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10887653-DS-21
| 10,887,653 | 27,225,287 |
DS
| 21 |
2147-04-07 00:00:00
|
2147-04-07 17:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Altered mental status, diabetic ketoacidosis, NSTEMI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with a history of T2DM on insulin for ___ years and using
an insulin pump for the past ___ years, COPD on home O2, and CAD
s/p PCI and CABG who presented to ___ on ___ via EMS for
confusion, malaise, and weakness. Per the ED notes, initial
history was provided by the patient's wife, as Mr. ___ was
unresponsive upon arrival to ___. His wife reported that Mr.
___ had been developing hyperglycemia over the two days
prior to presentation. He had been attempting to adjust his pump
settings. On ___, his wife noticed that he was not wearing the
pump, though it remains unclear how long he had gone without any
insulin therapy. He was acutely confused and weak, so his wife
called EMS who brought him to ___.
Upon arrival at ___, he was unresponsive and was intubated
and sedated for airway protection. Labs at ___ were
significant for BG 1453, Na 118, K 7.8, HCO3 12, BUN 63, Cr 2.4,
pH of 7.08, and lactate 5, WBC 19, and trop of 0.025. He was
found to be hypotensive and started on levophed. He also
received IVF, bicarb, CaCl, 30 units Insulin bolus and was then
started on insulin gtt as well as bicarb gtt. He was medflighted
to ___ and was reportedly in "slow Afib" at that time.
MICU course: Mr. ___ was extubated on ___ and was weaned
off levophed on ___. He was also weaned off insulin gtt.
Upon arrival to floor, the patient was alert and oriented and
was able to transfer from wheelchair to bed independently. He
was breathing comfortably on 4L NC. He had a cough productive of
brown/gray sputum which he said was fairly typical for him due
to COPD, but was otherwise feeling well. He was HDS.
Past Medical History:
Type II DM Mellitus (on insulin ___ years and pump for last ___
years)
Chronic Kidney Disease
Peripheral Neuropathy
COPD on home O2
CAD s/p stenting ___ ___)
CABG ___ years ago)
HTN
HLD
BPH
CHFpEF
Celiac Disease c/b severe dermatitis herpetiformis
GERD
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL:
VITALS: 98.0 77 144/44 Vent: 98% TV 400 RR 28 PEEP 5 40% FiO2
GENERAL: intubated,
HEENT: Sclera anicteric, significant oral secretions
NECK: unable to appreciate jvp, thick neck
LUNGS: coarse breath sounds at bases
CV: Regular rate and rhythm, normal S1 S2
ABD: obese soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: mult tattoos
DISCHARGE PHYSICAL:
Vitals: 97.9 138/78 64 24 92 4 L
General: Obese, poor dentition, chronically ill appearing,
pleasant this AM and A&Ox3
CV: RRR, no m/r/g
Pulm: Breath sounds distant bilaterally, very mild bibasilar
crackles
Abd: soft, non-distended, non-tender
Ext: 1+ pitting edema of the bilateral lower extremities, skin
changes (darkening/erythema) consistent w/ patient's baseline
lymphedema
Pertinent Results:
ADMISSION LABS:
___ 12:28AM BLOOD WBC-17.2* RBC-3.42* Hgb-10.2* Hct-30.5*
MCV-89 MCH-29.8 MCHC-33.4 RDW-13.0 RDWSD-42.4 Plt ___
___ 12:28AM BLOOD Neuts-86.6* Lymphs-5.0* Monos-7.3
Eos-0.2* Baso-0.1 Im ___ AbsNeut-14.89* AbsLymp-0.86*
AbsMono-1.26* AbsEos-0.03* AbsBaso-0.02
___ 01:38AM BLOOD ___ PTT-23.3* ___
___ 12:28AM BLOOD ___
___ 12:28AM BLOOD Glucose-928* UreaN-56* Creat-2.8* Na-130*
K-4.7 Cl-86* HCO3-22 AnGap-27*
___ 08:31PM BLOOD CK(CPK)-139
___ 12:28AM BLOOD LD(LDH)-268*
___ 01:38AM BLOOD ALT-47* AST-63* LD(LDH)-270* CK(CPK)-167
AlkPhos-129 TotBili-0.4
___ 08:31PM BLOOD Lipase-12
___ 08:31PM BLOOD cTropnT-0.04*
___ 08:31PM BLOOD CK-MB-9 MB Indx-6.5* proBNP-1643*
___ 01:38AM BLOOD CK-MB-19* MB Indx-11.4* cTropnT-0.33*
___ 01:38AM BLOOD Albumin-3.4* Calcium-10.1 Phos-3.1 Mg-2.6
___ 12:28AM BLOOD Hapto-61
___ 01:38AM BLOOD Free T4-1.0
___ 08:31PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:18PM BLOOD Type-ART Rates-28/ Tidal V-400 PEEP-5
FiO2-50 pO2-168* pCO2-35 pH-7.38 calTCO2-22 Base XS--3
Intubat-INTUBATED
___ 08:48PM BLOOD Glucose-GREATER TH Lactate-6.3* Na-126*
K-5.9* Cl-90* calHCO3-15*
INTERVAL LABS:
___ 01:38AM BLOOD CK-MB-19* MB Indx-11.4* cTropnT-0.33*
___ 07:46AM BLOOD CK-MB-14* MB Indx-9.5* cTropnT-0.68*
___ 02:00PM BLOOD CK-MB-8 cTropnT-0.55*
___ 05:22PM BLOOD ___ Temp-37.1 pO2-40* pCO2-51*
pH-7.40 calTCO2-33* Base XS-4
DISCHARGE LABS:
___ 06:05AM BLOOD WBC-7.0 RBC-2.83* Hgb-8.5* Hct-26.7*
MCV-94 MCH-30.0 MCHC-31.8* RDW-14.2 RDWSD-48.8* Plt ___
___ 06:05AM BLOOD Glucose-229* UreaN-24* Creat-1.4* Na-137
K-4.2 Cl-96 HCO3-30 AnGap-15
___ 06:05AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.2
Brief Hospital Course:
Patient summary: ___ M with a history of T2DM on insulin for ___
years and using an insulin pump for the past ___ years, COPD on
home O2, and CAD s/p PCI and CABG who presented with confusion,
malaise, and weakness, found to be in DKA (BG 1453) and w/
enzymes confirming NSTEMI.
ACUTE ISSUES:
#Diabetic ketoacidosis: Patient first presented with BG 1453 and
was unresponsive requiring intubation at ___. This was
most likely due to the inability to correct the insulin pump for
an undetermined time period. There was no concern for
precipitating infection as urine cultures were negative, sputum
stained for GNRs and aspergillus but the patient was afebrile
and with COPD these were likely baseline colonizers, and blood
cultures were negative. The DKA was initially corrected with
insulin gtt, IV fluids, and bicarb, all of which were able to be
weaned off prior to transfer from the ICU to the Medicine floor.
He was then initiated on a basal/bolus injectable insulin
regimen per ___: 10U Lantus qAM, 25 U Lantus
qPM, 10U Humalog standing TID with meals, and sliding scale (2U
for >150, plus 2U for every additional 50 mg/dL). Discharged on
that regimen.
#NSTEMI: Likely in the setting of demand ischemia due to
hypovolemia from intravascular volume depletion of DKA.
Alternate etiologies include acute demand ischemia as a result
of hyperkalemia-induced arrhythmia OR potentially NSTEMI as a
result of CAD serving as initial stressor that triggered DKA.
Per MICU, denied antecedent chest pain or non-specific sx of
nausea, gastritis, thus less likely to have precipitated this
episode of DKA. Trops rose w/o ST elevations and down-trended
prior to discharge.
#CHF pEF
Patient has a history of diastolic heart failure and upon
transfer from ICU to Medicine floor was found to be volume up
w/elevated JVP on exam and lower extremity edema. His most
recent CXR was consistent with pulmonary vascular congestion,
though his O2 sats remained appropriate while on O2 NC.
Diuretics had been held in light of recent intravascular volume
depletion. Home PO Bumex wasrestarted on ___. Medication history
showed patient also prescribed 40mg PO Lasix BID, though this
was not restarted initially. Due to concern for hypotension in
the setting of DKA, his home losartan was held during this
admission. As pressures normal, discharged with losartan held.
Discharged on home Bumex PO BID and home Lasix was held.
#CAD s/p stenting and CABG and arrest ___ ___:
Per EMS, collateral from wife stated that he had 2 stents 2
weeks prior to this admission at ___. Per this
report, he had a prior arrest ~3 mo ago in the setting of
hyperglycemia, was en route to ___ and arrested in
ambulance then transferred to ___ for definitive treatment
w/stenting. CABG ___ years ago. During this admission, he
received Plavix, aspirin, and a statin for CAD. Outside records
could not be obtained prior to discharge.
#Acute on chronic kidney disease: The patient's baseline Cr
initially thought to be 1.8, likely due to longstanding renal
dysfunction from diabetes mellitus. Upon arrival at ___,
Cr was 2.4. After extensive fluid resuscitation, holding
diuretics, and resolution of DKA, Cr down-trended to 1.3.
#Hypertension: Due to the patient's hypotension on initial
arrival, his home losartan was held. Held on discharge as
normotensive.
CHRONIC ISSUES:
#COPD: Remained on 4L NC O2 while here, slightly up from home O2
of ___. He received duonebs q6h and albuterol q2h. His home
advair was held.
#Celiac Disease: For his history of celiac disease c/b severe
dermatitis herpetiformis, he continued to receive dapsone (75mg
PO QPM and 50mg PO QAM) and iron daily.
#BPH: Initially held home tamsulosin 0.4 mg PO QHS in the
setting of low pressures. It was restarted ___.
#GERD: Continued home pantoprazole 40mg PO BID
#Chronic Constipation: Received senna, Colace BID.
#Allergies: Held home zysal (levocetirizine 5mg daily).
TRANSITIONAL ISSUES:
[] Discharged on injectable insulin regimen:
- 10U Lantus QAM
- 25U Lantus QPM
- 8 U Humalog TID standing (breakfast/lunch/dinner)
- Sliding scale: 2U Humalog for BG>150, plus 2U Humalog for
every additional increase of 50mg/dL
[] ___ Diabetes service anticipates that this insulin regimen
may require up-titration after discharge. Prior to admission,
Mr. ___ was likely taking closer to 120-130 U daily via
pump. Measures were more conservative here to avoid
hypoglycemia, and we anticipate he will eat more upon discharge,
so please monitor BG at rehab and adjust regimen as necessary to
maintain BG goal 140-180.
[] Patient is not to restart using insulin pump until seeing Dr.
___ as outpatient
[] Home Losartan held while in-patient due to concern for
hypotension. ___ restart as outpatient if pressures rise.
[] Consider starting beta blocker in this patient with CAD
[] Discharged on home Bumex BID, but Lasix held as unclear
prescription history. Consider restarting Lasix if needed.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Advair HFA (fluticasone-salmeterol) 230-21 mcg/actuation
inhalation BID
2. Dapsone 50 mg PO QAM
3. Dapsone 75 mg PO QPM
4. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
5. Furosemide 20 mg PO EVERY OTHER DAY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Pregabalin 100 mg PO TID
8. Xyzal (levocetirizine) 5 mg oral QPM
9. Losartan Potassium 25 mg PO DAILY
10. Clopidogrel 75 mg PO DAILY
11. Bumetanide 2 mg PO QAM
12. Bumetanide 1 mg PO Q AFTERNOON
13. Ferrous Sulfate 325 mg PO DAILY
14. Atorvastatin 80 mg PO QPM
15. Capsaicin 0.025% 1 Appl TP BID
16. Doxepin HCl 10 mg PO BID
17. Fluocinolone Acetonide 0.025% Ointment 1 Appl TP DAILY left
lower leg
18. Hydrocortisone Cream 2.5% 1 Appl TP PRN AAA
19. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q4H:PRN sore throat
3. Glargine 10 Units Breakfast
Glargine 25 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Advair HFA (fluticasone-salmeterol) 230-21 mcg/actuation
inhalation BID
5. Atorvastatin 80 mg PO QPM
6. Bumetanide 2 mg PO QAM
7. Bumetanide 1 mg PO Q AFTERNOON
8. Capsaicin 0.025% 1 Appl TP BID
9. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
10. Clopidogrel 75 mg PO DAILY
11. Dapsone 50 mg PO QAM
12. Dapsone 75 mg PO QPM
13. Doxepin HCl 10 mg PO BID
14. Ferrous Sulfate 325 mg PO DAILY
15. Fluocinolone Acetonide 0.025% Ointment 1 Appl TP DAILY left
lower leg
16. Fluticasone Propionate NASAL 2 SPRY NU DAILY
17. Furosemide 20 mg PO EVERY OTHER DAY
18. Hydrocortisone Cream 2.5% 1 Appl TP PRN AAA
19. Losartan Potassium 25 mg PO DAILY
20. Pregabalin 100 mg PO TID
21. Tamsulosin 0.4 mg PO QHS
22. Xyzal (levocetirizine) 5 mg oral QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Diabetic ketoacidosis
Diabetes mellitus, Type 2
Non-ST elevation myocardial infarction
Coronary artery disease
Acute on chronic heart failure with preserved ejection fraction
Secondary:
Celiac disease
Chronic obstructive pulmonary disease
Acute on chronic kidney disease
Hypertension
Benign prostatic hyperplasia
Gastroesophageal reflux disease
Chronic constipation
Seasonal allergies
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
What happened while you were in the hospital:
- You came to the hospital with a very high blood sugar level
and increased levels of acid in the blood because you were not
getting enough insulin. You needed a tube to help you breathe
when you first arrived. You also received insulin while you were
here to bring your blood sugar to a normal level again.
- Your heart was strained by the stress of having high blood
sugars. We checked on all your heart numbers to make sure they
were returning to normal. You did not require any procedures on
your heart while you were here.
What to do at home:
- You will go to rehab before going home so that you can
continue to recover.
- You should continue taking the injectable insulin AS YOU TOOK
IT IN THE HOSPITAL when you first go home. After you talk to Dr.
___ review all of the pump settings, then you can go
back to using your pump.
- Make sure to keep taking all your medications as prescribed.
It was a pleasure taking care of you!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10887779-DS-17
| 10,887,779 | 21,417,093 |
DS
| 17 |
2124-03-16 00:00:00
|
2124-03-18 19:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___
Chief Complaint:
Throat swelling, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old ___ speaking male with history of MI s/p CABG in
___, HLD, DM2, HTN who presents referred from OSH with concern
for angioedema. States that yesterday AM had feeling of dyspnea,
not worse with exertion. In afternoon noted swelling his neck
with difficulty swallowing. Presented to ___ where
CT reportedly showed 1.5 cm swelling in retropharyngeal space
w/o evidence of abscess.He was given 2 Units of FFP at OSH and
given racemic epinephrine, at which point patient was
transferred. In ED he was noted to have submandibular swelling
without airway compromise. and transferred to ICU for further
care. He denies any recent changes to medication, no known
allergies.
In the ED, initial vitals: T:96.5 P:67 BP: 137/69 R: 20 O2:100%
NC
On exam pt was: Notable for Submandibular fullness without
crepitus and with a patent airway
Labs were significant for:
Imaging was significant for: CT from OSH reportedly notable for
1.5cm retropharyngeal swelling
Consults:
Patient received: 2 Unit FFP
On transfer, vitals were: P: 57 BP: 130/76 R: 16 O2: 99% RA
Past Medical History:
MI in ___ s/p CABG
Hyperlipidemia
Diabetes Mellitus
Hypertension
Back pain s/p laminectomy ___ years ago
Social History:
___
Family History:
No history of angioedema
father with diabetes and ___
mother has hypertension
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: T:98.6 BP:147/82 P:69 R:16 O2:97% RA
___: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, non-edematous
lips, tongue
NECK: Palpable submandibular swelling, no lymphadenopathy. No
sublingual swelling.
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 lesions.
NEURO: A&O x3. CN II-XII intact. Sensation, strength intact.
ACCESS: PIVs
DISCHARGE PHYSICAL EXAM
=======================
VS - 97.9 PO 145 / 80 68 18 94 RA
___: middle aged male in NAD , sitting up eating breakfast
HEENT: anicteric, PERRL, EOMI, MOM, OP clear
Neck: supple, JVP not elevated, mild submandibular fullness,
soft, mobile, non-fluctuant, non-tender
Lungs: NLB on RA, CTAB
CV: RRR, normal S1S2, no M/R/G
Abdomen: soft, NT/ND, NABS
GU: no foley
Ext: WWP, 2+ pulses, no cyanosis or edema
Neuro: A&O, CN II-XII intact, SILT, ___ strength BUE/BLE, no
tremor
Pertinent Results:
ADMISSION LABS
==============
___ 04:55AM BLOOD WBC-7.9 RBC-4.01* Hgb-12.6* Hct-37.8*
MCV-94 MCH-31.4 MCHC-33.3 RDW-13.2 RDWSD-45.4 Plt ___
___ 04:55AM BLOOD Neuts-85.8* Lymphs-10.6* Monos-2.5*
Eos-0.4* Baso-0.3 Im ___ AbsNeut-6.78* AbsLymp-0.84*
AbsMono-0.20 AbsEos-0.03* AbsBaso-0.02
___ 04:55AM BLOOD ___ PTT-27.0 ___
___ 04:55AM BLOOD Glucose-163* UreaN-11 Creat-0.8 Na-139
K-4.5 Cl-102 HCO3-26 AnGap-16
___ 04:55AM BLOOD ALT-24 AST-28 AlkPhos-72 TotBili-1.0
___ 04:55AM BLOOD Albumin-3.9 Calcium-9.0 Phos-2.4* Mg-1.4*
PERTINENT LABS
==============
___ 04:55AM BLOOD CRP-3.5
DISCHARGE LABS
==============
None
IMAGING
=======
___ CT Neck
IMPRESSION:
1
.
T
h
e
re is fluid and stranding in the retropharyngeal, submandibular,
i
n
f
e
r
i
o
r
p
a
rotid, carotid spaces, with thickening of the epiglottis. Given
m
u
l
t
i
c
o
m
p
artmental and symmetric findings, appearance favors angioedema.
Infection cannot be excluded. There is no abscess.
2
.
T
h
ere is moderate airway narrowing at the level of the epiglottis.
3
.
T
h
e
r
e
i
s
extensive paranasal sinus opacification, suggestive of acute on
chronic paranasal sinusitis.
Brief Hospital Course:
___ year old male with hx of HTN, HLD, CAD, DM2 presenting with
throat swelling, difficulty swallowing, and difficulty breathing
with concern for angioedema. He was observed with consistent
improvement throughout admission.
#Throat swelling/Angioedema: On exam there was no evidence of
airway compromise. CRP, ESR, C4 WNL Patient received 2U FFP at
OSH. Differential includes acquired, hereditary, and
anaphylaxis, as well as neck space infections. Given lack of
other organ system/skin manifestations anaphylaxis is unlikely.
Infection is concerning cause but no evidence of fever, systemic
symptoms other than some mild cough/congestion. Second read of
CT from outside hospital was obtained, which concurred with
angioedema being the most likely etiology. His Lisinopril was
held. He was started on amlodipine 5 in place of lisinopril for
blood pressure control.
#Alcohol use. He was given thiamine, multivitamin, and folate.
He was also monitored on a CIWA scale and treated with valium
for EtOH withdrawal. No seizure activity.
====================
TRANSITIONAL ISSUES
====================
[] Lisinopril stopped due to concern for angioedema. Pt was
started on amlodipine 5 for BP control in place of lisinopril.
Please assess BP control on new regimen.
[] Please encourage pt to seek treatment for alcohol abuse. Pt
was seen by social work in-house and denied having a problem
with alcohol, but was treated with valium for withdrawal while
admitted.
# Communication/HCP: ___ (wife) ___
# Code: Full, presumed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Lisinopril 40 mg PO DAILY
3. MetFORMIN XR (Glucophage XR) 750 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Naltrexone 50 mg PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule
Refills:*1
5. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*1
6. Atorvastatin 80 mg PO QPM
7. MetFORMIN XR (Glucophage XR) 750 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Naltrexone 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Angioedema
Secondary Diagnoses: Alcohol withdrawal, hypertension, CAD, Type
2 Diabetes
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 DID YOU COME TO THE HOSPITAL?
You had swelling in your throat and were having trouble
breathing.
WHAT HAPPENED WHILE YOU WERE HERE?
We stopped your lisinopril because sometimes this can cause the
type of reaction you had (called "angioedema"). We monitored
your breathing very carefully. We started you on a new medicine
to help control your blood pressure(amlodipine).
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
Stop taking your lisinopril, and take the amlodipine instead.
Please follow up with your PCP.
Again, it was a pleasure taking care of you!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10887786-DS-9
| 10,887,786 | 29,692,777 |
DS
| 9 |
2198-03-21 00:00:00
|
2198-03-28 14:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Ampicillin / Aspirin / Penicillins / ciprofloxacin / tramadol
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with a PMH pertinent for multiple SBOs
requiring ex-lap/LOA now presenting with a recurrent SBO. She
began having low grade nausea one week ago and last night at
approximately 2200 she was awoken by sharp, ___ periumbilical
non-radiating pain. This progressed to include multiple episodes
of bilious emesis, chills, and sweats. Notably she denies BM for
the last 3 weeks and says she does not remember the last time
she passed flatus. She presented to ___ where a CT was
taken which demonstrated an SBO with a LLQ mid-ileal transition
point. NGT was placed which improved her pain to ___ and
resolved her nausea. She was then transferred to ___ for
definitive management. On exam her abdomen was distended though
soft, with rebound tenderness. Her lactate was 0.9, WBC 16.7 and
she had no significant metabolic derangements. Her NGT was
putting out a moderate amount of bilious fluid.
Past Medical History:
Depression, OCD (per previous notes)
s/p appendectomy
s/p TAH for PID
s/p titanium plate insertion into neck
s/p cervical c4, c5, c6 laminectomy, c4-c6 posterior fusion
s/p ___ L3-L5 laminectomy
s/p surgery to remove adhesions after SBO earlier this year
s/p car accident ___ years ago with ejection through windshield
Social History:
___
Family History:
Grandfather, grandmother with cancer (type unknown), mother with
breast ca.
Physical Exam:
Admission Physical Exam:
PHYSICAL EXAMINATION:
VS: 98.3 104 104/63 20 100% RA
GEN: NAD, mildly disheveled, uncomfortable
NEURO: AOx3, CN II-XII grossly intact
HEENT: Sclerae anicteric, trachea midline, no JVD
CV: RRR no MRG, 2+ peripheral pulses bilaterally
RESP: CTAB no WRC, no respiratory distress
GI: Abdomen soft, distended, diffusely tende with rebound.
Multiple well-healed scars from prevous surgical incisions.
Tympanic to percussion. Bowel sounds absent. Rectal exam
deferred
EXT: WWP no CCE. Multiple excoriations
Discharge Physical Exam:
Left against medical advice, before leaving her last physical
exam was:
VS: 99.1 98 ___ 100% RA
GEN: no acute distress
NEURO: AOx3, CN II-XII grossly intact
HEENT: Sclerae anicteric, trachea midline, no JVD
CV: RRR no MRG, 2+ peripheral pulses bilaterally
RESP: CTAB no WRC, no respiratory distress
GI: Multiple well-healed scars from previous surgical incisions.
Abdomen soft, non tender, non distended. Normal bowel sounds.
EXT: WWP no CCE. Multiple excoriations
Pertinent Results:
___ 02:17PM BLOOD WBC-9.5 RBC-5.02 Hgb-13.6 Hct-44.5 MCV-89
MCH-27.1 MCHC-30.6* RDW-19.6* RDWSD-61.7* Plt ___
___ 09:40AM BLOOD WBC-16.7*# RBC-4.94 Hgb-13.1 Hct-42.9
MCV-87 MCH-26.5 MCHC-30.5* RDW-18.8* RDWSD-59.4* Plt ___
___ 09:40AM BLOOD ___ PTT-27.7 ___
___ 09:40AM BLOOD Neuts-86.4* Lymphs-9.0* Monos-3.9*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-14.47* AbsLymp-1.50
AbsMono-0.65 AbsEos-0.02* AbsBaso-0.03
___ 02:17PM BLOOD Glucose-80 UreaN-8 Creat-0.5 Na-138 K-3.9
Cl-105 HCO3-19* AnGap-18
___ 09:40AM BLOOD Glucose-109* UreaN-11 Creat-0.7 Na-140
K-4.3 Cl-104 HCO3-27 AnGap-13
___ 09:40AM BLOOD ALT-11 AST-17 AlkPhos-145* TotBili-0.3
___ 02:17PM BLOOD Calcium-9.0 Phos-3.4 Mg-1.9
___ 09:40AM BLOOD Albumin-3.5 Calcium-9.2 Phos-3.6 Mg-2.1
___ 09:50AM BLOOD Lactate-0.9
___ 12:10PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:10PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-SM
___ 12:10PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-1
URINE CULTURE (Final ___: NO GROWTH.
Imaging:
___ 1. Small bowel obstruction with an abrupt transition
point within the pelvis. Considering the history of multiple
prior surgeries, adhesion is the most likely etiology.
2. Mild mesenteric vessel engorgement, but no evidence of bowel
wall
thickening, mesenteric edema, pneumatosis, or pneumoperitoneum.
3. Mild intra and extrahepatic biliary dilatation, unchanged
since ___.
Brief Hospital Course:
Ms. ___ is a ___ yo F admitted to the Acute Care Surgery
Service on ___ with abdominal pain, distension, and emesis.
She has a past medical history significant for small bowel
obstructions requiring exploratory laparotomy and lysis of
adhesions. She had a CT scan at an outside hospital that showed
a small bowel obstruction with a transition point in the pelvis.
She had a nasogastric tube placed and was transferred to ___
___. She was admitted to the surgical floor hemodynamically
stable for further monitoring and management.
On ___ the patient still had the NGT placed with minimal output
and NPO with bowel rest when she started to pass flatus
spontaneously and improve her pain. Her abdomen was soft and not
painful. Later that day she felt like having a bowel movement
and when she ran to the bathroom her NGT came out. She had not
had any nausea or vomit for the past day so it was not placed
again. She had a bowel movement at the moment which was dark and
mildly bloody, guaiac test was negative. Her diet was advanced
to clears which she tolerated and then to regular diet. On ___
the patient´s symptoms were subsided, she was not nauseated, had
had 3 normal bowel movement, she was tolerating without problems
her regular diet and was on dispo planning for the next day. The
patient left against medical advice on ___.
Medications on Admission:
1. CloNIDine 0.1 mg PO TID
2. Gabapentin 800 mg PO TID
3. Methadone 120 mg PO DAILY
4. OLANZapine 10 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
hold for diarrhea
2. Senna 8.6 mg PO BID:PRN constipation
3. CloNIDine 0.1 mg PO TID
4. Gabapentin 800 mg PO TID
5. Methadone 120 mg PO DAILY
6. OLANZapine 10 mg 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:
Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
with abdominal pain. You had a CT scan that was concerning for a
small bowel obstruction. You were given bowel rest, IV fluids,
and had a nasogastric tube placed to help decompress your
bowels. You had spontaneous return of bowel function. The
nasogastric tube was removed and your diet was slowly advanced
to regular which you tolerated well.
You are now ready to be discharged to home. Please note the
following discharge instructions.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Followup Instructions:
___
|
10888095-DS-12
| 10,888,095 | 22,298,015 |
DS
| 12 |
2166-06-11 00:00:00
|
2166-06-12 12:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
azithromycin / morphine
Attending: ___.
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo G1P0 at 22w3d with hx RNY presented with three weeks of
intermittent abdominal pain since she had her wisdom teeth
removed. Patient reports that three weeks ago she had wisdom
teeth extraction and later that same day reports severe mid
epigastic pain. It does not radiate. She experiences nausea and
vomiting. Pain is worse with eating. Has been taking pepcid,
zofran and one percocet per day without relief. She reports two
contractions today.
She initially was seen 3 weeks ago at OSH where she reports
normal CT scan. Yesterday she presented to ___ where she had
a KUB. She was then transferred to ___ for evaluation by
bariatrics.
Denies fever, chills, diarrhea, dysuria, constipation, VB, LOF.
+FM.
Past Medical History:
OBHx:
- G1: current
GynHx:
- Denies abnormal Pap, fibroids, Gyn surgery, STIs
PMH:
- Mild asthma: no hospitalizations or intubations
PSH:
- Open Roux en Y
- LSC CCY
- Wisdom teeth extraction
Social History:
___
Family History:
Noncontributory
Physical Exam:
Physical Exam on Admission
T98.0 HR-60 BP-90/44 RR-18 O2-99%
Gen: A&O, comfortable
CV: RRR
PULM: CTAB
Abd: +BS, soft, gravid, mild epigastric tenderness, no fundal
tenderness, no rebound or guarding.
fundus 1-2 cm above umbilicus
Ext: no calf tenderness
Physical Examination on Discharge
VSS
Gen: NAD, comfortable
CV: RRR
Pulm: CTAB
Abd: Soft, nondistended, nontender, gravid
Ext: warm well perfused, nontender
Pertinent Results:
___ 01:25AM BLOOD WBC-7.0 RBC-3.14* Hgb-9.7* Hct-27.8*
MCV-89 MCH-30.7 MCHC-34.7 RDW-13.9 Plt ___
___ 01:25AM BLOOD Neuts-63.2 ___ Monos-5.1 Eos-1.0
Baso-0.3
___ 01:25AM BLOOD Glucose-74 UreaN-10 Creat-0.5 Na-136
K-3.6 Cl-105 HCO3-24 AnGap-11
___ 01:25AM BLOOD ALT-19 AST-38 AlkPhos-59 TotBili-0.2
___ 04:30PM BLOOD Albumin-3.1* Iron-154
___ 04:30PM BLOOD calTIBC-403 VitB12-413 Folate-16.7
Ferritn-9.2* TRF-310
Abdominal Ultrasound ___:
There is a single live intrauterine gestation. The fetus is in
vertex position. The placenta is normal. There is no evidence of
previa. There is a normal amount of amniotic fluid. No fetal
morphologic
abnormalities are detected. The uterus is normal. The ovaries
are not
visualized; however, no adnexal abnormalities are seen. Limited
single views of the right and left upper quadrant are included
which are grossly
unremarkable. No free fluid is identified.
Single intrauterine pregnancy, size equal to dates. No
abdominal
free fluid.
Brief Hospital Course:
Ms ___ is a ___ yo G1 at 22weeks gestation with hx of Roux en Y
bypass who was transferred from OSH due to epigastric pain.
Bariatric surgery was consulted who felt this likely secondary
to ulcer and recommended GI consult for possible endoscopy. GI
was consulted and agreed her discomfort was likely caused by an
ulcer and felt endoscopy would not aid in management at this
time and recommended optimal medical management with PPI,
sucralfate and H2blocker. During admission patient with anemia-
HCT of 27. Folate, B12 and iron levels checked with normal b12
and folate levels and decreased ferritin. Patient given iron and
instructed to take increased iron BID at home. Patient improved
with medical treatment of presumed PUD (PPI, small slow meals)
and on hospital day #2 reported symptoms resolved. The patient
was tolerating a regular diet. GI and bariatric surgery both
evaluated the patient who felt discharge was reasonable. She
has outpatient followup with Bariatric surgery. Patient
discharged in stable condition on HD 2 tolerating regular diet
with no abdominal pain. She had reassuring fetal testing
throughout admission.
Medications on Admission:
PNV
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth twice a day Disp #*60 Tablet Refills:*3
3. Prenatal Vitamins 1 TAB PO DAILY
RX *PNV with ___ 27 mg iron-1 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*2
4. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth Twice a day Disp
#*8 Tablet Refills:*0
5. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*120 Tablet Refills:*2
6. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Pregnancy at 22 weeks
Epigastric pain, presumed peptic ulcer disease
Iron-deficiency anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were admitted to ___ with epigastric pain in pregnancy.
Because you have had a gastric bypass we were concerned you may
have peptic ulcer disease. Your symptoms improved with
medications for peptic ulcers and with adjusting your eating
patterns (small slow meals). It is now safe for you to be
discharged home.
While you were in the hospital we also noted that your iron was
low, causing anemia. You should take iron supplements twice
daily in addition to your prenatal vitamin.
Followup Instructions:
___
|
10888222-DS-2
| 10,888,222 | 24,564,154 |
DS
| 2 |
2159-11-08 00:00:00
|
2159-11-08 20:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
latex / propofol / lorazepam
Attending: ___.
Chief Complaint:
left basal ganglia hemorrhage, intraventriuclar hemorrhage
Major Surgical or Invasive Procedure:
___ Right EVD placement
___ Left Subclavian TLC placement
___ Right EVD replacement
___ PICC placement
___ Trach/ PEG
___ - 1 bag platelet transfusion
___ - 1 unit PRBC transfusion
___ - 1 unit PRBC transfusion
History of Present Illness:
___ y/o male on aspirin and ___ transferred to ___ from ___
___ with a left intraparenchymal hemorrhage with
intraventricular extension. At 3AM he awoke and reported his RUE
feeling "weird" and weak. He was last seen normal at 11:30PM
last night. His wife called EMS. He was taken emergently to ___
___. Upon arrival there patient was noted to be aphasic but
interactive however quickly declined and was intubated for
altered mental status and airway protection. He was given
paralytics at 5AM for intubation. There CT revealed IPH with IVH
and hydrocephalus. He transferred to ___ for further
evaluation. Upon arrival patient is intubated and sedated on
Fentanyl and Versed and unable to provide any history.
ROS: unable to obtain due to mental status
Past Medical History:
CAD, s/p CABG x4
CKD with hx of temporary dialysis
Diabetes
Hypertension
s/p R BKA ___ years ago
s/p TKR
Social History:
___
Family History:
not pertinent to current admission
Physical Exam:
On Admission:
HR: 81, RR: 20, O2Sats 100% Intubated.
Gen: Lying on stretcher; intubated. Ill appearing.
HEENT: Pupils: 1mm, NR bilaterally.
CN II-XII unable to obtain secondary to sedation
Extremities: No response to noxious stimuli x4 extremities. R
BKA
On Discharge:
Vitals- Tc 98.3, Tm 99.2, HR 81, BP 166/92, HR 81, 100% on TM
General- elderly gentleman with trach laying in bed in NAD
HEENT- Miotic pupils with sluggish reaction to light but no
tracking; anicteric sclera. OP with white plaque on tongue. No
noticeable nasal purulence, thick tracheal secreations.
Lungs- good air entry but diffusely rhonchorous on auscultation
anteriorly.
CV- Distant heart sounds, but RRR, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen- obese, soft, NT, ND, NABS, no rebound tenderness.
GU- Foley in place.
Ext- right BKA, warm, well perfused, no clubbing, cyanosis
Pitting edema bilaterally to the sacrum
Neuro- GCS 3- no eye opening to painful stimuli, no decorticate
or deceribrate response to painful stimuli, no verbal response
Pertinent Results:
INITIAL LAB RESULTS
==============================
___ 06:25AM BLOOD WBC-12.4* RBC-3.87* Hgb-10.9* Hct-34.5*
MCV-89 MCH-28.2 MCHC-31.6* RDW-14.6 RDWSD-46.6* Plt ___
___ 06:25AM BLOOD UreaN-49* Creat-2.2*
___ 12:40PM BLOOD LD(LDH)-169 CK(CPK)-46*
___ 12:53PM BLOOD Calcium-7.9* Phos-3.7 Mg-1.9
___ 12:40PM BLOOD Hapto-421*
___ 09:55AM BLOOD Osmolal-339*
___ 01:12PM BLOOD Type-ART pO2-143* pCO2-37 pH-7.37
calTCO2-22 Base XS--3
___ 06:33AM BLOOD Glucose-274* Lactate-1.8 Na-138 K-6.2*
Cl-109* calHCO3-19*
___ 06:25AM URINE Color-Straw Appear-Clear Sp ___
___ 06:25AM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:25AM URINE RBC-4* WBC-1 Bacteri-FEW Yeast-NONE Epi-0
___ 03:23PM URINE CastGr-6*
PERTINENT MICRO DATA
=============================
___ 12:08 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
cefepime MIC = 3MCG/ML Sensitivity testing performed by
Etest.
Interpretation of cefepime susceptibility is based on a
dose of 1
gram every 12h. This isolate is intermediate (I) to
cefepime, now
referred to as susceptible-dose dependent (SDD). SDD
isolates can
be treated with cefepime, but an optimized dosing
regimen should
be prescribed. Please contact the AST (pager ___ or
ID for
assistance in determining the appropriate SDD cefepime
dosing.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- I
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING
==============================
___ Echocardiogram
IMPRESSION: Suboptimal study. Likely at least moderately
depressed left ventricular systolic function. Likely immobile
right aortic cusp with no evidence of aortic stenosis.
___ CT Head
IMPRESSION:
1. Increase in intraventricular and a slightly the basal ganglia
blood since the comparison from 2 hours prior.
___ post-EVD CT HEAD
IMPRESSION:
1. Interval placement of a ventricular drainage catheter in the
right lateral ventricle.
2. Stable large intraventricular and smaller intraparenchymal
hemorrhage as compared to CT head contrast 4 hours prior to the
study.
3. Rightward midline shift of 7 mm is subtly increased as
compared to CT head without contrast for 4 hours prior.
___ PCXR
IMPRESSION:
1. The tip of the new left PICC line terminates in the mid SVC.
2. Mild pulmonary vascular congestion and retrocardiac
atelectasis is improved, and mild bibasilar atelectasis
persists.
___ PCXR
IMPRESSION:
ET tube tip is 5 cm above the carinal. Left subclavian line tip
is at the level of junction of left brachycephalic vein and SVC.
Cardiomediastinal silhouette is unchanged. Left basal
atelectasis is unchanged.
___ PCXR
IMPRESSION:
As compared to ___ chest radiograph, bibasilar
opacities have worsened, and small pleural effusions are not
appreciably changed.
___ CT HEAD
IMPRESSION:
1. Right transfrontal ventriculostomy catheter unchanged in
positioning with decreased size of the lateral ventricles
bilaterally.
2. Stable large left intraventricular and intraparenchymal
hemorrhage without evidence of new hemorrhage.
3. Slightly increased left-to-right midline shift.
4. Opacification of the paranasal sinuses and nasal cavity,
likely due to intubation.
___ PCXR
IMPRESSION:
Endotracheal tube and left subclavian central line are unchanged
in position. Nasogastric tube courses below the diaphragm with
the tip not identified. Cardiac and mediastinal contours are
stable status post median sternotomy for CABG. Interval
appearance of mild interstitial edema. Layering bilateral
effusions, left greater than right, with patchy bibasilar
airspace opacities favoring atelectasis. No pneumothorax,
although the sensitivity to detect pneumothorax is diminished
given supine technique.
___ PCXR
IMPRESSION:
Compared to prior chest radiographs ___ through ___.
Severe cardiomegaly is chronic. Small left pleural effusion has
increased.
Pulmonary vascular congestion and borderline edema persist. No
pneumothorax.
ET tube in standard placement. Nasogastric drainage tube passes
at least as far as the upper stomach. Left-sided central venous
catheter ends in the upper SVC. New
___ CT HEAD
IMPRESSION:
Unchanged positioning of ventriculostomy catheter. Interval
increase in the size of the lateral ventricles bilaterally.
Largely unchanged size and configuration of the thalamic
hemorrhage with intraventricular extension and stable midline
shift. No evidence of new hemorrhage. Unchanged opacification of
the paranasal sinuses and nasal cavity, likely due to
intubation.
___ CT HEAD
IMPRESSION:
S/p repositioning of the right frontal approach ventriculostomy
catheter, which now terminates along the lateral margin of the
frontal horn of the left lateral ventricle just above the
foramen of ___. The frontal horn of the left lateral
ventricle, as well as the right lateral ventricle, third
ventricle, and fourth ventricle, appear slightly decreased in
size. However, comparison to ___ is limited by
differences in patient position. Stable large left parenchymal
hemorrhage with stable surrounding edema and stable mass effect.
___ PCXR
IMPRESSION:
In comparison with the study of ___, there again are low
lung volumes, chronic severe enlargement of the cardiac
silhouette, pulmonary vascular congestion, and bilateral
layering pleural effusions with compressive atelectasis at the
bases. Endotracheal tube and left subclavian catheter remain in
standard position. The nasogastric tube extends at least to the
mid to lower body of the stomach, were crosses the lower margin
of the image.
___ PCXR
IMPRESSION:
ET tube tip is 6 cm above the carinal. Left subclavian line tip
is at the level of superior SVC. Heart size and mediastinum are
unchanged. Mild vascular congestion is present. Bibasal areas
of atelectasis are noted. Overall there is interval improvement
of pulmonary edema. No new consolidation to suggest interval
development of infection noted.
___ EEG
IMPRESSION:
This is an abnormal video-EEG monitoring session because of a
slow and disorganized background with multifocal slow
transients. No epileptiform abnormalities were seen. No
pushbutton activations were recorded.
___ PCXR
IMPRESSION:
Right PICC tip is in thecavoatrial junction. ET tube is in
standard position. NG tube tip is not visualized. Severe
cardiomegaly and widening of the mediastinum are stable.
Bibasilar consolidations have increased on the right. This could
be atelectasis or pneumonia in the appropriate clinical setting.
Mild Pulmonary edema is stable. Probably small bilateral
effusions.
___ CT HEAD
IMPRESSION:
Stable left-sided intraparenchymal hemorrhage and surrounding
edema, with extension of blood products into the ventricular
system, as above. Mass-effect is stable, including 8 mm shift of
normally midline structures and effacement of the left lateral
ventricle. Basal cisterns remain patent. No new focus of
hemorrhage. No ventriculomegaly status post clamping.
___ EEG
IMPRESSION:
This is an abnormal video-EEG monitoring session because of a
slow and disorganized background with multifocal slow
transients. No epileptiform abnormalities were seen. Although
the neurosurgery team indicated that the patient had an episode
around 10 a.m., no activations were recorded; the time around 10
a.m. was reviewed extensively with no changes seen. Interim
results were conveyed to the treating team intermittently
during this recording period.
___ PCXR
IMPRESSION:
There is no interval change in severe cardiomegaly, widening of
the mediastinum, bibasilar consolidations and mild pulmonary
edema. There are probably small bilateral effusions. There is
no pneumothorax. Lines and tubes are in standard position.
___ EEG
IMPRESSION:
This is an abnormal video-EEG monitoring session because of a
slow and disorganized background with multifocal slow
transients. No epileptiform abnormalities were seen. Interim
results were conveyed to the treating team intermittently during
this recording period.
___ CT HEAD
IMPRESSION:
Stable left intraparenchymal hemorrhage, surrounding vasogenic
edema, and intraventricular extent. Interval removal of
ventriculostomy. Ventricles are minimally increased in size
predominantly as indicated by increased size of the frontal
horns of the
lateral ventricles bilaterally, although this may be in part
artifactual secondary to differences in patient positioning.
Mass effect is unchanged with effacement of adjacent sulci and 7
mm rightward shift of normally midline structures.
___ PCXR
IMPRESSION:
Improved aeration of the bilateral lower lobes.
___ PCXR
IMPRESSION:
Compared to prior chest radiographs, ___ through ___.
Mild pulmonary edema improved in the right lung, stable on the
left. Wide postoperative cardiomediastinal silhouette
unchanged.
New tracheostomy tube is midline. No mediastinal widening,
pneumothorax, or associated pleural effusion.
Right PIC line ends upper right atrium
___ CT HEAD
IMPRESSION:
1. Evolving known large left thalamic intraparenchymal
hemorrhage with
intraventricular extension and extensive edema mass effect,
overall unchanged in extent.
2. No new hemorrhage.
3. Paranasal sinus disease.
___ EEG
IMPRESSION:
This telemetry captured no pushbutton activations. The
background was disorganized and slow, with ___ Hz maximum
frequencies in any given area and with some bursts of
generalized slowing. This finding is indicative of a moderate
encephalopathy that is nonspecific with regard to etiology but
can be seen with toxic metabolic disturbances or infections.
There were no focal abnormalities, definite epileptiform
discharges, or electrographic seizures.
___ EEG
IMPRESSION:
This telemetry captured no pushbutton activations, it showed a
slow and disorganized background with some bursts of generalized
delta slowing. these findings indicate a moderate to severe
encephalopathy. There were no clear focal abnormalities, but
encephalopathies may obscure focal findings. There were no
clearly epileptiform discharges or electrographic seizures.
Compared to prior day's recording, there was no significant
change.
___ CXR
In comparison ___, cardiomegaly is accompanied by
pulmonary
vascular congestion. Bibasilar atelectasis has worsened on the
left and
slightly improved on the right. Small left pleural effusion has
apparently
increased in size. No other relevant change.
DISCHARGE LABS
========================
___ 06:30AM BLOOD WBC-9.3 RBC-2.77* Hgb-7.7* Hct-25.7*
MCV-93 MCH-27.8 MCHC-30.0* RDW-14.5 RDWSD-48.5* Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-159* UreaN-96* Creat-2.0* Na-143
K-4.3 Cl-108 HCO3-25 AnGap-14
___ 06:30AM BLOOD Calcium-8.4 Phos-3.9 Mg-1.9
Brief Hospital Course:
Patient presented to the ER via Life Flight and was evaluated by
the neurosurgery and neuromedicine services. Ultimately decision
was made to place a right sided external ventricular drain and
admit him to the ICU for further care. The EVD was placed
without difficulty and placement was confirmed with non-contrast
CT scan. He underwent central line and arterial line placement
in the ICU. Off sedation his exam was quite poor as he was only
localizing with the LUE. Otherwise he had no motor response. His
EVD was working well and leveled at 10 cm H2O above the tragus.
On ___, Mr. ___ remained neurologically and hemodynamically
stable. He was intubated and minimally responsive to noxious
stimuli. His EVD was leveled at 10 cm H2O above the tragus and
draining appropriately. The patient's family was at the bedside
and updated on his status.
On ___, Mr. ___ remained neurologically and hemodynamically
stable. His EVD was leveled at 10cm H2O above the tragus and
draining appropriately. He remained unresponsive with a downward
gaze. His left upper extremity was localizing to pain and right
upper extremity to noxious stimuli. ___ was working with the
patient and noted some contraction of his right lower BKA and a
brace was applied. His left foot showed some flexion to noxious
stimulus. A repeat NCHCT was performed and remained essentially
unchanged.
On ___, the patient's exam remained stable. There were no acute
events.
On ___, the patient's exam very slightly declined. Discussed
with team that due to poor prognosis should not repeat
diagnostic imaging. He developed AFib in early evening,
Cardiology reported slow ventricular rates are likely related to
ongoing CNS process.
On ___, neurologically continues to be stable however EVD not
functioning. Repeat CT Head shows increased vents with small
acute blood in R occipital horn per Neuroradiology. Had
extensive conversation with the family regarding prognosis,
goals of care, and future medical care and they want to continue
at this point with full code, consent was obtained for EVD
exchanged. TSICU increased free h20 to 400cc q4h, will continue
with q4h checks.
On ___, the EVD was not draining in the AM. The EVD was flushed
x 1 and then draining appropriately. A NCHCT was done LT IPH
stable. The Ventricles decreased in size compared to previous.
___ consult for DM management. The ACS team was called by
TSICU for trach/PEG evaluation.
On ___, the EVD stopped working in AM- flushed distally then
proximally. Palliative care/Ethics was consulted for family
support. TPA given at 13:30 - tolerated clamp for about 13 mins.
The ICPs were ___ and the patients downward gaze became worse.
The serum NA was 147. The hematocrit was 25.7. The BUN 68/
creat 3.1 was noted to be trending up.
On ___, Mr. ___ remained hemodynamically and neurologically
stable. EVD continued to drain slowly at 8 cm above the tragus.
TPA was again instilled and the EVD was clamped for 15 minutes,
which the patient tolerated without any significant neuro
change.
On ___, the patient was febrile to 102.3. CSF cultures were
sent. His EVD continued to be level and draining at 8 cm. The
patient received a dose of TPA as of midnight last night and at
1130 today the EVD was clamped as a trial. The patient's ICPs
remained stable while clamped as of 1500.
On ___, the patient's EVD remained clamped. His neurologic exam
remained stable. A repeated head CT was stable. In the evening,
the patient was noted to have left facial twitching which was
not responsive to Ativan. His Keppra was increased. An EEG was
performed, which did not show any seizure activity. He became
febrile again over night to 102.5, so repeat blood cultures were
again sent.
On ___, there continued to be no seizure activity. His EVD was
pulled in the evening as his ICP remained normal after 48 hour
clamp trial. Staples were replaced at he EVD site as the
incision opened up.
On ___, a post pull head CT showed slight increased in
ventricles, but otherwise stable ICH. EEG monitoring continues
to be negative for seizures so it was discontinued.
On ___, neuro exam unchanged. ___ working with the patient.
Planning for family meeting ___.
On ___, neurologically stable. Family meeting to discuss
further steps in care; will progress with tracheostomy/peg
placement and rehab placement based on recovery of procedures.
ICU team increasing hypertension medications as tolerated to
better control HTN.
On ___, the patient underwent placement of a #8 Portex
tracheostomy and PEG. His operative course was uncomplicated
and he was transferred back to the ICU.
On ___, the patient remained on an insulin drip. The tube feeds
were restarted.
On ___, the patient remained neurologically stable on
examination. He was transitioned off of the insulin drip and
onto his home diabetes medications. His Hematocrit and
Hemoglobin were low and he received 1 unit of pRBCs.
On ___ the patients exam remained stable and his hematocrit was
26. This was up trending from the ___ result of 22.8 A
repeat hematocrit was sent for ___.
On ___ the patients exam was slightly declined as he was no
longer localizing his ___. On exam he was having weak withdrawal
to noxious stimuli to his LUE, otherwise his exam was stable. A
repeat hematocrit for today was 26.1 which is stable. He was
pending transfer and bed approval at a LTACH
On ___, the patient was found to have increased WOB and thick
secretions. He was on trach mask with 20% O2. His WBCs trended
up to 14. His BUN and creatinine was trending up to 68 and 2.3
and he was started on gentle hydration @ 75cc/hr of NS. He was
found to be more lethargic with a worsening neuro exam, however
repeat Head CT was stable. Chest XRay showed only mild
pulmonary edema. Both sputum and blood cultures were sent.
Given his complex medical history and lack of any current
Neurosurgical issues he is being transferred to Medicine.
Upon transfer to the Medicine service, a full work up for his
worsening lethargy was performed and his additional medical
issues were addressed as follows:
#Lethargy/leukocytosis:
In regards to infectious etiologies, the patient had negative
blood and urine cultures. Multiple endotracheal sputum cultures
were obtained demonstrating contamination from oral flora.
C.diff was negative. His CXR was not concerning for a new
consolidation. Review of CT scans notable for a persistent
sinusitis that partially responded to previous antibiotics
(meropenem and vancomycin received between ___. He
completed a course of IV Unasyn for an additional 5 days along
with mucinex (and glycopyrrolate for 1.5 days) and he had marked
improvement in his mucus secretions.
Additional causes of lethargy include seizure. EEG demonstrated
no epileptiform activity, but global encephalopathy. This can be
seen in many conditions, including cerebral edema, which the
patient continued to demonstrate on CT imaging. Steroids were
not indicated as per neurosurgery. Patient remained on seizure
ppx but the dose of keppra was reduced. Additional medical
causes of his lethargy include metabolic acidosis (see below).
#Acute on Chronic renal injury:
#Non-gap metabolic acidosis:
#Electrolyte derangements:
Family confirmed history of CKD but unknown baseline. Had been
on HD temporarily in the past for unclear reasons. New baseline
appears to be Cr ~2. At times, elevated creatinine thought to be
secondary hypovolemia as it improved with hydration. However, he
was then noted to have ongoing net positive fluid status and
torsemide was initiated. He was also noted to have a persistent
non-gap metabolic acidosis. Urine lytes consistent with impaired
NH4 secretion, likely metabolic acidosis of CKD. Patient with a
bicarb deficit of ~240 mEq, which was repleted with IV bicarb.
He was then started on PO bicarb 650mg BID. He was also noted to
have hyperkalemia with a peak of 5.6 that responded to IVF as
well as a mild hypernatremia that responded to free water
boluses. Torsemide was started and titrated to 20mg daily to
maintain fluid balance.
#HTN/CAD: on metoprolol at home. Goal BP 140-160 to maintain
perfusion in setting of edema but also reduced the risk of
further bleed from hypertension. He was kept within this range
effective with following regimen:
-labetol 400mg q6h
- PRN hydralazine for SBP > 160
#DM: on 32 units of glargine at home. Had significantly elevated
blood glucose that required an insulin drip initially (see
above) and then was ultimately better controlled with the
following regimen:
- Lantus 18 units q12h
- Novolog insulin 10units q6h.
- ISS.
#PVD: Home aspirin/Plavix restarted after cleared by
neurosurgery.
TRANSITIONAL ISSUES
- Will need to follow up with Dr. ___ Neurosurgery at
appointment above; will obtain repeat CT at this time. Please
also evaluate resolution of sinusitis.
- Significant new medications: Keppra, labetolol, bicarbonate,
torsemide.
- Patients last EF on ECHO was 35%, consider starting an ACEI
- New insulin regimen: 18 units glargine q12h; ISS Q6H
- Stopped medications: metoprolol succinate
- ASA/Plavix resumed at discharge
- Tube feeds and free water boluses as detailed in discharge
diet.
- Of note patient benefited with chest ___ for thick secretions,
consider continuing
- If significant change in neurologic status, please obtain stat
head CT
- patient's baseline Creatinine was unknown prior to admission.
Likely has new baseline Cr of ~2. Please monitor chem 10, while
on torsemide
- patient noted to be tachypneic with CXR showing pulmonary
vascular congestion on CXR. Tachypnea improved with torsemide
40mg. Now being discharged on Torsemide 20mg daily. Please
monitor volume status and adjust Torsemide dose PRN.
#Code: DNR/DNI
#Communication: wife ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Glargine 32 Units Bedtime
5. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain, fever
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
6. Docusate Sodium 100 mg PO BID
7. HydrALAzine 10 mg IV Q2HPRN SBP > 160
8. Labetalol 400 mg PO TID
9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
10. LeVETiracetam 750 mg PO BID
11. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
12. Senna 8.6 mg PO BID:PRN Constipation
13. Sodium Bicarbonate 650 mg PO BID
14. Aspirin 81 mg PO DAILY
15. Clopidogrel 75 mg PO DAILY
16. Tamsulosin 0.4 mg PO QHS
17. Miconazole Powder 2% 1 Appl TP QID:PRN rash
18. Glycopyrrolate 1 mg PO BID
19. Torsemide 20 mg PO DAILY
20. Glargine 18 Units Q12H
Insulin SC Sliding Scale using novolog Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L Basal ganglia Hemorrhage
Intraventricular Hemorrhage
Respiratory failure
Dysphagia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___ ,
It was a privilege to care for you at the ___
___. You were admitted to the hospital after
sustaining a severe brain bleed. You were treated by our
neurosurgeons for many days who feel that there is no major
further interventions to offer at this time. You were
transferred to the Internal Medicine service for management of
your other medical comorbidities. You were treated with a course
of antibiotics for possible sinusitis.
Please follow up with all scheduled appointments and continue
taking all medications as prescribed. If you develop any of the
danger signs below, please contact your health care providers or
go to the emergency room immediately.
We wish you the best.
Sincerely,
Your ___ team
Followup Instructions:
___
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2159-11-10 00:00:00
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2159-11-10 15:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
latex / propofol / lorazepam
Attending: ___.
Chief Complaint:
trach dislodgement
Major Surgical or Invasive Procedure:
replacement of tracheostomy tube with 7mm XLT
History of Present Illness:
___ with history of CABGx4, right BKA, DM, and HTN admitted on
___ with large left intraparenchymal hemorrhage with
intraventricular extension who is POD#13 from trach and PEG who
presents 1 days after discharge from neuromedicine team with
question of a dislodged tracheostomy tube. Per report, the
sutures were removed and cuff was deflated per protocol at
___ yesterday. He was doing well until his
nurse noted today the inability to suction through the
tracheostomy tube. He was subsequently transferred to ___ for
further workup. Of note, patient remained hemodynamically
appropriate, with normal oxygen saturation. He has maintained
the ability to protect his airway.
Past Medical History:
Past Medical History:
Intraparenchymal hemorrhage
CAD s/p CABG
Renal insufficiency (Hx of temporary dialysis)
Diabetes
Hypertension
Peptic ulcer - per wife, questionable
Past ___ History:
-Trach and PEG ___ ___
-R BKA
-knee replacement
-CABGx4
Social History:
___
Family History:
NC
Physical Exam:
Admission Physical Exam
GEN: NAD
HEENT: No scleral icterus, mucus membranes moist, trach not
flush
against skin, no drainage
CV: elevated HR
PULM: coarse breath sounds bilateral, +rhonchorous
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Discharge Physical Exam
Vitals: 99.6 90 140/70 13 97% on TC 38%
GEN: NAD
HEENT: No scleral icterus, mucus membranes moist, new
tracheostomy tube in placed and secured
CV: distant heart sounds, RRR, S1/S2
PULM: coarse breath sounds bilateral, +rhonchorous
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses, PEG in place and
secured
Ext: well healed right BKA, b/l extremity warm, well perfused,
no cyanosis, trace edema
Neuro: GCS 3- no eye opening to painful stimuli, no decorticate
or deceribrate response to painful stimuli, no verbal response.
Pertinent Results:
Discharge Labs
___ 01:33AM BLOOD WBC-10.0 RBC-2.88* Hgb-8.1* Hct-26.6*
MCV-92 MCH-28.1 MCHC-30.5* RDW-14.3 RDWSD-47.8* Plt ___
___ 01:33AM BLOOD ___ PTT-29.1 ___
___ 01:33AM BLOOD Glucose-131* UreaN-90* Creat-1.8* Na-143
K-4.5 Cl-107 HCO3-26 AnGap-15
___ 01:33AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.0
Imaging:
CXR ___
1. Poorly evaluated tracheostomy tube on this single portable
chest radiograph. Please refer to subsequent CT of the chest.
2. Low lung volumes with bibasilar atelectasis.
CT Neck with contrast ___
1. Malpositioned tracheostomy tube terminating in the soft
tissues of the neck anterior to the trachea.
2. 3.8 x 2.0 cm multiloculated cystic mass adjacent to the left
submandibular gland may represent a venous varix or an abnormal
lymph node. Further evaluation via non emergent ultrasound could
be performed.
Brief Hospital Course:
Mr. ___ presented to ___ 1 day after discharge with a
dislodged tracheostomy tube before a fully firmed tract had
developed. A tracheostomy exchange over a bougie with full
preparations for an oral crash intubation, if necessary, was
performed in the ED, and the former ___ portex tube was replaced
with a 7mm ___ XLT. His O2 saturations were labile for a
period of time in the ED and he was therefore placed in the ICU
overnight for monitoring, and then discharged back to rehab in
stable condition.
TRANSITIONAL ISSUES
- Continue follow up with Dr. ___ neurosurgery at
scheduled appointment. Repeat CT prior to follow-up. Please also
evaluate resolution of sinusitis.
- Continue tube feeds and free water boluses as detailed in
discharge diet.
- Incidental CT neck finding of a 3.8 x 2.0 cm multiloculated
cystic mass adjacent to the left submandibular gland which may
represent a venous varix or an abnormal lymph node. Further
evaluation will be needed via non emergent ultrasound by PCP.
COD STATUS: DNR/DNI
Communication: wife ___ ___
___ on Admission:
1. Acetaminophen 1000 mg PO Q6H:PRN pain, fever
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
6. Docusate Sodium 100 mg PO BID
7. HydrALAzine 10 mg IV Q2HPRN SBP > 160
8. Labetalol 400 mg PO TID
9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
10. LeVETiracetam 750 mg PO BID
11. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
12. Senna 8.6 mg PO BID:PRN Constipation
13. Sodium Bicarbonate 650 mg PO BID
14. Aspirin 81 mg PO DAILY
15. Clopidogrel 75 mg PO DAILY
16. Tamsulosin 0.4 mg PO QHS
17. Miconazole Powder 2% 1 Appl TP QID:PRN rash
18. Glycopyrrolate 1 mg PO BID
19. Torsemide 20 mg PO DAILY
20. Glargine 18 Units Q12H
Insulin SC Sliding Scale using novolog Insulin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain, fever
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes
4. Aspirin 81 mg PO DAILY
5. Bisacodyl 10 mg PO DAILY:PRN Constipation
6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
7. Clopidogrel 75 mg PO DAILY
8. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
9. Docusate Sodium 100 mg PO BID
10. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
11. Glucose Gel 15 g PO PRN hypoglycemia protocol
12. Glycopyrrolate 1 mg PO BID
13. Heparin 5000 UNIT SC BID
14. HydrALAzine 10 mg IV Q2H:PRN SBP > 160
15. Glargine 12 Units Q18H
Insulin SC Sliding Scale using REG Insulin
16. Labetalol 400 mg PO TID
17. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
18. LeVETiracetam 750 mg PO BID
19. Miconazole Powder 2% 1 Appl TP QID:PRN rash
20. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
21. Senna 8.6 mg PO BID:PRN Constipation
22. Sodium Bicarbonate 650 mg PO BID
23. Tamsulosin 0.4 mg PO QHS
24. Torsemide 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
tracheostomy dislodgement
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___ ,
You were brought back to ___
for evaluation of your tracheostomy tube. You required bedside
replacement of the tracheostomy tube.
Please follow up with all scheduled appointments and continue
taking all medications as prescribed. If you develop any of the
danger signs below, please contact your health care providers or
go to the emergency room immediately.
Sincerely,
___ Surgery Team
Followup Instructions:
___
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2159-12-07 00:00:00
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2159-12-07 20:27:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
latex / propofol / lorazepam / cefepime
Attending: ___.
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with history of CAD s/p CABG x
4, HFrEF, CKD stage III (previously on HD for 4 months ___ years
ago in the setting of bacteremia), type 2 DM, and recent left
intraparenchymal hemorrhage (___) s/p trach and PEG
presenting from rehab with acute blood loss anemia.
Since the patient's recent admission for intraparenchymal
hemorrhage, the patient has been at ___. There he had
been doing well, improving subjectively per his wife. However,
about 4 days prior, he was noted to have BRBPR. He was found to
have Hgb of 7.1 on ___ (baseline ___ as far back as recent
admission in ___ and was transfused 1 unit of blood ___
with rise to 7.8. He continued to have BRBPR and his hgb again
dropped to 7.1 on ___, and he was transfused another unit of
blood and started on a protonix gtt. 2 days PTA, the patient's
home ASA and Plavix were also held. His hgb ___ was noted to
have increased to 8.4. After a long discussion on GOC with pt's
wife and daughter, it was decided to keep pt full code and
transfer to ___ for management of GI bleed.
Of note, pt's recent rehab course was also complicated by ___
pneumonia, for which pt was started on cefepime, changed to
vancomycin, and finally narrowed to levaquin with plans to
complete a 10 day course on ___. Of note, the relevant culture
data was not included in transfer documents.
In the ED, initial vital signs were: 97.3 74 124/74 18 95% trach
mask . Exam was notable for: DRE with red blood and labs were
notable for ___ 9.6, H/H 8.1/25.7 from baseline, plts 190, Na
141, BUN/Cr 119/2.4 from baseline, INR 1.2, lactate 1.2. UA
showed 1 WBC, 1 RBC, mod blood, >300 protein and blood and urine
cultures were obtained. Imaging with CXR demonstrated mild
vascular congestion and atelectasis. The patient was given
Protonix 40mg IV x 1 and GI was consulted for possible
endoscopy, prior to admission to medicine.
Vitals prior to transfer were: 98.1 77 147/58 23 99% RA. Per the
patient's wife, who is at bedside, he appears to be at his
baseline mentation (non-verbal with spontaneous movements of his
left side - baseline right sided hemiparesis). Overnight, he
continued to have maroon stool and intermittent coughing.
Otherwise, he had a restful night per his wife.
Past Medical History:
PAST MEDICAL HISTORY:
-CAD, s/p CABG x4
-CKD with hx of temporary dialysis
-T2 Diabetes
-Hypertension
-Left intraparenchymal hemorrhage with intraventricular
extension s/p EVD placement and trach and PEG
-systolic CHF (EF35% on ___
PAST SURGICAL HISTORY:
-s/p R BKA ___ years ago
-s/p TKR
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION EXAM:
VITALS: 98.8 129/70 77 20 95% on 35% TM
GENERAL: Eyes closed, opens to voice and touch. in NAD
HEENT: Trach in place, JVP flat.
CARDIAC: RRR, normal S1/S2.
PULMONARY: Clear to auscultation anteriorly and laterally.
ABDOMEN: Normal bowel sounds, non-distended, G-tube in place, no
maroon stool visualized.
EXTREMITIES: LLE with chronic venous stasis changes, right BKA.
No pitting edema appreciated in ___.
SKIN: faint, pink, non-blanching macular rash involving L distal
extremity as well as anterior chest
NEUROLOGIC: Non-verbal, opens eyes to voice, some spontaneous UE
movements.
ACCESS: RUE MIDD line (c/d/I), LUE PIV
DISCHARGE EXAM:
VITALS: 99.1 ___ 140s-150s/60s-70s 18 100% on 35% FiO2 TM
GENERAL: NAD, eyes open, not responsive
HEENT: TM in place
CARDIAC: RRR, S1/S2.
PULMONARY: Clear to auscultation anteriorly and laterally.
ABDOMEN: Normal bowel sounds, non-distended, G-tube in place, no
maroon stool visualized.
EXTREMITIES: LLE with chronic venous stasis changes, right BKA.
No pitting edema appreciated in ___.
NEUROLOGIC: Non-responsive, opens eyes
Pertinent Results:
ADMISSION LABS:
___ 03:30PM BLOOD WBC-9.6 RBC-2.79* Hgb-8.1* Hct-25.7*
MCV-92 MCH-29.0 MCHC-31.5* RDW-17.7* RDWSD-57.7* Plt ___
___ 03:30PM BLOOD Neuts-68 Bands-2 Lymphs-15* Monos-4*
Eos-11* Baso-0 ___ Myelos-0 AbsNeut-6.72*
AbsLymp-1.44 AbsMono-0.38 AbsEos-1.06* AbsBaso-0.00*
___ 03:30PM BLOOD ___ PTT-29.5 ___
___ 03:30PM BLOOD Glucose-144* UreaN-119* Creat-2.4* Na-141
K-4.5 Cl-98 HCO3-30 AnGap-18
OTHER IMPORTANT LABS:
___ 03:31PM BLOOD Lactate-1.2
___ 08:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:30PM URINE Blood-MOD Nitrite-NEG Protein->300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-6.0 Leuks-NEG
___ 08:30PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
___ 08:30PM URINE Hours-RANDOM UreaN-532 Creat-29.1 Na-43
Cl-31 Phos-31.0
___ 08:30PM URINE Osmolal-332
CBC TREND:
___ 03:30PM BLOOD WBC-9.6 RBC-2.79* Hgb-8.1* Hct-25.7*
MCV-92 MCH-29.0 MCHC-31.5* RDW-17.7* RDWSD-57.7* Plt ___
___ 07:40AM BLOOD WBC-10.1* RBC-2.71* Hgb-7.9* Hct-25.7*
MCV-95 MCH-29.2 MCHC-30.7* RDW-18.2* RDWSD-59.3* Plt ___
___ 12:36AM BLOOD WBC-9.6 RBC-2.64* Hgb-7.7* Hct-24.6*
MCV-93 MCH-29.2 MCHC-31.3* RDW-17.3* RDWSD-57.0* Plt ___
___ 07:20AM BLOOD WBC-10.9* RBC-2.70* Hgb-7.8* Hct-25.5*
MCV-94 MCH-28.9 MCHC-30.6* RDW-17.6* RDWSD-58.7* Plt ___
___ 09:10PM BLOOD WBC-11.5* RBC-2.62* Hgb-7.6* Hct-24.7*
MCV-94 MCH-29.0 MCHC-30.8* RDW-17.2* RDWSD-57.9* Plt ___
___ 10:15AM BLOOD WBC-12.3* RBC-2.68* Hgb-7.7* Hct-25.8*
MCV-96 MCH-28.7 MCHC-29.8* RDW-17.1* RDWSD-59.1* Plt ___
___ 08:05AM BLOOD WBC-13.4* RBC-2.77* Hgb-8.2* Hct-26.8*
MCV-97 MCH-29.6 MCHC-30.6* RDW-17.2* RDWSD-60.5* Plt ___
___ 11:15AM BLOOD WBC-13.5* RBC-2.74* Hgb-7.9* Hct-26.1*
MCV-95 MCH-28.8 MCHC-30.3* RDW-16.7* RDWSD-57.8* Plt ___
CHEM 7 TREND:
___ 03:30PM BLOOD Glucose-144* UreaN-119* Creat-2.4* Na-141
K-4.5 Cl-98 HCO3-30 AnGap-18
___ 07:40AM BLOOD Glucose-129* UreaN-113* Creat-2.3* Na-145
K-4.0 Cl-102 HCO3-29 AnGap-18
___ 07:20AM BLOOD Glucose-174* UreaN-91* Creat-1.9* Na-147*
K-3.6 Cl-106 HCO3-30 AnGap-15
___ 10:15AM BLOOD Glucose-218* UreaN-74* Creat-1.8* Na-149*
K-4.0 Cl-109* HCO3-33* AnGap-11
___ 08:05AM BLOOD Glucose-199* UreaN-69* Creat-1.7* Na-149*
K-4.3 Cl-108 HCO3-32 AnGap-13
___ 11:15AM BLOOD Glucose-201* UreaN-66* Creat-1.6* Na-142
K-4.8 Cl-103 HCO3-30 AnGap-14
MICROBIOLOGY:
Sputum GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
IMAGING AND OTHER STUDIES:
CXR ___: Low lung volumes with mild pulmonary vascular
congestion and bibasilar atelectasis. Unchanged marked
enlargement of the cardiac silhouette.
US RUE ___
IMPRESSION:
Thrombus in the right basilic and cephalic veins, which are
superficial veins.
DISCHARGE LABS:
___ 11:15AM BLOOD WBC-13.5* RBC-2.74* Hgb-7.9* Hct-26.1*
MCV-95 MCH-28.8 MCHC-30.3* RDW-16.7* RDWSD-57.8* Plt ___
___ 11:15AM BLOOD Glucose-201* UreaN-66* Creat-1.6* Na-142
K-4.8 Cl-103 HCO3-30 AnGap-14
___ 11:15AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.3
Brief Hospital Course:
This is a ___ year old male with past medical history of CAD,
systolic CHF, type 2 diabetes complicated by diabetic
nephropathy (CKD stage IV) and peripheral vascular disease
status post R BKA, recent intraparenchymal hemorrhage with
chronic respiratory failure status post trach admitted ___ with
GI bleed of unclear origin, thought to have had a lower GI
bleed, but opting to not undergo colonoscopy because of his
history of a prior colonoscopy complicated by a PEA arrest,
bleeding resolving without intervention and remaining
hemodynamically stable.
# Acute blood loss Anemia / Lower GI Bleed: The patient
presented with bright red blood per rectum for several days,
initially treated at his long-term care facility. Given rate of
blood loss and hematochezia on exam, this was felt to be most
likely lower source, perhaps from AVM vs diverticulae. The
patient was closely and started on a PPI. His home aspirin and
plavix were held and he was evaluated by the GI service, who
felt that given the patient's overall poor health, the risks of
intervening outweighed the potential benefits (especially given
prior PEA arrest during endoscopy). Patient subsequently
remained stable without additional bleeding. Per discussion
with longitudinal providers, there was no clear ongoing
indication for clopidogrel--this was discontinued. His ASA was
restarted without event. At time of discharge, stool was brown,
H/H was 7.___.1.
# Acute Kidney Injury due to Pre-Renal Azotemia on Chronic
Kidney Disease, Stage III: The patiented with a Cr of 2.4 from a
baseline of 1.8-2.0 with rising BUN of 119 in the setting of GIB
and recent pneumonia. This was felt to be pre-renal in the
setting of active GIB and discontinuation of tube-feeds and
improved with IV rehydration and stabilization of her blood.
# Hypernatremia: The pt was admitted to the hospital with
hypernatremia. At long term care he had been on 250 cc Q4H free
water flushes. His free water deficit was calculated and he was
repleted, with free water flushes. His sodium normalized.
# Leukocytosis: Pt had persistent leukocytosis throughout
hospitalization. His WBC count was between ___. He had no
change in his secretions or evidence of decubitus ulcer
infection to suggest and infectious source. He remained
afebrile. His leukocytosis was ultimately most likely reactive.
# GPC Pneumonia: The patient presented with reported pneumonia
at rehab, initially started on cefepime (___) therapy and
eventually changed due to potential cutaneous drug eruption to
vancomycin and subsequently levofloxacin monotherapy. His
sputum from Kindred showed GPCs. His blood cultures from
Kindred were negative. He was continued on his planned 10 day
course of levaquin during this admission, with last day on
___.
# Eosinophilia and Cutaneous Eruption: The patient's wife stated
that he developed an eruption several days before admission
while he was at rehab. Given the time course of having been on
cefepime initially for pneumonia and peripheral, mild
eosinophilia (~1000k on admission), this was felt to be possible
drug eruption, macular/morbilliform, pink, and fading on exam.
His eruption was monitored closely and eosinophilia was trended
during this admission, with both trending downwards prior to
discharge.
# CAD s/p CABG x 4: The patient's home ASA and plavix were
initially held in the setting of active GI bleed. Given that the
patient was multiple years removed from his CABG, the patient
was only resumed back ton his ASA prior to discharge upon
stabilization of his GI bleed. Of note, the patient was also
changed from labetalol to carvedilol for added BP control this
admission.
# History of Intra-parenchymal Hemorrhage: The patient had
recently suffered a massive left basal ganglia and
intraventricular hemorrhage resulting in very limited mental
status. The patient was at his baseline mentation - unable to
verbalize and only able to move his left side - per his wife and
family. He was continued on his home levetiracetam for seizure
prophylaxis.
# Compensated systolic CHF: The patient has a history of
systolic CHF (EF 35% on most recent TTE ___ and did not
appear grossly fluid overloaded on exam. His home torsemide and
beta blocker were held on admission in the setting of active
GIB. His B-Blocker was quickly restarted once his bleeding and
hemodynamics were deemed stable. His torsemide was held on
discharge--would closely monitor volume status and consider
restarting.
# Insulin-Dependent Type 2 Diabetes Mellitus: The patient was
managed on a lower dose basal-bolus regimen of insulin while his
tubefeeds were initially held in the setting of active GIB. Upon
resuming his home tubefeed regimen, he was transitioned back to
his home regimen of regular and detemir insulin.
# Chronic Respiratory failure s/p trach: The patient suffered
respiratory failure due to his massive ICH as above and was
trach'ed during his prior admission. He was managed supportively
with humified air via trach-mask, albuterol nebulizers, mouth
care, and suction by nursing and respiratory therapy as needed
during this admission.
# Benign Prostatic Hyperplasia: Continued tamsulosin
Transitional Issues:
- Discontinued clopidogrel
-H/H on discharge: 7.___.1
-Na on discharge: 142
- Would consider repeating CBC and metabolic panel ___ to
follow up on hemoglobin/hematocrit, sodium
-Contact: ___ (Wife) ___
-Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg NG Q6H:PRN Fever, pain
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN Wheezing
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
4. Bisacodyl ___AILY:PRN Constipation
5. budesonide 0.5 mg/2 mL inhalation Q12H
6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
7. Docusate Sodium 100 mg NG BID
8. Glucagon 1 mg IM Q15MIN:PRN Hypoglycemia
9. Glycopyrrolate 1 mg NG BID
10. Detemir 20 Units Q12H<br> Regular 16 Units Q6H
11. Labetalol 400 mg NG Q8H
12. LevETIRAcetam 750 mg PO Q12H
13. Levofloxacin 750 mg IV Q48H
14. Miconazole Powder 2% 1 Appl TP QID:PRN Rash
15. Sodium Bicarbonate 650 mg PO BID
16. NovaSource Renal 2 Cal (nut.tx.impaired renal fxn,soy) 0.09
gram- 2 kcal/mL oral Q6H
17. Nystatin Oral Suspension 5 mL PO Q6H
18. Artificial Tears ___ DROP BOTH EYES PRN Dry eyes
19. Pantoprazole 8 mg/hr IV INFUSION
20. Polyethylene Glycol 17 g PO DAILY
21. Senna 8.6 mg PO Q12H
22. Tamsulosin 0.4 mg PO QHS
23. Torsemide 20 mg NG DAILY
24. Aspirin 81 mg PO DAILY
25. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg NG Q6H:PRN Fever, pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Artificial Tears ___ DROP BOTH EYES PRN Dry eyes
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
5. Glucagon 1 mg IM Q15MIN:PRN Hypoglycemia
6. Detemir 20 Units Q12H<br> Regular 16 Units Q6H
7. LevETIRAcetam 750 mg PO Q12H
8. Nystatin Oral Suspension 5 mL PO Q6H
9. Tamsulosin 0.4 mg PO QHS
10. Sodium Bicarbonate 650 mg PO BID
11. Senna 8.6 mg PO Q12H
12. Polyethylene Glycol 17 g PO DAILY
13. NovaSource Renal 2 Cal (nut.tx.impaired renal fxn,soy) 0.09
gram- 2 kcal/mL oral Q6H
14. Miconazole Powder 2% 1 Appl TP QID:PRN Rash
15. Glycopyrrolate 1 mg NG BID
16. Docusate Sodium 100 mg NG BID
17. budesonide 0.5 mg/2 mL inhalation Q12H
18. Bisacodyl ___AILY:PRN Constipation
19. Albuterol Inhaler 2 PUFF IH Q6H:PRN Wheezing
20. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
21. Carvedilol 12.5 mg PO BID
22. Aspirin 81 mg PO DAILY
23. Torsemide 20 mg NG DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Acute blood loss Anemia / Lower GI Bleed
# Acute Kidney Injury due to Pre-Renal Azotemia on Chronic
Kidney Disease, Stage III
# Hypernatremia
# Leukocytosis
# GPC Pneumonia
# Eosinophilia and Cutaneous Eruption
# CAD s/p CABG x 4
# History of Intra-parenchymal Hemorrhage
# Compensated systolic CHF
# Insulin-Dependent Type 2 Diabetes Mellitus
# Chronic Respiratory failure s/p trach
# Benign Prostatic Hyperplasia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you. You were admitted to the
hospital because you had blood in your stool. In the hospital,
you were seen by the gastroeneterology team (intestinal
doctors), who did not feel that a procedure would be helpful for
you. You were given medications to help protect the lining of
your stomach and monitored closely for any drops in blood
counts. Upon discussion of potential risks and benefits of
anticoagulant (blood thinner) medications, it was decided that
you should be on aspirin but not Plavix (clopidogrel). Please
do not take Plavix (clopidogrel), as this medication can raise
your risk of bleeding. After you were felt to be medically
stable, you were sent back to Kindred. You may continue to have
a small amount of bleeding in your stool, but you do not need to
come back to the hospital unless you are feeling sick or your
blood counts drop. Thank you for allowing us to participate in
your car.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10888529-DS-21
| 10,888,529 | 21,052,272 |
DS
| 21 |
2160-09-26 00:00:00
|
2160-09-27 11:42:00
|
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nifedipine / lactose / lactose / silver sulfadiazine
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w PMH s/f CAD, h/o basal cell ca, HLD, hypertrophic
cardiomyopathy, CKD Stage III, gout, found down in apartment,
confused. Patient does not remember any significant history,
does not remember events leading up to or after the fall, first
thing she remembers is waking up in the ED. Per ED
documentation, "fall was witnessed fall at her facility this
morning while using cane, rubber tip of cane slid up, metal
caught on the rug and she fell forward." Per patient she did not
notice any symptoms in days or hours preceding fall: ___ f/c/ns,
weight loss/gain, palpitations/tachycardia, SOB, cp. Last fall
per patient ___ years ago. ___ h/o of sz. Per pt ___ urinary/stool
incontinence.
Patient evaluted in ED:
In the ED, initial vitals were: 98.5 84 196/101 20 100%
ED exam significant for large left eye ecchymosis, surgical
pupils, ___ c spine tenderness, chest wall bruising, ___ posterior
T or L spine tenderness, acute confusion with AAOx1.
Labs: Only significant for hyperglycemia 130, Cr 1.1, bland U/A
Imaging: CT spine negative for fracture. CT sinus significant
for left orbital floor fracture extending to the maxillary sinus
with minimal displacement. CT abd/pelvis negative.
Plastics, Optho, Trauma consulted. ___ surgical intervention
necessary at this time. Recommended sinus precautions. ___ e/o
globe injury with orbital fracture, ___ clinical entrapment.
Patient given:
___ 20:42 PO/NG Ranitidine 150 mg
___ 08:00 PO/NG Lisinopril 20 mg
___ 08:00 PO Diltiazem Extended-Release 240 mg
___ 13:25 PO/NG Ranitidine 150 mg
Pt was initially observed in ED d/t initial disorientation, also
d/t late hour, with plans to return to original housing or
___. Orientation improved A&Ox 3, ___ evidence of
inattentiveness or disorientation or disorganized thought or
delirium. During this period blood cultures grew out gram
positive cocci in pairs and chains in ___ bottles, ___ known
source. Patient admitted for repeat blood cultures x 2 and
monitoring for fever.
On the floor, VS 97.7 150/56 78 20 96%RA. Pt denies any
symptomology preceding the event as listed above. Denies any
dental procedures in past ___ months. When asked about
constitutional sx, pt states that she has felt "worn out" for
several days; when asked further, she says that she feels
"perked up with coffee" and has not noticed any weakness,
malaise, dyspnea, etc. Denies any localizing signs of infection
including sinus tenderness, rhinorrhea or congestion, nausea,
vomiting, diarrhea, constipation or abdominal pain, change in
bowel or bladder habits, dysuria, increased frequency or
urgency, headaches. Pt denies any changes in vision or floaters
from the fall. Endorses remote h/o fall ___ years ago when
tripping over metal grate after leaving doctor's office,
otherwise ___ other falls. ___ h/o seizure. ___ substernal chest
pain or tightness, palpitations, DOE; rare use of NG. Stable
weight. Patient endorses mild tenderness on right breast
occuring after the fall.
Review of systems: A complete review of systems was conducted;
pertinent postives and negatives stated above.
Past Medical History:
Osteoarthritis
Coronary artery disease -- ___ h/o MI
Hypertension, essential
History of Basal Cell Carcinoma
Hypercholesterolemia
Macular Degeneration
Interventricular hemorrhage ___ car accident ___ years ago per pt
Mild Mitral Valve insufficiency
Osteopenia
Esophageal Reflux
___ buc pus= nl r ov.tiny simple cysts in l ov.
Hypertriglyceridemia
Obesity
s/p Small Bowel Resection for polyp ___ years ago
Hypertrophic cardiomyopathy
Chronic kidney disease (CKD), stage III (moderate)
Gout
Fall at home
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM on admission:
VS 97.7 150/56 78 20 96%RA
General: erly female, WDWN, Alert, oriented, ___ acute distress
HEENT: normocephalic, ___ fracture/discontinuities palpated on
scalp. Sclera anicteric ___ subconjctival hemorrhage, MMM,
oropharynx clear, EOMI, PERRL; ecchymosis to L orbit, fair
dentition.
Neck: Supple, JVP not elevated, ___ LAD, ___ cervical collar, ___
neck stiffness
CV: Regular rate and rhythm, normal S1 + S2, ___ holosystolic
murmurs best appreciated at LUSB, ___ rubs or gallops
Lungs: Clear to auscultation bilaterally, ___ wheezes, rales,
rhonchi. Focal TTP over R breast.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
___ organomegaly, ___ rebound or guarding
GU: ___ foley
Ext: Thin extremities. 1+ pitting edema b/l R >L. ___ hair on
pretibial surfaces. ___ open wounds. Warm, well perfused, 1+
pulses, ___ clubbing or cyanosis. ___ splinter hemorrhages or
___ nodes noted on fingers/nails.
Neuro: CNII-XII completely tested and intact, ___ strength
upper/lower extremities, grossly normal sensation, gait
deferred.
Pertinent Results:
Labs on admission
------------------
___ 01:40PM BLOOD WBC-10.8 RBC-4.29 Hgb-13.1 Hct-39.1
MCV-91 MCH-30.5 MCHC-33.4 RDW-14.1 Plt ___
___ 01:40PM BLOOD Neuts-52.6 ___ Monos-6.5 Eos-1.4
Baso-0.5
___ 01:40PM BLOOD ___ PTT-25.8 ___
___ 01:40PM BLOOD Plt ___
___ 01:40PM BLOOD Glucose-130* UreaN-20 Creat-1.1 Na-135
K-4.8 Cl-99 HCO3-23 AnGap-18
___ 01:40PM BLOOD CK(CPK)-96
___ 01:49PM BLOOD Lactate-2.8*
Imaging
---------
STUDIES:
___-SPINE W/O CONTRAST ___
___
IMPRESSION:
Degenerative changes without fracture or malalignment.
___ Imaging CT SINUS/MANDIBLE/MAXIL ___
___ IMPRESSION:
Left orbital floor fracture extending to the maxillary sinus
with minimal displacement. Left periorbital/preseptal soft
tissue swelling.
___HEST W/CONTRAST ___
IMPRESSION:
1. ___ acute sequelae of trauma.
2. Tiny nodules within the lungs measuring less than 4 mm. If
there is elevated risk factors for malignancy, repeat CT may be
performed in ___ year to ensure stability
___BD & PELVIS WITH CO ___
___
IMPRESSION:
1. ___ acute sequelae of trauma.
2. Tiny nodules within the lungs measuring less than 4 mm. If
there is elevated risk factors for malignancy, repeat CT may be
performed in ___ year to ensure stability.
___ Imaging CT HEAD W/O CONTRAST ___
___
___ acute intracranial process. Left periorbital and preseptal
hematoma/ soft tissue swelling -- please refer to dedicated CT
facial bones for further details.
Microbiology
---------------
Date 6 Lab # Specimen Tests Ordered By
All ___ All BLOOD CULTURE
All EMERGENCY WARD INPATIENT
___ BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {VIRIDANS STREPTOCOCCI}; Anaerobic Bottle
Gram Stain-FINAL EMERGENCY WARD
Brief Hospital Course:
___ w PMH s/f CAD, h/o basal cell ca, HLD, hypertrophic
cardiomyopathy, CKD Stage III, gout, referred to ED after beign
found down in apartment and confused. Although patient does not
remember any significant history, per ED documentation, fall was
witnessed and mechanical in nature. Patient's initially exam
concerning for confusion, AAOx1, also for large left eye
ecchymosis. Imaging ruled out C-spine injury, but revealed left
orbital fracture. Plastics, Optho, Trauma consulted. ___ surgical
intervention necessary at this time. Recommended sinus
precautions. ___ e/o globe injury with orbital fracture, ___
clinical entrapment. Pt was initially observed in ED, with
complete resolution of her altered mental status. During this
period, blood cultures grew out gram positive cocci in pairs and
chains in 2 out of 2 bottles, ___ known source, ___ localizing
signs of infection. Patient admitted for repeat blood cultures
and monitoring for fever. ___ antibiotics given. On floor, vitals
stable, ___ recent dental procedure, ___ localizing signs of
infection. ___ fevers or chills overnight. Repeat blood cultures
without growth. Original blood cultures on ___ speciated
out viridans streptococcim, most likely due to oral trauma
during fall. Patient was deemed medically stable for discharge.
She is to follow up with opthalmology and her primary care
provider.
TRANSITIONAL ISSUES
===================
[] PCP: CT with tiny nodules within the lungs measuring < 4 mm.
If there is elevated risk factors for malignancy, repeat CT may
be performed in ___ year to ensure stability
[] PCP: ___ precautions x 1 week (e.g. ___ using straws, sneeze
with
mouth open, ___ sniffing, ___ smoking, keep head of bed elevated
to
45 degrees).
[] PCP: ___ follow up pending blood cultures
[] Optho: Patient with L orbital fracture, ___ signs of
entrapment or globe injury
# CODE: DNR/okay to intubate
# CONTACT: patient's niece(HCP) who lives in ___ - ___
___ at Phone Number ___. (Other Emergency Contact,
___, not HCP: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranitidine 150 mg PO TID W/MEALS
2. Colchicine 0.6 mg PO DAILY
3. Lisinopril 20 mg PO BID
4. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID
5. Ketoconazole Shampoo 1 Appl TP ASDIR
6. Lactobacillus acidoph-L. bifid 1 tablet oral Daily
7. Psyllium 1 PKT PO DAILY
8. Diltiazem Extended-Release 240 mg PO DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Artificial Tears ___ DROP BOTH EYES BID
11. LOPERamide 2 mg PO QID:PRN diarrhea
12. Acetaminophen 325 mg PO Q6H:PRN fever/pain
13. lysine 500 mg oral daily
14. Multivitamins 1 TAB PO DAILY
15. Calcium with Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral daily
16. Aspirin 325 mg PO EVERY OTHER DAY
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN fever/pain
2. Artificial Tears ___ DROP BOTH EYES BID
3. Aspirin 325 mg PO EVERY OTHER DAY
4. Colchicine 0.6 mg PO DAILY
5. Diltiazem Extended-Release 240 mg PO DAILY
6. Lisinopril 20 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Ranitidine 150 mg PO TID W/MEALS
9. Calcium with Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral daily
10. Ketoconazole Shampoo 1 Appl TP ASDIR
11. Lactobacillus acidoph-L. bifid 1 tablet oral Daily
12. LOPERamide 2 mg PO QID:PRN diarrhea
13. lysine 500 mg oral daily
14. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
16. Psyllium 1 PKT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
-------------------
MECHANICAL FALL
L ORBITAL FRACTURE
STREPTOCOCCI VIRIDANS BACTEREMIA
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 for a fall. You fractured the orbit bone
around the eye. You were evaluated by plastic surgery and
opthalmology, who felt that surgical intervention was not
indicated at this time. You were also found to have bacteria
growing in the blood, so you were monitored overnight for any
signs of infection.
Please follow up with your primary care provider and
ophthalmologist. The plastic surgeons recommend "sinus
precautions for 1 week" which means ___ using straws, ___
sniffing, ___ smoking. Try to sneeze with your mouth open and
keep head of bed elevated at this time.
It was a pleasure taking care of your at ___. We wish you
well.
Sincerely,
Your Team at ___
Followup Instructions:
___
|
10888859-DS-12
| 10,888,859 | 20,124,262 |
DS
| 12 |
2150-01-04 00:00:00
|
2150-01-04 14:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Compazine
Attending: ___
Chief Complaint:
Jaw pain
Major Surgical or Invasive Procedure:
ORIF mandible
History of Present Illness:
___ yo male s/p assault (multiple blows to the face by back of
knife), -LOC presents to ED complaining of jaw pain. Pt was
assaulted last night and was transferred to ___ and from there
to
___. Pt complains of malocclusion, loose teeth and difficulty
swallowing. Denies chipped teeth, changes in vision, changes in
hearing, diplopia, headaches, chest pain, SOB, chills, fever,
sweats.
Past Medical History:
none
Social History:
___
Family History:
Non-contributory
Physical Exam:
Gen: Alert, oriented x3, NAD
Head: Normocephalic, linear laceration of 5 cm length superior
to
the left eyebrow
Eyes: EOMI, PERRL, no gross changes in vision, no diplopia
Ears: Hearing grossly intact, no battle sign, no ottorhea
Nose: Nontender, no crepitus, no septal hematoma, no rhinorrhea,
no epistaxis
Throat/IOE: Multiple carious teeth present, malocclusion, bony
stepoff between teeth 26 and 27, FOM non-elevated, soft and
tender to palpation. Pt gaurding to 15 mm. Uvula midline,
oropharynx clear.
EOE: Moderate swelling of lower left face, tender to palpation,
no LAD, no TMJ pain, clicking or crepitus.
Neuro: CN2-12 grossly intact
CV, Pulm, GU, GI: No other systemic issues
Pertinent Results:
CT/panorex (OMFS read):
Right displaced compound parasymphysis fracture between #26 and
#27, left displaced compound fracture of angle of mandible
___ 05:05AM BLOOD WBC-13.6* RBC-4.01* Hgb-12.7* Hct-39.0*
MCV-97 MCH-31.7 MCHC-32.6 RDW-12.8 Plt ___
___ 07:30AM BLOOD WBC-3.6* RBC-3.43* Hgb-10.8* Hct-33.2*
MCV-97 MCH-31.6 MCHC-32.6 RDW-12.0 Plt ___
Brief Hospital Course:
Patient admitted to ___ service on ___. Patient made NPO,
started on IV ancef, and pain control with IV dilaudid. Surgery
with OMFS on ___. Tolerated surgery well. Continued pain
management with IV toradol, tylenol, and dilaudid. On ___
transitioned to PO pain meds (ibuprofen, tylenol, morphine) and
JP drain pulled which was draining scant serosanginous fluid.
F/U arranged with OMFS for 1 week.
Patient in stable condition and pain well controlled with PO
pain meds at time of discharge.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg/20.3 mL 650 mg by mouth every six (6)
hours Refills:*0
2. Ibuprofen 400 mg PO Q8H:PRN pain
RX *ibuprofen [Advil] 100 mg 6 tablet(s) by mouth three times a
day Disp #*126 Tablet Refills:*0
3. Morphine Sulfate (Oral Soln.) ___ mg PO Q4H:PRN pain
RX *morphine 10 mg/5 mL ___ mL by mouth every four (4) hours
Disp ___ Milliliter Milliliter Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Mandible fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen by OMFS who operatedon your mandible fracture.
They removed the drain in your neck the morning of discharge.
You will follow-up with them in their clinic as instructed
below.
Please call the number below or come to the Emergency
Department if you experience:
* fevers/chills/sweats
* an increase in your pain despite pain medication
* any other symptoms that concern you
Followup Instructions:
___
|
10888963-DS-15
| 10,888,963 | 23,686,022 |
DS
| 15 |
2153-12-16 00:00:00
|
2153-12-16 14:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: laparoscopic appendectomy
History of Present Illness:
Per admitting resident: Patient is a ___ w/ history of
hypertension, hyperlipidemia, Grave's disease s/p thyroid
ablation, and cecal colitis in ___ treated with antibiotics who
presents with new onset abdominal pain that started yesterday
afternoon. She reports one episode of vomiting last night,
nonbloody. She reports anorexia.
Past Medical History:
HTN, HLD, Graves disease
Past Surgical History:
wisdom teeth
Social History:
___
Family History:
breast cancer/afib in mother, thyroid cancer in brother
Physical ___:
T 97.7 BP 102/52 P 82 RR ___ RA
Gen: 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/guarding
Wounds: abd with primary dressing, clean, dry and intact; no
periwound erythema
Ext: no lower extremity edema or tenderness, bilaterally
Pertinent Results:
LABS:
___ 09:00AM BLOOD WBC-16.6*# RBC-3.93 Hgb-11.6 Hct-35.3
MCV-90 MCH-29.5 MCHC-32.9 RDW-12.5 RDWSD-41.8 Plt ___
___ 09:00AM BLOOD Neuts-84.7* Lymphs-8.1* Monos-6.0
Eos-0.4* Baso-0.2 Im ___ AbsNeut-14.10*# AbsLymp-1.34
AbsMono-0.99* AbsEos-0.06 AbsBaso-0.04
___ 09:00AM BLOOD Plt ___
___ 09:00AM BLOOD ___ PTT-25.6 ___
CTA ABD & PELVIS
Acute appendicitis with no drainable fluid collection or
extraluminal air.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal
pain. Admission abdominal/pelvic CT revealed acute
appendicitis; patient had a mild leukocytosis with WBC of 16.
Given presentation and CT scan results, the patient was taken to
the operating room where she underwent laparoscopic
appendectomy; please see operative note for details. After a
brief, uneventful stay in the PACU, the patient was transferred
to the general surgery ward.
Post-operatively, the patient remained afebrile with well
controlled pain. She was mildly hypotensive (SBP 90-102), but
asymptomatic. Therefore, only her home metoprolol was resumed
and she will monitor her BP at home and restart her valsartan
and hctz pending results. Ms. ___ diet was advanced to
regular and well tolerated without pain, nausea or vomiting.
Additionally, she was ambulating and voiding without assistance
and subsequently discharged to home on POD1. 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. Valsartan 80 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Simvastatin 10 mg PO QPM
4. ValACYclovir 1000 mg PO ASDIR
5. Omeprazole 20 mg PO DAILY
6. calcium citrate-vitamin D3 200 mg calcium -250 unit oral
DAILY
7. Aspirin 81 mg PO DAILY
8. albuterol sulfate 90 mcg/actuation inhalation ASDIR
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Levothyroxine Sodium 112 mcg PO DAILY
11. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
Do not exceed 3000 mg per 24 hours.
2. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
4. Vitamin D unknown PO DAILY
5. albuterol sulfate 90 mcg/actuation inhalation ASDIR
6. Aspirin 81 mg PO DAILY
Begin ___
7. Atenolol 25 mg PO DAILY
Hold if your systolic blood pressure is less than 90.
8. calcium citrate-vitamin D3 200 mg calcium -250 unit oral
DAILY
9. Hydrochlorothiazide 12.5 mg PO DAILY
Restart ___ depending on BP readings.
10. Levothyroxine Sodium 112 mcg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Simvastatin 10 mg PO QPM
13. ValACYclovir 1000 mg PO ASDIR
14. Valsartan 80 mg PO DAILY
Restart ___ depending on BP readings.
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:
Dear Ms. ___,
You have undergone a laparoscopic appendectomy, recovered in the
hospital and are now preparing for discharge to home with the
following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. 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:
___
|
10889238-DS-3
| 10,889,238 | 25,266,962 |
DS
| 3 |
2170-05-10 00:00:00
|
2170-05-10 14:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right shoulder pain and chills
Major Surgical or Invasive Procedure:
___
___ Bilateral shoulder arthrocentesis
History of Present Illness:
___ year old Male who actively uses injectable heroin, who
presents with chest cellulitis with concern for mediastinitis.
He initially presented to ___ with several days of
pain ___ both shoulders, which then progressed to difficulty ___
lying on his back or leaning forward due to the pain. He reports
that it is extremely hard to move his shoulders due to the pain.
While he has a strong history of active heroin injection, he
states that his last injection before the onset of the shoulder
pain was ___ weeks prior. He reports that he did use some heroin
for pain control given the lack of relief from ibuprofen. After
his chest pain became severe he presented to ___. Given
their concern for mediastinitis/SC joint osteomyelitis he was
referred over to ___.
On the day of presentation his neck and his upper chest were
hurting as well. He denies fevers, but does note some "cold
chills" over the last several days. He vomited once the day
prior to admission. He has been taking ibuprofen for his pain
without relief.
___ the ED initial vitals were 99.6, tMax 100.2, 101, 134/79, 18,
96%. He was given vancomycin ___ the ED. CT of the chest and
neck, along with MRI of the ___ were performed.
Past Medical History:
Opiate Dependence
Hepatitis C
Social History:
___
Family History:
Mother: healthy
Father: died at ___ of brain cancer
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 99.6, 124/70, 112, 20, 93%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Non-Focal
MSK: Marked tenderness on passive ROM of B/L shoulder - unable
to raise above 90 degrees, able to tolerate pressure on b/l
mid-clavicles, marked skin tenderness over SC joint so hard to
assess where pain is coming from.
DERM: 15cm erythematous patch over manubrium extending to
mid-clavicular line and to base of neck
- Splinters, - janeways, - oslers
Discharge Physical Exam:
Vitals: 98.0 ___ 16 96RA
Gen: NAD, AOx3
HEENT: EMOI, MMM
Pulm: CTAB/L
Cor: RRR, s1/s2, no MRG
Abd: soft, nontender, nondistended
Ext: warm, well perfused no edema or cyanosis, bilateral 2+
radial pulses
MSK: s/p right clavicle debridement ~8cmx4cm with exposed bone
margins, muscle and tissue appear viable, no evidence of
necrosis, no purulent drainage, no surrounding skin erythema
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
___ 05:42 6.7 3.84* 11.3* 32.5* 85 29.5 34.8 13.2
410
___ 05:40 6.5 3.90* 11.2* 34.0* 87 28.7 32.9 13.3
361
___ 06:20 9.4 3.90* 11.6* 33.3* 85 29.8 34.9 13.1
304
___ 06:00 11.1* 4.05* 12.0* 34.0* 84 29.5 35.2* 13.1
271
___ 03:19 11.1* 4.18* 12.2* 34.5* 83 29.3 35.5* 13.1
259
___ 01:09 12.6* 4.36* 12.9* 36.8* 84 29.5 35.0 13.4
232
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
___ 01:09 83.3* 9.3* 6.8 0.5 0.2
Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 07:02 851 9 0.7 135 4.3 99 28 12
___ 05:42 791 13 0.6 134 4.4 100 25 13
___ 08:40 791 18 0.7 139 3.8 ___
___ 06:00 136*1 5* 0.7 129* 3.6 92* 25 16
___ 14:50 130* 3.6 92*
___ 03:19 ___ 130* 3.9 92* 26 16
___ 19:05 7 0.9 126* 4.0 87* 25 18
___ 01:09 ___ 129* 3.8 91* 22 20
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 01:09 21 41* 71 0.5
___ 1:09 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
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.
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 ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___ ON ___
- ___.
GRAM POSITIVE COCCI ___ CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ CLUSTERS.
___ 7:40 am BLOOD CULTURE SET#2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ PAIRS AND CLUSTERS.
___ 7:05 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES PERFORMED ON CULTURE # ___
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ CLUSTERS.
___ 7:25 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES PERFORMED ON CULTURE # ___
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ CLUSTERS.
___ 11:51 pm BLOOD CULTURE R HAND.
**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.
SENSITIVITIES PERFORMED ON CULTURE # 41___
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ PAIRS AND CLUSTERS.
___ 3:31 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.
SENSITIVITIES PERFORMED ON CULTURE # ___
___.
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___ ON ___
- ___.
GRAM POSITIVE COCCI ___ CLUSTERS.
___ 7:06 am BLOOD CULTURE Source: Venipuncture.
**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.
SENSITIVITIES PERFORMED ON CULTURE # ___
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ CLUSTERS.
___ 6:23 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.
SENSITIVITIES PERFORMED ON CULTURE # ___
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI.
___ CLUSTERS.
___ 9:55 am JOINT FLUID Site: SHOULDER
SOURCE: RIGHT SHOULDER.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 10:10 am JOINT FLUID Site: SHOULDER
SOURCE: LEFT SHOULDER.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 6:00 am BLOOD CULTURE 1 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:00 am BLOOD CULTURE 1 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:20 pm SWAB CHEST WALL ABSCESS.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(___).
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Time Taken Not Noted ___ Date/Time: ___ 4:33 pm
TISSUE MEDIA STINALM SOFT TISSUE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
Reported to and read back by ___ ___ ___
@___.
TISSUE (Final ___:
STAPH AUREUS COAG +. MODERATE 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.
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 ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Time Taken Not Noted ___ Date/Time: ___ 4:35 pm
TISSUE JOINT CAPSUEL.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
Reported to and read back by ___ ___ ___
___.
TISSUE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
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 ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
>> IMAGING:
CT NECK W/CONTRAST (EG:PAROTIDS) Study Date of ___ 6:07
AM
Normal CT of the neck.
Please see concurrently obtained chest CT report for
intrathoracic findings
CT CHEST W/CONTRAST Study Date of ___ 6:06 AM
1. Soft tissue stranding of the anterior chest wall with
extension above and behind the manubrium. This is concerning
for anterior mediastinal involvement of infection. No evidence
of abscess or fluid collection. Further evaluation for manubrial
osteomyelitis could be performed with MRI.
2. Mixed attenuation nodule measuring 7 mm ___ the lateral
aspect of the left upper lobe warrants ___ months followup CT
of the chest.
MR ___ W/O CONTRAST Study Date of ___ 4:04 AM
1. No epidural fluid collections or abscess.
No canal or foraminal narrowing or suspicious focal lesions ___
the spine or ___ the spinal cord, allowing for the motion and
pulsation artifacts on multiple sequences. Mild degenerative
changes ___ the cervical, thoracic and lumbar spine as described
above. C4-5, C5-6: Mild disc bulge, small central component; no
disc herniation, no canal or foraminal narrowing.
T4-T5: Small right paracentral protrusion, no canal or foraminal
disc
desiccation narrowing. L5-S1: Disc dessication, disc space
narrowing, mild diffuse disc bulge with shallow right
paracentral component indenting the thecal sac outline ; no
canal or foraminal narrowing
2. Moderate to marked distension of the urinary bladder,
correlate clinically.
3. Bilateral pleural effusions, consolidation/ collapse ___ the
left lung lower lobe, better assessed on the concurrent CT chest
study.
CT head: ___
1. No acute intracranial process.
2. Approximately 6 x 15 mm right occipital scalp soft tissue
mass, which may represent a sebaceous cyst. Recommend clinical
correlation and correlation with direct examination.
MRI Mediastinum/Chest: ___
Large infection and abscess centered at the right
manubrioclavicular joint, and right first chondral cartilage,
spanning up to 11.4 x 4.0 x 4.0 cm, with osteomyelitis of the
entire manubrium and suspected involvement of the left
manubrioclavicular joint. The abscess extends deep through the
first chondral articulation against the anterior mediastinum,
with posterior bulging but no obvious evidence of direct
invasion into the mediastinal compartment. Secondary mediastinal
inflammation is present, without evidence of thrombophlebitis.
___ CXR :
___ comparison with the study of ___, there is hazy
opacification at the bases with obscuration of the hemidiaphragm
on the left, consistent with layering pleural effusions and
compressive atelectasis. There has been placement of a left
subclavian PICC line that extends to the lower portion of the
SVC.
Brief Hospital Course:
___ with history of IVDU presents w/ 4 days of bilaetral
shoulder and chest pain, found to have an anterior chest wall
cellulitis with associated R sternoclavicular septic arthritis
with abscess and anterior mediastinitis.
# Sepsis due Chest wall cellulitis, R sternoclavicular septic
arthritis with abscess and anterior mediastinitis: Initial CT ___
ED concerning for soft tissue infection spreading into anterior
mediastinum. Given IVDU, pt covered broadly with Vanc/zosyn
after getting vanc at OSH ED and ___ ___ ED. Thoracic surgery
consulted. ID also consulted. MRI of mediastinum done and
revealed R sternoclavicular septic arthritis with abscess and
anterior mediastinitis. Pt given IV dilaudid for pain control.
Pt taken to the OR with thoracic surgery ___ for resection of
right sternoclavicular joint, medial portion of clavicle,
portion of manubrium and medial 1st rib and placement of VAC
sponge. Given active IVDU, also concern for endocarditis (though
no stigmanata) especially given high grade MRSA bacteremia. TEE
done ___ ___ the OR and showed no vegetations. He tolerated the
procedure well and returned to the PACU ___ stable condition.
His recovery was uneventful and he was evaluated by the Plastic
Surgery service for a potential flap closure. They will plan to
flap him ___ a few weeks as his wound continues to clean up. ___
the interim he was treated with VAC dressing changes every 3
days which he tolerated well. The VAC was removed for transfer
to the ___ and a mooist to dry dressing was replaced. The
VAC should be replaced after admission with white foam at the
base and black on top. His antibiotic was tapered to Vancomycin
as his blood cultures and intraop cultures grew MRSA. His joint
fluid cultures remain no growth and his blood cultures from
___ were no growth. He will be treated with Vancomycin
through ___ for a total of 6 weeks post debridement. He was
transferred on ___.
# Bilateral Shoulder Arthralgia: Given significant pain with
passive ROM bilaterally on presentation, concern for septic
arthritis. Ortho consulted. Pt went for bilateral ___
arthrocentesis ___. L shoulder fluid with 7 WBC and ___ was
negative. R shoulder fluid sent for ___ (not enough for
cell counts) and was negative. Suspect shoulder pain related to
R SC septic arthritis and also possibly referred pain on the
left.
# Drug Dependence, Opiates: Pt put on IV dilaudid piggyback PRN
for pain and a Dilaudid PCA post debridement. He was
transitioned to oral Dilaudid on ___ and has tolerated that
well requiring about 6 mg every 4 hrs. He does get 0.25 mg of IV
Dilaudid for VAC changes. The ID/addiction service followe him
closely and spent time talking with him about safe practices and
possible rehab. Please schedule ID f/u for patient after
discharged from ___ to provide ongoing management and
potential suboxone induction, as well as discuss HCV treatment.
# Chronic hepatitis C: mild AST elevation, will be followed as
an out patient.
# CODE STATUS: Full
# CONTACT: mother, ___ ___
___ on Admission:
No medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Heparin 5000 UNIT SC TID
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
5. Lorazepam 0.5-1 mg PO Q4H:PRN aggitation, anxiety, insomnia
6. Senna 8.6 mg PO BID:PRN constipation
7. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
8. Vancomycin 1500 mg IV Q 8H
through ___
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
MRSA bacteremia
Right manubrioclavicular abscess
Osteomyelitis of the manubrium
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 right shoulder pain and
chills. Blood cultures revealed MRSA bacteremia and an MRI
documented a right manubrioclavicular abscess and osteomyelitis
of the entire manubrium which required debridement and will
eventualoly require a plastic surgery repair to fix the defect.
* The infection is also ___ your blood.
* You will need long term antibiotics which will be given
through a ___ line. Due to your history of IV drug abuse, the
medication will need to be given ___ the hospital setting
therefore you will be transferred to rehab.
* The wound currently has a wet to dry dressing ___ place buta
VAC dressing should be placed after transfer.
* You will need to return to ___ to be examined by the
Plastic surgeons so that the closure date can be determined.
* Continue to stay well hydrated and eat well to help with
healing and fighting infection.
* If you develop any fevers > 101, chills or any symptoms that
concern you call Dr. ___ at ___.
Followup Instructions:
___
|
10889349-DS-13
| 10,889,349 | 29,487,538 |
DS
| 13 |
2118-08-11 00:00:00
|
2118-08-11 12:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
lisinopril
Attending: ___
Chief Complaint:
Traumatic brain injury
Major Surgical or Invasive Procedure:
___: Right craniotomy for subdural hematoma evacuation
History of Present Illness:
___ is a ___ male w/h/o alcohol abuse who was
transferred to ___ from OSH on ___ with a mild
TBI.
Mechanism of trauma: witnessed seizure and fall, +head strike,
+LOC
Past Medical History:
-HTN
-Alcohol abuse c/b alcoholic hepatitis, pancreatitis
-DM
-CKD stage 2
-depression
-OSA
-arthritis
Social History:
___
Family History:
NC
Physical Exam:
============
ON ADMISSION
============
Mental Status: EO to voice, drowsy but cooperative with exam
Orientation: Oriented to person, place, and date.
Language: Speech is fluent with good comprehension.
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 and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout.
Slight left pronator drift
Sensation: Intact to light touch
============
ON DISCHARGE
============
Unlabored breathing on RA
Hemodynamically stable
Scalp incision line c/d/I c staples; mild ___
redness, no swelling or drainage
Neuro:
Mental Status: Awake, eyes open spontaneously, drowsy but
cooperative with exam
Orientation: Oriented to person, place ("hospital"), and date.
Language: Speech is fluent with appropriate comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout.
Sensation: Intact to light touch
Pertinent Results:
==========
IMAGING
==========
___ CT head
1. No change in the right frontal hemorrhagic contusion,
subdural hematoma, mass effect and midline shift.
2. Unchanged left occipital bone fracture
3. Unchanged right inferior frontal subarachnoid hemorrhage.
___ CT head
1. Intracranial hemorrhage is largely stable compared with
prior. Minimally more prominent subdural component of
hemorrhage overlying right temporal lobe since prior. Minimally
more prominent midline shift now measuring 1.0 cm. There is
evidence of early left ventricular trapping. Close clinical and
imaging follow-up recommended.
2. There is stable occipital bone fracture.
___ CT Head:
IMPRESSION:
1. Enlargement of the right hemispheric subdural hemorrhage
measuring 18 mm, with worsened midline shift now measuring 1.8
cm, new right uncal herniation and left ventricular trapping.
2. Right basal frontal hemorrhagic contusion is similar. Left
cerebellar
small focus of hemorrhage is less conspicuous.
3. Unchanged left occipital fracture.
___ CT Head:
IMPRESSION:
1. Decreased size of the right subdural hematoma status post
interval right craniotomy and evacuation with subdural drain in
place. Substantial right frontal pneumocephalus. Mass effect
is persistent however improved, including less severe leftward
shift of midline and decreased effacement of the basilar
cisterns, as detailed above.
2. Unchanged inferior frontal hemorrhagic contusion.
3. Unchanged small foci of subarachnoid hemorrhage in the left
parietal
region.
___ CXR
IMPRESSION:
There are no prior chest radiographs available for review.
ET tube in standard placement. Nasogastric drainage tube ends
in the stomach.
Lungs are low in volume but aside from mild left basal
atelectasis essentially clear. Heart is borderline enlarged.
Widening of the upper mediastinum could be due to venous
engorgement in a non erect position and, suggestive but the
spine CT on ___, abundant mediastinal fat. If there is
clinical suspicion of either bleeding or adenopathy, chest CT
should be obtained.
___ ELBOW (AP & LAT) SOFT TISSUE LEFT PORT
IMPRESSION:
Soft tissue prominence surrounding the left elbow. No fracture
or dislocation detected.
___ US MSK ELBOW
IMPRESSION:
Olecranon bursitis of the left elbow with a fluid collection
measuring
approximately 2.5 cm.
___ CT HEAD
IMPRESSION:
1. Significant improvement in postoperative pneumocephalus with
small amount of residual air overlying the right frontal lobe
and significant decreased rightward midline shift, now measuring
4-5 mm. Significant improvement in degree of ventricular
effacement.
2. There remains a 5 mm thick mixed attenuation right
hemispheric subdural
fluid collection.
3. A new 4 mm thick left subdural mixed attenuation fluid
collection is
identified, which may represent a combination of re-
distributedhemorrhage
and effusions secondary to decreased mass effect.
4. Right orbital frontal parenchymal contusion is less
conspicuous with
expected evolving white matter edema pattern.
5. Right sided subgaleal fluid collection measures approximately
1.2 cm in
greatest thickness, increased in size from prior examination.
==========
LABS
==========
___: Na 134
Brief Hospital Course:
Mr. ___ is a ___ yo M who was admitted after fall resulting in
TBI.
#TBI
Imaging on admission revealed SDH, SAH, contusion, occipital
bone fracture. He was admitted to the Neuro ICU for close
monitoring. He was started on a 3% gtt for cerebral edema.
Sodium was closely monitored. Repeat CT on ___ showed stable
hemorrhage. He was transferred to the ___ where sodium
continued to be close monitored. 3% drip was tapered to off on
___, sodium was closely monitored and supplemented with oral
salt tabs. Neurologic examination remained intact. He became
obtunded and a STAT head CT was ordered which showed a right
subdural hematoma and cerebral edema. He was taken emergently to
the OR and underwent a right craniotomy for evacuation of
subdural hematoma. Subgaleal and subdural drains were placed.
Postoperatively, he remained intubated and was monitored in the
Neuro ICU. His post-operative CT showed expected post-operative
changes with improved midline shift. He was restarted on
hypertonic saline which was stopped on ___. He was extubated
on ___. Speech and swallow were reconsulted in the am on ___
(see below). The patient underwent interval repeat NCHCT on ___
which demonstrated improvement in pneumocephalus and ventricular
effacement. The patient also had correspondent improvement in
mental status. On ___, ___ evaluated the patient and recommended
acute rehab placement. Case management began the screening
process. Patient re-started on NA tabs on ___ for NA level
of 132, with appropriate response to 134 on ___. Sodium
levels should be monitored following discharge with appropriate
titration of supplementation.
#Alcohol Withdrawal
Given patient's significant alcohol use he was started on a
phenobarbital taper for alcohol withdrawal. The patient had
completed taper prior to discharge.
#Dysphagia
Patient's tongue was injured at time of fall which made it
difficult for patient to eat. He was evaluated by SLP who
recommended a ground diet and to advance as tolerated. He was
tolerating a regular diet on the day of discharge.
#Left elbow abrasion
The patient was noted to have an abrasion to the left elbow with
surrounding edema and erythema. He was empirically started on
cephalexin for cellulitis on ___ this was changed to ancef
postoperatively. Dermatology was consulted for evaluation of
left elbow abrasion. They recommended dressing with mupirocin,
xeroform, kerlix with daily dressing changes and continuing the
antibiotics. The patient will follow up in the ___
clinic after discharge. Xray and ultrasound were obtained which
demonstrated olecranon bursitis. The patient will plan to follow
up with the orthopedic surgery service as an outpatient for
further management.
#Hypertension
The patient's takes norvasc and labetaolol at home. His home
labetalol was gradually increased over the course of the
hospitalization to address hypertension. The patient was
discharged on a dose of 300 mg TID. The patient was also
discharged home on clonidine 0.1 mg PO TID. He was instructed to
follow up with his primary care physician for further blood
pressure management.
#Tongue Laceration: Plastics was consulted for management of
tongue laceration secondary to seizure. This was deemed to be
non-operative.
Medications on Admission:
Norvasc 10 mg, metformin 500 mg, Zoloft 50 mg, labetalol 100 mg
bid
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. CloNIDine 0.1 mg PO TID
4. Docusate Sodium 200 mg PO BID
5. Heparin 5000 UNIT SC BID
6. LevETIRAcetam 1000 mg PO BID
7. Multivitamins W/minerals 1 TAB PO DAILY
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth Every 4 hours
as needed Disp #*40 Tablet Refills:*0
9. Senna 17.2 mg PO QHS
10. Sodium Chloride 1 gm PO TID
11. Labetalol 300 mg PO TID
12. amLODIPine 10 mg PO DAILY
13. MetFORMIN (Glucophage) 500 mg PO DAILY
Please restart this medication as you were taking at home.
14. Sertraline 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subdural Hematoma
Subarachnoid Hemorrhage
Intracranial Hemorrhage
Occipital Skull Fracture
Alcohol withdrawal
Hyponatremia
Dysphagia
Cerebral Edema
Left olecranon bursitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance/supervision
Discharge Instructions:
Surgery
You underwent a surgery called a craniotomy to have blood
removed from your brain.
Please keep your staples along your incision dry until they
are removed.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You 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.
You were discharged on KEPPRA (levetiracetam) 1000 mg TWICE
daily. Please do not discontinue this medication at any point
until your follow up appointment.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10889482-DS-12
| 10,889,482 | 22,713,773 |
DS
| 12 |
2171-06-14 00:00:00
|
2171-06-14 17:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids / Wellbutrin
Attending: ___.
Chief Complaint:
nausea, abdominal pain, blood in g-tube
Major Surgical or Invasive Procedure:
- ___ MIC gastrostomy tube placement
- ___ anterior abdomen fluid collection aspiration
History of Present Illness:
___ w history of short bowel syndrome ___ Roux-en-Y gastric
bypasss surgery (___) with multiple complications necessitating
G-tube placement in gastric remnant presents with blood around
G-tube entry site and serosanguinous fluid in tubing now found
to
have malpositioned g-tube and 6 cm intrabdominal fluid
collection. Patient had G tube placed on ___ by ___ and has not
started using it. Patient called her PCP when she noted dark red
blood draining from G tube and she was told to present to the
ED.
She has chronic abdominal pain and takes dilauded every ___
hours. Her pain is currently at her baseline. She denies any
change to the quality or quantity or for pain recently. She
states she has had normal brown bowel movements. Denies nausea,
vomiting, fevers, chills. She has been taking her p.o. intake
through NG tube successfully.
In the ED, initial VS were:98.6 98 ___ 97% RA
Exam notable for:cachectic, blood around skin near tube entry,
blood in tube (sanguineous), no abdominal tenderness, soft,
non-distended
Labs showed: WBC 13.6, Hb 8.9, platelets 585, INR 0.9
Imaging showed:
1. Malpositioned percutaneous gastrostomy catheter with tip and
balloon located outside of the stomach lumen with adjacent
pneumoperitoneum.
2. 6 cm partially rim enhancing fluid collection posterior to
the
stomach abutting the pancreas within the lesser sac compatible
with an abscess.
3. Worse mild to moderate intra and extrahepatic biliary
dilation
likely due to compression of the bile duct by this fluid
collection.
4. Wall thickening of the cecum and ascending colon appears new
and mayrepresent colitis.
Consults: discussed with ___ Who will resite and drain collection
in AM.
Patient received: Dilaudid
Transfer VS were: T98.3, HR 79, BP 96/69, HR 20, O2 97% RA
On arrival to the floor, patient reports her abdominal pain is
at
baseline. Her pain was controlled IV dilaudid she received in
ED,
however she currently feels she needs more dilaudid. She has not
looked at G tube prior to today. Has significant leg swelling, R
>L. History of PE/DVT, has not taken her Lovenox since ___.
Denies fevers, chills, chest pain, shortness of breath.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
Asthma
Depression
Encephalopathy
Gastric ulcer
GERD (gastroesophageal reflux disease)
H/O splenectomy
Lumbar back pain
Sickle cell anemia (CMS/HCC)
Sleep apnea
returned CPAP
Spondylosis
Vitamin D deficiency
Social History:
___
Family History:
Father with history of colon cancer. No other relevant family
history.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS:98.3PO ___ 17 95 RA
___: NAD, Dobhoff present
HEENT: AT/NC, anicteric sclera, MMM
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: G-tube in place, bright red blood oozing around tube,
abdomen
soft, nondistended, diffusely tender to palpation, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 2+ pitting edema on LLE below knee, 3+ pitting
edema
on RLE
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DISCHARGE PHYSICAL EXAM
PHYSICAL EXAM:
___ 0821 Temp: 98.0 PO BP: 94/60 Lying HR: 88 RR: 18 O2
sat:
95% O2 delivery: Ra
___: NAD, cachectic appearing
CV: RRR, no g/m/r
PULM: CTAB, no wheezes, no rales, no rhonchi
GI: Abdomen soft, non-distended, diffusely tender without
guarding or rebound, g-tube dressing c/d/i with no serous or
bloody discharge.
EXTREMITIES: 2+ pitting edema to the ankle, DP and ___ 2+ bl,
NEURO: A&Ox3, CNII-XII grossly intact
DERM: Warm and well perfused, no rashes, no lesions
Pertinent Results:
ADMISSION LABS
==============
___ 04:00PM BLOOD WBC-13.6* RBC-3.01* Hgb-8.9* Hct-26.9*
MCV-89 MCH-29.6 MCHC-33.1 RDW-18.0* RDWSD-58.4* Plt ___
___ 04:00PM BLOOD Neuts-82.0* Lymphs-12.8* Monos-4.1*
Eos-0.4* Baso-0.2 Im ___ AbsNeut-11.13* AbsLymp-1.74
AbsMono-0.55 AbsEos-0.06 AbsBaso-0.03
___ 04:00PM BLOOD ___ PTT-30.1 ___
___ 04:00PM BLOOD Glucose-86 UreaN-11 Creat-0.5 Na-142
K-5.2 Cl-109* HCO3-25 AnGap-8*
___ 04:00PM BLOOD ALT-21 AST-30 AlkPhos-83 TotBili-0.3
DISCHARGE LABS
==============
___ 04:26AM BLOOD WBC-8.6 RBC-2.89* Hgb-8.5* Hct-24.4*
MCV-84 MCH-29.4 MCHC-34.8 RDW-17.0* RDWSD-52.2* Plt ___
___ 04:26AM BLOOD ___ PTT-117.7* ___
___ 04:26AM BLOOD Glucose-124* UreaN-2* Creat-0.4 Na-137
K-3.2* Cl-106 HCO3-23 AnGap-8*
___ 04:26AM BLOOD Calcium-7.6* Phos-2.3* Mg-1.6
PERTINENT IMAGES
================
CTAP w/ Co ___. Malpositioned percutaneous gastrostomy catheter with tip and
balloon
located outside of the stomach lumen with adjacent
pneumoperitoneum.
2. 6 cm partially rim enhancing fluid collection posterior to
the stomach
abutting the pancreas within the lesser sac compatible with an
abscess.
3. Worse mild to moderate intra and extrahepatic biliary
dilation likely due to compression of the bile duct by this
fluid collection.
4. Wall thickening of the cecum and ascending colon appears new
and may
represent colitis.
5. Extensive postsurgical changes from bowel surgeries which
appear overall similar to prior CT examination.
6. Anasarca.
7. Diffuse airway wall thickening in the lower lobes with
bibasilar opacities which may represent aspiration or
atelectasis.
8. 13 mm left renal cyst appears minimally complex with likely
septation which can be further evaluated with nonemergent
ultrasound or renal MRI.
b/l ___ VEINS US ___. Nonocclusive thrombus within the right popliteal vein and
nonocclusive
thrombus within the left femoral vein. These may be subacute or
chronic.
2. Right peroneal veins not well-visualized.
___ G-Tube Placement ___
FINDINGS:
1. Existing G-tube injected and contrast noted in the
peritoneal cavity
2. Abscess/hematoma anterior to the stomach
3. Successful placement of a MIC gastrostomy tube into the
excluded stomach.
Given the very difficult anatomy, only a single access was
utilized from which a T tack was passed and the eventual tube
passed as well.
IMPRESSION:
Successful placement of a 12 ___ MIC gastrostomy tube into
the excluded
stomach. A small catheter size was utilized given the extremely
difficult
access as above and the traversing of hematoma anterior to the
stomach. This can be upsized at the first exchange after the
tract has matured.
CT Abd ___. No significant interval change in size of a 4.0 x 2.2 cm
probable abscess in the lesser sac fluid collection posterior to
the level of the pylorus.
2. A second 4.4 x 2.4 cm collection in the midline anterior
abdomen appears more organized compared to ___.
3. New high-density fluid in the region of the falciform
ligament, possibly represents hemorrhage and could be related to
the gastrostomy tube repositioning.
4. Worsening colitis involving the ascending colon.
5. Circumferential enhancement of the urethra, which may
represent urethritis. Clinical correlation is recommended.
___ Procedure ___. Re-demonstrated gastrostomy tube which appears well
positioned in the
stomach. Surgical clips from prior cholecystectomy are
re-demonstrated. An IVC filter is present. Postsurgical
changes from prior Roux-en-Y gastric bypass with enteric
anastomoses are again noted.
2. Anterior to the stomach in the mid abdomen, a fluid
collection is
re-demonstrated which appears more attenuate on today's
non-contrast CT
examination suggesting hematoma. Aspiration yielded minimal
sanguinous fluid. After flushing, aspiration yielded a small
amount of sanguinous fluid which was sent to the microbiology
lab.
3. Contrast injection shows communication with multiple gas
bubbles
inferiorly, intermixed with high density material consistent
with hemorrhage.
IMPRESSION:
Technically successful CT-guided aspiration of the anterior
abdominal fluid collection suggestive of a hematoma with scant
fluid obtained after flushing which was sent to microbiology. No
drain was placed.
Brief Hospital Course:
This is a ___ F history of short bowel syndrome ___ Roux-en-Y
gastric bypasss surgery (___) with multiple complications
necessitating G-tube placement in gastric remnant, bilateral DVT
and subsegmental PE on Lovenox s/p IVC filter, who presented
___ with blood around G-tube entry site and serosanguinous
fluid in tubing. Pt previously had a g-tube placed in the
remnant stomach by Dr. ___. This tube
was dislodged ___ and she presented as direct admission for ___
replacement of g-tube to ___ on ___. During the hospital
course from ___, patient underwent attempted CT-guided
placement of G-tube on ___ and again on ___. A ___ MIC
gastrostomy tube was placed ___.
ACUTE ISSUES:
=============
#MALPOSITIONED G TUBE
#BLOODY DRAINAGE FROM G TUBE
On imaging, she was found to have malpositioned percutaneous
gastrostomy catheter with tip and balloon located outside of the
stomach lumen with adjacent pneumoperitoneum, on ___ CTAP. On
___ a MIC gastrostomy tube was placed into the excluded stomach
by ___. Dressings were c/d/i with no bloody discharge.
#INTRABDMONIAL FLUID COLLECTION C/F ABCESS
#INTRABDMONIAL FLUID COLLECTION C/F HEMATOMA
CTAP ___ and ___ showed a 4.0 x 2.2 cm probable abscess in the
lesser sac fluid collection posterior to the level of the
pylorus that was not accessible by ___ for drainage given its
location; a second 4.4 x 2.4 cm collection in the midline
anterior abdomen appears more organized compared to comparison.
___ aspirated the midline anterior abdominal fluid collection on
___. Preliminary reports suggested this was a hematoma. Pt was
stated empirically on ceftriaxone 2mg q 24h/ and flagyl (___). Infectious Disease was consulted and recommended
transitioning to PO regimen given pt's desire to return home as
soon as feasible. The ceftriaxone was discontinued, and the
patient was started on levofloxacin 500mg PO q 24 and told to
continue Metronidazole 500 mg PO/NG Q8H. Pt was instructed a
change in therapy and possible readmission will be required if
___ culture from ___ returns with growth not susceptible to this
regimen. Pt will require ID follow up in ___ weeks for repeat
imaging of posterior fluid collection. ID will schedule this
imaging and follow up appointment for her.
# Bilateral DVT
# Bilateral ___ edema
# Subsegmental PE
Patient was previously discharged on once daily lovenox for
patient's ease on discharge ___. A b/l lower extremity US from
this hospitalization showed nonocclusive thrombus within the
right popliteal vein and nonocclusive thrombus within the left
femoral vein. Per chart bx these findings were present from OSH
stay in ___. Pt was maintained on a heparin gtt during
hospitalization given procedures as above. She was discharged on
her home lovenox regimen; 1.5 mg/kg, 70mg SQ q daily. She is s/p
IVC filter placed in ___ will need ___ removal after
discharge.
# Short bowel syndrome ___ Roux-en-Y gastric bypass (___)
# Chronic Abdominal Pain
# Colitis
Patient short bowel syndrome with multiple intraabdominal
surgeries and chronic abdominal pain.
Previously discharged on Morphine Sulfate ER 30mg Q8hrs, which
was filled on ___. Per pt, she see's a pain ___ clinic through
___. During this hospitalization she was maintained on home
baclofen, Cymbalta, gabapentin 600mg qHS, ranitidine 300mg BID,
Tylenol and dilaudid 4mg q4h with 1mg IV dialudid once daily for
breakthrough pain.
#SEVERE MALNUTRITION
#HYPOPHOSPHATEMIA
#HYPOKALEMIA
Patient was receiving TF via dobhoff at home. Nutrition was
consulted. Patient was restarted on Osmolite 1.5 @ 10 mL/hr;
advance by 10 mL q8H; goal of 50cc/hour via her gastrostomy
tube. Her dobhoff was pulled on ___ prior to discharge.
#COLITIS on CT
No worsening of abdominal pain or diarrhea, so significance of
this finding unclear. Antibiotic regimen for abscess would cover
bacterial causes. Can consider further evaluation in follow-up
if appropriate.
#URETHRITIS on CT
No urinary symptoms, so significance unclear. Urine chlamydia
and gonorrhea ordered but not sent to lab prior to discharge.
Low suspicion, and antibiotics she has and will received would
cover either infection
CHRONIC ISSUES
=============
#Acute on Chronic Anemia
Likely multifactorial given bleeding in and around G-tube,
anemia of chronic disease. Previous Hb discharge on ___ was
8.8. Discharge on ___ was 8.5
TRANSITIONAL ISSUES
=================
#Interventional Radiology follow-up
- Pt has IVC filter was placed ___ at OSH per chart bx. Pt
was due to have IVC filter removed 2-weeks after previous
discharge ___. Pt will need to have follow-up appointment with
___ to remove IVC filter. This was unable to be scheduled given
discharge on ___.
#Infectious Disease follow-up
- Infectious Disease was consulted and recommended transitioning
to PO regimen given pt's desire to return home as soon as
feasible. The patient was started on levofloxacin 500mg PO q 24
and told to continue Metronidazole 500 mg PO/NG Q8H.
- Pt was instructed a change in therapy and possible readmission
will be required if ___ culture from ___ returns with growth not
susceptible to this regimen.
- Pt will require ID follow up in ___ weeks for repeat imaging
of posterior fluid collection.
#Renal cyst
- On CT, a 1.5 cm hypoenhancing mass in the superior pole was
seen. Cyst is minimally complex with likely septation. This can
be further evaluated with non-emergent US or renal MRI.
#CODE: Full (presumed)
#CONTACT:Name of health care proxy: ___
Relationship: Mother
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Baclofen 20 mg PO DAILY:PRN Muscle Spasms
2. DULoxetine 60 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Gabapentin 1200 mg PO QHS
5. Montelukast 10 mg PO DAILY
6. Ranitidine (Liquid) 150 mg PO BID
7. Vitamin D ___ UNIT PO DAILY
8. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
9. Enoxaparin Sodium 70 mg SC DAILY
10. Multivitamins W/minerals Chewable 1 TAB PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. Senna 8.6 mg PO BID
13. Magnesium Oxide 400 mg PO DAILY
14. Morphine SR (MS ___ 30 mg PO Q8H
15. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Severe
Discharge Medications:
1. Levofloxacin 500 mg PO Q24H
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*90 Tablet Refills:*0
3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
4. Baclofen 20 mg PO DAILY:PRN Muscle Spasms
5. DULoxetine 60 mg PO DAILY
6. Enoxaparin Sodium 70 mg SC DAILY
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Gabapentin 1200 mg PO QHS
9. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Severe
10. Magnesium Oxide 400 mg PO DAILY
11. Montelukast 10 mg PO DAILY
12. Morphine SR (MS ___ 30 mg PO Q8H
13. Multivitamins W/minerals Chewable 1 TAB PO DAILY
14. Polyethylene Glycol 17 g PO DAILY
15. Ranitidine (Liquid) 150 mg PO BID
16. Senna 8.6 mg PO BID
17. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
#Malpositioned gastric tube
#Abdominal fluid collections, concerning for abscesses
#Right politeal and L superficial femoral deep venous thrombosis
#Subsegmental pulmonary embolism
#Short bowel syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care you.
WHY WAS I IN THE HOSPITAL?
You were admitted to the hospital because you had bloody
discharge from your gastric tube.
WHAT HAPPENED TO ME IN THE HOSPITAL?
We took a CT, or CAT scan of your abdomen. This showed that
your gastric tube was not in the correct position. The pictures
also showed 3 small fluid collections in your abdomen.
Doctors ___ your ___ tube, so that it was in the
right place.
We drained a small sample of fluid from one of the fluid
collections in your abdomen.
We treated you with antibiotics because the fluid collections
in your belly could be infected.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please fill your prescriptions and take your antibiotics.
- You will be contacted by our infectious diseases doctors who
___ you to see them in the office in few weeks. They
will also wants you to get a repeat scan of your belly to
evaluate the fluid collections.
- Please follow up with your primary care doctor.
- Please do not drink alcohol or drive while you are taking your
narcotic pain medicine.
- Please seek care if you develop high fevers, severe worsening
abdominal pain, or feel unwell.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10889482-DS-9
| 10,889,482 | 28,031,872 |
DS
| 9 |
2165-04-29 00:00:00
|
2165-05-01 08:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids
Attending: ___.
