
# HYPOTHYROIDISM: Levothyroxine was continued.
.
# ARTHRITIS: Oxycodone, prednisone, Tylenol, and tramadol were
continued.
.
# DEPRESSION: Venlaflaxine and mirtazapine were continued.
.
# CAD WITH EF of 45% AND VT: Amiodarone was continued.
Lisinopril was initially held in setting of hypotension at rehab
and then decreased from 10mg to 5mg QD upon discharge. ASA was
initially held but continued on discharge.
.
# VITAMIN B12 DEFICIENCY: Cyanocobalamin was continued
.
# HYPERCHOLESTEROLEMIA: Simvastatin was continued.
.
# DM II: No active issues.
.
# CODE: DNR/DNI (confirmed)
.
TRANSITIONAL ISSUES:
[ ] Recheck hct in 1 week
[ ] Check H.Pylori serologies and treat if positive
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from rehab.
1. Lisinopril 10 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Amiodarone 200 mg PO DAILY
4. Mirtazapine 30 mg PO/NG HS
5. Aspirin 81 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Acetaminophen 650 mg PO TID
8. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
9. Cyanocobalamin 1000 mcg PO DAILY
10. PredniSONE 5 mg PO EVERY OTHER DAY
11. Calcium Carbonate 500 mg PO DAILY
12. Simvastatin 10 mg PO DAILY
13. FoLIC Acid 1 mg PO DAILY
14. Simethicone 40-80 mg PO BID
15. Ferrous Sulfate 325 mg PO BID
16. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
17. Vitamin D 400 UNIT PO DAILY
18. Venlafaxine XR 37.5 mg PO DAILY
19. Levothyroxine Sodium 112 mcg PO DAILY
20. traZODONE 50 mg PO HS:PRN insomnia
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Calcium Carbonate 500 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Ferrous Sulfate 325 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Levothyroxine Sodium 112 mcg PO DAILY
7. Mirtazapine 30 mg PO HS
8. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
hold for oversedation
9. PredniSONE 5 mg PO EVERY OTHER DAY
10. Simvastatin 10 mg PO DAILY
11. Lisinopril 5 mg PO DAILY
Hold if SBP < 100.
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 40 mg PO DAILY
14. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
15. Aspirin 81 mg PO DAILY
16. traZODONE 50 mg PO HS:PRN insomnia
17. Vitamin D 400 UNIT PO DAILY
18. Venlafaxine XR 37.5 mg PO DAILY
19. Amiodarone 200 mg PO EVERY OTHER DAY
20. Simethicone 80 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
possible UGIB secondary to AVMs vs ischemic colitis
Secondary diagnoses:
# ___, prerenal: attributed to hypovolemia
# CAD
# chronic systolic CHF
# rheumatoid arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
to the hospital because your blood pressure was low and you had
blood in your stool. A CT scan of your abdomen showed some
inflammation in your colon and stomach. We thought that the
blood in your stool could be related to your transient low blood
pressure. You received 1 unit of blood and IV fluids. Your
blood pressures and blood counts were stable upon discharge.
.
The following changes were made to your medications:
START taking lisinopril 5mg once a day instead of lisinopril
10mg once a day.
.
Please return to the hospital if you develop chest pain,
shortness of breath, nausea, vomiting, dizziness, blood in your
stools, fevers, chills, or other concerning signs or symptoms.
Followup Instructions:
___
|
10872930-DS-33
| 10,872,930 | 22,178,600 |
DS
| 33 |
2114-11-15 00:00:00
|
2114-11-18 21:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine / Celexa / Dilaudid / Ambien / Methotrexate /
citalopram
Attending: ___
Chief Complaint:
Cough and shortness of breath x1 week
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo female with coronary artery disease status post CABG,
polymorphic VT, diabetes,ischemic colitis status post
hemicolectomy (___), and small bowel and colonic
arteriovenous malformations, interstitial lung disease,
peripheral vascular disease. Patient was here for pre-cataract
operation evaluation, found to have cough x1 week, with sat 88%
RA with wheezing throughout.
In the ED, initial vs were: 97.7 80 111/42 20 100% 3L. Labs were
remarkable for WBC 8.8, H/H 8.6/26.4 (prior ___, Cr 1.2,
BUN 14, Na 132, lactate 1.3, CXR was suggestive of LLL opacity.
EKG showed normal axis, sinus rate 80, flat T wave III, aVF, TWI
V1-v3, poor R wave progression V1-v3 (compared to prior ___,
this is similar). She was given oxycodone, duonebs and levaquin
500mg IV. Blood cultures sent. Vitals on Transfer: 98.8 96
102/50 22 97%.
On the floor, pt coughing, sitting up in the bed, comfortable,
no complaints, asking about her pain medication.
Review of sytems:
(+) Per HPI , chills +, DOE + x 1 week
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies chest pain or tightness, palpitations. Denies orthopnea
or PND. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Ten point review of
systems is otherwise negative.
Past Medical History:
hemicolectomy ___ secondary to ischemic colitis
Papillary thyroid carcinoma with lymph node metastases
CAD s/p CABG
Syncope due to recurrent polymorphic ventricular tachycardia
HTN
Diabetes mellitus type II
PVD
carotid stenosis s/p left CEA
Rheumatoid arthritis
Factor V Leiden
Depression
Iron deficiency anemia
Hypothyroidism
s/p cholecystectomy
Interstitial lung disease
Restless leg syndrome
Social History:
___
Family History:
Her son had a papillary thyroid cancer that was removed. Her
sister has a rare throat cancer.
Physical Exam:
Admission PHysical Exam:
Vitals: 98.4 120/70 92 20 92% 2 L NC FSBG 232
General: Alert, orientedx3, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: anterior and axillary exam bilateral: fine insp crackles
with scattered wheeze, bibasal fine insp crackles when attempted
limited posterior exam.
CV: Regular rate and rhythm, normal S1 + S2, faint ___ systolic
murmur no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
left sided colostomy bag, normal looking mucosa, contains small
amount of brown stool
Ext: Warm, well perfused, pulses not palpable but dopplerable
bilaterally in the feet, no clubbing, cyanosis or edema
Neuro: power -___ in ___, 4+/5 in UE's. CN ___ grossly intact,
right pupil wider than left pupil due to pupil dilator applied
for cataract surgery
Discharge Physical Exam:
VS: Tc 98.4 BP 134/48 HR 84, RR 18 100% RA I/O: not
recorded/BRP
General: Lying in bed, comfortable, smiling
HEENT: Purple marking over R eyebrow (from planned cataract
surgery), EOM full. NCAT. No visible JVD.
CV: RRR, no m/r/g
Lungs: diminished crackles at the bases, and minimal crackles
anteriorly, but no wheezing anteriorly or posteriorly. No
accessory muscle use.
Abd: Soft, NDNT.
Ext: No edema.
Pertinent Results:
___ 04:17PM BLOOD WBC-8.8 RBC-2.97* Hgb-8.6* Hct-26.4*
MCV-89 MCH-29.1 MCHC-32.7 RDW-16.2* Plt ___
___ 11:48PM BLOOD Hgb-7.8* Hct-23.6*
___ 07:09AM BLOOD WBC-8.7 RBC-3.08* Hgb-8.9* Hct-26.8*
MCV-87 MCH-28.9 MCHC-33.1 RDW-16.3* Plt ___
___ 07:15AM BLOOD WBC-6.9 RBC-3.27* Hgb-9.4* Hct-28.5*
MCV-87 MCH-28.8 MCHC-33.1 RDW-16.0* Plt ___
___ 04:17PM BLOOD Neuts-62.2 ___ Monos-9.4 Eos-5.5*
Baso-1.1
___ 04:17PM BLOOD Plt ___
___ 04:17PM BLOOD Glucose-141* UreaN-14 Creat-1.2* Na-132*
K-4.5 Cl-95* HCO3-25 AnGap-17
___ 07:15AM BLOOD Glucose-113* UreaN-16 Creat-1.2* Na-137
K-4.1 Cl-96 HCO3-27 AnGap-18
___ 04:17PM BLOOD CK(CPK)-60
___ 04:17PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-406
___ 04:17PM BLOOD Calcium-8.9 Phos-3.8 Mg-1.9
___ 07:15AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.8
___ 07:14PM BLOOD Lactate-1.3
ECG on ___:
Normal sinus rhythm. Leftward axis. Borderline non-specific
intraventricular
conduction abnormality. Delayed R wave progression in the
precordial leads may
signal prior anteroseptal myocardial infarction. Diffuse
non-specific
ST-T wave abnormalities. Compared to the previous tracing of
___
ST segment abnormalities and intraventricular conduction delay
persist
unchanged. The precordial R wave transition is more marked.
Chest x-ray ___:
HISTORY: ___ female with hypoxia and productive cough
for 1 week.
COMPARISON: ___.
FINDINGS:
AP and lateral views of the chest. Again seen are mild
interstitial opacities
suggestive of interstitial edema. On the lateral view, there is
increased
opacity projecting over the lower lobes not definitively
identified on the
frontal noting that the left lung base is not well evaluated due
to overlying
soft tissues. Superiorly the lungs are clear. There is no
effusion. Cardiac
silhouette is stable with multiple clips and median sternotomy
wires.
Surgical clips also seen in the neck on the right. Trachea is
deviated to the
right at the thoracic inlet similar to prior. Degenerative
changes seen at
the left shoulder.
IMPRESSION:
Limited exam. Possible lower lobe opacity, potentially on the
left. This
could represent infection in the proper clinical setting.
Brief Hospital Course:
___ yo female with CAD s/p CABG, polymorphic VT,
diabetes,ischemic colitis s/p hemicolectomy (___), and small
bowel and colonic AVMs, ILD, PVD, here with DOE found to have
PNA on CXR. Also drop in her hematocrit consistent with
bleeding per ostomy x1 week before admission.
Active issues:
# DOE, cough, chills: CXR suggested PNA, so she was started on
levaquin. BNP was not suggestive of acute diastolic dysfunction,
and she had no leg edema or JVD. EKG was unchanged from prior
and not concerning for ischemia. Her oxygen requirement
diminished throughout her stay and was ultimately weaned to room
air before discharge. Her exam improved, with only minimal
crackls mostly in the bases bilaterally on discharge.
# chronic blood loss anemia: H/H 8.6/26.4 (prior ___. known
to have iron deficiency anemia and had BRB per ostomy x1 week.
On iron/b12/folate supplements at home, which were continued.
Likely due to chronic bleeding from her known arteriovenous
malformations. Got 1 unit pRBC with appropriate bump in HCT.
There was no visible blood in stool during hospitalization. Hct
was stable for 2 days prior to discharge.
# Hyponatremia: hypovolemic hyponatremia from poor PO intake
week before admission, with dry membranes on admission, though
lactate was normal and urine output normal. With appropriate
nutrition during hospitalization, her hyponatremia resolved.
# CKD: On review, pt's Cr ___ since ___, remained stable
during hospitalization.
Inactive issues:
#h/o Polymorphic VTach: no evidence of Vtach on EKG. Continued
amiodarone 200 mg every other day
#Diabetes mellitus: not on insulin or anti-diabetic agent at
home, Insulin sliding scale in hospital.
#Hypothyroidism: continue home levothyroxine
#CAD s/p CABG, PVD, HTN, HLD: Currently symptom free.
continued home ASA, lisinopril and simvastatin
#Rheumatoid arthritis: on prednisone. Pain control with
tylenol and oxycodone.
#GERD: continued on home PPI regimen
#Depression: History of depression, on mirtazepine and
venlafaxine
Transitional issues:
- hemotocrati stable on discharge, but needs follow up and
recheck within a week to make sure her bleeding through the
bowel is stable, since she required 1 unit of pRBCs while in
hospital.
- Last levaquin dose of 750 mg po QD on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amiodarone 200 mg PO EVERY OTHER DAY
3. Aspirin 81 mg PO DAILY
4. Bisacodyl ___AILY:PRN constipation
5. Cyanocobalamin 1000 mcg PO DAILY
6. Ferrous Sulfate 325 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Levothyroxine Sodium 125 mcg PO DAILY
9. Milk of Magnesia 30 mL PO DAILY:PRN constipation
10. Mirtazapine 7.5 mg PO HS
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 40 mg PO BID
13. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
14. PredniSONE 5 mg PO DAILY
15. Simethicone 40 mg PO BID
16. Simvastatin 10 mg PO DAILY
17. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
18. Venlafaxine XR 37.5 mg PO DAILY
19. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral BID
20. Ondansetron 4 mg PO Q8H:PRN nausea
21. Lisinopril 5 mg PO DAILY
22. OxycoDONE (Immediate Release) 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amiodarone 200 mg PO EVERY OTHER DAY
3. Aspirin 81 mg PO DAILY
4. Bisacodyl ___AILY:PRN constipation
5. Cyanocobalamin 1000 mcg PO DAILY
6. Ferrous Sulfate 325 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Levothyroxine Sodium 125 mcg PO DAILY
9. Lisinopril 5 mg PO DAILY
10. Milk of Magnesia 30 mL PO DAILY:PRN constipation
11. Simvastatin 10 mg PO DAILY
12. Venlafaxine XR 37.5 mg PO DAILY
13. Mirtazapine 7.5 mg PO HS
14. Omeprazole 40 mg PO BID
15. Ondansetron 4 mg PO Q8H:PRN nausea
16. PredniSONE 5 mg PO DAILY
17. Levofloxacin 750 mg PO Q48H Duration: 2 Days
Please take daily, with the last dose on ___.
18. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral BID
19. Multivitamins 1 TAB PO DAILY
20. Simethicone 40 mg PO BID
21. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
22. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
23. OxycoDONE (Immediate Release) 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
health-care associated pneumonia
chronic blood loss anemia
Secondary diagnoses:
gastrointestinal AVMs
CKD stage III
Diabetes mellitus type II
Hypothyroidism
CAD
PVD
HTN
HLD
GERD
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were seen at the ___ for
symptoms of cough and shortness of breath. You were found to
have a pneumonia and anemia, for which you were started on an
antibiotic (levaquin) and received one unit of blood. You
improved over your time here with supplemental oxygen and now
doing much better, no longer short of breath and not requiring
supplemental oxygen, ready to go home.
You will be sent back to your nursing home. Please continue to
take your antibiotic for one more day. Weigh yourself every
morning, call MD if weight goes up more than 3 lbs. If you
develop any concerning symptoms, please come back to the
hospital.
Followup Instructions:
___
|
10872930-DS-34
| 10,872,930 | 22,990,996 |
DS
| 34 |
2115-05-26 00:00:00
|
2115-05-26 15:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine / Celexa / Dilaudid / Ambien / Methotrexate /
citalopram
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with CAD s/p CABG, polymorphic VT,
diabetes,ischemic colitis s/p hemicolectomy (___), and small
bowel and colonic AVMs who presents to the ED for abdominal
pain. She reports a history of sharp abdominal pain located in
the ___ her abdomen, ___ in severity, nonradiating for
the past 6 months. The pain comes and goes but has been
occurring more frequently, lasting longer (for one day at a
time). The pain is not associated with eating, but when she has
the pain, she does not eat. The pain occurs during the day and
at night. She also notes a several month history of dark black
stools. She was noticed to have 30 mL of bright red blood coming
from her ostomy the day prior to admission. She feels like she
has to move her bowels and pass gas but can't. No
nausea/vomiting, fevers/chills, HA, CP, SOB, dysuria.
In the ED initial vitals were: 96.6 65 99/37 16 100% 2L. Labs
were significant for WBC 9.4 N: 72.7, H&H 9.9/31.2. Chem 7
notable for K5.4, Cr 1.4, BUN 25. Coags unremarkable. Lactate
1.5. UA grossly positive with >182 WBC with many bacteria, large
leuks, nitrite positive. LFTs were WNL. Patient underwent CT
abdomen pelvis that was notable for hypoenhancement of colon
wall leading up to ostomy consistent with colitis, no SBO, and
SMA stenosis which appears stable from ___ although study is
limited. CXR was unremarkable. Surgery was consulted and
recommended admission to medicine with GI consult, NPO and IVF.
Patient was given IVF, pantoprazole, morphine and ceftriaxone.
Vitals prior to transfer were:5 98.2 62 130/59 16 100% RA. On
the floor vital signs: T 98.8 BP 142/70 HR 76 RR 16 Wt 71 kg
Review of Systems:
(+)
(-) 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:
Papillary thyroid carcinoma with lymph node metastases
Syncope due to recurrent polymorphic ventricular tachycardia
CAD s/p CABG
Diabetes mellitus type II
HTN
PVD
carotid stenosis s/p left CEA
Rheumatoid arthritis
Factor V Leiden
Depression
Iron deficiency anemia
Hypothyroidism
s/p cholecystectomy
Interstitial lung disease
Restless leg syndrome
hemicolectomy in ___ secondary to ischemic colitis with end
colostomy
Social History:
___
Family History:
Her son had a papillary thyroid cancer that was removed. Her
sister has a rare throat cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 98.8 BP 142/70 HR 76 RR 16 Wt 71 kg
General: Alert, orientedx3, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bibasilar crackles
CV: Regular rate and rhythm, normal S1 + S2, faint ___ systolic
murmur no rubs, gallops
Abdomen: midline scars, left-sided ostomy with brown stool,
soft, non-distended, tender to deep palpation of right lower
quadrant, no rebound or guarding
Ext: Warm no clubbing, cyanosis or edema
Neuro: A+Ox3, power -___ in ___, 4+/5 in UE's. CN ___ grossly
intact
DISCHARGE PHYSICAL EXAM:
Vitals: Afebrile, VSS, BP 118/42
General: Alert, orientedx3, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bibasilar crackles
CV: Regular rate and rhythm, normal S1 + S2, faint ___ systolic
murmur no rubs, gallops
Abdomen: midline scars, left-sided ostomy with black stool,
soft, non-distended, tender to deep palpation of right lower
quadrant, no rebound or guarding
Ext: Warm no clubbing, cyanosis or edema
Neuro: A+Ox3, power -___ in ___, 4+/5 in UE's. CN ___ grossly
intact
Pertinent Results:
ADMISSION:
___ 10:00PM BLOOD WBC-9.4 RBC-3.75* Hgb-9.9* Hct-31.2*
MCV-83 MCH-26.4* MCHC-31.7 RDW-17.1* Plt ___
___ 10:00PM BLOOD Neuts-72.7* ___ Monos-5.2 Eos-1.0
Baso-0.5
___ 10:20PM BLOOD ___ PTT-30.1 ___
___ 10:00PM BLOOD Glucose-134* UreaN-25* Creat-1.4* Na-135
K-5.4* Cl-100 HCO3-25 AnGap-15
___ 10:00PM BLOOD ALT-15 AST-18 AlkPhos-76 TotBili-0.2
___ 10:00PM BLOOD Lipase-38
___ 10:00PM BLOOD Albumin-3.6 Calcium-9.1 Phos-4.7* Mg-2.3
___ 10:31PM BLOOD Lactate-1.5
___ 10:51PM BLOOD Lactate-1.3 K-5.4*
___:12AM URINE Color-Yellow Appear-Cloudy Sp ___
___ 03:12AM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 03:12AM URINE RBC-25* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
___ 03:12AM URINE WBC Clm-MANY
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SECOND
MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- =>32 R =>32 R
CEFAZOLIN------------- 16 R 16 R
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ =>16 R =>16 R
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I <=16 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ 4 S 4 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
Blood Culture, Routine (Final ___: NO GROWTH.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
EKG:
Sinus arrhythmia at a rate of 63. Non-specific intraventricular
conduction delay. Delayed R wave progression in the precordial
leads. Possibe prior anteroseptal myocardial infarction,
although could be a normal variant. Diffuse non-specific ST-T
wave abormalities. Compared to the previous tracing of ___ no
significant change
CXR:
IMPRESSION:
1. No pneumoperitoneum.
2. Mild cardiomegaly with chronic interstitial scarring.
CT ABDOMEN & PELVIS:
IMPRESSION:
1. Wall thickening of the transverse colon leading up to the
ostomy consistent with colitis.
2. No small bowel obstruction or other acute pathology.
3. Severe atherosclerotic calcifications of superior mesenteric
artery
stenosis, similar to prior.
HOSPITALIZATION & DISCHARGE:
___ 11:10AM BLOOD WBC-8.5 RBC-3.39* Hgb-8.7* Hct-28.8*
MCV-85 MCH-25.7* MCHC-30.3* RDW-16.7* Plt ___
___ 09:20PM BLOOD WBC-6.9 RBC-3.36* Hgb-8.7* Hct-28.1*
MCV-84 MCH-25.8* MCHC-30.8* RDW-16.8* Plt ___
___ 05:40AM BLOOD WBC-6.6 RBC-3.44* Hgb-8.8* Hct-29.0*
MCV-84 MCH-25.7* MCHC-30.5* RDW-16.7* Plt ___
___ 05:30AM BLOOD WBC-6.5 RBC-3.31* Hgb-8.4* Hct-27.8*
MCV-84 MCH-25.5* MCHC-30.3* RDW-16.9* Plt ___
___ 06:35AM BLOOD WBC-5.3 RBC-3.48* Hgb-8.9* Hct-28.8*
MCV-83 MCH-25.6* MCHC-30.9* RDW-17.0* Plt ___
___ 03:00PM BLOOD Hct-29.5*
___ 06:00AM BLOOD WBC-4.9 RBC-3.63* Hgb-9.6* Hct-29.9*
MCV-82 MCH-26.6* MCHC-32.3 RDW-17.2* Plt ___
___ 05:06PM BLOOD WBC-5.9 RBC-3.88* Hgb-9.9* Hct-32.5*
MCV-84 MCH-25.4* MCHC-30.4* RDW-17.1* Plt ___
___ 05:10AM BLOOD WBC-5.1 RBC-3.54* Hgb-9.2* Hct-29.5*
MCV-83 MCH-26.1* MCHC-31.2 RDW-17.6* Plt ___
___ 06:50AM BLOOD WBC-5.3 RBC-3.70* Hgb-9.8* Hct-30.9*
MCV-84 MCH-26.4* MCHC-31.6 RDW-17.7* Plt ___
___ 05:40AM BLOOD ___ PTT-29.1 ___
___ 05:30AM BLOOD ___ PTT-29.3 ___
___ 06:35AM BLOOD ___ PTT-29.2 ___
___ 06:00AM BLOOD ___ PTT-29.7 ___
___ 05:10AM BLOOD ___ PTT-28.6 ___
___ 06:50AM BLOOD ___ PTT-28.3 ___
___ 11:10AM BLOOD Glucose-106* UreaN-18 Creat-1.3* Na-135
K-4.1 Cl-99 HCO3-28 AnGap-12
___ 05:40AM BLOOD Glucose-77 UreaN-14 Creat-1.2* Na-140
K-4.3 Cl-103 HCO3-30 AnGap-11
___ 05:30AM BLOOD Glucose-101* UreaN-14 Creat-1.2* Na-136
K-3.4 Cl-99 HCO3-31 AnGap-9
___ 06:35AM BLOOD Glucose-85 UreaN-9 Creat-1.0 Na-141 K-4.1
Cl-105 HCO3-28 AnGap-12
___ 06:00AM BLOOD Glucose-113* UreaN-7 Creat-0.9 Na-138
K-3.5 Cl-98 HCO3-29 AnGap-15
___ 05:10AM BLOOD Glucose-122* UreaN-9 Creat-1.1 Na-137
K-3.8 Cl-99 HCO3-29 AnGap-13
___ 06:50AM BLOOD Glucose-117* UreaN-15 Creat-1.2* Na-143
K-3.9 Cl-103 HCO3-31 AnGap-13
___ 11:10AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.1
___ 05:40AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.1
___ 05:30AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.8
___ 06:35AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.8
___ 06:00AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.8
___ 05:10AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.3
___ 06:50AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.2
CTA:
IMPRESSION:
1. Extensive atherosclerotic calcification of the abdominal
aorta and its
branches as described above, moderate stenosis at the origin of
celiac artery and the SMA. Mild stenosis at the origin of renal
arteries.
2. Persistent thickening of the transverse colon leading up to
the ostomy in keeping with colitis. No adverse interval change
since recent CT examination of ___.
Brief Hospital Course:
___ yo female with CAD s/p CABG, polymorphic VT,
diabetes,ischemic colitis s/p hemicolectomy (___), and small
bowel and colonic AVMs, ILD, PVD, admitted with abdominal pain.
#Abdominal Pain: Differential diagnosis included pain related to
chronic mesenteric ischemia vs SBO vs peptic ulcer disease vs
UTI vs GI infection. CT scan on admission showed no definite
SBO, and patient had good output from ostomy. Hepatobiliary
etiology was unlikely given normal LFTs. Pancreatitis was also
unlikely given normal lipase. Lactate was within normal limits.
CT abdomen/pelvis showed bowel wall thickening of the transverse
colon leading up to the ostomy consistent with colitis as well
as moderate stenosis of the SMA (which was stable from a prior
CTA in ___. General surgery evaluated patient in the
emergency room and recommended NPO with IVF, admission to
medicine. Cdiff and stool culture were negative making GI
infection unlikely. Vascular surgery was consulted and
recommended a CTA which showed atherosclerotic calcification of
the aorta and its branches as well as moderate stenosis of the
SMA and celiac. Vascular surgery advised that surgery and stent
placemetn was not indicated. They advised that patient's
abdominal pain is most likely related to chronic mesenteric
ischemia caused by a low flow state which was likely
precipitated by dehydration (and possibly UTI as well). Patient
received tylenol for pain control. Her diet was advanced and she
was able to take PO by the time of discharge. Nutrition was
consulted and recommended Scandishake supplements with meals.
# ? GIB: Patient reportedly had 30 mL of bright red blood in
ostomy bag per ___. On presentation to the ED, she
had brown guaiac positive stool in bag. During the course of her
hospitalization, her stools became black and guaiac positive.
She does have significant history of ischemic colitis requiring
hemicolectomy and known colonic and small bowel AVMs. It is most
likely that her ischemic colitis or AVMs are the source. GI was
called and advised that a scope would not be indicated in the
case of mesenteric ischemia. She was initially started on IV
pantoprazole BID and was transitioned back to an oral PPI. Her
hemoglobin/hematocrit were monitored closely and remained
stable.
# UTI: Patient reported a history of increasing urinary
frequency on admission. It is possible that UTI precipitated
exacerbation of chronic mesenteric ischemia. Given age and DM,
treated patient for a complicated UTI with 7 days of ceftriaxone
1 gm IV daily. Her urine culture grew E. coli which was
sensitive to ceftriaxone. Blood cultures were negative.
#Anemia: Patient has history of iron deficiency anemia, ischemic
colitis s/p hemicolectomy (___), and small bowel and colonic
AVMs visualized on enteroscopy which are all potential
etiologies of her anemia. Hct remained around patient's baseline
(29) throughout her hospitalization. She was continued on her
B12 and ferrous sulfate supplements.
# CKD: On review, pt's Cr ___ since ___. Cr remained at
baseline throughout her hospitalization. Her Cr was 1.4 on
admission. Her lisinopril was initially held and she received IV
fluids. Her Cr trended down to 1.1-1.2 with adequate fluid
resuscitation and PO intake.
#h/o Polymorphic VTach: Patient was continued on amiodarone 200
mg every other day.
#Diabetes mellitus: Patient is not on insulin or anti-diabetic
agent at home and blood sugars were well-controlled during
hospitalization on a humalog sliding scale(ranging 100-170s).
#Hypothyroidism: Patient was continued on home levothyroxine.
#CAD and PVD, HTN, HLD: Patient has a significant history of
cardiac disease. S/p CABG many years ago. She denies any chest
pain throughout the course of her hospitalization. Her home
lisinopril 5 mg PO daily was initially held given Cr of 1.4 but
was restarted when Cr trended down to baseline of 1.1-1.2. She
was continued on home simvastatin. She was started on aspirin
81 mg daily as the cardioprotective effects likely outweigh the
risk of GI bleeding.
#Rheumatoid arthritis: Patient was continued on home
prednisone. She received pain control with tylenol. She was
not requiring her home oxycodone 5 mg daily so this was
discontinued during her hospitalization. She was continued on
her home oxycodone 2.5 mg PO Q6H prn.
#GERD: Patient was initially started on pantoprazole IV BID but
was transitioned to omeprazole 40 mg PO daily. She will continue
her home omeprazole 40 mg PO BID after discharge.
#Depression: Patient was continued on home mirtazapine and
venlafaxine.
#Hyperlipidemia: Patient was continued on home statin.
# CONTACT: son ___ ___ cell ___
TRANSITIONAL ISSUES:
-Please ensure patient takes good PO
-Please monitor abdominal pain
-Please continue to address goals of care with patient and her
family (son ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amiodarone 200 mg PO QOD
3. Bisacodyl ___AILY:PRN constipation
4. Cyanocobalamin 1000 mcg PO DAILY
5. Ferrous Sulfate 325 mg PO TID
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Milk of Magnesia 30 mL PO DAILY:PRN constipation
9. Simvastatin 10 mg PO DAILY
10. Venlafaxine XR 37.5 mg PO DAILY
11. Mirtazapine 15 mg PO HS
12. Omeprazole 40 mg PO BID
13. Ondansetron 4 mg PO Q8H:PRN nausea
14. PredniSONE 5 mg PO DAILY
15. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral BID
16. Multivitamins 1 TAB PO DAILY
17. Simethicone 40 mg PO BID
18. OxycoDONE (Immediate Release) 5 mg PO DAILY
19. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amiodarone 200 mg PO QOD
3. Cyanocobalamin 1000 mcg PO DAILY
4. Ferrous Sulfate 325 mg PO TID
5. Levothyroxine Sodium 125 mcg PO DAILY
6. Mirtazapine 15 mg PO HS
7. Multivitamins 1 TAB PO DAILY
8. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
9. PredniSONE 5 mg PO DAILY
10. Simvastatin 10 mg PO DAILY
11. Venlafaxine XR 37.5 mg PO DAILY
12. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral BID
13. Lisinopril 5 mg PO DAILY
14. Milk of Magnesia 30 mL PO DAILY:PRN constipation
15. Omeprazole 40 mg PO BID
16. Ondansetron 4 mg PO Q8H:PRN nausea
17. Simethicone 40 mg PO BID:PRN gas, stomach upset
18. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: mesenteric ischemia, urinary tract infection
Secondary diagnoses: anemia, chronic kidney disease, diabetes
mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___ was a pleasure caring for you at ___. You were admitted
with abdominal pain which has been going on for the past 6
months but has gotten worse recently. You also had blood in
your ostomy bag. You had a CT scan that showed some
inflammation of your bowel and some blockage of one of the
arteries supplying your bowel. You were followed by the
vascular surgeons who advised that there was no need for a
surgery and recommended that you stay hydrated. You also had a
urinary tract infection which was treated during your
hospitalization.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Please keep your follow-up appointments as below.
Please return to the emergency room if you experience fevers,
chills, worsening abdominal pain, inability to eat, blood in
your stools or dark black stools, or any other new or concerning
symptoms.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
10872930-DS-38
| 10,872,930 | 24,252,714 |
DS
| 38 |
2115-11-09 00:00:00
|
2115-11-09 12:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine / Celexa / Dilaudid / Ambien / Methotrexate /
citalopram / Zolpidem
Attending: ___.
Chief Complaint:
"cold"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female ___ hx of ischemic colitis, s/o hemicolectomy and
ostomy in ___, GI bleeds, AVMs, CABG here from ___ for weakness,
diarrhea. pt was discharged from ___ on ___ with a diagnosis
of GI bleed. She was on cipro and flagyl for possible
infectious colitis. She had a hx of c.diff in the past, but on
___ was negative.
Pt reports that today after breakfast she started haivng
problems. She felt cold, weak, tired. She was noted by the ___
staff to be having profuse diarrhea, watery. She reports that
she has some abd soreness and that she had some vomiting earlier
today and has nausea now. Pt denies cp, sob, cough,
lightheadness. She reports that she has been drinking lots of
water here. She denies fevers, shakes. Reports poor appetite
since this AM.
In the ED, liquid ostomy output, Hemeoccult +, but not grossly
bloody
ROS- 10 systems reviewed and are negative except where noted in
the HPI above.
Past Medical History:
CAD s/p CABG
Carotid stenosis s/p left CEA
Cataract surgery
Rheumatoid arthritis
? h/o Clostridium difficle colitis, suspected
Depression
Diabetes mellitus type II
Factor V Leiden
L Hemicolectomy in ___ ischemic colitis with end
colostomy
Hypertension
Hypothyroidism
Interstitial lung disease
Iron deficiency anemia
Papillary thyroid carcinoma with lymph node metastases
Peripheral vascular disease
Restless leg syndrome
S/p cholecystectomy
Syncope due to recurrent polymorphic ventricular tachycardia
Social History:
___
Family History:
per OMR: 1 son with hx of papillary thyroid cancer.
Sister has rare throat cancer.
Physical Exam:
Admission Exam:
Afeb, VSS
Cons: NAD, lying in bed, elderly frail appearing
Eyes: EOMI, surgical pupils, no scleral icterus
ENT: tachy MM
Cardiovasc: rrr, ii/vi SEM no edema
Resp: CTA B, decreased BS B at bases
GI: +bs,soft, diffuse TTP, liquid green watery stool
vomited a few times during exam, nonbloody, nonbilious
MSK: no significant kyphosis, +ulnar deviation B
Skin: no rashes
Neuro: no facial droop
Psych: full range of affect
Discharge Exam:
As above with the following exceptions:
GI: Soft, very mildly TTP in RLQ, brown ostomy output
Pertinent Results:
___ 07:26PM LACTATE-1.3
___ 07:00PM GLUCOSE-149* UREA N-17 CREAT-1.5* SODIUM-139
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-24 ANION GAP-12
___ 07:00PM estGFR-Using this
___ 07:00PM WBC-19.8*# RBC-3.52* HGB-9.9* HCT-31.8*
MCV-90 MCH-28.2 MCHC-31.2 RDW-16.0*
___ 07:00PM NEUTS-87.3* LYMPHS-7.4* MONOS-4.1 EOS-0.7
BASOS-0.5
___ 07:00PM PLT COUNT-344#
___ 07:00PM ___ PTT-27.5 ___
Discharge Labs:
___ 06:50AM BLOOD WBC-5.3 RBC-3.75* Hgb-10.5* Hct-32.9*
MCV-88 MCH-28.0 MCHC-32.0 RDW-15.9* Plt ___
___ 06:40AM BLOOD Glucose-83 UreaN-11 Creat-0.9 Na-137
K-4.0 Cl-101 HCO3-27 AnGap-13
Micro:
C.diff negative, stool cultures negative, UCx with mixed flora,
BCx from ___ NGTD
Brief Hospital Course:
___ with complicated PMH including CAD s/p CABG, Carotid
stenosis s/p left CEA, PVD, DMII, HTN, RA on chronic prednisone,
Factor V Leiden, L Hemicolectomy in ___ ischemic colitis
with end colostomy, ILD, iron deficiency anemia, papillary
thyroid carcinoma with lymph node metastases, and h/o syncope
due to recurrent polymorphic ventricular tachycardia now p/w
weakness, vomiting and diarrhea. Of note, patient was recently
hospitalized for a GI bleed and was given a course of
Cipro/Flagyl out of concern for infectious colitis. WBC on
admission 19.8, up from 5 on discharge ___.
1. Vomiting, diarrhea: ?A viral gastroenteritis that is slowly
resolving. C.diff negative on admission, stool cultures negative
as well. Symptoms have resolved with conservative management,
with mild residual nausea. Last dose of Cefepime given the
morning of ___ afebrile with normal WBC now for 24 hours
off of antibiotics.
2. Acute renal failure: Likely pre-renal given N/V/D on
presentation and resolution with IVF. Now back to baseline.
3. CAD s/p CABG; PVD; HTN: Continuing home aspirin and
simvastatin; patient not on anti-hypertensives as an outpatient
as Lisinopril had been held at her recent discharge. ___ be
re-started at PCP's discretion if blood pressures increase.
Chronic Issues:
4. H/O Polymorphic VT: Continuing home amiodarone qOD.
5. Rheumatoid Arthritis: Continuing home Prednisone 5mg.
6. DMII: No longer on medication for this; at previous admission
did not require ISS
7. Hypothyroidism: Continue home levothyroxine
8. Depression: continue Effexor and Remeron
9. Code Status: DNR, pt with home DNR order
Transitional Issues:
BCx pending at time of discharge, no growth x 4 days
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amiodarone 200 mg PO EVERY OTHER DAY
3. Aspirin 81 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Levothyroxine Sodium 125 mcg PO DAILY
6. Mirtazapine 15 mg PO HS
7. Multivitamins 1 TAB PO DAILY
8. PredniSONE 5 mg PO DAILY
9. Simvastatin 10 mg PO DAILY
10. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
11. Venlafaxine XR 37.5 mg PO DAILY
12. Bisacodyl 10 mg PO DAILY:PRN constipation
13. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral tid
14. Ferrous Sulfate 325 mg PO TID
15. TraZODone 50 mg PO HS:PRN sleep
16. Tobramycin-Dexamethasone Ophth Oint 1 Appl LEFT EYE QID
17. Fleet Enema ___AILY:PRN constipation
18. Milk of Magnesia 30 mL PO Q6H:PRN constipation
19. Omeprazole 40 mg PO BID
20. Ondansetron 4 mg PO Q8H:PRN nausea
21. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
22. Simethicone 40 mg PO QID:PRN gas
Discharge Medications:
1. Amiodarone 200 mg PO EVERY OTHER DAY
2. Aspirin 81 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Levothyroxine Sodium 125 mcg PO DAILY
5. Mirtazapine 15 mg PO HS
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 40 mg PO BID
8. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
9. PredniSONE 5 mg PO DAILY
10. Simethicone 40 mg PO QID:PRN gas
11. Tobramycin-Dexamethasone Ophth Oint 1 Appl LEFT EYE QID
12. Venlafaxine XR 37.5 mg PO DAILY
13. TraZODone 50 mg PO HS:PRN sleep
14. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
15. Simvastatin 10 mg PO DAILY
16. Acetaminophen 650 mg PO Q6H:PRN pain
17. Bisacodyl 10 mg PO DAILY:PRN constipation
18. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral tid
19. Ferrous Sulfate 325 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Viral infection
Rheumatoid Arthritis
Diabetes Mellitus
Coronary Artery Disease (heart disease)
Vascular Disease (build up of plaque in your arteries in your
abdomen and elsewhere)
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted with vomiting and loose stool output from your
ostomy bag. You also had fevers and elevation in your white
blood cell count, signaling an infection. However, we did not
find any bacterial infection in your urine, blood or stool. A
CT scan did not show any infection. We suspect that your
symptoms may have been from a virus that has run its course.
Followup Instructions:
___
|
10872930-DS-40
| 10,872,930 | 25,905,510 |
DS
| 40 |
2117-10-12 00:00:00
|
2117-10-14 20:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine / Celexa / Dilaudid / Ambien / Methotrexate /
citalopram / Zolpidem
Attending: ___.
Chief Complaint:
Hypoxia and RUQ pain.
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ year old female with a past medical history of ischemic
colitis s/p hemicolectomy and ostomy, diabetes type 2,
rheumatoid arthritis on chronic prednisone, ILD, Factor V
Leiden, papillary thyroid s/p total thyroidectomy, afibl, CAD
s/p CABG, PVD, recurrent GIB and AVMs who presents from ___
___ rehab for concern of hypoxia and acute RUQ.
Patient is a poor historian. Much of history taken from ___
___ records, collaborative history from ___
___, the patient's son.
Per ___ RN, that patient was in her usual state of
health until she was found to be awake at 2am, an usual hour for
her. When asked why she complained of abdominal pain. Bedside VS
notable for sat 72% on RA. Patient was given tramadol with no
relief of pain and sent to ___ ED. Collateral information from
RN -- no stools had been soft, formed and brown. Recently turned
watery melanotic quality, unclear for what duration. Nursing was
unable to comment on recent abdominal pain apart from acute RUQ
pain on ___.
At ___ initial VS 97.4 62 136/36 18 99%4L
Exam notable for: guaic positive black stool, ABD tender
greatest in RLQ
- Exam notable for: guaic positive black stool, ABD tender
greatest in RLQ
- Labs notable for:leukocytosis (12.6), anemia (10.6 Hgb), mild
transaminitis (AST 43), lytes WNL (Cr 1.1), P 5.2, proBNP 763,
tropT negative, lactate WNL.
- Imaging notable for:
CXR: with left retrocardiac opacity ?pleurla effusion v
consolidation; increased interstitial markings
CT torso: no e/o PE; no acute cause for RLQ pain. persistent
havy calcifications and severe stenosis of SMA, stable from
prior. Enlarging R hepatic dome lesion from 3.9 from 2.1. And
new 1.7 cm R thyroid nodule
- Pt given:
___ 06:56 PO/NG Levothyroxine Sodium 125 mcg
___
___ 08:30 PO/NG Amiodarone 200 mg ___
___ 08:30 PO Omeprazole 40 mg ___
___ 08:30 PO/NG Furosemide 20 mg ___
___ 08:30 IV Levofloxacin 750 mg ___
___ 09:36 IVF 1000 mL NS ___ Started 250
mL/hr
- Vitals prior to transfer: 98.2 79 128/36 24
On arrival to the floor, pt reports no pain at rest. She changes
her history with repeated interviews. Sometimes she reports pain
with eating, other times denies. She states that abd pain has
been occurring for the last 3 days. States that her melanotic
stool is longstanding. Denies ever having chest pain or chest
pressure. Denies ever having SOB. Denies fever, chills, cough.
Denies acute weight gain, PND, orthopnea, leg swelling. Denies
rash. Remaining systems reviewed, but unreliable due to
dementia
Past Medical History:
- CAD s/p CABG
- Carotid stenosis s/p left CEA
- Rheumatoid arthritis on prednisoine
- Recurrent polymorphic ventricular tachycardia
- Depression
- Diabetes mellitus type II
- Factor V Leiden
- Ischemic colitis s/p L Hemicolectomy with end colostomy
(___)
- Hypertension
- Hypothyroidism
- Interstitial lung disease
- Iron deficiency anemia
- Papillary thyroid carcinoma with lymph node metastases
- Peripheral vascular disease
- Restless leg syndrome
- S/p cholecystectomy
- h/o suspected Clostridium difficle colitis
- h/o Cataract surgery
Social History:
___
Family History:
Patient has four adult sons, 2 live nearby. 1 son with hx of
papillary thyroid cancer. Sister has rare throat cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
Vitals: 98.6 PO 116 / 34 81 16 92 3L NC
General: AAOx2, does not know the date. States Year is ___.
Somnolent but awakens easily ;
HEENT: JVP ~11; PERRL, +conjunctival pallor
LUNGS -- auscultated anterior, scattered crackles; ++orthopnea
ABD- +++TTP at RUQ and epigastrum; ostomy watery black stool;
voluntary guarding, no rebound; normoactive bowel sounds
EXREM- no edema
VASC- 1+ DP/radial pulses;
PSYCH- appropriate
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 98.1 141/45 82 20 95% RA
I/O: Today: 0/inc
___
Exam:
General: AAOx2, easily engaged and appropriate with interviwer.
LUNGS: Bibasilar crackles, clears with cough
CARD: Regular rate and rhythmn, no m/r/g
ABD: Soft, nontender, no distension, ostomy with gas and large
amount of dark green stool, soft, unformed
GU: No foley
EXREM: No peripheral edema, 1+ DP pulses
Neuro: cranial nerves grossly intact
Pertinent Results:
ADMISSION LABS
--------------
___ 05:00AM GLUCOSE-105* UREA N-19 CREAT-1.1 SODIUM-137
POTASSIUM-4.7 CHLORIDE-94* TOTAL CO2-32 ANION GAP-16
___ 05:00AM WBC-12.6*# RBC-4.08 HGB-10.6* HCT-35.8 MCV-88
MCH-26.0 MCHC-29.6* RDW-16.3* RDWSD-52.5*
___ 05:00AM PLT COUNT-303
___ 05:00AM cTropnT-<0.01
___ 05:00AM proBNP-763*
___ 05:00AM ALT(SGPT)-11 AST(SGOT)-43* ALK PHOS-94 TOT
BILI-0.1 DIR BILI-0.0 INDIR BIL-0.1
___ 05:00AM ___ PTT-28.5 ___
SIGNIFICANT LABS
----------------
___ 09:50PM BLOOD ___ pO2-180* pCO2-62* pH-7.33*
calTCO2-34* Base XS-4
___ 12:11AM BLOOD ___ pO2-164* pCO2-69* pH-7.31*
calTCO2-36* Base XS-5 Comment-GREEN TOP
___ 04:05AM BLOOD ___ pO2-133* pCO2-70* pH-7.30*
calTCO2-36* Base XS-6 Comment-GREEN TOP
___ 09:55AM BLOOD ___ pO2-175* pCO2-69* pH-7.33*
calTCO2-38* Base XS-7 Comment-GREEN TOP
DISCHARGE LABS
--------------
___ 05:08AM BLOOD WBC-8.3 RBC-3.71* Hgb-9.3* Hct-31.5*
MCV-85 MCH-25.1* MCHC-29.5* RDW-15.3 RDWSD-47.3* Plt ___
___ 05:08AM BLOOD Glucose-104* UreaN-16 Creat-0.8 Na-139
K-3.8 Cl-96 HCO3-33* AnGap-14
___ 05:25AM BLOOD ALT-8 AST-14 AlkPhos-82 TotBili-0.2
___ 05:08AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.0
SIGNIFICANT MICRO
-----------------
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
___ STOOL C. difficile DNA amplification
assay-negative; FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL
negative
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
SIGNIFICANT IMAGING
-------------------
___ CTA A/P
A heterogeneous right hepatic dome lesion is larger, measuring
3.9 cm
compared with 2.1 cm previously. Previously, this was described
as a
hemangioma. However, further characterization should be
performed with
nonemergent liver MRI, as this lesion is worrisome for
malignancy. 1.7 cm right thyroid nodule, for which nonemergent
thyroid ultrasound may be obtained, if no characterization has
been performed previously.
___ MRI LIVER W/WO CONTRAST
Growing hepatic dome lesion demonstrates features worrisome for
a metastatic lesion, which cannot be further characterized.
While this lesion would be amenable to ultrasound guided biopsy,
consideration for sonographic evaluation of lesion adjacent to
the right thyroid lobe as described on CT dated ___ is
advised as this may potentially reflect an abnormal lymph node,
versus thyroid nodule. Screening for primary site of malignancy
not otherwise identified on imaging is recommended.
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
Compared to chest radiographs since ___ most recently one
___.
Patient has had median sternotomy and at least coronary bypass
grafting.
Radiographic appearance is unchanged since ___, including
chronic left lower lobe atelectasis and small left pleural
effusion. Heart is moderately enlarged. There is no pulmonary
edema.
Brief Hospital Course:
This is an ___ year old female resident ___ with a
past medical history of ischemic colitis s/p hemicolectomy and
ostomy, diabetes type 2, rheumatoid arthritis on chronic
prednisone, ILD, Factor V Leiden, papillary thyroid carcinoma,
who was admitted for hypoxia and acute RUQ pain.
BRIEF HOSPITAL COURSE
=========================
ACTIVE ISSUES
# ACUTE HYPOXIC RESPIRATORY FAILURE: Multifactorial thought ___
to HAP and CHF exacerbation. Initially admitted with WBC (12),
CTA with evidence of pulmonary edema, no PE, BNP 730,
hypervolemic on exam She was initially treated with gentle IF
furosemide boluses and levofloxacin. Given her continued
hypoxia, her antibiotics were broadened to vancomycin and
cefepime. She improved with narrowing to cefepime. She should
continue an 8 day course with cefpodoxime and azithromycin. She
continued to require occasional oxygen overnight but was easily
weaned during the day with mobilization to a chair. Outpatient
providers might consider evaluating her for CPAP.
# ACUTE ON CHRONIC CONGESTIVE HEART FAILURE: see above.
Discharged on home dose furosemide 20mg daily. Please uptitrate
as necessary
# HAP PNEUMONIA: Patient initially treated with levofloxacin,
broaded to vancomycin/cefepime given altered mental status and
persistent hypoxia. Narrowed to cepodoxime and azithromycin on
discharge. Patieint to complete 8 day course from d1 of
broadening to vancomycin/cefepime
# RUQ Abdominal Pain/Metastatic Liver lesion: On admission she
was complaining of RUQ pain and tenderness to palpation;
physical exam c/f focal RUQ with voluntary guarding. Given her
extensive GI history CTA on arrival performed which
redemonstrated severe peripheral artery disease, but otherwise
negative for acute process and normal lactate. negative for
acute process. A CT scan on admission demonstrated interval
growth of a previously 2.1cm R hepatic dome lesion to 3.9cm. A
subsequent MRI further characterized the lesion as worrisome for
a metastatic lesion, which could not be further characterized.
Ms. ___ and ___ son opted to defer making a decision
about biopsy or evaluation for the primary tumor. Outpatient
follow-up with her PCP to discuss options of care encouraged. At
time of discharge, abdominal pain resolved.
# METABOLIC ENCEPHALOPATHY: Her hospital course was complicated
by intermittent altered mental status including somnolence and
disorientation. During an acute episode of delirium her
antibiotics were broadened from levofloxacin to
vancomycin/cefepime; she was also found to have hypercarbia. She
returned to her baseline mental status with continued pCO2 on
VBG at 70; CTA on admission ruled out PE. her mental status was
stable with conversion of quinolone to cephalosporin and
delirium precautions.
# DARK STOOLS: On admission, she reported that she had been
having dark stools for an unclear period of time, and her stools
were found to be guaiac positive. She was started on an IV
proton pump inhibitor, but her hemoglobin downtrended only
slightly before becoming stable, at which point she was switched
back to her home omeprazole. At the time of discharge, her
hemoglobin remained stable.
CHRONIC ISSUES
# PERIPHERAL ARTERY DISEASE
On a CT angiogram of her abdomen she was found to have ongoing,
severe peripheral artery disease. She had no evidence of
occlusion on that CTA and a normal lactate. Her systolic blood
pressure was maintained >100 during her admission.
# HISTORY OF VENTRICULAR TACHYCARDIA: She has a noted history of
ventricular tachycardia. She was continued on her home regimen
of amiodarone, and had her potassium and magnesium maintained
above 4 and 2, respectively. She had no documented arrhythmias
during her admission.
# H/O LUNG NODULES: Her previously noted lung nodules were
found on a CT on admission to be stable from ___.
# CORONARY ARTERY DISEASE: She has a documented history of
coronary artery disease. During her admission she was maintained
on her home regimen of ASA and statin. Beta blockers and ACEi
deferred on prior evaluated due to severe peripheral artery
disease and ischemic colitis.
# HYPOTHYROIDISM: During her admission she was maintained on her
home regimen of levothyroxine.
# GERD: She has a documented history of GERD. During her
admission she was initially treated with an IV proton pump
inhibitor as described above, but eventually switched back to
her home regimen of omeprazole.
# RHEUMATOID ARTHRITIS: During her admission she was maintained
on her home regimen of prednisone.
# DEPRESSION: During her admission she was maintained on her
home regimen of trazodone, and mirtazapine. Venlafaxine was
fractionated during this admission.
# DIABETES TYPE 2: She has a documented history of
diet-controlled diabetes. During her admission she was started
on a Humalog sliding scale with a goal blood glucose <180.
TRANSITIONAL ISSUES
-------------------
[ ] Continue Cefpodoxime and azithromycin for 8 day course
(___) [ ] MRI with R hepatic dome lesion concerning for
malignancy; biopsy deferred this admission. GOC to be
readdressed with patient and family
[ ] ] 1.7 cm right thyroid nodule, for which nonemergent thyroid
ultrasound may be obtained; patient with history of papillary
cell carcinoma
[ ] Nighttime desaturation on room air, consider CPAP
[ ] Patient discharged on supplemental oxygen; wean as
tolerated, goal Sat >90%
[ ] Respiratory alkalosis noted this admission, please pursue
outpatient workup
CODE STATUS: DNR/DNI, confirmed
# CONTACT: ___ HCP, (h) ___ (c)
___
Admission Weight: 71.49 kg (bed weight)
Discharge weight: 51.21 (standing) UNRELIABLE
Discharge Cr: 0.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN rectal pain
2. Amiodarone 200 mg PO EVERY OTHER DAY
3. Artificial Tears 2 DROP BOTH EYES TID
4. Aspirin 81 mg PO DAILY
5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral TID
6. Ferrous Sulfate 325 mg PO DAILY
7. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB
8. Furosemide 20 mg PO DAILY
9. Levothyroxine Sodium 125 mcg PO DAILY
10. Polyethylene Glycol 17 g PO EVER 72 HOURS:PRN CONSTIAPTION
constipation
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 40 mg PO DAILY
13. PredniSONE 5 mg PO DAILY
14. Mirtazapine 22.5 mg PO QHS
15. Senna 17.2 mg PO BID
16. Simvastatin 10 mg PO QPM
17. TraMADol 50 mg PO Q8H:PRN pain
18. TraZODone 25 mg PO QHS:PRN insomnia
19. Venlafaxine XR 37.5 mg PO DAILY
20. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN rectal pain
2. Aspirin 81 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Mirtazapine 22.5 mg PO QHS
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 40 mg PO DAILY
10. PredniSONE 5 mg PO DAILY
11. Simvastatin 10 mg PO QPM
12. TraZODone 25 mg PO QHS:PRN insomnia
13. Venlafaxine XR 37.5 mg PO DAILY
14. Amiodarone 200 mg PO EVERY OTHER DAY
15. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB
16. Artificial Tears 2 DROP BOTH EYES TID
17. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral TID
18. Polyethylene Glycol 17 g PO EVER 72 HOURS:PRN CONSTIAPTION
constipation
19. Senna 17.2 mg PO BID
20. TraMADol 50 mg PO Q8H:PRN pain
21. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 1 Day
Continue taking this antibiotic after your discharge.
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*8
Tablet Refills:*0
22. Azithromycin 500 mg PO Q24H Duration: 1 Day
Continue taking this antibiotic after your discharge.
RX *azithromycin 500 mg 1 tablet(s) by mouth twice a day Disp
#*8 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
--___ Associated Pneumonia
Congestive Heart Failure
Metastatic Cancer, Unknown Primary
Abdominal Pain
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 ___,
___ were admitted to the hospital because ___ were short of
breath and ___ had pain in your stomach. ___ were treated with
diuretics and antibiotics, and your breathing improved. ___
should continue antibiotics.
Your abdominal pain resolved over time as well. Likely this is
due to a mark on your liver. We did an MRI to evaluate it, and
it looks like it could be cancer. We discussed this with ___ in
your son. Please discuss it further with Dr. ___ if ___
would need a biopsy.
It was a pleasure taking care of ___, and we wish ___ the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10873131-DS-15
| 10,873,131 | 24,084,438 |
DS
| 15 |
2122-06-27 00:00:00
|
2122-06-27 15:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ with afib, valvular disease, legal blindness ___ glaucoma,
RA, graves disease s/p RAI, who presents with dyspnea.
On the morning of presentation, she woke up feeling dyspneic and
had a pressure in the ___ her chest that was
non-radiating. This was associated with some nausea, but she
denies vomiting, fevers, cough. This did not improve throughout
the day so she presented to ED. She has had 2 prior such
episodes of acute dyspnea, chest pressure, a/w palpitations in
the past month, but those spontaneously resolved after a few
minutes. She has stable 2 pillow orthopnea for many years which
she attributed to a-fib, and denies any new PND. Occasionally
she will wake up "gasping" when she has a bad dream, but this
stable and not worsening. She reports her weight has been stable
around 146lbs. She has had L leg edema for the past 3 weeks
which she attributed to a L knee "cartilage injury", and 1 day
of new R leg edema. Patient moved recently from ___ and has
not established care with a new cardiologist here.
In the ED initial vitals were: 97.6 74 181/116 18 98% RA
- EKG: afib 71bpm with LBBB
- Labs/studies notable for: BNP 10k and trop neg x 1.
- Left LENIS negative for DVT and CXR showing mild pulmonary
edema.
Patient was given: ASA 325mg, 20IV Lasix, nitro SL x 1.Foley put
out 1200ml clear yellow urine.
Of note, her warfarin has been on hold per her PCP due to ___
recent mechanical fall approx. 1 week ago in which she suffered
facial bruising, but no evidence of bleed or fracture.
Past Medical History:
Hypothyroidism ___ Graves Disease s/p RAI
glaucoma (blind x ___ years)
rheumatoid arthritis
atrial fibrillation
HTN
s/p hysterectomy
Social History:
___
Family History:
Father passed away from sudden death at age ___. Mother lived to
___.
Grandmother passed away from heart attack in her ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.9 145/61 79 18 98%2L
GENERAL: Alert, oriented, legally blind, appears comfortable
speaking in full sentences
HEENT: significant proptosis bilaterally, MMM
NECK: Supple. JVP just above clavicle with bed at 45degree angle
CARDIAC: Irreg rhythm, no murmurs
LUNGS: bibasilar crackles
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: ___ LLE edema, mild erythema in L shin without
tenderness, with <1cm pre-tibial skin erosion; significant hand
and feet deformities ___ RA
Discharge Physical Exam:
T= 98.1
BP= 158/74 (118/62-176/68)
HR= 60s
RR=20
O2 sat= 100% on RA
Wt: 63.5kg standing from ___ yesterday, 66.5 standing on
admission
I/O: 24hr: 1370/1618
8hr: 380/600
Telemetry: 5 sinus pauses ranging from 2.5seconds to 3.04
seconds, with HRs in the ___.
GENERAL: Patient lying in bed, no acute distress, Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 6 cm.
CARDIAC: Irregularly irregular rhythm, normal S1, S2. No m/r/g.
LUNGS: Crackles halfway up the lungs bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominal bruits.
EXTREMITIES: trace pitting edema; Hand deformities due to RA,
more extreme on the right hand than the left hand
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Admission Labs
___ 11:30AM BLOOD WBC-8.0 RBC-3.88* Hgb-10.8* Hct-36.1
MCV-93 MCH-27.8 MCHC-29.9* RDW-14.6 RDWSD-49.1* Plt ___
___ 11:30AM BLOOD Neuts-80.9* Lymphs-10.2* Monos-6.2
Eos-1.9 Baso-0.6 Im ___ AbsNeut-6.47* AbsLymp-0.82*
AbsMono-0.50 AbsEos-0.15 AbsBaso-0.05
___ 11:30AM BLOOD Plt ___
___ 11:30AM BLOOD ___ PTT-27.3 ___
___ 11:30AM BLOOD Glucose-128* UreaN-14 Creat-0.7 Na-140
K-3.8 Cl-104 HCO3-23 AnGap-17
___ 11:30AM BLOOD cTropnT-<0.01 ___
___ 11:30AM BLOOD Mg-2.2
___ 11:30AM BLOOD TSH-0.61
Discharge Labs:
___ 05:51AM BLOOD ___ PTT-36.7* ___
___ 05:51AM BLOOD Glucose-107* UreaN-21* Creat-0.8 Na-136
K-4.2 Cl-100 HCO3-26 AnGap-14
___ 02:00PM URINE RBC-2 WBC-53* Bacteri-FEW Yeast-NONE
Epi-1
___ 02:00PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG
Imaging results:
TTE ___
The left atrial volume index is severely increased. No left
atrial mass/thrombus seen (best excluded by transesophageal
echocardiography). 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.
There is mild global left ventricular hypokinesis (LVEF = 40 %).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of mitral regurgitation.] Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). There is no ventricular septal defect.
Right ventricular chamber size is normal with mild global free
wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] There is mild-moderate pulmonary artery
systolic hypertension. The end-diastolic pulmonic regurgitation
velocity is increased suggesting pulmonary artery diastolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with mild global biventricular hypokinesis.
Moderate mitral regurgitation. Mild-moderate pulmonary artery
systolic hypertension. Mild aortic regurgitation. Increased
PCWP.
Unilateral Lower Left Extremity Ultrasound ___:
No evidence of deep venous thrombosis in the left lower
extremity veins.
Cxr Pa and Lateral ___: Mild interstitial pulmonary edema
and small bilateral pleural effusions.
___ 2:00 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
Ms. ___ is a ___ lady with a PMH of a fib, mitral
regurgitation, legal blindness secondary to glaucoma, graves
disease s/p RAI, and RA who presented to ___ with dyspnea and
found to be in acute systolic heart failure.
#Acute systolic Heart Failure: No previous diagnosis. Echo
showing no appreciable change from outside echo ___ years prior
(EF 40%). However, MR severe on echo and thought to be
exacerbated by her uncontrolled HTN. She was diuresed with IV
Lasix, however remained euvolemic after initial diuresis without
the help of standing PO medications, especially once HTN control
was achieved. She was discharged on lisinopril 40mg daily,
amlodipine 5mg daily, and carvedilol 3.125mg BID.
#Afib: History of afib, anticoagulated with warfarin, but
warfarin has been held for the past 4 days due to a fall. INR on
admission 1.2. Given CHADS2 score of 3 (HTN, CHF, age) with no
indication for bridging. She was restarted on her home warfarin
dose, and her atenolol was switched to coreg for better blood
pressure control.
#HTN: History of HTN, managed at home on atenolol 75 daily. Her
atenolol was discontinued and she was started on carvedilol
3.125mg BID, amlodipine 5mg daily and lisinopril 40mg daily to
reach goal SBPs 110-120s.
___: Cr to 1.4, up from her baseline of 0.8 on admission. This
was likely secondary to overdiuresis. She was given a small IVF
bolus and her Cr returned to baseline.
#Hypothyroidism: Ms. ___ has a history of Graves disease, s/p
RAI. She was continued on her home levothyroxine dose during
this admission.
#Rheumatoid arthritis: History of RA, pain control with Tylenol
during hospitalization, with avoidance of NSAIDS.
#CAUTI: Had Catheter placed for UOP monitoring during acute
heart failure exacerbation. Complained of dysuria upon
discontinuation of catheter. UCx grew pansensitive E.coli, was
placed on CTX 1g x 3 days and then scheduled for Bactrim DS BID
x 7 days to complete course. Pyridium was added for dysuria.
Transitional Issues:
#New medications: Carvedilol 3.125mg BID, amlodipine 5mg BID,
lisinopril 40mg daily
#Changes in home medications: restarted on warfarin 2mg 6x/week
4mg 1x/week, stopped atenolol 75mg daily
#Please give Bactrim DS x 7 days for complicated UTI (last day
___
#Patient with asymptomatic ___ sinus pauses on telemetry this
admission. If becomes symptomatic, would first d/c beta-blockers
and then consider further intervention afterwards (?pacemaker)
#Continue to titrate BP meds to goal SBP 100-120 given severe MR
#Please draw INR on ___ and adjust warfarin as necessary
#Discharge weight: 63.5kg
#Patient new to the area and will establish cardiology care with
Dr. ___ at ___ internal medicine. Prior
cardiologist Dr. ___, ___ ___
#CODE: Full
#CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___)
2. Levothyroxine Sodium 200 mcg PO 2X/WEEK (MO,TH)
3. Warfarin 2 mg PO 6X/WEEK (___)
4. Warfarin 4 mg PO 1X/WEEK (MO)
5. Acetaminophen w/Codeine ___ TAB PO Frequency is Unknown
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Alphagan P (brimonidine) 0.1 % ophthalmic BID
8. Azopt (brinzolamide) 1 % ophthalmic TID
9. Atenolol 75 mg PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Carvedilol 3.125 mg PO BID
3. Lisinopril 40 mg PO DAILY
4. Phenazopyridine 100 mg PO TID Duration: 3 Days
5. Sulfameth/Trimethoprim DS 1 TAB PO BID
6. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN Pain - Mild
7. Alphagan P (brimonidine) 0.1 % ophthalmic BID
8. Azopt (brinzolamide) 1 % ophthalmic TID
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Levothyroxine Sodium 25 mcg PO 5X/WEEK (___)
11. Levothyroxine Sodium 50 mcg PO 2X/WEEK (MO,TH)
12. Warfarin 2 mg PO 6X/WEEK (___)
13. Warfarin 4 mg PO 1X/WEEK (MO)
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary diagnosis:
Acute systolic heart failure
CAUTI
Secondary Diagnosis:
Atrial Fibrillation
Hypertension
Hypothyroidism
Rheumatoid Arthritis
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 ___ on ___ after suffering from an
episode of shortness of breath and chest pressure. When you
arrived to the hospital you were found to be suffering from
heart failure and you were diuresed with IV medications. Over
the course of several days your shortness of breath improved as
volume was removed with diuresis.
You also had an echo during this hospitalization which was
largely unchanged from a prior echo ___ yrs ago. Your echo showed
severe mitral regurgitation, which can be worsened by
hypertension, and therefore your blood pressure was controlled
with two new medications.
During this hospitalization you were restarted on your warfarin
medication for your atrial fibrillation. It is important that
you continue taking this blood thinner medication on discharge
to avoid the development of a clot which could cause a stroke.
You will need to have your INR checked at rehab two days after
you leave the hospital.
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.
We have made changes to your medication list, so please make
sure to take your medications as directed. You will also need to
have close follow up with your heart doctor and your primary
care doctor.
It was a pleasure to take care of you. We wish you the best with
your health!
Your ___ Cardiac Care Team
Followup Instructions:
___
|
10873131-DS-16
| 10,873,131 | 24,279,136 |
DS
| 16 |
2123-08-05 00:00:00
|
2123-08-06 17:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weight gain, shortness of breath, leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with a past med hx of atrial fibrillation on
Coumadin, HpEF (EF 40%), mitral and aortic valve regurgitation,
rheumatoid arthritis, graves disease s/p RAI, who presents with
worsening ___ edema, dyspnea, and chest tightness.
Over the past month (___), the patient has experienced leg
swelling, L>R that has been progressive. 3 days later (___),
she
experienced new substernal chest tightness associated with
dyspnea. She was evaluated at ___ on ___, where she was
found to have an acute CHF exacerbation with a BNP elevated to
1451. She was given IV Lasix 20mg and titrated to 40mg IV during
her stay. She was discharged on Lasix 20mg PO daily.
She was well until 1 week ago (___), when she noticed a gradual
increase in LLE swelling and worsening dyspnea on exertion. At
baseline, she was able to walk 200 feet and has never required
oxygen at home. Recently, she states she can only walk about 40
feet before becoming short of breath. Over the past 3 days
(___), she began to feel dyspneic at rest, orthopneic requiring
2 pillows (which is an increase from her baseline of 1 pillow),
endorses PND, and chest tightness. She has also had a 7lbs
weight
gain over the past week and her dry weight is 150lbs.
She was seen by her primary care physician, ___
asked
her to increase her Lasix dose to 20mg BID, however this did not
alleviate her symptoms. The pt states she was told to decrease
her PO Lasix dose back to 20mg daily. She denies any recent
illnesses or travel, any dietary indiscretions (as she lives at
an ___ living ___), and endorses being compliant with
her medications.
After a continuous progression of her symptoms, she decided to
be
evaluated in the ED on ___. She denies any new symptoms.
In the ED initial vitals were:
T97.9 HR72 BP156/70 RR16 SPO294% RA
EKG: Afib with ___
Labs/studies notable for:
H/H: 10.3*/35.2
BMP: wnl
Trop-T: <0.01 X2
proBNP: ___
___: 26.7 PTT: 43.2 INR: 2.4 *
UA: wnl
LENIS: No evidence of deep venous thrombosis in the left lower
extremity veins.
CXR: No acute intrathoracic process
Patient was given:
IV Furosemide 20mg X1
Vitals on transfer:
T98.1 HR59 BP126/59 RR16 SPO298% RA
On the floor the patient continues to have chest tightness at
rest, with associated dyspnea at rest, orthopnea requiring 2
pillows, and new lightheadedness. She has occasional PND. She
denies any fevers, chills, palpitations, changes in vision,
nausea/vomiting, abdominal pain, rashes, constipation.
REVIEW OF SYSTEMS:
10 point ROS otherwise negative
Past Medical History:
1. CARDIAC RISK FACTORS
-Atrial fibrillation
-HTN
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
-Hypothyroidism ___ Graves Disease s/p RAI
-Glaucoma (blind x ___ years)
-Rheumatoid arthritis
-S/p hysterectomy
Social History:
___
Family History:
Father passed away from sudden death at age ___ from either DVT
or
MI. Mother lived to ___. Grandmother passed away from heart
attack in her ___. No FH of RA or Grave's disease.
Physical Exam:
======================
ADMISSION PHYSICAL EXAM
======================
VS: T97.5 PO BP144 / 72 HR68 RR20 SPO296 RA
Weight on Admission: 159.39 lbs
GENERAL: Legally blind. pleasant elderly female in NAD. Oriented
x3. speaks full sentences. Mood, affect appropriate.
HEENT: severe proptosis b/l. PERRLA. MMM. no conjunctival pallor
or cyanosis.
NECK: Supple with +JVD to 15cm at 45 deg with +HJR.
CARDIAC: Irregularly irregular. no m/r/g.
LUNGS: good inspiratory effort. decreased breath sounds at
bases. +crackles at posterior lung fields. No wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ edema L > R to knees. severe hand and feet
deformities from RA.
SKIN: moderate erythema in L shin without tenderness
PULSES: Distal pulses palpable and symmetric
======================
DISCHARGE PHYSICAL EXAM
======================
VS: Afebrile, 97.5 (afebrile), 137/70 (96-137/52-73), HR: 52
(50s), RR: ___, 100% RA
SO2: 98% on RA
Weight: 72.3 kg (159.39 lbs) -> 72.1 -> 72.1 -> 73 (bed) ->
74.0
kg (bed) -> 69.1 (standing) -> 69.2 -> 73.2 kg (bed)
I/O/N: ___ // 300 -300 ___
GENERAL: Legally blind. Pleasant elderly female in NAD.
HEENT: Severe proptosis b/l. MMM.
NECK: Supple with +JVD low neck.
CARDIAC: Irregularly irregular. No m/r/g.
LUNGS: Good inspiratory effort. Decreased breath sounds at
bases. +Sprase R basilar crackles. No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: RLE trace pedal edema. No LLE edema. Severe hand
and feet deformities from RA.
SKIN: No rashes noted.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
===============
ADMISSION LABS
===============
___ 01:20PM BLOOD WBC-4.9 RBC-4.03 Hgb-10.3* Hct-35.2
MCV-87 MCH-25.6*# MCHC-29.3* RDW-16.2* RDWSD-51.3* Plt ___
___ 01:20PM BLOOD Neuts-77.1* Lymphs-13.6* Monos-5.7
Eos-2.6 Baso-0.6 Im ___ AbsNeut-3.78 AbsLymp-0.67*
AbsMono-0.28 AbsEos-0.13 AbsBaso-0.03
___ 01:20PM BLOOD ___ PTT-43.2* ___
___ 01:20PM BLOOD Plt ___
___ 01:20PM BLOOD Glucose-108* UreaN-18 Creat-0.9 Na-141
K-3.4 Cl-100 HCO3-26 AnGap-15
___ 01:20PM BLOOD ALT-5 AST-12 AlkPhos-120* TotBili-0.3
___ 01:20PM BLOOD ___ 01:20PM BLOOD Albumin-3.7 Calcium-8.5 Phos-3.0 Mg-2.6
___ 01:20PM BLOOD TSH-7.8*
___ 06:40AM BLOOD Free T4-0.9*
============
IMAGING
============
TTE ___
The left atrial volume index is moderately increased. The right
atrium is moderately dilated. Left ventricular wall thicknesses
and cavity size are normal. Regional left ventricular wall
motion
is normal. Overall left ventricular systolic function is normal
(LVEF 55-60%). The right ventricular cavity is mildly dilated
with borderline normal free wall function. The diameters of
aorta
at the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. 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 moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Normal left ventricular systolic function. Mild
aortic regurgitation. Moderate mitral regurgitation. Moderate
pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
LV
function has improved. The other findings are similar.
CXR ___ IMPRESSION: No acute intrathoracic process
LLE ULTRASOUND ___ IMPRESSION: No evidence of deep venous
thrombosis in the left lower extremity veins.
===============
DISCHARGE LABS
===============
___ 06:35AM BLOOD WBC-5.9 RBC-3.67* Hgb-9.6* Hct-31.7*
MCV-86 MCH-26.2 MCHC-30.3* RDW-16.3* RDWSD-52.0* Plt ___
___ 06:35AM BLOOD Glucose-88 UreaN-49* Creat-1.3* Na-135
K-5.1 Cl-96 HCO3-25 AnGap-14
___ 06:35AM BLOOD Calcium-8.0* Phos-4.1 Mg-2.8*
Brief Hospital Course:
====================
PATIENT SUMMARY
====================
Mrs. ___ is a ___ year old F with past medical history of
atrial fibrillation onCoumadin, HFpEF (EF 40%), RA, Graves
disease s/p RAI now c/b hypothyroidism, who presented with one
week of worsening dyspnea, ___ edema, and 7 lbs of weight gain -
likely acute exacerbation of CHF in the setting of undertreated
hypothyroidism. She underwent diuresis with IV Lasix c/b mild
___ resolved with holding diuresis for 48 hours. Her discharge
weight is 73.6 kg bed weight (last standing weight 69.2 kg) with
a creatinine of 0.8 and oral diuretic regimen of Lasix 40mg
daily. She will require outpatient follow-up of creatinine and
weight by both primary care provider as well as ___ clinic here
at ___.
====================
ACUTE ISSUES
====================
#Acute on Chronic systolic heart failure: LVEF 40% prior to
admission. Mrs. ___ presented with worsening dyspnea,
orthopnea, ___ edema, and weight gain. Pro BNP ___, and on
initial exam appeared volume overloaded. Her repeat TTE
demonstrated an LVEF of 55-60%. The most likely trigger was
undertreated hypothyroidism (TSH 7.8), and as such her home dose
of Levothyroxine was increased. In terms of other potential
triggers, troponins <0.01, no recent illnesses, no dietary
indiscretions, and no medication incompliance. As such, she was
initially diuresed with IV Lasix. Diuresis held for 2 days i/s/o
___, remained euvolemic, and she was transitioned to Furosemide
40mg PO daily at discharge to be started ___. She was continued
on her home Carvedilol 3.125mg BID and Amlodipine 5mg PO daily.
She was also started on Lisinopril 5mg PO daily this admission,
which was held i/s/o ___, to be restarted ___.
#Afib: History of atrial fibrillation, anticoagulated with
warfarin. INR on admission 2.4. CHADS2 score of 3 (HTN, CHF,
age). She was continued on Warfarin, dosed daily for a goal INR
___. She was also continued on Carvedilol 3.125mg PO BID. Her
INR on discharge was 2.0.
#Acute Kidney Injury: Baseline Creatinine 0.9-1.0. Her
Creatinine peaked to 1.6, most likely in the setting of
overdiuresis. Her Creatinine at discharge was 0.8.
====================
CHRONIC ISSUES
====================
#HTN: Continued home Carvedilol 3.125 mg PO BID and AmLODIPine 5
mg PO DAILY. Started Lisinopril 5mg PO daily.
#Hypothyroidism: h/o Graves disease, s/p RAI. TSH 7.8 and FT4
0.9, and as such seemed inadequately treated. As such, her home
levothyroxine was increased from 50mcg to 75mcg PO daily. Will
need repeat TSH in ~6 weeks to be followed up with PCP.
#Rheumatoid arthritis: Not on active treatment. As such, her
pain control was continued with home Acetaminophen w/Codeine 1
TAB PO q4 hours PRN
#Glaucoma: Continued home Azopt (brinzolamide) 1 % ophthalmic
(eye) TID, Latanoprost 0.005% Ophth. Soln., and Brimonidine
Tartrate 0.15% Ophth.
#GERD: Continued on home Pantoprazole 40mg daily. Held Nexium
20mg daily. Provided Zofran and Simethicone PRN.
#Anxiety: Continued home Lorazepam 0.5 mg PO/NG TID:PRN anxiety
====================
TRANSITIONAL ISSUES
====================
[ ] DISCHARGE WEIGHT: 73.6 kg bed weight (last standing weight
69.2 kg)
[ ] DISCHARGE DIURETIC: restarted Lasix 40mg daily on ___
[ ] DISCHARGE ANTICOAGULATION: warfarin 6mg daily
[ ] FOLLOW UP LABORATORY TESTING: Recheck creatinine on ___,
two days after restarting Lasix on ___. Recheck INR ___.
[ ] Follow up TSH in ~6 weeks to determine adequacy of new dose
of Levothyroxine 75 mcg daily.
[ ] MEDICATION CHANGES:
[ ] NEW: Lisinopril 5mg daily
[ ] STOPPED: N/A
[ ] CHANGED: Furosemide 20mg changed to Furosemide 40 daily.
Levothyroxine 50mcg daily changed to 75 mcg
daily.
[ ] HELD: none
#CODE STATUS: FC
#CONTACT: ___ ___ (HCP)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Carvedilol 3.125 mg PO BID
3. amLODIPine 5 mg PO DAILY
4. Azopt (brinzolamide) 1 % ophthalmic (eye) TID
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Acetaminophen w/Codeine ___ TAB PO TID W/MEALS
7. Warfarin 2 mg PO DAILY16
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
10. Nexium 20 mg Other DAILY
11. LORazepam 0.25 mg PO QHS
12. Gas Relief (simethicone) 125 mg oral DAILY:PRN
13. Bisacodyl 10 mg PO DAILY:PRN constipation
14. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY:
#Acute exacerbation of Chronic systolic heart failure
#Atrial Fibrillation
#Acute Kidney Injury
SECONDARY:
#Hypertension
#Hypothyroidism
#Rheumatoid arthritis
#Glaucoma
#GERD
#Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ were admitted to the hospital because ___ had been feeling
short of breath and ___ were found to have fluid on your lungs.
This was felt to be due to a condition called heart failure,
where your heart does not pump hard enough and fluid backs up
into your lungs. ___ were given a diuretic medication through
the IV to help get the fluid out. ___ improved considerably and
were ready to leave the hospital.
WHAT DO ___ NEED TO DO WHEN ___ LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs. Your weight on discharge is
161.4 lbs (73.2 kg)
- Seek medical attention if ___ have new or concerning symptoms
or ___ develop swelling in your legs, abdominal distention, or
shortness of breath at night.
It was a pleasure participating in your care. We wish ___ the
best!
-Your ___ Care Team
Followup Instructions:
___
|
10873326-DS-9
| 10,873,326 | 26,590,555 |
DS
| 9 |
2185-08-21 00:00:00
|
2185-08-22 01:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Elevated LFTs, abnormal imaging
Major Surgical or Invasive Procedure:
___: Ultrasound Guided Needle Biopsy of the Liver
History of Present Illness:
___ presents with several weeks of abdominal pain, nausea, back
pain and general malaise. He reports that his symptoms have
worsened over the past 4 days and he specifically has had nausea
and epigastric/right upper quadrant pain radiating to the back.
He presented to ___ earlier tonight because he was
not getting any better. At ___ he was found to have a
leukocytosis as well as a slight transaminitis. CT scan was
performed of the abdomen and pelvis which demonstrated a
thickened gallbladder wall but was otherwise unremarkable. The
patient's lipase was found to be within normal limits. He was
sent to ___ for further evaluation and for
ultrasonography Sibyof the right upper quadrant. He denies any
fever, chills, chest pain, shortness of breath, bowel changes.
He does report several months of difficulty urinating.
Past Medical History:
HTN
ETOH abuse
Social History:
___
Family History:
Denies liver or lung cancer
Physical Exam:
ADMISSION:
PHYSICAL EXAM:
Vitals: wt 133.8kg T 98.3 BP 190/100 HR 50 RR 18 O2Sat 98%4L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Liver firm and edge palpable 4-5cm below costal margin,
otherwise soft, mild TTP, +BS, no rebound/guarding. Minimal
fluid by exam.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Palmar erythema
Neuro: No asterixis. CNII-XII intact, ___ strength upper/lower
extremities, grossly normal sensation, 2+ reflexes bilaterally.
LABS: See below
DISCHARGE:
Vitals: T 98 BP 158/96(128/92-161/102) HR 79(79-94) RR 18 O2Sat
96%RA
General: Thin. Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Liver firm and edge palpable 4-5cm below costal margin,
otherwise soft, mild TTP, +BS, no rebound/guarding. Minimal
fluid by exam. No caput medusa.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Palmar erythema, thickened ___ palmar tendons
Neuro: No asterixis. CNII-XII intact, ___ strength upper/lower
extremities, grossly normal sensation, 2+ reflexes bilaterally.
Neutral toes.
Pertinent Results:
LABS ON ADMISSION:
================
___ 09:32AM BLOOD WBC-16.8* RBC-5.09 Hgb-15.0 Hct-46.3
MCV-91 MCH-29.5 MCHC-32.4 RDW-14.9 RDWSD-49.0* Plt Ct-96*
___ 09:32AM BLOOD ___ PTT-29.1 ___
___ 09:32AM BLOOD Glucose-85 UreaN-23* Creat-0.6 Na-144
K-2.7* Cl-97 HCO3-37* AnGap-13
___ 09:32AM BLOOD Albumin-3.2* Calcium-8.8 Phos-2.4* Mg-2.0
___ 09:32AM BLOOD ALT-130* AST-95* AlkPhos-243* TotBili-0.8
IMAGING:
=====================
___ CT Abd/Pelvis with PO and IV Contrast:
1. Numerous (> 50) hepatic masses, involving all hepatic
segments, likely
metastases related to the left lung mass demonstrated on the ___
CT. This is amenable to US-guided biopsy.
2. Bilateral adrenal gland thickening is new since ___,
suspicious for
metastases.
3. Enlarged celiac, SMA, and retroperitoneal lymph nodes;
findings could
represent reactive change versus metastases.
4. New small bilateral pleural effusions with compressive
atelectasis.
5. Moderate intra-abdominal intrapelvic ascites.
6. Previously-suggested nonobstructing right renal stone was
likely excreted
contrast instead, as this is no longer present on the current
study. No
nephrolithiasis.
RELEVANT COURSE LABS:
==================
___ 06:54AM BLOOD ALT-140* AST-112* AlkPhos-289*
TotBili-0.8
___ 07:00AM BLOOD ALT-174* AST-123* AlkPhos-313*
TotBili-1.2
___ 07:40AM BLOOD ALT-167* AST-121* AlkPhos-335*
TotBili-1.3
___ 07:40AM BLOOD VitB12-654 Folate-12.1
___ 07:40AM BLOOD TSH-2.2
___ 09:32AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
___ 09:32AM BLOOD HCV Ab-NEGATIVE
___ 09:32AM BLOOD HIV Ab-Negative
___:32AM BLOOD AFP-2.8
LABS ON DISCHARGE:
===================
___ 07:40AM BLOOD WBC-19.0* RBC-5.22 Hgb-15.6 Hct-46.9
MCV-90 MCH-29.9 MCHC-33.3 RDW-16.2* RDWSD-50.5* Plt Ct-78*
___ 07:40AM BLOOD Glucose-108* UreaN-28* Creat-0.6 Na-136
K-3.9 Cl-94* HCO3-36* AnGap-10
___ 07:40AM BLOOD Calcium-9.3 Phos-2.8 Mg-2.1
___ 07:40AM BLOOD ALT-214* AST-202* AlkPhos-372*
TotBili-1.8*
Brief Hospital Course:
___ yo man with pmh of hypertension, smoking, ETOH abuse who
presented from OSH with abnormal LFTs and imaging.
#Concern for malignancy: Patient has a large perihilar mass,
which is thought to be the primary, as well as many smaller
masses in the liver and adrenals, and some concerning lymph
nodes. A needle biopsy was done of the liver for both
staging/diagnosis. He has a mild-moderate transaminitis, with
negative hepatitis and hiv serology, as well as a mild
thrombocytopenia (76-102).
*** FOLLOW UP ON PATHOLOGY *** ONCOLOGY TEAM MADE AWARE BY EMAIL
#Leukocytosis: His WBC has ranged from ___ (no trend). His UA
was clean but sent for culture out of caution. Urine and blood
cultures are pending. He did not have enough ascites for
diagnostic paracentesis. He has remained afebrile and VSS
throughout his stay, and we think this more likely a reactive
process ___ his probable metastatic disease, rather than
infectious.
#HTN: His BP on admission was 190/100 and he did not remember
his home blood pressure medication. We initially started him on
amlodipine 10mg and hctz 12.5mg, and added his home nadolol 20mg
QDay day of discharge when we were able to confirm his home
medication list. He likely needs BID dosing given his 24 hour
trends.
TRANSITIONAL ISSUES:
- He will follow up with Thoracic Oncology within a week or two
once his initial pathology returns. They will call to schedule.
- Amlodipine 10mg and hctz 12.5 QDay have been added to his HTN
regimen, nadolol was continued
- He is being discharged with 10 days of oxycodone, which should
be enough to get him to his PCP ___ appointment.
- he should have LFTs checked next ___. The results will be
faxed to his primary care office.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Vitamin B-1 (thiamine HCl) 100 mg oral DAILY
3. Nadolol 20 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Nadolol 20 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Hydrochlorothiazide 12.5 mg PO DAILY
RX *hydrochlorothiazide 12.5 mg 1 capsule(s) by mouth daily Disp
#*30 Capsule Refills:*0
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*60 Tablet Refills:*0
7. Senna 8.6 mg PO BID
8. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
9. Vitamin B-1 (thiamine HCl) 100 mg oral DAILY
10. Outpatient Lab Work
CBC, Chem10 (Na/K/Cl/Bicarb/BUN/Cr/BG/Ca/Mg/Ph), ALT, AST, Alk
Phos, TBili
ICD-9: 263.0, ___ MD, FAX: ___
11. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 17 gram/dose 17 g by mouth twice
per day Refills:*11
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Transaminitis
Abnormal CT concerning for undiagnosed metastatic cancer
Malnutrition
Hypertensive urgency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the ___ for evaluation of abdominal pain,
weight loss, abnormal liver function tests and an abnormal CT
scan of your lungs and abdomen. Your blood pressure was very
high and we gave you medicine for that. You also received
another CT scan and a liver biopsy because the CT scan is
concerning for a cancer that has spread and involves the lungs
and liver. The results of the biopsy are still pending. Your
blood tests show your liver is inflamed. Several cancer doctors
are aware of your situation and will be in touch with you after
the definitive diagnosis returns.
Our nutritionists recommend that you supplement your meals with
ensure boost plus shakes, or something similar. You should also
try to drink plenty of water, 8 glasses per day.
You met with social work about The RIDE and referral to
___ for Meals on Wheels.
We sent your medicines to the ___ Pharmacy here on
___
You will follow up with your PCP next ___ @ 10:45
and with our oncology team sometime in the next ___ weeks. They
will call you with an appointment time. If you don't hear from
them in the next ___ days please call the clinic at
___.
On discharge, it is important that you take your hypertension
medication. We are also giving you narcotic pain medication.
Please do not take tylenol unless directed to do so by a doctor
as it may injure your liver. If you develop a fever, see blood
in your stool or have black stool, nausea or vomiting, your skin
or eyes turn yellow, or your pain is not controlled by the
medication we gave you, or your symptoms are worsening, please
seek care again.
We really enjoyed meeting and taking care of you!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10873456-DS-11
| 10,873,456 | 29,725,714 |
DS
| 11 |
2133-03-26 00:00:00
|
2133-03-29 20:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
weight loss, lymphadenopathy, hypercalcemia
Major Surgical or Invasive Procedure:
___ Ex-lap, duo stump rsxn, ___ enteroenterostomy
___ Transverse colectomy, end colostomy
___ ___ guided lymph node biopsy
History of Present Illness:
___ y.o M with history of HTN, hypothyroidism, CVA with residual
right sided weakness presenting from SNF with lab significant
for hypercalcemia and significant cervical lymphadenopathy.
He reports that he has had decreased appetite for the last year.
He has noted significant weight loss, but per ED physician, the
nurse at his living facility notes that he lost approximately 13
pounds in the lsat four months. He reports that in the last
three months, he had noticed swollen lymph nodes in his neck,
initially painful, but currently painless.
In the ED, initial VS were 96.7 58 159/62 18 99% RA
His exam was notable for painless firm submandibular nodules up
to 2 cm in diameter inferior to the mandible.
Labs notable for hypercalcemia to 14.3, hyperkalemia to 5.1
CT chest and neck showed significant supraclavicular, axillary,
and meadiastinal lymphadenopathy most suspicious for lymphoma.
CT also showed a CBD dilatation up to 15 mm.
He was given IV fluids and admitted for management of
hypercalcemia and oncologic workup.
Upon arrival to the floor, the patient is in no acute distress.
He reports that over the past few months, he has had significant
weight loss. He reports he has only been eating half of his meal
instead of the whole meal. He states that he difficulty
swallowing solid food, which has been going on for several
months. He also dislikes the food at his living facility. He
reports lymphadenopathy present for several months, which was
originally tender, but is non nontender and seems to slowly be
growing in size. He otherwise denies fevers, chills, diaphoresis
or night sweats, nausea, vomiting, abdominal pain, chest pain,
shortness of breath. He denies lower extremity swelling or
numbness or tingling.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative. CT head and CTA
without pathology. He was given IV fluids and subsequently
returned to his assisted living facility.
Past Medical History:
HTN
Perforated gastric ulcer s/p subtotal ___
CVA with residual right-sided weakness -___
Hypothyroidism
Social History:
___
Family History:
Brother with diabetes
Physical Exam:
ADMISSION EXAM
VITALS: 97.7 PO 120 / 85 73 16 96 ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Oropharynx clear without lesion Neck Supple Bilateral
submandibular lymphadenopathy ~2 cm, nontender, R>L, + R
supraclavicular lymphadenopathy
CV: Heart regular, no JVD
RESP: Lungs clear to auscultation with good air movement
bilaterally, breathing is nonlabored
GI: Abdomen soft, non-distended, non-tender to palpation.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented to ___, initially guesses date as
"1000" but subsequently corrects himself to ___, face
symmetric, gaze conjugate with EOMI, speech fluent, moves all
limbs
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM
VS: 98.1 106/65 90 18 98%RA
GENERAL: Alert and interactive. Appears comfortable, no acute
distress.
EYES: No scleral icterus.
HEENT: Oropharynx clear, moist mucous membranes
LUNGS: Clear to auscultation bilaterally without any wheezes
rales or rhonchi over anterior chest fields. Exam limited as
patient unable to turn.
CV: Regular rate and rhythm without any murmurs, rubs, or
gallops
ABD: Soft, nondistended, nontender. Large vertical midline
incision which appears clean/dry/intact, covered partially with
bandage. Has RUQ ostomy with brown watery output.
EXT: Warm and well perfused without any edema or deformity
SKIN: Warm/dry/no rash, surgical incision in midline abdomen as
above.
NEURO: fluent speech
ACCESS: PICC in right upper extremity with dressing without
erythema or tenderness
Pertinent Results:
ADMISSION LABS:
=================
___ 03:05PM WBC-6.8 RBC-4.19* HGB-12.5* HCT-38.1* MCV-91
MCH-29.8 MCHC-32.8 RDW-14.0 RDWSD-46.8*
___ 03:05PM NEUTS-76.8* LYMPHS-14.7* MONOS-7.5 EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-5.20 AbsLymp-1.00* AbsMono-0.51
AbsEos-0.01* AbsBaso-0.02
___ 03:05PM ___ PTT-33.2 ___
___ 03:05PM GLUCOSE-105* UREA N-28* CREAT-1.6* SODIUM-139
POTASSIUM-5.3* CHLORIDE-96 TOTAL CO2-25 ANION GAP-18*
___ 03:05PM ALBUMIN-3.8 CALCIUM-14.3* PHOSPHATE-3.3
MAGNESIUM-1.7
___ 03:05PM ALT(SGPT)-9 AST(SGOT)-41* LD(LDH)-579* ALK
PHOS-129 TOT BILI-0.5
___ 03:05PM LIPASE-15
___ 03:05PM TSH-2.1
___ 08:34PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:34PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
NOTABLE LABS:
==============
___ 03:05PM BLOOD TSH-2.1
___ 01:23PM BLOOD PTH-81*
___ 01:23PM BLOOD 25VitD-27*
___ 09:15AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 02:00AM BLOOD IgG-633* IgA-136 IgM-109
___ 09:15AM BLOOD HIV Ab-NEG
___ 01:23PM BLOOD HCV Ab-NEG
___ 01:23PM BLOOD HBV VL-NOT DETECT HCV VL-NOT DETECT
CYTOGENETICS:
==============
FISH ___: UNDETERMINED HIGH GRADE LYMPHOMA PANEL. There was no
evidence of interphase lymph node cells with the IGH/BCL2 gene
rearrangement or rearrangements of the BCL6 and MYC genes.
FISH ___: POSITIVE for GAIN of BCL6 and BCL2. The large
majority of cells examined in this formalin fixed paraffin
embedded right submandibular lymph node biopsy had probe signal
patterns with an extra intact BCL6 signal and 3 to 5 BCL2
signals. There was no evidence of the IGH/BCL2 gene
rearrangement or rearrangements of the BCL6 and MYC genes.
PATHOLOGY:
==============
PATHOLOGIC DIAGNOSIS ___:
Lymph node, right submandibular, core needle biopsy:
DIFFUSE LARGE B-CELL LYMPHOMA, NOT OTHERWISE SPECIFIED; SEE
NOTE.
FLOW CYTOMETRY IMMUNOPHENOTYPING ___:
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by leukemia/lymphoma
are not seen in specimen. Correlation with clinical findings and
morphology (see separate pathology report ___ is
recommended. Flow cytometry immunophenotyping may not detect all
abnormal populations due to topography, sampling or artifacts of
sample preparation.
PATHOLOGIC DIAGNOSIS ___:
1. Omentum, resection:
- Fibroadipose tissue with acute inflammation and necrosis.
- Two (2) lymph nodes with findings consistent with partly
treated, residual diffuse large B-cell lymphoma, see
hematopathology note.
2. Transverse colon, resection:
- Colonic segment with acute diverticulitis, perforation and
abscess cavity formation in pericolonic adipose tissue.
- Resection margins are viable but involved by serositis.
PATHOLOGIC DIAGNOSIS ___:
1. Fat attached to duodenum, excision:
- Fibroadipose tissue with acute and chronic inflammation.
2. Duodenum stump, resection:
- Segment of duodenum with serosal acute inflammation and
fibrosis.
NOTABLE IMAGING:
=================
CT Neck with Contrast ___:
1. Diffuse cervical lymphadenopathy concerning for malignancy
including
lymphoma.
2. Irregular soft tissue along the mucosal surface of the
oropharynx, right greater than left, and nasopharynx. This is
most suspicious for malignancy, potentially lymphoma given
background of diffuse adenopathy. Clinical correlation with
direct visualization is suggested. Squamous cell carcinoma
would be possible though given extensive adenopathy, lymphoma is
more likely.
CT Chest with Contrast ___:
1. Diffuse supraclavicular, axillary, and mediastinal
lymphadenopathy most
suspicious for lymphoma.
2. No primary lung lesion identified.
3. CBD dilation measuring up to 15 mm. Recommend correlation
with LFTs to
exclude biliary obstruction.
Lymph Node Biopsy ___:
An enlarged, 4.5 x 4.3 x 1.7 cm heterogeneous submandibular
lymph node was
targeted for biopsy.
Technically successful ultrasound-guided core biopsy of right
submandibular lymph node.
CT A/P ___:
1. Bulky mesenteric, retroperitoneal, pelvic, and inguinal
lymphadenopathy.
The largest lymph nodes are in the inguinal regions, measuring
4.1 x 2.1 cm and 3.2 x 2.0 cm in the left and right inguinal
regions, respectively. The inguinal nodes are most amenable to
percutaneous biopsy.
2. Heterogeneous hypo-attenuated foci in the spleen are new as
compared from CT abdomen and pelvis ___ and are
also suspicious for neoplasm.
3. Small bilateral pleural effusions.
4. Colonic diverticulosis.
TTE ___:
The left atrium is normal in size. 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
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 tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
PET ___:
-Diffuse intensely FDG avid lymphadenopathy, D5. -Diffuse FDG
avidity of the mucosal surfaces of the oropharynx and right
palatine tonsil.
-The spleen is normal in size with multiple mildly FDG avid
lesions throughout.
-2 subcentimeter mildly FDG avid subcutaneous nodules along the
left anterior upper abdominal wall and left flank, nonspecific.
-Interval increase in size of moderate bilateral non FDG avid
pleural effusions.
CT A/P ___:
1. Long segment of transverse colon demonstrating
circumferential wall
thickening and surrounding fat stranding, compatible with the
provided
patient's history of C diff colitis. However, there is a
segment of
transverse colon, which demonstrates decreased wall enhancement,
suspicious for focal perforation.
2. Pneumoperitoneum and a 8.9 cm focal fluid collection with
small foci of air within the upper midline abdomen.
3. Dilatation of proximal small bowel loops without wall
thickening or
abnormal enhancement pattern, likely due to ileus.
4. Overall the extent of mesenteric, retroperitoneal, pelvic,
and inguinal
lymphadenopathy has significantly decreased in size compared to
the CT abdomen and pelvis dated ___. Innumerable
hypodense lesions throughout the spleen are unchanged,
consistent with metastases.
5. Anasarca with moderate bilateral pleural effusions, moderate
volume
ascites, and diffuse body wall edema.
6. Small focus of subcutaneous air within the right lower
anterior abdominal wall, unclear in etiology, possibly due to
injections
NOTABLE MICROBIOLOGY:
=====================
Blood culture ___: No growth.
Urine culture ___: No growth.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ (___) @ 737
ON ___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay. (Reference
Range-Negative).
Blood culture ___: No growth.
Blood culture ___: No growth.
Urine culture ___: >100,000 colonies yeast.
Blood culture ___: No growth.
Peritoneal fluid gram stain, aerobic culture, and anaerobic
culture ___: No growth.
Blood culture ___: No growth.
Urine culture ___: >100,000 colonies yeast.
DISCHARGE LABS:
====================
___ 12:00AM BLOOD WBC-9.2 RBC-2.64* Hgb-7.9* Hct-24.9*
MCV-94 MCH-29.9 MCHC-31.7* RDW-17.1* RDWSD-55.4* Plt ___
___ 12:00AM BLOOD Neuts-72* Bands-1 Lymphs-10* Monos-10
Eos-0 Baso-1 ___ Metas-2* Myelos-4* NRBC-2* AbsNeut-6.72*
AbsLymp-0.92* AbsMono-0.92* AbsEos-0.00* AbsBaso-0.09*
___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Tear Dr-OCCASIONAL
___ 12:00AM BLOOD Glucose-77 UreaN-11 Creat-0.9 Na-139
K-3.7 Cl-98 HCO3-24 AnGap-17
___ 12:00AM BLOOD ALT-13 AST-18 LD(LDH)-172 AlkPhos-172*
TotBili-0.2
___ 12:00AM BLOOD Albumin-3.3* Calcium-8.6 Phos-3.8 Mg-1.7
UricAcd-8.4*
Brief Hospital Course:
___ year old male with history of CVA with right sided weakness
who was admitted to the hospital on ___ for hypercalcemia to
14. He was noted to have cervical lymphadenopathy. Lymph node
biopsy was performed which showed DLBCL. He underwent a partial
transfusion of EPOCH on ___ for ~1hr which was interrupted due
to profound newonset diarrhea. He was found to have C. diff. He
underwent Cytoxan ___, but his cycle was stopped due to
worsening abdominal pain. His hospital course was complicated by
severe c.diff with bowel perforation and peritonitis/abscess. He
was taken to the operating room on ___ where he underwent
exploratory laparotomy, transverse colectomy, ___ colostomy
with esophagogastroduodenoscopy. He returned to the operating
room on ___ after bile was reported from his drain. At this
time, he was found to have a perforated viscus and underwent an
exploratory laparotomy, duodenal stump, and ___
enteroenterostomy. During his post-operative course, he
developed an episode of atrial fibrillation which was controlled
with metoprolol. He has had no further recurrences. Because he
failed his bedside swallow, he had a dobhoff tube placed in to
his stomach for tube feedings. On ___, the color of his drain
output changed to a milky white and there was concern for a
chyle leak. He also had an elevated triglyceride level from the
drain. ___ was consulted and recommended conservative management.
His tube feeding was changed to a low fat formula. The color of
the drain returned to a serous drainage and the patient was
transitioned back to osmolite 1.5. The amount of drainage
diminished and was removed on ___. The staple line from the
wound on his mid abdomen were also removed and the wound
appeared to be healing well. He was cleared by speech and
swallow for PO intake. His appetite has been diminished and he
was started on marinol with cycled tube feedings. His
electrolytes have been monitored and have remained stable. His
hematocrit decreased to 17 on ___ and he received a unit of
blood. He was transferred to the ___ service on ___. After
transfer to ___, the patient was transfused 1U of blood for Hgb
6.9. The patient was seen by ___ multiple times to help regain
his strength, and he was initiated on R-mini-CHOP when it was
felt his functional status had improved. He received rituxan on
___, and mini-CHOP on ___ and ___. He
tolerated these treatments well, with only mild nausea. The
patient was started on EPO, as the patient had anti-YTa and
anti-YKa antibodies which make it difficult to find blood
transfusions for the patient. On ___, the patient's dobhoff
fell out, and the patient was started on a trial without the
dobhoff. The patient began to regain his appetite slowly, and
his appetite was improving at time of discharge. His uric acid
was noted to be elevated on ___, and he was restarted on
allopurinol at that time. During his hospital course, he was
evaluated by physical therapy who recommended discharge to a
rehabilitation facility to help him regain his strength.
1. Acute Hypercalcemia
-Patient presenting with severe hypercalcemia > 14 mg/dL with
potential acute encephalopathy vs baseline mental status which
was thought to be due to malignancy.
-Calcium improved to 11.6 with IV fluids, IV pamidronate, and
calcitonin.
-Given improvement only IV fluids were continued
-Low calcium diet, home calcium carbonate was held as was his
vitamin D
-Further workup of malignancy as below
2. Diffuse Large B Cell Lymphoma
- Patient with significant cervical, supraclavicular, axillary,
and inguinal lymphadenopathy concerning for lymphoma.
- s/p ___ lymph node biopsy ___ which showed diffuse
large B cell lymphoma
- received a partial dose of EPOCH on ___, which was stopped
after 1 hour due to diarrhea
- received full dose of Cytoxan and prednisone on ___ prior to
developing bowel perforation
- After his surgeries, he was transferred back to ___ for
chemotherapy, and received rituxan on ___, and mini-CHOP on
___ and ___.
- uric acid was noted to be elevated on ___, and he was
restarted on allopurinol.
3. C. diff colitis
Bowel perforation
Bile leak
Chyle leak
- Patient developed diarrhea, and was found to have C. diff
infection.
- The patient was started on IV metronidazole and fidaxomycin.
- The patient subsequently developed worsening abdominal pain.
- CT A/P showed bowel perforation on ___.
- ACS was consulted and performed a exploratory laparotomy,
transverse colectomy, and colostomy on ___.
- ID was consulted and the patient was started on vancomycin PO
and vancomycin enemas.
- The patient's surgical course was complicated by peritonitis,
which was treated with cefepime and flagyl for a 10 day course.
- The patient had a bile leak, and underwent a partial duodenum
resection, ___ enteroenterostomy on ___.
- The patient's drain was noted to be leaking milky fluid
afterwards with high triglycerides, concerning for a chyle leak.
- ___ was consulted for chyle leak and recommended conservative
management with low fat diet.
- The patient's chylous drain output declined and was pulled on
___.
- The patient was continued on treatment course with vancomycin
PO and vancomycin enemas for C. diff colitis until ___. He was
then started on vancomycin PO for C. diff prophylaxis as he
underwent chemotherapy.
4. Malnutrition
- NG tube was placed ___ for failing a bedside swallow. He was
seen by nutrition and started on tube feeds.
- The patient was seen by speech and swallow who cleared him for
a regular or pureed diet, as patient is edentulous.
- The patient was started on cycled tube feeds and marinol for
appetite stimulation.
- On ___, the patient's dobhoff fell out, and the patient was
started on a trial without the dobhoff. The patient began to
regain his appetite slowly.
- Surgery was consulted for consideration of PEG placement, but
stated the patient was not a candidate given his surgical
anatomy.
- Psych was consulted and stated that patient likely does not
have MDD that could be contributing to poor PO intake. They did
recommend continuing marinol and mirtazapine. They suggested
starting low dose Ritalin, but this was not initiated as the
patient did not appear lethargic.
- The patient began to regain his appetite slowly, and should
continue to be encouraged to eat while at the SNF.
5. Anti YTA/anti YKA antibodies
- The patient has anti-YTA and anti-YKA antibodies, which make
it difficult to find blood products to transfuse for this
patient. Due to this, hemoglobin was trended closely, and EPO
was initiated to minimize transfusions while on chemotherapy.
6. ___
-Admission Cr of 1.6 (baseline of 1.0) which was likely pre
renal. Following IV fluids, his Cr normalized.
7. Back pain
The patient had onset of back pain ___ after initiating
filgrastim and epogen. The pain was thought to be medication
associated bone pain based on the time of onset of the pain. The
patient did not have any new onset leg weakness, and it was
difficult to assess urinary and bowel incontinence as pt with
Foley and colostomy. The patient's back pain resolved after one
time dose of Tylenol ___, ibuprofen 200mg, and oxycodone 5mg.
8. Dilated common bile duct
-Seen on CT imaging, with dilated CBD to 15 mm. LFTs/bilirubin
grossly unremarkable/normal and no symptoms of obstructive liver
disease.
CHRONIC MEDICAL PROBLEMS:
1. HTN: Continue Metoprolol Succinate and held Lasix.
2. Hypothyroidism: continue levothyroxine. TSH of 2.1.
3. h/o CVA, HLD: continue Aspirin and Atorvastatin
4. GERD/Prior gastric ulcer: Likely in the setting of
compression due to significant lymphadenopathy. He was on
standing antacids at his SNF. Continued Omeprazole and held
Calcium Carbonate.
5. Possible h/o dCHF: Patient on home furosemide unsure if has
known diagnosis of CHF. Held home furosemide 10 mg PO daily.
6. Depression: continue mirtazapine and gabapentin.
7. Edentulous: patient requests regular diet
====================
TRANSITIONAL ISSUES
====================
- The patient should follow-up with Dr. ___ surgeon, on
___ at 1pm.
- The patient should follow-up with Dr. ___
oncologist, on ___. The office should call to schedule the
appointment.
- The patient should be encouraged to eat as much as possible to
maintain his nutrition.
- The patient should work with physical therapy to improve his
strength.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 12.5 mcg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Furosemide 10 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Vitamin D 400 UNIT PO DAILY
6. Calcium Carbonate 1000 mg PO QHS
7. Atorvastatin 10 mg PO QPM
8. Gabapentin 100 mg PO QHS
9. melatonin 5 mg oral QHS
10. Mirtazapine 15 mg PO QHS
11. Omeprazole 20 mg PO BID
12. Ensure (food supplemt, lactose-reduced) ___ ensure oral
DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Allopurinol ___ mg PO DAILY
3. Dronabinol 5 mg PO BID
4. Epoetin Alfa 8000 UNIT SC QMOWEFR Duration: 1 Week
5. FoLIC Acid 1 mg PO DAILY
6. Heparin 5000 UNIT SC BID
7. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO BID
9. Multivitamins W/minerals Liquid 15 mL PO DAILY
10. Ondansetron 8 mg IV Q8H:PRN nausea
11. Prochlorperazine 10 mg PO Q8H:PRN nausea
12. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
14. Vancomycin Oral Liquid ___ mg PO/NG BID
15. Aspirin 81 mg PO DAILY
16. Atorvastatin 10 mg PO QPM
17. Calcium Carbonate 1000 mg PO QHS
18. Ensure (food supplemt, lactose-reduced) ___ ensure oral
DAILY
19. Gabapentin 100 mg PO QHS
20. Levothyroxine Sodium 12.5 mcg PO DAILY
21. melatonin 5 mg oral QHS
22. Mirtazapine 15 mg PO QHS
23. Vitamin D 400 UNIT PO DAILY
24. HELD- Furosemide 10 mg PO DAILY This medication was held.
Do not restart Furosemide until your doctor says it is OK
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Diffuse Large B-cell Lymphoma
Bowel Perforation
C. diff colitis
Hypercalcemia
___
Anemia
Malnutrition
Anti-YTA, anti-YKA antibodies
SECONDARY DIAGNOSES:
History of CVA
HTN
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 participating in your care!
WHAT BROUGHT YOU INTO THE HOSPITAL?
You came to the hospital with elevated calcium levels.
- You were found to have large lymph nodes on your neck.
- You had a lymph node biopsy on ___, which showed diffuse
large B cell lymphoma.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You received a partial dose of chemotherapy, which had to be
stopped because you developed a C. diff infection.
- You had a hole in your bowel which happened either because of
the C. diff infection or because of a different infection in
part of your bowel wall (diverticulitis).
- You had a part of your colon taken out (transverse colectomy)
and some of the remaining colon was connected to your abdominal
wall (colostomy).
- You had an infection in your abdominal lining (peritonitis)
which was treated with antibiotics.
- You had to get another operation to take out part of your
small intestine (duodenal resection, ___ enteroenterostomy)
because there was bile coming out of your surgical drain.
- You had some of your lymph fluid leak out of a drain, which is
why you were put on a low fat diet. The drain was taken out when
it stopped draining.
- You had a tube placed in your nose leading to your stomach to
give you nutrition. To help improve your appetite, you were
placed on a medication to make you hungry.
- Your blood counts were checked, and you received multiple
blood transfusions while you were in the hospital. You were also
started on a medication to increase your red blood cell counts.
- You were given a cycle of chemotherapy for your B cell
lymphoma.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- You should try to eat as much as possible to maintain your
nutrition.
- You should work with physical therapy to improve your
strength.
- You should follow-up with Dr. ___ surgeon, on ___ at
1:00 ___.
- You should follow-up with Dr. ___ cancer doctor,
on ___. The office should call you to schedule your
appointment.
Wishing you all the best,
Your ___ Treatment Team
Followup Instructions:
___
|
10873456-DS-12
| 10,873,456 | 29,916,398 |
DS
| 12 |
2133-05-26 00:00:00
|
2133-05-26 11:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypotension, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with recently diagnosed
diffuse large B cell lymphoma undergoing treatment (most
recently underwent C4D1 on mini-RCHOP), HTN, hypothyroidism, CVA
with right-sided weakness, who presents from SNF with
hypotension and altered mental status.
The patient was recently hospitalized from ___ to ___ after
being diagnosed with diffuse large B cell lymphoma. During that
hospitalization, the patient's treatment was initiated with
transfusion of EPOCH (___) and then Cytoxan (___). The patient
subsequently received 2 cycles of mini-RCHOP while in hospital.
The patient required filgrastim and epogen to improve his blood
counts. His hospital course was complicated by C diff colitis,
initially treated with IV metronidazole and fidaxomycin before
being switched to PO vancomycin. His infection was complicated
by bowel perforation requiring transverse colectomy and end
colostomy. Surgical course was also complicated by biliary leak
requiring partial duodenal resection and bowel re-anastomosis,
as well as chyle leak into his surgical drain which was treated
conservatively. Patient also developed atrial fibrillation
during the hospitalization, which converted to normal sinus
rhythm with several doses of IV metoprolol.
This morning, the patient was going routine blood pressure check
at his group home and was noted to have hypotension with SBP 73.
He was also noted to be altered at that time. EMS was called,
and they measured his mean BP as 53. As a result, he was
transferred to ___ ER.
In the ED, initial vitals: T 96.0F| HR 125| BP 91/57| RR 17| 95%
RA; BP dropped as low as 68/50, but was fluid responsive.
Exam notable for:
- Patient is confused, but oriented to year and president.
- Erythematous midline incision, leakage from around ostomy site
(?fistula). Ostomy with greenish output. Otherwise, abdomen is
soft, non-tender
- Right sided ___
Labs notable for:
WBC 49, ___ to 5.9 (b/l 1.0), Bicarb 16, VBG 7.___, lactate
2.3, albumin 3.2, ALT 7, AST 9, AlkPhos 170.
Imaging: CT abd/pelvis pending
Patient received: Empiric vanc/cefepime/flagyl. Given 2L IVF,
was fluid responsive (improved 92/52). Foley placed for urine
drainage. Midodrine given.
Vitals on transfer: 97.6F| HR 127| BP 71/56| RR 23| 98% RA
Upon arrival to ___, the patient confirmed the above history.
He denies any fevers, chest pain, shortness of breath, cough,
abdominal pain, nausea/vomiting. He is uncertain about whether
his ostomy output has increased.
Past Medical History:
Diffuse large B cell lymphoma
HTN
Perforated gastric ulcer s/p subtotal ___
CVA with residual right-sided weakness -___
Hypothyroidism
Social History:
___
Family History:
Brother with diabetes
Physical Exam:
ADMISSION EXAM:
VITALS: 97.6F| HR 127| BP 71/56| RR 23| 98% RA
GENERAL: patient appears cachectic
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: JVP not elevated, no LAD
LUNGS: Bibasilar crackles appreciated on auscultation
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: patient with midline incision with 1cm tract with bloody
drainage; blanching erythema noted around incision site. Ostomy
located in RUQ. Otherwise, abdomen is soft, non-distended, and
non-tender
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes appreciated
NEURO: patient is alert and oriented to person, place, month,
and year; CN II-XII intact; strength ___ in bilateral
ACCESS: double lumen picc right arm
=============================================
DISCHARGE EXAM: ***
Pertinent Results:
ADMISSION LABS:
___ 11:55AM BLOOD WBC-49.3*# RBC-2.61* Hgb-7.9* Hct-24.4*
MCV-94 MCH-30.3 MCHC-32.4 RDW-20.1* RDWSD-64.6* Plt ___
___ 11:55AM BLOOD Neuts-96* Bands-0 Lymphs-3* Monos-1*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-47.33*
AbsLymp-1.48 AbsMono-0.49 AbsEos-0.00* AbsBaso-0.00*
___ 11:55AM BLOOD ___ PTT-32.2 ___
___ 11:55AM BLOOD Glucose-133* UreaN-48* Creat-5.9*# Na-135
K-4.8 Cl-96 HCO3-16* AnGap-23*
___ 11:55AM BLOOD ALT-7 AST-9 AlkPhos-170* TotBili-<0.2
___ 06:15PM BLOOD Albumin-2.7* Calcium-8.4 Phos-5.6* Mg-1.6
UricAcd-5.1
___ 06:15PM BLOOD CRP-86.2*
___ 12:09PM BLOOD ___ pO2-73* pCO2-39 pH-7.24*
calTCO2-18* Base XS--10 Comment-GREENTOP
___ 12:09PM BLOOD Lactate-2.3*
MICRO:
Blood cultures:
___ - no growth x2 (final)
Midline wound swab (___): Mixed bacterial flora.
UCx (___): no growth (final)
Stool cultures:
C.diff (___) - negative
Fecal culture/Campylobacter (___) - negative
C.diff (___) - negative
IMAGING:
PET CT (___):
IMPRESSION: 1. No residual lymphadenopathy or abnormal FDG
uptake in the lymph nodes.
2. Postsurgical changes from subtotal gastrectomy,
gastrojejunostomy and end ileostomy are better evaluated on
contrast-enhanced CT performed 1 day prior.
3. ___ Score 1
CT abd/pelvis, ___:
IMPRESSION:
1. No evidence of abdominal pelvic drainable fluid collections
or
discrete abscess.
2. Postsurgical changes, as described, with several locule of
subcutaneous gas along the incision margin, with single locule
of
high density material seen adjacent to the incision margin.
Although this can be seen with enterocutaneous fistula, no clear
source is seen, and the bowel loops in this general area appear
normal, and evaluation is further complicated by the fact
that there was an attempted fluoroscopic sinogram on ___, which did not demonstrate a possible area to cannulate,
and
this most likely represents retained contrast from that study.
Given the relatively normal appearance of the bowel loops
adjacent to the ventral abdominal wall, retained
contrast from the fluoroscopic study is considered far more
likely rather than enterocutaneous fistula. Follow-up should be
on a clinical basis, and it should be closely monitored if there
is drainage of what appears to be barium contrast from the
surgical incision.
3. Minimal fluid and stranding at the level of the duodenal
stump
with single locule of gas is likely postoperative, with no
organized or drainable fluid collection in this area.
4. Interval development of moderate to large bilateral pleural
effusions and associated compressive atelectasis.
5. Interval development of diffuse anasarca.
6. Circumferential bladder wall thickening may be due to
underdistention, however infectious process such as cystitis
can't be excluded. Correlation with urinalysis and clinical
exam
is recommended.
7. Diverticulosis without diverticulitis.
Fistulogram, ___:
IMPRESSION:
No definite fistulous tract visualized on this exam.
Doppler US RUE, ___:
IMPRESSION:
No evidence of deep vein thrombosis in the right upper
extremity.
Fistulogram, ___:
IMPRESSION:
No definite fistulous tract visualized. The exam was aborted
after several
attempts of contrast injection due to patient discomfort.
CT abd/pelvis WO contrast, ___:
IMPRESSION:
1. Billroth changes and bowel anastomoses without bowel
obstruction or free intraperitoneal air. A few small foci of
subcutaneous gas seen along the right anterior abdominal wall,
most likely representing sequela of prior surgery and less
likely
due to enterocutaneous fistula due to the lack of
extraluminal contrast. If this is a clinical concern, the
potential fistulous opening could be injected under fluoroscopy.
2. No drainable fluid collections.
CT abd/pelvis WO contrast, ___:
IMPRESSION:
1. Small pockets of subcutaneous gas in the right anterior
abdominal wall, adjacent to a midline incision is incompletely
evaluated in the absence of IV or oral contrast. However, this
is concerning for a sinus tract or enterocutaneous fistula and
is
in close proximity to the presumed site of prior duodenal stump
resection in the right upper quadrant. Consider further
assessment with MRI or CT with IV/oral contrast when the patient
is able to tolerate performance of these studies.
2. No bowel obstruction or colitis.
DISCHARGE LABS:
___ 05:00AM BLOOD WBC-8.6 RBC-2.37* Hgb-7.0* Hct-22.4*
MCV-95 MCH-29.5 MCHC-31.3* RDW-22.3* RDWSD-73.9* Plt ___
___ 06:09AM BLOOD WBC-9.8 RBC-2.52* Hgb-7.4* Hct-23.5*
MCV-93 MCH-29.4 MCHC-31.5* RDW-22.3* RDWSD-71.7* Plt ___
___ 05:12AM BLOOD WBC-9.2 RBC-2.27* Hgb-6.7* Hct-21.5*
MCV-95 MCH-29.5 MCHC-31.2* RDW-23.5* RDWSD-78.7* Plt ___
___ 12:00AM BLOOD Neuts-79.5* Lymphs-10.8* Monos-8.5
Eos-0.2* Baso-0.3 Im ___ AbsNeut-10.12* AbsLymp-1.38
AbsMono-1.09* AbsEos-0.03* AbsBaso-0.04
___ 05:12AM BLOOD ___
___ 06:09AM BLOOD Glucose-143* UreaN-31* Creat-1.0 Na-144
K-4.4 Cl-102 HCO3-29 AnGap-13
___ 05:00AM BLOOD Glucose-91 UreaN-31* Creat-0.9 Na-142
K-4.9 Cl-101 HCO3-29 AnGap-12
___ 05:00AM BLOOD ALT-5 AST-12 AlkPhos-91 TotBili-<0.2
___ 05:00AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.1
___ 12:13AM BLOOD Type-MIX pO2-97 pCO2-42 pH-7.42
calTCO2-28 Base XS-2 Comment-GREEN TOP
Brief Hospital Course:
Mr. ___ is a ___ male with recently diagnosed
diffuse large B cell lymphoma undergoing treatment (most
recently underwent C4D1 on mini-RCHOP), HTN, hypothyroidism, CVA
with right-sided weakness, who presents from ___ with
hypotension and altered mental status.
# Septic shock ___ suspected infected enterocutaneous fistula
# Chronic Ventral Abdominal Wound
Patient was reportedly hypotensive on the day of presentation
(___) with MAP 53. He was subsequently transferred to the
___ ICU for further management. In the ER, the patient was
fluid responsive with improvement in BP with fluid boluses. He
also briefly required norepinephrine but was weaned off on
___. This finding, in combination with the patient's WBC to
45, suggested a distributive shock due to infection. There were
no localizing symptoms (e.g. abdominal pain, productive cough)
to suggest a specific source of infection. However, CT
abd/pelvis w/o contrast was obtained and demonstrated possible
enterocutaneous fistula, consistent with the patient's exam
findings of dark-green drainage from a 1cm defect in his
anterior abdominal wall. Fistulograms were unable to demonstrate
presence of a fistula, however given that he had continued
bilious/serous drainage from the mid-abdomen, he very likely had
an enterocutaneous fistula. ACS was consulted and did not feel
surgical intervention would be appropriate. As a result, the
patient was started on vancomycin, cefepime, and metronidazole
as treatment. Blood, urine, and wound cultures remained
negative. With stabilization of the patient's hemodynamics, the
patient was transferred from the ICU to the ___ service on ___. Since that time, patient remained afebrile with stable VS
and no evidence of hypotension or infection. He was transferred
to Medicine on ___. ID was consulted re: antibiotic duration
as he had been on broad spectrum abx for almost 2 weeks. They
recommended evaluating for ___ abscess with a CT
abd/pelvis with contrast. The imaging showed no evidence of
abscess so antibiotics were discontinued on ___. Throughout
the remainder of his hospital stay, he continued to remain
afebrile and hemodynamically stable.
Wound/ostomy care followed closely. They were able to place a
drainage bag over the fistula in order to prevent the bilious
drainage from causing injury to the surrounding skin.
# ___:
The patient's Creatinine was elevated at presentation to 5.9
from a baseline ~1.0. The etiology for the patient's ___ was
felt to be prerenal from poor PO intake and distributive shock.
Following administration of fluid and pressors, as well as
treatment of the patient's infection, his Creatinine steadily
improved. Patient Cr went back to baseline ___.
# Malnutrition, severe
The patient was noted to be malnourished at presentation, with
generalized cachectic appearance. Nasogastric tube was placed on
___ for feeding and nutrtion was consulted for feeding tube
recommendations. However, based on the recommendation of
surgery, the patient was not initiated on tube feeds at the time
of transfer to the regular nursing floor due to concern for
worsening the patient's enterocutaneous fistula. Further held
tube feeds given concern for re-feeding syndrome and
intolerability. Initiated TPN on ___. Tube feeds were
re-initiated on ___, which he tolerated well. TPN was
discontinued on ___. Luckily, he was able to transition off of
tube feeds to clear liquids on ___, and on ___ he did well
with a soft diet. He had no abdominal pain or nausea after
meals with controlled ostomy output. He should take nutritional
supplements with protein as well as a high protein, high calorie
diet.
# Diffuse large B-cell lymphoma: Currently s/p cycle 3 of
R-miniCHOP
(currently being held).
Restaging PET CT showed an impressive response to therapy. This
was discussed with Dr. ___, Mr. ___ oncologist. Will
hold off on chemotherapy for now given the marked response and
allow time for improvement in malnutrition and healing of the
enterocutaneous fistula. It is possible that he has achieved a
remission. He will see his oncologist within a week of discharge
to discuss the next steps in treatment.
# Asymptomatic bilateral pleural effusions
He had bilateral pleural effusions in the past. Given that they
are bilateral, they are most likely transudative in the
setting of hypoalbuminemia and aggressive volume resuscitation
for sepsis. He had no shortness of breath, cough, or chest
pain. He was gently diuresed with Lasix 10 mg IV daily which he
no longer required after ___.
# Normocytic anemia
# Anti YTA/anti YKA antibodies
He required a blood transfusion on ___ as his H/H dropped
below threshold for transfusion. He had no evidence of bleeding.
Guaiac stool was negative for occult blood. He is difficult to
cross match due to antibodies. Epoetin alfa 8000 units SC MWF
was resumed. He will continue this on discharge with iron; his
oncologist will determine the duration of therapy at the next
outpatient appointment.
# Coagulopathy:
Elevated INR to 1.4. This was most likely secondary to Vitamin K
deficiency. He received x1 dose of phytonadione on
___, and ___. There was no evidence
of bleeding.
# RUE Swelling:
Concerning for DVT given presence of PICC; however, obtained U/S
which was negative. Could be dependent
edema related to his hypoalbuminemia which is likely a
consequence of his severe malnutrition, continue to monitor site
closely.
# Non-gap metabolic acidosis (most likely from GI losses) -
resolved
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Gabapentin 100 mg PO QHS
4. Levothyroxine Sodium 12.5 mcg PO DAILY
5. Mirtazapine 15 mg PO QHS
6. melatonin 5 mg oral QHS
7. Vitamin D 400 UNIT PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Furosemide 10 mg PO DAILY
10. Multivitamins W/minerals Liquid 15 mL PO DAILY
11. amLODIPine 5 mg PO DAILY
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Omeprazole 20 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Epoetin Alfa 8000 UNIT SC QMOWEFR
3. Ferrous Sulfate (Liquid) 300 mg PO TID
4. Miconazole Powder 2% 1 Appl TP BID
5. amLODIPine 5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 10 mg PO QPM
8. FoLIC Acid 1 mg PO DAILY
9. Gabapentin 100 mg PO QHS
10. Levothyroxine Sodium 12.5 mcg PO DAILY
11. melatonin 5 mg oral QHS
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Mirtazapine 15 mg PO QHS
14. Multivitamins W/minerals Liquid 15 mL PO DAILY
15. Omeprazole 20 mg PO BID
16. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Suspected infected enterocutaneous fistula
# Chronic Ventral Abdominal Wound
# Septic Shock
# Asymptomatic bilateral pleural effusions
# Malnutrition, severe
# Normocytic anemia
# Coagulopathy
# ___ - resolved
# Diffuse large B-cell lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with a a severe infection from
enterocutaneous fistula and chronic ventral abdominal wound;
this also resulted in kidney injury, but all improved with
fluids and antibiotics. You also had malnutrition and resulted
IV nutrition (TPN) as well as tube feeds, but this improved, and
you were able to have a soft diet.
We wish you the best in your recovery,
Your ___ care team
severe infection from your abdomen that resulted in
enterocutaneous fistula
Followup Instructions:
___
|
10873456-DS-9
| 10,873,456 | 26,799,783 |
DS
| 9 |
2130-08-13 00:00:00
|
2130-08-13 20:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male who presents with approximately one week
history of malaise, and abdominal pain. He describes the pain as
sharp, non-radiating and constant ___. Located periumblical and
epigastric area mainly. Started about one week ago and is not
associated with food or drinking. Not associated with long
periods of fasting either. No nausea/vomiting. He has had no
previous episodes of this. He has a hx of a perforated gastric
ulcer and underwent a subtotal gastrectomy in ___ complicated
by peritonitis and CVA with right hemiparesis. He has had
chronic diarrhea since the surgery with no recent change in
bowel habits. Does not know if he has been given NSAIDs at ___
___ where he resides.
In the ED, initial vital signs were: T98.3 102 179/91 16 97% RA
- Exam notable for: TTP over epigastric region
- EKG-SR 85 LAD/NI, no prior
- Labs were notable for: WBC 13 (83%N), Hb 10.4, plt 396, BUN/Cr
___
- bl cx sent
- CTA abd with extensive inflammatory changes and complex fluid
in the right upper quadrant just lateral to the proximal
duodenum is most consistent with a severe duodenitis. A small
underlying rupture cannot be completely excluded, though there
is no free air or evidence of extravasated oral contrast.
- Patient was given: 1L NS, Cipro/flagyl
- The patient has been able to tolerate po without issue, no
diarrhea, no lactate, no peritoneal signs. No free air.
- On Transfer Vitals were: 98.2 98 134/83 16 96% RA
On the floor, he is comfortable. He states he felt better after
he received antibiotucs in the ED.
Vital were: 97.6 160/80 ___ RR20 99%ra wt 74.7kg
Past Medical History:
HTN
Perforated gastric ulcer s/p subtotal ___
CVA with residual right-sided weakness -___
Hypothyroidism
Social History:
___
Family History:
Brother with diabetes
Physical Exam:
Admissions Physical:
=============
Vitals: 97.6 160/80 ___ RR20 99%ra wt 74.7kg
GENERAL: Alert and oriented x 3. 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, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
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
Discharge Physical:
============
Pertinent Results:
Admissions Labs:
===========
___ 12:20PM BLOOD WBC-13.0* RBC-3.66* Hgb-10.4* Hct-31.6*
MCV-86 MCH-28.3 MCHC-32.8 RDW-15.1 Plt ___
___ 12:20PM BLOOD Neuts-83.0* Lymphs-12.7* Monos-3.9
Eos-0.2 Baso-0.1
___ 12:20PM BLOOD Glucose-116* UreaN-19 Creat-1.3* Na-142
K-3.8 Cl-99 HCO3-28 AnGap-19
___ 12:20PM BLOOD ALT-14 AST-15 AlkPhos-143* TotBili-0.2
___ 12:20PM BLOOD Albumin-3.8 Calcium-9.5 Phos-2.5* Mg-2.0
Discharge Labs:
==========
Pertinent Imaging:
===========
- CT abd:
1. Extensive inflammatory changes and complex fluid in the right
upper
quadrant just lateral to the proximal duodenum, with areas
appearing confluent
with the duodenal wall, is most consistent with severe
duodenitis. No free
air or extraluminal oral contrast to suggest frank perforation.
No organized
fluid collections are present. Etiologies for these findings
include infected
ulcer, a postoperative injury, or an inflammatory neoplasm.
Correlate with
surgical history. Endoscopy is recommended following resolution
of acute
condition as underlying mass cannot be excluded.
2. The gallbladder lies adjacent to this process, but appears
intact and
non-distended, and is not felt to be the source.
3. Nonspecific mild bile duct prominence which may be
age-related.
4. Colonic diverticulosis.
Brief Hospital Course:
___ y/o gentleman with PMH of HTN and gastric ulcer presenting
with abdominal pain found to have duodenitis.
#Abdominal pain/duodenitis: The patient presented to the
hospital with abdominal pain, malaise, nausea, and vomiting for
one week. CT Abdomen/Pelvis in the ED shows finding consistent
with severe duodenitis. No obvious free air but small underlying
rupture cannot be excluded; reassured by no evidence of perf on
imaging though. Given the acute inflammation, there was no role
for endoscopy on this admission. The patient was initially
started on IV cipro/flagyl, IV pantoprazole, and was made NPO.
His pain significantly improved overnight. According to the
___ stewardship team, there is no definitive role
for antibiotics in the treatment of duodenitis and thus his
antibiotics were discontinued on his second hospital day (___)
without clinical deterioration. His abdominal exam remained
benign without evidence of peritonitis. The patient's diet was
advanced without issue. He did have some mild abdominal pain on
his ___ hospital day for which he was started on sucralfate with
good response (total course 14 days ending ___. He was
discharged home with resumption of home services. The patient
should have an endoscopy after resolution of acute inflammation
(> approximately 6 weeks).
#HTN: Stable while admitted. Home metoprolol was continued.
#Hypothyroidism: Stable while admitted. Home levothyroxine was
continued.