Chief Complaint:
LBP
Major Surgical or Invasive Procedure:
___ drainage of lumbar subcutaneous mass
History of Present Illness:
The patient is a ___ with a history of DJD s/p surgery of the
lumbar spine and recently a superficial soft tissue swelling
over the lumbar spine which was aspirated 3 weeks ago and
negative for infection. She complains of increased back pain
last night with radiation to her right leg and up her back. The
exacerbation in her symptoms have been within the last 48 hours,
when she was trying to walk and she had an acute numbness in her
right hip/upper leg and exquisite back pain. She almost fell
over, but she had family members near by that were able to help
her. Because of this pain she presented to her PCP for
evaluation. She has been taking morphine, Percocet, Fentanyl and
Lidoderm for pain without significant improvement. She denies
and fevers, chills, chest pain, vomiting, bowel or bladdder
___ weakness. She was seen by her PCP this
morning who sent her for ER evaluation given intense pain. The
patient says that she had a fall 3 weeks ago and was seen at and
OSH ED. She reports that plain films of the spine were negative
at that time.
Regarding her lumbar mass, it has been worked up previously with
the following: aspiration under US guidance at ___ in ___
with negative cultures, excision in ___ at ___ with
benign path, MRI ___ which showed subcutaneous fluid
collection w/ surrounding inflammatory change worrisome for
superficial abcess, and a US guided biopsy ___ which was
negative for infection. Per the patient, drainiage has only
briefly improved her symptoms and she has never been on
antibiotics for her fluid collection.
In the ED, initial Vitals were T98.5, HR77, BP122/87, RR18
satting 98% on RA. Labs showed a normal CMP, slightly
contaminated UA, normal CBC however 38.8 % PMNs and 52.7%
lymphoycytes were seen on a WBC count of 5.3. An MRI of her
entire spinal column showed a superficial right-sided
rim-enhancing thick-walled fluid collection in the soft tissue
posterior to the L2-3 level with superficial sinus track
extending inferiorly to the S1 level without paravertebral
extension. No evidence of epidural collection or
osteomyelitis/discitis was seen, and old L3/L4 degenerative
vertebral body changes were seen consistent with prior imaging.
As her prior workups have been negative for infection, and the
patient did not have any evidence of SIRS, empiric antibiotics
were not started. For pain control she was provided with
dilaudid 1mg IV 2x and valium 5mg. Vitals prior to transfer were
T98.5 °F Pulse 67, RR: 16, BP: 123/93, O2Sat: 98 on RA.
On the floor, patient is very uncomfortable endorsing ___ pain
with spikes of ___ with movement/manipulation.
Past Medical History:
PMH: GERD/esophageal spasm (worsens with NSAIDs), chronic
gastritis, asthma, sickle cell trait,
PSH: funduduplication, BTL, hysterectomy, open RNYGB complicated
by bleed/hypotension/cardiac arrest ___, splenectomy for
bleeding control ___ RNYGB
Social History:
___
Family History:
Cancer - Colon (father @ ___ yoa)
Cancer - Colon (uncles x 4, youngest was in mid ___
DVT and HTN - Mother
Physical ___ exam
VS: T 98.4| 126/79 | HR 67 | RR 18| 100% on RA
GENERAL: Appears in pain sitting up in bed
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, bilateral anterior cervical LAD nontender in ___
nodes.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no ronchi/rales/wheezes, good air movement,
resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
BACK: approximately 12x7cm enlarged fluid collection to the
right of the vertebral column with exquisite tenderness to
palpation. Nonerythematous without ulceration or lesions. Scar
on sacral region consistent with prior surgeries.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact. Gait is hunched
and deliberate secondary to pain. Difficulty standing on one leg
secondary to pain. Cannot hip flex R worse than L secondary to
pain. No sensory deficits.
Discharge exam
Tm 98.4 BP 102/73 HR 68 RR 18 O2100%RA
GENERAL: middle-aged AA female, looks uncomfortable and in pain
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, bilateral anterior cervical LAD nontender in ___
nodes.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no ronchi/rales/wheezes, good air movement,
resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
BACK: approximately 12x7cm nodular mass to the right of the
vertebral column with tenderness to palpation. Non-erythematous,
without ulceration or lesions. Scar on sacral region consistent
with prior surgeries.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact. Has limited
right HF due to pain but does maintain antigravity strength.
Down-going toes. Upper extremities w/ normal sensation and
strength.
Pertinent Results:
Admission labs
___ 01:45PM BLOOD WBC-5.3 RBC-4.17* Hgb-11.7* Hct-37.5
MCV-90 MCH-28.1 MCHC-31.2 RDW-14.0 Plt ___
___ 01:45PM BLOOD Neuts-38.8* Bands-0 Lymphs-52.7*
Monos-4.4 Eos-3.4 Baso-0.8
___ 09:10AM BLOOD ___ PTT-29.2 ___
___ 01:45PM BLOOD Glucose-101* UreaN-10 Creat-0.8 Na-137
K-4.5 Cl-106 HCO3-22 AnGap-14
___ 01:45PM BLOOD Calcium-9.0 Phos-4.0 Mg-2.1
Discharge labs
___ 07:15AM BLOOD WBC-6.3 RBC-4.36 Hgb-12.2 Hct-40.1 MCV-92
MCH-28.1 MCHC-30.5* RDW-14.2 Plt ___
___ 07:15AM BLOOD Glucose-86 UreaN-11 Creat-0.8 Na-143
K-4.4 Cl-107 HCO3-29 AnGap-11
Studies
MRI spine ___:
1. 4.7 x 1.3 cm thick-walled rim-enhancing collection in the
subcutaneous soft tissues at the level of L5-S1, to the right
with a sinus tract extending superiorly to the L2-3 level. This
collection demonstrates thick enhancing walls, but is only
located to the subcutaneous soft tissues without evidence of
epidural or intramuscular extension. Findings may represent
postoperative seroma vs abscess.
2. There are degenerative type endplate changes at L3-4 level
but no evidence of discitis or osteomyelitis. Mild degenerative
changes of the lumbar spine as described above.
3. Unremarkable examination of the cervical and thoracic spine.
.
U/S drainage of fluid collection ___: After explaining the
risks, benefits and alternatives to the procedure, written
informed consent was obtained from the patient. The patient was
brought to the ultrasound suite and was laid prone on the
ultrasound table. A preprocedure timeout was performed using
three unique patient identifiers as per standard ___ protocol.
Limited sonographic images of the right flank at the level of
L3-L4 was performed for the purposes of skin entry site
localization. At this level note was made of a 6.5 x 0.7 cm
longitudinally shaped fluid collection. The overlying skin was
prepped and draped in the usual sterile fashion. Buffered 1%
lidocaine solution was used to anesthetize the skin overlying
the medial edge of this fluid collection. Under sonographic
guidance a more deeper anesthesia was provided with buffered 1%
lidocaine solution. A small skin incision was made and under
sonographic guidance a 5 ___ centesis catheter was
advanced into the fluid collection. We aspirated about 8 mL of
serosanguineous fluid. Post-aspiration there was complete
collapse of the cavity. The ___ catheter was removed. The
patient tolerated the procedure well without any immediate
post-procedural complications. The obtained sample was sent for
microbiological analysis. IMPRESSION: Successful percutaneous
ultrasound-guided aspiration of a superficial fluid collection
in the right lumbar region. Microbiological
results pending at this time.
Brief Hospital Course:
Ms ___ is a ___ with h/o vertebral DJD s/p surgery of the
lumbar spine and recently a superficial soft tissue swelling
over the lumbar spine, who presents w/ severe back pain and
enlarging swelling in lower back.
.
#Back pain with fluid collection: Unclear etiology. Appears to
be a chronic seroma, and seems to have been present prior to
previous surgery. Lymphedema also possible. MRI shows this is a
superficial collection, w/o spinal cord involvement. There
appears to be a thick rim around it, so resection seemed like a
possibility, and we consulted general surgery. They did not
recommend resectio, as unclear benefit, and may make chronic
seroma worse. Also discussed w/ her outpatient surgeon at ___,
who was also of the opinion that this was a chronic seroma and
resection may make it worse. Thus, she had ___ ultrasound guided
drainage, and 8cc of serosanguinous fluid was removed. No
evidence of infection, and cultures during this admission were
negative to date (still pending) on that fluid. Unfortunately,
drainage did not result in any pain relief, and her pain
continued to be significant. Of note, her neuro exam remained
normal, and there was no evidence of cord compression. She
occasionally felt weak in RLE, but this was ___ pani, not
neurologic weakness. We thus consulted with our pain management
team, and also discussed w/ her outpatient pain provider.
Decided to increase her fentanyl patch from 25mcg q72h to 50mcg
q2h. We also increased her amitriptyline and gabapentin. We
recommended CBT and biofeedback to her, which she will pursue w/
her PCP as an outpatient. She was discharged w/ close PCP and
pain specialist f/u.
.
#Asthma: no recent exacerbations. We continued her albuterol PRN
and montelukast
.
#GERD with Hx of Fundoplication: Some esophageal spasm causes
occassional chest pain for which she takes sublingual
nitroglycerin for. Has not been an issue in the recent weeks,
nor this admission. Continued ranitidine and omeprazole
.
# CODE: full
# CONTACT: ___ (mother) ___ / ___
.
====================================
TRANSITIONAL ISSUES
# f/u lumbar fluid pocket culture
# will need ongoing chronic pain management. On significant
narcotic and non-narcotic pain regimen. Also recommend CBT and
biofeedback for improved coping w/ her chronic pain
Medications on Admission:
Diazepam 5 mg po TID prn
Lidocaine HCl 5 % Topical Ointment apply to affected area 4
times a day
Prochlorperazine Maleate 10 mg Oral Tablet 1 po q6hr prn
Cyclobenzaprine 10 mg Oral Tablet ___ tablets qhs prn
Oxycodone-Acetaminophen ___ mg Oral Tablet 2 tablets q4hrs prn
Fentanyl 25 mcg/hr Transdermal Patch q patch q72 hrs prn
Gabapentin 1200 mg po qhs
Ranitidine HCl 300 mg Oral Tablet TAKE ONE TABLET AT BEDTIME
Montelukast (SINGULAIR) 10 mg Oral Tablet TAKE ONE TABLET DAILY
Amitriptyline 10 mg Oral Tablet TAKE ___ TABLETS AT BEDTIME.
Omeprazole 40 mg po bid
Nitroglycerin (NITROSTAT) 0.4 mg Sublingual Tablet prn cp (espho
spasm)
Sodium Chloride 0.9 % Inhalation Solution for Nebulization use
as directed with nebulizer machine
Budesonide-Formoterol (SYMBICORT) 160-4.5 mcg/Actuation 2 puffs
bid
Albuterol Sulfate (VENTOLIN HFA) 90 mcg/Actuation ___ q6hr
prn
Albuterol Sulfate 5 mg/mL Inhalation Solution for Nebulization
prn
Discharge Medications:
1. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for back spasms.
2. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*5 Patch 72 hr(s)* Refills:*0*
3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
4. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for back spasms.
5. gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
6. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
7. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
10. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation four times a day as needed for shortness of
breath or wheezing.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
13. amitriptyline 75 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
14. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
every four (4) hours as needed for pain: Do not drink or drive
while on this medication. It may make you drowsy.
Disp:*42 Tablet(s)* Refills:*0*
15. budesonide-formoterol 160-4.5 mcg/actuation HFA Aerosol
Inhaler Sig: Two (2) puffs Inhalation twice a day.
16. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual once a day as needed for chest pain.
17. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for menstrual cramps.
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic back pain
Subcutaneous Lumbar mass
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 for back pain and a lower back fluid
collection. You were underwent drainage by interventional
radiology which decreased the size of the mass but did not get
rid of it. You were seen by surgery who concluded the mass is
likely post-operative in nature possibly a seroma. It was
determined by the surgery team excision of this mass in the
operating room will not be helpful at this time. Imaging
indicated the mass is subcutaneous or under the skin in location
and not impinging on the spinal canal. You were seen by the pain
management team and the fentanyl patch was increased. The
gabapentin and amytriptyline was also increased.
.
We think you would benefit from Cognitive Behavioral Therapy,
and also a Biofeedback program. This can be set up through your
PCP, ___.
.
The following changes have been made to your medications:
** Increase Fentanyl patch to 50mcg every 3 days.
** Start Gabapentin to 400mg twice a day during the day and
continue to take 1200mg at night.
** INCREASE Amitriptyline for neuropathic back pain
** START Docusate and Senna as needed for constipation
.
Beware that these medications are sedating and your should not
operate heavy machinery or vehicles when using pain medications.
.
Please continue to take the rest of your home medications as you
were before coming to the hospital.
Followup Instructions:
___
|
10890203-DS-15
| 10,890,203 | 23,986,377 |
DS
| 15 |
2135-05-04 00:00:00
|
2135-05-04 20:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
Patient is a ___ with history of HCV/EtOH cirrhosis who
initially presented to ___ after several episodes
of hematemesis, now transferred to ___ for further work-up and
management.
Patient was recently discharged from ___ ___ (hospitalized
for BRBPR). During his admission, he underwent EGD which showed
mild portal hypertensive gastropathy, no report of esophageal
varices.
Patient awoke ___ with blood dripping from his mouth. He
then experienced a large episode of hematemesis. Patient also
noticed increased upper abdominal pain at this time, band-like
and ___ in severity (he endorses chronic low level abdominal
pain for the past several months). No diarrhea, melena,
hematochezia, or recent black stools. No fevers/chills.
Patient was brought to ___ given several
subsequent episodes of hematemesis.
At ___, patient was given octreotide,
pantoprazole, and dilaudid. Hct was by report 36.9. Given
concern for UGIB, decision was made to transfer to ___ ED.
Of note, patient was admitted to ___ ___ for
abdominal pain and diarrhea, subsequently found to have Cdiff
(treated with flagyl/vancomycin). He underwent EGD during that
admission, notable for esophageal varices s/p band ligation and
portal hypertensive gastropathy.
In the ED, initial vitals: 98.2 86 125/59 16 97% RA
Exam notable for: Abd diffusely tender, POCUS w/o ascites, trace
___ edema, guaiac positive stool.
Labs notable for:
CBC 5.7>13.2/38.6<47, 5.0>12.9/36.4<36
BMP 139, 5.0, 105, 21, 18, 1.1
Ca 8.2
Mg 1.8
P 3.3
Alt 98
Ast 133
Alp 60
Tbili 3.2
Alb 3.4
Lipase 104
Lactate 1.6
Serum APAP 8
Serum Tox NEG
Imaging:
CT A/P ___
1. Cirrhotic liver without focal suspicious liver lesions. Study
is
suboptimal for the evaluation of ___ for which MRI liver or
multiphasic liver studies recommended.
2. Splenomegaly and extensive esophageal, gastric, and splenic
varices.
Abd Plain Film ___
FINDINGS:
Image quality is degraded by motion.
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or
radiopaque foreign bodies.
IMPRESSION:
Nonobstructive bowel gas pattern. No evidence of free
intraperitoneal air.
Patient ___ 05:34 IV CefTRIAXone
___ 05:34 IV DRIP Octreotide Acetate (50 mcg/hr ordered)
___ 06:02 IV Esomeprazole sodium 40 mg
___ 06:12 IV CefTRIAXone 2 g
___ 07:35 IV HYDROmorphone (Dilaudid) .5 mg
___ 09:37 IV DRIP Octreotide Acetate
___ 09:38 IV HYDROmorphone (Dilaudid) .5 mg
___ 11:46 IV Fentanyl Citrate 50 mcg
___ 12:20 IV Fentanyl Citrate 50 mcg
___ 15:19 IV DRIP Octreotide Acetate
___ 15:44 IV HYDROmorphone (Dilaudid) 1 mg
___ 15:44 IVF NS (1000 mL ordered)
Consults:
Hepatology
Vitals on transfer: 97.2 61 121/74 14 100% RA
Upon arrival to ___, patient recounts the history as above,
AOx3. He denies any recurrent hematemesis since ___, though
did vomit after trying to eat a popsicle. No
melena/hematochezia. He continues to have upper abdominal pain.
No new fevers/chills.
Past Medical History:
EtOH/HCV Cirrhosis c/b varices
EtOH abuse
Hypertension
Social History:
___
Family History:
Father: testicular cancer, MI, stroke
Mother: lung cancer
Sister: SLE
Physical ___:
ADMISSION EXAM:
VITALS: 98.2 132/86 65 16 97%RA
GENERAL: Comfortable appearing, multiple tattoos, guards at
bedside.
HEENT: Sclera anicteric, MMM, oropharynx clear.
NECK: JVP not elevated.
LUNGS: Scattered wheezing in RUL, otherwise CTABL.
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Normoactive BS throughout. Diffuse tenderness to palpation
with guarding across the upper abdomen.
EXT: Warm, well perfused, 2+ pulses, 1+ pitting edema in the ___
___.
SKIN: No jaundice. Chronic venous stasis hyperpigmentation of
the anterior shins bilaterally. Multiple tattoos.
NEURO: AOx3. Grossly non-focal. No asterixis.
ACCESS: PIVs.
============================================================
DISCHARGE EXAM:
VITALS: unremarkable.
GENERAL: Comfortable appearing, multiple tattoos, guards at
bedside.
HEENT: Sclera anicteric, MMM, oropharynx clear.
NECK: JVP not elevated.
LUNGS: Scattered wheezing in RUL, otherwise CTABL.
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Normoactive BS throughout. Diffuse tenderness to palpation
with guarding across the upper abdomen.
EXT: Warm, well perfused, 2+ pulses, 1+ pitting edema in the ___
___.
SKIN: No jaundice. Chronic venous stasis hyperpigmentation of
the anterior shins bilaterally. Multiple tattoos.
NEURO: AOx3. Grossly non-focal. No asterixis.
Pertinent Results:
ADMISSION LABS:
___ 05:35AM BLOOD WBC-5.7 RBC-4.02* Hgb-13.2* Hct-38.6*
MCV-96 MCH-32.8* MCHC-34.2 RDW-14.3 RDWSD-50.4* Plt Ct-47*
___ 05:35AM BLOOD ___ PTT-31.0 ___
___ 05:35AM BLOOD Glucose-101* UreaN-18 Creat-1.1 Na-139
K-5.0 Cl-105 HCO3-21* AnGap-13
___ 05:35AM BLOOD ALT-98* AST-133* AlkPhos-60 TotBili-3.2*
___ 05:35AM BLOOD Albumin-3.4* Calcium-8.2* Phos-3.3 Mg-1.8
___ 05:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-8*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:40AM BLOOD Lactate-1.6
IMAGE/STUDIES:
COMPARISON: None.
FINDINGS:
LOWER CHEST: There is mild bibasilar atelectasis. There is no
evidence of
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver is nodular in contour compatible with
cirrhosis.
There is no evidence of focal lesions. There is no evidence of
intrahepatic
or extrahepatic biliary dilatation. The gallbladder wall is
mildly thickened
without distention.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen is enlarged measuring 16.1 cm, without
evidence of focal
lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
Subcentimeter hypodensities in bilateral kidneys are too small
to
characterize. There is no evidence of focal renal lesions or
hydronephrosis.
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The
colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No
atherosclerotic disease
is noted. The portal vein is patent. Extensive esophageal,
gastric, and
splenic varices.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Cirrhotic liver without focal suspicious liver lesions.
Study is
suboptimal for the evaluation of HCC for which MRI liver or
multiphasic liver
studies recommended.
2. Splenomegaly and extensive esophageal, gastric, and splenic
varices.
3. No small bowel obstruction.
EGD ___:
Normal mucosa in the whole esophagus
Varices at the IGV-1
Normal mucosa in the whole duodenum
Otherwise normal EGD to third part of the duodenum
DISCHARGE LABS:
___ 04:31AM BLOOD WBC-4.2 RBC-3.54* Hgb-12.0* Hct-34.0*
MCV-96 MCH-33.9* MCHC-35.3 RDW-13.6 RDWSD-48.4* Plt Ct-45*
___ 04:31AM BLOOD ___ PTT-33.4 ___
___ 04:31AM BLOOD Glucose-119* UreaN-14 Creat-1.0 Na-136
K-4.2 Cl-102 HCO3-26 AnGap-8*
___ 04:31AM BLOOD ALT-81* AST-116* LD(LDH)-246 AlkPhos-53
TotBili-3.0* DirBili-0.9* IndBili-2.1
___ 04:31AM BLOOD Albumin-3.0* Calcium-7.6* Phos-3.4 Mg-1.8
Iron-194*
___ 04:31AM BLOOD calTIBC-202* Hapto-<10* Ferritn-648*
TRF-155*
Brief Hospital Course:
Patient is a ___ with history of HCV/EtOH cirrhosis who
initially presented to ___ after several episodes
of hematemesis, now transferred to ___ for further work-up and
management of possible UGIB, currently hemodynamically stable
and with Hb at baseline. EGD performed which showed IGV-1
varices and otherwise normal mucosa. CT showed no cause for
abdominal pain.
# Hematemesis (MELD Na 14): Patient was transferred from
___ with several reported episodes of hematemesis.
Based on the patient's history, there was concern for UGIB given
his history of cirrhosis and reported esophageal varices. At
presentation, the patient was HD stable, and had stable Hb
around 13 from a last known baseline of 11.5-12.2 (___). The
patient also had no signs of acute infection (bedside US NEG for
ascites), and no other active form of decompensated cirrhosis.
He was started on octreotide drip, IV PPI BID, and ceftriaxone
for SBP prophylaxis. Additionally, the patient's nadolol,
furosemide, and spironolactone were held in the setting of
potential acute bleed. CBC was trended every six hours and the
patient's hemoglobin remained stable around 12 to 13. The
patient had several episodes of emesis overnight ___ to ___
which were non-bloody. EGD was performed on ___ and
demonstrated IGV-1 varices, and otherwise normal mucosa
throughout esophagus, duodenum. No signs of recent or active
bleeding. TIPS vs. BRTO was considered, however as patient
hemodynamically stable and Hgb stable, procedure was deferred.
CTX, octreotide, IV PPI were stopped as no signs of UGIB. Home
medications restarted.
# Nausea/vomiting, abdominal pain - At presentation, the patient
also reported a band-like upper abdominal pain. On exam, the
patient's abdomen was soft but tender to palpation in the upper
abdominal quadrants, and non-distended. A CT A/P was performed
and did not identify any potential causes. The patient also had
lactate and lipase measured, which were normal. The cause of the
pain was not identified and felt to be likely due to
malingering. He also endorsed swelling, no ascites seen, likely
___ insufflation during EGD. Prescribed simethicone.
# EtOh/HCV cirrhosis: Patient with diffuse, mild abdominal pain
that does not localize to RUQ. Bedside ultrasound negative for
ascites. CT abdomen with out evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder wall was mildly
thickened without distention. Diuretics held during ICU stay,
restarted prior to discharge. Nadolol held initially and
restarted at 20 mg daily given HR in ___.
# Normocytic anemia:
# Thrombocytopenia:
Likely chronic cytopenias iso cirrhosis.
CHRONIC ISSUES
=================
# Hypertension:
Held Lisinopril given normotensive and NPO for extended period.
Resume as needed for hypertension, goal SBP > 140.
TRANSITIONAL ISSUES:
[] f/u with ___ to be scheduled to discuss TIPS vs. BRTO as an
outpatient on an elective basis
[] f/u with hepatology at ___ in 1 - 2 weeks
[] Patient should have RUQUS every 6 months for ___ screening
given his cirrhosis
[] Patient can be restarted on lisinopril per outpatient
doctor's discretion as his blood pressure tolerates
[] Uptitrate Nadolol back to 40mg daily as tolerated by heart
rates and blood pressures
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
2. Nadolol 40 mg PO QAM
3. Spironolactone 100 mg PO DAILY
4. Levalbuterol Neb 0.63 mg NEB Q6H
5. Docusate Sodium 100 mg PO BID
6. Furosemide 40 mg PO DAILY
7. Acetaminophen 650 mg PO Q12H:PRN Pain - Mild
8. Pantoprazole 40 mg PO QAM
9. Lisinopril 10 mg PO QAM
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Simethicone 40-80 mg PO QID:PRN bloating
3. Thiamine 100 mg PO DAILY
4. Nadolol 20 mg PO DAILY
RX *nadolol 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Acetaminophen 650 mg PO Q12H:PRN Pain - Mild
6. Docusate Sodium 100 mg PO BID
7. Furosemide 40 mg PO DAILY
8. Levalbuterol Neb 0.63 mg NEB Q6H
9. Pantoprazole 40 mg PO QAM
10. Spironolactone 100 mg PO DAILY
11. HELD- Lisinopril 10 mg PO QAM This medication was held. Do
not restart Lisinopril until your doctor restarts once your
blood pressures are higher
Discharge Disposition:
Extended Care
Discharge Diagnosis:
PRIMARY
Hematemesis
Hepatitis C/Alcohol Cirrhosis
SECONDARY
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
WHY WAS I HERE?
-You vomited blood
WHAT WAS DONE WHILE I WAS IN THE HOSPITAL?
-an EGD showed that you were not having any bleeding or large
vessels at risk for bleeding
-your blood pressure and blood levels were all stable
WHAT SHOULD I DO WHEN I GO HOME?
-You should let your doctors know ___ have any more bleeding
Be well!
Your ___ Care Team
Followup Instructions:
___
|
10890203-DS-17
| 10,890,203 | 28,436,720 |
DS
| 17 |
2135-06-12 00:00:00
|
2135-06-13 07:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
___ TIPS, BATO, BRTO
History of Present Illness:
___ y/o male w/ a PMHx of EtOH/HCV cirrhosis with recent EGD
(showing IGV-1 varices and otherwise normal mucosa) who
presented to an OSH with multiple episodes of small volume
hematemesis (approximately ___ to 1 teaspoon. CT scan at outside
hospital was unremarkable, they gave him protonix, and
transferred him ___ for further management.
He states he was recently discharged from ___ an episode of
hematemesis on ___. He complains of about 25 pounds of
weight loss, increasing malaise, abdominal pain and distension,
and tremulousness. Endorses nausea and vomiting, early satiety
and abdominal pain. endorses diarrhea worsening in frequency.
Regarding his liver history. He has a diagnosis of hepatitis C
cirrhosis. His hepatology team is located at ___.
In ED initial VS: 97.0 62 144/85 14 97% RA
Labs significant for:
WBC 4.4
Hb 13.0
Platelets 58
Patient was given:
- Ceftriaxone
- Octreotide
Imaging notable for: CT AP "Cirrhosis with moderate to marked
spenomegaly and extensive portal collaterals extending along the
esophagus with no overt active extravasation or large hematoma,
mild mesenteric haziness likely accounts for suble questionable
scattered areas of bowel edema and pericholecystic edema. No
acites is noted"
Hepatology was consulted, who recommended admission to the ICU
for closer monitoring. Also recommended holding off on EGD as
patient had a plan was for a TIPS procedure +/- BATO/BRTO
scheduled for ___.
___ was consulted in the ED, but had not evaluated the patient at
time of transfer.
In the ED, per report, he has had multiple episode of small
volume hematemesis.
On arrival to the MICU, last episode of hematemesis on arrival
to ED. Initially coffee ground then bright red blood. Reports
abdominal pain and bloating. Denies fevers, chills, weight
loss. Reports 40lb weight loss over last few months. Also
reports bilateral lower extremity neuropathy.
Past Medical History:
EtOH/HCV Cirrhosis c/b varices
EtOH abuse
Hypertension
Social History:
___
Family History:
Father: testicular cancer, MI, stroke
Mother: lung cancer
Sister: SLE
Physical ___:
ADMISSION EXAM:
=====================================
VITALS: Reviewed in metavision
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM:
=====================================
VITALS: 98.9 153/79 84 18 94% Ra
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: firm, tender to palpation in RUQ and LUQ. +BS. No rebound,
guarding or rigidity.
EXT: Warm, well perfused. No ___ edema.
NEURO: Moving all extremities spontaneously.
Pertinent Results:
ADMISSION LABS
================================
___ 05:30AM BLOOD WBC-4.4# RBC-3.98* Hgb-13.0* Hct-37.9*
MCV-95 MCH-32.7* MCHC-34.3 RDW-15.0 RDWSD-52.4* Plt Ct-58*
___ 05:30AM BLOOD Neuts-48.7 ___ Monos-10.7
Eos-7.1* Baso-0.5 Im ___ AbsNeut-2.14 AbsLymp-1.44
AbsMono-0.47 AbsEos-0.31 AbsBaso-0.02
___ 05:30AM BLOOD ___ PTT-35.7 ___
___ 05:30AM BLOOD Glucose-91 UreaN-13 Creat-0.8 Na-142
K-4.1 Cl-108 HCO3-22 AnGap-12
___ 05:30AM BLOOD ALT-140* AST-198* AlkPhos-61 TotBili-3.3*
DirBili-0.9* IndBili-2.4
___ 05:30AM BLOOD Albumin-3.3* Calcium-8.2* Phos-3.3 Mg-1.8
___ 06:02AM BLOOD Lactate-1.5
MICRO RESULTS
================================
Blood culture ___ - no growth to date
RELEVANT STUDIES
================================
OSH CT AP ___:
"Cirrhosis with moderate to marked spenomegaly and extensive
portal collaterals extending along the esophagus with no overt
active extravasation or large hematoma, mild mesenteric haziness
likely accounts for suble questionable scattered areas of bowel
edema and pericholecystic edema. No acites is noted"
Abdominal ultrasound ___:
1. Cirrhotic morphology.
2. Patent hepatic vasculature.
3. Splenomegaly.
TIPS ___:
IMPRESSION:
Successful right internal jugular access with transjugular
intrahepatic
portosystemic shunt placement with decrease in porto-systemic
pressure
gradient.
Successful balloon occluded/coil assisted antegrade transvenous
obliteration and balloon occluded/coils assisted retrograde
transvenous obliteration of a large gastric varix as described
above.
DISCHARGE LABS
================================
___ 06:20AM BLOOD WBC-13.8* RBC-3.77* Hgb-12.6* Hct-36.1*
MCV-96 MCH-33.4* MCHC-34.9 RDW-14.5 RDWSD-50.7* Plt Ct-40*#
___ 06:20AM BLOOD ___ PTT-36.9* ___
___ 06:20AM BLOOD ALT-177* AST-200* AlkPhos-64 TotBili-4.7*
Brief Hospital Course:
___ y/o male w/ a PMHx of EtOH/HCV cirrhosis (Child's B, MELD 14)
with recent EGD showing IGV-1 varices who presented with small
volume hematemesis without associated acute blood loss anemia
s/p TIPS.
#Hematemesis
#Varices
#Portal hypertension
Patient presented after small volume hematemesis in setting of
known cirrhosis and extensive gastric, esophageal, splenic
varices on CT scan. Of note, Hb on admission was 13, which was
higher than previous discharge Hb in ___. There were no
further witnessed episodes of hematemesis. Unclear if he had any
GI bleed. Regardless, the patient underwent TIPS, BRTO, BATO
(Balloon-occluded Retrograde Transvenous Obliteration) with ___
on ___, without complications, which was originally scheduled
as outpatient. He initially on IV PPI, octreotide, ceftriaxone,
and which transitioned to PO PPI, Carafate. Nadolol was
continued as patient was hypertensive, but from variceal ppx, is
not needed given TIPS placement. Abx prophylaxis for GI bleed
was discontinued given low suspicion of true GI bleed.
#ETOH/HCV Cirrhosis
Child's B cirrhosis, MELD 14 on admission complicated by
possible GI bleeding as above. Has positive HCV Ab and VL. RUQUS
neg for PVT and ascites. He had +asterixes and was continued on
lactulose. He underwent TIPS as above on ___. Rifaximin was
added given high risk of hepatic encephalopathy s/p TIPS. He
will need outpatient liver f/up to discuss HCV therapy
#Abdominal pain
Patient with chronic abdominal pain, which has been present on
previous admission of unclear etiology. Report from OSH CT scan
negative for acute process. No ascites on exam. No e/o portal
vein thrombus on RUQ US. Some concern for drug seeking behavior,
given his frequent requests for IV pain medication. He was given
Tylenol and PRN oxycodone 5mg. Did not escalate narcotics use.
TRANSITIONAL ISSUES
======================
[]Discontinued Lasix/spironolactone as no evidence of ascites on
imaging and now patient is s/p TIPS
[]Continued nadolol on discharge for hypertension. Can
discontinue if patient is normotensive, as no indication for
beta blocker prophylaxis for varices now that patient is s/p
TIPS.
[]Patient complaining of chronic abdominal pain. High suspicion
for narcotic seeking behavior. Would not give narcotics if
possible.
[]Please continue lactulose and rifaximin for prevention of
hepatic encephalopathy.
[ ] If recurrent episodes of hemoptysis or bloody nose, would
consider referral to ENT specialist. If recurrent episodes of
hemoptysis, would also consider CXR and PPD given that the
patient lives in prison
[ ] F/u with hepatology at ___ in ___ weeks for discussion
of treatment of hepatitis C and management of cirrhosis
[ ] Patient should have RUQUS every 6 months for ___ screening
given his cirrhosis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Omeprazole 40 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Levalbuterol Neb 0.63 mg NEB Q6H
5. Nadolol 20 mg PO DAILY
6. Simethicone 40-80 mg PO QID:PRN bloating
7. Spironolactone 100 mg PO DAILY
8. Thiamine 100 mg PO DAILY
9. Lactulose 30 mL PO QID
10. Magnesium Oxide 800 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Sodium Chloride Nasal ___ SPRY NU BID:PRN dry sinuses
13. Ondansetron 4 mg PO TID
14. Zenpep (lipase-protease-amylase) 10,000-34,000 -55,000 unit
oral TID W/MEALS
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Do not exceed 3gm/day
2. Gabapentin 300 mg PO TID
3. Pantoprazole 40 mg PO Q12H
4. Rifaximin 550 mg PO BID
5. Sucralfate 1 gm PO QID
6. Docusate Sodium 100 mg PO BID
7. Lactulose 30 mL PO QID
8. Levalbuterol Neb 0.63 mg NEB Q6H
9. Magnesium Oxide 800 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Nadolol 20 mg PO DAILY
12. Omeprazole 40 mg PO DAILY
13. Ondansetron 4 mg PO TID
14. Simethicone 40-80 mg PO QID:PRN bloating
15. Sodium Chloride Nasal ___ SPRY NU BID:PRN dry sinuses
16. Thiamine 100 mg PO DAILY
17. Zenpep (lipase-protease-amylase) 10,000-34,000 -55,000 unit
oral TID W/MEALS
18. HELD- Furosemide 40 mg PO DAILY This medication was held.
Do not restart Furosemide until told by your doctor
19. HELD- Spironolactone 100 mg PO DAILY This medication was
held. Do not restart Spironolactone until told by your doctor
Discharge Disposition:
Extended Care
Discharge Diagnosis:
PRIMARY:
Hematemesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Why you were admitted to the hospital?
-You were admitted because you were vomiting up blood.
What happened while I was in the hospital?
-You received a procedure called TIPS which will help to prevent
further bleeding.
What should you do when you leave the hospital?
- Please continue taking your medications as prescribed.
- Please attend your follow up appointments as arranged.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
10890203-DS-20
| 10,890,203 | 29,963,395 |
DS
| 20 |
2135-11-22 00:00:00
|
2135-11-22 21:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine / Zofran (as hydrochloride) / Quinolones
Attending: ___.
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ with PMHx ETOH/HCV Cirrhosis c/b varices s/p
banding, TIPs (___) w/several recent presentations for
hematemesis and abd pain p/w hematemesis
Today, pt had 3x episodes of BRB emesis, reportedly witnessed by
guards. Pt reports that it is at least 3 cups worth. Last
episode of emesis was at noon. Emesis is also associated with
___ abdominal pain, constant/crampy pain. EMS with VSS.
Initially presented to ___ w/VS BP 130s HR ___, was
started on Octreotide and Protonix, also given IV dilaudid and
morphine, transferred to ___ ED.
Of note, pt was recently admitted on ___ & ___ for
hematemesis and abdominal pain. EGD in ___ was w/o esophageal
varices, though did show non-bleeding gastric varices. Had mild
asterixis w/o other signs of HE, w/patent TIPs w/o ascites or
signs of infxn. Repeat admit on ___ showed oral lesions with
suspicions that oral bleeding was for secondary gain. He was
seen in ED on ___ for unwitnessed hematemesis, H&H/RUQUS were
stable, guaiac neg, DC'd back to prison after monitoring. Per
Prison records, pt is on nadolol 20 BID, which appears to be a
new med from prior DC.
ED Course notable for:
2x 18g, 1x 20g in place
Initial VS: T96.8 57 123/68 18 97% RA
Labs w/Hb 11.9 (13.6 on ___, WBC 3.6, Plt 52, BUN 9, ALT/AST
120/220 (~baseline), Tbili 4.6 (baseline), Alb 2.7, UA neg leuk,
lac 1.8
Imaging with RUQ U/S w/dopplers w/patent TIPS
Liver consulted, rec'd admit to ICU for EGD tomorrow, but if
recurrent bleeding, liver fellow should be paged for more
emergent procedure
Given: IV dilaudid 0.5mg x2, IV CTX 1g, IV Protonix 40mg,
Octreotide gtt 50mcg
On arrival to the MICU, pt without complaints. States Sx are
similar to prior admissions. +epigastric pain. No black/red
stools. BRB emesis x3. No LH/dizziness, cp, sob, n/d, no BM
today, no confusion, no dysuria, no f/c/ns.
Past Medical History:
EtOH/HCV Cirrhosis
Hypertension
EtOH Abuse
TIPS ___
Social History:
___
Family History:
Father: testicular cancer, MI, stroke, died in ___
Mother: lung cancer, died in ___
Sister: SLE, died in ___
DM runs in the family
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: Reviewed in metavision
GENERAL: NAD
HEENT: AT/NC, pinpoint pupils, anicteric sclera, pink
conjunctiva, pinpoint upper palette lesion
NECK: supple, no JVD
HEART: RRR, s1/s2, no murmurs, gallops, or rubs
LUNGS: CTABL, no w/c/r
ABDOMEN: +BS, soft, firm, nondistended, mild tenderness to
epigastric
palpation, no rebound, mild guarding
EXTREMITIES: ___ pitting edema b/l LEs, wwp
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis
DISCHARGE PHYSICAL EXAM:
========================
VS: reviewed in OMR
General: Well-appearing, lying in bed, in NAD
HEENT: NC/AT, EOMI, PERRL, anicteric sclera, MMM
Neck: Supple, no lymphadenopathy
Lung: Diminished breath sounds, but CTAB, breathing comfortably
without use of accessory muscles, no wheezes/rhonci/rales
Card: RRR, normal S1/S2 with occasional ectopy, no m/r/g
Abd: Non-distended, soft, mild TTP in epigastrium and RUQ,
voluntary guarding without rebound, active bowel sounds
Ext: 3+ pitting edema in b/l lower extremities, no cyanosis or
clubbing
Neuro: Alert, oriented x3, moving all extremities with purpose,
no facial asymmetry, no asterixis
Pertinent Results:
ADMISSION LABS:
===============
___ 03:45PM BLOOD WBC-3.6* RBC-3.66* Hgb-11.9* Hct-34.7*
MCV-95 MCH-32.5* MCHC-34.3 RDW-15.1 RDWSD-52.5* Plt Ct-52*
___ 03:45PM BLOOD Neuts-56.3 ___ Monos-11.0 Eos-3.9
Baso-0.3 NRBC-0.8* Im ___ AbsNeut-2.04 AbsLymp-1.02*
AbsMono-0.40 AbsEos-0.14 AbsBaso-0.01
___ 03:45PM BLOOD Plt Ct-52*
___ 03:45PM BLOOD Glucose-73 UreaN-9 Creat-0.7 Na-141 K-4.3
Cl-109* HCO3-22 AnGap-10
___ 03:45PM BLOOD ALT-120* AST-220* AlkPhos-79 TotBili-4.6*
___ 03:45PM BLOOD Albumin-2.7*
___ 04:44PM BLOOD Lactate-1.8
DISCHARGE LABS:
===============
___ 10:33AM BLOOD WBC-3.9* RBC-3.87* Hgb-12.6* Hct-36.1*
MCV-93 MCH-32.6* MCHC-34.9 RDW-14.6 RDWSD-48.9* Plt Ct-52*
___ 10:33AM BLOOD ___ PTT-37.0* ___
___ 10:33AM BLOOD Glucose-146* UreaN-8 Creat-0.8 Na-138
K-4.5 Cl-104 HCO3-27 AnGap-7*
___ 10:33AM BLOOD Albumin-2.8* Calcium-8.1* Phos-2.5*
Mg-1.6
MICROBIOLOGY:
=============
URINE CULTURE (Final ___: NO GROWTH.
STUDIES:
========
___ Abdominal ultrasound:
1. Patent TIPS. When accounting for differences in technique no
SIGNIFICANT interval change in comparison to the prior study
dated ___. 2. Cirrhotic liver with mild splenomegaly. No
concerning focal lesions. No ascites.
Brief Hospital Course:
BRIEF SUMMARY:
==============
Mr ___ is a ___ with PMHx ETOH/HCV Cirrhosis c/b varices s/p
banding, TIPs (___) w/several recent presentations for
hematemesis and abd pain p/w hematemesis
ACUTE ISSUES:
=============
# Hematemesis: Per nurse at prison, had one episode of
clear/bilious emesis, followed by emesis with pink/red streaks,
followed by dark red hematemesis. Differential includes ___
___ tear vs. variceal bleed vs. gastric/duodenal ulcer. Does
have history of hematemesis for secondary gain, but this episode
was
witnessed/confirmed by prison personnel. Started on ___
gtt, IV PPI, and ceftriaxone in ED. Subsequent lab draws
revealed stable Hgb and no further episodes of hematemesis.
Transitioned to PO PPI, discontinued octreotide. Given low
concern for true hematemesis, discontinued ceftriaxone on ___
and will not discharge with PO ppx. Discharge Hgb 12.6.
# HCV/EtOH cirrhosis c/b varices s/p banding and recent TIPs
procedure ___
Currently decompensated by bleeding, as above. Held furosemide
initially but given stable Hgb and volume overload, restarted
home furosemide. Hematemesis management as above. Given TIPS
procedure, no evidence of esophageal varices on a recent EGD,
and a HR in the ___ at baseline, decision was made to
discontinue nadolol. Continued lactulose/rifaximin as well. MELD
score of 15 on ___. Adhere to 2g sodium diet.
# Transaminitis: AST:ALT > 2:1, concerning for alcoholic
hepatitis. No serum/urine
tox on admission. Notably, has had LFT elevations on past
admissions, as well. Serum tox negative. ALT/AST 115/234 on
___ and stable.
CHRONIC ISSUES:
===============
# Hypertension: held amlodipine in setting of possible upper GI
bleed. Continued to hold upon discharge given normotension.
# Asthma: low concern for exacerbation, continued home
levalbuterol PRN
# Pancytopenia: Chronic issue, likely ___ HCV cirrhosis.
Plts/WBCs within prior baselines.
# MEDREC: c/w home gabapentin, thiamine
TRANSITIONAL ISSUES:
====================
[] Holding amlodipine upon discharge given low SBPs. Consider
reinstitution if hypertensive on outpatient basis
[] Given low concern for true hematemesis, will not send home
with prescription for SBP ppx
[] Given prior TIPS, no esophageal varices on ___ EGD, and
low HRs at baseline off of nadolol in the ___, will hold nadolol
upon discharge with decision to restart per outpatient
hepatologist discretion.
[] Prior history of secondary gain from hospitalizations. Likely
patient returned to hospital this admission for similar reason
given stable hemoglobin and no more subsequent episodes of
hematemesis upon arrival to the hospital. Please consider this
prior to transfer back to hospital for concern for hematemesis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO DAILY:PRN Pain - Mild
2. Gabapentin 600 mg PO BID
3. Lactulose 30 mL PO DAILY
4. Levalbuterol Neb 0.63 mg NEB Q6H
5. Multivitamins 1 TAB PO DAILY
6. Rifaximin 550 mg PO BID
7. amLODIPine 5 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. Spironolactone 100 mg PO DAILY
10. Magnesium Oxide 400 mg PO BID
11. Nadolol 20 mg PO BID
12. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
13. Thiamine 100 mg PO DAILY
14. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Acetaminophen 650 mg PO DAILY:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
3. Furosemide 40 mg PO DAILY
4. Gabapentin 600 mg PO BID
5. Lactulose 30 mL PO DAILY
6. Levalbuterol Neb 0.63 mg NEB Q6H
7. Magnesium Oxide 400 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Rifaximin 550 mg PO BID
11. Spironolactone 100 mg PO DAILY
12. Thiamine 100 mg PO DAILY
13. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until evaluated by PCP
14. HELD- Nadolol 20 mg PO BID This medication was held. Do not
restart Nadolol until evaluated by hepatology
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnoses:
==================
Concern for hematemesis vs secondary gain
Secondary diagnoses:
====================
HCV/EtOH cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for vomiting up blood. You
were treated with medications to help stop the bleeding, and
fortunately, the bleeding resolved. Your medication list was
updated which will be given to you at your facility.
It was a pleasure to take care of you.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10890290-DS-11
| 10,890,290 | 28,774,198 |
DS
| 11 |
2122-09-13 00:00:00
|
2122-09-14 08:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
amoxicillin / adhesive tape / Tegaderm
Attending: ___.
Chief Complaint:
Right thigh infection
Major Surgical or Invasive Procedure:
___ Incision and debridement of skin, fat and fascia, right
thigh, 15 x 5 cm and then 10 x 4 cm, with a VAC placement in
both wounds
___ Replacement of wound VAC greater than 50 cm2
___ Replacement of wound VAC greater at bedside
History of Present Illness:
___ female with no significant past medical history
who presents with worsening thigh pain and fluid collection
found on OSH CT. ___ had a ATV accident with right thigh
laceration status post debridement repair at outside
hospital on ___. After being discharged from our
hospital, she had worsening pain so she presented to our
facility and had a right thigh washout by Dr. ___ on
___. She had a ___ left in the wound and
discharged this past ___ with a course of Augmentin for
which she completed this past ___. ___ states that
over the weekend, she started experiencing worsening right
thigh pain. She is to credit the pain to slowing down on her
analgesic medications. However for the past 2 days, she fell
as her right thigh is very indurated and becoming hardening
and worsening the pain. Also endorses some paresthesias
noted over the right knee. Denies any fevers or chills. No
nausea or vomiting. No abdominal pain. Pt seen at OSH and
had a CT scan done which is concerning for a "2.5 cm fluid
collection posteriorly". White count was 11.1. ___ was
given Ertapenem and transfered here for further care.
Currently complains of thigh pain with no other symptoms. No
chest pain or shortness of breath. No dysuria hematuria.
Past Medical History:
PMH:
-none
PSH:
-tubal ligation
-lap cholecystectomy
-suture of right leg laceration
Social History:
___
Family History:
non contributory
Physical Exam:
Admission Physical Exam:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: deferred
Ext: RLE with some increased edema. Incision with scabbing at
staples, some erythema immediately surrounding site, not
spreading. ___ in place with medial serosanguinous drainage.
posterior hard area at mid-thigh consistent with fluid
collection
seen on CT.
Discharge Physical Exam:
Vitals: 97.6 118 / 79 99 18 97 Ra
GEN: A&O, NAD, anxious, pressured
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation
ABD: Soft, non-distended, non-tender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: RLE with wound van in place, distal pulses DP 2+, Incision
with scabbing at
proximal end, TTP around wound vac site.
Vascular: Pulses radial and DP B/L 2+.
Pertinent Results:
Admission Labs:
===============
___ 05:22AM BLOOD WBC-9.4 RBC-3.67* Hgb-11.8 Hct-35.8
MCV-98 MCH-32.2* MCHC-33.0 RDW-12.0 RDWSD-42.7 Plt ___
Pathology:
==========
___ Pathology Tissue: SOFT TISSUE, DEBRIDEMENT
Soft tissue, right thigh, debridement:
- Fragments of fibrodipose tissue and skin with acute
inflammation and necrosis.
Discharge Labs:
===============
___ 04:40AM BLOOD WBC-7.2 RBC-3.70* Hgb-11.7 Hct-36.3
MCV-98 MCH-31.6 MCHC-32.2 RDW-11.7 RDWSD-42.2 Plt ___
___ 04:40AM BLOOD Glucose-90 UreaN-15 Creat-0.6 Na-141
K-4.4 Cl-105 HCO3-24 AnGap-12
___ 04:40AM BLOOD Calcium-9.2 Phos-5.6* Mg-1.6
Brief Hospital Course:
Ms. ___ is a ___ year old female who has a history of
a prior right thigh infection after an ATV accident, who was
admitted to ___ for right thigh
pain. She underwent a right thigh incision and debridement of
skin, fat and fascia, right thigh, 15 x 5 cm and then 10 x 4 cm,
with a VAC placement in both wounds. Over the following days she
recovered without complications, with two additional wound
vacuum changes, one in the operating room and one on the floor
at bedside. Given that the ___ pain was difficult to
manage, the acute pain service was consulted. At time of
discharge, the ___ was recovered adequately, though
continued to have pain with wound vacuum changes. That being
said, the ___ strongly communicated her desire to be
discharged and communicated that she felt that given her pain
tolerance she felt comfortable having future wound vacuum
changes done at home with a visiting nurse association Nurse.
Active Issues:
# Right thigh wound and infection: ___ underwent right thigh
wound debridement with VAC placemnt x3. She was empirically
treated with vancomycin and ceftazidime empirically due to
concern regarding infections. 1 of 2 wound cultures grew rare
coag negative staph, ___ complete 6 days of antibiotics. At
time of discharge the ___ was recovering well.
# Lack of Primary Care Physician: ___ was noted to lack a
primary care physician, case management assisted the ___ in
finding a new primary care physician. An appointment was made
for ___ @ 10:00am.
Chronic Issues:
# NA
Transitional Issues:
# Follow up with your New PCP
# ___ up with the Acute Care Surgery Clinic
# Medications Changes:
New:
Gabapentin 600 mg PO TID
OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
Tizanidine 2 mg PO TID
SAME:
Acetaminophen 1000 mg PO Q8H
Docusate Sodium 100 mg PO BID
Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
OxyCODONE (Immediate Release) 5mg PO Q4H:PRN Pain - Moderate
Polyethylene Glycol 17 g PO DAILY
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Polyethylene Glycol 17 g PO DAILY
2. Acetaminophen 1000 mg PO Q8H
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
5. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Gabapentin 600 mg PO TID
do not operate machinery while taking, hold for slow breathing
RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day
Disp #*18 Tablet Refills:*0
2. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
do not operate machinery while taking, hold for slow breathing
and or low blood pressure
RX *oxycodone 20 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*12 Tablet Refills:*0
3. Tizanidine 2 mg PO TID
do not operate machinery while taking, hold for dizziness
RX *tizanidine 2 mg 1 tablet(s) by mouth three times a day Disp
#*18 Tablet Refills:*0
4. Acetaminophen 1000 mg PO Q8H
5. Docusate Sodium 100 mg PO BID
6. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth Q6H: PRN Disp #*16
Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1) Infected necrotic wound of right thigh with cellulitis and
abscess formation
2) Incision and debridement of skin, fat and fascia, right
thigh, 15 x 5 cm and then 10 x 4 cm, with a VAC placement in
both wounds.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___ and
underwent a right thigh wound cleaning, washing, and placement
of a wound vacuum device. You are recovering well and given your
strong requests for discharge home and adequate recovery you are
now ready for discharge. Please follow the instructions below to
continue your recovery:
Follow up with the ___ clinic for evaluation of your right thigh
wound.
YOUR BOWELS:
-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.
-If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
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.
Warm regards,
Your ___ Surgery Team
Followup Instructions:
___
|
10890447-DS-4
| 10,890,447 | 23,126,792 |
DS
| 4 |
2148-02-28 00:00:00
|
2148-02-28 09:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Double vision
Major Surgical or Invasive Procedure:
TEE
History of Present Illness:
The patient is a ___ yo M PMHx 10 pack year smoking history
and morbid obesity who presents to the ___ ED ___ with acute
onset L hemiplegia, L facial droop, vertigo, and slurred speech
lasting ~45 minutes and persistent double vision.
Pt went boating on the day prior to presentation. He had no
trauma or head injury during this time. On the day of
presentation, around 20:00, he was sitting in his living room
when his neck felt stiff. This was not unusal and he moved his
head around which alleviated symptoms. He then bent over to itch
his L leg when he suddenly developed lightheadedness, room
spinning sensation (direction unclear), a "heavy" left arm and
leg, gait unsteadiness (falling to the L) and double vision. His
cousin observed this and noted that pt was slurring his speech
and had L facial drooping. He was hesitant to go to the hospital
at first but after symptoms did not improve EMS was called.
Around 20:45, EMS arrived. At this time, pt's symptoms resolved
apart from double vision and gait unsteadiness. En route to the
hospital, pt also noted that water tasted abnormal.
Upon arrival to ___, pt could not undergo CT or MRI due to his
weight. At the time of my assessment, pt reports ongoing double
vision and gait unsteadiness. The double vision resolved when pt
closes one eye and worsens when looking into the distance. Pt
denied any headache but reports L eye pain.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies vertigo, tinnitus, hearing
difficulty, dysarthria, or dysphagia. Denies focal muscle
weakness, numbness, parasthesia. Denies loss of sensation.
Denies
bowel or bladder incontinence or retention.
On general review of systems, the patient denies fevers, chest
pain, palpitations, cough, nausea, vomiting, diarrhea,
constipation, abdominal pain, dysuria or rash.
Past Medical History:
Nicotine dependence
Morbid obesity
No history of blood clots
Social History:
___
Family History:
+DM in multiple relatives. No family history of blood clots or
stroke.
Physical Exam:
Admission Exam:
Vitals: 98 ___ 16 98% RA
General: Obese, comfortable
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
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 dysarthria. No apraxia. No evidence of hemineglect.
No left-right agnosia.
- Cranial Nerves - R pupil 4->3, L pupil 3->2, both briskly
reactive. VF full to number counting. Eyes are disconjugate and
R
eye is esotrophic. Ocular bobbing is observed at rest. Nystagmus
is appreciated in both vertical and horizontal planes and is
direction changing. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
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, pin, or proprioception
bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 1
R 1 1 1 1 1
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - Deferred.
On discharge:
- CN: convergence nystagmus improved from admission but still
there, double vision on R gaze, impaired upward gaze on R (left
eye will elevate completely, R eye does not), R eye depresses
more than L eye, buries sclera bilaterally, no speech
difficulties, face symmetric, sensation intact to light touch in
face, tongue midline
- motor: ___ throughout
Pertinent Results:
___ TTE
Very suboptimal image quality. Grossly normal left ventricular
cavity size and systolic function. Biatrial enlargement. Unable
to assess valvular function or morphology.
___ CT Head - read pending
___ Carotid US
Right ICA no stenosis.
Left ICA no stenosis.
- Risk factors: HgbA1c 7.1, LDL 58, TSH 2.2
- carotid u/s: no stenosis in bilateral ICA
- vertebral u/s: difficult to visualize
- Transcranial doppler ultrasound:
Impression: Normal TCD evaluation. There was no evidence of
vasospasm.
- TTE: Very suboptimal image quality. Grossly normal left
ventricular cavity size and systolic function. Biatrial
enlargement. Unable to assess valvular function or morphology.
- TEE: No intracardiac source of embolism identified. Normal
global biventricular systolic function.
- Portable head CT: No evidence of infarction however evaluation
of the pons and posterior fossa is somewhat limited on CT
- ___: rehab
- counseled on smoking cessation
Brief Hospital Course:
Mr. ___ is a ___ yo M PMHx 10 pack year smoking history and
morbid obesity who presented with acute onset L hemiplegia, L
facial droop, vertigo, slurred speech, double vision and
dysequilibrium. Apart from persistent double vision and
dysequilibrium, his other symptoms resolved within 45 minutes of
onset. He was suspected to have a brainstem (midbrain/pontine)
stroke of unknown etiology.
# Neuro:
The patient presented with symptoms concerning for acute stroke,
and was admitted to the ICU in order to have a portable CT scan
(patient's weight is above limit for conventional CT and MRI).
Evaluation of the pons and posterior fossa was limited on the
portable CT, but it showed no evidence of infarction,
hemorrhage, edema, or mass. Also, carotid US was performed,
which showed no evidence of stenosis bilaterally. After numerous
efforts to find a facility that would accommodate the patient
for a conventional CT or MRI scan, none was found. The patient's
symptoms improved with resolution of L sided weakness, decreased
double vision and no recurrences of vertigo.
Laboratory tests were performed to assess multiple stroke risk
factors in the patient. HbA1c was elevated at 7.1 indicating
that the patient is likely diabetic and should be followed-up in
the outpatient setting. TSH and lipids were in the normal range.
# CV:
The patient was monitored on telemetry, which did not show afib.
He was normotensive. He had a TEE performed which identified no
intracardiac source of embolism and normal global biventricular
systolic function.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
3. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Likely ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro: convergence nystagmus, double vision on R gaze, impaired
upward gaze, no speech difficulties, motor exam ___ throughout
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of acute onset left sided
weakness and double vision likely resulting from an ACUTE
ISCHEMIC STROKE, a condition where a blood vessel providing
oxygen and nutrients to the brain is blocked by a clot. The
brain is the part of your body that controls and directs all the
other parts of your body, so damage to the brain from being
deprived of its blood supply can result in a variety of
symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- diabetes
- obesity
- obstructive sleep apnea
We are changing your medications as follows:
- aspirin 81mg daily
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10890482-DS-20
| 10,890,482 | 27,791,076 |
DS
| 20 |
2150-08-18 00:00:00
|
2150-08-19 06:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o UC s/p total abdominal colectomy and J pouch
presents with abdominal cramping and nausea/vomiting. He states
that starting on ___, after eating carrots and corn, he
started having right-sided abdominal pain. He called his PCP,
and
out of concern for appendicitis, sent him to the ___ ED.
There, he had a CT scan that reportedly showed a small bowel
obstruction. He was admitted and managed conservatively.
Yesterday, they advanced his diet, which he tolerated, and he
was
discharged home. His last PO intake was ___ and was yogurt
and half of a sandwich (which is the diet he tolerated prior to
discharge from ___. Since discharge, he complains of
worsening abdominal cramping, nausea, and he had one large bout
of emesis today. Due to concern for possibly needing surgery, he
came to ___ for evaluation. He reports that he continues to
pass flatus and had a bowel movement a few minutes ago upon
arrival to the ED (guiac negative). Denies fevers, but does
endorse chills.
Past Medical History:
Past Medical History: asthma, HTN, h/o UC
Past Surgical History: TAC and ileostomy (___), completion
proctectomy and J pouch (___), ileostomy takedown (___),
incarcerated hernia repair (through defect at previous ostomy
site)
Physical Exam:
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR
PULM: normal excursion, no respiratory distress
ABD: soft, appropriately tender, minimally distended. Wounds
C/D/I.
EXT: WWP
Pertinent Results:
Admission
___ 09:21PM BLOOD WBC-6.7 RBC-4.15* Hgb-13.2* Hct-40.2
MCV-97# MCH-31.8 MCHC-32.8 RDW-12.3 RDWSD-43.8 Plt ___
___ 09:21PM BLOOD Neuts-64.8 Lymphs-16.7* Monos-17.3*
Eos-0.5* Baso-0.2 Im ___ AbsNeut-4.33 AbsLymp-1.11*
AbsMono-1.15* AbsEos-0.03* AbsBaso-0.01
___ 09:21PM BLOOD ___ PTT-27.5 ___
___ 09:21PM BLOOD Glucose-112* UreaN-23* Creat-0.8 Na-142
K-3.8 Cl-97 HCO3-30 AnGap-15
___ 09:21PM BLOOD ALT-24 AST-22 AlkPhos-47 TotBili-0.5
___ 06:30AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.9
Admission
___ 07:26AM BLOOD WBC-5.4 RBC-3.89* Hgb-12.6* Hct-36.3*
MCV-93 MCH-32.4* MCHC-34.7 RDW-11.9 RDWSD-40.9 Plt ___
___ 07:26AM BLOOD Glucose-107* UreaN-17 Creat-0.7 Na-137
K-4.0 Cl-101 HCO3-24 AnGap-12
___ 07:26AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0
Brief Hospital Course:
Mr. ___ presented to the ED at ___ on ___ for
surgical evaluation for SBO. He was kept NPO and given IVF.
Neuro: Pain was well controlled.
CV: Vital signs were routinely monitored during the patient's
length of stay.
Pulm: The patient was encouraged to ambulate, sit and get out of
bed, use the incentive spirometer, and had oxygen saturation
levels monitored as indicated.
GI: The patient was initially kept NPO and later advanced to and
tolerated a regular diet at time of discharge.
GU: Urine output was monitored as indicated. At time of
discharge, the patient was voiding without difficulty.
ID: The patient's vital signs were monitored for signs of
infection and fever.
Heme: The patient had blood levels checked during the hospital
course to monitor for signs of bleeding. The patient had vital
signs, including heart rate and blood pressure, monitored
throughout the hospital stay.
On ___, the patient was discharged to home. At discharge,
he was tolerating a regular diet, passing flatus, stooling,
voiding, and ambulating independently. He will follow-up in the
clinic in ___ weeks. This information was communicated to the
patient directly prior to discharge.
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehab hospital disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
dispo
[x] No social factors contributing in delay of discharge.
Discharge Disposition:
Home
Discharge Diagnosis:
SBO with transition point at the site of prior ileostomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for small bowel obstruction.
Your were managed with conservative treatment with small bowel
rest and IVF. You are now ready to return home. You have
tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth. You may return home
to finish your recovery.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities.
Good luck!
Followup Instructions:
___
|
10890576-DS-2
| 10,890,576 | 29,676,328 |
DS
| 2 |
2159-09-15 00:00:00
|
2159-09-16 05:37:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Motrin / clarithromycin / tolmetin / Salsalate
Attending: ___.
Chief Complaint:
Constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with HTN, CHF, Afib, CKD presenting with constipation.
The patient is currently confused and slightly agitated and
unable to give a good history. He reports 3 days of "problems
moving my bowels". Describes some loose stools, then
constipation and possible some rectal pain. Associated with
abdominal pain. Denies bloody stool or melena.
In the ED initial vitals were: 98.0 68 138/109 19 98% RA
- patient had CT scan with contrast that showed impacted stool
in the distended rectum and mild fat stranding around the
rectum.
- Patient has several large formed bowel movements in the ED
after po contrast but was complaining of significant pain. He
was given 2mg IV morphine x 2 with little relief so he was
admitted for pain control.
On the floor, the patient appeared to be slightly confused but
not complaining of any pain. Appeared to be slightly incontinent
of stool.
Review of Systems: as per HPi, all other systems negative
Past Medical History:
- Dementia
- HTN
- Afib
- h/o AVR
- Complete heart block s/p PPM
- CKD
- Rheumatic Heart Dz
- BPH
- polymalgia Rheumatica
- DDD
- lacunar stroke
- CHF
- Spinal stenosis
- glaucoma
Social History:
___
Family History:
- patient unable to recall
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===================================
Vitals- 98.4 144/60 72 18 100% RA
General- thin, elderly man, appears anxious
HEENT- PERRL, no scleral icterus, MMM
Neck- supple, no JVP elevation
Lungs- CTAB
CV- RRR, no m/r/g
Abdomen- soft, but voluntary guarding, + TTP in RLQ, hyperactive
BS
Ext- thin, no edema
Neuro- AAOx1, knows hospital but not city or year. unable to
answer questions coherently
PHYSICAL EXAM ON DISCHARGE:
===================================
VS: 97.8 141/56 (SBPs 123-155) 67 16 100%RA
General: Awake, alert. Oriented to self, place, month. At times
mildly agitated, but easily re-directed.
HEENT: PERRL. Sclera nonicteric. MMM, no oral lesions.
Neck: No LAD.
CV: RRR. No murmur appreciated.
Lungs: CTA b/l.
Abdomen: Soft, nontender, nondistended. No masses or HSM
appreciated.
Ext: Thin, warm, no ___ edema.
Pertinent Results:
LABS:
================================
___ 09:15PM BLOOD WBC-8.0 RBC-4.72 Hgb-13.3* Hct-42.7
MCV-90 MCH-28.1 MCHC-31.1 RDW-12.8 Plt ___
___ 09:15PM BLOOD Neuts-68.0 ___ Monos-6.1 Eos-0.8
Baso-0.8
___ 09:15PM BLOOD Glucose-88 UreaN-30* Creat-1.6* Na-136
K-6.3* Cl-101 HCO3-24 AnGap-17
___ 09:15PM BLOOD ALT-18 AST-46* AlkPhos-87 TotBili-0.5
___ 09:15PM BLOOD Lipase-24
___ 09:15PM BLOOD Albumin-3.8
___ 09:15PM BLOOD Lactate-1.9 Na-139 K-5.2* Cl-100
calHCO3-27
___ 07:10AM BLOOD WBC-6.4 RBC-4.24* Hgb-11.6* Hct-38.6*
MCV-91 MCH-27.4 MCHC-30.1* RDW-12.7 Plt ___
___ 07:10AM BLOOD Glucose-69* UreaN-24* Creat-1.4* Na-138
K-4.3 Cl-105 HCO3-24 AnGap-13
___ 08:10AM BLOOD WBC-7.3 RBC-4.52* Hgb-12.6* Hct-40.5
MCV-90 MCH-27.9 MCHC-31.0 RDW-12.7 Plt ___
___ 08:10AM BLOOD Glucose-84 UreaN-21* Creat-1.5* Na-139
K-3.9 Cl-105 HCO3-25 AnGap-13
___ 10:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 10:00PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
IMAGING:
================================
-CT ABD & PELVIS WITH CONTRASTStudy Date of ___:
IMPRESSION:
1. Impacted stool in a distended rectum with moderate amount of
stool seen
within the right colon. No additional acute intraabdominal
findings to explain patient's pain.
2. Multiple small hypodensities are seen in the liver, too small
to further
characterize in this limited unenhanced examination but
concerning for
malignancy. Ultrasound is recommended for further
characterization.
3. Emphysematous changes at the lung bases with overlying
honeycomb/ fibrotic appearance most prominent in the left lung.
Comparison with prior
examinations would be helpful to assess chronicity. Clinical
correlation is
also recommended.
-LIVER OR GALLBLADDER US (SINGLE ORGAN)Study Date of
___:
FINDINGS: The liver is normal in contour and echotexture.
Scattered anechoic structures are scattered throughout the liver
which show through transmission and are most consistent with
simple cysts or biliary hamartomas. The largest is seen in the
inferior right lobe and measures 9 mm. There are no concerning
focal liver lesions identified. Doppler examination of the main
portal vein shows normal hepatopetal flow. The spleen is normal
in size. There is no ascites.
To the extent visualized, the pancreas is unremarkable, with the
body and tail largely being obscured by overlying bowel gas.
The gallbladder is normal. There is no cholelithiasis or
gallbladder wall thickening. Ectasia of the free portion of the
common bile duct is unchanged and ranges up to 1 cm, likely
normal for age. There is minimal prominence of the central
biliary ducts.
IMPRESSION: No concerning liver lesions.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
==============================================
___ y/o male with HTN, CHF, Afib, CKD who presented with
constipation.
ACTIVE ISSUES:
==============================================
# Constipation: Patient presented with constipation and
confusion. He reported not moving his bowels for 3 days. He
denied any nausea/vomiting. He did have lower abdominal pain. In
the ED intial vitals were: 98.0 68 138/109 19 98% RA. Labs were
relatively nonconcerning. Hbg was 13.3 (baseline from Atrius
records was around 14), Cr was 1.4 (baseline per Atrius records
was 1.4-1.6). He underwent abdominal CT with PO contrast which
was significant for impacted stool in a distended rectum.
Following his CT scan the patient had a large bowel movement and
felt better. He continued to have BMs during his stay. He was
discharged on standing colace and PRN miralax.
# Liver lesions: The CT scan showed some hypodense lesions that
could not be characterized. These were further evaluated by RUQ
ultrasound which showed scattered anechoic structures throughout
the liver most consistent with simple cysts or biliary
hamartomas.
# Anemia: Per review of Atrius records, Hbg baseline is around
14. Initial Hbg in the ED was 13.3, he had a drop overnight
after IVF to 11.6. This remained stable at 12.6 the following
day. Hct should be trended as outpatient.
# HTN: Patient with SBPs ranging from 123-155 during his
hospitalizations. His HCTZ was held upon discharge as it was
thought it had more harm than good given his age, renal
function, and fall risk.
# CKD: Patient with documented CKD, previous Cr of 1.47
___. Cr stable at 1.4-1.5 during this hospitalization.
# Dementia: Upon presentation, patient was confused. His mental
status improved and per wife and daughter he was at his baseline
at time of discharge (oriented to person, place, partial time;
forgetful and unable to fully provide history of symptoms). He
was continued on Namenda.
# Afib: He was continued on his home amiodarone.
# CAD: Continued on statin.
TRANSITIONAL ISSUES:
==============================================
- Discharged with instructions to discontinue
hydrochlorothiazide.
- Discharged with standing colace and PRN miralax.
- Follow-up with PCP on ___.
- Anemia should be trended.
- Discharged with home ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion 75 mg PO BID
2. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
3. Lorazepam 0.5 mg PO HS:PRN sleep/anxiety
4. Memantine 10 mg PO BID
5. Amiodarone 100 mg PO DAILY
6. Simvastatin 20 mg PO QPM
7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
8. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
Discharge Medications:
1. Amiodarone 100 mg PO DAILY
2. BuPROPion 75 mg PO BID
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
5. Lorazepam 0.5 mg PO HS:PRN sleep/anxiety
6. Memantine 10 mg PO BID
7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
8. Simvastatin 20 mg PO QPM
9. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
10. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
11. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice a day
Disp #*60 Capsule Refills:*1
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram/dose 17 grams by mouth
Daily Disp #*300 Gram Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Constipation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr ___,
It was a pleasure taking care of you while you were in the
hospital. You were admitted with constipation and rectal pain.
You had a CT scan (also called CAT scan) that showed large
amount of stool in the colon. Following the CT scan you had a
large bowel movement and you felt better. You were able to eat
and drink without pain or difficulty. You worked with physical
therapy and you did well. You will have physical therapy at home
to continue with your home rehab.
The CT scan showed some spots in your liver that were initially
concerning. You had an ultra-sound of your liver to evaluate and
these spots were found to be non-concerning. There is nothing
else that needs to be done at this time for this issue.
You had several medications added to your regimen to assist your
bowels. Please take them as directed. Please follow up with your
appointments as listed below.
Followup Instructions:
___
|
10890576-DS-3
| 10,890,576 | 28,264,621 |
DS
| 3 |
2160-02-15 00:00:00
|
2160-02-18 00:42:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Motrin / clarithromycin / tolmetin / Salsalate
Attending: ___.
Chief Complaint:
Altered Mental Status, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male hx. HTN, CHF, afib, CHB s/p pacemaker,
rheumatic heart disease s/p AV replacement, ILD thought due to
amiodarone toxicity, CKD, dementia presenting with c/o AMS and
hypotension.
History gathered from patient/family member and chart. Patient
was apparently doing some work on the stairs at home today when
he had acute onset confusion and sat on the steps. Family
members tried to get him to move but he couldn't. Per report, he
did not have syncope. The patient's wife called EMS who brought
him to ___ ED. The patient reports he was simply doing work on
the steps, he is not clear on the details of what led his wife
to call EMS. He denies any fevers/chills, chest pain,
palpitations, dyspnea, nausea/vomiting or diarrhea. No headaches
or visual changes.
Of note, patient was recently hospitalized at ___ with c/o
dyspnea, underwent bronchoscopy with BAL which grew pseudomonas.
He was discharged on levofloxacin as well as prednisone, as well
as home oxygen for presumed ILD. He was recently seen by his
pulmonologist and continued on a long prednisone taper for
presumed amiodarone induced lung injury. Per pulm note he has
finished his levaquin.
In the ED initial vitals were: 97.8 70 86/48 18 100% 4L Nasal
Cannula. Labs were notable for CBC with plt 108, chem-7 with Na
130, Bun/Cr 37/1.4, lactate 3.5. u/a was bland. CT head showed
no acute process, CXR showed evidence of worsening ILD. Patient
was given hydrocortisone 100mg IV as well as 1L IVF and admitted
to the floor. SBPs increased to ___ with steroids and IVF.
On the floor patient currently has no complaints other than
'decreased activity' for the past year. He says he is simply
unable to do the things he would like to do, is limited by
mobility. Son reports increasing falls at home, none recently.
Patient has no other complaints at this time.
Past Medical History:
- Dementia - per family oriented x2 at baseline.
- HTN
- Afib s/p cardioversion ___, previously on amio stopped due
to ?toxicity
- h/o AVR (___) - porcine
- Complete heart block s/p PPM ___: dual-chamber pacer placed
___
- CKD
- Rheumatic Heart Dz b/l Cr 1.4-1.6
- BPH
- polymalgia Rheumatica
- DDD
- lacunar stroke
- CHF
- Spinal stenosis
- glaucoma
- ILD thought due to amiodarone toxicity - on home 02 with
activity and currently on extended prednisone taper
Social History:
___
Family History:
Father ___ Cancer
Mother ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
==================
Vitals - 98.3 121/59 hr 71 96% RA
GENERAL: awake, alert, oriented to person and hospital not date
or president
HEENT: EOMI, PERRLA, OMM no lesions, JVP occasionally noted to
angle of mandible at 20deg
CARDIAC: RRR, S1/S2, ___ systolic murmur with click at LUSB, no
r/g
LUNG: inspiratory crackles at bases b/l, no wheezing
ABDOMEN: soft, nontender, nondistended
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or
edema
NEURO: CN II-XII intact, moves all fours
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
===================
Vitals: T:97.3-98.3 BP:96-121/57-59 P:71 R:18 O2:96-100% RA
General: Elderly gentleman, pleasant, calm, confused, A&Ox1
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: trachea midline, no cervical adenopathy
Lungs: bibasilar crackles, no wheezes or rhonchi
CV: ___ systolic murmur, audible click at apex from prosthetic
valve
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes or excoriations noted
Neuro: CN II-XII intact, moving all extremites, speech fluent
Pertinent Results:
LABS:
=====
___ 04:40PM BLOOD WBC-6.6 RBC-5.19 Hgb-13.5* Hct-44.7
MCV-86 MCH-26.0* MCHC-30.2* RDW-17.3* Plt ___
___ 06:20AM BLOOD WBC-7.8 RBC-4.96 Hgb-12.8* Hct-43.2
MCV-87 MCH-25.7* MCHC-29.5* RDW-17.2* Plt ___
___ 04:40PM BLOOD Neuts-68.3 ___ Monos-5.5 Eos-1.3
Baso-0.7
___ 04:40PM BLOOD Glucose-66* UreaN-37* Creat-1.4* Na-130*
K-7.3* Cl-102 HCO3-23 AnGap-12
___ 06:20AM BLOOD Glucose-100 UreaN-33* Creat-1.2 Na-138
K-4.9 Cl-106 HCO3-26 AnGap-11
___ 06:20AM BLOOD Mg-2.2
___ 04:40PM BLOOD TSH-2.1
___ 06:20AM BLOOD Cortsol-85.6*
___ 04:40PM BLOOD Cortsol-12.3
___ 06:20AM BLOOD Digoxin-0.4*
___ 04:49PM BLOOD Lactate-3.5* K-5.0
___ 06:50AM BLOOD Lactate-2.2*
___ 05:40PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:40PM URINE Hours-RANDOM UreaN-670 Creat-90 Na-28
K-36 Cl-28
IMAGING/STUDIES:
=============
ECG (___): Ventricular pacing at 60 beats per minute with an
appropriate left axis deviation and left bundle-branch block
morphology. Compared to the previous tracing of ___ atrial
pacing is no longer present. Accounting for slight differences
in left precordial electrode placement, ventricular paced
complexes have similar morphologies.
CT HEAD (___): FINDINGS: There is no evidence of acute
intracranial hemorrhage, edema, mass
effect or large territorial infarction. Similar to ___, the
ventricles and
sulci are extremely prominent, compatible with age-related
involutional
change. Periventricular white matter hypodensities are
nonspecific, but may
be seen in the setting of chronic microvascular ischemic
disease. The basal
cisterns are patent. There is preservation of gray-white matter
differentiation.
There is no fracture. The partially visualized paranasal
sinuses, mastoid air
cells and middle ear cavities are clear. There are
atherosclerotic
calcifications of the cavernous internal carotid arteries.
IMPRESSION: No evidence of acute intracranial abnormality.
CXR ___: IMPRESSION: Worsening asymmetric interstitial
abnormalities involving the
lung bases, greater on the left than right. Although an acute
on chronic
process is possible, it seems more likely that there is a
background process
of worsening interstitial lung disease to explain the
appearance.
MICRO: None
Brief Hospital Course:
___ year old male hx. HTN, CHF, afib, CHB s/p pacemaker,
rheumatic heart disease s/p AV replacement, ILD thought due to
amiodarone toxicity, CKD, dementia presenting with c/o AMS and
hypotension.
# Hypotension: Resolved. Likely related to poor PO intake given
family reported patient with chronically poor PO intake, likely
related to his dementia. Less likely was adrenal insufficiency
given patient was on slow prednisone taper and was still on 30
mg prednisone daily. SBPs improved with fluids and 100mg IV
hydrocort in ED. Elevated lactate suggested some hypoperfusion,
trended down with IVF. There were no signs of infection during
admission and U/A was negative. TSH was within normal limits.
Orthostatics were checked on the medical ward and were normal.
He was discharged on his home dose of prednisone to continue his
taper as directed by his pulmonologist and PCP.
# AMS, suspect toxic-metabolic encephalopathy: episode of
confusion on admission but patient returned back to baseline
mental status as per son. No syncope. Head CT negative for acute
process. Patient does have baseline dementia. Likely related to
hypoperfusion in setting of poor PO intake and underlying
dementia. Family was advised to assist patient in maintaining
good PO intake to help prevent hypotension and subsequent
hypoperfusion.
# Hyponatremia: Resolved. sodium 130 on admission, 138 with IVF
and steroids. Likely hypovolemic hyponatremia given
hypotension, improvement with IVF.
# ILD: Thought due to amiodarone toxicity, on intermittent home
02. Was comfortable on room air during hospitalization.
Discharged on home prednisone taper.
# afib s/p pacemaker: V paced on admission. Continued on his
home digoxin. Digoxin level was checked, was low at 0.4.
Recommend titrating dose as indicated.
# s/dCHF: last ECHO ___ with normal EF but mild MR and moderate
TR, stays post AV replacement for rheumatic heart disease. No
specific intervention during his admission for this issue.
# CKD: Creatinine at baseline on admission.
# s/p CVA: continued home plavix
# GERD: continued home omeprazole
# Dementia/Psych: continued home wellbutrin, memantine
TRANSITIONAL ISSUES:
___ with history of ILD (felt to be secondary to amiodarone
toxicity), atrial fibrillation, and dementia presented after
being found to be confused by a family member. He had been noted
to be asymptomatically hypotensive a few days earlier by his
___. On arrival, the patient's blood pressure was 86/48. His
labs were significant for a sodium 130 and a lactate of 3.5. He
was given stress dose steroids and IV fluids. His mental status
improved to baseline and his labs normalized. His BP, although
lower than his most recently recorded baseline, improved and was
within normal limits on discharge.
TRANSITIONAL ISSUES:
-On going, previously determined, prednisone taper
-Encourage PO intake
-Digoxin level pending on discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 20 mg PO DAILY
2. BuPROPion 75 mg PO BID
3. Omeprazole 20 mg PO BID
4. Ferrous Sulfate 325 mg PO TID
5. Digoxin 0.0625 mg PO EVERY OTHER DAY
6. antiox#10-om3-dha-epa-lut-zeax ___ mg oral daily
7. Codeine Sulfate 15 mg PO Q4H:PRN pain
8. Cyanocobalamin 1000 mcg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Clopidogrel 75 mg PO DAILY
11. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
12. Memantine 10 mg PO BID
13. Simvastatin 20 mg PO DAILY
Discharge Medications:
1. BuPROPion 75 mg PO BID
2. Clopidogrel 75 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Digoxin 0.0625 mg PO EVERY OTHER DAY
5. Memantine 10 mg PO BID
6. Omeprazole 20 mg PO BID
7. Simvastatin 20 mg PO DAILY
8. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. antiox#10-om3-dha-epa-lut-zeax ___ mg oral daily
11. Codeine Sulfate 15 mg PO Q4H:PRN pain
12. Ferrous Sulfate 325 mg PO TID
13. PredniSONE 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- Hypotension
- Acute toxic metabolic encephalopathy
- Dementia
- Hyponatremia
Secondary:
- Chronic kidney disease
- Atrial fibrillation
- Interstitial lung disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care at ___. You were
admitted with some confusion and low blood pressures. We think
you may have been dehydrated. You should be sure to eat and
drink enough at home. Your electrolytes were also slightly
abnormal on admission. They improved with some fluids and we
think this was due to dehydration.
We hope you continue to feel well.
-Your ___ team
Followup Instructions:
___
|
10890793-DS-18
| 10,890,793 | 21,597,112 |
DS
| 18 |
2135-02-09 00:00:00
|
2135-02-09 11:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: ___ year old man w/ PMH rheumatic heart disease,
endocarditis, tissue AVR, HTN, HLD presents as code stroke.
Patient states he was having lunch at ___ on ___, he went to the bathroom and had a bowel movement. He
states that when he came out of the bathroom he couldn't stand
properly. This was at 1:20pm he had to use a table to pull
himself up. A few minutes later, some other ___ patrons were
able to help him to his car. he then states he drove himself to
the emergency room at ___. He states he did not call an
ambulance, because in the area he was in, an ambulance would
have
taken him to the closest hospital, which was ___,
which he did not want to go to. He states it was only a ___ to ___. On the drive there he states he had trouble
using the turn signal because his left arm also began feeling
weak. He denies any sensory symptoms. When he arrived at ___, his car hit the curb and damaged one of the wheels.
Security came and helped him into a wheelchair and took him to
the emergency room. He was evaluated by tele stroke with NIHSS
at
the time reported to be 5. It is not clear what he was scored
for. Per ED note the following was his exam ___ LUE weakness,
___ LLE weakness, otherwise CN ___ intact, no dysmetria but
difficulty ___ weakness in LLE, NIHSS 5." tPA bolus given at
1659, drip started at 1705.
Initially it appeared he did not have a CTA done, as it was
listed as ordered but not completed. The call in from ___
stated that CTA was pending at the time of transfer. But after
his arrival here, radiology had noted he did in fact have a CTA
done at ___ already, but the wetread had not been placed
in an area that would make it viewable here by non radiologists.
CTA wetread stated no large vessel occlusion, did note a 5 mm
aneurysm. He was transferred from ___ to here for higher
level of care. On interview, patient states he began feeling
much
better after receiving tPA and feels like his weakness is
resolved now. He currently reports no symptoms. He mentions that
he had a lot of dental work done several weeks ago.
Past Medical History:
NAFLD since ___
Endocarditis-multiple episodes
AVR in ___
Dyslipidemia
Hypertension
Depression
paroxysmal SVT
mild carotid stenosis
Obstructive sleep apnea
GERD
DJD
impaired fasting glucose
Social History:
___
Family History:
non-contributory
Physical Exam:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis
noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, throughout. No extinction to DSS. Romberg
absent.
-DTRs:
___ Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: able to ambulate without assistance. Slightly unsteady,
but normal based with normal arm swing. Deferred on tandem
Pertinent Results:
TTE
The left atrial volume index is mildly increased. The estimated
right atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with a mildly increased/dilated cavity.
There is mild regional left ventricular systolic dysfunction
with hypokinesis of the basal inferolateral and inferior walls
(see schematic) and preserved/normal contractility of the
remaining segments. Quantitative biplane left ventricular
ejection fraction is 44 %. There is no resting left ventricular
outflow tract gradient. No ventricular septal defect is seen.
Normal right ventricular cavity size with normal free wall
motion. The aortic sinus diameter is normal for gender with
mildly dilated ascending aorta. The aortic arch diameter is
normal. There is no evidence for an
aortic arch coarctation. An aortic valve bioprosthesis is
present. The prosthesis is well seated with normal leaflet
motion and gradient. There is no aortic valve stenosis. There is
no aortic regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse. There is mild to
moderate [___] mitral regurgitation. Due to acoustic shadowing,
the severity of mitral regurgitation could be UNDERestimated.
The tricuspid valve leaflets appear structurally normal. There
is mild to moderate [___] tricuspid regurgitation. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
LEFT ATRIUM ___ ATRIUM (RA)
___: 5.4cm (nl<=4.0)
___ 4Chamber Length: 5.5cm (nl<5.2)
___ Volume: 75mL
___ Volume Index: 40mL/m² (nl <35)
RA 4Chamber Length: 4.7cm (nl<5.2)
Inferior vena cava diameter: 2.1cm
LEFT VENTRICLE (LV)
Septal Thickness: 1.4cm (nl M<1.1;F<1.0)
Inferolateral Thickness: 1.2cm (nl M<1.1;F<1.0)
End-diastolic (ED) Dimension: 5.8cm (nl M<5.9;F<5.3)
Biplane ED Volume: 198mL
Biplane ES Volume: 111mL
Biplane Ejection Fraction: 44%
AORTIC VALVE (AV)
Peak Velocity: 1.4m/sec (nl<=2.0)
Peak Gradient: 8mmHg
Mean Gradient: 5mmHg
AV VTI: 31cm
LVOT VTI: 9cm
MITRAL VALVE (MV)
Peak E: 0.9m/sec
E Deceleration: 158ms (nl 140-250)
Peak A: 1.2m/sec
Peak E/A: 0.8
MRI
1. Acute infarction involving the posterior right thalamus,
posterior right corona radiata and periventricular white matter.
No evidence of hemorrhagic conversion or intracranial
hemorrhage.
2. Multiple small areas of encephalomalacia related to a chronic
infarcts, as detailed above. Unchanged chronic microhemorrhage
in the anterior right frontal lobe.
___ 05:10PM BLOOD %HbA1c-7.3* eAG-163*
___ 05:10PM BLOOD Triglyc-295* HDL-35* CHOL/HD-4.8
LDLcalc-75
___ 05:10PM BLOOD TSH-1.4
Brief Hospital Course:
Summary:
___ year old man w/ PMH rheumatic heart disease, endocarditis,
tissue AVR, HTN, HLD presents as code stroke for acute onset
left leg and arm weakness and sensory changes. Initial NIHSS 5,
received tPA at OSH prior to transfer, with subsequent NIHSS 0
on arrival.
Acute issues addressed:
#AIS: CTA showed intra and extracranial atherosclerosis, but no
acute plaque. There was an incidentally discovered 5mm saccular
aneurysm. MRI showed an acute infarct of the right coronara
radiata and posterior thalamus. TTE revealed slightly worsened
mitral regurgitation - the patient reported having an
appointment on ___ with his outpatient cardiologist (Dr.
___ at ___, where he is planned
to undergo a stress test. He was noted on telemetry to have
prolonged PR interval and bundle branch block, which was
chronic. No atrial fibrillation was seen. Stroke risk factors
notable for elevated A1c, and mildly elevated LDL. The infarct
was felt to be most likely lacunar in etiology, in the presence
of multiple vascular risk factors, but a cardioembolic source
could not be completely ruled out, especially in the setting of
a significant valvular heart disease in the past. He was started
on aspirin 81mg daily, and his pravastatin was switched to
atorvastatin. He was advised to follow up with his PCP for
consideration of treatment (lifestyle modification or otherwise)
for elevated A1c. No tPA related complications. No physical
therapy needs as the patient was able to ambulate without
assistance.
Chronic issues addressed
#HTN: initially held lisinopril and home Lasix on admission,
resumed on discharge.
#HLD: pravastatin switched to a high intensity statin for
secondary stroke prevention.
#OSA: continued CPAP on admission.
Transitional issues
[ ] follow up with PCP ___: diabetes, consider starting
medication vs continued lifestyle modification
[ ] follow up with his cardiologist re: worsening mitral
regurgitation, planned on ___
[ ] consider long term telemetry monitoring for paroxysmal
events (e.g. atrial fibrillation)
[ ] follow up with stroke neurology, appointment TBD
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
2. FLUoxetine 20 mg PO DAILY
3. Furosemide 40 mg PO 3X/WEEK (___)
4. Gabapentin 100 mg PO QHS
5. Lisinopril 40 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Oxybutynin 5 mg PO DAILY
8. Pravastatin 20 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*360 Tablet
Refills:*2
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily at night Disp
#*360 Tablet Refills:*2
3. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
4. FLUoxetine 20 mg PO DAILY
5. Furosemide 40 mg PO 3X/WEEK (___)
6. Gabapentin 100 mg PO QHS
7. Lisinopril 40 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Oxybutynin 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right corona radiata and thalamus acute infarction, likely
lacunar
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of left sided numbness
and sensory changes resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Diabetes
High blood pressure
High cholesterol
We are changing your medications as follows:
START aspirin 81mg daily
START atorvastatin 40mg daily (to replace pravastatin, which
is your home medication)
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:
___
|
10891082-DS-16
| 10,891,082 | 27,195,588 |
DS
| 16 |
2120-04-30 00:00:00
|
2120-05-10 02:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Erythromycin Base / oral contraceptives / indomethacin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ - small bowel enteroscopy
History of Present Illness:
___ referred from ___ after 7 days of dull, waxing and
waning abdominal pain prompted an outpatient CT, which revealed
a
duodenal-jejunal intussusception. Ms. ___ reports that over
the past week, her pain has become increasingly prominent, but
not more severe. She describes this as originating in her left
mid-back, radiating around to the left flank, and occaisionally
in the LUQ. She denies associated symptoms - specifically
nausea, vomiting, change in bowel habits, unintentional weight
loss, fever, or chills.
On arrival to ___, she is comfortable with minimal pain. In
fact, after receiving a call from her PCP to present to the ED,
she attended her daughter's recital prior to driving herself to
___. She last took PO yesterday.
Past Medical History:
Past Medical History: migraines with associated vertigo
Past Surgical History: Lap CCY ___ yrs ago, bladder sling
procedure
Social History:
___
Family History:
DM, HTN, kidney stones
Physical Exam:
Admission Physical Exam:
Vitals: 99.6 92 130/81 18 97% RA
GEN: A&O, NAD. Pleasant and conversant.
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Obese. Soft, nondistended, minimal tenderness to deep
palpation in the LUQ and LLQ. No rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
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: Obese. Soft, nondistended, non-tender, No rebound or
guarding,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
PERTINENT LABS:
___ 09:55PM BLOOD WBC-9.5 RBC-4.32 Hgb-13.7 Hct-39.2 MCV-91
MCH-31.8 MCHC-35.0 RDW-12.5 Plt ___
___ 07:15AM BLOOD WBC-6.3 RBC-3.92* Hgb-12.1 Hct-35.6*
MCV-91 MCH-30.9 MCHC-34.0 RDW-12.4 Plt ___
___ 06:50AM BLOOD WBC-5.3 RBC-4.41 Hgb-13.6 Hct-40.0 MCV-91
MCH-30.8 MCHC-33.9 RDW-12.6 Plt ___
___ 04:40AM BLOOD WBC-6.8 RBC-4.16* Hgb-12.8 Hct-37.5
MCV-90 MCH-30.7 MCHC-34.1 RDW-12.7 Plt ___
___ 09:55PM BLOOD Neuts-65.2 ___ Monos-3.1 Eos-1.4
Baso-0.9
___ 09:55PM BLOOD Plt ___
___ 10:16PM BLOOD ___ PTT-31.6 ___
___ 07:15AM BLOOD Plt ___
___ 06:50AM BLOOD Plt ___
___ 04:40AM BLOOD Plt ___
___ 09:55PM BLOOD Glucose-85 UreaN-10 Creat-0.9 Na-143
K-4.1 Cl-108 HCO3-22 AnGap-17
___ 07:15AM BLOOD Glucose-80 UreaN-11 Creat-0.7 Na-139
K-3.6 Cl-109* HCO3-20* AnGap-14
___ 06:50AM BLOOD Glucose-90 UreaN-6 Creat-0.6 Na-140 K-4.1
Cl-111* HCO3-17* AnGap-16
___ 04:40AM BLOOD Glucose-110* UreaN-9 Creat-0.7 Na-140
K-4.7 Cl-110* HCO3-22 AnGap-13
___ 07:15AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.0
___ 04:40AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.1
___ 07:15AM BLOOD CRP-6.5*
___ 07:20PM BLOOD CRP-7.5*
___ 01:20PM BLOOD tTG-IgA-3
___ 10:14PM BLOOD Lactate-0.9
IMAGING:
KUB-
REASON FOR EXAMINATION: Suspected constipation.
Two AP radiographs of the abdomen were reviewed with comparison
to CT abdomen
from ___.
The substantial amount of barium is demonstrated in the
transverse colon,
descending colon as well as rectosigmoid. Intrauterine device
is projecting
over the expected location of the pelvis. The patient is after
cholecystectomy. Overall, normal distribution of contrast
material is
demonstrated and no evidence of dilated bowel to suggest
obstruction seen. No
free air below the diaphragm is present.
RADIOLOGY:
Abd CT: CT ABDOMEN:
The spleen is borderline enlarged, 13.3 cm. The liver
appears
unremarkable. The patient is status-post cholecystectomy.
There is no intrahepatic biliary ductal dilatation. Borderline
prominence of the common bile duct is likely secondary to the
cholecystectomy. The pancreas and adrenal glands are
unremarkable. There is no evidence for nephrolithiasis. There
is no hydronephrosis or ureteraldilatation. The kidneys enhance
and excrete symmetrically. No focal renal lesions are
identified.
There is a short-segment intussusception at the junction of
the
duodenum and jejunum (images 4:26 and 500b:34). The
proximal duodenum is not dilated. The remainder of the small
bowel is unremarkable. Orally administered contrast reaches the
hepatic flexure of the colon. There is stool throughout the
colon. There is no bowel wall thickening. There is no free
fluid, free air, or abscess. There is no lymphadenopathy. The
aorta is normal in caliber.
CT PELVIS: There is an IUD in place.
CT BONES: There is sclerosis along the sacroiliac joints
with associated osteophytes. The degree of sclerosis is
disproportionately extensive compared to the small size of the
osteophytes and the relatively smooth articular surfaces of the
joints, suggesting that there may be an inflammatory
sacroiliitis
with secondary degenerative changes. There is disc space
narrowing, extensive endplate sclerosis, and a disc bulge with
posterior endplate osteophytes at the lumbosacral junction.
IMPRESSION:
1. NO EVIDENCE OF NEPHROLITHIASIS OR OTHER RENAL
ABNORMALITIES.
2. BORDERLINE SPLENOMEGALY.
3. SHORT SEGMENT INTUSSUSCEPTION AT THE JUNCTION OF THE
DUODENUM AND JEJUNUM. SHORT SEGMENT SMALL BOWEL
INTUSSUSCEPTIONS
ARE USUALLY SELF RESOLVING AND ASYMPTOMATIC. THERE IS NO
ASSOCIATED OBSTRUCTION.
4. ABNORMAL APPEARANCE OF THE SACROILIAC JOINTS WITH AN
ELEMENT OF OSTEOARTHRITIS, BUT PRIMARY UNDERLYING INFLAMMATORY
SACROILIITIS OR OSTEITIS CONDENSANS ILII (CHILDBIRTH-RELATED
STRESS) CANNOT BE EXCLUDED.
Brief Hospital Course:
___ referred from ___ after seven days of dull, waxing
and waning abdominal pain prompted an outpatient CT, which
revealed question of a duodenal-jejunal intussusception.
Considering the vast majority of intussusception in adults is
pathologic GI was consulted who recommended a endoscopy which
was unrevealing. He abdominal pain continued to improve with
bowel rest and IVF and her diet was gradually advanced to
regular. She was discharged home on ___ with outpatient
follow up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Topiramate (Topamax) 150 mg PO DAILY
Discharge Medications:
1. Topiramate (Topamax) 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to ___ for abdominal pain. While you were
here, you underwent a small bowel enteroscopy with the
Gastroenterology specialists. You have done well in the
hospital, and are now prepared to complete your recovery at
home.
Please continue to take a regular diet as you have been. Please
continue to ambulate frequently and regularly every day. You do
not require any new prescription medications after discharge,
you may continue all your regular home medications.
Please call the Acute Care Surgery clinic to confirm your
follow-up appointment, at ___. This is very important.
Followup Instructions:
___
|
10891234-DS-20
| 10,891,234 | 28,538,012 |
DS
| 20 |
2129-08-19 00:00:00
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2129-08-19 17:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
hydrochlorothiazide / adhesive tape
Attending: ___
___ Complaint:
Rectal bleeding
Major Surgical or Invasive Procedure:
___ ABDOMINO-PERINEAL RESECTION ROBOTIC LAPAROSCOPIC;
PERMANENT ILEOSTOMY; PERINEAL RECONSTRUCTION W/ BILATERAL ___
FLAPS & SURGIMEND SLING
History of Present Illness:
Mr. ___ is a ___ male with history of NHL s/p
chemoradiation c/b chronic lymphedema of LLE and rectal melanoma
with multiple recent admissions for rectal bleeding, who
presented to ___ on ___ with symptomatic rectal bleeding and
pain.
He was admitted ___ for rectal pain and bleeding. At time
of discharge, combined procedure (APR with palliative ileostomy
with bilateral ___ advancements) by colorectal surgery and
plastic surgery was planned for ___ to stop the
bleeding. However after discharge, patient experienced continued
bleeding, accompanied by ___ pain and a sensation of acid
dripping on his open wound. He came into the ED in the setting
of progressive weakness at multiple falls at home.
On arrival to the ED vitals were T 98, HR 70, BP 152/70,
RR18,O2Sat 100% RA. Labs were sent remarkable for a Hgb 4.8, ___
with Cr up to 1.4. He was given 2 units of blood and admitted to
HMED, where he required an additional 4u PRBC due to ongoing
bleeding. Colorectal surgery was consulted and ultimately moved
up his OR date from ___ to ___.
Underwent APR with ___ flap on ___. No immediate intraoperative
complications. 150cc EBL during the procedure, received 1u PRBC
(Hgb 7.5->8.7) and 3L IVF. Briefly on phenylephrine gtt during
procedure, weaned prior to leaving the OR. Extubated prior to
arrival at ___.
On arrival to the ___, the patient was moaning in pain, which
he states is worst at his incision site. He was found to be
hypertensive to 210/102 at that time. Given IV labetalol 10mg
x1, IV labetalol 20mg x2, with improvement to 184/91.
REVIEW OF SYSTEMS: + per HPI. Otherwise, negative.
Past Medical History:
PAST MEDICAL HISTORY:
- Follicular Lymphoma s/p multiple courses of chemotherapy and
adiation ___, followed by Dr. ___ at ___
- Hypothyroidism
- Testicular Hypofunction
- Familial Combined Hyperlipidemia
- Dysthymia
- Importance
- Chronic Neuropathy
- Chronic Pain Syndrome
- Chronic Wound Edema
- Hypertension
- History of MRSA Arthritis of Left Hip
- Left Lip AVN
PAST SURGICAL HISTORY:
- s/p rectal melanoma resection at ___ with Dr. ___, ___
- s/ rectal melanoma second resection, Dr. ___ ___
- s/p left common iliac LN biopsy, Dr. ___ ___
- s/p left total hip arthroplasty
- s/p rectal exam under Anesthesia ___
Social History:
___
Family History:
His mother had a breast and pancreatic cancer.
Physical Exam:
GEN: Well appearing, no acute distress
HEENT: NCAT, EOMI, anicteric
CV: regular rate and rhythm, normal S1, S2
PULM: normal excursion, no respiratory distress
ABD: soft , generalized tenderness, JP drains with continued
serosanguineous output. 3 incision sites are clean, dry, and
intact. ostomy output with air and greenish liquid
Rectal: Flap covered in dressing
NEURO: A&Ox3, no focal neurologic deficits
PSYCH: normal judgment/insight, normal memory, normal
mood/affect
EXT: LLE lymphedema
Pertinent Results:
LABS ON ICU ADMISSION
___ 09:10AM BLOOD WBC-7.4 RBC-2.93* Hgb-8.3* Hct-26.2*
MCV-89 MCH-28.3 MCHC-31.7* RDW-15.3 RDWSD-49.1* Plt ___
___ 09:10AM BLOOD Plt ___
___ 09:10AM BLOOD ___ PTT-28.5 ___
___ 09:10AM BLOOD Glucose-99 UreaN-13 Creat-0.9 Na-143
K-4.8 Cl-106 HCO3-26 AnGap-11
___ 09:10AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9
___ 09:10AM BLOOD
___ 05:07PM BLOOD Hgb-7.5* calcHCT-23
___ 06:52PM BLOOD Hgb-8.7* calcHCT-26
IMAGING
___ ___
IMPRESSION:
1. Left calf veins not well seen.
2. No evidence of deep venous thrombosis in the left common
femoral, femoral
and popliteal veins.
3. Round 2.1 cm right inguinal lymph node is bigger and contains
internal
cystic spaces, suspicious for metastatic disease.
___ CXR
IMPRESSION:
No acute cardiopulmonary process.
___ NCHCT
IMPRESSION:
1. No acute intracranial process.
2. Old lacunar infarctions in the bilateral basal ganglia.
3. Known enhancing right hippocampal lesions seen on prior MRI
are not well assessed on the current noncontrast CT exam
MICRO
___ UCx No Growth
Brief Hospital Course:
Mr. ___ is a ___ male with history of NHL s/p
chemoradiation c/b chronic lymphedema of LLE and rectal melanoma
with multiple recent admissions for rectal bleeding, who
presented to ___ on ___ with symptomatic rectal bleeding and
pain.
#Rectal melanoma: Status post abdominal perineal resection with
palliative colostomy with bilateral ___ advancements. Patient
with rectal melanoma status post resection, with multiple
admissions for ongoing symptomatic rectal bleeding and severe
pain. Given admission for recurrent bleeding requiring
transfusion 6u PRBC over several days, he underwent APR with
palliative colostomy with bilateral ___ advancements on ___ in
order to stop the bleeding. The patient was maintained on
perineal precautions with a Foley and 3 JP drains in place.
#Rectal bleeding, rectal melanoma: Ongoing bleeding from his
rectal melanoma, requiring transfusion of a total of 6U PRBC
leading up to procedure. Transfused 1u PRBC intraoperatively,
Hgb incremented appropriately. He was maintained with an active
T&S, 2 large bore PIVs, and had q8h CBCs. He did not require
further transfusions in the intensive care unit or on surgical
floor.
#Post-operative pain control: Patient with significant opioid
tolerance at baseline, was requiring PCA for pain control even
prior to procedure. Anticipate that his pain will be challenging
to control in the acute post-operative setting. Palliative care
and chronic pain service followed throughout his stay and
provided recommendations of starting a fentanyl patch 37.5mcg/hr
(increased), oxycodone 20 mg Q4H prn, Topamax 25mg. This regimen
was continued at discharge to rehab.
#Hypertensive Urgency/essential hypertension: Does have HTN at
baseline with SBPs 140s-180s throughout the hospital course, but
this was suspected to be caused by acute post-operative pain. He
was continued on his home labetalol and losartan, with the
addition of clonidine 0.2 mg PO BID per the surgical team.
#Lymphedema associated LLE cellulitis: Developed acute erythema,
pain, and swelling in LLE on ___. ___ negative for DVT. Was
started on cefazolin on ___ for non-purulent cellulitis.
Improved on ABX. He was called-out with a plan for a 7 day
course of cefazolin (last day ___. Of note, the patient
refused wraps due to pain.
#Hypothyroidism: Continued on levothyroxine 50mcg IV daily in
the ICU with plan to switch back to 100mcg PO daily when able to
take PO.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CloNIDine 0.2 mg PO BID
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Labetalol 300 mg PO TID
4. Levothyroxine Sodium 100 mcg PO DAILY
5. LORazepam 1 mg PO Q6H:PRN anxiety/nausea/vomiting/insomnia
6. OxyCODONE (Immediate Release) 30 mg PO TID:PRN Pain -
Moderate
7. Valsartan 320 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
9. Senna 8.6 mg PO BID:PRN constipation
10. DULoxetine 60 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Bisacodyl 10 mg PO DAILY
3. Calcium Carbonate 500 mg PO QID:PRN heart burn
4. Enoxaparin Sodium 40 mg SC DAILY
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous daily Disp
#*30 Syringe Refills:*0
5. Fentanyl Patch 37 mcg/h TD Q72H
RX *fentanyl 37.5 mcg/hour 1 Patch TD every 72 hours Disp #*2
Patch Refills:*0
6. Topiramate (Topamax) 25 mg PO QHS
7. OxyCODONE (Immediate Release) 20 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 20 mg 1 tablet(s) by mouth every four (4) hours
Disp #*45 Tablet Refills:*0
8. CloNIDine 0.2 mg PO BID
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. DULoxetine 60 mg PO DAILY
11. Labetalol 300 mg PO TID
12. Levothyroxine Sodium 100 mcg PO DAILY
13. LORazepam 1 mg PO Q6H:PRN anxiety/nausea/vomiting/insomnia
14. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
15. Senna 8.6 mg PO BID:PRN constipation
16. Valsartan 320 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metastatic anal melanoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (___
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after a laparoscopic
abdominoperineal resection with end colostomy for surgical
management of your rectal melanoma. You have recovered from this
procedure well and you are now ready to return home. Samples of
tissue were taken and has been sent to the pathology department.
You will receive these pathology results at your follow-up
appointment. If there is an urgent need for the surgeon to
contact you regarding these results they will contact you before
this time.
You have a new colostomy. It is important to monitor the output
from this stoma. It is expected that the stool from this ostomy
will be solid and formed like regular stool. You should have ___
bowel movements daily. If you notice that you have not had any
stool from your stoma in ___ days, please call the office. You
may take an over the counter stool softener such as Colace if
you find that you are becoming constipated. Please watch the
appearance of the stoma (intestine that protrudes outside of
your abdomen), it should be beefy red/pink, if you notice that
the stoma is turning darker blue or purple, or dark red please
call the office for advice. The stoma may ooze small amounts of
blood at times when touched but this will improve over time. The
skin around the ostomy site should be kept clean and intact.
Monitor the skin around the stoma for any bulging or signs of
infection listed above. Please care for the ostomy as you have
been instructed by the ostomy nurses. ___ the skin around
the stoma for any bulging or signs of infection listed above.
You will be able to make an appointment with the ostomy nurse in
the clinic ___ weeks after surgery. Please call the ostomy
nurses clinic number which is listed in the ileostomy/colostomy
handout packet given to you by the nursing staff. You will also
have a visiting nurse at home for the next few weeks to help
monitor your ostomy until you are comfortable caring for it on
your own.
If you have any of the following symptoms please call the office
at ___:
fever greater than 101.5
increasing abdominal distension
increasing abdominal pain
nausea/vomiting
inability to tolerate food or liquids
prolonged loose stool
extended constipation
inability to urinate
Incisions:
You have ___ laparoscopic surgical incisions on your abdomen
which are closed with internal sutures. It is important that
you monitor these areas for signs and symptoms of infection
including: increasing redness of the incision lines,
white/green/yellow/malodorous drainage, increased pain at the
incision, increased warmth of the skin at the incision, or
swelling of the area.
You may shower; pat the incisions dry with a towel, do not rub.
If you have steri-strips (the small white strips), they will
fall off over time, please do not remove them. Please do not
take a bath or swim until cleared by the surgical team.
You will also be going home with your JP (surgical) drain, which
will be removed at your post-op visit. Please look at the site
every day for signs of infection (increased redness or pain,
swelling, odor, yellow or bloody discharge, warm to touch,
fever). Maintain suction of the bulb. Note color, consistency,
and amount of fluid in the drain. Call the doctor, nurse
practitioner, or ___ nurse if the amount increases significantly
or changes in character. Be sure to empty the drain frequently.
Record the output, if instructed to do so. You may shower; wash
the area gently with warm, soapy water. Keep the insertion site
clean and dry otherwise. Avoid swimming, baths, hot tubs; do not
submerge yourself in water. Make sure to keep the drain attached
securely to your body to prevent pulling or dislocation.
PERINEAL PRECAUTIONS: head of bed at 40 degrees, turn side to
side frequently in bed, no sitting, please reinforce teaching
for home
Pain
It is expected that you will have pain after surgery, this will
gradually improve over the first week or so you are home. You
should continue to take 2 Extra Strength Tylenol (___) for
pain every 8 hours around the clock. Please do not take more
than 3000mg of Tylenol in 24 hours or any other medications that
contain Tylenol such as cold medication. Do not drink alcohol
while taking Tylenol. You may also take Advil (Ibuprofen) 600mg
every 8 hours for 7 days, please take Advil with food. If these
medications are not controlling your pain to a point where you
can ambulate and perform minor tasks, you should take a dose of
the narcotic pain medication _____. Please do not take sedating
medications or drink alcohol while taking the narcotic pain
medication. Do not drive while taking narcotic medications.
You will be discharged home on Lovenox injections to prevent
blood clots after surgery. You will take this for 30 days after
your surgery date, please finish the entire prescription. This
will be given once daily. Please follow all nursing teaching
instruction given by the nursing staff. Please monitor for any
signs of bleeding: fast heart rate, bloody bowel movements,
abdominal pain, bruising, feeling faint or weak. If you have any
of these symptoms please call our office or seek medical
attention. Avoid any contact activity while taking Lovenox.
Please take extra caution to avoid falling.
Activity
You may feel weak or "washed out" for up to 6 weeks after
surgery. Do not lift greater than a gallon of milk for 3 weeks.
At your post op appointment, your surgical team will clear you
for heavier exercise. In the meantime, you may climb stairs,
and go outside and walk. Please avoid traveling long distances
until you speak with your surgical team at your post-op visit.
Again, please do not drive while taking narcotic pain
medications.
Thank you for allowing us to participate in your care, we wish
you all the best!
Followup Instructions:
___
|
10891267-DS-21
| 10,891,267 | 21,920,117 |
DS
| 21 |
2112-05-16 00:00:00
|
2112-05-16 13:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chronic progressive ___ and ___ weakness
Major Surgical or Invasive Procedure:
1. Open treatment of cervical fracture, posterior.
2. Laminectomy, C3-C4, C4-C5, C5-C6, C6-C7, C7-T1.
3. Posterior fusion, C3-C4, C4-C5, C5-C6, C6-C7, C7-T1.
4. Posterior instrumentation, C3 through T1.
5. Autograft, same incision.
6. Allograft.
History of Present Illness:
___ yo M presents abnormal MRI. Pt states for about 5 months
feels like UEs have been weaker than usual. ___ also endorses
fecal and urinary incontinence over the same time frame. Also
endorses neck discomfort x few days more L sided. Had CT/MRI
performed at OSH because he states that his sister wanted to
find out why he was not getting out of the rehabilitation
center. This is reported to show "C3-4 compression to spine" and
MRI w/ ? ___ matter changes (no offical report in paper, only
MD summary). Pt denies recent neck trauma, falls, additional
injuries or complaints. Pt was transferred to ED from rehab for
further management. pt states that he has been ambulatory, able
to walk with the help of a walker.
Past Medical History:
DM, HTN, HLD, anxiety. pt states no other medical problems
however he is a poor historian.
Social History:
Pt lives at rehab, denies drug use or ETOH
Physical Exam:
PHYSICAL EXAMINATION:
Vitals: 97.5 53 144/81 18 97% RA, hemodynamically stable.
General: Well-appearing male in no acute distress.
Spine exam:
No tenderness to palpation over C, T, or L spine.
Motor:
Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc
L 4 ___ ___ 4 3+ 3+ 3+ 3+ 3+
R 4 ___ ___ 4 3+ 3+ 3+ 3+ 3+
Sensory:
Sensory ___
C5 (Ax) R nl, L nl
C6 (MC) R nl, L nl
C7 (Mid finger) R nl, L nl
C8 (MACN) R nl, L nl
T1 (MBCN) R nl, L nl
T2-L2 Trunk R nl, L nl
Sensory ___
L2 (Groin): R nl, L nl
L3 (Leg) R nl, L nl
L4 (Knee) R nl, L nl
L5 (Grt Toe): R nl, L nl
S1 (Sm toe): R nl, L nl
S2 (Post Thigh): R nl, L nl
DTRs:
Bi Tri ___
L 2 2 2
R 2 2 2
___: neg
Babinski: downgoing
Clonus: +ten beats b/l ___
Vascular
Radial: L2+, R2+
DPR: L2+, R2+
Pertinent Results:
___ 01:20PM BLOOD WBC-8.5 RBC-4.18* Hgb-12.1* Hct-39.1*
MCV-94# MCH-28.9 MCHC-30.9* RDW-13.8 RDWSD-47.0* Plt ___
___ 08:15PM BLOOD Neuts-60.9 ___ Monos-7.9 Eos-1.7
Baso-0.4 Im ___ AbsNeut-4.68 AbsLymp-2.21 AbsMono-0.61
AbsEos-0.13 AbsBaso-0.03
___ 01:20PM BLOOD Plt Smr-NORMAL Plt ___
___ 01:20PM BLOOD Glucose-89 UreaN-19 Creat-0.7 Na-134
K-3.6 Cl-94* HCO3-24 AnGap-20
___ 01:20PM BLOOD Calcium-9.4 Phos-3.5 Mg-2.3
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#2. The patient was
alble to void however a post void residual was documented just
prior to discharge for 183cc. It is recommended to do another
post void residual on next void. UOP still remains mildly
concentrated. He is taking in a good amount of po fluids.
Physical therapy was consulted for mobilization OOB to ambulate.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Fluphenazine DECANOATE 50 mg IM/SC ASDIR
3. Furosemide 20 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. TraZODone 100 mg PO QHS
6. Vitamin D ___ UNIT PO DAILY
7. BuPROPion 200 mg PO DAILY
8. Zestoretic (lisinopril-hydrochlorothiazide) 40mg-25mg oral
once daily
9. CloniDINE 0.2 mg PO BID
10. GlipiZIDE 5 mg PO BID
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. CloniDINE 0.2 mg PO BID
4. GlipiZIDE 5 mg PO BID
5. TraZODone 100 mg PO QHS
6. Vitamin D ___ UNIT PO DAILY
7. BuPROPion 200 mg PO DAILY
8. Fluphenazine DECANOATE 50 mg IM/SC ASDIR
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
11. Furosemide 20 mg PO DAILY
12. Zestoretic (lisinopril-hydrochlorothiazide) ___ ORAL ONCE
DAILY
13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth every six (6)
hours Disp #*50 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Cervical spinal stenosis.
2. Cervical fracture, C3, C4.
3. Cervical spinal cord contusion.
4. Upper extremity and lower extremity weakness,
incontinence.
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:
Posterior cervical fusion
You have undergone the following operation: Posterior Cervical
Decompression and Fusion
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit in a car or chair for more than ~45 minutes without
getting up and walking around.
Rehabilitation/ Physical Therapy:
___ ___ times a day you should go for a walk
for ___ minutes as part of your recovery. You can walk as
much as you can tolerate.
___ Isometric Extension Exercise in the
collar: 2x/day x ___xercises as
instructed.
Cervical Collar / Neck Brace: You need to wear
the brace at all times until your follow-up appointment which
should be in 2 weeks. You may remove the collar to take a
shower. Limit your motion of your neck while the collar is off.
Place the collar back on your neck immediately after the shower.
Wound Care: Remove the dressing in 2 days. If
the incision is draining cover it with a new sterile dressing.
If it is dry then you can leave the incision open to the air.
Once the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. . Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead. You can either
have them mailed to your home or pick them up at the clinic
located on ___. We are not allowed to call in narcotic
prescriptions (oxycontin, oxycodone, percocet) to the pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision, take baseline x rays and answer any questions.
___ We will then see you at 6 weeks from the
day of the operation. At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Physical Therapy:
-Weight bearing as tolerated
-Gait, balance training
-No lifting >10 lbs
-No significant bending/twisting
-c-collar at all times, may take off for hygiene
Treatments Frequency:
Remove the dressing in 2 days. If the incision is draining
cover it with a new sterile dressing. If it is dry then you can
leave the incision open to the air. Once the incision is
completely dry (usually ___ days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Call the office at that time. If you have
an incision on your hip please follow the same instructions in
terms of wound care.
Followup Instructions:
___
|
10891332-DS-14
| 10,891,332 | 21,233,568 |
DS
| 14 |
2182-02-16 00:00:00
|
2182-02-16 15:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim DS / Hydrochlorothiazide / Simvastatin / Amlodipine
Besylate
Attending: ___
Chief Complaint:
Unresponsive episode
Major Surgical or Invasive Procedure:
None
History of Present Illness:
OUTPATIENT CARDIOLOGIST: ___, MD
PCP: ___, MD, MPH
CHIEF COMPLAINT: Unrepsonsive episode
HISTORY OF PRESENTING ILLNESS:
___ RHF PMHx insulin-dependent DM, complicated by nephropathy,
neuropathy, and retinopathy (A1C 7.4% ___, CAD s/p CABG,
HTN, PVD, HLF, and infarct of the left middle cerebellar
peduncle who presents to ___ transferred from ___
___.
Patient was found to be unresponsive by her husband per outside
hospital reports this morning. EMS was called and she had a
sugar of 19. Patient was given glucagon with no response and
transferred to ___ where she was given dextrose
and woke up.
Upon further questioning patient stated she had progressive
dyspnea over the last few weeks. CXR showed bilateral pleural
effusions and edema consistent with a CHF exacerbation. Patient
was treated with 40 of IV Lasix and with over 1L urine output.
Shortly after, patient was noted to go into A. fib RVR with
rates of 140-160. This is thought to be the first episode of A.
fib. with RVR. The patient is not on anticoagulation. Patient
was then was given 10 mg of IV dilt and started on a drip at 10
per hour with resolution of her A. fib. Patient has been in
sinus rhythm on arrival to ___. CT head from outside hospital
noted to be negative for any acute intracranial process.
On arrival to ___ ED the patient was noted to have no
complaints except for feeling extremely dry and thristy. Patient
noted to have a diffuse crusted erythematous rash across her
torso which patient states is not new but does not know when it
began and states that it is asymptomatic.
Exam notable for faint bibasilar crackles with a median
sternotomy.
In the ED initial vitals were:
97.8 81 170/76 18 96% 2L NC
EKG: Sinus rhythm
Labs/studies notable for:
WBC 11.4 (81% neutrophils), Hg 9.9, platelets 277, Na 137, K
4.4, Cl 102, bicarb 22, BUN 36, Cr 2.0, glucose 229, UA with 8
WBC's and trace leukocytes. BNP of 48,418 and trop of 0.03
(baseline 0.02-0.03) VBG showed pH 7.48 PCO2 31.
Patient was given:
PO Diltiazem 30 mg
IV CeftriaXONE 1 gm
PO/NG Labetalol 400 mg
Vitals on transfer:
98.4 80 154/61 20 96% Nasal Cannula
Notably the patient was seen in clinic on ___ for shortness
of breath and underwent evaluation. ECG unchanged from prior at
that time. Patient was noted to have drug eruption on her torso
as well. Her SOB was thought to be secondary to anxiety. She
also was noted to have elevated blood pressure with SBP of 200
at home requiring labetolol dose to be increased to 400 mg BID
in the last 2 weeks.
On the floor, the patient notes her foley is uncomfortable. She
notes she woke up this morning on her bed and recalls feeling as
though she was going to pass out and asked her husband for coke.
She doesn't recall anything else. She notes she did not have
loss of her bowel or bladder habits after his episode. She notes
her blood sugar has been very labile lately and that her lantus
and Humalog doses have varied considerably. She notes she took
18 units of lantus last night.
She endorses shortness of breath over the last few years noting
it has been worse in the last week especially when she wakes up.
She notes she thought it was due to anxiety and has been taking
lorazepam the last few days. She denies any orthopnea or leg
swelling. She notes she sleeps with 3 pillows at a 30 degree
angle for comfort. SHe denies SOB with exertion, palpitations,
or chest pain. She denies any recent fever, chills, cough,
nausea, vomiting, abdominal pain, or headache. She does not that
she urinates frequently but denies dysuria. She also notes a
rash on her trunk and back that she has had for over a week that
is not painful or itchy. She does note difficulty sleeping at
night due to anxiety and has increased her trazadone dose back
to 200 mg at bedtime. She lives with her husband and administers
her own medications. She uses a cane to move around since her
stroke.
ROS: On review of systems, denies recent fevers, chills or
rigors. Denies exertional buttock or calf pain. All of the other
review of systems were negative. Cardiac review of systems is
notable for absence of chest pain, dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema, or
palpitations.
Past Medical History:
Insulin-dependent DM (diagnosed at age ___ complicated by
nephropathy, neuropathy, and retinopathy (A1C 7.4% ___
CKD (baseline Cr 2.6-3.0)
CAD s/p CABG (___)
PVD
HTN
HLD
Hypothyroidism
Left eye cataract repair
No history of stroke
Per pt, colonoscopy normal
Social History:
___
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father with CABG in his ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: T= 98.4 BP= 153/63 HR= 74 RR= 20 O2 sat= 93% RA weight 54 kg
GENERAL: In NAD. Oriented x3. Mildly anxious appearing during
interview.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 8 cm above the sternal angle with HOB
at 30 degrees.
CARDIAC: Normal S1, S2. No thrills, lifts.
CHEST: Median sternotomy scar, appears well-healed
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bilateral crackles in
lower lung bases L> R
ABDOMEN: Soft, NTND. No HSM or tenderness.
GU: foley in place
NEURO: CN II-XII intact, mild dysdiadochokinesia in upper left
extremity. ___ strength in upper and lower extremities.
EXTREMITIES:2+ peripheral pulses. No edema
SKIN: Erythematous maculopapular rash across chest and back.
Area on left lower abdomen that appears to look like
erupted/excoriated vesicles.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
=======================
Vitals: 97.6 78 18 ___ 92% on ra
Tele: No events, Afib
Last 24 hours I/O: 780/850
Last 8 hours I/O: ___
Weight on admission: 54.0
Today's weight: 54.0 -> 54.7--> 54.3
General: sitting comfortably in bed, NAD
HEENT: nl OP, no scleral icterus
Lungs: nl wob on ra, faint crackles at bases
CV: irregular rhythm, no murmurs
Abdomen: soft, NT/ND
Ext: warm, no edema
Pertinent Results:
ADMISSION LABS:
====================
___ 07:30PM BLOOD WBC-11.4* RBC-3.16* Hgb-9.9* Hct-30.5*
MCV-97 MCH-31.3 MCHC-32.5 RDW-14.6 RDWSD-51.2* Plt ___
___ 07:30PM BLOOD Neuts-81.2* Lymphs-8.4* Monos-7.3 Eos-2.1
Baso-0.6 Im ___ AbsNeut-9.23*# AbsLymp-0.95* AbsMono-0.83*
AbsEos-0.24 AbsBaso-0.07
___ 07:30PM BLOOD ___ PTT-28.7 ___
___ 07:30PM BLOOD Glucose-229* UreaN-36* Creat-2.0* Na-137
K-4.4 Cl-102 HCO3-22 AnGap-17
___ 07:30PM BLOOD ALT-35 AST-25 AlkPhos-77 TotBili-0.4
___ 07:30PM BLOOD cTropnT-0.03* ___
___ 07:30PM BLOOD Calcium-9.3 Phos-3.2 Mg-2.0 Iron-66
___ 07:30PM BLOOD calTIBC-328 Ferritn-61 TRF-252
___ 07:30PM BLOOD TSH-1.1
___ 07:36PM BLOOD ___ pO2-51* pCO2-31* pH-7.48*
calTCO2-24 Base XS-0
OTHER PERTINENT LABS:
====================
___ 07:30PM BLOOD cTropnT-0.03* ___
___ 01:39AM BLOOD CK-MB-2 cTropnT-0.03*
OTHER DISCHARGE LABS:
====================
___ 06:25AM BLOOD WBC-6.5 RBC-2.84* Hgb-8.7* Hct-27.4*
MCV-97 MCH-30.6 MCHC-31.8* RDW-14.5 RDWSD-50.7* Plt ___
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD Glucose-316* UreaN-41* Creat-2.3* Na-138
K-4.5 Cl-102 HCO3-27 AnGap-14
___ 06:25AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.3
IMAGING/STUDIES:
====================
___ CXR:
FINDINGS:
The lungs are well-expanded and clear of consolidation but
notable for
pulmonary vascular congestion. The cardiac silhouette remains
enlarged. The patient is status post median sternotomy and
CABG, with intact sternotomy wires. Coronary artery stents are
noted. Dense mitral annular calcifications are seen. Blunting
of the bilateral costophrenic angles may represent pleural
effusion versus thickening. No pneumothorax or consolidation.
IMPRESSION:
Small bilateral pleural effusions and pulmonary vascular
congestion.
___
TTE:
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). There is no ventricular septal defect. The
right ventricular cavity is mildly dilated with normal free wall
contractility. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate (___) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of ___,
no change.
___ MRI/MRI BRAIN:
1. Expected evolution of the now chronic blood products in the
left middle
cerebellar peduncle with small amount of residual T1
hyperintensity.
Siderosis at the site of the prior adjacent subarachnoid
hemorrhage. No
evidence for an underlying lesion is seen within the limits of
noncontrast
MRI. Of note, no cavernous malformation was seen on the
___ MRI.
2. Brain MRA again demonstrates multiple foci of mild to
moderate arterial
narrowing, consistent with atherosclerosis, as detailed above.
RECOMMENDATION(S): Follow up MRI could be considered in 8 weeks
when T1
hyperintense blood products may be expected to resolve.
Brief Hospital Course:
BRIEF SUMMARY STATEMENT:
============================
___ RHF PMHx insulin-dependent DM, CAD s/p CABG, HTN, peripheral
vascular disease, and recent hemorrhagic infarct of the left
middle cerebellar peduncle who presented to an OSH after being
found unresponsive at home. She had pulmonary edema in the
setting of hypertensive emergency, so was diuresed with IV
Lasix. She subsequently developed Afib with RVR, so was
transferred to ___. Upon arrival to ___, she was in normal
sinus rhythm. For her CHF, she was diuresed with IV Lasix, which
was transitioned to PO Lasix 40mg daily. For her Afib, she
remained in NSR; she was continued on Diltiazem with HRs stable
in ___. Neurology evaluated to help with anticoagulation
plan due to her recent ICH; MRI/MRA brain showed no signs of
bleed, so she was started on Warfarin 5mg daily.
ACTIVE ISSUES:
============================
# Hypertensive Emergency:
Patient has history of hypertension, complicated by hypertensive
emergency and cerebellar hemorrhagic stroke in ___.
Blood pressure elevated to 170 on arrival with associated
pulmonary edema and elevated BNP. ECG also with T wave
inversions that may be secondary to poorly controlled blood
pressure. Recent elevated blood pressure at home with increase
in labetolol dosing to 400 mg BID per OMR note review. Patient
was started on Diltiazem 90mg QID and Carvedilol 6.25 mg BID.
Blood pressures remained elevated to 150s systolic, so
Carvedilol was increased to 12.5mg BID.
# Diastolic CHF (EF > 60%):
Patient presented with dyspnea on exertion, elevated BNP to
48,000, and bilateral pulmonary edema. She received Lasix 40mg
IV at the OSH with over 1L output. Trigger for pulmonary edema
is unclear, but was likely due to atrial fibrillation and/or
hypertension. Upon arrival to ___, patient was in normal sinus
rhythm. Repeat TTE showed LVEF>55%. She was diuresed with IV
Lasix, then transitioned to Lasix 40mg PO daily. At time of
discharge, she was satting well on room air and was euvolemic on
exam.
# Atrial Fibrillation with RVR (CHADS 4, HAS-BLED 5, 12.5 % risk
of bleeding annually)
Patient had a transient episode of atrial fibrillation with RVR
in the setting of diuresis at the OSH. No prior h/o atrial
fibrillation. CHADS score of 4. Of note, patient had a recent
hemorrhagic cerebellar infarct in the setting of hypertension.
Neurology was consulted for assistance in managing
anticoagulation. TSH was normal, patient continued home
Synthroid. Her rate was controlled with Diltiazem. She received
MRI/MRA head, which showed no signs of bleeding, so she was
started on anticoagulation with Aspirin 81mg daily and Warfarin
5mg daily. At time of discharge, she was in normal sinus rhythm.
# Leukocytosis:
On admission, patient had leukocytosis with mildly positive UA,
but denied urinary symptoms. CXR showed no PNA. Was initially
given Ceftriaxone (___), but this was discontinued on ___ as
leukocytosis was resolved and patient remained asymptomatic.
# Insulin Dependent Diabetes complicated by neuropathy,
neprhopathy, and retinopathy
On morning of admission to OSH, patient was found down with
blood glucose of 19. Blood glucose closely monitored, and
received Lantus 10units every night with ISS.
# Coronary artery disease s/p CABG CAD s/p CABG LIMA -> LAD, SVC
-> OM; SVC -> PDA. Patient with chronically elevated troponin of
0.03 in setting of CKD. Currently chest pain free. Not on statin
due to concern for increased intracerbral hemorrhage per neuro
discharge summary ___. ECG with inverted T waves in V1 and
III new compared to prior though may be in setting of poorly
controlled hypertension. No signs of right heart strain on ECG.
Patient was placed on Carvedilol (as above), and continued on
home Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY.
Statin was held given increased hemorrhage risk per neuro.
# Rash
Patient with maculopapular rash on chest and back that was
non-tender to palpation or itchy. Crosses midline and not in
dermatomal distribution. Had a component that appears to be
prior crusted over vesicles. LFTs wnl. Rash improved by time of
discharge, although still with some maculopapular erythema on
chest and back.
CHRONIC ISSUES:
============================
# Normocytic Anemia
Likely component of anemia of chronic disease in setting of CKD.
H/H stable since prior admission. Iron studies wnl.
# CKD (baseline Cr 2.6-3.0)
Creatinine monitored and remained stable.
# Hypothyroidism: TSH 1.1 on admission
Continued home Levothyroxine Sodium 175 mcg PO/NG DAILY
# Insomnia/Anxiety
Patient with reported insomnia. Had recently increased trazadone
to 200 mg QHS at home. Continued home TraZODone 200 mg PO/NG QHS
with lorazepam 0.5 mg PO/NG BID PRN SOB/anxiety.
# Peripheral vascular disease
Continued aspirin 81 mg daily
TRANSITIONAL ISSUES
=========================
Discharge weight: 54.3
Discharge creatinine: 2.3
New medications on discharge:
# AFIB: For anticoagulation, patient was started on Warfarin 5mg
daily. Rates well controlled with Diltiezam.
# ANTICOAGULATION: Please check INR every ___ days following
hospital discharge, and titrate Warfarin as needed. Next INR
will be drawn by ___ on ___.
# CHF: Patient was discharged on Lasix 40mg daily.
# HYPERTENSION: Please recheck BP within 1 week of discharge.
Continue on Diltiazem 240mg daily and Carvedilol 12.5mg BID, and
may uptitrate as needed
# DIABETES: Please check blood glucose as outpatient and titrate
insulin as needed
# BLOOD CULTURE: pending, no growth at time of discharge
# CODE: Full
# CONTACT: ___ - ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 240 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Glargine 12 Units Bedtime
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
4. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
5. Labetalol 400 mg PO BID
6. Levothyroxine Sodium 175 mcg PO DAILY
7. Lorazepam 0.5 mg PO BID PRN SOB/anxiety
8. TraZODone 200 mg PO QHS
9. Venlafaxine XR 300 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Viactiv (calcium-vitamin D3-vitamin K) 500-500-40
mg-unit-mcg oral BID
12. Vitamin D ___ UNIT PO DAILY
13. Melatin (melatonin) 5 oral QHS
14. Acetaminophen 650 mg PO Q6H:PRN pain
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 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Glargine 12 Units Bedtime
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
6. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
7. Levothyroxine Sodium 175 mcg PO DAILY
8. Lorazepam 0.5 mg PO BID PRN SOB/anxiety
9. TraZODone 200 mg PO QHS
10. Venlafaxine XR 300 mg PO DAILY
11. Viactiv (calcium-vitamin D3-vitamin K) 500-500-40
mg-unit-mcg oral BID
12. Vitamin D ___ UNIT PO DAILY
13. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
14. Warfarin 5 mg PO DAILY16 Duration: 1 Dose
RX *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
# Hypertensive emergency
# Diastolic congestive heart failure
# Atrial fibrillation
# Insulin Dependent Diabetes complicated by neuropathy,
neprhopathy, and retinopathy
# Coronary artery disease
# Recent intracerebral hemorrhage
SECONDARY DIAGNOSES
===============
# Chronic kidney disease
# Anemia
# Anxiety
# Peripheral vascular 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. You were admitted the
another hospital after you were found down at home, with a very
low blood sugar. At that hospital, you had some extra fluid on
your lungs, and you developed an irregular heart rhythm called
atrial fibrillation (afib). You were transferred to ___ for
treatment of the fluid in your lungs and your A fib.
While you were here, you received IV medications to help get
fluids off of your lungs. You had an ECHO of your heart, which
showed no change in your heart function from before. When you go
home, you will be taking a HIGHER DOSE of Lasix. You should take
Lasix 40mg by mouth daily.
While you were here, you also received an MRI of your head to
make sure you didn't have any more bleeding in your brain. This
showed no more bleeding. The Neurology team agreed that it was
safe for you to start a medication called Warfarin to prevent
strokes. You will need to have your labs checked frequently to
monitor you while on Warfarin.
For your blood pressure, we added a new medication called
Carvedilol. Please take all of your medications, and check your
blood pressure at least several times a week at home.
When you leave the hospital, it will be very important that you
take all of your medications as prescribed. It will also be
important that you go to your follow-up appointments, listed
below.
We wish you all the best in the future.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / lactose
Attending: ___
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
T12-L4 laminectomy and fusion
History of Present Illness:
___ yo female who has chronic lower back pain at baseline s/p
boating accident. The boat she was traveling in at an unknown
speed sharply detoured to avoid hitting another boat at the same
time their boat hit a large wake. The patient felt herself rise
off her sit and then heavily land back down on her buttocks as
the boat fell. She endorses instant, severe back pain after the
incident. Due to the level of pain, her husband called EMS. She
saws she was unable to walk after the incident, but not because
of any numbness or weakness, which she also currently denies.
Past Medical History:
Lime dz
D&C
Chronic low back pain
Allergy: PCN
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
O: AVSS
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2R EOMs
Neck: Supple, collared
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2-----------
Left 2-----------
Propioception intact
Toes downgoing bilaterally
Rectal exam normal sphincter control
Exam on discharge:
GEN: NAD, A+Ox3, comfortable and conversational.
Strength intact throughout - able to walk short distances down
hallway.
Staples removed - incision c/d/i, heaing well.
Abdomen: soft, not tender or distended, +BS. Reports slight
cramping d/t menstruation. Sensation intact throughout
Recent loose BMx2 prior to discharge.
Pertinent Results:
___ CT C/A/P
1. Transitional anatomy with 6 non rib-bearing lumbar type
vertebral bodies
Preliminary Reportwith L1 designated as the ___ non rib-bearing
vertebral body.
Preliminary Report2. Acute burst fracture of the L3 vertebral
body with disruption of the
Preliminary Reportanterior and middle columns including an
anteriorly displaced small fracture
Preliminary Reportfragment and retropulsion of the dominant
vertebral body fracture fragment
Preliminary Reportcausing moderate to severe central canal
narrowing. A followup MRI is
Preliminary Reportrecommended to evaluate for possible spinal
cord injury.
Preliminary Report3. No additional fracture or solid organ
trauma in the abdomen or pelvis.
___ MRI L-spine
L2 burst fracture with associated disruption of the anterior and
posterior
longitudinal ligaments. There is mild retropulsion of the
fracture fragments
into the spinal canal and a very small epidural hematoma. There
is no
compression of the cauda equina.
Cholelithiasis.
___: L-spine XR: The findings demonstrate the fusion of T12/L4.
The alignment is preserved and
appearance of the hardware is unremarkable.
Of note is substantial dilatation of the sigmoid colon up to 8
cm.
___: Abdominal XR: Current AP radiograph of the abdomen
demonstrates interval decrease of the
sigmoid and descending colon diameter up to 6.5 cm. There is no
evidence of
free air. The hardware appearance is unremarkable.
Brief Hospital Course:
Ms. ___ presented to the ED and was evaluated by Neurosurgery.
She was found to have a L2 burst fracture with retropulsion
into the spinal cannal.
She was admitted to the hospital, placed on log roll precautions
and flat bedrest. She was scheduled for a lumbar lamenectoy and
fusion on ___
She remained stable overnight into ___ while awaiting operative
intervention. On ___ she went to the OR for T12-L4 laminectomy
and fusion. Intra op/ post op uneventfull.
On ___ patient complained of large amount of pain to surgical
site on Morphine PCA regimen. Morphine PCA was discontinued and
she was place on Dilauded PO and IV prn.
On ___, The patient was very lethargic on the morning exam.
She exhibited signs of low motivation to mobilize and was
sleeping through the early morning. When the patient was woken
up for a neurological exam she reported a pain level of ___.
The patient was thought to be too sedated given narcotic
medication and dilaudid was changed to po oxycodone and valium
to robaxin. The patient was encouraged to mobilize and later
worked with ___. She was mobilzed out of bed to the chair with
much promting for a total of 3 hours. Physical therapy
consulted and recommended eventual disposition home with
outpatient ___ after another ___ vists in the hospital. The
patient ambulated with the brace on. The foley catheter was
discontinued and the patient was able to void on her own. Pain
management was consulted given the patients sleepiness and
lethargy with narcotic medications and continued complaints of
severe pain. The post operative standing films were performed
and were consistent with expected post operative change and
proper hardware placement. The patient later in the afternoon
reported that her mentral cycle began and she attributed the
majority of her pain to her monthly menses. She requested
ibuprofen for menstral cramps but this was denied by
neurosurgery as it would impair her bony fusion.
On ___ patient was more alert, still had not had a bowel
movement. Was started on Milk of Magnesia and written for fleet
enema. L-spine imaging showed 8cm distention of sigmoid colod,
which improved on repeat abd xr. General surgery was consulted.
Patient continued to have flatus, good apetite, abdomen soft on
exam. Abdominal imaging showed improvement of colonic distention
to 6.5cm.
On ___ the patient continued to refuse enema but received PO
bowel reg, had BMx2 prior to discharge
Medications on Admission:
Motrin
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
hold for loose stools
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*14 Capsule Refills:*0
2. Methocarbamol 750 mg PO TID
RX *methocarbamol 750 mg 1 tablet(s) by mouth three times daily
Disp #*21 Tablet Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN back pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*60 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
hold for loose stools
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 by mouth
every morning Disp #*7 Bottle Refills:*0
5. Senna 1 TAB PO DAILY
hold for loose stools
RX *sennosides [senna] 8.6 mg 2 tab by mouth every night Disp
#*14 Tablet Refills:*0
6. Outpatient Physical Therapy
Outpatient ___ eval and treatment - pt s/p T12-L4 laminectomy and
fusion
Discharge Disposition:
Home
Discharge Diagnosis:
L2 burst fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Lumbar Fusion
Dr. ___
Your large dressing may be removed the second day after
surgery.
*If you have staples, keep your wound clean and dry until they
are removed.
You should wear your brace when out of bed or when your head
of bed is above 30 degrees.
You may put the brace on at the edge of your bed.
You may use a shower chair to bathe without the brace on.
No tub baths or pool swimming for two weeks from your date of
surgery.
Do not smoke.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Have a friend or family member check your incision daily for
signs of infection.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort. Pain medication should
be used as needed when you have pain. You do not need to take it
if you do not have pain.
*Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. for two weeks.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 101.5° F.
Loss of control of bowel or bladder functioning
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Nickel / Bactrim
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cath on ___
History of Present Illness:
Mr. ___ is a ___ y/o male with CAD s/p stents x2, thoracic
aneurysm s/p grafting, HTN, bilateral RAS, MRSA UTI who presents
with dyspnea.
Patient reports that he first noticed feeling short of breath
about a week ago. He reports no cough, or fevers or chills.
Shortness of breath is worse with exertion, and resolves when he
sits down to rest. He reports no chest pain, neck pain, or arm
pain. However, around 2 days ago he started to have chest
pressure and tightness with his shortness of breath. This also
gets worse with exertion, and resolves with rest. It has lasted
up to a few hours, but most often will last for several minutes
until his shortness of breath is not worse with lying flat. He
does note also a sweating episode when he has a "moment of
panic"
when he was feeling unable to breathe.
Regarding his coronary artery disease, patient reports that he
continues on a statin. However he reports he is not on aspirin
at home due to issues he had with clotting in the past. He has
had 2 stents placed previously.
Regarding his history of incontinence, patient reports that he
has had somewhat increased urinary frequency, but no pain with
urination. Notes he had some bleeding in his urine a few weeks
ago, which is now resolved. He is followed by urology.
On review of records, patient was last hospitalized from ___
through ___ with abdominal pain, and labs concerning for
DIC.
He was seen by hematology and vascular surgery. Ultimately,
patient remained hemodynamically stable with no evidence of
bleeding. He was discharged with heme/onc follow-up. His
fibrinogen at discharge was 99.
He has been followed by vascular surgery for history of
abdominal
aortic aneurysm. He has undergone a TEVAR, open aortobi-iliac
repair with graft and reimplantation of ___ onto graft and also
a
left ___
bypass w GSV. He is followed by Dr. ___ as an outpatient.
Multiple notes also mention a 2.5 cm cerebral aneurysm.
However,
on review of ___ and ___ records, I am
unable to find details about this diagnosis or when it was made.
In the ED:
Initial vital signs were notable for: T 96.5, HR 116, BP
187/119,
RR 24, 88% RA
Exam notable for: Mild bibasilar crackles in lung bases
Labs were notable for:
- CBC: WBC 17.1, hgb 12.8, plt 113
- Lytes:
135 / 102 / 26 AGap=13
-------------- 337
7.4 \ 20 \ 2.1
- repeat K - 4.0
- ___: 12423
- trop 0.08 -> 0.1 -> 0.08
Studies performed include: CXR with opacities at the medial lung
bases are not able to be correlated given lack of lateral. In
the
correct clinical setting, these are concerning for underlying
infection.
Patient was given:
- Vancomycin, CefePIME and flagyll
- 1L NS
- insulin 10u SC
- hydralazine 50mg
- aspirin 81
- Lasix 20mg IV
- amlodipine 10mg
- insulin 2u SC
Vitals on transfer: T 98.8, HR 101, BP 148/89, RR 20, 98% RA
Upon arrival to the floor, patient states he is starting to feel
slightly more short of breath again. He otherwise recounts
history as above.
Past Medical History:
- CAD s/p 2 stents RCA ___
- DVT s/p IVC filter
- Thoracic aneurysm w/ h/o stent graft c/b post-op paresis
- L leg ischemia s/p L ___ graft
- HTN
- Bilat renal artery stenosis
- Urinary retention
- Incontinence
- PTSD
- Brain aneurysm (2.5cm)
- H. pylori
- Thoracic stent graft
- L ___ graft
- Laminectomy w/ fusion for spinal stenosis
Social History:
___
Family History:
Brother ___ - Type II; Hyperlipidemia;
Hypertension; Psych - Depression; Stroke
Father ___ CHF; Diabetes - Type II; Hypertension
Mother ___
Physical ___:
ADMISSION PHYSICAL EXAM
========================
VS: T 98.4F, BP 185/112, HR 94, RR 18, O2 sat 97% RA
GENERAL: Patient appears to be in no apparent distress.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: JVP 6.5 cm above the sternal angle.
CARDIAC: normal S1, S2 without murmurs, rubs, or gallops
LUNGS: clear to auscultation bilaterally
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. Trace pretibial edema
bilaterally.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM
========================
VITALS: T 98.4, HR 74, BP 108/64, RR 16, 96% RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Faint crackles at lower lung bases bilaterally
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs. No peripheral edema
SKIN: No rashes or ulcerations noted
NEURO: NEURO: CN II-XII intact, ___ strength in all extremities,
sensation intact to light touch in all extremities.
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission Labs:
___ 03:14AM BLOOD WBC-17.1* RBC-4.58* Hgb-12.8* Hct-41.8
MCV-91 MCH-27.9 MCHC-30.6* RDW-16.6* RDWSD-54.3* Plt ___
___ 03:14AM BLOOD Neuts-88.2* Lymphs-5.6* Monos-5.3
Eos-0.2* Baso-0.3 Im ___ AbsNeut-15.07* AbsLymp-0.95*
AbsMono-0.90* AbsEos-0.04 AbsBaso-0.05
___ 03:14AM BLOOD ___ PTT-21.2* ___
___ 09:30PM BLOOD ___
___ 09:30PM BLOOD Ret Aut-2.4* Abs Ret-0.09
___ 03:14AM BLOOD Glucose-337* UreaN-26* Creat-2.1* Na-135
K-7.4* Cl-102 HCO3-20* AnGap-13
___ 08:48AM BLOOD ALT-85* AST-42* LD(___)-293* AlkPhos-235*
TotBili-0.7
___ 03:14AM BLOOD CK-MB-4 ___
Trop Trend:
___ 03:14AM BLOOD cTropnT-0.08*
___ 08:29AM BLOOD CK-MB-5
___ 08:29AM BLOOD cTropnT-0.10*
___ 02:42PM BLOOD CK-MB-5 cTropnT-0.08*
___ 12:12AM BLOOD CK-MB-3 cTropnT-0.07*
Discharge Labs:
===============
___ 07:43AM BLOOD WBC-10.7* RBC-3.69* Hgb-10.3* Hct-33.2*
MCV-90 MCH-27.9 MCHC-31.0* RDW-16.6* RDWSD-55.1* Plt ___
___ 07:43AM BLOOD Glucose-180* UreaN-36* Creat-2.4* Na-141
K-4.6 Cl-101 HCO3-25 AnGap-15
___ 07:43AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.4
PERINENT MICROBIOLOGY:
___ 8:40 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPH AUREUS COAG +. >100,000 CFU/mL.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
IMAGING:
========
EKG ___:
Rate 69 bpm, PR 202 ms, QRS 122 ms, QTc 540 ms
___ rhythm with sinus arrhythmia
left atrial abnormality
Left axis deviation
Cannot rule out Anteroseptal infarct (cited on or before
___
ST & Marked T wave abnormality, consider inferolateral ischemia
When compared with ECG of ___ 07:44,the HR is slower and
the lateral
___ CXR:
No pulmonary edema. Small bilateral pleural effusions, right
greater than
left have increased since ___. No pneumothorax. Heart
size normal.
Thoracic aorta is extremely tortuous, somewhat dilated,
containing a long
Endograft, and all entirely unchanged since ___.
CTA ___:
1. No evidence of pulmonary embolism.
2. Status post endovascular repair of a descending thoracic
aortic aneurysm
with thoracic stent graft seen in situ. However evaluation of
the descending
thoracic aorta and the abdominal aorta is severely limited as
contrast has not
reached these levels. Further imaging with dedicated CTA of the
thoracic
aorta can be performed if clinically indicated.
3. Small bilateral pleural effusions new since ___.
There is mild
bilateral pulmonary edema.
4. Mediastinal and hilar lymphadenopathy are likely reactive.
Cardiac Cath ___
LM: The Left Main, arising from the left cusp, is a large
caliber vessel. This vessel bifurcates into the
Left Anterior Descending and Left Circumflex systems. There is a
20% stenosis in the proximal and mid
segments.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel. There is
a 40% stenosis in the proximal/mid segment.
The Septal Perforator, arising from the proximal segment, is a
small caliber vessel.
The Diagonal, arising from the proximal segment, is a medium
caliber vessel. There is a 70% stenosis in
the proximal segment.
The Superior lateral of the Diag, arising from the proximal
segment, is a medium caliber vessel.
Cx: The Circumflex artery, which arises from the LM, is a large
caliber vessel. There is a 30% stenosis
in the proximal and mid segments.
The ___ Obtuse Marginal, arising from the proximal segment, is a
medium caliber vessel.
The ___ Obtuse Marginal, arising from the mid segment, is a
medium caliber vessel.
RCA: The Right Coronary Artery, arising from the right cusp, is
a large caliber vessel. There is a stent
in the ostium and proximal segment. There is a 100% in-stent
restenosis in the ostium. Collaterals from
the distal segment of the SP connect to the distal segment.
The Acute Marginal, arising from the proximal segment, is a
small caliber vessel.
The Right Posterior Descending Artery, arising from the distal
segment, is a medium caliber vessel.
The Right Posterolateral Artery, arising from the distal
segment, is a medium caliber vessel.
Brief Hospital Course:
___ y/o male with CAD s/p DES x2 to RCA in ___ (___), thoracic
aneurysm s/p grafting TEVAR, s/p infrarenal aorta repair with
aorto right iliac graft, HTN, bilateral RAS, DVT s/p IVC filter,
PVD, CKD, who presented with shortness of breath, transferred to
Cardiology for management of unstable angina and HFpEF
exacerbation.
CORONARIES: 100% in-stent restenosis of RCA, R-L collaterals,
20%
stenosis of pLM, dLM, 40% pLAD, 40% mLAD, 70% pDiag
PUMP: EF 36% (___)
RHYTHM: Sinus tachycardia.
====================
TRANSITIONAL ISSUES:
====================
Discharge weight: 71.7 kg
Discharge Cr: 2.4
Discharge Diuresis: 80 mg Torsemide daily, 12.5 mg
Spironolactone daily
- Needs to check electrolytes on ___
===============
ACTIVE ISSUES:
===============
# Acute HFpEF exacerbation:
Patient presented with symptoms of exertional dyspnea,
orthopnea,
and PND. Per patient, estimated dry weight is around 160 lb. He
was diuresed requiring a Lasix gtt (rate 15cc/hr). He was also
managed on carvedilol 12.5 mg BID and Hydralazine 50 mg TID.
Discharge weight was 71.7 kg.
-Discharge weight: 71.7 kg
-Discharge Cr 2.4
-Discharge Diuresis: 80 mg Torsemide daily, 12.5 mg
Spironolactone daily
# Unstable angina:
# Coronary artery disease s/p DES x2 to RCA
Patient presented with substernal chest pressure, possibly
worsening with exertion. Given increasing frequency and
intensity
of discomfort, concern for unstable angina in the setting of
known CAD. Troponin peaked 1.0, downtrended -> 0.08 x3 -> 0.07.
Patient continued on aspirin, high dose statin, and carvedilol.
Hep gtt infused for 48 hours prior to ___, which showed
100% in-stent restenosis of RCA, R-L collaterals, 20% stenosis
of pLM, dLM, 40% pLAD, 40% mLAD, 70% pDiag and elevated LVEDP
___ mmHg. Complete restenosis appeared chronic, with R to L
collaterals. No intervention performed during LHC. CTA chest
without evidence of PE. Also considered acute aortic syndrome
given previous history of thoracic aortic aneurysm, however,
patient had complete repair via TEVAR and vascular surgery felt
that an acute aortic pathology was unlikely.
# Leukocytosis
# Staph aureus UTI
Patient has a history of neurogenic bladder with chronic
incontinence requiring pads. Patient is documented as being
colonized with staph in his urine previously. Patient's initial
report of increased urinary frequency is chronic, states about 8
month most likely secondary to BPH. Per chart review, multiple
UCx with +Staph, therefore, patient most likely a colonizer. He
had no signs of systemic infection and leukocytosis was stable
so vancomycin was discontinued. (He received two doses.)
# ___ on CKD:
# H/o Bilateral RAS:
Patient presented with Cr elevation to 2.1 from baseline
1.5-1.7. ___ thought possibly related to congestive nephropathy
given hypervolemia on exam, but it did not improve with
diuresis. Patient's Cr stable in 2.1 to 2.4 range, which could
represent a new baseline. Less likely malignant HTN as blood
pressures controlled and stable. He should have his chemistries
rechecked on ___.
# Thoracic aneurysm, AAA
Followed by Dr. ___ in outpatient setting. Some concern for
dissection as above, however, vascular team consulted and did
not
recommend repeating CTA of aorta at this time in setting ___
on CKD and low suspicion for dissection.
# Transaminitis: Most likely secondary to congestive
hepatopathy, as LFTs downtrended with diuresis. Patient without
RUQ tenderness to palpation on exam.
================
CHRONIC ISSUES:
================
# Coagulopathy
# History DIC
Coags were slightly elevated on admission (PTT: 21.2 INR: 1.4).
# DM2
Held home metformin and managed with insulin sliding scale.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HydrALAZINE 50 mg PO TID
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Atorvastatin 80 mg PO QPM
4. amLODIPine 10 mg PO DAILY
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. CARVedilol 12.5 mg PO BID
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. Spironolactone 12.5 mg PO DAILY
5. Torsemide 80 mg PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
7. amLODIPine 10 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. HydrALAZINE 50 mg PO TID
10. MetFORMIN (Glucophage) 500 mg PO BID
11.Outpatient Lab Work
N17: Acute kidney injury
Please obtain chem-7, calcium, magnesium, phosphorus on ___.
Please fax results to Pt's cardiologist, ___
(___).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
# Acute-on-chronic Heart failure with preserved ejection
fraction exacerbation
# Unstable angina
Secondary:
# Thoracic aneurysm
# Abdominal aortic aneurysm
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 were
experiencing shortness of breath.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were given a water pill to help you get rid of the extra
fluid buildup.
- You had a catheterization to look at your heart vessels. You
did not receive any stents.
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.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
- Your discharge weight: 71.7 kg. You should use this as your
baseline after you leave the hospital.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10892316-DS-20
| 10,892,316 | 22,599,503 |
DS
| 20 |
2122-05-03 00:00:00
|
2122-05-06 12:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Nickel / Bactrim / vancomycin
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
===============
Admission labs
===============
___ 06:22PM BLOOD WBC-7.5 RBC-4.49* Hgb-12.8* Hct-41.9
MCV-93 MCH-28.5 MCHC-30.5* RDW-16.9* RDWSD-57.1* Plt ___
___ 06:22PM BLOOD Neuts-70.8 Lymphs-18.1* Monos-5.9 Eos-4.3
Baso-0.5 Im ___ AbsNeut-5.28 AbsLymp-1.35 AbsMono-0.44
AbsEos-0.32 AbsBaso-0.04
___ 06:22PM BLOOD ___ PTT-35.4 ___
___ 06:22PM BLOOD Glucose-128* UreaN-79* Creat-4.1* Na-137
K-6.3* Cl-102 HCO3-18* AnGap-17
___ 06:22PM BLOOD Calcium-9.7 Phos-4.5 Mg-2.7*
___ 06:22PM BLOOD Osmolal-318*
___ 06:22PM BLOOD K-5.9*
===============
Pertinent labs
===============
___ 06:20AM BLOOD ___ PTT-27.7 ___
___ 06:02AM BLOOD ALT-10 AST-11 AlkPhos-76 TotBili-0.4
___:24AM BLOOD K-4.7
___ 12:46AM URINE Color-Straw Appear-CLEAR Sp ___
___ 12:46AM URINE Blood-MOD* Nitrite-NEG Protein-300*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-6.5
Leuks-LG*
___ 12:46AM URINE RBC->182* WBC-128* Bacteri-FEW*
Yeast-NONE Epi-0 TransE-<1
___ 12:46AM URINE CastHy-1*
___ 12:46AM URINE Mucous-RARE*
___ 05:17PM URINE Hours-RANDOM UreaN-793 Creat-107 Na-64
===============
Discharge labs
===============
___ 05:45AM BLOOD WBC-7.9 RBC-4.27* Hgb-12.0* Hct-37.9*
MCV-89 MCH-28.1 MCHC-31.7* RDW-17.2* RDWSD-55.9* Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD Glucose-125* UreaN-95* Creat-4.4* Na-138
K-5.1 Cl-99 HCO3-19* AnGap-20*
___ 05:45AM BLOOD Calcium-9.5 Phos-5.8* Mg-2.5
___ 05:45AM BLOOD
===============
Studies
===============
EKG: Atrial Flutter
CT Urogram w/o Contrast (___):
1. Within the limitations of a non enhanced study, no solid
renal lesions and
the decompressed urinary bladder appears unremarkable. No large
masses.
2. Nonobstructive 3 mm left cortical stone.
3. Severe prostatomegaly
4. Partially imaged descending thoracic aneurysm status post
TEVAR.
5. The juxtarenal AAA measures 6 x 5 cm, unchanged since ___.
6. 2.6 cm left internal iliac artery aneurysm also stable since
___.
Urine Cytology (___):
NEGATIVE FOR HIGH-GRADE UROTHELIAL CARCINOMA. Urothelial cells,
squamous cells, and abundant bacteria.
===============
Microbiology
===============
___ 5:30 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:09 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 12:46 am
URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPH AUREUS COAG +. 10,000-100,000 CFU/mL.
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
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
Brief Hospital Course:
Transitional Issues:
[] Initiated warfarin, ensure follow up with ___
___.
[] Please repeat BMP to evaluate renal function on lower
torsemide dose and electrolytes
[] Juxtarenal AAA measures 6 x 5 cm, unchanged since ___. 2.6 cm left internal iliac artery aneurysm also stable
since ___ consider what follow-up would be necessary
for these findings.
[] On home Aspirin 81 mg PO 3X/WEEK ___ unclear why on
this dose and would recommend daily.
[] Held home spironolactone and Sacubitril-Valsartan iso
___, could consider when/if to restart.
[] Due to hematuria, should get outpatient cystoscopy and have
discussion with urology regarding prostate MRI.
[] Initiated sodium bicarbonate and sevelemer given worsening
renal function (d/c Cr 4.4), hyperkalemia, and elevated phos
==================
SUMMARY STATEMENT:
==================
___ year old male with history of atrial flutter on apixaban,
HFrEF, HTN, T2DM, CKD, CAD s/p stenting, PVD s/p graft,
neurogenic bladder, and BPH who presented after 1 day of gross
hematuria and clots, then found to have worsening CKD.
ACUTE ISSUES:
=============
# ___ on CKD stage III
# Hyperkalemia
Worsened from 2.6 in ___. Per renal, likely progression of
his
underlying renal disease ___ DM/HTN and no need for further
workup while inpatient. Does not appear to be obstructed either.
Creatinine
was rising and breathing stable so decreased torsemide to 20mg
daily.
Holding home entresto, spironlactone. Renally dosed medications.
Utilized low potassium diet. Creatinine elevated above baseline
at 4.4, but no acute indication for HD. Will need close
nephrology follow up and repeat electrolytes.
# Hematuria
No obvious etiology on CTU. ___ be secondary to chronic BPH and
apixaban. Staph in urine cx likely contaminant given lack of
symptoms or bacteremia. Continued home Ferrous GLUCONATE PO
3X/WEEK (___) with slight dosage adjustment inpatient and
will have patient continue after discharge. Will need urology
follow up and cystoscopy that Dr. ___ At___ urology will
likely arrange. ___ also benefit from prostate MRI.
# HFrEF, not decompensated
# HTN
EF ___ during admission in ___. Euvolemic on exam during
this admission. Medically managed by atrius, although seems to
have not
been seen by cardiology outpatient in sometime. Recommend 2g Na
and 2L fluid restriction.
PRELOAD: Torsemide to 20mg PO daily.
Neurohormonal blockade: Increased carvedilol to 25 mg PO BID.
AFTERLOAD: held home spironolactone, Sacubitril-Valsartan;
decreased hydralazine to 25mg PO BID, increased carvedilol to 25
mg PO BID, continue home isosorbide mononitrate 60 mg PO DAILY.
Will need to determine when/if to re-start entresto and
spironolactone iso worsening renal function.
# Atrial flutter
Was initially on apixaban that was transitioned to warfarin
given poor renal function. Given CHADS2VASc score 5, warrented
bridging. Rate control with carvedilol as above. Will need
referral to ___ clinic after discharge.
CHRONIC ISSUES:
===============
# CAD s/p 2 stents RCA ___
Continued home Aspirin 81 mg PO 3X/WEEK ___ unclear why
on this dose and would recommend daily. Recommended patient
discuss with PCP/cardiologist. Continued home Atorvastatin 80 mg
PO QPM.
# T2DM
Not currently on insulin at home. Utilized SSI while inpatient.
# Asthma/COPD
Continued home Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
# Iliac artery aneurysm
Patient has juxtarenal AAA measures 6 x 5 cm, unchanged since ___. 2.6 cm left internal iliac artery aneurysm also
stable since ___. Will have patient discuss follow-up
plan for these findings with PCP and appears to have vascular
surgery follow up.
#CODE: Full, presumed
#CONTACT: Name of health care proxy: ___
Relationship: wife
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
2. Vitamin D ___ UNIT PO DAILY
3. Torsemide 20 mg PO QAM
4. Torsemide 10 mg PO QPM
5. HydrALAZINE 50 mg PO BID
6. Apixaban 5 mg PO BID
7. Spironolactone 12.5 mg PO DAILY
8. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
9. CARVedilol 18.75 mg PO QAM
10. CARVedilol 12.5 mg PO QPM
11. Aspirin 81 mg PO 3X/WEEK (___)
12. Atorvastatin 80 mg PO QPM
13. Ferrous GLUCONATE 240 mg PO 3X/WEEK (___)
14. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
Discharge Medications:
1. Nephrocaps 1 CAP PO DAILY
RX *B complex with C 20-folic acid [Renal Caps] 1 mg 1
capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0
2. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate 800 mg 1 tablet(s) by mouth Three times
daily with meals Disp #*90 Tablet Refills:*0
3. Sodium Bicarbonate 650 mg PO TID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
4. Warfarin 2.5 mg PO DAILY16
RX *warfarin 2.5 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
5. CARVedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. Ferrous GLUCONATE 324 mg PO 3X/WEEK (___)
RX *ferrous gluconate 324 mg (38 mg iron) 1 tablet(s) by mouth
three times weekly Disp #*30 Tablet Refills:*0
7. HydrALAZINE 25 mg PO TID
RX *hydralazine 25 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
8. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
10. Aspirin 81 mg PO 3X/WEEK (___)
11. Atorvastatin 80 mg PO QPM
12. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
14. HELD- Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID This
medication was held. Do not restart Sacubitril-Valsartan
(24mg-26mg) until your PCP or cardiologist tell you to do so.
15. HELD- Spironolactone 12.5 mg PO DAILY This medication was
held. Do not restart Spironolactone until your PCP or
cardiologist tell you to do so.
16.Outpatient Lab Work
ICD 10: I48. 3 Atrial flutter
Standing order to draw INR
Please fax results to Dr. ___ at ___
17.Outpatient Lab Work
ICD 10: N18. 3 CKD
Please draw Chem-10 panel (Na, K, Cl, Bicarb, BUN, Cr, Glucose,
Magnesium, Phosphate, and calcium)
Fax results to Dr. ___ at ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=====================
# ___ on CKD stage III
# Hyperkalemia
# Hematuria
SECONDARY DIAGNOSES
=======================
# HFrEF, not decompensated
# HTN
# Atrial flutter
# CAD s/p 2 stents RCA ___
# T2DM
# Asthma/COPD
# Iliac artery aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
===================================
- You were admitted because you had blood in your urine.
What happened while I was in the hospital?
==========================================
- We completed imaging and laboratory tests and did not find an
obvious cause for your bleeding. It is possible that this was
related to the apixaban you were taking. However, it also raises
the concern that you could have a cancer in your bladder,
urinary system, or prostate, and it is important that you follow
up with your urologist.
- Your kidney numbers were noted to have worsened compared to
your prior numbers, and we believe this led to electrolyte
abnormalities. We adjusted your medications to attempt to
improve these numbers and to bring your electrolyte levels
closer to normal. These numbers did not improve, so you will
need a follow up with a kidney doctor
___ should I do after leaving the hospital?
============================================
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10892549-DS-8
| 10,892,549 | 29,929,592 |
DS
| 8 |
2182-08-28 00:00:00
|
2182-08-31 16:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Simvastatin / Dicloxacillin / Bee Pollens / Poison ___
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with pmhs of hypothyroid, hypogonadism, dysautonomia,
orthostatic hypotension and recent pna c/b empyema who presents
with abdominal pain. Pt thinks he may have had background
epigastic pain for an unclear amount of time but that it has
been increasing over the last ___ days and today is noticably
worse. Pain is constant, described as a dull ache, and is not
worsened or improved with food or antacids. It is not exertional
or pleuritic. No N/V/D. No fevers/chills. No chest pain or SOB.
No dysuria, no blood in stool, no cough. Has been taking 650 asa
BID "for a long time" as he has a signficant family h/o CAD.
History of ulcer with h pylori treated years ago. He thought his
ulcer may have been coming back because he has been under
physical stress recently in the setting of recent empyema.
Symptoms of his pneumonia, including cough and SOB, have
completely resolved. He is no longer on antibiotcs. He states he
lost 17 pounds in setting of recent illness but has gained the
weight back. No sick contacts. He drinks several glasses of wine
per week but recently has been drinking pomegranate juice
instead.
In the ED, initial vitals were: ___ 66 158/78 16 100%
-Labs were significant for lipase 107 and relatively
unremarkable cbc and chem7
-Pt was given GI cocktain (Aluminum-Magnesium
Hydrox.-Simethicone 30 mL, Donnatal 10 mL, Lidocaine Viscous 2%
10 mL, 1L NS)
Vitals prior to arrival to floor, 97.6 76 147/68 18 93% RA
On the floor, he states his pain resolved with the GI cocktail
in the ED. He is very hungry and has no other complaints.
Review of systems:
(+) Per HPI plus chronic ___ pitting edema thought to be ___
venous insufficiency
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias.
Past Medical History:
# Hypothyroidism
# Nonalcoholic Steatohepatitis
# Gilberts syndrome
# PUD -- H.Pylori treated with abx in ___
# Internal hemorrhoids
# Hypertension
# Dyslipidemia
# Pericarditis history
# Occasional atrial premature beats
# Mitral valve prolapse
# Raynauds syndrome
# Multiple orthopedic procedures
# Septal deviation surgery
# Empyema in ___
# s/p appendectomy
# DJD
# Osteopenia
# Retinal tears
# bronchospams
Social History:
___
Family History:
Significant family h/o CAD with multiple uncles dying of MIs as
young as ___. Family h/o gastric cancer.
Physical Exam:
ADMISSION PHYSICAL:
=========================
Vitals: 97.6, 143/84, 53, 18, 100% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: decreased breath sounds at left lung base up to ___ of
lung, right lung clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, thin, +BS, nontender, nondistended, no rebound,
no guarding
Ext: Warm, well perfused, 1+ pulses, 1+ pitting edemas to shins
bilaterally, L leg slightly > R leg
Skin: no skins tears, ulcers or breakdowns
DISCHARGE PHYSICAL:
=========================
Vitals: T:97.6 BP:140/74 P:52 R:18 O2:100%(RA)
General: Alert, oriented, NAD
Lungs: Dimished breath sounds on L, normal to ausculation on R,
no wheezes, rales, rhonchi appreciated
CV: Bradycardic, murmur preceding S1 best appreciated at L lower
sternal border, normal S2, no rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly appreciated
Ext: Warm, well perfused, no clubbing, cyanosis; 1+ edema below
the ankles
Skin/nails: no rashes or lesions appreciated; cherry angiomas on
abdomen; L pointer finger nail lesion (? fungal infection)
Neuro: CN II-XII grossly intact, full strength in upper and
lower extremities, sensation to light touch in tact in distal
lower extremities bilaterally
Pertinent Results:
ADMISSION LABS:
=======================
___ 04:25PM BLOOD WBC-8.0 RBC-4.35* Hgb-13.1* Hct-39.1*
MCV-90 MCH-30.0 MCHC-33.4 RDW-16.4* Plt ___
___ 04:25PM BLOOD Neuts-41.8* ___ Monos-5.6
Eos-29.9* Baso-0.8
___ 04:25PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
___ 04:25PM BLOOD Glucose-87 UreaN-22* Creat-0.9 Na-136
K-3.8 Cl-98 HCO3-28 AnGap-14
___ 04:25PM BLOOD ALT-22 AST-34 AlkPhos-52 TotBili-0.3
___:25PM BLOOD Lipase-107*
___ 04:25PM BLOOD CK-MB-7 cTropnT-<0.01
___ 04:25PM BLOOD Albumin-4.0 Calcium-9.4 Phos-4.1 Mg-2.2
DISCHARGE LABS:
=======================
___ 09:05AM BLOOD WBC-5.6 RBC-4.24* Hgb-12.5* Hct-38.1*
MCV-90 MCH-29.5 MCHC-32.8 RDW-16.3* Plt ___
___ 09:05AM BLOOD Glucose-140* UreaN-14 Creat-0.8 Na-136
K-3.5 Cl-100 HCO3-29 AnGap-11
MICROBIOLOGY:
=======================
HELICOBACTER ANTIGEN DETECTION, STOOL
Test Result Reference
Range/Units
HELICOBACTER PYLORI AG, EIA, SEE NOTE
STOOL
HELICOBACTER PYLORI AG, EIA, STOOL
MICRO NUMBER: ___
TEST STATUS: FINAL
SPECIMEN SOURCE: STOOL
SPECIMEN QUALITY: ADEQUATE
RESULT: Not Detected
Antimicrobials, proton pump inhibitors, and
bismuth preparations inhibit H. pylori and
ingestion up to two weeks prior to testing
may
cause false negative results. If clinically
indicated the test should be repeated on a
new
specimen obtained two weeks after
discontinuing
treatment.
PERTINENT STUDIES:
=========================
___ EKG:
Sinus bradycardia. Non-diagnostic Q waves inferiorly.
Non-specific ST segment changes. Probable early repolarization
pattern. Compared to the previous tracing of ___ the
ventricular rate is slower.
Read by: ___.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
53 ___ 62 35 58
___ RUQ U/S:
FINDINGS:
The liver is homogeneous in echotexture and has a smooth
contour. There is no focal liver lesion. There is no
intrahepatic biliary dilation. The CBD measures 3 mm. Main
portal vein is patent with hepatopetal flow. The
gallbladder is normal without stones or wall thickening.
Pancreas is
unremarkable without evidence of pancreatic duct dilatation. The
spleen
measures 8.5 cm in length and has homogeneous echotexture.
Limited view of the right kidney does not show hydronephrosis.
There is no ascites.
IMPRESSION:
Normal gallbladder without evidence of cholelithiasis. No
biliary dilatation.
Brief Hospital Course:
Patient is a ___ with PMH significant for HTN, HLD, gastritis
s/p H. pylori tx in ___, ___, hypothyroidism, hypogonadism,
and recent empyema, who presented on ___ to the ___ ED with
epigastric pain. RUQ U/S unremarkable for liver/biliary/pancreas
disease. Mildly elevated lipase (107) though otherwise not
consistent with pancreatitis. Normal EKG and negative trops.
Pain improved dramatically with GI cocktail
(Al-Mg-OH/simethicone). Given high dose ASA 650 mg BID, favor
PUD.
#Abdominal pain - Favor PUD. In setting of eosinophilia, remote
chance of strongyloides (serum antigen pending). Started PPI.
Advised no more that ASA 81 mg daily, which patient understood.
F/U with GI outpatient. Stool H. pylori antigen also pending.
#Eosinophilia - unclear etiology. No allergic symptoms. Concern
for malignancy or, given history of endocrine disorders, adrenal
insufficiency. Strongyloides Ag sent as above. Patient to follow
up with heme/onc for further workup. A peripheral smear was
added on to his labs for future review.
Otherwise, no changes to home medications.
====TRANSITIONAL ISSUES====
[ ] patient given contact information for f/u with heme/onc for
eosinophilia
[ ] patient given contact information for f/u with GI for
further w/u and results of stool H. pylori
[ ] given no EKG changes and negative troponins, very low
suspicion for atypical angina, however PCP could consider ETT to
risk stratify given significant family h/o CAD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Adderall (dextroamphetamine-amphetamine) 10 mg oral BID
2. Aspirin 650 mg PO BID
3. galantamine 12 mg oral BID
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Memantine 10 mg PO DAILY
7. Niacin 500 mg PO TID
8. Pravastatin 20 mg PO DAILY
9. Vitamin D 1000 UNIT PO BID
10. alpha lipoic acid ___ mg oral QD
11. Centrum Complete (multivitamin-iron-folic acid) ___
mg-mcg oral QD
12. coenzyme Q10 200 mg oral QD
13. Cyanocobalamin 1000 mcg PO BID
14. Ferrous GLUCONATE 324 mg PO DAILY
15. Fish Oil (Omega 3) 4000 mg PO DAILY
16. Levocarnitine 500 mg PO QD
17. Potassium Chloride (Powder) 10 mEq PO BID
18. ___ (s-adenosylmethionine) 400 mg oral QD
19. Sildenafil 100 mg PO ___ MIN PRIOR TO INTERCOURSE
20. Magnesium Oxide 500 mg PO BID
21. testosterone cypionate 0.5 injection q 2 weeks
Discharge Medications:
1. Adderall (dextroamphetamine-amphetamine) 10 mg oral BID
2. Cyanocobalamin 1000 mcg PO BID
3. Ferrous GLUCONATE 324 mg PO DAILY
4. Fish Oil (Omega 3) 4000 mg PO DAILY
5. galantamine 12 mg oral BID
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Lisinopril 20 mg PO DAILY
8. Magnesium Oxide 500 mg PO BID
9. Memantine 10 mg PO DAILY
10. Niacin 500 mg PO TID
11. Pravastatin 20 mg PO DAILY
12. Vitamin D 1000 UNIT PO BID
13. Omeprazole 40 mg PO DAILY
Do not take with your dextroamphetamine
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
14. alpha lipoic acid ___ mg oral QD
15. Centrum Complete (multivitamin-iron-folic acid) ___
mg-mcg oral QD
16. coenzyme Q10 200 mg oral QD
17. Levocarnitine 500 mg PO QD
18. Potassium Chloride (Powder) 10 mEq PO BID
Hold for K >
19. ___ (s-adenosylmethionine) 400 mg oral QD
20. Sildenafil 100 mg PO ___ MIN PRIOR TO INTERCOURSE
21. testosterone cypionate 0.5 injection q 2 weeks
22. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: abdominal pain possibly due to peptic ulcer disease
SECONDARY: eosinophilia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for abdominal pain. An
abdominal ultrasound did not show signs of liver, gallbladder,
or pancreas disease. We also checked an EKG and troponins to
make sure your pain was not coming from your heart and these
were both normal. Our main concern is that your pain is coming
from an ulcer in your stomach or duodenum given the high dose
aspirin you have been taking. We are decreasing your aspirin
dose and starting you on an antacid to help control your pain.
We also noticed that your blood had a high number of
eosinophils. It is unclear why you have so many of these cells,
but we want you to schedule an appointment with our
hematology/oncology department for further investigation.
You should follow up with your PCP in the next ___ weeks and
call the numbers below to schedule appointments with our
gastroenterologists and hematologists.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10892801-DS-2
| 10,892,801 | 27,770,063 |
DS
| 2 |
2163-12-28 00:00:00
|
2164-01-03 00:06:00
|
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:
HA, ___ swelling, wound infection
Major Surgical or Invasive Procedure:
IV magnesium
IV antibiotics
History of Present Illness:
___ s/p LTCS/PPTL ___ p/w HA and worsening
wound infection.
Pt reports that she was seen at ___ last ___ and was
noted to have ___ erythema concerning for
cellulitis.
She was started on cephalexin, which she took once daily
(instead
of QID as prescribed), until yesterday when she took it four
times. She has noted spreading erythema since starting
antibiotics, and this morning noted 'pus-like drainage' from her
incision. Denies fevers and chills. Denies h/o skin infections
or
h/o MRSA. Received 2g cephazolin at time of LTCS.
Also reports ___ headache since this AM. She took APAP and
ibuprofen earlier without relief. She has a h/o migraines, but
this is unlike her prior migraines. Was on medication prior to
pregnancy but unsure of the name of the medication. While in the
ED, she received 5mg oxycodone which reduced her headache to
___. Denies visual changes, though her vision is blurry when
her
headache is really severe. No floaters. Denies epigastric pain
and SOB. Denies h/o hypertension.
Pt also reports bilateral and symmetric lower extremity swelling
x 1 week, which has been resolving over the course of the week.
Has pain in her feet bilaterally due to the swelling.
Denies fevers, chills, N/V/D.
Breastfeeding. Denies vaginal bleeding.
Past Medical History:
OBHx: G2P2
-G1 prior primary C/S due to severe HSV outbreak
-G2 rLTCS with PPTL
GynHx: HSV
PMH: migraines
PSH: LTCS, LTCS with PPTL
Social History:
___
Family History:
NC
Physical Exam:
Admission PE
BPs 154/94, 171/92, 145/81, 148/92
General: NAD, alert
Lungs: No respiratory distress. CTAB.
Abdomen: ~8x3cm area of erythema and induration with some
pockets
of underlying fluctuance in areas extending from right of
incision toward pt's right side. incision well closed. palpation
of indurated areas produces foul smell but not able to produce
drainage from mostly closed incision. pt with significant TTP on
palpation of areas of erythema.
GU: No pad
Neuro: DTRs 2+
Extr: 1+ edema B/L
Discharge PE
VSS
General: NAD, alert
Lungs: No respiratory distress. CTAB.
Abdomen: Erythema and induration resolved, incision well closed.
GU: No pad
Neuro: DTRs 2+
Extr: no ___ edema or tenderness
Brief Hospital Course:
Patient is a ___ s/p rLTCS/PPTL on ___ re-admitted with
wound infection and postpartum preeclampsia, severe by HA and
BPs. She was normotensive in pregnancy, but developed severe
pressures ___. She was continued on labetalol 200mg PO BID.
Labs were normal except for P/C 0.3 (trace blood in UA). She
received Mag x24 hours. She also received a head CT for
persistent headache that showed a non-specific 6mm lesion.
Headache resolved with medication and rest. For her pfannensteil
cellulitis, which was an 8x3cm area at right aspect of incision
on presentation, she received Unasyn 3mg Q6H hours + Vanco 1g
q12h (added ___, which was eventually transitioned to PO
clinda as patient improved. Her blood cultures showed no growth,
and she had no other signs or symptoms of systemic infection.
She received an ultrasound that showed a 1.1x0.7x4.2cm fluid
collection, superior/lat of right side of incision. She
underwent an ___ drainage of fluid pocket ___ AM, and was then
discharged on ___ in good condition with plan for
outpatient follow-up.
Medications on Admission:
acyclovir, ibupfrofen, acetaminophen, cephalexin
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain
do not exceed 4000 mg in 24 hours
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg ___
tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1
2. Docusate Sodium 100 mg PO BID:PRN Constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*50 Capsule Refills:*2
3. Labetalol 200 mg PO BID
RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*3
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not drive or drink while taking
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every 4 hours
Disp #*20 Tablet Refills:*0
5. Clindamycin 450 mg PO Q8H Duration: 10 Days
Be sure to complete full course of antibiotics even if symptoms
improve.
RX *clindamycin HCl 150 mg 3 capsule(s) by mouth every eight (8)
hours Disp #*93 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Postpartum severe preeclampsia
Pfannensteil wound infection
Lower extremity swelling
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were readmitted to the hospital for elevated blood pressures
with headache and wound infection. For your elevated blood
pressures you were started on labetalol 200 mg twice a day,
which you should continue upon going home. You were also treated
for a wound infection with IV antibiotics and should continue
oral antibiotics on discharge. Complete entire course of
antibiotics even if symptoms improve.
Please follow the directions below as well:
Nothing in the vagina for 6 weeks (No sex, douching, tampons)
No heavy lifting for 6 weeks
Do not drive while taking Percocet
Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
Do not take more than 2400mg ibuprofen in 24 hrs
Please call the on-call doctor at ___ if you develop
shortness of breath, dizziness, palpitations, fever of 101 or
above, abdominal pain, increased redness or drainage from your
incision, nausea/vomiting, heavy vaginal bleeding, or any other
concerns.
Followup Instructions:
___
|
10892947-DS-18
| 10,892,947 | 24,378,050 |
DS
| 18 |
2187-07-31 00:00:00
|
2187-08-06 08:19:00
|
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:
right lower quadrant pain
Major Surgical or Invasive Procedure:
dilation and curettage
Physical Exam:
Discharge physical exam
Vitals: VSS
Gen: NAD, A&O x 3
CV: RRR
Resp: no acute respiratory distress
Abd: soft, appropriately tender, no rebound/guarding
Ext: no TTP
Pertinent Results:
___ 01:20PM BLOOD Glucose-121* UreaN-6 Creat-0.6 Na-135
K-4.2 Cl-104 HCO3-16* AnGap-19
___ 01:20PM BLOOD Calcium-7.4* Phos-2.6* Mg-1.7
GC/CT: negative
Brief Hospital Course:
On ___, Ms. ___ is a ___ G4P0 with a history
of an ectopic pregnancy s/p a laparoscopic right salpingectomy
and endometriosis who was admitted to the gynecology service
after undergoing a dilation and curettage for a 9-week missed
abortion for monitoring for ovarian torsion in the setting of a
known large right ovarian cyst.
She was transferred from ___ with concern for ovarian
torsion. Patient reported acute onset severe sharp right lower
quadrant abdominal pain that awoke her from sleep the day of
admission. She described the pain as constant and associated
with nausea. She reported two episodes of emesis at the outside
hospital. The pain was unrelieved after 3 mg of the Dilaudid.
She reported a similar pain approximately 2 to 3 weeks prior to
presentation that lasted 1.5 hours and resolved with Tylenol. In
the ___ emergency room she received an additional 1 mg of
Dilaudid and 2 mg IV morphine without improvement of the pain.
She reported ___ pain and continued to have nausea despite an
additional 4 mg of Zofran.
Labs in ___ were significant for a normal white count
of 8.5 and a beta-hCG of 13,238. An ultrasound was done on
___ which showed an intrauterine gestational sac with yolk
sac and embryonic pole of 28 mm without cardiac activity. There
was also a large right ovarian cyst that measured approximately
8 x 8 x 5.7 cm.
On exam at ___ her vital signs were normal. She was
described as appearing uncomfortable and resting in the fetal
position. Her abdomen was soft and mildly distended with right
lower quadrant and lower mid-abdominal tenderness to palpation,
no rebound, and voluntary guarding. Pelvic exam was significant
for no CMT and moderate tenderness to palpation of the right
adnexa. A repeat pelvic ultrasound was performed at ___
which showed normal arterial and venous waveforms to the right
ovarian parenchyma and again demonstrated the large right
ovarian cysts measuring approximately 6.7 cm.
While in the emergency room the patient's clinical exam
improved. The decision was made to proceed with the D&C given
the missed abortion and defer a diagnostic laparoscopy. Given
the improvement in her exam the presentation was thought to be
most consistent with a corpus luteum cyst that was resolving and
had decreased in size over the last 48 hours. She was admitted
to the gynecology service for continued observation. Please see
the operative report for full details of the dilation and
curettage procedure.
Her post-operative course was uncomplicated. Immediately
post-op, her pain was controlled with Toradol and Tylenol. She
was monitored overnight and her vital signs remained stable and
her abdominal pain was improved. Her diet was advanced without
incident and she was transitioned to PO pain medications of
ibuprofen and acetaminophen.
By post-operative day 1, she was tolerating a regular diet,
voiding spontaneously, ambulating independently, and pain was
controlled with oral medications. She was then discharged home
in stable condition with outpatient follow-up scheduled.
Medications on Admission:
PNV
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
Do not exceed 4g in 24 hours
RX *acetaminophen 500 mg 1 tablet(s) by mouth every four (4)
hours Disp #*60 Tablet Refills:*2
2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
Take medication with food
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*60 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
miscarriage at 9 weeks
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the gynecology service after your
procedure. You have recovered well and the team believes you are
ready to be discharged home. Please call Dr. ___ office
with any questions or concerns. Please follow the instructions
below.
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
your postoperative appointment
* You may eat a regular diet.
* You may walk up and down stairs.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
10893121-DS-6
| 10,893,121 | 28,266,108 |
DS
| 6 |
2181-09-24 00:00:00
|
2181-10-01 08:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea, vomiting, abdominal pain, BRBPR
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy
History of Present Illness:
Mr. ___ is a ___ with a history of traumatic brain
injury and subsequent seizure disorder who presents with a 1-day
history of nausea, vomiting, severe abdominal pain and blood in
the stool. He states that he was feel well until yesterday, when
he began developing abdominal pain. Overnight, the pain
increased in intensity. He tried to have a bowel movement but
was unable to do so. Per his report, he was straining and
eventually passed a moderate amount of blood mixed with
yellowish stool. He took ___ Colace at that time. As the pain
intensified, he became nauseous and vomited ___ times
(non-bloody, non-bilious). Eventually the pain was so severe he
reports nearly crying from pain, and he came into the ED.
.
Of note, he was recently treated for positive urine gonorrhea
(symptomatic with purulent discharge) on ___. He reports
taking antibiotics as prescribed and that all symptoms resolved.
Since then, he has had receptive/insertive anal intercourse with
two male partners, once with a prior boyfriend about a month ago
and once with his cousin on ___ or ___ He states his
cousin was in town visiting, and brought him some sort of pill,
which he took. It made him sleepy and he fell asleep, and awoke
to penetrative anal intercourse by his cousin.
.
For the last ___ days, he has also been experiencing dysuria but
no penile discharge. No blood in the urine. He thinks he may
have had fever this AM, as he felt hot and sweaty, though did
not take his temperature. He usually has a good appetite, but
last night ate only rice and asparagus, and this morning had a
type of cereal similar to cornflakes.
.
In the emergency room, initial vitals were T 97.6, HR 77, BP
119/92, RR 16, O2 sat 100% on RA. CT of the abdomen revealed
inflammatory changes consistent with proctocolitis. Two PIVs
(18G & 20G) were placed, and the patient received 3L IVF. He
also received a total of 4 mg IV morphine for pain and 4 mg IV
Zofran for nausea. He was treated with 1g IV ceftriaxone, 1g PO
azithromycin, and 400 mg IV acyclovir to cover common STD
pathogens. Given the timing of his most recent unprotected
intercourse, he also received Truvada as PEP. On transfer to the
floor, his vitals were T 98.5, HR 65, BP 119/82, RR 16, O2 sat
98% RA.
.
On the floor, he continued to have waves of abdominal pain. He
curerntly endorses pain radiating into the scrotum as well. He
has not vomited or had bloody BM since arrival to the ED. The
nausea improved with Zofran recieved in the ED.
.
Review of systems:
.
(+) Per HPI
(-) Denies recent weight loss or gain. Denies headache, sinus
tenderness, rhinorrhea or congestion (except as with allergies).
Denies chest pain or tightness, palpitations. Denies cough,
shortness of breath, or wheezes. Denies arthralgias or myalgias.
Denies rashes or skin breakdown. No numbness/tingling in
extremities. No feelings of depression or anxiety (mood
currently stable). All other review of systems negative.
Past Medical History:
- Traumatic head injury (fell off a wall age ___
- Seizure disorder (well-controlled, last seizure ___
- Learning disability
- Psychiatric history: mood disorder NOS; cognitive disorder
NOS;
delusional disorder NOS, persecutory type (per psych records)
- Allergies
- Gonorrhea ___
- PPD positive
- HIV negative ___
Social History:
___
Family History:
Both parents are alive and general healthy. His mother suffers
from some problems with her vision and chronic constipation. He
has a brother and a sister, both healthy.
Physical Exam:
Vitals: T 98.1, BP 110/74, HR 67, RR 16, O2 sat 98% on RA
GEN: No acute distress.
HEENT: Mucous membranes moist, no lesions noted. Sclerae
anicteric. No conjunctival pallor noted.
NECK: JVP not elevated. No lympadenopathy.
CV: Regular rate and rhythm, no murmurs, rubs ___
PULM: Clear to auscultation bilaterally, no wheezes, rales or
rhonchi.
ABD: Soft, diffusely TTP in lower quadrants with some voluntary
guarding, non distended, active bowel sounds present. No
hepatosplenomegaly.
GU: Multiple pearly penile papules around the head of the glans,
not new per patient. Testicles are normal size and consistency
but tender to palpation bilaterally. No scrotal erythema or
edema noted. No penile discharge noted. No inguinal
lymphadenopathy.
EXTR: No edema, 2+ Dorsalis pedis and radial pulses bilaterally.
NEURO: Alert and oriented x3.
SKIN: No ulcerations or rashes noted.
Pertinent Results:
Labs on admission:
___ 12:34PM LACTATE-3.2*
___ 07:15AM URINE HOURS-RANDOM
___ 07:15AM URINE GR HOLD-HOLD
___ 07:15AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-SM
___ 07:15AM URINE RBC-<1 WBC-13* BACTERIA-NONE YEAST-NONE
EPI-0
___ 07:15AM URINE MUCOUS-MOD
___ 06:00AM UREA N-10 CREAT-0.7 SODIUM-134 POTASSIUM-3.9
CHLORIDE-97 TOTAL CO2-25 ANION GAP-16
___ 06:00AM estGFR-Using this
___ 06:00AM ALT(SGPT)-59* AST(SGOT)-54* ALK PHOS-122 TOT
BILI-0.6
___ 06:00AM LIPASE-17
___ 06:00AM PHENYTOIN-20.4*
___ 06:00AM WBC-10.8# RBC-5.15 HGB-15.5 HCT-43.1 MCV-84
MCH-30.1 MCHC-35.9* RDW-12.6
___ 06:00AM NEUTS-80.6* LYMPHS-13.7* MONOS-4.2 EOS-0.7
BASOS-0.8
___ 06:00AM PLT COUNT-200
Other relevant labs:
___ 06:30AM BLOOD HIV Ab-NEGATIVE
___ 09:45AM BLOOD Phenoba-15.7 Phenyto-16.3
___ 05:30PM BLOOD Ethanol-NEG
___ 09:45AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-POS Tricycl-NEG
MICROBIOLOGY:
- ___ Urine GC/chlamydia: No PCR detected
- ___ Rectal swab GC/chlamydia: No PCR detected
- ___ Rectal swab HSV: Preliminary result negative
- ___ Blood culture: NGTD
- ___ Blood culture: NGTD
- ___ RPR: Non-reactive
- ___ HIV viral load: Negative
- ___ Stool ulture, Campylobacter, Cryptosporidia/Giardia,
E. Coli, C. difficile: C. diff toxin negative, otherwise pending
- ___ O&P, Microsporidia, Cyclospora, Yersinia, Vibrio,
stool AFB: Pending (AFB smear negative)
- ___ Urine culture: Pending
- ___ Treponema agglutination study: Pending at the time of
discharge (to rule out false-negative RPR in acute cases with
high organism levels)
- ___ Lymphogranuloma venereum (chlamydia panel send-out):
Pending at the time of discharge
PATHOLOGY:
- Rectal mucosal biopsy ___: Pending at the time of
discharge
CT ABDOMEN & PELVIS ___: Final read
IMPRESSION: Wall thickening and inflammation involving the
rectum and distal sigmoid colon suggestive of proctocolitis.
.
FLEXIBLE SIGMOIDOSCOPY ___:
Friability, erythema, congestion and loss of normal vascularity
in the rectum and colon till 35 cm compatible with
proctosigmoiditis. Lot of stool with mixed ? blood seen at 40
cms. We could not advance beyond this point. Otherwise normal
sigmoidoscopy to 40 cm. Recommendations: Follow-up biopsy
results. The findings explain the blood. Patient would need full
colonoscopy at some point as an outpatient. Continue Ceftriaxone
and Doxycycline for presumptive treatment for
Gonorrhea/Chlamydia. Follow-up on rectal swabs for gonorrhea and
chlamydia. Follow-up on stool cultures, HSV viral cultures. Send
ova and parasites. Will follow closely with you.
Brief Hospital Course:
HOSPITAL SUMMARY: ___ with history of seizure disorder and mood
disorder who presented with a ___ day history of nausea,
vomiting, bloody diarrhea and abdominal pain 3 days after
receptive anal intercourse with a new partner. ___ by CT
consistent with proctocolitis. The ID and GI services were
contacted by phone on admission; the patient was started on
ceftriaxone and doxycycline to cover most common
sexually-transmitted infections and was observed for
improvement. However, after 48 hours on antibiotics, he was
still having liquid, grossly bloody stool so formal ID and GI
consults were called. Multiple laboratory studies were sent to
try to identify an etiology, but all were either negative or
pending at the time of discharge. In addition, he underwent
flexible sigmoidoscopy showing ulceration of large areas of the
rectum and distal sigmoid colon as above. No changes were made
to his treatment regimen, and he slowly improved over the next
___ days. Hematocrit remained stable throughout, and he was no
longer having bloody stool and only minimal abdominal pain at
the time of discharge. A family meeting was held at discharge
with the patient's mother and an interpreter present to ensure
all discharge instructions were well-understood.
ACTIVE ISSUES:
# PROCTOCOLITIS: In this young man who has recently had
unprotected receptive anal intercourse with a new partner, the
most likely etiology was felt to be an STD; the most common
organisms in this setting are HSV, N. gonorrhoeae, C.
trachomatis, and T. pallidum. His cousin, from whom he was felt
likely to have contracted an infection, is also originally from
___ but has been living in ___. for a
number of years. The patient reported that his cousin had been
asking him numerous questions about STDs prior to their sexual
encounter, and he was concerned in retrospect that his cousin
may have had one of these illnesses. Initial STD studies were
negative as above; stool studies were chiefly pending at the
time of discharge (negative AFB smear and C. difficile toxin).
Given his clinical improvement, he was planned to complete a
10-day course of ceftriaxone (converted to cefpodoxime at
discharge) and to continue doxycycline until follow up at
___ clinic (LGV should be treated with a 3-week
course of doxycycline; if LGV send-out studies are negative on
follow up and he is clinically well, this medication can likely
be stopped).
# SOMNOLENCE: The patient was frequently noted to be somnolent
on exam. He was generally able to be aroused and answer
questions appropriately, but there were repeated instances of
having to wake him continually to answer questions. He takes
high doses of antiepileptics which can be sedating, and by his
history he often stays awake at night and sleeps during the day.
His outpatient providers (PCP ___ neurologist Dr.
___ were contacted regarding this behavior and both reported
he was occasionally sleepy during office visits as well. His
dilantin and phenobarbital levels were checked and found to be
therapeutic, so no changes were made to his medications. Tox
screen was noted to be negative. He was awake and alert
throughout periods of each day, and was alert at the time of
discharge. The somnolence was felt most likely to be normal for
this patient (possibly related to sedating medications).
# SOCIAL ISSUES: The patient was followed closely by social work
during this admission. Given his cognitive impairment, there was
significant concern for the possibility of further sexual
assault/abuse by his cousin. The patient requested that no
information about his sexual encounter with his cousin be
communicated to his family, as he felt the news would make his
mother (who visited frequently) very upset. However, this case
was reported to the ___, who will conduct an investigation as
appropriate. The patient was counseled about the reasons for
this decision, and was accepting. The floor social worker
contacted the patient's outpatient therapist and explained the
circumstances of this admission. He will follow up with his
outpatient therapist to further address his emotional response
to this sexual assault (patient was having conflicting emotions
and in the early stages of processing at the time of dischrage).
INACTIVE ISSUES:
# SEIZURE DISORDER: Secondary to TBI at age ___. Last seizure
___. Outpatient neurologist Dr. ___ was contacted
regarding this admission. Continued Vimpat 200 mg PO BID,
Phenobarbital 130 mg PO QHS, Phenytoin sodium extended 400 mg
QHS.
# MOOD DISORDER NOS: Patient reports mood is stable. Zyprexa 15
mg PO QHS continued.
# ALLERGIES: No active symptoms. Fluticasone 50 mcg NS 2 puffs
puff qd right and left PRN.
TRANSITION OF CARE:
- If concern for syphilis remains present on follow up, RPR
should be repeated ___
- Dr. ___ check LGV serologies (pending at the time of
discharge) on follow up; if these are negative, doxycycline can
be stopped
- Dr. ___ follow stool and other micro studies (pending at
the time of discharge)
- Patient will follow up with his outpatient therapist (alerted
to this admission by ___ of ___) regarding sexual
assault by his cousin
- ___ will conduct investigation into this incident given
patient's cognitive impairment
- He will follow up with gastroenterology in early ___ may
need full colonoscopy as outpatient
- He will NOT need ___ clinic follow up unless any tests return
positive that will require specific consultation
- CONTACT: Mother will serve as emergency contact but only
speaks ___: ___ ___
- CODE: Full code
Medications on Admission:
- Zyprexa 15 mg PO QHS
- Calcium 500 + D 500 mg (1,250 mg)-400 unit PO three times a
day
- Vimpat 200 mg PO BID
- Phenobarbital 130 mg PO QHS
- Docusate sodium 100 mg ___ capsule BID PRN (took ___ today)
- Phenytoin sodium extended 400 mg QHS
- Fluticasone 50 mcg NS 2 puffs puff qd right and left
Discharge Medications:
1. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO twice a day
for 9 doses.
Disp:*9 Tablet(s)* Refills:*0*
2. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 8 days.
Disp:*16 Capsule(s)* Refills:*0*
3. olanzapine 5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
4. lacosamide 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. phenobarbital 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. phenobarbital 30 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. phenytoin sodium extended 100 mg Capsule Sig: Four (4)
Capsule PO HS (at bedtime).
8. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
- Proctocolitis
SECONDARY:
- Seizure disorder
- Traumatic brain injury (in childhood)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___ with symptoms of abdominal pain and
blood in the stool. We feel that your symptoms are most likely
due to an infection. You have been treated with antibiotics to
cover the likely cause(s) of your infection. You will need to
follow up with your primary care doctor's office and with
gastroenterology.
We have made the following changes to your medication regimen:
- CONTINUE doxycycline until you see Dr. ___
- CONTINUE cefpodoxime until ___ (last dose in the evening)
Please take your medications as prescribed and follow up with
your doctors as below.
Followup Instructions:
___
|
10893121-DS-9
| 10,893,121 | 29,390,904 |
DS
| 9 |
2183-03-03 00:00:00
|
2183-03-03 16:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Increased Seizure Frequency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with complex partial and at times secondarily generalised
epilepsy possibly secondary to a TBI age ___ ___
was previously well controlled on lacosamide, phenytoin and
phenobarbital, mild intellectual disability, h/o depression with
psychosis and h/o alcohol abuse presents with increased seizure
frequency after 3 seizures (at least one of these was a complex
partial seizure and report of others was of GTC) today with his
last seizure before this in ___.
The patient had been well controlled on his AEDs and had no
breakthrough seizures since ___ when he had several events in
the setting of medication non-compliance. He has recently been
treated with swab proven chlamydia after noting penile discharge
on ___. He was in his usual state of health until today
when he was at his ___ clinic when he had 1 typical
seizure in the clinic and another in the waiting room.
Unfortunately I have no further information about the semiology
of these although they were described as GTC. The events were
self-limiting of unclear duration and he was not given
lorazepam. He was sent to the ___ ED and here he then had a
third seizure at roughly 17:55 in the ED triage which was
described to me by the nurses. ___ stated that he had initial
left arm flexion and posturing followed by head and gaze
deviation to the right and left arm flexion with shaking of the
left arm. This lasted for 30 seconds. On assessment in the ED he
was post-ictal but able to give a history.
He denies any provocative factors including no recent infections
save the chlamydia treated with ceftriaxone and ceftriaxone and
no fevers or chills. He claims that he has been taking all his
AEDs at the correct doses. Denies poor sleep save restless at
times but not worse recently and denies other recent medication
changes. He notes no sick contacts. He was drowsy but able to
communicate well at my assessment. He did note some pain with
urination in his abdomen last night and some increased urinary
frequency recently.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation.
No recent change in bowel habits. Denies arthralgias or
myalgias. Denies rash.
Past Medical History:
- Seizure disorder. Secondary to TBI after fell off a wall age
___. Since childhood, difficult to control in the past, now with
excellent control with Dilantin, phenobarbital and Vimpat
(Keppra, Tegretol, and Depakote not previously helpful). Last
seizure ___ in the setting of not taking his AEDs after which
he was admitted to the epilepsy service and nne since. He has a
past history of poor medication compliance.
- Mental retardation - Mild, fairly high functioning but never
employed.
- Depression/psychosis. Developed psychosis in ___, previously
well-controlled on olanzapine. Followed by Cognitive Neurology
and psychiatry at ___. Per psychiatry no longer on olanzapine
and will observe for return of delusional symptoms.
- PPD-positive s/p INH for one year, ___.
- History hematuria/hematospermia. In ___, no recurrence.
- h/o proctocolitis. In ___, likely infectious, no BRBPR
or diarrhea since then.
- h/o STDs with gonorrhea ___ and chlamydia and treated with
IM ceftriaxone and po azithromycin for chlamydia swab positive
___ after penile discharge with negative RPR amnd
gonorrhoea. Patient HIv negative ___.
- s/p inguinal hernia repair ___
Epilepsy history:
- Patient had a TBI age ___ and seizures since childhood.
Social History:
___
Family History:
Both parents are alive and general healthy. His mother suffers
from some problems with her vision and chronic constipation. He
has a brother and a sister, both healthy.
Physical Exam:
Vitals: T:98.4 P:69 R:18 BP:118/75 SaO2:99% RA
General: Awake, cooperative, drowsy but attentive.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Full range of motion save slight limitation on rotation to the
right. No meningismus.
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: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Calves SNT bilaterally.
Skin: no rashes or lesions noted.
Neurological examination:
- Mental Status:
Somewhat post-ictal and drowsy.
ORIENTATION - Alert, oriented x person, place and time
The pt. knew president is ___.
SPEECH
Able to relate history without difficulty and recalls his
seizures.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors.
Speech was not dysarthric.
NAMING Pt. was able to name both high and low frequency objects.
READING - Able to read without difficulty
ATTENTION - Attentive, able to name ___ backward without
difficulty and difficulty with ___.
REGISTRATION and RECALL
Pt. was able to register 3 objects and recall ___ at 5 minutes.
COMPREHENSION
Able to follow both midline and appendicular commands
There was no evidence of apraxia or neglect
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 3mm and brisk. VFF to confrontation.
Funduscopic exam reveals no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI without nystagmus. Slightly jerky pursuits and
normal saccades.
V: Facial sensation intact to light touch. Good power in muscles
of mastication.
VII: No facial weakness, 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 with normal velocity movements.
- Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
SAb SAdd ElF ElE WrE FFl FE IO HipF HipE KnF KnE AnkD ___
L 5 5 ___ ___ 5 ___ ___
R 5 5 ___ ___ 5 ___ ___
- Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout in UE and ___. No
extinction to DSS.
- DTRs:
BJ SJ TJ KJ AJ
L ___ 1 0
R ___ 1 0
There was no evidence of clonus.
___ negative.
Plantar response was flexor bilaterally.
- Coordination: No intention tremor, normal finger tapping. No
dysdiadochokinesia noted. No dysmetria on FNF or HKS
bilaterally.
- Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without undue difficulty. Romberg
absent.
DISCHARGE EXAM:
- More awake alert, remainder of examination unchanged.
Pertinent Results:
___ 09:00PM URINE bnzodzpn-NEG barbitrt-POS opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-TR
___ 09:00PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 09:00PM URINE MUCOUS-MOD
___ 06:45PM ALT(SGPT)-57* AST(SGOT)-47* ALK PHOS-167* TOT
BILI-0.2
___ 06:45PM ALT(SGPT)-57* AST(SGOT)-47* ALK PHOS-167* TOT
BILI-0.2
___ 06:45PM ALBUMIN-4.9 CALCIUM-9.2 PHOSPHATE-3.2
MAGNESIUM-2.1
___ 06:45PM PHENOBARB-17.8 PHENYTOIN-7.3*
___ 06:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-POS tricyclic-NEG
___ 06:45PM WBC-6.1 RBC-5.45 HGB-16.7 HCT-47.3 MCV-87
MCH-30.6 MCHC-35.2* RDW-12.8
___ CXR IMPRESSION: No acute cardiopulmonary process
___ 06:30AM BLOOD Phenoba-15.0 Phenyto-25.0*
___ 12:03AM BLOOD Phenyto-21.7*
Brief Hospital Course:
ASSESSMENT: The patient presents with breakthough seizures with
a subtherapeutic phenytoin level. He has a past history of
medication non-compliance but states that he has been taking his
correct AED doses. It is unclear how acutely his phenytoin level
has dropped as it was last checked on our system in ___.
# NEURO:
The patient was loaded with IV fosphenytoin with good effect
increasing his PHT level to 25. No further ictal activity was
noted. He will return for labs on ___.
# ID:
No infectious source was identified.
Medications on Admission:
Medications - Prescription
FLUTICASONE - fluticasone 50 mcg/actuation Nasal Spray, Susp. 2
puffs(s) puff qd right and left1 Pt uses as needed -
(Prescribed
by Other Provider) (Not Taking as Prescribed)
LACOSAMIDE [VIMPAT] - Vimpat 200 mg tablet. 1 Tablet(s) by mouth
twice a day
PHENOBARBITAL - phenobarbital 100 mg tablet. 1 Tablet(s) by
mouth
at night
PHENOBARBITAL - phenobarbital 30 mg tablet. 1 Tablet(s) by mouth
at bedtime along with the 100 mg tablet
PHENYTOIN SODIUM EXTENDED - phenytoin sodium extended 100 mg
capsule. 4 Capsule(s) by mouth every night at bedtime
TRAZODONE - trazodone 50 mg tablet. ___ Tablet(s) by mouth at
bedtime
Medications - OTC
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 WITH D] - Calcium 500
With D 500 mg (1,250 mg)-400 unit tablet. 1 tablet(s) by mouth
twice a day
DOCUSATE SODIUM - docusate sodium 100 mg capsule. ___ Capsule(s)
by mouth once to twice daily Pt uses as needed - (Prescribed by
Other Provider) (Not Taking as Prescribed)
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary:
- Seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were evaluated at ___ for
your increase in seizure frequency which is in the setting of
antibiotic treatment. It is possible that your use of a
cephalosporin antibiotic, Rocephin(ceftriaxone), which was
administered intramuscularly may have transiently decreased your
seizure threshold resulting in your breakthrough seizures.
We recommended no changes to your anti-epileptic regimen; you
were given an additional dose of medication to increase your
blood level of the Phenytoin to theraputic.
Followup Instructions:
___
|
10893500-DS-11
| 10,893,500 | 24,599,208 |
DS
| 11 |
2171-12-09 00:00:00
|
2171-12-09 06:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
tetracycline
Attending: ___.
Chief Complaint:
Saw injury to the left thumb resulting in near complete
amputation of the left thumb at the level of the interphalangeal
joint
Major Surgical or Invasive Procedure:
___. ___: Open reduction and internal fixation
with repair of the extensor pollicis longus and flexor pollicis
longus, as well as repair of the radial digital nerve with
allograft and revascularization of the right thumb via vein
graft to the radial digital artery of the left thumb
History of Present Illness:
___ is a ___ year old male RHD who presents with L
thumb circular saw injury. Patient works as a ___
___
and was at work when his hand slipped while working with a
circular saw cutting a piece of wood resulting in a near
circumferential laceration of the L thumb. Patient has no
sensation at the distal thumb and no ability to flex or extend
the digit. His last meal was around 10:30am today.
Past Medical History:
Hidradenitis
Social History:
___
Family History:
NC
Physical Exam:
Gen: NAD, A&Ox3
HEENT: Normocephalic.
CV: RRR
R: Breathing comfortably on room air. No wheezing.
Ext: LUE in bulky dressing. Thumb tip exposed, warm, pink with
good capillary refill, K-wire in place.
Pertinent Results:
___ 06:48AM BLOOD WBC-7.7 RBC-3.97* Hgb-12.1* Hct-37.2*
MCV-94 MCH-30.5 MCHC-32.5 RDW-11.9 RDWSD-41.4 Plt ___
___ 01:04PM BLOOD WBC-8.2 RBC-4.73 Hgb-14.4 Hct-43.1 MCV-91
MCH-30.4 MCHC-33.4 RDW-11.9 RDWSD-39.5 Plt ___
___ 01:04PM BLOOD Neuts-56.9 ___ Monos-6.1 Eos-1.6
Baso-0.5 Im ___ AbsNeut-4.65 AbsLymp-2.81 AbsMono-0.50
AbsEos-0.13 AbsBaso-0.04
___ 06:48AM BLOOD Plt ___
___ 01:04PM BLOOD Plt ___
___ 01:04PM BLOOD ___ PTT-28.6 ___
___ 01:04PM BLOOD Glucose-89 UreaN-18 Creat-0.8 Na-144
K-4.1 Cl-104 HCO3-24 AnGap-16
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the hand surgery team. The patient was found to
have near complete amputation of the left thumb at the level of
the IP joint status post saw injury and was admitted to the hand
surgery service. The patient was taken to the operating room on
___ for open reduction internal fixation, with extensor
pollicis longus and flexor pollicis longus repair, as well as
repair of the radial digital nerve with allograft, and
revascularization of the radial digital artery via vein graft to
the left thumb, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The ___ 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
nonweightbearing to the left hand, and will be discharged on
aspirin 162 mg daily for 4 weeks for DVT prophylaxis. The
patient will follow up in the Hand Fellow's Clinic 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:
Remicade
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth five times daily
Disp #*60 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice daily Disp #*14 Tablet Refills:*0
3. Aspirin 162 mg PO DAILY Duration: 30 Days
RX *aspirin 81 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 to 2 tablet(s) by mouth every 4 hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Saw injury to left thumb through PIP joint
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER HAND/UPPER EXTREMITY SURGERY:
- You were in the hospital for upper extremity surgery. It is
normal to feel tired or "washed out" after surgery, and this
feeling should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing to the left hand
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.
DO NOT DRINK CAFFEINE OR EACH CHOCOLATE FOR THE NEXT MONTH
ANTICOAGULATION:
- Please take aspirin 162 mg daily for 4 weeks
WOUND CARE:
- You may shower but be very mindful to keep your dressings dry
at all times. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
-Dressings to be left on until follow up appointment unless
otherwise instructed
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Followup Instructions:
___
|
10893584-DS-6
| 10,893,584 | 28,523,029 |
DS
| 6 |
2142-01-10 00:00:00
|
2142-01-11 09:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dysarthria and gait unsteadiness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year-old right-handed man with HTN, HLD,
DM, CKD, prior TIAs from R carotid stenosis, recently admitted
to
___ ___ for R CEA which complicated by post-surgical stroke who
presents today with dysarthria and gait unsteadiness concerning
for new infarct/TIA.
The patient has known symptomatic R carotid stensosis, with
multiple prior episodes of slurred speech and LUE weakness felt
consistent with TIAs. He was recently admitted to ___
___ with transient LUE weakness and slurred speech that
resolved over hours. During that admission critical R carotid
stenosis was found and vascular surgery consult was obtained
for
a CEA which he underwent on ___. After that procedure the
patient had transient LUE numbness and slurred speech (details
not clearly noted on transfer documents) that were felt to be
due
to a new post-operative stroke. The symptoms improved and he
was
placed on ASA 81mg, atorvastatin 80mg and discharged. Of note,
was also found on TEE with a PFO with interatrial septal
aneurysm
but no apparent discussion of anticoagulation is documented in
the Discharge Summary.
The patient presents today because of new onset dysarthria, left
facial droop and gait instability. Earlier today around noon
his
son noted that his speech seemed slightly abnormal, perhaps
slightly slower than usual. The patient notes that symptoms
started at 10PM when he got out of bed to try to go to the
bathroom. He had significant gait instability with weakness of
the bilateral legs, and severe dysarthria was evident when he
spoke to his wife. EMS was alerted and he was taken urgently to
___. Telestroke evaluated him this evening and found
NIHSS-4 (left facial asymmetry-1, dysarthria-1, and bilateral
leg
drift-2). He was out of the window for tPA and his recent
post-CEA stroke was felt to be a contraindication. CTA could
not
be done due to creatinine 1.9 (baseline 1.4-2.2). He was given
a
full dose aspirin transferred to ___ for further workup.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
comprehending speech. No bowel or bladder incontinence or
retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- HTN
- HLD
- DM
- CKD (creatinine 1.9)
- PFO with anteratrial aneurysm
- prior TIAs from presumed R carotid stenosis
Social History:
___
Family History:
No family history of stroke.
Physical Exam:
Admission Physical Exam:
Vitals: 97.7 64 125/87 16 98% 2L
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: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. There were no paraphasic errors. Pt was able to
name both high and low frequency objects. Able to read without
difficulty. Speech was severely dysarthric. Able to follow both
midline and appendicular commands. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Left NLF flattening.
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.Slight left
pronation/drift.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___- 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2 3 3 0
R 2 2 2 2 0
Plantar response was flexor with withdrawal bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Deferred
##############################################
Discharge Physical Exam:
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Attentive, followed
commands without asking for clarification. Language is fluent,
no paraphasic errors. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Left NLF flattening.
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. Slight left pronation, no
drift noted.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2 3 3 0
R 2 2 2 2 0
Plantar response was flexor with withdrawal bilaterally.
-Coordination: No intention tremor noted. No dysmetria on FNF
bilaterally.
-Gait: Deferred
Pertinent Results:
___ 05:25AM BLOOD WBC-10.1 RBC-4.51* Hgb-14.3 Hct-43.4
MCV-96 MCH-31.8 MCHC-33.0 RDW-14.1 Plt ___
___ 04:40AM BLOOD ___ PTT-31.2 ___
___ 05:25AM BLOOD Glucose-131* UreaN-22* Creat-1.6* Na-143
K-4.2 Cl-106 HCO3-27 AnGap-14
___ 05:25AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:25AM BLOOD CK(CPK)-49
___ 05:25AM BLOOD Calcium-8.5 Phos-2.3* Mg-1.9 Cholest-120
___ 05:25AM BLOOD TSH-2.8
___ 05:25AM BLOOD Triglyc-184* HDL-36 CHOL/HD-3.3
LDLcalc-47
___ 05:25AM BLOOD %HbA1c-10.6* eAG-258*
Brief Hospital Course:
___ is a ___ year-old right-handed man with HTN, HLD,
DM, prior TIAs from R carotid stenosis, recent R CEA, presented
with dysarthria and gait unsteadiness, with noted left facial
droop, dysarthria and slight LUE weakness on exam. He was
admitted for MRI/MRA to evaluate for possible re-stenosis or
carotid thrombus following R CEA earlier this month.
Unfortunately, given bullet fragments found in left hand as a
part of MRI safety screening, patient was unable to undergo MRI
scan while inpatient. He plans to follow up with a neurologist
closer to home, who will evaluate his last MRI done earlier this
month. CT head was performed, which showed calcifications along
the vertex, no evidence of acute intracranial hemorrhage, mass
effect or large territorial infarction, and hypodensity in the L
lentiform nucleus, likely old lacunar infarct.
His home HTN med nifedipine was held while inpatient to allow
his BP's to auto-regulate, with SBP's up to the 190's.
Nifedipine XR 90mg daily was restarted prior to discharge.
Bedside swallow study found difficulty with thin liquids. Video
swallow study performed on ___, pending read.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? (x) Yes (LDL =
47) - () No
5. Intensive statin therapy administered? () Yes - (x) No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? (x) Yes - () No [if no,
reason: () non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? x() Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (ASA) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - (x) N/A
Medications on Admission:
1. aspirin 81mg daily
2. atorvastatin 80mg daily
3. losartan 100mg daily
4. nifedipine XL 90mg daILY
5. LASIX 20MG DAILY
6. Humalog 50/50
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. NIFEdipine CR 90 mg PO DAILY
5. Outpatient Physical Therapy
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
TIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory with assistance, has home ___.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of trouble speaking and
left arm 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.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are: hypertension, hyperlipidemia,
prior TIA's from right carotid stenosis, recently repaired.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
10893880-DS-6
| 10,893,880 | 23,686,366 |
DS
| 6 |
2162-08-06 00:00:00
|
2162-08-11 20:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Wellbutrin
Attending: ___.
Chief Complaint:
Intractable vomiting
Major Surgical or Invasive Procedure:
Gastric emptying study
Nasogastric tube placement
History of Present Illness:
Ms. ___ is a ___ year old female with history of diabetes,
depression, hypertension and obesity who re-presented with
intractable vomiting and wretching. Patient was just discharged
the day prior to this re-admission (admitted ___ after
intractable wretching with minimal vomiting in the ED. The
workup from that previous admission demonstrated a negative
workup and benign abdominal exam. Her symptoms had resolved soon
after arrival to the floor. In the ED, she received 4mg IV
Ondansetron x 2, 1 mg Lorazepam IV, 10mg IV Metoclopramide, and
Benadryl 25mg IV x 1. Post-discharge, per the patient's mother,
the patient had one loose stool the morning of admission, ate a
piece of toast with peanut butter, and then again began
wretching and vomiting. She denied fever, chills, dysuria, or
hematuria.
The patient has no history of abdominal surgery, and has never
had episodes like this prior to just a few days ago. She also
reports taking her depression medications as prescribed, and
currently denies any suicidal/homicidal ideation. Patient passed
a few loose stools the day in between admissions.
In the ED, her initial vitals were: Temp 98.2, BP 154/88, HR 72,
RR 16, SpO2 99% RA. Her labs were significant for WBC 11.6 and
Alk phos 119. EKG demonstrated normal sinus rhythm without
ischemia. She received Ondansetron x2, Lorazepam x2, and
Droperidol x1. She was unable to tolerate any PO, and was
transferred to the floor for further evaluation and management.
Upon transfer, her vital signs were: Temp 98.2, BP 160/86, HR
63, RR 16, SpO2 99% RA. On the floor, the patient was still
vomiting, and was noted to have abdominal pain from wretching.
Past Medical History:
ADULT ONSET DIABETES MELLITUS ___
--On Lantus, Metformin, last HgA1c 9.4%
DEPRESSION ___
--history of multiple psychiatric hospitalizations, non since
age ___
HYPERCHOLESTEROLEMIA ___
--declines statin
IMPULSE CONTROL ___
history of INSOMNIA
sleeps during the day and not at night. Refuses sleep studies.
No success with trazadone or ambien in the past
history of IRON DEFICIENCY ANEMIA ___
history of IRREGULAR MENSTRUATION
ISOLATED ELEVATION OF ALK PHOS ___
MAJOR DEPRESSION ___
OBESITY --referral to gastric bypass attempted in the past and
not covered by insurance
TEETH PAIN
--pt has not had regular teeth care in many years
--she has significant anxiety around dentists and wishes to be
sedated for routine dental care
HYPERTENSION
Social History:
___
Family History:
Her mother had diabetes.
Physical Exam:
On admission:
Vitals - T: 97.8 159/71 64 20 100RA BS 176
GENERAL: NAD
HEENT: AT/NC, EOMI
NECK: 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: Some RUQ tenderness, nondistended, +BS, nontender in
all quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
On discharge:
Vitals- Tmax 99.3 Tcurr 98.4 BP 102/57 (103-158/64-85) HR 93
(72-90) RR 18 (___) SpO2 100% RA (98-100% RA)
GENERAL: Sitting up, conversant, no emesis in bedside basin
HEENT: AT/NC, EOMI
NECK: 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: Soft, non-tender throughout, non-distended, +BS, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP Pulses bilaterally
Pertinent Results:
On admission:
___ 05:15PM BLOOD WBC-11.6* RBC-5.00 Hgb-12.8 Hct-40.2
MCV-81* MCH-25.7* MCHC-31.9 RDW-13.7 Plt ___
___ 05:15PM BLOOD Neuts-82.9* Lymphs-11.5* Monos-3.6
Eos-1.8 Baso-0.3
___ 05:15PM BLOOD Plt ___
___ 05:15PM BLOOD ___ PTT-23.0* ___
___ 05:15PM BLOOD Glucose-178* UreaN-13 Creat-0.7 Na-140
K-3.4 Cl-102 HCO3-25 AnGap-16
___ 05:15PM BLOOD ALT-28 AST-35 AlkPhos-119* TotBili-0.4
___ 05:15PM BLOOD Albumin-4.2
___ 05:15PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
On discharge:
___ 07:00AM BLOOD WBC-8.7 RBC-5.18 Hgb-13.3 Hct-41.4
MCV-80* MCH-25.8* MCHC-32.2 RDW-14.2 Plt ___
___ 07:00AM BLOOD Glucose-176* UreaN-10 Creat-0.8 Na-137
K-3.3 Cl-100 HCO3-26 AnGap-14
___ 07:00AM BLOOD ALT-15 AST-14 AlkPhos-103 TotBili-0.6
___ 07:00AM BLOOD Albumin-3.8 Calcium-9.3 Phos-4.0 Mg-2.1
Microbiology:
None
Imaging:
Abdominal X-ray (___):
FINDINGS:
The bowel gas pattern is unremarkable with gas seen in
nondistended loops of large and small bowel. There is no
evidence of ileus or obstruction. The bony structures are
unremarkable.
IMPRESSION:
Non-obstructive bowel gas pattern.
RUQ ultrasound (___):
IMPRESSION:
1. Small amount of sludge in the gallbladder but no focal
shadowing stones nor evidence of cholecystitis.
2. Fatty liver. More advanced forms of chronic liver disease
such as significant fibrosis and cirrhosis cannot be excluded by
ultrasound.
Gastric emptying study (___):
FINDINGS:
Residual tracer activity in the stomach is as follows:
At 30 mins 83% of the ingested activity remains in the stomach.
IMPRESSION:
No emptying of the liquid meal over 30 minutes.
CXR (___):
IMPRESSION:
Heart size and mediastinum are stable. The last image
demonstrates the NG tube tip being in the stomach. No pleural
effusion or pneumothorax.
CT abdomen/pelvis with IV contrast (___):
IMPRESSION:
Fatty liver. Otherwise normal CT of the abdomen and pelvis. No
explanation for the patient's vomiting.
Brief Hospital Course:
Ms. ___ is a ___ y/o female with diabetes mellitus type II,
complicated by an element of dietary non-compliance,
hypertension, hyperlipidemia, obesity, and depression,
re-presenting with intractable vomiting (non-bilious,
non-bloody) of unknown etiology.
#Intractable vomiting, nausea: The etiology of the patient's
vomiting on presentation was unclear. She is of childbearing
age, but a urine beta-HCG this admission and on the prior
admission were both negative. An infectious or inflammatory
etiology such as gastritis or gastroenteritis were considered,
but did not seem to explain the severity and persistence of her
symptoms. Diabetic gastroparesis was strongly considered, given
her history of poor compliance with dietary recommendations. Of
note, she does have a history of isolated elevated alkaline
phosphatase (again of unknown etiology). As preliminary studies,
she received a right upper quadrant ultrasound, which
demonstrated a small amount of sludge in the gallbladder, and a
fatty liver, neither of which were conclusive in terms of her
current presentation (see Pertinent Results), and also do not
point towards an obstructive pathology for the elevated alkaline
phosphatase. She also received an abdominal X-ray, showing a
non-obstructed bowel gas pattern. The following morning, she
received a gastric emptying study, which demonstrated no
empyting of a liquid meal over 30 minutes. (Patient was unable
to tolerate the full breakfast normally administered for a
gastric emptying study, and only received radiolabeled water.)
Based on these findings, patient was thought to have
gastroparesis. Due to increased wretching post-study, patient
had a ___ tube placed, but it was discontinued hours
later due to lack of improvement in symptoms. She was started on
10 mg of Metoclopramide qACHS (4 times a day). She was observed
over the course of the next 2 days, progressed to tolerating
portions of a diabetic/heart healthy regular diet, and was
discharged home on the same Reglan schedule that was started
in-house.
Over the course of her stay, her nausea was treated with
Ondansetron, Promethazine, and Lorazepam. Her EKGs were
monitored daily for QTc interval prolongation.
#Diabetes mellitus type II: The patient's last documented
hemoglobin A1c was 9.4% on ___. Fluids containing dextrose
were avoided during this hospitalization. Her home dose of
metformin was switched to a Novolog sliding scale in house, and
due to her poor PO intake, her Lantus dinnertime dose was
decreased to 35 units while she was admitted. Her Lantus was
increased at discharge to 45 units, and dosing can be
re-assessed by her primary care physician at her next follow-up
visit, taking into consideration her PO tolerance.
#Depression: Patient had been taking her home Sertraline as
prescribed, except the past few days prior to admission when she
was unable to tolerate her PO pills. In-house, she was stable
and denied SI/HI. Sertraline was continued at 50 mg PO qday.
#Hypertension: Patient's blood pressures in-house were as high
as 160s-180s, likely due to anxiety and intractable wretching.
Her blood pressures were not treated this admission, and she did
not come in on any home anti-hypertensives prior to this stay.
TRANSITIONAL ISSUES:
- She is discharged on a standing Reglan regimen, with a 14-day
supply, following discussion of risks and benefits, with plan to
readdress ongoing need for standing Reglan in the outpatient
setting.
- She was also discharged on Pantoprazole 40 mg PO qday, for
possible contribution to her episodes of emesis from GERD.
- QTc was essentially stable at 453 at discharge on Reglan, and
she may benefit from reevaluation of QTc on outpatient
follow-up.
- Potassium was low-normal (3.3) at discharge, and she may
benefit from repeat electrolyte check at follow-up; she was
encouraged to eat a diet rich in fruits and vegetables.
-Patient discharged on 45 units of Glargine at dinnertime;
decrease from home regimen of 56 units due to decreased PO
intake in-house requiring less insulin. Patient will benefit
from re-evaluation of this decreased dosing regimen, and
possible need to re-introduce her previous dosing, once she
resumes a regular, diabetic gastroparesis diet after this
admission.
- Pending studies: None
- Code Status: Full (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 50 mg PO DAILY
2. MetFORMIN (Glucophage) 500 mg PO DAILY
3. Glargine 56 Units Dinner
Discharge Medications:
1. Sertraline 50 mg PO DAILY
2. MetFORMIN (Glucophage) 500 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Metoclopramide 10 mg PO QIDACHS
Please take one tablet 30 minutes before each meal, and one at
bedtime.
RX *metoclopramide HCl 10 mg 1 tablet by mouth four times a day
Disp #*56 Tablet Refills:*0
5. Glargine 45 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Diabetic gastroparesis
Secondary:
Diabetes mellitus type II
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care during your hospital
admission to ___. You were
admitted for episodes of vomiting that would not go away. You
were previously admitted for similar symptoms just prior to this
admission. While you were admitted this time, you had an
abdominal x-ray, which showed no evidence of blockage in your
bowels. You also had an abdominal ultrasound that was
reassuring. A CT of your abdomen showed no signs of infection. A
study to determine the speed of transit of food through your
stomach showed some delay, raising concern for slowing of
transit due to changes from diabetes (diabetic gastroparesis).
You were treated with nausea medications, as well as a
medication called Reglan to help your stomach pass food along at
a more normal rate. You tolerated this medication well, and you
were also eating a regular diet and tolerating it without nausea
on the morning of your discharge. As your potassium level is
low-normal at discharge, please eat a diet rich in fruits and
vegetables, including bananas and oranges, at discharge.
Followup Instructions:
___
|
10893933-DS-10
| 10,893,933 | 26,541,007 |
DS
| 10 |
2187-01-03 00:00:00
|
2187-01-03 16:13:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Abdominal pain, Nausea/Vomiting
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Adhesiolysis.
3. Small-bowel resection.
History of Present Illness:
___ with history of malrotation and intusussception as infant
which to her recollection was reduced without operation and who
has since had multiple episodes of SBO, 3 of which required
lysis of adhesions at age ___, ___ now presents with recurrent
SBO. She was admitted in ___ and ___ for the same issue,
both times resolving with bowel rest and NGT decompression.
Symptoms this time were similar to her prior episodes, starting
with abdominal pain around 10pm ___, crampy in nature, then
with multiple large volume bouts of non-bilious emesis. No
hematemesis. No recent illness, fevers, chills. Reports loose
stools earlier this evening, but no flatus or BM since arrival
to ED. Feels a bit better presently.
Past Medical History:
Congenital malrotation
Recurrent small bowel obstructions
Lower extremity varicosities
Benign parotid gland tumor (right), status post resection
Fibroids
Thyroid Nodule
PSH:
To best of her recollection (at ___:
___ old - reduction of intussusception (CHB)
___ years-old - first SBO -> LOA and appendectomy (CHB)
___ years-old - SBO -> LOA
___ years-old - SBO -> LOA
Right parotid gland benign tumor removal (Mass Eye and Ear)
Left lower extremity microphlebectomy
Social History:
___
Family History:
Brother - ulcerative colitis
Sister - breast ca x2 in ___ (both breasts), BRCA I/II negative;
hypothyroidism
Father - ___ lymphoma, deceased age ___, prostate cancer
Paternal grandfather - heart disease
___ grandfather - heart disease
Physical Exam:
Admission PE:
T98.8, HR 84, BP 110-150/60-70, SpO2 99-100% on RA
GEN: NAD, AAOx3
HEENT: trachea midline
CV: S1S2 RRR
PULM: CTAB
ABD: soft, mild distension, mild tenderness to deep palpation of
lower abdomen, no rebound, no guarding, well-healed upper
transverse incision and right paramedian incision from prior
surgeries, no hernias appreciated
BACK: no CVA tenderness
EXTR: ROM intact, warm, no edema
Discharge PE:
Vitals: Temp 98.2 PO, BP 128/68, HR 85, RR 18 O2sat 99% RA
GEN: NAD, A&O
CV: RRR
PULM: CTAB, normal WOB
ABD: soft, non-tender/non-distended, midline incision with
staples is clean dry and intact, without erythema or induration,
no rebound or guarding
EXTR: WWP, no CCE
Pertinent Results:
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 3:19 AM
IMPRESSION:
1. Multiple dilated loops of small bowel with a transition point
dentified in the right lower quadrant, very similar to prior
examinations. Small bowel wall enhances normally. No free
fluid or free air in the abdomen or pelvis.
Brief Hospital Course:
Ms. ___ is a ___ year-old Female who presented to the ED
___ with complaints of bloating and acute abdominal pain. CT
was consistent with SBO and a transition point in the right
lower quadrant. The patients history is notable for 3 prior
episodes of SBO the preceding year and a history of malrotation
and multiple pediatric abdominal procedures. An NGT was placed
with clear output and the patient was made NPO with IV fluids.
On review of imaging, it was felt that adhesions and not
malrotation were likely the etiology of her SBO and after
explanation of the risks and benefits of the procedure, the
patient gave informed consent for diagnostic laparoscopy,
possible small bowel resection, possible laparotomy, and
adhesiolysis to be performed the following ___. HD 2 the
patient passed gas, her NGT was removed, and she was given a
clear liquid diet which she tolerated. HD 5 she was taken to
the OR for underwent exploratory laparotomy, adhesiolysis, and
small-bowel resection. An epidural was also placed
preoperatively. POD 1 the patient's SBP dipped to the ___. Her
epidural rate was reduced, 12->7 and she received a 500LR bolus
with good effect. The patient remained asymptomatic and
mentating normally throughout. A PICC was placed, TPN begun,
and Flagyl administered for one day post-op. POD 2 and 3 the
patient continued NPO with NGT and TPN awaiting return of bowel
function. POD 4, HD 10, the patient was passing flatus and her
NGT was removed. POD 5 she was advanced to a clear liquid diet
and transitioned to PO pain medications. POD 9 she was advanced
to full liquids which she tolerated well and TPN was halved. She
was discharged home on a full liquid diet POD 10.
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:
HYDROCORTISONE - Anusol-HC 2.5 % rectal cream. TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Recurrent small-bowel obstruction.
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 here at ___
___. You were admitted to our hospital
after undergoing exploratory laparotomy and lysis of adhesions.
You have recovered from surgery and are now ready to be
discharged to home. Please follow the recommendations below to
ensure a speedy and uneventful recovery.
ACTIVITY:
- Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
- You may climb stairs.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- Don't lift more than 10 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
- You may start some light exercise when you feel comfortable.
- You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your
throat during surgery.
- You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
- You could have a poor appetite for a while. Food may seem
unappealing.
- All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
- Your incision may be slightly red around the edges. This is
normal.
- You may gently wash away dried material around your incision.
- It is normal to feel a firm ridge along the incision. This
will go away.
- Avoid direct sun exposure to the incision area.
- Do not use any ointments on the incision unless you were told
otherwise.
- You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
- You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
- Over the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
- Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluitds and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
PAIN MANAGEMENT:
- It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
-You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied.
- Do not take it more frequently than prescribed. Do not take
more medicine at one time than prescribed.
- Your pain medicine will work better if you take it before your
pain gets too severe.
- Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
- If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
- Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, 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:
___
|
10894563-DS-2
| 10,894,563 | 20,787,898 |
DS
| 2 |
2158-05-09 00:00:00
|
2158-05-09 20:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
peanut / legumes / sesame seeds
Attending: ___.
Chief Complaint:
Nausea/Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a difficult historian and was noted to be likely
intoxicated with marijuana by the ED.
Mr. ___ is a ___ with h/o asthma, daily chronic marijuana
use, and allergies who present for abd pain and vomiting since
4am the day prior to admission to the ward. He tells me that he
was in his usual state of health until that morning save for
possible body aches and tension. He is intermittently smiling
during my interview and is inattentive at times. Per the ED he
was having lower abdominal pain and emesis on arrival to triage.
He reported 12 episodes of NBNB emesis. He uses marijuana daily
but has never had nausea/vomiting as a result of his marijuana
use. He reports normal PO intake prior to this morning. Denies
any h/o vomiting. He denies chest pain, shortness of breath,
diarrhea, leg swelling. He does have sore throat, runny nose,
and
body aches that have worsened since yesterday. He did have a
friend who was sick with a cold who was recently exposed to. In
the ED hew as given Zofran, IVF, and capsaicin cream for
hyperemesis related to marijuana use. His symptoms improved on
arrival to the floor. He was also noted to have Ca ___, Phos 7.5,
Cre 2.8. He reports no history of kidney disease personally or
in
his family. He was also noted to have "inappropriate" affect in
the ED with laughter and inattention. He has been noted to be
intoxicated with marijuana during several atrius visits. He
denies hematuria, dysuria, testicular swelling, or trouble
urinating. He denies fevers, chills. Patient also denies any
recent ingestions, new medications, other illicits,
Past Medical History:
Eczema
Mild intermittent asthma without complication
Non morbid obesity
Food allergy, peanut and shellfish
Hypertriglyceridemia
Social History:
___
Family History:
Mother with ___. No history of psychiatric
disease or kidney disease he is aware of.
Physical Exam:
Afebrile and vital signs stable (reviewed in bedside record)
General Appearance: pleasant, comfortable, no acute distress,
smiling inappropriately at times, bearded man appearing his
stated age, disheveled.
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: nd, +b/s, soft, nt, no masses or HSM
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization. Though cannot fully recall what happened in the
ED. At times says yes when he meant no and vice-versa. fluent
but
stilted speech.
Psychiatric: pleasant, inappropriate affect, inattentive
GU: no catheter in place
Pertinent Results:
___ 09:24PM GLUCOSE-126* UREA N-13 CREAT-2.8* SODIUM-140
POTASSIUM-4.5 CHLORIDE-92* TOTAL CO2-21* ANION GAP-27*
___ 09:24PM estGFR-Using this
___ 09:24PM ALT(SGPT)-31 AST(SGOT)-22 CK(CPK)-575* ALK
PHOS-113 TOT BILI-0.6
___ 09:24PM LIPASE-10
___ 09:24PM ALBUMIN-5.9* CALCIUM-11.0* PHOSPHATE-7.8*
MAGNESIUM-2.2
___ 09:24PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 09:24PM WBC-16.3* RBC-6.61* HGB-19.3* HCT-53.9*
MCV-82 MCH-29.2 MCHC-35.8 RDW-13.3 RDWSD-37.8
___ 09:24PM NEUTS-86.6* LYMPHS-7.4* MONOS-4.9* EOS-0.2*
BASOS-0.3 NUC RBCS-0.1* IM ___ AbsNeut-14.08* AbsLymp-1.20
AbsMono-0.79 AbsEos-0.03* AbsBaso-0.05
___ 09:24PM PLT COUNT-342
RENAL US:
FINDINGS:
The right kidney measures 9.3 cm. The left kidney measures 8.8
cm. There is no
hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity
and corticomedullary differentiation are seen bilaterally.
The bladder is moderately well distended and normal in
appearance.
IMPRESSION:
Normal renal ultrasound. No hydronephrosis.
Brief Hospital Course:
___ y/o M h/o of daily marijuana use, asthma, presented with
nausea, vomiting likely from hyperemesis secondary to cannabis
use, and ___ from dehydration now clinically improved with
supportive care. Also likely to have underlying psychiatric
disorder
Acute nausea/vomiting - Cannabis hyperemesis:
Gastroenteritis vs marijuana induced. Improved with supportive
care
ARF
Hypercalcemia:
Resolved with IVF and likely due to subacute volume depletion.
I encouraged increased PO intake in the coming days
Folliculitis:
Mild and chronic. Will prescribe topical agents: mupirocin
Psychosis, NOS:
Appreciate Psych input. He is currently well compensated and
has good family supports. I will arrange PCP follow up and
psychiatric referral can be considered going forward.
Asthma:
-Continue Albuterol PRN currently no evidence of exacerbation
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of
breath/wheezing
2. HydrOXYzine 25 mg PO Q6H:PRN itching
Discharge Medications:
1. Mupirocin Ointment 2% 1 Appl TP BID
to affected areas
RX *mupirocin 2 % apply a small amount to affected areas twice a
day Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of
breath/wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puff INH every six
(6) hours Disp #*1 Inhaler Refills:*0
3. HydrOXYzine 25 mg PO Q6H:PRN itching
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperemesis
Acute kidney injury
Hypercalcemia
Psychosis NOS
Folliculitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with nausea and GI symptoms, possibly from a
viral infection or due to the use of marijuana. We recommend
limiting your usage and following up with your primary care
doctor.
You were also seen by the psychiatry team and we recommend that
if you have any concerns that you be referred to see a
psychiatrist.
We will be giving you a refill of your albuterol and giving a
topical treatment for your folliculitis
Followup Instructions:
___
|
10894591-DS-2
| 10,894,591 | 20,264,351 |
DS
| 2 |
2132-08-04 00:00:00
|
2132-08-05 13:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with PMHx of left-sided
weakness s/p car accident in ___ who presents with chest
pressure, shortness of breath, and left lower extremity
swelling. She reports her chest pain started last night, was
located in the left anterior chest, radiated to her left neck,
occurred at rest and is constant in nature. She described the
pain as squeezing in nature. She took an aspirin at home when
this occurred without relief of symptoms. She has never had this
pain before. She reports that her chest pain is worse with deep
inspiration. She denies any diaphoresis; it is not worse with
exercise but is associated with shortness of breath. She also
thinks her left arm and left leg are a little more swollen than
baseline beginning 2 days ago. Patient denies prior history of
DVT, tobacco use, or recent immobilization. She denies CAD risk
factors, however, she has not had significant primary care
follow up (as her ___ PCP ___. No recent trauma. She denies
cough, fever, chills, orthopnea, or PND. She states she has
never had a prior stress test (although a negative vasodilator
nuclear stress test was subsequently found in the ___ electronic
medical records).
In the ED intial vitals were: pain ___, T 96.7 HR 73 BP 120/69
RR 16 SaO2 95%. Labs were notable for normal CBC & chem-7,
Trop-T <0.01 x2, D-Dimer 444, negative UA. EKG reportedly showed
no acute ischemic changes. A bedside cardiac ultrasound
reportedly showed normal cardiac function. CXR showed no acute
cardiopulmonary abnormality. Left upper and left lower extremity
LENIS were negative for DVT. Patient was given aspirin 325 mg.
She was initially placed in ED observation for serial troponins
and an exercise stress test in the morning. However, the patient
is unable do an exercise stress test due to difficulty with
ambulation and a pharmacologic stress test was not available on
the weekend. The ED determined that the patient should be
admitted for monitoring over the holiday weekend for
pharmacologic stress test the following ___. Vitals on
transfer to ___ 3: T 98 HR 70 BP 129/70 RR 16 SaO2 96% on RA.
After arrival to ___ 3, the patient reported that her chest
pain and shortness of breath had resolved. She states that the
swelling in her left arm and leg have also improved as well.
ROS: On review of systems, she 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. She denies recent
fevers, chills or rigors. She denies exertional buttock or calf
pain. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Left sided weakness s/p a car accident in ___
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On Admission
GENERAL: WDWN elderly Hispanic woman in NAD. Oriented x3. Mood,
affect appropriate.
VS: T 98. HR 71 RR 16 O2 sat 98% on RA
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple without elevated JVP
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs, rubs or gallops.
LUNGS: No accessory muscle use. CTAB--no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness.
Abd aorta not enlarged by palpation. No abdominal bruits.
EXTREMITIES: minimal swelling proximal to left wrist, minimal
left lower extremity edema
Neuro: ___ strength in LLE and LUE, ___ RUE and RLE
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ bilaterally DP and radial
At discharge
VS: T 97.4 BP 97-126/59-74 HR ___ RR 16 SaO2 95% on RA
Exam unchanged from admission
Pertinent Results:
___ 01:25PM BLOOD WBC-4.4 RBC-4.49 Hgb-14.2 Hct-41.4 MCV-92
MCH-31.6 MCHC-34.3 RDW-13.5 Plt ___
___ 01:25PM BLOOD Neuts-65.2 ___ Monos-4.6 Eos-0.9
Baso-0.8
___ 07:50AM BLOOD ___ PTT-34.1 ___
___ 01:25PM BLOOD Glucose-97 UreaN-15 Creat-0.6 Na-142
K-4.3 Cl-106 HCO3-25 AnGap-15
___ 07:50AM BLOOD Calcium-9.6 Phos-4.4 Mg-2.3 Cholest-247*
___ 07:50AM BLOOD Triglyc-186* HDL-49 CHOL/HD-5.0
LDLcalc-161*
___ 01:25PM BLOOD D-Dimer-444
___ 06:40AM BLOOD %HbA1c-5.3 eAG-105
___ 01:25PM BLOOD cTropnT-<0.01
___ 06:34PM BLOOD cTropnT-<0.01
___ 01:36AM BLOOD cTropnT-<0.01
___ 07:50AM BLOOD cTropnT-<0.01
Discharge Labs:
___ 07:10AM BLOOD Glucose-94 UreaN-17 Creat-0.6 Na-140
K-4.6 Cl-104 HCO3-26 AnGap-15
___ 07:10AM BLOOD Calcium-9.6 Phos-4.0 Mg-2.2
Urine:
___ 03:10PM URINE Color-Straw Appear-Clear Sp ___
___ 03:10PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 03:10PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE
Epi-<1
___ 03:10PM URINE CastHy-1*
___ 03:10PM URINE Mucous-RARE
ECG ___ 12:43:52 ___
Sinus rhythm. Left axis deviation with left anterior fascicular
block. Early anterior R wave transition. No previous tracing
available for comparison.
___ CXR: The heart size is normal. Mediastinal and hilar
contours are unremarkable. The pulmonary vascularity is normal
and the lungs are clear. No pleural effusion, focal
consolidation or pneumothorax is seen. No acute osseous
abnormalities are visualized.
___ Upper and lower extremity U/S: No evidence of deep
venous thrombosis. The bilateral subclavian veins demonstrate
normal respiratory phasicity. There is normal compressibility
and flow in the left internal jugular, axillary, brachial,
basilic, and cephalic veins. There is normal respiratory
phasicity in the common femoral veins bilaterally. There is
normal compressibility, flow, and augmentation in the left
common femoral, superficial femoral, and popliteal veins. There
is normal flow and compressibility in left posterior tibial and
deep peroneal veins.
___ Pharmacologic MIBI
___ yo woman was referred to evaluate an atypical chest
discomfort and dyspnea. The patient was administered 0.142
mg/kg/min of Persantine over 4 minutes. During the procedure the
patient reported a non-progressive left sided chest discomfort;
___. In addition, the patient reported increasing shortness of
breath. These symptoms resolved following the administration of
125 mg Aminophylline IV and were absent 5 minutes post-infusion.
No ST segment changes were noted. The rhythm was sinus with no
ectopy noted. The hemodynamic response to the Persantine
infusion was appropriate.
IMPRESSION: Atypical Persantine-induced symptoms with no
ischemic ST segment changes. Appropriate hemodynamic response to
the Persantine infusion.
Imaging: The image quality is limited by patient motion. Left
ventricular cavity size is normal with an EDV of 52 cc. Rest and
stress perfusion images reveal uniform tracer uptake throughout
the left ventricular myocardium. Gated images reveal normal wall
motion. The calculated left ventricular ejection fraction is
75%.
IMPRESSION:
Normal myocardial perfusion study
Brief Hospital Course:
___ woman with PMHx of left-sided weakness s/p auto
accident in the ___ who presented with chest pressure,
shortness of breath, and left lower extremity swelling, normal
myocardial perfusion study but some social concerns.
# Chest Pain: Patient presented with chest pressure and
shortness of breath for 2 days, initially concerning for
unstable angina. She had no prior history of CAD, however, she
has not been regularly followed in the medical system. She had
four sets of troponin which were negative and no acute ischemic
EKG changes. She was intermediate risk for adverse events given
her age. After waiting over the holiday weekend following
admission to Cardiology by the ED physicians, she underwent
pharmacological nuclear stress testing which was completely
normal without any perfusion deficits or wall motion
abnormalities (similar to her prior BWH study). She was
monitored on telemetry without arrhythmias. She was started on a
statin for her hyperlipidemia (LDL 161, HDL 49) and a baby
aspirin. Metoprolol on admission was discontinued given no
objective evidence of flow-limiting or symptomatic CAD.
# Left lower and upper extremity swelling: In the ED, D-dimer
was negative and LENIS was negative for DVT. No evidence of
infection. The patient denied any new topical exposures (e.g.,
detergent, perfume, animals). Unclear etiology. Swelling
eventually resolved without specific intervention. She was
maintained on subcutaneous heparin for DVT prophylaxis.
# Social concerns: Nursing initially with some concern about
discharging patient and her ability to take care of herself
independently at home alone. This was also further corraborated
with Ms. ___ family who also thought there may be some
decline in her previous functionality baseline. Physical therapy
was consulted prior to discharge and ___ rehab which
she adamantly refused. Social work was also consulted and
reccommended initiation of elder services to further support her
as an outpatient. Her family agreed to check-in on her at home,
she was given a rolling walker and she was also set-up with ___.
TRANSITIONAL ISSUES:
# Started on atorvastatin and ASA
# Continued social work evaluation for home services
# Continued physical therapy for improvement in safe ambulation
and home evaluation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Chest pain
Hyperlipidemia
Left upper and lower extremity edema without identified etiology
Left sided weakness from prior motor vehicle accident
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 stay at ___
___. You were admitted to the
hospital because of chest pain and as a result you had a stress
test. The stress test was normal. Your chest pain is NOT due to
blockages in your heart. It may have been a result of anxiety.
Your cholesterol was elevated and we started you on a medication
to help better control your cholesterol.
Followup Instructions:
___
|
10894700-DS-14
| 10,894,700 | 22,074,469 |
DS
| 14 |
2178-11-11 00:00:00
|
2178-11-11 16:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Cephalosporins / Penicillins
Attending: ___.
Chief Complaint:
right sided rib/chest pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ h/o OA, here after fall in shower yesterday complaining of
chest pain, difficulty breathing ___ pain. No head strike, loc,
vomiting, abd pain, n/v.
Past Medical History:
PMH: Osteoporosis - three rib fractures ___, early 2000s x2)
treated with motrin and binder, one right ___ fracture, and one
tib fib fracture. Not on any medications currently
HTN - diagnosed in early ___, Hypothyroidism
PSH:
ORIF for tib fib fracture - ___
? Drainage of retroperitoneal hematoma, complication of delivery
- ___
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
Vitals: T98 HR91 BP145/113 RR19 O292% RA
Gen: A&Ox3, mildly uncomfortable, in NAD
HEENT: PERRLA, no scleral icterus, no palpable LAD
Pulm: CTAB, no decreased breath sounds, no w/r/r
CV: NRRR, no m/r/g
Chest: moderate/severe TTP in posterior right back. Mild TTP in
anterior right chest.
Abd: soft, NT/ND, no rebound/guarding, no palpable masses
Ext: UE and ___ pulses intact bilaterally, WWP bilaterally, no
c/c/e, no ulcerations
Neuro: moves all limbs spontaneously, no focal deficits
Discharge Physical Exam:
VS: 97.5 PO ___ 20 90 RA
HEENT: PERRL. EOMI. Nares patent. No deformity.
CV: RRR
PULM: Clear bilaterally.
ABD: Soft, non-tender, non-distended.
EXT: Warm and dry. 2+ ___ pulses.
NEURO: A&Ox3. Follows commands and moves all extremities.
Pertinent Results:
___ 12:50PM BLOOD WBC-10.6* RBC-3.88* Hgb-13.5 Hct-40.1
MCV-103* MCH-34.8* MCHC-33.7 RDW-12.5 RDWSD-47.5* Plt ___
___ 12:50PM BLOOD Plt ___
___ 12:50PM BLOOD Glucose-103* UreaN-15 Creat-0.8 Na-142
K-4.3 Cl-102 HCO3-27 AnGap-13
OSH Imaging:
CXR shows small L PTX and hemothorax.
CT: Rib ___ fracture.
___: New right base opacity may represent atelectasis.
Small bilateral pleural effusions. Small left apical
pneumothorax better seen on outside CT and difficult to compare
to outside chest radiograph on life image. Bilateral fractures
better seen on outside chest CT.
___ CXR:
Persistent small right apical pneumothorax. Unchanged right
lung base
opacity.
Brief Hospital Course:
Ms. ___ is a ___ yo F admitted to the Acute Care Trauma
Surgery Service on ___ with right sided chest pain and
shortness of breath after sustaining a fall the day prior. Chest
xray and CT scan from outside hospital showed right sided rib
fractures ___ and a small right apical pneumothorax. She was
admitted to the trauma service for pain management and
respiratory monitoring.
Neuro: The patient was alert and oriented throughout
hospitalization. She was given a pain regimen of Tylenol,
ibuprofen, lidocaine patch and oxycodone as needed with good
effect.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. The patient initially
required supplemental oxygen to maintain O2 sat greater than 92%
which was weaned to room air on hospital day 3.
GI/GU/FEN: The patient was given a regular diet which was
tolerated without difficulty. Patient's intake and output were
closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible. The patient was seen and
evaluated by social work and requested prescription for nicotine
patch on discharge. Education was provided regarding not smoking
while patch in place.
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 is accurate and complete.
1. Levothyroxine Sodium 88 mcg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
Do not exceed 4000 mg acetaminophen/24 hours.
2. Docusate Sodium 100 mg PO BID
3. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
4. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % apply to rib pain daily Disp #*15 Patch
Refills:*0
5. Nicotine Patch 14 mg TD DAILY
DO NOT smoke while patch in place.
RX *nicotine 14 mg/24 hour apply 1 patch to skin daily Disp #*30
Patch Refills:*0
6. OxyCODONE (Immediate Release) 2.5 mg PO Q2H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Take lowest effective dose.
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 2
hours Disp #*20 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
8. Senna 8.6 mg PO BID:PRN Constipation
9. Hydrochlorothiazide 25 mg PO DAILY
take as prescribed.
10. Levothyroxine Sodium 88 mcg PO DAILY
11. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right sided rib fractures ___
Right apical hemo/pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Acute Care Trauma Surgery Service on
___ after a fall sustain right sided rib fractures and a
small amount of air in your right lung spaced (called a
pneumothorax). You were given pain medication and encouraged to
mobilize and take deep breaths. You had multiple xrays of your
chest that showed the air in your lung space resolving. You are
now doing better, pain is better controlled, and you are ready
to be discharged to home with the following discharge
instructions:
* Your injury caused right sided rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
**Please have repeat chest xray done prior to clinic follow up
appointment. Bring xray slip to ___ Building ___ floor
radiology department prior to appointment. (You can have this
done same day or ___ days prior to follow up appointment).
Followup Instructions:
___
|
10895149-DS-11
| 10,895,149 | 26,079,930 |
DS
| 11 |
2146-10-01 00:00:00
|
2146-10-01 20:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Ace Inhibitors / gabapentin / desvenlafaxine
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Ms. ___ is an ___ year old F with history of metastatic
EGFR
mutant NSCLC s/p wedge resection ___, R hilar recurrence c/b
hemoptysis ___, s/p XRT ___ on crizotinib since ___
presenting with acute worsening of subacute shortness of breath.
Regarding oncologic history, initially presented with 1.6 cm
right upper lobe mass in ___, underwent wedge resection
___
in ___. Pathology showing adenocarcinoma. In ___
subsequently had hemoptysis with evidence of right hilar disease
recurrence. Restaging showed metastatic recurrence at T4.
Underwent palliative radiation to the right hilum in ___
with
resolution of hemoptysis. Was recently started on crizotinib
___. Recently seen by primary oncologist Dr. ___ ___,
noted to have ___ history of worsening shortness of
breath,
recently was started on home O2, had CXR with plan for repeat CT
in 4 weeks.
In the interim, patient has noted several week history of
severely worsening shortness of breath. At her previous
baseline,
was independent, was able to walk unassisted, with no dyspnea on
exertion. Over the last several weeks, patient has noted
worsening shortness of breath, with intermittent severe gasping
at rest per niece. Has been maintained on 3L O2 at night, during
the day at rest, ___ to 4 L, however subsequently trying
to be weaned down. Patient states she has most recently been on
3
L O2, however has noted intermittent desaturations to <90.
Endorses some mild cough, with scant sputum production over the
last 2 weeks. Denies any fevers, chills. Denies any PND.
Currently sleeps upright. Missed 2 doses of Lasix 1 week prior,
however has otherwise been adherent. Adherent to ___ diet.
Acute worsening of shortness of breath with minimal exertion now
prompting ED visit.
On arrival to the ED,
Initial VS: T 98.6 HR 77 BP 133/52 RR 20 O2 97% 4LNC
Exam Notable for:
-Mildly increased work of breathing on nasal cannula; saturation
in the mid ___.
-No jugular venous distention
Regular tachycardia without murmurs, rubs, or gallops
-Lungs with bibasilar crackles, distant breath sounds in all
lung
fields without wheezes or rales. Minimal respiratory
prolongation.
-Abdomen soft. ___ without edema. Neuro AOx3 without facial
droop or gross focal deficit.
Labs notable for:
- WBC 6.4, Hb 10.6, HCT 33.4, PLT 98
- MB 2, troponin <0.01 x2
- proBNP 351
Imaging:
CXR: Small to moderate right pleural effusion is minimally
increased in size. Hazy opacification in the right upper lobe
with associated pleural thickening reflects known pleural
metastatic disease. Patchy opacities in lung bases may
reflect atelectasis. Mild pulmonary vascular congestion.
CTA Chest:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Interval progression of right pleural metastatic disease and
increased size
of right cardiophrenic lymph nodes.
3. Increased, moderate size, partially loculated right pleural
effusion
Administered:
___ 20:30 IH Ipratropium Bromide Neb 2 NEB
___ 20:30 IH Albuterol 0.083% Neb Soln 2 NEB
___ 23:41 PO/NG Atorvastatin 10 mg
___ 23:41 PO OXcarbazepine 150 mg
___ 00:00 IH ___ Diskus (250/50)
___ 00:38 NEB ___ Neb 1 NEB
___ 06:31 NEB ___ Neb 1 NEB
___ 08:00 IH ___ Diskus (250/50)
___ 10:15 PO/NG Amiodarone 100 mg
___ 10:15 PO/NG amLODIPine 5 mg
___ 10:15 PO/NG Aspirin 81 mg
___ 10:15 PO/NG Furosemide 40 mg
___ 10:15 PO/NG Losartan Potassium 50 mg
___ 10:15 PO Omeprazole 20 mg
___ 10:15 PO OXcarbazepine 150 mg
Consults: IP consulted for possible drainage
Subjective: On arrival to the floor, patient confirms the above
history. Currently complaining of mild shortness of breath.
Endorsing mild cough with scant sputum production. Currently
denies any fevers, chills, chest pain, abdominal pain, nausea,
vomiting, diarrhea, or urinary symptoms.
Past Medical History:
CARDIAC:
-Heart failure with preserved ejection fraction and diastolic
dysfunction.
-Dilated right ventricle with mild pulmonary hypertension (TR
gradient 24 to 26 mm Hg).
-Mildly dilated ascending aorta of 3.7 cm.
-Valvular heart disease. Moderate aortic stenosis peak vel
3.4/mean gradient 27/ ___ 1.0 on TTE ___ with (1+) AR and
(1+) MR.
-___ fibrillation on warfarin
Basal cell carcinoma
-Charcot ___
-Chronic obstructive pulmonary disease (Gold stage III)
-Glucose intolerance
-Hyperlipidemia
-Hypertension
-S/P Total knee replacement
-Cholelithiasis
-Squamous cell carcinoma
-Nephrolithiasis
-Back pain
Social History:
___
Family History:
Mother with MI, dementia died at age ___. Father and sister with
lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: ___ 1654 Temp: 98.3 PO BP: 125/66 HR: 76 RR: 20 O2 sat:
92% O2 delivery: 2.5L
General: Mildly labored breathing on NC. Speaking in full
sentences.
HEENT: NC/AT, PERRLA, EOMI
Lungs: Decreased breath sounds throughout. Bibasilar rales.
Scattered low pitched expiratory wheezes. No rhonchi
CV: Regular rate and rhythm, no murmurs, rubs, or gallops
Abdomen: Soft, NT/ND. Normoactive bowel sounds. No evidence
organomegaly
Extremities: 2+ peripheral pulses. 1+ pitting edema to knees
bilaterally.
Neuro: CN ___ intact. No focal neurological deficits.
DISCHARGE PHYSICAL EXAM:
======================
VS: ___ 0011 Temp: 98.1 PO BP: 103/64 HR: 74 RR: 18 O2 sat:
94% O2 delivery: 3LNC
General: Mildly labored breathing on NC. Speaking in full
sentences.
HEENT: NC/AT, PERRLA, EOMI, rhinophyma
Lungs: no lung sounds appreciated in right lung field middle and
lower. decreased lung sounds on right upper luung field
ant/post. mild rales in left lung fields. No rhonchi, chest tube
site dressings c/d/i / NT
CV: Regular rate and rhythm, no murmurs, rubs, or gallops
Abdomen: Soft, NT/ND. Normoactive bowel sounds. No evidence
organomegaly
Extremities: 2+ peripheral pulses. 1+ pitting edema to knees
bilaterally.
Neuro: CN ___ intact. No focal neurological deficits.
Pertinent Results:
ADMISSION LABS:
==============
___ 07:55PM BLOOD ___
___ Plt ___
___ 07:55PM BLOOD ___
___ Im ___
___
___ 07:55PM BLOOD ___
___
___
___ 07:55PM BLOOD ___ ___
___ 07:55PM BLOOD ___
___
___ 07:55PM BLOOD CK(CPK)-47
___ 07:55PM BLOOD ___
___ 07:55PM BLOOD cTropnT-<0.01
___ 11:51PM BLOOD ___
___ 11:51PM BLOOD cTropnT-<0.01
STUDIES:
========
___ (PORTABLE AP)
IMPRESSION:
Comparison to ___. The pleural catheter has been
removed. The
extent of the pleural effusion on the right has slightly
increased. Stable appearance of the left lung bases. Stable
borderline size of the cardiac silhouette. No pulmonary edema.
___ (PORTABLE AP)
IMPRESSION:
1. Interval improvement of the right small pleural effusion
with a right
pigtail pleural drainage catheter. Small left pleural effusion
has worsened.
2. Unchanged bibasilar atelectasis. No new acute
cardiopulmonary process.
___ PORT. LINE PLACEM
IMPRESSION:
Interval placement of a right basilar chest tube. No
pneumothorax. Slight
improvement in ___ right pleural effusion.
___ FLUID
Report not finalized.
___ CHEST
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Interval progression of right pleural metastatic disease and
increased size
of right cardiophrenic lymph nodes.
3. Increased, moderate size, partially loculated right pleural
effusion.
___ (PORTABLE AP)
IMPRESSION:
Small to moderate right pleural effusion is minimally increased
in size. Hazy
opacification in the right upper lobe with associated pleural
thickening
reflects known pleural metastatic disease. Patchy opacities in
lung bases may
reflect atelectasis. Mild pulmonary vascular congestion.
___ EKG:
Left bundle branch block. Sgarbossa negative.
Rate 79, PR 163, QRS 143, QT 428, QTc (___) 471/503,
P -15, QRS -26 T 86
Discharge Labs:
============
___ 08:15AM BLOOD ___
___ Plt ___
___ 08:15AM BLOOD ___
___
___ 08:15AM BLOOD ___
Brief Hospital Course:
Ms. ___ is an ___ year old F with history of metastatic
EGFR mutant NSCLC s/p wedge resection ___, R hilar recurrence
c/b hemoptysis ___, s/p XRT ___ on crizotinib since ___
who presented with acute worsening of subacute shortness of
breath, s/p chest tube placement and removal ___ goal to home
with hospice.
ACUTE ISSUES
==============
#GOC:
On hospital day 2 a discussion was had regarding the patient's
declining clinical and functional status at which time the
patient decided that she wanted to focus on QOL and wanted to
pursue a plan of home with hospice. With this decision the plan
was made to hold further chemo and nonessential medications.
#Acute on chronic shortness of breath
#Hypoxemic Respiratory Failure
Patient with history of ___ s/p wedge resection, palliative
XRT ___ now on crizotinib, with a several week history of
worsening shortness of breath, who presented with with acute
worsening, intermittently severe dyspnea with minimal exertion.
Patient reported that over the prior several weeks she was
started on home O2, most recently on
3L NC, up to 4.5, and had been attempting to titrated down. On
admission, CTA chest showed interval progression of right
pleural metastatic disease and increased size of right
cardiophrenic lymph nodes, in addition to moderate right
partially loculated pleural effusion. It was felt that hypoxemia
was likely secondary to pleural effusion and progression of
disease. It was felt that increasing O2 requirements were due to
accumulating pleural effusion. Pateint appears euvolemic to
mildly volume overloaded during admission with chronic lower
extremity edema. IP was consulted who briefly placed a chest
tube for relief of pleural effusion, interval imaging showed
accumulation of fluids and were associated with mildly
increasing O2 requirements. Patient experienced pain with chest
tube and asked not to have a pleurex placed in future despite
potential for palliating symptoms. Recieved Duonebs Q6H
standing, albuterol nebs Q2H:PRN, guaifenasin PRN. continued on
home ___ mcg/actuation inhalation
QHS Pt was discharged on home O2.
#Anemia:
Patient remained Stable throughout admission, hgb 10.6 on
admission, within recent baseline ___.
#Thrombocytopenia:
Patient presented with a thrombocytopenia, last recorded in a
normal range in ___. this was likely ___
chemotherapy. New baseline is likely ~100.
#Metastatic lung adenocarcinoma
#Secondary malignancy of spine(T4)
#Secondary malignancy of pleura
History of metastatic EGFR mutant NS___ s/p wedge resection
___, R hilar recurrence c/b hemoptysis ___, s/p XRT ___
on crizotinib since ___ followed by outpatient oncologist Dr.
___. CTA on admission showed progression of disease.
After discussions with Dr ___ patient decided to
hold off on further treatments to focus on quality of life and
change code status to DNR/DNI.
CHRONIC ISSUES
===============
#HFpEF
History of HFpEF (EF ___ ___ maintained on Lasix 40 PO QD.
With chronic lower extremity edema, unchanged at present
per patient. Weights remained stable during admission. Some mild
pulmonary vascular congestion on admission CXR, BNP 351 did not
appear to be in decompensated heart failure. was continue home
preload agents, home Lasix 40 PO QD, Afterload, home Losartan
Potassium 50 mg PO DAILY, amLODIPine 5 mg PO DAILY.
#Severe AS s/p AVR
#H/o CHB S/p PPM:
Most recent TTE ___ ___ bioprothetic AVR with normal
transvalvular gradient. Pacer appeared to be functioning well on
ECG. Mainatianed on Losartan Potassium 50 mg PO DAILY,
amLODIPine 5 mg PO DAILY.
Chronic Issues:
==================
#AF
Rates controlled via PPM. Not on anticoagulation
- Cont home ASA 81mg QD
- Cont home amiodarone
#COPD:
Remained stable on home in inhalers
#HTN
Was continued on home losartan and amlodipine.
#HLD
Was continued on home atorvastatin.
#Depression
Was continued on home citalopram.
# Charcot ___:
Patient was stable on home oxcarbazepine.
- Cont home
#GERD
Was continued on home Omeprazole 20 mg PO DAILY.
Transitional Issues:
======================
New Meds:
- Ondansetron 4 mg PO Q8H:PRN
- TraMADol 50 mg PO Q6H:PRN
- home with hospice
- Follow up with palliative care
- Follow up with radiology for imaging
- Follow up with oncologist
#HCP/CONTACT:
Name of health care proxy: ___
Relationship: niece
Phone number: ___
#CODE STATUS: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO DAILY
2. OXcarbazepine 150 mg PO BID
3. ___ mcg/actuation inhalation QHS
4. crizotinib 250 mg oral DAILY
5. Amiodarone 100 mg PO DAILY
6. amLODIPine 5 mg PO DAILY
7. Atorvastatin 10 mg PO QPM
8. Furosemide 40 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth Q8H:PRN Disp #*15
Tablet Refills:*0
2. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth Q6H:PRN Disp
#*15 Tablet Refills:*0
3. Amiodarone 100 mg PO DAILY
4. amLODIPine 5 mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Furosemide 40 mg PO DAILY
7. Losartan Potassium 50 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. OXcarbazepine 150 mg PO BID
10. ___ mcg/actuation inhalation
QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Acute on chronic dyspnea
Secondary Diagnosis:
Goals of Care
Hypoxemic Respiratory Failure
Anemia
Thrombocytopenia
Metastatic lung adenocarcinoma
Secondary malignancy of spine(T4)
Secondary malignancy of pleura
compensated HFpEF
Severe AS s/p AVR
H/o CHB S/p PPM
atrial fibrillation
COPD
HLD
depression
Charcot ___
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you were having
shortness of breath.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While you were in the hospital we found that you had
progression of your disease.
- While you were hospitalized we found that you had fluid
surrounding your right lung as a result of your cancer and it
was drained.
- While in the hospital you chose to change your code status and
made plans to leave on hospice.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- When you leave the hospital you will be getting extra health
support from hospice.
- Continue to take all your medicines and keep your
appointments.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs in 1 day.
- Follow up with your palliative care provider
- ___ up with radiology for imaging
- Follow up with your oncologist
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10895183-DS-7
| 10,895,183 | 23,158,922 |
DS
| 7 |
2180-10-18 00:00:00
|
2180-10-18 14:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hand pain s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ YO M s/p mechanical fall out of bed on ___ night.
Fell out of bed while sleeping and hit his face on a cabinet.
Denies LOC. Was seen that night at ___, where he
had imaging of his face and head that was unremarkable. Since
then, he has had bruising around his right eye. He has also
noted some pain and tingling in both of his hands since then,
which has been worsening. No neck pain, back pain, saddle
anesthesia, urinary or bowel symptoms.
Past Medical History:
H. pylori, headache, chronic hep B, knee pain
Social History:
___
Family History:
NC
Physical Exam:
Vitals- 97.9 60 142/89 18 98%
Gen- NAD, collared
HEENT- periorbital edema and swelling around R eye, EOMI
NECK- collared, not complaining of pain
MSK- full ROM of all extremities
NEURO- ___ strength in bil upper extremities, DTRs 1+ bil at
elbows and wrists, ___ strength in bil lower
extremities
pins and needles sensation on radial side of both hands
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service for
observation. Decompressive surgery for his severe cervical
stenosis was discussed with the patient but given his mild and
stable symptoms he would like to continue observation and
declines surgery at this point. TEDs/pnemoboots were used for
DVT prophylaxis. Pain is controlled with oral medications with
IV breakthrough medication. Diet was advanced as tolerated.
Physical therapy was consulted for mobilization OOB to ambulate.
Hospital course was otherwise unremarkable. Ophthalmology
consult obtained for hematoma. On the day of discharge the
patient was afebrile with stable vital signs, comfortable on
oral pain control and tolerating a regular diet.
Medications on Admission:
Vicodin, Ibuprofen, Omeprazole
Discharge Medications:
Gabapentin, Oxycodone, Colace
Discharge Disposition:
Home
Discharge Diagnosis:
cervical stenosis
fall with hand numbness and tingling
Discharge Condition:
good
Discharge Instructions:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit in a car
or chair for more than ~45 minutes without getting up and
walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can
tolerate.
oIsometric Extension Exercise in the collar: 2x/day x ___xercises as instructed.
-Soft Cervical Collar / Neck Brace: You need to wear the brace
at all times until your follow-up appointment which should be in
2 weeks. You may remove the collar to take a shower. Limit
your motion of your neck while the collar is off. Place the
collar back on your neck immediately after the shower.
-You should resume taking your normal home medications.
-You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___ 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
-Follow up:
oPlease Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
Please call the office if you have any questions.
Followup Instructions:
___
|
10895795-DS-22
| 10,895,795 | 24,268,007 |
DS
| 22 |
2200-04-18 00:00:00
|
2200-04-18 22:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain, shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___, ___ only, with CAD s/p LAD stenting in ___,
mild left ventricular dysfunction, mitral regurgitation,
tricuspid regurgitation, history of GI bleed, recent PNA
presents with a brief episode of chest pain and shortness of
breath this morning. He woke this morning, sat on the side of
the bed, and then noted a sharp pain on his left chest
accompanied by shortness of breath. There was no
lightheadedness, dizziness, nausea, vomiting, diaphoresis, pain
radiation to the back or arm, or other symptoms. These symptoms
self-resolved in a few minutes without intervention. The rest
of the morning he was his normal healthy self, and when a friend
came to take him to the hospital he was dressed and ready to go,
able to walk downstairs on his own. He denies any previous
episodes of similar pain, and in fact the pain he had at the
time of his prior cardiac presentation was both more severe and
accompanied by more significant dyspnea.
.
On presentation to the ED, he was found to be bradycardic HR <
50 and hypotensive SBP < 70. Initial vitals were 97.6 35 69/47
18 98%. EKG showed likely new paroxysmal Afib; this EKG not
currently available in the chart. CXR showed no acute process.