Transitional Issues:
- DNR, ok to intubate
- The patient should have an upper endoscopy in > 6 weeks or
when acute inflammation resolves
- The patient should follow up with his PCP upon discharge
- Stool h. pylori and h. pylori antibody test pending at
discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 12.5 mg PO BID
2. Furosemide 20 mg PO DAILY
3. Vitamin D ___ UNIT PO DAILY
4. Levothyroxine Sodium 12.5 mcg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. Gabapentin 100 mg PO BID
8. Acetaminophen 650 mg PO TID
9. Calcium Carbonate 1000 mg PO QHS:PRN dyspepsia
10. Mirtazapine 15 mg PO QHS
11. DiphenhydrAMINE 25 mg PO Q8H:PRN itching
12. Hydrocortisone Cream 1% 1 Appl TP BID:PRN inflammation
13. Guaifenesin 10 mL PO Q6H:PRN cough
14. Fleet Enema ___AILY:PRN constipation not relieved
by dulcolax
15. Milk of Magnesia 30 mL PO Q6H:PRN dyspepsia
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 1000 mg PO QHS:PRN dyspepsia
3. Gabapentin 100 mg PO BID
4. Guaifenesin 10 mL PO Q6H:PRN cough
5. Levothyroxine Sodium 12.5 mcg PO DAILY
6. Metoprolol Tartrate 12.5 mg PO BID
7. Milk of Magnesia 30 mL PO Q6H:PRN dyspepsia
8. Mirtazapine 15 mg PO QHS
9. Vitamin D ___ UNIT PO DAILY
10. Acetaminophen 650 mg PO TID
11. DiphenhydrAMINE 25 mg PO Q8H:PRN itching
12. Fleet Enema ___AILY:PRN constipation not relieved
by dulcolax
13. Furosemide 20 mg PO DAILY
14. Hydrocortisone Cream 1% 1 Appl TP BID:PRN inflammation
15. Omeprazole 20 mg PO BID
16. Sucralfate 1 gm PO QID Duration: 14 Days
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*52 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Duodenitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you were having
abdominal pain. You were found to have inflammation in your
abdomen around the first part of your small intestine called the
duodenum. There was evidence of inflammation but no signs of
infection. Your abdominal pain improved significantly while you
were in the hospital. It's important that you follow up with
your primary care doctor who will be able to refer you for an
upper endoscopy to further investigate the fluid collection once
the inflammation has resolved.
You are now ready to be discharged. Please continue taking your
medications as instructed.
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
10873681-DS-21
| 10,873,681 | 20,228,116 |
DS
| 21 |
2183-08-15 00:00:00
|
2183-08-18 10:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
adhesive / cats / latex
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ year-old man with CAD s/p CABG x1, AVR,
atrial
fibrillation, and symptomatic second degree type I AV block s/p
PPM who presents with witnessed syncope.
He reports feeling tired yesterday ___, then during dinner with
wine he lost consciousness for 30 seconds. There was mild
lightheadedness immediately before the event. He was not
attempting to stand up or reach for anything when this occurred.
He was guided to the ground (carpeted) by surrounding family
members, there was no head strike or evident trauma. He was
reported as looking sweaty and pale. He awoke without confusion.
There was no tongue biting or loss of continence. There was also
no chest pain, tightness, SOB, palpitations, dizziness, or
sensation of weakness in his torso or LEs before the episode. He
had drunk 4 glasses of wine.
He endorses mild dizziness "time to time" in recent months,
never
before causing LOC. There are no apparent triggers, the
sensation
may occur at rest or with movement. He reports this sometimes
causes mild loss of balance. Each episode is several seconds in
duration. He also endorses occasional "darkness" in his R eye.
There is no associated pain.
Past Medical History:
Aortic Insufficiency
Coronary Artery Disease
s/p AVR, CABG this admission
PMH:
aortic insufficiency
mitral insufficiency
NSTEMI ___
coronary artery disease ( S/p BMS to LAD, PTCA to Diag)
mild normocytic anemia
chronic renal insufficiency ( baseline Cr 1.5)
hypertension
hyperlipidemia
pacemaker ___ ( first degree and type-1 second degree AVB)
Raynaud's syndrome
benign prostatic hypertrophy
RLL PNA ___
gastroesophageal reflux
left gynecomastia
right ___ varicosities
Social History:
___
Family History:
There is no family history of premature coronary artery disease,
unexplained heart failure, or sudden death.
Physical Exam:
INITIAL EXAM:
VITALS: T 97.5F, BP 129/79, HR 61, RR 18, O2 Sat 95% on RA
GENERAL: Well-developed, well-nourished. NAD. Able to sit up
without assistance.
HEENT: NCAT. Sclera anicteric. Conjunctiva pink, no pallor or
cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple.
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No
thrills,
lifts.
LUNGS: No chest wall deformities or excess kyphosis. Respiration
unlabored, no accessory muscle use. No crackles or rhonchi.
Occasional central airway sound on inspiration.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No gross rash or erythema. Scattered raised skin tags on
back.
PSYCH: Mood, affect appropriate.
DISCHARGE EXAM:
GENERAL: Well-developed, well-nourished. NAD. Able to sit up
without assistance.
HEENT: NCAT. Sclera anicteric. Conjunctiva pink, no pallor or
cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple.
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No
thrills,
lifts.
LUNGS: No chest wall deformities or excess kyphosis. Respiration
unlabored, no accessory muscle use. No crackles or rhonchi.
Occasional central airway sound on inspiration.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No gross rash or erythema. Scattered raised skin tags on
back.
PSYCH: Mood, affect appropriate.
Pertinent Results:
ADMISSION LABS:
___ 10:10PM BLOOD WBC-7.6 RBC-4.02* Hgb-13.4* Hct-39.8*
MCV-99* MCH-33.3* MCHC-33.7 RDW-13.1 RDWSD-47.5* Plt ___
___ 10:10PM BLOOD Plt ___
___ 11:21PM BLOOD Glucose-122* UreaN-29* Creat-1.9* Na-141
K-4.7 Cl-102 HCO3-24 AnGap-15
___ 01:45AM BLOOD cTropnT-<0.01
___ 11:21PM BLOOD Calcium-9.5 Phos-3.4 Mg-1.7
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-7.9 RBC-4.12* Hgb-13.5* Hct-40.5
MCV-98 MCH-32.8* MCHC-33.3 RDW-12.8 RDWSD-45.7 Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-93 UreaN-26* Creat-1.4* Na-141
K-4.1 Cl-105 HCO3-24 AnGap-12
___ 06:10AM BLOOD ALT-18 AST-20 AlkPhos-67 TotBili-0.3
___ 06:45AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.5*
STUDIES:
The left atrial volume index is mildly increased. 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%. There is
no resting left ventricular outflow tract gradient with no
change with Valsalva. No ventricular septal defect is seen.
Diastolic parameters are indeterminate. Normal right ventricular
cavity size with uninterpretable free wall motion assessment.
There is abnormal septal motion c/w conduction abnormality/paced
rhythm. The aortic sinus diameter is normal for gender with
mildly dilated ascending aorta. The aortic arch is mildly
dilated with a normal descending aorta diameter. There is no
evidence for an aortic arch coarctation. An aortic valve
bioprosthesis is present. The prosthesis is well seated with
normal gradient. There is no aortic regurgitation.
The mitral valve leaflets are mildly thickened with no mitral
valve prolapse. There is moderate mitral annular calcification.
There is mild [1+] mitral regurgitation. The tricuspid valve
leaflets appear structurally normal.
There is mild [1+] tricuspid regurgitation. Due to acoustic
shadowing, the severity of tricuspid regurgitation
may be UNDERestimated. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial
effusion.
IMPRESSION: No structural cardiac cause of syncope identified.
Well seated, normally functioning bioprosthetic aortic valve
prosthesis with normal gradient and no aortic regurgitation.
Mild
symmetric left ventricular hypertrophy with normal biventricular
cavity sizes and regional/global systolic function. Mild mitral
and tricuspid regurgitation.
Brief Hospital Course:
This is an ___ year old man with CAD s/p CABG x1, CHB s/p PPM,
atrial fibrillation on apixiban, AI s/p bioprosthetic AVR who
presents with witnessed syncope.
===================
TRANSITIONAL ISSUES
===================
[] please continue to advise pt about moderating alcohol intake.
ACTIVE ISSUES:
==============
# Syncope
History if pre-syncopal clamminess and witnessed diaphoresis in
the setting of recent diarrhea and ___ most consistent with
orthostasis with some contribution of vasovagal syncope. HCT was
negative for acute bleed. Extensive cardiac work up; including
EKG, troponins, PPM interrogation, and TTE were without concern
for MI, PE, arrhythmia, or new valvular disease.
# ___
Presented with Cr 1.9 from baseline 1.1, consistent with
pre-renal due to preceding diarrhea. Trended down to 1.4 on
discharge.
# Atrial fibrillation
# CHB s/p PPM
Continue home apixiban.
CHRONIC ISSUES:
===============
# CAD: continue atorvastatin, aspirin, and metoprolol
# Asthma/COPD (unclear history): continued advair
# BPH: continued finasteride, tadalafil, alfuzosin
# Sciatica in RLE: continue acetaminophen
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Atorvastatin 20 mg PO QPM
3. Finasteride 5 mg PO DAILY
4. alfuzosin 10 mg oral DAILY
5. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Omeprazole 20 mg PO BID
8. Acetaminophen 325 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325 mg PO DAILY
2. alfuzosin 10 mg oral DAILY
3. Apixaban 5 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Finasteride 5 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
Syncope
Acute Kidney Injury
SECONDARY DIAGNOSES
Corornary artery disease
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you passed out.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- We monitored your heart closely on telemetry. We interrogated
your pacemaker to look for abnormal heart rhythms. We took an
ultrasound of your heart. These tests were all normal.
WHAT SHOULD I DO WHEN I GO HOME?
- You should try to drink a little bit more water.
- You should continue to moderate your alcohol intake.
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10873966-DS-20
| 10,873,966 | 23,457,719 |
DS
| 20 |
2184-07-14 00:00:00
|
2184-07-14 16:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Naproxen / Haldol
Attending: ___.
Chief Complaint:
Agitation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with hx of MDD, frontotemporal dementia, ___ ankle
fracture (___), recent inpatient psychiatric admission at
___ (discharged ___, presented to ___ after
his wife called an ambulance ___ increasing agitation.
Briefly, pt had a ___ from a 4-foot wall on ___,
initial radiograph showed no fracture, but presented to ___
___ w/ continued pain, repeat imaging showed nondisplaced
talus fx. He was given a plastic splint, but then admitted to
inpt psychiatric unit for agitation, where his medications were
changed (updated in OMR). Discharged on ___. Shortly after
discharge he was seen by orthopedics who placed a hard cast,
which appeared to precipitate the pt's recent behavioral
decompensation: pt became increasingly difficult for his wife to
manage, exhibiting physically violent behaviors to self and
others (trying to cut his cast off with a knife, throwing his
wife against a wall, threatening to jump off a ___ floor
balcony). He also insisted on walking on his cast (he is
reportedly meant to be touch-down weight-bearing).
In the ED, pt's initial vitals were T 96.7, HR 55, BP 131/68, RR
20, O2sat 99%, with no focal neurologic deficits. Also underwent
RLE films which showed no fx. Ankle cast removed and boot
placed. He presented significant behavioral challenges, yelling
and threatening staff, requiring 4-point restraints. He was
placed with a 1:1 sitter and given olanzipine for sedation. Wife
reported that aside from agitation, pt is at psychiatric
baseline.
Pt was seen by psychiatry at 11 am on morning of presentation
(___), who felt that his presentation was consistent with a
decompensation of his underlying dementia owing to the stressor
of his R ankle pain and especially discomfort and irritation
from the new cast. Given his unsafe behaviors at home, he was
felt to meet ___ criteria for inpatient psychiatric
admission for safety, stabilization, and aftercare planning.
Pt continued to display physically violent behaviors overnight
in the ED, lashing out at staff, including biting and spitting.
At approximately 1 am he began receiving doses of lorazepam; in
total he received 8 mg IM lorazepan, 37.5 mg IM and SL
olanzapine, along with home dose of divalproex and seroquel
(home med administratin needs confirmation as pt appears not to
be accepting po). ICU request placed ___ high level of nursing
care, frequent med administration. However, pt became very
sedated, felt by psychiatry attending to be acutely delerious
___ aggressive medication; psych attending also concerned as IM
zyprexa and benzodiazepines carry a black box warning for
respiratory depression. Pt admitted to ICU for monitoring,
placement.
Past Medical History:
___'s dementia (severe, followed by psychiatry (Dr ___ and
neurology (Dr ___
R ankle fx
HTN
AAA (3.6cm on ___
Enlarged prostate
Proclactinoma
Social History:
___
Family History:
Unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vitals: T 96, 69, 160/79, 12, 98 on RA
General- Somnolent, responds to sternal rub with moans. Four
point ___.
HEENT- Sclera anicteric, MMM,
Lungs- CTAB but anterior exam only
CV- Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen- soft, non-tender, non-distended, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused bilaterally, 2+ pulses, RLE w/ 1+
pitting edema. No cast or boot in place. 4-point restraints in
place
Neuro- Moving all extremities independently
DISCHARGE PHYSICAL EXAM:
=========================
AVSS
Walking floor in boot.
Confused. Oriented to self and family, but not to time and
location.
Pertinent Results:
ADMISSION LABS:
================
___ 09:15AM GLUCOSE-84 UREA N-12 CREAT-1.0 SODIUM-142
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-27 ANION GAP-13
___ 09:15AM WBC-5.1 RBC-4.21* HGB-12.2* HCT-37.8* MCV-90
MCH-28.9 MCHC-32.2 RDW-15.7*
___ 09:15AM NEUTS-73.5* LYMPHS-16.3* MONOS-7.6 EOS-1.9
BASOS-0.6
___ 09:15AM PLT COUNT-154
___ 01:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 01:35PM URINE COLOR-Straw APPEAR-Clear SP ___
PERTINENT IMAGING:
==================
___ Imaging ANKLE (AP, MORTISE & ___
___ the tibia and fibula, frontal and lateral views of the
___ ankle
frontal and lateral views. Overlying cast material obscures
fine detail. No displaced fracture is detected. The ankle
mortise appears congruent on this non weight-bearing view.
Chondrocalcinosis of the ___ knee is noted with mild
degenerative changes. No radiopaque foreign body.
___ Imaging TIB/FIB (AP & LAT) RIGH
___ the tibia and fibula, frontal and lateral views of the
___ ankle
frontal and lateral views. Overlying cast material obscures
fine detail. No displaced fracture is detected. The ankle
mortise appears congruent on this non weight-bearing view.
Chondrocalcinosis of the ___ knee is noted with mild
degenerative changes. No radiopaque foreign body.
___ CXR
IMPRESSION: AP chest compared to ___:
Lung volumes are much lower today, but the lungs are clear,
heart is normal size and there is no pleural abnormality.
Brief Hospital Course:
___ yo M w/ advanced fronto-temporal dementia, admitted for
agitation s/p cast placement for R ankle fracture.
# Agitation/delirium: Pt w/ advanced dementia at baseline,
recent issue appears to have initially represented an acute
decompensation of his dementia owing to the stressor of cast
placement a few days ago. Subsequent delerium and lowered level
of consciousness in the ED is likely ___ overmedication in
response to challenging behaviors in ED. Unlikely infection
given afebrile, no leukocytosis. Cast was removed by ortho and
risks of cast removal discussed with family. Sedating
medications were limited and patient returned to baseline
agitation.
#Frontotemporal dementia: Pt w/ baseline advanced dementia;
merits placement to ___ ward. He was treated with zyprexa
5mg BID and 5mg BID PRN for agitation.
- Dr. ___ is the ___ outpatient neuro-psychiatrist
#Ankle fracture. No evidence of fracture on ___ films, but
owing to increased pain had f/u film revealing nondisplaced
talus fracture. Ortho removed cast with family understanding
that this increases chance of fracture displacement and future
complications. Followed by Dr. ___ as a outpatient.
#Prolactinoma. Managed as outpt. No risperdal as this is
contraindicated.
The patient is medically stable for transfer to a ___
facility
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO HS
2. Citalopram 40 mg PO QHS
3. cabergoline 0.5 mg oral qMON, qTHURS
4. Donepezil 10 mg PO BREAKFAST
5. Lisinopril 40 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Nitroglycerin SL 0.3 mg SL PRN chest pain
8. QUEtiapine Fumarate 25 mg PO TID
9. Ranitidine 300 mg PO DAILY
10. Acetaminophen 500 mg PO Q6H:PRN pain
11. Aspirin 81 mg PO DAILY
12. Vitamin D ___ UNIT PO DAILY
13. ramelteon 8 mg oral qHS
14. Divalproex (DELayed Release) 500 mg PO BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain fever
2. Aspirin 81 mg PO DAILY
3. Citalopram 40 mg PO QHS
4. Divalproex (DELayed Release) 750 mg PO BID
5. Donepezil 10 mg PO BREAKFAST
6. Lisinopril 40 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Ranitidine 300 mg PO DAILY
9. OLANZapine 5 mg PO BID:PRN agitation
10. OLANZapine 5 mg PO BID
11. Atorvastatin 40 mg PO HS
12. cabergoline 0.5 mg ORAL QMON, QTHURS
13. Nitroglycerin SL 0.3 mg SL PRN chest pain
14. QUEtiapine Fumarate 25 mg PO TID
15. ramelteon 8 mg oral qHS
16. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
- Acute Metabolic Encepahlopathy
- Fronto-Temporal Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for acute on chronic
confusion. This was likely due to your medications. You are now
being discharged to a psychiatric facility.
Followup Instructions:
___
|
10874048-DS-23
| 10,874,048 | 21,854,563 |
DS
| 23 |
2133-08-26 00:00:00
|
2133-08-26 16:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Heparin Agents
Attending: ___.
Chief Complaint:
right facial droop, right upper and lower extremity weakness.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a pleasant ___ man with extensive medical
history notable for hypertension, hyperlipidemia, remote left
frontal aneurysmal bleed status post VP shunt placement, and
bladder cancer, who presents to the ED as a code stroke in the
setting of acute onset right facial droop, right upper and lower
extremity weakness.
Per the wife at the bedside he was last known well on ___
at around 7 ___. She reports he went upstairs to change his
plans
for church. When she came into the bedroom she found him
sitting
down on a bench confused, dysarthric, with marked right facial
droop, right arm and leg weakness. He told her that he was not
feeling well but it was very hard for her to understand him as
his speech was very garbled. EMS was called, on arrival blood
pressure 170/80.
On arrival to the ED ___ stroke scale was 12 scoring for loss of
consciousness questions, facial palsy, right arm and leg
weakness, limb ataxia, language, and dysarthria. Non-contrast
head CT was obtained which showed no new areas of left frontal
encephalomalacia from his previous bleed ___ years ago, VP shunt
in place, no evidence of acute large territory bleed, and a
possible dense left MCA. TPA was offered, risks and benefits
were explained to the family, and they have elected to proceed
with treatment. At 9:30 ___ he was given a bolus of 6.8 mg over
1
minute, followed by an infusion of 61.2 mg for a total of 68 mg.
He was taken back for CTA head and neck which showed complete
occlusion of the left internal carotid artery from the petrous
portion to the cavernous carotid.
Repeat exam after administration of TPA at around 1045 with ___
stroke scale of 2 scoring for loss of consciousness questions,
right arm drift.
Past Medical History:
1. Status post intracranial hemorrhage, ___, near drowning
event on ___ in the ocean, resuscitated on the beach and
taken to ___, s/p ventriculoperitoneal shunt.
(Last seen by neurologist, Dr. ___ in ___
2. Vitamin D deficiency
3. Hypertension
4. Renal insufficiency
5. Depression
6. Osteoarthritis of knees and left shoulder
7. Urinary incontinence
8. Hyperlipidemia
9. History of kidney stone 50+ yrs ago, no recurrence, on
Allopurinol chronically for this
10. Skin cancer of face and back, recently diagnosed
11. Prostate Cancer s/p cystoscopy and tx with BCG
Social History:
___
Family History:
His mother died - stroke. His father died in young age from
heart disease. He had four siblings, whom died of heart disease,
and his one brother did have dementia. His sister died of
breast cancer.
Physical Exam:
Admission exam:
On arrival:
97.9
75
141/70
20
95% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: Clear bilaterally
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, left arm IV site infiltrated
Neurologic Examination after TPA:
- Mental status: Awake, alert, oriented to self partially to
place and date. Unable to relate history without difficulty.
Speech is fluent with ___ word sentences, intact repetition, and
intact verbal comprehension. Able to name objects on the stroke
card, such as key, chair, and feather (in ___, which his son
translates at the bedside). No dysarthria, compared to initial
examination when he was severely dysarthric with almost no
exchange of information. No evidence of hemineglect. No
left-right confusion. Able to follow both midline and
appendicular commands.
- Cranial Nerves: PERRL 4->2 brisk. Blinks to threat in all
visual fields. EOMI, no nystagmus. V1-V3 without deficits to
light touch bilaterally. No facial movement asymmetry, as
compared to profound right lower facial weakness on arrival.
Hearing intact to finger rub bilaterally. Palate elevation
symmetric. SCM/Trapezius strength ___ bilaterally. Tongue
midline.
- Motor: Normal bulk and tone. Mild right drift. No tremor at
rest. Left upper and lower extremity full in all muscle groups.
Right upper extremity antigravity, with at least ___ strength
throughout. Right lower extremity with ___ proximal weakness.
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 1 1
R 2+ 2+ 2+ 1 1
Plantar response flexor on the left, extensor on the right.
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: Deferred given fall risk
*******************
Discharge exam:
Vitals: afebrile, 140-150/80, 70-80, 98%RA
General: appears comfortable, resting in bed in NAD
HEENT: atraumatic/normocephalic
CV: No pallor no diaphoresis
Lungs: Breathing comfortably on room air
Abdomen: soft NT ND
Ext: no pedal edema, symmetric
Skin: no open areas, no rashes
Neuro:
MS- EO spont, alert. Follows simple commands. Language is
fluent,
however difficult to understand his
language at times due to dysarthria.
CN- mild anisocoria R>L briskly reactive, slight R facial droop
but face activates symmetrically. Dysarthria
Sensory/Motor- moves all 4 extremities anti gravity
Coordination- deferred
Gait- Deferred
Pertinent Results:
___ 09:49PM URINE HOURS-RANDOM
___ 09:49PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 09:49PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:49PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 09:49PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 09:49PM URINE MUCOUS-RARE
___ 08:40PM CREAT-1.5*
___ 08:40PM UREA N-35* CREAT-1.6* SODIUM-141
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14
___ 08:40PM estGFR-Using this
___ 08:40PM estGFR-Using this
___ 08:40PM ALT(SGPT)-12 AST(SGOT)-14 ALK PHOS-71 TOT
BILI-0.2
___ 08:40PM LIPASE-42
___ 08:40PM ALBUMIN-3.7
___ 08:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:40PM GLUCOSE-103 NA+-144 K+-3.7 CL--105 TCO2-23
___ 08:40PM WBC-8.7 RBC-4.21* HGB-12.1* HCT-37.1* MCV-88
MCH-28.7 MCHC-32.6 RDW-15.8* RDWSD-50.2*
___ 08:40PM PLT COUNT-193
___ 08:40PM ___ PTT-28.2 ___
CTA head and neck
IMPRESSION:
1. Stable appearance of the head with chronic encephalomalacia
involving the
left frontal lobe and ex vacuo dilatation of the frontal horn of
the left
lateral ventricle status post left pterional craniotomy and
aneurysm clipping.
2. Extremely limited CTA of the head given partially
extravasated of contrast
into the soft tissues of the left antecubital fossa and timing.
Evaluation of
the cavernous segments of the internal carotid arteries is
extremely limited
given the lack of appropriate opacification, although there is
distal flow.
3. Asymmetric decreased arborization of the distal left MCA
vessels, could be
secondary to suboptimal technique/artifact however ischemia
cannot be excluded
on this study. Repeat study with MRI/MRA of the head is
recommended for
further evaluation.
4. Severe stenosis is seen involving the V4 segment of the left
vertebral
artery likely secondary to atherosclerotic disease.
5. The left posterior cerebral artery is not visualized on this
exam.
6. Extremely limited CTA of the neck secondary to suboptimal
contrast bolus.
No definite evidence of internal carotid artery stenosis by
NASCET criteria.
RECOMMENDATION(S): Repeat MRI/MRA of the head is recommended
for further
evaluation.
EEG
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of
(1) nearly continuous slowing in the left frontal and temporal
region and rare
slowing in the right frontal region, indicative of focal areas
cerebral
dysfunction; (2) diffuse slowing of the background, indicative
of moderate
encephalopathy, which is non-specific with regard to etiology
but may be due
to toxic-metabolic disturbances or medication. There are no
electrographic
seizures.
MRI/MRA brain
IMPRESSION:
1. Multifocal small late acute infarcts in bilateral cerebellar
hemispheres,
bilateral occipital lobes, and left anterior pons, consistent
with embolic
phenomena in the posterior circulation.
2. Moderate to severe narrowing of the distal left cervical
internal carotid
artery at the skullbase as a result of calcified atherosclerotic
disease.
3. Severe focal narrowing or near occlusion of the distal left
vertebral
artery, at the result of calcified atherosclerotic plaque, just
proximal to
the vertebrobasilar junction.
4. Unchanged chronic left frontal encephalomalacia and gliosis.
5. Postsurgical changes related to right frontal ventriculostomy
catheter with
unchanged position terminating in the frontal horn of the left
lateral
ventricle. The ventricles are stable in size.
6. Head MRA is moderately motion degraded and further limited by
extensive
susceptibility artifact from a left suprasellar aneurysm clip
obscuring
portions of the internal carotid artery and the proximal
branches along the
left side of the circle of ___. Within these limitations,
the posterior
inferior and anterior inferior cerebellar arteries are not well
visualized.
The remaining vessels are grossly patent.
EEG ___
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of
(1) nearly continuous slowing in the left frontal and temporal
region and rare
slowing in the right frontal region, indicative of focal areas
cerebral
dysfunction; (2) diffuse slowing of the background, indicative
of moderate
encephalopathy, which is non-specific with regard to etiology
but may be due
to toxic-metabolic disturbances or medication. There are no
electrographic
seizures.
TTE ___
The left atrium is elongated. 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. No aortic regurgitation is seen. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Very limited study. Grossly preserved biventricular
systolic function.
CXR ___
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Previous vascular congestion has improved. There is still right
infrahilar
consolidation, possibly aspiration. Heart is mildly enlarged.
Thoracic aorta
is very tortuous in generally enlarged. No appreciable pleural
effusion. No
pneumothorax.
Humerous xray ___
IMPRESSION:
No fracture
CT head ___
IMPRESSION:
There are no acute intracranial changes compared to prior.
There are small early subacute infarcts, better seen on prior
MRI.
Stable chronic encephalomalacia, generalized parenchymal
atrophy.
Brief Hospital Course:
___ year old right handed ___ gentleman with
prior left frontal ICH due to now secured aneurysm with new
onset
confusion, dysarthria and right sided weakness, s/p IV tPA. His
CTA showed lack of flow in the left ICA distal to
the bifurcation but with distal filling and filling of the MCA,
likely cross filling through the ACOM. Unknown chronicity. MRI
confirmed multiple infarcts in the posterior circulation. Likely
mechanism is cardioembolism. Although there is also an area of
high grade stenosis of the left V4 segment of the vertebral
artery, emboli from this area would be highly unlikely to
account for the right ___ cerebellar stroke, given the arterial
anatomy. He underwent a TTE which was a very limited study but
showed an elongated left atrium and EF 55%.
He was started on ASA 81 mg.
His course was complicated by UTI for which he was started on
ceftriaxone which was switched to cefpodoxime upon discharge
(EOT ___.
He was also noted to be agitated at night for which he was
started on Seroquel 12.5mg qhs.
He will need ___ of heart monitor as outpatient.
Transitional issues:
-complete 7 day course of Cefpodoxime (EOT ___
-will need ___ of heart monitor as outpatient
-hypernatremia. Pt noted to be mildly hypernatremic this am
(147). Will need to have sodium monitored, with next check tmrw.
Please encourage PO water intake.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL =84 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >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 - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Venlafaxine 37.5 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cefpodoxime Proxetil 100 mg PO Q12H UTI Duration: 3 Days
3. QUEtiapine Fumarate 12.5 mg PO QHS agitation
4. Allopurinol ___ mg PO DAILY
5. amLODIPine 5 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Venlafaxine 37.5 mg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ischemic stroke
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic sometimes but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear MR. ___,
You were hospitalized due to symptoms of right facial droop and
right sided weakness 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.
You underwent an echo of your heart ( imaging of your heart)
which showed normal ejection fraction. You will need to get a
___ OF HEART monitor as an outpatiemt to monitor your heart
rhythm. You were also noted to have a urinary tract infection
for which you will complete a course of antibiotics.
We are changing your medications as follows:
-start ASA 81mg daily
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10874066-DS-17
| 10,874,066 | 20,501,678 |
DS
| 17 |
2151-09-30 00:00:00
|
2151-10-01 11:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mrs. ___ is a ___ year old female presenting with
progressive abd pain that started at 0300 and was periumbilical
then moving to RUQ and RLQ. This pain has gradually gotten worse
through day and is associated with nausea but no vomiting. She
has chronic low back pain for approx ___ years related to an
injury and she is also having this pain currently.
Of note is that she had EGD in ___ and ___. @006 was for
epigastric pain, she was found to have antrum gastritis but
duodenum was normal. In ___ she was noted to have guaiac
positive stool and had colonscopy and EGD. EGD this time showed
normal stomahc and duodenum.
She denies any recent steroid use, h/o smoking, or NSAID use
(although she states she has been using a pain medication for
her chronic low back pain related to injury ___ years ago that
she can not recall the name of). She also denies any fevers,
weigh loss, appetite changes, BRPBPR or black/tarry stools. She
also denies dysuria.
She was guaiac negative in the ED.
Past Medical History:
Past Medical History:
GERD (scopes as listed above), low back pain, thyroid nodule
(been followed by endocrine)
Past Surgical History: none
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
Vitals: 98.3 HR 93 BP 123/72 RR 16 99RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, tender in RUQ and RLQ with no
rebound/guarding, has small epigastric scar well healed non
surgical, no hernias or palpable masses
She also had right flank tenderness.
Ext: No ___ edema, ___ warm and well perfused
On discharge:
VS 98.2, 72, 128/65, 14, 100% on room air.
Pertinent Results:
___ 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 02:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:30PM PLT COUNT-197
___ 02:30PM NEUTS-91.6* LYMPHS-5.3* MONOS-2.9 EOS-0.1
BASOS-0.1
___ 02:30PM WBC-11.7*# RBC-4.08* HGB-11.9* HCT-36.8
MCV-90 MCH-29.1 MCHC-32.3 RDW-12.3
___ 02:30PM URINE UCG-NEGATIVE
___ 02:30PM URINE HOURS-RANDOM
___ 02:30PM ALBUMIN-4.6
___ 02:30PM LIPASE-32
___ 02:30PM ALT(SGPT)-32 AST(SGOT)-33 ALK PHOS-44 TOT
BILI-0.6
___ 02:30PM estGFR-Using this
___ 02:30PM GLUCOSE-129* UREA N-11 CREAT-0.6 SODIUM-137
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-29 ANION GAP-14
___ 05:09PM LACTATE-1.0
CT A/P ___ - IMPRESSION:
1.5 cm focal air and fluid collection adjacent to the second
portion of
duodenum along with adjacent fat stranding and small amount of
fluid extending inferiorly along the right anterior pararenal
space. Findings could reflect duodenitis with a diverticulum,
focal duodenal diverticulitis, or a duodenal ulcer with
contained perforation.
RUQ U/S ___ - IMPRESSION: Cholelithiasis without evidence
of acute cholecystitis.
___ Upper GI
No evidence of duodenal perforation or mucosal abnormality.
Brief Hospital Course:
Mrs. ___ is a ___ year old ___ woman admitted for abdominal
pain found to have duodenal diverticulitis vs. a contained
perforation of a duodenal ulcer. She was known to take a number
of various NSAIDs. Initial CT imaging revealed a 1.5 cm focal
air and fluid collection adjacent to the second portion of the
duodenum. This was likely due to a perforated duodenal ulcer.
Helicobacter pylori testing was negative. The patient was kept
NPO and given IV fluids until her abdominal pain subsided.
While NPO, the patient's electrolytes were checked and repleted
as necessary.
On hospital day 5, the patient had one episode of emesis which
she stated was likely due to having nothing to eat. She also
felt as though she had symptoms of GERD. Her IV proton pump
inhibitor was increased from 40mg daily to 60mg daily. On
hospital day 6, the patient underwent an upper endoscopy with
the gastroenterology team. Results showed no evidence of a
duodenal injury or mucosal abnormality.
At the time of discharge, Mrs. ___ was hemodynamically
stable, afebrile, and tolerating an oral diet without pain,
nausea or vomiting. An interpreter was utilized during the
discharge process. She was comfortable an looking forward to
her discharge. An appointment was scheduled for the patient to
follow up with her PCP within one week. In the meantime, she
was instructed to not take any aspirin or NSAIDs until
consulting her PCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral BIDWM
3. Vitamin D ___ UNIT PO DAILY
4. Meclizine 25 mg PO TID
5. Diclofenac Sodium ___ 75 mg PO BID
6. Ponstel *NF* (mefenamic acid) 500 Oral PRN
7. meloxicam *NF* 15 mg Oral daily
Discharge Medications:
1. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral BIDWM
2. Meclizine 25 mg PO TID
3. Multivitamins 1 TAB PO DAILY
4. Vitamin D ___ UNIT PO DAILY
5. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Duodenal diverticulitis vs. contained perforated duodenal ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the acute care surgery service for duodenal
diverticulitis. Because there was concern for a perforation of
your duodenum, you were given bowel rest (nothing by mouth) and
observed for improvements in your pain and abdominal exams. You
had an upper endoscopy on ___ which showed no perforation.
You are now ready to be discharged home with the following
instructions.
General Discharge Instructions:
Please resume all regular home medications, but do not take
aspirin or NSAIDs (non-steroidal anti-inflammatory medications).
Please take any new medications as prescribed.
You may also take acetaminophen (Tylenol) as directed, but do
not exceed 4000 mg in one day.
Please also follow-up with your primary care physician at the
appointment below.
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*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 an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
Followup Instructions:
___
|
10874066-DS-20
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2157-08-07 00:00:00
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2157-08-08 19:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim / dapsone
Attending: ___.
Chief Complaint:
Hematochezia
Major Surgical or Invasive Procedure:
Thoracentesis
History of Present Illness:
This is a ___ ___ speaking woman with myasthenia ___ and
thymic carcinoma c/b myasthenia crisis s/p PEG (___) and
chemoradiation and recent admission (___) for sternotomy,
radical thymectomy, L innominate v to R atrium and R innominate
to ___ bypasses (10mm goretex) and recent diagnosis of
granulomatous colitis, who presents with four days of maroon
stools.
Of note, patient has a recent hospital stay from ___ for
sternotomy, radical thymectomy, L innominate v to R atrium and R
innominate to SVC bypasses (10mm goretex). Her hospital course
was notable for multiple episodes of tachycardia and HTN,
controlled by metoprolol. She also started to have nausea and
loose stools, for which an extensive workup was done but showed
no infectious source. EGD and colonoscopy on ___ demonstrated
granulomatous colitis with no clear cause. She was given banana
flakes and immodium to reduce the bouts of diarrhea.
This time, the patient said her diarrhea continued since
discharge, and 4 days ago, she started to have maroon colored
liquidy stool. She was not able to quantify the amount of blood,
but had to go to the bathroom ___ times a day and each time she
would have bloody stool. Today, she already had 4 BMs and had
the
stool color was bright red.
She also endorsed ___ periumbilical and LLQ intermittent
abdominal pain for 3 days, which is worse around the site of PEG
tube.
In addition, she had nausea since recent hospitalization and
today she had one episode of vomiting but no hematemesis. She
can
take very soft food per mouth, but denied any suspicious food or
sick contacts.
Of note, she was seen by her PCP ___ ___ and found to have
elevated INR on Coumadin (4.1).
On ROS, she had chronic chest pain since thymectomy and endorsed
dizziness, which was described as room spinning and persists
when
she lies down but worsens when she gets up and walks around.
She otherwise denies heart palpitations, SOB, or dysuria.
In the ED, initial vitals were:
T 98.9 HR 115 BP 103/65 RR 18
- Exam notable for:
Abdomen soft, with only mild TTP near the PEG site. PEG site
without signs of infection. No concern for peritonitis or acute
abdomen.
- Labs notable for:
8.6 >8.8/___.3< ___
----------------< AGap=18
4.1 28 0.6
CRP: 13.7
___: 40.8 PTT: 48.6 INR: 3.8
- Imaging was notable for:
CT ABD/PELVIS:
1. Diffuse pneumatosis intestinalis throughout the colon and
rectum. No findings to suggest colitis or ischemia. Tiny foci of
extraluminal gas are not unexpected for a benign entity.
2. Moderate pleural effusion at the right lung base is new from
prior CT in ___, previously imaged on multiple radiographs.
3. Cholelithiasis without evidence of cholecystitis.
4. Left IVC central line via a left common femoral vein
approach.
- Patient was given:
___ 10:05 IV Pantoprazole 40 mg
___ 12:58 IVF NS 1000 mL
___ 15:13 PO/NG OxyCODONE (Immediate Release) 5 mg
___ 15:13 PO/NG Acetaminophen 650 mg
Upon arrival to the floor, patient reports abdominal pain is
under control but feels nauseous.
ROS:
(+) per HPI 10 point ROS reviewed and negative other than those
stated in HPI.
Past Medical History:
MYASTHENIA ___
THYMIC CARCINOMA s/p sternotomy, radical thymectomy, L
innominate
v to R atrium and R innominate to SVC bypasses (10mm goretex)
OSTEOPOROSIS
COUGH
GERD
HYPERTENSION
CERVICAL SPONDYLOSIS
VITAMIN D DEFICIENCY
HEADACHE
GOITER
ANXIETY
HERPES SIMPLEX II
Social History:
___
Family History:
Maternal aunt-colon CA, maternal aunt-brain tumor, maternal
cousin-breast CA
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Temp: 98.0 (Tm 98.0), BP: 119/68 (119-136/68-86), HR:
115 (109-115), RR: 18 (___), O2 sat: 98% (98-99), O2 delivery:
3L Nc, Wt: 105.38 lb/47.8 kg
GENERAL: Alert, interactive and pleasant. Lying in bed, NAD
HEENT: PERRL, EOMI. No ptosis or miosis. Sclera anicteric and
without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: On NC. Clear to auscultation bilaterally. No wheezes,
rhonchi or rales.
ABDOMEN: Normal bowels sounds, non distended, mild tenderness to
light palpation in periumbilical region and PEG tube region. No
peritoneal signs. PEG site without signs of infection.
EXTREMITIES: No edema. Pulses DP/Radial 2+ bilaterally.
NEUROLOGIC: AOx3. CN2-12 intact. ___ strength throughout. Normal
sensation.
DISCHARGE PHYSICAL EXAM:
VITALS:
24 HR Data (last updated ___ @ 1117)
Temp: 98.2 (Tm 98.5), BP: 98/60 (98-120/60-78), HR: 95
(88-100), RR: 16 (___), O2 sat: 91% (91-96), O2 delivery: 1l
GENERAL: Alert, interactive. Lying in bed. In NAD.
HEENT: PERRL, EOMI. No ptosis. Sclera anicteric and
without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: On NC. Diminished breath sounds in R lung base. No
wheezes, rhonchi or rales.
ABDOMEN: Normoactive bowel sounds, non distended, mild
tenderness
to light palpation medial to PEG tube site. No rebound or
guarding. PEG site without signs of infection.
BACK: R sided chest tube placed and removed, dressing site
c/d/i.
Pertinent Results:
ADMISSION LABS:
================
___ 09:57AM BLOOD WBC-8.6 RBC-2.84* Hgb-8.8* Hct-29.3*
MCV-103* MCH-31.0 MCHC-30.0* RDW-16.6* RDWSD-61.3* Plt ___
___ 09:57AM BLOOD Neuts-87.8* Lymphs-5.4* Monos-6.3
Eos-0.0* Baso-0.0 NRBC-0.2* Im ___ AbsNeut-7.55*
AbsLymp-0.46* AbsMono-0.54 AbsEos-0.00* AbsBaso-0.00*
___ 09:57AM BLOOD ___ PTT-48.6* ___
___ 08:45PM BLOOD ___ 09:57AM BLOOD Glucose-125* UreaN-8 Creat-0.6 Na-141
K-4.1 Cl-95* HCO3-28 AnGap-18
___ 08:45PM BLOOD ALT-18 AST-18 LD(LDH)-241 AlkPhos-78
TotBili-0.5 DirBili-<0.2 IndBili-0.5
___ 08:45PM BLOOD Albumin-3.6 Calcium-8.3* Phos-3.6 Mg-2.2
CYTOLOGY:
==========
Cytology ReportPLEURAL FLUIDProcedure Date of ___
Report not finalized.
MICROBIOLOGY:
===============
___ 7:09 pm PLEURAL FLUID RIGHT PLEURAL EFFUSION.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
___ 5:43 am SEROLOGY/BLOOD Source: Line-L thigh port.
**FINAL REPORT ___
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Test performed by Lateral Flow Assay.
A negative serum does not rule out localized or
disseminated
cryptococcal infection.
Appropriate specimens should be sent for culture.
___ 5:43 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-L thigh port.
BLOOD/FUNGAL CULTURE (Pending): No growth to date.
BLOOD/AFB CULTURE (Pending): No growth to date.
___ 5:31 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
___ 5:31 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
ACID FAST CULTURE (Pending):
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
___ 3:53 am SEROLOGY/BLOOD Source: Line-Port cath.
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
___ 10:55 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
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.
___ 12:13 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
___ 12:13 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
(Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of C.
difficile and detects both C. difficile infection (CDI)
and
asymptomatic carriage.
A negative C. diff PCR test indicates a low likelihood of
CDI or
carriage.
___ 9:30 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:45 pm BLOOD CULTURE Source: Line-port.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 9:56 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
========
CT ABDOMEN/PELVIS ___:
IMPRESSION:
1. Diffuse pneumatosis intestinalis throughout the colon and
rectum with a tiny focus of extraluminal gas, findings
suggestive of benign pneumatosis. No findings to suggest
colitis or ischemia, and no portal venous gas.
2. Moderate pleural effusion at the right lung base is new from
prior CT in ___, previously imaged on multiple radiographs.
3. Cholelithiasis without evidence of cholecystitis.
4. Left SVC central line via a left common femoral vein
approach.
CXR ___:
IMPRESSION:
Similar right perihilar and right lower lobe opacity, query
atelectasis,
although an infectious process is not excluded. Persistent
likely unchanged right-sided, mostly subpulmonic, pleural
effusion, although not well characterized with this technique.
RIB XR ___:
IMPRESSION:
Nondisplaced right fifth and sixth rib fractures. Recurrent
right-sided
pleural effusion. Trace suspected right apical pneumothorax.
No evidence for rib fracture on the left.
DISCHARGE LABS:
=================
___ 07:55AM BLOOD WBC-6.3 RBC-2.70* Hgb-8.5* Hct-28.5*
MCV-106* MCH-31.5 MCHC-29.8* RDW-16.5* RDWSD-63.6* Plt ___
___ 07:55AM BLOOD ___ PTT-26.2 ___
___ 07:55AM BLOOD Glucose-163* UreaN-8 Creat-0.4 Na-140
K-3.6 Cl-97 HCO3-28 AnGap-15
___ 07:55AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.1
Brief Hospital Course:
Ms. ___ is a ___ ___ speaking woman with myasthenia ___
and thymic carcinoma c/b myasthenia crisis s/p PEG (___) and
chemoradiation and recent admission (___) for sternotomy,
radical thymectomy, L innominate v to R atrium and R innominate
to ___ bypasses (10mm goretex) and recent diagnosis of
granulomatous colitis, who presents with four days of maroon
stools and found to have elevated INR on Coumadin.
ACTIVE ISSUES:
=========================
# Hematochezia
# Abdominal pain
# Diarrhea
# Nausea
# Granulomatous colitis
Granulomatous colitis of undeterminate etiology (GVH-like from
thymic carcinoma vs. Crohn's vs. infectious). Presenting with
BRBRP and maroon colored stool. On latest admission, work up
revealed ESR (70) and CRP (13) elevated but of unclear
significance, CMV VL neg (___), SPEP/UPEP neg (___),
chomogranin A neg (___), immunoglobulins normal (___), TTGA
negative (___). CTAP (___) with contrast showed no indication
for ischemic colitis. ID was consulted and infectious etiologies
explored and considered elss likely. C. diff negative, stool
cultures and stool ova and parisite negative. No indication for
repeated EGD or colonoscopy per GI this admission. Thought most
likely to be inflammatory bowel disease, started on budesonide
9mg daily. CMV and HSV stains added to biopsy from ___ and
still pending at discharge. Warfarin held duirng admission with
plan to resume 1mg daily for discharge with goal INR ___ s/p
cardiovascular surgery for ___ months (starting from ___.
Restarted home Imodium in setting of diarrhea.
#Anemia
Patient with slight drop in Hgb from 8.8 to 7.8. She was
slightly hypotensive to SBP ___ which improved s/p IVF. Her Hgb
stabilized and there was no concern for active bleed at time of
discharge.
#Right pleural effusion
#Hypoxia
Patient with mild O2 requirement and found to have large R
pleural effusion. She has chest tube placement with IP on ___.
Pleural fluid analysis showed lymphocytic exudative effusion
which may
represent post-operative change vs malignancy. Pleural fluid
cytology and cultures pending at time of discharge, culutres
preliminarily without growth or organisms.
#L chest wall pain
Patient described pain along left anterior rib cage below
breast. This pain ikely represents costochondritis from coughing
and vomiting. Rib series was obtained which incidentally showed
fracture on R side which does not explain left sided discomfort.
Pain control with acheived with oxycodone and tylenol as needed.
#Tachycardia
Tachycardic on admission perhaps in setting of GI losses and
holding home metoprolol. Had previous episodes of tachycardia
controlled by metoprolol on prior hospitalizations. Resumed home
metoprolol with resolution of tachycardia.
CHRONIC ISSUES:
# Myasthenia ___
Patient currently has minimal MG symptoms without ptosis or
proximal weakness. Tracheostomy placed in ___ but was removed
in ___ due to stable respiratory status. She saturated well
on room air but was maintianed on 1L oxygen vai NC for patient
comfort. She was continued on prednisone 15 mg daily. Continued
dapsone for PCP ___.
# S/p Thymectomy with SVC reconstruction
Underwent L innominate vein to R atrium and R innominate to SVC
bypasses (10mm goretex). Warfarin was held this admission with
plan to resume 1mg daily for dicharge. She was continued on home
tylenol, home chlorhexidine gluconate 0.12% Oral Rinse, and
oxycodone 5mg q6h as well as home lidocaine jelly.
#Elevated PTT
PTT elevated to 120s on admission. Did not appear to have
received heparin or other PTT prolonging agent. This resolved on
repeat. Held heparin this admission in setting of hematochezia.
# GERD
- Home omeprazole switched to lanzoprazole while inpatient for
ease of use, continued ranitidine
# HSV2
- Continued home acyclovir
# Vaginal atrophy
- Continued home estrogen conjugated
# Allergy
- Continued home Albuterol
# Cough
- Continued Guaifenesin
# Primary prevention
- Continued home aspirin
# Anxiety
# Insomnia
- Continued home escitalopram, trazodone
# Vitamin D deficiency
- Continued home multivitamin
TRANSITIONAL ISSUES:
[] Patient receives all medications from the ___ pharmacy,
please get discharge medications on future hospitalizations
through ___.
[] Follow up pleural fluid cytology and cultures pending at time
of discharge.
[] Please follow up mycolytic blood culture from ___ pending at
time of discharge.
[] Patient discharged on warfarin 1 mg daily, please titrate for
goal INR 2.0-2.5
[] Hemoglobin 8.5 on discharge, please check repeat hemoglobin
within 2 weeks of discharge to monitor
[] IP is planning to schedule follow up with patient in ___
weeks, please ensure follow up is scheduled.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen (Liquid) 1000 mg PO Q8H:PRN Pain - Moderate
2. PredniSONE 15 mg PO DAILY
3. Escitalopram Oxalate 10 mg PO/NG DAILY
4. TraZODone 75 mg PO/NG QHS:PRN insomnia
5. GuaiFENesin ___ mL PO Q6H:PRN cough
6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID:PRN
dry mouth
7. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze, dyspnea
8. Aspirin 81 mg PO/NG DAILY
9. Estrogens Conjugated 1 gm VG DAILY
10. Lidocaine Jelly 2% 1 Appl TP DAILY:PRN to surgical incision
11. LOPERamide 4 mg PO/NG QID diarrhea
12. Metoprolol Tartrate 25 mg PO/NG Q8H
13. Opium Tincture (morphine 10 mg/mL) 3 mg PO QHS
14. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
15. Ranitidine 150 mg PO/NG BID
16. Sodium Chloride 3% Inhalation Soln 15 mL NEB Q6H:PRN
wheezing, difficulty breathing
17. Warfarin 2 mg PO/NG DAILY
18. Multivitamins W/minerals Chewable 1 TAB PO DAILY
19. Omeprazole 20 mg PO DAILY prevention of gastritis on
steroids
20. Acyclovir 800 mg PO Q8H
21. Dapsone 100 mg PO DAILY
22. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN Diarrhea
23. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line
flush
Discharge Medications:
1. Budesonide 9 mg PO DAILY
RX *budesonide 9 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Budesonide 9 mg PO DAILY
RX *budesonide [Entocort EC] 3 mg 3 capsule(s) by mouth once a
day Disp #*90 Capsule Refills:*0
3. Warfarin 1 mg PO ONCE Duration: 1 Dose
RX *warfarin 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Acetaminophen (Liquid) 1000 mg PO Q8H:PRN Pain - Moderate
5. Acyclovir 800 mg PO Q8H
6. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze, dyspnea
7. Aspirin 81 mg PO DAILY
8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID:PRN
dry mouth
9. Dapsone 100 mg PO DAILY
10. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN Diarrhea
11. Escitalopram Oxalate 10 mg PO DAILY
12. Estrogens Conjugated 1 gm VG DAILY
13. GuaiFENesin ___ mL PO Q6H:PRN cough
14. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line
flush
15. Lidocaine Jelly 2% 1 Appl TP DAILY:PRN to surgical incision
RX *lidocaine HCl 3 % Apply to affected area of skin once a day
Refills:*0
16. LOPERamide 4 mg PO QID diarrhea
RX *loperamide 2 mg 2 tablets by mouth four times a day Disp
#*60 Tablet Refills:*0
17. Metoprolol Tartrate 25 mg PO Q8H
18. Multivitamins W/minerals Chewable 1 TAB PO DAILY
19. Omeprazole 20 mg PO DAILY prevention of gastritis on
steroids
20. Opium Tincture (morphine 10 mg/mL) 3 mg PO QHS
21. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 10 mg 1 tablet(s) by mouth every six (6) hours
Disp #*20 Tablet Refills:*0
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
22. PredniSONE 15 mg PO DAILY
23. Ranitidine 150 mg PO BID
24. Sodium Chloride 3% Inhalation Soln 15 mL NEB Q6H:PRN
wheezing, difficulty breathing
25. TraZODone 75 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Granulomatous colitis
Pleural effusion
Myasthenia ___
Thymic carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___.
You were admitted to the hospital because you were having
diarrhea and blood in your stool.
At the hospital you were started on medication to treat your
colitis. You had fluid around your lungs and you had a chest
tube placed to drain the fluid.
When you leave the hospital, please take all of your medicine.
Please follow up with your doctors ___.
We wish you the best!
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
10874140-DS-5
| 10,874,140 | 21,586,365 |
DS
| 5 |
2149-12-11 00:00:00
|
2149-12-11 23:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Bactrim
Attending: ___.
Chief Complaint:
Face and neck swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ presents with left facial swelling and pain
while swallowing. Of note, she did have a dental fillings
performed on ___. Procedure done with novocaine. After the
procedure she notes swelling over her left cheek and mandible
region, that progressed to pain with swallowing. Patient denies
fevers/chills/n/v/ cough/dyspnea.
- In the ED, initial vitals were: 97.1 90 169/89 10 96% RA
- Exam notable for: left maxilla/mandible soft tissue swelling,
soft crepitus to left submandibular region
- Labs notable for:
WBC 11.1, Neut 78.3%
Ca 9.5, Mg 2.1, P 4.4
___
Lactate 1.1
-Imaging was notable for:
--CT neck w/o contrast:
1. Extensive subcutaneous emphysema is seen throughout the left
side of the face the maxilla and extends into the left neck,
left axilla, and right neck.
2. No evidence of abnormal fluid collection
--CXR:
IMPRESSION:
Subcutaneous gas tracking along the soft tissues of the left
neck into the left subclavian region. Please correlate with
subsequent CT of the neck for further details.
--Neck Soft Tissues
IMPRESSION:
Subcutaneous gas tracking along the soft tissues of the left
neck into the left subclavian region. Please correlate with
subsequent CT of the neck for further details.
- ___ was consulted and recommended IV unasyn and admission to
medicine with OMFS following. Also recommended ENT be consulted
in AM
- Patient was given:
___ 22:33 IV Morphine Sulfate 2 mg
___ 23:27 IV Ampicillin-Sulbactam
___ 00:18 IV Acetaminophen IV 1000 mg
___ 03:39 IVF 1L NS
___ 05:33 IVF 1L NS
- Vitals prior to transfer: 119/88 68 16 99%RA
Upon arrival to the floor, patient reports feeling much better
than she did on presentation. She recounts feeling unusual with
her novacaine injection, and after the numbing effects wore off,
she saw she was still very swollen in the face. She could barely
swallow secondary to pain on presentation. Prior to her dentist
appointment, she felt completely normal. She does endorse mild
lightheadedness in the emergency department when getting up to
urinate. She now reports that her ears feel less clogged, that
she no longer has dysphagia, only a feeling of swelling in her
throat.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
Barrets esophagus
Osteoporosis
Migraines
Rosacea
Breast CA
Patent foramen ovale
Hypothyroidism
Migraines
Social History:
___
Family History:
no family history of cat bites
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 97.8 97/63 71 55 96%RA
General: Alert, oriented, no acute distress
HEENT: PERRLA, EOMI, edema along the left mandible and cheek
along with crepitus
Neck: supple, no lymphadenopathy, no crepitus
CV: regular rate and rhythm, no murmurs
Lungs: clear to auscultation, no wheezing. No tenderness to
chest wall palpation
Abdomen: soft, nontender
GU: no foley
Ext: ulnar deviation deviation in bilateral hands, trace LLE
pitting edema
Neuro: A&Ox3, normal gait
DISCHARGE PHYSICAL EXAM:
Vital Signs: 98.2PO 114 / 98 L Sitting___
General: Alert, oriented, no acute distress
HEENT: PERRLA, EOMI, edema along the left mandible and cheek
along with crepitus
Neck: supple, no lymphadenopathy, no crepitus
CV: regular rate and rhythm, no murmurs
Lungs: clear to auscultation, no wheezing. No tenderness to
chest wall palpation
Abdomen: soft, nontender
GU: no foley
Ext: ulnar deviation deviation in bilateral hands, trace LLE
pitting edema
Neuro: A&Ox3, normal gait
Pertinent Results:
PERTINENT LABS:
==============
___ 09:02PM BLOOD WBC-11.1*# RBC-4.19 Hgb-13.1 Hct-40.3
MCV-96 MCH-31.3 MCHC-32.5 RDW-13.9 RDWSD-49.6* Plt ___
___ 09:02PM BLOOD Neuts-78.3* Lymphs-13.8* Monos-6.3
Eos-0.9* Baso-0.3 Im ___ AbsNeut-8.72*# AbsLymp-1.53
AbsMono-0.70 AbsEos-0.10 AbsBaso-0.03
___ 09:02PM BLOOD Glucose-89 UreaN-18 Creat-0.8 Na-142
K-3.9 Cl-104 HCO3-28 AnGap-14
___ 09:02PM BLOOD Calcium-9.5 Phos-4.4 Mg-2.1
___ 04:27AM BLOOD ___ pO2-69* pCO2-44 pH-7.40
calTCO2-28 Base XS-1
___ 09:09PM BLOOD Lactate-1.1
___ 04:27AM BLOOD Lactate-1.0
___ 03:40AM URINE Color-Straw Appear-Clear Sp ___
___ 03:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-SM
___ 03:40AM URINE RBC-1 WBC-7* Bacteri-FEW Yeast-NONE Epi-0
___ 03:40AM URINE Mucous-RARE
IMAGING:
=========
CT NECK W/O CONTRAST
1. Soft tissue emphysema involving the left face and neck
extending into the
deep spaces. No airway compromise.
2. No drainable fluid collection.
3. Degenerative changes noted in the cervical spine.
Brief Hospital Course:
Ms. ___ is a very pleasant ___ woman with a history
of ___ esophagus, breast cancer s/p chemotherapy,
hypothyroidism, osteoporosis, and Jaccoud's arthroprathy who
presented from her dentist's office with left sided facial
swelling and pain after a dental filling procedure and was
admitted after she was found to have subcutaneous emphysema on
CT scan.
# Facial swelling
# Subcutaneous emphysema:
On ___ the patient underwent dental filling and subsequently
developed the sensation of her ear popping, throat closing, and
her face began to visibly swell. She was concerned about a
"tightening" sensation in her throat so she decided to go to the
emergency room. On presentation patient was afebrile. There was
no concern for anaphylaxis or respiratory compromise. She
underwent CT head and neck that showed significant subcutaneous
emphysema in left face, neck, and retropharyngeal space. No
pneumo-mediastinum or pneumothorax. There was no fluid
collection or evidence of airway compromise. OMFS evaluated the
patient and recommended to monitor patient for spread of
emphysema and ampicillin/sulbactam (Unasyn) 3gm Q6H. It was
thought the drilling during the patient's dental procedure
introduced the air. The patient significantly improved by early
morning ___. Since the patient was continuing to improve, she
was discharged home on amoxicillin/clavulanate (Augmentin; total
course 7 days, day 1: ___ and with ___ outpatient follow-up
on ___ with Dr. ___ at ___.
#Osteoporosis:
- Continued calcium, vitamin D, takes zoledronic acid as
outpatient once yearly
#Hypothyroidism:
- Continued on levothyroxine 88 mcg daily
___:
- Continued outpatient regimen including ranitidine 150 daily,
omeprazole 40mg PO daily
===================
TRANSITIONAL ISSUES:
===================
MEDICATION CHANGES:
[ ] Amoxicillin-Clavulanic Acid ___ mg PO Q12H (total of 7 days;
day 1: ___
ITEMS FOR FOLLOW-UP:
[ ] Examine patient to ensure left facial swelling and
subcutaneous emphysema has improved.
[ ] Lung nodule: 5 mm right upper lobe lung nodule (Stable from
___
# CODE: full (confirmed)
# CONTACT: Name of health care proxy: ___ Phone
number: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Relpax (eletriptan HBr) 40 mg oral PRN
2. Tretinoin 0.025% Cream 1 Appl TP QHS
3. Levothyroxine Sodium 88 mcg PO DAILY
4. Acetaminophen-Caff-Butalbital ___ TAB PO PRN Headache
5. Ranitidine 150 mg PO DAILY
6. Calcium Carbonate 500 mg PO BID
7. Vitamin D ___ UNIT PO DAILY
8. Reclast (zoledronic acid-mannitol-water) 5 mg/100 mL
injection yearly
9. Omeprazole 40 mg PO DAILY
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*12 Tablet Refills:*0
2. Acetaminophen-Caff-Butalbital ___ TAB PO PRN Headache
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO BID
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Ranitidine 150 mg PO DAILY
8. Reclast (zoledronic acid-mannitol-water) 5 mg/100 mL
injection yearly
9. Relpax (eletriptan HBr) 40 mg oral PRN
10. Tretinoin 0.025% Cream 1 Appl TP QHS
11. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Subcutaneous Emphysema
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. You came to the hospital
because your face and throat felt like they were swelling
shortly after you had a dental procedure. You had a CAT Scan
that showed air underneath your skin. You were seen by oral
surgery, who recommended antibiotics. You were given antibiotics
through your vein and were discharged on antibiotics. You
continued to improve so you were able to go home.
Please be sure to finish all of the antibiotics you were
prescribed.
You will have a follow-up appointment with the oral surgeons on
___.
It was a pleasure caring for you.
Sincerely,
Your Medical Team.
Followup Instructions:
___
|
10874140-DS-8
| 10,874,140 | 23,189,018 |
DS
| 8 |
2151-11-25 00:00:00
|
2151-11-26 11:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics) / Iodinated Contrast-
Oral and IV Dye / atorvastatin
Attending: ___.
Chief Complaint:
Worsening cellulitis
Major Surgical or Invasive Procedure:
U/S guided drainage/aspiration of right medial calf fluid
collection ___
History of Present Illness:
Ms. ___ is a ___ woman with history of CAD c/b
NSTEMI
s/p ___, osteoarthritis, jaccoud arthropathy,
hypothyroidism, ___ syndrome, GERD c/b ___
esophagus,
hiatal hernia, right inguinal hernia s/p herniorrhaphy with mesh
___, migraines, remote history of DCIS of right breast s/p
radiation, basal cell carcinomas, hearing loss, cervicofascial
sub-cutaneous emphysema here today with concern for persistent
right lower extremity cellulitis not responsive to oral
antibiotics (PO Keflex, then PO Augmentin).
On ___, the patient remembers hitting her anterior right
lower
shin at a point where two walls meet. She had no skin breakdown
at the time but noted a "small dent" at impact site. She noted
that she was developing some erythema around this area in the
subsequent days but ignored it as she scheduled for a right
inguinal hernia repair on ___. She notes that this procedure
had been rescheduled multiple times and she did not want
anything
to prevent her from undergoing the repair. She was off her
Plavix
for 5 days prior to the procedure and restarted the medication
on
POD #1. She continued her aspirin throughout.
After the procedure, she noted erythema, swelling, and warmth
extending proximally from her right ankle to her mid shin. She
went to ___ urgent care on ___ for these symptoms and
was diagnosed with cellulitis. She was told to take Keflex ___
TID for 5 days. At that visit, she had RLE US that showed no DVT
but a small pocket (4.4 x 3.1 x 1 cm) of fluid interposed
between
the superficial fascia of the anterior compartment and the
subcutaneous fat. This was located over the ___ aspect
of the shin.
On ___, she followed up with Dr. ___ thought that her
cellulitis was resolving and noted minimal residual erythema. At
that visit, her pain was localized to an area along the medial
aspect of her right calf. He obtained a soft tissue US, which
re-demonstrated the 4.3 x 1.1 x 3.1 cm fluid collection. Dr.
___ that her pain was a result of the stable
hematoma.
He wrote a letter to Dr. ___ the patient was
scheduled
to see for follow-up.
On ___, the patient followed up with Dr. ___. He noted that her RLE was somewhat swollen but that there
was no evidence of cellulitis. He felt that aspirating the small
fluid collection would not change her recovery course. He
suggested that she use ACE bandages to reduce the swelling.
On ___, she saw Dr. ___ at ___. The patient reported that
the
fluid collection in her right shin had started to improve but
then one day prior, the redness progressed up to her knee. Dr.
___ her presentation was concerning for persistent
cellulitis and wrote her for amoxicillin/clavulonate (875/125)
PO
BID for 7 day course.
The patient then saw Dr. ___ on the morning of admission.
The
patient told him that the erythema continued to progress
proximally. He sent her to the ED to be admitted for initiation
of IV antibiotics.
Today, the patient endorses shooting pains that radiate up from
the medial and lateral shins. Intermittently throbbing in
nature.
Pain is present at rest, even when legs are elevated. Currently
it is ___ but can become ___. She also indicates that her
skin
gets taught during the latter part of the evening, causing her
toes to cramp.
She has not had any fevers, chills, night sweats. She wears
compression stockings on both legs at baseline but has only used
stockings on the left leg given the right leg pain and swelling.
The patient denies any chest pain, shortness of breath, nausea,
vomiting, changes in bowel movements, headaches.
Past Medical History:
- ___ esophagus
- Hypothyroidism
- Osteoporosis
- Migraines
- 20 pack year smoker
- inguinal hernia s/p mesh ___ on R
- CAD s/p DES to ___ intermedius ___
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: Temp 98.2, BP 142/87, HR 59, RR 18, O2 sat 94% RA
GENERAL: Very pleasant woman, in no acute distress, cooperative.
HEENT: Moist mucous membranes.
CV: RRR, normal S1 and S2, no murmurs or gallops.
RESP: CTAB with no crackles or wheezing.
ABD: Soft, nontender, nondistended, normoactive bowel sounds.
SKIN: Right lower extremity with erythema and swelling extending
from right ankle to ~12cm below right knee. Erythema is
contained
within the demarcated border marked on ___. Warm and mildly
tender to touch. No evidence of skin breakdown or drainage. 2+
pitting edema to mid shin on right lower extremity, 1+ pitting
edema to mid shin on left lower extremity. ___ pulse right foot
2+.
NEURO: CN ___ intact. Moving bilateral extremities
spontaneously.
PSYCH: Normal mood and effect.
DISCHARGE PHYSICAL EXAM:
========================
Vitals ___ 0750: T 97.7 (Tmax 98.4) | BP 130/71
(107-130/58-77) | HR 59 (55-66) | RR 18| spO2 96% on RA
General: Very pleasant women, alert, oriented, no acute distress
Eyes: Sclera anicteric
HEENT: MMM, oropharynx clear
Resp: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
GI: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
Extremities: Right lower extremity with mild erythema and
continued swelling extending from right ankle to proximal shin.
Warm and very tender to touch on the medial aspect. No evidence
of skin breakdown or drainage, some dry/peeling skin around R
ankle. 2+ pitting edema to mid shin on right lower extremity, 1+
pitting edema to mid shin on left lower extremity. Decreased ROM
in R ankle relative to L in plantar and dorsiflexion. Bilateral
pulses 2+ (dorsalis pedis), posterior tib and dp pulses
dopplerable bilaterally and symmetric.
Neuro: Ambulating in hallway independently
Pertinent Results:
ADMISSION LABS:
===============
___ 05:50PM URINE HOURS-RANDOM
___ 05:50PM URINE UHOLD-HOLD
___ 05:50PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 03:47PM LACTATE-0.7
___ 03:20PM GLUCOSE-88 UREA N-20 CREAT-0.7 SODIUM-145
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-24 ANION GAP-16
___ 03:20PM estGFR-Using this
___ 03:20PM WBC-6.5 RBC-4.08 HGB-12.7 HCT-40.9 MCV-100*
MCH-31.1 MCHC-31.1* RDW-13.8 RDWSD-50.6*
___ 03:20PM NEUTS-69.8 ___ MONOS-6.3 EOS-2.3
BASOS-0.8 IM ___ AbsNeut-4.57 AbsLymp-1.34 AbsMono-0.41
AbsEos-0.15 AbsBaso-0.05
___ 03:20PM PLT COUNT-165
IMAGING:
========
TIB/FIB (AP & LAT) RIGHT ___
FINDINGS:AP and lateral views of the right tibia and fibula
provided. There is diffuse soft tissue edema without soft
tissue gas or radiopaque foreign body is seen. The bones appear
intact without fracture or signs of bone destruction.
IMPRESSION: Soft tissue edema, without gas.
UNILAT LOWER EXT VEINS RIGHT ___
IMPRESSION: No evidence of deep venous thrombosis in the right
common femoral, femoral, and popliteal veins. Evaluation of the
posterior tibial and peroneal veins is limited by patient
tenderness.
US R LOWER EXTREMITY, SOFT TISSUE ___
IMPRESSION:
Overall stable small fluid pocket over the right medial calf
with persistent overlying soft tissue edema. Findings may
represent focal edema, difficult to exclude abscess in the
correct clinical setting.
US GUIDED ASPIRATION OF RIGHT CALF FLUID COLLECTION ___
Using continuous sonographic guidance, the right lower leg
collection was
aspirated. Approximately 5 cc of sanguinous fluid was drained
with a sample sent for microbiology evaluation. Sterile
dressing was applied.
The procedure was tolerated well, and there were no immediate
post-procedural complications.
FINDINGS: 5 cc of sanguinous fluid was aspirated from the right
lower leg collection.
DISCHARGE LABS:
=============
___ 05:40AM BLOOD WBC-5.6 RBC-3.62* Hgb-11.3 Hct-35.8
MCV-99* MCH-31.2 MCHC-31.6* RDW-13.8 RDWSD-50.6* Plt ___
___ 05:40AM BLOOD Glucose-80 UreaN-24* Creat-1.0 Na-146
K-4.3 Cl-109* HCO3-24 AnGap-13
MICROBIOLOGY:
============
___ 2:03 pm ABSCESS Source: RLE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
___ 5:45 am BLOOD CULTURE Site: ARM
Blood Culture, Routine (Pending): No growth to date.
___ 5:05 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 5:05 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
Brief Hospital Course:
Ms. ___ is a ___ woman with complex PMHx here with
concern for persistent right lower extremity cellulitis (s/p
failure of outpatient Keflex) with c/f superficial right medial
calf abscess not responsive to oral antibiotics.
ACUTE MEDICAL ISSUES:
=====================
#RLE Cellulitis
#Right calf fluid collection, c/f abscess
She has seen multiple providers over the past several weeks for
her RLE erythema and swelling. In the outpatient setting, she
completed 5 day course of PO Keflex ___ TID. Prior to
admission, she had been on PO amoxicillin/clavulanate (875/125)
BID since ___ but continued to have progression of her erythema
and swelling. Her presentation here is consistent with
persistent cellulitis with concern for purulent MRSA cellulitis
given unresponsiveness to Keflex. Notably, she has had two RLE
US that demonstrated fluid pocket, and there is concern that she
could have an infected fluid collection. This fluid pocket was
drained on ___ (5cc of serosanguinous fluid), and cultured,
with results pending at the time of discharge but preliminarily
no growth to date. She had no signs or symptoms to suggest
systemic infection. Blood cultures were no growth to date as of
___. She was treated with IV vancomycin, and transitioned to
100mg BID doxycycline for a 5 day course of antibiotics, day 1
to be date of drainage on ___.
CHRONIC MEDICAL ISSUES:
========================
#CAD c/b NSTEMI s/p ___:
Continued on home DAPT(aspirin 81mg, plavix 75mg), pravastatin
20mg, and metoprolol succinate XL 25mg.
#Hypothyroidism:
Continued home levothyroxine 75mcg.
#GERD:
Continued home pantoprazole 20mg and ranitidine 150mg.
TRANSTIONAL ISSUES:
[ ] Microbiology Results Pending on Discharge - no growth at
completion of discharge summary
___ 15:08 ABSCESS GRAM STAIN; FLUID CULTURE; ANAEROBIC
CULTURE - please follow up growth and culture sensitivities.
___ 06:12 BLOOD CULTURE Blood Culture, Routine
___ 17:17 BLOOD CULTURE Blood Culture, Routine
___ 15:24 BLOOD CULTURE Blood Culture, Routine
[ ] Final radiology aspiration procedure report pending at time
of discharge.
[ ] Antibiotic regimen: Doxycycline 100mg BID to complete ___ s/p drainage.
[ ] Plavix was held on morning of ultrasound guided calf fluid
collection drainage but restarted 4 hours after procedure (6pm)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
4. Ranitidine 150 mg PO QHS
5. Pravastatin 20 mg PO QPM
6. ubidecarenone-omega 3-vit E ___ mg-mg-unit oral DAILY
7. flaxseed oil 1,000 mg oral DAILY
8. Clopidogrel 75 mg PO DAILY
9. Pantoprazole 20 mg PO Q12H
10. Calcium Carbonate 500 mg PO BID
11. Aspirin 81 mg PO DAILY
12. Levothyroxine Sodium 75 mcg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
14. Cyanocobalamin Dose is Unknown PO DAILY
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO BID
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*9 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO BID
4. Clopidogrel 75 mg PO DAILY
5. Cyanocobalamin 400 mcg PO DAILY
6. flaxseed oil 1,000 mg oral DAILY
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Pantoprazole 20 mg PO Q12H
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
11. Pravastatin 20 mg PO QPM
12. Ranitidine 150 mg PO QHS
13. ubidecarenone-omega 3-vit E ___ mg-mg-unit oral
DAILY
14. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right lower extremity cellulitis
Right medial calf fluid collection s/p aspiration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for right lower leg soft tissue infection
called cellulitis.
What was done for me while I was in the hospital?
- You were given IV antibiotics to treat your infection. You
also had an ultrasound which showed a pocket of fluid, which was
drained. This fluid was also sampled to check for infection. At
the time of discharge, the culture result was not yet finalized.
What should I do when I leave the hospital?
- Please go to your follow up appointments as scheduled in the
discharge papers. Please call the office of Dr. ___ to
change this appointment if this does not work for your schedule.
- Please finish your doxycycline, you need to take 9 more
tablets.
- Please wear sunscreen while in the sun for the next week.
- You can take your Plavix at 6pm and then regularly in the
morning starting tomorrow.
- The fluid from the drainage procedure was sent to the lab. If
this grows a bacteria that is not treated by the doxycycline,
you will be called and a new antibiotic will be given.
- Please monitor for new/or worsening symptoms (fevers,
increased pain, redness, swelling). If you do not feel like you
are getting better or have any other concerns, please call your
doctor to discuss or return to the emergency room.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10874214-DS-18
| 10,874,214 | 21,585,942 |
DS
| 18 |
2135-04-27 00:00:00
|
2135-04-28 17:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ACE Inhibitors
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with medical history notable for HTN,
HLD, depression, CAD s/p CABG, CHF, asthma, GERD, CKD who
presented from his nursing home with x1 day of chest pain.
Per ED records: per patient, the chest pain started this
morning, described as left sided, constant, and radiated to the
right. He also noticed increased shortness of breath. He denies
___ edema, orthopnea, PND. Given his ongoing chest pain, he
presented to the ED for further evaluation.
In the ED, initial VS were 98.3 50 133/64 18 98% NC
-Exam notable for:
"Vital signs notable for bradycardia otherwise vital signs
stable.
Bilateral crackles in the lung fields on inspiration. No JVp
elevation. No lower lymphedema."
-Labs showed
6.2>12.7/39.8<172
___: 12.0 PTT: 27.8 INR: 1.1
Na 144 K 4.3 Cl 105 HCO3 28 BUN 24 Cr 1.6 Gluc 103
Trop-T: <0.01, proBNP: 379
Lactate:1.5
U/A few bacteria, 122 WBCs, large leuks
-Imaging showed
CXR (___):
IMPRESSION: Findings compatible with mild pulmonary edema.
ECG (___): NSR, rate 48bpm, normal axis, no ST segment
changes
-Received:
___ 16:46 IV Furosemide 40 mg Gi
___ 18:54 IV CefTRIAXone 1gm
Transfer VS were 52 154/65 19 98% Nasal Cannula
On arrival to the floor, patient reports that he was feeling
"bubbles in his chest" extending across and to his back. It has
now resolved. Denies sharp pain/pressure. Denies F/C, vomiting.
Has "a bit" of abdominal pain on ROS. Endorses both constipation
and diarrhea on occasion. Currently does not feel constipated.
He does endorse burning with urination. He has some SOB and his
cough has "been with him for a while".
Past Medical History:
HTN
HLD
Depression
CAD s/p CABG
CHF
Asthma
GERD
CKD
Social History:
___
Family History:
No family history of CAD
Physical Exam:
Admission Exam:
VS: 97.6 PO 196 / 84 57 20 94 2L
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, pseudophakia, anicteric sclera, pink
conjunctiva, MMM. + purple 0.6cm tongue lesion.
NECK: supple, does have neck pulsations to ear but not
compressible.
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Coarse breath sounds + wet cough.
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding . No suprapubic tenderness
GU: + foley
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Exam:
VS: 98.1 150 / 77 63 18 97 2L, 97% when taken off 2L
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM
NECK: nontender supple neck, no LAD, no JVD
HEART: Regular Rhythm, bradycardia, S1/S2, no murmurs, gallops,
or rubs
LUNGS: some bilateral crackles throughout lung fields
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, trace edema, moving all 4 extremities
with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, excoriations on the Right middle
side of his back but no lesions, no rashes, Sternal incision
site from prior CABG c/d/i
Pertinent Results:
ADMISSION LABS:
___ 01:18PM BLOOD WBC-6.2 RBC-4.21* Hgb-12.7* Hct-39.8*
MCV-95 MCH-30.2 MCHC-31.9* RDW-15.7* RDWSD-54.1* Plt ___
___ 01:18PM BLOOD Neuts-61.6 ___ Monos-7.4 Eos-6.1
Baso-1.0 Im ___ AbsNeut-3.81 AbsLymp-1.46 AbsMono-0.46
AbsEos-0.38 AbsBaso-0.06
___ 01:18PM BLOOD ___ PTT-27.8 ___
___ 01:18PM BLOOD Plt ___
___ 01:18PM BLOOD Glucose-103* UreaN-24* Creat-1.6* Na-144
K-4.3 Cl-105 HCO3-28 AnGap-15
___ 01:18PM BLOOD proBNP-379
___ 01:18PM BLOOD
___ 01:18PM BLOOD
___ 01:24PM BLOOD Lactate-1.5
___ 01:18PM BLOOD cTropnT-<0.01
DISCHARGE LABS:
___ 08:10AM BLOOD Plt ___
___ 08:10AM BLOOD WBC-6.1 RBC-4.77 Hgb-14.3 Hct-45.6 MCV-96
MCH-30.0 MCHC-31.4* RDW-15.6* RDWSD-55.0* Plt ___
MICRO:
__________________________________________________________
___ 5:18 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 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-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
+ ___ Cardiovascular ECHO
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Doppler parameters are
most consistent with Grade I (mild) left ventricular diastolic
dysfunction. 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 (?#).
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild diastolic LV dysfunction
+ ___ Imaging CHEST (PA & LAT)
Findings compatible with mild pulmonary edema.
Brief Hospital Course:
Mr. ___ is a ___ man with medical history notable for HTN,
HLD, depression, CAD s/p CABG, CHF, asthma, GERD, CKD who
presented from his nursing home with x1 day of chest pain.
ACTIVE Issues:
#Chest pain: Patient presented with some atypical chest pain
symptoms. EKG on admission showed TWI in V2-V5 (previous EKGs
from ___ had had TWI in anterior leads). Troponins neg x2.
Symptoms were not consistent with typical angina. We continued
his home aspirin, metoprolol, and simvastatin. Patient should
follow up with outpatient cardiologist.
#CHF: CXR with mild congestion. S/p 40 IV Lasix in ED on
admission. Patient's ECHO (___) showed: Normal global and
regional biventricular systolic function. Mild diastolic LV
dysfunction (EF>55%). We restarted his home furosemide on
discharge.
#UTI: Endorsed dysuria in the ED. No fevers or leukocytosis
but urine culture grew E coli sensitive to cipro. We started
ciprofloxacin 250 mg q12h; day ___ 7 days total ending
on ___.
#COPD: Chronic per patient. CXR with mild edema. No evidence of
pneumonia. Patient's SOB is at baseline. We continued his
duonebs and gave him supplemental oxygen, which was weaned off
prior to discharge.
#Renal injury: Cr 1.6 on admission and 1.5 on discharge.
Unclear baseline but has PMH of CKD. Meds were renally dosed in
the hospital and he should f/u with his PCP ___ discharge.
CHRONIC:
#HTN: Chronic issue. We cont metop, amlodipine
#BPH: Patient wears diapers and cannot control urine. We
continued terazosin
#Insomnia: We continued home mirtazapine and held his
trazodone
#GERD: We decreased his home ranitidine to qday
Transitional Issues:
[]discharged on ciprofloxacin to complete 7 day course for UTI
[]patient should follow up with cardiology; please monitor
volume status.
#CODE: Full (presumed)
#CONTACT: ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Bisacodyl 5 mg PO DAILY con
3. Cetirizine 10 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. GuaiFENesin ER 400 mg PO DAILY
6. amLODIPine 10 mg PO DAILY
7. Mirtazapine 22.5 mg PO QHS
8. Senna 17.2 mg PO QHS
9. Simvastatin 20 mg PO QPM
10. Terazosin 2 mg PO QHS
11. Cyanocobalamin 1000 mcg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Metoprolol Tartrate 100 mg PO BID
14. raNITIdine HCl 150 mg oral BID
15. TraMADol 50 mg PO BID:PRN Pain - Moderate
16. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
17. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB, wheeze
18. TraZODone 25 mg PO QHS:PRN insomnia
19. Milk of Magnesia 30 mL PO PRN constipation
20. Polyethylene Glycol 17 g PO DAILY:PRN constipation
21. Artificial Tear Ointment 1 Appl BOTH EYES QID:PRN dry eye
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q12H Duration: 7 Days
Please take for 7 days ending on ___
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. amLODIPine 10 mg PO DAILY
4. Artificial Tear Ointment 1 Appl BOTH EYES QID:PRN dry eye
5. Aspirin 81 mg PO DAILY
6. Bisacodyl 5 mg PO DAILY con
7. Cetirizine 10 mg PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Furosemide 40 mg PO DAILY
10. GuaiFENesin ER 400 mg PO DAILY
11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB, wheeze
12. Metoprolol Tartrate 100 mg PO BID
13. Milk of Magnesia 30 mL PO PRN constipation
14. Mirtazapine 22.5 mg PO QHS
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. raNITIdine HCl 150 mg oral BID
17. Senna 17.2 mg PO QHS
18. Simvastatin 20 mg PO QPM
19. Terazosin 2 mg PO QHS
20. TraMADol 50 mg PO BID:PRN Pain - Moderate
21. TraZODone 25 mg PO QHS:PRN insomnia
22. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Heart Failure with Preserved Ejection Fraction
Coronary Artery Disease
Urinary Tract Infection
Secondary Diagnoses:
Chronic Obstructive Pulmonary Disorder
Hypertension
Chronic Kidney Disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
WHY WERE YOU HERE?
- You were having chest pain.
WHAT DID WE DO FOR YOU?
- We took a picture of your heart and lungs
- We looked at your heart function with an echocardiogram
- We started you on antibiotics for an infection
WHAT DO YOU NEED TO DO NOW?
- Please go to the doctor for chest pain
- Please take your antibiotics as instructed
Thank you for allowing us to participate in your care!
- Your ___ Team
Followup Instructions:
___
|
10874692-DS-8
| 10,874,692 | 20,786,973 |
DS
| 8 |
2152-01-31 00:00:00
|
2152-01-31 17:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with a past medical history of CHF secondary to idiopathic
dilated cardiomyopathy, presenting with 5 days of worsening
shortness of breath.
The patient started feeling short of breath 5 days ago ___
___. The shortness of breath was associated with a feeling
of "heaviness" in his chest. The patient states that he still
has good exercise function and his SOB is worsened only with
lying flat. Per the pt, he is now sleeping on 6 pillows (nearly
sitting up).
The patient endorses subjective fever, night sweats,
palpitations, and mild swelling of his ankles. The swelling is
not as bad as it has been in the past.
Of note, the patient has been taking no medications at home for
the last 5 months since he lost his insurance. He recently got
insurance back again.
The patient was diagnosed with congestive heart failure due to
dilated cardiomyopathy in ___. The cause of his cardiomyopathy
is unclear, though the patient thinks it might be viral.
No history of hypertension, diabetes, or hyperlipidemia. The
patient has never been hospitalized for a CHF exacerbation
before. Pt states that he eats a low-salt, ___ diet.
Pt is concerned about several recent environmental exposures.
His house was recently "bombed" for fleas. In addition, the
patient works as an ___ for ___ and worked in a
___ ___ building ___. He also complained about recently
driving through a ___ tunnel with a "snow"-like
substance floating around in it.
In the ED, initial vitals were 97.8 56 118/80 18 99% RA. He was
given 40mg of IV lasix. Per pt, he put out about a liter of
urine. He had a chest xray that was suggestive of moderate to
severe interstitial pulmonary edema. He had a TTE that showed
worsened EF of ___, worsened dilated severely hypokinetic
left ventricle, worsened mitral regurgitation, mildly dilated
ascending aorta, borderline pulmonary artery systolic
hypertension.
Labs notable for:
141 | 102 | 11
---------------<100
4.0 | 23 | 1.0
5.9 > 15.6 / 46.0 < 136
Trop-T: 0.02, 0.01 on repeat
The patient was admitted to the cardiology service for further
management. On the floor, the patient states that he is feeling
much better after diuresis. He still complains of feeling
flushed and being very sweaty.
Past Medical History:
idiopathic dilated cardiomyopathy
congestive heart failure
Polysubstance abuse in the past
s/p bilateral inguinal hernia repair
Social History:
___
Family History:
Younger brother s/p 2 stents. No other family history of early
MI, arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: Tm98.0, BP 117/82, HR 106, RR 20, O2 96%RA
General: well-appearing man, diaphoretic, in bed in NAD
HEENT: NCAT, MMM, EOMI
Neck: JVD 10cm at 30 degrees
CV: tachycardic, holosystolic murmur at the apex, no
rubs/gallops, normal S1S2
Lungs: bibasilar crackles appreciated, no wheezes, normal work
of breathing
Abdomen: soft, non-tender, non-distended, +BS
GU: no foley
Extr: no cyanosis, clubbing, or edema appreciated, 2+ DP pulses
bilaterally
Neuro: A&Ox3
DISCHARGE PHYSICAL EXAM:
Vitals: Tm 99.2, BP 85-135/64-112, HR 84-108, RR 16, O2 94-97%RA
I/O: 8h: 240/200 24h: ___
Wt: 95.3 <- 95.4
General: well-appearing man, sitting in bed in NAD
HEENT: NCAT, MMM, EOMI
Neck: JVD 6-7 cm at 90 degrees
CV: regular rate, holosystolic murmur at the apex, no
rubs/gallops, normal S1S2
Lungs: bibasilar crackles appreciated, no wheezes, normal work
of breathing
Abdomen: soft, non-tender, non-distended, +BS
GU: no foley
Extr: no cyanosis, clubbing, or edema appreciated, 2+ DP pulses
bilaterally
Neuro: A&Ox3
Pertinent Results:
ADMISSION LABS:
___ 05:30AM WBC-5.9 RBC-5.08 HGB-15.6 HCT-46.0 MCV-91#
MCH-30.7 MCHC-33.9 RDW-13.4 RDWSD-44.6
___ 05:30AM GLUCOSE-100 UREA N-11 CREAT-1.0 SODIUM-141
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-23 ANION GAP-20
___ 05:30AM ___ PTT-28.4 ___
___ 05:30AM cTropnT-0.02*
___ 05:30AM proBNP-2309*
___ 05:30AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
DISCHARGE LABS:
___ 05:54AM BLOOD WBC-5.9 RBC-5.06 Hgb-15.3 Hct-47.0 MCV-93
MCH-30.2 MCHC-32.6 RDW-13.5 RDWSD-45.8 Plt ___
___ 05:54AM BLOOD Glucose-77 UreaN-19 Creat-1.1 Na-138
K-3.7 Cl-97 HCO3-25 AnGap-20
___ 05:54AM BLOOD Calcium-9.5 Phos-5.2* Mg-2.2
TROPONIN TREND/OTHER LABS:
___ 11:35AM BLOOD cTropnT-0.01
___ 05:30AM BLOOD cTropnT-0.02*
___ 07:55AM BLOOD ALT-22 AST-23 LD(LDH)-257* AlkPhos-50
TotBili-0.5
IMAGING/STUDIES:
TTE (___):
The left atrium is dilated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is severely dilated. Overall left ventricular
systolic function is severely depressed (LVEF= ___. No
masses or thrombi are seen in the left ventricle. Right
ventricular chamber size is normal. with mild global free wall
hypokinesis. The ascending aorta is mildly dilated. 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. Moderate to
severe (3+) mitral regurgitation is seen. Due to the eccentric
nature of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Biatrial enlargement. Dilated, severely hypokinetic
left ventricle. At least moderate to severe mitral
regurgitation. Mildly dilated ascending aorta. Borderline
pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___, the
left ventricle is further dilated and the global systolic
function is worse. The severity of mitral regurgitation is
markedly worse.
CXR ___:
FINDINGS:
Marked cardiomegaly is unchanged. Compared with the prior
radiograph, there are increased bilateral diffuse interstitial
lung markings and ___ B-lines, suggesting worsened pulmonary
edema. Small bilateral pleural effusions are also identified.
No focal consolidation is identified. No large pleural
effusions or pneumothorax.
IMPRESSION:
Findings suggestive of moderate to severe interstitial pulmonary
edema.
EKG ___:
Sinus rhythm. Occasional premature atrial contractions. Left
ventricular
hypertrophy with secondary repolarization changes. Compared to
the previous tracing of ___ ectopy is seen.
Brief Hospital Course:
___ y.o. man with history of non-ischemic cardiomyopathy, LVEF
___, presenting with dyspnea.
# Acute on Chronic CHF: The patient presented with progressively
worsening dyspnea for the past five days. His BNP was 2309 on
admission. On his exam, JVP was very elevated. His CXR was
notable for pulmonary edema. A TTE was done, which showed
worsened EF of ___, worsened dilated severely hypokinetic
left ventricle, worsened mitral regurgitation, mildly dilated
ascending aorta, borderline pulmonary artery systolic
hypertension. Troponin on admission was 0.02, and normalized to
0.01 on repeat. Of note, patient had not taken home medications
in about 5 months because he lost his insurance, though he
recently got insurance again. The patient's presentation is
consitent with acute on chronic systolic CHF exacerbation in the
setting of medical noncompliance, possibly with an environmental
or viral trigger. The patient was treated with aggressive IV
diuresis and improved dramatically in terms of symptoms and
physical exam. After a trial of PO diuretics, he was discharged
on PO torsemide 40mg (to replace home furosemide) and lower
doses of home lisinopril and metoprolol succinate, as he had not
been taking them recently. We continued his home eplerenone at
his normal dose. The patient was instructed to make a follow-up
appointment with Dr. ___ in 2 weeks. In addition, a script was
provided for an outpaitnet electrolyte check.
# Mitral Regurgitation: The patient's admission TTE was notable
for moderate to severe mitral regurgitation, not previously seen
on TTE in ___. We starting lisinopril as above.
***Transitional Issues***
[ ] continued management of oral diuresis, electrolyte
repletion, management of home cardiac medications
FULL CODE
CONTACT: ___ ___
DISCHARGE WEIGHT: 95.3 kg
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 200 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Eplerenone 25 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Eplerenone 25 mg PO DAILY
RX *eplerenone 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
5. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
6. Outpatient Lab Work
ICD-9 Heart failure 428.0
Please draw chem-10 on ___, and fax results to:
Name: ___ MD
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic congestive heart failure exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted with shortness of breath. You
had extra fluid on your chest x-ray and physical exam. We
diagnosed you with an exacerbation of heart failure based on
these findings and your blood work. We treated you with IV
diuretics, which made you lose a lot of your extra fluid. Your
symptoms and physical exam improved with the diuretics.
We are discharging you on torsemide, which is an oral diuretic,
as well as smaller doses of your home medications. Dr. ___
___ modify these doses at your follow-up appointment.
We would like you to call Dr. ___ office to make a follow-up
appointment in about 2 weeks. His contact information is below.
We would like you to get labwork done on ___ to
assess your electrolyte levels. You can get them done at any
lab, and the results will be faxed to Dr. ___.
Weigh yourself every morning and record the results. Bring the
list of weights to your follow-up appointment. Please call Dr.
___ weight goes up more than 3 lbs in one day.
On behalf of your cardiology team, take care and be well.
-___ medical team
Followup Instructions:
___
|
10874692-DS-9
| 10,874,692 | 28,648,396 |
DS
| 9 |
2155-08-29 00:00:00
|
2155-09-01 13:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lasix
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Right heart catheterization on ___
History of Present Illness:
___ with a PMH of dilated cardiomyopathy (EF ___,
severe MR who ___ subacute SOB.
Pt has a history of dilated cardiomyopathy, last admitted
___. Since then his PCP at ___ has managed his CHF.
___ ___ lost health insurance and has been unable to pay for
his medications with the exception of torsemide.
Approximately 1.___elieves ___ got the Flu
(myalgias, dry cough, fatigue, anorexia). During this time was
essentially only able to eat salty soup. ___ had decreased
appetite and fluid intake but found himself gaining weight and
w/ increasing DOE and orthopnea. ___ went from 217 lbs to 250
lbs. ___ increased him home torsemide dose from 40 mg QD to 80 mg
QD. ___ endorses constipation during this time, last BM
yesterday.
Over the past few days pt reports increasing dyspnea with and
without exercise. Weight on admission 235 lbs. ___ endorses
orthopnea, and abdominal swelling, dry cough, chest tightness,
back tightness. Of note slipped and fell on L hip several days
ago.
In the ED, initial vitals: 97.7 60 ___ 98% RA Exam notable
for: Constitutional: Comfortable. Head/eyes: NCAT, PERRLA, EOMI.
ENT/neck: OP WNL. +JVD. Chest/Resp: Speaking in complete
sentences. Diminished breath sounds at the bilateral bases.
Otherwise clear to auscultation. Cardiovascular: RRR, Normal
S1/S2. Abdomen: Soft, moderately distended. Nontender.
Musc/Extr/Back: ___. No significant edema. Skin: No rash.
Warm and dry. Neuro: Speech fluent. Psych: Normal mood. Normal
mentation.
Labs notable for: 1) BMP: Na 142, K 3.9, Cl 101, HCO3 24, BUN
24, Cr 1.1 2) CBC: WBC 7.8, Hb 13.0, plt 188 3) Coags: INR 1.4,
PTT 26.3 4) BNP: 6357 5) LFT: ALT 68, AST 42, AP 68, Tbili 1.1,
Albumin 4.1 6) CK: 111, Trop-T 0.03
Imaging notable for: 1) CXR: Mild interstitial pulmonary edema,
trace bilateral pleural effusions, mild bibasilar atelectasis 2)
EKG: SR, LAD, LVH, TWIV6
Pt given: ___ 20:48 IV Furosemide 40 mg
Consults: None
Vitals prior to transfer: 98.4 105 ___ 95% RA Upon arrival
to the floor, the ___ reports persistent SOB, non-radiating
chest tightness and back tightness.
REVIEW OF SYSTEMS: A 10-point ROS was taken and is negative
except otherwise stated in the HPI.
Past Medical History:
Idiopathic dilated cardiomyopathy (Dx ___
Chronic systolic heart failure
Polysubstance use in the past
S/p bilateral inguinal hernia repair
Social History:
___
Family History:
Younger brother s/p 2 stents. No other family history of early
MI, arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VITALS: 98 PO 118 / 70 84 20 98 ra (weight 235 lb)
GEN: NAD, sitting up in bed
HEENT: PERRL, EOMI intact, OP clear
NECK: JVD 14 cm, supple
CARD: RRR, S1 + S2 present, ___ SEM
ABD: Distended, nontender, soft, no rebound/guarding
EXT: ___, 1+ ___ edema
NEURO: Alert, oriented, motor strength grossly intact ___
DISCHARGE PHYSICAL EXAM
========================
VS:24 HR Data (last updated ___ @ 855)
Temp: 97.4 (Tm 98.5), BP: 113/66 (91-115/42-66), HR: 100
(71-100), RR: 18 (___), O2 sat: 94% (94-97), O2 delivery: RA,
Wt: 233.02 lb/105.7 kg
GEN: NAD
NECK: JVP 8 cm H2O.
CARD: RRR, S1 + S2 present, ___ SEM best heard at the apex with
radiation to the axilla.
CHEST: No TTP
LUNGS: CTAB. No wheezes/rales/rhonchi.
ABD: +BS, Distended, nontender, soft, no rebound/guarding
EXT: ___, no edema
Pertinent Results:
ADMISSION LABS
===============
___ 05:32PM BLOOD WBC-7.8 RBC-4.52* Hgb-13.0* Hct-39.5*
MCV-87 MCH-28.8 MCHC-32.9 RDW-14.2 RDWSD-44.3 Plt ___
___ 05:32PM BLOOD Neuts-74.0* ___ Monos-4.6*
Eos-0.6* Baso-0.4 Im ___ AbsNeut-5.74 AbsLymp-1.56
AbsMono-0.36 AbsEos-0.05 AbsBaso-0.03
___ 05:32PM BLOOD ___ PTT-26.3 ___
___ 05:32PM BLOOD Glucose-100 UreaN-24* Creat-1.1 Na-142
K-3.9 Cl-101 HCO3-24 AnGap-17
___ 05:32PM BLOOD ALT-68* AST-42* CK(CPK)-111 AlkPhos-68
TotBili-1.1
___ 05:32PM BLOOD CK-MB-3 cTropnT-0.03* proBNP-6357*
___ 05:32PM BLOOD Albumin-4.1 Calcium-9.0 Phos-5.2* Mg-1.9
___ 05:32PM BLOOD TSH-2.3
___ 08:47PM BLOOD Lactate-2.0
PERTINENT INTERVAL LABS
========================
___ 07:13AM BLOOD cTropnT-0.01
___ 03:25PM BLOOD TotProt-6.2* Calcium-9.1 Phos-5.1* Mg-2.0
___ 07:13AM BLOOD Calcium-9.1 Phos-4.8* Mg-2.0 Iron-64
___ 07:13AM BLOOD calTIBC-390 Ferritn-217 TRF-300
___ 07:04AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
___ 03:25PM BLOOD ___ Fr K/L-1.1
___ 03:25PM BLOOD PEP-HYPOGAMMAG IgG-684* IgA-103 IgM-79
IFE-NO MONOCLO
___ 07:04AM BLOOD HIV Ab-NEG
DISCHARGE LABS
===============
___ 06:38AM BLOOD WBC-5.8 RBC-4.43* Hgb-12.8* Hct-39.1*
MCV-88 MCH-28.9 MCHC-32.7 RDW-14.6 RDWSD-47.3* Plt ___
___ 06:38AM BLOOD Glucose-105* UreaN-24* Creat-0.8 Na-135
K-4.8 Cl-99 HCO3-24 AnGap-12
___ 06:38AM BLOOD ALT-37 AST-20 LD(LDH)-199 AlkPhos-64
TotBili-0.5
___ 06:38AM BLOOD Albumin-4.0 Calcium-9.0 Phos-4.5 Mg-2.4
IMAGING
========
CXR (___)
IMPRESSION:
Mild interstitial pulmonary edema with trace bilateral pleural
effusions and mild bibasilar atelectasis.
TTE (___)
The left atrial volume index is SEVERELY increased. The right
atrium is moderately enlarged. There is no evidence for an
atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is ___ mmHg. There is normal left ventricular
wall thickness with a SEVERELY increased/dilated cavity. There
is SEVERE global left ventricular hypokinesis. No thrombus or
mass is seen in the left ventricle. Quantitative biplane left
ventricular ejection fraction is 20 %. Left ventricular cardiac
index is depressed (less than 2.0 L/min/m2). There is no resting
left ventricular outflow tract gradient. No ventricular septal
defect is seen. Tissue Doppler suggests an increased left
ventricular filling pressure (PCWP greater than 18 mmHg). Mildly
dilated right ventricular cavity with mild global free wall
hypokinesis. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch is
mildly dilated with a normal descending aorta diameter. There is
no evidence for an aortic arch coarctation. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. There is no aortic regurgitation. The mitral valve
leaflets appear structurally normal with failure of the leaflets
to fully coapt. There is an eccentric, inferolaterally directed
jet of SEVERE [4+] mitral regurgitation. Due to the Coanda
effect, the severity of mitral regurgitation could be
UNDERestimated. The pulmonic valve leaflets are normal. The
tricuspid valve leaflets appear structurally normal. There is
mild [1+] tricuspid regurgitation. There is moderate pulmonary
arterysystolic hypertension. There is no pericardial effusion.
Compared with the prior TTE (images reviewed) of ___, the
severity of mitral regurgitation has increased (previously
moderate). Moderate pulmonary hypertension is now appreciated
(unable to be assessed previously).
RHC (___)
Elevated left and right heart filling pressures. Large v wave on
PCW tracing consistent with severe MR. ___ cardiac
output.Moderate pulmonary hypertension.
TTE (___)
CONCLUSION: The left atrial volume index is SEVERELY increased.
The right atrium is moderately enlarged. There is no evidence
for an atrial septal defect by 2D/color Doppler. The right
atrial pressure could not be estimated. There is normal left
ventricular wall thickness with a SEVERELY increased/ dilated
cavity. There is SEVERE global left ventricular hypokinesis.
Quantitative biplane left ventricular ejection fraction is 24 %.
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. Diastolic parameters are
indeterminate. There is Grade III diastolic dysfunction. Mildly
dilated right ventricular cavity with low normal free wall
motion. Tricuspid annular plane systolic excursion (TAPSE) is
normal. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch
diameter is normal with a normal descending aorta diameter.
There is no evidence for an aortic arch coarctation. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. There is no aortic regurgitation. The mitral
valve leaflets are mildly thickened with failure of the leaflets
to fully coapt. There is a central jet of moderate to severe
[3+] mitral regurgitation. Due to acoustic shadowing, the
severity of mitral regurgitation could be UNDERestimated. The
pulmonic valve leaflets are normal. The tricuspid valve leaflets
are mildly thickened. There is mild [1+] tricuspid
regurgitation. There is moderate pulmonary artery systolic
hypertension. There is a trivial pericardial effusion.
IMPRESSION: Severe global left ventricular systolic dysfunction
with relative sparing of the apex suggestive of a non-ischemic
cardiomyopathy. Moderate to severe functional centrally-directed
mitral regurgitation. At least moderate pulmonary artery
systolic hypertension.
Brief Hospital Course:
SUMMARY
=========
___ with a PMH of idiopathic dilated cardiomyopathy and severe
MR who presented with acute decompensated systolic heart
failure.
ACUTE ISSUES:
=============
#Acute on Chronic HFrEF (EF 24% ___
#Idiopathic non-ischemic cardiomyopathy (dating back to ___
Likely ___ inability to take medications, recent viral illness
and salty diet. Repeat TTE showed EF 20%, severe global left
ventricular hypokinesis, severe MR, moderate pulmonary
hypertension. TSH, iron studies were within normal limits. HIV
and Hepatitis serologies were negative. ___ was actively diuresed
and transitioned from home lisinopril to valsartan and then
transitioned to Entresto ___ prior to discharge. ___ had a
right heart cath on ___ which showed mildly elevated
biventricular filling pressure, mod pulm hypertension (___
group II) and known MR. ___ had a repeat TTE once euvolemic which
showed 3+ MR and EF of 24%. His heart failure regimen upon
discharge: Entresto 24mg-26mg, metoprolol succinate XL 25 mg BID
(changed from home dose of 75 mg daily), eplerenone 25 mg BID
(increased from 25 mg daily), and torsemide 60 mg daily.
#Severe MR
___ with known severe MR prior to admission. Repeat TTE once
euvolemic on ___ showed 3+ mod-severe MR. ___ was
scheduled for follow-up to discuss Mitraclip after discharge.
#Transaminitis:
___ presented with transaminitis that was likely congestive.
As ___ was actively diuresed, his LFTs continued to
normalize.
#Coagulopathy:
___ presented with INR 1.4, likely iso poor nutrition.
CHRONIC ISSUES:
===============
#Allergies:
- Continued cetirizine 10 mg QD PRN
#Prevention:
- Continued aspirin 81 mg QD
TRANSITIONAL ISSUES
====================
[ ] Non-immune to Hepatitis B
[ ] ICD: ___ is a candidate for primary prevention given EF
< 35%
[ ] TTE w/ 3+ mod-severe MR, please continue discussion about
mitraclip as an outpatient.
[ ] Consider CPET as an outpatient
[ ] Entresto: Started low dose on ___ consider uptitration
as an outpatient if blood pressure and kidney function will
allow
[ ] Switched his metoprolol XL to 25 mg BID, increased his
eplerenone to 25 mg BID
[ ] Discharge diuretic: Torsemide 60 mg qd (increased from home
dose of 40 mg daily)
- Discharge weight: 105.1 kg
- Discharge Cr: 0.8, K 4.8
CORE MEASURES:
==============
#CODE: Full (confirmed)
#CONTACT: ___ (___) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Cetirizine 10 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Metoprolol Succinate XL 75 mg PO DAILY
5. Torsemide 40 mg PO DAILY
6. Eplerenone 25 mg PO DAILY
7. Ocuvite Adult 50 Plus (C,E,zinc,copper 11-omega3s-lut)
250-5-1 mg oral DAILY
Discharge Medications:
1. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
RX *sacubitril-valsartan [Entresto] 24 mg-26 mg 1 tab-cap by
mouth twice a day Disp #*60 Tablet Refills:*0
2. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg 3 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
3. Eplerenone 25 mg PO BID
RX *eplerenone 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Metoprolol Succinate XL 25 mg PO Q12H
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Cetirizine 10 mg PO DAILY
7. O___ Adult 50 Plus (C,E,zinc,copper 11-omega3s-lut)
250-5-1 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Idiopathic dilated cardiomyopathy
Acute on chronic systolic heart failure
Secondary diagnoses:
Mitral regurgitation
Transaminitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
=================================
- You were admitted because you had volume overload from an
acute exacerbation of heart failure.
What happened while I was in the hospital?
====================================
- You were given IV diuretics to get the excess fluid off.
- You had a right heart catheterization to assess your volume
status.
- You were started on a medication called Entresto for your
heart.
What should I do after leaving the hospital?
====================================
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Please weigh yourself everyday and call your cardiologist if
your weight increases by 3 lbs.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10874930-DS-13
| 10,874,930 | 23,741,178 |
DS
| 13 |
2133-03-23 00:00:00
|
2133-03-25 22:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with HTN, diet-controlled pre-diabetes, CHF, admitted s/p
fall of unclear etiology. Per her report, she showered and was
getting dressed per her usual routine. She recalls having been
standing in her room and next memory is being in the ambulance
on the way to the ED. She has no recollection of the event,
including the moments immediately surrounding it. She does not
recall if she experienced any chest pain, palpitations,
vagal-type symptoms, focal neurological deficits, or whether she
simply tripped and fell. No one was around to witness it.
Fortunately, she wears a Lifeline type device around her neck,
which was somehow activated prompting the EMTs to come to her
home. Her daughter ___ had been on her way to her home in
her retirement community though had not been aware of the event
and did not arrive until after the ambulance had already taken
her.
Of note, she was just recently started on cipro 250mg BID x3
days on ___ for symptoms of UTI including dysuria with u/a
showing + nitrite, + leuk esterase, and 68 WBCs with urine
culture growing >100k pan-sensitive E. coli. No other recent
medication changes.
In the ED, initial VS were 97.9, 73, 15, 150/67, 97% RA,
___ pain(aches).
While in ED, noted to have minor scalp laceration requiring 4
staples on rear occiput. FAST exam, CT head, CT C-spine all
negative for acute abnormalities. Tetanus given. Did not receive
fluids. Initially collared and boarded until cleared. Admitted
to Medicine for further evaluation and management.
On the floor, she reports feeling back to her baseline save for
some MSK discomfort on shoulders and neck. She denies any recent
CP, palpitations, SOB, HA, seizures, numbness, tingling,
weakness, confusion. Does report history of mechanical falls
with prior broken ribs. Sleeps propped up on ___omfort, denies orthopnea or PND. Does endorse ___ edema. Denies
lightheadedness upon standing. Did not bite tongue. Stable
history of urine incontinence, denies stool incontinence.
Past Medical History:
Hypertension
ear surgery
Diabetes mellitus
Hyperlipidemia
Pagets disease of bone
Congestive heart failure
Appendectomy
TAHBSO : Around age ___, for unknown reasons.
Degenerative joint disease
Sinus congestion
Urinary incontinence
kyphosis
Palpitations
Skin cancer
Breast lump
Abnormal vision
- Congestive heart failure history per ___ records:
Hospitalized in ___ with some CHF in context of pneumonia. She
has been on ASA, lasix and KCl since. She had an ECHO in ___
with EF 65%, had a negative stress test at that time as well.
- Palpitations
She had this evaluated with an event recorder in ___ and this
was normal. She is on dilt without symptoms.
HEALTH MONITORING LABS (per ___:
Health Monitoring
HbA1c ___ 6.00; Overdue
Hct (Hematocrit) ___ 34.1
Hgb (Hemoglobin) ___ 10.9
GFR (estimated) ___ 69.8 Units: ml/min/1.73msq
TSH ___ 0.743
UA-Protein ___ TRACE
Urine Culture ___ See Report
Vitamin D (25 OH) ___ 26 "Desired: > 32 ng/ml".
Smoking status ___ Former Smoker
Influenza ___ Done
Pneumococcal ___
Varicella Zoster ___
Tdap ___
Cholesterol ___ 247 DESIRABLE: <200
Cholesterol-HDL ___ 85
Cholesterol-LDL ___ 149 DESIRABLE: <130
Triglycerides ___ 64
IMMUNIZATIONS:
Influenza
Dose: ___ : Influenza, unspecified
Dose: ___ : Influenza, unspecified
Dose: Done ___ : Influenza, unspecified
Tdap
Dose: ___ : Tdap, unspecified
Zoster
Dose: ___ : Zostavax
Pneumococcal
Dose: ___ : Pneumococcal, unspecified
Social History:
___
Family History:
Mother died at age ___.
Father died at age ___.
She had 4 siblings, they are all deceased. Her last sister died
in ___.
She had 2 children, one died in an MVA at age ___ her daughter
is ___ and is doing well, she has 3 children -- she sees her 3
grandchildren and enjoys them very much.
Physical Exam:
Admission Physical Exam
VS - 97.4 167/69 73 20 99%RA
GEN - well-developed, elderly female lying comfortably in bed,
alert, interactive, appropriate, NAD.
HEENT - rear occiput laceration with staples in place. MMM,
sclera anicteric, oropharynx clear
NECK - supple, borderline high-normal JVP around 7-8cm
PULM - CTAB in all lung fields, no w/r/r
CV - normal rate, regular rhythm, mild II/VI SEM at RUSB, normal
S1/S2, no rubs or gallops
ABD - soft, minimal distention and tympany, non-tender,
normoactive bowel sounds, no guarding or rebound
EXT - WWP, 2+ pitting edema bilaterally in LEs. 2+ pulses
palpable bilaterally
NEURO - CN II-XII intact. RUE adductors/abductors active
strength limited due to chronic shoulder pain, otherwise
strength in bilateral upper extremities full. lower extremity
strength full and equal. sensation intact to light touch. did
not assess gait at this time.
COGNITIVE: fully oriented to ___, date, year,
president ___. registers 3 objects. draws clock-face perfectly
though draws time of 10:50 instead of 11:10. recalled ___
objects after clock-drawing.
SKIN - no ulcers or lesions
Discharge Exam:
VS: T: 98.2, P: 79, BP: 107/62, RR: 18, 98% on RA
GENERAL: elderly female, laying in bed, comfortable
HEENT: NC/AT, sclerae anicteric, whitish plaque over tongue
NECK: supple, no LAD, no JVD
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-distended, TTP in
epigastrium, no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Pertinent Blood Work
___ 02:00PM BLOOD WBC-6.3 RBC-4.14* Hgb-11.1* Hct-34.4*
MCV-83 MCH-26.8* MCHC-32.3 RDW-14.3 Plt ___
___ 02:00PM BLOOD ___ PTT-27.7 ___
___ 07:55AM BLOOD Glucose-109* UreaN-22* Creat-0.7 Na-138
K-4.6 Cl-104 HCO3-21* AnGap-18
___ 02:00PM BLOOD ALT-18 AST-22 AlkPhos-265* TotBili-0.3
___ 02:00PM BLOOD Lipase-17
___ 02:00PM BLOOD cTropnT-<0.01
___ 07:55AM BLOOD CK-MB-7 cTropnT-<0.01
___ 02:00PM BLOOD Albumin-4.8 Calcium-9.7 Phos-3.3 Mg-2.1
___ 02:00PM BLOOD VitB12-449 Folate-16.5
___ 02:00PM BLOOD TSH-1.6
___ 02:00PM BLOOD 25VitD-11*
___ 02:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Urine:
___ 07:39PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 07:39PM URINE Color-Straw Appear-Clear Sp ___
___ 07:39PM URINE
Imaging:
___ Imaging CHEST (SINGLE VIEW)
FINDINGS: The heart is mildly enlarged. There is calcification
and unfolding along the aorta. A mild interstitial abnormality
is probably due to mild vascular congestion. No focal
opacification is present. There is no pleural effusion or
pneumothorax. Non-displaced right posterior fifth through
seventh rib fractures are probably older, although not depicted
in great detail. On the left, fractures of the left fifth
through seventh ribs might be acute or old.
IMPRESSION: Rib fractures. Correlation with physical findings
is suggested. No displacement. Mild vascular congestion.
___-SPINE W/O CONTRAST
No evidence of fracture. Mild to moderate degenerative changes
with mild
anterolisthesis of C3 on C4, which can probably be explained by
faceter
arthropathy although correlation with physical findings is
suggested.
___ Imaging CT HEAD W/O CONTRAST
No evidence of acute intracranial process. Findings suggestive
fibrous
dysplasia of the skull.
DISCAHRGE LABS:
___ 06:10AM BLOOD WBC-5.0 RBC-3.79* Hgb-10.0* Hct-31.3*
MCV-83 MCH-26.3* MCHC-31.8 RDW-14.6 Plt ___
___ 06:10AM BLOOD Glucose-129* UreaN-26* Creat-0.7 Na-141
K-4.7 Cl-103 HCO3-27 AnGap-16
___ 06:10AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.2
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION:
___ F with HTN, diet-controlled glucose intolerance, and CHF,
who was admitted s/p fall of unclear etiology. Syncope workup
was negative. Found to have multiple rib fractures of unclear
chronicity.
ACTIVE ISSUES:
# Unwitnessed fall: Unclear etiology, differential included
mechanical fall with head trauma or syncope. There was low
clinical concern for seizure or PE. Patient ruled out for ACS
and was monitored on tele for 48 hours. Patient was not
orthostatic. Patient had been recently started on ciprofloxacin
for UTI, which can cause increased confusion especially in the
elderly. Further infectious workup was unremarkable with repeat
urine bland and negative culture, therefore cipro was stopped.
She was also found to have low vitamin D levels which can
increase risk of both falls and subsequent injury, and 6 week
high dose repletion was initiated.
# Pain: Found to have multiple rib fractures on CXR, although
unclear chronicity, and patient has history of multiple
mechanical falls. Pain was responsive to tylenol. Avoided
narcotics due to age and current responsiveness to tylenol. ___
was consulted who recommended home with 24 hour care vs. rehab.
The family discussed the options and the decision was made to go
to rehab.
# UTI: Patient received about 2 days of cipro treatment for
planned 3-day course. She was asymptomatic on arrival and
ciprofloxacin was held due to her fall. ___ u/a and urine
culture in setting of report of dysuria were very convincing for
UTI. Repeated urine studies which showed bland urine without
signs of infection, therefore no further treatment given.
CHRONIC ISSUES:
# Hypertension: BP elevated to SBP 160s on admission,
asymptomatic. Given unclear etiology of fall, did not treat
aggressively and continued home regimen.
# Diabetes mellitus: Diet-controlled at home. Maintained on SSI.
# Paget's disease of bone: Not acute. Likely etiology of her
elevated alk phos.
# Congestive heart failure: Continued home lasix, as patient
appeared euvolemic on exam.
# Degenerative joint disease: Continued tylenol.
# CODE: DNR/DNI (confirmed with patient and HCP daughter ___
___
# EMERGENCY CONTACT HCP: ___ (daughter) home ___
cell ___
TRANSITIONAL ISSUES:
# Started 6 week high dose vitamin D repletion
# Could consider MRI/EEG as outpatient if any clinical concern
for seizure, though none during this admission.
# ___ and pain control for falls at home with apparent rib
fractures
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. ipratropium bromide *NF* 0.03 % NU BID
3. Ciprofloxacin HCl 250 mg PO Q12H UTI
___
4. Diltiazem Extended-Release 240 mg PO DAILY
5. I-Caps *NF* (antiox#10-om3-dha-epa-lut-zeax) ___ mg Oral
QDAY
6. Klor-Con M20 *NF* (potassium chloride) 40 meq Oral QDAY
7. Furosemide 20 mg PO DAILY
8. Lidocaine 5% Patch 1 PTCH TD DAILY
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Nitroglycerin SL 0.4 mg SL PRN chest pain
7. I-Caps *NF* (antiox#10-om3-dha-epa-lut-zeax) ___ mg Oral
QDAY
8. ipratropium bromide *NF* 0.03 % NU BID
9. Klor-Con M20 *NF* (potassium chloride) 40 meq Oral QDAY
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
Take every ___ for 5 more weeks
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth qweek Disp #*5 Capsule Refills:*0
12. Vitamin D 800 UNIT PO DAILY
Take after completing weekly high dose vitamin D prescription
RX *cholecalciferol (vitamin D3) 400 unit 2 capsule(s) by mouth
daily Disp #*60 Capsule Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fall
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 were admitted because you fell and lost
consciousness. We evaluated you for many dangerous causes for
passing out, including looking for infections. We were unable to
find any cause of your fall.
Our physical therapists evaluated you, and recommended you go
home with 24 hour assitance or go to rehab.
Followup Instructions:
___
|
10874939-DS-16
| 10,874,939 | 24,153,301 |
DS
| 16 |
2183-01-28 00:00:00
|
2183-01-30 09:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tetracycline
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ with no significant PMHx who presents with
syncope. She states that she was eating dinner at a restaurant
when she began to feel lightheaded and nauseous. She then had a
witnessed syncopal event which lasted about 30 seconds.
Reportedly HR was in ___ (there was an MD at dinner with her who
checked her pulse). Per report, no seizure like activities. When
she woke up, she did not feel confused but did feel very
nauseous and weak. She then felt like she needed to go to the
bathroom. She fainted again while walking to the bathroom with
her sons and was seated in a chair. She states that while she
was in the chair, still unconscious, she had a bowel movement.
She then woke up and threw up many times. No head strike or
fall. She regained consciousness, but continued to feel weak and
was very sweaty. No tongue biting or confusion to suggest
post-ictal state. She had 2 glasses of wine with dinner.
She denies recent fever, chills, chest pain, shortness of
breath, palpitations, abdominal pain, diarrhea, melena,
hematochezia, urinary symptoms. No confusion, dysarthria. She
states that her dizziness resolved by the time she came to the
ED.
Patient had a similar episode ___ years ago. She fainted at her
son's house after feeling very dizzy. She had a facial
laceration at that time. She was admitted to ___ for
workup and she reports that workup was normal. She states that
she was diagnosed with vagal syncope. She states that she had a
stress test and ?CTA neck at that time.
In the ED, initial vitals:
97.8 64 86/61 16 100% RA
- Labs notable for: normal CBC, K 3.2, normal LFTs, trop neg x1
and lactate 3.4.
EKG: sinus, TWI I, II, aVL, V2-V6, no STE, NANI
- Imaging notable for: CXR normal.
- Patient given: 1L NS, Zofran, 324mg ASA. KCl 40mEq ordered,
not given.
On arrival to the floor, pt reports that her sons feel like the
food "didn't sit well" with them. She states that she feels
"practically" at her baseline. No palpitations, recent illness.
She has never had syncope with activity. She states that she
continues to feel "queasy". Also states that multiple people who
were at the dinner with her also now feel nauseous.
She states that she used to faint "a lot" when she was a
teenager and always had very low BP.
Past Medical History:
h/o vasovagal syncope
Social History:
___
Family History:
mother with dementia. Details unclear about father health, but
patient states that he had obesity and DM. No FHx of sudden
cardiac death
Physical Exam:
ADMISSION EXAM:
===============
Vitals: 97.6, 66, 123/65, 97/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple,
JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no cyanosis or edema
Skin: Without rashes or lesions
Neuro: A&Ox3. CN2-12 intact. ___ strength in all extremities
DISCHARGE EXAM:
===============
Vitals: Tmax 98.5 Tcurrent 97.6 | 100-123/60-71 | 60-66 | 18 |
97/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no cyanosis or edema
Skin: Without rashes or lesions
Neuro: A&Ox3.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:45PM BLOOD WBC-7.0 RBC-4.56 Hgb-13.5 Hct-40.9 MCV-90
MCH-29.6 MCHC-33.0 RDW-13.4 RDWSD-43.9 Plt ___
___ 09:45PM BLOOD Neuts-45.9 ___ Monos-6.6 Eos-1.4
Baso-0.4 Im ___ AbsNeut-3.21 AbsLymp-3.19 AbsMono-0.46
AbsEos-0.10 AbsBaso-0.03
___ 09:45PM BLOOD ___ PTT-30.3 ___
___ 09:45PM BLOOD Glucose-107* UreaN-16 Creat-0.8 Na-142
K-3.2* Cl-102 HCO3-19* AnGap-24*
___ 09:45PM BLOOD ALT-19 AST-28 AlkPhos-72 TotBili-0.3
___ 09:45PM BLOOD Lipase-48
___ 09:45PM BLOOD cTropnT-<0.01
___ 09:45PM BLOOD Albumin-4.7 Calcium-9.8 Phos-3.8 Mg-2.3
___ 09:59PM BLOOD Lactate-3.4*
___ 04:41AM BLOOD Lactate-0.9
DISCHARGE LABS:
================
___ 07:13AM BLOOD WBC-4.6 RBC-4.31 Hgb-12.8 Hct-40.0 MCV-93
MCH-29.7 MCHC-32.0 RDW-13.6 RDWSD-46.3 Plt ___
___ 07:13AM BLOOD Glucose-107* UreaN-18 Creat-0.8 Na-141
K-4.6 Cl-106 HCO3-24 AnGap-16
UA UNREMARKABLE
MICRO:
======
___ 11:34 am URINE Source: ___.
URINE CULTURE (Pending):
___ 9:45 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING:
========
Imaging CHEST (PA & LAT) ___
FINDINGS:
Cardiac silhouette size is normal. Mediastinal and hilar
contours are within normal limits. The pulmonary vasculature is
not engorged. Pleuro-parenchymal scarring is noted within the
lung apices. No focal consolidation, pleural effusion or
pneumothorax is seen. Moderate multilevel degenerative changes
are noted in the thoracic spine.
IMPRESSION:
No acute cardiopulmonary abnormality.
ECHO ___ (___):
All cardiac chambers are normal in size. Left ventricular
systolic function is preserved with an estimated ejection
fraction of 60%. There is mild concentric LVH. Right
ventricular systolic function is normal. The aortic and mitral
leaflets are minimally thickened with no aortic and mild mitral
regurgitation. There is mild tricuspid regurgitation with a
normal pulmonary artery pressure. A minimal pericardial effusion
is seen.
CAROTID DUPLEX ___ (___):
Carotid duplex examination reveals no plaque within the right
and left carotid bulbs. Velocities within the right and left
internal carotid arteries are within normal limits, indicating
no stenosis. Flow within the right and left vertebral arteries
is antegrade.
CONCLUSIONS:
There is no stenosis of the right and left internal carotid
arteries.
EKG EXERCISE STRESS TEST ___ (___)
Normal exercise duration of 8 minutes 7 seconds in this
___ female referred for syncope. The patient had normal
heart rate, blood pressure and oxygen saturation response. The
patient had no arrhythmias. The patient had no symptoms of chest
pain, stopped for fatigue. There were no significant ST segment
changes seen. The test was negative by ST segment criteria.
EKG
====
EKG ___ (___. ___)
Vent. Rate : 068 BPM Atrial Rate : 068 BPM
P-R Int : 176 ms QRS Dur : 100 ms
QT ___ : 412 ms P-R-T Axes : ___ degrees
QTc Int : 438 ms
EKG ___
Sinus, TWI I, II, aVL, V2-V6, no STE, NANI.
EKG ___
Sinus, TWI V1-V6, no STE
Brief Hospital Course:
___ with a PMH of vasovagal syncope who presented after an
episode of syncope.
#Vasovagal syncope:
Patient felt lightheaded and nauseous immediately prior to
episode of syncope. Regained consciousness briefly and began
walking to bathroom when she lost consciousness again; she was
seated in a chair and had a BM. When she regained consciousness,
she threw up several times and felt nauseous, weak, and sweaty.
Denied head strike, tongue biting, post-ictal confusion.
Patient's nausea and weakness subsided after she arrived at
___. Etiology of syncope thought to be vasovagal possibly
secondary to gastroenteritis or viral etiology given dehydration
(lactate 3.4 on presentation), vomiting, diarrhea. Other
possible etiologies include arrhythmia (pulse of 40 could
suggest bradycardia) or atypical angina equivalent. ED EKG
showed NSR with T wave inversion in leads I, II, avL, V2-V6, no
ST changes. Reassuringly, previous EKGs from years past had also
been notable for T-wave inversions. The patient also has a
history of negative stress test (___) and negative carotid
ultrasound. The patient was monitored on telemetry and no
arrhythmias were noted. Her symptoms completely resolved. Urine
and blood cultures showed no growth to date.
# Diffuse T wave inversion
Likely chronic given report of nonspecific T wave abnormality
during ___ admission in ___. Possible diagnoses
includes physiologic precordial t wave inversion, memory t
waves, type II demand ischemia, and LVH (given mild concentric
LVH on echo in ___.
TRANSITIONAL ISSUES:
===================
- Please consider ordering ___ monitor to monitor for
any potential arrhythmias as an outpatient.
- Consider outpatient echocardiogram.
- Please consider repeating echo stress test as an outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glucosamine (glucosamine sulfate) unknown oral DAILY
2. Vitamin B Complex 1 CAP PO DAILY
3. Potassium Iodide Dose is Unknown PO Frequency is Unknown
4. Vitamin E Dose is Unknown PO DAILY
5. Calcium Carbonate 1000 mg PO DAILY
6. Vitamin D Dose is Unknown PO DAILY
7. biotin unknown oral DAILY
Discharge Medications:
1. biotin unknown oral DAILY
2. Calcium Carbonate 1000 mg PO DAILY
3. Glucosamine (glucosamine sulfate) unknown oral DAILY
4. Potassium Iodide unknown PO ASDIR
5. Vitamin B Complex 1 CAP PO DAILY
6. Vitamin D UNKNOWN PO DAILY
7. Vitamin E UNKNOWN PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: vasovagal syncope
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 ___ to determine why you lost
consciousness at dinner on ___. Based on testing that
you received here, we think that you fainted due to a phenomenon
called vasovagal syncope. We know that you have had previous
episodes of vasovagal syncope. Here are some ways that you can
prevent loss of consciousness/passing out in the future when you
start to feel lightheaded:
+Leg-crossing - cross one leg over the other and squeeze the
muscles in your legs, abdomen and buttocks. Hold this position
as long as you can or until your symptoms disappear.
+Arm-tensing - grip one hand with the other and pull them
against each other without letting go. Hold this grip as long as
you can or until your symptoms disappear.
+Water ingestion - drink water when you feel as though you are
going to faint.
It is also possible that you fainted due to an issue with your
heart, although we think that this is less likely given that
your stress test and echo were normal when you were hospitalized
at Mount ___ in ___. However, we still think that it would
be beneficial to do some additional testing as an outpatient
(another stress test and potentially a 24-hour cardiac monitor).
We have scheduled a follow up appointment. Please see below.
It was a pleasure taking care of you!
Your ___ Team
Followup Instructions:
___
|
10875292-DS-6
| 10,875,292 | 25,385,589 |
DS
| 6 |
2126-10-10 00:00:00
|
2126-10-10 13:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___ who presented with syncopal event and headache, found
to have subarachnoid hemorrhage
Major Surgical or Invasive Procedure:
___ Coiling of acom aneurysm
History of Present Illness:
HPI: ___ who was last seen by her family members on ___.
A
neighbor reportedly found her altered today at her apartment
complex and called EMS. She reportedly had a syncopal event as
well. She was brought to ___ where she
reported a severe headache, neck pain and nausea. A head CT
demonstrated SAH for which she was transferred to ___. At the
other hospital she was started on nicardipine gtt for SBP that
was initially above 200. She was also given 150 mcg fentanyl, 4
mg zofran, and 1 gm phosphenytoin. She is primarily ___
speaking and accompanied today by her daughter and two sons.
Past Medical History:
PMHx: hypertension, hyperlipidemia
All: NKDA
Social History:
Social Hx: No tobacco, no alcohol, retired, lives alone
Physical Exam:
PHYSICAL EXAM:
___ and ___: 2 Fisher: 3
GCS 14 E: 3 V: 5 Motor: 6
O: T: 97.5 BP: 140/96 HR:66 RR 16 O2Sats 99% on NC
Gen: WD/WN
HEENT: Pupils: PERRL EOMs intact
Neck: Supple.
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Sleeping, opens eyes to voice.
Cooperative with exam, speaks some ___.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension (in ___.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to
3 mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength intact and symmetric.
IX, X: Palatal elevation symmetrical.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. No pronator drift. BUE ___ throughout. BLE - initially
___, on later exam with encouragement gave full strength ___.
Sensation: Intact to light touch
EXAM ON DISCHARGE:
A&Ox3, PERRL, EOMI, face symmetrical,
No drift, MAE ___.
R groin with no bruising or hematoma, +PP
Pertinent Results:
___ CTA:
1. Diffuse subarachnoid hemorrhage with intraventricular
extension, slightly increased in the interhemispheric fissure.
The ventricles are stable in size.
2. Bilobed aneurysm arising from the anterior communicating
artery which
projects anterior superiorly and to the right and measures 7 mm
in maximal dimension.
ECHOCARDIOGRAPHY ___:
Normal left ventricular regional/global systolic function. Right
ventricular dilatation with preserved systolic function. No
signifcant valvular disease.
CAROTID/CEREBRAL BILAT ___
Successful primary coiling of a ruptured anterior communicating
artery aneurysm without any proximal or distal thromboembolic
complications. The patient remained neurologically intact
afterwards. No other aneurysm was found in anterior or
posterior circulation. The left A1 is the dominant one and was
filling both A2s and anterior communicating artery aneurysm.
___ Chest X ray
Heart size normal. Lungs clear. No cardiomediastinal hilar or
pleural
abnormality.
___ Bilateral lower extremity Ultrasound
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
___ CXR
As compared to ___ radiograph, mild pulmonary
vascular congestion is new. No definite new areas of
consolidation are identified to suggest a site of infection.
___ Head CTA w/&w/o contrast
Decreased subarachnoid hemorrhage with interval coiling of
anterior
communicating artery aneurysm and persistent cerebral edema.
Right parafalcine area of hypodensity may represent evolving
infarct. Multifocal ares of decreased caliber of intracranial
vessels with irregular contour compatible with vasospasm.
Appearance of hypervascularity within the left cerebral
hemisphere likely represent collateral flow in relation to
decreased arterial flow from vasospasm.
___ Chest X ray
As compared to the previous radiograph, no relevant change is
seen. The lung volumes have increased. Normal size of the
cardiac silhouette. Normal hilar and mediastinal structures. No
pneumonia, no pulmonary edema, no pleural effusions.
___ bilateral lower extremity ultrasound
No evidence of deep vein thrombosis in either lower extremity
Radiology Report CHEST (PA & LAT) Study Date of ___ 11:06
AM
IMPRESSION:
As compared to the previous image, no relevant change is seen.
Borderline size of the cardiac silhouette. Normal hilar and
mediastinal structures. No pneumonia, no pulmonary edema, no
pleural effusions.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
10:31 AM
IMPRESSION:
1. No new intracranial hemorrhage is visualized.
2. There is decreased cerebral swelling with better
visualization of the basal cisterns and ventricles.
3. The previously seen hypodensity in the right parafalcine
region is less apparent.
Brief Hospital Course:
Ms. ___ was admitted to the neurosurgical service in the ICU
for close monitoring. She was taken Neuro ___ on ___ for a
coiling of her aneurysm under ___ anesthesia. She was
extubated after her procedure and transferred to the ICU for
care. Her right femoral artery was closed with angioseal and her
left femoral had a sheeth that was removed in the ICU. She was
mentating clearly and was full strength in her upper extremitys
and antigravity in her lowers. Isolated muscle group testing
was difficult given both effort and our language barrier and
patients lethargy.
On ___, patient reported nausea and vomited x1. She was
neurologically intact on examination. TCDs were performed and
showed no vasospasm in the L PCA, MCA, bilateral verts. She
remained on 100cc/hr IVF and Q1H neuro checks.
___, the patient spiked a fever to 101 and a chest xray as
well as bilateral lower extremity ultrasounds were ordered which
were within normal limits. Blood and urine cultures were sent
which were pending. She had a normal white blood cell count.
She ambulated with ___. She had TCD's done which showed no
evidence of vasospasm
___, the patient remained stable and afebrile. Her nausea and
vomiting resolved.
On ___ Patient c/o of continued nausea. She was started on
scopalamine patch and standing zofran. She was found to be
febrile to 101.7 pan cultures were sent.
On ___: She was started on ceftriaxone for UTI. Neurologic
exam stable. Nausea improved. TCDs were obtained however only
able to evaluate M2 of L MCA which revealed normal velocities.
Limited study secondary to poor bone windows/pt motion.
On ___ Patient remained neurologically stable. Her course of
nafcillin ended.
On ___ Antibiotics were changed to augmentin. Her foley was
discontinued. Patient underwent a CTA which did not show a
significant increase in vasospasm. She was transferred to the
floor.
On ___, the patient was stable over night on the floor. Her
neurologic exam remained stable. Her IV fluids were
discontinued.
On ___, the patient was stable over night. Her neurologic
exam was stable. She had a bilateral lower extremity ultrasound
which was negative.
On ___, A urine analysis was consistent with moderate leuks
and 67 wbc and the antibiotics were changed to Ceftriaxone for
five day course.
On ___, The patient had a fever of 101.3. The patient was
having loose stools and a specimen for cdiff which was negative.
On ___, The patient was started on difucan x 7 days for yeast
noted in the urine. The patient overnight was nauseous and
vomited. The patient was initiated on intravenous fluids at 100
cc/hr. Neurologically the patient was intact. Given headache
and nausea and vomiting a NCHCT was performed which was found to
be stable.
On ___, The patient was initiated on calcorie counts for poor
appetite. The patient denied nausea or vomiting today. The
patient denies headache. The patient complained of dizziness
when getting out of bed dizzy and the patient was given a 500 cc
IV bolus x 1. Orthostatic signs were performed and orthastaic
hypotension resolved.
on ___, the patient was cleared from a nutrition standpoint,
she has been eating 80% of her meals. She is neurologically and
hemodynamically stable. The patient was discharged to rehab in
stable conditions.
Medications on Admission:
lisinopril, simvastatin, ASA 81
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
2. CeftriaXONE 1 gm IV Q24H
One more dose on ___. Docusate Sodium 100 mg PO BID
4. Famotidine 20 mg PO BID
5. Fluconazole 200 mg PO Q24H Duration: 7 Days
stop on ___ for 7 day course for Yeast.
6. Heparin 5000 UNIT SC TID
7. Senna 17.2 mg PO QHS
8. Lisinopril 10 mg PO BID
9. Nimodipine 60 mg PO Q4H
Stop on ___ for full course of 21 days.
10. LeVETiracetam 1000 mg PO BID
11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Please do not drive or operate mechanical machinery while taking
pain meds.
12. Simvastatin 10 mg PO QPM
13. Ibuprofen 400 mg PO Q6H:PRN pain, fevers
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
___
Anterior Communicating Artery Aneurysm
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:
Discharge Instructions
Aneurysmal Subarachnoid Hemorrhage
Surgery/ Procedures:
You had a cerebral angiogram to coil the aneurysm. You may
experience some mild tenderness and bruising at the puncture
site (groin).
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
You may take a shower.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you must refrain
from driving.
Medications
Resume your normal medications and begin new medications as
directed.
Please do NOT take any blood thinning medication (Aspirin,
Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on a medication called Nimodipine.
This medication is used to help prevent cerebral vasospasm
(narrowing of blood vessels in the brain).
***You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication until follow-up. It is important that you take this
medication consistently and on time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
Mild to moderate headaches that last several days to a few
weeks.
Difficulty with short term memory.
Fatigue is very normal
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site or puncture site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
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2132-06-10 00:00:00
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2132-06-10 22:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Cipro
Attending: ___.
Chief Complaint:
Idiopathic thrombocytopenia purpura
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old lady with a history of
hypothyroidism who presented to her PCP's office because of new
onset of a diffuse petechial rash first noted on her shoulders
in the morning and subsequently on her chest, abdomen and legs.
The rash worsened throughout the day new red spots appearing at
the sites of blood pressures checks, tight fitting clothes, etc.
She was found to have a platelet count of 1 K in her check at
her outpatient clinic and was sent in to ___ for further
evaluation.
In the ED, initial VS: T 98.4, P 86, BP 146/85, RR 16, O2 sat
100% RA. She was noted to have a petechial rash but normal
neuro exam and no other signs of bleeding except for trace blood
in her urine. She received 40 mg of dexamethasone and was
admitted to the floor.
On arrival to the floor she was comfortable without complaint,
no headache, vision changes, confusion, bleeding isolated
musculoskeletal pain. She denied new medications, new sexual
partners, IV drug use, dietary changes, recent illnesses, She
denied dysuria, hematuria, hematochezia.
ROS: Denied 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:
Hypothyroidism
Social History:
___
Family History:
No family history of bleeding, platelet or autoimmune disease
Physical Exam:
On Admission:
VS: 98.4 132/84 96 16 98% RA
GENERAL: Well-appearing woman in NAD, comfortable, appropriate.
HEENT: NC/AT, EOMI, no palatine petechiae
NECK: Supple.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: no edema 2+ peripheral pulses.
SKIN: Fine non-blanching petechial rash on shoulders, chest
legs, worse around contact lines, IV draw sites.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact
On Discharge:
VS: All vital signs stable and within normal limits
Exam essentially normal and unchanged from presentation except
for fading of initial petechial rash with no new marked areas of
rash.
Pertinent Results:
===================
LABORATORY RESULTS
===================
On Admission:
WBC-7.9 RBC-4.95 Hgb-15.2 Hct-42.8 MCV-87 RDW-12.5 Plt Ct-10*
---Neuts-79.4* Lymphs-16.0* Monos-3.5 Eos-0.8 Baso-0.3
Glucose-89 UreaN-8 Creat-0.8 Na-139 K-4.3 Cl-106 HCO3-25
VitB12-447 Folate-11.8 TSH-3.3
HCG-<5 HIV Ab-NEGATIVE
On Discharge:
WBC-17.7*# RBC-4.52 Hgb-13.7 Hct-38.5 ___ MRDW-13.0 Plt
Ct-82*#
----Neuts-89.2* Lymphs-6.9* Monos-3.8 Eos-0 Baso-0
Brief Hospital Course:
This is a ___ year old woman with past medical history of
hypothyroidism who presented with ITP.
1) Idiopathic Thrombocytopenia Purpura: The patient presented
with low platelets but no other cytopenias and per Dr. ___
___ hematology consultant) smear with no platelets but no
other abnormal forms. She had no recent illnesses or
medications likely to cause ITP and work up for secondary causes
(pregnancy/HIV) were initially negative. She was treated with
40 mg dexamethasone * 4 days and IVIG at 1 g/ kg of ideal body
weight *1 and by hospital day three (the day of discharge)
platelet count had risen to 82K. Pt will complete one
additional day of dexamethasone as an outpatient and follow up
for a CBC recheck at ___ three days after discharge. She
never had signs of hemodynamically significant bruising and had
no obvious bleeding except petechiae noted.
2) Leukocytosis: On the day of discharge the patient was noted
to have a leukocytosis to 17 without band forms. She had no
localizing signs of infection and this likely represents
demargination from the steroids. She will have a repeat CBC in
three days to make sure this is resolved.
3) Hypothyroidism: She continued levothyroxine at her home dose.
She tolerated a regular diet. Pneumoboots were worn when she
was in bed for DVT prophylaxis. She was full code.
Transitional Issues:
-___ and HCV were pending at the time of discharge and will be
followed up by the patient's hematologist Dr. ___.
-The patient will have a repeat CBC on ___ with results
followed by Dr. ___.
Medications on Admission:
Synthroid 75 mcg PO daily
Depo-Provera q 3 months
Discharge Medications:
1. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. dexamethasone 4 mg Tablet Sig: Ten (10) Tablet PO DAILY
(Daily) for 1 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Idiopathic thrombocytopenia purpura
Secondary Diagnosis:
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with low platelets due to a condition called
idiopathic thrombocytopenia purpura (ITP). This is a condition
where your immune system destroys your own platelets causing low
counts and an increased risk of bleeding. You have been treated
with steroids and intravenous immune globulin (IVIG) to diminish
your immune response and your platelet count has improved and
you are being discharged. It is VERY important you keep your
follow up visits and count checks to make sure your platelet
counts continue to improve.
Your medications have been changed. You have been started on
dexamethasone 40 mg daily, which you will take a final dose of
tomorrow. You should be careful over the next weeks and avoid
any activity where you have a risk of having something strike
you or that could generally cause brusing. You should report
ANY trauma to your head to your Hematologist and/or your PCP
until your platelet count has normalized and is stable.
Followup Instructions:
___
|
10875624-DS-18
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2158-03-06 00:00:00
|
2158-03-07 22:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
S/p orbital fracture
Major Surgical or Invasive Procedure:
Nasal packing
History of Present Illness:
The patient is an ___ with a history of CAD s/p CABG,
"arrhythmia" s/p AICD, and remote leg injury leaving him
requiring a leg brace who presents after a fall the prior
evening. He reports that around ___ pm, he was walking back from
his bathroom to his bed while wearing his "half leg brace". The
patient report sustaining an GSW and ___ bite while serving in
the ___ war and currently wears a brace on his leg and uses a
walker.
.
He denies LOC following or prior to his fall. He is not sure if
he "tripped" but assumed it was over his brace as he was not
using his walker at the time. He denies LH or dizziness prior to
his fall, no confusions following, and no bowel/bladder
incontinence. His fall was unwitnessed. Of note, he had a
cataract surgery on ___.
.
The patient called EMS and was brought to an OSH. He was found
to ahve a fracture of the the right maxillary sinus and a
comminuted blowout of the orbital floor causing hemorrhage in
the inferior rectus muscle. His Cspine and skull were not
fractured, and no intracranial hemorrhage was noted. He received
ancef and was transferred to ___ ED.
.
Upon arrival, initial vital signs were 98.4 54 150/57 17 98/2L.
He was seen by plastic surgery who felt this was non-operative
and left nasal packing in place. While ophtho was notified, ED
exam revealed good visual acuity OS ___ OD ___ with
?pressure recordings of OS 20 OD 19. A 3mm corneal abrasion was
noted for which erythromycin gel was given. Unasyn was started.
Of note, initial EKG showed LBBB with STE in the anterior leads.
A Troponin was 0.04 with elevated CK but normal MB. ___ fellow
was unimpressed and recommended against heparin. He received
ASA. Vitals prior to transfer 97.9 50 150/49 20 98%.
.
Currently the patient denies being in pain. He is able to
accurately and thoroughly describe both the event and his past
medical history. He states that he feels "great" other than
disappointment that he is back in the hospital around the
holidays. No current CP or SOB. No HA/LH, no N/V, no abdominal
pain. He reports feeling that his vision is improving, as it
felt a little blurry while in the ED.
.
ROS: per HPI, denies fever, chills, night sweats, headache,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
-CABG; 4 vessels, ___
-CEA; right ___, left ___
-AICD, multiple, most recent ___
-___ bite while serving in the ___ leaving him with
permanent sensory difficulties
-HLD
-Gout
-HTN
-BPH
-S/p MI (___)
-Right eye cataract extraction 2 wks prior
Social History:
___
Family History:
Noncontributory
Physical Exam:
VS - Temp 96.3F, BP 142/57, HR 55, R 18, O2-sat 99% RA
GENERAL - well-appearing elderly man in NAD, comfortable,
appropriate
HEENT - NC/AT, large ecchymosis over right eye and forhead,
mildly TTP, able to open and close his right eye, but
significant swelling limits full lid ROM. +subconjuntival
hemorrhage medially. pupil reactive, visual acquity ___ on
6ft near eye chart. EOMI intact, no pain with EOM. Left eye wnl.
MMM, OP clear
NECK - supple, no JVD,
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
NEURO - awake, A&Ox3, CNs II-XII grossly intact with limited
visual acuty on right as noted above, muscle strength ___
throughout, sensation grossly intact throughout other than RLE,
gait not done.
Pertinent Results:
Admission-
___ 02:50AM BLOOD WBC-7.1 RBC-3.75* Hgb-12.6* Hct-37.4*
MCV-100* MCH-33.7* MCHC-33.8 RDW-13.6 Plt ___
___ 02:50AM BLOOD ___ PTT-23.4 ___
___ 02:50AM BLOOD Glucose-118* UreaN-44* Creat-1.1 Na-138
K-4.7 Cl-101 HCO3-29 AnGap-13
___ 02:50AM BLOOD CK(CPK)-378*
___ 07:50AM BLOOD Calcium-9.4 Phos-2.7 Mg-2.6
Discharge-
___ 07:50AM BLOOD WBC-6.1 RBC-3.44* Hgb-12.0* Hct-34.8*
MCV-101* MCH-35.0* MCHC-34.6 RDW-13.5 Plt ___
___ 07:50AM BLOOD Glucose-102* UreaN-32* Creat-1.1 Na-141
K-4.2 Cl-103 HCO3-33* AnGap-9
___ 05:30PM BLOOD CK(CPK)-321
___ 02:50AM BLOOD CK-MB-9
___ 02:50AM BLOOD cTropnT-0.04*
___ 06:55AM BLOOD CK-MB-8 cTropnT-0.04*
___ 05:30PM BLOOD CK-MB-6 cTropnT-0.04*
UA
Blood NitriteProteinGlucoseKetone BilirubUrobiln pH Leuks
NEG NEG NEG NEG NEG NEG NEG 6.5 NEG
XR AP Pelvis:
No fracture or dislocation. Moderate degenerative changes at
both femoroacetabular joints, left greater than right, with
joint space narrowing and subchondral sclerosis. Degenerative
changes of the lower lumbar spine and bilateral sacroiliac
joints are also seen. Surgical clips
overlie the left medial thigh.
Brief Hospital Course:
___ yo M with extensive cardiac history and remote leg injury
presenting following a mechanical fall, found to have orbital
fracture and troponin of 0.04.
# Orbital fracture
Patient noted to have "right maxillary sinus and a comminuted
blowout of the orbital floor causing hemorrhage in the inferior
rectus muscle". Was seen by plastics in the ED, no surgical
intervention and packed his nostril. They recommended keeping
the head of the bed elevated as well as "sinus precautions" (no
straw use, no nose blowing, open mouth sneezing) and outpatient
follow up.
Ophthamology was consulted to evaluate the eye. They
recommended ophthalmic antibiotic ointment to the laceration
above his eye lid and for him to follow up with his outpatient
ophthamologist upon discharge.
Patient was given Unasyn during his hospital course which was
transitioned to augmentin for a total of a 5 day course.
# Mechanical fall
As per all descriptions of the report, it appears his fall was
mechanical. He sustained a GSW c/b frostbite while serving in
the military and currently wears a brace. Patient was monitored
on telemetry. He had one episode of asymptomatic bradycardia to
39.
# Troponin leak
Etiology not entirely unclear. His troponins were been flat
with no increase in CKMB. EKG reveals LBBB, but no overt
evidence of ischemia based on Sgarbossa criteria. It was felt
that this was possibly secondary to traumatic injury complicated
by some decrease in renal function (high BUN, Cr 1.1; baseline
unknown).
# Coronary artery disease
Patient has had significant cardiac history, but as above, there
is limited evidence that this event is due to a cardiac origin.
Digoxin was continued but his home metoprolol was held on
admission given his asymptomatic bradycardic episode; it was
restarted upon discharge as there were no other events on
telemetry.
Inactive medical issues:
# HLD: Continued home meds (simvastatin)
# BPH: Continued home meds (terazosin)
# Gout: Continued home meds (allopurinol) adjusted for renal
function
================================================
Transitions of care
================================================
-Pts allopurinol was redosed for renal function to 150 mg po
qday.
-Pt was discharged on the completion of a 5 day antibiotic
course (augmentin) and a 3 day antibiotic ointment for his eye
lid laceration
-He is to follow up with plastics and his outpatient
ophthamologist following discharge.
Medications on Admission:
-Aspirin 81 mg po qday
-Plavix 75 mg po qday
-Allopurinol ___ mg po qday
-Simvastatin 40 mg po qhs
-Terazosin 2 mg po ?BID
-Potassium 20 mEq po qday
-Furosemide 40 mg po BID
-Metoprolol 12.5 mg po qday
-Digoxin 0.125 mg po qday
-benicar 20 mg po qday
-Docusate 100 mg po qday
-Artificial tears both eyes QID
-Tramadol 50 mg 4 times daily PRN (confirmed)
-Centrum
-Flush free niacin
-Pred forte 1% TID to operative eye (right)
-Zymar TID to operative eye (right)
-Acular TID to operative eye (right)
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. allopurinol ___ mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. terazosin 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a
day).
6. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day.
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO once a day.
9. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Benicar 20 mg 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).
12. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: ___
Drops Ophthalmic QID (4 times a day).
13. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
14. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 4 days: Please take 1 dose the evening of ___.
Last dose ___.
Disp:*9 Tablet(s)* Refills:*0*
16. Pred Forte 1 % Drops, Suspension Sig: One (1) drop
Ophthalmic three times a day: As directed to right eye.
17. Zymaxid 0.5 % Drops Sig: One (1) drop Ophthalmic three times
a day: As directed to right eye.
18. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
19. ketorolac 0.5 % Drops Sig: One (1) Drop Ophthalmic TID (3
times a day): As directed to right eye.
20. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
application Ophthalmic QID (4 times a day) for 3 days: Please
apply to laceration above right eye lid. 0.5inch.
Continue for 3 days unless otherwise directed.
Disp:*1 tube* Refills:*3*
21. niacin Oral
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Oribital blow out fracture, inferior rectus hemorrhage,
maxillary sinus fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
It was a pleasure meeting you and taking part in your part in
your care. You were transferred to our hospital because after
you fell you sustained a fracture to the bones around your eye.
You were evaluated by the plastic surgery team, who placed
packing in your nose to help stop the bleeding. They did not
feel your required surgery at this time, but would like you to
follow up with them as an outpatient on ___.
You were evaluated by the ophthalmologists who did not find any
damage to your eye other than a small cut above you eye lid.
They recommended an antibiotic cream and that you follow up with
the ophthalmologist that performed your surgery.
Please make the following changes to your medications:
-Start: Augmentin twice daily. Take one dose the evening of
discharge and continue for 4 additional days.
-Start: Erythromycin ophthalmic ointment to your right eye and
eye lid for three days unless otherwise directed.
-Decrease: Allopurinol to 150 mg by mouth daily; this dose may
be better for your kidneys, please speak to your primary care
physician regarding this dose.
Followup Instructions:
___
|
10876550-DS-16
| 10,876,550 | 23,981,116 |
DS
| 16 |
2150-03-12 00:00:00
|
2150-03-12 13:41:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
___: CABG x4, LIMA to LAD, reverse saphenous vein
graft to PDA, reverse saphenous vein graft to OM, and reverse
saphenous vein graft to diagonal.
History of Present Illness:
___ T2DM, HTN presenting with exertional chest pain. He
presented to PCP office with intermittent exertional lower chest
and upper abd pain after walking about four blocks for the past
month. It is described as crushing chest pain with associated
sob and sometimes diaphoresis. Pain usually occurs at the end of
his walk and subsides after 15 minutes of rest. He had one
episode of nausea, no vomiting. The episodes have been becoming
more frequent and even at rest. The last episode was last night
while taking out the trash and lasted ___ minutes and self
resolved.
He was sent in from PCP office to ___. Initial VS: 97.7 61 126/69
16 100% RA. EKG showed EKG NSR, IVCD, primary AV block. His
troponin was <0.01 x 2, BNP 195, CXR showed LLL opacity and
patient was given dose of azithromycin. At 8PM patient developed
chest pain while urinating and EKG showed new ST depressions
with TWI. His symptoms self resolved after ___ minutes. He was
given full dose ASA, metoprolol 25 mg, simvastatin 20 mg.
Patient also received 3L NS.
Transfer VS: 98.6 65 122/65 18 99% Nasal Cannula.
On arrival, VS 97.5 148/86 64 18 100% RA. Patient denies any
chest pain and reports his last CP, described as soreness in his
epigastrum was in the ___ at 8PM. Currently denies any SOB, any
discomfort, nausea, diaphoresis.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, palpitations. Denies vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias.
Past Medical History:
CAD
Adult onset DM
Lipids
HTN
Bilat inguin hernias
Subdural hematoma ___
Prostate cancer s/p RT
EKG w/ 1d AV Block
R shoulder pain (chronic)
Social History:
___
Family History:
Unknown, thinks his father had prostate cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.5 148/86 64 18 100% RA
General: Alert, normal speech, oriented to person only, not to
time or place, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis; 1+
edema bilaterally
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Pertinent Results:
ADMISSION LABS:
==========================
___ 11:30AM BLOOD WBC-6.0 RBC-3.85* Hgb-12.1* Hct-35.2*
MCV-91 MCH-31.4 MCHC-34.4 RDW-12.4 RDWSD-40.5 Plt ___
___ 11:30AM BLOOD Neuts-65.6 ___ Monos-8.1 Eos-4.9
Baso-0.7 Im ___ AbsNeut-3.92 AbsLymp-1.22 AbsMono-0.48
AbsEos-0.29 AbsBaso-0.04
___ 11:53AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 11:30AM BLOOD ___ PTT-31.3 ___
___ 11:30AM BLOOD Glucose-144* UreaN-19 Creat-1.4* Na-138
K-4.3 Cl-100 HCO3-26 AnGap-16
___ 11:30AM BLOOD ALT-23 AST-18 AlkPhos-61 TotBili-0.5
___ 11:30AM BLOOD proBNP-195
___ 11:30AM BLOOD cTropnT-<0.01
___ 06:00PM BLOOD cTropnT-<0.01
___ 06:00PM BLOOD %HbA1c-7.6* eAG-171*
STUDIES:
==========================
CXR ___
IMPRESSION:
Subtle left basal opacity is concerning for an early pneumonia.
ECG:
Sinus 60bpm, poor baseline, AV delay 232, QTc 470, IVCD, flat T
waves II, avF, I and avL.
STUDIES:
===============
+ Nuclear Perfusion Study (___):
1. Probably normal myocardial perfusion. Significant left arm
attenuation.
2. Normal left ventricular cavity size and systolic function.
In the setting of diabetes, normal myocardial perfusion does not
necessarily imply a low risk of adverse cardiovascular events.
+ Cardiovascular Report Stress Study (___):
RESTING DATA
EKG: SINUS WITH AV DELAY, IVCD, NSSTTW
HEART RATE: 60 BLOOD PRESSURE: 150/76
STAGE TIME SPEED ELEVATION WATTS HEART BLOOD RPP
(MIN) (MPH) (%) RATE PRESSURE
I ___ .142MG KG/MIN 68 128/68 8704
TOTAL EXERCISE TIME: 4 % MAX HRT RATE ACHIEVED: 48
SYMPTOMS: NONE
ST DEPRESSION: NONE
INTERPRETATION: ___ yo man with HL, HTN and DM, ___ reporting
non-sustained VT was referred to evaluate his exertional chest
discomfort. The patient was administered 0.142 mg/kg/min of
Persantine over 4 minutes. No chest, back, neck or arm
discomforts were reported. In the presence of nonspecfic ST
segment changes at baseline, no additional ST segment changes
were noted during the procedure. The rhythm was sinus with one
VPB noted. Resting systolic hypertension with an appropriate
hemodynamic response to the Persantine infusion. Post-infusion,
the patient was administered 125 mg Aminophylline IV.
IMPRESSION: No anginal symptoms or additional ST segment changes
from baseline. Appropriate hemodynamic response to the
vasodilator stress. Nuclear report sent separately.
+ CXR (___): Subtle left basal opacity is concerning for an
early pneumonia.
+ ECG (___): Sinus 60bpm, poor baseline, AV delay 232, QTc
470, IVCD, flat T waves II, avF, I and avL.
+ TTE (___): The left atrium is normal in size. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with mild
hypokinesis of the mid to distal inferior wall and of the mid
inferolateral wall. Doppler parameters are indeterminate for
left ventricular diastolic function. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion. IMPRESSION: Mild regional left ventricular systolic
dysfunction. At least mild mitral regurgitation.
.
___ Intra-op TEE
Conclusions
There is a moderate sized pericardial effusion with some
echogenic components, suggestive of pericardial clot. Right
ventricular systolic function is mildly depressed compared to
previous study. There is no echocardiographic sign of tamponade.
Overall left ventricular systolic function is low normal (LVEF
50%).There is a left pleural effusion with echogenic components,
suggestive of clot.
After clot evacuation from left chest and mediastinum, the right
ventricular systolic function returns to normal. The LVEF is
>55%. The descending thoracic aorta is mildly dilated. No
thoracic aortic dissection is seen. The IABP is no longer seen.
Dr. ___ was notified in person of the results at time
of study.
I certify that I was present for this procedure in compliance
with ___ regulations.
Electronically signed by ___, MD, Interpreting physician ___
___ 15:08
.
___ 06:00AM BLOOD WBC-8.4 RBC-3.80* Hgb-11.3* Hct-33.7*
MCV-89 MCH-29.7 MCHC-33.5 RDW-13.8 RDWSD-44.2 Plt ___
___ 02:58AM BLOOD WBC-9.3 RBC-3.73* Hgb-11.3* Hct-31.5*
MCV-85 MCH-30.3 MCHC-35.9 RDW-14.9 RDWSD-44.9 Plt ___
___ 01:18AM BLOOD WBC-10.5* RBC-3.50* Hgb-10.7* Hct-30.2*
MCV-86 MCH-30.6 MCHC-35.4 RDW-14.1 RDWSD-43.2 Plt ___
___ 02:01AM BLOOD ___ PTT-31.0 ___
___ 02:58AM BLOOD ___ PTT-30.9 ___
___ 06:00AM BLOOD UreaN-34* Creat-1.3* Na-138 K-4.4 Cl-99
___ 03:28AM BLOOD Glucose-168* UreaN-33* Creat-1.4* Na-138
K-4.0 Cl-99 HCO3-26 AnGap-17
___ 01:53AM BLOOD ALT-13 AST-31 LD(LDH)-293* AlkPhos-40
Amylase-41 TotBili-4.2*
Brief Hospital Course:
___ with history of T2DM, HTN presenting with exertional chest
pain at rest. He presented to PCP office with intermittent
exertional upper abdominal pain after walking about four blocks
for the past month. Non-invasive imaging was unrevealing but
because of rest symptoms and EKG changes, he underwent cardiac
catheterization on ___ which revealed tight left main disease.
Given high risk lesion he was started on IABP and presented for
urgent CABG, which he underwent on ___.
The patient was brought to the Operating Room on ___ where
the patient underwent CABG x 4 with Dr. ___. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. Soon after arrival in the ICU, he
returned to the Operating Room for re-exploration due to
bleeding. Hemostasis was achieved and the patient was
transferred to the ICU in stable but critical condition. IABP
was discontinued without complication. Pressors were weaned
over the following days as the patient developed hemodynamic
stability. The patient was diuresed and extubated on POD 2. He
received blood for post-operative blood loss anemia. The patient
does have a baseline dementia and in the initial post-op course,
he was confused and impulsive. He failed a swallow evaluation
and Dob Hoff tube was placed for tube feeds. He subsequently
passed a swallow evaluation, Dob Hoff was discontinued and
regular diet initiated.
Glipizide and Metformin were resumed for Diabetes. Zyprexa was
initiated for sun-downing/delerium. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 7 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to ___ Rehab in ___ in good condition with
appropriate follow up instructions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO BID
2. Metoprolol Tartrate 25 mg PO BID
3. Simvastatin 20 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. GlipiZIDE 10 mg PO BID
6. MetFORMIN (Glucophage) 850 mg PO BID
7. Vitamin D ___ UNIT PO DAILY
8. Ocuvite with Lutein (vit A,C & E-lutein-minerals) 1,000
unit-200 mg-60 unit-2 mg oral daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Vitamin D ___ UNIT PO DAILY
3. GlipiZIDE 10 mg PO BID
4. Lisinopril 10 mg PO BID
Hold SBP < 110
5. MetFORMIN (Glucophage) 850 mg PO BID
6. Ocuvite with Lutein (vit A,C & E-lutein-minerals) 1,000
unit-200 mg-60 unit-2 mg oral daily
7. Acetaminophen 650 mg PO Q4H:PRN pain, fever
8. Atorvastatin 80 mg PO DAILY
9. Bisacodyl ___AILY:PRN constipation
10. Docusate Sodium 100 mg PO BID
11. Furosemide 20 mg PO DAILY
12. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
13. Metoprolol Succinate XL 100 mg PO DAILY
14. Milk of Magnesia 30 ml PO DAILY
15. Potassium Chloride 10 mEq PO DAILY
16. Ranitidine 150 mg PO DAILY
17. Sarna Lotion 1 Appl TP TID back rash
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
Coronary Artery Disease s/p
CABGx4(Lima-lad;SVG-diag;SVG-Om;SVG-PDA)
SECONDARY:
BPH
type 2 DM
hyperlipidemia
hypertension
nephrolithiasis
h/o prostate CA
h/o L SAH after fall ___ long recovery at rehab
Discharge Condition:
A&O x 1
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10876693-DS-12
| 10,876,693 | 25,896,542 |
DS
| 12 |
2162-12-29 00:00:00
|
2163-01-03 15:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dizziness, visual changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a ___ y.o male with h.o prostate ca s/p radiation, DM2,
HTN, HL, generalized sensory motor axonal neuropathy with who
reportedly presented for evaluation of R.sided weakness and
associated blurry vision/dizziness that happened earlier today
and has since improved completely.
Pt states that early today he felt "dizzy" while lying down. He
states that he sat up and that "everything looked dark" in both
of his eyes and then they became red. He also reports that when
walking he felt as though he was leaning to his right side. He
reports that these symptoms lasted about 25 min and then
completely resolved. Wife states that she took his BP during
these events and noted 197/81. Pt denies any headache, neck
pain/stiffness, eye pain, chest pain, new paresthesias or
weakness (has chronic neuropathy). He does report palpitations
and CP on ___. He thinks that he may have had palpitations
today prior to this episode. He reports that he stopped smoking
marijuana and stopped drinking beer (few cans a day) about 1
week ago. He reports that he has been able to eat and drink ok.
Pt notes that his finger sticks are rarely above 200.
.
In the ED, pt was evaluated by neurology who felt that his
decreased vision, unsteadiness and decreased speech were in the
setting of HTn, hyperglycemia and hyponatremia and that most of
his neuro findings have been documented before and that given
his metabolic defects he likely had recrudescence of prior
deficits vs. TIA vs HTN encephalopathy. Exam notable for R.sided
weakness and subjective diminishment of sensation RLE. VSS but
with HTN.
.
10Pt ROS reviewed and otherwise negative including headache, CP,
fever, chills, abdominal pain, nausea, vomiting, diarrhea,
constipation, melena, brbpr, dysuria, new paresthesias/weakness.
Past Medical History:
- Prostate cancer s/p radiation (completed ___ and Lupron
(completed ___
- DM2 (insulin dependent)
- HTN
- hyperlipidemia
-neuropathy
Social History:
___
Family History:
Mother father and brother with DM
Physical Exam:
GEN: well appearing, NAD
vitals: T 98.2 BP 172/91 HR 81 RR 18 sat 100% on RA
HEENT: ncat eomi anicteric MMM
neck: supple
chest: b/l ae no w/c/r
heart: s1s2 rr no m/r/g
abd:+bs, soft, NT, ND, no guarding or rebound
ext: no c/c/e 2+pulses
neuro: face symmetric, speech fluent, AAOx3, CN ___ intact,
motor ___ x4. Pt reports subjective decrease in sensation LLE
(chronic), no tremor
psych: calm, cooperative
Pertinent Results:
___ 09:15PM WBC-6.5 RBC-4.78 HGB-13.3* HCT-39.0* MCV-82
MCH-27.8 MCHC-34.1 RDW-13.7 RDWSD-40.4
___ 09:15PM NEUTS-72.3* LYMPHS-17.7* MONOS-8.9 EOS-0.6*
BASOS-0.3 IM ___ AbsNeut-4.70 AbsLymp-1.15* AbsMono-0.58
AbsEos-0.04 AbsBaso-0.02
___ 09:15PM PLT COUNT-252
___ 07:33PM ___ PTT-30.0 ___
___ 05:06PM GLUCOSE-282* LACTATE-1.4 K+-4.1
___ 04:50PM GLUCOSE-303* UREA N-18 CREAT-1.3* SODIUM-128*
POTASSIUM-4.6 CHLORIDE-92* TOTAL CO2-27 ANION GAP-14
___ 04:50PM ALT(SGPT)-64* AST(SGOT)-83* ALK PHOS-94 TOT
BILI-0.4
___ 04:50PM LIPASE-39
___ 04:50PM cTropnT-<0.01
___ 04:50PM ALBUMIN-4.2
___ 04:50PM WBC-7.5 RBC-4.78 HGB-13.2* HCT-39.0* MCV-82
MCH-27.6 MCHC-33.8 RDW-13.8 RDWSD-40.8
___ 04:50PM NEUTS-79.1* LYMPHS-11.0* MONOS-8.7 EOS-0.5*
BASOS-0.4 IM ___ AbsNeut-5.90 AbsLymp-0.82* AbsMono-0.65
AbsEos-0.04 AbsBaso-0.03
___ 04:50PM PLT SMR-UNABLE TO PLT COUNT-UNABLE TO
___ 04:50PM ___ PTT-21.6* ___
___ 06:00AM BLOOD WBC-5.4 RBC-4.29* Hgb-11.9* Hct-35.5*
MCV-83 MCH-27.7 MCHC-33.5 RDW-14.1 RDWSD-41.7 Plt ___
___ 06:00AM BLOOD Glucose-242* UreaN-14 Creat-0.8 Na-138
K-3.2* Cl-100 HCO3-27 AnGap-14
.
CXR:
IMPRESSION:
No acute cardiopulmonary process.
.
CT head:
IMPRESSION:
No acute intracranial process.
Low-lying cerebellar tonsils are again noted, suggesting Chiari
1
malformation.
.
EKG-similar to prior ___
___ blood culture: NO growth
Brief Hospital Course:
___ y.o male with h.o DM, axonal neuropathy, ?prior CVA, HTN, h.o
prostate ca, who presented with reports of R.sided weakness,
decreased vision and unsteadiness/dizziness.
.
#TIA vs. recrudescence of prior ?CVA (given metabolic
abnormalities) vs. HTN encephalopathy
#weakness/unsteadiness
#visual changes
-Pt with reports of R.sided weakness, decreased vision,
unsteadiness and decreased speech. He was noted to be
hypertensive during this episode. He was noted to have slow
___ baseline speech, intact visual fields, and mild RLE
weakness and LLE foot drop in the ED. These symptoms
completely resolved during his hospitalization. Head CT
negative for acute process. He was seen by the neurology
service who felt that his symptoms were due to a metabolic
encephalopathy. His neurologic exam at discharge was felt to
be at his baseline.
.
#palpitations-Pt reports palpitations 1 week ago and possibly
prior to the onset of this event. Denies any current
palpitations. Trop neg in ED. EKG unchanged from prior. No
events seen on telemetry.
#acute renal failure-Resolved with IVF and holding
ace-inhitbitor
.
#hyponatremia-. Pt does endorse ETOH last week but states he has
quit. Could be due to low solute. Resolved with IVF and holding
hctz.
# Hypertension: Pressures improved during hospitalization; he
was continued on his home regimen of medication with the
exception of hctz. He was to discuss this in outpatient f/u.
.
#poorly controlled type 2 diabetes-Dm diet, ___ ___
continue home regimen for now of lantus, HISS and standing
Humalog. Adjust prn.
.
#transaminitis-mild, nearly normalized LFTs by the time of
discharge.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. NIFEdipine CR 90 mg PO DAILY
2. Glargine 40 Units Bedtime
Humalog 10 Units Breakfast
Humalog 4 Units Lunch
Insulin SC Sliding Scale using HUM Insulin
3. Aspirin 81 mg PO DAILY
4. GlipiZIDE XL 10 mg PO BID
5. Hydrochlorothiazide 25 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Glargine 40 Units Bedtime
Humalog 10 Units Breakfast
Humalog 4 Units Lunch
Insulin SC Sliding Scale using HUM Insulin
3. Lisinopril 40 mg PO DAILY
4. NIFEdipine CR 90 mg PO DAILY
5. GlipiZIDE XL 10 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
1. Dizziness
2. Acute kidney injury
3. Hypertension
4. Diabetes Mellitus.
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with some lightheadedness and vision changes
that resolved. We do not feel that you had a stroke and now you
are back to baseline. You were seen by our neurologists who do
not recommend any additional testing or treatment.
You may have been dehydrated after having some diarrhea earlier
in the week. Please hold your hydrochlorothiazide for now.
You can continue your other blood pressure medications.
Followup Instructions:
___
|
10877113-DS-11
| 10,877,113 | 21,999,011 |
DS
| 11 |
2179-08-03 00:00:00
|
2179-08-05 06:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Periods of confusion, difficulty concentrating and not being
herself
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
The patient is a ___ year old right handed woman with a
history of a left posterior cerebral artery territory ischemic
stroke, migraine with visual aura, and ADD presenting with an
episode of confusion this morning and subsequently experiencing
witnessed generalized convulsions in the ___. This interview was
conducted with the patient's husband as she was too somnolent to
provide a history.
The patient has a history of suspected migraines with a visual
aura of flashing lights and persisting visual symptoms which
recurred just prior to her admission in ___, precipitating
Neurology clinic evaluations and an outpatient MRI which
revealed
a subacute left PCA stroke. The investigation of stroke etiology
only revealed an ASD. She was taken off her Concerta and
methylphenidate for ADD at that time, owing to the potential
increased risk for stroke. Since that time, she has reported
intermittent episodes of "confusion" and difficulty with
accomplishing work-related tasks. Per her husband, she has been
vague in the description of these episodes. This has recurred
steadily over the past year until she noticeably starting
reporting more frequent episodes in the past few weeks
associated
with an unusual "tiredness." She normally is a very active and
fit person, so this seemed atypical to her husband. She would
have episodes lasting anywhere from one to three hours where she
felt confused and tired; he could not describe an exact
frequency, but they at least occurred several times weekly. This
morning, he dropped her off at the subway around 7 AM and she
appeared normal at that time. Around 10 AM, she called him
saying
that she didn't feel well. When he spoke with her on the phone,
her responses did not correlate with the questions he asked. She
did speak in short sentences at that time. He brought her from
___ to the ___ ___. In the ___, she appeared tired and did not
speak very much. At triage, she was answering questions albeit
inappropriately. She kept blinking her left eye, which he
thought
might represent her testing her own vision which was a problem
in
her previous stroke. She reportedly only spoke her name to the
___
physicians prior to her CT scan. After her CT scan around ___,
she was noted to have the sudden onset of generalized
convulsions. She was noted to have rightward eye deviation,
right
lower face distortion and movements "as though she was trying to
say something", up and down head jerking, and jerking of her
limbs. It was not noted if one side of the body started moving
first. This lasted for one minute and she was given 1 mg of
lorazepam before Neurology was called for assistance.
The patient could not provide a review of systems. The patient's
husband endorsed that she has had intermittent headaches and
confusion prior to this episode. Prior to this episode, he
denied
that she had any lightheadedness, speech changes, loss or change
in vision, muscle weakness, numbness, incontinence, or gait
difficulty. He denied that she had any notable fevers, rigors,
night sweats, noticeable weight loss, chest pain, dyspnea,
cough,
nausea, vomiting, diarrhea, or pain. She has had no change in
sleep patterns (sleeps 7 hours per night).
Past Medical History:
-Migraine-variant headache
-ADD, followed by outpatient psychiatry and taking Concerta
daily with PRN short-acting methylphenidate apparently
-"borderline high cholesterol"
Social History:
___
Family History:
The patient has multiple family members with migraines (sister,
aunt, cousin all have migraines), no known history of
bleeding/clotting
disorders. She thinks some family members may have had a
history
of miscarriages but she is not sure.
Physical Exam:
Physical Examination on Admission:
VS T: 99.2 HR: 78 BP: 172/74 RR: 16 SaO2: 97%RA
General: NAD, lying in bed comfortably. / Head: NC/AT, no
conjunctival icterus, no oropharyngeal lesions / Neck: Supple,
no
nuchal rigidity or meningismus, no lymphadenopathy /
Cardiovascular: RRR / Pulmonary: Equal air entry bilaterally but
unable to provide full effort, no crackles or wheezes / Abdomen:
Soft, NT, ND, +BS, no guarding / Extremities: Warm, no edema,
palpable radial/dorsalis pedis pulses / Skin: No rashes or
lesions but right hand and forearm are slightly redder than the
left
Neurologic Examination:
- Mental Status - Somnolent. Brief arousal to forced eye
opening,
able to keep eyes open for a second before closing them again.
No
verbalization or vocalization. Does not consistently follow
commands, although she did arouse for about 30 seconds and
looked
to the right when commanded.
- Cranial Nerves - [II] PERRL 4->2 brisk. [III, IV, VI]
Oculocephalic reflexes intact. [V] Corneal reflexes intact.
[VII]
No facial asymmetry at rest, no asymmetry apparent with brief
grimace.
- Motor - Normal tone. Flexion withdraws left hand and left
foot.
No movement of right upper or lower extremities.
- Sensory - Responds (grimaces and withdraws) to noxious stimuli
on left upper and lower extremities, but not right upper or
lower
extremities.
- Reflexes
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 3 3 2 2 2
R 3 3 2 2 2
Plantar response equivocal bilaterally.
- Coordination - Unable to assess at the time of examination.
- Gait - Unable to assess at the time of examination.
Pertinent Results:
Labs on Admission:
___ 01:15PM BLOOD WBC-7.6 RBC-4.31 Hgb-13.0 Hct-39.0 MCV-90
MCH-30.1 MCHC-33.3 RDW-12.3 Plt ___
___ 01:15PM BLOOD Neuts-63.5 ___ Monos-3.5 Eos-0.9
Baso-0.5
___ 01:15PM BLOOD ___ PTT-27.4 ___
___ 01:15PM BLOOD Glucose-129* UreaN-10 Creat-0.8 Na-138
K-4.1 Cl-98 HCO3-30 AnGap-14
___ 01:15PM BLOOD ALT-22 AST-25 AlkPhos-90 TotBili-0.5
___ 01:15PM BLOOD Calcium-9.6 Phos-4.9* Mg-2.2
___ 01:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:18PM BLOOD Lactate-0.7
___ 05:45PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:45PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:45PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 05:45PM URINE CastHy-12*
___ 05:45PM URINE Mucous-RARE
___ 05:45PM URINE UCG-NEGATIVE
___ 05:45PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
___ 12:43PM CEREBROSPINAL FLUID (CSF) TotProt-127*
Glucose-71
___ 12:43PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-0
___ ___ 12:43PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Negative
___ 01:45PM CEREBROSPINAL FLUID (CSF) BORRELIA BURGDORFERI
ANTIBODY INDEX FOR CNS INFECTION-pending
Microbiology:
CSF Cultures: Gram stain negative, no organisms seen
Urine Cultures: No organisms seen
Stool Cultures: Negative for campylobacter, shigella.
Stool C diff: Negative for C diff toxins
Lyme serology: Negative
Reports:
EEG ___: This is an abnormal video EEG monitoring session
because of abundant electrographic seizures arising from the
left temporal region
consistent with non-convulsive status epilepticus. There are
continuous
periodic lateralized epileptiform discharges and focal
attenuation in
the same region, indicative of an acute epileptogenic focal
structural
lesion in this region. These findings are superimposed on mild
diffuse
background slowing, consistent with a mild encephalopathy, which
is
etiologically non-specific. The continuous EEG shows a decrease
in
seizure frequency compared to the initial stat EEG recording in
the
emergency room, but she continues to have between one and 15
brief
electrographic seizures per hour until 7 a.m. No clinical
correlate is
visible on the video for the two events for which video is
recorded.
NCHCT ___: No hemorrhage or CT evidence of acute
territorial infarct. Encephalomalacia related to previously
imaged left PCA territory infarct is noted. If there is high
concern for acute ischemia, consider MRI for increased
sensitivity.
CXR ___: No radiographic evidence of pneumonia. Gaseous
distention of the stomach with mild elevation of the overlying
left hemidiaphragm.
MRI Head ___: No evidence of acute infarct. Chronic left
posterior cerebral artery infarct. Mild changes of small vessel
disease. No enhancing brain lesions, mass effect, midline shift
or hydrocephalus.
EEG ___: This is an abnormal video EEG monitoring session
because of abundant electrographic seizures arising from the
left temporal region.
There is no clear clinical correlate to the electrographic
seizure is
apparent on video, although there is a report of possible
worsened
aphasia following the seizures. There are continuous periodic
lateralized epileptiform discharges and focal attenuation in the
same
region, indicative of an acute epileptogenic focal structural
lesion in
this region. There is also mild diffuse background slowing,
consistent
with a mild encephalopathy, which is etiologically non-specific.
Compared to the prior day's recording, electrographic seizures
have
decreased in frequency. Particularly after midnight, seizures
decrease
to approximately one per hour, and there are no seizures after
5:30 a.m.
EKG ___: Sinus rhythm. Indeterminate QRS axis.
Non-specific lateral ST-T wave changes. Compared to the previous
tracing of ___ the findings are similar.
Rate PR QRS QT/QTc P QRS T
63 174 86 454/459 54 0 51
EEG ___: This is an abnormal video EEG monitoring session
because of
continuous periodic lateralized epileptiform discharges in the
left
temporal region with a somewhat variable repetition rate of
0.3-0.5 Hz.
This is superimposed on nearly continuous focal slowing and
attenuation
of faster frequencies in the left temporal region. These
findings are
indicative of a highly potentially epileptogenic focus in the
left
temporal region. There is also mild diffuse background slowing
consistent with a mild encephalopathy which is etiologically
non-
specific. Compared to the prior day's recording, no
electrographic
seizures are present. The periodic lateralized epileptiform
discharges
are of lower voltage and have a more blunted morphology. The
patient
also spends many more daytime hours awake.
EEG ___: This is an abnormal video EEG monitoring session
because of
continuous periodic lateralized epileptiform discharges in the
left
temporal region with a repetition rate of 0.3-0.5 Hz. This is
superimposed on nearly continuous focal slowing and attenuation
of
faster frequencies in the left temporal region. These findings
are
indicative of a highly potentially epileptogenic focus in the
left
temporal region. There is also mild diffuse background slowing
consistent with a mild encephalopathy, which is etiologically
non-
specific. Compared to the prior day's recording, the periodic
lateralized epileptiform discharges are of lower voltage and
have a more
blunted morphology. No electrographic seizures are seen in this
study.
EEG Reports ___ and ___: Pending at the time of
discharge
Brief Hospital Course:
Ms. ___ was admitted to the Epilepsy Monitoring Unit of the
___ for her and her husband's subjective reports of periods of
confusion, difficulty performing work related tasks and periods
of concentration difficulties. At the time of her ___
presentation, she sustained a generalized tonic clonic seizure.
EEG recordings at the time of her admission showed almost
continuous PLEDs over the left temporal region, likely
representing an epileptogenic region arising following her old
PCA stroke. She was brought to ___ where she remained on
continuous video EEG monitoring until her discharge.
She was initiated on antiepileptic therapy with levetiracetam
and standing ativan, and the doses were uptitrated relatively
quickly to alleviate her epileptiform discharges. She received
an MRI which showed sequelae of her old PCA infarct on the left.
She did display some intermittent fevers, and to rule out a
meningitic process, she received an LP which revealed elevated
protein (127) but no WBC. She was empirically started on IV
acyclovir therapy (with pre- and post-infusion hydration), and
this was discontinued when her CSF HSV PCR returned negative.
While on the floor, she did have some transient problems of 1)
urinary retention and 2) diarrhea. She did require a foley
catheter briefly, but by the time of her discharge, she was able
to void without difficulty and retention. Stool studies at the
time of her symptoms did not reveal any obvious infectious
origin for her diarrhea.
She did have one episode of bradycardia with normotension during
her stay, which coincided with a hypokalemia to 3.2. This was
repleted orally and intravenously, and subsequently she did not
have any arrhythmias.
Her abnormal EEG patterns improved towards the end of her stay,
and she was discharged to home with recommendations to follow up
with her private neurologist as well as her ___ neurologist,
Dr. ___. We answered her and her husband's questions about
seizures and seizure precautions. They will also follow up with
their outside neurologist at ___.
Her discharge physical examination was unremarkable.
Medications on Admission:
ASA 81mg daily
Atorvastatin 20mg daily
Verapamil 120mg daily
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. verapamil 120 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q24H (every 24 hours).
3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 2 doses: take one tonight and one tomorrow morning
then stop.
Disp:*2 Tablet(s)* Refills:*0*
5. Keppra 750 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure disorder
History of left posterior cerebral artery infarction
Migraine headaches with aura
Discharge Condition:
Mental Status: Clear and coherent mostly, confused at times,
improved on discharge
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Epilepsy Monitoring Unit of the
___ following some vague symptoms of confusion and difficulty
performing your work related tasks, as well as a convulsion that
we observed in the ___. You were monitored on EEG monitoring
(electroencephalography), which showed the presence of
epileptiform discharges from the left side of your brain, likely
as a consequence of your old stroke in that area. We started you
on at least two "antiepileptic medications", which helped
control your symptoms, and you have since remained seizure free.
Infections of the brain and it's outer coverings can also cause
seizures. We performed a lumbar puncture to examine your
cerebrospinal fluid to look for signs of infection. This did not
reveal any signs of common viral or bacterial infections. We
have tapered off the ativan and will keep you on Keppra
Your medications were changed as follows:
KEPPRA was added at 1500mg BID
you will taper off ativan, take one 0.5mg tablet and night, and
one in the morning then stop.
- Please take your medications as listed below.
- We encourage you to follow up with a psychiatrist who may be
able to provide more recommendations about medications that may
be safe for your problems with mood changes, emotional lability,
difficulties with concentrations.
- Do not hesitate to contact us with any further questions.
- Please make sure to follow up with your PCP and your
neurologist as noted below. If you decide to follow up with your
neurologist at ___, please call Dr. ___ office
(phone number listed below) and cancel your appointment.
- Please present to your nearest ER should you experience any of
the symptoms listed below. Also present to the ___ if you
experience any abnormal sensations such as strange tastes or
smells, abnormal headaches, visual disturbances, periods of loss
of consciousness or staring spells. It is important to be
careful around fire, water and heights especially when
unsupervised.
- It was a pleasure taking care of you during this
hospitalization.
Followup Instructions:
___
|
10877420-DS-17
| 10,877,420 | 23,400,804 |
DS
| 17 |
2140-12-30 00:00:00
|
2140-12-30 22:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydrochlorothiazide / Penicillins / clindamycin / Cephalexin /
Tetracycline
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with a remote history of
alcohol use disorder, pancreatitis, who presents with abdominal
pain.
Patient reports that this episode of abdominal pain started
around 5 days prior to admission. It felt like a "nervous
stomach", which she describes "like a fist in the stomach" with
tightness and pulling located in the middle of her stomach. She
thought this was related to stress, but it continued to get
worse and has been severe at times. Associated with nausea, but
no vomiting, and generally a poor appetite. She notes that she
has had hard stool, but that her pain did not improve after a
bowel movement. She states that she will often have one bowel
movement a week.
On review of records, patient has been seen in GI clinic at
___. She underwent an upper endoscopy in ___ which
showed gastric polyps. She was started on esomeprazole twice
daily, which she continues to take.
In the ED:
Initial vital signs were notable for: T 99.6, HR 87, BP 102/67,
RR 18, 98% RA
Exam notable for: Abd: Soft, mildly tender in the middle abdomen
otherwise nontender to palpation without rebound or guarding,
Nondistended. No masses or overlying skin changes. No
organomegaly.
Upon arrival to the floor, patient recounts history as above.
She is currently having less pain, though still doesn't feel
well.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- CKD stage III
- Esophageal reflux
- Hypertension, essential
- History of pancreatitis
- Hematuria
- Sciatica
- Vitamin D Deficiency
- Obesity
- Menopause
- Hepatic fibrosis
- Fracture of ankle, trimalleolar
- Advanced directives, counseling/discussion
- Microalbuminuria
- S/P lumbar fusion
- Chronic back pain
- Narcotic Contract
- Anxiety disorder
- Alcoholism /alcohol abuse
- Greater tuberosity of humerus fracture
- OSA (obstructive sleep apnea)
- Low tension glaucoma of right eye, moderate stage
- Alcohol abuse, in remission
- Major depressive disorder, recurrent episode
- S/P insertion of spinal cord stimulator
- Uncontrolled type 2 diabetes mellitus with stage 3 chronic
kidney disease, with long-term current use of insulin
- Lumbar facet arthropathy
- Bilateral thigh pain
- Low-tension glaucoma of left eye, mild stage
Social History:
___
Family History:
- Father - hemorrhaging stroke
- Mother - ___, glaucoma, hypertension
Physical Exam:
VITALS: T 98.1, HR 76, BP 104/72, RR 16, 99% Ra
GENERAL: Alert and in no apparent distress, tired-appearing
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, moderately tender to palpation
in band across upper abdomen without rebound or guarding. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
The patient was examined on the day of discharge
Pertinent Results:
ADMISSION/SIGNIFICANT LABS:
=======================
___ 01:43PM BLOOD WBC-3.9* RBC-3.55* Hgb-10.3* Hct-32.6*
MCV-92 MCH-29.0 MCHC-31.6* RDW-13.1 RDWSD-44.2 Plt ___
___ 01:43PM BLOOD Neuts-53.3 ___ Monos-10.4 Eos-2.5
Baso-1.3* Im ___ AbsNeut-2.10 AbsLymp-1.26 AbsMono-0.41
AbsEos-0.10 AbsBaso-0.05
___ 01:43PM BLOOD Glucose-67* UreaN-20 Creat-1.5* Na-139
K-4.8 Cl-109* HCO3-19* AnGap-11
___ 01:43PM BLOOD ALT-14 AST-16 AlkPhos-67 TotBili-0.3
___ 01:43PM BLOOD Lipase-26
___ 06:50PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 07:00AM BLOOD %HbA1c-4.8 eAG-91
___ 01:43PM BLOOD TSH-1.1
___ 06:15AM BLOOD Cortsol-10.6
___ 02:02PM BLOOD Lactate-0.9
___ 07:00PM BLOOD Lactate-2.4*
___ 09:35PM BLOOD Lactate-1.4
___ 06:17AM BLOOD Lactate-1.6
MICRO:
=====
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
All Blood Cultures NGTD at time of discharge
IMAGING/OTHER STUDIES:
====================
___ CXR
There is no focal consolidation, pleural effusion or
pneumothorax. The size of the cardiomediastinal silhouette is
within normal limits. Spinal stimulator leads are again noted.
___ CT a/p w/ contrast:
IMPRESSION: No findings to account for pain.
LABS ON DISCHARGE:
=================
___ 06:15AM BLOOD WBC-3.0* RBC-3.18* Hgb-9.2* Hct-29.3*
MCV-92 MCH-28.9 MCHC-31.4* RDW-13.2 RDWSD-44.9 Plt ___
___ 06:15AM BLOOD Glucose-98 UreaN-13 Creat-1.3* Na-145
K-4.4 Cl-112* HCO3-23 AnGap-10
Brief Hospital Course:
Ms. ___ is a ___ female with a remote history of
alcohol use disorder, pancreatitis, who presents with acute
abdominal pain. Course complicated by hypovolemic hypotension.
# Acute Abdominal Pain:
Patient presented with several days of intense
___ pain. Low concern for atypical angina
as ECG unchanged and cardiac enzymes normal. Patient with CT
scan that revealed moderate stool burden but no acute
intraabdominal pathology. Labs including CBC, LFTs, lipase were
also normal. EGD approximately ___ years ago was normal. Her
pain is associated with stress and constipation raising concern
for IBS-D or functional dyspepsia, particularly in absents of
other clear pathology. Additionally, semaglutide is known to
cause abdominal pain in 6-7% of patients taking the drug.
Patient treated with supportive care including hydration,
increased bowel regimen, and trial of hyoscyamine with
improvement of GI discomfort to ___ from peak of ___ prior to
admission. Patient met with social worker to discuss stress
management. Her home semaglutide was discontinued prior to
discharge.
# Hypotension:
Noted to have incidental asymptomatic hypotension of 78/52 with
associated elevated lactate. Likely due to hypovolemia from poor
PO intake. Improved with 2L IVF. Review of outside records
indicate patient's BPs run at the lower end at baseline.
Infectious workup negative. AM cortisol normal, thus not
consistent with adrenal insufficiency.
with associated newly elevated lactate. No other new lab
abnormalities. Improved with 2L IVF bolus. ECG without acute
changes and cardiac enzymes negative. H/H stable and infectious
workup negative including CXR, UA, blood Cx. No hyperk/hypoNa to
suggest adrenal insufficiency. Review of Atrius records shows
borderline low BP of 105/78 back in early ___ at outpatient
visit. - encourage PO, additional IVF prn - f/u AM cortisol -
f/u pending culture data.
# Type II diabetes:
Recently has needed to decrease dose of semaglutide, and was
hypoglycemic in ED, likely from poor PO intake. A1c 4.8%.
Semaglutide discontinued.
# CKD stage III secondary to diabetes - Cr 1.5 on admission,
remained within baseline range.
# Depression - continued home bupropion and venlafaxine
# Chronic pain - continued home gabapentin
# Glaucoma - continued home eye drops
TRANSITIONAL ISSUES:
==================
[] ensure patient is having regular bowel movements
[] recommend NOT restarting semaglutide given known side effects
of abdominal pain and fact that patient likely does not need to
be on any diabetic agent as her A1c is 4.8.
[] recommend ongoing outpatient SW for coping with multiple life
stressors
> 30 mins spent on discharge planning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 600 mg PO TID
2. Venlafaxine XR 300 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Topiramate (Topamax) 200 mg PO BID
5. BuPROPion 150 mg PO BID
6. semaglutide 0.25 mg or 0.5 mg(2 mg/1.5 mL) subcutaneous
1X/WEEK
7. Esomeprazole 40 mg Other BID
8. Acetaminophen 325 mg PO Q8H:PRN Pain - Mild/Fever
9. Docusate Sodium 100 mg PO BID
10. Senna 8.6 mg PO BID:PRN Constipation - First Line
11. Vitamin D 5000 UNIT PO DAILY
Discharge Medications:
1. Hyoscyamine 0.125 mg PO QID
RX *hyoscyamine sulfate 0.125 mg 1 tablet(s) by mouth four times
a day Disp #*30 Tablet Refills:*0
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
RX *polyethylene glycol 3350 17 gram/dose 1 dose by mouth once a
day Refills:*0
3. Acetaminophen 325 mg PO Q8H:PRN Pain - Mild/Fever
4. BuPROPion 150 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Esomeprazole 40 mg Other BID
7. Gabapentin 600 mg PO TID
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. Topiramate (Topamax) 200 mg PO BID
11. Venlafaxine XR 300 mg PO DAILY
12. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Functional dyspepsia:
# hypotension secondary to hypovolemia:
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 to care for you at the ___
___. You were admitted with worsening abdominal pain.
You had a CT scan of the abdomen and lab testing that were
reassuring against any dangerous causes. We suspect that your
stomach pain is related to a condition known as Irritable Bowel
Syndrome (IBS) which can be exacerbated by stress. We started a
new medication called hyosciamine that can help with crampy
abdominal pain. Additionally, we suspect that your symptoms will
improve with more regular bowel movements. We recommend that you
continue to take senna after discharge along with miralax as
needed. Lastly, we recommend that you STOP taking your diabetes
medication Ozempic ___ as this can also cause
abdominal pain as a side effect and furthermore you're A1c was
very low and thus you do not need it to control your blood
sugars.
Please take all medications as prescribed and follow up with all
appointments as detailed below.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10877472-DS-13
| 10,877,472 | 27,957,509 |
DS
| 13 |
2128-12-31 00:00:00
|
2129-01-02 13:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is a ___ yo right handed male, previously healthy
who presents with his second episode of acute onset of vertigo,
ataxia, and vomiting. Patient reports that after lunch he was
leaving work and felt "woozy". He then had relatively acute
onset vertigo. He felt that the world was spinning and it
persisted all positions and was also present when his eyes were
closed. He reports that this has made him very nauseous and has
vomited several times. He denies headache, vision changes,
dysarthria, dysphagia, change in hearing. He got home and
vomited several times, despite lying down and trying to rest.
While walking to the car to come to the ED his daughters were on
each side of him and he was very wide based and staggering back
and forth. His sxs persisted for about 3 hours. They have
subsided significantly since arriving in the ED.
He has had one previous similar episode about a month ago. Again
while he was walking home from work. He rested at home and the
sxs eventually subsided.
Review of Systems: On neuro ROS, lightheadedness, vertigo,
dizziness as above. Denies ataxia, HA, loss of vision, diplopia,
dysarthria, dysphagia, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. Denies focal
weakness, numbness, parasthesiae. No bowel incontinence. Gait
problems with ataxia as above.
On general review of systems, He denies any URI sxs, rhinorrhea.
He denies recent fever or chills. No night sweats or recent
weight loss or gain. Denies shortness of breath, palpitations,
chest pain. 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:
none
Social History:
___
Family History:
No strokes, seizures or migraines.
Physical Exam:
Physical Exam on Admission:
Vitals: T: 97.8, HR 68, BP 139/72, RR 18, O2 98% RA
General: Awake, cooperative, in NAD.
HEENT: NC/AT, no sclera 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
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to hospital, person, and date.
Attentive. Language appears fluent in ___. Speech is normal
and verrified with family. Following commands appropriately. No
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 3 mm and brisk. VFF to confrontation. Fundoscopic
exam reveals sharp disc margins, but difficult due to nystag.
III, IV, VI: EOMI with left beating nystagmus in all directions
of gaze, including primary. No diplopia.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to voice.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
Negative Head thrust test.
-Motor: Normal bulk, tone throughout. No pronator drift. No
tremor or other adventitious movements. No asterixis noted. Nml
finger tapping.
Delt Bic Tri FFl FE IO IP Quad Ham TA ___
L 5 5 ___ 5 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5 5
-Sensory: Intact and symmetric sensation to light touch and
sharp.
- DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor b/l.
-Coordination: No dysmetria on FNF or heel to shin.
-Gait: Mildly wide based, no obvious ataxia. Falls to either
side on tandem gait. No Rhomberg.
Physical Exam on Discharge:
unchanged from above
Pertinent Results:
Labs:
___ 06:25PM WBC-19.7* RBC-4.58* HGB-14.6 HCT-42.2 MCV-92
MCH-31.9 MCHC-34.7 RDW-13.0
___ 06:25PM NEUTS-84.5* LYMPHS-10.1* MONOS-3.0 EOS-2.1
BASOS-0.2
___ 06:25PM GLUCOSE-151* UREA N-19 CREAT-1.0 SODIUM-139
POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-27 ANION GAP-17
___ 05:30AM BLOOD %HbA1c-5.8 eAG-120
___ 05:30AM BLOOD Triglyc-48 HDL-60 CHOL/HD-2.5 LDLcalc-80
Imaging:
Non contrast head CT
FINDINGS: There is no CT evidence for acute intracranial
hemorrhage, mass effect, edema, or hydrocephalus. There is
preservation of gray-white matter differentiation. The basal
cisterns appear patent. The ventricles and sulci are normal in
caliber and configuration. Mucosal thickening is seen in the
ethmoid air cells. The remainder of the visualized portions of
the paranasal sinuses and mastoid air cells appear well aerated.
Few arterial calcifications are seen. No acute bony
abnormality is detected.
IMPRESSION: No acute intracranial process.
Chest xray ___. Slight blurring in the medial portion of the left
hemidiaphragm and
Preliminary Reportadjacent vague opacity may represent
atelectasis or pneumonia.
2. Nodular opacity in the left lower lobe laterally. Recommend
oblique views for better assessment.
Chest xray ___
With the exception of the nodular opacity in the left lower
lung, the
lungs are clear without evidence of airspace consolidation,
pleural effusions, or pneumothorax. No pulmonary edema.
Overall cardiac contours are stable. In the absence of more
remote chest films to document stability of the opacity in the
left lower lobe, further imaging evaluation with a dedicated CT
scan should be considered.
Brief Hospital Course:
Mr. ___ is a ___ yo right handed male, generally healthy
who presents with his second episode of acute onset vertigo,
ataxia, and vomiting that remains unclear whether it represents
a peripheral or central process.
# Neurologic: The patient's symptoms have essentially completely
resolved with only nystagmus and some unsteadiness on tandem
gait. This temporal profile is more consistent with a peripheral
etiology, however it is difficult to prove on exam alone.
Ataxia and vomiting were prominent in the patient's history and
may suggest a cerebellar TIA. Suspicion for stroke/TIA was quite
low. Risk factors checked: HbA1c 5.8, LDL 80. TTE deferred
given low suspicion for ischemic infarct. Attempted to obtain
MRI, but patient did not tolerate it. Most likely, symptoms
were due to a transient vestibular neuronitis. Will f/u with Dr.
___ in neurology clinic.
# Cardiovascular: Monitored on telemetry, no aberrant rhythms
observed.
# Pulm: Incidental left lower lobe pulmonary nodule observed.
Will need this followed by PCP (emailed regarding this issue)
TRANSITIONS OF CARE:
- will f/u in neurology clinic with Dr. ___
- lung nodule to be followed by PCP
___ on ___:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Disposition:
Home
Discharge Diagnosis:
Meniere's Vs Transient vestibular neuronitis Vs BPPV
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 dizzines and we were
worrid that you may have had a stroke. An MRI was attempted but
you did not tolerate the prodecdure. Most likely, your dizziness
was from something called Meniere's disease.
On discharge, please follow up in clinic with Dr. ___ in
neurology clinic.
Also please follow up with your primary care provider so that
you can follow up with regards to the solitary pulmonary nodule
that was seen on chest X-ray.
It was a pleasure taking care of you, we wish you all the best!
Followup Instructions:
___
|
10877472-DS-16
| 10,877,472 | 24,433,104 |
DS
| 16 |
2129-07-20 00:00:00
|
2129-07-22 13:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Oxycodone / latex
Attending: ___.
Chief Complaint:
left flank pain after sneezing
Major Surgical or Invasive Procedure:
___
talc pleurodesis at bedside
History of Present Illness:
___ year old male with a history of a stage 1A moderately
differentiated adenocarcinoma of the lung s/p robotic VATS left
lower lobectomy on ___ and a readmission from ___
for a spontaneous left pneumothorax found on an outpatient CT
scan now presents with left flank pain after sneezing with a CXR
showing a recurrent spontaneous large left pneumothorax. Patient
had a cold a few days ago with soar throat and runny nose that
is
now resolving, but denies any recent fevers, chills, night
sweats, wieght loss or poor appetite, nausea, vomiting, BRBPR or
melena, dysuria, or hematuria.
Past Medical History:
PMH
Meniere's disease
Stage 1A moderately differentiated adenocarcinoma
Post op left pneumothorax
PSH
s/p robotic VATS left lower lobectomy on ___
Social History:
___
Family History:
No strokes, seizures or migraines.
Physical Exam:
T 97.9 HR 84 BP 136/68 RR 20 SPO2 98% 2LNC
GENERAL
[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [x] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY
[x] CTA/P [x] Excursion normal [x] No fremitus
[x] No egophony [x] No spine/CVAT
[x] Abnormal findings: decreased lung sounds at left
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema
[x] Peripheral pulses nl [x] No abd/carotid bruit
[ ] Abnormal findings:
GI
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings:
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] Strength intact/symmetric [x] Sensation intact/ symmetric
[x] Reflexes nl [x] No facial asymmetry [x] Cognition intact
[x] Cranial nerves intact [ ] Abnormal findings:
MS
[x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl
[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl
[x] Nails nl [ ] Abnormal findings:
LYMPH NODES
[x] Cervical nl [x] Supraclavicular nl [x] Axillary nl
[x] Inguinal nl [ ] Abnormal findings:
SKIN
[x] No rashes/lesions/ulcers
[x] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
___ 08:00PM WBC-13.5* RBC-4.74 HGB-14.2 HCT-43.7 MCV-92
MCH-30.0 MCHC-32.5 RDW-13.3
___ 08:00PM NEUTS-63.3 ___ MONOS-6.0 EOS-10.3*
BASOS-0.9
___ 08:00PM PLT COUNT-368
___ 08:00PM GLUCOSE-99 UREA N-12 CREAT-0.8 SODIUM-137
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-26 ANION GAP-17
___ CXR :
Large left pneumothorax without signs of tension, increased in
size dramatically from prior exam. Findings were posted and
flagged to the ED
dashboard at the time of this dictation
___ CXR post pleurodesis :
Stable left apical pneumothorax with slight increase in left
Preliminary Reportbasilar pleural effusion. Left pleural
catheter in stable position.
Brief Hospital Course:
Mr. ___ was evaluated by the Thoracic Surgery service in
the Emergency Room and a pigtail catheter was placed in the left
chest with a notable air leak. His chest xray post placement
showed increased expansion of the left lung and he was admitted
to the hospital for further management.
Following transfer to the Surgical floor his tube remained on
suction with a persistent air leak. His serial chest xrays
showed improvement in expansion but unfortunately the air leak
remained. On hospital day #3 he underwent chemical pleurodesis
with 5Gm. of sterile talc slurry mixed with Lidocaine.
Following instillation his pain increased requiring some IV
Dilaudid. This was eventually stopped due to nausea and
vomiting and he was placed on IV fluids and IV Tylenol with
decreased pain and no further nausea.
His chest tube was elevated for 2 hours to allow the talc to
stay intrapleural and was subsequently placed back on suction
for 48 hours. His air leak resolved, his pain decreased and his
chest xray showed only a small left apical space along with a
small left pleural effusion. A waterseal trial showed a stable
left apical pneumothorax along with the left pleural effusion
and then a clamp trial was done. After 3 hours his chest xray
remained stable. His chest tube was removed on ___ and a
post pull film revealed that his small left apical pneumothorax
had decreased in size since the prior film before the chest tube
was pulled, and he was deemed stable for discharge home with
outpatient followup.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 200 mg PO Q12H:PRN pain
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Ibuprofen 200 mg PO Q12H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent left pneumothorax
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 another left
pneumothorax requiring chest tube placement and eventually
sterile talc was instilled which aided in sealing the leak.
* Your chest xray now shows re expansion of the lung and
hopefully that will remain.
* The discomfort from the talc should gradually ease but take
Tylenol as needed for pain.
* Your chest tube dressing can be removed in 48 hours as long as
the site is dry. If there's any drainage, keep a dressing over
the site and change daily.
* If you develop any more chest pain, shortness of breath or any
new symptoms that concern you, call Dr. ___ at ___ or
return to the Emergency Room.
Followup Instructions:
___
|
10877494-DS-9
| 10,877,494 | 23,836,848 |
DS
| 9 |
2131-05-05 00:00:00
|
2131-05-05 21:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
BM biopsy
History of Present Illness:
___ w/PMhx of recently diagnosed Autoimmune Hemolytic anemia
with cold and warm antibody positive, as well as lymphadenopathy
with possible underlying malignancy p/w SOB, generalized
weakness. He reports that he was seen in clinic today for a
possible bone marrow bx but given his persistent symptoms, he
was referred for further evaluation. He reports dyspena with
minimal exertion now. No cough, fevers, chills, + 10 lbs weight
loss in the last 3 weks. He also has intermittent discomfort
under his left rib intermitently q ___ days. It says it is not
a 'pain'.
.
Had a LN biopsy earlier this month. pathology is still pending.
.
ROS: poor Po intake but negative for fevers chils, headahce, CP,
palpitations, cough, abd pain, n/v/d/c, dysuria, focal weakness,
rash, + baseline numbness in left hand since carpel tunnel
surgery. Pt does not note any LAD although he has a hx of it.
.
heme negative PR
Admission Vitals: 98.7-108-18 98% 117/58
Past Medical History:
GERD
hypertension
hyperlipidemia
LAD of uncertain significance
autoimmune hemolytic anemia
PSH: bilateral total knee replacement
ALLERGIES: NKDA
Social History:
___
Family History:
brother - prostate cancer, no hx of lymphoma
Physical Exam:
ADMISSION FEX
___ 112->now ___ ___ 99% on RA
GEN: NAD
HEENT: EOMI, oropharynx clear
Neck: supple, no LAD appreciated, LN biopsy site c/d/i
CV: RRR no m/r/g
PULM: CTAB
ABD: +BS, soft, NTND, no HSM
EXT: no edema
MS: ___ in all extremities
Neuro: A&O x 3, CN ___ intact, moves all extremities, no focal
deficits
DERM: no rashes
PSYCH: normal affect
DISCHARGE FEX
Tm 98.3 BP 116/60 P 76 RR 18 O2 95%RA
GEN: NAD
HEENT: EOMI, oropharynx clear
Neck: supple, two isolated 1-2cm nontender mobile lymph nodes
over left cervical and right supraclavicular fields, LN biopsy
site c/d/i
CV: RRR no m/r/g
PULM: CTAB
ABD: +BS, soft, NTND, no HSM
EXT: no edema
MS: ___ in all extremities
Neuro: A&O x 3, CN ___ intact, moves all extremities, no focal
deficits
DERM: no rashes
PSYCH: normal affect
Pertinent Results:
OSH CT CHEST/ABDOMEN/PELVIS
CT abdomen showed splenomegaly and lymphadenopathies involving
mainly anterior medistinal lymph node of 3 cm just above the
diaphragm in the right epicardial space. Retrocrural lymph
nodes
measuring up to 2-3 cm. Contracted gallbladder with stones.
Nondilated bile ducts. Duodenal diverticulae. Diverticulosis.
Small hiatal hernia.
OSH RUQ US
Ultrasound of the abdomen showed contracted gallbladder with
nondilated bile ducts, moderate splenomegaly with splenic cyst
and
nonvisualized pancreas.
ADMISSION LABS:
___ 09:50PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:36PM K+-4.5
___ 04:36PM HGB-6.0* calcHCT-18
___ 02:20PM GLUCOSE-118* UREA N-27* CREAT-1.1 SODIUM-135
POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-22 ANION GAP-17
___ 02:20PM ALT(SGPT)-17 AST(SGOT)-19 LD(LDH)-225 ALK
PHOS-80 TOT BILI-3.1*
___ 02:20PM cTropnT-<0.01
___ 02:20PM CK-MB-2 cTropnT-<0.01
___ 02:20PM ALBUMIN-4.2 CALCIUM-9.4 PHOSPHATE-3.4
MAGNESIUM-2.2 URIC ACID-10.3* IRON-51
___ 02:20PM calTIBC-286 FERRITIN-540* TRF-220
___ 02:20PM WBC-10.9 RBC-1.81* HGB-5.9* HCT-17.8* MCV-98
MCH-32.5* MCHC-33.1 RDW-19.1*
___ 02:20PM NEUTS-87.9* LYMPHS-9.5* MONOS-2.1 EOS-0.4
BASOS-0.2
___ 02:20PM PLT COUNT-476*
___ 02:20PM ___ PTT-27.3 ___
___ 02:20PM ___
STUDIES
EKG ___
NSR, no acute ischemic changes
___ Radiology CHEST (PA & LAT)
The lung volumes are normal. Normal transparency and structure
of
the lung parenchyma. No evidence of acute lung disease, in
particular no
pneumonia, pulmonary edema, or lung nodules. Normal size of the
cardiac
silhouette. Minimal tortuosity of the thoracic aorta. Normal
hilar and
mediastinal structures.
___ Cardiovascular ECHO
Borderline dilated left ventricular cavity size with preserved
global and regional systolic function. Mild mitral regurgitation
___ Radiology CT NECK W/CONTRAST
1. Diffuse cervical lymphadenopathy involving all stations with
superior
mediastinal and bilateral axillary lymphadenopathy is consistent
with
lymphoma.
2. Mild carotid atherosclerosis without significant stenosis.
___ Cardiovascular ECHO
Compared with the prior study (images reviewed) of ___,
pulmonary hypertension is now detected (but unlikely new as RV
was enlarged on prior study as well).
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION
___ yo M with recent diagnosis of autoimmune hemolytic anemia
with cold and warm antibody positive with LAD presents with DOE,
Anemia with a hct of 17. Found to have new angioimmunoblastic
lymphoma and underwent ___ cycle of CHOP.
ACTIVE PROBLEMS
# Anemia - Patient presented with significant dyspnea on
exertion and HCT of 17.8 on admission. Presumed due to
autoimmune hemolytic anemia recently diagnosed at OSH and
confirmed by Coomb's test. Patient received 3 units pRBC shortly
after admission with resolution of symptoms. He was originally
placed on 80mg prednisone daily, but was increased to 100mg
daily x5 days per CHOP protocol. He was discharged with 3 days
remaining of 100mg daily, and will resume 20mg daily once this
is completed. HCT remained somewhat volatile during remainder of
admission fluctuating between 21.1 and 27.2 without additional
product. HCT on discharge was 24.2.
# Lymphoma - CT of the abdomen and CT of the chest at OSH showed
mediastinal lymphadenopathy and spleenomegaly but no masses. He
underwent LN biopsy at OSH, and pathology was reviewed by our
pathologist. Review of LN biopsy showed angio-immunoblastic
lymphadenopathy: a form of T-cell lymphoma. Bone marrow biopsy
was performed on ___ and results are pending at time of
writing. Patient was started on CHOP chemotherapy on ___ which
he tolerated well.
# Abd pain - Intermittent left subcostal pain noted over the
past few weeks resolved prior to admission to floor. Likely due
to splenomegaly; ER checked troponins, which were negative x 2.
CHRONIC PROBLEMS
# HTN- Normotensive during stay. Continued home lisinopril.
# HLD - Continued statin.
# GERD - Continued PPI.
TRANSITIONAL ISSUES
- Note is made of pulmonary hypertension on echocardiogram
- CT Torso at OSH has been uploaded into PACS
- Patient is to start neulasta at clinic visit on ___
- Continue chronic prednisone 20mg daily following CHOP protocol
or as necessary to remain stable HCT. ___ need PPI and PCP
prophylaxis if chronic steroids are to be used.
- Would monitor uric acid as outpatient as it was high on
admission.
Medications on Admission:
lisinopril 40 mg po daily
folic acid 1 mg po daily
omeprazole 20 mg po daily
simvastatin 40 mg po q hs
tylenol prn pain
prednisone 20 mg po daily
folic acid 1 mg po daily
Percocet ___ 1 tab po q 4 hrs prn pain
cyanocobalamin 1000 mcg po daily
thiamine 100 MG ORAL mg po daily
Discharge Medications:
1. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Tylenol Oral
6. prednisone 20 mg Tablet Sig: Five (5) Tablet PO once a day
for 3 days: Take 5 tablets for 3 days (starting on ___.
Disp:*15 Tablet(s)* Refills:*0*
7. prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day:
After finishing 5 pills per day, start taking 1 pill per day.
Disp:*30 Tablet(s)* Refills:*2*
8. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
11. ondansetron 4 mg Tablet, Rapid Dissolve Sig: ___ Tablet,
Rapid Dissolves PO every eight (8) hours as needed for nausea.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*2*
12. Neulasta 6 mg/0.6mL Syringe Sig: One (1) injection
Subcutaneous as directed: You will receive this medication at
clinic.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Angio-immunoblastic lymphoma
2. Auto-immune hemolytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you were having
worsening shortness of breath related to your anemia. We gave
you blood transfusions and you felt better. While you were here,
we reviewed your lymph node pathology and did a bone marrow
biopsy, which unfortunately showed you have lymphoma. We gave
you a round of chemotherapy called CHOP which you tolerated
well, and it is safe for you to go home. You will need to follow
up closely Dr. ___ to follow your blood counts and
your progress. Please note the following changes to your
medications:
START Acyclovir 400mg 1 tablet by mouth three times daily
START Prednisone 20mg 5 tablets by mouth once a day (for a total
of 100mg) for 3 days starting tomorrow.
START Prednisone 20mg 1 tablet by mouth daily AFTER finishing
your three days of 100mg of prednisone
START Ondansetron (Zofran) 4mg tablet ___ tablets by mouth every
8 hours as needed for nausea.
No other changes were made to your medications. Please note the
following appointments that have already been scheduled. It has
been a pleasure taking care of you!
Followup Instructions:
___
|
10877695-DS-20
| 10,877,695 | 23,592,064 |
DS
| 20 |
2165-11-01 00:00:00
|
2165-11-02 11:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Levaquin / Doxycycline
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: EGD
History of Present Illness:
Ms. ___ is a ___ year-old woman with a PMHx of depression,
GERD, and ___ esophagus who presents to ___ from urgent
care with initial symptoms of dizziness and poor PO intake. In
the ___ ___ complained of epigastric pain, weakness,
odynophagia. She notes several months of progressive epigastric
pain, with occasional nonbloody vomiting. She has had no weight
loss during this period. The epigastric pain is burning,
radiates to beneat her sternum and is worsened with eating. She
is often woken up at night with a burning pain in her stomach
and lower throat. Over the past few days she has only tolerated
cups of soup broth secondary to pain. She previously was on
pantoprazole BID but stopped this several months ago. She has
been taking ranitidine 150mg qHS and PRN ___ seltzer.
She had an EGD in ___, significant for gastritis and Barretts
via biopsy. She denies any use of NSAIDs.
In the ___ she denied any dizziness, chest pain, dyspnea, cough,
diarrhea. Her last BM was 3 days ago, she reports flatus. She
notes some diarrhea last week and thinks some of her stools were
dark black in color.
Initial vitals in the ___: 98.2 74 128/88 18 100% RA. Labs
notable for Chem-7 with Glu 160 otherwise wnl, LFTs and lipase
wnl, Chem-7 wnl but with 7.0%E (AEC 497), lactate 4.6, Trop
<0.01, and negative flu swab. CT A/P notable for "1. Mild
thickening of distal esophageal wall worrisome for esophagitis.
2. Moderate sized hiatal hernia." CXR without cardiopulmonary
process.
Patient given 1L NS with decreased in lactate to 0.8. Also
administered GI cocktail, ondansetrom 4mg x1, and donnatol 10mL
x1.
Vitals prior to transfer: 98.1 78 ___ 99% RA.
On the floor, she reports continued epigastric pain, but
improved from presentation. She feels very thirsty.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, diarrhea, BRBPR, hematochezia, dysuria, hematuria.
Past Medical History:
Depression
___ esophagus
History of abnormal LFTs
Axillary granula parakeratosis
Hx eosinophilia
Back pain
Seasonal allergies
Insomnia
HLD
Social History:
___
Family History:
- Mother and aunt with DM, HTN
- Mother and maternal grandmother with gastric cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 99.7 128/70 76 20 100%RA
GENERAL: Flat affect, in no distress.
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva. MMM, no
oral lesions.
NECK: nontender supple neck, no LAD, no JVP elevation.
CARDIAC: RRR, S1/S2, no murmurs.
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably.
ABDOMEN: BS+. Soft, nondistended. Tender to palpation over the
epigastric region, no reound or tenderness. No
hepatosplenomegaly.
RECTAL: Brown stool, guiaic negative.
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
DISCHARGE PHYSICAL EXAM:
Vitals: T 98.2 HR 68 BP 108/65 RR 20 SAT 99%RA
General: Lying in bed, alert, cooperative, tired appearing, NAD
HEENT: Sclera anicteric, MMM
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no
murmur/rubs/gallops
Lungs: CTAB, no wheezes/rales/rhonchi
Abdomen: Soft, obese, minimal tenderness to palpation in
epigastric region, extinction of pain with distraction, no
guarding, question of rebound, no hepatosplenomegaly,
non-distended, bowel sounds present, vertical suprapubic scar
from prior c-section
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: EOMI, grossly normal sensation
Pertinent Results:
ADMISSION LABS
==============
___ 05:00PM BLOOD WBC-7.1 RBC-4.16* Hgb-12.7 Hct-36.8
MCV-88 MCH-30.5 MCHC-34.5 RDW-13.8 Plt ___
___ 05:00PM BLOOD Neuts-42.2* Lymphs-46.5* Monos-3.6
Eos-7.0* Baso-0.6
___ 05:00PM BLOOD Glucose-160* UreaN-11 Creat-0.8 Na-138
K-3.8 Cl-101 HCO3-24 AnGap-17
___ 05:00PM BLOOD ALT-26 AST-30 AlkPhos-57 TotBili-0.2
___ 05:00PM BLOOD Lipase-37
___ 05:00PM BLOOD cTropnT-<0.01
___ 05:00PM BLOOD Albumin-4.5
___ 05:05PM BLOOD Lactate-4.6*
___ 09:10PM BLOOD Lactate-0.8
___ 04:25PM URINE Color-Straw Appear-Clear Sp ___
___ 04:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 07:00PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
PERTINENT LABS
==============
___ 06:10AM BLOOD Cortsol-21.2*
MICROBIOLOGY
============
___ 1:00 pm URINE
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final
___:
Negative for Chlamydia trachomatis by PANTHER System,
APTIMA COMBO 2
Assay.
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Final ___:
Negative for Neisseria gonorrhoeae by PANTHER System,
APTIMA COMBO 2
Assay.
RADIOLOGY
=========
___ 5:58 ___ CHEST (PA & LAT)
FINDINGS:
Heart size is normal. A small hiatal hernia is noted. The
mediastinal and hilar contours are otherwise unremarkable. The
pulmonary vasculature is normal. Lungs are clear. No pleural
effusion or pneumothorax is seen. There are no acute osseous
abnormalities. No subdiaphragmatic free air is visualized.
IMPRESSION:
No acute cardiopulmonary abnormality. Small hiatal hernia.
___ 7:___BD & PELVIS WITH CONTRAST
FINDINGS:
CHEST: Limited assessment of the lung bases are clear. No
pleural effusion. The visualized heart is normal in size without
pericardial effusion.
ABDOMEN: The liver is homogeneous in enhancement. No focal
lesion identified.No intrahepatic or extrahepatic biliary
dilatation. The gallbladder is normal without calcified
gallstones. The portal vein, SMV, and splenic vein are patent.
The spleen is normal. The pancreas enhances homogenously and is
without focal lesions, peripancreatic fat stranding, or focal
fluid collection. The adrenal glands are unremarkable.
The kidneys display symmetric nephrograms and excretion of
contrast. No focal renal lesions. No hydronephrosis or
hydroureter identified. No renal or proximal ureter calculi.
A small to moderate size hiatal hernia is present. Mild
circumferential thickening of the distal esophageal wall suggest
esophagitis. The stomach is grossly unremarkable in appearance.
The small bowel is normal in caliber without wall thickening.
The large bowel is normal in caliber without wall thickening,
fat stranding, or focal mass lesion. The appendix is normal
without evidence of acute appendicitis.
The abdominal aorta is normal in caliber without aneurysmal
dilatation. The celiac axis, SMA, and ___ are patent . Small
amount of atherosclerotic calcification noted. The iliac
arteries are normal in course and caliber.
No retroperitoneal or mesenteric lymph node enlargement by CT
size criteria. No free abdominal fluid, abdominal wall hernia,
or pneumoperitoneum.
PELVIS: The bladder is well distended and normal. No pelvic
side-wall or inguinal lymph node enlargement by CT size
criteria. No free pelvic fluid seen. Calcified fibroid uterus
the uterus is present.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion
concerning for malignancy.
IMPRESSION:
Small to moderate sized hiatal hernia. Mild circumferential
thickening of the distal esophageal wall suggests esophagitis.
___ 8:48 AM ESOPHAGUS
FINDINGS:
BARIUM ESOPHAGRAM:
The esophagus was not dilated. There was no stricture within
the esophagus. There was no evidence of an esophageal mass.
There was initiation of the primary peristaltic wave which
appeared normal in the proximal esophagus. However, the primary
peristaltic wave was incomplete and did not carry the contrast
bolus all the way to the stomach. The distal esophagus
demonstrated ineffective propulsion of the contrast with visible
tertiary contractions. The patient reported feeling nauseous at
this time. The lower esophageal sphincter opened and closed
normally.
A 13-mm barium tablet was administered, which passed into the
stomach without significant holdup.
There was no gastroesophageal reflux. There is a moderate-sized
hiatal hernia of approximately 2 vertebral bodies height.
There is no overt abnormality in the stomach on limited
evaluation.
CHEST SCOUT:
There is slight prominence of the pulmonary vasculature on the
right compared to the left. There is no focal consolidation,
pleural effusion, pneumothorax, or frank pulmonary edema. The
heart size is normal. The mediastinal and cardiac silhouette
are stable from the prior exam. There is no acute osseous
abnormality. There is no sub-diaphragmatic free air. The
hiatal hernia demonstrated on the barium esophagram today and
the chest radiograph on ___ is not as well seen on the chest
scout due lack of air distention.
IMPRESSION:
1. Esophageal dysmotility.
2. Moderate hiatal hernia.
PATHOLOGY
=========
___ Tissue: UPPER GASTROINTESTINAL BIOPSY
1. Mid esophagus, biopsy: Squamous epithelium with rare
intraepithelial eosinophils consistent with mildly active
esophagitis.
2. Gastroesophageal junction, biopsy: Mildly active esophagitis
(6 eosinophils per high power field); no glandular epithelium
seen.
3. Stomach, body, biopsy: Corpus mucosa within normal limits.
4. Stomach, antrum, biopsy: Antral mucosa within normal limits.
5. Duodenum, biopsy: Small intestinal mucosa within normal
limits.
OTHER STUDIES
=============
ECGStudy Date of ___ 1:34:22 ___
Sinus rhythm. Diffuse non-specific anterolateral ST-T wave
changes, similar to that recorded on ___. The rate has
increased. Otherwise, no apparent diagnostic interim change.
___
___
DISCHARGE LABS
==============
___ 06:20AM BLOOD WBC-7.4 RBC-3.55* Hgb-11.0* Hct-31.1*
MCV-88 MCH-31.2 MCHC-35.5* RDW-13.7 Plt ___
___ 06:20AM BLOOD ___ PTT-34.2 ___
___ 06:20AM BLOOD Glucose-92 UreaN-5* Creat-0.8 Na-142
K-3.7 Cl-105 HCO3-26 AnGap-15
___ 06:20AM BLOOD Calcium-8.6 Phos-4.3 Mg-1.9
Brief Hospital Course:
SUMMARY: ___ with history of GERD diagnosed in ___, ___
esophagus, gastritis, depression, presented with worsening
epigastric pain with meals, odynophagia, nonbloody emesis,
dysphagia for solids. EGD found evidence of mild gastritis and
possible abnormal esophageal peristalsis. Barium swallow
confirmed eosphageal dysmotility. Treated symptomatically for
nausea and given IVF with transition to liquid and solid PO
intake. Started on PPI.
# Esophageal Dysmotility | # Gastritis: Given the presentation
of acute odynophagia and dysphagia such that patient is unable
to tolerate PO intake and the positive family history of gastric
cancer, GI was consulted. The patient had an upper endoscopy
that showed mild inflammation and signs of abnormal peristalsis
of the esophagus. A barium swallow was pursued, which confirmed
signs of abnormal peristalsis. Biopsy results showed
esophagitis. Given these findings, the patient was discharged
with recommendation for outpatient manometry study to better
characterize the dysmotility. She was treated symptomatically
with pantoprazole 40mg BID, ranitidine 150mg QHS, ondansetron,
viscous lidocaine, and Maalox.
# Eosinophilia: Patient has had borderline eosinophilia with
absolute count close to 500 for several years. Had previously a
work up for parasites that was negative. AM cortisol level was
normal here. Likely due to history of atopy.
# Depression: Severe depression, followed by Dr. ___ in
Psychiatry (last seen ___. Patient reported depressed mood
but no active suicidal or homicidal thoughts. She refused her
home medications while inpatient, citing that they made her feel
bad. At discharge, she was recommended to continue those
medications and follow up with her outpatient providers.
# Headache: Patient reported severe headaches during her stay.
Has a history of chronic headaches, and there was no
phonophobia, photophobia, nausea/vomiting, aura or pain to
suggest migraines. She was treated symptomatically with
acetaminophen and metoclopramide with good resolution.
TRANSITIONAL ISSUES
- Continue high dose PPI BID until instructed otherwise by
outpatient GI doctor
- Will need outpatient esophageal manometry to further
characterize dysmotility
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea, wheezing
2. Diazepam 5 mg PO QHS:PRN insomnia
3. Duloxetine 60 mg PO BID
4. LaMOTrigine 50 mg PO DAILY
5. Lorazepam 2 mg PO QHS
6. Lorazepam 2 mg PO DAILY:PRN anxiety
7. MethylPHENIDATE (Ritalin) 10 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Ranitidine 150 mg PO QHS
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea, wheezing
2. Diazepam 5 mg PO QHS:PRN insomnia
3. Duloxetine 60 mg PO BID
4. LaMOTrigine 50 mg PO DAILY
5. Lorazepam 2 mg PO QHS
6. Lorazepam 2 mg PO DAILY:PRN anxiety
7. MethylPHENIDATE (Ritalin) 10 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Ranitidine 150 mg PO QHS
10. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
11. Ondansetron 4 mg PO Q8H:PRN Nausea
RX *ondansetron 4 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: GERD, Esophageal Dysmotility
SECONDARY: Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for abdominal pain and pain in your
throat, which resulted in dehydration from inability to drink
much fluids. We gave you medications to treat your symptoms and
IV fluids. The gastroenterologists were concerned by your
symptoms and performed an endoscopy, which showed mild gastritis
and suggestions of abnormal peristalsis, or contraction, of the
eosphagus. We performed a barium swallow study that confirmed
abnormal peristalsis of the esophagus.
We recommend that you resume taking a proton pump inhibitor, or
acid suppressing medication. You will need close follow up with
your gastroenterologist to further work up the esophageal
contraction problem. It was a pleasure to take care of you
during your stay. Please do not hesistate to contact us with any
questions or concerns.
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10877695-DS-21
| 10,877,695 | 21,944,541 |
DS
| 21 |
2166-06-17 00:00:00
|
2166-06-25 21:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Levaquin / Doxycycline / Reglan
Attending: ___.
Chief Complaint:
shortness of breath / wheezing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old woman with a PMHx of depression, GERD
c/b ___ esophagus, h/o tobacco abuse who presents with
wheezing, SOB and worsening heartburn with dysphagia.
Ms. ___ reports that over the past month she has had
worsening shortness of breath and cough. At the same time she
has noted a worsening in her acid reflux symptoms as well as
feeling of food being caught in her throat. She presented to ___
one week ago where she was diagnosed with asthma exacerbation
and given 60mg x5d prednisone. Patient reports that steroid did
not help, cough/wheeze/SOB have been progressively worse, using
albuterol inhaler q2h as well as albuterol neb without relief.
In the ED, intial vitals were: 17:32 2 98.3 102 120/86 22 98%
RA
- She was markedly dyspneic with bilateral expiratory wheezes.
Peak flow 200.
- EKG - SR, NANI, TWI V1-V4
- CXR - No acute cardiopulmonary process
- Labs were notable for: negative trop x2 and negative D-dimer.
CBC of 10 and Hgb of 10.
- She was given: ___ 20:43 IH Albuterol 0.083% Neb Soln
1 NEB ___
___ 20:43 IH Ipratropium Bromide Neb 1 NEB
___ 20:43 IV MethylPREDNISolone Sodium Succ 125 mg
___ 21:01 PO Acetaminophen 1000 mg
___ 23:08 PO Azithromycin 1000 mg
___ 23:08 IH Albuterol 0.083% Neb Soln 1 NEB
___ 00:13 PO/NG Diazepam 5 mg
___ 00:13 PO/NG Lorazepam 2 mg
___ 00:13 PO/NG QUEtiapine Fumarate 100 mg
___ 00:13 PO Zolpidem Tartrate 5 mg
___ 06:14 IH Albuterol Inhaler 2 PUFF
___ 08:51 IH Albuterol 0.083% Neb Soln 1 NEB
___ 08:51 IH Ipratropium Bromide Neb 1 NEB
___ 08:51 PO Duloxetine 60 mg
___ 08:51 PO/NG LaMOTrigine 50 mg
___ 08:54 PO NIFEdipine CR 30 mg
___ 16:56 IH Ipratropium Bromide Neb 1 NEB
___ 21:19 PO Duloxetine 60 mg
___ 21:22 PO/NG Diazepam 5 mg
___ 21:22 PO/NG Lorazepam 2 mg
___ 21:22 PO/NG QUEtiapine Fumarate 100 mg
___ 21:22 PO/NG Ropinirole 4 mg
___ 21:25 PO/NG Azithromycin 500 mg
___ 21:26 PO/NG PredniSONE 60 mg
Vitals on transfer were: 0 98.1 102 120/67 18 97% RA
On the floor, patient reports continued symptoms. Reports
shortness of breath and wheezing despite continuous nebs.
Substernal chest pain only when coughing which is nonexertional
and nonpleuritic. No history of CAD, CHF. Recent travel to
___. No major accidents/injuries, history of
DVT/PE/malignancy. Denies OCPs. Former 30 pack year smoker. Had
not had asthma for many years. She reports nebulizer treatment
make her nauseated. Feels hot often but no fevers or chills.
Mild nausea with breathing treatment. Cough is not productive.
Reports that her GERD has been worse with water brash sensation
often. She reports a sensation of food being stuck in her
esophagus.
ROS: per HPI
Past Medical History:
Depression
___ esophagus
History of abnormal LFTs
Axillary granula parakeratosis
Hx eosinophilia
Back pain
Seasonal allergies
Insomnia
HLD
Social History:
___
Family History:
- Mother and aunt with DM, HTN
- Mother and maternal grandmother with gastric cancer
Physical Exam:
Admission Physical Exam:
=========================
Vitals: 98.0 115/60 99 22 98RA
GENERAL: Flat affect, in no distress. Speaking in full
sentences. Appears fatigued.
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva. MMM, no
oral lesions.
NECK: nontender supple neck, no LAD, no JVP elevation.
CARDIAC: RRR, S1/S2, no murmurs.
LUNG: Diffuse expiratory wheeze. Good airmovement.
ABDOMEN: BS+. Soft, nondistended. Tender to palpation over the
epigastric region, no reound or tenderness. No
hepatosplenomegaly.
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
Discharge Physical Exam:
========================
Vitals: T:98 Tm 98.6 BP 121/67 HR96 R14 (___) O2 96% RA
(96-99%RA)
General: Alert, oriented, in no acute distress.
HEENT: Sclera anicteric, MMM. PERRLA.
Lungs: Dry cough with inspiration. Rare rhonchi but no wheezing
on inspiration or expiration.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, bowel sounds present. Mild ttp on R and L side. L
side with echymossis and small subcutaneous hematomas in area of
heparin injections.
Ext: Warm, well perfused, no edema. No UE edema.
Neuro: Alert. Moving extremities grossly.
Pertinent Results:
Admission Labs:
================
___ 08:43PM BLOOD WBC-10.4* RBC-3.52* Hgb-10.9* Hct-31.6*
MCV-90 MCH-31.0 MCHC-34.5 RDW-13.6 RDWSD-44.5 Plt ___
___ 08:43PM BLOOD Neuts-54.2 ___ Monos-7.7 Eos-5.4
Baso-0.9 Im ___ AbsNeut-5.63# AbsLymp-3.22 AbsMono-0.80
AbsEos-0.56* AbsBaso-0.09*
___ 08:43PM BLOOD Plt ___
___ 08:43PM BLOOD Glucose-86 UreaN-8 Creat-0.7 Na-141 K-3.5
Cl-103 HCO3-26 AnGap-16
___ 08:43PM BLOOD cTropnT-<0.01
___ 08:43PM BLOOD D-Dimer-197
Pertinent Labs During Hospital Stay:
======================================
___ 06:20AM BLOOD proBNP-596*
___ 06:42AM BLOOD ANCA-NEGATIVE B
___ 06:42AM BLOOD ___ * Titer-1:40
___ 08:43PM BLOOD D-Dimer-197
Imaging:
================
___ CXR No acute cardiopulmonary process.
___ CT chest
IMPRESSION:
1. Small bilateral pleural effusions. There is minimal
paraseptal emphysema.
There are no consolidations or findings worrisome for pneumonia.
2. Moderate hiatal hernia.
___ Echo
The left atrium and right atrium are normal in cavity size. 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 >65%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of ___
there has been no significant change.
Micro:
============
___ 8:43 am URINE CHEM # ___ ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
___ 11:37 pm STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
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 BLASTOCYSTIS HOMINIS. CLINICAL SIGNIFICANCE
UNCERTAIN
Discharge Labs:
===================
___ 07:09AM BLOOD WBC-16.7* RBC-3.34* Hgb-10.4* Hct-31.0*
MCV-93 MCH-31.1 MCHC-33.5 RDW-13.7 RDWSD-46.6* Plt ___
___ 07:09AM BLOOD Plt ___
___ 07:09AM BLOOD Glucose-80 UreaN-15 Creat-0.7 Na-140
K-3.5 Cl-100 HCO3-30 AnGap-14
___ 07:09AM BLOOD Phos-3.5 Mg-2.6
Brief Hospital Course:
Summary:
===========
Ms. ___ is a ___ year-old woman with a PMHx of depression,
GERD, h/o tobacco abuse who presented with wheezing, SOB and
worsening heartburn with dysphagia.
Acute Issues:
===========
# Reactive Airway disease: Patient reported recent worsening of
wheezing and reactive airway symptoms for past month. Patient
was evaluated at ___ on ___ and most recently ___. On ___
she received a 5 days of prednisone 60mg that per patient did
not help. On her ___ HCA visit she was noted to have decreased
peak flow (200) and after peak flow testing demonstrated
accessory muscle use with breathing. She was consequently
referred to the ED. In the ED she received IV methypred 125
once, 60 prednisone po, and azithromycin 500mg. ED CXR read as
demonstrating no acute process. Initial differential diagnoses
included congestive heart failure given elevated BNP 596,
pleural effusions on CT chest, and trace pedal edema on exam,
however TTE was performed and showed no evidence of congestive
heart failure. Atypical pneumonia was considered though urine
legionella was negative, as well as COPD exacerbation though
patient without COPD changes on imaging. A CT thorax was
performed on ___ that demonstrated small bilateral pleural
effusions, minimal paraseptal emphysema, and trace subtle
subpleural ground-glass opacities that were read as likely
postinflammatory. Pulmonary was consulted who felt that her
symptoms likely represented adult onset asthma and were likely
also attributed at least in part to her severe chronic GERD.
Pulmonary additionally sent out testing for ABPA (IgE levels,
___, ANCA) that were pending at time of discharge. Systemic
blastocystis was also briefly considered given patient with
stool blastocystis with TINIDAZOLE TAB 500MG in ___, however
this was ultimately felt to be unlikely. Patient was treated
with prednisone 60mg daily, ___nd
omeprazole plus ranitidine during hospital stay and was
discharged on prednisone taper. At time of discharge, patient
with marked decrease in inspiratory and expiratory wheeze on
lung exam. Patient to have pulmonary follow up after discharge.
# GERD: Patient with long standing history of poorly controlled
GERD with recent worsening over 6 months prior to admission.
Patient has undergone multiple diagnostic tests prior to
admission suggestive of type III achalasia and hiatal hernia.
Per records, it appears that surgery is not felt to be best
option for the patient given that the main cause of her symptoms
does not appear to be tightening of her LES. Per records,
surgeons are planning to meet to discuss her studies and case
and formulate further treatment options. During hospital stay,
outpatient ranitidine was continued and patient was also started
___ omeprazole BID
# Dysphagia: Patient has had multiple diagnostic tests prior to
admission suggestive of type III achalasia and hiatal hernia.
Her nifedipine was continued during hospital stay. A speech and
swallow evaluation was performed after CT chest reviewed by
Pulmonary and felt to have some findings that could potentially
represent aspiration, however speech and swallow evaluation
showed no evidence of oropharyngeal dysphagia.
# Depression: Patient with recent unexpected death of her sister
week prior to admission. Denied SI/HI and was in stable mood.
Social work was consulted to help with bereavement and patient
was visited by her outpatient psychiatrist, Dr. ___ her
admission. Her Lorazepam 2 mg PO/NG DAILY:PRN anxiety,
duloxetine 60mg BID, lamotrigine 50mg daily were continued.
Chronic Issues:
==============
# Severe Insomnia: Patient was noted to be on multiple agents
for sleep. Regimen was modified on admission with no reports of
insomnia. QUEtiapine Fumarate 100-200 mg PO QHS was continued
along with orazepam 2 mg PO/NG DAILY:PRN anxiety per above.
Zolpidem Tartrate ___ mg PO QHS and Diazepam 5 mg PO QHS:PRN
insomnia were discontinued.
Transitional Issues:
=================
#) Reactive airway disease: Patient discharged on 2 week 60mg
prednisone taper with pulmonary follow up (Day #1 ___ 40mg
x3 days, 30mg x3 days, 20mg x 3 days, 10mg x 3 days, 5mg x 2
days). IgE, ___, ANCA, Aspergillus antibodies were pending at
the time of discharge. Pulmonary follow up with plan for PFTs
and RAAST testing.
#) GERD: Patient with long-standing h/o poorly controlled GERD
with type III achalasia and hiatal hernia. Per records, Dr.
___ with Dr. ___ Dr. ___ to discuss her
studies and formulate further surgical options. Please follow
up. Discharged on ranitidine and omeprazole 40mg BID.
#) Grief: Patient with recent loss of sister. Seen by Dr. ___
as an outpatient who visited patient while she was admitted.
#) Blastocystis: Patient with h/o stool blastocystis treated by
PCP with TINIDAZOLE by PCP. Stool O&P sent to assess for
clearance were pending at time of discharge. F/up to ensure
stool clearance.
#) Insomnia: Patient on multiple sedating and activating
medications on medical reconciliation. methylphenidate 10mg BID,
Zolpidem Tartrate ___ mg PO QHS, and Diazepam 5 mg PO QHS:PRN
insomnia were held during hospitalization. Please follow up and
modify medication regimen as clinically warranted.
#) Urinary urgency: Patient reported symptoms of urinary urgency
occurring for past month. UA in ED was bland. Please follow up
and investigate as clinically warranted.
***#) Blastocystis infection results: At time of discharge,
stool O&P was pending. Recently resulted as FEW BLASTOCYSTIS
HOMINIS. CLINICAL SIGNIFICANCE UNCERTAIN. Please follow up
and treat if necessary.
#) Code status: Full
#) Contact: ___ (Husband) ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 1 PUFF IH Q2H:PRN dyspnea, wheezing
2. Diazepam 5 mg PO QHS:PRN insomnia
3. Duloxetine 60 mg PO BID:PRN anxiety
4. LaMOTrigine 50 mg PO DAILY:PRN depression
5. Lorazepam 2 mg PO QHS
6. Lorazepam 2 mg PO DAILY:PRN anxiety
7. MethylPHENIDATE (Ritalin) 10 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Ranitidine 150 mg PO QHS
10. Zolpidem Tartrate ___ mg PO QHS
11. QUEtiapine Fumarate 100-200 mg PO QHS
12. NIFEdipine CR 30 mg PO DAILY
13. Ropinirole 2 mg PO QPM
14. Naproxen 375 mg PO Q12H:PRN pain
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q2H:PRN dyspnea, wheezing
2. Duloxetine 60 mg PO BID:PRN anxiety
3. LaMOTrigine 50 mg PO DAILY:PRN depression
4. NIFEdipine CR 30 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. QUEtiapine Fumarate 100-200 mg PO QHS
7. Ranitidine 150 mg PO QHS
8. Ropinirole 2 mg PO QPM
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1
Puff Inhaled twice a day Disp #*1 Disk Refills:*3
10. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
11. PredniSONE 60 mg PO DAILY
RX *prednisone 10 mg ___ tablet(s) by mouth Daily Disp #*31
Tablet Refills:*0
12. Tiotropium Bromide 18 mcg IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1
Capsule Inhaled daily Disp #*30 Capsule Refills:*3
13. Lorazepam 2 mg PO QHS:PRN Anxiety
14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 3 ml Inhaled every
six (6) hours Disp #*30 Vial Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
======================
1. Reactive airway disease
Secondary diagnoses:
======================
1. Gastroesophageal reflux disease
2. Dysphagia
3. Depression
4. Insomnia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was our pleasure caring for you at ___. You were admitted
for wheezing and shortness of breath. We imaged your lungs and
treated you with steroids, a short course of antibiotics, and
nebulizers which improved your breathing significantly. You were
seen by the pulmonary doctors who ___ that your symptoms could
be due to asthma, due to your gastroesophageal reflux disease
(GERD), or a different process. There are a few more blood tests
and lung tests that the pulmonary doctors would ___ to have you
do as an outpatient, so you will be following up with them after
discharge. You will also follow up with your primary care
physician. You will continue the steroids for the next 2 weeks.
We wish you a speedy recovery!
- Your ___ Care Team
Followup Instructions:
___
|
10877695-DS-26
| 10,877,695 | 29,914,534 |
DS
| 26 |
2167-11-16 00:00:00
|
2167-11-16 08:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Levaquin / Doxycycline / Reglan / amoxicillin
Attending: ___.
Chief Complaint:
___ s/p ___ for achalasia and paraesophageal
hernia ___ with revision for slipped wrap ___ now with
persistent dysphagia/PO intolerance
Major Surgical or Invasive Procedure:
paraesophageal hernia ___ with revision for slipped wrap
___
History of Present Illness:
___ s/p ___ for achalasia and paraesophageal
hernia ___ with revision for slipped wrap ___ now with
persistent dysphagia/PO intolerance, concern for extrav on CT,
with stable Hct and w/o worsening symptoms.
Past Medical History:
Depression
___ esophagus
Achalasia
GERD
Restless leg syndrome
History of abnormal LFTs
Axillary granula parakeratosis
Hx eosinophilia
Back pain
Seasonal allergies
Insomnia
HLD
Asthma
Social History:
___
Family History:
- Mother and aunt with DM, HTN
- Mother and maternal grandmother with gastric cancer
Physical Exam:
General: Well appearing in NAD
CV: RRR
Pulm: Breathing comfortably on RA
GI: Abd soft, ND, mild tenderness to deep palpation in
mid-epigastric region
Ext: WWP
Pertinent Results:
___ 06:55PM LACTATE-3.1*
___ 06:45PM GLUCOSE-138* UREA N-12 CREAT-0.8 SODIUM-140
POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-20* ANION GAP-18
___ 06:45PM estGFR-Using this
___ 06:45PM CALCIUM-8.5 PHOSPHATE-2.8 MAGNESIUM-2.0
___ 06:45PM WBC-5.7 RBC-4.18 HGB-10.8* HCT-34.4 MCV-82
MCH-25.8* MCHC-31.4* RDW-15.3 RDWSD-46.2
___ 06:45PM NEUTS-78.4* LYMPHS-17.8* MONOS-2.3* EOS-0.5*
BASOS-0.5 IM ___ AbsNeut-4.49 AbsLymp-1.02* AbsMono-0.13*
AbsEos-0.03* AbsBaso-0.03
___ 06:45PM PLT COUNT-370
___ 06:45PM ___ PTT-28.9 ___
EXAMINATION: Single contrast fluoroscopic leak check
INDICATION: ___ year old woman with dysphagia after
___
___// anatomic obstruction or issue, additionally team asked
to rule out
leak.
TECHNIQUE: Single contrast upper GI.
DOSE: Acc air kerma: 39 mGy; Accum DAP: 584.6 uGym2; Fluoro
time: 2 min
COMPARISON: Upper GI fluoroscopic study from ___
FINDINGS:
Water-soluble contrast (Optiray) was administered followed by
thin consistency
barium with the patient upright.
Barium passed freely through the esophagus into the stomach and
then into the
proximal small bowel. There is no evidence of leak or
obstruction.
IMPRESSION:
No evidence of leak or obstruction.
Brief Hospital Course:
Mrs. ___ presented to ___ on ___ with persistent symptoms
of dysphagia, chronic cough, PO intolerance, and mid-epigastric
pain. Patient underwent CTA at ___ which demonstrated
question of "blush" concerning for extravasation at prior
surgical site (paraesophageal hernia ___ with revision for
slipped wrap ___ around wrap. Patient's Hgb remained stable
throughout hospital course. No signs of vital drop or concern
for bleed. Underwent UGI study which demonstrated no leak.
Patient was advanced to regular diet on HD1. Patient has small
episode of emesis on HD2 which was non-bloody. Diet changed to
soft. Tolerating well on day of discharge. Patient reports cough
has resolved and has returned to baseline with respect to
abdominal pain and dysphagia.
Medications on Admission:
albuterol inhaler, valium prn, duloxetine 30', eszopiclone
3HS', advair, mirtazapine 30', montelukast 10', omeprazole 20',
prednisone unclear dose, tramadol for restless leg
Discharge Medications:
1. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl [Zofran (as hydrochloride)] 4 mg 1 tablet(s)
by mouth Q8 PRN Disp #*15 Tablet Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
___ take 1 pill every 4 hr as needed for pain relief. Do not
drive or drink while taking narcotics.
RX *oxycodone 5 mg 1 (One) tablet(s) by mouth Q4 PRN Disp #*20
Tablet Refills:*0
3. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheeze
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
6. Docusate Sodium 100 mg PO BID
7. DULoxetine 30 mg PO BID
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Mirtazapine 45 mg PO QHS
10. Montelukast 10 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. PredniSONE 20 mg PO DAILY
13. Senna 8.6 mg PO BID:PRN constipation
14. Tiotropium Bromide 1 CAP IH DAILY
15. TraMADol 50 mg PO QHS:PRN restless leg
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic Dysphagia
Discharge Condition:
Stable
Discharge Instructions:
Please continue soft regular diet while at home until follow up
in clinic.
Please call number listed below for follow up time and date.
Should be seen in 2 weeks. :
Office ___
Office Location: ___ ___: ___ ___
Continue home medications. Minimize narcotics, if taking
narcotics, do not drink or drive
Please call ___ for return to the ER if:
Severe pain not tolerated by medication which is not allowing
you to tolerate soft diet
If have any episodes of bloody vomiting
Pass out at home
Unsteady walking or not being able to stand up due to
lightheadedness
Blood bowel movement or black bowel movement
Followup Instructions:
___
|
10877695-DS-27
| 10,877,695 | 21,386,767 |
DS
| 27 |
2168-06-05 00:00:00
|
2168-06-05 15:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Levaquin / Doxycycline / Reglan / amoxicillin /
sucralfate malate, polymerized
Attending: ___.
Chief Complaint:
vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ woman with a history of a achalasia, hiatal
hernia s/p repair & fundoplication in ___, recent H pylori,
and GERD, who has begun an outpatient workup for dysphagia &
nausea, and is presenting with worsening nausea, vomiting, and
abdominal pain. For the past 2 week, she has only been able to
tolerate liquids because she had pain with swallowing solids and
nausea after eating them. Over the past few days, she has been
unable to tolerate liquids. She has many bouts of emesis daily,
and now has blood-tinged secretions when she throws up. She also
noticed some bright red blood in her stool. She has felt
febrile,
with chills, weakness, and lethargy. She has had intractable
pain
in her abdomen & chest, radiating up to her throat. It's ___
at
its worst, and intermittently dulls to ___.
Recent workup has included CT torso, EGD with biopsies, and
stress echo 8 days ago which was normal. She is currently
scheduled for outpatient barium swallow and esophageal manometry
for potential achalasia. Of note, her H pylori biopsies were
positive, but she has not been started on treatment. Also of
note, she recently stopped taking her Bethanechol because the
tablets were too big, and she felt they were getting stuck in
her
throat.
- In the ED, initial VS were: 97.9 93 149/84 20 98% RA
- Exam notable for: alert in distress and crying and constantly
spitting up secretions, Abd very tender in epigastric region,
nondistended.
- Labs showed: lactate 2.5, otherwise normal
- No imaging
-Patient received:
___ 22:16 IVF NS
___ 22:25 IV Ondansetron 4 mg
___ 23:59 IV Famotidine
___ 00:01 IV Ondansetron 4 mg
___ 00:15 IV Acetaminophen IV 1000 mg
___ 00:18 IVF NS ( 1000 mL ordered)
- Transfer VS were: 98.2 81 121/65 18 99% RA
On arrival to the floor, patient feels terrible. She continues
to
have abdominal pain, the same as in the ED. The Zofran hasn't
done much to help her nausea.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
Depression
___ esophagus
Achalasia
GERD
Restless leg syndrome
History of abnormal LFTs
Axillary granula parakeratosis
Hx eosinophilia
Back pain
Seasonal allergies
Insomnia
HLD
Asthma
Social History:
___
Family History:
- Mother and aunt with DM, HTN
- Mother and maternal grandmother with gastric cancer
Physical Exam:
============================
ADMISSION PHYSICAL EXAM:
============================
VS: 98.1 PO 129 / 80 74 18 96 RA
GENERAL: sitting on edge of bed, tearful but nontoxic
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: extensive expiratory wheezing in all lung fields
ABDOMEN: soft but mildly distended, diffuse tenderness to
palpation, no rebound/guarding, normal bowel sounds
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
============================
DISCHARGE PHYSICAL EXAM:
============================
VS: 97.9 111 / 70 71 20 96 Ra
GENERAL: lying in bed, appearing well, NAD
HEENT: AT/NC, EOMI, anicteric sclera
NECK: supple
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTABL, no w/r/c
ABDOMEN: soft, mildly distended, no TTP, no rebound/guarding,
normal bowel sounds
EXTREMITIES: no cyanosis, clubbing, or edema
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
======================
ADMISSION LABS:
======================
___ 08:08PM BLOOD WBC-7.2 RBC-4.58 Hgb-13.9 Hct-41.0 MCV-90
MCH-30.3 MCHC-33.9 RDW-12.6 RDWSD-41.4 Plt ___
___ 08:08PM BLOOD Neuts-41.3 ___ Monos-7.2
Eos-10.9* Baso-1.1* Im ___ AbsNeut-2.99 AbsLymp-2.84
AbsMono-0.52 AbsEos-0.79* AbsBaso-0.08
___ 08:08PM BLOOD Glucose-98 UreaN-11 Creat-0.8 Na-144
K-4.1 Cl-106 HCO3-24 AnGap-14
___ 08:08PM BLOOD ALT-12 AST-12 LD(LDH)-192 AlkPhos-63
TotBili-0.2
___ 08:08PM BLOOD Albumin-4.4
___ 10:15PM BLOOD Lactate-2.5*
======================
INTERVAL LABS:
======================
___ 06:30AM BLOOD WBC-6.6 RBC-3.77* Hgb-11.8 Hct-34.1
MCV-91 MCH-31.3 MCHC-34.6 RDW-12.5 RDWSD-41.1 Plt ___
___ 08:10AM BLOOD WBC-6.6 RBC-3.95 Hgb-11.8 Hct-34.9 MCV-88
MCH-29.9 MCHC-33.8 RDW-12.4 RDWSD-39.9 Plt ___
___ 06:31AM BLOOD WBC-7.2 RBC-3.96 Hgb-11.9 Hct-34.9 MCV-88
MCH-30.1 MCHC-34.1 RDW-12.3 RDWSD-39.6 Plt ___
___ 06:30AM BLOOD Glucose-91 UreaN-9 Creat-0.8 Na-145 K-4.1
Cl-111* HCO3-22 AnGap-12
___ 08:10AM BLOOD Glucose-91 UreaN-8 Creat-0.8 Na-146 K-4.1
Cl-108 HCO3-27 AnGap-11
___ 06:31AM BLOOD Glucose-103* UreaN-7 Creat-0.9 Na-144
K-3.8 Cl-106 HCO3-26 AnGap-12
___ 06:30AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.8
___ 08:10AM BLOOD Calcium-9.2 Phos-4.3 Mg-1.8
___ 06:31AM BLOOD Calcium-8.6 Phos-4.9* Mg-1.8
======================
DISCHARGE LABS:
======================
___ 05:06AM BLOOD WBC-7.0 RBC-3.94 Hgb-12.0 Hct-35.0 MCV-89
MCH-30.5 MCHC-34.3 RDW-12.3 RDWSD-40.2 Plt ___
___ 05:06AM BLOOD Glucose-91 UreaN-12 Creat-1.0 Na-145
K-4.3 Cl-105 HCO3-27 AnGap-13
___ 05:06AM BLOOD Calcium-8.8 Phos-5.5* Mg-1.8
======================
MICROBIOLOGY:
======================
___: urine culture: NEGATIVE
___: blood culture: pending
======================
IMAGING:
======================
___ Barium swallow
1. Patient is status post ___ myotomy with Nissen
fundoplication. Barium
passes freely through the esophagus into the stomach without
evidence of leak
or obstruction.
2. Poor primary peristalsis with a minimally dilated distal
esophagus is
stable compared to prior exam performed ___.
Brief Hospital Course:
==================
BRIEF SUMMARY
==================
___ year old female with history of achalasia, hiatal hernia s/p
repair & fundoplication ___, recent EGD with H pylori (not
on treatment), GERD, depression, and asthma, who is presenting
with acute on chronic nausea, vomiting, and abdominal pain, with
inability to take PO. She was treated supportively and her diet
was advanced as tolerated. Barium swallow inpatient was
unremarkable. By discharge, she was able to tolerate a regular
diet with improvement in her symptoms. She was instructed to
start on triple therapy for h pylori treatment upon discharge.
========================
PROBLEM-BASED SUMMARY
========================
ACUTE ISSUES:
# NAUSEA, VOMITING, ABDOMINAL PAIN, INABILITY TO TAKE PO
She has chronic symptoms of the above, for which she has been
undergoing outpatient GI workup, with recent EGD, CT torso, and
stress echo. She presented with acute worsening of her symptoms
for two weeks. She was treated supportively, with MIVF, standing
IV zofran, IV tylenol prn, IV ativan prn nausea, and IV
famotidine. Her diet was slowly advanced as tolerated. By
discharge, she tolerated regular diet and PO pills. Barium
swallow this admission did not show any obstruction. H pylori
(found on EGD ___ may be contributing to her overall
picture. She will need to follow up for scheduled esophageal
manometry as an outpatient to evaluate for esophageal
dysmotility. She was discharged with PO Zofran to take prior to
meals as needed for nausea and triple therapy for her H. Pylori
as below.
# H PYLORI
Outpatient EGD ___ was positive for h pylori. She was unable
to tolerate pills initially this admission, so she was started
on triple therapy for h pylori treatment upon discharge. Given
her amoxicillin allergy, she is planned for a 14-day course of
clarithromycin and metronidazole, in addition to her home PPI.
# HEMATEMESIS
She reported trace red streaks of blood in her emesis, after
numberous episodes of retching. This was likely ___
tear due to trauma from repeated retching. She did not have any
further episodes of hematemesis this admission and H/H was
stable.
# BRBPR
She reported one episode of trace red blood in her stool prior
to admission, sounding most consistent with hemorrhoids. As
above, low concern for active bleeding, with stable H/H and no
recurrences this admission.
CHRONIC ISSUES:
# ASTHMA: Wheezing on lung exam but comfortable on room air. She
was continued on her home regimen: Advair, Spiriva, Albuterol
nebs as needed, codeine/guaifenesin as needed for cough, home
Montelukast.
# DEPRESSION: Continued on home duloxetine, mirtazipine once
able to take pills. Held home PO ativan while receiving IV
ativan for nausea as inpatient; she was restarted on home
regimen for discharge.
# INSOMNIA: Home eszopiclone 3 mg tablet was not on formulary
and restarted for discharge.
=======================
TRANSITIONAL ISSUES
=======================
- Has scheduled esophageal manometry as outpatient, to evaluate
for esophageal dysmotility.
- Consider need for gastric emptying study as outpatient, as she
may have an element of gastroparesis
- She was started on h pylori treatment (home PPI,
metronidazole, clarithromycin) for discharge and should be on
metronidazole and clarithromycin for planned 14 day course.
- She was discharged with limited PO Zofran, instructed to take
1 hour prior to meals as needed for nausea.
- Please obtain EKG at PCP appointment ___, to
monitor for QTc given Zofran and clarithromycin use. EKG on ___
with QTc 392. (EKG ___ with QTc 429.)
New medications: metronidazole, clarithromycin, PO Zofran,
ranitidine
Changed medications: none
Stopped medications: none
#CODE: Full (presumed)
#CONTACT: ___
Relationship: husband Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Tiotropium Bromide 1 CAP IH DAILY
3. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze
4. Aspirin 81 mg PO DAILY
5. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
6. Docusate Sodium 100 mg PO BID
7. DULoxetine 60 mg PO DAILY
8. eszopiclone 3 mg oral QHS
9. LORazepam 1 mg PO BID
10. Mirtazapine 30 mg PO QHS:PRN insomnia
11. Montelukast 10 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Senna 8.6 mg PO BID:PRN constipation
15. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Clarithromycin 500 mg PO Q12H
RX *clarithromycin 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*27 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8
hours Disp #*41 Tablet Refills:*0
3. Ondansetron 4 mg PO Q8H:PRN nausea
Can take 1 hour prior to meals, as needed for nausea.
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*20 Tablet Refills:*0
4. Ranitidine 150 mg PO DAILY
RX *ranitidine HCl [Acid Control (ranitidine)] 150 mg 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
5. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze
6. Aspirin 81 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. DULoxetine 60 mg PO DAILY
9. eszopiclone 3 mg oral QHS
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
12. LORazepam 1 mg PO BID
13. Mirtazapine 30 mg PO QHS:PRN insomnia
14. Montelukast 10 mg PO DAILY
15. Omeprazole 20 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Senna 8.6 mg PO BID:PRN constipation
18. Tiotropium Bromide 1 CAP IH DAILY
19. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
=====================
PRIMARY DIAGNOSIS:
=====================
Nausea and vomiting
Abdominal pain
H pylori infection
Hematemesis
BRBPR
======================
SECONDARY DIAGNOSIS
======================
Asthma
Depression
Insomnia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at ___
___. Please find detailed discharge instructions
below:
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted because you had acutely worsened nausea,
vomiting and abdominal pain.
WHAT HAPPENED TO YOU IN THE HOSPITAL?
- You were treated supportively, with IV fluids, pain
management, and anti-nausea medications. Your symptoms gradually
improved.
- You were able to slowly tolerate a diet, advancing to a
regular diet by discharge.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Please make a follow up appointment with you primary care
provider (Dr. ___: ___ ), scheduled for
within 1 week from discharge.
- Please make a follow up with your gastroenterologist (Dr.
___: ___, scheduled for 1 month from
discharge.
- Please follow up for esophageal manometry (testing for
motility function of your esophagus), as scheduled.
- Please start and complete antibiotic treatment for h pylori,
the bacterial infection in your stomach. You will take
clarithromycin and metronidazole for a total of 14 days.
We wish you the best!
- Your ___ treatment team
Followup Instructions:
___
|
10878238-DS-12
| 10,878,238 | 27,542,323 |
DS
| 12 |
2141-12-21 00:00:00
|
2141-12-27 13:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
SOB, increased sputum production, nausea and vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ M with COPD who presents with nausea and
vomiting, SOB and increasing sputum production. 10 days ago, he
began feeling nauseaus while taking a routine walk along the
beach. That evening, he felt congested with increased yellow
sputum production. He experienced drenching night sweats with
chills and shakes for three nights, as well as increased sputum
production. He now coughs up to a pint of dark, yellow sputum
(previously two tsp volume). Five days ago, his wife witnessed
him fall down after feeling "lightheaded" upon standing up. He
caught himself with his hand on the wall; he was talking
throughout the episode. No LOC or head trauma per wife. This
afternoon, he took the bus to see his PCP for evaluation of his
weight loss and SOB. He was found to be hypoxic with oxygen
saturations at 91%, and was sent to the emergency department.
The patient does not use oxygen at home.
In the ED, initial vitals were 98.6 84 116/86 20 99% 3L Nasal
Cannula. Exam was notable for diffuse wheezing and L basilar
crackles. Labs were significant for WBC 13.8 with 70.3% PMNs.
Patient received albuterol and ipratropium nebs x3, 2L NS, and
ceftriaxone, 1g and azithromycin, 500mg for presumed PNA. CXR
showed subsegmental linear atelectasis in R midlung with
pulmonary effusion but no focal consolidation or acute pulmonary
process. Blood cultures were sent and are pending. Vitals
prior to transfer: 98.3 83 ___ 94% on RA.
Currently, the patient reports feeling much better. He ate a
___ sandwich in the afternoon and has been able to keep it
down. He feels short of breath, similar to an episode 3 months
ago when he was prescribed azithromycin. No recent travel or
sick contacts.
ROS: Lost 12 lbs in the past ten days (baseline weight 155
lbs). Frequent emesis but no hematemesis or hemoptysis.
Hematochezia 1 week ago after taking advil for general body
aches. Chronic "chest pressure" after walking ___ a mile,
relieved with rest. Was in detox for alcoholism one month ago.
Isolated seizure ___ years ago from EtOH withdrawal, none since.
No dysphagia, abdominal pain, paresthesias, dysuria,
constipation or diarrhea.
Past Medical History:
COPD
Emphysema
Duodenal ulcer, s/p ligation (___)
Alcohol abuse, s/p detox one month ago
Colonic adenoma, s/p resection (___)
Anxiety
L3, L4 disk herniation
Osteocartilagenous exostosis (R proximal tibia), s/p excision
(___)
L knee trauma, s/p TKR (as a child)
Social History:
___
Family History:
Father and mother both alcoholics, deceased at ages ___ and ___,
respectively. No family history of CAD or diabetes per patient.
1 sister passed away from lung cancer (non smoker). 1 brother
passed away from heroin abuse. 2 brothers and 1 sister alive.
Physical Exam:
On admission:
VS - Temp 97.5F, BP 122/79, HR 94, R 22, O2-sat 95% RA
General: Appeared comfortable but short of breath, interviewed
lying on bed
HEENT: Full EOM. PERRLA. Oral mucosa moist, no lesions.
Symmetric palate elevation.
Neck: Supple, no LAD.
CV: Distant heart sounds, clear S1 S2. RRR.
Lungs: Decreased breath sounds. Coarse, bilateral crackles
from base to mid back.
Abdomen: Soft, nontender. No masses.
Ext: Two clean IV access over dorsum of both hands. 10cm well
healed scar over R knee.
Neuro: Alert, interactive, oriented to time, place. Able to
recite days of the week backwards. Fluent speech.
Skin: No rashes, cyanosis or bruises.
Rectal: Exam deferred (guaic negative x2 in ED)
On discharge:
VS - Temp 97.7F, BP 110-123/62-82, HR 79-95, RR ___, 93-95% O2
on RA. 92% ambulatory O2.
General: Appears very comfortable, walking the hallways
CV: RRR
Lungs: Improved bilateral basilar crackles
Abdomen: Soft, nontender. No masses.