His SBP improved to 100 with 1L NS. Heparin gtt was started for
concern for PE, then held given history of GIB.
.
Of note, the patient was recently seen in the ED on ___ for
constipation and CXR at that time was suspicious for PNA. He
was provided a 7 day course of levofloxacin on ___ he completed
this course, but continues to have cough. His cardiologist held
lisinopril starting ___ in case this was contributing to cough.
.
On arrival to the floor, the patient has no complaints. He
denies any recurrence of chest pain or dyspnea since this
morning.
.
REVIEW OF SYSTEMS
On review of systems, he notes occasional leg pain which may be
exertional. He has a large lesion on his right nose that bleeds
at times in response to excoriation.
He denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.
.
Initial history assisted by daughter ___ who both provided
information and translation from ___ to ___.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension, CAD s/p stent, 2+
moderate mitral regurgitation, mod-to-sev tricuspid
regurgitation
2. CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS: s/p LAD bare metal stent
(___)
3. OTHER PAST MEDICAL HISTORY:
- PVD
- Kidney stones
- Basal cell CA L ear, s/p resection ___
- Glaucoma
- h/o GIB in ___ NSAID use
- s/p chole ___ years ago
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.7 124/51 55 12 98% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink.
Multiple brown lesions on face and ears, consistent with SK.
Large brown lesion on right nose with excoriation and evidence
of recent bleeding.
NECK: Supple with JVP of 9 cm
CARDIAC: RRR, normal S1 S2, no MRG
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
rales, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No HSM or tenderness.
EXTREMITIES: Right foot cool to the touch with decreased pulses.
1+ edema at b/l ankles, trace at mid-calf.
NEURO: CN II-XII tested and intact, strength ___ throughout,
sensation grossly normal. Gait not tested.
SKIN: Dry eczematous skin throughout, particularly feet and
face. Multiple brown lesions on face as described above.
PULSES:
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
.
DISCHARGE PHYSICAL EXAMINATION:
VS: 98.9 146/77 54 18 96% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: EOMI. Conjunctiva pink. Multiple brown lesions on face
and ears, consistent with SK. Large brown lesion on right nose
with excoriation and evidence of recent bleeding.
NECK: Supple with JVP of 9 cm
CARDIAC: RRR, normal S1 S2, no MRG
LUNGS: CTAB, no rales, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No HSM or tenderness.
EXTREMITIES: No cyanosis or clubbing. Right foot cool to the
touch with decreased pulses. 1+ edema at b/l ankles, trace at
mid-calf.
Pertinent Results:
Admission Labs:
___ 09:00AM BLOOD WBC-5.7 RBC-4.70 Hgb-15.5 Hct-48.1#
MCV-102*# MCH-32.9* MCHC-32.2# RDW-15.2 Plt ___
___ 09:00AM BLOOD Neuts-65.0 Lymphs-14.8* Monos-5.4
Eos-13.2* Baso-1.6
___ 09:00AM BLOOD ___ PTT-31.3 ___
___ 09:00AM BLOOD Glucose-95 UreaN-18 Creat-1.1 Na-138
K-4.2 Cl-106 HCO3-25 AnGap-11
___ 09:00AM BLOOD ALT-15 AST-21 AlkPhos-87 TotBili-1.0
___ 09:00AM BLOOD Albumin-4.2 Calcium-9.4 Phos-2.8 Mg-2.2
Cardiac Labs:
___ 09:00AM BLOOD cTropnT-0.01
___ 06:22PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:22PM BLOOD CK(CPK)-26*
___ 07:20AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:20AM BLOOD CK(CPK)-18*
___ 11:06AM BLOOD D-Dimer-4594*
Interim Labs:
___ 09:00AM BLOOD TSH-3.2
___ 07:20AM BLOOD WBC-5.6 RBC-4.13* Hgb-13.5* Hct-42.6
MCV-103* MCH-32.8* MCHC-31.8 RDW-15.1 Plt ___
___ 07:20AM BLOOD Neuts-62.3 ___ Monos-4.4
Eos-12.5* Baso-1.0
___ 07:20AM BLOOD ___ PTT-31.2 ___
___ 06:36PM URINE Color-Straw Appear-Clear Sp ___
___ 06:36PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
Discharge Labs:
___ 07:35AM BLOOD WBC-3.7* RBC-4.25* Hgb-13.8* Hct-43.5
MCV-102* MCH-32.5* MCHC-31.7 RDW-15.2 Plt ___
___ 07:35AM BLOOD Glucose-85 UreaN-15 Creat-0.9 Na-138
K-3.7 Cl-107 HCO___ AnGap-12
Microbiology: none
EKG ___: Sinus bradycardia. Compared to the previous tracing
intermittent atrial fibrillation is no longer evident.
EKG ___: Sinus rhythm with intermittent irregular
supraventricular tachycardia, possibly atrial fibrillation.
Incomplete left bundle-branch block with non-diagnostic
repolarization abnormalities. Compared to the previous tracing
of ___ intermittent atrial fibrillation now appears to be
present.
CXR ___: FINDINGS: One portable AP upright view of the chest.
Bibasilar linear opacities likely representing mild chronic
fibrotic changes are unchanged. The lungs are overall clear
without evidence of consolidation. There is no pneumothorax or
pleural effusion. Cardiac, mediastinal, and hilar contours are
normal.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Likely mild chronic fibrotic lung changes.
CTA Chest ___:
1. No evidence for pulmonary embolus. Motion artifact obscures
the peripheral lower lobe pulmonary arteries, in which pulmonary
embolism cannot be excluded on this study.
2. Right lower lobe calcified granuloma and calcified
mediastinal and hilar lymph nodes, suggestive of prior
granulomatous process.
TTE ___: The left atrium is normal in size. The estimated
right atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function appears
normal; however regional wall motion is not fully visualized.
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. An eccentric, anteriorly directed jet of mild
to moderate (___) mitral regurgitation is seen (may be slightly
underestimated). The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
[In the setting of at least moderate to severe tricuspid
regurgitation, the estimated pulmonary artery systolic pressure
may be underestimated due to a very high right atrial pressure.]
There is no pericardial effusion.
Brief Hospital Course:
___ with CAD s/p LAD stenting in ___, mild left ventricular
dysfunction, mitral regurgitation, tricuspid regurgitation,
history of GI bleed, recent PNA presents with a brief episode of
chest pain and shortness of breath this morning.
.
# CORONARIES: In ___ the patient had 30% mid vessel LAD
stenosis, 60% OM1 stenosis, 70% stenosis of a branch of OM2. 2
bare metal stents placed in LAD at that time. Since that time
the patient had no recurrence of chest pain, EKG had been stable
with LBBB. This presentation had low probability for ACS given
negative cardiac enzymes x3, lack of EKG changes. Aspirin and
statin continued. The patient had previously been on an ACE,
however this was discontinued in early ___ due to residual
cough.
.
# PUMP: Repeat TTE shows no substantive change from last study
in ___, possibly improved systolic function.
.
# RHYTHM: This appears to be new onset Afib, as there is no
prior report of dysrhythmia. Given elevated D-dimer, SOB and
CP, concern for PE as inciting event. However, repeat EKG
showed sinus bradycardia. All EKGs and telemetry once the
patient reached the floor were in NSR. Rate per telemetry was
largely in the 50-70 range, with a few episodes of HR > 120.
___ AM one episode to 170 when straining to stool, ___ ___ a
episode to 130. These were ASx, rate self-resolved with rest.
The precipitating event for his admission could have been
tachycardia, symptomatic bradycardia, or paroxysmal Afib. Given
the uncertainty and lack of repeat occurrence, it was determined
that he would benefit from long-term monitoring. Depending on
the results of this monitoring, it may be reasonable to consider
pacemaker placement in future. The patient's home metoprolol
was initially held given bradycardia, but this was restarted
following described episodes of tachycardia. There was no
recurrence of Afib since leaving the ED.
.
# Elevated D-dimer: As the patient was not hypoxic or
tachycardic and the chest pain resolved, the likelihood of PE
was lower than otherwise would be suspected by this level of
D-dimer elevation. Other causes of elevated D-dimer include
DIC, CHF, renal failure, MI or other ischemia, SIRS, liver
disease. There was no sign of infection, renal function at
baseline, no sign of ischemia. Anti-coagulation with heparin
gtt was started in the ED, stopped on the floor due to high risk
of bleeding and uncertain benefit. CTA Chest negative for PE.
.
# Glaucoma: stable, continued home dorzolamide and latanoprost
.
# h/o GIB: ___ NSAID use for back pain. Patient was on
ranitidine therapy for several years, but stopped this a year
ago. No sign of ongoing bleeding.
.
# Peripheral eosinophilia: Patient episodically has peripheral
eosinophilia, no clear assoication with medications or clinical
status. Persistent on repeat diff. No new medications, no sign
of current infection. Suggest rechecking as outpatient to
ensure resolution.
.
# Thrombocytopenia: Currently at baseline in low 100s
.
CODE: FULL
EMERGENCY CONTACT: ___ (___)
.
Transitional Issues:
- Review long-term monitoring for any possible paroxysmal
arrhythmia. Consider pacemaker placement if indicated.
Discussed with outpatient Cardiologist. ___ support provided
for holter adjustment and instructions for use.
- Dermatology follow-up for nose lesion booked prior to
discharge.
- Consider restarting ACE once cough resolves.
Medications on Admission:
DORZOLAMIDE [TRUSOPT] 2% 1 gtt in eye TID
LATANOPROST 0.005% 1 gtt in each eye QHS
METOPROLOL SUCCINATE 12.5 mg daily
SIMVASTATIN 20 mg daily
ASPIRIN 81mg daily
SENNOSIDES 8.6 mg tabs, ___ tabs QHS
[ LISINOPRIL 5 mg daily ON HOLD since ___ ]
Discharge Medications:
1. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3
times a day).
2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. senna 8.6 mg Tablet Sig: ___ Tablets PO once a day as needed
for constipation.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
paroxysmal sinus tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at ___
___. You came to the hospital after an episode of
chest pain and shortness of breath. Although this passed
rapidly, you were appropriately concerned. We did a number of
tests to investigate a possible cause of these symptoms. We
were able to rule out a number of problems including heart
attack, pulmonary embolism (clot in the lung) and heart failure.
We kept you on continuous heart monitoring which showed short
periods of a rapid heart rate. We suspect that a similar
episode of rapid heart rate caused your symptoms.
We discharged you with a long-term heart monitor to capture any
rapid heart rate that might occur at home. If you have periods
of a very fast or very slow heart rate, your cardiologist may
recommend a pacemaker. The monitor results will help him
determine if this would be helpful for you.
We made no changes to your home medications.
Please follow-up with your physicians as noted below.
Followup Instructions:
___
|
10895795-DS-23
| 10,895,795 | 21,048,102 |
DS
| 23 |
2200-12-28 00:00:00
|
2200-12-30 22:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tetracaine
Attending: ___.
Chief Complaint:
Cough, SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ of CAD, MR/TR, HTN, BCC presents with cough and
overall "not feeling well" for two days. History obtained both
from patient and daughter. Patient was in usual state of health
until yesterday morning when he felt more tired than normal.
States "something was off" but could not pinpoint exactly what
was bothering him. Over the course of the day he did state he
was coughing and felt short of breath. Today he woke up and
slept much longer than usual. He asked one of his caretakers to
take him to the hospital because he didn't feel right. He
specifically denied chest pain, palpitations, nausea, vomiting,
light-headedness, numbness/weakness, problems with speech,
diaphoresis, gastrointesinal or urinary symptoms. Of note,
patient has been undergoing radiation for basal cell carcinoma
over his R eye and recently had a "procedure" done on ___. He
also follows with cardiology for past MI with stent and MR/TR.
In the ED, initial VS were: 98.2 125 63/49 24 98% in AFib
Improved to ___ 95% after 2L of fluid and metoprolol 5 mg
IV. Received ceftriaxone and azithromycin, and fentanyl. Labs
were notable for trop of 0.07, CK-MB 5, CK 655, K 5.2, HCO3 of
19 with AG of 16, Cr 1.9. Lactate was 2.0. CXR was
unremarkable. EKG in ED showed "atrial fibrillation" per notes,
however, assessment from CCU shows runs of supraventricular tach
at 113.
Of note, EKG in ___ had "sinus rhythm with intermittent
irregular supraventricular tachycardia, possibly atrial
fibrillation", however subsequent EKGs have not redemonstrated
this rhythm.
On arrival to the MICU, patient was saturating in the mid ___
with HR in the 100s, BPs ___. He was conversant and states.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension, CAD s/p stent, 2+
moderate mitral regurgitation, mod-to-sev tricuspid
regurgitation
2. CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS: s/p LAD bare metal stent
(___)
3. OTHER PAST MEDICAL HISTORY:
- PVD
- Kidney stones
- Basal cell CA L ear, s/p resection ___
- Glaucoma
- h/o GIB in ___ NSAID use
- s/p chole ___ years ago
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, 8 cm JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
DISCHARGE PHYSICAL EXAM:
VS 97.5, 126/65, 63, 20, 97RA
PVR 167cc
General: Alert, oriented, pleasant, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
darkly pigmented BCC lesions on sides of nose/corner of eye
Neck: supple, 8 cm JVP, no LAD
CV: Regular rhythm, normal S1 + S2, no appreciation of murmurs
although heart sounds are very distant
Lungs: wheezes bilaterally bases>apices
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, finger-to-nose intact
Pertinent Results:
ADMISSION LABS:
___ 11:50AM BLOOD WBC-7.6# RBC-4.96 Hgb-17.3# Hct-50.2
MCV-101* MCH-34.8* MCHC-34.3 RDW-14.9 Plt ___
___ 11:50AM BLOOD Neuts-76.1* Lymphs-13.8* Monos-7.1
Eos-2.1 Baso-0.9
___ 11:50AM BLOOD ___ PTT-35.4 ___
___ 11:50AM BLOOD Glucose-106* UreaN-41* Creat-1.9* Na-138
K-5.2* Cl-103 HCO3-19* AnGap-21*
___ 11:50AM BLOOD CK(CPK)-655*
___ 11:50AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.4
___ 11:55AM BLOOD Lactate-2.0 K-4.5
DISCHARGE LABS:
___ 06:05AM BLOOD WBC-4.4 RBC-4.03* Hgb-14.0 Hct-40.6
MCV-101* MCH-34.8* MCHC-34.5 RDW-14.7 Plt ___
___ 06:05AM BLOOD ___ PTT-35.8 ___
___ 06:05AM BLOOD Glucose-96 UreaN-28* Creat-0.9 Na-140
K-3.8 Cl-105 HCO3-25 AnGap-14
___ 06:05AM BLOOD Calcium-8.7 Phos-2.2* Mg-2.2
PERTINENT MICRO:
Urine culture negative x2
Blood culture negative x2
PERTINENT IMAGING:
CXR ___ Mild pulmonary vascular congestion. No evidence of
pneumonia.
CXR ___: AP upright portable chest radiograph obtained. The
lungs appear
clear bilaterally. Prominent costochondral calcification
projects over the lungs. Cardiomediastinal silhouette is normal.
Bony structures are intact. No effusion or pneumothorax.
Echo ___
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function appears normal; however
regional wall motion is not fully visualized. Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. An
eccentric, anteriorly directed jet of mild to moderate (___)
mitral regurgitation is seen (may be slightly underestimated).
The tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is no pericardial
effusion.
EKG: In ED: Rate 133, appears to have short bursts of possible
AVNRT 5 beats at a time. Unclear whether there is ST changes.
Brief Hospital Course:
___ y/o male with ___ of cardiac disease s/p stent, MR and TR,
incompletely treated basal cell carcinoma presented with cough
and general malaise found to be hypotensive and tachycardic.
ACTIVE ISSUES:
#) Tachycardia: New onset per review of old ECGs and records.
His HR appears to have 5 beat runs of AVNRT followed by small
pauses. Initially got better with IVF and small doses of
Metoprolol. Cardiology was consulted and felt this was atrial
tachycardia and agreed with Metoprolol 12.5mg BID (increased
from his home dose of 12.5 metoprolol succinate daily). With
atrial tach, no indication for anti-coagulation just titration
of beta-blockers. Possible inciting event was infection and
dehydration as patient responded to fluid repletion. Once
transferred to the regular medicine floor, he no longer had
episodes of tachycardia.
#) SIRS: Met ___ including respirations and tachycardia.
Initially treated empirically for infection. Antibiotics d/c'd
because felt likely source viral bronchitis. His SIRS symptoms
later resolved.
#) Wheezing: pt was noted to have wheezing and symptoms of
bronchitis with no infiltrate on CXR or fever. He was treated
for viral bronchitis with reactive airway disease with a 3 day
steroid burst and standing duonebs. His wheezing resolved by day
of discharged.
#) Hematuria: pt had hematuria due to traumatic foley placement.
He received CBI with passage of clots. Once transferred to the
medicine floor, he no longer had hematuria and was able to void
normally.
#) ___: Likely pre-renal given initially presented with BPs of
___ with hyperkalemia a likely consequence. BUN/CR and blood
pressure improved with fluid repletion. Lisinopril was held
given ___ and hypotension. This can be restarted as an
outpatient if pt become hypertensive.
#) Troponin Leak, Cardiac Disease (MR/TR, CAD). Resolved
problem, the pt broke to a rate of 55-60 from 110-130 and he was
in sinus rhythm, with no ST changes. His trops trended down 0.07
to 0.04. On admission, Trop mildly elevated with flat MB.
Likely demand ischemia, although questionable ST depressions on
initial EKG are somewhat worrisome but resolved with resolution
of tachycardia. Patient continued on ASA and statin.
#) AG Acidosis- mild elevation which may be due to renal failure
or hypoperfusion, although lactate is normal. This resolved with
fluid repletion.
#) Elevated INR - felt to be due to poor dietary intake.
resolved with vitamin K supplementation. Pt's daughter later
said he eats mostly bread at home. Nutrition was consulted, who
recommended BID ensure drinks and multivitamin.
#) Thrombocytopenia - chronic, unchanged from baseline.
TRANSITIONAL ISSUES:
- F/u BCx
- Cardiology to follow (Dr. ___
- Restart as lisinopril as needed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE TID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE TID
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. Senna 1 TAB PO BID:PRN constipation
5. Simvastatin 20 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*14 Tablet Refills:*0
7. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
RX *albuterol sulfate 90 mcg 2 puffs inhaled every four hours
Disp #*1 Inhaler Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Viral bronchitis
Hypotension
Atrial Tachycardia
Hematuria
Acute kidney injury
Secondary diagnosis:
basal cell cancer
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 ___ at ___. ___
were admitted for cough and malaise. ___ were found to have a
very low blood pressure and fast heart rate. This improved with
IV fluids and heart medications. ___ will need to take a higher
dose of metoprolol when ___ leave the hospital. In addition, we
feel ___ may have had an upper respiratory tract infection. This
appears to be improving. ___ will need to use an inhaler once
___ leave the hospital.
Your lisinopril was stopped due to low blood pressure. Your
primary care physician ___ need to decide if it should be
restarted.
The nutrition service spoke with ___ while ___ were here. They
recommend ___ drink ensure twice a day and take a multivitamin
daily.
Lastly, while ___ were here, ___ had some blood in your urine
after a catheter was placed. This has resolved. If this
continues, your PCP ___ need to refer ___ to a urologist.
We made the following changes to your home medications:
STOP lisinopril until told to restart by your PCP
INCREASE metoprolol succinate to 25mg daily ___ were previously
taking half dose)
START albuterol inhaler every 4 hours as needed
START multivitamin daily
Followup Instructions:
___
|
10895795-DS-27
| 10,895,795 | 24,584,128 |
DS
| 27 |
2201-10-06 00:00:00
|
2201-10-06 21:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
Tetracaine
Attending: ___.
Chief Complaint:
Hematuria
Major Surgical or Invasive Procedure:
___: Cystoscopy, clot evacuation, attempted fulguration of
prostatic bleeding
___: Prostatic embolization
History of Present Illness:
___ with significant BPH who presents in clot retention.
Patient was recently seen for a void trial one week ago after a
prolonged bout with urinary retention and an episode of clot
retention. Foley was removed and patient left before voiding. He
now returns after the onset of gross hematuria beginning
yesterday evening. He became unable to urinate and so presented
to the ED with worsening suprapubic discomfort and passage of
clots. An ___ 3-way was unfortunately placed which reportedly
failed to drain urine. Hand irrigation was attempted but with
minimal clot return. A bedside ultrasound showed a distended
bladder with a large hyperechoic structure in the bladder.
Urology was consulted for assistance.
Of note, patient with close to 450cc g prostate. He's had prior
CT with contrast shopwing no upper tract lesions. He's refused a
cystoscopy in the office previously.
Past Medical History:
BPH, with very recent foley catheter placement
CAD
Glaucoma
HTN
HLD
H/o Upper GI bleed in ___ NSAID use
Varicose veins
Nose lesion
Basal cell Ca Lt ear s/p resection
s/p Chole ___ years ago
Social History:
___
Family History:
Non-contributory to this acute presentation
Physical Exam:
AVSS
NAD
WWP
Unlabored breathing
Abd soft, NT, ND
Foley with clear, yellow urine
Ext WWP
Pertinent Results:
___ 06:25AM BLOOD WBC-13.4*# RBC-2.74*# Hgb-9.1*#
Hct-27.2*# MCV-99* MCH-33.4* MCHC-33.6 RDW-18.0* Plt ___
___ 07:20AM BLOOD WBC-6.8 RBC-2.04* Hgb-6.8* Hct-21.0*
MCV-103* MCH-33.4* MCHC-32.5 RDW-15.7* Plt ___
___ 12:45PM BLOOD WBC-7.0 RBC-2.37* Hgb-8.4* Hct-24.5*
MCV-103* MCH-35.6* MCHC-34.4 RDW-15.6* Plt ___
___ 08:30AM BLOOD WBC-8.6 RBC-2.44* Hgb-8.5* Hct-25.2*
MCV-103* MCH-34.9* MCHC-33.8 RDW-15.4 Plt ___
___ 07:40AM BLOOD WBC-8.2 RBC-3.01* Hgb-10.4* Hct-30.9*
MCV-103* MCH-34.5* MCHC-33.7 RDW-15.4 Plt ___
___ 04:40PM BLOOD WBC-12.5* RBC-3.36* Hgb-11.7* Hct-34.6*
MCV-103* MCH-34.7* MCHC-33.7 RDW-15.3 Plt ___
___ 05:20AM BLOOD WBC-8.7 RBC-3.92* Hgb-13.8* Hct-39.8*
MCV-102* MCH-35.2* MCHC-34.6 RDW-15.9* Plt ___
___ 06:25AM BLOOD Glucose-113* UreaN-20 Creat-1.1 Na-138
K-3.9 Cl-103 HCO3-20* AnGap-19
___ 07:45AM BLOOD Glucose-120* UreaN-16 Creat-0.9 Na-138
K-4.0 Cl-104 HCO___-27 AnGap-11
___ 05:20AM BLOOD Glucose-115* UreaN-20 Creat-1.0 Na-138
K-4.1 Cl-105 HCO3-24 AnGap-13
Brief Hospital Course:
HOSPITAL COURSE: Patient was transferred to the Urologic surgery
service after undergoing a c with Dr. ___. Patient
tolerated the procedure well and without complications. 500 cc
of clot was evacuated and a 3 way Foley was placed on CBI,
please see operative note for complete details. Patient was
extubated in the OR and taken to the PACU in stable condition.
He further recovered in the PACU before being transferred to the
floor for further post-operative care.
NEURO: Patient's pain was controlled during his stay with low
dose IV and oral pain medications and tylenol
CV: Patients vital signs remained stable throughout hospital
stay. .
PULM: Patient was weaned to RA on POD 0
GI: The patient tolerated a regular diet during his stay.
GU: Patient had a ___ 3way foley placed in the OR. He required
intermittent hand irrigation for continued hematuria and blood
clots. The ___ Fr catheter placed in the OR was exchanged to ___
on ___ with irrigation of 500 cc of clot to clear. The
patient's hematocrit had trended down to 21 on ___. The patient
then developed worsening hematuria refractory to hand irrigation
and CBI, so ___ was consulted for embolization of the prostate.
He tolerated the procedure well and urine was clear initially
after the procedure. The following day the patient's catheter
again began draining poorly with increased hematuria. The
catheter was aggressively hand irrigated free of 1L-1.5 L of old
clot. The urine was subsequently clear on CBI and remained clear
for the duration of his hospitalization.
HEME: Patient was offered subcutaneous heparin and pneumoboots
for DVT prophylaxis. Hematocrit was trended during his stay in
the setting of continued hematuria. His HCT was 40 on admission
and slowly trended down to 21 on ___. He was transfused 2 units
of pRBC on ___ and HCT improved to 27 on ___
ID: Patient received appropriate ___ antibiotics.
ENDO: No issues.
MSK: Patient ambulating on floors independently. ___ was
consulted and felt it was safe to return home.
The patient was deemed ready for discharge on POD6 with ___. On
the day of discharge the physical exam upon d/c was
unremarkable. He was AVSS, hemodynamically stable,
neurologically intact and his urine was yellow off CBI. Pt was
given explicit instructions to follow-up in clinic with Dr.
___.
Medications on Admission:
. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 1 TAB PO BID
8. Simvastatin 20 mg PO DAILY
9. Bacitracin Ointment 1 Appl TP BID
RX *bacitracin zinc 500 unit/gram apply to penis twice daily
Disp #*1 Tube Refills:*0
10. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
RX *betamethasone dipropionate 0.05 % apply to penis twice daily
Disp #*1 Tube Refills:*0
11. Tamsulosin 0.4 mg PO HS
Discharge Medications:
1. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
2. Finasteride 5 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Tamsulosin 0.4 mg PO HS
7. Docusate Sodium 100 mg PO BID
8. Senna 1 TAB PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
URINARY CLOT RETENTION, HEMATURIA (LIKELY PROSTATIC SOURCE)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume all of your pre-admission medications, except HOLD
aspirin until you see your urologist in followup AND your foley
has been removed (if not already done)
-Continue taking PROSCAR (Finasteride) AND/OR your other
prostate shrinking medications until you are otherwise advised
.
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place.
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthrough pain >4.
Replace Tylenol with narcotic pain medication.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery. Also, if the Foley catheter and Leg
Bag are in place--Do NOT drive (you may be a passenger).
IF YOU ARE DISCHARGED HOME WITH A FOLEY CATHETER:
-Please refer to the provided nursing instructions and handout
on Foley catheter care, waste elimination and leg bag usage.
-Your Foley should be secured to the catheter secure on your
thigh at ALL times until your follow up with the surgeon.
-Follow up in 1 week for wound check and Foley removal. DO NOT
have anyone else other than your Surgeon remove your Foley for
any reason.
-Wear Large Foley bag for majority of time, leg bag is only for
short-term when leaving house.
-IF PRESCRIPTION IS PROVIDED: Start prescribed antibiotic
(Ciprofloxacin) 1 day prior to scheduled Foley catheter removal
and for two subsequent days (unless otherwise written)
Followup Instructions:
___
|
10895795-DS-28
| 10,895,795 | 28,287,488 |
DS
| 28 |
2201-10-18 00:00:00
|
2201-10-26 14:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tetracaine
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo male with a h/o BPH s/p recent
hospitalization for hematuria with cytoscopy/clot evacuation and
prostate embolization who presents with encephalopathy, RUQ pain
and neck pain.
Of note, patient was started on ___ on ___ after home ___
found him to febrile to 101.6. He was discharged on ___ after
hospitalization on the urology service for hematuria with
cytoscopy/clot evacuation and expirimental prostate embolism ___
continued hematuria.
He denies any fevers, chills, nausea, vomiting, diarrhea or
constipation. Also denies any chest pain or shortness od breath.
In the ED labs were notable for Hct 23.3 (discharge Hct of 25),
U/A that grossly positive. CT scan showed fluid collections
within the prostate but was otherwise unremarkable. Urology c/s
was called and recommended full course of antibiotics before
intervention for the prostate fluid collections. He was given
Zosyn and admitted to medicine for further management.
On the floor patient reports the RUQ and shoulder pain has
resolved.
Review of sytems:
(+) Per HPI
Past Medical History:
BPH, with very recent foley catheter placement
CAD
Glaucoma
HTN
HLD
H/o Upper GI bleed in ___ NSAID use
Varicose veins
Nose lesion
Basal cell Ca Lt ear s/p resection
s/p Chole ___ years ago
Social History:
___
Family History:
Non-contributory to this acute presentation
Physical Exam:
Initial Physical Exam
Vitals- 98 68 119/42 24 94% RA
General- Alert and pleasant
HEENT- dry mucous membranes, sclera anicteric
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, moderately distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU- foley present draining clear urine
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, ecchymosis on right hand, right groin
Discharge Physical Exam
Vitals: T 97.8 BP 126/82 P 73 R 16 98% RA
General: Resting in bed, NAD
HEENT: EOMI, NC/AT, yellow skin lesions on nose
Neck: supple
Lungs: clear to auscultation b/l, no wheezes, rales, or rhonchi
CV: regular rate and rhythm, no murmurs, rubs, or gallops
Abdomen: moderately distended, no TTP, bowel sounds present, no
peritoneal signs
Ext: ecchymosis at right forearm, right hip, and suprapubic
region. No TTP at ecchymosis. Warm and well perfused.
Neuro: Alert, responding to questions appropriately
Pertinent Results:
Initial Lab Results
___ 03:24PM BLOOD WBC-14.5* RBC-2.36* Hgb-7.3* Hct-23.3*
MCV-99* MCH-31.1 MCHC-31.5 RDW-16.8* Plt ___
___ 03:24PM BLOOD Glucose-144* UreaN-26* Creat-1.1 Na-134
K-4.7 Cl-105 HCO3-23 AnGap-11
___ 03:24PM BLOOD ALT-43* AST-31 AlkPhos-95 TotBili-0.6
___ 03:24PM BLOOD Albumin-2.6*
___ 07:45PM BLOOD calTIBC-125* Ferritn-311 TRF-96*
___ 08:54PM BLOOD Lactate-0.8
Initial Imaging
CXR ___
FINDINGS:
There is slight blunting of the posterior right costophrenic
angle which may be due to a trace pleural effusion. Minimal
left pleural effusion is
difficult to exclude. The lungs remain relatively
hyperinflated, with
flattening of the diaphragms. Mild left base
atelectasis/scarring persists. Opacity projecting over the
posterior left 7th rib likely corresponds to a vessel as seen on
multiple prior studies dating back to at least ___.
There is mild central pulmonary vascular engorgement. No
definite focal consolidation is seen. There is no evidence of
pneumothorax. The cardiac silhouette is mildly enlarged. The
aortic knob is calcified.
CT A/P ___
IMPRESSION:
1. Markedly enlarged prostate, slightly smaller compared to the
prior exam, now measuring up to 8.8-cm. Areas of hypodensity
within the prostate are likely secondary to the recent
embolization procedure, however a superinfection of the prostate
cannot be excluded.
2. New right groin hematoma measuring 2.9 cm x 5.2 cm, also
likely secondary
to recent embolization procedure. Mild-to-moderate fecal loading
is noted
within the colon.
3. Lesion of intermediate density in each kidney, which can be
further
characterized by a non-urgent ultrasound or MRI
EKG ___
Sinus rhythm with baseline artifact. Left bundle-branch block.
Compared to the previous tracing of ___ there is no
diagnostic change.
Discharge Labs
___ 07:40AM BLOOD WBC-8.3 RBC-2.69* Hgb-8.5* Hct-26.0*
MCV-97 MCH-31.4 MCHC-32.6 RDW-16.9* Plt ___
___ 07:40AM BLOOD Glucose-89 UreaN-29* Creat-1.1 Na-138
K-4.2 Cl-107 HCO3-22 AnGap-13
___ 07:40AM BLOOD Calcium-8.1* Phos-3.0 Mg-2.3
Brief Hospital Course:
Mr. ___ is a ___ yo male with a h/o BPH s/p recent
hospitalization for hematuria with cytoscopy/clot evacuation and
prostate embolization who presents with confusion, found to have
bacteriuria and pyuria.
ACUTE ISSUES
# Confusion: Per the patient's daughter, Mr. ___ was
becoming increasingly confused over the last few days prior to
admission. In the Emergency Department, a UA was significant for
bacteriuria and pyuria. Though these findings were difficult to
interpret in the setting of an in-dwelling foley catheter, given
the patient's confusion, recent fever to 101.6 and UA positive
for bacteria and leukocytosis, the patient was treated for a
UTI. As he was initially started on Cipro by his home nurse 2
days prior to admission, Ciprofloxacin 500mg BID was continued,
given that he had not completed a full course to indicate
treatment failure. On day 2 of admission, the patient's urine cx
grew coag (+) staph aureus. Given these finding, his antibiotics
were changed to Bactrim DS BID, with a planned treatment course
of 10 days.
The patient remained asymptomatic during his admission, and
denied any pain. He remained afebrile, and his leukocytosis
down-trended to 8.3.
# Anemia: The patient presented w/ anemia with a Hct of 20.9%
from 44% on ___. The etiology of this anemia was unclear
though per urology, the patient lost a significant amount of
blood during his recent admission. The patient was asx, and
denied dizzyness or lightheadedness. He was transfused 1 unit
PRBCs. Post-transfusion, the patient's Hct continued to up-trend
to 26% on ___. The patient did have a bowel movement which
was guaiac negative. Iron studies revealed low iron, TIBC, and
Transferrin, indicating a possible mixed etiology of anemiaof
chronic disease and iron deficiency anemia. The patient also has
multiple ecchymosis on right hip, right forearm, and right
supra-pubic region which he developed during his recent
admission, which may be contributing to his anemia. The patient
was started on iron supplementation of 325 mg Fe daily.
# RUQ/neck pain: the patient complained of RUQ abdominal pain
and neck pain which had resolved upon arrival to the floor.
CHRONIC ISSUES
# CAD: The patient has a known diagnosis of coronary artery
disease which remained clinically stable on his home regimen of
Metoprolol.
# BPH: The patient has a known diagnosis of BPH and he remained
clinically stable on his home regimen of Finasteride and
Doxasin.
# HLD: The patient was continued on his home regimen of
Simvastatin.
# Glaucoma: The patient was continued on his home regimen of
Latanoprost and Dorzolamide.
TRANSITIONAL ISSUES
#: CT A/P showed fluid collections in pt's prostate which are
susceptible to infection. Pls monitor for constipation and pain
which would indicate infection of these collections.
# Please also monitor for abdominal distention and bowel
movements to evaluate for constipation
# Please continue treatment with Bactrim DS BID for 8 more days
# Please continue to monitor for hypotension, tachycardia,
melena, or bloody bowel movements given patient's anemia
# Please assist patient with eating as he had poor PO intake and
required assistance with eating during admission
# Final urine culture pending on discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
2. Finasteride 5 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. Metoprolol Succinate XL 12.5 mg PO BID
5. Simvastatin 20 mg PO DAILY
6. Tamsulosin 0.4 mg PO HS
7. Docusate Sodium 100 mg PO BID
8. Senna 1 TAB PO BID
9. Ciprofloxacin HCl 500 mg PO Q12H
10. Polyethylene Glycol 17 g PO Frequency is Unknown
11. Bacitracin Ointment 1 Appl TP BID
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*16 Tablet Refills:*0
2. Tamsulosin 0.4 mg PO HS
3. Simvastatin 20 mg PO DAILY
4. Senna 1 TAB PO BID
5. Polyethylene Glycol 17 g PO DAILY
6. Metoprolol Succinate XL 12.5 mg PO BID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Finasteride 5 mg PO DAILY
9. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
10. Docusate Sodium 100 mg PO BID
11. Bacitracin Ointment 1 Appl TP BID
12. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Urinary Tract Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___:
It was a pleasure caring for you at ___
___. You were admitted here because your nurse and
your daughter noticed you were confused. At the hospital, you
were found to have an infection in your urinary tract. We
started you on antibiotics to treat your infection, and you
remained comfortable and without pain.
The physical therapists came to evaluate you and felt that you
will be safer going to a rehabilitation center. At the
rehabilitation center, you will continue to be treated with
antibiotics, and they will work with you to improve your
strength.
Please follow up with the urologists (the doctors who ___
your urinary tract system) at the appointment listed below.
Followup Instructions:
___
|
10895937-DS-18
| 10,895,937 | 29,123,184 |
DS
| 18 |
2156-08-15 00:00:00
|
2156-08-16 15:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cold leg
Major Surgical or Invasive Procedure:
Left femoral artery cutdown with bypass graft thrombectomy and
stenting to the distal anastomosis
History of Present Illness:
Ms. ___ is an ___ female, active smoker, who
recently underwent a left profunda to below-knee popliteal
bypass on ___. She presented to the Emergency
Department on ___ after two days of recurrent left leg rest
pain. A prosthetic bypass graft was used for prior operation
because of the lack of ipsilateral greater saphenous vein on
exploration. She was found to have a cyanotic left foot with
delayed capillary refill and some decreased sensation. A CTA was
performed demonstrating left bypass graft occlusion. We
therefore offered an open thrombectomy and arteriogram to reopen
the bypass and evaluate the cause of the graft thrombosis.
Past Medical History:
Rheumatoid Arthritis, Peripheal Vascular Disease, GERD,
Hypothyroidism
SURGICAL HISTORY:
___ - distal SFA stent
___ - LLE angio for claudication, spectranetics 1.4 laser
catheter and subsequent stent placement at SFA and AK-Pop for
occlusion
___ LLE angio - completely occluded L SFA with
reconstitution at below knee popliteal. (___)
___: L Femoral profundal to BK Popliteal bypass using
distaflow 6MM PTFE (___)
Social History:
___
Family History:
Noncontributory
Physical Exam:
VITAL SIGNS: 98.3, 71, 110/66, 18, 99% RA
GENERAL: Well appearing, NAD
NEURO: AOx3, Strength in B/L ___ ___ dorsiflexion/plantarflexion,
sensory deficit along heel of LLE and medial aspect of the leg
unchanged from discharge
HEENT: EOMI, no scleral icterus
CARDIO: RRR
PULM: breathing comfortably on room air
ABD: soft, NT/ND, no guarding
Extremities: incision over left groin and left medial thigh; no
erythema or drainage and nontender to palpation, cool feet-
equal
bilateral
PSCYH: appropriate mood and affect
PULSES: R: p/-/d/p L:p/graft -/-/-
Pertinent Results:
___ 05:24AM BLOOD WBC-6.5 RBC-2.92* Hgb-8.3* Hct-26.5*
MCV-91 MCH-28.4 MCHC-31.3* RDW-14.8 RDWSD-49.2* Plt ___
___ 02:45PM BLOOD Neuts-57.0 ___ Monos-8.2 Eos-2.3
Baso-0.7 Im ___ AbsNeut-4.76 AbsLymp-2.59 AbsMono-0.68
AbsEos-0.19 AbsBaso-0.06
___ 07:49PM BLOOD PTT-58.7*
___ 05:24AM BLOOD Plt ___
___ 05:24AM BLOOD ___ PTT-70.4* ___
___ 05:24AM BLOOD Glucose-98 UreaN-15 Creat-1.0 Na-144
K-4.9 Cl-108 HCO3-27 AnGap-9*
___ 05:24AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.1
___ 03:50AM BLOOD %HbA1c-5.0 eAG-97
___ 09:34PM BLOOD Hgb-9.3* calcHCT-28
Brief Hospital Course:
Ms. ___ is an ___ female, active smoker, who
recently underwent a left profunda to below-knee popliteal
bypass on ___. A prosthetic bypass graft was used for
prior operation because of the lack of ipsilateral greater
saphenous vein on exploration. She presented to the Emergency
Department on ___ after two days of recurrent left leg rest
pain. She was found to have a cyanotic left foot with delayed
capillary refill and some decreased sensation. A CTA was
performed demonstrating left bypass graft occlusion. We
therefore offered an open thrombectomy and arteriogram to reopen
the bypass and evaluate the cause of the graft thrombosis.
Patient underwent a left femoral artery cutdown with bypass
graft thrombectomy and stenting to the distal anastomosis on
___ ___. She had a Prevena wound vac placed
to the incision to assist with wound healing. For full details
of the surgical procedure please see the dictated operative
report. After a brief stay in PACU she was transferred to the
vascular surgery floor where she remained for the rest of her
hospitalization.
Patient did continue to have some left lower extremity leg pain
which was well controlled with APAP and gabapentin. Her diet
was advanced to a house diet which she tolerated well. She was
able to void on her own QS. She was able to ambulate ad lib
around the unit prior to discharge.
Patient was discharged home with the Prevena wound vac for
continued assistance with wound care. This will need be removed
on ___ or ___ by ___ services. Wound care orders have been
placed with patient's ___.
Due to stent placement at the graft anastomosis, she has been
placed on Plavix 75mg daily and will need to remain on the for
30 days. After this course she should resume ASA 81mg daily. She
has also been placed back on xarelto to help maintain graft
patency. She was provided with a new prescription for this and
instructed to not stop the medication unless instructed by
vascular surgery.
Patient has a PMH of HTN which was stable throughout her
admission. Her home regimen was continued.
Patient has significant smoking history. Education on the
benefit of smoking cessation on her bypass graft was discussed
and smoking cessation information was offered and declined.
We would like for Ms. ___ to return to the vascular surgery
clinic in 3 weeks for staple removal and a left lower extremity
duplex to assess graft patency. She has voiced concern over
travel distance from her home in ___ so she was
provided with contact information for vascular surgery ___
___, MD) at ___. She may establish care there after
her postoperative check at ___ in ___ or with Dr. ___ at
___. She is amenable to establishing
vascular surgery care in ___.
Patient is discharged home with services in an improved and
stable condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Venlafaxine XR 150 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Zolpidem Tartrate 10 mg PO QHS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Clopidogrel 75 mg PO DAILY
Continue for 30 days and then stop
RX *clopidogrel 75 mg 1 (One) tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
decrease frequency and dose as pain level improves
RX *oxycodone 5 mg 1 (One) tablet(s) by mouth three times a day
Disp #*12 Tablet Refills:*0
5. Rivaroxaban 20 mg PO DAILY
continue lifelong
RX *rivaroxaban [Xarelto] 20 mg 1 (One) tablet(s) by mouth once
a day Disp #*30 Tablet Refills:*3
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
7. Atorvastatin 80 mg PO QPM
8. Gabapentin 300 mg PO TID
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Metoprolol Succinate XL 12.5 mg PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Venlafaxine XR 150 mg PO DAILY
13. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Critical Limb Ischemia
Secondary: Peripheral vascular disease, hypertension, nicotine
addiction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital because of
occlusion in the PTFE graft in your leg. You had surgery to
remove the clot and improve blood flow to your leg. You
tolerated the procedure well and are now ready to be discharged
from the hospital. Please follow the recommendations below to
ensure a speedy and uneventful recovery.
You also had a stent placed in your left leg. You have been
started on Plavix and will need to continue this 30 days.
Additionally, you have a Prevena wound vac placed to your left
thigh incision. This is placed to assist with healing. Your
visiting nurse ___ help you manage this. Under the vac are
staples that have closed this incision. You will need these to
be removed by the vascular surgery clinic.
Vascular Leg Surgery Discharge Instructions
What to except:
It is normal feel tired for ___ weeks after your surgery
It is normal to have leg swelling. Keep your leg elevated as
much as possible. This will decrease the swelling.
Your leg will feel tired and sore. This usually passes
within a few weeks.
Your incision will be sore, slightly raised, and pink. Any
drainage should decrease or stop with in the first 2 weeks.
If you are home, you will likely receive a visit from a
Visiting Nurse ___. Members of your health care team will
discuss this with you before you go home.
Medications:
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
It is very important that you take Aspirin every day! You
should never stop this medication before checking with your
surgeon
Pain Management:
It is normal to feel some discomfort/pain following surgery.
This pain is often described as soreness.
You may take Tylenol (acetaminophen ) as needed for pain.
You will also receive a prescription for stronger pain medicine,
if the Tylenol doesnt work, take prescription medicine.
Narcotic pain medication can be very constipating, please also
take a stool softner such as Colace. If constipation becomes a
problem, your pharmacist can suggest additional over the counter
medications.
Your pain medicine will work better if you take it before your
pain gets to severe.
Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
Activity:
Do not drive until your surgeon says it is okay. In general,
driving is not allowed until
-the staples in your leg have been taken out
-your leg feels strong
-you have stopped taking pain medication and feel you could
respond in an emergency
Walking is good because it helps your muscles get stronger and
improves blood flow. Start with short walks. If you can, go a
little further each time, letting comfort be your guide.
Try not to go up and downstairs too much in the first weeks.
Use stairs only once or twice a day until your incision is fully
healed and you are back to your usual strength.
Avoid things that may constrict blood flow or put pressure on
your incision, such as tight shoes, socks or knee highs.
Do not take a tub bath or swim until your staples are removed
and your wound is healed.
When you sit, keep your leg elevated to reduce swelling.
If swelling in your leg is getting worse, lie down with your
leg up on a pillows. If your swelling continues, please call
your surgeon. You may be instructed to use special elastic
bandages or stockings.
Try not to sit in the same position for a long while. For
example, ___ go on a long car ride.
You may go outside. But avoid traveling long distances until
you see your surgeon at your next visit.
You may resume sexual activity after your incisions are well
healed.
Your incision
Your incision may be slightly red around the stitches or
staples. This is normal.
It is normal to have a small amount of clear or light red
fluid coming from your incision.
This will decrease and stop in a few days. If it does not stop,
or if you have a lot of fluid coming out., please call your
surgeon.
You may shower 48 hours after your surgery. Do not let the
shower spray right on the incision, Let the soapy water run
over the incision, then rinse. Gently pat the area dry. Do not
scrub the incision, Do not apply ointment or lotions to the
incision.
You do not need to cover the incision if there is no drainage,
If there is a small amount of drainage, put a small sterile
gauze or Bandaid over the incison.
It is normal to feel a firm ridge along the incision, This
will go away as your wound heals.
Avoid direct sun exposure to the incision area for 6 months.
This will help keep the scar from becoming discolored.
Over ___ months, your incision will fade and become less
prominent.
Diet and Bowels
It is normal to have a decreased appetite. Your appetite will
return over time. Follow a well-balanced, health healthy diet,
without too much salt and fat.
Prescription pain medicine might make you constipated. If
needed, you may take a stool softener (such as Colace) or gentle
laxative (ask your pharmacist for recommendations).
Drinking more fluid may also help.
If you go 48 hours without a bowel movement, or having pain
moving your bowels, call your primary care physician.
Followup Instructions:
___
|
10895937-DS-19
| 10,895,937 | 23,234,616 |
DS
| 19 |
2156-11-04 00:00:00
|
2156-11-04 14:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left lower extremity pain with foot discoloration
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. ___ is an ___ yo F, currently smoking, w/ PAD
recently admitted for left profundal to BK popliteal bypass with
PTFE (___), sp open thrombectomy with stenting of distal
anastomosis (___) who represents with 1 day of cold purple toes
which resolved upon presentation. To review, she has a history
of claudication and was admitted ___ for L profunda to BK
pop bypass. Her initial surgery was uncomplciated and she was
readmitted ___ after 4 days of foot pain with occluded
graft which was treated with open thrombectomy and stenting of
distal anastomosis. She returns today without any foot pain or
evidence of ischemia on presentation but with reported purple
toes/cold toes for 3 hours this morning when evaluated by ___.
Past Medical History:
Rheumatoid Arthritis, Peripheal Vascular Disease, GERD,
Hypothyroidism
SURGICAL HISTORY:
___ - distal SFA stent
___ - LLE angio for claudication, spectranetics 1.4 laser
catheter and subsequent stent placement at ___ and AK-Pop for
occlusion
___ LLE angio - completely occluded L SFA with
reconstitution at below knee popliteal. (___)
___: L Femoral profundal to BK Popliteal bypass using
distaflow 6MM PTFE (___)
Social History:
___
Family History:
Noncontributory
Physical Exam:
Vitals: 97.9 148/73 66 17 94%/RA
GENERAL: Well appearing, NAD, AAOx3
EYES: EOMI, no scleral icterus
CARDIO: RRR
PULM: breathing comfortably on room air
ABD: soft, NT/ND, no guarding
Extremities: sensory deficit along heel of LLE and medial aspect
of the leg
unchanged from prior exam, brisk capillary refill
PULSES: R: p/p/p/p, L: p/d/peroneal/d
Pertinent Results:
Labs---------------
___ 02:43AM BLOOD WBC-6.3 RBC-4.63 Hgb-12.1 Hct-39.8 MCV-86
MCH-26.1 MCHC-30.4* RDW-13.9 RDWSD-43.8 Plt ___
___ 12:05AM BLOOD Neuts-54.1 ___ Monos-8.7 Eos-3.4
Baso-0.4 Im ___ AbsNeut-3.65 AbsLymp-2.24 AbsMono-0.59
AbsEos-0.23 AbsBaso-0.03
___ 09:10AM BLOOD PTT-90.3*
___ 02:43AM BLOOD Glucose-89 UreaN-19 Creat-0.9 Na-141
K-4.4 Cl-109* HCO3-24 AnGap-8*
___ 02:43AM BLOOD Calcium-8.8 Phos-4.3 Mg-2.2
Brief Hospital Course:
Mrs. ___ is an ___ yo F, currently smoking, w/ PAD
recently admitted for left profundal to BK popliteal bypass with
PTFE (___), sp open thrombectomy with stenting of distal
anastomosis (___) who represents with 1 day of cold purple toes
which resolved upon presentation. To review, she has a history
of claudication and was admitted ___ for L profunda to BK
pop bypass. Her initial surgery was uncomplciated and she was
readmitted ___ after 4 days of foot pain with occluded
graft which was treated with open thrombectomy and stenting of
distal anastomosis. She returns today without any foot pain or
evidence of ischemia on presentation but with reported purple
toes/cold toes for 3 hours this morning when evaluated by ___.
Patient was initially seen at ___ and transferred to
___. She was placed on a heparin drip and received
non-invasive testing. She was deemed stable by her workup. Her
pain resolved and discoloration improved. She was re-started on
Xarelto and ASA prior to discharge home on Hospital Day 1.
Additionally she was discharged on cilostazol 100mg BID to help
with her claudication symptoms.
Patient will need to present for follow up with Dr. ___ in
approximately 3 weeks. She should call sooner for any new or
concerning symptoms
Patient is discharged home without services in an improved and
stable condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
2. Zolpidem Tartrate 10 mg PO QHS
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Pantoprazole 40 mg PO Q24H
6. Aspirin 81 mg PO DAILY
7. Venlafaxine XR 150 mg PO DAILY
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Gabapentin 300 mg PO TID
Discharge Medications:
1. Cilostazol 100 mg PO BID
RX *cilostazol 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*5
2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Gabapentin 300 mg PO TID
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Metoprolol Succinate XL 12.5 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Rivaroxaban 20 mg PO DAILY
10. Venlafaxine XR 150 mg PO DAILY
11. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Peripheral Vascular disease, Rheumatoid arthritis
Secondary; nicotine dependence,
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Ms. ___,
You were admitted to ___ over concern for low blood flow to
your left leg. You received a blood thinner and had
non-invasive imaging done on your leg and your peripheral
vascular disease appears stable.
You have been transitioned back to your home dose of Xarelto as
well as, a baby aspirin and it is very important that you do not
stop these medications without speaking to your surgeon.
Additionally, you have been started on a new medication to help
with claudication symptoms in the leg called cilostazol. This
medication will take a couple of weeks before effects may be
seen.
It is important to keep your follow up appointment. You have
been scheduled for an office visit with Dr. ___ in one month.
Please call the office if you experience an increase in
claudication symptoms, rest pain, skin ulceration, or change in
foot/toe coloring.
Followup Instructions:
___
|
10896131-DS-12
| 10,896,131 | 28,492,008 |
DS
| 12 |
2129-05-14 00:00:00
|
2129-05-14 10:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
rib pain/fractures left ___ ribs
left ___ finger distal phalanx human bite/fracture
scalp lacerations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old gentleman assaulted and stabbed right
anterior chest wall. Patient also reported falling and hitting
the back of his head on train
tracks ___. He also sustained a human bite to his Left ___
finger
distal phalanx. He sustained ___ rib fractures. He received
sutures and
volar hand splint for finger ___. Patient had sutures for scalp
laceration ___.
Past Medical History:
- seziure d/o since age ___ s/p right temporal lobectomy who p/w
unsteadiness
- sustained a right distal radius fracture in ___ after falling
while trying to jump over handicap rail at a train station. He
has been wearing a cast
- known history of gait instability in the absence of truncal or
___ ataxia; he has been referred to the ED in the past and has
been seen by the neurology staff on numerous occasions regarding
his unsteadiness.
- seizure disorder
> described as "petit mal"
> followed by ___ in neurology
> onset @ age ___ yo possibly secondary to meningitis at 6 mo.
> meds: dilantin, phenobarbital, mysoline, tegretol
> s/p right temporal lobectomy in ___ with subsequent left
homonymous hemianopsia
Social History:
___
Family History:
no seizure
Physical Exam:
PHYSICAL EXAMINATION: Upon admission ___
HR: 80 BP: 152/105 Resp: 12 O(2)Sat: 100
Constitutional: Comfortable
HEENT: Small laceration on the occiput
Oropharynx within normal limits, no midline C-spine
tenderness
Chest: Clear to auscultation, superficial wound left
anterior chest
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
___: No petechiae
PHYSICAL EXAMINATION: Upon discharge ___
HR:
Constitutional: Comfortable
HEENT: Small laceration on the occiput intact with sutures
without drainage or erythema. Oropharynx within normal limits,
no midline C-spine
tenderness
Chest: Clear bilaterally, superficial wound left
anterior chest
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender
Skin: No rash
Ext: Left volar splint applied, sensation intact distally, no
discoloration, no numbness or tingling, left hand is tender to
touch over splint, no swelling or tenderness of the lower
extremities. Palpable pedal pulses bilaterally.
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
___: No petechiae
Pertinent Results:
___ 10:50PM PO2-65* PCO2-23* PH-7.54* TOTAL CO2-20* BASE
XS-0 COMMENTS-GREEN TOP
___ 10:50PM GLUCOSE-89 LACTATE-4.4* NA+-136 K+-5.8*
CL--104
___ 10:50PM HGB-13.9* calcHCT-42 O2 SAT-93 CARBOXYHB-2
MET HGB-0
___ 10:50PM freeCa-0.97*
___ 10:45PM UREA N-19 CREAT-1.0
___ 10:45PM estGFR-Using this
___ 10:45PM LIPASE-67*
___ 10:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-POS tricyclic-NEG
___ 10:45PM WBC-6.9 RBC-4.58* HGB-13.6* HCT-42.1 MCV-92
MCH-29.7 MCHC-32.4 RDW-12.4
___ 10:45PM ___ PTT-23.6* ___
___ 10:45PM PLT COUNT-195
___ 10:45PM ___
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
IMPRESSION:
1. Encephalomalacia in the right temporal lobe with overlying
likely
postoperative changes. However, small subdural hemorrhage in
this area cannot be excluded. Correlation with penetrating
injury in this area is recommended. A short-term followup may be
obtained for further evaluation, or comparison with priors may
be pursued.
2. Paranasal sinus disease.
Radiology Report HAND (AP, LAT & OBLIQUE) LEFT Study Date of
___
IMPRESSION: Obliquely oriented fracture through the second
distal tuft. No other definite fracture. No radiopaque foreign
body.
Radiology Report ELBOW (AP, LAT & OBLIQUE) LEFT Study Date of
___
There is no fracture or dislocation. There is no suspicious
osseous lesion. There is no joint effusion. There is no soft
tissue swelling or radiopaque foreign body.
Brief Hospital Course:
___ RHD who, after being mugged and stabbed alongside a railroad
track while minding his own business, presented to ___ and was
found to have a nondisplaced tuft fracture of the distal phalanx
of the index finger immediately subjacent to a human bite wound.
Orthopaedic hand surgery consulted. A hand splint was placed at
that time. ___ was consulted to evaluate for discharge home.
Unfortunately at this time, he was unstable, likely secondary to
a remote TBI, seizures, and temporal lobectomy. At that time, it
was recommended that he go to a rehab facility. Has has remained
stable throughout his hospital course, with no acute issues. He
has ambulated with ___ and nursing, and is alert and oriented.
Medications on Admission:
carbamazepine ER 200", carbamazepine ER 300", finasteride 5',
naproxen 500", primidone 750', tamsulosin ER 0.8', ASA 81'
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carbamazepine (Extended-Release) 500 mg PO BID
3. Finasteride 5 mg PO DAILY
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every four (4)
hours Disp #*10 Tablet Refills:*0
5. PrimiDONE 250 mg PO HS
6. PrimiDONE 500 mg PO QAM
7. Tamsulosin 0.8 mg PO HS
8. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 2 Weeks
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 875 mg
by mouth every twelve (12) hours Disp #*28 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Finger fracture
Discharge Condition:
Good with pain control. Tolerating regular diet and ambulatory.
Discharge Instructions:
You were treated by the Acute Care Surgery service at ___
___. You have multiple lacerations
(cuts) on your body, rib fractures, and a left index fingertip
fracture from a bite. You will need to be on antibiotics for
this.
Please take your antibiotics as prescribed for 2 weeks.
You will also be received oxycodone for your injury. DO NOT
DRINK ALCOHOL with this medication! Also do not drive a car or
any machinery while taking this.
Go to your physician or the nearest Emergency Department if your
condition worsens or you have any concerns.
Some warning signs are increased redness, fevers, chills, or any
other concern. Follow up with your doctor in ___ days to
reevaluate your finger.
Rib Fractures:
* Your injury caused 5 rib fractures which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10896131-DS-13
| 10,896,131 | 29,670,258 |
DS
| 13 |
2132-07-27 00:00:00
|
2132-07-27 15:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Transient worsening of ataxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo man with history of temporal lobe
epilepsy
s/p temporal lobectomy in the remote past who presents with an
episode of increased gait ataxia.
Mr. ___ was in his USOH when he stood to walk with a friend
down the train platform to get on the train and started walking.
He then says he began walking in a serpiginous path and he says
he felt like he was walking as if he were drunk. Despite
multiple
attempts to clarify whether gait was initially normal and then
became abnormal or whether gait was abnormal as soon as he
started walking, he is unable to answer the question.
He then sat down on the train, and approx. 15 minutes later EMS
arrived and he tried walking again. He says that his walking
weaved less, but was still abnormal. He did not try walking
again
until several minutes before my evaluation, which was hours
after
his initial presentation to OSH.
He initially presented to ___ where he
underwent NCHCT which was read as foci of density and gas in
craniotomy site concerning for infection/SDH. They had no prior
studies to which to compare. They transferred to ___ for
neurosurgical evaluation.
Mr. ___ states he currently feels at baseline.
Denies any recent infectious s/s.
Mr. ___ has had epilepsy since age ___, and had R temporal
lobectomy approx. ___ years ago. Since the lobectomy he has had
only rare seizures, last several years ago. He has difficulty
describing his seizures, but says he feels dizzy then sits down,
doesn't lose consciousness and has shaking of both arms.
He has chronic deficits from the lobectomy, including L
hemianopsia and ataxic gait.
Past Medical History:
Epilepsy
s/p R temporal lobectomy
posterior circulation atherosclerosis per ___ MRA.
BPH
osteopenia
Social History:
___
Family History:
No family history of seizures nor stroke.
Physical Exam:
ADMISSION EXAMINATION
Vitals: T: 97.4 HR: 58 BP: 147/87 RR: 18 SaO2: 98% RA
General: Awake, cooperative, NAD.
HEENT: no scleral icterus, MMM, no oropharyngeal lesions.
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: Skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema.
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___
backward.
Speech is fluent with normal grammar and syntax. No paraphasic
errors. Naming intact to low frequency words. Repetition intact.
Comprehension intact to complex, cross-body commands. Normal
prosody. Mildly disinhibited.
-Cranial Nerves: PERRL 3->2. VFF to confrontation. EOMI without
nystagmus. Facial sensation intact to light touch. Face
symmetric
at rest and with activation. Hearing intact to conversation.
Palate elevates symmetrically. ___ strength in trapezii
bilaterally. Tongue protrudes in midline and moves briskly to
each side. No dysarthria.
- Motor: Normal bulk and tone. No drift. L>R action tremor.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach Pec jerk Crossed Abductors
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was flexor bilaterally.
-Sensory: Proprioception intact to small excursions bilateral
great toes. Intact to LT throughout.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with gross and fine
rapid alternating movements. Cerebellar check without rebound
bilaterally.
- Gait: Normal initiation. Wide base (i.e shoulder-width apart).
Good gait speed, Ataxic gait. Occasionally surprised by objects
on his left, and almost loses his balance. Turns with ___ steps.
DISCHARGE EXAMINATION
Vitals: T: 98.4 HR: 76 BP: 133/90 RR: 18 SaO2: 94% RA
General: Awake, cooperative, NAD.
HEENT: no scleral icterus, MMM
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: Skin warm, well-perfused.
Extremities: Symmetric, no edema.
Neurologic Examination:
- Mental status: Awake, alert, cooperative. Speech is fluent
without dysarthria, comprehension intact. Able to follow midline
and appendicular commands. Mildly disinhibited.
-Cranial Nerves: EOMI without nystagmus. Face symmetric at rest
and with activation. Hearing intact to conversation.
- Motor: Full throughout.
-DTRs: ___.
-Sensory: Intact to LT throughout.
- Coordination: Deferred.
- Gait: Wide-based but steady with fast pace. Turns with ___
steps.
Pertinent Results:
HEMATOLOGY AND CHEMISTRIES
___ 04:50AM BLOOD WBC-7.1 RBC-4.38* Hgb-12.9* Hct-39.7*
MCV-91 MCH-29.5 MCHC-32.5 RDW-13.1 RDWSD-43.8 Plt ___
___ 04:50AM BLOOD ___ PTT-28.6 ___
___ 04:50AM BLOOD Glucose-86 UreaN-20 Creat-1.0 Na-142
K-4.6 Cl-103 HCO3-26 AnGap-13
___ 03:55AM BLOOD %HbA1c-5.7 eAG-117
___ 03:55AM BLOOD Triglyc-166* HDL-40* CHOL/HD-5.6
LDLcalc-150*
___ 03:55AM BLOOD TSH-1.8
IMAGING
___ 6:06 AM CTA HEAD AND CTA NECK (Preliminary)
CT HEAD WITHOUT CONTRAST:
No acute intracranial abnormality. Compared to ___
and ___, no significant change in encephalomalacia of the
entire right temporal lobe and ex vacuo enlargement of the
posterior components of the right lateral ventricle.
CTA HEAD:
The vessels of the circle of ___ and their principal
intracranial branches appear normal without stenosis, occlusion,
or aneurysm formation. The dural venous sinuses are patent.
CTA NECK:
No evidence of dissection. The carotid arteries and their major
branches
appear normal with no evidence of stenosis or occlusion. The
bilateral
vertebral arteries are diminutive, but patent without evidence
of occlusion. There is no evidence of internal carotid stenosis
by NASCET criteria.
___ 1:02 AM MR HEAD W/O CONTRAST
1. Cystic encephalomalacia of most of the right temporal lobe
with associated ex vacuo dilatation of the adjacent right
lateral ventricle.
2. The basilar artery is small with intermittent areas of loss
of flow void in keeping with basilar artery stenosis which is
better seen on prior CTA done ___.
3. No acute infarct. No intracranial hemorrhage.
Brief Hospital Course:
Mr. ___ is a ___ old man with a history of childhood
epilepsy s/p remote R temporal lobe resection who presented with
acute onset worsening of his chronic ataxic gait. On exam, his
gait difficulty had resolved. CTA showed mid-occlusion of the
basilar artery with good collaterals in the setting of known
progressive stenosis on prior vessel imaging. He was also seen
to have fetal PCA on the left and a remnant right trigeminal
artery on the right, stable from prior imaging, and the likely
source of collateral flow noted above. This explains the
hypoplastic appearance of his vertebral arteries and the
proiximal/mid basilar. The etiology of his symptoms was
therefore thought to be a TIA in the setting of basilar
occlusion/stenosis rather than acute occlusion. MRI brain
accordingly did not show new infarct or hemorrhage. He was
started on aspirin and clopidogrel, with plan to continue on
dual antiplatelet for three months and then continue on Aspirin
81mg daily thereafter. He was also started on a high dose
statin.
Stroke risk factors were checked, including:
1) DM: A1c 5.7%
2) Basilar artery stenosis
3) Hyperlipidemia: LDL 150
He was able to ambulate independently on discharge and was
discharged home. He was provided counseling medication
adherence.
Transitional issues:
1) Continue Aspirin and Plavix for 3 months (through
___ and then continue Aspirin 81mg thereafter
indefinitely.
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 = 150) - () No
5. Intensive statin therapy administered? (x) Yes - () No
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?
() Yes - (x) No - asymptomatic
9. Discharged on statin therapy? (x) Yes - () No
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:
1. Carbamazepine (Extended-Release) 600 mg PO BID
2. PrimiDONE 500 mg PO QAM
3. PrimiDONE 250 mg PO QPM
4. Tamsulosin 0.8 mg PO QHS
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*5
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
3. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*5
4. Carbamazepine (Extended-Release) 600 mg PO BID
5. PrimiDONE 500 mg PO QAM
6. PrimiDONE 250 mg PO QHS
7. Tamsulosin 0.8 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Transient ischemic attack (TIA)
Basilar artery stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of difficulty with walking
resulting from a TRANSIENT ISCHEMIC ATTACK (TIA), a condition
where a blood vessel providing oxygen and nutrients to the brain
is temporarily blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- narrowing of the basilar artery which supplies blood to the
brain
- high cholesterol
We are changing your medications as follows:
START ASPIRIN 81MG DAILY
START CLOPIDOGREL 75MG DAILY
START ATORVASTATIN 80MG NIGHTLY
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
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2120-03-26 16:18:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Wellbutrin
Attending: ___
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Cardiac Catheterization, Cardioversion
History of Present Illness:
Patient is a ___ yo man w/ hx of CHF, bipolar I, afib, HTN and
AVR x2 presenting with chest pressure and SOB after a recent
hospitalization 3 weeks ago at ___ for CHF. ___
reports a ___ month period of increasing dyspnea on exertion
(walking 2 blocks) and worsening orthopnea. ___ describes
left-sided exertional chest pressure that is relieved with rest.
This has been occuring almost daily, but the pressure is not
persistent. Three weeks ago, ___ was admitted to ___ for acute
on chronic systolic heart failure exacerbation and was treated
with IV diuresis. ___ was ruled out for PE and ECHO was repeated
which showed EF 35% and new mitral regurg which were new
findings from previously. ___ was discharged with instructions
to start Carvedilol 3.125mg and increase Lasix dose to 80mg po
bid, but these adjustments were not followed through. Since
discharge ___ has continued to report dyspnea, orthopnea, fatigue
and a 20lb weight increase in past 3 weeks. Patient seen by PCP
this am who recommended hospitalization for IV diuresis. Of
note, ___ has not experienced fevers, chills, rashes, or syncope.
.
In the ED, initial vitals were 98.6, 60, 106/80, 20, 99%RA
Labs and imaging significant for small right pleural effusion.
There is no pulmonary vascular congestion or redistribution.
Troponin reported to be mildly elevated at 0.02 and was given
325 mg aspirin. Patient given 40 mg IV lasix x1 as well.
.
On arrival to the floor, patient vitals 98.2 113/58 58 18
96%RA. Pt alert, oriented x3, in no acute distress.
REVIEW OF SYSTEMS:
On review of systems, ___ denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. ___ denies recent fevers, chills or
rigors. ___ denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for positive chest pressure
on exertion, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, mild ankle edema. Denies syncope, dizziness,
paliptations.
Past Medical History:
PAST MEDICAL HISTORY:
-atrial fibrillation/flutter
-Aortic valve replacement x 2 (___)
-chronic systolic congestive heart failure
-benign prostatic hypertrophy
-asthma
-obesity
-hypertension
-History of head trauma ___ years ago with LOC, "fell out of
truck")
PSYCHIATRIC HISTORY: As above in HPI. Also, ___ Pt reports
being on numerous medications over the years, but is unable to
recall others than what ___ is currently taking. ___ underwent "6
or so" courses of ECT ___ years ago with equivocal response.
___ was in treatment for over ___ years with psychiatrist (now
retired), ___, MD. ___ currently sees ___ for
therapy and ___, MD for ___ at ___
___ in ___.
Social History:
___
Family History:
-mother died of ruptured aneurysm at age ___
-otherwise, non-contributory
FAMILY PSYCHIATRIC HISTORY: The patient does not report any
mental illness in his family, however ___ does mention an uncle
(father's brother) from the ___ who used to "show up at our
house unannounced and stay for three weeks at a time" whom ___
suspects may have also had BPAD.
Physical Exam:
PHYSICAL EXAMINATION on Admission:
VS: 98.2 113/58 58 18 96%RA.
Weight:97.4 kg
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 15 cm.
CARDIAC: Irregularly irregular, S1 with mechanical S2. No
m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities. CTAB, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Edema to knees b/l +2. Pedal pulses intact. No
femoral bruits.
NEURO: CN II-XII tested and intact, strength ___ throughout,
sensation grossly normal. Gait not tested.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PHYSICAL EXAMINATION on discharge:
VS: 98.0 ___ 18 97RA
I:820 O:3300 (net negative 2480)
Weight: 96.2kg
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 11 cm.
CARDIAC: RRR, S1 with mechanical S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities. CTAB, no crackles, wheezes or
rhonchi.
ABDOMEN: Obese, Soft, NTND. No HSM or tenderness.
EXTREMITIES: +1 Edema to midcalf, r>l. Pedal pulses intact.
NEURO: CN II-XII tested and intact, strength ___ throughout,
sensation grossly normal. Gait not tested.
SKIN: No stasis dermatitis.
Pertinent Results:
Labs on Admission:
___ 10:00AM BLOOD WBC-9.3 RBC-4.20* Hgb-13.7* Hct-42.0
MCV-100* MCH-32.6* MCHC-32.6 RDW-12.7 Plt ___
___ 11:34AM BLOOD ___ PTT-46.3* ___
___ 10:00AM BLOOD Glucose-139* UreaN-27* Creat-1.3* Na-139
K-3.7 Cl-102 HCO3-29 AnGap-12
___ 10:00AM BLOOD ALT-61* AST-49* LD(LDH)-340* AlkPhos-60
TotBili-0.4
___ 10:00AM BLOOD proBNP-1748*
___ 05:50PM BLOOD CK-MB-14* cTropnT-0.02*
___ 06:18AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.3
Labs on discharge:
___ 02:34AM BLOOD WBC-6.9 RBC-4.07* Hgb-13.5* Hct-41.2
MCV-101* MCH-33.3* MCHC-32.8 RDW-12.8 Plt ___
___ 02:34AM BLOOD ___ PTT-54.6* ___
___ 02:34AM BLOOD Glucose-125* UreaN-33* Creat-1.5* Na-138
K-4.2 Cl-105 HCO3-29 AnGap-8
___ 02:34AM BLOOD Calcium-8.5 Phos-5.0*# Mg-2.4
CXR ___
FINDINGS: PA and lateral chest radiographs demonstrate moderate
cardiomegaly with bibasilar plate atelectasis. There is a small
right pleural effusion. There is no pulmonary vascular
congestion or redistribution. Median sternotomy wires and
aortic valve replacement are noted. There is no pneumothorax.
Abdomen US ___
1. Dilated IVC and hepatic veins consistent with CHF.
2. Trace free fluid within the right lower quadrant.
3. There is no evidence of portal venous thrombosis.
ECG ___
Organized atrial fibrillation, most apparent in lead V1.
Premature ventricular complexes. Intraventricular conduction
delay. Non-specific repolarization abnormalities, may be due to
ventricular hypertrophy or ischemia. Clinical correlation is
suggested. Compared to the previous tracing of ___ the
rhythm is no longer sinus, ventricular ectopy is new,
repolarization abnormalities are similar.
ECG ___
Atrial fibrillation with a slow ventricular response. Baseline
artifacts in
precordial leads. Intraventricular conduction delay of left
bundle-branch
block type. Compared to the previous tracing of ___ the rate
has
decreased.
Cardiac Catheterization ___
1. Selective coronary angiography of this right dominant system
demonstrated normal coronary arteries.
2. Resting hemodynamics revealed elevated biventricular filling
pressures with mean PCWP 23mmHg and RVEDP 13mmHg. Mild
pulmonary
arterial hypertension secondary to elevated left sided pressures
noted
with mean PA 30mmHg and PASP 44mHg. Cardiac output was
preserved with
index of 1.82 L/min/m2. FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Elevated left and right sided filling pressures.
SOCIAL WORK: Pt was referred to SW by RN's re: concern pt has
bipolar disorder and reported anxiety in anticipation of cardiac
cath later this week. Case discussed during morning rounds. Pt
had reported to RN that ___ felt somewhat unsafe, and had noticed
objects around the unit ___ could harm himself with. Psychiatry
was consulted, please refer to Dr ___. Pt
provided similar history to this SW. Pt reports ___ first
experienced bipolar symptoms after his first heart valve surgery
in ___. Pt reports psychiatric symptoms have been stable for
several years. ___ has weekly therapy visits and biweekly
psychiatry visits at ___, where ___ receives his
primary and cardiac care. Pt reports having no adjustment
difficulty after cardiac surgery in ___. ___ denies feeling
particularly worried about upcoming cardiac procedures. Pt's
primary concern is potential loss of employment if his illness
impacts his ability to work. Pt reports work provides him with
structure in his life, that ___ feels helps him manage his mood
disorder. Pt is not concerned about the Economic,ic impact of
loss of work. Pt is currently an independent ___. ___ formerly was a ___.
Pt states ___ would notify staff ___ felt at risk of harming
himself. ___ states that ___ believes his mood would be improved
when his symptoms of SOB resolve, if ___ has positive outcome
from
cath, and is able to return to work soon.
Role and availability of SW explained to pt and ___ is receptive
to f/u. SW will follow with team to provide supportive
counseling. Discussed above with RN, recommend frequent
check-in
with pt.
PSYCHIATRY CONSULTATION SERVICE ATTENDING NOTE
We are asked to evaluate safety in this ___ yo man admitted ___
with CHF exacerbation, a fib, also with bipolar disorder
controlled on lithium with hx of several suicide attempts.
Pt told staff today ___ 'sees things that ___ could use to hurt
himself', raising concern about pt's safety.
Medical plan is to go to cath tomorrow and then cardiovert the
following day.
Chart and OMR reviewed, discussed with team; pt seen.
___ has been described here as 'pleasant', cooperative and
appropriate, but today voiced suicidal ideation, told staff ___
was 'noticing' objects (such as knives in kitchen) that ___ might
be able to use to harm himself. In interview now ___
acknowledges
having such thoughts yesterday and today, although says ___ feels
better having shared these thoughts and having an opportunity to
talk with staff: 'If I can talk about it it helps, so long as I
can keep it in the open'.. ___ tells me that ___ feels safe here
and is confident ___ would be able to tell staff if ___ did not
feel safe. ___ has often had such thoughts in the past and when
able to talk with clinicians and others ___ has generally been
able to feel safe. ___ also spoke by phone with his therapist Dr
___.
Although ___ has a history of severe bipolar disorder and past
suicide attempts ___ has been quite stable for the past several
years with stable mood, no psychiatric admissions (? since ___
and no suicide attempts in several years, no recent mania.
Prior to coming in the hospital ___ was sleeping well and mood
was
fairly good, although ___ has been dealing with significant
stresses related to ongoing divorce, work, and now medical
concerns.
The past couple of nights ___ has had difficulty sleeping despite
high dose trazodone and also clonazepam.
Appetite and energy are ok. ___ has chronic/intermittent
feelings
of hopelessness, has thoughts 'I'm not too worried if I die',
but
at the same time says that ___ wants necessary medical care to
stabilize his condition.
I spoke by phone with his therapist Dr ___ ___.
She confirms history, pt has been stable in recent years. Some
chronic/intermittent SI. ___ is generally reliable in reporting
his current state and needs.
I spoke by phone with his psychiatrist Dr ___
___. ___ agrees with above, no addl safety concerns.
Discussed used of quetiapine or olanzapine for sleep while in
hospital.
Psych hx: ___ hospitalizations since his first manic episode
in ___ at the age of ___. The pt was hospitalized
psychiatrically here at ___ in ___ and those records were
reviewed. At that time ___ had been admitted to ___
with suicidal ideation and 'crazy thoughts' and then was
transferred to ___ for possible ECT but improved and was
discharged without ECT.
Prior suicide attempts or ideation included "hanging, drowning,
knives, crashing my truck, drinking bleach...."
Therapist Dr ___ ___ ___
(phone contact--see above)
PMH: CHF, afib/flutter, cardiomyopathy, HTN, aortic valve
replacement x 2 (___), asthma, obesity
h/o head trauma ~ ___
Allergy: wellbutrin
Current meds: lithium carbonate 900, lamotrigine 200 mg,
clonazepam 1 mg hs, trazodone 600 hs;
lisinopril, tamsulosin, vit D, metoprolol, ASA 325,
spironolactone, furosemide, heparin
Substance use: none
SH: Patient grew up in ___, ___. Parents deceased;
1 brother, 1 sis.
Grad ___ with a degree in biology.
Long career as a ___, now works for ___. Separated from wife; married three times and has two
grown daughters from his first marriage who live in ___
and ___.
Lives in ___.
FH: no known family psych hx
Labs: nl CBC INR 1.3 BUN 24 Cr 1.4 ALT 48 Ca 8.2
ECG Coarse atrial fibrillation. Premature ventricular
complexes.
Left axis
deviation. Intraventricular conduction delay of left
bundle-branch block type.
QTc 461
Exam: T 98.3 100/78 ___ 18 99%RA
Well appearing man lying still in bed, appears calm, no
restlessness or agitation. No abn movt. Speech is clear/nl,
non
pressured. Affect euthymic, reactive; mood ok. Thought form
linear without LOA, content without delusions. No current SI
(see above- recent SI), no HI. No halluc.
Cogn: alert, fully oriented, intact attn, memory, language,
good
___ insight appears good, judgment fair-good.
Imp: Bipolar disorder- pt appears euthymic without signs of
depression or mania, however in the hospital setting and in the
context of various situational stressors ___ is having occasional
thoughts of self harm.
This appears to be a familiar pattern for this pt and does not
necessarily signal significant risk although it warrants
continued monitoring. Review of history, pt exam and contact
with outpt therapist all indicate pt is safe at this time in
this
setting. His ability to share his thoughts and concerns with
staff is helpful for him and reassuring. ___ does not appear to
need 1:1 observer; however, would reassess this if any
escalation
of SI or any concerning change in pt behavior.
Sleep disturbance is distressing to pt and may put him at risk
for mood dysregulation (or might be early sign of
hypomania-mania). We discussed treatment options including
antipsychotic medications and ___ agrees to try this. Pt does
have some QTc prolongation so this needs to be considered in
weighing risks/benefits of treatment. Alternative to
neuroleptic
would be additional benzodiazepine but this may be less
effective
as anti-manic agent and also risks causing confusion.
Rec:
-Do not need 1:1 obs at this time but would reassess if any addl
concerns or any worrisome change in behavior
-Suggest olanzapine 5mg at hs for sleep if felt reasonable from
cardiac risk standpoint
-Continue to monitor QTc with addition of antipsychotic
-Alternative would be increase in clonazepam to 2 mg hs
-Continue other psych meds as ordered
-We will follow
Brief Hospital Course:
___ yo man w/ hx of CHF, bipolar I, afib, HTN and AVR x2
presenting with fluid overload, chest pressure and SOB in the
setting of atrial fibrillation and acute on chronic systolic
heart failure.
Active Diagnoses:
#Acute on chronic systolic heart failure: Pt with hx of chronic
systolic HF (EF 40-45%) and recent CHF exacerbation at OSH (EF
35% and new MR). Pt did not follow discharge medication regimen
as prescribed, notably ___ was not taking Carvedilol and did not
increase his Lasix dose from 40mg BID to 80mg BID. Now
presenting with lower leg edema, elevated JVP, clinical signs
and symptoms of heart failure and fluid overload. ___ responded
to fluid restriction and IV Lasix diuresis x4 days, achieving a
dry weight of 96.2kg. ___ was taken to the cath lab to evaluate
for coronary artery disease given the recent change in cardiac
function. No significant coronary stenosis found. We continued
his home lisinopril. We changed his home lasix to Torsemide
20mg daily and added Metoprolol Succinate XL 25 mg daily.
Discharge weight 96.2 kg.
# Coronary Artery Disease: Current exacerbation of systolic CHF
unlikely related to CAD. There were no anginal symptoms, no
notable EKG changes and trops were negative. Cardiac cath did
not show significant stenosis. Pt started on high dose ASA.
# Atrial Fibrillation: Pt has a known history of afib on
coumadin. ___ presented in atrial fibrillation without rapid
ventricular rate. ___ was cardioverted back to normal sinus
rhythm after achieving euvolemia and s/p cardiac cath. ___
remained in normal sinus rhythm for the rest of the
hospitalizaiton. ___ was bridged back to Coumadin with Lovenox.
#Supratherapeutic INR: Pt on long-term Coumadin for
anticoagulation. Found to be supratherapeutic (INR 4.7) on
admission. Treated with 2mg Vitamin K and held coumadin until
INR restored to therapeutic level ___. Pt was anticoagulated
with heparin gtt before cardiac cath and then bridged back to
coumadin via Lovenox. Discharged home with Lovenox to continue
bridging with help of PCP.
#Transaminitis: Mild elevation in AST/ALT, most likely due to
hepatic congestion ___ acute exacerbation of CHF. Abdominal US
revealed dilated IVC and hepatic veins consistent with CHF. PCP
to recheck transaminases.
#Bipolar Disorder: Pt with long-standing history of bipolar
disorder s/p ECT and multiple suicide attempts. Pt developed
significant anxiety regarding his cardiac catheterization and
the possibility of needing a CABG. This caused him to have poor
sleep hygiene and ___ became concerned that ___ would hurt
himself. ___ was seen by psychiatry who did not recommend
further inpatient psych treatment. We started him on Olanzapine
for the remainder of the inpatient stay. ___ is scheduled to
follow-up with his outpatient psychiatrist next week.
Chronic Diagnoses:
# BPH: Stable, continued tamsulosin
#COPD: Stable, continued home meds: Advair, Albuterol prn
Transitional Issues:
___ (daughter) is HCP
#Full code
#Pt with hx of bipolar disorder and multiple suicide attempts in
the past. His anxiety levels increase drastically with matters
that would prohibit him from working or being active.
# PCP to follow INR and transaminases
# Cardiologist should review med list with patient to prevent
another admission ___ poor medication awareness and compliance
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Furosemide 40 mg PO BID
2. Tamsulosin 0.4 mg PO QAM
3. traZODONE 600 mg PO HS
4. lithium carbonate *NF* 900 Oral HS
5. LaMOTrigine 200 mg PO DAILY
6. Clonazepam 1 mg PO QHS
7. Warfarin 5 mg PO DAILY16
Take 7.5mg on ___ and ___ and 5mg on other days.
8. Vitamin D 1000 UNIT PO DAILY
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
Rinse after each use
10. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation QID
nebulizer
11. Lisinopril 10 mg PO DAILY
12. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
Discharge Medications:
1. Enoxaparin Sodium 96 mg SC BID
RX *enoxaparin 100 mg/mL please inject ___ mg (1 mL) under the
skin twice daily twice daily Disp #*10 Syringe Refills:*1
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
3. Clonazepam 1 mg PO QHS
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
Rinse after each use
5. LaMOTrigine 200 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Lithium Carbonate *NF* 900 mg ORAL HS
8. Tamsulosin 0.4 mg PO QAM
9. traZODONE 600 mg PO HS
10. Vitamin D 1000 UNIT PO DAILY
11. Warfarin 5 mg PO DAILY16
Take 7.5mg on ___ and ___ and 5mg on other days.
12. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
13. Spironolactone 25 mg PO DAILY
RX *spironolactone 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
14. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
15. Outpatient Lab Work
INR check for ___. Please fax results to PCP ___.
___ at ___: ___.
ICD-9 code: ___.31
16. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic systolic heart failure
Atrial fibrillation
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 admitted to
___. You were admitted for an
acute worsening of your heart failure. You tolerated IV
medications to remove excess fluid that were building up in your
lungs and legs. You also went for a cardiac catheterization to
visualize your coronary arteries which were normal. There was
no need for stent placement or surgery. You also had your heart
shocked back into normal rhythm. We have made changes to your
medication. These are listed on the next page. You were
discharged to follow up with your primary care doctor, a
cardiologist nurse ___, and your
cardiologist Dr. ___. Please also make sure to
follow-up with your outpatient psychiatrist and psychologist as
scheduled. If you require an urgent visit, please call.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Your weight at discharge was 96.2kg or
approximately 212 lbs.
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Wellbutrin
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___ Transthoracic echocardiogram and cardioversion
History of Present Illness:
Mr. ___ is a ___ gentleman with CHF (EF 35-45%, and MR),
bipolar I, AFib s/p DCCV in ___, HTN, and AVR x2 who was
referred to the ED for admission due to heart failure
exacerbation.
Of note, ___ was admitted to Cardiology from ___ for
chest pressure and SOB in the setting of atrial fibrillation and
acute on chronic systolic heart failure. This was attributed to
medication noncompliance with Carvedilol and Lasix; furthermore
___ was in AFib. ___ was taken to cath lab to evaluate for
coronary artery disease which showed no significant coronary
stenosis. ___ was diuresed and underwent DCCV with a significant
improvement in symptoms. ___ was discharged on Torsemide 20mg
daily and Metoprolol Succinate XL 25 mg daily. Discharge weight
96.2 kg.
___ reports good medication and dietary compliance since
discharge. ___ was able to walk about two flights of stairs
without having to stop for dyspnea.
___ was doing OK until 1 week ago when ___ started to feel
progressively short of breath. ___ has gained weight
(currently). ___ was seen in his Primary Care clinic on ___
(3 days ago) and ___ was found to be in AFib, rate-controlled.
After discussion with Cardiology, ___ was started on Amiodarone
200mg BID and his Torsemide was increased to 20mg BID. Today ___
went to Cardiology clinic and was found to be volume overloaded
so ___ was urged to go to the ED.
In the ED, initial VS were 97.6 70 ___ 97% RA. EKG ahowed
AFib, rate 70, multiple PVCs. Labs were notable for BUN/Cr
33/1.4 (baseline Cr 1.3), BNP 2693, INR 4.1, Trop 0.02. CXR
showed stable cardiomegaly, no edema. ___ Cardiology was
consulted and recomended admission for TEE/CV ___.
Currently, ___ feels fine. No specific complaints unless ___
ambulates.
REVIEW OF SYSTEMS:
On review of systems, ___ denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. ___ denies recent fevers, chills or
rigors. ___ denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is negative for chest pressure on
exertion. Positive for dyspnea on exertion, paroxysmal
nocturnal dyspnea, orthopnea, mild ankle edema. Denies syncope,
dizziness, paliptations.
Past Medical History:
-AS/AI and ascending aortic aneurysm s/p AVR x 2 (bioprosthesis
___ and ascending aortic replacement most recently in
___
-atrial fibrillation/flutter s/p DCCV ___
-Aortic valve replacement x 2 (___)
-chronic systolic congestive heart failure
-benign prostatic hypertrophy
-asthma
-obesity
-hypertension
-History of head trauma ___ years ago with LOC, "fell out of
truck")
PSYCHIATRIC HISTORY: As above in HPI. Also, ___ Pt reports
being on numerous medications over the years, but is unable to
recall others than what ___ is currently taking. ___ underwent "6
or so" courses of ECT ___ years ago with equivocal response.
___ was in treatment for over ___ years with psychiatrist (now
retired), ___, MD. ___ currently sees ___ for
therapy and ___, MD for ___ at ___
___ in ___.
Social History:
___
Family History:
-mother died of ruptured aneurysm at age ___
-otherwise, non-contributory
FAMILY PSYCHIATRIC HISTORY: The patient does not report any
mental illness in his family, however ___ does mention an uncle
(father's brother) from ___ who used to "show up at our
house unannounced and stay for three weeks at a time" whom ___
suspects may have also had BPAD.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.7 - ___ - ___ - 97RA I/O: 200/375
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 15 cm.
CARDIAC: Irregularly irregular, S1 with mechanical S2. No m/r/g.
No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities. CTAB, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Edema to knees b/l +2. Pedal pulses intact. No
femoral bruits.
NEURO: CN II-XII tested and intact, strength ___ throughout,
sensation grossly normal. Gait not tested.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
DISCHARGE Physical Exam
VS: 98.0 - 98/68 - 54 - 18 - 99RA - p54-78 (93-136/65-108) - wt
94.8 <--97.3 i/o t ___
GENERAL: NAD, slightly anxious
CARDIAC: heart rate regular, S1 with mechanical S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: CTA throughout; no rales/crackles
EXTREMITIES: improved pedal edema. Pedal pulses intact. No
femoral bruits.
Pertinent Results:
ADMISSION LABS
___ 11:00AM BLOOD WBC-8.8 RBC-4.12* Hgb-13.2* Hct-39.8*
MCV-97 MCH-32.1* MCHC-33.2 RDW-13.2 Plt ___
___ 11:00AM BLOOD Neuts-81.7* Lymphs-11.8* Monos-3.6
Eos-2.3 Baso-0.7
___ 11:00AM BLOOD ___ PTT-52.2* ___
___ 11:00AM BLOOD Glucose-89 UreaN-33* Creat-1.4* Na-141
K-3.8 Cl-104 HCO3-31 AnGap-10
___ 11:00AM BLOOD proBNP-2693*
___ 11:00AM BLOOD cTropnT-0.02*
___ 11:00AM BLOOD Calcium-8.7 Mg-2.3
DISCHARGE LABS
___ 06:28AM BLOOD WBC-9.4 RBC-3.91* Hgb-12.5* Hct-39.1*
MCV-100* MCH-31.9 MCHC-31.9 RDW-13.0 Plt ___
___ 06:28AM BLOOD Glucose-89 UreaN-29* Creat-1.4* Na-137
K-4.0 Cl-102 HCO3-30 AnGap-9
___ 06:28AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.4
ECG ___ 10:28:24 AM
Atrial flutter with ventricular premature depolarizations. Left
bundle-branch block with secondary repolarization abnormalities.
Compared to the previous tracing of ___ atrial flutter is
now present.
ECG ___ 4:06:00 ___
Atrial fibrillation with mean ventricular rate of 66 beats per
minute.
Compared to the previous tracing cardiac rhythm is now atrial
fibrillation.
CHEST (PA & LAT) ___ 11:31 AM
IMPRESSION: Moderate cardiomegaly with mild central pulmonary
vascular
congestion and interstitial edema.
TRANSESOPHAGEAL ECHOCARDIOGRAM ___ at 8:51:31 AM
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. Left atrial appendage ejection velocity is depressed
(<0.2m/s). No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is
depressed. The right ventricular cavity is dilated with
depressed free wall contractility. A bioprosthetic aortic valve
prosthesis is present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
(___) mitral regurgitation is seen. There is no pericardial
effusion.
IMPRESSION: No SEC or thrombus in the ___. Global
biventricular hypokinesis. Mild to moderate mitral
regurgitation.
Brief Hospital Course:
Mr. ___ is a ___ gentleman with bipolar I, AFib s/p DCCV in
___, CHF (EF 35-45%, and MR) with last exacerbation ___ in
the setting of AFib, HTN, and AVR x2 who was admitted for heart
failure exacerbation and found to be in atrial fibrillation. ___
underwent successful DC cardioversion on ___. ___ was
restarted on Amiodarone and was discharged home.
ACTIVE ISSUES
#. Shortness of breath: acute on chronic systolic heart failure.
BNP 2700. Patient with non-ischemic cardiomyopathy (EF 35%
three months ago). This admission ___ reports good med/diet
compliance, so most likely cause of CHF is loss of atrial kick
due to being in AFib. Had a clean cath 2 months ago so unlikely
to be ischemic. To restore his atrial kick, ___ was cardioverted
on ___. ___ was also diuresed with 40 mg BID of IV
furosemide, to which ___ responded quite well. On discharge, his
home torsemide was increased to 40 mg daily. His home
metoprolol lisinopril were continued. ___ will be contacted
within a few days with an appointment to meet with the ___
Cardiology Heart Failure team. It will be important to follow
up his volume status, as now that ___ is back in sinus rhythm, ___
might be able to be decreased to his prior dose of Torsemide.
#. AFib: now s/p TEE/CV, in sinus.
___ was rate controlled with metoprolol. His amiodarone was held
initially to avoid inadvertent cardioversion prior to
anticoagulation ___ was not therapeutic on INR for the entire
month prior to admission, though ___ was supratherapeutic on
admission). Then on ___ ___ underwent successful TEE/CV.
After TEE, ___ was loaded with amiodarone at 400mg BID x one
week, then will take 200mg BID and will follow up with ___
Cardiology. ___ continues to follow up at his ___
___ clinic.
***Note that ___ will need baseline PFT/DLCO as an outpatient.***
___ was in sinus rhythm, but note that ___ had a very prolonged PR
(~300), and his EKG should be monitored while ___ is getting
loaded on Amiodarone.
#. Leg cramps: unclear etiology.
History & exam not concerning for vascular cause. Electrolytes
normal. ___ was started on magnesium oxide and this problem
resolved. ___ continues on magnesium oxide.
INACTIVE ISSUES
#. BPH: stable.
Continued Tamsulosin.
#. Bipolar disorder: stable.
With increased anxiety in the hospital, treated with PO
diazepam. Continued Lithium, Trazodone, Clonazepam, Lamotrigine.
#. COPD: stable.
Continued home meds: Advair, Albuterol PRN
TRANSITIONAL ISSUES
#. Code status: Full code
#. Emergency Contact: ___ (daughter) is HCP
#. ___ pending on discharge: None
#. Follow-up: ___ Primary Care, ___ General Cardiology, ___
Cardiology Heart Failure
#. Note that ___ will need baseline PFT/DLCO as an outpatient
because ___ was recently started on Amiodarone.
#. After cardioversion, ___ was in sinus rhythm, but note that ___
had a prolonged PR (~300); his EKG should be monitored while ___
is getting loaded on Amiodarone.
#. It will be important to follow up his volume status, as now
that ___ is back in sinus rhythm, ___ might be able to be
decreased to his prior dose of Torsemide.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. LaMOTrigine 200 mg PO DAILY
2. traZODONE 600 mg PO HS
3. Lithium Carbonate 900 mg PO QHS
4. Clonazepam 1 mg PO QHS
5. Amiodarone 200 mg PO BID
6. Torsemide 20 mg PO DAILY
7. Albuterol Inhaler ___ PUFF IH Q4-6H:PRN sob/wheeze
8. Warfarin 5 mg PO DAILY16
9. Tamsulosin 0.4 mg PO DAILY
10. Spironolactone 25 mg PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
"one pill daily"
13. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation QID:PRN SOB
via neb
14. Lisinopril 10 mg PO DAILY
15. Sildenafil 50 mg PO PRN sexual acitivity
16. Aspirin 81 mg PO DAILY
17. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
Discharge Medications:
1. Amiodarone 200-400 mg PO BID
-___ twice a day for 6 more days.
-Then 200mg twice a day.
RX *amiodarone 400 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
2. Albuterol Inhaler ___ PUFF IH Q4-6H:PRN sob/wheeze
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
5. traZODONE 600 mg PO HS
6. Vitamin D 1000 UNIT PO DAILY
"one pill daily"
7. Spironolactone 25 mg PO DAILY
8. LaMOTrigine 200 mg PO DAILY
9. Lithium Carbonate 900 mg PO QHS
10. Clonazepam 1 mg PO QHS
11. Aspirin 81 mg PO DAILY
12. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation QID:PRN SOB
via neb
13. Lisinopril 10 mg PO DAILY
14. Metoprolol Succinate XL 25 mg PO DAILY
15. Sildenafil 50 mg PO PRN sexual acitivity
16. Tamsulosin 0.4 mg PO DAILY
17. Magnesium Oxide 250 mg PO DAILY
RX *magnesium oxide 250 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
18. Warfarin 5 mg PO DAILY
-Take 7.5mg tonight.
-Then continue with 5mg daily.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Congestive heart failure
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because you were short of breath and were
found to be in heart failure. This was likely because your
heart was back in the irregular heart rhythm (atrial
fibrillation). During your stay, you were diuresed with IV
medications and then you underwent a TEE/cardioversion in order
to restore normal heart rhythm.
After cardioversion, you were restarted on Amiodarone, which is
a medication that might help to keep your heart out of atrial
fibrillation. The dose of this medication will change over
time. Do not stop amiodarone unless directed to stop by your
Cardiologist.
Please follow up with your Primary Care doctor and Cardiology.
Remember to weigh yourself every morning, call your doctor if
weight goes up more than 3 lbs.
We made the following changes to your home medication list:
-CHANGE Amiodarone dose:
400mg twice a day for 1 week,
then 200 mg twice a day
-INCREASE Torsemide dose
-START Magnesium for muscle cramps
-For Warfarin:
tonight take 1.5 tabs (7.5mg)
then continue with 5mg daily
Followup Instructions:
___
|
10896351-DS-25
| 10,896,351 | 20,674,239 |
DS
| 25 |
2121-11-17 00:00:00
|
2121-11-18 07:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Wellbutrin
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ severe AS (s/p 2 AVRs due to bicuspic valve) now recently
s/p TAVR ___, aortic aneurysm (s/p ascending aortic replacement
in ___, pAfib s/p pacemaker and ICD, systolic CHF with LVEF of
25% presenting with left anterior chest pain radiating to the
left axilla and left arm since yesterday. Patient states that he
was at rest when he pain started. He describes it as a
pressure-like sensation as if it was "a belt around his chest".
The pain is not exertional. There is some associated shortness
of breath with it. The pain does appear to get worse with deep
inspiration. He's never had pain like this before. Denies any
new calf pain or swelling. He is taking Coumadin as prescribed.
After dc from ___ on ___, patient was seen by CHF NP on
___ at which time he was noted be in decompensated HF, with JVP
elevation and weight up to 220 lb from baseline of 210.
Patient's torsemide was doubled from 20mg qd to 40mg qd.
ED Course (labs, imaging, interventions, consults):
- Initial Vitals/Trigger: 8 97.6 60 118/75 16 100%
- EKG: afib @75, IVCD, no clear pacer spikes seen but spikes
seen on monitor, no acute ST-T changes
- Notable labs: pro BNP 1390, INR 3.1, Trop 0.05, Cr 1.5
(baseline 1.0)
- CTA: Interval changes of Carevalve Aortic bioprothesis
placement. No change in caliber of the ascending aorta. No
dissection. Cannot assess for presence of pulmonary embolism
given lack of opacification of the pulmonary arteries. Enlarged
main pulmonary artery compatible with pulmonary hypertension.
On arrival to the floor, patient was stable but continued to
complain of chest pain that appeared to be pleuritic in nature.
Review of sytems:
(+) Per HPI
Past Medical History:
-AS/AI and ascending aortic aneurysm s/p AVR x 2 (bioprosthesis
___ and ascending aortic replacement most recently in
___ followed by TAVR in ___
-atrial fibrillation/flutter s/p DCCV ___ and ___
-chronic systolic congestive heart failure EF 25%
-benign prostatic hypertrophy
-asthma
-obesity
-hypertension
-bipolar disorder, multiple previous suicide attempts
-History of head trauma ___ years ago with LOC, "fell out of
truck")
-RSV in ___ treated with steroids
Social History:
___
Family History:
-mother died of ruptured aneurysm at age ___
Physical Exam:
ADMISSION:
VS: 98.1 118/72 72 16 98 ra ___
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rhythm, coarse systolic murmur, loudest in RUSB
Lungs: CTAB, no w/r/r
Abdomen: soft, NT/ND, BS+
Ext: WWP, 1+ edema upto knees 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
DISCHARGE:
VS: 98.3 102-103/60-61 59-70 20 96 ra
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rhythm, coarse systolic murmur, loudest in RUSB
Lungs: CTAB, no w/r/r
Abdomen: soft, NT/ND, BS+
Ext: WWP, 1+ edema upto knees 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
Pertinent Results:
ADMISSION:
___ 02:10PM BLOOD WBC-10.5 RBC-3.87* Hgb-12.1* Hct-38.8*
MCV-100* MCH-31.4 MCHC-31.3 RDW-14.3 Plt ___
___ 02:10PM BLOOD Neuts-85.7* Lymphs-9.0* Monos-4.1 Eos-0.6
Baso-0.5
___ 02:10PM BLOOD ___ PTT-45.8* ___
___ 02:10PM BLOOD Glucose-85 UreaN-21* Creat-1.5* Na-136
K-4.6 Cl-99 HCO3-30 AnGap-12
___ 02:10PM BLOOD ALT-27 AST-33 CK(CPK)-67 AlkPhos-66
TotBili-0.7
___ 02:10PM BLOOD CK-MB-5 ___ 02:10PM BLOOD cTropnT-0.05*
___ 02:10PM BLOOD Albumin-4.1
___ 06:10AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.5
DISCHARGE:
___ 06:10AM BLOOD WBC-8.1 RBC-3.51* Hgb-11.3* Hct-35.5*
MCV-101* MCH-32.1* MCHC-31.7 RDW-14.3 Plt ___
___ 06:10AM BLOOD ___ PTT-43.3* ___
___ 06:10AM BLOOD Glucose-84 UreaN-22* Creat-1.2 Na-139
K-4.5 Cl-105 HCO3-25 AnGap-14
___ 06:10AM BLOOD CK-MB-4 cTropnT-0.05*
___ 05:00PM URINE Color-Straw Appear-Clear Sp ___
___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 05:00PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 05:00PM URINE Mucous-RARE
CHEST PA LAT ___: Moderate-to-severe cardiomegaly with mild
pulmonary vascular congestion. No focal consolidation.
CTA W/ W/O CONTRAST ___: Interval placement of Carevalve
Aortic bioprothesis. No change in caliber of the ascending
aorta. No dissection. Cannot assess for presence of pulmonary
embolism given lack of opacification of the pulmonary arteries.
Enlarged main pulmonary artery compatible with pulmonary
hypertension.
ECHO ___: The left atrium is markedly dilated. The right
atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is moderate to severe regional left
ventricular systolic dysfunction with basal to mid
inferior/inferolateral akinesis and inferoseptal hypokinesis.
There is an inferobasal left ventricular aneurysm. Right
ventricular chamber size is normal. with mild global free wall
hypokinesis. The ascending aorta is mildly dilated. An aortic
___ prosthesis is present. The transaortic gradient is
normal for this prosthesis. A paravalvular aortic valve leak is
probably present. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. 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). The tricuspid valve leaflets are
mildly thickened. [Due to acoustic shadowing, the severity of
tricuspid regurgitation may be significantly UNDERestimated.]
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Regional left ventricular systolic dysfunction
suggestive of prior inferior infarction. Moderate to severe,
posteriorly directed mitral regurgitation, likely due to leaflet
tethering. Normall positioned ___ with mild paravalvular
leak. Mild elevation of pulmonary artery systolic pressure.
Compared with the prior study (images reviewed) of ___,
the left ventricle does not appear as dilated. The degree of
mitral regurgitation was UNDERestimated on the prior study - it
was eccentric and probably moderate-to-severe on prior study
also. Other findings are similar.
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ severe AS (s/p 2 AVRs due to bicuspic
valve) now recently s/p TAVR ___, aortic aneurysm (s/p
ascending aortic replacement in ___, pAfib s/p pacemaker and
ICD, systolic CHF with LVEF of 25% presenting with left anterior
chest pain. Workup including CTA, EKG, enzymes and TTE were
negative. likely ___ MSK or anxiety. DC-ed with no medication
changes.
# Chest Pain; patient developed chest pain yesterday but has -ve
CTA (although no assessed for PE), no ischemic changes on EKG,
trop of 0.05, and recent clean cath on ___. Patient has AS but
had recent TAVR which resulted in symptomatic improvement. PE
possible but unlikely given therapeutic on coumadin, no
tachycardia. Patient CP free since midnight without intevention;
possible anxiety or MSK component. TTE unchanged from prior as
well and enzymes remained flat. Gave tylenol for relief. We
continued home asa 81, plavix and home torsemide 40mg qd
# AFIB: stable, has PPM. Anticoagulated with warfarin. We
continued amiodarone 200mg qd, coumadin and metoprolol tartarate
12.5 mg bid.
# Gout: stable off prednisone
# HTN: stable on home lisinopril 2.5
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. ClonazePAM 1 mg PO QHS
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. LaMOTrigine 200 mg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Lithium Carbonate 600 mg PO QHS
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Tamsulosin 0.4 mg PO HS
10. TraZODone 500 mg PO HS
11. Vitamin D 1000 UNIT PO DAILY
12. Aspirin 81 mg PO DAILY
13. Clopidogrel 75 mg PO DAILY
14. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H sob
15. Torsemide 20 mg PO BID
16. Warfarin 2.5 mg PO DAILY16
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. ClonazePAM 1 mg PO QHS
4. Clopidogrel 75 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. LaMOTrigine 200 mg PO DAILY
7. Lisinopril 2.5 mg PO DAILY
8. Lithium Carbonate 600 mg PO QHS
9. Pantoprazole 40 mg PO Q24H
10. Tamsulosin 0.4 mg PO HS
11. Torsemide 40 mg PO DAILY
12. TraZODone 500 mg PO HS
13. Vitamin D 1000 UNIT PO DAILY
14. Warfarin 2.5 mg PO DAILY16
15. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet extended release(s) by mouth
q6 Disp #*30 Tablet Refills:*0
16. Metoprolol Succinate XL 25 mg PO DAILY
17. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H sob
Discharge Disposition:
Home With Service
Facility:
___
___:
Costochondroitis
Aortic Valve stenosis
Congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with chest pain, however you had a
thorough workup that did not show anything wrong with your heart
lungs and great vessels. Most likely your pain is muscular in
origin. Please take tylenol if you have recurrence of your pain.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10896351-DS-27
| 10,896,351 | 25,374,967 |
DS
| 27 |
2122-04-13 00:00:00
|
2122-04-14 06:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Wellbutrin
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ M w/ AS and ascending aortic aneurysm s/p AVR x 3
___, TAVR in ___ & ascending aortic replacement
___, PAfib s/p pacemaker & DCCV ___ & ___ and AV nodal
ablation ___ on warfarin, sCHF (last EF of 25%),
amiodarone-induced hyperthyroidism, asthma, obesity, HTN who
presents with worsening shortness of breath and 20lb weight gain
over the past few weeks. He reports that he had substernal
non-radiating chest pain on arrival to the ED which began the
evening of ___ and lasted until he was on CPAP in the ED early
on the morning of ___. Prior to this developing, he reports
significant worsening of his respiratory symptoms for the past 2
days (since ___, and dyspnea has not been responsive to his
usual asthma nebulizers and diuretic treatments. Also with
worsened orthopnea, leg swelling and abdominal swelling. He does
report change in his diet over the past few weeks, as he has
been avoiding fish (and so eating more beef/chicken) in
preparation for thyroid scan. He has also been off of
methimazole and on prednisone in preparation for this.
In the ED intial vitals were: 10 98.7 76 150/90 30 93% ra. Labs
significant for trop 0.04->0.02, BNP 1284. CXR showed asymmetric
pulmonary edema. EKG showed atrial fibrillation, ventricular
paced beats as well as PVCs.
Patient transiently required BiPap until approximately 8am. He
received 60mg IV lasix x 2, SL nitro x 2, duonebs. Per nursing
note, he put out approximately 3500cc urine over approximately
14 hours (ins not well recorded).
Vitals on transfer: 98.5 80 122/66 19 96% RA
On arrival to the floor, patient still complaining of
significant dyspnea and wheezing and requests duoneb.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: Pacesetter/St. ___ Model: Unify Quadra;
Implant date: ___
- Atrial fibrillation: Diagnosed ___, s/p DCCV ___ and
___.
- Aortic valve disease: Bicuspid aortic valve with aortopathy.
He had a first porcine aortic valve replacement in ___, but
that valve became regurgitant and the patient underwent
reimplantation of a 29 mm pericardial in ___, at which time he
also a 34 mm Hemashield aortic graft placed for ascending aortic
enlargement. Transcatheter aortic valve replacement on ___
at ___.
- Systolic CHF (EF ___.
3. OTHER PAST MEDICAL HISTORY:
-benign prostatic hypertrophy
-asthma
-obesity
-hypertension
-bipolar disorder, multiple previous suicide attempts
-History of head trauma ___ years ago with LOC, "fell out of
truck")
-RSV in ___ treated with steroids
Social History:
___
Family History:
- Mother died of ruptured aneurysm at age ___.
Physical Exam:
Exam on Admission:
PHYSICAL EXAMINATION:
VS: T= 98.7 BP= 158/95 HR= 74 RR= 18 O2 sat= 96%/RA
GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP of 11 cm.
CARDIAC: regular rate and rhythm, + S3, no murmurs appreciated
LUNGS: mildly tachypneic but able to speak in full sentences.
Prolong expiratory phase. Good air entry, diffuse wheezing
ABDOMEN: Soft, NTND.
EXTREMITIES: 1+ pitting edema
PULSES: 2+ DP pulses
Exam on Discharge:
Vitals: T 98.5 90-127/54-76 HR ___ 96% RA
Ins/Outs: -3.5L Wt 97.0 ___ yesterday)
Tele: V paced, HR ___
General: Alert, oriented, no acute distress, mood and affect
appropriate
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP 9-10 cm
Cardiac: regular rate and rhythm, +S3, no
murmurs/rubs/gallops/thrills
Lungs: Wheezing has resolved. Continues to have coarse breath
sounds in all lung fields b/l, R>L
Abdomen/GU: Soft, non-tender, non-distended
Extremities: No clubbing, cyanosis. No ___ edema.
Skin: No stasis dermatitis, ulcers, scars, xanthelasmas, or
xanthomas.
Vasc: ___ 2+ pulses
Pertinent Results:
___ 04:48AM BLOOD WBC-13.5*# RBC-4.32* Hgb-13.6* Hct-44.5
MCV-103* MCH-31.5 MCHC-30.6* RDW-15.0 Plt ___
___ 04:48AM BLOOD ___ PTT-43.7* ___
___ 04:48AM BLOOD Glucose-119* UreaN-32* Creat-1.2 Na-139
K-5.0 Cl-102 HCO3-29 AnGap-13
___ 04:48AM BLOOD CK(CPK)-128
___ 04:48AM BLOOD CK-MB-8 cTropnT-0.04* proBNP-1284*
___ 12:21AM BLOOD Calcium-9.1 Mg-2.3
___ 07:50AM BLOOD Type-ART pO2-57* pCO2-42 pH-7.46*
calTCO2-31* Base XS-5
___ 05:40AM BLOOD WBC-7.0 RBC-4.19* Hgb-13.4* Hct-42.4
MCV-101* MCH-31.9 MCHC-31.5 RDW-14.8 Plt ___
___ 05:40AM BLOOD ___ PTT-36.2 ___
___ 05:40AM BLOOD Glucose-94 UreaN-33* Creat-1.3* Na-138
K-4.4 Cl-96 HCO3-37* AnGap-9
___ 06:00AM BLOOD Free T4-1.0
___ 06:00AM BLOOD TSH-0.76
___ 08:59PM BLOOD Type-ART pO2-73* pCO2-45 pH-7.48*
calTCO2-34* Base XS-8
___ 08:59PM BLOOD Lactate-1.7
___ 05:55AM BLOOD WBC-13.8* RBC-4.04* Hgb-12.9* Hct-39.7*
MCV-98 MCH-32.0 MCHC-32.6 RDW-14.2 Plt ___
___ 05:55AM BLOOD Glucose-95 UreaN-37* Creat-1.3* Na-138
K-4.2 Cl-98 HCO3-32 AnGap-12
___ 05:55AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.4
___ 07:40PM BLOOD Vanco-17.8
CXR (___):
IMPRESSION:
Mild increased vascular congestion, slightly more prominent the
right base.
The most ready explanation for this finding is asymmetric
pulmonary edema.
Urine Culture (___):
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
Echo (___):
IMPRESSION: Biatrial enlargement. Well-seated, normally
functioning aortic ___ prosthesis with mild paravalvular
leak. Severely dilated left ventricle with mild to moderate
regional left ventricular systolic dysfunction consistent with
coronary artery disease. Increased left ventricular filling
pressure. Mildly dilated aortic root and aortic arch. Mild to
moderate mitral regurgitation. Moderate pulmonary artery
systolic hypertension.
Compared with the prior study (images reviewed) of ___,
the severity of mitral regurgitation may have decreased
(previously moderate to severe) and the left ventricular
systolic function appears slightly better; however, the image
quality was superior previously and thus, the above findings may
not represent a true physiologic change.
Chest CT with contrast (___):
IMPRESSION:
1. Peribronchiolar ___ opacities in the right upper,
middle and both
lower lobes consistent with aspiration or infection.
2. Pulmonary arterial enlargement is stable since the prior
study from ___, and suggests underlying pulmonary arterial hypertension.
CXR (___):
IMPRESSION:
In comparison with the study of ___, there is continued
substantial
enlargement of the cardiac silhouette with mild elevation of
pulmonary venous
pressure. There is increased opacification at the right base
with is poor
definition of the right heart border, worrisome for a middle
lobe pneumonia.
Sputum gram stain and culture:
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
HEAVY GROWTH Commensal Respiratory Flora.
Oropharyngeal swallowing videofluroscopy (___):
FINDINGS:
Barium passes freely through the oropharynx and esophagus
without evidence of
obstruction. There was no gross aspiration or penetration.
Degenerative
changes are noted in the cervical spine on sagittal view.
IMPRESSION:
Normal oropharyngeal swallowing videofluoroscopy.
Please refer to the speech and swallow division note in OMR for
full details, assessment, and recommendations.
CXR (___):
IMPRESSION:
IN COMPARISON WITH THE STUDY OF ___, THERE IS AGAIN
SUBSTANTIAL
ENLARGEMENT OF THE CARDIAC SILHOUETTE WITH MILD ELEVATION OF
PULMONARY VENOUS PRESSURE. SLIGHTLY LOWER LUNG VOLUMES.
BIBASILAR ATELECTATIC CHANGES ARE SEEN. RELATIVELY MORE INCREASE
IN OPACIFICATION AT THE RIGHT BASE COULD WELL REPRESENT MERELY
ATELECTASIS, THOUGH IN THE APPROPRIATE CLINICAL SETTING
SUPERIMPOSED PNEUMONIA WOULD HAVE TO BE CONSIDERED.
CXR (___):
Severe cardiomegaly is unchanged. Biventricular pacemaker
defibrillator is unchanged in appearance. Lungs are essentially
clear except for minimal bibasal atelectasis. Overall, no
substantial change since prior examinations demonstrated
Brief Hospital Course:
This is a ___ yoM with a history of Afib s/p nodal ablation, s/p
BiV ICD, sCHF (EF ___, and TAVR ___ and asthma who p/w
chest pain, dyspnea, and weight gain.
#HCAP: The patient became febrile to 102 during his
hospitalization. There was concern for CAP given WBC of 13.5 on
admission, fever, SOB, and CXR showing asymmetric pulmonary
edema. The patient was started on empiric CAP coverage with
ceftriaxone and azithromycin. His fever resolved later the same
day. However, a few days after starting ceftriaxone and
azithromycin he developed worsening SOB and cough and a repeat
CXR was concerning for worsening infiltrative process, and the
patient was started on vancomycin and switched from ceftriaxone
to cefepime for treatment of presumed HCAP. Due to concerns for
opportunistic infection from findings on CXR in the setting of
having taken high-dose prednisone since ___, the patient was
started on PCP prophylaxis with ___
trimethoprim/sulfamethoxazole; however, due to hyperkalemia,
TMP/SMX was discontinued and the hyperkalemia resolved. Due to
concerns for aspiration events, a videofluroscopy swallow study
was performed which showed no evidence of aspiration. The
patient remained on vancomycin/cefepime and completed an 8 day
course.
# Systolic CHF: The patient presented with pulmonary edema on
CXR, weight gain, and peripheral edema, which concerns for a
systolic CHF exacerbation. Dietary changes or increased steroid
dose (as the patient was taking steroids for amiodarone-induced
hyperthyroidism) could have been possible triggers. An Echo
___ : biatrial enlargement, ___ functioning
normal w/ mild paravalvular leak, severely dilated LV w/
mild-to-moderate regional LV dysfunction c/w CAD, EF 40-45%,
mild-to-moderate MR, mild TR, moderate pulm artery hypertension
- vs prior study MR may have decreased, LV systolic function
appears improved , but image quality on previous study was
better. (echo from ___ had LVEF 35%). The patient was
aggressively diuresed with multiple doses of furosemide which
was added on to his home torsemide. His torsemide was increased
to 40 mg daily. He continued to diurese well and his SOB greatly
improved. He was discharged on torsemide, spironolactone, and
was continued on his home dose of lisinopril 2.5 mg daily.
# Afib s/p AV nodal ablation: Rhythm was vent.paced on
telemetry, albeit with frequent PACs and PVCs and v-couplets.
In the setting of his acute shortness of breath and fever, his
home dose of metoprolol succinate 50 mg PO daily was decreased
to 25 mg daily, which he continued upon discharge. He continued
on warfarin, and his INRs remained therapeutic.
# Amiodarone-induced Hyperthyroidism: Per the patient's
outpatient endocrinologist, his hyperthyroidism was thought to
be secondary to amiodarone (which has now been discontinued). It
was unclear whether his hyperthyroidism was more of a
thyroiditis vs a Graves' disease picture, and thus he had been
taking prednisone 40 mg daily as well as methimazole. However,
the patient had planned to have a thyroid scan on ___, and so
he had been holding his methimazole since ___. He was admitted
to ___ and thus missed his appointment. During this admission,
methimazole was continued to be held. TFTs returned showing a
TSH of 0.76 and a free T4 of 1.0. He began to taper his
prednisone to 30 mg daily on ___ and he was discharged on this
dose. He was discharge with follow up arranged with his
outpatient endocrinologist.
# Wheezing: Given the patient's history of asthma, it was likely
contributing to his dyspnea given significant wheezing during
hospitalization. Pt had been taking 40 mg prednisone (as
treatment for amiodarone-induced hyperthyroidism, as noted
above) for the 2 weeks prior to admission. On ___ he began a
slow prednisone taper with 30 mg prednisone daily and was
discharged on that dose. He continued on albuterol/ipratropium
nebulizers every four hours as needed. Due to concerns for
upper airway wheezing, ENT was consulted for direct
visualization of vocal cords and no evidence of upper airway
obstruction was found. Although no distinct pathology was found
on laryngeal exam, small discoloration was noted that warrants
follow up. Per pulmonary recommendations, the patient was
started on pantoprazole and discharged with recommendations for
standing nebulizers at home.
# Sleep apnea: The patient was continued on CPAP (which he uses
at home) and maintained good oxygen saturation.
# Bipolar disorder: The patient was continued on home lithium,
lamotrigine, trazodone, clonazepam. There were no active issues
during hospitalization.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. ClonazePAM 1 mg PO QHS
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. LaMOTrigine 200 mg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Lithium Carbonate 600 mg PO QHS
7. Metoprolol Succinate XL 50 mg PO DAILY
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4-6H:PRN sob
9. Tamsulosin 0.4 mg PO HS
10. Torsemide 20 mg PO BID
11. TraZODone 400 mg PO HS
12. Vitamin D 1000 UNIT PO DAILY
13. Warfarin 5 mg PO 4X/WEEK (___)
14. Warfarin 2.5 mg PO 3X/WEEK (___)
15. Magnesium Oxide 125 mg PO DAILY
16. PredniSONE 40 mg PO DAILY
17. Sildenafil 50 mg PO DAILY:PRN erectile dysfunction
18. Ipratropium-Albuterol Neb 1 NEB NEB Q6H Shortness of breath
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. ClonazePAM 1 mg PO QHS
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. LaMOTrigine 200 mg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Lithium Carbonate 600 mg PO QHS
7. PredniSONE 30 mg PO DAILY
30mg daily until ___, 20 mg ___, 10 mg ___, 5 mg
___. Or as otherwise directed
Tapered dose - DOWN
RX *prednisone 10 mg ASDIR tablet(s) by mouth DAILY Disp #*50
Tablet Refills:*0
8. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
9. Tamsulosin 0.4 mg PO HS
10. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth DAILY Disp #*60 Tablet
Refills:*0
11. TraZODone 400 mg PO HS
12. Warfarin 5 mg PO 4X/WEEK (___)
13. Warfarin 2.5 mg PO 3X/WEEK (___)
14. Montelukast 10 mg PO DAILY
RX *montelukast 10 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
15. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
16. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
17. Spironolactone 12.5 mg PO EVERY OTHER DAY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth Every
other day Disp #*15 Tablet Refills:*0
18. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4-6H:PRN sob
19. Sildenafil 50 mg PO DAILY:PRN erectile dysfunction
20. Vitamin D 1000 UNIT PO DAILY
21. Outpatient Lab Work
Please have INR drawn on ___
Central IM Anticoagulation Program ___, RN
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Health Care Associated Pneumonia
Secondary diagnosis:
Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your admission at the
___. You were admitted because
of your worsening shortness of breath and recent weight gain.
You were given medications to help remove some fluid from your
body. You were also treated for a pneumonia during your
admission here with IV antibiotics. Some of your medications
were adjusted during your admission. Please take your
medications as prescribed. Your discharge weight was 97.0 kg.
Please call a physician if you should gain more than 3 pounds in
a short period of time of if you notice increased swelling in
your legs or progressive shortness of breath as this may
indicate a need to adjust your medications.
You also have cardiology appointments scheduled for ___, as
well as an appointment with Dr. ___ endocrinologist, on
___. Please call your PCP to schedule ___ follow up appointment
within one week.
It was a pleasure taking care of you during your
hospitalization. We wish you the best in your future health.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10897040-DS-4
| 10,897,040 | 21,596,869 |
DS
| 4 |
2196-11-13 00:00:00
|
2196-11-13 17:24:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Leukocytosis
Major Surgical or Invasive Procedure:
-Bone Marrow Bx (___)
History of Present Illness:
Ms. ___ is a ___ female with history of
isolated femoral LN grade 1 follicular lymphoma diagnosed in
___
s/p radiation, then with biopsy-proven recurrence in
retroperitoneal lymph nodes and evidence of slow progression on
recent PET's in retrocrural, ___, aorto-caval,
para-esophageal, and mesenteric nodes (no treated as
asymptomatic/not wanted treatment) who presents with new
leukocytosis.
Patient was found to have new WBC 25K by PCP, on repeat
diff showed atypical cells and heme path reviewed with
concern for blasts. She also had PET with diffuse
marrow uptake. She says reports she is feeling well other than
some leg
cramping since coming back from ___. She also notes dog
bite in ___ while in ___. Denies any constitutional
symptoms. She was called by the ___ fellow who explained
possibility of circulating lymphoma or leukemia. She agreed to
present to the ED but says she would never want any
chemotherapy.
On arrival to the ED, initial vitals were 98.5 75 173/88 18 100%
RA. Labs were notable for WBC 26.8 (69% blasts), H/H 13.0/40.1,
Plt 213, INR 1.0, fibrinogen 385, Na 138, K 4.3, BUN/CR ___,
LDH 997, uric acid 7.5, lactate 2.6, and UA negative. Patient
had
CXR, read pending. Patient was given allopurinol ___ PO and 1L
NS. Prior to transfer vitals were 98.1 76 164/76 16 100% RA.
On arrival to the floor, patient reports feeling well. She has
no
complaints. She denies fevers/chills, night sweats, headache,
vision changes, dizziness/lightheadedness, weakness/numbnesss,
shortness of breath, cough, hemoptysis, chest pain,
palpitations,
abdominal pain, nausea/vomiting, diarrhea, hematemesis,
hematochezia/melena, dysuria, hematuria, and new rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONC HISTORY
Ms. ___ was first diagnosed with follicular lymphoma in
___ and was treated with radiation therapy to a singular
femoral
node. She has shown signs of progressive retroperitoneal
adenopathy on CT and PET scans though has been very reluctant to
start therapy. Biopsy of the RP adenopathy performed in ___
showed involvement by her known follicular lymphoma.
PET-CT ___ was unchanged. The plan was to continue
monitoring
her since she was adamant that she would never want to receive
chemotherapy. She then missed several follow-up appointments due
to an extended trip to ___.
PET-CT ___: showed increase in size and FDG avidity of
retrocrural nodes with stable RP nodes.
The patient did recently have a tongue lesion that was resected
without evidence of lymphoma or other malignancy.
PAST MEDICAL HISTORY:
- Hypertension
- Hyperlipidemia
- GERD
- Asthma
- History of ___
- Low Back Pain
- Cervical DJD
- s/p right rotator cuff in ___
Social History:
___
Family History:
Mother died age ___ of 'old age'. Her father died
at the age of ___ of unknown causes. Her mother and father had 4
children together, and her father had 46 (!) children by other
women. Her brother has type ___ diabetes mellitus, and another
brother died of pancreatic cancer. No other disorders that she
is
aware of run in her family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 98.6, BP 160/90, HR 64, RR 18, O2 sat 99% RA.
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN ___
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
DISCHARGE PHYSICAL EXAM:
VS: Tm 98.6 HR 79, BP 130/80 RR 18 100% RA
GENERAL: NAD, resting comfortably in bed
HEENT: PERRL, anicteric, oropharynx clear
CARDIAC: rrr, normal s1/s2, no m/r/g.
LUNG: CTAB, no wheezing, rales, rhonchi
ABD: Soft, non-tender, non-distended, normal bowel sounds
EXT: Warm, non-edematous, 2+ ___ pulses
Neuro: A&Ox3
Skin: ecchymotic patches on abdomen from lovenox shots
Pertinent Results:
LABS ON ADMISSION:
=============================
___ 10:37PM BLOOD WBC-26.8* RBC-4.24 Hgb-13.0 Hct-40.1
MCV-95 MCH-30.7 MCHC-32.4 RDW-15.2 RDWSD-52.2* Plt ___
___ 10:37PM BLOOD Neuts-11* Bands-0 Lymphs-16* Monos-3*
Eos-1 Baso-0 ___ Myelos-0 Blasts-69* NRBC-2*
AbsNeut-2.95 AbsLymp-4.29* AbsMono-0.80 AbsEos-0.27
AbsBaso-0.00*
___ 10:37PM BLOOD ___ PTT-27.8 ___
___ 10:37PM BLOOD ___ 10:37PM BLOOD Ret Aut-2.2* Abs Ret-0.09
___ 10:37PM BLOOD Glucose-118* UreaN-12 Creat-0.8 Na-138
K-4.3 Cl-98 HCO3-25 AnGap-19
___ 10:37PM BLOOD ALT-39 AST-71* LD(LDH)-997* CK(CPK)-362*
AlkPhos-60 TotBili-0.3 DirBili-<0.2 IndBili-0.3
___ 10:37PM BLOOD Albumin-4.3 Calcium-9.6 Phos-3.7 Mg-1.8
UricAcd-7.5*
___ 10:43PM BLOOD Lactate-2.6*
MICRO:
================
___ 11:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 11:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING/OTHER STUDIES:
===========================
___ VENOUS DUPLEX UPPER EXTREMITY: Occlusive thrombus
surrounding the PICC which is in 1 of the brachial veins.
___ RUQ US WITH DOPPLER: Patent hepatic vasculature by
color Doppler. Unremarkable abdominal ultrasound.
___ Cardiovascular ECHO
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function.
___ Cytogenetics Tissue: BLOOD, NEOPLASTIC
1) FISH: POSITIVE for BCR/ABL. 92% of the interphase peripheral
blood cells examined had a probe signal pattern consistent with
the BCR/ABL1 gene rearrangement.
2) FISH: NEGATIVE for MLL REARRANGEMENT. No evidence of
interphase peripheral blood cells with rearrangement of the MLL
gene.
3) FISH: NEGATIVE HIGH GRADE LYMPHOMA PANEL. No evidence of
interphase peripheral blood cells with the IGH/BCL2 gene
rearrangement or rearrangements of the BCL6 and MYC genes.
___ Pathology Tissue: BONE MARROW, BIOPSY, CORE
DIAGNOSIS:
B ACUTE LYMPHOBLASTIC LEUKEMIA/LYMPHOMA WITH BCR-ABL1 GENE
REARRANGEMENT; SEE NOTE.
Note: A population of circulating blasts representing 60% of the
peripheral blood differential count is seen. Blasts represent
80-90% of the overall bone marrow cellularity. Concurrent flow
cytometry
revealed a population of CD34 positive blasts which co-express
CD19, CD10, ___, nTdT and showed no expression of MPO (see
separate report ___ for full results). Cytogenetics
work-up revealed evidence of BCR/ABL1 gene rearrangement (see
separate reports CY17-___ and
CY17-887 for full results). The findings are in keeping with
involvement by B acute lymphoblastic leukemia/lymphoma with
BCR-ABL1 gene rearrangement. Correlation with clinical and
laboratory findings is recommended.
PET-CT ___
1. Diffusely increased FDG uptake throughout the bone marrow.
In
the absence of marrow stimulation (none listed on OMR), these
findings are concerning for lymphoma involvement. If there has
been recent marrow stimulation, these findings are consistent
with physiological response.
2. Increased FDG uptake at the left axilla and subpectoral
region
with scattered mildly enlarged lymph nodes. Focal area of
uptake
at the left posterior deltoid muscle. These findings can be
attributed to recent immunization, but clinical correlation is
needed.
3. Slightly increased prominence and FDG avidity of soft tissue
adjacent to the aorta with SUV max 6.6.
4. Interval improvement in left para-aortic lymph node
conglomerate.
LABS ON DISCHARGE:
===============================
___ 06:20AM BLOOD WBC-10.1* RBC-3.56* Hgb-11.6 Hct-35.7
MCV-100* MCH-32.6* MCHC-32.5 RDW-16.0* RDWSD-59.9* Plt ___
___ 06:20AM BLOOD Neuts-77.6* Lymphs-14.9* Monos-5.3
Eos-0.0* Baso-0.2 Im ___ AbsNeut-7.84* AbsLymp-1.51
AbsMono-0.54 AbsEos-0.00* AbsBaso-0.02\
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD ___ PTT-25.1 ___
___ 01:18PM BLOOD Glucose-372* UreaN-28* Creat-0.9 Na-132*
K-3.5 Cl-91* HCO3-19* AnGap-26*
___ 06:20AM BLOOD ALT-53* AST-16 LD(LDH)-268* AlkPhos-58
TotBili-1.4
___ 06:20AM BLOOD Calcium-9.6 Phos-3.8 Mg-2.0 UricAcd-4.3
Right Upper Extremity Veins Ultrasound ___:
No evidence of deep vein thrombosis in the right upper
extremity. Interval
removal of PICC line and resolution of occlusive thrombus
surrounding the
previously placed and now removed PICC in 1 of the brachial
veins, previously
characterized on right upper extremity ultrasound ___.
Brief Hospital Course:
Ms. ___ is a ___ female with history of
isolated femoral LN grade 1 follicular lymphoma diagnosed in
___ s/p radiation, complicated by biopsy-proven recurrence in
retroperitoneal lymph nodes and evidence of slow progression on
recent PET's (not treated as asymptomatic/not wanted treatment)
who presents w/ new leukocytosis w/ 60% blasts concerning for
acute leukemia. Ms ___ underwent bone marrow biopsy (___)
with pathology concerning for PH+ ALL, and was started on
dasatinib/prednisone on ___ without any symptoms. However
patient did develop transaminitis during treatment likely in the
setting of Dasatinib administration. RUQUS was normal and liver
workup for common causes was unremarkable. Dasatinib was held
and she was switched to Nilotinib on ___ (though Prednisone was
continued and tapered to 60 mg on ___. LFTs subsequently
trended down. During her stay, she also developed right upper
extremity occlusive DVT in one of the brachial veins; PICC was
removed from that arm and she was subsequently started on
Lovenox. Repeat U/S showed resolved thrombus and patent veins.
==================
ACUTE ISSUES
==================
# ALL: history of isolated femoral LN grade 1 follicular
lymphoma diagnosed in ___ s/p radiation, complicated by
biopsy-proven recurrence in retroperitoneal lymph nodes and
evidence of slow progression who presents w/ new leukocytosis w/
60% blasts concerning for new acute leukemia. Ms ___
underwent bone marrow biopsy (___) with pathology concerning for
PH+ ALL, and was started on dasatinib/pred on ___ without any
symptoms. However patient did develop transaminitis during
treatment likely in the setting of Dasatinib administration,
which was subsequently held. She was switched to Nilotinib with
subsequent decreasing/stable LFTs.
# Transaminitis. LFT rise during her hospital stay correlates
with Dasatinib administration. Per LiverTox "In large clinical
trials, elevations in serum aminotransferase levels during
dasatinib therapy occurred in up to 50% of patients, but were
usually mild and self-limited. Elevations above 5 times the
upper limit of normal (ULN) occurred in 1% to 9% of patients and
generally responded to dose adjustment or temporary
discontinuation and restarting at a lower dose, which is
recommended if liver test results are markedly elevated (ALT or
AST persistently greater than 5 times ULN or bilirubin more than
3 times ULN)." Also see ___, ___ ___.
___ tyrosine kinase inhibitors: clinical and
regulatory perspectives. Drug Saf ___ 36: ___.). She did
not experience significant abdominal pain and tolerated po
intake well. RUQUS without concerning gallbladder or liver
lesions and with patent hepatic vasculature. Liver workup was
otherwise unremarkable. LFTs had been downtrending off
Dasatinib.
# RUE DVT. Occlusive DVT in one of the brachial veins of the
RUE. DVT likely secondary to PICC which had subsequently been
removed. Patient was treated with Lovenox. Since repeat U/S
showed resolved thrombus, she was not discharged on Lovenox.
# History of Follicular Lymphoma: History of isolated femoral LN
grade 1 follicular lymphoma diagnosed in ___ s/p radiation, c/b
biopsy-proven recurrence in retroperitoneal lymph nodes and
evidence of slow progression on recent PET's in retrocrural,
___, aorto-caval, para-esophageal, and mesenteric nodes
(not treated as asymptomatic/did not want treatment).
# Hypertension: Continued on home lisinopril/HCTZ.
Intermittently hypertensive to SBP 180, requiring Labetalol PRN
# HLD: Holding statin in the setting of transaminitis.
# Insomnia: Restarted home alprazolam
===================
TRANSITIONAL ISSUES
===================
NEW MEDICAITONS:
[] Acyclovir for prophylaxis while on chemotherapy
[] Atovaquone for prophylaxis while on chemotherapy
[] Nilotinib for treatment of ALL
QTc (___): 415 ms
ACTION ITEMS:
[] Please administer HBV vaccine as outpatient
[] Please draw LFTs within two weeks from time of discharge. If
liver enzymes are trending up, please contact the patient's
oncologist (Dr. ___ as she may need modifications to
her treatment regimen and/or prophylaxis medications.