Pertinent Results:
ADMISSION LABS
--------------
___ 02:30PM BLOOD WBC-13.8*# RBC-4.69# Hgb-14.3# Hct-41.4#
MCV-88 MCH-30.5 MCHC-34.6 RDW-13.7 Plt ___
___ 02:30PM BLOOD Neuts-70.3* ___ Monos-7.5 Eos-1.0
Baso-0.7
___ 02:15PM BLOOD Glucose-85 UreaN-11 Creat-0.8 Na-141
K-3.8 Cl-103 HCO3-26 AnGap-16
___ 02:15PM BLOOD proBNP-33
___ 12:00PM BLOOD D-Dimer-170
___ 12:34PM BLOOD Lactate-0.6
DISCHARGE LABS
--------------
___ 08:00AM BLOOD WBC-9.2 RBC-4.80 Hgb-14.7 Hct-42.8 MCV-89
MCH-30.7 MCHC-34.4 RDW-13.9 Plt ___
___ 08:00AM BLOOD Neuts-54 Bands-2 ___ Monos-13*
Eos-0 Baso-0 ___ Metas-1* Myelos-0
___ 08:00AM BLOOD Glucose-97 UreaN-10 Creat-0.7 Na-140
K-3.7 Cl-105 HCO3-25 AnGap-14
MICROBIOLOGY
------------
___ 12:00 pm BLOOD CULTURE: Blood Culture, Routine
(Pending)
IMAGING
-------
___ 1:18 ___ CXR
IMPRESSION: Bilateral hilar prominence could reflect pulmonary
vascular
congestion, however an atypical bronchopneumonia cannot be
excluded.
Brief Hospital Course:
Mr. ___ is a ___ M with COPD who presented with nausea
and vomiting, SOB and increasing sputum production.
ACTIVE ISSUES
-------------
# COPD
He presented to the ED with dyspnea that improved with albuterol
and ipratropium nebs. On physical exam, his basilar crackles
were concerning for community-acquired pneuomina, prompting
empiric treatment with ceftriaxone 1g and azithromycin 500mg.
The chest X-ray showed no focal consolidation but he had WBC
13.8 with 70.8% PMNs. We also considered congestive heart
failure as an etiology for his dyspnea, unlikely given his BNP
of 33. Given that he was afebrile, we favored a diagnosis of
COPD exacerbated by bronchitis.
He was treated overnight with continued nebulizers and
azithromycin. The next morning he was much improved. He no
longer felt short of breath, he did not produce sputum that
morning, and he continued to remain afebrile.
We prescribed a home nebulizer for him to self administer
nebulizers for further COPD exacerbations. We also discussed
the importance of smoking cessation in managing his COPD. He
was prescribed a five-day total course of azithromycin.
INACTIVE ISSUES
---------------
# Nausea and vomiting
Given his history of poor PO intake, he received 2L NS in the
ED. His nausea and vomiting greatly improved and he had a
vigorous appetite with no further emesis. His initial nausea
and vomiting was likely secondary to dehydration.
TRANSITIONAL ISSUES
-------------------
# Continue to discuss smoking cessation. His presentation is
likely due to his underlying COPD, exacerbated by continued
smoking.
# Recent history of EtOH abuse (three weeks ago). Continue
substance abuse counseling
Follow-up: with Dr. ___ on ___ @ 10am
Code status: confirmed full
Medications on Admission:
1. Tizanidine 4 mg PO TID
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, dyspnea
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Propranolol 5 mg PO DAILY
5. Naltrexone 50 mg Oral BID
6. Citalopram 40 mg PO DAILY
7. Omeprazole 20 mg PO BID
8. Mirtazapine 15 mg PO HS
Discharge Medications:
1. Home nebulizer for COPD management
2. Citalopram 40 mg PO DAILY
3. Mirtazapine 15 mg PO HS
4. Omeprazole 20 mg PO BID
5. Tizanidine 4 mg PO TID
6. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob, wheezing
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb solution IH
every six (6) hours Disp #*10 Each Refills:*0
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, dyspnea
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Naltrexone 50 mg Oral BID
10. Propranolol 5 mg PO DAILY
11. Azithromycin 250 mg PO Q24H #*3 Tablets Refills:*0
12. Ipratropium Bromide MDI 2 PUFF IH QID
RX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 2 puffs
QID every six (6) hours Disp #*1 Inhaler Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
COPD exacerbation from upper respiratory infection (likely
bronchitis)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. 92% lowest O2
saturation on RA with ambulation.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
As you know, you were admitted for low oxygen saturation and 10
days of nausea, vomiting, and increasing sputum with difficulty
breathing. You received some fluids, antibiotics and
nebulizers.
We are very pleased by how your appetite has returned, breathing
has improved, and sputum production has decreased. Your oxygen
saturation has improved (even while walking down the hallways!)
and your emesis has resolved. We think you had a mild
bronchitis that triggered your COPD exacerbation. We are
prescribing you azithromycin tablets to continue taking at home
(2 tablets the first day, 1 tablet for 4 additional days). We
are also prescribing a home nebulizer machine so that you may
administer these medications at home during future COPD
exacerbations.
In addition to completing the full Azithromycin prescription,
please remember to follow up with your PCP for continued
management of your COPD. You should also follow up with your
PCP for the chest pressure you experience while walking. As we
discussed, cutting back on EtOH and smoking will make a big
difference for your health. We hope you will continue treatment
for your alcoholism and think about quitting smoking. In
addition, please remember to avoid all NSAIDs (ibuprofen, Advil,
Aleve) given your history of GI bleeds.
Sincerely,
___, HMS IV
Followup Instructions:
___
|
10878238-DS-13
| 10,878,238 | 26,780,052 |
DS
| 13 |
2143-05-14 00:00:00
|
2143-05-14 14:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chief Complaint: tremors
Reason for MICU transfer: alcohol withdrawal and intubation for
airway protection
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
___ M w/ hx etoh abuse and COPD p/w hallucinations and
tremours. Pt has been sober since detox in ___ but 10
days ago began drinking again due to nephew's death (substance
abuse). He drinks numerous bottles of vodka daily and last drank
on ___. On ___ began experiencing withdrawal symptoms
including tremors, spastic limb and jaw movements, diaphoresis,
vertigo, visual and auditory hallucinations (hallucinated
kittens, wires "sparkling", confusion, and memory issues). Per
wife, no episodes of bladder or bowel incontinence. Did not
appear to have a seizure. Seen at ___ office today who
recommended admission to ___ for further management. Per report,
no SI/HI. No fevers/ falls/ CP/ new SOB. Chronic constipation.
Sick earlier in the month with flu like symptoms that resolved.
He has been unable to sleep since ___ due to tremours and
racing thoughts. Last had etoh withdrawal seizures ___ yrs ago. No
new medication changes.
In the ED initial vitals were 96.1 116 148/79 18 97% RA. Labs
notable for WBC 12.4, H/H 14.8/43.9, platelets 364, BUN/Cr
___, serum tox and urine tox negative. After given valium he
became increasingly agitated with medication and flailing.
Patient given multiple doses of benzos - 4mg IV lorazepam, 30 mg
IV diazepam + 20 mg PO diazepam, 3L NS, 100 mg IV thiamine.
Patient was subsequently intubated and sedated for airway
protection, sedated with propofol and fentanyl.
On the floor, vitals stable on arrival. On CXR, OG tube noted to
be in the sphincter. While trying to reposition OG tube, the
cuff wire was cut and the cuff deflated. Propofol and fentanyl
stopped. Remained sedated and maintained 96% oxygen saturation
during event. Anesthesia was called and reintubated patient
without difficulty. Pressures remained stable. Propofol and
fentanyl restarted. Phenobarbital protocol started. Repeat CXR
showed showed OG and ET tube in correct place.
Past Medical History:
COPD
Emphysema
Duodenal ulcer, s/p ligation (___)
Alcohol abuse, s/p detox
Colonic adenoma, s/p resection (___)
Anxiety
L3, L4 disk herniation
Osteocartilagenous exostosis (R proximal tibia), s/p excision
(___)
L knee trauma, s/p TKR (as a child)
Social History:
___
Family History:
Father and mother both alcoholics, both deceased in ___. 1
sister passed away from lung cancer (non smoker). 1 brother
passed away from heroin abuse. History of CAD/PVD, htn in
family.
Physical Exam:
Admission Physical Exam:
Vitals- T:98 BP: 108/66 P: 75 R:22 O2: 99% on CMV
General: sedated, no acute distress
HEENT: PERRL, Sclera anicteric, MMM, oropharynx clear, hard bony
growth on back of head.
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: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neruo: intubated and sedated
Pertinent Results:
ADMISSION LABS:
___ 12:40PM BLOOD WBC-12.4* RBC-5.14 Hgb-14.8 Hct-43.9
MCV-85 MCH-28.7 MCHC-33.7 RDW-14.8 Plt ___
___ 12:40PM BLOOD Neuts-66.6 ___ Monos-8.3 Eos-2.0
Baso-0.4
___ 02:51AM BLOOD ___ PTT-30.2 ___
___ 12:40PM BLOOD Glucose-94 UreaN-14 Creat-1.0 Na-135
K-4.5 Cl-99 HCO3-22 AnGap-19
___ 12:40PM BLOOD ALT-14 AST-18 AlkPhos-96 TotBili-0.6
___ 12:36AM BLOOD CK-MB-2 cTropnT-<0.01
___ 02:51AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.9
___ 02:51AM BLOOD TSH-2.3
___ 12:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
CXR ___:
The inspiratory lung volumes are decreased from the most recent
prior study. Biapical lucency is unchanged, compatible with
bullous emphysema. Prominent perihilar interstitial lung
markings bilaterally are similar in comparison to the prior
chest radiograph of ___ but not seen on earlier prior
studies. There is no pleural effusion or pneumothorax. The
cardiomediastinal and hilar contours are within normal limits.
No acute osseous abnormality is detected.
IMPRESSION:
Bilateral perihilar interstitial prominence may represent
pulmonary vascular congestion/interstitial edema although
atypical infection is not excluded.
Brief Hospital Course:
___ year old man with PMH alcohol abuse and COPD, p/w tremors,
agitation, and alcohol withdrawal.
# AMS: Presented to the ED. He has a history of EtOH s/p
multiple failed attempts at detox, most recently spent 18 days
in detox center in ___. Has history of EtoH withdrawal
seizures. Per report he had ~5 days of heavy EtOH use with
blackouts, stopped ~5 days prior to admission. THe ED felt that
he was withdrawing and he was given 50mg diazepam and 4 mg
ativan in ED for withdrawal symptoms and he was incresingly
agitated and could have been an atypical reaction to the
bezodiapines. He was intubated for airway protection and then
successfully extubated. He was placed on the phenobarb protocol
but taken off as the suspicion of EtOH withdrawl was low. He was
seen by psych who recomended minimizing benzodiazepines. His
symptoms improved. Of note, his home buproprion and
cyclobenzaprine were stopped on admit and not restarted.
# Mechanical ventilation for airway protection: s/p reintubation
for cuff deflation. Remained well oxygenated during cuff
deflation/ reintubation. No episodes of hypoxia. Intubated
purely for airway protection and he was extubated several hourse
following intunation without incident.
# COPD: Per Pulm note from ___: CT scan from ___ with
extensive bullous changes superiorly, upper lobe pan lobular
emphysema. PFTs ___ FEV1 2.30, 64% predicted. FVC 3.24, 70%
predicted. FEV1/FVC 0.71. mild obstructive defect, cannot rule
out restrictive component. On advair, ventolin and spiriva at
home, but not taking consistently. Continued those medications
once extubated.
# Chronic back pain: held cyclobenzaprine.
# GERD: continued omeprazole
TRANSITIONAL
# Communication: Wife- ___ ___: ___
# Medication changes: his home buproprion and cyclobenzaprine
were stopped on admit and not restarted.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
2. Epinephrine 1:1000 0.3 mg IM ONCE MR1
3. Tiotropium Bromide 1 CAP IH DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. naltrexone 100 oral daily
6. BuPROPion (Sustained Release) 150 mg PO BID
7. Paroxetine 40 mg PO DAILY
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
9. Omeprazole 20 mg PO DAILY
10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN difficulty
breathing
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Omeprazole 20 mg PO DAILY
4. Paroxetine 40 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour apply daily Disp #*30 Patch
Refills:*0
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN difficulty
breathing
8. naltrexone 100 oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with alcohol withdrawal. You were treated with
medications for withdrawal and you improved. Please do not drink
alcohol or smoke cigarettes.
While you were hospitalized BuPROPion and Cyclobenzaprine were
held as these medications can contribute to confusion and
hallucinations. Please do not resume taking these medications
until you see your primary care doctor.
Followup Instructions:
___
|
10878611-DS-9
| 10,878,611 | 22,594,163 |
DS
| 9 |
2156-08-12 00:00:00
|
2156-08-12 14:43:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
ciprofloxacin
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of umbilical and left inguianal hernia repair in the past
presents with abdominal pain. He reports developing diffuse
abdominal pain since last evening. It is constant and radiates
to the back, worse with movement. He has been having nausea,
with bilious emesis x2 today. No flatus. Last BM was this AM and
was loose. No hx of prior obstructions. Went to his PCP where ___
KUB demonstrated dilated small bowel with air-fluid levels. He
was sent to ___ for further care.
Past Medical History:
PMH: Prostate CA
PSH: total prostatectomy (___), umbilical hernia repair (___), Left inguinal hernia repair (___)
Social History:
___
Family History:
Father: MI, Mother: breast CA
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T 97.9 HR 100 BP 140/80 RR 20 SpO2 100%
Gen: Alert, NAD
CV: RRR
Pulm: CTAB
Abd: distended, tympanitic. TTP diffusely, no rebound or
guarding. Well healed umbilical and left inguinal scars, no
hernias.
Ext: w/d
Pertinent Results:
ADMISSION LABS
___ 05:30PM BLOOD WBC-18.0* RBC-5.03 Hgb-16.4 Hct-47.4
MCV-94 MCH-32.5* MCHC-34.6 RDW-12.5 Plt ___
___ 05:30PM BLOOD Neuts-90.7* Lymphs-5.7* Monos-3.5 Eos-0
Baso-0.2
___ 05:30PM BLOOD ___ PTT-28.6 ___
___ 05:30PM BLOOD Glucose-130* UreaN-25* Creat-1.0 Na-140
K-5.4* Cl-102 HCO3-24 AnGap-19
___ 05:30PM BLOOD ALT-29 AST-50* AlkPhos-70 TotBili-0.7
___ 05:30PM BLOOD Albumin-4.5 Calcium-9.3 Phos-4.4 Mg-2.1
___ 05:56PM BLOOD Lactate-1.4
LAB TRENDS
___ 06:00AM BLOOD WBC-13.6* RBC-4.22* Hgb-13.9* Hct-40.4
MCV-96 MCH-33.0* MCHC-34.4 RDW-13.1 Plt ___
___ 06:50AM BLOOD WBC-9.4 RBC-4.05* Hgb-13.2* Hct-38.8*
MCV-96 MCH-32.5* MCHC-33.9 RDW-12.7 Plt ___
___ 06:00AM BLOOD Glucose-101* UreaN-21* Creat-1.0 Na-141
K-4.1 Cl-107 HCO3-25 AnGap-13
___ 06:50AM BLOOD Glucose-70 UreaN-20 Creat-0.9 Na-141
K-3.8 Cl-106 HCO3-23 AnGap-16
___ 08:00AM BLOOD Glucose-83 UreaN-13 Creat-0.8 Na-141
K-3.8 Cl-108 HCO3-24 AnGap-13
IMAGINS:
OSH KUB: Dilated small bowel with multiple air fluid levels
___ CT ABDOMEN/PELVIS: IMPRESSION: Constellation of findings
consistent with small bowel obstruction with probable transition
point in the right lower quadrant, most likely due to an
adhesion. No evidence of pneumatosis intestinalis or abdominal
free air to suggest perforation.
Brief Hospital Course:
Mr. ___ was admitted to the inpatient surgical ward on
___ under the Acute Care Surgical service for management of
his small bowel obstruction. Imaging, including a KUB and CT
abdomen/pelvis, both revealed dilated and fluid filled loops of
proximal small bowel. A transition point was identified in the
right lower quadrant distal to a small bowel anastamosis.
In terms of management, Mr. ___ was kept NPO, given IV
fluids/medications and a nasogastric tube was inserted for
gastric decompression. As he regained bowel function as
exhibited with positive flatus/bowel movements, his nasogastric
tube was removed and his diet was slowly advanced to regular on
___. He was given his home medications. He tolerated oral
intake well. His pain was treated with oral non-narcotic and
narcotic analgesics as needed.
At the time of discharge, Mrs. ___ was hemodynamically
stable, afebrile and in no acute distress. She was tolerating a
regular diet without issue. A follow-up appointment has been
scheduled with the ___ service.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO BID
3. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ on
___ with complaints of abdominal pain. On further evaluation
via x-ray and CT scanning, you were found to have a small bowel
obstruction. A nasogastric tube was inserted for gastric
(stomach) decompression. You were given bowel rest (NPO) and IV
fluids/medications. As your symptoms improved and you regained
bowel function, you were slowly advanced to a regular diet.
Now that you have regained bowel function, you are being
discharged with the following instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids
CONSTIPATION:
Drink liquids as directed: Adults should drink between 9 and 13
eight-ounce cups of liquid every day. For most people, good
liquids to drink are water, tea, broth, and small amounts of
juice and milk.
Eat a variety of high-fiber foods: This may help decrease
constipation by adding bulk and softness to your bowel
movements. Healthy foods include fruit, vegetables, whole-grain
breads and cereals, and beans.
Get plenty of exercise: Regular physical activity can help
stimulate your intestines. Talk to your primary healthcare
provider about the best exercise plan for you.
Schedule a regular time each day to have a bowel movement: This
may help train your body to have regular bowel movements. Bend
forward while you are on the toilet to help move the bowel
movement out. Sit on the toilet at least 10 minutes, even if you
do not have a bowel movement.
Followup Instructions:
___
|
10878728-DS-19
| 10,878,728 | 25,500,145 |
DS
| 19 |
2183-04-29 00:00:00
|
2183-04-30 14:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
Left Craniotomy for tumor
History of Present Illness:
___ woman with no significant PMH found by her son at home ___
to be very confused. She then had a tonic clonic seizure that he
witnessed. She was brought to an OSH where she was witnessed to
seize again. While obtaining a CT she began to vomit so she was
intubated. CT revealed a left parietal lesion.
She was transferred to ___ and was given Keppra and 10mg
decadron then neurology and neurosurgery consultations were
requested.
Past Medical History:
Obesity, Hyperlipidemia, Diabetes, Hypertension, depression and
anxiety, thyroid biopsy
Social History:
___
Family History:
non-contributory
Physical Exam:
O: BP: 158/91 HR: 82 R 18 O2Sats 100%
Gen: intubated and sedated (propofol and versed held for exam).
Neuro:
Mental status: EO to voice
Pupils: PERRL 3mm, tracks examiner
Motor: following commands x4 extremities, antigravity x4
Reflexes: R Br Pa Ac
Right 1+ 1+ 1+ 1+
Left 1+ 1+ 1+ 1+
Toes upgoing bilaterally
PHYSICAL EXAM UPON DISCHARGE:
VS: 98.2, 62, 138/83, 15, 96% on trach mask
HEENT: trach in place, no exudate or erythema noted on
examination of tympanic membranes bilaterally
CV: RRR
PULM: mildly rhonchorous breath sounds throughout.
ABD: soft, NT, ND
EXT: no edema
NEURO EXAM:
MS - AAOx3 (whispering over the trach)
CN - PERRL 3->2, EOMI, tongue midline, face symmetrical, facial
sensation intact
MOTOR - ___ throughout
SENSATION - intact to light touch throughout
Pertinent Results:
___ CXR: IMPRESSION:
1. Endotracheal tube in standard position. Nasogastric tube
courses below
the diaphragm, with the tip not visualized, off the inferior
borders of the film.
2. Low lung volumes with probable mild pulmonary vascular
congestion and
bibasilar atelectasis.
___ MRI BRAIN: IMPRESSION: Homogeneously enhancing extra-axial
lesion along the left parietal convexity with mild mass effect
on the left parietal lobe associated with perilesional edema.
This likely represents a meningioma.
___ CXR The patient is intubated with the ET tube and NG tube
in appropriate position. Heart size and mediastinum are
unchanged in appearance. Interval resolution of pulmonary edema
has been demonstrated with overall clear lungs currently seen
with no definitive evidence of masses or consolidations.
___ CTA head:
1. CT shows a partially calcified mass in the left
parietooccipital region consistent with a meningioma.
2. CT angiography demonstrates increased vascularity in the
region, but exact origin of this vascular structure is difficult
to ascertain given the limited ability of the CTA, but there
appears to be some meningeal supply from the superficial aspect
of the mass. The parietooccipital branch of the left middle
cerebral/posterior cerebral artery is seen draped over the mass.
___ CXR preop: The cardiomediastinal contours are within normal
limits. Lungs and pleural surfaces are clear, and no acute
skeletal abnormalities are detected.
___ MRI brain Wand: Unchanged enhancing extra-axial mass lesion
along the left parietal region, with mild mass effect on the
left parietal lobe and
associated with perilesional edema.
___ CT head: Expected post-surgical changes with a small amount
of hemorrhage and pneumocephalus in the region of previously
visualized left occipital mass. Previously visualized calcified
occipital masse is no longer seen
MR HEAD W & W/O CONTRAST Study Date of ___ 3:21 ___
IMPRESSION:
1. Post-surgical changes status post resection of left parietal
extra-axial mass, likely representing meningioma. No evidence
of residual enhancement to suggest residual tumor.
2. There is an area of slow diffusion anterior to the resection
cavity,
likely representing an area of ischemia or related to surgical
procedure.
CXR ___: IMPRESSION: Status post endotracheal tube removal
and tracheostomy tube placement. No acute cardiopulmonary
process.
CXR ___: FINDINGS: Tracheostomy tube in standard position.
An orogastric tube ends into the stomach. Both lungs are clear.
No opacities of concern. Mildly enlarged heart size is stable,
mediastinal and hilar contours are unremarkable. There is no
pleural effusion or pneumothorax.
Brief Hospital Course:
Ms. ___ was admitted to the Neurosurgery service, to the
ICU. She was continued on Keppra for seizure phophylaxis and
steroids for cerebral edema. She underwent MRI imaging which
revealed a left parietal lesion, likely meningioma. She was
extubated and her neurological exam was nonfocal and so she was
transferred to the step down unit.
After discussion with the patient and family the decision was
made for surgical resection of the lesion. On ___ she
underwent a left parietal craniotomy for excision of mass. She
was a difficult intubation and thus remained intubated
postoperatively. She was placed on dexamethasone 4Q6 for the
mass but also for airway edema. Postoperative head CT showed
post operative changes, but was stable. On ___, patient
remained intubated and on decadron. She was a&ox2 and full
strength on exam. MRI of the head was performed to evaluate for
residual tumor. On ___ she was unable to be extubated due to a
lack of cuff leak. She was evalauted by ENT who scoped her at
the bedside and she was noted to still have edema. Eventually
ENT recommended that she remain intubated until ___. She
remained stable on ___ and ___ while on the ventilator. She
continued to have airway issues and a tracheostomy was
recommended. The ___ team was consulted and they agreed to
proceed with tracheostomy on ___. The patient had a
tracheostomy placed and continued to be on the ventilator and
was weaned as tolerated. The patient was neurologically intact.
The incision was clean dry and intact. She remained
neurologically intact but continued to need some ventilator
support until ___, when she was taken off the vent. She
remained in the ICU until ___ when she was able to be sent to a
vented rehab (in case she needed to be placed back on the vent).
Medications on Admission:
zoloft, zocor, klonopin, metformin, ativan, abilify, glypizide
Discharge Medications:
1. sertraline 50 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
2. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. aripiprazole 1 mg/mL Solution Sig: Two (2) PO DAILY (Daily).
4. acetaminophen 650 mg/20.3 mL Solution Sig: Six Hundred Fifty
(650) mg PO Q6H (every 6 hours) as needed for pain, T>38.5.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. hydrochlorothiazide 12.5 mg Capsule Sig: Four (4) Capsule PO
DAILY (Daily).
8. olmesartan 20 mg Tablet Sig: One (1) Tablet PO qday ().
9. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal Q12H (every 12 hours) as needed for rhinitis.
10. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
11. levetiracetam 100 mg/mL Solution Sig: 1,000 mg PO BID (2
times a day).
12. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q6H (every 6 hours) as needed for
sob/wheeze.
13. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO once a day.
14. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. heparin (porcine) 5,000 unit/mL Solution Sig: 5,000 units
Injection TID (3 times a day).
16. insulin regular human 100 unit/mL Solution Sig: per sliding
scale units Injection QAHS.
17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left parietal mass
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:
General Instructions/Information
Have a friend/family member, doctor or nurse check your
incision daily for signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
You have dissolvable sutures so you may wash your hair
and get your incision wet day 3 after surgery. You may shower
before this time using a shower cap to cover your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace) &
Senna while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam), so you
will not require blood work monitoring.
While you are on steroid medication, make sure you are taking
a medication to protect your stomach (Prilosec, Protonix, or
Pepcid), as these medications can cause stomach irritation.
Make sure to take your steroid medication with meals, or a glass
of milk.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home once you are able to have your tracheostomy removed.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
Fever greater than or equal to 101° F.
We made the following changes to your medications:
1) We STARTED you on TYLENOL ___ every 6 hours as needed for
pain or fever.
2) We STARTED you on SENNA 8.6mg once a day to help prevent
constipation.
3) We STARTED you on BISACODYL 10mg once a day as needed for
constipation.
4) We STARTED you on HYDROCHLOROTHIAZIDE 50mg once a day.
5) We STARTED you on FLUTICASONE 1 spray every 12 hours as
needed.
6) We STARTTED you on DOCUSATE 100mg twice a day.
7) We STARTED you on KEPPRA 1,000mg twice a day.
8) We STARTED you on ALBUTEROL 6 puffs inhaled every 6 hours as
needed for SOB/wheeze.
9) We STARTED you on DEXAMETHASONE 2mg once a day. At your
Brain Tumor Clinic follow-up they will determine if you should
stop taking this.
10) We STARTED you on FAMOTIDINE 20mg twice a day.
11) We STARTED you on SUBCUTANEOUS HEPARIN 5,000 units three
times a day while you are in rehab.
12) We STARTED you on an INSULIN SLIDING SCALE while you are in
rehab.
13) We STOPPED your CLONAZEPAM.
14) We STOPPED your METFORMIN as you are now on an insulin
sliding scale.
15) We STOPPED your ATIVAN.
16) We STOPPED your GLIPIZIDE as you are now on an insulin
sliding scale.
17) We STARTED you on OXYCODONE 5mg every 6 hours as needed for
pain. Do not drive, operate heavy machinery, drink alcohol or
take other sedating medications with this until you know how it
effects you.
Followup Instructions:
___
|
10878868-DS-15
| 10,878,868 | 29,097,897 |
DS
| 15 |
2164-12-03 00:00:00
|
2164-12-04 17:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
inability to urinate for 24 hours
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ G0 presenting to ED with inability to urinate and
abdominal pressure. Patient reports diagnosis of uterine
fibroids
"years ago" on routine pelvic exam, however has had no
complaints
or symptoms related to this for several years. For the past 24
hours, patient has had difficulty urinating with the need to
strain to release urine, and only being able to urinate minimal
amounts. She also has noticed increasing abdominal distention
over the past few weeks. Denies dysuria/vaginal bleeding/unusual
vaginal discharge/fever/chills/nausea/vomiting/change in bowel
habits.
On arrival to the ED, patient initially had a bedside US
performed by ED team concerning for ?fibroid causing urinary
obstruction. A foley catheter was placed with 700cc of urine
that
immediately drained. Following placement of the foley, patient
reported significant improvement in her symptoms.
Past Medical History:
OB-GYN Hx: G0. LMP ___. Has monthly periods, however periods
have recently gone from lasting ___ days to close to 10 days.
Last Pap ___ year ago, no hx of abnl Paps. Does not see a
gynecologist. Remote hx of chlamydia. Hx of uterine fibroids as
described above (pt only recalls pelvic ultrasound performed
"years ago" to confirm this diagnosis)
PMH: HTN
PSH: denies
Social History:
___
Family History:
Fam Hx: Father had multiple myeloma. Denies hx of breast/GYN
cancer.
Physical Exam:
On admission
Physical Exam:
98 81 157/93 16 100
Gen: NAD, appears comfortable
Abd: soft, ND, NT, large firm palpable mass with superior most
portion slightly above and to the left of umbilicus.
Spec: normal vaginal mucosa. Cervix extremely anterior, w/o
lesions or discharge.
BME: Enlarged firm uterus with limited mobility,extending
laterally to both pelvic side walls, fundus palpated at
umbilicus
with ?fibroid extension to patient's left. Unable to appreciate
adnexa.
On day of discharge
VSS
CTAB
RRR
Gen: NAD, appears comfortable
Abd: soft, ND, NT, large firm palpable mass with superior most
portion slightly above and to the left of umbilicus.
___: nt, ne
Pertinent Results:
___ 09:45AM GLUCOSE-116* UREA N-17 CREAT-1.1 SODIUM-141
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-28 ANION GAP-13
___ 09:45AM WBC-10.7 RBC-3.79* HGB-9.6* HCT-31.2* MCV-82
MCH-25.2* MCHC-30.7* RDW-15.5
___ 09:45AM NEUTS-81.9* LYMPHS-12.1* MONOS-5.1 EOS-0.7
BASOS-0.3
___ 09:45AM PLT COUNT-213
___ 06:49AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:49AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
___ 06:49AM URINE MUCOUS-RARE
___ 06:49AM URINE RBC-9* WBC-14* BACTERIA-NONE YEAST-NONE
EPI-0
___ 09:09PM GLUCOSE-127* UREA N-19 CREAT-1.5* SODIUM-136
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-21* ANION GAP-21*
___ 09:09PM estGFR-Using this
___ 09:09PM URINE HOURS-RANDOM
___ 09:09PM URINE UCG-NEGATIVE
___ 09:09PM WBC-11.8*# RBC-4.12* HGB-10.7* HCT-33.8*
MCV-82 MCH-25.9* MCHC-31.6 RDW-15.1
___ 09:09PM NEUTS-84.2* LYMPHS-10.0* MONOS-5.4 EOS-0.2
BASOS-0.2
___ 09:09PM PLT COUNT-213
___ 09:09PM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 09:09PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 09:09PM URINE RBC-30* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-11
___: Abd/Pelvic U/S FINDINGS: The uterus is enlarged.
There are multiple masses consistent with fibroids. The largest
measures 15.5 x 15.2 x 9.7 cm. Evaluation of the ovaries is
limited. There is no free fluid. IMPRESSION: Fibroid uterus.
Limited evaluation of the ovaries.
___: Renal U/S FINDINGS: The right kidney measures 12.2
cm. The left kidney measures 11.6 cm. There is mild
hydronephrosis bilaterally. There are no renal stones or
masses. Renal echogenicity and corticomedullary architecture is
within normal limits. Limited evaluation of the bladder.
IMPRESSION: Mild bilateral hydronephrosis. No evidence of stones
or renal masses.
___: MRI A/P: FINDINGS:
The uterus is massively enlarged, measuring up to 22.2 x 11.8 x
14.6 cm,
essentially filling the entire pelvis. There are multiple T2
hypointense
well-defined masses throughout the uterus, most compatible with
fibroids, the
largest of which is predominantly exophytic, extending from the
right aspect
of the lower uterus, measuring 14.6 x 10.4 x 10.6 cm (CC x AP x
TV). This
fibroid markedly distorts the adjacent cervix and endometrium,
which are
displaced to the left. Several additional heterogeneously
enhancing fibroids
are seen within the uterine fundus, measuring up to 5.0 cm (4:
13), some of
which demonstrate submucosal components.
The ovaries are displaced superiorly, but otherwise normal. The
bladder is
markedly compressed and displaced anteriorly by the enlarged
fibroid uterus.
A Foley catheter is seen within the bladder. There is bilateral
hydronephrosis and hydroureter, as seen on the prior ultrasound
dated ___. T2 hyperintense nonenhancing lesions within both
kidneys
measure up to 9 mm in the left interpolar region, compatible
with simple
cysts. Limited assessment of the liver, pancreas, adrenal
glands, stomach,
small bowel, and colon is unremarkable. There are no
pathologically enlarged
abdominal or pelvic lymph nodes. The abdominal aorta is normal
in caliber.
There is minimal free fluid in the pelvis.
IMPRESSION:
1. Massively enlarged fibroid uterus with a dominant 14.6 cm
fibroid along
the right aspect of the lower uterine body, causing distortion
and
displacement of the cervix and adjacent endometrium. Multiple
additional
smaller fibroids throughout the remainder of the uterus, some of
which have
submucosal components.
2. Bilateral hydronephrosis and hydroureter, as seen on prior
ultrasound from
___, almost certainly secondary to compression from
the enlarged
uterus.
3. Bilateral simple renal cysts
Brief Hospital Course:
Ms ___ was seen in the emergency department with acute
urinary retention. A foley catheter was placed for 700cc urine.
On ultrasound evaluation her multifibroid uterus was seen to be
severely compressing her urinary bladder and there was bilateral
mild hydronephrosis and hydroureter. Her creatinine was 1.5 at
this time. She was thus admitted overnight for IVF and
observation. An MRI was also done, given the rapid time course
of onset of symptoms to r/o leimyosarcoma. MRI was c/w prior
ultrasound results and fibriods did not have the appreance of
leiomyosarcomas. Please see separate MRI report for full
details. On the morning of hospital day number 2 her Cr had
fallen to 1.1. She was discharged on HD#2 with a urinary foley
catheter to prevent further urinary retention. She was discharge
with a plan for likely hysterectomy and close outpatient
follow-up to further discuss management.
Medications on Admission:
HCTZ and "cholesterol medication"
Discharge Medications:
same
Discharge Disposition:
Home
Discharge Diagnosis:
fibroid uterus causing obstruction of your bladder and acute
kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General instructions:
* You may eat a regular diet
Call your doctor for:
* fever > 100.4, chills
* severe abdominal pain
* changes in the appearance of your urine
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
*) You were discharged home with a Foley (bladder) catheter and
received teaching for it prior to discharge. You may need to
keep this catheter in place until your surgery.
Followup Instructions:
___
|
10879112-DS-16
| 10,879,112 | 26,591,797 |
DS
| 16 |
2141-09-14 00:00:00
|
2141-09-15 10:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Progressive weakness and headache
Major Surgical or Invasive Procedure:
___ Craniotomy for subdural hematoma evacuation
___ TEE with cardioversion
History of Present Illness:
In brief this is a ___ yoM ___ man with a history of AS and
MS due to rheumatic heart disease status post mechanical AVR/MVR
and MAZE procedure ___ who was on outpt aspirin and
warfarin. He is s/p GI bleed in ___ in setting of
supratherapeutic INR at which point warfarin dose was reduced
from 2mg to 1mg, and HBV (on tenofovir), who presented on
___ with altered mental status and gait instability. Initial
imaging showed right>left large bilateral subdural hematomas
with midline shift and subfalcine herniation. He received
vitamin K to reverse his INR and was taken to the OR on ___
for craniotomy and subdural drain placement. He has not received
anticoagulation since admission and his aspirin has been held.
On ___ he had one episode of mild chest discomfort in the
___ his chest while lying in bed that lasted ___ minutes,
was not accompanied by any sweating, shortness of breath, or
nausea/vomiting. ECG showed atrial flutter with no ST changes,
and troponins were negative x 1. He was started on metop which
was uptitrated to 25 QID for atrial flutter.
He was transferred to ___ on post operative day 7 as patient is
neurologically ready for discharge, but cardiology would like
him to restart anticoagulation on heparin gtt as soon as
possible for his mechanical valves. Discussion regarding
anticoagulation between neurosurgery and cardiology attendings
concluded that patient would be transferred to ___, and on post
op day 10, can restart AC with heparin drip and once stable on
that, bridge pt to coumadin.
Past Medical History:
- Mechanical MVR/AVR on Coumadin
- S/p Left atrial appendage ligation. Cryoablation Maze
procedure concomitant.
- Atrial Fibrillation
- Chronic Hepatitis B
Social History:
___
Family History:
- Mother with some sort of heart condition.
- Father unknown medical history.
Physical Exam:
PHYSICAL EXAM ON ADMISSION TO ___
===================================
VS: T 98.3 BP=100/66.HR=79 RR=18 O2 sat=100% RA
GENERAL: In NAD. Oriented x3. Mood, affect appropriate.
HEENT: Patient with craniotomy scar extending anterior to
posterior along right frontal/parietal area. Well healing,
without erythema or swelling. Sclera anicteric. PERRL, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Jugular venous pressure is within normal limits, neck is
supple and non-tender without lymphadenopathy or thyromegaly,
carotids are brisk in upstroke bilaterally without any bruit,
mucous membranes are moist, conjunctivae pink
CARDIAC: regular rate, mechanical aortic and mitral valve
sounds, ___ holosystolic murmur throughout the precordium
LUNGS: Midline scar through sternum, well healed. Resp were
unlabored, no accessory muscle use. CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, or ulcers. left knee with bruise.
PULSES: 2+ bilaterally.
NEURO: CN II-XII
ON DISCHARGE
=============
VS: 98.3, HR 98-107/56-73,65-96, 18, 100% on RA
I/O: ___
Weight 47.0<-46.9<-46.8kg<- 49.6
Tele: NSR ___.
GENERAL: In NAD. Oriented x3. Mood, affect appropriate.
HEENT: Patient with craniotomy scar extending anterior to
posterior along right frontal/parietal area. Well approximated,
without erythema or swelling. Anicteric sclera, mucous membranes
moist
NECK: Supple, carotids are brisk in upstroke bilaterally without
bruits
CARDIAC: regular, mechanical aortic and mitral valve sounds, ___
holosystolic murmur throughout the precordium
LUNGS: Midline scar through sternum, well healed. Resp were
unlabored, no accessory muscle use. CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c. Trace edema to mid shins
SKIN: No stasis dermatitis, or ulcers.
PULSES: 2+ bilaterally.
NEURO: CN II-XII intact. strength ___ in UE and ___
___ Results:
LABS ON ADMISSION
=================
___ 05:46AM BLOOD WBC-12.4* RBC-3.30* Hgb-10.5* Hct-33.2*
MCV-101* MCH-31.8 MCHC-31.6* RDW-18.3* RDWSD-68.0* Plt ___
___ 05:46AM BLOOD Neuts-66.0 ___ Monos-10.2
Eos-0.2* Baso-0.2 Im ___ AbsNeut-8.17* AbsLymp-2.84
AbsMono-1.26* AbsEos-0.02* AbsBaso-0.03
___ 05:46AM BLOOD ___ PTT-32.3 ___
___ 05:46AM BLOOD Glucose-107* UreaN-15 Creat-1.2 Na-134
K-4.2 Cl-100 HCO3-25 AnGap-13
___ 05:46AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.3
___ 05:54AM BLOOD Lactate-1.8
LABS ON DISCHARGE
==================
___ 11:20AM BLOOD WBC-6.5 RBC-3.52* Hgb-11.1* Hct-34.9*
MCV-99* MCH-31.5 MCHC-31.8* RDW-16.7* RDWSD-60.7* Plt ___
___ 08:10AM BLOOD ___ PTT-40.5* ___
___ 06:13PM BLOOD Glucose-114* UreaN-17 Creat-1.1 Na-134
K-4.4 Cl-101 HCO3-23 AnGap-14
___ 11:20AM BLOOD FacVIII-PND
___ 11:20AM BLOOD VWF AG-PND VWF Act-PND
___ 06:13PM BLOOD Calcium-9.2 Phos-4.8* Mg-2.2
___ ECHO
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or the body of the right atrium/right atrial
appendage. Mild spontaneous echo contrast is seen in the left
atrial appendage remnant. The left atrial appendage emptying
velocity is depressed (<0.2m/s). The right atrial appendage
ejection velocity is depressed (<0.2m/s). No atrial septal
defect is seen by 2D or color Doppler. There is symmetric left
ventricular hypertroph with normal cavity size. Right ventricle
with normal free wall contractility. The ascending, transverse
and descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 37 cm from the incisors. A mechanical
aortic valve prosthesis is present. The aortic valve prosthesis
appears well seated, with normal disc motion. No masses or
vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. A bileaflet mitral valve prosthesis is
present. The mitral prosthesis appears well seated, with normal
disc motion and transvalvular gradient. No mass or vegetation is
seen on the mitral valve. Trivial mitral regurgitation is seen
(normal for this prosthesis). The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Mild spontaneous contrast but no thrombus in ___
remnant. Well-seated bileaflet mitral valve prosthesis with
normal disc motion and gradient. Trivial mitral regurgitation.
Mild-moderate tricuspid regurgitation.
___ NCHCT
1. Interval increase in the left subdural hematoma, which still
layers along the entire left cerebral convexity, but which now
demonstrates a maximum thickness of 17 mm (previously 10 mm).
Interval increase in the rightward midline shift, which now
measures 7 mm (previously 4 mm). No increased hyperdense
component to the left subdural hematoma is identified to suggest
acute hemorrhage.
2. Right subdural hematoma unchanged in size, measuring 7 mm in
maximum
thickness. There remains a hyperdense component along the
posterior aspects, similar in appearance to prior examination
allowing for technical differences.
___ ECG
Irregular supraventricular tachycardia, probably atrial flutter
with variable block with flutter configuration that is not
typical. There is prominent precordial voltage. Consider left
ventricular hypertrophy with ST-T wave abnormalities of strain
and/or ischemia. Compared to the previous tracing of ___ the
rate is slightly less. Otherwise, unchanged. Clinical
correlation is suggested.
___ NCHCT
IMPRESSION:
1. Stable bilateral acute and chronic subdural hematomas as
described.
2. No evidence of midline shift or new intracranial hemorrhage.
3. Evolving postsurgical changes related to recent right frontal
craniotomy and subdural hematoma evacuation.
___ ___
1. Interval decrease in size of the right frontoparietal and
temporal subdural hematoma post evacuation with interval
normalization of midline structures and no midline shift.
2. Interval increase in size of the left holo hemispheric
evolving subdural hematoma with layering blood products along
the dependent aspect, likely secondary to expansion from
evacuation of the contralateral side rather than new hemorrhage.
However, a short-term follow-up CT is recommended to exclude
re- hemorrhage.
___
Atrial flutter with 4:1 block. Prominent precordial voltage.
ST-T wave
abnormalities of strain and/or ischemia. Compared to the
previous tracing
of ___ the rhythm was then more irregular and atrial
activity more chaotic. Precordial voltage was then more
prominent in leads V4-V6. Clinical correlation is suggested.
___ 5:55am Head CT without contrast
Impression:
Right greater than left large bilateral subdural hematomas,
acute on the left and acute on chronic on the right, combine to
cause 1.3 cm of leftward midline shift with associated
subfalcine herniation and effacement of nearly all sulci, the
right lateral ventricle, and the basal cisterns.
___ 4:36pm Head CT without contrast:
IMPRESSION:
1. Status post right craniotomy and evacuation of right mixed
density subdural hematoma. Residual hypodense fluid collection
with layering pneumocephalus in the right subdural space is
smaller than the evacuated hematoma, with decreased mass effect.
Specifically, there is decreased subfalcine and uncal
herniation, decreased effacement of the third and right lateral
ventricle, and decreased entrapment of the left lateral
ventricle.
2. Stable hyperdense subdural hematoma along the left convexity
with stable mild sulcal effacement. Stable small hyperdense
subdural hematoma along the left falx and along the superior
tentorium bilaterally.
Brief Hospital Course:
Mr. ___ is a ___ year old ___ man with a history of
AS and MS due to rheumatic heart disease status post mechanical
AVR/MVR and MAZE procedure ___, s/p GI bleed in ___ in
setting of supratherapeutic INR 5.5, and HBV, who presented on
___ with altered mental status and gait instability, and was
subsequently diagnosed with bilateral subdural hematomas and was
transferred to the ___ service s/p craniotomy and evacuation to
manage anticoagulation for AVR/MVR.
#Subdural hematomas: Patient had subdural hematoma evacuation
with craniotomy on ___ and his subdural drain was removed
without complications on ___. Patient was ready for discharge
from neurosurgical standpoint early on in his hospitalization,
but was transferred to ___ service out of concern for
anticoagulation for his mechanical valves. His course was also
complicated by atrial flutter (see below). Patient was initiated
on heparin gtt on POD 10 and then was bridged to warfarin after
remaining stable on heparin gtt. Interval NCHCT ___ to eval for
SDH stability s/p initiation of heparin gtt demonstrated
increase in SDH that could not be ruled out as new bleeding.
Follow-up NCHCT later same day was unchanged, making new
bleeding related to heparin unlikely. He also obtained a NCHCT
after he was therapeutic on warfarin, and there was no new bleed
appreciated. No new focal neurological deficits appreciated
during his hospitalization. Because of history of two bleeds,
with SDH occurring in setting of INR of 2.1, we also sent VWF
activity and antigen, and factor VIII serum tests to evaluate
for any underlying clotting disorder.
# Rheumatic Heart disease s/p AVR/MVR: Patient had hx of AS and
MS ___ rheumatic heart disease and is now s/p mechanical AVR/MVR
and MAZE procedure on ___. Cardiology was consulted while
pt on neurosurgical service in regards to AC in setting of
recent GI bleed (with supratherapeutic INR) and SDH with INR of
2.1. Heparin gtt was started on POD 10 and warfarin was started
when patient was stable on heparin gtt. He had interval NCHCTs
while on heparin and warfarin to monitor for new bleeding. No
new bleeding appreciated. Aspirin is being held in setting of no
hx of CAD. Despite mechanical valves, given recent SDH even at
INR level of 2.1, it was decided that the patient INR goal will
be ___ instead of standard 2.5-3.5.
#Atrial flutter: Patient had hx of atrial fibrillation and is
now s/p MAZE procedure in ___. On this admission, he was
found to be in atrial flutter. He was restarted on metoprolol
which was somewhat effective in controlling rate, but he
continued to be in a-flutter with V rate bumping up into the
140s occasionally. He had TEE with cardioversion on ___ and
subsequently was in normal sinus rhythm with rates mostly in
___. He will be continued on Metop succinate 100 daily x 1
week, 50 daily x 1 week and 25 from then on. He will continue on
amiodarone 200 BID x 1 month and then will decrease to 200 daily
thereafter.
#Hepatitis B:
He was continued tenofovir 300 mg daily
#Recent upper GI bleed: Patient found to have bleeding ulcer in
___ in setting of supratherapeutic INR. He was continued on
Pantoprazole 40 mg BID and CBC monitored.
#Hypertension: Home lisinopril was withheld at last admission bc
of softer SBPs. Continued to withhold during this admission for
softer SBPs in ___.
====================
TRANSITIONAL ISSUES
====================
[ ] can restart lisinopril when SBPs tolerable
[ ] patient needs close follow up with INR now that he is on
amiodarone. ___ need to adjust warfarin 1 mg daily to qod while
on amiodarone.
[ ] Despite mechanical valves, given recent SDH even at INR
level of 2.1, it was decided that the patient INR goal will be
___ instead of standard 2.5-3.5.
[ ] VWF activity and antigen, and factor VIII serum tests send
for evaluation of clotting disorder given bleeding in the
setting of valvular replacement, results pending on discharge
[ ] INR on ___ and fax results to: Dr. ___ ___
and Dr. ___ at fax number: ___
#CODE: Full Code
#CONTACT: Son/health care proxy: ___, ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Pantoprazole 40 mg PO Q12H
2. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
3. Warfarin 1 mg PO DAILY16
4. Aspirin 81 mg PO DAILY
5. Calcium Carbonate 500 mg PO Frequency is Unknown
6. Multivitamins 1 TAB PO DAILY
7. Metoprolol Tartrate 50 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO TID
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
2. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
3. Warfarin 1 mg PO DAILY16
4. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*56 Tablet Refills:*2
5. Metoprolol Succinate XL 100 mg PO DAILY Duration: 7 Days
After one week of taking 100 daily, please take 50 daily for 1
week.
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*7 Tablet Refills:*0
6. Metoprolol Succinate XL 50 mg PO DAILY Duration: 7 Days
please take 50 mg for 7 days after taking 100 mg for 7 days.
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*7 Tablet Refills:*0
7. Multivitamins 1 TAB PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
Please take daily after taking 100 x 7 days and 50 x 7 days.
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*28 Tablet Refills:*2
9. Amiodarone 200 mg PO BID Duration: 4 Weeks
please take for 4 weeks
RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*56
Tablet Refills:*0
10. Amiodarone 200 mg PO DAILY
please take daily after taking it twice daily for a month.
RX *amiodarone 200 mg 1 tablet(s) by mouth daily Disp #*28
Tablet Refills:*2
11. Outpatient Lab Work
___.32
Please obtain INR on ___ and fax results to: Dr. ___
___ and Dr. ___ at fax number: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Bilateral subdural hematomas (right > left)
Atrial flutter
rheumatic heart disease s/p aortic valve replacement and mitral
valve replacement
SECONDARY DIAGNOSIS
====================
Hepatitis B
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear. Mr. ___,
You were admitted to ___ with
some confusion and were found to have a brain bleed. You
underwent neuro-surgery to help remove blood clots and have been
in recovery since. While you were here, you were initially off
your blood thinner because of the brain bleed. We carefully
monitored you and restarted the blood thinner at the appropriate
time.
You also were noted to have an abnormally heart beating pattern
which was corrected. You were started on a medication to prevent
the abnormal heart beating pattern from returning.
Please make sure you follow the instructions below and attend
all follow up appointments.
SURGERY INSTRUCTIONS
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your activity
at your own pace once you are symptom free at rest. ___ try to
do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
***You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if you
are not otherwise restricted from taking this medication.
___ Team
Followup Instructions:
___
|
10879284-DS-21
| 10,879,284 | 28,117,833 |
DS
| 21 |
2174-01-21 00:00:00
|
2174-01-21 19:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
environmental allergies / Timolol / mussels
Attending: ___.
Chief Complaint:
Hydrocephalus
Major Surgical or Invasive Procedure:
___ - Right frontal VP shunt placement - ___ Strata
1.0
History of Present Illness:
___ is a ___ year old female with known non small cell
lung cancer with leptomeningeal spread status post both
chemotherapy and radiation therapy. The patient presented to the
Emergency Department on ___ with vague neurologic
complaints and outpatient imaging concerning for hydrocephalus.
The Neurosurgery Service was consulted for evaluation and
management recommendations.
Past Medical History:
- allergic rhinitis
- alopecia areata
- glass eye on the right
- hyperlipidemia
- non small cell lung cancer with leptomeningeal spread status
post chemotherapy, radiation therapy
- right renal mass
- squamous cell carcinoma
- synovitis of forearm
Social History:
___
Family History:
Noncontributory.
Physical Exam:
On Admission:
-------------
Physical Exam:
Vital Signs: T 97.5F, HR 109, BP 114/80, RR 16, O2Sat 100% on
room air
General: Well nourished, comfortable, no acute distress.
Head, Eyes, Ears, Nose, Throat: Glass eye on the right from
childhood injury. Left pupil round and reactive to light, 4-3mm.
Extraocular movements intact on the left without nystagmus.
Extremities: Warm and well perfused.
Neurologic:
Mental Status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and time.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested.
II: Glass eye on the right from childhood injury. Left pupil
round and reactive to light, 4-3mm.
III, IV, VI: Glass eye on the right from childhood injury.
Extraocular movements intact on the left without nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength ___ throughout with the exception of the left
quadriceps, AT, and ___, which are all 4+/5, and the left
gastrocnemius, which is ___. No drift.
Sensation: Intact to light touch bilaterally.
On Discharge:
-------------
General:
Vital Signs: T 98.1F, HR 72, BP 101/67, RR 16, O2Sat 97% on room
air
Exam:
Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious
Orientation: [x]Person [x]Place [x]Time
Follows Commands: [ ]Simple [x]Complex [ ]None
Pupils: Glass eye on right from childhood injury, left pupil
round and reactive to light
Extraocular Movements: [x]Full - On the left, glass eye on right
from childhood injury [ ]Restricted
Face Symmetric: [x]Yes [ ]No
Tongue Midline: [x]Yes [ ]No
Drift: [ ]Yes [x]No
Speech Fluent: [x]Yes [ ]No
Comprehension Intact: [x]Yes [ ]No
Motor:
Trapezius Deltoid Biceps Triceps Grip
Right5 5 5 5 5
Left5 5 5 5 5
IP Quadriceps Hamstring AT ___ Gastrocnemius
Right5 5 5 5 5 5
Left5 5 5 5 5 5
[x]Sensation intact to light touch
Cranial Incision:
[x]Clean, dry, intact
[x]Staples
Abdominal Incision:
[x]Clean, dry, intact
[x]Dermabond
Pertinent Results:
Please see ___ Record for relevant laboratory and
imaging results.
Brief Hospital Course:
___ year old female with known non small cell lung cancer with
leptomeningeal spread and hydrocephalus.
#Hydrocephalus
The patient was taken from the Emergency Department to the OR
for a right frontal VP shunt placement. The right frontal VP
shunt is a ___ Strata Valve set at 1.0. The procedure was
uncomplicated. Please see ___ Record for further
intraoperative details. The patient was extubated in the OR and
recovered in the PACU. She was then transferred to the step down
unit for close neurologic monitoring. She remained
neurologically stable postoperatively. On ___, she was
afebrile with stable vital signs, ambulating independently,
tolerating a diet, voiding and stooling without difficulty, and
her pain was well controlled with oral pain medications. She was
discharged home on ___ in stable condition.
#Tachycardia
The patient was intermittently tachycardic with ambulation
postoperatively. She was given intravenous fluids and boluses as
needed, and her tachycardia resolved.
#Disposition
The patient ambulated with the nurse and was determined to be
independent. She was discharged home on ___ in stable
condition.
Medications on Admission:
- Advil
- Ativan 0.5mg PO QHS
- compazine 10mg PO PRN nausea
- docusate sodium 100mg PO TID PRN constipation
- folic acid 1mg PO daily
- omeprazole 20mg PO daily
- senna 8.6mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
Do not exceed 4000mg in 24 hours.
2. Docusate Sodium 100 mg PO TID
3. FoLIC Acid 1 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Hydrocephalus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory, independent.
Discharge Instructions:
Surgery:
- You had a VP shunt placed for hydrocephalus. Your surgical
incision should be kept dry until your staples are removed.
- Your VP shunt is a ___ Strata Valve, which is
programmable. This will need to be readjusted after all MRIs or
exposure to large magnets. Your VP shunt is programmed to 1.0.
- It is best to keep your surgical incision open to air, but it
is okay to cover it when outside.
- Please call your neurosurgeon if there are any signs of
infection like fever, redness, or drainage.
Activity:
- We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up.
- You may take leisurely walks and slowly increase your activity
at your own pace once you are symptom free at rest. ___ try to
do too much all at once.
- No driving while taking narcotics or any other sedating
medications.
- If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
- No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for at least six months.
Medications:
- Please do NOT take any blood thinning medications like
aspirin, clopidogrel (Plavix), ibuprofen, warfarin (Coumadin),
etc. until cleared by your neurosurgeon.
- You may use acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
- Headache or pain along your surgical incision.
- Neck tenderness along your VP shunt tubing.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high fiber diet. You may also try and over the counter
stool softener if needed.
Please Call Your Neurosurgeon At ___ For:
- Severe pain, redness, swelling, or drainage from the surgical
incision.
- Fever greater than 101.5 degrees Fahrenheit.
- Nausea or vomiting.
- Extreme sleepiness and not being able to stay awake.
- Severe headaches not relieved with pain medications.
- Seizures.
- Any new problems with your vision or ability to speak.
- Weakness or changes in sensation in your face, arms, or legs.
Call ___ And Go To The Nearest Emergency Department If You
Experience Any Of The Following:
- Sudden numbness or weakness in the face, arms, or legs.
- Sudden confusion or trouble speaking or understanding.
- Sudden trouble walking, dizziness, or loss of balance or
coordination.
- Sudden severe headaches with no known reason.
Followup Instructions:
___
|
10879375-DS-19
| 10,879,375 | 29,157,224 |
DS
| 19 |
2160-02-08 00:00:00
|
2160-02-10 07:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Sulfamethoxazole / Macrobid
Attending: ___
Chief Complaint:
"Pain brought me in "
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ right handed woman with a past
medical history of heterozygous factor 5 leiden and chronic back
pain who presents for evaluation of worsened back pain and
headache. Neurology consulted for ? spinal cord infarction.
History gathered from the patient.
Essentially, Mrs. ___ has a history of chronic migraine and
chronic back pain. Her back pain is chronic, worsened by
activity and predominalty right lumbar. She cannot walk or
stand
for long periods of time at baseline.
For the past 3 weeks, the patient has noticed a gradual
worsening
of her lumbar back pain that worsened more acutely in the last
week to 3 days. There was no clear inciting event, activity or
trauma. Her pain just slowly spread to starts at the base of
her
skull and goes all the way down her spine to her tailbone. It
is
achy in nature and feels like she needs to "crack her back".
There are spots down her back that are more tender than others.
In the setting of this backpain, she reports left leg weakness.
This is associated with a painful left hip. Her gait has also
worsened, due to a combination of the severe back pain and LLE
weakness. She has not been using assistive devices, but states
she might if she had them at home. Additionally, she endorses a
patch of numbness on her left buttock which she feels when
pulling up her pants.
Of note, she endorses a recent history of melena in the setting
of heavy NSAID use for pain. During this time, she had a single
period of melena diarrheal incontinence (did not feel she had to
go) while on the couch. Since then bowel movements have been
normal, without incontinence or loss. She has since stopped
NSAIDs as of 1 week ago without further issue or melena.
Additionally, she reports sensation of incomplete emptying when
urinating (ie having to back back to the bathroom shortly after
just urination). However, she is able to tell when she must
urinate and is able to do so ___ difficulty. No incontinence.
Regarding her new headache, at baseline, Ms. ___ gets frequent
migraines. Her migraine is typically located bifrontal and at
the top of her head. It is associated with taste/smell aura.
The pain is burning in nature and associated with photo-,
phono-sensitivity and nausea.
Regarding her new headache, as above, she stopped NSAIDS 1 week
ago after melena. Since that time she reports new onset of a
posterior headache that is very different from her migraines.
This posterior headache is a squeezing/pushing pain. It may
intermittently be associated with right eye blurry vision. It
is
contant, questionably worse when laying down. It does not wake
her at night There is no photo- phono-phobia with this. She
gets some relief with imetrex and Tylenol.
For the above pains, she has been smoking "a lot of pot"
The patient initially presented to our ED yesterday, but left
AMA
prior to MR imaging. She was seen by orthopedic doctor today,
who hearing the above details recommended ED presentation.
RoS positive for nightly fevers (not above ___ and "constant"
night sweats
On neuro ROS, the pt denies dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. No radiating
pains.
On general review of systems, the pt denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
vomiting,constipation or abdominal pain. No recent change in
bowel or bladder habits. Denies arthralgias or myalgias.
Past Medical History:
-Depression/Anxiety
-Factor V Leiden- Heterozygous, intermittent aspirin.
-Heartburn.
-Migraines
-Bulemia
-PTSD
Social History:
___
Family History:
- Mother with significant back pain and multiple spinal surgery.
MOther also had protein S deficiency and multiple strokes in
that
setting..
- Father and brother with MI and strong general family
psychiatric history.
Physical Exam:
Admission Exam
=====================
Vitals: 98.3 71 127/87 18 97% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: WWP. Attempting leg raise causes back pain at less
than 15degrees on the left, closer to 30 degrees on right. No
radicular symptoms.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent. Normal prosody. There were no
paraphasic errors. Speech was not dysarthric. Able to follow
both
midline and appendicular commands. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 5 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. No red desaturation. VFF to
confrontation. Fundoscopic exam limited but revealed no
papilledema.
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 4+ 5 5- 5-
R 5 ___ ___ 5 5 5 5 5 5 5
*Exam is very pain limited. It requires significant coaching
and
breaks between tests. There is significant give-away, but she
is
able to be coached through it. Above are best assessments.
-Sensory:
To pinprick, there is a semi-consistent T1-T3 spinal level to
pinprick. Tt resolved (back to totally normal) below those
levels. There is fair variation in the level of this on repeat
testing, occasionally starting lower or ending lower, but
inconsistently. Also endorses a T8-T9 level to pinprick,
roughly
50% to normal. Returns to normal below this.
In the upper extremities and right lower extremity, no deficits
to light touch, pinprick, proprioception throughout. No
extinction to DSS.
Her Left lower extremity has a complex sensory exam. To light
touch and pinprick, sensation is roughly 80% normal in the
medial
left leg. There is decreased sensation to pinprick and light
touch (roughly 50% of normal) along the posterior left calf.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 2
R 2 2 2 3 2
- Toes are downgoing bilaterally.
+ Crossed Adductors
-Coordination: No intention tremor, no dysdiadochokinesia noted.
Mild dysmetria with left hand on FNF. Somewhat clumsy with palm
over balm bilaterally (no clear asymmetry). Heel shin pain
limited.
-Gait: Good initiation. Narrow-based, shortened, somewhat
antalgic stride. Tandem is pain limited. Romberg is absent.
Later seen to be spontaneously ambulating as above without
significant difficulty.
Discharge Exam
============================
VSS
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: WWP.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent. Normal prosody. There were no
paraphasic errors. Speech was not dysarthric. Able to follow
both
midline and appendicular commands. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 5 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. No red desaturation. VFF to
confrontation. Fundoscopic exam limited but revealed no
papilledema.
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 4+ 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
*Exam is very pain limited. It requires significant coaching
and
breaks between tests. There is significant give-away, but she
is
able to be coached through it. Above are best assessments.
In the upper extremities and right lower extremity, no deficits
to light touch, pinprick, proprioception throughout. No
extinction to DSS.
Her Left lower extremity has a complex sensory exam. To light
touch and pinprick, sensation is roughly 80% normal in the
medial
left leg. There is decreased sensation to pinprick and light
touch (roughly 50% of normal) along the posterior left calf.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 2
R 2 2 2 3 2
- Toes are downgoing bilaterally.
+ Crossed Adductors
-Coordination: No intention tremor, no dysdiadochokinesia noted.
Mild dysmetria with left hand on FNF. Somewhat clumsy with palm
over balm bilaterally (no clear asymmetry). Heel shin pain
limited.
-Gait: Good initiation. Narrow-based, shortened, somewhat
antalgic stride. Tandem is pain limited. Romberg is absent.
Later seen to be spontaneously ambulating as above without
significant difficulty.
Pertinent Results:
Labs
=====================
___ 02:52PM BLOOD WBC-10.6* RBC-4.46 Hgb-13.4 Hct-40.1
MCV-90 MCH-30.0 MCHC-33.4 RDW-12.3 RDWSD-40.4 Plt ___
___ 12:05PM BLOOD Neuts-56.3 ___ Monos-4.5* Eos-1.6
Baso-0.6 Im ___ AbsNeut-5.53 AbsLymp-3.61 AbsMono-0.44
AbsEos-0.16 AbsBaso-0.06
___ 02:52PM BLOOD Glucose-98 UreaN-14 Creat-0.6 Na-138
K-4.3 Cl-103 HCO3-24 AnGap-15
___ 12:05PM BLOOD ALT-31 AST-24 LD(LDH)-161 AlkPhos-78
TotBili-0.1
___ 05:30AM BLOOD Calcium-8.8 Phos-4.4 Mg-2.1 Cholest-228*
___ 05:30AM BLOOD Triglyc-271* HDL-40 CHOL/HD-5.7
LDLcalc-134*
___ 05:30AM BLOOD %HbA1c-5.3 eAG-105
Imaging
========================
MR ___ ___
FINDINGS:
There is no evidence of 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. Major intracranial vessels are patent.
IMPRESSION: Normal ___ MR.
___
MR ___
IMPRESSION:
1. Findings are suspicious for spinal cord infarct from T7
through T10 with abnormal T2 hyperintensity within bilateral
anterior horns of spinal cord.
2. Mild degenerative changes of lumbar spine most prominent at
L2-L3 with small posterior disc bulge causing mild canal
narrowing.
___
CTA Torso
IMPRESSION:
Normal CTA of the chest abdomen and pelvis. No findings to
explain patient's symptoms.
___
MR ___ contrants diffusion sequences
IMPRESSION:
1. Study is moderately degraded by motion, limiting evaluation
of spinal cord lesions.
2. Within limits of study, previously noted T7 through T10
spinal cord signal abnormality not clearly demonstrated on
current examination.
3. Limited diffusion imaging of thoracic spinal cord does not
definitely demonstrate cord infarct.
Brief Hospital Course:
___ with h/o heterozygous factor 5 leiden and chronic back pain
who p/w acute on chronic back pain and LLE weakness. Admitted
due to MRI read of "T7-T10 infarction vs artifact" which was not
seen on DWI sequences. History and exam not consistent with
spinal cord infarction. Exam notable for left L4 sensory
deficit, left leg giveaway weakness. Gait is antalgic (from back
pain). She has mild disc bulges in the lumbar spine and likely
L4 radiculopathy. We are treating her muscle spasms with valium.
Holding NSAIDs given gastritis from overuse of NSAIDs. She is
followed by Dr. ___ in orthopaedics and should return
there for follow up.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Venlafaxine 225 mg PO DAILY
2. Vitamin D ___ UNIT PO DAILY
3. TraZODone 50 mg PO QHS:PRN insomnia
4. Sumatriptan Succinate 100 mg PO PRN migraine headache
5. Acetaminophen 650 mg PO Frequency is Unknown pain
Discharge Medications:
1. TraZODone 50 mg PO QHS:PRN insomnia
2. Vitamin D ___ UNIT PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Diazepam 5 mg PO Q6H:PRN muscle spasm
5. Sumatriptan Succinate 100 mg PO PRN migraine headache
6. Venlafaxine 225 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
L4 radiculopathy. Mild lumbar spinal stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because of worsening of your
back pain and left leg weakness. You received MRI of your ___
and whole spine. Initially, there was an equivocal finding on
your thoracic spine. We repeated the MRI of your thoracic sign
to clarify and it did not show the initial concern of spinal
infarction. We do think that you may have irritation to your
nerve roots from the lumbar disc bulges that can cause your left
leg symptom. Also, you have muscle spasms in your back for
which we started you on valium. Please continue physical
therapy. Please return to the ___ and see Dr. ___
___ for follow up.
___ Care team
Followup Instructions:
___
|
10879723-DS-14
| 10,879,723 | 26,796,154 |
DS
| 14 |
2130-10-28 00:00:00
|
2130-10-28 14:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ with history of CAD/MI and stents x 2 in
___ who presents with non-exertional chest discomfort for at
least 10 days and dyspnea since this AM. She describes
intermittent chest pressure, mainly over the right side with
radiations to the left as well as bilateral shoulders and
right-side of neck. It has no association with exertion,
position, or breathing and she rates it as a ___. This AM she
awoke with dyspnea, or feeling "like she couldn't get enough
air." She noticed this while walking up the stairs. She denies
cough, hemoptysis, fevers/chills or URI symptoms. She denies
lower extremity edema, orthopnea, PNA, palpitations. She has had
no recent travel except a 3-hr flight on ___ and denies
personal/family history of DVT.
Of note, this is not the first time she has had chest pressure
like this. She had this one year ago, during which they thought
it was esophagitis and treated her with prilosec. This was
successful at relieving the discomfort. She presented to her PCP
at the beginning of ___ again with chest pressure and she
was restarted on omprazole BID. This has not helped her chest
discomfort. She denies dysphagia, odynophagia, abdominal pain,
nausea/vomiting or heartburn.
In the ED VS 98.2 57 138/73 19 98%, and remained unchanged. Her
EKG was concerning for possible T wave inversion on V2-V3 and
flattening in V4. She was given IV Morphine x 4mg, SL Nitro x
0.8mg (2 doses), ASA 243mg (took 81mg in AM), and Ativan x 1mg.
CXR did not show any acute process. She reports that the sl
nitro made no appreciable difference in her chest pain, however,
the morphine helped slightly. She also says this pain is very
different than her previous MI.
Labs showed normal CBC, Hemolyzed BMP showed K 6.4, normal GFR
(BUN/Cr ___, and ___ TnT (2:13pm) was <0.01. UA clean.
Repeat K within normal limits.
On arrival to the floor, vital signs were stable. She reports
continuous ___ mainly right-sided chest pressure. She currently
denies dyspnea.
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, or dysuria.
Cardiac review of systems is notable for chest pain and dyspnea,
as well as absence of dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
Past Medical History:
Inferior MI, s/p DES in ___ (anatomy unknown)
Cardiac stress echo ___ of maximum heart rate 88%,
LVEF 60%, normal. ETT - neg BI ___.
HYPERTENSION
RemoteHEADACHES
LOWER BACK PAIN, L4 ON L5 ANTEROLISTHESIS
ADENOMATOUS POLYP, ___ AT ___
RIGHT OVARIAN ___ ___
VITAMIN D INSUFFICIENCY
GENITAL HERPES - HSV 1
H/O RIGHT SHOULDER PARTIAL THICKNESS SUPRASPINATUS
TEAR ___
H/O HELICOBACTER PYLORI TREATED ___
Social History:
___
Family History:
History of early MI in her father (late ___. History of HLD
in father and brother. History of breast cancer in maternal and
paternal grandmothers. Her paternal uncle had pancreatic cancer.
Denies history of diabetes, DVTs.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.5 54 18 128/70 98RA
General: Well-developed, well-nourished. No acute distress
HEENT: PERRL. EOMI. Sclera anicteric. Oropharynx clear and
without exudate.
Neck: Soft, supple. No lymphadenopathy
Chest: No obvious deformities. No tenderness to palpation of
precordium.
CV: Bradycardia. S1 and S1. No murmurs, rubs or gallops.
Lungs: No increased work of breathing. Clear to auscultation
bilaterally
Abdomen: Normoactive bowel sounds. Soft, non-tender,
non-distended. No appreciable organomegaly. No epigastric
tenderness.
Ext: Symmetrical without erythema. Trace edema bilaterally, no
cyanosis or clubbing; No tenderness to palpation of calves
bilaterally
Neuro: CN2-12 grossly intact. Moves all extremities
spontaneously and to command.
Skin: Warm, no rashes
PULSES: 2+ carotids, 2+ radial, 2+ DP and 2+ ___ bilaterally
DISCHARGE PHYSICAL EXAM:
VS T 97.9 53-62 18 ___ 97-99RA
General: Well-developed, well-nourished. No acute distress
HEENT: PERRL. EOMI. Sclera anicteric. Oropharynx clear and
without exudate.
Neck: Soft, supple. No lymphadenopathy
Chest: No obvious deformities. No tenderness to palpation of
precordium.
CV: Bradycardia. S1 and S1. No murmurs, rubs or gallops.
Lungs: No increased work of breathing. Clear to auscultation
bilaterally
Abdomen: Normoactive bowel sounds. Soft, non-tender,
non-distended. No appreciable organomegaly. No epigastric
tenderness.
Ext: Symmetrical without erythema. Trace edema bilaterally, no
cyanosis or clubbing; No tenderness to palpation of calves
bilaterally
Neuro: CN2-12 grossly intact. Moves all extremities
spontaneously and to command.
Skin: Warm, no rashes
PULSES: 2+ carotids, 2+ radial, 2+ DP and 2+ ___ bilaterally
Pertinent Results:
ADMISSION LABS:
___ 01:50PM BLOOD WBC-4.6 RBC-4.59 Hgb-14.5 Hct-41.2 MCV-90
MCH-31.6 MCHC-35.2* RDW-13.4 Plt ___
___ 01:50PM BLOOD Neuts-61.0 ___ Monos-5.6 Eos-3.4
Baso-0.6
___ 01:50PM BLOOD ___ PTT-29.6 ___
___ 01:50PM BLOOD Glucose-100 UreaN-20 Creat-0.9 Na-139
K-6.4* Cl-102 HCO3-29 AnGap-14
___ 01:50PM BLOOD Calcium-9.4 Phos-3.6 Mg-2.0
___ 01:50PM BLOOD D-Dimer-196
___ 03:12PM BLOOD K-3.4
___ 03:25PM URINE Color-Straw Appear-Clear Sp ___
___ 03:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
CARDIAC BIOMARKERS:
___ 01:50PM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:20PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:45AM BLOOD CK-MB-1 cTropnT-<0.01
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-4.2 RBC-4.31 Hgb-12.9 Hct-37.8 MCV-88
MCH-30.0 MCHC-34.2 RDW-13.5 Plt ___
___ 06:45AM BLOOD Glucose-105* UreaN-20 Creat-0.8 Na-144
K-3.6 Cl-105 HCO3-30 AnGap-13
___ 06:45AM BLOOD Calcium-8.9 Phos-4.5 Mg-1.8
STUDIES:
___ EKG: Sinus bradycardia @ ventricular rate of 59. ___
degree A-V block with non-specific T wave inversions in V2-V3
and T-wave flattening in V4.
___ EKG: Sinus bradycardia @ ventricular rate of 59. ___
degree A-V block with non-specific T wave inversion V3 and with
normalization of previous T-wave abnormalities in V2 and V4.
___ CXR:FINDINGS:
The lungs are clear.The cardiac, hilar and mediastinal contours
are normal. Fat containing Morgagni hernia at the right
cardiophrenic angle is similar compared to chest CT from 2
months prior. No pleural abnormality is seen.
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
Mrs. ___ is a ___ yo female with past medical history
significant for CAD/MI s/p DES in ___, GERD who presents with
atypical chest pain and dyspnea. PE and ACS were ruled out and
she was discharged with plans to follow-up with Dr. ___ on
___.
# Atypical chest pain: It appeared atypical in that it was
different than her angina in the past, it was not relieved by sl
nitro in the ED, and it had no association with exertion. In the
ED, troponin was negative x 1, EKG showed non-specific T-wave
inversions in V2-3 and flattening in V4 compared to prior in
___. However, repeat EKG showed resolution of the non-specific
T wave changes and two more sets of cardiac biomarkers were
negative. Moreover, her D-Dimer was <500 and Wells score 0,
making PE unlikely. CXR was also unremarkable. The day after
admission, her chest pain and dyspnea had resolved. She was
discharged with plans to follow-up with her new cardiologist Dr.
___ on ___ to discuss the possibility of stress testing
(an inpatient stress echo was unable to be performed due to
staffing). She was also given lorazepam, as per her request, she
reported anxiety.
TRANSITIONAL ISSUES:
-- Consider imaging stress test as an outpatient
-- Given prescription for lorazepam for anxiety; ___ benefit
from SSRI as an outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Omeprazole 20 mg PO BID
4. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
5. Aspirin 81 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Omeprazole 20 mg PO BID
5. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Lorazepam 0.25 mg PO Q6H:PRN anxiety
Take ___ tablets. Please don't drive/operate heavy machinery or
take with alcohol.
RX *lorazepam [Ativan] 0.5 mg 0.5-1 tablets by mouth Q6H PRN
Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Atypical chest pain
Secondary diagnosis: hypertension, coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ due to chest and breathing
discomfort. We evaluated your heart with an EKG and blood tests
that did NOT show evidence of heart injury. We monitored you
overnight and your heart rate was normal. You have a follow up
on ___ with a Cardiologist Dr. ___ and at that visit
you will have a discussion about doing a "stress test."
Best Wishes,
Your ___ Team
Followup Instructions:
___
|
10880089-DS-13
| 10,880,089 | 29,339,287 |
DS
| 13 |
2178-08-05 00:00:00
|
2178-08-06 20:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
angioedema and acute respiratory failure
Major Surgical or Invasive Procedure:
- nasophyrangeal intubation
- mechanical intubation
- direct fibroscopic visualization of the vocal cords prior to
extubation
- ACE-I added as an allergy (adverse reaction: angioedema)
History of Present Illness:
___ w/ PMH HTN, presented to ED with CC angioedema. took
lisinopril for ___ years, felt like tongue was getting swollen,
came in 5 hrs later.
In ED, nasal intubation with anesthesia. O2 sats were ok.
Intubated sedated with propofol drip. Reports came into ED once
prior. Received epi, IV benadryl, methypred and famotidine.
Anesthesia said call before pull tube.
call parents in AM after ___.
On arrival to the MICU, VS: afebrile, HR56 BP87/54 on CMV R16
Vt500 PEEP5. Pt was sedated but arousable, appeared
comfortable. denied abd pain. Due to hypotension on propofol,
switched to fentanyl and versed gtt.
Past Medical History:
HTN
HLD
Anxiety
Psoriasis
Depression
Gout
Hx of BCC
T2DM
Social History:
___
Family History:
Father CAD/PVD
Maternal Grandmother ___
Mother ___ Stroke
Paternal Grandmother Cancer - ___
Paternal Uncle ___ Onset
Physical Exam:
Admission PE:
Temperature of 98.6, HR 50-80s, SBPs 80-130s, SpO2 95-98% on CMV
500 / 16 / 5/ 40% with PIPs of ~17. I/O -1.4L (since admission).
He is alert, interactive, writing on a piece of paper. His
tongue and posterior oropharynx are swollen, and he is nasally
intubated. His lungs are clear, abdomen benign, and heart
regular without murmurs or extra heart sounds.
.
Brief Hospital Course:
___ man with a h/o hypertension presents with angioedema
secondary to lisinopril.
>> Active issues:
# Angioedema: Likely secondary to lisinopril. Mr. ___
received epi, methylpred and IV benadryl in ED and was intubated
for airway protection. He was admitted to the MICU, and on
arrival was intubated and sedated. His sedation was stopped, and
he was monitored on the vent for improvement in swelling of
posterior pharynx. Prior to extubation, he underwent direct
fibroscopic visualization of the vocal cords which showed marked
improvement in largyngeal, aretnoid and vocal cord swelling. He
was extubated without complication, and given respiratory and
clinical stability, and given he was able to vocalize and
swallow without difficulty, he was discharged to home. He did
receive explicit instructions to immediately re-present to the
ED with any further tongue swelling, throat tightness, or
difficulty breathing, and he endorsed understanding these
recommendations.
>> Chronic issues:
# Hypertension: He was hypotensive after intubation and after
initiating a propofol infusion, so his home antihypertensives
were held. After stopping the propofol on arrival to the MICU,
his blood pressures normalized and he was restarted on
amlodipine and HCTZ at his home doses. Aspirin was restarted as
well. He may need another alternative non-ACE-I blood pressure
medication to optimize out-patient blood pressure control; this
decision was deferred to his primary care physician.
# Hyperlipidemia: We continued his home simvastatin at 20mg
q24h.
# Depression/Anxiety: We continued his home citalopram.
>> Transitional issues:
- ALLERGY TO ACEIs was added to his medical record and clearly
communicated to him.
- f/u with primary care physician, particularly with regard to
longitudinal blood pressure control (specifically to assess the
need to start another antihypertensive given Lisinopril has been
stopped.)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Amlodipine 10 mg PO DAILY
5. Citalopram 10 mg PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Citalopram 10 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Simvastatin 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Angioedema from lisinopril
hypertension
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 while you were in the
hospital. You were admitted to the ICU after developing acute
swelling of your tounge and throat. This was felt to be related
to your lisinopril and you should avoid this medication or any
other ACE-inhibitor at all costs. You were given medications to
reduce the swelling in your throat and did well. You were
extubated and discharged home after your voice returned.
IT IS EXTREMELY IMPORTANT that if you develop any wheezing,
trouble swallowing, changes in your voice or difficulty
breathing you return to the closest emergency room IMMEDIATELY!
Followup Instructions:
___
|
10880723-DS-16
| 10,880,723 | 20,968,184 |
DS
| 16 |
2203-08-23 00:00:00
|
2203-08-23 17:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
LP ___
History of Present Illness:
___ year old female with chief complaint of presents with altered
mental status and headache. Patient has a history of metastatic
breast cancer with intracranial metastases. She has had a
chronic
headache as a result of this. Her husband last saw her normal
around 4 ___. Earlier in the day, she been acting normally and
walking with a steady gait. The husband arrived home between 7
and 8 ___ to find her very confused, having difficulty walking,
difficulty with word finding.
In the ED, patient was clearly confused, on review of systems
she
endorsed headache confusion, she complains of word finding
difficulty. Endorses clumsiness. She denies fever and chills.
She
denies double vision, blurry vision, seizure. Denies any other
complaints.
Full labs in ___
CTH up, stable edema / findings c/w prior
tox, lactate neg
Na 128
1x episode emesis in ED NBNB but MAES, stable neuro exam
A&O to self only, does not know date or birthday
On arrival to the floor, patient continues to state "I don't
know" to questions, though is able to respond to commands.
History obtained further from husband ___ who notes similar
behavior in the ED, as well as past episodes of confusion.
Past Medical History:
PAST ONCOLOGIC HISTORY:
(per last visit with Dr ___ in ___
___ when she found a lump in her left breast. She
underwent a mastectomy and there were ___ lymph nodes positive
for malignant cells. The tumor was estrogen receptor positive
as
well. She underwent adjuvant chemotherapy with ___,
M.D. at ___. She received Adriamycin and cyclophosphamide, followed
by taxol and chest irradiation. She completed Taxol and chest
irradiation in ___. She experienced balance problems two
weeks later. When she walked she was veering to the right. She
also experienced word-finding difficulty and right upper
extremity weakness.
CT head showed multiple brain mets. She had:
(1) Whole brain cranial irradiation from ___ to ___,
(2) s/p aspiration of 2 brain cysts by ___, M.D. on
___,
(3) s/p Cyberknife radiosurgery on ___ to a left frontal
metastasis (2,000 cGy) and to a left posterior frontal tumor
(2,000 cGy),
(4) s/p Cyberknife radiosurgery on ___ to a right parietal
(2,000 cGy) and a right temporal (2,000 cGy) lesion in one
fraction each to 75% isodose line,
(5) ASL MRI on ___ showed hyperperfusion in the right
temporal lobe,
(6) Thallium SPECT on ___ showed increased uptake of
radionuclide in the right temporal lobe,
(7) FDG-PET on ___ did not show any increase in uptake in
the right temporal lobe,
(8) status stereotaxic brain biopsy of the right temporal lobe
showing recurrent metastasis on ___ ___,
(9) status post CyberKnife radiosurgery to the right temporal
metastasis on ___ to ___ cGy at 77% isodose line,
(10) admission to the Neurosurgery Service from ___ to
___ for headache, and
(11) admission to the OMED Service on ___ for headache and
nausea, her head MRI from ___ showed increased enhancement
in the right temporal white matter and adjacent cerebral edema.
PAST MEDICAL HISTORY:
Breast cancer with metastases to the brain
Social History:
___
Family History:
FAMILY HISTORY:
No family history of malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
VITAL SIGNS: VSS
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
supple
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent, no dysarthria, cannot recall symptoms
earlier today, symmetric smile, tongue midline, has hard
time following instructions for UE and ___ strength but is
able to lift both up off the bed w/o limitation and w/o
evidence of assymetric
Psych: calm, cooperative, confuse
___: No petechiae
DISCHARGE PHYSICAL EXAMINATION
VS: 97.8 ___ 45-58 16 99RA
General: NAD, A&Ox3, conversive, appropriate
HEENT: NC/AT, PERRL, EOMI, MMM, tongue midline on protrusion,
symmetric palatal elevation
Chest: Clear to auscultation, no w/r/r
CV: RRR, no m/r/g
Abd: Soft, Nontender, Nondistended; BS+
Extr: Warm, Well perfused, no pitting edema b/l
Skin: warm, dry, no appreciable rash; R anterior port not
accessed
Neuro: Speech fluent, no dysarthria, only answering yes/no.
Symmetric smile, moving all extremities well, able to keep b/l
___
up against gravity.
ACCESS: PIV, R anterior chest port
Pertinent Results:
ADMISSION LABS
___ 01:25PM BLOOD WBC-4.1 RBC-3.77* Hgb-10.5* Hct-31.5*
MCV-84 MCH-27.9 MCHC-33.3 RDW-14.0 RDWSD-42.5 Plt ___
___ 01:25PM BLOOD AbsNeut-2.57
___ 12:50AM BLOOD Neuts-78.5* Lymphs-14.1* Monos-5.8
Eos-0.7* Baso-0.5 Im ___ AbsNeut-6.46*# AbsLymp-1.16*
AbsMono-0.48 AbsEos-0.06 AbsBaso-0.04
___ 01:25PM BLOOD Plt ___
___ 12:50AM BLOOD ___ PTT-30.3 ___
___ 12:50AM BLOOD Plt ___
___ 07:25AM BLOOD Plt ___
___ 04:07PM BLOOD ___ 01:25PM BLOOD UreaN-13 Creat-0.7 Na-128* K-4.5 Cl-92*
HCO3-25 AnGap-16
___ 12:50AM BLOOD Glucose-86 UreaN-13 Creat-0.7 Na-127*
K-4.0 Cl-92* HCO3-25 AnGap-14
___ 07:25AM BLOOD Glucose-84 UreaN-11 Creat-0.6 Na-128*
K-4.2 Cl-93* HCO3-26 AnGap-13
___ 12:50AM BLOOD ALT-14 AST-31 AlkPhos-45 TotBili-0.2
___ 12:50AM BLOOD Lipase-23
___ 12:50AM BLOOD cTropnT-<0.01
___ 01:25PM BLOOD Albumin-4.0
___ 12:50AM BLOOD Albumin-4.3 Calcium-9.0 Phos-3.2 Mg-2.1
___ 07:25AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.1
___ 12:50AM BLOOD Osmolal-264*
___ 07:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS
___ 05:07AM BLOOD WBC-8.6 RBC-3.81* Hgb-10.3* Hct-32.0*
MCV-84 MCH-27.0 MCHC-32.2 RDW-13.9 RDWSD-42.9 Plt ___
___ 04:07PM BLOOD Neuts-93.2* Lymphs-4.6* Monos-1.8*
Eos-0.0* Baso-0.0 Im ___ AbsNeut-11.59*# AbsLymp-0.57*
AbsMono-0.22 AbsEos-0.00* AbsBaso-0.00*
___ 05:07AM BLOOD Plt ___
___ 05:21AM BLOOD Plt ___
___ 05:07AM BLOOD Glucose-83 UreaN-13 Creat-0.6 Na-136
K-3.6 Cl-100 HCO3-28 AnGap-12
___ 04:07PM BLOOD LD(LDH)-154
___ 05:07AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.2
___ 05:07AM BLOOD Phenyto-<0.8*
__________________________________________________________
___ 10:40 am CSF;SPINAL FLUID TUBE 3.
VIRAL CULTURE (Pending):
__________________________________________________________
___ 10:40 am CSF;SPINAL FLUID TUBE 3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary):
__________________________________________________________
___ 10:40 am CSF;SPINAL FLUID TUBE 3.
**FINAL REPORT ___
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Test performed by Lateral Flow Assay.
Results should be evaluated in light of culture results
and
clinical
presentation.
__________________________________________________________
___ 5:21 am BLOOD CULTURE Source: Line-Port.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 12:27 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
__________________________________________________________
___ 12:27 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH
SKIN AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 10:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 1:30 pm URINE Site: NOT SPECIFIED
GRAY TOP HOLD # ___ ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 1:00 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 12:50 am BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING:
___ Head CT (___) - persistent edema, no acute changes
___ CXR: Silhouette sign of the left heart border and left
basilar opacity may be due to aspiration, given the clinical
setting.
___ MRI Head: IMPRESSION:
1. Unchanged metastatic parenchymal and calvarial disease as
described above. No new lesions.
2. No interval change in degree of surrounding FLAIR white
matter
edema pattern.
3. No acute infarct or intracranial hemorrhage.
4. Equivocal FLAIR hyperintense signal of the left parietal and
occipital lobe, not confirmed on other sequences, and felt to be
almost certainly artifact. However, if patient's symptoms
persists, repeat MRI could be performed to document persistence
of the finding.
___ EEG
This is an abnormal continuous video-EEG monitoring study due to
the presence of rare isolated left temporal and left posterior
quadrant sharp waves, suggesting a possible focus of
epileptogenesis in the left hemisphere, as well as continuous
focal slowing over the left hemisphere and a slow, disorganized
background, indicating focal cerebral dysfunction as from a
structural lesion on the left side as well as more widespread
cerebral dysfunction. There are no pushbutton activations or
electrographic seizures. Compared to the prior day`s recording,
this study was largely unchanged.
Brief Hospital Course:
___ y/o woman with PMH of metastatic breast cancer s/p chemo/rads
with known intracranial metastases and possible recent tumor
progression, presenting with acute onset altered mental status
likely ___ seizure.
#Seizure, altered mental status: pt w/known metastatic disease
to the brain from breast CA, currently on Avastin. Infectious
workup negative. Underwent LP which showed normal CSF studies,
cytology negative. MRI brain showed unchanged metastatic
parenchymal and calvarial disease, no new lesions. EEG showed
rare isolated left temporal and left posterior quadrant sharp
waves, suggesting a possible focus of epileptogenesis in the
left hemisphere, as well as continuous focal slowing over the
left hemisphere and a slow, disorganized background, indicating
focal cerebral dysfunction as from a structural lesion on the
left side as well as more widespread cerebral dysfunction.
Initial presenting AMS very likely due to seizure. Started on
keppra 750mg IV q8H, transitioned to 1500mg PO BID for discharge
home. Started Dex 6mg IV q6H during hospitalization, tapered to
4mg PO QAM at time of discharge in the setting of stable
cerebral edema no worse than prior imaging. continued PPX while
on Dex with PPI daily and ISS. Patient returned to baseline
mental status during hospitalization. She was A&Ox3, NAD,
walking in hallways with ___ assistance prior to discharge.
Evidence of some imbalance and deconditioning with walking, pt
will need home ___ services after discharge.
# Metastatic Breast CA: hx of metastatic breast CA without
systemic disease outside of CNS as recently as ___ year ago. No
active therapy apart from bevacizumab for necrosis related
edema. Per o/p oncologist, Dr. ___ pursue CT torso
and bone scan for restaging once acute ams is resolved or
stabilized. Patient will follow up closely with Dr. ___
Dr. ___.
# Concern for aspiration: Patient on CXR had possible opacity
with concern for aspiration. Patient had no symptoms of PNA,
pneumonitis, or respiratory distress otherwise. Afebrile
throughout admission. No indication for treatment given low
level of suspicion for active infection.
# Hyponatremnia, mild, chronic: Patient with baseline sodium of
high 120's. Unclear etiology with possible differential
including central (SIADH), which would fit with euvolemic volume
status. Patient does not appear to be taking in significant
water to
suggest primary polydipsia. Relative decrease in sodium/solute
to free water intake could also explain this on chronic basis.
Low serum osm, high urine osm with elevated urine Na consistent
with concentrated urine output and inappropriate solute
diuresis, consistent with SIADH. Patient's Na WNL at time of
discharge (136).
CHRONIC/STABLE/RESOLVED PROBLEMS:
# Depression: continued home escitalopram, which is being held
I/s/o unknown cause for AMS
# Vitamin Supplementation: Continued home VitC, VitD, and VitB12
TRANSITIONAL ISSUES:
=============================
#Started on dexamethasone while inpatient; discharged on
dexamethasone 4mg PO daily. Will follow up with neuro oncology;
may consider discontinuing at that time (patient started on
dexamethasone empirically in house; however imaging showed no
cerebral swelling)
# Will follow up with Dr. ___ Bevacizumab; will
likely continue regimen (no new contraindication noted in house)
#started on keppra 1500mg PO BID in the setting of likely
seizures
#d/c home with home ___ services for progress balance, gait,
provide family training and education, ___ for 1 week
# given short course Zofran for nausea to continue with home
prochlorperazine
# Urine, blood cx and CSF fungal/enterovirus culture pending on
d/c
#CODE STATUS: FULL CODE (Confirmed with patient's husband)
#EMERGENCY CONTACT: ___ (husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prochlorperazine 10 mg PO Q6H:PRN nausea
2. Omeprazole 20 mg PO DAILY
3. Escitalopram Oxalate 20 mg PO DAILY
4. Ascorbic Acid ___ mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Vitamin B Complex 1 CAP PO DAILY
7. Sodium Chloride 1 gm PO BID
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. Prochlorperazine 10 mg PO Q6H:PRN nausea
3. Ascorbic Acid ___ mg PO DAILY
4. Vitamin B Complex 1 CAP PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth
CONSTIPATION Disp #*30 Capsule Refills:*0
7. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*12 Tablet Refills:*0
8. LevETIRAcetam 1500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 3 tablet(s) by mouth twice a
day Disp #*120 Tablet Refills:*0
9. Dexamethasone 4 mg PO QAM
RX *dexamethasone 4 mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*0
10. Escitalopram Oxalate 20 mg PO DAILY
take 10 mg daily for a week and then start at 20 mg)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
AMS likely secondary to seizures
metastatic breast cancer
known intracranial mets
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 for confusion and altered
mental status. ___ were seen by the oncology team and underwent
evaluation for cause of your altered mental status. An MRI of
your brain showed relatively unchanged cancer. However, ___
started to appear better, and given the nature of your existing
cancer it was deemed most likely that ___ had an unwitness
seizure event, and were confused in the post-ictal ("post
seizure") phase. ___ were started on a new medication, Keppra
(levetcitarem), to prevent seizures in the future. ___ are now
safe for discharge home with close follow up.
It was a pleasure caring for ___ - we wish ___ all the best!
Sincerely,
Your ___ Oncology Team
Followup Instructions:
___
|
10880723-DS-17
| 10,880,723 | 29,827,821 |
DS
| 17 |
2204-03-31 00:00:00
|
2204-03-31 19:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending: ___.
Chief Complaint:
Fall, Bilateral C1 Arch Fractures and C2 Dens Fracture
Major Surgical or Invasive Procedure:
___ - Posterior C1-C2 Fusion
History of Present Illness:
___ yo female with metastatic breast CA presents after fall down
12 stairs and found to have C2 dens fracture and C1 posterior
and anterior arch fractures.
HPI: ___ (___ ___) is a ___
year old female with history of metastatic breast cancer
including brain lesions and seizures who was found down at the
bottom of 14 stairs. The fall was unwitnessed, but family
reported hearing the fall. They called ___ and per EMS, there is
a question of seizure at the time of her fall; she appeared
post-ictal on EMS evaluation. She was transported to ___ ED
where a CT C-spine was concerning for oblique fracture through
the base of the dens, with 4mm retropulsion and undisplaced left
and right C1 arch fractures possibly extends to involve the
right occipital condyles. The patient is unable to provide
history or participate in full exam due to baseline poor
cognition. She has a 1:1 sitter at bedside for restlessness.
Imaging reviewed with family. Goals of care discussion was had
with family. The patient is full code. They are amenable to
pursuing further imaging including MRI even if required
intubation. The are also amenable to surgery if indicated.
Past Medical History:
Left mastectomy ___ ER+ breast cancer.
Metastases to brain
Treated with chemo and chest irradiation through ___.
GERD
Peptic Ulcer disease
Hyponatremia
Seizures
PAST ONCOLOGIC HISTORY:
(per last visit with Dr ___ in ___ when she found a
lump in her left breast. She underwent a mastectomy and there
were ___ lymph nodes positive for malignant cells. The tumor
was estrogen receptor positive as well. She underwent adjuvant
chemotherapy with ___, M.D. at ___
___. She received Adriamycin and cyclophosphamide, followed
by taxol and chest irradiation. She completed Taxol and chest
irradiation in ___. She experienced balance problems two
weeks later. When she walked she was veering to the right. She
also experienced word-finding difficulty and right upper
extremity weakness.
CT head showed multiple brain mets. She had:
(1) Whole brain cranial irradiation from ___ to ___,
(2) s/p aspiration of 2 brain cysts by ___, M.D. on
___,
(3) s/p Cyberknife radiosurgery on ___ to a left frontal
metastasis (2,000 cGy) and to a left posterior frontal tumor
(2,000 cGy),
(4) s/p Cyberknife radiosurgery on ___ to a right parietal
(2,000 cGy) and a right temporal (2,000 cGy) lesion in one
fraction each to 75% isodose line,
(5) ASL MRI on ___ showed hyperperfusion in the right
temporal lobe,
(6) Thallium SPECT on ___ showed increased uptake of
radionuclide in the right temporal lobe,
(7) FDG-PET on ___ did not show any increase in uptake in
the right temporal lobe,
(8) status stereotaxic brain biopsy of the right temporal lobe
showing recurrent metastasis on ___ ___,
(9) status post CyberKnife radiosurgery to the right temporal
metastasis on ___ to ___ cGy at 77% isodose line,
(10) admission to the Neurosurgery Service from ___ to
___ for headache, and
(11) admission to the OMED Service on ___ for headache and
nausea, her head MRI from ___ showed increased enhancement
in the right temporal white matter and adjacent cerebral edema.
Social History:
___
Family History:
Daughter (from first husband) deceased ___ years old - melanoma.
Physical Exam:
========================
Admission Physical Exam:
========================
O: BP: 134/66 HR: 95 R: 16 O2Sats: 96% RA
Gen: WD/WN, restless in bed. 1:1 sitter at bedside. Generally
comfortable. Stated "I don't know" when asked if in pain. NAD.
HEENT: Pupils: PERRL. EOMs intact.
Neck: In hard cervical collar.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert. Poor participation in entire
exam given poor mental status at baseline. Follows some simple
commands. Answers "I don't know" to many questions. Restless and
has a sitter at bedside for safety.
Orientation: Oriented to self only.
Language: Occasionally yells out. Occasional paraphasic errors.
Unable to name objects.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2mm
bilaterally. Unable to accurately test visual fields.
III, IV, VI: Unable to accurately test EOMs.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Moving all extremities spontaneously, purposefully and
antigravity. Able to resist on all extremities but difficult to
obtain dedicated motor exam.
Sensation: Denies numbness and tingling.
Reflexes: B Br Pa Ac
Right 3+ 2+ 1+ 1+
Left 2+ 2+ 2+ 1+
Toes upgoing bilaterally
========================
Discharge Physical Exam:
========================
VS: Temp 97.6, BP 105/62, HR 87, RR 16, O2 sat 99% RA.
General: Lying in bed, in no acute distress.
HEENT: EOMI, PERRLA, moist mucous membranes.
Heart: RRR, S1 and s2 heard, no murmurs.
Lungs: Bilateral air entry present. No crackles heard.
Abdomen: Soft, non-tender, non-distended, normoactive bowel
sounds.
Extremities: No edema. She can move the legs very well and kicks
them out when asked to. ___ shows good movements on commands.
RUE able to lift off bed and grasp but weaker than right.
Neuro: A&Ox2 (name, when asked year states her birthday of ___,
___, often responds with birth date to questions but
answers correctly with prompting, ___ and ___ forward, and
counting back from 10. No facial droop. Symmetric smile.
Pertinent Results:
===============
Admission Labs:
===============
___ 04:45AM BLOOD WBC-7.2 RBC-4.20 Hgb-10.6* Hct-33.9*
MCV-81* MCH-25.2* MCHC-31.3* RDW-15.1 RDWSD-44.6 Plt ___
___ 04:45AM BLOOD Neuts-74.0* Lymphs-14.5* Monos-9.1
Eos-1.1 Baso-0.3 Im ___ AbsNeut-5.37 AbsLymp-1.05*
AbsMono-0.66 AbsEos-0.08 AbsBaso-0.02
___ 04:45AM BLOOD ___ PTT-29.6 ___
___ 04:45AM BLOOD ___
___ 04:45AM BLOOD Glucose-120* UreaN-13 Creat-0.8 Na-131*
K-3.7 Cl-92* HCO3-21* AnGap-22*
___ 04:45AM BLOOD ALT-50* AST-61* AlkPhos-75 TotBili-0.3
___ 04:45AM BLOOD Lipase-23
___ 04:45AM BLOOD cTropnT-<0.01
___ 04:45AM BLOOD Albumin-4.2 Calcium-8.8 Phos-2.5* Mg-2.1
___ 04:54AM BLOOD Glucose-115* Lactate-0.9 Na-133 K-3.5
Cl-96
___ 04:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
==============
Interval Labs:
==============
___ 01:12PM BLOOD Ammonia-48
___ 02:06AM BLOOD TSH-1.7
___ 04:45AM BLOOD Prolact-48*
___ 02:06AM BLOOD T4-5.8
___ 04:37AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative
___ 05:52AM BLOOD HCV Ab-Negative
===============
Discharge Labs:
===============
___ 05:00AM BLOOD WBC-6.1 RBC-2.98* Hgb-7.4* Hct-24.2*
MCV-81* MCH-24.8* MCHC-30.6* RDW-15.9* RDWSD-47.3* Plt ___
___ 05:00AM BLOOD Glucose-95 UreaN-12 Creat-0.5 Na-134
K-4.4 Cl-96 HCO3-29 AnGap-13
=============
Microbiology:
=============
___ Urine Culture - No Growth
___ Urine Culture - Pan-Sensitive E. Coli
___ Blood Culture x 2 - No Growth
========
Imaging:
========
___ Pelvis XRay
1. No focal consolidation, pleural effusion, or pneumothorax.
Within the limitations of chest radiography, no evidence of
acute bony injury in the thorax.
2. No evidence of pelvic fracture or hip dislocation.
3. Please refer to the torso CT report of the same date for
further findings.
___ CT Cervical Spine
1. Limited study due to motion. Acute oblique fracture through
the base of the dens, with 4 mm retropulsion of the proximal
fracture fragment and mild prevertebral swelling. Mild spinal
canal narrowing at this level.
2. Undisplaced fracture of the left C1 arch and the right C1
arch, where it possibly extends to involve the right occipital
condyles (2:13).
___. Severely limited study due to motion artifact. No definite
acute intracranial hemorrhage detected.
2. White matter edema in the left frontal, parietal and
occipital lobes, in the context of given history of brain
malignancy, for which further details are not currently
available.
3. Encephalomalacia in the right temporal lobe, with ex vacuo
dilatation of the occipital horn of the right lateral ventricle.
4. Diffusely mottled calvarium, concerning for osseous
metastatic disease.
___ CT Torso
1. Evaluation of the bony pelvis and hips was severely limited,
due to patient motion. However, no evidence of pelvic fracture.
There is no free fluid in the pelvis or adjacent muscular
hematoma at this level. No evidence of injury to the pubic
symphysis or sacroiliac joints.
2. Superior endplate deformities of T9 and T12 are of
indeterminate age. Comparison with outside hospital films, when
able to be obtained, is advised.
3. No evidence of visceral injury abdomen or pelvis.
___ MRI Cervical Spine
1. Acute oblique fracture through the base of the dens with 4 mm
retropulsion of the proximal fracture fragment.
2. Prevertebral soft tissue edema extending from the clivus to
C5 with questionable ligamentous injury of the anterior
longitudinal ligament at C2.
3. Mild posterior paraspinal soft tissue edema.
4. Mild degenerative changes of the cervical spine.
5. No evidence of cord compression, hematoma, osseous metastasis
or abnormal enhancement.
6. Please see the same day brain MRI for further evaluation of
brain lesions.
___ Brain MRI
1. Multiple brain lesions with surrounding FLAIR hyperintensity,
some of which demonstrate internal hemorrhagic content, cystic
appearance, and enhancing nodularity, as detailed above.
Findings are suspicious for brain metastasis. While the lesions
are somewhat atypical the could still be consistent with
metastatic disease given the multiple areas of involvement.
However, some of these lesions demonstrate minimal or no
enhancement and clinical correlation recommended to exclude any
prior treatment for metastatic disease.
2. Mild mass effect on the left lateral ventricle without
midline shift.
3. Osseous infiltration adjacent to the largest enhancing medial
left
occipital lobe lesion. Superimposed diffuse heterogeneity of
the marrow,
suspicious for diffuse osseous metastasis.
4. Pachymeningeal enhancement, more prominent posteriorly.
5. Suspicious enhancing lesion within the left middle ear cavity
(100 a: 54) measuring 5 mm.
6. Multiple foci of microhemorrhage within bilateral cerebral
and cerebellar hemispheres, which may be related to hypertension
or possible amyloidosis. Possibility of previously treated
hemorrhagic metastasis is not entirely excluded, although there
is no discrete surrounding FLAIR abnormality or enhancement.
7. Bilateral mastoid air cells opacification; correlate for
infectious or
inflammatory process.
___ Cervical CTA
CTA neck: The vertebral arteries are patent along their course,
without
evidence of dissection or occlusion. The internal carotid
arteries are also patent, without evidence of dissection,
occlusion, or aneurysm.
CHEST (PORTABLE AP) Study Date of ___ 5:26 AM
IMPRESSION: No previous images. The endotracheal tube extends
into the right mainstem bronchus. Right IJ catheter tip is in
the region of the cavoatrial junction. No evidence of acute
pneumonia, vascular congestion, or pleural effusion.
___ CXR
1. Interval retraction of endotracheal tube out of right
mainstem bronchus, now terminating 1 cm above the carina.
Further retraction of the endotracheal tube by approximately 1-2
cm may allow for superior ventilation.
2. No significant change in cardiopulmonary findings since prior
examination at 05:27.
CHEST (PORTABLE AP) Study Date of ___ 4:22 AM
IMPRESSION: There has been placement of a new endotracheal tube
whose distal tip is 2.1 cm above the carina. This could be
pulled back 1-2 cm for more optimal placement. There is an
unchanged right-sided Port-A-Cath with the distal lead tip at
the cavoatrial junction. Heart size is within normal limits.
There is no focal consolidation. There has been improvement of
the pulmonary interstitial markings. Surgical clips are seen at
the left lung base. There are no pneumothoraces.
CT C-SPINE W/O CONTRAST Study Date of ___ 3:57 ___
IMPRESSION: The patient is status post C1-C2 fusion for a
transverse C2 fracture with persistent 0.4 cm posterior
displacement of the dens. Suggestion of additional hairline
nondisplaced fractures of the left lateral mass of C2, and right
C6 lamina. New asymmetric opacity in the left leg apex is
indeterminate, may represent infection or posttreatment change
follow-up chest CT in 8 weeks is recommended
CHEST (PORTABLE AP) Study Date of ___ 8:18 AM
IMPRESSION: Serial radiographs demonstrate placement of the
Dobhoff tube with tip and sideport in the body the stomach.
Endotracheal tube and right-sided Port-A-Cath tips are unchanged
in position and appropriately sited. Heart size is within normal
limits. There is no focal consolidation, large pleural
effusions, or pneumothoraces.
CT HEAD W/O CONTRAST Study Date of ___ 2:56 ___
1. Intracranial metastases were better seen on MRI ___. There is minimally more prominent low-attenuation change
in the left occipital lobe, with previously seen metastasis
developing punctate focus of high attenuation, which may
represent calcification or microhemorrhage. Remaining
intracranial changes are stable.
2. There is stable calvarial appearance, consistent with diffuse
osseous
metastases.
3. Fluid in the paranasal sinuses,, mastoid air cells, is likely
from nasal, oral tube use.
___ Chest xray
Stable and appropriate positioning of monitoring and support
devices without radiographic evidence of acute cardiopulmonary
abnormality.
___ CXR
In comparison with the study of ___, the monitoring and
support devices are stable. There are lower lung volumes but no
evidence of acute pneumonia, vascular congestion, or pleural
effusion. Mild atelectatic changes are seen at the left base.
___ CXR
Compared to chest radiographs since ___ most recently
___.
ET tube, transesophageal gastric feeding tube, right subclavian
infusion port catheter, in standard placements respectively.
Lungs clear. Heart size normal. No pleural abnormality.
___ CXR
In comparison with the study of ___, the monitoring and
support devices are stable. The tip of the endotracheal tube
measures approximately 3 cm above the carina. The left
hemidiaphragm is not as sharply seen, consistent with small
pleural effusion and mild atelectatic changes at the left base.
___ CXR
1. Interval removal of the endotracheal tube.
2. Satisfactory location of right chest wall port catheter tip
and enteric
tube.
___ Liver/Gallbladder US
1. Unremarkable right upper quadrant ultrasound. No biliary
dilatation.
2. Unchanged 2.6 cm bilobed simple appearing cyst within segment
8 of the
liver.
___ CT Head w/o Contrast
1. Multiple intracranial and calvarial metastases, grossly
stable in appearance compared to the prior study.
2. No CT evidence of acute infarction.
3. Fluid within the paranasal sinuses and mastoid air cells,
likely secondary to nasogastric tube use.
___ Right Shoulder X-Ray
Impression: No acute fracture or dislocation.
Brief Hospital Course:
The patient presented to the emergency room after falling down a
flight of stairs. She was found to have right and left C1 arch
fractures and C2 Dens fracture. The patient was kept in a
cervical collar and admitted for further work up and surgical
planning.
# C1 Arch/C2 Dens Fracture: Patient placed in SOMI brace for
unstable fractures. Pt is confused and agitated due to brain
metastasis. A discussion was had with her sister the HCP about
options and given that she would likely not tolerate the SOMI
brace decision was to proceed with surgery. She was intubated in
order to obtain MRIs and CTA for surgical planning. She
underwent C1/2 posterior fusion on ___. Post-operatively she
was given 10mg IV decadron x1 for airway edema with goal to
extubate. A CT c-spine shows that the hardware is intact and in
good alignment. Her JP drain was removed on ___. She will
need to follow-up four weeks from surgery with Neurosurgery and
repeat cervical spine CT.
# Respiratory Compromise: She was extubated on ___ however
required reintubation due to somnolence and concern for airway
protection. In attempt to improve some airway edema the patient
was given a dose of decadron and will continue on a course for 1
week. On ___ the patient exam improved and she was able to
be extubated without re-intubation. No other breathing issues
till date
# Breast Cancer with Brain Metastasis/Cerebral Edema: CT on
admission showed right encephalomalacia and left
parietal/occipital cerebral edema. Neurology was consulted and
there were no recommended changes for her oncological care in
the acute setting. She was continued on her Keppra and decadron.
MRI brain revealed multiple brain lesions. A CT head was
obtained for R arm weakness and was stable on ___. EEG
remained negative for seizures. Her decadron was weaned. She
will follow-up with her Oncologist.
# Transaminitis: LFTs were elvated on ___. Her ceftriaxone
was discontinued and she was started on MacroBID for UTI. Liver
US was negative of obstruction. LFTs were monitored nad
continue to trend down. Medicine was consulted and think this is
likely shock liver and should resolve. LFTs improved at time of
discharge.
# Hyponatremia: Pt has chronically low Na typically around 133.
Thought to be from ___ in the past. On admission trended down
to 129. Since she was started on NACL tabs she has since
normalized. Started 200cc water flush Q 6 so she can get some
free water. She was continued on sodium tabs at time of
discharge. Her sodium had normalized to 134 at time of discharge
# RUE Weakness: New since post surgery. CT head was ordered
which did not reveal any acute stroke. Right Shoulder XR ruled
out fracture. ___ be resolving neurological injury secondary to
fracture of C1 vertebra. Needs stretches to prevent
contractures. Physical therapy was consulted. Her right upper
extremity weakness was improving at time of discharge.
# Toxic Metabolic Encephalopathy/Delirium: Due to metastatic
lesions + age + stress from major surgery and hospitalizations
as well as background poor substrate due to previous brain
radiation and mild cognitive impairment. Treated adequately for
her E coli pansensitive UTI with ceftriaxone for 7 days total.
Slow recovery but she is moving in the right direction. CTH
shows no acute changes or stroke. Her mental status continued at
time of discharge. She was started on zyprexa QHS to help with
sleeping.
# E. Coli UTI: Patient completed 7-day course of ceftriaxone.
# Poor PO Intake/Dysphagia: She was initially on tube feeds due
to poor PO intake. Her PO intake is limited predominantly due to
her delirium and poor attention. She is also somewhat limited by
her RUE weakness. She was evaluate by Speech and Swallow and
cleared for regular diet with thin liquids. She requires
assistance and prompting with eating due to her resolving
delirium with inattention. Please continue to support nutrition.
====================
Transitional Issues:
====================
- Please provide assistance with patient eating. Patient able to
swallow without difficulty and was cleared for regular diet with
thin liquids prior to discharge. Due to resolving delirium with
inattention and right upper extremity weakness patient requires
assistance with oral intake. Please continue to monitor PO
intake and weights to ensure adequate nutrition. If patient does
not continue to improve and take adequate nutrition, please
discuss with family regarding need for feeding tube.
- Patient started on zyprexa 10mg QHS to assist with delirium.
Please continue to monitor and adjust medication as needed.
Please continue to monitor QTc (QTc ___ is 403).
- Patient with increased dose of salt tabs due to hyponatremia.
Sodium normal at 134 at time of discharge. Please continue to
monitor sodium and adjust medication as needed.
- Patient noted to be orthostatic by Physical Therapy prior to
discharge most likely due to severe deconditioning from
prolonged hospitalization and immobility. Please continue to
work with Physical Therapy and Occupational Therapy to regain
strength.
- Please continue to titrate bowel regimen.
- Dexamethasone was held at time of discharge per Neurosurgery
recommendations. If patient reports worsening headaches can
restart dexamethasone 0.5mg daily.
- Please ensure follow-up with Oncology and Neurosurgery.
- Code Status: Full Code
- Contact: ___ (sister/HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Sodium Chloride 1 gm PO BID
2. Escitalopram Oxalate 20 mg PO DAILY
3. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
4. LevETIRAcetam 1500 mg PO BID
5. Dexamethasone 0.5 mg PO DAILY
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
7. Restasis 0.05 % ophthalmic BID
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Bisacodyl ___AILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. OLANZapine (Disintegrating Tablet) 10 mg PO QHS
5. Senna 8.6 mg PO BID
6. LevETIRAcetam Oral Solution 750 mg PO QAM
7. LevETIRAcetam Oral Solution 1250 mg PO QPM
8. Sodium Chloride 2 gm PO BID
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
10. Escitalopram Oxalate 20 mg PO DAILY
11. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
12. Restasis 0.05 % ophthalmic BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Right and Left C1 Arch Fracture
- Displaced Dens Fracture
- Urinary Tract Infection
- Hyponatremia
- Elevated LFTs
- Metastatic Breast Cancer
- Toxic-Metabolic Encephalopathy/Delirium
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital
after a fall at home. You were found to have a cervical fracture
and had surgery to repair this. You were then monitored in the
ICU and were also found to have a urinary tract infection. You
continued to improve and got stronger. You are being discharged
to rehab to help get stronger.
All the best,
Your ___ Team
Followup Instructions:
___
|
10881070-DS-10
| 10,881,070 | 25,417,041 |
DS
| 10 |
2154-01-01 00:00:00
|
2154-01-02 07:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
cardiac arrest, seizure
Major Surgical or Invasive Procedure:
- none
History of Present Illness:
___ y/o female with hx of HCV s/p recent bowel perforation 1
month ago surrounding a complicated ERCP presents s/p report of
cardiac arrest and seizures.
Per report, patient was at home with her sister when she
___ a seizure. The patient has been feeling lethargic for
the last several days, and today was found by her sister to be
"shaking" on the couch with seizure like activity, clenching her
jaw with staring and rigid posturing. Her sister called the
neighbor over who is an MA, and no pulse could be palpated so
CPR was intiated and 911 was called. Emergency responders
arrived, the patient was placed on an AED and had reportedly two
shocks with return of spontaneous circulation. During this
time, patient started to have seizues with bladder incontinence.
She was taken to ___ where vitals were BP 132/72, HR
131, satting 100% on RA with no recroded RR. Patient was
intubated and given fosphenytoin, phenobarbital, diazepam, and
propfol without resolution of her seizures. EKG at the OSH
showed sinus tachycardia to 133, normal axis, normal intervals,
flattened TW in AvL and V1 with good R wave progression in the
anterior leads. Labs were significant for an EtOH <10, WBC of
37.4 with 28.9 absolute PMN count, HCT of 39.5, plts of 502.
.
In the ED, nursing notes document patient seizing on arrival.
She was given 2 mg of midazolam Initial VS were: temp 102.6,
Labs showed WBC of 24.5, H/H 10.7/33.7, K 2.6, lactate 2.4. ABG
showed ___. Blood cultures were sent. Given continued
sizure activity given another 2 mg of midazolam 10 minutes after
inital dose. Neurology, surgery, and the Post-Arrest team were
consulted. A propofol gtt was titrated to sedation to control
seizure activity. Surgery rec'd a CT A/P which showed stable
positioning of patient's perc drain with minimal resolution of
prior fluid collection and no evidence of new collections or
abscesses. Neuro rec'd to continue the cooling protocol with
EEG, check dilantin level and continue 100mg q8hrs, obtain LP to
eval for infectious source of fevers and seizure, and to
consider loading with Keppra or start midazolam drip if
continued seizures. LP was done which showed no evidence of
infection. Given fevers, she was given vancomycin 1gm, zosyn
4.5gm, acetaminophen 650mg PR, and IV potassium repletion and
sedated with fentanyl and versed. EKG showed shivering artifact
but evidence was ventricular bigeminy and sinus waves. No
troponins were present at time of ICU admission. Cooling
protocal initaited at 0350 hrs with temperature prob in foley
and rectum. Patient was started on fentanyl and midazolam at
this time prior to transfer to the floor. At 4:10 AM pt was
noted to be awake, pulling at lines and tubing with noted
seizure activity, moving extremities but not collowing commands.
Midazolam gtt was uptitrated.
.
On arrival to the MICU, patient is intubated on the vent shaking
with Arctic Sun cooling being underway. Rectal and bladder
temperature probes were affirmed by patient's nurse.
Past Medical History:
Perforated bowel
Heroin Abuse
ERCP on ___
HCV
migraines
Chronic LBP
Anxiety/Depression
CBD stones
Cholilithiasis
History of sphincterotmy complicated by duodenal perforation
Social History:
___
Family History:
Mother and sister with symptomatic cholelithiasis requiring CCY.
Father died in ___ from MI, mother, alive, with alcoholic
cirrhoisis.
Physical Exam:
On admission to ICU:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Coarse to auscultation bilaterally. No wheezes
Abdomen: Abdominal scar located midline. Abdominal distention
with respiratory effort. Bowel sounds present, no organomegaly
appreciated. Purulent drainage from grenade drain on right.
GU: clear urine
Ext: cold to touch with mottled appearance. 2+ pulses. Prior
IV site on dorsum of left hand. PIVs in antecubital vv
bilaterally.
Neuro: Unconscious sedated on vent. Gag reflex. Pupils from 6
to 2-3 mm with light. Right corneal reflex intact, left not
brisk to corneal irritation. Decerabrate posturing. Down going
babinski's b/l with 2+ patellar/bicipital reflexes b/l.
Discharge Exam:
General: pt awake, NAD
Skin: PICC site no erythema, mild crusting, last changed on
___.
HEENT: Sclera anicteric, MMM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended. Surgical incision site intact, no
erythema, no drainage. mild tenderness to palpation over
incision site, tenderness over drain site improved.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: no focal deficits
Pertinent Results:
___ 02:25AM BLOOD WBC-24.5* RBC-3.69* Hgb-10.7* Hct-33.7*
MCV-92 MCH-28.9 MCHC-31.6 RDW-14.1 Plt ___
___ 02:25AM BLOOD Neuts-81.0* Lymphs-13.3* Monos-5.3
Eos-0.2 Baso-0.2
___ 02:25AM BLOOD Plt ___
___ 02:25AM BLOOD ___ 06:28AM BLOOD Glucose-124* UreaN-3* Creat-0.7 Na-145
K-4.1 Cl-112* HCO3-17* AnGap-20
___ 02:25AM BLOOD ALT-17 AST-31 AlkPhos-107* TotBili-0.4
___ 02:25AM BLOOD Lipase-76*
___ 02:25AM BLOOD cTropnT-0.06*
___ 06:28AM BLOOD CK-MB-4 cTropnT-<0.01
___ 01:20PM BLOOD CK-MB-13* MB Indx-1.3 cTropnT-<0.01
___ 03:35PM BLOOD CK-MB-14* MB Indx-1.5 cTropnT-<0.01
___ 09:02AM BLOOD CK-MB-13* MB Indx-1.9 cTropnT-<0.01
___ 06:28AM BLOOD Calcium-7.1* Phos-3.8 Mg-1.1*
___ 07:37AM BLOOD HCG-<5
___ 06:00AM BLOOD Vanco-35.2*
___ 07:00AM BLOOD Vanco-8.5*
___ 06:48PM BLOOD Vanco-7.3*
___ 05:14AM BLOOD Vanco-46.1*
___ 01:07PM BLOOD Vanco-14.1
___ 07:45AM BLOOD Vanco-24.3*
___ 06:00AM BLOOD Phenyto-11.7
___ 10:20PM BLOOD Phenyto-11.5
___ 02:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-POS Tricycl-NEG
___ 03:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-POS Tricycl-NEG
___ 02:32AM BLOOD pO2-139* pCO2-31* pH-7.38 calTCO2-19*
Base XS--5
___ 02:32AM BLOOD Glucose-134* Lactate-2.4* Na-143 K-2.6*
Cl-117*
___ 02:32AM BLOOD Hgb-10.7* calcHCT-32 O2 Sat-98 COHgb-1
MetHgb-0
___ 02:25AM URINE Color-Straw Appear-Clear Sp ___
___ 02:25AM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 02:25AM URINE RBC-13* WBC-8* Bacteri-FEW Yeast-NONE
Epi-<1
___ 03:30AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0
___ ___ 03:30AM CEREBROSPINAL FLUID (CSF) TotProt-37 Glucose-83
___ 04:41AM BLOOD WBC-10.4 RBC-3.44* Hgb-9.9* Hct-31.1*
MCV-90 MCH-28.9 MCHC-31.9 RDW-15.6* Plt ___
___ 04:41AM BLOOD Glucose-109* UreaN-7 Creat-0.4 Na-138
K-4.0 Cl-102 HCO3-28 AnGap-12
___ 04:41AM BLOOD ALT-46* AST-37 AlkPhos-212* TotBili-0.2
___ 04:41AM BLOOD Calcium-8.4 Phos-5.1* Mg-1.7
.
MICROBIOLOGY
___ STOOL C. difficile DNA amplification
assay-NEGATIVE
___ BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
___ BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
___ BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
___ STOOL C. difficile DNA amplification
assay-NEGATIVE
___ STOOL C. difficile DNA amplification
assay-NEGATIVE
___ BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
___ BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
___ BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
___ BILE GRAM STAIN-FINAL; FLUID
CULTURE-{PSEUDOMONAS AERUGINOSA, PSEUDOMONAS AERUGINOSA};
ANAEROBIC CULTURE-NO GROWH
___ URINE URINE CULTURE-NEGATIVE
___ MRSA SCREEN MRSA SCREEN-NEGATIVE
___ CSF;SPINAL FLUID GRAM STAIN-NO ORGANISM;
FLUID CULTURE-NO GROWTH
___ BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE, STAPHYLOCOCCUS
EPIDERMIDIS}; Aerobic Bottle Gram Stain-NO ORGANISM; Anaerobic
Bottle Gram Stain-NO GROWTH
___ BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram
Stain-NO ORGANISM; Anaerobic Bottle Gram Stain-NO GROWTH
.
IMAGING:
___ Radiology MR HEAD W & W/O CONTRAST: No evidence of
intracranial mass, infarction, or infectious process.
Acute-on-chronic inflammatory disease in the left sphenoid air
cell; correlate clinically.
___ Cardiovascular ECHO ___: The estimated right
atrial pressure is ___ mmHg. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size is normal. with
borderline normal free wall function. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
___ Neurophysiology EEG ___: This is an abnormal
continuous ICU monitoring study because of the presence of a few
isolated paroxysmal potential epileptiform transients in the
left central region. Compared to the prior day's recording, this
record shows improvement in background rhythms.
___ Cardiovascular ECHO ___: The left atrium and
right atrium are normal in cavity size. Left ventricular wall
thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with hypokinesis
of the septum and the inferolateral wall. Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
___ Neurophysiology EEG ___: This is an abnormal
continuous ICU monitoring study because of the presence of a
diffuse severe encephalopathy. While the frequencies are in a
range that would suggest reasonable brain activity there
continues to be a reverse anterior posterior gradient. This may
still be the effect of medication and the cooling protocol
itself. It is necessary to monitor this to see if it evolves
into and alpha coma pattern. There also exists multifocal and
independent appearing interictal sharp transients. These also
should be monitored for detection of seizures. In comparison to
the previous today's recording, there does appear to be some
improvement in this record. There is more evident background
activity in the occipital poles. Near the end of the record
there appeared to be some variability to the background
suggesting some cyclic behavior.
___ Radiology CT HEAD W/O CONTRAST: No acute intracranial
pathology. Mucus-retention cyst with aerosolized secretions
within the left sphenoid air cell, with inflammatory changes in
the anterior ethmoidal air cells; correlate clinically.
___BD & PELVIS WITH CO:Residual
rim-enhancing fluid collection in the right posterior perirenal
and pararenal spaces, slightly smaller since ___.
Percutaneous pigtail drainage catheter is appropriately
positioned within this cavity. No new fluid collections.
___ Neurophysiology EEG ___ is an abnormal
continuous ICU monitoring study because of a severe diffuse
encephalopathy with some multifocal interictal epileptic
features. Additionally, there were short runs of semi- rhythmic
activity which may represent brief abortive seizure discharges.
None of them had clinical accompaniments.
Brief Hospital Course:
___ y/o female with Hep C and recent bowel/biliary perforation
s/p ERCP with drain in place who presents s/p reported cardiac
arrest with ROSC after 2 shocks in addition to seizure activity
and clinical pararamaters consistent with sepsis.
.
# Possible VF/VT arrest: Pt was initially brought to OSH s/p
reported cardiac arrest. Events surrounding the event was
unclear. Per report, she had seizures prior to the arrest and
was found with loss of pulse with shockable rhythm. She was
shocked twice. EMS and police were contacted to attempt to
discern her heart rhythm at the time but AED could not be
interrogated. She was intubated at OSH. Post-cardiac arrest
team was consulted. She was started on cooling protocol upon
arriving to ___ MICU and then re-warmed. She was also on
neuromuscular blockade during this time. Trop was initially
0.06 but then downtrended to <0.01. CKs were elevated by MB was
largely unremarkable. Initial TTE showed EF 35-40% with
moderate regional LV systolic dysfunction in a non-coronary
distribution. However, this had been performed while pt was on
cooling protocol was likely unreliable. TTE was later repeated
which showed normal functions in both ventricles. Patient has
been stable since hospitalization.
.
#Sepsis: On admission to MICU, pt met SIRS criteria with fever,
leukocytosis, and tachycardia and also had elevated lactate.
Concern was high for GI source of infection given recent history
of bowel perforation. She had recently completed course of
augmentin/fluconazole prior to admission. She was broadly
covered with vancomycin/zosyn initially. Four sets of blood
cultures from ___ grew staph epi and coag neg staph (not
sensitive to oxacillin). Ob/gyn was also curbsided regarding
possible removal of IUD but did not feel IUD was source of
infection. Her JP drain was sent for culture and grew
pseudomonas sensitive to ciprofloxacin. She was transitioned to
vancomycin and ciprofloxacin PO. She was followed by surgery
for her JP drain. JP drain fell out prior to transfer to
medicine floor; surgery recommended no replacement of drain or
reimaging unless patient was febrile. Patient was seen by ID
while on the floor who recommended her to be switched to IV
ceftazidime for 2 weeks.
Patient had mild increase in WBC and transaminitis during day 11
of hospitalization while on vancomycin and ceftazidime. Repeat
blood cultures and c.diff assay were sent which returned
negative. Patient was asymptomatic during this period and
remained afebrile. Patient completed a 14 day course of
vancomycin on ___ and 2 weeks of IV ceftazidime on ___ with
appropriate decreased in WBC and LFTs. See below for abdominal
abcess.
.
# Seizure - No history of seizures in the past. Urine tox was
positive for barbs and benzos which she had received at OSH.
There was no evidence of IC mass/process on stat head CT.
Lumbar puncture showed no growth in CSF fluid. She was kept on
continuous EEG monitoring initially. This did not show
seizures. She was followed by neurology who recommended
initiation of dilantin 100mg q8H. On week 2 of hospitalization,
patients dilantin level was found to be subtherapeutic and she
was loaded with 1000mg of Dilantin to therapeutic level. Patient
was maintained on 100mg q8H. She will need to follow up with
neurology in 4 weeks.
.
# Bowel perforation - Etiology was due to duodenal perforation
after ERCP. She had been treated with Perc drain in perinephric
space and abx course recently completed. CT A/P in the ED
showed drain in appropriate place and no new evidence for
abdominal catastrophe. Surgery consulted in ED and followed pt
on floor. She was kept on vanc/zosyn initially and switched to
vanc/cipro when JP drain culture grew pseudomonas sensitive to
cipro. JP Drain fell out on ___ surgery recommended no
replacement of drain unless patient is febrile. Patient finished
a 2-week course of IV ceftazidime on ___. Repeat CT of the
abdomen showed only slight decrease in the size of the abdominal
fluid collection. Given this ID and surgery were reconsulted
and recommended drainage. The patient refused to stay in the
hospital for this procedure even after explaining her the high
risk for spreading of the infection, her becoming septic again
and potentially dying from this. She refused to stay as she was
very upset she had to be here for so long and this was not found
earlier. Prior to discharge she was given a prescription for
ciprofloxacin 500 mg BID until she is instructed otherwise by
her PCP or Dr. ___. Appointments were made with these
doctors.
.
# Hep C - last month VL at 72,762 IU/mL. Stable, with LFT's WNL.
.
# Diarrhea: After extubation, pt developed diarrhea associated
with profound electrolyte abnormalities that required frequent
monitoring and repletion. C.diff was negative. She was treated
with loperamide. Diarrhea may have been due to narcotic
withdrawal. She was continued on her home dilaudid for chronic
abdominal pain. Patients diarrhea resolved on its own 4 days
after being on the floor and patient remained asymptomatic off
of loperamide.
.
# Psych: Addictions/social work consult was obtained for
polysubstance abuse, including active IVDU. She appeared quite
depressed with flat affect, had issues with polydipsia (drinking
liters of water daily), and had anorexia. Psych was consulted
who did not think she was at acute risk of harming herself and
her anorexia in the ICU was most likely appetite related.
Patient was initially maintained on a 1.5L fluid restriction but
given well-compensated kidneys and normonatremia, the fluid
restriction was lifted with no issues. Patients appetite
improved progressively during her hospitalization. She was seen
by nutrition who initially recommended ensure puddings then
multivitamins.
.
# IV Access: Pt had difficult IV access. She was maintained on
peripheral IVs while at ICU and ordered for ___ guided PICC
placement while on the floor for the completion of her
antibiotic course. The PICC line was taken out prior to
discharge.
Medications on Admission:
lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY
acyclovir 5 % Ointment Sig: One (1) Appl Topical ASDIR
alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID prn
acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO BID prn
gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H prn pain
amoxicillin-pot clavulanate 500-125 mg Tablet 1 po q12 (just
completed with this admission)
fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 10 days (just completed with this admission)
ZOFRAN ODT 4 mg Tablet 1 po q8hrs prn
Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*16 Tablet(s)* Refills:*0*
2. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO Q8H (every 8 hours).
Disp:*90 Capsule(s)* Refills:*0*
3. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
- Cardiac Arrest
- Seizure
- Intra-abdominal abscess
- Bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to be involved in your care. You were admitted
because your heart stopped and had a seizure.
.
You were initially intubated in the intensive care unit where
you were given medication and cooled to stop your seizures. You
did not have any further seizures during your hospitalization.
You will need to follow up with neurologist (brain doctors) 4
weeks after discharge.
.
Initial image of your heart showed slowing of activities but
that was in the setting of you going through cooling for your
seizures. You had a repeat image after you left the intensive
care unit which showed normal function of your heart.
.
You also had blood cultures which showed a bacteria in your
blood. You were given antibiotics to treat that for 14 days.
You completed your course on ___.
.
You were also found to have an infection in your stomach from
your prior intestine performation. You were given antibiotics
for the infection and you finished that course on ___. You had
a repeat CAT scan of your stomach which showed that the
infection was not completely gone. We recommended you stay in
the hospital for a procedure to drain this infection but you
decided you wanted to be discharged against our advice. We
explained that in doing so this infection might worsen and it
can be catastrophic for your health. Please take the
antibiotics prescribed, see your PCP and Dr. ___
general surgery to have this draining procedure arranged soon.