[] Please draw a follow-up potassium level in
___ clinic on ___
[] Please monitor QTc while on Nilotinib (most recent, 415 ms)
Name of health care proxy: ___
Relationship: Daughter
Phone number: ___
Code: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of
breath/wheezing
2. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
3. lisinopril-hydrochlorothiazide ___ mg oral DAILY
4. Omeprazole 40 mg PO DAILY
5. Potassium Chloride 10 mEq PO DAILY
6. Simvastatin 20 mg PO QPM
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
8. Aspirin 81 mg PO DAILY
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
10. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
2. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 10 ml by mouth daily Refills:*0
3. nilotinib 400 mg PO BID
4. PredniSONE 10 mg TABs
RX *prednisone 10 mg See instructions tablet(s) by mouth Daily
Disp #*40 Tablet Refills:*0
___: 6 TABs daily
___: 4 TABs daily
___: 2 TABs daily
___: 1 TAB daily
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of
breath/wheezing
6. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
7. Aspirin 81 mg PO DAILY
8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
9. lisinopril-hydrochlorothiazide ___ mg oral DAILY
10. Multivitamins 1 TAB PO DAILY
11. Potassium Chloride 10 mEq PO DAILY
Hold for K >
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
=========================
-Acute lymphoblastic Leukemia
-Deep Vein Thrombosis
Secondary Diagnosis:
============================
-Follicular Lymphoma
-Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure being involved in your care.
Why you were here:
-You came in after your primary doctor discovered that you had a
high white blood cell count concerning for a blood cancer
What we did while you were here:
-We diagnosed you with a blood cancer called, Acute
Lymphoblastic Leukemia. For this condition we started you on an
oral medication called Dasatinib and prednisone. Your liver
enzymes increased while taking the Dasatinib so we have switched
you to a different, but similar medication called Nilotinib.
-You were also found to have a blood clot in your arm. You were
treated with a blood thinner and your blood clot improved.
What to do when you are discharged:
-Continue taking your medications as prescribed
-Attend your follow-up appointments
It was a pleasure taking care of you! We wish you the best!
Your ___ Team
Followup Instructions:
___
|
10897217-DS-21
| 10,897,217 | 25,935,566 |
DS
| 21 |
2121-07-19 00:00:00
|
2121-07-19 14:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Biaxin / Sulfa (Sulfonamide Antibiotics) / Cefzil /
Meclofenamate Sodium / cefazolin / vancomycin
Attending: ___
___ Complaint:
Left lower extremity pain and swelling
Major Surgical or Invasive Procedure:
radiation therapy x10 days to C1/C2
History of Present Illness:
___ y/o F recently diagnosed with MM s/p 1 cycle of
Velcade/dexamethasone who comes in complaining of left lower
extremity edema and pain. The pt reports her symptoms started
about 5 days ago, she initially had swelling and progressed to
redness and a small blister on her L leg, which is more swollen
than the R. her main complaint is that she has decreased
mobility because her legs feel heavy and stiff. She has very
slight tingling on the soles of her feet, denies numbness. She
denies any fevers, chills, SOB, although she does get SOB when
going up stairs. She also reports mild CP described as
sensitivity and a bump on her L chest.
Of note, she had a f/u appt with Oncology on ___ which she
missed due to ___ pain. She says she presented today for a
scheduled appt for chemo on ___ ___? but that there was no
one there so she was directed to the ED.
On ROS, she complains of constipation, no BM since ___ or
___ last week, denies abd pain, bony pains, confusion.
Has difficulty starting stream, no dysuria. Otherwise, full ten
point ROS was negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___: presented to OSH ED with chest pain, treated for
costochondritis with NSAIDS
- ___: presented to ___ to establish care, found to have a
creatinine of 1.4, was instructed to stop NSAIDs and was
referred
for physical therapy
- ___: presented as an episodic visit with hip/back pain.
Laboratory data revealed hypercalcemia with calcium of 11.8,
anemia with a hematocrit of 29.3 and acute renal failure with a
creatinine of 3.1. She underwent plain films of the hip and
chest, which showed a lytic lesion in her right femur as well as
both clavicles. She was instructed to report to the emergency
room.
- ___: Admission to ___. CT Torso showed lytic lesions in
both clavicles. MRI L-spine showed L5 subacute compression
fracture and degenerative changes of the vertebrae without cord
compression. Skeletal survey showed multiple lytic lesions
throughout her skeleton. Immunoglobulin levels showed IgG of
456, IgA of 9, and an IgM of 5. Her urine protein
electrophoresis showed monoclonal free Bence ___ kappa protein
representing 92% of the urinary protein, which it was 8830 mg
per
day. Her free kappa serum level was 12.15 g and her free kappa
to lambda ratio was greater than 1000. Bone marrow biopsy
showed
54% plasma cells in the aspirate. Cytogenetics were normal.
She
was treated with fluids and was started on dexamethasone 40 mg
daily. She started Velcade on ___ while inpatient and has
received a full cycle.
.
Other PMHx:
-pre-HTN
-pre-HLP
-allergic rhinitis
-BPPV
-stress urinary incontinence
-Depression/Adjustment d/o
Social History:
___
Family History:
Brother with kidney stones, mother with skin cancer (unknown
type) and dementia, father died of CAD/MI age ___. Maternal
grandfather may have had leukemia.
Physical Exam:
Admissoin Exam
Gen: In NAD.
HEENT: EOMI. No scleral icterus. No conjunctival injection.
Mucous membranes moist. No oral ulcers.
Neck: Supple, no LAD.
Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal
respiratory effort.
CV: RRR, no murmurs, rubs, gallops.
Abdomen: soft, NT, ND, NABS, no HSM.
Extremities: warm and well perfused, no cyanosis,RLE 1+ edema
to mid shin, LLE ___ edema to knee with slight erythema and an
open blister.
Neurological: alert and oriented X 3, grossly intact.
Skin: as above
Psychiatric: Appropriate.
GU: deferred.
Discharge Exam:
Vitals: 98.4/98.2 120/72 88 18 96%RA
General: no acute distress
HEENT: ___ J in place
Lungs: CTAB
CV: rrr, no mrg
Ext: mild edema
Neuro: A&Ox3
Pertinent Results:
Admission Labs:
___ 03:25PM WBC-9.2 RBC-2.81* HGB-8.5* HCT-24.2* MCV-86
MCH-30.3 MCHC-35.2* RDW-14.0
___ 03:25PM NEUTS-79.9* LYMPHS-16.4* MONOS-2.4 EOS-0.4
BASOS-0.9
___ 03:25PM PLT COUNT-357
___ 03:25PM CALCIUM-13.3* PHOSPHATE-4.1 MAGNESIUM-2.4
___ 03:25PM GLUCOSE-130* UREA N-37* CREAT-2.6*
SODIUM-130* POTASSIUM-3.4 CHLORIDE-94* TOTAL CO2-25 ANION GAP-14
___ 03:29PM LACTATE-0.9
Discharge Labs:
*****************
___ 07:40AM BLOOD WBC-6.2 RBC-2.55* Hgb-8.2* Hct-23.5*
MCV-92 MCH-32.1* MCHC-34.9 RDW-17.2* Plt ___
___ 07:40AM BLOOD Neuts-72.0* ___ Monos-4.9 Eos-3.3
Baso-1.3
___ 07:40AM BLOOD ___ PTT-32.6 ___
___ 07:40AM BLOOD Glucose-89 UreaN-24* Creat-3.1* Na-137
K-3.9 Cl-104 HCO3-25 AnGap-12
___ 07:40AM BLOOD ALT-10 AST-13 LD(LDH)-177 AlkPhos-67
TotBili-0.4
___ 07:40AM BLOOD ALT-10 AST-13 LD(LDH)-177 AlkPhos-67
TotBili-0.4
___ 07:40AM BLOOD Calcium-9.5 Phos-4.8* Mg-1.8
Reports:
Bilateral ___ Doppler U/S: No DVT.
CXR ___
-No evidence of pneumonia.
-Pathologic fracture of the sternum appears more prominent which
may be
related to low lung volumes. This can be assessed clinically for
stability.
MRI ___
Since the previous examination, slight progression of height
loss at L5 and mild height loss at T11-T12 with slight
retropulsion at this level. No
evidence for significant canal compromise is seen
Renal US ___
1. Hyperechoic kidneys consistent with medical renal disease. No
evidence
for hydronephrosis.
2. Normal Doppler examination. No evidence for renal artery
stenosis
CT Chest ___
1. No evidence of pneumonia.
2. Widespread osseous lytic lesions consistent with multiple
myeloma with
multiple pathologic fractures seen within the ribs bilaterally
as well as new compression deformities of the T11 and T12
vertebral bodies, likely
pathologic.
MRI T/Lspine ___
1. Mild progression of the loss of height of T11 and T12
vertebral bodies
since ___ MR ___ spine study with areas of marrow edema
pattern as
described above There is no canal stenosis or compression of the
cord.
2. Persistent loss of height of the L5 vertebral body with areas
of marrow
edema pattern without significant change compared to the prior
study allowing for the expected evolution. Evaluation of the
compression fractures is incomplete given the lack of
post-contrast images for focal lesions.
3. Diffusely abnormal heterogeneous signal intensity of the
marrow with areas of increased signal intensity as described
above related to the underlying hematologic disorder/anemia.
Multilevel, multifactorial degenerative changes as described
above.
4. T2 hyperintense focus in the right lobe of the liver;
correlate with prior CT torso study.
TTE ___
IMPRESSION: Normal left ventricular cavity size and wall
thickness with preserved (near-hyperdynamic) left ventricular
systolic function. Mild resting LVOT gradient. Mild mitral
regurgitation. Normal pulmonary artery systolic pressure.
Trivial pericardial effusion.
___ ___ No DVT
CXR ___ There are persistent low lung volumes. Left lower
lobe atelectasis has worsened. Rounded opacity in the right
lower lobe is concerning for a new infectious process. There is
no pulmonary edema. If any, there is a small left pleural
effusion.
CT C-SPINE W/O CONTRAST ___: 1. Innumerable lytic lesions and
profound osteopenia involving the cervical spine, the base of
the skull, the ribs, and the sternum. 2. Subacute to chronic
anterior wedge compression fracture of T1. 3. Prominent lytic
lesions in the anterior tubercle of C1 and in the base of the
dens are concerning due to their strategic location, although no
pathologic fracture is present at these sites, at this time. 4.
No acute compression fracture or spinal canal or neural
foraminal narrowing.
Brief Hospital Course:
Patient is a ___ yo F with recent diagnosis of light chain kappa
multiple myeloma who was admitted with LLE cellulitis and
hypercalcemia developed a drug rash now improved who developed
volume overload, ARF and hypoxia
.
# Multiple Myeloma: Completed 1 cycle of Velcade/Dex as an
outpatient. During inpatient second cycle completed and third
cycle with the addition of Cyclophosphamide was started. Third
cycle discontinued early given new SOB, new fevers and concern
for velcade reaction. Pt developed new onset neck pain, so a CT
cervical spine was done which revealed multiple lytic lesions
throughout the c-spine, with a prominent, lesion in the C1/C2
region concerning for imminent fracture. Neurosurgery was
reconsulted and pt was advised to wear ___ collar with
thoracic spine brace at all times. She was started on 10 day
cycle of XRT to prevent fracture which could result in
quadraplegia or death. Pt tolerated XRT well. During XRT
treatment, pt was started on cycle 4 of velcade/dex, without
addition of cyclophosphamide (so as to reduce the chance of
cervical fracture during therapy). She tolerated cycle velcade
without recurrence of SOB or rash. Pt's disease burden has not
responded particularly well to chemotherapy and it appears that
she has a very resistant myeloma. Pt was approved for
lenolidamide therapy with plan to start after cycle 4 velcade,
Day 1 = ___.
# Rash: Patient was treated for cellulitis with Cefazolin and
Vancomycin. She shortly therafter developed a severe rash which
began on ___ bilaterally and spread superiorly. 2 distinct
rashes. Rash on UE, chest and back pink morbiliform appearing
but with surrounding ring most consistent with erythema
multiforme. Rash on ___ ascending with non-blanching, raised
bright red coalescing lesions is likely hypersensitivity
reaction ___ drug, most likely Cefazolin. Hypersensitivity is
supported by ARF, trace blood on UA and eosinophils on punch
biopsy of lesions. C3 C4 normal, Hepatitis panels negative and
cryoglboulins negative. Rash resolved with withdrawl of
offending agent and topical steroid agents. Following this
incident, patient found to have a new pruritic eruption on
___, most itchy on her thighs, thought to be ___ levaquin
(given ___ but diff to tease out whether mobiliform rash
occured due to other abx or velcade. Less likely would
be daptomycin>meropenem>linezolid.
.
# SOB: Pt had new O2 requirement. Initially thought volume
overload but CXR most consistent with developing infectious
process. TTE negative. Received 20mg IV Lasix, 2mg IV morphine,
A/A nebs with some improvement in symptoms. Patient remained on
2L NC and holding saturations in mid-90s. After pt started
wearing thoracic spine brace, her SOB resolved, so likely a
component of restrictive lung disease secondary to kyphosis.
.
#Renal Failure: Acute renal failure on chronic, creatinine
elevated from admission 2.3. CRF ___ MM. ARF related to
hypercalcemia on admit but Hypersensitivity reaction likely
contributed given trace blood on UAs and increasing creatinine
with appearance of rash. Creatinine improved as rash cleared.
Creatinine then elevated to 3.1 and did not improve. Light chain
myeloma likely contributing most to renal failure. ARF intrinsic
with aspects of both non-gap and anion gap acidosis. RTA
reversed with PO bicarb. Pt's renal function remained stable for
remainder of hospital course.
.
# Fever: Intermittently febrile during admission. Initially
febrile in setting of rash thought related to systemic
inflammation from drug reaction or vasculitis. Cultures NGTD,
CXR unremarkable. Febrile again after antibiotics discontinued.
Patient started on HCAP coverage given new infilitrated on CXR.
Linezolid and Meropenem given cephalosporin allergy and possible
vancomycin allergy. Pt completed course during hospitalization
and Abx were d/ced. She remained afebrile for remainder of
admission.
.
#LLE Cellulitis: Blanching erythema acute in nature with central
lesion on anterior tibia on admission has resolved and has been
replaced by the above described rash. ___ negative, s/p Vanc
x5d. Cellulitis recurred and Daptomycin was used given concern
for vancomycin allergy and also for VRE growing in urine. Pt
completed abx course during hospitalization and Abx were d/ced.
She remained afebrile for remainder of admission.
.
# Compression Fractures: Pathologic compression of T11, T12 and
L5 without cord involvement related to Multiple Myeloma. INR
recommending kyphoplasty for pain control, RadOnc recommending
10 fractions for pain control. Patient favoring conservative
management and will wear TLSO brace. As mentioned above, pt was
later found to have numerous lytic lesions in cervical spine
with most concerning lesion at level of dens with risk of
imminent fracture. Neurosurgery and rad-onc were reconsulted
and she was given ___ collar with thoracic support and given
a 10 day course of XRT. She tolerated procedure well and will
need to follow up with neurosurgery for repeat imaging 6 weeks
from initial evaluation.
.
#Hypercalcemia: Resolved with IVF, Lasix and Pamidronate 30 mg
IV ONCE. Related to multiple myeloma and ___ lesions.
.
#Anemia: ___ MM, monitor
.
TRANSITIONAL ISSUES:
- CODE STATUS: DNR/DNI, confirmed while inpatient
- F/U with neurosurgery/ rad/onc
- Allergy to Cefazolin, possible allergy to Vancomycin, levaquin
(morbiliform rash)
Medications on Admission:
Medications - Prescription
ACYCLOVIR - (Prescribed by Other Provider) - 400 mg Tablet - 1
Tablet(s) by mouth twice a day
ALLOPURINOL - (Prescribed by Other Provider) - 100 mg Tablet -
1
Tablet(s) by mouth DAILY (Daily)
FUROSEMIDE [LASIX] - (Prescribed by Other Provider) - 20 mg
Tablet - 1 Tablet(s) by mouth once a day as needed for LEG
SWELLING Take once per day for 3 days, then as-needed for ankle
swelling.
HYDROCODONE-ACETAMINOPHEN [VICODIN ES] - (Prescribed by Other
Provider) - 7.5 mg-750 mg Tablet - ___ Tablet(s) by mouth every
six (6) hours as needed for pain Note to pharmacist: please
dispense 7.5-500 tabs rather than 7.5-750 tabs if available.
NOTE
TO PATIENT: maximum tylenol dose 2 grams per day
LORAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet -
___
Tablet(s) by mouth every four (4) hours as needed for anxiety,
insomnia
ONDANSETRON - (Prescribed by Other Provider) - 4 mg Tablet,
Rapid Dissolve - ___ Tablet(s) by mouth every eight (8) hours as
needed for nausea
OXYCODONE - (Prescribed by Other Provider) - 5 mg Tablet - 0.5
(One half) Tablet(s) by mouth every six (6) hours as needed for
breakthrough pain
TRAZODONE - (Prescribed by Other Provider) - 50 mg Tablet - 0.5
(One half) Tablet(s) by mouth HS (at bedtime) as needed for
insomnia
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg Tablet
-
1 Tablet(s) by mouth every six (6) hours as needed for pain
maximum tylenol dose 2 grams per day *including* tylenol in
vercodan
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
POLYETHYLENE GLYCOL 3350 [MIRALAX] - (Prescribed by Other
Provider) - 17 gram Powder in Packet - 1 Powder(s) by mouth once
a day
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. lorazepam 0.5 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for anxiety/insomnia/nausea.
3. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for
nausea/vomiting.
4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for sob/wheezing.
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
9. lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed for mouth pain.
10. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for nausea.
11. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheeze/SOB.
12. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
13. white petrolatum-mineral oil Cream Sig: One (1) Appl
Topical BID (2 times a day) as needed for dry skin.
14. hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours) as needed for pain.
15. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO once a day.
16. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) mL PO DAILY
(Daily).
17. hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for itchiness.
18. guaifenesin 100 mg/5 mL Syrup Sig: ___ MLs PO Q6H (every 6
hours) as needed for cough.
19. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itchiness.
20. saliva substitution combo no.2 Solution Sig: Thirty (30)
ML Mucous membrane QID (4 times a day).
21. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12hrs
on 12hrs off.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
multiple myeloma
thoracic compression fractures
renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ were admitted to ___ with multiple myeloma. We treated
___ with several rounds of chemotherapy. During your
hospitalization we discovered that ___ have several compression
fractures in your thoracic spine, which need to be stabilized
with a TLSO brace. ___ were also found to have a C1/C2 lytic
lesion in your cervical spine. This lesion was determined to be
in danger of imminent fracture, so we performed 10 days of
radiation therapy to prevent the lesion from progressing
further.
We now think that ___ are safe for discharge, but your will
require assistance to regain your strength. For these reasons, a
rehab facility would be the safest place for ___ to go from
here.
We have made the following changes to your home medications:
Please STOP the following medications:
ALLOPURINOL
FUROSEMIDE [LASIX]
HYDROCODONE-ACETAMINOPHEN [VICODIN ES]
OXYCODONE
TRAZODONE
.
START the following medications:
famotidine 20mg daily
atovaquone 1500mg daily
olanzapine 5mg by mouth every 12hrs for as needed nausea
prochlorperazine 10mg every 8hrs as needed for nausea
dilaudid 1mg by mouth every 6hrs as needed for pain
morphine SR (MS ___ 15mg by mouth once daily
caphosol 30mL by mouth 4 times daily as needed for dry mouth
hydroxazine 25mg tab, two tables by mouth every 6 hours as
needed for itchiness
Sarna lotion for dryness as needed up to 4 times daily
lidocaine patch 5%, one patch over painful area. q24hrs: 12
hours on 12 hrs off. PRN: pain
albuterol nebs: 1 neb every 6 hours for shortness of breath,
wheeze
iptratropium nebs: 1 neb every 6 hrs for shortness of breath,
wheeze
.
Please continue all the rest of your home medications.
.
We have arranged follow up appointments for ___ below.
Followup Instructions:
___
|
10897217-DS-26
| 10,897,217 | 28,753,264 |
DS
| 26 |
2122-03-02 00:00:00
|
2122-03-02 14:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Biaxin / Sulfa (Sulfonamide Antibiotics) / Cefzil /
Meclofenamate Sodium / cefazolin / vancomycin
Attending: ___.
Chief Complaint:
encephalopathy, hypercalcemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a ___ F with multiple myeloma, CKD stage IV-V,
receives Velcade and Decadron with Revlimid twice a week
presents to the ER with encephalopathy and hypercalcemia. Of
note, she also has a history of instability of ___ s/p 10
cycles of XRT, now only requiring ___ collar with exercise
as well as pathologic compression of T11, T12 and L5 without
cord involvement related to Multiple Myeloma. History is
partially obtained via Rehab worker at 1230am via phone who
states that the patient has been confused for over a month. She
was not aware of any acute change, but when blood drawn today,
Calcium was 11.5 with Albumin of 2.5. (Calcium 9.9 at ___
yesterday). Md note states that IV fluids and Calcitonin
(presumably 200mg SC x1) were given. Pt describes feeling
anxious about the course of her treatment plan but denies any
change in bone pain, new trauma, headaches, chest pain, fevers,
chills or shakes.
.
Of note, records state Pt completed Ertapenam ___ - ___ for
UTI
.
Vitals in the ER: 97.5 108 113/69 18 95% RA. She was given
Dilaudid 1mg IV x2, Dexamethasone 40mg IV x1, and 2L NS.
.
Review of Systems:
(+) Per HPI + nausea without vomiting
(-) Denies fever, chills, night sweats, loss of vision, Denies
headache, chest pain or tightness, cough, shortness of breath,
or wheezes. Denies vomiting, diarrhea, constipation, abdominal
pain, melena, hematemesis, hematochezia. No numbness/tingling in
extremities. All other systems negative.
.
Past Medical History:
Past Medical History:
- ___: presented to OSH ED with chest pain, treated for
costochondritis with NSAIDS
- ___: presented to ___ to establish care, found to have a
creatinine of 1.4, was instructed to stop NSAIDs and was
referred for physical therapy
- ___: presented as an episodic visit with hip/back pain.
Laboratory data revealed hypercalcemia with calcium of 11.8,
anemia with a hematocrit of 29.3 and acute renal failure with a
creatinine of 3.1. She underwent plain films of the hip and
chest, which showed a lytic lesion in her right femur as well as
both clavicles. She was instructed to report to the emergency
room.
- ___: Admission to ___. CT Torso showed lytic lesions in
both clavicles. MRI L-spine showed L5 subacute compression
fracture and degenerative changes of the vertebrae without cord
compression. Skeletal survey showed multiple lytic lesions
throughout her skeleton. Immunoglobulin levels showed IgG of
456, IgA of 9, and an IgM of 5. UPEP showed monoclonal free
Bence ___ kappa protein representing 92% of urinary protein
(~8830 mg per day). Her free kappa serum level was 12.15 grams
and her free kappa to lambda ratio was greater than 1000. Bone
marrow biopsy showed 54% plasma cells in the aspirate.
Cytogenetics were normal.
- To date she has received 7 cycles of treatment. For cycles 1
and 2 she received Velcade and Decadron alone on days 1,4,8, and
11. She got a dose of Cytoxan on day 13 of her ___ cycle as she
was not having a great response. For her ___ cycle of treatment
she received Velcade/Decadron on days 1,8,11 (day 4 held d/t ?
of pneumonitis) and Cytoxan on days 1 and 8. During her ___
cycle she developed acute neck pain and had trouble holding her
head up. A cervical spine CT revealed multiple lytic lesions
with a prominent lesion in C1/C2 concerning for imminent
fracture. Neurosurgery recommended she wear a ___ J collar at
all times in addition to the TLSO brace she had already been
wearing for pathologic compression fractures of T11, T12 and L5
without cord involvement. She also received a 10 day course of
radiation to C1/C2. For her ___ cycle of treatment she received
Velcade and Decadron as before, Cytoxan was held to reduce the
risk of fracture given her new C-spine findings. Revlimid was
started with her ___ cycle of Velcade and Decadron at a low dose
of 5 mg twice a week.
- Missed C8 due to switch from ___ to another rehab that
cannot due chemo, and then has had osteomyelitis
OTHER PMHx: Depression, adjustment disorder, allergic rhinitis,
borderline hypertension, pre-hyperlipidemia, BPPV, stress
urinary incontinence, stage 4 mandibular and sacral ulcers s/p
debridement ___ with associted osteomyelitis.
Social History:
___
Family History:
Brother with kidney stones, mother with skin cancer (unknown
type) and dementia, father died of CAD/MI age ___. Maternal
grandfather may have had leukemia.
.
Physical Exam:
Admission Exam
VS: T 97.5 bp 100/69 HR 95 SaO2 94 RA
GEN: cachectic, NAD, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, global distention and mild tenderness without rebound
or guarding, bowel sounds present
MSK: poor muscle bulk, normal tone
EXT: No c/c, normal perfusion, PICC dressing site on the left AC
fossa
SKIN: Multiple ecchymoses on extremities but not core, warm skin
NEURO: oriented x 3, no focal motor deficits. normal attention,
PSYCH: circumstantial thought process, normal thought content
.
Pertinent Results:
Admit Labs:
___ 03:35PM GLUCOSE-125*
___ 03:35PM UREA N-58* CREAT-2.1* SODIUM-133
POTASSIUM-5.3* CHLORIDE-96 TOTAL CO2-30 ANION GAP-12
___ 03:35PM ALT(SGPT)-10 AST(SGOT)-19 LD(LDH)-205 ALK
PHOS-109* TOT BILI-0.3
___ 03:35PM ALBUMIN-2.5* CALCIUM-11.1* PHOSPHATE-4.3
MAGNESIUM-3.0*
___ 03:35PM WBC-8.9 RBC-3.32* HGB-10.9* HCT-32.3* MCV-97
MCH-32.9* MCHC-33.9 RDW-17.3*
___ 03:35PM NEUTS-90.7* LYMPHS-6.2* MONOS-2.4 EOS-0.3
BASOS-0.5
___ 03:35PM PLT COUNT-256
.
Discharge Labs:
___ 04:04AM BLOOD WBC-7.3 RBC-2.48* Hgb-8.6* Hct-24.7*
MCV-100* MCH-34.4* MCHC-34.6 RDW-17.9* Plt ___
___ 03:58AM BLOOD Glucose-112* UreaN-49* Creat-1.6* Na-142
K-3.0* Cl-104 HCO3-30 AnGap-11
___ 03:58AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.5*
___ 06:20AM BLOOD VitB12-631 Folate-8.8
___ 06:18PM BLOOD ACTH - FROZEN-PND
___ 06:05AM BLOOD b2micro-10.7*
___ 06:18PM BLOOD Cortsol-13.1
___ 07:10PM BLOOD Cortsol-29.9*
___ 07:50PM BLOOD Cortsol-34.6*
___ 01:20AM URINE Color-Straw Appear-Cloudy Sp ___
___ 01:20AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 01:20AM URINE RBC-7* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
.
.
Micro Data:
.
___ Stool C. diff: POSITIVE
___ Blood cx x 2 sets: NGTD, final pending
___ Fungal Isolator blood culture: NGTD, final pending
___ Urine Cx
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
AMPICILLIN------------ =>32 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 256 R <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- 8 I 2 S
VANCOMYCIN------------ =>32 R 1 S
.
.
.
IMAGING
___
PCXR
FINDINGS: Portable AP supine view of the chest was provided.
There is a left arm PICC line with its tip extending into the
cavoatrial junction or possibly into the right atrium. The
heart is moderately enlarged. There is mild left basal
subsegmental atelectasis. Lung volumes are low. No
pneumothorax.
.
.
Brief Hospital Course:
This is a ___ F with multiple myeloma, CKD stage IV-V,
receives Velcade and Decadron with Revlimid twice a week
presents to the ER with encephalopathy and hypercalcemia also
found to have ARF.
.
#Hypercalcemia secondary to Multiple Myeloma causing
encephalopathy
The patient had a subacte AMS according to rehab. She was
treated aggresively with IV fluids, lasix and pamidronate with
good result. Her MS improved while on the floor. Her calcium
levels returned to ___ and her mental status returned to
baseline, and she is alert, oriented x 3, and interactive on the
day of discharge.
.
# Sepsis with hypotension ___ C. diff colitis and possible
complicated UTI.
The patient was found to have a SBP in the 80's 1 into into her
hospital admission. Her baseline BP was though to be in the
110-120 range. Her foley was changed, BC, UC and a CXR was
taken. The presumed source of her infection was her GU tract.
She was empirically started on meropenum due to multiple
antibiotics allergies. Fugal isolator blood cultures were also
sent because the patient is on TPN. The patients picc line did
not appear to be infected. A random cortisol was checked and
found to be low at 1, but she underwent a cosyntropin stim test,
which was negative for adrenal insufficiency. She had an
appropriate adrenal reponse, with basal cortisol at 13, cortisol
level at 29 and 34, at time points 30min and 60min
post-cosyntropin. Her urine culture ended up growing CoNS and
VRE, so she was switched from Meropenem to Linezolid, and then
ultimately to Daptomycin out of concern for possible marrow
suppresion from Linezolid. These 2 pathogens may represent
colonization in the setting of Foley catheter as opposed to true
infection, but given her immunosuppression and poor nutritional
status, we opted to treat her for complicated UTI with a 7 day
course of appropriate antibiotic coverage, from ___. As
noted above, her Foley was exchanged. She was also noted to
have loose stoo, which was initially presumed to be due to her
bowel regimen, however, a stool sample returned C. diff
positive, and she was started on PO Flagyl. PO Vancomycin was
not used due to her severe Vanco allergy (per her report, a
desquamating rash). Her diarrhea improved on the Flagyl. She
will complete a 2 week course of PO Flagly from ___ to
___. At time of discharge, her blood cultures and fungal
isolator are still pending, although show no growth to date.
.
# ARF with CKD stage IV secondary to multiple myeloma
Baseline Cr variable but appears to be 1.7, and presented with
elevated Cr to 2.1, as well as elevated K. The patient was
given aggresive IVF and her Cr returned to baseline with a Cr of
1.6 on day of discharge. Likely her diarrhea also contributed
to her dehydration and with improvement of her diarrhea, her
renal function remained stable.
.
# Hyperkalemia
The was thought to be due to acute on chronic RF. She was
treated medically for this and IVF and this improved.
.
# Pulm Edema: shortly following admission, pt developed some
mild SOB and was noted to have an mild O2 requirement ___
liters). She was noted to have crackles on exam and PCXR
confirmed pulm edema. This was likely due to volume overload in
the setting of aggressive IVF repletion. She received a single
dose of IV Lasix with good UOP and resolution of her resp
symptoms and O2 requirement. She remains stable on room air at
this time and is breathing comfortably.
.
# Multiple Myeloma:
Diagnosed ___, currently dexamethasone and revlimid. Many
diffuse lytic lesions. Is on infection prophylaxis with
Acyclovir, Fluconazole, and atovaquone. She was continued on
the antibiotic prophylaxis. Her case was reviewed with Dr.
___ primary ___. She
recommended increasing her Revlimid dose to 5mg 3 x per week.
She does not recommend additional dexamethasone at this time.
She will continue to follow Ms. ___.
.
#Anorexia, cachexia, severe maluntrition:
Was on TPN at ___ for poor appetite, calorie counts on
previous admission showed intake of 300-500kcal/day, patient
requirements closer to 1800/day. She was seen by Nutrition
Consult and remained on PO intake as tolerated and supplemental
TPN.
.
#Hx of transaminitis which previously normalized following
discontinuation of TPN and Fluconazole, but curently normal on
both of these.
.
# Coccyx ulcer with history of osteomyelitis:
Pressure ulcer, had debridement ___. Was scheduled to
receive daptomycin &
moxifloxacin until ___ for osteomyelitis, which was switched
to linezolid given desire to cover HCAP on prior admission. Plan
was
for plastic surgery re-evaluation around ___ as she
will likely need a flap to close the sacral decubitus ulcer,
unless goals of care change. ___ RN, wound is improving.
Wound was re-evaluated on this admission by Wound Care and felt
that the wound was improving in all aspects and did not appear
infected, and bone could not be seen or palpated. Please see
additional paperwork for full wound care recommendations.
.
# Anemia secondary to inflammation and malignancy - transfuse as
needed. Her Hct was noted to drop during the admission, but
likely was due to hemoconcentration on presentation in the
setting of severe dehydration. Her Hct has been stable in the
mid-___, which is c/w her recent baseline. No blood was
transfused during the hospitalization.
.
# T11/12 fracture, cervical instability: She requires TLSO brace
when out of bed and if head of bed >45 degrees, or when working
with physical thearpy. Followed by Dr. ___ neurosurgery.
She should wear a soft cervical collar at night for additional
support.
.
# Anxiety / depression: Evaluated by psychiatry at ___ on
___ and felt that although depressed, Pt has full capacity
to make medical decisions. Stable moood, denied SI.
- continued mirtazipine
- seen by social work
.
F/E/N: PO as tolerated, TPN for supplement
FOLEY CATHETER in place for incontinence in the setting of
sacral decubitus ulcer.
ACCESS: Left arm PICC line
CODE STATUS: DNR/DNI
HEALTH CARE PROXY: ___ (Brother) ___
.
# Transitional Issues
[] complete course of antibiotics for C. diff colitis with PO
Flagyl and VRE/CoNS complicated UTI with daptmoycin
[] continue on-going chemotherapy treatment for MM with Revlimid
and f/u with Dr. ___
[] f/u with Neurosurgery for cervical instability and multiple
compression fracture of T- and L-spine
[] resume stool softeners and laxatives when her diarrhea
resolves
[] continue TPN
[] monitor her electrolytes
[] f/u pending lab studies and culture data, including ACTH
level and pending blood cultures and fungal isolator blood
culture
.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Rehab records.
1. Acetaminophen 650 mg PO Q6H:PRN fever
2. Acyclovir 400 mg PO Q8H
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
4. Artificial Tears ___ DROP BOTH EYES QID
5. Atovaquone Suspension 1500 mg PO DAILY
6. Bisacodyl 10 mg PR Q12H:PRN constipation
7. Calcitonin Salmon 200 UNIT SC Q 12H
8. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID
9. Dexamethasone 20 mg IV DAYS (TH)
10. Docusate Sodium 100 mg PO BID
11. ertapenem *NF* 1 gram Injection daily
Day 1 = ___ finished on ___ for UTI
12. Fluconazole 200 mg PO Q24H
13. Heparin 5000 UNIT SC BID
14. HYDROmorphone (Dilaudid) ___ mg IV Q3H:PRN pain
15. Lactulose 15 mL PO DAILY:PRN constipation
16. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
17. Metoclopramide 5 mg IV TID
18. Miconazole Powder 2% 1 Appl TP QID:PRN rash
19. Mirtazapine 15 mg PO HS
20. Morphine SR (MS ___ 15 mg PO Q12H
21. Lenalidomide 5 mg PO TUE, FRI
22. Polyethylene Glycol 17 g PO DAILY
23. Simethicone 80 mg PO TID
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
3. Artificial Tears ___ DROP BOTH EYES QID
4. Atovaquone Suspension 1500 mg PO DAILY
5. Fluconazole 200 mg PO Q24H
6. Heparin 5000 UNIT SC BID
7. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
8. Simethicone 80 mg PO TID
9. Morphine SR (MS ___ 15 mg PO Q12H
10. Mirtazapine 15 mg PO HS
11. Miconazole Powder 2% 1 Appl TP QID:PRN rash
12. Metoclopramide 5 mg IV TID
13. Lenalidomide 5 mg PO 3X/WEEK (___)
14. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
take from ___ - ___ for total ___. Daptomycin 220 mg IV Q48H
7 day course for presumed complicated UTI with antibiotic
coverage from ___ to ___. Last day is ___.
16. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID
17. HYDROmorphone (Dilaudid) ___ mg IV Q3H:PRN pain
18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypercalcemia
acute on chronic renal failure
hypotension
c. diff colitis
UTI - CoNS and VRE
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 ___ with and altered mental status and
your were found to have elevated calcium levels and renal
failure. You were treated with medications and IV fluids to
lower your calcium. Your blood pressure was also found to be
low. This was thought to be due to an infection and you were
found to have both a urinary tract infection and a bowel
infection with an organism called C. diff, which is causing your
diarrhea. Your blood pressure improved with IV fluids and
treatment of your underlying infection.
.
Please take your medications as listed/prescribed below.
.
Please f/u with your doctors as listed below.
.
Followup Instructions:
___
|
10897258-DS-10
| 10,897,258 | 22,989,380 |
DS
| 10 |
2141-09-15 00:00:00
|
2141-09-15 14:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
cephalexin
Attending: ___
Chief Complaint:
Facial numbness, headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with history of PCOS, obesity, T2DM and HLD
presenting with 4 days of left facial numbness. Patient reports
initially numbness was intermittent, then the day prior to
presentation became constant. She also developed a severe
bifrontal headache which has resolved. She also has intermittent
light headedness and numbness in the tips of all her fingers.
Denies vision changes, vertigo, nausea/vomiting, weakness or
other numbness/paresthesias. CT revealed pneumocephalus and MRI
revealed likely ruptured right temporal dermoid cyst with fat
droplets in the subarachnoid space and lateral ventricles.
Neurosurgery consulted for further treatment recommendations.
Past Medical History:
PMHx:
Obesity
PCOS
Diabetes
Dyslipidemia
Anxiety
Migraine
PSHx: Removal of fallopian cyst age ___
Social History:
___
Family History:
NC
Physical Exam:
ON ADMISSION: ___
============
PHYSICAL EXAM:
O: T: 97.9 BP: 123/81 HR: 113 R: 14 O2Sats: 99%RA
Gen: WD/WN, comfortable, NAD.
HEENT: Atraumatic
Neck: Supple.
Lungs: No resp distress
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 equally round and reactive to light.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Paresthias to left V1 & V2 distribution, otherwise
sensation intact to light touch.
ON DISCHARGE
============
Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious [ ]None
Orientation: [x]Person [x]Place [x]Time
Follows Commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL 5-3mm bilaterally
Denies blurred/double vision.
EOMs: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]No
Tongue Midline: [x]Yes [ ]No
Speech Fluent: [x]Yes [ ]No
Comprehension Intact: [x]Yes [ ]No
Motor:
Trap Deltoid Biceps Triceps Grip
Right5 5 5 5 5
Left5 5 5 5 5
IP Quad Ham AT ___ ___
Right5 5 5 5 5 5
Left5 5 5 5 5 5
Sensation: Reports ongoing left facial, left torso,
anterior/medial left leg numbness. Sensation normal in bilateral
feet.
Light pink rash noted on bilateral upper anterior thighs. No
open areas.
Pertinent Results:
Please see OMR for pertinent lab and imaging results.
Brief Hospital Course:
On ___, Ms. ___ was admitted to the neurosurgery service
after NCHCT and MRI were concerning for ruptured dermoid cyst.
Left facial numbness improved after admission. She was treated
for chemical meningitis with IV dexamethasone and seizure
prophylaxis with Keppra. She remained in ___ for close
neurologic monitoring due to risk for hydrocephalus. She was
started on high dose dexamethasone for 24 hours prior to
decreasing to 4mg Q6H. Repeat NCHCT on ___ was stable. On ___,
the patient remained neurologically stable on examination. She
complained of dizziness and was repleted with 1L normal saline.
Patient worked with ___ who noticed patient was orthostatic with
activity. Patient again was given an additional liter of fluids
which improved patients complaints of lightheadedness and
dizziness. Patient in the evening of ___ began to complain of
LLE weakness and paresthesia. LENIs performed and were negative
for an acute DVT. Repeat CTH also obtained due to these new
complaints and stable from prior imaging. Neurologically patient
remained stable with continued, slight LLE weakness. Patient was
transferred to the floor on ___. Patient was started on a
dexamethasone taper on ___, which ended ___. Patient continued
to complain of intermittent headaches which were relieved with
PRN analgesics (Fioricet and Ibuprofen). On ___ patient was
given migraine cocktail which resolved her headache. She was
discharged with instructions to follow-up with Dr. ___ in 3
months with MRI +/- contrast.
#Bradycardia/ Hypotension/ Chest tightness
On ___ patient began to complain of chest tightness along with
lightheadedness and dizziness. Patient was found to be
bradycardic and hypotensive. The medicine service was consulted
for help in management and recommended a fluid bolus which was
given. UA was obtained and negative for infection. KUB was also
obtained due to complaints of chest tightness and abdominal
discomfort which was negative for an acute obstruction.
Troponins and an EKG were also obtained during complaints of
chest tightness and abdominal discomfort which were WNL as well
as patient's electrolytes. Medicine recommended discontinuing
patient's scopolamine patch which helped resolve patient's
bradycardia. Patient started on Famotidine ___ ___s tums
and Maalox PRN. On ___ Famotidine was switched to Pantoprazole
due to continued complaints of acid reflux and the patients
symptoms improved.
#T2DM
Blood sugars were elevated during her admission in the setting
of dexamethasone. ___ was consulted for insulin management.
Patient's HbA1C was checked on ___ which resulted as 12.2.
Throughout ___ hospital stay, ___ continued to manage
insulin doses and blood sugars. ___ provided education prior
to the patient's discharge from the hospital. She was discharged
with instructions to continue her home Januvia and continue
Lantus qAM. She was given prescriptions for the diabetic
supplies and emergency kit. Since her initial visit with her new
PCP is about ___ month away she was advised to follow-up in ___
Diabetes clinic for follow-up on her blood glucose control as
well as her PCP for long term management.
#Peripheral neuropathy
On ___, the patient was started on Gabapentin 100mg TID for
complaints of bilateral leg paresthesias. On ___, the dose was
increased to 200mg TID. On ___, the patient had an increase in
severity of her intermittent left facial numbness. Out of family
concern for seizures, a twenty minute EEG was done that showed
that there were no clear interictal epileptiform activity
identified. The family was reassured that her symptom was likely
not seizure related.
#Rash
On ___ the patient noted a light pink rash on her bilaterally
upper anterior thighs. She denied rash on her torso, arms or
chest. Due to concern for possible drug reaction to the Keppra
we touched base with neurology who agreed that calling the
clinic to discuss possible need for changing the AED if contact
dermatitis was ruled out and the rash became more generalized.
The patient and her father agreed with the plan. The number to
contact the neurology clinic was provided to the patient.
#Disposition
Patient was evaluated by physical therapy on ___ who recommended
___ rehab. Occupational therapy evaluated patient on ___
who also recommended ___ rehab. Case manager met with
patient and her family and discussed rehab placement options
close to home however insurance did not authorize acute care.
Patient was re-evaluated by ___ and OT who worked with the
patient and her father to progress her to home with a walker.
She was discharged to home with ___, ___, and OT on ___ after
mobility training with her father.
Medications on Admission:
Januvia 100 mg tablet 1 tablet(s) by mouth daily
Altavera (28) 0.15 mg-30 mcg tablet 1 tablet(s) by mouth daily
citalopram 20 mg tablet 1 tablet(s) by mouth daily - stopped
taking
pravastatin 10 mg tablet 1 tablet(s) by mouth daily - stopped
taking
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache
Do not exceed 4GM acetaminophen in 24 hours.
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth q6h PRN Disp #*20 Tablet Refills:*0
2. Gabapentin 200 mg PO TID
RX *gabapentin 100 mg 2 capsule(s) by mouth three times a day
Disp #*180 Capsule Refills:*0
3. Glargine 8 Units Breakfast
RX *blood sugar diagnostic [OneTouch Verio] Test blood glucose
4 times daily Disp #*100 Strip Refills:*2
RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL
(3 mL) AS DIR 8 Units before breakfast; Disp #*2 Syringe
Refills:*0
4. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. LORazepam 0.5 mg PO Q8H:PRN anxiety
7. SITagliptin 100 mg oral DAILY
RX *sitagliptin [Januvia] 100 mg 1 tablet(s) by mouth once a day
Disp #*60 Tablet Refills:*0
8.One Touch Verio Meter
Test BG 4 times daily
#1
9.One Touch Verio Strips
Test BG 4 times daily
#100 strips
2 refills
10.One Touch Delica
Test BG 4 times daily
#100 lancets
2 refills
11.Lantus Solostar Pen
Up to 10 units per day
#2 pens
12.Insulin Pen Needles 32G (BD ultra nano)
Use to inject Insulin 5 times daily
#150
2 refills
13.Glucagon Emergency Kit
1 for emergency use
14.Rolling Walker
Diagnosis: Ruptured dermoid cyst
Prognosis: Good
___: 13 mos
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Ruptured dermoid cyst
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(walker).
Discharge 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.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10897834-DS-12
| 10,897,834 | 27,612,385 |
DS
| 12 |
2132-05-28 00:00:00
|
2132-05-29 21:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
prednisone
Attending: ___.
Chief Complaint:
Pleur-evac malfunction
Major Surgical or Invasive Procedure:
___ guided diagnostic paracentesis ___
History of Present Illness:
___ female with history of asthma, IgA nephropathy, Nash
cirrhosis, left side pleural effusion with a Pleur-evac in
place,
presenting with Pleur-evac malfunction.
In terms of the patient's need for pleurex, she underwent
placement after multiple thoracenteses were consistent with
chylothorax. Workup for infections and malignancy have been
negative so chylothorax believed to be from NASH cirrhosis.
She
was unable to have a PET scan due to insurance issues. She is on
furosemide and midodrine at home without improvement in her
breathing. She recently needed to be increased from drainage
three times weekly to 4 times weekly.
The patient was scheduled to have the Pleur-evac drained at home
___ ___s have a therapeutic paracentesis. The visiting
nurse came to the house and were unable to drain the Pleur-evac.
There was soft tissue swelling around the Pleur-evac and it was
leaking serous fluid so the ___ called IP, who instructed her to
be sent to the emergency department for evaluation of the drain.
She was originally sent to ___ ___ who drained 3L and sent her
home. Her ___ then came ___ and could not drain her pleurex
so
send her to the ED.
Patient reports increasing dyspnea over the weekend. Denies
increasing abdominal distention, abdominal pain, fever, or
chills.
In the ED, initial vitals were:
97.4 70 94/47 20 100% RA
- Exam notable for:
+drain at left site w/ cap on, no erythema or induration, + soft
tissue swelling around the site of the Pleur-evac
Abdomen distended with fluid wave, nontender
No lower extremity edema
- Labs notable for:
WBC 7.0, hgb 11.5, plt 151
Na 137, K 4.5, CL 104, bicarb 23, BUN 44, Cr 2.2
ALT 23, AST 42, ALP 115, tbili 0.5, albumin 1.8
IP saw the patient in the ED and was able to drain pleurex and
performed a diagnostic paracentesis of 2.4 L. They were
concerned
for an ulcer with purulence at the pleurex site so they
suggested
admission to start treatment and ensure catheter was functioning
well.
- Imaging was notable for:
CAR PA and Lateral: Large left pleural effusion, likely slightly
larger compared to prior exam with suspected increased rightward
mediastinal shift despite slight rotation of the patient on this
exam.
CXR:
Substantial interval decrease in size of the left pleural
effusion, now small, status post placement a left-sided chest
tube. Interval development of a small left pneumothorax with no
mediastinal shift. Residual left basilar atelectasis.
- Patient was given:
IV Morphine Sulfate 2 mg
IV Vancomycin 1000 mg
IVF NS 1000 mL
Upon arrival to the floor, patient reports she is feeling better
than before. Her breathing is improved from baseline and her
abdomen feels less distended than before. She denies fevers,
chills, dysuria, diarrhea, confusion, chest pain, or back pain.
Past Medical History:
- DM type II
- Asthma
- Cirrhosis
- Gastritis
- Insomnia
- Depression
- Anemia
Social History:
___
Family History:
No family hx of liver disease
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
VITAL SIGNS: 98.1 PO 114 / 58 71 18 96 Ra
GENERAL: Alert, following commands
HEENT: Sclera anicteric, MMM
LUNGS: decreased lung sounds bilaterally, pleurex catheter in
place on left lower lobe draining whitish/pink fluid with mildly
erythematous skin surrounding site, area of 3cm x 2cm fluctuance
near catheter site non painful to palpation
CV: irregular rhythm, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, mildly distended, non-tender, bowel sounds present,
no
rebound tenderness or guarding, no organomegaly, no asterixis
EXT: No lower extremity edema
SKIN: no rashes
NEURO: Alert and oriented
========================
DISCHARGE PHYSICAL EXAM
========================
GENERAL: awake and alert. Able to follow simple commands
HEENT: Sclera anicteric, MMM
LUNGS: decreased lung sounds at base on R, near absent breath
sounds on left to upper lung fields. Pleurex catheter in
place on left lower lobe draining whitish/pink fluid with mildly
erythematous skin surrounding site, area of 3cm x 2cm fluctuance
near catheter site non painful to palpation. Tube clamped today.
CV: irregular rhythm, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, mildly distended, mildly tender, bowel sounds
present,
no rebound tenderness or guarding, no organomegaly.
EXT: No lower extremity edema
SKIN: no rashes
NEURO: oriented to self today, still confused. ___ beats of
asterixis.
Pertinent Results:
===============
ADMISSION LABS
===============
___ 03:04PM BLOOD WBC-7.0 RBC-3.85* Hgb-11.5 Hct-36.1
MCV-94 MCH-29.9 MCHC-31.9* RDW-14.5 RDWSD-48.8* Plt ___
___ 03:04PM BLOOD Neuts-65.7 ___ Monos-10.1 Eos-1.9
Baso-0.7 Im ___ AbsNeut-4.57 AbsLymp-1.47 AbsMono-0.70
AbsEos-0.13 AbsBaso-0.05
___ 03:15PM BLOOD ___
___ 03:04PM BLOOD Plt ___
___ 03:04PM BLOOD Glucose-189* UreaN-44* Creat-2.2* Na-137
K-4.5 Cl-104 HCO3-23 AnGap-10
___ 03:04PM BLOOD ALT-23 AST-41* LD(LDH)-259* AlkPhos-115*
TotBili-0.5
___ 03:04PM BLOOD TotProt-7.0 Albumin-1.8* Globuln-5.2*
==============
DISCHARGE LABS
==============
___ 06:40AM BLOOD WBC-7.4 RBC-4.04 Hgb-12.1 Hct-37.5 MCV-93
MCH-30.0 MCHC-32.3 RDW-14.7 RDWSD-49.1* Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD ___ PTT-32.8 ___
___ 04:35PM BLOOD Glucose-206* UreaN-44* Creat-2.2* Na-137
K-4.4 Cl-107 HCO3-15* AnGap-15
___ 06:40AM BLOOD ALT-21 AST-34 LD(LDH)-245 AlkPhos-105
TotBili-0.4
___ 04:35PM BLOOD Calcium-8.5 Phos-4.1 Mg-2.2
==================
IMAGING/PROCEDURES
==================
___ pleural fluid
NEGATIVE FOR MALIGNANT CELLS.
- Mesothelial cells, lymphocytes, and histiocytes
___ CXR
Large left pleural effusion, likely slightly larger compared to
prior exam
with suspected increased rightward mediastinal shift despite
slight rotation
of the patient on this exam.
___ CXR
In comparison with the study of ___, the there has been
reaccumulation of a
large amount of left pleural effusion related to Pleur-Evac
malfunction
according to the clinical history.
The right lung remains clear and there is no evidence of
pulmonary vascular
congestion. The due to the large effusion, the left border of
the heart
cannot be evaluated.
___ Abdominal US w/ duplex
Small scarred cirrhotic liver with massive ascites. No focal
liver lesions
seen. Patent main left and right portal veins with low velocity
but
hepatopetal flow.
___ peritoneal fluid
PERITONEAL FLUID:
NEGATIVE FOR MALIGNANT CELLS.
Mesothelial cells, lymphocytes, histiocytes, and red blood
cells.
___ CXR
Compared to chest radiographs since ___ most recently ___.
Left pleural drainage catheter is been replaced or repositioned.
The tip now
impinges on the midline. Large left hydropneumothorax, mostly
fluid, is
larger, reflected in more rightward mediastinal shift. Left
lung is almost
entirely collapsed. Right lung is grossly clear. Cardiac
silhouette is
obscured but there is no indication that it is enlarged.
Mediastinal veins
are not engorged.
___ DIAG PARA
1. Technically successful ultrasound guided diagnostic and
therapeutic
paracentesis.
2. 700 cc of fluid were removed.
___ CT CHEST W/O contrast
1. No evidence of intrathoracic lymphadenopathy or mediastinal
mass.
2. Persistent large left hydropneumothorax with mild
left-to-right mediastinal
shift. Left pleural drain is in place with the tip in the upper
anterior
pleural space. Correlation with drain output is recommended.
Brief Hospital Course:
=========
SUMMARY
=========
Ms. ___ is a ___ female with history of
asthma, IgA nephropathy, Nash cirrhosis, left side pleural
effusion with a Pleur-evac in place, presented with Pleur-evac
malfunction which has been fixed. Hospital course complicated by
hepatic encephalopathy started empirically on CTX for possible
SBP. Had diagnostic paracentesis which ruled out SBP and was
consistent with chylous ascites. Patient's mental status
improved with lactulose and rifaximin to baseline.
==============================
ACUTE MEDICAL ISSUES ADDRESSED
==============================
# Hepatic encephalopathy
Patient presented with pleur-evac site pain and dysfunction but
on further evaluation was found to be confused and disoriented
and with Asterixis. Per patient's PCA, she has noticed patient
has become increasingly sleepy and confused over the last week.
She was guaiac negative, no portal vein thrombosis on abd US,
but with massive ascites and vague complaint of abdominal
discomfort. Due to concern for SBP, she was empirically started
on IV ceftriaxone and was started on lactulose and rifaximin for
hepatic encephalopathy. Had diagnostic paracentesis that was
negative for SBP. CTX was discontinued. Mental status improved
with lactulose and rifaximin. Will be discharged on lactulose
30mL TID titrated to three bowel movements daily and rifaximin
550mg BID.
# NASH Cirrhosis: MELD 18, MELD-Na 19, Mortality 3 month: 6%
# Portal HTN
Admission MELD 18, MELD-Na 19, Mortality 3 month: 6%. Presented
with acute decompensation with hepatic encephalopathy treated as
above. Also noted to have large-volume ascites and portal HTN
via US. Patient had a diagnostic paracentesis which showed a
SAAG >1.1 and chylous ascites. No varices per EGD done at OSH
___. No HCC on Liver US ___.
In terms of etiology, NASH cirrhosis diagnosed in ___ via
biopsy done with outside provider. Lab evaluation for other
cirrhosis etiologies was largely unrevealing. AIH studies were
not suggestive of autoimmune hepatitis (low titer smooth
positivity), negative hepatitis markers (prior HAV infection and
non-immune hepatitis B). HIV negative. Ferritin WNL. AST>ALT but
patient without alcohol history. Patient does have mildly
elevated ALP concerning for biliary pathology but no abdominal
pain. Patient was seen by hepatology who felt findings most
consistent with NASH cirrhosis. She was continued on PO
furosemide 40mg BID and spironolactone 50mg PO BID for portal
hypertension and ascites and was arranged for follow-up with
___.
# Transudative Chylothorax:
Discovered in ___. Pleural fluid from ___ done on admission
showed transudative process. Interventional pulmonology
restiched tube and discomfort improved. Hepatology was consulted
to aid in optimizing medication management of portal HTN and
whether TIPS may be an option. Recommended optimizing with
diuretics. Not candidate for TIPS given renal function and age.
Recommended continued medical management with furosemide and
spironolactone as above and low fat diet. Nutrition was
consulted and provided information to patient and PCA.
Chylothorax reaccumulates very quickly and plan per IP is to
drain for a maximum of 1 liter, 4 days a week and will continue
to follow as outpatient.
In terms of the etiology of transudative chylothorax, includes
amyloidosis, cirrhosis, nephrotic syndrome, superior vena cava
obstruction, heart failure, and chylous ascites that has crossed
the diaphragm into the pleural space. Etiology is presumed to be
due to NASH cirrhosis with chylous ascites crossing the
diaphragm. It is certainly strange that develops left sided
pleural effusion if truly is crossing diaphragm. Malignancy
workup has been negative (planned to get PET but denied for
insurance reasons). TTE in ___ without evidence of ___
normal and AFB negative x1 so TB less likely. Had CT chest
without any evidence of lymphatic obstruction. Not likely to be
amyloid.
# IGA Nephropathy:
# CKD
Patient with recent renal biopsy ___ showing basement
membrane disease and IgA nephropathy but minimal glomerular
pathology on light microscopy, no evidence of diffuse FP
effacement on EM, and only low grade proteinuria. Per renal, no
indication for immunosuppression and no indication for ___
given no proteinuria. Baseline creatinine appears between
1.9-2.2. UA showed some hyaline casts and 9 RBCs but no RBC
casts. Continued lasix and spironolactone at discharge as above.
# Hypoalbuminemia:
Patient with albumin of 1.8. Could be secondary to renal disease
given UA of 30 protein and underlying cirrhosis. Nutrition
consulted as above, added ensure clear TID w/ meals given PO
intake.
CHRONIC ISSUES:
================
#PAML: Confirmed pAML with PCA. Notably was not taking
spironolactone, midodrine, ranitidine, loratadine, ferrous
sulfate, citalopram, fluticasone at home.
# Moderate persistent Asthma:
Will continue home inhalers at discharge
# DM2:
Discharged on diabetic diet and home lantus 15U QAM
# Depression:
Discontinued mirtazapine as per PCA making her more confused at
home
# Hypertension:
Continued metoprolol 25mg PO BID
# GERD:
Continued home PPI
#insomnia:
Discontinued mirtazapine as seems to be worsening mental status
per PCA.
====================
TRANSITIONAL ISSUES
====================
[] Chylothorax management: Pleur-evac to be drained four days a
week (___) for a maximum amount
of 1 liter each day. Please look at drain closely when draining
as can fill up to 1 liter very quickly
[] Diet: Patient discharged on a low fat, medium chain fatty
acid diet to reduce chylothorax accumulation. Patient was
provided materials in ___ and educated by nutrition services
on diet.
[] ___ Cirrhosis: Continued on PO furosemide 40mg BID and
spironolactone 50mg PO BID for portal hypertension and ascites
and was arranged for follow-up with ___.
[] Risk of hepatic encephalopathy: Will be discharged on
lactulose 30mL TID titrated to three bowel movements daily and
rifaximin 550mg BID.
[] Discontinued mirtazapine as seems to be worsening mental
status per PCA.
[] Medication list: Discontinued ranitidine, loratadine, ferrous
sulfate, citalopram, fluticasone as not on home medication list
provided by PCA. If these medications were prescribed as
outpatient please be advised they were discontinued and should
be added back if felt to be necessary as outpatient.
[] Stopped aspirin as risk outweighed benefit given cirrhosis
and on for primary prevention.
# CODE: full
# CONTACT: ___ ___
Patient's PCA ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 25 mg PO BID
2. Mirtazapine 7.5 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. Furosemide 40 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Daliresp (roflumilast) 500 mcg oral DAILY
7. Glargine 15 Units Breakfast
8. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
Discharge Medications:
1. Lactulose 30 mL PO TID:PRN confusion
RX *lactulose 20 gram/30 mL 30 mL by mouth three times a day
Disp #*1892 Milliliter Refills:*0
2. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
3. Spironolactone 50 mg PO BID
RX *spironolactone 50 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Glargine 15 Units Breakfast
5. Daliresp (roflumilast) 500 mcg oral DAILY
6. Furosemide 40 mg PO BID
7. Metoprolol Tartrate 25 mg PO BID
8. Omeprazole 20 mg PO DAILY
9. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
==================
PRIMARY DIAGNOSIS
==================
- Left-sided transudative chylothorax
- Hepatic encephalopathy
===================
SECONDARY DIAGNOSIS
===================
- ___ cirrhosis
- Chylous ascites
- CKD secondary to IgA Nephropathy
- Hypoalbuminemia
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
======================
Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you were having pain
at your chest catheter site and it was not draining correctly
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Your chest tube was fixed but the interventional pulmonology
team and is now draining correctly and a new stitch was placed
so that it would be more comfortable.
- You were found to be confused likely from toxins building up
in your blood that could not be removed by your liver. This
caused you to become confused and you required medications
called lactulose and rifaximin to help remove the toxins.
- Your thinking improved and you started to feel better with the
medication.
- We got a scan of your belly which showed you had free fluid
there. This fluid was drained by interventional radiology. It
did not show an infection and likely accumulated from your liver
disease.
- We continued to drain your the fluid from your chest catheter
4 times a week per recommendations from the lung doctors
- We continued your diuretic medications called furosemide and
spironolactone to treat your liver disease and slow down the
fluid coming out of the chest tube.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please make sure your chest catheter is drained four days a
week (___) for a maximum amount
of 1 liter each day. Please look at drain closely when draining
as can fill up to 1 liter very quickly
- Please continue to take the medication called lactulose every
day three times a day or until you have 3 bowel movements in the
day. Please take you medication called rifaximin every day as
well to prevent toxin build up in your blood.
- Please continue to take your furosemide 40mg twice a day and
spironolactone 50mg twice a day to help decrease the fluid build
up in your belly and lung.
- If you develop fevers, chills, worsening abdominal swelling or
pain, worsening shortness of breath, or feel confused or unwell
at home, please call your doctor or go to the nearest emergency
room.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10898038-DS-12
| 10,898,038 | 27,261,738 |
DS
| 12 |
2158-06-05 00:00:00
|
2158-06-07 11:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
glucosamine / levofloxacin
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient states she had dinner as usual. She then woke up with
nausea and dry heaving. She subsequently had multiple episodes
of
emesis. She developed severe sharp pain in the RLQ. She called
urgent care who advised her to present to the ED.
Here, she received 4mg IV morphine. She had CT abdomen/pelvis
which showed no acute process. The right ovary was noted to be
enlarged. She then had a PUS which showed a paraovarian cyst and
unable to rule out ovarian torsion. OB/GYN was consulted for
rule
out torsion.
Pt states her pain is now ___. She is starting to feel hungry
again but is nervous to eat. She initially had pain with
movement
and that has resolved. She has not ambulated yet.
Past Medical History:
HCM
- colonoscopy in last ___ years
POB/GYN Hx:
- h/o fibroids s/p open mmy and then total hysterectomy
- denies h/o STIs
- denies h/o abnormal paps
PMH: denies
PSH: open myomectomy, TLH/BS
Meds: none
All: glucosamine, levofloxacin
Social History:
___
Family History:
non-contributory
Physical Exam:
Vitals: stable and within normal limits
General: NAD, comfortable
CV: RRR
Lungs: CTAB
Abdomen: soft, non-distended, nontender to palpation, +BS
Extremities: no edema, no TTP, pneumoboots in place bilaterally
Pertinent Results:
___ 06:52AM BLOOD WBC-7.3 RBC-4.31 Hgb-13.7 Hct-41.3 MCV-96
MCH-31.8 MCHC-33.2 RDW-11.9 RDWSD-42.2 Plt ___
___ 06:52AM BLOOD Neuts-69.7 ___ Monos-6.0 Eos-0.5*
Baso-0.8 Im ___ AbsNeut-5.10 AbsLymp-1.66 AbsMono-0.44
AbsEos-0.04 AbsBaso-0.06
___ 06:52AM BLOOD Glucose-123* UreaN-14 Creat-0.8 Na-143
K-4.5 Cl-103 HCO3-23 AnGap-17
___ 06:52AM BLOOD ALT-15 AST-24 AlkPhos-67 TotBili-0.5
___ 06:52AM BLOOD Lipase-37
___ 06:52AM BLOOD Albumin-4.7
___ 07:53AM BLOOD Lactate-1.5
Brief Hospital Course:
On ___, Ms. ___ was admitted to the GYN service from the ED
with right lower quadrant pain concerning for intermittent
ovarian torsion. She was observed overnight and kept NPO in the
event that surgery was indicated. She remained hemodynamically
stable with minimal ongoing pain throughout the night and into
the morning of hospital day 2. On Hospital day 2, her diet was
advanced and she tolerated a regular diet without issue. She
continued to ambulate independently and void, and had minimal
residual pain and pain medication requirements. She was then
discharged home in stable condition with outpatient follow-up
scheduled, including recommendations for evaluation of
incidental findings on imaging.
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
Intermittent ovarian torsion
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 GYN service for pain control and
observation for suspected ovarian torsion, based on imaging and
your symptom profile. Your pain improved and you remained
stable, with improved pain and resolution of your nausea and
vomiting. The team feels you are stable and ready to be
discharged home.
Your imaging just indicate an enlarged right ovary with an
ovarian cyst measuring approximately 3-4 cm in diameter. You
should follow up with your primary OBGYN provider in the next
___ weeks to discuss management and surveillance for this.
Call your doctor for:
* fever > 100.4F
* 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:
___
|
10898075-DS-8
| 10,898,075 | 20,375,980 |
DS
| 8 |
2162-02-10 00:00:00
|
2162-02-11 11:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
steroids
Attending: ___.
Chief Complaint:
Abdominal pain and fevers
Major Surgical or Invasive Procedure:
___ - Small bowel resection and anastomosis x1 for
diverticular abscess
History of Present Illness:
___ PMH significant for metastatic melanoma (currently starting
on pembrolizumab), who presents to ED with CC acute abdominal
pain. He reports 2 days of abdominal cramping, constipation,
most
recently diarrhea. Additionally, he endorses fevers (Tmax 101.2)
earlier today. He denies any nausea or vomiting. He has not had
any blood in his stools.
Of note, he had recently been on treatment for URI.
ROS:
(+) per HPI
Past Medical History:
Past Medical History:
CAD and MI (___) s/p cardiac stent
Atrial fibrillation on Xarelto
CHF
OSA on CPAP
HTN
HLD
TIA
Colonic polyps
Metastatic melanoma
Port placement
Social History:
___
Family History:
Family History:
Maternal aunt - breast cancer
___ cousin - breast cancer
___ grandmother - skin cancer
Brother - brain tumor
Physical Exam:
Admission Physical Exam:
Vitals: 97.9 101 111/56 20 96% R
GEN: A&O, NAD, morbidly obese
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 / ND / TTP lower abdomen more so on the left. Marginal
rebound. No guarding. Not frankly peritonitic.
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
Vitals T 97.8 / BP 115/56 / HR 72 / RR 18 / O2sat 96%RA
General NAD, comfortable
HEENT normocephalic/atraumatic, PERRLA/EOMI, moist mucous
membranes
Neck full ROM
Cardiac RRR, no M/R/G
Chest CTAB
Abdomen soft, NT, ND, normoactive bowel sounds, incision
well-healed (staples removed prior to discharge)
Extremities warm and well-perfused, no edema, 2+ DPs
bilaterally
Neuro A&OX3, sensorimotor function intact in all 4 extremities
Pertinent Results:
Lab Results:
CBC:
___ 04:45AM BLOOD WBC-8.2 RBC-3.81* Hgb-11.5* Hct-35.8*
MCV-94 MCH-30.2 MCHC-32.1 RDW-12.4 RDWSD-42.5 Plt ___
___ 05:51AM BLOOD WBC-9.5 RBC-3.85* Hgb-11.6* Hct-35.7*
MCV-93 MCH-30.1 MCHC-32.5 RDW-12.2 RDWSD-40.9 Plt ___
___ 05:52AM BLOOD WBC-10.7* RBC-3.97* Hgb-11.8* Hct-37.2*
MCV-94 MCH-29.7 MCHC-31.7* RDW-11.9 RDWSD-40.9 Plt ___
___ 05:26AM BLOOD WBC-11.4* RBC-3.76* Hgb-11.6* Hct-35.7*
MCV-95 MCH-30.9 MCHC-32.5 RDW-12.0 RDWSD-41.3 Plt ___
___ 04:06AM BLOOD WBC-11.7* RBC-3.71* Hgb-11.5* Hct-35.3*
MCV-95 MCH-31.0 MCHC-32.6 RDW-12.0 RDWSD-42.1 Plt ___
___ 05:48AM BLOOD WBC-12.8* RBC-3.74* Hgb-11.5* Hct-35.8*
MCV-96 MCH-30.7 MCHC-32.1 RDW-12.2 RDWSD-42.7 Plt ___
___ 08:09AM BLOOD WBC-13.0* RBC-3.85* Hgb-11.9* Hct-36.7*
MCV-95 MCH-30.9 MCHC-32.4 RDW-12.1 RDWSD-41.8 Plt ___
___ 09:55AM BLOOD WBC-14.9* RBC-4.23* Hgb-13.1* Hct-39.9*
MCV-94 MCH-31.0 MCHC-32.8 RDW-12.0 RDWSD-41.8 Plt ___
___ 10:10PM BLOOD WBC-14.8* RBC-4.00* Hgb-12.4* Hct-37.2*
MCV-93 MCH-31.0 MCHC-33.3 RDW-12.0 RDWSD-41.1 Plt ___
___ 09:45PM BLOOD WBC-15.5*# RBC-4.74 Hgb-14.7 Hct-43.4
MCV-92 MCH-31.0 MCHC-33.9 RDW-11.9 RDWSD-39.8 Plt ___
___ 09:45PM BLOOD Neuts-66.5 Lymphs-17.4* Monos-12.0
Eos-2.6 Baso-0.5 Im ___ AbsNeut-10.30*# AbsLymp-2.69
AbsMono-1.86* AbsEos-0.40 AbsBaso-0.08
Coagulation Panel:
___ 05:51AM BLOOD ___ PTT-88.3* ___
___ 01:45PM BLOOD ___ PTT-49.7* ___
BMP:
___ 04:45AM BLOOD Glucose-107* UreaN-13 Creat-0.8 Na-139
K-3.9 Cl-101 HCO3-27 AnGap-15
___ 04:35AM BLOOD Glucose-131* UreaN-9 Creat-0.8 Na-139
K-4.0 Cl-101 HCO3-29 AnGap-13
___ 05:51AM BLOOD Glucose-111* UreaN-11 Creat-0.8 Na-139
K-3.8 Cl-100 HCO3-28 AnGap-15
___ 04:03AM BLOOD Glucose-129* UreaN-12 Creat-0.7 Na-139
K-3.7 Cl-101 HCO3-31 AnGap-11
___ 05:52AM BLOOD Glucose-153* UreaN-11 Creat-0.7 Na-137
K-3.7 Cl-99 HCO3-30 AnGap-12
___ 05:26AM BLOOD Glucose-158* UreaN-12 Creat-0.8 Na-141
K-3.5 Cl-98 HCO3-34* AnGap-13
___ 02:35PM BLOOD Glucose-132* UreaN-11 Creat-0.7 Na-138
K-3.7 Cl-100 HCO3-31 AnGap-11
___ 05:35PM BLOOD Glucose-140* UreaN-11 Creat-0.8 Na-141
K-3.6 Cl-98 HCO3-33* AnGap-14
___ 04:06AM BLOOD Glucose-177* UreaN-13 Creat-0.7 Na-140
K-3.2* Cl-97 HCO3-37* AnGap-9
___ 05:48AM BLOOD Glucose-154* UreaN-15 Creat-0.8 Na-140
K-3.6 Cl-97 HCO3-31 AnGap-16
___ 08:09AM BLOOD Glucose-159* UreaN-16 Creat-0.8 Na-137
K-4.0 Cl-97 HCO3-29 AnGap-15
___ 09:55AM BLOOD Glucose-208* UreaN-16 Creat-1.2 Na-138
K-4.3 Cl-99 HCO3-25 AnGap-18
___ 10:10PM BLOOD Glucose-200* UreaN-16 Creat-0.9 Na-138
K-3.9 Cl-98 HCO3-31 AnGap-13
___ 09:45PM BLOOD Glucose-164* UreaN-17 Creat-1.1 Na-134
K-5.7* Cl-93* HCO3-28 AnGap-19
LFTs:
___ 10:10PM BLOOD TotBili-0.5
___ 09:45PM BLOOD ALT-58* AST-53* AlkPhos-104 TotBili-0.6
Other:
___ 04:06AM BLOOD %HbA1c-9.1* eAG-214*
___ 09:51PM BLOOD Lactate-2.4* K-5.1
Imaging Results:
CHEST (PORTABLE AP)Study Date of ___ 12:51 AM
IMPRESSION:
In comparison with the study ___, there has been placement of
a nasogastric
tube that extends at least to the upper stomach. If the precise
position of
the tip is of clinical importance, an abdominal view could be
obtained.
The cardiac silhouette remains at the upper limits of normal.
No definite
vascular congestion, pleural effusion, or acute focal pneumonia.
Once again, pulmonary nodules seen on prior radiograph in CT are
difficult to
identify on the current study.
PORTABLE ABDOMENStudy Date of ___ 12:17 ___
IMPRESSION:
NG tube is seen with
CT ABD & PELVIS WITH CONTRASTStudy Date of ___ 1:00 AM
IMPRESSION:
1. Small bowel diverticulitis with possible microperforation.
2. No drainable fluid collection.
3. Hepatic steatosis.
4. Smaller left adrenal mass consistent with metastasis.
Pathology:
PATHOLOGIC DIAGNOSIS:
Small bowel, resection:
Diverticulitis of the small intestine with mural abscess
formation and focal perforation.
Resection margins appear unremarkable.
Brief Hospital Course:
___ PMHx significant for metastatic melanoma (on pembrolizumab)
and afib on xarelto, who presented to ED with acute abdominal
pain. He reported 2 days of abdominal cramping, constipation and
then diarrhea, as well as fevers, no nausea/vomiting. His CT
scan demonstrated a contained small bowel perforated
diverticulitis. He was managed non-operatively while we waited
for the Xarelto to clear. He then underwent an exploratory
laparotomy and small-bowel resection with primary anastomosis
for small bowel diverticulitis with abscess on ___. The
patient tolerated the procedure without complications, he had an
NGT placed and remained hemodynamically stable post-op. He
remained NPO/NGT/IVF until he began having bowel function, which
occurred on POD4. He was also started on a hep gtt for his
history of cancer and afib. He complained of some nausea and
abdominal pain in the early post-op course, but began passing
flatus on POD4 and the NGT was removed on POD5. His diet was
gradually advanced and tolerated through POD5-9. Once he was
tolerating a regular diet, his home medications, including
xarelto, were restarted. The patient's pain is well-controlled
with PO pain medications, he is tolerating a regular diet and
having bowel function. He is ambulating and voiding without
assistance and is now ready for discharge home with clinic
follow-up. The ___ office will follow-up with him regarding the
best time to restart his pembrolizumab treatment. His staples
were removed on POD10 prior to discharge. Per discussion between
Dr. ___ surgeon) and Dr. ___, patient
will resume Pembrolizumab treatment after ___ (3 weeks
post-op).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 150 mg PO BID
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Rivaroxaban 20 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Furosemide 40 mg PO BID
6. Spironolactone 25 mg PO DAILY
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*45 Tablet Refills:*0
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole [Protonix] 40 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Furosemide 40 mg PO BID
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Metoprolol Tartrate 150 mg PO BID
10. Rivaroxaban 20 mg PO DAILY
11. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticular abscess secondary to small bowel diverticulitis
Diabetes Mellitus II
Atrial fibrillation
Chronic CHF
CAD
Metastatic melanoma
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 here at ___. You were
admitted with abdominal pain and fevers and found on imaging to
have perforated diverticulitis of the small bowel with abscess.
You were taken to the operating room for a small bowel
resection. You tolerated the procedure well without
complications. You had a ___ tube placed for
decompression and were monitored closely post-op. You had some
abdominal pain and nausea during the early post-operative period
which is normal after an exploratory laparotomy. On post-op day
___ you began having bowel function and so your ___ tube
was removed and your diet was slowly advanced. You tolerated
your diet as advanced and continued to have bowel function.
You are now ready for discharge home with clinic follow-up. With
regards to your Pembrolizumab treatment, Dr. ___ is aware and
the office will let you know on ___ whether to proceed with
the treatment on ___. He may want to see you in clinic
first prior to deciding, in which case he will tell you to come
into clinic this ___. Otherwise, you may schedule a
follow-up appointment with him in ___ weeks time at your
convenience. You were offered visiting nursing services for
wound check but you have refused those services. You may
continue all of your other home medications.
General Surgery:
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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2127-08-20 22:46:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI(4): Ms. ___ is a ___ female with the past medical
history
of hypertension, hyperlipidemia, type 2 diabetes mellitus and
recently diagnosed persistent AFib currently on Eliquis who
presents with 2 week history of low back pain.
History obtained from EMR and daughter as patient confused /
unable to provide history at the time of my exam.
Patient initially presented to her PCP with low back pain that
started 2 weeks ago after lifting a bucket of water. She has had
no falls or trauma but notes she heard something crack when the
pain first developed 2 weeks ago. She continued to c/p pain
despite rest and hot packs so daughter took her to see her PCP
who started her on valium 5mg tid prn muscle spasm, tramadol for
pain and advil. Per daughter, her mother does not like to take
narcotics and took the tramadol only once but has been taking
the
valium 3 times a day every day since it was prescribed (___).
Yesterday, due to continued pain in her back and decreased
mobility, her daughter again brought her in for evaluation and
was advised to bring her to the ED where she was found to have a
compression fracture at L1.
In the ED:
VS: afebrile, P 80-90's, BP 130-140's, 95-99% on RA
PE: initially A&O but on reassessment this am noted to be
increasingly confused. No saddle anesthesia, midline upper L
spine ttp, strength and reflexes intact / symmetrical
Labs: lactate 1.7, CBC at b/l, BUN/Cr ___, AG 16, UA pos ___,
nitr, WBC> 182, +bact, 1sq Epi
Imaging: LS spine AP/lat showed compression fx at L1
Interventions: 1g Tylenol, ___ ibuprofen, Lidoderm patch, 1L
NS, 1g Ceftriaxone, 10mg Zyprexa
Consults: Spine surgery recommended conservative management with
TLSO brace when OOB. ___ attempted to see patient but she was too
confused to participate.
Course: patient was noted to be increasingly confused while in
the ED and was given 10mg IM zyprexa for this, attempts to give
her home pills failed due to confusion. Her UA was concerning
for
infection and she was started on CTX and admitted for further
management of altered mental status, possible UTI, pain control
and ___ / CM eval.
On arrival to the floor, patient continued to be confused and
communicating mainly in ___ though she was able to recognize
her daughter. She denied pain when asked. Per daughter, patient
is previously independent in all her ADLs and has never been
confused like this.
In terms of her AFib, patient was seen in clinic in ___ and
found to have newly noted persistent AFib. She was referred to
Cardiology clinic and was started on Eliquis with plan to pursue
cardioversion in ___. Daughter states that she has been
getting the Eliquis directly from Cardiology clinic (samples)
and
was initially on 2.5mg BID but she was later referred to a
different cardiologist, Dr. ___ who left her a voice
message stating she should be taking it 4 times a day so she has
been doing so since mid-late ___. She has not had any falls
at home and daughter states that her confusion didn't really
start until last night.
ROS: Pertinent positives and negatives as noted in the HPI. All
other system
Past Medical History:
PAST MEDICAL / SURGICAL HISTORY:
Hypertension
Type 2 Diabetes Mellitus
Hyperlipidemia
Persistent AFib on Eliquis (first noted in ___
Social History:
___
Family History:
___ and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
Admission Physical Exam:
========================
VITALS: Afebrile and vital signs stable
GENERAL: Alert, delirious, anxious but without grimacing or
visible signs of pain
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart irregular, normal rate, no murmur, no S3, no S4. No
JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, unable to perform
strength testing but able to lift against gravity in all
extremities
SKIN: stage 1 pressure ulcer to coccyx
NEURO: Alert, disoriented, face symmetric, unable to perform
full
neuro exam due to inattentiveness / active delirium, moves all
limbs
PSYCH: fidgety but calm, disoriented, speaking in ___ only
with
minimal spont speech, actively pulling at gown with restless
legs
and pulling at things in the air at times. Eyes closed mosly
with
minimal eye contact when open.
Discharge Physical Exam:
========================
Gen: Lying in bed in no apparent distress
Vitals: Reviewed in E flowsheets
HEENT: Anicteric, eyes conjugate, MMM, no JVD
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Lung fields clear to auscultation throughout
Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present, no HSM
MSK:
spine no point tenderness
Skin: No rashes or ulcerations evident
Neurological: moves all extremities. face symmetric, speech
fluent, AAox1 did not know the date or place today.
psych: calm
Pertinent Results:
Admission Labs:
===============
___ 05:30AM BLOOD WBC-11.2* RBC-5.11 Hgb-12.9 Hct-40.0
MCV-78* MCH-25.2* MCHC-32.3 RDW-14.3 RDWSD-39.8 Plt ___
___ 10:40PM BLOOD Neuts-80.3* Lymphs-11.8* Monos-5.3
Eos-1.6 Baso-0.5 Im ___ AbsNeut-9.66*# AbsLymp-1.42
AbsMono-0.64 AbsEos-0.19 AbsBaso-0.06
___ 05:30AM BLOOD Glucose-129* UreaN-9 Creat-0.6 Na-145
K-3.3 Cl-99 HCO3-27 AnGap-19*
___ 06:50AM BLOOD ALT-12 AST-17 AlkPhos-133* TotBili-0.4
___ 05:30AM BLOOD TotProt-6.8 Calcium-11.1* Phos-2.9
Mg-1.5*
___ 07:14AM BLOOD PTH-106*
___ 06:04AM BLOOD freeCa-1.26
___ 02:38AM BLOOD Glucose-100 Lactate-1.7
___ 10:44PM BLOOD ___ pO2-76* pCO2-40 pH-7.37
calTCO2-24 Base XS--1
Imaging:
========
EXAMINATION: LUMBO-SACRAL SPINE (AP AND LAT)
1. No evidence of infarct or hemorrhage.
2. Possible bifrontal subdural hygromas. If clinically
concerning, MR may be considered.
3. Subcortical white matter hypodensities suggestive of chronic
small vessel
disease.
___ 11:15 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.
GRAM POSITIVE BACTERIA. >100,000 CFU/mL.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Discharge Labs:
===============
___ 06:47AM BLOOD WBC-8.4 RBC-4.90 Hgb-12.5 Hct-38.6
MCV-79* MCH-25.5* MCHC-32.4 RDW-14.7 RDWSD-41.8 Plt ___
___ 06:47AM BLOOD Glucose-122* UreaN-23* Creat-0.8 Na-143
K-3.3 Cl-99 HCO3-27 AnGap-17
___ 06:50AM BLOOD ALT-12 AST-17 AlkPhos-133* TotBili-0.4
___ 06:47AM BLOOD Calcium-11.5* Phos-3.6 Mg-1.6
Brief Hospital Course:
Ms. ___ is a ___ female with a past medical history of
hypertension, hyperlipidemia and type 2 diabetes mellitus who
presents with 2 week history of low back pain found to have L1
compression fracture, course c/b encephalopathy, UTI, and
hypercalcemia.
ACUTE/ACTIVE PROBLEMS:
# L1 Compression Fracture:
Found to have a nontraumatic compression fracture at L1 with
pain starting 2 weeks ago. Spine service recommended
conservative management including pain control, ___
eval and lumbar corset (can use TLSO for comfort). She will need
a dexa scan if not up to date as an outpatient. Pain was
controlled with standing Tylenol and lidocaine patches. ___
recommended rehab but family preferred to take patient home
# Altered mental status
# Metabolic Encephalopathy
Likely multifactorial in the setting of pain, polypharmacy,
infection, hypercalcemia and recent insomnia. Treated with
ramelteon for insomnia. Also treated for UTI as below
# UTI: complicated due to DM. Urine culture is now grew E. coli
and lactobacillus. Treated with ceftriaxone and later PO
ciprofloxacin and completed a 7 day course
# Hypercalcemia
Presented with hypercalcemia (10.7 on admission, 11.5 on
discharge) with elevated PTH and low vitamin D (14). Likely due
to primary hyperparathyroidism. Started on vitamin D repletion.
She will need PTH, calcium, and vitamin D rechecked as an
outpatient
# Hygroma
Found the have hygroma on head CT. Prior provider talked to
neurosurgery who
reviewed imaging and felt there was no need for further
intervention and no need to stop apixaban
# Recently diagnosed atrial fibrillation on apixaban: has been
receiving apixaban directly from Cardiology clinic and was
initially on 2.5mg BID but she was later
referred to a different cardiologist, Dr. ___ who left
her a voice message stating she should be taking it four times a
day so she has been doing so since mid-late ___. Provided
2.5mg BID and atenolol. She should follow up with her outpatient
cardiologist
CHRONIC/STABLE PROBLEMS:
# Hypertension: continued home BP meds with holding parameters
# Hyperlipidemia: continued home statin
# Type 2 Diabetes Mellitus: held home metformin while
hospitalized, placed on ISS
Transitional Issues:
====================
- found to have elevated calcium (10.4 - 11.5) with high PTH
(111) and low vitamin D (14). Likely primary
hyperparathyroidism. She will need calcium, PTH, and vitamin D
rechecked as an outpatient
- she developed signs of delirium while hospitalized, likely
secondary pain, UTI, poor PO intake, and hospitalization itself.
If mental status does not return to baseline after leaving the
hospital, would consider further neurocognitive workup
- discharged with lumbar corset. If pain does not improve in ___
weeks, can schedule an appointment with ortho spine for
evaluation for possible kyphoplasty
> 30 minutes spent on discharge coordination and planning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraMADol 50 mg PO Q6H:PRN BREAKTHROUGH PAIN
2. Diazepam 5 mg PO Q8H:PRN muscle spasm
3. Atorvastatin 20 mg PO QPM
4. Omeprazole 20 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. amLODIPine 5 mg PO DAILY
8. Atenolol 25 mg PO BID
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Apixaban 2.5 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*90 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Lidocaine 5% Patch 2 PTCH TD QAM
RX *lidocaine 5 % Apply 2 patches to lower back QAM Disp #*60
Patch Refills:*0
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
7. Vitamin D ___ UNIT PO 1X/WEEK (WE) Duration: 12 Doses
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth once a week Disp #*12 Capsule Refills:*0
8. amLODIPine 5 mg PO DAILY
9. Apixaban 2.5 mg PO BID
10. Atenolol 25 mg PO BID
11. Atorvastatin 20 mg PO QPM
12. Hydrochlorothiazide 12.5 mg PO DAILY
13. Lisinopril 40 mg PO DAILY
14. MetFORMIN (Glucophage) 500 mg PO BID
15. Omeprazole 20 mg PO DAILY
16.hospital bed
Hospital bed
dx: Lumbar 1 compression fracture/back pain, deconditioning
expected use 6months
17.commode
Commode dx: lumbar 1 compression fracture, deconditioning, poor
mobility
expected use: 6 months
Patient confined to one room due to lack of mobility
18.___ lift
Please provide ___ Lift
Dx: L1 Compression fracture ICD 10 S32.0
Expected duration: 6 months
Prognosis: good
19.Rolling walker
please provide rolling walker
Dx: S32.0
Prognosis: good
Expected length of need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
L1 compression fracture
delirium
urinary tract infection
elevated calcium levels and low vitamin d levels.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted after you had increasing back pain at home.
You were found to have a compression fracture of your L1
vertebrae. You were seen by the spine team who recommended a
lumbar corset and no surgical intervention.
You also had some confusion which is likely from multiple causes
(pain, urinary tract infection) but this improved. You were
treated for a urinary tract infection and vitamin D deficiency
with elevated blood calcium.
You were also found to be confused which was thought to be
secondary to pain medications and UTI.
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with h/o afib on apixaban, HTN, type 2
diabetes, recent spinal compression fracture diagnosed ___
presenting with recurrent agitation and confusion.
Of note, patient hospitalized at ___ in ___ and was
found to have compression fracture, complicated UTI, and
hypercalcemia at that time contributing to delirium. She was
discharged home with services. She was then more recently
hospitalized at ___ for similar symptoms in ___ after 3
weeks
of symptoms at that point. During that evaluation, she was noted
to have waxing and waning mental alertness and was thought to
have delirium on dementia (after receiving narcotics and benzos
for a recent spinal compression fracture); she was evaluated by
psychiatry and neurology and noted to have had worsening
function
after her son died a year ago. Neurology suggested thiamine and
CoQ10 150 mg daily. However her family also reported that she
was
previously high-functioning, so this did not completely match
up.
She received Haldol and was noted to have extrapyramidal
symptoms
so this was stopped. She received trazodone for sleep.
A workup including brain MRI, EEG, UA, TSH, B12, RPR was
unrevealing. She had hypernatremia in the setting of poor PO
intake. Lisinopril, amlodipine, and HCTZ held at time of
discharge. She presented again to ___ on ___ and was noted to
answer "It is cold, it is cold" in response to all questions.
She
got IV fluids. Based on risk/benefit discussion, did not pursue
LP during that evaluation, but in this setting apixaban was
briefly held ___.
During that admission per ___ records, ___ (daughter) has had
multiple negative confrontations with multiple members of the
medical team. [Also refused ___ evaluation as she did not want
patient to go to rehab] She is the next of kin but pt doesn't
have HCP form filled out. On ___ she asked the medical team to
fill out guardianship application because her understanding was
that she needed guardianship to apply for Mass Health. Per
hospital attorney, this was not true, and [it was not thought
that guardianship was truly necessary unless major changes like
CMO were being discussed]."
In the ED on this admission, "family called due to abnormal
fatigue and lethargy x 2 hours, with witnessed onset. Baseline
pt
is ambulatory and verbal. Per family, she is falling asleep
spontaneously, when she awakens she is fairly oriented but then
falls asleep again. She complained to family of bilateral leg
pain this morning but unclear if chronic issue. Pt is not able
to
provide a complete history due to confusion but with daughter
translating denies any pain or fever. Daughter provides
collateral history that the patient was complaining of chest
pain
at home just prior to calling the ambulance. Patient now denies
chest pain or dyspnea."
In the ED, initial VS were: 36.2 C, HR 100, BP 130/80, RR 16,
98% RA
Exam notable for: Mental status - Responds to location with
___, "hospital"
EKG: compared to ___, deeper TWI in lead I, V4, Q wave in
lead III with upsloping STE
Labs showed:
WBC 9.6, Hgb 11.9, plts 256, AST 62, ALT 84, AP 112, tbili 0.9
CK 327
Ca ___, Mag 1.7
Na 139, CO2 19, Cr 1.1
Lactate 1.4
Contaminated UA, utox + benzos
trop 0.01 to 0.02, flat CKMB and MB index
Imaging showed:
NCHCT: 1. No acute intracranial process.
2. Unchanged bifrontal extra-axial fluid collections, possibly
representing
enlarged subarachnoid spaces or subdural hygromas.
CHEST X-RAY: no acute abnormalities
Consults: n/a
Patient received:
___ 22:53IMOLANZapine 7.5 ___
___ 00:12IMHaloperidol 2.5 ___
On arrival to the floor, patient is arousable to sternal rub and
unable to provide history.
Past Medical History:
PAST MEDICAL / SURGICAL HISTORY:
Hypertension
Type 2 Diabetes Mellitus
Hyperlipidemia
Persistent AFib on Eliquis (first noted in ___
Social History:
___
Family History:
___ and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
ADMISSION EXAM:
VS: 97.8 F, BP 119 / 72, HR 82, RR 18, 97%RA
GENERAL: arousable to sternal rub, moans and doesn't answer
questions
HEENT: AT/NC, EOMI, PERRL, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB in the upper lung fields, no wheezes or crackles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: unable to assess orientation, withdraws to pain in all
four extremities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
Vitals: 97.4 156/89 90 18 98 Ra
GENERAL: sleepy, unable to answer questions
HEENT: EOMs intact, anicteric sclerae.
NECK: Supple
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTA b/l, with scant upper field wheezes.
ABDOMEN: Soft, non-tender, non-distended, NABS.
BACK: No spinal point tenderness.
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: Alert, oriented to person and city, not to year.
Pertinent Results:
ADMISSION LABS:
___ 05:11PM BLOOD WBC-9.6 RBC-4.56 Hgb-11.9 Hct-37.7 MCV-83
MCH-26.1 MCHC-31.6* RDW-16.4* RDWSD-49.0* Plt ___
___ 05:11PM BLOOD ___ PTT-25.4 ___
___ 05:11PM BLOOD Glucose-121* UreaN-26* Creat-1.1 Na-139
K-4.4 Cl-99 HCO3-19* AnGap-21*
___ 05:11PM BLOOD ALT-84* AST-62* CK(CPK)-327* AlkPhos-112*
TotBili-0.9
___ 05:11PM BLOOD CK-MB-10 MB Indx-3.1 cTropnT-0.01
___ 05:11PM BLOOD Albumin-3.9 Calcium-10.1 Phos-3.8 Mg-1.7
___ 05:27PM BLOOD Lactate-1.4
DISCHARGE LABS:
___ 09:33AM BLOOD WBC-6.8 RBC-4.09 Hgb-10.6* Hct-33.4*
MCV-82 MCH-25.9* MCHC-31.7* RDW-17.1* RDWSD-50.1* Plt ___
___ 09:33AM BLOOD ___ PTT-34.0 ___
___ 09:33AM BLOOD Glucose-112* UreaN-13 Creat-0.6 Na-141
K-3.8 Cl-105 HCO3-24 AnGap-12
___ 08:51AM BLOOD ALT-39 AST-27 AlkPhos-115* TotBili-1.3
___ 05:55AM BLOOD CK-MB-8 cTropnT-<0.01
___ 09:33AM BLOOD Albumin-3.2* Calcium-9.7 Phos-2.7 Mg-1.8
___ 01:15PM BLOOD PTH-71*
___ 01:15PM BLOOD 25VitD-10*
IMAGING
CT HEAD ___
1. No significant change since the prior study from ___. No
acute intracranial hemorrhage.
2. Unchanged bifrontal chronic appearing extra-axial fluid
collections,
possibly representing subdural hygromas.
MICRO
UCx, BCx ___ negative
Brief Hospital Course:
___ with history Afib on apixaban, HTN, type 2 diabetes, recent
spinal compression fracture diagnosed ___ presenting with
recurrent agitation and confusion and found to have BZ in urine
on admission, likely etiology. Patient cleared and discharged
home.
Investigations/Interventions:
1. Acute toxic metabolic encephalopathy: on admission,
benzodiazepines found in urine tox. This is not a home
medication, and it is unclear where this was obtained. Family
denies any BZ's at home. She has had extensive workup at ___
for declining mental status over the past few months; it is felt
she has Alzheimer's dementia with a possible component ___
Body Dementia (would cause ongoing hallucinations). Family
meetings between patient, family, case management, social work,
geriatrics consultants, and primary team determined that best
environment for patient is home with maximal services. On
discharge she is sleepy in the morning but wakes up during the
day to answer several questions appropriately. Not AOx3.
2. Nutrition: related to mental status changes, nutrition is
sub-optimal. Required intermittent IVF for poor UOP in house.
This was addressed with daughter ___ who will support
patient's nutrition as best able at home.
3. Hypercalcemia, hyperparathyroidism: mild hypercalcemia
prompted checking PTH levels in house which were high.
Endocrine felt she may be vitamin D deficient, recommended
vitamin D supplementation, and outpatient follow up. She was
started on 50,000 units vitamin D weekly in house and will
follow up as outpatient.
4. Afib: on apixaban 2.5 bid at home; proper dose for patient
based on age/renal function/weight is 5 mg bid. This was
increased on discharge.
5. Med reconciliation, c/f polypharmacy: to reduce medication
burden, we removed Asa/statin and thiamine from home medication
list.
Transitional Issues:
[]Apixaban increased to 5mg bid as this is proper dosing for
age, renal function, weight
[]Vitamin D 50,000 units weekly added to medication regimen;
needs to continue x 7 additional doses, then can change to ___
units daily
[]Discontinued Asa, statin, thiamine to reduce medication burden
[]Patient has prior L1 compression fracture treated
conservatively; if pain does not improve in ___ weeks, can
schedule an appointment with ortho spine for evaluation for
possible kyphoplasty
[]Patient discharged with maximal home services
#Contact: ___ (daughter) ___
========
Greater than 30 minutes was spent on discharge planning and
coordination
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. coenzyme Q10 150 mg oral DAILY
2. Polyethylene Glycol 17 g PO DAILY
3. Thiamine 100 mg PO DAILY
4. TraZODone 50 mg PO QHS
5. Apixaban 2.5 mg PO BID
6. Atenolol 50 mg PO DAILY
7. Atorvastatin 20 mg PO QPM
8. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Vitamin D ___ UNIT PO 1X/WEEK (___) Duration: 8 Doses
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth once weekly Disp #*7 Capsule Refills:*0
2. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
3. Atenolol 50 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY
6. TraZODone 50 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute toxic metabolic encephalopathy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
You were hospitalized with changes in mental status, which is
likely from underlying dementia and benzodiazepines we found in
your system. This cleared with IVF. It is likely that you may
have fluctuating mental status related to underlying dementia;
please follow up with your PCP.
It was a pleasure taking care of you!
Your ___ team
Followup Instructions:
___
|
10898214-DS-15
| 10,898,214 | 22,752,547 |
DS
| 15 |
2121-02-06 00:00:00
|
2121-02-06 09:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / morphine
Attending: ___.
Chief Complaint:
Right upper quadrent abdominal pain
Major Surgical or Invasive Procedure:
Open cholecystectomy ___
History of Present Illness:
Mrs. ___ is a ___ with a history of colorectal cancer,
subtotal colectomy, pelvic tumor, DVT, TIA, and hypertension who
presents to the ED for epigastric pain following a meal. Mrs.
___ had an early supper of pasta and meat sauce followed 1.5
hours later with epigastric pain, nausea without vomiting,
sweating, and SOB. The pain was described as a tightness, ___
in
severity, located in the LUQ, MUQ, and RUQ without radiation,
without alleviating or aggravating factors. The patient's last
bowel movement was this morning. Mrs. ___ reports that it was
non-painful, normal in consistency, not unusually foul smelling,
or normal color, and non-bloody. Since her colorectal
procedures,
Mrs. ___ reports that she has continued to have colonoscopies,
if not quite regularly. The patient denies any trauma, chest
pain, dyspnea on exertion, dysuria, fevers, chills, or weight
loss. Additionally, Mrs. ___ also described events of milder
periodic epigastric pain ___ year ago that resulted in outpatient
doctor visits and positive imaging for gallstones.
Past Medical History:
Past Medical History:
1. Colorectal cancer, ___
2. Groin tumor, ___, radiation therapy
3. DVTs, on Coumadin
4. Hypertension, on Lisinopril and Clonidine
5. GERD
6. Depression, on Celexa
7. Seasonal allergies, on Allegra PRN
Past Surgical History:
1. Subtotal distal colectomy, ___, with RLQ stoma and reversal
2. Tracheotomy, ___
3. Groin tumor, ___
Social History:
___
Family History:
1. Father passed away age ~___, lung cancer associated with
asbestos exposure
2. Brother, living age ___, brain tumor
Physical Exam:
Admission Physical Exam:
Vitals: 97.6, 97.6, 65, 145/63, 14, 100% RA
GEN: A&O x 3, pleasant and in NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Irregularly irregular, nl S1&S2, no M/G/R appreciated
PULM: CTA b/l, No W/R/R
ABD: +BS, Soft, nondistended, tender to deep palpation in the
RUQ
w/o ___ sign, no rebound or guarding, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
Vitals: 99.0, 131/80, 18, 94%RA
GEN: A&O x 3, pleasant and in NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Irregularly irregular, nl S1&S2, no M/G/R appreciated
PULM: CTA b/l, No W/R/R
ABD: +BS, Soft, nondistended, well healing incision,
w/o ___ sign, no rebound or guarding, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
Admission results:
___ 07:48PM BLOOD WBC-8.1 RBC-4.20 Hgb-12.3 Hct-37.9 MCV-90
MCH-29.4 MCHC-32.6 RDW-12.7 Plt ___
___ 07:48PM BLOOD Plt ___
___ 08:54PM BLOOD ___ PTT-37.0* ___
___ 07:48PM BLOOD Glucose-106* UreaN-27* Creat-1.5* Na-138
K-4.0 Cl-102 HCO3-23 AnGap-17
___ 07:48PM BLOOD ALT-48* AST-118* AlkPhos-131* TotBili-0.4
___ 07:48PM BLOOD Albumin-4.4
___ 06:45AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.7
Discharge results:
___ 06:40AM BLOOD WBC-8.5 RBC-3.59* Hgb-10.6* Hct-32.0*
MCV-89 MCH-29.5 MCHC-33.1 RDW-12.8 Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD ___
___ 06:40AM BLOOD Glucose-89 UreaN-12 Creat-1.0 Na-137
K-3.7 Cl-98 HCO3-25 AnGap-18
___ 06:40AM BLOOD ALT-50* AST-46* AlkPhos-114* TotBili-0.6
___ 06:40AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.2*
Imaging:
CT A+P - ___
HISTORY: ___ female with right upper quadrant pain,
elevated LFTs, and recent ultrasound demonstrating
cholelithiasis, now requiring assessment for prior pelvic mass.
TECHNIQUE: MDCT imaging of the abdomen and pelvis before and
after
intravenous contrast was performed. Multiplanar reformats were
prepared and reviewed. Three minute delayed images were also
acquired and reviewed.
COMPARISON: Comparison is made with right upper quadrant
ultrasound from ___.
FINDINGS:
ABDOMEN: The visualized lung bases are clear. The liver is
homogeneous in texture with no focal lesions. There is no
biliary ductal dilatation. The gallbladder is normal. The
spleen, pancreas, and adrenal glands are normal. Small
hypoenhancing lesions are seen in the bilateral kidneys,
consistent in appearance with renal cysts. There is a larger
lesion in the left kidneythat measures 2.2 cm and demonstrates a
higher density, consistent with a
hemorrhagic cyst. The kidneys are otherwise unremarkable. The
stomach,
duodenum, and intra-abdominal loops of bowel are normal in
caliber and
unremarkable. There is no retroperitoneal or mesenteric
lymphadenopathy. The intra-abdominal aorta is normal in
appearance. An IVC filter is noted to be in place.
PELVIS: The patient is status post rectal surgery. The distal
ureters and bladder are normal. The patient is status post
surgical removal of the uterus and adnexa. There is no pelvic
or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
BONE WINDOWS: No focal lytic or sclerotic osseous lesion
suspicious for
infection or malignancy is seen.
IMPRESSION:
1. No evidence of recurrent disease at the site of rectal
surgery. No
evidence of metastatic disease.
2. Bilateral renal cysts, with a larger hemorrhagic cyst on the
left.
The study and the report were reviewed by the staff radiologist.
US - Gallbladder ___
INDICATION: History of acute onset abdominal pain, worse in the
right upper
quadrant.
COMPARISONS: None.
TECHNIQUE: Grayscale and Doppler ultrasound images of the
abdomen were
obtained.
FINDINGS: The liver shows no evidence of focal lesions or
textural
abnormality. There is no evidence of intrahepatic biliary
dilatation. There
is evidence of mild dilatation of the proximal common bile duct
up to 0.8 cm
with subsequent tapering to 0.5 cm. There does not appear to be
any evidence
of choledocholithiasis or obstructing biliary lesion. There is
no evidence of
choledocholithiasis. Small gallstones are seen layering along
the body of the
gallbladder. There is no evidence of gallbladder wall thickening
or
pericholecystic fluid. The visualized pancreas is unremarkable
without
evidence of focal lesions or pancreatic duct dilatation. The
right kidney
measures 9 cm. There is no evidence of hydronephrosis or
stones. The
visualized aorta and IVC are unremarkable.
Doppler assessment of the main portal vein shows patency and
normal
hepatopetal flow.
IMPRESSION:
1. Distended gallbladder with cholelithiasis. While there are
no specific
signs of acute cholecystitis, this cannot be completely
excluded.
2. Proximal mild dilatation of the CBD to 0.8 cm with tapering
to a normal
size, without evidence of choledocholithiasis or obstructing
lesion. No
evidence of intrahepatic biliary ductal dilatation.
Brief Hospital Course:
Mrs. ___ was admitted on ___ under the acute care surgery
service for management of her acute
cholecystitis/cholelithiasis. She was taken to the operating
room and underwent a open cholecystectomy secondary to
significant intra-abdominal adhesions. Please see operative
report for details of this procedure. She tolerated the
procedure well and was extubated upon completion. She we
subsequently taken to the PACU for recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced on the morning of
___ to regular, which she tolerated without abdominal pain,
nausea, or vomiting. She was voiding adequate amounts of urine
without difficulty. She was encouraged to mobilize out of bed
and ambulate as tolerated, which she was able to do
independently. Her pain level was routinely assessed and well
controlled at discharge with an oral regimen as needed.
On ___, she was discharged home with scheduled follow up in
___ clinic on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 2.5 mg PO 3X/WEEK (___)
___
2. Warfarin 5 mg PO 4X/WEEK (___)
___
3. Lisinopril 40 mg PO DAILY
4. Chlorthalidone 25 mg PO DAILY
5. Venlafaxine 37.5 mg PO BID
6. Fexofenadine 60 mg PO BID:PRN Allergies
Discharge Medications:
1. Chlorthalidone 25 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Venlafaxine 37.5 mg PO BID
4. Warfarin 2.5 mg PO 3X/WEEK (___)
5. Warfarin 5 mg PO 4X/WEEK (___)
6. Acetaminophen 650 mg PO Q6H:PRN pain
7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
Do not drink or drive while taking this medication.
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*40 Tablet Refills:*0
8. Fexofenadine 60 mg PO BID:PRN Allergies
Discharge Disposition:
Home
Discharge Diagnosis:
Cholelithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute cholelithiasis. You
were taken to the operating room and had your gallbladder
removed. You tolerated the procedure well and are now being
discharged home to continue your recovery with the following
instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You 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:
___
|
10898434-DS-14
| 10,898,434 | 27,133,932 |
DS
| 14 |
2159-09-04 00:00:00
|
2159-09-04 21:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
lower GI bleeding
Major Surgical or Invasive Procedure:
colonoscopy
CT colonography
History of Present Illness:
___ year old male with prior CVA on ASA, and DMII who
presents for acute onset dizziness and bright red blood per
rectum.
He felt dizzy and lightheaded for the past 2 days. Then at 4am
on
morning of ___ (day of presentation) pt woke and had an episode
of bright red blood per rectum. Some urgency with that
defecation. He said that he was about a few tablespoons to about
half a cup of bright red blood. Then throughout the course of
the
day he had 4 more episodes of similar amounts of bright red
blood
per rectum. First two episodes in close succession but have been
more spaced since then. Denies any since arriving to ED although
he has now had one mod-large volume maroon stool on floor
arrival. He denies any new onset abdominal pain but does say
that
he had some nausea not associated with any emesis.
He denies ongoing ibuprofen use but does use aspirin 81 mg daily
I/s/o CVA Hx. He is not on any other anticoagulation and has a
history of diabetes. He denies any recent weight loss or history
of malignancy.
In ED:
VS: 147/77 --> 124/65, HR 115 --> 87, RA
wbc 15, hb 10.0, bcb 20, Cr 0.8, INR 1.1
UA: few bact, wbc 8, small leuk
lactate 1.8
Received 1L NS
GI consult in ED: likely diverticular, rec serial H/H, close
monitor VS; rec investigate ASA indication
___, ___ with diverticulosis
Limited records in BI system; goes ot see ___ at
___.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
1. Diabetes mellitus for ___ years. Does not know HgbA1c. Does
not check finger sticks
2. Hyperlipidemia for ___ years
3. Right trigger finger
4. Arthritis
Social History:
___
Family History:
Mother with diabetes. Father died from unknown causes.
Physical Exam:
ADMISSION
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, ___ systolic murmur loudest at RUSB, intact
S2, radiates to carotid, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
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. ___ UE, ___ strength, CN2-12 intact
PSYCH: pleasant, appropriate affect
DISCHARGE
VITALS: 98.3 PO 128 / 63 90 16 97 Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, ___ systolic murmur loudest at RUSB, intact
S2, radiates to carotid, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
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. ___ UE, ___ strength, CN2-12 intact
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION
___ 02:23PM BLOOD WBC-15.1* RBC-3.58* Hgb-10.0* Hct-31.4*
MCV-88 MCH-27.9 MCHC-31.8* RDW-14.0 RDWSD-44.9 Plt ___
___ 02:23PM BLOOD Plt ___
___ 03:09PM BLOOD ___ PTT-19.6* ___
___ 02:23PM BLOOD Glucose-187* UreaN-23* Creat-0.8 Na-139
K-4.5 Cl-103 HCO3-20* AnGap-16
___ 02:23PM BLOOD Calcium-9.1 Phos-2.6* Mg-2.0
___ 05:45AM BLOOD calTIBC-332 Ferritn-48 TRF-255
___ 02:34PM BLOOD Lactate-1.8
DISCHARGE
___ 05:19AM BLOOD WBC-8.4 RBC-3.22* Hgb-9.0* Hct-28.2*
MCV-88 MCH-28.0 MCHC-31.9* RDW-14.3 RDWSD-45.3 Plt ___
___ 05:19AM BLOOD Plt ___
___ 05:19AM BLOOD ___ PTT-24.7* ___
___ 05:19AM BLOOD Glucose-134* UreaN-5* Creat-0.6 Na-145
K-3.6 Cl-107 HCO3-28 AnGap-10
___ 05:19AM BLOOD Calcium-9.2 Phos-3.0 Mg-2.4
Colonoscopy ___
High residue material throughout. Multiple attempts to irrigate
the colon but the mucosa could not be visualized adequately.
Severe diverticulitis of the whole colon. Large pathology could
not be ruled out due to very poor prep and complex anatomy.
CT Colonography ___
IMPRESSION
4 cm area of concentric wall thickening in the sigmoid colon on
a background
of extensive diverticulosis without evidence of diverticulitis.
This area
needs to be evaluated by conventional colonoscopy for potential
sampling.
Brief Hospital Course:
#Painless hematochezia: likely diverticular bleed. Ddx for lower
GI bleeding includes colon cancer (though minimal weight loss,
energy/appetite seem good), ulcers, angiodysplasia, and
hemorrhoidal bleeding. Unlikely upper bleed given hemodynamic
stability, normal BUN/Cr ratio, lack of melena. After admission,
he was asymptomatic and hemodynamically stable with stable H/H
and did not require a transfusion. GI consulted. Colonoscopy on
___ showing diverticuli but with poor prep so did CT
colonography on ___. Colonography also shows extensive
diverticuli and an area in the sigmoid colon with wall
thickening where a mass cannot be entirely excluded. Discussed
with GI and felt reasonable to discharge today given the patient
is clinically well-appearing and no longer bleeding. PCP follow
up scheduled and GI follow up scheduled in ___. Held
aspirin during admission given bleeding. Apparently he has a
history of an old CVA. Left message with PCP to discuss and will
recommend discussing this with his PCP at his follow up
appointment.
#Leukocytosis, resolved: likely reactive i/s/o GIB, resolved. No
localizing sx. No empiric abx.
#T2DM: held home glipizide, metformin; HISS in house
#AS: Had mild AS on echo ___ years ago; does not report any
recent echo with his PCP; at one point was referred to
cardiology as outpatient but this was never scheduled; the
rationale is not clear from talking to patient, perhaps related
to c/f angina, as
he was complaining of some left arm pain. Does not appear
recently to have recent TTE. Denies angina, syncope, dyspnea sx.
Would recommend outpatient echo.
CHRONIC/STABLE PROBLEMS:
#Hx CVA: held ASA given bleed - left message with PCP as above
to discuss
Transitional issues:
- currently holding ASA; discuss with PCP ___ to resume
- outpatient echo
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. GlipiZIDE XL 5 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Medications:
1. GlipiZIDE XL 5 mg PO DAILY
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until you discuss further with your PCP
___:
Home
Discharge Diagnosis:
Lower gastrointestinal bleeding
Diverticulosis
Diabetes mellitus
Hyperlipidemia
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 GI bleeding. Your blood
counts fortunately remained stable and you didn't require a
transfusion. The GI team consulted and did a colonoscopy, which
showed extensive diverticuli (pouches in the colon) but given
there was still stool in the colon, we did another study for a
better look. This study was a CT colonography. This also showed
extensive diverticuli. It didn't show a mass. It did show an
area of wall thickening in the sigmoid colon, which may need to
be further evaluated in the future. Please follow up with your
GI appointment to discuss any further workup.
It was a pleasure taking care of you!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10898555-DS-16
| 10,898,555 | 28,313,519 |
DS
| 16 |
2129-08-06 00:00:00
|
2129-08-06 19:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
erythromycin base
Attending: ___.
Chief Complaint:
Weakness, cough and shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with HTN, HLD, COPD, RA, HFpEF
(TTE ___ with grade II diastolic dysfunction and EF 70%) and
pHTN who presented with cough and DOE for the past 2 weeks found
to have sinus bradycardia in the ED now transferred to ___ for
further management.
The patient states that over the past year she has been feeling
more fatigued with generalized malaise. She notes she has had
multiple falls where she feels sudden weakness and has to sit
down or she will fall. She denies any LOC, CP, palpitations,
lightheadedness, dizziness, diaphoresis, or nausea during these
episodes. She also reports DOE over the past year.
Then 2 weeks ago, patient reports she developed a cough
productive of clear/pale yellow sputum and congestion. At the
same time, she also developed worsening DOE. No fevers, chills,
nausea, vomiting or chest pain. The 1 day prior to admission,
she was out walking her dog and began to feel more weak and SOB.
No LOC. She sat down to catch her breath at which point a
bystander helped her call EMS and she was brought to the ED.
En route to the hospital, the patient was noted to be
bradycardic with HRs in the ___. She was given 0.5 mg of
Atropine and her HR improved to the ___.
In the ED initial vitals were: 97.5 58 105/52 18 98% RA
EKG: sinus bradycardia with HR 47. PR 237/QRS 87/QTc 453. Non
specific TWIs diffusely.
Labs/studies notable for:
137 | 104 | 31
------------------
3.8 | 21 | 1.1
Ca: 8.4 Mg: 1.8 P: 3.9
10.9
7.7>------<148
32.1
CXR:
1. Subtle opacification at the right base, concerning for early
bronchopneumonia.
2. Reticular opacities throughout the lungs bilaterally,
consistent with mild interstitial lung disease.
EP evaluated the patient and deemed that given the patient's HR
improved with appropriate augmentation with leg raise and
exercise, there was no indication for PPM. Likely her symptoms
were a result of underlying pulmonary process (bronchopneumonia)
and the patient vagaled in response to coughing. Recommended
holding beta blocker and further work-up of pulmonary process.
Patient was given:
___ 02:18 IVF NS
___ 02:18 PO/NG Donepezil 10 mg
___ 02:18 PO/NG Atorvastatin 10 mg
___ 08:57 PO Omeprazole 40 mg
___ 08:57 PO/NG Ranitidine 150 mg
Vitals on transfer: AF 65 133/51 18 97% RA
On the floor, patient reports continued fatigue, cough and DOE.
Denies diaphoresis, CP, palpitations, N/V, lightheadedness,
dizziness, PND, orthopnea, ___ swelling, abdominal pain, or
recent changes in bowel or urine.
Past Medical History:
-palindromic seropositive rheumatoid arthritis - dx'ed ___ years
ago, joint pain and swelling and positive serology, most notable
in hips and arms
-hypertension
-hypercholesterolemia
-spinal stenosis
-insomnia
-anxiety
-left Achilles tendon complete rupture
-hiatal hernia
-lactose intolerance
-diverticulitis
-hearing loss
Social History:
___
Family History:
Father with gastric cancer, d.___. Mother with breathing problems
from muscular dystrophy. Only child. One healthy son, the other
is a quadriplegic after traumatic injury.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T 97.8 BP 154/62 HR 65 RR 20 O2 SAT 95% RA
Weight: weight 113<-111 pounds ___ in clinic with ___
GENERAL: elderly woman, frail appearing, lying comfortably in
bed, short of breath with speaking, in NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple, unable to appreciate JVP.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Increased work of breathing. Diffuse expiratory wheezes with
decreased breath sounds at the bases. No crackles or rhonchi.
ABDOMEN: Soft, NTND, no rebound or guarding.
EXTREMITIES: 1+ pitting edema of b/l ___ to knee.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE PHYSICAL EXAM
Vitals: 97.3 ___ 93% RA
I/O= 60/450 (8hrs), 1000/800+ (24hrs)
Weight: 48.8 kg <-49.4 kg
Weight on admission: 51.9 kg
Telemetry: Intermittent SVT.
General: NAD well appearing.
HEENT: MMM symmetric
Lungs: Decreased air movement, but mostly CTAb. No wheezes.
CV: RRR, no m/g/r
Abdomen: Soft, ND NT
Ext: WWP no edema
Pertinent Results:
ADMISSION PHYSICAL EXAM
___ 09:30PM WBC-7.7 RBC-3.21* HGB-10.9* HCT-32.1*
MCV-100* MCH-34.0* MCHC-34.0 RDW-16.2* RDWSD-58.9*
___ 09:30PM CALCIUM-8.4 PHOSPHATE-3.9 MAGNESIUM-1.8
___ 09:30PM GLUCOSE-119* UREA N-34* CREAT-1.3* SODIUM-133
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-22 ANION GAP-17
___ 09:30PM NEUTS-84.3* LYMPHS-8.5* MONOS-6.1 EOS-0.5*
BASOS-0.1 IM ___ AbsNeut-6.44* AbsLymp-0.65* AbsMono-0.47
AbsEos-0.04 AbsBaso-0.01
___ 09:30PM PLT COUNT-148*
IMPORTANT STUDIES
--------------------
CXR ___:
1. Subtle opacification at the right base, concerning for early
bronchopneumonia.
2. Reticular opacities throughout the lungs bilaterally,
consistent with mild interstitial lung disease.
EKG: sinus bradycardia with PACs at a rate of 47 bpm, normal
axis, intervals: PR 237/QRS 87/QTc 453. Non specific TWIs
diffusely
DISCHARGE LABS
------------------
___ 05:20AM BLOOD WBC-5.3 RBC-3.62* Hgb-12.3 Hct-35.0
MCV-97 MCH-34.0* MCHC-35.1 RDW-15.9* RDWSD-56.3* Plt ___
___ 05:20AM BLOOD Glucose-139* UreaN-39* Creat-1.2* Na-135
K-6.1* Cl-101 HCO3-21* AnGap-19
___ 09:14AM BLOOD K-4.0
___ 05:20AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.1
Brief Hospital Course:
Ms. ___ is a ___ year old female with HTN, HLD, COPD, RA, HFpEF
(TTE ___ with grade II diastolic dysfunction and EF 70%) and
pHTN who presented with acute onset weakness with bradycardia to
the ______ that improved with atropine given by EMS. On admission,
patient found to have community acquired pneumonia and COPD. She
was evaluated by EP who deemed that her bradycardia may have
been in the setting of increased vagal tone with coughing with
no indication of pacemaker placement. Her labatelol was held
later transitioned to carvedilol given improvement in symptoms.
The patient's course was complicated by an acute HFpEF
exacerbation that resolved with Lasix IV.
#Sinus Bradycardia:
Patient found to be bradycardic with HR ___ in setting of
collapsing when walking her dog. Improved to 40-50s with
atropine given by EMS. Labetalol was held on admission and
patient was not bradycardiac on cardiac monitoring. No e/o
complete heart block or Mobitz type 2 on EKG. Evaluated by EP
who deemed that there was no indication for PPM. She had no
further episodes of bradycardia during this admission. She was
started on low dose carvedilol given episodes of SVT and
hypertension which she tolerated well. Will need close follow-up
as an out-patient.
#Pneumonia
#COPD Exacerbation:
Patient with 2 week history of productive cough and worsening
DOE. Exam with expiratory wheezes concerning for COPD
exacerbation and CXR with subtle opacification at the right
base, concerning for early bronchopneumonia. Patient also with
initial lactate 4.0, repeat lactate 2.2 after 1L IVF in ED.
Treated with standing nebs, 5 day burst of 50 mg prednisone, and
8 day course of levofloxacin (end date ___ for CAP and
COPD exacerbation. Initially required O2, but on day of
discharge, ambulatory saturations were 88%.
# Acute Exacerbation of Diastolic HF: Patient dry on admission,
with lactate bump to 4.4. Given IVF total about 2 L and
developed worsening O2 requirement in this setting and in the
setting of Hypertensive urgency. Diuresis with x2 ___ IV Lasix to
euvolemia.
# Hypertensive urgency: HTN to 180's systolic in setting of
prednisone burst as well as holding home labetalol ___
bradycardia described above. Amlodipine started and increased to
10 mg. Lisinopril increased from 20 to 40 mg daily. Taken off of
combination HCTZ-Lisinopril to facilitate increased dose of
lisinopril. Was on hydralazine 10 mg Q6H for control while on
prednisone . This was stopped on discharge as prednisone was
completed. Prior to discharge, the patient was started on low
dose carvedilol given episodes of SVT and persistent
hypertension. Will need close monitoring as out-patient and
consider initiation of imdur if persistently hypertensive.
# SVT: Following discontinuation of labetalol patient developed
intermittent SVT to the 150's which was most c/w an atrial
tachycardia. She was started on a low dose of coreg as detailed
above.
Chronic Issues:
#RA: Being initiated on entaracept weekly infusions. Missed her
infusion ___, this was rescheduled by her outpatient
Rheumatologist.
#HLD: Restarted on home Lovastatin at discharge
#Dementia: Continued home donepezil 5mg qHS
TRANSITIONAL ISSUES
=====================
Discontinued Medications:
- Labetalol 200 mg BID
New Medications
- Amlodipine 10 mg daily
- Carvedilol 3.125mg BID
Changed Medications
- Lisinopril increased to 40 mg (combination pill of
HCTZ-Lisinopril discontinued in favor of Lisinopril 40 mg and
HCTZ 25 mg)
Other Transitional Issues
- Please monitor blood pressure as an outpatient, if elevated
SBP > 140 consider up-titrating coreg versus initiation of
IMDUR.
- Discharge Weight: 48.8 kg
- Discharge Creatinine: 1.0
# CODE: Full
# CONTACT: HCP: ___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of
breath/wheezing
2. FoLIC Acid 1 mg PO DAILY
3. Labetalol 200 mg PO BID
4. lisinopril-hydrochlorothiazide ___ mg oral DAILY
5. Lovastatin 20 mg oral QHS
6. LOPERamide 2 mg PO QID:PRN diarrhea
7. Donepezil 10 mg PO QHS
8. Orencia (with maltose) (abatacept (with maltose)) 500 mg
injection EVERY 2 WEEKS
9. Methotrexate 10 mg PO QTHUR
10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
11. Fiber (calcium polycarbophil) (calcium polycarbophil) 625 mg
oral BID
12. Vitamin D 1000 UNIT PO DAILY
13. Cyanocobalamin 500 mcg PO DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
2. Carvedilol 3.125 mg PO BID
RX *carvedilol 3.125 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth QAM Disp #*30
Tablet Refills:*3
4. Levofloxacin 750 mg PO Q48H Duration: 2 Doses
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth once
Disp #*2 Tablet Refills:*0
5. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of
breath/wheezing
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
8. Cyanocobalamin 500 mcg PO DAILY
9. Donepezil 10 mg PO QHS
10. Fiber (calcium polycarbophil) (calcium polycarbophil) 625
mg oral BID
11. FoLIC Acid 1 mg PO DAILY
12. LOPERamide 2 mg PO QID:PRN diarrhea
13. Lovastatin 20 mg oral QHS
14. Methotrexate 10 mg PO QTHUR
15. Orencia (with maltose) (abatacept (with maltose)) 500 mg
injection EVERY 2 WEEKS
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Community Aquired Pneumonia
COPD exacerbation
Iatrogenic sinus bradycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
Why were you admitted to the hospital?
- You were admitted to the hospital after you were found to be
weak and to have a very low heart rate.
What was done for you in the hospital?
- You were treated with antibiotics for a possible pneumonia and
a steroid burst for a likely COPD exacerbation.
- You were given fluids because you looked to be dehydrated.
- We changed your labetalol to carvedilol for better blood
pressure control.
- You were evaluated by our physical therapists and were deemed
to be ready to go home.
What should you do after leaving the hospital?
- take all your medications as listed below on your discharge
medication list.
- please follow up with your outpatient doctors as listed below.
- Please weigh yourself every morning and call your cardiologist
should your weight increase by 3 lb's or more. ___.
We wish you all the ___!
Your ___ Team
Followup Instructions:
___
|
10898691-DS-19
| 10,898,691 | 27,720,060 |
DS
| 19 |
2168-07-17 00:00:00
|
2168-07-18 17:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Gluten / Doxycycline / lactose
Attending: ___.
Chief Complaint:
MEDICINE ATTENDING ADMISSION NOTE
Time of Initial Eval: ___ 01:30
CC: N/V/Abdominal Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a ___ y/o F with PMHx of celiac dz, fibromyalgia,
depression/anxiety, who is presenting with abdominal pain and
bloody diarrhea. Pt reports that she was in her USOH until
approximately 2 months ago, when she developed abdominal
bloating and mild constipation, with associated 10 lb weight
gain. This persistent until 1 week ago, when her abdomen became
soft and she developed abdominal pain and green watery diarrhea.
Abdominal pain is diffuse in location and radiates into the
back. Then, approximately 2 days ago, she began to notice bright
red blood in her stool. She reports that eating or drinking
anything exacerbates the diarrhea. Per ED report, she gets some
pain relief after defecation. Pt denies any nausea or vomiting
during this time.
ED Course:
Initial VS: 97.4 67 102/66 18 100% ra Pain ___
Labs significant for Hct 34.1 (32.3). Prior Hct in our system
was 26.9 (from ___, in the post-operative setting). Negative
UA.
Imaging: CT A/P with no acute process.
Meds given: dilaudid, zofran
VS prior to transfer: 97.4 65 110/65 16 100% RA
ED rectal exam: external hemorrhoids, no external blood.
Hemocult positive.
On arrival to the floor, the patient reports ongoing abdominal
pain. She does report some recent dizziness as well as a
self-limited episode of chest pressure several days ago.
Otherwise, she denies any acute concerns.
ROS: As above. Denies headache, lightheadedness, sore throat,
sinus congestion, heart palpitations, shortness of breath,
cough, nausea, vomiting urinary symptoms, muscle or joint pains,
focal numbness or tingling, skin rash. The remainder of the ROS
was negative.
Past Medical History:
PMH: Celiac, fibromyalgia, MDD/anxiety, Raynaud's
PSH: Hip surg ___ injury, appendectomy, hysterectomy ___ cysts
and fibroids), shoulder surg.
Social History:
___
Family History:
+ for Crohn's and UC
Father with waldenstrom's
Both grandfathers with bladder CA
Grandmother with breast CA
Physical Exam:
Admission Exam:
VS - 97.8 67 101/71 18 99%RA
GEN - Alert, uncomfortable
HEENT - NC/AT, OP clear
NECK - Supple, no JVD, no cervical or supraclavicular LAD
CV - RRR, no m/r/g
RESP - CTA B
ABD - S/ND, BS present, diffusely TTP worst in the LLQ, no
rebound or guarding
EXT - No ___ edema or calf tenderness
SKIN - No apparent rashes
NEURO - Non-focal
PSYCH - Calm, appropriate
Discharge Exam:
Largely unchanged from admission
Pertinent Results:
Admission Labs:
___ 03:50PM BLOOD WBC-4.2# RBC-3.56* Hgb-11.4* Hct-34.1*#
MCV-96 MCH-32.1* MCHC-33.5 RDW-13.0 Plt ___
___ 03:50PM BLOOD Neuts-44.8* Lymphs-43.3* Monos-6.6
Eos-3.5 Baso-1.9
___ 04:54PM BLOOD ___ PTT-32.1 ___
___ 03:50PM BLOOD Glucose-92 UreaN-12 Creat-0.8 Na-141
K-4.4 Cl-111* HCO3-25 AnGap-9
___ 03:50PM BLOOD ALT-27 AST-23 AlkPhos-41 TotBili-0.3
___ 03:50PM BLOOD Lipase-57
___ 05:06PM BLOOD Lactate-1.4
___ 10:15PM BLOOD WBC-3.9* RBC-3.35* Hgb-10.8* Hct-32.3*
MCV-97 MCH-32.3* MCHC-33.4 RDW-13.3 Plt ___
___ 03:56PM URINE Color-Straw Appear-Clear Sp ___
___ 03:56PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 03:56PM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1 ___ 03:56PM URINE UCG-NEG
Discharge Labs:
___ 06:10AM BLOOD WBC-3.9* RBC-3.36* Hgb-10.6* Hct-32.4*
MCV-97 MCH-31.6 MCHC-32.7 RDW-13.0 Plt ___
___ 06:10AM BLOOD Glucose-97 UreaN-6 Creat-0.8 Na-142 K-3.5
Cl-111* HCO3-24 AnGap-11
___ 06:10AM BLOOD Calcium-9.4 Phos-4.6* Mg-1.8
Inflammatory markers:
___ 06:10AM BLOOD CRP-0.2
___ 06:10AM BLOOD ESR-2
====================================
Microbiolgy
====================================
___ 3:59 am STOOL CONSISTENCY: LOOSE PRESENCE OF
BLOOD.
Source: Stool.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Pending):
FECAL CULTURE - R/O VIBRIO (Pending):
FECAL CULTURE - R/O YERSINIA (Pending):
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
=====================
Imaging:
=====================
CT A/P: IMPRESSION:
1. No evidence of acute intra-abdominal process.
2. 10 mm liver segment VI hypoenhancing lesion cannot be fully
characterized on this single phase CT.
3. 9 mm left renal midpole hypoenhancing lesion is too small to
fully characterize.
Brief Hospital Course:
___ y/o F with PMHx of celiac dz, fibromyalgia,
depression/anxiety, who is presenting with abdominal pain and
diarrhea.
# Abdominal Pain / hematochezia: No acute process visualized on
CT A/P. Her inflammatory markers were negative. Her CBC was
trended and was stable over her admission. Her case was
discussed with her outpatient gastro-enterologist, and it was
relayed that she has a history of IBS, with a mutation for
celiac, though not thought to have phenotypic disease. Her
diarrhea ceased when she hit the floor which she attributed to
the contrast she drank. She asked for bisacodyl and colace to
help expel the contrast given that it has constipated her in the
past. Frequent stools resumed after that. She remained
hemodynamically stable, C. diff was negative. Culture was
negative for E. Coli, other stool culture results were pending.
She was very concerned for IBD and colon cancer. She was
reassured that with negative inflammatory markers and CT scan,
IBD was very unlikely. Also, given colonoscopies in the past as
recent as ___ without neoplasm was also very reassuring.
She was initially nauseated and treated with standing
anti-emetics. She was transitioned to clears and she was
ultimately able to tolerate a diet without nausea or vomiting.
She was given immodium for diarrhea without much help. She was
scheduled for outpatient eveluation with GI at ___. She was
requesting a second opinion.
# Fibromyalgia: Home nabumetone was on hold given GI bleeding,
and restarted on discharge. Continued gabapentin.
# Depression/Anxiety: Continued home venlafaxine
# Headaches: Continued topamax. She received Imitrex for
migraine.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Venlafaxine XR 150 mg PO DAILY
2. Topiramate (Topamax) 200 mg PO HS
3. Nabumetone 500 mg PO BID
4. Gabapentin 300 mg PO BID
Discharge Medications:
1. Gabapentin 300 mg PO BID
2. Topiramate (Topamax) 200 mg PO HS
3. Venlafaxine XR 150 mg PO DAILY
4. Nabumetone 500 mg PO BID
5. Ondansetron 4 mg PO Q8H:PRN nuasea
RX *ondansetron 4 mg ___ tablet,disintegrating(s) by mouth every
eight (8) hours Disp #*20 Tablet Refills:*0
6. Prochlorperazine 5 mg PO Q8H nausea
RX *prochlorperazine maleate 5 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*20 Tablet Refills:*0
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Gastroenteritis
Celiac
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 nausea, vomiting, and diarrhea.
You had a CT scan which showed no signs of inflammation, or
infection. Your nausea, vomiting, and pain improved with
medications. You were given fluids for hydration.
Your inflammatory markers were normal, and you had no fevers, or
signs of infection. I discussed your results with your
outpatient gastro-enterologist.
I have set up an appointment for our gastroenterology department
for you for a second opinion.
Followup Instructions:
___
|
10898862-DS-14
| 10,898,862 | 26,424,475 |
DS
| 14 |
2181-04-16 00:00:00
|
2181-04-20 21:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ yo M with h/o CLL discharged on ___ from
general surgery service after admission for mechanical fall with
contusion, facial fracture and intraparenchymal brain
hemorrhage, now re-admitted from rehab for fevers (rectal temp
102.3).
.
One week prior to presentation (___), patient had a
mechanical fall down 1 flight of stiars without LOC. Presented
initially to an OSH, found to have blood in the mouth concerning
for skull fracture and was intubated for airway protection.
Transferred to ___. CT scans on hospital evaluation revealed R
frontal hemorrhagic contusion, R intraparenchymal hemorrhage
with midline shift, right superior orbital fracture, right
zygomatic fracture, and right maxillary sinus fracture.
Neurosurgery was consulted for intraparenchymal hemorrhage, and
initially placed the patient on phenytoin for seizure
prophylaxis. Per report no neurosurgical procedures were
necessary. Plastics was consulted and felt fractures will
require operative repair on an elective basis and can be done in
___ weeks as an outpatient once swelling resolves and if
medically stable. They also suggested an opthalmology consult on
arrival to ___, although does not appear patient was ever
evaluated. Additionally, clindamycin x 7 days for sinus
precautions
was recommended; however review of recent discharge records and
orders (no discharge summary available yet) show patient did not
receive clindamycin ppx. Was discharged yesterday with plans to
f/u with plastics on ___ for surgical correction of facial
trauma. Per verbal report from ___ resident, patient was
afebrile in house and discharge to rehab today, but re-presented
after fevers per above.
.
In the ED, initial vitals were: T99.9 HR88 BP175/85 RR15 satting
99%. Patient had good range of motion of the neck and no
meningismal signs. Labs showed a WBC of 30.4 (baseline 20___-30's
given CLL) with 55% lymphocytes/45% PMNs. HCT of 30.2 at
baseline and creatinine of 1.4 at baseline. Rest of CMP was WNL.
LFT's wer WNL. UA was bland. Blood and urine cultures were
obtained. CXR was without intrathoracic process. Patient did
have some maxillary sinus tenderness on exam, and was provided
empirically with vancomycin, levofloxacin, cefepime for
sinusitis. Surgery was consulted who deemed no surgical issues
at this time but will continue to follow.
VS prior to transfer: T101.3 °F (38.5 °C), Pulse 84, Respiratory
Rate 18, Blood Pressure 154/81, O2 Saturation 99.
.
On arrival to the floor last night, patient was lethargic but
arousable. Denies pain symptoms.
.
On exam this morning, vitals are: 101.9 101.9 160/94
[142-160-50-94] ___ 20 97% RA. Patient is lethargic but opens
eyes to command and responds appropriately, if briefly, to
questions. He denies neck pain or stiffness, headache, sinus
pain, chest pain, dyspnea, abdominal pain, nausea/vomiting, back
pain, leg pain/swelling, rash, dysuria.
Past Medical History:
Gastric Ulcer
CLL (oncologist Dr. ___ in ___)
Inguinal Hernia
HTN
Recent hospitalization with the following diagnoses (___)
1. Right frontal hemorrhagic contusion
2. Right IPH with midline shift
3. Right superior orbital fracture
4. Right zygomatic fracture
5. Right maxillary sinus fracture
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 101.9 101.9 160/94 [142-160/50-94] ___ 20 97% RA
GENERAL: Lethargic. Contusions on face/forehead/neck/arms.