Medication Changes:
Start: ciprofloxacin 500 mg BID until told to stop by your PCP
or Dr. ___.
Start: phenytoin 100 mg three times a day
Followup Instructions:
___
|
10881485-DS-19
| 10,881,485 | 20,722,174 |
DS
| 19 |
2171-06-24 00:00:00
|
2171-06-26 14:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of
panhypopituitarism who presents with a chief complaint of
weakness and fever x 24 hours and noted to be hypotensive upon
arrival.
Ms. ___ was in her usual state of health until 24 hours ago
when she began to note a dry cough, chills, rigors, myalgias,
and malaise. This worsened gradually over the last 24 hours
until she was noted on the evening of ___ to be lethargic in
bed having soiled herself prompting her family to call ___. Upon
their arrival, she was hypotensive to ___ and was given IVF
in the field with initial improvement.
She and her family deny sick contacts. Although she works as a
___, the children were on vacation for the last week.
Otherwise, she complained of earache last few weeks which was
waxing and waning.
In the ED, initial vs were: 102.3 ___ 18 98%. Labs notable
for elevated WBC to 11.7, ___ with Cr of 3.3, lactate of 2.4.
CXR, CT head were both unremarkable. CT abdomen demonstrated no
acute process. In the ED, she was given Vancomycin, Cefepime,
and 100mg of Hydrocortisone. She was given 4L of normal saline
and started on levophed due to persistent hypotension. R femoral
central line placed after RIJ attempt was aborted due to patient
movement. Waxing and waning mental status downstairs and quite
combative.
Past Medical History:
Panhypopituitarism secondary to ___ syndrome in the setting
of a post-partum hemorrhage
Remote History of Zoster
Social History:
___
Family History:
Mother with hypothyroidism, Father with ___
Physical Exam:
ADMISSION:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE:
VITALS: Afebrile, VSS BP 120s
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION:
___ 08:30PM BLOOD WBC-11.7* RBC-4.46 Hgb-14.3 Hct-43.0
MCV-96 MCH-32.0 MCHC-33.2 RDW-13.0 Plt ___
___ 08:30PM BLOOD Neuts-57.5 ___ Monos-7.3 Eos-0.4
Baso-0.7
___ 08:30PM BLOOD ___ PTT-31.3 ___
___ 08:30PM BLOOD Glucose-76 UreaN-33* Creat-3.3*# Na-139
K-3.9 Cl-103 HCO3-20* AnGap-20
___ 08:30PM BLOOD ALT-128* AST-192* AlkPhos-121*
TotBili-0.6
___ 08:30PM BLOOD Albumin-3.9 Calcium-8.2* Phos-2.7 Mg-1.6
___ 08:30PM BLOOD Cortsol-4.0
___ 08:38PM BLOOD Lactate-2.4*
RADIOLOGY:
___ CXR
No acute cardiopulmonary process.
___ CT A/P
No acute intraabdominal process.
___ CT Head
No acute intracranial process.
ECHOCARDIOGRAPHY
___
Poor image quality. The left atrium is elongated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve is not well seen. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
DISCHARGE LABS:
___ 05:50AM BLOOD WBC-10.2 RBC-3.57* Hgb-11.3* Hct-34.9*
MCV-98 MCH-31.6 MCHC-32.4 RDW-13.2 Plt Ct-96*
___ 05:50AM BLOOD Glucose-102* UreaN-22* Creat-0.8 Na-142
K-3.9 Cl-109* HCO3-23 AnGap-14
___ 05:50AM BLOOD ALT-66* AST-61* LD(LDH)-314* AlkPhos-72
TotBili-0.4
___ 05:50AM BLOOD Albumin-3.1* Calcium-7.8* Phos-3.2 Mg-2.4
___ 08:30PM BLOOD TSH-0.76
___ 08:30PM BLOOD T4-5.7
___ 08:30PM BLOOD Cortsol-4.0
___ 03:02AM BLOOD Lactate-1.7
___ 8:10 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ 2:54 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Refer to respiratory viral antigen screen and respiratory
virus
identification test results for further information.
Respiratory Viral Antigen Screen (Final ___:
Positive for Respiratory viral antigens.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to Respiratory Virus Identification for further
information.
Respiratory Virus Identification (Final ___:
Reported to and read back by ___ ___
11:27AM.
POSITIVE FOR INFLUENZA A VIRAL ANTIGEN.
Viral antigen identified by immunofluorescence.
___ 5:07 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 12:42 am CSF;SPINAL FLUID # 3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of
panhypopituitarism who presents with vasodilatory shock in the
setting of likely adrenal crisis precipitated by influenza.
# Shock: Patient presenting with shock likely secondary to
adrenal crisis in setting of influenza A infection. Patient was
fluid resuscitated, given stress dose steroids, and covered
initially with broad-spectrum antibiotics, oseltamivir, and
acyclovir. She initially required pressors for BP support.
Pressors were discontinued on HD#1. A LP was performed which was
unremarkable, thus acyclovir was discontinued. CT head, abdomen,
and CXR were unremarkable. Patient was found to be (+) for
influenza A on respiratory viral swab and influenza likely
precipitated her adrenal crisis. She will continue a 7 day
course of oseltamivir 75 mg BID (first day ___. Endocrinology
was consulted who provided recommendations about her treatment
course. Endocrinology recommended a steroid taper as follows:
hydrocortisone 50 mg IV Q8H x24 hrs, 25 mg IV Q8H x24 hrs,
prednisone 10 mg x3 days followed by 5 mg x3 days then back to
home dose of prednisone 3 mg daily. Patient was called out to
the medical floor on ___ and her blood pressures remained
stable in the 110s-120s. Antibiotics (vanco/cefepime) were
discontinued on ___ given cultures were negative to date and
patient had no evidence of focal infection besides influenza.
down to 25 mg iv q8 x24 hs today, then hydrocortisone 40mg am,
20 mg pm, then resume home dose).
# Adrenal Crisis: In context of patient's panhypopituitarism,
her hypotension likely represents an adrenal crisis precipitated
by influenza infection. She was followed by endocrine who
recommended stress dose steroid taper as above. Patient was
advised to obtain Medical Bracelet for AI. Patient was
prescribed Solucortef 100 mg injection IM prescription at the
time of discharge for medical emergency.
Patient and family educated by endocrine team re: importance of
having access to prednisone when ill and not missing doses
(doubling instead) when ill.
# Panhypopituitarism: Patient was continued on home
levothyroxine and received stress dose steroids as above. She
received a Solucortef 100 mg injection IM prescription at the
time of discharge for medical emergency.
# ___: Patient presenting with elevated creatinine likley
secondary to vasodilatory shock. Her creatinine downtrended to
normal with IVF.
# Transaminitis: Patient presenting with a transaminitis most
consistent with hypotension. Enzymes trended down without
intervention.
TRANSITIONAL ISSUES
-Please continue to monitor BP
-Please ensure patient completes steroid taper as above
-Please ensure patient has endocrine follow-up
-Please ensure patient has Solucortef injection
-Please follow-up final blood cultures from ___
-Please follow-up final CSF culture from ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 3 mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 50 mcg PO DAILY
2. OSELTAMivir 75 mg PO Q12H
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*8 Capsule Refills:*0
3. PredniSONE 10 mg PO DAILY Duration: 3 Days
Please start on ___.
RX *prednisone 5 mg 2 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
4. PredniSONE 5 mg PO DAILY Duration: 3 Days
Please start on ___
Tapered dose - DOWN
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
5. PredniSONE 3 mg PO DAILY
Please start on ___ and continue thereafter
Tapered dose - DOWN
RX *prednisone 1 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
6. Hydrocortisone Na Succ. 100 mg IV ONCE Duration: 1 Dose
RX *hydrocortisone sod succinate [Solu-Cortef] 100 mg 100 mg SC
once Disp #*1 Vial Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: adrenal crisis, influenza
SECONDARY DIAGNOSES: panhypopituitarism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ was a pleasure taking care of you at ___. You were admitted
with fever and low blood pressure. You were found to have the
flu which likely caused an adrenal crisis (and resulting low
blood pressure) requiring medications to keep your blood
pressure normal and steroids. Please continue to take your
steroid as prescribed.
Please keep your follow-up appointments as below. Please
schedule a follow-up appointment with your primary care
physician and with your endocrinologist within the next ___
weeks. Please return to the emergency room if you experience
fevers, chills, shortness of breath, confusion, muscle aches,
lightheadedness or any other new or concerning symptoms.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
10881690-DS-16
| 10,881,690 | 26,965,003 |
DS
| 16 |
2163-06-18 00:00:00
|
2163-06-18 13:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
morphine / succinylcholine
Attending: ___.
Chief Complaint:
Fevers, R groin pain and discharge
Major Surgical or Invasive Procedure:
___ groin exploration with washout and VAC placement.
___: Right groin washout, rotational sartorius muscle flap
and VAC dressing placement.
History of Present Illness:
This is a ___ female who had a prior cardiac
catheterization that led to V-Fib arrest and Impella device
insertion. During that time, she had some injury to the right
common femoral artery. We were consulted and followed until
removal of Impella device where we had to do a common femoral
endarterectomy on the right common femoral artery with bovine
patch closure. There was also an antegrade femoral line in the
SFA to perfuse the right limb during Impella insertion that was
sutured closed at that time as well. She had a known right
hematoma and this had become grossly infected with the patient
presenting with fevers and chills.
For more details, see Admission note ___
Past Medical History:
1. CARDIAC RISK FACTORS
- hypertension
- hyperlipidemia
- h/o tobacco use
- type 2 diabetes
2. CARDIAC HISTORY
- aortic stenosis
- peripheral vascular disease
3. OTHER PAST MEDICAL HISTORY
- CKD-4
- peripheral vascular disease
- bilateral carotid stenosis
- subclavian arterial stenosis
- low back pain
- tubular adenoma
- migraines
- rectocele
- basal cell carcinoma of nose
- h/o patella fracture
- thyroid nodule
- melanoma in situ of cheek
- tarsal tunnel syndrome
- osteoarthritis of left hip
- h/o C. difficile colitis
- gout
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION
Vital Signs: Temp: 98.7 RR: 18 Pulse: 90 BP: 139/54
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: No masses, Trachea midline.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, No masses, No
hepatosplenomegally, No hernia.
Rectal: Not Examined.
Extremities: Abnormal: Right groin erythema, warmth, tenderness,
induration. right foot drop
DISCHARGE
Vitals: 24 HR Data (last updated ___ @ 746) Temp: 97.9 (Tm
98.3), BP: 146/73 (112-151/59-74), HR: 81 (81-92), RR: 18
(___), O2 sat: 98% (96-99), O2 delivery: RA, Wt: 159.17
lb/72.2 kg
GENERAL: NAD, A/Ox3
CV:RRR
PULM: CTAB, not in respiratory distress
ABD: soft, non tender, non distended, no rebound or guarding
WOUND: [x]CD&I , erythema and induration around wound
improving,
wound vac in place on right groin
EXTREMITIES: b/l lower extremity swelling, right worse than left
PULSES: R: p/p/p/p L: p/p/p/p
Pertinent Results:
___ US femoral
1. Approximately 10 x 5.4 x 5.5 cm complex collection within the
right
inguinal region, likely a hematoma. Infection cannot
definitively be
excluded.
2. No definite pseudoaneurysm identified.
___ US Doppler ___
No evidence of deep venous thrombosis in the visualized right or
left lower extremity veins. Nonvisualized right common femoral
vein due to overlying wound VAC.
___ TTE
Depressed biventricular systolic function with regional wall
motion abnormalities that may suggest mixed ischemic-
nonischemic etiology (possibly stress cardiomyopathy). No
evidence of vegetations.
Discharge labs
___ 06:37AM BLOOD WBC-10.6* RBC-2.68* Hgb-8.1* Hct-26.3*
MCV-98 MCH-30.2 MCHC-30.8* RDW-15.4 RDWSD-54.6* Plt ___
___ 06:37AM BLOOD Glucose-115* UreaN-19 Creat-1.6* Na-139
K-4.3 Cl-103 HCO3-21* AnGap-15
___ 12:43 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Brief Hospital Course:
The patient was admitted to the floor. She was febrile and WBC
16. US of the right inguinal area showed a 10 x 5.4 x 5.5 cm
complex collection, which seemed the be the infectious focus as
all other work-up was negative.
She was taken to the OR on ___ for right groin exploration with
washout and VAC placement followed 48 hours later by right groin
washout, rotational sartorius muscle flap and VAC placement.
She was admitted to the ICU for postoperative monitoring given
her risk of bleeding. Her hospital course was relevant for the
following:
- Bacteremia MSSA: Blood cultures on admission (___) grew MSSA.
Her antibiotics were changed from Vanc/Cipro/Flagyl to Cefazolin
per ID recommendations. TTE showed no evidence of endoscarditis
and TEE was deferred. All other blood cultures have been
negative or not final at the time of discharge. CXR and urine
cultures showed no evidence of infection. ID recommended PICC
placement (48 hours of negative cultures, ___ for 6 weeks of
cefazolin (Start date ___.
- Right groin wound: After operative debridement, the patient
underwent VAC changes every 3 days. At the time of discharge,
the wound was clean and had abundant granulation tissue. There
was no evidence of residual infection or bleeding. R ___ edema
prompted an US that showed no evidence of DVT. ___ was set up to
continue VAC therapy.
- Anemia: The patient required transfusion of 2 units of RBC on
___. The patient continued ASA through her hospitalization and
re-started Brilinta ___. Thereafter, her H/H was stable without
additional blood products transfused.
- ___: The patient was evaluated by physical therapy
that recommended discharge home.
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. All her home medications had been re-started. The
patient was discharged home with ___. 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. Allopurinol ___ mg PO DAILY
2. TiCAGRELOR 90 mg PO BID
3. Furosemide 20 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
8. Rosuvastatin Calcium 10 mg PO QPM
Discharge Medications:
1. Acetaminophen 1000 mg PO QID
2. CeFAZolin 2 g IV Q8H
RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 1 every eight
(8) hours Disp #*126 Intravenous Bag Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Famotidine 20 mg PO Q24H
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
Please hold for loose stools
6. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override:
Please do not drive while taking narcotic pain medication
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*10 Tablet Refills:*0
7. Allopurinol ___ mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Furosemide 20 mg PO DAILY
10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Rosuvastatin Calcium 10 mg PO QPM
13. TiCAGRELOR 90 mg PO BID
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right groin wound infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___
___ were admitted to ___ and
were found to have a right groin infection. ___ went to the
operating room where ___ had the infectious tissue removed, and
a muscle flap to cover the exposed graft. ___ had a wound vac
placed to help aid in faster wound recovery. ___ have now
recovered from surgery and are ready to be discharged home with
services, including home nursing and IV antibiotics. Please
follow the instructions below to continue your recovery:
1. It is normal to feel weak and tired, this will last for ___
weeks
___ should get up out of bed every day and gradually increase
your activity each day
___ may walk and ___ may go up and down stairs
Increase your activities as ___ can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
Wear loose fitting pants/clothing (this will be less
irritating to incision)
Elevate your legs above the level of your heart with ___
pillows every ___ hours throughout the day and at night
Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite
will return with time
___ will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATIONS
Take all the medications ___ were taking before surgery,
unless otherwise directed
Take one Aspirin 81 mg, as well as continue your Brillenta for
your heart
- ___ are being discharged on new medication which includes pain
medication, Tramadol, as well as IV antibiotics. Home nursing
will teach ___ how to administer the IV antibitoics
ACTIVITIES:
No driving until post-op visit and ___ are no longer taking
pain medications
___ should get up every day, get dressed and walk, gradually
increasing your activity
___ may up and down stairs, go outside and/or ride in a car
Increase your activities as ___ can tolerate- do not do too
much right away!
WOUND CARE
___ have a wound vac placed to help aid in wound healing
- The black sponge/dressing should be changed every 2 days
- ___ may shower, keep the area dry, no soaking of the wound
CALL THE OFFICE FOR : ___
Redness that extends away from your wound
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your leg or the
ability to feel your leg
Temperature greater than 101.5F for 24 hours
Bleeding from the wound
New or increased drainage from the wound or white, yellow or
green drainage from the wound
Best Regards,
Your ___ Vascular Surgery Team
Followup Instructions:
___
|
10881703-DS-27
| 10,881,703 | 25,377,804 |
DS
| 27 |
2149-03-14 00:00:00
|
2149-03-14 16:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / Lasix / egg
Attending: ___
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an ___ year old woman with hypertension and history of PE
(on warfarin, s/p IVC filter) who presented with weakness.
She states that she slid out of her chair today and was unable
to get off of the ground because she was too weak. Denies any
head strike or loss of consciousness. Patient not complaining of
pain anywhere. No fevers or chills. Had diarrhea 2 weeks ago
which has since stopped over the last week. Patient denies any
dysuria or frequency. No abdominal pain. One episode of nausea
and vomiting yesterday.
She has had one day of productive cough, with dyspnea (___)
but no chest pain, palpitations, lower extremity edema,
abdominal distension, fevers, chills or sweats.
In the ED, initial vitals were: T 98, BP 113/52, HR 80, R 18,
Spo2 96%/RA
- Exam notable for: Dry oral mucosa. Abdomen benign. No CVA
tenderness.
- Labs notable for: WBC 4.1, Hb 10, proBNP 3308, Cr 1.4, UA
with many hyaline casts, but otherwise contaminated, INR 2.5
- Chest XR showed:
1. Right-sided Port-A-Cath tip terminates at the SVC/right
atrial junction.
2. Patchy left basilar opacity, potentially atelectasis, but
infection or aspiration cannot be excluded.
3. Moderate centrilobular emphysema and probable mild pulmonary
arterial hypertension.
- 1L NS and 1 g ceftriaxone were given.
Given frailty with apparent weakness in the context of
pneumonia and dehydration unlikely to improve enough in the ED.
Will admit for further care.
Upon arrival to the floor, patient reports dyspnea and cough.
Past Medical History:
1. Recurrent GI bleeds (most recent ___
2. Chronic Anemia - receives regular iron infusions
3. HTN Cardiomyopathy EF >75%, functional outflow obstruction
4. s/p Hysterectomy
5. S/p PE's, s/p IVC filter (___), on coumadin
Social History:
___
Family History:
Mother with diabetes, several family members with tuberculosis.
Physical Exam:
ADMISSION
VITAL SIGNS - 98.1 93/50 75 18 92%/RA 58.3 kg
GENERAL - thin, elderly woman, in no distress
HEENT - sclerae anicteric, moist membranes, PERRL
NECK - no JVD, slight dilation of EJ
CARDIAC - regular, normal S1/S2, no murmurs
LUNGS - rhonchi and crackles at the left lung base, otherwise
clear; rhoncorous coughing but no increased work of breathing
ABDOMEN - soft, non-tender, non-distended, normal bowel sounds
EXTREMITIES - warm, no edema
NEUROLOGIC - oriented x3, face symmetric
SKIN - xerosis
DISCHARGE
VITAL SIGNS - 97.4 111/57 67 18 96RA
GENERAL - thin, elderly woman, in no distress
HEENT - sclerae anicteric, moist membranes, PERRL
NECK - no JVD, slight dilation of EJ
CARDIAC - regular, normal S1/S2, no murmurs
LUNGS - rhonchi at the left lung base, otherwise clear
ABDOMEN - soft, non-tender, non-distended, normal bowel sounds
EXTREMITIES - warm, no edema
NEUROLOGIC - oriented x3, face symmetric
Pertinent Results:
ADMSSION LABS
___ 11:00AM BLOOD WBC-4.1 RBC-3.35* Hgb-10.0* Hct-30.1*
MCV-90 MCH-29.9 MCHC-33.2 RDW-13.8 RDWSD-45.6 Plt ___
___ 11:00AM BLOOD Glucose-100 UreaN-35* Creat-1.4* Na-140
K-3.4 Cl-103 HCO3-23 AnGap-17
___ 11:00AM BLOOD proBNP-3308*
___ 11:00AM BLOOD cTropnT-<0.01
___ 05:10PM BLOOD cTropnT-<0.01
DISCHARGE LABS
___ 05:48AM BLOOD WBC-4.1 RBC-2.92* Hgb-8.8* Hct-26.1*
MCV-89 MCH-30.1 MCHC-33.7 RDW-14.0 RDWSD-46.1 Plt ___
___ 05:48AM BLOOD Glucose-93 UreaN-32* Creat-1.0 Na-139
K-3.0* Cl-103 HCO3-23 AnGap-16
___ 05:48AM BLOOD Calcium-7.9* Phos-2.1* Mg-1.4*
MICROBIOLOGY:
___ Blood cultures pending NGTD
___ Urine culture pending NGTD
REPORTS
___
IMPRESSION:
1. Right-sided Port-A-Cath tip terminates at the SVC/right
atrial junction.
2. Patchy left basilar opacity, potentially atelectasis, but
infection or
aspiration cannot be excluded.
3. Moderate centrilobular emphysema and probable mild pulmonary
arterial
hypertension.
Brief Hospital Course:
This is an ___ year old woman with hypertension and history of PE
(on warfarin, s/p IVC filter) who presented with weakness.
# Pneumonia: chronic hemidiagphram elevation on CXR, with ?
patchy infiltrate at left lung base. SpO2 in low-mid ___,
however hyperinflated lungs suggestive of underlying COPD No
leukocytosis or fever, but productive cough with dyspnea. Given
ceftriaxone in ED and started on azithromycin on arrival to the
floor. Ceftriaxone was transitioned to cefpodoxime on discharge.
Plan is for a 1 week antibiotic course.
# Weakness: Patient appears frail, but is independent at
baseline. Her underlying frailty is worsened by this infection.
She was seen by ___, who felt she would benefit from rehab.
# ___: Cr 1.4 on admission, improved to 1.0 with IVF.
Chronic Issues
# Hypertension: Continued home labetalol, Lisinopril and
verapamil
# History of DVT, PE: in ___. Uncertain need for continued
anticoagulation, especially given age & frailty, with risk to
falls. Continued for present time. INR therapeutic. Should be
monitored closely while on azithromycin.
# CODE: DNR/DNI
# CONTACT: ___ - nephew - ___
> 30 minutes were spent on discharge care planning and
coordination
TRANSITIONAL ISSUES:
#Continue cefpodoxime and azithromycin until ___ for a 1 week
course of antibiotics.
#Ensure patient is safe to return home given that she
independently manages all of her ADLs and IADLs at baseline and
has very little support
#Check INR ___, monitor closely. There is an increased risk
of supratherapeutic INR while on antibiotics
#PCP should discuss need/safety of ongoing anticoagulation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Verapamil SR 240 mg PO Q24H
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Labetalol 200 mg PO BID
4. Lisinopril 20 mg PO DAILY
5. Warfarin 4 mg PO DAILY16
6. Multivitamins 1 TAB PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Calcium Carbonate 1500 mg PO BID
9. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 5 Doses
first dose ___, threat through ___. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 5 Doses
first dose ___, treat through ___. Calcium Carbonate 1500 mg PO BID
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Labetalol 200 mg PO BID
6. Lisinopril 20 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Verapamil SR 240 mg PO Q24H
10. Vitamin D 1000 UNIT PO DAILY
11. Warfarin 4 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pneumonia
Deconditioning
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 for weakness. We found that
you had pneumonia and started you on antibiotics. Our physical
therapists worked with you and felt that you would benefit from
some rehabilitation to regain some of your strength and balance
before returning home.
Best wishes,
Your ___ Care Team
Followup Instructions:
___
|
10881788-DS-4
| 10,881,788 | 29,793,675 |
DS
| 4 |
2150-05-28 00:00:00
|
2150-05-28 13:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chief Complaint: leg weakness, fatigue
Reason for MICU transfer: Hypotension- requiring pressors
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with a PMHx of HTN, metastatic vulvar
cancer, and sp recent admission ___ for hypercalcemia, who
presents for weakness, urinary incontinence and lower extremity
numbness.
Pt was seen in ___ clinic today with diffuse pain,
nausea, and was noted to have Ca 9.6 and received 2L NS. She
presented to ___ outpatient clinic for ___ opinion (Dr. ___.
There, she was noted to be hypotensive to SBP ___ and was
referred to ___.
In the ED, initial VS: T 97.1 (Tm 100.6) P ___ BP 97/41 (67/43)
R 20 O2 Sat 92-99%. Labs were remarkable for UA with WBC 9, few
bacteria, 30 protein; Na 132, Cr 1.7, HCT 28.5, PLT 122. CTAP
showed extensive
RP/inguinal adenopathy; increased RP fluid and RP edema thought
sequelae of metastatic process, possibly lymphatic congestion;
unchanged mod R hydronephrosis w/o nephrolithiasis or
ureterolithiasis (likely ___ adenopathy causing compression).
CXR showed bilateral atelectasis. She received 5L NS in the ED.
On ROS, she reported chronic diffuse abd discomfort. All other
systems were reviewed and negative.
Past Medical History:
- HTN
- HLD
- Obesity
- RLS
- sp L 9th rib fx
- Stage IB vulvar SCC
-- s/p radical hemi vulvectomy, L inguinal femoral LN
dissection, and R node bx in ___ [Dr ___
-- ___ R groin mass, abd pain, constipation; subsequent CT
with extensive new RP LAD
-- ___ Bx showed SCC
-- PTH of malignancy
-- sp Port placement ___
-- ___ C1D1 ___ - Onc may consider cispaltin
afterwards but caroplatin is more well tolerated so was given on
C1
Social History:
___
Family History:
Brother died of bone cancer
Sister died of sepsis
Physical Exam:
Physical Exam on arrival to ___:
General: Alert, oriented, patient complaining of abdominal and
back pain
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic Regular and rhythm, no murmurs/rubs/gallops
Abdomen: soft, diffusely tender (LUQ is most intense),
mildly-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: + foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge Physical Exam:
VS: 98.4 142/80 100 18 98 RA
GENL: pleasant, NAD, lying in bed
HEENT: MMM, no OP lesions
NECK: supple
CARD: RRR, normal S1, S2, no murmurs / rubs / gallops
PULM: clear to auscultation bilaterally
ABDM: obese, soft, NT, ND, +BS
EXTR: warm and well perfused, no edema, 2+ DP pulses palpable
bilaterally
SKIN: no rashes, no jaundice. port site c/d/i
NEURO: awake, alert and oriented x3, moving all extremities
Pertinent Results:
Labs on admission
========================
___ 06:30PM BLOOD WBC-7.6 RBC-3.22* Hgb-9.6* Hct-28.5*
MCV-89 MCH-29.8 MCHC-33.7 RDW-13.4 Plt ___
___ 06:30PM BLOOD Neuts-85* Bands-12* ___ Monos-3
Eos-0 Baso-0 ___ Myelos-0
___ 06:30PM BLOOD Plt Smr-LOW Plt ___
___ 02:54AM BLOOD ___ PTT-29.1 ___
___ 06:30PM BLOOD Glucose-99 UreaN-25* Creat-1.7* Na-132*
K-3.8 Cl-98 HCO3-23 AnGap-15
___ 02:54AM BLOOD ALT-14 AST-25 LD(LDH)-182 AlkPhos-113*
TotBili-0.4
___ 06:30PM BLOOD Calcium-8.5 Phos-3.5 Mg-1.5*
___ 06:39PM BLOOD Lactate-1.5
___ 09:09PM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:09PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 09:09PM URINE RBC-1 WBC-9* Bacteri-FEW Yeast-NONE Epi-2
___ 09:09PM URINE CastHy-16*
___ 09:09PM URINE Mucous-FEW
Pertinent Labs:
___ 11:29AM URINE Hours-RANDOM UreaN-570 Creat-89 Na-14
K-27 Cl-30
___ 11:29AM URINE Osmolal-364
Labs on Discharge:
======================
___ 05:38AM BLOOD WBC-9.4 RBC-3.11* Hgb-9.4* Hct-27.7*
MCV-89 MCH-30.1 MCHC-33.8 RDW-15.2 Plt ___
___ 05:38AM BLOOD Glucose-88 UreaN-12 Creat-0.7 Na-134
K-4.2 Cl-96 ___ AnGap-13
___ 05:38AM BLOOD Calcium-9.7 Phos-2.4* Mg-1.9
IMAGING
==================
CXR ___: Bibasilar atelectasis without definite signs of
pneumonia.
CT Abd+Pelvis wo/con ___:
1. Limited exam in the absence of intravenous contrast.
Extensive
retroperitoneal /inguinal adenopathy in keeping with known
metastatic disease and overall similar in appearance to prior
study dated most recently ___. Increased
retroperitoneal fluid and retroperitoneal edema thought sequelae
of metastatic process, possibly lymphatic congestion.
2. Unchanged moderate right hydronephrosis without
nephrolithiasis or
ureterolithiasis. Compression of distal ureter secondary to
pelvic adenopathy is thought most likely the source.
AP Pelvis ___:
Moderate bilateral degenerative changes but no evidence of right
hip fracture.
Moderate degenerative changes at the sacroiliac joints and the
symphysis.
HIP Unilateral ___:
Moderate bilateral degenerative changes but no evidence of right
hip fracture.
Moderate degenerative changes at the sacroiliac joints and the
symphysis.
TTE ___:
The left atrium is mildly dilated. Normal left ventricular wall
thickness, cavity size, and regional/global systolic function
(biplane LVEF = 63 %). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic arch is mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. No masses or vegetations are seen on the mitral valve,
but cannot be fully excluded due to suboptimal image quality.
Mild to moderate (___) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is high normal.
There is no pericardial effusion.
IMPRESSION: Mild moderate mitral regurgitation with normal valve
morphology. Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Mildly
dilated thoracic aorta.
If the clinical suspicion for endocarditis is moderate or high,
a TEE is suggested to better define the mitral valve morphology.
MR ___ and W/O Contrast ___:
1. Widespread metastatic disease throughout the lumbar spine. No
evidence of spinal cord or nerve root compression.
2. Bilateral neural foraminal narrowing at L5-S1, severe on the
left and
moderate to severe on the right.
MR ___ and W/O Contrast ___:
1. Multiple osseous metastases diffusely throughout the thoracic
spine. No pathologic fracture. No extension of metastases into
the spinal canal. No spinal cord or meningeal metastases.
2. Multiple rib osseous metastases.
3. Scattered bilateral retrocrural lymph nodes, suspicious for
metastatic
lymphadenopathy.
MICROBIOLOGY
==================
___ 6:35 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
BETA STREPTOCOCCUS GROUP G.
___. ___ (___) REQUESTED
CEFTRIAXONE
SENSITIVITIES ___. CEFTRIAXONE MIC = 0.064MCG/ML.
CEFTRIAXONE Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP G
|
CEFTRIAXONE----------- S
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by ___ ___ 0838.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
___ 6:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
BETA STREPTOCOCCUS GROUP G.
IDENTIFICATION PERFORMED ON CULTURE #
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by ___ ___ ___.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
___ 9:09 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Blood cultures ___: NO GROWTH
___ 8:46 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
Brief Hospital Course:
BRIEF MICU COURSE
Ms. ___ is a ___ with a PMHx of HTN, metastatic vulvar
cancer, and s/p recent admission ___ for hypercalcemia, who
presents with hypotension.
# Septic Shock, unknown source, though likely from a necrotic
cancerous lesions within the ABD: Pt presented w fever,
hypotension requiring levophed, 7L NS, ___ GPCs bacteremia in
pairs and chains growing. Initial CT abdomen with no abscess,
although contrast deferred due to ___. Empirically started on
vancomycin and cefepime on ___. ID consulted d/t possible
port infection, who recommended TTE, vancomycin troughs, d/c
cefepime. She was called out of the ICU after 24 hours in
stable condition. Later found to be growing Group G Strep,
sensitive to ceftriaxone. TTE negative for valvular involvement.
ID recommended ___ weeks ceftriaxone. Patient to be discharged
to ___ with high dose amoxicillin while traveling and
resumption of IV ceftriaxone for total 4 week course.
___ Weakness and Urinary Incontinence: Pt first noticed bladder
incontinence in ___ and notes that when she stands up, she
loses urine. Also with new weakness in her leg and pain in her
hip since a few days prior to admission. Neurology was consulted
and saw her ___ and felt that her symptoms were consistent
with an UMN pattern, potentially to the frontal lobe given her
difficulty with attention, or anywhere along the spinal cord. It
was recommended to get MRI brain and rest of the the spine;
however, the patient did not wish to know the results of anymore
scans, as it will not change her decision--she is very clear
about no more interventions to extend her life. She is ok with
palliative radiation for pain. She wants quality and states,
"I'd rather have 3 months of good quality than a year of in and
out of hospitals." Rad-onc saw patient and based on lack of cord
involvement, declined one time radiation dose. ___ evaluated
patient and she was able to ambulate well including going up 1
flight of stairs. Discharged with dexamethasone. Patient to
follow-up in ___.
# Pain: Likely ___ widespread disease burden. Seen by palliative
care and started on long-acting morphine and gabapentin with
good results.
Resolved Issues:
# ___: Patient presented with acute renal injury in the setting
of septic shock, unknown source. The etiology is likely prerenal
in the setting of dehydration and sepsis. Resolved with IV
fluids.
# Anemia: Patient had large drop in H/H on admission. Likely in
the setting of dilution since patient had been given 7L NS at
time of draw. Active T&S, no evidence of bleeding. Blood counts
remained stable throughout remainder of admission.
# Hyponatremia: Likely hypovolemic hyponatremia in the setting
of septic shock. Resolved w fluids.
Chronic Issues:
# Vulvar carcinoma- patient seeking paliative chemo treatments
for her metastatic cancer. It appears this is a recurrence of
vulvar cancer with extensive involvement in the ABD and spine.
Patient elected measures that contributed to comfort rather than
further workup.
# h/o HTN: home dose lisinopril was held in setting of
hypotension, patient normotensive throughout stay and this was
discontinued.
# HLD: continued simvastatin on admission; however, in keeping
with the patients goals of continuing medications that
contributing to quality of life, this medication was stopped.
Transitional Issues
==========================================
1. Pt's prognosis is less than 6 months and her goals are
focused on quality of life. As such, managing symptoms with
adquate pain relief is central to her goals. Other symptoms to
assess include: sleep, anxiety, mood and mobility.
2. Pt will need 4 weeks of antibitoics for bacteremia. TTE did
show some mitral regurg but vegtiations could not be ruled out.
A source of infection was not identified; however, the bacteria
she grew is commonly gound in the GU and GI tract, and on the
skin. The most likely source is a necrotic cancerous lesion in
her abdomen. As such, she may need long-term supressive
antibiotic treatment to prevent another occurence of sepsis.
Plan for 4 weeks total of IV ceftriaxone. Patient will get last
dose in ___ prior to discharge, take high dose amoxicillin
while traveling, and resume IV ceftriaxone through outpatient
___ in ___ (details provided). Last dose:
___
3. Check weekly CBC, Chem7 and LFTs per ID
# Access: PORT and peripherals
# Communication: Name of health care proxy: ___: husband
Phone number: ___
Cell phone: ___
# Code: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Simvastatin 20 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Acetaminophen 1000 mg PO Q8H:PRN pain
5. Docusate Sodium 100 mg PO BID constipation
6. TraZODone 50 mg PO QHS:PRN insomnia
7. Morphine Sulfate ___ 7.5-15 mg PO Q4H:PRN pain
8. Ondansetron 8 mg PO DAILY
9. Lorazepam 2 mg PO Q8H:PRN anxiety/nausea
10. Prochlorperazine 10 mg PO Q8H:PRN nausea
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Docusate Sodium 100 mg PO BID constipation
3. Lorazepam 2 mg PO Q8H:PRN anxiety/nausea
4. Morphine Sulfate ___ 7.5-15 mg PO Q4H:PRN pain
5. Omeprazole 20 mg PO DAILY
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. TraZODone 50 mg PO QHS:PRN insomnia
8. Bisacodyl 10 mg PO QHS
RX *bisacodyl [Laxative] 5 mg 2 tablet(s) by mouth nightly Disp
#*30 Tablet Refills:*0
9. Dexamethasone 4 mg PO BID
RX *dexamethasone 4 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
10. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth twice a day Disp #*24 Packet Refills:*0
11. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 2 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
12. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram 1 vial IV Q24H Disp #*16 Vial Refills:*0
13. Gabapentin 300 mg PO QHS
RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*15
Capsule Refills:*0
14. Gabapentin 100 mg PO BID
RX *gabapentin 100 mg 1 capsule(s) by mouth twice a day Disp
#*30 Capsule Refills:*0
15. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % (700 mg/patch) apply to back QAM Disp #*30
Patch Refills:*0
16. Morphine SR (MS ___ 15 mg PO Q12H
RX *morphine 15 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*30 Tablet Refills:*0
17. Amoxicillin 1000 mg PO Q8H Duration: 2 Days
take this while traveling until resuming IV ceftriaxone
RX *amoxicillin 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic vulvar cancer.
Septic Shock
Group G Strep Bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ came to us for low blood pressure and were found to be in
septic shock from a bacterial blood stream infection. ___ were
transferred to the ICU to be stabilized. ___ recovered and based
on complaints of hip and back pain we got an MRI of your lower
back which showed spread of cancer, likely an aggressive
recurrence of vulvar cancer. We had a goals of care discussion
and ___ elected to not have imaging of the rest of the spine or
your head. Based on the findings in your spine, the radiation
team here felt a single dose of therapy was not warranted, and
___ should follow-up in ___ for further discussion of
radiation.
For your bloodstrem infection, ___ will take IV ceftriaxone for
4 weeks total. As ___ travel from ___ to ___ should
take amoxicillin until ___ resume IV antibiotics at the infusion
center in ___. The last date of antibiotics will be: ___
It was such a pleasure taking care of ___! We wish ___ all the
best and that Flordia treats ___ oh so well!
Your ___ Oncology Team
Followup Instructions:
___
|
10882616-DS-9
| 10,882,616 | 21,576,088 |
DS
| 9 |
2161-12-20 00:00:00
|
2161-12-24 15:09:00
|
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 (MVC):
Right occipital condylar fracture
?L AO dissociation
small bilateral IVH
subcapsular liver hematoma
bilateral rib fracture, sternal fracture
Left tibial plateau fracture
right mid-shaft humerus fracture
Major Surgical or Invasive Procedure:
___: left chest tube placed
___:
Open treatment craniocervical fracture dislocation.
Posterior instrumentation occiput to C1, C2, C3.
Posterior fusion craniocervical.
Posterior fusion C1-C2.
Posterior fusion C2-C3.
Iliac crest bone graft harvest, structural.
Laminectomy C1
___: removal of left chest tube
___: Percutaneous trach
___: PEG
___ Right humerus IM nail, ORIF left tibial plateau
___ IVC filter
___: trach removed
History of Present Illness:
HPI:
___ s/p MVC with R occiptial condyle fracture and central canal
hemorrhage concerning for brain stem injury. Patient also noted
to have R mid-shaft humerus fracture. High-speed motor
vehicle accident today, +ETOH ~200. Patient was presumed driver,
passenger was arrested. Upon EMS arrival GCS = 3. Patient was
intubated with a MAC airway and needle decompression of L chest
performed on the field. Patient transferred to ___ ED via life
flight.
Upon arrival in ED, patient was intubated and noted to be
bradycardic and hypotensive. A L chest was placed in the ED and
patient taken to scanner, where imaging was concerning for R
occipital condyle fracture, R vertebral artery dissection, R
mid-shaft humerus fracture, R liver hematoma, multiple b/l rib
fractures.
Past Medical History:
PMH:
glaucoma, htn
PSH:
knee surgery
Social History:
___
Family History:
Noncontributory
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
HEENT: Pupils equal, round and reactive to light
C collar in place
Chest: bilat breath sounds, no chest wall crepitus
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nondistended
GU/Flank: no spine stepoff
Extr/Back: deformity R upper arm
Neuro: GCS3
Physical examination upon discharge:
VS: 98.0, 70, 110/61, 18, 100%ra
GEN: A&O x3, NAD
HEENT: PERRLA, hard collar in place, steri strips to neck
incision
RESP: LS ctab
CV: HRR
ABD: soft, NT/ND
GU: foley in place
EXT: LLE +bruising to lower leg, ankle, foot. +csm bilaterally.
___ brace on LLE, incisional staples removed steri-strips in
place; R-shoulder with steri-strips
NEURO: CN II-XII grossly in tact, speech fluent. Lumbar incision
OTA
Pertinent Results:
IMAGING:
CTA neck: Irregularity and attenuation of the right vertebral
fracture as it passes near the right skull bases fracture is
worrisome for possible dissection. The study is however limited
by poor opacification of the vessels and motion artifact and MRA
would be helpful for definitive evaluation. The basilar artery,
and circle of ___ appear patent; CTA was not performed
through the entire head.
CT torso: Tiny left pneumothorax with chest tube already in
place. Chest tube terminates near the anterior upper mediastinum
and should be withdrawn about 4-5 cm to ensure it is not
compromising the mediastinal structures. There is significant
atalectasis of both lungs dependently with near complete
collapse of the right lower lobe. Multiple rib fractures
bilaterally: right 1, 3, 4, 5, 6, 7, 8, 9, 11. Left 3, 4, 5, 6.
Likely non-displaced sternal fracture. LIVER: Right 8.4 x 3 cm
subcapsular liver hematoma with more high density focus
centrally suggesting active bleeding. Gaseous distension of the
small and large bowel without frank dilation. No free air or
free fluid.
INCIDENTALS: 2.5 cm right adrenal nodule incompletely evaluated
would need 3 phase CT when clinically appropriate.
update- multiphasic liver for ? pseudoaneursym, active
extrasvastion
CT head: Large posterior subgaleal hematoma. Small bilateral
intraventricular hemorrhages layering in the occipital horns of
the lateral ventricles, left greater than right. Right occipital
condyle fracture to be detailed in C-spine CT preliminary
report. Posterior fossa difficult to evaluate due to streak
artifact but there is apparent effacement of the quadrigeminal
plate cistern and the ___ ventricle; there may be edema in the
brainstem. The oropharynx and
narospharynx are opacified
f/u read per rads possible herniation- transtenorial herniation
CT Cspine: Transverse avulsion fracture of the right occipital
condyle and widening of the left atlanto-occipital joint. There
is high density material surrounding the spinal cord in the
central canal suggesting hemorrhage although this should be
evaluated by MR. ___ findings worrisome for
atlanto-occipital dissociation and brain stem injury. There is
hemorrhage throughout the soft tissues of the neck. CTA is also
recommended to rule out vertebral artery compromise.
CXR- ___ ETT- advance 1-2 cm
MRA/MRI neck and head:
IMPRESSION:
Bilateral occipital lobe contusions, left greater than right,
with associated the edema and ischemia. These contusions were
not clearly identified on prior noncontrast head CT. There is
also on small focus of intraparenchymal hemorrhage within the
right superior frontal gyrus. The pattern of abnormalities is
indicative of coup-contrecoup injury and not characteristic of
diffuse axonal injury.
Bilateral parietal lobes subarachnoid hemorrhages at the vertex
are more conspicuous than on prior study. Stable bilateral
intraventricular hemorrhages. There has been redistribution of
the subgaleal hemorrhage.
There is loss of flow related signal within the V 3 segments of
both vertebral arteries likely related to artifact from the
adjacent orthopedic hardware. There is no evidence of arterial
dissection.
There are findings suggestive of mild vasospasm involving A1 and
M1 segments. There is no vessel occlusion, or aneurysm.
MRI throacic/cervical
IMPRESSION:
1. Edema at the pontomedullary junction, and within the left
posterior aspect of the brainstem and extending into the upper
cervical cord to the C2-C3 level.
2. Small ventral and dorsal epidural hematomas within the
cervical spine resulting in moderate thecal sac narrowing at
C1-C2.
3. Prevertebral soft tissue hematoma extending from the clivus
to the C2-C3 level. There is fluid posterior to the anterior
longitudinal ligament extending from the skullbase to the upper
thoracic spine which is suggestive of ligamentous injury. There
is also posterior paraspinal and interspinous edema extending
from the occiput to the upper thoracic spine which may represent
a combination of postoperative changes and ligamentous injury.
4. From T3-T4 level and extending inferiorly to the visualized
portions of the upper lumbar spine there is layering posterior
subarachnoid hemorrhage.
5. Right greater than left pleural effusions with bilateral
lower lobe atelectasis. Also bilateral rib fractures better
appreciated on prior CT scan.
CXR ___- As compared to the previous radiograph, no relevant
change is seen. Improved lung ventilation, potentially caused by
increased ventilatory pressures. Unchanged atelectasis and
potential minimal left pleural effusion. Adjacent to a slightly
displaced rib fracture. The monitoring and support devices are
constant. Moderate cardiomegaly persists
Ct head ___- No evidence for new intracranial abnormalities.
Moderate, predominantly nonhemorrhagic contusions in bilateral
occipital poles and a small hemorrhagic contusion in the
superior right frontal lobe are better seen than on the ___ CT
but are unchanged compared to the ___ MRI.
Subacute bilateral subarachnoid hemorrhage, similar to prior
exams.
Stable mild intraventricular hemorrhage.
Decreased effacement of the ventricles and basal cisterns
compared to ___. Resolution of transtentorial herniation.
Right occipital condyle fracture. Partially imaged fusion of the
occiput and posterior cervical spine. Partially image the
persistent blood in the spinal canal.
Left knee ___ : 1. Medial tibial plateau fracture, as described
above. 2. Moderate joint effusion.
Left foot ___: Subtle cortical disruption of the distal
epiphysis of the first toe proximal phalanx, is equivocal for
fracutre and may be artifactual. Correlate clinically for focal
pain. If high clinical suspicion for a fracture, consider
dedicated radiographs.
LABS:
___ 05:40AM BLOOD WBC-8.5 RBC-3.14* Hgb-9.7* Hct-30.7*
MCV-98 MCH-30.9 MCHC-31.6 RDW-13.7 Plt ___
___ 02:59AM BLOOD WBC-10.5 RBC-3.15* Hgb-9.9* Hct-30.3*
MCV-96 MCH-31.4 MCHC-32.7 RDW-13.3 Plt ___
___ 01:26AM BLOOD WBC-11.3* RBC-2.99* Hgb-9.3* Hct-29.5*
MCV-99* MCH-31.1 MCHC-31.6 RDW-14.1 Plt ___
___ 02:03AM BLOOD WBC-13.7* RBC-2.86* Hgb-9.2* Hct-27.4*
MCV-96 MCH-32.0 MCHC-33.4 RDW-13.4 Plt ___
___ 01:30AM BLOOD WBC-13.2* RBC-3.38* Hgb-10.4* Hct-32.4*
MCV-96 MCH-30.9 MCHC-32.3 RDW-13.9 Plt ___
___ 02:28PM BLOOD Hct-29.2*
___ 01:45AM BLOOD WBC-10.4 RBC-2.84* Hgb-9.2* Hct-26.7*
MCV-94 MCH-32.3* MCHC-34.4 RDW-13.5 Plt ___
___ 01:48AM BLOOD WBC-9.7 RBC-2.92* Hgb-9.0* Hct-27.9*
MCV-96 MCH-30.9 MCHC-32.3 RDW-14.1 Plt ___
___ 02:25AM BLOOD WBC-10.8 RBC-3.01* Hgb-9.4* Hct-28.7*
MCV-95 MCH-31.4 MCHC-32.9 RDW-14.2 Plt ___
___ 07:00AM BLOOD WBC-9.7 RBC-3.06* Hgb-9.8* Hct-28.2*
MCV-92 MCH-32.1* MCHC-34.8 RDW-14.1 Plt ___
___ 02:17AM BLOOD WBC-7.0 RBC-2.31* Hgb-7.4* Hct-21.7*
MCV-94 MCH-31.8 MCHC-33.9 RDW-13.5 Plt ___
___ 05:40AM BLOOD Plt ___
___ 05:40AM BLOOD ___ PTT-24.4* ___
___ 02:59AM BLOOD Plt ___
___ 02:59AM BLOOD ___ PTT-27.2 ___
___ 01:26AM BLOOD Plt ___
___ 01:26AM BLOOD ___
___ 01:09AM BLOOD ___
___ 02:20AM BLOOD ___
___ 03:34AM BLOOD ___
___ 05:40AM BLOOD Glucose-124* UreaN-27* Creat-0.6 Na-135
K-4.4 Cl-100 HCO3-28 AnGap-11
___ 02:59AM BLOOD Glucose-128* UreaN-29* Creat-0.6 Na-138
K-4.6 Cl-102 HCO3-29 AnGap-12
___ 01:26AM BLOOD Glucose-136* UreaN-29* Creat-0.7 Na-138
K-4.7 Cl-104 HCO3-26 AnGap-13
___ 09:41AM BLOOD Glucose-139* UreaN-27* Creat-0.6 Na-142
K-4.6 Cl-107 HCO3-26 AnGap-14
___ 09:41AM BLOOD Glucose-139* UreaN-27* Creat-0.6 Na-142
K-4.6 Cl-107 HCO3-26 AnGap-14
___ 02:03AM BLOOD Glucose-163* UreaN-26* Creat-0.6 Na-140
K-3.1* Cl-107 HCO3-25 AnGap-11
___ 01:30AM BLOOD Glucose-150* UreaN-26* Creat-0.7 Na-139
K-4.4 Cl-104 HCO3-27 AnGap-12
___ 01:45AM BLOOD Glucose-125* UreaN-30* Creat-0.7 Na-140
K-4.5 Cl-105 HCO3-28 AnGap-12
___ 01:47PM BLOOD Glucose-135* UreaN-29* Creat-0.8 Na-139
K-4.3 Cl-104 HCO3-27 AnGap-12
___ 01:48AM BLOOD Glucose-126* UreaN-27* Creat-0.8 Na-138
K-4.3 Cl-104 HCO3-27 AnGap-11
___ 02:08PM BLOOD Glucose-115* UreaN-26* Creat-0.9 Na-136
K-4.0 Cl-100 HCO3-27 AnGap-13
___ 01:48AM BLOOD ALT-89* AST-62* AlkPhos-69 Amylase-56
TotBili-0.9
___ 03:45AM BLOOD ALT-127* AST-86* AlkPhos-69 TotBili-0.9
___ 02:17AM BLOOD ALT-166* AST-117* CK(CPK)-3866*
AlkPhos-63 TotBili-1.1
___ 01:09AM BLOOD ALT-233* AST-192* CK(CPK)-6309*
AlkPhos-67 TotBili-1.2
___ 02:30PM BLOOD CK(CPK)-7542*
___ 02:20AM BLOOD ALT-322* AST-300* LD(LDH)-612*
CK(CPK)-9647* AlkPhos-63 TotBili-1.1
___ 09:20PM BLOOD ___
___ 11:58AM BLOOD ___
___ 03:42AM BLOOD ALT-449* AST-455* LD(LDH)-671*
___ AlkPhos-39* TotBili-0.9
___ 08:51PM BLOOD ___
___ 01:48AM BLOOD Lipase-129*
___ 03:34AM BLOOD Lipase-28
___ 03:34AM BLOOD Lipase-28
___ 01:50AM BLOOD Lipase-174*
___ 03:34AM BLOOD CK-MB-111* MB Indx-0.7 cTropnT-0.02*
___ 09:30AM BLOOD CK-MB-165* MB Indx-1.5 cTropnT-0.07*
___ 01:50AM BLOOD cTropnT-<0.01
___ 05:40AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.1
___ 02:59AM BLOOD Calcium-7.9* Phos-3.8 Mg-2.2
___ 01:26AM BLOOD Calcium-8.0* Phos-4.0 Mg-2.1
___ 09:41AM BLOOD Calcium-7.8* Phos-3.3 Mg-2.1
___ 02:03AM BLOOD Calcium-7.5* Phos-3.3 Mg-2.2
___ 09:41AM BLOOD TSH-0.73
___ 09:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE IgM
HBc-NEGATIVE
___ 09:30AM BLOOD HIV Ab-NEGATIVE
___ 07:00AM BLOOD Vanco-13.2
___ 01:50AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:41AM BLOOD RedHold-HOLD
___ 03:45AM BLOOD EDTA ___
___ 03:45AM BLOOD RedHold-HOLD
___ 07:50AM BLOOD EDTA ___
___ 07:50AM BLOOD EDTA ___
___ 09:30AM BLOOD HCV Ab-NEGATIVE
___ 02:14AM BLOOD Type-ART pO2-104 pCO2-38 pH-7.45
calTCO2-27 Base XS-2
___ 07:55PM BLOOD Type-ART pO2-132* pCO2-38 pH-7.46*
calTCO2-28 Base XS-3
___ 05:04PM BLOOD Type-ART pO2-70* pCO2-30* pH-7.55*
calTCO2-27 Base XS-4
___ 01:15PM BLOOD Type-ART pO2-99 pCO2-31* pH-7.51*
calTCO2-26 Base XS-1
___ 09:40AM BLOOD ALDOSTERONE-PND
___ 09:40AM BLOOD RENIN-Test
___: x-ray of neck:
The patient is status post occipital cervical fusion, with
posterior plate and screws transfixing the occiput to the upper
cervical spine, with pedicle screws at C2 and C3. Hardware is
nominal. Overlying material/artifact is noted. Alignment from C1
through C7 is preserved. No interval fracture is detected.
Moderately severe degenerative changes at C ___ with splaying of
the corresponding spinous process is noted. Mild prominence of
retropharyngeal soft tissues as well as mild soft tissue
swelling anterior to C1 and C2 is noted. The patient's known
occipital fracture is noted. Skin staples noted.
Brief Hospital Course:
The patient was admitted to the trauma intensive care unit after
he was involved in a motor vehicle accident. Reportedly he was
the driver who was ejected from the vehicle. The airway was
initially secured with a LMA and needle decompression of the
left chest was performed in the field. The patient was
transferred via Life Flight. He arrived in a cervical-collar,
but not intubated. He was paralyzed and intubated in the
emergency room shortly after arrival when he began to become
bradycardic, hypotensive and began to hypoventilate. He had a
brief course of CPR. The patient was reportedly hypotensive,
and acidotic with a large fluid requirement. Pressors were
later added for hemodynamic support. A left chest tube was
placed. By imaging, the patient was reported to have a right
occipital condylar fracture, bilateral rib fractures, a sternal
fracture, a left tibial plateau fracture, a subcapsular liver
hematoma, and a small bilateral IVH. On CTA imaging of the neck,
there was suspicion of a right vertebral artery dissection at
the C1 transverse foramen and intracranially. The stroke service
was consulted and recommended an MRA of the brain which did not
show an arterial dissection.
Because of the patient's orthopedic injuries, the Ortho-spine
service was consulted. The patient was taken to the operating
room on HD #1 where he underwent a posterior fusion C1-C2,
posterior fusion C2-C3, iliac crest bone graft harvest, and a C1
laminectomy. Post-operatively, the patient was following all
commands and moving all extremities. Ten days later, he
returned to the operating room with the Orthopedic service where
he underwent an ORIF of left medial tibial plateau fracture and
a right humeral shaft fracture with intramedullary nail.
Intensive care unit course:
___: The patient was evaluated by the Neurosurgery service. Cat
scan imaging showed small bilateral intra-ventricular
hemorrhages and a left frontal subarachnoid hemorrhage. It was
determined that no surgical intervention was indicated and the
patient was started on a 7 day course of keppra. The patient's
hemodynamic status was monitored and he was weaned off the
pressors. His creatinine began to normalize. The patient was
transitioned to pressure support ventilation. His vital signs
were closely monitored and he was cultured when he became
febrile.
___: THe patient's hematocrit stabilzed to 24 after 1 unit
PRBC. His left chest tube was removed. (Sputum ___ >25PMNs, 4+
GNRs, 1+ GPCs). He was febrile 102.2 -> Bcx, UCx, mini-BAL sent
were sent. The final sputum specimen grew staph aureus coag +
and enterobacter and the patient was started on a course of
vancomycin and zosyn. The patient's oxygen saturation began to
drift down and there was concern for fluid overload and the
patient was given lasix. His oxygen saturation improved after
diuresis and with the addition of antibiotics.
___: The patient began weaning on pressure support ventilation.
The patient was hypertensive and tachypnic while being moved
concerning for possible pain despite pain medication and
precedex was started to help with the anxiety. The patient was
given Lasix with good response. A bronch was done which showed
only clear secretions, no obvious purulence. He continued to
have febrile spikes and the vancomycin and zosyn were changed to
levaquin and ceftriaxone.
___: He was febrile overnight despite antibiotics. The patient
was moving all extremities on neuro exam. Because of his
limited mobility, he was started on Lovenox. Discussion was
underway for placement of a Peg, trach, and IVC filter. The
patient was again febrile to 102.4 and was cultured.
___: The patient was reported to have a decrease in his
hematocrit to 21., he was given 2 u PRBC which increased the
hematocrit to 28. Nutrition was started with tube feedings.
The patient continued to require increments of lasix for
diuresis which improved his oxygen saturation. Mini BAL showed
Staph aureus 10,000-100,000, H flu 10,000-100,000 (resistant to
ampicillin), and enterobacter 10,000-100,000 (panS
___: The patient continued to be febrile to 102. Diuresis
continued with lasix based on patients I+O's. A trach and peg
were performed at the bedside. Per radiology bilateral upper
extremity ultrasound was negative.
___: Febrile course continued. Both keppra and vancomycin were
discontinued. The patient was maintaining an adequate urine
output. His lipase was mildly elevated, with a decreased
calcium and there was concern for pancreatitis.
___: Febrile 102.2 and the propofol was discontinued and
precedex was weaned off. The patient's mental improved.
Ativan was given to aid in the weaning of precedex. He resumed
his metoprolol for management of his hypertension.
___: The patient was taken to the operating room with
orthopedic service for ORIF of his right humerus fracture and
left tibial plateau fracture. Because of the patients decreased
mobility, a IVC filter was placed. Bronch showed scant
secretions. Post-op, the patient required 1 unit PRBC for a
decreased hematocrit. During the post-operative course, he
required additional pain medication.
___: The patient was placed on a trach mask in attempts at
weaning. The precidex was slowly decreased. The patient became
hypertensive and tachycardic. He was given fentanyl, labetalol,
amlodipine, and hydralazine with minimal effect. Pt "raises
thumb" to signal he has pain but couln not localize. He also
appeared anxious. He was placed back on the ventilator and
given ativan and haldol without much improvement in his vital
signs. At this time, he was started on a labatelol drip amd the
precedix was weaned. He was febrile and blood, urine, and sputum
cultures were sent. The labatelol was discontinued.
___: Hypertensive with an elevated ___ blood cell count. A
chest x-ray was done which showed interstitial pulmonary edema
and bilateral pleural effusions.
Ortho spine was consulted to assess the neck wound and
determined that this was not a cause of his febrile episodes.
The patient continued to have pain and agitaiton and methadone
was added to his medical regimen and his dilaudid was
discontinued.
___: The patient's central line was removed and he received
additional lasix with a 1.6 liter negative response. He was
tolerating the trach mask with stable vital signs.
___: The lovenox was resumed for long bone prophalaxsis and
will be addressed at the Orthopedic follow-up. The patient was
evaluated by speech and swallow for placement of a speaking
valve. The speaking valve was well tolerated with no evidence
of respiratory distress or aspiration.
The patient was transferred to the surgical floor on ___:
REVIEW OF SYSTEMS:
CV: The patient's hemodynamic status has remained stable. He
has continued on his oral metoprolol. He did experience an
isolated episode of mild hypertension and tachycardia which
resolved with an intravenous dose of metoprolol.
RESP: His trach tube was removed on ___ and the site was
covered with DSD. He has been able to vocalize and has not
exhibited any signs of respiratory distress. His oxygen
saturation has been maintained at 97%.
GI: Tube feedings via the PEG were discontinued on ___ and the
patient was encouraged to eat a regular diet with the addition
of supplements. His appetite has slowly been improving.
GU: The foley catheter has remained to gravity drainage.
Attempts were made to remove the foley catheter but the patient
has been unable to void after removal. Flomax was started in
anticipation of future foley removal. There was a voiding trial
done on ___ but the patient developed urinary retention and the
foley was replaced.
SKIN: DSD to post aspect of neck, staples right shoulder and
left knee which will be removed in clinic.
MENTATION: THe patient has been alert and oriented x3 with
clear speech. THe cervical collar to be worn at all times.
MUSCULOSKELETAL: Cervical collar at all times, right arm weaker
than left, left leg weaker than right. Transfers out of bed with
assistance of ___. Bledoe brace to left lower extremity. Lovenox
duration to be addressed at follow-up visit with Orthopedics.
During the hospital course, the patient and his family received
emotional support from the social worker. In preparation for
discharge, the patient was evaluated by physical and
occupational therapy. Recommendations were made to discharge to
a rehabilitation facililty. The patient was discharged on HD #
20 in stable condition. Appointments for follow-up were made
with the Spine, Orthopedic, Neurology, and acute care services.
********* 2.5 cm right adrenal nodule incompletely evaluated
would need 3 phase CT when clinically appropriate************
Medications on Admission:
Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
Metoprolol Tartrate 37.5 mg PO/NG BID
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN fever
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Docusate Sodium (Liquid) 100 mg PO BID
4. Bisacodyl ___AILY:PRN constipation
5. CloniDINE 0.2 mg PO TID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Lorazepam 1 mg IV Q4H:PRN anxiety
RX *lorazepam 1 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
8. Methadone 10 mg PO BID
RX *methadone 10 mg 1 tablet by mouth twice a day Disp #*60
Tablet Refills:*0
9. Metoprolol Tartrate 37.5 mg PO BID
hold for hr <100
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
11. QUEtiapine Fumarate 25 mg PO BID
12. Senna 8.6 mg PO BID
13. Tamsulosin 0.4 mg PO HS
14. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
please address duration of lovenox at Orthopedic visit
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Trauma: MVC:
Right occipital condylar fracture
?left AO dissociation
small bilateral IVH
subcapsular liver hematoma
rib fractures bilaterally: right 1, 3, 4, 5, 6, 7, 8, 9,
11. Left 3, 4, 5, 6.
non-displaced sternal fracture
right mid-shaft humerus fracture
Left tibial plateau fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after you were involved in a
motor vehicle accident. You sustained fractures to your left leg
and right arm. You also sustained rib fractures and a fracture
to the base of your head and neck. You were taken to the
operating room where you had a fusion of your neck. You also had
surgical repair of your left leg and right arm. Because of your
injuries, you were monitored in the intensive care unit. You
underwent a tracheostomy to help with your breathing and had a
feeding tube placed to maintain your nutrition. You are slowly
recovering from your injuries. Your trach tube has been removed
and you are tolerating a regular diet. You were seen by
physical therapy and recommendations made for discharge to a
___ facility where you could further regain your
strength and mobility.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks (Please confirm
this at the visit with the Orthopedic surgeon.)
Your staples from your right left leg, right shoulder, and neck
will be removed at your follow-up visit with the Orthopedist,
and spinal surgeon.
WOUND CARE:- No baths or swimming for at least 4 weeks.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:-
Rt upper extremity -partial weight bearing
Lt lower extremity- touch down wt bearing
Followup Instructions:
___
|
10882818-DS-9
| 10,882,818 | 21,077,218 |
DS
| 9 |
2177-12-11 00:00:00
|
2177-12-16 21:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ yo male with a history of bladder cancer and right
nephrostomy
tube who is admitted with fevers and likely UTI. The patient
states he has had two days of fevers as high as 39.7. He also
has
right flank pain and had urinary frequency and dysuria and
increased nausea. He states he contacted the interventional
radiologist at ___ who had placed his right nephrostomy tube and
they at advised him to uncap his nephrostomy tube, he has never
before had it draining to a bag. Since then he has noticed that
he hasn't urinated at all despite not having a nephrostomy on
the
left. He was due to have his nephrostomy tube changed but it had
been delayed to be at the best time during his chemo cycle. He
otherwise denies any nasal congestion, sore thoat, shortness of
breath, diarrhea, or rashes. Of note he last received
chemotherapy on ___ and received neulasta on ___.
REVIEW OF SYSTEMS:
- All reviewed and negative except as noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
History of superficial bladder cancer treated with BCG, who has
been diagnosed with high-grade urothelial carcinoma invasive
into
the lamina propria in ___ in the setting of gross
hematuria.
On ___, after re-resection, there was minimal residual
disease with no muscle invasive component (pTa). He underwent a
6-week induction course of intravesical BCG, which concluded in
___. Surveillance cystoscopy evaluation and CT urogram on
___ showed no evidence of disease.
On ___, on surveillance cytstoscopy, a papillary tumor
consistent with recurrence was found at the right trigone.
On ___, transurethral resection of the bladder tumor;
papillary tumor obscured visualization of the right ureteral
orifice. After through resection, it was felt that there was
tumor involving the intramural portion of the right ureter. Deep
resection were obtained until concern for extravesical space.
Pathology showed invasive papillary urothelial carcinoma, high
grade (former WHO grade 3 or 3) with squamous differentiation.
Tumor invaded into the muscularis propria.
On ___ CT chest showed no definitive evidence of pulmonary
metastases. CT urogram at that time showed right obstructive
uropathy on the right with thickening and possible filing defect
in the distal ureter, as well as asymmetric thickening along the
anterior, superior, and lateral bladder wall. There was also
stable retroperitoneal lymphadenopathy.
On ___, he was seen by Dr. ___ at ___ to
discuss
neoadjuvant chemoterapy, who recommended platinum-based
neoadjuvant therapy (gem-cis vs MVAC pending cardiac
evaluation).
On ___, he was seen by Dr. ___, who obtained a PET:
On ___, PET showed persistent right hydroureteronephrosis
and some focal FDG uptake near te right vesicuretral junction in
the region of the filing defect noted on CT. The FDG-avid right
external iliac LN (1.6x1,1cm with SUV 2.8 was suspicious for
regional LN involvement, but may be reactive lymph node gien the
mild -moderate SUV.
On ___, given distal in the right ureter involvement and
right hydronephrosis, he underwent ___ percutaneous
nephroureteral
stenting. Due to obstruction, he had a percutanous nephrostomy
tube placed, which recently has its 3 month change at ___.
Seen at ___ by Dr. ___ oncologist, who recommend
ddMVAC, followed by radical cystectomy and LND.
Presented to ___ ___ to discuss options for therapy and
had done much research on immunotherapy. He is very hesistant to
have chemotherapy or cystectomy and is interested in additional
options. He reported ~30lb weight loss in the last few months,
which is not intentional, but reports otherwise feeling well.
Without headaches, URI symptoms, CP or SOB, abdominal pain or
pain with urination. He has a nephrostomy tubes, which was
recently changed without complication.
___ CT showed no distant metastatic disease, but growth of
his known suspicious lymph node.
___ After discussing cystectomy with Dr. ___, Mr
___ decided to not pursue neoadjuvant chemotherapy and
cycstectomy for curative intent, since he didn't want to loss
his
bladder and was anxious to start treatment and hoped to pursue
immunotherapy in the future. Therefore we started C1D1
gem/cisplatin.
- ___ C2D1 gemcitabine and cisplatin.
- ___ C3D1 gemcitabine and cisplatin.
- ___ C4D1 gemcitabine and cisplatin.
PAST MEDICAL HISTORY:
CAD for unstable angina and had 90% RCA ds, s/p DES ___ (___)
with stable sx and stress (___) "normal" per patient
emphysema on imaging ___
HTN
dyslipidemia
osteoarthritis
h/o arthroscopic knee surgery left ___
Social History:
___
Family History:
mother passed at ___, had cancer.
father h/o bladder removal and died in ___
Physical Exam:
DISCHARGE PHYSICAL EXAM:
General: NAD
VITAL SIGNS: 98.3 104/58 73 18 100%RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB nonlabored
ABD: Soft, NTND, no masses or hepatosplenomegaly, R nephrostomy
c/d/i no erythema or drainage nontender
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, ___, EOMI, face symmetric, moves all
ext, sensation intact to light touch
Pertinent Results:
ADMISSION LABS:
WBC: 12.9*. RBC: 2.33*. HGB: 8.0*. HCT: 24.3*. MCV: 104*. RDW:
17.4*. Plt Count: 81*.
Neuts%: 89*. Lymphs: 6*. MONOS: 0. Eos: 0. BASOS: 0. Atyps: 0.
Metas: 0. Myelos: 0.
___: 13.6*. INR: 1.2*. PTT: 27.3.
Na: 135. K: 4.3. Cl: 101. CO2: 21*. BUN: 15. Creat: 1.1.
DISCHARGE LABS:
___ 05:34AM BLOOD WBC-11.4* RBC-2.08* Hgb-7.1* Hct-21.6*
MCV-104* MCH-34.1* MCHC-32.9 RDW-16.6* RDWSD-63.3* Plt Ct-19*
___ 05:34AM BLOOD UreaN-21* Creat-1.2 Na-139 K-3.5
IMAGING:
Renal Ultrasound:
1. No hydronephrosis, nephrolithiasis, or focal renal lesion.
2. Completely decompressed bladder.
3. Right percutaneous nephrostomy and nephroureteral stents
appear well positioned.
CXR:
1. Subtle increased opacity in the right infrahilar region
probably reflects superimposed normal structures and/or
atelectasis. However, early bronchopneumonia cannot be excluded
in the appropriate clinical situation.
2. Hyperinflated lungs with widening of AP diameter compatible
with history of chronic pulmonary disease.
Perc Neph exchange ___
FINDINGS:
1. Existing right 8 ___ nephroureteral stent in expected
position with flow into the bladder.
2. Successful placement of new, right 8 ___ x 24 cm
nephroureteral stent.
IMPRESSION:
Successful exchange for a new 8 ___ x 24 cm nephroureteral
stent, which was capped.
CT abdomen
IMPRESSION:
1. Mild bladder wall thickening is stable compared to ___.
2. The right external iliac lymph node, which was FDG avid on
prior PET, is smaller.
3. A prominent left para-aortic lymph node is slightly larger.
No FDG avidity was noted in this location on prior PET, however
warrants attention on future follow up.
4. Right percutaneous double J ureteral stent is in unchanged
position. Right kidney is atrophic and excretes in delayed
fashion, similar to before.
CT chest
IMPRESSION:
1. A prominent right periaortic lymph node is unchanged in size
from ___ and only equivocally increased compared to ___.
No FDG avidity was
demonstrated on an intervening prior PET. Therefore, this
prominent node is likely not of significance, however recommend
continued attention on future follow-up studies.
2. Mild emphysema.
Echocardiogram
The left atrium is normal in size. 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 root is mildly dilated at the sinus level. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. No
masses or vegetations are seen on the aortic valve. The mitral
valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
Lasix renal scan
IMPRESSION: 1. Decreased right kidney flow likely due to atrophy
and decreased
function. 88% of total renal function performed by left kidney.
2. No high grade obstruction.
3. Washout T1/2 following furosemide is 5 minutes.
Brief Hospital Course:
___ yo male with a hx CAD s/p stenting in ___ and history of
high-grade superficial bladder cancer with recurrence of a T2
urothelial carcinoma of bladder cancer now s/p right nephrostomy
tube and undergoing treatment with gemcitabine/cisplatin. He is
admitted with fevers and complicated UTI.
#Complicated UTI/Pyelonephritis - presented w/ fever, flank
pain,
nausea, and marked pyuria on UA. Ucx Coag+ SA
- started vancomycin ___, trough is low and given MSSA was
changed to nafcillin.
- ___ replaced nephroureteral stent ___
#Bacteremia,MSSA - ___ bld cx bottle + ___, subsequent blood cx
after starting vanco NGTD x 2. likely seeded from UTI in setting
of indwelling stent as above. Plan for 2 weeks IV nafcillin from
first negative blood culture via home infusion, PICC placed
prior to discharge. TTE to eval for endocarditis was negative.
Given rapid clearance TEE not obtained.
#Bladder Cancer - prev superficial treated w/ intrabladder BCG,
recurrence in regional LN and R ureter s/p nephroureteral stent
at ___. Currently treated with gemcitabine and cisplatin, D8
gemcitabine given ___. Plan for possible atezolizumab vs PD1 if
has progressive disease per Dr ___.
- was due for restaging, scan here showed improvement in R ext
iliac node, stable bladder thickening and stable ___
node that was prev PET negative
- Neulasta given ___ as outpatient.
- Continue home Ativan and Zofran.
#Anemia - ___ ACD and hematuria from malignancy as well as
chemotherapy. Hgb 7.1 and unclear if reached nadir at time of
discharge, discussed and will hold off on PRBCs per patient
request. Discussed symptoms of anemia to monitor for at home inc
severe fatigue, lightheadedness, dyspnea, chest pain.
#Thrombocytopenia - ___ recent chemotherapy, no bleeding other
than microscopic hematuria, cont to monitor, transfuse Plt <10
or more significant bleeding. holding ASA until Plt recover
#CAD
- Continue home atorvastatin.
- Held home aspirin given nephrostomy tube change procedure.,
plan to resume when plt recover as above
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. LORazepam 1 mg PO QHS:PRN Insomnia
3. Ondansetron 8 mg PO Q8H:PRN Nausea
4. Prochlorperazine 5 mg PO Q8H:PRN Nausea
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. CeFAZolin 2 g IV Q8H
RX *cefazolin in dextrose (iso-os) 2 gram/100 mL 2 g IV every 8
hours Disp #*33 Intravenous Bag Refills:*0
2. Atorvastatin 40 mg PO QPM
3. LORazepam 1 mg PO QHS:PRN Insomnia
4. Ondansetron 8 mg PO Q8H:PRN Nausea
5. Prochlorperazine 5 mg PO Q8H:PRN Nausea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Complicated urinary tract infection
Staph aureus bacteremia
Anemia
Thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___, it was a pleasure caring for you during your stay
at ___. You were admitted with fever and found to have urine
as well as bloodstream infection with Staph aureus. You
underwent exchange of the nephrostomy tube and were treated with
IV antibiotics. We will continue for a total of 2 weeks. A PICC
line was placed in order to continue IV antibiotics at home.
While here your blood counts have decreased (red blood cells and
platelets). This is due to effects of chemotherapy. There has
been no bleeding and you have not had symptoms of anemia thus
far and elected not to have transfusion thus far but in case the
blood counts drop further requiring transfusion we will monitor
labs again at home. Please avoid any strenuous or other activity
with risk of injury as minor trauma could cause bleeding.
Followup Instructions:
___
|
10882911-DS-6
| 10,882,911 | 28,704,779 |
DS
| 6 |
2177-12-20 00:00:00
|
2177-12-26 12:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with a history of paroxysmal
atrial fibrillation, on eliquis (took this morning), and
prostate cancer s/p cyber knife who presents s/p mechanical fall
down fall ___ stairs (slipped on ice), no head strike or loss of
consciousness. He states that he was walking his dog around 6am
when he slipped and fell and noted immediate left hip pain. He
attempted to go about his day as usual but while teaching class
this morning in the high school where he worked felt
progressively ill-at-ease and developed difficulty ambulating.
Patient presented to ED and was found on CT scan to have a left
psoas intramuscular hematoma but no fractures. a NCHCT was
negative. He denies tingling or numbness in his extremities,
dizziness, vertigo, transient loss of vision, BRBPR, melena, or
incontinence. His last void was 10am. Hct 38.1 lactate 1.6 Cr
0.6. Patient is currently hemodynamically stable with BP
119/66, HR 70. He is in sinus rhythm.
Past Medical History:
Past Medical History:
HTN
HLD
Hemochromatosis
Paroxysmal atrial fibrillation, on eliquis
Past Surgical History:
excision of lesion from posterior neck in ___
Social History:
___
Family History:
Mother deceased from breast Ca at age ___. Father deceased from
___ at ___. No h/o premature ASCVD in any first degree family
members.
Physical Exam:
Admission Physical Exam:
Vitals: T 98.6, HR 71, BP 117/71, RR 18, SaO2 99%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l, No W/R/C, comfortable on RA,
normal WOB
ABD: Soft, nondistended, nontender, no rebound or guarding, no
ecchymosis or excoriations
Ext: No ___ edema, ___ warm and well perfused, sensation intact,
flexor weakness at left hip
Discharge Physical Exam:
VS: 98.7 PO, BP: 130/83 HR: 67 RR: 18 O2: 96% RA
GEN: A+Ox3, NAD
HEENT: normocephalic, atraumatic
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, non-tender to palpation
EXT: mild left hip tenderness to palpation, no overlying skin
changes, sensation intact. Extremities warm, well-perfused, no
edema b/l
Pertinent Results:
IMAGING:
___: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT:
No fracture.
___: CT Head:
No acute intracranial hemorrhage.
___: CT L-spine:
1. Extremely enlarged left psoas muscle with increased density,
representing intramuscular hematoma. Moderate amount of
surrounding soft tissue density, likely representing
retroperitoneal hemorrhage.
2. No evidence of acute fracture. Moderate degenerative disc
disease, most severe at L4-5 and L5-S1.
3. 11 mm left adrenal adenoma.
___: CT Pelvis:
1. Left psoas intramuscular hematoma with additional component
of free
left-sided RP hematoma. Evaluation for active extravasation is
limited without IV contrast.
2. No evidence of acute fracture.
Brief Hospital Course:
Mr. ___ is a ___ y/o M with a hx of paroxysmal atrial
fibrillation on eliquis who presented s/p mechanical fall down
fall ___ stairs after slipping on the ice. He had left hip pain
following the fall and later presented to ED and was found on CT
scan to have a left psoas intramuscular hematoma but no
fractures. A NCHCT was
negative. Eloquis and subcutaneous heparin were held. HCTs were
trended and remained stable. The patient was admitted to the
Trauma Surgery service for pain control and physical therapy.
On HD2, the patient was written for a regular diet and IV fluids
were discontinued. HCT was stable. The patient worked with
Physical Therapy.
The patient was alert and oriented throughout hospitalization;
pain was initially managed with IV hydromorphone and then
transitioned to oral oxycodone and acetaminophen once tolerating
a diet. The patient remained stable from a cardiovascular and
pulmonary standpoint; vital signs were routinely monitored. Good
pulmonary toilet and early ambulation were encouraged throughout
hospitalization.
The patient's intake and output were closely monitored. The
patient's fever curves were closely watched for signs of
infection, of which there were none. The patient's PCP's office
was called and notified that Eloquis was held during
hospitalization and that the decision to restart this medication
would be at the PCP or ___ discretion. Subcutaneous
heparin was held during the ___ hospital stay. ___ 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 with a cane, 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:
Atenolol 25 mg PO DAILY
Simvastatin 40 mg PO QPM
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
do NOT drink alcohol or drive while taking pain medication
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
5. Atenolol 25 mg PO DAILY
6. Simvastatin 40 mg PO QPM
7.Straight cane
Dx: gait instability
Px: good
Duration: 13 (thirteen) months
Discharge Disposition:
Home
Discharge Diagnosis:
Left sided retroperitoneal hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after a fall and were found to
have a deep bruise overlying your left hip. Your blood counts
were monitored for any signs of active bleeding and you have
remained stable. You have worked with Physical Therapy and have
been cleared for discharge home.
Your pain is now better controlled and you are ready to be
discharged home to continue your recovery. Please follow the
discharge instructions below to ensure a safe recovery while at
home:
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:
___
|
10882916-DS-59
| 10,882,916 | 21,419,667 |
DS
| 59 |
2187-11-08 00:00:00
|
2187-11-08 18:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Reglan / Compazine / Gentamicin / Sulfa (Sulfonamide
Antibiotics) / Tigan / Meperidine / Prednisone / Cefotaxime /
Vancomycin / Cephalosporins / Infliximab / Mercaptopurine /
Mesalamine / Heparin Agents / Fluconazole / Meropenem /
Tizanidine / Ativan / Loperamide / Iodine Containing Agents
Classifier / Feraheme / Naltrexone
Attending: ___
Chief Complaint:
Vomiting/R Flank Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ witha PMH significant for history of Crohns and multiple
episodes of obstruction/psuedoobstruction and abdominal pain
presents with abdominal distention.
.
Her story begins at the end of ___, when she saw Dr. ___,
___ ___ physician, who performed a colonscopy with some lysis of
adhesions. She was in ___ on ___, when she noticed "air
from her vagnia) as well as severe right flank pain. She was
seen in urgent care in ___ at the time, and was prescribed
Cipro and oral pain medications for suspected UTI and/or passed
urinary stone given some blood on UA, with instructions to
return to an ER if symptoms reoccurred. She had abdominal pain
again with R flank pain in ___ in the AM, and so went to an
ER at which point she had a CT scan which apparently revealed no
kidney stones, but a possible early small bowel ileus w/ no
transition points. Pt was advised to stay in ___ for
treatment, but flew to ___ for further care.
.
On her ROS, she endorses low grade fevers to 100, chills for hte
past two days, a dry cough she attributes to allergies, DOE and
SOB, abdominla pain, nausea and vomiting since ___,
perisistent diarrhea (not new), hematuria, R back pain radiating
to R flank and lower abdomen.
.
In the ED, initial VS 99.4 ___ 18 97% ra. On transfer,
she was ___.4-105-18 122/56. Her labs were notable for a Ca: 8.3,
and a HCT of 32.1.
.
KUB at ___ showed diffuse colonic distention with stool and
high-density material, presumably from recent CT scan, a few
scattered small bowel loops which do not appear dilated,
suggestive of colonic ileus, similar to prior and slightly high
NG tube.
.
Patient recieved a total of 4mg Dilaudid IV, DiphenhydrAMINE 50
mg IV ONCE, and 1 L NS.
.
Past Medical History:
1. Crohn's disease:
- Diagnosed ___
- S/p ~13 surgeries including transverse / ascending colectomy
- Rectovaginal fistula
2. Short bowel syndrome
3. History of multiple SBOs
4. SVC syndrome s/p angioplasty
- ___: episode of facial and neck swelling; noted to have
stenoses of right subclavian and SVC
- Angioplasty by ___
5. HIT+ Ab: s/p 30 days treatment with Fondaparinux
6. Mediastinal lymphadenopathy NOS: followed by Dr. ___
7. Pulmonary nodules
8. Hypothyroidism
9. Parathyroid adenoma s/p removal
10. PTSD, particularly active when in hospital setting due to
prior assault in hospital setting many years ago
11. Depression & Anxiety
12. Fibromyalgia
13. History of gastric dysmotility; has been on TPN in past
14. History of line/portocath infections (partic w/ coag neg
staph)
15. Fatty liver with mildly elevated LFTs at baseline
16. Anemia, iron deficiency
17. S/p TAH BSO
18. S/p cholecystectomy
___. S/p Right knee meniscal surgery ___
20. S/p Left knee meniscal surgery ___
21. nephrolithiasis
Social History:
___
Family History:
Significant for family history of Crohn's disease and
osteoarthritis. No reported family history of CAD or DM.
Physical Exam:
PHYSICAL EXAM:
VS - Temp 99.8 BP 104/73 HR 106 RR 22 965 RA
GENERAL - Alert, interactive, well-appearing but in intermittent
distress
HEENT - PERRLA, EOMI, sclerae anicteric, dry MM
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - distended, diffuse TTP, could not appreciate any bowel
sounds
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
___ 09:40PM BLOOD WBC-5.7# RBC-3.92* Hgb-10.0* Hct-32.1*#
MCV-82 MCH-25.6* MCHC-31.3 RDW-16.4* Plt ___
___ 09:40PM BLOOD Neuts-70.9* ___ Monos-5.3 Eos-3.6
Baso-0.9
___ 09:40PM BLOOD ___ PTT-38.7* ___
___ 09:40PM BLOOD Glucose-88 UreaN-11 Creat-0.9 Na-136
K-3.6 Cl-102 HCO3-23 AnGap-15
___ 09:40PM BLOOD ALT-10 AST-17 AlkPhos-120* TotBili-0.4
___ 09:40PM BLOOD Albumin-4.1 Calcium-8.3* Phos-4.0 Mg-2.0
___ 09:47PM BLOOD Lactate-1.1
___ 05:30PM URINE RBC-6* WBC-3 Bacteri-FEW Yeast-NONE Epi-2
TransE-<1
___ 05:30PM URINE Color-Straw Appear-Clear Sp ___
___ 05:30PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
Micro:
___ Ucx - mixed flora
___ RadiologyABDOMEN (SUPINE & ERECT
IMPRESSION:
1. Diffuse colonic distention with stool and high-density
material,
presumably from recent CT scan. A few scattered small bowel
loops which do
not appear dilated. Findings are suggestive of colonic ileus,
similar to
prior, however clinical correlation with close followup and
repeat exams can be performed as indicated. 2. NG tube seen at
the superior aspect of the film proximal to the GE junction, and
if so repositioning is suggested.
___ urine culture ESCHERICHIA COLI
|
AMPICILLIN------------ 16 I
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
blood culture ___ pending
DISCHARGE LABS
___ 05:50AM BLOOD WBC-2.1* RBC-3.40* Hgb-8.9* Hct-28.2*
MCV-83 MCH-26.2* MCHC-31.5 RDW-17.1* Plt ___
___ 05:50AM BLOOD Glucose-117* UreaN-7 Creat-0.6 Na-140
K-3.9 Cl-103 HCO3-28 AnGap-13
___ 05:50AM BLOOD Calcium-8.5 Phos-4.4 Mg-1.5*
Brief Hospital Course:
___ with a PMH significant for history of Crohns and multiple
episodes of obstruction/psuedoobstruction and abdominal pain
presents with abdominal distention.
.
# Abdominal Pain: Pt had one fever in setting of UTI, no WBC
count, and not locally tender. She endorses intermittent ileus
of unclear the etiology. KUB at time of presentation does not
point to a SBO, but rather a colonic ileus. Etiologies for her
ileus include pain medications, hypothyroidism, electrolyte
abnormalities, or less likely peritonitis or intestinal
ischemia. Her current bowel symptoms are likely from having
received extra medication for her R flank pain. Pt's outpt
gastroenterologist does not feel that she would benefit from
methylnaltrexone. Pt's abdominal symptoms improved with NGT,
ambulation, NPO advanced to Regular diet. Her nausea was
controlled with diphenhydramine, ondansetron, promethazine and
scopolamine patch. Her pain was initially controlled with
Dilaudid IM 3mg q4h PRN, this was transitioned to Dilaudid 8mg
PO q4h.
.
# UTI: the patient reports that she had shaking chills and she
measured her own temperature to be 100.8; upon recheck, her Tm
was 100.3 on ___, then remained afebrile. Her UA was positive,
she was initially empirically started on Ciprofloxacin but then
sensitivites returned and the patient grew E.coli resistant to
cipro but otherwise sensitive, so her abx was changed to
Macrobid. Her blood cultures remained negative but were pending
at time of discharge. Leukopenia noted, similar to previous
values.
.
# tachycardia: unclear etiology; resolved during
hospitalization, likely was secondary to Dehydration vs. pain vs
anxiety vs unable to take / absorb PO oxazepam.
.
# Crohn's disease: S/p ~13 surgeries including transverse /
ascending colectomy. Pt has had multiple SBOs in the past. Pt is
not on any standard medications for Crohns reportedly because
she develops leukopenia (although, of note, she is leukopenic in
house). Currently on naltrexone 4.5mg po qhs but pt is not
taking her naltrexone because it "causes her calf spasms." Her
pain was initially controlled by IM dilaudid (very poor IV
access and NPO initially) and then transitioned to PO Dilaudid.
Her nausea was controlled with benadryl, scopolamine patch,
ondansetron and promethazine.
.
# HIT+ Ab: Continued Fondaparinaux
.
# Hypothyroidism: Continued Levothyroxine
.
# PTSD/Depression/Fibromyalgia: continue home oxazepam 15mg
.
# Anemia, iron deficiency: initially was hemoconcentrated at
32.1, was 25.3 on last discharge.
.
TRANSITIONAL ISSUES:
- Blood cultures pending at time of discharge.
Medications on Admission:
Hydromorphone 2 mg Q4H PRN pain
Fondaparinux 2.5 mg Daily
Levothyroxine 50 mcg Daily
Amlodipine 5 mg Daily
naltrexone 4.5 mg QHS
-also roxicet which pt denied she had but was found in her bag
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. hydromorphone 2 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain: Do not drive while taking this
medication. Do not drink alcohol.
4. fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1) Subcutaneous
once a day.
5. oxazepam 15 mg Capsule Sig: One (1) Capsule PO twice a day
for 3 days.
Disp:*5 Capsule(s)* Refills:*0*
6. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6)
hours as needed for nausea for 7 days.
7. nitrofurantoin monohyd/m-cryst 100 mg Capsule Sig: One (1)
Capsule PO Q12H (every 12 hours) for 5 days.
Disp:*11 Capsule(s)* Refills:*0*
8. phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
9. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
10. promethazine 25 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for nausea.
11. Dilaudid 4 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for pain for 4 days.
Disp:*25 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
colonic ileus
Secondary:
urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms ___,
You came to the hospital because you had abdominal pain, nausea,
and vomiting. Our studies suggested that you had a condition
called colonic ileus, when your colon stops moving material
through. This may have been caused by the additional opiate
medications that you received for your suspected urinary stone,
or it may have been caused by an acute worsening of your Crohn's
disease. You were treated conservatively with fluids,
nasogastric tube with suctioning, and your pain and nausea were
controlled with several medications.
We have made the following changes to your medications:
- START Macrobid to complete one week course
- Take dilaudid, your anti-nausea meds and oxazepam as needed
- START Pyridium for your bladder discomfort for up to 3 days as
needed.
- Please continue the rest of your medications as prescribed.
Followup Instructions:
___
|
10882916-DS-60
| 10,882,916 | 27,666,782 |
DS
| 60 |
2188-01-12 00:00:00
|
2188-01-15 11:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Reglan / Compazine / Gentamicin / Sulfa (Sulfonamide
Antibiotics) / Tigan / Meperidine / Prednisone / Cefotaxime /
Vancomycin / Cephalosporins / Infliximab / Mercaptopurine /
Mesalamine / Heparin Agents / Fluconazole / Meropenem /
Tizanidine / Ativan / Loperamide / Iodine Containing Agents
Classifier / Feraheme / Naltrexone
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old woman with PMH significant for history of Crohn's
and multiple episodes of obstruction/psuedoobstruction and
abdominal pain presents with one week of worsening abdominal
pain and vomiting. She states that she has been experiencing
"one episode of ileus per week", but this week had 4 days of
abdominal distention and vomiting small amounts. She says that
these symptoms are the same as her prior obstructions /
pseudoobstructions. She has been trying to manage her symptoms
at home with PO pain meds. However, last night she experienced
new onset sharp right sided abdominal pain that she could not
control with PO dilaudid. She did have 1 small bowel movement
and passed gas yesterday morning. However, she has not passed
gas or had a bowel movement in the past 24 hours.
.
The patient also notes that since ___, she has had recurrent
UTIs, raising a concern for a fistula to the bladder. She does
endorse passing air through her urethra. She states that
despite not passing gas through her anus, she has continued to
pass air through her urethra during this hospitalization.
.
In the ED, initial VSS. CT showed Long-segment wall thickening
of distal ileum in R abdomen, possibly chronic. Continued
dilation at ileocolonic anastomosis and narrowing beyond this
point. Surgery was consulted, who felt there was no surgical
intervention needed. Potassium was notable for K=2.8 at 4pm,
which was not repleted until 40meQ IV started at 2am. NGT was
placed and placed at low wall suction. Patient recieved a total
of 16mg Dilaudid IV or SQ, 5mg valium while in the ER. On
transfer, VS 98.0, 88, 111/56, 16, 98 RA.
.
Currently, the patient complains of moderate right lower
quadrant pain. She states that she experiences severe sharp
pain that comes in waves. Pain is alleviated with dilaudid.
Past Medical History:
1. Crohn's disease:
- Diagnosed ___
- S/p ~13 surgeries including transverse / ascending colectomy
- Rectovaginal fistula
2. Short bowel syndrome
3. History of multiple SBOs
4. SVC syndrome s/p angioplasty
- ___: episode of facial and neck swelling; noted to have
stenoses of right subclavian and SVC
- Angioplasty by ___
5. HIT+ Ab: s/p 30 days treatment with Fondaparinux
6. Mediastinal lymphadenopathy NOS: followed by Dr. ___
7. Pulmonary nodules
8. Hypothyroidism
9. Parathyroid adenoma s/p removal
10. PTSD, particularly active when in hospital setting due to
prior assault in hospital setting many years ago
11. Depression & Anxiety
12. Fibromyalgia
13. History of gastric dysmotility; has been on TPN in past
14. History of line/portocath infections (partic w/ coag neg
staph)
15. Fatty liver with mildly elevated LFTs at baseline
16. Anemia, iron deficiency
17. S/p TAH BSO
18. S/p cholecystectomy
___. S/p Right knee meniscal surgery ___
20. S/p Left knee meniscal surgery ___
21. nephrolithiasis
Social History:
___
Family History:
Significant for family history of Crohn's disease and
osteoarthritis. No reported family history of CAD or DM.
Physical Exam:
Admission Physical Exam:
VS - 98.2 ___ 18 97%RA
GENERAL - Alert, interactive, well-appearing but in intermittent
distress
HEENT - PERRLA, EOMI, sclerae anicteric, dry MM
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - distended, diffuse TTP, could not appreciate any bowel
sounds
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact
.
Discharge Physical Exam:
VS - 98.1 135-143/91 ___ 18 97%RA
GENERAL - Alert, interactive, appears comfortable; NGT in place,
clamped
HEENT - PERRLA, EOMI, sclerae anicteric, dry MM
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - mildly distended - improved from yesterday, areas of
superficial firmness related to scar tissue; midline vertical
scar; normoactive bowel sounds- mildly improved from yesterday;
abdomen moderately tender to palpation on right side (lower
quadrant > upper quadrant); no rebound or guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Admission Labs ___ 03:35PM:
WBC-4.8 RBC-4.64 Hgb-11.6* Hct-36.5 MCV-79* MCH-25.0* MCHC-31.8
RDW-16.0* Plt ___
Neuts-61.5 ___ Monos-5.9 Eos-3.4 Baso-0.7
Glucose-92 UreaN-9 Creat-0.8 Na-142 K-2.8* Cl-107 HCO3-22
AnGap-16
ALT-13 AST-18 AlkPhos-106* TotBili-0.3
Lipase-62*
Albumin-4.2 Calcium-9.1 Phos-2.9 Mg-1.6
Lactate-1.7
.
Discharge Labs ___ 08:50AM:
WBC-3.2* RBC-3.78* Hgb-9.4* Hct-29.3* MCV-78* MCH-24.8*
MCHC-31.9 RDW-15.5 Plt ___
Glucose-124* UreaN-6 Creat-0.8 Na-141 K-3.1* Cl-102 HCO3-29
AnGap-13
Calcium-8.5 Phos-2.6* Mg-1.3*
PTH-65
.
Inflammatory Markers:
___ 06:30AM BLOOD ESR-51*
___ 06:30AM BLOOD CRP-7.9*
.
Urinalysis:
___ 12:10PM
Color-Yellow Appear-Clear Sp ___
Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
RBC-3* WBC-8* Bacteri-NONE Yeast-NONE Epi-<1 TransE-<1
CastHy-9*
Mucous-MANY
URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
.
___ 11:27AM
Color-Yellow Appear-Clear Sp ___
Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-40
Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
RBC-1 WBC-5 Bacteri-NONE Yeast-NONE Epi-1 TransE-<1
CastHy-1*
Mucous-RARE
URINE CULTURE (Final ___: <10,000 organisms/ml.
.
Imaging:
.
CT abd/pelvis with contrast ___:
1. Mild wall thickening of the distal ileum, likely reflecting
chronic inflammation.
2. No definite small bowel obstruction. Unchanged focal
dilation at ileo-colonic anastomosis.
.
Abdominal X-ray supine/erect ___:
1. NG tube with side port in the distal esophagus needs to be
advanced at least 4 cm to position the side port within the
proximal stomach.
2. Nonspecific gas-filled loops of large bowel with evidence of
oral contrast transit into the rectum from ___. No evidence
of ileus or obstruction at this time.
Brief Hospital Course:
___ year old woman with a history of Crohn's complicated by
multiple episodes of obstruction/pseudoobstruction and abdominal
pain presents with abdominal pain/vomiting, found to have likely
ileus.
.
# Abdominal Pain: The patient was admitted with 1 day of sharp
right sided abdominal pain associated with nausea and vomiting.
At the time of admission, she had not had a bowel movement or
passed gas in 24 hours. The patient underwent CT abdomen/pelvis
in the ED that did not show any evidence of obstruction or
active Crohn's flare. No air fluid levels or dilated bowel on
KUB. She was made NPO and placed on an NG tube with suction as
treatment for ileus. Etiology of ileus unclear; likely
combination of hypokalemia and Dilaudid use at home. Potassium
was repleted. She was given IV dilaudid and zofran for pain and
nausea control. The patient's symptoms improved, and she began
to have normal bowel movements. NG tube was removed. Her diet
was advanced, and she tolerated it well. She was discharged on
home medications, including dilaudid 8 mg q4-6 hours as needed
for pain for the next 1 week. The patient was urged to taper
dilaudid as possible, as it contributes to poor gut motility.
The patient will follow up with Dr. ___ as an outpatient.
.
# Crohn's disease: Chronic. Status post ~13 surgeries including
transverse / ascending colectomy. This has led to multiple small
bowel obstructions in the past. Patient also with multiple UTIs
and pneumaturia since ___, concerning for developing fistula.
She has a known rectovaginal fistula, and did pass stool through
her vagina during admission. On admission, no evidence of acute
Crohn's flare on CT scan. The patient was scheduled to undergo
MR pelvis and MR enterography as an outpatient to evaluate for
fistula. She will follow up with Dr. ___ the results
of these tests.
.
# HIT+ Ab: The patient was continued on home Fondaparinaux.
.
# Hypothyroidism: Chronic. TSH in ___ within normal limits.
The patient was continued on home Levothyroxine.
.
# PTSD/Depression/Fibromyalgia: Chronic. The patient's home
oxazepam was held while she was strict NPO. It was resumed once
able to take PO.
.
# Anemia, iron deficiency: Chronic. The patient's hematocrit
remained stable throughout admission.
.
# h/o parathyroid adenoma: Per patient, she was due for repeat
level PTH level during hospitalization. PTH level returned
normal on the day of discharge. The patient should follow up
with her PCP regarding the results.
.
# CODE: Full
============================================
TRANSITIONAL ISSUES:
# Patient to follow up with PCP for electrolyte check
(hypokalemic and hypomagnesemic on admission)
# Patient scheduled for outpatient MRI pelvis/MRE to evaluate
for fistula formation. She will follow up with Dr. ___
___ the results
# Patient to follow up with PCP regarding PTH level
Medications on Admission:
AMLODIPINE - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day
CYANOCOBALAMIN (VITAMIN B-12) [NASCOBAL] - 500 mcg Spray once a
week
DULOXETINE [CYMBALTA] - 60 mg daily
FONDAPARINUX [ARIXTRA] - 7.___aily
HYDROCHLOROTHIAZIDE - 12.5 mg daily
HYDROMORPHONE - 8mg qid as needed for pain
LEVOTHYROXINE - 50 mcg daily
METRONIDAZOLE - 500 mg BID-TID
ONDANSETRON - ___ mg Tablet, BID PRN
OXAZEPAM - 15 mg Capsule - 1 qam and 2 qhs PRN anxiety, insomnia
POTASSIUM CHLORIDE
PROMETHAZINE - 25 mg Tablet - BID as needed
TRAMADOL - 50 mg Tablet - ___ Tablet(s) TID PRN
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - 1,000 unit Tablet
- 1
Tablet(s) by mouth once a week
MAGNESIUM OXIDE
Discharge Medications:
1. fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
2. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
3. Nascobal 500 mcg Spray, Non-Aerosol Sig: One (1) Nasal once
a week.
4. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
8. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) as needed for nausea.
9. oxazepam 15 mg Capsule Sig: One (1) Capsule PO qAM as needed
for anxiety.
10. oxazepam 15 mg Capsule Sig: Two (2) Capsule PO at bedtime as
needed for insomnia, anxiety.
11. potassium chloride Oral
12. promethazine 25 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for nausea.
13. tramadol 50 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
14. Vitamin D3 1,000 unit Tablet Sig: One (1) Tablet PO once a
week.
15. magnesium oxide Oral
16. Dilaudid 8 mg Tablet Sig: One (1) Tablet PO every ___ hours
as needed for pain for 7 days.
Disp:*35 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: ileus
Secondary diagnosis: Crohn's disease complicated by fistula
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
.
You were admitted to the hospital with abdominal pain caused by
a slowing of your intestines called ileus. You underwent
imaging on admission that did not show any evidence of
obstruction. A nasogastric tube was placed, and you were
treated with bowel rest and pain control. Your intestines began
to function properly again, and your pain improved. You were
able to pass bowel movements. Your diet was advanced, and you
tolerated it well. You were discharged to home on oral pain
control.
.
As an outpatient, you should undergo an MRI of your intestines
and pelvis to evaluate for fistula formation. Please call
___ to schedule the MRI appointment.
.
MEDICATIONS CHANGED THIS ADMISSION:
none
Followup Instructions:
___
|
10882916-DS-62
| 10,882,916 | 23,971,509 |
DS
| 62 |
2188-05-12 00:00:00
|
2188-05-13 09:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Reglan / Compazine / Gentamicin / Sulfa (Sulfonamide
Antibiotics) / Tigan / Meperidine / Prednisone / Cefotaxime /
Vancomycin / Cephalosporins / Infliximab / Mercaptopurine /
Mesalamine / Heparin Agents / Fluconazole / Meropenem /
Tizanidine / Ativan / Loperamide / Iodine Containing Agents
Classifier / Feraheme / Naltrexone
Attending: ___
Chief Complaint:
RUE hematoma, abdominal pain
Major Surgical or Invasive Procedure:
1. Nasogastric tube placement (self placed).
History of Present Illness:
Ms. ___ is a ___ year old woman with history of Crohn's disease
c/b rectovaginal fistula and multiple small bowel resections,
h/o SVC syndrome s/p angioplasty on fondaparinux, (h/o HIT), h/o
parathyroid adenoma who presents with progressive RUE pain and
developing hematoma, as well as subacute onset of lower
abdominal pain. She had blood drawn on ___ from her right arm
to check her labs. The following day, the patient reported
worsening right upper extremity pain and a large developing
hematoma. She presented to the ED on ___ where an
ultrasound did not show evidence of clot, but did show large
hematoma. She subsequently saw her PCP the following day where
her hematoma was marked out. Yesterday, the patient bumped her
arm during a fall and had acute severe pain.
In addition, for the preceding 24 hours, she reports progressive
abdominal distension, and decreased passage of bowel movements.
She usually passes 5 loose stools per day. She has vomited about
once per day for the past week she reports as "bilious." Patient
does have long standing history of vomiting per pt, and reports
worse after methotrexate which she had on ___. She
subsequently came into the ED for evaluation. She complains of
low grade fevers ~100 since ___. In the ED, she was told
that she had a pneumonia based on CXR. She denies any cough,
bloody stools/emesis, chest pain, or shortness of breath.
Of note according to GI, she has been on many regimens for her
Crohn's disease. Remicade was complicated by Serum Sickness,
___ led to leukopenia, and prednisone was complicated by
psychosis. In ___,
she was started on Methotrexate, which she thinks helped her
Crohn's symptoms. She was seen in clinic by Dr. ___ on ___
where she wascomplaining of abdominal pain and diarrhea. At that
time, she was started on Entocort at 9mg, as well as
Methotrexate. She was also
started on Hydromorphone for control of severe pain. Of note,
she was admitted in ___ with a low hematocrit to 23.1.
At that time, she was complaining of intermittent bright red
blood per stool for several weeks. At that hospitalization, a
flex sig was normal to the splenic flexure.
In the ED, initial VS were: 98 ___ 18 98%RA.
On arrival to the MICU, vital signs were T 98.2 HR 99 BP 118/72
RR 11 O2 sat 98% RA patient reported the history above and
complained of severe pain in the right arm and mild abdominal
pain and distension. She notes that she has not had a bowel
movement since ___, but has been passing flatus.
Review of systems: negative except for above.
Past Medical History:
1. Crohn's disease:
- Diagnosed ___
- S/p ~13 surgeries including transverse / ascending colectomy
- Rectovaginal fistula
2. Short bowel syndrome
3. History of multiple SBOs
4. SVC syndrome s/p angioplasty
- ___: episode of facial and neck swelling; noted to have
stenoses of right subclavian and SVC
- Angioplasty by ___
5. HIT+ Ab: s/p 30 days treatment with Fondaparinux
6. Mediastinal lymphadenopathy NOS: followed by Dr. ___
7. Pulmonary nodules
8. Hypothyroidism
9. Parathyroid adenoma s/p removal
10. PTSD, particularly active when in hospital setting due to
prior assault in hospital setting many years ago
11. Depression & Anxiety
12. Fibromyalgia
13. History of gastric dysmotility; has been on TPN in past
14. History of line/portocath infections (partic w/ coag neg
staph)
15. Fatty liver with mildly elevated LFTs at baseline
16. Anemia, iron deficiency
17. S/p TAH BSO
18. S/p cholecystectomy
___. S/p Right knee meniscal surgery ___
20. S/p Left knee meniscal surgery ___
21. nephrolithiasis
Social History:
___
Family History:
Significant for family history of Crohn's disease and
osteoarthritis. No reported family history of CAD or DM.
Physical Exam:
Admission Physical exam:
Vitals: T 98.2 HR 99 BP 118/72 RR 11 O2 sat 98% RA
Gen: NAD
Neck: no masses
CV: NR, RR, no murmurs
Pulm: CTAB, good air movement, no coughing
Abd: distended, soft, +BS
Ext: right arm ecchymosis encompassing most of her upper arm,
soft, no swelling, no lower extremity edema,
Rectal: in ED: guiaic negative
Discharge Physical Exam:
Vitals: T 98.2 HR 72 BP 120/69 RR 24 O2 sat 100% RA
Gen: NAD
Neck: no masses, JVP not elevated
CV: RRR, no murmurs
Pulm: CTAB, good air movement, no coughing
Abd: distended, soft, minimally tender to palpation, +BS
Ext: right arm ecchymosis encompassing most of her upper arm,
soft, no lower extremity edema, full range of motion of elbow
and fingers, no numbness
Pertinent Results:
Admission labs:
___ 04:30AM BLOOD WBC-4.8 RBC-3.23*# Hgb-8.2*# Hct-24.3*#
MCV-75* MCH-25.4* MCHC-33.7 RDW-19.8* Plt ___
___ 10:05PM BLOOD WBC-3.9* RBC-3.29* Hgb-8.1* Hct-24.6*
MCV-75* MCH-24.6* MCHC-32.8 RDW-20.5* Plt ___
___ 04:30AM BLOOD Neuts-77.4* Lymphs-17.3* Monos-2.4
Eos-2.3 Baso-0.5
___ 04:30AM BLOOD Glucose-121* UreaN-12 Creat-0.7 Na-139
K-2.9* Cl-98 HCO3-31 AnGap-13
___ 04:30AM BLOOD Albumin-4.0 Calcium-8.4 Phos-3.2# Mg-1.7
___ 04:30AM BLOOD ALT-17 AST-20 AlkPhos-121* TotBili-0.4
___ 05:07AM BLOOD Lactate-1.7
Discharge labs:
Team recommended following hematocrit to ensure continued
stability, but patient declined due to psychological stressors
(see hospital course).
Studies:
___ CXR PA/Lat:
1. Hazy opacity in the right upper lung field is not
significantly changed and likely represent an area of chronic
airspace disease. Overlying infection cannot be excluded.
2. Nasogastric tube with both side port and the tip above the
gastroesophageal junction raised increased risk for aspiration.
The tube should be advanced at least 12 cm.
___ CT Abd/Pelv:
There is no retroperitoneal bleed. There is no free air or free
fluid.
___ X-ray shoulder and elbow:
No specific radiographic evidence of displaced fracture or
dislocation of the right elbow and right shoulder. Soft tissue
contusion overlying the right elbow.
___ KUB
1. Multiple air-fluid levels with dilated loops of bowel suggest
small-bowel obstruction.
2. NG tube with both tip and side port above the GE junction
should be advanced at least 12 cm.
Micro: None
Brief Hospital Course:
Ms. ___ is a ___ year old woman with Crohn's disease
complicated by rectovaginal fistula and multiple SBOs s/p
multiple abdominal surgeries, also with prior SVC surgery now on
___, who was transferred to ICU from ED for hypotension
and HCT drop of 15 in past 4 days likely due to her right upper
extremity hematoma.
# Acute blood loss anemia: Patient had 14 point Hct drop over
the course of 5 days (38.7 on ___ to 24.3 on ___. The
most likely source of this anemia is acute blood loss from large
hematoma in RUE (below) thought to be related to trauma from
venipuncture on routine outpatient lab work in the setting of
her anticoagulation with fondaparinux. Patient also noted a fall
onto right arm as well, which also could have contributed to the
large hematoma. Other possible causes of anemia were considered
including retroperitoneal bleed, GI losses, or hemolysis, but
there was no evidence of RP bleed on CT, NG lavage and guaiac
were negative in the ED, and Tbili was normal. Her fondaparinux
was discontinued by her PCP on ___. Her hematocrit
remained stable at 12 hours (24.6, up from 24.3) and the arm
ecchymosis appeard to be resolving. The team recommended
trending the hematocrit the following morning to evaluate for
continued stability, especially since she would be restarting
fondaparinux. Due to the patients psychological stressors from
being in the hospital, she declined further lab draws. She
understood the risks of declining the lab draw, including the
risk of a continued bleed and even death, and she accepted these
risks. She did agree to have her blood drawn the following day
as an outpatient and to return to the hospital if she
experienced any concerning symptoms.
# Right Upper Ext Hematoma: Likely due to deep stick in right
antecubital fossa on ___ while on ___ for her SVC
surgery in ___. Patient stopped her fondaparinux ___ per
PCP. No evidence of compartment syndrome on exam and she
remained neurovascularly intact. The ecchymosis had spread far
beyond the markings drawn by PCP, but hematocrit remained stable
(24.3 on admission to 24.6 approx 12 hours later), and the
ecchymosis improved while hospitalized. She was seen by
vascular surgery who felt she should restart her fondaparinux on
___ given that there was no longer evidence of active
bleeding. She declined further lab draws (as above), but agreed
to have blood drawn as outpatient within ___ days.
# Partial SBO: Patient has history of Crohn's disease and has
had multiple bowel obstructions and surgeries. Last abdominal
surgery was ___ per pt. One day prior to admission patient
reported progressive abdominal distension and decreased passage
of bowel movements. Patient self placed an NGT on arrival to the
ED. KUB showed distended loops and air fluid levels concerning
for obstruction, and CT revealed large amount of stool in the
colon with no evidence of free air or transition point. She was
passing flatus throught. Surgery was consulted and felt that no
surgical intervention was indicated. Of note, patient ate solid
foods including a hamburger in the ED and oatmeal for breakfast
the following morning while advised to be NPO. She
self-discontinued her NGT after having a bowel movement.
# Hypotension: Patient had isolated blood pressure reading in
the ___ systolic, otherwise remained in the ___. The most
likely source of her hypotension is poor po intake in the
setting of vomiting and diarrhea. On the differential would be
hypovolemia secondary to acute blood loss from hematoma in arm
(above). Sepsis is unlikely given that she has afebrile without
leukocytosis, and her BPs have stabilized and the remainder of
her vitals are normal. She responded well to IV fluids and did
not require pressors. Her home antihypertensives were held on
admission and restarted on discharge.
# Right apical lung opacity: Patient with RUL opacity on CXR in
ED. This has been noted on multiple prior CXRs and CTA on
___. She was given one dose of levofloxacin emperically in
the ED, but there was no concern for infection on the floor and
this was discontinued. This opacity has been followed by Dr.
___ back to at least ___. CT stability
documented and there is no acute change to suggest infection or
malignancy. This can be followed by xray only unless change or
symptoms are noted.
# Pain Management: Patient's home pain regimen had been
escalated by PCP given pain from hematoma (above) to ___ mg
dilaudid PO Q4H prior to admission. Of note, she is on a
narcotics contract with her PCP. She was transitioned to IV
dilaudid while in house given the partial bowel obstruction
(above) and also requested 50 mg IV benadryl for itching. When
her partial bowel obstruction resolved and she self-discontinued
her NGT, she was transitioned back to PO pain medications.
# Crohn's disease: Diagnosed ___. S/p ~13 surgeries including
transverse / ascending colectomy with ostomy reversal in ___.
History of rectovaginal fistula and short bowel syndrome. She is
currently on methotrexate and Entocort. Initially complianing of
abdominal pain and distension on admission with KUB concerning
for obstruction. Patient symptoms resolved the morning after
admission following a bowel movement.
# SVC syndrome s/p angioplasty: Patient noticed episodes of
facial and neck swelling in ___. She was noted to have stenoses
of right subclavian and SVC and underwent angioplasty by ___ in
___. She has been anticoagulated as outpatient on fondaparinux,
though this was held by PCP two days prior to admission. She was
seen by vascular surgery while in house and they recommended
restarting fondaparinux on ___ given apparent stability
of RUE hematoma.
# Hypothyroidism: Stable. Euthyroid on exam, home levothyroxine
50mcg po daily was continued.
# Hypertension: Home antihypertensives were held on admission
given transient hypotension (above) and were restarted on
discharge.
# Depression/Anxiety/PTSD
# Fibromyalgia: Stable.
# Poor IV access: Unable to have central line. Her only access
on admission was a 20G peripheral in R axilla. If she needs
emergency access, she will require intraosseous access.
# Hx HIT: Avoid all heparin products.
# Transitional issues:
- Patient should have hematocrit checked within ___ days of
discharge to monitor for stability (last hct 24.6)
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/CaregiverwebOMR.
1. Ondansetron 8 mg PO BID:PRN nausea
2. Budesonide 3 mg PO DAILY
3. Magnesium Oxide 500 mg PO ONCE Duration: 1 Doses
4. Methotrexate Sodium P.F. 25 mg IT 1X/WEEK (MO) Duration: 1
Doses
5. Oxazepam 30 mg PO HS:PRN anxiety, insomnia
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm, not with
narcotics/sedating meds
8. Amlodipine 2.5 mg PO DAILY
9. Fondaparinux Sodium 7.5 mg SC DAILY
10. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
11. TraMADOL (Ultram) 50-100 mg PO TID:PRN pain
12. Promethazine 25 mg PO BID:PRN nausea
13. Nystatin Oral Suspension 5 mL PO TID:PRN thrush
swish and swallow
14. Potassium Chloride 20 mEq PO BID Duration: 24 Hours
Hold for K >4
15. Duloxetine 60 mg PO DAILY
16. Hydrochlorothiazide 12.5 mg PO QAM
17. Levothyroxine Sodium 50 mcg PO DAILY
18. Vitamin D 1000 UNIT PO 1X/WEEK (MO)
Discharge Medications:
1. Budesonide 3 mg PO DAILY
2. Duloxetine 60 mg PO DAILY
3. Fondaparinux Sodium 7.5 mg SC DAILY
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Oxazepam 30 mg PO HS:PRN anxiety, insomnia
7. Amlodipine 2.5 mg PO DAILY
8. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm, not with
narcotics/sedating meds
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Hydrochlorothiazide 12.5 mg PO QAM
11. Nystatin Oral Suspension 5 mL PO TID:PRN thrush
swish and swallow
12. Ondansetron 8 mg PO BID:PRN nausea
13. Promethazine 25 mg PO BID:PRN nausea
14. TraMADOL (Ultram) 50-100 mg PO TID:PRN pain
15. Vitamin D 1000 UNIT PO 1X/WEEK (MO)
16. Cyanocobalamin 500 mcg PO QWEEK
17. FoLIC Acid 1 mg PO DAILY
18. Magnesium Oxide 500 mg PO DAILY
19. Methotrexate Sodium P.F. 25 mg IT 1X/WEEK (MO) Duration: 1
Doses
20. Potassium Chloride 20 mEq PO BID Duration: 24 Hours
Hold for K >4
21. Outpatient Lab Work
Please draw hematocrit and have result faxed to Dr. ___
at ___. ICD9 = 285.9.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Right upper extremity hematoma, Partial small
bowel obstruction,
Secondary diagnosis: Crohn's disease, Heparin induced
thrombocytopenia, SVC syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to take care of during your stay at ___.
You were admitted for a collection of blood in your right arm.
Your fondaparinaux was temporarily stopped while your blood
levels stabilized. The fondaparinaux was then resumed. Please
keep your arm elevated and have your blood levels drawn tomorrow
at ___.
In addition, your bowels slowed down and caused you to have a
partial obstruction. You placed a nasogastric tube to help
relieve the pressure and were able to have a bowel movement.
You tolerated a diet prior to discharge.
There were no changes made to your medication regimen.
Followup Instructions:
___
|
10882916-DS-67
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| 67 |
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2190-03-23 10:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Reglan / Compazine / Gentamicin / Sulfa (Sulfonamide
Antibiotics) / Tigan / Meperidine / Prednisone / Cefotaxime /
Vancomycin / Cephalosporins / Infliximab / Mercaptopurine /
Mesalamine / Heparin Agents / Fluconazole / Meropenem /
Tizanidine / Ativan / Loperamide / Iodine Containing Agents
Classifier / Feraheme / Naltrexone
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with crohn's sense of abdominal surgery history presents
with abdominal pain. She says she has had right upper quadrant
pain for the last several weeks, "feels like a balloon is under
her ribs." It is constant but also comes in waves she said and
radiates into her back. this has occured in the past, but has
gone away. Previous removal of gallbladder. Some nausea.
Vomiting every other day, not associated with food, but usually
after walking up the stairs with her grandchildren. Patient has
diarrhea at baseline, stating she had 6 b.m. in the ED today.
Has had a history of obstructions. Had a colonoscopy last year
which showed no problems. Other symptoms include lethargyx2
weeks, barely getting out of bed and an increase in depression.
Patient states since ___ she has been on 6mg dilaudid qid for
pain No sick contacts. Recent travel to ___. Denies fever,
headache, chest pain, shortness of breath.
Past Medical History:
- SVC syndrome, s/p angioplasty, ___: episode of facial and
neck swelling; noted to have stenoses of right subclavian and
SVC, s/p Angioplasty by ___
- HIT+ Ab: s/p 30 days treatment with Fondaparinux
- Crohn's dx ___, s/p ~13 surgeries for obstruction and
adhesiolysis as well as transverse/ascending colectomy,
Rectovaginal fistula
- h/o SBO's
- short bowel syndrome
- Mediastinal LAD NOS: followed by Dr. ___
- ___ nodules
- Hypothyroidism
- Parathyroid adenoma s/p removal
- PTSD, particularly active when in hospital setting due to
prior assault in hospital setting many years ago
- Depression
- Anxiety
- Fibromyalgia
- gastric dysmotility, previously on TPN
- line/portocath infections (partic w/ coag neg staph), mult
central venous access for TPN
- Fatty liver, with mildly elevated LFTs at baseline
- Anemia, iron deficiency
- Nephrolithiasis
- Venogram for SVC ___
- SVC thromboendarterectomy with recon with bovine pericardiu
(___)
- TAH BSO
- CCY
- b/l knee meniscal surg, right knee meniscal surgery ___ and
left knee meniscal surgery ___
Social History:
___
Family History:
Significant for family history of Crohn's disease and
osteoarthritis. No reported family history of CAD or DM.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
Vitals: T: BP:128/60 P:103 R:20 O2: 96%RA
General: Alert, oriented, no acute distress
Neck: Could not appreciate JVD, supple,
LYMPH: No submandibular, cervical, or supraclavicular
adenopathy.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
PULMONARY: Clear to auscultation bilaterally. no wheezes,
rales, rhonchi. bilaterally.
Abdomen: soft, tenderness noted to RUQ. Non-distended. Previous
midline abdominal incision. Bowel sounds present in all
quadrants. Slight Right flank tenderness. No rebound tenderness.
Mild excoriations to upper abdomen.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis .
Skin: dry, no petechia. no edema noted to legs.
PHYSICAL EXAM ON DISCHARGE:
Vitals: 97.8 102/59-134/66 ___ 18 99%RA,
General: Alert, oriented, no acute distress
Neck: Could not appreciate JVD, supple,
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
PULMONARY: Clear to auscultation bilaterally. no wheezes,
rales, rhonchi. bilaterally.
Abdomen: soft, tenderness noted to RUQ. Non-distended. Previous
midline abdominal incision. Bowel sounds present in all
quadrants. Slight Right flank tenderness. No rebound tenderness.
Mild excoriations to upper abdomen.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
excoriations on dorsal aspect hand.
Skin: dry, no petechia. no edema noted to legs.
Pertinent Results:
Labs on Admission
___ 05:15AM BLOOD WBC-5.7 RBC-3.62* Hgb-9.1* Hct-28.2*
MCV-78* MCH-25.3* MCHC-32.4 RDW-16.8* Plt ___
___ 05:15AM BLOOD Neuts-65.0 ___ Monos-9.8 Eos-1.6
Baso-0.6
___ 05:15AM BLOOD ___ PTT-36.2 ___
___ 05:15AM BLOOD Glucose-96 UreaN-19 Creat-1.2* Na-127*
K-3.9 Cl-91* HCO3-20* AnGap-20
___ 05:15AM BLOOD ALT-26 AST-61* AlkPhos-117* TotBili-0.7
___ 05:15AM BLOOD Albumin-4.4 Calcium-8.7 Phos-2.7 Mg-1.2*
___ 05:23AM BLOOD Lactate-1.8
Labs on Discharge
___ 08:00AM BLOOD WBC-2.5* RBC-3.05* Hgb-7.8* Hct-24.8*
MCV-81* MCH-25.5* MCHC-31.3 RDW-17.8* Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD Glucose-99 UreaN-7 Creat-0.6 Na-140 K-3.4
Cl-105 HCO3-24 AnGap-14
___ 08:00AM BLOOD ALT-22 AST-32 LD(LDH)-228 CK(CPK)-455*
AlkPhos-98 TotBili-0.3
___ 08:00AM BLOOD Calcium-8.0* Phos-2.1* Mg-1.7
Imaging Studies
CT Scan Abdomen and Pelvis without Contrast: No acute
intra-abdominal findings. A few small foci of gas in the
anterior abdominal wall likely related to subcutaneous
injections. Small hiatal hernia with oral contrast in the
distal esophagus which may be evidence of gastroesophageal
reflux.
Brief Hospital Course:
___ year old F with PMH of crohns, short bowel syndrome, hx of
superior vena cava collapse on anticoagulation who presents with
abominal pain in right upper quadrant pain for the last 2 weeks.
Patient presented to the ED where a CT scan was performed
revealing no acute intra-abdominal processes. She was then
transferred to the medical floor for further management and pain
control.
#Right Upper Quadrant Pain: A broad differential diagnosis was
entertained on admission including adhesions, intermittent
obstruction, hepatobiliary pathology, pancreatitis,
nephrolithiasis, pyelonephritis, crohns flare, viral gastro. CT
scan was performed revealing no acute intra-abdominal processes.
UA negative. LFTs without clear pathology. Per patient not
similar to previous crohns flare. No true dermatomal pattern of
pain or rash that would indicate Zoster. MRE was requested to
rule out intra-abdominal adhesions vs intermittent obstruction.
However, this was not performed, as it would not be able to be
performed until ___ and patient requested to go home
as pain had returnred to baseline.
___: Pre-renal due to decreased PO intake and emesis. Patients
baseline creatining ~.7, and 1.2 upon admission. Patient
received IVF and creatinine returned to baseline.
# Hypovolemic Hyponatremia. NA on admission was 127 and upon
receiving fluids, became 135.
# Crohns: Patient kept on a gluten free diet
# History of SVC Syndrome: Continued on home fondaparinux
# Depression: Patient relays an increase in depression symptoms
in the past few weeks, likely related to increasing GI symptoms.
Denied SI. Remained on home citalopram.
# PTSD, Anxiety: Particular attention was placed to avoid male
transporters, only males in the room and ensuring that the
entire team was rounding on the patient as a team.Valium was
utilized as needed for anxiety.
Transitional Issues:
# Code Status: Full Code
# Contact, ___, Husband ___
# Follow up with GI and PCP
# continue home pain medication: dilaudid 6mg PO q 6 hours
# MRE to be performed as an outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Citalopram 60 mg PO DAILY
3. Fondaparinux 7.5 mg SC DAILY
4. Potassium Chloride 20 mEq PO DAILY:PRN hypokalemia
5. Nascobal (cyanocobalamin (vitamin B-12)) 500 mcg/spray nasal
once a week
6. Slow-Mag (magnesium chloride) 250 mg oral daily PRN low Mg
7. TraMADOL (Ultram) 50 mg PO QID:PRN Pain
8. HYDROmorphone (Dilaudid) 6 mg PO Q6H:PRN pain
Discharge Medications:
1. Nascobal (cyanocobalamin (vitamin B-12)) 500 mcg/spray nasal
once a week
2. Potassium Chloride 20 mEq PO DAILY:PRN hypokalemia
3. Slow-Mag (magnesium chloride) 250 mg oral daily PRN low Mg
4. Amlodipine 10 mg PO DAILY
5. Citalopram 60 mg PO DAILY
6. HYDROmorphone (Dilaudid) 6 mg PO Q6H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every six (6)
hours Disp #*20 Tablet Refills:*0
7. TraMADOL (Ultram) 50 mg PO QID:PRN Pain
8. Fondaparinux 7.5 mg SC DAILY
9. Diazepam ___ mg PO ONCE PRIOR TO MRI Duration: 1 Dose
RX *diazepam 5 mg ___ tablet(s) by mouth ONCE Disp #*2 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Abdominal Pain, Unclear Etiology
Sceondary: Crohns, Short Bowel Syndrome, PTSD, Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___ was a pleasure taking care of you during your stay at ___.
You presented to the emergency room on ___ for abdominal
pain and generalized malaise. This is likely an acute
exacerbation of pain.
A CT Scan revealed no abnormalities. The MRE was not able to be
done as an inpatient. We will communicate with your outpatient
providers to have the imaging study done after you leave the
hospital.
Your pain was controlled with your home dose of Dilaudid and you
received medication for anxiety and PTSD.
Appointments have been provided for you for your GI doctor and
your primary care physician.
We wish you the best of luck,
Your team at ___
Followup Instructions:
___
|
10882916-DS-72
| 10,882,916 | 21,837,221 |
DS
| 72 |
2191-09-22 00:00:00
|
2191-09-24 07:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Reglan / Compazine / Gentamicin / Sulfa (Sulfonamide
Antibiotics) / Tigan / Meperidine / Prednisone / Cefotaxime /
Vancomycin / Cephalosporins / Infliximab / Mercaptopurine /
Mesalamine / Heparin Agents / Fluconazole / Meropenem /
Tizanidine / Ativan / Loperamide / Feraheme / Naltrexone /
fentanyl
Attending: ___.
Chief Complaint:
Fall/Right Hip Pain
Major Surgical or Invasive Procedure:
Right Hip fracture repair with Trochanteric Fixation Nail
History of Present Illness:
HISTORY OF PRESENT ILLNESS: ___ old female complex PMHx
including Crohn's, multiple prior SBO and bowel resections,
short gut syndrome, HIT, severe venous restrictions ___ TPN,
recurrent kidney stones and UTI, recurrent PNA, narcotic pain
dependence, SVC syndrome s/p SVC graft on fondaparinux now
presenting post fall at 1AM ___. Pt is uncertain of the etiology
of the fall, she recalls being stressed about a family
situation. She has previously fainted in stressful situations.
She endorses feeling some shortness of breath, but no chest pain
or palpitations. She was unable to provide further history
regarding the event. Husband found her after she was calling for
help, unclear of duration of LOC. She was neurologically intact
when husband found her.
Of note, recently evaluated in ___ ___ prior for PNA,
discharged on Bactrim and started on codeine for cough, also
started on flexeril for LBP/spasms night prior to fall. She has
continued to have cough and subjective fevers, in addition to
her chronic abdominal pain and back pain.
OSH Course: On exam, pt has s/sx of supratherapeutic dose of
opiiates. Her resp status is preserved with no indication for
emergent reversal. R hip with painful ROM, TTP over greater
troch, no distal n/m/v deficits. No signs/symptoms or workup
concerning for ACS or neurologic event. Setting of fall
concerning for narcotic oversedation. Tramua evaluation revealed
acute R femur/hip fracture, but no ICH, neck fracture.
Transferred to ___ for medical comorbidities.
OSH EKG: sinus, 94, NA, NI, TWF ___ that is ___ to ___
In the ED, initial VS were 98.0 96 130/80 16 94% RA .
Exam notable for TTP right anterolateral thigh with ecchymoses,
painful PROM knees, right ankle with no painful A/P ROM,
sensation/motor/perfusion intact distally..
Labs showed microcytic anemia to 7.4,
CXR showed unchanged parenchymal opacities and Pelvic X-ray
showed Right oblique subtrochanteric fracture with significant
medial displacement and medial angulation of the distal fracture
segment
Received IV dilaudid for pain control and pre-operative workup.
Transfer VS were Tmax 101.8, Tc 100.8 98 148/59 16 99% RA
Orthopedics were consulted for R proximal femur fracture.
Requested pre-op workup, x-rays, vascular surgery, admission to
medicine with intended OR date tomorrow. Vascular surgery
suggested using argatroban drip. Trauma deferred surgery to
orthopedic in setting of isolated R femur fx.
Decision was made to admit to medicine for further management.
Past Medical History:
- Crohn's disease s/p ~13 surgeries for obstruction and
adhesiolysis
- Rectovaginal fistula
- SVC syndrome
- HIT
- Mediastinal lymphadenopathy NOS: followed by Dr. ___
- ___ nodules
- Hypothyroidism
- PTSD
- Depression & Anxiety
- Fibromyalgia
- gastric dysmotility, short gut syndrome, has been on TPN in
the
past
- h/o portacath infections
- Fatty liver with mildly elevated LFTs at baseline
- Anemia, iron deficiency
- Nephrolithiasis
PSH:
- Parathyroid adenoma s/p removal
- Multiple central venous access for TPN
- TAH BSO
- Cholecystectomy
- Bilateral knee meniscal surgery
- Stent placement on R IJ vein and CIV and EIV ___
- exploratory laparotomy & lysis of adhesions ___
- cystoscopy, pyelogram ___
Social History:
___
Family History:
Significant for family history of Crohn's disease and
osteoarthritis. No reported family history of CAD or DM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS - 100.7 138/64 94 20 97%
GENERAL: Uncomfortable, obese women
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, poor dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, systolic murmur heard best and LLSB
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, tender with deep palpation in RLQ
(Chronic per pt), no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: TTP anterolateral R hip with ecchymoses; R knee
with effusion as well. Pain with PROM of R knee, full ROM at
ankle.
PULSES: 2+ DP/TP pulses bilaterally
NEURO: CN II-XII intact, AOx3, Tangential speech. Sensation
intact R leg.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=====================
Pertinent Results:
ADMISSION LABS
=============
___ 01:24PM BLOOD WBC-5.1 RBC-3.29*# Hgb-7.4*# Hct-25.3*#
MCV-77* MCH-22.5* MCHC-29.2* RDW-19.9* RDWSD-53.1* Plt ___
___ 01:24PM BLOOD Neuts-67.0 Lymphs-18.9* Monos-10.7
Eos-2.2 Baso-0.8 Im ___ AbsNeut-3.40 AbsLymp-0.96*
AbsMono-0.54 AbsEos-0.11 AbsBaso-0.04
___ 01:05PM BLOOD ___ PTT-42.1* ___
___ 12:11PM BLOOD Glucose-103* UreaN-16 Creat-0.9 Na-134
K-4.8 Cl-103 HCO3-17* AnGap-19
___ 01:05PM BLOOD ALT-23 AST-29 LD(LDH)-237 AlkPhos-113*
TotBili-0.5
___ 01:05PM BLOOD CK-MB-4 cTropnT-<0.01
___ 12:11PM BLOOD Calcium-8.4 Phos-2.9 Mg-1.6
MICRO:
======
___ Urine and Blood Cultures without growth
___ ___ Sputum Culture grew Fluoroquinolone resistant
E.coli
___ ___ Sputum Culture grew MRSA
IMAGING
=======
___:
CT RLE (___) - Comminuted, impacted proximal femoral
predominantly intertrochanteric and extending below the
intratrochanteric region to exit along the lateral cortex with
varus angulation of the fracture. There is lateral rotation of
the distal femoral fracture fragment. The femoral head remains
articulated with the acetabulum
CXR ___
Right upper lobe parenchymal opacities are grossly unchanged
from ___. No superimposed acute cardiopulmonary
process.
Pelvic/R femur X-ray ___. Right oblique subtrochanteric fracture with significant
medial displacement and medial angulation of the distal fracture
segment.
2. Mild degenerative change of the bilateral hips and bilateral
knees.
___ CXR:
In comparison to ___ chest radiograph, patchy
bibasilar opacities are new as well as a poorly defined opacity
in the right upper lobe. These findings may be due to
multifocal atelectasis, aspiration, or pneumonia.
DISCHARGE LABS
=============
Brief Hospital Course:
___ yoF with complex PMH significant for SVC syndrome on
fondaparinux, chronic narcotic use, Crohn's, and HIT presenting
for R femur fracture s/p syncopal fall
#R Femur fracture: Patient with right proximal femur fracture in
setting of syncopal fall. Patient does carry a history of
osteoporosis. Underwent successful fracture repair ___. She
was anti coagulated with argatroban preoperatively and
transitioned back to her home ___ dose.
Post-operatively, she required 1 unit pRBC transfusion on two
separate occasions. She was able to work with physical therapy
who suggested discharge to rehab. Her pain was well controlled
with acetaminophen and PO hydromorphone with occasional IV
hydromorphone for breakthrough pain. She worked with ___ and was
discharged to rehab.
#Syncope/Unwitnessed fall: Patient had unwitnessed fall
overnight under unclear circumstances. Patient had recently
increased narcotic regimen from oxycodone to hydrocodone and 3
hours prior to fall took cyclobenzaprine tab. Also noted to have
stressful family situation that may have triggered vasovagal
fall, but more likely medication effect. . No CP, SOB, or
palpitations. EKG not consistent with heart block, arrhythmia,
or ischemia. No ICH or neck fracture on outside CT. No focal
deficit or history of seizure to suggest neurologic origin.
Patient did not have any cardiac events on 72 hours of
telemetry. Patient was cautioned about use of sedating
medications and risk of falls.
# Fever/Recent PNA: Tmax 101.8 in ED. Suspected to be secondary
to fracture but was recently treated for MRSA and/or E.coli PNA
at ___ with discharge ___ on 14-day course of
Bactrim. Given fever in the perioperative period, she was
started on Vancomycin and Zosyn ___. On ___ overnight, spiked
fever postoperatively to 101. Her fever resolved and she
remained without cough after this point. Given negative blood
and urine cultures, as well as a CXR generally consistent with
prior, antibiotics were stopped ___.
# Anemia: Patient with chronic anemia (___) presented with
acute loss of blood likely secondary to fracture Patient
required pRBC transfusion on two separate days in the post
operative period.
#SVC Syndrome with graft / HIT / Hx of DVTs: Patient was on
argatroban drip in the preoperative period before restarting her
home fondaparinux
# chronic abdominal pain/Crohn's: Patient did not have a flare
of Crohn's this admission. Her pain was controlled as outlined
above in addition to her home gabapentin
# PTSD: Hx of sexual assault in hospital setting. Diazepam 5 BID
PRN
#HTN/GERD: Continued home medications
TRANSITIONAL ISSUES
=================
-Patient's pain regimen increased to PO hydromorphone ___
q4hours PRN pain in setting of acute fracture, repair, and ___.
Would suggest tapering back to home regimen 4mg PO hydromorphone
q6h PRN pain as soon as clinically tolerated
-Would monitor patient's chronic anemia with twice weekly CBC
-Would monitor electrolytes with twice weekly BMPs
-Has chronic low level pancyctopenia; appears
chronic/intermittent, warrants work-up as an outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Cyclobenzaprine 10 mg PO BID:PRN pain
3. Escitalopram Oxalate 20 mg PO DAILY
4. Fondaparinux 7.5 mg SC DAILY
5. Gabapentin 600 mg PO TID
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Ondansetron ___ mg PO BID:PRN nausea
9. cyanocobalamin (vitamin B-12) 500 mcg/spray nasal 1X/WEEK
10. Saccharomyces boulardii 750 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Magnesium Oxide 500 mg PO DAILY
13. TraMADOL (Ultram) 50-100 mg PO TID:PRN pain
14. Potassium Chloride 20 mEq PO DAILY
15. Clotrimazole 1 TROC PO QID
16. Codeine Sulfate 30 mg PO Q8H:PRN pain
17. HYDROmorphone (Dilaudid) 4 mg PO Q8H:PRN pain
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Escitalopram Oxalate 20 mg PO DAILY
3. Fondaparinux 7.5 mg SC DAILY
4. Gabapentin 600 mg PO TID
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth q4hrs Disp #*30
Tablet Refills:*0
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Acetaminophen 1000 mg PO Q8H
10. Docusate Sodium 100 mg PO BID:PRN constipation
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Senna 8.6 mg PO BID:PRN constipation
13. Saccharomyces boulardii 750 mg PO DAILY
14. Potassium Chloride 20 mEq PO DAILY
15. Ondansetron ___ mg PO BID:PRN nausea
16. Magnesium Oxide 500 mg PO DAILY
17. cyanocobalamin (vitamin B-12) 500 mcg/spray nasal 1X/WEEK
Discharge Disposition:
Extended Care
Facility:
___
___
___ Diagnosis:
Primary:
- Mechanical fall c/b right intertrochanteric femur fracture
- Syncope secondary to medication effect
- Presumptive HCAP
Secondary:
- Crohn's disease c/b fistula and recurrent SBO s/p numerous
resections and LOA, now with short gut syndrome
- SVC syndrome, secondary to chronic IV access requirements s/p
thromboendarterectomy and reconstruction with bovine patch
(___) and RIJ, R CIV & EIV stent placement in ___ on chronic
fondaparinux
- hx of HIT w/ thrombosis
- Hypothyroidism
- PTSD, particularly active when in hospital setting due to
prior assault in hospital setting many years ago
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory
Discharge Instructions:
Dear Ms. ___
It was a pleasure to care for you at ___. You were transferred
here after it was found you had a right hip fracture after a
fall. The fall was suspected to be due to a medication effect
from the addition of Flexeril in addition to narcotic
medications. It did not appear to be cardiac or neurologic in
origin. Your hip was successfully repaired by orthopedics ___
and you did well in the postoperative period.
Please continue to take all medications as prescribed and attend
any follow up appointments scheduled. Continue with physical
therapy as recommended to strengthen your hip. Please be careful
when taking medications that may increase sedation such as pain
medications and muscle relaxants. Seek medical attention if you
develop fevers, chills, nausea, vomiting, shortness of breath,
worsening pain or rash at the surgical site.
Wishing you the best of health moving forward,
Your ___ team
Followup Instructions:
___
|
10882916-DS-75
| 10,882,916 | 22,874,432 |
DS
| 75 |
2192-10-03 00:00:00
|
2192-10-03 14:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Reglan / Compazine / Gentamicin / Sulfa (Sulfonamide
Antibiotics) / Tigan / Meperidine / Prednisone / Cefotaxime /
Vancomycin / Cephalosporins / Infliximab / Mercaptopurine /
Mesalamine / Heparin Agents / Fluconazole / Meropenem /
Tizanidine / Ativan / Loperamide / Feraheme / Naltrexone /
fentanyl / Remicade
Attending: ___
Chief Complaint:
Abdominal Pain and fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ lady w/ hx of Crohn's disease,
multiple abdominal surgeries and multiple obstructions who
presented with abdominal pain and fever by her PCP with concern
for small bowel obstruction.
She reported having abdominal pain and distension for the last
day, starting on ___. Overnight on ___ she woke up with a
fever to 103 and with rigors. She also reports nausea, vomiting,
and not having a BM since the day before when normally she has
multiple bowel movements per day. She also endorses decreases
flatus. She reports that at baseline, she will have 3 episodes
per week of constipation and abdominal distention which usually
self resolve. On this occasion, the fever and rigoring caused
her to seek medical attention. She denies hematemesis, melena,
hematochezia. She also denies cough, headache, sore throat, leg
swelling, rash, or dysuria.
She was previously admitted in ___ for SBO and abdominal
pain. She was managed with pain medications and supportive care.
In the ED, initial vitals were: T 100.8, HR 110, BP 153/82, RR
22, O2 94% RA, T increased to 101.7.
Exam had been notable for diffusely firm to palpation, non-rigid
abdomen with no tenderness.
Labs notable for normal ___ count at 8.1 (but neutrophil
79.8%); Hct 28.6 (34.8 on ___, alkphos 108, hyponatremia
at 131, bicarb at 19, and normal lactate at 1.5. UA showed 4 red
cells with a few bacteria. FluAPCR and FluBPCR were negative.
Imaging notable for CXR (___) showing possible multifocal PNA
and abdominal CT (___) concerning for partial SBO.
Patient was given IV Vanc 1000 mg, IV Levofloxacin 750mg, IV
hydromorphone 1mg X4, IV diphenhydramine 25mg and 1L NS.
Patient was seen by Surgery who recommended NG tube placement
for the time. She had seen Dr. ___ ___ weeks ago, who did
not believe she was an appropriate candidate for surgery due to
her extensive abdominal surgery history with increased risks for
short gut and possible fistulas.
Decision was made to admit for management of PNA and partial
SBO.
On the floor, patient reported ___ out of 10 abdominal pain.
She expressed her request to be in a single room due to her
history of PTSD ___ sexual assault.
Past Medical History:
- Crohn's disease s/p ~13 surgeries for obstruction and
adhesiolysis
- Rectovaginal fistula
- SVC syndrome
- HIT
- Mediastinal lymphadenopathy NOS
- Pulmonary nodules
- Hypothyroidism
- PTSD
- Depression & Anxiety
- Fibromyalgia
- gastric dysmotility, short gut syndrome, has been on TPN in
the
past
- h/o portacath infections
- Fatty liver with mildly elevated LFTs at baseline
- Anemia, iron deficiency
- Nephrolithiasis
- Chronic pain on opioids
PSH:
- Parathyroid adenoma s/p removal
- Multiple central venous access for TPN
- TAH BSO
- Cholecystectomy
- Bilateral knee meniscal surgery
- Stent placement on R IJ vein and CIV and EIV ___
- exploratory laparotomy & lysis of adhesions ___
- cystoscopy, pyelogram ___
Social History:
___
Family History:
Significant for family history of Crohn's disease and
osteoarthritis. No reported family history of CAD or DM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VS: Tc 99.2, BP 110/58, HR 92, RR 20, O2 93 Ra
Gen: Well-groomed female in moderate distress.
HEENT: PERRLA; No scleral icterus; MMM
CV: RRR; No murmurs/rubs/gallops
Pulm: Clear to auscultation; +ve egophony on the right upper
chest
Abd: Bowel sounds present; Soft, but distended abdomen, no
rebound but voluntary guarding with diffuse tenderness to
palpation
GU: No foley
Ext: No peripheral edema, no gross abnormalities noted
Skin: Subcutaneous hematoma around the LLQ
Neuro: No focal abnormalities
Psych: Tearful, but appropriate affect.
DISCHARGE PHYSICAL EXAM
==========================
Vitals: 98.8PO 136 / 80 86 18 96 Ra
Gen: Well-groomed female in NAD
HEENT: PERRLA; No scleral icterus; MMM
CV: RRR; No murmurs/rubs/gallops
Pulm: Clear to auscultation; Crackles in right middle/upper.
Abd: normoactive BS ; Soft, non-distended, and non-tender
Ext: No peripheral edema, no gross abnormalities noted
Skin: Subcutaneous hematoma around the LLQ
Neuro: No focal abnormalities
Psych: normal affect
Pertinent Results:
ADMISSION LABS
------------------
___ 08:00AM WBC-8.1# RBC-3.59* HGB-8.6* HCT-28.6* MCV-80*
MCH-24.0* MCHC-30.1* RDW-18.0* RDWSD-51.5*
___ 08:00AM NEUTS-79.8* LYMPHS-10.3* MONOS-6.7 EOS-2.5
BASOS-0.5 IM ___ AbsNeut-6.43* AbsLymp-0.83* AbsMono-0.54
AbsEos-0.20 AbsBaso-0.04
___ 08:00AM LIPASE-20
___ 08:00AM estGFR-Using this
___ 08:00AM ALBUMIN-3.8
___ 08:00AM GLUCOSE-112* UREA N-15 CREAT-1.1 SODIUM-131*
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-19* ANION GAP-20
___ 08:11AM LACTATE-1.5
___ 12:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 12:15PM URINE RBC-4* WBC-1 BACTERIA-FEW YEAST-NONE
EPI-1 RENAL EPI-<1
___ 09:30PM WBC-4.8 RBC-3.28* HGB-8.0* HCT-25.8* MCV-79*
MCH-24.4* MCHC-31.0* RDW-18.2* RDWSD-51.6*
___ 09:30PM CALCIUM-8.3* PHOSPHATE-2.7 MAGNESIUM-1.3*
MICROBIOLOGY
----------------
- influenza PCR negative
- urine legionella negative
- step pneumo ag pend
- Urine cltx - no growth
- Blood cltx x2 - NGTD after 48 hours
IMAGING
---------------
___ CT A/P
IMPRESSION:
1. Mildly dilated loops of small bowel in the mid abdomen
measuring up to 3.6 cm with some stasis of ingested food but
without a definite transition point and distal loops not
collapsed. This is concerning for a partial small bowel
obstruction likely due to adhesions.
2. Ileocolonic anastomosis is again noted in the right mid
abdomen which is collapsed but slightly thickened with slightly
increased enhancement in
keeping with chronic Crohn's disease unchanged from prior MRE.
No convincing evidence of active disease.
3. Patchy opacities in the posterior lower lobes and posterior
right middle lobe are likely from aspiration.
CXR ___. Patchy airspace opacities in bilateral lower lobes
concerning for
multifocal pneumonia.
2. The enteric tube extends into the abdomen with tip out of
view.
DISCHARGE LABS
------------------
patient refused
Brief Hospital Course:
___ lady w/ hx of Crohn's disease and multiple SBOs who
presented with abdominal pain, fever, NBNB emesis and absence of
BM, with CT c/w pSBO. Patient had NGT placed to suction but
improved rapidly over a couple days, tolerating a regular diet
prior to discharge. She was treated with a course of
levofloxacin for a CAP. She was discharged home on her home
medications and instructions to complete a five day course of
levofloxacin.
# Abdominal Pain
# Partial SBO:
Patient with history of SBO, s/p multiple surgeries for Crohn's
disease. Abdominal distension and imaging (CT and CXR
X2)concerning for partial SBO. Exam not concerning for
peritonitis. Patient with NG tube placed in ED (___). Given IV
narcotics dilaudid 1 mg IV Q3H:PRN Pain - Severe which she took
every 3 hours rarely missing a dose. She also was given 50 mg IV
benadyl Q8H:PRN for complaint of itching with hydromorphone.
These were spaced an hour apart and diluted in 50cc of saline
and given over ___ min. She self discontinued her NGT as she
began to feel better and advanced her diet without knowledge of
the medical team, asking to leave as she had been tolerating PO
for almost 24 hour on ___. Her exam was completely benign so
she was discharged home on her home medications with
instructions to follow up with her PCP.
# CAP: R patchy opacity and fever concerning for CAP. She was
discharged to complete a 5 day course of levofloxacin. She was
minimally symptomatic with minor cough, but no shortness of
breath.
CHRONIC ISSUES:
==========================
# Crohn Disease: longstanding since ___ s/p multiple small
bowel resections, prior TPN for ___ years (off since ___, c/b
recurrent SBO, likely ___ anastomotic stricture s/p dilation in
___. CRP 3 in ___, has not been on budesonide.
# Depression/anxiety:
- Hold escitalopram Oxalate 20 mg PO DAILY
- Hold Mirtazapine 30 mg PO QHS
- Valium IV (for anxiety due to stated assault during a prior
hospitalization)
# Essential HTN- controlled:
- Hold Amlodipine 10mg PO daily
- Hydralazine PRN
# Hypothyroidism:
- IV Levothyroxine 37.5 mg as on previous admission ___
# H/o HIT and SVC syndrome
-Fondaparinux SQ 7.5 mg
# GERD:
-Substitute Pantoprazole IV 40 mg for home Omeprazole 40 mg
TRANSITIONAL ISSUES
======================
[] Patient had fever RLL infiltrate and cough and was treated
for CAP with 5 day course of levofloxacin
[] Consistent with care plan from prior admissions, patients
received IV narcotics and Benadryl diluted in saline and given
over 15 minutes and was transitioned back to home dilaudid when
tolerating PO
[] Please repeat CBC with diff and chemistries as an outpatient
to evaluate leukopenia and hypokalemia.
Discharge planning took > 30 minutes with direct counseling with
patient, setting up appointments, and d/c note.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Calcitrate (calcium citrate) 200 mg (950 mg) oral BID
3. cyanocobalamin (vitamin B-12) 500 mcg/spray nasal 1X/WEEK
4. Escitalopram Oxalate 20 mg PO DAILY
5. Magnesium Oxide 500 mg PO DAILY:PRN low mag
6. Omeprazole 40 mg PO DAILY
7. Ondansetron ODT ___ mg PO Q8H:PRN nausea
8. Potassium Chloride 20 mEq PO DAILY:PRN low potassium
9. Vitamin D 1000 UNIT PO DAILY
10. TraMADol 50-100 mg PO Q8H:PRN Pain - Moderate
11. Gabapentin 600 mg PO BID
12. Gabapentin 300 mg PO DAILY
13. Fondaparinux 7.5 mg SC DAILY
14. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Severe
15. Budesonide 9 mg PO DAILY
16. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___)
17. Mirtazapine 30 mg PO QHS
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*3
Tablet Refills:*0
2. Amlodipine 10 mg PO DAILY
3. Calcitrate (calcium citrate) 200 mg (950 mg) oral BID
4. cyanocobalamin (vitamin B-12) 500 mcg/spray nasal 1X/WEEK
5. Escitalopram Oxalate 20 mg PO DAILY
6. Fondaparinux 7.5 mg SC DAILY
7. Gabapentin 600 mg PO BID
8. Gabapentin 300 mg PO DAILY
9. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Severe
10. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___)
11. Magnesium Oxide 500 mg PO DAILY:PRN low mag
12. Mirtazapine 30 mg PO QHS
13. Omeprazole 40 mg PO DAILY
14. Ondansetron ODT ___ mg PO Q8H:PRN nausea
15. Potassium Chloride 20 mEq PO DAILY:PRN low potassium
16. TraMADol 50-100 mg PO Q8H:PRN Pain - Moderate
17. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Small Bowel Obstruction
Secondary Diagnosis
Community Acquired Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to ___ with symptoms
consistent with a partial bowel obstruction. You were also found
to have fever and imaging findings consistent with a pneumonia.
You were treated appropriately for both conditions and improved.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10882916-DS-76
| 10,882,916 | 26,542,620 |
DS
| 76 |
2193-02-14 00:00:00
|
2193-02-15 18:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Reglan / Compazine / Gentamicin / Sulfa (Sulfonamide
Antibiotics) / Tigan / Meperidine / Prednisone / Cefotaxime /
Vancomycin / Cephalosporins / Infliximab / Mercaptopurine /
Mesalamine / Heparin Agents / Fluconazole / Meropenem /
Tizanidine / Ativan / Loperamide / Feraheme / Naltrexone /
fentanyl / Remicade
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with medical history notable for
active Crohn's disease, multiple abdominal surgeries, SVC
syndrome, bronchiectasis who presented to ___ with
abdominal pain and distension with imaging concerning for ___
transferred to ___ for further management.
Per patient, after receiving her first dose of ___ on ___
she had low grade fevers, nausea, vomiting and diarrhea. These
symptoms improved by ___. However, on ___ she developed
new abdominal distension, severe, stabbing abdominal pain, and
intense nausea associated with projectile vomiting. She noticed
she was no longer passing gas; she reports her last BM was two
days ago. She presented to ___, where exam was notable
for uncomfortable appearing, lab work showed ___ with Cr 2.9,
and KUB concerning for possible early/partial SBO. The patient
placed her own NGT, with 500cc of output. Surgery was consulted,
who recommended transfer to ___ for further management.
In the ED, initial VS were 99.5 89 144/80 19 97% RA
-Exam notable for not recorded
-Labs showed
6.5>7.6/25.1<144
ALT: 11 AST: 20 AP: 107 Tbili: 0.4 Alb: 3.7
Na 133 K 3.8 Cl 100 HCO3 19 BUN 20 Cr 1.5 Gluc 103
Lactate:1.3
-Imaging showed: none repeated
-Received:
___ 17:41 SC HYDROmorphone (Dilaudid) .5 mg
___ 18:59 PR Acetaminophen 650 mg
___ 20:15 IV HYDROmorphone (Dilaudid) 1 mg
___ 20:15 IV Ondansetron 4 mg
___ 20:15 IVF LR ___ Started 100 mL/hr
___ 20:26 IV DiphenhydrAMINE 25 mg
___ 22:22 IV MetRONIDAZOLE (FLagyl) 500 mg
___ 22:22 IV HYDROmorphone (Dilaudid) 1 mg
___ 23:12 IV Acetaminophen IV 1000 mg
-Surgery was consulted, who recommended: admission to medicine
for management of SBO
Transfer VS were 102.7 102 ___ 95% RA
On arrival to the floor, patient reports ongoing severe
abdominal pain.
REVIEW OF SYSTEMS:
(+)PER HPI, otherwise 10pt ROS obtained and negative
Past Medical History:
- Crohn's disease s/p ~13 surgeries for obstruction and
adhesiolysis; currently on ___
- Recurrent pulmonary infections thought to be ___ Crohns;
currently takes ciprofloxacin x1 week the first week of each
month
- Rectovaginal fistula
- SVC syndrome
- HIT
- Mediastinal lymphadenopathy NOS
- Pulmonary nodules
- Hypothyroidism
- PTSD
- Depression & Anxiety
- Fibromyalgia
- Gastric dysmotility, short gut syndrome, has been on TPN in
the past
- h/o portacath infections
- Fatty liver with mildly elevated LFTs
- Anemia, iron deficiency
- Nephrolithiasis
- Chronic pain on opioids
- Parathyroid adenoma s/p removal
- Multiple central venous access for TPN
- TAH BSO
- Cholecystectomy
- Bilateral knee meniscal surgery
- Stent placement on R IJ vein and CIV and EIV ___
- Exploratory laparotomy & lysis of adhesions ___
- Cystoscopy, pyelogram ___
Social History:
___
Family History:
Significant for family history of Crohn's disease and
osteoarthritis. No reported family history of CAD or DM.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 100.4 114/60 99 20 95% RA
-Weight: 87.8 kg (193.56 lb)
GENERAL: anxious, in pain
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM, dentures in
place
NECK: supple, no LAD, no JVD
HEART: tachycardic, (+) S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, mildly distended, diffuse mild TTP with rebound
and guarding, decreased bowel sounds
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=======================
VS: 99.2PO 130 / 77 L Lying 84 18 95 Ra
GENERAL: Sleepy, lying in bed
HEENT: PERRL, anicteric sclera, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1 and S2 present, no mrg
LUNGS: Coarse crackles at bases up to mid-lung b/l
ABDOMEN: soft, mildly distended, TTP in RUQ and RLQ, + guarding,
no rebound, decreased bowel sounds
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: No focal deficits, alert and appropriately interactive,
moving all 4 extremities with purpose
SKIN: WWP, no rashes
Pertinent Results:
ADMISSION LABS
==============
___ 07:53PM BLOOD WBC-6.5 RBC-3.40* Hgb-7.6* Hct-25.1*
MCV-74* MCH-22.4* MCHC-30.3* RDW-18.0* RDWSD-48.4* Plt ___
___ 07:53PM BLOOD Neuts-80.5* Lymphs-10.4* Monos-6.0
Eos-2.5 Baso-0.3 Im ___ AbsNeut-5.24 AbsLymp-0.68*
AbsMono-0.39 AbsEos-0.16 AbsBaso-0.02
___ 07:53PM BLOOD Plt ___
___ 07:53PM BLOOD Glucose-103* UreaN-20 Creat-1.5* Na-133
K-3.8 Cl-100 HCO3-19* AnGap-18
___ 07:53PM BLOOD ALT-11 AST-20 AlkPhos-107* TotBili-0.4
___ 07:53PM BLOOD Albumin-3.7
___ 06:25AM BLOOD CRP-96.1*
___ 06:25AM BLOOD calTIBC-451 Ferritn-32 TRF-347
___ 08:19PM BLOOD Lactate-1.3
IMAGES:
======
CT A/P (___):
___ with a PMH of Crohn's disease s/p multiple abdominal
surgeries on ___, SVC syndrome s/p stent placement,
bronchiectasis who presented to OSH with N/V and right-sided
abdominal pain with OSH KUB concerning for partial SBO, course
c/b ___. Admission blood cultures growing pan-sensitive
Klebsiella and coag+ staph.
CXR (___): Reviewed personally, formal report below
Compared to chest radiographs since ___ most recently ___. Patient had pneumonia, predominantly in the right
upper and lower lobes on ___, substantially resolved by ___. Regions of peribronchial infiltration in the right upper
and both lower lobes are probably due to mild edema deposited in
areas of previous recent infection. Heart size normal. No
pleural effusion. Nasogastric drainage tube can be traced as far
as the upper stomach, but the tip is indistinct and it may need
to be advanced 8 cm to move all the side ports into the stomach.
Right central venous stent unchanged in position since ___.
MICRO:
======
Blood culture (___):
Blood Culture, Routine (Final ___:
LACTOCOCCUS SPECIES.
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
CIPROFLOXACIN sensitivity testing performed by ___
___.
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
VIRIDANS STREPTOCOCCI.
Isolated from only one set in the previous five days.
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
Daptomycin MIC OF 0.5 MCG/ML = SUSCEPTIBLE.
Daptomycin Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| STAPH AUREUS COAG +
| | ESCHERICHIA
COLI
| | |
ENTEROCOCCUS FAE
| | | |
AMPICILLIN------------ 8 S <=2 S
AMPICILLIN/SULBACTAM-- 4 S 8 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- R =>4 R
CLINDAMYCIN----------- <=0.25 S
DAPTOMYCIN------------ S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=1 S <=0.5 S <=1 S
LEVOFLOXACIN---------- 4 R
MEROPENEM-------------<=0.25 S <=0.25 S
OXACILLIN------------- =>4 R
PENICILLIN G---------- 2 S
PIPERACILLIN/TAZO----- 8 S <=4 S
RIFAMPIN-------------- <=0.5 S
TOBRAMYCIN------------ <=1 S 2 S
TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S <=1 S
VANCOMYCIN------------ 1 S 2 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS IN SHORT CHAINS.
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ (___), ___
@ 10:50AM.
Reported to and read back by ___ (___),
___ @
11:00AM.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS IN SHORT CHAINS.
Urine culture (___): negative
Blood culture (___): pending
DISCHARGE LABS:
===============
___ 06:30AM BLOOD WBC-5.9 RBC-3.89* Hgb-8.9* Hct-30.0*
MCV-77* MCH-22.9* MCHC-29.7* RDW-20.0* RDWSD-51.8* Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-85 UreaN-6 Creat-0.7 Na-140 K-4.2
Cl-102 HCO3-22 AnGap-20
___ 06:30AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.4*
Brief Hospital Course:
___ with a PMH of Crohn's disease s/p multiple abdominal
surgeries on ___, SVC syndrome s/p stent placement,
bronchiectasis who presented to OSH with partial SBO, course c/b
___ and polymicrobial bacteremia.
ACUTE ISSUES:
=============
# Polymicrobial Bacteremia: Blood cultures from admission
growing multiple organisms including klebsiella, viridans, MRSA,
E. coli, Enterococcus. C/f bacterial gut translocation vs.
possible contamination. No e/o infectious source seen on CT A/P
___. Given fevers and immunocompromised state pt was treated
for presumed bacteremia. The infectious disease team was
consulted and recommended a two week course of PO linezolid and
IV zosyn. A midline was placed ___ and pt was discharged with
___ services. Mid-line should be flushed with sodium citrate
given heparin allergy.
# Pain: Pt is on home dilaudid 4 mg PO Q6H, tramadol 50-100 mg
PO Q8H, and gabapentin 600 mg BID, 900 mg QHS prescribed by PCP.
Pt received 1.5 mg IV dilaudid Q3H (diluted in 50 cc given over
15 minutes) with benadryl IV 50 mg Q5H:PRN provided one hour
prior to IV dilaudid administrations. She also received 0.5-1 mg
ativan Q8H:PRN during admission. Increases in IV dilaudid,
benadryl and ativan doses were avoided given nursing concern for
patient sedation. She was seen by pain service, who recommended
transitioning to PCA if necessary however this was never
initiated as pain was controlled on IV dilaudid as above. Pt was
discharged on home pain regimen, with dilaudid prescriptions
provided by PCP. Of note, per communication with PCP outpatient
pain regimen consists of PO dilaudid, PCP is only prescribing
___ for situational anxiety (MRI, procedures, etc) in
order to avoid prescribing opiates with benzodiazepam.
# Partial SBO: Pt p/w nausea, vomiting and constipation with OSH
KUB c/w SBO. Likely ___ adhesions from multiple previous
surgeries. Pt has a h/o recurrent SBOs. NG tube was placed
initially to suction. Surgery was consulted and recommended no
intervention. NGT was discontinued as symptoms improved. Pt
having regular BM and taking in regular PO prior to discharge.
# Anemia. Microcytic anemia, Hb 7.2 on admission (baseline
___. H/o of micro to normocytic anemia. Repeat Fe studies
notable for low-normal ferritin and high-normal
TIBC/transferrin, likely c/w iron deficiency in addition to
AOCD. Of note, pt has allergy to IV Fe and requires Benadryl
with infusions. Received 1U pRBC on ___ and responded
appropriately, Hb stable since.
# Thrombocytopenia: Pt has intermittently low plts. Likely
reactive iso chronic inflammation. Stable during admission.
# Leukopenia: Pt has intermittent leukopenia. Documented
leukopenic responses to certain antibiotics. Relatively stable
during admission.
# Active Crohn's disease: Longstanding since ___ s/p multiple
small bowel resections, prior TPN for ___ years (off since ___,
c/b recurrent SBOs. She is followed by Dr. ___ recently
initiated therapy with ___ given evidence of active disease
on colonoscopy. CRP elevated to 96 on admission, but has been
more elevated in the past.
# ___: Baseline Cr 0.7-1.1. Pt w/ elevated Cr on admission
likely pre-renal in setting of poor po intake, obstruction, and
infection. Resolved with IVF.
CHRONIC ISSUES:
===============
# Depression/anxiety: Home escitalopram 20 mg PO and mirtazapine
30 mg QHS were held while pt was on linezolid. Home oxazepam 10
mg PO TID was held while pt received IV ativan and discharged
upon discharge.
# Essential HTN: Stable BP during admission. Pt was continued on
home amlodipine 10 mg PO daily
# Hypothyroidism: Pt received on IV levothyroxine and
transitioned to home PO levothyroxine 75 mcg 6x/week
# H/o HIT and SVC syndrome: Pt was continued on home
fondaparinux SQ 7.5 mg
# GERD: Received pantoprazole and transitioned to home
omeprazole 40 mg when she was able to take PO
TRANISITIONAL ISSUES:
====================
[ ] Continue PO linezolid ___ mg BID and IV zosyn 4.5 mg Q8H for
a 2 week course, last day ___
[ ] Continue sodium citrate flushes for mid-line. Any issues
with mid-line antibiotic administration during 2 week period
please contact PCP
[ ] Pt will be discharged on home PO dilaudid, rx provided by
PCP
[ ] Discuss with Dr. ___ for restarting
ciprofloxacin
[ ] F/u CBC on ___ to monitor for leukopenia, anemia and
thrombocytopenia
[ ] F/u with Dr. ___ restarting ___
[ ] Restart home anti-depressants after linezolid course has
finished, with discussion with PCP
#CODE: Full presumed
#CONTACT: ___) ___
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fondaparinux 7.5 mg SC DAILY
2. Gabapentin 900 mg PO QHS
3. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Severe
4. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___)
5. Omeprazole 40 mg PO QD:PRN acid reflux
6. Amlodipine 10 mg PO DAILY
7. Escitalopram Oxalate 20 mg PO DAILY
8. Mirtazapine 30 mg PO QHS
9. Ondansetron ODT ___ mg PO Q8H:PRN nausea
10. TraMADol 50-100 mg PO Q8H:PRN Pain - Moderate
11. Potassium Chloride 20 mEq PO DAILY:PRN low potassium
12. Magnesium Oxide 500 mg PO DAILY:PRN low mag
13. Gabapentin 600 mg PO BID
14. cyanocobalamin (vitamin B-12) 500 mcg/spray nasal 1X/WEEK
15. Calcitrate (calcium citrate) 200 mg (950 mg) oral QD
16. Vitamin D ___ UNIT PO 1X/WEEK (SA)
17. Ustekinumab Dose is Unknown IV ONCE
18. Ciprofloxacin HCl 500 mg PO Q12H
19. Oxazepam 10 mg PO TID
Discharge Medications:
1. Linezolid ___ mg PO Q12H Duration: 8 Days
RX *linezolid ___ mg 1 tablet(s) by mouth twice a day Disp #*15
Tablet Refills:*0
2. Piperacillin-Tazobactam 4.5 g IV Q8H
RX *piperacillin-tazobactam 4.5 gram 4.5 g IV every eight (8)
hours Disp #*22 Vial Refills:*0
3. Sodium CITRATE 4% 2 mL DWELL Q8H:PRN midline flush
RX *sodium citrate 4 % (3 mL) 2 cc every eight (8) hours Disp
#*21 Syringe Refills:*0
4. Amlodipine 10 mg PO DAILY
5. Calcitrate (calcium citrate) 200 mg (950 mg) oral QD
6. cyanocobalamin (vitamin B-12) 500 mcg/spray nasal 1X/WEEK
7. Fondaparinux 7.5 mg SC DAILY
8. Gabapentin 900 mg PO QHS
9. Gabapentin 600 mg PO BID
10. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Severe
11. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___)
12. Magnesium Oxide 500 mg PO DAILY:PRN low mag
13. Omeprazole 40 mg PO QD:PRN acid reflux
14. Ondansetron ODT ___ mg PO Q8H:PRN nausea
15. Potassium Chloride 20 mEq PO DAILY:PRN low potassium
16. TraMADol 50-100 mg PO Q8H:PRN Pain - Moderate
17. Vitamin D ___ UNIT PO 1X/WEEK (SA)
18. HELD- Ciprofloxacin HCl 500 mg PO Q12H This medication was
held. Do not restart Ciprofloxacin HCl until Discuss with
pulmonologist
19. HELD- Escitalopram Oxalate 20 mg PO DAILY This medication
was held. Do not restart Escitalopram Oxalate until discontinue
linezolid
20. HELD- Mirtazapine 30 mg PO QHS This medication was held. Do
not restart Mirtazapine until discontinue linezolid
21. HELD- Oxazepam 10 mg PO TID This medication was held. Do
not restart Oxazepam until Discuss with PCP
22. HELD- Ustekinumab Dose is Unknown IV ONCE This medication
was held. Do not restart Ustekinumab until Dicsuss with
gastroenterologist
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
Polymicrobial bacteremia
Small bowel obstruction
Chronic pain
Anemia
Acute kidney injury
SECONDARY DIAGNOSIS:
====================
Thrombocytopenia
Leukopenia
Crohn's Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to be part of your care.
You were admitted to the hospital because you were having
terrible abdominal pain in addition to not having bowel
movements, which was concerning for another bowel obstruction.
You received imaging at another hospital that showed that you
likely did have another bowel obstruction. You had a nasogastric
tube placed to help empty the contents of your stomach initially
and improve your nausea. Your bowel function improved and you
started eating regular food and having bowel moments.
During your admission you were found to have multiple bacteria
growing from a sample of your blood. We were concerned given the
presence of bacteria and ongoing fevers that this represented a
serious infection. Likely these bacteria came from your
gastrointestinal tract. You received CT imaging of your abdomen
which did not show any source of this infection. The infectious
disease team was consulted and recommended a two week course of
IV antibiotics to treat this infection (last day ___.
If you experience any worsening fevers, abdominal pain, or
symptoms of a bowel obstruction then please seek medical
attention.
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
10882948-DS-7
| 10,882,948 | 23,471,682 |
DS
| 7 |
2190-06-01 00:00:00
|
2190-06-02 19:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Asacol / Methotrexate / tomatoe / horses / Keppra / Fioricet /
zinc oxide eugenol / hydrolyzed vegetable protein / natural or
artificial flavors, unidentified spices / aspirin
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
left heart catheterization (___)
History of Present Illness:
MR. ___ is a ___ with a h/o ASD s/p ?TIA on plavix,
polyarthritis (on Humira), narcolepsy with cataplexy, and strong
FH of CAD who presents with intermittent chest pain x 3d. First
had CP after eating on ___, described as dull ache
radiating to back, no associated sx, nonpleuritic or positional.
This resolved spontaneously after 1h and then was stuttering
over course of the next several days. Last night, CP started at
night after eating while sitting on couch, non-resolving,
causing him to seek care.
Past Medical History:
Polyarthritis (on Humira) and followed by rheumatology
?TIA/vasovagal symptoms (recently started on Plavix)
Small atrial septal defect
Narcolopsy with cataplexy
Idiopathic proctitis and suspected IBD now s/p multiple
colonoscopies ruling out IBD
Multiple food and medication allergies - eats a very restrictd
diet
Social History:
___
Family History:
Notable for his maternal great-grandmother who had periods of a
slow heartbeat and passing out. All of her offspring had more or
less similar problems and many of them received pacemakers but
at an advanced age. His father had CABG in his ___.
Physical Exam:
ADMISSION:
VS: Wt= T=98.3 BP=130/82 HR=57 RR=20 O2 sat=97%
General: NAD, lying in bed
HEENT: MMM, PERRL
Neck: no JVP, neck supple
CV: RRR, S1, S2, no murmurs, pain not reproducible with
palpation
Lungs: CTAB, no wheezes
Abdomen: soft, non-tender to palpation, +BS, no organomegaly
Ext: warm, well-perfused, +pulses
Neuro: A&Ox3, CNII-XII grossly intact
Skin: warm, dry, no rashes or lesions
PULSES: 2+ bilaterally
DISCHARGE:
VS: 97.6, 67, 120/79, 20, 97% RA
General: NAD, sitting on bed
HEENT: MMM, PERRL
Neck: no JVP, neck supple
CV: RRR, S1, S2, no murmurs
Lungs: CTAB, no wheezes
Abdomen: soft, non-tender to palpation, +BS, no organomegaly
Ext: warm, well-perfused, +pulses
Neuro: A&Ox3, CNII-XII grossly intact
Skin: warm, dry, no rashes or lesions
PULSES: 2+ bilaterally
Pertinent Results:
Admission:
___ 08:00AM BLOOD WBC-7.8 RBC-5.27 Hgb-17.1 Hct-47.2 MCV-90
MCH-32.4* MCHC-36.2* RDW-13.8 Plt ___
___ 08:00AM BLOOD Neuts-60.1 ___ Monos-5.3 Eos-1.3
Baso-0.5
___ 08:00AM BLOOD ___ PTT-28.5 ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD Glucose-105* UreaN-15 Creat-1.0 Na-138
K-4.0 Cl-101 HCO3-28 AnGap-13
___ 08:00AM BLOOD ALT-31 AST-18 AlkPhos-50 TotBili-0.8
___ 08:00AM BLOOD Lipase-44
___ 08:00AM BLOOD Albumin-4.5
Cardiac enzymes:
___ 08:00AM BLOOD cTropnT-<0.01
___ 02:30PM BLOOD CK-MB-4
___ 02:30PM BLOOD cTropnT-0.03*
___ 08:55PM BLOOD CK-MB-8 cTropnT-0.15*
___ 05:37AM BLOOD CK-MB-8 cTropnT-0.22*
___ 01:10PM BLOOD CK-MB-7
___ 01:10PM BLOOD cTropnT-0.26*
___ 06:50AM BLOOD CK-MB-3 cTropnT-0.27*
___ 06:46PM BLOOD cTropnT-0.19*
___ 06:28AM BLOOD cTropnT-0.20*
Discharge:
___ 01:10PM BLOOD %HbA1c-5.4 eAG-108
___ 01:10PM BLOOD Triglyc-181* HDL-60 CHOL/HD-4.0
LDLcalc-142*
___ 06:28AM BLOOD WBC-9.0 RBC-5.20 Hgb-16.8 Hct-47.1 MCV-91
MCH-32.2* MCHC-35.6* RDW-13.0 Plt ___
___ 06:28AM BLOOD Plt ___
___ 06:28AM BLOOD ___ PTT-31.3 ___
___ 06:28AM BLOOD
___ 06:28AM BLOOD Glucose-85 UreaN-17 Creat-1.2 Na-141
K-4.2 Cl-102 HCO3-30 AnGap-13
___ 06:28AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.3
Brief Hospital Course:
# NSTEMI: Patient with atypical chest pain with no known prior
cardiac history. TIMI score 3. Troponin peaked at ___, then
began downtrending. EKG was unchanged throughout admission.
Chest pain the first night of admission, reportedly helped by
both sublingual nitro and GI cocktail, but no chest pain after
the first evening. Hx hyperlipidemia; labs ___ w/ TC 238, ___
181, HDL 60 LDL 142. No HTN and HA1C 5.4. On adrenergic
medications for narcolepsy that could have cardiac effects.
Possible association of pain with food and hx "esophageal spasm"
___ years ago, though this wouldn't explain the troponin
elevation. Patient was initially convinced that his Humira was
the cause of the troponin elevation. Agreed to cardiac
catherization by the third day of admission. Cath showed
occluded ramus best ___ for medical treatment as event
occurred a few days prior. He was continued on clopidogrel 75g
daily (given issue of ASA allergy causing tinnitus) and started
on metoprolol 12.5 mg and atorvastatin 80 mg.
# HYPERLIPIDEMIA: Last cholesterol levels ___. TC 238, ___ 181,
HDL 60 LDL 142. Started on Atorvastatin 80 mg.
# POLYARTHRITIS - worst in L shoulder, also in R shoulder, hands
and other extremities. On Humira injections, last one ___.
Gave NSAIDs for pain.
# NARCOLEPSY - w/ episodes of cataplexy. On methylin 20 mg TID
and Nuvigil 200 mg qAM and 100 mg qPM. Continued home
medications.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Humira (adalimumab) Dose is Unknown subcutaneous Weekly
2. Clopidogrel 75 mg PO DAILY
3. Nuvigil (armodafinil) 200 mg oral qAM
4. Nuvigil (armodafinil) 100 mg oral qPM
5. cromolyn 100 mg/5 mL oral daily
6. Liothyronine Sodium 1 mcg PO TID
7. methylphenidate 20 mg oral TID
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. cromolyn 100 mg/5 mL oral daily
3. Liothyronine Sodium 1 mcg PO TID
4. methylphenidate 20 mg oral TID
5. Nuvigil (armodafinil) 200 mg oral qAM
6. Nuvigil (armodafinil) 100 mg oral qPM
7. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
8. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin [Nitrostat] 0.3 mg 1 tablet(s) sublingually
q5min Disp #*30 Tablet Refills:*3
10. Humira (adalimumab) 0 mg SUBCUTANEOUS WEEKLY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Non ST elevation MI
Secondary:
Narcolepsy with cataplexy
Autoimmune polyarthritis
Multiple allergies
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
with chest pain and were found to have an obstruction in one of
your coronary arteries. Given that you did not have EKG changes,
this is called an NSTEMI (non ST-elevation myocardial
infarction). You had a cardiac catheterization which revealed a
100% obstruction in one of your distal coronary arteries. This
is likely the cause of you elevated cardiac enzymes, called
troponin. You were started on atorvastatin and metoprolol and
you should follow-up with an outpatient cardiologist.
Regards,
Your ___ Team
Followup Instructions:
___
|
10883273-DS-10
| 10,883,273 | 22,306,014 |
DS
| 10 |
2123-08-16 00:00:00
|
2123-08-16 16:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Odontoid fracture, s/p unwitnessed fall
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ year old lady with a PMH Alzheimer's Disease
and multiple falls, who was transferred to ___ from ___
for an odontoid fracture after an unwitnessed fall. At the time
of admission, patient was sedated from haloperidol; this history
was obtained from previous records, family members and staff at
___ (___). Per
the patient's daughter/HCP ___ and daughter ___, the
patient was found in her room sometime between 10 and 11 pm last
night. Her nurse at ___ that she was at supper
___ pm, then when checked on "soon after supper," she was found
on the floor, awake, arousable and responsive to her name ___
is her baseline); the incident report was from 11 pm. She lives
in a private room, and has her door shut most of the time.
___ notes that a voicemail from the assisted living facility
indicated that they thought she fell out of bed, and she was
probably on the floor for about 15 minutes. It is unclear
whether there was every any loss of consciousness, or mechanical
obstacles. In the incident report, there was no documented loss
of continence. The patient was taken this morning to ___
___, where non-contrast CT neck showed a minimally
discplaced fracture at the base of the odontoid process.
Non-contrast CT head was negative for any intracranial bleed or
mass effect. She was then transferred to ___ for further
evaluation.
.
In the ___ ED, initial VS were: 96.2 104 100/62 16 98%. UA
with few bacteria, small leuk. Patient was given haldol 2.5 mg
IV x2, and ondansetron x1. Spine service, who was consulted in
the ED, determined optimal management of fracture to be
non-operative; they recommended a ___ J collar and admission
to Medicine for ___, pain control and placement.
.
On arrival to the floor, patient was sedated from haloperidol.
She was accompanied by her daughter ___, and son-in-law, who
provided details of story, PMH and functional status. Initial
vital signs were 98.1 140/55 56 18 100%2L. When haloperidol
eventually wore off, patient knew who she was, but not the time
and date. She reported pain in her neck, and a desire to take
off the collar. She needed to be reminded multiple times that
she had broken her neck, and needed to keep the collar on as a
treatment.
.
Review of sytems:
(+) Per HPI. Also positive for dementia with baseline
orientation to self and family members; urinary ___ at
baseline.
(-) Patient's family reported patient was in usual state of
health recently with outany fever, chills, night sweats, recent
weight loss or gain; headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath; chest pain or
tightness, palpitations; nausea, vomiting, diarrhea,
constipation or abdominal pain; no stool incontinence; dysuria;
arthralgias or myalgias.
Past Medical History:
1.) Multiple falls: Son-in-law notes that patient is "nimble,"
but does not have the best "judgement" when ambulating.
- Mechanical fall in ___ resulting in arm fracture
- Mechanical fall last ___ with compression fracture of
spine.
- Most recently, patient fell one month ago and sustained a
subdural hematoma, which has resolved. At that time, she was
admitted to ___ from ___.
- other past falls with resultant bruising
2.) Alzheimer's Dementia: at baseline, patient has very poor
short term memory. She knows herself and her family members. She
often perseverates on talking about grandchildren. She has
intact longterm memory. She is able to feed herself, but has
assistance with bathing and medications. She intermittently
walks with a walker, when prompted. She has urinary (but not
bowel incontinence).
3.) STEMI (RCA 100% occlusion) ___, s/p BMS
4.) HTN
5.) Multiple UTIs
6.) Breast Cancer
7.) Hypothyroidism
8.) B12 Deficiency
Social History:
___
Family History:
Unknown, patient was adopted.
Physical Exam:
ADMISSION PHYSICAL EXAM:
98.1 140/95 56 18 100%2L
General: Awake, in moderate distress due to neck pain, lying in
bed
HEENT: Red ecchymoses on the right forehead and temple, with
some skin abrasions. Sclera anicteric, dry MM, oropharynx clear
Neck: Stabilized in a stiff collar
Lungs: Clear to auscultation bilaterally, no
wheezes/rales/rhonchi
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmuer at ___
Abdomen: Normoactive bowel sounds. Soft, non-tender,
non-distended, no rebound tenderness or guarding, no
organomegaly. +Foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Red ecchymoses and skin abrasions on right
forehead/temple. Small skin abrasions on knees bilaterally.
Ecchymoses on dorsa of hands bilaterally.
Neuro: Awake, alert. Oriented to self; not oriented to date and
place. Very poor short term memory, needs to be reminded that
she is in the hospital and broke her neck multiple times. Speech
is fluent, and thought process logical. Upset about her neck
collar. CNs II-XII intact. Moving arms and legs without
difficulty, ___ strength in upper and lower extremities. No
clonus. Sensation to light touch intact and equal on both sides.
.
DISCHARGE PHYSICAL EXAM:
VS: Tc 97.8, Tm 98.4, BP 124/72 (124-144/70-91), HR 90 (90-98),
R 20, O2 95% RA
General: Awake, in NAD, sitting in chair at nurses' station
HEENT: Healing red ecchymoses on the right forehead and temple,
with some skin abrasions. Sclera anicteric, MMM, oropharynx
clear
Neck: Intermittently wearing soft collar
Lungs: Clear to auscultation bilaterally, no
wheezes/rales/rhonchi
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmuer at RUSB
Abdomen: Normoactive bowel sounds. Soft, non-tender,
non-distended.
Ext: Warm, well perfused, no edema
Neuro: Awake, alert. Conversing more appropriately today,
significant change from yesterday. Poor short term memory, and
needs to be reminded that she is in the hospital. Speech is
fluent, and thought process logical. Moving arms and legs
spontaneously and without difficulty. Ambulates with walker
without difficulty.
Pertinent Results:
ADMISSION LABS:
___ 05:21AM BLOOD WBC-4.2 RBC-3.95* Hgb-12.7 Hct-39.8#
MCV-101*# MCH-32.3* MCHC-32.0 RDW-12.5 Plt ___
___ 05:21AM BLOOD WBC-4.2 RBC-3.95* Hgb-12.7 Hct-39.8#
MCV-101*# MCH-32.3* MCHC-32.0 RDW-12.5 Plt ___
___ 05:21AM BLOOD Neuts-76.4* Lymphs-17.2* Monos-3.4
Eos-2.4 Baso-0.7
___ 05:21AM BLOOD ___ PTT-25.5 ___
___ 05:21AM BLOOD Glucose-164* UreaN-11 Creat-0.7 Na-144
K-3.5 Cl-108 HCO3-26 AnGap-14
___ 07:05PM URINE Color-Yellow Appear-Hazy Sp ___
___ 07:05PM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 07:05PM URINE RBC-15* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
.
RELEVANT LABS:
___ 07:05PM URINE Color-Yellow Appear-Hazy Sp ___
___ 07:05PM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 07:05PM URINE RBC-15* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
.
DISCHARGE LABS:
___ 05:30AM BLOOD VitB12-1416* Folate-17.8
___ 05:30AM BLOOD TSH-3.2
___ 05:18AM BLOOD WBC-6.4 RBC-3.59* Hgb-11.5* Hct-36.1
MCV-101* MCH-32.0 MCHC-31.8 RDW-12.5 Plt ___
___ 05:18AM BLOOD Glucose-84 UreaN-14 Creat-0.9 Na-137
K-4.3 Cl-101 HCO3-26 AnGap-14
___ 05:18AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.1
.
IMAGING: CT done at ___
.
MICROBIOLOGY:
___ 7:05 pm URINE Source: Catheter.
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in MCG/ML
______________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
Ms. ___ is a ___ year old lady with a PMH Alzheimer's Disease
and multiple falls, who was transferred to ___ from ___
for an odontoid fracture after an unwitnessed fall.
ACTIVE ISSUES
# Odontoid fracture: Minimally-displaced fracture demonstrated
on CT neck from ___ status post unwitnessed fall. Pt's fall
is most likely mechanical based on the patient's history of
multiple mechanical falls. However, pt also found to have a
urinary tract infection, which may have contributed to her fall.
She was evaluated by spine service, and they have opted for
non-surgical management, including soft collar for comfort and
pain control. Pain control was attained with Tylenol ___ mg PO
TID, lidocaine patch, and oxycodone liquid 2.5-5 mg PO q6 hours
as needed for breakthrough pain. She has been requiring ___
per 24 hour period of oxycodone liquid over the past several
days for pain control. She will follow up in the ___
with Dr. ___ ON ___ for x-rays and
re-evaluation.
# Urinary tract infection: Pt found to have an infection with
E.Coli, resistant to Ciprofloxacin and Bactrim. She was started
on treatment with Macrodantin 50mg q8h for three days for
treatment of uncomplicated UTI. The last dose of the antibiotic
should be aministered ___ morning (___).
# Agitation: Patient intermittently upset about collar and
pain, since she was unable to remember why she is in the
hospital though she is easily re-oriented. Despite receiving
Haldol in the ED, further QT-prolonging medications were avoided
because her QTc was prolonged at ___, though QTc ~440 on the
second day of admission. She did not require additional
anti-psychotics on the medicine floor. She responded to frequent
reorientation and was continued on her home Abilify and
Venlafaxine ER.
CHRONIC ISSUES
# Alzheimer's dementia: Patient's baseline mental status may be
slightly off secondary to infection. Additionally, she is at
increased risk for dementia during this hospitalization. She
responded well to frequent re-orientation and she is being
treated for her urinary tract infection. She was continued on
her home memantine.
# Hypertension: Pt was continued home metoprolol tartrate 12.5
mg PO BID.
# CAD: s/p STEMI with BMS in ___. Has been off aspirin for the
past month because of a subdural hematoma. She was continued on
metoprolol tartrate at home dose as above.
# Hypothyroidism: TSH was normal. She was continued home
levothyroxine 50 mcg PO daily
# Macrocytosis: Hct was normal, and B12 and folate were normal.
# Difficulty swallowing: Patient reporting difficulty
swallowing. Per Emeritus, has meds crushed usually. She was
evaluated by speech and swallow, who recommended thin liquids
and pureed foods with crushed medications.
# Healthcare maintenance: She was continued on her multivitamin,
vitamin D.
TRANSITIONAL ISSUES
# Pt will need to continue antibiotic, Macrodantin, for
treatment of UTI until ___ morning (___). This will be a
total of 5 additional doses after discharge.
Medications on Admission:
Abilify 2.5 mg PO daily
Acetaminophen 650 mg PO TID
(Aspirin 81 mg PO daily -> held for the past month)
Carnation instant breakfast at 8am and 8pm
Cranberry 300 mg PO BID
Docusate sodium 100 mg PO BID
Gabapentin 100 mg PO qHS every other day
Levothyroxine 50 mcg PO daily
Metoprolol tartrate 12.5 mg PO BID
Multivitamin PO daily
Namenda 10 mg PO daily
Senna PO BID
Venlafaxine ER 75 mg PO daily
Vitamin D 1000 unit PO daily
Discharge Medications:
1. aripiprazole 1 mg/mL Solution Sig: 2.5 mg PO DAILY (Daily).
2. acetaminophen 650 mg/20.3 mL Solution Sig: Six Hundred Fifty
(650) mg PO TID (3 times a day): Please no more than 3g per day.
3. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day): Please hold for loose stools.
4. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q48H (every
48 hours).
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. therapeutic multivitamin Liquid Sig: One (1) Tablet PO
DAILY (Daily).
8. memantine 10 mg Tablet Sig: One (1) Tablet PO daily ().
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Please hold for loose stools.
10. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
11. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. nitrofurantoin macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO Q8H (every 8 hours) for 5 doses. Capsule(s)
13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) for 10
days: 12 hours on, 12 hours off.
14. oxycodone 5 mg/5 mL Solution Sig: 2.5-5 mg PO every six (6)
hours as needed for pain for 5 days.
Disp:*80 ml* Refills:*0*
15. Carnation instant breakfast at 8am and 8pm
16. Cranberry 300 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Odontoid fracture status post fall
Secondary Diagnosis
Urinary tract infection
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your
hospitalization. You were admitted because you had a fall, and
were found to have a small fracture of a bone in your neck. You
were evaluated by the spine doctors who recommend that you wear
a soft collar around your neck for comfort. If you are unable to
tolerate collar, it can be removed, especially if you are in
bed. It is preferable to keep the collar on when you are out of
the bed or walking. You should follow-up with Dr. ___
in the Spine clinic on ___ for x-rays and re-evaluation.
During your hospitalization, you were also found to have a
urinary tract infection. You are being treated with antibiotics.
These antibiotics should continue until ___.
Please note the following changes to your medications:
Please START taking:
1. Nitrofurantoin 50mg every 8 hours until ___ (your last dose
will be in the morning of ___
2. Tylenol for pain
3. Lidocaine patch for pain
4. Oxycodone liquid only as needed for pain
Please continue taking your other medications as prescribed.
Followup Instructions:
___
|
10884018-DS-13
| 10,884,018 | 24,239,230 |
DS
| 13 |
2183-12-05 00:00:00
|
2183-12-06 15:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
aspirin
Attending: ___
Chief Complaint:
Bilateral facial weakness
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
___ is a ___ year-old man who presents with bilateral
facial weakness and headache. He was in his usual state of
health until he awoke ___ morning. He felt different but
could not pinpoint what was wrong until he tried to eat his
lunch
noticed that the right side of his face felt abnormal. He did
not look in the near to see if his face was asymmetric and he
did
not notice any trouble closing his eyelid side but did feel like
his right face was numb. He also felt that his right eye was
flickering. He called his PCPs office and spoke with a nurse
who
referred him to the ED. He was seen at ___ and was told that he
had some mild weakness of his right face on exam. They
diagnosed
him with a Bell's palsy and discharged him home.
The next morning, yesterday when he awoke his right face
symptoms
had resolved. However, he had similar yet more severe
"numbness"
on the left side of his face. He looked in the mirror he
noticed
that his smile was asymmetric with weakness on the left side of
his face. He has been having trouble closing his left eye in
drooling when trying to drink. He saw his primary care
physician
yesterday who sent a Lyme test (results unknown) and referred
him
to neurology clinic for further evaluation of his bilateral
facial weakness. She instructed him that if any new symptoms
arise or if he develops headache that he should re-present to
the
emergency department.
Last night he began to have zinging pains on his occiput
bilaterally, like electric shock sensations lasting for movement
at a time. He is never had this before. He awoke in the middle
of the night and saw to white halos in his right visual field
while his eyes were closed that looked like a child's drawing of
the sun. This lasted briefly, seconds, before resolving. He
also began having headaches last night described as a pressure
sensation associated with light sensitivity. He denies neck
pain/stiffness and has no pain with eye movements. He has had
headaches in the past that this headache feels different from
his
typical headaches.
Earlier today while driving he had a "wave of fatigue" and also
felt that his left arm was heavy. He did not feel as though he
would pass out and he did not have vertigo. He was driving at
the time and the symptoms prompted him to pull over to the side
of the road. The symptoms lasted for about 1 minute.
He also reports some mild difficulty with speaking but has
difficulty describing this. He recently took a boating trip to
___. He denies having any rashes and did not notice any tick
bites.
In the ED his visual acuity was tested: visual Acuity Right:
___, Left: ___, Both: ___. Noncontrast head CT was
obtained and was unremarkable.
Review of Systems: Positive for slurred speech and URI symptoms
(cough, sore throat) since yesterday. The pt denies loss of
vision, diplopia, dysphagia, vertigo, tinnitus or hearing
difficulty. Denies focal parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait. The pt
denies recent fever or chills. No recent weight loss. Denies
cough, shortness of breath. Denies chest pain or palpitations.
Denies nausea, vomiting, diarrhea, constipation or abdominal
pain. No dysuria. Denies rash.
Past Medical History:
- ___ yrs ago had sinus surgery
- low platelets, unclear etiology
- astigmatism
- migraines
Social History:
___
Family History:
- Father: lung disease, heavy smoker
Physical Exam:
================
Admission Exam:
================
Vitals: 99.1 82 137/90 16 99% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT. No rashes seen in the ear canal on otoscopic exam
bilaterally. Mild throat erythema.
Neck: No neck stiffness; negative Kernig and Brudzinski signs
Pulmonary: breathing comfortably on RA; clear bilaterally
Cardiac: RRR, no murmurs
Abdomen: soft, nondistended
Extremities: no edema, warm
Skin: no rashes or lesions noted.
NEUROLOGIC EXAMINATION
-Mental Status: Alert, oriented. Able to relate history without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects on the
stroke card. Able to read without difficulty. Speech was not
noticeably dysarthric. Able to follow both midline and
appendicular commands. Attentive, able to name ___ backward
without difficulty. Able to register 3 objects and recall ___
at
5 minutes.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm on right, 4 to 3.5mm on left with ?subtle
left
RAPD. Funduscopic exam revealed his optic discs are crisp
temporally but not crisp nasally bilaterally.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch and pinprick in all
distributions
VII: Weakness of the upper and lower face on the left; cannot
fully close his left eye. Eye closure and lip pursing is full
strength on the right.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: Shoulder shrug is symmetric.
XII: Tongue protrudes in midline with full ROM right and left
-Motor: Normal bulk throughout. No pronator drift bilaterally.
No
tremor noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
- Toes were downgoing bilaterally.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout.
-Coordination: No dysmetria on FNF bilaterally.
-Gait: Good initiation. Narrow-based, normal stride. Able to
walk in tandem without difficulty. Romberg absent.
================
Discharge Exam:
================
Temp: 98.4
HR: ___
BP: ___
RR: 16
O2 Sat: 94-98% on room air.
General: Well appearing, walking around the hall.
HEENT: NCAT, no oropharyngeal lesions, moist mucous membranes,
sclerae anicteric
Neck: Supple
CV/R: Breathing comfortably on room air.
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. Attention to examiner easily maintained. Recalls a
coherent
history. Speech is fluent with full sentences, intact
repetition,
and intact verbal comprehension. Content of speech demonstrates
intact naming (high and low frequency) and no paraphasias.
Normal
prosody. No evidence of hemineglect. No left-right agnosia.
- Cranial Nerves - Left sided facial weakness, upper and lower,
improved from admission in that more symmetric at rest, able to
purse his lips better, eye closure may also be slightly better
(~1mm opening when attempting to close eyes with Bell's
phenomenon). PERRL 5->4mm brisk. VF full to finger
wiggling. EOMI, no nystagmus. V1-V3 without deficits to light
touch bilaterally. No facial movement asymmetry. No dysarthria.
Palate elevation symmetric. Trapezius strength ___ bilaterally.
Tongue midline. Hearing intact subjectively.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
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. No extinction to DSS.
Intact to sharp touch, including bilateral face.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - Normal initiation. Narrow base. Normal stride length
and
arm swing. Stable without sway.
Pertinent Results:
___ 03:10PM URINE HOURS-RANDOM
___ 03:10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 03:10PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 02:48PM GLUCOSE-91 UREA N-13 CREAT-0.7 SODIUM-141
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-27 ANION GAP-16
___ 02:48PM estGFR-Using this
___ 02:48PM ALT(SGPT)-20 AST(SGOT)-24 ALK PHOS-52 TOT
BILI-0.4
___ 02:48PM cTropnT-<0.01
___ 02:48PM ALBUMIN-4.5 CALCIUM-9.7 PHOSPHATE-3.5
MAGNESIUM-1.9
___ 02:48PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 02:48PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 02:48PM NEUTS-73.4* LYMPHS-16.4* MONOS-6.1 EOS-3.5
BASOS-0.3 IM ___ AbsNeut-4.44 AbsLymp-0.99* AbsMono-0.37
AbsEos-0.21 AbsBaso-0.02
___ 02:48PM PLT COUNT-112*
___ 02:48PM PLT COUNT-112*
Brief Hospital Course:
___ is a ___ year-old man with no significant past
medical history who presented initially with multiple neurologic
symptoms including prominent left-sided facial weakness,
transient right face numbness 2 days prior to admission,
transient left arm weakness the day prior to admission, headache
with photophobia and transient bright flashing lights in his
right visual field. His exam was notable for left sided facial
weakness in a lower motor neuron pattern at presentation. Given
his multifactorial neurological symptoms, he was admitted to the
general neurology service for further evaluation and
observation.
He underwent a MRI brain with and without contrast which was
unremarkable (there was no meningeal or CN enhancement). He
underwent a LP which showed a pleocytosis (8 WBC tube 1, 21 WBC
tube 4). He was started initially on prednisone 60mg daily with
IV ceftriaxone and acyclovir for concern for aseptic meningitis.
However, after his left Bell's palsy improved during his
hospital stay and he remained neurologically stable without new
neurological symptoms, fevers or peripheral leukocytosis, the IV
antibiotics were discontinued due to low concern for
meningoencephalitis. This decision was made in discussion with
patient and infectious disease consult service. He was
discharged on a course of PO prednisone with PO doxycycline and
Valtrex. Plans were to discontinue Valtrex and doxycycline if
Lyme, HSV or VSV studies were negative. Results were pending at
time of discharge. Follow-up with PCP, ID and neurology were
arranged at time of discharge.
==========================
TRANSITIONS OF CARE
==========================
- CSF labs and serum studies (infectious and autoimmune labs)
pending per above.
- Please stop valacyclovir and doxycycline if Lyme, HSV or VZV
negative. Please contact ID/neurology to determine course of
antibiotics if studies positive.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Artificial Tears ___ DROP LEFT EYE Q2H dry eye
Please apply as needed to ensure your left eye remains hydrated
3. Doxycycline Hyclate 100 mg PO Q12H
Please stop if contacted by MD to do so; e.g. Lyme test negative
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Capsule Refills:*0
4. PredniSONE 60 mg PO DAILY
RX *prednisone 10 mg 6 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
5. ValACYclovir 1000 mg PO Q12H
Please stop if contacted MD to do so (e.g. Herpes tests
negative)
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Bell's palsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You presented with left facial droop with exam indicating a
Bell's palsy. As you had had right sided symptoms days prior
(e.g. right sided facial droop), we did a lumbar puncture to
evaluate for meningitis. You did have an elevated white blood
cell count in your spinal fluid to indicate inflammation.
However, during your hospital course you did not have signs of
meningitis including severe headache with neck stiffness,
fevers, and/or elevated white blood cell count in blood. You
also did not develop any new neurologic symptoms during your
hospital stay, which was reassuring.
For these reasons, we think it is safe for you to be discharged
home on oral antibiotics and steroids for Bell's palsy. You
should continue the steroids (prednisone) as instructed. Please
continue the antibiotics until a physician contacts you; the
duration will be determined based on the results of the spinal
fluid and bloodwork.
Please return to the emergency department immediately if you
were to develop new fevers or neurologic symptoms or feel unwell
in any way.
We wish you all the best!
Followup Instructions:
___
|
10884125-DS-10
| 10,884,125 | 21,855,134 |
DS
| 10 |
2176-04-25 00:00:00
|
2176-04-28 02:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Wellbutrin / trazodone
Attending: ___.
Chief Complaint:
Alcohol intoxication, hypoxia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ y/o man with history of alcohol abuse,
alcoholic pancreatitis, multiple admissions at the ___ for
withdrawal, COPD, and seizure disorder presenting to the ED with
alcohol intoxication and hypoxia. Of note, he was recently
admitted from ___ to ___ for acute alcoholic pancreatitis
that improved with supportive care and alcohol intoxication for
which he received phenobarbital loading in the FICU and was
started on a phenobarbital taper.
The patient was brought in by EMS from his friend's house after
heavy alcohol use with inability to ambulate. On EMS evaluation,
the patient was tachycardic and hypoxic to mid ___. Pt reports
he fell yesterday, striking his head on the ground. He denies
loss of consciousness. On presentation to the ED, he endorsed
shortness of breath but denied chest pain. No N/V, no abdominal
pain.
In the ED, initial vitals: T 98.0 HR 128 BP 152/81 RR 18 86% RA
Labs notable for: WBC 3.8 (25N, ___, H/H 12.3/36.4, platelets
297, anion gap 24, AST/ALT 43/22, lipase 72. D-dimer 1397.
Lactate 5.8-->5.6
UA with glucose and trace ketones
Serum EtOH: 389; serum tox negative
Urine tox: Pos for barbiturates, otherwise negative
Exam notable for: Clinically intoxicate, R buttocks with
significant erythema, warm to touch.
Imaging: CTA negative for PE. CT Chest with RLL consolidation
vs. atelectasis. CT head without acute abnormality. CT spine
without acute process.
Patient was given:
IV Lorazepam .5 mg
IV Lorazepam 1 mg
IV Lorazepam 2 mg
IVF 1000 mL NS 1000 mL
IVF 1000 mL NS 1000 mL
IVF 1000 mL ___ 1000 mL
IV Haloperidol 5 mg
IM Haloperidol 5 mg
IV Vancomycin 1000 mg
IV CeftriaXONE 1 gm
IV MetRONIDAZOLE (FLagyl) 500 mg
IV Thiamine 100 mg
IV FoLIC Acid 1 mg
On transfer, vitals were: HR 102 BP 154/88 RR 18 98%
Non-Rebreather
On arrival to the MICU, the patient complaints of being hungry
and thirsty. He denies any shortness of breath or cough. He
denies any chest pain. Denies nausea, abdominal pain, emesis, or
diarrhea. Denies headache, change in vision. He reports that he
began drinking again on the day he was last discharged from the
hospital several days ago. He reports that he drinks ___ fifth
of vodka daily. His last drink was on the day of admission. He
reports that he has not taken any of his medications in several
days. He also reports that his PTSD has been worse recently.
Review of Systems: As per HPI.
Past Medical History:
seizure disorder Dx ___ ___
COPD
chronic back pain
EtOH abuse: sober for ___ years, ___ and in fact became a
drug and alcohol ___ with the ___ system.
s/p liver resection ___ GSW
left knee ACL tear
h/o left lung trauma
h/o right wrist injury
left biceps tendon rupture
Social History:
___
Family History:
Brother with ___ syndrome, ICD placed.
Physical Exam:
======================
ADMISSION EXAM:
======================
Vitals: T: 98.9 BP: 157/89 P: 118 R: 22 O2: 96% on 4L via ___
GENERAL: AOx3, no acute distress, poor dentition
HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition
NECK: Supple, JVP not elevated, no LAD
LUNGS: CTAB, 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, no clubbing, cyanosis or
edema
SKIN: Bruising on left anterior forehead, bruising on knees,
erythema on buttocks
NEURO: AOx3, mild tremor
======================
DISCHARGE EXAM:
======================
VS: Tc 99.0 | HR 107 | BP 153/100 | R 18 | O2 98% 2L NC
I/O: n.r./800 over 8H
GENERAL: NAD. Alert and interactive, eating breakfast. A+Ox2-3.
HEENT: Sclera anicteric. MMM, oropharynx clear, poor dentition.
NECK: Supple, JVP not elevated, no LAD
LUNGS: CTAB, no wheezes, rales, rhonchi.
CV: Mildly tachycardic, regular rhythm. Normal S1/S2. No
murmurs, rubs, gallops.
ABD: Soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Tattoos on arms b/L.
SKIN: Ecchymosis and erosion on left anterior forehead, bruising
on knees.
NEURO: AOx3, mild tremor.
Pertinent Results:
==========================
ADMISSION LABS:
==========================
___ 11:36PM BLOOD WBC-3.8* RBC-3.60* Hgb-12.3* Hct-36.4*
MCV-101* MCH-34.2* MCHC-33.8 RDW-15.5 RDWSD-57.9* Plt ___
___ 11:36PM BLOOD Neuts-24.9* ___ Monos-18.9*
Eos-1.3 Baso-2.4* Im ___ AbsNeut-0.95* AbsLymp-1.99
AbsMono-0.72 AbsEos-0.05 AbsBaso-0.09*
___ 11:36PM BLOOD Glucose-95 UreaN-16 Creat-0.7 Na-141
K-4.9 Cl-99 HCO3-18* AnGap-29*
___ 11:36PM BLOOD ALT-22 AST-43* AlkPhos-96 TotBili-0.3
___ 11:36PM BLOOD Lipase-72*
___ 11:36PM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:36PM BLOOD Albumin-4.5 Calcium-9.4 Phos-3.4 Mg-1.5*
___ 11:36PM BLOOD D-Dimer-1397*
___ 11:36PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:41PM BLOOD Lactate-5.8*
==========================
PERTINENT RESULTS:
==========================
LABS:
==========================
___ 11:36PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:36PM BLOOD D-Dimer-1397*
___ 11:36PM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:41PM BLOOD Lactate-5.8*
___ 04:10AM BLOOD Lactate-5.6*
___ 11:14AM BLOOD Lactate-4.0*
___ 03:48PM BLOOD Lactate-1.9
==========================
IMAGING:
==========================
CXR (___): Interval increase in atelectasis with lower lung
volumes likely. No definite focal pneumonia.
===
CT C-spine without contrast (___):
1. No evidence for a fracture. No acute subluxation.
2. Multilevel degenerative disease.
3. Centrilobular and paraseptal emphysema at the included lung
apices is
again demonstrated.
===
CT Head without Contrast (___): No evidence for an acute
intracranial abnormality. No interval change.
===
CTA Chest and CT Abdomen (___):
1. Bilateral lower lobe aspiration pneumonitis.
2. Hepatic steatosis.
3. 1.4 cm left renal lower pole probable cyst with
proteinaceous debris
within it. Further characterization by renal ultrasound to be
performed.
4. T6 vertebral body anterior compression deformity is age
indeterminate, but new since ___. No associated prevertebral
soft tissue swelling or fat stranding. Correlate with clinical
assessment.
==========================
MICROBIOLOGY:
==========================
BLOOD CULTURE ___
GRAM NEGATIVE ROD(S). PRELIMINARY SENSITIVITY.
GRAM POSITIVE COCCUS(COCCI) IN CLUSTERS.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
GRAM NEGATIVE ROD(S)
|
AMPICILLIN------------ S
AMPICILLIN/SULBACTAM-- S
CEFEPIME-------------- S
CEFTAZIDIME----------- S
CEFTRIAXONE----------- S
CIPROFLOXACIN--------- S
GENTAMICIN------------ S
MEROPENEM------------- S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ S
==========================
DISCHARGE LABS:
==========================
___ 06:00AM BLOOD WBC-4.5 RBC-3.26* Hgb-11.1* Hct-32.6*
MCV-100* MCH-34.0* MCHC-34.0 RDW-15.1 RDWSD-55.9* Plt ___
___ 06:00AM BLOOD ___ PTT-28.3 ___
___ 06:00AM BLOOD Glucose-91 UreaN-6 Creat-0.7 Na-139 K-3.8
Cl-97 HCO3-29 AnGap-17
___ 06:00AM BLOOD ALT-18 AST-29 LD(LDH)-234 AlkPhos-87
TotBili-0.8
___ 06:00AM BLOOD Calcium-9.0 Phos-4.2 Mg-1.1*
Brief Hospital Course:
***LEFT AGAINST MEDICAL ADVICE***
Mr. ___ is a ___ y/o man with history of alcohol abuse,
alcoholic pancreatitis, multiple admissions at the ___ for
withdrawal, COPD, and seizure disorder who presented to the ED
with alcohol intoxication and hypoxemia. *Left the hospital
against medical advice overnight between ___ and ___. He
left before his discharge paperwork could be completed and
before he could be given any prescriptions.*
====================
ACTIVE ISSUES:
====================
# Alcohol Intoxication: The patient has a history of alcohol
abuse with recent admission for alcohol intoxication/withdrawal
for which he received phenobarbital loading and presented for
this admission with alcohol intoxication. His last drink was on
the day of admission. Per patient report, no history of alcohol
withdrawal seizures. He was admitted to the MICU, where he
received phenobarbital loading and was started on phenobarbital
taper. He was given thiamine, folate, and a multivitamin. Social
work was consulted.
# Hypoxemia: Patient was hypoxemic to ___ on admission. His
D-dimer was 1397; CTA was negative for PE. CT Chest showed
possible RLL consolidation in setting of recent hospitalization.
He was started on vancomycin and cefepime (Day 1: ___. He was
continued on his home albuterol and ipratropium.
# Acute blood stream infection: Blood cultures from day of
admission grew (a) Gram Negative Rods in the aerobic bottle, and
(b) Gram positive cocci in pairs and clusters in the anaerobic
bottle. GPCs thought to be a contaminant. The patient was
continued on broad spectrum antibiotics as above. After the
patient had left AMA, cultures speciated into pan-sensitive
Enterococcus. We called his PCP and request she prescribe a
course of levofloxacin if she could get into contact with him. A
message was left on his cell phone explaining the importance of
getting this prescription.
# Elevated lactate: Lactate was elevated to 5.8 on admission and
improved with fluid resuscitation. Thought to be secondary to
starvation ketoacidosis especially given ketones in urine.
====================
CHRONIC ISSUES:
====================
# COPD: Continued albuterol and ipratropium.
# Depression: Continued paroxetine
# Seizure disorder: Continued home lacosamide and gabapentin.
# GERD: Continued home omeprazole.
# Hypomagnesemia: Started on magnesium oxide 400 BID on last
admission. Monitored and repleted as needed.
# Pancytopenia: Chronic, stable. Likely secondary to alcohol.
========================
TRANSITIONAL ISSUES:
========================
- The patient left against medical advice on ___.
# Communication: HCP: Brother (patient does not know phone
number)
# Code: Full (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Gabapentin 200 mg PO QAM
3. Gabapentin 600 mg PO QHS
4. LACOSamide 100 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Paroxetine 20 mg PO QHS
7. Thiamine 100 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Magnesium Oxide 400 mg PO BID
10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
11. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
12. Omeprazole 40 mg PO DAILY
Discharge Medications:
LEFT AGAINST MEDICAL ADVICE
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Alcohol intoxication
- Acute hypoxic respiratory failure
- Gram-negative bacteremia
- Healthcare-associated pneumonia
SECONDARY DIAGNOSES:
- Chronic alcohol use disorder
- COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted with alcohol intoxication and breathing
problems causing your oxygen level to be low. This was probably
caused by a combination of alcohol and pneumonia. Your blood
cultures were positive for bacteria, probably from a pneumonia.
You were treated with antibiotics and were breathing well on
room air without fevers.
Please be sure to follow up with your regular primary care
doctor. As you know, the best thing you can do for your health
is to cut back on your drinking. We highly recommend you discuss
safe and effective strategies to do this with your doctor.
Thank you for letting us participate in your care,
Your ___ care team
Followup Instructions:
___
|
10884125-DS-11
| 10,884,125 | 28,732,979 |
DS
| 11 |
2176-05-26 00:00:00
|
2176-05-30 13:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Wellbutrin / trazodone
Attending: ___.
Chief Complaint:
alcohol intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with alcohol use disorder, COPD, seizure disorder with
recent elopement/AMA discharge after acute bloodstream infection
presents with alcohol intoxication.
He was admitted in ___ with alcohol intoxication. Workup
revealed one blood culture growing LECLERCIA ADECARBOXYLATA but
he left AMA without paperwork or prescriptions. His PCP was
contacted and asked to call in levofloxacin to treat pneumonia
and bacteremia. It is unclear if he followed up with treatment.
He was found by a friend to be intoxicated today.
In the ED, initial vitals were: 98.0 110 146/87 18 97RA. He was
combative on arrival requiring sedation and restraints. CXR
showed bibasilar opacities with concern for aspiration or
infection. He was initially in 4-point restraints which was
removed. He was more cooperative and then placed in soft
restraints. He pulled out his PIV twice. Labs notable for K 5.1,
Na 149. Cr 0.9. Lactate 5.2->5.1. He was given 1L NS x2,
lorazepam 2mg IM, haloperidol 5mg IM x2, levofloxacin 750mg IV,
thiamine 100mg IV, folic acid 1mg IV.
On the floor, he has no complaints. He states he was recently
admitted to ___ ___ days ago for abdominal pain but
cannot relay further details. He is a poor historian as he is
intoxicated. His last drink was today with "half a gallon of
vodka". He normally drinks a fifth of vodka daily.
Of note, since elopement in ___, was admitted to the ___
hospital for etoh abuse/withdrawal, discharged on ___. That
admission, diagnosed with cdiff colitis, started on PO vanc. At
that time, pt reported he was very motivated to quit drinking.
ROS: Denies any fever, chills, nausea, vomiting, chest pain,
dyspnea, abdominal pain, diarrhea, constipation, dysuria.
Past Medical History:
seizure disorder Dx ___ ___
COPD
chronic back pain
EtOH abuse: sober for ___ years, ___ and in fact became a
drug and alcohol counselor with the ___ system.
s/p liver resection ___ GSW
left knee ACL tear
h/o left lung trauma
h/o right wrist injury
left biceps tendon rupture
Social History:
___
Family History:
Brother with ___ syndrome, ICD placed.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T97.4 150/93 114 18 98 2L NC
GEN: Disheveled and unkempt adult male in no distress
HEENT: No scleral icterus, OP clear
HEART: Tachycardic, normal S1 S2, no murmurs
RESP: Poor respiratory effort, clear, no wheezes or rals
ABD: Soft, NT ND, normal BS
EXT: No ___ edema, 2+ DP pulses
NEURO: Alert, oriented to name, hospital, date. Moves all
extremities. +Asterixis, left worse than right.
SKIN: 2 cm right wrist ganglion cyst
DISCHARGE PHYSICAL EXAM:
========================
VS: T98.1 136/99 89 16 97RA
GEN: Disheveled and unkempt adult male in no distress
HEENT: No scleral icterus, OP clear
HEART: RRR, normal S1 S2, no murmurs, rubs or gallops
RESP: Poor respiratory effort, distant breath sounds, otherwise
clear, no wheezes or rales
ABD: Soft, mildly tender epigastric, left upper quadrant,
otherwise ND, normal BS
EXT: No ___ edema, 2+ DP pulses
NEURO: Alert, oriented to name, hospital, date. Moves all
extremities. minimal tremor, no asterixis
SKIN: 2 cm right wrist ganglion cyst
Pertinent Results:
ADMISSION LABS:
===============
___ 04:20PM BLOOD WBC-4.2 RBC-3.52* Hgb-12.4* Hct-36.7*
MCV-104* MCH-35.2* MCHC-33.8 RDW-15.5 RDWSD-58.6* Plt ___
___ 04:20PM BLOOD Neuts-25.5* ___ Monos-19.0*
Eos-2.9 Baso-2.2* Im ___ AbsNeut-1.06* AbsLymp-2.09
AbsMono-0.79 AbsEos-0.12 AbsBaso-0.09*
___ 04:20PM BLOOD Glucose-121* UreaN-14 Creat-0.9 Na-144
K-5.6* Cl-104 HCO3-20* AnGap-26*
___ 04:20PM BLOOD ALT-44* AST-86* AlkPhos-67 TotBili-0.2
___ 05:38AM BLOOD Lipase-87*
___ 04:20PM BLOOD Albumin-4.5 Calcium-9.3 Phos-4.2 Mg-1.3*
Iron-126
___ 04:20PM BLOOD calTIBC-354 VitB12-396 Folate-GREATER TH
Ferritn-118 TRF-272
___ 04:20PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:33PM BLOOD Glucose-108* Lactate-5.2* Na-149* K-5.0
Cl-107 calHCO3-22
___ 05:33PM BLOOD Hgb-12.5* calcHCT-38
DISCHARGE LABS:
===============
___ 08:05AM BLOOD WBC-5.0 RBC-3.12* Hgb-10.8* Hct-33.2*
MCV-106* MCH-34.6* MCHC-32.5 RDW-14.7 RDWSD-57.2* Plt ___
___ 08:05AM BLOOD Glucose-94 UreaN-19 Creat-0.9 Na-137
K-4.4 Cl-99 HCO3-26 AnGap-16
___ 08:05AM BLOOD Calcium-9.9 Phos-4.6* Mg-1.6
IMAGING:
========
CXR, portable ___: There are persistent bibasilar opacities,
which are now worse on the left than on the right, previously
worse on the right than on the left. Superiorly, the lungs are
clear. The cardiomediastinal silhouette is within normal
limits. No acute osseous abnormalities.
IMPRESSION: Bibasilar opacities, now worse on the left compared
to the right suspicious for aspiration and/or infection
Brief Hospital Course:
___ with alcohol use disorder, COPD, seizure disorder with
recent elopement/AMA discharge after acute bloodstream infection
presents with alcohol intoxication.
# Alcohol intoxication. Longstanding history of alcohol use
disorder with prior admissions for withdrawal and alcohol
pancreatitis requiring phenobarbital loading in the past. His
last drink was on day of admission (___). Per patient report,
no history of alcohol withdrawal seizures. On presentation, was
actively withdrawing with tremors, anxiety, tachycardia and
hypertension, but without seizures or hallucinations. Monitored
on CIWA and given diazepam 10mg as needed for withdrawal
symptoms. At the time of discharge, not scoring on CIWA and did
not require diazepam for over 12 hours. Encouraged to abstain
from etoh and offered to speak with social work regarding
resources available, but refused to see her on day of discharge
stating he knows how to quit.
#Bibasilar opacities/aspiration: CXR on presentation with
slightly worse bibasilar opacities compared to studies from
___, likely secondary to aspiration given prior history. CTA
chest last month with bilateral lower lobe aspiration
pneumonitis. PE was ruled out. Afebrile without leukocytosis or
localizing symptoms to suggest active infection. Completed five
day course of levofloxacin for CAP given concern for possible
untreated bacteremia/prior pneumonia which was pansensitive on
prior BCx (avoiding Zosyn and cefepime due to h/o seizure
disorder and risk of lowering threshold). Continued to be
afebrile, and urine and blood cultures showed no growth.
# History of acute blood stream infection: Blood culture from
___ with GNR LECLERCIA ADECARBOXYLATA. Also with GPC which was
likely contaminant. Elevated lactate on presentation at 5.1
likely ___ starvation ketoacidosis (ketonuria last admission)in
setting of alcohol abuse disorder. Source of the GNR bacteremia
remains unclear, unclear if potential contaminant. Completed
five day course of levofloxacin for CAP given low suspicion for
active bacteremia. Surveillance blood cultures were obtained
with no growth to date.
#Tachycardia: On initial presentation, with sinus tachycardia to
the 120s-130s in the setting of likely hypovolemia as well as
active etoh witdrawal. However, tachycardia noted to persist
despite improvement in other withdrawal symptoms. Noted to have
brief burst of SVT to the 190s-200s on review of tele, and
continued tachycardia to the 110s-120s despite sedation after
diazepam, unclear etiology. On obtaining further collateral
information from the ___ hospital, likely secondary to beta
blocker withdrawal, as apparently previous h/o SVT on metop at
home, pt unaware and not on medication list in our system.
Started on home metop 12.5 QID with good rate control,
discharged on long acting metop succinate 50mg daily.
#H/o cdiff colitis: Per collateral information from ___ hospital,
pt apparently with recent admission to ___ hospital for etoh
withdrawal, diagnosed with cdiff colitis on ___ and started on
PO vanc. When discharged on ___ picked up RX for PO vanc but
never completed the course as he was not having diarrhea. Noted
to have no diarrhea, leukocytosis this admission with benign
abdominal exam. Decided to not resume treatment for cdiff this
admission.
#Elevated lactate: Lactate was elevated to 5.1 on admission.
Thought to be secondary to starvation ketoacidosis especially
given ketones in urine, in the setting of alcohol abuse
disorder. Low suspicion for active infection as above. Lactate
trended down with IVF.
# Macrocytic Anemia: Hgb 12.4 with macrocytic to MCV 104. Likely
due to alcohol use disorder. Iron studies normal. Given
multivitamin, folate and encouraged to abstain from drinking as
above.
#Hypomagnesemia: Noted to require magnesium repletion daily in
the setting of etoh abuse. On day of discharge, pt in need of
magnesium repletion but refused staying for IV magnesium. Given
PO magnesium and discharged home with PCP ___, encouraged to
abstain from etoh use.
# COPD: Continued home albuterol and ipratropium.
# Depression: Continued paroxetine
# Seizure disorder: Continued home lacosamide and gabapentin on
presentation. On clarification with ___ provider, not taking
gabapentin anymore so medication discontinued on discharge.
# GERD: Continued home omeprazole.
===================
TRANSITIONAL ISSUES:
===================
-Noted on CT from recent AMA admission ___ to have abnormal
finding on left kidney; recommend non urgent renal ultrasound to
characterize the left renal lower pole likely cyst with
proteinaceous debris within it.
-Etoh abuse: multiple admissions for alcohol intoxication and
withdrawal despite stated motivation to quit. Given information
on resources available this admission. Continue to encourage
abstinence from etoh in outpatient setting
-Hypomagnesiemia: Required daily magnesium repletion during this
admission likely in the setting of alcohol use. If continues to
use alcohol, consider prescribing daily magnesium supplement as
an outpatient.
-Tachycardia: H/o SVT, with tachycardia this admission in
setting of betablocker withdrawal, pt not aware that he was
taking metoprolol. Rates well-controlled on metop tartrate
12.5q6h, discharged on long acting 50mg daily, titrate as needed
for rate control in outpatient setting.
-History of partially treated cdiff colitis during recent
admission to the ___ hospital, discharged ___. Did not treat
with PO vanc given lack of diarrhea. If diarrhea recurs or signs
of infection, consider treating for cdiff colitis
-History of partially treated bacteremia: treated with 5 day
course of levofloxacin for CAP (last day ___. Blood cultures
this admission with no growth to date, final reports pending on
discharge
-CODE: Full, presumed
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. FoLIC Acid 1 mg PO DAILY
2. Gabapentin 200 mg PO QAM
3. Gabapentin 600 mg PO QHS
4. LACOSamide 100 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Paroxetine 20 mg PO QHS
7. Thiamine 100 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Magnesium Oxide 400 mg PO BID
10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
11. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
12. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
2. LACOSamide 100 mg PO BID
RX *lacosamide [Vimpat] 100 mg 1 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
4. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*14
Capsule Refills:*0
5. Paroxetine 20 mg PO QHS
RX *paroxetine HCl 20 mg 1 tablet(s) by mouth at bedtime Disp
#*14 Tablet Refills:*0
6. Senna 17.2 mg PO QHS
RX *sennosides 8.6 mg 2 tabs by mouth at bedtime Disp #*14
Tablet Refills:*0
7. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*14 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap ih
daily Disp #*14 Capsule Refills:*0
9. 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
10. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
-Alcohol use disorder, alcohol withdrawal
SECONDARY DIAGNOSIS:
-Partially treated CAP/bacteremia
-SVT
-COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You came into the hospital because you were found to be very
intoxicated. You were admitted to the hospital because you had
left the hospital in ___ when you were diagnosed with a
blood stream infection. You had tests done which showed no
active infection, but you were given a five day course of
antibiotics which you finished on your last day. You were given
medication for your alcohol withdrawal and our social worker
talked with you about resources to help you quit drinking.
It is very important that you take all your medications as
prescribed and stop drinking because it is very bad for your
health. Please be sure to see your primary care provider before
you leave for your trip.
It was a pleasure being involved in your care,
Your ___ Care Team
Your ___ Care Team,
Followup Instructions:
___
|
10884125-DS-8
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| 8 |
2174-04-06 00:00:00
|
2174-04-06 19:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Wellbutrin
Attending: ___.
Chief Complaint:
EtOH withdrawal, requesting detox
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PCP: ___
Location: ___
Address: ___
Phone: ___
Fax: ___
HPI: ___ with Hx seizure disorder, multiple traumatic injuries,
EtOH abuse, recent admission at ___ for EtOH withdrawl (d/c
___, presents for detox.
The patient has a distant history of drug and alcohol abuse,
quit in ___. He was sober for ___ years, and in fact became a
drug and alcohol counselor with the ___ system. Last ___,
he had a seizure and was hospitalized. Shortly thereafter he
stopped his volunteer work at the ___ and started drinking.
His intake was not signficant until ___, when his best
friend died. Since ___ he has been drinking up to a fifth of
vodka a day. He has had sober periods, but cannot sustain
sobriety. He has also restarted smoking since ___. He sought
help earlier in ___ at ___, where he was admitted
for detox, discharged ___. Since discharge he has been
drinking a fifth of vodka a day, last drink this morning at 9am.
He lives alone, but this morning after a night of drinking went
next door and asked his neighbor to call ___.
In the last week he has had several falls, although he cannot
recall the details due to intoxication. He injured his left
knuckles and his back, at one point needed help getting back to
his apartment, but cannot recall a head strike. He does have a
small lump on his scalp that he can't remember getting.
He has never had a seizure triggered by EtOH withdrawl, and his
seizure disorder was discovered when he was sober.
In the ED, initial vitals ___ 110 170/98 18 96% RA. He
complained of chronic back pain from an old injury, but was
noted to be able to ambulate with a steady gait. He received
folic acid, thiamine, and MVI, as well as 1L NS. He received
diazepam 10mg at 1300 for withdrawl prevention. He also
received an ipratropium nebulizer treatment. CIWA = 4 at time
of transfer.
On the floor, he is complaining of mild back pain and is
slightly tremulous. He also notes pain at his right hand IV
site and requests replacement.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, rhinorrhea or congestion. Denies
shortness of breath, cough, dyspnea or wheezing. Denies chest
pain, chest pressure, palpitations. Denies constipation,
abdominal pain, diarrhea, dark or bloody stools. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
seizure disorder Dx ___ ___
chronic back pain
EtOH abuse
s/p liver resection ___ GSW
left knee ACL tear
h/o left lung trauma
h/o right wrist injury
left biceps tendon rupture
Social History:
___
Family History:
Brother with ___ syndrome, ICD placed.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.7 163/85 106 18 97% RA
GENERAL: NAD, awake and alert
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, MMM
NECK: nontender and supple, no LAD, no JVD, no thyromegaly
BACK: mild midline tenderness over coccyx, no CVA tenderness
CARDIAC: RRR, nl S1 S2, no MRG
LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding, no HSM
EXT: warm and well-perfused, no cyanosis, clubbing or edema.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII tested and intact, strength ___ throughout,
sensation grossly normal, pain over coccyx with SLR on
initiation of movement only, not with passive movement. L
biceps torn tendon with Popeye bulge, pain with L shoulder
movement. DTRs 2+ at biceps, brachioradialis, patella,
achilles.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals: 98.5, 98.0, 129/78 (110-140/70-90), 92, 17, 100RA
-has not scored on CIWA
GENERAL: NAD, awake and alert, lying in bed comfortably and
relaxed appearing
HEENT: EOMI, PEERLA, no oropharyngeal lesions
CARDIAC: RRR, nl S1 S2, no MRG
LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding, no HSM
EXT: warm and well-perfused, no cyanosis, clubbing or edema.
SKIN: multiple tattoos on the arms bilaterally, IV in place in
the left forearm
Pertinent Results:
ADMISSION LABS:
___ 12:20PM BLOOD WBC-4.2 RBC-3.83* Hgb-13.5* Hct-40.7
MCV-106* MCH-35.3* MCHC-33.2 RDW-13.9 Plt ___
___ 12:20PM BLOOD Neuts-34.2* Lymphs-54.7* Monos-5.3
Eos-3.0 Baso-2.7*
___ 12:20PM BLOOD Glucose-141* UreaN-13 Creat-0.9 Na-143
K-4.1 Cl-99 HCO3-21* AnGap-27*
___ 12:20PM BLOOD ALT-36 AST-52* AlkPhos-86 TotBili-0.3
___ 12:20PM BLOOD Lipase-45
___ 12:20PM BLOOD cTropnT-<0.01
___ 12:20PM BLOOD Albumin-4.9 Calcium-9.0 Phos-3.5 Mg-1.8
Iron-153
___ 12:20PM BLOOD calTIBC-337 VitB12-607 Folate-17.0
Ferritn-481* TRF-259
___ 12:20PM BLOOD TSH-0.91
___ 12:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 02:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
___ 02:30PM URINE RBC-1 WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1
___ 02:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
DISCHARGE LABS:
___ 07:12AM BLOOD WBC-4.9 RBC-3.55* Hgb-12.8* Hct-38.3*
MCV-108* MCH-36.2* MCHC-33.5 RDW-13.3 Plt ___
___ 07:12AM BLOOD Glucose-90 UreaN-18 Creat-0.8 Na-137
K-4.1 Cl-99 HCO3-26 AnGap-16
___ 07:12AM BLOOD Calcium-9.8 Phos-5.0* Mg-1.6
MICROBIOLOGY: NONE
IMAGING:
CXR ___:
FINDINGS: There is no focal consolidation, pulmonary edema, or
pneumothorax seen. There is minimal blunting of the posterior
costophrenic angles, similar to ___. The heart and
mediastinal contours are normal.
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
___ with Hx seizure disorder, multiple traumatic injuries, EtOH
abuse, recent admission at ___ for EtOH withdrawl (d/c ___,
presents for detox.
# EtOH withdrawal: Patient requested medical detox, will plan
to seek longer-term assistance via the ___ system. He has a
social worker, psychiatrist, and psychologist that he works with
in the ___ system. Refused our social work/case management
support. He has no history of withdrawal-related seizures. Only
scored on CIWA once, the night of ___. Continued thiamine,
folic acid, and MVI.
# h/o seizure disorder: No history of EtOH withdrawl seizure.
Continued Keppra
# Back pain: Likely ___ injury from a fall. No evidence of
neurological deficit. Only mild midline tenderness. Provided
ibuprofen PRN.
# ADHD: held methylphenidate, continue propranolol
# Tobacco abuse: nicotine lozenges
# Med rec: ideally we could get his medication list from the
___, however given the holiday this was not possible
# Code: FULL
Transitional Issues:
- Support for continued sobriety
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation
1. FoLIC Acid 1 mg PO DAILY
2. LeVETiracetam 500 mg PO BID
3. methylphenidate 50 mg oral daily
4. Multivitamins 1 TAB PO DAILY
5. Propranolol 20 mg PO BID
6. Sildenafil 100 mg PO PRN sexual activity
7. Thiamine 100 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Nicotine Lozenge Dose is Unknown PO Frequency is Unknown
The patient is not sure of his entire medication list. He uses
the ___ Pharmacy.
He was on Paxil, but stopped taking it about a week ago.
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. LeVETiracetam 500 mg PO BID
4. Nicotine Lozenge 4 mg PO Q1H:PRN withdrawl
5. Propranolol 20 mg PO BID
6. Thiamine 100 mg PO DAILY
7. methylphenidate 50 mg oral daily
8. Multivitamins 1 TAB PO DAILY
9. Sildenafil 100 mg PO PRN sexual activity
Discharge Disposition:
Home
Discharge Diagnosis:
primary: EtOH dependence
secondary: h/o seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___ ___
___. You came to the hospital for alcohol
withdrawal, and requesting assistance with sobriety. During
your stay you did not require many doses of medication for
withdrawal, and you had no sign of instability or seizure.
It is important for your recovery that you work with your Social
Worker, Psychiatrist, and Psychologist to help you have a
sustained sobriety. You were given a list of locations for
possible partial programs by social work on discharge.
We have made no changes to your medications. Please follow-up
with your primary care physician as listed below.
Best of luck on your recovery and sobriety.
Followup Instructions:
___
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2176-04-19 00:00:00
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2176-04-19 19:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Wellbutrin / trazodone
Attending: ___.
Chief Complaint:
The patient is a ___ gentleman with known Hx seizure disorder,
multiple traumatic injuries, EtOH abuse, and pancreatitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient has had previous success at sobriety and by chart
review ahd reportedly functioned as a substance abuse counselor
within the ___.
It appears he relapsed in ___ and has continued to have issues
with recurrentr alcohol abuse since then. He carries a prior
diagnosis of pancreatitis and presents to the ED this admission
with complaint of one month of abdominal pain similar to prior
bouts of pancreatitis. He was treated conservatively and planned
for admission to the medicine service yesterday, he did however
develop acute withdrawal symptoms warranting overnight
observation on phenobarbital protocol in the ICU overnight
Past Medical History:
seizure disorder Dx ___ ___
COPD
chronic back pain
EtOH abuse: sober for ___ years, ___ and in fact became a
drug and alcohol ___ with the ___ system.
s/p liver resection ___ GSW
left knee ACL tear
h/o left lung trauma
h/o right wrist injury
left biceps tendon rupture
Social History:
___
Family History:
Brother with ___ syndrome, ICD placed.
Physical Exam:
Admission exam:
Vitals: 98.7 149.80 124 21 94% 3L NC
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi, diminished breath sounds in bases bilaterally L>R.
CV: Tachycardic rate and regular rhythm, normal S1 S2, no
murmurs, rubs, gallops
ABD: soft, moderately tender to palpation in RUQ and epigastrum,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Soft mass present on R wrist.
SKIN: extensive tattoos, otherwise no lesions
NEURO: CN ___ intact, strength ___ and sensation intact
proximally and distally upper and lower extremities.
Discharge exam:
Vitals: 98.2, 122/78, 84, 18, 96% on RA
Gen: NAD, sitting up in bed, AAOx3
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. CNs II-XII intact. MAEE.
Psych: Full range of affect
Pertinent Results:
Admission labs:
___ 02:20AM BLOOD WBC-4.3 RBC-3.24* Hgb-11.2* Hct-32.3*
MCV-100* MCH-34.6* MCHC-34.7 RDW-15.3 RDWSD-57.0* Plt ___
___ 06:25AM BLOOD WBC-3.7* RBC-3.69* Hgb-12.7* Hct-37.3*
MCV-101* MCH-34.4* MCHC-34.0 RDW-16.1* RDWSD-59.6* Plt ___
___ 02:20AM BLOOD Plt ___
___ 02:20AM BLOOD Glucose-90 UreaN-6 Creat-0.6 Na-137 K-3.9
Cl-101 HCO3-23 AnGap-17
___ 01:33PM LACTATE-2.7*
___ 10:20AM ___
___ 06:25AM ALT(SGPT)-37 AST(SGOT)-52* ALK PHOS-93 TOT
BILI-0.4
___ 06:25AM LIPASE-230*
___ 06:25AM ALBUMIN-4.4
___ 01:33PM O2 SAT-83
Discharge labs:
___ 06:40AM BLOOD WBC-3.3* RBC-3.07* Hgb-10.7* Hct-31.5*
MCV-103* MCH-34.9* MCHC-34.0 RDW-15.8* RDWSD-60.3* Plt ___
___ 06:40AM BLOOD Glucose-113* UreaN-13 Creat-0.8 Na-139
K-3.8 Cl-102 HCO3-25 AnGap-16
___ 06:30AM BLOOD ALT-17 AST-25 AlkPhos-85 TotBili-0.4
___ 06:40AM BLOOD Mg-1.4*
Micro:
___ CULTURE-FINALINPATIENT -
NEGATIVE
___ VIRAL LOAD-FINALINPATIENT -
NEGATIVE
___ SCREENMRSA SCREEN-FINALINPATIENT -
NEGATIVE
Imaging:
CXR
Comparison to ___. The lung volumes are normal.
Mild elevation
of the right hemidiaphragm. Minimal right basilar atelectasis.
Borderline
size of the cardiac silhouette. No pulmonary edema, no pleural
effusions, no
pneumonia.
CT head
1. No acute intracranial process.
2. Moderate cortical atrophy with probable chronic small vessel
ischemic
disease.
CT C spine
1. No acute fracture or traumatic malalignment. Multilevel
degenerative
changes.
Brief Hospital Course:
___ with EtOH abuse, multiple admissions for w/d at the ___,
alcoholic pancreatitis, COPD, cleared HBV and HCV, and seizure
disorder who presented to ED with EtOH intoxication and
abdominal pain, initially admitted to FICU for phenobarbital
protocol, and now stable on the floor on phenobarb taper.
# Abdominal pain
# nausea and vomiting
# Acute pancreatitis
Patient was diagnosed with acute alcoholic pancreatitis based on
lab findings and physical exam. He improved with IV fluids and
bowel rest. By discharge, he was tolerating a regular diet
without nausea or vomiting. Pain was well controlled with low
dose oxycodone.
# Alcohol withdrawal
The patient was seen by social work and started on the
phenobarbital taper, MVI, thiamine, and folate.
# Fall
# Orthostatic hypotension
The patient had a mechanical falll while in the hospital on
___. No injuries sustained on CT head and C spine. On ___ eval,
orthostatic were positive, felt to be due to deconditioning.
Home metoprolol was stopped and he was prescribed metoprolol and
home ___. He will use his cane at all times.
# Seizure disorder
Patient was continued on home lacosamide and gabapentin.
# Hypomagnesemia
Persistent. Patient was started on magnesium oxide 400 BID on
discharge.
# Pancytopenia
Chronic. Stable. Likely from alcohol. Continue to monitor as an
outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LACOSamide 100 mg PO BID
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
4. Paroxetine 20 mg PO QHS
5. Thiamine 100 mg PO DAILY
6. Tiotropium Bromide 1 CAP IH DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Gabapentin 200 mg PO QAM
9. Gabapentin 600 mg PO QHS
10. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Gabapentin 200 mg PO QAM
RX *gabapentin 100 mg 2 capsule(s) by mouth every morning Disp
#*60 Capsule Refills:*0
3. Gabapentin 600 mg PO QHS
RX *gabapentin 300 mg 2 capsule(s) by mouth every evening Disp
#*60 Capsule Refills:*0
4. LACOSamide 100 mg PO BID
RX *lacosamide [Vimpat] 100 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
5. Multivitamins 1 TAB PO DAILY
6. Paroxetine 20 mg PO QHS
7. Thiamine 100 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Magnesium Oxide 400 mg PO BID
RX *magnesium oxide 400 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth daily Disp #*5 Tablet
Refills:*0
11. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
12. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawal
Alcoholic pancreatitis
Fall
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted for abdominal pain and alcohol withdrawal. You
were treated with medications for withdrawal and IV fluids with
significant improvement. It is now safe to leave the hospital.
You were found to be weak as well, so please participate in
physical therapy when you leave.
Followup Instructions:
___
|
10884428-DS-18
| 10,884,428 | 28,227,438 |
DS
| 18 |
2117-08-21 00:00:00
|
2117-08-22 22:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath, fever
Major Surgical or Invasive Procedure:
Surgical staple removal
History of Present Illness:
Mr. ___ is a ___ with history COPD, HTN, recently
discharged after lumbar laminectomy on ___ who presents with
two days of cough, SOB and fever to 102 with chills.
He was feeling well until ___ AM when he woke up with chills,
mild SOB and frontal headache. He denies ever having chest pain.
Cough is mild and improved now without sputum. Presented to ___
___ where labs notable for: WBC 23.8, Hb 14.4,
Hct 42.5, Plt 249, Na 136, K 4.0, Cl 99, CO3 27, AG 10, BUN 21,
Cr 1.4, Glu 118, Lactate 0.9, Ca 8.7, trop 0.06. There, he
received levaquin, vancomycin 1 g, solumedrol, duonebs.
CXR showed infiltration at right lung base. OSH CTA chest showed
RML consolidation with question of small PE due to small filling
defects in RLL. Patient was not started on heparin drip. CT head
showed old R thalamic lacunar infarct, small focus of increased
attenuation which may be hemorrhage in posterior limb of
internal capsule.
He was transferred to ___ for further management. Neurosurgery
evaluated patient and head imaging in the ED and felt CT
findings are unlikely to represent new hemorrhage and that
patient was at neurologic baseline and did not need
neurogsurgical intervention. They also felt that it would be
safe for patient to be on heparin drip from surgery perspective
should he need it for his PE.
Of note, last admission for laminectomy was complicated by new
left facial droop postoperatively and patient was found to have
10x6 mm right internal capsule hemorrhage. Repeat head CT prior
to discharge was stable so patient was discharged home and
instructed to resume plavix on ___.
Patient reports that since discharge, his foley was removed but
he had problems with retention so it was replaced. It was
removed a second time and he was able to void however had
problems making it to the bathroom in time. He now has a foley
again that was placed at OSH. (Of note, at baseline prior to
laminectomy he gets up every ~2 hours at night to urinate, has
never been on BPH medications.)
In the ED initial vitals were: 97.8 67 114/73 14 96% 4L NC
- Labs were significant for WBC 23, Cr 1.3, lactate 1
- Patient was given albuterol, ipratropium, metoprolol
Vitals prior to transfer were: 98.1 64 117/73 22 95 2L NC %
Nasal Cannula
On the floor, patient reports feeling well at the moment. He
denies fever, chills, SOB, chest pain, headache.
Past Medical History:
HTN
COPD
Idiopathic cardiomyopathy
Elevated PSA
TIA
SVT/PVCs
Skin soft tissue neoplasm, unspecified
S/p lumbar laminectomy ___
Social History:
___
Family History:
Reports both parents are healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
98.1 117/91 80 18 95RA
GENERAL: NAD, alert and oriented x3
HEENT: EOMI, PERRL, MMM, slight left sided facial droop
NECK: Supple, full ROM, no stiffness
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Crackles at right lung base, no wheezes, breathing
comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
BACK: Staples intact in lower midline back with mild redness, no
tenderness to palpation
EXTREMITIES: no cyanosis, no edema or calf tenderness
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, tongue midline, strength ___ in all
extremities
DISCHARGE PHYSICAL EXAM:
99.5 98.1 121/92 70 18 95RA
UOP 1600 o/n
GENERAL: NAD, alert and oriented x3
HEENT: EOMI, PERRL, MMM, slight left sided facial droop
NECK: Supple, full ROM, no stiffness
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Crackles at right lung base, high pitched breath sounds
over right lung field, breathing comfortably without use of
accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
BACK: Staples intact in lower midline back with mild redness, no
tenderness to palpation
EXTREMITIES: no cyanosis, no edema or calf tenderness
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, tongue midline, strength ___ in all
extremities
Pertinent Results:
___ 10:27AM BLOOD WBC-23.2*# RBC-4.10* Hgb-14.0 Hct-40.3
MCV-98 MCH-34.1* MCHC-34.6 RDW-12.4 Plt ___
___ 06:55AM BLOOD WBC-22.4* RBC-3.98* Hgb-13.4* Hct-40.3
MCV-101* MCH-33.6* MCHC-33.1 RDW-12.3 Plt ___
___ 07:00AM BLOOD WBC-14.6* RBC-4.03* Hgb-13.4* Hct-40.6
MCV-101* MCH-33.2* MCHC-32.9 RDW-12.3 Plt ___
___ 10:27AM BLOOD Neuts-95.6* Lymphs-2.8* Monos-1.4*
Eos-0.1 Baso-0.1
___ 06:55AM BLOOD ___ PTT-51.5* ___
___ 10:27AM BLOOD Glucose-119* UreaN-22* Creat-1.3* Na-136
K-4.2 Cl-100 HCO3-27 AnGap-13
___ 07:00AM BLOOD Glucose-83 UreaN-23* Creat-1.1 Na-141
K-3.5 Cl-103 HCO3-26 AnGap-16
___ 10:27AM BLOOD CK-MB-4 cTropnT-0.04*
___ 06:55AM BLOOD CK-MB-3 cTropnT-0.02*
___ 06:55AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.2
___ 10:43AM BLOOD Lactate-1.0
IMAGING:
CT head w/o contrast ___ (OSH film):
1. Interval resolution of hemorrhage within the right putamen.
2. Due to the stability of the hyperdensity in the right
thalamus, this likely represents a more chronic abnormality and
is unlikely to represent a recent subacute hemorrhage; more
likely older hemorrhagic products and/or mineral deposition is
likely with suspicion that this may be associated with a small
vascular anomaly, probably cavernoma.
CTA chest w and w/o contrast ___ (OSH film):
1. No evidence of pulmonary embolism or acute aortic pathology.
2. Linear opacities predominantly in the right lower lobe
likely reflects combination of motion artifact, atelectasis, and
parenchymal scarring.
3. Thickening of airways with air trapping in the left lower
lobe which
likely represents sequelae from prior infection or aspiration
event.
4. Moderate emphysema.
Lower extremity bilateral ultrasound ___:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
Brief Hospital Course:
Mr. ___ is a ___ with COPD, HTN, recently discharged from
___ after lumbar laminectomy on ___ who presented to ___
___ with SOB, found to have HCAP and possible PE
on CTA.
# HCAP: He was febrile with leukocytosis, subjective dyspnea,
mild cough and mild hypoxia with radiographic evidence of
pneumonia. This was HCAP given patient was recently
hospitalized. Received vancomycin and levofloxacin at OSH. On
admission he was afebrile with interval improvement in symptoms.
Vanc was discontinued ___ and he continued to improve with
oxygen saturation in mid ___ on ambulation. He was discharged
with plan to continue levofloxacin to complete 8 day course
(___).
# Question of PE: Patient at increased risk given recent back
surgery. CTA from OSH showed possible RLL PE. He was initially
treated with heparin drip. ___ official re-read of OSH CTA
showed no PE, LENIs also negative, so heparin gtt was
discontinued.
# Urinary incontinence:
A foley placed at OSH was unable to be discontinued ___ urinary
retention, so he was discharged with a foley and leg-bag and a
follow-up appointment in ___ clinic.
# Chronic intracranial hemorrhage:
Stable on head CT per neurosurgery with stable neurologic exam,
mild left sided facial droop. His neurologic exam was at
baseline with no acute intervention recommended.
# S/P Lamintectomy:
Surgical site appears C/D/I. Per neurosurgery recommendations,
the staples in his back from his laminectomy were removed.
# Idiopathic CMP:
Patient with mild trop leak but no symptoms of ACS and stable
EKG. Continued home ASA, plavix, metoprolol.
# History of TIA:
Continued ASA, plavix
TRANSITIONAL ISSUES:
====================
- Patient discharged on Levofloxacin to complete a total 8-day
course for HCAP (last day of antibiotics ___.
- Staples from his laminectomy were removed per neurosurgery
- OSH CTA was re-read by ___ radiologists and he was
determined not to have a PE. He was maintained on a heparin gtt
in-house until this could be determined, and was discharged home
on no anticoagulation.
- It is unclear why the patient is on clopidogrel (plavix). If
he has not had recent cardiac stents placed, this should be
discontinued.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 12.5 mg PO BID
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
4. Aspirin 81 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY do not START until ___
___
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY do not START until ___
___
3. Docusate Sodium 100 mg PO BID
4. Metoprolol Tartrate 12.5 mg PO BID
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
6. Levofloxacin 750 mg PO Q48H
last day of antibiotics: ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth every other day
Disp #*2 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Health care associated pneumonia
SECONDARY DIAGNOSIS:
Chronic obstructive pulmonary disease, hypertension, status post
recent lumbar laminectomy, history of transient ischemic attack
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 being part of your care at ___. You were
transferred to our hospital with shortness of breath. You were
found on scans to have an infection of the lung, for which you
were treated with antibiotics. Your shortness of breath
subsequently improved.
You were also evaluated by the neurosurgery team, and determined
to have no evidence of new stroke or bleeding in the brain. Your
staples from your previous surgery were removed.
A CT scan of your chest from ___ showed a
possible blood clot in your lung (called a "pulmonary
embolism"). You were treated with a blood thinner (heparin)
until we were able to review your CT scan images with our
radiologists here, who determined that you do not have a blood
clot.
A urinary catheter (foley) was placed in your bladder at the
outside hospital. Unfortunately, when we tried to remove this
you were unable to pee, so we had to put it back in. You will
go home with the foley in place and follow-up with the
urologists in clinic (see below) to have it removed.
After discharge, please follow up with your physicians as below.
Followup Instructions:
___
|
10884708-DS-10
| 10,884,708 | 26,625,127 |
DS
| 10 |
2171-11-04 00:00:00
|
2171-11-05 13:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ yo ___ speaking F with high grade ER/PR+
metastatic breast cancer to lungs, chest wall, and brain
currently receiving ___ and s/p whole brain radiation,
who presents with newly depressed EF after chemoRX for
metastatic breast cancer, EF 10% and concern for developing
shock.
The patient is currently undergoing therapy with ___,
but previously received doxorubicin from ___ to ___,
last dose ___.
She was recently discharged ___ after hospitalization for
dyspnea on exertion, found to have worsening of a known R sided
pleural effusion (presumed malignant), s/p TPC was placed on
___ that was
eventually removed ___. She was unable to tolerate
thoracentesis due to discomfort and anxiety. This was deferred
for outpatient follow-up with IP on ___ when she again did not
tolerate the procedure and it was deferred.
Patient presented on day of admission to ___ clinic where
she complained of progressive shortness of breath as well as
fatigue. She also reports recent onset of lower extremity edema
over the past couple of weeks. She denies any chest pain,
dizziness, or syncope. She denies any fevers or chills. She
reports that she is only able to ambulate 2 minutes without
feeling short of breath. Her weight is up almost 7 pounds since
her last chemotherapy appointment on ___.
The patient was sent for TTE which showed EF 10%, severe TR,
and low cardiac index concerning for developing shock. After 1.5
hours of discussion she was sent to the ED. In the ED, course
was as follows. Despite extensive counseling she refused lab
draws.
Of note, patient reports that she had an episode of chest pain
radiating to her arms bilaterally 2 weeks ago that waxed and
waned over 48h then resolved. She described it as
epigastric/lower chest, squeezing, ___ (Unclear because she has
chest wall mets however).
In the ED initial vitals were:
97.9 98 ___ 97% RA
EKG: Sinus, 98bpm, borderline L axis, QTC 454
Labs/studies notable for:
4.1 > 13.0 < 131
39.3
ALT: 29 AP: 109 Tbili: 1.2 Alb: 3.4
AST: 37 LDH: 429
143 ? 12
===========
3.5 ? 0.7
MB: 2 Trop-T: 0.02
CXR: MY READ: Stable loculated R effusion and known metastases
Patient was given: 20mg IV lasix
Vitals on transfer: 97.9 ___ 18 95 RA
On the floor, patient reports she has had a very long day with
multiple lab draws and will not allow any more lab draws, even
from her port. See Cardiology Fellow Note fur discussion, which
was repeated at the bedside upon admission. The patient was
determined to have capacity to refuse lab draws.
Otherwise, the patient reports some very mild center-chest pain
which has been constant for the past few months. Today is no
different than any other day in terms of her pain. She is mildly
dyspneic which has been progressive over past few days, but
stable since yesterday. Cough productive of frothy sputum. She
vomited once this morning and feel some abdominal fullness but
otherwise denies an entire ROS including fevers/chills.
REVIEW OF SYSTEMS:
Cardiac review of systems is notable for absence of syncope,
fevers/chills, abdominal pain, diarrhea/constipation,
hematochezia/melena. All of the other review of systems were
negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
As per OMR:
Her oncologic problem began in ___ when a mammogram revealed a
mass in the right breast. She underwent a right mastectomy,
with right axillary sentinel lymph node biopsy, on ___.
The pathology was ER+, PR+ and Her2- ductal carcinoma. She later
received 4 cycles of taxotere and cyclophosphamide from ___
to ___, followed by radiotherapy to the right chest to
5,040 cGy (180 cGy x 28 fractions) from ___ to ___.
She then received ___ years of tamoxifen. She was well until ___
when a lump was palpated at the surgical scar on the right
side. A biopsy on ___ showed metastasis. She was treated
with taxol from ___ to ___, followed by 1 cycle of
eribulin from ___ to ___, and then doxorubicin from
___ to ___.
Her neurologic problem began on ___ when she experienced
dizziness. Her symptoms progressed and by ___, she had
ataxia as well as nausea and vomiting. She came to our
emergency department at ___ and a head CT there on ___
disclosed brain metastases. A gadolinium-enhanced head MRI on
___ mshowed multiple enhancing intraparenchymal masses as
well as ___ lesions that are on the subependymal surface of the
left lateral ventricle and on the convexity of the left parietal
brain. She received dexamethasone and her symptoms improved. She
completed whole brain radiotherapy on ___
Most recently receiving ___ (started ___. She
has tolerated this regimen well; however secondary to
thrombocytopenia she is no longer receiving ___ on day 8 and
receives both ___ and ___ on day 1 and day 15
PAST MEDICAL HISTORY:
-Metastatic breast cancer (as above)
-Paranoid schizophrenia
-H/o LTBI (s/p 6 of 9 planned months INH in ___, stopped by Dr
___ in light of LFT abnormalities, unclear if ___ chemo or
INH)
-H. pylori
Social History:
___
Family History:
No known history of breast cancer
Physical Exam:
============================
ADMISSION PHYSICAL EXAM
============================
VS: 97.9 ___ 18 95 RA
GENERAL: NAD, A&Ox3, flat affect
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with no LAD
CARDIAC: RRR, S1/S2, no MRG, JVP halfway up neck with prominent
V waves suggestive of TR
LUNGS: No chest wall deformities, Resp were unlabored, no
accessory muscle use. Faint crackles mid-lung fields and
decreased lung sounds at the right base
ABDOMEN: Soft, NTND. No tenderness.
EXTREMITIES:
There is trace pitting edema to the shins, and 1+ at the ankles
Peripheral pulses including pedal pulses are strong
The skin is dry and lukewarm on evaluation, color unremarkable
PSYCH: Normal, well-ordered thinking, no hallucinations, A&Ox3,
attention intact
============================
DISCHARGE PHYSICAL EXAM
============================
VS: Afebrile, 90-100s/60-70s, 80-100s, ___, 94-97% RA
I/Os: ___
Weight: 58.7 -> 57.9 -> 57.7 -> 56.8 -> 55.6
GENERAL: NAD, Alert, sitting in bed eating breakfast
HEENT: NCAT. Sclera anicteric.
CARDIAC: RRR, S1/S2, no MRG, JVP low-mid neck
LUNGS: No chest wall deformities, resp were unlabored, no
accessory muscle use. No crackles appreciated.
ABDOMEN: Soft, NT, ND.
EXTREMITIES: Trace ___ edema of feet. The skin is dry
and lukewarm on evaluation, color unremarkable.
PSYCH: Normal, well-ordered thinking, A&Ox3, attention intact
Pertinent Results:
============================
ADMISSION LABS
============================
___ 08:54AM BLOOD WBC-4.1 RBC-3.89* Hgb-13.0 Hct-39.3
MCV-101* MCH-33.4* MCHC-33.1 RDW-17.4* RDWSD-63.4* Plt ___
___ 08:54AM BLOOD Plt ___
___ 05:06AM BLOOD Glucose-120* UreaN-13 Creat-0.7 Na-141
K-3.2* Cl-101 HCO3-27 AnGap-13
___ 08:54AM BLOOD ALT-29 AST-37 LD(LDH)-429* AlkPhos-109*
TotBili-1.2
___ 08:54AM BLOOD CK-MB-2 cTropnT-0.02* proBNP-7290*
___ 05:06AM BLOOD CK-MB-2 cTropnT-0.03*
___ 05:06AM BLOOD Albumin-3.0* Calcium-8.0* Phos-4.7*
Mg-1.0*
___ 08:54AM BLOOD CEA-1.9
___ 05:41AM BLOOD Lactate-1.7
___ 05:41AM BLOOD Type-MIX pO2-56* pCO2-44 pH-7.42
calTCO2-30 Base XS-3
============================
IMAGING
============================
CXR ___: 1. Similar appearance of a known moderate, loculated
pleural effusion as compared to prior study in ___. No
evidence of pulmonary edema or left pleural effusion.
2. Multiple pulmonary metastatic nodules are better seen on the
recent CT exam from ___.
TTE ___: The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is severe global left ventricular hypokinesis
(LVEF = 10 %). The estimated cardiac index is depressed (1.28
L/min/m2). The right ventricular free wall thickness is normal.
The right ventricular cavity is mildly dilated with severe
global free wall hypokinesis. 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. Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. Mild
(1+) mitral regurgitation is seen. The left ventricular inflow
pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure. Severe [4+] tricuspid
regurgitation is seen. [In the setting of at least moderate to
severe tricuspid regurgitation, the estimated pulmonary artery
systolic pressure may be underestimated due to a very high right
atrial pressure.] Significant pulmonic regurgitation is seen.
There is a very small pericardial effusion. There are no
echocardiographic signs of tamponade.
============================
MICROBIOLOGY
============================
URINE CULTURE (Final ___: < 10,000 CFU/mL.
============================
DISCHARGE LABS
============================
___ 03:05PM BLOOD WBC-5.3 RBC-3.90 Hgb-13.3 Hct-40.5
MCV-104* MCH-34.1* MCHC-32.8 RDW-17.5* RDWSD-65.6* Plt ___
___ 03:05PM BLOOD Neuts-54.7 ___ Monos-9.9 Eos-0.8*
Baso-0.8 Im ___ AbsNeut-2.92 AbsLymp-1.79 AbsMono-0.53
AbsEos-0.04 AbsBaso-0.04
___ 03:05PM BLOOD Plt ___
___ 06:02AM BLOOD Glucose-92 UreaN-14 Creat-0.7 Na-138
K-4.7 Cl-96 HCO3-27 AnGap-15
___ 03:05PM BLOOD ALT-24 AST-32 LD(LDH)-481* CK(CPK)-83
AlkPhos-111* TotBili-1.2
___ 06:02AM BLOOD proBNP-5627*
___ 06:02AM BLOOD Calcium-8.2* Phos-3.8 Mg-1.2*
Brief Hospital Course:
====================
PATIENT SUMMARY
====================
Mrs. ___ is a ___ yo ___ speaking woman with high grade
ER/PR+
metastatic breast cancer to the lungs, chest wall, and brain
who previously received ___ and is s/p whole
brain radiation, who presented with shortness of breath, dyspnea
on exertion, and lower extremity edema and was found to have new
cardiomyopathy with an EF 10% and acute systolic heart failure.
She underwent IV diuresis with Lasix and was transitioned to
oral torsemide 20mg daily as well as daily electrolyte
repletion.
====================
ACUTE ISSUES
====================
#Acute systolic heart failure:
#Severe Cardiomyopathy likely ___ Anthrocycline:
Mrs. ___ presented from ___ clinic with worsened
shortness of breath, dyspnea on exertion, and lower extremity
edema. Her TTE demonstrated acutely worsened LVEF 10%, a low CI
(1.28 L/min/m2), and severe TR - thought to be most likely
secondary to anthracycline-induced CM (cumulative doxorubicin
lifetime dose of 400 mg/m2). Other causes on differential
included ischemia, myocarditis, and infiltrative disease -
however all seemed much less likely given her history.
Throughout her stay, she appeared to have adequate perfusion as
she had lukewarm extremities and clear mental status. She was
started on IV Lasix and PO Captopril 3.125mg TID. Of note
though, Mrs. ___ frequently refused diagnostic and treatment
recommendations. As such, a family meeting was held on ___
with Oncology (Dr. ___, Palliative Care (Drs. ___,
Cardiology (Drs. ___, Social Work,
and Patient support (___) - where treatment options
were discussed and eventually agreed upon. Her weight was
decreased from 58.7 to 55.6 kg (122.57 lb), and she was
discharged on Torsemide 20mg PO daily, Lisinopril 2.5mg PO
daily, and Metoprolol XL 12.5mg daily. Her Potassium and
Magnesium received repletion throughout her stay, and as such
she we discharged with daily PO Potassium 20 mEq daily and
Magnesium Oxide 400mg PO daily.
====================
CHRONIC ISSUES
====================
# Chronic Loculated Pleural Effusion: S/p multiple attempts at
thoracentesis that were not well-tolerated. Given hemodynamic
stability, no further treatment was pursued. It was believed
that her dyspnea was more likely related to her pulmonary edema
rather than her pleural effusion.
# Paranoid Schizophrenia: Not on medications (started refusing
medications in ___. However, her thinking was
well-ordered throughout her stay. Palliative Care became
involved and determined that she had capacity. The primary team
confirmed this as well.
====================
TRANSITIONAL ISSUES
====================
[ ] DISCHARGE WEIGHT: 55.6 kg (122.57 lb)
[ ] DISCHARGE DIURETIC: Torsemide 20mg PO daily
[ ] DISCHARGE ANTICOAGULATION: None
[ ] FOLLOW UP LABORATORY TESTING: BMP on ___
[ ] MEDICATION CHANGES:
[ ] NEW: Torsemide 20mg PO daily, Lisinopril 2.5mg PO daily,
Metoprolol XL 12.5mg daily, KCL 20mEq PO daily, Magnesium 400mg
PO daily
[ ] STOPPED: None
[ ] CHANGED: None
[ ]Follow up with Cardiology to discuss diuretic dosage,
electrolyte follow up on ___
[ ]Follow up with Oncology (Dr. ___ to discuss further
treatment options
[ ]Follow up with Palliative Care to discuss further comfort
care treatment options on ___
# CODE STATUS: FULL (confirmed)
# CONTACT: ___ (HUSBAND) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benzonatate 100 mg PO TID:PRN cough
2. Fentanyl Patch 25 mcg/h TD Q72H
3. Omeprazole 40 mg PO BID
Discharge Medications:
1. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth once per day Disp
#*30 Tablet Refills:*0
2. Magnesium Oxide 400 mg PO DAILY
RX *magnesium oxide 400 mg 1 capsule(s) by mouth once daily Disp
#*30 Capsule Refills:*0
3. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
once per day Disp #*15 Tablet Refills:*0
4. Potassium Chloride 20 mEq PO DAILY
Hold for K >5.5
RX *potassium chloride [Klor-Con] 20 mEq 1 packet(s) by mouth
once per day Disp #*30 Packet Refills:*0
5. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth once per day Disp #*30
Tablet Refills:*0
6. Benzonatate 100 mg PO TID:PRN cough
7. Fentanyl Patch 25 mcg/h TD Q72H
8. Omeprazole 40 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute systolic heart failure
Cardiomyopathy
Secondary:
Metastatic breast cancer
Chronic loculated pleural effusion
Paranoid schizophrenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to the hospital because ___ had been feeling
short of breath and ___ were found to have fluid on your lungs.
This was felt to be due to a condition called heart failure,
where your heart does not pump hard enough and fluid backs up
into your lungs. ___ were given a diuretic medication through
the IV to help get the fluid out. ___ improved considerably and
were ready to leave the hospital.
WHAT DO ___ NEED TO DO WHEN ___ LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs. Your weight on discharge is 55.6
kg (122.57 lb)
- Seek medical attention if ___ have new or concerning symptoms
or ___ develop swelling in your legs, abdominal distention, or
shortness of breath at night.
It was a pleasure participating in your care. We wish ___ the
best!
-Your ___ Care Team
Followup Instructions:
___
|
10884708-DS-11
| 10,884,708 | 20,333,485 |
DS
| 11 |
2171-11-10 00:00:00
|
2171-11-10 15:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___
Chief Complaint:
Chest pain and dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ speaking F with high grade ER/PR+
metastatic breast cancer to lungs, chest wall, and brain,
currently C6D22 of ___ and s/p whole brain radiation
in ___, who presents to the emergency department with chest
pain and dyspnea. Patient developed retrosternal, nonradiating
sharp chest pain the night prior to admission. This pain was
associated with dyspnea both at rest and with minimal exertion.
She notes that she frequently experiences both of these symptoms
at baseline, but that they were worse than normal on the evening
prior to admission. She has also experienced associated nausea,
and nonbloody vomiting. She reports that the baseline chest
discomfort she experiences is a retrosternal pressure sensation
and is due to her chest wall metastases. The chronic dyspnea on
exertion is due to her chronic pleural effusion. Last night when
the pain started, she reports that she was not exerting herself,
had not recently eaten. Cannot identify a trigger for these
symptoms.
She also endorses a gradual headache that started on the day
prior to admission, left-sided, not associated with any fevers,
photophobia, phonophobia or any weakness or paresthesias.
Headache was relieved with 1 dose of oxycodone. She has reported
intermittent dizziness over the last several days, as well. She
reported this to her outpatient oncologist, who had ordered her
to have an outpatient MRI head (scheduled for ___.