HEENT: Right maxillary region appears somewhat swollen.
Eccyhmoses under right eye with conjunctival hemorrhage/bloody
sclera in left eye. Thick mucous in oral cavity, but patient
cannot open mouth well to fully evaluate. Nasopharynx clear.
Ecchymoses around neckline. No ecchymoses around mastoids.
Eschars on forehead/apex of head.
NECK: Supple, no thyromegaly, no JVD
HEART: Distant. RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no ronchi/rales/wheezes, good air movement,
resp unlabored.
ABDOMEN: NBS Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: Diffuses ecchymoses on face. Left hand with large
ecchymoses on extensor surface. Eschars on forehead.
LYMPH: No cervical LAD.
NEURO: Lethargic. A&Ox3, can concentrate and say days of week
backwards. PERRLA. EOMI. Mouth/face symmetric. Uvula midline.
Can protrude tongue. Can MAE. ___ strength LLE, 3+/5 RLE. ___
hand/flexor/extensor strength in UE B/L. Left arm appears flexed
at rest but patient able to extend on command. Mild past
pointing on finger to nose test. 2+ patellar reflexes
bilaterally. Difficult to elicit UE reflexes. Downgoing
Babinskis.
.
DISCHARGE PHYSICAL EXAM:
Vitals: T 98.2 Tm 99.4 144/85 (114-152/68-85) 72 (70-81) 18 99RA
GENERAL: thin elderly M in NAD, ecchymoses on face, lethargic
and very slow to respond to questions, does not speak, will nod
yes/no
HEENT: Right maxillary region appears somewhat swollen.
Eccyhmoses under right eye with conjunctival hemorrhage/bloody
sclera in left eye, improving since admission. Oropharynx clear.
Nasopharynx clear. Ecchymoses around neckline, improving.
NECK: Supple, no thyromegaly, no JVD
HEART: Distant. RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no rhonchi/rales/wheezes, good air movement,
resp unlabored.
ABDOMEN: NBS Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: Diffuses ecchymoses on face, resolving. Left hand with
large ecchymoses on extensor surface. Eschars on forehead.
LYMPH: No cervical LAD.
NEURO: Lethargic, nods yes/no in response to questions,
minimally responsive to questions, PERRLA. EOMs restricted but
intact, upgaze severely restricted. Uvula midline. Can protrude
tongue.
Strength = ___ RUE and RLE. ___ hand/flexor/extensor strength in
LUE. ___ quadriceps, hamstrings, calf muscle strength in LLE.
Left arm appears flexed at rest and did not extend on command.
Exam waxes and wanes.
Pertinent Results:
ADMISSION LABS:
-WBC-30.4* RBC-3.21* Hgb-9.6* Hct-30.2* MCV-94 MCH-30.1
MCHC-31.9 RDW-14.2 Plt ___
-Neuts-45* Bands-0 Lymphs-55* Monos-0 Eos-0 Baso-0 Atyps-0
___ Myelos-0
-Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL
Microcy-NORMAL Polychr-NORMAL
-___ PTT-22.6* ___
-Glucose-116* UreaN-32* Creat-1.4* Na-142 K-3.8 Cl-104 HCO3-22
AnGap-20
-ALT-16 AST-20 AlkPhos-77 TotBili-0.8
-Albumin-3.9
-Lactate-1.1
-URINALYSIS: Color-Yellow Appear-Clear Sp ___ Blood-TR
Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG
Urobiln-NEG pH-5.5 Leuks-NEG
RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0
.
MICROBIOLOGY:
-Blood cultures ___, final): NEGATIVE
-Urine culture ___, final): NEGATIVE
-C. diff amplification assay ___, final): NEGATVE
-Blood cultures ___, pending): NO GROWTH TO DATE
-Urine culture ___, final): YEAST, <10,000 organisms/ml
.
AP CHEST X-RAY (___): Clips are noted in the epigastric
region. The lungs appear clear. No definite signs of pneumonia.
Heart size appears top normal. Mediastinal contour is mildly
prominent, reflective of an unfolded thoracic aorta.
Atherosclerotic calcifications along the thoracic aorta noted.
No bony abnormalities are seen. IMPRESSION: No signs of
pneumonia.
.
CT HEAD WITHOUT CONTRAST (___): There is an increase in
edema and hemorrhage since the head CT of ___. This is
associated with increased mass effect and right to left midline
shift.
.
CT HEAD WITHOUT CONTRAST (___):
1. Very slight increase in edema surrounding the right frontal
hemorrhagic
contusion, which causes stable subfalcine herniation, sulcal
effacement, and effacement of the right lateral ventricle. Loss
of gray-white differentiation superior to this contusion raises
question of possible infarction along this site, and should be
followed closely with serial NECTs of the head.
2. Intraparenchymal hemorrhage in the left parietal lobe likely
as a result of contrecoup injury is unchanged.
3. Small subdural foci of blood along the posterior falx
unchanged from prior study.
4. No evidence of central herniation
.
CT HEAD WITHOUT CONTRAST (___): Overall unchanged appearance
to evolving large right frontal intraparenchymal hemorrhage with
grossly stable 11 mm of leftward shift and mass effect and
unchanged small left parietal intraparenchymal hemorrhage and
right posterior parafalcine subdural hemorrhage.
.
CT HEAD WITHOUT CONTRAST (___):
1. Unchanged appearance of a large right frontal
intraparenchymal hematoma
and left subfalcine herniation and some degree of edema. Trace
subdural and subarachnoid blood products are unchanged. No new
mass effect is detected. F/u closely
2. Multiple fractures, better visualized on the reference study
from ___.
.
20-MINUTE EEG (___): This is an abnormal EEG due to focal
right hemispheric slowing indicative of a subcortical
dysfunction in the right frontal region. In addition the
background is difusely slow, indicative of a mild to moderate
diffuse encephalopathy, which is etiologically
nonspecific. There were no epileptiform discharges.
.
24-HOUR EEG (___): IMPRESSION: This is an abnormal continuous
ICU monitoring study because of continuous focal slowing, poorly
sustained alpha rhythm, and attenuation of faster frequencies
and sleep architecture over the right hemisphere. These findings
are indicative of focal cerebral dysfunction involving cortical
and subcortical structures on the right. These findings are
consistent with the known right frontal intracerebral
hemorrhage. There is mild to moderate diffuse background slowing
and a slow alpha rhythm on the left as well, indicating more
diffuse cerebral dysfunction, which is etiologically
non-specific. There are no epileptiform discharges or
electrographic seizures. Compared to the prior day's recording,
there are no significant changes.
CT Head (___):
FINDINGS: There has been interval evolution of the hemorrhagic
contusion in the right frontal lobe, with decreased central
hyperdense components.
Surrounding hypodense edema is present in a primarily vasogenic
pattern,
effacing the sulci and right frontal horn. There is persistent
leftward
subfalcine herniation, with up to 14-mm shift.
Multifocal subarachnoid and right parafalcine subdural
hemorrhage are less well visualized on this examination. No new
hemorrhage or vascular
territorial infarct. There are calcifications in the cavernous
carotid
arteries.
Large retention cysts persist in the bilateral maxillary
sinuses. The mastoid air cells and middle ear cavities are
clear. Orbits and intraconal structures are symmetric.
Nondisplaced right frontal and facial bone fractures are better
visualized on outside facial bone CT from ___.
IMPRESSION:
1. Evolution of right frontal hemorrhagic contusion, with
unchanged left
subfalcine herniation.
2. Resolving subarachnoid and subdural hemorrhage.
3. Right frontal fracture, better visualized on prior
examination.
BILAT LOWER EXT VEINS
FINDINGS: Grayscale and color Doppler sonograms with spectral
analysis of the bilateral common femoral, superficial femoral,
popliteal, posterior tibial and peroneal veins were performed.
There is non-occlusive echogenic thrombus in the left common
femoral vein. The remainder of the left lower extremity veins
demonstrate normal
compressibility and flow.
In the right lower extremity, there is normal compressibility,
flow and
augmentation.
IMPRESSION: Non-occlusive thrombus in the left common femoral
vein. No other deep venous thrombosis identified in the right
and left lower extremities.
Brief Hospital Course:
___ with CLL with recent trauma resulting in traumatic brain
injury and facial fractures, returning from rehab with fevers
with rectal temp of 102.3, course c/b worsening lethargy and
left-sided weakness.
.
# FEVER: On admission, hospital-acquired sinusitis was the
presumed diagnosis given recent facial fractures, presence of
maxillary sinus opacity on head CT. More over, the patient had
not received prophylactic antibiotics for sinusitis as
recommended by plastic surgery on last hospitalization. However,
given lethargy and multiple facial fractures in which it was
unclear whether disruption of meninges could have occurred,
bacterial meningitis was also on differential. Patient therefore
was started on empiric Vancomycin/Ceftriaxone/Flagyl to cover
for sinusitis (including anaerobic organisms) and bacterial
meningitis. He fevers resolved on HOD#1 except for two more
low-grade fevers on ___ (100.4) and ___ (101.0); repeat blood
and urine cultures and stool C diff were all negative and
antibiotics were not broadened as unclear what organism would be
covering. He completed his 10-day course of IV antibiotics on
___. A blood culture was pending at the time of discharge.
.
# INTRAPARENCHYMAL HEMORRHAGE, MIDLINE SHIFT, CEREBRAL EDEMA/
LETHARGY: On admission, patient was lethargic and slow to
respond to questions or commands, although responses were
typically short but appropriate. He was also noted to have
left-sided weakness. His lethargy waxed and waned during
hospitalization: at times he was much more alert, conversant,
quick to respond to questions, and with improved LUE and LLE
strength, yet conversely he would be found to non-responsive
(nodding only yes or no) and poorly following commands. Head
imagine from ___ to ___ was stable, but continue to
demonstrated significant cerebral edema and mass effect. Given
the cerebral edema and subfalcine herniation, keppra was
increased to 1000mg PO BID per Neurosurg on ___. However,
both 20-minute EEG and 24-hour EEG have shown no epileptiform
discharges. Given his ICH, the patient blood pressure should be
kept below SBP<160mmHg which was done with lisinopril + PRN
Labetalol. The bed was kept at >30 degrees. Aspirin was
stopped due to the ICH and not restart, given that she was also
on heparin gtt for her DVT. Also he was started on an
aggressive bowel regimen to avoid valsalva or to increase ICP.
Finall the patient should no use straws given the extensive
fracture and Traumatic Brain Injury.
He was discharged on Keppra 1000mg BID and will need to follow
up with both neurology and neurosurgery for further evaluation
and management of his traumatic brain injury. A Keppra level
was pending at the time of discharge.
.
# MULTIPLE FACIAL FRACTURES: The patient will need to follow up
with Plastic Surgery to schedule an elective repair of the
multiple facial fractures.
.
#. Deep Vein Thrombosis- The patient was found to have
nonocclusive DVT in the left common femoral vein 2 days prior to
discharge. Per discussion with neurosurgery, the risk for a
significant PE outweight the risk for a repeat ICH and the
patient was started on a heparing gtt for a bridge until he
became therapeutic on coumadin. He will need to continue on
heparin IV sliding scale with a therapeutic PTT goal of 40-60
until he is therapeutic on coumadin. He should then continue on
coumadin with a goal INR of 2.0-2.5. He should follow up with
his PCP with regards to when to stop coumadin for this provoked
DVT.
.
# HYPERTENSION: Lisinopril 10 mg daily. Was given PRN labatalol
if SBP's >160mm Hg. The patient BP was typically between
100-120, but at time would elevated into the 140-150's.
.
# LEUKOCYTOSIS: The patient has baseline WBC count of ___ due
to underlying CLL.
===================================
TRANSITION OF CARE:
- continue on heparin gtt with target PTT from 40-60. Heparin
gtt can be stop after therapeutic on coumadin
- continue on coumadin with goal INR of 2.0-2.5
- f/u with Neurology, Neurosurgery, and Plastic Surgery
-Needs outpatient MRI two months s/p head injury to assess
extent of cerebral ischemia once IPH has resorbed. This will
inform whether to restart Aspirin.
Medications on Admission:
-acetaminophen 325 mg Tablet ___ Tablets PO Q6H prn
-oxycodone 5 mg Tablet Sig: ___ Tablet PO Q4H prn
-aspirin 81 mg Tablet, Chewable 1 po qday
-tramadol 50 mg Tablet 0.5 tab q6 hrs prn
-lisinopril 10 mg Tablet 1 po qday
-docusate sodium 100 mg Capsule 1 po bid
-polyethylene glycol 3350 17 gram Powder in Packet 1 po qday prn
-levetiracetam 500 mg Tablet 1 po BID for 4 weeks
Discharge Medications:
1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. oxycodone 5 mg Tablet Sig: ___ Tablet PO Q4H (every 4
hours) as needed for pain: hold for sedation or if asleep.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___: adjust to achieve an INR of 2.0-2.5.
6. heparin
please start on Heparin Sliding Scale for a target PTT of 40-60
seconds.
7. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day)
as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ACUTE ISSUES:
1. Fever (suspected etiology sinusitis vs. meningitis)
2. Lethargy
3. Recent mechanical fall with multiple facial fractures,
intraparenchymal hemorrhage, right frontal hematoma c/b cerebral
edema and subfalcine herniation
4. deep vein thrombosis
CHRONIC ISSUES:
1. CLL
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at ___
___. You were admitted to the hospital
because you had a fever in rehab after a recent admission for a
fall with face fractures and brain injury. You were treated with
IV antibiotics for sinus infection (and possibly meningitis) and
your fevers resolved. You had many periods of increased fatigue
and slowed mental status which were concerning for seizures, so
the neurology team was consulted and you had a 48-hour EEG which
showed no seizure activity.
.
We also found a deep vein thrombosis in the left common femoral
vein. He will be discharged on heparin until he is therapeutic
on coumadin.
.
Please attend the follow-up appointments listed below with
Neurology Plastic Surgery and Neurosurgery.
.
We made the following changes to your medications:
1. STOP aspirin 81mg daily
2. INCREASE levetiracetam (Keppra) to 1000mg by mouth twice
daily
3. START Heparin IV Sliding Scale with a goal ___ of 40-60.
4. START Coumadin with a goal INR of 2.0-2.5; once therapeutic
on Coumadin for 24 hours, please stop Heparin Sliding Scale
Followup Instructions:
___
|
10898945-DS-21
| 10,898,945 | 29,086,291 |
DS
| 21 |
2127-07-15 00:00:00
|
2127-07-15 16:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hip pain s/p fall
Major Surgical or Invasive Procedure:
ORIF right hip fracture, intertrochanteric with
DHS.
History of Present Illness:
___ with extensive PMH (HCC, recently discharged from ___
for SBP), s/p mechanical fall this afternoon onto his right hip.
Patient was reaching in his dishwasher when he tripped and fell
onto his right hip with immediate pain and inability to
ambulate.
He was BIBA to ___ for further evaluation. His pain is in his
lateral hip, worse with motion. He denies numbness/tingling
distally and pain elsewhere in his extremities.
Past Medical History:
- dx w/ ___ in ___
- underwent TACE in ___ and ___
- CAD s/p LAD stent in ___ found on stress test. Stress tests
since then normal. No chest pain hx ? ___ diabetic neuropathy.
Plavix x 9 months. on ASA since then.
- HTN
- peripheral neuropathy manifested by weakness and burning on
b/l
feet to ankle
- peripheral vascular disease
- essential tremor
- diabetes dx ___. no needed from insulin
- PSA=5; s/p TURP in ___
- R cataract
Social History:
___
Family History:
No liver cancer. One nephew and one daughter with hepatitis C.
Younger brother with cardiac disease. Brother died at age ___
from apparent MI. Multiple family members with diabetes. No
history of prostate cancer or other cancers except for skin
cancers.
Physical Exam:
on admission:
Vitals: AVSS
A&O x 3
Calm and comfortable
RLE skin clean and intact. TTP at lateral hip. No deformity,
erythema, edema, induration or ecchymosis
Thighs and legs are soft
Pain with logroll of hip, no pain at knee, leg, ankle.
Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire
1+ ___ and DP pulses
on discharge:
dressing c/d/i in place
Extremity without obvious deformity
___ Gsc, Ta, ___
SILT LFCN, PFCN, Obturator, Saphenous, Sural, DP, SP, Plantar
2+ DP, ___ pulses; foot warm, well-perfused
Compartments soft (thigh, leg, foot)
Minimal pain to passive stretch of toes
No noted joint effusions
Pertinent Results:
___ 05:10AM BLOOD WBC-8.5 RBC-3.49* Hgb-11.1* Hct-32.5*
MCV-93 MCH-31.9 MCHC-34.3 RDW-14.9 Plt Ct-99*
___ 05:10AM BLOOD Glucose-167* UreaN-23* Creat-0.8 Na-133
K-4.3 Cl-103 HCO3-22 AnGap-12
___ 05:10AM BLOOD Calcium-8.1* Mg-1.9
Brief Hospital Course:
Mr. ___ was admitted to the Orthopedic service on ___
for right hip fracture after being evaluated and treated with
closed reduction in the emergency room. He underwent open
reduction internal fixation of the right hip without
complication on ___. He was extubated without difficulty
and transferred to the recovery room in stable condition. In
the early post-operative course he did well and was transferred
to the floor in stable condition.
On hospital day 2 he was transfused 2 U PRBC for post-operative
anemia. On hospital day 3 he was transfused an additional 1
PRBC. On hospital day 4 hepatology evaluated the patient and
increased his Spironolactone to 100 mg daily and his Lasix to 40
mg daily. He will need electrolytes, BUN, creatinine and CBC
checked twice per week in rehab.
He had adequate pain management and worked with physical therapy
while in the hospital. The remainder of his hospital course was
uneventful and he is being discharged to rehab. on date in
stable condition.
Medications on Admission:
GLYBURIDE - (Prescribed by Other Provider; Dose adjustment - no
new Rx) - 5 mg Tablet - 1 Tablet(s) by mouth in AM per ___
LISINOPRIL - 20 mg Tablet - one Tablet(s) by mouth once a day
METFORMIN - (Prescribed by Other Provider) - 1,000 mg Tablet -
1
Tablet(s) by mouth twice a day
METOPROLOL TARTRATE - 25 mg Tablet - 1 Tablet(s) by mouth twice
a
day
PEG 3350-ELECTROLYTES - 236 gram-22.74 gram-6.74 gram-5.86
gram-2.97 gram Recon Soln - 4 liters(s) by mouth As directed
Start drinking solution at 1pm the day before your exam. Drink
8
ounces every ___ minutes for about 3 hours. Finish drinking
solution by 5pm.
PHYSICAL THERAPY - - evaluate and treat for lower extremity
strengthening, gait training, balance, risk of fall reduction,
diabetic neuropathy
ASPIRIN - (OTC) - 325 mg Tablet, Delayed Release (E.C.) - one
Tablet(s) by mouth once a day
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - (Prescribed
by Other Provider) - 600 mg-400 unit Tablet - one tablet
Tablet(s) by mouth twice daily
LACTOBACILLUS RHAM. GG-INULIN [CULTURELLE] - (Prescribed by
Other Provider) - Dosage uncertain
MULTIVITAMIN - (Prescribed by Other Provider) - Dosage
uncertain
VITAMIN E - 400 unit Capsule - 1 Capsule(s) by mouth twice a day
- No Substitution
Discharge Medications:
1. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
QPM (once a day (in the evening)) for 2 weeks.
Disp:*14 * Refills:*0*
2. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
___ MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO DAILY (Daily).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
10. vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
14. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
15. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for Pain.
Disp:*90 Tablet(s)* Refills:*0*
17. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for fever/pain.
18. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
start medication on ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right hip fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Wound Care:
- Keep Incision clean and dry.
- You can get the wound wet or take a shower starting from 7
days after surgery, but no baths or swimming for at least 4
weeks.
- Dry sterile dresssing may be changed daily. No dressing is
needed if wound continues to be non-draining.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Activity:
- Continue to be weight bearing as tolerated on your right leg
- You should not lift anything greater than 5 pounds.
- Elevate right leg to reduce swelling and pain.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- You are being started on a Bisphosphonates to help prevent
fragility fractures. Take Alendronate weekly as prescribed. Take
first thing in the morning on an empty stomach. Take with at
least 8 ox of water. Remain upright for at least 30 minutes. Do
not eat, drink or take other medications for at least 30
minutes.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
- If you have questions, concerns or experience any of the below
danger signs then please call your doctor at ___ or go
to your local emergency room.
Physical Therapy:
RLE: WBAT, ROMAT
Treatments Frequency:
- Keep Incision clean and dry.
- the wound can get wet or take a shower starting from 7 days
after surgery, but no baths or swimming for at least 4 weeks.
- Dry sterile dresssing may be changed daily. No dressing is
needed if wound continues to be non-draining.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Followup Instructions:
___
|
10898945-DS-22
| 10,898,945 | 20,571,313 |
DS
| 22 |
2129-05-03 00:00:00
|
2129-05-06 20:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fatigue, anemia
Major Surgical or Invasive Procedure:
Diagnostic paracentesis (___)
Upper endoscopy (___)
Colonoscopy (___)
Small capsule endoscopy (___)
History of Present Illness:
___ with PMH NASH/cirrhosis with hepatocellular carcinoma (s/p
TACE x 4 and cyberknife now in remission), with hx of ascites,
SBP, hepatic encephalopathy, presents with low Hct 24. Patient
reports feeling generalized fatigue. Went to PCP today and had
blood tests and was told to come to ED after Hct came back at 24
today. No lightheadedness, LOC, hematochezia/melena,
hematemesis, CP/SOB, fevers/chills, abdominal pain. Does report
slightly increased abd. distention and bilateral ankle swelling
over past 2 weeks. Does report 2 days of having about ___ bowel
movements per day instead of ___ on his lactulose, but he does
not think that these bowel movements were black or bloody. He
notes a general darkening of his bowel movements over the past
month, which he thought was due to starting iron pills per Dr.
___ recommendation.
In the ED, initial vitals were 97.6 65 116/48 13 98%. He
recieved 1 unit of RBCs for the anemia and IVF at 250 cc/hr. He
was also given ceftriaxone 1 gram for SBP prophylaxis in the
setting of suspected GI bleed and he was started on IV
pantoprazole 40 mg BID for the GI bleed. The liver team was
consulted and agreed with admission.
Past Medical History:
- dx w/ HCC in ___
- underwent TACE in ___ and ___
- CAD s/p LAD stent in ___ found on stress test. Stress tests
since then normal. No chest pain hx ? ___ diabetic neuropathy.
Plavix x 9 months. on ASA since then.
- HTN
- peripheral neuropathy manifested by weakness and burning on
b/l
feet to ankle
- peripheral vascular disease
- essential tremor
- diabetes dx ___. no needed from insulin
- PSA=5; s/p TURP in ___
- R cataract
Social History:
___
Family History:
No liver cancer. One nephew and one daughter with hepatitis C.
Younger brother with cardiac disease. Brother died at age ___
from apparent MI. Multiple family members with diabetes. No
history of prostate cancer or other cancers except for skin
cancers.
Physical Exam:
Admission Exam:
VS-98.4, 118/46, 58, 16, 100% RA
General- NAD, comfortably laying flat in bed, alert and oriented
x 3
HEENT- MMM, EOMI, no scleral icterus
Neck- no JVD, no LAD
CV- RRR, SEM, no r/g
Lungs- clear to auscultation bilaterally, slight decreased
breath sounds on the right
Abdomen- soft, NT, + distension with fluid wave
GU- no foley
Ext- 3+ pitting edema in the legs bilaterally to the knees
Neuro- CN ___ intact, gait stooped with cane, strength ___ in
BUE and ___, tremor in hands bilaterally but not classic asterxis
Skin-no rashes
Discharge Exam:
VS: afebrile, wnl
General- NAD, comfortably laying flat in bed, in no distress
HEENT- MMM, EOMI, no scleral icterus
Neck- no JVD, no LAD
CV- RRR, SEM
Lungs- CTA b/l
Abdomen- soft, NT, + distension with fluid wave
GU- no foley
Ext- 2+ pitting edema in the legs bilaterally to the knees
Neuro- CN ___ intact. Fine resting in hands.
Pertinent Results:
Admission labs:
___ 04:25PM BLOOD WBC-5.3 RBC-2.67* Hgb-7.4*# Hct-24.4*#
MCV-92 MCH-27.9 MCHC-30.5* RDW-14.2 Plt Ct-65*
___:28PM BLOOD Neuts-68.7 ___ Monos-10.1 Eos-2.7
Baso-0.4
___ 04:28PM BLOOD Hypochr-2+ Anisocy-OCCASIONAL Poiklo-1+
Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Acantho-OCCASIONAL
___ 04:28PM BLOOD ___
___ 04:25PM BLOOD ___ ___
___ 04:25PM BLOOD ALT-38 AST-36 AlkPhos-88 TotBili-0.5
___ 04:28PM BLOOD Albumin-3.5 Mg-2.3
Discharge labs:
___ 09:20AM BLOOD WBC-4.8 RBC-3.47* Hgb-10.2* Hct-31.3*
MCV-90 MCH-29.3 MCHC-32.4 RDW-14.6 Plt Ct-50*
___ 11:00PM BLOOD Neuts-70.9* Lymphs-16.6* Monos-9.4
Eos-2.7 Baso-0.4
___ 09:20AM BLOOD ___ PTT-30.9 ___
___ 01:20PM BLOOD Glucose-175* UreaN-16 Creat-1.0 Na-136
K-5.7* Cl-108 HCO3-20* AnGap-14 ***SPECIMEN WAS HEMOLYZED***
___ 01:20PM BLOOD ALT-34 AST-64* AlkPhos-86 TotBili-0.6
___ 01:20PM BLOOD Albumin-3.2* Calcium-8.0* Phos-3.1 Mg-1.9
Imaging:
RUQ U/S (___):
IMPRESSION:
1.Limited assessment of the left lobe of the liver due to
overlying bowel
gas. Main and right portal veins are patent with hepatopetal
flow. The left portal vein is not visualized due to overlying
bowel gas.
2. Known liver tumor is better visualized on previous MRI.
3. Cirrhosis and sequelae of portal hypertension including
splenomegaly and
mild to moderate ascites.
CXR (___):
IMPRESSION: No evidence of pneumonia.
MRI abdomen (___):
IMPRESSION:
1. Post-treatment changes within segments VII and VIII are
stable since the ___ MR examination. No evidence of
recurrent HCC.
2. Liver cirrhosis and evidence of portal hypertension,
including parasplenic varices and splenomegaly.
3. Large volume ascites is markedly increased since ___.
4. Cholelithiasis.
5. Unchanged left arterial-portal fistula.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
___ year old man with h/o NASH cirrhosis c/b HCC (now in
remission), with h/o ascites, SBP, HE, and portal gastropathy,
who presents with anemia and increasing abdominal distension.
ACTIVE ISSUES:
========
# Acute on chronic Anemia: Presented with Hgb 7.4 from 10.8 at
baseline. Has known iron deficiency anemia, no increasingly dark
stools since starting iron replacement therapy and no frank
melena or BRBPR. Guaiac was positive in the ED. His last EGD was
over ___ year prior to admission, but showed portal gastropathy
with active oozing. He had EGD on ___ which showed 3 cords
of grade l-II varices were seen in the lower third of the
esophagus without red whale sign or high risk features. No
intervention was performed. He was started on nadolol 4omg daily
(he had been on metoprolol for atrial fibrillation. This was
discussed with his cardiologist and discontinued). He underwent
colonoscopy on ___ which showed many nonbloody medium patchy
angioectasias that were not bleeding were seen in the proximal
ascending colon. Since no definitive source of bleeding was
found, he underwent small capsule endoscopy on ___. He was
discharged later that day; results of the study were pending at
time of discharge. He received a total of 4 transfusions of
pRBCs during his hospitalization. At time of discharge his Hct
was stable at 31.
# Acute kidney injury: Patient presented with elevated
creatitine, likely due to pre-renal azotemia with decreased
circulating blood volume from the blood loss above. This
normalized with volume resuscitation using NS, blood, and
albumin. He was continued on his diuretics.
CHRONIC ISSUES:
=========
# NASH cirrhosis c/b HCC which is now in remission: Recent MRI
from ___ showed no recurrence of his HCC and AFP in the
ED was 1.0. He presented with increased ascites and peripheral
edema but without encephalopathy. He reported full compliance
with SBP prophylaxis. He was continued on lasix and aldactone,
as well as lactulose and rifaximin. Cipro was held, and CTX was
stared at 1gram in the ED, which was increased to 2gm Q24h on
the floor for empiric SBP coverage until diagnostic tap could be
obtained. Diagnostic tap was negative. Given that he had a
likely GI bleed, he was continued on CTX 1g daily during his
hospitalization as ppx. He was discharged on Cipro 500mg daily
for 2 days (to complete a 7-day course of CTX/Cipro (high dose))
and instructed to resume his Cipro 250mg daily ppx afterwards.
# Peripheral edema: Patient initially presented with worse edema
in the legs not improving with elevation or home doses of
diuretics. Thought to be due to decreased oncotic pressures from
anemia. His home diuretics were continued.
# H/o CAD: Aspirin was initially held in setting of possible GI
bleed, was resumed prior to discharge.
# H/o afib: rate controlled on metoprolol, anticoagulated with
ASA only. Afib has been triggered by infections in the past.
Metoprolol was initially held to avoid masking tachycardia in
setting of GI bleed, but was resumed. After the finding of grade
II varices on EGD, the metoprolol was stopped and he was placed
on nadolol 40mg daily (this was discussed with his primary
cardiologist).
# DMT2, well controlled, with complications: followed by ___,
sugars have been less well controlled recently. Patient was
covered on sliding scale insulin.
Transitional Issues
============
- Metoprolol was stopped and replaced with nadolol to treat his
grade II varices as well as a fib. This was discussed with his
primary cardiologist.
- Prior to admission he was taking Cipro 250mg daily as SBP ppx.
During his hospitalization he was maintained on ceftriaxone 1g
daily given his likely GI bleed. On discharge he was instructed
to take Cipro 500mg daily for two days (to complete a 7-day
course of the more intense ppx) and then resume taking his Cipro
205mg daily.
- Per colonoscopy report, will need an out patient colonoscopy
for polypectomy and compelte cecal evaluation after discharge
(as this scope was only for evaluation of GI bleeding).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 250 mg PO Q24H
2. Furosemide 20 mg PO DAILY
3. Lactulose 30 mL PO TID
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Metoprolol Tartrate 25 mg PO BID
6. Rifaximin 550 mg PO BID
7. Spironolactone 50 mg PO DAILY
8. Repaglinide 4 mg PO TID W/MEALS
9. Ascorbic Acid ___ mg PO BID
10. Aspirin 81 mg PO DAILY
11. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit Oral BID
12. lactobacillus rham. GG-inulin 10 billion cell -200 mg Oral
daily
13. Multivitamins 1 TAB PO DAILY
14. Vitamin E 400 UNIT PO BID
15. Ferrous GLUCONATE 324 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO BID
2. Aspirin 81 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Lactulose 30 mL PO TID
5. Multivitamins 1 TAB PO DAILY
6. Rifaximin 550 mg PO BID
7. Spironolactone 50 mg PO DAILY
8. Vitamin E 400 UNIT PO BID
9. Nadolol 40 mg PO DAILY
RX *nadolol [Corgard] 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
10. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit Oral BID
11. Ciprofloxacin HCl 250 mg PO Q24H
RESUME THIS MEDICATION STARTING ___.
12. Ferrous GLUCONATE 324 mg PO DAILY
13. lactobacillus rham. GG-inulin 10 billion cell -200 mg Oral
daily
14. MetFORMIN (Glucophage) 1000 mg PO BID
15. Repaglinide 4 mg PO TID W/MEALS
16. Ciprofloxacin HCl 500 mg PO Q24H Duration: 2 Days
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth daily Disp
#*2 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you here at ___
___. You were admitted on ___ with fatigue and
anemia (low red blood cell count). While here you underwent an
upper endoscopy and colonoscopy to examine your gastrointestinal
tract for bleeding. We did not find a source of bleeding. While
here you received red blood cell transfusions and your blood
level stabilized. On the day of your discharge, you underwent a
small capsule endoscopy study. You will need to follow-up with
Dr. ___ to discuss the results of this study.
Since you have esophageal varices, we started you on a
medication called nadolol. This will REPLACE your metoprolol.
Additionally, you will need a repeat EGD in ___ year to reassess
your varices.
Finally, please continue to take Cipro 500mg daily for 2 days
after discharge (last day ___. Starting ___ take Cipro 250mg
daily.
Again it was a pleasure to meet and care for you!
-Your ___ team
Followup Instructions:
___
|
10898945-DS-25
| 10,898,945 | 28,001,679 |
DS
| 25 |
2130-11-22 00:00:00
|
2130-11-22 18:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
weakness, s/p fall
Major Surgical or Invasive Procedure:
EGD ___
Diagnostic Paracentesis ___
History of Present Illness:
Mr. ___ is an ___ year old man with a PMH of ___ cirrhosis c/b
HCC (s/p 4 TACE procedures and cyberknife with no recurrence
since ___, ___, CAD, HTN, neuropathy, and PVD who presents
for confusion after experiencing a fall.
The patient has reportedly been increasingly somnolent and tired
this week but was still able to go to work. His wife also
reported recent mild nonproductive cough. She takes daily
weights and reports that they were normal. On the day of
admission, he went to the bathroom at 4am, sat back down on his
bed, and slid to the floor. He denied head strike or any
resulting injury. He was unable to get back up and had to crawl,
giving himself rugburn on his knees. His family helped him back
to bed and he was brought to ___.
Of note, Dr. ___ recommended keeping him on 10
mg of torsemide with possible increase to 20 mg if he gains
weight. When his Cr rose to 1.3, however, Dr. ___ him
back to furosemide 20 mg. His wife had also reported black
stools recently but there was minimal concern about a GI bleed
per Dr. ___.
Vitals in the ED: 97.8 62 150/60 18 97%. Labs significant for:
Hct 32.2 (baseline), Plt 48 (baseline low 50's), INR 1.2, K 5.3
(moderately hemolyzed, BUN/Cr of 33/1.0 (baseline), Na 129
(baseline 129), lactate 2.3, ALT/AST 35/66 (up from baseline
37/40). Urine/blood/ascites fluid pending. Para results: WBC
140, RBC 550, 0 polys. Bland UA. A head CT, CXR, and ___ were
negative. RUQ showed moderate ascites, cirrhosis, and
splenomegaly. He was given lactulose and rifaximin in the ED. No
pericardial effusion was noted on exam. A dignostic para was
performed with no SBP. Hepatology saw the patient and
recommended loading with lactulose and rifaximin and then
continuing the lactulose 30 mL q6 hours. They also recommended a
full infectious work-up. He also received 1L NS in the ED. He
was admitted to the hepatology service for further management.
Vitals prior to transfer: 98.7 60 128/53 18 100% RA
On the floor, the patient and his family reported that he has
not necessarily been more confused but has been extremely tired
and weak. He has had a productive cough for the past several
weeks. He has had continued dark stools. In addition they are
concerned about a pressure sore on his bottom. His wife has
taken daily weights and they have been stable around 170-171
lbs.
Review of Systems:
(+) per HPI, all other ROS negative
Past Medical History:
___ CIRRHOSIS
BENIGN ESSENTIAL TREMOR ___
COLON POLYP ADENOMA ___
CORONARY ARTERY DISEASE ___
DIABETES TYPE II ___
ELEVATED PSA ___
GAIT DISORDER seen by Dr. ___ ___ and felt to be
multifactorial, with polyneuropathy as major contributor
HEPATOCELLULAR CARCINOMA ___
HYPERTENSION
LEG WEAKNESS
LUNG NODULES
NEUROPATHY
NOCTURIA ___
PERIPHERAL EDEMA ___
PERIPHERAL VASCULAR DISEASE ___
PULMONARY NODULE ___
S/P TURP ___
HIP FRACTURE
Social History:
___
Family History:
Mother: ___
Mother and daughter: hypothyroid
Brother: leukemia
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 98.5 121/54 58 18 100 ra
GENERAL: NAD, fatigued, thin, lying in bed
HEENT: AT/NC, dry mucous membranes, anicteric sclera
NECK: nontender supple neck
CARDIAC: RRR, S1/S2, ___ SEM loudest RUSB (family reports it is
chronic, worse when he is ill)
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: somewhat distended but soft and non-tender, +BS, no
rebound/guarding, unable to palpate liver edge due to
distention.
EXTREMITIES: 2+ pitting edema bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: Alert and conversing well but fatigued. Fully oriented,
occasional mistakes on serial 7's but spelled "world" backwards
correctly. Significant intention tremor with past-pointing on
exam. Asterixis present. Diffusely deconditioned with weakness
in all extremities. Gait not assessed.
SKIN: warm and well perfused, thin skin with ecchymoses
Discharge
GENERAL: NAD, fatigued, thin, lying in bed
HEENT: AT/NC, dry mucous membranes, anicteric sclera
NECK: nontender supple neck
CARDIAC: RRR, S1/S2, ___ SEM loudest RUSB
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: somewhat distended but soft and non-tender, +BS, no
rebound/guarding, unable to palpate liver edge due to
distention.
EXTREMITIES: 2+ pitting edema bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: A&OX3, no asterxis
SKIN: warm and well perfused, thin skin with ecchymoses
Pertinent Results:
ADMISSION LABS:
=================
___ 08:36PM GLUCOSE-234* UREA N-33* CREAT-1.0 SODIUM-135
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-24 ANION GAP-14
___ 08:36PM CALCIUM-8.3* PHOSPHATE-3.0 MAGNESIUM-1.9
___ 04:25PM ASCITES TOT PROT-0.7 GLUCOSE-183
___ 04:25PM ASCITES WBC-140* RBC-550* POLYS-0 LYMPHS-13*
MONOS-2* MESOTHELI-3* MACROPHAG-82*
___ 03:40PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 03:40PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 02:20PM ___ PO2-31* PCO2-38 PH-7.43 TOTAL CO2-26
BASE XS-0
___ 02:20PM LACTATE-2.3*
___ 02:20PM O2 SAT-51
___ 02:20PM freeCa-1.13
___ 02:05PM WBC-4.5 RBC-3.39* HGB-11.4* HCT-32.2* MCV-95
MCH-33.6* MCHC-35.4* RDW-14.0
___ 02:05PM NEUTS-67.1 ___ MONOS-12.6* EOS-1.1
BASOS-0.6
___ 02:05PM PLT COUNT-48*
___ 02:05PM ___ PTT-32.5 ___
___ 11:50AM GLUCOSE-199* UREA N-33* CREAT-1.0 SODIUM-129*
POTASSIUM-5.3* CHLORIDE-98 TOTAL CO2-20* ANION GAP-16
___ 11:50AM ALT(SGPT)-35 AST(SGOT)-66* ALK PHOS-112 TOT
BILI-0.9
___ 11:50AM LIPASE-25
___ 11:50AM ALBUMIN-3.1*
___ 11:50AM WBC-ERROR RBC-ERROR HGB-ERROR HCT-ERROR
MCV-ERROR MCH-ERROR MCHC-ERROR RDW-ERROR
___ 11:50AM NEUTS-ERROR LYMPHS-ERROR MONOS-ERROR
EOS-ERROR BASOS-ERROR
___ 04:25PM ASCITES WBC-140* RBC-550* Polys-0 Lymphs-13*
Monos-2* Mesothe-3* Macroph-82*
___ 04:25PM ASCITES TotPro-0.7 Glucose-183
DISCHARGE
=========
___ 05:45AM BLOOD WBC-5.1 RBC-3.05* Hgb-10.1* Hct-30.0*
MCV-98 MCH-33.2* MCHC-33.7 RDW-13.9 Plt Ct-49*
___ 05:45AM BLOOD ___ PTT-33.7 ___
___ 05:45AM BLOOD Glucose-181* UreaN-20 Creat-1.0 Na-131*
K-4.2 Cl-97 HCO3-23 AnGap-15
___ 05:45AM BLOOD ALT-49* AST-44* AlkPhos-125 TotBili-0.7
___ 05:45AM BLOOD Albumin-3.1* Calcium-8.5 Phos-3.0 Mg-1.9
___ 05:45AM BLOOD AFP-<1.0
___ 05:45AM BLOOD TSH-1.3
___ 05:45AM BLOOD Cortsol-9.4
MICRO:
========
___
UCx negative
BCx pending
Peritonal fluid: no growth
IMAGING:
=========
___ CT head
IMPRESSION:
Limited examination due to patient motion. There is no evidence
of acute
intracranial process.
___ CXR
IMPRESSION:
No evidence of acute cardiopulmonary process.
___ ___
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ RUQ US
IMPRESSION:
1. Cholelithiasis.
2. Cirrhosis with moderate volume ascites and splenomegaly. The
treated
lesion in segment ___ is not well visualized on the current
exam.
Last EGD: ___
EGD ___
Impression: Esophagitis in the gastroesophageal junction
compatible with mild esophagitis
Varices at the gastroesophageal junction
Mosaic appearance in the fundus and stomach body compatible with
portal hypertensive gastropathy
Angioectasias in the antrum (thermal therapy)
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
Mr. ___ is an ___ year old man with a PMH of NASH cirrhosis c/b
HCC (s/p 4 TACE procedures and cyberknife with no recurrence
since ___, ___, CAD, HTN, neuropathy, and PVD admitted with
lower extremity weakness.
# Weakness: Unclear source of weakness. But given mild asterxis
noted on admission, possible a component of pt's weakness could
be due to hepatic encephalopathy. Pt's wife also stating pt was
only having 2 BMs. No signs of infection with no fever,
leuckocytosis. Neg UA/CXR, diagnostic para. No new focal
neurological deficit. Asterxis resolved with lactulose.
Evaluated by ___ and discharged to rehab.
#Hepatic Encephalopathy: Asterxis on admission. Wife reported
that patient has been having about 2 formed stools/day
suggesting pt likely not taking adequate lactulose. No focal
signs of infection. CXR clear. No signs of SBP on diagnostic tap
and UA bland. CT head neg. RUQ US unremarkable. Asterxis
resolved with lactulose.
#NASH Cirrhosis c/b HCC s/p treatment and ascites: MELD 8 at
admission. Childs class C. Currently followed by Dr.
___. Only small lower esophageal varices on last EGD in
___. Repeat EGD notable for grade 1 varice, GAVE s/p thermal
therapy
-Continued lactulose and rifaximin
-Continued furosemide/spirnolactone/nadolol
-Continue nadolol
# HypoNa: Na of 138 on ___, 130 on ___. urine lytes consistent
with inappropriately activated ADH likely in the setting of
decompensated cirrhosis. Na improving on discharge, 131.
# Recent dark stools: Patient with recent history of dark stools
likely from iron supplement. H/H stable. EGD notable for GAVE.
Had thermal therapy.
#Iron-deficiency anemia:
-continued iron supplements
# Diabetes mellitus.
- held metformin/repaglinide, managed on insulin ss, restarted
home oral meds on discharge
# Coronary artery disease
-continued ASA
#GERD:
-continued omeprazole
===================================
TRANSITIONAL ISSUES
===================================
[ ] Titrate lactulose for ___ bowel movements a day
[ ] Check chem 7 in ___ days to ensure resolving hypoNa
[ ] Repeat EGD in ___ months
CODE: FULL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO BID
2. Aspirin 81 mg PO DAILY
3. Ciprofloxacin HCl 250 mg PO Q24H
4. Ferrous GLUCONATE 236 mg PO DAILY
5. Lactulose 30 mL PO TID
6. Multivitamins 1 TAB PO DAILY
7. Nadolol 10 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Rifaximin 550 mg PO BID
10. Spironolactone 50 mg PO DAILY
11. Vitamin E 400 UNIT PO BID
12. Furosemide 20 mg PO DAILY
13. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit Oral BID
14. HumaLOG (insulin lispro) 100 unit/mL SUBCUTANEOUS PER
SLIDING SCALE
15. lactobacillus rham. GG-inulin 10 billion cell -200 mg Oral
bid
16. MetFORMIN (Glucophage) 1000 mg PO BID
17. Repaglinide 4 mg PO TID W/MEALS
18. Clotrimazole Cream 1 Appl TP BID:PRN skin cracks
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hepatic Encephalopathy
Weakness
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___,
You were admitted due to weakness and were found to have some
signs of confusion. It is somewhat unclear what is causing your
weakness but it could be a manifestation of what we call hepatic
encephalopathy, when toxins related to your liver disease are
not being cleared adequately. To prevent further episodes of
weakness and/or confusion, please make sure to take enough
lactulose at home so you can have ___ bowel movements a day. We
checked for infections, but nothing was positive on testing. You
also underwent endoscopy(a procedure where a camera is inserted
to see your bowel). There were some areas concerning for future
bleeding, so they were treated. Finally, you were seen by our
physical therapists who recommended a stay at a rehabilitation
facility to improve your strength.
Sincerely,
___ medical team
Followup Instructions:
___
|
10899454-DS-19
| 10,899,454 | 28,542,033 |
DS
| 19 |
2186-10-23 00:00:00
|
2186-10-31 16:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
cephalexin
Attending: ___.
Chief Complaint:
Left hand pain
Major Surgical or Invasive Procedure:
Open amputation of left index and long fingers at PIP
joint level (___)
History of Present Illness:
Mr. ___ is a ___ man with history of ESRD on HD
(MWF via LUE AVF), IDMII, Charcot left foot presenting with left
hand pain and purulent drainage.
The patient reports that the difficulties with his left hand
began about 7 months ago. He works as a ___ and he was
repairing a car's brakes. The following day he noted that the
skin was coming off his left index and middle finger.
Ultimately,
his skin healed. However, beginning about 2 weeks prior to
admission, he noticed purulence drainage coming from his left
middle finger and nail bed. He then removed what appeared to him
to be a piece of nail, and he believes that a piece of bone was
also removed when he did this. He had progressively worsening
pain in his left hand. He denies any fevers or chills.
He reports that on the ___ prior to admission, he received
vancomycin at HD. He subsequently soaked his left hand in warm
water and epsom salts this weekend with good effect, but
continued to have pain, swelling, and progression of his
symptoms. In this setting, he was told to present to ___ ED
for
evaluation.
In the ED, initial vitals: 9 98.2 80 154/79 20 100% RA
Exam: MSK: Swollen and tight L middle finger, tightness of index
finger with degloving of both digits to DIP, appearance of bone
beneath wound. No ROM of middle finger, very limited ROM of ring
finger. Swelling extending to L transverse palmar crease. ___
Kanavel's Signs
Labs: WBC 11 H/H ___, plt 353, INR 2.2; Na 133, K 5.8-> 5.6,
Cl
88, HCOe 22, BUN/Cr ___ lactate 1.0
Imaging:
Consults:
- Hand surgery: Evidence of chronic osteo on hand films; index
and middle finger are likely unsalvageable and will require
amputation.
- Recommend admission to medicine for IV antibiotics,
medicaloptimization and clearance for likely operative
amputation
- Please make patient NPO at midnight
-Hand surgery will discuss timing of amputation vs debridement
with staff in AM
Patient given:
___ 22:12 IV Morphine Sulfate 4 mg
___ 22:58 IV Ciprofloxacin
___ 00:31 IV Morphine Sulfate 4 mg
___ 00:39 IV Ciprofloxacin 400 mg
___ 01:17 IV HYDROmorphone (Dilaudid) .5 mg
___ 01:37 IV Insulin (Regular) for Hyperkalemia 10 units
___ 01:37 IV Calcium Gluconate 2 g
___ 01:37 IV Dextrose 50% 12.5 gm
___ 01:42 IV Vancomycin 1000 mg
On arrival to the floor, the patient reports ongoing severe left
hand pain. He denies any other complaints at present.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- ESRD on HD MWF via LUE AVF
- IDDMII
- Charcot join (left foot; on bedrest)
- ADHD
- Recent L ?vitrectomy for diabetic retinopathy with current gas
bubble
- Fistula clots (multiple)
Social History:
___
Family History:
Strong family history of DMII. Mother with MS.
___ with renal disease on dialysis and colon cancer
Physical Exam:
Admission physical exam
VITALS: 98.6 140/80 93 20 97% RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Moist mucous membranes
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.
MSK: Left hand wrapped; foul-smelling sanguinous drainage on
dressing; left foot deformity and swelling consistent with
Charcot joint
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: Depressed mood and affect
Discharge physical exam
VS: T 98.2, HR 82, BP 120/69, RR 18, SpO2 96% on RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: mmm, OP clear
CV: NR/RR, no m/r/g
RESP: CTAB, no wheezes, crackles, or rhonchi
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, Left hand wrapped; left
foot edematous and diffusely tender to palpation
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission labs
=================
___ 11:55PM BLOOD WBC-11.1* RBC-4.33* Hgb-10.4* Hct-36.4*
MCV-84 MCH-24.0* MCHC-28.6* RDW-16.6* RDWSD-50.9* Plt ___
___ 11:55PM BLOOD ___ PTT-33.8 ___
___ 11:55PM BLOOD Glucose-161* UreaN-104* Creat-10.4*
Na-133* K-5.8* Cl-88* HCO3-22 AnGap-23*
___ 12:03AM BLOOD Lactate-1.0
Discharge labs
=================
___ 06:40AM BLOOD WBC-7.6 RBC-4.29* Hgb-10.1* Hct-35.7*
MCV-83 MCH-23.5* MCHC-28.3* RDW-16.5* RDWSD-50.4* Plt ___
___ 06:40AM BLOOD Neuts-65.1 Lymphs-18.9* Monos-9.3 Eos-5.1
Baso-0.8 Im ___ AbsNeut-4.96 AbsLymp-1.44 AbsMono-0.71
AbsEos-0.39 AbsBaso-0.06
___ 09:25AM BLOOD ___ PTT-47.3* ___
___ 06:40AM BLOOD Glucose-208* UreaN-87* Creat-9.1*#
Na-134* K-5.4 Cl-87* HCO3-24 AnGap-23*
___ 06:40AM BLOOD Calcium-9.6 Phos-8.2* Mg-2.6
___ 09:28AM BLOOD Vanco-11.7
MICRO:
- Blood cultures (___): no growth
- Tissue cultures (___): (prelim) coag negative Staph, MSSA,
mixed bacterial flora, GNRs
Imaging
=================
CXR PA/Lat (___):
IMPRESSION:
Possible mild interstitial pulmonary abnormality. Possible
right lower
paratracheal mediastinal adenopathy.
RECOMMENDATION(S): Repeat chest radiograph at full inspiration.
XR left ankle and foot (___):
IMPRESSION:
No previous images. As described in the clinical history, there
is severe
neural arthropathy involving the midfoot and hindfoot in a
patient with
extensive vascular calcification consistent with underlying
diabetes. The
disorganization of the bony structures makes it impossible to
exclude the
possibility of acute fracture unless comparison images are
available.
In the ankle, there is no evidence of acute fracture of the
distal tibia or fibula and the ankle mortise appears intact, as
does the talar dome.
CXR PA/Lat (___):
IMPRESSION:
In comparison with the study of ___, a a more lordotic study
with low
inspiration shows the cardiomediastinal silhouette to be within
normal limits with no evidence of pulmonary vascular congestion
or acute focal pneumonia. Mild prominence of the superior
mediastinum may merely represent lipomatosis.
Brief Hospital Course:
Mr. ___ is a ___ man with history of ESRD on HD (MWF
via LUE AVF), IDMII, Charcot left foot presenting with left hand
pain and purulent drainage.
# Polymicrobial acute osteomyelitis osteomyelitis
# Cellulitis: Patient presented with several weeks of left hand
(index finger and middle finger) pain, swelling, and purulent
drainage and necrosis of fingers of left hand concerning for
acute on chronic osteomyelitis (with elevated CRP) vs.
cellulitis vs. flexor tenosynovitis. He was treated with
vanc/cipro/flagyl initially and was taken to surgery on
___ for amputation of the left index and middle fingers.
Tissue cultures grew MSSA, coag negative staph, mixed bacterial
flora, Strep anginosus, and GNRs. Pathology showed that the
margins were clear on the index finger. However, on the
pathology from the middle finger, they found "gangrene with
acute osteomyelitis involving the bone resection margin." ID
recommended continuing vancomycin, ceftazidime, and
metronidazole for up to 6 weeks with OPAT follow up.
# Hyperkalemia
# ESRD on HD MWF via LUE AVF: In the setting of skipping
dialysis. He was dialyzed on ___ and ___ due to high
K+. He was also dialyzed on ___ and ___ during this hospital
stay.
# Charcot joint, left foot
Podiatry was consulted. Left foot/ankle XRs showed midfoot bony
changes and breakdown. Per podiatry he appears to be in the
acute phase of Charcot and they recommended non-weight bearing
to avoid
further deformity. The patient will follow up with Dr. ___
in ___ ___ weeks.
# H/o fistula clot
He is on lifelong warfarin for 2 episodes of fistula clot. His
INR was subtherapeutic, so he was started on a heparin gtt. In
discussion with the patient's outpatient nephrologist, who
manages his warfarin, his INR is very often subtherapeutic
because the patient is often not compliant with the medication.
Typically, he just will increase his warfarin dose for a few
days and monitor closely. In light of this, the heparin gtt was
discontinued for further monitoring/titration as an outpatient.
# Insulin dependent diabetes mellitis: Patient on determir at
home but given lantus while inpatient. He reported taking a
___ units of Humalog
TRANSITIONAL ISSUES
====================
- INR is subtherapeutic; dose by INR
Mr. ___ is clinically stable for discharge today. The total
time spent today on discharge planning, counseling and
coordination of care was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
2. Fluticasone Propionate NASAL 1 SPRY NU BID
3. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Mild
4. Warfarin 4 mg PO DAILY16
5. Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 15 Units Dinner
Other 50 Units Breakfast
Other 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Midodrine 10 mg PO BID
7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
8. Docusate Sodium 100 mg PO BID
9. Amphetamine-Dextroamphetamine 30 mg PO DAILY
10. Lanthanum 1000 mg PO TID W/MEALS
Discharge Medications:
1. CefTAZidime 2 g IV POST HD (MO,WE)
2 grams on days with 2 day intervals and 3 grams on days with 3
day intervals between HD
2. CefTAZidime 2 g IV TWICE A WEEK Duration: 5 Weeks
Post-HD dosing: 2gm on days with 2-day intervals & 3gm on days
with 3 day intervals between HD
3. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*113 Tablet Refills:*0
4. ___ MD to order daily dose IV HD PROTOCOL
RX *vancomycin 1 gram 1000 mg IV with HD ___,
___ Disp #*16 Vial Refills:*0
5. Vancomycin IV Sliding Scale Duration: 1 Dose
6. Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 15 Units Dinner
Other 50 Units Breakfast
Other 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Amphetamine-Dextroamphetamine 30 mg PO DAILY
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
9. Docusate Sodium 100 mg PO BID
10. Fluticasone Propionate NASAL 1 SPRY NU BID
11. Lanthanum 1000 mg PO TID W/MEALS
12. Midodrine 10 mg PO BID
13. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Mild
14. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
15. Warfarin 4 mg PO DAILY16
16.ceftazidime
CefTAZidime 2 g IV POST HD (MO,WE)
Post-HD dosing: Dose 2 grams on days with 2 day intervals and 3
grams on days with 3 day intervals between HD
Start date: ___, End date ___, duration 26 days
Dispense 11 vial, 0 refills
17.ceftazidime
CefTAZidime 3 g IV POST HD (___)
Post-HD dosing: 2 grams on days with 2 day intervals and 3 grams
on days with 3 day intervals between HD
Start date ___, End date ___, Duration 28 days
Dispense #5 vials, 0 refills
18.Outpatient Lab Work
Weekly labs on ___, and ___:
CBC with diff, CRP, BUN, Cr, and vancomycin trough
ICD-9 code: 730.04 (acute osteomyelitis, hand)
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Chronic osteomyelitis
# Cellulitis
# Hyperkalemia
# Subtherapeutic INR
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to wheelchair or
knee walker.
Discharge Instructions:
Dear Mr ___,
You were admitted due to chronic osteomyelitis and cellulitis of
your left hand. You had an amputation of the left index and
middle fingers and were treated with antibiotics for
osteomyelitis.
Your INR was low so you were started on a heparin drip. In
discussion with your nephrologist, this is a common occurrence
as an outpatient. They will check your INR at HD again on
___ and adjust your warfarin from that.
It was a pleasure being part of your care.
Your ___ team
Followup Instructions:
___
|
10899766-DS-19
| 10,899,766 | 21,710,222 |
DS
| 19 |
2189-02-20 00:00:00
|
2189-02-20 18:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
spironolactone
Attending: ___.
Chief Complaint:
Dizziness, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with hx of CAD s/p CABG in ___, ___, HLD, DM2 who
presents with hypotension.
Patient was recently in rehab for a long stay. He was discharged
in ___ to home. He says he has been having issues with his
blood pressures since then and has been to ___ twice in the last
few weeks. He went to ___ the day prior to admission for
hypotension. They ended up changing the timing of his imdur dose
but made no other medication adjustments. Today he was
reportedly doing the laundry. He said that after he was walking
back with the laundry he felt some mild chest tightness without
radiation or diaphoresis and lightheaded and dizzy. He had to
sit down. The ___ came around this time and took his blood
pressure which was 90/58 and then after a few minutes was 74/44.
At this point he was referred to the ED. He denies any
persistent chest pain, shortness of breath. He had no new
medication changes. He was recently treated for a left toe ulcer
but completed antibiotics. No fevers or chills.
In the ED, initial vitals were 97.5 60 117/56 16 97%
Labs significant for Cr of 1.8, BNP 2769, trops negative x 2.
ECG showed Vpaced rhythm
CXR showed mild vascular congestion.
He was given 500 cc of NS and admitted for further workup and
evaluation.
Vital signs prior to transfer 98.0 70 139/59 18 100% RA
Currently, he feels improved.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. he denies recent fevers, chills or rigors.
he denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations
Past Medical History:
-Coronary artery disease status post myocardial
infarction. Coronary artery bypass graft times five vessels
in ___ at the ___ with left
internal mammary coronary artery to left anterior descending
coronary artery, saphenous vein graft wide graft to the AM
and right coronary artery and an saphenous vein graft to the
diagonal and saphenous vein graft to the obtuse marginal.
PCI times two in ___.
-CHF- EF 20%, s/p BiV pacer
-HLD
-DM2
-Parkinsons (patient says neurologist said he actually has
essential tremors)
-Macular degeneration
-PVD
-Osteoarthritis
-depression
-left leg ulcer/toe infection
Social History:
___
Family History:
father died of cerebral hemorrhage
brothers with heart disease, lymphoma
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.4 148/84 76 18 100% RA
General: comfortable in NAD
HEENT: sclera anicteric, MMM
Neck: supple. JVP not elevated. no cervical lymphadenopathy
CV: RRR. normal s1/s2. systolic murmur heard over left sternal
border
Lungs:clear to auscultation bilaterally
Abdomen: +BS. soft. nt/nd
Ext: no edema. left toe ulcer appears to be well healing
Neuro: A&Ox3. speech is slow. moving all extremities.
Skin: warm and dry
DISCHARGE PHYSICAL EXAM
VS: 96.7 128/79 (100s-140s/60s-70s) 77 (60s-70s) 18 99% on RA
Weight: 89kg
GENERAL: Well-appearing, pleasant male. Oriented x3. Mood,
affect appropriate.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink
NECK: Supple, no JVP elevation.
CARDIAC: RRR, normal S1, S2, soft early systolic murmur at LUSB
that does not radiate, no rubs or gallops.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominal bruits.
EXTREMITIES: No clubbing or edema.
SKIN: B/l lower extremity chronic venous stasis changes.
PULSES:
Right: Carotid 2+ DP 1+
Left: Carotid 2+ DP 1+
Pertinent Results:
ADMISSION LABS
=====================
___ 01:40PM BLOOD WBC-5.3 RBC-4.78 Hgb-14.2# Hct-43.9
MCV-92 MCH-29.8 MCHC-32.4 RDW-16.2* Plt ___
___ 01:40PM BLOOD Neuts-56.3 ___ Monos-7.8 Eos-4.8*
Baso-2.6*
___ 01:40PM BLOOD ___ PTT-37.3* ___
___ 01:40PM BLOOD Glucose-198* UreaN-55* Creat-1.8* Na-133
K-3.5 Cl-96 HCO3-27 AnGap-14
CARDIAC LABS
======================
___ 01:40PM BLOOD proBNP-2769*
___ 01:40PM BLOOD cTropnT-0.02*
___ 08:15PM BLOOD cTropnT-<0.01
IMAGING AND STUDIES
======================
___ ECG
VPaced
___ CXR PA AND LAT
Mild vascular congestion in the setting of moderate
cardiomegaly.
The cardiomegaly appears slightly worsened from ___
DISCHARGE LABS
=======================
___ 05:04AM BLOOD WBC-5.2 RBC-5.20 Hgb-15.2 Hct-47.4 MCV-91
MCH-29.2 MCHC-32.0 RDW-16.3* Plt ___
___ 05:04AM BLOOD Glucose-150* UreaN-46* Creat-1.5* Na-137
K-3.6 Cl-100 HCO3-29 AnGap-12
___ 05:04AM BLOOD Calcium-9.7 Phos-3.2 Mg-1.8
Brief Hospital Course:
Mr. ___ was admitted for dizziness and hypotension. There
were no signs or symptoms of infection, decompensated heart
failure, or autonomic dysfunction. His symptoms were likely due
to his cardiac medications which were adjusted and he was
discharged asymptomatic.
ACTIVE ISSUES
# Hypotension, dizziness
Most likely a result of his mulitple cardiac medications
combined with some decreased PO intake of fluids. He received a
500cc bolus in the ED. Isosorbide mononitrate was stopped, and
home torsemide was held and decreased upon discharge from 20mg
to 10mg daily. He appeared euvolemic on exam, was not
orthostatic, and was discharged without symptoms and with SBP
120s-130s.
# ___
Creatinine on admission elevated to 1.8, decreased to 1.5 which
is more of his basline after a small bolus of fluids. Likely
related to decreased PO intake. Lisinopril initially held but
restarted upon discharge.
# CHF
Ischemic, EF on echo ___ 20%. Euvolemic, no signs of
decompensation on admission. Last noted dry weight from ___
was 222lb, weight on admission 195.8lb. Held lisinopril for 1
day and decreased dose from 20mg to 10mg daily in setting of
intermittent dizziness/hypotension. Restarted lisinopril on
discharge. NP from Dr. ___ will call patient 2 days
after discharge to reassess symptoms, and he already has
follow-up with Dr. ___ 2 weeks after discharge.
# CAD s/p CABG
Cardiac catheterization in ___ with 2-vessel CAD with patent
SVG-RCA and LIMA-LAD. No anginal symptoms upon admission, and
troponins negative x 2. Continued on ASA, clopidogrel,
metoprolol, and added back lisinopril on discharge as above.
CHRONIC ISSUES
# DM, insulin-dependent, c/b neuropathy
- Continue home lantus, humalog
- Continue gabapentin for neuropathy
# GERD
- Continue omeprazole
# Essential tremor
- Continue primidone
TRANSITIONAL ISSUES
- Discontinued isosorbide mononitrate, follow-up anginal
symptoms as outpatient
- Decreased torsemide from 20mg to 10mg daily, follow-up
dizziness/hypotension and edema
- Discharge weight 89kg
- Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 100 mg PO TID
2. Glargine 15 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
3. Aspirin 325 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Metoprolol Tartrate 100 mg PO BID
10. Niacin 100 mg PO BID
11. PrimiDONE 25 mg PO BID
12. QUEtiapine Fumarate 12.5 mg PO QHS
13. Simvastatin 20 mg PO DAILY
14. Torsemide 20 mg PO DAILY
15. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 325 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 100 mg PO TID
6. Glargine 15 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
7. Lisinopril 2.5 mg PO DAILY
8. Metoprolol Tartrate 100 mg PO BID
9. Omeprazole 40 mg PO DAILY
10. PrimiDONE 25 mg PO BID
11. QUEtiapine Fumarate 12.5 mg PO QHS
12. Simvastatin 20 mg PO DAILY
13. Niacin 100 mg PO BID
14. Torsemide 10 mg PO DAILY
RX *torsemide 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: hypotension
Secondary: CHF, CAD, HTN, HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to ___ for dizziness and low blood
pressures. You received some fluids. Your low blood presure was
caused by the many cardiac medications that you are on for your
heart failure and heart disease. We have stopped your isosorbide
mononitrate and decreased the dose of your torsemide (water
pill). You did not have recurrence of symptoms or low blood
pressures while hospitalized, and your blood pressure did not
drop when standing. Please be sure to keep the follow up
appointments as below. If you have recurrence of dizziness or
low blood pressure, have your visiting nurse ___ Dr. ___
___ office first, unless it is an emergency and in
that case you should call ___. Weigh yourself every morning,
call Dr. ___ if weight goes up more than 3 lbs.
Followup Instructions:
___
|
10900387-DS-33
| 10,900,387 | 27,980,114 |
DS
| 33 |
2146-11-21 00:00:00
|
2146-11-21 17:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"epigastric pain, nausea, vomiting, loose stools."
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old gentleman with HIV (CD4 619 on ___, HIV-1 RNA
undetectable ___, HCV (viral load 61,900 IU/mL ___,
ESRD on dialysis ___, history of cryoglobulinemia,
comes with epigastric pain. He was recently admitted in ___
for recurring bilateral swelling and erythema on the dorsal
aspect of both feet for which skin biopsy was done and showed
findings suggestive of eosinophilic fasciitis (left against
medical advise on that admission).
.
His abdominal pain for this admission prevented him from
completing his dialysis today. He only finished about one hour
thereof. Then, he has had central abdominal pain radiating to
the lower quadrants associated with loose stools (yellowish, no
blood), nausea, vomiting (yellowish, no blood). Of note, 2 days
ago he had similar symptoms and went to ___ and
per outside hospital report had CT abdomen-pelvis without
contrast and showed finding suggestive of questionable mild
sigmoid colitis in the right clinical setting.
.
In the ED Initial vitals were: 99.2 83 ___ RA. He
complained of sharp constant abdominal pain since ___,
subjective fever and chills, reported nausea, vomiting, diarrhea
with dysuria. No CP, no SOB. Had HD PTA [Completed by ___
___. EKG showed SR 81, TWI in II, minimal ST depression
II,III,aVF and biphasic T wave in V2 compared to prior. Liver
enzymes, Tpn CKMB x1 normal. UA and coagulation profile
unremarkable. Cr 4.7 K 3.6. Patient on probation has ankle
bracelet. Probation officer ___ (___)
notified of admission. Patient received nitro SL 0.4 x1 for
chest pain but developed headache. Afterwards, he received
morphine 4mg iv x 2, dilaudid 1mg iv x 2, zofran IV 4 mg. Given
questionable colitis at outside hospital, flagyl 500 IV and
cipro 400 IV were administered. He took his hypertension
medications on admission day but then vomited. He received IV
metoprolol 5 mg x2 for hypertension. He was seen by renal and
decided to get him hemodialysis the next day (patient refused
afterwards to be dialyzed the next day morning). Vitals on
transfer were: 98.1 87 ___ 99% RA.
Past Medical History:
1. HIV - He was diagnosed with HIV in ___. Risk factors
included unprotected heterosexual sex as well as intravenous
drug use. His nadir CD4 count is 91 and he has no known
opportunistic infections. Last viral load undetectable, CD4 556
(___).
2. Hepatitis C. Genotype 1B. Viral load 187,000 in ___.
3. Cryoglobulinemia
4. Cardiomyopathy with an EF of 45-50%.
5. Chronic renal insufficiency - MPGN by biopsy in ___ and
hypertensive nephrosclerosis
5. GERD.
6. Hypertension.
7. Gynecomastia; s/p bilateral gynecomastia excision with
liposuction ___.
8. Polysubstance abuse, including cocaine and alcohol.
9. Anemia, hematocrit ___.
10. Hypertriglyceridemia - ___ 282 in ___
11. Right hydrocele.
12. A subacute infarct in the right caudate head seen on MRI in
___. Influenza B, ___.
14. Erectile dysfunction.
15. Depression
16. Inguinal hernia repair in ___.
17. Left ankle ORIF in ___.
18. Appendectomy in ___.
Social History:
___
Family History:
Mother and father have hypertension; has 3 bros, 3 sis: all
healthy, none with HTN. There is also a family history of type 2
diabetes mellitus. No family history of sudden death and
premature atherosclerotic cardiovascular disease.
Physical Exam:
Admission physical exam:
Vitals: T: 98.9 BP: 224/114 (on repeat 160/90) P: 71 R: 20 O2:
99%RA
General: Alert, oriented, no acute distress but in pain and
talks with closed eyes
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, ___ ESM best heard
at ___ but heard throughout the precordium, no rubs, gallops
Abdomen: soft, tender epigastrium, unable to appreciate prior
documented epigastric hernia given patient's severe discomfort
upon palpation of the epigastrium, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
.
Discharge vital signs:
T 99.2, BP 151/70, HR 89, RR 12, Sat 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, ___ ESM best heard
at ___ but heard throughout the precordium, no rubs, gallops
Abdomen: soft, NTND, active BS
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
Labs:
___ 08:41AM BLOOD WBC-9.7 RBC-3.46* Hgb-11.1* Hct-32.3*
MCV-93 MCH-32.0 MCHC-34.4 RDW-14.6 Plt ___
___ 08:41AM BLOOD Neuts-80.7* Lymphs-11.4* Monos-6.0
Eos-1.3 Baso-0.6
___ 09:59AM BLOOD ___ PTT-34.7 ___
___ 08:41AM BLOOD WBC-9.7 Lymph-11* Abs ___ CD3%-57
Abs CD3-604 CD4%-40 Abs CD4-422 CD8%-16 Abs CD8-173* CD4/CD8-2.4
___ 08:41AM BLOOD Glucose-86 UreaN-42* Creat-4.7*# Na-143
K-3.6 Cl-96 HCO3-33* AnGap-18
___ 07:32AM BLOOD UreaN-54* Creat-6.2*# Na-139 K-4.1 Cl-96
___ 07:32AM BLOOD Calcium-8.8 Phos-4.3 Mg-2.4
___ 08:41AM BLOOD ALT-22 AST-32 CK(CPK)-331* AlkPhos-106
TotBili-0.5
___ 05:55PM BLOOD CK(CPK)-206
___ 07:32AM BLOOD CK(CPK)-148
___ 08:41AM BLOOD cTropnT-0.01
___ 05:55PM BLOOD CK-MB-2 cTropnT-0.01
___ 07:32AM BLOOD CK-MB-2 cTropnT-0.01
___ 08:41AM BLOOD Lipase-111*
___ 08:45AM BLOOD Lactate-1.4
.
Urine:
___ 08:44AM URINE Blood-NEG Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-NEG
___ 08:44AM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 08:44AM URINE Color-Yellow Appear-Clear Sp ___
___ 08:44AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
CXR PA and LAT:
FINDINGS: The heart is mildly enlarged. Mediastinal and hilar
contours
appear unchanged. There is no pleural effusion or pneumothorax.
There is
some mild prominence of upper zone pulmonary vessels suggesting
slight fluid overload or pulmonary venous hypertension. These
findings are less prominent than on the prior examination,
however. Otherwise, the lungs appear clear. The bony structures
were unremarkable.
IMPRESSION: Mild pulmonary vascular prominence, but similar to
baseline.
Brief Hospital Course:
___ year old gentleman with HIV (CD4 619 on ___, HIV-1 RNA
undetectable ___, HCV (viral load 61,900 IU/mL ___,
ESRD on dialysis ___, history of cryoglobulinemia,
comes with epigastric pain, nausea, vomiting, loose stools
concerning for viral gastroenteritis, refused dialysis on
___ and agreed to do dialysis at his dialysis center on
___. Discharged home in stable condition.
.
# Abdominal pain: symptoms concerning of viral gastroenteritis.
Also has history of small epigastric midline hernia. Lipase was
111 and outside hospital CT abdomen does not report
pancreatitis. EGD in ___ was normal. We provided tylenol for
pain control and did not give further opioids on the floor.
Mesenteric ischemia and volume shifts during Hd were also
considered as etiologies but were less likely given rapid
improvement with supportive care
.
# Hypertensive urgency: Has history of difficult to control
hypertension. Morning of admission he took his medications but
vomited. Received IV metoprolol 5 mg x2 in the ED with
relatively good response on the floor. On the floor he received
IV hydral 10 mg in addition to gradual initiation of his home
medications.
.
# HCV/HIV: Continued on his home meds. Repeat CD4 count 422.
.
# CKD, stage V, ESRD on HD: Renal team was involved. He refused
dialysis on ___ and agreed to go to his dialysis center
for dialysis on ___. Electrolytes were stable.
.
# Chronic Anemia: Patient with chronic anemia over several
years.
Likely related to ESRD, HIV and/or Hep C. Stable without
evidence of bleeding.
.
.
# Transitional issues:
- please follow up blood cultures from ___
- Follow up with PCP ___ ___ weeks
- routine follow up with Renal phyicians
Medications on Admission:
Medications: confirmed with patient
-ABACAVIR [ZIAGEN] - 600 mg daily
-CARVEDILOL - 50mg BID
-CLONIDINE - 0.4 mg TID
-EFAVIRENZ [SUSTIVA] - 600 mg daily
-Emtricitabine 200mg ___ and ___ after dialysis
-HYDRALAZINE - 100 mg q8H
-ISOSORBIDE MONONITRATE ER - 30 mg daily
-METHADONE - 30mg daily (reports not taking it anymore)
-NIFEDIPINE ER- 60 mg BID
-OMEPRAZOLE - 20 mg BID
-PROCHLORPERAZINE MALEATE - ___ mg PRN, take 30 minutes prior
to
Sustiva/Ziagen/Epivir
-TERAZOSIN - 3 mg qHS
-ASCORBIC ACID [VITAMIN C] - 500 mg BID
-ASPIRIN - 81 mg daily
-B COMPLEX-VITAMIN C-FOLIC ACID [___] - 0.8 mg daily
-DOCUSATE SODIUM [COLACE] - 100-200 mg BID
Discharge Medications:
1. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day.
3. clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. emtricitabine 200 mg Capsule Sig: One (1) Capsule PO 2X/WEEK
(___): after dialysis, every ___ and ___ .
6. hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
7. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
8. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO twice a day.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
10. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO
once a day as needed for nausea: take 30 minutes prior to
Sustiva/Ziagen/Epivir
.
11. terazosin 1 mg Capsule Sig: Three (3) Capsule PO at bedtime.
12. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day.
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. B complex-vitamin C-folic acid 0.8 mg Tablet Sig: One (1)
Tablet PO once a day.
15. docusate sodium 100 mg Capsule Sig: ___ Capsules PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
gastroenteritis
epigastric hernia
end stage renal disease on dialysis
Hypertensive urgency
Secondary Diagnoses:
HIV
HCV
Cardiomyopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were admitted to ___ for
abdominal pain. Your symptoms were consistent with a viral
illness leading to nausea, vomiting and loose stools. It seems
your belly pain is secondary to your epigastric hernia.
You refused to do hemodialysis on ___ and you agreed to do
your dialysis at the dialysis center on ___.
We did not make changes in your medication list. Please continue
taking your home medications the way you were taking them at
home prior to admission.
Please follow with your appoinmtments as illustrated below.
Followup Instructions:
___
|
10900387-DS-36
| 10,900,387 | 22,791,179 |
DS
| 36 |
2147-11-30 00:00:00
|
2147-12-07 16:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Cough and fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with HIV (CD4 447 ___, Hep C, ESRD on
HD who presented to the ED complaining of fever and cough for
four days. He reports associated myalgias, nasal congestion and
cough, headache and abdomnal pain. Pt reports the symptoms
started four days prior, however he was seen at his PCP's office
on ___ with similar symptoms. Temperature as high as 101 at
home. No headache, neck pain, neck stiffness, photophobia. He
also had a fall last week when it was snowing and injured his
left anklee. No chest pain, shortness of breath.
In the ED, initial VS were: T100.0 81 145/69 20 95% RA. He had a
CXR which showed LLL consolidation concerning for pneumonia and
was given 750 mg IV levofloxacin. Given his abdominal pain he
had a CTAb/pelvis which showed no acute process. Given ankle
pain and swelling he had an ankle x-ray that showed no fracture.
He was admitted to medicine. VS on transfer: 99.2 87 155/100 16
95%.
Currently patient continues to complain of cough and general
malaise. He has a slight headache but no neck stiffness,
photophobia. He no longer has any abdominal pain. No nausea,
vomiting, diarrhea.
REVIEW OF SYSTEMS:
(+) per HPI
(-) night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, nausea, vomiting, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
1. HIV - He was diagnosed with HIV in ___. Risk factors
included unprotected heterosexual sex as well as intravenous
drug use. His nadir CD4 count is 91 and he has no known
opportunistic infections.
2. Hepatitis C. Genotype 1B. Viral load 187,000 in ___.
3. Cryoglobulinemia
4. Cardiomyopathy with an EF of 45-50%.
5. Chronic renal insufficiency - MPGN by biopsy in ___ and
hypertensive nephrosclerosis
5. GERD.
6. Hypertension.
7. Gynecomastia; s/p bilateral gynecomastia excision with
liposuction ___.
8. Polysubstance abuse, including cocaine and alcohol.
9. Anemia, hematocrit ___.
10. Hypertriglyceridemia - ___ 282 in ___
11. Right hydrocele.
12. A subacute infarct in the right caudate head seen on MRI in
___. Influenza B, ___.
14. Erectile dysfunction.
15. Depression
16. Inguinal hernia repair in ___.
17. Left ankle ORIF in ___.
18. Appendectomy in ___.
Social History:
___
Family History:
Mother and father have hypertension; has 3 brothers, 3 sisters:
all healthy, none with HTN. There is also a family history of
type 2 diabetes mellitus. No family history of sudden death and
premature atherosclerotic cardiovascular disease.
Physical Exam:
Admission Exam
VS: 99.3, 170/90, 86, 20, 95% on RA
GENERAL: Appears comfortable, walking around the floor, in no
acute distress
HEENT: NC/AT, PERRLA, injected sclera, EOMI, MMM
NECK: supple, no LAD
LUNGS: LLL crackles and rhonchi, diffuse b/l expiratory wheezing
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, mild right-sided tenderness
to palpation, non-distended, no rebound or guarding, no masses
EXTREMITIES: LLE with 2+ edema, no clubbing/cyanosis, fistula on
LUE with palpable thrill
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Discharge Exam
VS: 98.7, 143/87, 70, 14, 96% on RA
GENERAL: Lying in bed watching dvd
HEENT: NC/AT, PERRLA, injected sclera with puffy eyes, EOMI, MMM
NECK: supple, no LAD, distended JVD
LUNGS: Diffuse crackles and rhonchi, diffuse b/l expiratory
wheezing
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, mild right-sided tenderness
to palpation, non-distended, no rebound or guarding, no masses
EXTREMITIES: LLE with 2+ edema, no clubbing/cyanosis, fistula on
LUE with palpable thrill
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
Admission Labs
___ 02:35PM WBC-7.4 RBC-4.47* HGB-12.5* HCT-39.9* MCV-89
MCH-27.9 MCHC-31.2 RDW-15.2
___ 02:35PM NEUTS-76.8* LYMPHS-11.9* MONOS-8.1 EOS-2.6
BASOS-0.7
___ 02:35PM PLT COUNT-321
___ 02:35PM ___ PTT-39.2* ___
___ 02:35PM GLUCOSE-152* UREA N-43* CREAT-6.9*#
SODIUM-141 POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-28 ANION GAP-19
___ 02:35PM estGFR-Using this
___ 02:35PM ALT(SGPT)-13 AST(SGOT)-18 ALK PHOS-108 TOT
BILI-0.3
___ 02:35PM LIPASE-24
___ 02:35PM ALBUMIN-3.5
___ 02:52PM LACTATE-1.5
Discharge Labs
___ 07:00AM BLOOD WBC-8.4 RBC-4.20* Hgb-12.0* Hct-37.5*
MCV-89 MCH-28.6 MCHC-32.0 RDW-15.1 Plt ___
___ 07:00AM BLOOD Glucose-130* UreaN-53* Creat-6.9*# Na-136
K-5.0 Cl-99 HCO3-24 AnGap-18
___ 07:40AM BLOOD ALT-13 AST-23 AlkPhos-101 TotBili-0.4
___ 07:00AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.4
Micro
**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.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
Blood Cultures x 2 - negative, final
Reports
CT Abdomen/Pelvis
IMPRESSION:
1. Left lower lobe pneumonia.
2. No acute intra-abdominal process.
3. Body wall edema, mesenteric haziness and periportal edema.
Findings
suggest fluid overload.
4. Bilateral iliac artery aneurysms, unchanged from ___.
CXR
IMPRESSION: Findings worrisome for left lower lobe pneumonia.
Persistent
cardiomegaly.
Brief Hospital Course:
Impression: ___ yo M w/ PMH of HIV, HCV, ESRD on HD who presented
with fever, cough, myalgias for four days, found to have
evidence of pneumonia on CXR, treated for HCAP.
#Pneumonia- patient with cough and found to have new infiltrate
on CXR, that appears to be a lobar pneumonia and not diffuse
infiltrates. He was not at risk for PCP given his current CD4
count that was checked 1 week prior and therefore did not
necessitate induced sputum to rule this out at this time. He was
recnetly incarcerated and has HIV which puts him at increased
risk for TB, but the acute onset symptoms did not seem
consistent with TB. Given the patient is dialysis dependent, he
qualified for HCAP. He was treated with Vancomycin, Cefepime,
and Levofloxacin, all renally dosed. Cefepime was transitioned
to ceftazidime for ease of post HD dosieng as an outpatient.
Patient is to complete an ___s seen in the results
section, there was no positive microbiology to narrow down
antibiotics.
#Abdominal pain- likely secondary to LLL pneumonia given vague
nature and onset of symptoms a few days after onset of cough. CT
A/P was unremarkable. Given his cardiomyopathy, an EKG was
checked which did not show ischemic changes. LFTs were normal.
Patient's abdominal pain improvement with treatment of his
pneumonia.
# Fever/Body Aches- patient was just recently seen by his PCP ___
___ and was swabbed for flu at that time, but it was not an
adequate specimen. Currently having four days of influenza-like
symptoms. Focal consolidation could potentially represent
influenza. The repeat respiratory viral panel was negative.
These symptoms were attributed to his pneumonia
#HIV- patient is well controlled on his current regimen with
last CD4 count of 447 and VL undetectable. We continued home
regimen HAART
#ESRD- continued dialysis this admission
#Hypertension: Continued home regimen carvedilol, clonidine,
hydralazine, isosorbide, nifedipine, terazosin
#Left leg swelling: Following fall in snow in ankle patient
previously had surgery on. No DVT or evidence of fracture.
Advised patient elevation and ice packs to LLE
#GERD: Continued home omeprazole
Transitional Issues
-Patient continued to take Levofloxacin PO to complete ___dditionally, he was to get IV doses of Vancomycin and
Cefepime post ID to complete 8 day course
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Terazosin 3 mg PO HS
2. Carvedilol 50 mg PO BID
Hold for SBP < 100, HR < 60
3. Abacavir Sulfate 600 mg PO DAILY Start: In am
4. Emtricitabine 200 mg PO 2X/WEEK (___)
Every ___ and ___ after dialysis.
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. HydrALAzine 100 mg PO Q8H
Hold for SBP <100
7. Ibuprofen 600 mg PO Q12H:PRN pain
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Start: In am
Hold for SBP <100
9. NIFEdipine CR 60 mg PO BID
Hold for SBP < 100
10. Omeprazole 20 mg PO DAILY Start: In am
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
12. traZODONE 50 mg PO HS:PRN insomnia
13. Aspirin 81 mg PO DAILY
14. CloniDINE 0.2 mg PO TID
Hold for SBP < 100
15. Efavirenz 600 mg PO DAILY
Discharge Medications:
1. Abacavir Sulfate 600 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Carvedilol 50 mg PO BID
Hold for SBP < 100, HR < 60
4. CloniDINE 0.2 mg PO TID
Hold for SBP < 100
5. Efavirenz 600 mg PO DAILY
6. Emtricitabine 200 mg PO 2X/WEEK (___)
Every ___ and ___ after dialysis.
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. HydrALAzine 100 mg PO Q8H
Hold for SBP <100
9. Ibuprofen 600 mg PO Q12H:PRN pain
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Hold for SBP <100
11. NIFEdipine CR 60 mg PO BID
Hold for SBP < 100
12. Omeprazole 20 mg PO DAILY
13. sevelamer CARBONATE 800 mg PO TID W/MEALS
14. Terazosin 3 mg PO HS
15. traZODONE 50 mg PO HS:PRN insomnia
16. CefTAZidime 1 g IV POST HD
RX *ceftazidime-dextrose (iso-osm) [Fortaz in dextrose 5 %] 1
gram/50 mL 1 g(s) POST HD Disp #*2 Bottle Refills:*0
17. Levofloxacin 250 mg PO DAILY
RX *levofloxacin [Levaquin] 250 mg 1 tablet(s) by mouth daily
Disp #*4 Tablet Refills:*0
18. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth q 4 hrs prn Disp #*42
Tablet Refills:*0
19. Vancomycin 1000 mg IV HD PROTOCOL
RX *vancomycin 1 gram 1 gram post HD Disp #*2 Tube Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
-Health care associated pneumonia
Secondary
-HIV
-Cardiomyopathy
-End stage renal disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to ___ for pneumonia. We treated you
with 3 strong antibiotics and you slowly improved. You also
received dialysis while you were here.
Please continue to get the vancomycin and ceftazadine at the
next tow dialysis sessions and continue taking the levofloxacin
for the next four days ( an oral antibiotic you can take at
home).
If you are still having pain, please take tramadol as directed
on your prescription.
Please make sure to follow up with Dr. ___ at your
appointment scheduled below
Followup Instructions:
___
|
10900387-DS-37
| 10,900,387 | 29,962,010 |
DS
| 37 |
2147-12-14 00:00:00
|
2147-12-15 21:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
lower extremity pain and swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS: ___ with HIV, HCV , ESRD on
dialysis, HCAP on vanc/ceftaz with HD who presents with multiple
days of worsening LLE pain, swelling and erythema. It was noted
by his nephrologist at his dialysis sessiono n ___ and was
decided to monitor as there was no erythema at that time and he
had just had ___ which was negative for DVT. Pt reports that
his left ankle normally looks symmetric to his right ankle, and
that over the past ___ days it has increased in size and he has
developed pain in his ankle and his left shin and noticed some
redness. He reports coming to the emergency room because his
nephrologist saw it at dialysis on ___ and was concerned
about it. He denies any fevers or chills, no nauase, or
vomiting. Denies cough, shortness of breath, chest pain or
palpitations. He is not sure if he is still getting IV
antibiotics at dialysis.
In the ED, initial VS were: 98.8 80 123/68 20 96% RA. In the ED
he had LENIs which were ngative for fluid collection or DVT but
did note that he has extensive atherosclerotic plaque. He was
given 600mg clindamycin and 5mg iV morphine and admitted for
management of his cellulitis.
On arrival to the floor the patient is complaining of pain in
his left leg.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
1. HIV - He was diagnosed with HIV in ___. Risk factors
included unprotected heterosexual sex as well as intravenous
drug use. His nadir CD4 count is 91 and he has no known
opportunistic infections.
2. Hepatitis C. Genotype 1B. Viral load 187,000 in ___.
3. Cryoglobulinemia
4. Cardiomyopathy with an EF of 45-50%.
5. Chronic renal insufficiency - MPGN by biopsy in ___ and
hypertensive nephrosclerosis
5. GERD.
6. Hypertension.
7. Gynecomastia; s/p bilateral gynecomastia excision with
liposuction ___.
8. Polysubstance abuse, including cocaine and alcohol.
9. Anemia, hematocrit ___.
10. Hypertriglyceridemia - ___ 282 in ___
11. Right hydrocele.
12. A subacute infarct in the right caudate head seen on MRI in
___. Influenza B, ___.
14. Erectile dysfunction.
15. Depression
16. Inguinal hernia repair in ___.
17. Left ankle ORIF in ___.
18. Appendectomy in ___.
Social History:
___
Family History:
Mother and father have hypertension; has 3 brothers, 3 sisters:
all healthy, none with HTN. There is also a family history of
type 2 diabetes mellitus. No family history of sudden death and
premature atherosclerotic cardiovascular disease.
Physical Exam:
On Admission:
VS: 98.4, 177/99, 83, 18, 94%RA wt 69.2kg
GENERAL: well appearing male in NAD, walking around putting away
his clothes
HEENT: PEERLA< MMM, scattered pinpoint red macules on his buccal
mucosa
NECK: supple, no LAD
LUNGS: CTA bilaterally
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: left leg with ankel that is ___ the size of the
right ankle, most swelling in located on the medial portion.
Limited ROM, but able to move in all directions actively. Able
to move toes, tender to palpation of the left lateral maleolus.
+fluid wave over the dorsum of the ankle. Nonpitting edema. Left
anterior shin is shiny with mild pink erythema hue and a focal
area of darker red erythema that is the siiee of a quarter. mild
tenderness to palpation of the area. No open areas are present
on the left. Left lateral malleolus with intact old scar from
ORIF.
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, gait is
stable
On Discharge:
VS: 98.7/97.5, 156/87 (124-156), 67, 16, 100%RA
GENERAL: well appearing male in NAD
HEENT: EOMI, MMM
LUNGS: CTA bilaterally
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: LUE with AVF, +thrill. Left leg with less ankle
swelling. Nonpitting edema with hyperpigmentation to anterior
and lateral tibia. Tenderness to palpation to lateral leg, also
with induration. No open areas are present on the left. Left
lateral malleolus with well-healed surgical scar from ORIF.
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, gait
deferred
Pertinent Results:
Admission labs:
___ 08:55PM BLOOD WBC-7.1 RBC-4.09* Hgb-11.4* Hct-36.2*
MCV-89 MCH-27.8 MCHC-31.4 RDW-15.4 Plt ___
___ 08:55PM BLOOD Neuts-67.6 Lymphs-15.4* Monos-12.0*
Eos-4.2* Baso-0.7
___ 01:50PM BLOOD ___ PTT-40.1* ___
___ 08:55PM BLOOD Glucose-121* UreaN-35* Creat-6.2* Na-144
K-4.2 Cl-98 HCO3-33* AnGap-17
___ 01:50PM BLOOD Calcium-8.4 Phos-6.2*# Mg-2.6
___ 08:55PM BLOOD CRP-28.4*
___ 08:55PM BLOOD Vanco-22.1*
___ 09:04PM BLOOD Lactate-1.2
Micro:
___ Bcx- no growth to date
Studies:
___ Left ___
IMPRESSION:
1. No evidence of left lower extremity deep venous thrombosis.
2. Calcified atherosclerotic plaque throughout the arterial
system in the
lower extremity.
3. Soft tissue edema without any drainable fluid collection.
___ CXR
FINDINGS: Frontal and lateral views of the chest demonstrate
cardiomegaly.
The lungs are clear. Left lower lobe opacities previously
visualized appear
to have resolved. No pneumothorax or effusion.
IMPRESSION: Resolution of left lower lobe pneumonia.
___ L ankle radiograph
The patient is status post lateral plate and screws for fixation
of a distal
fibular fracture with hardware appearing similar to the prior
study and no
visible fracture line or dislocation. There is heterotopic
ossification
along the syndesmosis and ankle mortise appear similar compared
to the prior
study. there is a small amount of soft tissue swelling.
IMPRESSION:
plate and screws through the distal fibular fracture. No acute
fracture seen
Discharge labs:
___ 05:44AM BLOOD WBC-7.0 RBC-3.90* Hgb-10.9* Hct-34.8*
MCV-89 MCH-27.8 MCHC-31.3 RDW-15.8* Plt ___
___ 05:44AM BLOOD Glucose-95 UreaN-47* Creat-7.4* Na-140
K-5.0 Cl-97 HCO3-27 AnGap-21*
___ 05:44AM BLOOD Calcium-8.9 Phos-7.1* Mg-2.6
___ 08:03AM BLOOD Vanco-14.9
Brief Hospital Course:
Mr. ___ is a ___ yo M w/ HIV, HCV, ESRD on Dialysis, HTN and
s/p ORIF to his left ankle who presents with swelling, erythema
and pain of his left leg consistent with cellulitis.
# Cellulitis: Left leg with impressive swelling and tenderness.
Radiographs showed no fracture or impressive joint space. Left
sided doppler showed no DVT or drainable fluid collection.
Patient did not spike fevers. With elevation and antibiotics,
the swelling improved significantly. Patient's primary
nephrologist reported that current swelling was much improved
compared to week prior (had extra week of vancomycin at HD after
HCAP treatment completed given nephrologist's concern for
cellulitis). Initially patient was put on vanc/ceftaz and
clindamycin for anaerobic coverage. This was narrowed to
vancomycin at time of discharge and patient is to complete
another week of IV vanc with HD, end date on ___. The
patient's nephrologist was notified with plan and patient was
discharged with significant improvement in pain and swelling.
Patient will follow-up with PCP to discuss possible compression
stockings.
#NSVT: Patient had 12 beats of ventricular tachycardia while
receiving HD on day of discharge. Patient was also symptomatic
during this episode where he felt palpitations. As per patient
these symptoms recur about twice a week and are long-standing.
The rhythm strip was shown to the patient's outpatient
cardiologist, Dr. ___. Given patient was already of maximum
dose of beta blocker, no further changes were made to medication
list and patient is to follow-up with cardiology as outpatient
as per Dr. ___.
#HCAP: Patient was diagnosed with HCAP on his last admission and
was underoing an ___XR appears to have improved LLL
infiltrate.
# HIV: patient is well controlled on his current regimen with
last CD4 count of 447 and VL undetectable. Continued home HAART
regimen.
# ESRD: MWF. He was euvolemic on exam on admission. Continued HD
in house according to ___ schedule.
# Hypertension: patient was hypertensive on arrival to the
floor. Continued home regimen home regimen carvedilol,
clonidine,
hydralazine, isosorbide, nifedipine, terazosin
# GERD: Continued home omeprazole
Transitional issues:
-Patient is to complete IV vancomycin with HD on ___
-Patient is to continue leg elevation and will f/u with PCP to
discuss compression stocking fitting and further pain management
-Patient is to follow-up with Dr. ___ for further
management of palpitations/NSVT
-Patient is to continue HD ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Abacavir Sulfate 600 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Carvedilol 50 mg PO BID
hold for sbp<100 or hr<60
4. CloniDINE 0.4 mg PO TID
hold for sbp<100 or hr<60
5. Efavirenz 600 mg PO DAILY
6. Emtricitabine 200 mg PO ___
7. HydrALAzine 100 mg PO TID
hold for sbp<100 or hr<60
8. Ibuprofen 600 mg PO Q12H:PRN pain
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for sbp<100
10. NIFEdipine CR 60 mg PO BID
hold for sbp<100 or hr<60
11. Omeprazole 20 mg PO BID
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
13. Terazosin 3 mg PO HS
hold for sbp<100
14. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
15. Vancomycin IV Sliding Scale
with dialysis
16. CefTAZidime Dose is Unknown IV POST HD
with dialysis
17. Minoxidil 2.5 mg PO DAILY
Discharge Medications:
1. Abacavir Sulfate 600 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Carvedilol 50 mg PO BID
4. CloniDINE 0.4 mg PO TID
5. Efavirenz 600 mg PO DAILY
6. Emtricitabine 200 mg PO ___
7. HydrALAzine 100 mg PO TID
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. NIFEdipine CR 60 mg PO BID
10. sevelamer CARBONATE 800 mg PO TID W/MEALS
11. Terazosin 3 mg PO HS
12. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
13. Vancomycin IV Sliding Scale
end ___
14. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Q6H PRN Disp #*16 Tablet
Refills:*0
15. Omeprazole 20 mg PO BID
16. Minoxidil 2.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
Human immunodeficiency virus infection
End stage renal disease
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 for a skin infection of your left leg called
cellulitis. You did well with antibiotics and leg elevation.
Ultrasound of your leg showed no clots in your veins and x-rays
showed no fracture. After the infection is treated, you may
benefit from compression stockings- please discuss this with
your primary care doctor.
Please continue to follow-up with your outpatient providers and
continue hemodialysis on ___.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Also, please follow-up with your heart doctor, ___ to
discuss your palpitations. Continue to take your blood pressure
and heart rate medications.
Followup Instructions:
___
|
10900387-DS-40
| 10,900,387 | 27,228,814 |
DS
| 40 |
2148-09-04 00:00:00
|
2148-09-04 16:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypoxic respiratory failure, leg pain
Major Surgical or Invasive Procedure:
Intubation for respiratory failure
History of Present Illness:
___ with h/o HIV, ESRD on dialysis MWF, sCHF, HTN, and recurrent
cellulitis presets with pain, redness, and swelling in bilateral
feet since this AM. Pt has had similar symptoms with prior
episodes of cellulitis. Pt noted fever, chills, sweats. On
initial presentation, he denied CP, SOB, N/V, HA, back pain.
Left ___ was more painful than the right.
His initial vital signs in the ED were 99.4 ___ 16 92%.
Labs in the ED were significant for: WBC 16.6 (83%PMN), K+5.4,
HCO3- 28, BUN 60, Cr 9.4, Anion Gap 22, lactate 1.6
His initial CXR was unremarkable. Bilateral LENIs were negative
for DVT.
He was given a dose of vancomycin and a 200cc fluid bolus.
Shortly after this, he became hypoxic to the low ___ w/
worsening dyspnea. His exam was concerning for flash pulmonary
edema. He was briefly trialed on BiPAP, but the patient did not
tolerate this. He became progressively hypoxic and dyspneic on
NRB, so he was intubated for hypoxic respiratory failure. Repeat
CXR showed frank pulmonary edema. A nitroglycerin gtt was
started. Despite maximum dosing of nitro gtt, his SBPs remained
elevated in the 190s.
At time of transfer, his vital signs were 101.8 ___ 20
96% on vent.
On arrival to the MICU, pt. is intubated and sedated. BP was
improved to SBPs in the 130s.
Past Medical History:
1. HIV: Most recent CD4 is 447. He was diagnosed with HIV in
___. Risk factors included unprotected heterosexual sex as well
as intravenous drug use. His nadir CD4 count is 91 and he has no
known opportunistic infections.
2. Hepatitis C genotype 1B
3. Cryoglobulinemia
4. Cardiomyopathy with an EF of 45-50%
5. ESRD on HD on MWF
5. Hypertension
6. GERD
7. Gynecomastia; s/p bilateral gynecomastia excision
8. Polysubstance abuse, including cocaine, heroin, and alcohol
9. Anemia
10. Hypertriglyceridemia
11. Right hydrocele
12. A subacute infarct in the right caudate on MRI in ___
13. Influenza B ___
14. Erectile dysfunction
15. Depression
16. Inguinal hernia repair in ___
17. Left ankle ORIF in ___
18. Appendectomy in ___
Social History:
___
Family History:
Per OMR. Mother and father have hypertension; has 3 brothers, 3
sisters: all healthy, none with hypertension. There is also
family history of type 2 diabetes. No family history of sudden
death and premature atherosclerotic disease.
Physical Exam:
ADMISSION:
Vitals- 101.8 136/83 87 97% on FiO2 50%
General- chronically ill-appearing man, intubated, sedated
HEENT- PERRL, sclerae anicteric
Neck- JVP elevated to mandible w/ patient at 45 degrees
CV- RRR, no m/r/g, normal S1/S2
Lungs- b/l inspiratory crackles upon anterior auscultation
Abdomen- soft, non-distended, NABS, no organomegaly
Ext- venous stasis changes over b/l lower extremities to
mid-shin level. Very mild erythema overlying b/l LEs to mid-shin
level. 1+ pitting edema to mid-shin level. 2+ distal pulses b/l.
Neuro- sedated on propofol
DISCHARGE:
Vitals- afebrile, VSS (SBP 100s-130s) saO2 100% RA
General- chronically ill-appearing man
HEENT- PERRL, sclerae anicteric
CV- RRR, no m/r/g, normal S1/S2
Lungs- diffuse expiratory wheezes
Abdomen- soft, non-distended, tender to deep palpation of RLQ
Ext- ill-defined purple purpura on bilateral lower extremities
Neuro- A+O to person, place, year and month. CN's II-XII intact.
Strength and sensation intact
Pertinent Results:
ADMISSION:
___ 10:30PM BLOOD WBC-16.6*# RBC-3.94* Hgb-11.9* Hct-38.0*
MCV-97 MCH-30.3 MCHC-31.4 RDW-14.9 Plt ___
___ 10:30PM BLOOD Neuts-83.6* Lymphs-7.6* Monos-8.3 Eos-0.4
Baso-0.3
___ 10:30PM BLOOD ___ PTT-39.9* ___
___ 10:30PM BLOOD Glucose-101* UreaN-60* Creat-9.4*# Na-141
K-5.4* Cl-91* HCO3-28 AnGap-27*
___ 10:30PM BLOOD ALT-14 AST-35 CK(CPK)-90 AlkPhos-93
TotBili-0.4
___ 10:30PM BLOOD cTropnT-0.05*
___ 04:00AM BLOOD Calcium-8.5 Phos-9.8*# Mg-2.7*
___ 06:00PM BLOOD CRP-152.3*
___ 09:21AM BLOOD C3-99 C4-37
___ 01:13AM BLOOD ___ pO2-63* pCO2-54* pH-7.39
calTCO2-34* Base XS-5 Intubat-NOT INTUBA
___ 10:40PM BLOOD Lactate-1.6
___ 01:13AM BLOOD O2 Sat-86
REPORTS:
ECHO: The left atrium is mildly dilated. The estimated right
atrial pressure is at least 15 mmHg. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is moderate to severe global left
ventricular hypokinesis (LVEF = 30 %). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). 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. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the left ventricular ejection farction is further reduced.
Patent ductus arteriosus not visualized. The prior study
suggests the presence of both patent ductus arteriosus and
possible left coronary artery to pulmonary artery fistula.
However, neither anomaly was visualized in the present study.
CXR:
IMPRESSION:
1) Marked cardiomegaly again seen.
2) Interval improvement in previously seen CHF, LLL collapse,
and pleural
effusion.
3) Right paratracheal soft tissue density, unchanged.
HOSPITALIZATION & DISCHARGE:
___ 04:00AM BLOOD WBC-17.2* RBC-3.58* Hgb-10.7* Hct-34.5*
MCV-97 MCH-30.0 MCHC-31.0 RDW-14.8 Plt ___
___ 04:52AM BLOOD WBC-8.1# RBC-3.29* Hgb-10.1* Hct-31.8*
MCV-97 MCH-30.7 MCHC-31.7 RDW-15.0 Plt ___
___ 05:15AM BLOOD WBC-5.8 RBC-3.57* Hgb-10.8* Hct-34.3*
MCV-96 MCH-30.2 MCHC-31.3 RDW-15.2 Plt ___
___ 04:00AM BLOOD Neuts-90.8* Lymphs-4.3* Monos-4.2 Eos-0.5
Baso-0.3
___ 04:00AM BLOOD ___ PTT-39.1* ___
___ 04:52AM BLOOD ___ PTT-34.4 ___
___ 05:15AM BLOOD ___ PTT-34.3 ___
___ 06:00PM BLOOD ESR-87*
___ 04:00AM BLOOD Glucose-106* UreaN-62* Creat-9.4* Na-141
K-5.0 Cl-95* HCO3-28 AnGap-23*
___ 04:52AM BLOOD Glucose-94 UreaN-42* Creat-6.6*# Na-138
K-4.5 Cl-94* HCO3-29 AnGap-20
___ 05:15AM BLOOD Glucose-107* UreaN-55* Creat-8.6*# Na-136
K-4.5 Cl-93* HCO3-27 AnGap-21*
___ 04:00AM BLOOD CK(CPK)-62
___ 09:21AM BLOOD CK(CPK)-47
___ 04:52AM BLOOD CK(CPK)-74
___ 10:30PM BLOOD Lipase-25
___ 04:00AM BLOOD CK-MB-3 cTropnT-0.08*
___ 09:21AM BLOOD CK-MB-4 cTropnT-0.12*
___ 06:00PM BLOOD CK-MB-5 cTropnT-0.15*
___ 04:52AM BLOOD CK-MB-4 cTropnT-0.18*
___ 04:00AM BLOOD Calcium-8.5 Phos-9.8*# Mg-2.7*
___ 04:52AM BLOOD Calcium-8.4 Phos-7.0*# Mg-2.4
___ 05:15AM BLOOD Calcium-9.1 Phos-8.0* Mg-2.6
___ 06:00PM BLOOD Cryoglb-PND
___ 06:00PM BLOOD CRP-152.3*
___ 09:21AM BLOOD C3-99 C4-37
___ 10:17AM BLOOD Vanco-18.1
___ 2:00 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
GRAM NEGATIVE ROD(S). RARE GROWTH.
Brief Hospital Course:
___ w/ h/o HIV, ESRD on HD, HTN, sCHF (EF 30%), polysubstance
abuse and recurrent lower-extremity cellulitis presented to the
ED at ___ with evidence of lower extremity cellulitis and
hypoxic respiratory failure requiring intubation initially
admitted to the MICU.
# Acute hypoxic respiratory failure:
Patient required intubation in the ED after receiving IVFs (200
cc NS) and becoming hypertensive. CXR with evidence of flash
pulmonary edema in the ED. It is unclear why the patient
developed such significant pulmonary edema so quickly. It may
have been precipitated by volume overload in HD-dependent
patient, as well as very difficult to control hypertension. It
is unclear how compliant the patient has been with
antihypertensive regimen at home. Also, he has a history of
polysubstance abuse, including cocaine, which could potentially
be contributing to his hypertension. EKG shows new inferior and
lateral TWIs, which is concerning for ACS as precipitant of
flash pulmonary edema. He was intubated for hypoxic respiratory
failure because he did not tolerate BiPAP ___ anxiety related to
the mask. He was seen by the renal team in the ED and received
HD the morning of ___ for volume removal. Patient is anuric,
so did not receive diuretics (as would not benefit from
diuretics). Patient successfully extubated on ___.
#Lower extremity rash / sepsis
Patient met ___ SIRS criteria on admission with cellulitis as
presumed infectious source. Lower extremity skin lesions are not
typical for cellulitis. The rash actually appears to be more
pettechial in nature or may simply represent chronic venous
stasis changes. His fever and elevated WBC argue for presence of
infection. AVF is not indurated or erythematous. There are no
other obvious sources of infection. His lactate is normal. He is
hypertensive. He has had recurrent episodes of cellulitis in the
setting of chronic lower extremity edema. He has multiple risk
factors for MRSA infection, so will treat empirically with
vancomycin. Recent CD4 count was >500, so opportunistic
infection is unlikely. LENIs were negative for DVTs. He was
started on vancomycin and cefepime. Patient was evaluated by
dermatology who suspected vasculitis but could not entirely
exclude cellulitis. Vasculitis studies were sent; complement
levels were normal and cryoglobulin was pending at time of
patient's discharge (patient has h/o cryoglobulinemia). Cefepime
was discontinued but vancomycin was continued (and dosed with
HD) since cellulitis could not be completely ruled out. Given no
evidence of cellulitis on exam on transfer to medical floor,
vancomycin was discontinued on ___ and the plan was to monitor
the patient for progression of cellulitis off antibiotics but
patient left against medical advice on ___. An email was sent
to the renal fellow asking him to have the dialysis team monitor
patient's lower extremities for evidence of cellulitis.
#HTN: Patient was initially persistently hypertensive with SBPs
in 190s despite maximal dosing of nitro gtt. He has a history of
very difficult to control hypertension. This may be worsened in
the setting of increased sympathetic tone due to acute illness.
There was also concern for possible cocaine ingestion. After
extubation, nitro gtt was discontinued and he was continued on
home antihypertensive regimen (Carvedilol 50 mg PO BID,
CloniDINE 0.4 mg PO TID, HydrALAzine 100 mg PO TID, NIFEdipine
CR 60 mg PO BID) with better BP control. On arrival to the
floor, patient's BP was in 110s-130s and hydralazine was
decreased from 100 mg PO TID to 50 mg PO TID. Overnight the
evening of ___, his BP was as low as 100/50 and hydralazine
was discontinued on the morning of ___. Patient left against
medical advice on ___ and his home anti-hypertensive regimen
was restarted on discharge (Carvedilol 50 mg PO BID, CloniDINE
0.4 mg PO TID, HydrALAzine 100 mg PO TID, NIFEdipine CR 60 mg PO
BID).
# Troponin leak: Patient had elevated troponins to 0.18 with
flat MB. Troponin leak presumed to be due to demand ischemia in
setting of hypertensive urgency and ESRD.
#abdominal pain: Patient developed abdominal pain in RLQ only
with movement on the day of discharge (no evidence of rebound,
guarding or acute abdomen on exam) which was most likely
musculoskeletal vs GERD (since home omeprazole held on
admission) vs constipation. Patient was encouraged to get out
of bed and ambulate and encouraged to take prn bowel meds
(lactulose, senna, colace). Home omeprazole was restarted.
Patient left against medical advice.
# ESRD: Renal HD team followed the patient from admission.
Underwent HD ___. Per report, patient had been going to
HD as an outpatient. Patient was continued on home sevelamer.
#HIV infection: Currently well controlled with recent CD4 >500.
Patient was continued on home regimen (Abacavir Sulfate 600 mg
PO DAILY, Efavirenz 600 mg PO DAILY, Emtricitabine 200 mg PO
___.
TRANSITIONAL ISSUES:
-please follow-up final sputum culture from ___ and blood
cultures from ___
-please follow-up cryoglobulin from ___
-please ensure patient is taking home anti-hypertensives
-please monitor patient's lower extremities (for worsening
redness, swelling, pain of lower extremities or fevers/chills)
and restart vancomycin 1000 mg IV per HD protocol if concern for
ongoing cellulitis (patient will need 10 day course from ___
-if patient develops worsening respiratory status after AMA
discharge, note that the patient had sparse gram negative rods
growing in sputum and would need repeat CXR to evaluate for
possible pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Abacavir Sulfate 600 mg PO DAILY
2. Ascorbic Acid ___ mg PO BID
3. Aspirin 81 mg PO DAILY
4. Carvedilol 50 mg PO BID
5. CloniDINE 0.4 mg PO TID
6. Efavirenz 600 mg PO DAILY
7. Emtricitabine 200 mg PO ___
8. HydrALAzine 100 mg PO TID
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. NIFEdipine CR 60 mg PO BID
11. Omeprazole 20 mg PO BID
12. Sertraline 50 mg PO DAILY
13. sevelamer CARBONATE 800 mg PO TID W/MEALS
14. Terazosin 3 mg PO HS
15. ___ (B complex-vitamin C-folic acid) 0.8 mg oral DAILY
16. Lactulose 30 mL PO BID PRN constipation
Discharge Medications:
1. Abacavir Sulfate 600 mg PO DAILY
2. Ascorbic Acid ___ mg PO BID
3. Aspirin 81 mg PO DAILY
4. Carvedilol 50 mg PO BID
5. CloniDINE 0.4 mg PO TID
6. Efavirenz 600 mg PO DAILY
7. Emtricitabine 200 mg PO ___
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Lactulose 30 mL PO BID PRN constipation
10. NIFEdipine CR 60 mg PO BID
11. Omeprazole 20 mg PO BID
12. Sertraline 50 mg PO DAILY
13. sevelamer CARBONATE 800 mg PO TID W/MEALS
14. Terazosin 3 mg PO HS
15. HydrALAzine 100 mg PO TID
16. ___ (B complex-vitamin C-folic acid) 0.8 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Respiratory failure
Secondary: Hypertensive urgency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
****YOU ARE LEAVING AGAINST MEDICAL ADVICE.****
You were admitted with pain and swelling in your feet, and you
developed respiratory failure requiring intubation and an
intensive care unit stay after receiving fluids in the emergency
room. Your blood pressure was also very high. You received
dialysis and medications to bring down your blood pressure. You
were extubated and transferred to the medical floor. While the
medical floor, you decided to leave against medical advice. We
recommended that you stay so that we could observe your legs off
antibiotics, but you decided to leave. Please return to the
emergency room if you experience fevers, chills, worsening
shortness of breath, development of worsening redness in the
lower legs or other new or concerning symptoms.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Please follow-up for dialysis on ___ and ___.
Please follow-up with your primary care physician ___ ___
weeks. Please follow-up at your appointments (listed below).
Followup Instructions:
___
|
10900387-DS-42
| 10,900,387 | 20,202,943 |
DS
| 42 |
2149-01-24 00:00:00
|
2149-01-30 13:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___ - Hemodialysis
History of Present Illness:
Mr. ___ is a ___ male with HIV, Hep C, substance
abuse, and hypertension who is being admitted to the general
medicine service with abdominal pain and shortness of breath.
He complains of a ___ day history of epigastric abdominal pain
described mostly as "fullness." He's had decreased appetite and
nausea. He vomited 4 times yesterday. These symptoms led him to
___ where he was admitted two days ago. He says he
was diagnosed with "water in the belly" and was discharged back
home. The pain persisted, leading to this presentation. He
denies fevers, chills, or diarrhea. He is very hungry right now
and wants to eat. He denies acid reflux symptoms or burning
abdominal sensations. He is on a PPI chronically. No sick
contacts at home. He also complains of acute on chronic
shortness of breath over the past few days. He has PND,
orthopnea, and coughing. He is ___ over his dry weight. He
denies any salt indiscretions.
His vitals on presentation were 99.8 90 180/102 16 97%. His labs
showed a potassium of 5.5, nonhemolyzed. A CXR showed pulmonary
edema. A CT of the abdomen and pelvis did not reveal any acute
abnormality. He was admitted to medicine for pain control and
HD.
He was briefly admitted for <24hr in ___ with a
heroin overdose responsive to narcan. He last used IV heroin a
few days ago.
Full 10-system review otherwise negative except as noted above.
Past Medical History:
RENAL HISTORY:
# HD SCHEDULE: MWF
# ESRD DUE TO: ___ MPGN d/t hepatitis C and cryoglobulinemia and
hypertensive nephrosclerosis.
# ON RENAL REPLACEMENT SINCE: ___
# ACCESS HISTORY AND COMPLICATIONS: LUE AVF created ___ yrs ago
per patient, c/b stenosis, s/p angioplasty in ___
PAST MEDICAL HISTORY:
1. HIV - He was diagnosed with HIV in ___. MOST RECETN CD4 373,
___. Risk factors included unprotected heterosexual sex as
well as intravenous drug use. His
nadir CD4 count is 91 and he has no known opportunistic
infections.
2. Hepatitis C, Genotype 1B. Viral load 187,000 in ___.
3. Cryoglobulinemia
4. Cardiomyopathy with an EF of 45-50%
5. GERD
6. Hypertension
7. Gynecomastia; s/p bilateral gynecomastia excision with
liposuction ___
8. Polysubstance abuse, including cocaine and alcohol
Social History:
___
Family History:
Per OMR. Mother and father have hypertension; has 3 brothers, 3
sisters: all healthy, none with hypertension. There is also
family history of type 2 diabetes. No family history of sudden
death and premature atherosclerotic disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
------
VITALS: T99.1 HR 89 RR 21 BP 189/101
PRE-WEIGHT: 67.7 LAST POST: 64.9 EDW: 65
GENERAL: no acute distress
HEENT: MMM, OP is clear
CARDS: regular rate and rhythm, transmitted bruit from AVF
PULM: diffuse crackles and wheezing in the posterior lung fields
ABDOMEN: soft, diffuse mild TTP, mostly in the epigastrium
EXTREMITIES: 2+ edema of the lower extremities bilaterally
ACCESS: LUE AVF with needles in place
NEURO: answering questions appropriately
DISCHARGE PHYSICAL EXAM:
-----
VITALS: 98.8 176/96 89 18 100/RA Wt: 64.4kg
EDW: 65
GENERAL: no acute distress
HEENT: MMM, OP is clear
CARDS: regular rate and rhythm, transmitted bruit from AVF
PULM: diffuse crackles and wheezing in the posterior lung fields
ABDOMEN: soft, NT, distended
EXTREMITIES: 1+ edema of the lower extremities bilaterally
ACCESS: LUE AVF
NEURO: answering questions appropriately
Pertinent Results:
ADMISSION LABS:
------
___ 11:30AM BLOOD WBC-9.3 RBC-2.73* Hgb-9.2* Hct-28.4*
MCV-104* MCH-33.8* MCHC-32.6 RDW-12.8 Plt ___
___ 11:30AM BLOOD Neuts-87.0* Lymphs-5.3* Monos-6.6 Eos-0.9
Baso-0.2
___ 11:30AM BLOOD Glucose-102* UreaN-48* Creat-7.8* Na-139
K-5.5* Cl-97 HCO3-27 AnGap-21*
___ 11:30AM BLOOD ALT-12 AST-23 CK(CPK)-55 AlkPhos-82
TotBili-0.3
___ 11:41AM BLOOD Lactate-1.2
DISCHARGE LABS:
------
___ 09:10AM BLOOD WBC-7.6 RBC-3.16* Hgb-10.4* Hct-33.2*
MCV-105* MCH-32.7* MCHC-31.2 RDW-13.3 Plt ___
___ 07:15AM BLOOD Glucose-132* UreaN-32* Creat-5.7*# Na-138
K-4.5 Cl-97 HCO3-31 AnGap-15
IMAGING:
-----
CTAP ___
IMPRESSION:
ABDOMEN: The liver enhances homogeneously and is without focal
abnormality.
The gallbladder and biliary tree appear normal. The pancreas,
spleen, and
adrenal glands appear normal. The kidneys enhance normally and
excrete
contrast symmetrically. The stomach, duodenum, and abdominal
loops of small
and large bowel are of normal caliber, without wall thickening,
or associated
mass. There is no ascites, fluid collection, or
pneumoperitoneum.
The portal, splenic, and mesenteric veins are patent. The
abdominal aorta is
not enlarged and its main branches are patent. There is no
retroperitoneal,
periportal, or mesenteric lymphadenopathy.
PELVIS: The rectum and urinary bladder are normal. The
prostate and seminal
vesicles are normal. There is no pelvic or inguinal
lymphadenopathy.
MUSCULOSKELETAL: There are no lytic or sclerotic osseous
lesions concerning
for malignancy.
IMPRESSION:
No fluid collection or other acute process to account for
patient's symptoms.
CXR ___
FINDINGS: Frontal and lateral chest radiographs. There is mild
cardiomegaly
as well as trace bilateral effusions within the fissures. There
is minimal
pulmonary edema as evidenced by interlobular septal thickening,
particularly
in the left lower lobe. There is no pneumothorax.
IMPRESSION: Interstitial pulmonary edema.
ECG ___
Sinus rhythm. Delayed precordial R wave progression. Left
ventricular
hypertrophy with associated repolarization abnormalities.
Compared to the
previous tracing of ___ the findings are similar.
Brief Hospital Course:
___ male with ESRD, HIV, HepC, ongoing IVDU, systolic
cardiomyopathy here with abdominal pain and shortness of breath
due to pulmonary edema in the setting of volume overload.
ACTIVE ISSUES:
--------------
#. ABDOMINAL PAIN: IMPROVED. Due to constipation, evidenced by
absence of defecation the preceding 4 days, waves of crampy
pain, recent heroin use, and improvement with defecation.
Underwent CTAP in ED which did not reveal evidence of a
mechanical or inflammatory process which would otherwise suggest
an alternate etiology. Alternate diagnoses which were
entertained included 1) gastritis, which is less likely in the
setting of chronic PPI use or 2) narcotic withdrawl, which was
less likely in the absence of tachycardia or diaphoresis. No
evidence of pancreatitis by labs or imaging. No ascites or other
intraabdominal abnormalities seen on CTAP.
- Continue home PPI
- Continue bowel regimen with senna, colace, PEG, and PR
bisacodyl
- on the day of discharge from the hospital pt. was
independently ambulatory around the ward, and complained only of
paraspinal muscle spasms, which he reported routinely
experiencing following his HD sessions.
# TROPONEMIA: STABLE, ___ DEMAND, NO EVIDENCE OF RISE TO SUGGEST
ACS. Patient does not endorse chest pain nor is abdominal pain
consistent with chest pain equivalent.
- Followup with outpatient cardiology given underlying
cardiomyopathy.
# ONGOING HEROIN ABUSE: Patient endorsed wish to stop injecting
heroin. He wsa provided with multiple resources for outpatient
assistance from social work.
#. HTN: RESOLVED, RETURNED TO BASELINE. Due to volume overload
in the setting of ESRD and medication non-adherence.
- Continue home antihypertensive regimen, as outlined below.
- Carvedilol 50mg BID
- Clonidine 0.4mg TID
- Hydralazine 100 mg Q8H
- Isosorbide mononitrate ER 30 mg daily
- Nifedipine ER 60 mg daily
#. SHORTNESS OF BREATH: RESOLVED. Due to pulmonary edema,
improved following HD.
# ESRD on HD (___): Due to MPGN (Hep C), cryoglobulinemia
and hypertensive nephrosclerosis. Has been on HD since ___. Has
LUE AVF created ___ years ago; complicated by stenosis s/p
angioplasty in ___.
#. Bone/Mineral: will check Ca and phos
- Doxercalciferol 6 mcg qHD
- sevelamer 800mg TID with meals for binding
CHRONIC ISSUES:
---------------
# HIV: Last CD4 count was 373 with an undetectable viral load
(___). Diagnosed in ___.
- Continue on home medication regimen: abacavir, efavirenz, and
emtricitabine(only on ___ and ___ after dialysis).
# Vasculitis: Most likely cryoglobulinemic vasculitis in context
of untreated Hep C infection.
# Hepatitis C: Untreated. Viral load on ___ was 61,900
IU/mL.
No recent viral load.
# Cardiomyopathy: STABLE. LVEF 30% on ___.
- Continue home ASA
- Carvedilol, as above.
# Depression: STABLE. Continue home sertraline.
# GERD: Patient remained clinically stable on home omeprazole.
TRANSITIONAL ISSUES:
--------------------
# ESTABLISH OUTPATIENT CARDS FOLLOWUP.
# SUPPORT WITH IVDU CESSATION
# HEPATITIS C TREATMENT, GENOTYPE 1B
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Abacavir Sulfate 600 mg PO DAILY
2. Ascorbic Acid ___ mg PO BID
3. Aspirin 81 mg PO DAILY
4. Carvedilol 50 mg PO BID
5. CloniDINE 0.4 mg PO TID
6. Efavirenz 600 mg PO DAILY
7. Emtricitabine 200 mg PO QTUES/SAT
8. HydrALAzine 100 mg PO TID
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. NIFEdipine CR 60 mg PO BID
11. Omeprazole 20 mg PO BID
12. Sarna Lotion 1 Appl TP BID:PRN itch
13. Sertraline 50 mg PO DAILY
14. sevelamer CARBONATE 800 mg PO TID W/MEALS
15. Terazosin 3 mg PO HS
16. Lactulose 30 mL PO BID:PRN constipation
17. ___ (B complex-vitamin C-folic acid) 0.8 mg oral daily
Discharge Medications:
1. Abacavir Sulfate 600 mg PO DAILY
2. Ascorbic Acid ___ mg PO BID
3. Aspirin 81 mg PO DAILY
4. Carvedilol 50 mg PO BID
5. CloniDINE 0.4 mg PO TID
6. Efavirenz 600 mg PO DAILY
7. Emtricitabine 200 mg PO QTUES/SAT
8. HydrALAzine 100 mg PO TID
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Lactulose 30 mL PO BID:PRN constipation
11. NIFEdipine CR 60 mg PO BID
12. Omeprazole 20 mg PO BID
13. Sarna Lotion 1 Appl TP BID:PRN itch
14. Sertraline 50 mg PO DAILY
15. sevelamer CARBONATE 800 mg PO TID W/MEALS
16. Terazosin 3 mg PO HS
17. ___ (B complex-vitamin C-folic acid) 0.8 mg oral daily
18. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 2 capsule(s) by mouth TWICE A DAY
Disp #*60 Capsule Refills:*0
19. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 TAB by mouth DAILY Disp #*30
Capsule Refills:*0
20. Nephrocaps 1 CAP PO DAILY
RX *B complex-vitamin C-folic acid ___ mcg 1 tablet(s) by mouth
DAILY Disp #*30 Tablet Refills:*0
21. Zolpidem Tartrate 5 mg PO HS insomnia
RX *zolpidem 5 mg 1 tablet(s) by mouth EVERY NIGHT Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
-----
HYPERTENSIVE URGENCY
END STAGE RENAL DISEASE
CONSTIPATION
HEROIN ABUSE
PULMONARY EDEMA
SECONDARY DIAGNOSES:
----------
HIV
HEPATITIS C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted
with abdominal pain due to constipation, which resolved after
your received medications to move your bowels. Your blood
pressure was also found to be extremely high as you had missed
your medications. Please be sure to take all your medications
exactly as they are prescribed to you.
You expressed a desire for help with your addiction. We provided
those resources for you and wish you the best with your
recovery. We encourage you to stop using heroin and other
injectable or illicit drugs as these can have serious negative
consequences for your health, including overdose and death.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10900387-DS-43
| 10,900,387 | 28,246,942 |
DS
| 43 |
2149-03-23 00:00:00
|
2149-03-23 15:29:00
|
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:
Cardiopulmonary resuscitation
Inbutation and extubation
G-tube placement
R PICC placement
sacral debridement x2
History of Present Illness:
___ with PMH significant for ESRD (on hemodialysis), HIV and HCV
coinfection (last CD4 count 373, 51%, HIV VL undetectable as of
___, polysubstance abuse (IVDU, cocaine, heroin and
alcohol), cryoglobulinemia, non-ischemic cardiomyopathy with
systolic congestive heart failure (LVEF 30%), GERD and
hypertension who presented to the emergency department with
abdominal pain of unclear etiology, was subsequently admitted to
the medical floor who developed episodic hypertension with acute
pulmonary edema resulting ___ PEA with ROSC after ___ minutes of
resuscitation who is now with poor neurologic response now s/p
48 hours of cooling.
Past Medical History:
RENAL HISTORY:
# HD SCHEDULE: ___
# ESRD DUE TO: ___ MPGN d/t hepatitis C and cryoglobulinemia and
hypertensive nephrosclerosis.
# ON RENAL REPLACEMENT SINCE: ___
# ACCESS HISTORY AND COMPLICATIONS: LUE AVF created ___ yrs ago
per patient, c/b stenosis, s/p angioplasty ___ ___
PAST MEDICAL HISTORY:
1. HIV - He was diagnosed with HIV ___ ___. MOST RECETN CD4 373,
___. Risk factors included unprotected heterosexual sex as
well as intravenous drug use. His nadir CD4 count is 91 and he
has no known opportunistic infections.
2. Hepatitis C, Genotype 1B. Viral load 187,000 ___ ___.
3. Cryoglobulinemia
4. Cardiomyopathy with an EF of 45-50%
5. GERD
6. Hypertension
7. Gynecomastia; s/p bilateral gynecomastia excision with
liposuction ___
8. Polysubstance abuse, including cocaine and alcohol
Social History:
___
Family History:
Per OMR. Mother and father have hypertension; has 3 brothers, 3
sisters: all healthy, none with hypertension. There is also
family history of type 2 diabetes. No family history of sudden
death and premature atherosclerotic disease.
Physical Exam:
MICU ADMISSION PHYSICAL EXAM:
=============================
Vitals: 98.0 91 194/84 24 99% ETT
Vent: CMV/AC ___
General: patient appears ___ NAD. Appears stated age. Non-toxic
appearing. Intubated and sedated.
HEENT: normocephalic, atraumatic. PERRL but minimally reactive
from 3-to-2 mm. EOMI. Oropharynx with no notable lesions,
plaques or exudates. Neck supple.
___: regular rate and rhythm. II/VI holosystolic murmur at LUSB,
no audible rubs. S1 and S2 noted.
Respiratory: Faint inspiratory crackles are noted bilaterally
without adventitious wheezing.
Abdomen: soft, non-distended with hypoactive bowel sounds
Extremities: cool (on protocol), well-perfused distally; 2+
distal pulses bilaterally with minimal peripheral edema
Derm: skin appears intact with no significant rashes or lesions;
LUE AVF with palpable thrill and audible bruit. Tattoo on right
arm.
Neuro: Intubated and sedated to RASS -5. Normal bulk and tone.
Motor and sensory function not able to assess. Gait deferred.
FLOOR DISCHARGE EXAM:
=====================
VS: 97.4 75 169/100 18 100% RA
General: Middle-aged male, awake, NAD
HEENT: NCAT, pupils symmetric, MMM
CV: RRR, no r/g/m
Chest: Anterolateral exam CTA b/l, no w/r/r.
Abdomen: Soft, ND, +BS. G-tube ___ place.
Ext: WWP, no edema. LUE w/ dialysis catheters ___ place
Small area of erosion, pentip size, clean & dry. R UE PICC site
c/d/i
Neuro: Orients to voice, does not follow commands
Skin: no rashes or lesions of the upper chest, arms except as
above ___ Ext. sacral decubitus exam deferred.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:30PM BLOOD WBC-7.0 RBC-2.74* Hgb-9.4* Hct-28.9*
MCV-105* MCH-34.4* MCHC-32.7 RDW-13.5 Plt ___
___ 09:30PM BLOOD Neuts-75.2* Lymphs-12.5* Monos-7.7
Eos-4.0 Baso-0.6
___ 09:43AM BLOOD ___ PTT-37.9* ___
___ 09:30PM BLOOD Glucose-105* UreaN-47* Creat-8.0*# Na-139
K-4.9 Cl-100 HCO3-23 AnGap-21*
___ 09:30PM BLOOD ALT-11 AST-19 AlkPhos-80 TotBili-0.2
___ 09:30PM BLOOD Calcium-9.5 Phos-5.8* Mg-2.6
___ 09:14AM BLOOD Type-ART pO2-91 pCO2-109* pH-7.04*
calTCO2-32* Base XS--4
PERTINENT LABS:
===============
___ 04:23PM BLOOD Ret Aut-1.5
___ 09:43AM BLOOD Lipase-23
___ 05:28AM BLOOD CK-MB-4 cTropnT-0.10*
___ 02:46AM BLOOD Hapto-232*
___ 05:19AM BLOOD Hapto-359*
___ 02:14PM BLOOD calTIBC-183* Ferritn-1294* TRF-141*
___ 06:04AM BLOOD PTH-145*
___ 07:00AM BLOOD PTH-91*
___ 06:06AM BLOOD PTH-73*
___ 09:43AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 10:32AM BLOOD Lactate-0.9
___ 06:28PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 06:28PM URINE Blood-MOD Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG
___ 06:28PM URINE RBC-28* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
MICROBIOLOGY:
============
Blood cultures negative:
___,
___
___ 12:00 pm IMMUNOLOGY Source: Line-pic.
**FINAL REPORT ___
HIV-1 Viral Load/Ultrasensitive (Final ___:
HIV-1 RNA is not detected.
Performed using the Cobas Ampliprep / Cobas Taqman HIV-1
Test v2.0.
Detection Range: ___ copies/mL.
This test is approved for monitoring HIV-1 viral load ___
known
HIV-positive patients. It is not approved for diagnosis of
acute HIV
infection.
___ symptomatic acute HIV infection (acute retroviral
syndrome), the
viral load is usually very high (>>1000 copies/mL). If
acute HIV
infection is clinically suspected and there is a
detectable but low
viral load, please contact the laboratory for
interpretation.
It is recommended that any NEW positive HIV-1 viral load
result, ___
the absence of positive serology, be confirmed by
submitting a new
sample FOR HIV-1 PCR, ___ addition to serological testing.
___ 11:18 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
RARE GROWTH Commensal Respiratory Flora.
YEAST. RARE GROWTH.
___ 6:29 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-picc.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ 1:35 pm TISSUE SACRAL DECUBITUS.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
Reported to and read back by ___. ___ @ 1630,
___.
TISSUE (Final ___:
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 BELOW, THEY ARE NOT
PRESENT ___
this culture..
ENTEROCOCCUS SP.. SPARSE GROWTH STRAIN 1.
STREPTOCOCCUS ANGINOSUS (___) GROUP. SPARSE GROWTH.
ENTEROCOCCUS SP.. SPARSE GROWTH STRAIN 2.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
PROBABLE MICROCOCCUS SPECIES. RARE GROWTH.
ANAEROBIC CULTURE (Final ___:
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. The presence of B.fragilis,
C.perfringens,
and C.septicum is being ruled out.
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
___ 6:28 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
ENTEROBACTERIACEAE. >100,000 ORGANISMS/ML..
PREDOMINATING ORGANISM. INTERPRET RESULTS WITH
CAUTION.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROBACTERIACEAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ C diff negative
___ 3:30 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. MODERATE GROWTH.
YEAST. SPARSE GROWTH SECOND TYPE.
___ 8:30 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
___ 5:15 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
FUNGAL CULTURE (Final ___:
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
___ 12:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 11:00 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
EEG READS:
==========
___ EEG:
IMPRESSION: This is an abnormal continuous ICU monitoring study
due to the presence of abundant high amplitude generalized spike
and wave discharges particularly during the second half of the
recording occurring at a frequency of ___ Hz. No clinical
correlate is seen with these discharges. These findings are
indicative of highly epileptogenic cortex ___ a generalized
distribution. The background initially begins with extremely low
voltage ___ Hz delta activity which later improves to ___ Hz
theta activity and periods of generalize suppression consistent
with a severe encephalopathy. These findings are consistent with
the patient's history of anoxic brain injury.
___ EEG:
IMPRESSION:
This is an abnormal continuous ICU monitoring study due to the
presence of generalized periodic epileptiform that reach up to 2
Hz ___ frequency. There is no significant change from the prior
days telemetry. These findings are consistent with hypoxic
encephalopathy.
___ EEG:
IMPRESSION: This was an abnormal continuous ICU EEG monitoring
study because of an unreactive background, with continuous high
voltage generalized periodic discharges (GPDs), and polyspike
discharges, which correlated with myoclonic eye movements. These
findings are consistent with post anoxic myoclonic status
epilepticus. ___ comparison to the prior day's record, there were
no significant changes. These findings are usually associated
with poor prognosis following cardiac arrest.
___ EEG:
IMPRESSION: This was an abnormal continuous ICU EEG monitoring
study because of a pattern of generalized periodic epileptiform
discharges (GPEDs), occurring at a ___ Hz frequency, with no
reactivity seen ___ EEG following stimulation, and myoclonic
eyelid fluttering associated with polyspike activity. These
findings are consistent with post anoxic myoclonic status
epilepticus. There were no significant changes from the prior
day's recording.
___ NEUROLOGY ELECTROPHYSIOLOGY:
FINDINGS:
MEDIAN NERVE SOMATOSENSORY EVOKED POTENTIALS: After stimulation
of either
median nerve there were reasonably well-formed evoked potential
peaks, with normal latencies at Erb's point and at the P/N13 and
N19 waveform positions. Interpeak latencies were normal, as
well, and these are bilaterally normal median nerve
somatosensory evoked potentials, including for presence of the
N19 (or N20) potential. It must be noted ___ terms of prognosis
after presumed anoxia, that a present potential is of
substantially less prognostic reliability than is an absent
potential.