Of note, the patient was recently admitted to the heart failure
service from ___ she has a newly depressed EF of 10%. She
was admitted for acute systolic heart failure, discharged on
metoprolol, lisinopril, torsemide, and potassium.
In the ED, initial VS were: T 97.7, HR 91, BP 91/61, RR 16,
SpO2 100% RA
Labs were notable for: trop 0.03, K 2.7
Imaging included: CXR showing improvement in loculated,
right-sided pleural effusion, multiple metastatic nodules
Consults called: none
Treatments received: PO Potassium Chloride 40 meq x2
On arrival to the floor, patient reports ongoing chest pain and
DOE; improved from last night but still not back to her
baseline. Also endorsing nausea, which she says is at her
baseline. Endorses minimal to no appetite and occasional
vomiting.
Past Medical History:
PAST ONCOLOGIC HISTORY:
As per OMR:
Her oncologic problem began in ___ when a mammogram revealed a
mass in the right breast. She underwent a right mastectomy,
with right axillary sentinel lymph node biopsy, on ___.
The pathology was ER+, PR+ and Her2- ductal carcinoma. She later
received 4 cycles of taxotere and cyclophosphamide from ___
to ___, followed by radiotherapy to the right chest to
5,040 cGy (180 cGy x 28 fractions) from ___ to ___.
She then received ___ years of tamoxifen. She was well until ___
when a lump was palpated at the surgical scar on the right
side. A biopsy on ___ showed metastasis. She was treated
with taxol from ___ to ___, followed by 1 cycle of
eribulin from ___ to ___, and then doxorubicin from
___ to ___.
Her neurologic problem began on ___ when she experienced
dizziness. Her symptoms progressed and by ___, she had
ataxia as well as nausea and vomiting. She came to our
emergency department at ___ and a head CT there on ___
disclosed brain metastases. A gadolinium-enhanced head MRI on
___ mshowed multiple enhancing intraparenchymal masses as
well as ___ lesions that are on the subependymal surface of the
left lateral ventricle and on the convexity of the left parietal
brain. She received dexamethasone and her symptoms improved. She
completed whole brain radiotherapy on ___
Most recently receiving ___ (started ___. She
has tolerated this regimen well; however secondary to
thrombocytopenia she is no longer receiving ___ on day 8 and
receives both ___ and ___ on day 1 and day 15
PAST MEDICAL HISTORY:
-Metastatic breast cancer (as above)
-Paranoid schizophrenia
-H/o LTBI (s/p 6 of 9 planned months INH in ___, stopped by Dr
___ in light of LFT abnormalities, unclear if ___ chemo or
INH)
-H. pylori
Social History:
___
Family History:
No known history of breast cancer
Physical Exam:
ADMISSION EXAM
===========================
VS: T 97.6, BP 93/65, HR 93, RR 18, SpO2 97/RA
GENERAL: Pleasant, thin, lying propped up in bed comfortably,
NAD.
HEENT: PERRL, EOMI, sclera anicteric. MMM, no oral thrush or
erythema.
CARDIAC: RRR, S1+S2, no M/R/G. JVP flat.
LUNG: decreased though not absent breath sounds at R base,
otherwise CTAB. Chest wall notable for R mastectomy scar, ~4cm
firm lump over sternum that is mildly TTP.
ABD: non-distended, soft, non-tender
EXT: WWP, no edema
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: alert, oriented to self, ___, ___.
SKIN: No significant rashes
DISCHARGE EXAM
===========================
VS: T 97.5 83/56 86 96% RA
GENERAL: Thin, lying propped up in bed comfortably, NAD.
HEENT: EOMI, sclera anicteric. MMM, no oral thrush or
erythema.
CARDIAC: RRR, S1+S2, no M/R/G. JVP flat.
LUNG: decreased though not absent breath sounds at R base,
otherwise CTAB. Chest wall notable for R mastectomy scar, ~4cm
firm lump over sternum that is mildly TTP.
ABD: non-distended, soft, non-tender
EXT: WWP, no edema
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: alert, oriented to self, ___, ___.
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS
==============================
___ 01:25AM BLOOD WBC-3.9* RBC-4.13 Hgb-13.8 Hct-41.9
MCV-102* MCH-33.4* MCHC-32.9 RDW-17.2* RDWSD-63.7* Plt ___
___ 01:25AM BLOOD Neuts-46.4 ___ Monos-11.7 Eos-1.5
Baso-1.0 Im ___ AbsNeut-1.83 AbsLymp-1.54 AbsMono-0.46
AbsEos-0.06 AbsBaso-0.04
___ 01:25AM BLOOD Plt ___
___ 01:25AM BLOOD Glucose-89 UreaN-14 Creat-0.7 Na-136
K-3.2* Cl-88* HCO3-32 AnGap-16
___ 01:25AM BLOOD CK(CPK)-79
___ 01:25AM BLOOD CK-MB-2 cTropnT-0.03*
___ 03:11AM BLOOD K-2.7*
DISCHARGE LABS
==============================
___ 06:17AM BLOOD WBC-3.1* RBC-4.02 Hgb-13.5 Hct-39.9
MCV-99* MCH-33.6* MCHC-33.8 RDW-16.6* RDWSD-61.5* Plt ___
___ 06:17AM BLOOD Glucose-101* UreaN-13 Creat-0.6 Na-138
K-3.1* Cl-92* HCO___-29 AnGap-17
___ 06:17AM BLOOD Calcium-7.8* Phos-3.6 Mg-1.2*
RELEVANT STUDIES
==============================
___ Imaging CHEST (PA & LAT)
1. Moderate right loculated pleural effusion is decreased since
the prior study.
2. Multiple pulmonary metastatic nodules better evaluated on
most recent chest CT from ___.
MICROBIOLOGY
==============================
__________________________________________________________
___ 1:10 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Brief Hospital Course:
___ ___ speaking F with high grade ER/PR+
metastatic breast cancer to lungs, chest wall, and brain,
currently receiving ___ and s/p whole brain radiation,
who presented to the emergency department with chest pain and
dyspnea.
#CHEST PAIN: unclear what the etiology is. EKG was unchanged,
trop was 0.03 (which was consistent with trop from prior
admission). Unlikely to be cardiac in origin. PE was on the
differential, though patient was not tachycardic or hypoxic and
pain comes and goes. She may have pleurodynia or pleuritis
related to her chronic effusion, though the location,
waxing/waning nature of pain is less consistent with this.
Presentation was not consistent with pericarditis. ___ be
related to chest wall mets and associated pain. Also may be
related to significant anxiety regarding her disease. Of note,
we discussed repeating a troponin with the patient, who
declined, even with a risk/benefit discussion of testing
troponin to rule out cardiac ischemia through a medical
interpreter. We offered to treat her pain and/or her anxiety,
but she declined. Ultimately her chest pain returned back to
baseline (___) without intervention.
#METASTATIC BREAST CANCER, ER/PR+:
#METS TO LUNG, CHEST WALL, BRAIN: currently C6D22 of
___ and s/p whole brain radiation in ___. Followed
by Dr ___ and ___, NP. Has been reporting
intermittent dizziness over the last several days - in the
setting of known brain mets, an outpatient MRI was ordered and
was scheduled for ___. We ordered the study to be done
inpatient, but the patient declined. We explained the risk of
worsening brain metastases, but the patient reported that even
if she did have worsening brain disease, she would not want
radiation. We will defer further work-up and management of her
malignancy to her outpatient team, who was made aware of her
inpatient stay.
#HErEF: due chemotoxicity, EF 10%. Appeared euvolemic during
admission. Of note, the patient has been consistently
hypokalemic on torsemide, requiring standing potassium. Her
potassium was low in the ED, for which she was given 80 mEq of
oral potassium. She then vomited multiple times, and may have
vomited some or all of this dose up. She declined a blood draw
to assess her potassium level on arrival to the floor. We
discussed, at length, the risks of hypokalemia and hyperkalemia
through a medical interpreter. She continued to decline blood
draws until the next day, when her K returned at 3.1. She was
repleted with oral potassium prior to discharge (she declined to
have her port accessed and pulled out her peripheral IV and did
not allow it to be replaced). Continue torsemide, metoprolol,
and lisinopril. Did not change her home cardiac meds. She missed
an outpatient heart failure appointment while admitted; the
outpatient provider was notified and asked to reschedule the
patient.
#DYSPNEA:
#CHRONIC LOCULATED PLEURAL EFFUSION: previously drained with
Pleurex catheter, though the effusion subsequently
re-accumulated. This is the likely explanation for her DOE,
though there may also be a component of anxiety behind this, as
her baseline chest pain and dyspnea seem to acutely worsen and
resolved without specific intervention, and she had no evidence
of cardiac ischemia during these events. She was started on
torsemide 20mg daily during prior admission; CXR on arrival this
admission showing that the effusion is decreased in size. Of
note, s/p multiple attempts at thoracentesis during recent
admission that were not well-tolerated. Pt was not hypoxic
during this admission. Denied cough.
#PARANOID SCHIZOPHRENIA: Not on medications (started refusing
medications in ___. During her prior admission, there
was a question of whether or not the patient had capacity;
palliative care became involved and determined that she had
capacity. The primary team confirmed this as well. Pt was
paranoid during this admission - she refused to be moved from ___
___ to ___ as she insisted ___ for
cancer patients and she reported that her headaches were due to
the medications that her mother were injecting into her head.
She continued to demonstrate adequate understanding of her
immediate medical issues.
TRANSITIONAL ISSUES
===================
[ ] Pt is declining further head imaging to assess for disease
progression. Could be re-discussed with outpatient team.
[ ] Pt missed heart failure appointment while admitted - have
asked Dr ___ office to reschedule.
[ ] DISCHARGE WEIGHT: 50.3 kg (110.89 lb)
[ ] No changes were made to medications.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benzonatate 100 mg PO TID:PRN cough
2. Fentanyl Patch 25 mcg/h TD Q72H
3. Omeprazole 40 mg PO BID
4. Lisinopril 2.5 mg PO DAILY
5. Magnesium Oxide 400 mg PO DAILY
6. Potassium Chloride 20 mEq PO DAILY
7. Torsemide 20 mg PO DAILY
8. Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Medications:
1. Potassium Chloride 20 mEq PO DAILY
Hold for K > 5.5
RX *potassium chloride 20 mEq One tablet(s) by mouth Once a day
Disp #*30 Tablet Refills:*0
2. Benzonatate 100 mg PO TID:PRN cough
3. Fentanyl Patch 25 mcg/h TD Q72H
4. Lisinopril 2.5 mg PO DAILY
5. Magnesium Oxide 400 mg PO DAILY
6. Metoprolol Succinate XL 12.5 mg PO DAILY
7. Omeprazole 40 mg PO BID
8. Torsemide 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic breast cancer
Heart failure with reduced ejection fraction
Chronic pleural effusion
Paranoid schizophrenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were having chest pain and shortness of breath. You also
had been having headaches and were dizzy. Your cancer doctor
wanted you to have an MRI of your head.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You declined several blood tests to test for injury to your
heart and to test your potassium and magnesium. We explained to
you that, without knowing what your potassium and magnesium are,
you could develop a dangerous heart rhythm that could become
deadly.
- You declined CT scan of your chest to look closely at your
heart and lungs to see if we could find a reason for your chest
pain and shortness of breath.
- You declined an MRI of your brain to look for growing tumors
in your brain. That could explain your headache and dizziness,
and could possibly be treated with radiation to the brain. You
were not interested in getting this MRI done.
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
- Continue to take all of your medicines as prescribed.
- If you develop worsening of your chest pain or shortness of
breath, please call Dr ___.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10884708-DS-13
| 10,884,708 | 25,005,846 |
DS
| 13 |
2172-06-04 00:00:00
|
2172-06-04 18:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___
Chief Complaint:
Poor PO intake, poor appetite
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo woman with metastatic breast cancer (chest wall, brain,
lungs) most recently s/p C1D8 Navelbine on ___, CHF with
ejection fraction of ___, paranoid schizophrenia,
neutropenia, presented with hypotension, hyponatremia,
hypomagnesaemia, hypokalemia, and ___, transferred to MICU for
further management.
The patient is unable to recount any history, so it is obtained
using the family and ___ interpreter, as well as through
OMR data.
She was recently seen in ___ clinic two days ago, reporting
11 pound weight loss in 8 days, poor appetite, and poor PO
intake. Her blood pressure was 87/55 and she had ANC 20, and was
started on ciprofloxacin for prophylaxis. She continued to take
torsemide (prescribed 20mg daily, but unclear if she took more
than this at home). Her chemotherapy treatments were held at the
time as the patient was planning to leave for ___ on ___ for
___ weeks. Last night, per family, patient developed shortness
of breath associated with nausea and vomiting. She had no
fevers, chills, abdominal pain, urinary symptoms or diarrhea.
She has history of constipation and has chronic chest pain from
her anterior mediastinal mass that has been growing steadily.
She has chronic headaches. Additionally, she has chronic
shortness of breath that has been getting worse over the past
few months. Sick contacts include son with cold for the past few
days.
In the ED, the patient triggered on arrival for hypotension to
87/52, which improved with IV fluids to ___ systolic, but
subsequently had drop in BP to ___, and started on levophed.
HR was in ___ 100s, with good O2 saturation. She had
leukopenia at 1.8, with ANC 110, and Hgb 10.3 stable. She also
had K 2.5 and 2.1 on re-check, and was given 40 PO + 40 IV K.
She had Mg of 0.8 and was given 2mg IV Mg. She also had Na of
121, 118 on recheck, with osm 249, and urine lytes pending.
Chemistry was also notable for ___ to 1.1 from baseline of 0.5,
with BUN 22, chloride 71 and bicarb 31. and VBG revealed
7.54/45. UA and UCG negative, BNP 2772. She had CTA torso that
was negative for PE, with round density in R lower lung
correstponding to loculated effusion in R major fissure seen
previously, and showed stable mediastinal mass, pulmonary
metastases, hepatic metastases (1 which appears to have
decreased in size), increased sclerosis of L iliac bone, no
evidence for pneumonia. Bedside ultrasound revealed reduced
ejection fraction, normal aorta, negative FAST. She was given
1.5 L NS, vancomycin and cefepime, Benadryl, Zofran, lorazepam,
potassium, magnesium, and levophed.
On arrival to the MICU, she was very agitated and demanding to
drink water. She was not interacting with staff and jumping out
of the bed. She was unable to remember why she came to the ICU.
Code purple was called. She was subsequently calmed down after
being given a commode.
Past Medical History:
- Diagnosis: High-grade estrogen receptor positive, breast
cancer with recurrence in the right lung and pleural space as
well as right chest wall.
- ___, she was diagnosed with brain metastasis, initiated on
___ which she tolerated well other than for
thrombocytopenia, thus schedule was changed to ___ on
day 1 and day 15. She continued on ___ until ___.
- ___, diagnosed with new heart failure. EF of 10%. Admitted
to the cardiac service. She was discharged on metoprolol,
lisinopril, torsemide, and potassium. Her most recent f/u ECHO
on ___ revealed an LVEF of ___.
- ___, re-initiated on ___ on ___. Increase
in size of her chest wall tumor. Therefore, gemcitabine was
added to her current regimen of ___ on ___.
- ___, chemo regimen was changed to gemcitabine/Avastin and
carboplatin was removed to reduce the risk of increased
cytopenias.
- ___, patient presented to the ED with shortness of breath.
A CTA was performed, which was negative for PE, but worsening
thoracic mets, anterio mass, lymphadenopathy, and findings
concerning for lymphangitic carcinomatosis.
- ___, given recent progression, patient was initiated on
Navelbine
PAST MEDICAL HISTORY:
-Metastatic breast cancer (as above)
-Paranoid schizophrenia
-H/o LTBI (s/p 6 of 9 planned months INH in ___, stopped by
Dr. ___ in light of LFT abnormalities, unclear if ___ chemo
or
INH)
-H. pylori
Social History:
___
Family History:
No known history of breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
VITALS: Reviewed in metavision
GENERAL: Acutely distressed, unable to remember why she came,
refusing to answer several questions
___: Sclera anicteric
NECK: JVP at 4 cm
CHEST: Large, 4 inch mass on anterior chest with overlying
ecchymosis, non-tender
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
SKIN: No rash, port site c/d/i
NEURO: Disoriented and agitated, but otherwise in tact
DISCHARGE PHYSICAL EXAM:
==========================
GENERAL: NAD, alert and interactive, cooperative
NEURO: A&Ox3, agitated, does not participate in further MS exam
___: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, dentition poor
NECK: nontender supple neck, no LAD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
SKIN: Erythematous mass protruding from chest wall that is
nontender. R sided mastectomy scar noted
Pertinent Results:
ADMISSION LABS:
=================
___ 06:32AM BLOOD WBC-1.8* RBC-3.49* Hgb-10.3* Hct-29.1*
MCV-83 MCH-29.5 MCHC-35.4 RDW-16.5* RDWSD-49.3* Plt ___
___ 06:32AM BLOOD Neuts-6* Bands-0 ___ Monos-65*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.11*
AbsLymp-0.52* AbsMono-1.17* AbsEos-0.00* AbsBaso-0.00*
___ 06:32AM BLOOD ___ PTT-27.8 ___
___ 06:32AM BLOOD Glucose-169* UreaN-22* Creat-1.1 Na-121*
K-2.5* Cl-71* HCO3-31 AnGap-19*
___ 06:32AM BLOOD ALT-12 AST-22 AlkPhos-55 TotBili-1.1
___ 06:32AM BLOOD proBNP-2772*
___ 06:32AM BLOOD Albumin-3.3* Calcium-7.6* Phos-3.7
Mg-0.8*
___ 06:32AM BLOOD Osmolal-249*
___ 06:32AM BLOOD Osmolal-249*
DISCHARGE LABS:
===============
___ 03:15AM BLOOD WBC-7.6 RBC-2.99* Hgb-8.7* Hct-27.1*
MCV-91 MCH-29.1 MCHC-32.1 RDW-17.1* RDWSD-56.7* Plt ___
___ 03:15AM BLOOD Glucose-141* UreaN-7 Creat-0.5 Na-138
K-3.9 Cl-96 HCO3-30 AnGap-12
___ 03:15AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.5*
MICRO:
======
___ Blood Cultures Pending
___ 8:55 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING/STUDIES:
================
CXR ___:
No acute cardiopulmonary abnormality. Previous pleural
effusions have largely resolved.
Extensive intrathoracic malignancy unchanged since ___.
CTA CHEST AND ABDOMEN ___:
1. No evidence of acute aortic abnormality or pulmonary
embolism. No acute
intra-abdominal abnormality.
2. No significant interval change in large sternal/anterior
mediastinal mass
with similar appearing mediastinal and bilateral hilar
lymphadenopathy, as
well as pulmonary metastases and right basilar pleural based
metastasis.
3. Redemonstration of multiple hepatic metastases, 1 of which
appears
decreased in size prior CT.
4. Increased sclerosis of a left iliac bone metastasis, possibly
secondary to
treatment changes.
5. Decreased size of right pleural effusion, now small, and
resolution of
previously noted septal thickening.
Brief Hospital Course:
MICU Course ___:
======================
___ yo woman with metastatic breast cancer (chest wall, brain,
lungs) most recently s/p C1D8 Navelbine on ___, CHF with
ejection fraction of ___, paranoid schizophrenia,
neutropenia, presented with hypotension, hyponatremia,
hypomagnesaemia, hypokalemia, and ___, transferred to MICU for
further management.
#) Hypotension, initial shock
Was likely hypovolemic in the setting of nausea, vomiting, poor
PO intake, and diuretic use. Unclear if she took extra doses of
diuretics as she often does this. She was also neutropenic on
arrival, and therefore susceptible to infections, so was covered
with vancomycin/cefepime. Potential sources include port site
(although, c/d/I) vs pneumonia (has chronic loculated pleural
effusion). Levophed was on but weaned over course
#) Hyponatremia
Hypo-osmolar, hypovolemic given history and hypotension above,
UNa < 20. Improved with NS infusions, but at risk for
over-correction, required brief amount of D5W to correct.
#) ___, prerenal
Cr up to 1.1 from 0.5. Improved with IV fluid resuscitation.
#) Hypochloremic metabolic alkalosis
#) HypoK, hypoMg, hypoPhos, hypoCa
Potential etiologies include diuretic over-use and re-feeding
syndrome. Repleted aggressively.
#) Neutropenia: Last chemotherapy on ___. ANC 110 on admission.
#) Meatastatic breast CA
Patient with brain, lung, and chest wall metastasis. Currently
s/p C1D8 Navelbine on ___. Has chronic chest pain from chest
wall metastasis, worsening, as well as chronic headaches and
dyspnea. Continued home anostrozole
#) Schizophrenia
#) Agitated delirium
Per psychiatry assessment, she is at her baseline level of
suspiciousness. She likely has worsening agitation due to
multiple electrolyte abnormalities. She was unable to engage in
detailed decisions, but able to DNR/DNI.
#) HF - Holding metoprolol, lisinopril, and torsemide in setting
of hypotension and ___
#) GERD - Continue home omeprazole 20mg daily
Floor Course:
=============
___ y/o F with metastatic breast cancer (chest wall, brain,
lungs), most recently initiated on C1 (D1: ___ Navelbine,
CHF (EF ___ from anthracycline toxicity, paranoid
schizophrenia, who presented on ___ with hypotension and
multiple electrolyte derangements, transferred from MICU to the
Oncology floor for further management.
ACUTE ISSUES:
=============
#Hypotension.
#Shock (now resolved). Initially presented with SBPs ___,
requiring brief course of Levophed and resolved with IVF
administration. Likely secondary to poor po intake and
unconfirmed but possible Torsemide over-use. Torsemide was held
during this admission, fluids given, and encouraged po intake.
She also initially presented with neutropenia, but resolved
without Neupogen administration, however given concern for
septic shock on admission, she was initiated on
Vancomycin/Cefepime (D1: ___. Cultures and imaging to without
clear infectious source, therefore, antibiotics were stopped on
___.
#Metastatic breast cancer. Imaging in ___ with worsening
thoracic mets, anterior mass, lymphadenopathy, and findings
concerning for lymphangitic carcinomatosis. Most recent CTA
shows stability of these findings compared to prior imaging
since being initiated on Navelbine (C1D1: ___. Endorses
chronic chest pain likely from chest wall metastasis. We
continued her Anastrazole daily. She missed her oncology follow
up scheduled for today ___. Her outpatient oncologist was
notified of her admission and will reschedule her appointment.
#Schizophrenia
#Agitated delirium. Likely aggravated by toxic-metabolic
derangements as above. Evaluated by psychiatry on admission and
felt to be at 'her baseline level of suspiciousness'. She was
agitated and delusional on ___ perserverating on people putting
bad things in her port. She de-accessed her port multiple times.
She was found to not have capacity on ___ and was given 2.5mg
of IM Haldol. Of note, her husband reports that she has not been
taking her Resperidone. Psychiatry evaluated her on day of
discharge ___ for concerns of poor self care/danger in the
setting of possible Torsemide overuse. They found her to be safe
for discharge with close follow up. We continued her Mirtazpine
daily and restarted her home Resperidone.
#HFrEF (EF ___. EF reduced in the setting of anthracycline
cardiomyopathy. Once resuscitated she remained euvolemic. We
restarted her home Metoprolol and Lisinopril but held her
Torsemide in the setting of electrolyte abnormalities. Her
Torsemide will need to be restarted.
CHRONIC ISSUES:
===============
#GERD
She was continued on home Omeprazole.
#Anemia. Baseline Hgb ___ and currently stable. She did not
have
signs of active blood loss. Hbd remained stable for this
admission.
TRANSITIONAL ISSUES:
===================
- Consider MRI head for re-evaluation given hx of brain
metastasis.
- She has not consistently been taking her Risperdone at home.
This medication was restarted at 1mg daily. Compliancy with this
medication should be encouraged.
- Her home Torsemide was held in the setting of hypotension and
electrolyte abnormalities. She was euvolemic on exam during this
admission, therefore, her Torsemide was held. Please reassess
re-starting this medication at PCP visit next week.
- stopped prophylaxis ciprofloxacin given recovery of ANC
- Please refer patient for psychiatry outpatient evaluation.
- Patient confirmed she is DNR/DNI during this admission
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Anastrozole 1 mg PO DAILY
2. Benzonatate 100 mg PO TID:PRN cough
3. Ciprofloxacin HCl 500 mg PO Q12H
4. Fentanyl Patch 25 mcg/h TD Q72H
5. Lisinopril 2.5 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Mirtazapine 15 mg PO QHS
8. Omeprazole 20 mg PO DAILY
9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH
PAIN
10. Torsemide 20 mg PO DAILY
11. Prochlorperazine 25 mg PR Q8H:PRN nausea
12. RisperiDONE 1 mg PO DAILY
Discharge Medications:
1. RisperiDONE 1 mg PO BID
2. Anastrozole 1 mg PO DAILY
3. Benzonatate 100 mg PO TID:PRN cough
4. Fentanyl Patch 25 mcg/h TD Q72H
5. Lisinopril 2.5 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Mirtazapine 15 mg PO QHS
8. Omeprazole 20 mg PO DAILY
9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH
PAIN
10. Prochlorperazine 25 mg PR Q8H:PRN nausea
11. HELD- Torsemide 20 mg PO DAILY This medication was held. Do
not restart Torsemide until you are told to restart this
medication by your primary care doctor.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hypotension
Hypokalemia
Hypomagnesemia
Hyponatremia
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 ___
due to low blood pressure and abnormal levels of electrolytes
(potassium, magnesium, and sodium). We believe that the cause of
this problem was due to not eating enough food and due to your
medication Torsemide. Torsemide causes you to urinate out water
and electrolytes. This medication should only be used as
directed by your primary care provider. You were given
treatments with electrolytes and fluids and you improved.
Please follow up with you primary care provider and
oncologist. If you experience dizziness, feeling like you are
going to loss consciousness, rapid heartbeat, difficulty
breathing, muscle cramps, or seizures please contact your
primary care provider. Weigh yourself every morning, call MD if
weight goes up more than 3 lbs.
Thank you for allowing us to be a part of your care.
___ Oncology Team
Followup Instructions:
___
|
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DS
| 15 |
2172-07-13 00:00:00
|
2172-07-15 14:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Mucositis/SEPSIS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old woman with recurrent metastatic
breast cancer who is admitted from the ED with mouth and throat
pain.
Patient has extensive treatment history for breast cancer dating
back to ___, with recurrent and metastatic disease since ___
with progression through multiple lines of therapy. She has
known
metastatic disease to lung, brain, and anterior mediastinal
mass.
Her recent medical course has been notable for worsening heart
failure.
She was discharged from the hospital on ___, and received
palliative Taxotere/Cytoxan on ___. Since that time she has
been increasing sedated and weak. She has not been eating over
the last several days due to severe odynophagia, and she is
losing significant weight.
She was seen in ___ clinic on ___. Per clinic notes,
extensive discussion was had with the patient, her family, our
___ patient navigator, ___, and Dr. ___. The
decision was made to discontinue any additional cancer directed
care, and to transition to home-based hospice care. Dr. ___ holding her cardiac medications due to risk of
aspiration and medical complications. She was referred to ___ and services were initiated. However, after
returning home from clinic she has been unable to take any oral
intake due to sever odynophagia. She was brought to the ED.
In the ED, initial VS were pain 10, T 99.6, HR 119, BP 94/58, RR
14, O2 100%RA. Initial labs notable for Na 126, K 3.9, HCO3 25,
Cr 0.7, Ca 8.8, Mg 1.6, P 4.0, ALT 15, AST 36, ALP 74, TBili
1.7,
Alb 3.3, WBC 1.0 (ANC 20; 16% Other), HCT 26.8, PLT 189, lactate
3.1. CXR showed persistent large chest wall mass over right
lower
lung. She was given 1LNS and IV dilaudid. VS prior to transfer
were
On arrival to the floor, patient is unable to speak due to
severe
mouth pain. Above history was confirmed with her husband over
the
phone.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ was first seen in the oncology program in ___ when
she was referred by Dr. ___ to Dr. ___ treatment
of
a newly diagnosed right breast cancer.
___ had immigrated to the ___ approximately ___
years earlier and was ___ years of age at the time of her first
visit to us. She had palpated a right breast mass in the ___
___ in the upper outer quadrant. She was ultimately seen by
Dr.
___ and underwent a core needle biopsy of the right
breast mass. This showed a high-grade ductal carcinoma in situ
with comedo, solid and micropapillary patterns.
On ___, she underwent a right simple mastectomy and
axillary sentinel node procedure. The tumor revealed a grade
III
invasive ductal carcinoma with multiple foci, the largest
measuring 3mm as well as lymphovascular invasion. This occurred
in a background of extensive high nuclear grade ductal carcinoma
in situ. Immunohistochemical stains were positive for estrogen
and progesterone receptors and negative for HER-2/neu by FISH
with an amplification of 1.4.
Postoperatively, she was treated with four cycles of
cyclophosphamide and docetaxel. This was completed in ___.
She also received postmastectomy radiation therapy from Dr.
___
with completion in ___. After completing radiation therapy,
tamoxifen was recommended and started in ___.
Her early care was complicated by an underlying psychosis,
latent
tuberculosis requiring isoniazid therapy, and an H. pylori
infection. Nevertheless, she got through her early phase of
therapy and did well until late ___, when she presented with
probable recurrent disease with a right medial anterior chest
wall mass. She was on tamoxifen at the time of the recurrence.
Thereafter, she received a series of therapies for recurrent
disease. She initially declined an aromatase inhibitor.
She received 7 doses of weekly paclitaxel beginning in early
___
with progression evident by ___. She was then started on
capecitabine and remained on this until ___. She had a brief
exposure to eribulin ( 2 doses) with evidence of continued
disease progression.
Accordingly, doxorubicin was started in ___. She
responded
very well to this with prompt and progressive reduction of
disease manifestations including the right medial chest wall
mass. While on doxorubicin, she was diagnosed with multiple CNS
metastases in ___. These were treated with WBRT with good
clinical response.
As a result of response to doxorubicin and WBRT, ___ was
able
to fulfill her wish of a return visit to ___ to see family and
friends. She was gone for several weeks and by all accounts
felt
well and had a wonderful visit.
She returned to resume additional therapy with doxorubicin but
disease progression was again evident by ___. She was started
on carboplatin at AUC of 2 with bevacizumab added q ___ weeks to
address her CNS as well as systemic disease. She responded well
to this regimen as well but developed several cardiomyopathy
requiring hospitalization in ___. This was likely primarily
related to her doxorubicin exposure but ___, that had been
the only agent to which she had clearly responded. She was
discharged from a cardiology admission on meds including
torsemide. Her EF on meds improved from approximately 15 % to
the ___ range, but she was not consistently adherent to her
cardiac regimen.
In ___, gemcitabine was added because of disease progression
and
ultimately continued with avastin after discontinuation of
___.
Progression was again evident by early ___, and she began
vinorelbine. After 2 doses, she was hospitalized with further
disease progression, increasing heart failure and an increase in
psychotic episodes. Adherence to all oral medications has been
consistently problematic.
___ recently presented to the ED on ___, secondary to
worsening shortness of breath. She was recently inpatient for 3
days and found to have worsening heart failure and progression
of
her disease. During her hospitalization, she was found to be
hyponatremic and hypotensive. This was corrected with fluid
administration and she was discharged on ___, with
instruction to hold home torsemide dosing.
She received palliative Taxotere/Cytoxan on ___
PAST MEDICAL HISTORY:
- Metastatic breast cancer (as above)
- Paranoid schizophrenia
- H/o LTBI (s/p 6 of 9 planned months INH in ___, stopped by
Dr.
___ in light of LFT abnormalities, unclear if ___ chemo or
INH)
- H. pylori
- AFib with RVR
- HFrEF
Social History:
___
Family History:
No known history of breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 99.5 HR 111 BP 94/61 RR 18 SAT 98% O2 on RA
GENERAL: Pleasant woman in NAD sitting up in bed. Does not speak
due to mouth pain
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Trismic jaw greatly limiting evaluation of OP - appears to
have white plaques over tongue. JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses
RESPIRATORY: Appears in no respiratory distress, decrease breath
sound over right hemithorax with anterior crackles
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; large subcutaneous mass over sternum with
brawny
discoloration
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: Dark ___ discoloration over back, scattered excoriations
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy.
DISCHARGE PHYSICAL EXAM
=======================
24 HR Data (last updated ___ @ 846)
Temp: 97.9 (Tm 97.9), BP: 88/60 (88-100/50-67), HR: 103
(102-107), RR: 18 (___), O2 sat: 100% (97-100), O2 delivery:
2L
GEN: Ill appearing woman sitting up in bed NAD, speaking short
phrases.
HEENT: L. posterior pharynx white plaque
Chest: Large, erythematous and brawny anterior chest wall mass.
CV: RRR
EXTREMITIES: Warm, palpable pulses; ___ ___ 2+ pitting edema on
dosum of feet.
NEURO: Alert, answering questions appropriately.
Pertinent Results:
ADMISSION LABS
==============
___ 09:40AM BLOOD WBC-0.7* RBC-2.94* Hgb-8.6* Hct-26.9*
MCV-92 MCH-29.3 MCHC-32.0 RDW-20.8* RDWSD-69.9* Plt ___
___ 09:40AM BLOOD Plt ___
___ 09:40AM BLOOD UreaN-8 Creat-0.5 Na-131* K-4.1 Cl-89*
HCO3-29 AnGap-13
___ 09:40PM BLOOD ALT-15 AST-36 AlkPhos-74 TotBili-1.7*
___ 09:40PM BLOOD Albumin-3.3* Calcium-8.8 Phos-4.0 Mg-1.6
___ 09:45PM BLOOD Lactate-3.1*
PERTINENT RESULTS
=================
___ 02:59AM BLOOD WBC-5.2 RBC-3.05* Hgb-8.8* Hct-28.4*
MCV-93 MCH-28.9 MCHC-31.0* RDW-20.8* RDWSD-71.0* Plt ___
___ 02:59AM BLOOD Neuts-36 Bands-4 Lymphs-17* Monos-37*
Eos-1 Baso-0 ___ Metas-3* Myelos-1* Promyel-1* NRBC-9*
AbsNeut-2.08 AbsLymp-0.88* AbsMono-1.92* AbsEos-0.05
AbsBaso-0.00*
___ 01:00PM BLOOD ___
___ 03:17AM BLOOD Lactate-2.9*
___ 08:27AM BLOOD Lactate-2.0
___ 03:25PM BLOOD Lactate-13.6*
Brief Hospital Course:
___ with HFrEF and recurrent metastatic breast cancer c/b chest
wall, lung, and brain mets who presented at C1D9 palliative
taxotere/cyclophosphamide c/b mucositis, esophageal candidiasis,
and neutropenic septic shock. She was treated with
vancomycin/cefepime and fluids as tolerated with improvement in
her shock. Her neutropenia recovered without intervention. Her
functional status continued to decline and she was transitioned
to hospice house with CMO.
TRANSITIONAL ISSUES
===================
NEW MEDICATIONS: Hydromorphone, Caphosol,
Maalox/Diphenhydramine/Lidocaine solution, Sarna lotion
CHANGED MEDICATIONS: Lorazepam changed to liquid
[] Fentanyl 50 mcg patch Q72H
[] Pain control
[] Maalox/Diphenhydramine/Lidocaine solution ___ ml QID:PRN
for mouth pain
[] Hydromorphone ___ mg liquid Q1H:PRN pain/air hunger
[] Lorazepam 0.5 mg Q4H:PRN: Agitation
[] Continue nutrition
[] ___ mg PO fluconazole daily ___ - ___
CONTACT: ___ He ___
CODE STATUS: CMO
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Anastrozole 1 mg PO DAILY
2. Fentanyl Patch 50 mcg/h TD Q72H
3. Lisinopril 2.5 mg PO DAILY
4. LORazepam 0.5 mg PO Q4H:PRN nausea
5. Metoprolol Succinate XL 25 mg PO DAILY
6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH
PAIN
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. Potassium Chloride (Powder) 20 mEq PO DAILY
9. magnesium chloride 71.5 mg oral DAILY
10. Mirtazapine 15 mg PO QHS
11. Torsemide 10 mg PO DAILY
Discharge Medications:
1. Caphosol 30 mL ORAL QID:PRN dry mouth
2. Fluconazole 200 mg PO Q24H
3. Glycopyrrolate 0.2 mg IV Q6H:PRN secretion
4. Hydromorphone (Oral Solution) 1 mg/1 mL ___ mg PO Q1H:PRN
severe pain, air hunger
RX *hydromorphone 1 mg/mL ___ mg by mouth every hour Refills:*0
5. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth
pain
6. Polyethylene Glycol 17 g PO DAILY
7. Sarna Lotion 1 Appl TP TID:PRN Pruritus
8. Fentanyl Patch 50 mcg/h TD Q72H
RX *fentanyl 50 mcg/hour Apply one patch every 72 hours Disp #*5
Patch Refills:*0
9. LORazepam 0.5 mg PO Q4H:PRN nausea
RX *lorazepam 2 mg/mL 0.5 (One half) mg by mouth every four
hours Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Septic Shock
Febrile neutropenia
Metastatic Breast Cancer c/b Mucositis and odynophagia
Hypovolemic hyponatremia
Acute on chronic heart failure with reduced ejection fraction
Anthracycline-induced cardiomyopathy
SECONDARY DIAGNOSIS
===================
SCHIZOPHRENIA
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___ and family,
You were admitted to the hospital for worsening mouth sores.
You were unable to eat, drink, or talk because of your sores.
You were kept in the hospital for an infection. The infection
made your blood pressure very low, and your heart rate very
fast.
While in the hospital, we found your mouth sores were because of
chemotherapy and fungus. We gave you medicine and your sores
improved. Your infection was treated with anitbiotics. Your
blood pressure and heart rate went back to normal. You
continued to feel worse from your cancer. We discussed with you
and your family about getting to a facility to make you more
comfortable. We continued to control your pain symptoms while
you were in the hospital.
On behalf of our team, it was our privilege to take care of you.
Your ___ Oncology Team
Followup Instructions:
___
|
10884708-DS-8
| 10,884,708 | 28,268,875 |
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| 8 |
2171-02-17 00:00:00
|
2171-02-19 12:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___
Chief Complaint:
dizziness/lightheadedness
Major Surgical or Invasive Procedure:
Whole brain radiation 5 doses
History of Present Illness:
___ is a ___ female with metastatic high-grade ER+
breast
cancer who is admitted from the ED with dizziness.
Patient reports 5 days of vertigo, better with lying still and
worse with movement. Has associated emesis. No headaches. She
was
seen in clinic for unscheduled visit on ___, as she was having
restaging scans. Of note, CT torso showed recurrent metastatic
disease in the liver, although patient is currently unaware of
scan results. Due to persistent symptoms she presented to the ED
on day of admission.
In the ED, initial VS were: pain 3, T 97.9, HR 83, BP 106/55,
RR
16, O2 100%RA. Labs notable for Na 142, K 4.8, HCO3 25, Cr 0.5,
WBC 8.4, HCT 34.2, PLT 250. Neurology was consulted who
recommended head imaging. CTA head/neck showed 3.9 x 3.6 cm area
vasogenic edema within the left frontal lobe with central
ring-enhancing 1 x 0.8 cm lesion, worrisome for metastatic
disease. CXR showed no acute process, but was notable for
pulmonary nodules concerning for metastatic disease. Patient was
given 1mg IV lorazepam, 25mg po meclizine, and 3L NS prior to
transferred to ___ for further management.
On arrival to the floor, patient is doing well. She endorses
some
dizziness only on moving but not when lying still. No change in
vision. She denies recent URI sx. Her husband helps translate
for
patient although patient knows some ___.
Patient aware of her labs and imaging results.
She ha an episode of emesis today which is new to her, no blood
in vomitus. some HA but not too severe per pt. No neck
stiffness.
No fevers or chills.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
Mrs. ___ is a ___ yo F with history of right breast
cancer initially diagnosed in ___. Now with recurrent
metastatic
breast cancer.
She initially presented with a stage I tumor that was high
grade.
She had a single lymph node with isolated tumor cells, but also
had lymphovascular invasion in the breast. The tumor was double
hormone receptor positive and HER-2/neu negative. After four
cycles of chemotherapy and postmastectomy radiation therapy, she
was on adjuvant tamoxifen for about ___ years. While
attempting to transition her to an aromatase inhibitor, she
developed right anterior chest wall discomfort.
Evaluation showed a 3.8 cm chest wall mass invading into the
chest wall from a probable internal mammary lymph node. This is
the cause of her pain and has caused slight bulge on the
anterior
surface of the right chest wall near her mastectomy scar. As an
alternative to an internal mammary site, this could represent
residual tumor in the chest wall itself. Further staging
evaluation is now complete and shows multiple pulmonary nodules,
two possible hepatic metastases and a bone scan that shows
sternal uptake, likely related to the chest wall invasion and
also a low lumbar lesion, which may or may not be malignancy
versus degenerative.
On ___, she had a CT-guided biopsy of right anterior
mediastinal mass. Pathology returned c/w "The histologic
features
of the tumor in the current specimen are consistent with tumor
seen in the prior mastectomy specimen (___). Immunostains
are negative for TTF-1, GCDFP and mammoglobin. There is a small
proportion of cells (1-5%) that are positive for ER and PR.
Findings are most consistent with breast origin."
Patient completed PACLItaxel(Taxol)Weekly for 6 weeks x 2
(80 mg/m2)
Started Capecitabine - ___. Her metastatic breast cancer
has
progressed on Capecitabine. ___ MD note for more detailed
information)
On ___, Patient seen in ED for increasing dyspnea and
weakness and worsening cough. Found to have enlarging R-sided
pleural effusion on CXR. She was admitted for further
management.
Underwent diagnostic/therapeutic thoracentesis with removal of
1800 cc of seronanguinous fluid.
Breathing somewhat improved following Pleurx catheter placement
on ___ per IP. Now with improved small R spical
pneumothorax.
___ - Eribulin IV Days 1 and 8
___ C1D1 Doxorubicin
___ C2D1 Doxorubicin
___ C3D1 Doxorubicin
___ C4D1 Doxorubicin
___ C5D1 Doxorubicin
___ Tunneled pleural catheter removed
___ C6 D1 Doxorubicin
PAST MEDICAL HISTORY:
-Metastatic breast cancer (as above)
-Paranoid schizophrenia
-H/o LTBI (incompletely treated with INH)
-H. pylori
Social History:
___
Family History:
No known history of breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
VSS
GENERAL: Pleasant, lying in bed comfortably
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses, 2+ DP pulses
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
DISCHARGE PHYSICAL EXAM
======================
VS: stable baseline BP ___ (from prior admissions and
outpatient as well), afebrile
GENERAL: Pleasant, tired appearing middle-aged female, sitting
up
in bed, speaks some ___
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses, 2+ DP pulses
RESPIRATORY: no increased WOB or accessory muscle use, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact, ambulation steady with walker
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
Back: no spinal tenderness
Psych: very flat, pleasant
Pertinent Results:
ADMISSION LABS
=============
___ 05:18PM GLUCOSE-109* UREA N-9 CREAT-0.5 SODIUM-142
POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-25 ANION GAP-21*
___ 05:18PM WBC-8.4# RBC-4.14 HGB-11.3 HCT-34.2 MCV-83
MCH-27.3 MCHC-33.0 RDW-14.2 RDWSD-42.5
___ 05:18PM NEUTS-89.4* LYMPHS-7.3* MONOS-2.5* EOS-0.0*
BASOS-0.4 IM ___ AbsNeut-7.51*# AbsLymp-0.61* AbsMono-0.21
AbsEos-0.00* AbsBaso-0.03
___ 05:18PM PLT COUNT-250
IMAGING
=======
___ CXR
No signs of pneumonia. Metastatic burden in the chest better
assessed on CT from 1 day ago.
___ CTA HEAD
IMPRESSION:
1. Ring-enhancing lesions within the left frontal lobe measuring
up to 1.___s extensive vasogenic edema with mild local mass effect
spanning 3.9
cm, is concerning for intracranial metastatic disease. An MRI
may be helpful
for further evaluation.
2. Unremarkable CTA of the head without evidence of aneurysm or
stenosis.
3. Unremarkable CTA of the neck without evidence of internal
carotid artery
stenosis by NASCET criteria.
4. Patent right internal jugular vein. Absence of flow is seen
within the
left internal jugular vein as well as attenuated opacification
of the left
sigmoid sinus. This is most likely secondary to timing of the
bolus, however,
left internal jugular ultrasound can be performed to evaluate
for thrombus.
5. Multiple pulmonary nodules, consistent with patient's known
metastatic
disease and better characterized on the CT scan performed on the
prior day.
6. Incidental 1.5 cm left thyroid nodule. A dedicated
ultrasound of thyroid
gland may be helpful for further evaluation.
RECOMMENDATION(S):
1. MRI of the brain is recommended for further evaluation.
2. Left internal jugular ultrasound can be performed.
3. Nonurgent thyroid ultrasound.
MR brain with and without contrast:
Study is mildly degraded by motion. Multiple intracranial
supra and
infratentorial enhancing lesions with associated FLAIR signal
abnormality
concerning for metastatic disease are seen, including:
- A bilobed lesion with extensive vasogenic edema is seen within
the left
frontal lobe, with the superior component measuring 1.3 cm x 1.2
cm, series
1000, image 106, and an inferior component measuring
approximately 1.5 cm by 1
cm.
- a punctate cortical enhancing lesion in the left frontal lobe
measures 0.5
cm, series 1000, image 111.
- enhancing left frontal lobe lesion measures 0.5 cm, series
1000, image 88.
- a left frontal lobe lesion measures approximately 0.8 cm x 0.7
cm, series
1000, image 84
- a 0.7 cm x 0.7 cm enhancing lesion within the left centrum
semiovale, series
1000, image 98 is seen.
- an enhancing left cerebellar lesion is seen, measuring 1.2 cm
x 1.2 cm,
series 1000, image 60.
- a 0.5 cm x 0.6 cm is seen in the right post central gyrus,
series 1000,
image 105.
- a focus of increased FLAIR signal abnormality, series 8, image
14 is seen
however without evidence of associated enhancement.
- a 0.4 cm focus of enhancement, series 1000, image 107 is seen
within the
left precentral gyrus.
- a 0.5 cm focus of enhancement is seen, series 1000, image 93
within the left
frontal lobe.
There is no acute intracranial infarction. Ventricles and sulci
are age
appropriate. Mild mucosal sinus thickening is seen involving
the ethmoid air
cells. The remainder the visualized paranasal sinuses, mastoid
air cells, and
middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
1. Study is mildly degraded by motion.
2. Numerous intracranial supratentorial and infratentorial
enhancing lesions,
concerning for metastases, with the largest lesion within left
frontal lobe
measuring up to 1.5 cm and a large left cerebellar lesion is
seen measuring up
to 1.2 cm.
3. No evidence of acute infarction.
Labs prior to discharge:
___ 10:15AM BLOOD WBC-11.9* RBC-4.46 Hgb-12.0 Hct-36.8
MCV-83 MCH-26.9 MCHC-32.6 RDW-14.5 RDWSD-42.5 Plt ___
___ 12:15AM BLOOD Glucose-140* UreaN-15 Creat-0.4 Na-137
K-3.9 Cl-101 HCO3-25 AnGap-15
___ 12:15AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.1
Brief Hospital Course:
___ is a ___ y F with hx of metastatic cancer likely from
breast, mets to lungs and liver last Chemo with doxorubicin in
___, who presented with new dizziness and imaging findings
of new brain metastastic lesions.
# Dizziness:
# New CNS metastatic disease:
New metastatic disease, most likely from known metastatic breast
cancer, which MRI confirmed. Neuro-onc, Rad-onc following,
started WBRT ___. Declined inpatient LP, may obtain as
outpatient. Neurosurgery consulted but no surgical intervention
and signed off. Started on dexamethasone which helped resolve
nausea but dizziness persisted. She completed her 5 doses of
whole brain radiation as inpatient and was discharged.
- dexamethasone 4mg PO q8h x3 days (through ___, then
decrease to q12h x 3 days, then daily indefinitely
# Metastatic breast cancer: Most recently completed 6 cycles
single agent doxorubicin, last dose ___, with good response
of her recurrent chest disease. Most recent scans show
widespread metastatic disease. Patient is very overwhelmed and
anxious regarding her new imaging findings. She was continued
on a fentanyl patch and oxycodone for pain control though
declined to take throughout her hospitalization. She was also
seen by SW who knows her well.
# Leukocytosis
# Weakness/dizziness: Baseline low BPs and intermittent
orthostasis, suspected primarily related to brain mets. Labs
done showed mild leukocytosis which improved with decreasing dex
dose, and elevated lactate which also improved with some IVF
though she declined most interventions. No signs or symptoms of
infection throughout her hospitalization. Suspect ongoing
dizziness attributable to metastatic disease.
# Hypotension:
# Elevated lactate: Baseline borderline BPs, no further episodes
of lower BP and suspect mild dehydration. Improved lactate.
Given that patient wishes to avoid blood draws and has refused
most of them, will not repeat unless clinical change. ___ worked
with her when she was accepting of this and recommended home ___.
On day of discharge she was able to do stairs with ___.
# Schizophrenia. Continued home risperidone, which she
attributes her dizziness to and refused to take. She declined
inpatient psych consultation and states she would ___ her
outpatient psychiatrist.
***TRANSITIONAL ISSUES***
- Patient to have outpatient f/u with Dr. ___: further chemo
and care
- Incidental finding on CTA head: Incidental 1.5 cm left thyroid
nodule. A dedicated ultrasound of thyroid gland may be helpful
for further evaluation.
- Patient discharged on decadron taper as follows: decrease by
4mg every 3 days until taking 4mg daily indefinitely
Medically stable for discharge home with 24 hour supervision.
> 30 minutes spent on discharge day planning, counseling, and
coordination of care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. RisperiDONE 1 mg PO BID
2. LORazepam 0.5 mg PO Q4H:PRN anxiety
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Mild
4. Prochlorperazine 10 mg PO Q6H:PRN nausea
5. Ondansetron 4 mg IV Q8H:PRN nausea
6. Fentanyl Patch 12 mcg/h TD Q72H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Dexamethasone 4 mg PO Q8H
RX *dexamethasone 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*40 Tablet Refills:*0
3. Meclizine 12.5 mg PO Q8H:PRN dizziness
RX *meclizine 12.5 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
5. Fentanyl Patch 12 mcg/h TD Q72H
6. LORazepam 0.5 mg PO Q4H:PRN anxiety
7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Mild
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. RisperiDONE 1 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Metastatic breast cancer
Metastatic brain lesions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital for dizziness
and nausea/vomiting. You had a CT scan of your head which
unfortunately showed that your breast cancer had spread to your
brain. You were treated with steroids as well as whole brain
radiation. Your symptoms improved. You will need to continue
the steroids when you return home - the taper is listed as
below:
DEXAMETHASONE 4mg PO every 8 hours until ___
on ___, take DEXAMETHASONE 4mg PO every 12 hours until
___
on ___, take DEXAMETHASONE 4mg PO every morning
Please take OMEPRAZOLE to protect your stomach lining while you
take dexamethasone.
Please follow-up with your outpatient providers as instructed
below.
We wish you all the best
Followup Instructions:
___
|
10884708-DS-9
| 10,884,708 | 21,918,855 |
DS
| 9 |
2171-10-15 00:00:00
|
2171-10-17 14:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Chest Pain, Shortness of Breath
Major Surgical or Invasive Procedure:
Thoracentesis ___
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ PMH of Metastatic Breast Cancer (on ___, with
brain mets s/p whole brain radiation), Latent TB (s/p INH),
Paranoid schizophrenia, who presented to the ED with dyspnea on
exertion found to have increase in size of known loculated right
pleural effusion so was admitted to oncology awaiting
thoracentesis
Pt is ___ speaking, but also speaks limited ___.
Husband speaks fluent ___ and ___ and was used as
interpretation at family's request.
Pt reported that she had worse dyspnea on exertion for the past
___ days prior to admission. She noted that she has an
occasional productive cough with yellow sputum of small
quantity,
but is not a predominant symptom. She denied any fever or
chills
and does take her temperature at home. She noted that she is
not
short of breath at rest but gets dyspneic with walking. Does
not
use home O2. Denied any constitutional symptoms, weight loss.
Denied any sick contacts, sore throat, headache,
nausea/vomiting/abdominal pain, rash.
In the ED, initial vitals: 98.4 81 114/83 16 100% RA. CBC with
normak WBC, Hgb 13.3, plt 110, BNP 7000, CHEM with K of 6.1
which
was grossly hemolyzed as repeat was 4.8, lactate 3.1, trop 0.01,
INR 1.2, PTT 143.3. CXR read as opacity in the right mid and
lower lung likely represents a combination of malignant
consolidation as well as a small pleural effusion, w/ a
retrocardiac rounded density and right upper lobe nodule both
consistent known sites of metastasis, no left-sided effusion, no
edema, cardiomediastinal silhouette is stable. CTA revealed no
evidence of pulmonary embolism or acute aortic abnormality, new
loculated right pleural effusion is likely malignant, interval
increase in septal thickening in the right lower lobe likely
represents a component of interstitial edema, but is difficult
to
exclude lymphangitic carcinomatosis, increased central bronchial
wall thickening, likely due to airway inflammation, lung
metastases are similar to prior in overall size and
distribution.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
As per OMR:
Her oncologic problem began in ___ when a mammogram revealed a
mass in the right breast. She underwent a right mastectomy,
with
right axillary sentinel lymph node biopsy, on ___. The
pathology was ER+, PR+ and Her2- ductal carcinoma. She later
received 4 cycles of taxotere and cyclophosphamide from ___
to ___, followed by radiotherapy to the right chest to
5,040
cGy (180 cGy x 28 fractions) from ___ to ___. She
then
received ___ years of tamoxifen. She was well until ___ when a
lump was palpated at the surgical scar on the right side. A
biopsy on ___ showed metastasis. She was treated with
taxol
from ___ to ___, followed by 1 cycle of eribulin from
___ to ___, and then doxorubicin from ___ to
___.
Her neurologic problem began on ___ when she experienced
dizziness. Her symptoms progressed and by ___, she had
ataxia as well as nausea and vomiting. She came to our
emergency
department at ___ and a head CT there on ___ disclosed
brain metastases. A gadolinium-enhanced head MRI on ___
showed multiple enhancing intraparenchymal masses as well as ___
lesions that are on the subependymal surface of the left lateral
ventricle and on the convexity of the left parietal brain. She
received dexamethasone and her symptoms improved. She completed
whole brain radiotherapy on ___
Most recently receiving ___ (started ___. She has
tolerated this regimen well; however secondary to
thrombocytopenia she is no longer receiving ___ on day 8 and
receives both ___ and ___ on day 1 and day 15
PAST MEDICAL HISTORY:
-Metastatic breast cancer (as above)
-Paranoid schizophrenia
-H/o LTBI (s/p 6 of 9 planned months INH in ___, stopped by Dr
___ in light of LFT abnormalities, unclear if ___ chemo or
INH)
-H. pylori
Social History:
___
Family History:
No known history of breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals: 97.9 PO ___ 18 98 Ra
GENERAL: Sitting in bed, appears calm and comfortable, no acute
distress, husband and mother at bedside
EYES: PERRLA
HEENT: Moist mucous membranes, oropharynx clear
NECK: Supple
LUNGS: Clear to auscultation on left side, decreased breath
sounds on right side with crackles at right lung base, no
increased work of breathing, normal respiratory rate, no cough,
speaks in full sentences
CV: Regular rate and rhythm, no murmurs rubs or gallops
ABD: Soft/nondistended/nontender, normoactive bowel sounds
EXT: Warm and well perfused without edema
SKIN: Warm dry/no rash
NEURO: Alert and oriented ×3, fluent speech
ACCESS: Left chest port with dressing clean/dry/intact, accessed
DISCHARGE PHYSICAL EXAM
========================
Vitals: 97.9 ___ 18 96 Ra
GENERAL: Appears calm and comfortable, no acute distress
EYES: PERRLA
HEENT: Moist mucous membranes, oropharynx clear
NECK: Supple
LUNGS: Clear to auscultation on left side, mildly decreased
breath sounds on right side with crackles in the mid-lung and
right lung base, no increased work of breathing, normal
respiratory rate, no cough, speaks in full sentences
CV: Regular rate and rhythm, no murmurs rubs or gallops
ABD: Soft/nondistended/nontender, normoactive bowel sounds
EXT: Warm and well perfused without edema
SKIN: Warm dry/no rash
NEURO: Alert and oriented ×3, fluent speech, some mild dysmetria
with finger to nose, on the right side. CNII-XII in tact. Rapid
alternating movements in tact. Strength ___ and sensation
grossly
in tact in upper and lower extremities bilaterally. Romberg
negative. Patellar reflexes 2+.
ACCESS: Left chest port with dressing clean/dry/intact, accessed
Pertinent Results:
ADMISSION LABS
===============
WBC-4.7 RBC-4.10 HGB-13.3 HCT-41.8 MCV-102* MCH-32.4* MCHC-31.8*
RDW-15.6* RDWSD-57.1*
NEUTS-55.0 ___ MONOS-9.6 EOS-1.1 BASOS-1.1* IM ___
AbsNeut-2.58 AbsLymp-1.54 AbsMono-0.45 AbsEos-0.05 AbsBaso-0.05
HCG-<5
proBNP-7298*
cTropnT-0.01
LACTATE-3.1* K+-4.8
___ PTT-143.3* ___
IMAGING
========
___ CXR:
FINDINGS: Left chest wall Port-A-Cath terminates in the region
of the mid SVC. Opacity in the right mid and lower lung likely
represents a combination of malignant consolidation as well as a
small pleural effusion. A retrocardiac rounded density and
right upper lobe nodule are both consistent known sites of
metastasis. No left-sided effusion. No edema.
Cardiomediastinal silhouette is stable.
___ CTA Chest:
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. New loculated right pleural effusion tracking along the major
fissure.
3. Interval increase in septal thickening in the right lower
lobe likely
represents a component of interstitial edema, but is difficult
to exclude
lymphangitic carcinomatosis.
4. There is increased central bronchial wall thickening, likely
due to airway inflammation.
5. Lung metastases are similar to prior in overall size and
distribution.
___ Ultrasound Thorax:
IMPRESSION:
Unsuccessful attempted ultrasound-guided thoracentesis.
Procedure was
considered unsafe to continue due to excessive patient motion
and pain. While the patient complained of severe chest pain and
shortness of breath after the procedure, and immediate portable
radiograph demonstrated no notable pneumothorax. If
thoracentesis is required clinically, it must be performed with
a higher level of anesthesia, possibly moderate sedation.
___ CXR:
IMPRESSION:
Similar-appearing right-sided partially loculated pleural
effusion. No pneumothorax. Pulmonary nodules better seen on
recent CT.
Brief Hospital Course:
Ms. ___ is a ___ lady with history of metastatic breast cancer
(on ___, with brain mets s/p whole brain radiation),
latent TB (s/p incomplete treatment with INH), paranoid
schizophrenia, who presented to the ED with dyspnea on exertion
and cough found to have increase in size of loculated right
pleural effusion.
# Metastatic breast cancer
# R pleural effusion
Patient has had known pleural effusion, presumably related to
malignancy, and had previously undergone right thoracentesis in
___ with 1800 cc removed. Pleural fluid analysis showed a
lymphocyte-predominant exudate, but cytology was not obtained.
The effusion recurred so a TPC was placed on ___ and
eventually removed ___. The patient reports that the
drainage had helped with her breathing. On this admission,
patient was found to have reaccumulation of effusion. Bedside
thoracentesis was attempted by interventional pulmonology, but
unable to access pocket. Hence she was taken to interventional
radiology. Thoracentesis was attempted on ___, but patient was
extremely anxious and it was unable to be completed. CXR without
pneumothorax.
Even prior to thoracentesis she was ambulating the halls on RA
without any desaturations. Upon discharge the patient was
ambulating on room air with out any desaturations. On the day of
discharge, she was re-evaluated by interventional pulmonology
who felt that her pleural effusion was still too small to drain,
hence she was scheduled for outpatient follow up on ___, at
which time, she will undergo thoracentesis with placement of
Pleurx catheter. Upon discharge, the patient's pain chest and
back was well controlled with benzonatate for cough.
# Dizziness
Ms. ___ has had months of dizziness, both when changing
positions and while she walks, which she attributes to low blood
pressure. She had slight dysmetria on exam. Orthostatics
negative this admission. We wondered whether this could be
related to known brain metastases including a L cerebellar
lesion measuring 1.4 x 1.1 cm in ___. We discussed MRI brain
for further evaluation with patient and outpatient oncologist;
patient's inclination was to hold off on further imaging as
symptoms have been fairly stable.
TRANSITIONAL ISSUES:
[] The patient will follow up in Interventional Pulmonology
clinic on ___ for evaluation and placement of
pleurx catheter. The ___ clinic will contact the patient with an
appointment. Please also send cytology in addition to usual
studies; was not done in ___.
[] Continue to monitor dizziness and consider outpatient MRI,
which may inform goals of care discussions.
#HCP/Contact: Husband/HCP ___ He, ___
#Code: FULL confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LORazepam 0.5 mg PO Q6H:PRN nausea/insomnia
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times daily
Disp #*30 Capsule Refills:*0
2. LORazepam 0.5 mg PO Q6H:PRN nausea/insomnia
3. fentanyl 12 mcg/hr transdermal patch Apply 1 patch q 72
hours for cancer pain
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic breast cancer
R pleural effusion
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 ___ at ___.
___ came to us initially because ___ were experiencing some
difficulty breathing and some sharp chest pressure.
While ___ were here, ___ received imaging of your chest, which
DID NOT demonstrate a clot. It did, however, show fluid in your
right lung ("Pleural Effusion"). We asked the interventional
pulmonary doctors and the ___ radiologists to try to
take the fluid out of your lung with a needle ("thoracentesis"),
in the hopes that this would make ___ feel better. However, ___
became very anxious during the procedure, and ultimately it
could not be completed. ___ were walking around the halls
comfortably, without any need for additional oxygen.
After leaving the hospital, please continue to take all your
medications as prescribed and follow up with your cancer
doctors.
___ will follow up with Interventional Pulmonology on ___ - Their office will contact ___ to set up an
appointment.
Please take care, we wish ___ the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10884840-DS-19
| 10,884,840 | 26,355,672 |
DS
| 19 |
2111-01-03 00:00:00
|
2111-01-03 12:36:00
|
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 ___ digit pain
Major Surgical or Invasive Procedure:
Left ___ digit I&D ___, ___, repeat I&D, ___ look,
___, ___.
History of Present Illness:
___ yo RHD male with L MF high-pressure injection injury by paint
gun at work on ___.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory
Physical Exam:
Left Upper Extremity:
Resting splint in place, dressing c/d/i
SILT in exposed finger tips
Finger tips BCR, WWP
Pertinent Results:
___ 04:55AM BLOOD WBC-11.8* RBC-4.46* Hgb-13.1* Hct-40.2
MCV-90 MCH-29.4 MCHC-32.6 RDW-12.6 RDWSD-41.2 Plt ___
___ 04:55AM BLOOD Glucose-109* UreaN-13 Creat-0.9 Na-136
K-3.9 Cl-104 HCO3-22 AnGap-10
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the hand surgery team. The patient was found to
have a high-pressure injection injury to the Left ___ digit and
was admitted to the hand surgery service. The patient was taken
to the operating room on ___ for Left ___ digit I&D, which the
patient tolerated well. He was subsequently taken to the
operating room on ___ for a second look and closure, which the
patient also tolerated well. For full details of the procedures
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 following each procedure. The patient was
given ___ antibiotics and anticoagulation per
routine. The patient's home medications were continued
throughout this hospitalization. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non weight bearing in the Left upper extremity, and will be
discharged on PO doxycycline for 10 days for antibiotic
coverage. The patient will follow up in hand clinic in 7 days
per routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, HA, T>100 degrees
2. Doxycycline Hyclate 100 mg PO BID Duration: 10 Days
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*20 Tablet Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Do not drive, drink alcohol, or use drugs while taking this
medication.
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left ___ digit high-pressure injection injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER HAND SURGERY:
- You were in the hospital for hand surgery. It is normal to
feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non weight bearing Left upper extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add [] as needed for increased pain. Aim to wean off this
medication in 1 week or sooner. This is an example on how to
wean down:
Take 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- No anticoagulation required.
ANTIBIOTICS:
- Please take oral doxycycline for 10 days.
WOUND CARE:
- Dressing to remain in place until your follow up visit.
- If you have a splint in place, Do NOT get 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
FOLLOW UP:
Please follow up in hand clinic in 7 days for re-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:
___
|
10884861-DS-3
| 10,884,861 | 25,003,939 |
DS
| 3 |
2173-08-28 00:00:00
|
2173-08-28 15:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Sepsis, hypoxemic respiratory failure
Major Surgical or Invasive Procedure:
___ ERCP
___ percutaneous cholecystectomy drain placement
___ R PICC Placement
___ repeat ERCP with stent removal and sphincterotomy
History of Present Illness:
HPI as per admitting MD:
___ year old male with a history of type II diabetes and HTN who
presented to an OSH with abdominal pain. Found to have HR 115
and temp 99. CT Abdomen revealed gallbladder sludge and a stone
in the CBD. Labs showed lipase >2250 t bili 6.7 alk phos 270 alt
724 ast 427 lactate 5.5 wbc 15. He was given vanc/pip-tazo and
evaluated by surgery and GI. However, pt was transferred to
___ to expedite ERCP.
At ___ ED, pt was somnolent and found to have T 101.2, HR 116,
125/78, RR 28, 96% non-rebreather. Labs significant for WBC 3.1,
plts 111, INR 1.4, ALT 548, AST 357, Alk phos 318, T bili 6.8,
lipase 2496, VBG 7.25/36, Lactate 6.3, UA: trace blood, 30
protein, glucose 1000, few bacteria. Patient was intubated for
escalating O2 requirements, with SpO2 ~95% on non-rebreather. Pt
responsive to fluids (received 4L) and hemodynamically stable in
ED (121/76 post intubation). Pt sedated with versed/fentanyl and
continued on vancomycin/pip-tazo. The ERCP team was consulted.
On arrival to the ICU, pt was intubated and sedated. Vitals:
99.4, HR 108, BP 89/54, spO2% 87-93% (intubated on cmv at RR 15
PEEP 5 Vt 430, FiO2 40%). Patient received 1L LR for
hypotension. Soon after assessment, pt was quickly taken to the
ERCP suite. He returned to the suite following ERCP in which an
ampullary stone was removed and a bile duct stent was placed.
They noted duodenum was very edematous and sphincterotomy was
not performed at this time. He required boluses of phenylephrine
during the procedure and pressures were 107/62 (MAP 72) upon
arrival to the unit.
Later in the evening, his blood pressures lowered and he
required 4 pressure support (vasopressin, norepi,
phenylephrine). Anaerobic BCx x2 growing G+ bacilli at OSH, and
4 bottles growing G-rods at ___. He had a R. IJ central line
placed and was found to have CV O2 90. Fem A-line also placed.
Of note, spoke to son (___) who is pt's HCP. Son is aware that
pt's situation is serious; however, pt seems to not have had
close relationship with his sons.
Past Medical History:
Hypertension
Diabetes
Hyperlipidemia
BPH
Social History:
___
Family History:
Unknown/None significant per patient
Physical Exam:
ADMISSION:
VITALS: Reviewed in metavision
GENERAL: Sedated, unresponsive. intubated.
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Tachycardic, regular rhythm rhythm, normal S1 S2, no
murmurs, rubs, gallops
ABD: soft, distended, nt.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No rashes or lesions apparent
NEURO: Sedated, unresponsive.
DISCHARGE:
T98.6, BP 144/80, HR 75, RR 18, O2 97 Ra
Gen - no distress, sitting up in the chair, well appearing
HEENT - nc/at, moist oral mucosa
Eyes - anicteric, PERRL
___ - RRR, s1/2, no murmurs
Pulm - CTAb/l, no w/r/r
GI - soft, non tender, +bowel sounds, +RUQ drain with some
serous brown drainage, no tenderness to palpation, drain site
c/d/i
Ext - trace ___ edema
Skin - warm, dry, no rashes
Psych - calm and cooperative
Pertinent Results:
IMAGING
-------
ERCP ___:
Successful ERCP with findings of an impacted stone which was
removed by sphincterotome. Plastic biliary stent placed with
excellent drainage of pus, contrast and bile.
KUB ___:
Mildly distended gas-filled loops of small bowel, consistent
with ileus.
RUQ US ___:
Gallbladder wall thickening and edema likely due to
cholecystitis in the
setting of ascending cholangitis. Linear echogenicity about the
gallbladder wall could represent intraluminal air following
biliary stent placement.
Perc chole placement ___:
Successful ultrasound-guided placement of ___ pigtail
catheter into the gallbladder. Samples was sent for microbiology
evaluation.
CTA A/P ___:
1. No arterial extravasation to suggest active arterial bleeding
within the
abdomen and pelvis. No retroperitoneal hematoma.
2. Intrahepatic biliary ductal dilatation with paired ductal
enhancement,
worst in the hepatic segment II and III, consistent with known
cholangitis.
3. Ill-defined 2.9 x 2.4 cm hypodensity in the hepatic dome with
foci of air. Although air could be related to CBD stent
placement, in the setting of cholangitis findings could
represent a small developing abscess. Attention on follow-up is
recommended.
4. New small volume simple free fluid in the abdomen and pelvis
and foci of
air and fluid tracking along the left anterior pararenal space
(series 5,
image 51). Although findings are nonspecific, in the setting of
recent ERCP, small perforation of the duodenum cannot be
excluded.
5. Percutaneous cholecystostomy tube in situ without evidence of
fluid
collection in the gallbladder fossa or within the liver.
6. Multiple bilateral indeterminate cystic renal lesions. Non
urgent
ultrasound can provide further assessment if clinically
indicated.
7. Bilateral moderate pleural effusions, right greater than
left.
MRCP ___:
9 mm stone at the junction of the cystic duct and CHD/CBD. No
intra or
extrahepatic bile duct dilation.
CXR ___:
Interval near complete resolution of bilateral pulmonary edema.
RUQ US ___:
Findings consistent with cholangitis. No well-formed abscess or
drainable
fluid collection in the liver.
ERCP ___:
Successful ERCP with sphincterotomy and extraction of stones.
Plastic stent placed.
MICROBIOLOGY
------------
___ 4:29 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
Daptomycin MIC = 2.0 MCG/ML test result performed by
Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| ENTEROCOCCUS FAECALIS
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
DAPTOMYCIN------------ S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PENICILLIN G---------- 2 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ 0430 ON ___
- ___.
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ AT 12:18 ___
___.
GRAM POSITIVE COCCI IN PAIRS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
GRAM POSITIVE COCCI IN PAIRS.
___ 4:36 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
KLEBSIELLA PNEUMONIAE.
Identification and susceptibility testing performed on
culture #
49___ ___.
ENTEROCOCCUS FAECALIS.
Identification and susceptibility testing performed on
culture #
493-___ (___).
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ AT 1218 ___
___.
GRAM POSITIVE COCCI IN PAIRS.
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
___ 5:16 am BLOOD CULTURE Source: Line-A line.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
KLEBSIELLA PNEUMONIAE.
Identification and susceptibility testing performed on
culture #
___ ___.
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
___ 8:10 am BLOOD CULTURE Source: Line-a line.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
KLEBSIELLA PNEUMONIAE.
Identification and susceptibility testing performed on
culture #
___ (___).
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ @ 2413 ___.
___ 2:28 pm BILE Site: GALLBLADDER GALLBLADDER.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final ___:
KLEBSIELLA OXYTOCA. HEAVY GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
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.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
| ENTEROBACTER CLOACAE
COMPLEX
| |
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ANAEROBIC CULTURE (Final ___:
CLOSTRIDIUM PERFRINGENS. QUANTITATION NOT AVAILABLE.
Blood culture x ___: negative
___ 9:47 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
(Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of C.
difficile and detects both C. difficile infection (CDI)
and
asymptomatic carriage.
A negative C. diff PCR test indicates a low likelihood of
CDI or
carriage.
DISCHARGE LABS
--------------
___
WBC 9.3, Hg 8.2, Hct 24, Plt 421
Na 133, K 4.5, Cl 101, CO2 23, BUN 17, Cr 1.2, Glu 160
ALT 73, AST 83, ALP 574, T bili 1.9, LDH 291
Hapto 171
___
TIBC 216, B12 1707, Folate 9, Ferritin 806, Transferrin 166
A1c 6.7
Stool guiac negative x 3
Brief Hospital Course:
Mr. ___ is a ___ year old male with a history of type II
diabetes and HTN who presented to an OSH with abdominal pain and
transferred to ___ on ___ for septic shock with K. pneumoniae,
E. faecalis bacteremia ___ ascending cholangitis a/w acute
pancreatitis s/p ERCP with removal of ampullary stone + CBD
stent placement on ___, s/p bedside ___ percutaneous
cholecystotomy on ___ acute hypoxic respiratory failure s/p
intubation on ___ and subsequent extubation on ___ mixed
respiratory/metabolic acidosis; and ___ with course c/b
thrombocytopenia and findings c/w DIC. He was admitted to the
intensive care unit for the above and was subsequently
transferred to the medical floor after management of his
bacteremia and cholecystitis. Active issues once stabilized on
the medical floor have included ___, hyponatremia, and anemia.
#Septic shock
#Ascending cholangitis
#Choledocolithiasis
Patient febrile, tachycardic, imaging from OSH showing a stone
in the common bile duct. Labs notable for leukopenia, elevated
lipase (>2250), t bili 6.7, alk phos 270, and elevated
transaminases (AST 427, ALT 724), ScVO2 90 and lactate 5.5,
concerning for septic shock ___ acute ascending cholangitis with
acute pancreatitis secondary to choledocolithasis. Hypotensive
to 89/54 on arrival to ICU requiring fluid bolus, requiring
multiple pressors and stress dose steroids, and weaned off
pressors on ___. Intubated on ___ and s/p extubation on ___.
s/p ___ ERCP w/ biliary stent placement in CBD, ampullary stone
removal; s/p ___ ___ bedside percutaneous cholecystotomy. ERCP
repeated ___ with sphincterotomy, stone removal, and plastic
stent removal. Initial blood cultures with two species of
klebsiella and enterococcus. Biliary cultures with enterobacter,
klebsiella, and clostridium. He completed two weeks of
vancomycin and meropenem on ___. Patient will be discharged to
rehab with percutaneous cholecystotomy drain in place with plan
to drain to gravity. Duration of cholecystotomy tube to be
determined at ACS follow up appointment on ___. Tentative plan
is for eventual surgical cholecystectomy. He will require repeat
ERCP in 3 months, to be arranged by the ERCP team. At rehab,
patient should be monitored for evidence of recurrent biliary
tract infection: fevers, RUQ pain, jaundice, which would warrant
readmission. His LFTs are slightly elevated at the time of
discharge but as his tube is draining and he has no abdominal
pain or leukocytosis, this can be monitored at rehab.
#Bleeding
#Thrombocytopenia
#Elevated INR
#DIC
Blood smear demonstrated occasional schistocytes and additional
labs notable for decreased haptoglobin, increased d-dimer.
Overall consistent with DIC in setting of severe sepsis.
#Anemia
Initially there was bleeding from the cholecystotomy site but
none further. His
hemoglobin has slowly drifted down from ___ (perhaps
hemoconcentrated at admission) now in the low 7 range.
DIC/thrombocytopenia resolved, in fact now platelets are in the
400's (thrombocytosis) likely reactive. Hemoglobin has continued
to drift down and is in the range of ___. Iron studies siggest
anemia of chronic disease, and stool guiac negative x 3.
Hemolysis workup was repeated and negative, suggestive of anemia
of chronic disease/inflammation, and consideration of phlebotomy
as a contributing factor. He received 1 unit of blood early in
his hospital course, and received a second unit of blood
___. Hemoglobin at the time of discharge is 8.2/24. He
has been hemodynamically stable with no signs of acute blood
loss. He should have a CBC checked at rehab to ensure stability
within the next several days. Should his anemia persist he may
pursue outpatient anemia workup.
#Acute Hypoxemic respiratory failure
#Pulmonary edema
Patient intubated on ___ in ___ ED for escalating oxygen
requirements, stability during transport, and anticipated ERCP.
CXR notable for pulmonary vascular congestion and right base
atelectasis. He was given IV Lasix with good UOP and was
successfully intubated on ___. He did not require further
diuresis.
# Acute kidney injury
# Urinary retention
Cr 1.3 at admission (baseline unknown), peak 3.9, likely
prerenal vs ATN in setting of septic shock. Now having urinary
retention, has history of BPH, with intermittent straight
catheterization. He is on tamsulosin and finasteride. Creatinine
currently at 1.2 (likely settling to be his true baseline). He
requires intermittent straight catheterizations. If this
persists he may be evaluated by urology.
# Hepatocellular injury
LFTs improving overall but still remain slightly elevated,
likely in the setting of infection/obstruction. Note that HAV
antibody is positive, likely has had hepatitis A infection in
the past. Currently has no symptoms of Hep A infection and
positive result is > 2 weeks old, would not likely benefit from
immunoglobulin. As his cholecystotomy tube is functioning
well/draining there has been no indication to pursue a drain
study or further imaging, but LFTs should be trended while at
rehab. At the time of discharge, LFTs: ALT 73, AST 83, ALP 574,
T bili 1.9.
# Hyponatremia:
Na today 133 <- 132 <- 138. Does have some trace ___ swelling
(symmetric) and would like to resume HCTZ, if Na stable in AM
resume thiazide. Etiology is not fully clear but could be due to
hypervolemia since he now has some trace leg swelling. However,
thiazide would exacerbate hyponatremia and Na has remained
steady in the 132-133 range. Resume diuretic if Na stabilizes
within the next few days.
# Type II Diabetes
# Hyperglycemia
At home he takes metformin and glipizide. In the hospital he has
been maintained on an insulin sliding scale. A1c 6.7%. On
discharge okay to resume glipizide with caution/regular
fingersticks. Metformin held ___ borderline renal function.
Continue diabetic diet and resume metformin if renal function
stays stable.
# HTN
Holding home valsartan/HCTZ in setting of ___ and as
above with hyponatremia. If renal function stays stable can
reintroduce valsartan. Blood pressure in the 130-140's and no
alternate agent was initiated.
#CAD: Continue home ASA 81mg, home statin
#BPH: continue home tamsulosin, finasteride
#Acute pancreatitis: Resolved
#Mixed metabolic and respiratory acidosis, lactic acidosis:
Resolved
#Acyclovir: Prescribed 30 tabs in ___ which was filled in
___, not being given in hospital, can resume as outpatient if
needed
# Homelessness: Social Work has been following, sounds like he
is sometimes homeless, sometimes intermittently stays with woman
friend. She is willing for him to stay at her house after
eventual discharge from rehab.
TRANSITIONAL ISSUES:
[] Perc chole drain to remain in place, draining to gravity,
with duration to be determined at surgery appointment on ___.
Monitor for clinical signs of recurrent cholangitis (fever,
abdominal pain, jaundice.)
[] Monitor for urinary retention. Has required intermittent
straight cath prior to discharge.
[] Recommend repeat labs (CBC and BMP, LFT) within the next ___
days to ensure stable.
Time spent: 65 minutes
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Hydrochlorothiazide 12.5 mg PO DAILY
2. Valsartan 320 mg PO DAILY
3. Acetaminophen 500 mg PO DAILY:PRN Pain - Mild
4. Simvastatin 20 mg PO QPM
5. mupirocin calcium 2 % topical TID:PRN
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. GlipiZIDE 5 mg PO DAILY
8. Finasteride 5 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Acyclovir 800 mg PO Frequency is Unknown
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
Discharge Medications:
1. Acetaminophen 500 mg PO DAILY:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. GlipiZIDE 5 mg PO DAILY
6. Simvastatin 40 mg PO QPM
7. Tamsulosin 0.4 mg PO QHS
8. HELD- Acyclovir 800 mg PO Frequency is Unknown This
medication was held. Do not restart Acyclovir until confirm
indication with PCP
9. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until your sodium
levels stabilize
10. HELD- MetFORMIN (Glucophage) 1000 mg PO BID This medication
was held. Do not restart MetFORMIN (Glucophage) until your renal
function stabilizes
11. HELD- mupirocin calcium 2 % topical TID:PRN This medication
was held. Do not restart mupirocin calcium until confirm
indication with PCP
12. HELD- Valsartan 320 mg PO DAILY This medication was held.
Do not restart Valsartan until your renal function stabilizes
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Septic shock
Cholangitis
Cholecystitis
Anemia
___
Hyponatremia
Acute hypoxemic respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to ___ with a severe infection from you
gallbladder and the bile duct. You were treated with
antibiotics, drainage, and removal of gallstones. You were
severely ill and required ICU care. Fortunately, you have
recovered very well and are now ready to be discharged to rehab,
where you will work to regain your strength.
On ___, you will be seeing a surgeon, Dr. ___, to
discuss the plan for surgical removal of your gallbladder. Your
gall bladder drain will remain in place until that time.
You will be sent to rehab to regain strength and continue to be
monitored medically for a short term.
We wish you the best in your continued recovery.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10884861-DS-4
| 10,884,861 | 29,637,723 |
DS
| 4 |
2173-09-22 00:00:00
|
2173-09-23 20:54:00
|
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:
ERCP
Drainage of liver abscess
History of Present Illness:
Mr. ___ is a ___ male with a history of T2DM, HTN who
was recently discharged ___ after being treated for sepsis and
bacteremia ___ cholangitis s/p ERCP (___), percutaneous
cholecystectomy drain placement (___), and repeat ERCP with
stent removal and sphincterotomy (___) who presents to the ED
from OSH (from rehab) with c/o fever.
He was seen by Dr. ___ where he was reportedly
afebrile and doing well. When he returned to rehab he became
febrile to 100.9F and appeared lethargic. EMS note that he was
tachycardic and appeared jaundiced. He was taken to OSH where
lab work identified WBC 18.8, lactate 2.0, creatinine 1.5, total
bilirubin 2.5, AP 893, AST 109, ALT 130, lipase 189. He was
written for Cefepime, Flagyl and Vancomycin. He was transferred
to ___ for further evaluation. Upon arrival he denies any
subjective fever, chest pain, SOB, abdominal pain, vomiting, or
other complaints.
US showed mild intrahepatic biliary dilatation, mildly dilated
common bile duct, with a common bile duct stent in place, and a
decompressed gallbladder around a cholecystostomy tube.
CT however showed prominence of the intrahepatic biliary ducts
which may reflect cholangitis, ill-defined hypodensities, most
prominent within segment VII, measure up to approximately 3.4
cm, concerning for abscess in the setting of cholangitis. Also,
peripancreatic fat stranding and partially organizing fluid may
reflect ongoing pancreatitis, of unclear etiology. Small,
bilateral pleural effusions with associated atelectasis.
Previous culture data notable for blood cultures with two
species of klebsiella and enterococcus. Biliary cultures with
enterobacter and klebsiella. OSH klebsiella was resistant to
ampicillin. Isolates here were susceptible to all tested
antibiotics. Meropenem was used because enterobacter has the
potential to produce an inducible chromosomal AmpC
beta-lactamase. Consequently, pip-tazo should not be used
Past Medical History:
Hypertension
Diabetes
Hyperlipidemia
BPH
Social History:
___
Family History:
Unknown/None significant per patient
Physical Exam:
Admission Exam
___ ___ Temp: 97.6 PO BP: 106/68 HR: 78 RR: 18 O2
sat: 99% O2 delivery: RA FSBG: 120
GENERAL: Alert and in no apparent distress
EYES: icteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. Perc chole in place with bilious output
MSK: Neck supple, moves all extremities
SKIN: Jaundiced
NEURO: Alert, oriented, face symmetric
PSYCH: pleasant, appropriate affect
Discharge Exam
Gen: Lying in bed in no apparent distress
___ ___ Temp: 98.4 PO BP: 126/88 HR: 96 RR: 16 O2
sat: 100% O2 delivery: Ra FSBG: 158
HEENT: Anicteric, eyes conjugate, MMM, no JVD
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Lung fields clear to auscultation throughout
Gastrointestinal: Moderately distended but soft to palpation
nontender in all quadrants drain in place
MSK: No edema
Skin: No rashes or ulcerations evident
Neurological: Alert, interactive, speech fluent, face symmetric,
moving all extremities
Psychiatric: pleasant, appropriate affect
Pertinent Results:
___ 01:00PM BLOOD WBC: 15.8* Hgb: 7.8*
___ 01:00PM BLOOD Creat: 1.3*
___ 01:00PM BLOOD ALT: 104* AST: 113* AlkPhos: 631*
TotBili: 2.5*
US showed mild intrahepatic biliary dilatation, mildly dilated
common bile duct, with a common bile duct stent in place, and a
decompressed gallbladder around a cholecystostomy tube.
CT however showed prominence of the intrahepatic biliary ducts
which may reflect cholangitis, ill-defined hypodensities, most
prominent within segment VII, measure up to approximately 3.4
cm, concerning for abscess in the setting of cholangitis. Also,
peripancreatic fat stranding and partially organizing fluid may
reflect ongoing pancreatitis, of unclear etiology. Small,
bilateral pleural effusions with associated atelectasis.
MRCP ___: 1. Multifocal abnormalities consistent with
abscess/phlegmon in the liver.
2. Findings consistent with widespread acute ascending
cholangitis.
3. Collapsed gallbladder containing a cholecystostomy tube for
acute
cholecystitis.
4. Findings consistent with recent or active acute
pancreatitis.
US ___: 1. Irregular complex lesion in the right hepatic lobe
with solid and cystic
components and ill-defined borders measuring approximately 8.4 x
5.4 x 4.1 cm,
concordant with abscess/phlegmon better characterized on prior
MRCP. No other
focal lesions noted.
2. Mild intrahepatic biliary and CBD dilatation. Appearance of
possible
intraluminal tubular structure in the CBD could represent stent,
clinical
correlation recommended.
US ___: 1. Interval increase in now moderate intrahepatic
biliary dilatation of the
right anterior and left biliary systems. Increase in echogenic
material
within the bile ducts may represent an increase in intraductal
debris and/or
increase in ___ inflammation. Common bile duct stent is
not well
visualized. Repeat MRCP/ERCP should be considered for further
evaluation.
2. Unchanged size of right hepatic lobe heterogeneous collection
measuring 8.4
x 5.1 x 4.1 cm. However, there is been interval increase in
central fluid
component of this phlegmon/abscess. Drainage of this collection
could be
considered if repeat ERCP does not improve patient's
symptomatology.
OSH blood Cx: enterobacter cloacae
___ CT A/P -- IMPRESSION: 1. Interval increase in the size
and extent of complex, multiloculated, rim enhancing hepatic
lesions most consistent with phlegmon/abscesses. 2. Similar
mild right intrahepatic biliary dilation with a common bile duct
stent in place. 3. Increased organization of an acute
peripancreatic collection. No evidence of pancreatic necrosis.
4. Patent portal veins with unchanged attenuation of the right
posterior portal vein. 5. Interval increase in small bilateral
pleural effusions.
___ ___ drainage -- FINDINGS: Again seen is an unchanged
hepatic collection in the right lobe of the liver. This
collection was targeted for drainage. IMPRESSION: Successful
US-guided placement of ___ pigtail catheter into the right
hepatic collection. 25 mL of bilious, serous fluid was
aspirated. Sample was sent for microbiology evaluation.
___ 05:33AM BLOOD WBC-8.9 RBC-2.82* Hgb-8.3* Hct-25.2*
MCV-89 MCH-29.4 MCHC-32.9 RDW-14.8 RDWSD-49.2* Plt ___
___ 07:43PM BLOOD Neuts-94.9* Lymphs-1.5* Monos-2.3*
Eos-0.1* Baso-0.1 Im ___ AbsNeut-14.95* AbsLymp-0.23*
AbsMono-0.36 AbsEos-0.02* AbsBaso-0.01
___ 05:33AM BLOOD ___
___ 05:33AM BLOOD Glucose-138* UreaN-18 Creat-1.0 Na-132*
K-4.3 Cl-96 HCO3-22 AnGap-14
___ 05:33AM BLOOD ALT-79* AST-80* AlkPhos-1376*
TotBili-2.3*
___ 05:33AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.8
___ 05:43AM BLOOD calTIBC-151* VitB12-1049* Folate-10
___ Ferritn-1434* TRF-116*
___ 06:49PM BLOOD PTH-105*
___ 06:49PM BLOOD 25VitD-11*
___ 08:35AM BLOOD Vanco-15.9
___ 09:37AM BLOOD Lactate-1.1
Brief Hospital Course:
Mr. ___ is a ___ y/o M with a history of HTN, DMII, and recent
admission for septic shock d/t polymicrobial cholangitis
requiring placement of a percutaneous cholecystostomy drain who
was readmitted on ___ as a transfer from ___ with fevers. He was found to have high grade E. cloacae
bacteremia, and has been stable and afebrile here at ___ while
on meropenem and vancomycin (the latter because of recent E.
faecalis bacteremia on ___. MRCP on ___ was concerning for
multifocal liver abscess/phlegmon and ascending cholangitis and
a
decompressed gallbladder. The perc chole tube accidentally fell
out, and abdominal ultrasound obtained ___ showed a large
complex lesion in the right hepatic lobe c/w abscess/phlegmon.
Initially fluid collection not amenable to drainage but given
persistence of symptoms and LFT abnormalities, eventually
underwent successful US-guided placement of ___ pigtail
catheter into the right hepatic collection on ___. Hepatic
surgeons were consulted and felt that ___ decompression was all
that was needed for now. Cultures from his grew C. glabrata;
patient initially managed with fluconazole IV/PO when Gram stain
showed budding yeast w/in hours of procedure, but switched to
micafungin now improved and stable for rehab.
#Recurrent cholecystitis, cholangitis, s/p multiple ERCPs, and
stent placement
#Hepatic phlegmon/abscess, Gram stain with budding yeast
#Possible prior pancreatitis
Presented with cholangitis and underwent multiple ERCPs. He
also had a percutaneous cholecystostomy tube for period of time
which has since been removed. Per report, OSH cx from ___ grew
Enterobacter cloacae sensitive to ertapenem. MRCP on ___ was
concerning formultifocal liver abscess/phlegmon and ascending
cholangitis and a
decompressed gallbladder. The perc chole tube accidentally fell
out, and abdominal ultrasound obtained ___ showed a large
complex lesion in the right hepatic lobe c/w abscess/phlegmon.
Initially fluid collection not amenable to drainage but given
persistence of symptoms and LFT abnormalities, eventually
underwent successful US-guided placement of ___ pigtail
catheter into the right hepatic collection on ___. Cultures
from his grew C. glabrata; patient initially managed with
fluconazole IV/PO when Gram stain
showed budding yeast w/in hours of procedure, but switched to
micafungin with identification of species and only
dose-dependent
susceptibility for fluconazole. Infectious disease was involved
and recommended 6 weeks of IV ertapenem, vancomycin, and
micafungin. He has a PICC line in place and will complete the
course at rehab. The drain will need to be monitored daily and
when it is putting out less than 10 cc for several days in a row
he should make an appointment with interventional radiology to
have it removed. We have given him directions on how to contact
them
[]Continue micafungin, vancomycin, ertapenem until ___
[]Follow-up in infectious disease clinic appointment scheduled
for 4 days from now
[]Will need weekly CBC BMP and LFTs for monitoring
[]Will need to meet with an outpatient surgeon to discuss
getting his gallbladder removed
[] will need out the output from the drain monitored and if less
than 10cc per day he should make an appointment with ___ to have
it removed
#Elevated LFTs
Patient noted to have severely elevated alk phos, spoke with
ERCP team and with interventional radiology team and both feel
this is likely from the drain that remains in place. He should
have these LFTs monitored and if our worsening should reach out
to Dr. ___ in ERCP and his interventional radiologist.
[] Weekly liver function tests
#Sinus tachycardia
Had low-grade sinus tachycardia in the setting of
deconditioning. Usually in the ___ to low 110s. He is without
any signs or symptoms and has been on subcu heparin and
ambulatory his entire hospitalization.
#Moderate normocytic anemia, hypoproliferative, stable
-Suspect anemia of chronic disease from infections
-Required 1 unit on ___
#Mild coagulopathy, stable/improved
-Continue to monitor INR, suspect nutritional, versus related to
infection, got oral phytonadione x 5d
#Hyponatremia, euvolemic
-Suspect SIADH related to infection/hepatic process, this is
corroborated by the urine electrolytes and urine osmolality and
low uric acid, will continue to monitor
#Distended abdomen
-Asymptomatic, have prescribed a bowel regimen
#BPH w/chronic retention (high post-voids but able to urinate)
-tamsulosin and finasteride
-f/u w/Urology
#Type 2 diabetes
Was controlled with an insulin sliding scale while in the
hospital on discharge was placed back on his home meds of
glipizide and metformin
#Vitamin D deficiency
-High-dose oral repletion, for 6 weeks followed by 1000 U daily
for long-term management
#Possible CKD
-If anything, possibly stage II, but currently his GFR is
greater
than 60
#CAD
-ASA, statin
Greater than 30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Simvastatin 40 mg PO QPM
5. Tamsulosin 0.4 mg PO QHS
6. Acetaminophen 500 mg PO DAILY:PRN Pain - Mild
7. mupirocin calcium 2 % topical TID:PRN
8. Acyclovir 800 mg PO Frequency is Unknown
9. GlipiZIDE 5 mg PO DAILY
10. Hydrochlorothiazide 12.5 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Valsartan 320 mg PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
2. Docusate Sodium 100 mg PO BID
3. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
4. Micafungin 100 mg IV Q24H
5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*28 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
8. Vancomycin 750 mg IV Q 12H
9. Vitamin D ___ UNIT PO 1X/WEEK (TH) Duration: 6 Doses
10. Acetaminophen 500 mg PO DAILY:PRN Pain - Mild
11. Aspirin 81 mg PO DAILY
12. Finasteride 5 mg PO DAILY
13. Fluticasone Propionate 110mcg 2 PUFF IH BID
14. GlipiZIDE 5 mg PO DAILY
15. MetFORMIN (Glucophage) 1000 mg PO BID
16. mupirocin calcium 2 % topical TID:PRN
17. Simvastatin 40 mg PO QPM
18. Tamsulosin 0.4 mg PO QHS
19. HELD- Valsartan 320 mg PO DAILY This medication was held.
Do not restart Valsartan until you have high blood pressure
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cholangitis
Hepatic abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after you began to spike high fevers. You
were found to have cholangitis and the ERCP team was consulted.
You underwent an ERCP which showed that your stent was patent.
You had a subsequent CT scan which showed a large liver abscess.
Interventional radiology was consulted and you had a drain
placed into the abscess. Cultures from this fluid grew multiple
bacteria as and yeast. Infectious disease was involved in your
care and started you on IV antibiotics which she will need to
remain on until ___. You will have the drain in place
until it is putting out less than 10 cc of fluid per day for
many days in a row. We have provided you with instructions on
how to care for the drain. You were quite deconditioned and
will need to go to rehab to build strength.
It was a pleasure caring for you,
your medical team
Followup Instructions:
___
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2173-11-03 00:00:00
|
2173-11-04 07:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
___ w/ HTN, DMII, two lengthy admissions in ___ for septic
shock due to cholangitis (s/p ERCP w/ plastic CBD stent) and
cholecystitis (requiring perc chole tube - now removed), and
again in ___ for polymicrobial hepatic abscesses (requiring
percutaneous drain - now removed) sent in by ID for suspicion of
smoldering sepsis of hepatobiliary source.
He has been on a long course of ertapenem/vanco/micafungin for
his pyogenic liver abscess. He underwent a CT-guided ___ drain
removal on ___ and was switched to levofloxacin and
fluconazole
at that time for ongoing treatment of a slow-to-resolve segment
7
satellite abscess.
After the switch in antibiotics and/or the drain pull he seemed
to slowly worsen clinically. Over the past week, he has noted
some night sweats. He was reportedly noted to have fevers at his
rehab. Orthostatic with drop from SBP in the ___ to the ___ on
standing at rehab. He went to ___ clinic on ___ where he was
found to again have soft BP, HR 108, WBC 15.0 (81% polys), and
worsening of his transaminases (although Tbili was unchanged at
2.9). A blood culture was collected at that visit, which remains
negative. ID was concerned about inadequate source control,
given
his slow clinical deterioration and possible low-grade sepsis;
he
was sent to the ED.
Past Medical History:
Ascending cholangitis with biliary drain placement
Recurrent cholecysitis awaiting cholecystecomty
Hepatic abscesses s/p drainage by ___, micro as above
T2DM
HTN
HLD
BPH
Family History:
None known according to patient
Physical Exam:
Admission:
VITALS: all vitals since arrival on the medical ward were
reviewed
CONSTITUTIONAL: thin man in NAD
EYE: sclerae anicteric, EOMI
ENT: audition grossly intact, MMM, OP clear
LYMPHATIC: No LAD
CARDIAC: RRR, no M/R/G, JVP not elevated, no edema
PULM: normal effort of breathing, LCAB
GI: soft, NT, ND, NABS
GU: no CVA tenderness, suprapubic region soft and nontender
MSK: no visible joint effusions or acute deformities.
DERM: no visible rash. No jaundice.
NEURO: AAOx3. No facial droop, moving all extremities.
PSYCH: Full range of affect
Pertinent Results:
Admission:
___ 08:16PM ___ PTT-42.5* ___
___ 07:24PM LACTATE-3.1*
___ 07:17PM GLUCOSE-111* UREA N-29* CREAT-1.5*
SODIUM-131* POTASSIUM-5.3 CHLORIDE-97 TOTAL CO2-19* ANION GAP-15
___ 07:17PM ALT(SGPT)-117* AST(SGOT)-146* ALK PHOS-1595*
TOT BILI-2.0*
___ 07:17PM LIPASE-91*
___ 07:17PM ALBUMIN-3.4*
___ 07:17PM WBC-11.8* RBC-2.76* HGB-8.2* HCT-24.7* MCV-90
MCH-29.7 MCHC-33.2 RDW-14.5 RDWSD-46.5*
___ 07:17PM NEUTS-78.0* LYMPHS-10.8* MONOS-7.7 EOS-1.0
BASOS-0.3 IM ___ AbsNeut-9.20* AbsLymp-1.27 AbsMono-0.91*
AbsEos-0.12 AbsBaso-0.04
___ 07:17PM PLT COUNT-416*
___ 12:00PM UREA N-25* CREAT-1.7* SODIUM-132*
POTASSIUM-5.4 CHLORIDE-91* TOTAL CO2-19* ANION GAP-22*
___ 12:00PM estGFR-Using this
___ 12:00PM ALT(SGPT)-137* AST(SGOT)-159* ALK PHOS-1845*
TOT BILI-2.9*
___ 12:00PM TOT PROT-8.1 ALBUMIN-4.3 GLOBULIN-3.8
___ 12:00PM AFP-3.1
___ 12:00PM WBC-15.0* RBC-3.32* HGB-10.0* HCT-29.8*
MCV-90 MCH-30.1 MCHC-33.6 RDW-14.3 RDWSD-46.7*
___ 12:00PM NEUTS-80.6* LYMPHS-9.1* MONOS-7.2 EOS-0.6*
BASOS-0.3 IM ___ AbsNeut-12.08* AbsLymp-1.37 AbsMono-1.08*
AbsEos-0.09 AbsBaso-0.04
___ 12:00PM PLT COUNT-548*
Discharge:
Imaging:
IMPRESSION:
1. Stable to mildly decreased size of hepatic abscesses in
comparison to
___. The largest collection of segment 7 measures
approximately
1.9 cm. A previously seen right lateral approach hepatic
abscess drainage
catheter has been removed.
2. Persistent mild-to-moderate intrahepatic biliary dilatation
is also
unchanged.
3. Multiple complex cortically based renal cysts, measuring up
to 4.3 cm. 1
of the lesions appear to have a nodular enhancing component vs
two adjacent
cysts separated by renal tissue, and further characterization
can be performed
with MRI vs renal ultrasound.
RECOMMENDATION(S): A dedicated nonemergent MRI or renal
ultrasound can be
obtained for further evaluation of renal lesions.
ERCP ___: Stent removal and re-evaluation-complete
clearance: ERCP with stent removal and re-evaluation. complete
clearance of biliary system as described.
Renal Ultrasound ___:
IMPRESSION:
5.2 cm exophytic left renal cyst containing a single thin
internal septation.
No specific follow-up is recommended.
Brief Hospital Course:
___ w/ HTN, DMII, cholangitis s/p stent, and cholecystitis
(requiring perc chole tube - now removed), and recurrent
polymicrobial hepatic abscesses (requiring
percutaneous drain - now removed) in ___ presented from ___
clinic for concern of cholangitis and sepsis, s/p ERCP on ___
with stent removal and biliary clearance, who also underwent
cholecystectomy on ___.
#LIVER ABSCESSES
#RECENT CHOLANGITIS, CURRENTLY WITH PLASTIC CBD STENT
#RECENT CHOLECYSTITIS (CONSERVATIVELY MANAGED)
Pt with recent hx of cholangitis with complication of liver
abscess initially presented with signs of severe sepsis
(tachycardia, leukocytosis and lactate). S/p ERCP with stent
removal and clearance of biliary tree. ID following,
recommending initially broadening to Zosyn then de-escalated to
levaquin and fluconazole
post ERCP after biliary stent removal. His fluconazole was
decreased to 200 mg daily due to his decreased creatinine
clearance. He will follow up with his ID doctor Dr. ___ on
___ for further management of antibiotics. ACS consulted, who
recommended cholecystectomy prior to discharge on ___
# HTN
#ORTHOSTATIC HYPOTENSION: resolved with fluids
# ___
Likely ___ to prerenal azotemia from sepsis. Improved with IVF
hydration.
[] Recommend checking outpatient chemistry. If creatinine
clearance improves to >50, can go back up to 400 mg daily.
# Renal cyst:
Multiple mildly complex cortically based renal cysts, measuring
up to 4.3 cm, with the dominant cyst demonstrating septation
with calcification. Bosniak ___ classification. Will need further
work up as it has a 5% chance of malignancy.
Plan
- work up as outpatient
#BPH
- continue Flomax and Proscar
# DM: moderately well controlled DM as outpatient (last A1C in
___ 6.7), but had some high values this admission, likely due
to prolonged NPO periods followed by large meals and difficult
to dose insulin. His metformin and glipizide were held
throughout the hospitalization and he was on insulin. By
discharge***
# HLD: Held simvastatin initially but it can be restarted on
discharge. Continued ASA 81mg daily
# homelessness
Per pt's roommate, he does not want the patient to return to his
current residence. He was seen by ___ who gave him information on
homelessness resources. He will be discharged to ___.
# Renal cyst:
Multiple mildly complex cortically based renal cysts, measuring
up to 4.3 cm, with the dominant cyst demonstrating septation
with calcification. Bosniak ___ classification. Will need further
work up as it has a 5% chance of malignancy.
Plan
- work up as outpatient
#BPH
- continue Flomax and Proscar
# HLD
- Hold simvastatin
- ASA 81mg daily
On ___ the patient was transferred to the Acute Care
Surgery Service for laparoscopic cholecystectomy. Please see
operative report for details. Post operatively the patient was
extubated and taken to the PACU in stable condition.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged to rehab. 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. Fluconazole 400 mg PO Q24H
2. Levofloxacin 500 mg PO Q24H
3. Acetaminophen 500 mg PO DAILY:PRN Pain - Mild
4. Aspirin 81 mg PO DAILY
5. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
6. Docusate Sodium 100 mg PO BID
7. Finasteride 5 mg PO DAILY
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Tamsulosin 0.4 mg PO QHS
10. GlipiZIDE 5 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Senna 8.6 mg PO BID:PRN Constipation - First Line
13. Simvastatin 40 mg PO QPM
14. Vitamin D ___ UNIT PO 1X/WEEK (TH)
Discharge Medications:
1. MetFORMIN XR (Glucophage XR) 500 mg PO BID
Do Not Crush
RX *metformin [Fortamet] 500 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth three times a day Disp
#*5 Tablet Refills:*0
3. Ursodiol 300 mg PO BID
RX *ursodiol 300 mg 1 capsule(s) by mouth twice a day Disp #*40
Capsule Refills:*0
4. Acetaminophen 500 mg PO DAILY:PRN Pain - Mild
5. Aspirin 81 mg PO DAILY
6. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
7. Docusate Sodium 100 mg PO BID
8. Finasteride 5 mg PO DAILY
9. Fluconazole 400 mg PO Q24H
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
11. Levofloxacin 500 mg PO Q24H
12. Senna 8.6 mg PO BID:PRN Constipation - First Line
13. Simvastatin 40 mg PO QPM
14. Tamsulosin 0.4 mg PO QHS
15. Vitamin D ___ UNIT PO 1X/WEEK (TH)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
orthostatic hypotension
?Sepsis
Liver abscess
Discharge Condition:
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___,
You were admitted from the infectious disease clinic because we
were concern that you had another infection. When you were
admitted the gastroenterologist took out your biliary stent. You
were given IV antibiotics and you since improved. Please follow
up with your PCP and infectious disease doctor.
Followup Instructions:
___
|
10884861-DS-7
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2173-11-16 00:00:00
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2173-11-17 16:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
simvastatin
Attending: ___
Chief Complaint:
Rhabdomyolysis
Major Surgical or Invasive Procedure:
PICC placement and revision (___)
History of Present Illness:
In brief, Mr. ___ is a ___ y/o M with a history of HTN, DMII,
persistent liver abscesses, recent lengthy admissions in ___
and
___ for septic shock d/t polymicrobial cholangitis s/p ERCP
with stent removal ___ and lap cholecystectomy ___, who
presented on ___ with fatigue/lethargy and found to have
leukocytosis and elevated transaminases as well as rising CK
concerning for rhabdomyolysis.
During his prior admission (___) he underwent lap chole
on
___ and was discharged to his nursing facility on ___ on
fluconazole and Levaquin. He re-presented to ___ on ___ with
fatigue, lethargy, and decreased appetite. Per his nursing
facility, he did not have fevers while at facility (T max 99.7).
CT on amdission showed stable liver abscesses, dilated CBD and a
small amt of fluid in gallbladder fossa, which is nonspecific.
He
was admitted to ___ for management of possible post-op
infection.
ID was consulted due to his leukocytosis and was concerned about
rhabdomyolysis given the patient's AST elevation out of
proportion to ALT and UA with large blood but no RBCs. The
suspected etiology of rhabdomyolysis is co-administration of
simvastatin and fluconazole. For this reason his fluconazole was
changed to micafungin by ID. He was transferred to a medicine
service for management of rhabdomyolysis and acute liver injury.
On transfer, the patient's vitals were remarkable for: ___
1130 BP: 133/93 HR: 73 O2 sat: 100%. On interview, the patient
confirms the above history and endorses pain in his shoulders
and
thighs.
Complete ROS obtained and is otherwise negative.
Past Medical History:
Ascending cholangitis with biliary drain placement
Recurrent cholecysitis awaiting cholecystecomty
Hepatic abscesses s/p drainage by ___, micro as above
T2DM
HTN
HLD
BPH
Social History:
___
Family History:
None known according to patient
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: 24 HR Data (last updated ___ @ 1130)
Temp: 97.4 (Tm 98.6), BP: 133/93 (110-133/72-93), HR: 73
(73-91), RR: 20 (___), O2 sat: 100%
GENL: thin, in no acute distress, AOx3
EENT: PERRL, EOMI, sclerae anicteric, moist mucous membranes, no
lesions
NECK: supple, no LAD
CARD: RRR, normal S1, S2, no murmurs/rubs/gallops
PULM: clear to auscultation bilaterally w/o wheezes, rhonchi or
rales
BACK: no focal tenderness, no CVA tenderness
ABDM: non-distended, normoactive bowel sounds, soft, tender on
deep palpation of RUQ,
no hepatosplenomegaly, surgical site with c/d/I dressings
EXTR: warm and well perfused, no edema, 2+ DP pulses palpable
bilaterally. Tender on palpation of thighs and shoulder muscles
but muscles soft
SKIN: no rashes, mild jaundice
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 713)
Temp: 98.6 (Tm 98.8), BP: 118/83 (113-143/71-86), HR: 83
(71-91), RR: 18, O2 sat: 100% (98-100), O2 delivery: Ra
GENL: thin, in no acute distress, AOx3
EENT: PERRL, EOMI, sclerae anicteric, moist mucous membranes
CARD: RRR, normal S1, S2, no murmurs/rubs/gallops
PULM: clear to auscultation bilaterally w/o wheezes, rhonchi or
rales
ABDM: normoactive bowel sounds, soft, non-distended, no
tenderness on palpation
EXTR: warm and well perfused, no edema, 2+ DP pulses palpable
bilaterally. PICC to R arm with c/d/I dressing
SKIN: no rashes, mild jaundice
NEURO: CN II-XII intact grossly, moving all extremities with
purpose. no asterixis
Pertinent Results:
ADMISSION LABS
===============
___ 06:15PM BLOOD WBC-17.9* RBC-3.06* Hgb-9.2* Hct-27.6*
MCV-90 MCH-30.1 MCHC-33.3 RDW-15.0 RDWSD-48.6* Plt ___
___ 06:15PM BLOOD Neuts-85.9* Lymphs-6.1* Monos-5.7
Eos-0.4* Baso-0.2 Im ___ AbsNeut-15.38* AbsLymp-1.09*
AbsMono-1.02* AbsEos-0.08 AbsBaso-0.04
___ 06:15PM BLOOD ___ PTT-38.7* ___
___ 05:55AM BLOOD Glucose-135* UreaN-25* Creat-1.3* Na-129*
K-5.4 Cl-92* HCO3-18* AnGap-19*
___ 07:46PM BLOOD ALT-188* AST-608* AlkPhos-1015*
TotBili-1.7*
___ 07:46PM BLOOD Lipase-76*
___ 07:46PM BLOOD Albumin-3.3*
___ 10:26AM BLOOD Calcium-9.7 Phos-4.8* Mg-1.9
___ 09:50PM BLOOD calTIBC-186* Hapto-292* Ferritn-1654*
TRF-143*
___ 09:50PM BLOOD Triglyc-275*
___ 09:36PM BLOOD Acetmnp-NEG
___ 06:28PM BLOOD Lactate-3.1* K-4.9
___ 08:11AM BLOOD Hgb-9.1* calcHCT-27
MICRO
======
___ blood and urine cultures - negative
IMAGING
========
___ MRCP
Findings suggest persistent hepatic abscesses. Similar moderate
biliary
dilatation including irregularities in contour and caliber of
intrahepatic
biliary ducts suggesting sclerosing cholangitis like picture.
Mild dilatation
and inflammatory changes involving extrahepatic biliary tree.
Small quantity
of hepatic biliary contrast agent shown to enter the duodenum.
___ US-guided liver abscess aspiration
US-guided aspiration attempt of the known segment VII hepatic
abscess, with no
fluid obtained.
___ CXR
The right PICC line projects to the head. Cardiomediastinal
silhouette is
stable. The small left pleural effusions unchanged. No
pneumothorax is seen. There is subsegmental atelectasis in the
right lung base.
PERTINENT INTERVAL LABS
========================
___ 03:25PM BLOOD WBC-16.7* RBC-2.73* Hgb-8.2* Hct-23.9*
MCV-88 MCH-30.0 MCHC-34.3 RDW-14.9 RDWSD-46.6* Plt ___
___ 05:50AM BLOOD WBC-15.1* RBC-2.57* Hgb-7.8* Hct-22.5*
MCV-88 MCH-30.4 MCHC-34.7 RDW-15.0 RDWSD-47.4* Plt ___
___ 08:06AM BLOOD WBC-14.4* RBC-2.43* Hgb-7.3* Hct-22.6*
MCV-93 MCH-30.0 MCHC-32.3 RDW-15.2 RDWSD-51.4* Plt ___
___ 03:25PM BLOOD ___ PTT-36.3 ___
___ 05:50AM BLOOD Glucose-207* UreaN-32* Creat-2.0* Na-131*
K-4.1 Cl-84* HCO3-33* AnGap-14
___ 05:42AM BLOOD Glucose-132* UreaN-23* Creat-1.8* Na-136
K-3.7 Cl-101 HCO3-21* AnGap-14
___ 05:30AM BLOOD Glucose-156* UreaN-20 Creat-1.6* Na-138
K-3.7 Cl-102 HCO3-23 AnGap-13
___ 10:26AM BLOOD ALT-250* AST-805* ___
AlkPhos-1068* TotBili-2.1*
___ 05:55AM BLOOD ALT-376* AST-1570* LD(LDH)-1031*
___ AlkPhos-1015* TotBili-2.2* DirBili-1.2*
IndBili-1.0
___ 09:50PM BLOOD ALT-523* AST-2540* LD(LDH)-___*
___ AlkPhos-899* TotBili-2.1*
___ 06:05AM BLOOD ALT-530* AST-2435* ___
___ AlkPhos-856* TotBili-1.9*
___ 03:25PM BLOOD ALT-567* AST-2469* LD(___)-2161*
___ AlkPhos-903* TotBili-2.2*
___ 05:50AM BLOOD ALT-565* AST-2175* ___
___ AlkPhos-909* TotBili-2.1*
___ 01:38PM BLOOD ___
___ 08:06AM BLOOD ALT-473* AST-1317* LD(LDH)-988*
___ AlkPhos-999* TotBili-1.7*
___ 08:24AM BLOOD ALT-372* AST-656* LD(LDH)-643*
CK(CPK)-4845* AlkPhos-1153* TotBili-1.4
___ 05:20AM BLOOD ALT-291* AST-335* LD(LDH)-474*
CK(CPK)-1150* AlkPhos-1196* TotBili-1.2
___ 05:42AM BLOOD ALT-235* AST-180* LD(LDH)-392*
CK(CPK)-387* AlkPhos-1450* TotBili-1.3
___ 07:46PM BLOOD Lipase-76*
___ 05:55AM BLOOD Lipase-103*
___ 09:50PM BLOOD Lipase-90*
___ 12:55PM BLOOD Calcium-9.0 Phos-2.5* Mg-1.7
___ 05:20AM BLOOD Calcium-9.0 Phos-2.4* Mg-1.6
___ 05:42AM BLOOD Calcium-10.2 Phos-2.7 Mg-1.6
___ 05:30AM BLOOD Calcium-11.2* Phos-3.3 Mg-1.7
___ 02:55PM BLOOD Calcium-11.6* Phos-3.4 Mg-1.8
___ 09:50PM BLOOD calTIBC-186* Hapto-292* Ferritn-1654*
TRF-143*
___:05AM BLOOD Ferritn-1611*
___ 08:24AM BLOOD Hapto-256*
___ 09:50PM BLOOD Triglyc-275*
DISCHARGE LABS
===============
___ 04:55AM BLOOD WBC-11.4* RBC-2.74* Hgb-8.4* Hct-26.0*
MCV-95 MCH-30.7 MCHC-32.3 RDW-16.6* RDWSD-55.9* Plt ___
___ 04:55AM BLOOD Glucose-135* UreaN-19 Creat-1.7* Na-140
K-3.4* Cl-101 HCO3-25 AnGap-14
___ 04:55AM BLOOD ALT-150* AST-105* LD(LDH)-262*
AlkPhos-1168* TotBili-1.6*
___ 04:55AM BLOOD Calcium-11.6* Phos-3.8 Mg-1.8
Brief Hospital Course:
In brief, Mr. ___ is a ___ y/o M with a history of HTN, DMII,
persistent liver abscesses, recent lengthy admissions in ___
and ___ for septic shock d/t polymicrobial cholangitis s/p
ERCP with stent removal ___ and lap cholecystectomy ___, who
presented on ___ with fatigue/lethargy, was admitted to ACS
for infectious work-up, and was transferred to medicine for
management of rhabdomyolysis and acute liver injury.
ACUTE ISSUES:
=============
# Rhabdomyolysis - resolved
His AST elevation out of proportion to ALT elevation is most
consistent with rhabdomyolysis, especially given his UA with
large blood but no RBCs. CPK elevation to ___ on admission
confirms rhabdo. Likely etiology is co-administration of
simvastatin and fluconazole. Fluconazole was switched to
micafungin. He received aggressive hydration with IVF. Relaxed
diet from low K to regular on ___ given improvement in K. IVF
stopped ___ due to ___. ___ recommended rehab placement.
Statin was listed as an allergy.
# Liver abscesses
He follows with ID for persistent liver abscesses. On antibiotic
therapy since ___ (vanc/erta/mica->Levaquin/fluc). Fluconazole
was switched to micafungin on ___ per ID recs due to
rhabdomyolysis. MRCP redemonstrates 2 hepatic abscesses. changed
zosyn from 4.5g IV Q8H to 2.25 g IV Q6H on ___ due to
worsening Cr. attempted liver abscess aspiration by ___ on ___
was unsuccessful. He was continued on Zosyn and micagungin per
ID recs, with plan to continue these antibiotics until
outpatient ID follow up on ___. He underwent PICC placement
during hospitalization to facilitate home IV antibiotics.
# ___ - improving
Likely intrarenal (ATN) in setting of rhabdomyolysis. He was
supported with IVF and also given calcium gluconate. Medications
were really dosed.
# Acute liver injury - improving
Likely secondary to rhabdomyolysis, though MRCP is suggestive of
sclerosing cholangitis. His transaminitis could be caused by
biliary injury from his cholecystectomy, and MRCP was
recommended by ID to evaluate for this. There is no current
evidence of acute liver failure (INR is 1.3, no HE, plts 535).
MRCP shows no clear obstructive process and possible secondary
scarring (sclerosing cholangitis). He was monitored for signs of
liver failure and rhabdo was managed as above.
# Leukocytosis - improving
In the setting of known liver abscesses. Possibly reactive in
the setting of recent surgery. UCx negative. Downtrended during
admission. He was treated with Zosyn and mica as above.
# Hypercalcemia - elevated Ca on last few days of discharge.
Review of medications revealed patient prescribed vit D 50,000u
weekly x6 weeks in early ___, and was still prescribed this.
Was removed from his pre-admission medication list and should
not be continued. Ca stable on discharge. Should be followed-up
in ___ days.
CHRONIC/STABLE ISSUES:
======================
# Acute on chronic anemia
Hgb downtrending recently. Iron studies are consistent with
anemia of chronic disease. Most likely dilutional as he is on
aggressive IVF. No s/s active bleeding.
# Secondary sclerosing cholangitis
Suggested by MRCP. Per discussion w hepatology, not unexpected
to have sclerosis in biliary tree given recent infections and
instrumentation. They do not think MRCP findings are consistent
w primary sclerosing cholangitis and did not feel further w/u
necessary.
# Recent lap cholecystectomy
s/p lap chole on ___. APAP was given for pain.
# T2DM
Held home metformin and glipizide as inpatient. Given SSI while
inpatient.
# Hypertension
Held home antihypertensives and monitored BP during this
admission.
# BPH
Continued home Flomax. Home finasteride was held in setting of
hepatic dysfunction.
TRANSITIONAL ISSUES:
===================
[] His PICC should be removed when his course of IV antibiotics
are completed.
[] His outpatient providers should consider restarting his home
finasteride when LFTs normalize.
[] Continue IV micafungin and pip-tazo to treat liver abscesses
until further instruction from infectious disease specialists.
[] Check chemistry panel on ___ or ___ to ensure calcium
level not still elevated. If so, discuss w PCP/MD at facility.
#CODE: Full code, presumed
#CONTACT: ___ (son/HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO DAILY:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
4. Docusate Sodium 100 mg PO BID
5. Fluconazole 400 mg PO Q24H
6. Finasteride 5 mg PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Levofloxacin 500 mg PO Q24H
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. Simvastatin 40 mg PO QPM
11. Tamsulosin 0.4 mg PO QHS
12. MetFORMIN XR (Glucophage XR) 500 mg PO BID
13. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN pain
14. Ursodiol 300 mg PO BID
15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
16. Mupirocin Ointment 2% 1 Appl NU TID
Discharge Medications:
1. Micafungin 100 mg IV Q24H
2. Piperacillin-Tazobactam 2.25 g IV Q6H
3. Acetaminophen 500 mg PO DAILY:PRN Pain - Mild
4. Aspirin 81 mg PO DAILY
5. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
6. Docusate Sodium 100 mg PO BID
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. MetFORMIN XR (Glucophage XR) 500 mg PO BID
9. Mupirocin Ointment 2% 1 Appl NU TID
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
11. Senna 8.6 mg PO BID:PRN Constipation - First Line
12. Tamsulosin 0.4 mg PO QHS
13. Ursodiol 300 mg PO BID
14. HELD- Finasteride 5 mg PO DAILY This medication was held.
Do not restart Finasteride until your doctor tells you to
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Rhabdomyolysis
Liver abscesses
Acute kidney injury
Secondary diagnoses:
Acute on chronic anemia
Secondary sclerosing cholangitis
Acute liver injury
Type 2 diabetes mellitus
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- you were more tired than usual, and your bloodwork was
concerning for an infection
What did you receive in the hospital?
- You were treated for the infection in your liver, and other
causes of infection were ruled out
- You were found to have dangerous muscle breakdown (rhabdo),
which we believe was caused by the combination of your
cholesterol medication and one of your antibiotics.
- You were supported with fluids and your kidney function was
watched closely.
What should you do once you leave the hospital?
- Take your medicines as prescribed.
- Attend your follow up appointments.
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10884869-DS-5
| 10,884,869 | 21,244,934 |
DS
| 5 |
2183-07-09 00:00:00
|
2183-07-09 18:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Worst headache of life
Major Surgical or Invasive Procedure:
___ Diagnostic cerebral angiogram
History of Present Illness:
Mr. ___ is a ___ M who presents today with severe HA since
830am this morning. He awoke with the HA. He endorses some
nausea and vomiting this afternoon. The headache is in the
setting of a recent diagnosis of sinusitis and right otitis
media, for which he started amoxicillin yesterday. He
experienced fevers to 101.5 last week, but has been afebrile
today. He also was noted to be hypertensive since ___ and
was started on lisinopril yesterday. He describes his headache
as bandlike over the forehead. He denies any photophobia, neck
stiffness, numbness, weakness, double or blurry vision,
paresthesias, or any other neurological complaints. Also c/o of
sore throat.
He presented initially to an OSH where CTH was negative for
SAH. An LP was performed to w/u SAH; there were 29 RBC/2 WBC in
tube 1 and 308 RBC/0 WBC in tube 4. Because of the increasing
RBCs, he was transferred for neurosurgical evaluation.
Past Medical History:
Hypertension
Social History:
___
Family History:
Denies family h/o cerebral aneurysms or intracranial hemorrhage.
Physical Exam:
On admission:
O: T: 99.2 BP: 157/101 HR: 80 RR 15 O2Sats 99%
Gen: WD/WN, comfortable, NAD.
HEENT: ATNC
Neck: Supple, no nuchal rigidity.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension. No dysarthria
or
paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils round and reactive to light, right 3 to
2 mm, left 3.5 to 2.5mm. Visual fields are full to
confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
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 bilaterally.
Reflexes: B T Pa Ac
Right ___ 2
Left ___ 2
Toes downgoing bilaterally
On discharge:
AAO x 3, PERRL, no drift, MAE x 4, sensation intact to light
touch.
Pertinent Results:
___ CT/CTA head and neck
1. Normal appearance of the vasculature of the head and neck,
without significant stenosis (by NASCET criteria), dissection,
or aneurysm.
2. Unremarkable non-contrast head CT. No acute territorial
infarct,
space-occupying lesion, or intracranial hemorrhage.
___ MR head with and without contrast
No significant intracranial abnormalities on MRI of the brain
with and without gadolinium. No abnormal flow voids mass effect
enhancing or hydrocephalus identified mucosal thickening left
maxillary and sphenoid sinuses and right middle ears and mastoid
air cells.
Brief Hospital Course:
Mr. ___ was admitted to the Neurosurgery service on ___ due
to concerns of a possible subarachnoid hemorrhage or vascular
anomaly contributing to his headaches. He was kept NPO and
given IV fluids overnight.
On the morning of ___, the patient was taken to the angiography
suite where he underwent a diagnostic cerebral angiogram which
was negative for aneurysm, av malformation or dissection. The
patient tolerated the procedure well and recovered in PACU. His
diet was advanced as tolerated.
On ___, Mr. ___ was discharged home with recommendations to
follow up with a Neurologist to further manage his headaches.
Prior to discharge, he was afebrile, hemodynamically and
neurologically stable. He was given a small supply of oxycodone
as needed for headaches.
Medications on Admission:
Lisinopril 5mg daily, amoxicillin
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN headache
2. Amoxicillin 500 mg PO Q8H
3. Lisinopril 5 mg PO DAILY
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain, headache
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Headaches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Post cerebral angiogram:
What activities you can and cannot do:
When you go home, you may walk and go up and down stairs.
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
After 1 week, you may resume sexual activity.
After 1 week, gradually increase your activities and distance
walked as you can tolerate.
No driving until you are no longer taking pain medications
Followup Instructions:
___
|
10885026-DS-21
| 10,885,026 | 21,709,864 |
DS
| 21 |
2111-03-22 00:00:00
|
2111-03-23 13:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Intubated at OSH, extubated ___
Left heart cath ___
History of Present Illness:
___ year old woman with HTN, hypothyroidism, CVA ___ ___, and
recurrent idiopathic episodes of severe pancreatitis starting ___
___ who presents ___ respiratory failure, found to have profound
acidosis and Hyponatremia.
History provided by her son, who is a physician/endocrinologist
at ___. she was ___ her usual state of health
until 4 weeks ago when she developed a URI. She had a lingering
cough for which she was given doxycycline ___ weeks ago with
improvement. Then ___ days ago she developed burping with some
nausea and small amounts of vomiting. She took some Zofran with
relief. She also started developing dyspnea related to these
episode of burping which worsened, prompting her son to take her
to urgent care. At urgent care she could barely walk to the door
and was sent to the ED at ___. She had no chest pain,
abdominal pain, diarrhea, edema, rashes, fevers, or chills. She
had no mental status changes whatsoever until right before she
was intubated when she was ___ distress.
At ___ she was noted initially to be uncomfortable. There
was some concern for stridor and for allergic reaction so she
was given an epi pen with improvement, and then 30 minutes later
she felt dyspneic again and was given epi pen without
improvement, and was intubated. At ___ her workup was
notable for WBC 13, Hgb 9.8, VBG 7.27/24, lactate was 7, Cr at
baseline 0.61, **Na 112, Bicarb 11, AST/ALT 192/137, proBNP
4600, trop negative. Lipase was 41.
She had a CT which showed the following:
1. Fluid overload and cardiac decompensation. Large bilateral
pleural effusions, near complete collapse of the
bilateral lower lobes, and moderate left upper lobe atelectasis.
2. Acute pancreatitis with limited assessment of the pancreatic
parenchyma and veins due to bolus timing. Correlation
with lipase recommended. Mildly attenuated splenic artery. No
evidence of arterial injury. 5.8 and 1.8 cm
peripancreatic fluid collections. Superinfection cannot be
excluded on imaging.
3. Duodenal wall thickening and mucosal hyperenhancement is
likely reactive to adjacent pancreatitis and due to third
spacing.
4. Severe gallbladder wall thickening likely due to third
spacing.
Of note, her son relays the following history: around ___
she developed an episode of pancreatitis for which she was
admitted, treated with fluids and medical management and
discharged home. She had no alcohol use or gallstones
identified. ___ she had another episode requiring admission
to ___. ___ ___ ___ had another episode at ___
___ where she had an Na of 120 and was again treated
medically. Through these episodes no trigger was identified. She
underwent an evaluation by a specialist at ___ included
MRCP, endoscopy and autoimmune panel which were negative.
___ our ED she was hemodynamically stable off of pressors. She
was given 40mg IV Lasix.
ROS: Positives as per HPI; otherwise negative.
====
Past Medical History:
Hypothyroidism
Type II Diabetes Mellitus on insulin
Mixed Hyperlipidemia
Depressive Disorder
Essential Hypertension
CVA ___
Recurrent pancreatitis, idiopathic
Gastroesophageal Reflux Disease
Sciatica
Disorder of Bone and Articular Cartilage
Tachycardia
Social History:
___
Family History:
Her mother had diabetes
Her father had brain and lunch cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
================================
GEN: ___, intubated and sedated
HEENT: moist mucous membranes
CV: RRR, no m/g/r
RESP: CTAB, no wheezing or crackles
GI: Soft, nontender, nondistended with bowel sounds
MSK: legs with trace to 1+ pretivial edema, warm
SKIN: warm, no rashes
NEURO: follows commands, moves all extremities, PERRL
DISCHARGE PHYSICAL EXAM:
=================================
___ 0526 Temp: 97.4 PO BP: 124/73 L Lying HR: 79 RR: 20 O2
sat: 96% O2 delivery: RA
Gen: awake, conversant, ___ NAD
CV: JVP hard to assess given TR. RRR, no m/r/g.
Resp: CTAB
Abd: soft, NDNT, no palpable HSM.
Ext: WWP, no edema
Neuro: AlOx3. Right upper and lower extremity strength slightly
weaker than left (chronic per patient). No increased tone.
Pertinent Results:
ADMISSION LABS:
====================
___ 10:00PM ___ PO2-34* PCO2-28* PH-7.43 TOTAL
CO2-19* BASE XS--4
___ 10:00PM NA+-117*
___ 06:01PM ___ TEMP-37.1 PO2-34* PCO2-29* PH-7.43
TOTAL CO2-20* BASE XS--4
___ 06:01PM NA+-117*
___ 05:50PM GLUCOSE-180* UREA N-16 CREAT-0.7 SODIUM-117*
POTASSIUM-4.0 CHLORIDE-88* TOTAL CO2-16* ANION GAP-13
___ 05:50PM CALCIUM-7.6* PHOSPHATE-2.9 MAGNESIUM-1.9
___ 03:37PM NA+-119*
___ 03:27PM GLUCOSE-117* UREA N-16 CREAT-0.7 SODIUM-121*
POTASSIUM-4.5 CHLORIDE-92* TOTAL CO2-16* ANION GAP-13
___ 03:27PM cTropnT-<0.01
___ 03:27PM CALCIUM-7.2* PHOSPHATE-2.9 MAGNESIUM-1.9
CHOLEST-116
___ 03:27PM TRIGLYCER-104 HDL CHOL-33* CHOL/HDL-3.5
LDL(CALC)-62
___ 01:36PM ___ TEMP-36.7 PO2-43* PCO2-30* PH-7.40
TOTAL CO2-19* BASE XS--4
___ 01:36PM NA+-118*
___ 09:59AM ___ TEMP-36.6 PEEP-5 O2-40 PO2-44*
PCO2-31* PH-7.42 TOTAL CO2-21 BASE XS--2 INTUBATED-INTUBATED
VENT-SPONTANEOU
___ 09:59AM LACTATE-2.0 K+-3.6
___ 09:41AM GLUCOSE-147* UREA N-17 CREAT-0.7 SODIUM-119*
POTASSIUM-3.9 CHLORIDE-89* TOTAL CO2-16* ANION GAP-14
___ 09:41AM CALCIUM-8.2* PHOSPHATE-3.3 MAGNESIUM-2.3
___ 09:41AM URINE HOURS-RANDOM UREA N-354 CREAT-26
SODIUM-25
___ 09:41AM URINE OSMOLAL-369
___ 06:40AM ___ PO2-38* PCO2-34* PH-7.35 TOTAL
CO2-20* BASE XS--5
___ 06:40AM LACTATE-2.8*
___ 06:26AM GLUCOSE-192* UREA N-16 CREAT-0.7 SODIUM-118*
POTASSIUM-4.2 CHLORIDE-85* TOTAL CO2-16* ANION GAP-17
___ 06:26AM CALCIUM-7.9* PHOSPHATE-3.4 MAGNESIUM-3.1___ 06:26AM OSMOLAL-256*
___ 03:44AM ___ PO2-38* PCO2-39 PH-7.31* TOTAL
CO2-21 BASE XS--6
___ 03:44AM LACTATE-3.0* NA+-114*
___ 03:24AM GLUCOSE-276* UREA N-16 CREAT-0.8 SODIUM-114*
POTASSIUM-4.3 CHLORIDE-84* TOTAL CO2-16* ANION GAP-14
___ 03:24AM CALCIUM-8.3* PHOSPHATE-3.5 MAGNESIUM-1.3*
___ 02:27AM URINE HOURS-RANDOM CREAT-10 SODIUM-65
___ 02:27AM URINE OSMOLAL-296
___ 02:27AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:27AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 01:20AM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30*
GLUCOSE-150* KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:20AM URINE RBC-71* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 12:21AM ___ PO2-67* PCO2-42 PH-7.17* TOTAL
CO2-16* BASE XS--12
___ 12:21AM LACTATE-3.9* NA+-115*
___ 12:21AM O2 SAT-83
___ 12:15AM ALBUMIN-3.6 CALCIUM-8.0* PHOSPHATE-3.7
MAGNESIUM-1.4* IRON-40
___ 12:15AM calTIBC-308 FERRITIN-416* TRF-237
___ 12:15AM WBC-18.8* RBC-3.41* HGB-9.5* HCT-28.5* MCV-84
MCH-27.9 MCHC-33.3 RDW-13.4 RDWSD-40.6
___ 12:15AM NEUTS-80.2* LYMPHS-7.5* MONOS-10.8 EOS-0.0*
BASOS-0.1 NUC RBCS-0.1* IM ___ AbsNeut-15.10* AbsLymp-1.41
AbsMono-2.04* AbsEos-0.00* AbsBaso-0.02
___ 12:15AM PLT COUNT-310
___ 12:15AM ___ PTT-27.9 ___
IMAGING:
___ CXR
IMPRESSION:
Lungs are low volume with worsening pulmonary edema. Support
lines and tubes are ___ acceptable position. Small bilateral
effusions are stable.