___ EEG
This is an abnormal continuous video EEG study due to the
presence of a slow, disorganized background with frequent
bilateral
frontocentral epileptiform discharges, occasionally recurring ___
runs lasting up to 10 seconds at about a one-per-second
frequency. These findings indicate an activate bilateral
epileptogenic process, though no actual electrographic seizures
were seen. The background indicated a moderate diffuse
encephalopathy.
IMAGING:
========
___ CXR:
IMPRESSION:
1. Stable moderate cardiomegaly with worsening interstitial
pulmonary edema.
2. Dense opacity ___ the right middle lobe obscuring the right
heart border may reflect pneumonia although the appearance was
similar during prior episodes of pulmonary edema. Followup
chest radiographs are suggested after treatment of pulmonary
edema to ensure there is no underlying pneumonia.
___ LENIs:
IMPRESSION:
1. No evidence of deep venous thrombosis ___ the bilateral lower
extremity
veins.
2. 3.8 cm incidental ___ cyst ___ the right popliteal fossa.
___ ECHO:
Conclusions
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
severely dilated. There is severe global left ventricular
hypokinesis (LVEF = ___ %) with inferior akinesis. 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 borderline normal
free wall function. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
___ MRI BRAIN W/O CONTRAST:
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect,
or recent
infarction. Again seen is an old left putaminal hemorrhage with
tissue loss and focal enlargement of the body and frontal horn
of the left lateral ventricle. The ventricles and sulci
otherwise are normal ___ caliber and configuration. There are no
diffusion abnormalities to suggest anoxic ischemic brain injury.
Note that such findings may be require several days to evolve
to the point where visible MR.
___: old left putaminal hemorrhage with tissue loss.
___ CT ABD & PELVIS W/O CONTRAST:
IMPRESSION:
1. No retroperitoneal hematoma or other large intra-abdominal
fluid
collection.
2. Free intraperitoneal air is likely related to the recent
G-tube placement. The gastrointestinal tube appears to be within
the lumen of the stomach.
3. Gallstones without evidence of acute cholecystitis.
___ CXR
SINCE THE PRIOR STUDY. IT HAS BEEN INTERVAL DEVELOPMENT OF
PULMONARY EDEMA.
BIBASILAR OPACITIES ARE ALSO PROMINENT AND ALTHOUGH MIGHT
REPRESENT PART OF
PULMONARY EDEMA, BIBASAL CONSOLIDATION REPRESENTING PNEUMONIA IS
A
POSSIBILITY.
RIGHT PICC LINE TIP IS AT THE LEVEL OF CAVOATRIAL JUNCTION
BILATERAL PLEURAL EFFUSIONS ARE MOST LIKELY PRESENT. THERE IS NO
PNEUMOTHORAX
___ MR head w/contrast
FINDINGS:
No significant changes are seen since the prior examination.
Again an old left putaminal hemorrhage is redemonstrated,
causing ex vacuo dilatation of the lateral ventricle, and no
diffusion abnormalities are detected to suggest acute or
subacute ischemic changes, there is no evidence of acute
intracranial hemorrhage or hydrocephalus. The major vascular
flow voids are present, the orbits are unremarkable, the
paranasal sinuses again demonstrate mild mucosal thickening ___
the left maxillary sinus, the mastoid air cells are clear.
IMPRESSION:
There is no evidence of acute intracranial process. Unchanged
chronic left
putaminal hemorrhage, causing a slight dilatation of the left
lateral
ventricle as described above.
___ TTE
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated with moderate to severe global hypokinesis.
Systolic function of apical segments is relatively preserved.
Quantitative (biplane) LVEF = 30 %. No masses or thrombi are
seen ___ the left ventricle. Right ventricular chamber size and
free wall motion are normal. The descending thoracic 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. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. A patent ductus arteriosus or
coronary artery to pulmonary artery is suggested (clips ___.
There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
moderate cavity dilation and moderate to severe global systolic
dysfunction ___ a pattern most c/w a non-ischemic cardiomyopathy.
Pulmonary artery hypertension. Mild mitral regurgitation.
Possible patent ductus arteriosus.
Compared with the prior study (images reviewed) of ___, the
findings are similar (cavity size was overestimated on the prior
study and a possible PDA is now identified. Is there a
continuous murmur on examination?
___ CXR
Increasing bibasilar opacities consistent with aspiration of
developing
pneumonia.
___ MRI pelvis w/o contrast:
FINDINGS:
A soft tissue ulcer extends near the bone at the level of the
sacrococcygeal junction (03:20). There is trace edema ___ the S5
vertebral body. There is no discrete fluid collection, although
no intravenous contrast was ___. Most of the sacrum and pelvis
has low marrow signal, which has signal drop out on the
out-of-phase images consistent with red marrow. There is normal
T1 hyperintense marrow signal ___ the coccyx, thus excluding
osteomyelitis ___ that location. There is no fracture,
malalignment, or concerning osseous lesion.
There is trace physiologic fluid ___ the bilateral femoral
acetabular joints. Limited images of the pelvic viscera show no
abnormalities. A rectal tube is ___ situ.
IMPRESSION:
1. Soft tissue ulcer extending near the bone at the
sacrococcygeal junction. There is no fluid collection or
definitive MR evidence of acute osteomyelitis.
2. Decreased marrow signal ___ the sacrum is likely due to red
marrow
reconversion, possibly secondary to medications. Coccygeal
marrow signal is normal.
DISCHARGE LABS:
===============
___:04AM BLOOD WBC-5.7 RBC-2.45* Hgb-7.9* Hct-24.7*
MCV-101* MCH-32.0 MCHC-31.8 RDW-17.2* Plt ___
___ 06:04AM BLOOD Glucose-84 UreaN-58* Creat-3.3*# Na-136
K-4.8 Cl-96 HCO3-29 AnGap-16
___ 06:04AM BLOOD Calcium-8.5 Phos-6.4* Mg-3.5*
___ 06:04AM BLOOD Vanco-20.3*
Brief Hospital Course:
___ w/ PMH of ESRD on HD (___), HIV on HAART (CD4 373),
HCV, polysubstance abuse on methadone, cryoglobulinemia, sCHF
___ NICM, resistant hypertension and GERD, s/p PEA arrest w/
neurologic devastation on ___ ___ the setting of HTN
emergency (flash pulmonary edema), ___ MICU w/ myoclonic seizures
prior to cooling protocol, and since protocol completed has
continued to have seizures on quadruple AED therapy. However,
neuro status improving, now intermittently responding to simple
commands and minimally interactive.
ACTIVE ISSUES:
==============
# s/p PEA arrest:
Most likely due to hypercarbic vs. hypoxemic respiratory failure
___ setting of acute pulmonary edema from hypertensive emergency.
Patient was resuscitated on the medical floor and achieved ROSC
after ___ minutes. Hypothermia protocol was initiated and
patient cooled to 36 degrees Celsius for 24 hours and
subsequently re-warmed. He required paralysis during the
procedure due to shivering. He was treated empirically with an 8
day course of vancomycin and cefepime for HCAP ___ the event
infection precipitated the event, though this was thought
unlikely. As a result of the arrest, he suffered anoxic brain
injury with myoclonic seizures (see below), though he has become
steadily more and more interactive since the event.
# Myoclonic Status Epilepticus:
EEG ___ MICU showed continued seizures despite phenobarbital,
locosamide, levetiracetam and valproate. Last MRI Head ___ did
not show recent infarction or anoxic brain injury, though note
was made that several days may be required for anoxic brain
injury to be apparent on MR. ___ recent return of some higher
brain function, re-evaluated by Neurology who recommended on HD
days dose Keppra 500 mg after HD and continue 1 mg PO QD. Goal
Valproate level range 50-100, continue current dose. Goal
Phenobarb level range ___ dose increased on ___ for
persistently low levels. Continue Lacosamide at current dose.
# Goals of care:
Family and MICU team had multiple discussions regarding goals of
care. Per Neurology, ___ his myoclonic status epilepticus and
no underlying cortical activity on EEG, his prognosis was
thought poor. Patient maintained corneal reflexes although did
not have gag or cough. MRI did not show anoxic brain injury as
anticipated, but this was likely due to early evaluation with
imaging. Neuron specific enolase was normal. 2 ICU attendings
testified that CPR was not indicated and thus, he was made DNR.
Ethics was consulted as family insisted on full support; he
remained DNR on arrival to the floor, but OK to reintubate. He
is s/p PEG placement for nutrition. Later ___ his stay, he
recovered more and more neurologic function, and would
intermittently respond to commands ___ ___ ___ (repeating
names, attempting motor function). He continued to improve
throughout his hospitalization and was able to answer questions
with single words and follow simple commands by the time of
discharge. His family decided that "full code" status was most
consistent with his goals of care, and ultimately he did need to
be re-intubated for HCAP (see above). Currently, his family's
wishes are that he be full code.
# Stage IV Sacral ulcer, complicated soft-tissue infection:
The patient has a large sacral ulcer that was debrided at the
bedside on ___ and again ___ the OR for deeper debridement on
___. Tissue culture grew several organisms but no pseudomonas.
The patient completed a 2 week course of vancomycin and
ceftriaxone for complicated soft-tissue infection. At the
recommendation of the surgery service, plastic surgery was
consulted for consideration of wound closure options; plastics
felt he was not a surgical candidate ___ his poor neurologic
prognosis. An MRI of the pelvis without gadolinium ruled out
osteomyelitis prior to discharge. A wound vac was used to
promote healing and should be continued at discharge.
# Hypoxemic respiratory distress / HCAP:
The patient was transferred to the MICU on ___ ___ the setting
of a likely aspiration event with resultant RML pneumonia. He
required intubation for impending respiratory failure and was
started on an 8-day course of Vancomycin and Zosyn. A
significant amount of fluid was also dialyzed off ___ the MICU.
He was extubated 48 hours later, and his respiratory status
improved back to baseline. No pathogens were isolated on BAL.
# Enterobacteriaceae UTI:
The patient spiked a fever to 102 and his UA had many bacteria
and >182 whites; previously it has been clean. Despite previous
concern for central fever, this current episode was more
concerning for infection. UCx on ___ speciated to pan-sensitive
Enterobacteriaceae. The patient completed a 14-day course of
Ceftriaxone from ___.
# Anemia:
Basline Hgb appears around ___. The patient has anemia that is
likely multifactorial, for which he is transfusion-dependent
(requiring ~10u pRBCs during this admission. He has required
transfusions approximately every other dialysis session (~every
5 days). He likely has some component of anemia of chronic
disease, anemia ___ ESRD (for which he receives Epo), iron
deficiency anemia (for which he gets IV Iron at dialysis), and
GI losses (guaiac positive stool; but per GI, the risks of
scoping outweight the benefits). Retic count 2.5 suggesting
underproduction. Heme/onc consulted and agreed with our
assessment.
# Thrombocytopenia:
platelets drifting downward without clear etiology. HITT
unlikely as time course not suggestive and no evidence of
thrombosis. DIC unlikely ___ coags not significantly
different from previously. Per pharmacy, Raltegravir can cause
TTP, but this is exceedingly rare and not compatible w/ clinical
picture. Valproate is a much more plausible culprit. If
worsens, discuss changing valproate to something else w/ neuro.
# Hypertension:
Known poor compliance, difficult to control at baseline.
Previously on clonidine 0.6mg TID; his antihypertensives were
held initially ___ the setting of PEA arrest and sepsis.
Restarted isosorbide dinitrate 40mg TID ___, restarted
carvediolol 50 mg PO BID ___, and restarted Amlodipine 10 mg PO
QD on ___. Due to persistent hypertension, he required further
escalation of his antihypertensives to 6 agents at the time of
discharge. His discharge regimen is Hydralazine 100 mg PO Q8H,
Cavedilol 50 mg PO BID, Isosorbide dinitrite 40 mg PO Q8H,
Amlodipine 10 mg PO QD, Clonidine 0.2 mg PO TID, and Losartan
100 mg PO QD,
# Nutrition / GI Motility / swallowing function:
PEG tube was placed on ___, tube feeds initiated on ___. His
nutritional status remained poor, with most recent albumin
before discharge 1.9. Reglan was used periodically to to
increase GI motility ___ increased TF residuals; however, this
should be avoided ___ possibility of lowering seizure
threshold. If the patient has high TF residuals, would instead
slow down the rate. The patient had diarrhea during this
admission that was C. diff negative; it improved with banana
flakes and loperamide. The patient's swallowing function was
evaluated several times by speech and swallow; they recommended
a video swallow eval before he can be cleared for PO intake. He
should be NPO until then due to high aspiration risk and receive
Q4H oral care.
CHRONIC ISSUES:
===============
# ESRD:
Secondary to MPGN from HepC and cryoglobulinemia and
hypertensive nephrosclerosis. Dialyzed ___ via LUE AVF.
Not currently on sevelamer or nephrocaps; he was maintained on
Lanthanum 500 mg PO TID w/ meals. He also received IV Iron and
Epo with dialysis. Nephrocaps were switched to MVI ___
difficulty administering through feeding tube. The patient
required blood transfusions with dialysis approximately every
other session.
# HIV:
Viremic control established, CD4 count > 300. However, due to
concern for interaction between phenobarbital and efavirenz
leading to subtherapeutic ARV levels, ___ consultation with ID
pharmacist and his PCP, decision was made to switch efavirenz to
Raltegravir on ___. His HIV viral load remained undetectable.
He was continued on his home emtricitabine, Continue abacavir.
# sCHF:
No indication of acute cardiac ischemia during this admission,
although inferior TWIs likely reflect recent hypoperfusion and
CPR. LVEF 30% ___ ___. Home medications include beta-blocker,
hydralazine-nitrate combination. TTE after rewarming with no
significant changes. Continued ASA and anti-HTN meds as above.
# Chronic HCV infection:
Genotype 1b. Viral load on ___ was 61,900 IU/mL. No recent
viral load. Polysubstance abuse barrier to treatment.
# Polysubstance abuse:
Recent active user. He was continued on his home MVI, thiamine,
folate.
# Depression:
His home SSRI was stopped ___ anoxic brain injury.
# GERD:
The patient was continued on his home PPI.
TRANSITIONAL ISSUES:
====================
- The patient's Efavirenz was switched to Raltegravir ___
concern for interaction with AEDs. His VL remained suppressed.
- The patient has unexplained thrombocytopenia that has
stabilized ___ the low 100s may be due to a medication side
effect - if it worsens, valproate may be the most likely culprit
and should be switched for a suitable alternative.
- The patient has unexplained anemia that is thought to be
multifactorial (iron deficiency, for which he receives IV ferric
gluconate 125 mg at each HD session, anemia of chronic disease,
and chronic kidney disease, for which he receives Epogen at
dialysis). His stools were intermittently guiac positive on this
admission without frank blood or melena. Gastric secretions
were gastroccult negative. GI evaluated the patient and felt
that he currently is too high-risk for EGD/colonoscopy. He will
require transfusion of packed red blood cells approximately 1
unit every 5 days (or about every other HD session).
- The patient should recieve IV Iron and Epo at least every
month with dialysis
- The patient had persistent hypertension during this admission,
requiring 6 antihypertensives at discharge. Amlodipine may be
dosed before HD, but all other blood pressure medications will
be dialyzed off and therefore should be dose after hemodialysis.
- For systolic BP >180, consider Hydrlazine 10 mg IV PRN.
- Patient with large stage IV sacral decubitous ulcer that has
been debrided x2 and managed by ___ wound care RN. He completed a
two-week course of Vancomycin for a complicated soft-tissue
infection. Osteomyelitis was ruled out with an MRI prior to
discharge. A wound vac should be applied to the wound to
promote drainage and healing.
- If the patient develops fever, leukocytosis, and sacral wound
clinically appears infected, consider osteomyelitis and would
recommend bone biopsy to obtain culture data to direct
antibiotic therapy (his last day of antibiotics was ___
- The patient has an evolving pressure ulcer between the penis
and scrotum. This should be offloaded with a cushioned dressing.
- The patient's wound culture from ___ grew Bacteroides spp that
was beta lactamase resistant. This was thought not to represent
an infection but rather colonization. If the patient develops
fever/leukocytosis and the clinical suspicion for osteomyelitis
is high, consider coverage for ESBL.
- The patient will need ongoing speech and swallow assessment.
He is to remain NPO until he is cleared by speech and swallow
for safe swallowing. He should be re-assessed with a video
speech and swallow evaluation.
- If patient's mental status continues to do well on 4 AEDs,
consider repeat neurological evaluation for de-escalation of his
medications.
- The patient will need Q4H oral care.
- To minimize phlebotomy, consider checking labs on dialysis
days only, as his electrolytes have been stable and his anemia
been a slow downdrift.
- Patient with partial thickness perianal ulcers concerning for
HSV. He should continue on topical acyclovir until the ulcers
resolve.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Abacavir Sulfate 600 mg PO DAILY
2. Ascorbic Acid ___ mg PO BID
3. Aspirin 81 mg PO DAILY
4. Carvedilol 50 mg PO BID
5. CloniDINE 0.4 mg PO TID
6. Efavirenz 600 mg PO DAILY
7. Emtricitabine 200 mg PO QTUES/SAT
8. HydrALAzine 100 mg PO TID
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Lactulose 30 mL PO BID:PRN constipation
11. NIFEdipine CR 60 mg PO BID
12. Omeprazole 20 mg PO BID
13. Sarna Lotion 1 Appl TP BID:PRN itch
14. Sertraline 50 mg PO DAILY
15. sevelamer CARBONATE 800 mg PO TID W/MEALS
16. Terazosin 3 mg PO HS
17. ___ (B complex-vitamin C-folic acid) 0.8 mg oral daily
18. Docusate Sodium 100 mg PO BID
19. Senna 8.6 mg PO BID
20. Nephrocaps 1 CAP PO DAILY
21. Zolpidem Tartrate 5 mg PO HS insomnia
Discharge Medications:
1. Abacavir Sulfate 600 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. FoLIC Acid 1 mg PO DAILY
5. LACOSamide 200 mg PO BID
6. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
7. LeVETiracetam Oral Solution 1000 mg PO DAILY
On HD days, give 1000mg before HD, ___ addition to giving the
separately ordered 500mg after HD
8. LOPERamide 4 mg PO QID:PRN diarrhea
9. Thiamine 100 mg PO DAILY
10. Carvedilol 50 mg PO BID
give after dialysis on HD days
11. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
12. Emtricitabine Oral Solution 240 mg PO 2X/WEEK (___)
13. Senna 8.6 mg PO BID:PRN constipation
14. Acetaminophen 1000 mg PO Q6H:PRN fever
15. Amlodipine 10 mg PO DAILY
okay to give prior to dialysis
16. Valproic Acid ___ mg PO Q8H
17. Raltegravir 400 mg PO BID
18. PHENObarbital 129.6 mg PO BID
19. Multivitamins W/minerals 1 TAB PO DAILY
20. Heparin 5000 UNIT SC TID
21. Isosorbide Dinitrate 40 mg PO Q8H
___ after dialysis on HD days
22. LACOSamide 200 mg IV BID:PRN high tube feed residuals
23. Lanthanum 500 mg PO TID W/MEALS
24. LeVETiracetam 500 mg PO 3X/WEEK (___)
give this medication on dialysis days after dialysis
25. HydrALAzine 100 mg PO Q8H
___ after dialysis on HD days
26. CloniDINE 0.2 mg PO TID
___ after dialysis on HD days
27. Acyclovir Ointment 5% 1 Appl TP Q6H buttocks Duration: 10
Days
28. Losartan Potassium 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Pulseless electrical activity arrest, anoxic brain
injury, myoclonic seizures, anemia, infected sacral decubitus
ulcer, urinary tract infection, aspiration pneumonia
Secondary: End-stage renal disease on hemodialysis, intravenous
drug use, HIV and Hepatitis C
Discharge Condition:
Intermittently attentive to commands ___ ___ ___,
intermittently verbally responds but cannot carry on
conversation. Capable of spontaneous but non-purposeful
movements of the head and LUE. Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You will be
discharged to a rehabilitation facility following a prolonged
hospitalization for PEA complicated by brain injury with some
recovery of mental status. You have PEG tube to receive
nutrition and we recommend a video swallow evaluation at your
rehab to further evaluate your swallowing function. You were
treated with a course of antibiotics for an infected stage III
sacral ulcer, aspiration pneumonia and urinary tract infection.
You have completed all antibiotic treatment and are ready to
transition to a rehabilitation facility where you will continue
dialysis and close monitoring.
Followup Instructions:
___
|
10900387-DS-44
| 10,900,387 | 21,029,515 |
DS
| 44 |
2149-04-26 00:00:00
|
2149-04-28 06:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Rectus sheath hematoma
Major Surgical or Invasive Procedure:
Sacral bone biopsy
History of Present Illness:
___ w/ PMH of ESRD on HD ___, HIV on ART (CD4 73 VL
undetectable), HCV, polysubstance abuse on methadone,
cryoglobulinemia, ___ ___ NICM, resistant hypertension and
GERD, s/p PEA arrest w/neurologic devastation w/seizures on
quadruple AED therapy presenting from ___ rehab with
spontaneous right rectus sheath hematoma.
In the ED initial vitals were: T100.2 P81 BP159/87 RR20 97%.
Temp later increased to 101.2. Labs were notable for Hct 26.6,
which downtrended to 24.7. CT abdomen revealed active
extravasation, likely from the right inferior epigastric artery
resulting in a Right sided rectus sheath hematoma. Both ACS and
___ were consulted. They recommended serial Hcts and abdominal
binder to compress the hematoma. ___ anticipates the hematoma
will tamponade off. 2 20G IVs were placed. His G-tube was found
to be clogged. He was given tylenol and IV valproate. He did not
require any transfusions. He was noted to have hypogycemia of
65, he was given 2 amps of D50.
On transfer, vitals were: 88 143/80 16 100% RA.
On arrival to the MICU, patient is not following commands,
speaking ___ and ___.
Past Medical History:
- HIV: He was diagnosed with HIV in ___. Most recent CD4 373,
___ VL undetectable on last admission. Risk factors included
unprotected heterosexual sex as well as intravenous drug use.
His nadir CD4 count is 91 and he has no known opportunistic
infections.
- s/p PEA arrest ___ acute pulmonary edema from hypertensive
emergency, resulting in anoxic brain injury and myoclonic
seizures.
- Hepatitis C, Genotype 1B. Viral load 187,000 in ___.
- ESRD ___ MPGN d/t hepatitis C and cryoglobulinemia and
hypertensive nephrocalcinosis. On HD ___. LUE AVF c/b
stenosis, s/p angioplasty in ___.
- Cryoglobulinemia
- Cardiomyopathy with an EF of 30%
- Hypertension
- GERD
- Stage IV sacral ulcer
- Gynecomastia; s/p bilateral gynecomastia excision with
liposuction ___
- Polysubstance abuse, including cocaine and alcohol
- s/p PEG placement
Social History:
___
Family History:
Per OMR. Mother and father have hypertension; has 3 brothers, 3
sisters: all healthy, none with hypertension. There is also
family history of type 2 diabetes. No family history of sudden
death and premature atherosclerotic disease.
Physical Exam:
Admission Physical Exam:
GENERAL: Somnolent, speaking words intermittently in ___ and
___, appears cachectic with no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Right medial abdomen TTP with visible buldging of abdominal
wall w/o overlying skin changes, otherwise soft, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN:Large sacral decubitus ulcer.
Discharge Physical Exam:
VS: 98.1 (Tmax 100.3) ___ non-labored breathing 100% RA
General: No acute distress
HEENT: Sclera anicteric, poor dentition, very dry mm
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Abdominal binder in place. Hematoma appears stable in
size, no erythema noted. Skin around PEG with no erythema,
exudate
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No tenderness noted over right or left hip
Skin: Stage IV decubitus ulcer with protruding bone over sacral
area, otherwise intact
Neuro: Responds to commands
Pertinent Results:
Admission Labs:
___ 05:25PM BLOOD WBC-5.7 RBC-2.63* Hgb-8.6* Hct-26.6*
MCV-101* MCH-32.7* MCHC-32.3 RDW-19.1* Plt ___
___ 11:30PM BLOOD Hct-24.1*
___ 05:25PM BLOOD ___ PTT-48.9* ___
___ 05:25PM BLOOD Plt ___
___ 05:25PM BLOOD Glucose-66* UreaN-59* Creat-3.4* Na-134
K-4.0 Cl-95* HCO3-29 AnGap-14
___ 05:35PM BLOOD Lactate-1.1
___ 05:32AM BLOOD WBC-8.8# RBC-2.04* Hgb-6.9* Hct-21.3*
MCV-104* MCH-33.7* MCHC-32.4 RDW-20.4* Plt ___
Other pertinent labs:
T LYMPHOCYTE SUBSET WBC Lymph Abs ___ CD3% Abs CD3 CD4% Abs CD4
CD8% Abs CD8 CD4/CD8
___ 07:15 5.5 10* 550 78 428* 58 319* 18 101* 3.1*
Relevant Microbiology:
___ 1:22 pm SWAB Source: Sacral decubitus ulcer.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final ___:
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 BELOW, THEY ARE NOT
PRESENT in
this culture..
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 1:42 pm SWAB Source: PEG tube.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- 16 R
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 4:40 pm TISSUE SACRAL BONE BIOPSY.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
Blood Cultures through ___: Negative
Blood Cultures drawn ___: NGTD
UCX ___: Pending
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefepime sensitivity testing confirmed by ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Imaging:
ABD ___: No radiographic findings suggestive of free air
or colonic volvulus. Mild colonic distention and air-fluid
levels, which are non-specific findings.
CT ABD/PELVIS (___)
1. Active extravasation likely from the right inferior
epigastric artery into a large right rectus sheath hematoma
2. Splenomegaly.
3. Cardiomegaly.
4. Ectatic common iliac arteries.
5. Small left pleural effusion and left basilar atelectasis
Echocardiogram (___)
No 2D echocardiographic evidence of endocarditis. Compared with
the prior study (images reviewed) of ___ global left
ventricular systolic function has improved somewhat. Pulmonary
pressures are lower. The possible PDA flow is not as well seen.
A very small pericardial effusion is seen. Other findings are
similar.
MRI pelvis (___)
1. Markedly limited study due to patient motion. A soft tissue
ulcer is again seen overlying the sacrococcygeal junction. Edema
within the underlying coccyx is nonspecific in nature, although
could be due to osteomyelitis.
2. Large right-sided rectus sheath hematoma that has ruptured
into the right aspect of the pelvis, overall markedly increased
in size compared to the CT from ___. Of note, active
arterial extravasation was seen on the prior CT. Correlation
with hematocrit trend is recommended.
3. Diffuse intramuscular edema is non-specific in nature,
although can be seen in the setting of myositis. Clinical
correlation is recommended.
CTA Abdomen (___)
1. Interval increase in size of right rectus sheath hematoma
extending into the pelvis compared to CT of ___, but
relatively stable compared MR of the pelvis from ___. No
evidence of active extravasation. Superinfection of the hematoma
cannot be excluded.
2. Bilateral hip joint effusions and fluid in the right
trochanteric bursa.
3. Small bilateral nonhemorrhagic pleural effusions.
4. Cholelithiasis
5. Diffuse anasarca
CXR (___)
1. Right basilar opacity, likely atelectasis, has slightly
increased; and left basilar opacity has improved since the prior
study.
2. Bilateral interstitial opacities persist, most likely edema,
however PCP pneumonia could be considered in the appropriate
clinical setting, as it can have a similar radiographic
appearance.
Discharge Labs:
___ 07:40AM BLOOD WBC-7.7 RBC-2.03* Hgb-6.5* Hct-20.9*
MCV-103* MCH-31.9 MCHC-31.0 RDW-18.9* Plt ___
___ 07:40AM BLOOD Glucose-118* UreaN-77* Creat-2.9* Na-137
K-4.6 Cl-98 HCO3-32 AnGap-12
___ 07:40AM BLOOD LD(LDH)-265* TotBili-0.2
___ 07:40AM BLOOD Calcium-8.0* Phos-3.4 Mg-2.9*
___ 07:30AM BLOOD Hapto-<5*
Brief Hospital Course:
___ w/ PMH of ESRD on HD, HIV on ART, HCV, polysubstance abuse
on methadone, cryoglobulinemia, sCHF ___ NICM, resistant
hypertension and GERD, s/p PEA arrest w/neurologic devastation
w/seizures on quadruple AED therapy presenting from rehab with
spontaneous right rectus sheath hematoma.
ACTIVE ISSUES:
# Rt rectus sheath hematoma: On admission, CT abdomen revealed
active extravasation likely from Rt inferior epigastric arterial
source. Etiology of bleed remains unclear, no obvious inciting
factors were identified and INR was 1.3 on admission. The pt
remained hemodynamically stable throughout his stay in the MICU
though required 5 U PRBC. ACS and ___ evaluated the patient,
however neither service thought that any intervention was
necessary as long as the patient remained stable. Over the next
several days the pt's Hgb and Hct slowly trended down to Hgb 6.9
at which time 1uPRBC was transfused just before discharge.
Patient received a total of 6U PRBC during this admission. This
anemia was thought to be more likely attributable to his chronic
transfusion-related anemia rather than representative of a
continued bleed.
# Stage IV Sacral ulcer: Pt required wound vac upon discharge
from a previous admission. On initial physical exam the ulcer
had a clean base without significant purulence or odor. Wound
care was consulted and determined that the ulcer would likely
again require a wound vac to heal. ACS saw him and performed a
bedside debridement. He was scheduled for outpatient follow up
with ACS to evaluate for need for further
debridement/reconstruction. They can refer him to plastic
surgery if necessary.
# Nutrition/PEG tube: Pt has PEG tube for nutrition. On
admission, the PEG tube was noted to be clogged and was
subsequently unclogged during MICU stay. Tube feeds were
initially held in anticipation of possible procedure if pt
became unstable. Nutrition was consulted and pt was restarted on
tube feed regimen from rehab at their recommendation prior to
leaving the MICU. Pt will need follow-up with speech and swallow
and possibly further evaluation including video swallow study
when he returns to rehab.
# Hypertension:
On arrival patient's home/rehab antihypertensive regimen was
continued. During his MICU stay it was noted on several
occasions that his SBP dropped following his morning medication
administration. As a result, his home isosorbide and hydralazine
were held and his clonidine dose was decreased to 0.1mg TID. His
blood pressures remained well-controlled while in the MICU.
# Anemia: Pt has transfusion-dependent anemia with baseline Hgb
___. The eiology is likely multifactorial, including anemia of
chronic inflammation, secondary to ESRD, iron deficiency for
which he receives IV iron, and GI losses with documented
intermittent guaiac positive stools on last admission. On
previous admission required 10u PRBCs, approx 1u PRBC with every
other HD session which was continued at rehab. Pt required 1u
PRBC for Hgb 6.9 during his stay in the MICU.
# Goals of care: Please see previous discharge summary and
inpatient documentation for extensive family meeting notes
regarding poor prognosis. Ultimately due to neurological
recovery, patient's family felt ___ should be full code upon
discharge from ___ ___. This was readdressed with family
discussion regarding ICU consent and code status during this
admission, with Mother (healthcare decision-maker) keeping ___
full code.
CHRONIC ISSUES:
# Seizure disorder: As a result of PEA arrest, on 4
antiepileptics. Continued home/rehab antiepileptic regimen
during this admission.
# Thrombocytopenia: Stable above 100 during MICU stay. This
problem was worked up over previous admission and thought to be
___ raltegravir vs valproate.
# ESRD: Secondary to MPGN from HepC and cryoglobulinemia and
hypertensive nephrosclerosis on current dialysis regimen of
___ via LUE AVF. Continued dialysis on regular schedule
while in the hospital.
# HIV: Home raltegravir, emtricitabine, abacavir were continued.
# sCHF: No indication of acute cardiac decompensation on
admission. Home medications were continued.
# Chronic HCV infection: Genotype 1b. Viral load on ___ was
61,900 IU/mL. No recent viral load. Polysubstance abuse barrier
to treatment.
# Polysubstance abuse: Recent active user prior to multiple
admissions and neurologic devastation. Home MVI, thiamine and
folate were continued.
# GERD: Home PPI was continued.
TRANSITIONAL ISSUES (FROM ___ DC SUMMARY):
- The patient should recieve IV Iron and Epo at least every
month with dialysis
- Patient will need follow up with plastic surgery to discuss
wound closure
- Patient should have a video swallow evaluation at ___
- Patient needs to complete a 14 day course of abx to treat
urinary tract infection. Cefepime was started on ___ and was
transitioned to cipro due to culture showing some resistance to
cephalosporins. Will complete course ___.
- The patient/ rehabilitation facility will be contacted with
any positive results
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Abacavir Sulfate 600 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. FoLIC Acid 1 mg PO DAILY
5. LACOSamide 200 mg PO BID
6. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
7. LeVETiracetam Oral Solution 1000 mg PO DAILY
8. LOPERamide 4 mg PO QID:PRN diarrhea
9. Thiamine 100 mg PO DAILY
10. Carvedilol 50 mg PO BID
11. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
12. Emtricitabine Oral Solution 240 mg PO 2X/WEEK (___)
13. Senna 8.6 mg PO BID:PRN constipation
14. Acetaminophen 1000 mg PO Q6H:PRN fever
15. Amlodipine 10 mg PO DAILY
16. Valproic Acid ___ mg PO Q8H
17. Raltegravir 400 mg PO BID
18. PHENObarbital 129.6 mg PO BID
19. Multivitamins W/minerals 1 TAB PO DAILY
20. Heparin 5000 UNIT SC TID
21. Isosorbide Dinitrate 40 mg PO Q8H
22. LACOSamide 200 mg IV BID:PRN high tube feed residuals
23. Lanthanum 500 mg PO TID W/MEALS
24. LeVETiracetam 500 mg PO 3X/WEEK (___)
25. HydrALAzine 100 mg PO Q8H
26. CloniDINE 0.2 mg PO TID
27. Acyclovir Ointment 5% 1 Appl TP Q6H buttocks
28. Losartan Potassium 100 mg PO DAILY
Discharge Medications:
1. Abacavir Sulfate 600 mg PO DAILY
2. Acetaminophen 1000 mg PO Q6H:PRN fever
3. Amlodipine 10 mg PO DAILY
4. Carvedilol 50 mg PO BID
5. CloniDINE 0.2 mg PO TID
6. Emtricitabine Oral Solution 240 mg PO 2X/WEEK (___)
7. LACOSamide 200 mg PO BID
8. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
9. LeVETiracetam 500 mg PO 3X/WEEK (___)
10. LeVETiracetam Oral Solution 1000 mg PO DAILY
11. LOPERamide 4 mg PO QID:PRN diarrhea
12. Losartan Potassium 100 mg PO DAILY
13. PHENObarbital 129.6 mg PO BID
14. Raltegravir 400 mg PO BID
15. Thiamine 100 mg PO DAILY
16. Valproic Acid ___ mg PO Q8H
17. Multivitamins 5 mL PO DAILY
18. Ondansetron 4 mg IV Q8H:PRN Nausea
19. Sarna Lotion 1 Appl TP BID:PRN Itch
20. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days
21. Acyclovir Ointment 5% 1 Appl TP Q6H buttocks
22. FoLIC Acid 1 mg PO DAILY
23. HydrALAzine 100 mg PO Q8H
24. Isosorbide Dinitrate 40 mg PO Q8H
25. LACOSamide 200 mg IV BID:PRN high tube feed residuals
26. Multivitamins W/minerals 1 TAB PO DAILY
27. Lanthanum 500 mg PO TID W/MEALS
28. Ciprofloxacin HCl 500 mg PO Q24H Duration: 11 Days
Last day ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Rectus Sheath Hematoma
2. ESRD on HD
3. HIV
4. Chronic Hepatitis C Infection
5. Anoxic Brain Injury s/p PEA arrest
6. Multifactorial Anemia
7. Hypertension
8. Stage IV Sacral Decubitus Ulcer
9. Thrombocytopenia
10. Nutritional Deficiency
11. Systolic Heart Failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
___. You were brought to the hospital because one of the small
arteries in your abdominal wall started bleeding spontaneously.
You were seen by the surgery and radiology teams and it was
determined that the artery stopped bleeding on its own and no
other intervention was needed.
While in the hospital, you also developed fevers which were
likely due to a combination of a urinary tract infection and
your hematoma. You were treated with cefepime started on ___,
which was then changed to ciprofloxacin on ___.
Please continue to take the rest of your home medications as
prescribed.
Followup Instructions:
___
|
10900387-DS-45
| 10,900,387 | 20,272,386 |
DS
| 45 |
2149-05-17 00:00:00
|
2149-05-17 18:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered mental status, anemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ pmh HIV, Hep C, autoimmune hemolytic anemia, abd wall
hematoma, ESRD on HD p/w AMS. Had a full run of HD today after
which she developed decreased level of alertness. No witnessed
seizure activity. While being transported by EMS he became more
arousable. He is currently at his baseline per discussion with
his mother. ___ any recent illnesses. He has had diarrhea
intermittently since starting the tube feeds. History of chronic
anemia, abdominal wall hematoma
Patient was admitted to ___ ___ for rectus sheath
hematoma and stage IV sacral decubitus ulcer. He required 6U
PRBC total during this admission and was discharged with H/H
6.2/___. He has a known chronic anemia that is intermittently
transfusion dependent.
In the ED, initial vitals were: 97.9, 72, 158/77, 20, 100% 3LNC
The patient was found to have H/H ___ and was given 1U PRBC.
Past Medical History:
- HIV: He was diagnosed with HIV in ___. Most recent CD4 373,
___ VL undetectable on last admission. Risk factors included
unprotected heterosexual sex as well as intravenous drug use.
His nadir CD4 count is 91 and he has no known opportunistic
infections.
- s/p PEA arrest ___ acute pulmonary edema from hypertensive
emergency, resulting in anoxic brain injury and myoclonic
seizures.
- Hepatitis C, Genotype 1B. Viral load 187,000 in ___.
- ESRD ___ MPGN d/t hepatitis C and cryoglobulinemia and
hypertensive nephrocalcinosis. On HD ___. LUE AVF c/b
stenosis, s/p angioplasty in ___.
- Cryoglobulinemia
- Cardiomyopathy with an EF of 30%
- Hypertension
- GERD
- Stage IV sacral ulcer
- Gynecomastia; s/p bilateral gynecomastia excision with
liposuction ___
- Polysubstance abuse, including cocaine and alcohol
- s/p PEG placement
Social History:
___
Family History:
Per OMR. Mother and father have hypertension; has 3 brothers, 3
sisters: all healthy, none with hypertension. There is also
family history of type 2 diabetes. No family history of sudden
death and premature atherosclerotic disease.
Physical Exam:
Admission Physical Exam:
Vitals: 97.5 157/81 71 18 100% RA
GENERAL: Somnolent, appears cachectic with no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: visible buldging of R lower abdominal wall w/o overlying
skin changes, otherwise soft, non-distended, non-tender, bowel
sounds present
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN:Large sacral decubitus ulcer.
========================
Discharge Physical Exam:
Vitals: 98.5 (Tmax 100.2) BP 129/62 (104/60-152/67) 86 (86-99)
24 98% RA
GENERAL: Awake, appears cachectic with no acute distress
LUNGS: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: visible buldging of R lower abdominal wall w/o overlying
skin changes, otherwise soft, non-distended, non-tender
EXT: Warm, well perfused, no clubbing, cyanosis or
edema
SKIN: Large sacral decubitus ulcer.
Pertinent Results:
Admission Labs:
___ 11:35AM BLOOD WBC-5.8 RBC-1.86* Hgb-6.1* Hct-18.8*
MCV-101* MCH-32.8* MCHC-32.4 RDW-18.1* Plt Ct-83*
___ 11:35AM BLOOD Glucose-62* UreaN-89* Creat-2.9* Na-135
K-4.8 Cl-97 HCO3-24 AnGap-19
___ 11:35AM BLOOD Albumin-1.7* Calcium-9.4 Phos-5.0*
Mg-3.2*
___ 11:47AM BLOOD Lactate-0.9
___ 11:35AM BLOOD ALT-13 AST-30 AlkPhos-120 TotBili-0.2
___ 11:35AM BLOOD Lipase-60
___ 11:47AM BLOOD ___ pO2-52* pCO2-37 pH-7.48*
calTCO2-28 Base XS-3 Intubat-NOT INTUBA Comment-CENTRAL VE
===============
Imaging:
___ CT Abdomen:
IMPRESSION:
1. Interval decrease in size of the right abdominal wall and
pelvic sidewall hematoma. No other findings to explain
patient's hematocrit drop.
2. Findings suggestive of congestive failure with cardiomegaly,
effusions and edema.
3. Bilateral common iliac artery aneurysms up to 2.0 cm in
size.
4. Cholelithiasis.
___ Noncontrast CT Head:
No acute intracranial process.
___ CXR:
IMPRESSION:
No change in the interstitial disease which has been present on
multiple
previous examinations.
Increased markings in the retrocardiac area which could indicate
early
consolidation. This has improved since the previous examination
although this could be a matter technique.
===============
Pertinent Labs:
TEST RESULT
---- ------
HEPARIN DEPENDENT ANTIBODIES Negative
COMMENT: Negative for Heparin PF4 Antibody Test by ___
___ 06:33AM BLOOD Phenoba-17.0 Valproa-67
===============
Discharge Labs:
___ 06:33AM BLOOD WBC-6.5 RBC-2.13* Hgb-7.0* Hct-21.5*
MCV-101* MCH-32.7* MCHC-32.5 RDW-19.5* Plt ___
___ 06:33AM BLOOD Glucose-59* UreaN-96* Creat-3.5* Na-137
K-4.8 Cl-96 HCO3-26 AnGap-20
___ 06:33AM BLOOD Calcium-9.3 Phos-7.4* Mg-3.2*
Brief Hospital Course:
# Anemia: He has history of chronic anemia, likely
multifactorial in nature due to ESRD, anemia of chronic disease,
and slow GI bleed given history of guiaic positive stools. He
was tranfused 1 unit of PRBCs, after which his hemoglobin and
hematocrit increased appropriately. He was imaged with an
abdominal CT, which showed that the rectus sheath hematoma was
decreased in size. GI was consulted and felt that he may have a
slow GI bleed, but that this accounted for only a small part of
his anemia. They felt that the risk of a colonscopy or other
procedure would outweigh the benefits in this particular case.
Hematology was also consulted about the possibility of hemolysis
given his elevated LDH and low haptoglobin as well as positive
direct Coombs test. They felt that he was not actively
hemolyzing, since titers for the Coombs test were much lower
than what is typically seen in a warm autoimmune hemolytic
anemia. They also felt that his elevated hemolysis labs were due
to reabsorption of blood from his rectus hematoma, with
subsequent RBC breakdown in the circulation. It is likely that
he will require repeated transfusions in the future. He was
transfused an additional unit of PRBCs on ___.
# Unresponsiveness: He was noted to be unresponsive but his
mental status had returned to baseline at time of arrival in the
ED. Neurology was consulted and felt that his anti-epilectic
drugs were optimized in order to minimize sedation but decrease
risk of seizure activity. They recommended checking levels of
his antiepilectic drugs. Phenobarbital and valproate levels were
within normal limits, with lacosamide and keppra levels still
pending. They also felt that hypoglycemia could lead to
increased seizure activity, and so tube feeds were increased to
6 per day to minimize hypoglycemia.
# Thrombocytopenia: Lower than previous baseline but remained
stable throughout admission. This problem was worked up over
previous admission and thought to be
___ raltegravir vs valproate. Heparin was held due to risk of
HIT, but was restarted after heparin dependent antibodies were
negative.
CHRONIC ISSUES:
# Seizure disorder: As a result of PEA arrest, on 4
antiepileptics. Continued home/rehab antiepileptic regimen
during this admission. Phenobarbital and valproate levels were
therapeutic, with lacosamide and keppra still pending.
# ESRD: Secondary to MPGN from HepC and cryoglobulinemia and
hypertensive nephrosclerosis on current dialysis regimen of
___ via LUE AVF. Continued dialysis on regular schedule
while in the hospital.
# HIV: Home raltegravir, emtricitabine, abacavir were continued.
Emtricitabine dosing was changed to conventional dose of 60 mg
Qdaily
# sCHF: No indication of acute cardiac decompensation on
admission. Home medications were continued.
# Chronic HCV infection: Genotype 1b. Viral load on ___ was
61,900 IU/mL. No recent viral load. Polysubstance abuse barrier
to treatment.
# Polysubstance abuse: Recent active user prior to multiple
admissions and neurologic devastation. Home MVI, thiamine and
folate were continued.
# GERD: Home PPI was continued.
Transitional Issues:
- will likely require repeated transfusions for his anemia, and
perhaps a designated transfusion schedule at dialysis would be
appropriate
- The patient should recieve IV Iron and Epo at least every
month with dialysis
- Patient will need follow up with surgery to discuss
wound closure. Has an appointment scheduled for ___
- tube feeds increased to 5 cans per day due to morning
hypoglycemia
- emtricitabine dosing changed to conventional dose of 60 mg
Qdaily (on MWF dose should be given at HD)
- The patient/ rehabilitation facility will be contacted with
any positive results
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Abacavir Sulfate 600 mg PO DAILY
2. Acetaminophen 1000 mg PO Q6H:PRN fever
3. Amlodipine 10 mg PO DAILY
4. Carvedilol 50 mg PO BID
5. CloniDINE 0.2 mg PO TID
6. Emtricitabine Oral Solution 240 mg PO 2X/WEEK (___)
7. LACOSamide 200 mg PO BID
8. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
9. LeVETiracetam 500 mg PO 3X/WEEK (___)
10. LeVETiracetam Oral Solution 1000 mg PO DAILY
11. LOPERamide 4 mg PO QID:PRN diarrhea
12. Losartan Potassium 100 mg PO DAILY
13. PHENObarbital 129.6 mg PO BID
14. Raltegravir 400 mg PO BID
15. Thiamine 100 mg PO DAILY
16. Valproic Acid ___ mg PO Q8H
17. Multivitamins 5 mL PO DAILY
18. Ondansetron 4 mg IV Q8H:PRN Nausea
19. Sarna Lotion 1 Appl TP BID:PRN Itch
20. Zinc Sulfate 220 mg PO DAILY
21. Acyclovir Ointment 5% 1 Appl TP Q6H buttocks
22. FoLIC Acid 1 mg PO DAILY
23. HydrALAzine 100 mg PO Q8H
24. Isosorbide Dinitrate 40 mg PO Q8H
25. LACOSamide 200 mg IV BID:PRN high tube feed residuals
26. Multivitamins W/minerals 1 TAB PO DAILY
27. Lanthanum 500 mg PO TID W/MEALS
Discharge Medications:
1. Abacavir Sulfate 600 mg PO DAILY
2. Acetaminophen 1000 mg PO Q6H:PRN fever
3. Acyclovir Ointment 5% 1 Appl TP Q6H buttocks
4. Amlodipine 10 mg PO DAILY
5. Carvedilol 50 mg PO BID
6. CloniDINE 0.2 mg PO TID
7. FoLIC Acid 1 mg PO DAILY
8. HydrALAzine 100 mg PO Q8H
9. Isosorbide Dinitrate 40 mg PO Q8H
10. LACOSamide 200 mg PO BID
11. LACOSamide 200 mg IV BID:PRN high tube feed residuals
12. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
13. Lanthanum 500 mg PO TID W/MEALS
14. LeVETiracetam 500 mg PO 3X/WEEK (___)
15. LeVETiracetam Oral Solution 1000 mg PO DAILY
16. LOPERamide 4 mg PO QID:PRN diarrhea
17. Losartan Potassium 100 mg PO DAILY
18. Multivitamins 5 mL PO DAILY
19. Ondansetron 4 mg IV Q8H:PRN Nausea
20. PHENObarbital 129.6 mg PO BID
21. Raltegravir 400 mg PO BID
22. Sarna Lotion 1 Appl TP BID:PRN Itch
23. Thiamine 100 mg PO DAILY
24. Valproic Acid ___ mg PO Q8H
25. Zinc Sulfate 220 mg PO DAILY
26. Heparin 5000 UNIT SC TID
27. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
28. Emtricitabine Oral Solution 60 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Anemia
Altered mental status
Secondary:
Rectus Sheath Hematoma
ESRD on HD
HIV
Chronic Hepatitis C Infection
Anoxic Brain Injury s/p PEA arrest
Hypertension
Stage IV Sacral Decubitus Ulcer
Thrombocytopenia
Nutritional Deficiency
Systolic Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
You were admitted to the hospital because you were anemic, which
is a problem that you have had before. You received a blood
transfusion and the anemia improved. We think that many things
are causing your anemia, including kidney disease and low levels
of iron. You may need to get blood transfusions at dialysis
sometimes. The GI doctors saw ___ and did not think you needed
any procedures.
Please see your appointments below.
Followup Instructions:
___
|
10900387-DS-46
| 10,900,387 | 22,496,293 |
DS
| 46 |
2149-07-06 00:00:00
|
2149-07-06 19:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
___: Endotracheal intubation en route to ___
___: Bronchoscopy with removal of mucous plug
___: Tracheostomy and PEG tube placement
History of Present Illness:
___ male with anoxic brain injury admitted to ___ after being
intubated ___ the ED for respiratory distress. Over the past two
days at his rehab facility, the patient has been having
worsening of mental status. He had tachypnea to 32-36 and was
not responding to his name, which is a change from his reported
baseline, which is AAOx1. He had a CXR that showed worsening of
his CHF compared to two weeks prior. He was transferred to
___, and this morning he was progressively congested and
tachypneic, and developed a fever. He had an ABG 7.___.
Therefore, he was transferred to the ED here for further
management.
On the way here, he was noted to be rhoncorous and tachypnic,
but maintained his sats. ___ the ED, he went into respiratory
failure and had to be intubated.
Vitals ___ ED: T103.2F HR99 BP145/85 RR24 Sat94%NC. Labs notable
for WBC 8.3, Cr 2.5, Na 129, bicarb 17, lactate 1.1, UA Hazy
WBC>182 Bac:mod Blood:tr Nit:neg. CXR notable for L lung
collapse with leftward shift of mediastinal structures and
abrupt cut off of the distal left mainstem bronchus suggestive
of an endobronchial lesion such as mucous plugging. CT with left
lung collapse and left pleural effusion. He was started
empirically on vanc/zosyn.
On arrival to the floor, pt was intubated and ___ stable
condition.
Past Medical History:
- HIV: He was diagnosed with HIV ___ ___. Most recent CD4 373,
___ VL undetectable on last admission. Risk factors included
unprotected heterosexual sex as well as intravenous drug use.
His nadir CD4 count is 91 and he has no known opportunistic
infections.
- s/p PEA arrest ___ acute pulmonary edema from hypertensive
emergency, resulting ___ anoxic brain injury and myoclonic
seizures.
- Hepatitis C, Genotype 1B. Viral load 187,000 ___ ___.
- ESRD ___ MPGN d/t hepatitis C and cryoglobulinemia and
hypertensive nephrocalcinosis. On HD ___. LUE AVF c/b
stenosis, s/p angioplasty ___ ___.
- Cryoglobulinemia
- Cardiomyopathy with an EF of 30%
- Hypertension
- GERD
- Stage IV sacral ulcer
- Gynecomastia; s/p bilateral gynecomastia excision with
liposuction ___
- Polysubstance abuse, including cocaine and alcohol
- s/p PEG placement
Social History:
___
Family History:
Mother and father have hypertension; has 3 brothers, 3 sisters:
all healthy, none with hypertension. There is also family
history of type 2 diabetes. No family history of sudden death
and premature atherosclerotic disease.
Physical Exam:
ADMISSION EXAM:
================
Vitals- T:98.6F BP:157/83 P:73 R:21 O2:96% intubated on 70% FiO2
General: Not arousable to name, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: on R, diffuse rhonchi; on L, decreased breath sounds,
particularly at the base
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 present
Ext: warm, well perfused, edema ___ both hands b/l, 2+ pulses, no
clubbing, cyanosis or edema
DISCHARGE EXAM:
================
Vitals: 37.3 100 112/65 29 99%
General: Not arousable to name, no acute distress. Minimally
intermittently opening eyes.
HEENT: Sclera anicteric, MMM,3mm equal with sluggish reaction to
light.
Neck: supple, JVP not elevated, no LAD
Lungs: Coarse breath sounds anteriorly, bilaterally; noted to
have periods of apnea; on trach mask
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds
diminished, no rebound tenderness or guarding, PEG tube ___ place
with surrounding gauze
GU: no foley
Ext: warm, well perfused, edema ___ both hands b/l, 2+ pulses, no
clubbing, cyanosis or edema
Pertinent Results:
ADMISSION LABS:
===============
___ 12:02PM BLOOD WBC-8.3 RBC-2.53* Hgb-8.6* Hct-26.1*
MCV-103* MCH-34.0* MCHC-33.0 RDW-18.9* Plt Ct-86*
___ 12:02PM BLOOD Neuts-68 Bands-1 Lymphs-11* Monos-16*
Eos-0 Baso-0 ___ Myelos-4*
___ 12:02PM BLOOD ___ PTT-40.9* ___
___ 12:02PM BLOOD Glucose-67* UreaN-60* Creat-2.5* Na-129*
K-5.0 Cl-97 HCO3-17* AnGap-20
___ 06:41PM BLOOD ALT-7 AST-28 LD(LDH)-160 AlkPhos-159*
TotBili-0.5
___ 12:02PM BLOOD Calcium-10.1 Phos-5.1*# Mg-2.5
___ 12:02PM BLOOD Valproa-53
___ 02:34PM BLOOD Type-ART Rates-14/ Tidal V-450 PEEP-5
FiO2-100 pO2-148* pCO2-30* pH-7.39 calTCO2-19* Base XS--5
AADO2-544 REQ O2-89 -ASSIST/CON Intubat-INTUBATED
___ 12:10PM BLOOD Lactate-1.1
___ 12:15PM URINE Color-Yellow Appear-Hazy Sp ___
___ 12:15PM URINE Blood-TR Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 12:15PM URINE RBC-3* WBC->182* Bacteri-MOD Yeast-NONE
Epi-0
INTERIM LABS:
===============
___ 04:12AM BLOOD WBC-7.8 RBC-2.17* Hgb-7.4* Hct-22.2*
MCV-102* MCH-34.1* MCHC-33.3 RDW-19.8* Plt Ct-71*
___ 02:30PM BLOOD WBC-7.8 RBC-2.73*# Hgb-9.6*# Hct-27.4*
MCV-101* MCH-35.1* MCHC-35.0 RDW-20.1* Plt Ct-85*
___ 04:18AM BLOOD WBC-13.3*# RBC-2.43* Hgb-8.1* Hct-24.6*
MCV-101* MCH-33.3* MCHC-33.0 RDW-20.0* Plt ___
___ 11:12AM BLOOD ___ PTT-50.8* ___
___ 03:30PM BLOOD Glucose-99 UreaN-72* Creat-3.4* Na-135
K-3.3 Cl-97 HCO3-19* AnGap-22*
___ 04:18AM BLOOD Glucose-88 UreaN-38* Creat-2.2*# Na-131*
K-3.7 Cl-92* HCO3-29 AnGap-14
___ 04:12AM BLOOD CK(CPK)-20*
___ 03:30PM BLOOD CK(CPK)-17*
___ 04:12AM BLOOD CK-MB-1 cTropnT-0.21*
___ 03:30PM BLOOD CK-MB-1 cTropnT-0.19*
___ 03:06AM BLOOD PTH-21
___ 03:06AM BLOOD 25VitD-17*
___ 09:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
___ 07:50PM BLOOD Phenoba-11.8 Valproa-47*
___ 03:31PM BLOOD ___ pO2-51* pCO2-39 pH-7.42
calTCO2-26 Base XS-0
___ 06:09AM BLOOD Lactate-1.0
___ 03:31PM BLOOD Lactate-1.8
DISCHARGE LABS:
===============
___ 03:57AM BLOOD WBC-10.3 RBC-2.29* Hgb-7.8* Hct-23.9*
MCV-105* MCH-34.0* MCHC-32.5 RDW-21.8* Plt ___
___ 03:57AM BLOOD Glucose-102* UreaN-25* Creat-1.9*# Na-137
K-3.3 Cl-98 HCO3-28 AnGap-14
___ 03:57AM BLOOD Calcium-8.7 Phos-2.1*# Mg-2.1
IMAGING:
===============
CXR ___:
Left lung collapse with probable small component of left pleural
effusion. Underlying pneumonia cannot be excluded.
CT CHEST ___:
IMPRESSION: Complete left lung collapse with secretions filling
the airways. Bronchoscopy is recommended. There is a small
simple pleural effusion and no evidence of empyema.
CXR ___:
Re-expansion of the left lung with residual retrocardiac opacity
which likely reflects a combination of atelectasis and pleural
fluid.
ECG ___:
Sinus rhythm. Left ventricular hypertrophy. Compared to the
previous tracing of ___ no diagnostic interval change.
CXR ___:
Endotracheal tube has its tip 4 cm above the carina. The right
subclavian PICC line is unchanged. There has been interval
removal of the nasogastric tube. Cardiac and mediastinal
contours are stable. There is improving aeration at the left
base with residual patchy opacity which likely reflects
persistent partial lower lobe atelectasis. Overall, the
pulmonary markings are more prominent which suggests a component
of superimposed mild pulmonary edema. Clinical correlation is
advised. No pneumothorax.
EEG ___:
This is an abnormal EEG because of occasional bilateral
frontocentral discharges with shifting laterality but without
any evolution. These findings are indicative of cortical
irritability ___ these regions with an increased risk of
epileptogenesis. The slow background can be seen with global
cerebral dysfunction, such as with anoxia and is consistent with
moderate encephalopathy. No state changes nor reactivity to
noxious stimulation was appreciated.
MRI Head ___:
Large intraparenchymal hemorrhage centered ___ the right insula
and temporal lobe with extensive surrounding vasogenic edema and
mass effect as detailed above. Differential diagnosis includes
hypertensive hemorrhage, an underlying hemorrhagic mass, and a
primary vascular lesion such as an AVM.
CT Head ___:
Moderate-sized, 5.9 x 3.4 x5.3 cm acute intraparenchymal
hematoma ___ the right frontal and temporal lobes with moderate
surrounding edema and left or shift of midline structures with
mass effect on the right lateral ventricle. A smaller dense
focus ___ the left sub insular location may represent another
focus of acute-subacute hemorrhage.
MICROBIOLOGY:
==============
___ 12:02 pm BLOOD CULTURE (Final ___: NO GROWTH.
___ 12:15 pm URINE (Final ___: <10,000
organisms/ml.
___ 1:25 pm BLOOD CULTURE (Final ___: NO GROWTH.
___ 2:02 pm SPUTUM
GRAM STAIN (Final ___:
___ PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
___ 6:41 pm MRSA SCREEN (Final ___: POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS.
___ 10:30 pm BRONCHIAL WASHINGS
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
OF THREE COLONIAL MORPHOLOGIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
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 ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
___ 9:20 am BLOOD CULTURE (Final ___: NO GROWTH.
___ 10:13 am BLOOD CULTURE (Final ___: NO GROWTH.
___ 11:12 am SPUTUM
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
Brief Hospital Course:
BRIEF SUMMARY
=============
___ male with HIV, HCV and anoxic brain injury transferred to
the ICU with respiratory distress s/p bronchoscopy with removal
of mucous plug with course complicated by intracranial
hemorrhage not amenable to surgical treatment.
ACTIVE ISSUES
===============
# Brain hemorrhage: Patient initially presented with AMS, with
mental status decreased from baseline. Unable to assess ___ the
FICU on admission due to intubation for respiratory failure (see
below). However, when patient was weaned off sedation, he had
minimal improvement of mental status, not responding to voice or
noxious stimuli. MRI obtained ___ showed large amount of
intraparenchymal hemorrhage centered ___ the right cerebral
hemisphere. EEG performed with occasional discharges and shows
moderate encephalopathy. Neuro c/s on ___ and did not recommend
aggressive interventions. BP was controlled initially with
labetalol gtt and eventually transitioned to a regimen of
multiple oral anti-hypertensives (amlodipine, clonidine,
hydralazine, isosorbide dinitrate, labetalol, lisinopril). The
patient was noted to have intermittent fevers, which were
believed to be related to his neurologic insult. Infectious
workup was negative.
# Goals of care: Family is noted to be very religious and
believes ___ miracles. Per PCP ___, has had extensive
conversations ___ the past and family still wishes patient to be
full code. Family meeting was held on ___ with ICU attending
and neurology attending present. Neurology communicated to the
family that there would not be any aggressive measures
indicated. A medical decision was made to amke the patient DNR
during this hospitalization should he have cardiac arrest. On
transfer to ___, pt's code status is DNR, okay to
ventilate via trach.
# Respiratory failure: On admission, the patient presented with
respiratory failure with his imaging showing a L pleural
effusion and collapse of lung, with possible necrotic foci. This
is changed from two weeks ago, when no effusion or atelectasis
was noted. On the CT, it was also noted there is a mucous plug
___ the L mainstem bronchus. Bronchoscopy was performed on ___
with removal of plug. Sputum grew MRSA and the patient was
treated with vanc x 8 days per HD protocol. His ventilator
settings were essentially weaned with favorable RSBI; however
due to low GCS score and inability to protect airway (no gag, no
cough reflex), he was kept intubated. IP placed a trach on ___
and the patient was on trach collar at discharge.
# Sacral ulcer: Patient has had a history of stage IV sacral
ulcer prior to this admission. Over hospitalization, appeared to
worsen with increasing drainage. Surgery was consulted and
performed minimal debridement. Surgery suggested that the
patient may be a candidate for stool diversion with colostomy ___
the future, though he is not a candidate for this surgery at the
present time given his poor baseline status. This evaluation was
communicated to the patient's primary care physician, ___
___.
CHRONIC ISSUES
==============
# Anoxic brain injury with seizures: The patient has a history
of anoxic brain injury on prior hospitalization now with
seizures. He was maintained on his home anti-epileptic regimen
(valproic acid, lacosamide, phenobarb, keppra).
# ESRD: secondary to HepC-induced MPGN. On MWF HD that was
continued ___. His lanthanum was discontinued ___ the
setting of low phos levels and because it was clogging the PEG
tube. Per renal, he may be initiated on calcium acetate or
calcium carbonate should he require a phos binder. Additionally,
they recommended checking biweekly labs checks rather than daily
labs.
# Hypertension: Patient had episode of hypotension upon
transport to CT on ___. All anti-hypertensive medications were
stopped except PO clonidine. ___ the setting of his hemorrhagic
brain bleed, the patient was started on a labetalol gtt to
control blood pressure. Patient was resumed on oral
anti-hypertensives per PEG tube on ___ (see above).
# Thrombocytopenia: On admission, plt was 86. Has been
intermittently low ___ the past. Platelets remained stable
throughout hospitalization.
# Chronic anemia: Secondary to ESRD. At baseline.
# HIV: Last CD4 count was 319 ___ ___, viral load
undetectable ___ ___. He was continued on his home HHART
regimen.
# Hepatitis C: Liver fxn has been stable, no cirrhosis ever
noted.
#GERD: stable. Continued on home lansoprazole.
TRANSITIONAL ISSUES:
====================
-DNR while ___ ICU
-Pt has intermittent fevers with negative infectious workup.
Fevers are believed to be secondary to CNS insult.
-Family requests that mother not be told about prognosis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Abacavir Sulfate 600 mg PO DAILY
2. Acetaminophen 1000 mg PO Q6H:PRN fever
3. Acyclovir Ointment 5% 1 Appl TP Q6H buttocks
4. Amlodipine 10 mg PO DAILY
5. Carvedilol 50 mg PO BID
6. CloniDINE 0.2 mg PO TID
7. FoLIC Acid 1 mg PO DAILY
8. HydrALAzine 100 mg PO Q8H
9. Isosorbide Dinitrate 40 mg PO Q8H
10. LACOSamide 200 mg PO BID
11. LACOSamide 200 mg IV BID:PRN high tube feed residuals
12. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
13. Lanthanum 1000 mg PO TID W/MEALS
14. LeVETiracetam 500 mg PO 3X/WEEK (___)
15. LeVETiracetam Oral Solution 1000 mg PO DAILY
16. LOPERamide 4 mg PO QID:PRN diarrhea
17. Losartan Potassium 100 mg PO DAILY
18. Multivitamins 5 mL PO DAILY
19. Ondansetron 4 mg IV Q8H:PRN Nausea
20. PHENObarbital 129.6 mg PO BID
21. Raltegravir 400 mg PO BID
22. Sarna Lotion 1 Appl TP BID:PRN Itch
23. Thiamine 100 mg PO DAILY
24. Valproic Acid ___ mg PO Q8H
25. Zinc Sulfate 220 mg PO DAILY
26. Heparin 5000 UNIT SC TID
27. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
28. Emtricitabine Oral Solution 60 mg PO Q24H
29. Piperacillin-Tazobactam 2.25 g IV Q8H
30. Vancomycin 1000 mg IV Q 12H
Discharge Medications:
1. Abacavir Sulfate 600 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. CloniDINE 0.2 mg PO TID
4. Emtricitabine Oral Solution 60 mg PO Q24H
5. FoLIC Acid 1 mg PO DAILY
6. Heparin 5000 UNIT SC TID
7. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
8. HydrALAzine 100 mg PO Q8H
9. Isosorbide Dinitrate 40 mg PO Q8H
10. LACOSamide 200 mg PO BID
11. LACOSamide 200 mg IV BID:PRN high tube feed residuals
12. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
13. LeVETiracetam 500 mg PO 3X/WEEK (___)
14. LeVETiracetam Oral Solution 1000 mg PO DAILY
15. Multivitamins 5 mL PO DAILY
16. Ondansetron 4 mg IV Q8H:PRN Nausea
17. PHENObarbital 129.6 mg PO BID
18. Raltegravir 400 mg PO BID
19. Sarna Lotion 1 Appl TP BID:PRN Itch
20. Thiamine 100 mg PO DAILY
21. Valproic Acid ___ mg PO Q8H
22. Zinc Sulfate 220 mg PO DAILY
23. Artificial Tear Ointment 1 Appl BOTH EYES BID:PRN not
blinking
24. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
25. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
26. Labetalol 600 mg PO TID
hold for SBP <100
27. Lisinopril 5 mg PO DAILY
28. Senna 8.6 mg PO BID:PRN Constipation
29. Acyclovir Ointment 5% 1 Appl TP Q6H buttocks
30. Acetaminophen (Liquid) 650 mg PO Q6H Duration: 2 Weeks
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
-acute hypoxemic respiatory distress secondary to mucous plug
-hemorrhagic stroke
Secondary Diagnosis:
-resistant hypertension
-anoxic brain injury
-end stage renal disease on hemodialysis
Discharge Condition:
Mental Status: unresponsive to voice, sternal rub, or noxious
stimuli
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were found to have some mucous
that was blocking your airways causing you to have shortness of
breath. The mucous was removed, however it was difficult to take
you off the breathing machine (ventilator) given your altered
mental status. An MRI of your head showed that you had a major
bleed that most likely contributed to your altered mental
status. Since then, you had a tube connected to your windpipe
(tracheostomy) to continue helping you breath. ___ addition, you
had a stomach tube (PEG) placed for nutrition. Your blood
pressure also has been elevated and required several medications
to control at an appropriate level.
Please follow-up with the appointments listed below.
Wishing you the best of health,
Your ___ team
Followup Instructions:
___
|
10900906-DS-18
| 10,900,906 | 25,499,884 |
DS
| 18 |
2158-12-23 00:00:00
|
2158-12-23 16:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin / Ibuprofen / Fentanyl
Attending: ___
Chief Complaint:
acute on chronic chest pain
Major Surgical or Invasive Procedure:
___ Intravenous ketamine infusion
History of Present Illness:
___ Year old male with chronic chest pain following electrocution
presented to the ___ ED with chest pain similar to prior
episodes.
He reports the pain is an intense left side burn pain that is
located on the left side of his chest from the lower rib cage to
collar bone. He is followed by Dr. ___ chronic pain
service and recently started on IV ketamine infusions with
limited improvment of pain. Of note, patient had decreased
ketamine from 50mg 4x daily to 25mg TID with ketamine 50mg at
bedtime on ___. He doesn't believe the ketamine is working
well and wants to stop.
.
In the ED, initial vs were: 96 101 130/84 20 100% Labs were
remarkable for Trop-T: <0.01, Cr 1.1. CXR showed: EKG showed:
He was given morphine total 8mg, 1mg dilaudid. The patient was
encourage to be admitted so that the pain service could see him
prior to his already scheduled thurday appointment. He reported
that he was feeling well prior to transfer after recieving IV
Diluadid. Vitals on Transfer: T 98.1 hr 83 b/p ___ rr21 02
sat 97 %
.
On the floor, vs were: T-98.0 P-94 BP-118/86 R-18 96% O2 sat
on RA. He reports that his pain is marketly improved to his
typical baseline of ___.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
Chronic left chest/arm myofascial pain s/p electrocution (___)
- Working at home in basement using an outlet connected to
clothes washer
Hypertension
Severe GERD
Dust mite, seasonal allergies
Ventral hernia repair (___)
Social History:
___
Family History:
Positive for maternal history of arthritis, cancers, multiple
sclerosis. No history of diabetes, sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T-98.0 P-94 BP-118/86 R-18 96% O2 sat on RA.
General: Alert, oriented, no acute distress, resting comfortably
in bed, obese
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no lesions
Neuro: non-focal
.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.3 (98.5) 137/82 (111-137/83-86)
84 (72-88) 16 (___) 98%RA (94-98RA)
General: Alert, oriented, no acute distress, lying comfortably
in bed, obese
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no lesions
Neuro: non-focal
Pertinent Results:
ADMISSION LABS:
___ 12:05PM BLOOD WBC-5.9 RBC-4.87 Hgb-14.8 Hct-40.6 MCV-83
MCH-30.5 MCHC-36.5* RDW-12.6 Plt ___
___ 12:05PM BLOOD Neuts-65.7 ___ Monos-7.8 Eos-2.2
Baso-0.6
___ 12:05PM BLOOD Glucose-98 UreaN-18 Creat-1.1 Na-139
K-4.5 Cl-101 HCO3-31 AnGap-12
___ 12:05PM BLOOD cTropnT-<0.01
.
DISCHARGE LABS:
___ 05:50AM BLOOD WBC-5.5 RBC-4.39* Hgb-13.4* Hct-36.2*
MCV-83 MCH-30.6 MCHC-37.1* RDW-12.9 Plt ___
___ 05:50AM BLOOD Glucose-94 UreaN-21* Creat-1.1 Na-142
K-4.0 Cl-104 HCO3-29 AnGap-13
___ 05:50AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.2
.
IMAGING:
___ EKG: Normal sinus rhythm. Crista pattern in lead V1, a
normal variant. Early precordial R wave transition of uncertain
significance. Diffuse non-specific ST-T wave abnormalities.
Compared to the previous tracing of ___ ventricular ectopic
activity is no longer seen. Rate 90 bpm, PR 152, QRS 88, QTc
394.
.
___ CXR PA/lat: The cardiomediastinal and hilar contours are
normal. The lung volumes are low, but no focal consolidation,
pleural effusion, or pneumothorax is seen. Bibasilar opacities
suggestive of atelectasis are noted.
IMPRESSION: No acute cardiopulmonary pathology, especially no
pneumothorax.
Brief Hospital Course:
___ year old gentleman, with chronic chest pain following
electrocution, admitted with chest pain similar to prior
episodes.
.
.
ACTIVE ISSUES:
# Chest pain: History of of CRPS type 1 status post
electrocution injury ___ years ago, admitted with constant
burning pain in the left chest for 4 days. Unclear what
exacerbation for this episode is, possibly development of higher
tolerance, given long-term treatment. Cardiac origin of pain was
less likely, given duration of pain for four days, no ischemic
EKG changes, and negative troponin. Initially, patient's pain
was controlled with hydromorphone IV, since it did not respond
to hydromorphone PO, on top of his home tramadol and baclofen.
Patient was evaluated by the chronic pain service, who
recommended increasing his tramadol, and giving a ketamine IV
infusion while in house. Patient received ketamine infusion on
___, and developed lightheadedness after the infusion, but
was hemodynamically stable throughout. At the time of discharge,
pain had decreased to ___. Patient will be followed closely by
the chronic pain clinic, and by cognitive behavioral therapy
specialists soon after discharge for longterm pain management.
There is a large component of somatization of the patient's
depression involved in his chronic pain. He was discharged with
a small amount of oral hydromorphone for breakthrough pain.
.
.
CHRONIC ISSUES:
# GERD: Well controlled on omeprazole at home. Was covered with
pantorpzole (on formulary) while in house.
.
.
TRANSITIONAL ISSUES:
# Per Chronic Pain Service, there is a large component of
somatization of depressive symptoms involved in the patient's
chronic pain. Close follow-up with CBT may be extremely
beneficial.
# Patient mentioned that he has intermittent episodes of
sweating and shaking, with and without anxiety. We understand
that work-up of these symptoms has started. Would consider
imaging of adrenals to evaluate for pheochromocytoma.
Medications on Admission:
Lyrica 300 mg TID
Omeprazole 40 mg daily
Baclofen 20 mg TID
Tramadol 50 mg BID then
Tramadol 100mg at Bedtime
Carbamazepine 200 mg TID
Sucralfate 100 mg/mL 1 tablespoon by mouth three to four times
daily with meals
Fluticasone 50 mcg 2 sprays intranasal once daily
ketamine 25mg two to three times daily
Ketamine 50mg At bedtime.
Discharge Medications:
1. Lyrica 300 mg Capsule Sig: One (1) Capsule PO three times a
day.
2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. baclofen 20 mg Tablet Sig: One (1) Tablet PO three times a
day.
4. tramadol 50 mg Tablet Sig: Two (2) Tablet PO three times a
day.
Disp:*180 Tablet(s)* Refills:*2*
5. carbamazepine 200 mg/10 mL Suspension Sig: Two Hundred (200)
mg PO TID (3 times a day).
6. sucralfate 100 mg/mL Suspension Sig: One (1) tablesppon PO
___ times per day: with meals.
7. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
sprays Nasal once a day.
8. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO q6 hours
PRN as needed for breakthrough pain.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Acute on chronic chest pain (CRPS Type 1)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to participate in your care here at ___
___! You were admitted with an acute
exacerbation of your chronic chest pain. We gave you a ketamine
infusion and adjusted your home medications to control your
pain.
Please note, the following changes have been made to your
medications:
1.) CHANGE TRAMADOL to 100 mg by mouth three times a day
2.) For breakthrough pain, please take HYDROMORPHONE 2 mg by
mouth every six hours as needed
3.) Please stop your oral ketamine, until you see the Pain
Medicine specialists
Please continue to take all of your other pain medications as
you had prior to this hospitalization. It is important that you
follow up with your doctors at the ___ listed below.
Wishing you all the best!
Followup Instructions:
___
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2160-04-05 16:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Aspirin / Ibuprofen / Nucynta
Attending: ___.
Chief Complaint:
severe low back pain that radiates to the left foot anteriorly
Major Surgical or Invasive Procedure:
___ L5 lami with fusion L5-S1
History of Present Illness:
This is a ___ year old male with history of spinal cord
stimulator was to undergo low back surgery today which was
cancelled. The patient presents to the ED this morning with
worsening low back pain over the past week. The pain is
progressively worse and radiates anteriorly to the thigh down to
the ankle and to the large toe. The patient has numbness and
tingling sensation in this distribution as well. He states that
he is weak secondary to pain and can not ambulate on his leg.
He
walks with a cane at baseline. Currently he takes gabapentin 800
mg TID and fentanyl patch 50 mcq changed every 72 hours which is
not providing relief.
The patient denies urine or bowel incontinence. He does report
urinary retention. The patient was bladder scanned and post
void
was found to have 325cc of residual urine in the bladder.
Past Medical History:
Chronic left chest/arm myofascial pain s/p electrocution (___)
- Working at home in basement using an outlet connected to
clothes washer
Hypertension
Severe GERD
Dust mite, seasonal allergies
Ventral hernia repair (___)
Social History:
___
Family History:
Positive for maternal history of arthritis, cancers, multiple
sclerosis. No history of diabetes, sudden cardiac death. mother
passed away from breast CA
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
O: T:96 BP: 138/105 HR:106 R: 18 O2Sats: 98% on room air
Gen: WD/WN, comfortable,facial grimaces with movement
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
ON LEFT ___- appears full strength but patient gives
full effort then breaks.
Sensation: Intact to light touch bilaterally.
PHYSICAL EXAM ON DISCHARGE:
A&Ox3
PERRL
Motor: full strength throughout
Incision: c/d/i, staples in place
Pertinent Results:
___ 03:22AM BLOOD WBC-12.6* RBC-5.16 Hgb-15.3 Hct-43.8
MCV-85 MCH-29.6 MCHC-34.9 RDW-12.7 Plt ___
___ 08:20AM BLOOD Neuts-74.6* ___ Monos-4.9 Eos-1.5
Baso-0.6
___ 03:22AM BLOOD Plt ___
___ 08:20AM BLOOD ___ PTT-31.7 ___
___ 08:20AM BLOOD Glucose-104* UreaN-12 Creat-0.9 Na-142
K-4.2 Cl-104 HCO3-26 AnGap-16
___: Chest x-ray
No consolidation.
___: AP/Lat Lumbar
The patient is status post L5 through S1 posterior spinal fusion
and laminectomy procedure, with hardware in place. At the time
of this
dictation, a CT scan has been performed separately to more fully
evaluate the hardware placement. Please see clip ___ for
full evaluation of the hardware by CT.
___ CT L-spine
IMPRESSION:
1. S/p instrumented posterior L5-S1 fusion as described above.
2. Unchanged 1.4 cm anterolisthesis of L5 on S1.
3. Postsurgical posterior paravertebral fluid. Its relationship
to the spinal
canal is poorly seen due to hardware-related artifacts.
___ CXR
The cardiomediastinal contours are stable in appearance
allowing
for slightly greater lung volumes on the current study compared
to the prior. Improving aeration at the right lung base with
residual patchy opacity, likely due to patchy atelectasis.
Minor atelectasis is also demonstrated in the left retrocardiac
area. No new areas of consolidation to suggest the presence of
pneumonia, and no evidence of pleural effusion or pneumothorax.
___: Blood Culture
GRAM POSITIVE COCCI IN CLUSTERS.
___ Urinary Analysis
No growth
CHEST (PORTABLE AP) ___
In comparison with study of ___, there is little overall change.
The patient has taken a slightly better inspiration. Minimal
atelectatic
changes are seen at the right and left bases with no vascular
congestion or pleural effusion. The stimulator devices remain
in place nears the thoracic inlet.
Brief Hospital Course:
The patient was admited to neurosurgery on ___. The patient
went to the OR and underwent an L5-S1 lami with fusion. The
patient tolerated the procedure well. He was extubated in the
OR, taken to PACU to recover. Please refer to operative note for
details. Post operatively the patient was on a Dilaudid PCA.
Diet was advanced as tolerated.
___: The patient PCA was discontinued and he was started on
increased oral pain medications. He was fitted for a LSO brace.
___: Mr. ___ was complaining of ___ pain despite his
agressive regimen. Chronic pain was consulted because of a past
history of dilaudid abuse and a concern from the family about
opiod dependence. They recommended that that we d/c the dilaudid
and start him on long acting pain regimen. Given that the
patient continued to have low grade fevers while on
acetaminophen a urine analysis was obtained which was negative
for infection. A chest x-ray was obtained which showed no
consolidation.
On ___, patient refused to get OOB. Once encouraged and OOB with
___, he complained of dizziness and headaches. He was placed on
fiorcet. On ___, patient continued to report headaches once in
elevated position. Some scant drainage was seen on patient
sheets from incision, but he was not actively draining and no
collection seen. His hemocrit was decreasing from yesterday and
now is 29.1. He was bolused 1L of NS for low blood pressure and
tachycardia. A u/a was resent. His HOB was lowered to flat for 3
hours with no improvement in headaches, he was slowly elevated.
On ___, patient reported LLE pain located in the back of the
leg, l-spine films were normal, CT L-spine was ordered. Valium
was changed to tizanidine. He was encouraged to be OOB. Patient
had a temp of 101.4, CXR was done and cultures were sent.
___: Mr. ___ foley was removed. He was still complaining of
back pain and dizziness when sitting up in bed. Physical therpay
evaluated the patient and felt that while his strengths were
good, his L knee was buckling when he walked. They recommended
rehab.
___: Blood cultures from the ___ grew out gram positive cocci
in clusters. New blood cultures were ordered and infectious
disease was consulted. He was started on vancomycin 1500mg BID.
Mr. ___ had urinary retention. He was straight cathed, but
required the foley catheter to be replaced. He also reported
chest pain in which work up was negative. CXR showed
atelectasis. He was encouraged to use incentive spirometer.
___: Patient was stable on examination, incision appeared c/d/i
with staples and pain better controlled. ID recommendations were
to discontinue vancomycin because culture was coag negative
staph. He was OOB to chair and ambulating with ___. He also
reported that his chest felt heavy, but was improved with deep
coughing and incentive spirometer. He was discharged to rehab in
stable condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rosuvastatin Calcium 20 mg PO DAILY
2. Gabapentin 800 mg PO TID
3. Fentanyl Patch 50 mcg/h TP Q72H
4. Metoprolol Tartrate 25 mg PO BID
5. Sertraline 100 mg PO DAILY
Discharge Medications:
1. Fentanyl Patch 50 mcg/h TP Q72H
2. Gabapentin 800 mg PO TID
3. Metoprolol Tartrate 25 mg PO BID
4. Rosuvastatin Calcium 20 mg PO DAILY
5. Sertraline 50 mg PO DAILY
6. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/Wheeze
8. Bisacodyl 10 mg PO/PR DAILY
9. Bismuth Subsalicylate 15 mL PO TID:PRN heartburn
10. Calcium Carbonate 500 mg PO QID:PRN heartburn
11. Docusate Sodium 100 mg PO BID
12. Heparin 5000 UNIT SC TID
13. Metoclopramide 10 mg IV Q6H:PRN nausea
14. Morphine Sulfate ___ ___ mg PO Q4H:PRN pain
15. Omeprazole 20 mg PO DAILY
16. Tizanidine ___ mg PO TID
17. Senna 1 TAB PO HS
18. Fleet Enema ___AILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lower 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:
Your large dressing may be removed the second day after
surgery.
**If you have staples, keep your wound clean and dry until
they are removed.
You should wear your brace when out of bed or when your head
of bed is above 30 degrees.
You may put the brace on at the edge of your bed.
You may use a shower chair to bathe without the brace on.
No tub baths or pool swimming for two weeks from your date of
surgery.
Do not smoke.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Have a friend or family member check your incision daily for
signs of infection.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort. Pain medication should
be used as needed when you have pain. You do not need to take it
if you do not have pain.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. for two weeks.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Aspirin / Ibuprofen / Nucynta / Lamictal
Attending: ___
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ LH M with h/o refractory complex
regional pain syndrome following electrocution injury (___),
s/p
right motor cortex stimulator placement (___) complicated by
complex partial and secondary generalized tonic-clonic seizures,
hardware infection, PICC-related DVT and PE, and now nocturnal
confusional episodes which have been increasing in frequency. He
presents to the ED at the request of his epileptologist ___ for inpatient cvEEG to assess and treat the confusional
episodes.
For a complete, detailed summary of his entire medical history
and treatment course following the electrocution injury in ___,
please see Dr. ___ note in ___ dated ___. In brief, he
developed severe, refractory complex regional pain syndrome
following electrocution injury in ___. This failed multiple
medical therapies, trigger point injections and even spinal cord
stimulator, so in ___ a right motor cortex stimulator was
placed by Dr. ___. He had an extremely complicated post-op
course. From a medical standpoint, he developed a DVT and PE due
to clotting at his PICC line, and the stimulator itself was
thought to likely be infected (or at least chronically
colonized)
by ID but was not removed because, amazingly, the stimulator was
quite successful in controlling his pain.
Per above, he has experienced excellent pain relief from the
motor cortex stimulator. Unfortunately he has developed
refractory, difficult to control seizures since the time that
the
stimulator was turned on. The first definite seizure occurred on
___: an episode of LUE shaking lasting ~15 without any
impairment in consciuosness. Later in the day he developed left
hand shaking the progressed up the arm and culminated in a GTC
seizure lasting ___ min. There was some post-ictal left arm/leg
weakness and a 15-minute post-ictal confusion. He was taken to
___ where the stimulator was turned off except for occasional
use as needed for severe pain. Keppra was also started at that
time, and for a few weeks he only had a few brief sensorimotor
seizures.
In early ___ he was admitted for swelling and erythema at
the
incision and chest battery site which revealed pan-sensitive
Staph aureus infection. Per above, decision was made not to
remove the hardware since he had a good response. During the
admission he continued to have frequent seizures (with device
OFF). These were of two types:
(1) unusual feeling in his left hand, radiating up his arm with
some stiffening and spasm of his left hand, particularly the
fifth digit, sometimes progressing to LUE shaking. Occasionally
this would be a/w pain in his chest and tingling of the left
side of his face. Would typically last for several minutes.
On several occasions, have progressed to confusion and
nonsensical speech.
(2) episodes of nocturnal confusion (noted by his wife). Would
awaken and have some abnormal movements, then nonsensical
speech. These episodes could be quite prolonged, lasting more
than an hour, but then he goes back to sleep. He has no
recollection of the episodes in the morning. Keppra was
increased
to 1500 mg twice daily over several days. Video-EEG monitoring
showed right hemisphere breach artifact, periods of right
centroparietal delta slowing admixed with occasional spike and
spike and wave discharges with phase reversal at C4 and P4.
During this admission he also had several episodes of left hand
myoclonus and left hand clumsiness which had no ictal EEG
correlate, but were felt to likely represent simple partial
seizures based on appearance on video. He also had increased
episodes of confusion, including 1 episode when he wandered to
another floor in the hospital with no recall of how he had
gotten
there. Oxcarbazepine was added with some improvement in seizure
frequency. It is not clear whether any of his episodes of
confusion were recorded during his video-EEG monitoring session,
as he has little recollection of
what occurred during that time.
Since discharge on ___, he has continued to have both seizure
types. The motor cortex stimulator is turned OFF, but he can
activate it for 5 minutes if he has severe pain. He has a
continuous abnormal sensation in the left hand and says it is
"about 90 percent of functioning". The nocturnal episodes of
confusion and nonsensical speech are now quite prolonged,
lasting
up to 45 minutes at a time. On ___ Dr. ___ his
___ to 1200mg BID which did not decrease the
confusional episodes: he continued to have them over the weekend
and had another one last night. He has remained afebrile and his
incision site remains well-healed. Given the increasing
frequency
and severity of the events. Dr. ___ him to present to
ED for admission and cvEEG monitoring.
In addition, the patient states he has felt more confused and
foggy than usual over the past several days. He also complains
of
a general "pressure" sensation in his head. He recognizes that
he
has been confused for the past few days, recalls asking his wife
"How can you tell if Ragu jars are sick or not?" and later
realizing that this question made no sense. In the ED lobby, he
thought one of the nurses was wearing a "varsity letter" jacket
but in retrospect isn't sure whether he just imaginated or
hallucinated this.
Neurologic and General ROS are positive per above, otherwise
negative.
Past Medical History:
Chronic left chest/arm myofascial pain ___ electrocution (___)
s/p
right motor cortex stimulator ___ ___
seizures
surgical site infection ___
PE
HTN
GERD
seasonal allergies
ventral hernia repair (___)
Social History:
___
Family History:
Positive for maternal history of arthritis, cancers, multiple
sclerosis. No history of diabetes, sudden cardiac death. Mother
passed away from breast CA.
Physical Exam:
- Vitals: 98.9 61 133/82 18 99%
- General: overweight, generally well-appearing middle aged man
with well healing right craniotomy scar, cooperative, NAD.
- HEENT: NC/AT, MMM
- Neck: Supple, no carotid bruits appreciated. No nuchal
rigidity
- Pulmonary: CTABL
- Cardiac: RRR, no murmurs
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
NEURO EXAM:
- Mental Status: Awake, alert, oriented to person, place, and
date ___, does not know day of month but does know
___ is coming up). Able to relate history without
difficulty. Mildly inattentive, transposed ___ and ___
when naming ___ backward. Language slowed but 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. Able to register 3 objects and recall ___ at 5 minutes
___ with prompting). No evidence of apraxia or neglect.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
- Motor: Normal bulk, tone throughout. +Left pronator drift. No
adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
- Sensory: No deficits to light touch, pinprick throughout. No
extinction to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was flexor bilaterally.
- Coordination: No intention tremor, no dysdiadochokinesia
noted.
No dysmetria on FNF or HKS bilaterally.
- Gait: not tested
DISCHARGE EXAM
Mild LUE weakness with left pronator drift, slow LUE rapid
alternating movements. Otherwise full strength and
neurologically intact, with no sensory defecits and a normal
cranial nerve exam.
Pertinent Results:
Na - 133, 127, 125, 136 once off of trileptal
Brief Hospital Course:
Mr. ___ was admitted to the general neurology service to rule
out seizures as a cause of his confusional episodes at home.
While admitted, Mr. ___ had multiple episodes of confusion
with no EEG correlate. His sodium was noted to be low at 133,
which downtrended to 125 with fluid restriction. Urine lytes
revealed pre-renal FeNa of 0.7. He was given a bolus of normal
saline, His trileptal was titrated off with no change in events
and no seizures. His sodium then improved to 136. His trileptal
was replaced with Vimpat 150mg BID.
He was placed on continuous O2 monitoring overnight, and noted
to have some desaturations which resolved with CPAP.
He was noted to have mild urinary retention, and was started on
flomax.
He was discharged home, he has follow up with Dr. ___ in
early ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Oxcarbazepine 1200 mg PO BID
2. LeVETiracetam 1500 mg PO BID
3. Gabapentin 1200 mg PO TID
4. Warfarin 6 mg PO DAILY16
5. Metoprolol Tartrate 25 mg PO BID
6. Rosuvastatin Calcium 20 mg PO HS
7. Sertraline 100 mg PO DAILY
8. Tizanidine 2 mg PO BID:PRN spasm
9. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
10. Omeprazole 40 mg PO BID
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
2. Gabapentin 1200 mg PO TID
3. LeVETiracetam 1500 mg PO BID
4. Metoprolol Tartrate 25 mg PO BID
5. Omeprazole 40 mg PO BID
6. Rosuvastatin Calcium 20 mg PO HS
7. Sertraline 100 mg PO DAILY
8. Tizanidine 2 mg PO BID:PRN spasm
9. Warfarin 6 mg PO DAILY16
10. Buprenorphine-Naloxone (2mg-0.5mg) 2 TAB SL Q6H
11. LACOSamide 150 mg PO BID
RX *lacosamide [Vimpat] 150 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
12. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule,extended release 24hr(s) by
mouth at bedtime Disp #*30 Capsule Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Hyponatremia
Obstructive Sleep Apnea
Discharge Condition:
Stable. Ambulating independently.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the epilepsy service for nighttime events
which were concerning for seizures. We do not think that these
were seizures but rather that they were associated with low
sodium in your blood, as well as a low oxygen level from your
sleep apnea. You had no seizures, even after we stopped your
trileptal. We have taken you off of your trileptal, as it causes
low sodium. We have replaced this with another medication called
Vimpat. You will be able to pick this up at ___. We also
noted that you had some urinary retention likely from an
enlarged prostate, and we started you on a medication which will
help, called Tamsulosin.
NEW MEDICATIONS:
- Lacosamide (vimpat) 150mg twice a day
- Tamsulosin 0.4mg at night
You have now FINISHED your course of doxycyline, you no longer
need to take this.
Please DO NOT TAKE your trileptal, as you had an adverse
reaction to this medication.
Your last INR was 2.3. You should continue your current dose of
Warfarin and follow up with your PCP to get your bloodwork
checked as planned.
Please start wearing your CPAP at night, as we think that your
breathing may be contributing to your confusional episodes at
night.
It was a pleasure taking care of you this hospital stay.
Followup Instructions:
___
|
10901084-DS-25
| 10,901,084 | 25,004,448 |
DS
| 25 |
2129-09-29 00:00:00
|
2129-10-01 09:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ exploratory laparotomy, SBR x 2
History of Present Illness:
___ year old male presents to the emergency room with
intermittent abdominal pain
which is been getting worse. He was having these
pains pre-operatively prior to surgery for bowel obstruction
here around ___ time. He is continued to have
episodes of the pain postoperatively. At triage, he was
noted to have an EKG showing ST segment elevation so was
triggered back rapidly. He has no cardiopulmonary symptoms
whatsoever. Looking through his old EKGs, there are several
EKGs that are similar to the current EKG and he was
diagnosed recently as having silent MI according to him. He
also had an echo that showed possible apical aneurysm.
No fevers or chills. He has had one episode of vomiting
today. No urinary tract symptoms.
Past Medical History:
Small bowel obstruction
Infrarenal AAA
Coronary artery disease
"rhabdomyolysis" with ___ in ___
Hypertension
Peripheral arterial disease
Past Surgical History:
Open ventral hernia repair with mesh
Social History:
___
Family History:
FH: Father-died of ruptured brain aneurysm at age ___.
Mother-died
of metastatic lung cancer.
Physical Exam:
PHYSICAL EXAMINATION upon admission: ___:
Temp: 97.8 HR: 79 BP: 135/77 Resp: 18 O(2)Sat: 96 normal
Normal
Constitutional: Comfortable
HEENT: Extraocular muscles intact
Mucous membranes moist
Chest: Clear to auscultation
Cardiovascular: No murmur
Abdominal: His abdomen is soft in the epigastrium. He has a
clean dressing over the surgical midline incision
GU/Flank: No costovertebral angle tenderness
Extr/Back: No edema or calf tenderness
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mentation
Pertinent Results:
___ 06:25AM BLOOD WBC-7.0 RBC-3.31* Hgb-9.8* Hct-30.8*
MCV-93 MCH-29.6 MCHC-31.8* RDW-14.0 RDWSD-47.8* Plt ___
___ 06:20AM BLOOD WBC-6.2 RBC-3.29* Hgb-9.8* Hct-30.9*
MCV-94 MCH-29.8 MCHC-31.7* RDW-14.0 RDWSD-48.7* Plt ___
___ 04:39PM BLOOD WBC-24.0*# RBC-4.65 Hgb-14.0 Hct-43.4
MCV-93 MCH-30.1 MCHC-32.3 RDW-14.0 RDWSD-47.8* Plt ___
___ 04:39PM BLOOD Neuts-83.2* Lymphs-9.0* Monos-4.8*
Eos-2.0 Baso-0.3 Im ___ AbsNeut-19.96*# AbsLymp-2.15
AbsMono-1.16* AbsEos-0.48 AbsBaso-0.08
___ 06:25AM BLOOD Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:09AM BLOOD ___ PTT-55.4* ___
___ 06:25AM BLOOD Glucose-93 UreaN-11 Creat-0.8 Na-147
K-4.0 Cl-108 HCO3-27 AnGap-12
___ 03:10PM BLOOD CK(CPK)-20*
___ 04:39PM BLOOD ALT-10 AST-12 AlkPhos-66 TotBili-0.2
___ 04:39PM BLOOD Lipase-28
___ 03:10PM BLOOD CK-MB-2 cTropnT-<0.01
___ 04:39PM BLOOD cTropnT-<0.01
___ 06:25AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.8
___: CT abdomen and pelvis:
1. Dilated proximal small bowel loops with air-fluid levels,
compatible with a small bowel obstruction, progressed from
prior. Hyperemia and wall thickening at the transition point,
likely representing an inflammatory stricture. Small volume
free fluid within the pelvis.
2. Unchanged prominent mesenteric nodes measuring up 10 mm.
3. Unchanged infra-renal abdominal aortic aneurysm measures to
4.2 cm.
4. Anterior abdominal wall seroma has resolved, however now
there is a small incisional hernia containing fat.
___: ECHO:
There is an apical left ventricular aneurysm. No masses or
thrombi are seen in the left ventricle.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
___: MRE:
. Persistent mechanical small-bowel obstruction, with transition
point at
focal 4.2 cm segment of strictured small bowel with mild edema
and mucosal
hyper-enhancement. Stricture cause most likely ischemic, with
alternative
differential being inflammation.
2. Stable saccular infra-renal abdominal aortic aneurysm.
___: US lower ext:
No evidence of acute deep venous thrombosis in the right or
left lower extremity veins
___: x-ray of abdomen:
1. Dense material in the ascending colon may represent
administered contrast
2. No evidence of bowel obstruction.
3. A small amount of free air under the left hemi-diaphragm,
likely related to recent surgery.
___: incisional culture:
___ 3:32 pm SWAB Source: abdominal incision.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final ___:
ESCHERICHIA COLI. SPARSE GROWTH.
CEFEPIME test result confirmed by ___.
ENTEROBACTER CLOACAE COMPLEX. SPARSE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROBACTER CLOACAE
COMPLEX
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- 4 S <=1 S
CEFTRIAXONE----------- 8 R <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 6:50 am SWAB Site: ABDOMEN
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final ___:
ESCHERICHIA COLI. MODERATE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
ENTEROBACTER CLOACAE COMPLEX. SPARSE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
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.
Work-up of organism(s) listed discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Brief Hospital Course:
___ year old male admitted to the hospital with abdominal pain.
Upon admission the patient was made NPO, given intravenous
fluids, and underwent a cat scan which showed dilated proximal
small bowel loops with air-fluid levels, compatible with a
small bowel obstruction. This finding showed progression of the
bowel obstruction from the prior imaging. Based on these
findings, the patient was placed on bowel rest. He was placed on
a heparin drip because of his history of LV thrombus.
Coagulation studies were monitored and adjustments in the rate
were made according to protocol. After return of bowel function,
the patient resumed clear liquids and slowly advanced to a
regular diet. He again experienced a recurrence of abdominal
pain and was made NPO. He underwent an MRE which showed a
persistent mechanical small-bowel obstruction. Based on these
findings, the decision was made to take the patient to the
operating room. He underwent cardiac clearance and was taken to
the operating room on HD #7 where he underwent an exploratory
laparotomy, extensive lysis of adhesions, and jejunal resection
x 2. His operative course was stable with a 75cc blood loss.
The patient was extubated after the procedure and monitored in
the recovery room.
The patient did well in the PACU. He was alert and oriented x3.
His pain was well controlled and his urine output was
appropriate. After a brief stay in the PACU he was safely
transferred to the floor where his vital signs remained stable.
On ___, pod 1, a heparin drip was restarted which was
subsequently kept at a therapeutic range by trending ptt's every
6 hours. His wbc was slightly elevated which was attributed to
the normal stress incurred during the procedure. His Cr was 1.5
which was attributed to him being slightly volume down. He
received appropriate Iv fluids and his Cr trending down to his
baseline level. He received metoprolol IV while we were awaiting
return of bowel function. The patients pain remained well
controlled and he was able to ambulate early and often after
surgery. The patient started on a clear liquid diet on ___
as he was passing flatus. The patient reported some difficulty
tolerating the full liquid diet at first but had no episodes of
nausea, vomiting, or change in physical exam of his abdomen.
Some erythema around his wound was noted on ___ and some
staples were removed to express any fluid that had accumulated
in his wound. The wound was probed and cultures were sent. On
the following day, more staples were removed and the track was
further probed to express any remaining fluid. The wound was
packed with a wet to dry gauze dressing that was changed twice a
day. At this point, the patient was starting to tolerate a full
liquid diet better. On ___, the patient was transitioned to
po pain meds, which enabled us to discontinue the heparin drip
and start his home dose of apixaban. Further, he was
transitioned to a regular diet and put on a bowel regimen. He
tolerated this transition well. On ___, a wound vac was
placed in his surgical midline wound to aid in healing. His
wound healed nicely and the wound vac was discontinued on
___ and he was transitioned back to bid dressing changes
prior to his discharge to his rehab facility. At the end of his
hospital course, the patients vital signs were stable, he is
ambulatory independently, his pain is well controlled, he was
tolerating a regular diet, and his surgical site is healing
appropriately. He was provided with the appropriate discharge
instructions and an appointment for follow up.
Medications on Admission:
MEDS:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Milk of Magnesia 30 mL PO Q6H:PRN Constipation
4. Senna 8.6 mg PO BID:PRN constipation
5. ALPRAZolam ___ mg PO BID:PRN anxiety
6. Apixaban 5 mg PO BID
7. Aspirin 81 mg PO ___
8. Atorvastatin 80 mg PO QPM
9. DULoxetine 60 mg PO BID
10. Gabapentin 300 mg PO TID
11. Losartan Potassium 12.5 mg PO ___
12. Metoprolol Succinate XL 100 mg PO ___
13. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
14. Pantoprazole 40 mg PO Q24H
15. Polyethylene Glycol 17 g PO ___
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
3. Pantoprazole 40 mg PO Q24H
4. Polyethylene Glycol 17 g PO ___
5. Senna 8.6 mg PO BID Constipation - First Line
6. Apixaban 5 mg PO/NG BID
7. Aspirin 81 mg PO ___
8. Atorvastatin 80 mg PO QPM
9. DULoxetine 60 mg PO BID
10. Gabapentin 300 mg PO TID
11. Losartan Potassium 12.5 mg PO ___
12. Metoprolol Tartrate 25 mg PO BID
Discharge Disposition:
Home
Facility:
___
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted to the hospital with abdominal pain and poor
tolerance to food. You were placed on bowel rest and given
intravenous fluids. The abdominal pain recurred when you resumed
food and you again were placed on bowel rest. Because of this,
you were taken to the operating room where you underwent an
exploratory laparotomy and lysis of adhesions. You have resumed
a diet without abdominal pain. A small area of your abdominal
wound is open and VAC dressing was placed to help facilitate
closure. Your vital signs have been stable and you are
preparing for discharge with the following instructions:
You were admitted to the hospital with abdominal pain and poor
tolerance to food. You were placed on bowel rest and given
intravenous fluids. The abdominal pain recurred when you resumed
food and you again were placed on bowel rest. Because of this,
you were taken to the operating room where you underwent an
exploratory laparotomy and lysis of adhesions. You have resumed
a diet without abdominal pain. A small area of your abdominal
wound is open and VAC dressing was placed to help facilitate
closure. Your vital signs have been stable and you are
preparing for discharge with the following instructions:
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red aroudn the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
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).
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing r clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluitds and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
IF you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, 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.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
10901419-DS-4
| 10,901,419 | 26,503,641 |
DS
| 4 |
2152-12-26 00:00:00
|
2152-12-27 10:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
CT and ultrasound-guided core needle biopsy of the liver
(___)
attach
Pertinent Results:
ADMISSION LABS:
___ 06:15AM BLOOD WBC-5.5 RBC-4.71 Hgb-13.8 Hct-41.6 MCV-88
MCH-29.3 MCHC-33.2 RDW-11.7 RDWSD-37.4 Plt ___
___ 06:15AM BLOOD Neuts-77.5* Lymphs-16.1* Monos-5.8
Eos-0.2* Baso-0.2 Im ___ AbsNeut-4.30 AbsLymp-0.89*
AbsMono-0.32 AbsEos-0.01* AbsBaso-0.01
___ 06:15AM BLOOD Glucose-123* UreaN-19 Creat-1.4* Na-137
K-4.4 Cl-103 HCO3-21* AnGap-13
___ 06:15AM BLOOD Albumin-4.0 Calcium-9.1 Phos-4.0 Mg-2.1
___ 06:15AM BLOOD ALT-10 AST-12 AlkPhos-65 TotBili-0.4
___ 06:15AM BLOOD CEA-59.0* CA ___
DISCHARGE LABS:
___ 08:14AM BLOOD WBC-5.0 RBC-4.57* Hgb-13.1* Hct-41.1
MCV-90 MCH-28.7 MCHC-31.9* RDW-11.6 RDWSD-37.6 Plt ___
___ 12:40PM BLOOD Glucose-112* UreaN-20 Creat-1.6* Na-135
K-3.9 Cl-95* HCO3-28 AnGap-12
PATHOLOGY:
LIVER, BIOPSY FOR TUMOR (___): pending at the time of
discharge
IMAGING:
MRI abdomen (___):
IMPRESSION:
1. There is a large left renal mass measuring up to 8.7 cm, with
extension
into the left adrenal gland and contiguous with conglomerate
retroperitoneal lymphadenopathy, which compresses and narrows
the infrarenal IVC, though without thrombus. There is moderate
left hydronephrosis.
2. A 4.3 cm minimally peripherally enhancing mass in the right
hepatic lobe is indeterminate, though likely represents
metastatic disease.
3. A 1.9 cm lesion in the upper pole of the right kidney is
consistent with a ___ IIF lesion.
4. A paraesophageal T2 hyperintense rim enhancing cystic
structure is
nonspecific, and may represent a bronchogenic cyst.
CTA torso from ___:
CT Angiography Chest With Contrast
FINDINGS: Pulmonary arteries: Unremarkable. No pulmonary emboli.
Aorta: Unremarkable. No thoracic aortic aneurysm. No thoracic
aortic dissection. Lungs: Right upper
lobe pulmonary nodule measuring 4 mm (series 11, image 125).
Right middle lobe calcified granuloma.
Right middle lobe pulmonary nodule measuring 5 mm (series 5,
image 87). Left upper lobe pulmonary
nodule measuring 4 mm (series 5, image 52). Left lower lobe
pulmonary nodule measuring 4 mm (series
5, image 84). Pleural space: No pleural effusion. No
pneumothorax. Heart: No cardiomegaly. Small
pericardial effusion. Lymph nodes: A paraesophageal lymph node
measures 2 cm in short axis. No
abnormally enlarged hilar lymph nodes. Bones/joints:
Unremarkable. No acute fracture. Soft tissues:
Unremarkable.
IMPRESSION: 1. No evidence of thoracic aortic dissection.
2. Pulmonary nodules measuring a maximum of 5 mm. Follow-up
should be guided by oncology (see report of CT
abdomen pelvis). 3. Paraesophageal lymphadenopathy.
CT Angiography Abdomen and Pelvis With Contrast
FINDINGS: Aorta: The abdominal aorta is normal in course and
caliber. No
abdominal aortic dissection. Celiac trunk and mesenteric
arteries: The celiac artery, superior
mesenteric artery, and inferior mesenteric artery are patent
without significant stenosis. Renal
arteries: Solitary right renal artery is patent without
significant stenosis. There are 2 left renal
arteries, both are patent without significant stenosis. Right
iliac arteries: The right common
iliac, external iliac, and internal iliac arteries are patent
without significant stenosis. Left
iliac arteries: The left common iliac, external iliac, and
internal iliac arteries are patent
without significant stenosis. Other veins: The left renal vein
is
either surrounded by or directly
invaded by tumor. Liver: Hypodense mass in the right liver
measuring approximately 3.5 cm.
Gallbladder and bile ducts: The gallbladder is unremarkable.
Pancreas: The pancreas is unremarkable.
Spleen: The spleen is unremarkable. Adrenals: The right adrenal
gland is unremarkable. There is a
mass of the left adrenal gland measuring approximately 2 cm.
Kidneys and ureters: Hypodense right
renal lesion is too small to accurately characterize. A left
renal mass at the renal hilum with
calcifications measures 7.5 x 7 cm. The left renal mass
demonstrates contiguous spread to the
retroperitoneum and the left adrenal gland. There is
hypoenhancement of the left renal cortex. There
is marked left hydronephrosis. The right ureter is unremarkable.
Stomach and bowel: The stomach is
unremarkable. There is mild sigmoid colon diverticulosis. The
small bowel is unremarkable. No bowel
obstruction. Appendix: The appendix is normal. Intraperitoneal
space: Unremarkable. No free air. No
significant fluid collection.
Retroperitoneal space: There is thickening of
Gerota's fascia. There are soft tissue density nodules in the
anterior para renal space. Lymph
nodes: There is extensive para-aortic lymphadenopathy.
Conglomerate lymph node mass measures
approximately 5 x 3.1 x 7 cm. Bladder: The urinary bladder is
unremarkable. Reproductive:
Unremarkable as visualized. Bones/joints: No acute fracture. No
dislocation. Soft tissues: There is a small fat-containing
umbilical hernia.
IMPRESSION:
1. Left renal neoplasm measuring approximately
7.5 cm. There is extensive retroperitoneal tumor, metastatic
lymphadenopathy and metastases in the anterior para renal space.
2. Liver mass. Metastasis suspected.
3. Marked left hydronephrosis, due
to mass effect from large hilar mass.
4. Left renal vein either surrounded by or directly invaded by
tumor.
DISCHARGE EXAM:
VITALS: ___ 0756 Temp: 98.2 PO BP: 156/100 HR: 84 RR: 18 O2
sat: 96% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
___ 0850 BP: 135/81 HR: 78
GENERAL: Alert, NAD
EYES: Anicteric, PERRL
ENT: mmm, OP clear
CV: NR/RR, no m/r/g
RESP: CTAB
ABD/GI: Soft, ND, NTTP, normoactive bowel sounds
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
VASC/EXT: No ___ edema, 2+ DP pulses
SKIN: No rashes or lesions noted on visible skin
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, moves all limbs
PSYCH: pleasant, appropriate affect
Brief Hospital Course:
SUMMARY:
___ yo M PMHx HTN who p/w acute on chronic left flank pain, found
to have large left renal mass with severe left hydronephrosis,
___, and imaging with concern for metastatic disease (to liver),
now s/p biopsy of liver lesion.
HOSPITAL COURSE BY PROBLEM:
# Left renal mass
Concerning for malignancy based on imaging findings.
Complicated
by hydronephrosis and ___. Imaging revealed a liver lesion
consistent with a metastasis which was biopsied. CEA was
elevated at 59. CA ___ was
low/normal. His left flank pain was controlled with lidocaine
patches, Tylenol, and oxycodone (used sparingly).
[ ] F/u results of liver biopsy pathology
# ___ vs. CKD (unclear baseline)
# Left hydronephrosis
FeUrea and FeNa were consistent with pre-renal etiology likely
due to poor PO intake in the setting of flank pain. Cr improved
with IV fluids and encouraging PO intake. Baseline Cr appears to
be 1.4-1.6.
# HTN, poorly controlled
His home amlodipine was continued. In addition, HCTZ 25 mg daily
and labetalol 200 mg BID were started with improved control.
# Access to care
Pt primarily resides in ___ and is just here for the
holidays. He will need to establish care with a PCP in ___.
He is also unsure of his insurance status.
TRANSITIONAL ISSUES:
[ ] F/u results of liver biopsy pathology
[ ] Patient to establish PCP in ___
>30 minutes spent on discharge
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. amLODIPine 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
2. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
3. Labetalol 200 mg PO BID
RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % Apply 1 patch to painful area once a day Disp
#*30 Patch Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tab by mouth every four (4) hours Disp #*18
Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*10 Tablet Refills:*0
7. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Renal mass
Liver masses
Hypertension
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for flank pain and you were
found to have a left kidney mass. You were also found to have
spots in your liver that are concerning for spread of the kidney
mass to the liver. You had a biopsy of one of the liver lesions
completed on ___. The pathology from that biopsy is still
pending at discharge.
Your blood pressure was also quite elevated and you were treated
with new medications to control your blood pressure. You should
continue to take those at home.
Your kidney function also fluctuated while you were in the
hospital but responded well to fluid. You should make sure that
you stay very hydrated to protect your kidneys. You should also
not take NSAID medications (like ibuprofen - Motrin and Tylenol)
because those can injure the kidney further.
The most important thing will be to establish a primary care
doctor in ___ so the records from this hospital stay and the
pathology results can be sent to a doctor there.
Best wishes for your continued health.
Take care,
Your ___ Care Team
Followup Instructions:
___
|
10901490-DS-9
| 10,901,490 | 26,707,606 |
DS
| 9 |
2190-02-21 00:00:00
|
2190-02-21 11:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fall
chest pain
back pain
T7, T8, T10 compression fx
chronic rib fx of the R ___ ribs
nondisplaced L ___ rib fx
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ PMH of COPD, HTN, depression, and GERD p/w T7, T8,
T10 compression fx, chronic rib fx of the R ___ ribs, and
nondisplaced L ___ rib fx. The patient presented with back
pain
since falling off of her couch on ___. She reports that she
fell asleep on her couch, and woke up on the floor between her
couch and the coffee table with severe back pain. She also
endorses an abrasion on her left shin following the fall. She
required her husband's assistance to stand up and walk to bed.
She has been resting in bed since the fall, getting up only to
use the bathroom. She does not believe she could have hit the
coffee table, and reports that the couch is about 2 feet above
the ground. Her back pain ranges from lower cervical spine to
upper thoracic spine, as well as her right flank.
Of note, patient endorses approximately 20lb weight loss in past
year, as her appetite has decreased following her mother's
passing from pancreatic cancer. At bedside, the patient reports
severe back pain but is resting comfortably in bed. She denies
fevers, chills, nausea, vomiting, diarrhea, constipation, or any
neurological Sx.
Past Medical History:
Hypertension
Depression not adherent with citalopram
Anxiety
COPD/Asthma
GERD
EtOH use
headaches
urinary incontinence
Social History:
___
Family History:
Father - MI at ___
Mother - No known medical problems
Children - Healthy
Physical Exam:
Admission Physical Exam:
VS: T 97.8 HR 78 BP 131/63 RR 18 O2 Sat 94% RA
General: well-appearing, thin woman in NAD
HEENT: NC, AT, sclera anicteric, PERRL, EOMI
Cardiac: normal S1, S2, RRR, no m/r/g
Respiratory: breathing comfortably on room air, diffuse wheezes
Abdomen: soft, ND, RUQ tenderness at costal margin
MSK: point tenderness from lower cervical spine to upper
thoracic
spine, tenderness over right flank
Extremities: WWP, clean bandage over left shin, no clubbing,
cyanosis, edema
Neuro: A&O x 3, moving all four extremities, CN II-VII intact
Discharge Physical Exam:
General: well-appearing, thin woman in NAD
HEENT: NC, AT, sclera anicteric, PERRL, EOMI
Cardiac: normal S1, S2, RRR, no m/r/g
Respiratory: breathing comfortably on room air, diffuse wheezes
Abdomen: soft, ND, RUQ tenderness at costal margin
MSK: point tenderness from lower cervical spine to upper
thoracic
spine, tenderness over right flank
Extremities: WWP, clean bandage over left shin, no clubbing,
cyanosis, edema
Neuro: A&O x 3, moving all four extremities, CN II-VII intact
Pertinent Results:
Imaging:
___ CT C SPINE
1. No acute fracture identified.
2. Multilevel degenerative changes and age-indeterminate
alignment
abnormalities, as described above, most notably resulting in at
least moderate
canal stenosis at C6-C7.
___ CT L SPINE
1. Diffuse osteopenia with no acute fracture identified.
2. Multilevel degenerative changes, as described above, most
notable for
moderate to severe canal narrowing at L3-L4.
___ CT HEAD
No acute intracranial abnormality.
___ CT CHEST - OSH
T7, T8, T10 compression fx, chronic rib fx of the R ___ ribs,
and nondisplaced L ___ rib fx
___ 06:50AM BLOOD WBC-5.6 RBC-2.66* Hgb-10.1* Hct-29.9*
MCV-112* MCH-38.0* MCHC-33.8 RDW-15.2 RDWSD-63.3* Plt ___
___ 05:23AM BLOOD WBC-8.5 RBC-2.99* Hgb-11.4 Hct-34.3
MCV-115* MCH-38.1* MCHC-33.2 RDW-15.2 RDWSD-64.3* Plt ___
___ 06:34AM BLOOD WBC-6.9 RBC-2.80* Hgb-10.6* Hct-30.9*
MCV-110* MCH-37.9* MCHC-34.3 RDW-14.6 RDWSD-59.6* Plt ___
___ 04:00AM BLOOD Neuts-48.4 ___ Monos-26.2*
Eos-0.4* Baso-0.4 Im ___ AbsNeut-2.70 AbsLymp-1.36
AbsMono-1.46* AbsEos-0.02* AbsBaso-0.02
___ 04:00AM BLOOD Hypochr-NORMAL Anisocy-2+* Poiklo-NORMAL
Macrocy-2+* Microcy-NORMAL Polychr-NORMAL
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD ___ PTT-26.3 ___
___ 05:23AM BLOOD Plt ___
___ 06:34AM BLOOD Plt ___
___ 06:34AM BLOOD ___ PTT-26.9 ___
___ 06:50AM BLOOD Glucose-75 UreaN-6 Creat-0.4 Na-131*
K-5.0 Cl-90* HCO3-30 AnGap-11
___ 05:23AM BLOOD Glucose-61* UreaN-10 Creat-0.6 Na-134*
K-5.0 Cl-90* HCO3-22 AnGap-22*
___ 06:34AM BLOOD Glucose-73 UreaN-10 Creat-0.4 Na-129*
K-3.6 Cl-89* HCO3-23 AnGap-17
___ 04:00AM BLOOD ALT-13 AST-18 AlkPhos-54 TotBili-0.5
___ 06:50AM BLOOD Calcium-9.5 Phos-3.2 Mg-1.5*
___ 05:23AM BLOOD Calcium-9.6 Phos-4.0 Mg-2.2
___ 06:34AM BLOOD Calcium-9.4 Phos-4.5 Mg-1.6
Brief Hospital Course:
Ms. ___ is a ___ year old woman with history of COPD,
hypertension, depression, and ___ transferred from ___ for
chest and back pain in setting of fall 3 days ago. At outside
hospital, she was found to have T7, T8, T10 compression
fractures, chronic rib fractures of the right ___ ribs, and
nondisplaced L ___ rib fractures on imaging. She was
transferred to ___ for further evaluation and management.
In the ___ ED, patient was alert and oriented, moving all
extremities, with stable vital signs and intact cranial nerves.
Her exam was further notable for midline tenderness over the
cervical, thoracic & lumbar spine, no step-off or deformity, and
open superficial avulsion wound on the left shin. Screening labs
were notable for hyponatremia to 128. EKG was without signs of
ischemia. She received IV morphine and hydromorphone for pain.
Spine and acute care services were consulted in the ED. Spine
service evaluated patient, cleared C-spine, and recommended TLSO
brace for acute thoracic vertebral compression fracture and
further MRI imaging due to long tract signs and concern for
myelopathy.
___ evaluated patient and admitted her on ___ for further
monitoring and management of pain and injury. Patient refused
inpatient MRI scan citing claustrophobia, so she will be
referred to outpatient center with recommendation to obtain
study at later date. She received her home medications.
Patient's WBC, hematocrit, and creatine were within limits
during her admission; urine culture and blood cultures showed no
growth to date. She remained afebrile with stable vital signs.
Inpatient ___ teams evaluated patient with recommendation of
discharge to rehab.
HD1: Admitted. Regular diet. Pain control. Incentive spirometer.
TLSO brace, continued pain, ___: will evaluate again tomorrow,
tramadol to 50 q6, lidocaine patch
HD2: Given oxycodone, discontinued ultram, productive cough,
sputum cultures sent
HD3: Awaiting rehab
HD4: Oxycodone to q3 from q6, CXR unremarkable
HD5: Discharged to rehab facility
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
voiding without assistance, and pain was well controlled. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation
BID
2. Zolpidem Tartrate 5 mg PO QHS
3. LORazepam 0.5 mg PO DAILY:PRN anxiety
4. Escitalopram Oxalate 10 mg PO DAILY
5. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
6. Tudorza Pressair (aclidinium bromide) 400 mcg/actuation
inhalation BID
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH DAILY
8. Itraconazole 200 mg PO Q12H
Discharge Medications:
1. Escitalopram Oxalate 10 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH DAILY
3. Itraconazole 200 mg PO Q12H
4. LORazepam 0.5 mg PO DAILY:PRN anxiety
5. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
6. Pulmicort Flexhaler (budesonide) 180 mcg/actuation
inhalation BID
7. Tudorza Pressair (aclidinium bromide) 400 mcg/actuation
inhalation BID
8. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
fall
chest pain
back pain
T7, T8, T10 compression fx
chronic rib fx of the R ___ ribs
nondisplaced L ___ rib fx
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 Acute Care Surgery Service on ___
after a fall sustaining vertebral and rib fractures. You were
given pain medications and your breathing was closely monitored.
You were seen by the spine surgeons, who recommended a body
brace (thoracolumbosacral orthosis or TLSO) follow up by your
neurologist for your ___ Body Dementia and intra-parenchymal
hemorrhage. You were seen by the spine doctors, who recommended
a TLSO brace and follow up as an outpatient. You were offered
You were seen and evaluated by the physical therapists who
recommend that you continue to ambulate with a rolling walker.
You are now doing better, tolerating a regular diet, and
ambulating well. You are now ready to be discharged to home to
continue your recovery.
Please note the following discharge instructions:
* Your injury caused vertebral and rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of spine and rib fractures
secondary to pain. In order to decrease your risk you must use
your incentive spirometer 4 times every hour while awake. This
will help expand the small airways in your lungs and assist in
coughing up secretions that pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for numbness,
tingling, weakness, fecal or urinary incontinence, any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10901772-DS-34
| 10,901,772 | 21,819,026 |
DS
| 34 |
2151-10-10 00:00:00
|
2151-10-10 20:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
absorbable surgical gauze
Attending: ___.
Chief Complaint:
Tremors "Bouncing Spells"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH CAD s/p multiple MIs, ___ with EF of ___, AICD,
IDDM, HTN, HLD, COPD, and PAD who presented with tremor and was
found to have ___.
Ms. ___ states that over the last two weeks she has
noticed episodes of shaking tremors. She describes them as
"bouncing episodes." When these episodes occur she can fully
recall antecedent events and describes no confusion after the
events. She does note that she has to lower to the ground and
will have episodes of bilateral head and leg or arm shaking. She
does not endorse loss of consciousness or full body jerking at
any point. No hx of tongue biting, loss of continence or post
ictal paralysis/weakness/confusion.
Two weeks ago after feeling weak she was sent to ___
___ ___, where she was treated for
hypovolemic shock and ___ in the setting of GI bleed and
supratherapeutic INR. Creatinine at discharge was 0.8. An Upper
and lower endoscopy showed no source of bleeding found (Grade 1
reflux esophagitis and sessile cecal polyp, 4mm, resected).
Last week, states that prior to a "bouncing" episode she was
walking around the house with her cane/boot normally when, on
the way to the bathroom she fell backwards into a seated
position and began having body "bouncing shakes." She was
calling for her husband during this episode who called an
ambulance which brought her to ___. There
is no record of this admission, but she states they found
nothing wrong (no studies seen).
Symptoms have worsened in the past 2 days. Yesterday,
following an episode of "leg bouncing" she called ___ and was
directed to an appointment. At primary care appointment patient
was sitting in wheelchair when she had an episode of what
appeared like tonic/clonic movement of her head and upper arms
that lasted 1 to 2 minutes. The episode resolved when "her
friend ___ shook her."
She reports chronically poor PO intake, not recently worse, and
tried to keep up with fluid intake. She denies any diarrhea or
nausea/vomiting. She reports that swelling in her legs has
significantly decreased over the past few days. Weight has
slightly decreased over the past week. She does report some new
onset dyspnea only when talking, as well as chronic dyspnea with
exertion. Denies orthopnea. Denies chest pain. Has not had any
fevers.
Additionally, She endorsed a 2 week history of blurring of
vision bilaterally. She says it comes and goes and looks like
"bright sparkles" or "fireworks." She denies black spots or
"curtain falling" like vision. She does endorse bumping into
things lately, but cannot say it is more on one side than
another. She also endorses an approximate ___ month history of
memory difficulties. She has no family history of alzheimers or
early onset of dementia. Lastly, she reports about a ___ month
history of new onset pounding excrutiating headaches which are
localized predominantly to the right temporal-parietal region.
She cannot say with certainty that her visual changes are
associated with these headaches. They are not associated with
her "bouncing episodes." While light and sound don't explicitly
bother her during these headaches, she does say she needs to be
alone with her eyes closed. They have woken her up out of her
sleep, but do not seem to be worsened after napping or in the
morning. No family history of migranes. Denies neck pain. Denies
new weakness or difficulty with speech.
Incidentally, notes that her mother also started having
headaches ___ months ago. She currently has a diagnosis of
metastatic renal cell carcinoma treated at ___. She has a remote
history of spontaneous nipple discharge since "around ___ years
old" and loss of sex drive. Last mammogram was in ___. No
family hx of breast cancer, melanoma, lung cancer or lymphoma.
Past Medical History:
PMH: CAD, s/p multiple MIs and PCIs last ___, ischemic
cardiomyopathy, EF ___, AICD, DM, HTN, HLD, PAD, Active
smoking, Heroin abuse(drug free for ___ years on methadone)
PSH:
___ L CFA endarterectomy, bovine pericardial patch
angioplasty from mid CFA into mid profunda femoral artery
___ Aortogram bilateral lower extremity runoff
___arotid artery to left subclavian
artery bypass with 6-mm PTFE graft
___ CABG x 3vessels, Mitral valve repair
Social History:
___
Family History:
No family history of breast or lung cancer, melanoma or
lymphoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 97.7 140/80 91 18 98% RA
___: Alert, oriented, no acute distress
HEENT: Sclera anicteric, EOMI. PERRLA. no anisicoria. No
peripheral/visual field defects.
Neck: Supple, JVP not elevated. Left sided carotid bruit
appreciated.
CV: Regular rate and rhythm, normal S1 + S2, soft I/VI SEM, no
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, scars from prior
bypass exams in midline.
BREAST: to axillary lymphadenopathy, peau d'orange. Rubbery,
mobile nodules palpated on inferior aspect of left breast. No
masses appreciated on right breast. There is flaking, dry skin
on b/l nipples w/out evidence of erythematous excoriations. No
expression of nipple discharge.
GU: No foley
Ext: Upper extremities: Bilaterally; radial 2+ warm well
perfused. Left lower extremity with post surgical gauze from
amputation of toe. Bilaterally, diabetic dermopathy v stasis
dermatitis. Dopplerable pulses bilaterally.
Neuro: CNII-XII intact, Negative for past pointing,
dysdiadechokinesia. gait is limited by boot on left foot. No
evidence of cerebellar dysfunction. Romberg deferred.
DISCHARGE PHYSICAL EXAM:
Vitals- 97.4 94/42 73 16 99% RA
24hr Blood Sugar: Received am 10 glargine and 28 meal time
9a:484 11a:333 3p:345 4:331 ___
___: Alert, oriented, no acute distress
HEENT: Sclera anicteric, EOMI. PERRLA. no anisicoria. No
peripheral/visual field defects. Has EEG leads on forehead.
Neck: Supple, JVP not elevated. Left sided carotid bruit
appreciated.
CV: Regular rate and rhythm, normal S1 + S2, soft I/VI SEM, no
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, scars from prior
bypass exams in midline.
BREAST: to axillary lymphadenopathy, peau d'orange. Rubbery,
mobile nodules palpated on inferior aspect of left breast. No
masses appreciated on right breast. There is flaking, dry skin
on b/l nipples w/out evidence of erythematous excoriations. No
expression of nipple discharge.
GU: No foley
Ext: Upper extremities: Bilaterally; radial 2+ warm well
perfused. Left lower extremity with post surgical gauze from
amputation of toe. Bilaterally, diabetic dermopathy v stasis
dermatitis. Dopplerable pulses bilaterally.
Neuro: CNII-XII intact, Negative for past pointing,
dysdiadechokinesia. gait is limited by boot on left foot. No
evidence of cerebellar dysfunction. Romberg deferred.
Pertinent Results:
ADMISSION LAB RESULTS:
___ 03:45PM WBC-6.9 RBC-4.11 HGB-11.8 HCT-36.8 MCV-90
MCH-28.7 MCHC-32.1 RDW-15.2 RDWSD-49.6*
___ 03:45PM PLT COUNT-282
___ 03:45PM ___
___ 07:54PM NEUTS-65.2 ___ MONOS-9.5 EOS-3.5
BASOS-0.7 IM ___ AbsNeut-3.72 AbsLymp-1.18* AbsMono-0.54
AbsEos-0.20 AbsBaso-0.04
___ 07:54PM WBC-5.7 RBC-3.86* HGB-11.1* HCT-34.1 MCV-88
MCH-28.8 MCHC-32.6 RDW-15.2 RDWSD-48.4*
___ 07:54PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 07:54PM CALCIUM-9.8 PHOSPHATE-5.4* MAGNESIUM-1.9
___ 07:54PM ALT(SGPT)-20 AST(SGOT)-21 ALK PHOS-160* TOT
BILI-0.2
___ 07:54PM estGFR-Using this
___ 07:54PM GLUCOSE-260* UREA N-51* CREAT-2.3* SODIUM-133
POTASSIUM-4.6 CHLORIDE-89* TOTAL CO2-30 ANION GAP-19
___ 05:02AM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-1
___ 05:02AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 05:02AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:02AM URINE OSMOLAL-508
___ 05:02AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-POS
PERTINENT IMAGING/STUDIES:
___ VIDEO EEG:
No evidence of epileptiform activity
CXR ___
IMPRESSION:
No radiographic evidence of pneumonia or other acute
cardiopulmonary
abnormalities. Right pleural thickening is unchanged since at
least ___.
CT Head w/o ___:
FINDINGS:
There is no evidence of acute hemorrhage, edema, mass effect, or
loss of gray-white matter differentiation. Ventricles, sulci,
and basal cisterns are normal in size for age. Visualized bones
are unremarkable. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized portion of the orbits are unremarkable on
noncontrast assessment.
IMPRESSION:
No evidence for acute intracranial abnormalities.
DISCHARGE LAB VALUES:
___ 07:15AM PROLACTIN-3.2* TSH-1.7
___ 06:34AM BLOOD WBC-6.0 RBC-3.71* Hgb-10.3* Hct-33.3*
MCV-90 MCH-27.8 MCHC-30.9* RDW-15.0 RDWSD-49.1* Plt ___
___ 06:34AM BLOOD Plt ___
___ 06:34AM BLOOD Glucose-318* UreaN-45* Creat-1.5* Na-137
K-4.2 Cl-95* HCO3-30 AnGap-16
___ 07:15AM BLOOD ALT-17 AST-17 AlkPhos-149* TotBili-0.2
___ 06:34AM BLOOD Calcium-10.4* Phos-4.4 Mg-1.7
___ 06:34AM BLOOD PTH-PND
___ 03:22PM BLOOD PARATHYROID HORMONE RELATED PROTEIN-PND
Brief Hospital Course:
Ms. ___ is a ___ year old F with a pmhx significant for CAD
s/p multiple MIs, sCHF with EF of ___, AICD, IDDM, HTN, HLD,
COPD, and PAD who presented with tremor directly from Health
Care Associates found to have ___.
#Tremors
With respect to these "bouncing episodes" we had a moderate
suspicion for seizure, however given the report from the
resident at ___ Associates we felt she should be
monitored on 24 hour EEG. Neurology monitored EEG x24 hours with
no epileptiform waves noted on exam. Additionally, her clinical
exam was non focal. This was very reassuring.
Additionally, during her admission a nurse noticed one of her
"tremor" episodes of "bouncing." She was standing at the sink
when her knees buckled and she continued to try to stand and her
knees would buckle. This repeated a few times before stabilizing
her on the counter top. Ms. ___ stated that what was
observed by the nurse were the "tremors" she was having.
In considering a recent left toe amputation, neuropathy and
___ lower extremity deconditioning in the setting ___
which likely increased her serum concentration of home
gabapentin it is very likely that her gait instability and
bouncing episodes were all a result poorly controlled diabetes
leading to ___ and a snowball effect.
#ACUTE KIDNEY INJURY
On admission found to have ___ with creatinine of 2.3 (baseline
0.9-1.5). The most likely etiology was pre-renal from osmotic
diuresis secondary to miscommunication regarding home Lantus
dose. After rehydration and correction of blood sugars her renal
function improved. At the time of discharge her Cr. was 1.5.
At the time of discharge her gabapentin, torsemide, metolazone
and lisinopril were held. She will be seen at ___
Associates ___ or ___ with labs in the AM. Diuretics will
be restarted if her Cr. continues to downtrend or is stable.
#HYPERGLYCEMIA
At the time of her admission her blood sugar was in the low
500s. It became clear in talking with Ms. ___ that she got
the impression she should decrease her ___ Lantus dose from
32units to 10units. She required significant sliding scale doses
on this admission. She was discharged with the following
instructions:
RESTART 32U LANTUS EACH MORNING WITH BREAKFAST AND UTILIZE
HUMALOG SLIDING SCALE.
#HYPERCALCEMIA
Incidental finding on day of discharge. TSH normal. Sent for
PTH and PTH-RP.
#HYPOPROLACTINEMIA
Mild. Patient has complained of headaches without any obvious
mass on head CT and more consistent with migraines. Labs do not
support panhypopituitarism, however micro adenoma cannot be
ruled out. This should be followed up as an outpatient.
#BREAST NODULES
Patient has prior history of asymmetric, bilateral benign
breast masses. Prior mammogram in ___ BIRADS-2 without evidence
of microcalcifications. Patient needs screening mammogram to
follow these nodules.
1. Ensure established insulin regimen is adequate
2. Follow up work up for migranes w/possible aura
3. Follow up outpatient labs for glucose control and Cr.
4. Will need ___ for lower extremity deconditioning as weakness
precipitates falls.
5. Follow up mammogram results (ensure she went, order placed in
OMR)
6. Patient will require a community resource specialist as she
needs assistance in scheduling and following up/transportation
for:
A. Optometry appointment for presbyopia
B. Podiatry for better fitting shoe for diabetic foot s/p toe
amputation
7. Please restart torsemide and metolazone when creatinine back
to baseline
8. Follow up Hypercalcemia workup-PTH, PTHRP
9. Follow up hypoprolactinemia as needed
10. Will require screening mammogram
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 4 PUFF IH Q4H:PRN wheeze
3. Amitriptyline 25 mg PO QHS
4. Atorvastatin 80 mg PO QPM
5. Clopidogrel 75 mg PO DAILY
6. Collagenase Ointment 1 Appl TP DAILY
7. Gabapentin 600 mg PO TID
8. Guaifenesin ER 600 mg PO Q12H:PRN congestion
9. Lisinopril 10 mg PO DAILY
10. Methadone 69 mg PO DAILY
11. Metolazone 2.5 mg PO DAILY:PRN diuresis
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Tiotropium Bromide 1 CAP IH DAILY
15. Torsemide 40 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. Warfarin 2.5 mg PO DAILY16
18. Aspirin 81 mg PO DAILY
19. Glargine 32 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
20. Pantoprazole 40 mg PO Q24H
21. budesonide-formoterol 160-4.5 mcg/actuation inhalation Q12H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 4 PUFF IH Q4H:PRN wheeze
3. Aspirin 81 mg PO DAILY
4. Amitriptyline 25 mg PO QHS
5. Atorvastatin 80 mg PO QPM
6. Clopidogrel 75 mg PO DAILY
7. Collagenase Ointment 1 Appl TP DAILY
8. Glargine 32 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
9. Methadone 69 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. Pantoprazole 40 mg PO Q24H
13. Tiotropium Bromide 1 CAP IH DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Warfarin 2.5 mg PO DAILY16
16. Guaifenesin ER 600 mg PO Q12H:PRN congestion
17. budesonide-formoterol 160-4.5 mcg/actuation inhalation Q12H
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary Diagnosis: 1. Acute Kidney Injury 2. Hyperglycemia
Secondary Diagnosis: Mechanical Gait Instability
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
You were admitted to ___
following an episode of tremors at your primary care physician's
office.