Cardiomediastinal silhouette is unchanged. No pneumothorax.
___ CXR
IMPRESSION:
Lungs are low volume with worsening pulmonary edema. Support
lines and tubes are ___ acceptable position. Small bilateral
effusions are stable.
Cardiomediastinal silhouette is unchanged. No pneumothorax.
___ RUQUS
IMPRESSION:
1. ___ the setting of known recurrent pancreatitis, a 5.1 x 4.7 x
5.6 cm cyst with debris which abuts the left hepatic lobe and
the pancreas is favored to represent a subhepatic peripancreatic
fluid collection, either a pseudocyst or
area of walled-off necrosis.
2. Normal gallbladder. No biliary ductal dilatation.
3. Normal hepatic parenchymal echotexture.
4. Small volume ascites and small bilateral pleural effusions.
5. Pulsatility of the main portal vein suggestive of right heart
failure or tricuspid regurgitation.
___ TTE
IMPRESSION: Normal left ventricular cavity size with moderate to
severe global left ventricular
dysfunction with regional variation involving the inferoseptum,
and inferior wall. Severe mitral and
tricuspid regurgitation with failure of leaflets to fully coapt
and some posterior mitral leaflet
tethering. Right ventricular pressure/volume overload. At least
mild pulmonary hypertension.
___ CXR
IMPRESSION:
___ comparison with the study ___, there are improved lung
volumes. The monitoring and support devices have been removed.
Continued enlargement of the cardiac silhouette with stable
elevation of pulmonary venous pressure and bilateral pleural
effusions with compressive basilar atelectasis, more prominent
on the right.
___ CARDIAC CATH
No angiographically apparent coronary artery disease.
___ CXR
Heart size and mediastinum are enlarged, moderately. Aorta is
calcified.
There is moderate interstitial pulmonary edema. Right basal
opacity is more conspicuous and might represent pulmonary edema
but infectious process is a possibility. Small bilateral
pleural effusions are present.
Right PICC line tip is at the level of cavoatrial junction.
Right
MICROBIO:
___ 9:41 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 3:43 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
___ 2:27 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 12:15 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
DISCHARGE LABS
===================================
___ 03:30PM BLOOD WBC-9.5 RBC-3.63* Hgb-9.8* Hct-32.3*
MCV-89 MCH-27.0 MCHC-30.3* RDW-14.8 RDWSD-46.9* Plt ___
___ 03:30PM BLOOD Plt ___
___ 03:30PM BLOOD Glucose-194* UreaN-16 Creat-0.8 Na-133*
K-4.8 Cl-96 HCO3-26 AnGap-11
___ 03:30PM BLOOD Calcium-9.5 Phos-4.3 Mg-3.0*
Brief Hospital Course:
===============================
PATIENT SUMMARY STATEMENT
===============================
___ year old woman with HTN, hypothyroidism, CVA ___ ___, and
recurrent idiopathic episodes of severe pancreatitis starting ___
___ who presented ___ respiratory failure, found to have
profound
acidosis, hyponatremia, and HFrEF.
===============================
ACTIVE ISSUES:
===============================
#Acute HFrEF (LVEF 28%, 4+ MR, 4+ TR)
High concern for missed MI as she reported chest pressure,
dyspnea,
and nausea ~1 week prior to presentation. TTE with global
hypokinesis, MR and TR raising concern for a global process like
stress cardiomyopathy ___ setting of some other insult vs
degenerative
valvular disease (though suspect MR/TR are functional from
dilation).She underwent a cardiac catheterization which showed
no coronary artery disease. No arrythmias noted since admission
to explain HF.
Her JVD was hard to assess given TR. She also had no lower
extremity edema but had presented initially with pulmonary
edema. Therefore, trialed IV Lasix 80 mg and she responded well
to this. She was then transitioned to Lasix 40mg on discharge
for maintenance diuresis. She was also discharged on Lisinopril
20mg QD, metoprolol succinate 100mg QD.
#Hyponatremia
History of hyponatremia, although unknown recent baseline,
presented with hyponatremia to 113. Urine osm 296 and urine
sodium ___. Suspect cause may be medication related; is on home
medications can cause SIADH including duloxetine and
nortriptyline. Also presented with pancreatitis which may have
contributed to a pseudohyponatremia component, although
triglycerides not significantly elevated. Unlikely
glucocorticoid insufficiency or hypothyroidism given the
unremarkable am cortisol TSH. Suspected some component of poor
solute intake contributing and ongoing SIADH component from pain
as well. She was fluid restricted and sodium was stable for a
couple of days prior to discharge (Dc sodium =133).
#Transaminitis
Imaging suggested hepatic congestion, but severity of ALT/AST
elevation (___) raised concern for alternate etiologies,
thought to be most likely shock.
Viral serologies and autoimmune markers sent with ___ 1:160.
Imaging negative for Budd Chiari. No reported hypotension
episodes to suggest
ischemic hepatitis. No reported toxic ingestions. Does have
large
peripancreatic fluid collection abutting the liver but no lab or
imaging evidence of biliary obstruction. LFTs improved were ALT
361 and AST 169. If continues to be elevated, would consider
further autoimmune workup as outpatient.
#Metabolic Acidosis:
Mixed anion gap and non-gap. Had marked lactic acidosis on
admission but without clear evidence for hypoperfusion other
than LFT abnormalities raising concern for metformin induced or
liver injury. Urine pH >6 suggesting possible type 1 RTA (defect
___ distal tubular acidification). This was resolved on
discharge.
# Diarrhea: had episodes of loose stools which apparently is her
baseline, with c diff ordered at time of discharge. Family
requested she be discharged home despite pending c diff. Will
call if positive test.
#Acute hypoxemic respiratory failure
Predominantly driven by pulmonary edema from ADHF, with
contribution from metabolic acidosis. No clinical evidence of
infection, pancreatitis, or other cause for non-cardiogenic
pulmonary edema. She was diuresed as above and was discharged on
room air.
#Pancreatic fluid collections
#Leukocytosis:
No fevers or localizing symptoms to suggest infection.
Abdominal imaging likely chronic. On empiric antibiotics which
were subsequently discontinued.
#Anemia
New per her son. No history of bleeding. Iron studies most
suggestive of chronic disease with possible superimposed iron
deficiency.
===============================
CHRONIC ISSUES:
===============================
#Hyperglycemia
#T2DM
Continued home lantus and ISS
#HTN:
Restarted metoprolol and Lisinopril. Held amlodipine as patient
was hypotensive earlier ___ the course of the asmission.
#Depression:
Held duloxetine as per renal recs
#Hypothyroidism:
Continued home levothyroxine
#Fibromyalgia:
Held home amitryptiline as per renal recs
===============================
TRANSITIONAL ISSUES
===============================
Cr: 0.7
Hg: 9.8
AST/ALT: 361/169
New meds
-----------------
-Metoprolol succinate dose increased to 100mg QD
-Furosemide 40 mg daily
Held
----------------
-Duloxetine (hyponatremia)
-Amitriptyline (hyponatremia)
-Metformin (metabolic acidosis)
[] Please check a BMP within 1 week of discharge. Patient had
stable hyponatremia and was also discharged on lasix 40mg PO
[] Please repeat iron studies when recovered from this acute
illness. Studies indicated anemia of chronic disease but please
rule out iron deficiency anemia
[] Metformin held this admission as felt it was the potential
culprit for metabolic acidosis
[] follow up diarrhea,
#CODE STATUS: Full
#EMERGENCY CONTACT: Son, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. amLODIPine 5 mg PO DAILY
3. DULoxetine ___ 60 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
6. Pantoprazole 40 mg PO Q24H
7. Nortriptyline 10 mg PO QHS
8. levemir 40 Units Bedtime
9. Meclizine 12.5 mg PO Q12H:PRN dizzyness
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Lisinopril 20 mg PO DAILY
12. Levothyroxine Sodium 75 mcg PO DAILY
Discharge Medications:
1. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. levemir 40 Units Bedtime
3. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Meclizine 12.5 mg PO Q12H:PRN dizzyness
8. Pantoprazole 40 mg PO Q24H
9. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
10. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until your doctors ___ to restart
11. HELD- DULoxetine ___ 60 mg PO DAILY This medication was
held. Do not restart DULoxetine ___ ___ doctor tells you
to
12. HELD- Nortriptyline 10 mg PO QHS This medication was held.
Do not restart Nortriptyline until your doctor tells you to
13.Outpatient Lab Work
Cr, Na, K
___
ICD___.0
Name: ___, MD
Location: ___, ___.
Address: ___
Phone: ___
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
====================
Acute hypoxemic respiratory failure
Acute heart failure with reduced ejection fraction
Acute liver injury
Metabolic Acidosis
SECONDARY DIAGNOSIS
=====================
Large peripancreatic fluid collection
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
trouble breathing.
WHAT HAPPENED WHILE I WAS ___ THE HOSPITAL?
- You were intubated to help you breath
- You were found to have new heart failure so we started you on
a medication called lasix that helps get rid of excess fluids ___
the body.
- You also had low sodium which we think some of your home
medications were causing this so we stopped them (duloxetine and
the amitriptyline)
- Your liver function tests were abnormal initially but improved
to baseline. Sometimes this can help when people are very sick.
Your doctor should continue to monitor this.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Weigh yourself every morning, call your doctor at ___
if your weight goes up more than 3 lbs.
- You should not drink more than 2L of fluids daily.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling ___ your legs, abdominal distention, or
shortness of breath at night.
- Your discharge weight: 52.1 kg (114.86 lb) You should use
this as your baseline after you leave the hospital.
- Please get your labs checked on ___. These will be faxed
to your cardiologist.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10885062-DS-21
| 10,885,062 | 27,615,701 |
DS
| 21 |
2110-12-12 00:00:00
|
2110-12-12 16:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ EOTH use disorder presents from inpatient psych facility
w/ abd pain, hematemesis, and poor PO intake x3d.
He usually drinks 2 twelve packs a day, last ETOH use was 2 days
ago. He is currently on treatment for withdrawal. He is
complaining of black stools for a few months. He initially went
to ___ and was admitted for
suicidality (plan to jump out of window) and EOTH withdrawal.
After he was admitted for a day after starting CIWA protocol and
ativan, he was transferred to ___ due to abnormal LFTs (AST
90,
ALT 50, Tbili 2.9).
In the ED, vitals were: T 98.4, HR 80, BP 112/76, RR 17, 96%
room
air
Exam: Guaiac positive brown stool.
Labs: wbc 6.7, hgb 14.6, plt 106, AST 103, ALT 54, AP 66, Tbili
2.9, lipase 138, INR 1.4. His tbili is stable, but AST/ALT
increased from when he was at ___.
Studies: RUQUS w/ steatohepatitis, no ascites
They were given: Diazepam 10 mg for CIWA 13, IV PPI, ondansetron
4 mg IV, ketorolac 15 mg IV, 1 L LR. No tapable ascites pocket
on
POCUS.
On arrival to the floor, he states that for 6 months, he has had
anxiety, thoughts of jumping out of his window, and suicidal
ideation. He drinks from the night to the morning nonstop and
does not eat for ___ days straight. He states that he has had
seizures before with withdrawal. He states that he has been
having abdominal pain for 3 months (b/l RUQ/LUQ radiating to
lower quadrants), he vomits everyday for 6 months due to
withdrawal symptoms (improved with drinking). He noticed the
specks of blood 4 months ago and started getting scared. Denies
coffee-ground emesis. States that he is chronically LH since he
has been drinking. He states that he has fallen 3x a day for
months. He states that he has hit his head in the past from
this.
He states that he has had black bowel movements for about 6
months. States that he "cannot hold anything in his stomach."
Past Medical History:
EtOH abuse c/b withdrawal seizures (once ___
Asthma (takes 2 inhalers, does not remember names)
___ back pain
Social History:
___
Family History:
Denies any family history of liver problems. Brother had 2
heroin
overdoses this past year. Denies any family history of MI, CVA,
blood clots.
Physical Exam:
Admission:
___ 0002 Temp: 99.6 PO BP: 133/81 L Lying HR: 69 RR: 18 O2
sat: 97% O2 delivery: RA Dyspnea: 0 RASS: 0
GENERAL: NAD, lying confortably
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
No tongue fasciculations.
NECK: No cervical lymphadenopathy. No JVD. No JVP elevation.
CARDIAC: RRR, no m,r,g
LUNGS: CTAB, no w,r,r
BACK: No CVA tenderness.
ABDOMEN: NTTP, ND, NBS. Patient states he has pain, but not when
it is pressed.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. CN2-12
intact. ___ strength throughout. Normal sensation. Mild
dyskinesia w/ FTN, no nystagmus, no tongue fasciculations.
Discharge:
___ 2307 Temp: 98.2 PO BP: 108/67 R Lying HR: 59 RR: 20 O2
sat: 95% O2 delivery: Ra
GEN: Well appearing, in no acute distress
LUNGS: CTAB
HEART: RRR, nl S1, S2. No m/r/g.
NEURO: AOx3. No active SI or hallucinations at this time
Pertinent Results:
Admission Labs:
___ 03:28PM BLOOD WBC-6.7 RBC-4.64 Hgb-14.6 Hct-44.1 MCV-95
MCH-31.5 MCHC-33.1 RDW-13.9 RDWSD-48.4* Plt ___
___ 03:52PM BLOOD ___ PTT-32.6 ___
___ 03:28PM BLOOD Glucose-97 UreaN-9 Creat-0.5 Na-139 K-3.6
Cl-99 HCO3-24 AnGap-16
___ 03:28PM BLOOD ALT-54* AST-103* AlkPhos-66 TotBili-2.9*
___ 08:05AM BLOOD Albumin-3.8 Calcium-8.7 Phos-3.5 Mg-1.5*
Discharge Labs:
___ 08:14AM BLOOD WBC-6.6 RBC-4.54* Hgb-14.3 Hct-43.0
MCV-95 MCH-31.5 MCHC-33.3 RDW-14.6 RDWSD-51.1* Plt ___
___ 08:14AM BLOOD Glucose-112* UreaN-13 Creat-0.6 Na-141
K-3.7 Cl-104 HCO3-25 AnGap-12
___ 08:13AM BLOOD ALT-93* AST-92* AlkPhos-77 TotBili-0.8
___ 08:14AM BLOOD Albumin-3.9 Calcium-9.4 Phos-4.9* Mg-1.8
Studies:
___ RUQUS
1. Echogenic liver consistent with steatosis. Other forms of
liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot
be excluded
on the basis of this examination.
2. Gallbladder containing sludge and cholelithiasis with wall
edema without
distension to suggest acute cholecystitis.
Brief Hospital Course:
Mr ___ is a ___ y/o M with PMH significant for alcohol use
disorder who was initially admitted to inpatient psychiatry
facility for suicidal ideation, then transferred for abd pain
and abnormal liver function tests concerning for ETOH hepatitis.
There were also reports of possible hematemesis but he had none
here and had normal RBC counts. Workup was consistent with EtOH
hepatitis, which slowly improved with supportive care. Psych
evaluated patient and deemed that he no longer was a risk to
self and was safe to be discharged home with follow up as an
outpatient.
ACTIVE ISSUES:
=============
#ETOH Abuse
#ETOH hepatitis:
Patient presented with abdominal pain and LFT abnormalities
concerning for alcoholic hepatitis. MDF of 22 so no steroids
were given. LFTs downtrending over time with supportive care
alone. He was maintained on CIWA protocol without any
significant withdrawal symptoms. He did have a workup, that was
negative for hepatitis A, Hep B immune, Hep C Ab + but viral
load negative, and HIV negative. He will be continued on
multiple vitamins at the time of discharge, including folic
acid, multivitamin, thiamine. He should have LFTs followed up in
1 week at his primary care appointment.
#Suicidal Ideation
#Major Depressive Episode
Had SI prompting admission to ___, but no longer
endorsed suicidal ideation once admitted to ___. He had a 1:1
sitter at admission. He was eventually evaluated by psychiatry
here who deemed that he was no longer a risk to self and that he
was safe to go home with follow up. He was contracted for
safety. He will need close outpatient followup and initiation of
payschotherapy and/or pharmacotherapy. He will also need further
counseling for EtOH abstinence and possibly medical therapy for
this.
#Hematemesis:
Patient reported dark stool and bloody specks in vomit prior to
admission, but no longer had any bleeding after admitted and
blood counts were stable.
TRANSITIONAL ISSUES:
====================
[ ] Patient has been previously prescribed Quetiapine and other
psych meds in past, and reportedly has history of depression,
anxiety, and/or bipolar disorder, but has not been routinely
taking any of these medication. Will need consistent psych
following and determination of good pharm/therapy regimen and
regular follow up
[ ] Patient needs continue follow-up regarding EtOH abstinence,
consider medication such as acamprosate
[ ] F/u CBC and LFTs in 1 week at next PCP ___
[ ] Patient should be evaluated for epigastric pain, and very
low threshold to give PPI for likely gastritis
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. DiphenhydrAMINE 50 mg PO QHS
2. ClonazePAM 4 mg PO Q6H:PRN while qutting
3. Thiamine 100 mg PO DAILY
4. Multivitamins W/minerals 1 TAB PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Prazosin 1 mg PO QHS
7. QUEtiapine Fumarate 100 mg PO QHS
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Vitamins and Minerals] 1
tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) [Vitamin B-1] 100 mg 1 tablet(s)
by mouth once a day Disp #*30 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Alcohol missuse disorder
Alcoholic hepatitis
Suicidal ideation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure caring of you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for abnormal liver tests
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received testing for you liver, which revealed that
alcohol use was most likely responsible for the abnormal liver
tests
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments, as below.
- Please let you primary doctor know or go to the ED if you feel
like you are going to harm yourself
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10885680-DS-20
| 10,885,680 | 27,989,204 |
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| 20 |
2175-01-31 00:00:00
|
2175-02-04 09:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Dilantin / Penicillins
Attending: ___.
Chief Complaint:
Cough and fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old female who presented to the ED with
one week of productive cough and fevers at home. Her symptoms
started abruptly about 8 days ago without any upper respiratory
symptoms. She reports that she frequently gets brochitis, but
that it usually starts with URI symptoms. Her cough has been
productive of yellow brown sputum. She has seen a few streaks of
blood. She has been having high fevers to 104 at home with
diffuse myalgias, fatigue, and malaise. She has not been eating
or drinking very much and has developed some left flank pain
which she attributes to dehydration. She does not recall any
recent sick contact.
.
Initial vitals in ED triage were T 98.6, HR 93, BP 132/66, RR
22, and SpO2 93% on RA. Labs were notable for mild hyponatremia
with Na 132, WBC 6.5 with neutrophil predominance, and Hct 34.9
near recent baseline. CXR showed a RLL opacity concerning for
pneumonia. She was started on Ceftriaxone and Azithromycin. She
also received normal saline ___ ml.
.
She was admitted to medicine for further management of RLL
pneumonia.
Vitals prior to floor transfer were T 100.2, HR 89, BP 121/53,
RR 20, and SpO2 99% on 2L NC. On reaching the floor, she
reported feeling somewhat better after the fluids. She continues
to have a productive cough and mild headache.
Past Medical History:
# Seizure Disorder
# Hypothyroidism
# Hypercholesterolemia
# Obesity
# Anemia
# Menorrhagia History -- now menopausal
-- s/p failed endometrial ablation in past
# Plantar Fasciitis
# Colonic Adenoma
# Hepatic Adenoma
# Psoriasis
Social History:
___
Family History:
# Mother: ___ Cancer
# Father: ___
# ___ Grandmother: ___
# ___ Grandfather: ___ Disease
Physical Exam:
ADMISSION:
VS: T 99.2, BP 122/59, HR 86, RR 20, SpO2 99% on RA, Wt 177.7
lbs
Gen: Middle aged female in NAD. Oriented x3.
HEENT: Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: Supple. JVP not elevated. No cervical lymphadenopathy.
CV: RRR with normal S1, S2. No M/R/G.
Chest: Respiration unlabored. Crackles and rhonchi at right
base, otherwise clear.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Back: Left CVA tenderness to percussion, none on right.
Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses
intact radial 2+, DP 2+, ___ 2+.
Skin: No concerning rashes or other lesions noted.
Neuro: CN II-XII grossly intact. Strength ___ in all
extremities. Normal speech.
DISCHARGE:
VS: 98.8 116/78 85 20 96% RA, 89% with ambulation
Gen: Middle aged female in NAD. Oriented x3.
HEENT: Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: Supple. JVP not elevated. No cervical lymphadenopathy.
CV: RRR with normal S1, S2. No M/R/G.
Chest: Respiration unlabored. Crackles and rhonchi at right
base, otherwise clear. End expiratory wheezes
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Back: Left CVA tenderness to percussion, none on right.
Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses
intact radial 2+, DP 2+, ___ 2+.
Skin: No concerning rashes or other lesions noted.
Neuro: CN II-XII grossly intact. Strength ___ in all
extremities. Normal speech.
Pertinent Results:
ADMISSION:
___ 06:27PM BLOOD WBC-6.5 RBC-3.96* Hgb-11.9* Hct-34.9*
MCV-88 MCH-30.1 MCHC-34.1 RDW-12.5 Plt ___
___ 06:27PM BLOOD Neuts-82.5* Lymphs-12.3* Monos-4.3
Eos-0.1 Baso-0.7
___ 06:27PM BLOOD Plt ___
___ 06:27PM BLOOD Glucose-98 UreaN-14 Creat-0.8 Na-132*
K-3.7 Cl-92* HCO3-27 AnGap-17
___ 05:45AM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:55AM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:45AM BLOOD Calcium-7.7* Phos-2.9 Mg-2.6 Iron-14*
___ 05:45AM BLOOD calTIBC-217* Ferritn-379* TRF-167*
___ 06:37PM BLOOD Lactate-1.1
___ 03:05PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:05PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
___ 03:05PM URINE RBC-<1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
___ 03:05PM URINE Mucous-RARE
DISCHARGE:
___ 06:45AM BLOOD WBC-7.3 RBC-3.79* Hgb-11.3* Hct-34.6*
MCV-91 MCH-29.7 MCHC-32.6 RDW-13.9 Plt ___
___ 05:45AM BLOOD WBC-4.6 RBC-3.39* Hgb-10.1* Hct-30.6*
MCV-90 MCH-29.8 MCHC-33.1 RDW-12.7 Plt ___
___ 06:45AM BLOOD Glucose-100 UreaN-7 Creat-0.5 Na-144
K-4.6 Cl-107 HCO3-27 AnGap-15
___ 06:45AM BLOOD Calcium-8.2* Phos-4.3 Mg-2.5
___ 05:45AM BLOOD calTIBC-217* Ferritn-379* TRF-167*
HIV neg
Blood Cx neg
Urine Legionella neg
Sputum Cx contaminated with respiratory flora
CXR:
Patchy ill-defined opacity within the right lower lobe which is
concerning for
an infectious process in the correct clinical context.
EKG:
Sinus rhythm. Non-specific ST segment changes. No previous
tracing available
for comparison.
Echo:
The left atrium is mildly dilated. Color-flow imaging of the
interatrial septum raises the suspicion of an atrial septal
defect with left-to-right shunt, but this could not be confirmed
on the basis of this study (agitated saline contrast study
recommended if clinically indicated). Left ventricular wall
thickness, cavity size, and 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 leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
CT Chest:
1. Multifocal pneumonia is more severe in right lower lobe.
2. Exophytic inferior thyroid lesion will have to be
investigated by a
sonogram.
Brief Hospital Course:
The patient is a ___ year old female with seizure disorder and
hypothyroidism who presented to the ED with one week of
productive cough and fevers at home. She was found to have a RLL
pneumonia.
.
ACUTE
# RLL Pneumonia: Patient endorsed a week of cough and fever on
admission and CXR showed a RLL pneumonia. She was started and
CTX and azithro then transictioned to doxicyclin 100 BID for 5
days for treatment of CAP. However, here symptoms persisted
after 3 days of abx therapy, and given her hx suggestive of
reactive airwary disease and wheeze on exam, she was started on
a pred burst x 5 days and scheduled duonebs. After completing
her course of abx, she was still noted to desat into the low ___
while on room air. As a result, we obtained an echo and CT
chest. Echo was unremarkable, but CT chest showed multifocal
pneumonia at bases r>l. We were concerned given her persistent
hypoxia with ambulation and this radiologic finding that we had
not treated her appropriately. Therefore, we started her on
cefpedoxime 400 mg BID x 7 days and azithromycin x 5 days. Her
symptoms improved over the next day, and she did not desat with
ambulation. She was discharged with the remainder of her
cefpodoxime and azithromycin course, albuterol nebs, PCP
followup, and ___ recommendation to follow-up with pulmonology.
Consideration should also be given to obtaining PFTs and serum
immunoglobulin levels given frequent respiratory infection.
.
# Hyponatremia: Na 132 on admission, felt most likely to be
hypovolemic hyponatremia from poor PO intake. She received IVF
in the ED and this resolved.
.
CHRONIC
# Seizure Disorder: Continued on home Carbamazepine and
Divalproex
.
# Anemia: Normocytic anemia with Hct currently close to recent
baseline. She has a history of menorrhagia s/p failed
endometrial ablation, but is now menopausal with no recent
vaginal bleeding. Iron studies were sent, which suggested iron
deficiency anemia. Consideration should be given to replacement
in the outpatient setting.
.
# Hypothyroidism: Continued on home Levothyroxine 100 mcg PO
DAILY
.
# Hypercholesterolemia: Continued on home Rosuvastatin 20 mg PO
DAILY
.
TRANSITIONAL
# Pulmonary follow-up
# W/U of thyroid lesion seen on CT scan of chest
# Consider iron repletion
# Consider measurement of PFTs and serum immunoglobulin levels
given frequent resp infx
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientAtrius.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Divalproex (DELayed Release) 1500 mg PO DAILY
3. Carbamazepine (Extended-Release) 900 mg PO DAILY
4. Rosuvastatin Calcium 20 mg PO DAILY
5. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
6. Fluocinonide 0.05% Cream 1 Appl TP BID
Discharge Medications:
1. Carbamazepine (Extended-Release) 900 mg PO DAILY
2. Divalproex (DELayed Release) 1500 mg PO DAILY
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Rosuvastatin Calcium 20 mg PO DAILY
5. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
6. Fluocinonide 0.05% Cream 1 Appl TP BID
7. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*24 Tablet Refills:*0
8. Please provide patient with nebulizer machine
9. Nebulizer
Please dispense patient a nebulizer machine
10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
RX *albuterol sulfate 0.63 mg/3 mL 1 neb inhaled q6hrs Disp
#*120 Unit Refills:*0
11. Azithromycin 250 mg PO Q24H Duration: 3 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: pneumonia
Secondary: Reactive Airway Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care of you during your recent
admission to ___. You were admitted because of your
pneumonia. We treated you with antibiotics, nebulizers and
steroids. Unfortunately, you did not improve as quickly as
expected. A CT scan showed progression of your pneumonia.
Despite your clinical improvement, we started you on a different
course of antibiotics. You were discharged with follow-up at
your PCP as well as a prescription for a course of antibiotics.
You should also follow-up with a pulmonologist to discuss your
frequent pulmonary infections and get pulmonary function tests
and serum immunoglobulin levels.
Followup Instructions:
___
|
10885696-DS-8
| 10,885,696 | 24,388,326 |
DS
| 8 |
2148-12-22 00:00:00
|
2148-12-23 14:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Recurrent falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of lung cancer,
laryngeal cancer, chronic trach, and multiple DVTs on warfarin,
transferred from ___ per patient's request after
presenting with repeated falls. Patient cannot give clear
history of falls, does recall falling out of bed while sleeping
several months ago, and also within past several days. Also has
stated feeling unsteady on her feet. Denies any
dizziness/lightheadedness prior to falls. No LOC, but did hit
head. Per report, was brought to ___ by her health
aide after a fall yesterday and 2 day. At ___, was found to
have lower extremity edema and was concern for white-out of left
lung on CXR. She received lasix 40mg. Her labs there were
notable for Hct 32, K 5.2, Cr 2.1, INR 1.9, BNP 106. CT head was
negative. Transferred to ___.
.
In the ED, initial VS: 98.9 81 140/73 20 91%. She had pitting
edema to knees, but was speaking in full sentences and sats up
to 100% on 3L NC. Labs notable for Cr 2.0. No leukocytosis. UA
was c/w UTI, and patient received levofloxacin. CXR here showed
post left upper lobectomy changes, with no superimposed acute
intrathoracic process detected. Vitals prior to transfer 82
141/83 13 100% 2L.
.
Currently, patient comfortable. On 3L NC at home, though patient
admits she has not always been adherent. Of note, was recently
on lasix, but not for past several days. Feels lower extremity
swelling improved after lasix at OSH. Reports chills, but denies
fevers. Denies CP, but has chronic productive cough and dyspnea
(no recent changes, no hemoptysis).
Past Medical History:
1. Lung cancer - Initially diagnosed with left lung cancer in
___, which was treated with wedge excision. Recurrent squamous
cell cancer in the left upper lobe in ___, which was treated
with a left thoracotomy with left upper lobectomy in ___.
She is followed by Dr. ___ Dr. ___.
2. Laryngeal cancer - The patient is status post laryngectomy,
radiation therapy, and chemotherapy. She has a tracheostomy. She
is followed by Dr. ___
3. Sleep apnea
4. DVT - The patient has had multiple DVTs in the past and is on
chronic anticoagulation with Coumadin. Her goal INR is ___.
5. Asthma
6. Chronic back pain
7. Hypothyroidism
8. Obesity
9. Gastroesophageal reflux disease
10. Subretinal hemorrhage nasal to the optic nerve and inferior
to the macula in the left eye associated with vitreous
hemorrhage
- ___
Social History:
___
Family History:
Daughter has diabetes. Granddaughter with lupus.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 98.1 F, BP 144/96, HR 90, R 20, O2-sat 96% RA
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, trach in place, JVD to mandible
LUNGS - diffuse wheezing throughout, no rales or rhonchi, good
air movement, able to speak in full sentences
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - 2+ lower extremity edema, 2+ DP pulses
SKIN - no jaundice, approximate 1cmx1cm lesion on left anterior
shin with fibrinous material, no active bleeding, surrounding
erythema but no warmth or fluctuance
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout
.
DISCHARGE PHYSICAL EXAM:
VS - Temp 98.8 F, BP ___, HR 87, R 20, O2-sat 93% RA
GENERAL - well-appearing in NAD
HEENT - MMM, OP clear
NECK - supple, trach in place, no JVD
LUNGS - no rales or rhonchi, good air movement
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - 1+ lower extremity edema, 2+ DP pulses
SKIN - unchanged
NEURO - awake, A&Ox3
Pertinent Results:
Admission Labs:
WBC-4.2 RBC-4.03* HGB-12.3 HCT-38.9 MCV-97 MCH-30.5 MCHC-31.5
RDW-13.6
NEUTS-74.8* LYMPHS-15.9* MONOS-6.6 EOS-1.9 BASOS-0.9
PLT COUNT-165
.
DISCHARGE LABS
___ 06:45AM BLOOD WBC-5.4 RBC-3.29* Hgb-10.0* Hct-31.6*
MCV-96 MCH-30.5 MCHC-31.8 RDW-13.9 Plt ___
___ 06:45AM BLOOD ___ PTT-36.6* ___
___ 06:45AM BLOOD Glucose-83 UreaN-30* Creat-2.2* Na-137
K-4.7 Cl-99 HCO3-30 AnGap-13
___ 06:45AM BLOOD Mg-2.0
.
U/A- URINE COLOR-Straw APPEAR-Hazy SP ___
BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-LG
RBC-<1 WBC-50* BACTERIA-FEW YEAST-NONE EPI-1
GLUCOSE-76 UREA N-34* CREAT-2.0* SODIUM-140 POTASSIUM-5.2*
CHLORIDE-103 TOTAL CO2-23 ANION GAP-19
.
MICROBIOLOGY:
___ 7:50 pm URINE Site: CATHETER
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML. SECOND TYPE.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 8 S 8 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I 32 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
.
IMAGING:
.
CXR ___ (___): Post left upper lobectomy changes, with no
superimposed acute intrathoracic process detected.
.
CT Head (___): No acute intracranial abnormality or e/o
intracranial bleed or mass. Mild small vessel ischemic changes.
Mild-mod involutional changes noted.
.
___ TTE
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thicknesses and cavity size
are normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Left ventricular
systolic function is hyperdynamic (EF>75%). There is a mild
resting left ventricular outflow tract obstruction. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is no
valvular aortic stenosis. The increased transaortic velocity is
likely related to high cardiac output. Trace aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Trivial mitral regurgitation is seen. Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Normal left ventricular cavity size and wall
thickness with hyperdynamic left ventricular systolic function.
Mild resting left ventricular outflow tract obstruction. Mildly
dilated abdominal aorta. Moderate to severe tricuspid
regurgitation. Moderate pulmonary artery systolic hypertension.
Brief Hospital Course:
___ female with history of lung cancer, laryngeal cancer, chronic
trach, and multiple DVTs on warfarin, transferred from ___
___ s/p multiple recent falls, and with UTI.
.
ACTIVE ISSUES:
.
# Multiple recent falls: Likely multifactorial in setting of
degenerative changes of the cervical and lumbar spine,
neuropathy, and new UTI. In addition, patient was orthostatic on
admission, which is likely secondary to hypovolemia from lasix
use. Patient was rehydrated with small boluses of IVF and was
no longer orthostatic on the day of discharge. CT head from OSH
showed mild small vessel ischemic changes. Specific mention of
ventricles was not sent in report, however, on discussion with
the radiologist from OSH, there was no evidence of dilation of
the temporal horns (most specific area for identifying NPH), the
___ and ___ ventricles were normal and the atria were prominent,
but within normal limits given degree of atrophy. The
radiologist recommended MRI for better evaluation for subacute
ischemia. This should be done in the outpatient setting.
Clinical suspicion for NPH was low given lack of incontinence
and other reasons for patient to have gait instability. She was
evaluated by physical therapy who recommended rehab.
.
# UTI: Though patient was asymptomatic without leukocytosis or
fever, urinalysis was positive for white cells and bacteria,
without epithelials and culture grew >100,000 gram negative
rods. Patient was started on bactrim for planned 7 day course
which was switched to cipro 7-day course after sensitivities
showed 2 species of E-coli both resistant to bactrim.
.
# Anticoagulation due to history of recurrent DVTs: Pt is on
chronic anticoagulation with goal INR ___. INR was
supratherapeutic during admission, likely ___ bactrim and cipro
given for her UTI. Her d/c INR was 2.2. She was discharged on
1.5mg warfarin daily with recommendation for close monitoring.
.
# Anemia: Hct dropped about 7 pts from baseline high 30's on
admission and previously, to 30 or 31. She had no signs of acute
blood loss; Fe studies were wnl, blood smear unremarkable; LFT's
wnl. Her guaiacs were not obtained as she had no bowel
movement, and hemolysis labs were negative. Patient's HCT on
discharge was 31.6.
.
CHRONIC ISSUES:
.
#. Asthma: Patient w/ diffuse wheezing on exam at the time of
admission. Patient was continued on home albuterol nebulizers
and tiotropium. Oxygen saturations were good on home 2L NC.
There was no evidence of pulmonary edema or consolidations on
CXR.
.
# Lower extremity edema: Patient was recently started on
furosemide for lower extremity edema. Edema has improved,
however, falls may have been related to lightheadedness
secondary to hypovolemia. Therefore furosemide was discontinued
and patient was given compression stockings to help decrease
swelling. Patient was kept on low salt diet. TTE showed
hyperdynamic left ventricular systolic function, mild resting
left ventricular outflow tract obstruction, moderate to severe
tricuspid regurgitation, and moderate pulmonary artery systolic
hypertension. Furosemide was resumed prior to discharge at dose
of 10mg daily.
.
#. Hypothyroidism: TSH and T4 checked during admission and
within normal limits. Continued home levothyroxine.
.
# Depression: Continued home citalopram 40 mg daily.
.
# Chronic back pain: Concern that dilaudid may have been causing
vivid dreams vs visual hallucinations. Patient given
acetaminophen as needed for pain. Her pain was well controlled
throughout admission.
.
# GERD: Continued PPI.
.
# Constipation:
Patient had no bowel movement over a three day period but
asymptomatic with no concerning signs on exam. Started bowel
regimen.
.
TRANSITIONAL ISSUES:
- can consider MRI head for better evaluation for subacute
ischemia if indicated on outpt basis
- follow up INR
- follow up CBC to monitor anemia
Medications on Admission:
-Albuterol sulfate 0.63 mg/3 mL Solution for Nebulization 3
ml(s) nebulized ___ times daily as needed
-Albuterol sulfate [ProAir HFA] 90 mcg HFA Aerosol Inhaler 2
puffs(s) inhaled four times a day as needed for shortness of
breath or wheeze
-Citalopram 40 mg Tablet daily
-Furosemide 20 mg Tablet, ___ Tablet(s) by mouth daily Take 1
tablet for 4 days then ___ a tablet for 4 days then stop.
___
-Gabapentin 100 mg Capsulem, 1 Capsule(s) by mouth twice a day
Please take 1 tablet at bedtime for two weeks then add a second
tablet in the morning. ___
-Hydromorphone [Dilaudid] 2 mg Tablet 2 Tablet(s) by mouth Q6H
PRN or 1 Q4H PRN
-Levothyroxine 100 mcg Tablet 1 Tablet(s) by mouth daily
-Pantoprazole 40 mg Tablet, Delayed Release (E.C.) 1 Tablet(s)
by mouth daily
-Tiotropium bromide [Spiriva with HandiHaler] 18 mcg Capsule,
w/Inhalation Device 1 dose inhaled daily
-Warfarin 2.5 mg Tablet 1 Tablet(s) by mouth daily Adjust per
INR.
-Zolpidem 5 mg Tablet 1 Tablet(s) by mouth QHS PRN
-Calcium-vitamin D3-vitamin K [Viactiv] 500 mg-200 unit-40 mcg
Tablet, Chewable 1 Tablet(s) by mouth three times daily
.
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation ___ times daily as needed
for SOB or wheezing.
2. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain/fever.
8. calcium-vitamin D3-vitamin K 500-200-40 mg-unit-mcg Tablet,
Chewable Sig: One (1) Tablet, Chewable PO three times a day.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
12. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
Inhalation four times a day as needed for shortness of breath
or wheezing.
13. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
14. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days: day 1 of 7= ___.
15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily): hold for ___
stools.
16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
17. warfarin 1 mg Tablet Sig: 1.5 mg PO Once Daily at 4 ___.
18. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Multifactorial gait instability
2. Urinary tract infection
SECONDARY DIAGNOSIS:
1. Asthma
2. Chronic tracheostomy for history of laryngeal cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your recent
admission to ___.
You were admitted because you were falling frequently. A CT scan
at ___ showed that you did not injure your head when
you fell. We believe that this is due to multiple issues,
including your neuropathy, low blood pressure from dehydration,
and deconditioning. Physical therapy evaluated your walking
and felt that you would benefit from rehab where you can work on
getting your strength back.
In addition, you were found to have a urinary tract infection.
You were started on antibiotics.
For the swelling in your legs, you were given compression
stockings.
Please weigh yourself daily. If your weight increases by >3lb,
call your doctor.
The following changes were made to your medication regimen:
NEW:
- Ciprofloxacin twice a day through ___
- senna, bisacodyl, miralax for constipation
CHANGED:
DECREASED Furosemide to 10mg
DECREASED Warfarin TO 1.5mg
Followup Instructions:
___
|
10885696-DS-9
| 10,885,696 | 28,812,737 |
DS
| 9 |
2149-02-07 00:00:00
|
2149-02-08 12:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
worsening dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ F PMHx lung ca, and laryngeal ca s/p laryngectomy, lots of
radiation who presents from ___, who states pt has had
progressive worsening of her shortness of breath. The patient
states that she has been feeling poorly for the past four days.
She has had worsening shortness of breath and trouble catching
breath. Reportedly pt had O2 saturations in mid-80s at ___
___ with 2L NC. She had nebs at ___ which partially
improved symptoms. The patient denies any fevers but does state
that she has a mild cough, occasionally productive of sputum.
Also she does have bilateral lower extremity swelling
chronically.
.
Pt states that has had more trouble recently with coughing while
eating/drinking. She also has pleuritic chest pain that started
a few days ago. Denies palpitations.
.
There is a tracheostomy tube in place, capped. She lives at
rehab ___). Pt is on ___ NC at home at ___
___. Pt denies diarrhea. Pt endorses some chronic back pain.
.
In the ED inital vitals were, ___ 24 99% neb.
On exam, pt was wheezy at RLB, 1+ pitting edema b/l. Pt received
duonebs in the ED. got nebulizer. CXR w infiltrates, t100.0 -->
pt received vanc+levoflox+zosyn. Fever spiked to 102.4, and
patient received tylenol. Blood cultures were sent in the ED.
HR in the 110s. Vitals on transfer are: t102.4 HR116 ___
105/56 96%4L. Access: 20 gauge R antecubital.
.
On arrival to the ICU, 99.8 ___ 99% 3L. Patient unable
to give a thorough history secondary to fatigue and difficulty
speaking. Breathing unlabored and patient comfortable.
.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Endorses congestion. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
-Lung cancer - Initially diagnosed with left lung cancer in
___, which was treated with wedge excision. Recurrent squamous
cell cancer in the left upper lobe in ___, which was treated
with a left thoracotomy with left upper lobectomy in ___.
She is followed by Dr. ___ Dr. ___.
-Laryngeal cancer - The patient is status post laryngectomy,
radiation therapy, and chemotherapy. She has a tracheostomy. She
is followed by Dr. ___
-___ apnea
-DVT - The patient has had multiple DVTs in the past and is on
chronic anticoagulation with Coumadin. Her goal INR is ___.
-Asthma
-Chronic back pain
-Hypothyroidism
-Obesity
-Gastroesophageal reflux disease
-Subretinal hemorrhage nasal to the optic nerve and inferior to
the macula in the left eye associated with vitreous
hemorrhage
Social History:
___
Family History:
Daughter has diabetes. Granddaughter with lupus.
Physical Exam:
ADMISSION PHYSICAL EXAM:
99.8 ___ 99% 3L
GENERAL - comfortable with eyes closed, in NAD
HEENT - NC/AT, EOMI, sclerae anicteric, MM mildly dry, OP clear
NECK - supple, trach in place and capped, with trach collar, JVP
difficult to assess secondary to trach collar
LUNGS - scarce crackles b/l, moderate air movement b/l, no
wheeze appreciated
HEART - RRR, no MRG, nl S1-S2, no tenderness to palpation of
chest wall
BACK - no midline spinal tenderness, no CVA tenderness
ABDOMEN - NABS, obese, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - 2+ lower extremity edema to knee b/l, 2+ DP pulses
SKIN - unremarkable
NEURO - sleepy but arousable, CNs II-XII grossly intact, muscle
strength ___ throughout
Discharge Exam:
VS: AFebrile 70-80s 120-130s/60-80s ___ 96% 40% TM
GENERAL: appears generally comfortably, tracheostomy in place,
smiling, obese
HEENT: anicteric
NECK: tracheostomy stoma c/d/i. Healing pressure ulcer around
trach.
HEART: RRR. nl s1s2. No mrg.
LUNGS: scattered rhonchi continuing to improve. comfortable.
talking audibly and clearly with finger covering trach
ABDOMEN: Soft/NT/ND
EXTREMITIES: warm, wearing pneumatic boots, mild nonpitting
edema in bilateral LEs. Swollen left arm without tenderness to
palpation or pitting. Full ROM. No erythema.
NEURO: Awake, alert, interactive (closes trach when wanting to
speak),
Pertinent Results:
Admission Labs:
___ 07:27PM BLOOD WBC-9.3# RBC-3.57* Hgb-11.2* Hct-34.4*
MCV-96 MCH-31.4 MCHC-32.6 RDW-13.8 Plt Ct-95*
___ 07:27PM BLOOD Neuts-85.5* Bands-0 Lymphs-9.5* Monos-4.5
Eos-0.2 Baso-0.3
___ 09:13PM BLOOD ___ PTT-32.0 ___
___ 08:00PM BLOOD Glucose-117* UreaN-26* Creat-1.6* Na-144
K-4.2 Cl-101 HCO3-28 AnGap-19
___ 08:00PM BLOOD cTropnT-<0.01 proBNP-1374*
___:00PM BLOOD Calcium-9.4 Phos-3.0 Mg-1.8
___ 07:46PM BLOOD Type-ART Temp-37 pO2-64* pCO2-51* pH-7.40
calTCO2-33* Base XS-4 Intubat-NOT INTUBA
___ 07:24PM BLOOD Glucose-105 Lactate-2.1* Na-143 K-4.0
Cl-99
___ 08:25PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
MICRO:
blood cultures ___: no growth to date
urine legionella antigen ___: negative
sputum culture ___:
___ 9:37 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
PROTEUS MIRABILIS. SPARSE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
GRAM NEGATIVE ROD #2. SPARSE GROWTH.
MORPHOLOGY CONSISTENT WITH ISOLATE #1.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| STAPH AUREUS COAG +
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 8 I <=0.5 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 0.5 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R <=0.5 S
VANCOMYCIN------------ 1 S
blood culture ___: no growth to date
IMAGING:
Radiology Report CHEST (PORTABLE AP) Study Date of ___ 7:13
___
IMPRESSION: Right basilar opacity silhouetting the
hemidiaphragm, possibly
due to any combination of effusion, atelectasis or
consolidation. Clinical
correlation recommended. Two-view chest x-ray may also offer
additional
detail.
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
___ 7:42 ___
IMPRESSION: AP chest compared to ___:
Tip of the new left PIC line projects over the low SVC.
Opacification at the lung bases is more pronounced on the left
today, stable on the right compared to ___. Left-sided
changes are particularly suggestive of pneumonia due to recent
aspiration since right lower lobe atelectasis has been present
since ___. Azygous distention indicates volume
overload. Bulbous contour of the left hilus is stable and better
evaluated by CT scanning. Heart size top normal, no change.
Small bilateral pleural effusions are presumed. No pneumothorax.
The study and the report were reviewed by the staff
radiologist.
Videoswallowing: IMPRESSION: Gross aspiration of thins,
nectar-thicks, and ground solids.
LUE Venous Duplex:
IMPRESSION: No evidence of DVT.
Discharge/Notable Labs:
___ 06:00AM BLOOD WBC-3.5* RBC-3.32* Hgb-9.9* Hct-30.3*
MCV-91 MCH-29.8 MCHC-32.6 RDW-13.7 Plt ___
___ 06:00AM BLOOD ___
___ 06:00AM BLOOD Glucose-73 UreaN-13 Creat-1.0 Na-144
K-3.2* Cl-104 HCO3-33* AnGap-10
Studies pending at discharge:
None
Brief Hospital Course:
___ yo F with history of laryngeal squamous cell carcinoma s/p
supraglottic laryngectomy, non-small cell lung cancer s/p left
upper lobectomy with subsequent chemotherapy and neck
irradiation with chronic tracheostomy admitted with multifocal
pneumonia felt to be due to aspiration.
#Pneumonia due to Proteus and Methicillin resistant staph
aureus:
Patient was admitted with hypoxia above ___ home needs and was
found to have right basilar opacification on CXR and CT showed
RLL heterogenous consolidation and RUL ill defined opacification
with trace right sided effusion. She was initially treated with
Vancomycin, Cefepime, Levaquin, and Azithromycin and was
narrowed to Vancomycin and Cefepime and then to Vancomycin and
Ceftriaxone based on sputum culture sensitivities. She was
discharged to complete an 8 day course of antibiotics to end
___. Her oxygen requirement decreased to 40% FiO2 via 10L/min
TM satting in the high ___. Given that patient was satting well
on 40% FiO2 she can likely have her oxygen weaned further at
rehab.
#Aspiration:
Patient is known to aspirate when eating, but has not had
history of recurrent aspiration pneumonias. It is unclear why
the patient aspirated resulting in pneumonia this admission, but
it may have been related to an underlying viral URI as
subglottic edema was seen on evaluation laryngoscopy with ENT.
The patient had a videoswallowing study that was similar to
previous. She was allowed to eat a soft diet with thinned
liquids and all crushed pills and tolerated this without
significant desaturations. She should continue on this diet on
discharge.
#Chronic deep venous thrombosis:
Patient had a supratherapeutic INR during admission and Coumadin
was held. Coumadin can be restarted when INR drops to <3. INR
continued to be >3 on the day of discharge.
.
#Left Uppe extremity swelling:
Patient was noted to have left upper extremity swelling related
to the RUE without pitting edema, change in temparature or skin
changes of the limb, reduced ROM, or pain. INR was >3 entire
admission and LUEUS showed no DVT. Given that the patient had a
PICC in that arm, it was felt that this swelling related to
reduced venous outflow from PICC. Since the patient had one more
day left of IV abx, the PICC was left with instructions to the
rehab to pull PICC as soon as last dose of antibiotics on the
day after discharge.
#THROMBOCYTOPENIA: This was stable between 90-120 during
admission and improved with treatment of infection.
#Anemia: Hematocrit dropped from 34 to 27 but remained stable in
the high ___ thereafter. This should be followed on discharge to
make sure it remains stable. There was low suspicion for blood
loss.
.
#Hypothyroidism: Patient was continued on home levoxyl.
#Chronic back pain: Continued on prn dilaudid and standing
Tylenol. To help keep pain controlled would consider assessing
pain every ___ hours and giving dilaudid ___ every 4 hours to
keep control of the pain.
#Depression: Continued on citalopram
#Pressure ulcer: Patient has healing ulcer under trach which has
been treated with Xeroform guaze.
#GERD: continued on PPI
#Access: ___ Line - placed ___ 07:30 ___. Should be
removed after completion of IV antibiotics (last doses ___.
#Prophylaxis: INR>2
#Contact: ___ (HCP, not related), ___ ___
(daughter) ___
#CODE: DNR
#Disposition: Patient was discharged to rehab to continue abx
for pneumonia until ___ and for continued monitoring of
aspiration and respiratory status improvement. She may require
occasional deep suctioning if she has desaturation and should
eat with trach button, but otherwise should not have the trach
button in per ENT recs. She should have PCP and ENT follow up
arranged in ___ weeks (PCP) and ___ weeks (ENT) by rehab
facility.
Medications on Admission:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation ___ times ___ as needed
for SOB or wheezing.
2. citalopram 20 mg Tablet Sig: One (1) Tablet ___ once a day.
3. gabapentin 100 mg Capsule Sig: One (1) Capsule ___ Q12H (every
12 hours).
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet ___
(___).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) ___ Q24H (every 24 hours).
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation ___.
7. acetaminophen 325 mg Tablet Sig: ___ Tablets ___ Q6H (every 6
hours) as needed for pain/fever.
8. calcium-vitamin D3-vitamin K 500-200-40 mg-unit-mcg Tablet,
Chewable Sig: One (1) Tablet, Chewable ___ three times a day.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule ___ BID (2
times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet ___ BID (2 times a
day) as needed for constipation.
11. hydromorphone 2 mg Tablet Sig: One (1) Tablet ___ Q4H (every
4 hours) as needed for pain.
12. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
Inhalation four times a day as needed for shortness of breath
or wheezing.
13. zolpidem 5 mg Tablet Sig: One (1) Tablet ___ at bedtime as
needed for insomnia.
14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) ___: hold for ___
stools.
15. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
___ as needed for constipation.
16. warfarin 2.5 mg qd
17. furosemide 20 mg Tablet
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
2. citalopram 20 mg Tablet Sig: One (1) Tablet ___.
3. levothyroxine 50 mcg Tablet Sig: Two (2) Tablet ___
(___).
4. gabapentin 250 mg/5 mL Solution Sig: Two (2) mL ___ Q12H
(every 12 hours): please crush all pills.
5. lansoprazole 30 mg Tablet,Rapid Dissolve, ___ Sig: One (1)
Tablet,Rapid Dissolve, ___ ___.
6. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
7. acetaminophen 650 mg/20.3 mL Solution Sig: Thirty (30) mL ___
three times a day.
8. calcium-vitamin D3-vitamin K 500-200-40 mg-unit-mcg Tablet,
Chewable Sig: One (1) Tablet, Chewable ___ three times a day:
crush pills.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule ___ BID (2
times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet ___ BID (2 times a
day) as needed for constipation: crush pills.
11. hydromorphone 2 mg Tablet Sig: One (1) Tablet ___ every four
(4) hours as needed for pain: crush pills.
12. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
13. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
___ and PRN per lumen.
14. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
15. Ambien 5 mg Tablet Sig: One (1) Tablet ___ at bedtime as
needed for insomnia: crush pills.
16. Miralax 17 gram/dose Powder Sig: One (1) dose ___ once a day
as needed for constipation.
17. Lasix 20 mg Tablet Sig: One (1) Tablet ___ once a day: crush
pills.
18. vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
every twelve (12) hours for 1 days: Last dose ___. Please pull
PICC line after last dose to reduce LUE swelling.
19. ceftriaxone 1 gram Piggyback Sig: Two (2) grams Intravenous
every ___ hours for 1 days: Last dosse ___.
Please remove PICC line after last dose of antibiotics to reduce
LUE swelling.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Aspiration pneumonia due to Proteus and MRSA
Secondary:
Chronic deep venous thrombosis
Hypothyroidism
GERD
Back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for aspiration pneumonia and treated with
antibiotics. You were also seen by the ENT sevice (Dr. ___
and had your tracheosomy examined. You improved on antibiotics
and were able to eat well without significant pulmonary
complications prior to discharge.
At rehab, you should continue to have your airway suctioned if
you have obstruction. It is also very important that you not
wear your tracheostomy plug except when you are eating until you
have your follow up appointment with ENT (Dr. ___.
Also, your Coumadin was held because your INR was >3, but this
should be restarted when your INR drops below 3.
Please call your doctor if you experience worsening breathing or
have increased trouble swallowing properly.
Followup Instructions:
___
|
10885927-DS-22
| 10,885,927 | 29,871,798 |
DS
| 22 |
2207-08-14 00:00:00
|
2207-08-14 20:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
Lower back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ year old man with a history of chronic
intermittent LBP who presented to the ED for acutely worsening
back pain. He reports his pain has been worsening for
approximately 2 weeks, initially exacerbated after he bent over
to pick something up and felt like he pulled a muscle. He
reports
severe pain upon awakening this morning causing him to present
to ___ for an urgent care visit. Pain located in the left lower
back. Associated with shooting pains down the left leg. Not
relieved by ibuprofen and tylenol. Denies fevers, chills,
weakness, numbness, incontinence. Given significant pain,
patient was referred to the ED from HCA.
- In the ED, initial vitals were:
Temp 97.8 | HR 76 | BP 148/84 | RR 20 | SpO2 100% RA
- Exam was notable for:
TTP L paravertebral tenderness. Pt writhing in pain. Unable to
lie on his back, sit up, or ambulate. Normal sensation. Normal
___ strength. Normal ___ reflexes
- The patient was given:
Ketorolac 15mg IM
Diazepam 5mg PO
Lidocaine patch
Ondansetron 4mg PO
Oxycodone 5mg PO
Morphine Sulfate 8mg IV
On arrival to the floor, patient still endorsing significant
left sided back/flank pain.
Past Medical History:
-Severe depression with evidence of bipolar symptoms
-Hyperlipidemia
-Hypertension
-Allergic rhinitis
-Musculoskeletal pain
-Erectile dysfunction
Social History:
___
Family History:
Mother with anxiety and heart disease. Father with depression.
Physical Exam:
ADMISSION
=========
VITALS: Temp: 98.3 PO BP: 138/82 R Lying HR: 74 RR: 20 O2
sat:98% O2 delivery: Ra
GENERAL: Alert and interactive. Lying in bed, appears
uncomfortable.
HEENT: Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: Tender to palpation paraspinally in left lumbar region,
across flank into abdomen.
ABDOMEN: Normal bowel sounds. Tender in left lower
abdomen/flank. Non-distended.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AAOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. Strength in lower extremities reduced due to
pain, but symmetric without focal deficit. Normal sensation.
DISCHARGE
=========
VITALS: Temp: 98.2 (Tm 98.2), BP: 102/66 (102-116/56-72), HR: 65
(65-79), RR: 16 (___), O2 sat: 97% (97-99), O2 delivery: Ra
GENERAL: Alert and oriented, no acute distress
ENT: NT/AC, MMM, EOMI
CV: RRR, no murmurs, rubs, or gallops
RESP: CTAB, normal work of breathing
GI: NT/ND, BS+
EXT: Warm and well perfused, non-edematous
MSK: ROM intact in BLEs, pain with internal rotation of the Left
Hip and positive straight leg raise on the Left. Moderate
paraspinal tenderness at the low thoracic/upper lumbar spine. No
erythema, fluctuance, or induration.
NEURO: CNII-XII grossly intact, no focal neurologic deficits
Pertinent Results:
ADMISSION
=========
___ 03:45PM PLT COUNT-340
___ 03:45PM NEUTS-85.6* LYMPHS-8.3* MONOS-4.9* EOS-0.5*
BASOS-0.4 IM ___ AbsNeut-9.53* AbsLymp-0.93* AbsMono-0.55
AbsEos-0.06 AbsBaso-0.04
___ 03:45PM WBC-11.1* RBC-4.53* HGB-12.0* HCT-37.8*
MCV-83 MCH-26.5 MCHC-31.7* RDW-15.8* RDWSD-47.2*
___ 03:45PM estGFR-Using this
___ 03:45PM GLUCOSE-97 UREA N-26* CREAT-0.9 SODIUM-136
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-23 ANION GAP-12
___ 04:40PM URINE MUCOUS-RARE*
___ 04:40PM URINE AMORPH-RARE*
___ 04:40PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0 TRANS EPI-3
___ 04:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 04:40PM URINE COLOR-Straw APPEAR-Hazy* SP ___
___ 04:40PM URINE UHOLD-HOLD
___ 04:40PM URINE HOURS-RANDOM
DISCHARGE
=========
None
IMAGING/REPORTS
===============
___ MRI Thoracic and Lumbar Spine with and without contrast:
THORACIC:
Alignment is normal. Vertebral body and intervertebral disc
signal intensity appear normal. The spinal cord appears normal
in caliber and configuration. There is a small disc bulge at
T1-T2 causing mild central canal narrowing. There is diffuse
disc bulge and small central disc protrusion T7-T8 causing
moderate central canal narrowing.
Tiny right paramedian disc protrusion T8-T9 level.
Mild central canal narrowing T9-T10 level, broad-based disc
bulge.
Left T11-T12 foraminal disc protrusion, mild adjacent paraspinal
edema,
moderate foraminal narrowing.
Otherwise, multilevel mild foraminal narrowing.
Small benign simple cyst right hepatic lobe, right kidney.
There is no evidence of infection or neoplasm. There is no
abnormal
enhancement after contrast administration. Subpleural scarring
right upper chest.
LUMBAR:
Degenerative changes lumbar spine. Normal spinal alignment.
Multilevel disc space narrowing, endplate hypertrophic changes,
diffuse disc bulges, lumbar facet arthritis. No fracture. No
evidence of infection. Normal visualized cord. Congenital
narrowing spinal canal.
At L1-L2, mild central canal narrowing. Mild bilateral
foraminal narrowing.
At L2-L3, annular disc tear. Mild-to-moderate central canal
narrowing,
preserved CSF. Left paramedian, inferior small disc extrusion
extends 7 mm below disc space, measures 4 mm in AP diameter.
Mass-effect on both traversing L3 nerves, left greater than
right. Moderate bilateral foraminal
narrowing.
At L3-L4, mild central canal narrowing. Moderate bilateral
foraminal
narrowing.
At L4-5, mild central canal narrowing. Moderate left, moderate
to severe right foraminal narrowing.
At L5-S1, patent central canal. Moderate bilateral foraminal
narrowing.
No abnormal enhancement.
IMPRESSION:
1. Degenerative changes thoracic spine. Moderate central canal
narrowing T7-T8 level. Multilevel foraminal narrowing.
2. Degenerative changes lumbar spine. Small disc extrusion
L2-L3 level, mild-to-moderate central canal narrowing.
Multilevel significant foraminal narrowing, as above.
Brief Hospital Course:
SUMMARY
=======
Mr. ___ is a ___ year old male with a history of HTN, HLD,
depression, and low back pain presenting with two weeks of
progressive low back pain and leukocytosis. He initially
required IV morphine but was quickly transitioned to naproxen,
Tylenol, and cyclobenzaprine. He received an MRI of the thoracic
and lumbar spine which showed diffuse disc bulging but no signs
of infection or need for urgent intervention.
ACUTE ISSUES
============
#Acute on chronic back pain
Likely multifactorial in the setting of recent strain while
moving heavy boxes also with underlying DJD and disc disease.
Pain well controlled with Tylenol, naproxen, and
cyclobenzaprine. No need for acute surgical intervention. Plan
to discharge on oral pain regimen as above along with
alternating heat, ice, and activity as tolerated.
CHRONIC/STABLE ISSUES
=====================
#HTN: Continued home lisinopril 20mg and HCTZ 25mg daily
#HLD/Primary prevention: Continued home atorvastatin 40mg, ASA
81mg
#Depression
Followed closely by psychiatry. Responded to ECT.
-Continued home duloxetine 60mg daily, trazodone 50mg qhs,
quetiapine 200mg qhs
#GERD: Continued home pantoprazole 40mg daily
TRANSITIONAL ISSUES
===================
[] Continue to monitor back pain. If worsening or not
progressing after ___ weeks, consider referral for Cortisone
injections versus neurosurgical intervention.
#CONTACT: ___ (former partner/friend) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO DAILY
2. DULoxetine ___ 60 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
5. lisinopril-hydrochlorothiazide ___ mg oral DAILY
6. Nabumetone 750 mg PO BID
7. Pantoprazole 40 mg PO DAILY
8. QUEtiapine Fumarate 200 mg PO QHS
9. Sildenafil 100 mg PO DAILY:PRN erectile dysfunction
10. tadalafil 20 mg oral DAILY:PRN
11. TraZODone 50 mg PO QHS
12. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Cyclobenzaprine 5 mg PO TID:PRN Back pain
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
2. Naproxen 500 mg PO Q12H
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. DULoxetine ___ 60 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. lisinopril-hydrochlorothiazide ___ mg oral DAILY
8. Nabumetone 750 mg PO BID
9. Pantoprazole 40 mg PO DAILY
10. QUEtiapine Fumarate 200 mg PO QHS
11. Sildenafil 100 mg PO DAILY:PRN erectile dysfunction
12. tadalafil 20 mg oral DAILY:PRN
13. TraZODone 50 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
=======
Degenerative joint disease of the thoracic and lumbar spine
Secondary
=========
Hypertension
Hyperlipidemia
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had severe lower back pain
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given IV medications to control your pain which were
transitioned to oral Tylenol, naproxen, and cyclobenzaprine.
- You had an MRI that showed that you have degenerative joint
disease in your back that is likely causing your pain but
fortunately it did not show any signs of infection or need for
surgery.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10885949-DS-2
| 10,885,949 | 25,353,598 |
DS
| 2 |
2128-08-27 00:00:00
|
2128-08-27 20:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic appendectomy
History of Present Illness:
___ year old year old male with no significant PMHx, p/w RLQ pain
starting ___ after lunch, associated w/ mild nausea, no
emesis. Patient reports anorexia but otherwise denies
fevers/chills. Patient denies migration or radiation of pain
anywhere. Upon evaluation in ED, patient appeared comfortable.
Abdomen significant for focal RLQ TTP, no rebound/guarding.
Past Medical History:
Anxiety
Social History:
___
Family History:
Father with hematologic malignancy
Physical Exam:
Physical Exam on admission ___:
Vitals - T 98.3 / HR 68 / BP 118/74 / RR 16 / O2sat 100% RA
General - comfortable, NAD
HEENT - moist mucous membranes, PERRLA, EOMI
Cardiac - RRR, no M/R/G
Chest - CTAB
Abdomen - soft, nondistended, focal TTP in RLQ, no
rebound/guarding
Extremities - warm and well-perfused
Neuro - A&OX3
Physical Exam on discharge ___:
Vitals - T 98.2 HR 74 BP 119/75, RR 16 O2 sat 97% on RA.
General: NAD
Neuro: Alert and oriented x 3, follows commands
Cardiac: Regular rate and rhythm
Pulmonary: Lung sounds clear bil
Abdomen: +bs, soft, non-distended, slightly tender to touch, no
erythema or exudate at port sites.
Extremities: No edema, no calf pain
Skin: Warm, dry
Pertinent Results:
___ 11:30AM BLOOD WBC-7.4 RBC-4.65 Hgb-14.2 Hct-41.5 MCV-89
MCH-30.5 MCHC-34.2 RDW-12.3 RDWSD-39.6 Plt ___
___ 11:30AM BLOOD Neuts-69.6 Lymphs-16.1* Monos-13.5*
Eos-0.1* Baso-0.3 Im ___ AbsNeut-5.16 AbsLymp-1.19*
AbsMono-1.00* AbsEos-0.01* AbsBaso-0.02
___ 04:00PM BLOOD ___ PTT-29.1 ___
___ 11:30AM BLOOD Glucose-118* UreaN-10 Creat-0.7 Na-139
K-4.2 Cl-101 HCO3-25 AnGap-13
___ 11:30AM BLOOD ALT-22 AST-17 AlkPhos-61 TotBili-0.3
___ 11:30AM BLOOD Albumin-4.4
___ 11:56AM BLOOD Lactate-1.2
Abd/Pelvis CT with contrast on ___:
IMPRESSION:
Early acute uncomplicated appendicitis.
Brief Hospital Course:
___ year old male, admitted for RLQ abdominal pain,
abdomen/pelvis CT showed acute uncomplicated appendicitis. The
patient was made NPO and given intravenous fluids. Subsequently
went to the OR on ___ for a laparoscopic appendectomy. No
complications. He has been tolerating a regular diet and has no
issues voiding. His pain has been well controlled on
analgesics. He has been ambulatory. Follow up appointment was
made with Dr. ___.
Medications on Admission:
Sertraline 50mg PO twice daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID constipation
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
do not drive while on this medication, may cause drowsiness
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Senna 8.6 mg PO BID:PRN constipation
6. Sertraline 50 mg PO BID
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 came to the hospital with abdominal pain. Your abdominal
imaging showed acute appendicitis. You were brought to the
operating room and had your appendix removed. There were no
complications. Your pain is being controlled and you are
tolerating your diet. You are ready for discharge home.
Please continue your recovery at home by following the
instructions below:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10886101-DS-19
| 10,886,101 | 21,638,984 |
DS
| 19 |
2199-11-07 00:00:00
|
2199-11-08 20:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lipitor
Attending: ___
Chief Complaint:
left arm cellulitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ y/o female with a history of breast cancer
(left sided s/p excision, chemotherapy in ___, then in ___
developed new ER+ infiltrating ductal carcinoma s/p excision,
letrozole) c/b chronic lymphedema of left arm who presented to
the ED on ___ with confusion and arm redness. Patient reports
that she was at her ___ class 2 days ago and cut her
hand while working with the floral arrangements. She
subsequently developed erythema and swelling of her left arm as
well as chills and subjective fevers. She also reports
developing full body aches and confusion (which has happened to
her in the past with prior episodes of cellulitis).
In the ED, initial vitals: T 100.2, HR 94, BP 111/54, RR 18, 98%
RA.
Labs were significant for WBC 11.7, Hb 11.9, PLT 167, Na 132,
Glucose 134, Cr 0.9, lactate 1.3, UA <1 WBC. An US of the LUE
was performed and was negative for DVT. Patient received vanc 1g
x2 (last dose at 1600), ampicillin-sulbactam 3 gm IV x1, 1L IVF,
APAP 1000 mg x1.
Vitals prior to transfer: T 98.9, HR 75, BP 118/49, RR 21, 100%
RA.
Upon arrival to the floor, T 97.7, BP 152/89, HR 85, RR 18, 100%
RA, 152/89. Patient was A+Ox3 and complained of moderate left
arm pain, but states that the pain improved since presentation.
ROS:
In addition to the above, patient denies weight loss, appetite
changes. Also denies CP, SOB, cough, abdominal pain,
nausea/vomiting, diarrhea. Has lower extremity edema at baseline
for which she takes HCTZ. Of note, patient was recently treated
as an outpatient for pneumonia. Denies recent hospitalizations.
Traveled to ___ in the past month.
Past Medical History:
breast cancer (left sided s/p excision, chemotherapy, radiation
in ___, then in ___ developed new ER+ infiltrating ductal
carcinoma s/p excision, letrozole)
HTN
?asthma v. reactive airways
chronic lymphedema of left arm
h/o recent pneumonia
Social History:
___
Family History:
Significant for breast cancer in daughter, sister.
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
VS: T 97.7, BP 152/89, HR 85, RR 18, 100% RA, 152/89
GEN: Alert, lying in bed, no acute distress
HEENT: PERRL, EOMI, sclera anicteric, oropharynx normal w/o
ulceration
NECK: Supple without LAD, no JVD
LN: no cervical, supraclavicular, or axillary LAD
PULM: CTAB, no w/r/r
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended, normal bowel sounds, no
hepatosplenomegaly
EXTREM: left arm with erythema extending from wrist to shoulder,
1+ pitting edema of arm, tender to touch, + induration at left
elbow but no fluctuance appreciated; no pain with active/passive
ROM of left wrist, elbow, shoulder; + linear abrasion over ___
left digit w/o surrounding erythema; <2 sec cap refill, intact
sensation; trace peripheral edema in b/l lower extremities
NEURO: CN II-XII grossly intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM
==========================
VS: Tc 98.6, 134/67 (118-134/60's), 66 (60-70's), 18, 94% RA
GEN: Alert, lying in bed, no acute distress
HEENT: PERRL, EOMI, sclera anicteric, oropharynx normal w/o
ulceration
PULM: CTAB, no w/r/r
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended, normal bowel sounds, no
hepatosplenomegaly
EXTREM: minimal erythema of left arm, trace pitting edema of
left arm, no pain with active/passive ROM of left wrist, elbow,
shoulder; + linear abrasion over ___ left digit w/o surrounding
erythema; <2 sec cap refill, intact sensation; trace peripheral
edema in b/l lower extremities. RUE without erythema or edema
NEURO: CN II-XII grossly intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
=================
___ 03:20AM BLOOD WBC-11.7*# RBC-3.71* Hgb-11.9 Hct-35.2
MCV-95 MCH-32.1* MCHC-33.8 RDW-13.1 RDWSD-45.2 Plt ___
___ 03:20AM BLOOD Glucose-134* UreaN-17 Creat-0.9 Na-132*
K-4.1 Cl-94* HCO3-27 AnGap-15
___ 03:25AM BLOOD Lactate-1.3
DISCHARGE LABS
=================
___ 07:50AM BLOOD WBC-4.3# RBC-3.82* Hgb-11.9 Hct-37.0
MCV-97 MCH-31.2 MCHC-32.2 RDW-13.2 RDWSD-47.5* Plt ___
___ 07:50AM BLOOD Glucose-104* UreaN-9 Creat-0.8 Na-141
K-4.0 Cl-105 HCO3-31 AnGap-9
___ 07:50AM BLOOD ALT-21 AST-31 AlkPhos-52 TotBili-0.3
___ 07:50AM BLOOD Calcium-9.3 Phos-2.8 Mg-2.0
MICRO
================
BCx pending
IMAGING
================
LUE US
No evidence of deep vein thrombosis in the left upper extremity.
RUE US
No evidence of deep vein thrombosis in the right upper
extremity.
Brief Hospital Course:
Ms. ___ is a ___ y/o female with a history of breast cancer
c/b chronic lymphedema of left arm who presented to the ED on
___ with left arm cellulitis.
# Left Arm Cellulitis: Patient reports minor trauma to left hand
while working with a ___ and subsequently developed
erythema and swelling of her left arm. She was started on vanc
and unasyn (day 1: ___ with clinical improvement. Ultrasound
was negative for DVT. Her arm was wrapped and elevated. She was
discharged with PO keflex and bactrim to complete a total 7 day
course (day ___.
# Confusion: Patient was reportedly confused in the ED which was
attributed to fever and acute infection. Her confusion quickly
resolved with treatment of her cellulitis.
TRANSITIONAL ISSUES
=========================
- discharged patient with PO Keflex and Bactrim to complete a
total 7 day course (day ___: ___.
- continue to wrap left arm and elevate
- f/u pending blood culture
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 12.5 mg PO DAILY:PRN swelling
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
2. Acetaminophen 1000 mg PO Q8H:PRN pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*60 Tablet Refills:*0
3. Hydrochlorothiazide 12.5 mg PO DAILY:PRN swelling
4. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 tablet(s) by mouth every 6 hours Disp
#*20 Tablet Refills:*0
5. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: cellulitis
Secondary diagnosis: lymphedema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you during your
hospitalization. You were admitted with a cellulitis of your
left arm. You were treated with antibiotics and your symptoms
improved. You will be discharged with antibiotics and will
follow up with your primary care doctor.
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
10886389-DS-21
| 10,886,389 | 26,681,122 |
DS
| 21 |
2167-11-24 00:00:00
|
2167-11-24 19:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Lisinopril
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with morbid obesity, asthma, HTN, T2DM, HLD, and other
medical issues presents today with worsening dyspnea.
.
Started with cough and cold symptoms in the beginning of the
month. Recent sick contact with her grandson who had a cold for
3 days. Was seen at ___ office and started on steroid taper x 5
days with increased inhaler use, completed about 1 week ago.
Symptoms improved over 5 days but recurred worse than before 1
day after stopping her steroid. She states that she has been
having green sputum. DOE with even 10 feet. + chest discomfort
with coughing but no other associated symptoms.
She does not recall being intubated with asthma exacerbation.
However, states this is the worst of the asthma attacks.
In the ED, initial VS: 96.5 71 150/73 18 96%. Exam was notable
for scattered wheezes. CXR did not show consolidation, but has
mild/mod enlargement of cardiac silohoutte. She received duoneb,
azithromycin (bronchitis), and 60 mg prednisone. Vitals upon
transfer: 98.6po 102 104/55 20 97% 3L nc. She is admitted b/c of
asthma flare in the setting of bronchitis, refractory to
outpatient therapy.
Currently, feeling slightly better with her breathing.
Past Medical History:
1. Morbid obesity.
2. Osteoarthritis.
3. Diabetes mellitus.
4. Hypertension.
5. Iron deficiency anemia. (not taking Fe currently)
6. Obstructive sleep apnea.
7. Depression.
8. Asthma
9. h/o subarachnoid hemorrhage ___, s/p coiling of vertebral
artery aneurysm.
Social History:
___
Family History:
- father passed away from PE
- sister has asthma, anemia, peptic ulcer
Physical Exam:
Physical Exam on admission:
VS - Temp 98.2 F, BP 167/91, HR 79, R 80, O2-sat 97% RA, BS 293
GENERAL - obese female, appropriate
HEENT - sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - scattered expiratory wheeze throughout, diminished
breath sounds at the bases, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c, 1+ pitting edema to the knees
bilaterally, 2+ DP peripheral pulses bilat
NEURO - awake, A&Ox3
Physical Exam on discharge:
VS - Temp 97.8 F, BP 144/87, HR 88, R 20, O2-sat 98% RA
GENERAL - obese female, resting comfortably
HEENT - sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - scattered expiratory wheezes throughout, diminished
breath sounds at the bases, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c, 1+ pitting edema to the knees
bilaterally, 2+ DP peripheral pulses bilaterally
NEURO - awake, A&Ox3
Pertinent Results:
Labs on admission:
___ 09:00PM BLOOD WBC-7.1 RBC-3.88* Hgb-8.9* Hct-29.1*
MCV-75* MCH-22.8* MCHC-30.4* RDW-17.0* Plt ___
___ 09:00PM BLOOD Glucose-176* UreaN-16 Creat-0.9 Na-140
K-4.4 Cl-101 HCO3-33* AnGap-10
___ 07:00AM BLOOD Calcium-9.7 Phos-2.5* Mg-1.5*
Labs on discharge:
___ 06:45AM BLOOD WBC-6.7 RBC-4.20 Hgb-9.3* Hct-31.1*
MCV-74* MCH-22.2* MCHC-29.9* RDW-17.2* Plt ___
___ 06:45AM BLOOD Glucose-111* UreaN-18 Creat-0.9 Na-138
K-4.4 Cl-100 HCO3-33* AnGap-9
___ 06:45AM BLOOD Calcium-9.7 Phos-3.5 Mg-2.0\
Imaging on admission:
CXR ___
FINDINGS: Frontal and lateral views of the chest are obtained.
No focal
consolidation, pleural effusion, or evidence of pneumothorax is
seen.
Relative opacity of the left base on the frontal view, not
substantiated on the lateral view, is most consistent with
overlying soft tissue. The cardiac silhouette is mildly to
moderately enlarged. No overt pulmonary edema is seen. The
mediastinal and hilar contours are stable.
IMPRESSION: No findings to suggest acute pneumonia.
Mild-to-moderate
enlargement of the cardiac silhouette.
Brief Hospital Course:
___ yo female with h/o asthma who presents with shortness of
breath and productive cough, consistent with asthma exacerbation
in the setting of bronchitis.
Active Isssues:
# Asthma exacerbation: Likely developed ___ viral bronchitis
that pt experienced earlier in the month. She was comfortable
from a respiratory standpoint on RA, saturating in the high 90's
during her hospitalization. We did not feel that her bronchitis
was bacterial in nature since she was afebrile without a
leukocytosis. Also, the extended time course did not support a
bacterial cause of infection. We therefore discontinued
antibiotics and treated her with high dose steroids and duonebs.
Pt had improvement in her breathing and has less dyspnea on
exertion at discharge. She will be treated with an 18-day taper
of prednisone to help to prevent a rebound phenomenon,
especially since she failed a 10-day course as outpt. She was
also discharged with duonebs and a prescription for a nebulizer
machine. Finally, she was given a prescription for
guafenesin/codeine for cough, which worked very well for pt in
house.
# DM type 2: Pt was on glargine 28 units qhs and metformin 2.5
g daily at home. We continued metformin as her creatinine was
stable and she did not undergo any studies while hospitalized.
Since her blood glucose levels increased greatly, as would be
expected after initiation of prednisone, we added a humalog
sliding scale. Pt was given this sliding scale to continue as
an outpt and was given detailed verbal and written instructions
to only use the humalog sliding scale only while she is on the
prednisone taper.
Inactive issues:
# HTN: Stable. Cont. amlodipine, diovan, metoprolol.
# HLD:
- continued rosouvastatin 10 mg daily
# Depression:
- continued fluoxetine
# Iron deficiency anemia: Hct was at about baseline- upper ___
to low ___.
Transitional Issues:
# Restrictive lung disease: When looking back at PFT's, it is
questionable whether pt actually has asthma. Her PFT's
certainly do not support the diagnosis. In fact, they are more
consistent with restrictive lung disease, likely due to her
obesity. However, pulmonary notes from ___ mention a diagnosis
of asthma. We thought that a further pulmonary work-up as an
outpt would be warranted, including repeat PFTs and an ECHO.
Given that she does not use her CPAP for OSA, it may be possible
that pulmonary hypertension is contributing to her dyspnea on
exertion. She should have outpt Pulmonary f/u resumed.
Medications on Admission:
- albuterol inhaler 2 puffs TID prn
- amlodipine 5 mg daily
- fluoxetine 40 mg daily
- flovent 220 mcg 2 puffs BID
- hydrocortisone lotion BID for itch
- glargin 28 u qHS
- metformin 1000 mg in AM, 500 mg at noon, and 1000 mg qHS
- metoprolol 100 mg BID
- omeprazole 20 mg daily
- crestor 10 mg daily
- diovan 320 mg daily
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. codeine-guaifenesin ___ mg/5 mL Syrup Sig: ___ MLs PO Q6H
(every 6 hours) as needed for cough for 7 days.
Disp:*qs ML(s)* Refills:*0*
4. metformin 500 mg Tablet Sig: One (1) Tablet PO NOON (At
Noon).
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation three times a day as needed for
shortness of breath or wheezing.
6. fluticasone 220 mcg/actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
7. hydrocortisone 1 % Lotion Sig: One (1) Topical twice a day.
8. insulin glargine 100 unit/mL Solution Sig: ___ (28)
units Subcutaneous at bedtime.
9. insulin sliding scale
Please take humalog as prescribed on chart
10. insulin lispro 100 unit/mL Solution Sig: as prescribed on
sliding scale chart Subcutaneous three times a day.
Disp:*4 * Refills:*2*
11. prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day for 18 days: please take five tablets a day from
___, four tablets a day from ___, three tablets a
day from ___, two tablets a day from ___, one tablet a
day from ___, one-half tablet a day from ___.
Disp:*47 Tablet(s)* Refills:*0*
12. fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
13. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
14. Crestor 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
15. valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day.
16. metformin 1,000 mg Tablet Sig: One (1) Tablet PO qam.
17. metformin 1,000 mg Tablet Sig: One (1) Tablet PO at bedtime.
18. nebulizers Kit Sig: One (1) Miscellaneous four times a
day for 14 days.
Disp:*1 * Refills:*2*
19. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) Inhalation four times a day as
needed for shortness of breath or wheezing for 14 days.
Disp:*qs * Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Asthma Exacerbation
Secondary:
Hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you during your hospitalization
at ___. You were admitted for
worsening shortness of breath and a productive cough. We
believe that you had a bad viral bronchitis early in the month
that has caused your lungs to be hypersensitive. We treated you
with high dose steroids and a cough suppressant that improved
your breathing and cough. You do not need antibiotics. You are
now stable for discharge home.
Because we started you on steroids this has caused an elevation
of your blood glucose levels. For the remainder of your 18-day
course of steroids we would like you to take additional
short-acting insulin called "humalog" or "lispro". We will
provide you with a sliding scale to dose the insulin. If your
blood glucose level is above 400, please call your PCP.
MEDICATIONS STARTED:
1. PREDNISONE 50 MG DAILY FOR 3 DAYS, 40 MG DAILY FOR THREE
DAYS, 30 MG DAILY FOR THREE DAYS, 20 MG DAILY FOR THREE DAYS, 10
MG DAILY FOR THREE DAYS AND 5 MG DAILY FOR THREE DAYS
2. Guaifenesin-CODEINE Phosphate ___ mL PO/NG Q6H as needed for
cough
3. Humalog insulin sliding scale (see separate sheet)
4. Albuterol-Ipratropium nebulizer treatment up to four times a
day as needed for shortness of breath or wheezing
Followup Instructions:
___
|
10886389-DS-22
| 10,886,389 | 23,742,477 |
DS
| 22 |
2168-06-10 00:00:00
|
2168-06-10 19:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Lisinopril
Attending: ___.
Chief Complaint:
shortness of breath, wheeze
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with morbid obesity, asthma, HTN, T2DM, HLD, sleep
apnea, and multiple other medical issues presents today with
worsening dyspnea x 2 weeks. She states she has had this cough
for about one month, but has gotten progressively worse
especially over the past two weeks with fits of coughing and
shortness of breath. Has been using her cousin's nebulizer for
the past several days with some transient improvement of
symptoms, but still waking up from sleep ___ times/night in
coughing fits. Last night her cough was not responding to the
neb treatments and she came to the ED. She denies having
fever/chills, but states she has had some occasional dizziness.
Nonproductive cough. No diarrhea or constipation, last normal BM
one hour prior to exam.
In the ED, initial vital signs were 96.8 106 170/99 18 93% ra.
Exam was s/f wheeze in all lung fields. Initial labs
demonstrated hct 31.6, wbc 5.7, plts 222 and creatinine 1.0. A
CXR revealed linear bibasilar opacities likely atelectasis. She
was given 1g ceftriaxone and 500mg Azithromycin for a pneumonia.
She was treated with albuterol and ipratropium nebs in addition
to 60mg prednisone. Vitals on transfer were: 98.1 °F (36.7 °C),
Pulse: 101, RR: 24, BP: 147/85, O2Sat: 97.
Past Medical History:
1. Morbid obesity.
2. Osteoarthritis.
3. Diabetes mellitus.
4. Hypertension.
5. Iron deficiency anemia. (not taking Fe currently)
6. Obstructive sleep apnea.
7. Depression.
8. Asthma
9. h/o subarachnoid hemorrhage ___, s/p coiling of vertebral
artery aneurysm.
Social History:
___
Family History:
- father passed away from PE
- sister has asthma, anemia, peptic ulcer
Physical Exam:
Admission Physical Exam:
Vitals- 98.3 BP 185/99 HR 103 RR20 94% RA
General- Alert, oriented, no acute distress, morbidly obese,
pleasant, cooperative
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, unable to appreciate JVP , no LAD
Lungs- bilateral wheezing heard throughout, no rales, rhonchi
appreciated
CV- tachycardic rate and regular rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, unable to appreciate
organomegaly, large panus
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal, moving all
extremities
Discharge Physical Exam:
Vitals- 97.9 BP 146/80 HR 80 RR20 93% RA
General- Alert, oriented, no acute distress, morbidly obese,
pleasant, cooperative
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, unable to appreciate JVP , no LAD
Lungs- decreased mild wheezing heard throughout bases-upper
lobes clear, no rales, rhonchi appreciated
CV- tachycardic rate and regular rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, unable to appreciate
organomegaly, large panus
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal, moving all
extremities
Pertinent Results:
___ 05:50AM BLOOD Plt ___
___ 05:50AM BLOOD ___ PTT-31.6 ___
___ 05:50AM BLOOD Glucose-200* UreaN-20 Creat-1.0 Na-138
K-4.5 Cl-100 HCO3-32 AnGap-11
Blood Culture, Routine (Pending): NGTD
EKG: Sinus rhythm. Normal tracing.
CXR: FRONTAL AND LATERAL CHEST RADIOGRAPHS: The heart is
slightly enlarged. The hilar and mediastinal contours are
within normal limits. Linear bibasilar opacities likely reflect
atelectasis in the ascending of low lung volumes. There is no
pneumothorax or pleural effusion. IMPRESSION: Linear bibasilar
opacities likely atelectasis.
Brief Hospital Course:
___ yo F with morbid obesity, asthma, HTN, T2DM, HLD, and other
medical issues presents today with worsening dyspnea and wheeze
consistent with acute asthma exacerbation.
# Dyspnea: She has longstanding asthma and reports symptoms
consistent with her asthma exacerbations. She notes that she
only has asthma attacks "when it rains" and reports that she was
recently in the rain. She does not note any other triggers. She
was treated with albuterol/ipratroprium nebs, prednisone (40mg
x5 days), and azithromycin (x5 days). She felt improved. She was
able to ambulate without desaturating and at her chronic level
of dyspnea. Her wheezing was much improved prior to discharge.
# OSA: The patient had OSA and she does not use her CPAP. She
states that this is secondary to the mask not fitting properly.
She was given an appointment to sleep clinic and will likely
need to be referred to mask fitting clinic.
Inactive issues:
# DM type 2: Most recent hba1c 8.2% on ___. She was discharged
on levemir, metformin, and insulin sliding scale.
# HTN: Stable. Continued on home meds of amlodipine, diovan,
metoprolol.
# HLD: Stable. Continued on rosouvastatin.
# Depression: Stable. Continued on fluoxetine.
# Iron deficiency anemia: Stable. Hct was at baseline. She will
need to follow up with primary care physician for further
management.
Transitional issues:
-blood cultures - no growth to date
-obstructive sleep apnea-follow up at sleep clinic, needs mask
fitting
-follow up with NP/PCP for asthma exacerbation
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Amlodipine 5 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO QPM
4. MetFORMIN (Glucophage) 1000 mg PO QAM
5. MetFORMIN (Glucophage) 1000 mg PO QHS
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Albuterol Inhaler 2 PUFF IH TID:PRN wheeze
8. Glargine 28 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. Fluoxetine 40 mg PO DAILY
10. Metoprolol Tartrate 100 mg PO BID
11. Rosuvastatin Calcium 10 mg PO DAILY
12. Valsartan 320 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH TID:PRN wheeze
2. Amlodipine 5 mg PO DAILY
3. Fluoxetine 40 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Levemir 28 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. MetFORMIN (Glucophage) 500 mg PO QPM
7. MetFORMIN (Glucophage) 1000 mg PO QAM
8. MetFORMIN (Glucophage) 1000 mg PO QHS
9. Metoprolol Tartrate 100 mg PO BID
10. Omeprazole 20 mg PO DAILY
11. Rosuvastatin Calcium 10 mg PO DAILY
12. Valsartan 320 mg PO DAILY
13. Azithromycin 250 mg PO Q24H
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
14. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma exacerbation
Upper respiratory 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 hospital with an asthma exacerbation
that was probably brought on by a bad cold or respiratory
infection. You were given nebulizer treatments to help with your
breathing, steroids to help with your asthma and breathing, and
antibiotics to help with the infection and inflammation. Your
breathing improved and we made sure you were able to ambulate
without dropping your oxygen levels.
Please make sure you go to your follow up appointments with
primary care and sleep medicine.
We made the following changes to your medication regimen:
Please START Prednisone 60mg by mouth daily for 3 more days
Please START azithromycin 250mg by mouth daily for 3 more days
Followup Instructions:
___
|
10886389-DS-26
| 10,886,389 | 29,412,923 |
DS
| 26 |
2173-11-29 00:00:00
|
2173-11-28 16:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Lisinopril / Cipro
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ PMH of Asthma, DM, Metastatic endometrial serous
adenocarcinoma (carboplatin/taxol), OSA, HTN, who presented with
CDiff infection and shortness of breath ___ asthma exacerbation
for which she was admitted
Of note patient was recently admitted for Asthma exacerbation
___
viral bronchitis, with hospital course c/b ___, hypercarbia
requiring CPAP/Bipap, Anemia, HSV infection. She then followed
up
in ___ clinic for her next cycle of chemotherapy which was
ultimately deferred while ruling out CDiff
On this admission patient presents reporting diarrhea 4 days
PTA,
occurring 2 times per day, watery stools, but no abdominal pain,
nausea, or vomiting. She noted that she had stable appetite and
PO intake and was urinating normally. Denied any fever or
chills.
Noted that she has had shortness of breath on and off at rehab
but denied cough. She noted that they have used Bipap on/off
there but she said she frequently falls asleep with it on, and
doesn't like it because it dries her mouth out. She noted that
she feels more comfortable after whatever medications were given
to her in the emergency department. Denied chest pain or
palpitations. Noted that he leg swelling is chronic but that her
abdomen has gotten bigger.
In the ED, initial vitals: 99.2 82 134/91 20 99% RA. CBC with
normal WBC, Hgb 8.7, plt 233, CHEM w/ K of 5.6 (4.9 on repeat),
Cr 1.5, VBG 7.27/59. CXR revealed interval increase in moderate
to large left pleural effusion. EKG without STEMI criteria and
was normal sinus. Patient was given oral vancomycin, methylpred,
and duonebs before admission
Past Medical History:
PAST ONCOLOGIC HISTORY:
As per last ___ clinic note:
"She initially presented with vaginal bleeding and an
endometrial
biopsy revealed high grade serous carcinoma.
On ___, PET CT showed increased uptake in the upper vagina,
extending to the uterus. There was an enlarged 1.3 cm FDG avid
right inguinal lymph node concerning for metstatic disease.
There
was also noted to be an FDG avid 1.1 right axillary lymph node.
MRI on ___ showed endometrial mass without definite
myometrial extension as well as prominent right inguinal lymph
node with FGD avidity on previous imaging concerning for disease
involvement. There was no clear cervical stromal or parametrial
involvemet. She underwent axillary node lymph node biopsy by
interventional radiology on ___, which was nondiagnostic.
Chest CT on ___ did not show any suspicious nodules.
On ___ she underwent a robotic assisted total laparoscopic
hysterectomy, bilateral salpingo-oophorectomy, lysis of
adhesions, omental biopsy and cystoscopy. On exam she was found
to have a 10 cm uterus with tumor protruding from the
ectocervix.
There was no parametrial involvement and the uterus was mobile.
On laparoscopic evaluation, there was 4-5 cm hernia with ventral
wall hernia with incarcerated omentum. There were omental
implant, the largest measuring 1-2 cm. There was studding on the
anterior wall peritoneum that extended up to her diaphragm. In
the pelvic there were serosal implants involving the anterior
and
posterior pelvic peritoneum. There were bilateral ovarian
implants.
Final pathology revealed metastatic endometrial serous
adenocarcinoma. There was metastasis that involved the uterus,
cervix, bilateral ovaries, left fallopian tube, uterine serosa,
and omentum. The tumor in greatest dimension was 6 cm and
invades
40% of the the myometrium. No lymph nodes were submitted and
lymphovascular invasion was present.
- ___ C1 Carboplatin 5 AUC
- ___ C2 Carboplatin 5 AUC
- ___ C3 held due to thrombocytopenia
- ___ C3 Carboplatin dose-reduced to 4.5 AUC
- ___ CT shows disease progression
- ___ C1W1 Taxol 60mg/m2- 3 weeks on , 1 week off
- ___ C2W21 held due to URI sxs"
PAST MEDICAL HISTORY:
___ ___ aneurysm s/p coiling
ASTHMA
DM2
HL
HTN
OSA
Anemia
Pyelonephritis with e coli sepsis (admit ___
Colon polyps
Gastritis
DJD of b/l knees
metastatic endometrial carcinoma as above
Social History:
___
Family History:
Family History: sister with breast cancer, no family history of
ovarian, colon, or endometrial cancer
Physical Exam:
GENERAL: laying in bed, comfortable, speaking
EYES: Left pupil is slightly assymetrical (which she notes is
chronic), pupils equally reactive
HEENT: OP clear, MMM
NECK: supple, thick
LUNGS: CTA anteriorly only as unable to sit forward, is able to
speak in moderate sentences, is not using accessory muscles and
does not have prolonged expiratory phase
CV: has systolic murmur at left sternal border, has 2+ edema to
knees b/l, normal distal perfusion
ABD: soft, NT, large abdomen/pannus, hard to tell if she has
ascites or not
GENITOURINARY: no foley
EXT: warm, dry, thick legs
SKIN: warm, dry, no rash
NEURO: AOx3, fluent speech, occasionally falls asleep during
interview but awakens easily to voice
ACCESS: POrt with dressing c/d/i
Pertinent Results:
Admission labs
==============
___ 07:24PM BLOOD WBC-7.7 RBC-3.12* Hgb-8.7* Hct-29.0*
MCV-93 MCH-27.9 MCHC-30.0* RDW-19.9* RDWSD-67.7* Plt ___
___ 07:24PM BLOOD Neuts-82.7* Lymphs-6.1* Monos-6.8 Eos-3.9
Baso-0.1 Im ___ AbsNeut-6.35* AbsLymp-0.47* AbsMono-0.52
AbsEos-0.30 AbsBaso-0.01
___ 04:51AM BLOOD ___ PTT-26.1 ___
___ 07:24PM BLOOD Glucose-84 UreaN-54* Creat-1.5* Na-141
K-5.6* Cl-104 HCO3-25 AnGap-12
___ 07:24PM BLOOD Calcium-9.7 Phos-3.1 Mg-2.4
___ 10:06PM BLOOD ___ pO2-38* pCO2-59* pH-7.27*
calTCO2-28 Base XS-0
___ 08:34PM BLOOD K-4.9
.
.
Notable labs during hospitalization
=============
___ 11:45PM BLOOD CK-MB-1 cTropnT-0.01 proBNP-495*
___ 11:45PM BLOOD CK(CPK)-27*
.
.
Micro
======
___ Stool Cx: NEGATIVE for Salmonella, Shiggella, and
Campylobacter (final).
___ Stool C. diff: POSITIVE
.
.
Imaging:
=========
___ CXR: "FINDINGS: Right-sided Port-A-Cath terminates in
the low SVC/cavoatrial junction, without evidence of
pneumothorax. Moderate to large left pleural effusion has
increased in size.. No right pleural effusion is seen. Cardiac
size is stable compared the prior study. Mediastinal contours
are stable.
IMPRESSION: Interval increase in moderate to large left
pleural effusion."
.
.
Discharge labs:
===============
Brief Hospital Course:
# C. diff colitis
First time she has had C. diff colitis. Started on PO vancomycin
___ - ) with improvement in diarrhea and resolution of
leukocytosis. Plan for ___sthma with acute exacerbation
# Acute hypoxic respiratory failure (mild)
Treated with prednsione and nebs. Prednisone stopped after 5days
on ___.
# Left pleural effusion
Read as moderate to large by radiology on admission imaging. IP
consulted for possible Dx/Tx thoracentesis in setting of
patient's increased SOB and hypoxia. They evaluated with u/s at
bedside, found the effusion to be small with associated
atelectasis (perhaps making it appear larger on imaging) and
advised against thoracentesis at that time. Patient was started
on incentive spirometry.
# Hyperkalemia
# ___ (mild) on CKD
Stopped home losartan. Resumed home lasix on ___ with
improvement in BUN/Cr and stable mild hyperkalemia. Continue
low-potassium diet.
# Metastatic endometrial carcinoma
Dr. ___ patient while she was in hospital, and plan is for
patient to return to ___ clinic next week to see Dr. ___ to be
evaluated for potentially resuming palliative chemotherapy at
that time.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. FLUoxetine 40 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN Shortness of
Breath / Wheezing
6. Benzonatate 100 mg PO TID:PRN cough
7. Furosemide 20 mg PO DAILY
8. Cetirizine 10 mg PO DAILY
9. Docusate Sodium 100 mg PO BID:PRN Constipation
10. Ferrous Sulfate 325 mg PO DAILY
11. Guaifenesin-CODEINE Phosphate 10 mL PO Q6H:PRN Cough
12. Hydrochlorothiazide 25 mg PO DAILY
13. Metoprolol Tartrate 100 mg PO BID
14. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
15. Prochlorperazine 10 mg PO Q8H:PRN Nausea
16. Senna 8.6 mg PO QHS:PRN Constipation
17. Ipratropium-Albuterol Neb 1 NEB NEB BID
18. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
19. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
20. ___ Original (aspirin-sod bicarb-citric acid)
325-1,916-1,000 mg oral DAILY:PRN
21. Losartan Potassium 100 mg PO DAILY
22. MetFORMIN (Glucophage) 1000 mg PO BID
23. Ondansetron 8 mg PO Q12H:PRN Nausea
24. GuaiFENesin 10 mL PO Q6H:PRN cough
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Docusate Sodium 100 mg PO BID:PRN Constipation
3. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day
Disp #*40 Capsule Refills:*0
4. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN Shortness of
Breath / Wheezing
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
6. ___ Original (aspirin-sod bicarb-citric acid)
325-1,916-1,000 mg oral DAILY:PRN
7. amLODIPine 10 mg PO DAILY
8. Atorvastatin 20 mg PO QPM
9. Benzonatate 100 mg PO TID:PRN cough
10. Cetirizine 10 mg PO DAILY
11. Ferrous Sulfate 325 mg PO DAILY
12. FLUoxetine 40 mg PO DAILY
13. Fluticasone Propionate 110mcg 2 PUFF IH BID
14. Furosemide 20 mg PO DAILY
15. Guaifenesin-CODEINE Phosphate 10 mL PO Q6H:PRN Cough
16. GuaiFENesin 10 mL PO Q6H:PRN cough
17. Hydrochlorothiazide 25 mg PO DAILY
18. Ipratropium-Albuterol Neb 1 NEB NEB BID
19. Losartan Potassium 100 mg PO DAILY
20. MetFORMIN (Glucophage) 1000 mg PO BID
21. Metoprolol Tartrate 100 mg PO BID
22. Ondansetron 8 mg PO Q12H:PRN Nausea
23. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
24. Prochlorperazine 10 mg PO Q8H:PRN Nausea
25. Senna 8.6 mg PO QHS:PRN Constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# C. diff colitis
# Asthma with acute exacerbation
# Acute hypoxic respiratory failure (mild)
# Left pleural effusion
# Hyperkalemia
# ___ (mild) on CKD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms ___,
You were admitted to the hospital with diarrhea from an
infection of the colon called C. diff, as well as worsened
shortness of breath due to an asthma exacerbation. You were
treated for the C. diff infection with an oral antibiotic
(vancomycin) and you will need to continue this to complete a
total of 14 days. For the asthma exacerbation you were treated
with prednisone and nebulizers, and your breathing gradually
improved.
We think it is very important that you use the CPAP machine at
night because it treats your obstructive sleep apnea and enables
you to get effective, healthy sleep. Please do your best to use
this machine throughout the night, every night.
Regarding treatment for your cancer, Dr. ___ see you in
clinic next week to evaluate for resuming chemotherapy.
It was a pleasure caring for you while you were in the hospital,
and we wish you a full and speedy recovery.
Sincerely,
The ___ Medicine Team
Followup Instructions:
___
|
10886445-DS-20
| 10,886,445 | 27,855,549 |
DS
| 20 |
2127-12-21 00:00:00
|
2127-12-21 20:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Motrin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ultrasound-guided transvaginal drainage of pelvic abscess
History of Present Illness:
___ s/p TLH, bilat salpingectomy ___ for menorrhagia,
adenomyosis presenting with abdominal pain starting ___, one
day
prior to presentation. Post-op course complicated by suspected
vaginal cuff cellulitis treated with course of cipro/flagyl
started ___. Pt's worsening pain was evaluated by PCP today and
pt was sent to emergency room for evaluation and CT scan. CT
shows pelvic fluid collection. Had been scheduled for outpt CT
___ to evaluate for etiology of sxs.
Pt reports nausea accompanying her pain, but no vomiting. Also
reports decreased appetite and discomfort in her abdomen with
eating and drinking. Pain exacerbated by urination and bowel
movements. Diarrhea x 10 days since starting abx. Denies
fevers/chills at home, but reports a fever in PCP's office today
and then here in the ED (100.9 documented in ED). Has been
taking
motrin, tylenol with codeine and more recently oxycodone for
pain.
Patient has received morphine 5mg IV x 1 and IV Zofran in ED.
CT abd/pelvis showing rim enhancing organizing fluid collection
in pelvis. Study equivocal for appendicitis. Also ? enhancing
diverticulum associated woth fluid collection (per verbal
report). Pt seen by general surgery who feel there is no
clinical
evidence for appendicitis at this time (case discussed directly
with gen surg).
Pt denies personal hx of diverticulitis or other GI issues.
Past Medical History:
POb/Gyn:
- G2P2, SVD x 2
- denies hx of STIs, +abnl Pap w/ nl follow up
PMH: HTN, GERD and as above
PSH:
- endometrial ablation
- ___ TLH, bilat salpingectomy as above -> adenomyosis
- knee surgery x 2
Social History:
___
Family History:
denies hx of gyn, breast and GI cancers
Physical Exam:
Admission Exam:
O: Tm 100.9 Tc 99.8 HR 108-114 BP 120s/70s-80s RR ___
97-100%RA
NAD
RRR
Abd obese, ND, diffusely TTP, +rebound, no guarding
Pelvic: thin pale yellow vaginal discharge without odor, no
blood, vaginal cuff intact, no tenderness with palpation of
vaginal cuff on exam, diffusely tender lower abdomen on bimanual
Ext without edema, NT
Exam on Discharge:
Afebrile
General: Patient appears comfortable an in no acute distress.
Lungs: CTA bilaterally
Cardiac: RRR w/ no murmurs of extra sounds
Abdomen: Soft and non-distended. Mildly TTP R>L. No rebound or
guarding
Ext: No edema, pain, or signs of DVT
Pertinent Results:
ON ADMISSION
LAB VALUES
- ___ WBC-12.6*# RBC-3.97* Hgb-12.6 Hct-36.0 MCV-91
MCH-31.7# MCHC-34.9 RDW-12.0 Plt ___
- ___ Neuts-80.7* Lymphs-12.5* Monos-5.4 Eos-1.0 Baso-0.4
- ___ Plt ___
- ___ Glucose-95 UreaN-6 Creat-0.7 Na-134 K-3.1* Cl-95*
HCO3-25 AnGap-___ Lactate-1.0
URINE
- ___ Color-Straw Appear-Clear Sp ___
- ___ Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 ___
HOSPITAL COURSE
LAB VALUES
- ___ WBC-10.2 RBC-3.47* Hgb-10.7* Hct-32.4* MCV-94
MCH-30.9 MCHC-33.0 RDW-12.3 Plt ___
- ___ WBC-7.1 RBC-3.25* Hgb-10.3* Hct-30.7* MCV-95 MCH-31.7
MCHC-33.5 RDW-12.2 Plt ___
- ___ WBC-5.3 RBC-3.45* Hgb-11.1* Hct-32.1* MCV-93 MCH-32.0
MCHC-34.4 RDW-12.0 Plt ___
MICROBIOLOGY
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
LACTOBACILLUS SPECIES. SPARSE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
- ___ 6:15 pm BLOOD CULTURE #2 SOURCE: VENIPUNCTURE.
Blood Culture, Routine (Pending):
RADIOLOGY
- CT ABD & PELVIS WITH CONTRAST Study Date of ___ 6:54 ___
IMPRESSION:
1. Rim-enhancing fluid collection in the pelvis with adjacent
inflamed loops of small bowel. These findings are concerning
for an infected fluid
collection.
2. Small amount of free air adjacent to the liver without a
clear
identifiable source. Query integrity of the recent hysterectomy
surgical
closure.
3. Appendix with equivocal findings for acute appendicitis.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
On ___ Ms. ___ presented to the emergency department
with a fever of 100.9, pelvic pain, and a fluid collection
concerning for possible pelvic abscess. She was admitted to
gynecology on ___ and was started on IV
Ampicillin/Gentamicin/Clindamycin and IV dilaudid was started as
needed for pain control.
On hospital day 1 (___), she underwent U/S guided drainage
of pelvic fluid collection, which was noted to be small (~5cc)
and multiloculated. A culture was sent, which ultimately grew
out sparse growth of lactobacillus species. Her pain markedly
improved after the drainage procedure, and she was continued on
IV antibiotics until hospital day 3, at which point she had been
afebrile x 48 hours and her white blood count had decreased from
12.6 to a normal level. She was thus transitioned to oral
Augmentin/Flagyl. Her pain was controlled with oral percocet.
With respect to her hypertension, she was continued on her home
medications HCTZ and Lisinopril and her blood pressure was well
controlled.
She was observed on oral antibiotics until hospital day #4, at
which point she was tolerating a regular diet, pain was
controlled on oral medications, and she remained afebrile. She
was discharged for plan to complete a 14 day course of
antibiotics, and outpatient follow-up was arranged.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*22 Tablet Refills:*0
4. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*33 Tablet Refills:*0
5. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
Do not take more than 4000mg acetaminophen in 24 hours
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every four (4) hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pelvic abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to the gynecology service with abdominal pain
and were found to have an abscess. You were started on IV
antibiotics and the abdominal pain improved and you underwent
ultrasound-guided drainage of abscess. You were observed for 48
hours on IV antibiotics and then transitioned to oral
antibiotics. Given your continued improvement on oral
antibiotics we felt it was safe to discharge you home.
Please follow these general instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* No strenuous activity until your post-op appointment
* Nothing in the vagina (no tampons, no douching, no sex) until
follow-up appointment
* No heavy lifting of objects >10lbs for 6 weeks.
* You may eat a regular diet
Call your doctor for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
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2139-03-03 16:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
IV contrast
Attending: ___.
Chief Complaint:
Abdominal pain, nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with unclear history of
Crohns disease and previous partial SBOs managed conservatively.
He presents today with 3 days of abdominal pain, nausea, and
low-grade fevers to 100.4F. Yesterday evening he had a syncopal
episode, which he says happens whenever he has an obstruction.
He presented to ___ following his syncopal episode. A CT A/P
was performed, which showed dilated small bowel and stomach with
a decompressed colon and mild ascites. There is no evidence of
perforation or pneumatosis. He had on ___ surgery was
consulted for management of partial SBO.
Upon initial assessment by ___ surgery, Mr. ___ denies
chest pain, shortness of breath, diarrhea, hematochezia, or
dysuria. He endorses continued passage of flatus, nausea, and
hiccups.
Past Medical History:
Past Medical History:
-TMJ
-gastritis
-recurrent severe abd pain a/w syncopal episode
-? Crohns disease, terminal ileitis, ulceration and granulation
tissue on colonoscopy & pathology, no evidence of disease on
MRE.
-IPMN
-pSBO managed conservatively
Past Surgical History:
-lap ccy (___), pathology benign (cholelithiasis),
-bilateral knee surgery
-right inguinal hernia repair
Social History:
Marital status: Married
Children: Yes
Lives with: ___
Sexual activity: Present
Sexual orientation: Female
Contraception: None
Tobacco use: Never smoker
Alcohol use: Denies
drinks per week: <1
Recreational drugs Denies
(marijuana, heroin,
crack pills or
other):
Depression: Based on a PHQ-2 evaluation, the patient
does not report symptoms of depression
Exercise: Activities: walking
Diet: regular
Seat belt/vehicle Always
restraint use:
Family History:
Child with severe Crohns disease
Physical Exam:
T 97.8 P 81 BP 146/84 RR 18 02 96%RA
General: no acute distress, alert and oriented x 3
Cardiac: regular rate and rhythm, no murmurs appreciated
Resp: clear to auscultation, bilaterally
Abdomen: soft, non-tender, non-distended, no rebound tenderness
or gaurdign
Ext: no lower extremity edema or tenderness, bilaterally
Pertinent Results:
LABS:
___ 03:00AM BLOOD WBC-13.6*# RBC-4.96 Hgb-15.5 Hct-43.1
MCV-87 MCH-31.3 MCHC-36.0 RDW-12.5 RDWSD-39.3 Plt ___
___ 06:33AM BLOOD WBC-5.3 RBC-4.10* Hgb-12.3* Hct-35.9*
MCV-88 MCH-30.0 MCHC-34.3 RDW-12.0 RDWSD-38.7 Plt ___
___ 03:25AM BLOOD ALT-15 AST-19 AlkPhos-55 TotBili-0.7
___ 03:25AM BLOOD Lipase-13
___ 03:00AM BLOOD cTropnT-<0.01
___ 03:00AM BLOOD proBNP-33
___ 03:25AM BLOOD CRP-43.5*
___ 03:29AM BLOOD Lactate-1.9
IMAGING:
CT ABD & PELVIS W/O CONTRAST
Small-bowel obstruction with transition point in the right lower
quadrant and associated small amount of ascites and mesenteric
edema. No free air.
CHEST (PORTABLE AP)
Enteric tube terminates overlying the expected location of
stomach.
MR ENTEROGRAPHY (___) SBFT:
1. Resolving partial small bowel obstruction. Edematous loops of
small bowel just proximal to the transition in the right lower
quadrant which likely relates to obstruction. No convincing MR
evidence of inflammatory bowel disease.
2. Persistent but decreased interloop fluid and mesenteric
edema.
3. Distended stomach without mechanical obstruction notably
stomach was also distended on prior CT, when small-bowel
obstruction resolved, consider gastric emptying study to
evaluate for underlying gastroparesis.
4. Small bilateral pleural effusions.
Brief Hospital Course:
The patient presented to the Emergency Department on ___.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with either intravenous
morphine or hydromorphone. The patient's pain resolved entirely
prior to discharge.
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 ambulation were encouraged throughout
hospitalization.
GI/GU/FEN: The patient was initially placed on bowel rest with a
___ tube in place for decompression. On HD 3, given
evidence of resolving obstruction, the NGT was removed. On HD
4, he underwent MR ___ to evaluate for evidence of
crohn's disease. The MR was suggestive of resolving partial
bowel obstruction without definitive evidence of active
inflammation, but did not possible delayed gastric emptying.
Additionally, per the radiology fellow, there was no evidence of
stricture suggesting chronic inflammation. Following the MR,
the patient's diet was resumed and advanced to low residue per
gastroenterology, which he tolerated without pain, nausea or
vomiting. Given po tolerance, he was discharged to home and
will follow-up with his gastroenterologist and surgeon as an
output for further work-up of possible crohn's disease.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. mometasone 0.1 % topical ASDIR
2. Ranitidine 150 mg PO QHS
3. Cyanocobalamin 1000 mcg IM/SC ONCE
Discharge Medications:
1. Cyanocobalamin 1000 mcg IM/SC ONCE
2. mometasone 0.1 % topical ASDIR
3. Ranitidine 150 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Partial small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized for a partial obstruction of your small
bowel and have undergone testing to determine the cause of your
obstruction. Thus far, testing has been inconclusive.
You obstruction has since resolved and you are now tolerating a
low residue diet. You are now preparing for discharge to home,
but will need to follow-up with your gastroenterologist for
ongoing evaluation.
Please note the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
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|
2202-07-31 22:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Abdominal pain, nausea and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old female who was in a general state of good
health at work until she experienced the acute onset of severe
___ epigastric pain with radiation to the back associated with
yellow non-bilious emesis. She then couldn't stop vomiting with
emesis x 10. She had diarrhea x 2. She has no history of
cholelithiasis. She does not drink alcohol heavily. Her last
drink was 5 days ago on ___ when she had two glasses of wine.
She cannot tell me what made the pain better or worse. Upon
leaving the ER she was able to tolerate a sip of water. No
respirophasic variation to her pain. The patient asked the ED
physician if this might be compatible with her being poisoned
but when I questioned her she denied that anyone would be trying
to poison her or threaten her life. She denies overt sick
contacts.
.
She also reports that she feels as though she has a vibration
going through her whole body.
.
[x]CMP/Lipase 180-->acute pancreatitis
In ER: (Triage Vitals: 97.8, 125/77, 18, 100% on RA)
Meds Given:zofran, dilaudid IV 0.5 mg IV x 2
Fluids given: 1L NS
Radiology Studies: RUQ US
consults called: none
.
PAIN SCALE: ___
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[ ] Fever [ +] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[+ ] _30____ lbs. gain over _1.5____ months secondary to
depo provera for menorhaggia
Eyes [X] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT [X]WNL
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat
[] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [] All Normal
[ +] Shortness of breath <- thought to be secondary to asthma
and anxiety-> [+] Dyspnea on exertion - worsening - she
thinks that this is secondary to her recent weight gain - there
is no chest pain [ ] Can't walk 2 flights [- ] Cough [ ]
Wheeze [ ] Purulent sputum [ ] Hemoptysis [ ]Pleuritic
pain
[ ] Other:
CARDIAC: [] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ +]
Chest Pain- usually precipitated by stress [ ] Dyspnea on
exertion [ ] Other:
GI: [] All Normal
[ +] Nausea [+] Vomiting [] Abd pain [] Abdominal swelling
[+ ] Diarrhea [ ] Constipation [ ] Hematemesis
[- ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [X] All Normal
[ ] Dysuria [ ] Incontinence or retention [ ] Frequency
[ ] Hematuria []Discharge []Menorrhagia
SKIN: [X] All Normal
[ ] Rash [ ] Pruritus
MS: [X] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [] All Normal
[+ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ +]Numbness of extremities intermittent of the
fingers even in the warmth
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [X] All Normal
[ ] Skin changes [ ] Hair changes [ ] Heat or cold
intolerance [ ] loss of energy
HEME/LYMPH: [] All Normal
[+ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [] All Normal
[+ ] Mood change [-]Suicidal Ideation [ -] Other:
Homicidal idation
ALLERGY:
[+]Medication allergies - rocephin - > rash? but she is not sure
[ ] Seasonal allergies
[X]all other systems negative except as noted above
Past Medical History:
? MENORRHAGIA
ABNORMAL PAP SMEAR
DEPRESSION
DOMESTIC ABUSE
DYSMENORRHEA
GYNECOLOGIC
HEADACHE
HYPOTHYROIDISM
INSOMNIA
OVERWEIGHT
PELVIC PAIN
TOBACCO ABUSE
ATYPICAL CHEST PAIN
CONTRACEPTION
Social History:
___
Family History:
Mother is dead. She had DM and had CABG x 3 and died
perioperatively during the bypass. She had toe amputations
Physical Exam:
DISCHARGE PHYSICAL EXAM:
VS: 98.8 104/51 52 18 99%RA
Pain: ___ with palpation (pain is minimal without abdominal
palpation)
GEN: Alert, NAD
HEENT: NC/AT
CV: RRR, no m/r/g
PULM: CTA B
GI: S/ND, BS present, TTP in the epigastrum and RUQ, no r/g
Pertinent Results:
Admission Labs:
___ 08:55PM BLOOD WBC-8.2 RBC-4.11* Hgb-13.6 Hct-42.7
MCV-104* MCH-33.1* MCHC-31.9 RDW-12.6 Plt ___
___ 08:55PM BLOOD Neuts-81.5* Lymphs-11.5* Monos-3.6
Eos-3.0 Baso-0.5
___ 08:55PM BLOOD Glucose-106* UreaN-11 Creat-0.7 Na-139
K-3.8 Cl-102 HCO3-25 AnGap-16
___ 08:55PM BLOOD ALT-15 AST-17 CK(CPK)-97 AlkPhos-57
TotBili-0.5
___ 08:55PM BLOOD Lipase-180*
___ 08:55PM BLOOD CK-MB-1 cTropnT-<0.01
___ 08:55PM BLOOD Albumin-4.5 Calcium-10.0 Phos-3.6 Mg-2.0
___ 08:55PM BLOOD Triglyc-43
___ 08:55PM BLOOD Lipase-180*
___ 06:50AM BLOOD Lipase-45
Discharge Labs:
___ 06:20AM BLOOD WBC-3.6* RBC-3.39* Hgb-11.3* Hct-34.5*
MCV-102* MCH-33.2* MCHC-32.6 RDW-12.8 Plt ___
___ 06:20AM BLOOD Glucose-86 UreaN-3* Creat-0.7 Na-143
K-3.6 Cl-113* HCO3-25 AnGap-9
UA:
___ 09:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:30PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:30PM URINE RBC-5* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-1
___ 09:30PM URINE UCG-NEGATIVE
URINE CULTURE (Final ___: NO GROWTH.
Stool Studies:
C. difficile DNA amplification assay (Final ___: Negative
for toxigenic C. difficile by the Illumigene DNA amplification
assay.
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
NOROVIRUS PCR PENDING
ECG ___ - Sinus rhythm. Compared to the previous tracing of
___ T wave changes are
noted in leads V2-V3 - these could be non-specific. Clinical
correlation is
suggested to exclude myocardial ischemia.
CXR ___ - IMPRESSION:
Normal chest radiograph. No subdiaphragmatic free air.
RUQ U/S ___ - IMPRESSION:
1. Normal gallbladder without gallstones.
2. Mildly dilated pancreatic duct. Head of the pancreas not
well seen. Further assessment of the pancreatic duct and
parenchyma can be obtained with MRCP.
MRCP ___ - IMPRESSION: No pancreatic abnormality, especially no
evidence for pancreatitis or pancreatic ductal dilation. No
acute abdominal pathology identified to explain the patient's
pain.
Brief Hospital Course:
Pt presented with N/V/D and abdominal pain. There was initial
concern for pancreatitis given elevated lipase and ? dilation of
PD on U/S. However, lipase normalized by day 2 and MRCP was
unremarkable. Likely, this was ___ gastroenteritis. Stool
studies sent, pending at the time of discharge. Tolerating PO
with pain controlled at the time of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 150 mcg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 150 mcg PO DAILY
2. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours AS
NEEDED Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Presumed Gastroenteritis
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 sudden-onset nausea,
vomiting, diarrhea, and abdominal pain. There was initially some
evidence of pancreas inflammation on your lab work, but this
improved by the next day. Otherwise your lab work and the MRI of
your abdomen were normal. Probably, these symptoms represent a
gastroenteritis, most likely from a viral infection. We did send
some stool studies, which were still pending at the time of
discharge.
It is very important that you follow up at ___ as listed below.
Followup Instructions:
___
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2202-09-29 15:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
___
Attending: ___
Chief Complaint:
Headache, transient aphasia and right-sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ is a ___ RH AAF with h/o obesity, migraines,
hypothyroidism, depression and tobacco use who is transferred
from ___ after a transient episode of right face/arm
weakness, slurred speech and headache concerning for TIA.
She was in her usual state of health earlier today. At 6:15pm,
while sitting at the dinner table celebrating a family birthday,
her sister noticed that right side of her mouth looked "twisted"
and droopy and drool was coming out of right corner of mouth.
When pt attempted to speak, her words sounded mumbled and
garbled
and could not be understood by family. She could understand what
others were saying to her. Her sister called ___. A couple of
minutes after the facial weakness began, pt developed a
throbbing
___ right-sided retroorbital headache associated with
photophobia, nausea, blurred vision and flashing lights in her
right visual field. When EMS arrived, they noticed right lower
facial weakness as well as right arm weakness. FSBS was 78,
received IV glucose en route to hospital. On arrival to ___, vitals were BP 120/84 and P 83 (BP 97/66 sitting). Speech
and
right-sided weakness had completed resolved on arrival. NIHSS
was
0 with no neurologic deficits noted. Head CT unremarkable. Pt
was
given IV fluids and reglan and transferred to ___ for possible
MRI. At present (10pm), pt complains of ongoing right-sided
retroorbital headache, otherwise asymptomatic.
Of note, pt has a history of migraine headaches, though no h/o
complex migraines in the past. Also strong FHx of migraines
(both
her children have them, as does her sister).
Neuro ROS: +mild lightheadedness. +chronic neck and back pain.
Denies loss of vision, diplopia, dysphagia, vertigo, tinnitus or
hearing difficulty. Denies focal numbness, parasthesiae. No
bowel
or bladder incontinence or retention. Denies difficulty with
gait
(though has not tried walking yet).
General ROS: denies recent fever or chills. No night sweats or
recent weight loss or gain. Denies cough, shortness of breath.
Denies chest pain or tightness, palpitations. Denies vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias. Denies rash.
Past Medical History:
? MENORRHAGIA
ABNORMAL PAP SMEAR
DEPRESSION
DOMESTIC ABUSE
DYSMENORRHEA
GYNECOLOGIC
HEADACHE
HYPOTHYROIDISM
INSOMNIA
OVERWEIGHT
PELVIC PAIN
TOBACCO ABUSE
ATYPICAL CHEST PAIN
CONTRACEPTION
Social History:
___
Family History:
Mother is dead. She had DM and had CABG x 3 and died
perioperatively during the bypass. She had toe amputations
Physical Exam:
ADMISSION:
GENERAL EXAM:
- Vitals: 98.4 100 95/41 (as low as 82/60 in ED) 18 100%
- General: overweight woman in NAD, lying in darkened room
- HEENT: NC/AT, MMM
- Neck: Supple, no carotid bruits appreciated.
- Pulmonary: CTABL
- Cardiac: RRR, no murmurs
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
NEURO EXAM:
- Mental Status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects. Able to read
without difficulty. Speech was not dysarthric. Able to follow
both midline and appendicular commands. No evidence of apraxia
or
neglect.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 3mm and brisk. VFF to finger counting.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI with ___ beats of endgaze nystagmus
bilaterally
(R>L). 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: markedly decreased vibration sense in RUE, moderately
decreased vibration sense in RLE. Otherwise intact sensation to
pinprick, cold and proprioception. No extinction to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 1
R 2 2 2 3 1
Plantar response was FLEXOR bilaterally.
- Coordination: No intention tremor, no dysdiadochokinesia
noted.
No dysmetria on FNF or HKS bilaterally.
- Gait: Good initiation. Pronates right foot when walking, and
notes that she feels "like I am dragging that leg". Able to walk
in tandem. Romberg absent.
DISCHARGE:
GENERAL EXAM:
- General: NAD
- HEENT: NC/AT, MMM
- Neck: Supple, no carotid bruits appreciated
- Pulmonary: CTABL
- Cardiac: RRR, no murmurs
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted
NEURO EXAM:
- Mental Status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive. Language is fluent with
intact
comprehension. Normal prosody. There were no paraphasic errors.
Speech was not dysarthric. Able to follow both midline and
appendicular commands. No evidence of apraxia or neglect.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 3mm and brisk.
III, IV, VI: EOMI with ___ beats of endgaze nystagmus
bilaterally
(R>L). 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: Intact to light touch.
- DTRs: ___ response was FLEXOR bilaterally.
- Coordination: No intention tremor, no dysdiadochokinesia
noted.
No dysmetria on FNF or HKS bilaterally.
- Gait: Good initiation. Able to walk in tandem. Romberg absent.
Pertinent Results:
___ 06:10AM GLUCOSE-87 UREA N-10 CREAT-0.7 SODIUM-140
POTASSIUM-4.1 CHLORIDE-114* TOTAL CO2-19* ANION GAP-11
___ 06:10AM ALT(SGPT)-14 AST(SGOT)-17 CK(CPK)-103 ALK
PHOS-44 TOT BILI-0.4
___ 06:10AM CK-MB-1 cTropnT-<0.01
___ 06:10AM CALCIUM-7.9* PHOSPHATE-2.8 MAGNESIUM-1.8
CHOLEST-122
___ 06:10AM %HbA1c-5.4 eAG-108
___ 06:10AM TRIGLYCER-59 HDL CHOL-42 CHOL/HDL-2.9
LDL(CALC)-68
___ 06:10AM WBC-6.9 RBC-3.40* HGB-11.1* HCT-35.2*
MCV-104* MCH-32.6* MCHC-31.5 RDW-12.8
___ 06:10AM PLT COUNT-190
___ 06:10AM ___ PTT-31.0 ___
___ 02:30AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 01:30AM GLUCOSE-104* UREA N-14 CREAT-0.7 SODIUM-141
POTASSIUM-4.2 CHLORIDE-113* TOTAL CO2-20* ANION GAP-12
___ 01:30AM ALT(SGPT)-15 AST(SGOT)-19 ALK PHOS-45 TOT
BILI-0.2
___ 01:30AM LIPASE-47
___ 01:30AM cTropnT-<0.01
___ 01:30AM ALBUMIN-3.6
___ 01:30AM WBC-7.3# RBC-3.50* HGB-11.4* HCT-35.8*
MCV-102* MCH-32.5* MCHC-31.7 RDW-12.4
___ 01:30AM NEUTS-57.2 ___ MONOS-3.5 EOS-5.9*
BASOS-0.4
___ 01:30AM PLT COUNT-193
CTA Head and Neck: IMPRESSION: Normal CT of the head. Normal
CT angiography of the head.
MR Head: IMPRESSION: No significant abnormalities are seen on
MRI of the brain without gadolinium.
Brief Hospital Course:
Ms ___ was admitted to the Stroke Service at ___
___ after presenting with right face and
arm weakness followed by a headache. She had had a CT scan of
her head at ___ that was normal. She had an MRI at
___ that was also normal. Her presentation was felt to be most
consistent with a complex migraine. However, a transient
ischemic attack could not be definitively ruled out. For this
reason, we started her on a baby aspirin. We also started her on
Topamax for migraine prophylaxis at 25mg BID to increase to 50mg
BID in 1 week.
Medications on Admission:
- Levothyroxine 150mcg daily
- Albuterol 90mcg HFA ___ puffs inh q4-6hrs PRN
- Fluticasone 60mcg ___ sprays per nostril PRN
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*6
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Topiramate (Topamax) 25 mg PO BID
RX *topiramate 25 mg 1 tablet(s) by mouth twice daily Disp #*120
Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Complex migraine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were admitted to the Stroke Service at ___
___ after presenting with right face and arm weakness
followed by a headache. You had had a CT scan of your head at
___ that was normal. You had an MRI at ___ that
was also normal. Your presentation was felt to be most
consistent with a complex migraine. However, a transient
ischemic attack or mini-stroke cannot be definitively ruled out.
For this reason, we started you on a baby aspirin and you
should take this every day to help prevent strokes. We also
started you on a medication called Topamax to try to prevent
headache. This may make you feel sleepy and slow in the
beginning but your body will most likely adjust to the
medication over time. You will take 25mg of Topamax twice daily
for 1 week and then increase to 50mg twice daily. You
complained of pain in your right leg when walking. You had no
evidence of a blood clot in your right leg on physical
examination; however, if you develop worsening pain or swelling
of your right leg you should seek medical attention.
Followup Instructions:
___
|
10887458-DS-4
| 10,887,458 | 22,894,487 |
DS
| 4 |
2185-10-01 00:00:00
|
2185-10-01 17:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Elbow pain
Major Surgical or Invasive Procedure:
ORIF R elbow
History of Present Illness:
___ otherwise healthy s/p fall w/ R elbow pain transferred to
___ ED for R radial head and capitellar fracture. Patient fell
on ice landing on his R arm. He denies any head strike or LOC.
He has pain in his R elbow and wrist. No loss of motor or
sensory function.
Past Medical History:
nc
Social History:
nc
Physical Exam:
98 87 144/97 16 100%RA
Gen: alert, no distress
Pulm: Breathing comfortably
___: Regular rate
Abd: Soft, NT, ND
Ext: full ROM at R shoulder and wrist, limited at elbow ___
pain, swelling R elbow, 2+ radial pulse, intrinsic movements of
R hand intact
Neuro: ___xcept at R elbow w/ flexion,
extension, and with pronation and supination of forearm ___
pain, sensation intact throughout including r/m/u nerve
distributions
Skin: swelling but no open lesions at R elbow
Pertinent Results:
___ 06:20PM BLOOD WBC-14.7* RBC-5.24 Hgb-15.2 Hct-44.6
MCV-85 MCH-29.0 MCHC-34.1 RDW-13.8 Plt ___
___ 06:20PM BLOOD Glucose-85 UreaN-20 Creat-1.0 Na-138
K-4.1 Cl-101 HCO3-24 AnGap-17
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R elbow fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF R elbow, 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
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is NWB in the RUE extremity. The
patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4-6 Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Elbow fracture
Discharge Condition:
stable
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
WOUND CARE:
- You can get the wound wet/take a shower after your first
postoperative appointment. 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:
- NWB
Followup Instructions:
___
|
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