We were initially concerned that you had had a seizure,
however after thorough examination, testing and a video
monitoring your brain wave activity we were very reassured that
you did not have a seizure. While here you experienced one of
these "bouncing episodes." It was determined that this was
primarily due to your knees buckling and not having the strength
to support your walking when standing after certain periods of
time. We have recommended that you obtain physical therapy and
your primary care physician refer you to see podiatry.
While you were brought in for this concern, we also noticed
that you had experienced a minor kidney injury from dehydration
due to a recent medication change in your Lantus which led to
poor control of your blood sugar. We provided you with fluids
and treated your high blood sugar and your kidneys began to
recover nicely.
With respect to your high blood sugar you discussed that
someone had mentioned lowering your nighttime insulin dose from
32 units to 10 units. This resulted in very high blood sugars
which led to dehydration and kidney injury (discussed above). We
restarted you on your home dose of insulin and your blood sugars
were very well controlled.
IMPORTANT: Please note that your Lantus dose was given the
MORNING of ___ (today). You should continue to take 32 units
at breakfast.
You should not take your gabapentin, torsemide, metolazone and
lisinopril until you meet with a physician on ___.
We have scheduled an appointment for you at ___
___ for this ___ to follow up on your
renal function. Prior to this appointment you should obtain labs
done here at ___ morning (or prior to your
appointment). You should also obtain your mammogram prior to
this appointment at the same time you get your labs done. We
have ordered these tests for you.
Additionally, you have an appointment on ___. You
should still keep this appointment.
It was a pleasure taking care of you.
Best,
Your ___ Team
Followup Instructions:
___
|
10901772-DS-38
| 10,901,772 | 22,072,768 |
DS
| 38 |
2152-03-11 00:00:00
|
2152-03-12 13:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
absorbable surgical gauze
Attending: ___.
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
Right Femoral CVC (___)
Intubation (___)
Arterial Line (___)
EGD
Capsule endoscopy
History of Present Illness:
Ms. ___ is a ___ yo F with a complicated past medical
history significant for systolic CHF (EF 20% to 25% in ___,
s/p AICD), CAD (s/p PCI ___ and CABG in ___, diabetes, CKD
(baseline Cr 1.4), PVD (on warfarin/plavix), past heroin abuse
on methadone, HTN, and COPD who presented to the ED s/p fall and
was found to have a LGIB.
She was recently admitted to the CHF service from ___ for
a CHF exacerbation. Her pacer was interrogated for bradycardia
and her lower rate limit was adjusted. She was diuresed and
underwent a R heart cath that showed moderate pulmonary HTN.
Of note, she has a history of a slow GIB with gradually
downtrending H&H. She had a normal colonoscopy and EGD on
___. She also had a capsule study that never reached the
small bowel.
In the ED, initial vitals: 96.7 90 104/65 18 97% RA. BP's
dropped to the 80's. Labs were significant for a Hgb/Hct of
4.4/14.2 (previously 9.3/29.5 on ___, INR of 5 (previously
2.4 ON ___, lactate 3.6, Cr of 3.0, and tox screen that was
pending. Her last Cr was 2.0 on ___. The patient had difficulty
providing a history in the ED but stated that she fell and now
has neck pain and mild abdominal pain. She was noted to have
maroon stool. Access was obtained with a R femoral line. She was
given 10 IV vitamin K and K centra. A T&S was sent. CT
head/C-spine/abdomen were obtained; reads pending but no
evidence of head/C-spine trauma.
GI was consulted and recommended large bore IV access, FFP, INR
reversal, IV PPI gtt, and gastric lavage to determine whether
bleed was upper or lower. Plan was to admit to the ICU if
positive lavage and perform a CTA if negative to identify the
lower GI source. Surgery was also consulted and planned to
follow resuscitative efforts.
The massive transfusion protocol was initiated. She was
subsequently intubated for airway protection in the setting of
massive fluid resuscitation in the setting of CHF. An OGT lavage
was negative for blood. She received 3U blood. As she appeared
to be stabilizing and given her elevated Cr, CTA was initially
not obtained. Upon further discussion with Dr. ___,
there was concern for an aorto-enteric fistula given her
multiple prior procedures. Therefore, despite her elevated Cr,
the decision was made to proceed with EGD by GI and then CTA if
negative.
On transfer, vitals were: 92 90/66 24 100% RA.
On arrival to the MICU, patient intubated and sedated. Levophed
started, 2L NS bolus, 1 upRBC for BP 78/46. A line placed in R
radial artery.
Called patient's husband (HCP) who reported patient with
multiple episodes of hematochezia since recent discharge from
___, most recently day prior to presentation. Denies
associated abdominal pain or hematemesis. Patient appearing pale
and complaining of dizziness, with low BP noted by visiting ___
on ___. On day of presentation, patient walking with walker
when she fell. Denies head strike.
Past Medical History:
PMH: CAD, s/p multiple MIs and PCIs last ___, ischemic
cardiomyopathy, EF ___, AICD, DM, HTN, HLD, PAD, Active
smoking, Heroin abuse(drug free for ___ years on methadone)
PSH:
___ L CFA endarterectomy, bovine pericardial patch
angioplasty from mid CFA into mid profunda femoral artery
___ Aortogram bilateral lower extremity runoff
___arotid artery to left subclavian
artery bypass with 6-mm PTFE graft
___ CABG x 3vessels, Mitral valve repair
Social History:
___
Family History:
No family history of breast or lung cancer, melanoma or
lymphoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
Vitals: 97.3 84 ___ 22 92%RA
GENERAL: Intubated, sedated.
HEENT: Sclera anicteric, PERRL. MMM.
NECK: JVP non elevated.
LUNGS: Clear to auscultation on anterior lung exam.
CV: Regular rate and rhythm, II/VI systolic murmur heard best at
LUSB
ABD: soft, non-tender, non-distended, bowel sounds present
EXT: Warm, well perfused, no edema. L hallux amputated at base,
granulation tissue but no drainage, erythema, purulence. R wrist
with A-line. R groin with femoral line, dressing c/d/I
SKIN: Per above
NEURO: Exam limited by sedation.
DISCHARGE PHYSICAL EXAM
==================
Vitals: T:98.2, 130/62, 79, 18 O2:98 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple
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: Cool distal extremities, warm proximal extremities, pulses
1+, PICC line in place RUE, dressing C/D/I. Left lower extremity
with absent ___ toe, dressing in place, non pitting edema b/l
lower extremities.
Skin: various brusies, raised subcutaneous lesions on anterior
left shin, not erythematous
Neuro: AOx3, grossly non focal
Pertinent Results:
MICU ADMISSION LABS:
===================
___ 07:40AM BLOOD WBC-5.6 RBC-1.63*# Hgb-4.4*# Hct-14.2*#
MCV-87 MCH-27.0 MCHC-31.0* RDW-19.7* RDWSD-61.1* Plt ___
___ 07:40AM BLOOD Neuts-80.5* Lymphs-11.4* Monos-7.3
Eos-0.2* Baso-0.2 Im ___ AbsNeut-4.53# AbsLymp-0.64*
AbsMono-0.41 AbsEos-0.01* AbsBaso-0.01
___ 07:40AM BLOOD ___ PTT-95.0* ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-718* UreaN-127* Creat-3.0*
Na-130* K-5.8* Cl-90* HCO3-24 AnGap-22*
___ 07:40AM BLOOD ALT-18 AST-15 AlkPhos-116* TotBili-0.2
___ 07:40AM BLOOD Lipase-28
___ 07:40AM BLOOD cTropnT-<0.01
___ 07:40AM BLOOD Albumin-2.8* Calcium-9.3 Phos-7.0*#
Mg-2.0
___ 07:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:40AM BLOOD GreenHd-HOLD
___ 07:54AM BLOOD ___ pO2-31* pCO2-50* pH-7.38
calTCO2-31* Base XS-2
___ 07:54AM BLOOD Lactate-3.6* K-5.5*
___ 07:54AM BLOOD Hgb-4.6* calcHCT-14 O2 Sat-50
___ 02:51PM BLOOD freeCa-0.64*
Micro:
=======
___ Blood CX No growth final
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
STENOTROPHOMONAS MALTOPHILIA. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STENOTROPHOMONAS MALTOPHILIA
|
TRIMETHOPRIM/SULFA---- <=1 S
C. difficile DNA amplification assay (Final ___:
___ Reported to and read back by ___ AT 3:00
___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
HCV VIRAL LOAD (Final ___:
HCV-RNA NOT DETECTED.
Performed using Cobas Ampliprep / Cobas Taqman HCV v2.0
Test.
Linear range of quantification: 1.50E+01 IU/mL - 1.00E+08
IU/mL.
Limit of detection: 1.50E+01 IU/mL.
IMAGING:
========
CTA Abdomen and Pelvis ___
VASCULAR: There is no abdominal aortic aneurysm. The patient is
status post aortobifemoral bypass, which is patent. The proximal
aspect of the left femoral popliteal bypass is occluded. The
native superficial femoral arteries bilaterally also appear
occluded. There is extensive calcium burden in the abdominal
aorta and great abdominal arteries with irregularity of the SMA
reflecting atherosclerotic disease. The ___ is occluded. A left
common femoral venous catheter is in expected position. LOWER
CHEST: Bibasilar atelectasis is present with small bilateral
pleural effusions. There is no pericardial effusion. ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout. There is no evidence of focal lesions. There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits, without stones or
gallbladder wall thickening. PANCREAS: The pancreas has normal
attenuation throughout, without evidence of focal lesions or
pancreatic ductal dilatation. There is no peripancreatic
stranding. SPLEEN: The spleen shows normal size and attenuation
throughout, without evidence of focal lesions. ADRENALS: The
right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram. There is no evidence of stones, focal renal
lesions, or hydronephrosis. There are no urothelial lesions in
the kidneys or ureters. There is no perinephric abnormality.
GASTROINTESTINAL: An NG tube terminates in the stomach. Small
bowel loops demonstrate normal caliber, wall thickness and
enhancement throughout. Colon and rectum are within normal
limits. There is no hyperdensity within the bowel to suggest
active extravasation. Appendix is not visualized. There is no
evidence of mesenteric lymphadenopathy. RETROPERITONEUM: There
is no evidence of retroperitoneal lymphadenopathy. PELVIS: A
Foley catheter is present within a partly collapsed bladder. Air
within the bladder is likely due to recent instrumentation.
There is no evidence of pelvic or inguinal lymphadenopathy.
There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The
uterus and adnexa are unremarkable. BONES: There is no evidence
of worrisome osseous lesions or acute fracture. SOFT TISSUES:
The abdominal and pelvic wall is within normal limits.
IMPRESSION: 1. No evidence of active extravasation into the
bowel. 2. No fluid collection or other finding to account for
leukocytosis. 3. Patent aorto-bifemoral bypass with occlusion of
the proximal aspect of the left femoral popliteal bypass.
CT chest/abd pelvis ___
1. Predominantly perihilar bilateral opacities with interseptal
thickening
and a small right pleural effusion may indicate pulmonary edema.
2. Prominent left paratracheal lymph nodes are likely reactive.
3. Patient is status post aorto-bifemoral bypass.
4. Subcutaneous sites of focal edema in the anterior abdominal
wall are
likely injection sites.
5. ETT, feeding tube, and Foley catheter are incidentally noted.
EEG ___
This telemetry captured no pushbutton activations. Throughout,
it
showed a slow and disorganized background, mostly in the theta
range. There
were frequent generalized blunted sharp waves of a triphasic
morphology,
occasionally appearing in a somewhat rhythmic pattern with a
frequency of up
to 1 Hz for several seconds, but never appearing frequent or
sustained enough
as to suggest ongoing seizures. These findings are consistent
with a moderate
to severe encephalopathy. There were no definitely epileptiform
discharges or
any electrographic seizures.
DISCHARGE LABS
===========
___ 05:16AM BLOOD WBC-4.2 RBC-2.65* Hgb-7.9* Hct-26.2*
MCV-99* MCH-29.8 MCHC-30.2* RDW-17.8* RDWSD-64.8* Plt ___
___ 05:16AM BLOOD Plt ___
___ 05:16AM BLOOD Glucose-213* UreaN-35* Creat-1.3* Na-136
K-4.3 Cl-101 HCO3-26 AnGap-13
___ 05:16AM BLOOD ALT-93* AST-84* AlkPhos-391* TotBili-1.6*
___ 05:16AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.6
Brief Hospital Course:
Ms. ___ is a ___ yo F with a complicated past medical
history significant for systolic CHF (EF 20% to 25% in ___,
s/p AICD), CAD (s/p PCI ___ and CABG in ___, diabetes, CKD
(baseline Cr 1.4), PVD (on warfarin/plavix), past heroin abuse
on methadone, HTN, and COPD who presented to the ED s/p fall and
was found to have a LGIB and mixed shock, initially treated for
several weeks in the ICU before being transferred to the general
medicine floor.
ACTIVE ISSUES
=========
#GIB c/b anemia. Upon presentation, patient had a Hgb of 4.4
with ongoing maroon stool in the ED. BP's initially stable after
3u PRBC's but subsequently hypotensive to SBP ___ requiring
initiation of levophed, 2L NS bolus, and one additional unit
blood on arrival. EGD performed by GI at bedside with no
evidence of active bleed. CTA did not show any active
extravastation of blood. Source was presumed lower or small
intestinal. Her Hg remained stable at the time of transfer out
of the ICU with no further melanotic stool. H/H was trended and
remained stable. She underwent capsule endoscopy on ___ with
results still pending at the time of discharge.
#Hypotension/C. diff Colitis. Likely secondary to mixed shock
septic/cardiogenic picture given profound anemia in setting of
GIB and infection. Initially had broad abx coverage with vanc,
flagyl, ceftaz when source was unclear. She was ultimately found
to have C.diff colitis and was treated with Metronidazole
(___) PO vancomycin (___). Also treated for 7 days
with bactrim after sputum culture grew Stenotrophomonas
maltophilia, but this was discontinued as thought to be an
insignificant pathogen. Ms. ___ was initially difficult to
wean off pressors and required midodrine 20mg TID initially
which was slowly tapered and eventually taken off upon transfer
to the general medicine floor. She will continue PO Vancomycin
to complete a 2 week course from the end date for all other
antibiotics on ___. She did not have further febrile
episodes after being transfered out of the ICU. She was
instructed to contact her PCP if her diarrhea continued to
discuss prolonging the duration of her vancomycin treatment.
#Abdominal pain/nausea/vomiting: Patient noted abdominal pain
upon arrival to the ED. A CT abdomen/pelvis non-contrast was
obtained in the ED with no significant intra-abdominal pathology
idenitified. She subsequently had several repeat KUB's given
concern for ileus, all of which were benign. Norovirus was
negative. She was diagnosed with c. dif. These symptoms
eventually resolved.
# AMS. In the setting of infection and shock, she was intiailly
very altered in the ICU. Several bedside EEGs were performed
which demonstrated some signs of encephalopathy without clinical
signs of seizure activity. Methadone was initially held in the
setting of somnolance but eventually restarted at decreased
dose. Methadone was uptitrated to 30mg daily by the time of
discharge (below her home dose of 69mg daily). She was AOx3,
without focal deficits at the time of discharge.
#Transaminitis: LFTs peaked in the 1,000s with quick downtrend,
thought likely ___ ischmic shock liver in the setting of
hypotension. Statin was held and she will have follow up LFTs as
an outpatient prior to restarting.
# PAD: Admitted on Warfarin/Plavix/ASA s/p recent vascular
procedures. Held all anticoagulants given bleed on admission.
Warfarin and plavix were restarted on ___ along with a heparin
gtt to bridge. She was continued on these agents until INR was
therapeutic. Multiple discussions were had amongst her
outpatient providers (including cardiology and vascular surgery)
and it was decided that she should not be on triple
anticoagulation therapy given her risk of bleeding. Aspirin was
not restarted and should be held indefinitely. She was
discharged on warfarin/plavix. INR was 3.0 on the day of
discharge. She was set up for repeat INR monitoring with her PCP
2 days after discharge.
#Hyperglycemia: HbA1c 8.4% in ___. BS 716 on ED admission
chem 10. She initially required an insulin gtt in the ICU but
was gradually restarted on home glargine and ISS while inpatient
and will continue with both as an outpatient.
#Chronic CHF: Discharge weight from last hospital stay was 76.6
kg. LVEF of ___ in ___, now ___ based on TTE this
admission. Her fluid management was difficult in the ICU. On the
floor she was eventually restarted on home metroprolol and
lisinopril. Torsemide was restarted but she had a subsequent
increase in her Cr from 1.0 to 1.4 so this was discontinued and
held on discharge. She appeared euvolemic on discharge and will
have follow up weight check at her appointment with her PCPs
office 2 days after discharge for titration of diuretics
medicaitons based on need. Her cardiologist Dr. ___ was made
aware of these changes and was in agreement with the plan.
# CAD(s/p multiple MIs and PCIs last ___ CABGx3 in ___.
Home medications were initially held in the setting of shock.
She also experienced an NSTEMI during admission while in the
ICU. She had several additional episodes of chest pain, without
EKG changed during the remainder of her hospital stay. Beta
blocker and plavix were continued. As per the discussion above,
aspirin was not restarted given dual therapy with
warfarin/plavix. Statin was held in the setting of LFTs
elevation.
#Heroin abuse on methadone maintenance: Initially was giving
only 10mg daily in setting of AMS, but this was gradually
increased to 30mg daily by the time of discharge. She was
provided with a last letter. Her ___ clinic was notified
of her admission and discharge plans. They will be responsible
for uptitration to prior home dose of 69 mg daily. She was
provided a prescription for a narcan kit on discharge to be used
in the case of emergency overdose.
#Acute on chronic CKD: Cr peaked at 3 above normal baseline in
the setting of hypovolemia. She was resuscitated with pRBC and
fluid and Cr downtrended. As above, home torsemdie was held on
discharge.
# Other. Upon transfer to the floor the patient informed the
primary team that her wedding ring was removed at some point
either in the Emergency room or the ICU. Both locations were
notified and efforts were made to locate this item but
unfortunately neither the ICU or ED have a record of her wedding
ring. Patient relations was notified and will be in contact with
the patient after discharge with any updates regarding this
situation. The patient was in agreement with this plan.
CHRONIC ISSUES
==========
# COPD: Continued home inhalers
TRANSITIONAL ISSUES
===================
# Labs
- Recheck Chem 10 and CBC on ___ with results faxed to
Dr. ___ at ___
- Please draw INR on ___ and fax result to ___
___ at ___
# GIB
- Capsule endoscopy results pending at the time of discharge
# C. Diff:
- Pt. to complete PO Vanc course from D1 (___), needs 2 weeks
to complete ___.
# PAD/CAD.
- Discussed risks/benefits of triple anticoagulation with Drs
___ who both agreed that the risk of significant
gastrointestinal bleeding with adding Aspirin to the regimen of
warfarin and plavix was greater than the potential benefit.
Discharged on only warfarin and plavix. Held aspirin.
- Should f/u with Dr. ___ in 1 month after discharge with
consideration of outpatient angiography. Ongoing discussions
regarding possible revascularization procedure when medically
stable.
# Anticoagulation
- Warfarin 1 mg daily starting ___ (warfarin held on ___ given
elevated INR at discharge)
- INR on day of discharge 3.0 (goal ___
- Next INR should be checked on ___ and fax result to ___
___ at ___
# CHF
- Discharge weight 73.8kg
- Discharge diuretics: Held home torsemide in setting ___ and
___. Consider restarting pending Cr and volume status at
follow-up visit on ___.
- Please check weight and follow-up labs on ___ and consider
restarting diuretics. If concerns for worsening heart failure or
with any questions, please call the heart failure clinic at
___ attn: Dr. ___.
# Methadone.
- Discharged on 30mg once daily.
- Home dose previously 69mg. ___ clinic # ___ case
manager ___. Confirmed with ___ clinic that they will
be able to provide delivered dosing to Ms. ___ after
hospitalization. Last dose letter provided.
- Provided patient with narcan packet on discharge
# Neuropathy.
- Held home gabapentin and amitriptyline as patient was not
experiencing any symptoms while inpatient. Consider reinitiation
if clinically indicated in the outpatient setting.
# Transaminitis
- Recommend trending LFTs 1x/week to ensure normalization
- Restart stain once LFTs have normalized
# CODE: FULL
# CONTACT: Husband, ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q4H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
3. Amitriptyline 25 mg PO QHS
4. Atorvastatin 80 mg PO QPM
5. Clopidogrel 75 mg PO DAILY
6. Collagenase Ointment 1 Appl TP DAILY
7. Gabapentin 400 mg PO TID
8. Methadone (Concentrated Oral Solution) 10 mg/1 mL 69 mg PO
DAILY
9. Metoprolol Succinate XL 25 mg PO QHS
10. Pantoprazole 40 mg PO Q24H
11. Tiotropium Bromide 2 CAP IH DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Warfarin 1.5 mg PO DAILY16
14. LOPERamide 2 mg PO QID:PRN diarrhea
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
16. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
17. Lisinopril 2.5 mg PO DAILY
18. Torsemide 80 mg PO BID
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp
#*22 Capsule Refills:*0
2. Clopidogrel 75 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Methadone 30 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO QHS
6. Pantoprazole 40 mg PO Q24H
7. Tiotropium Bromide 2 CAP IH DAILY
8. Acetaminophen 325-650 mg PO Q4H:PRN pain
9. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
10. Collagenase Ointment 1 Appl TP DAILY
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
13. Vitamin D 1000 UNIT PO DAILY
14. nalOXone 4 mg/actuation nasal prn opioid overdose
Apply 1 spray (4mg) to nostril for opioid overdose. ___ repeat
every 2 to 3 minutes in alternating nostrils until medical
assistance becomes available.
RX *Narcan 4 mg/actuation 1 spray nasal as needed for opioid
overdose Disp #*1 Spray Refills:*1
15. Outpatient Lab Work
ICD-10: I50.2
Dx: Systolic Congestive Heart Failure
Please drawn Chem 10 and CBC on ___
Please fax results to Dr. ___ at ___ fax: ___
16. Warfarin 1 mg PO DAILY16
Start taking on ___
17. Glargine 20 Units Bedtime
18. Outpatient Lab Work
ICD 10: T82.898 LOWER EXTREMITY BYPASS GRAFT OCCULUSION HX
Please draw INR on ___ and fax result to ___
___ at ___
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary Diagnosis
Septic Shock
Cardiogenic Shock
C. diff, severe infection
Lower gastrointestinal bleed
Secondary Diagnosis
Peripheral vascular disease
Coronary artery disease
Systolic heart failure, chronic
Type 2 Diabetes
Obstructive Sleep Apnea
Acute Kidney Injury
Stenotrophemonis respiratory infection
Methadone maintenance therapy
Transaminitis
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
hospitalization. Briefly, you were hospitalized after bleeding
from your gastrointestinal tract. You were very sick and
required a several week stay in the Intensive Care Unit with
multiple blood transfusions. During that time, you were treated
for infections and gradually restarted on your home medications.
By the time you were transfered out of the ICU, you were feeling
better. You underwent a Capsule Study, where you swallowed a
camera to look for sources of bleeding in your gastrointestinal
tract. The results of this study are still pending. You will
also continue taking antibiotics (Vancomycin) to treat an
infection (C. diff) in your stool. You should not restart
Aspirin and should only take warfarin and plavix.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the best,
Your ___ Treatment Team
Followup Instructions:
___
|
10901772-DS-42
| 10,901,772 | 21,899,235 |
DS
| 42 |
2152-06-24 00:00:00
|
2152-06-25 18:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
absorbable surgical gauze
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
-___ L toe amputation ___
-CVL placement
-R IJ temporary tunneled line placement
History of Present Illness:
___ h/o CAD s/p CABG, PVD s/p multiple procedures (most recently
repeat bypass in LLE ___, CHF w/ EF ___ s/p ICD for
primary prevention, HTN, DM, presents w/ 19 lb weight gain in 3
days, dyspnea, and hypotension.
In the ED, pt reported that she gained 19 lbs in 3 days with
increasing dyspnea on exertion. She was recently discharged from
the vascular service when she underwent aort/fem bypass surgery.
She also endorses pain at her incision site, denies cough, chest
pain, fevers, or chills. She endorses left leg swelling since
leaving the hospital. Denies any increased swelling
Of note, the patient also has dry gangrene on her left second
and third toes.
-In the ED initial vitals: T 97.0 P 70 BP 81/49 RR 22 O2Sat 100%
RA.
-Exam was notable for tenderness to palpation over the bypass
site, significant lower extremity edema with dry gangrene
-Labs notable for:
-wbc 7.1, H/H 8.2/25.7, Plt 347. INR 2.9.
-Na 126, K 5.6, BUN 65, Cr 3.4 (baseline 1.3-1.6)
-lactate 2.3
-Tn .04, bnp 1077
-u tox: positive for methadone and opiates
-UA negative for nitrites, leukocytes, and no bacteria
-CXR showed mild pulmonary edema but was a limited exam.
-Left Foot AP showed: spft tissue edema, difficult to exclude
osteo at the ___ through ___ toes. No soft tissue gas.
-EKG showed
-the patient received 250 CC NS, 10 IV insulin, vanc and zosyn
and was admitted to the floor.
-An IJ was attempted but was aborted due to the patient's
inability to lay flat
On arrival to the floor, patient was verbose, and asking for
pain medication. She endorsed pain at her left lower extremity,
in addition to tachypnea.
Her SBP on arrival was 72. She was started on peripheral
levophed and consented for a CVL. She received 1mg of IV Ativan
in preparation for the CVL. Due to worsening tachypnea, she was
given 120mg of IV Lasix. A VBG at this time showed
___. She put out 300 cc of IVF, her tachypnea
improved with a RR 12, and her levophed was weaned.
Vascular surgery was notified of her admission and recommended
continuing aspirin, Plavix, and warfarin, in addition to
vancomycin and zosyn.
Past Medical History:
PAST MEDICAL HISTORY:
-CAD with the following interventions:
A. ___ - 2.5 x 18 Cypher to LAD
B. ___ - inferior STEMI with overlapping Endeavor stents to
the distal RCA,
C. ___ - ISR RCA stent status post POBA
D. ___ - progression of left main disease resulting in CABG
(free LIMA to LAD because of clotted off left subclavian stent,
SVG to RCA, SVG to OM). LIMA and SVG to RCA are known to be
occluded with SVG to OM patent (___)
E. ___ - Admission with congestive heart failure and non-ST
elevation MI in ___, transferred to ___. Angiography
showed
with 90% in-stent restenosis distal RCA stent, status post 2.75
x
20 mm PROMUS drug-eluting stent.
F. There is residual 40% of LMCA and a tighter distal LAD
stenosis in a small vessel
-ICD for primary prevention
-PVD with multiple surgeries, subclavian stent
-DM2 with last A1c 11%, macroalbuminuria, diabetic neuropathy
-HLD
-Tobacco use
-Sleep Apnea
-History of polysubstance abuse
PAST SURGICAL HISTORY:
PSH:
___ left femoral to above knee popliteal bypass
graft with 6 mm ringed PTFE.
___: Debriedment left ___ toe, including partial metatarsal
head resection.
___ left first ray amputation
___ aorto-bifem w dacron & L fem-pop bypass w PTFE
___ L CFA endarterectomy, bovine pericardial patch
angioplasty from mid CFA into mid profunda femoral artery
___ Aortogram bilateral lower extremity runoff
___arotid artery to left subclavian
artery bypass with 6-mm PTFE graft
___ CABG x 3vessels, Mitral valve repair
Social History:
___
Family History:
No family history of breast or lung cancer, melanoma or
lymphoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GEN: alert, oriented, rapid speech
HEENT: NC/AT, EOMI
NECK: supple
CV: RRR, no m/r/g
LUNGS: fair air movement, decreased breath sounds at bases,
mild wheeze and b/l crackles
ABD: soft, ND, ND
EXT: LLE stapled in place with erythema and mild lower
extremity edema
SKIN: erythema of LLE as above. left heel dressings c/d/i
NEURO: oriented, answers questions appropriately, then drowsy
but arousable to voice and answers questions appropriately
DISCHARGE PHYSICAL EXAM:
========================
VS: Tm 97.6 ___ 16 97%RA
I/O: ___
Wt: 77.6< 76.2 <- 76.3 <- 76.8 < 76.6 < 77.3 < 77.2 < 75.9 <
76.7 < 78.2
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 7cm, tunneled R IJ line c/d/I without
erythema at insertion site. Multiple well healed surgical scars
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. Soft ___ early systolic murmur heard
best along LSB. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles in bottom
third of lung fields without wheezing.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No clubbing or cyanosis. Tr pitting edema to
mid-shin bilaterally (L > R chronically per patient), bilateral
stasis dermatitis. No femoral bruits.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:52PM BLOOD WBC-7.1 RBC-2.93* Hgb-8.2* Hct-25.7*
MCV-88 MCH-28.0 MCHC-31.9* RDW-17.7* RDWSD-57.2* Plt ___
___ 04:52PM BLOOD Neuts-68.8 Lymphs-15.0* Monos-13.4*
Eos-1.6 Baso-0.4 Im ___ AbsNeut-4.87 AbsLymp-1.06*
AbsMono-0.95* AbsEos-0.11 AbsBaso-0.03
___ 11:59AM BLOOD ___ PTT-54.2* ___
___ 04:52PM BLOOD Glucose-509* UreaN-65* Creat-3.4* Na-126*
K-5.6* Cl-88* HCO3-20* AnGap-24*
___ 04:52PM BLOOD ALT-10 AST-28 AlkPhos-110* TotBili-<0.2
___ 04:52PM BLOOD Lipase-20
___ 04:52PM BLOOD cTropnT-0.04* proBNP-1077*
___ 04:52PM BLOOD Albumin-3.3* Calcium-8.4 Phos-7.9* Mg-1.8
___ 04:52PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:17PM BLOOD ___ pO2-21* pCO2-56* pH-7.28*
calTCO2-27 Base XS--2
___ 05:03PM BLOOD Lactate-2.3* K-5.4*
___ 10:17PM BLOOD Lactate-2.4* K-4.3
___ 06:16PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:16PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 06:16PM URINE RBC-0 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-1
___ 06:16PM URINE CastHy-23*
___ 06:16PM URINE bnzodzp-NEG barbitr-NEG opiates-POS*
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-POS*
OTHER PERTINENT/DISCHARGE LABS:
===============================
___ 04:52PM BLOOD cTropnT-0.04* proBNP-1077*
___ 11:15AM BLOOD CK-MB-3.7 cTropnT-0.19*
___:28AM BLOOD CK-MB-2 cTropnT-0.08*
___ 10:17PM BLOOD Lactate-2.4* K-4.3
___ 06:14PM BLOOD Lactate-1.2
___ 04:53AM BLOOD WBC-6.0 RBC-2.68* Hgb-8.0* Hct-24.8*
MCV-93 MCH-29.9 MCHC-32.3 RDW-17.9* RDWSD-59.4* Plt ___
___ 04:41AM BLOOD Neuts-61.4 ___ Monos-12.6 Eos-5.1
Baso-0.9 Im ___ AbsNeut-3.47 AbsLymp-1.10* AbsMono-0.71
AbsEos-0.29 AbsBaso-0.05
___ 04:53AM BLOOD ___ PTT-61.2* ___
___ 04:53AM BLOOD Glucose-194* UreaN-59* Creat-1.8* Na-135
K-3.9 Cl-96 HCO3-23 AnGap-20
___ 04:53AM BLOOD Calcium-9.1 Phos-6.8* Mg-2.6
IMAGING/STUDIES/REPORTS:
================
++CXR (Portable AP) ___
Mild pulmonary edema. Limited exam.
++Left Foot, 2 views - ___
AP, lateral views of the left foot provided portably. There is
evidence of prior transmetatarsal amputation at the great toe.
First metatarsal stump appears preserved without signs of bony
destruction. There is diffuse soft tissue edema. The second
through fifth toes are suboptimally assessed due to hammertoe
deformities and partial flexion. Difficult to exclude subtle
osteomyelitis at these sites. Elsewhere, no bony destruction to
suggest osteomyelitis. No soft tissue gas or radiopaque foreign
body. Faint vascular calcification noted. There is a small
plantar heel spur.
SURGICAL PATHOLOGY REPORT - Final
"LEFT ___ TOE", AMPUTATION:
- Acute osteomyelitis, present at the amputation margin.
- Gangrenous necrosis, ulceration, and acute inflammation,
present at the amputation margin.
CHEST (PORTABLE AP) Study Date of ___ 4:37 ___
IMPRESSION:
No focal consolidation, pneumothorax, pleural effusion, or
mediastinal
widening.
MICROBIOLOGY:
=============
___- blood cultures x2 - negative
___- c diff PCR - negative
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
SPECIATION AND SENSITIVITY TESTING PER ___. ___
(___)
___.
ENTEROCOCCUS SP.. RARE GROWTH.
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.
Work-up of organism(s) listed discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
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.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
AMPICILLIN------------ <=2 S
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- 2 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 2 S 2 S
Brief Hospital Course:
___ woman w/ h/o systolic CHF (EF was ___ in ___, s/p
AICD in ___, CAD (s/p PCI in ___, CABG in ___, PVD (s/p
aorto-bifem & L fem-pop bypass ___ w/ chronic occlusion of L
graft, on warfarin) w/ redo left femoral to above knee opliteal
bypass ___, HTN, h/o IVDU (on methadone), and COPD who p/w
dyspnea, tachypnea, volume overload, admitted for an acute on
chronic systolic heart failure exacerbation.
# ACUTE ON CHRONIC SYSTOLIC HEART FAILURE:
Hx of LVEF of ___ in ___. Pt endorsed gaining 19 lbs in 3
days with worsening SOB and dyspnea on exertion. Patient has had
multiple admissions for heart failure exacerbations in the past
requiring IV diuresis. Physical exam notable for elevated JVP,
mild pulmonary edema on CXR, wheezes and crackles on exam.
Patient's Cr also elevated to 3.4 from baseline of 1.2-1.6.
Her most recent diuretic regimen is Torsemide 60mg daily and
metolazone. Her weight is up 4.5 kg from her prior discharge
weight from the cardiology service. She was diuresed with IV
Lasix, and maintained on fractionated metoprolol prior to
transfer to vascular surgery. Once euvolemic, she was
transferred to the vascular surgery service, as she was planned
for elective ___ L toe amp while in house (see below for
details). Following her surgery the patient was transferred to
the CHF service, and was further diuresed with IV Lasix, which
was transitioned to 60mg torsemide daily upon discharge.
# Lower extremity dry gangrene of toes and left heel ulcer:
Pt with known peripheral vascular disease. Was scheduled for
elective left second toe amputation during this admission;
underwent procedure on ___ once stabilized and euvolemic;
transferred to surgical service for post-operative management.
Had wet to dry dressing with eventual vac placement
post-operatively. Required 1 u PRBC transfusion for continued
oozing from wound post-operatively while anticoagulated. Once
stable from surgery, transferred back to medical service for
ongoing diuresis and medical optimization. Pathology was
consistent with osteomyelitis in the amputated bone, and thus ID
was consulted. The patient was placed on IV ceftriaxone,
vancomycin, and oral metronidazole, which she will need to
continue until ___. She had a wound vac in place and will
follow-up with vascular surgery for this.
# PAD:
PVD with bilateral limb ischemia and left foot dry gangrene s/p
aorto-bifemoral bypass and left fem-pop bypass w PTFE ___
___ c/b left fem-pop bypass graft thrombosis, now recently
s/p redo left femoral-AKpop bypass graft ___ ___.
Surgical care of her ___ L great toe as above. Pt was maintained
on her home aspirin, clopidogrel and anticoagulation with
warfarin.
#Episode of bradycardia and hypotension: Pt had one episode
while on CHF service of profound hypotension and bradycarida. It
was unclear what triggered this event, pt's beta-blockade was
held, given 1U pRBC's for concern of possible bleeding. Her H/H
responded appropriately. She was transferred breifly to the ICU
for further care. Her BP improved with increased pacer rate.
Unclear etiology. Pt has been brady o/n during her stay and her
pacer would start at 40's. When pacer rate increased, then
decreased, noted to be sinus bradycardia. She remained stable
following setting her device back to it's native settings. She
will have an electrophysiology evaluation as an outpatient to
determine the need for additional leads.
# ACUTE ON CHRONIC KIDNEY DISEASE:
Admission Cr of 3.2 from baseline 1.3-1.6. Likely due to
cardiorenal syndrome given overall presentation. Good urine
output response to IV Lasix and subsequent improvement in kidney
function. Her ACE-inhibitor was eventually restarted. Her
creatinine on the day of discharge was 1.8 and her kidney
function should be checked weekly while on antibiotics.
# CAD(s/p multiple MIs and PCIs last ___ CABGx3 in ___:
continued atorvastatin and Plavix.
# COPD - continued home albuterol and tiotropium
# History of IVDU on methadone - continued on home methadone
# DM - ___ diabetes service consulted and managed the
patient's insulin regimen while in house, she is being
discharged on the same regimen she was taking while in house
Transitional issues:
-The patient will be discharged off of her beta-blocker
following an episode of profound bradycardia and hypotension.
She will have follow-up with electrophysiology in the future re:
atrial lead placement for her device
-The patient needs a dilated eye exam for diabetic nephropathy
in the future
-Pt will continue vancomycin, ceftriazone, and metronidazole for
osteomyelitis until ___
- Pt will require weekly safety labs including: LFTs, CBC w/
diff, ESR, vancomycin trough, CRP and CK. Please fax results to
ATTN: ___ CLINIC - FAX: ___. First lab check due
on ___
- The patient was continued on her home 65mg of methadone daily
- The patient will have BID wet-to-dry dressings on her L ___
toe site until wound vac can be replaced
-Vac settings: Please place VAC dressing to left ___ toe
amputation site, VAC pressure -125mmHg, change every 3 days.
-Once the patient's antibiotic regimen has been completed, she
will require removal of the temporary IJ line for antibiotic
infusions. Please call ___ to coordinate a time for the
patient to return for removal
-The patient's warfarin was held on the day of discharge
(___) for an INR of 4.1, please see anticoagulation
work-sheet for more details. Next INR should be checked on
___
-Discharge diuretic: 60mg torsemide daily
-Discharge weight: 77.6 kg
-Pt was full code this admission
-Pt's emergency contact is ___ (Husband,
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
3. Atorvastatin 80 mg PO QPM
4. Gabapentin 400 mg PO TID
5. Methadone 65 mg PO DAILY
6. Metolazone 5 mg PO 2X/WEEK (WE,SA)
7. Nicotine Patch 7 mg TD DAILY
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
9. Pantoprazole 40 mg PO Q24H
10. Tiotropium Bromide 1 CAP IH DAILY
11. Torsemide 60 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Aspirin 81 mg PO DAILY
14. Ciprofloxacin HCl 500 mg PO Q12H
15. Docusate Sodium 100 mg PO BID
16. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
17. MetroNIDAZOLE 500 mg PO Q8H
18. Senna 8.6 mg PO BID:PRN constipation
19. Sulfameth/Trimethoprim DS 1 TAB PO BID
20. ___ MD to order daily dose PO DAILY16
21. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
22. Naloxone 4 mg PO PRN overdose
23. Metoprolol Succinate XL 25 mg PO DAILY
24. Lisinopril 2.5 mg PO DAILY
25. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Outpatient Lab Work
WEEKLY labs, starting on ___
Please draw CBC w/ differential, BUN, Cr, AST, ALT, TBili, Alk
Phos, ESR, CRP and vancomycin trough
Fax results to ___ CLINIC (Fax: ___
2. Acetaminophen 1000 mg PO Q8H
3. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Clopidogrel 75 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Gabapentin 400 mg PO TID
9. Lisinopril 2.5 mg PO DAILY
10. Methadone 65 mg PO DAILY
Last dose administered ___ at 06:37 AM.
11. MetroNIDAZOLE 500 mg PO Q8H
12. Pantoprazole 40 mg PO Q24H
13. Senna 8.6 mg PO BID:PRN constipation
14. Tiotropium Bromide 1 CAP IH DAILY
15. Torsemide 60 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. Warfarin 2 mg PO DAILY16
18. CefTRIAXone 2 gm IV Q24H
19. Vancomycin 1000 mg IV Q 24H
20. Naloxone 4 mg PO PRN overdose
21. Nicotine Patch 7 mg TD DAILY
22. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
23. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
24. Glargine 42 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Acute on chronic systolic heart failure
Peripheral arterial disease
Dry gangrene
Osteomyelitis of ___ left toe
Acute on chronic anemia
Type 2 diabetes mellitus
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms ___
___ were admitted to the hospital for a heart failure
exacerbation. ___ were given medications to help remove the
extra fluid from your body, and were eventually transitioned to
an oral diuretic, torsemide, which ___ will continue to take
going forward.
While ___ were here, ___ had a surgery to remove the infection
of your L second toe. ___ will need to continue seeing the
vascular surgeons and infectious disease doctors. ___ will also
continue getting antibiotics for a total of 6 weeks.
During your time in the hospital, ___ also had an episode of
very low blood pressure, which was believed to be due to your
heart beating very slowly. We are working on an appointment for
___ to see the doctors who ___ in these devices.
Please take all of your medications as prescribed below, and
please attend all follow-up appointments listed. We wish ___ the
best in the future-
-Your ___ Care Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10901772-DS-44
| 10,901,772 | 21,554,440 |
DS
| 44 |
2152-08-08 00:00:00
|
2152-08-10 13:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
absorbable surgical gauze
Attending: ___.
Chief Complaint:
hypotension, ___
Major Surgical or Invasive Procedure:
Left IJ in ED ___
History of Present Illness:
___ y/o W with a h/o sCHF (EF ___, CAD s/p CABG/ICD, severe
PAD s/p revision L fem-pop bypass ___, brittle DM type 2,
recent osteomyelitis s/p amputation of Left great toe ___,
and many hospitalizations over the last 6 months for infections
and CHF exacerbations, presenting today with anuria, right flank
pain, renal failure, and 10 pound weight gain.
Of note, patient has had many recent hospitalizations (12 in the
past year). Most recently, she had a L fem-pop bypass in ___.
Following discharge she was readmitted for CHF exacerbation.
Once stabilized she went for L toe amputation on ___.
Pathology was positive for acute osteomyelitis with positive
margins. Tissue cx were polymicrobial with enterococcus, CoNS,
and diphtheroids and she was treated with Vancomycin,
ceftriaxone, and metronidazole. Diuresed with IV Lasix and
transitioned to torsemide. Discharged to rehab with IJ in place
for IV antibiotics. Discharge weight 80kg. On ___, she went
to ___ clinic for OPAT follow up. During that visit, she
expressed that she no longer wanted to stay at rehab, and IV
antibiotics were stopped on ___ instead of ___, and she was
switched to doxy/augmentin for 7 days of PO treatment. Since
that time, her IJ was removed on ___. She has noted increasing
purulence and drainage at her wound site. She has also noted
that she has significant weight gain, 164 lbs to 173 lbs,
despite taking additional 20mg torsemide on ___ and ___. She
did miss torsemide dose earlier this week when at an
appointment. She had vascular follow up for her toe on ___, and
labs were drawn. Cr 2.7 up from 1.5, and she was sent to the ED.
In the ED, initial vitals: 96.6, 69, 80/33, 18, 100% RA
- Labs significant for: wbc 5.2, H/H 7.8/25.1, plt 164. INR 2.
BNP 1409. Na 133, K5.1, Cl 100, Bicarb 17, BUN 140, Cr 2.8, AG
16. Lactate 1.7.
- VBG: pH 7.3, pCO2 46.
- Urine positive for methadone
- UA negative
- AST/ALT 97/64, AP 543, lipase 114. Tbili <0.2, Alb 3.4.
- repeat Labs with wbc 10.6, H/H 8.3/26.3, plt 188. Cr 2.6.
- Left IJ placed for access
- She was given 1.5L, 500mg IV Meropenem, Lorazepam 0.5mg IV.
Started on norepherine 0.21 for SBP 70-80s, with improvement to
SBP 130s. Norepi was weaned down to 0.18.
- CXR: no edema or effusions
- Cardiology evaluated in the ED, felt that this was not
cardiogenic shock and that she should go to the ICU.
- Renal evaluated her and did not feel that she needed emergent
renal replacement therapy.
- Vitals prior to transfer: 98.9, 85, 128/88, 26, 98% RA
On arrival to the MICU, patient is lethargic but awakens to
stimuli. Complaining of pain in her arm when being moved. She is
unable to give much more history due to lethargy.
Spoke to husband on the phone. He reports that she came home
from rehab a little over a week ago. She has been taking all her
PO antibiotics as prescribed, and they completed 4 days ago. He
feels like her foot is doing a little better. Vascular surgery
debrieded it in clinic yesterday. She continues to have shaking
and jerking of extremities for months. Her urine output
decreased 4 days ago and she started gaining weight. She has
been taking increased torsemide doses of 120mg daily for the
last few days. He thinks she has gained 10 lbs in 1 week. She
has also been having uncontrollable diarrhea, sometimes she has
a bowel movement at night and doesn't realize. She also had
intermittent epistaxis. She has also been complaining of
headaches.
Past Medical History:
-CAD with the following interventions:
A. ___ - 2.5 x 18 Cypher to LAD
B. ___ - inferior STEMI with overlapping Endeavor stents to
the distal RCA
C. ___ - ISR RCA stent status post POBA
D. ___ - Progression of left main disease resulting in CABG
(free LIMA to LAD because of clotted off left subclavian stent,
SVG to RCA, SVG to OM). LIMA and SVG to RCA are known to be
occluded with SVG to OM patent (___).
E. ___ - Admission with congestive heart failure and non-ST
elevation MI in ___, transferred to ___. Angiography
showed 90% in-stent restenosis distal RCA stent, status post
2.75x20mm PROMUS DES.
F. There is residual 40% of LMCA and a tighter distal LAD
stenosis in a small vessel.
-Systolic CHF with EF ___ with multiple hospitalizations for
CHF exacerbations including CCU stays
-ICD for primary prevention
-Peripheral arterial disease (PAD) s/p multiple surgeries (see
below)
- Osteomyelitis of Right great toe. s/p amputation in ___,
required long course of IV antibiotics.
-DM2 with last A1c 11%, macroalbuminuria, diabetic neuropathy
-HLD
-Tobacco use
-Sleep Apnea
-History of polysubstance abuse
- hepatitis C
Social History:
___
Family History:
No family history of breast or lung cancer, melanoma or
lymphoma.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 97.6 BP: 134/84 P: 78 R: 17 O2: 97RA
GENERAL: lethargic, arousable to stimuli, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, dentures in
place, oropharynx clear
NECK: bandage on R IJ where attempt was made, Left IJ in place.
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no m/r/g
ABD: soft, minimally distended, tender in RUQ and epigastrum, no
rebound
EXT: bilateral hands cool, but forearms warm. Right foot cool to
the touch, calf warm. Left foot with amputated first toe.
4cmx3cm open wound on left first toe, fibrinous material, non
purulent. No erythema surrounding the wound. Left foot warm.
SKIN: No other skin lesions
NEURO: AOx2 (name, place), moving all extremities, non
compliant with full neurologic exam. Has random jerking of all
extremities, which is her baseline.
DISCHARGE EXAM:
Vitals: 97.9, 90s-120s/50s-70s, 60s-70s, 18, >94% RA, FSBG 410
at 6:30 pm
Exam:
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - sclerae anicteric, MMM, OP clear,
Neck: JVP not elevated
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB
ABDOMEN - NABS, soft/NT/ND
EXTREMITIES - WWP, no edema
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Weights (per outpatient records/notes):
Dry weight from prior d/c summaries ___ kg
___ kg
___
Pertinent Results:
ADMISSION LABS:
___ 08:10PM BLOOD WBC-5.2 RBC-2.68* Hgb-7.8* Hct-25.1*
MCV-94 MCH-29.1 MCHC-31.1* RDW-17.2* RDWSD-58.8* Plt ___
___ 08:10PM BLOOD Neuts-71.1* Lymphs-17.3* Monos-8.1
Eos-2.9 Baso-0.4 Im ___ AbsNeut-3.69 AbsLymp-0.90*
AbsMono-0.42 AbsEos-0.15 AbsBaso-0.02
___ 01:50PM BLOOD ___
___ 08:10PM BLOOD Glucose-110* UreaN-140* Creat-2.8* Na-133
K-5.4* Cl-100 HCO3-17* AnGap-21*
___ 01:05AM BLOOD ALT-64* AST-97* AlkPhos-543* TotBili-<0.2
___ 01:05AM BLOOD CK-MB-6 cTropnT-0.02* proBNP-1607*
___ 01:05AM BLOOD Albumin-3.4* Calcium-8.8 Phos-7.5* Mg-2.1
___ 11:49PM BLOOD ___ pO2-36* pCO2-46* pH-7.30*
calTCO2-24 Base XS--4
___ 08:19PM BLOOD Lactate-1.7 Na-139 K-5.1
PERTINENT LABS:
___ 08:10PM BLOOD proBNP-1409*
___ 01:05AM BLOOD CK-MB-6 cTropnT-0.02* proBNP-1607*
___ 05:47AM BLOOD CK-MB-5 cTropnT-0.05*
___ 03:10PM BLOOD CK-MB-5 cTropnT-0.04*
___ 01:05AM BLOOD Lipase-114*
___ 05:47AM BLOOD GGT-207*
___ 05:47AM BLOOD HBsAg-Negative HBsAb-Negative
___ 06:02AM BLOOD CRP-12.4*
DISCHARGE LABS:
___ 06:35AM BLOOD WBC-4.5 RBC-2.79* Hgb-8.1* Hct-26.0*
MCV-93 MCH-29.0 MCHC-31.2* RDW-16.2* RDWSD-55.9* Plt ___
___ 06:35AM BLOOD Glucose-85 UreaN-48* Creat-1.5* Na-140
K-4.0 Cl-106 HCO3-27 AnGap-11
___ 06:35AM BLOOD Albumin-3.2* Calcium-9.1 Phos-3.4 Mg-2.0
___ 06:35AM BLOOD ALT-24 AST-21 LD(LDH)-207 AlkPhos-243*
TotBili-0.2
MICROBIOLOGY:
___ 5:47 am IMMUNOLOGY Source: Line-Lt IJ.
**FINAL REPORT ___
HCV VIRAL LOAD (Final ___:
HCV-RNA NOT DETECTED.
Performed using Cobas Ampliprep / Cobas Taqman HCV v2.0
Test.
Linear range of quantification: 1.50E+01 IU/mL - 1.00E+08
IU/mL.
Limit of detection: 1.50E+01 IU/mL.
URINE CULTURES ___ and ___: negative
BLOOD CULTURES ___ and ___ x3: negative
___ 4:04 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
IMAGING:
Chest X ray ___: 1. Newly placed left IJ approach central
venous catheter tip projects over
the expected region of the cavoatrial junction.
2. Persistent low lung volumes.
3. Persist and bilateral small pleural effusions.
___ CT abd: 1. No hydronephrosis or obstructing renal
stones. Punctate left lower renal
pole and right midpole non-obstructing stones.
2. Cholelithiasis.
3. No acute abdominal or pelvic process.
Echo ___:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thicknesses and cavity size
are normal. There is moderate regional left ventricular systolic
dysfunction with akinesis of the inferoseptum, inferior wall and
inferolateral wall and hypokinesis of the remaining segments.
Overall left ventricular systolic function is moderately
depressed (LVEF= ___ %). The estimated cardiac index is
borderline low (2.0-2.5L/min/m2). Diastolic function could not
be assessed. Right ventricular chamber size is normal with mild
global free wall hypokinesis.Aortic valve leaflets are mildly
thickened with no aortic stenosis detected. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. A mitral valve annuloplasty ring is present. The
gradient across the mitral valve is increased (mean = 5 mmHg).
Mild (1+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Moderate regional left
ventricular systolic dysfunction, c/w multivessel CAD.
Well-seated mitral annuloplasty ring with mild residual
regurgitation and mildly increased transvalvular gradient. At
least moderate pulmonary hypertension with mild/moderate
tricuspid regurgitation.
Compared with the prior study (images reviewed) of ___,
overall systolic function is similar. The cavity size is
smaller. There is more tricuspid regurgitation and pulmonary
artery systolic pressures are higher.
RUQ US ___: 1. Cholelithiasis.
2. Prominent CBD measures 8 mm. No ultrasound evidence of
choledocholithiasis
or intrahepatic bile duct dilation.
3. Nonvisualization of pancreas due to overlying bowel gas.
CXR ___: Comparison to ___. Pre-existing
parenchymal opacities have completely resolved. Lung volumes are
low. Minimal atelectasis at the right lung bases. Sternal wires
and valvular repair are unremarkable. No edema, no pneumonia.
R ___ ___: No evidence of deep venous thrombosis in the
right lower extremity veins.
There is a small amount of subcutaneous edema in the right lower
leg.
Brief Hospital Course:
___ is a ___ with sCHF (EF ___, CAD s/p
CABG/ICD, brittle DM type 2, remote h/o IVDU on methadone, and
osteomyelitis s/p amputation of left great toe who presented
with anuric renal failure and hypotension requiring pressors in
the MICU, most likely secondary to overdiuresis.
# Anuric renal failure: Patient presented with several days of
anuria and creatinine 2.7 (electrolytes normal). Based on review
of outpatient notes/PACT RN notes, this occurred in the setting
of steadily decreasing weights. On prior discharges, her weight
was 80 kg (although she reported being volume up at this
weight). At her last d/c at this weight on ___, she was
discharged on 100 mg torsemide daily (an increase from 60 mg
previously). Her weight then downtrended (recorded to be 75 kg
on ___. The next recorded note/weight was on ___ when she
reported low urine output and significant weight gain (weight 78
kg). She was 81 kg and anuric on admission. Most likely, she
became hypovolemic in the setting of overdiuresis and developed
renal failure and anuria, which then caused weight gain. She was
given gentle fluid boluses in the ICU and her renal function
returned to baseline. With re-initiation of torsemide and
lisinopril, her weight again declined and creatinine began to
rise in the setting of hypotension (SBPs 60-70s). She again
received IV fluids with recover of renal function and
normalization of BPs. Her torsemide was then re-started at a
decreased dose of 80 mg, but her lisinopril and spironolactone
were held. Although advised that it would be preferable for her
to stay in the hospital to allow for reinitiation of additional
medications in a monitored setting and to assess the efficacy of
her torsemide, Mr. ___ wanted to leave the hospital as soon
as possible, so was discharged on ___ after reinitiation of
torsemide with clear instructions to weigh herself daily and
stop torsemide if her weight began to drop. She also has follow
up with her PCP ___ ___.
# Hypotension: On admission, patient had SBPs in the ___, which
is close to her baseline. However due to concomitant renal
failure, there was concern for sepsis. UA was bland, chest X ray
was unremarkable, blood cultures were negative. RUQ US showed a
dilated CBD at 8 mm and she was found to have elevated liver
enzymes (but normal bilirubin) so was started on ceftriaxone and
Flagyl. However, due to otherwise, negative workup, absence of
abdominal symptoms, and no fever, antibiotics were subsequently
discontinued. Her blood pressures improved with IV fluids.
# Systolic heart failure: EF ___ percent. She was not volume
overloaded per exam on this admission, rather she appeared
hypovolemic as above. A TTE was done which was unchanged from
prior. Her torsemide was decreased on discharge to 80 mg. Her
lisinopril and spironolactone had not been restarted as she had
only recently been transferred out of the ICU for hypotension
but did not want to stay in the hospital for titration of
medications/monitoring. They can be restarted in the outpatient
setting as tolerated.
# Elevated liver enzymes: patient found to have elevated liver
enzymes on admission (ALT 64, AST 97, Alk phos 543). RUQ US
showed dilated CBD at 8 mm and gallstones but no obstructing
stones or other pathology. Enzymes downtrended throughout her
admission. ___ have been secondary to hypotension as an
outpatient. Due to the dilated CBD, however, should have repeat
imaging to ensure resolution.
# Type 2 diabetes: Patient with brittle type 2 diabetes and had
frequent low blood sugars while in the hospital. Her Lantus was
decreased from 42 U to 30 U with a sliding scale. She was
discharged on this regimen but should uptitrate as needed. She
has follow up with ___.
# Osteomyelitis of left great toe s/p amputation: Patient with
recent amputation but area was without erythema or purulence.
She was evaluated by vascular while in house who felt her wound
was healing well. She has follow up scheduled.
# Methadone use: Patient on methadone at 65 mg daily. Dose was
confirmed with clinic. She was continued on this while
inpatient.
Transitional issues:
- Patient's torsemide decreased to 80 mg daily, please watch for
changes in weight and adjust as needed
- Discharge (dry) weight: 76.0 kg (167.55 lb)
- Patient discharged off lisinopril and spironolactone as
patient wanted to leave before time for starting medications and
monitoring blood pressures after initiation of torsemide;
restart as tolerated
- Patient's insulin regimen decreased (Lantus decreased from 42
to 40 U) due to hypoglycemia; she has follow up with ___
scheduled for ___
- Please repeat imaging to assess for resolution of CBD dilation
-CODE: full
-CONTACT: HCP: ___ (Husband, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Gabapentin 400 mg PO BID
5. Lisinopril 2.5 mg PO DAILY
6. Methadone 65 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. Tiotropium Bromide 1 CAP IH DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Warfarin 2 mg PO DAILY16
11. Spironolactone 25 mg PO DAILY
12. Naloxone 4 mg PO PRN overdose
13. Nicotine Patch 7 mg TD DAILY
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
15. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
16. Torsemide 100 mg PO DAILY
17. Potassium Chloride 20 mEq PO DAILY
18. Glargine 42 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Collagenase Ointment 1 Appl TP DAILY
RX *collagenase clostridium histo. [Santyl] 250 unit/gram apply
to wound Daily Refills:*0
2. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Torsemide 80 mg PO DAILY
RX *torsemide 20 mg 4 tablet(s) by mouth daily Disp #*112 Tablet
Refills:*0
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
5. Atorvastatin 80 mg PO QPM
6. Clopidogrel 75 mg PO DAILY
7. Gabapentin 400 mg PO BID
8. Methadone 65 mg PO DAILY
9. Naloxone 4 mg PO PRN overdose
10. Nicotine Patch 7 mg TD DAILY
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. Pantoprazole 40 mg PO Q24H
13. Potassium Chloride 20 mEq PO DAILY
Hold for K >
14. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
15. Tiotropium Bromide 1 CAP IH DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. Warfarin 2 mg PO DAILY16
18. HELD- Lisinopril 2.5 mg PO DAILY This medication was held.
Do not restart Lisinopril until talking with your cardiologist
or PCP
19. HELD- Spironolactone 25 mg PO DAILY This medication was
held. Do not restart Spironolactone until talking with your
cardiologist or PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Hypovolemic shock
Acute kidney injury
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 hospitalized at ___
because you had gained weight and were not making urine. You
were found to have very low blood pressures requiring admission
to the medical ICU for IV fluids and medications to raise your
blood pressures. At first, you were started on antibiotics in
case of a bloodstream infection; it was determined that the most
likely cause of your low blood pressures was that instead of
having too much fluid, you had actually lost too much fluid,
which injured your kidneys, causing you to stop making urine and
then to gain weight. Once we gave you IV fluids and medications
to increase your blood pressure, your kidney function gradually
recovered. No source of infection was found, so the antibiotics
were stopped.
Most likely, you are now at about your ideal or dry weight (167
lb). We will be restarting you torsemide at 80 mg. It would be
safer to keep you in the hospital to monitor you after starting
torsemide but you wanted to go home so please make sure you
weight yourself every day. If your weight goes down by more than
1 lb (166 lbs), stop the torsemide and call your doctor. If your
weight goes up by more than 3 lbs (170 lbs), call your doctor.
Also, if you are feeling lightheaded/dizzy over the weekend,
stop your torsemide and go to urgent care or the ED.
Your insulin regimen was decreased due to low blood sugars. You
have a follow up appointment with a diabetes specialist on
___ at 2:30PM.
You have a follow up appointment with Dr. ___ on ___,
___ at 9AM.
It was a pleasure participating in your care. We wish you all
the best in the future.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10901772-DS-46
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DS
| 46 |
2153-01-24 00:00:00
|
2153-01-25 09:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
absorbable surgical gauze
Attending: ___.
Chief Complaint:
Right Leg Pain and Swelling
Major Surgical or Invasive Procedure:
___: Right Fem-Pop Bypass with PTFE
History of Present Illness:
Ms. ___ is a ___ with hx of CAD s/p CABG x3 (___), CHF (EF
___, PVD with bilateral limb ischemia and left foot dry
gangrene s/p aorto-bifemoral bypass and left fem-pop bypass w
PTFE (Dr. ___ ___ c/b left fem-pop bypass graft
thrombosis, s/p redo left femoral-AKpop bypass graft (Dr. ___
___. She is followed closely by Dr. ___ with the
podiatry service and has undergone L TMA on ___.
Today Ms. ___ endorses right lower extremity pain beginning
at the upper calf and extending all the way down her right leg
to
the right foot. She reports associated redness and swelling of
the RLE and states that these symtpoms have been worsening over
the course of the past week. She denies fevers, nausea/vomiting,
abdominal pain, diarrhea, though she does endorse subjective
chills. She follows as an outpatient with podiatry for two
ulcers
on the foot, which at present she reports appear improved from
previous.
Past Medical History:
PMH:CAD s/p multiple MIs and PCIs last ___, ischemic
cardiomyopathy (EF ___, last ECHO ___ CI 2.8), AICD, DM2,
HTN, HLD, PAD, COPD
PSH:
- L TMA ___
- Redo left femoral to above knee popliteal bypass graft with 6
mm ringed PTFE ___ ___
- Debriedment left ___ toe, including partial metatarsal head
resection ___ ___
- left first ray amputation ___ ___
- aorto-bifem w dacron & L fem-pop bypass w PTFE ___
___
- Diagnostic ___ angiogram ___ ___
- L CFA endarterectomy, bovine pericardial patch angioplasty
from
mid CFA into mid profunda femoral artery ___ ___
- Aortogram bilateral lower extremity runoff ___
___
- Irrigation and closure of left neck wound ___ ___
- Incision and drainage of left neck wound ___ ___
- Left common carotid artery to left subclavian artery bypass
with 6-mm PTFE graft ___ ___
- CABG x 3vessels, Mitral valve repair, closure of patent
foramen
ovale ___ ___
Social History:
___
Family History:
No family history of breast or lung cancer, melanoma or
lymphoma.
Physical Exam:
VITALS: Temp 97.0, HR 71, BP 103/63, RR 18, SpO2 98%
GEN: NAD, well appearing
HEENT: NCAT, EOMI, no scleral icterus
CV: RRR, no rubs or murmurs, radial pulses 2+ b/l
RESP: CTAB, breathing comfortably on room air
GI: soft, non-TTP, no R/G/D, BS+ throughout
EXT: WWP, right distal thigh and groin incisions C/D/I with
staples in place and appropriate, well healing surgical scars in
the BLE, no peripheral edema
PULSES: RLE: P/P/D/D LLE: P/D/D/D
Pertinent Results:
LABWORK:
___
IMAGING:
CTA ___:
IMPRESSION:
1. Patent aorto-bifem and left fem-pop bypass grafts. Moderate
luminal
narrowing at the distal left fem-pop anastomosis, which remains
patent.
Patent left lower extremity three-vessel runoff to the left foot
in this
patient status post left transmetatarsal amputation.
2. Unchanged occlusion of the right SFA, reconstituted from
collaterals from the deep femoral artery. Moderately stenosed
right above-knee popliteal artery. Normal right lower extremity
three-vessel runoff.
3. Normal caliber abdominal aorta with diffuse mixed calcified
and
noncalcified atherosclerotic disease. Patent major tributaries,
however with note made of unchanged severe luminal narrowing of
the proximal common hepatic artery due to noncalcified plaque
and unchanged multifocal SMA disease with multiple areas of mild
to moderate narrowing.
4. Diffuse subcutaneous soft tissue edema is worst within the
left lower
extremity, as on prior exam.
5. Cholelithiasis. Left tarsal disuse osteopenia. Other
incidental findings,as above.
VEIN MAPPING ___:
Patent right great saphenous vein and bilateral small saphenous
veins with
diameters as described above. Left great saphenous vein not
visualized.
Brief Hospital Course:
Ms. ___ is a ___ with hx of CAD s/p CABG x3 (___), CHF (EF
___, PVD with bilateral limb ischemia and left foot dry
gangrene s/p aorto-bifemoral bypass and left fem-pop bypass w
PTFE (___) c/b left fem-pop bypass graft
thrombosis, s/p redo left femoral-AKpop bypass graft (Dr. ___
___ and L TMA (___). On the present admission, she was
admitted to the vascular surgery service on ___ with
complaints of right calf pain, redness, and swelling for one
week. She was started on IV antibiotics (vanc/cipro/flagyl) due
to concern for right leg cellulitis. She underwent CTA of the
RLE which demonstrated occlusion of her right superficial
femoral artery. She subsequently underwent vein mapping to
facilitate bypass planning. She continued on IV antibiotics for
several days and her right leg cellulitis/swelling improved
markedly. She was transitioned to oral antibiotics (augmentin)
after 14 days of IV antibiotic treatment. She was started on a
heparin drip on HD6 once her INR was less than 2 to replace her
home Coumadin given the upcoming planned intervention.
Additionally, she was seen by the podiatry service for wound
care for her left TMA stump and no intervention was required as
it was noted to be healing well.
She was closely followed by the cardiology service given her
history of congestive heart failure. She was continued on her
home diuretic regimen (reconciled as spironolactone 25mg daily,
torsemide 120 daily). The torsemide was switched to 60mg BID due
to complaints of leg cramping, with improvement. Her diuretics
were briefly held secondary to ___ (Cr elevated to 2.5 from
baseline 1.2), and then restarted prior to her bypass procedure
per cardiology recs as her ___ improved and her weight started
to increase again.
She was seen by the chronic pain service to assist in management
of her pre-operative opiate regimen given her home methadone
usage. They were also involved in her post-operative pain
management as discussed below. She was additionally seen by the
___ diabetes service for assistance in controlling her
glucose levels. At time of discharge, she was sent home on a
higher dose of her home Lantus and Sliding Scale of Humalog with
the instructions to follow up closely with her own
Endocrinologist.
She was taken to the operating room on ___ for a right Fem-Pop
PTFE bypass. For further information about the procedure, please
see the operative note in the OMR. She tolerated the procedure
well and was sent to the PACU post-operatively. CPS was involved
again and started her on a Ketamine drip. She had a short stay
in the CVICU for pain control and post-operative monitoring. The
Ketamine drip was weaned off and she was sent to the floor where
she remained for the duration of her stay. Post-operatively, she
did well. Her pain was originally controlled with the assistance
of IV pain medications on top of her normal dose of Methadone.
Her pain control was switched to PO medications when
appropriate. She was slow to normalize and follow the lower
extremity bypass pathway. ___ was consulted who worked with her
throughout her stay; she refused to go back to rehab and she was
ultimately cleared to return home.
For the first several days of her post-operative period, we saw
her kidney function improve and monitored her Creatinine which
trended back towards her normal baseline. On prior admissions,
she was noted to have a tenuous balance between CHF and ___ on
CKD during her post-operative periods. Subsequently, we began to
see incremental increases in her Creatinine starting on POD#4
which ultimately rose to a maximum of 3.2. We consulted
cardiology and nephrology and we liberalized her PO intake and
briefly held her home diuretics. On FEUrea, she was shown to
have an intra-renal process; she continued to have good PO
intake and appropriate UOP. Ultimately, we saw her Creatinine
improve towards her baseline and was noted to be 1.5 on the day
of her discharge.
By the time of her discharge, she was ambulating with the
assistance of a walker, tolerating a regular diet, voiding
appropriately and having good bowel function. Her pain was
controlled with PO medications in addition to her methadone. She
was discharged home on ___ with the appropriate information
and follow up instructions regarding her ___,
___, Diabetic Monitoring and Insulin Regimen
Control. She was sent home with ___ for wound care and ___.
Medications on Admission:
___ AVIVA METER - ___ Aviva Meter . Use as directed
four times a day ICD-10-CM E11.40 HbA1c 8.4% (___). QID
testing necessary: frequent hypoglycemia
ALBUTEROL SULFATE - albuterol sulfate HFA 90 mcg/actuation
aerosol inhaler. ___ puffs inh every four to six hours as needed
for shorntess of breath
AMOXICILLIN-POT CLAVULANATE - amoxicillin 875 mg-potassium
clavulanate 125 mg tablet. 1 tablet(s) by mouth twice a day
ATORVASTATIN - atorvastatin 80 mg tablet. 1 tablet(s) by mouth q
day
BUDESONIDE-FORMOTEROL [SYMBICORT] - Symbicort 160 mcg-4.5
mcg/actuation HFA aerosol inhaler. 1 (One) puffs inh twice daily
CLOPIDOGREL [PLAVIX] - Plavix 75 mg tablet. 1 Tablet(s) by mouth
once a day
COLLAGENASE CLOSTRIDIUM HISTO. [SANTYL] - Santyl 250 unit/gram
topical ointment. apply to heel wound daily
CYCLOBENZAPRINE - cyclobenzaprine 10 mg tablet. 1 tablet(s) by
mouth three times a day as needed for for back pain -
(Prescribed by Other Provider: outside ___ provider)
DIFLUNISAL - diflunisal 500 mg tablet. 1 tablet(s) by mouth
twice
daily as needed for for pain do not take at same time as
cyclobenzaprine - (Prescribed by Other Provider: ___
provider)
GABAPENTIN - gabapentin 400 mg capsule. 1 capsule(s) by mouth
twice a day
HYDROMORPHONE - hydromorphone 2 mg tablet. ___ tablet(s) by
mouth
q 4 hours as needed for pain
INSULIN GLARGINE [LANTUS] - Lantus 100 unit/mL subcutaneous
solution. 12 units SC qpm dose reduced due to decreased renal
function. - (Prescribed by Other Provider; Dose adjustment - no
new Rx)
INSULIN LISPRO [HUMALOG] - Humalog 100 unit/mL subcutaneous
solution. ___ units sc tid ac
INSULIN SYRINGE-NEEDLE U-100 - insulin syringe-needle U-100 1 mL
30 gauge x ___. use as directed five times per day to
administer
insulin
METHADONE - methadone 10 mg/mL oral concentrate. ml by mouth
Dose of 65mg/day - (Prescribed by Other Provider; Dose
adjustment - no new Rx)
NALOXONE [NARCAN] - Narcan 4 mg/actuation nasal spray. 1 spray
nasal opioid overdose Opioid overdose ONLY. Repeat spray every 3
minutes in alternating nostrils until 911 available. -
(Prescribed by Other Provider: during ___ hospitalization)
NITROGLYCERIN - nitroglycerin 0.4 mg sublingual tablet. 1
Tablet(s) sublingually every ___ minutes x 3 as needed for
chest
pain
PANTOPRAZOLE - pantoprazole 40 mg tablet,delayed release. 1
tablet(s) by mouth qam 30 minutes before breakfast, to reduce
stomach acid
POTASSIUM CHLORIDE - potassium chloride ER 20 mEq
tablet,extended
release(part/cryst). 1 tablet by mouth q day
SPIRONOLACTONE - spironolactone 25 mg tablet. 1 tablet(s) by
mouth twice daily with torsemide
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - Spiriva with
HandiHaler 18 mcg and inhalation capsules. 1 capsule inhaled
once
daily - (Prescribed by Other Provider)
TORSEMIDE - torsemide 20 mg tablet. 3 tablet(s) by mouth Twice a
day for two days THEN 3 tabs (60 mg) daily - (Prescribed by
Other Provider: ___
WARFARIN - warfarin 1 mg tablet. 1 tablet(s) by mouth Daily or
as
directed by ___ clinic
WARFARIN [COUMADIN] - Coumadin 2.5 mg tablet. dose via ___
clinic according to INR tablet(s) by mouth - (Prescribed by
Other Provider)
Medications - OTC
BLOOD SUGAR DIAGNOSTIC ___ AVIVA] - ___ Aviva
strips. use as directed four times a day for frequent
hypoglycemia. HbA1c 8.4% (___) ICD-10-CM E11.40
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
1,000
unit tablet. 1 (One) tablet(s) by mouth once a day
LANCETS ___ FASTCLIX] - ___ FastClix. Use as
directed four times a day ICD-10-CM E11.40 HbA1c 8.4%
(___).
QID testing necessary: frequent hypoglycemia
MULTIVITAMIN [DAILY MULTI-VITAMIN] - Daily Multi-Vitamin tablet.
1 tablet(s) by mouth once a day - (Prescribed by Other
Provider)
NICOTINE - nicotine 7 mg/24 hr daily transdermal patch. apply
one
patch qam and remove an hour prior to bedtime - (Not Taking as
Prescribed: does not use consistently)
SILVER-FOAM BANDAGE [AQUACEL AG FOAM] - Aquacel AG Foam 1.2 %-6"
X 8" bandage. Apply to the bed of your ulcers Change everyother
day
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every
four (4) hours Disp #*30 Tablet Refills:*0
4. Glargine 37 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Senna 8.6 mg PO BID:PRN constipation
6. Warfarin 2 mg PO DAILY16
RX *warfarin [Coumadin] 2 mg 1 tablet(s) by mouth Daily Disp #*5
Tablet Refills:*0
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
8. Atorvastatin 80 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
10. Gabapentin 400 mg PO BID
11. Methadone 65 mg PO DAILY
12. Naloxone 4 mg PO PRN overdose
13. Nicotine Patch 7 mg TD DAILY
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
15. Pantoprazole 40 mg PO Q24H
16. Spironolactone 25 mg PO BID
17. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
18. Tiotropium Bromide 1 CAP IH DAILY
19. Torsemide 120 mg PO DAILY
20. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Peripheral Vascular Disease
Superficial Femoral Artery Occlusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. ___,
You were admitted to the ___
for a right femoral artery to popliteal artery (Fem-Pop) bypass
surgery. You tolerated the procedure well and you are ready to
return home to continue your recovery.
You will return home and are to receive the same ___ care as
prior to your admission.
Your diabetes was managed by the ___ during
your stay. They adjusted your Insulin regimen as listed below.
Please continue this regimen and talk to your primary
Endocrinologist (whoever usually manages your Diabetes) to
verify any changes in your medications. If your sugars are too
low (<70) or too high (consistently >250), you should contact
your Diabetes doctor immediately.
You should follow up with your ___ clinic as usual. You
were provided with a copy of the "Last Dose" of Methadone for
verification.
Continue to dose your Coumadin at 2.0 mg per day and titrate
your home doses to your therapeutic INR as prior.
You will have Physical Therapists visit you at home should you
need any further assistance returning to your baseline status.
WHAT TO EXPECT:
1. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
Elevate your leg above the level of your heart (use ___
pillows or a recliner) 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
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
Continue Plavix and Coumadin
Follow your discharge medication instructions
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
Unless you were told not to bear any weight on operative foot:
You should get up every day, get dressed and walk
You should gradually increase your activity
You may up and down stairs, go outside and/or ride in a car
Increase your activities as you can tolerate- do not do too
much right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
CALL THE OFFICE FOR: ___
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your leg or the
ability to feel your leg
Temperature greater than 100.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Good Luck
Followup Instructions:
___
|
10901772-DS-48
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| 48 |
2153-02-18 00:00:00
|
2153-02-19 21:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
absorbable surgical gauze
Attending: ___.
Chief Complaint:
Knee pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ w/ R fem-pop artery bypass graft ___,
CAD, CHF, ICCM, PAD s/p numerous surgeries including L TMA, DM,
polysubstance abuse, HCV, COPD, presenting with worsening right
medial knee pain for the past 24 hours, with bloody
discharge from the site, per the patient. Mild pain at the right
thigh as well, but pain is more severe at the right medial thigh
at the site of the wound.
Notes ___ days of cough, mucous production. No fevers (noted one
temp to 99.1 at home), some chills. No abd pain, diarrhea. Notes
one episode of vomiting earlier today, saw small amount of
blood. Notes an episode of CP yesterday under the R breast, then
under the left breast, which resolved.
Of note, patient was recently admitted to ___ for CHF
exacerbation and ___, with a discharge weight of 77.4kg and
discharge Cr of 2.6 (up from reported baseline of ~1.4-1.6)
In the ED, initial vitals were: 97.4 88 112/53 20 96% RA
- Exam was notable for: R medial thigh incision site c/d/I with
adjacent erythema, tender to palpation, distally without
serosanguinous fluid expressible. R inguinal incision site c/d/I
R ___ palpated, L foot s/p L TMA. lungs CTABL.
Vascular saw the patient, and per their assessment: 'likely
benign finding of adjacent erythema, no indication for
antibiotic therapy, requesting RLE graft ultrasound. Will
follow. Unable to obtain ultrasound at this time (after 4p).
Given elevated D-dimer, also needs V/Q scan, unable to obtain
CTA given creatinine elevation.
T&C2u for anemia.
- Labs notable for: H/H 7.___.0, WBC 7.6,
- Imaging was notable for: Unilateral ___ U/S:
Extremely limited exam secondary to patient pain and inability
to tolerate scanning over the mid-distal thigh. Allowing for
this, no evidence of deep venous thrombosis in the visualized
right lower extremity veins.
EKG with no acute ST changes seen, nonspecific intraventricular
delay
CXR: IMPRESSION: No focal consolidation. Vascular congestion
without definite frank pulmonary edema.
- Patient was given: oxycodone 5mg x 1, Tylenol ___, NS
500mL.
Upon arrival to the floor, patient reports ongoing significant R
medial knee pain. She notes that the pain radiates up towards
her hip. Notes SOB over the past few days, associated with
increased sputum production.
Past Medical History:
- CAD with the following interventions:
A. ___ - 2.5 x 18 Cypher to LAD
B. ___ - inferior STEMI with overlapping Endeavor stents to
the distal RCA
C. ___ - ISR RCA stent status post POBA
D. ___ - Progression of left main disease resulting in CABG
(free LIMA to LAD because of clotted off left subclavian stent,
SVG to RCA, SVG to OM). LIMA and SVG to RCA are known to be
occluded with SVG to OM patent (___).
E. ___ - Admission with congestive heart failure and non-ST
elevation MI in ___, transferred to ___. Angiography
showed 90% in-stent restenosis distal RCA stent, status post
2.75x20mm PROMUS DES.
F. There is residual 40% of LMCA and a tighter distal LAD
stenosis in a small vessel.
- Ischemic Cardiomyopathy (EF ___, last ECHO ___ CI 2.8)
- ICD for primary prevention
- Peripheral arterial disease (PAD) s/p multiple surgeries, s/p
L TMA for ulcer disease ___ (c/b post-operative hypotension)
- Osteomyelitis of Right great toe. s/p amputation in ___,
required long course of IV antibiotics.
- DM2 with last A1c 7.9% ___, macroalbuminuria, diabetic
neuropathy
- HLD
- Tobacco use
- Sleep Apnea
- History of polysubstance abuse
- hepatitis C
- COPD
PSH:
- Right Fem-Pop PTFE ___
- L TMA ___
- Redo left femoral to above knee popliteal bypass graft with 6
mm ringed PTFE ___ ___
- Debridement left ___ toe, including partial metatarsal head
resection ___ ___
- left first ray amputation ___ ___
- aorto-bifem w dacron & L fem-pop bypass w PTFE ___
___
- Diagnostic ___ angiogram ___ ___
- L CFA endarterectomy, bovine pericardial patch angioplasty
from
mid CFA into mid profunda femoral artery ___ ___
- Aortogram bilateral lower extremity runoff ___
___
- Irrigation and closure of left neck wound ___ ___
- Incision and drainage of left neck wound ___ ___
- Left common carotid artery to left subclavian artery bypass
with 6-mm PTFE graft ___ ___
- CABG x 3vessels, Mitral valve repair, closure of patent
foramen
ovale ___ ___
Social History:
___
Family History:
CAD/MI, DM, cancer: esophageal, brain, lung
No family history of breast or lung cancer, melanoma or
lymphoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: 98.1 108/63 68 20 99% RA pain ___
GENERAL: Patient appears to be in pain, tremulous at times, able
to recall history of present illness but with some memory gaps
(eg doesn't remember getting ___ ultrasound in ED), otherwise
A&Ox3
HEENT: PERRL, no scleral icterus, clear oropharynx, adentulous
NECK: No appreciable cervical lymphadenopathy
CARDIAC: RRR, distant heart sounds, soft II/VI systolic murmur
LUNGS: CTAB, no wheezes, rhonchi, crackles
ABDOMEN: normal BS, soft, nontender, nondistended
EXTREMITIES: warm well-perfused. no significant edema. L
metatarsal amputation. R medial knee with some erythema at
recent surgical site, and exquisitely painful to palpation. R
inguinal site appears c/d/i ___ bilaterally.
NEUROLOGIC: A&Ox3, strength is ___ in ___ bilaterally. decreased
sensation in feet bilaterally, gait deferred.
SKIN: R foot with two ulcers ~2cm ulcers on heel and ___ MTP
plantar aspect, dry, black base, non-malodorous, right thigh,
groin leg incision without edema, erythema, warmth
============================
DISCHARGE PHYSICAL EXAM:
VITAL SIGNS: Afeb, Tc 97.6, BP 107 / 58, HR 94, RR 18, O2 94% RA
GENERAL: A&Ox3 in NAD
HEENT: PERRL, no scleral icterus, clear oropharynx,
NECK: No LAD
CARDIAC: RRR, distant heart sounds, soft II/VI systolic murmur
LUNGS: CTAB, no w/r/r
ABDOMEN: normal BS, soft, nontender, nondistended
EXTREMITIES: warm well-perfused. no significant edema. Lt
metatarsal amputations. R medial knee with some erythema at
recent surgical site, and severely painful to palpation. R
inguinal site appears c/d/i ___ bilaterally.
NEUROLOGIC: A&Ox3, strength is ___ in ___ b/l. decreased
sensation in feet bilaterally, gait deferred.
SKIN: R foot with two ulcers ~2cm ulcers on heel and ___ MTP
plantar aspect, dry, black base, non-malodorous. Lt ___ with
several ulcers on anterior shin with black base, no erythema or
drainage
Rt thigh with incision with mild erythema extending over large
area of medial/anterior thigh. No edema, warmth, fluctuance.
Pertinent Results:
ADMISSION LABS:
___ 02:53PM BLOOD WBC-7.6 RBC-2.84* Hgb-7.5* Hct-24.0*
MCV-85 MCH-26.4 MCHC-31.3* RDW-20.5* RDWSD-63.0* Plt ___
___ 02:53PM BLOOD Neuts-79.2* Lymphs-11.9* Monos-7.5
Eos-0.9* Baso-0.1 Im ___ AbsNeut-6.00# AbsLymp-0.90*
AbsMono-0.57 AbsEos-0.07 AbsBaso-0.01
___ 02:53PM BLOOD Glucose-177* UreaN-75* Creat-2.0* Na-134
K-3.5 Cl-91* HCO3-25 AnGap-22*
___ 02:53PM BLOOD cTropnT-0.02*
___ 05:10AM BLOOD cTropnT-0.02*
========================
DISCHARGE LABS:
___ 03:00PM BLOOD WBC-6.6 RBC-2.99* Hgb-7.9* Hct-25.7*
MCV-86 MCH-26.4 MCHC-30.7* RDW-21.2* RDWSD-65.6* Plt ___
___ 05:10AM BLOOD Glucose-271* UreaN-67* Creat-1.8* Na-137
K-3.5 Cl-95* HCO3-25 AnGap-21*
=========================
IMAGING:
RLE Arterial US ___:
FINDINGS:
Evaluation of the write lower extremity demonstrates a
femoral-popliteal
bypass graft which appears to be patent and have flow on color
evaluation.
The common femoral artery demonstrates a monophasic waveform
with peak
systolic velocities of 40.1 cm/second.
The proximal anastomosis demonstrates a monophasic waveform with
a peak
systolic velocity of 53.6 cm/second.
The proximal graft demonstrates a monophasic waveform with a
peak systolic
velocity of 50.5 cm/second.
The mid graft demonstrates a monophasic waveform with a peak
systolic
velocities ranging between 46.2-53.3 cm/second.
The distal graft demonstrates a monophasic waveform with a peak
systolic
velocities ranging between 52.4-70.5 cm/second.
The distal anastomosis demonstrates a monophasic waveform with a
peak systolic
velocity of 50.3 cm/second.
The popliteal artery demonstrates a monophasic waveform with a
peak systolic
velocity of 70.1 cm/second.
IMPRESSION:
No evidence of stenosis identified. Patency of RIGHT
femoral-popliteal graft.
RLE Venous US ___:
FINDINGS:
There is normal compressibility, flow, and augmentation of the
right common
femoral, femoral, and popliteal veins. Normal color flow and
compressibility
are demonstrated in the tibial and peroneal veins.
There is normal respiratory variation in the common femoral
veins bilaterally.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
Brief Hospital Course:
___ F with PMHx CAD s/p CABG ___ (and multiple other
procedures), ischemic CM (EF ___ s/p AICD, PAD s/p
right femoral-popliteal bypass ___, DM2, COPD and history of
polysubstance abuse on methadone admitted with Rt leg pain and
erythema and URI symptoms. Vascular surgery was consulted and
felt that these were reasonable post-surgical changes that are
healing appropriately. They recommended against antibiotics. She
had no fever or elevated WBC, and therefore antibiotics were
deferred. She had RLE arterial and venous US, which showed
patent vessels. In terms of her URI symptoms, CXR was clear. She
was given guaifenesin and felt improved from admisison. She was
sent home with PCP follow up scheduled for ___ and vascular
surgery follow up on ___.
Problems:
R leg pain s/p fem pop nypass
Upper respiratory infection
PAD
CAD/CABG
Chronic systolic CHF
===========================
TRANSITIONAL ISSUES:
- New Meds: Benzonatate
- Stopped/Held Meds: N/A
- Changed Meds: Warfarin (increased to 2 mg per ___ clinic)
- Post-Discharge Follow-up Labs Needed: INR, CBC
- Incidental Findings: N/A
- Discharge weight: 78.0 kg
- RLE Erythema: Demarcated. Please continue to evaluate for
worsening/spreading erythema, or other signs of infection
- Anemia: Hgb was 7.5 on admission down from 8.3. Hgb increased
to 7.9 prior to discharge. Should have repeat CBC as outpatient
# CODE: Full code (confirmed)
# CONTACT: ___ (husband, HCP) ___,
cell: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 27 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Torsemide 80 mg PO BID
3. Atorvastatin 80 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Gabapentin 400 mg PO BID
6. Lactic Acid 12% Lotion 1 Appl TP ASDIR
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
8. Acetaminophen 1000 mg PO Q8H
9. Methadone 65 mg PO DAILY
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Naloxone 4 mg PO PRN overdose
12. Nicotine Patch 7 mg TD DAILY
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Pantoprazole 40 mg PO Q24H
15. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
16. Vitamin D 1000 UNIT PO DAILY
17. Warfarin 1 mg PO DAILY16
18. Tiotropium Bromide 1 CAP IH DAILY
19. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN Cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*21 Capsule Refills:*0
2. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Severe
RX *hydromorphone 2 mg 1 tablet(s) by mouth every six (6) hours
Disp #*4 Tablet Refills:*0
3. Glargine 27 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Warfarin 2 mg PO DAILY16
5. Acetaminophen 1000 mg PO Q8H
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
7. Atorvastatin 80 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Gabapentin 400 mg PO BID
10. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
11. Lactic Acid 12% Lotion 1 Appl TP ASDIR
12. Methadone 65 mg PO DAILY
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Naloxone 4 mg PO PRN overdose
15. Nicotine Patch 7 mg TD DAILY
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
17. Pantoprazole 40 mg PO Q24H
18. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
19. Tiotropium Bromide 1 CAP IH DAILY
20. Torsemide 80 mg PO BID
21. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
# Right leg pain
Secondary Diagonses:
# Peripheral artery disease
# Upper respiratory infection
# Anemia
# Chronic heart failure
# Chronic obstructive pulmonary disease
# Chronic kidney disease
# Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (cane).
Discharge Instructions:
Dear ___,
You were admitted to the hospital because of pain in your right
leg and cough. An ultrasound of your leg showed that there were
no issues with your blood vessels. Vascular surgery saw you and
did not feel that the leg was infected. They felt that the leg
was healing nicely from the surgery last month.
You improved and were allowed to leave with close follow up with
vascular surgery and your primary care doctor.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
-Weigh yourself daily and tell your doctor if you gain more than
3 lbs
-Take all of your medications as prescribed (listed below)
-Follow up with your doctors as listed below
-___ medical attention if you have new or concerning symptoms
or you develop fever, chills, worsened fatigue, drainage from
surgical wounds.
It was a pleasure participating in your care. We wish you the
best!
-Your ___ Care Team
Followup Instructions:
___
|
10901772-DS-50
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2153-04-07 00:00:00
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2153-04-13 14:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
absorbable surgical gauze
Attending: ___.
Chief Complaint:
RLE redness, swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMh of HFrEF (LVEF=35%) s/p AICD, CAD s/p CABG (___),
severe PVD w/ R fem-pop artery bypass graft (___), T2DM, LLE
toe amputation, diabetic neuropathy, COPD, polysubstance abuse
on methadone; presenting with pain and redness on the lateral
aspect of the RLE. Patient reports 1 week of gradually worsening
pain on the lateral aspect of the RLE, worsening over the last
___ days. Pain has been accompanied by increased redness. She
denies fevers, chills, nausea, vomiting, chest pain, SOB,
history of DVT/PE, recent trauma or injury, or increased
drainage from ulcer.
Of note, patient has had multiple admissions for cellulitis and
limb swelling. Had R fem-pop artery bypass graft on ___ with
recent admission on ___ due to RLE swelling and erythema
around the scar on her right inner thigh. Thought to be
postsurgical changes at the time. Was readmitted on ___ for
L hand cellulitis and RLE cellulitis on inner thigh extending
down past knee; patient was successfully treated with
augmentin/doxycycline per outpatient notes on ___.
In the ED, initial vitals: T 97, HR 80, BP 116/82, RR 18, 99%
RA, ___ pain
Exam notable for erythema over RLE from ankle to upper ___ of
the tib-fib. Foot nontender. 2 chronic ulcers on the plantar
foot with no evidence of acute infection around the ulcers.
Labs were significant for glucose 178, 6.0 WBC, Hct 27.1,
lactate 1.4. Blood cultures drawn and pending.
Imaging: Tib/Fib XR showed no evidence of osteomyelitis
Patient was given IV vancomycin 1000 mg x1,
Vitals unchanged prior to transfer. Patient admitted for IV abx
and observation.
On arrival to the floor, patient is alert and oriented x3.
Patient is slightly somnolent, hasn't slept in 4 days due to
son's back surgery. Afebrile, vital signs stable. Patient
endorses ___ pain on RLE, has said dilaudid is the only thing
that will work for her.
Past Medical History:
- CAD with the following interventions:
A. ___ - 2.5 x 18 Cypher to LAD
B. ___ - inferior STEMI with overlapping Endeavor stents to
the distal RCA
C. ___ - ISR RCA stent status post POBA
D. ___ - Progression of left main disease resulting in CABG
(free LIMA to LAD because of clotted off left subclavian stent,
SVG to RCA, SVG to OM). LIMA and SVG to RCA are known to be
occluded with SVG to OM patent (___).
E. ___ - Admission with congestive heart failure and non-ST
elevation MI in ___, transferred to ___. Angiography
showed 90% in-stent restenosis distal RCA stent, status post
2.75x20mm PROMUS DES.
F. There is residual 40% of LMCA and a tighter distal LAD
stenosis in a small vessel.
- Ischemic Cardiomyopathy (EF ___, last ECHO ___ CI 2.8)
- ICD for primary prevention
- Peripheral arterial disease (PAD) s/p multiple surgeries, s/p
L TMA for ulcer disease ___ (c/b post-operative hypotension)
- Osteomyelitis of Right great toe. s/p amputation in ___,
required long course of IV antibiotics.
- DM2 with last A1c 7.9% ___, macroalbuminuria, diabetic
neuropathy
- HLD
- Tobacco use
- Sleep Apnea
- History of polysubstance abuse
- hepatitis C
- COPD
PAST SURGICAL HISTORY
- Right Fem-Pop PTFE ___
- L TMA ___
- Redo left femoral to above knee popliteal bypass graft with 6
mm ringed PTFE ___ ___
- Debridement left ___ toe, including partial metatarsal head
resection ___ ___
- left first ray amputation ___ ___
- aorto-bifem w dacron & L fem-pop bypass w PTFE ___
___
- Diagnostic ___ angiogram ___ ___
- L CFA endarterectomy, bovine pericardial patch angioplasty
from
mid CFA into mid profunda femoral artery ___ ___
- Aortogram bilateral lower extremity runoff ___
___
- Irrigation and closure of left neck wound ___ ___
- Incision and drainage of left neck wound ___ ___
- Left common carotid artery to left subclavian artery bypass
with 6-mm PTFE graft ___ ___
- CABG x 3vessels, Mitral valve repair, closure of patent
foramen
ovale ___ ___
Social History:
___
Family History:
CAD/MI, DM, cancer: esophageal, brain, lung
No family history of breast or lung cancer, melanoma or
lymphoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T96.9, BP 108/64, HR 67, RR 18, 97% RA
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 I/VI holosystolic murmur
ABD: Soft, non-tender, non-distended
EXTREM: Erythema over RLE from ankle to upper ___ of the
tib-fib. Foot +TTP. 2 chronic ulcers on the plantar foot with no
evidence of acute infection around the ulcers. 2+ ___. No
edema or cyanosis.
NEURO: CN II-XII grossly intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
Vitals: T97.5, 113/71, HR 60, RR 16, 95% RA
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 I/VI holosystolic murmur
ABD: Soft, non-tender, non-distended
EXTREM: Erythema over RLE from ankle to upper ___ of the
tib-fib.
Foot +TTP. 2 chronic ulcers on the plantar foot with no evidence
of acute infection around the ulcers. 2+ ___. No edema or
cyanosis.
NEURO: CN II-XII grossly intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
====================
___ 01:50PM BLOOD WBC-6.0 RBC-3.20* Hgb-8.3* Hct-27.1*
MCV-85 MCH-25.9* MCHC-30.6* RDW-17.5* RDWSD-54.5* Plt ___
___ 01:50PM BLOOD Neuts-76.1* Lymphs-14.0* Monos-7.9
Eos-1.2 Baso-0.5 Im ___ AbsNeut-4.55 AbsLymp-0.84*
AbsMono-0.47 AbsEos-0.07 AbsBaso-0.03
___ 01:50PM BLOOD Plt ___
___ 01:50PM BLOOD ___ PTT-37.6* ___
___ 01:50PM BLOOD Glucose-178* UreaN-19 Creat-1.1 Na-131*
K-3.7 Cl-92* HCO3-28 AnGap-15
___ 01:50PM BLOOD Calcium-8.7 Phos-2.8 Mg-1.8
___ 01:55PM BLOOD Lactate-1.4
DISCHARGE LABS:
==============
___ 06:03AM BLOOD WBC-5.4 RBC-3.12* Hgb-8.2* Hct-26.6*
MCV-85 MCH-26.3 MCHC-30.8* RDW-17.9* RDWSD-55.5* Plt ___
___ 09:23AM BLOOD ___ PTT-37.2* ___
___ 06:03AM BLOOD Plt ___
___ 06:03AM BLOOD Glucose-140* UreaN-22* Creat-1.3* Na-135
K-3.6 Cl-95* HCO3-26 AnGap-18
___ 06:03AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.8
MICRO:
======
___ 1:25 pm BLOOD CULTURE NGTD
___ 1:20 pm BLOOD CULTURE NGTD
IMAGING:
=========
TECHNIQUE: Two views of the right tibia and fibula
IMPRESSION: No radiographic evidence for osteomyelitis. Please
note that MRI would be a more sensitive examination for
detection of osteomyelitis
Brief Hospital Course:
___ w/ PMH of HFrEF (LVEF=35%) s/p AICD, CAD s/p CABG (___),
severe PVD w/ R fem-pop artery bypass graft (___), T2DM, LLE
toe amputation, diabetic neuropathy, COPD, polysubstance abuse
on methadone; presenting with pain and redness on the lateral
aspect of the RLE consistent with stasis dermatitis.
# Stasis dermatitis: initial concern for cellulitis given
warmth, erythema, swelling. No fevers or leukocytosis. There
were two chronic ulcers present on plantar aspect of right foot
with no evidence of infection. Podiatry also examined ulcers and
agreed that they were not infected appearing. Xrays of
tibia/fibula negative for evidence of osteomyelitis. She was
initially treated with vancomycin but this was discontinued
after her symptoms were thought to be more consistent with
stasis dermatitis.
# Leg pain: reported b/l leg pain, R > L. Symptoms were
difficult to characterize but were thought to possibly be
secondary to neuropathy vs. claudication. Home gabapentin was
increased to 300mg TID. She was also seen by vascular surgery
who did not feel that she needed any acute intervention and
recommended outpatient follow up.
# History of heroin use disorder, in remission. Continued on
40mg methadone
# Chronic systolic heart failure: LVEF=35% ___, s/p AICD.
Weight on admission was 169 (167 dry weight). Patient was
continued on home torsemide 60 mg daily, and was followed
closely with daily weights and I/Os. Patient did not exhibit any
signs or symptoms of an exacerbation.
# DM: While an inpatient, patient was maintained on 27 units
Lantus QHS, Humalog ISS. No hyperglycemic or hypoglycemic events
occurred.
# CAD s/p multiple MIs and PCIs: Patient continued on home
Atorvastatin 80 mg PO DAILY, Clopidogrel 75mg PO daily
# COPD: There was no evidence of exacerbation on this admission.
Patient continued on home albuterol prn and tiotropium.
Symbicort was converted to advair given symbicort not on
formulary
# CKD: Per ___ medical records, patient's baseline creatinine
was 1.4-1.6. Her current levels were 1.1-1.3 and were below
baseline
Transitional Issues:
- home gabapentin increased to 300mg TID
- has podiatry f/u on ___ for right foot ulcers
- should f/u with vascular surgery as an outpatient for ongoing
management of her PVD
- needs next INR check on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
2. Atorvastatin 80 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Vitamin D 1000 UNIT PO DAILY
6. Warfarin 1 mg PO 4X/WEEK (___)
7. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
9. Naloxone 4 mg PO PRN overdose
10. Gabapentin 200 mg PO BID
11. Methadone (Concentrated Oral Solution) 10 mg/1 mL 40 mg PO
DAILY
12. Torsemide 60 mg PO DAILY
13. Glargine 32 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
14. Prochlorperazine 5 mg PO Q6H:PRN Nausea
15. HYDROmorphone (Dilaudid) 1 mg PO Q6H:PRN Pain - Severe
16. Warfarin 2 mg PO 3X/WEEK (___)
Discharge Medications:
1. Gabapentin 300 mg PO TID
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
3. Atorvastatin 80 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. HYDROmorphone (Dilaudid) 1 mg PO Q6H:PRN Pain - Severe
6. Glargine 32 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Methadone (Concentrated Oral Solution) 10 mg/1 mL 40 mg PO
DAILY
8. Naloxone 4 mg PO PRN overdose
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Pantoprazole 40 mg PO Q24H
11. Prochlorperazine 5 mg PO Q6H:PRN Nausea
12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
13. Torsemide 60 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Warfarin 1 mg PO 4X/WEEK (___)
16. Warfarin 2 mg PO 3X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Stasis dermatitis
Diabetic neuropathy
Peripheral vascular disease
Secondary:
Chronic systolic congestive heart failure
Diabetes type II, poorly controlled
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
WHY YOU CAME TO THE HOSPITAL:
You came to the hospital because you were having pain in your
leg
WHAT WE DID FOR YOU HERE:
We did not think you had any signs of infection in your leg. The
podiatry doctors looked at the ulcers on your foot. They did not
think they looked infected. The vascular surgeons also came to
see you and did not think that you needed any more testing. You
should follow up with your podiatry doctors and ___
___ as an outpatient
WHAT YOU SHOULD DO AFTER LEAVING THE HOSPITAL:
1. Please continue to take all of your medications as prescribed
2. Please follow up with your outpatient doctors ___
appointments are below)
3. Please call Dr. ___ (vascular surgeon) at
___ to schedule an appointment
Followup Instructions:
___
|
10901772-DS-54
| 10,901,772 | 22,974,902 |
DS
| 54 |
2153-11-05 00:00:00
|
2153-11-07 23:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
absorbable surgical gauze / ephedrine
Attending: ___.
Chief Complaint:
Right BKA stump dehiscence and infection
Major Surgical or Invasive Procedure:
___: Debridement of right below knee amputation
___: Revision and closure of right below knee amputation
History of Present Illness:
___ with significant cardiac history (CAD s/p multiple
PCI/stents then CABG, CHF with EF 35%) and severe PAD s/p
aorto-bifem BPG, left fem-pop bypass (___), re-do left fem-AK
pop bypass with PTFE (___), left TMA and right fem-pop bypass
with PTFE (___) c/b graft infection s/p graft excision,
sartorious flap, and R BKA complicated by wound infection
previously managed with VAC therapy presents with open R BKA
stump.
She was last discharged at the end of ___ with VAC in place.
Patient reports that the rehab facility stopped VAC therapy
within 1 week of discharge and has since been doing wet-to-dry
dressings which are changed every other day or more often if
needed. She has had worsening pain over the stump over the past
several days. Denies any fevers, chills, or night sweats.
Past Medical History:
PAST MEDICAL HISTORY
- CAD with the following interventions:
A. ___ - 2.5 x 18 Cypher to LAD
B. ___ - inferior STEMI with overlapping Endeavor stents to
the distal RCA
C. ___ - ISR RCA stent status post POBA
D. ___ - Progression of left main disease resulting in CABG
(free LIMA to LAD, SVG to RCA, SVG to OM). LIMA and SVG to RCA
are known to be occluded with SVG to OM patent (___).
E. ___ - Admission with congestive heart failure and non-ST
elevation MI in ___, transferred to ___. Angiography
showed 90% in-stent restenosis distal RCA stent, status post
2.75x20mm PROMUS DES.
F. There is residual 40% of LMCA and a tighter distal LAD
stenosis in a small vessel.
- Ischemic Cardiomyopathy (EF ___, last ECHO ___ CI 2.8)
- ICD for primary prevention
- Peripheral arterial disease (PAD) s/p multiple surgeries, s/p
L TMA for ulcer disease ___ (c/b post-operative hypotension)
- Osteomyelitis of Right great toe. s/p amputation in ___,
required long course of IV antibiotics.
- DM2 with last A1c 7.9% ___, macroalbuminuria, diabetic
neuropathy
- HLD
- Tobacco use
- Sleep Apnea
- History of polysubstance abuse
- hepatitis C
- COPD
PAST SURGICAL HISTORY
- Right Fem-Pop PTFE ___
- L TMA ___
- Redo left femoral to above knee popliteal bypass with 6mm
ringed PTFE ___ ___
- Debridement left ___ toe, including partial metatarsal head
resection ___ ___
- left first ray amputation ___ ___
- aorto-bifem w dacron & L fem-pop bypass w PTFE ___
___
- Diagnostic ___ angiogram ___ ___
- L CFA endarterectomy, bovine pericardial patch angioplasty
from mid CFA into mid profunda femoral artery ___
___
- Aortogram bilateral lower extremity runoff ___
___
- Irrigation and closure of left neck wound ___ ___
- Incision and drainage of left neck wound ___ ___
- Left common carotid artery to left subclavian artery bypass
with 6-mm PTFE graft ___ ___
- CABG x 3vessels, Mitral valve repair, closure of patent
foramen ovale ___ ___
Social History:
___
Family History:
CAD/MI, DM, cancer: esophageal, brain, lung
No family history of breast or lung cancer, melanoma or
lymphoma.
Physical Exam:
Vitals-afebrile, WNL
GEN: Alert, O X 3, NAD
HEENT: EOMI, PERRLA
CV: RRR
PULM: non-labored breathing, on room air
ABD: soft, NT/ND
EXT: Right BKA stump without evidence of discharge, erythema or
swelling. Left extremity with continued erythema and evidence of
small blister on shin with slightly indurated skin.
NEURO: CN ___ intact.
Pertinent Results:
___ 11:28PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 11:28PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-30*
GLUCOSE-TR* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG*
___ 11:28PM URINE RBC-6* WBC->182* BACTERIA-FEW*
YEAST-NONE EPI-7
___ 11:28PM URINE HYALINE-4*
___ 11:28PM URINE MUCOUS-OCC*
___ 10:10PM PTT-150*
___ 12:57PM ___ COMMENTS-GREEN TOP
___ 12:57PM LACTATE-1.5
___ 12:32PM URINE UHOLD-HOLD
___ 11:37AM GLUCOSE-154* UREA N-10 CREAT-0.8 SODIUM-140
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-26 ANION GAP-12
___ 11:37AM WBC-6.2 RBC-3.71*# HGB-10.1* HCT-32.6* MCV-88
MCH-27.2 MCHC-31.0* RDW-14.8 RDWSD-47.6*
___ 11:37AM URINE BLOOD-SM* NITRITE-POS* PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG*
Brief Hospital Course:
Ms. ___ arrived to ___ on
___ with an open Right below the knee amputation stump.
She was previously discharged with a VAC in place which was
stopped by the rehab facility within 1 week and had been getting
wet-to-dry dressings changed every other day. She was
complaining of worsening pain. Wound had evidence of obvious
infection with dead liquified tissue and necrosis of the wound
margin anteriorly with surrounding skin exquisitely tender to
palpation. The patient was admitted to the Vascular Surgery
service and placed on cefepime and micafungin per ID
recommendations and culture data demonstrating coagulase
positive staphylococcus, enterococcus, and corynebacterium in
tissue culture. The patient was placed on a heparin gtt given
sub therapeutic INR and plan for Right below the knee amputation
stump debridement on ___.
On ___, the patient went for debridement of he Right
below-the-knee amputation down to the muscle and fascia of 100
sq cm. Deep tissue cultures were obtained for microbiology. For
details of the procedure, please see the surgeon's operative
note. The patient tolerated the procedure well without
complications and was brought to the post-anesthesia care unit
in stable condition. After a brief stay, the patient was
transferred to the vascular surgery floor. Postoperatively, the
patient had increased pain and oxycodone was increased to every
4 hours.
On ___, the patient had a low urine output and a
creatinine of 1.4 with evidence of ___. Given the ___, ID
recommended to change cefepime to 2g q24h. Sensitivities for
MRSA due to a recent positive MRSA screen were pending.
Micafungin was continued. Given bone involvement, 6 weeks course
of antibiotics was anticipated.
On ___, per ID, vancomycin was added given both Staph
aureus and enterococcus while awaiting sensitivities. Micafungin
was stopped per their recommendations. Cefepime was changed to
2g q12h. This same day, Chronic pain service was consulted due
to post-operative pain in her Right stump and recommended
Oxycodone 15mg Q4H scheduled, Oxycodone ___ Q4H PRN pain,
tizanidine 2mg QHS at bedtime, continue Gabapentin 300mg TID,
Methadone 45mg QD, APAP 1000mg Q8H with holding orders on
narcotics, gabapentin and tizanidine for sedation.
On ___, the patient was therapeutic on heparin get and
patient was sent to ___ for a ___ line placement for plans to
discharge home on antibiotics.
On ___, cultures were growing MRSA, VRE, diptheroids,
and mixed flora. Per ID, vancomycin and cefepime were stopped
and daptomycin 400mg IV q24h and ceftriaxone 2g IV q24h were
started.
On ___, the patient returned to the OR for her Right
below the knee amputation revision. Tissue and muscle was
irrigated and derided and achieved good hemostasis. Skin was
closed with interrupted nylon and xeroform dry, sterile dressing
was placed. For further details of the procedure, please see the
surgeon's operative note. The patient tolerated the procedure
well without complications and was brought to the
post-anesthesia care unit in stable condition. After a brief
stay, the patient was transferred to the vascular surgery floor
where she remained through the rest of the hospitalization.
On ___ Coumadin 5 mg was started as well as rehab
screening for discharge with PICC line for IV antibiotics for
six weeks.
On ___, Physical therapy saw the patient, recommending
rehabilitation. INR at that time was 1.4 and Coumadin 5 mg were
given. The patient was given a scheduled bowel regimen given
decreased bowel movements.
On ___, INR was 1.6 and Coumadin 5 mg were given.
Physical therapy worked once again with the patient recommending
rehab and rehab screening took place. Steri-strips were applied
to patients wound.
On ___, INR was 2.7, 2 mg of Coumadin were given and
heparin gtt was discontinued. Dispo planning took place and was
scheduled to go to rehab on ___.
On ___, her INR was 4 and Coumadin was held
On ___, the patient experienced tight chest pain and
cardiac workup was done, resulting negative. A chest x-ray was
also performed and was unremarkable. Given her poor diabetes
control, the patient was started on insulin.
On ___, her INR was 2.2 and 2 mg of Coumadin were given.
Patient was fluid overloaded at that time with BNP of 9062 and
lasix 20 mg IV were given together with here scheduled home
torsemide.
On ___, INR was 1.9 (subtherapeutic), Coumadin 3 mg.
On ___, BUN/Cr were elevated with soft blood pressures and
her scheduled torsemide was discontinued.
On ___ the patient complained of blurry vision and glucose
was noted to be greater than 350, insulin sliding scale was
given.
On ___, her SBP was in ___ and 250cc 5% albumin were
given. The patient was complaining of pain at groin site. ___
was consulted for her persistently high glucose levels.
On ___, her blood pressure continued to be in ___. The
patient and her visitor were found somnolent with RR <10 and
difficult to arouse. Narcan was administered.
On ___, INR was 4.4 from 4.3, 2.5 mg of Vit K were
administered. Steristrips were re-applied to BKA wound.
On ___, INR was 3.1 and Coumadin continued to be held.
Torsemide 5 mg was given.
On ___, INR was 1.9 and Coumadin 3 mg were given. INR on
___ was therapeutic at 2.
In brief, Coumadin continued to be dosed throughout her hospital
course with great difficulties to achieve a therapeutic level,
being constantly either above or below the aim therapeutic level
goal.
On ___, per Case Management, given disposition issues due
to drug abuse and home issues and no place to go, the patient
had to stay hospitalized through ___.
On ___, patient was complaining of blurry vision in Left
eye which was transient. Glucose level was found to be 405,
improving the following day.
On ___, the patient was found to have an area or
erythema/cellulitis of her left shin with a central blister
evident on exam while being on daptomycin and ceftriaxone. Final
decision was to observe patient.
On ___, the patient was found to be 6 pounds above dry
weight and home torsemide was restarted. Area of
erythema/celullitis of her left shin was found to have worsened.
ID was consulted who had a low suspicion for infection and
preferred not to drive resistance in this heavily
antibiotic-exposed patient and recommended to obtain additional
imaging with CT/US/MRI if further concern to assess for
drainable collection and/or bone involvement.
On ___, erythema was found to be slightly improved.
Throughout the next few days the erythema remained stable
without any evidence of progression.
On ___, per Vascular surgery, antibiotics were stopped
given no evidence of fevers, WBC count, progression of erythema,
or fluctuation on physical exam. Physical Therapy saw the
patient and recommended home with home ___ with ___ visits.
Disposition continued to be an issue.
On ___, INR was 1.3, Coumadin 2 mg was administered and
heparin gtt was started given longstanding sub therapeutic INR
level. The next days, INR and PTT continued to be adjusted with
Coumadin and hep gtt.
On ___, the patient was ready to be discharged, PICC line
was removed but given sudden patient´s complaints of being
unable to return home due to issues with her father in law who
owned the house, the patient was unable to be discharged. The
patient remained in the hospital until ___ and was
ultimately discharged home with ___ services for methadone
delivery and home safety.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Ascorbic Acid ___ mg PO BID
3. Bisacodyl 10 mg PR QHS:PRN constipation
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Gabapentin 300 mg PO TID
7. Methadone 45 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Pantoprazole 40 mg PO Q24H
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Prochlorperazine 5 mg PO Q6H:PRN nausea
13. TraZODone 50 mg PO QHS:PRN insomnia
14. Vitamin D 1000 UNIT PO DAILY
15. Zinc Sulfate 220 mg PO DAILY
16. Lactobacillus acidophilus 1 billion cell oral DAILY
17. naloxone 4 mg/actuation nasal DAILY:PRN
18. Tizanidine 1 mg PO QAM
19. Tizanidine 2 mg PO QPM
20. Acetaminophen 1000 mg PO Q8H
21. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
22. CefePIME 1 g IV Q24H
23. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
24. Micafungin 100 mg IV Q24H
25. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
26. OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN Pain -
Moderate
27. Warfarin 2 mg PO DAILY16
28. Torsemide 20 mg PO DAILY
29. Senna 8.6 mg PO DAILY:PRN constipation
30. Lisinopril 2.5 mg PO DAILY
Discharge Medications:
1. HumaLOG (insulin lispro) 3 units subcutaneous TID
RX *insulin lispro [Humalog] 100 unit/mL 3 units SC three times
a day Disp #*1 Vial Refills:*0
2. Lantus (insulin glargine) 14 units subcutaneous QHS
RX *insulin glargine [Lantus] 100 unit/mL 14 units SC Bedtime
Disp #*1 Vial Refills:*0
3. OneTouch Ultra Test (blood sugar diagnostic) 4 strips
miscellaneous QID
RX *blood sugar diagnostic [OneTouch Ultra Test] 4 times a day
4 times a day Disp #*150 Strip Refills:*0
4. Psyllium Powder 1 PKT PO TID:PRN constipation
5. Warfarin 2 mg PO DAILY16
RX *warfarin 2 mg 1 (One) tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
6. Acetaminophen 1000 mg PO Q8H
7. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
8. Ascorbic Acid ___ mg PO BID
9. Atorvastatin 80 mg PO QPM
10. Bisacodyl 10 mg PR QHS:PRN constipation
11. Clopidogrel 75 mg PO DAILY
12. Docusate Sodium 100 mg PO BID:PRN constipation
13. Gabapentin 300 mg PO TID
14. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
15. Lactobacillus acidophilus 1 billion cell oral DAILY
16. Lisinopril 2.5 mg PO DAILY
17. Methadone 45 mg PO DAILY
18. Micafungin 100 mg IV Q24H
19. Multivitamins 1 TAB PO DAILY
20. naloxone 4 mg/actuation nasal DAILY:PRN
21. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
22. Pantoprazole 40 mg PO Q24H
23. Polyethylene Glycol 17 g PO DAILY:PRN constipation
24. Prochlorperazine 5 mg PO Q6H:PRN nausea
25. Senna 8.6 mg PO DAILY:PRN constipation
26. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
27. Tizanidine 2 mg PO QPM
28. Tizanidine 1 mg PO QAM
29. Torsemide 20 mg PO DAILY
30. TraZODone 50 mg PO QHS:PRN insomnia
31. Vitamin D 1000 UNIT PO DAILY
32. Zinc Sulfate 220 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right BKA stump dehiscence and infection
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 ___ with an infection of your right BKA
stump. You were taken to the Operating Room for debridement and
revision. You have recovered well and are now ready for
discharge home. Please follow the instructions below regarding
your care to ensure a speedy recovery:
MEDICATIONS:
Resume all your home medications
Take your Coumadin daily and have you ___ nurse constantly
checking your INR to dose Coumadin appropriately.
ACTIVITY:
On the side of your amputation you are non weight bearing for
___ weeks.
You should keep this amputation site elevated when ever
possible.
You may use the opposite foot for transfers and pivots.
No driving until cleared by your Surgeon.
No heavy lifting greater than 20 pounds for the next 3 weeks.
BATHING/SHOWERING:
You may shower when you get home
No tub baths or pools / do not soak your foot for 4 weeks from
your date of surgery
WOUND CARE:
Sutures / Staples may have been removed before discharge. If
they are not, an appointment will be made for you to return for
staple removal.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
CAUTIONS:
If you smoke, please make every attempt to quit. Your primary
care physician can help with this. Smoking causes narrowing of
your blood vessels which in turn decreases circulation.
DIET:
Low fat, low cholesterol / if you are diabetic follow your
dietary restrictions as before
CALL THE OFFICE FOR: ___
Bleeding, redness of, or drainage from your foot wound
New pain, numbness or discoloration of the skin on the
effected foot
Fever greater than 101 degrees, chills, increased redness, or
pus draining from the incision site.
Thank you for allowing us to participate in your medical care.
Sincerely,
Your ___ Surgery Team
Followup Instructions:
___
|
10901772-DS-55
| 10,901,772 | 25,839,096 |
DS
| 55 |
2154-07-18 00:00:00
|
2154-07-18 10:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
absorbable surgical gauze / ephedrine
Attending: ___
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo lady with h/o ischemic cardiomyopathy (LVEF ___, ___
primary prevention ICD on ___, MR ___ MV repair (___),
PAD
___ numerous interventions, HLD, OSA, DM2, polysubstance abuse
on
methadone who presented with 2 weeks of weakness, nausea, and
dry
heaving. She was in her usual state of health until 2 weeks ago
when she noticed onset of nausea and dry-heaving causing poor PO
intake, urinary frequency and dysuria, fatigue, lightheadedness,
subjective fevers, and chills. She was evaluated in clinic and
found to have a UTI and has now completed her OP course of PO
nitrofurantoin. Her dysuria resolved but her other symptoms
remained. Today her visiting nurse was concerned she looked
jaundiced and referred her to the ED for evaluation. She
recently
moved which caused disruption in her medication adherence,
including her insulin. She reports that her glucose levels have
been "good" recently, but had a glucose in the 400s several days
ago, and has had significant urinary frequency recently. She
also
reports having a black stool this morning. She denies chest
pain,
shortness of breath, cough.
She also had a recent fall onto her R leg stub (from BKA), which
was evaluated in clinic with no fracture found. She was also
treated recently for oral thrush.
Past Medical History:
PAST MEDICAL HISTORY
- CAD with the following interventions:
A. ___ - 2.5 x 18 Cypher to LAD
B. ___ - inferior STEMI with overlapping Endeavor stents to
the distal RCA
C. ___ - ISR RCA stent status post POBA
D. ___ - Progression of left main disease resulting in CABG
(free LIMA to LAD, SVG to RCA, SVG to OM). LIMA and SVG to RCA
are known to be occluded with SVG to OM patent (___).
E. ___ - Admission with congestive heart failure and non-ST
elevation MI in ___, transferred to ___. Angiography
showed 90% in-stent restenosis distal RCA stent, status post
2.75x20mm PROMUS DES.
F. There is residual 40% of LMCA and a tighter distal LAD
stenosis in a small vessel.
- Ischemic Cardiomyopathy (EF ___, last ECHO ___ CI 2.8)
- ICD for primary prevention
- Peripheral arterial disease (PAD) ___ multiple surgeries, ___
L TMA for ulcer disease ___ (c/b post-operative hypotension)
- Osteomyelitis of Right great toe. ___ amputation in ___,
required long course of IV antibiotics.
- DM2 with last A1c 7.9% ___, macroalbuminuria, diabetic
neuropathy
- HLD
- Tobacco use
- Sleep Apnea
- History of polysubstance abuse
- hepatitis C
- COPD
PAST SURGICAL HISTORY
- Right Fem-Pop PTFE ___
- L TMA ___
- Redo left femoral to above knee popliteal bypass with 6mm
ringed PTFE ___ ___
- Debridement left ___ toe, including partial metatarsal head
resection ___ ___
- left first ray amputation ___ ___
- aorto-bifem w dacron & L fem-pop bypass w PTFE ___
___
- Diagnostic ___ angiogram ___ ___
- L CFA endarterectomy, bovine pericardial patch angioplasty
from mid CFA into mid profunda femoral artery ___
___
- Aortogram bilateral lower extremity runoff ___
___
- Irrigation and closure of left neck wound ___ ___
- Incision and drainage of left neck wound ___ ___
- Left common carotid artery to left subclavian artery bypass
with 6-mm PTFE graft ___ ___
- CABG x 3vessels, Mitral valve repair, closure of patent
foramen ovale ___ ___
Social History:
___
Family History:
CAD/MI, DM, cancer: esophageal, brain, lung
No family history of breast or lung cancer, melanoma or
lymphoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.9, 50, 144/67, 18, 99% on RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended. Mild tenderness to
deep palpation in all four quadrants. Chronic, well-healed
surgical scars. No organomegaly.
EXTREMITIES: R BKA with stub site showing no edema or redness. L
TMA with well healed stub. No clubbing, cyanosis, or edema.
Pulses Radial 2+ bilaterally.
SKIN: No jaundice. Dry, flaking, erythematous LLE. Warm. Cap
refill <2s.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. AOx4.
Discharge Physical Examination
___ 1538 Temp: 97.4 PO BP: 122/70 L Sitting HR: 54 RR: 16
O2 sat: 98% O2 delivery: Ra l
GENERAL: NAD, A&Ox3, lying in bed comfortably
EYES: Sclera clear, anicteric, PERRL
ENT: ___ pearly gray bilaterally, nares patent and
nonerythematous, throat clear and without erthyema or tonsilar
exudate
Neck: no JVD
CV: RRR, normal s1/s2, no MRG
RESP: CTAB, no wheezes/crackles/rhonci. No accessory muscle
usage
ABD: Bowel sounds normoactive, soft and NTND, no HSM. No
guarding/rebound tenderness.
Rectal: Guaiac negative, prostate smooth without
nodules/tenderness.
Ext: No clubbing/cyanosis. Pulses 2+ bilaterally. right BKA,
left
pulse 2+
SKIN:No rashes/lesions. No jaundice. Warm. No evidence of skin
breakdown.
NEURO: Grossly normal,
PSYCH: Mood/affect appropriate.
Pertinent Results:
___ 11:51AM GLUCOSE-239* UREA N-17 CREAT-0.9 SODIUM-134*
POTASSIUM-5.7* CHLORIDE-96 TOTAL CO2-24 ANION GAP-14
___ 12:30PM LACTATE-3.3* K+-3.7
___ 12:57PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-600*
GLUCOSE-1000* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 11:51AM ALT(SGPT)-11 AST(SGOT)-35 ALK PHOS-252* TOT
BILI-0.7
___ 11:51AM LIPASE-30
___ 11:51AM ALBUMIN-2.7* CALCIUM-8.9 PHOSPHATE-2.6*
MAGNESIUM-1.5*
___ 11:51AM WBC-6.0 RBC-4.63 HGB-11.7 HCT-36.6 MCV-79*
MCH-25.3* MCHC-32.0 RDW-20.5* RDWSD-55.8*
___ 11:51AM ___ PTT-38.0* ___
___ 12:57PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-600*
GLUCOSE-1000* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 11:51AM CK-MB-2 cTropnT-<0.01
Brief Hospital Course:
This is a ___ female with a history of ischemic
cardiomyopathy (ejection fraction ___, status post primary
prevention with an ICD on ___, mitral regurgitation status
post mitral valve repair (___), peripheral artery disease,
hyperlipidemia, obstructive sleep apnea, diabetes, polysubstance
abuse on methadone who presented to the emergency room with
weakness, nausea, and dry heaving likely due to hyperglycemia
and dehydration.
==========================
Transitional Issues
==========================
-Diabetes education
-Adherence to insulin regimen and diet
-F/u HIV status given Thrush
-No medication changes
-Consider ACE inhibitor ___ for their mortality benefit in
heart failure
#Hyperglycemia
Patient has poorly controlled diabetes type 2, with documented
nonadherence to her insulin regimen. She reports that she had
glucoses in the range of 400-450 at home, with ___ weeks of
urinary frequency, and her urinalysis was significant for
glucose of 1000. There is no evidence of urinary tract
infection, as there was no leukocyte esterase and only small
blood. During this hospitalization, we restarted the patients
home insulin regimen. Her blood glucose had decreased to 239.
#Nausea, vomiting
-Nausea at baseline however she says that for the last 2 weeks
she has been having increased nausea, weakness, abdominal pain,
and lightheadedness. Given her elevated urinary glucose, she
most likely became dehydrated. She did have an elevated alkaline
phosphatase on admission and she did report some right upper
quadrant abdominal pain. On ultrasound, there were no
significant findings. Thus, we feel the most likely her nausea
and weakness is most likely related to dehydration and should
improve with better control of her diabetes and adequate
hydration. There was no evidence of DKA or HHS on admission.
#Bradycardia
Had heart rates of 35 reported in the ED, baseline rate of ___
per ICD interrogation. She is advised to follow-up as an
outpatient with the device clinic.
#Hypoxia: Oxygen saturation in the ___ in the emergency
department, required 2 L nasal cannula with normalization of her
oxygen saturation and weaned to room air. She required
additional oxygen overnight, most likely due to her underlying
OSA. Denied chest pain, shortness of breath, fevers, chills,
cough.
Chronic Issues
#PAD
-continued home anticoagulation
#CAD ___ CABG
#HLD
#HFrEF
-Continued home atorvastatin, follow up with cardiac device
clinic
#OSA
#Opioid Use Disorder: Continued home methadone 4.5ml PO qd.
#Peripheral neuropathy secondary to DM2: Continued home
gabapentin 400mg TID
#GERD: Continued home pantoprazole 40mg qAM
#Insomnia: Continued home trazodone 50mg PRN for insomnia
#Anxiety/Depression: Continued home venlafaxine 150mg qd
>30 minutes spent on discharge planning and coordination
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 400 mg PO TID home med
2. Atorvastatin 80 mg PO QPM home med
3. Clopidogrel 75 mg PO DAILY home med
4. Glargine 18 Units Bedtime
5. Pantoprazole 40 mg PO Q24H home med
6. Prochlorperazine ___ mg PO Q8H:PRN home med
7. TraZODone 75 mg PO QHS:PRN insomnia
8. Venlafaxine XR 150 mg PO DAILY depression/anxiety
9. Warfarin 2 mg PO DAILY16 home med
10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
11. Albuterol Inhaler 2 PUFF IH Q6H home med
Discharge Medications:
1. Glargine 18 Units Bedtime
2. Albuterol Inhaler 2 PUFF IH Q6H home med
3. Atorvastatin 80 mg PO QPM home med
4. Clopidogrel 75 mg PO DAILY home med
5. Gabapentin 400 mg PO TID home med
6. Pantoprazole 40 mg PO Q24H home med
7. Prochlorperazine ___ mg PO Q8H:PRN home med
8. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
9. TraZODone 75 mg PO QHS:PRN insomnia
10. Venlafaxine XR 150 mg PO DAILY depression/anxiety
11. Warfarin 2 mg PO DAILY16 home med
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: In wheel chair
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
-Because your visiting nurse was concerned for your jaundice and
weakness.
WHAT HAPPENED IN THE HOSPITAL?
-Your blood work showed her liver was functioning normally. Your
other labs were normal.
We also did a ultrasound which showed that there were
gallstones in her gallbladder, but no evidence that they were
causing any pain.
WHAT SHOULD YOU DO AT HOME?
-Please follow-up with your primary care provider.
Please take your insulin as prescribed
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
10901995-DS-22
| 10,901,995 | 26,178,799 |
DS
| 22 |
2196-04-09 00:00:00
|
2196-04-11 18:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tetracycline Analogues / Flagyl / Isoniazid /
Avandia / metformin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ year old woman with Crohn's disease with history of
colectomy, ileostomy and prior enterocutaneous fistula, presents
with ___ week history of intermittent abdominal pain. Pain is
located in bilateral lower quadrants and below umbilicus. She
had a CT scan last week which showed active ileitis. She saw
her GI physician (Dr. ___ last week due to worsening
redness, induration and pain at the area of her prior
enterocutaneous fistula site below the umbilicus. She was
perscribed keflex and stopped ciprofloxacin. Ultimately she was
sent to the ED by Dr. ___ who is concerned for
abscess/enterocutaneous fistula and requested IV antibiotics, GI
and colorectal consults.
In the ED, initial vitals: 97.0 67 146/62 18 95% RA. Labs
notable for Cr 1.2, AP 115, Plt 581. CT abdomen showed wall
thickening and hyperemia of approx 25 cm of distal ileum
extending into ileostomy with a sinus tract extending from the
inflammed loop of ileum to the umbilicus with inflammation of
the bladder dome. She received vancomycin and ciprofloxacin
(she has an allergy to flagyl). Vitals prior to transfer: 97.2
62 152/68 16 99r/a.
Currently, she denies pain, nausea, vomiting. BM are 4-5/day
loose and non-bloody, occasional mucus (baseline). No
fever/chills.
ROS: per HPI, denies night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, dysuria, hematuria.
Past Medical History:
Crohn's disease: see below for details
Bell's palsy at birth
Endometriosis
DM with neuropathy
Iron deficiency anemia
Hypothyroid
COPD - steroid dependent for exacerbations
Positive PPD - history of elevated LFTs related to INH
Degenerative joint disease
History of thrombocytosis
History of renal insufficiency and acute renal failure in ___
Crohn's disease: History of enterocutaneous fistula with abscess
formation, Status post Remicade therapy, History of leukopenia
secondary to ___, History of recurrent UTIs secondary to
fistula, History of iron-deficiency anemia.
PAST SURGICAL HISTORY:
Tonisllectomy ___
Ileostomy ___
ex lap/LOA ___
ex lap/LOA ___
Hysterectomy ___
ex lap/abd abscess drainage ___
Social History:
___
Family History:
nephew with ___, mother DM/CAD, father died of old age
Physical Exam:
VS - 97 129/65 64 16 97%RA FSG 65
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement
ABDOMEN - hypoactive BS, ileostomy c/d/i, 4cm scar tender and
slightly erythematous with local induration below umbilicus
(prior EC fistula site), ND, NT, 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, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
Labs upon admission:
___ 07:35AM BLOOD WBC-10.9 RBC-4.66 Hgb-14.0 Hct-42.8
MCV-92 MCH-30.1 MCHC-32.8 RDW-14.0 Plt ___
___ 07:35AM BLOOD Neuts-48.4* ___ Monos-7.4
Eos-9.7* Baso-0.7
___ 07:00AM BLOOD ___ PTT-28.8 ___
___ 07:00AM BLOOD ESR-55*
___ 07:35AM BLOOD Glucose-74 UreaN-17 Creat-1.2* Na-141
K-4.2 Cl-106 HCO3-26 AnGap-13
___ 07:35AM BLOOD ALT-21 AST-22 AlkPhos-115* TotBili-0.2
___ 07:00AM BLOOD Albumin-3.3* Calcium-8.6 Phos-3.7 Mg-1.9
___ 07:35AM BLOOD CRP-23.8*
___ 06:55AM BLOOD Vanco-12.7
___ 06:55AM BLOOD THIOPURINE METHYLTRANSFERASE (TPMT),
ERYTHROCYTES-PND
Labs upon discharge:
___ 10:00AM BLOOD Glucose-161* UreaN-8 Creat-1.5* Na-136
K-3.8 Cl-102 HCO3-27 AnGap-11
___ 10:00AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.8
___ 07:00AM BLOOD ALT-19 AST-23 AlkPhos-104 TotBili-0.3
___ 10:00AM BLOOD WBC-12.6* RBC-4.16* Hgb-12.4 Hct-37.9
MCV-91 MCH-30.0 MCHC-32.9 RDW-13.8 Plt ___
Imaging:
___: CT abd/pelvis: IMPRESSION:
1. Active Crohn's disease with wall thickening and
hyperenhancement in
approximately 40 cm of the most distal ileum, extending to and
involving the ostomy.
2. Sinus tract arising from the inflamed distal ileum extending
to the
umbilicus and the dome of the bladder. No definite connection
with the
bladder lumen is identified. This is similar in appearance to
prior exams from ___ and ___, but worsened since the most
recent exam in ___. No abscess or fluid collection is
identified.
3. Fibro-fatty proliferation and prominent lymph nodes in the
right lower quadrant consistent with changes of chronic Crohn's
disease.
4. Cholelithiasis.
___: KUB: IMPRESSION: Nonspecific bowel gas pattern with no
evidence of obstruction or ileus.
___: CXR: FINDINGS: In comparison with the study of
___, there is little overall change. Mild atelectatic
changes are seen at the left base. However, no evidence of
acute focal pneumonia or definite old granulomatous disease.
Brief Hospital Course:
___ year old woman with Crohn's disease with history of
colectomy, ileostomy and prior enterocutaneous fistula, presents
with active Crohn's flair. She was made NPO and hydrated with
intravenous fluids. She was treated initially with vancomycin
and ciprofloxacin. Vancomycin was directing possible cellulitis
at the site of her prior healed enterocutaneous fistula. She
was soon transitioned to ciprofloxacin and metronidazole (which
she tolerated well orally even though she has a documented
allergy with paresthesias). Diet was advanced and tolerated
well. She was seen by the gastroenterology consult team who
recommended 7 days of antibiotics followed by prednisone and
then initiation of Humira. Prednisone and Humira will be
started by her outpatient gastroenterologist. Her mesalamine
was stopped. She also received a CXR which did not show
evidence of latent tuberculosis (note she was fully treated for
latent TB in ___ with four months of rifampin).
She was treated with her home medications for her other chronic
medical issues.
She was FULL CODE for this admission.
TRANSITIONAL ISSUES:
- f/u TMPT level
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Carvedilol 6.25 mg PO BID
hold for HR <60 or SBP<90
2. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
3. FoLIC Acid 1 mg PO DAILY
4. GlipiZIDE XL 10 mg PO BID
5. Glargine 8 Units Bedtime
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Mesalamine ___ 800 mg PO TID
8. Omeprazole 20 mg PO BID
9. sitaGLIPtin *NF* 100 mg Oral qsupper
10. zoledronic acid *NF* 5 mg/ml Injection yearly
11. Ascorbic Acid ___ mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. Cyanocobalamin 500 mcg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Pyridoxine 50 mg PO DAILY
Discharge Medications:
1. Carvedilol 6.25 mg PO BID
hold for HR <60 or SBP<90
2. Glargine 8 Units Bedtime
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Omeprazole 20 mg PO BID
5. Ciprofloxacin HCl 500 mg PO Q12H
RX *Cipro 500 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
6. MetRONIDAZOLE (FLagyl) 250 mg PO Q8H
RX *Flagyl 250 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*21 Tablet Refills:*0
7. Prochlorperazine ___ mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 5 mg ___ tablet(s) by mouth q8H PRN
Disp #*30 Tablet Refills:*0
8. Ascorbic Acid ___ mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Cyanocobalamin 500 mcg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. GlipiZIDE XL 10 mg PO BID
13. Multivitamins 1 TAB PO DAILY
14. Pyridoxine 50 mg PO DAILY
15. sitaGLIPtin *NF* 100 mg Oral qsupper
16. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
17. zoledronic acid *NF* 5 mg/ml Injection yearly
Discharge Disposition:
Home
Discharge Diagnosis:
Active Crohn's ileitis
Diabetes Mellitus
Chronic renal insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital because of a flair of your Crohn's
disease. You were treated with antiobiotics and fluids and
improved. You will follow up next week with Dr. ___ to
start prednisone followed by Humira. You will continue to take
ciprofloxacin and flagyl for the next 7 days.
Followup Instructions:
___
|
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